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‘She can choose, as long as I’m happy with it’: A qualitative study of expectant fathers’ views of birth place
Sexual & Reproductive Healthcare 2 (2011) 71–75
Contents lists available at ScienceDirect
Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
‘She can choose, as long as I’m happy with it’: A qualitative study of expectant fathers’ views of birth place Carol Bedwell a,⇑, Gillian Houghton b, Yana Richens c, Tina Lavender a a
The University of Manchester, School of Nursing, Midwifery & Social Work, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool, Merseyside L7 8SS, UK c University College Hospitals Foundation Trust, Institute of Women’s Health, 2nd Floor North, 250 Euston Road, London, NW1 2PG, UK b
a r t i c l e
i n f o
Article history: Received 9 September 2010 Revised 2 December 2010 Accepted 6 December 2010
Keywords: Fathers Birth place Qualitative Interviews
a b s t r a c t Objectives: A programme of research was undertaken to explore which factors contributed to decisions regarding birth place. As part of this programme, the views of male partners of pregnant women were examined to gain understanding of their contribution to the decision making process, with regard to different birth settings. Study design: A qualitative interpretive approach was utilised to explore, in-depth, the views of 19 expectant fathers, in the North West of England. Semi-structured interviews were conducted, audio recorded and transcribed, following consent. Data were analysed using a thematic approach. Findings: Four main themes were identified; Silent decisions, Powers of persuasion, Trust in a medical environment and Personal vulnerability. Conclusions: Choice regarding place of birth is multi-dimensional. Expectant fathers are likely to contribute to their partner’s decision making; their motivation can relate to their own beliefs and personal vulnerability as well the need to protect the women. The overwhelming trust in the medical environment dominates partner’s views regarding birth place. The lack of discussion regarding birth place, between partners and with health professionals, reinforces the notion that hospital birth is safest, thus strengthening the normalization of birth in this environment. Midwives need to engage with expectant fathers to ensure that their contributions to decisions around birth place are fully informed. Ó 2010 Elsevier B.V. All rights reserved.
Introduction Place of birth is a highly debated issue amongst health professionals world wide [1]. Rates of home birth vary across the globe, from 0.65% in the United States [2] to 70–80% in parts of Central Asia [3], influenced by a number of political, contextual and historical factors. In the United Kingdom the recommendation for 100% hospital birth, brought about by the Peel Report in 1970 [4], has been consistently challenged [5,6]. Yet, despite this, evidence provided by large population based studies [7–9] has failed to convince many health professionals of the relative safety of home birth. In the United States, for example, the American College of Obstetricians and Gynecology issued a position paper opposing home birth [10], thus reinforcing beliefs about the dangers of this setting. In the UK, there has been a growing emphasis on the need to enable women to make childbirth choices [11]; place of birth being a central tenet. However, although several birth settings are available to women, recent figures suggest that the majority continue ⇑ Corresponding author. Tel.: +44 (0) 161 306 7782; fax: +44 (0) 161 306 7707. E-mail address: [email protected] (C. Bedwell). 1877-5756/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.srhc.2010.12.001
to give birth in hospital [12]. The number of births taking place in NHS hospitals increased by 20,630 (3.3%) to 649,837 during 2007–2008 [12], with home birth rates ranging from 2.84% in England to 1.46% in Scotland and 3.73% in Wales 2007–2008 [13]. The mean home birth rate in the UK is 2.7% [14]. Factors thought to influence women’s birth place decisions include safety, avoidance of unnecessary medical interventions common in hospital births, previous negative hospital experiences, more control, and a comfortable and familiar environment [15]. The influence of partners has received little attention, despite the fact that, in most western societies, a partner is likely to be present at the birth. The partner has been shown to be influential in a number of pregnancy and childbirth areas, including antenatal screening [16], pain relief in labour [17] and method of infant feeding [18]. It is conceivable, therefore, that the partner may also be influential in choices regarding birth place. We conducted a programme of work to explore the views of key stakeholders in the decision making process [19]. As part of this programme we examined the views of male partners of pregnant women to gain understanding of their contribution to the decision making process regarding different birth settings.
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Methods
Analysis
A qualitative interpretive approach was adopted in this study, utilising in-depth interviews to explore research participants’ views of birth setting. This approach enabled the collection of rich data, enabling a deep exploration of issues important to the participant [20]. Ethical approval was sought and gained from the local research ethics committee (Ref: 05/Q1505/38) in the North West of England and Trust Research and Development department. All research governance requirements were met.
All interview data were transcribed verbatim, using pseudonyms to protect identity. Data were managed manually, with the aid of a word processor. Thematic analysis was conducted, utilising a cyclical yet systematic approach to ensure rigour [21]. This process, which drew on that described by Miles and Huberman [22], involved familiarisation with the data, de-contextualising or breaking down of the data, data display and recompilation. In the ‘familiarisation’ phase, the transcripts were read and re-read to achieve a general understanding of the individual and collective accounts. In the ‘de-contextualisation’ phase, a formative and iterative process was used to generate codes. These codes were then grouped into categories and displayed under headings, for ease of interpretation. Overarching themes were generated through the amalgamation of categories, after returning to the original transcripts to ensure that the ultimate messages being conveyed were truthful to the participants’ accounts. To ensure trustworthiness, two researchers (TL and CB) carried out simultaneous analysis; consensus was reached. Field notes and an audit trail were kept throughout the process to ensure transparency. Negative cases were identified. Verbatim quotes have been selected to represent the most frequently occurring themes.
Participants This study took place in the North West region of England, a large tertiary referral hospital, which supports more than 8000 births per annum. The hospital contains an obstetric unit, which supports women with medical or pregnancy complications, and those requesting epidurals. It also houses a midwife led unit, which caters for straightforward pregnancies and offers pharmacological and non pharmacological methods of pain relief, including pool births. Epidurals are not provided in this unit and, if a complication should arise, the woman is transferred to the obstetric unit. The community midwives in the unit offer a home birth service; the home birth rate at the time of the study was 1.8%. All partners of women participating in the larger study [19] were eligible to participate. At the point of contact, the couple’s birth place expectations were unknown to the researcher. Recruitment Expectant fathers were approached to participate when they attended the initial antenatal appointment with their partner (n = 37). Written information was provided, and expressions of interest were followed up by a telephone call from the research midwife. For those wishing to participate, an appointment was made for interview, at a time and location convenient to the expectant father. Written consent was obtained from all participants. Data collection Base line details were recorded from all participants using a brief, baseline questionnaire. Interviews took place in the 34th week of the woman’s pregnancy. This was an important time point as the main birth place decision was made around this time. Furthermore, it enabled participants to reflect on the pregnancy experience and recall any influencing factors related to birth place. Semi-structured, in-depth Interviews were conducted using a broad topic guide that had been piloted in advance (see Fig. 1 for examples of interview questions). The guide prompted questions regarding general views of birth place and personal decision making. In order to allow privacy to disclose their views, all the participants were interviewed without their partner being present. The majority of interviews took place in the home (n = 13) with others taking place in the hospital (n = 5) or workplace (n = 1). Interviews were audio recorded.
Example of questions used in interview Where is your partner planning on giving birth? Which factors influenced the decision on birthplace? What other choices are available for place of birth in this area? What previous experience have you had of birth? Have you spoken to anyone about placesto give birth? What did they say? Fig. 1. Example of Interview Questions.
Findings Thirty seven partners agreed to participate, of which 19 were interviewed. The sample size was dictated by the availability of partners for interview and the study duration. Nevertheless, data saturation was reached; therefore the need to sample more would not have been appropriate. Previous studies have demonstrated that data saturation is likely to be reached with 12 interviews, with main themes emerging after 6 interviews [23]. Interviews lasted between 35 min and 70 min. Table 1 displays the baseline details for all participants. As can be seen, the majority of men declared themselves as White British. Participants were employed in a range of occupations and had various qualifications. The median age of participants was 34 years (range 21–52). All participants were living with their partner at the time of interview. Three participants were already fathers; all had experienced the birth of their baby in a hospital setting. All of the participants were planning a hospital birth. This was confirmed by their partners. Although the participants were made aware of the different birth settings (obstetric unit, midwife led unit and home birth), they did not differentiate between the two hospital areas; their main focus was on hospital versus home birth. Four main themes were identified, Silent decisions, Powers of persuasion, Trust in a medical environment and Personal vulnerability. Although presented separately, these themes are not mutually exclusive, each having a relationship with the others. Silent decisions With regard to choice of birthplace it became clear that there was little or no discussion between couples when making a choice of place of birth. When approached about participating in the study, it was interesting to note that couples appeared (from their body language and facial expressions) to be puzzled about the need for such questioning (field notes). There was a general assumption that birth would take place in the hospital setting and expectant fathers all indicated that they were very happy to go along with this. ‘‘We hadn’t even discussed it, we just assumed you know, you go to hospital to have a baby, and that’s that’’. [Sid]
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C. Bedwell et al. / Sexual & Reproductive Healthcare 2 (2011) 71–75 Table 1 Participant profiles. Participant (pseudonym)
Age
Ethnicity
Occupation
Marital Status
Previous birth
Highest qualification
Mike Jay Tom Mark Sid Kevin Billy Frank George Bob Paul Peter Luke John James Dean Matthews Chris David Alex
35 36 37 28 Missing 31 37 34 33 32 32 52 37 34 33 43 32 40 32 21
White White White White White White White White White White White White White White White White Indian White White White
IT system developer Electrician Solicitor Sales Production operator Printer BT engineer Builder Civil servant Sales Landscape designer Retail Lecturer Sales IT Sales Medical doctor Lecturer Minister of Religion None
Married Married Married Married Married Separated Living with Married Married Married Living with Married Married Married Married Living with Married Married Married Living with
None None None None None None None One None None None One None None None None None None One None
Degree HNC Degree, Postgraduate diploma Degree GCSE, NVQ GCSE Technical college exams GCSE A levels Degree Degree, Postgraduate diploma A levels Postgraduate degree Degree Degree HNC Postgraduate degree Postgraduate degree Postgraduate degree GCSE
Hospital birth was seen as the ‘norm’ and partners expressed an opinion that suggested that to disrupt the ‘status quo’ was unjustified. Comments such as ‘we just assumed’ and it was an ‘automatic decision’ were common: ‘It wasn’t really discussed. . .it was just, you know. . .it was always gonna be the hospital’ [Kevin] Those who had given some thought to a home birth had quickly dismissed the idea as being alien to them. Frank, for example, rejected the idea saying: ‘It was like an automatic decision to go to exactly the same place and have it in exactly the same way as last time. . .[we are] not really adventurous, you know [laughs]’ Similarly, George stated: ‘I know that some people would prefer a home birth. . .I think some people have a few sort of slightly way out ideas on how and where to give birth’ The emphasis on the words ‘way out’, highlight George’s belief that home birth was not considered mainstream.
partner
partner
partner
partner
although they stated that their partner should have the ‘final say’, they were open about the persuasive words that they would use if the decision opposed their own. Even when partners said that they would support women who requested a home birth, the extent of that support was questionable. ‘‘I don’t think I’d pressurise her if she really said ‘‘I want this baby at home’’ I wouldn’t say no, no that’s it but I would I would say like have a think about it a. . .you know I would prefer you to be in the hospital. . .That’s what I’d say. It might cause problems. . .you know if anything happened. . .I would probably give her loads of grief but. . .if she’d have said this time I want a home birth I’d have said well look everything went smoothly at the hospital lets do it again, but if she was adamant, yeah I’d support her. But if it was my choice it’d be there (hospital)’’. [Jay] Unlike hospital birth, some women would have to strongly justify any desire for a home birth. Furthermore, they would have to make the decision in the knowledge that there may be repercussions, in the form of blame, if they chose a home birth and something went wrong.
Powers of persuasion Although decisions regarding hospital birth were accepted without discussion, when asked about birthplaces other than hospital, expectant fathers indicated that they would want some sort of discussion before reaching a decision: ‘well it would be her choice at the end of the day. I’d let her know that I would want. . .prefer the birth to be at the hospital but it’s a team decision in this household so if she felt strongly about it then so long as I could be convinced that there’s the support and the facilities and that it was quite a natural thing to do then I know it’s right I’d let her make the choice [John] John went on to say: ‘I think I’m reasonable so if she gave a good reason why, and the midwives and the doctors said you know look its perfectly safe and don’t worry about it. . .then it would be her decision ultimately; cos she’s the one who is gonna do the hard part’. As the quote illustrates, many of the men interviewed acknowledged that their partner was the primary focus and therefore had a slightly better bargaining position in any decision making. Yet,
Trust in a medical environment Overwhelmingly participants perceived hospital to be the safest place for birth. The desire for their baby to be born in hospital was motivated by the need to protect their partner from harm. Men undoubtedly viewed their partners as their main priority: ‘Well as long as she survives the whole experience, the baby comes second. . .the mother comes first’ [Dean] Expectant fathers clearly dichotomised the two birth environments; hospital birth as safe and home birth as a risk. Their desire to protect their partner meant that home birth was dismissed as an option. ‘‘I mean I didn’t want to push her into any decision anyway but I felt that she’d be more safe and she’d feel safer being at a medical site. . .homebirth wasn’t an option’’. [Paul] Paul then continued by saying: ‘It may sound brutal and mercenary but as far as I’m concerned, my wife comes first and the child second. . .it sounds very mer-
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cenary saying it, I love my wife and we can always have another, attempt a another child, however I don’t have a second wife’. Men also felt that hospital offered a safe environment to them personally. For example, one partner said: ‘‘It’s just the way I feel I just want a bit of safety and need to be in hospital’’ [Kevin] Their views were also influenced by their perception of health professional roles. Luke, for example, said that he would want the birth to be in hospital because ‘I like the idea of being where the experts are’. Midwives were therefore not necessarily seen as the expert. Similarly Bob said: Subconsciously, I’m not really for having the birth at home for numerous reasons. One cos if there were any complications. . .uhm. . .I don’t want to have to wait for an ambulance. . .I need to know that the professionals are there. . .and if anything really went wrong I don’t think I’d want to have the memories in the house Although expectant fathers acknowledged the importance of the midwife, this tended to be in the context of a supportive role. Medical doctors where considered an important part of the birth event, and this provided men with the additional rationale for wanting a hospital birth: [A doctor] is specifically trained in all the finer details of childbirth. . .but even so it still requires the help of a midwife who’s good at the basic level. . .if there were problems and the doctor didn’t turn up then I would be upset about it [Matthews] Interestingly, views were similar, regardless of whether or not the expectant father had been present at a previous birth. However all of their previous births had been conducted in the hospital. Personal vulnerability Many men had concerns about their ability to cope when their partner was in labour; they viewed the hospital and staff as a means of protection. ‘Well I knew that if I, if I flipped and went ‘I can’t cope with it any more’ then walking out the house and leaving her to it is completely different to going ‘‘I’m sorry I’ve just got to leave the room for a minute’’ cos there’s a doctor and midwife thereat least I know that I wouldn’t be leaving her in the lurch if I couldn’t actually handle things.’ [Mike] Many of the partners’ views highlighted their own feelings of vulnerability. They constantly referenced themselves when asked about the birth place decision. Kevin said ‘I feel safer in hospital.’ Similarly, Jay said: ‘‘it’s just the way I feel. . .I just want a bit of safety and need to be in hospital’’ Expectant father’s views of birth environment were influenced by their views of labour and birth. Kevin, for example, said that he would not want a home birth because labour was ‘nerve wrackin[g] enough.’ Those who had already been present at a birth (n = 3), demonstrated their vulnerability when they drew on their previous experiences. For example, David said: ‘Last time the baby’s heart rate dropped suddenly. . .If I’d been at home I would have really panicked. . .Everyone stayed really calm which was reassuring’ Such examples were used to reinforce their decision to give birth in the hospital.
Discussion The study findings demonstrated a naivety amongst male partners regarding birth place. Their unanimous opinion that hospital birth was ‘safer’ being influenced by multiple sources. It is perhaps not surprising that they held these views, especially as nationally home birth rates are low [13], and at the study hospital they were even lower. Furthermore, only one partner had personally known of anyone who gave birth at home, and despite the outcome being positive, he considered this to be unusual. Moreover, this is a fiercely debated area amongst health professionals [10,24]; those with negative views of home birth have the potential to influence the views of expectant couples [19]. Given that informed choice of birth place is considered integral to maternity care [11], and communication between partners is seen as a pivotal aspect of this, it was surprising to discover that decisions appeared to be made subliminally. Views were never challenged during the pregnancy, confounding the belief that the ‘silent decision’ made was the correct one. There was no evidence of any objective decision making; no facts were ever mentioned and there was no attempt to draw on any type of evidence. This is perhaps surprising given that stereotypically, men are thought to be less subjective than women. When explicitly questioned about home birth, most expectant fathers appeared almost relieved that it was not a major part of their childbirth discussions. When prompted to reflect on how they would react if their partner wished a home birth, their strategy was almost always to use some form of verbal persuasion. Their transcripts demonstrated a technique of expressing a desire to listen to their partner’s wishes, whilst ensuring that their own feelings were given equal, if not more, precedence. Whilst father engagement has been promoted within maternity care and partnership decisions have been encouraged, the dynamics of shared decision making has received relatively little attention. Women, in our larger study [19], reported similar views to the men. It may be that our results reflect a social desirability of reporting joint decision making; the actual decision was likely to be the result of a complex interplay of external and internal factors. Exploration of these factors warrants longitudinal collection of data from multiple sources. The expectant fathers in our study demonstrated that if their partner had have wanted a home birth, she would have to do it in the knowledge that the father disapproved and that she would possibly be blamed if a favourable outcome was not achieved. This finding resonates with the earlier work of Chamberlain et al. [25] who concluded that ‘women planning home birth did so in the face of a certain amount of perceived discouragement’ (p. 132). The fathers suggested that the main reason for wanting a hospital birth was to protect their partner. However, this patriarchal standpoint was somewhat undermined by expressions of their own vulnerability. It may be that they used the idea of protecting their partner, as a means of hiding their own feelings of uncertainty. As Hall [26] notes, ‘a man can help to empower a woman, but can also have a negative effect if he is unable to deal with his own feelings’. Being interviewed by female researchers may have influenced these responses; a factor identified in previous research [27]. It is unclear whether the fact that the interviewers were also midwives had any influence on participants’ responses. The lack of preparation for men accompanying their partners in labour [28] may be a further reason for the views stated, although this information was not obtained in the current study. Unlike studies that have demonstrated that pregnant women prioritised their babies’ protection [29], fathers showed little evidence of this. It may be, as suggested by Longworth and Kingdon [30], that fathers felt disembodied from the pregnancy; attachment to the baby only occurring when visible outside the womb.
C. Bedwell et al. / Sexual & Reproductive Healthcare 2 (2011) 71–75
Although our study findings describe the views of a relatively small sample, in one part of England, the in-depth material generated offers important insight into expectant fathers’ views. Individual interviews enabled comprehensive exploration of views yielding a significant amount of useful data which not only highlights the views of men towards birth place, but also gives insight into the potential difficulties faced by women who may desire a home birth. This study should be replicated in other settings, where the home birth rate is higher, to ascertain the impact of this on fathers views. Furthermore, our study was limited by the participants who agreed to be interviewed. All the men were English speaking. The study does not, therefore, represent the cultural diversity of expectant fathers who accompany their partners in labour. This is particularly important given that recent research suggests that men from different cultures wish to take a more active role in supporting partners during the birth journey [31]. In addition, younger participants were underrepresented with the mean age of participants being 34. Our findings suggest that there is a need to rethink the current information provision about birth setting. Unbiased Information should be supplied to couples, by health professionals, early in pregnancy. Communication around birth setting should be an ongoing process throughout the pregnancy, thus enabling decisions to change as appropriate. Health professionals should engage with the media to ensure that a balanced view of home birth is presented, to counteract the sensationalism which often accompanies reported birth stories.
Conclusion Expectant fathers, in our study, did not perceive home birth to be a reasonable option for their partners. Hospital birth was considered the norm; views were motivated by personal vulnerability as well the need to protect their partner. The overwhelming trust in the medical environment dominated partner’s views regarding birth place; perceptions of the ‘expert’ contributed to these views. The lack of discussion regarding birth place, between partners and with health professionals reinforced the notion that hospital birth is safest, thus strengthening the normalization of birth in this environment. Midwives need to engage with expectant fathers to ensure that their contributions to decisions around birth place are fully informed. Acknowledgements This study was funded by the Liverpool Women’s NHS Foundation Trust. The authors wish to thank all the expectant fathers who gave up their valuable time to contribute to this study. References [1] Young G, Hey E, Macfarlane A, McCandlish R, Campbell R, Chamberlain G. Choosing between home and hospital delivery. BMJ 2000;320:798. [2] Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al. Births final data for 2005 vital statistics report. Available from: http:// www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf; 2007 [accessed 18.08.10].
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[3] Blua A. ‘‘South/Central Asia: women dying in childbirth at high rate’’. Radio free Europe. Available from: http://www.rferl.org/content/article/ 1057692.html; 2005 [accessed 19.08.10]. [4] Department of health and Social Security (Welsh Office). Domiciliary midwifery and maternity beds needs report of the sub committee (peel report). London: HMSO; 1970. [5] Tew M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985;35:390–4. [6] Shaw R, Kitzinger C. Calls to a home birth helpline: empowerment in childbirth. Soc Sci Med 2005;61:2374–83. [7] Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Br Med J 1996;313:1313–8. [8] Johnson CK, Davis BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416. [9] Janssen PA, Saxell L, Klein MC, Robert M, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009;181:6–7. [10] Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203. Available from: http://www.ajog.org/article/S00029378(10)00671-X/references. [11] Department of Health. Maternity matters: choice, access and continuity of care in a safe service. London: Department of Health; 2007. [12] National Health Service Maternity Statistics. Available from: http:// www.ic.nhs.uk/statistics-and-data-collections/hospital-care/maternity/nhsmaternity-statistics-england:-2007-08; 2009. [13] BirthChoiceUK. Available from: http://www.birthchoiceuk.com/; 2009 [accessed 19.08.10]. [14] Dodwell M, Gibson R. An investigation into the choice of place of birth. NCT; 2009. [15] Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health 2009;54(2):119–26. [16] Locock L, Alexander J. ‘Just a bystander’? Men’s place in the process of fetal screening and diagnosis. Soc Sci Med 2006;62:1349–59. [17] Capogna G, Camorcia M, Stirparo S. Expectant fathers’ experience during labor with or without epidural Analgesia. Int J Obstet Anesth 2007;16:110–5. [18] Earle S. Why some women do not breastfeed: formula feeding and fathers’ role. Midwifery 2000;16,323–330. Available From: http://oro.open.ac.uk/ 2796/1/WSIF_-_2002.pdf. [19] Houghton G, Bedwell C, Forsey M, Baker L, Lavender T. Factors influencing choice in birthplace. An exploration of the views of women, their partners and professionals. Evid Based Midwifery 2008;6(2):59–64. [20] Crotty M. The foundations of social research. Meaning and perspective in the research process. London: Sage Publications; 2003. [21] Carter B. How do you analyse qualitative data? In: Lavender T, Edwards G, Alfirevic Z, editors. Demystifying qualitative research in pregnancy and childbirth. Wiltshire, UK: MA Healthcare Ltd.; 2004. p. 87–108. [22] Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2nd Ed. Sage Publications, Inc.; 1994. [23] Guest G, Bunce A, Johnson L. How many interviews are enough? Field Methods 2006;18(1):59–82. [24] Gyte G, Dodwell N, Newburn M, Sandall J, McFarlane A, Bweley S. Findings of meta-analysis cannot be relied on. BMJ 2010;341:c4033. [25] Chamberlain G, Wraight A, Crowley P. Choice and satisfaction. In: Chamberlain G, Wraight A, Crowley P, editors. Home births: the report of the 1994 confidential enquiry by the National Birthday Trust. Carnforth; Parthenon; 1997, pp. 129–153. [26] Hall J. Attendance not compulsory. Nurs Times 1993;89(46):69–71. [27] Russell Bernard H. Research methods in anthropology qualitative and quantitative approaches. Altamira Press; 2006. [28] Hallgreen A, Kihlgren M, Forslin L, Norberg A. Swedish fathers’’ involvement in and experiences of childbirth preparation and childbirth. Midwifery 1999;15(1):6–15. [29] Kingdon C, Neilson J, Singleton V, Gyte G, Hart A, Gabbay M, et al. Choice and birth method: mixed-method study of caesarean delivery for maternal request. Br J Obst Gynaecol 2009;116(7):886–95. [30] Longworth H, Kingdon C. Fathers in the birth room: what are they expecting and experiencing? A phenomenological study. Midwifery 2010; doi:10.1016/ j.midw.2010.06.013. [31] David M, Aslan G, Siedentopf JP, Kentenich H. Ethnic Turkish fathers in birth support roles in a Berlin labour and delivery room–motives, preparation and incidence in a 10-year comparison. J Psychosom Obstet Gynecol 2009;30(1):5–10.
Contents lists available at ScienceDirect
Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
‘She can choose, as long as I’m happy with it’: A qualitative study of expectant fathers’ views of birth place Carol Bedwell a,⇑, Gillian Houghton b, Yana Richens c, Tina Lavender a a
The University of Manchester, School of Nursing, Midwifery & Social Work, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool, Merseyside L7 8SS, UK c University College Hospitals Foundation Trust, Institute of Women’s Health, 2nd Floor North, 250 Euston Road, London, NW1 2PG, UK b
a r t i c l e
i n f o
Article history: Received 9 September 2010 Revised 2 December 2010 Accepted 6 December 2010
Keywords: Fathers Birth place Qualitative Interviews
a b s t r a c t Objectives: A programme of research was undertaken to explore which factors contributed to decisions regarding birth place. As part of this programme, the views of male partners of pregnant women were examined to gain understanding of their contribution to the decision making process, with regard to different birth settings. Study design: A qualitative interpretive approach was utilised to explore, in-depth, the views of 19 expectant fathers, in the North West of England. Semi-structured interviews were conducted, audio recorded and transcribed, following consent. Data were analysed using a thematic approach. Findings: Four main themes were identified; Silent decisions, Powers of persuasion, Trust in a medical environment and Personal vulnerability. Conclusions: Choice regarding place of birth is multi-dimensional. Expectant fathers are likely to contribute to their partner’s decision making; their motivation can relate to their own beliefs and personal vulnerability as well the need to protect the women. The overwhelming trust in the medical environment dominates partner’s views regarding birth place. The lack of discussion regarding birth place, between partners and with health professionals, reinforces the notion that hospital birth is safest, thus strengthening the normalization of birth in this environment. Midwives need to engage with expectant fathers to ensure that their contributions to decisions around birth place are fully informed. Ó 2010 Elsevier B.V. All rights reserved.
Introduction Place of birth is a highly debated issue amongst health professionals world wide [1]. Rates of home birth vary across the globe, from 0.65% in the United States [2] to 70–80% in parts of Central Asia [3], influenced by a number of political, contextual and historical factors. In the United Kingdom the recommendation for 100% hospital birth, brought about by the Peel Report in 1970 [4], has been consistently challenged [5,6]. Yet, despite this, evidence provided by large population based studies [7–9] has failed to convince many health professionals of the relative safety of home birth. In the United States, for example, the American College of Obstetricians and Gynecology issued a position paper opposing home birth [10], thus reinforcing beliefs about the dangers of this setting. In the UK, there has been a growing emphasis on the need to enable women to make childbirth choices [11]; place of birth being a central tenet. However, although several birth settings are available to women, recent figures suggest that the majority continue ⇑ Corresponding author. Tel.: +44 (0) 161 306 7782; fax: +44 (0) 161 306 7707. E-mail address: [email protected] (C. Bedwell). 1877-5756/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.srhc.2010.12.001
to give birth in hospital [12]. The number of births taking place in NHS hospitals increased by 20,630 (3.3%) to 649,837 during 2007–2008 [12], with home birth rates ranging from 2.84% in England to 1.46% in Scotland and 3.73% in Wales 2007–2008 [13]. The mean home birth rate in the UK is 2.7% [14]. Factors thought to influence women’s birth place decisions include safety, avoidance of unnecessary medical interventions common in hospital births, previous negative hospital experiences, more control, and a comfortable and familiar environment [15]. The influence of partners has received little attention, despite the fact that, in most western societies, a partner is likely to be present at the birth. The partner has been shown to be influential in a number of pregnancy and childbirth areas, including antenatal screening [16], pain relief in labour [17] and method of infant feeding [18]. It is conceivable, therefore, that the partner may also be influential in choices regarding birth place. We conducted a programme of work to explore the views of key stakeholders in the decision making process [19]. As part of this programme we examined the views of male partners of pregnant women to gain understanding of their contribution to the decision making process regarding different birth settings.
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Methods
Analysis
A qualitative interpretive approach was adopted in this study, utilising in-depth interviews to explore research participants’ views of birth setting. This approach enabled the collection of rich data, enabling a deep exploration of issues important to the participant [20]. Ethical approval was sought and gained from the local research ethics committee (Ref: 05/Q1505/38) in the North West of England and Trust Research and Development department. All research governance requirements were met.
All interview data were transcribed verbatim, using pseudonyms to protect identity. Data were managed manually, with the aid of a word processor. Thematic analysis was conducted, utilising a cyclical yet systematic approach to ensure rigour [21]. This process, which drew on that described by Miles and Huberman [22], involved familiarisation with the data, de-contextualising or breaking down of the data, data display and recompilation. In the ‘familiarisation’ phase, the transcripts were read and re-read to achieve a general understanding of the individual and collective accounts. In the ‘de-contextualisation’ phase, a formative and iterative process was used to generate codes. These codes were then grouped into categories and displayed under headings, for ease of interpretation. Overarching themes were generated through the amalgamation of categories, after returning to the original transcripts to ensure that the ultimate messages being conveyed were truthful to the participants’ accounts. To ensure trustworthiness, two researchers (TL and CB) carried out simultaneous analysis; consensus was reached. Field notes and an audit trail were kept throughout the process to ensure transparency. Negative cases were identified. Verbatim quotes have been selected to represent the most frequently occurring themes.
Participants This study took place in the North West region of England, a large tertiary referral hospital, which supports more than 8000 births per annum. The hospital contains an obstetric unit, which supports women with medical or pregnancy complications, and those requesting epidurals. It also houses a midwife led unit, which caters for straightforward pregnancies and offers pharmacological and non pharmacological methods of pain relief, including pool births. Epidurals are not provided in this unit and, if a complication should arise, the woman is transferred to the obstetric unit. The community midwives in the unit offer a home birth service; the home birth rate at the time of the study was 1.8%. All partners of women participating in the larger study [19] were eligible to participate. At the point of contact, the couple’s birth place expectations were unknown to the researcher. Recruitment Expectant fathers were approached to participate when they attended the initial antenatal appointment with their partner (n = 37). Written information was provided, and expressions of interest were followed up by a telephone call from the research midwife. For those wishing to participate, an appointment was made for interview, at a time and location convenient to the expectant father. Written consent was obtained from all participants. Data collection Base line details were recorded from all participants using a brief, baseline questionnaire. Interviews took place in the 34th week of the woman’s pregnancy. This was an important time point as the main birth place decision was made around this time. Furthermore, it enabled participants to reflect on the pregnancy experience and recall any influencing factors related to birth place. Semi-structured, in-depth Interviews were conducted using a broad topic guide that had been piloted in advance (see Fig. 1 for examples of interview questions). The guide prompted questions regarding general views of birth place and personal decision making. In order to allow privacy to disclose their views, all the participants were interviewed without their partner being present. The majority of interviews took place in the home (n = 13) with others taking place in the hospital (n = 5) or workplace (n = 1). Interviews were audio recorded.
Example of questions used in interview Where is your partner planning on giving birth? Which factors influenced the decision on birthplace? What other choices are available for place of birth in this area? What previous experience have you had of birth? Have you spoken to anyone about placesto give birth? What did they say? Fig. 1. Example of Interview Questions.
Findings Thirty seven partners agreed to participate, of which 19 were interviewed. The sample size was dictated by the availability of partners for interview and the study duration. Nevertheless, data saturation was reached; therefore the need to sample more would not have been appropriate. Previous studies have demonstrated that data saturation is likely to be reached with 12 interviews, with main themes emerging after 6 interviews [23]. Interviews lasted between 35 min and 70 min. Table 1 displays the baseline details for all participants. As can be seen, the majority of men declared themselves as White British. Participants were employed in a range of occupations and had various qualifications. The median age of participants was 34 years (range 21–52). All participants were living with their partner at the time of interview. Three participants were already fathers; all had experienced the birth of their baby in a hospital setting. All of the participants were planning a hospital birth. This was confirmed by their partners. Although the participants were made aware of the different birth settings (obstetric unit, midwife led unit and home birth), they did not differentiate between the two hospital areas; their main focus was on hospital versus home birth. Four main themes were identified, Silent decisions, Powers of persuasion, Trust in a medical environment and Personal vulnerability. Although presented separately, these themes are not mutually exclusive, each having a relationship with the others. Silent decisions With regard to choice of birthplace it became clear that there was little or no discussion between couples when making a choice of place of birth. When approached about participating in the study, it was interesting to note that couples appeared (from their body language and facial expressions) to be puzzled about the need for such questioning (field notes). There was a general assumption that birth would take place in the hospital setting and expectant fathers all indicated that they were very happy to go along with this. ‘‘We hadn’t even discussed it, we just assumed you know, you go to hospital to have a baby, and that’s that’’. [Sid]
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C. Bedwell et al. / Sexual & Reproductive Healthcare 2 (2011) 71–75 Table 1 Participant profiles. Participant (pseudonym)
Age
Ethnicity
Occupation
Marital Status
Previous birth
Highest qualification
Mike Jay Tom Mark Sid Kevin Billy Frank George Bob Paul Peter Luke John James Dean Matthews Chris David Alex
35 36 37 28 Missing 31 37 34 33 32 32 52 37 34 33 43 32 40 32 21
White White White White White White White White White White White White White White White White Indian White White White
IT system developer Electrician Solicitor Sales Production operator Printer BT engineer Builder Civil servant Sales Landscape designer Retail Lecturer Sales IT Sales Medical doctor Lecturer Minister of Religion None
Married Married Married Married Married Separated Living with Married Married Married Living with Married Married Married Married Living with Married Married Married Living with
None None None None None None None One None None None One None None None None None None One None
Degree HNC Degree, Postgraduate diploma Degree GCSE, NVQ GCSE Technical college exams GCSE A levels Degree Degree, Postgraduate diploma A levels Postgraduate degree Degree Degree HNC Postgraduate degree Postgraduate degree Postgraduate degree GCSE
Hospital birth was seen as the ‘norm’ and partners expressed an opinion that suggested that to disrupt the ‘status quo’ was unjustified. Comments such as ‘we just assumed’ and it was an ‘automatic decision’ were common: ‘It wasn’t really discussed. . .it was just, you know. . .it was always gonna be the hospital’ [Kevin] Those who had given some thought to a home birth had quickly dismissed the idea as being alien to them. Frank, for example, rejected the idea saying: ‘It was like an automatic decision to go to exactly the same place and have it in exactly the same way as last time. . .[we are] not really adventurous, you know [laughs]’ Similarly, George stated: ‘I know that some people would prefer a home birth. . .I think some people have a few sort of slightly way out ideas on how and where to give birth’ The emphasis on the words ‘way out’, highlight George’s belief that home birth was not considered mainstream.
partner
partner
partner
partner
although they stated that their partner should have the ‘final say’, they were open about the persuasive words that they would use if the decision opposed their own. Even when partners said that they would support women who requested a home birth, the extent of that support was questionable. ‘‘I don’t think I’d pressurise her if she really said ‘‘I want this baby at home’’ I wouldn’t say no, no that’s it but I would I would say like have a think about it a. . .you know I would prefer you to be in the hospital. . .That’s what I’d say. It might cause problems. . .you know if anything happened. . .I would probably give her loads of grief but. . .if she’d have said this time I want a home birth I’d have said well look everything went smoothly at the hospital lets do it again, but if she was adamant, yeah I’d support her. But if it was my choice it’d be there (hospital)’’. [Jay] Unlike hospital birth, some women would have to strongly justify any desire for a home birth. Furthermore, they would have to make the decision in the knowledge that there may be repercussions, in the form of blame, if they chose a home birth and something went wrong.
Powers of persuasion Although decisions regarding hospital birth were accepted without discussion, when asked about birthplaces other than hospital, expectant fathers indicated that they would want some sort of discussion before reaching a decision: ‘well it would be her choice at the end of the day. I’d let her know that I would want. . .prefer the birth to be at the hospital but it’s a team decision in this household so if she felt strongly about it then so long as I could be convinced that there’s the support and the facilities and that it was quite a natural thing to do then I know it’s right I’d let her make the choice [John] John went on to say: ‘I think I’m reasonable so if she gave a good reason why, and the midwives and the doctors said you know look its perfectly safe and don’t worry about it. . .then it would be her decision ultimately; cos she’s the one who is gonna do the hard part’. As the quote illustrates, many of the men interviewed acknowledged that their partner was the primary focus and therefore had a slightly better bargaining position in any decision making. Yet,
Trust in a medical environment Overwhelmingly participants perceived hospital to be the safest place for birth. The desire for their baby to be born in hospital was motivated by the need to protect their partner from harm. Men undoubtedly viewed their partners as their main priority: ‘Well as long as she survives the whole experience, the baby comes second. . .the mother comes first’ [Dean] Expectant fathers clearly dichotomised the two birth environments; hospital birth as safe and home birth as a risk. Their desire to protect their partner meant that home birth was dismissed as an option. ‘‘I mean I didn’t want to push her into any decision anyway but I felt that she’d be more safe and she’d feel safer being at a medical site. . .homebirth wasn’t an option’’. [Paul] Paul then continued by saying: ‘It may sound brutal and mercenary but as far as I’m concerned, my wife comes first and the child second. . .it sounds very mer-
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cenary saying it, I love my wife and we can always have another, attempt a another child, however I don’t have a second wife’. Men also felt that hospital offered a safe environment to them personally. For example, one partner said: ‘‘It’s just the way I feel I just want a bit of safety and need to be in hospital’’ [Kevin] Their views were also influenced by their perception of health professional roles. Luke, for example, said that he would want the birth to be in hospital because ‘I like the idea of being where the experts are’. Midwives were therefore not necessarily seen as the expert. Similarly Bob said: Subconsciously, I’m not really for having the birth at home for numerous reasons. One cos if there were any complications. . .uhm. . .I don’t want to have to wait for an ambulance. . .I need to know that the professionals are there. . .and if anything really went wrong I don’t think I’d want to have the memories in the house Although expectant fathers acknowledged the importance of the midwife, this tended to be in the context of a supportive role. Medical doctors where considered an important part of the birth event, and this provided men with the additional rationale for wanting a hospital birth: [A doctor] is specifically trained in all the finer details of childbirth. . .but even so it still requires the help of a midwife who’s good at the basic level. . .if there were problems and the doctor didn’t turn up then I would be upset about it [Matthews] Interestingly, views were similar, regardless of whether or not the expectant father had been present at a previous birth. However all of their previous births had been conducted in the hospital. Personal vulnerability Many men had concerns about their ability to cope when their partner was in labour; they viewed the hospital and staff as a means of protection. ‘Well I knew that if I, if I flipped and went ‘I can’t cope with it any more’ then walking out the house and leaving her to it is completely different to going ‘‘I’m sorry I’ve just got to leave the room for a minute’’ cos there’s a doctor and midwife thereat least I know that I wouldn’t be leaving her in the lurch if I couldn’t actually handle things.’ [Mike] Many of the partners’ views highlighted their own feelings of vulnerability. They constantly referenced themselves when asked about the birth place decision. Kevin said ‘I feel safer in hospital.’ Similarly, Jay said: ‘‘it’s just the way I feel. . .I just want a bit of safety and need to be in hospital’’ Expectant father’s views of birth environment were influenced by their views of labour and birth. Kevin, for example, said that he would not want a home birth because labour was ‘nerve wrackin[g] enough.’ Those who had already been present at a birth (n = 3), demonstrated their vulnerability when they drew on their previous experiences. For example, David said: ‘Last time the baby’s heart rate dropped suddenly. . .If I’d been at home I would have really panicked. . .Everyone stayed really calm which was reassuring’ Such examples were used to reinforce their decision to give birth in the hospital.
Discussion The study findings demonstrated a naivety amongst male partners regarding birth place. Their unanimous opinion that hospital birth was ‘safer’ being influenced by multiple sources. It is perhaps not surprising that they held these views, especially as nationally home birth rates are low [13], and at the study hospital they were even lower. Furthermore, only one partner had personally known of anyone who gave birth at home, and despite the outcome being positive, he considered this to be unusual. Moreover, this is a fiercely debated area amongst health professionals [10,24]; those with negative views of home birth have the potential to influence the views of expectant couples [19]. Given that informed choice of birth place is considered integral to maternity care [11], and communication between partners is seen as a pivotal aspect of this, it was surprising to discover that decisions appeared to be made subliminally. Views were never challenged during the pregnancy, confounding the belief that the ‘silent decision’ made was the correct one. There was no evidence of any objective decision making; no facts were ever mentioned and there was no attempt to draw on any type of evidence. This is perhaps surprising given that stereotypically, men are thought to be less subjective than women. When explicitly questioned about home birth, most expectant fathers appeared almost relieved that it was not a major part of their childbirth discussions. When prompted to reflect on how they would react if their partner wished a home birth, their strategy was almost always to use some form of verbal persuasion. Their transcripts demonstrated a technique of expressing a desire to listen to their partner’s wishes, whilst ensuring that their own feelings were given equal, if not more, precedence. Whilst father engagement has been promoted within maternity care and partnership decisions have been encouraged, the dynamics of shared decision making has received relatively little attention. Women, in our larger study [19], reported similar views to the men. It may be that our results reflect a social desirability of reporting joint decision making; the actual decision was likely to be the result of a complex interplay of external and internal factors. Exploration of these factors warrants longitudinal collection of data from multiple sources. The expectant fathers in our study demonstrated that if their partner had have wanted a home birth, she would have to do it in the knowledge that the father disapproved and that she would possibly be blamed if a favourable outcome was not achieved. This finding resonates with the earlier work of Chamberlain et al. [25] who concluded that ‘women planning home birth did so in the face of a certain amount of perceived discouragement’ (p. 132). The fathers suggested that the main reason for wanting a hospital birth was to protect their partner. However, this patriarchal standpoint was somewhat undermined by expressions of their own vulnerability. It may be that they used the idea of protecting their partner, as a means of hiding their own feelings of uncertainty. As Hall [26] notes, ‘a man can help to empower a woman, but can also have a negative effect if he is unable to deal with his own feelings’. Being interviewed by female researchers may have influenced these responses; a factor identified in previous research [27]. It is unclear whether the fact that the interviewers were also midwives had any influence on participants’ responses. The lack of preparation for men accompanying their partners in labour [28] may be a further reason for the views stated, although this information was not obtained in the current study. Unlike studies that have demonstrated that pregnant women prioritised their babies’ protection [29], fathers showed little evidence of this. It may be, as suggested by Longworth and Kingdon [30], that fathers felt disembodied from the pregnancy; attachment to the baby only occurring when visible outside the womb.
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Although our study findings describe the views of a relatively small sample, in one part of England, the in-depth material generated offers important insight into expectant fathers’ views. Individual interviews enabled comprehensive exploration of views yielding a significant amount of useful data which not only highlights the views of men towards birth place, but also gives insight into the potential difficulties faced by women who may desire a home birth. This study should be replicated in other settings, where the home birth rate is higher, to ascertain the impact of this on fathers views. Furthermore, our study was limited by the participants who agreed to be interviewed. All the men were English speaking. The study does not, therefore, represent the cultural diversity of expectant fathers who accompany their partners in labour. This is particularly important given that recent research suggests that men from different cultures wish to take a more active role in supporting partners during the birth journey [31]. In addition, younger participants were underrepresented with the mean age of participants being 34. Our findings suggest that there is a need to rethink the current information provision about birth setting. Unbiased Information should be supplied to couples, by health professionals, early in pregnancy. Communication around birth setting should be an ongoing process throughout the pregnancy, thus enabling decisions to change as appropriate. Health professionals should engage with the media to ensure that a balanced view of home birth is presented, to counteract the sensationalism which often accompanies reported birth stories.
Conclusion Expectant fathers, in our study, did not perceive home birth to be a reasonable option for their partners. Hospital birth was considered the norm; views were motivated by personal vulnerability as well the need to protect their partner. The overwhelming trust in the medical environment dominated partner’s views regarding birth place; perceptions of the ‘expert’ contributed to these views. The lack of discussion regarding birth place, between partners and with health professionals reinforced the notion that hospital birth is safest, thus strengthening the normalization of birth in this environment. Midwives need to engage with expectant fathers to ensure that their contributions to decisions around birth place are fully informed. Acknowledgements This study was funded by the Liverpool Women’s NHS Foundation Trust. The authors wish to thank all the expectant fathers who gave up their valuable time to contribute to this study. References [1] Young G, Hey E, Macfarlane A, McCandlish R, Campbell R, Chamberlain G. Choosing between home and hospital delivery. BMJ 2000;320:798. [2] Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al. Births final data for 2005 vital statistics report. Available from: http:// www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf; 2007 [accessed 18.08.10].
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[3] Blua A. ‘‘South/Central Asia: women dying in childbirth at high rate’’. Radio free Europe. Available from: http://www.rferl.org/content/article/ 1057692.html; 2005 [accessed 19.08.10]. [4] Department of health and Social Security (Welsh Office). Domiciliary midwifery and maternity beds needs report of the sub committee (peel report). London: HMSO; 1970. [5] Tew M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985;35:390–4. [6] Shaw R, Kitzinger C. Calls to a home birth helpline: empowerment in childbirth. Soc Sci Med 2005;61:2374–83. [7] Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Br Med J 1996;313:1313–8. [8] Johnson CK, Davis BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416. [9] Janssen PA, Saxell L, Klein MC, Robert M, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009;181:6–7. [10] Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203. Available from: http://www.ajog.org/article/S00029378(10)00671-X/references. [11] Department of Health. Maternity matters: choice, access and continuity of care in a safe service. London: Department of Health; 2007. [12] National Health Service Maternity Statistics. Available from: http:// www.ic.nhs.uk/statistics-and-data-collections/hospital-care/maternity/nhsmaternity-statistics-england:-2007-08; 2009. [13] BirthChoiceUK. Available from: http://www.birthchoiceuk.com/; 2009 [accessed 19.08.10]. [14] Dodwell M, Gibson R. An investigation into the choice of place of birth. NCT; 2009. [15] Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health 2009;54(2):119–26. [16] Locock L, Alexander J. ‘Just a bystander’? Men’s place in the process of fetal screening and diagnosis. Soc Sci Med 2006;62:1349–59. [17] Capogna G, Camorcia M, Stirparo S. Expectant fathers’ experience during labor with or without epidural Analgesia. Int J Obstet Anesth 2007;16:110–5. [18] Earle S. Why some women do not breastfeed: formula feeding and fathers’ role. Midwifery 2000;16,323–330. Available From: http://oro.open.ac.uk/ 2796/1/WSIF_-_2002.pdf. [19] Houghton G, Bedwell C, Forsey M, Baker L, Lavender T. Factors influencing choice in birthplace. An exploration of the views of women, their partners and professionals. Evid Based Midwifery 2008;6(2):59–64. [20] Crotty M. The foundations of social research. Meaning and perspective in the research process. London: Sage Publications; 2003. [21] Carter B. How do you analyse qualitative data? In: Lavender T, Edwards G, Alfirevic Z, editors. Demystifying qualitative research in pregnancy and childbirth. Wiltshire, UK: MA Healthcare Ltd.; 2004. p. 87–108. [22] Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2nd Ed. Sage Publications, Inc.; 1994. [23] Guest G, Bunce A, Johnson L. How many interviews are enough? Field Methods 2006;18(1):59–82. [24] Gyte G, Dodwell N, Newburn M, Sandall J, McFarlane A, Bweley S. Findings of meta-analysis cannot be relied on. BMJ 2010;341:c4033. [25] Chamberlain G, Wraight A, Crowley P. Choice and satisfaction. In: Chamberlain G, Wraight A, Crowley P, editors. Home births: the report of the 1994 confidential enquiry by the National Birthday Trust. Carnforth; Parthenon; 1997, pp. 129–153. [26] Hall J. Attendance not compulsory. Nurs Times 1993;89(46):69–71. [27] Russell Bernard H. Research methods in anthropology qualitative and quantitative approaches. Altamira Press; 2006. [28] Hallgreen A, Kihlgren M, Forslin L, Norberg A. Swedish fathers’’ involvement in and experiences of childbirth preparation and childbirth. Midwifery 1999;15(1):6–15. [29] Kingdon C, Neilson J, Singleton V, Gyte G, Hart A, Gabbay M, et al. Choice and birth method: mixed-method study of caesarean delivery for maternal request. Br J Obst Gynaecol 2009;116(7):886–95. [30] Longworth H, Kingdon C. Fathers in the birth room: what are they expecting and experiencing? A phenomenological study. Midwifery 2010; doi:10.1016/ j.midw.2010.06.013. [31] David M, Aslan G, Siedentopf JP, Kentenich H. Ethnic Turkish fathers in birth support roles in a Berlin labour and delivery room–motives, preparation and incidence in a 10-year comparison. J Psychosom Obstet Gynecol 2009;30(1):5–10.