Characteristics of the sample
Eighty-eight people answered the survey but 36 either entered the survey and did not answer any questions, or only completed demographic details, leaving 52 completed or partially completed surveys for analysis. Twenty-six respondents (50%) were midwives, 24 (46%) were doulas, and 2 (4%) were ‘other’ health care professionals (a psychotherapist, and a birth counsellor). The majority (n = 42, 81%) were aged 31 to over 40 years. Almost half of them had been working in maternity care for longer than 6 years (n = 24, 46%), with 11 (21%) and 16 (31%) working for 3–6 years and 1–3 years, respectively. Seven worked with home births only (14%), 6 (12%) did not wish to answer, and the remainder (n = 39) worked in one or more of 51 hospitals.
Mode of birth and rates of intervention in labour
Only 11 (28%) of those who worked in hospitals said they knew the exact rates of mode of birth for their hospital, which they gave as between 20 and 32% for CS and 1.5 and 8% for instrumental birth. The remaining 41 respondents (72%) estimated rates ranging between 7 and 50% (average 26%) for CS and between 3 and 35% (average 10%) for instrumental birth.
Rates of induction and acceleration of labour
Only 3 (6%) indicated they knew their hospital’s rates for induction of labour. The estimates made by the other respondents ranged from 15 to 50% (average 25.8%). “Overdue” was the main reason given for induction of labour (n = 40, 91%), defined by respondents as: “mostly reaching [the] due date and beyond without other reason but time”. The average timing of induction of labour was given as 41 weeks’ gestation but varied from 40+ 0 weeks to 41+ 3 weeks. One respondent stated induction of labour was performed at 42 weeks’ gestation. Estimated rates for acceleration of labour ranged from 10 to 90%, and the average rate, calculated from 20 responses, was 56%, with one respondent stating “most – giving them oxytocin without asking – because they have applied preventively a cannula”.
Twenty-three respondents (62%) said that women were given a choice as to whether or not they had induction of labour, and 17 (33%) respondents offered explanatory comments such as: “[women]…have choice [but are] put are under big pressure so they give up and let them be induced…”, “…women have [an] option officially but… …in reality, they are often threatened that if they don’t accept induction, they will put the baby’s health in danger…” and “…in theory they [women] might choose but [only after] manipulative threatening negotiation”. Five (15%) said that women in their hospital had a choice as to whether or not they had an elective CS, and six others commented that it could happen unofficially, one of whom said “officially maybe not, but there is always [a] way to do it.”
Rates of episiotomy and third/fourth degree perineal tears
Similarly, only 2 (6%) knew their hospital’s rates for episiotomy and third/fourth degree tears. Estimated episiotomy rates varied mostly from 20 to 90% (with 2 responses of 2%), giving an average of 40%. Respondents caring for women in home settings stated they did not perform episiotomies.
Intrapartum interventions always or frequently used
In hospital, the following interventions were described as being used ‘always or ‘frequently’: directed, closed-glottal pushing (n = 32, 94%); pushing back the cervix when it is nearly, but not fully, dilated (n = 11, 33%); offering drugs to relieve pain (n = 22, 67%); tying the woman’s legs up in stirrups (n = 2, 6%); shaving the perineum (n = 10, 29%) giving an enema in early labour (n = 20, 59%); asking questions and taking down details while the woman is having a contraction (n = 17, 52%); routine cannulation to give intravenous fluids (with no reason) (n = 16, 49%). At home, none of the above interventions were ‘always’ used and only one (asking questions and taking down details while the woman is having a contraction) was said by one respondent to be used frequently.
Pulling hard on the baby’s head to get him/her out, without waiting for the next contraction and for rotation of the head to occur, was said to occur ‘frequently’ (n = 16, 47%) or ‘sometimes’ (n = 12, 35%) in hospital births. In contrast, in relation to home births, only one midwife (5%) said that such efforts would be made ‘sometimes’.
Care in normal labour
Forty respondents (91%) said that electronic fetal monitoring (EFM) was applied frequently in normal labour without a clear indication. A large majority (n = 27, 64%) said that when EFM was applied, women were informed of the reason why it was needed. However, 18 respondents (45%) commented that EFM was regarded as part of basic care, and only 13 (31%) said that the women were given a choice as to whether or not they accepted it. Eighteen respondents made comments such as “CTG is taken as basis for care of all women,” “no asking, no option, no discussion,” “you have to have this”. If women refused, “manipulative treatment” was instituted and if refusal continued a “negative reverse” form had to be signed, indicating that they had refused recommended treatment.
Once electronic monitoring was applied, 29 respondents (71%) said that women took up various positions in bed (lying flat, lying on their side, sitting upright), while 4 (10%) said they had to lie flat, and 8 (20%) said they could mobilise freely. Thirty-five respondents (88%) said that all women in hospital could move around freely in labour as did all 34 who had knowledge of home births.
Performing vaginal examinations intrapartum
When asked whether or not the midwife or doctor in hospital would explain to women why they thought it was necessary to carry out a vaginal examination, 18 (46%) said ‘no’ and 8 (21%) said ‘yes, always’. In addition, 21 (51%) said clinicians in hospital would never ask the woman’s permission to do the examination, and six (15%) stated that they would inform the woman of what they were going to do. Of those who cared for women at home, 25 (89%) said that they always explained to women the necessity for carrying out a vaginal examination, and 22 (81%) ‘always’ and 5 (19%) ‘sometimes’ asked her permission. These described differences between hospital and home care are statistically significant (chi-sq = 32.06, d.f. = 2, p < 0.0001 (explaining) and chi-sq = 32.9, d.f. = 2, p < 0.0001 (asking permission).
Performing artificial rupture of membranes (amniotomy)
Thirteen respondents (32%) stated that the midwife or doctor in hospital would explain to women why they thought it was necessary to carry out artificial rupture of membranes (ARM) and a further 24 (59%) would sometimes explain. Twelve respondents (30%) also commented that women were told “…it’s dangerous to leave it [amniotic membranes] intact…” or that “it’s [ARM] necessary” and eight respondents (20%) stated that women were told that ARM was “…necessary to speed up the labour”. However, only 10 (25%) said that clinicians would ‘always,’ and 19 (48%) would ‘sometimes,’ ask the woman’s permission. At home, 15 midwives (88%) would ‘always’ and 1 (6%) would ‘sometimes’ explain why it was necessary to carry out ARM, and 14 (82%) and 2 (12%) would ‘always’ and ‘sometimes’ ask permission. These statements comparing differences between hospital and home care were also statistically significant (chi-sq = 15.89, d.f. = 2, p < 0.001 (explaining) and chi-sq = 16.1, d.f. = 2, p < 0.001 (asking permission)).
Eating and drinking in labour
All women labouring at home, with no high-risk factors, were permitted to drink fluids in labour, and eat a light diet such as yoghurt, soup, bread, biscuits or fruit. Fewer respondents said that similar women in hospital were allowed to drink fluids (n = 39, 95%), a non-significant difference, and eat light diet (n = 31, 76%), a statistically significant difference (Yates’ chi-sq = 6.86, d.f. = 1, p < 0.01).
Clinicians’ reactions to women’s refusal of treatment or intervention
Respondents were asked: “When women refuse any treatment or intervention offered in hospital, what is the midwife’s, doctor’s or doula’s reaction?” Fourteen (37%) of the 38 respondents described the midwives’, doctors’ or doulas’ reactions as “blackmailing” or “threatening”, that they “frighten[ed]”, “reject[ed]”, “accused” or “[put] pressure” on women, became “aggressive” or “reacted emotively”. Respondents stated that women were “threatened, undergo negative or unpleasant reactions and are … manipulated”, that they were told that “their baby is being endangered” or that their “decision is putting your baby at risk of death”. Eleven (29%) described clinicians as being “argumentative” and that they “attempted to convince” women to accept the intervention. Clinicians were described as “upsetting [women]”, “[displaying] arrogance”, “[becoming] distant”, “[being] pushy,” “forcing [women],” with some “calling the head obstetrician”.
Ten respondents (26%) said clinicians would “explain the benefits” “[of the intervention or treatment]” and while they were “sometimes not happy” with the woman’s decision, they were “accepting” and “respected her decision”. Three respondents (8%) stated that clinicians’ reactions depended on the situation, and any of the aforementioned reactions might occur.
Outcomes for women when clinicians disagreed with women’s refusal of treatment or intervention
Thirteen (35%) of the 37 respondents stated that if “the woman defends and holds [on to] her position [and] her decision”, she might be asked to sign a “negative reverse” (waiver of responsibility for the hospital) and be told to “face its consequences”. In addition, women “might experience an unpleasant atmosphere or [be made feel] fearful”, that clinicians may “put emphasis on harming [the] baby” and that their attitude towards women might change, and they may display intolerance.
Six respondents (16%) stated that the “psychological pressure, fear and coercion” women experienced caused them to “…resign, give up and give their permission to perform procedure”. A further four (11%) stated that “pressure is strong and manipulative, women do not get choice and [the] intervention is performed without discussion or asking [her], or against her will”. Twelve respondents (33%) stated that, depending on the specific situation, any one of the above outcomes might arise. Just two (5%) stated that the will and wish of women was respected.
Positions for labour and birth
The position most used in hospital for women having a spontaneous vaginal birth was semi-recumbent (on a bed or couch propped up with a back-rest or pillows) (n = 31, 65%) or lying flat with one or two pillows under her head (n = 15, 31%). This contrasted with the positions used most often at home, which were upright (standing, squatting, kneeling, on all fours, on a birthing stool) (n = 27, 100%). These statements comparing positions used in hospital and at home showed a statistically significant difference (chi-sq = 63.79, d.f. = 1, < 0.001).
Pushing on the woman’s abdomen or pulling the baby’s head during vaginal births
Respondents were asked how often, in their view, midwives or doctors pressed hard on a woman’s abdomen to push the baby out, during spontaneous or instrumental birth. In relation to hospital births, 13 (45%) said ‘in about a quarter of all births’ and 9 (31%) said ‘in about half of all births’. The answer in relation to home births, from 23 respondents (96%), was ‘never’. Twenty-two respondents (63%) said that the clinicians in hospital would explain to the woman why they thought this was necessary and 6 (18%) said that they would ask the woman’s permission.
Performing episiotomy and using local anaesthetic prior to suturing perineal trauma
Respondents were asked if, when the midwife or doctor in hospital was about to perform an episiotomy, they did explain the reason to the woman, ask her permission, and give a local anaesthetic beforehand. Thirteen (34%) said the clinicians ‘never’ or ‘almost never’ explained the reason, 20 (54%) said they ‘never’ or ‘almost never’ asked permission and 19 (51%) ‘never’ or ‘almost never’ gave a local anaesthetic. Thirty-two (84%) said that the clinician would always give a local anaesthetic before suturing, if one had not been given before. In contrast, when asked about home births (where episiotomy was very seldom performed), 17 (100%) said that the midwife would explain the reason for the episiotomy and ask permission, but 8 (53%) said that local anaesthetic would ‘never’ or ‘almost never’ be given, similar to the results in hospital births. However, 15 (100%) said that a local anaesthetic would then always be given before suturing the perineum.
Newborn outcomes and care
Respondents were asked how often they would see a baby with any diagnosed injuries from birth in hospital (e.g., bruises, fractured bones, nerve damage, paralysis). Nine (27%) gave figures of between one in every 10 to 30 births and 18 (55%) said ‘occasionally’. Twenty (95%) respondents said they had never seen such injuries after a home birth. In hospital, it was reported by 50% of respondents that the baby’s cord was either clamped or cut immediately (n = 6), or after one minute (n = 10). Eight respondents (25%) said that the cord was left unclamped for 2–3 min, and a further 8 (25%) said it was left until pulsation ceased. For births at home, 100% (n = 23) said the cord was left until it stopped pulsating.
After hospital births, it was reported that babies were frequently placed ‘skin-to-skin’ with their mothers immediately after birth (n = 17, 50%) or after the baby was weighed and measured (n = 15, 47%). For babies who were given to their mothers immediately, however, 22 respondents (67%) said they were only left for up to 5–20 min, with 5 (15%) saying they were left over an hour. For those babies who were weighed first, ten respondents (35%) said they were only left for up to 5–20 min with their mothers, and 9 (31%) said they were then left over an hour. After home births, all respondents (n = 24) said babies were frequently placed ‘skin-to-skin’ immediately after birth, for more than an hour.
Mother-baby separation postpartum
Babies were said to stay ‘frequently’ beside their mothers at all times while they were in hospital, by 13 respondents (39%), or ‘sometimes’ by 16 (49%). Four respondents (12%) said this ‘almost never’ occurred.
Support for home births
Respondents were asked if, in their view, women had easy access to professional support for home births. Two (6%) believed they did, but the majority (n = 33, 94%) said they did not.