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

Birth outcomes for women planning Vaginal Birth after Caesarean (VBAC) in midwifery led settings: A systematic review and meta-analysis

PROBLEM

There is a limited knowledge base available to midwives, obstetricians and women planning vaginal birth after caesarean (VBAC), impeding their ability to make informed choices regarding planned place of birth.

BACKGROUND

A VBAC is associated with fewer complications for both mother and baby, but little is known on the safety and success of planning a VBAC in midwifery led settings such as birth centres and home birth, compared to obstetric led settings.

AIM

To synthesise the findings of published studies regarding maternal and neonatal outcomes with planned VBAC in midwifery setting compared to obstetric units.

METHODS

PubMed, EMBASE, CINAHL complete, Maternity and Infant Care, PsycINFO, and Science Citation Index databases were systematically searched on 16/08/2022 for all quantitative research on the outcomes for women planning VBAC in midwifery led settings compared to obstetric led settings in high income countries. Included studies were quality assessed using the CASP Checklist. Binary outcomes are incorporated into pairwise meta-analyses, effect sizes reported as risk ratios with 95 % confidence intervals. A τ² estimate of between-study variance was performed for each binary outcome analysis. Other, more heterogeneous outcomes are narratively reported.

FINDINGS

Two high-quality studies, out of 420 articles, were included. VBAC planned in a midwifery-led setting was associated with a statistically significant increase in unassisted vaginal birth (RR=1.42 95 % CI 1.37 to 1.48) and decrease in emergency caesarean section (RR= 0.46 95 % CI 0.39 to 0.56) and instrumental birth (RR= 0.33 95 % CI 0.23 to 0.47) compared with planned VBAC in an obstetric setting. There were no significant differences in uterine rupture (RR= 1.03 95 % CI 0.52 to 2.07), admission to special care nursery (RR= 0.71 95 % CI 0.47 to 1.23) or Apgar score of 7 or less at 5 min (RR= 1.16 95 % CI 0.66 to 2.03).

CONCLUSION

Planning VBAC in midwifery led settings is associated with increased vaginal birth and a reduction in interventions such as instrumental birth and caesarean section. Adverse perinatal outcomes are rare, and further research is required to draw conclusions on these risks.

Ethics round table: choice and autonomy in obstetrics

Decisions about how and where they deliver their baby are extremely important to pregnant women. There are very strong ethical norms that women's autonomy should be respected, and that plans around birth should be personalised. However, there appear to be profound challenges in practice to respecting women's choices in pregnancy and labour. Choices carry risks and consequences-to the woman and her child; also potentially to her caregivers and to other women.What does it mean for women's autonomy to be respected in obstetrics? How should health professionals respond to refusals of treatment or requests for care outside normal guidelines? What are the ethical limits to autonomy? In this clinical ethics round table, service users, midwives, obstetricians, philosophers and ethicists respond to two hypothetical cases drawn from real-life scenarios.

Women who desire 'natural childbirth' in hospitals in a highly medicalized birth care system

'Natural childbirth' continues to matter to women in today's world. Building on qualitative research informed by constructivist grounded theory, I aim to bring insight into the birth experiences of women who demanded 'natural childbirth' in Czech hospitals in the context of a highly medicalized birth care system. I explore four themes: (1) the requirements of birth care, (2) strategies to achieve 'natural childbirth', (3) women's views of the hospital environment, (4) that of healthcare providers. These themes address prospective and retrospective aspects of the core process of negotiating good and respectful care.

FIGO good practice recommendations on optimizing models of care for the prevention and mitigation of preterm birth

The global challenge of preterm birth persists with little or no progress being made to reduce its prevalence or mitigate its consequences, especially in low-resource settings where health systems are less well developed. Improved delivery of respectful person-centered care employing effective care models delivered by skilled healthcare professionals is essential for addressing these needs. These FIGO good practice recommendations provide an overview of the evidence regarding the effectiveness of the various care models for preventing and managing preterm birth across global contexts. We also highlight that continuity of care within existing, context-appropriate care models (such as midwifery-led care and group care), in primary as well as secondary care, is pivotal to delivering high quality care across the pregnancy continuum-prior to conception, through pregnancy and birth, and preparation for a subsequent pregnancy-to improve care to prevent and manage preterm birth.

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.

Shroud waving self-determination: A qualitative analysis of the moral and epistemic dimensions of obstetric violence in the Netherlands

Obstetric violence is an urgent global problem. Recently, several studies have appeared on obstetric violence in the Netherlands, indicating that it is a more widespread phenomenon in Dutch maternity care than commonly thought. At the same time, there has been very little public outrage over these studies. The objective of this qualitative research is to gain insight into the working and normalization of obstetric violence by focusing on the moral and epistemic injustices that both facilitate obstetric violence and make it look acceptable. Following the study design of Responsive Evaluation, interviews, homogenous, and heterogenous focus groups were done in three phases, with thirty-one participants, consisting of ten mothers, eleven midwives, five doulas and five midwives in training. All participants were already critically engaged with the topic, which was a selection criterion to be able to bring the existing depth of knowledge on this topic of people in the field to the fore. Data was analyzed through Thematic Analysis. We elaborate on two groups of results. First, we discuss the forms of obstetric violence most commonly mentioned by the participants, which were vaginal examinations, episiotomies, and pelvic floor support. Second, we demonstrate two major themes that concern practices related to moral and epistemic injustice: 1) 'Playing the dead baby card', with the sub-themes 'shroud waving', 'hidden agenda', and 'normalizing obstetric violence'; and 2) 'Troubling consent', with sub-themes 'not being asked for consent', 'saying "yes"', 'saying "no"', and 'giving up resistance'. While epistemic injustice has been analyzed in relation to obstetric violence, moral injustice has not yet been conceptualized as a fundamental part of both the practice and the justification of obstetric violence. This research hence contributes not only to the better understanding of obstetric violence in the Netherlands, but also to a further theorization of this specific form of gender-based violence.

Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment

Psychological birth trauma and childbirth-related posttraumatic stress disorder represent a substantial burden of disease with 6.6 million mothers and 1.7 million fathers or co-parents affected by childbirth-related posttraumatic stress disorder worldwide each year. There is mounting evidence to indicate that parents who develop childbirth-related posttraumatic stress disorder do so as a direct consequence of a traumatic childbirth experience. High-risk groups, such as those who experience preterm birth, stillbirth, or preeclampsia, have higher prevalence rates. The main risks include antenatal factors (eg, depression in pregnancy, fear of childbirth, poor health or complications in pregnancy, history of trauma or sexual abuse, or mental health problems), perinatal factors (eg, negative subjective birth experience, operative birth, obstetrical complications, and severe maternal morbidity, as well as maternal near misses, lack of support, dissociation), and postpartum factors (eg, depression, postpartum physical complications, and poor coping and stress). The link between birth events and childbirth-related posttraumatic stress disorder provides a valuable opportunity to prevent traumatic childbirths and childbirth-related posttraumatic stress disorder from occurring in the first place. Childbirth-related posttraumatic stress disorder is an extremely distressing mental disorder and has a substantial negative impact on those who give birth, fathers or co-parents, and, potentially, the whole family. Still, a traumatic childbirth experience and childbirth-related posttraumatic stress disorder remain largely unrecognized in maternity services and are not routinely screened for during pregnancy and the postpartum period. In fact, there are gaps in the evidence on how, when, and who to screen. Similarly, there is a lack of evidence on how best to treat those affected. Primary prevention efforts (eg, screening for antenatal risk factors, use of trauma-informed care) are aimed at preventing a traumatic childbirth experience and childbirth-related posttraumatic stress disorder in the first place by eliminating or reducing risk factors for childbirth-related posttraumatic stress disorder. Secondary prevention approaches (eg, trauma-focused psychological therapies, early psychological interventions) aim to identify those who have had a traumatic childbirth experience and to intervene to prevent the development of childbirth-related posttraumatic stress disorder. Tertiary prevention (eg, trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing) seeks to ensure that people with childbirth-related posttraumatic stress disorder are identified and treated to recovery so that childbirth-related posttraumatic stress disorder does not become chronic. Adequate prevention, screening, and intervention could alleviate a considerable amount of suffering in affected families. In light of the available research on the impact of childbirth-related posttraumatic stress disorder on families, it is important to develop and evaluate assessment, prevention, and treatment interventions that target the birthing person, the couple dyad, the parent-infant dyad, and the family as a whole. Further research should focus on the inclusion of couples in different constellations and, more generally, on the inclusion of more diverse populations in diverse settings. The paucity of national and international policy guidance on the prevention, care, and treatment of psychological birth trauma and the lack of formal psychological birth trauma services and training, highlight the need to engage with service managers and policy makers.

'My doctor just called me a good girl and I died a bit inside': From everyday misogyny to obstetric violence in UK fertility and maternity services

This paper begins with the common phrase 'good girl' as a lens through which to explore the insidious nature of patronising and paternalistic language on women's agency in obstetric care. Here we see how misogynistic language is both violence against women in its own right, and serves to create a context in which more extreme obstetric violence can be precipitated. Based on thematic analysis of discussion on Mumsnet, and on contributions to a research-focused Facebook group, this paper illustrates the complexity of recognising and refuting misogyny as a female patient as well as the damage that can occur from a cultural context in which this language is normalised. Here, words both boast a materiality through the environments they reify, and become transient and slippery, with semiotic uncertainty.

Single-session visuospatial task procedure to prevent childbirth-related posttraumatic stress disorder: a multicentre double-blind randomised controlled trial

Preventive evidence-based interventions for childbirth-related posttraumatic stress disorder (CB-PTSD) are lacking. Yet, 18.5% of women develop CB-PTSD symptoms following an unplanned caesarean section (UCS). This two-arm, multicentre, double-blind superiority trial tested the efficacy of an early single-session intervention including a visuospatial task on the prevention of maternal CB-PTSD symptoms. The intervention was delivered by trained maternity clinicians. Shortly after UCS, women were included if they gave birth to a live baby, provided consent, and perceived their childbirth as traumatic. Participants were randomly assigned to the intervention or attention-placebo group (allocation ratio 1:1). Assessments were done at birth, six weeks, and six months postpartum. Group differences in maternal CB-PTSD symptoms at six weeks (primary outcomes) and six months postpartum (secondary outcomes) were assessed with the self-report PTSD Checklist for DSM-5 (PCL-5) and by blinded research assessors with the Clinician-administered PTSD scale for DSM-5 (CAPS-5). Analysis was by intention-to-treat. The trial was prospectively registered (ClinicalTrials.gov, NCT03576586). Of the 2068 women assessed for eligibility, 166 were eligible and 146 were randomly assigned to the intervention (n = 74) or attention-placebo control group (n = 72). For the PCL-5, at six weeks, a marginally significant intervention effect was found on the total PCL-5 PTSD symptom count (β = -0.43, S.E. = 0.23, z = -1.88, p < 0.06), and on the intrusions (β = -0.73, S.E. = 0.38, z = -1.94, p < 0.0525) and arousal (β = -0.55, S.E. = 0.29, z = -1.92, p < 0.0552) clusters. At six months, a significant intervention effect on the total PCL-5 PTSD symptom count (β = -0.65, S.E. = 0.32, z = -2.04, p = 0.041, 95%CI[-1.27, -0.03]), on alterations in cognition and mood (β = -0.85, S.E. = 0.27, z = -3.15, p = 0.0016) and arousal (β = -0.56, S.E. = 0.26, z = -2.19, p < 0.0289, 95%CI[-1.07, -0.06]) clusters appeared. No group differences on the CAPS-5 emerged. Results provide evidence that this brief, single-session intervention carried out by trained clinicians can prevent the development of CB-PTSD symptoms up to six months postpartum.

Systematic review of women's experiences of planning home birth in consultation with maternity care providers in middle to high-income countries

AIM

To synthesise findings from published studies, which reported on women's experiences of planning a home birth in consultation with maternity care providers.

DESIGN

Systematic Review DATA SOURCES: We searched seven bibliographic databases, (Ovid Medline, Embase, PsycInfo, CINAHL plus, Scopus, ProQuest and Cochrane (Central and Library), from January 2015 to 29th April 2022.

REVIEW METHODS

Primary studies were included if they investigated women's experiences of planning a home birth with maternity care providers, in upper-middle and high-income countries and written in English language. Studies were analysed using thematic synthesis. GRADE-CERQual was used to assess the quality, coherence, adequacy and relevance of data. The protocol is registered on PROSPERO registration ID: CRD 42018095042 (updated 28th September 2020) and published.

RESULTS

1274 articles were retrieved, and 410 duplicates removed. Following screening and quality appraisal, 20 eligible studies (19 qualitative and 1 survey) involving 2,145 women were included.

KEY CONCLUSIONS

Women's prior traumatic experience of hospital birth and a preference for physiological birth motivated their assertive decision to have a planned home birth despite criticisms and stigmatisation from their social circle and some maternity care providers. Midwives' competence and support enhanced women's confidence and positive experiences of planning a home birth.

IMPLICATIONS FOR PRACTICE

This review highlights the stigma that some women feel and the importance of support from health professionals, particularly midwives when planning a home birth. We recommend accessible evidence-based information for women and their families to support women's decision-making for planned home birth. The findings from this review can be used to inform woman-centred planned home birth services, particularly in the UK, (although evidence is drawn from papers in eight other countries, so findings are relevant elsewhere), which will impact positively on the experiences of women who are planning home birth.

The role of birth plans for shared decision-making around birth choices of pregnant women in maternity care: A scoping review

BACKGROUND

Birth plans can be used to facilitate shared decision-making in childbirth. A birth plan is a document reflecting women's preferences for birth, which they discuss with their maternity care provider.

AIM

This scoping review aims to synthesize current findings on the role of birth plans for shared decision-making around birth choices of pregnant women in maternity care.

METHODS

We conducted a scoping review using the Joanna Briggs Institute three-step search strategy in multiple databases PubMed, EMBASE, CINAHL, Web of Science, PsycINFO. We synthesized the results using a metasynthesis approach to identify themes and subthemes.

RESULTS

From the 21 articles included, five themes were identified: birth plan as a tool for shared decision-making, autonomy, sense of control, professionalism of the care provider, and trust. Primarily, midwives seemed to use birth plans to explore and facilitate women's choices around birth. Other healthcare providers involved in studies were obstetricians and nurses. The interrelationship between care providers and women, the attitude of care providers and women towards each other and the birth plan, and how providers and women use the birth plan influence shared decision-making.

DISCUSSION AND CONCLUSION

Birth plans can facilitate shared decision-making, and women's sense of autonomy and control before, during, and after giving birth. When discussing the birth plan, exploring different scenarios may help women prepare for unforeseen circumstances. This will likely facilitate shared decision-making even if the birth process is not unfolding as hoped for.

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.

Giving birth: A hermeneutic study of the expectations and experiences of healthy primigravid women in Switzerland

Switzerland experiences one of the highest caesarean section rates in Europe but it is unclear why and when the decision is made to perform a caesarean section. Many studies have examined from a medical and physiological point of view, but research from a women's standpoint is lacking. Our aim was to develop a model of the emerging expectations of giving birth and the subsequent experiences of healthy primigravid women, across four cantons in Switzerland. This longitudinal study included 30 primigravidae from the German speaking, 14 from the French speaking and 14 from the Italian speaking cantons who were purposively selected. Data were collected by semi-structured interviews taking place around 22 and 36 weeks of pregnancy and six weeks and six months postnatally. Following Gadamer's hermeneutic, which in this study comprised 5 stages, a model was developed. Four major themes emerged: Decisions, Care, Influences and Emotions. Their meandering paths and evolution demonstrate the complexity of the expectations and experiences of women becoming mothers. In this study, women's narrated mode of birth expectations did not foretell how they gave birth and their lived experiences. A hermeneutic discontinuity arises at the 6 week postnatal interview mark. This temporary gap illustrates the bridge between women's expectations of birth and their actual lived experiences, highlighting the importance of informed consent, parent education and ensuring women have a positive birth and immediate postnatal experiences. Other factors than women's preferences should be considered to explain the increasing caesarean section rates.

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.

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.

Women's characteristics and care outcomes of caseload midwifery care in the Netherlands: a retrospective cohort study

BACKGROUND

The maternity care system in the Netherlands is well known for its support of community-based midwifery. However, regular midwifery practices typically do not offer caseload midwifery care - one-to-one continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led) care.

METHODS

We selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background (Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other maternal and perinatal outcomes.

RESULTS

In caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and 22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage (intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both groups.

CONCLUSIONS

We found that when compared to regular midwife-led care, caseload midwifery care in the Netherlands is associated with a lower referral rate to obstetrician-led care - both antenatally and in the intrapartum period - and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload care available and affordable for more women.

Women's experiences of decision-making and informed choice about pregnancy and birth care: a systematic review and meta-synthesis of qualitative research

BACKGROUND

The purpose of this systematic review (PROSPERO Ref: CRD42017053264) was to describe and interpret the qualitative research on parent's decision-making and informed choice about their pregnancy and birth care. Given the growing evidence on the benefits of different models of maternity care and the prominence of informed choice in health policy, the review aimed to shed light on the research to date and what the findings indicate.

METHODS

a systematic search and screening of qualitative research concerning parents' decision-making and informed choice experiences about pregnancy and birth care was conducted using PRISMA guidelines. A meta-synthesis approach was taken for the extraction and analysis of data and generation of the findings. Studies from 1990s onwards were included to reflect an era of policies promoting choice in maternity care in high-income countries.

RESULTS

Thirty-seven original studies were included in the review. A multi-dimensional conceptual framework was developed, consisting of three analytical themes ('Uncertainty', 'Bodily autonomy and integrity' and 'Performing good motherhood') and three inter-linking actions ('Information gathering,' 'Aligning with a birth philosophy,' and 'Balancing aspects of a choice').

CONCLUSIONS

Despite the increasing research on decision-making, informed choice is not often a primary research aim, and its development in literature published since the 1990s was difficult to ascertain. The meta-synthesis suggests that decision-making is a dynamic and temporal process, in that it is made within a defined period and invokes both the past, whether this is personal, familial, social or historical, and the future. Our findings also highlighted the importance of embodiment in maternal health experiences, particularly when it comes to decision-making about care. Policymakers and practitioners alike should examine critically current choice frameworks to ascertain whether they truly allow for flexibility in decision-making. Health systems should embrace more fluid, personalised models of care to augment service users' decision-making agency.

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.

Left powerless: A qualitative social media content analysis of the Dutch #breakthesilence campaign on negative and traumatic experiences of labour and birth

INTRODUCTION

Disrespect and abuse during labour and birth are increasingly reported all over the world. In 2016, a Dutch client organization initiated an online campaign, #genoeggezwegen (#breakthesilence) which encouraged women to share negative and traumatic maternity care experiences. This study aimed (1) to determine what types of disrespect and abuse were described in #genoeggezwegen and (2) to gain a more detailed understanding of these experiences.

METHODS

A qualitative social media content analysis was carried out in two phases. (1) A deductive coding procedure was carried out to identify types of disrespect and abuse, using Bohren et al.'s existing typology of mistreatment during childbirth. (2) A separate, inductive coding procedure was performed to gain further understanding of the data.

RESULTS

438 #genoeggezwegen stories were included. Based on the typology of mistreatment during childbirth, it was found that situations of ineffective communication, loss of autonomy and lack of informed consent and confidentiality were most often described. The inductive analysis revealed five major themes: ''lack of informed consent"; ''not being taken seriously and not being listened to"; ''lack of compassion"; ''use of force"; and ''short and long term consequences". "Left powerless" was identified as an overarching theme that occurred throughout all five main themes.

CONCLUSION

This study gives insight into the negative and traumatic maternity care experiences of Dutch women participating in the #genoeggezwegen campaign. This may indicate that disrespect and abuse during labour and birth do happen in the Netherlands, although the current study gives no insight into prevalence. The findings of this study may increase awareness amongst maternity care providers and the community of the existence of disrespect and abuse in Dutch maternity care, and encourage joint effort on improving care both individually and systemically/institutionally.

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.

'She convinced me'- partner involvement in choosing a high risk birth setting against medical advice in the Netherlands: A qualitative analysis

Home births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. There is a lack of qualitative data on women’s partners’ involvement in these choices in the Dutch maternity care system, where integrated midwifery care and home birth are regular options in low risk pregnancies. The majority of available literature focuses on the women’s motivations, while the partner’s influence on these decisions is much less well understood. We aimed to examine partners’ involvement in the decision to birth outside the system, in order to provide medical professionals with insight and recommendations regarding their interactions with these partners in the outpatient clinic. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with twenty-one partners on their involvement in the decision to go against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. Four main themes were found: 1) Talking it through, 2) A shared vision, 3) Defending our views, and 4) Doing it together. One overarching theme emerged that covered all other themes: ‘She convinced me’. These data show that the idea to choose a high risk birth setting almost invariably originated with the women, who did most of the research online, filtered the information and convinced the partners of the merit of their plans. Once the partners were convinced, they took a very active and supportive role in defending the plan to the outside world, as well as in preparing for the birth. Maternity care providers can use these findings in cases where there is a discrepancy between the wishes of the woman and the advice of the professional, so they can attempt to involve partners actively during consultations in pregnancy. That will ensure that partners also receive information on all options, risks and benefits of possible birth choices, and that they are truly in support of a final plan.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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