Taking a decision according to Fishburn (1972) is simply making up our minds and is a “deliberate act of selection” (p.19). Decisions commit us to a set of actions or inactions, though these are not irreversible and can change in response to altered circumstances or desires (ibid). Changing ones mind about the direction being taken may be prompted by dissatisfaction with the way things are going within the constant flux of our environment. These changes can thus be seen as normative in that they seek to maximise utility and satisfy desire (ibid); in other words looking for the best outcome in the birth, while preserving the woman’s hope of birthing her baby normally. Thus, while we may be anchored to a particular position, environmental, political and social influences rather than cognitive calculations about outcome, may well be the catalyst for change (ibid). Consideration of these external factors can add to the urgency to make a decision; in this case to transfer.
In the rural scenario we were aware that we were outside accepted guidelines for duration of the second stage of labour, and the question of transfer needed to be raised (Ministry of Health, 2007). Prolonged labour in second stage with a first birth is deemed to be a level two referral; this means that the LMC in accordance with Section 88 of the Maternity Services Notice, (2007) must recommend consultation with a specialist. There is scope for the midwife to vary these responses taking into account their experience and skills and the particular clinical and personal preferences of the woman. Thus a midwife in a rural area may elect to transfer care at the lower end of the guideline in some situations, or conversely make a professional judgement in consultation with the
woman as to when it is appropriate to consult or transfer (Ministry of Health, 2007).
When reflecting on this event, it seemed that the decision was primarily made in relation to the clinical situation and in line with practice guidelines. The decision to transfer in this scenario was the end point of a decision process that potentially began as time ticked on and progress did not appear to be happening. It seemed in hindsight, given that the woman eventually birthed without assistance, that we were premature in our assessment of the situation. It is possible that the slowing of labour progress was related in part to a growing anxiety in us (the midwives) or in the couple. Was there a frown, or a change in our demeanour that sent a signal of increased watchfulness or concern? Was the woman or her partner feeling that this was not how it should be? If so, did a doubt set in train an interruption to the flow of oxytocin (Foureur, 2008); or was this labour pattern unique to this woman; consistent with her physiology and hormonal rhythms?
Our next move was to locate the ambulance and arrange transfer. This meant that transfer of care was not a simple hand over, but entailed a journey of 1-2 hours depending on how soon an ambulance could be provided. In this scenario we had to wait at the rural facility, thus the possibility of intervention was delayed. In this situation the weather was not an issue, however in winter this area is subject to snow and icy conditions. On another night these factors would have needed to be added to the mix.
It is possible that coming to a decision to transfer provided the sense of purpose that allowed the woman to relax and birth her baby. The delay in transfer may have provided the woman with the opportunity to birth in the place she had chosen. An earlier transfer may have resulted in the baby being born in the ambulance in less comfort and safety. Equally the wait may have increased the risks to the baby if progress had not occurred in labour. What the scenario does exemplify is the importance of timing for some decisions and how distance and delays can occur in the course of rural practice. Given these particular rural
requires the balancing of the desire for a local birth experience with a safety margin for a baby who might not be able to sustain a prolonged labour.
Summary
Decisions need to be made in any setting when the outcome is perceived as uncertain. Probabilistic calculations can be made using mathematical computations of probability. These linear projections are based on a logical and rational expectation of what will happen next and may be used as a means of providing prescriptive advice as to the most logical decision to make. Such decision making trees while helpful in some decision making contexts, do not account for the cognitive, social and emotional components of a situation. Similarly they do not account for how groups make decisions or how the particular contextual features influence those making the decision. Thus descriptive theories are offered to explain how individuals use a range of heuristic devices and biased reasoning to manage complex decisions; these include biases of representativeness, availability and anchoring.
Styles and models of decision making were canvassed. These included intuition used by midwives and others as a way of dealing with ill defined situations. This idea is examined for its contribution to decision making but also its limitations as an uncritical strategy. Models and styles of shared decision making were also discussed. These included paternalistic, informed and shared styles. A hybrid mix of these styles is an option for practitioners to draw on in different situations; though it is suggested that the quality of the relationship of trust and respect is foundational for this to be appropriate and successful.
Reflection is proposed as a tactic to examine the decision making and to tease out biases, emotions and distractions, with the aim of learning from the situation and improving how we make decisions. Such reflection can also be incorporated into the activity to avoid the possibility of compounding an error of judgement at an earlier stage. It is assumed that any reflection on an action, whether in the midst of the activity or after the event will be partial; a reconstruction of fragments with the luxury of hindsight. Despite these reservations, retrospection can bring clarity not obvious at the time.
How rural women and midwives make decisions around transfer is the aim of this study. Of interest in view of the literature canvassed above is to what degree the strategies and styles of decision making are similar or different for each group. Also of interest is the part, if any, reflection plays both in the process of deciding about transfer, and when looking back on events with the benefit of hindsight, what contextual factors are identified as influential. To research this complex process a mix of methods has been chosen. In the following chapter the mixed method research (MMR) approach to the study is presented. Typologies, or options for the design are discussed, and the rationale for choosing a concurrent mixed model design for this project justified.