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My Birthplace: a computerised decision making tool to support women, their partners and midwives to make a decision about place of birth
Government policy promotes choice regarding place of birth, but inconsistent information makes it a decision difficult for many women (1). This innovative project will utilise a bespoke Smartphone or tablet application (app) to improve the decision making process for women and their partners. The results will have local and international consequences: better outcomes for women and cost savings in Portsmouth, and a tool that can be adapted for use in other countries to facilitate choice about place of birth.
Less than half of all women giving birth in England do so 'normally' i.e. without surgical intervention, induction, epidural or general anaesthetic (2). Rates of epidurals in childbirth have escalated (3) and caesarean sections now account for a quarter of all births (5). Intervention in childbirth is associated with an increased risk of mortality and long term morbidity (3,5). Recent research shows that women who plan to give birth at home or in a midwife-led unit have substantially less intervention and are more likely to have a ‘normal birth’ (1). However, inconsistencies in the quality of information provided and inequity in access to this information (particularly among less socially advantaged groups) means that not all women have a choice regarding place of birth (1). Local data from Portsmouth Hospitals NHS Trust (PHT) suggest that lack of information regarding choice is resulting in low risk women giving birth in the consultant unit, thus increasing their risk of intervention.
The proposed project will evaluate the impact of a simple computer programme that will support shared decision making for prospective parents and midwives, through decision analysis software. The programme will combine national and local data on interventions, outcomes and preferences with respect to place of birth. PHT has secured funding from the Health Foundation for the initial development of this Smartphone or tablet application (app), which is being developed by a private company. Application of the tool will enable standardised and evidence based information about outcomes in the birth settings to be offered to women and their partners, and facilitate greater involvement in the decision making process with their midwives. The effectiveness and acceptability of the tool will be the focus of the PhD studentship.
The PhD project will be a randomised controlled trial comparing two groups of women; those for whom the decision making process involves using the app and those who make the decision without the app. Two midwives from each community based clinical team (14 teams), covering 3 distinct geographical areas will be trained to use the tool. They will use the tool with a random sample of 250 women and their partners from 20 weeks of pregnancy. Women randomised to the intervention group will be given information about the tool and will be given the option to use it at home and then complete the exercise with their midwife in an antenatal clinic. After a discussion about their birth place choice with the midwife, the final decision will be documented at 36 weeks of pregnancy in their maternity notes. The control group of 250 women will receive standard care.
The primary outcome will be the woman's chosen place of birth (i.e. the decision) at 36 weeks. Secondary outcomes will include: place where labour starts, place of birth, and acceptability of the app from both women’s and midwives’ perspectives. The impact that the app has on intervention rates, such as caesarean section rates, will also be measured but detecting a statistically significant difference will be outside the scope of the PhD studentship (since it would require a very large sample size involving a number of hospitals).
Routinely collected data will be used to assess choice, place of birth and interventions. The acceptability of the tool will be assessed through the use of focus groups and questionnaires.
This timely project stems from an identified clinical need in the NHS and addresses a priority area for PHT (6). In addition, Queen Alexandra Hospital in Portsmouth has made significant efforts to reduce its caesarean section rate, which at one time was higher than average (2,6). Their commitment to reducing intervention makes this an appropriate site to test the impact of the app.
- A valid and reliable tool to facilitate consistent, evidence based information regarding place of birth.
- Increased choice for women and their partners regarding place of birth. Increasing choice regarding place of birth meets the needs of PHT and responds to the recommendations of the recent national study on place of birth that highlighted the need for health care providers to improve the information offered to women and their partners and to
facilitate choice regarding place of birth (1).
- Increase in the number of out of hospital births. Previous studies have shown a lower rate of intervention among out of hospital births (1). Reducing unnecessary intervention will improve outcomes for women and result in cost savings for the NHS.
- The findings will underpin UK recommendations regarding intrapartum care (e.g. NICE guideline 55) and will have international relevance for countries with high intervention rates.
- A series of peer-reviewed publications in high impact journals - e.g. BMC Pregnancy and Childbirth (IF 2.8)
References: (1) Hollowell J. (on behalf of the Birthplace in England Collaborative Group) Birthplace in England research programme. Final report part 1. NIHR Service Delivery and Organisation Programme. 2011. (2) Birthchoice UK www.birthchoiceuk.com/ (3) Walsh D. Pain and epidural use in normal childbirth. Evidence Based Midwifery. 2009 7(3): 89-93. (4) NHS Statistics. NHS Maternity Statistics, England: 2010-2011. The Information Centre. 2011. (5) Anim-Somuah M, et al. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2011, Issue 12. (6) Walton G. Nurturing Maternity Service Development. Portsmouth Hospitals NHS Trust 2011.
The project is part of a programme of work between PHT and Bournemouth University (BU) that builds research expertise in the clinical area. This is one of three doctoral studentships requested for 2013 in order to develop a critical mass of research proficient midwives, who are able to utilise their research skil s to support the ‘Nurturing Maternity Service Development’.
The student will benefit from existing collaborations. Prof. Hundley is part of an international group looking at decision making in early labour.
The study findings will inform the 'Normalising birth and reducing caesarean section' workstream of PHT's Maternity Service Development. We will hold a workshop to discuss the implications with key stakeholders (consumer groups, midwives, and obstetricians). The findings will also underpin recommendations for health care professionals regarding intrapartum care (e.g. NICE guideline 55) and information provided to women to enable them to make informed choices (e.g. MIDIRS informed choice leaflets - P10 Place of birth).
The findings will be disseminated through academic papers in leading journals such as BMC Pregnancy and Childbirth (IF 2.8).
The proposed project was developed in response to an identified clinical need in the NHS and is a priority area for Portsmouth Hospitals NHS Trust. However, the project also addresses an area of national and international concern. The findings of the recent national study on place of birth highlight the need for health care providers to improve the information offered to women and their partners and to faciliitate choice regarding place of birth (1). Similar debates about place of birth can be seen in other high income countries, in particular the USA. Thus this study will have local, national and international implications.
Societal impact will be seen in terms of:
- Increased choice for women and their partners regarding place of birth.
- Increased out of hospital births, which will reduce unnecessary intervention
- Improved outcomes for women - reduction in morbidity associated with assisted birth.
- Reduced intervention will result in cost savings for the NHS.
The training programme, directed by Prof. Hundley and Dr Angell, will have the following objectives:
1. Formal training in qualitative interviewing and focus groups provided through BU’s Centre for Qualitative Research (CQR). CQR is internationally recognised in the field of qualitative health and social care research. In addition, Dr Angell has substantial experience in conducting qualitative interviews.
2. Transferable skills – networking, communication and change management – developed through the process of establishing an advisory group and working to draw up a strategy in response to study findings. Guidance and support from PhD supervisors will ensure that the student is able to develop in these areas.
3. Formal training in evaluation methods will be provided through Bournemouth University Clinical Research Unit (BUCRU). This unit provides training and support for researchers in improving the quality, quantity and efficiency of research across BU and local NHS Trusts. In addition, Prof. Hundley has substantial expertise in programme
4. Transferable skills – communication and presentation. The student will develop these skills through seminars and conference presentations, and in preparing and submitting peer reviewed publications.
Research Ethics, Health & Safety Considerations
Ethical approval and permission to conduct the study will be sought from the HSC Research Ethics Committee. The study will take place on NHS facilities, involving both women and staff, and therefore ethical approval from the local National Research Ethics Service (NRES) will also be required. As non-medical research, the study will have minimal potential for harm - only participants’ attitudes will be assessed and outcome measures will be obtained from routinely collected data. Participation will be voluntary and all groups will be assured that non-participation will not affect their care / working conditions. Research will conform with the Department of Health’s Research Governance Framework for Health and Social Care. We do not forsee any health or safety concerns.
Recent publications by
Both supervisors are research active and are in consideration for the UoA3 REF
supervisors relevant to this
submission. Listed publications are relevant to: decision making, attitudes /
perceptions; labour care management; morbidity and mortality measurement:
Angell C & Taylor A (2012) Alien knowledge: Preparing student midwives for learning about infant feeding – education practice at a UK university. Nurse Education Today (accepted – in press)
Angell C, Alexander J, Hunt JA. (2012) How are babies fed? Primary school children's perceptions of infant feeding Birth, 38: 346–53.
Hundley V, Avan B, Sullivan C, and Graham WJ. (2012) Should oral misoprostol be used to prevent postpartum haemorrhage in home birth settings in low resource countries? BJOG. (DOI: 10.1111/1471-0528.12049)
Hundley V, Avan B, Braunholtz D, and Graham WJ. (2012) Are birth kits a good idea? A systematic review of the evidence. Midwifery 28(2): 204-215.
Scotland G, McNamee P, Cheyne HC, Hundley V, & Barnett C. (2011) Women’s Preferences for aspects of labour and delivery care: results from a discrete choice experiment. Birth 38 (1): 36-46
Hundley V, Cheyne HC, Bland JM, et al. (2010) Lessons from a national cluster trial of early labour. Journal of Evaluation in Clinical Practice 16: 632-638.
Cheyne H and Hundley V (2009) Has labor started? A judgment made in uncertainty. Birth 36 (4): 336-337.
Cheyne H, Hundley V, Dowding D et al. (2008) The effects of an algorithm for diagnosis of active labour: a cluster randomised trial. BMJ 337:1396-1400.
Barnett C, Hundley V, Cheyne H and Kane F. (2008) “Not in labour” – the impact of being sent home in the latent phase. Br J Midwifery 16 (3): 144-153.
Cheyne H, Terry R, Niven C, Dowding D, Hundley V, and McNamee P. (2007) A qualitative investigation of how women’s experiences in early labour influence their decision of when to go to hospital. Br J Midwifery 15 (10): 604-626.
To discuss this opportunity further please contact (via email): Professor Vanora Hundley or Dr Catherine Angell
How to apply
Information on how to apply can be found on:
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