Title: Interactional practices of decision making during childbirth in maternity units
Funder: Department of Health and Social Care

Abstract: The DoH and NHS are clear that service users benefit from engagement in decision-making about their care.Indeed, the importance of informed consent and shared-decision making in birth has been recognised for decades and endorsed in the last ten years.Evidence exists on the relationship between women’s feelings of control (a key component of which is involvement in decision-making)and greater satisfaction, emotional well-being, and decreased anxiety, as well as better perinatal outcomes. Yet women’s accounts after birth show considerable variation in shared decision-making during birth.The CQC report National Findings from the 2013 Survey of Women's Experience of Maternity Care states, ‘Almost one in five women felt that their concerns during labour were not taken seriously’ (p.2), with some reporting feeling demeaned by dismissive and disrespectful conduct of staff. Good communication is key to creating opportunities for women to participate in decisions about what happens to them. However, existing knowledge about communication during birth tends to be captured retrospectively. Hence, we know little about how decisions are actually made in interactions between labouring women, their partners, and healthcare professionals (HCPs). So, the actual situated birth context is under-researched and we aim to address this significant knowledge gap. The two key research questions are: (1) what communication strategies are used by HCPs, women and their birth partners to initiate decision-making (e.g. open questions, option-listing, yes/no interrogatives)? And, (2) what responses are made relevant by these strategies (e.g. a narrative, selection of an option, yes/no)? Addressing these questions will provide an understanding of interactional practices for managing decision-making and how far it is shared. The interactional data will be considered alongside antenatal and postnatal surveys to assess whether women expect to be involved in decision-making and the extent to which the communication strategies actually used are associated with satisfaction with the birth experience. To identify how decisions are initiated, managed, and responded to moment-by-moment in real-time we will video or audio record (as consented to) 50 births in maternity units in two hospital trusts. In recognition of the ambitious and ethically challenging nature of the research we will first conduct a staged pilot study to ensure its feasibility (with opt out at 4 & 12 months). A diverse sample of first time and subsequent mothers from different socio-economic and ethnic backgrounds will be recruited. Recordings will be transcribed verbatim and communication between healthcare professionals, women, and their birth-partners analysed using Conversation Analysis (CA) – the leading methodology for examining, in detail, how interaction works. Prenatal (35 weeks) and postnatal (6 weeks) questionnaires will determine women’s expectations and satisfaction with decisions made and with how they were made during labour. We will interview a sample of 20 HCPs to provide insights into professional perceptions of the factors that facilitate, or constrain, shared decision-making during labour, as well as contextual information about the organisational arrangements in which they work.Findings from the full study will be useful for all those with responsibility for facilitating shared decision-making in the intrapartum period and therefore contribute to an area of major strategic importance to the NHS.

Lay abstract: Background to the research: Government policy states that women in labour should be involved in decisions about their care and treatment. We know what is said during labour matters for how women experience birth. However, policy recommendations to staff about how to communicate with women in labour are not based on evidence about what actually happens in birth. This is because most existing research is based on interviewing or surveying women some weeks after birth, so the details of what was said in labour are lost. We need research that provides details of actual talk about decisions during labour. The details of talk matter because as other studies of communication in medical settings have shown, even small changes in use of words can make a difference to what happens in healthcare e.g. one study in a GP setting showed that changing from ‘is there anything else?’ to ‘is there something else?’ increased the number of reported symptoms told to the doctor. We aim: •To find out how decisions are reached and communicated through the talk that happens between staff, women in labour and their birth partners when giving birth in maternity units. •To provide staff and women with detailed information about the effects of talk during labour. For example, consider the difference between, ‘we need to…', which suggests that a decision has already been made, and ‘how do you feel about…', which invites a woman’s view. •To inform and empower staff, women and birth partners to communicate in ways that promote choice. To do this, we will: •Video (or audio record if women prefer) the labours of 50 low-risk, full-term women and write down in full what was said and how it was said (e.g. laughing, sighing). Recording will take place only when all parties (women, partners and staff) agree to it. Women will have the explicit right to change their mind at any point during the recording, and request that the recording is stopped and/or not used for the project. •Analyse how decisions are discussed using Conversation Analysis, which is the leading research method for understanding how talk works. •Use questionnaires before birth to ask women about their expectations and after birth to ask about their satisfaction. •Look at patterns between how satisfied women were with their experience and the kinds of talk that actually happened during birth. •Conduct one-to-one interviews with selected health care staff (midwives and doctors) to ask about what they think is helpful and unhelpful in giving women choice. To help understand the viewpoint of our labouring women participants, patients and the public will be involved at all stages of our research. One of our research team is a member of the public and we will set up groups for other patients and the public to help ensure that our information sheets and methods protect the interests of women in labour (and their birth partners). Pilot Study: We know this research will raise ethical and practical issues. We will first perform a pilot study to check whether aspects of the research design will work in the main study. For example, to check that enough staff, women and partners are willing to take part and that the videos are clear enough to use in the research. Promoting the findings: Findings will be circulated to other healthcare staff through workshops and academic publications. We will share findings with women (and families) through relevant websites and organisations that inform pregnant women of their choices.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH