Women's experiences of transfer from a midwife-led to a consultant-led maternity unit in the UK during late pregnancy and labor

All the right moves: why in utero transfer is both important for the baby and difficult to achieve and new strategies for change

The best way to ensure that preterm infants benefit from relevant neonatal expertise as soon as they are born is to transfer the mother and baby to an appropriately specialised neonatal facility before birth (“ in utero”). This review explores the evidence surrounding the importance of being born in the right unit, the advantages of in utero transfers compared to ex utero transfers, and how to accurately assess which women are at most risk of delivering early and the challenges of in utero transfers.

Accurate identification of the women most at risk of preterm birth is key to prioritising who to transfer antenatally, but the administrative burden and pathway variation of in utero transfer in the UK are likely to compromise optimal clinical care. Women reported the impact that in utero transfers have on them, including the emotional and financial burdens of being transferred and the anxiety surrounding domestic and logistical concerns related to being away from home. The final section of the review explores new approaches to reforming the in utero transfer process, including learning from outside the UK and changing policy and guidelines. Examples of collaborative regional guidance include the recent Pan-London guidance on in utero transfers. Reforming the transfer process can also be aided through technology, such as utilising the CotFinder app.

In utero transfer is an unavoidable aspect of maternity and neonatal care, and the burden will increase if preterm birth rates continue to rise in association with increased rates of multiple pregnancy, advancing maternal age, assisted reproductive technologies, and obstetric interventions. As funding and capacity pressures on health services increase because of the COVID-19 pandemic, better prioritisation and sustained multi-disciplinary commitment are essential to maximise better outcomes for babies born too soon.

Disconnection: Exploring transfer from midwifery-led to consultant-led care a phenomenological study of women's views

BACKGROUND

Understanding women's feelings during the transfer process can illuminate women's perspectives thus minimising the risk for postnatal psychological and emotional morbidity, and inform midwifery practice.

AIM

To explore the meaning women ascribe to their feelings when transferred from an environment emphasising a social model of pregnancy and birth in a Midwifery Led Unit, to a contrasting, more 'medicalised' setting of a Consultant Led Unit.

METHODS

The study adopted an idiographic focus, by conducting semi-structured interviews with new mothers. A purposive sample of eleven women was recruited via participating midwifery led units and their 'Facebook' page. An interpretative phenomenological approach was selected to explore mothers' individual perceptions of experiences.

FINDINGS

Participants described feeling a strong sense of community in the midwifery led unit, where they enjoyed a sense of belonging, safety, and support. The overarching theme of 'disconnection' signified feelings of muted agency when transferred to a different environment. Women used adaptive processes to reconcile themselves to a medicalised ideology. The impact of the transfer also resulted in a sense of alienation and 'not belonging'.

CONCLUSION

Adjustment to a different model of care meant women needed to rapidly amend their notions of normality and agency, at the same time as entering motherhood. Raising awareness about the possible psychological adjustments women have to make during at this time could provide reassurance to other women. It also highlights the need for support during and after transfer. Strengthening continuity of care could help facilitate the adjustment process.

Remote rural women's choice of birthplace and transfer experiences in rural Otago and Southland New Zealand

BACKGROUND

Birth in primary midwife-led maternity units has been demonstrated to be a safe choice for well women anticipating a normal birth. The incidence of serious perinatal outcomes for these women is comparable to similarly low risk women, who choose to birth in hospital. New Zealand women have a choice of Lead Maternity Carer (LMC) and birthplace; home, primary birthing unit, or a base hospital, though not all women may have all these choices available locally. Women in rural and rural remote areas can also choose to birth in their rural primary maternity unit. A percentage of these women (approx. 15-17%) will require transfer during labour, an event which can cause distress and often loss of midwifery continuity of care.

OBJECTIVE

To explore retrospectively the choice of birth place decisions and the labour and birth experiences of a sample of women resident in remotely zoned, rural areas of the lower South Island of New Zealand.

DESIGN

A purposive sample of women living in remote rural areas, recruited by advertising in local newspapers and flyers. Individual semi-structured interviews were digitally recorded using a pragmatic interpretive approach. The data (transcripts and field notes) were analysed using thematic and content analysis. Ethical approval was obtained from the Health and Disability Ethics Committee (HEDC) MEC/06/05/045.

PARTICIPANTS

Thirteen women consented to participate. Each was resident in a remote rural area having given birth in the previous 18 months. The women had been well during their pregnancies and at the onset of labour had anticipated a spontaneous vaginal birth.

SETTING

Rural remote zoned areas in Otago and Southland in the South Island of New Zealand FINDINGS: Five women planned to birth in a regional hospital and eight chose their nearest rural primary maternity unit. All of the women were aware of the possibility of transfer and had made their decision about their birthplace based on their perception of their personal safety, and in consideration of their distance from specialist care. Themes included, deciding about the safest place to give birth; making the decision to transfer; experiencing transfer in labour, and reflecting on their birth experience and considering future birthplace choices.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE AND POLICY

The experiences of the women show that for some, distance from a base hospital influences their place of birth decisions in remote rural areas of New Zealand and increases the distress for those needing to transfer over large distances. These experiences can result in women choosing, or needing to make different choices for subsequent births; the consequences of which impact on the future sustainability of midwifery services in remote rural areas, a challenge which resonates with maternity service provision internationally. While choices about birth place cannot be reliably predicted, creative solutions are needed to provide rural midwifery care and birth options for women and more timely and efficient transfer services when required.

Women's experience of intrapartum transfer from a Western Australian birth centre co-located to a tertiary maternity hospital

BACKGROUND

The aim of this Western Australian study was to describe the overall labour and birth experience of women who were transferred during the first and second stages of labour from a low risk woman-centred, midwifery-led birth centre to a co-located tertiary maternity referral hospital.

METHODS

Using a descriptive phenomenological design, fifteen women were interviewed up to 8 weeks post birth (July to October, 2013) to explore their experience of the intrapartum transfer. Giorgi's method of analysis was used.

RESULTS

The following themes and subthemes emerged: 1) The midwife's voice with subthemes, a) The calming effect and b) Speaking up on my behalf; 2) In the zone with subthemes, a) Hanging in there and b) Post birth rationalizing; 3) Best of both worlds with subthemes a) The feeling of relief on transfer to tertiary birth suite and b) Returning back to the comfort and familiarity of the birth centre; 4) Lost sense of self; and 5) Lost birth dream with subthemes a) Narrowing of options and b) Feeling of panic. Women found the midwife's voice guided them through the transfer experience and were appreciative of continuity of care. There was a sense of disruption to expectations and disappointment in not achieving the labour and birth they had anticipated. There was however appreciation that the referral facility was nearby and experts were close at hand. The focus of care altered from woman to fetus, making women feel diminished. Women were glad to return to the familiar birth centre after the birth with the opportunity to talk through and fully understand their labour journey which helped them contextualise the transfer as one part of the whole experience.

CONCLUSIONS

Findings can inform midwives of the value of a continuity of care model within a birth centre, allowing women both familiarity and peace of mind. Maternity care providers should ensure that the woman remains the focus of care after transfer and understand the significance of effective communication to ensure women are included in all care discussions.

Women's experiences of transfer from primary maternity unit to tertiary hospital in New Zealand: part of the prospective cohort Evaluating Maternity Units study

Background

There is worldwide debate regarding the appropriateness and safety of different birthplaces for well women. The Evaluating Maternity Units (EMU) study’s primary objective was to compare clinical outcomes for well women intending to give birth in either a tertiary level maternity hospital or a freestanding primary level maternity unit. Little is known about how women experience having to change their birthplace plans during the antenatal period or before admission to a primary unit, or transfer following admission. This paper describes and explores women’s experience of these changes-a secondary aim of the EMU study.

Methods

This paper utilised the six week postpartum survey data, from the 174 women from the primary unit cohort affected by birthplace plan change or transfer (response rate 73 %). Data were analysed using descriptive statistics and thematic analysis. The study was undertaken in Christchurch, New Zealand, which has an obstetric-led tertiary maternity hospital and four freestanding midwife-led primary maternity units (2010–2012). The 702 study participants were well, pregnant women booked to give birth in one of these facilities, all of whom received continuity of midwifery care, regardless of their intended or actual birthplace.

Results

Of the women who had to change their planned place of birth or transfer the greatest proportion of women rated themselves on a Likert scale as unbothered by the move (38.6 %); 8.8 % were ‘very unhappy’ and 7.6 % ‘very happy’ (quantitative analysis). Four themes were identified, using thematic analysis, from the open ended survey responses of those who experienced transfer: ‘not to plan’, control, communication and ‘my midwife’. An interplay between the themes created a cumulatively positive or negative effect on their experience. Women’s experience of transfer in labour was generally positive, and none expressed stress or trauma with transfer.

Conclusions

The women knew of the potential for change or transfer, although it was not wanted or planned. When they maintained a sense control, experienced effective communication with caregivers, and support and information from their midwife, the transfer did not appear to be experienced negatively. The model of continuity of midwifery care in New Zealand appeared to mitigate the negative aspects of women’s experience of transfer and facilitate positive birth experiences.

Continuity of care: what matters to women when they are referred from primary to secondary care during labour? a qualitative interview study in the Netherlands

BACKGROUND

Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care.

METHODS

A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used.

RESULTS

Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women's personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital.

CONCLUSIONS

In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a fluid concept rather than a dichotomous choice.

An ethnographic organisational study of alongside midwifery units: a follow-on study from the Birthplace in England programme

Background

Alongside midwifery units (AMUs) were identified as a novel hybrid organisational form in the Birthplace in England Research Programme, to which this is a follow-on study. The number of such units (also known as hospital birth centres) has increased greatly in the UK since 2007. They provide midwife-led care to low-risk women adjacent to maternity units run by obstetricians, aiming to provide a homely environment to support normal childbirth. Women are transferred to the obstetric unit (OU) if they want an epidural or if complications occur.

Aims

This study aimed to investigate the ways that AMUs in England are organised, staffed and managed. It also aimed to look at the experiences of women receiving maternity care in an AMU and the views and experiences of maternity staff, including both those who work in an AMU and those in the adjacent OU.

Methods

An organisational ethnography approach was used, incorporating case studies of four AMUs, selected for maximum variation on the basis of geographical context, length of establishment of an AMU, size of unit, management, leadership and physical design. Interviews were conducted between December 2011 and October 2012 with service managers and key stakeholders (n = 35), with professionals working within and in relation to AMUs (n = 54) and with postnatal women and birth partners (n = 47). Observations were conducted of key decision-making points in the service (n = 20) and relevant service documents and guidelines were collected and reviewed.

Findings

Women and their families valued AMU care highly for its relaxed and comfortable environment, in which they felt cared for and valued, and for its support for normal birth. However, key points of transition for women could pose threats to equity of access and quality of their care, such as information and preparation for AMU care, and gaining admission in labour and transfer out of the unit. Midwives working in AMUs highly valued the environment, approach and the opportunity to exercise greater professional autonomy, but relations between units could also be experienced as problematic and as threats to professional autonomy as well as to quality and safety of care. We identified key themes that pose potential challenges for the quality, safety and sustainability of AMU care: boundary work and management, professional issues, staffing models and relationships, skills and confidence, and information and access for women.

Conclusions

AMUs have a role to play in contributing to service quality and safety. They provide care that is satisfying for women, their partners and families and for health professionals, and they facilitate appropriate care pathways and professional roles and skills. There is a potential for AMUs to provide equitable access to midwife-led care when midwifery unit care is the default option (opt-out) for all healthy women. The Birthplace in England study indicated that AMUs provide safe and cost-effective care. However, the opportunity to plan to birth in an AMU is not yet available to all eligible women, and is often an opt-in service, which may limit access. The alignment of physical, philosophical and professional boundaries is inherent in the rationale for AMU provision, but poses challenges for managing the service to ensure key safety features of quality and safety are maintained. We discuss some key issues that may be relevant to managers in seeking to respond to such challenges, including professional education, inter- and intraprofessional communication, relationships and teamwork, integrated models of midwifery and women’s care pathways. Further work is recommended to examine approaches to scaling up of midwifery unit provision, including staffing and support models. Research is also recommended on how to support women effectively in early labour and on provision of evidence-based and supportive information for women.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Women's experience of transfer from midwifery unit to hospital obstetric unit during labour: a qualitative interview study

BACKGROUND

Midwifery units offer care to women with straightforward pregnancies, but unforeseen complications can arise during labour or soon after birth, necessitating transfer to a hospital obstetric unit. In England, 21% of women planning birth in freestanding midwifery units are transferred; in alongside units, the transfer rate is 26%. There is little high quality contemporary evidence on women's experience of transfer.

METHODS

We carried out a qualitative interview study, using semi-structured interviews, with women who had been transferred from a midwifery unit (freestanding or alongside) in England up to 12 months prior to interview. Maximum variation sampling was used. Interviews with 30 women took place between March 2009 and March 2010. Thematic analysis using constant comparison and exploration of deviant cases was carried out.

RESULTS

Most women hoped for or expected a natural birth and did not expect to be transferred. Transfer was disappointing for many; sensitive and supportive care and preparation for the need for transfer helped women adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from freestanding units, the ambulance journey was a "limbo" period. Women wondered, worried or were fearful about what was to come and could be passive participants who felt like they were being "transported" rather than cared for. For many this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but did not necessarily seek this out if it was not offered.

CONCLUSIONS

Transfer affects a significant minority of women planning birth in midwifery units and is therefore a concern for women and midwives. Transfer is not expected by women, but sensitive care and preparation can help women adjust to changing circumstances. Particular sensitivity around decision-making may be required by midwives caring for women during prolonged labour. Some apparently straightforward changes to practice have the potential to make an important difference to women's experience of ambulance transfer.

The best of both worlds--parents' motivations for using an alongside birth centre from an ethnographic study

OBJECTIVE AND DESIGN

An ethnographic study was undertaken in a birth centre to explore the model of care provided there from the perspectives of midwives and parents.

SETTING

A five birthing-room, alongside, inner-city, birth centre in England, situated one floor below the hospital labour ward, separately staffed by purposively recruited midwives.

PARTICIPANTS

Around 114 hours were spent at the birth centre observing antenatal, intrapartum and postnatal care; 11 in-depth interviews were recorded with parents after their baby's birth (four with women; seven with women and men together), including three interviews with women who transferred to the labour ward, and 11 with staff (nine midwives and two maternity assistants).

FINDINGS

Most women and men using the birth centre perceived it as offering the 'best of both worlds' based on its proximity to and separation from the labour ward. It seemed to offer a combination of biopsychosocial safety, made evident by the calm, welcoming atmosphere, the facilities, engaging, respectful care from known midwives and a clear commitment to normal birth, and obstetric safety particularly because of its close proximity to the labour ward.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This alongside birth centre provided a social model of care and appealed strongly to a group of parents; similar birth centres should be widely available throughout the NHS.

The impact of choice of maternity care on psychological health outcomes for women during pregnancy and the postnatal period

RATIONALE

Psychological factors are acknowledged to impact on pregnancy, birth, neonatal outcomes and maternal mental health. The importance of psychological well-being is now recognized within maternity care and UK maternity policy advocates choice and control, equating this to increased quality of experience and improved psychological outcomes. There remains, however, lack of substantive and consistent evidence with regard to the psychological benefits of choice in maternity care. The aim of this study is to investigate the impact of choice of maternity care on psychological health outcomes.

METHODS

165 antenatal women were recruited and sampled according to their choices for care. Women were assessed utilizing the Hospital Anxiety and Depression Scale (HADS), Edinburgh Postnatal Depression Scale (EPDS), Cambridge Worry Scale (CWS), Multidimensional Health Locus of Control (MHLC), SF-36, Pittsburgh Sleep Quality Index (PSQI) and Culture Free Self-esteem Inventory (CFSEI) at 12 and 32 weeks pregnant and 14 days and 6 months postnatal.

RESULTS

No significant differences between groups were revealed on any of the scales or subscales measured. Significant and corresponding differences were identified within groups over time for CWS socio-medical worries, MHLC 'powerful others', SF-36 bodily pain, vitality personal health and change in health, PSQI global sleep. An interaction effect for CFSEI general and social self-esteem was revealed between birth centre and midwifery-led care/main unit women at 14 days postnatal.

CONCLUSIONS

These results demonstrate that pregnancy represents a psychological challenge regardless of care type chosen and choice of no one care option confers greater psychological benefit across the maternity experience as a whole. It is possible, however, that differences in experience or environment at critical times can affect psychological status.

Do we have enough evidence to judge midwife led maternity units safe? No

The UK government claims it is trying to give women more choice by converting local maternity units to midwife led services. Lesley Page believes such units improve the birth experience, but Jim Drife remains worried about the risks of delivering outside hospital

The impact of the establishment of a midwife managed unit on women in a rural setting in England

OBJECTIVE

to determine what impact the changes from consultant-led care to midwife-led care in a local maternity service have had on women using that service.

DESIGN

case study, data were collected by postal questionnaire, semi-structured, tape-recorded interviews, observations and scrutiny of records.

SETTING

a small town in rural England.

PARTICIPANTS

all pregnant women eligible for a midwife-managed unit (MMU) birth in a small rural town in England.

FINDINGS

the women using the MMU were satisfied with the care they received and the MMU style of care. Women giving birth at the MMU and at home required less pain relief and were more likely to have an intact perineum than a similar group of women giving birth in hospital. Continuity of carer did not appear to be an issue for women as long as they felt supported by a known team of midwives. Transfer for complications during the birthing process was a cause for anxiety and stress for women and their partners. Women, whilst satisfied with the MMU, would prefer the consultant-led maternity hospital to be re-established in the town. The home-birth rate rose by 28% when the consultant unit closed.

IMPLICATIONS FOR PRACTICE

while the establishment of a midwife-managed unit has provided increased choice for a minority of women, the removal of the consultant unit in the town has disadvantaged the majority of pregnant women. While guidelines are needed when establishing these units the application of restrictive inclusion and exclusion criteria can sometimes force women to make less appropriate birth choices.

A comparative study in Stockholm, Sweden of labour outcome and women's perceptions of being referred in labour

OBJECTIVE

to study the outcome of labour and women's perceptions of being referred after onset of labour.

DESIGN

a comparative study carried out between October 1998 and April 1999.

SETTING

prospective parents in Stockholm, Sweden are offered a choice of which of the five hospitals in which they want to give birth. In reality, there is a lack of maternity beds in Stockholm to implement this policy and therefore nearly 10% of labouring women are being referred during labour.

PARTICIPANTS

the study population was selected from one of the five hospitals. Included in the study were 266 labouring women, with a 37-42 weeks uncomplicated pregnancy, fetus presenting by the vertex and spontaneous onset of labour. During pregnancy, all the women had chosen the same labour ward where they planned to deliver. However, at the onset of labour half of the women, case group I (n = 133) were referred to another maternity unit due to lack of space in the labour ward. For every referred woman a control woman matched for age, parity and date of delivery was selected, with the same inclusion criteria, except being referred, control group II (n = 133).

METHODS

a questionnaire with closed and open questions was posted to the women after birth and used to collect quantitative and qualitative data on the outcome of labour and the women's perceptions of referral during labour.

FINDINGS

routines such as epidural analgesia (EDA) (p<0.002), episiotomies (p<0.015) and morphine/pethidine during labour (p<0.023) were more common in the referred group. The women in the referred group considered to a higher extent that referral during labour had affected their emotional state (p<0.001). Women in both groups had been worried during pregnancy by the thought of having to be referred when labour had started and the referral had caused practical problems, stress and a feeling of not being welcome in the referral labour ward.

KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE

referral during established normal labour may affect labour outcome, and the possibility that they may be referred worries women during pregnancy. Maternity policies and practices should be organised so that caring goals, such as continuity of care and women's' participation in birth planning, can be met.