"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland.

OBJECTIVE: To explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available. SETTING AND METHODS: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. RESULTS: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice." CONCLUSIONS: Provision of different models of maternity services may not be sufficient to convince women they have "choice." The paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

The importance of conducting and reporting pilot studies: the example of the Scottish Births Survey.

BACKGROUND: In many research papers, pilot studies are only reported as a means of justifying the methods. This justification might refer to the overall research design, or simply to the validity and reliability of the research tools. It is unusual for reports of pilot studies to include practical problems faced by the researcher(s). Pilot studies are relevant to best practice in research, but their potential for other researchers appears to be ignored. OBJECTIVE: The primary aim of this study was to identify the most appropriate method for conducting a national survey of maternity care. METHODS: Pilot studies were conducted in five hospitals to establish the best of four possible methods of approaching women, distributing questionnaires and encouraging the return of these questionnaires. Variations in the pilot studies included (a) whether or not the questionnaires were anonymous, (b) the staff involved in distributing the questionnaires and (c) whether questionnaires were distributed via central or local processes. For this purpose, five maternity hospitals of different sizes in Scotland were included. RESULTS: Problems in contacting women as a result of changes in the Data Protection Act (1998) required us to rely heavily on service providers. However, this resulted in a number of difficulties. These included poor distribution rates in areas where distribution relied upon service providers, unauthorized changes to the study protocol and limited or inaccurate information regarding the numbers of questionnaires distributed. CONCLUSIONS: The pilot raised a number of fundamental issues related to the process of conducting a large-scale survey, including the method of distributing the questionnaire, gaining access to patients, and reliance on 'gatekeepers'. This paper highlights the lessons learned as well as the balancing act of using research methods in the most optimal way under the combined pressure of time, ethical considerations and the influences of stakeholders. Reporting the kinds of practical issues that occur during pilot studies might help others avoid similar pitfalls and mistakes.

A national survey of women's views of their maternity care in Scotland.

OBJECTIVE: A survey of women's views of their care was undertaken as part of a national audit of maternity services in Scotland. The overall aim of the audit was to determine the extent to which recommendations from recent national policy documents had been adopted in practice. DESIGN: A cross-sectional study seeking the views of all women giving birth throughout Scotland during a 10-day period in September 1998. PARTICIPANTS: All women giving birth in Scotland within the survey period were eligible to participate in the study. Women unable to complete the questionnaire in English, women for whom the midwife deemed it inappropriate, and women who delivered but no longer resided in Scotland by their 10th postnatal day were excluded. DATA COLLECTION: A self-complete questionnaire given to the woman by her community midwife for completion on her 10th postnatal day. DATA ANALYSIS: Analysis was carried out using the statistical package SPSS for Windows. Descriptive statistics were produced for all variables. Statistical tests of significance were not used, as this was primarily a descriptive survey. FINDINGS: Of the 1152 questionnaires returned, 1137 were suitable for analysis. This gave a response rate of 69% of the eligible population (1639). Most women (80%) had the majority of their antenatal care in the community but only one third had a choice about this. Sixty-nine per cent of women received care from one or two people. However, only 37% had a choice about who these people were. The majority of women gave birth in hospital (99%). Sixty-one per cent felt that they had a choice about where they could have their baby. However, fewer women had a choice about having a home birth (41%) or a DOMINO delivery (23%). Just over half the women felt that it was important to be cared for by a midwife that they had met during pregnancy but only 12% of women achieved this. Sixty-two per cent of women had talked to a health professional about what happened during labour and delivery but less than half had spoken with a professional who was present during her labour or birth. CONCLUSIONS: Considerable efforts have been made to improve information and choice for women. However, it is clear that further work is needed if women are to be offered informed choice in the provision of their maternity care.

Cord-care practice in Scotland.

OBJECTIVE: To identify the range of policies, practices and rationale for umbilical-cord stump care in the NHS in Scotland. DESIGN: A postal questionnaire survey completed in two stages. The first stage elicited the views of Heads of Midwifery/Senior Midwives, and the second stage the views of midwives, enrolled nurses and nursery nurses. SETTING: NHS units in Scotland providing intrapartum care. They were separated into large and small units with small units having < or = 1000 deliveries per year (n = 178), and large units > 1000 deliveries per year (n = 300). PARTICIPANTS: The Heads of Midwifery/Senior Midwives from the 51 units were invited to participate in the study and 49 (96.1%) replied. In stage two 512 maternity unit employees were sent questionnaires and 390 (76.2%) replied. These were six enrolled nurses, 20 nursery nurses and 360 midwives and four respondents of unspecified occupation. MEASUREMENTS: The existence of cord-care policies and their rationale. FINDINGS: About half of the units that responded had a written policy. Large units were four times more likely than small units to have a written policy. Both managers and staff reported that the most common policy/agreed practice was no specific care (cord observed and only cleaned if soiled). Where a written policy existed, less than one-half of the Heads of Midwifery/Senior Midwives and less than one third of the staff reported that the basis for this policy was research. KEY CONCLUSIONS: Units with a written policy are in the minority and small units are far less likely to have such a policy. Wide variation exists in policy, practice and rationale. Diversity within and between units creates anxiety and disillusionment for practitioners. It may also cause confusion for patients who are exposed to different cord-care practices either as these change over time or because they use different units. IMPLICATIONS FOR PRACTICE: The midwifery profession must examine this area of practice and determine how to address this lack of evidence. Further research is required to determine the most effective method of cord care and how best to put the findings into practice. Outstanding questions which beg further investigation are: How do cords heal and separate and what bacteria are naturally involved in this process? What constitutes an infected cord as opposed to a colonised cord?

Can anxiety in pregnant women be measured using the State-Trait Anxiety Inventory.

OBJECTIVE: To explore the stability of the State-Trait Anxiety Inventory (STAI), which was used to explain shifts in women's priorities for intrapartum care. DESIGN: A comparative survey of women's priorities for intrapartum care, using a self-complete questionnaire at two intervals, 34 weeks gestation and 10 days postpartum. The questionnaire incorporated the full 40 item STAI. SETTING: Aberdeen, Scotland. PARTICIPANTS: 217 women presenting at Aberdeen Maternity Hospital at 34 weeks gestation who were 'booked' for delivery within the hospital, and who lived within Aberdeen city. One hundred and thirty-six were expecting their first baby and 81 were expecting their second. MEASUREMENTS: Women's priorities for intrapartum care as ascertained at 34 weeks gestation and 10 days postpartum; shifts in priorities observed during this time period; and factors, such as anxiety (measured by the STAI), which could explain these shifts. FINDINGS: Regardless of parity, women had significantly lower A-Trait scores postnatally than antenatally, when compared over a relatively short time period. Differences between nulliparous and parous women were found where the time lapse, between completion of the scales, was more than 45 days. For nulliparous women significant differences in A-Trait scores were still evident in the 45-56 day interval, but not in the later interval of 57-91 days. Parous women appeared to follow the opposite trend, however the numbers were considerably smaller. CONCLUSION: The findings reported in this paper are derived from a study assessing women's priorities for intrapartum care. Anxiety was not a primary outcome measure in this study, but rather a factor which was measured as a possible explanation for shifts in priorities. However, the findings suggest that the STAI may not be stable around the time of delivery. In particular, the test-retest reliability of the STAI A-Trait scale appears to be quite low. IMPLICATIONS: The study reported here raises the need for further research in this area and cautions against the unqualified use of this tool until its performance, specifically in the context of pregnant or recently-delivered women, has been thoroughly assessed.

The application of ergonomics to consumer product evaluation.

Consumer products may be evaluated by technical tests or by ergonomics assessments. If an ergonomics assessment is required, then three types of test are available to the researcher. These are the user trial, the expert appraisal and the performance test. These three methods are described briefly and some advantages, disadvantages and issues arising from each are discussed. It is concluded that although the user trial will always assume an important role for the evaluation of many products, expert appraisals and performance tests can prove to be cost effective methods in certain circumstances. Some controversial areas requiring further research are highlighted.