The women in this study went into their labour and birth experience expecting, or hoping for, a particular kind of birth and commonly this meant a “natural” birth. A small number of women had very strong feelings about their “ideal” birth. This included Katelyn (F), who described her experience as “a tractor through your wedding day” and contrasted it with her first birth which was as an “amazing experience” that “went exactly according to plan”. Most had less clear ideals and a few described themselves as “open” to or “expecting” intervention. Some had thought about transfer, but most just did not think that transfer would happen to them and looking back described themselves as “blasé” or “naïve”. Women’s expectations, their experience of labour and their perceptions of the way in which they were cared for, affected how women experienced transfer and how far it was perceived as a catastrophic event as in Katelyn’s case or as something that could be worked through and accepted.
Women were generally positive about their experience of care in the midwifery unit before transfer and described feeling supported by midwives who understood their needs. Most talked about feeling disappointed when the decision to transfer was made; disappointment was commonly about the loss of their anticipated “ideal” birth, while some also talked of a sense of personal loss or disappointment in themselves. Despite this disappointment, most were able to adjust to their changing circumstances and accept the need for transfer. Some ascribed this acceptance to the trusting relationship that had been built up with their midwives or the degree to which their midwives had prepared them for the idea that transfer might be needed. In contrast, a small number of women described a negative or deteriorating experience of their care in the midwifery unit, often, but not always, in the context of prolonged labour. They described feeling anxious, frightened, not in control and not safe, often perceived that they were transferred too late and were relieved to be transferred.
While a few women talked about the transfer journey in positive terms, women’s accounts commonly revealed the transfer journey as a period of ‘watchful waiting’ or ‘anxious anticipation’, a “limbo” period during which women wondered, worried or were fearful about what was to come and could be passive participants in a process which felt more like being “transported” than being cared for. This was a contrast with the care many had experienced in the midwifery unit. For women whose care was necessarily ‘fractured’ by transfer the best possible continuity was ensured by the same midwife continuing to care for the woman after transfer. Failing this, being met by hospital staff who appeared to care and a thorough handover of care in the presence of the woman maximised continuity of care. Finally, women expressed a clear need to understand and make sense of their experience and most appreciated or would have liked the opportunity to talk about their experience afterwards with a midwife or doctor.
The results of this study are consistent with other evidence from maternity care research. Women commonly described being given some information about transfer, knowing that transfer was a theoretical possibility, but at the same time not wanting to think about it or thinking that it would not happen to them. Qualitative research on women’s experience of operative delivery has revealed similar comments from women, for example, “I didn’t even read the chapter [on caesarean], it just wasn’t going to happen”
. The authors of this study suggested that this was indicative of a gap in antenatal education and information
 and others have argued that antenatal care and education may not adequately prepare women for complications arising during labour
[28, 29]. In the study reported here, some women described the information they were given about transfer as vague or imprecise, so there may be room for improvement in terms of women’s preparation for transfer during pregnancy. However, it seems likely that women find it difficult to take in information about potential risks and complications during pregnancy. The authors of a meta-synthesis of research on women’s decision-making processes in relation to antenatal screening for Down’s syndrome describe women as “wishing to know and not wishing to know” about risks and possible outcomes, which has some resonance with the accounts of women interviewed for this study
If women find it difficult to think about transfer during pregnancy, the support and preparation for transfer they receive during labour is likely to be even more important. A recent review of the literature on women’s experience of childbirth found that relationship with the caregiver, support and control were key themes emerging from the large body of research in this area
. While these are important factors in women’s perceptions of positive or negative experiences of care
, they may be particularly important for women whose care is potentially fragmented through transfer. In this study, some women talked positively about being “prepared” for the need for transfer by their midwife and this appeared to help them adjust to their changing circumstances. Particularly negative experiences of care occurred often, but not always, in the context of prolonged labour and severe pain. Studies of women’s experience of prolonged and complicated labour have reported similar findings
[33–36]. This suggests that the care of women with prolonged labour in midwifery units may need particular attention, with sensitive consideration by the midwife of when is the optimum time to transfer.
Other studies of women’s experience of transfer have not explicitly explored women’s experience of the ambulance or car journey from one birth setting to another
[15–20]. Research on the journey from home to hospital in early labour for women in rural settings has also been carried out, but gives only limited insight into the experience of women who transfer, usually in established labour, from their planned birth setting to hospital
[37, 38]. While women’s experience is an explicit focus of midwifery care, women’s accounts suggest that during an ambulance journey, their experience was no longer an important focus; women felt less ‘cared for’ and more like being ‘transported’ at this time. The transfer journey is therefore an important and neglected area, where there is the potential to improve women’s experience. In this context it may be helpful to think of the ambulance as a ‘liminal space’, described by Horvath et al. as “in-between situations and conditions… characterized by the dislocation of established structures, the reversal of hierarchies, and uncertainty regarding the continuity of tradition and future outcomes”
. Women being transferred by ambulance are in effect in limbo between hospitals and between midwives; between natural birth and a more medicalised approach; potentially separated from their birth partner; and uncertain of the outcome. As anthropologist Victor Turner puts it, they are “neither here nor there; they are betwixt and between”
. Having choices, being supported by a husband or birth partner and being appropriately dressed or covered helped women feel cared for rather than transported and meant that the journey could be less distressing, but these choices were not always available to women. While the transfer journey could have been an opportunity for midwives to talk to women about their care and give them information about what to expect in the hospital obstetric unit, there was little evidence from women’s accounts of midwives using it in this way, leaving women with unanswered questions and concerns.
It is likely that the change in environment experienced and described by women during an ambulance transfer might also have an impact on midwives’ capacity to continue to provide high quality individualised care. However, there seems little rationale for the apparent variation in NHS policy on how many and which people are permitted to accompany a woman in an ambulance. The transfer journey is one area where some apparently straightforward changes to practice could make an important difference to women’s experience. Similarly, arrangements need to be in place so that midwives are not dependent on the returning ambulance for transport back to the midwifery unit and therefore have sufficient time to devote to a thorough handover of care.
Responsibility for the care of women who have been transferred should not end with the handover of care to hospital staff or when the woman is discharged home. Adjusting to a labour and birth experience that has not gone as expected is a process that extends into the postnatal period and beyond, even for women whose experience was not an overwhelmingly traumatic one. Women who have experienced transfer appreciate the opportunity to talk about their experience in order to understand and make sense of what happened and to help them plan for future pregnancies, but will not necessarily seek this out if it is not offered.
The most significant difference between the transfer experiences of women planning birth in the two types of midwifery unit was the transfer journey. This was a more important consideration for women transferred from freestanding units, although the brief comments of some women transferred from alongside units, particularly those transferred in an emergency situation, suggest that many of the same issues may apply. Beyond this, in terms of their experience of care before, during and after transfer, the accounts of women planning birth in the two types of midwifery unit revealed many common themes. Overall, in terms of implications for policy and practice, the findings of this study should be considered equally applicable to women planning birth in both types of midwifery unit.
Limitations of the study
By using maximum variation sampling and a variety of recruitment approaches, this study aimed to represent as broad a range of experience as possible. As with other qualitative studies, the aim is not to obtain a statistically ‘representative’ sample or ‘generalisable’ results, but to represent a broad range of experience, including the ‘minority’ experience. In terms of socio-demographic characteristics, the sample interviewed for this study was less varied than was hoped, being predominantly White, older and more affluent than the national average. This reflects the characteristics of most women planning birth in most freestanding midwifery units, but does not reflect the wider social diversity seen in many alongside units
[1, 6]. It also proved difficult to identify and recruit women having a second or subsequent baby to take part in the study. This is in part because multiparous women are less likely to be transferred and therefore make up a minority of the population of women who have experienced transfer
[1, 6]. Finally, because all but two of the women interviewed were transferred during labour, before the birth of their baby, it was not possible to explore whether women who are transferred in the immediate postnatal period have particular concerns or support needs. Notwithstanding these issues there was wide variation across other important dimensions of experience. Women taking part in the study came from many different parts of England, had planned birth in both types of midwifery unit and had a wide range of different experiences and ‘stories’ to tell. There was no evidence that women who had more problems or who had a particular issue to raise were more motivated to come forward to take part in this study.