NIHR DC Discover

Woman in labour being looked after by nurses

NIHR Signal Women rate quality and safety of birth experience as important

Published on 25 September 2018

doi: 10.3310/signal-000647

Most healthy women would like a natural birth if possible, but acknowledge the unpredictability and risks of childbirth. They also appreciate the supportive care environment where healthcare providers are competent, kind and respectful to them, their partners and their baby. 

In a large review of studies with over 1,800 women’s views on what matters in childbirth, having a healthy baby was important. Avoiding unnecessary medical intervention and retaining a sense of control over their birth experience was equally important to many women.  

Women have different hopes and fears concerning labour itself. These are shaped by their individual experiences as well as their social and cultural background, and the care they receive needs to reflect this.

Basing the review on what matters to women, rather than surveys of patient satisfaction after the birth, ensured that their views were not limited by what was actually available to them. The high quality findings have already informed WHO recommendations on childbirth and so could be useful for commissioners of UK-based maternity services.

Share your views on the research.

Why was this study needed?

Worldwide around 140 million women give birth every year, around 77,000 in the UK. Maternity provision varies according to local resources and staff attitudes to childbirth which may not reflect the needs and preferences of particular groups or individuals. This disparity can lead to suboptimal care.

In the UK there are a number of projects aiming to improve maternity services, such as the Royal College of Midwives’ Better Births initiative. However, the Care Quality Commission recently found that 23% of women did not feel they were involved enough in decisions about their care. While the concept of woman-centred care is supported in principle, it is not always the reality.

This study focused on exploring women’s expectations and preferences around childbirth rather than their thoughts of the actual service provided after birth. In this way, their views were less likely to be influenced or constrained by the status quo.

What did this study do?

This systematic review synthesised 35 qualitative studies on women’s childbirth beliefs, expectations and values. Around half the studies were from high-income countries, meaning they were representative of the UK. Most studies used interviews or focus groups.

Studies were analysed to generate common themes. A quality tool was used to assess confidence in the quality, relevance and adequacy of the data contributing to the themes, and low-quality studies were excluded. The authors also tried to minimise bias resulting from their preconceptions.

The authors acknowledge that some women had already given birth and that this potentially undermines their aim to find out what women actually want, unconstrained by what is actually on offer or what they received.

What did it find?

Three broad summary themes were identified.

  • The first summary theme was on hopes and fears, looking towards a positive outcome but also being aware of the potential for pain and vulnerability. Key points included having a birth without medical intervention (18 studies, high certainty of evidence), and wanting a healthy baby (15 studies, high certainty of evidence).
  • The second concerned the influence of social and cultural expectations. There was less evidence supporting this. The main point was expectations were influenced by family and friends (14 studies, moderate certainty of evidence).
  • The final theme explored how expectations can be met taking into account external factors. The main point was expecting staff to be sensitive, caring and kind (17 studies, high certainty of evidence).

What does current guidance say on this issue?

The NICE 2014 guideline (updated 2017) on intrapartum care for healthy women and babies stresses the need for women to be enabled to make informed decisions. Healthcare professionals should explain to women that they have a choice of where to give birth. Access to midwives, medical staff and pain relief options should also be covered in depth. Throughout pregnancy and during labour there needs to be a culture of respect where the woman is in control and her wishes are listened to.

In 2016, NHS England published Better Births, a wide-ranging review outlining a five-year plan for the NHS to take forward improvements in maternity services.  Implementation resources were published in 2017. 

What are the implications?

Health service commissioners and managers can now draw on this large-scale review's findings on women's expectations. The findings could inform woman-centred maternity services so that a necessary focus on safety is balanced with women's individual wishes.  This is in line with current policy, emphasising women’s choices and reflecting personal preferences as well as providing high quality and safe care. Other findings such as the importance of continuity of care also echo current service goals.

Healthcare professionals are key to creating a supportive environment where women feel confident to ask for what they want. Women should be encouraged to tailor their birth plans to reflect changes during the birth. One important finding from this study was the need for women to stay informed and retain some sense of control, including when intervention is needed.

Citation and Funding

Downe S, Finlayson K, Oladapo O, Bonet M, Gulmezoglu AM. What matters to women during childbirth: a systematic qualitative review. PLoS One. 2018;13(4):pe0194906. 

This work was commissioned by the University of Central Lancashire by the UNDP/UNFPA/UNICEF/WHO World Bank Special Programme of Research, Development and Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Switzerland as part of the evidence base preparation for the WHO recommendations on intrapartum care.

Bibliography

Care Quality Commission. 2017 survey of women’s experiences of maternity care. London: Care Quality Commission; 2018.

NHS England. Implementing better births: a resource pack for local maternity systems. London: National Health Service England; 2017.

NICE. Intrapartum care for healthy women and babies. CG190. London: National Institute for Health and Care Excellence; 2014.

RCM. Better Births. London: Royal College of Midwives; 2018.

WHO. Intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.

Why was this study needed?

Worldwide around 140 million women give birth every year, around 77,000 in the UK. Maternity provision varies according to local resources and staff attitudes to childbirth which may not reflect the needs and preferences of particular groups or individuals. This disparity can lead to suboptimal care.

In the UK there are a number of projects aiming to improve maternity services, such as the Royal College of Midwives’ Better Births initiative. However, the Care Quality Commission recently found that 23% of women did not feel they were involved enough in decisions about their care. While the concept of woman-centred care is supported in principle, it is not always the reality.

This study focused on exploring women’s expectations and preferences around childbirth rather than their thoughts of the actual service provided after birth. In this way, their views were less likely to be influenced or constrained by the status quo.

What did this study do?

This systematic review synthesised 35 qualitative studies on women’s childbirth beliefs, expectations and values. Around half the studies were from high-income countries, meaning they were representative of the UK. Most studies used interviews or focus groups.

Studies were analysed to generate common themes. A quality tool was used to assess confidence in the quality, relevance and adequacy of the data contributing to the themes, and low-quality studies were excluded. The authors also tried to minimise bias resulting from their preconceptions.

The authors acknowledge that some women had already given birth and that this potentially undermines their aim to find out what women actually want, unconstrained by what is actually on offer or what they received.

What did it find?

Three broad summary themes were identified.

  • The first summary theme was on hopes and fears, looking towards a positive outcome but also being aware of the potential for pain and vulnerability. Key points included having a birth without medical intervention (18 studies, high certainty of evidence), and wanting a healthy baby (15 studies, high certainty of evidence).
  • The second concerned the influence of social and cultural expectations. There was less evidence supporting this. The main point was expectations were influenced by family and friends (14 studies, moderate certainty of evidence).
  • The final theme explored how expectations can be met taking into account external factors. The main point was expecting staff to be sensitive, caring and kind (17 studies, high certainty of evidence).

What does current guidance say on this issue?

The NICE 2014 guideline (updated 2017) on intrapartum care for healthy women and babies stresses the need for women to be enabled to make informed decisions. Healthcare professionals should explain to women that they have a choice of where to give birth. Access to midwives, medical staff and pain relief options should also be covered in depth. Throughout pregnancy and during labour there needs to be a culture of respect where the woman is in control and her wishes are listened to.

In 2016, NHS England published Better Births, a wide-ranging review outlining a five-year plan for the NHS to take forward improvements in maternity services.  Implementation resources were published in 2017. 

What are the implications?

Health service commissioners and managers can now draw on this large-scale review's findings on women's expectations. The findings could inform woman-centred maternity services so that a necessary focus on safety is balanced with women's individual wishes.  This is in line with current policy, emphasising women’s choices and reflecting personal preferences as well as providing high quality and safe care. Other findings such as the importance of continuity of care also echo current service goals.

Healthcare professionals are key to creating a supportive environment where women feel confident to ask for what they want. Women should be encouraged to tailor their birth plans to reflect changes during the birth. One important finding from this study was the need for women to stay informed and retain some sense of control, including when intervention is needed.

Citation and Funding

Downe S, Finlayson K, Oladapo O, Bonet M, Gulmezoglu AM. What matters to women during childbirth: a systematic qualitative review. PLoS One. 2018;13(4):pe0194906. 

This work was commissioned by the University of Central Lancashire by the UNDP/UNFPA/UNICEF/WHO World Bank Special Programme of Research, Development and Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Switzerland as part of the evidence base preparation for the WHO recommendations on intrapartum care.

Bibliography

Care Quality Commission. 2017 survey of women’s experiences of maternity care. London: Care Quality Commission; 2018.

NHS England. Implementing better births: a resource pack for local maternity systems. London: National Health Service England; 2017.

NICE. Intrapartum care for healthy women and babies. CG190. London: National Institute for Health and Care Excellence; 2014.

RCM. Better Births. London: Royal College of Midwives; 2018.

WHO. Intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.

What matters to women during childbirth: A systematic qualitative review

Published on 18 April 2018

Downe, S.,Finlayson, K.,Oladapo, O.,Bonet, M.,Gulmezoglu, A. M.

PLoS One Volume 13 Issue 4 , 2018

INTRODUCTION: Design and provision of good quality maternity care should incorporate what matters to childbearing women. This qualitative systematic review was undertaken to inform WHO intrapartum guidelines. METHODS: Using a pre-determined search strategy, we searched Medline, CINAHL, PsycINFO, AMED, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-August 2016 (updated to January 2018), reporting qualitative data on womens' childbirth beliefs, expectations, and values. Studies including specific interventions or health conditions were excluded. PRISMA guidelines were followed. DATA COLLECTION AND ANALYSIS: Authors' findings were extracted, logged on a study-specific data form, and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed. RESULTS: 35 studies (19 countries) were included in the primary search, and 2 in the update. Confidence in most results was moderate to high. What mattered to most women was a positive experience that fulfilled or exceeded their prior personal and socio-cultural beliefs and expectations. This included giving birth to a healthy baby in a clinically and psychologically safe environment with practical and emotional support from birth companions, and competent, reassuring, kind clinical staff. Most wanted a physiological labour and birth, while acknowledging that birth can be unpredictable and frightening, and that they may need to 'go with the flow'. If intervention was needed or wanted, women wanted to retain a sense of personal achievement and control through active decision-making. These values and expectations were mediated through womens' embodied (physical and psychosocial) experience of pregnancy and birth; local familial and sociocultural norms; and encounters with local maternity services and staff. CONCLUSIONS: Most healthy childbearing women want a positive birth experience. Safety and psychosocial wellbeing are equally valued. Maternity care should be designed to fulfil or exceed womens' personal and socio-cultural beliefs and expectations.

Expert commentary

This is a robust evaluation conducted by key individuals with sufficient expertise in analyses. The data obtained is sufficient to state that women want a positive birth experience. Being in control and making decisions about their birth are also key factors in their experience.

What matters to most women during childbirth is giving birth to a healthy baby in a safe place with confident and competent healthcare staff and close family.

Marlene Sinclair, Professor of Midwifery Research, Ulster University

Expert commentary

Providing woman-centred services requires an understanding of what matters to women. Maternity services are traditionally assessed using satisfaction, but this drives services to maintain the status quo as respondents often assume that “what is, must be best”. Knowing women’s expectations and preferences enables change, but such studies are usually very small.

Synthesis of qualitative data from 35 studies provides substantial evidence of how women view quality maternity care. One could question whether it was reasonable to combine the studies given their diversity, but cultural context was considered in developing themes. This valuable work underpins WHO’s 2018 recommendations on childbirth.

Professor Vanora Hundley, Acting Dean and Deputy Dean for Research and Professional Practice, Bournemouth University

Expert commentary

Women all over the world should have access to high-quality maternity care during childbirth that achieves the best physical, emotional and social outcomes for them and their babies.

The findings of this review can support health professionals, and health service managers provide care that is tailored to women's preferences and circumstances. This means providing care that is both clinically effective and respectful.

Evidence from high-income countries suggests that the best way to achieve this is through continuity of care by midwives. More research is needed to learn whether this approach works in low and middle-income countries

Dr Alison McFadden, Senior Research Fellow, University of Dundee