1

Do Maternity Policies in the UK, in

practice, enable and empower women to

make informed choices during pregnancy and

childbirth?

A case study in Greater Manchester.

Claire Carey

@00367300

May 2016

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Acknowledgment

After being away from education for sixteen years the concept of me returning to

study at degree level was fraught with fear and a severe lack of self-confidence.

However, this three-year journey has empowered me beyond my expectations and my

success and confidence has grown significantly which will undoubtedly enable me to

succeed beyond graduation.

As a self-confessed ‘Birth Activist’ since having my first child in 2000, I have tailored

many of my assignments to the subject of childbirth. Therefore, to focus on this for

my dissertation and to undertake primary research seemed like a natural progression.

As a result of this research I have been inspired to train as a Doula: a woman who

offers holistic and emotional support to other women during pregnancy and birth.

None of this would have been possible without the support of my programme leader

and informal mentor Karen Kinghorn who has offered me support since I applied for

the degree programme and for the whole duration. My supervisor Professor Louise

Ackers has also been a source of inspiration and has provided me with a wealth of

information and support throughout my second year, my time in Uganda and through

writing my dissertation.

Finally, I have to thank my family. My husband and children who have been there

throughout this journey and my parents who have been an invaluable support both

practically and emotionally.

Thankyou!

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Table of contents

4. Abbreviations

5. Abstract

7. Introduction

9. Methodology

14. Chapter One – Policy Analysis

20. Chapter Two – Literature Review

26. Chapter Three – Research Findings

39. Conclusion

42. References

46. Appendix

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Abbreviations

AIMS The Association of Improvements to Maternity Services

BECG Birthplace in England Collaborative Group

DoH Department of Health

GP General Practitioner

NCT National Childbirth Trust

NHS National Health Service

ONS Office for National Statistics

NMR National Maternity Review

PPH Postpartum haemorrhage

UKCC United Kingdom Central Council for Nursing, Midwifery, and Health Visiting

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Abstract

This abstract offers a synopsis of the research undertaken. Four key subheadings

have been created for clarity.

Background

Childbirth is a life-changing phenomenon and policy development in this area has

evolved since the second world war, most notably, with the introduction of the NHS,

and the change in attitude towards birth by health professionals. The subject has

attracted the attention of academic researchers, and has gathered momentum

through feminist groups over the notion that childbirth has become over-medicalised,

and a victim of the patriarchal society in which we live that has resulted in the

obstruction of choice.

Methods

A phenomenological approach was applied to the study as this is an effective way to

consider the participant’s perceptions. Ten participants were selected using social

media and a snowball method. Each participant was interviewed and the data was

thematically analysed. A policy analysis and literature review was conducted to

collaborate with the primary research and provide a balanced analysis.

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Findings

Ten themes emerged from the data, however, some do interlink with each other. The

key findings identified were; that induction was commonplace without an explanation

or rationale; choice was restricted; information was sought and shared by woman as

opposed to health professionals, and woman are transferring their NHS care to private

midwifery companies.

Conclusion

The Department of Health’s policies on maternity and childbirth are satisfactory in

theory, yet, ineffective in practice. This is demonstrable by the research undertaken

and is corroborated by the discussion within the literature review. Women feel that

they are not taken seriously and are not always fully informed of all the options

available to them during pregnancy and childbirth. Likewise, the use of language is a

powerful tool in gaining control over women by health professionals and is attributed

to women feeling like they do not have a choice. Women are, therefore, taking the

initiative and seeking support and advice from other women and ‘birth groups’, often

via social media, to challenge the health care practices and become fully informed. It

was identified that a growing number of women are also transferring their care to

private midwifery companies who are offering an alternative to NHS care that

promotes a woman-centred approach to birth and facilitates informed choice in

practice.

The following section offers an introduction to the dissertation.

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Introduction

This is where the journey begins and the introduction will inform the reader of what

can be expected throughout. The following quote, from world renowned midwife and

childbirth activist Ina May Gaskin, sets the tone of the upcoming discussion and

epitomises the importance of a woman achieving a ‘good birth’ which is a concept at

the heart of the research.

A society that places a low value on its mothers and the process of birth will

suffer an array of negative repercussions for doing so. Good beginnings make a

positive difference in the world, so it is worth our while to provide the best

possible care for mothers and babies throughout this extraordinarily influential

part of life (Gaskin, 2011).

This dissertation will focus on how women perceive the options available during

pregnancy and childbirth and whether they felt they were equipped with the correct

knowledge and information to make informed choices. To begin with it is important

to provide an historical policy analysis leading up to current policies, in particular,

The Changing Childbirth Report 1993, Maternity Matters 2007, and Better Births

2016, to show what the policy recommendations are and how they have evolved.

At this point it will be necessary to conduct a literature review from within the last

seven years, that corresponds with the time frame of the Maternity Matters Report up

to the present day, to show a contrast with the policy analysis undertaken and

establish any significant similarities and differences between policy theory and

implementation in practice. The literature review will also serve to discuss the claims

made, by AIMS and the NCT, that childbirth has become over-medicalised and the

current ‘system’ does not facilitate choice. This also fits with the feminist discourse.

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Following on, a discussion of the research findings, from the interviews undertaken,

presents a vital element to the whole dissertation as it draws upon the recent

experiences of women in a specific geographical area who have given birth within the

last two years. This enables the dissertation to have a contemporary element and a

third dimension to the dialogue between the policy analysis and literature review

which will certainly strengthen the conclusion and subsequent recommendations.

The concluding part will determine how the participant’s perceptions correspond with

the literature review by considering how government policies have been implemented

in practice. Furthermore, appropriate recommendations will be made to ensure that

all women are able to make informed choices and achieve a positive birth experience.

The following section will focus on the research methodology.

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Methodology

This section underpins the research that has been undertaken, in chronological order,

focusing on the whole journey; from obtaining ethical approval, to conducting

interviews, the subsequent analysis and findings, and the research limitations.

Ethics

Before I could carry out any research I required full ethical approval. Therefore, I

referred back to my research proposal, consulted the University of Salford guidance

and liaised with my supervisor to ensure I had met the criteria before I submitted an

application in October 2015 (App, 74-81). However, after a four week wait my

application was rejected. The main basis for the rejection was a lack of clear rationale

for the research, and limited aims and objectives. The remaining issues surrounded

administration and required closer attention to detail on how to safely store data to

assure anonymity. One particular ethical issue was raised about the selection of

participants. It was recognised that some women may be vulnerable if they had

recently given birth. Therefore, I made the decision that only those who had given

birth at least six months prior to December 2015 would be suitable participants.

I immediately sought to address the concerns raised by concentrating on each issue

individually and explicitly detailing what changes had been made. I submitted a

revised application which, after a two week wait, was approved without the need for

further amendments (App, 46-61).

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Participants

A phenomenological approach was adopted for this research, which focuses on the

participant’s perception of their experiences as opposed to the views of others. Once

ethical approval was confirmed I began to advertise, initially on social media, for

participants. I placed an enquiry in four online parenting groups in the Greater

Manchester area and two women responded immediately asking for more

information. A snowball method took force and the remaining participants were

identified through word of mouth and information sharing. I received an

overwhelming response, via email, from over twenty women asking for more detailed

information. I sent each of them a participant information pack (App, 62-73) which

included in-depth material, a general set of guide questions, and a consent form

should they wish to participate. Ten women returned their pack and agreed to

participate. The eligibility criteria for each participant was that they had to have given

birth between January 2014 and June 2015. Children who were born prior to 2014

but after 2008 would also be included in the research as they fell within the policy

timeframe: since the introduction of ‘Maternity Matters’.

Data collection

Qualitative research was undertaken by conducting informal interviews with each

woman lasting between sixty and ninety minutes. Four pre-set questions were sent

to each woman, as a guide, so they would be familiar with the information I would be

seeking. However, each interview progressed naturally and the dialogue flowed

without the need to refer to the questions. Each interview was recorded using a

Dictaphone. Qualitative research enabled me to gain a deeper insight and

understanding into each woman’s experience as opposed to quantitative research

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which would purely be statistical and unable to probe into women’s experiences.

However, secondary research has been used to offer statistical evidence where

appropriate and to support the empirical work.

Data analysis

Before the participants had been identified it was decided that general questions

would be used as a guidance tool only and each woman would be encouraged to

speak openly, from the heart, without interruption about their experiences of

childbirth. This was an appropriate way to conduct the interviews and is demonstrable

by each of the proposed questions being answered, without prompting, which

maintained the natural flow of the dialogue. As the interviews progressed, and before

the formal analysis had begun, themes were being identified. I transcribed each

recording with the assistance of voice recognition software and I immediately deleted

the recordings to maintain anonymity. Each transcription was anonymised so the

participant could not be identified. I undertook a training course on how to use NVIVO

software which assisted me in thematically analysing the data. Eight clear themes

were identified and the relevant quotes and discussions were separated into each one

to ensure clarity and accuracy when writing the research findings. These themes were

strengthened and further narrowed down into key arguments which have formed the

basis of the overall findings. Although the main part of this dissertation is the

qualitative research it is imperative to include a policy analysis and literature review

to provide a comparison and to support the experiences of the participants by way

of peer reviewed academic articles, thus, strengthening the main body of the research

which will be evident within the conclusion.

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Research Limitations

Upon reflection, there are unavoidable limitations. In particular, due to time

constraints, it was not possible to select participants over a longer period of time

which may have resulted in a more diverse range of participants who had significantly

different experiences to each other. It is likely that the snowball effect played a part

in a large number of women having similar experiences, such as; transferring their

care to a private midwifery company. This was not realised until each woman was

interviewed as their experiences were not discussed until then. However, it would

have been inappropriate to ask women about their experiences beforehand as this

could be construed as being self-selecting. If the research was undertaken again, over

a longer time period, then it would be possible to use a considerably larger sample

size which may result in the research being more representative of women as a whole.

Sample Characteristics

The following table shows the characteristics of the selected participants: year and

place of birth. ‘121’ is the abbreviation of One to One midwives, a private midwifery

company. Some of the sample did have other children, however, they were omitted

from the research as they were not born between 2008 and 2015: the identified time

period to coincide with the policy, Maternity Matters, up to the present day. When

referring to a participant, during the chapter on research findings, they will be

identified by their number, such as; (01).

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Year Place Year Place Year Place

01 2015 Hospital

02 2012 Home 2014 Home121

03 2011 Hospital 2014 Home121

04 2012 Hospital 2015 Hospital

05 2008 Hospital 2015 Home

06 2013 Hospital 2014 Home121

07 2011 Hospital 2014 Home121

08 2015 Home121

09 2010 Hospital 2014 Home121

10 2011 Hospital 2012 Hospital 2015 Hospital

The following chapter provides an analysis of maternity policy development from the

second world war to the most recent guidelines.

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Chapter One. Policy Analysis

This chapter provides a historical background, and the development of maternity

policies in England up to the present day. This section is particularly important as it

affirms what role the government has, and who has influenced policy development.

It also offers guidelines and a theoretical overview of what woman should expect

during pregnancy and childbirth.

Following the introduction of the NHS, in 1948, a renewed interest in maternal health

and well-being ensued (Oakley, 1984). Consequently, the availability of universal

health care for all was seen to be the driving force in an increase in hospital births

and the rapidly declining rate of maternal and infant mortality that had previously,

pre-war, been 40 in 10,000 and 170 in 1000 respectively (Walton & Hamilton, 1995).

However, regardless of this progress there remained a distinct lack of forward

thinking over maternity care and the responsibility for care was now part of a

complicated, multilateral, system that involved hospital services, GP’s, midwives, and

public health services such as ante-natal and post-natal clinics (Davis, 2013)

The first review of maternity services occurred in 1959 and was conducted by the Earl

of Cranbrook in response to an inquiry over the cost of the NHS which had highlighted

the complexity of maternity care provision. The Cranbrook Report 1959

recommended that seventy percent of births should now take place in hospital and

the remaining thirty percent were deemed to be low risk and therefore able to give

birth safely at home (Walton & Hamilton, 1995). However, the medical community

disputed these figures and argued in favour of all births taking place in a hospital

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setting due to the advancement in obstetric knowledge that had subsequently

regarded, an increasing number of, women as ‘high-risk’ (Davis, 2013).

The recommendations of The Cranbrook Report formed the basis of the next report

on maternity services, in 1967, which was undertaken by consultant obstetrician John

Peel. The resulting proposals, of The Peel Report 1970, were that one hundred

percent of births should now take place in hospital, as it was considered to be the

safest place, and it was this report that caused a significant shift from home births

to hospital births over the following decade (Davis, 1981). However, this report

attracted substantial criticism over the absence of evidence in support of his claims

and that women had not been consulted with over their own experiences and what

they deemed to be necessary during childbirth (Oakley. 1984). It was this report that

stimulated a response from recently formed pressure groups such as AIMS and NCT,

who began to campaign on behalf of women over their right to make informed

choices in their pregnancy and birth (Davis, 2013; Walton & Hamilton, 1995).

After the Peel Report the Maternity Services Advisory Committee was set up by the

Government and produced three influential reports: Maternity Care in Action Part 1,

1982; Antenatal Care Part 2, 1984; and Care during childbirth Part 3, 1985. The

guidelines within these reports re-enforced, as per the recommendations of The Peel

Report, that hospital births were the safest place and were consequently adopted by

Maternity Service Liaison Committees, Heads of Midwifery Services, Health

Authorities, and Obstetricians as a common goal in improving Maternal care.

However, the alternative view of decreasing medical intervention in childbirth and

empowering women to become actively involved in their care was gathering

momentum amongst many health professionals who were citing the inaccuracies

within these reports. Most notably, statistician, Marjorie Tew (1990) argued against

the suggestion that the decline in maternal and infant mortality was directly linked

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to the increase in hospital births and was, in fact, due to the overall improvements in

women’s health and called for further analysis and for birth to be recognised as much

more than a medical process that is only concerned with the final outcome. Likewise,

whilst safety may be paramount, becoming complacent over the idea that hospital is

one hundred per cent safe is inaccurate and counterproductive. Tew (1990) argues

that Health care professionals should be equally concerned with a mother's social and

emotional needs during pregnancy and childbirth and by educating them over the

choices available will empower them to make informed decisions (Kitzinger, 1991;

Walton & Hamilton, 1995).

Moving forward, Government Policies were slow to respond to the findings of the

aforementioned reports undertaken between the 1950s and 1980s. It was another

ten years, in 1991, before further action was taken when they set up a select health

committee that would probe into maternity services (Davis, 2013)2. It is important to

note that the NHS and Community Care Act 1990, amongst other health care reforms,

came into force at this time and at the forefront of this legislation was to enable

patient choice and autonomy within health services and for greater user participation

in the decision making process (Glasby, 2012). The select committee, unlike its

predecessors, consulted, and gained evidence from many individuals and

organisations including; mothers, midwives, and the UKCC. The final report, entitled

‘The Winterton Report’ 1992, considered the views of mothers alongside statistics

and testimonials from health professionals and produced a six-part set of

recommendations for the future of maternity services (DoH, 1992). The report

detailed the negative aspects of maternity care by including criticisms of the over

medicalised reports constructed previously. Furthermore, the lack of government

policy intervention up until this point sent the far-reaching message that to achieve

a positive outcome for mother's and baby's then it was equally important to draw

upon the skills of midwives, obstetricians, and paediatricians as it was to improve the

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dialogue between mothers and health practitioners. This would be possible by

ensuring that services are adapted to acknowledge the needs of individual women

and child and not the other way round (Walton & Hamilton, 1995).

In response to the Winterton Report the government agreed with many of the

recommendations and that changes were necessary. It was from here that The Expert

Maternity Group was established and marked the beginning of significant changes.

Therefore, as a consequence of The Winterton Report, The Changing Childbirth

Report 1993 was commissioned by The Expert Maternity Group and Baroness

Kimberlee and was the first Government policy that attempted to revolutionise

maternity care and practice in the UK. The core emphasis of the report was to promote

choice, control, and continuity of care through seven action points (DoH, 1992):

Accessible services – balance achievability and women satisfaction

Information giving – deliberate appropriate methods of delivery

The named midwife – consider the expectation of women and midwife

Lead professional – implications for women and professionals

Making choices – recognising social, cultural and professional factors

Flexible systems of care – ensuring effectiveness and efficiency

Place of birth – considering individual choice and the implications

Today, the recommendations of the 1993 report are as relevant as they were twenty

years ago when the report was published. However, according to Professor Mavis

Kirkham, who was speaking at a Royal College of Obstetricians and Gynaecologists

seminar in 2013, the 1993 report, whilst having a profound effect on the rhetoric,

has not had a significant effect in practice and still required further advancement

(McIntosh & Hunter, 2014).

The Changing Childbirth Report was instrumental in the subsequent reports at the

turn of the twenty first century, although very few of the recommendations had been

put into practice, which resulted in the development of The National Service

Framework for Children, Young People, and Maternity Services (DoH, 2005); the

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report, entitled, Making it Better: For mother and baby, and Maternity Matters

(Shribman, 2007). Many of the points raised within these reports were carried forward

as equally relevant. However, the emphasis of the Maternity Matters report was to

ensure that the recommendations were being carried out in practice by the health

care professionals. Furthermore, the report was sanctioned to reflect upon

suggestions that women were pressured to use a hospital setting, thus, they were not

being empowered or enabled to make choices (Stephens, 2004). Likewise, childbirth

was becoming increasingly medicalised and often resulting in unnecessary

interventions (Cheyney, 2008). Therefore, Maternity Matters, made a commitment to

guarantee choice to all women. (DoH, 2007):

Choice of how to access maternity care: through the GP or direct to the

midwives.

Choice of type of antenatal care: midwifery, or Obstetrician led.

Choice of place of birth: at home, birth centre, or in a hospital.

Choice of postnatal care: at home, or in the community.

Since the introduction of Maternity Matters, there has been a change in government

which has brought about a renewed interest in maternity and further policy

developments. In 2010, Midwifery 2020 – Delivering Expectations, was collaboratively

commissioned, for the first time, by the Chief Nursing Officers of England, Ireland,

Scotland and Wales. The programme begins by recognising the achievements already

made since The Changing Childbirth Report and then sets out its aims and objectives

towards the challenges and opportunities for the professional development of the

midwives’ role during the next decade to ensure quality of care (DoH, 2010). The

focus remains on achieving positive outcomes for mothers and babies, by also

managing their holistic and social needs, and it is recommended that these outcomes

are measured by gaining feedback directly from women (Kent, 2010).

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The final policy development ‘Better Births’ was published in February 2016. This

initiative was commissioned by Baroness Cumberlege who was instrumental in The

Changing Childbirth Report and depicts a clear vision for the future (NMR, 2016):

Personalised care – genuine, informed, unbiased choice, control of budget.

Continuity of care – each woman is linked with a small team of midwives.

Safer care – working across boundaries to ensure rapid referral.

Better postnatal and perinatal mental health care – increased funding.

Multi-professional working – information sharing between maternity health

professionals.

A fair payment system – that compensates providers for providing excellent

care whilst adhering to the commissioner’s guidelines of; personalisation,

safety and choice

This up to date review of maternity services in England recognises that the quality of

services is not consistent across all NHS trusts and that there has been an increase in

litigation over negligence. The report has received input from health professionals,

women, and the third sector and has an ambitious vision that aims to revolutionise

maternity services once again (NMR, 2016). However, as this is a very recent review,

an analysis in practice will not be possible, thus, for the purpose of this dissertation,

its proposals will only be taken into account with regards to any future

recommendations as part of the dissertation conclusion.

The following chapter will review literature relevant to the policies and

recommendations that have been discussed in this chapter, in particular, Maternity

Matters 2007 and Better Births 2016.

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Chapter Two. Literature Review

The rationale behind this chapter is to deliberate the perceived link between the

increase in hospital births, the medicalisation of childbirth, and the lessening of

choice for women. In order to do this there will be a discussion from a feminist

ideological viewpoint before a brief historical and statistical overview of maternity

settings is provided. An analysis of current and relevant literature on the subject will

follow. The policy focus for this literature review will be from Maternity Matters 2007

up to Better Births 2016 and will consider whether women have been empowered as

the former suggests and what the future may hold according to the latter.

Birth is, arguably, a Feminist Issue and women are often seen as victims of their

biology (Pascall, 1997). It could be argued that the future generation of women may

be uninformed, and unfamiliar with the concept of a natural physiological birth and

unaware that it can be safer than a surgical birth. They may fear a natural birth which

could cause them to make irrational decisions and clamour for surgical intervention

without fully understanding the risks that come with it to themselves and their baby

(Gaskin, 2009). Paradoxically, this is the direct opposite to what feminists believe in

and have campaigned for. In particular, second wave feminists, from the 1960s

onwards, sought to reclaim their bodies from male control, most notably, from a male

dominated medical profession, who had largely influenced the development of

obstetric knowledge, which then influenced policy and practice over pregnancy and

childbirth (Shilling, 2010). Furthermore, there is a biological assumption that women

are the natural carers of children, yet, the historic idea that women require a man to

make decisions on their behalf and are unable to think for themselves has been

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reinforced during pregnancy and childbirth when a woman’s knowledge and

understanding of her body is dismissed (Abbot et al, 2005).

To further illustrate the feminist idea, for centuries, childbirth was primarily the

concern of women, and births took place at home, attended by female friends,

relatives, and neighbours who had experience of delivering children. By the 1940s,

through the introduction of the NHS, and with the majority of the decision makers in

healthcare being male, birth in a medicalised hospital setting started to become more

commonplace (Oakley, 1984). Subsequently, the rate of homebirths has rapidly

declined and has not risen above five percent since the 1970s (Macfarlane, Mugford,

& Henderson, 2000). This decline is illustrated by the following graph (ONS, 2013).

It is important to note that a homebirth, for low risk women, is as safe as a hospital

birth, if not safer, and the overall outcomes for mother and baby are positive

(Kitzinger, 2012). This is supported by The Birthplace Study, from 2008 to 2010,

which found that planning a homebirth can lower the risk of a caesarean section,

induction, an assisted delivery, and post-partum haemorrhage. Additionally, the

research suggests that there is an increase in skin to skin bonding and the successful

initiation of breastfeeding (BECG, 2011).

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When considering birth to be a natural physiological state, put simply, a woman in

labour has seven basic needs (Erhardt, 2011):

To feel safe

To leave the neo-cortex, the thinking part of the brain, switched off

Silence

Darkness or low lights

Warmth

Not feeling observed

No adrenaline

When these needs are fulfilled they enable a labouring woman to release oxytocin

which causes the uterus to contract during labour. If a woman is disturbed in any

way, or does not have one or more of her needs taken care of, then her labour will be

hindered, thus, the environment she is in and the people around her are paramount

to meeting these needs and ensuring that medical intervention does not become a

consequence of her disturbance (Erhardt, 2011; Gaskin, 2003). Whilst medical

intervention may be necessary, at times, it should not form part of the natural

progression of labour for the majority of women as it can result in further

intervention, a traumatic birth, and a fear of further childbirth (Kitzinger, 2012).

Moving forward, women are able to reclaim their bodies during pregnancy and

childbirth by exercising their right to make informed choices; which is supported by

Maternity Matters (DoH, 2007). However, many women have become conditioned to

think that hospital birth and intervention is the norm and is the safest option, this

idea is often perpetuated by health professionals, also, within the media, and on

television programmes (Bellaby, 2001; Maclean, 2014), such as; One Born Every

Minute (Otley, 2012), thus, making the right decision can place immense pressure

upon women (Davis, 2003). Women, consequently, do not expect to be given a choice

in the place of birth (Devries, Salvesen & Weigers, 2001). Yet, there is little evidence

to support the notion that a hospital birth is safer than a homebirth (Savage, 2007).

In fact, there is a higher risk of post-partum haemorrhage if a woman gives birth in

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hospital compared to a home birth (Nove, Berrington, & Matthews, 2012).

Furthermore, there is the presumption that whatever a woman is told by a medical

professional will be unbiased and in their best interest, as they are more

knowledgeable and qualified, similarly, research has shown that the language used

by health professionals can be authoritarian which may leave a woman feeling as

though they are unable to challenge them and to just go along with what the Doctor

or Midwife says (Edwards, 2008). This, traditional, ‘Doctor Knows Best’ mind-set is

argued to be deep-rooted within a patriarchal society and without a significant change

in behaviour from health care professionals the ‘illusion’ of choice will unfortunately

remain (Lupton, Peckham, & Taylor, 2009)

Continuing on the theme of ‘Doctor Knows Best’; very often, the Doctor or Midwife

will justify their actions by stating that they are acting in the best interest of mother

and baby and they adopt the stance of ‘Better Safe Than Sorry’. For instance; when

explaining to a woman why they want to induce them they may say that it is better to

begin induction before a certain point in gestation just in case the placenta fails (Hart,

2004: Reed, 2010). However, the risks are often exaggerated to fit with their own

agenda and management of labour, and are not easily quantifiable. Furthermore,

there is often very little discussion on the potential risks of induction itself for mother

and baby (Lothian, 2012). These include; emergency caesarean section, and shoulder

dystocia, although, this list is not exhaustive (Hart, 2004). Research suggests that

Doctors make a conscious decision to adopt this approach as it can reduce the ‘risk’

of litigation, yet, this too is argued to be exaggerated (Cartwright & Thomas, 2001).

It is important for women to be informed about risks, however, it is equally important

to be aware that birth, like many other aspects of life, is not risk-free, it is about

calculating the risks which can only be done when fully informed (Lothian, 2012).

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Consequentially, when a mother is respected, has control, and is fully informed, she

is more likely to experience a ‘good birth’. This is regardless of whether her birth was

natural at home, an assisted delivery, or a caesarean section. Birth is often

undervalued and not recognised as an emotional process which can have negative

repercussions if a woman feels that her birth was anything less than a positive

experience. Instead, medical care should be empathetic, and communication is

crucial (Talbot, 2014). Likewise, whilst there should be an emphasis on baby being

well, at birth, this should not be ‘all that matters’. Dismissing a woman’s claim to

have had a poor birth experience is reducing her experience to an insignificant event,

something to get over. However, for many women, this experience, good or bad, can

stay with them for a long time and have a direct effect on their well-being (Henderson

& Redshaw, 2012).

To conclude, if birthing at home is a safe option, and can result in less intervention

and overall better outcomes for mother and baby, and women truly have a choice in

their place of birth, then further research is necessary to establish what influences

the majority of women to opt to give birth in hospital (Gardner, 2015). The,

aforementioned, ‘illusion’ of choice seems to play a crucial role in this as there would

surely be a higher proportion of women opting to give birth at home if they were fully

informed (Crossley, 2007; Hadjigeorgiou et al, 2012). Moving forward, one of the

recommendations of The NMR report, Better Births 2016, could be interpreted as a

positive step forward. A woman who is able to devise an individualised care plan is a

clear way of being in control, likewise, having control of their own personalised care

budget should also enable them to exercise their right to choose the most

appropriate setting that suits their needs. In both situations, women will receive

unbiased information so that they can make an informed choice (DoH, 2016).

However, at the moment this is purely theoretical, as the policy has had little time to

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be implemented in practice, and will require in-depth research analysis to take place

before conclusions can be drawn over its effectiveness.

The following chapter will focus on the qualitative research findings and will

incorporate elements of the policy analysis and literature review to provide a contrast.

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Chapter Three. Research findings

This chapter will concentrate on the thematic findings of the empirical research which

will be identifiable by subheadings. Each theme will be analysed in contrast with the

policy analysis, and literature review to provide a coherent and evidence based

discussion.

The concept of a good birth

The quote, used in the introduction, considered a health professional’s

understanding of the concept ‘A Good Birth’. Each woman who participated in this

research gave their personal thoughts on this concept and their responses truly

encompasses the heart of this research; in terms of what woman expect during

childbirth and, in contrast, what they experienced in reality. The general consensus

was that a ‘good birth’ is personal to the woman:

As long as it feels good to you, a caesarean section, assisted delivery, at home,

unassisted, trussed up to machines, if it feels right to you then it’s a good birth

personally is what I think. Some women want to be a patient, some don’t. It’s not

a case of one birth is better than another (03).

Furthermore, a common thought was that being empowered and experiencing a

natural birth was an important aspect of a good birth and is also the start of the

journey into motherhood:

Generally, one where you are informed, empowered. Being pregnant can be the

beginning of a journey where you can find skills that you will use throughout

your life. Personally, it being natural, the way it is supposed to be, unless there

is a need for medical intervention. I don’t see birth as the end of pregnancy, it’s

the beginning of being a mum so it matters for breastfeeding, it matters for

mental health, it matters for the family unit (08).

27

The good birth concept sets the tone for this dissertation and maintains the focus

upon women; their perceived perceptions, and their experiences. As per the policy

recommendations, in Maternity Matters 2007, women are encouraged to be involved

in choosing their place of birth and to make their own choices to ensure this is

achieved.

Birth choices and plan: homebirth

However, what a woman believes is necessary to achieve a good birth is not always

experienced in practice. The process of birth begins when a woman finds out she is

pregnant and is booked in with a midwife. It is at this point, that the first discussion

over choice takes place (Beech, 2014). A key choice is the place of birth; and it is the

European Human Right of every woman to choose where to give birth (Eggermont,

2012). A woman may have a clear idea in her mind that she would prefer a hospital

or a homebirth, however, some women may have given this little thought and,

therefore, rely on the midwife at the booking in appointment to discuss this with

them. Six of the women, that were interviewed, reported that a hospital birth was

assumed and the only option available was which hospital in which to give birth in

(01, 03, 05, 06, 08, & 09).

Furthermore, when four of the women expressed that they would like a homebirth

the immediate response was cautionary in one case:

I went to my first appointment with the midwife who wanted to know about my

previous pregnancies, I told her one had been a haemorrhage and both had had

pre-eclampsia, she said ‘oh I won’t offer you a homebirth then and I said ‘well,

actually’. She said she couldn’t guarantee anything as it depends on what

happens but would reassess at 36 weeks which I felt was a bit late but it is when

they do the usual home birth checks. I was never told I couldn’t have a homebirth,

it was a wait and see approach which I was fine with. I was ‘hoping’ for a

homebirth (05).

28

In another case it was instant dismissal:

The midwife was pro-homebirth until I spoke about my previous birth and

haemorrhage, her attitude changed, told me ‘you can’t have a homebirth’. The

midwife turned to my husband and said ‘what if your wife dies in your living

room and you are left with two children’? I thought my husband was going to

punch her! He still supported me but it shook him up (03).

Consequently, the start of these women’s journeys was on a path of uncertainty. Yet,

for many women this, restriction of choice, is accepted as normal (Lothian, 2008). We

also know, from the literature review, that the risk of PPH is less at home, yet, this

was not mentioned (Nove, et al, 2012). The period between booking in and giving

birth is usually monitored through ante-natal appointments which serve to keep an

eye on the progress of mother and baby and be alert for any potential problems

(Gaskin, 2003). It is also a time for a woman to organise her thoughts and make firm

plans for her impending birth in the form of a birth plan (NHS, 2015). A birth plan is

used by women to express their feelings before they give birth over how they expect

the labour and birth to proceed and often relates to pain relief, position in labour,

place of birth, and more, and is for the midwife and other health care professionals

to fulfil those requests where possible and within their clinical boundaries (Wickham,

2002). However, a birth plan is often seen to be whimsical and unrealistic and has

lost its value over the years which, in turn, can mean that women are not having their

thoughts recognised or acknowledged (Kitzinger, 2012):

I did find it strange when you get the emails from the NHS saying to think about

a birth plan. I asked the Midwife about it and she said yeah, make a birth plan,

go and have a look on line, there wasn’t really a focus on it and offer to sit down

and talk about these options. She just said to go online on the NHS website, look

at the options and if I did want to discuss any of the options then to go back. I

look back on it and there are things I definitely would have done differently and

looked into more. I know funding is really tight and they have to keep things to a

minimum but I definitely think this could have had more discussion and more

support from midwife (01).

29

Furthermore, it seems that the emphasis on making plans is a non-committal, wait

and see, approach which may suit the health professionals but it could be argued that

this is not listening to a woman and allowing her to discuss the many options

available to her and to make informed choices before the birth (Kitzinger, 2012).

The midwife asked for my wishes, I got information from them but still felt I

needed to do my own research. When information was given very little was given

with an explanation. At the moment women passing onto other women seems to

be the common way. Empowering each other. Health professionals are offering

information but not necessarily anything to back it up with and not all women

will know or think to look into it further (05).

Therefore, as woman are not receiving enough information from midwives and health

professionals, they are seeking it elsewhere. The women I interviewed talked about

parenting groups, online and offline, where they could ask other mothers about their

experiences of childbirth and seek advice. Two of the women said:

At the moment women passing onto other women seems to be the common way.

Empowering each other. Rather than believing everything a Doctor says. We are

challenging practice and opinions. Although, stories are often anecdotal, its

knowing we have a choice either way (05).

Other women can be a good source of information. Especially as part of positive

birth groups, there are plenty of places to go and get support from women, both

professional and personal. Women who are passionate about natural birth and

women being empowered. Women empowering Women (08).

However, anecdotal evidence cannot replace evidence based research, yet, without

health professionals providing it then women are going to seek advice and validation

from whomever they can and other mothers may be the next best way. Although, in

contrast, one women felt that midwives would not necessarily be unbiased even if

they were to provide the information:

30

I have learnt that nothing is black-and-white and very often opinions are given

based on the midwives own personal experience and I felt it was my responsibility

to research and get unbiased information. We don’t want the midwives to

pressure women to have a homebirth if they don’t want one but they should

support it and give information so they can make an informed choice (02).

Induction and the potential impact on the mother and baby.

Another significant theme was the subject of induction. This has been a particularly

harrowing part of their experience for some of the women and comes at a time when

a pregnant woman is at her most vulnerable (Wickham, 2014). She can be coerced

into a process that she either did not want to happen or did not fully understand the

risks, or the potential impact on the birth, and on her emotional well-being afterwards

(Jomeen & Martin, 2008). This was familiar for one participant whose baby had

difficulty breastfeeding after the birth:

No information was given to me; I was just swept along with it. They just told me

I would put on a drip. I wasn’t aware of the after effects. I have since learned

that there is a link between induction, antibiotics, and breastfeeding (04)

Likewise, the following two participants were coerced into being induced without

being fully informed:

Induction was being pushed on me. The only reason for induction was guidelines,

no known medical reason. I was never made aware of the risks of induction.

Intervention breeds intervention (07).

One week and half before he was due they said ‘we will induce you’ There was no

mention of what can happen if you are induced to early. But I learned afterwards

(09).

Inducement of labour occurs in twenty-five percent of births (NCT, 2015) and

although induction is common practice and may be necessary for a woman in some

circumstances such as: foetal distress, the consequential risks are ignored and,

instead, the induction of some, otherwise fit and healthy women, fits within the

31

medical model of childbirth and is a way to manage the process to suit the health

professionals (Gaskin, 2003: Kitzinger, 2012).

Birth as a process

Emerging from the theme of induction was the idea that giving birth is a set process:

Once you were in and being induced, you become their property, you cease to

exist, you’re on a conveyor belt (03)

Once you start, you’re on a timescale, if nothing much happens after one pessary,

they will do another one, it’s a process (05)

Policies have tried to make birth into a process. You can’t dictate how labour will

progress. Milestones are expected to be hit but it doesn’t work like that. The

process of birth has evolved negatively (10).

It is not uncommon for birth to progress this way and for women to be on a timescale

before the next level of intervention is applied. This has been described, by the

participants, as being like a conveyor belt and allows the health professionals to

remain in control (01.03.05 &10). Yet, as mentioned earlier, interfering with a natural

process can cause complications for mother and baby (Jomeen & Martin, 2008).

Risk: experience of complications and Trauma.

Continuing on the theme of complications; there was a recurrent theme, throughout

the research, on risk and the potential complications. It is important to note that all

of the women who were interviewed had given birth when they were classed as full

term gestation, between thirty-seven and forty-two weeks (NHS, 2015) so a premature

birth is not part of the analysis and outcome. How can a woman be aware of potential

32

complications without being fully informed? Instead, women are told very little which

may cause fear as the pregnancy progresses:

Health professionals can play on the fear of not knowing what may happen.

Consultants are often looking for something to go wrong, like pre-eclampsia, and

presuming things will go wrong, which can cause unnecessary anxiety, for

instance, baby showing as large on scans can make a woman fear birthing a

large baby and the baby is born smaller than predicted (05)

Additionally, the risks are not always quantifiable and are just used, again, as a way

for health professionals to remain in control and assumptions are often made as to

how the pregnancy and birth will progress. One particular participant had two

previous hospital births due to pre-eclampsia so it was assumed that her third would

be the same:

One of the male consultants made a comment ‘when you get pre-eclampsia again’

and I came out and broke my heart to my husband. I didn’t want to hear that.

They were doing regular growth scans as my first two were low birthweight and

there may be a link between that and pre-eclampsia. I was being scanned every

two weeks. I still wanted a homebirth even if they were small, both previous

children were fine despite being small, and they were induced at 38 weeks so

their weight is surely linked to that! (05).

Yet, she exercised her right to choose, and made an informed decision to have a

homebirth, despite the consultant citing the risks, and she went on to achieve the

birth she wanted, safely (05).

A participant on her fifth baby was told that she could no longer give birth on the

midwife led unit due to the risk of complications. However, after challenging the

decision, it was decided that there was currently no reason why the option should be

removed:

33

It came down to risk factors: I was over 40, family history of strokes, I was an

ex-smoker, 5th baby. So I was given the option of two hospitals. I challenged this

decision and went to see the chief gynaecologist, who checked me, looked at my

history who agreed with me and couldn’t see why I couldn’t give birth on the

birthing suite (10).

However, one participant felt that the issue of risk was more about the risk of

litigation for the health professionals and argued that if women were more informed

then there would be less pressure:

There is a blame culture so doctors may be concerned about being sued so do

everything, ‘just in case’ if the fear wasn’t there, the care would probably be

better. And if people were more informed it would less pressure on services (04).

Whilst it is important to recognise that some births may be complicated, the risk

should be calculated and the mother involved in the process so she can determine

her options (Beech, 2014). As mentioned in the literature review, it is not simply

enough to just go along with ‘Doctor Knows Best’, just in case.

The language used by health professionals.

Referring back to the ‘Doctor Knows Best’ mentality, in the literature review, it is

further evident, from the women interviewed, that when discussing their impending

birth, health professionals often use language that can increase fear and worry:

I explained to the consultant that I was having panic attacks at the thought of

going into hospital again. She said: “this is what I think should happen, I want

you on the consultant ward, a needle in the hand in case we need to give you

stimulating drugs, no pool” Which part of that me saying I didn’t want any of that

did he not hear (09).

Furthermore, some of the comments made were not constructive at all and just plain

hideous:

34

Things may be fine in the morning but not by the evening, baby could die which

would be very sad (07).

If we don’t get this baby out I am going to cut you, I’m going to cut you” and I

remember thinking I didn’t want any of this. I was put on the monitor, everyone

was panicked, no-one explained why. Baby wasn’t in distress. It was hideous.

They made me get on my back and telling me how to push (07).

These are women, in labour, and their experiences are real, emotional, and could be

tantamount to bullying if this was experienced in any other setting. One participant

refused to accept how they were being treated and challenged her care givers:

I was told by the doctor, at one point, that I was not pushing efficiently and if I

didn’t push properly they would cut me. I told him if they go anywhere near me

then I would kick him in the effing face (10).

The mother, in this situation, did not give consent to the doctor, however, she pointed

out in the interview that first time mothers, or mothers who did not feel confident

standing up to the doctors, may have been cut without their consent if put in a similar

situation (10). Furthermore, some women may be conditioned to think that ‘as long

as baby is ok’ then nothing else matters:

Interestingly, a baby has no legal status until they are born in any other situation

yet when pregnant and it comes to decision-making health professionals expect

a woman to take priority over a baby and of course they should be a priority but

not the only priority (03).

Often, the women were made to feel guilty for challenging the health professionals

and it was implied that they should just get on with it:

There seems to be a mentality of, I don’t want to take the chance; grin and bear

it; just get through it, as long as baby is ok, that’s all that matters (08).

The amount of people who tell me, ‘well you had a healthy baby so it doesn’t

matter’ don’t take away the trauma I experienced, don’t belittle it (09).

35

If a woman has experienced a traumatic birth, then this should not be dismissed. As

mentioned in the literature review, birth is, arguably, a feminist issue (Pascall, 1997).

This was confirmed as true by some participants who also felt that women have to

fight against a male dominated profession and the dominant attitudes of health

professionals:

Women are seen as crazy, Michel Odent, a male obstetrician is taken seriously

when he discusses natural birth and is very respected. Yet, a female counter part

can be ridiculed for championing natural birth (08).

I have become a feminist. Birth is all about telling women what they can and

cannot do. No other area of healthcare would do this (09).

The feminist idea was also challenged by one women who believed that attitudes

towards birth in general need changing:

We become other people’s property in pregnancy, it is a male dominated society.

Men shouldn’t be telling us what our bodies should be doing. Problems should be

dealt with at the time they arise they should not be pre-empted at the start of

pregnancy and treat them a certain way, then if XYZ does happen it justifies their

original actions. Attitudes need changing, it’s just women though, we are just a

species we are subordinate. Birth is a feminist issue but it shouldn’t be its just

birth (03).

Consent: being in control and being controlled

When considering the experiences of the participants and the language used by

health professionals, there is a pattern of behaviour evolving whereby women are

losing control of their experiences and instead being controlled:

I didn’t feel in control in my first pregnancy, especially during labour and birth.

I didn’t know what was going on, scared and went into my own little world. I was

pushing even when there were no contractions (04).

36

I wasn’t frightened about giving birth, I was frightened about losing control again

(03).

There is also an issue of consent, in some situations, where women have spoken

about having to argue during labour as a Doctor attempted to carry out a procedure

without their full consent:

They said I have to have a catheter as my bladder needed to be emptied I begged

them to let me try and they gave me a bowl but stayed there which made it

difficult to pass urine with an audience. The horrible doctor came back in again,

catheterized me, didn’t work so took me to theatre, the anaesthetist was awful, I

was upset as I didn’t have my baby with me and he said “what are you crying

now for”, he was horrible (07).

When women do not consent and are not in control they can be left with a legacy of

birth just being something to endure, a traumatic experience, which can then justify

the hospital birth, that is then passed to other women and the cycle continues (08).

Likewise, the whole birth experience can feel undignified (07).

One to One Midwives and the case-loading model of care

The final theme identified was unexpected and appears to be an outcome of the

negative experiences that have been mentioned which resulted in some women

seeking an alternative model of care. Six out of the ten women interviewed had

chosen to transfer their care to One to One midwives; a private company funded by

the NHS. It was abundantly clear, from each of the women, that the service they

received from One to One was by far superior than their experiences with the NHS for

previous births and they felt that birth was normalised:

37

With my second I went with one-to-one midwives. Having the same midwife

throughout my pregnancy made a big difference, like having the midwife come

to my home especially as I had a one -year-old. it was a half an hour appointment

instead of ten minutes and even though the NHS midwives had been open to

homebirth I still felt like an oddity with them whereas with one-to-one midwives

it was run-of-the-mill. Overall I felt like I had choices but that was through one-

to-one midwives, not the NHS, and from my own research. I found out since my

first birth that if I had phoned up and they said they didn’t have a midwife

available they legally had to provide one, but this wasn’t always put into practice

in the NHS and was one of my fears to happen (02).

Everything is normalized with One to One. I was still breastfeeding my first child

when I got pregnant with my second and I tandem fed, I bed-shared, nothing was

an issue. The midwife I had was also on my wavelength, she helped me bathe

etc., she knew, after I had given birth, that I was going upstairs to bed with him

and my daughter and didn’t push any of the NHS stuff on me. She supported my

choices by giving me information and advice on how to bed share safely (06).

The sheer relief of having the choice to transfer her care from the NHS where she had

felt severely let down in her first pregnancy, after suffering a traumatic labour and

birth, caused one woman to break down:

Two days later I got a phone call from one to one, from my midwife. I cried down

the phone. I contacted my GP and advised them I had transferred my care (03).

One to One home birth rates are thirty-one percent, which is considerably higher than

the two percent with the NHS and the induction and intervention rates are over twenty

percent lower (Collins & Kingdon, 2014). Furthermore, some of the women did

acknowledge that the NHS model of care was restrictive in what could be offered to

women, yet, felt this could be addressed so all women could have the same

experience:

It’s a shame that negative experiences cause a woman to have to look for

alternatives. My NHS midwife was dismissive and her attitude is bound by her

own personal experiences. The NHS is so tightly bound by protocols, unlike One

to One who had protocols but were autonomous and case-loading, the NHS cannot

provide this care although they could change the model of care to case loading if

they wanted to. Also, the attitude of NHS midwives, they don’t want the hassle it

seems (03).

38

Overall, One to One midwives are offering women continuity of care, informed choice,

and are empowering women:

NHS care is administrative, treating you like you are passing through, rather

than holistic. I was empowered as a woman with my birth with One to One, I was

in control. I gave birth with no help, I was encouraged. This is the ethos of the

women who work for One to One. I know a lot about homebirth now, I know about

doulas’ but so many women don’t. My One to One midwife was in tune with me

and how I was labouring. I experienced the foetal ejection reflex. I didn’t actively

push; my body took over. I was visualizing the end result, rather than focusing

on the labour, which helped me as I had felt scared beforehand (08).

Ultimately, the women interviewed believe that One to One midwives are raising the

bar for practicing midwives in the NHS and raising expectations for mothers:

One to One were the first and only people to mention choices. ‘you know you have

the choice, we can inform you of risks, but ultimately it is your choice’. The case

loading midwife model of care is brilliant. She was at the end of a phone call or

text when I needed her. Whereas the community midwife was there every other

Thursday, I had no idea whether I could get hold of her in between (09).

The following chapter concludes what has been discussed throughout this

paper.

39

Conclusion

This final section brings together the policy analysis, the literature review, and the

research findings and presents an overall closing argument and recommendations.

In conclusion, the in-depth policy analysis does advocate choice, in theory, although,

this appears to be a token gesture as it is not always applied in practice (Beech, 2014).

Likewise, women are conditioned to think that the default option is to give birth in

hospital due to the inherent risks (Coxon, Sandall & Fulop, 2014). This is further

evident by the extensive literature review undertaken. That is not to say that the NHS

model of care is all negative and this is not intended to be a scathing attack on the

NHS, nor, that this research is indicative of all maternal care within the NHS, however,

it is relevant and cannot be ignored or dismissed. The research emphasis is on each

individual woman’s perception, rather than an overall collective view, and it is

essential that health professionals strive to consider this and adopt practices that will

ensure all women are informed and empowered (Beech, 2014; Wickham, 2014).

The primary research shows that if the mother perceives her labour to be

mismanaged by the midwife and other health professionals then this may lead to an

overall poor-experience (01, & 07). Likewise, the language used by midwives and

health professionals is powerful, often dictatorial, and can be the difference between

a positive and negative experience. It is not appropriate to use language such as;

‘your baby might die’ without further explanation or reasoning as this only serves to

instil fear in women which is counter-productive (07), and could be conducive to them

experiencing a decline in their post-natal mental health (Henderson & Redshaw,

2013). Out of the ten women interviewed, they all experienced positive aspects, and

40

had their choices facilitated, in at least one of their births, however, the majority of

the women had, what they described as horrendous, or traumatic experiences, at

some point, which did have an impact on their well-being (03) and affected their

decision to have further children (01). Furthermore, for those women who expressed

choice and questioned the policies and practices they had a less than positive

experience overall as they were made to feel like they were being deliberately

challenging (03, 07 & 09). However, communication is a two-way process and if a

woman wishes to ask questions, challenge the status-quo and educate herself then

this should not be met with resistance, it should be welcomed and facilitated (10).

This research shows that women are, instead, perceived as being radical, or

alternative (08). Likewise, they can also be perceived as aspiring to have an almost

impossible birth experience; for instance, a homebirth, or one without pain relief,

and should just accept that it is a nice idea in theory but in reality it is better to accept

that it is unlikely to happen (02). It is the responsibility of the health professionals to

change attitudes and behaviour patterns by altering how they practice and there

being consistency with the practice of other midwives (03 & 09).

Consequently, six of the women interviewed looked at alternative types of maternal

care. One to One midwives are one such alternative whose ethos fits the women’s

expectations of providing women-led care in the form of the case-loading model of

midwifery which is argued to be the preferable way to support choice as it can result

in fewer interventions and more positive birth outcomes (Wainwright & Collins, 2015).

In comparison, the NHS model of midwifery care is, arguably, outdated and not fit for

purpose when it comes to offering women continuity of care which is, also, attributed

to achieving a good birth (02, 03, 06, 07, 08, & 09).

A positive step forward, in policy development, is the publication of Better Births

2016. Whilst it is early days, this review of maternity services was overseen by the

41

person who instigated The Changing Childbirth Report in 1993, which did, initially,

have a massive impact and subsequent changes in practice, therefore, confidence in

this new report may not be misplaced. It will be interesting to observe how the policy

is implemented over time and how it is received by health professionals and women

alike. In particular, allowing women to be in control of their maternity budget may

encourage them to be more actively involved in the decision making and enable them

to make informed choices (DoH, 2016).

Finally, the following ancient Chinese proverb has been replicated many times in

writings about midwifery and symbolises the overall ethos of the research findings

within this dissertation:

You are a midwife, assisting at someone else’s birth. Do good without show or

fuss. Facilitate what is happening rather than what you think ought to be

happening. If you must take the lead, lead so that the mother is helped, yet still

free and in charge. When the baby is born, the mother will rightly say ‘we did it

ourselves! (Tao Te Ching, cited in Kirkham, 2000)

Recognising the quintessential feminine potency, and offering greater choice,

autonomy, along with, an overall recognition of women, who understand their bodies

and want respect and choice, should be at the centre point of maternity policy.

10000 words

42

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Eggermont, M. (2012). The choice of child delivery is a European Human Right,

European Journal of Health Law, 19, 257-269. doi: 10.1163/157180912X639125.

Erhardt. R. (2011). The basic needs of a woman in labour. South Africa: True

Midwifery.

Gardner, S. (2015). Choice of place of birth: Is it really that simple? British Journal

of Midwifery, 23(1), pp 4-4. doi: 10.12968/bjom.2015.23.1.4.

Gaskin, I.M. (2003). Ina may’s guide to childbirth. London: Random House.

Gaskin, I.M. (2009). Foreword. In S.J. Buckley (ed.), Gentle Birth, Gentle Mothering

(pp. 4-8). Brisbane, QLD: One Moon.

Gaskin, I.M. (2011). Birth matters: a midwife’s manifesta. London: Printer & Martin.

Glasby, J. (2012). Understanding health and social care. Bristol: Policy.

Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopolous, I., & Martensson, LB.

(2012). Women’s perception of their right to choose the place of childbirth: an

integrated review. Midwifery, 28(3), 380-90. doi: 10.1016/j.midw.2011.05.006.

Hart, G. (2004). A timely birth, Midwifery Today, 72, 10-14. Retrieved from

https://www.midwiferytoday.com.

Henderson, J., & Redshaw, M. (2012). Who is well after childbirth? Factors related to

positive outcome, Birth, 40(1), 1-9. doi: 10.1111/birt.12022.

Jomeen, J., & Martin, C. (2008). The impact of choice of maternity care on

psychological health outcomes for women during pregnancy and the postnatal

period, Journal of Evaluation in Clinical Practice, 14, 391-398. doi: 10.1111/j.1365-

2753.2007.00878.x.

44

Kent, N. (2010). The road ahead. Retrieved from https://www.rcm.org.uk/news-

views-and-analysis/analysis/the-road-ahead.

Kirkham, M. (2000). The midwife-mother relationship. Basingstoke: Macmillan.

Kitzinger, S. (1991). The midwife challenge. London: Pandora Press.

Kitzinger, S. (2012). Birth crisis. London: Routledge.

Lindsey, P., & Peate, I. (2015). Introducing the Social Sciences for Midwifery Practice:

Birthing in a Contemporary Society. London: Routledge.

Lothian, J. (2008). Choice autonomy and childbirth education, The Journal of

Perinatal Education, 17(1), 35-38. doi: 10.1624/105812408X266278.

Lothian, J. (2012). Risk, safety and choice in childbirth. The Journal of Perinatal

Education, 21(1), 45-47. doi: 10.1891/1058-1243.21.1.45.

Lupton, C., Peckham, C., & Taylor, P. (1999). Managing public involvement in

healthcare purchasing. Buckingham: OUP.

Macfarlane, A., Mugford, M., & Henderson, J. (2000). Birth Counts: Statistics of

Pregnancy and Childbirth. The Stationery Office Books.

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in British newspapers, British Journal of Midwifery, 22(8), 580-588. doi:

10.1186/s12884-016-0827-x.

McIntosh, T., & Hunter B. (2014). Unfinished business? Reflections on changing

childbirth 20 years on, Midwifery, 30(3), 279-281. doi:

10.1016/j.midw.2013.12.006.

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review-report.pdf.

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https://www.nct.org.uk

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Nove, A., Berrington, A., & Matthews, Z. (2012). Comparing the odds of postpartum

haemorrhage in planned home birth against planned hospital birth: results of an

observational study of over 500,000 maternities in the UK. BMC Pregnancy and

Childbirth, 12(1), pp 1-11. doi: 10.1186/1471-2393-12-130.

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Women. Oxford: Basil Blackwell.

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April, 2016, from http://www.ons.gov.uk.

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Practising Midwife, 15(2), 25-26. Retrieved from http://www.ingentaconnect.com.

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45

Reed, R. (2010). Induction of labour: balancing risks, Retrieved from https://midwifethinking.com/2010/09/16/induction-of-labour-balancing-risks/

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), Sociology:

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London.

Stephens, L. (2004). Pregnancy. In: Stewart M (ed). Pregnancy, Birth and Maternity

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Tew, M. (1997). Where to be born, New Society, 39, 120-121

Walton, I., & Hamilton, M. (1995). Midwives and changing childbirth. Cheshire:

Books for Midwives Press.

Wainwright, K., & Collins, M. (2015). Case loading midwifery – an ever evolving

model of care, Midwifery Digest, 25(2), 186-190. Retrieved from

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Wickham, S. (2002). What’s right for me. London: AIMS.

Wickham, S. (2014). Inducing labour, making informed decisions. London: AIMS.

46

APPENDIX

47

College Ethical Approval Panel for Taught Programmes

Ethical Approval Application Form for Taught Programme Students

ETHICAL APPROVAL MUST BE OBTAINED BY ALL STUDENTS PRIOR TO STARTING

RESEARCH WITH HUMAN SUBJECTS, ANIMALS OR HUMAN TISSUE.

The completed Proportionate Review checklist and full Application form should be submitted to:

CHSC-TaughtEthics@salford.ac.uk

Applications will only be processed with approval of the supervisor.

48

Proportionate Review Criteria

All student research that collect primary data should consider the ethical issues involved in their

project. It is acknowledged that student research should have educational and training benefits for

the student through submission of research proposals to ethics committees. The Economic Social

Research Council (ESRC) advises that student research should be treated in the same manner as all

other research and subject to ethics review. In some cases, student research may receive a ‘light

touch,’ or proportionate review, where such applications involve minimal risk. Minimal risk should be

determined based on the guidance provided in appendix 2 Ethics panel’s therefore approach the

review in a facilitative and proportionate way that recognises that limited experience of the student

and guides what is expected of them. However, student projects that involve more than minimal risk

must be subject to a full review.

The College Ethical Approval Panel for Taught Programmes has developed a ‘proportionate review’

system to facilitate an appropriate appraisal of the ethical issues in student research. Supervisors are

encouraged to work with their student and identify whether the student’s proposed project requires

full or proportionate review. The guidance below and contained in the appendices has been developed

to support the supervisor’s assessment of their student’s research proposal.

Please select a response to the following questions. Projects that indicate that potential risk is involved

will be subject to a full review by the ethics panel. Projects that select mainly ‘YES’ or NA will be subject

to a proportionate review by an ethics panel member. Once approved, the applicants will receive

feedback within ONE week of submission for proportionate review. Projects that are not subject to

Proportionate Review will be sent to full ethical review, which normally takes 4-5 weeks. Each project

should be carefully assessed with the supervisor according to the relevant professional regulatory

guidelines for research ethics.

All students should be encouraged by their dissertation supervisors to apply the relevant professional

regulatory guidelines as a standard to underpin their research. All projects should ensure that the

participant’s autonomy is paramount and that the benefits of undertaking the project are clearly

assessed against the potential risks. Students and supervisors should consult the appropriate

professional regulatory guidance and can contact the ethics team for further guidance if required.

Links to professional regulatory ethical frameworks can be located on the College Ethics website for

taught programmes at http://www.salford.ac.uk/chsc/research/taught-programme-ethics:

All students should ensure that they submit the following documents:

1. Fully completed and signed ethics application form X

2. Consent form (if required) X

3. Data collection tools (for example interview schedules, questionnaires etc.) X

4. Risks assessment form X

5. Checklist X

6. Participant information sheet X

7. Any organisational letters or correspondence. N/A

49

College Ethical Approval Panel for Taught

Programmes Proportionate Review Criteria

Office use only

Ref No:

Name of Applicant: Claire Carey

Full Programme Title: BSc (HON) Social Policy

Award: BA BScX MA MSc

Name of Supervisor: Professor Louise Ackers

Title of Study: Do Maternity Policies in the UK, in practice, enable and empower

women to make informed choices on childbirth?

All student research that collects primary data should consider the ethical issues involved in their project. It is acknowledged that student research should have educational and training benefits for the student through submission of research proposals to ethics committees. The Economic Social Research Council (ESRC) advises that student research should be treated in the same manner as all other research and subject to ethics review. In some cases, student research may receive a ‘light touch,’ or proportionate review, where such applications involve minimal risk. Minimal risk should be determined based on the guidance provided in appendix 2. Ethics panel’s therefore approach the review in a facilitative and proportionate way that recognises that limited experience of the student and guides what is expected of them. However, student projects that involve more than minimal risk must be subject to a full review. Please note that systematic and other forms of literature reviews do not need ethical approval. Please use the guidance in the Appendix to support your appraisal

.

Evidence

(Ethical approval ref

no/application page

no etc.)

Supervisor

and

Applicant

(please delete

as appropriate)

Reviewer

(please delete

as appropriate)

1 The project is part of a larger research study that already has ethical approval?

No Yes/No

2 The project proposes to collect secondary data only? * If ‘YES’ please ensure that the project meets the requirements for data protection

No Yes/No

3 The project uses validated Questionnaires that only include non-sensitive or low risk research areas or where accidental disclosure would NOT have serious consequences. (Please use the guidance in appendix to guide your selection.)

No Yes/No

4 The project is proposing to use interviews that only include non-sensitive or low risk research areas or where accidental disclosure would NOT have serious consequences

Yes Yes/No/NA

5 The project includes minimally invasive basic science studies that have full supervisor support undertaken on healthy volunteers.

NA Yes/No/NA

50

6a The project includes the use of the PAR-Q to assess participant suitability.

NA Yes/No/NA

6b The project involves testing/protocols/equipment which has previously been used in an approved application.

NA Yes/No/NA

6c The project involves testing/protocols/equipment which has previously been used in an approved application, and involves the same population.

NA Yes/No/NA

7 The project’s recruitment strategies exclude the use of social media sites?

NA Yes/No/NA

Signed by Student: ca carey Date: 7th October 2015

Signed by Supervisor: Date: 7th November 2015

Supervisor Recommendation: Proportionate Review *Please delete as appropriate

Reviewer Recommendation: Proportionate Review/Full Review* *Please delete as appropriate

Feedback from Reviewer in support of decision:

Appendix: College Guidance for Sensitive or High Risk Research Subjects

The College Guidance for Sensitive or High Risk Research Subjects is predicated on the following

range of professional regulatory ethics frameworks: British Psychological Society, Social Research

Association, Economic Social Research Council, Social Policy Association (SPA), RESPECT Code of

Practice for Socio-Economic Research & Royal College of Nursing Guidance on Ethics (2009).

It is acknowledged that some research may pose risks to participants in a way that is legitimate in the

context of that research and its outcomes. However, it is advised that the longer-term gains should

outweigh the short-term immediate risks to participants. Students and supervisors need to provide a

robust rationale for sensitive subjects and articulate what the longer term gains are and whether there

are any potential benefits for the participants (BPA 2012). No generic formula or guidelines exist for

assessing the likely benefit or risk of various types of social enquiry. Nonetheless, social researchers

must be sensitive to the possible consequences of their work and should as far as possible, guard

against predictably harmful effects (SRA). The following research (as per BPS/ESRC guidance) would

normally be considered as involving more than minimal risk:

51

Research involving potentially vulnerable groups (such as children aged 16 and under; those

lacking capacity; or individuals in a dependent or unequal relationship, powerless individuals);

Research involving those who lack capacity or who come during the research project to lack

capacity must be approved by an appropriate ‘body’ (for example a flagged NREs Panel) that

operates under the Mental Capacity Act (2005)

Research involving sensitive topics (such as participants’ sexual behaviour; their legal, illegal or

political behaviour; their experience of violence; their mental health gender or ethnic status);

Research involving deceased persons, body parts or other human elements

Research involving a significant element of deception;

Research involving access to records of personal or confidential information (including genetic or

other biological information);

Research involving respondents through the internet – in particular where visual images are

used and where sensitive issues are discussed.

Research involving access to potentially sensitive data through third parties (such as employee

data);

Research that could induce psychological stress, anxiety or humiliation or cause more than

minimal pain (e.g. repetitive or prolonged testing);

Research involving invasive interventions (such as the administration of drugs or other

substances or techniques such as hypnotherapy) that would not usually be encountered during

everyday life;

Research involving physical exercise protocols that would not usually be encountered;

Research that may have an adverse impact on employment or social standing (e.g. discussion of

an employer, discussion of commercially sensitive information);

Research that may lead to ‘labelling’ either by the researcher (e.g. categorisation) or by the

participant (e.g. ‘I am stupid’, ‘I am not normal’);

Research that involves the collection of human tissue, blood or other biological samples.

52

College Ethical Approval Panel for Taught

Programmes Application Form

Office use only

Ref No:

Ethical Approval Form for undergraduates and post graduates (taught programmes)

Ethical approval must be obtained by all students prior to starting research with human subjects, animals or human tissue. The student must discuss the content of the form with their dissertation supervisor who will advise them about revisions. A final copy of the summary will then be agreed and the student and supervisor will ‘sign it off’. The applicant must forward a hard copy of the form to the College Teaching and Learning Team, Room AD101, Allerton Building (CHSC-TaughtEthics@salford.ac.uk) once it is has been signed by their Supervisor.

The form must be completed electronically; the sections can be expanded to the size

required but not exceeding the word count specified. To assist you with the completion of

this form there are ‘Guidance Notes for Completing the College Ethics Form’ on the website

(http://www.salford.ac.uk/chsc/research/taught-programme-ethics) which indicate what is

required for each section.

Is this application a resubmission? (delete as appropriate) Yes

If Yes, please indicate Ref No. (if known)

Is this an amended version of the original application? (Please

highlight any changes) (delete as appropriate)

Yes

Name of Student: Claire Carey

Full Programme Title: BSc (HONS) Social Policy

Award:

(delete as appropriate)

BSc

Supervisor: Professor Louise Ackers

53

Will this project use any NHS sites? (delete as appropriate) No

Will this project include children? (delete as appropriate) No

Will this project involve adults lacking the capacity to consent for

themselves? (delete as appropriate)

No

Will this project take place on University premises?

(delete as appropriate)

Yes

Is a DBS check required? (delete as appropriate) No

Have you read the Lone Worker Policy? (delete as appropriate) Yes

1. Title of proposed research project (refer to guidelines section 1)

Do Maternity Policies, in practice, enable and empower women to make informed

choices on childbirth? A case study in Greater Manchester.

2. Project focus (refer to guidelines section 2)

The project will explore mothers’ perceptions, and their experiences of the

choices available to them throughout pregnancy. From their ante natal care and

decision-making around where to give birth, home or hospital, pain relief,

induction and the impact this had on their overall experience and well-being.

The study will involve women who have given birth at least 6 months ago;

between January 2014 and June 2015.

54

I aim to demonstrate the level of awareness women have, in practice, over the

choices available to them and whether they were able to make ‘informed’ choices.

3. Project objectives (refer to guidelines section 3)

To review national and local policies on maternal health.

To analyse existing academic literature and statistical data.

To interview women in the Greater Manchester area to discuss their

previous births.

To highlight any differences between policy and practice

To understand the potential consequences of women not being involved

in decision making surrounding childbirth

4. What is the rationale which led to this project? (refer to guidelines section 4)

Maternal health began to attract government interest during the Second World

War due to the on-going attempts at increasing the population. Before the launch

of the National Health Service (NHS), in 1948, women routinely gave birth at

home, however, as obstetric knowledge progressed further, which in turn began

to label more women as being ‘high-risk’, many medical professionals argued

that giving birth within a hospital setting was safer than remaining at home. One

report in particular, constructed by Consultant Obstetrician John Peel,

recommended that one hundred per cent of births should take place in hospital.

Consequently, medicalised, hospital births rose rapidly and by the 1970s the rate

was above ninety-five per cent and did not drop below this figure. However, the

report did face significant criticism over the absence of evidence in support of his

claims, and, furthermore, for failing to consult with women over their experiences

and what they felt they needed during pregnancy and childbirth. This report

marked the beginning of pressure groups, and organisations such as; The

National Childbirth Trust (NCT) and The Association for Improvements in the

Maternity Service (AIMS), who both began to campaign on behalf of women and

55

their right to make informed choices over their care during pregnancy and

childbirth (Davis, 1981, 2013; Oakley, 1984).

The changing childbirth report in 1993 and The Maternity Matters Policy in 2007

have both been prominent influences in attempting to change maternity practices

in the UK. The Department of Health (1993) made recommendations that were

then implemented from 1994 onwards and stated that women should be fully

informed of all of their choices in childbirth to allow them to make decisions over

their care, thus, improving their overall experience. However, research

undertaken by Banyana and Crow (2003) demonstrated that this was not being

achieved in practice and, in fact, seventy-two per cent of the women interviewed

were not even aware that they were able to make their own choices. In particular,

with regards to having a homebirth and it was only those women who were

already planning one who were given further information and the opportunity to

discuss it in more detail. Further policy intervention ensued with the

implementation of the Maternity Matters Policy in 2007 that aimed to re-evaluate

maternity policy and ensure that the recommendations were implemented in

practice by health professionals. Moreover, one of the most important decisions

for a woman to make, when pregnant, is where to give birth; at home or in

hospital, and according to Cheyney (2008) the debate of where to give birth has

risen due to the claims that childbirth, in a hospital setting, is becoming

unnecessarily medicalised and often leads to, otherwise, preventable

interventions.

There has been numerous research on this topic, however, the research I plan to

undertake will focus on a case study of a group of women from the Greater

Manchester who have given birth within between January 2014 and June 2015

area to gain their perceptions and gain current perceptions.

5. Is your project linked to any other projects? (refer to guidelines section 5)

No

56

6. Research Strategy. Please provide an indication of the project duration or project schedule in your research strategy or as an appendix. Please detail where the study will take place (setting), how data will be collected and how data will be analysed. (refer to guidelines section 6)

The methodology will be qualitative; method will be interviews.

The women will be interviewed individually over a 4-5-week period and will

take place at the University of Salford.

The interview will be conducted using pre-set interview questions that will allow

for the conversation to flow naturally using gentle probing questions when

necessary. It is my intention not to lead the participants in any way. Following the

interviews all the data collected will be transcribed and then thematically

analysed, and discussed with my dissertation supervisor. The data will be

analysed by myself and the findings will be presented in detailed answers, using

quotes from the participants where necessary.

7. How many participants will be recruited and/or involved in the research study, and what is the rationale behind this number? (refer to guidelines section 7)

I will recruit approximately 10 female participants within the Greater

Manchester area. My aim is for the women to represent various groups in

society, including, age, disability, ethnic origin. If more than 10 women

apply I will select the women who will best represent the above proposed

demographic.

This number of women will be a suitable sample when taking into account

the time frame available for the proposed research and enables me to gain

depth into their experiences.

57

8. Please describe how you plan to obtain organisational agreement for your project. (refer to guidelines section 8)

N/A

9. Are you going to recruit individuals to be involved in your research? Please detail how, rather than who you will recruit. (refer to guidelines section 9)

YES (delete as appropriate and if Yes explain clearly how participants will be recruited)

I will use my existing contacts in the Greater Manchester area to access informal

parenting groups such as; mums and toddler groups, and I will ask community

buildings, to display a leaflet explaining my research and a request for interested

participants to email me.

This will be open to women aged 18+.

A sample poster is attached to this form.

10. How will you ensure you gain informed consent from anyone involved in the study? Please also refer to the participant information sheet and consent procedure (refer to guidelines section 10)

I will gain written consent from each mother, to be interviewed and recorded, and

provide them with a participation information sheet to explain the aims and

objectives of the study and to explain that all information will be remain

confidential and the data will be anonymised.

I would design this document in conjunction with my supervisor.

58

11. Are there any data protection issues that you need to address? (refer to guidelines section 11)

(delete as appropriate and explain response)

All participants will be given a code word for their information to remain

anonymous and confidential to all except the researcher.

All data that is stored electronically will be stored on the F drive on a

password controlled computer

Hard copies will be stored in a locked filing cabinet, in a locked room at

the University.

All data will be stored for at least three years

Only the researcher and supervisor will be able to access the data.

12. Other ethical issues that need to be considered (refer to guidelines section 12)

Participants will not be discriminated against for being part of a minority group

and I aim to have a range of participants from different backgrounds.

Childbirth is an emotive subject and may invoke feelings of distress in the

participant if the interview is not handled sensitively. This can be managed by

ensuring that participants are at least 6 months’ post-partum and not recently

delivered and that they are given sufficient time to read the participant

information, no less than one week, before agreeing to the interview.

If, during the interview, any participant becomes distressed I shall cease the

interview. Any ethical issues that arise during the study will be discussed in detail

with my supervisor.

59

13. References – provide full list of all references used

Banyana, CM, & Crow, R. (2003). A qualitative study of information about

available options for childbirth venue and pregnant women’s preference

for a place of delivery. Midwifery, 19(4), 328-336. doi: 10.1016/50266-

6138(03)00042-1/midw.2003.0369

Cheyney, J. (2008). Homebirth as systems-challenging praxis: knowledge,

power and intimacy in the birthplace. Qualitative Health Research, 18(2),

254-67. doi: 10.1177/1049732307312393 Coxon, K., Sandall, J., & Fulop, N.J. (2013). To what extent are women

free to choose where to give birth? How discourses of risk, blame and

responsibility influence birth place Decisions. Health, risk and society,

16(1), pp 56-67. doi: 10.1080/13698575.2013.859231

Davis, A. (1981). Modern motherhood: women and family in England, c.

1945-2000. New York: Manchester University Press

Davis, A. (2013). Wartime women giving birth: narratives of pregnancy

and childbirth, Britain c. 1939-1960. Studies in History and Philosophy of

Biological and Biomedical Sciences, 47(B), pp 257-266. doi:

10.1016/j.shpsc.2013.11.007

Department of Health. (1993). Changing childbirth, part 1, report of the

expert maternity group. HMSO: London Gardner, S. (2015). Choice of place of birth: Is it really that simple? British

Journal of Midwifery, 23(1), pp 4-4. doi: 10.12968/bjom.2015.23.1.4

Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopolous, I., &

Martensson, LB. (2012). Women’s perception of their right to choose the

place of childbirth: an integrated review. Midwifery, 28(3), 380-90. doi:

10.1016/j.midw.2011.05.006

Lothian, J. (2012). Risk, safety and choice in childbirth. The Journal of

Perinatal Education. 21(1), 45-47. doi: 10.1891/1058-1243.21.1.45 Nove, A., Berrington, A., & Matthews, Z. (2012). Comparing the odds of

postpartum haemorrhage in planned home birth against planned

hospital birth: results of an observational study of over 500,000

maternities in the UK. BMC Pregnancy and Childbirth, 12(1), pp 1-11.

doi: 10.1186/1471-2393-12-130

Oakley, A. (1980). Women Confined: Towards a Sociology of

Childbirth. New York: Schocken Brooks

Oakley, A. (1984). The Captured Womb: A History of the Medical Care of

Pregnant Women. Oxford: Basil Blackwell

60

Simkin, P. (2006). Just another day in a woman’s life? Women’s long term

perceptions of their birth experience, part 1. Birth, 18(4), pp 203-210.

doi: 10.1111/j.1523-536X.1992.tb00382

Stockill, C. (2007). Trust the experts? A commentary on choice and

control in childbirth. Feminism and Psychology. 17(4), 571-577. doi:

10.1177/0959353507083093 Talbot, D. (2014). Exploring the ‘good’ birth: what is it and why does it

matter. British Journal of Midwifery, 22(12), pp 854-860. doi.

10.12968/bjom.2014.22.12.854

NB. Projects that involve NHS patients, patients’ records or NHS staff, will require ethical approval by the appropriate NHS Research Ethics Committee (REC). The College Research Governance and Ethics Committee will require written confirmation that such approval has been granted. Where a project forms part of a larger, already approved, project, the approving REC should be informed about, and approve, the use of an additional co-researcher. NB: The ethical and efficient conduct of research by students is the direct responsibility of the supervisor. I certify that the above information is, to the best of my knowledge, accurate and correct. I understand the need to ensure I undertake my research in a manner that reflects good principles of ethical research practice. Signed by Student: …ca carey………………………………………………………. Date …7th November 2015…………………………………………. Please note that whilst the College indemnifies student research projects, the supervisor is signing that they are satisfied that the student has considered the ethical implications of their work and to confirm for the student’s project to proceed subject to approval by the ethics panel

Signed by Supervisor Date ………………………7/11/2015……………….

Prior to submitting the application form:

Please refer to the ‘Application Checklist’ and ensure appropriate supporting

documentation is submitted with the application form

Failure to complete the necessary documents will result in the application being returned to the applicant without being reviewed for re-submission thus delaying the approval process.

61

Interview Questions.

Some of the questions may not be asked, if they are already answered previously.

1) Tell me about your experience/s of childbirth.

2) What is your understanding of the concept ‘good birth’?

3) How aware are/were you of the choices available to you in childbirth?

Place of birth

Pain relief

Induction

Vaginal examinations

4) How would you describe your birth? Positively, negatively.

5) Is there anything that you learned along the way? With regards to choice,

language used by professionals.

62

Participants Wanted

Do Maternity Policies, in practice, enable and empower women to

make informed choices on childbirth? A case study in Greater

Manchester.

Aims and Objectives

This project will explore mothers’ perceptions, and their experiences of the choices available

to them throughout pregnancy. From their ante natal care and decision-making around where

to give birth, home or hospital, pain relief, induction and the impact this had on their overall

experience and well-being.

I aim to involve approximately ten women who have given birth at least 6 months ago;

between January 2014 and June 2015.

A consent form and participation information form will be provided before the interview to

peruse.

Interviews to be held at a mutually convenient time and date at the University of Salford.

63

Contact

Claire Carey at the University of Salford: c.carey@edu.salford.ac.uk

Dissertation Supervisor: h.l.ackers@salford.ac.uk

Participant Information Sheet

Study Title

Do Maternity Policies, in practice, enable and empower women to make informed

choices on childbirth? A case study in Greater Manchester.

Invitation paragraph

I would like to invite you to take part in a research study. Before you decide you need to

understand why the research is being done and what it would involve for you. Please take

time to read the following information carefully. Ask questions if anything you read is not clear

or would like more information. Take time to decide whether or not to take part.

This study will form part of an undergraduate dissertation.

The focus of the dissertation is on childbirth and the choices women have during this time and their perception of this in practice.

What is the purpose of the study?

The purpose of this study is to enhance the existing literature on the subject and focus on the

mother’s perceptions of choices in childbirth. This will focus on one geographical area; Greater

Manchester. This project will explore mothers’ perceptions, and their experiences of the

choices available to them throughout pregnancy. From their ante natal care and decision-

making around where to give birth, home or hospital, pain relief, induction and the impact this

had on their overall experience and well-being.

I aim to involve approximately ten women who have given birth at least 6 months ago; between

January 2014 and June 2015.

I aim to demonstrate the level of awareness women have, in practice, over the choices

available to them and whether they were able to make ‘informed’ choices.

Why have I been invited?

Participants have been identified through the contacts I have in the Greater Manchester area

by displaying a leaflet in community venues and at mother and toddler groups. I have only

selected women who have given birth between January 2014 and June 2015. There will be

approximately 10 women interviewed.

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Do I have to take part?

It is up to you to decide. We will describe the study and go through the information sheet,

which we will give to you. We will then ask you to sign a consent form to show you agreed to

take part. You are free to withdraw at any time, without giving a reason. (if applicable – this

will not affect the standard of care you receive).

What will happen to me if I take part?

The participant will be required to be interviewed by the researcher, a set time frame has not

been identified. However, I would expect this to be no more than one morning or afternoon.

The one interview should suffice, however, if further contact is required then email contact

may be sufficient.

The interview will be recorded on a Dictaphone and will be transcribed and anonymised after

the interview and stored on the university F drive.

When accessing the data from another location it will be via a password protected computer

and each participant will only be recognised by a code word.

A consent form will be required to be signed before commencing the interview.

Expenses and payments?

The research will take place at the participant’s convenience to ensure they are not out of

pocket.

What will I have to do?

I will have a few set questions about your experiences of childbirth for you to consider and

then answer. From there a discussion will flow and further questions will naturally be asked.

Questions will be provided before the interview to give the participant opportunity to prepare

themselves and ensure that they are happy to continue.

What are the possible disadvantages and risks of taking part?

. It is important to recognise that discussing childbirth may be a sensitive issue, in particular,

if a woman has not experienced what they believe to be a ‘good birth’. This will be handled

with the utmost understanding and, where necessary, will be signposted to appropriate

support that will be provided on an information sheet.

All women will be given a minimum of one week to peruse the information, ask any questions,

before being interviewed.

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What are the possible benefits of taking part?

We cannot promise the study will help you but the information we get from the study will help

to increase the understanding of mother’s perceived choices in childbirth and the possible

impact on their well-being.

What if there is a problem?

If you have a concern about any aspect of this study, you should ask to speak to the

researchers who will do their best to answer your questions (07729 189726)

If you remain unhappy and wish to complain formally you can do this through Professor

Louise Ackers, University of Salford. H.L.Ackers@salford.ac.uk

Or through

Matthew Stephenson

Head of Information Governance

Governance Services Unit

Crescent House

University of Salford

Salford

M5 4WT

Tel: 0161 295 6856

Email: m.stephenson@salford.ac.uk

Will my taking part in the study be kept confidential?

All information which is collected, via a Dictaphone and recorded about you during the course

of the research will be anonymised, all information will be stored on the University F drive and

will have your name and address removed so that you cannot be recognised. Only myself and

my supervisor will be able to access the data. This will be kept for up to three years and only

used for the research proposed.

Involvement of the General Practitioner/Family Doctor (GP)

The participants GP will not be involved.

What will happen if I don’t carry on with the study?

If you withdraw from the study we will destroy all your identifiable samples/ tape recorded

interviews, but we will need to use the data collected up to your withdrawal.

What will happen to the results of the research study?

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Unless consent is given the information collected will not be published. The results of the study

will form part of an undergraduate dissertation.

Who is organising or sponsoring the research?

University of Salford

Further information and contact details:

Contact details of researcher.

Claire Carey

c.carey@edu.salford.ac.uk

07729 189726

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Research Participant Consent Form

Title of Project: Do Maternity Policies, in practice, enable and empower women to

make informed choices on childbirth? A case study in Greater Manchester.

Ethics Ref No:

Name of Researcher: Claire Carey

(Delete as appropriate)

I confirm that I have read and understood the information sheet for the above study (version x- date) and what my contribution will be.

Yes

No

I have been given the opportunity to ask questions (face to face, via telephone and e-mail)

Yes

No

I agree to take part in the interview

Yes

No

NA

I agree to the interview being tape recorded

Yes

No

NA

I agree to digital images being taken during the research exercises

Yes

No

NA

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I understand that my participation is voluntary and that I can withdraw from the research at any time without giving any

reason

Yes

No

I understand how the researcher will use my responses, who will see them and how the data will be stored.

Yes

No

I agree to take part in the above study

Yes

No

Name of participant

……………………………………………………………………………

Signature

…………………………………………………………………………….

Date ……………………………….

Name of

researcher

taking

consent

Claire Carey……………………………………………………

Researcher’

s e-mail

address

c.carey@edu.salford.ac.uk………………………………………………………

……

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Risk Assessment Summary of Student Projects

All student projects must include a risk assessment. If this summary assessment of

the risk proves insignificant: i.e. answer no to all questions, no further action is

necessary. However, if you identify risks you must identify the precautions you will

put in place to control these.

Please answer the following questions.

1. What is the title of the project?

2. Is the project purely literature based? NO

If YES, please go to the bottom of the assessment and sign where indicated. If NO,

complete question 3 and then list your proposed controls.

3. Identifying the Risks

Hazards Risks If yes, consider what precautions will be taken to

minimise risk and discuss with your Supervisor

Use of ionising or non-

ionising radiation

Exposure to

radiation NO

Obtain copy of existing risk assessment from place of

research and attach a copy to this risk assessment

summary.

Use of hazardous

substances

Exposure to

harmful substances

NO

Obtain copy of existing risk assessment from place of

research and attach a copy to this risk assessment

summary.

Do Maternity Policies, in practice, enable and empower women to make informed

choices on childbirth? A case study in Greater Manchester

70

Use of face-to-face

interviews

Interviewees could be

upset by interview and

become aggressive or

violent toward

researcher

Interviewing;

Own

classmates=Low

risk Yes

Other University

students=Medium

risk Yes

Non-University

personnel=High

risk Yes

NB. Greater precautions are required for medium & high

risk activities

Consider:

How will contact with participants be made - i.e. do not

give out personal mobile no., home number or home

email, etc.

Location of interviews – to be held in a safe environment,

e.g. University building, workplace

What support will be available, i.e. will anyone else be

available to assist if you call for help, etc. e.g. colleague

knows where interview to take place and telephoned when

completed and safe- what action to take after certain time

if not phoned

How to deal with aggressive/violent behaviour, what

precautions will be taken to prevent this from happening?

Use of face-to-face

interviews

Participants or

interviewees could

become upset by

interview and suffer

psychological effects

YES Consider:

What initial and subsequent support will be made

available for participants or interviewees?

What to do if researcher uncovers information regarding

an illegal act?

What/who will be used to counsel distressed participants/

interviewees, what precautions will be taken to prevent

this from happening?

Sensitive data Exposure to data or

information which

may cause

upset or distress to

Researcher

NO

Consider:

What initial and subsequent support will be available to

the researcher

Physical activity Exposure to levels

of excerption

unsuitable for an

Consider:

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individual’s level of

fitness

NO

Health Questionnaire/ Medical declaration form / GP

clearance.

Trained First aid personnel/ Equipment.

Equipment Exposure to faulty

unfamiliar

equipment.

NO

Consider:

Equipment is regularly checked and maintained as

manufactures instructions.

Operators receive adequate training in use of.

Participants receive induction training prior to use.

Sensitive issues i.e.

Gender / Cultural

e.g. when observing or

dealing with undressed

members of the

opposite sex

Children

Exposure to

vulnerable

situations/ sensitive

issues that may

cause distress to

interviewer or

interviewee

NO

Consider:

Use of chaperones/ Translators.

What initial and subsequent support will be made

available for participants or interviewees?

Adhere;

to local guidelines and take advice from research

supervisor

Manual Handling

Activities

Exposure to an

activity that could

result in injury

NO

Adapt the task to reduce or eliminate risk from manual

handling activities. Ensure that participants understand

and are capable of the manual handling task beforehand.

Perform health questionnaire to determine participant

fitness prior to recruitment

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If you have answered yes to any of the hazards in question 3, please list the proposed

precautions below:

All contact between myself and the participant will be via my university email.

All interviews will take place at the University in a pre-booked room.

If I required assistance I would call a colleague on campus, as pre-arranged, on the phone.

I would ensure that before each interview a colleague, on campus, would be aware of where I was

and the time I intended to finish and I would agree to call them within one hour of that time. An

agreement would be made that if I do not make contact as agreed they would come to find me.

To avoid aggressive or violent behaviour I would ensure the participants were fully aware, using the

participant information sheet and consent form, of what the interview will entail. If I saw the witness

becoming upset or distressed I would promptly stop and ask the participant if they were ok, only

continuing if they felt they were fine to do so.

To prevent participants from becoming distressed, having a clear and transparent information sheet

will lower the risk of this happening, however, I will provide a signposting information sheet for the

participants of where to seek help or support should they require it.

Signature of student……ca carey Date…7/11/15…………………….

Signature of Supervisor ……………………………… Date ……………………….

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Information.

NHS choices – comprehensive information service

http://www.nhs.uk/pages/home.aspx

Breastfeeding Network

https://www.breastfeedingnetwork.org.uk/

Birth Trauma Association

http://www.birthtraumaassociation.org.uk/

Pre and postnatal depression advice and support

http://www.pandasfoundation.org.uk

Drugs in Breastmilk Helpline - 0844 412 4665

NHS non-emergency number – 111

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Office Use Only

Ref No:

New submission / Re-

submission

College Ethical Approval Panel for Taught

Programmes Application Checklist

Name of applicant: Claire Carey

Programme of study: BSc (HONS) Social Policy

Title of Study: Do Maternity Policies, in practice, enable and empower women to make

informed choices on childbirth? A case study in Greater Manchester.

.

The checklist below helps you to ensure that you have all the supporting documents submitted with your ethics

application form. This information is necessary for the committee to be able to review and approve your application.

Please complete the relevant boxes indicating whether a document is enclosed and where appropriate identifying

the date and version number allocated to the specific document (in the header/footer). Additional documents can

be recorded in the boxes provided or extra boxes added to the list if necessary.

Enclosed? (circle

appropriate response)

Date

Version

No

Office Use Document Yes No

Application Form Mandatory

Risk Assessment Form Mandatory

Participant Invitation Letter No

Participant Information Sheet Yes

Participant Consent Form Yes

Participant Recruitment Material - e.g. copies

of Posters, newspaper adverts, website,

emails

Yes No

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Organisation Management

Consent/Agreement Letter

No

Research instrument, validated questionnaire No

Research instrument, non-validated

questionnaire

Yes

Draft Interview guide/ Topic guides for

participants

No

National Research Ethics Committee

application (LREC form)

No

NOTE: If the appropriate documents are not submitted with the application form then the application will be returned

directly to the applicant and will need to be re-submitted at a later date thus delaying the approval process.

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Ethics Committee Response Form

Application Ref Number: 15/16-07 Student Name: Claire Carey

Ethical criteria and Area on form

Comments Minor Major

Science (Q1-7) Project Focus The title suggests a study of National (UK) policy;

however, the researcher aims to focus on one particular geographical area of service (Manchester) which may not actually utilise the National guidance in its exact form. Title changed to ‘Do Maternity Policies, in

practice, enable and empower women to

make informed choices on childbirth? A case

study in Greater Manchester’

The project will explore mothers’ perceptions,

and their experiences of the choices available

to them throughout pregnancy. From their

ante natal care and decision-making around

where to give birth, home or hospital, pain

relief, induction and the impact this had on

their overall experience and well-being.

The study will involve women who have given

birth at least 6 months ago and no longer than

2007.

I aim to demonstrate the level of awareness

women have, in practice, over the

choices available to them and whether they

were able to make ‘informed’ choices.

√

Rationale This section is very limited and contains no support from the evidence. The researcher offers that much has been written already on this subject but that

√

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women’s views have not been recorded. This is not correct as there have been numerous studies on women’s perceptions of choice and control in pregnancy. There have been numerous studies, however, I propose to focus only on Greater Manchester and the study will be very current. I have amended the rationale section of the form to show the supporting evidence.

Project Aims and Objectives

There are no formal aims / objectives offered except that the researcher aims to compare and contrast the experiences the 10 women against “National policy” which I feel is impossible within this study due to the subjective nature of the women’s perceptions. Already amended to show that the study will be based on local policy in greater Manchester. Given considerably more information on the form.

√

Research Strategy A qualitative study where 10 women will be recruited and asked to discuss their experiences of choice in childbirth for 90 minutes. They will then be followed up via email which I feel will impact on the anonymity and confidentiality of the study. I think this may need some attention in relation to sample selection as the sampling frame is quite loose. You state you are going to recruit from a variety of sources, my question is what are you going to do if you get more than 10 offers of participation? I think the solution is to tighten up 2 elements of your sampling framework. Firstly, you need to label your framework as being purposive and to do this you need to include some very clear inclusion exclusion criteria, such has given birth in the last 6 months. You also need to spell out how you would reduce the number of offers to the desired numbers, so are you going to randomly select from the pool of offers or what? I also think you need to rethink your analysis in respect of you state you are going to do some form of statistical analysis. This is very difficult with qualitative data, I would suggest you simplify your approach and just use thematic analysis (save the higher powered stuff for your Masters and PhD).

I will recruit approximately 10 female

participants within the Greater

Manchester area. My aim is for the

women to represent various groups in

society, including, age, disability, ethnic

origin. If more than 10 women apply I

√

78

will select the women who will best

represent the above proposed

demographic.

The methodology will be qualitative;

method will be interviews.

The women will be interviewed

individually over a 4-5-week period and

will take place at the University of

Salford.

This number of women will be a suitable

sample when taking into account the

time frame available for the proposed

research and enables me to gain depth

into their experiences.

The interview will be conducted using pre-set

interview questions that will allow for the

conversation to flow naturally using gentle

probing questions when necessary. It is my

intention not to lead the participants in any

way. Following the interviews all the data

collected will be transcribed and then

thematically analysed, and discussed with my

dissertation supervisor. The data will be

analysed by myself and the findings will be

presented in detailed answers, using quotes

from the participants where necessary.

Autonomy (Q9, 10) Approaching Individuals

This is to be via Facebook and twitter as the researcher declares she already knows these women as a new mother herself. I feel this again will breach confidentiality and may lead to a breach of confidentiality; additionally, the researcher uses these social media sites as a mother and not as a healthcare professional and student. amended

√

Recruitment methods

As above, additionally the letter is exceptionally basic and does not inform the participants about the study details. amended

√

Informed Consent Needs addressing in response to the other comments. amended

Participant information sheet

Very limited (as above) amended √

Right to withdraw Satisfactory. 24 hours’ notice This needs to be included in your letter and

information sheet.

79

Research university contact details

Satisfactory

Data Protection (Q11)

Confidentiality See above, additionally the researcher offers that “it is unlikely that their GP will be informed” This is vague and could breech confidentiality. Changed the wording on the information form to state that the GP will not be involved.

√

Anonymity See above You state you will offer anonymity. As a qualitative researcher you cannot offer this, what you can offer is to anonymise the data. amended

Storage of data This is to be held on a laptop but there is no information regarding how this data will be stored or for how long. You need to clarify how you intend to store the data both on your computer and as transcripts during your study. You cannot just destroy them after the study as they are the property of the university, so how will they be stored. amended

√

Access to data There is no indication as to how the information gained from the study will be used. Who will be able to access the data? amended

√

Transport of data How will you ensure safe transportation?

Risk I think there is a fundamental issue regarding your own safety and how you are going to ensure this. You say you are going to conduct the interviews in a quite public place, these are very difficult to identify and if you are talking about confidential topics are they the most appropriate? I think you need to include a protocol you will follow for each interview. As a bare minimum I would suggest that you include a contact person. This would be an individual you inform by phone that you are starting the interview and who would also be available for you to contact as soon as you had left the interview. They would also have a safe time, so if you had not called them say 1 hour after the start of the interview they would call you. Made

necessary amendments to the risk assessment form and now reads, ‘All contact between myself and the participant will be via my

university email. All interviews will take place at the University

in a pre-booked room. If I required assistance I would call a

colleague on campus, as pre-arranged, on the phone. I would

ensure that before each interview a colleague, on campus,

would be aware of where I was and the time I intended to

finish and I would agree to call them within one hour of that

time. An agreement would be made that if I do not make

80

contact as agreed they would come to find me. To avoid

aggressive or violent behaviour I would ensure the

participants were fully aware, using the participant information

sheet and consent form, of what the interview will entail. If I

saw the witness becoming upset or distressed I would

promptly stop and ask the participant if they were ok, only

continuing if they felt they were fine to do so.

Sensitive issues There is no indication as to how sensitive situations might be managed. To prevent participants from becoming distressed, having a clear and transparent information sheet will lower the risk of this happening, however, I will provide a signposting information sheet for the participants of where to seek help or support should they require it You highlight the possibility of your participants becoming distressed, which displays good awareness. However, you also state that you would refer them on for example to the GP. You are not in a position to do this, what you can do is signpost them to different support services and I would suggest that you have an information sheet available to do this. The wording has been changed, from refer to signpost, and ‘GP’ has been removed as an example. I have created an information sheet as mentioned here.

√

Psychological distress As above. Invasive procedures N/A

Other Issues (Q12) Vulnerable groups Recently delivered mothers are deemed as a

particularly vulnerable group and I feel that there needs to be more consideration as to how they will be managed and supported. Amended to add;

Childbirth is an emotive subject and may invoke

feelings of distress in the participant if the

interview is not handled sensitively. This can be

managed by ensuring that participants are at least

6 months’ post-partum and not recently delivered

and that they are given sufficient time to read the

participant information, no less than one week,

before agreeing to the interview.

If, during the interview, any participant becomes

distressed I shall cease the interview. Any ethical

issues that arise during the study will be discussed

in detail with my supervisor.

√

Children N/A

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People who may lack capacity to consent

N/A

Organisational agreement (Q8)

There is no information regarding the premises of where the social media sites will be accessed from (is an agreement required??) √√ Does this mean where I will access the internet from? I will be at home.

√

Recommendation:

Accepted with no required changes

Accepted with minor changes (to be approved by

supervisor)

Accepted subject to changes outlined above (to be

approved by original reviewers)

Rejected – Address changes and resubmit to panel √