THE EXPERIENCES, TIMING, FREQUENCY, REASONS, URGENCY AND CLINICAL OUTCOMES FOR WOMEN WHO CHANGED THEIR PLANNED PLACE OF BIRTH OR TRANSFERRED FROM PRIMARY MATERNITY UNITS TO A TERTIARY MATERNITY HOSPITAL

Abstract

Introduction. Little is known about how women experience a change in plans or transfer from a planned birth in a primary maternity unit (PMU) to a tertiary maternity hospital (TMH). We explored this and also examined the outcomes for women of these changes during the antenatal or pre-admission, pre and post-admission labour and postnatal time periods. All women received continuity of midwifery care regardless of plan changes or their intended or actual birthplace. Materials and Methods. The Evaluating Maternity Units (EMU) prospective cohort study used a mixed method methodology and collected clinical outcome, survey and focus group data. Participants were well, pregnant women booked to give birth in a primary unit or tertiary hospital in New Zealand (2010-2012). Results. There were 407 women in the PMU cohort and 285 in the TMH cohort. • Four themes emerged relating to transfer: ‘not to plan’, control, communication and ‘my midwife’. The interplay between the themes created a cumulatively positive or negative effect on women’s experience. Their experience of transfer in labour was generally positive, and none expressed trauma with transfer. • Of those who planned a PMU birth 47% gave birth there. Of the 28.5% of women who changed their planned birthplace type antenatally, 62% were due to a clinical indication. Most (73%) labour changes occurred before admission in labour to the PMU, the most common reason was rapid labour (24%) or PROM (24%). Of the 27 (12.6%) who transferred in labour from PMU to TMH 96% were nulliparous women. Of these 78% transferred for “slow labour progress”, and 63% were ‘non-emergency’ transfers. The mean ‘emergency’ transfer time was 58 minutes. The mean time for all labour transfers from specialist consultation to birth was 4.5 hours. • After adjustments, PMU women were significantly more likely to have a vaginal birth, spontaneous labour onset, no analgesia and physiological management of the third stage than TMH women. PMU women were significantly less likely to have instrumental vaginal birth, labour augmentation and an episiotomy compared to the TMH cohort. The cohorts had similar rates of PPH, induction, caesarean section and 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. Conclusion. The women understood the potential for plan change or transfer, although it was not necessarily wanted or planned. When they maintained a sense control, experienced effective communication with caregivers, and support and information from their midwife, the transfer did not appear to be experienced negatively. Birthplace changes were not uncommon. Most changes were due to the development of complications or ‘risk factors’. Most transfers were not urgent and took approximately one hour from the decision to transfer from the primary unit to arrival at the tertiary hospital. Despite the transfers the neonatal clinical outcomes were comparable between both cohorts; however, the rate of maternal morbidity was higher in the tertiary hospital cohort. The model of continuity of midwifery care in New Zealand appeared to mitigate the negative aspects of women’s experience of transfer and facilitate positive birth experiences.