The effect of a birthplace decision support tool on women’s decision-making and information gathering behaviours during pregnancy: mybirthplace study protocol

Background

The Government’s ambition for the National Health Service (NHS) to achieve world-leading health outcomes1 relies on a strategy of shared decision-making (SDM) and patient-led decisions.2 The white paper promotes the philosophy of ‘no choice about me without me’ and stresses the need for SDM.3^,4

SDM has been defined as a ‘Two way process of information giving between the clinician and patient, whereby the final decision is made jointly’.1

A prerequisite is information sharing, which is positively associated with adherence to treatment and care.5

The National Maternity Review highlighted the need for greater access to unbiased information with the aim of supporting inclusive decision-making about care.1 Most women still give birth in hospital,6 but the National Childbirth Trust7 found that 49% of women were dissatisfied with the information they received about birthplace. New ways of providing women with information to support choice are needed.

Existing Interventions

One way is through use of decision support tools (DSTs).8 DSTs have a long history of use within health, for example, cancer treatment;9 however, their use in midwifery care has been limited to only a few clinical scenarios that include mode of birth following a caesarean section,10^–14 antenatal screening for fetal anomaly15 and delivery options for breech birth.16 Research shows that these DSTs are effective in reducing the decisional conflict that women have when it comes to making a choice.14^,17 Although tools exist to support choice with regard to birthplace, for example, WHICH website,18 no studies have reported the effectiveness of these tools.

THE INTERVENTION – THE MYBIRTHPLACE APP

MyBirthplace19 is a DST created to support women’s choice regarding place of birth.

The app, which is publicly owned and copyrighted to the Hospital that created it, offers information about the different local birthplace options available to pregnant women. All underpinning data are based on local statistics and information derived from the Birthplace in England national prospective cohort study.20 The application programming interface (API) is open but licensed and is available via the internet https://mybirthplace.org/portsmouth/21^,22 with an option to download to a smart device. No personal information is taken or used in the app and therefore poses no security risks.

MyBirthplace is provided to women at the initial appointment with their midwife, but can be accessed throughout pregnancy. A clear preference for place of birth is required by the hospital at 36 weeks’ gestation.23

This paper describes a protocol for a study to evaluate the effectiveness of the app.

Recruitment protocol

Women willing to participate will return the opt-in slip, allowing the researcher to contact them. Women will meet the researcher prior to their first midwifery appointments and written consent obtained. Participants will be advised that they can withdraw from the study without their care being affected.

Following consent, women will complete the first questionnaire and attend the appointment. A second questionnaire will be completed post-appointment.

Consent for the 28-week survey will be gained at this time and women will choose either a paper survey or an online survey.

Questionnaires, delivered in paper or online format, were created by the research team to meet the specific needs of the study. The questionnaires are free to use and the author may be contacted for use in the future.

For the qualitative interviews at 36 weeks of pregnancy, women will be purposively chosen from participants who accessed the DST. Purposive sampling selects participants who have experienced the phenomenon of the study,27 in this case, exposure to the DST. Interviews will be conducted with at least 10 women to provide a rounded selection of opinions on the phenomenon being studied.

Study procedures

The questionnaires went through a four-stage validation procedure, involving verification by

• the supervisory team;

• an independent public engagement officer who specialises in ensuring questions are accessible to the public and easily understood in terms of language and layout;

• peers for face validity and to iron out any issues;

• a small group of antenatal women.

Measures

SDMS

The primary outcome measure is the SDMS.28 This determines an individual’s willingness and ability to engage in decision-making, how they progress into making a decision, and how receptive they are in considering/reconsidering their options.29 This is especially significant when considering how decision-making changes when the individual has access to a DST.30 Figure 1 shows the SDMS.

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Figure 1

The SDMS is the only decision-making tool with the ability to assess women’s decision-making at various points and allow for changes. This is important in pregnancy as there are many changes in health and wellbeing of mother and baby. SDMS data will provide a clear understanding of how participants feel about the decision at each stage of the study.

Data collection

Data collection for the study is depicted in the flow diagram (Figure 2)

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Figure 2

Data management and analysis

Data management and analysis will follow a pre-set analysis plan. Data collated from phases 1 and 2 will be analysed via the statistical package for the social sciences. Descriptive analysis will be used to produce measures of central tendency for ordinal, interval and ratio data.33 Non-parametric tests will be used to show relationships between the key variables using chi-square test.33^,34

Thematic analysis will be utilised to analyse the face-to-face interviews. This was chosen due to its ability to get close to the data, while staying flexible.35

Discussion

Evidence exists on choice of place of birth,20 including factors that impact on a woman’s choice36^,37 and midwives’ influence on choice.38 Despite this, women feel they lack information to make an informed choice;39 MyBirthplace was designed to improve women’s decision-making about place of birth. The study will contribute to knowledge and understanding of the effectiveness of MyBirthplace and will identify whether the use of the tool is justified within the shared discussion, recommending it for use to support other pregnant women in other localities. The study will begin to address the possibility of moving from NHS delivering information in traditional formats to digital information delivery.

The research outlined in this protocol aims to provide explicit, quantitative expressions of women’s valuations and qualitative experience of the MyBirthplace DST and its use within pregnancy. Our protocol provides a template for other researchers interested in assessing DSTs specifically related to choice of birthplace. This study is timely and is the first study of its kind, no other study has looked at a birthplace DST and therefore it will be an original contribution to the field.

The app has been developed at a time where women are becoming more information savvy and the use of online resources is increasing. Digital services are more widely available, including access to medical records, as more is done to make online services accessible to patients40 research is need to assess their effectiveness.