Having a baby in Scotland 2013: Women's experiences of maternity care

3. Chapter 3: Care During Labour and Birth: Intrapartum Care

Summary of key results

• Place of birth - 96% who responded to the survey gave birth in a consultant led maternity unit.
• Quality of care during labour and birth - 74% of women reported that during labour they were able most of the time to move around and choose positions in which they were most comfortable.
• 34% of women reported that they adopted upright positions (e.g. sitting, kneeling) for birth - 26% said that they gave birth lying flat and 31% lying flat with legs in stirrups.
• 91% of women had skin to skin contact with their baby shortly after birth.
• Trust and confidence in staff - 83% of women said that they definitely had trust and confidence in staff caring for them and 80% that they were never left alone at a time when it worried them.
• Respect and dignity - 88% of women reported that they were always treated with respect and dignity through labour and birth.
• Communication, information and involvement - 89% of women said that they were always spoken to in ways that they could understand. 95% of women who had a partner or birth companion with them reported that they were able to be involved as much as they wanted.
• How women rated their care during labour and birth - 73% of women rated their care as excellent and 21% as good.

Care during labour and birth

3.1. Labour and birth have traditionally been considered to be the time of highest risk and vulnerability for mothers and babies and for this reason provision of safe care during labour and birth has been a longstanding priority for maternity care providers. However, women's experiences of childbirth are also important;²⁴ women are usually able to recall their childbirth experiences in vivid detail many years later. Positive experiences during childbirth may enhance women's confidence and self-esteem, while negative childbirth experiences may have long lasting detrimental effects on women's physical and psychological wellbeing ²⁵ and on the health and wellbeing of their newborn infants. The provision of safe, effective and women centred care during labour and birth is therefore of the utmost priority.

Place of birth

3.2. Based on information contained in the survey sample file, most women gave birth in a consultant led unit (96%) with only 3% giving birth in a birth centre/community midwifery led unit. Overall, only 1% of women gave birth at home.

3.3. Survey results indicated that the level of home births in Scotland was low for both mainland and island NHS Boards. The NHS Boards with the most home births reported in the survey were NHS Dumfries and Galloway and NHS Western Isles, where 3.1% and 6.8% of women reported giving birth at home, respectively.

Quality of care during labour and birth - support for normal birth

3.4. Support for normal birth has been a key focus of maternity care through the work-streams of the Scottish Government's KCND programme completed in 2010.⁸ An overarching principle for care during labour and birth is that all women should receive safe and effective care tailored to their needs, avoiding unnecessary intervention and providing every woman with the opportunity to have as normal a birth experience as possible.⁸ Throughout labour and birth women should be provided with an environment in which they feel safe and secure with one to one care from a midwife once labour is established. Women should be encouraged and enabled to move around and to choose positions in which they feel most comfortable.²⁶ Women's planned choice of pain relief, including non-pharmacological methods should be facilitated, while staff must also be responsive to women's changing needs for pain relief during labour and birth.

3.5. Excluding women who had a planned caesarean section women, were asked whether they were able to move around and choose the position that made them most comfortable during labour. They were asked about their planned preferences for pain relief and whether and why their plan had changed during labour.

3.6. Seventy-four per cent of women reported being able to move around and choose the position that made them most comfortable, whereas 20% said that they were only sometimes able to do this and 6% said not at all (Table 14). There were some health board variations; in NHS Forth Valley 61% of women reported being able to move around to choose a position that was most comfortable compared to 85% of the women in NHS Dumfries and Galloway.

Table 14: Freedom of movement during labour

Question: During your labour, were you able to move around and choose the position that made you most comfortable?
	Per cent	Frequency (1,738)	Confidence interval (%)
Yes, most of the time	74	1,298	72.2	76.0
Yes, sometimes	20	332	17.8	21.3
No, not at all	6	108	5.3	7.4

3.7. Women were asked about their planned methods of pain relief (women could indicate that they planned to use several types of pain relief) and whether they ultimately followed this plan. Table 15 describes women's planned options for pain relief. The most commonly planned choice for pain relief was gas and air (76%). Fifteen per cent of women reported that they either did not want to use pain relief or had not made a plan. Those women who used pain relief for labour, and who indicated that they had made a plan were asked whether the pain relief actually used had changed from their original plan. Over half of these women (52%) reported that they had not actually used their planned method of pain relief. Most women indicated that the change was either due to medical reasons (38%) or because there was not time to use the planned method (26%; Table 15).

Table 15: Planned and actual methods of pain relief

Question: During your pregnancy, what type of pain relief did you plan to use when giving birth?
	Per cent	Frequency (n=2,089)	Confidence interval (%)
Natural methods	33	705	31.0	34.7
Water or a birthing pool	34	743	32.6	36.2
TENS machine	18	382	16.2	19.1
Gas and air	76	1,586	74.0	77.3
Injection of Pethidine or similar painkiller	22	465	20.4	23.6
Epidural	22	427	20.4	23.6
Other	1	20	0.6	1.3
I did not want to use pain relief	5	96	3.7	5.3
I had not decided	10	205	8.9	11.3
Question: Did the pain relief you used change from what you had originally planned?
	Per cent	Frequency (n=1,787)	Confidence interval (%)
Yes	52	914	49.9	54.2
No	48	873	45.8	50.1
Question: Why did you not use the choice of pain relief that you had originally planned to?*
	Per cent	Frequency (n=893)	Confidence interval (%)
For medical reasons	38	339	35.3	41.6
I changed my mind	18	158	15.3	20.2
I did not need to use this pain relief	8	76	6.5	9.9
There was not time to use my planned pain relief	26	238	22.9	28.4
This pain relief did not work	18	158	15.8	20.8
I was not told why I could not have my choice of pain relief	6	50	4.1	7.0

Type of birth

3.8. Women were asked about the type of birth that they had. Just over half of women who responded to the survey reported that they had a normal vaginal birth (56%), 30% reporting that they gave birth by caesarean section (either planned or emergency; Table 16; Figure 3). There were some differences between health boards with 47% of women in NHS Lothian and 67% in NHS Dumfries and Galloway reporting that they had a normal vaginal birth. The overall results correspond closely to figures provided by ISD for the year ending 31st March 2012 (the most recently reported national data), discrepancies within health boards for type of birth reported by women and clinical data may be due to differences in local response rates.

Table 16: Type of birth

Question: Thinking about the birth of your baby, what type of delivery did you have?*
	Per cent	Frequency (n=2,349)	Confidence interval (%)
A normal vaginal delivery	56	1,343	54.0	57.6
An assisted vaginal delivery (forceps or ventouse)	14	322	12.9	15.4
A planned caesarean delivery	13	302	12.1	14.6
An emergency caesarean delivery	17	382	15.3	18.0

*for twins or more than two babies results refer to the baby who was born first.

Figure 3: Type of birth

Use of upright positions and use of water to support normal birth.

3.9. There is some evidence that use of upright positions for birth may be of some benefit in facilitating normal birth. Research recommendations²⁷ are that women should be given the choice to adopt upright positions (e.g. sitting, kneeling) wherever possible. Excluding those women who reported that they gave birth either by planned or emergency caesarean section, women were asked specifically where they give birth (on a bed, a mat on the floor, in a birthing pool, or other place) and about the position they were in when their baby was born.

3.10. The majority of women reported that they gave birth on a bed (88%; Table 17) and this was the case across most of the health boards.

Table 17: Where did you give birth?

Question: Where did you give birth?
	Per cent	Frequency (n=1,668)	Confidence interval (%)
On a bed	88	1,439	86.7	89.5
On a mat on the floor	2	42	1.6	2.9
In a water or birthing pool	6	124	5.1	7.1
Other	4	63	2.7	4.4

3.11. Overall the use of upright positions for birth appeared to be low. Only 14% of women who had a vaginal birth reported that they were standing, squatting or kneeling and a further 19% that they adopted a sitting position. Over half of women reported that they gave birth either lying flat (or flat supported with pillows) or lying with their legs in stirrups. While this group includes the 14% of women who reported having an assisted birth (forceps or ventouse) this suggests that 43% of women who had a spontaneous vaginal birth gave birth in a supine position (Table 18; Figure 4). There was considerable variation between mainland health boards; in NHS Ayrshire and Arran only 16% of women reported that they gave birth lying flat with their legs in stirrups compared to 39% in NHS Lothian.

Table 18: Birth position

Question: What position were you in when your baby was born?
	Per cent	Frequency (1,662)	Confidence interval (%)
Sitting / sitting supported by pillows	19	317	17.5	21.1
On my side	7	113	5.6	7.9
Standing, squatting or kneeling	14	268	12.7	15.8
Lying flat / lying supported by pillows	26	430	23.8	27.8
Lying with legs in stirrups	31	486	29.0	33.2
Other	3	48	2.0	3.4

Figure 4: What position were you in when your baby was born?

Skin to skin contact

3.12. Direct skin to skin contact between mother and baby for a period of time immediately after birth has been credited with a number of benefits for both mother and baby. It is important for supporting pre-feeding behaviour before attachment at the breast and is considered important in bonding of mother and baby. UNICEF currently encourage a period of uninterrupted skin to skin contact between mother and infant at least up until the first feed.²⁸

3.13. Women were asked whether they had skin to skin contact with their baby shortly after birth. Almost all women (92%) responded that they did (Table 19), ranging from 72% (NHS Western Isles) to 97% (NHS Borders and NHS Dumfries and Galloway) across health boards.

Table 19: Skin to skin contact shortly after birth

Question: Did you have skin to skin contact with your baby shortly after birth?
	Per cent	Frequency (n=2,052)	Confidence interval (%)
Yes	91	1864	89.3	91.7
Yes, but I did not want this	1	12	0.3	0.9
No	9	176	7.7	10.0

Trust and confidence in staff

3.14. Maternity care policy indicates that during labour and birth women should receive care in an environment in which they feel safe and secure, and that all women will receive one to one care from a midwife during established labour.⁶ Implicit within the concept of a safe and secure environment is the principle that women will not be left alone when this is likely to cause them to feel concerned and that when concerns are raised or help sought by women or their partners their needs are responded to in a timely manner. Women were asked if they and/ or their partner were left alone during their labour and birth at a time when it worried them. They were asked whether if they called they received assistance within a reasonable time and if they raised concerns during labour and birth whether they felt that these concerns were taken seriously.

3.15. Overall 83% of women said that they definitely had trust and confidence in staff and 80% of women reported that they were not left alone when it worried them. This ranged from 73% in NHS Grampian to 92% in NHS Borders. Most instances of women reporting being left alone when it worried them occurred during early labour (10%). However, 14% of women reported being left alone during later stages of labour, during the birth or shortly after birth. Twenty-one per cent reported that when they called they only sometimes, or did not, receive assistance within a reasonable time.

3.16. Of women who said that they raised a concern during labour and birth the majority felt that this was taken seriously however, 16% of women felt that concerns raised were not taken seriously (Table 20).

Table 20: Trust and confidence in staff

Question: Did you have confidence and trust in the staff caring for you during your labour and birth?
	Per cent	Frequency (n=2,338)	Confidence interval (%)
Yes, definitely	83	1,955	82.1	84.8
Yes, to some extent	15	337	13.2	15.8
No	2	46	1.5	2.5
Question: Were you (and/or your partner or a companion) left alone by midwives or doctors at a time when it worried you?
	Per cent	Frequency (n=2,337)	Confidence interval (%)
Yes, during early labour	10	226	8.9	11.1
Yes, during the later stages of labour	7	152	5.7	7.6
Yes, during the birth	1	28	0.8	1.6
Yes, shortly after the birth	6	136	5.1	6.8
No, not at all	80	1,894	78.9	81.8
Question: When you called did you receive assistance within a reasonable time?
	Per cent	Frequency (n=2,162)	Confidence interval (%)
Yes, always	79	1,717	77.0	80.1
Yes, sometimes	17	347	15.3	18.2
No	5	98	3.9	5.5
Question
Question: If you raised a concern during labour and birth, did you feel that it was taken seriously?
	Per cent	Frequency (n=1,331)	Confidence interval (%)
Yes	84	1,124	82.5	86.2
No	16	207	13.8	17.6

Respect and dignity

3.17. Women were asked whether the staff caring for them introduced themselves and whether they felt that they were treated with respect and dignity. Over 80% of women reported that all staff introduced themselves and 17% that some of the staff did so (Table 21), ranging from 76% in NHS Borders to 87% in NHS Highland and 88% in NHS Western Isles. Overall 88% of women reported that they were always treated with respect and dignity. However, 10% of women said that they were only treated with respect and dignity sometimes and 2% said no.

Table 21: Respect and dignity

Question: Did the staff caring for you introduce themselves?
	Per cent	Frequency (n=2,310)	Confidence interval (%)
Yes, all of the staff introduced themselves	81	1,885	80.0	82.9
Some of the staff introduced themselves	17	388	15.4	18.2
Very few or none of the staff introduced themselves	2	37	1.2	2.2
Question: Thinking about your care during labour and birth, were you treated with respect and dignity?
	Per cent	Frequency (n=2,332)	Confidence interval (%)
Yes, always	88	2,060	86.7	89.1
Yes, sometimes	10	226	9.0	11.2
No	2	46	1.5	2.5

Communication, information and involvement

3.18. Communication between women and the staff caring for them during labour is a key element of women centred care. Labour and birth is a time of heightened stress and anxiety for most women and their partners and/ or birth companions. It is essential that women are always given appropriate advice and spoken to in ways that they can understand. This is of particular importance in early labour as recent research has identified that women are often dissatisfied with the care and communication that they receive when they contact the hospital at this time.²⁹ Scottish Government maternity care policy recommends that women should be involved in decisions about their care during labour and birth and their partner or birth companion should be as involved in care during labour and birth to the extent that is wanted.⁶

3.19. Women were asked whether they felt that they were given appropriate advice and support when they contacted a midwife or the hospital at the start of labour and whether during labour they were spoken to in ways that they could understand. Overall 85% of women who sought advice at the start of labour reported that they did receive appropriate advice and support. Eighty-nine per cent of women reported that they were always spoken to in ways that they could understand during their labour and birth. Women were asked about their own involvement in care decisions and about their partner or companions involvement in their care. The majority of women reported that they were always involved enough in care decisions although 22% reported that they were either only sometimes or that they were not sufficiently involved. Almost all women (95%) reported that their partner or companion was as involved in care as much as they wanted, and this was the case across all health boards (Table 22).

Table 22: Advice and support from midwives at hospital

Question: At the very start of your labour, did you feel that you were given appropriate advice and support when you contacted a midwife or the hospital?
	Per cent	Frequency (n=1,835)	Confidence interval (%)
Yes	85	1,572	83.3	86.4
No	15	263	13.6	16.7
Question: Thinking about your care during labour and birth, were you spoken to in a way you could understand?
	Per cent	Frequency (n=2,337)	Confidence interval (%)
Yes, always	89	2,096	88.2	90.4
Yes, sometimes	9	205	8.1	10.3
No	1	36	1.1	1.9
Question: Thinking about your care during labour and birth, were you involved enough in decisions about your care?
	Per cent	Frequency (n=2,287)	Confidence interval (%)
Yes, always	78	1,800	76.7	79.7
Yes, sometimes	17	387	15.9	18.7
No	5	100	3.7	5.3
Question: If your partner or someone else close to you was involved in your care during labour and birth, were they able to be involved as much as they wanted?
	Per cent	Frequency (n=2,300)	Confidence interval (%)
Yes	95	2,185	94.0	95.6
No	5	115	4.4	6.0

Overall rating of care during labour and birth

3.20. Overall 93% of women rated their care during labour and birth as either excellent or good (Figure 5). There were some variations between the health boards. Of the mainland boards 99% of the women in NHS Borders reported their care during labour and birth as excellent or good, compared to 91% of the women in Glasgow. Of the women resident in island health boards 100% of the women in NHS Western Isles reported their care during labour and birth as excellent or good compared to 92% of the women in NHS Orkney.

Figure 5: Overall rating of care received during labour and birth

Conclusions

3.21. Based on information contained in the survey sample file, the majority of women gave birth in a consultant led unit and only 3% gave birth in a community midwife led unit. Further, only 1% of mothers gave birth at home. It is not clear why this is the case. Women may need more information about the options available to them. Only just over half of women in this survey reported being given enough information to help them decide where to give birth and around one quarter felt that they were not given any choice of place of birth (Chapter 2). It may be that women are concerned about safety when giving birth outside of consultant led maternity units. There is evidence that some women may opt to travel a distance from their local area in order to give birth in a consultant led maternity unit, which they perceive as being safer.³⁰ However, the findings of the recent Birth Place in England research programme demonstrated that community midwife led units provide safe and effective care for women ascribed to be at low obstetric risk.³¹ Further research is required to understand the mismatch between policy intent and women's decision making in relation to place of birth.

3.22. The national results suggest that across Scotland high standards are being achieved in relation to treating women with respect and dignity through labour and birth. The majority of women reported that staff always introduced themselves and that they were always treated with respect and dignity, although for a small number of women this was not their experience and this is a concern. Most women reported that they received appropriate advice (even in early labour) and that they were always spoken to in ways that they could understand. A very positive finding of this survey is that almost all women reported that their partner or birth companion was involved in their care as much as was wanted.

3.23. Almost all women reported that they received a period of skin to skin contact shortly following birth and this appears to be being achieved consistently across all health boards.

3.24. A considerable number of women reported giving birth either lying flat or flat with their legs in stirrups. Some of these women had an assisted vaginal birth (forceps or ventouse) and would therefore have been anticipated to give birth in this position. However it appears that a number of women who experienced a normal vaginal delivery also give birth while lying flat. There is some evidence that this position may have some negative impact on the physiological processes of birth as well as possibly increasing the incidence of perineal damage.²⁷ Where possible, women should be encouraged to adopt more upright positions for birth.

3.25. While the majority of women reported definitely having trust and confidence in the staff who cared for them there was a number of women who reported that they were left alone during labour at a time when it worried them and not all reported receiving assistance within a reasonable time when they called. These women may have been receiving safe care however it appears that they did not always feel safe. During early labour there may be a mismatch between the care needs expressed by women and their birth partners and the assessments of maternity care staff and this may lead to anxiety and dissatisfaction with care.^{32, 33} Sensitive communication between mothers and maternity care staff is always required and women should know that their concerns are taken seriously. One-to-one midwifery care for women in established labour is a key principle of safe maternity care. Short periods in which the midwife caring for a woman leaves the birth room may be inevitable. However, care must be taken in communicating with women about these periods and in ensuring that women have easy access to midwife call systems and that calls for assistance are responded to promptly.