Background: Historically, the focus of the UK and international research exploring planned home birth decision making has been largely focused on understanding the experiences of women who decide to birth at home. As a result of high-profile research that suggests that non-OU birth locations are safe for low risk women, there has been a recent shift in focus resulting in research studies that aim to increase the rates of planned home birth, or more often the rates of all non-obstetric unit birth within the UK. However, despite this increased level of attention, the rate of home birth remains stubbornly low. Whilst there is some research to indicate why this might be the case, research that sheds a new light on the issue, and that develops an evidence base for new interventions is required. This thesis illuminates the factors that need to be considered in order to increase women’s abilities to make an informed decision about planned birth. Methodology: A pragmatic approach, using mixed methods, was used to explore the current way that we offer planned home birth to maternity service users, and to ultimately make suggestions about how this could be improved. The following studies have been undertaken: Study 1: Initial exploratory study: The case notes of one hundred and sixty nine women, from one health board and who had planned to birth at home, were audited. Non-participant observation of birth planning meetings at thirty-six weeks gestation were undertaken with seven community midwife and low-risk women dyads. These were followed by individual semi-structured interviews with the participants. Study 2: Scoping review: Qualitative and quantitative research, and non-research based literature, were analysed to produce a qualitative review of planned home birth decision making. Study 3: Active offer of planned home birth concept analysis The findings of the initial exploratory study and the scoping review, in addition to active offer literature that is predominantly applied to support the provision of services within minority official languages, were used to create an active offer of planned home birth. Study 4: Workshop study testing the findings of the concept analysis Narrative based exercises were used to explore the concept analysis findings with twenty previous service users who had birthed at home, nine previous service users who had chosen an institutional birth, and fourteen community midwives. Findings: Women will either take a ‘passive’ or ‘active’ approach to the offer of planned home birth, with a passive approach likely where no motivation for an active approach has been provided. Where a woman takes a passive approach, her ability to make an informed decision about planned home birth will depend on an active offer being made by her midwife. This will be most effective when it is supported by a midwife’s employing organisation. The findings of this thesis suggest that a two stage active offer of planned home birth (AOPHB) process, consisting of ‘Creating the conditions’ and ‘Positive reinforcement’ stages, can be used to underpin the offer of planned home birth. Discussion: There has previously been minimal understanding of how to facilitate the home birth decision making process, and a passive offer is routinely provided to women in the UK. The proposed two-stage AOPHB process provides a structured way for midwives to underpin their offer to women, in order that an increased percentage of women are able to make an informed decision about home birth and/or decide to birth at home. Where midwives apply the AOPHB, women who may take a passive approach could be ‘activated’ to engage in home birth decision making. A pilot intervention has been drafted to implement the AOPHB within clinical practice. The intervention provides support for the implementation of the two-stage AOPHB process through the use of individual components focused on midwives and their employing organisation; student midwives; and women, and their significant others. Implications: This thesis has contributed to the developing knowledge base about planned home birth decision making. The application of active offer theory to the offer of planned home birth has been undertaken for the first time, and this has generated a new and useful perspective on this area of midwifery practice. The resultant two-stage AOPHB process has the potential for developing midwifery practice in terms of supporting midwives to understand and facilitate women’s decision making around home birth, providing a flexible tool that can be used in clinical practice. This is the first approach that has been developed with the aim of increasing the ability of women to make an informed decision about whether they wish to birth at home. Additionally, the pilot AOPHB intervention has implications around the understanding of how employing organisations can best support midwives in this aspect of their role, and developing how student midwives are educated about offering home birth to women.

Background: Health systems around the world are facing significant shifts in demographic profiles due to increasing ethnic, cultural and linguistic diversity of populations they serve. However, the provision of health care and health services in the language of the minority has been difficult and inconsistent. The concept of the health-literate organization has been developed amid growing recognition that system changes are needed to align health-care delivery with the needs, skills, and abilities of the population. Despite the recent proliferation of research on health literacy, studies of organizational health literacy are still uncommon. Objective: This dissertation addresses the concept and practical application of “organizational health literacy” in the context of an active offer of health services in French in Ontario, Canada. I attempt to answer the question “How can health literacy advance the development of health-care designs that are responsive and accessible to official language minority?” Methods: My research consists of a three-part project that used health services research methodology and has been accomplished in academic partnership with the French Language Health Services Network of Eastern Ontario. I first conducted a review both of the literature on health literacy in linguistic minorities and of the content of organizational health literacy guides. Using a practical example of an active offer of French-language services in Ontario, I applied the organizational health-literacy framework in order to examine the strategies used by health-care organizations to provide for the active offer of health services in French. My analysis focuses on health-literacy dimensions (e.g., access and navigation, communication), quality improvement characteristics (e.g., assessment, improvement actions), and also organizational-level changes (e.g., administrative strategies, direct client services, governance). A focus group of health-care administrators provided a unique insight into the planning and implementation of the active offer and organizational health literacy and associated challenges. Results: Overall, my results show that, although organizational changes may be implemented with the purpose of improving the quality of care by providing linguistically appropriate services, these changes are largely insufficient to achieve this goal. Conclusions: The concept of organizational health literacy has not yet received the attention it deserves, but its relevance is clear: Health-care organizations must be health-literate to be able to address healthcare needs of their diverse patients. There is a significant gap between where health services are and where they ought to be to satisfy the designation criteria for the active offer of services in French. The concept and the novel theoretical framework of organizational health literacy offers the potential of improving and strengthening the process of designation and planning of an active offer of health services in French.

As has been reported in Canadian research on the experiences of Francophone patients and Francophone health professionals, active offer is not common or well performed in the Ontario healthcare system (Bernier, 2009; Boileau, 2016; Bouchard & Desmeules, 2013; Drolet et al., 2014; Hien & Lafontant, 2013). This descriptive quantitative research explored the self-reported awareness and implementation of the active offer concept during clinical placements by English language program 4th year undergraduate nursing students. A total of 69 participants were recruited in April 2017 to complete a paper or online-based survey. The survey consisted of questions on French language abilities, awareness of the patient safety risk of language discordance, communication experiences with Francophone patients and opinions of the role of the nurse, healthcare organizations and universities in the implementation of active offer. The participating nursing students reported little knowledge and training for implementing active offer during clinical settings. Despite the lack of preparation, the majority of them (92%) reported caring for a Francophone patient at least once with 25% doing that eight times or more during their clinical placements. More than 84% reported finding a way to communicate with Francophone patients in French, by speaking to them in French themselves or by asking Francophone colleagues, a professional interpreter or the patients’ family to interpret for them. Study recommendations include training nursing students during their undergraduate studies about the patient safety risks of language discordance, active offer and how to implement it. All English program nursing students should also be taught how to access and work with a professional interpreter. Those with French language skills should be encouraged to take healthcare specific language training. New research should be done to explore communication between English language program nursing students and Francophone patients to identify if it is safe and adequate from both the student and the patient’s point of view.