Elsevier

Midwifery

Volume 66, November 2018, Pages 134-140
Midwifery

Birthplace in Australia: Antenatal preparation for the possibility of transfer from planned home birth

https://doi.org/10.1016/j.midw.2018.08.005Get rights and content

Highlights

  • Back-up hospital bookings reduce uncertainty for all concerned in the event of transfer.

  • Women found it helpful to feel open to the possibility, prior to a transfer.

  • Feeling open to transfer during pregnancy involved seeking information and exploring feelings.

  • Homebirth midwives fostered professional connections with hospitals, to enhance collaboration.

Abstract

Objective

The aim of the study was to explore how women and midwives prepare, during the antenatal period, for the possibility of intrapartum transfer from planned home birth.

Design

A Constructivist Grounded Theory approach was taken in order to focus upon the social interactions and processes that emerged.

Setting

Urban and regional areas in four states of south eastern Australia.

Participants

Thirty-one semi-structured interviews were conducted with women and midwives.

Findings

There were three sub-categories relating to preparation for the possibility of transfer. These were 'Building the midwife–woman partnership', 'Fostering professional connections' and 'Reducing uncertainty'. The reciprocal trust inherent in the midwife–woman partnership helped women feel safe in relation to the possibility of intrapartum transfer to hospital. Midwives who had positive transfer experiences spoke about their commitment to fostering professional connections with hospitals and health professionals as a part of building the capacity for collaboration if, and when, a transfer occurred. Reducing uncertainty involved preparation that included not only providing information and emotional support to the woman around the possibility of transfer, but also arranging for her to book in to a back-up hospital.

Introduction

The safety of planned home birth for women with low risk pregnancies, when professional midwifery care and adequate collaborative arrangements for referral and transfer are in place, has been supported in a number of studies, especially for women having their second and subsequent babies (Brocklehurst et al., 2011, Catling-Paull et al., 2013, de Jonge et al., 2009, de Jonge et al., 2013, Hutton et al., 2016, Keirse, 2014). In Australia, relatively few women give birth at home. For example, in 2013, only 0.3% of all births occurred at home (Australian Institute of Health and Welfare, 2015). Publicly funded home births have emerged as a model of maternity care in Australia, with approximately 15 services established in the past decade (Catling-Paull et al., 2011, 2012, Catling-Paull et al., 2013, Chapman and Matha, 2011, McMurtrie et al., 2009). Women may also access home birth in Australia by engaging a privately practising midwife, who is self-employed and working either in a group practice or independently. Privately practising midwives provide antenatal and postnatal care in the community and may also offer home birth care and/or birth support in a hospital.

For pregnant women planning to give birth at home, the possibility of intrapartum transfer is real and may be daunting. Transfer rates vary across different settings (Table 1) and range from 8% to 28%, depending on the context. Reasons for variations in transfer rates between services are complex and a detailed analysis is beyond the scope of this article. However, women having their first baby are more likely to require transfer than women having their second or subsequent baby (Blix et al., 2012, 2014, Blix et al., 2016, Brocklehurst et al., 2011, Fox et al., 2014, Tyson, 1991, Wiegers et al., 1998). Other reasons may include variations in local policy and practice around the threshold for transfer, and may depend upon travel time to hospital (longer travel times may mean higher transfer rates due to concerns about potential emergency transfers).

In preparing pregnant women for the possibility of transfer, midwives usually provide information about the processes of transfer and ensure that women are willing to acknowledge the potential that transfer may occur (Vedam and Kolodji 1995). It has been suggested that it may be helpful to frame these discussions in the context of decision making about the safest place to give birth in the clinical circumstances at the time (Ball et al., 2016). There is a paucity of literature that addresses the ways in which women and midwives prepare for the possibility of transfer from planned home birth. This study addresses this gap, by exploring the experiences and views of women, midwives and hospital staff about what information they need to have in place to assist them in caring for transferred women.

The aim of this study, therefore, was to explore antenatal preparation for the possibility of intrapartum transfer from planned home birth, for women, their midwives and hospital staff. This includes the ways in which pregnant women planning to give birth at home prepared for the possibility of transfer, what their midwives did to support their preparation, and what antenatal preparations hospital staff found assisted them to provide optimal care for women transferred into their birth unit. Issues related to intrapartum and postpartum phases of care are not addressed in this article. We have previously published on processes and interactions during intrapartum transfers from planned home birth (Fox et al. 2018).

Section snippets

Methodology

This article is derived from a larger, qualitative PhD study exploring the views and experiences of women, midwives and obstetricians involved in the intrapartum transfer of women from planned home birth to hospital. In Australia, obstetricians may counsel women about their place of birth choices but do not usually have a role in preparing women for the possibility of transfer from planned home birth. Hence, data from obstetricians is not included in this article. The data collected from the

Data generation (collection and analysis)

The term ‘data generation’ is used in constructivist grounded theory to encompass data collection and analysis, because these two processes occur simultaneously. Thirty-one semi-structured interviews were conducted with women and midwives in 2014 and 2015. The interviews were audio recorded and transcribed immediately. Field notes were taken, to describe the setting and context of the interview, and to make note of significant non-verbal actions and interactions.

Initial and focussed coding,

Findings

The Findings, ‘Fostering relationships and reducing uncertainty’, comprise three sub-categories that relate to preparation for the possibility of transfer. These were ‘Building the midwife–woman partnership’, ‘Fostering professional connections’ and ‘Reducing uncertainty’. The sub-categories are linked and overlapping, because the interactions involved in fostering relationships helped to reduce uncertainty. Likewise, processes of reducing uncertainty brought about interactions that fostered

Building the midwife–woman partnership

The reciprocal trust inherent in the midwife–woman partnership was mentioned frequently in relation to preparing for the possibility of transfer. Midwives were aware that trust played a key role in women's decision making if, and when, a transfer became necessary: ‘It is unusual…that a woman won't transfer if we encourage it, because they tend to trust us…we develop that trust through the pregnancy’ (Kim, HBM). Women trusted their midwives to recognise when transfer was indicated. One woman

Reducing uncertainty

Receiving information about transfer reduced uncertainty for women by helping them to attach meaning to how the processes of transfer might unfold in their individual circumstances. During pregnancy, women asked their midwives questions such as, ‘What if I did need to be transferred, what would happen?’ (Belinda, home birth woman). Such questions led to discussions about the practicalities of transfer, which reduced uncertainty about managing variations of normal. ‘We had a lot of conversations

Discussion

The aim of the study was to explore antenatal preparation for the possibility of transfer from planned home birth, for women, their midwives and hospital staff. This is important because of the influence such preparations have upon the processes and interactions that will unfold in the event of transfer.

The Findings, ‘Fostering relationships and reducing uncertainty’, include linked and overlapping sub-categories. They are overlapping because the interactions involved in fostering relationships

Conclusion

This is the first qualitative study to synthesise the views and experiences of women and midwives about preparations for the possibility of intrapartum transfer of women from a planned home birth. Previous studies have focussed upon the experiences of either women or midwives. This study adds to the literature by demonstrating how hospitals may play a role in making admissions more efficient for their staff, and the transition more seamless for women and their midwives.

Recommendations for

Conflict of interest

The first author reports grants from National Health and Medical Research Council Australia, grants from Australian College of Midwives, and grants from Nurses' Memorial Centre, Australia, during the conduct of the study. For further details, please refer to Conflict of Interest (COI) declaration form attached to the submission.

Ethical approval was granted by the HRECs of the University of Technology Sydney

(Approval number UTS HREC REF NO. 2014000069), the Government of South Australia Women and Children's Health Network (HREC/13/WCHN/179) and the New South Wales Health Hunter New England Local Health District (14/04/09/4.04).

Funding sources

The first author reports grants from National Health and Medical Research Council Australia, grants from Australian College of Midwives, and grants from Nurses' Memorial Centre, Australia, during the conduct of the study. For details please see COI declaration form attached to the submission.

Key conclusions and implications for practice

Aligning the needs of women and caregivers with hospital policies may improve interactions and processes during intrapartum transfer from planned home birth. Where visiting rights for privately practising midwives are not available, quality of care in the home birth transfer context could be enhanced through access to hospital booking in services for women planning a home birth. Opportunities to build connections between home birth midwives and hospital staff need to be supported, to improve

Acknowledgements

The first author was supported by a Ph.D. scholarship from a National Health and Medical Research Council Project that funds the Birthplace in Australia Study at The University of Technology Sydney (Grant ID. 1022422). Additional funding was provided by the Australian College of Midwives and the Nurses’ Memorial Centre. The authors also wish to thank the women, midwives and obstetricians who generously participated in this study.

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