Choosing an out-of-hospital birth centre: Exploring women's decision-making experiences

"It's my Home away from Home:" A hermeneutic phenomenological study exploring decision-making experiences of choosing a freestanding birth centre for perinatal care

PROBLEM

The high-value, midwifery-led birth centre (BC) model of care is underutilized in the United States, a country with high rates of obstetric intervention and maternal morbidity and mortality.

BACKGROUND

Birth setting decision-making is a complex, preference-sensitive, and resource-dependent process. Understanding how people choose BCs for care may help increase the utilization of BCs and generate positive perinatal outcomes.

AIM

This study explores the decision-making experiences of people with Medicaid insurance who chose to give birth in a BC in Massachusetts by gathering interview data to interpret and provide meaning about their selection of birth setting.

METHODS

We employed a hermeneutic phenomenology study to interview people about their decision to give birth in a BC. Interview data were coded using a hybrid deductive-inductive approach and analyzed using reflexive thematic analysis to interpret and provide meaning.

FINDINGS

Twelve women participated in the study. Five themes emerged that described participants' decision-making processes: 1) Stepping Away from "the System," 2) Decision-Making with External Influences, 3) Accessing BC Care, 4) Finding a Home at the BC, and 5) Decision-Making as a Temporal Process.

DISCUSSION

The decision to choose a BC was a dynamic process that occurred over time and was influenced by factors such as the quality of care, accessibility, external influences, and the physical environment.

CONCLUSION

Prioritizing an individual's capacity to choose their birth setting and fostering awareness about options in the context of informed decision-making are pivotal steps toward attaining equity in perinatal health. Securing public insurance coverage and equitable reimbursement for BCs represent essential policies aimed at facilitating universal access to the BC model for all people.

Birth houses in Australia: Discovery of safe, transformative birthplaces

BACKGROUND

Institutionalised birth settings do not meet the needs or wishes of all women. Current literature has reported on women's experiences of alternative birthplaces, however there is no published data on Australian birth houses. Birth houses are low-technology home-like birthplaces where women receive care from endorsed private practice midwives. Knowledge of women's perspectives and experiences of birth houses is unreported.

AIMS

To gain understanding of women's motivations for accessing and experiences of birth houses; and develop insight into the role of birth houses within Australian maternity services.

METHODS

A qualitative descriptive study was conducted in 2020. This methodology was chosen to centre women's voices of their experiences. Women who had utilised birth houses for labour and birth were invited to participate. Those who responded completed a brief questionnaire to support diversity in participant selection. Interviews were conducted via video-link, based on semi-structured open-ended questions. These were transcribed verbatim and thematically analysed.

FINDINGS

Ten women who utilised any of three known birth houses in Australia for labour and/or birth were interviewed. Four themes were revealed: "I knew there must be another way", "The best of both worlds", "Discovering a safe space" and "Transformation" with safety interwoven through each of these.

DISCUSSION

Women sought birthplaces and care congruent with their values and knowledge. Birth houses offered women a level of agency unavailable within hospital-based maternity care. While proximity to medical facilities was important, women's definitions of safety transcended biomedical perspectives to incorporate emotional and psychosocial wellbeing. Women described their experiences in birth houses as transformational, highly satisfying, and positive influences for future birthplace choices.

CONCLUSION

Women sought birth houses for safety, convenience, agency and autonomy. This study demonstrated these needs were met within birth houses, highlighting these birthplaces as a middle ground between home and hospital. High levels of satisfaction illustrate the validity of birth houses and reiterate the call for greater birthplace choice for all women.

Factors impacting the demonstration of relational autonomy in medical decision-making: A meta-synthesis

BACKGROUND

Relational autonomy is an alternative concept of autonomy in which an individual is recognized as embedded into society and influenced by relational factors. Social context, including social location, political structure, and social forces, significantly influence an agent to develop and exercise autonomy skills. The relational approach has been applied in clinical practice to identify relational factors impacting patient autonomy and decision-making, yet there is a knowledge gap in how these factors influence the demonstration of relational autonomy in the context of medical decisions of adults.

OBJECTIVE

The present study targeted the existing knowledge of what and how relational factors impact individuals making medical decisions using the theoretical framework of relational autonomy.

METHODS

A meta-synthesis study was utilized. Four electronic databases, including Embase, OVID Medline, CINAHL, and PubMed, were searched, along with gray literature and reference lists, to identify relevant studies.

RESULTS

23 studies reporting 21 qualitative and two mixed-method studies were reviewed. Four themes emerged from the qualitative findings: (1) supportive relationships facilitate an individual's relational autonomy; (2) obtaining comprehensive information from broader sources helps individuals exercise relational autonomy; (3) undue family pressure impedes the exercising of patient relational autonomy; and (4) healthcare providers' dominant voice hampers the demonstration of relational autonomy.

CONCLUSIONS

Applying relational autonomy to assist adults in making well-considered decisions is essential. The meta-synthesis suggests establishing a supportive relationship between individuals, healthcare providers, and family. A supportive relationship will allow healthcare providers to make judgments in line with an individual's values and wishes with the aim of promoting relational autonomy. Advance care planning was proposed as the effective solution to obtain a consensus between individuals and their families while respecting an individual's values and preferences. Furthermore, it is considered crucial for healthcare providers to appreciate an individual's values and incorporate their preferences into recommendations.

A mixed-methods study of women's birthplace preferences and decisions in England

PROBLEM

Choice has been a key aspect of maternity care policy in England since 1993, however a gap remains between the birthplaces women want and where they actually give birth.

BACKGROUND

The latest maternity care policy in England acknowledges that women are not being given 'real choice' in their care and often being told what to do. This is problematic since unfulfilled preferences have been linked to negative childbirth experiences.

AIM

To understand the factors affecting women's birthplace preferences and decisions, and why these might differ.

METHODS

A sequential mixed-methods study consisting of an online questionnaire (n=49) and follow-up interviews (n=14) with women who were either currently pregnant or had recently given birth in a metropolitan region in England.

FINDINGS

Most women in this study said that they would prefer to give birth in an alongside maternity unit because it offered a compromise between the risk of poor outcomes and risk of unnecessary medicalisation. However, the majority of women's preferences were medicalised at the point of decision-making as the minimisation of clinical risk was ultimately prioritised.

DISCUSSION

Women's preference for the alongside maternity unit demonstrates the growing popularity for this less medicalised, 'alternative' birthplace option. However pre-existing conditions, reproductive histories and experiential knowledge influence women's decision to give birth in the labour ward and suggests that minimising clinical risk is women's key priority.

CONCLUSION

Women navigate complex and competing discourses when forming childbirth preferences and making decisions, selectively considering different risks and knowledges to make the decisions right for them.

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.

"Putting the baby back in the body": The re-embodiment of pregnancy to enhance safety in a free-standing birth center

The general discourse in most countries is that technological surveillance during pregnancy and childbirth is synonymous with safety, while women's individual experiences are less likely regarded as critical. The aim of this ethnographic study at a birth center in Germany was to describe how midwives and their clients construct risk and safety. The data collection methods included participant observation and semi-structured interviews. 'Putting the baby back in the body' was the major theme that emerged, supported by three sub-themes. The women in this study relied on scans at the beginning of pregnancy to make their baby real to them, but became more confident in their capacity to sense their baby after experiencing the first fetal movements. The midwives fostered this confidence by using interactive palpation of the abdomen with the women, thus supporting their individual sensory experience, and, in the midwives' view, enhancing overall safety during pregnancy and at birth.

The role of pandemic-related pregnancy stress in preference for community birth during the beginning of the COVID-19 pandemic in the United States

BACKGROUND

The COVID-19 pandemic introduced unparalleled uncertainty into the lives of pregnant women, including concerns about where it is the safest to give birth, while preserving their rights and wishes. Reports on the increased interest in community births (at home or in birth centers) are emerging. The purpose of this project was to quantitatively investigate psychological factors related to this birth preference.

METHODS

This study included 3896 pregnant women from the COVID-19 Pregnancy Experiences (COPE) Study who were anticipating a vaginal birth. COPE Study participants were recruited online between April 24 and May 15, 2020, and completed a questionnaire that included preference with respect to place of birth and psychological constructs: fear of childbirth, basic beliefs about birth, pandemic-related preparedness stress, and pandemic-related perinatal infection stress.

RESULTS

Women who preferred a community birth, on average, had less childbirth fear, had stronger beliefs that birth is a natural process, were less likely to see birth as a medical process, and were less stressed about being unprepared for birth and being infected with COVID-19. In multivariate models, higher stress about perinatal COVID-19 infection was associated with greater likelihood of preferring a community birth. The effect of perinatal infection stress on preference was stronger when preparedness stress was high.

DISCUSSION

Women's birth preferences during the COVID-19 pandemic are associated with psychological processes related to risk perception. Community births are more appealing to women who view being in a hospital as hazardous because of the pandemic. Policies and prenatal care aimed to increase access to safe in-hospital and out-of-hospital birth services should be encouraged.

Putting the Patient First: A Scoping Review of Patient Desires in Canada

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

Is there a relationship between basic birth beliefs and pregnancy-related anxiety in Turkey

AIM

It is important to investigate the relationship between the beliefs about birth as a natural or medical process and the pregnancy-related anxiety that has a powerful impact on the negative outcomes of labor. This study was aimed at investigating the relationship between basic birth beliefs and pregnancy-related anxiety in Turkey.

METHODS

This descriptive, cross-sectional and correlational study was conducted in a University hospital located in eastern Turkey. The study sample included 473 primiparae having completed 14 weeks of pregnancy. The Birth Belief Scale and Pregnancy-Related Anxiety Questionnaire/PRAQ-R2 were used to collect the data.

RESULTS

A relationship was found between birth beliefs and pregnancy-related anxiety. Strong beliefs about birth as a medical process or weak beliefs about birth as a natural process were found to be related with fear of giving birth and worries about bearing a handicapped child.

CONCLUSION

A relationship was detected between beliefs of pregnant women about birth as a medical and natural process and fear of giving birth, worries about bearing a handicapped child., concern about own appearance. It is highly important to detect the birth beliefs in order to help women have a healthy pregnancy period and to decrease their anxiety levels. Pregnancy-related anxieties of women must be detected, and their birth beliefs that result in anxiety must not be overlooked during the provision of prenatal healthcare services.

Freestanding Midwife-Led Units: A Narrative Review

Background

Strengthening of midwives' position and support for freestanding birth centers, frequently referred to as Freestanding Midwife-led Units (FMUs), raise hopes for a return to humanized labor. Our study aimed to review published evidence regarding FMUs to systematize the knowledge of their functioning and to identify potential gaps in this matter.

Materials and Methods

A structured integrative review of theoretical papers and empirical studies was conducted. The literature search included MEDLINE, Cochrane, Scopus, and Embase databases. The analysis included papers published in 1977-2017. Relevant documents were identified using various combinations of search terms and standard Boolean operators. The search included titles, abstracts, and keywords. Additional records were found through a manual search of reference lists from extracted papers.

Results

Overall, 56 out of 107 originally found articles were identified as eligible for the review. Based on the critical analysis of published data, six groups of research problems were identified and discussed, namely, 1) specifics of FMUs, 2) costs of perinatal care at FMUs, 3) FMUs as a place for midwife education, 4) FMUs from midwives' perspective, 5) perinatal, maternal, and neonatal outcomes, and 6) FMUs from the perspective of a pregnant woman.

Conclusions

FMUs offers a home-like environment and complex midwifery support for women with uncomplicated pregnancies. Although emergency equipment is available as needed, FMU birth is considered a natural spontaneous process. Midwives' supervision over low-risk labors may provide many benefits, primarily related to lower medicalization and fewer medical interventions than in a hospital setting.

Factors associated with women's desire for control of healthcare during childbirth: Psychometric analysis and construct validation

The desire for control of healthcare is a significant moderator of outcomes related to childbirth. Researchers have shown that a sense of control of healthcare during childbirth is strongly correlated with postpartum maternal well-being. The aims of this study were to examine (a) the psychometric characteristics of an instrument to assess women's desire for control of healthcare during childbirth, and (b) examine desire for control in relation to parity, medical complications of pregnancy, and women's choices of childbirth providers and setting. The study design was cross-sectional using two different samples totaling 385 pregnant women. In Sample 1, (n = 193) we conducted an exploratory factor analysis to reduce the initial item pool. In Sample 2, (n = 192) we conducted a confirmatory factor analysis (CFA) of the final 12-item instrument and examined factors related to the desire for control. Results of the analysis in Sample 1 were supportive of a single-factor structure reflecting women's desire to influence the childbirth healthcare environment and decision-making. The final 12-item instrument had high internal consistency reliability (Cronbach's alpha = 0.93). CFA in Sample 2 was supportive of the single-factor structure with good model fit. The desire for control was directly correlated with an internal locus of control. Nulliparous women reported a lower desire for control compared with multiparous women. The desire for control among women with self-reported medical complications of pregnancy was comparable to that among women without pregnancy complications. The desire for control was a predictor of choosing midwives (vs. obstetricians), home or birth center (vs. hospitals), and professional labor support (e.g., doulas). Implications for future research on the impact of desire for control on maternal health outcomes are discussed.

PREGNANT WOMEN'S RECOLLECTIONS OF EARLY MATERNAL BONDING: ASSOCIATIONS WITH MATERNAL-FETAL ATTACHMENT AND BIRTH CHOICES

Recollections of own maternal care measured by parental bonding were found to be important in the pregnant woman's construction of herself as a mother. Although these recollections were studied with regard to various variables, there is a dearth of studies associated with pregnancy and childbirth. In this cross-sectional study, 341 pregnant women were recruited. Measures included a Sociodemographics-Obstetric History Questionnaire; the Childbirth Choices Questionnaire (H. Preis, M. Gozlan, U. Dan, & Y. Benyamini, 2018); the Parental Bonding Instrument (G. Parker, H. Tupling, & L.B. Brown, 1979); a question regarding the planned presence of the woman's mother at delivery; and the Maternal-Fetal Attachment Scale (M.S. Cranley, 1981). Parental recollections of Care were associated with fewer natural birth choices (hence, a more "medicalized" delivery), lower maternal-fetal attachment, and a wish for the mother's mother to be present at the birth. Parental recollections of Encouragement of Behavioral Freedom in childhood were associated with more natural choices regarding childbirth. In addition, women with higher scores on the parental bonding Denial of Autonomy factor reported stronger maternal-fetal attachment. Thus, early recollections of experiences with caregivers as manifested in parental bonding may be a possible influence on the transition to motherhood, and working through possible difficulties associated with these recollections may improve adjustment to motherhood.

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.

First-time mothers' birth beliefs, preferences, and actual birth: A longitudinal observational study

PROBLEM

Birth preferences, such as mode and place of birth and other birth options, have important individual and societal implications, yet few studies have investigated the mechanism which predicts a wide range of childbirth options simultaneously.

BACKGROUND

Basic beliefs about birth as a natural and as a medical process are both predictive factors for childbirth preferences. Studies investigating birth beliefs, preferences, and actual birth are rare.

AIM

To test a predictive model of how these beliefs translate into birth preferences and into actual birth related-options.

METHODS

Longitudinal observational study including 342 first-time expectant mothers recruited at women's health centres and natural birth communities in Israel. All women filled out questionnaires including basic birth beliefs and preferred birth options. Two months postpartum, they filled out a questionnaire including detailed questions regarding actual birth.

FINDINGS

Stronger beliefs about birth being natural were related to preferring a more natural place and mode of birth and preferring more natural birth-related options. Stronger beliefs about birth being medical were associated with opposite options. The preferences mediated the association between the birth beliefs and actual birth. The beliefs predicted the preferences better than they predicted actual birth.

DISCUSSION

Birth beliefs are pivotal in the decision-making process regarding preferred and actual birth options. In a medicalized obstetric system, where natural birth is something women need to actively seek out and insist on, the predictive powers of beliefs and of preferences decrease.

CONCLUSION

Women's beliefs should be recognized and birth preferences respected.

Testing a biopsychosocial model of the basic birth beliefs

BACKGROUND

Women perceive what birth is even before they are pregnant for the first time. Part of this conceptualization is the basic belief about birth as a medical and natural process. These two separate beliefs are pivotal in the decision-making process about labor and birth. Adapting Engel's biopsychosocial framework, we explored the importance of a wide range of factors which may contribute to these beliefs among first-time mothers.

METHOD

This observational study included 413 primiparae ≥24 weeks' gestation, recruited in medical centers and in natural birth communities in Israel. The women completed a questionnaire which included the Birth Beliefs Scale and a variety of biopsychosocial characteristics such as obstetric history, birth environment, optimism, health-related anxiety, and maternal expectations.

RESULTS

Psychological dispositions were more related to the birth beliefs than the social or biomedical factors. Sociodemographic characteristics and birth environment were only marginally related to the birth beliefs. The basic belief that birth is a natural process was positively related to optimism and to conceiving spontaneously. Beliefs that birth is a medical process were related to pessimism, health-related anxiety, and to expectations that an infant's behavior reflects mothering. Expectations about motherhood as being naturally fulfilling were positively related to both beliefs.

CONCLUSION

Psychological factors seem to be most influential in the conceptualization of the beliefs. It is important to recognize how women interpret the messages they receive about birth which, together with their obstetric experience, shape their beliefs. Future studies are recommended to understand the evolution of these beliefs, especially within diverse cultures.

Remote rural women's choice of birthplace and transfer experiences in rural Otago and Southland New Zealand

BACKGROUND

Birth in primary midwife-led maternity units has been demonstrated to be a safe choice for well women anticipating a normal birth. The incidence of serious perinatal outcomes for these women is comparable to similarly low risk women, who choose to birth in hospital. New Zealand women have a choice of Lead Maternity Carer (LMC) and birthplace; home, primary birthing unit, or a base hospital, though not all women may have all these choices available locally. Women in rural and rural remote areas can also choose to birth in their rural primary maternity unit. A percentage of these women (approx. 15-17%) will require transfer during labour, an event which can cause distress and often loss of midwifery continuity of care.

OBJECTIVE

To explore retrospectively the choice of birth place decisions and the labour and birth experiences of a sample of women resident in remotely zoned, rural areas of the lower South Island of New Zealand.

DESIGN

A purposive sample of women living in remote rural areas, recruited by advertising in local newspapers and flyers. Individual semi-structured interviews were digitally recorded using a pragmatic interpretive approach. The data (transcripts and field notes) were analysed using thematic and content analysis. Ethical approval was obtained from the Health and Disability Ethics Committee (HEDC) MEC/06/05/045.

PARTICIPANTS

Thirteen women consented to participate. Each was resident in a remote rural area having given birth in the previous 18 months. The women had been well during their pregnancies and at the onset of labour had anticipated a spontaneous vaginal birth.

SETTING

Rural remote zoned areas in Otago and Southland in the South Island of New Zealand FINDINGS: Five women planned to birth in a regional hospital and eight chose their nearest rural primary maternity unit. All of the women were aware of the possibility of transfer and had made their decision about their birthplace based on their perception of their personal safety, and in consideration of their distance from specialist care. Themes included, deciding about the safest place to give birth; making the decision to transfer; experiencing transfer in labour, and reflecting on their birth experience and considering future birthplace choices.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE AND POLICY

The experiences of the women show that for some, distance from a base hospital influences their place of birth decisions in remote rural areas of New Zealand and increases the distress for those needing to transfer over large distances. These experiences can result in women choosing, or needing to make different choices for subsequent births; the consequences of which impact on the future sustainability of midwifery services in remote rural areas, a challenge which resonates with maternity service provision internationally. While choices about birth place cannot be reliably predicted, creative solutions are needed to provide rural midwifery care and birth options for women and more timely and efficient transfer services when required.

What influences birth place preferences, choices and decision-making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a 'best fit' framework approach

BACKGROUND

English maternity care policy has supported offering women choice of birth setting for over twenty years, but only 13% of women in England currently give birth in settings other than obstetric units (OUs). It is unclear why uptake of non-OU settings for birth remains relatively low. This paper presents a synthesis of qualitative evidence which explores influences on women's experiences of birth place choice, preference and decision-making from the perspectives of women using maternity services.

METHODS

Qualitative evidence synthesis of UK research published January 1992-March 2015, using a 'best-fit' framework approach. Searches were run in seven electronic data bases applying a comprehensive search strategy. Thematic framework analysis was used to synthesise extracted data from included studies.

RESULTS

Twenty-four papers drawing on twenty studies met the inclusion criteria. The synthesis identified support for the key framework themes. Women's experiences of choosing or deciding where to give birth were influenced by whether they received information about available options and about the right to choose, women's preferences for different services and their attributes, previous birth experiences, views of family, friends and health care professionals and women's beliefs about risk and safety. The synthesis additionally identified that women's access to choice of place of birth during the antenatal period varied. Planning to give birth in OU was straightforward, but although women considering birth in a setting other than hospital OU were sometimes well-supported, they also encountered obstacles and described needing to 'counter the negativity' surrounding home birth or birth in midwife-led settings.

CONCLUSIONS

Over the period covered by the review, it was straightforward for low risk women to opt for hospital birth in the UK. Accessing home birth was more complex and contested. The evidence on freestanding midwifery units (FMUs) is more limited, but suggests that women wanting to opt for an FMU birth experienced similar barriers. The extent to which women experienced similar problems accessing alongside midwifery units (AMUs) is unclear. Women's preferences for different birth options, particularly for 'hospital' vs non-hospital settings, are shaped by their pre-existing values, beliefs and experience, and not all women are open to all birth settings.