Culture, control and the birth environment.

These findings illustrate that women's needs are not being adequately met in many hospital birth units. Women, particularly those expecting their first baby, often know little about how the culture of hospitals varies, or the helpfulness of facilities and opportunities for control and one-to-one support that are more readily available at home or in a midwife-led unit. Nor do they know how much their opportunities for comfort and control may be compromised in a conventional hospital setting. If they are feeling anxious about whether they will be able to cope with the pain of labour and whether their baby will be born safely, it is perhaps not surprising that a significant proportion feel it is important to have access to an epidural service and a special care baby unit (House of Commons Health Committee 2003a). However, these facilities are not in themselves more likely to make labour straightforward and manageable. Midwives and organisations such as the NCT have a key role to play in sharing knowledge about what women actually find useful--or disruptive and unhelpful--during labour, so that all pregnant women can make choices that are informed by the full range of relevant information. The recommendations from the early 1990s, that women should have care from a known midwife, has not been realised consistently, although in environments that are highly medicalized neither knowing your midwife nor one-to-one support seem sufficient to affect labour outcomes substantially (Johanson et al 2002). Where there is strong midwifery leadership, a clear philosophy of normality and one-to-one support, outcomes are different (Biringer, Davies. Nimrod et al 2000). Women appear to be offered more choices than a decade ago, but the range of options available still tends to be dominated by a medical model of care. Women still do not receive adequate information on the significance of alternatives as good-quality, evidence-based information is not [table: see text] consistently available, nor are they given the support to choose freely from the full range of options (Singh and Newburn 2000). However, evidence-based information leaflets alone are known to be inadequate to overcome a range of cultural barriers (O'Cathain et al 2002; Stapleton et al 2002). A small and growing proportion of women are having home births and have access to a midwife-led unit. Use of a birthpool in labour has become more accepted in all birth settings, although access to suitable facilities and protocols for use in hospital units are sometimes restrictive. Further change is needed to provide care during labour as part of a midwifery model, so that the kinds of medical interventions women find intrusive can be limited as far as possible without compromising safety.