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First Birth at Home Or in Hospital in Aotearoa/New Zealand: Intrapartum Midwifery Care and Related Outcomes

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First Birth at Home Or in Hospital in Aotearoa/New Zealand: Intrapartum Midwifery Care and Related Outcomes FIRST BIRTH AT HOME OR IN HOSPITAL IN AOTEAROA/NEW ZEALAND: INTRAPARTUM MIDWIFERY CARE AND RELATED OUTCOMES by Suzanne Claire Miller A thesis submitted to the Victoria University of Wellington in fulfilment of the requirements for the degree of Master of Midwifery Victoria University of Wellington 2008 Abstract A woman’s first birth experience can be a powerfully transformative event in her life, or can be so traumatic it affects her sense of ‘self’ for years. It can influence her maternity future, her physical and emotional health, and her ability to mother her baby. It matters greatly how her first birth unfolds. Women in Aotearoa/New Zealand enjoy a range of options for provision of maternity care, including, for most, their choice of birth setting. Midwives who practice in a range of settings perceive that birth outcomes for first-time mothers appear to be ‘better’ at home. An exploration of this perception seems warranted in light of the mainstream view that hospital is the optimal birth setting. The research question was: “Do midwives offer the same intrapartum care at home and in hospital, and if differences exist, how might they be made manifest in the labour and birth events of first-time mothers?” This mixed-methods study compared labour and birth events for two groups of first-time mothers who were cared for by the same midwives in a continuity of care context. One group of mothers planned to give birth at home and the other group planned to give birth in a hospital where anaesthetic and surgical services were available. Labour and birth event data were collected by a survey which was generated following a focus group discussion with a small group of midwives. This discussion centred around whether these midwives believed their practice differed in each setting, and what influenced care provision in each place. Content analysis of the focus group data saw the emergence of four themes relating to differences in practice: midwives’ use of space, their use of time, the ‘being’ and ‘doing’ of midwifery and aspects relating to safety. Survey data were analysed using SPSS. Despite being cared for by the same midwives, women in the hospital-birth group were more likely to use pharmacological methods of pain management, experienced more interventions (ARM, vaginal examinations, IV hydration, active third stage management and electronic foetal monitoring) and achieved spontaneous vaginal birth less often than the women in the homebirth group. These findings strengthen the evidence that for low risk first-time mothers a choice to give birth at home can result in a greater likelihood of achieving a normal birth. The study offers some insights into how the woman’s choice of birth place affects the care provided by midwives, and how differences in care provision can relate to differences in labour and birth event outcomes. Keywords – birth place, intrapartum care, home childbirth, midwifery, primiparas, mixed methods. ii Acknowledgements I wish to honour those midwives and women who have inspired and sustained me throughout. To the women and babies I have cared for: you were the spark that got me wondering. My colleagues at BirthWorks Midwifery Service have supported me (and challenged me) with generosity, questions, reflections and food both metaphysical and real and I thank you all. My supervisors at Victoria University have sustained me academically, and guided me gently back on track on a number of occasions. Thanks to Professor Maralyn Foureur, Dr Cheryle Moss, Dr Katherine Nelson, and Dr Joan Skinner for your wisdom and belief in me. Most importantly, love and thanks to Jim, Jackson, Finn and Stella: my earth, my water, my fire and my air. You are what keeps me whole. iii TABLE OF CONTENTS Abstract .................................................................................................................................... ii Acknowledgements .................................................................................................................iii Table of Contents ....................................................................................................................iv List of Tables ...........................................................................................................................ix List of Figures ...........................................................................................................................x Introduction: A Whole in One ................................................................................................1 Metaphor and the Content of the Thesis ...............................................................................5 EARTH Grounding the Study Giving Birth for the First Time: Why it Matters to Get it Right.............................................9 Settings for Birth....................................................................................................................13 Giving birth at home ..................................................................................................14 Giving birth in hospital ..............................................................................................16 Physiology and Giving Birth.................................................................................................18 Working with the Sensations of Labour................................................................................20 Summary...............................................................................................................................25 Unearthing the Research Midwifery Care in Different Settings...................................................................................27 Comparing Birth Outcomes in Relation to Place of Birth....................................................33 Comparing Outcomes in Relation to Parity..........................................................................37 Comparing Outcomes in Relation to Practitioner.................................................................38 iv WATER The Study Design Introduction: Two Streams of Thought....................................................................................42 Why Mixed-Methods?..............................................................................................................43 The Mixed-Methods Approach................................................................................................43 Deciding on the Sequence........................................................................................................47 The Babbling Brook that was the Focus Group ..................................................................47 Focus Group Planning and Implementation.............................................................................49 Recruitment of Participants......................................................................................................49 Implementation.........................................................................................................................50 Data Analysis...........................................................................................................................50 Development of the Survey: The Bridge..................................................................................53 Piloting the Survey: Testing the Water....................................................................................54 The Canal that was the Survey .............................................................................................55 Why a Survey?.........................................................................................................................55 Recruitment of Participants......................................................................................................56 Implementation of the Survey..................................................................................................57 Data Analysis of the Survey.....................................................................................................57 Putting the Two Together: Confluence ................................................................................59 Ethical Considerations..............................................................................................................62 Some Thoughts about Rigour, Validity, and Trustworthiness.................................................63 Summary..................................................................................................................................65 v FIRE Findings from the Focus Group and the Survey Mapping the Discursive Landscape: The Focus Group .....................................................66 Beginnings................................................................................................................................68 Time.........................................................................................................................................69 Who’s Safety and Who’s Danger?...........................................................................................73 Midwives’ Use of Space..........................................................................................................78 The ‘Being’ and ‘Doing’ of Midwifery..................................................................................82 The first half hour ........................................................................................................82
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