WOMEN’S BIRTHPLACE DECISION-MAKING, THE ROLE OF CONFIDENCE: PART OF THE EVALUATING MATERNITY UNITS STUDY, NEW ZEALAND.

Abstract

Introduction Birthplace is a profoundly important aspect of women's experience of childbirth. Birthplace decision-making is complex, in common with many other aspects of childbirth. I describe the influences on women's birthplace decision-making in New Zealand and identify the factors which enable women to plan to give birth in a freestanding midwifery-led primary level maternity unit (PMU) rather than in an obstetric-led tertiary level maternity hospital (TMH). Materials and Method The Evaluating Maternity Units (EMU) prospective cohort study used a mixed method methodology. Data from eight focus groups (37 women) and a six week postpartum survey (571 women, 82%) were analysed using thematic analysis and descriptive statistics. Participants were well, pregnant women booked to give birth in a PMU or TMH in Christchurch, New Zealand (2010-2012). The participants received continuity of midwifery care regardless their intended or actual birthplace. Results Almost all the participants perceived themselves as the primary 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. Both groups believed their chosen birthplace was the right and ‘safe’ place for them. The concept of ‘safety’ was integral and based on the participants’ differing perception of safety in childbirth. Five core themes were identified: the birth process, women’s self-belief in their ability to give birth, women’s midwives, the health system and birth place. “Confidence” was identified as the overarching concept influencing the themes and found to be a key enabler for women to plan to give birth in a freestanding midwife-led primary level maternity unit in New Zealand. Conclusion The groups’ responses expressed different ideologies about childbirth. The TMH group appear to identify with the ‘technocratic model’ of birth, and the PMU group identified with the ‘holistic model’. Research evidence affirming the ‘clinical safety’ of primary units addresses only one aspect of the beliefs influencing women’s birthplace decision-making. The findings from this study suggest that women who have confidence in the birth process, their ability to give birth, their midwife, the health system and the intended birthplace are able to plan a PMU birth. Addressing the underlying beliefs which influence these confidences in women may facilitate well women in western resource-rich countries to comfortably plan to give birth away from high-tech hospitals.