Do Maternity Policies in the UK in practice enable and empower women to make informed choices during pregnancy and childbirth

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Do Maternity Policies in the UK, in
practice, enable and empower women to
make informed choices during pregnancy and
childbirth?
A case study in Greater Manchester.
Claire Carey
@00367300
May 2016

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Acknowledgment
After being away from education for sixteen years the concept of me returning to
study at degree level was fraught with fear and a severe lack of self-confidence.
However, this three-year journey has empowered me beyond my expectations and my
success and confidence has grown significantly which will undoubtedly enable me to
succeed beyond graduation.
As a self-confessed ‘Birth Activist’ since having my first child in 2000, I have tailored
many of my assignments to the subject of childbirth. Therefore, to focus on this for
my dissertation and to undertake primary research seemed like a natural progression.
As a result of this research I have been inspired to train as a Doula: a woman who
offers holistic and emotional support to other women during pregnancy and birth.
None of this would have been possible without the support of my programme leader
and informal mentor Karen Kinghorn who has offered me support since I applied for
the degree programme and for the whole duration. My supervisor Professor Louise
Ackers has also been a source of inspiration and has provided me with a wealth of
information and support throughout my second year, my time in Uganda and through
writing my dissertation.
Finally, I have to thank my family. My husband and children who have been there
throughout this journey and my parents who have been an invaluable support both
practically and emotionally.
Thankyou!

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Table of contents
4. Abbreviations
5. Abstract
7. Introduction
9. Methodology
14. Chapter One – Policy Analysis
20. Chapter Two – Literature Review
26. Chapter Three – Research Findings
39. Conclusion
42. References
46. Appendix

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Abbreviations
AIMS The Association of Improvements to Maternity Services
BECG Birthplace in England Collaborative Group
DoH Department of Health
GP General Practitioner
NCT National Childbirth Trust
NHS National Health Service
ONS Office for National Statistics
NMR National Maternity Review
PPH Postpartum haemorrhage
UKCC United Kingdom Central Council for Nursing, Midwifery, and Health Visiting

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Abstract
This abstract offers a synopsis of the research undertaken. Four key subheadings
have been created for clarity.
Background
Childbirth is a life-changing phenomenon and policy development in this area has
evolved since the second world war, most notably, with the introduction of the NHS,
and the change in attitude towards birth by health professionals. The subject has
attracted the attention of academic researchers, and has gathered momentum
through feminist groups over the notion that childbirth has become over-medicalised,
and a victim of the patriarchal society in which we live that has resulted in the
obstruction of choice.
Methods
A phenomenological approach was applied to the study as this is an effective way to
consider the participant’s perceptions. Ten participants were selected using social
media and a snowball method. Each participant was interviewed and the data was
thematically analysed. A policy analysis and literature review was conducted to
collaborate with the primary research and provide a balanced analysis.

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Findings
Ten themes emerged from the data, however, some do interlink with each other. The
key findings identified were; that induction was commonplace without an explanation
or rationale; choice was restricted; information was sought and shared by woman as
opposed to health professionals, and woman are transferring their NHS care to private
midwifery companies.
Conclusion
The Department of Health’s policies on maternity and childbirth are satisfactory in
theory, yet, ineffective in practice. This is demonstrable by the research undertaken
and is corroborated by the discussion within the literature review. Women feel that
they are not taken seriously and are not always fully informed of all the options
available to them during pregnancy and childbirth. Likewise, the use of language is a
powerful tool in gaining control over women by health professionals and is attributed
to women feeling like they do not have a choice. Women are, therefore, taking the
initiative and seeking support and advice from other women and ‘birth groups’, often
via social media, to challenge the health care practices and become fully informed. It
was identified that a growing number of women are also transferring their care to
private midwifery companies who are offering an alternative to NHS care that
promotes a woman-centred approach to birth and facilitates informed choice in
practice.
The following section offers an introduction to the dissertation.

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Introduction
This is where the journey begins and the introduction will inform the reader of what
can be expected throughout. The following quote, from world renowned midwife and
childbirth activist Ina May Gaskin, sets the tone of the upcoming discussion and
epitomises the importance of a woman achieving a ‘good birth’ which is a concept at
the heart of the research.
A society that places a low value on its mothers and the process of birth will
suffer an array of negative repercussions for doing so. Good beginnings make a
positive difference in the world, so it is worth our while to provide the best
possible care for mothers and babies throughout this extraordinarily influential
part of life (Gaskin, 2011).
This dissertation will focus on how women perceive the options available during
pregnancy and childbirth and whether they felt they were equipped with the correct
knowledge and information to make informed choices. To begin with it is important
to provide an historical policy analysis leading up to current policies, in particular,
The Changing Childbirth Report 1993, Maternity Matters 2007, and Better Births
2016, to show what the policy recommendations are and how they have evolved.
At this point it will be necessary to conduct a literature review from within the last
seven years, that corresponds with the time frame of the Maternity Matters Report up
to the present day, to show a contrast with the policy analysis undertaken and
establish any significant similarities and differences between policy theory and
implementation in practice. The literature review will also serve to discuss the claims
made, by AIMS and the NCT, that childbirth has become over-medicalised and the
current ‘system’ does not facilitate choice. This also fits with the feminist discourse.

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Following on, a discussion of the research findings, from the interviews undertaken,
presents a vital element to the whole dissertation as it draws upon the recent
experiences of women in a specific geographical area who have given birth within the
last two years. This enables the dissertation to have a contemporary element and a
third dimension to the dialogue between the policy analysis and literature review
which will certainly strengthen the conclusion and subsequent recommendations.
The concluding part will determine how the participant’s perceptions correspond with
the literature review by considering how government policies have been implemented
in practice. Furthermore, appropriate recommendations will be made to ensure that
all women are able to make informed choices and achieve a positive birth experience.
The following section will focus on the research methodology.

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Methodology
This section underpins the research that has been undertaken, in chronological order,
focusing on the whole journey; from obtaining ethical approval, to conducting
interviews, the subsequent analysis and findings, and the research limitations.
Ethics
Before I could carry out any research I required full ethical approval. Therefore, I
referred back to my research proposal, consulted the University of Salford guidance
and liaised with my supervisor to ensure I had met the criteria before I submitted an
application in October 2015 (App, 74-81). However, after a four week wait my
application was rejected. The main basis for the rejection was a lack of clear rationale
for the research, and limited aims and objectives. The remaining issues surrounded
administration and required closer attention to detail on how to safely store data to
assure anonymity. One particular ethical issue was raised about the selection of
participants. It was recognised that some women may be vulnerable if they had
recently given birth. Therefore, I made the decision that only those who had given
birth at least six months prior to December 2015 would be suitable participants.
I immediately sought to address the concerns raised by concentrating on each issue
individually and explicitly detailing what changes had been made. I submitted a
revised application which, after a two week wait, was approved without the need for
further amendments (App, 46-61).

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Participants
A phenomenological approach was adopted for this research, which focuses on the
participant’s perception of their experiences as opposed to the views of others. Once
ethical approval was confirmed I began to advertise, initially on social media, for
participants. I placed an enquiry in four online parenting groups in the Greater
Manchester area and two women responded immediately asking for more
information. A snowball method took force and the remaining participants were
identified through word of mouth and information sharing. I received an
overwhelming response, via email, from over twenty women asking for more detailed
information. I sent each of them a participant information pack (App, 62-73) which
included in-depth material, a general set of guide questions, and a consent form
should they wish to participate. Ten women returned their pack and agreed to
participate. The eligibility criteria for each participant was that they had to have given
birth between January 2014 and June 2015. Children who were born prior to 2014
but after 2008 would also be included in the research as they fell within the policy
timeframe: since the introduction of ‘Maternity Matters’.
Data collection
Qualitative research was undertaken by conducting informal interviews with each
woman lasting between sixty and ninety minutes. Four pre-set questions were sent
to each woman, as a guide, so they would be familiar with the information I would be
seeking. However, each interview progressed naturally and the dialogue flowed
without the need to refer to the questions. Each interview was recorded using a
Dictaphone. Qualitative research enabled me to gain a deeper insight and
understanding into each woman’s experience as opposed to quantitative research

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which would purely be statistical and unable to probe into women’s experiences.
However, secondary research has been used to offer statistical evidence where
appropriate and to support the empirical work.
Data analysis
Before the participants had been identified it was decided that general questions
would be used as a guidance tool only and each woman would be encouraged to
speak openly, from the heart, without interruption about their experiences of
childbirth. This was an appropriate way to conduct the interviews and is demonstrable
by each of the proposed questions being answered, without prompting, which
maintained the natural flow of the dialogue. As the interviews progressed, and before
the formal analysis had begun, themes were being identified. I transcribed each
recording with the assistance of voice recognition software and I immediately deleted
the recordings to maintain anonymity. Each transcription was anonymised so the
participant could not be identified. I undertook a training course on how to use NVIVO
software which assisted me in thematically analysing the data. Eight clear themes
were identified and the relevant quotes and discussions were separated into each one
to ensure clarity and accuracy when writing the research findings. These themes were
strengthened and further narrowed down into key arguments which have formed the
basis of the overall findings. Although the main part of this dissertation is the
qualitative research it is imperative to include a policy analysis and literature review
to provide a comparison and to support the experiences of the participants by way
of peer reviewed academic articles, thus, strengthening the main body of the research
which will be evident within the conclusion.

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Research Limitations
Upon reflection, there are unavoidable limitations. In particular, due to time
constraints, it was not possible to select participants over a longer period of time
which may have resulted in a more diverse range of participants who had significantly
different experiences to each other. It is likely that the snowball effect played a part
in a large number of women having similar experiences, such as; transferring their
care to a private midwifery company. This was not realised until each woman was
interviewed as their experiences were not discussed until then. However, it would
have been inappropriate to ask women about their experiences beforehand as this
could be construed as being self-selecting. If the research was undertaken again, over
a longer time period, then it would be possible to use a considerably larger sample
size which may result in the research being more representative of women as a whole.
Sample Characteristics
The following table shows the characteristics of the selected participants: year and
place of birth. ‘121’ is the abbreviation of One to One midwives, a private midwifery
company. Some of the sample did have other children, however, they were omitted
from the research as they were not born between 2008 and 2015: the identified time
period to coincide with the policy, Maternity Matters, up to the present day. When
referring to a participant, during the chapter on research findings, they will be
identified by their number, such as; (01).

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Year Place Year Place Year Place
01 2015 Hospital
02 2012 Home 2014 Home121
03 2011 Hospital 2014 Home121
04 2012 Hospital 2015 Hospital
05 2008 Hospital 2015 Home
08 2015 Home121
10 2011 Hospital 2012 Hospital 2015 Hospital
The following chapter provides an analysis of maternity policy development from the
second world war to the most recent guidelines.

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Chapter One. Policy Analysis
This chapter provides a historical background, and the development of maternity
policies in England up to the present day. This section is particularly important as it
affirms what role the government has, and who has influenced policy development.
It also offers guidelines and a theoretical overview of what woman should expect
during pregnancy and childbirth.
Following the introduction of the NHS, in 1948, a renewed interest in maternal health
and well-being ensued (Oakley, 1984). Consequently, the availability of universal
health care for all was seen to be the driving force in an increase in hospital births
and the rapidly declining rate of maternal and infant mortality that had previously,
pre-war, been 40 in 10,000 and 170 in 1000 respectively (Walton & Hamilton, 1995).
However, regardless of this progress there remained a distinct lack of forward
thinking over maternity care and the responsibility for care was now part of a
complicated, multilateral, system that involved hospital services, GP’s, midwives, and
public health services such as ante-natal and post-natal clinics (Davis, 2013)
The first review of maternity services occurred in 1959 and was conducted by the Earl
of Cranbrook in response to an inquiry over the cost of the NHS which had highlighted
the complexity of maternity care provision. The Cranbrook Report 1959
recommended that seventy percent of births should now take place in hospital and
the remaining thirty percent were deemed to be low risk and therefore able to give
birth safely at home (Walton & Hamilton, 1995). However, the medical community
disputed these figures and argued in favour of all births taking place in a hospital

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setting due to the advancement in obstetric knowledge that had subsequently
regarded, an increasing number of, women as ‘high-risk’ (Davis, 2013).
The recommendations of The Cranbrook Report formed the basis of the next report
on maternity services, in 1967, which was undertaken by consultant obstetrician John
Peel. The resulting proposals, of The Peel Report 1970, were that one hundred
percent of births should now take place in hospital, as it was considered to be the
safest place, and it was this report that caused a significant shift from home births
to hospital births over the following decade (Davis, 1981). However, this report
attracted substantial criticism over the absence of evidence in support of his claims
and that women had not been consulted with over their own experiences and what
they deemed to be necessary during childbirth (Oakley. 1984). It was this report that
stimulated a response from recently formed pressure groups such as AIMS and NCT,
who began to campaign on behalf of women over their right to make informed
choices in their pregnancy and birth (Davis, 2013; Walton & Hamilton, 1995).
After the Peel Report the Maternity Services Advisory Committee was set up by the
Government and produced three influential reports: Maternity Care in Action Part 1,
1982; Antenatal Care Part 2, 1984; and Care during childbirth Part 3, 1985. The
guidelines within these reports re-enforced, as per the recommendations of The Peel
Report, that hospital births were the safest place and were consequently adopted by
Maternity Service Liaison Committees, Heads of Midwifery Services, Health
Authorities, and Obstetricians as a common goal in improving Maternal care.
However, the alternative view of decreasing medical intervention in childbirth and
empowering women to become actively involved in their care was gathering
momentum amongst many health professionals who were citing the inaccuracies
within these reports. Most notably, statistician, Marjorie Tew (1990) argued against
the suggestion that the decline in maternal and infant mortality was directly linked

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to the increase in hospital births and was, in fact, due to the overall improvements in
women’s health and called for further analysis and for birth to be recognised as much
more than a medical process that is only concerned with the final outcome. Likewise,
whilst safety may be paramount, becoming complacent over the idea that hospital is
one hundred per cent safe is inaccurate and counterproductive. Tew (1990) argues
that Health care professionals should be equally concerned with a mother's social and
emotional needs during pregnancy and childbirth and by educating them over the
choices available will empower them to make informed decisions (Kitzinger, 1991;
Walton & Hamilton, 1995).
Moving forward, Government Policies were slow to respond to the findings of the
aforementioned reports undertaken between the 1950s and 1980s. It was another
ten years, in 1991, before further action was taken when they set up a select health
committee that would probe into maternity services (Davis, 2013)2. It is important to
note that the NHS and Community Care Act 1990, amongst other health care reforms,
came into force at this time and at the forefront of this legislation was to enable
patient choice and autonomy within health services and for greater user participation
in the decision making process (Glasby, 2012). The select committee, unlike its
predecessors, consulted, and gained evidence from many individuals and
organisations including; mothers, midwives, and the UKCC. The final report, entitled
‘The Winterton Report’ 1992, considered the views of mothers alongside statistics
and testimonials from health professionals and produced a six-part set of
recommendations for the future of maternity services (DoH, 1992). The report
detailed the negative aspects of maternity care by including criticisms of the over
medicalised reports constructed previously. Furthermore, the lack of government
policy intervention up until this point sent the far-reaching message that to achieve
a positive outcome for mother's and baby's then it was equally important to draw
upon the skills of midwives, obstetricians, and paediatricians as it was to improve the

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dialogue between mothers and health practitioners. This would be possible by
ensuring that services are adapted to acknowledge the needs of individual women
and child and not the other way round (Walton & Hamilton, 1995).
In response to the Winterton Report the government agreed with many of the
recommendations and that changes were necessary. It was from here that The Expert
Maternity Group was established and marked the beginning of significant changes.
Therefore, as a consequence of The Winterton Report, The Changing Childbirth
Report 1993 was commissioned by The Expert Maternity Group and Baroness
Kimberlee and was the first Government policy that attempted to revolutionise
maternity care and practice in the UK. The core emphasis of the report was to promote
choice, control, and continuity of care through seven action points (DoH, 1992):
 Accessible services – balance achievability and women satisfaction
 Information giving – deliberate appropriate methods of delivery
 The named midwife – consider the expectation of women and midwife
 Lead professional – implications for women and professionals
 Making choices – recognising social, cultural and professional factors
 Flexible systems of care – ensuring effectiveness and efficiency
 Place of birth – considering individual choice and the implications
Today, the recommendations of the 1993 report are as relevant as they were twenty
years ago when the report was published. However, according to Professor Mavis
Kirkham, who was speaking at a Royal College of Obstetricians and Gynaecologists
seminar in 2013, the 1993 report, whilst having a profound effect on the rhetoric,
has not had a significant effect in practice and still required further advancement
(McIntosh & Hunter, 2014).
The Changing Childbirth Report was instrumental in the subsequent reports at the
turn of the twenty first century, although very few of the recommendations had been
put into practice, which resulted in the development of The National Service
Framework for Children, Young People, and Maternity Services (DoH, 2005); the

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report, entitled, Making it Better: For mother and baby, and Maternity Matters
(Shribman, 2007). Many of the points raised within these reports were carried forward
as equally relevant. However, the emphasis of the Maternity Matters report was to
ensure that the recommendations were being carried out in practice by the health
care professionals. Furthermore, the report was sanctioned to reflect upon
suggestions that women were pressured to use a hospital setting, thus, they were not
being empowered or enabled to make choices (Stephens, 2004). Likewise, childbirth
was becoming increasingly medicalised and often resulting in unnecessary
interventions (Cheyney, 2008). Therefore, Maternity Matters, made a commitment to
guarantee choice to all women. (DoH, 2007):
 Choice of how to access maternity care: through the GP or direct to the
midwives.
 Choice of type of antenatal care: midwifery, or Obstetrician led.
 Choice of place of birth: at home, birth centre, or in a hospital.
 Choice of postnatal care: at home, or in the community.
Since the introduction of Maternity Matters, there has been a change in government
which has brought about a renewed interest in maternity and further policy
developments. In 2010, Midwifery 2020 – Delivering Expectations, was collaboratively
commissioned, for the first time, by the Chief Nursing Officers of England, Ireland,
Scotland and Wales. The programme begins by recognising the achievements already
made since The Changing Childbirth Report and then sets out its aims and objectives
towards the challenges and opportunities for the professional development of the
midwives’ role during the next decade to ensure quality of care (DoH, 2010). The
focus remains on achieving positive outcomes for mothers and babies, by also
managing their holistic and social needs, and it is recommended that these outcomes
are measured by gaining feedback directly from women (Kent, 2010).

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The final policy development ‘Better Births’ was published in February 2016. This
initiative was commissioned by Baroness Cumberlege who was instrumental in The
Changing Childbirth Report and depicts a clear vision for the future (NMR, 2016):
 Personalised care – genuine, informed, unbiased choice, control of budget.
 Continuity of care – each woman is linked with a small team of midwives.
 Safer care – working across boundaries to ensure rapid referral.
 Better postnatal and perinatal mental health care – increased funding.
 Multi-professional working – information sharing between maternity health
professionals.
 A fair payment system – that compensates providers for providing excellent
care whilst adhering to the commissioner’s guidelines of; personalisation,
safety and choice
This up to date review of maternity services in England recognises that the quality of
services is not consistent across all NHS trusts and that there has been an increase in
litigation over negligence. The report has received input from health professionals,
women, and the third sector and has an ambitious vision that aims to revolutionise
maternity services once again (NMR, 2016). However, as this is a very recent review,
an analysis in practice will not be possible, thus, for the purpose of this dissertation,
its proposals will only be taken into account with regards to any future
recommendations as part of the dissertation conclusion.
The following chapter will review literature relevant to the policies and
recommendations that have been discussed in this chapter, in particular, Maternity
Matters 2007 and Better Births 2016.

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Chapter Two. Literature Review
The rationale behind this chapter is to deliberate the perceived link between the
increase in hospital births, the medicalisation of childbirth, and the lessening of
choice for women. In order to do this there will be a discussion from a feminist
ideological viewpoint before a brief historical and statistical overview of maternity
settings is provided. An analysis of current and relevant literature on the subject will
follow. The policy focus for this literature review will be from Maternity Matters 2007
up to Better Births 2016 and will consider whether women have been empowered as
the former suggests and what the future may hold according to the latter.
Birth is, arguably, a Feminist Issue and women are often seen as victims of their
biology (Pascall, 1997). It could be argued that the future generation of women may
be uninformed, and unfamiliar with the concept of a natural physiological birth and
unaware that it can be safer than a surgical birth. They may fear a natural birth which
could cause them to make irrational decisions and clamour for surgical intervention
without fully understanding the risks that come with it to themselves and their baby
(Gaskin, 2009). Paradoxically, this is the direct opposite to what feminists believe in
and have campaigned for. In particular, second wave feminists, from the 1960s
onwards, sought to reclaim their bodies from male control, most notably, from a male
dominated medical profession, who had largely influenced the development of
obstetric knowledge, which then influenced policy and practice over pregnancy and
childbirth (Shilling, 2010). Furthermore, there is a biological assumption that women
are the natural carers of children, yet, the historic idea that women require a man to
make decisions on their behalf and are unable to think for themselves has been

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reinforced during pregnancy and childbirth when a woman’s knowledge and
understanding of her body is dismissed (Abbot et al, 2005).
To further illustrate the feminist idea, for centuries, childbirth was primarily the
concern of women, and births took place at home, attended by female friends,
relatives, and neighbours who had experience of delivering children. By the 1940s,
through the introduction of the NHS, and with the majority of the decision makers in
healthcare being male, birth in a medicalised hospital setting started to become more
commonplace (Oakley, 1984). Subsequently, the rate of homebirths has rapidly
declined and has not risen above five percent since the 1970s (Macfarlane, Mugford,
& Henderson, 2000). This decline is illustrated by the following graph (ONS, 2013).
It is important to note that a homebirth, for low risk women, is as safe as a hospital
birth, if not safer, and the overall outcomes for mother and baby are positive
(Kitzinger, 2012). This is supported by The Birthplace Study, from 2008 to 2010,
which found that planning a homebirth can lower the risk of a caesarean section,
induction, an assisted delivery, and post-partum haemorrhage. Additionally, the
research suggests that there is an increase in skin to skin bonding and the successful
initiation of breastfeeding (BECG, 2011).

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When considering birth to be a natural physiological state, put simply, a woman in
labour has seven basic needs (Erhardt, 2011):
 To feel safe
 To leave the neo-cortex, the thinking part of the brain, switched off
 Silence
 Darkness or low lights
 Warmth
 Not feeling observed
 No adrenaline
When these needs are fulfilled they enable a labouring woman to release oxytocin
which causes the uterus to contract during labour. If a woman is disturbed in any
way, or does not have one or more of her needs taken care of, then her labour will be
hindered, thus, the environment she is in and the people around her are paramount
to meeting these needs and ensuring that medical intervention does not become a
consequence of her disturbance (Erhardt, 2011; Gaskin, 2003). Whilst medical
intervention may be necessary, at times, it should not form part of the natural
progression of labour for the majority of women as it can result in further
intervention, a traumatic birth, and a fear of further childbirth (Kitzinger, 2012).
Moving forward, women are able to reclaim their bodies during pregnancy and
childbirth by exercising their right to make informed choices; which is supported by
Maternity Matters (DoH, 2007). However, many women have become conditioned to
think that hospital birth and intervention is the norm and is the safest option, this
idea is often perpetuated by health professionals, also, within the media, and on
television programmes (Bellaby, 2001; Maclean, 2014), such as; One Born Every
Minute (Otley, 2012), thus, making the right decision can place immense pressure
upon women (Davis, 2003). Women, consequently, do not expect to be given a choice
in the place of birth (Devries, Salvesen & Weigers, 2001). Yet, there is little evidence
to support the notion that a hospital birth is safer than a homebirth (Savage, 2007).
In fact, there is a higher risk of post-partum haemorrhage if a woman gives birth in

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hospital compared to a home birth (Nove, Berrington, & Matthews, 2012).
Furthermore, there is the presumption that whatever a woman is told by a medical
professional will be unbiased and in their best interest, as they are more
knowledgeable and qualified, similarly, research has shown that the language used
by health professionals can be authoritarian which may leave a woman feeling as
though they are unable to challenge them and to just go along with what the Doctor
or Midwife says (Edwards, 2008). This, traditional, ‘Doctor Knows Best’ mind-set is
argued to be deep-rooted within a patriarchal society and without a significant change
in behaviour from health care professionals the ‘illusion’ of choice will unfortunately
remain (Lupton, Peckham, & Taylor, 2009)
Continuing on the theme of ‘Doctor Knows Best’; very often, the Doctor or Midwife
will justify their actions by stating that they are acting in the best interest of mother
and baby and they adopt the stance of ‘Better Safe Than Sorry’. For instance; when
explaining to a woman why they want to induce them they may say that it is better to
begin induction before a certain point in gestation just in case the placenta fails (Hart,
2004: Reed, 2010). However, the risks are often exaggerated to fit with their own
agenda and management of labour, and are not easily quantifiable. Furthermore,
there is often very little discussion on the potential risks of induction itself for mother
and baby (Lothian, 2012). These include; emergency caesarean section, and shoulder
dystocia, although, this list is not exhaustive (Hart, 2004). Research suggests that
Doctors make a conscious decision to adopt this approach as it can reduce the ‘risk’
of litigation, yet, this too is argued to be exaggerated (Cartwright & Thomas, 2001).
It is important for women to be informed about risks, however, it is equally important
to be aware that birth, like many other aspects of life, is not risk-free, it is about
calculating the risks which can only be done when fully informed (Lothian, 2012).

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Consequentially, when a mother is respected, has control, and is fully informed, she
is more likely to experience a ‘good birth’. This is regardless of whether her birth was
natural at home, an assisted delivery, or a caesarean section. Birth is often
undervalued and not recognised as an emotional process which can have negative
repercussions if a woman feels that her birth was anything less than a positive
experience. Instead, medical care should be empathetic, and communication is
crucial (Talbot, 2014). Likewise, whilst there should be an emphasis on baby being
well, at birth, this should not be ‘all that matters’. Dismissing a woman’s claim to
have had a poor birth experience is reducing her experience to an insignificant event,
something to get over. However, for many women, this experience, good or bad, can
stay with them for a long time and have a direct effect on their well-being (Henderson
& Redshaw, 2012).
To conclude, if birthing at home is a safe option, and can result in less intervention
and overall better outcomes for mother and baby, and women truly have a choice in
their place of birth, then further research is necessary to establish what influences
the majority of women to opt to give birth in hospital (Gardner, 2015). The,
aforementioned, ‘illusion’ of choice seems to play a crucial role in this as there would
surely be a higher proportion of women opting to give birth at home if they were fully
informed (Crossley, 2007; Hadjigeorgiou et al, 2012). Moving forward, one of the
recommendations of The NMR report, Better Births 2016, could be interpreted as a
positive step forward. A woman who is able to devise an individualised care plan is a
clear way of being in control, likewise, having control of their own personalised care
budget should also enable them to exercise their right to choose the most
appropriate setting that suits their needs. In both situations, women will receive
unbiased information so that they can make an informed choice (DoH, 2016).
However, at the moment this is purely theoretical, as the policy has had little time to

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be implemented in practice, and will require in-depth research analysis to take place
before conclusions can be drawn over its effectiveness.
The following chapter will focus on the qualitative research findings and will
incorporate elements of the policy analysis and literature review to provide a contrast.

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Chapter Three. Research findings
This chapter will concentrate on the thematic findings of the empirical research which
will be identifiable by subheadings. Each theme will be analysed in contrast with the
policy analysis, and literature review to provide a coherent and evidence based
discussion.
The concept of a good birth
The quote, used in the introduction, considered a health professional’s
understanding of the concept ‘A Good Birth’. Each woman who participated in this
research gave their personal thoughts on this concept and their responses truly
encompasses the heart of this research; in terms of what woman expect during
childbirth and, in contrast, what they experienced in reality. The general consensus
was that a ‘good birth’ is personal to the woman:
As long as it feels good to you, a caesarean section, assisted delivery, at home,
unassisted, trussed up to machines, if it feels right to you then it’s a good birth
personally is what I think. Some women want to be a patient, some don’t. It’s not
a case of one birth is better than another (03).
Furthermore, a common thought was that being empowered and experiencing a
natural birth was an important aspect of a good birth and is also the start of the
journey into motherhood:
Generally, one where you are informed, empowered. Being pregnant can be the
beginning of a journey where you can find skills that you will use throughout
your life. Personally, it being natural, the way it is supposed to be, unless there
is a need for medical intervention. I don’t see birth as the end of pregnancy, it’s
the beginning of being a mum so it matters for breastfeeding, it matters for
mental health, it matters for the family unit (08).

27
The good birth concept sets the tone for this dissertation and maintains the focus
upon women; their perceived perceptions, and their experiences. As per the policy
recommendations, in Maternity Matters 2007, women are encouraged to be involved
in choosing their place of birth and to make their own choices to ensure this is
achieved.
Birth choices and plan: homebirth
However, what a woman believes is necessary to achieve a good birth is not always
experienced in practice. The process of birth begins when a woman finds out she is
pregnant and is booked in with a midwife. It is at this point, that the first discussion
over choice takes place (Beech, 2014). A key choice is the place of birth; and it is the
European Human Right of every woman to choose where to give birth (Eggermont,
2012). A woman may have a clear idea in her mind that she would prefer a hospital
or a homebirth, however, some women may have given this little thought and,
therefore, rely on the midwife at the booking in appointment to discuss this with
them. Six of the women, that were interviewed, reported that a hospital birth was
assumed and the only option available was which hospital in which to give birth in
(01, 03, 05, 06, 08, & 09).
Furthermore, when four of the women expressed that they would like a homebirth
the immediate response was cautionary in one case:
I went to my first appointment with the midwife who wanted to know about my
previous pregnancies, I told her one had been a haemorrhage and both had had
pre-eclampsia, she said ‘oh I won’t offer you a homebirth then and I said ‘well,
actually’. She said she couldn’t guarantee anything as it depends on what
happens but would reassess at 36 weeks which I felt was a bit late but it is when
they do the usual home birth checks. I was never told I couldn’t have a homebirth,
it was a wait and see approach which I was fine with. I was ‘hoping’ for a
homebirth (05).

28
In another case it was instant dismissal:
The midwife was pro-homebirth until I spoke about my previous birth and
haemorrhage, her attitude changed, told me ‘you can’t have a homebirth’. The
midwife turned to my husband and said ‘what if your wife dies in your living
room and you are left with two children’? I thought my husband was going to
punch her! He still supported me but it shook him up (03).
Consequently, the start of these women’s journeys was on a path of uncertainty. Yet,
for many women this, restriction of choice, is accepted as normal (Lothian, 2008). We
also know, from the literature review, that the risk of PPH is less at home, yet, this
was not mentioned (Nove, et al, 2012). The period between booking in and giving
birth is usually monitored through ante-natal appointments which serve to keep an
eye on the progress of mother and baby and be alert for any potential problems
(Gaskin, 2003). It is also a time for a woman to organise her thoughts and make firm
plans for her impending birth in the form of a birth plan (NHS, 2015). A birth plan is
used by women to express their feelings before they give birth over how they expect
the labour and birth to proceed and often relates to pain relief, position in labour,
place of birth, and more, and is for the midwife and other health care professionals
to fulfil those requests where possible and within their clinical boundaries (Wickham,
2002). However, a birth plan is often seen to be whimsical and unrealistic and has
lost its value over the years which, in turn, can mean that women are not having their
thoughts recognised or acknowledged (Kitzinger, 2012):
I did find it strange when you get the emails from the NHS saying to think about
a birth plan. I asked the Midwife about it and she said yeah, make a birth plan,
go and have a look on line, there wasn’t really a focus on it and offer to sit down
and talk about these options. She just said to go online on the NHS website, look
at the options and if I did want to discuss any of the options then to go back. I
look back on it and there are things I definitely would have done differently and
looked into more. I know funding is really tight and they have to keep things to a
minimum but I definitely think this could have had more discussion and more
support from midwife (01).

29
Furthermore, it seems that the emphasis on making plans is a non-committal, wait
and see, approach which may suit the health professionals but it could be argued that
this is not listening to a woman and allowing her to discuss the many options
available to her and to make informed choices before the birth (Kitzinger, 2012).
The midwife asked for my wishes, I got information from them but still felt I
needed to do my own research. When information was given very little was given
with an explanation. At the moment women passing onto other women seems to
be the common way. Empowering each other. Health professionals are offering
information but not necessarily anything to back it up with and not all women
will know or think to look into it further (05).
Therefore, as woman are not receiving enough information from midwives and health
professionals, they are seeking it elsewhere. The women I interviewed talked about
parenting groups, online and offline, where they could ask other mothers about their
experiences of childbirth and seek advice. Two of the women said:
At the moment women passing onto other women seems to be the common way.
Empowering each other. Rather than believing everything a Doctor says. We are
challenging practice and opinions. Although, stories are often anecdotal, its
knowing we have a choice either way (05).
Other women can be a good source of information. Especially as part of positive
birth groups, there are plenty of places to go and get support from women, both
professional and personal. Women who are passionate about natural birth and
women being empowered. Women empowering Women (08).
However, anecdotal evidence cannot replace evidence based research, yet, without
health professionals providing it then women are going to seek advice and validation
from whomever they can and other mothers may be the next best way. Although, in
contrast, one women felt that midwives would not necessarily be unbiased even if
they were to provide the information:

30
I have learnt that nothing is black-and-white and very often opinions are given
based on the midwives own personal experience and I felt it was my responsibility
to research and get unbiased information. We don’t want the midwives to
pressure women to have a homebirth if they don’t want one but they should
support it and give information so they can make an informed choice (02).
Induction and the potential impact on the mother and baby.
Another significant theme was the subject of induction. This has been a particularly
harrowing part of their experience for some of the women and comes at a time when
a pregnant woman is at her most vulnerable (Wickham, 2014). She can be coerced
into a process that she either did not want to happen or did not fully understand the
risks, or the potential impact on the birth, and on her emotional well-being afterwards
(Jomeen & Martin, 2008). This was familiar for one participant whose baby had
difficulty breastfeeding after the birth:
No information was given to me; I was just swept along with it. They just told me
I would put on a drip. I wasn’t aware of the after effects. I have since learned
that there is a link between induction, antibiotics, and breastfeeding (04)
Likewise, the following two participants were coerced into being induced without
being fully informed:
Induction was being pushed on me. The only reason for induction was guidelines,
no known medical reason. I was never made aware of the risks of induction.
Intervention breeds intervention (07).
One week and half before he was due they said ‘we will induce you’ There was no
mention of what can happen if you are induced to early. But I learned afterwards
(09).
Inducement of labour occurs in twenty-five percent of births (NCT, 2015) and
although induction is common practice and may be necessary for a woman in some
circumstances such as: foetal distress, the consequential risks are ignored and,
instead, the induction of some, otherwise fit and healthy women, fits within the

31
medical model of childbirth and is a way to manage the process to suit the health
professionals (Gaskin, 2003: Kitzinger, 2012).
Birth as a process
Emerging from the theme of induction was the idea that giving birth is a set process:
Once you were in and being induced, you become their property, you cease to
exist, you’re on a conveyor belt (03)
Once you start, you’re on a timescale, if nothing much happens after one pessary,
they will do another one, it’s a process (05)
Policies have tried to make birth into a process. You can’t dictate how labour will
progress. Milestones are expected to be hit but it doesn’t work like that. The
process of birth has evolved negatively (10).
It is not uncommon for birth to progress this way and for women to be on a timescale
before the next level of intervention is applied. This has been described, by the
participants, as being like a conveyor belt and allows the health professionals to
remain in control (01.03.05 &10). Yet, as mentioned earlier, interfering with a natural
process can cause complications for mother and baby (Jomeen & Martin, 2008).
Risk: experience of complications and Trauma.
Continuing on the theme of complications; there was a recurrent theme, throughout
the research, on risk and the potential complications. It is important to note that all
of the women who were interviewed had given birth when they were classed as full
term gestation, between thirty-seven and forty-two weeks (NHS, 2015) so a premature
birth is not part of the analysis and outcome. How can a woman be aware of potential

32
complications without being fully informed? Instead, women are told very little which
may cause fear as the pregnancy progresses:
Health professionals can play on the fear of not knowing what may happen.
Consultants are often looking for something to go wrong, like pre-eclampsia, and
presuming things will go wrong, which can cause unnecessary anxiety, for
instance, baby showing as large on scans can make a woman fear birthing a
large baby and the baby is born smaller than predicted (05)
Additionally, the risks are not always quantifiable and are just used, again, as a way
for health professionals to remain in control and assumptions are often made as to
how the pregnancy and birth will progress. One particular participant had two
previous hospital births due to pre-eclampsia so it was assumed that her third would
be the same:
One of the male consultants made a comment ‘when you get pre-eclampsia again’
and I came out and broke my heart to my husband. I didn’t want to hear that.
They were doing regular growth scans as my first two were low birthweight and
there may be a link between that and pre-eclampsia. I was being scanned every
two weeks. I still wanted a homebirth even if they were small, both previous
children were fine despite being small, and they were induced at 38 weeks so
their weight is surely linked to that! (05).
Yet, she exercised her right to choose, and made an informed decision to have a
homebirth, despite the consultant citing the risks, and she went on to achieve the
birth she wanted, safely (05).
A participant on her fifth baby was told that she could no longer give birth on the
midwife led unit due to the risk of complications. However, after challenging the
decision, it was decided that there was currently no reason why the option should be
removed:

33
It came down to risk factors: I was over 40, family history of strokes, I was an
ex-smoker, 5th baby. So I was given the option of two hospitals. I challenged this
decision and went to see the chief gynaecologist, who checked me, looked at my
history who agreed with me and couldn’t see why I couldn’t give birth on the
birthing suite (10).
However, one participant felt that the issue of risk was more about the risk of
litigation for the health professionals and argued that if women were more informed
then there would be less pressure:
There is a blame culture so doctors may be concerned about being sued so do
everything, ‘just in case’ if the fear wasn’t there, the care would probably be
better. And if people were more informed it would less pressure on services (04).
Whilst it is important to recognise that some births may be complicated, the risk
should be calculated and the mother involved in the process so she can determine
her options (Beech, 2014). As mentioned in the literature review, it is not simply
enough to just go along with ‘Doctor Knows Best’, just in case.
The language used by health professionals.
Referring back to the ‘Doctor Knows Best’ mentality, in the literature review, it is
further evident, from the women interviewed, that when discussing their impending
birth, health professionals often use language that can increase fear and worry:
I explained to the consultant that I was having panic attacks at the thought of
going into hospital again. She said: “this is what I think should happen, I want
you on the consultant ward, a needle in the hand in case we need to give you
stimulating drugs, no pool” Which part of that me saying I didn’t want any of that
did he not hear (09).
Furthermore, some of the comments made were not constructive at all and just plain
hideous:

34
Things may be fine in the morning but not by the evening, baby could die which
would be very sad (07).
If we don’t get this baby out I am going to cut you, I’m going to cut you” and I
remember thinking I didn’t want any of this. I was put on the monitor, everyone
was panicked, no-one explained why. Baby wasn’t in distress. It was hideous.
They made me get on my back and telling me how to push (07).
These are women, in labour, and their experiences are real, emotional, and could be
tantamount to bullying if this was experienced in any other setting. One participant
refused to accept how they were being treated and challenged her care givers:
I was told by the doctor, at one point, that I was not pushing efficiently and if I
didn’t push properly they would cut me. I told him if they go anywhere near me
then I would kick him in the effing face (10).
The mother, in this situation, did not give consent to the doctor, however, she pointed
out in the interview that first time mothers, or mothers who did not feel confident
standing up to the doctors, may have been cut without their consent if put in a similar
situation (10). Furthermore, some women may be conditioned to think that ‘as long
as baby is ok’ then nothing else matters:
Interestingly, a baby has no legal status until they are born in any other situation
yet when pregnant and it comes to decision-making health professionals expect
a woman to take priority over a baby and of course they should be a priority but
not the only priority (03).
Often, the women were made to feel guilty for challenging the health professionals
and it was implied that they should just get on with it:
There seems to be a mentality of, I don’t want to take the chance; grin and bear
it; just get through it, as long as baby is ok, that’s all that matters (08).
The amount of people who tell me, ‘well you had a healthy baby so it doesn’t
matter’ don’t take away the trauma I experienced, don’t belittle it (09).

35
If a woman has experienced a traumatic birth, then this should not be dismissed. As
mentioned in the literature review, birth is, arguably, a feminist issue (Pascall, 1997).
This was confirmed as true by some participants who also felt that women have to
fight against a male dominated profession and the dominant attitudes of health
professionals:
Women are seen as crazy, Michel Odent, a male obstetrician is taken seriously
when he discusses natural birth and is very respected. Yet, a female counter part
can be ridiculed for championing natural birth (08).
I have become a feminist. Birth is all about telling women what they can and
cannot do. No other area of healthcare would do this (09).
The feminist idea was also challenged by one women who believed that attitudes
towards birth in general need changing:
We become other people’s property in pregnancy, it is a male dominated society.
Men shouldn’t be telling us what our bodies should be doing. Problems should be
dealt with at the time they arise they should not be pre-empted at the start of
pregnancy and treat them a certain way, then if XYZ does happen it justifies their
original actions. Attitudes need changing, it’s just women though, we are just a
species we are subordinate. Birth is a feminist issue but it shouldn’t be its just
birth (03).
Consent: being in control and being controlled
When considering the experiences of the participants and the language used by
health professionals, there is a pattern of behaviour evolving whereby women are
losing control of their experiences and instead being controlled:
I didn’t feel in control in my first pregnancy, especially during labour and birth.
I didn’t know what was going on, scared and went into my own little world. I was
pushing even when there were no contractions (04).

36
I wasn’t frightened about giving birth, I was frightened about losing control again
(03).
There is also an issue of consent, in some situations, where women have spoken
about having to argue during labour as a Doctor attempted to carry out a procedure
without their full consent:
They said I have to have a catheter as my bladder needed to be emptied I begged
them to let me try and they gave me a bowl but stayed there which made it
difficult to pass urine with an audience. The horrible doctor came back in again,
catheterized me, didn’t work so took me to theatre, the anaesthetist was awful, I
was upset as I didn’t have my baby with me and he said “what are you crying
now for”, he was horrible (07).
When women do not consent and are not in control they can be left with a legacy of
birth just being something to endure, a traumatic experience, which can then justify
the hospital birth, that is then passed to other women and the cycle continues (08).
Likewise, the whole birth experience can feel undignified (07).
One to One Midwives and the case-loading model of care
The final theme identified was unexpected and appears to be an outcome of the
negative experiences that have been mentioned which resulted in some women
seeking an alternative model of care. Six out of the ten women interviewed had
chosen to transfer their care to One to One midwives; a private company funded by
the NHS. It was abundantly clear, from each of the women, that the service they
received from One to One was by far superior than their experiences with the NHS for
previous births and they felt that birth was normalised:

37
With my second I went with one-to-one midwives. Having the same midwife
throughout my pregnancy made a big difference, like having the midwife come
to my home especially as I had a one -year-old. it was a half an hour appointment
instead of ten minutes and even though the NHS midwives had been open to
homebirth I still felt like an oddity with them whereas with one-to-one midwives
it was run-of-the-mill. Overall I felt like I had choices but that was through one-
to-one midwives, not the NHS, and from my own research. I found out since my
first birth that if I had phoned up and they said they didn’t have a midwife
available they legally had to provide one, but this wasn’t always put into practice
in the NHS and was one of my fears to happen (02).
Everything is normalized with One to One. I was still breastfeeding my first child
when I got pregnant with my second and I tandem fed, I bed-shared, nothing was
an issue. The midwife I had was also on my wavelength, she helped me bathe
etc., she knew, after I had given birth, that I was going upstairs to bed with him
and my daughter and didn’t push any of the NHS stuff on me. She supported my
choices by giving me information and advice on how to bed share safely (06).
The sheer relief of having the choice to transfer her care from the NHS where she had
felt severely let down in her first pregnancy, after suffering a traumatic labour and
birth, caused one woman to break down:
Two days later I got a phone call from one to one, from my midwife. I cried down
the phone. I contacted my GP and advised them I had transferred my care (03).
One to One home birth rates are thirty-one percent, which is considerably higher than
the two percent with the NHS and the induction and intervention rates are over twenty
percent lower (Collins & Kingdon, 2014). Furthermore, some of the women did
acknowledge that the NHS model of care was restrictive in what could be offered to
women, yet, felt this could be addressed so all women could have the same
experience:
It’s a shame that negative experiences cause a woman to have to look for
alternatives. My NHS midwife was dismissive and her attitude is bound by her
own personal experiences. The NHS is so tightly bound by protocols, unlike One
to One who had protocols but were autonomous and case-loading, the NHS cannot
provide this care although they could change the model of care to case loading if
they wanted to. Also, the attitude of NHS midwives, they don’t want the hassle it
seems (03).

38
Overall, One to One midwives are offering women continuity of care, informed choice,
and are empowering women:
NHS care is administrative, treating you like you are passing through, rather
than holistic. I was empowered as a woman with my birth with One to One, I was
in control. I gave birth with no help, I was encouraged. This is the ethos of the
women who work for One to One. I know a lot about homebirth now, I know about
doulas’ but so many women don’t. My One to One midwife was in tune with me
and how I was labouring. I experienced the foetal ejection reflex. I didn’t actively
push; my body took over. I was visualizing the end result, rather than focusing
on the labour, which helped me as I had felt scared beforehand (08).
Ultimately, the women interviewed believe that One to One midwives are raising the
bar for practicing midwives in the NHS and raising expectations for mothers:
One to One were the first and only people to mention choices. ‘you know you have
the choice, we can inform you of risks, but ultimately it is your choice’. The case
loading midwife model of care is brilliant. She was at the end of a phone call or
text when I needed her. Whereas the community midwife was there every other
Thursday, I had no idea whether I could get hold of her in between (09).
The following chapter concludes what has been discussed throughout this
paper.

39
Conclusion
This final section brings together the policy analysis, the literature review, and the
research findings and presents an overall closing argument and recommendations.
In conclusion, the in-depth policy analysis does advocate choice, in theory, although,
this appears to be a token gesture as it is not always applied in practice (Beech, 2014).
Likewise, women are conditioned to think that the default option is to give birth in
hospital due to the inherent risks (Coxon, Sandall & Fulop, 2014). This is further
evident by the extensive literature review undertaken. That is not to say that the NHS
model of care is all negative and this is not intended to be a scathing attack on the
NHS, nor, that this research is indicative of all maternal care within the NHS, however,
it is relevant and cannot be ignored or dismissed. The research emphasis is on each
individual woman’s perception, rather than an overall collective view, and it is
essential that health professionals strive to consider this and adopt practices that will
ensure all women are informed and empowered (Beech, 2014; Wickham, 2014).
The primary research shows that if the mother perceives her labour to be
mismanaged by the midwife and other health professionals then this may lead to an
overall poor-experience (01, & 07). Likewise, the language used by midwives and
health professionals is powerful, often dictatorial, and can be the difference between
a positive and negative experience. It is not appropriate to use language such as;
‘your baby might die’ without further explanation or reasoning as this only serves to
instil fear in women which is counter-productive (07), and could be conducive to them
experiencing a decline in their post-natal mental health (Henderson & Redshaw,
2013). Out of the ten women interviewed, they all experienced positive aspects, and

40
had their choices facilitated, in at least one of their births, however, the majority of
the women had, what they described as horrendous, or traumatic experiences, at
some point, which did have an impact on their well-being (03) and affected their
decision to have further children (01). Furthermore, for those women who expressed
choice and questioned the policies and practices they had a less than positive
experience overall as they were made to feel like they were being deliberately
challenging (03, 07 & 09). However, communication is a two-way process and if a
woman wishes to ask questions, challenge the status-quo and educate herself then
this should not be met with resistance, it should be welcomed and facilitated (10).
This research shows that women are, instead, perceived as being radical, or
alternative (08). Likewise, they can also be perceived as aspiring to have an almost
impossible birth experience; for instance, a homebirth, or one without pain relief,
and should just accept that it is a nice idea in theory but in reality it is better to accept
that it is unlikely to happen (02). It is the responsibility of the health professionals to
change attitudes and behaviour patterns by altering how they practice and there
being consistency with the practice of other midwives (03 & 09).
Consequently, six of the women interviewed looked at alternative types of maternal
care. One to One midwives are one such alternative whose ethos fits the women’s
expectations of providing women-led care in the form of the case-loading model of
midwifery which is argued to be the preferable way to support choice as it can result
in fewer interventions and more positive birth outcomes (Wainwright & Collins, 2015).
In comparison, the NHS model of midwifery care is, arguably, outdated and not fit for
purpose when it comes to offering women continuity of care which is, also, attributed
to achieving a good birth (02, 03, 06, 07, 08, & 09).
A positive step forward, in policy development, is the publication of Better Births
2016. Whilst it is early days, this review of maternity services was overseen by the

41
person who instigated The Changing Childbirth Report in 1993, which did, initially,
have a massive impact and subsequent changes in practice, therefore, confidence in
this new report may not be misplaced. It will be interesting to observe how the policy
is implemented over time and how it is received by health professionals and women
alike. In particular, allowing women to be in control of their maternity budget may
encourage them to be more actively involved in the decision making and enable them
to make informed choices (DoH, 2016).
Finally, the following ancient Chinese proverb has been replicated many times in
writings about midwifery and symbolises the overall ethos of the research findings
within this dissertation:
You are a midwife, assisting at someone else’s birth. Do good without show or
fuss. Facilitate what is happening rather than what you think ought to be
happening. If you must take the lead, lead so that the mother is helped, yet still
free and in charge. When the baby is born, the mother will rightly say ‘we did it
ourselves! (Tao Te Ching, cited in Kirkham, 2000)
Recognising the quintessential feminine potency, and offering greater choice,
autonomy, along with, an overall recognition of women, who understand their bodies
and want respect and choice, should be at the centre point of maternity policy.
10000 words

42
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Edwards. A. (2008)/ Place of birth: can ‘maternity matters’ really deliver choice?
British Journal of Midwifery, 16(12), 771-775. doi:
10.12968/bjom.2008.16.12.31818.
Eggermont, M. (2012). The choice of child delivery is a European Human Right,
European Journal of Health Law, 19, 257-269. doi: 10.1163/157180912X639125.
Erhardt. R. (2011). The basic needs of a woman in labour. South Africa: True
Midwifery.
Gardner, S. (2015). Choice of place of birth: Is it really that simple? British Journal
of Midwifery, 23(1), pp 4-4. doi: 10.12968/bjom.2015.23.1.4.
Gaskin, I.M. (2003). Ina may’s guide to childbirth. London: Random House.
Gaskin, I.M. (2009). Foreword. In S.J. Buckley (ed.), Gentle Birth, Gentle Mothering
(pp. 4-8). Brisbane, QLD: One Moon.
Gaskin, I.M. (2011). Birth matters: a midwife’s manifesta. London: Printer & Martin.
Glasby, J. (2012). Understanding health and social care. Bristol: Policy.
Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopolous, I., & Martensson, LB.
(2012). Women’s perception of their right to choose the place of childbirth: an
integrated review. Midwifery, 28(3), 380-90. doi: 10.1016/j.midw.2011.05.006.
Hart, G. (2004). A timely birth, Midwifery Today, 72, 10-14. Retrieved from
https://www.midwiferytoday.com.
Henderson, J., & Redshaw, M. (2012). Who is well after childbirth? Factors related to
positive outcome, Birth, 40(1), 1-9. doi: 10.1111/birt.12022.
Jomeen, J., & Martin, C. (2008). The impact of choice of maternity care on
psychological health outcomes for women during pregnancy and the postnatal
period, Journal of Evaluation in Clinical Practice, 14, 391-398. doi: 10.1111/j.1365-
2753.2007.00878.x.

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Kent, N. (2010). The road ahead. Retrieved from https://www.rcm.org.uk/news-
views-and-analysis/analysis/the-road-ahead.
Kirkham, M. (2000). The midwife-mother relationship. Basingstoke: Macmillan.
Kitzinger, S. (1991). The midwife challenge. London: Pandora Press.
Kitzinger, S. (2012). Birth crisis. London: Routledge.
Lindsey, P., & Peate, I. (2015). Introducing the Social Sciences for Midwifery Practice:
Birthing in a Contemporary Society. London: Routledge.
Lothian, J. (2008). Choice autonomy and childbirth education, The Journal of
Perinatal Education, 17(1), 35-38. doi: 10.1624/105812408X266278.
Lothian, J. (2012). Risk, safety and choice in childbirth. The Journal of Perinatal
Education, 21(1), 45-47. doi: 10.1891/1058-1243.21.1.45.
Lupton, C., Peckham, C., & Taylor, P. (1999). Managing public involvement in
healthcare purchasing. Buckingham: OUP.
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childbirth 20 years on, Midwifery, 30(3), 279-281. doi:
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Nove, A., Berrington, A., & Matthews, Z. (2012). Comparing the odds of postpartum
haemorrhage in planned home birth against planned hospital birth: results of an
observational study of over 500,000 maternities in the UK. BMC Pregnancy and
Childbirth, 12(1), pp 1-11. doi: 10.1186/1471-2393-12-130.
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Women. Oxford: Basil Blackwell.
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April, 2016, from http://www.ons.gov.uk.
Otley, H. (2012). One born every minute: mother’s performance anxiety, The
Practising Midwife, 15(2), 25-26. Retrieved from http://www.ingentaconnect.com.
Pascall, G. (1997). Social policy: a new feminist analysis. London: Routledge.

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Reed, R. (2010). Induction of labour: balancing risks, Retrieved from
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Care: Feminist perspectives. Oxford: Books for Midwives.
Talbot, D. (2014). Exploring the ‘good’ birth: what is it and why does it matter.
British Journal of Midwifery, 22(12), pp 854-860. doi.
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Walton, I., & Hamilton, M. (1995). Midwives and changing childbirth. Cheshire:
Books for Midwives Press.
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Wickham, S. (2002). What’s right for me. London: AIMS.
Wickham, S. (2014). Inducing labour, making informed decisions. London: AIMS.

47
College Ethical Approval Panel for Taught Programmes
Ethical Approval Application Form for Taught Programme Students
ETHICAL APPROVAL MUST BE OBTAINED BY ALL STUDENTS PRIOR TO STARTING
RESEARCH WITH HUMAN SUBJECTS, ANIMALS OR HUMAN TISSUE.
The completed Proportionate Review checklist and full Application form should be submitted to:
CHSC-TaughtEthics@salford.ac.uk
Applications will only be processed with approval of the supervisor.

48
Proportionate Review Criteria
All student research that collect primary data should consider the ethical issues involved in their
project. It is acknowledged that student research should have educational and training benefits for
the student through submission of research proposals to ethics committees. The Economic Social
Research Council (ESRC) advises that student research should be treated in the same manner as all
other research and subject to ethics review. In some cases, student research may receive a ‘light
touch,’ or proportionate review, where such applications involve minimal risk. Minimal risk should be
determined based on the guidance provided in appendix 2 Ethics panel’s therefore approach the
review in a facilitative and proportionate way that recognises that limited experience of the student
and guides what is expected of them. However, student projects that involve more than minimal risk
must be subject to a full review.
The College Ethical Approval Panel for Taught Programmes has developed a ‘proportionate review’
system to facilitate an appropriate appraisal of the ethical issues in student research. Supervisors are
encouraged to work with their student and identify whether the student’s proposed project requires
full or proportionate review. The guidance below and contained in the appendices has been developed
to support the supervisor’s assessment of their student’s research proposal.
Please select a response to the following questions. Projects that indicate that potential risk is involved
will be subject to a full review by the ethics panel. Projects that select mainly ‘YES’ or NA will be subject
to a proportionate review by an ethics panel member. Once approved, the applicants will receive
feedback within ONE week of submission for proportionate review. Projects that are not subject to
Proportionate Review will be sent to full ethical review, which normally takes 4-5 weeks. Each project
should be carefully assessed with the supervisor according to the relevant professional regulatory
guidelines for research ethics.
All students should be encouraged by their dissertation supervisors to apply the relevant professional
regulatory guidelines as a standard to underpin their research. All projects should ensure that the
participant’s autonomy is paramount and that the benefits of undertaking the project are clearly
assessed against the potential risks. Students and supervisors should consult the appropriate
professional regulatory guidance and can contact the ethics team for further guidance if required.
Links to professional regulatory ethical frameworks can be located on the College Ethics website for
taught programmes at http://www.salford.ac.uk/chsc/research/taught-programme-ethics:
All students should ensure that they submit the following documents:
1. Fully completed and signed ethics application form X
2. Consent form (if required) X
3. Data collection tools (for example interview schedules, questionnaires etc.) X
4. Risks assessment form X
5. Checklist X
6. Participant information sheet X
7. Any organisational letters or correspondence. N/A

49
College Ethical Approval Panel for Taught
Programmes Proportionate Review Criteria
Office use only
Ref No:
Name of Applicant: Claire Carey
Full Programme Title: BSc (HON) Social Policy Award: BA BScX MA MSc
Name of Supervisor: Professor Louise Ackers
Title of Study: Do Maternity Policies in the UK, in practice, enable and empower
women to make informed choices on childbirth?
All student research that collects primary data should consider the ethical issues involved in their
project. It is acknowledged that student research should have educational and training benefits for the
student through submission of research proposals to ethics committees. The Economic Social
Research Council (ESRC) advises that student research should be treated in the same manner as all
other research and subject to ethics review. In some cases, student research may receive a ‘light
touch,’ or proportionate review, where such applications involve minimal risk. Minimal risk should be
determined based on the guidance provided in appendix 2. Ethics panel’s therefore approach the
review in a facilitative and proportionate way that recognises that limited experience of the student
and guides what is expected of them. However, student projects that involve more than minimal risk
must be subject to a full review. Please note that systematic and other forms of literature reviews do
not need ethical approval.
Please use the guidance in the Appendix to support your appraisal
.
Evidence
(Ethical approval ref
no/application page
no etc.)
Supervisor
and
Applicant
(please delete
as appropriate)
Reviewer
(please delete
as appropriate)
1 The project is part of a larger research study that already has ethical
approval?
No Yes/No
2 The project proposes to collect secondary data only? *
If ‘YES’ please ensure that the project meets the requirements for
data protection
No Yes/No
3 The project uses validated Questionnaires that only include non-
sensitive or low risk research areas or where accidental disclosure
would NOT have serious consequences. (Please use the guidance in
appendix to guide your selection.)
No Yes/No
4 The project is proposing to use interviews that only include non-
sensitive or low risk research areas or where accidental disclosure
would NOT have serious consequences
Yes Yes/No/NA
5 The project includes minimally invasive basic science studies that
have full supervisor support undertaken on healthy volunteers.
NA Yes/No/NA

50
6a The project includes the use of the PAR-Q to assess participant
suitability.
NA Yes/No/NA
6b The project involves testing/protocols/equipment which has
previously been used in an approved application.
NA Yes/No/NA
6c The project involves testing/protocols/equipment which has
previously been used in an approved application, and involves the
same population.
NA Yes/No/NA
7 The project’s recruitment strategies exclude the use of social media
sites?
NA Yes/No/NA
Signed by Student: ca carey Date: 7th October 2015
Signed by Supervisor: Date: 7th November 2015
Supervisor Recommendation: Proportionate Review
*Please delete as appropriate
Reviewer Recommendation: Proportionate Review/Full Review*
*Please delete as appropriate
Feedback from Reviewer in support of decision:
Appendix: College Guidance for Sensitive or High Risk Research Subjects
The College Guidance for Sensitive or High Risk Research Subjects is predicated on the following
range of professional regulatory ethics frameworks: British Psychological Society, Social Research
Association, Economic Social Research Council, Social Policy Association (SPA), RESPECT Code of
Practice for Socio-Economic Research & Royal College of Nursing Guidance on Ethics (2009).
It is acknowledged that some research may pose risks to participants in a way that is legitimate in the
context of that research and its outcomes. However, it is advised that the longer-term gains should
outweigh the short-term immediate risks to participants. Students and supervisors need to provide a
robust rationale for sensitive subjects and articulate what the longer term gains are and whether there
are any potential benefits for the participants (BPA 2012). No generic formula or guidelines exist for
assessing the likely benefit or risk of various types of social enquiry. Nonetheless, social researchers
must be sensitive to the possible consequences of their work and should as far as possible, guard
against predictably harmful effects (SRA). The following research (as per BPS/ESRC guidance) would
normally be considered as involving more than minimal risk:

51
 Research involving potentially vulnerable groups (such as children aged 16 and under; those
lacking capacity; or individuals in a dependent or unequal relationship, powerless individuals);
 Research involving those who lack capacity or who come during the research project to lack
capacity must be approved by an appropriate ‘body’ (for example a flagged NREs Panel) that
operates under the Mental Capacity Act (2005)
 Research involving sensitive topics (such as participants’ sexual behaviour; their legal, illegal or
political behaviour; their experience of violence; their mental health gender or ethnic status);
 Research involving deceased persons, body parts or other human elements
 Research involving a significant element of deception;
 Research involving access to records of personal or confidential information (including genetic or
other biological information);
 Research involving respondents through the internet – in particular where visual images are
used and where sensitive issues are discussed.
 Research involving access to potentially sensitive data through third parties (such as employee
data);
 Research that could induce psychological stress, anxiety or humiliation or cause more than
minimal pain (e.g. repetitive or prolonged testing);
 Research involving invasive interventions (such as the administration of drugs or other
substances or techniques such as hypnotherapy) that would not usually be encountered during
everyday life;
 Research involving physical exercise protocols that would not usually be encountered;
 Research that may have an adverse impact on employment or social standing (e.g. discussion of
an employer, discussion of commercially sensitive information);
 Research that may lead to ‘labelling’ either by the researcher (e.g. categorisation) or by the
participant (e.g. ‘I am stupid’, ‘I am not normal’);
 Research that involves the collection of human tissue, blood or other biological samples.

52
College Ethical Approval Panel for Taught
Programmes Application Form
Office use only
Ref No:
Ethical Approval Form for undergraduates and post graduates (taught programmes)
Ethical approval must be obtained by all students prior to starting research
with human subjects, animals or human tissue. The student must discuss the
content of the form with their dissertation supervisor who will advise them about
revisions. A final copy of the summary will then be agreed and the student and
supervisor will ‘sign it off’. The applicant must forward a hard copy of the form to the
College Teaching and Learning Team, Room AD101, Allerton Building (CHSC-
TaughtEthics@salford.ac.uk) once it is has been signed by their Supervisor.
The form must be completed electronically; the sections can be expanded to the size
required but not exceeding the word count specified. To assist you with the completion of
this form there are ‘Guidance Notes for Completing the College Ethics Form’ on the website
(http://www.salford.ac.uk/chsc/research/taught-programme-ethics) which indicate what is
required for each section.
Is this application a resubmission? (delete as appropriate) Yes
If Yes, please indicate Ref No. (if known)
Is this an amended version of the original application? (Please
highlight any changes) (delete as appropriate)
Yes
Name of Student: Claire Carey
Full Programme Title: BSc (HONS) Social Policy
Award:
(delete as appropriate)
BSc
Supervisor: Professor Louise Ackers

53
Will this project use any NHS sites? (delete as appropriate) No
Will this project include children? (delete as appropriate) No
Will this project involve adults lacking the capacity to consent for
themselves? (delete as appropriate)
No
Will this project take place on University premises?
(delete as appropriate)
Yes
Is a DBS check required? (delete as appropriate) No
Have you read the Lone Worker Policy? (delete as appropriate) Yes
1. Title of proposed research project (refer to guidelines section 1)
Do Maternity Policies, in practice, enable and empower women to make informed
choices on childbirth? A case study in Greater Manchester.
2. Project focus (refer to guidelines section 2)
The project will explore mothers’ perceptions, and their experiences of the
choices available to them throughout pregnancy. From their ante natal care and
decision-making around where to give birth, home or hospital, pain relief,
induction and the impact this had on their overall experience and well-being.
The study will involve women who have given birth at least 6 months ago;
between January 2014 and June 2015.

54
I aim to demonstrate the level of awareness women have, in practice, over the
choices available to them and whether they were able to make ‘informed’ choices.
3. Project objectives (refer to guidelines section 3)
 To review national and local policies on maternal health.
 To analyse existing academic literature and statistical data.
 To interview women in the Greater Manchester area to discuss their
previous births.
 To highlight any differences between policy and practice
 To understand the potential consequences of women not being involved
in decision making surrounding childbirth
4. What is the rationale which led to this project? (refer to guidelines section 4)
Maternal health began to attract government interest during the Second World
War due to the on-going attempts at increasing the population. Before the launch
of the National Health Service (NHS), in 1948, women routinely gave birth at
home, however, as obstetric knowledge progressed further, which in turn began
to label more women as being ‘high-risk’, many medical professionals argued
that giving birth within a hospital setting was safer than remaining at home. One
report in particular, constructed by Consultant Obstetrician John Peel,
recommended that one hundred per cent of births should take place in hospital.
Consequently, medicalised, hospital births rose rapidly and by the 1970s the rate
was above ninety-five per cent and did not drop below this figure. However, the
report did face significant criticism over the absence of evidence in support of his
claims, and, furthermore, for failing to consult with women over their experiences
and what they felt they needed during pregnancy and childbirth. This report
marked the beginning of pressure groups, and organisations such as; The
National Childbirth Trust (NCT) and The Association for Improvements in the
Maternity Service (AIMS), who both began to campaign on behalf of women and

55
their right to make informed choices over their care during pregnancy and
childbirth (Davis, 1981, 2013; Oakley, 1984).
The changing childbirth report in 1993 and The Maternity Matters Policy in 2007
have both been prominent influences in attempting to change maternity practices
in the UK. The Department of Health (1993) made recommendations that were
then implemented from 1994 onwards and stated that women should be fully
informed of all of their choices in childbirth to allow them to make decisions over
their care, thus, improving their overall experience. However, research
undertaken by Banyana and Crow (2003) demonstrated that this was not being
achieved in practice and, in fact, seventy-two per cent of the women interviewed
were not even aware that they were able to make their own choices. In particular,
with regards to having a homebirth and it was only those women who were
already planning one who were given further information and the opportunity to
discuss it in more detail. Further policy intervention ensued with the
implementation of the Maternity Matters Policy in 2007 that aimed to re-evaluate
maternity policy and ensure that the recommendations were implemented in
practice by health professionals. Moreover, one of the most important decisions
for a woman to make, when pregnant, is where to give birth; at home or in
hospital, and according to Cheyney (2008) the debate of where to give birth has
risen due to the claims that childbirth, in a hospital setting, is becoming
unnecessarily medicalised and often leads to, otherwise, preventable
interventions.
There has been numerous research on this topic, however, the research I plan to
undertake will focus on a case study of a group of women from the Greater
Manchester who have given birth within between January 2014 and June 2015
area to gain their perceptions and gain current perceptions.
5. Is your project linked to any other projects? (refer to guidelines section 5)
No

56
6. Research Strategy. Please provide an indication of the project duration or project
schedule in your research strategy or as an appendix. Please detail where the
study will take place (setting), how data will be collected and how data will be
analysed. (refer to guidelines section 6)
 The methodology will be qualitative; method will be interviews.
 The women will be interviewed individually over a 4-5-week period and will
take place at the University of Salford.
The interview will be conducted using pre-set interview questions that will allow
for the conversation to flow naturally using gentle probing questions when
necessary. It is my intention not to lead the participants in any way. Following the
interviews all the data collected will be transcribed and then thematically
analysed, and discussed with my dissertation supervisor. The data will be
analysed by myself and the findings will be presented in detailed answers, using
quotes from the participants where necessary.
7. How many participants will be recruited and/or involved in the research study, and
what is the rationale behind this number? (refer to guidelines section 7)
 I will recruit approximately 10 female participants within the Greater
Manchester area. My aim is for the women to represent various groups in
society, including, age, disability, ethnic origin. If more than 10 women
apply I will select the women who will best represent the above proposed
demographic.
 This number of women will be a suitable sample when taking into account
the time frame available for the proposed research and enables me to gain
depth into their experiences.

57
8. Please describe how you plan to obtain organisational agreement for your project.
(refer to guidelines section 8)
N/A
9. Are you going to recruit individuals to be involved in your research? Please detail
how, rather than who you will recruit. (refer to guidelines section 9)
YES (delete as appropriate and if Yes explain clearly how participants will be recruited)
I will use my existing contacts in the Greater Manchester area to access informal
parenting groups such as; mums and toddler groups, and I will ask community
buildings, to display a leaflet explaining my research and a request for interested
participants to email me.
This will be open to women aged 18+.
A sample poster is attached to this form.
10.How will you ensure you gain informed consent from anyone involved in the
study? Please also refer to the participant information sheet and consent
procedure (refer to guidelines section 10)
I will gain written consent from each mother, to be interviewed and recorded, and
provide them with a participation information sheet to explain the aims and
objectives of the study and to explain that all information will be remain
confidential and the data will be anonymised.
I would design this document in conjunction with my supervisor.

58
11.Are there any data protection issues that you need to address?
(refer to guidelines section 11)
(delete as appropriate and explain response)
 All participants will be given a code word for their information to remain
anonymous and confidential to all except the researcher.
 All data that is stored electronically will be stored on the F drive on a
password controlled computer
 Hard copies will be stored in a locked filing cabinet, in a locked room at
the University.
 All data will be stored for at least three years
 Only the researcher and supervisor will be able to access the data.
12.Other ethical issues that need to be considered (refer to guidelines section 12)
Participants will not be discriminated against for being part of a minority group
and I aim to have a range of participants from different backgrounds.
Childbirth is an emotive subject and may invoke feelings of distress in the
participant if the interview is not handled sensitively. This can be managed by
ensuring that participants are at least 6 months’ post-partum and not recently
delivered and that they are given sufficient time to read the participant
information, no less than one week, before agreeing to the interview.
If, during the interview, any participant becomes distressed I shall cease the
interview. Any ethical issues that arise during the study will be discussed in detail
with my supervisor.

59
13.References – provide full list of all references used
 Banyana, CM, & Crow, R. (2003). A qualitative study of information about
available options for childbirth venue and pregnant women’s preference
for a place of delivery. Midwifery, 19(4), 328-336. doi: 10.1016/50266-
6138(03)00042-1/midw.2003.0369
 Cheyney, J. (2008). Homebirth as systems-challenging praxis: knowledge,
power and intimacy in the birthplace. Qualitative Health Research, 18(2),
254-67. doi: 10.1177/1049732307312393
 Coxon, K., Sandall, J., & Fulop, N.J. (2013). To what extent are women
free to choose where to give birth? How discourses of risk, blame and
responsibility influence birth place Decisions. Health, risk and society,
16(1), pp 56-67. doi: 10.1080/13698575.2013.859231
 Davis, A. (1981). Modern motherhood: women and family in England, c.
1945-2000. New York: Manchester University Press
 Davis, A. (2013). Wartime women giving birth: narratives of pregnancy
and childbirth, Britain c. 1939-1960. Studies in History and Philosophy of
Biological and Biomedical Sciences, 47(B), pp 257-266. doi:
10.1016/j.shpsc.2013.11.007
 Department of Health. (1993). Changing childbirth, part 1, report of the
expert maternity group. HMSO: London
 Gardner, S. (2015). Choice of place of birth: Is it really that simple? British
Journal of Midwifery, 23(1), pp 4-4. doi: 10.12968/bjom.2015.23.1.4
 Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopolous, I., &
Martensson, LB. (2012). Women’s perception of their right to choose the
place of childbirth: an integrated review. Midwifery, 28(3), 380-90. doi:
10.1016/j.midw.2011.05.006
 Lothian, J. (2012). Risk, safety and choice in childbirth. The Journal of
Perinatal Education. 21(1), 45-47. doi: 10.1891/1058-1243.21.1.45
 Nove, A., Berrington, A., & Matthews, Z. (2012). Comparing the odds of
postpartum haemorrhage in planned home birth against planned
hospital birth: results of an observational study of over 500,000
maternities in the UK. BMC Pregnancy and Childbirth, 12(1), pp 1-11.
doi: 10.1186/1471-2393-12-130
 Oakley, A. (1980). Women Confined: Towards a Sociology of
Childbirth. New York: Schocken Brooks
 Oakley, A. (1984). The Captured Womb: A History of the Medical Care of
Pregnant Women. Oxford: Basil Blackwell

60
 Simkin, P. (2006). Just another day in a woman’s life? Women’s long term
perceptions of their birth experience, part 1. Birth, 18(4), pp 203-210.
doi: 10.1111/j.1523-536X.1992.tb00382
 Stockill, C. (2007). Trust the experts? A commentary on choice and
control in childbirth. Feminism and Psychology. 17(4), 571-577. doi:
10.1177/0959353507083093
 Talbot, D. (2014). Exploring the ‘good’ birth: what is it and why does it
matter. British Journal of Midwifery, 22(12), pp 854-860. doi.
10.12968/bjom.2014.22.12.854
NB. Projects that involve NHS patients, patients’ records or NHS staff, will require ethical approval by
the appropriate NHS Research Ethics Committee (REC). The College Research Governance and
Ethics Committee will require written confirmation that such approval has been granted. Where a project
forms part of a larger, already approved, project, the approving REC should be informed about, and
approve, the use of an additional co-researcher.
NB: The ethical and efficient conduct of research by students is the direct responsibility of the
supervisor.
I certify that the above information is, to the best of my knowledge, accurate and correct. I
understand the need to ensure I undertake my research in a manner that reflects good principles
of ethical research practice.
Signed by Student: …ca carey……………………………………………………….
Date …7th
November 2015………………………………………….
Please note that whilst the College indemnifies student research projects, the supervisor is signing that
they are satisfied that the student has considered the ethical implications of their work and to confirm
for the student’s project to proceed subject to approval by the ethics panel
Signed by Supervisor
Date ………………………7/11/2015……………….
Prior to submitting the application form:
Please refer to the ‘Application Checklist’ and ensure appropriate supporting
documentation is submitted with the application form
Failure to complete the necessary documents will result in the application being
returned to the applicant without being reviewed for re-submission thus
delaying the approval process.

Do Maternity Policies in the UK in practice enable and empower women to make informed choices during pregnancy and childbirth

Do Maternity Policies in the UK in practice enable and empower women to make informed choices during pregnancy and childbirth

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