Background
Methods
Eligibility criteria
Type of report
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Full primary research reports, published in a scientific journal between January 1992 and February 2015, in English.
Topic of research
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Studies designed to describe and explore women’s preferences in relation to place of birth.
Research design
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Quantitative studies including experimental stated preference studies, surveys and other quantitative studies designed to describe or explore women’s preferences, and, mixed methods studies that included an eligible quantitative study. For mixed methods studies, eligibility criteria were applied solely to the quantitative component of the study.
Study population and setting
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Studies that collected data from other groups such as partners, healthcare professionals or women of childbearing age irrespective of pregnancy history.
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Studies that contained only incidental quantitative data on women’s preferences.
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Studies that reported only descriptive data on women’s reasons for choosing or not choosing a particular maternity unit or setting where the quantitative component of the study was not explicitly designed to describe or explore women’s preferences.
Search strategy
Study selection
Quality assessment
Data extraction and analysis
Results
Results of the search
Description of included studies
Study | Study context/objective | Methods, sample characteristics, response rate and sample size | Study period | Choices compared |
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Donaldson (1998) [19] | This study was conducted in Aberdeen (Scotland), an area with an OU and an AMU in the same hospital, to assess the feasibility of the use of ‘willingness to pay’ as a measure of women’s strengths of preference for intrapartum care (OU vs. AMU). | Methods: Willingness to pay study designed to evaluate ‘low risk’ women’s preference for type of intrapartum care (OU vs. AMU) at around the time of the booking visit. Questionnaires were mailed to ‘low risk’ women before booking. Sample characteristics: Women at ‘low obstetric risk’. No details reported. Response rate: 75 %, n = 113 (only 102 questionnaires (69 %) were used for analysis for various reasons). | May 1994 | Hypothetical attributes of OU vs. AMU. |
Emslie (1999) [21] | This study was conducted to explore women’s preferences and experiences following the opening of an FMU in the study area (Peterhead near Aberdeen in Scotland). Women in this area had four choices: home birth, FMU and both OU and AMU available approximately 35 miles away (in Aberdeen). A DOMINO (Domiciliary in and out) delivery service was also available to women registered with the FMU. The FMU was based in the Peterhead Community Hospital. The largest general practice is located in Peterhead with two rural practices in the surrounding area. | Methods: Questionnaire survey mailed to women in the FMU’s catchment area at around 14 weeks gestation, at 36 weeks gestation and 6 weeks postnatally. This survey was one component of a mixed methods study. Sample characteristics: Over half (59 %) of respondents (n = 254) were registered with the main GP practice in the FMU catchment area; 41 % of women were nulliparous; 70 % were aged under 29 years and 28 % were under 24 years of age. Response rate: 77 % for 14 week survey, n = 254. Of these 83 % responded to 36 week survey, n = 210. | January to December 1995 | Study focuses on FMU vs. hospital (OU/AMU) choices made by women in the catchment area of a newly opened FMU. |
Hundley (2001) [16] | Pilot study to explore feasibility of using discrete choice experiment to assess women’s preferences for aspects of intrapartum care. The study was conducted in three areas in Grampian, Scotland where different models of care were available. Linked study: Hundley (2004). | Methods: Discrete choice experiment. Data were collected by postal questionnaire from women recruited at booking. Sample characteristics: Of the 301 ‘low risk’ respondents, the mean age was 28; 55 % were nulliparous; the vast majority (91 %) were married or cohabiting. The women were more socioeconomically advantaged than the national population. Response rate: Estimated response rate was 40 %, n = 301. | January to November 1999 | Study evaluates preferences for different service attributes. |
Hundley (2004) [15] | This study was conducted to investigate the effect of service provision on consumer preferences, in particular, whether women who have access to systems of care which offer particular attributes value these attributes more highly than women for whom the attributes are not a realistic option. Three groups of ‘low risk’ women participated from areas with different services available (OU/AMU, FMU and OU/AMU without an epidural service). The areas also differed in the degree of continuity of carer offered. For primary report see Hundley (2001). | Methods: Discrete choice experiment. Data were collected by postal questionnaire from women recruited at booking. Sample characteristics: See Hundley (2001) for characteristics of the overall sample. ‘Low risk’ women in the three study groups were similar, but there were more nulliparous women in the Aberdeen (OU/AMU) group and women in the Elgin (OU/AMU without epidural service) group were less deprived. The Peterhead and Elgin groups were relatively small (n = 48 and n = 60) compared to the Aberdeen group (n = 193). Response rate: Estimated response rate overall was 40 %. Response rate varied by area (33 %–44 %), n = 301 (193 from the Aberdeen group, 48 from the Peterhead Group and 60 from the Elgin group). | January to November 1999 | Preferences for particular service attributes in women with access to: OU/AMU vs. FMU ~30 miles from OU/AMU vs. OU/AMU without an epidural service. |
Lavender (2005) [22] | This project was commissioned by the Department of Health (UK) to inform the Children’s National Service Framework. The aim was to identify models of maternity care which provide a safe, equitable and sustainable service that meets the needs of the current and future population and offers choice to women. | Methods: Questionnaire survey of pregnant women in a purposive sample of 12 maternity units in England. Units were included that offered different birth settings (home, FMU, AMU and OU) and varied in size (50 births to 6000 births). This survey was one component of a mixed methods study. Sample characteristics: Half (51 %) of the 2071 questionnaires returned were from district general hospitals (presumed to be OUs), 38 % were from university hospitals incorporating midwife-led units (presumed to be OU/AMUs) and 11 % were from FMUs. The mean age of participants was 29 and the mean gestational age was 29 weeks. Just over half (54 %) were multigravid with most having given birth to one child previously (46 %); 84 % were ‘white-European’ and 90 % had English as a first language; approximately 15 % (n = 303) were classified as being from ‘ethnic minority groups’. Response rate: Overall 71 %, with unit response rates varying from 59 to 85 %. n = 2071. | January to March 2002 | Preferences for a range of service attributes. |
Pitchforth (2008) [20] | A discrete choice experiment to evaluate preferences for key attributes of intrapartum care in women living in remote rural areas in Scotland served by FMUs and small consultant units without neonatal facilities. | Methods: Discrete choice experiment. Sample characteristics: The mean age of respondents was 30 years, 43 % women had delivered their first baby. Response rate: 62 %, n = 877 (including 22 of whom returned blank questionnaires). | April 2004 to January 2005 | Preference for hypothetical attributes of midwifery-led vs. consultant care |
Rennie (1998) [23] | A pilot study to identify women’s preferences for aspects of intrapartum care and to evaluate whether they differ in the postnatal period compared with late pregnancy. | Methods: A questionnaire survey of pregnant women at around 34 weeks gestation, with a follow-up questionnaire 10 days after the birth. Sample characteristics: Despite stratified sampling there was a preponderance of nulliparous women (65 %); 81 % of participants were married and two thirds (66 %) were owner occupiers. Most (70 %) were planning to attend antenatal education. The mean age of respondents was 27. Response rate: 96 % for the 34 week survey (n = 207); 86 % of respondents also completed the postnatal questionnaire (n = 185). | February to March 1996 | Study focuses on service attributes preferred antenatally vs. postnatally. |
Rogers (2011) [24] | This study was conducted to evaluate the viability of converting an AMU in outer London to an FMU following the planned closure of the OU in the hospital. The study focused on whether users of the existing AMU would choose the new FMU or would look for an alternative. | Methods: A questionnaire survey conducted amongst a cross-sectional sample of ‘AMU users’: women who were either booked, considering booking or who had given birth at the AMU situated in a hospital where a relocation of the OU was planned. Sample characteristics: The majority of study participants were pregnant (89 %) and the remaining 11 % had just had a baby. Sixty percent of participants were nulliparous. Response rate: 53 %, n = 121. | October 2009 | AMU vs. FMU |
Methodological quality of included studies
Women’s preferences and service attributes influencing choice
Study & method | Preferences evaluated |
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Donaldson (1998) [19]
Willingness to pay
| Labour ward vs. midwives unit |
Labour ward characterised as: | |
- Doctors more likely to be involved in decision-making; midwives involved but women will not see the same midwife all the time; Electronic fetal monitoring; because of monitoring/other reasons 1 in 2 women have limitations on movement during labour; 1 in 12 women try alternative positions for delivery; 1 in 5 have an epidural; 1 in 3 have episiotomy | |
Midwives unit characterised as: | |
- Decisions made by women and midwives; most care from one midwife; traditional fetal monitoring, transfer to labour ward needed if continuous monitoring required; 1 in 4 women transferred to labour ward for electronic monitoring; because of monitoring/other reasons 1 in 3 have limitations on movement during labour; 1 in 8 try alternative positions for delivery; all types of pain relief available but transfer to labour ward required for epidural; 1 in 7 have an epidural; 1 in 4 have episiotomy | |
Emslie (1999) [21]
Questionnaire survey - longitudinal follow-up
| Features of place of birth rated by women at 14 and 36 weeks (selected list – not all reported) |
- Quiet atmosphere - Baby with you at all times - Availability of specialist facilities - Convenience for visitors - Choices in pain relief - Choices in delivery | |
Aspects of labour management rated by women (at 36 weeks): | |
- Partner being there - Availability of specialist staff/equipment - Being kept informed - Being involved in decisions - Time alone with partner - Choice of pain relief - Freedom to choose different positions - Handed baby immediately - Cared for by known staff - Not being left alone - Homely atmosphere - Cared for by named midwife - Being introduced to people - Provision of music/TV | |
Discrete choice experiment
| Continuity (midwife): |
- Meet midwife antenatally, same midwife present throughout labour/birth vs. meet team of midwives antenatally, one present throughout labour/birth vs. previously unknown midwife but present throughout labour/birth vs. midwives working shifts may change during labour/birth | |
Pain relief: | |
- All methods except epidural vs. all methods available but epidural requires transfer vs. all methods available. | |
Fetal monitoring: | |
- Continuous, movement may be restricted during labour vs. intermittent unless complications develop, then continuous if required | |
Appearance of room: | |
- Homely vs. clinical appearance | |
Medical staff: | |
- Involved in care vs. only involved if complications develop | |
Decision-making: | |
- Staff make decisions vs. staff make decisions but keep woman informed vs. staff discuss things with women before deciding vs. staff give woman assessment, woman in control of decisions | |
Lavender (2005) [22]
Questionnaire survey
| Women were asked to state their level of agreement/disagreement with the following: |
- It is not important for me to have my baby in the same place as I receive antenatal care - It is important that my antenatal appointments are at a location close to where I live - I would be willing to travel if it meant I would receive higher quality care for my baby and me around the time of birth - It is important to me that a midwife helps me to give birth to my baby even if complications develop - I would feel unsafe if a specially trained doctor was not immediately available when I am in labour - It is not important to me that a midwife I know helps me to give birth to my baby - It is important to me to that [sic] a special care baby unit is in the same place that I give birth - It is important to me to be able to have an epidural at any time of day or night - It is important to me that a pool is available for my labour/birth - I want to be looked after by midwives and not have doctors involved - I would not want to transfer to a hospital a few miles away if my baby or I develop a problem | |
Longworth (2001) [18]
Conjoint analysis
| Continuity: |
- Have not met midwives prior to labour vs. have met midwives but don’t know them well vs. know midwives well | |
Location: | |
- Labour ward vs. maternity unit with a home-like environment vs. home | |
Pain relief: | |
- Gas & air/breathing only, no epidural, no birthing pool vs. gas & air and birthing pool, no epidural vs. all options including epidural | |
Decision-making during labour and delivery: | |
- Midwives and doctors will decide vs. decisions will be made jointly following discussion vs. woman will make own decisions | |
Probability of transfer to another hospital during labour: | |
- No need for transfer if problems develop vs. low probability of transfer vs. high probability of transfer | |
Pitchforth (2008) [20]
Discrete choice experiment
| Model of care: |
- Consultant-led vs. midwife-managed care - Pain relief: all methods available vs. no epidurala | |
Distance (‘time travelled’): | |
- Zero (home birth) vs. 30 mins vs. 60 mins vs. 90 mins vs. 120 mins | |
Rennie (1998) [23]
Questionnaire survey
| Aspects of intrapartum care rated by study participants: |
- Birth companion - Known midwife - In control - Few interventions - Able to do what you want - Same midwife in labour - Not to lose control of behaviour - Preferences and wishes followed - Attendance of midwife: - all the time vs. easy access vs. present only when I say - Information: - constant flow vs. staff to decide vs. only when asked for - Option for pain relief - pain-free with drugs vs. minimum drugs vs. drug free labour/other - Decision-making in labour: - staff decides vs. reach decision together vs. woman decides | |
Rogers (2011) [24]
Questionnaire survey
| Women who would use the local AMU when it becomes a stand-alone unit (FMU) were asked to select reasons for their choice: |
- Easy to get to - Physical environment - Previous bad experience - Previous good experience - Can use water in labour and for birth - Wants natural childbirth - Homely/small - Family can be involved - Other Women who would not use the local AMU when it becomes a stand-alone unit were asked to select reasons for their choice: | |
- Difficult to get to - Want an epidural - Feel safer - Previous bad experience - Previous good experience - Physical environment - Pressure from partner/family/friends - Would prefer a midwife-led unit on the same site as the hospital labour ward - Concern about transfer |
Methods of pain relief, including availability of birthing pool
Continuity of midwife
Medical staff involvement/availability of specialist clinical services
‘Homely’ environment and atmosphere
Style of decision-making
Distance
Transfer
Obstetric unit vs. midwifery unit
Other preferences
Variations in preferences by parity, ethnicity, and level of area deprivation
Discussion
Main findings
Attribute of care | Women’s birth place preferences |
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Pain relief | Women attach considerable importance to the availability of pain relief options. Some wish to have access to an epidural if needed, without necessarily intending to have one. |
Pain relief preferences appear to be influenced by women’s expectations of the options available to them. | |
Medical staff involvement/availability | A substantial proportion of women have a strong preference for care in a hospital setting where medical staff are not necessarily involved in their care, but are readily available. |
Ethnic minority women may be more likely to prefer a hospital birth and to have a range of medical facilities available on site. | |
‘Homely’ environment/atmosphere | Women tend to prefer more homely environments but preferences may be weaker than for other attributes. |
Style of decision-making | Many women attach considerable importance to models of decision-making in which the woman is involved in decisions about her care. |
Distance | Proximity of services and/or travel time are important considerations for most women. Many women have a preference for a local unit and in some instances will trade off other preferences in order to attend a local unit, but women who have a strong preference for a consultant-led unit (or for specific services only available in a hospital with an OU) will travel further in order to access a unit where they feel safe. |
Women living in remote areas may accept long travel times whereas women living in urban areas where hospitals are typically closer may be less prepared to travel. | |
Nulliparous women may be willing to travel further to a maternity unit that they perceive provides ‘higher quality care’. | |
Transfer | Women who prefer a hospital birth tend to express concern about transfer, whereas women who prefer a midwifery-led setting tend to be less concerned about transfer. |
Other | Having a birth companion present, information and being kept informed, a quiet atmosphere, and having a special care baby unit (SCBU) on site are amongst other attributes found to be important. |