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.