Women’s birthplace decision-making, the role of confidence:
part of the Evaluating Maternity Units study Aotearoa New Zealand.
Celia Grigg
Rea Daellenbach, Sally Tracy, Mary Kensington, Mark Tracy, Amy Monk and Virginia Schmied
Midwifery and Women’s Health Research Unit
Evaluating primary level, free-standing midwife-led Maternity Units
– Australian (NHMRC) funded Australasian project – New Zealand arm – Christchurch (2010-2012)
– Mixed method prospective cohort study : – Clinical data
– Surveys (6 weeks & 6 months postpartum) – Focus groups
AIMS:
To evaluate any differences in birth outcome for well women planning to give birth in either a primary unit or tertiary
hospital in New Zealand, explore how they choose between and experience these birthplaces and evaluate transfers from
Background
New Zealand’s unique maternity system
• Continuity of care as a core tenet, regardless of planned or actual birthplace.
• Midwives are the primary maternity care
provider (Lead Maternity Carer) for 93.4% of women nationally.
• Women choose their midwife
• 2014: 87.6% of births occurred in a secondary or tertiary hospital, 9.1% in a freestanding
birth units and 3.4% were home births.
Study participants’ demographics
Characteristics Primary n= 407
(%) Tertiary n=
285 (%) p value
Age (mean) 30.8 32.1 0.001
Parity (mean) 1 (0.9) 0 (0.5) <0.0001
Having 1st baby 168 (41.2%) 156 (54.9%) <0.0001 Ethnicity
NZ European Māori
Other
309 (75%) 30 (7) 69 (17)
225 (79%) 6 (2)
53 (19) <0.009
Smoker 31 (7.6%) 15 (5.3%) 0.2
Residence
City or semi-rural
Rural or remote rural 308 (75%)
100 (25) 248 (87%)
36 (13) <0.0001
Closed Question Results – Influence of people How much did the following people influence your initial decision on where to give birth?
– Myself
– Husband / partner – Family (whanau) – My midwife
– My family doctor (GP) – Obstetrician
– Friend(s)
– Closed question - Likert scale
• None A Bit Some A Lot N/A
cc Flickr by Eik Huiberts
People who had “A Lot” of influence on women’s birthplace decision
Myself Partner Midwife Family Friends Obstetn GP
0%
20%
40%
60%
80%
100% 95
43
26
9 8
1 1
89
41
25
9 5 8
2
Primary Tertiary
The level of influence of “My Midwife”
A Lot Some A Bit None
26 29
23 23
25
19 18
Primary 39
Tertiary
Reasons for birthplace choice
Specialist services Confidence in staff My beliefs about birth Other women's experiences Closeness to home Atmosphere, 'feel' of the unit
8%
39%
46%
34%
47%
55%
91%
59%
36%
16%
20%
12%
So... what do well women need to plan to give birth in a Primary Unit?
Safety
Safety was a common theme in the comments from both groups
Primary Unit: “What’s important... ultimately to have a nice safe baby, and if it’s safe and you have it at [Primary Unit], but if you need help and can get to CWH if you need to, then I think that’s the most important”. (FG, Joy)
Tertiary: “The most important thing for me is making sure that baby’s out safely, and if there is some issue then I’d hate to have gambled in my mind the risks of having a nice sort of birth if you like, or a more relaxed situation.” (FG, Meg)
Confidence enabling plan for Primary Unit birth
• P - process
• S - self
• M - midwife
• S - system
• P - place
cc Flickr Carolyn Coles
Confidence
• Confidence is a positive emotion/ belief/
judgement about the outcomes of actions
• Opposite of anxiety
• Differs from faith which is a firm belief (in the absence of tangible evidence)
• Differs from trust (based on an external locus of control)
Process – confidence I
Women who planned to birth in a primary unit expressed confidence in birth process
“… it’s a hospital, which if you are sick or if you’ve had an accident, that’s great, that’s exactly what you want; but I wasn’t sick, I was having a baby – it’s a perfectly natural process that millions of women all around the world have managed to do without nice shiny hospitals” (FG, Ivy).
“I was also confident that there would be no concerns with the actual birth since my first birth went well, so felt I would not need medical back up” (S, 3009).
Process – confidence II
Women who planned to birth in tertiary hospital often expressed no confidence in birth process
“just in case”, “if anything goes wrong” (very common survey responses)
“it is the most riskiest thing a woman can do and the only reason you have such a good survival rate of infants now and their mothers is because of that intervention...” (FG, Nia).
Self – confidence I
Primary Unit group expressed confidence in their ability to give birth
“you feel like, you kind of have some idea that you might be able to, you can do it” (FG, Princess)
“I ended up feeling really good about it … because of that I felt confident, like I was able to do it” (FG, Ivy)
Self – confidence II
Tertiary group did not express confidence in themselves and ability to birth
“I wanted to go to CWH particularly being the first
pregnancy and I hadn’t been in hospital before with any illness or anything, so I didn’t know about allergies or how I would really cope” (FG, Viv)
“I always knew I would go there, because I’m very paranoid and anxious” (FG, Ana)
Midwife – confidence
Both Primary Unit and Tertiary groups expressed confidence in their midwives
Primary Unit: “I felt safe in the hands of my confident
midwives which led to an empowered birth experience” (S, 3023)
Tertiary: “Feeling confident in the care and expertise of my midwife - trust her completely” (S, 3044)
System – confidence
Confidence in the health system, for transfer and access to specialist facilities and staff
Primary Unit: “And like every other woman there is
always an ambulance or a team close by, and I can’t help but think sometimes perhaps people end up in such
emergency situations because they have had all the intervention.” (FG, Sue)
Tertiary: “I just wanted to be somewhere if I needed any intervention it was just down the hallway, not an
ambulance ride away, and for my piece of mind I needed to be somewhere where it was, what I consider safer,
because everything was available for me” (FG, Ana).
Place – confidence
Women from both groups expressed confidence in the intended birth place
Primary Unit: “I felt comfortable as i was confident in the people around me. Just a great place to birth” (S, 3383)
“I’d read a lot as well about being comfortable with your
surroundings, and also you know, having confidence in it, and like then you tend to do a lot better, in the birth.”(FG, Amy)
Tertiary: “Best place to be if anything goes wrong” (S, 3034)
“And I would have in the back of my mind if something happened I’d never forgive myself for not having been in the right place when I
Conclusion
Birthplace decision-making based on beliefs
– Women believe that they are the primary birthplace decision-makers
– Safety central for all
– Midwives may have some influence for women who would consider choosing a primary unit, and much less for Tertiary hospital women (complex context)
– Confidence – Process, Self, Midwife, System, Place
Publications... (open access)
Grigg CP, Tracy SK, Daellenbach R, Kensington M &
Schmied V. (2014) An exploration of influences on
women's birthplace decision-making in New Zealand: a mixed methods prospective cohort within the
Evaluating Maternity Units study. BMC Pregnancy and Childbirth, 14:210. Available at:
http://bmcpregnancychildbirth.biomedcentral.com/art icles/10.1186/1471-2393-14-210
Grigg CP, Tracy SK, Schmied V, Daellenbach R &
Kensington M. (2015) Women’s birthplace decision- making, the role of confidence: part of the Evaluating Maternity Units study, New Zealand. Midwifery, 31, 597-605. Available at: http://
Publications... (open access)
Grigg CP, Tracy SK, Tracy M, Schmied V & Monk A. (2015)
Transfer from primary maternity unit to tertiary hospital in New Zealand – timing, frequency, reasons, urgency and outcomes: part of the Evaluating Maternity Units study.
Midwifery, 31, 879-887. Available at:
http://www.midwiferyjournal.com/article/S0266-6138(15)0 0147-3/pdf
Grigg C, Tracy S, Schmied V, Monk A & Tracy M. (2015)
Women’s experience of transfer from primary maternity unit to tertiary hospital in New Zealand: part of the
prospective cohort study Evaluating Maternity Units study.
BMC Pregnancy and Childbirth 15:339. Available at:
http://bmcpregnancychildbirth.biomedcentral.com/articles /10.1186/s12884-015-0770-2
