Developing consumer‐led maternity services: a survey of women’s views in a local healthcare setting

Abstract

Objective This paper describes a prospective study of women’s views and experiences of maternity services. The aim was to examine the way women make choices and decisions about maternity care and the factors which influence decision making, with a view to developing services which best meet the needs of the population. Patient choice issues reviewed included: choice of place of birth, choice of lead professional and choices in labour management.

Design, setting and participants A cohort of women attending maternity booking clinics, within the catchment area of Peterhead Maternity Unit (PMU) in north‐east Scotland, were surveyed by means of postal questionnaires at three stages during their contact with maternity services. A subset of women also took part in in‐depth interviews.

Results Not all women were given information about all the available options for place of birth and many women were unclear of the differences between them. Factors influencing choice of place of birth can change, with the medical aspects of maternity care becoming more important as the pregnancy progresses. Women rated the importance of seeing the same staff at antenatal visits highly, but were less concerned with their ability to choose which professional to see. More importance was attached to being able to choose a particular midwife rather than a particular obstetrician. Women’s choices with regard to labour management were largely met. Insufficient information, however, was provided about choices in pain relief.

Conclusions The survey revealed the importance of locally based research, involving all stakeholders, in developing services which best meet the needs of a population.

Introduction

The National Health Service (NHS) reforms of 1991 first introduced the concept of patient‐focussed services into the UK system of health care. The Patient’s Charter set out the standards of service patients could expect to receive from the NHS and set the scene for a growing movement of consumerism in public services. ^{1 , 2} Since then, developments in health policy have re‐affirmed this commitment to involving users and providing services which are designed around the need of patients. The challenge for health service managers has been how to put this ideology into practice.

Maternity services in the UK have been the subject of a series of major policy reviews in recent years. In keeping with the commitment to user involvement, one of the key focuses of this work has been the consumer view and a number of principles have been established for maternity services, based on the views expressed by women themselves. These are that maternity services should offer women an informed choice about their care, provide continuity of care and maximize opportunities for women to have control over their situation. ³ , 4, 5, ^–6

In the UK, there is a system of devolved management for NHS services. The NHS in Scotland is funded centrally and provides services in line with the broad policy established by the national government. The Scottish Office has responsibility for decisions about how this national policy should be implemented in Scotland. In 1992, a policy appraisal ⁴ was carried out to establish the factors which would need to be considered in deciding how best to balance the maternity care needs of the Scottish population. For the consumer aspect of maternity services, this review relied heavily on work undertaken by the CRAG/SCOTMEG working group on maternity services. ^{5 , 6} In line with previous reviews, the key issues for women which emerged from this work were a desire to receive continuity of care from health professionals and that informed choice was the key to giving women the level and quality of care they wanted from maternity services.

In order to meet the needs of a local population and provide services which are patient centred, health planners and providers of maternity care services need to have a clear idea of the factors which are important to, and which influence how women make choices about their maternity care. Matching the preferences of women with what is provided can best be achieved by close assessment of the views of local women. For consumer feedback to be useful, it must focus on specific aspects of care that can be manipulated to improve services. ⁷ , 8, ^–9 Local research is important in that it can clarify support for national developments and enables local providers to assess their own performance and identify potential for improving and reshaping local services against the background of national policy guidance. ¹⁰

The establishment of the Peterhead Maternity Unit (PMU) in the north‐east of Scotland in December 1993, run and staffed by midwives, provided an opportunity to develop a truly consumer‐led service for the area. By examining the factors which influence the way women make choices and decisions about their maternity care, the locality team could develop services which would enhance the ability of women to make informed decisions and could develop services which would more closely meet the needs of local women.

In this paper, we describe a prospective study following a cohort of women from the Peterhead locality, examining women’s preferences for and subsequent experience of maternity care. Women’s views and preferences during the antenatal period and actual experiences at the time of birth were examined for a number of patient choice issues: choice of place of birth, choice of lead professional and choices for management during labour. Grampian Local Health Council was commissioned by the local management team to undertake the survey work. The council is a statutory organization funded by, but operating independently of, the NHS in Scotland. Its function is to represent the interests of the user in the NHS.

Setting

Peterhead Maternity Unit

Peterhead Maternity Unit is located within Peterhead Community Hospital, approximately 35 miles from the main consultant unit at the Aberdeen Maternity Hospital (AMH). The unit serves an area of around 100 square miles, encompassing three general practices. The largest general practice is located in Peterhead itself, the remaining two being rural practices, located some 10 miles to the south and east of Peterhead. The combined general practice population is approximately 30 000 with around 400 births registered annually.

The unit has six‐beds (four single and one double room) and is staffed and run by midwives – 13 (eight whole time equivalent (WTE)) midwives and five WTE midwifery assistants. A named midwife system operates with each mother allocated a named midwife in early pregnancy – usually a midwife linked to the woman’s GP. An integrated community and hospital based midwifery service was introduced when the unit opened.

The Peterhead Maternity Unit aims to offer a ‘home from home’ environment with no specified labour rooms. All rooms offer comfortable surroundings with en‐suite facilities. Choices in pain relief at the PMU are: relaxation/massage (including bath/shower but not a water birth); transcutaneous electrical nerve stimulation (TENS) machines (available on a rental scheme); pethidine injection; and entenox.

Aberdeen Maternity Hospital

Aberdeen Maternity Hospital ‘is the main consultant maternity hospital serving the north‐east of Scotland and offers the full range of specialist maternity facilities. It serves the Grampian region with approximately 6000 births registered annually. It provides consultant‐led labour ward care and also houses a midwife‐led maternity unit for low risk women.

Antenatal care

Antenatal care for all women in the north‐east of Scotland follows locally recommended protocols. Care is shared between the obstetrician, general practitioner (GP) and the midwife. On confirmation of pregnancy, mothers are referred for a booking appointment with their midwife. This is normally arranged before 12 weeks of pregnancy. Thereafter women attend clinics either with the midwife and/or the GP at set intervals throughout pregnancy. Unless there are specific problems, which require more frequent antenatal clinics, women would normally attend 10 or 12 antenatal clinics during pregnancy. At the time of the study, women also received a consultant appointment in early pregnancy (between 10 and 12 weeks) and a further consultant review offered again in late pregnancy. Appointments with the consultant are available throughout pregnancy for women who require specialist care.

Midwifery care is provided by teams of midwives attached to each of the three general practices. A named midwife system operates with each mother allocated a named midwife in early pregnancy. This is a midwife linked to the women’s GP. For women registered with the Peterhead Medical practice antenatal midwifery care is provided by midwives at the PMU. These midwives provide a fully integrated hospital and community based service. The consultant service is provided by visiting consultants from AMH. Consultant clinics are held in the PMU and the outlying practices.

Choices available

Women in the Peterhead locality of the north‐east of Scotland have four choices with regard to place of birth: home birth (although not encouraged); birth at the PMU; birth in the labour ward at the AMH; and birth in the midwives unit at the AMH. A DOMINO (Domiciliary in and out) delivery by named midwife is available for women registered with the PMU, but a modified DOMINO service is more usually offered whereby women come into the PMU whilst in early labour, rather than remaining at home. Only women whose pregnancy and delivery is expected to be normal can be booked for the PMU. Women booked for elective caesarean, who have experienced pregnancy problems or have an underlying medical condition will all be booked for consultant‐led care at the AMH. The midwives unit in AMH can also only accept bookings for women who are deemed low risk.

Methods

The aims for the project were initially drawn up by a multi‐disciplinary team which included user representatives, midwives, GP’s and locality management staff.

Between 1 January 1995 and 31 December 1995, all women attending maternity booking clinics within the catchment area of the PMU were eligible to take part in the study (immaterial of whether they were eventually booked into either the PMU or AMH).

At approximately 14 weeks gestation, women were mailed a letter explaining the aims of the project, together with a questionnaire eliciting women’s views on, and experiences of early pregnancy. By returning the questionnaire, women indicated their consent to take part in the project. Themes included details of and factors affecting place of booking, preferences for antenatal care and sources of advice and information. One reminder letter was sent after 3 weeks; names of women who did not respond at this stage were withdrawn from the project.

Forms were provided for midwives from the three practices to inform the Health Council of the names of any woman who had suffered a miscarriage or had developed other problems during pregnancy for whom it was inappropriate to send out questionnaires.

A second questionnaire was mailed at approximately 36 weeks gestation. This questionnaire elicited views on experiences of antenatal care, preferences for labour management including pain relief and plans for baby feeding.

A third questionnaire was sent out 6 weeks postnatally. Topics covered in this questionnaire included experiences of labour, postnatal care in hospital and at home, experiences of baby feeding, and opinions on advice and information received.

At the time of the first questionnaire, women were asked to indicate their willingness to be interviewed at approximately 30 weeks gestation and again 9 weeks postnatally. A sample of these women (20), stratified by area of residence and parity was selected and interviewed by one of the study researchers. The taped interviews were semi‐structured and explored a specific set of themes. Themes explored antenatally included: opinions and experiences of antenatal care, preferences and reasons for choice of place of birth, information needs during pregnancy, expectations of baby feeding, and preparations for labour and childbirth. Themes explored postnatally included: opinions and experiences of labour management and pain control, baby feeding, and postnatal care both in hospital and at home.

Analysis

Results are presented as numbers and percentages for categorical variables. Differences in proportions were examined with the Chi‐squared test with Yates correction in the 2 × 2 case. A two‐tailed significance level of 5% was adopted. Confidence intervals of 95% are presented where appropriate.

The taped transcripts were analysed thematically and the information obtained used to illustrate (by use of direct quotes) and expand the data obtained from the questionnaires.

Results

Three hundred and sixty‐two women were identified at the booking clinics as eligible to take part in the study. Of these, 31 (9%) suffered a miscarriage or other serious pregnancy problem and were excluded. Of the remainder, 254 (77%) women agreed to take part by responding to the early pregnancy questionnaire, and became the study population. For the late pregnancy questionnaire, a response rate of 83% (210/254) was obtained and for the postnatal questionnaire the response rate was 81% (206/254).

Of the 254 respondents, 151 (59%) women were registered with the Peterhead practice. One hundred and three (41%) women were primiparous and the majority of women, 176 (70%), were aged under 29 years, with 71 (28%) aged under 24 years of age.

Place of booking/birth

At 14 weeks gestation, 57% of women had been given information about delivery at the PMU, and 54% had been given information about delivery at the AMH (Table 1). At this stage, 52% of women were booked for delivery at the PMU, 31% at AMH, 1 for a DOMINO delivery and the others were unsure. Women from one of the rural practices, however, were less likely to have been given information about delivery at the PMU (P < 0.001), and this was reflected in their place of booking (fewer women from that practice were booked in for delivery at the PMU).

Table 1.

 Choice of place of birth

Factors which women reported as having affected the choice of where to have the baby were numerous; however, responses varied according to parity (Table 1). Multiparous women were more likely to base their choice of place of birth on previous experience. Primiparous women, however, were more likely to base their choice on the experience of friends (30 vs. 11%, P < 0.001, 95% CI for the difference: 9 to 29%) and to a lesser extent on the advice of the midwife (29 vs. 18%, P=0.03, 95% CI for the difference: 1 to 22%).

Features which were rated as important about place of birth changed over the antenatal period, with a greater percentage of women rating methods of pain relief and choices in delivery as important in the latter stages of pregnancy (Table 1).

The relationships between preferences for place of birth and actual place of booking and actual place of birth are summarized in Table 2. The majority of women were booked into their place of preference (86% to PMU and 88% to AMH, respectively). Around half (47%) of those who were booked to have their baby born in the PMU, did not finally give birth in the PMU, and mainly delivered in the AMH. The main reasons for these transfers were medical, e.g. problems developed during the pregnancy (49%) or during labour (24%). Postnatally, only four women (3%) felt that the place where their baby was born was not the best place for them.

Table 2.

 Actual place of birth

The antenatal interviews revealed there were a number of factors which influenced the way women made choices about place of birth. For example, previous pregnancy problems meant the option of a subsequent delivery in the PMU was not available, but this was accepted by women:

The decision about where to have my baby was taken following the birth of my previous baby. I am quite happy about that.

The environment at the PMU and the integrated system of midwifery care was a factor which was welcomed by many women and had a positive influence on their choices:

I chose PMU because I would like the midwife I have had all through my pregnancy to be the midwife to deliver my baby. […] After visiting PMU and meeting the staff, I never considered having my baby anywhere else.

However, it was clear from the interview group, that not all mothers were fully aware of the differences in the facilities available between the PMU and AMH. Some women appeared to assume, that being in a hospital, the PMU would offer all facilities and care. For others, the lack of specialist facilities at the PMU was a cause of concern and they found themselves facing difficult decisions:

I am very unsure where to have my baby. Aberdeen has all the facilities available if needed, but PMU is nearer and the atmosphere is more relaxed. […] I would be a lot happier if the same facilities were available at PMU as there are in AMH, to save unnecessary stress during labour if I have to be transferred.

Some women preferred to be guided by professionals with regard to choice of place of booking:

I think you should be willing to listen to take advice from medical staff […] I would rather speak to the consultant before I decide finally.

Lead professional

At 14 weeks, women rated the importance of seeing the same staff at each antenatal visit highly, especially the same GP and midwife, indicated by 93 and 90% of women, respectively (Table 3). The ability to choose which professional to see, was not rated so highly, although women deemed it more important to be able to choose the midwife than the obstetrician (46 vs. 32%, P=0.001, 95% CI for the difference: 6 to 23%).

Table 3.

 Choice of lead professional

The preferred lead professional during antenatal care was shared care between midwife and GP, indicated by 54% of women (Table 3). The relationship between preferences for lead professional and actual antenatal care is summarized in Table 4. Approximately half of the women received care according to their preference (45% for midwife‐led care and 55% for shared care).

Table 4.

 Actual lead professional

Experiences of care did not appear to be affected by type of lead professional, except in relation to feelings of receiving conflicting advice (Table 4). Women were more likely to feel that they had received conflicting advice with midwife‐led care (P=0.02).

The antenatal interviews revealed a number of factors relating to obstetrician involvement in care. Many women were unaware they could choose a particular obstetrician, and many indicated that they had not been given a choice, nor had sufficient information to make such a choice. Others felt if would only be necessary to have a choice of obstetrician if they were not happy with the obstetrician that was allocated. Some mothers had experienced previous pregnancy problems and expressed a desire to see the same consultant for their subsequent pregnancy. The majority, however, expressed the view that obstetricians were equally well qualified and therefore choice was not that important to them. A few women questioned the need to be seen by an obstetrician, as they felt it was not necessary:

The consultant appointment I had was a waste of time. It left me with a complete lack of confidence in them. I felt he was not interested in me because I was not a special case. […] I think consultants are better to see women referred to them who have the possibility of problems rather than seeing everybody.

Women expressed similar views about choosing a midwife. Many were happy to be seen by any midwife, but some did acknowledge that there were some midwives they felt happier with than others. For some women, being able to get on well with their midwife was viewed as more important than being able to have a choice.

Labour management

At 36 weeks, the majority of women, generally over 80%, had received information on different methods of pain relief (Table 5). Despite this, a sizeable percentage of women would have liked to have known more, especially about natural methods such as massage, breathing, and the role of different positions (40, 37 and 37% of women would have liked more information about each method, respectively).

Table 5.

 Labour management

Having their partner there, availability of specialist facilities, being kept informed and being involved in decisions were seen as the most important factors when preparing for labour and childbirth (indicated by 89, 65, 58 and 53%, respectively, at 36 weeks) (Table 5). Of those who indicated prior to labour that having their partner there was important, 91% actually had their partner present during labour. Similarly, of those who identified the availability of specialist facilities as important, 66% delivered in the AMH; and of those who highlighted the desire to be kept informed, 89% of mothers indicated that they had indeed been kept informed during labour. For the 21% of women who indicated that it was important to them not to be left alone, however, 75% of them were left alone for at least some of the time (of whom a fifth (21%) were worried at times and two women were worried all the time they were left alone).

Discussion

This study examined the views of local women in an attempt to inform the development of consumer‐led maternity services in the Peterhead locality of the north‐east of Scotland. A key component of the study was that it sought to involve all stakeholders in the provision of maternity services in the area. A multi‐disciplinary project group, which included user representation discussed and agreed the project aims and the group was involved in all stages of discussion of the project findings, reflecting the ideals advocated in policy reviews and research studies promoting the provision of truly women‐centred maternity care. ³ , 4, 5, ^{–6 , 11}

By taking a longitudinal approach to the study, it was possible to examine women’s choices and preferences and compare them with what actually took place. This approach also allowed us to demonstrate how preferences and opinions changed over time during the antenatal period. Opinion of the importance of factors relating to place of birth can change as pregnancy progresses, with issues deemed important at the start of pregnancy not necessarily remaining important at a later stage. In this study, women in later pregnancy attached greater importance to the more medical aspects of childbirth, availability of specialist facilities and choices in pain relief than in the earlier stages.

The findings relating to choice of place of birth revealed that healthcare staff may be selective about the information they give to women about place of birth options. Real choice for women can only be achieved when options for choice are provided. ¹¹ For women to make informed decisions they need to have received appropriate information. At the time of the first questionnaire, around 14 weeks, all women should have been officially booked in for delivery. For an informed choice to have been made, women should have been made aware of the different choices of place of birth and where they were booked for delivery. It is clear that, for many women in this study, this did not happen. Only half of the women had been given the relevant information by early pregnancy, thus their ability to make an informed choice was compromised. In addition, the differences in facilities between the PMU and AMH were not well understood by many women. It emerged from the interviews that many women were not clear about the differences between the two locations. There appeared to be an assumption that both being ‘hospitals’, the facilities in both units would be the same (e.g. women assumed that birth by induction would be available at both locations). Lack of knowledge about the potential advantages and disadvantages of different places of birth has been demonstrated in others studies. ^{12 , 13} The apparent reluctance on the part of health professionals to provide all the relevant information may in part be due to concerns that informed choice may create anxiety. Organizational issues can also create barriers to providing information. ¹⁴ , 15, 16, ^–17 In this study, local influences are also thought to be having an impact on choices of place of birth in the study population. There was a tendency for women registered with the practice to the south of Peterhead, which is nearest to Aberdeen, to be steered towards delivery at the AMH.

It is of interest to note that almost half of the women originally booked for the PMU were delivered in the AMH. The reasons for the transfer from place of booking were mainly due to problems which developed during pregnancy, e.g. bleeding, high blood pressure and problems with the baby’s progress. The transfer rate is similar to rates found in other studies. ^{18 , 19}

Information about pain relief is an area where this study also revealed deficiencies. Pain experience is an issue which is highly individual and the importance of discussing options with women has been stressed. ²⁰ Although many women did receive information about different methods of pain relief, at least a third of women indicated that they would like to have known more about the different techniques. This is also an important factor which can influence choice of place of birth, with the choices in pain relief being more limited in the PMU compared with the AMH. The CRAG/SCOTMEG working group on maternity services revealed that women are anxious about the lack of information about the availability of methods of pain relief. ⁵ It is clearly an issue which needs to be given a high priority in the delivery of antenatal care.

There has been much debate about who the ‘lead professional’ in maternity care should be and how maternity care should be delivered and managed by professionals. ^{18 , 21 , 22} In this study provision of maternity care differed slightly across the three general practices. The responses to the survey revealed that women’s preferences tended to reflect the care they were already receiving. In keeping with findings from other research, ²³ women who expressed a preference for shared care by midwife and GP were more likely to be receiving that type of care. It was encouraging, however, that women’s preferences about lead professional appeared to have been largely met, although interviews revealed that some women were not aware that they could have a choice about who looks after them during pregnancy. Many women commented that it would be difficult for them to make an informed choice if they did not know any of the staff or had no prior knowledge. Overall the involvement of a consultant obstetrician was not highly valued by the women in this study. For some, it was necessary due to pregnancy problems or previous complications, but for the majority the role played by the obstetrician did not feature highly in their antenatal care. It is of interest that, as a result of Scottish research, recent developments in antenatal care protocols in the north‐east of Scotland have concluded that not all women need to receive consultant care during pregnancy, nor as many antenatal clinic appointments, and accordingly recommended antenatal care schedules have been changed. ²¹

Many women having a second or subsequent pregnancy expressed a preference for having the same midwife look after them as in the previous pregnancy or pregnancies. The interviews revealed that women form very close attachments and friendships with their midwife or midwives. Many expressed that they felt comfortable asking questions and reassured by the fact that a midwife was ‘always at the end of the phone’ (PMU is staffed 24‐h per day by midwives). This demonstrates the value of providing an integrated community and hospital based midwifery service.

For the women from the rural practices some dissatisfaction was recorded due to the fact they did not always have the opportunity to ‘get to know’ their midwife. This was due to practical difficulties of covering large rural areas. Midwives were unable to attend all the antenatal clinics, which in some areas were always run by the GP. Although women spoke favourably about their GP, in common with other studies, it was the relationship and the time available to spend with the midwife they valued highly. ²⁴ , 25, ^–26

With regard to labour management, it would appear that women’s choices were largely met with the exception of preferences about being left alone during labour. This is an issue which can be readily addressed by staff involved in providing care during labour, to ensure that women and/or their companions are not distressed by being left alone during labour, even for a short length of time.

To be truly consumer‐led, service providers must take account of the factors which affect their users. In this study, the findings from the project were discussed by the multi‐disciplinary team at a specially organized day‐long seminar. The implications for local practice were discussed and an action plan drawn up to address some of the key findings. Of prime importance was the recognition that women needed to be given clear, accurate information about the choices relating to place of birth options. This information should spell out the differences in facilities and services between the local maternity unit and the specialist maternity hospital in Aberdeen, and should also offer women more information about choices in pain relief. The production of a video tape to introduce women to the PMU and its services, along with illustrated leaflets was also considered.

A further recommendation was that a local maternity care forum be set up. This would be made up of service users and local staff including midwifery, medical and management representatives. It was felt that the setting up of a local forum would enable ongoing access to the consumer perspective on maternity services and would assist in creating a culture of local ownership of the maternity unit and its services amongst a population which is relatively poor at speaking out about healthcare services. In addition, as a result of this study, support groups for local mothers are now operating in the PMU which aim to address other issues identified by the project, e.g. low breast feeding rates.

Whilst the generalizability of the findings of this study in relation to women’s preferences may be limited, especially in populations with a lower use of early antenatal care, we believe that the attributes displayed in this research, especially the involvement of all the stakeholders, from the definition of the research to the implementation of the findings, could lead to greater consumer involvement in service planning in the future.

Acknowledgements

We would like to thank Liz Howard and Janice Paton (midwifery team leaders) for their time and commitment throughout the project. We would also like to thank Anne Mutten for data processing and administrative assistance. Funding for this study was received from Grampian Healthcare NHS Trust; however, the views expressed are those of the authors alone. Finally we would like to thank all the women who took the time to complete the questionnaires and those who agreed to be interviewed.