Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on 'birthing outside the system'

Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study

OBJECTIVE

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling).

DESIGN

Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats).

SETTING

Planned community birth (homes and birth centers), United States.

SAMPLE

Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset.

METHODS

Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death.

RESULTS

One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded.

CONCLUSIONS

All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Exploring women's motivations to freebirth and their experience of maternity care: A systematic qualitative evidence synthesis

BACKGROUND

Freebirth is currently defined as the deliberate decision to give birth without a regulated healthcare professional. Previous reviews have identified factors influencing women's decision to freebirth, yet there is limited evidence on what is the care experience for women who opt to freebirth.

AIM

To synthesise the qualitative evidence on women's motivations to freebirth and their experience of maternity care when deciding to freebirth.

METHODS

We conducted a qualitative evidence synthesis using a sensitive search strategy in May 2022 and August 2023. Twenty-two publications between 2008 and 2023 and from ten different high-income countries were included. Thematic synthesis, underpinned by a feminist standpoint, was used to analyse the data.

FINDINGS

Three main analytical themes were developed in response to each of the review questions. 'A quest for a safer birth' describes the factors influencing women's decision to freebirth. 'Powerful and powerless midwives' describes women's perceptions of their care providers (mostly midwives) and how these perceptions influenced their decision to freebirth. 'Rites of self-protection' describes women's care experiences and self-care practices in the pregnancy leading to freebirth DISCUSSION: Freebirth was rarely women's primary choice but the result of structural and relational barriers to access wanted care. Self-care in the form of freebirth helped women to achieve a positive birth experience and to protect their reproductive self-determination.

CONCLUSION

A new woman-centred definition of freebirth is proposed as the practice to self-care during birth in contexts where emergency maternity care is readily available.

"I had no choice": A mixed-methods study on access to care for vaginal breech birth

INTRODUCTION

Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth.

METHODS

We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care.

RESULTS

Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system.

CONCLUSION

Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

An online survey of women's views of respectful and disrespectful pregnancy and early labour care in the Czech Republic

OBJECTIVE

To ascertain and explore the views of women and their partners, giving birth in the Czech Republic, of the level of respectful or disrespectful care provided during pregnancy and early labour.

DESIGN

Ethical approval was granted for a descriptive, online anonymous survey of 65 questions, with quantitative and qualitative responses.

SETTING

The Czech Republic.The survey was completed by 8,767 women and 69 partners in 2018.

MEASUREMENTS AND FINDINGS

Descriptive statistics and thematic analysis were used to present results. The majority of women were aged 26-35 years. Most had birthed in one of 93 hospitals, with 1.5% home births. Almost 40% never had an abdominal examination.in pregnancy. Quantitative data analysis revealed that less than half were given information on place of birth, or how to keep labour normal or non-interventionist. Almost 60% did not get information on positions for birth. Most (68%) commenced labour naturally, 25% had labour induced, 40% of them before term, and 7% had an elective caesarean section; 55% stated they had not been given any choice in the decision. Over half of those who had a membrane sweep said permission had not been sought. Half (54%) only had 'checking' visits from the midwife in labour.

KEY CONCLUSIONS

Findings reveal a lack of information-giving, discussion and shared decision-making from healthcare professionals during pregnancy and early labour. Some practices were non-evidenced-based, and interventions were sometimes made without consent.

IMPLICATIONS FOR PRACTICE

The examples of disrespectful care described in this study caused women distress during childbirth, which may result in an increased fear of childbirth or an increase in free-birthing.

Midwives', obstetricians', and nurses' perspectives of humanised care during pregnancy and childbirth for women classified as high risk in high income countries: A mixed methods systematic review

Women classified as 'high risk' or 'complicated' in pregnancy and childbirth have increased difficulty in accessing humanised care/humanisation in childbirth due to perceptions that this approach rejects the use of intervention and/or technology. Humanised care recognises the psychological and physical needs of women in pregnancy and birth. A mixed methods systematic review using a convergent segregated approach was undertaken using the Joanne Briggs Institute (JBI) methodology. The objective of the review was to identify the presence of humanisation for women with high risk pregnancy and/or childbirth in high income countries. Studies were included if they measured humanisation and/or explored the perspectives of midwives, obstetricians, or nurses on humanisation for women classified as having a high-risk or complicated pregnancy or childbirth in a high income country. Qualitative data were analysed using a meta-aggregative approach and a narrative synthesis was completed for the quantitative data. All studies were assessed for their methodological quality using the MMAT tool. Four databases were searched, and nineteen studies met the inclusion criteria. A total of 1617 participants from nine countries were included. Three qualitative findings were synthesised, and a narrative synthesis of quantitative data was completed. The integration of qualitative and quantitative data identified complimentary findings on: (i) the importance of developing a harmonised relationship with women; (ii) increased time counselling women on their choices; and (iii) fear of professional reputational damage if caring outside of protocols. Negotiating with women outside of protocols may have a wider impact on the professional than first thought. Understanding how healthcare professionals individualise care for women at risk in labour requires further investigation.

Freebirth, the only option for women who do not fit into common practice- A Swedish national interview study

OBJECTIVE

To explore women's experience of freebirth, as giving birth without the presence of a skilled healthcare professional such as a midwife.

METHODS

Online semi-structured interviews with nine multiparous women in Sweden. A qualitative experiential approach, as described by Burnard, was followed for data analysis.

RESULTS

The five main categories explored were: (i) previous negative experiences of hospital care as a reason for freebirth; (ii) receiving support for the decision of freebirth was crucial; (iii) longing for individual midwifery-assisted home-birthing support; (iv) to give birth in peace and in self-control, in the safe home environment; and (v) helpful support during labor and birth was appreciated.

CONCLUSIONS

The women in the study had a powerful and positive experience of freebirth, but individual midwifery birthing support was also requested. Easily available and respectful midwifery support should be offered to all childbearing women.

Exploring the Role of Birth Environment on Italian Mothers' Emotional Experience during Childbirth

The physical environment is one of the factors that affect mother's experience of childbirth and psychological health. A woman's childbirth experience has been found to influence not only the mother's own health and future births but also the well-being of her child and family. The present study's objective was to investigate mothers' perceptions of spatial-physical humanization, affective quality of place, and emotions during childbirth. To achieve this goal, the first part of our work was dedicated to selecting two birth environments (hospital and birth center) with different degrees of humanization. The methods include observations and field survey which mainly concerned the environmental quality of the spaces and the layout of the birth unit, and self-report questionnaire about perceived environment, affective quality attributed to place, and delivery experience. Participants are 66 low-risk women, choosing hospital or birth center. The findings indicate an enhanced perception of both the spatial-physical aspects and the social and functional aspects of the care unit among mothers who give birth at the birth center. These same mothers also report a more positive perception of the childbirth experience. In conclusion, this study contributes to the understanding of the role of birth environments in shaping mothers' emotional experiences during childbirth.

Trends and motivations for freebirth: A scoping review

BACKGROUND

Even when maternity care facilities are available, some women will choose to give birth unassisted by a professional (freebirth). This became more apparent during the pandemic of coronavirus disease 2019 (COVID-19), as women were increasingly concerned they would contract the virus in health care facilities. Several studies have identified the factors that influence women to seek alternative places of birth to hospitals, but research focusing specifically on freebirth is limited.

METHODS

Eight databases were searched from their respective inception dates to April 2022 for studies related to freebirth. Data from the studies were charted and a thematic analysis was subsequently conducted.

RESULTS

Four themes were identified based on findings from the 25 included studies: (1) Geographical and socio-demographic determinants influencing freebirth, (2) Reasons for choosing freebirth, (3) Factors hindering freebirth, and (4) Preparation for and varied experiences of freebirth.

DISCUSSION

More women chose to give birth unassisted in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Overall, motivation for freebirth included previous negative birth experiences with health care professionals, a desire to adhere to their birth-related beliefs, and fear of contracting the COVID-19 virus. Included studies reported that study participants were often met with negative responses when they revealed that they were planning to freebirth. Most women in the included studies had positive freebirth experiences. Future research should explore the different motivators of freebirth present in LMICs or HICs to help inform effective policies that may improve birth experiences while maintaining safety.

Why freebirth in a maternity system with free midwifery care? A qualitative study of Danish women's motivations and preparations for freebirth

OBJECTIVE

Even in maternity care systems with free midwifery care, some women intentionally choose to birth unattended by any health professional (freebirth). Women who choose freebirth represent an enigma for many, and a provocation to some. However, people who do not conform to dominant medical practices are a source of valuable insights that can reveal shortcomings in the mainstream health care system. Thus, the aim of this study was to explore and understand women's motivations and preparations for freebirth.

METHODS

The study was informed by the theoretical lens of the 'undisciplined patient'. Qualitative, in-depth interviews were performed with ten Danish women, who for their most recent birth had planned to freebirth. Data were analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. "The standard system is not for me" describes negative experiences during previous births and the desire for more individualised support. "Re-establishing trust in myself" describes the women's quest for recognizing their own needs and re-building autonomy and inner strength. "I do my research" describes how the women sought new ways of knowing and prioritised experiential knowledge. And finally, "I create my safe space" describes the women's efforts to create the best possible physical and emotional space for themselves and their babies in order to have a safe and autonomous birth experience.

CONCLUSION

Freebirth is not undertaken lightly or without preparation by women. Improved continuity of care as well as greater flexibility in hospital guidelines could accommodate some of these women's demand for autonomy in birth.

Women's view on shared decision making and autonomy in childbirth: cohort study of Belgian women

Background

Health care providers have an important role to share evidence based information and empower patients to make informed choices. Previous studies indicate that shared decision making in pregnancy and childbirth may have an important impact on a woman’s birth experience. In Flemish social media, a large number of women expressed their concern about their birth experience, where they felt loss of control and limited possibilities to make their own choices. The aim of this study is to explore autonomy and shared decision making in the Flemish population.

Methods

This is a cross-sectional, non-interventional study to explore the birth experience of Flemish women. A self-assembled questionnaire was used to collect data, including the Pregnancy and Childbirth Questionnaire (PCQ), the Labor Agentry Scale (LAS), the Mothers Autonomy Decision Making Scale (MADM), the 9-item Shared Decision Making Questionnaire (SDM–Q9) and four questions on preparation for childbirth. Women who gave birth two to 12 months ago were recruited by means of social media in the Flemish area (Northern part of Belgium).

Linear mixed-effect modelling with backwards variable selection was applied to examine relations with autonomy in decision making.

Results

In total, 1029 mothers participated in this study of which 617 filled out the survey completely. In general, mothers experienced moderate autonomy in decision-making, both with an obstetrician and with a midwife with an average on the MADM score of respectively 18.5 (± 7.2) and 29.4 (±10.4) out of 42. The linear mixed-effects model showed a relationship between autonomy in decision-making (MADM) for the type of healthcare provider (p < 0.001), the level of self-control during labour and birth (LAS) (p = 0.003), the level of perceived quality of care (PCQ) (p < 0.001), having epidural analgesia during childbirth (p = 0.026) and feeling to have received sufficient information about the normal course of childbirth (p < 0.001).

Conclusions

Childbearing women in Flanders experience moderate levels of autonomy in decision- making with their health care providers, where lower autonomy was observed for obstetricians compared to midwives. Future research should focus more on why differences occur between obstetrics and midwives in terms of autonomy and shared decision-making as perceived by the mother.

“I got to catch my own baby”: a qualitative study of out of hospital birth

Background

About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse.

Methods

This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling.

Results

All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth.

Conclusion

Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA.

This study shares information from qualitative interviews with Black women and women who are survivors of abuse regarding their choice to have a planned out-of-hospital birth, or to choose an unassisted birth (UAB) with no midwife or other professional birth attendant. Black women are less well represented among those who choose OOHB, and little is known about the reasons that they may choose OOHB. Previous studies show that women who have experienced childhood physical or sexual abuse may prioritize having a sense of control and autonomy during their birthing experiences; however, little is known about their specific choice for OOHB. Our study recruited 18 women who had an OOHB or UAB and who identified as either Black and/or survivors of trauma to participate in in-depth interviews concerning their choice to give birth out of hospital. Through qualitative research methods, we analyzed transcripts of these interviews and developed a theoretical model about women’s decision making related to OOHB or UAB. We found that women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition, and that choosing OOHB or UAB allowed them to have more control during the process of giving birth. Understanding the role that previous trauma and experiences of discrimination play in birthplace choice may help birth professionals to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as important factors in their clinical interactions with birthing women.

'Stories of distress versus fulfilment': A narrative inquiry of midwives' experiences supporting alternative birth choices in the UK National Health Service

BACKGROUND

Some childbearing women/birthing people prioritize out of maternity care organizational guidelines' approaches to childbirth as a way of optimizing their chances of a normal physiological birth. Currently, there is little known about the experiences of midwives who support their choices.

AIM

To explore the experiences of UK midwives employed by the NHS, who self-defined as supportive of women's alternative physiological birthing choices.

METHODS

A narrative inquiry was used to collect and analyse professional stories of practice via self-written narratives and interviews. Forty-five midwives from across the UK were recruited.

FINDINGS

Three overarching storylines were developed with nine sub-themes. 'Stories of distress' highlights challenging experiences due to poor supportive working environments, ranging from small persistent challenges to extreme situations. Conversely, 'Stories of fulfilment' offers a positive counter-narrative where midwives worked in supportive working environments enabling woman-centred care unencumbered by organisational constraints. 'Stories of transition' abridge these two polarized themes.

CONCLUSION

The midwives' experiences were mediated by their socio-cultural working contexts. Negative experiences were characterised by a misalignment between the midwives' philosophy and organisational cultures, with significant consequences for the midwives. Conversely, examples of good organisational culture and practice reveal that it is possible for organisations to fulfil their obligations for safe and positive maternity care for both childbearing women who make alternative birthing choices, and for attending staff. This highlights what is feasible and achievable within maternity organisations and offers transferable insights for organisational support of out-of-guideline care that can be adapted across the UK and beyond.

Between a Rock and a Hard Place: Considering "Freebirth" During Covid-19

Background: The global coronavirus (Covid-19) pandemic concerns all people, but has a specific effect on those who are expecting a baby during this time. The advice in the UK changed rapidly, with 14 different sets of national guidance issued within 1 month. Individual NHS Trusts released various guidance relating to the withdrawal of homebirth services, the closure of birth centers, restrictions on the number of birth partners (if any) allowed during labor, and whether any visitors were allowed to attend after birth. With the landscape of maternity care changing so rapidly, research was carried out to provide real-time data to capture the lived experiences of expectant families.

Methods: A mixed methods online survey was carried out over 2 weeks between 10th and 24th April 2020. The survey was open to those in the third trimester of pregnancy, those who had given birth since the beginning of the “lockdown” period in the UK, and the partners of pregnant women and people who were in these circumstances. The survey asked questions about how respondents' holistic antenatal experiences had been affected, whether their plans for birth had changed, and the effect of these changes on respondents' emotional wellbeing. Of the 1,700 responses received, 72 mentioned that they had seriously considered “freebirthing” (giving birth without a healthcare professional present).

Findings: An analysis of the respondents' reasons for considering freebirth was conducted, finding that reasons for considering freebirth were complex and multifaceted. Lesbian, bisexual, pansexual, and queer women were more likely to have considered freebirth than heterosexual people (p < 0.001).

Conclusions: Considering giving birth without a healthcare professional present is unusual in the Global North and represents an emerging field of study. The literature examining the reasons that people consider freebirth shows a variety of underlying motivations. A global pandemic represents a new factor in such considerations. The findings from this research can help inform maternity service planning in future crises.

How to Make the Hospital an Option Again: Midwives' and Obstetricians' Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines

BACKGROUND

An increasing number of maternity care providers encounter pregnant women who request less care than recommended. A designated outpatient clinic for women who request less care than recommended was set up in Nijmegen, the Netherlands. The clinic's aim is to ensure that women make well-informed choices and arrive at a care plan that is acceptable to all parties. The aim of this study is to make the clinic's approach explicit by examining care providers' experiences who work with or within the clinic.

METHODS

qualitative analysis of in-depth interviews with Dutch midwives (n = 6) and obstetricians (n = 4) on their experiences with the outpatient clinic "Maternity Care Outside the Guidelines" in Nijmegen, the Netherlands.

RESULTS

Four main themes were identified: (1) "Trusting mothers, childbirth and colleagues"; (2) "A supportive communication style"; (3) "Continuity of carer"; (4) "Willingness to reconsider responsibility and risk". One overarching theme emerged from the data, which was "Guaranteeing women's autonomy". Mutual trust is a prerequisite for a constructive dialogue about birth plans and can be built and maintained more easily when there is continuity of carer during pregnancy and birth. Discussing birth plans at the clinic was believed to be successful because the care providers listen to women, take them seriously, show empathy and respect their right to refuse care. A change in vision on responsibility and risk is needed to overcome barriers such as providers' fear of adverse outcomes. Taking a more flexible approach towards care outside the guidelines demands courage but is necessary to guarantee women's autonomy.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

In order to fulfil women's needs and to prevent negative choices, care providers should care for women with trust, respect for autonomy, and provide freedom of choice and continuity. Care providers should reflect on and discuss why they are reluctant to support women's wishes that go against their personal values. The structured approach used at this clinic could be helpful to maternity care providers in other contexts, to make them feel less vulnerable when working outside the guidelines.

Global stakeholder perspectives of home birth: a systematic scoping review

Home birth is experienced by people very differently worldwide. These experiences likely differ by the type of stakeholder involved (women, their support persons, birth attendants, policy-makers), the experience itself (low-risk birth, transfer to hospital, previous deliveries), and by the health system within which home birth occurs (e.g., high-resource versus low- and middle-resource countries). Research evidence of stakeholders' perspectives of home birth could usefully inform personal and policy decisions about choosing and providing home birth, but the current literature is fragmented and its breadth is not fully understood.We conducted a systematic scoping review to understand how the research literature on stakeholders' perspectives of home birth is characterized in terms of populations, settings and identified issues, and what potential gaps exist in the research evidence. A range of electronic, web-based and key informant sources of evidence were searched. Located references were assessed, data extracted, and descriptively analyzed using robust methods.Our analysis included 460 full reports. Findings from 210 reports of studies in high-resource countries suggested that research with fathers and same-sex partners, midwives, and vulnerable populations and perspectives of freebirth and transfer to hospital could be synthesized. Gaps in primary research exist with respect to family members, policy makers, and those living in rural and remote locations. A further 250 reports of studies in low- and middle-resource countries suggested evidence for syntheses related to fathers and other family members, policy makers, and other health care providers and examination of issues related to emergency transfer to hospital, rural and remote home birth, and those who birth out of hospital, often at home, despite receiving antenatal care intended to increase healthcare-seeking behavior. Gaps in primary research suggest an examination is needed of perspectives in countries with higher maternal mortality and among first-time mothers and young mothers.Our scoping review identified a considerable body of research evidence on stakeholder perspectives of home birth. These could inform the complex factors influencing personal decisions and health system planning around home birth in both high- and low- and middle-resource countries. Future primary research is warranted on specific stakeholders worldwide and with vulnerable populations in areas of high maternal mortality.

"I knew there has to be a better way": Women's pathways to freebirth in Poland

BACKGROUND

Each year a small number of women decide to birth at home without midwifery and medical assistance despite the availability of maternity services in the country. This phenomenon is called freebirth and can be used as a lens to look into shortcomings of maternity care services.

AIM

By exploring women's pathways to freebirth, this article aims to examine the larger context of maternity services in Poland and identify elements of care contributing to women's decision to birth without midwifery and medical assistance.

METHODS

A qualitative methodology was used employing elements of ethnographic fieldwork, including digital ethnography. Semi-structured interviews with twelve women who freebirth, analysis of online support groups, secondary sources of information and elements of participant observation were used.

FINDINGS

Women's decisions to freebirth were born out of their previous negative experiences with maternity care. Persistent use of medical technology and lack of respect from maternity care providers played a major role in pushing women away from available Polish maternity services. While searching for a better environment for themselves and their babies for the subsequent births, women experienced a rigidity of both mainstream and homebirth services and patchy availability of the latter that contributed to their decisions to freebirth.

CONCLUSIONS

Freebirth appears to be a consequence of inadequate maternity services both mainstream and homebirth rather than a preference. Women's freebirth experiences can be used to improve maternity care in Poland and inform similar contexts globally.

Risk perceptions among high-risk pregnant women in Nepal: a qualitative study

BACKGROUND

A woman's perception of risk affects her decisions about seeking obstetric care and following prescribed regimens of care. This study explored the perceptions of high-risk pregnancy among women with high-risk factors.

METHODS

A qualitative study was conducted in the Morang district, Nepal. A phenomenological approach was used. In-depth interviews were conducted with 14 participants. Postpartum women with one risk factor for high-risk pregnancy who non-adhere to referral hospital birth were selected purposively. Thematic analysis was done to generate themes and categories.

FINDINGS

Two main themes emerged in this study: (i) knowledge and understanding of risk and (ii) normalizing and non-acceptance of risk. The participants had inadequate knowledge of risk in pregnancy and childbirth. Their information source was their personal experiences of risk, witnessing their close relatives, and community incidents. The participants perceived pregnancy as a normal event and did not consider themselves as at risk. They tended to deny risk and perceived that everything was fine with their pregnancy.

CONCLUSIONS

The findings of this study provide a glimpse into how women perceived risk and the reasons that lead them to deny the risks and gave home birth. In the presence of risk factors in pregnancy, some women were not convinced that they were at risk. An antenatal check-up should be utilized as a platform to educate women, explore their intentions, and encourage safer births.

Teenage Pregnancies and Childbirth Experience in Romania From the Midwives Point of View

In Romania, in 2017, the infant mortality rate was eight per thousand; with 41,000 women who had no medical visits during pregnancy; 18,500 were teenagers. Our objective was to analyze how many teen pregnancies were in an Obstetrics and Gynaecology Hospital from Romania over a two-year period and underline the role that midwives have in preventing teenage pregnancies. A descriptive study of a group of 343 childbearing teenagers out of 7020 childbearing women who gave birth in 2017-2018 is presented. The teenagers were evaluated by age, the number of pregnancies, birth complications, way of delivery, and place of origin. The involvement of the midwife was highlighted. From the total of 7020 analyzed cases, 4.8% (n=343) were teen pregnancies. Within this group, 4.37%(n=15)were already at the third birth and 89.79 (n=308)were un-investigated during the entire pregnancy. Sixty-eight point fifty-one percent (68.51%; n=235)of the teenagers gave birth with the aid of a midwife while 4.66 (n=16) gave birth with no medical attendance and experienced homebirth. All the teenagers that gave birth at home were from rural areas and not married. High teenage pregnancy rates are determined in Romania by the low level of information about sexuality and family planning at young ages. The midwives have the ability to help to resolve these problems if they were more allowed to be involved in these programs, especially in rural areas.

Exploring the conceptualisation and study of freebirthing as a historical and social phenomenon: a meta-narrative review of diverse research traditions

Freebirthing is a clandestine practice whereby women intentionally give birth without healthcare professionals (HCPs) present in countries where there are medical facilities available to assist them. Women who make this decision are frequently subjected to stigma and condemnation, yet research on the phenomenon suggests that women's motivations are often complex. The aim of this review was to explore how freebirth has been conceptualised over time in the English-language academic and grey literature. The meta-narrative methodology employed enables a phenomenon to be understood within and between differing research traditions, as well as against its social and historical context. Our research uncovered nine research traditions (nursing, autobiographical text with birthing philosophy, midwifery, activism, medicine, sociology, law and ethics, pregnancy and birth advice, and anthropology) originating from eight countries and spanning the years 1957-2018. Most of the texts were written by women, with the majority being non-empirical. Empirical studies on freebirth were usually qualitative, although there were a small number of quantitative medical and midwifery studies; these texts often focused on women's motivations and highlighted a range of reasons as to why a woman would decide to give birth without HCPs present. Motivations frequently related to women's previous negative maternity experiences and the type of maternity care available, for example medicalised and hospital-based. The use of the meta-narrative methodology allowed the origins of freebirth in 1950s America to be traced to present-day empirical studies of the phenomenon. This highlighted how the subject and the publication of literature relating to freebirth are embedded within their social and historical contexts. From its very inception, freebirth aligns with the medicalisation of childbirth, the position of women in society, the provision of maternity care and the way in which women experience maternity services.

Birthing outside the system: the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia

BACKGROUND

Childbirth in Australia occurs predominantly in a biomedical context, with 97% of births occurring in hospital. A small percentage of women choose to birth outside the system - that is, to have a midwife attended homebirth with risk factors, or a freebirth, where the birth at home is intentionally unattended by any health professional.

METHOD

This study used a Grounded Theory methodology. Data from 13 women choosing homebirth and 15 choosing freebirth were collected between 2010 and 2014 and analysed over this time.

RESULTS

The core category was 'wanting the best and safest,' which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was 'finding a better way'. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies.

CONCLUSION

Shortfalls in the Australian maternity care system is the major contributing factor to women's choice to give birth outside the system. Systematic improvements should prioritise humanising maternity care and the expansion of birth options which prioritise midwifery-led care for women of all risk.

Addressing a need. Holistic midwifery in the Netherlands: A qualitative analysis

The Netherlands has a maternity care system with integrated midwifery care, including the option of home birth for low risk women. A small group of Dutch (holistic) midwives is willing to assist women in high risk pregnancies during a home birth against medical advice. We examined holistic midwives’ motivations and way of practice, in order to provide other maternity care professionals with insight into the way they work and to improve professional relationships between all care providers in the field. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. We performed in-depth interviews with twenty-four holistic midwives on their motivations for working outside their professional boundaries. Open, axial and selective coding of the interview data was done in order to generate themes. We held a focus group for a member check of the findings. Four main themes were found: 1) The regular system is failing women, 2) The relationship as basis for empowerment, 3) Delivering client centered care in the current system is demanding, and 4) Future directions. One core theme emerged that covered all other themes: Addressing a need. Holistic midwives explained that many of their clients had no other choice than to choose a home birth in a high risk pregnancy because they felt let down by the regular system of maternity care. Holistic midwives appear to deliver an important service. They provide continuity of care and succeed in establishing a relationship with their clients built on trust and mutual respect, truly putting their clients’ needs first. Some women feel let down by the regular system, and holistic midwives may be the last resort before those women choose to deliver unattended by any medical professional. Maternity care providers should consider working with holistic midwives in the interest of good patient care.

Women desiring less care than recommended during childbirth: Three years of dedicated clinic

BACKGROUND

Some women decline recommended care during pregnancy and birth. This can cause friction between client and provider.

METHODS

A designated outpatient clinic was started for women who decline recommended care in pregnancy. All women who attended were analyzed retrospectively. The clinic used a systematic multidisciplinary approach. During the first visit, women told their stories and explained the reasoning behind their birth plan. The second visit was used to present the evidence underpinning recommendations and attempt to reach a compromise if care within recommendations was still not acceptable to the woman. During the third visit, a final birth plan was decided on.

RESULTS

From January 1, 2015, until December 31, 2017, 55 women were seen in the clinic, 29 of whom declined items of recommended care during birth and were included in the study. After discussions had been completed, 38% of birth plans were within recommendations, 38% were a compromise, in which both the woman and the care provider had made certain concessions, and 24% did not reach an agreement and delivered with another provider either at home or elsewhere. All maternal and perinatal outcomes were good.

CONCLUSIONS

Using a respectful and systematic multidisciplinary approach, in which women feel heard and are invited to explain their motivations for their birth plans, we are able to arrive at a plan either compatible with or much closer to recommendations than the woman's initial intentions in most cases, thereby preventing negative choices.

Freebirthing: a case for using interpretative hermeneutic phenomenology in midwifery research for knowledge generation, dissemination and impact

AIM

This study explored women's reasons for and their experiences of decision making that related to the phenomenon of freebirthing within the United Kingdom. Freebirthing is the active choice to birth without a health professional present, even where there is access to maternity care.

METHODS

In total, 10 women were recruited to participate in an interpretative hermeneutic phenomenological study. Data were collected via written narratives and follow-up interviews.

FINDINGS

The findings revealed direct implications for midwifery practice, namely that the complex and nuanced reasons to freebirth were often related to a previous birth trauma or negative interactions with maternity professionals. Additional findings revealed that women faced distressing opposition and conflict from midwives in relation to their decision to freebirth, despite its current legality in the United Kingdom. These findings have been published elsewhere. However, the purpose of this paper is twofold: first, using my research into freebirthing as a case study, I will demonstrate the use and benefits of interpretative hermeneutic phenomenology to midwifery and nursing research in order to generate knowledge for the benefit of service users, healthcare professionals, researchers and policy makers; second, I will discuss the activities I carried out to enhance dissemination and impact for the benefit of service users and clinicians.

Caring for women making unconventional birth choices: A meta-ethnography exploring the views, attitudes, and experiences of midwives

INTRODUCTION

Women can face opposition when exerting autonomous decision-making regarding their birth choices, particularly when the decisions involve going against medical advice and/or outside of national guidelines. Termed 'unconventional birth choices', some research has explored women's reasons and experiences of making such choices, but less is known about the midwives caring for them.

OBJECTIVES

To synthesize existing qualitative literature on the views, attitudes, and experiences of midwives caring for women who make unconventional birth choices.

METHODS

A systematic search and meta-ethnography informed by Noblit and Hare and Schutz was undertaken. Eight databases were searched using predetermined search terms, alongside author, reference, citation chasing, and hand searching. Searches were conducted in July 2016 and updated in October 2017. Qualitative studies published since 1993 in English were included. Included studies were subjected to quality appraisal, conducted independently by two reviewers. Analysis was informed by the interpretative meta-ethnography methods.

MAIN RESULTS

Five studies met the inclusion criteria. Eight subthemes emerged. These resulted in three higher level interpretative themes emerged: perceptions of women's decision making, conflicting tensions as caregivers, ways of working with-woman.

CONCLUSIONS

Midwives can play a pivotal role in ensuring that respectful maternity care includes supporting women in their birthing decisions. Whilst limited research has been undertaken in this area, available insights suggest that midwives' views in this area are situated along a spectrum from 'willingly facilitative' to 'reluctantly accepting'. Views were influenced by context, as well as prior philosophies and values. While further research is needed, this study offers insights into the challenges women can face in seeking unconventional birth choices if they require support from midwives to do so.

When the Hospital Is No Longer an Option: A Multiple Case Study of Defining Moments for Women Choosing Home Birth in High-Risk Pregnancies in The Netherlands

Some women in a high-risk pregnancy go against medical advice and choose to birth at home with a "holistic" midwife. In this exploratory multiple case study, grounded theory and triangulation were employed to examine 10 cases. The women, their partners, and (regular and holistic) health care professionals were interviewed in an attempt to determine whether there was a pattern to their experiences. Two propositions emerged. The dominant one was a trajectory of trauma, self-education, concern about paternalism, and conflict leading to a negative choice for holistic care. The rival proposition was a path of trust and positive choice for holistic care without conflict. We discuss these two propositions and make suggestions for professionals for building a trusting relationship using continuity of care, true shared decision making, and an alternative risk discourse to achieve the goal of making women perceive the hospital as safe again.

A quantitative investigation into women's basic beliefs about birth and planned birth choices

OBJECTIVE

Perceptions about the nature of the birth process are important in determining women's birth choices regarding labour and delivery but are scarcely the subject of empirical research. The aim of the current study was to assess women's beliefs about birth as a natural and safe or medical and risky process and study the associations of these beliefs with fear of childbirth and planned birth choices.

DESIGN

An observational study using self-administered questionnaires during pregnancy.

SETTING

1. Community women's health centres in a metropolitan area in Israel; 2. Purposeful sampling of women who plan to birth naturally, through home midwives and targeted internet forums.

PARTICIPANTS

746 women with a singleton pregnancy in their second and third trimester.

MEASUREMENTS

Beliefs about birth as a natural and a medical process, fear of childbirth, and a range of natural birth choices.

FINDINGS

The birth beliefs were associated with women's birth intentions. The more women believed birth to be natural and the less they believed it to be medical, the more likely they were to make more natural birth-related choices. In the presence of the birth beliefs, fear of childbirth no longer had an independent association with birth choices. The beliefs interacted with each other, revealing a stronger association of viewing birth as natural with planning more natural choices among women who did not view birth as very medical.

KEY CONCLUSION

It is important to recognize women's beliefs about birth and how they may affect their fear of childbirth and birth intentions. Further studies on the origin of such beliefs and their development are needed.

IMPLICATIONS FOR PRACTICE

Women should be allowed to choose how they would like to birth in accordance with their beliefs. At the same time, strengthening women's belief in the natural birth process and their body's ability to perform it, could help lower fear of childbirth and medical intervention rates.

Coping with the stigma of home birth: Strategies of engagement and disengagement

Background

Home birth in most developed countries is stigmatised. Negative discourses frame women planning home births as risk mothers who put their desire for a particular birthing experience above the health and safety of their children. As a result, one of the primary challenges home-birthing women face during pregnancy is how to cope with this stigma.

Participants and procedure

This study was conducted in the upper Midwest region of the United States with women who were planning home births with midwives. Eleven women participated in the study. Data included in-depth interviews, participant-observation field notes, and content from one participant’s blog. Data were analysed using inductive content analysis.

Results

Participants coped with home birth stigma in three ways: (1) avoidance, (2) engaging in an education campaign, and (3) focusing on a family tradition of home birth. These responses represent both disengagement and engagement approaches to coping. Nine participants exhibited one dominant coping strategy: three relied on avoidance, three on an education campaign, and three on family tradition. Two participants used more than one approach. Both of these participants used avoidance and family tradition.

Conclusions

Home birth stigma is a source of chronic stress for women who choose to give birth at home. Women cope with this stress in a number of ways. Interventions to increase women’s coping resources and processes may be helpful. Changing the environment through efforts to destigmatise home birth may reduce the overall stress experienced by home-birthing women and improve their wellbeing.

Less or more? Maternal requests that go against medical advice

PROBLEM AND BACKGROUND

This study explores the experiences of Dutch midwives and gynaecologists with pregnant women who request more, less or no care during pregnancy and/or childbirth.

METHODS

All Dutch midwives and (trainee) gynaecologists were invited to fill out a questionnaire specifically designed for the purposes of this study. Holistic midwives were analysed separately from regular community midwives.

FINDINGS

Most maternity care providers in the Netherlands receive requests for less care than recommended at least once a year. The most frequently maternal requests were declining testing for gestational diabetes (66.3%), opting for a home birth in case of a high risk pregnancy (65.3%), and declining foetal monitoring during labour (39.6%). Holistic midwives are more convinced of an increasing demand for less care than community midwives (73.1% vs. 35.2%, p=<0.001). More community midwives than hospital staff reported to have declined one or more request for less care than recommended (48.6% vs. 27.9%, p=<0.001). The majority of hospital staff also receive at least one request for an elective caesarean section every year.

DISCUSSION AND CONCLUSION

Requests for more and less care than indicated during pregnancy and childbirth are equally prevalent in this study. However, a request for less care is more likely to be declined than a request for more care. Counselling women who disagree with their care provider demands time. In case of requests for less care, second best care should be considered.

Women's motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis

BACKGROUND

Home births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. Until now there were no qualitative data on women's motivations for these choices in the Dutch maternity care system where integrated midwifery care and home birth are regular options in low risk pregnancies. We aimed to examine women's motivations for birthing outside the system in order to provide medical professionals with insight and recommendations regarding their interactions with women who have birth wishes that go against medical advice.

METHODS

An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with 28 women on their motivations for going against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. A focus group was held for a member check of the findings.

RESULTS

Four main themes were found: 1) Discrepancy in the definition of superior knowledge, 2) Need for autonomy and trust in the birth process, 3) Conflict during negotiation of the birth plan, and 4) Search for different care. One overarching theme emerged that covered all other themes: Fear. This theme refers both to the participants' fear (of interventions and negative consequences of their choices) and to the providers' fear (of a bad outcome). Where for some women it was a positive choice, for the majority of women in this study the choice for a home birth in a high risk pregnancy or an unassisted childbirth was a negative one. Negative choices were due to previous or current negative experiences with maternity care and/or conflict surrounding the birth plan.

CONCLUSIONS

The main goal of working with women whose birthing choices do not align with medical advice should not be to coerce them into the framework of protocols and guidelines but to prevent negative choices. Recommendations for maternity caregivers can be summarized as: 1) Rethink risk discourse, 2) Respect a woman's trust in the birth process and her autonomous choice, 3) Have a flexible approach to negotiating the birth plan using the model of shared decision making, 4) Be aware of alternative delivery care providers and other sources of information used by women, and 5) Provide maternity care without spreading or using fear.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States

BACKGROUND

There is little agreement on who is a good candidate for community (home or birth center) birth in the United States.

METHODS

Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education.

RESULTS

The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups.

DISCUSSION

The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Tensions and conflicts in 'choice': Womens' experiences of freebirthing in the UK

BACKGROUND

the concept of choice is a central tenet of modern maternity care. However, in reality women's choice of birth is constrained by a paucity of resources and dominant medical and risk adverse discourses. In this paper we add to this debate through highlighting the tensions and conflicts that women faced when enacting a freebirthing choice.

METHODS

secondary analysis of data collected to explore why women choose to freebirth in the UK was undertaken. Ten women were recruited from diverse areas of the UK via invitations on freebirthing websites. Women provided a narrative and/or participated in an in-depth interview. A thematic analysis approach was used.

FINDINGS

we present three key themes. First 'violation of rights' highlights the conflicts women faced from maternity care systems who were unaware of women's legal rights to freebirth, conflating this choice with issues of child protection. 'Tactical planning' describes some of the strategies women used in their attempts to achieve the birth they desired and to circumnavigate any interference or reprisals. The third theme, 'unfit to be a mother' describes distressing accounts of women who were reported to social services.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

women who choose to freebirth face opposition and conflict from maternity providers, and often negative and distressing repercussions through statutory referrals. These insights raise important implications for raising awareness among health professionals about women's legal rights. They also emphasise a need to develop guidelines and care pathways that accurately and sensitively support the midwives professional scope of practice and women's choices for birth.