Extending maternity choices: Insight desk research

The Audience of Pregnant Women

Key variables within the population of pregnant women that influence experiences of maternity care and approaches to information and choice are parity (ie. whether the pregnancy is a woman’s first or not), stage of pregnancy. socio-economic grade, and education.

A number of relevant typologies have been developed to classify pregnant women, based on attitudinal and emotional variables.  These include classifications by: approaches to information; anxiety and empowerment; the degree of support available to women.  These provide useful insights into further key dimensions in understanding pregnant women’s experiences of maternity care, choice and communications.

In addition, a number of priority subgroups are identified in the literature as having specific needs in relation to maternity services and information provision.  These different subgroups can be grouped in the following categories: cultural backgrounds (both ethnicity and faith), socially vulnerable groups (eg. homeless or drug/alcohol dependent women), hard to engage groups (eg. teenage parents and fathers), and women with increased medical risk (eg. obese, or with heart disease).

Service Experiences and Perceptions

Significant evidence exists about women’s expressed views about maternity care.  This needs to be read in light of key limitations inherent in measuring experiences and satisfaction, which include: the conservative tendency for pregnant women to assume that whatever care they have received is the best; and limitations of quantitative surveys to elucidate women’s experiences because they miss important detail revealed by women’s stories.

The majority of women tend to be fairly positive about the maternity care they have received, both overall and when talking about specific aspects of care.  However, unequivocally positive responses are only given by approximately 30-40% of women and more negative responses by a notable minority of 20-30%.  Satisfaction with care provided by healthcare professionals generally seems to be higher than that regarding other aspects of care. Some evidence suggests that women are least positive about postnatal care and least satisfied with the amount of information they receive from maternity staff. 

The evidence reviewed suggests the following factors as key in determining women’s satisfaction with maternity care and other important outcomes:

• the care received from, and relationships with, maternity professionals
• empowerment, control and expectations – both during birth and antenatally
• birth environment
• place of birth
• choice
• the role of the baby’s father
• reassurance about medical care in case of emergencies

There is extensive evidence of worse experiences and lower satisfaction among priority subgroups (eg. teenage parents).  However, this is not universal and there are cases where some aspects of satisfaction are higher for certain subgroups (eg. Black and Asian women).  Experiences of care from maternity staff also include some positive stories, and good care has the potential to improve vulnerable women’s experiences and outcomes.

Staff views provide important insights because staff can determine the experiences of women and the care they provide is often key to satisfaction.  The majority of evidence here is from midwives with little from doctors or consultants.  Much feedback from staff about maternity services relates to shortcomings and problems with care, including concern about high caesarean rates, lack of service capacity (including low staffing levels), and the inadequate training, skills and experience of healthcare professionals, coupled with the increasing social and medical complexity of the ever increasing population of pregnant women.

Different cultures associated with different healthcare professions (essentially consultants and midwives) and different models of care are identified as a key and recurring point, with a medicalised ‘illness-based’ culture at one end of a continuum of care and a more holistic ‘normalised’ approach at the other.

Choice

Choice is a contested concept that needs to be located as one aspect of women-centred care.  Three styles of decision making – paternalistic, informed and shared –help illuminate the issue of choice in maternity care as a dynamic concept.  No one style is ultimately preferred, and they should be adopted as needed by the woman at the time.

Risk and uncertainty are inescapable aspects of maternity care which play a key role in maternity choices.  Different approaches to the problem of risk are associated with different models of care , which lead to different views on choice; interestingly, neither the midwifery nor medical models entirely supports free choice for women.

In addition to the four ‘national choice guarantees’ set out in Maternity Matters (DH, 2007) the literature identifies a large number of choices along the maternity care pathway.  However, research data suggest that many of these are ‘non-choices’ for many women, in that women are not made aware that they have choice at such points.

Evidence about the choices offered to women and their views on choice in maternity care reveals notable shortcomings.  For instance, of the three quarters of women who, when pregnant, first contact a GP, only 14% realise contacting a midwife is an option.  Also, while 81% of women reported being offered choice of place of birth, only 57% were offered the option of a home birth.

There is some evidence that important choices are often made very early in pregnancy, or pre-pregnancy.  For instance, it is reported that many women have already chosen their place of birth, and preferred form of pain relief, before they have first access maternity services.

A wide range of factors can influence choice for women in maternity care. Personal factors include experience, the influence of family, friends and social factors, and skills, education and confidence. ‘Extrinsic’ factors relating to maternity services include the extent to which choices are offered, control and influencing of choice by healthcare professionals, available facilities and capacity, and institutional factors such as local policies.  Wider influences on choice include cultural and geographic factors.

Information

Women express a variety of information needs during pregnancy and new parenthood, with a focus on information relating to labour and birth (especially relating to anxiety about birth and pain, and practical techniques for labour); information to provide reassurance (especially about progress of pregnancy and well being of the baby); and postnatal information (the most frequently mentioned – especially practical baby care and transition to parenthood).

Women from priority subgroups may have specific needs for information, but generally do not want to feel singled out or stigmatised and so prefer to have the same sources of information as other pregnant women; these need to be made more inclusive and extended to cover information relevant to different subgroups.  Fathers are a notable exception, tending to respond better to specifically tailored and targeted information.

A number of key information needs emerge from the evidence that could potentially influence important outcomes.  In particular, antenatal and pre-pregnancy information that provides women with confidence to give birth without medical intervention and to expect normality could be important. 

There appears to be a fair amount of dissatisfaction among women about the amount of information they receive during pregnancy, and again the picture is largely less positive for priority subgroups.  In general, women tend to report wanting more in-depth information, although this varies widely (eg. by parity, and typology – see above).

Information clearly plays an important role in choice but is only part of what is needed for good decision making; the provision of information can be best regarded as the starting point in a supported process of deliberation involving women and maternity staff.

Key issues relating to handing over information to pregnant women include timing, allowing sufficient time for deliberation, ensuring that healthcare professionals have the skills to successfully communicate information and support decisions, and ensuring that information is in line with the reality of choices available (and supported by healthcare professionals in practice).

An approach involving clearly signposting decisions, then ‘staging and layering’ information to meet the needs of specific women is suggested as effective for extending maternity choice.

Among the evidence on formats and channels preferred by women, there is a strong preference for information delivered face to face, especially when it relates to the experiences of other women. However, authoritative information is also valued, both that received verbally from maternity staff and in written formats (eg. DH’s The Pregnancy Book).  Emerging evidence suggests web-based communications have the capacity to combine the strengths of factual information with women-to-women support.

Media and culture

Cultural norms can be seen to proscribe the range of choices taken by women, and to shape their expectations of the birth experience (thereby potentially influencing outcomes).  The media is understood to play a key role in shaping cultural norms, and there is evidence that this effect is at work in relation to maternity choices, perpetuating a medicalised model of birth.