Introduction
Maternity and Neonatal care in England, Scotland and Wales is based on the principle of providing continuity of care during pregnancy, labour, birth and postpartum period.1-3 Based on these policies and previous reports4, maternity care is organised from community to hospital maternity and neonatal units in a stratified fashion whereby the care is flexible and responsive to the needs of individual mothers and babies. This provides women with choices about their preferred place of birth from: home; to small community maternity units; to large consultant obstetric and neonatal facilities where services such as epidurals are available. This choice is primarily available to women who do not have pregnancy complications or underlying medical conditions.
This model enhances outcomes for women including lower rates of induction of labour, fewer intra-partum interventions and higher rates of spontaneous vaginal births and breastfeeding babies.5-7 Maternity services across England Scotland and Wales are working in partnership with women and their families to implement national and local policies to make maternity services safer and more personal.8, 9 However, there are challenges in delivering a breadth of options to women living in geographically isolated and remote areas, as was recognised in the Morecambe Bay Report.10
There are two potentially competing policy drivers: care closer to home11 and a drive to reduce in morbidity and mortality rates, which are used internationally as markers of high quality care.12 The dilemma is particularly acute in remote and rural settings. Hoang et al. 13reviewed qualitative studies on rural maternity care and found 12 studies across four countries (Australia, Canada, Scotland and England). The main themes from the research were: the challenges rural women face accessing services; women’s expectations about service quality; and safety of care. Midwifery led care, was associated with personal care, locally accessed care and appropriate risk assessment. Safety was considered alongside the long distances that women and babies may have to travel to access care. Across the studies a medical model of care, able to deal with all obstetric and neonatal emergencies was considered as the safest. Access challenges affected women and also their family and had financial implications. Pitchforth et al. 14, 15 found women associated consultant-led care with increased safety, although many women had, or thought they had, no choice of place of birth. Kornelsen and Grzybowski 16found that women recognised that their childbirth experience was affected by geographic location, the healthcare resources available and by their parity.17 Women tried to overcome these challenges by having induced labour, timing pregnancy to avoid winter due dates, presenting late to avoid transfer, or choosing to give birth at home (unassisted). All women were aware of the logistical problems of giving birth away from home and worried about on-route birth. Most women were anxious about the financial costs of being away, and the cost to their partner of missed work.
The research described above is somewhat dated, and expectations of pregnant women in relation to where they give birth merits fresh research. This study has therefore undertaken to update our understand women’s knowledge of obstetric and paediatric risks during pregnancy and understand the relationship between women’s knowledge of these risks, the care they received and the care they wanted.