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

This thesis reports the findings of the New Zealand Evaluating Maternity Units (EMU) prospective cohort study which included 407 pregnant women who booked to give birth in a primary maternity unit and 285 well women who booked at the tertiary maternity hospital in New Zealand during 2010-2012. Data were also received from a six week postpartum survey (82% response rate) and focus groups (37 women). A mixed method methodology was used to explore the influences on women’s decision-making; to identify and evaluate the frequency, timing, reasons outcomes and experience of antenatal, intrapartum and postpartum transfers; and describe the clinical outcomes. For tertiary hospital women accessing a ‘specialist facility’ was most important, compared to multiple reason including 'closeness to home', 'ease of access' and the 'feel' of the unit for primary unit women. “Confidence” was the overarching concept influencing the five core themes: ‘the birth process’, ‘women’s belief in their ability to give birth’, ‘midwives’, ‘the health system’ and ‘birth place’. Of those who planned a primary unit birth, 50% changed their plan (mostly antenatally); and 12.6% transfers made during labour (most non-urgent and due to “slow progress” of labour). Themes around experience of transfer were: ‘not to plan’, ‘control’, ‘communication’ and ‘my midwife’. Primary unit women were less likely to have an instrumental assisted birth, labour augmentation or an episiotomy and significantly more likely to have spontaneous onset of labour, normal vaginal birth, no analgesia and physiological management of the third stage of labour, compared to the tertiary hospital women. All other maternal and neonatal outcomes were similar. The study is the first undertaken in the context of a publicly funded maternity system where all women had midwifery-led continuity of care regardless of planned or eventual place of birth.