Risk perception and choice of place of birth in women with high risk pregnancies: A qualitative study

Abstract

Objective To examine the perception of risk among a group of women with high risk pregnancies who were either planning to give birth in hospital, or at home despite medical advice to the contrary. The intention was to consider differences and similarities between the groups to examine how perception of risk relates to choice of place of birth.

Design Qualitative study using semi-structured interviews. Setting Maternity department in a hospital in South East England.

Participants Twenty-six women with high risk pregnancies, at least 32 weeks pregnant. Half were planning hospital births and half homebirths.

Measurements and findings Semi-structured interviews to investigate women's understanding and assessment of risk. Results were analysed using thematic analysis. Five themes emerged: understanding of situation; judgement of risk; reassuring factors; impact of risk; and coping with risk. Women from both groups had some understanding of the implications of their medical/obstetric conditions. They displayed concerns about their babies' wellbeing. Women planning homebirths assessed their risks as lower and expressed less concerns than women planning hospital births. Women planning hospital births more frequently described following professional advice.

Key conclusions Risk perception is individual and subjective. Women with high risk pregnancies who plan to give birth at home perceive risk differently to women who plan hospital births.

Implications for practice Healthcare professionals working with women with high risk pregnancies should be aware of the potential for differences in definitions and perceptions of risk within this group.

Introduction

The determination of risk in pregnancy is a complex process influenced by social and cultural factors (Chadwick and Foster, 2014). These include family histories, childhood experiences, nationality, and experiences of healthcare, and combine over time to establish an assessment of risk (Coxon et al., 2014). Women whose pregnancies are deemed medically as high-risk pregnancies will also make assessments regarding how at risk they feel. How women with high-risk pregnancies perceive the risks they face affects their decisions during pregnancy and labour, and the extent to which they follow advice from healthcare professionals (Bayrampour et al., 2012). Professionals caring for these women in contemporary Western society do so against a cultural background of increasing focus on the assessment and management of risk (Kringeland and Moller, 2006). Pregnant women's perception of risk is, therefore, of interest to the professionals involved in their care.

Evidence shows pregnant women and healthcare professionals do not define or assess risk in the same way. A recent systematic review (ref removed for blind review) found little association between the perception of risk by women and by healthcare professionals. It also found that women with high-risk pregnancies do not rate their risks highly; on average just below the midpoint of linear scales. This work is supported by a metasynthesis of qualitative studies (ref removed for blind review) which showed women with high-risk pregnancies are committed to the wellbeing of their babies and will take whatever steps they believe will achieve this. However this may not involve following all recommended medical advice.

Where to give birth is a key decision for pregnant women. While homebirth is considered medically safe for women with low-risk pregnancies (de Jonge et al., 2009), some women with more complicated pregnancies will also choose homebirths, often going against medical advice to do so. Reasons given by women for choosing homebirths against medical advice include the beliefs that hospital is not safer than home and that higher medical intervention rates in hospitals can increase childbirth risks (Jackson et al., 2012). Healthcare professionals are likely therefore to provide care for women whose decisions reflect perceptions of risk different from their own.

Obstetricians have reported difficulties when communicating with women with high-risk pregnancies (Pozzo et al., 2010). If women are reluctant to comply with medical advice, obstetricians may also be reluctant to discuss women's choices due to the fear of appearing to condone their decisions (Ecker and Minkoff, 2011). Healthcare consultations in Western society also usually occur against a cultural background which typically regards professional interpretations of knowledge as more reliable and objective than lay perspectives (Browner and Press, 1996). An increased understanding of how women with high-risk pregnancies perceive risk can, therefore, potentially improve communication with this group and facilitate understanding of their decision making.

The aim of this study was to investigate the perception of risk among a group of women with high-risk pregnancies. Half the women were planning to give birth in hospital and half were planning to give birth at home, despite medical advice to the contrary. The intention was to consider differences and similarities between the groups to examine how the perception of risk relates to the choice of place of birth.