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Birthplace safety: An exploration of differences between primary maternity units and tertiary hospitals in women’s decision-making, transfers and birth outcomes – the New Zealand ‘Evaluating Maternity Units’ study

Abstract:

Background Birthplace is a profoundly important aspect of childbearing, and can have powerful personal and socio-cultural implications. There is worldwide debate surrounding the safety and appropriateness of different birthplaces for well women having uncomplicated pregnancies. This thesis reports the New Zealand Evaluating Maternity Units (EMU) study. The study is part of a large prospective cohort study undertaken in Australia and New Zealand. It is the first such study on birthplace to be undertaken in the context of a publicly funded, midwifery-led continuity of care maternity system. Methods A mixed methods methodology, with a ‘concurrent QUANTITATIVE + qualitative’ typology was used. The study was a prospective cohort design. It aimed to: * Describe and explore the influences on women’s decision-making of primary maternity unit (PMU) or tertiary maternity hospital (TMH) as their planned place for birth; * Identify and evaluate the frequency, timing, reasons and maternal and neonatal outcomes of antenatal, intrapartum and postpartum transfers from primary unit to tertiary hospital; * Describe and explore women’s experiences of transfer; and * Report the clinical outcomes of ‘low risk’ women who intended to give birth at either a primary maternity unit or tertiary maternity hospital. Data were collected data from four sources – a maternity database and midwives for the clinical outcome and transfer data, and a postpartum survey and focus groups for the decision-making and transfer data. The quantitative data were analysed using either descriptive or inferential statistics, and the qualitative data were analysed using either content or thematic analysis; and most integration occurs at the interpretation stage. Findings Data from 702 well pregnant women (407 PMU, 285 TMH) who booked to give birth in the Christchurch area in New Zealand (2010-2012) were analysed. Data also included a six week postpartum survey (571 women, 82%) and eight focus groups (37 women) to explore and compare the views, beliefs and experiences of the different cohorts. All participants received midwifery-led continuity of care, regardless of their intended or actual birthplace. Almost all the respondents perceived themselves as the main birthplace decision-makers. Accessing a ‘specialist facility’ was the most important factor for the TMH group. The PMU group identified several factors, including 'closeness to home', 'ease of access', the 'atmosphere' or 'feel' of the unit and avoidance of ‘unnecessary intervention’ as important. Five core themes in further analysis of birthplace decisionmaking were identified: the birth process, women’s self-belief in their ability to give birth, midwives, the health system and birth place. “Confidence” was identified as the overarching concept influencing the themes. The study found that women plan their birthplace based on which one they perceive to offer the greatest ‘safety’ for themselves and their babies. Both groups believed their chosen birthplace was the right and ‘safe’ place for them, although they had different ideas about what makes a birthplace ‘safe’. Birthplace changes were not uncommon, with fewer than half of the women who planned a PMU birth giving birth there. The majority of those who changed their planned birthplace type antenatally were due to a clinical indication. Most labour changes occurred before admission in labour to the PMU. Transfers in labour from PMU to TMH occurred for only 12.6%, with most non-urgent and due to “slow progress” of labour. The women who planned a PMU birth understood the potential for plan change or transfer. Four themes were identified relating to transfer: ‘not to plan’, control, communication and ‘my midwife’. An interplay between the themes created a cumulatively positive or negative effect on their experience, although none expressed trauma with transfer. The comparative clinical maternal and perinatal outcome findings found that, after adjustments, women from the primary cohort were significantly more likely to have an unassisted vaginal birth, spontaneous labour onset, have no analgesia or have physiological management of the third stage of labour than women from the tertiary unit group. Women from the primary cohort were significantly less likely to have an instrumental vaginal birth, labour augmentation or an episiotomy compared to women from the tertiary unit cohort. The cohorts had similar rates of postpartum haemorrhage, induction, caesarean section or other perineal trauma. There were no significant differences in the measured neonatal outcomes of Apgar score <7 at 5 minutes, need for resuscitation, admission to neonatal unit, perinatal mortality, birthweight, gestational age or breastfeeding rates. Conclusions Birthplace decision-making is complex. ‘Safety’ was the goal for all participants, although they chose different means to achieve a sense of it. The groups’ responses expressed different beliefs about childbirth. ‘Confidence’ was identified as the key enabler for women to plan a PMU birth. The study showed that the model of continuity of midwifery care in New Zealand appeared to enable women to plan a PMU birth, and to mitigate the negative aspects of women’s experience of transfer and facilitate positive birth experiences. The neonatal clinical outcomes were comparable between both cohorts, and there was higher maternal morbidity in the tertiary cohort. Research evidence affirming the ‘clinical safety’ of primary units addresses only one aspect of the beliefs influencing women’s birthplace decision-making and experiences. Multiple factors have the potential to influence the experience and safety of birth, with women drawing on a broader perception of safety than that accounted for in clinical safety.

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birth outcomes, birthplace, primary maternity unit, tertiary hospital, transfer, women's decision-making