Abstract
Background:
Historically, the focus of the UK and international research exploring planned home birth decision making has been largely focused on understanding the experiences of women who decide to birth at home. As a result of high-profile research that suggests that non-OU birth locations are safe for low risk women, there has been a recent shift in focus resulting in research studies that aim to increase the rates of planned home birth, or more often the rates of all non-obstetric unit birth within the UK. However, despite this increased level of attention, the rate of home birth remains stubbornly low. Whilst there is some research to indicate why this might be the case, research that sheds a new light on the issue, and that develops an evidence base for new interventions is required. This thesis illuminates the factors that need to be considered in order to increase women’s abilities to make an informed decision about planned birth.
Methodology:
A pragmatic approach, using mixed methods, was used to explore the current way that we offer planned home birth to maternity service users, and to ultimately make suggestions about how this could be improved.
The following studies have been undertaken:
Study 1: Initial exploratory study:
The case notes of one hundred and sixty nine women, from one health board and who had planned to birth at home, were audited.
Non-participant observation of birth planning meetings at thirty-six weeks gestation were undertaken with seven community midwife and low-risk women dyads. These were followed by individual semi-structured interviews with the participants.
Study 2: Scoping review:
Qualitative and quantitative research, and non-research based literature, were analysed to produce a qualitative review of planned home birth decision making.
Study 3: Active offer of planned home birth concept analysis
The findings of the initial exploratory study and the scoping review, in addition to active offer literature that is predominantly applied to support the provision of services within minority official languages, were used to create an active offer of planned home birth.
Study 4: Workshop study testing the findings of the concept analysis
Narrative based exercises were used to explore the concept analysis findings with twenty previous service users who had birthed at home, nine previous service users who had chosen an institutional birth, and fourteen community midwives.
Findings:
Women will either take a ‘passive’ or ‘active’ approach to the offer of planned home birth, with a passive approach likely where no motivation for an active approach has been provided.
Where a woman takes a passive approach, her ability to make an informed decision about planned home birth will depend on an active offer being made by her midwife. This will be most effective when it is supported by a midwife’s employing organisation.
The findings of this thesis suggest that a two stage active offer of planned home birth (AOPHB) process, consisting of ‘Creating the conditions’ and ‘Positive reinforcement’ stages, can be used to underpin the offer of planned home birth.
Discussion:
There has previously been minimal understanding of how to facilitate the home birth decision making process, and a passive offer is routinely provided to women in the UK.
The proposed two-stage AOPHB process provides a structured way for midwives to underpin their offer to women, in order that an increased percentage of women are able to make an informed decision about home birth and/or decide to birth at home. Where midwives apply the AOPHB, women who may take a passive approach could be ‘activated’ to engage in home birth decision making.
A pilot intervention has been drafted to implement the AOPHB within clinical practice. The intervention provides support for the implementation of the two-stage AOPHB process through the use of individual components focused on midwives and their employing organisation; student midwives; and women, and their significant others.
Implications:
This thesis has contributed to the developing knowledge base about planned home birth decision making. The application of active offer theory to the offer of planned home birth has been undertaken for the first time, and this has generated a new and useful perspective on this area of midwifery practice.
The resultant two-stage AOPHB process has the potential for developing midwifery practice in terms of supporting midwives to understand and facilitate women’s decision making around home birth, providing a flexible tool that can be used in clinical practice. This is the first approach that has been developed with the aim of increasing the ability of women to make an informed decision about whether they wish to birth at home.
Additionally, the pilot AOPHB intervention has implications around the understanding of how employing organisations can best support midwives in this aspect of their role, and developing how student midwives are educated about offering home birth to women.