Why do women choose an unregulated birth worker to birth at home in Australia: a qualitative study

Who plans to give birth with a doula? Demographic factors and perceptions of birth

PROBLEM

Research has demonstrated the benefits of continuous care during childbirth, particularly with doula support. However, much less is known about the factors underlying pregnant women's plans to have doula support.

BACKGROUND

Doulas provide one-on-one continuous care, emotional support, and advocacy, in a culturally sensitive way.

AIM AND QUESTIONS

We aimed to investigate the characteristics of pregnant women who consider doula support and whether it is related to their birth experiences, beliefs and concerns, including fear of childbirth and of the staff, beliefs about birth as a natural and as a medical process, and expectations of motherhood.

METHOD

A cross-sectional study, in which pregnant women (N = 1593) recruited in prenatal clinics completed questionnaires regarding socio-demographics, obstetric history, beliefs and concerns about birth, maternal expectations, and their plans for mode and place of birth and for having doula care.

FINDINGS

Women who planned to have doula care were more likely to be nulliparous and to plan a more natural birth. A doula plan was more prevalent among recent immigrants, religious women, women who viewed birth as natural and not as medical, and were concerned about the staff's attitude and control during birth.

DISCUSSION

In a medicalised maternity care system, women who view birth as natural birth and who have concerns regarding the care they will receive, are more likely to plan doula care.

CONCLUSION

Understanding the factors related to a doula plan may uncover unmet needs, particularly the need for culturally sensitive care and support for women's personal choices.

Insights from a publicly funded homebirth program

BACKGROUND

There are high levels of consumer demand for homebirth in Australia, however access is limited due to a wide range of factors, including associated costs of a private midwife and the limited number of publicly funded homebirth models. Homebirth with a qualified midwife, networked into a health system, is a safe option for women with a low-risk pregnancy. This paper has two aims. The first is to describe the implementation of a publicly funded homebirth service with an employed mentor. The second is to provide the outcomes from a matched cohort of women who received care from the same Midwifery Group Practice [MGP] who gave birth at home, compared with those who gave birth in hospital.

METHODS

The retrospective comparative cohort study used routinely collected perinatal data from the hospital's electronic database (eMaternity) from July 2018 - October 2021. The cohort of interest were women who received care through MGP. They were identically matched by parity, age, Body Mass Index (BMI), spontaneous labour and gestation of 37-42 weeks. A description of the employed midwifery mentor to implement this model of care is also provided.

FINDINGS

100 women gave birth at home during the study period. They were more likely to have a physiological birth (p < 0.001), intact perineum (p < 0.0001), and less likely to have a postpartum haemorrhage (p < 0.0001) compared to the matched cohort of women who birthed in hospital. There were less assisted births and caesarean section births for women who transferred from home to hospital (p < 0.0001). No statistical differences were seen between groups for postpartum haemorrhage, and Apgar score of < 7 at 5 minutes.

CONCLUSION

This study demonstrated favourable outcomes for women receiving MGP who planned to birth at home compared to those women who chose a hospital birth. This is consistent with the existing literature that place of birth makes a difference. A description of the role of a mentor in supporting the sustainability of a publicly funded homebirth program is provided. Further research is recommended to evaluate the mentor's role in implementing and sustaining the model.

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.

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.

"Make it better for the women and babies who come after me": Findings from women in Australia completing the international Babies Born Better survey

BACKGROUND

Woman-centered maternity service delivery is endorsed by Australian federal health policy. Despite this, little evaluation of maternity care is conducted through the lens of women. We examined the responses of women birthing in Australia to the international Babies Born Better 2018 (Version 2) open-response survey.

METHODS

An online international survey was distributed primarily by means of social media for women who had given birth in the last 5 years. In addition to closed-ended questions to describe the sample, a series of open-ended questions recorded women's experiences and satisfaction with their maternity care and place of birth.

RESULTS

Of 1249 women who reported birthing their most recent baby in Australia and speaking English, 84% responded to at least one open-ended evaluation question. We thematically analyzed the data to identify three related themes of safety, choice, and respect for women. Women's experiences of these were closely tied to their model of care; those birthing at home with a private midwife more so reported positive experiences than those discussing obstetric care or, to a lesser extent, midwifery-led care in a hospital. There was a strong preference and need for (1) access to affordable care with a known practitioner from early pregnancy to postpartum, and (2) individualized care with the removal of restrictive hospital policies not aligned with woman-centered practice.

DISCUSSION

This is the first Australian national study of women's maternity experiences and evaluations. Consistent with previous state-based research, women birthing in Australia continue to report maternity "care" that is physically and emotionally harmful. They also stated a need to address the psychosocial aspects of becoming a mother, in addition to the biological ones. Women and other birthing people must be at the center of defining quality maternity health service delivery, and services must be accountable for preventing and addressing harm, as defined by all birthing people.

Cooperation between midwives and doulas in the context of perinatal care - a integrative review of qualitative and quantitative studies

BACKGROUND

A doula is a person who provides support to women in the perinatal period without providing medical services. During childbirth, the doula becomes a member of the interdisciplinary team. This integrative review aims to analyse the nature of the cooperation between doulas and midwives, its efficiency and challenges and ways of strengthening this cooperation.

METHODS

A structured integrative review of empirical and theoretical studies written in English was conducted. The literature search included MEDLINE, Cochrane, Scopus, ProQuest, Science Direct, Web of Science, and Embase Health Source: Nursing/Academic Edition databases. The analysis included papers published in 1995-2020. Dedicated documents were searched for different combinations of terms and standard logical operators. A manual search of the studies was included for additional references.

RESULTS

Twenty-three articles from 75 full-text records were analysed. Three main themes emerged. (1) doulas are needed to prop up the system (2) barriers in collaboration between midwives and doulas; and (3) how cooperation between midwives and doulas can be strengthened. None of the articles referred directly to the impact of collaboration between midwives and doulas on the quality of perinatal care.

CONCLUSION

This is the first review to analyse the impact of collaboration between midwives and doulas on the quality of perinatal care. Ensuring adequate collaboration between doulas and midwives requires effort from both of these professional groups and the health care system. However, such collaboration is supportive for birthing women and the perinatal care system. Further research in terms of the impact of this collaboration on the quality of perinatal care is needed.

Optimising maternity care for a subsequent pregnancy after a psychologically traumatic birth: A scoping review

BACKGROUND

Psychological birth trauma is recognised as a significant and ubiquitous sequelae from childbirth, with the incidence reported as up to 44%. In a subsequent pregnancy, women have reported a range of psychological distress symptoms from anxiety, panic attacks, depression, sleep difficulties and suicidal thoughts.

AIM

To summarise evidence on optimising a positive pregnancy and birth experience for a subsequent pregnancy following a psychologically traumatic pregnancy and identify research gaps.

METHODS

This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR check list. Six databases were searched using key words relating to psychological birth trauma and subsequent pregnancy. Utilising agreed criteria, relevant papers were identified, and data were extracted and synthesised.

RESULTS

A total of 22 papers met the inclusion criteria for this review. All papers addressed different aspects of what was important to women in this cohort, summarised as women wanting to be at the centre of their care. Pathways of care were diverse ranging from free birth to elective caesarean. There was no systematic process for identifying a previously traumatic birth experience and no education to enable clinicians to understand the importance of this.

CONCLUSION

For women who have experienced a previous psychologically traumatic birth, being at the centre of their care, in their subsequent pregnancy, is a priority. Embedding woman-centred pathways of care for women with this experience, as well as multidisciplinary education on the recognition and prevention of birth trauma, should be a research priority.

Death doula working practices and models of care: the views of death doula training organisations

BACKGROUND

The role of death doula has emerged in recent years, arguably as a result of overwhelming demands on carers, healthcare professionals and service providers in end-of-life care. Death doulas work independently without governing oversight and enact the role in various ways. The main driver of this evolving role is the organisations that train them. The aim of this study was to examine death doula training organisations' views with regard to DD business models, incorporating the death doula role into other existing models of care, and role enactment.

METHODS

An electronic survey was administered to 15 death doula training organisations in 5 countries asking additionally that they disseminate the survey. Responses were received from 13 organisations, based in Australia (n = 4), the US (n = 4), Canada (n = 2), the UK (n = 1), Sweden (n = 1) and New Zealand (n = 1). This paper provides the qualitative findings from four open-text questions posed within the survey related to models of care.

RESULTS

Qualitative data analysis was inductive, themes were determined in relation to: (1) standardised business model for death doulas, (2) death doulas incorporated into existing models of care or existing funding options, (3) death doulas who volunteer their services rather than charge money, and (4) role specialisation such as has occurred with birth doulas.

CONCLUSIONS

The death doula role has the potential to be formally recognised in the future under national registration schemes, accompanied by death doula training required via certification. Until such time the death doula role will continue to evolve much as the birth doula role has, organically and unstructured. How and if death doulas are incorporated into existing models of health or social care remains to be seen as the organisations that train them push for independence, flexibility and fiscal independence.

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.

Getting kicked off the program: Women's experiences of antenatal exclusion from publicly-funded homebirth in Australia

PROBLEM

Eligibility criteria for publicly-funded homebirth models are strict and, as such, many women who initially plan a homebirth later become excluded.

BACKGROUND

Fifteen publicly-funded homebirth programs are operating in Australia, offering eligible women the opportunity to give birth at home at no cost, with the care of a hospital-employed midwife.

AIM

To explore the experiences of women who planned a publicly-funded homebirth and were later excluded due to pregnancy complications or risk factors.

METHODS

A qualitative descriptive approach was taken. Recruitment was via social media sites specifically related to homebirth in Australia. Data collection involved semi-structured telephone interviews. Transcripts were thematically analysed.

FINDINGS

Thirteen women participated. They were anxious about 'Jumping through hoops' to maintain their low-risk status. After being 'Kicked off the program', women carefully 'negotiated the system' in order to get the birth they wanted in hospital. Some women felt bullied and coerced into complying with hospital protocols that did not account for their individual needs. Maintaining the midwife-woman relationship was a protective factor, decreasing negative experiences.

DISCUSSION

Women plan a homebirth to avoid the medicalised hospital environment and to gain access to continuity of midwifery care. To provide maternity care that is acceptable to women, hospital institutions need to design services that enable continuity of the midwife-woman relationship and assess risk on an individual basis.

CONCLUSION

Exclusion from publicly-funded homebirth has the potential to negatively impact women who may feel a sense of loss, uncertainty or emotional distress related to their planned place of birth.

Challenging norms: Making non-normative choices in childbearing. Results of a meta ethnographic review of the literature

OBJECTIVE

Women have the right to make choices during pregnancy and birth that sit outside clinical guidelines, medical recommendations, or normative expectations. Declining recommended place or mode of birth, routine intervention or screening can be considered 'non-normative' within western cultural and social expectations around pregnancy and childbirth. The aim of this review is to establish what is known about the experiences, views, and perceptions of women who make non-normative choices during pregnancy and childbirth to uncover new understandings, conceptualisations, and theories within existing literature.

METHODS

Using the meta-ethnographic method, and following its seven canonical stages, a systematic search of databases was performed, informed by eMERGe guidelines.

FINDINGS

Thirty-three studies met the inclusion criteria. Reciprocal translation resulted in three third order constructs - 'influences and motivators', 'barriers and conflict and 'knowledge as empowerment'. Refutational translation resulted in one third order construct - 'the middle ground', which informed the line of argument synthesis and theoretical insights.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings of this review suggest that whilst existing literature from a range of high-income countries with similar healthcare systems to the UK have begun to explore non-normative decision-making for discrete episodes of care and choices, knowledge based, theoretical and population gaps exist in relation to understanding the experiences of, and wider social processes involved in, making non-normative choices across the UK maternity care continuum.

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.

Ten years of a publicly funded homebirth service in Victoria: Maternal and neonatal outcomes

BACKGROUND

Rates of homebirth in Australia remain low, at less than 0.3% of all births.

AIMS

To report maternal and neonatal outcomes of ten years of a publicly funded homebirth service, 2009-2019.

METHOD

Retrospective analysis of clinical outcome data including neonatal outcomes of women who requested a homebirth at a large metropolitan health service in Victoria, Australia. The primary outcomes included: maternal outcomes (mortality, transfer to hospital, place and mode of birth, perineal status, type of third stage of labour, postpartum haemorrhage), and neonatal outcomes (mortality, Apgar score at five minutes, birthweight, breastfeeding initiation, significant morbidity, transfer to hospital).

RESULTS

Referrals for 827 women were reviewed; 633 remained eligible at 36 weeks gestation, and 473 (57%) birthed at home. Compared to women who did not, women who had a homebirth were significantly more likely to be multiparous, have a normal vaginal birth and an intact perineum, less likely to require suturing and less likely to have blood loss of more than 500 mL. Compared to infants not born at home, infants born at home were significantly less likely to require resuscitation, more likely to be of normal birthweight and exclusively receive breastmilk on discharge. There were no maternal deaths and one neonatal death of a baby born at home before the arrival of a midwife.

CONCLUSIONS

The outcomes for women accepted into the publicly funded homebirth program suggest appropriate triaging and case selection. A publicly funded homebirth program, with appropriate governance and clinical guidelines, appears to be a safe option for women experiencing low-risk pregnancies.

Inclusion and exclusion criteria for publicly-funded homebirth in Australia: A scoping review

BACKGROUND

There are fifteen publicly-funded homebirth programs currently operating in Australia. Suitability for these programs is determined by a series of inclusion and exclusion criteria.

AIM

The aim of this scoping review is to identify common inclusion and exclusion criteria for publicly-funded homebirth programs and other related factors that affect access to these programs.

METHODS

A Google search was conducted for publicly-funded homebirth programs listed on the National Publicly-funded Homebirth Consortium website. Public websites, documents, and policies were analysed to identify inclusion and exclusion criteria for these programs.

FINDINGS

Eleven of the 15 publicly-funded homebirth programs mention the availability of homebirth on their health service website, with varying levels of information about the inclusion and exclusion criteria available. Two of the programs with no information on their health service website are covered by a state-wide guideline. Additional details were sought directly from programs and obtaining further information from some individual homebirth programs was challenging. Variation in inclusion and exclusion criteria exists between programs. Common areas of variation include restrictions relating to Body Mass Index, parity, age, English language ability, tests required during pregnancy, and gestation at booking to the homebirth program.

CONCLUSION

The inclusion and exclusion criteria for a publicly-funded homebirth program determines women's access to the program. Limited publicly available information regarding inclusion and exclusion criteria for many publicly-funded homebirth programs is likely to limit women's awareness of and access to these programs.

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.

Women's perceptions of inclusion and exclusion criteria for publicly-funded homebirth - A survey

BACKGROUND

There are 15 publicly-funded homebirth programs in Australia. Women's access to these programs is determined by program specific inclusion and exclusion criteria.

AIMS

To examine women's perception of inclusion and exclusion criteria for publicly-funded homebirth programs in Australia and how these perceptions may influence women's choices and access to these programs.

METHODS

A national online survey was conducted and promoted through social media networks to women interested in homebirth in Australia. Quantitative data were analysed to generate descriptive statistics and a content analysis was performed on qualitative data.

FINDINGS

A total of 830 surveys were collected. Most women were supportive of inclusion and exclusion criteria related to social and environmental factors, although there was ambivalence about requiring ambulance cover, not having a history of domestic violence in the current relationship and requiring the woman to speak basic English. With regards to obstetric factors, only a requirement for labour to commence spontaneously at term was supported by over half of participants. All other obstetric related criteria had over half of participants disagreeing or strongly disagreeing that they should be used to prevent a woman from birthing at home. A desire for choice and access was frequently mentioned in the qualitative data.

CONCLUSION

There is a need to address the lack of choice many women experience when pregnant and the lack of equitable access to affordable homebirth services in Australia.

Validating a scale to measure respectful maternity care in Australia: Challenges and recommendations

OBJECTIVE

Respectful maternity care is a pervasive human rights issue, but little is known about its realisation in Australia. Two scales, developed in North America, measure key aspects of respectful maternity care: the Mothers on Respect Index and Mothers Autonomy in Decision Making scale. This study aimed to validate these two scales in Queensland, Australia, and to determine the extent to which women currently experience respectful maternity care and autonomy in decision making.

DESIGN

A sequential two-phase study. A focus group reviewed the scales, made adaptations to scale items and completed a Content Validation Survey. The Respectful Maternity Care in Queensland survey, comprising the validated Australian scales and demographic questions was distributed online in early 2020.

SETTING

Queensland, Australia.

PARTICIPANTS

Focus group involved women (n=10) who were aged over 18, English-speaking, and had given birth during the preceding two years. All women who had birthed in Queensland between September 2019 and February 2020, were eligible to participate in the cross-sectional survey. 161 women participated in the survey.

MEASUREMENTS AND FINDINGS

Item content validity (>0.78) was established for all but one item. Scale content validity was established for both scales (0.92 and 0.99 respectively). Survey participants (n= 161) were mostly married/partnered (95%), heterosexual (93%), tertiary educated (47%), Caucasian (88%), and had experienced a range of maternity models of care. Median scores on each scale (74 and 26 respectively) indicated that participants felt well respected and highly autonomous. Free-text comments highlighted the importance of relationship-based care.

KEY CONCLUSIONS

Both scales appear valid for use in Australia. Although most participants reported high levels of respect and autonomy, the proportion of participants who had experienced continuity of midwifery care was also high.

IMPLICATIONS FOR PRACTICE

Both scales could be routinely deployed as patient reported experience measures in Australia, broadening the data that informs maternity service planning and delivery.

What influences rural women's choices in maternity care: A qualitative exploratory study

Rural women are likely to experience difficulties accessing maternity care that is readily available in metropolitan areas. This limited access can impede women's ability to make informed choices that enhance safety and minimize harm. This study explored the experiences of women who had given birth in a rural environment and the factors that influenced their choices regarding their maternity care. Semistructured interviews were conducted with 10 women for this qualitative, exploratory study. These women had birthed within rural areas of Victoria, Australia, between May 2016 and May 2017. Thematic analysis was undertaken. Three main themes emerged: (i) being influenced by previous childbirth experiences, (ii) feeling safe and supported with their maternity care provider, and (iii) being supported in their birthing choices. The availability of maternity care providers and travel time to facilities limited the choices of rural women. This study provided valuable insights into what was behind the decisions of rural women's choices regarding their maternity care. To assist with making informed decisions regarding their maternity care, all available models of maternity care should be presented to rural women.

Differential access to continuity of midwifery care in Queensland, Australia

ObjectiveTo determine maternal access to continuity of midwifery care in public maternity hospitals across the state of Queensland, Australia. MethodsMaternal access to continuity of midwifery care in Queensland was modelled by considering the proportion of midwives publicly employed to provide continuity of midwifery care alongside 2017 birth data for Queensland Hospital and Health Services. The model assumed an average caseload per full-time equivalent midwife working in continuity of care with 35 women per annum, based on state Nursing and Midwifery Award conditions. Hospitals were grouped into five clusters using standard Australian hospital classifications. ResultsTwenty-seven facilities (out of 39, 69%) across all 15 hospital and health services in Queensland providing a maternity service offered continuity of midwifery care in 2017 (birthing onsite). Modelling applying the assumed caseload of 35 women per full-time equivalent midwife found wide variations in the percentage of women able to access continuity of midwifery care, with access available for an estimated 18% of childbearing women across the state. Hospital classifications with higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. Regional health services with level 3 district hospitals assisting with &lt;500 births showed higher levels of access, potentially due to additional challenges to meet local population needs to those of a metropolitan service. Access to full continuity of midwifery care in level 3 remote hospitals (&lt;500 births) was artificially inflated due to planned pre-labour transfers for women requiring specialised intrapartum care and women who planned to birth at other hospitals. ConclusionsDespite strong evidence that continuity of midwifery care offers optimal care for women and their babies, there was significant variation in implementation and scale-up of these models across hospital jurisdictions. What is known about the topic?Access to continuity of midwifery care for pregnant women within the public health system varies widely; however, access variation among different hospital classification groups in Australian states and territories has not been systematically mapped. What does this paper add?This paper identified differential access to continuity of midwifery care among hospital classifications grouped for clinical services capability and birth volume in one state, Queensland. It shows that higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. What are the implications for practitionersScaling up continuity of midwifery care among all hospital classification groups in Queensland remains an important public health strategy to address equitable service access.

From hopelessness to some hope: A qualitative interpretive research project to improve birthing experiences in Jordan

BACKGROUND

Many women living in Middle Eastern countries report negative, dehumanising experiences of childbirth. Finding effective ways of changing maternity care to improve women's experience is needed but is challenging.

AIM

This paper explores the potential strategies to improve birthing experiences of women in Jordan and identifies the facilitators and obstacles to change.

METHOD

A qualitative interpretive research design underpinned by a feminist approach was used. Seventeen community women, 14 midwives and midwifery leaders were engaged in workshops and face-to-face semi-structured interviews. Data were transcribed verbatim and thematic analysis undertaken.

RESULTS

An overarching theme "From hopelessness to some hope" emerged from data analysis and comprised of two themes: 'It's hopeless-there are so many obstacles'; and 'Finding some hope for the way forward'. The community women were unhappy with the current maternity services but accepted the situation. Midwives offered explanations for the way women are treated, including that women have no voice. For these participants, the obstacles seemed almost insurmountable; however, there was some hope expressed about potential for small changes to occur.

CONCLUSIONS

This study highlights the value of women and midwives sharing experiences and listening to the stories of women. Listening to women's birth stories may also be an important element of undergraduate and continuing education in Jordan. Small changes, such as promoting women's dignity by ensuring they are covered during birth are possible, but real change needs to be generated at a professional and societal level.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries

BACKGROUND

The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States.

METHOD

We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system.

RESULTS

The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems.

CONCLUSIONS

The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

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.

Why do women choose homebirth in Australia? A national survey

BACKGROUND

In Australia there have been regulatory and insurance changes negatively affecting homebirth.

AIM

The aim of this study is to explore the characteristics, needs and experiences of women choosing to have a homebirth in Australia.

METHODS

A national survey was conducted and promoted through social media networks to women who have planned a homebirth in Australia. Data were analysed to generate descriptive statistics.

FINDINGS

1681 surveys were analysed. The majority of women indicated a preference to give birth at home with a registered midwife. However, if a midwife was not available, half of the respondents indicated they would give birth without a registered midwife (freebirth) or find an unregistered birthworker. A further 30% said they would plan a hospital or birth centre birth. In choosing homebirth, women disclosed that they wanted to avoid specific medical interventions and the medicalised hospital environment. Nearly 60% of women reported at least one risk factor that would have excluded them from a publicly funded homebirth programme. Many women described their previous hospital experience as traumatic (32%) and in some cases, leading to a diagnosis of post-traumatic stress disorder (PTSD, 6%). Only 5% of women who reported on their homebirth experience considered it to be traumatic (PTSD, 1%). The majority of these were associated with how they were treated when transferred to hospital in labour.

CONCLUSION

There is an urgent need to expand homebirth options in Australia and humanise mainstream maternity care. A potential rise in freebirth may be the consequences of inaction.

Jordanian women's experiences and constructions of labour and birth in different settings, over time and across generations: a qualitative study

Background

Overwhelmingly, women in Middle Eastern countries experience birth as dehumanising and disrespectful. Women’s stories can be a very powerful way of informing health services about the impact of the care they receive and can promote practice change. The aim of this study is to examine Jordanian women’s experiences and constructions of labour and birth in different settings (home, public and private hospitals in Jordan, and Australian public hospitals), over time and across generations.

Method

A qualitative interpretive design was used. Data were collected by face-to-face semi-structured interviews with 27 Jordanian women. Of these women, 20 were living in Jordan (12 had given birth in the last five years and eight had birthed over 15 years ago) while seven were living in Australia (with birthing experience in both Jordan and Australia). Interview data were transcribed verbatim and analysed thematically.

Results

Women’s birth experiences differed across settings and generations and were represented in the four themes: ‘Birth at home: a place of comfort and control’; ‘Public Hospital: you should not have to suffer’; ‘Private Hospital: buying control’ and ‘Australian maternity care: a mixed experience’. In each theme, the concepts: Pain, Privacy, the Personal and to a lesser extent, Purity (cleanliness), were present but experienced in different ways depending on the setting (home, public or private hospital) and the country.

Conclusions

The findings demonstrate how meanings attributed to labour and birth, particularly the experience of pain, are produced in different settings, providing insights into the institutional management and social context of birth in Jordan and other Middle Eastern countries. In the public hospital environment in Jordan, women had no support and were treated disrespectfully. This was in stark contrast to women birthing at home only one generation before. Change is urgently needed to offer humanised birth in the Jordanian maternity system,

Why women chose unassisted home birth in Malaysia: a qualitative study

BACKGROUND

Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions.

METHODS

Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs.

CONCLUSIONS

Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers' awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers' beliefs and values.

Why women chose unassisted home birth in Malaysia: A qualitative study.. [DOI: 10.21203/rs.2.16973/v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions. Methods: Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.Results: Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs.Conclusions: Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers' awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers’ beliefs and values.

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.

Norwegian women's motivations and preparations for freebirth-A qualitative study

AIM

This study was aimed at describing Norwegian women's motivations and preparations for freebirth.

METHODS

This qualitative study involved 12 individual interviews conducted face to face or via Skype with women from different parts of Norway. The material was analysed using qualitative content analysis inspired by Graneheim and Lundman.

RESULTS

Three categories describing the women's motivations and preparations for freebirth were identified. Unsatisfied with the care offered today described how the women thought that hospitals did not support normal birth and made an inadequate homebirth offer. The category earlier uncomplicated and traumatic births influence freebirth choices described two different dimensions of motivations for freebirth. Trust in one's own knowledge and capacity referred to how women viewed birth as a natural process, their faith in themselves, how this view and faith influenced their preparation and how they gained knowledge about the birth process to prepare. An overall theme emerged: deep trust in birth as a natural process and the women's own capacity to give birth embedded in distrust of the maternity care system.

CONCLUSION

This study showed that motivations for freebirth were embedded in overall dissatisfaction with today's maternity care, the inadequate homebirth offer and deep trust in the women's own capacity to give birth.

Why women chose unassisted home birth in Malaysia: A qualitative study.. [DOI: 10.21203/rs.2.16973/v2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions. Methods: Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literatures. The interviews were audio recorded, transcribed verbatim and analysed using thematic analysis. Results: Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and strong despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs. Conclusions: Women may choose unassisted home birth to express their personal beliefs and values, at the expense of the health risks. Apart from increasing mothers’ awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers’ beliefs and values.

Exploring social and health care representations about home birth: An Integrative Literature Review

AIMS

Exploring social and health care representations of home birth by conducting an integrative review of the literature.

DESIGN

Integrative Literature Review.

DATA SOURCES

The search was based on the following keywords: "birth, home," "home birth," "childbirth, home." And the terms: "planned home birth," and "empowerment women homebirth" (in English). "partos en casa," and "partos domiciliarios" (in Spanish) in the following databases: Biomedical Central, Cochrane Library, Dialnet, DOAJ, Lilacs, PubMed, Scopus, Scielo, and Web of Science.

REVIEW METHODS

A total of 156 publications dated between 2004 and 2017 were initially obtained and a total of 41 articles were finally selected according to the criteria of inclusion, methodological rigor, and researchers' triangulation.

RESULTS

Four dimensions of the issue emerged out of the 41 articles analyzed: (a) the Dimension of "Empowerment in Childbirth;" (b) the Dimension of "Comparative Socio-Medical Childbirth Studies;" (c) the "Institutional Dimension of Childbirth;" (d) the "Cultural Dimension of Childbirth."

CONCLUSION

From the health management perspective, home birth is not widely accepted today as a valid and safe alternative. However, women's social representations indicate an interest in returning to birth at home as a response to the excessive medicalization and institutionalization of childbirth, and value highly its autonomy and comfort.

A pathway to establish a publicly funded home birth program in Australia

BACKGROUND

Home births provide women a birth choice where they may feel more comfortable and confident in their ability to give birth.

PROBLEM

Most women in Victoria do not have publicly funded access to appropriately trained health professionals if they choose to give birth at home.

METHODS

This paper describes the process of setting up a publicly funded home birth service and provide details of description of the set up and governance. We also report outcomes over 9 years with respect to parity, transfer to hospital, adverse maternal and neonatal outcomes.

RESULTS

Of the 191 women who were still booked into the home birth program at 36 weeks gestation, 148 (77.5%) women gave birth at home and 43 (22.5%) women were transferred into the hospital. The overall rate of vaginal birth was also high among the women in the home birth program, 185 (96.9%) with no added complications ascribed to home births. Such as severe perineal trauma [n=1] 0.6% PPH [n=4] 2.7%, Apgar score less than 7 at 5min [n=0] admissions post home birth to special care nursery [n=2] 1.35%.

DISCUSSION

This unique study provides a detailed road map of setting up a home birth practice to facilitate other institutions keen to build a publicly funded home birth service. The birth outcome data was found to be consistent with other Australian studies on low risk home births.

CONCLUSION

Well-designed home birth programs following best clinical practices and procedures can provide a safe birthing option for low risk women.

Understanding Myths in Pregnancy and Childbirth and the Potential Adverse Consequences: A Systematic Review

The trend of choosing natural birth at home without proper supervision is gaining more attention and popularity in Malaysia. This is partly due to wrong beliefs of modern medical care. It prompts the need to explore further into other myths and wrong beliefs present in communities around the world surrounding pregnancy and childbirth that may lead to harmful consequences. A total of 25 literatures were selected and reviewed. The most reported wrong belief is the eating behaviour such as avoiding certain nutritious fruits besides eating saffron to produce fairer skinned babies which in fact contains high doses of saffron that may lead to miscarriage. The most worrying myth however, is that unregulated birth attendants such as doulas have the necessary knowledge and skills to manage complications in labour which may well end up in perinatal or even maternal death. Other myths suggested that modern medical care such as vaginal examinations and baby's heart monitoring in labour as unnecessary. A well-enforced health education programme by well-trained healthcare personnel besides sufficient number of antenatal care visits are needed to overcome these myths, wrong beliefs and practices. In conclusion, potential harmful beliefs and practices in pregnancy and childbirth are still abound in today's communities, not just in least developed and developing countries but also in developed countries. Women and children are two very vulnerable groups, therefore debunking myths and eliminating harmful practices should be one of a healthcare provider priority especially those in the primary care settings as they are the closest to the community.

Respectful and disrespectful care in the Czech Republic: an online survey

BACKGROUND

Respectful maternity care includes treating women with dignity, consulting them about preferences, gaining consent for treatment, respecting their wishes, and giving care based on evidence, not routines. In the absence of any documented evidence, this study aimed to ascertain maternity care-givers' perceptions of respectful care provided for childbearing women in Czech Republic.

METHODS

Following ethical approval, an online quantitative survey with qualitative comments was completed by 52 respondents recruited from workshops on promoting normal birth, followed by snowball sampling. The majority were midwives (50%) or doulas (46%) working in one of 51 hospitals, or with homebirths. Chi-square analysis was used for comparisons.

RESULTS

Non-evidenced-based interventions, described as 'always' or 'frequently' used in hospitals, included application of electronic fetal monitoring in normal labour (n = 40, 91%), shaving the perineum (n = 10, 29%), and closed-glottal pushing (n = 32, 94%). Positions stated as most often used for spontaneous vaginal births were semi-recumbent (n = 31, 65%) or lying flat (n = 15, 31%) in hospital, and upright at home (n = 27, 100%). Average episiotomy and induction of labour rates were estimated at 40 and 26%, respectively, higher than accepted norms. Eighteen respondents (46%) said reasons for performing vaginal examinations were not explained to women in hospitals, and 21 (51%) said consent was 'never' sought. At home, 25 (89%) said reasons were explained, and permission 'always' sought (n = 22, 81%). Thirteen (32%) said hospital clinicians explained why artificial rupture of membranes was necessary, but only ten (25%) said they 'always' sought permission. The majority said that hospital clinicians 'never'/'almost never' explained reasons for performing an episiotomy (13 = 34%), gained permission (n = 20, 54%) or gave local anaesthetic (n = 19, 51%). Contrastingly, 17 (100%) said midwives at home explained the reasons for episiotomy and asked permission. When clinicians disagreed with women's decisions, 13 (35%) respondents said women might be told to 'face the consequences', six (16%) stated that the 'psychological pressure' experienced caused women to 'give up and give their permission', and four (11%) said the intervention would be performed 'against her will.'

CONCLUSIONS

Findings reveal considerable levels of disrespectful, non-evidenced-based, non-consensual and abusive practices that may leave women with life-long trauma.

Experiences of Greek women of water immersion during normal labour and birth. A qualitative study

INTRODUCTION

There is scarce information on water births in Greece, as few women labour and give birth in water. The Greek public health system does not provide water immersion as a birthing option, and so women can only experience this option in private healthcare settings. The aim of this study was to explore the key concepts and themes identified from an analysis of the experiences of women who laboured and gave birth immersed in water.

METHODS

This was a qualitative study involving twelve women who used water immersion during labour, of which nine had also a water birth. Individual interviews were conducted and their content was analysed using thematic analysis.

RESULTS

Three main themes were identified: Water use as a natural way of birth, Mixed messages from the healthcare professionals, and Partner's supportive role during water birth. All women reported a positive birth experience and water immersion helped them cope with the pain of labour. They felt greatly empowered following birth and this contributed to successful breastfeeding for more than one year, in the majority of cases. They reported difficulties in finding healthcare professionals that were in support of their choices. The women felt highly supported by the partner's role.

CONCLUSIONS

Labouring and giving birth immersed in water was met with great satisfaction by all women. The findings of this study have added to the current body of midwifery knowledge on how water immersion can improve a woman's experience and so support a normal birth outcome.

Born before arrival in NSW, Australia (2000-2011): a linked population data study of incidence, location, associated factors and maternal and neonatal outcomes

OBJECTIVES

To determine incidence, associated factors, outcomes and geographical occurrence of born before arrival (BBA) in New South Wales, Australia.

DESIGN

A linked population data study involving population-based surveillance systems was undertaken for the years 2000-2011.

SETTING

New South Wales, Australia.

PARTICIPANTS

All women who underwent BBA compared with women who birthed in hospital/birth centre settings.

RESULTS

During the time period, there were 1 097 653 births and a BBA rate of 4.6 per 1000 births. The BBA rate changed from 4.2 to 4.8 per 1000 births over time (p=0.06). Neonates BBA were more likely to be premature (12.5% compared with 7.3%), of lower birth weight (209.8 g mean difference) and/or be admitted to a special care nursery or neonatal intensive care unit (20.6% compared with 15.6%). The perinatal mortality rate was significantly higher in the BBA cohort (34.6 compared with 9.3 per 1000 births). Women in the BBA cohort were more likely to be in the lowest socioeconomic decile, multiparous, have higher rates of smoking (30.5% compared with 13.8%) and more likely to suffer a postpartum haemorrhage requiring transfusion than the non-BBA cohort (1.5% compared with 0.7%). The most commonly occurring complications for neonates were suspected infection (6.9%), hypothermia (6.9%), respiratory distress (5.4%), congenital abnormality (4.0%) and neonatal withdrawal symptoms (2.4%). BBA more commonly occurred in geographical areas where the distance to a maternity unit is >2 hours drive and in coastal regions where there is also a high rate of homebirth.

CONCLUSION

BBA occurs more frequently in multiparous women of lower socioeconomic status. There potentially is an effect of geography on the occurrence of BBA, as geographical area of high homebirth and BBA coexists, indicating that freebirth followed by an unplanned transfer to hospital may be occurring.