This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Midwives can find it challenging to involve women fully in decision-making during labour, a study found. They may struggle to balance women’s choices with their own concerns about following standard practice. However, most women were satisfied with how decision-making took place, and with the care they received. An exception was when they had to ask multiple times for strong pain relief (such as opiates).
The National Institute for Health and Care Excellence (NICE) recommends that women should be involved in decisions about their care during labour. However, there is a lack of research on how decisions are made in practice.
This mixed methods study was based on video and audio recordings of labours and births in 2 midwife-led units in England. Researchers analysed the conversations of 37 women in labour, 43 birth partners and 74 healthcare professionals. Women completed questionnaires before and after the birth; midwives and obstetricians were interviewed about how and why certain decisions were made.
Most decisions were led by midwives who did not seek to involve women beyond getting their consent. The extent of women’s involvement varied depending on the type of decision being made. They were routinely offered a choice about how they would like to deliver the placenta. They were less involved in decisions around monitoring and assessing the progress of labour.
Women were generally satisfied with how decision-making took place. They were less satisfied when they had to ask repeatedly for strong pain relief. Midwives had appropriate concern about giving opiates when women were near the pushing stage of labour. They were likely to offer encouragement or alternative pain relief, or to emphasise the risks of opiates. This meant that some women had to keep asking for opiates, often over several hours.
Policies and clinical guidelines on decision-making during labour and birth could better reflect midwives’ difficulty in balancing good clinical practice with women’s choices. Midwives could have more open conversations with women about pain relief, in which they acknowledge women’s requests and explain their clinical concerns.
More information about shared decision-making is available on the NHS website.
The issue: are decisions shared during labour?
Obstetricians and midwives are advised to engage women in decision-making during labour and birth. This is best practice, and has been shown to give women a sense of control, improve wellbeing and decrease anxiety during and after birth.
However, women report different levels of engagement in decision-making during labour. A 2020 Care Quality Commission report found that around 1 in 5 (22%) women were never or only sometimes involved in decisions about their care.
This study fills a gap in the evidence about how decision-making happens in real-time during labour. The researchers also examined whether the way decisions are made influences women’s satisfaction with their birthing experience.
What’s new?
The audio and video recordings of labour included 37 women, 43 birth partners, and 74 clinicians (including midwives and obstetricians) from midwife-led units at 2 English trusts. Most (97%) of the women giving birth were white.
The research team analysed the recordings to assess how decisions were made. These women, plus others who had intended to give birth in the 2 units, completed questionnaires before and after birth. They answered questions on how far they wanted to be, and were, involved in decision-making, and whether they were satisfied with their birth experience. In interviews, a separate sample of clinicians described the context in which decisions were made (what the guidelines recommend, for example).
Decision-making was most often led by midwives in ways that did not explicitly invite women in labour to participate (for instance, saying ‘I’m going to . . .’ as opposed to ‘What would you like?’). Birth partners were not treated as decision-makers, except when deciding who would cut the cord. But overall, most women were satisfied with their birth experience.
Women were less satisfied with decision-making when they had repeatedly asked for strong pain relief. Midwives had appropriate concern about giving opiates when women were thought to be in or near the pushing stage (because of the risk to the baby if given soon before birth). They tended to redirect requests for opiates by offering encouragement (saying that women were coping well) or alternatives (such as massage, or gas and air, and saying that opiates could be considered later). Or they emphasised the risks of opiates. Since the length of labour is always uncertain, this meant that some women were asking for opiates over several hours.
Midwives’ interactions were influenced by guidelines and recommended practice to manage risks. But they also expected to facilitate choice, which created a tension for them.
Why is this important?
This study demonstrated the challenges midwives face in sharing decisions during labour. Women wanted to be involved in decisions during labour and birth. But midwives’ capacity to enable this was limited by guidelines and standard practices. They gave options only in certain circumstances and often phrased choices in a way that guided women to a preferred option. Nonetheless, most women were satisfied with their experience.
Some women felt their requests for pain relief went unheard when midwives deferred or avoided conversations about pain relief, particularly during the later stages of labour. The researchers say this highlights the importance of midwives listening to women and explaining the steps they are taking during birth.
This study explored how conversations about common procedures during labour took place. But further research is needed. The study involved only 2 hospital trusts, and might not be representative of elsewhere in the UK. Most women were white, so the experiences of mothers from other ethnicities may have been different. Women from ethnic minority groups are less likely to give birth in midwife-led units than white women, and are more likely to have poor outcomes from childbirth.
What’s next?
Midwives are expected to follow standard practice and to use their own judgement, but also to consider the needs, preferences, and values of women giving birth. Training and support could help midwives balance these demands, the researchers say. They, and other clinicians, may benefit from policies on shared decision-making that reflect their difficulties, the researchers say.
Women need more information about decisions that need to be made during the birth process. Opiate pain relief during labour can benefit the mother but increase risks for the baby if given close to the time of birth. These decisions are often complex and challenging for midwives because the time of birth is uncertain. The researchers suggest that midwives discuss the complexity of pain relief decisions with women. Women could be better informed about the benefits and risks of pain relief medications in antenatal classes.
The research team is using the study data to explore further how decisions – including on pain relief – are taken.
You may be interested to read
This Alert was based on: Annandale E, and others. Shared decision-making during childbirth in maternity units: the VIP mixed-methods study. Health and Social Care Delivery Research 2022; 10: 1–190.
YouTube video of a presentation of the study findings including a dramatisation of some of the case studies from the research.
Birthrights website, which supports human rights in pregnancy.
Pilot study analysing recordings of labour and birth from the television series One Born Every Minute: Jackson, C. and others. Healthcare professionals’ assertions and women’s responses during labour: A conversation analytic study of data from One born every minute. Patient Education and Counselling 2017; 100: 465–472.
Funding: This study was funded by the NIHR Health and Social Care Delivery Research programme.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
