A systematic review to examine the evidence regarding discussions by midwives, with women, around their options for where to give birth Cathy Shneerson, Lead Researcher Beck Taylor, Co-researcher Sara Kenyon, Chief Investigator School of Health and Population Studies, Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, B15 2TT. Aims The aim of this systematic review is to identify any existing themes in the existing research literature, which can be used to inform a focus group study exploring midwives views of their discussions with women about their options for where to give birth i. Any themes identified in the review process will be used to inform our analysis of the focus group data, by identifying what is already known in the literature about midwives place of birth (PoB) discussions with women (deductive analysis of the data) and what new information has been identified from the focus groups with midwives (inductive analysis of the data). The systematic review will aim to answer the following questions to inform our understanding of midwives views of their discussions with women about their options for where to give birth. Question 1: What is known about midwives views of the discussions with women about their options for where to give birth (the how, what, where and when)? Question 2: Have any interventions been implemented to support midwives PoB discussions with women? If so, what were the barriers and facilitators to implementing them and have the interventions been effective? 1
Background Discussion of PoB is important for women and maternity services, yet presently the detail, content and delivery of these discussions are not clear. We have little understanding of midwives perceptions of PoB discussions, including what good place of birth discussion should look like, or what challenges midwives face in integrating PoB discussion into their practice. The 2011 Birthplace Study ii found that for low risk, multiparous women, there was no significant difference in safety outcomes between women who gave birth in obstetric units, midwifery-led units, or at home. It also found fewer maternal interventions in women giving birth at home and a low transfer rate of 12%. The Birthplace study found that for low risk women, planned birth at home was more cost effective than in other settings. An increase in the numbers of suitable women planning birth at home could deliver cost savings to the NHS. Offering choice in PoB may also increase satisfaction, with many studies reporting increased satisfaction with nonobstetric unit settings. iii,iv Birmingham Women s NHS Foundation Trust (BWNFT) has seen a significant increase in the birth rate in recent years and increasing the uptake of other birth settings may relieve some of the pressure on inpatient maternity service capacity. Midwives have the opportunity to provide information and discussion to women to open up choice of PoB by raising awareness and allowing women to consider different PoB options. However, women don t always know about the full range of PoB options. v Elsewhere, midwives have been observed to allow their own beliefs to influence their PoB discussions with women. vi Anecdotal evidence from local stakeholders at BWNFT suggests that there is also variation in the way PoB is discussed in community maternity services. It is important therefore to examine the evidence regarding discussions by midwives, with women, around their options for where to give birth. The systematic review will do this by establishing what is known, from midwives perspectives, about their discussions with women about their options for where to give birth. In addition the systematic review will attempt to inform this topic by exploring whether any interventions have been implemented to support midwives PoB discussions with women and, if so, whether they been effective. It is important to examine which interventions (if any) have been implemented in the past to understand what has proved successful in facilitating PoB discussions with women, as well as identifying any challenges and facilitators to implementing these interventions. By doing so, we can then identify ways of moving PoB discussions between midwives and women forward. The findings from the review will be 2
used to inform a focus group study exploring midwives views of their discussions with women about where to give birth. Aims of systematic review To undertake a systematic literature review, to examine the evidence regarding discussions by midwives, with women, around their options of where to give birth. This will firstly examine what is known about midwives views of their discussions with women about their options for where to give birth (how, what, where and when). It will also examine whether any interventions have been implemented to support midwives PoB discussions with women, and if so, whether they been effective. Methods Search Strategy Electronic Searches Relevant trials will be identified from the following sources: Medline, Cochrane Database, CINAHL, PsycINFO, Popline, EMBASE Grey literature will also be searched, through searching the Department of Health, Royal College of Midwifery, Royal College of Obstetricians and Gynaecologists, National Childbirth Trust, Association for Improvements in the Maternity Services, Maternity Action, Which? Birth Choice, NHS England and King s Fund, websites. Internet searches will also be performed in Google and Google Scholar to search for any relevant, unpublished studies. Reference lists of key full text articles included in the review will be checked to identify any potentially eligible studies. Registration: The review will be registered with PROSPERO (registration number a/w). The PRISMA statement will be followed to ensure that all studies identified in the search strategy are systematically filtered through the stages of the systematic review. vii, vii Search Terms In order to answer both of the research questions posed by the review, an explicit search strategy will be followed (table1) to search for relevant literature. Search terms will be combined using the following Boolean operators (and, or). A combination of both text 3
words and indexed terms (such as MeSH) will be applied in each database. Search terms will be modified as necessary for each electronic database searched. An example of the search terms used in the Medline database is shown in table 1. Reference lists of key full text articles included in the review will be checked to identify any potentially eligible studies. Table 1: Example of Search Strategy from Medline (R) 1946 to February Week 1 2015 # Searches 1 (birthplace or place of birth) ti,ab. 2 ((home or hospital or institut$ or place or locat$ or setting$) adj3 (birth$ or confine or confinement or confining or deliver$)). ti,ab. 3 Home childbirth.mp. or Home Childbirth/ 4 Delivery, Obstetric/px 5 1 or 2 or 3 or 4 6 (choice or preference or decision$ or dialog$ or discussion$ or consultation$ or conversation$ or communication$ or attitude$ or perspective$ or view$). Ti,ab. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, unique identifier] 7 Patient Preference/ 8 (Women$ adj3 Preference$).ti,ab 9 Midwifery/ 10 (midwife$ or midwives)ti,ab. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, unique identifier] 11 6 and 10 12 7 or 8 or 9 or 11 13 5 and 12 Study Selection All studies identified using the search strategy described will be screened for inclusion in the review using the eligibility criteria outlined on the study selection checklists (appendix 1). To be included in the review, identified studies must meet the eligibility criteria outlined in the study selection checklist for either, question one, question two, or both. The eligibility criteria for both are outlined below: 4
Inclusion criteria for questions 1 and 2: Is the study a systematic review, randomised or quasi- randomised controlled trial, observational study or qualitative study? Is the study focused around place of birth discussions between midwives and women, from the perspective of the midwife? Is the study in the English language? Has the study been carried out in Europe, North America or Australasia? Has the study been published since 2000? In addition, the following study inclusion criteria will also be adhered to for question 2: Does the study include an intervention (tool/training programme/procedure) that midwives have either received or been responsible for delivering? Does the study explore the effectiveness, barriers or facilitators, of the intervention in supporting midwives PoB discussions with women? Exclusion criteria for questions 1 and 2: Is the study focused around place of birth discussions between midwives and women, from the perspective of the women (or anyone else except the midwife? Has the study been published prior to the year 2000? In order to systematically and transparently filter the flow of information through the different phases of the systematic review, all studies identified in the search strategy will be filtered using the PRISMA flow chart vi, viii (figure 1). All titles and abstracts of articles identified in the search will be scanned and papers which clearly do not fulfil all of the eligibility criteria will be excluded. Full text copies of the remaining articles will be obtained and checked against the eligibility criteria, and those that do not meet the eligibility criteria will also be discarded. Those articles that remain will all be included in the systematic review. To ensure rigor in the study selection process two reviewers (CS, BT) will independently check through all of the full text articles identified by the search strategy to ensure study selection bias is minimised. Any papers that are not unanimously excluded or included by both reviewers will be re-examined by both reviewers until an outcome is agreed. If the two reviewers cannot reach an agreement regarding the eligibility status of the 5
paper, a third reviewer (SK) will be asked to make the final decision as to whether or not the study should be included. Any disagreements regarding eligibility of studies will be recorded to ensure transparency of the review process. Additionally, all full-text articles that are screened in the identification process will be logged in a table which will state the reasons for every study excluded from the review. It is possible that the eligibility criteria stated may need to be adjusted if it becomes apparent that relevant studies are being excluded from the review or irrelevant studies are being included. As a result the eligibility criteria will be piloted on a small number of papers at the start of the identification process, and if any problems arise, changes to the eligibility criteria will be made at this early stage. Any changes will be reported in the review. Figure 1: Flow of information through the different phases of a systematic review 6
Data Extraction In order to answer the research question a data extraction form (appendix 2) will be used to extract data from the articles included in the systematic review. Quality Assessment For both qualitative and quantitative study designs, the CASP checklist critical appraisal tools will be used to assess study quality ix. Any information on the study that has not been reported in the article under review will be sought by contacting the author of the study for further details, in order to carry out a thorough quality assessment. Methods of Analysis and Identification of Common Themes Data analysis will be undertaken to examine the evidence regarding discussions by midwives, with women, around their options of where to give birth. It will examine how, what, why and when PoB discussions take place. It will also measure, whether any of the interventions (if any are identified) used were effective in supporting midwives PoB discussions with women and what the barriers and facilitators were to the intervention. Effectiveness of the intervention will be measured by any of the following outcome measures: Improving midwives knowledge about PoB Improving midwives confidence in delivering PoB discussions to women Improving women s choice or knowledge about PoB options Changes in women s place of birth setting The proportion of time midwives spend discussing choice of PoB with women Due to the anticipated variety of study designs included in the systematic review, metaanalyses of the data is unlikely to be appropriate, but will be used, if necessary, to provide a panoramic view of results beyond individual studies, allow a pooling of results across studies. However, it is more likely that thematic analysis of the qualitative data will be carried out. Thematic analysis focuses on what is said, rather than how it is said. It identifies units of meaning by attributing codes to blocks of text throughout the 7
narrative. Patterns of codes and group characteristics develop into themes and the relationships between themes can then be assessed and interpreted x. Thematic analysis will allow us to establish any common themes regarding discussions by midwives, with women, around their options of where to give birth, within and between the studies included in the review. These themes will be used to inform the subsequent focus group study i, by identifying what is already known in the literature about midwives PoB discussions with women (deductive analysis of the data). Timescale for Completion of Systematic Review Feb 2015 March 2015 April 2015 May 2015 June 2015 Database Searching X Identification of Relevant Studies X X Data Extraction Quality Assessment X X Data Analysis and Synthesis X Interpretation of Data and Report Writing X X 8
References i Shneerson, C, Taylor, B, Kenyon, S. Midwives views of their discussions with women about their options for where to give birth. 2015. ii Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400 iii Royal College of Midwives/Royal College of Obstetricians. Joint statement on home births. 2007. Available from https://www.rcm.org.uk/sites/default/files/home_births_rcog_rcm0607.pdf. iv Hodnett E.D., Downe S., Walsh D. & Weston J. Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews 2010, Issue 9. v Pitchforth E., Van Teijlingen E.R., Watson V., Tucker J., Kiger A., Ireland J., Farmer J., Rennie A.M., Gibb S., Thomson, E.& Ryan M. "Choice" and place of delivery; a qualitative study of women in remote and rural Scotland. Quality and Safety in Health Care 2009;18:42-48. vi Finlay S, Sandall J. "Someone's rooting for you": continuity, advocacy and street-level bureaucracy in UK maternal healthcare. Soc Sci Med. 2009 Oct;69(8):1228-35. vii PRISMA. Transparent reporting of systematic reviews and meta-analyses; 2012. http://www.prismastatement.org/statement.htm viii Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reportingitems for systematic reviews and metaanalyses: the PRISMAstatement. British Medical Journal 2009;339:332 6. ix CASP Checklists. Critical Appraisal Skills Programme. 2015. Available from http://www.casp-uk.net/#!casptools-checklists/c18f8 x Ritchie J, Lewis J. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: Sage Publications; 2003. 9
Appendix 1 Study Selection Checklist: Question 1 Eligibility Criteria Yes No Inclusion Criteria Is the study a systematic review, randomised or quasi- randomised controlled trial, observational study or qualitative study? Is the study focused around place of birth discussions between midwives and women, from the perspective of the midwife? Is the study in the English language? Has the study been carried out in Europe, North America or Australasia? Has the study been published since 2000? Exclusion Criteria Is the study focused around place of birth discussions between midwives and women, from the perspective of the women (or anyone else except the midwife)? Has the study been published prior to the year 2000? Not Sure Question 2 Eligibility Criteria Yes No Inclusion Criteria Is the study a systematic review, randomised or quasi- randomised controlled trial, observational study or qualitative study? Is the study focused around place of birth discussions between midwives and women, from the perspective of the midwife? Is the study in the English language? Has the study been carried out in Europe, North America or Australasia? Has the study been published since 2000? Does the study include an intervention (tool/training programme/procedure) that midwives have either received or been responsible for delivering? Does the study explore the effectiveness of the intervention in supporting midwives PoB discussions with women? Exclusion Criteria Not Sure 10
Is the study focused around place of birth discussions between midwives and women, from the perspective of the women (or anyone else except the midwife)? Has the study been published prior to the year 2000? Place an X in the box to answer the questions above when identifying papers for inclusion in the review. For inclusion in the review the study must answer YES to ALL the inclusion criteria and NO to ALL the exclusion criteria. Papers that answer NO to any of the inclusion criteria or YES to any of the exclusion criteria MUST be excluded from the study. If any X s are placed in the NOT SURE box, then a decision as to whether it should be included in the review must be discussed with the second reviewer. If no agreement is made, the decision must be passed onto a third reviewer. Is the study to be included in the review? YES/NO Name of Study:......... Study Reference:......... 11
Appendix 2 Table 2: Data Extraction Checklist This checklist will be piloted on the first few studies identified in the systematic review and modified accordingly to ensure all relevant data is recorded. Data Extraction Checklist Study ID/Title Publication Date Reviewers Name/Date of Review Article Reference Author Contact Details Eligibility Confirm Eligible for Inclusion Reason for Exclusion Study Characteristics Aim of Study Study Design (systematic review/quasi RCT/RCT/observational/qualitative study)? Multi/Single Centre Study Total Study Duration (start and finish date) Analysis Methods Used? Concerns about bias? Number of women in caseload Age of participants Gender Country of study Educational qualifications Ethnicity Date of study Outcomes and Findings: Question 1 Definition of outcome measure(s) Outcomes presented and reported Measurement tool/type of analysis used Location of PoB discussions Timing of PoB discussions Length of PoB discussions Information covered in PoB discussion Midwives rationale for discussing PoB Outcome and Findings: Question 2 Definition of outcome measure 12
Outcomes presented and reported Measurement tool/type of analysis used Description of intervention Length of intervention Setting of intervention Was the intervention effective? Participants Total number of participants Midwifery setting (community, homebirth, obs etc ) Do participants carry out PoB discussions with women? Frequency of PoB discussions Other Funding source Author s key conclusions Reference to other relevant studies Correspondence required *Additional data may be extracted on individual studies that are specific to their study design (if relevant). This data will be logged in a separate data extraction table. Conflict of Interest The author(s) declare no conflicts of interest. Acknowledgements/ Sources of Funding The CLAHRC Maternity Theme The Maternity and Child Health team of the West Midlands CLAHRC (Collaboration for Leadership in Applied Health Research and Care) programme is based at the University of Birmingham. They undertake research that is close partnership with local health services, with the aim of improving services and outcomes for patients within five years (though often much sooner than this). As part of their maternity research activity, the team has committed to work with the Home Birth Service (HBS) to evaluate the new programme. This protocol describes one of a number of proposed HBS-related projects. Others include qualitative research exploring the perspectives of potential HBS patients, fathers, women who have been cared for by the service and work with midwives to explore communication about birthplace options. 13