‘Where do you want to have your baby?’ Most women are faced with this question at their very first midwife appointment. So it is not surprising that ‘choice’ is one of the mantras of the modern age (Symon, 2006). This is particularly true of maternity care within the NHS, and is a key topic resonating throughout the recent publication of the National Maternity Review (2016).
Choice of birthplace for low-risk women is a central theme in current national guidelines and, depending on geographical location and availability, options include an obstetric-led hospital service, a midwife-led birth centre—which might be either stand-alone or alongside hospital services—and birth at home.
The benefits of providing midwife-led care, at home or in a midwife-led birth centre, are well documented (Brocklehurst et al, 2011; Hodnett et al, 2012). The Birthplace study (Brocklehurst et al, 2011) is a seminal research project that was undertaken to compare outcomes in birth settings offered by the NHS. The findings revealed that there was no significant difference in outcomes for perinatal mortality and intrapartum-related neonatal morbidities in any of the midwife-led care settings (home or birth centre) when compared with obstetric-led services. The study also indicated that there were substantially fewer interventions and significantly higher rates of normal birth in all midwife-led settings when compared to obstetric services (Brocklehurst et al, 2011). The authors concluded by endorsing current policies relating to birthplace choice, and emphasised the safety of midwife-led care outside of hospital settings and the associated benefits of such forms of care.
Government policies and national guidelines relating to maternity care place a high priority on choice of birthplace as a cornerstone of high-quality care: women must be able to decide where to give birth. UK guidelines acknowledge that pregnancy and childbirth are both physical and psychological experiences (National Institute for Health and Care Excellence (NICE), 2016). This is why they prioritise choice and women-centred services, in an effort to increase women's quality of experience, in both these dimensions (Jomeen, 2007).
There is however, a worrying disconnection between the proven benefits of birth outside of a hospital and the relatively low interest in alternative birthplace options. This has prompted many midwives to question why women are making the choices they do.
Five key studies (Barber et al, 2006; Jomeen, 2007; Houghton et al, 2008; Pitchforth et al, 2009; Rogers et al, 2011) have explored the factors that influence women's choice of birthplace. A further study has also been undertaken to explore first-time fathers' views and influence surrounding birthplace choice (Mottram, 2008). In all six of these studies, the clearest recurring theme is safety. The studies show that hospitals are still considered by the majority of women (and their partners) to be the safest location in which to give birth. These perceptions, though not borne out by the research, were revealed to be the strongest contributing factor to a woman's decision of where to give birth. Without exception, all studies highlighted the pre-eminence of a concern for safety and the belief that the hospital was the safest place in which to give birth. Nevertheless, some women are increasingly choosing to give birth outside of the traditional hospital environment (Dodwell, 2012) and previous studies have not specifically explored what other factors contribute or are considered of greater significance to these women. Research ubiquitously suggests that safety is a foundational consideration when choosing place of birth, although this priority does not lead all women to make the same choice of birthplace. This suggests that multiple factors are grouped together under the single term ‘safety’, which requires more detailed exploration if we are to fully understand what is influencing women's choices.
To build on existing knowledge and to address the limitations in existing research, this study seeks to explore what key issues influenced women's experiences of decision-making when they were choosing their birth location, drawing on the experiences of women who chose to give birth in each of the three options available through the NHS.
Method
A qualitative design with a narrative approach was used for this study. Narrative research is rooted in stories of human experiences (Webster and Mertova, 2007) and is considered a variant of phenomenology (Finlay and Gough, 2003). Savage (2001) suggested that telling birth stories is an essential task of women who have given birth. From personal experience, the author has found that women enjoy sharing stories of their birth and the events surrounding it. A narrative design that allowed women to share their stories in written form was believed to be the method best suited to enable them to communicate their personal experience—one that appealed to women's intrinsic desires to discuss birth.
Sample
A purposive sample was used and consisted of nine low-risk, first-time mothers, all of whom had received, as a minimum, two birthplace options. The participants comprised three women who chose to give birth in a hospital (coded Hospital1, Hospital2 and Hospital3), three who chose a birth centre (BC1, BC2 and BC3) and three who chose to give birth at home (Home1, Home2 and Home3).
Inclusion criteria stipulated that a minimum of 8 weeks must have passed since the birth, care must have been provided by a NHS midwife in the woman's chosen birthplace within the UK, and with good outcomes for both mother and baby. The sample population comprised first-time, low-risk mothers, aged 28–45 years old. All were singleton pregnancies, all gave birth in the UK and received NHS midwifery care. All of the women's children were aged ≤ 3 years old at the time of sharing their stories.
Participation was voluntary and participants were recruited via the social networking site Mumsnet (www.mumsnet.com). Eight of the women had been given the option of all three birth locations, while the other had been offered either hospital or homebirth. All of the birth centres were stand-alone units.
Data collection
A questionnaire was used to collect women's stories, which asked the following question:
‘Please can you tell me your story of how you chose your place of birth? Within this, please include what influenced your decision and what, specifically relating to your experience, was important to you and as well as your birth partner.’
Data analysis
A two-phased approach, involving categorical-content analysis as described by Lieblich et al (1998) and referred to as content analysis, was used to analyse the data. The first phase involved the creation of a ‘core story’. A modified version of a narrative analysis approach was used to concentrate each woman's story into a shorter story to aid the analysis process (Emden, 1998).
Returning the core stories to the participants was a key component of the analysis process. This sought cor rob oration and increased rigour of the study by ensuring that the formulated core stories were, in fact, an authentic, validated account of the women's submitted stories.
Following on from phase one, the core stories were analysed using a categorical-content method. A thematic map was created for each set of stories from each birthplace. Some themes were present across all stories and some were unique. Six sub-themes were identified, which were later refined into two core themes.
Ethics
The research proposal was registered with the University of the West of England's Research Ethics Committee to ensure that research governance requirements were met and ethical approval was obtained.
Findings
Analysis of the results revealed two core themes, which collectively explore influences on women's birthplace choices: women's expectations of birth, protecting the birthing process and perceptions of safety; and the influence of the midwife, antenatal education and the woman's partner.
Women's expectations of birth, protecting the birthing process and perceptions of safety
Expectations of birth
Women's expectations of birth were clearly divided as either positive or negative, and the findings demonstrate that this was the most significant factor in shaping their choice of birthplace. A positive perception of birth appeared to be born out of a belief in the normality of pregnancy and birth, whereas a negative perception was associated with the medicalised view of birth, which focused on pathology and only accepted a determination of normal birth retrospectively.
‘If we were already in hospital we would have expert emergency care within a few minutes.’ (Hospital1)
‘I also felt more comfortable choosing the hospital in the event that [if] anything went wrong it would be attended to quickly.’ (Hospital3)
It was apparent that the negative expectations of birth and the associated complications that could occur made women prioritise their desire to be safe and ultimately choose a location that they strongly associated with increased safety, specifically when compared to other birthplaces.
In contrast to this, the women who chose to give birth in midwife-led settings had positive expectations of birth, which were expressed in numerous ways. These women conveyed a desire for minimal pain relief and a natural birth:
‘I was determined to have a normal delivery with as little pain relief as I could.’ (BC1)
‘I wanted to have as natural a birth as possible, and wasn't planning on an epidural.’ (Home3)
Women also spoke of being influenced and inspired by positive birth experiences achieved by others:
‘I had two friends who had had good experiences, and knew it wasn't inherently dangerous. I also read a report on home births (Birthplace study), which reassured me it was pretty safe.’ (Home3)
Familiarity with positive birthing experiences encouraged women to be confident in the decisions they made and emboldened self-belief that they too would have a positive experience.
Environment and the nesting instinct
Environment was a key consideration for women who chose to give birth at home and in a birth centre, and this was specifically linked to its impact on facilitating a good birth. Women's desires to protect the birthing process, particularly to safeguard the natural and physiological process of birth, were expressed in their reasoning for wanting certain elements in their preferred birth environment. Several features were evident across both birth-places and some were unique; all were important to the woman in creating the right birthing environment and atmosphere. Women who chose to give birth in a birth centre spoke of the importance of a homely environment:
‘The birthing centre provided a caring, homely environment with the option of birthing pools.’ (BC1)
Women who opted to give birth in a birth centre shared the importance of a familiar and comfortable environment, and women who chose to give birth at home listed the importance of a spacious, calm and relaxing environment. These features were instinctively felt by the women to be fundamental to a positive outcome and ultimately facilitate, as described by one woman (Home2), a ‘good birth’.
‘I felt that the more comfortable I felt in my surroundings the better I would do in labour and feel more at ease and not panic.’ (BC1)
‘I also believed moving about would aid labour, and did not like the idea of being on my back on a bed. I know you can be just as mobile in hospital, but knew I would have more space at home.’ (Home3)
This woman elaborated further on the importance of mobility in labour and linked it to her interaction with her personal environment:
‘I really believed that being in a nice environment where I could go between different rooms, make myself food, watch TV, be in my own bath etc. would keep me much calmer, and that this would make birth easier.’ (Home3)
Relaxation and the surroundings that foster it were also reported to be important. One woman, who gave birth at home, considered relaxation as central to facilitating a positive birth:
‘I realised I would be more relaxed at home, which would help my body in labour, giving me and my baby the best chance of having a stress free good birth.’ (Home2)
Women who chose to give birth at home shared the importance of feeling more in control and a belief that they could exert more influence in this environment.
‘[I] knew I would have more space at home, and be in more control of how I interacted with the environment. Maybe that's the crux of it. I would be in more control of how I moved/controlled pain/where I went.’ (Home3)
One woman shared her deep fear of hospitals, which was associated with her social anxiety.
‘I knew immediately that I didn't want to give birth in a hospital as it seemed like my worst nightmare, surrounded by needles, stretchers and emergencies.’ (Home1)
This demonstrates that the medicalised element of birth in hospital may be off-putting to some women.
Safety
Safety was a key concern for all women, regardless of where they chose to give birth; however, different women had varying ideas about what was or was not safe. The extent to which a woman trusted her midwife was a fundamental element of this:
‘The team of familiar experienced midwives meant that I felt safe and could just focus on my breathing.’ (BC2)
This woman believed that the midwives had the appropriate level of expertise to care for her. This is in contrast to the women who chose to give birth in a hospital, who felt that they needed the full range of medical expertise offered in this ‘alien’ setting in order to feel secure and safe.
Influence of the midwife, antenatal education and the partner
Midwives appear to play a pivotal role in influencing how women make decisions regarding birthplace. This influence may be either negative or positive. Women who chose to give birth in a hospital shared what appears to be weak encouragement from their midwives to consider alternative environments.
‘The options available were not run through in detail but I understood, from my research, that they were a home birth, an obstetric unit very close by, another north of the city centre, or a separate community birth centre.’ (Hospital1)
This implies that a lack of sufficient information regarding options for place of birth may have contributed to some women's decision to give birth in a hospital as the ‘traditional’ setting for birth in modern British culture.
The influence of the midwife was also discussed in relation to care provision and how this inspired trust in the midwife:
‘Consistent antenatal visits with midwives who would then possibly deliver your baby had a big role for me trusting them and influenced my decision. The quality of antenatal care reassured me and I felt I could trust the midwives.’ (Home2)
This woman expressed how continuity of care encour aged trust in her midwife, and this was considered to positively influence her decision. This theme of trust born out of familiarity with midwives was echoed by another two women who chose to give birth in a birth centre. This familiarity is encouraged by continuity of care, which allows relationships to form and enables the woman to feel confident in her decision to be cared for by these midwives.
The value of an organised approach to antenatal education, provided by both the NHS and the National Childbirth Trust (NCT), and its impact on birthplace choice was only evident in the stories shared by those who chose a homebirth.
‘In NCT classes I heard that being in hospital makes most women more likely to receive medical intervention. I was told that 4 in 10 women who try for a home birth with their first pregnancy end up in hospital, I was convinced I'd have a relaxing few days at home in labour then end up transferred to hospital. My thinking was that by having a home birth I would have more relaxed “waiting” time at home and avoid being sent home.’ (Home2)
The provision of NHS antenatal education also played a role in reassuring this womans’ partner:
‘For my husband a factor was the mess! We attended a home birth meeting put on by the hospital. This was key to him feeling comfortable. He met midwives and could ask questions. He was sceptical at first but when he realised the quality of care offered (busy labour ward vs 2 midwives at birth) he was happy.’ (Home2)
Excluding the above example, the influence of partners on birthplace choice was largely reported as negative and shaped by pessimistic expectations of birth:
‘My husband was concerned he might lose me so hospital gave him comfort and confidence too.’ (Hospital2)
Discussion
Women's expectations of birth, protecting the birthing process and perceptions of safety
Expectations of birth
The main factor that shaped women's birthplace choice was their expecations of birth, whether positive or negative. This is similar to the findings of Barber et al (2006), where women's decisions appeared to be based primarily on their personal views and beliefs. Negative expectations, particularly around potential complications, led some women to choose a hospital setting as they associated it with safety. This is demonstrated in previous studies (Barber et al, 2006; Jomeen, 2007; Houghton et al, 2008; Pitchforth et al, 2009; Rogers et al, 2011) and largely highlights the prevalence of the medical model of maternity care, which places higher value on morbidity and mortality outcomes above all others (Walsh, 2006), in shaping women's perception of birth.
Some women asserted their desire for a ‘normal’ or ‘natural’ birth. Statements around not wanting interventions or epidurals suggest that the women were not only confident in their ability to give birth without medical assistance, they also felt they were capable of doing so with minimal pain relief. Their positive expectations shaped their decisions to give birth outside of a hospital. These expectations appear to be congruent with the social model of maternity care, which embraces the normal and natural life event of birth and ultimately the anticipation that all will be well until proven otherwise (MacKenzie Bryers and van Teijlingen, 2010).
Environment and the nesting instinct
From the comments of women who gave birth at home or in a birth centre, it was clear that birthing in a homelike setting was preferable to them; this is consistent with the findings in other studies (Barber et al, 2006; Houghton et al, 2008; Rogers et al, 2011). The desire of some women to be in an environment that mimics their own home, rather than opting to give birth actually at home, suggests that a birth centre provides a compromise between a birth at home and in a hospital.
One woman who opted to give birth at home spoke of being able to move around, relax, have a bath or watch television. The importance of these elements and their interaction in creating what is felt by the woman to be the optimal birthing environment can be seen as represen tative of the nesting instinct. This nesting instinct is, as described by Johnston (2004), a built-in protective force for a woman and her child; it takes a woman into a quiet space so she can progress through the birthing process without interruption.
A relaxing environment was also considered important, which reflects the findings of Barber et al (2006). Similar to the nesting instinct, these women intuitively knew what would make labour easier for them; actively seeking an environment that would encourage this.
One woman (Home3) spoke of being able to ‘be more in control of how I moved/controlled pain/where I went’ at home than she would in hospital. This statement implies that she felt that if she had opted to give birth in a hospital she would have relinquished control of how she experienced labour. The rich descriptions of what women were seeking in their birth environment were not validated by research; they appeared instinctive and were rooted in the women's desire to protect the birthing experience and physiological processes.
Another woman (Home1) expressed a fear of hospitals, describing the idea of a hospital birth as her ‘worst nightmare’. It is interesting to note the degree to which this woman is repelled by a highly medicalised environment, suggesting that the medical model of childbirth was a key factor in her decision to give birth at home. The women who chose to give birth in a hospital similarly appeared to be influenced by the medical model of childbirth, but saw this as the hospital's primary appeal.
Safety
The theme of safety is woven throughout women's stories in a range of applications. As already discussed, women who chose to give birth in a hospital had over-whelmingly negative expectations of birth, and their choice of birthplace was largely influenced by their desire for safety; to protect themselves and their babies from the worst-case scenario by having comparatively immediate access to emergency care.
In contrast to this, a woman's concept of safety, and what ultimately influenced her feelings about what was or was not safe, was presented very differently by those who opted to give birth at home or in a birth centre.
‘Women's expectations of birth, whether they are negative or positive, appear to shape their perception of how they can protect the birthing process’
This was largely influenced by the woman's trust in her midwife, and her confidence that the midwife would ensure the safety of both the woman and baby.
Women's comments about trusting their midwives to facilitate homebirth suggest that the desire for safety appears to be fulfilled by the midwife. This also highlights the importance of the influence of the midwife in promoting births outside of a hospital, and is an illustration of how familiarity with caregivers is linked to trust and ultimately feeling safe.
Safety is a significant consideration for women when they are choosing their birthplace. Women's expectations of birth, whether they are negative or positive, appear to shape their perception of how they can protect the birthing process. Women who opt to give birth in a hospital appear to be concerned with emergencies and having immediate access to medical support, and the setting that they believe facilitates this is, therefore, considered the safest environment in which to give birth. They want to protect themselves and their babies by being in a hospital with the associated immediate access to medical expertise and support. Their decision appears to be based on fear of not only the process of birth but worst-case scenarios, without placing it in the context of the possible risk and the evidence that giving birth in the UK in the 21st century is safer than ever before (Walsh, 2006).
In contrast to this, women giving birth outside of the hospital setting appear to be making choices based on what factors will optimise their experience of birth and facilitate an easier birth. Negative perceptions of hospital as held by women opting to birth at home convey a distinct dislike of the care offered in this setting, and a perception that it may actually make birth more difficult for them. They appear to see beyond the perceived safety associated with doctors and medical equipment and make decisions based on facilitation of the birth process, ultimately aiming to protect it.
Influence of the midwife, antenatal education and the partner
One woman who chose hopsital birth (Hospital1) reported a lack of detail given to her about the options available. The lack of sufficient information has been shown to be a contributory factor in other studies on birthplace (Barber et al, 2006; Jomeen, 2007; Houghton et al, 2008; Pitchforth et al, 2009). Women are unable to make informed choices if they do not know, at the very least, all the available options. This is particularly significant as current guidelines state that low-risk women should be encouraged to give birth outside of the hospital, therefore directing midwives to actively discuss these options and encourage women to opt for birth in alternative environments.
Meanwhile, a woman who gave birth at home (Home2) discussed how her husband's initial misgivings about homebirth had been assuaged by the information provided by midwives. This example demonstrates the value of a formalised approach to information dissemination, specifically to partners. This is consistent with the findings of Mottram (2008), where a father whose partner had decided to give birth at home felt reassured under the care of a midwife because of the level and quality of information shared via the NCT class that he attended.
Previous studies have highlighted the variation in which birthplace choice is offered, specifically in relation to the amount of information presented, the manner in which it is presented and the presence of conflicting advice from health professionals (Barber et al, 2006; Jomeen, 2007; Houghton et al, 2008; Pitchforth et al, 2009). It is worth considering whether a formalised antenatal education programme specifically addressing birthplace choice, held at a time that enabled partners to attend, would help standardise the dissemination and manner in which this information is shared.
A concern with the worst-case scenario influenced some of the partners' preferences for a hospital birth. These findings echo previous studies where the hospital was considered safer and consistent with the best possible care (Houghton et al, 2008; Mottram, 2008). Such expectations are similar to those held by the women in this dataset. In this group of women (those who chose to give birth in hospital) there appeared to be weak midwifery leadership in the promotion of birth outside of the hospital. This suggests that the ‘vacuum’ may have been filled by the women's partners, increasing their influence on birthplace choice more so than in other groups.
As this small-scale study has identified, the clear distinction between women's differing birthplace choices appears to be shaped by their perception of birth (negative or positive). This is reflective of the differing influences of the medical and social models of maternity care. With most women continuing to favour birth in a hospital, it is evident that they remain largely influenced by the legacy of the medical model of care. Davis (2003) argues that women are already socialised before they make decisions regarding their pregnancy and birth. She suggests that women make choices in a space already constructed by ‘powerful discourses’ (Davis, 2003: 575) such as the perceived expectant medical management of childbirth. If a woman has been led to believe that she can only give birth with the assistance of technology and the support of a full team of medical professionals, and that birth is inherently risky, then her options are already limited. The findings of this study suggest that women choosing to give birth in the hospital are doing so out of fear that something will go wrong. Morris (2005) further conceptualises this by suggesting that we are living in a society that has lost its belief in birth as a normal and physiological life process. Conversely, women seeking alternative environments appear confident in their belief in the physiological process of birth and convinced of their body's ability to give birth; their views emanate from the notions constituting the social model of maternity care.
Current research and guidelines emphasise the safety of birth for low-risk women and endorse the provision of birthplace choice. Furthermore, national guidelines actually advise low-risk women to give birth outside of a hospital, owing to the associated benefits (NICE, 2016), but it appears that many are not taking this recommendation seriously. It is worth asking whether medical staff and hospital-based midwives reinforce the view that birth outside hospital is risky, because—contrary to the evidence—the majority of women still choose to give birth in hospital. While current guidelines and research emphasise the safety and benefits of a social model of maternity care, it does not yet appear to have convinced the majority of women; it is necessary to ask why this is the case, and consider what we can do to change this adverse perception.
How can we bridge the divide between the evidence and women's perceptions? Walsh and Devane (2012) challenges the ethical responsibilities surrounding maternity care by encouraging midwives to actively promote what is best, rather than simply offering choices. It appears that this is no longer a debate solely about choice, but rather about how midwives can encourage women to make choices that facilitate the best outcome for themselves and their babies.
Limitations
This study has several limitations that should be considered when interpreting the results. Using an internet-based research method did produce a certain level of selection bias. Walker (2013) indicated that this method necessitates that participants be reasonably computer-literate and able to speak or read English.
The participants all wrote well-articulated stories, indicating a certain level of education; therefore, further research involving a more diverse population is indicated.
Murray-Davis et al (2012) suggest that women's recall process may be influenced by their actual birth. It is reasonable to ask, therefore, whether this study may have provided deeper and less biased insights into what influenced women's experience of decision-making had the research been carried out during the antenatal period.
Further to this, information regarding participants' locality within the UK at time of birth was not collected. This represents a further limitation, as findings may not be generalisable. Evidence highlights that the majority of women choosing to give birth at home are aged between 35–39 years (Office for National Statistics, 2015), suggesting that further research on this topic should include a larger-scale study with a broarder demographic and geographic spread.
Implications for practice
It is hoped that the insights and awareness raised from this study will encourage midwives by providing an illustration of (a) what is contributing to promoting births outside of a hospital, and (b) the central role midwives play in supporting women to experience positive births.
Midwives can be emboldened by the stories of women who appear to embrace the normality of birth and strive for this to be the standard, rather than the exception. The stories shared by women indicate a level of inconsistency and lack of clarity surrounding the manner in which midwives presented their birthplace options. This highlights the importance of educating women on the benefits and evidence of safety of birth outside of a hospital, including a discussion around all available options.
What appears evident from these findings is that there is an absence of balance in women's perspectives on birth, both in terms of their expectations and their fears; specifically, fatalistic attitudes about the need for intervention. These expectations exert a strong influence on birthplace choice, regardless of the benefits and safety of birth outside of the hospital setting for lowrisk mothers. How do we, then, encourage women to make choices that facilitate the best outcomes for woman and baby? Morris (2005) explains that knowledge can result in fear, but its impact on reducing fear is of greater significance. The way in which knowledge is delivered is paramount; this is particularly evident in the positive role that antenatal education had in promoting the normality of childbirth and the subsequent birthplace choices. Efforts must be made to promote the normality of pregnancy and birth. The role of the midwife is crucial in providing a non-medicalised perspective on childbirth. This is especially true when hospital births are considered the norm and a medical model of childbirth appears central to most women's expectations. The role of the midwife is clearly pivotal in this, but midwives' influence is limited to their immediate client group (Kightley, 2007). The findings of this study, as well as those of previous studies (Barber et al, 2006; Houghton et al, 2008), suggest that women have preconceived ideas of where they would like to give birth, even prior to engaging with antenatal care. Davis (2003: 575) suggests these women are already ‘socialised’ into thinking about what is the most appropriate place to give birth. The media have been accused of shaping expectations (Agustsson, 2006) and dramatising birth (Kightley, 2007; Mottram, 2008), which can be argued as a contributory factor. Popular culture frequently defines what is ‘normal’ (Agustsson, 2006), suggesting that the dramatisation of birth could be addressed on a national level.
‘The existence of birthplace choice may be viewed as an attempt to empower women to make the choices that they feel are most appropriate, and to create the freedom for them to do so’
Conclusion
The findings of this study demonstrate that women's expectations of birth were the primary influencing factor affecting their choice of birthplace. A positive percep tion of birth appeared born out of a belief in the normality of pregnancy and birth; these women wanted to give birth in an environment that they believed would facilitate this. In contrast, a negative perception of birth was associated with a medicalised view, focusing on pathology and the risk of things going wrong. These associations illustrate the contrast between medical and social models of maternity care.
It seems clear that all of the women made what they believed to be the ‘right’ choice. The existence of birthplace choice may be viewed as an attempt to empower women to make the choices that they feel are most appropriate, and to create the freedom for them to do so. But if women are not equipped with accurate information, or if there is a historical precedent that exerts undue influence, then there is work to be done to make this empowerment more fully realised.
That said, the findings of this study and previous literature suggest that most women give birth in a hospital because this is still widely considered to be the safest place for them and their baby. This study has presented some of the reasons for this mindset, but the subsequent challenge is to address current and future generations of women who, despite evidence to the contrary, believe that hospital is the most appropriate and safest place to give birth.
There is a need for further research regarding the best way to undertake this formidable task; excellent work is being done by the Birthplace Choices project (National Perinatal Epidemiology Unit, 2016), and it is necessary to continue to explore and explain the complexity of birth in varied settings. In doing so, it may help both women and midwives to give greater consideration to the evidence that for low-risk women, birth at home or in midwife-led birth settings is often as safe as—and preferable to—birth in a medicalised, consultant-led obstetric service.