Plan de medios edición digital 2017

The beginning of the narrated stories mostly related to the midwives’ understanding of the woman’s situation, needs and decision-making. The initial interaction between woman-midwife marks the beginning of most of the participants’ main story.

However, the role the midwife appeared variable across the accounts. Whether this was an intentional positioning of the midwife or in response to the individual woman was not always clear, therefore, this interpretation does not suggest that this is the only way that the midwives operated. Respondents appeared to be positioned in three different ways; first, to accept and support women’s pre-determined decisions: in this case, the midwives themselves contributed little to the women’s decision-making. Second, some were positioned within a collaborative role wherein the women

required support, information and access to services, thus creating a decision-making partnership. Finally, a third position related to midwives who reported that they actively provided additional options and choices, usually for women who did not have prior knowledge or understanding regarding their birth options or choices or women who did not make their preferences known. These three aspects are represented by the following sub-themes: ‘woman-led affirmative decision-making’, ‘woman-midwife collaborative decision-making’ and ‘midwife-led widening women’s choices’.

Affirming women’s prior decisions

Many of the midwives reported supporting women who had made specific birthing decisions independently of any discussion with health professionals, usually on the basis of previous birthing experiences. or desires to experience normal/natural labour and birth. Therefore, the midwife participants did not seem to be a factor in women’s decision-making processes. For example, midwives referred to how women used language such as ‘decided’, ‘planning’ [a homebirth] or ‘insistent’ to denote their definitive decision-making:

‘…I am working with a lady who is (.) totally going against all (..) obstetric opinion whatsoever and (.) and so has clear medical risks and complications (.)…because she is

quite clear in what she wants from her birth…’ [Isabel (I): 6-6]

In some cases, midwives reported women asserted their decision-making regardless of whether support was offered or not, as highlighted by Jenna:

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‘…so I went out, sat down with her and the first thing she said was that she was going to have a breech homebirth, with or without us really (.) so I felt she would freebirth

anyway no matter what we said’ [Jenna (I): 5-5]

Other women were reported to be quietly assertive in their decision-making, simply resisting offers of induction (for postmaturity), or avoiding recommendations for screening, testing, scans or medical input as medical factors arose. In some intrapartum situations, the midwives referred to how women declined some or all midwifery input. For instance, Maria reported being called to a homebirth ‘just in case’:

‘…When I got to her flat a doula was present and the woman was mobilising and looked to be in established labour. She declined any baseline observations and told me she didn’t want me to listen in to the baby at all, she said she’d called me just in case I was needed but that I was not to call for a second midwife as she didn’t want anyone else in

the flat!’ [Maria (N): 9-11]

Here, most of the midwives followed the woman’s lead simply supporting their prior decision-making to maintain good relationships and to instil ‘confidence and trust that her choices would be respected.’ [Kelly]. However, for one midwife, following the woman’s lead was felt to be ‘blurring the lines of consent [Leanne]’. In this particular situation, rather than the woman making a definitive decision to decline vaginal examinations, she agreed to vaginal examinations but delayed the procedure several times.

Collaborative decision-making

In contrast to the women who had made resolute decisions before meeting the midwife, some respondents reported women required varying levels of support, information and guidance to inform their decision-making. Therefore, the midwives’ role was influential in facilitating women’s decision-making and navigating the system to actualise the women’s wishes. In these type of situations, it appeared that women were either tentative in their decision-making or had voiced their wishes but were uncertain about available options. Sam stated:

‘Yea, I was working as a community midwife, and uhm, she had a uhm a disappointing birth experience with her first baby…She said 'you know I'd really like a homebirth, what

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what the evidence says but at the end of the day so as long as you are aware of the pros and cons and the fact that you have got epilepsy, it's your choice.' [Sam (I): 7-7] For some, the midwives reported women felt the decision had been made for them by previous health professionals until they had the opportunity to discuss it further with the midwife participant:

"… I offered to go round to see her at home for the 41 week, so I came around to her house, it was her first baby and at this point she'd had brief conversations about induction of labour and uhm (..) I think from her point of view it was all going to be booked in for her (.) and that was it (.) we had this conversation about it and it was at

this point she said 'I don't really want to (.) get induced... ‘[Kate (I): 6-6] Stella demonstrated a proactive, collaborative approach with a woman who had numerous decisions to make regarding her baby that was breech:

‘We began discussing choices, not only vaginal birth versus caesarean section, but place of birth and professional to help with the birth. At my encouragement, Maisie and Callum accessed all of Jane Evans’ material and read a recent (brilliant) dissertation

from one of the newly qualified midwives, bringing together all recent research on breech...’ [Stella (N): 7-10]

Widening women’s choices

This subtheme relates to midwives ‘widening women’s choices’, a phrase coined by Kelly. In essence, the midwives widened the women’s knowledge and access to different choices, that were midwife-led but woman-driven. Kelly reported providing a woman with a number of options including homebirth. In this situation, the woman was a grand multipara30_{, which guidelines usually precluded from homebirth.}

However, Kelly noted that the woman almost experienced a BBA31 _{in her previous}

labour, so Kelly suggested a homebirth, an option that Kelly said the woman did not know she could access. Once the seed was sown, the woman went on to have a number of successful homebirths. Kelly believed that not all women know their options. She felt that pointing them out - ‘just seems to be the right thing to do’. She said:

30 _{>5 births}

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‘…But in the same way that she hadn't breastfed before either and she went onto breastfeed some of the other ones. It's the same thing isn't it, exactly, once you have

widened somebody's choices then they make different choices.’ [Kelly (I): 47-55] Moreover, Kelly’s approach captured a sense of equitable care provision, where she did not just work with women who make specific requests but practiced in a way that offered everybody the same choices:

‘…It's offering, it's giving everybody the whole range of choices. Not saying to her 'no you can't have your baby at home because you are high risk', it's going 'these are your choices, you know, what do you want to do? How do you want to take this?’ [Kelly (N):

47-55]

Echoing Kelly’s ethos of care, those who reported widening women’s choices held a strong ethos of ensuring women were provided with full information to make an informed decision. Like Kelly, other midwives observed that when women were given a wide range of options, their decisions ‘very rarely correspond exactly to the

guidelines’ [Clara, Georgina, Catherine, Meg], insinuating that the information that is provided (or not) is a key component of decision-making. In one example, Kerry highlighted that where meaningful conversations occurred, women may make different decisions to that of their original plans:

‘…we are really lucky here as we have a specialist midwife for women who birth outside of the guidelines and I think she [the woman] was just feeling quite overwhelmed by the

whole (..) process because she just wanted to have her baby but there was so much surrounding her bio status and everything (..) which was very well controlled (.) she came along wanting a pool birth in our home from home room and it ended up with her

having a homebirth (.) I think that was just speaking to X [specialist midwife] that she realised 'actually I don't even want to be here, I want to be at home.' [Kerry (I): 10-10]