The paradox of contemporary midwifery practice: Promoting an out-of-hospital birth setting

In New Zealand women choose their place of birth in partnership with their Lead Maternity Care (case loading) midwife, with most choosing a hospital regardless of their lack of risk factors. The reasons why most women in western countries choose to birth in hospital have been widely investigated. Risk aversity is most commonly implicated. For both women and health professionals this powerful discourse persists despite consistent research findings indicating higher rates of normal birth, and lower rates of maternal morbidity associated with interventions for healthy women who birth in out-of-hospital (primary) maternity units, with no difference in neonatal outcomes. There is however a gap in the literature regarding what is known about how midwives might positively influence the choice to birth in a primary unit. A qualitative descriptive design through an appreciative inquiry lens enabled insight from 12 midwives who have a higher ratio of women within their caseload who choose to birth in a primary unit. Four focus groups were formed with these midwives to explore their perspectives and approaches as they assist women to make their place of birth decisions. From thematically analysed data, five themes emerged, Ways of knowing: woman, art, science and research; Trusting in you, me, and the process of childbirth; Setting boundaries as a ‘primary birth midwife’; and Delaying and diverting, a malleable approach, centered around the theme When it matters what we say: reframing safety and risk. Alongside supporting current research, this study adds to the body of knowledge about birthplace choice by bringing to the fore the notion of paradox in practice, setting boundaries whilst remaining malleable for example. In a contemporary maternity context, these midwives dance between two worlds fundamentally at odds with one another, effectively managing contradiction, complexity and uncertainty to achieve a high primary unit caseload. The experience of what works to promote the primary unit for a cohort of New Zealand midwives is uncovered in this research. The social recalibrations needed to adjust the hospital birth norm are much broader issues than midwives alone can change, but in this study, we see they are staying the course in order to protect and promote normal birth. How midwives might inform decision-making for place of birth choice is described.