Shared learning database

Portsmouth Hospitals NHS Trust
Published date:
October 2014

Portsmouth Hospitals NHS Trust Maternity Service has completed a three year major transformation programme, 'Nurture'. The priority is to provide 1 to 1 midwifery care in labour, achieved by a flexible integrated midwifery model, to support birth in and out of hospital. Portsmouth offers a full range of options for place of birth as recommended in the NICE intrapartum care guideline; home, 3-standalone midwifery led units (FMU), an integrated midwifery led unit (AMU) and a traditional consultant led labour ward (OU).

Despite this choice and a flexible midwifery workforce to support 1 to 1 care in labour, not many women were making a conscious choice to give birth in the MLU's or at home. The team at Portsmouth wanted to offer women choice, unbiased evidenced based information and engage them in a shared decision making (SDM) process. A successful application was made to the Health Foundation Shine 2012 scheme; £73,000 was awarded to develop a web app.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of My Birthplace® project, funded by a 2012 Shine Health Foundation award was to develop, with maternity service users and the evidence base, a computerised tool to support birthplace decision-making. It was an iterative process with midwives and maternity service user's engagement at all stages of development. Each stage was checked with them for usability and applicability and each stage incorporated their feedback to refine the end product. The tool, My Birthplace® was designed as an application (app) adapted for Smartphone or tablet technology from a web based platform. It uses standardised and evidence based information about outcomes for each birth setting using national and local data to support women and partners in decision making.

Reasons for implementing your project

Despite Portmouth's full range of choice and a flexible midwifery workforce to support 1 to 1 care in labour, not many women were making a conscious choice to give birth in the units or at home. Recent policy and now NICE guidance has encouraged birth out of hospital for women at low risk of intervention (low risk women). However until 2011 robust research outcome data were limited to underpin this recommendation and at that time only 8% of births nationally and 10.9% of births in Portsmouth were out of hospital. A cohort study of 79,774 low risk women, published by Hollowell et al in 2011, identified that giving birth is very safe in all settings, with lower intervention rates and higher likelihood of a normal birth when labour starts out of hospital.

Information about choices for place of birth is widely available via the internet, local NHS websites and midwives give written information to all pregnant women. Limited and potentially subjective information about risk and the outcomes of place of delivery has been inconsistent between midwives and across maternity services. Women in Portsmouth have complained to midwifery managers that this information is not personalised to meet individual preference and risk.

This apparent lack of information may contribute to a low level of a decisive birthplace preference. Just over half of women in Portsmouth (59%) make a birthplace decision at 12 weeks of pregnancy and the midwife, throughout the pregnancy, does not revisit this again. This creates unnecessary hospital births for low risk women linked with increased interventions and inefficiencies in workforce planning. Using technology to improve health outcomes is increasing and Smartphone technology is changing the face of health information. However the use of this technology is limited in maternity services with a reliance on paper information, professional subjective opinion and lack of consistent information.

How did you implement the project

Birth data between October and November 2012 were used as the project baseline data; 59% of women had made a decision about place of birth at 12 weeks of pregnancy. Data was not recorded on place of birth preference at 36 weeks.

Thirty midwives, covering 4 distinct geographical areas were trained to use My Birthplace® app and training also included the theory of shared decision-making. These pilot midwives identified 250 eligible women who would deliver between October and November 2013. Their initial preference for place of birth was documented in the maternity notes at 12 weeks of pregnancy. It was planned the midwives would test the prototype app with women and their partners from 25 weeks of pregnancy. Women were able to use the app at home and then complete the exercise together with their midwife in the antenatal clinic. The final birthplace preference was documented at 36 weeks of pregnancy using digital pens and specifically designed digital forms within the handheld maternity notes. Individual interviews were held and surveys undertaken with women and midwives to understand the utility, applicability and acceptability of My Birthplace®. Feedback from the surveys along with interviews and focus groups with women and midwives was used to shape the final app and a graphics expert was commissioned to design the final product. You can view the web app here:

Key findings

Data recorded at booking was compared against that recorded at 36 weeks to show that women had reached a preference having had access to the app.

236 women were entered into the pilot. Of these, 163 (69%) had expressed a birthplace preference at both 12 and 36 weeks. Seventy-three women (31%) had either delivered before or after the pilot dates or their notes contained incomplete birthplace preference data at 12 or 36 weeks so were not included in the final results. Of 163 women, 73 (45%) had decided a preferred place of birth at their 12 week appointment and this increased to 143 women (88%) at 36 weeks of pregnancy, 23 (14%) had moved out of the area. Initial data indicates the use of this app is acceptable to women and midwives and both groups valued the evidence-base information.

The App's survey tool, which was embedded in the app and post-pilot surveys, demonstrated that using an app was acceptable in communicating this information to women and midwives and that they valued the evidence-based information.

"Statistics were great especially when making such an important decision like where to have your baby".

"It cemented my decision. I knew what I wanted to do but it gave me more information so that I knew it was the right decision".

Key learning points

This project was the first of its kind to integrate research findings into a tool for women and midwives to use together to discuss birthplace choices.

Providing women with standardised non-subjective information about place of birth appears to influence their preference and is acceptable to them.

Incorporating SDM into practice ensures women are active partners in decision making Understanding the preferences of local women can assist in planning maternity services so that midwives are in the right place for the right women.

The app will be rolled out across the service for all women in early summer and it is attracting interest from other Trusts.

The team has been highly commended by NHS England for its work in patient participation.

Contact details

Gill Walton
Director of Midwifery
Portsmouth Hospitals NHS Trust

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