Using Real-Time Simulation to Improve the Dialogue when Discussing Women’s Options for Place of Birth

CLAHRC WM Theme 1, Maternity and Child Health, has been involved in carrying out some simulation training with midwives as part of their ‘place of birth’ study. This study has explored midwives’ views of their discussions with women about their options for where to give birth and followed on from the 2011 Birthplace study,[1] which found that for low risk, multiparous women, there was no significant difference in composite perinatal outcomes between women who gave birth in obstetric units, in maternity led units, or at home. Despite this, many women are not offered the full range of birth place options by their midwife and are often unaware that they have a choice about where they can choose to give birth, instead viewing hospital as the ‘default’ option.[2] The ‘place of birth’ study aimed to help promote choice of place of birth in midwives’ discussions with women. This involved a co-production approach, with midwives being involved in the study process and design. Findings from the literature, focus groups with midwives and a preliminary midwifery workshop resulted in identification of the need for a pragmatic, standardised ‘place of birth’ dialogue, that midwives could use as a tool for use in their discussions with women about where to give birth. A provisional draft of this dialogue was put together by midwives working at BWNFT (with input and guidance from the CLAHRC team) and covered aspects relating to the safety and practicalities of giving birth at home, in the Birth Centre and in Delivery Suite. It aimed to use appropriate language and openers so that women would consider all three of the birth place options available to them.

We decided to use role players in a second midwifery and PPI workshop to simulate the interactions between a midwife and a woman when using the dialogue. This was to explore how well the dialogue worked in ‘real’ practice and whether it sounded right or needed amending. At the workshop, two female role players acted out the dialogue (one playing a midwife and one a pregnant woman) and workshop attendees had the opportunity to modify the dialogue based on what sounded and felt right and what didn’t, until a finalised dialogue for multiparous women was agreed on. This process was repeated again, but for nulliparous women, resulting in the formation of two slightly different dialogues, due to differences in safety and risk meaning that slightly different information needed to be conveyed.

The role playing and subsequent discussions were audio recorded to allow any changes to the dialogue which were agreed on to be saved and transcribed. This ensured that a precise final dialogue could be written up by the CLAHRC team, which accurately detailed what was agreed on by the midwives and PPI during the workshop session. This finalised dialogue is intended as a prompt and a supportive tool to convey the sort of information midwives should be giving to women when talking to them about their place of birth options, rather than a script which midwives have to rigidly stick to. However, the final dialogue should convey a true reflection of what works in practice, to provide a useful resource to midwives when thinking about how to approach these discussions.

The role playing was very well received by the midwives and PPI representatives and encouraged interaction, discussion and debate as to the best way to approach place of birth discussions with women. Having the role players present at the workshop meant that any suggested changes to the dialogue could be incorporated and re-enacted by the role players, until a version of the dialogue emerged that had been developed and refined by the midwives who will be using the dialogue in their everyday practice.

The CLAHRC team are continuing to work with midwives at BWNFT to think about the best ways of successfully implementing the place of birth dialogue into midwives everyday practice. We have utilised the COM-B framework [3] to identify a variety of behaviour change techniques that might be useful mechanisms to help embed the dialogue in the short and longer term. We are currently finalising a protocol to support the implementation of the place of birth dialogue in clinical practice and to evaluate how successful it has been in changing the way that midwives talk to women about their options for where to give birth.

— Catherine Shneerson, Research Fellow, CLAHRC WM Theme 1


  1. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011; 343: d7400
  2. Coxon K, Sandall J, Fulop N J. To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisionsHealth, Risk & Society. 2014; 16(1): 52-67.
  3. Michie S, van Stralen M, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventionsImplement Sci. 2011; 6: 42.

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