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Midwives’ experiences of home birth transfer

25 February, 2013

Midwives’ experiences of home birth transfer

The aim of this paper is to explore the midwives’ experience of home birth transfer from a planned home birth to an obstetric unit (OU).

Evidence Based Midwifery: March 2013

Marion Wilyman-Bugter1 MSc, RM, RN.
Thelma Lackey2 PG cert, MA, RM, RN.

1 Team leader midwife, Royal Sussex County Hospital, Community Midwives Office, Eastern Road, Brighton BN2 5BE England. Email: marion.wilyman@bsuh.nhs.uk
2 Senior midwifery lecturer, Aldro 110, c/o Robert Dodd, 49 Darley Road, Eastbourne BN20 7UR England. Email: T.L.Lackey@brighton.ac.uk


The authors would like to thank the midwives who generously shared their thoughts, feelings and fears which have added greatly to the richness of the data.

Abstract
Background. Transfer rates from home to hospital for mothers in labour range from 7%-45%.
Aim. To explore the midwives’ experience of home birth transfer from a planned home birth to an obstetric unit (OU).
Method. A phenomenological approach was adopted in an attempt to understand what it was like for midwives to transfer a mother birthing at home to obstetric care in the hospital. Unstructured interviews involving ten midwives were undertaken. The interviews were recorded, transcribed and analysed.
Ethical approval. Granted by the research governance and ethics committee at the Institute of Postgraduate Medicine and the NHS trust where the research project was carried out.
Findings. The study identified issues relating to five themes which include: difficulties surrounding the decision to transfer, the importance of supporting the parents, the significance of collaborative working, the ongoing organisational challenges and the need for a reliable ambulance service.
Conclusion. The study highlights the necessity for a home birth protocol, which reinforces appropriate action with regards to transfer. This needs to include a strategy for dealing with parents who oppose transfer, and a procedure for prompt handover of care to an OU. It is apparent that midwives appear confident and well-trained in dealing with transfer, despite the challenges faced. There are concerns about the availability of a second midwife, which need to be addressed.

Key words: Midwives, home birth, transfer, low-risk pregnancy, phenomenology, evidence-based midwifery

Background
Choice regarding place of birth has been at the forefront of many government papers, encouraging low risk-women to seek alternative birth settings to the traditional obstetric units (OUs) (DH, 1993, 2004, 2007; RCOG, 2011). At present, approximately 92% of births in England take place in OUs, regardless of whether the high-technology facilities are needed (Hollowell et al, 2011).

Strong evidence exists about the benefits of midwife-led care for low-risk women outside of an OU, such as midwife-led units and home births. Women choosing these options experience more spontaneous vaginal births, fewer medical interventions and greater satisfaction with the care (Olsen and Jewell, 1998; Walsh, 2008; Mori et al, 2008; Begley et al, 2009; de Jonge et al, 2009; Hodnett et al, 2010; Hollowell et al, 2011). The latter option is also significantly more cost effective (Hollowell et al, 2011).

Birth is a life-changing event and it is important that women and their partners are able to choose a setting that feels safe and comfortable and welcoming; this includes home birth (NICE, 2007; RCM, 2008; NCT, 2009). Nevertheless, complications during labour requiring intervention can occur without warning and may necessitate prompt transfer to the nearest OU (Wax et al, 2010; Evers et al, 2010; Hollowell et al, 2011). Transfer rates, especially for women having their first baby, range from 7.4% to 45%, according to the place and the literature available on this subject (Mori et al, 2008; Evers et al, 2010;  Hollowell et al, 2011). Rates have seen a sharp rise over the last decade (Hollowell et al, 2011) and are thought to be influenced by changing risk profiles and an increased analgesia demand (Amelink-Verburg et al, 2009).

The professionals responsible for the safety of mother and baby in UK home births are registered, qualified midwives. It is the midwives, NHS or independent, who are expected to deal with appropriate and timely home birth transfers and who are in charge of the event (NMC, 2010). A midwife’s ability to manage a transfer safely and competently is crucial for the wellbeing of mother and baby (Hollowell et al, 2011). With a potential increase in women choosing the home birth option, midwives need to be prepared to take on this challenge. The focus of this study will be on midwives conducting home births within one NHS facility.

Over the last decade, numerous studies on alternative birth settings have shown positive maternal and perinatal outcomes (Maternity Care Working Party, 2007; Fullerton et al, 2007; Walsh, 2008; Begley et al, 2009; Hodnett et al, 2010) including birth at home (Janssen et al, 2003; Lindgren et al, 2008; de Jonge et al, 2009). However, while previous research demonstrated good outcomes, some recent studies contradict these findings. The Birthplace study reported that the risk of poor outcomes for babies of first-time mothers is found to be significantly higher in planned home birth (Hollowell et al, 2011). This confirms earlier reports of an increase in risk of perinatal mortality in home birth settings, particularly surrounding emergency transfer (Mori et al, 2008; Wax et al, 2010; Evers et al, 2010). It should be noted that concerns regarding the methodological quality of these latter studies have been raised and outcomes should be interpreted with caution (Walsh and Downe, 2008; Reitsma, 2009; de Jonge et al, 2010; de Vries and Buitendijk, 2012).

Method
A phenomenological approach was chosen as it uncovers the lived experience of individuals or groups (Rees, 2003; Bowling and Ebrahim, 2005; Greenhalgh, 2006; Vivilaki and Johnson, 2008) and attempts to articulate, through the content and form of text, the structures of meaning embedded in lived experience (van Manen, 1990).

Sample
Ten qualified midwives from an NHS trust consisting of two separate OUs consented to participate in the study. Letters containing participant information sheets with consent forms were sent to the midwives’ home addresses and individual consent was obtained via the return forms. Sampling in phenomenology is purposive because it selects participants who will have knowledge of the phenomena concerned, and allows an understanding of the lived experience (Mapp, 2008). Six midwives were based in the community setting and four were in the OU at the time of the interviews.

Inclusion and exclusion criteria
Research participants were required to be qualified midwives who had been in charge of at least one planned home birth that required transfer during labour to an OU. Planned home births were defined as all births that were planned at home at the start of care in labour, regardless of whether a transfer occurred during labour or immediately after birth (Hollowell et al, 2011). The midwives needed to be employed by the local trust at the time of conducting home birth transfers. This was important as variations in practice between different trusts could have affected the transferability of data.

Data collection
Interviews were conducted in the privacy of a previously booked room within the trust, surgeries or children’s centres and pseudonyms were provided by the midwives. Interviews were audio recorded and took between 17 and 50 minutes. Field notes were taken.

Ethical considerations
This study was approved by the research governance and ethics committee at the Institute of Postgraduate Medicine. It gained further approval from the research and development directorate and the head of midwifery at the local NHS trust where the research project was carried out.

Trustworthiness and rigour
In qualitative research, trustworthiness is one of the criteria used in establishing the authenticity and accuracy of the information presented (Rees, 2003). Revealing the meaning of an experience can be difficult as phenomenology always looks to go beyond the first layer of description (Snow, 2009). By member checking, keeping field notes, arranging an audit trail and incorporating a reflexive account within this study, an attempt has been made to prove credibility and increase trustworthiness. By using the tools according to the specific underpinning philosophy of Heidegger, analyses of data could be carried out in a reflective and epistemological way. In doing so, an attempt has been made to add rigour to this enquiry (Vivilaki and Johnson, 2008). A written report containing topics identified during the interviews was sent to the midwives for verification.

Analysis
Interviews were transcribed verbatim into the same format. All transcripts were given a serial number for reference purposes in order to relocate material quickly and return to points in the data of particular interest (Denscombe, 2003). A summary of topics for possible categories from each interview was created by searching for the essence in the midwives’ individual stories. A matrix was used, as described by Greenhalgh (2006), and the following five key themes were identified:
• The decision to transfer
• Supporting the parents
• Collaborative working
• Organisational challenges
• Ambulance services.
The themes are made up from 12 categories (see Table 1, below) and represent the essence of the midwives’ lived experiences of home birth transfer.

 

Findings
Analysis of the data revealed five key themes of midwives’ experience of home birth transfer (see Table 1). These have been subdivided into categories in which aspects of the findings have been described. Each category presents data excerpts directly taken from the interviews in an attempt to capture the midwives’ perceptions of their experience. The findings and the discussion are presented separately in order to consider the significance of data within the context of the overall aims of the research (Denscombe, 2003).

The decision to transfer
Decision-making surrounding transfer seemed to be influenced by a midwife’s level of confidence and expertise, as well as the parents’ willingness to comply. In some cases, there was evidence of strong emotions at play during the transfer process. 

Making the decision
Midwives considered themselves well-trained to make decisions and relied on their own professional judgement, as well as a generic protocol and national guidelines for parameters of normality:
“It is getting the balance right and it’s doing what is right for everybody and giving women exactly what they want, bearing in mind that they have an agenda and I have an agenda. And it is my responsibility, at the end of the day, to make sure that they are all safe” (Alf).

Obstructions to the decision
Problems occurred when a midwife’s decision was challenged by a partner, family member, friend or doula. This could subsequently delay the transfer and thus put mother and baby in potential danger. Alice desperately tried to convince the parents that there were serious concerns regarding the wellbeing of their unborn baby, necessitating immediate transfer. In this case, it was the woman’s partner who challenged Alice’s decision by not agreeing to the transfer:
He [the dad] really wanted a home birth: she was in advanced labour and she was already ‘fully’ by the time we got there. She wasn’t bothered, she said: ‘yes I will’. But she could barely even get the words out because she was so in labour. He said: ‘I don’t want to.’”

Midwives wanted the home birth to be successful, but not by compromising the health of the mother and baby. Although they felt well-equipped to deal with challenging behaviour, it was also a source of serious concern, as they felt that this could affect the birthing process, delay admission to the OU and possibly result in further complications. Situations similar to that of Alice were experienced by a number of midwives who were interviewed.

Midwives’ emotions
Midwives admitted to feeling a host of emotions when asked what it was like for them to transfer labouring women. Although most felt confident about dealing with emergencies, there were situations in which they described feeling anxious, scared, panicky, or even terrified. Murriel summed this up with the following statement:
“Sometimes there is a sense of blind terror, when you get a fetal heart of 60 and you are 12 miles from the hospital and you are transferring in. So, you know, there are many, many different emotions depending on the situation.”

Supporting the parents
Midwives worked to support parents by trying hard to build good relationships, providing evidence-based information and aiming to offer feedback after transfer.

Good relationships
Building a rapport through open discussion with the labouring woman and her birthing partner was considered extremely important. Trust appeared to be achieved through honesty and openness. Midwives made considerable efforts to give explanations that parents could understand, welcomed questions and tried to provide a clear plan of care for transfer, including the parents in the process. Sam explains:
“They [the parents] know that I have tried my hardest and that I have kept them there as long as I could. And you built up a relationship, hopefully, with those people and they get to know you and they know that you aren’t just towing the line and that you are doing it for a reason.”

Dealing with parents’ expectations
Parents’ expectations of labour and birth appeared to play key roles in accepting advice from health professionals. Midwives felt that this was influenced by the quality of education and evidence-based information offered to women during the antenatal period, as Beatrice illustrates:
“I think preparation of women antenatally is of utmost importance. And I think the service run by our local midwives, who try to provide information for women who are thinking of having a home birth, is invaluable. To give people real, sort of a chance to ask questions and to be able to give them knowledge about what we would be looking at a transfer for.”

Furthermore, midwives believed that continuity of care enhanced good relationships, as well as encourage realistic expectations. This process could facilitate positive experiences for women, as well as midwives.

Debriefing the parents
Postnatal debriefing after transfer was seen as an important part of accepting the transfer and maintaining good relations with the parents. This usually took place shortly after birth or during a postnatal visit at home. Although not always easy due to different shift patterns, the majority of midwives made debriefing a priority, particularly after a traumatic event.

Furthermore, this gave midwives an opportunity to gain feedback about the way they handled the transfer:
“So we had a chat about what happened and that was quite therapeutic for both of us. Because as it turned out she was relieved and scared and she did not realise that I was relieved and scared. She thought I was just being very professional so it is good getting someone who has been in the same situation. She thought I coped very well, whereas I thought that I had panicked but I hadn’t obviously” (Beth).

Collaborative working
The need for excellence in communication, teamwork and support between health professionals was highlighted by most midwives taking part in this study.

Communication and teamwork
Midwives believed that good communication inspired confidence in parents and helped resolve possible conflict. They felt that evidence of good teamwork and effective communication influenced how parents perceived their  competency. Jinny’s statement reflects good teamwork:
“I think it is who is coordinating and how much you have communicated with the midwife [labour ward coordinator] that you are coming in to. I think communication at home is really important, and preparing them [labour ward staff] for what you are going to bring in.”

Collegial support
The labour ward coordinator was considered to be the main source of advice and support. The possibility of transfer was always discussed with the coordinator by telephone and she or he would be the first person notified of an incoming transfer. The presence of a second midwife at a home birth has always been considered good practice in the trust but seemed hampered by a lack of available midwives. Nevertheless, attendance at the house of a second midwife during the birth was seen as invaluable and midwives expressed serious concerns if this was not organised in time, as Emily describes:
“Sometimes it has sort of been, ‘well we will do our best to get you a second’, and sometimes it hasn’t happened. Or it is ‘we will try to send you a second when more staff come on’. And sometimes it doesn’t happen, and there are times when midwives are out there on their own.”

Without exception, all midwives interviewed felt very strongly about the provision of extra midwifery support when a birth was imminent. The presence of a second midwife could become crucially important during a neonatal resuscitation, or when dealing with a postpartum haemorrhage at home, as Alf experienced:
“That was really, really scary, but she [the woman] was fine and that shows again that we are well trained – the pair of us – we just flew into action, dealt with the situation.”

Organisational challenges
Attention to logistics in addition to good-quality guidelines and protocols were seen as an essential part of the smooth running of home birth transfer.

Logistics surrounding transfer
Organising transfer, particularly during an emergency, required a host of different skills from midwives. Not only did they have to manage an unexpected event without immediate assistance, they also had to cope with basic equipment only. The sometimes cramped and cluttered home birth environment was very different from the relatively sterile clinical labour ward. Although this has many benefits for women in labour, it can be a challenge for the health professionals. For example, midwives found it extremely problematic to make phone calls and arrange for urgent transfers without alarming the parents. The challenge surrounding the organisation of an emergency transfer is illustrated by Beth when she was called to a home birth some distance away from the hospital:
“Trying to organise transfer, explaining to the parents what is going on, getting her [the woman] out of the pool all at the same time. And blue lighting it into the unit. It all went OK, but this is one of those where you do not have the luxury of the time. You’ve just got to act really quickly and it is afterwards when the baby is born in the unit and you think afterwards: ‘Oh my God, what if?’”

Protocols and guidelines
At present there is no dedicated home birth protocol, thus midwives are guided by a generic labour ward protocol, NICE guidelines and locally agreed practice for home birth transfer. As a result, confusion with respect to the interpretation of current practice is not uncommon. Sarah gives an example of confusion regarding place of arrival of a very sick baby following emergency transfer from home:
“I hadn’t had a transfer like that, where it was such an emergency that labour ward were asking me ‘where have you sent the first ambulance with the baby to? Are they going to A&E or are they coming straight up?’ And I didn’t really know. I didn’t… I was like: ‘Oh well they have just gone and I am assuming they are going to A&E’. And she said ‘well, where do you want me to send the paeds? Are they coming up here or down there?’ So that got a bit confusing.”

There was a preference for written agreements in order to provide clarity. Beatrice sums up what several midwives voiced during their interview:
“So, for myself, I think, you know, the question of transfer is about having a really robust protocol – robust in that it covers options so that, obviously women still have the choice and they don’t have to stick to these – but if we were actually able to come up with a protocol that is going to be safe for them and it is going to give, you know, the reasons why we are saying this, then I think that will go a long way towards making women… keeping women safe.”

All midwives interviewed were extremely happy with their local service provision, in particular when an emergency transfer was requested.

Paramedics were invaluable during obstetric emergencies at home, as they would bring extra equipment as well as being a reassuring presence and assist the midwife where necessary. This is illustrated in the following examples:
“It was like the cavalry have arrived wasn’t it? It was just like they are here” (Sam).

“Yes, yes, it was myself and the paramedic who then did the resuscitation, and he had already brought in all the oxygen and had the bag and mask and everything ready. Of course we have our bag and mask out ready at the home birth, but we don’t have oxygen and things like that. And he was very familiar with resuscitation on a neonate, so yes, he became part of the team straight away” (Sarah).

 Inevitably, some babies were born in the ambulance.
“We ended up stopping in a lay-by and delivering the baby, which of course came out screaming and pink” (Murriel).

Discussion
Working in partnership with parents
Working in partnership and including parents in decisions about their care is an essential part of building good relationships (Smith, 2011; Boyle, 2011; Catling-Paull et al, 2011; Jefford et al, 2011) and influences how parents perceive the midwives’ competency (Catling-Paull et al, 2011; Dabrowski, 2012). Midwives in this study made considerable efforts to achieve this. Nonetheless, opposing a midwife’s decision to transfer by parents or birth supporters did undermine this process and midwives expressed concerns about the effects this could have on labouring women. Midwives in the UK use their expertise and evidence-based knowledge to support and empower women in exercising autonomy (Jefford et al, 2011). However, difficulties may arise when a fundamental conflict of views about care management occurs between parents and the midwife. This study highlights that quality antenatal preparation and continuity of care could possibly help prevent such a situation, as midwives felt that this not only encouraged realistic expectations of labour and birth, but also appeared to play a key role in informed choice. Available literature emphasises the importance of making parents aware that a normal low-risk pregnancy is no guarantee of an uncomplicated birth, thus education should include the possibility of an unplanned transfer when choosing birth in midwife-led settings (Creasy, 1997; Wiegers and Keirse, 1998; Jevon and Raby, 2002).

Findings in the study indicate that making time to debrief after transfer, particularly during an emergency, is extremely beneficial for parents. This is supported by several studies on the subject, suggesting that debriefing parents cannot only assist in the process of acceptance (Creasy, 1997; Lucas, 2011) but help prevent postnatal depression or post-traumatic stress as well (Boyle, 2011).

Handover from midwifery-led to obstetric-led care
The quality of leadership demonstrated by the labour ward coordinators was a significant factor in the seamless operation of transfer. Good communication, mutual respect and supportive leadership are vital components when trying to maintain a sense of urgency during transfers (Jevon and Raby, 2002; de Jonge et al, 2009; Dabrowski, 2012). Communication problems, as well as misinterpretation of a transfer situation between healthcare professionals (HCPs), could delay obstetric intervention and thus influence outcomes (Symon et al, 2010). Prompt handover to obstetric care was highlighted as problematic by several midwives during the interviews in this study. This could be an important finding and may go some way towards explaining the higher risk of intrapartum related perinatal mortality among the low-risk planned home birth group that required transfer during the course of labour (Mori et al, 2008; Evers et al, 2010; Wax et al, 2010; Hollowell et al, 2011).

Changes in midwifery practice
Traditionally, home birth was organised entirely by community midwives, as the community setting provided the midwives with more opportunity to offer continuity of care, thus knowing the women’s wishes. However, it appears from the interviews that this is no longer achieved. Benefits of continuity of care are well-documented (Walsh, 2008; Hodnett et al, 2010; Kirkham, 2010). Findings in this study suggest that frequently, neither hospital nor community midwives met the parents and were required to establish a good rapport quickly. This may have influenced the number of transfers, as evidence suggests an increased risk of transfer if continuity could not be achieved (Lindgren et al, 2008).

Evidence from this study suggests a further change in practice which is causing concern among local midwives. All midwives without exception hugely valued the support of a second midwife when a birth was imminent. Until quite recently, this was accepted by the local trust as common practice in home birth. However, findings from this study suggest a lack of availability of this additional support. It became clear during the interviews that the apparent unreliability of a second midwife is extremely challenging and, consequently, has an effect on practice, as midwives admitted to being less keen to attend a home birth in this situation. This reluctance could have an influence on midwives’ attitudes towards home birth. This is another significant finding which needs to be addressed in order to promote local home birth provision. The availability of a second midwife for NHS home births has come under scrutiny following midwife shortages and a rise in birth rate (Healthcare Commission, 2008). As a result, alternative options of less-qualified personnel, such as the use of MSWs, are currently under review (Warwick, 2012).

Midwives experienced several situations at the home that warranted the presence of two skilled HCPs, such as postpartum haemorrhage following birth and resuscitation of the baby. Failed resuscitation after a home birth was found to be the most significant contributory factor to infant death in a study by Wax et al (2010). The above findings suggest the necessity of two skilled HCPs which could pose a dilemma for the planning of future home birth services. The RCM (2008) promotes one-to-one care for all women, whether at home or in hospital. The request for a second midwife at a home birth could potentially deny other women this one-to-one care, given the current climate of staff shortages (Healthcare Commission, 2008). However, additional support at home is extremely important to midwives, and clear policies regarding the use of a second HCP skilled in neonatal resuscitation need to be in place to achieve continued high standards of care.

Home birth outcomes
Midwives achieved good overall outcomes following transfer, despite a number of emergency situations at home. This suggests high levels of competency in managing these situations. Good results are known to give midwives increased confidence and more faith in their ability to provide safe, competent care (Lucas, 2011; Jefford et al, 2011). It became clear from the findings that making good use of knowledge and being well supported had a positive effect on midwives as well as parents. This is confirmed by several studies on the subject (Creasy, 1997; Walker, 2000; Jevon and Raby, 2002).

Adverse maternal outcomes are rare, but poor perinatal outcomes do occur, regardless of birth setting, and cannot always be avoided, no matter how competent an attending midwife might be (Olsen and Jewell, 1998; de Jonge et al, 2009; Evers et al, 2010; Wax et al, 2010; Hollowell et al, 2011). Although no serious adverse outcomes were discussed during the research interviews, it is possible that midwives did not wish to share this experience.
Nevertheless, being given time to debrief after a traumatic event was considered extremely important. The value of debriefing should not be underestimated, as adverse events may significantly influence subsequent referral behaviour (Styles et al, 2011).

The need for protocols
Good relationships between maternity staff are likely to improve women’s experiences of transition from home to OU (Creasy, 1997; Wiegers and Keirse, 1998; Catling-Paull et al, 2011). This study exposed some of the difficulties that midwives experienced when communications break down, or when logistics are not in place, leaving them concerned about the influence this would have on the women in their care. Midwives interviewed in this study believed that high-quality guidelines and protocols would avoid some of these problems, as well as assist them in making an acceptable plan of care. They believed this would send a clear message to parents, avoid confusion with other HCPs and improve communication within the maternity team. These findings not only suggest a need for a home birth protocol, but also one that deals specifically with the issue of transfer. The quality of transfer protocols in England is unsatisfactory and there is an urgent need to improve the system (Rowe, 2010; Hollowell et al, 2011; Dabrowski, 2012). More attention to the transfer process would become especially relevant given the government’s drive to create more midwife-led facilities (Warwick, 2012; RCOG, 2011; Dabrowski, 2012).

Despite obstacles and changes to midwifery practice, most midwives thoroughly enjoyed the autonomy required for home birth settings. They also recognised their limitations and relied on the ambulance and OU team if complications became apparent. A  focus on birth outside an OU would promote a change in midwifery practice with the potential for benefits for midwives as well as women and their families (Pettersson et al, 2001; Baird, 2007; Warwick, 2012).

Limitations
Seeking the women’s views would have strengthened these findings but, despite this limitation, the study is able to highlight many aspects of transfer, as seen through the eyes of the midwives involved.

Implications
The most significant outcome from the findings is the clear necessity of a home birth protocol with emphasis on home birth transfer. This should include:
• The provision of a skilled second HCP/midwife when birth is imminent at home
• Strategies for dealing with parents opposed to a midwife’s decision to transfer
• Prompt handover to obstetric care to avoid delays
• Allocated time to debrief for both parents and midwives
• Up-to-date information on transfer audit and statistics
• Evidence-based antenatal preparation, specifically aimed at parents planning a home birth.
This study reveals changes in midwifery practice, such as the much reduced continuity of care and a reduction in the availability of a second midwife. These are likely to have an impact on current and future services and need to be taken into consideration when developing a home birth protocol.

Conclusion
Giving birth at home offers many benefits for low-risk women, as well as midwives, and is significantly more cost-effective (Begley et al, 2009; Hollowell et al, 2011). Action on the key issues revealed by the midwives who took part in this study could make a significant contribution in strengthening the home birth provision in the local community consistent with government recommendations.

Addressing these issues would not only benefit midwives but has the potential to enhance midwife-led services for the local women and their families, ultimately increasing quality of care and choice in place of birth. This small scale ‘in depth study’ could form the basis for larger scale work in this area in the future.
 

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References

Amelink-Verburg MP, Rijnders ME, Buitendijk SE. (2009) A trend analysis in referrals during pregnancy and labour in Dutch midwifery care 1988-2004. British Journal of Obstetrics and Gyneacology 116(7): 923-32.

Baird K. (2007) Exploring autonomy in education: preparing student midwives. British Journal of Midwifery 15(7): 400-5.

Begley C, Devane D, Clarke M. (2009) An evaluation of the effectiveness of midwifery-led service in the health service executive – North Eastern area: the MidU study – a randomised trial. See: controlled trials.com/ISRCTN14973283 (accessed 8 February 2013).

Bowling A, Ebrahim S. (2005) Handbook of health research methods: investigation, measurement and analysis. Open University Press: Maidenhead.

Boyle M. (2011) Emergencies around childbirth : a handbook for midwives. Radcliffe Publishing: Abingdon.

Catling-Paull C, Dahlen H, Homer CS. (2011) Multiparous women’s confidence to have a publicly-funded home birth: a qualitative study. Women and Birth 24(3): 122-8.

Creasy JM. (1997) Women’s experience of transfer from community-based to consultant-based maternity care. Midwifery 13(1): 32-9.

Dabrowski R. (2012) Travelling into the unknown. Midwives 15(1): 36-8.

de Jonge A, van der Goes B, Ravelli AC Amelink-Verburg MP, Mol BW, Nijhuis JG, Bennebroek Gravenhorst J, Buitendijk SE. (2009) Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. British Journal of Obstetrics and Gyneacology 116(9): 1177-84.

de Jonge A, Mol BW, Birgit YG, Nijhuis JG, Joris AP, Buitendijk SE. (2010) Dutch perinatal mortality. Too early to question effectiveness of Dutch system. British Medical Journal 341: c7020.

de Vries R, Buitendijk E. (2012) Science, safety and place of birth. Lessons from the Netherlands. European Obstetrics & Gynaecology 7(suppl 1): 13-7.

Department of Health. (1993) Changing childbirth: report of the expert matenity group. HMSO: London.

Department of Health. (2004) National Service Framework for children, young people and maternity services. HMSO: London.

Department of Health. (2007) Maternity matters : choice, access and continuity of care in a safe service. HMSO: London.

Denscombe M. (2003) The good research guide: for small-scale research projects (second edition). Open University Press: Buckingham.

Evers ACC, Brouwers HAA, Hukkelhoven CWP, Nikkels PGJ, Boon J, van Egmond-Linden A, Hillegersberg J, Snuif YS, Sterken-Hooisma S, Bruinse HW, Kwee A. (2010) Perinatal mortality and severe morbidity in low- and high-risk term pregnancies in the Netherlands: prospective cohort study. British Medical Journal 341: c5639.

Fullerton JT, Navarro AM, Young SH. (2007) Outcomes of planned home birth: an integrative review. Journal of Midwifery & Women’s Health 52(4): 323-33.

Greenhalgh T. (2006) How to read a paper: the basics of evidence-based medicine (third edition). BMJ Books: Oxford.

Healthcare Commission. (2008) Towards better births: a review of maternity services in England. Commission for Healthcare Audit and Inspection: London. See: image.guardian.co.uk/sys-files/Society/documents/2008/07/10/Towards_better_births.pdf (accessed 8 February 2013).

Hodnett ED, Downe S, Walsh D, Weston J. (2010) Alternative versus conventional institutional settings for birth. Cochrane Database Syst Rev 9: CD000012.

Hollowell J, Puddicombe D, Rowe R, Linsell L, Hardy P, Stewart, M, et al. (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. British Medical Journal 343: d7400.

Janssen PA, Lee SK, Ryan ER, Saxell L. (2003) An evaluation of process and protocols for planned home birth attended by regulated midwives in British Columbia. Journal of Midwifery & Women’s Health 48(2): 138-45.

Jefford E, Fahy K, Sundin D. (2011) Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives. International Journal of Nursing Practice 17(3): 246-53.

Jevon P, Raby M. (2002) Resuscitation and the community midwife. Practising Midwife 5(1): 18-20.

Kirkham M. (2010) Midwifery and medical models: do they have to be opposites? Practising Midwife 13(3): 14.

Lindgren HE, Hildingsson IM, Christensson K, Rådestad IJ. (2008) Transfers in planned home births related to midwife availability and continuity: a nationwide population-based study. Birth: Issues in Perinatal Care 35(1): 9-15.

Lucas A. (2011) Learning and skills counsel. Midwives 14(4): 40-1.

Mapp T. (2008) Understanding phenomenology: the lived experience. British Journal of Midwifery 16(5): 308-11.

Maternity Care Working Party (MCWP), NCT, RCGO, RCM. (2007) Making normal birth a reality. Consensus statement from the Maternity Care Working Party: our shared views about the need to recognise, facilitate and audit normal birth. Maternity Care Working Party: London. See: rcog.org.uk/files/rcog-corp/uploaded-files/JointStatmentNormalBirth2007.pdf (accessed 8 February 2013).

Mori R, Dougherty M, Whittle M. (2008) An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003. British Journal of Obstetrics and Gyneacology 115(5): 554-9.

NCT. (2009) Location, location, location: making choice of place of birth a reality. NCT: London.

NICE. (2007) Intrapartum care: care of healthy women and their babies during childbirth. NICE: London.

NMC. (2010) Supporting women in their choice of home birth. NMC: London. See: nmc-uk.org/Documents/CouncilPapersAndDocuments/Committees/MC/14July2010/M_10_15_Annexe2SupportingWomenInTheirChoiceOfHomeBirth.pdf (accessed 8 February 2013).

Olsen O, Jewell D. (1998) Home versus hospital birth. Cochrane Database Syst Rev 3: CD000352.

Pettersson KO, Svensson ML, Christensson K. (2001) The lived experiences of autonomous Angolan midwives working in midwifery-led maternity units. Midwifery 17(2): 102-14.

Rees C. (2003) An introduction to research for midwives (second edition). Books for Midwives: Edinburgh and New York.

Reitsma AH. (2009) A review of ‘An estimation of intrapartum-related perinatal mortality rates for booked home birth in England and Wales between 1994 and 2003’. Canadian Journal of Midwifery Research and Practice 8(1): 23-4.

Rowe RE. (2010) Local guidelines for the transfer of women from midwifery unit to obstetric unit during labour in England: a systematic appraisal of their quality. Quality and Safety in Health Care 19(2): 90-4.

RCM. (2008) RCM evidence-based guidelines for midwifery-led care in labour: good practice points (fourth edition). RCM: London.

RCOG. (2011) High-quality women’s health care: a proposal for change. RCOG: London.
Smith D. (2011) Decision-making in maternity care: how women influence decisions. British Journal of Midwifery 19(5): 329-32.

Snow S. (2009) Nothing ventured, nothing gained: a journey into phenomenology (part 1). British Journal of Midwifery 17(5): 288-90.

Styles M, Cheyne H, O’Carroll R, Greig F, Dagge-Bell F, Niven C. (2011) The Scottish Trial of Refer or Keep (the STORK study): midwives’ intrapartum decision-making. Midwifery 27(1): 104-11.

Symon A, Winter C, Donnan P. (2010) Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth 37(4): 280-7.

Van Manen M. (1990) Researching lived experience : human science for an action sensitive pedagogy (SUNY series, the philosophy of education). State University of New York Press: Albany, New York.

Vivilaki V, Johnson M. (2008) Research philosophy and Socrates: rediscovering the birth of phenomenology. Nurse Researcher 16(1): 84-92.

Walker J. (2000) Women’s experiences of transfer from a midwife-led to a consultant-led maternity unit in the UK during late pregnancy and labor. Journal of Midwifery Women’s Health 45(2): 161-8.

Walsh D. (2008) Promoting normal birth: weighing the evidence: In: Downe S. (Ed.). Normal childbirth: evidence and debate. Churchill Livingstone: Edinburgh: 175-90.

Walsh D, Downe S. (2008) Uncertainty around home birth transfers. Journal of Obstetrics and Gynaecology 115(9): 1184-5.

Warwick C. (2012) Outcomes by planned place of birth: implications of the Birthplace Study. British Journal of Midwifery 20(1): 20-1.

Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: a meta-analysis. American Journal of Obstetrics and Gynecology 203(3): 243.e1-8.

Wiegers TA, Keirse MJN. (1998) Transfer from home to hospital: what is its effect on the experience of childbirth? Birth: Issues in Perinatal Care 25(1): 19-24.