Nurse‐Midwives' Experiences with Planned Home Birth: Impact on Attitudes and Practice

Background: Health care providers' attitudes toward maternity care options influence the nature of informed decision‐making discussions and patient choice. A woman's choice of birth site may be affected by her provider's opinion and practice site. The objectives of this study were to describe American nurse‐midwives' attitudes toward, and experiences with, planned home birth, and to explore correlates and predictors of their attitudes toward planned home birth as measured by the Provider Attitudes towards Planned Home Birth (PAPHB) scale. Methods: A survey instrument, which incorporates the PAPHB and assesses demographic, education, practice, personal experience, and external barrier variables that may predict attitudes toward planned home birth practice, was completed by 1,893 nurse‐midwives. Bivariate analysis identified associations between variables and attitudes. Linear regression modeling identified predictors of attitudes. Results: Variables that significantly predicted favorable attitudes to planned home birth were increased clinical and educational experiences with planned home birth (p < 0.001), increased exposure to planned home birth (p < 0.001), and younger age (p < 0.001). External barriers that significantly predicted less favorable attitudes included financial (p = 0.03) and time (p < 0.001) constraints, inability to access medical consultation (p < 0.001), and fear of peer censure (p < 0.001). Willingness to practice in the home was correlated with factors related to nurse‐midwives' confidence in their management abilities and beliefs about planned home birth safety. Conclusions: The results suggest that nurse‐midwives' choice of practice site and comfort with planned home birth are strongly influenced by the nature and amount of exposure to home birth during professional education or practice experiences, in addition to interprofessional, logistic, and environmental factors. Findings from this research may inform interdisciplinary education and collaborative practice in the area of planned home birth.     

Assessing Certified Nurse‐Midwives' Attitudes Towards Planned Home Birth

Introduction: Certified nurse‐midwives (CNMs) and certified midwives (CMs) are prepared for care in many settings and could increase access to planned home birth for American women. However, only 4% of American College of Nurse‐Midwives members offer the home as a birth setting. CNMs'/CMs' attitudes towards birth place and the factors underlying their choice of practice site are largely unstudied. This article describes the development, content validation, and psychometric testing of an instrument to assess the attitudes of CNMs towards planned home birth. Methods : A scale was designed to measure Provider Attitudes to Planned Home Birth (PAPHB). Item generation was informed by literature review and a systematic expert panel appraisal. Reliability and validity of the scale were evaluated with a sample of 1893 CNMs. Results : Expert review indicated high relevancy and clarity of the scale items (scale‐content validity index, 0.93). Construct validity was assessed using the Cattell scree test and factor analysis. The resultant 1‐factor, attitude scale had strong internal consistency (Cronbach α = .94). The average PAPHB scale score among CNMs was 78.77 (range, 20–100; standard deviation, 15.9), with significant differences in attitude scores according to clinical home birth experience, educational background, and external barriers reported by CNMs. Discussion : The PAPHB scale is a reliable and valid instrument for the measurement of attitudes towards home birth. It can be used to assess the impact of education, environment, and clinical experiences on maternity practice choices.     

Midwifery Provision of Home Birth Services

The number of women in the United States choosing to give birth at home has risen substantially in the past decade, creating an increased need for understanding of the evidence regarding the provision of midwifery care to women and families considering this option. The safety of home birth has been evaluated in observational studies in several industrialized nations, including the United States. Most studies find that women who are essentially healthy at term with a singleton fetus and give birth at home have positive outcomes and a lower rate of interventions during labor. Although some studies have found increased neonatal morbidity and mortality in newborns born at home when compared to newborns born in a hospital, the absolute numbers reported in both birth sites are very low. The purpose of this clinical bulletin is to review the evidence on provision of care to women and families who plan to give birth at home, including roles and responsibilities, shared decision making, informed consent, and ongoing assessment for birth site selection.     

Outcomes Associated with Planned Home and Planned Hospital Births in Low‐Risk Women Attended by Midwives in Ontario,Canada, 2003–2006: A Retrospective Cohort Study

Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low‐risk women who planned a hospital birth between 2003 and 2006. Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low‐risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68–1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.     

Transfers in Planned Home Births Related to Midwife Availability and Continuity: A Nationwide Population‐Based Study

ABSTRACT: Background: Planning a home birth does not necessarily mean that the birth will take place successfully at home. The object of this study was to describe reasons and risk factors for transfer to hospital during or shortly after a planned home birth. Methods: A nationwide study including all women who had given birth at home in Sweden between January 1, 1992, and July 31, 2005. A total of 735 women had given birth to 1,038 children. One questionnaire for each planned home birth was sent to the women. Of the 1,038 questionnaires, 1,025 were returned. Reasons for transfer and obstetric, socioeconomic, and care‐related risk factors for being transferred were measured using logistic regression. Results: Women were transferred in 12.5 percent of the planned home births. Transfers were more common among primiparas compared with multiparas (relative risk [RR] 2.5; 95% CI 1.8–3.5). Failure to progress and unavailability of the chosen midwife at the onset of labor were the reasons for 46 and 14 percent of transfers, respectively. For primiparas, the risk was four times greater if a midwife other than the one who carried out the prenatal checkups assisted at the birth (RR 4.4; 95% CI 2.1–9.5). A pregnancy exceeding 42 weeks increased the risk of transfer for both primiparas (RR 3.0; 95% CI 1.1–9.4) and multiparas (RR 3.4; 95% CI 1.3–9.0). Conclusions: The most common reasons for transfer to hospital during or shortly after delivery were failure to progress followed by the midwife’s unavailability at the onset of labor. Primiparas whose midwife for checkups during pregnancy was different from the one who assisted at the home birth were at increased risk of being transferred. (BIRTH 35:1 March 2008)     

In The Literature: Home Birth: Safe Enough,But Not for the First Baby

The “Birthplace in England” study compared low‐risk pregnancies by planned place of birth at the onset of labor: home, midwifery unit, or obstetric unit. The study showed that childbirth interventions were less frequent in all nonobstetric settings than in obstetric units, confirming what has been noted elsewhere. For parous women, there was no difference in perinatal outcomes by place of birth. For nulliparous women, perinatal outcomes were similar in midwifery and obstetric units, but the frequency of poor outcomes with planned home births was higher. The major strengths of the study are its prospective design and large sample size. The results support providing choices to women, but suggest that women should not be encouraged to give birth at home for their first baby. (BIRTH 39:2 June 2012)     

Transfer from Planned Home Birth to Hospital: Improving Interprofessional Collaboration

Women's heightened interest in choice of birthplace and increased rates of planned home birth in the United States have been well documented, yet there remains significant public and professional debate about the ethics of planned home birth in jurisdictions where care is not clearly integrated across birth settings. Simultaneously, the quality of interprofessional interactions is recognized as a predictor of health outcomes during obstetric events. When care is transferred across birth settings, confusion and conflict among providers with respect to roles and responsibilities can adversely affect both outcomes and the experience of care for women and newborns. This article reviews findings of recent North American studies that examine provider attitudes toward planned home birth, differing concepts of safety of birthplace as reported by women and providers, and sources of conflict among maternity care providers during transfer from home to hospital. Emerging evidence and clinical exemplars can inform the development of systems for seamless transfer of women and newborns from planned home births to hospital and improve experience and perceptions of safety among families and providers. Three successful models in the United States that have enhanced multidisciplinary cooperation and coordination of care across birth settings are described. Finally, best practice guidelines for roles, communication, and mutual accommodation among all participating providers when transfer occurs are introduced. Research, health professional education, and policy recommendations for incorporation of key components into existing health care systems in the United States are included.     

Introducing Birth Plans in Mexico: An Exploratory Study in a Hospital Serving Low‐Income Mexicans

ABSTRACT: Background: Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries, pregnant women often prepare written birth plans, outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low–socioeconomic status Mexicans and to document women’s and health practitioners’ perspectives on the advantages and barriers in implementing a birth plan program. Methods: We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in‐depth interviews with 4 women who had given birth in the past year, and with 2 nurses, 2 social workers, and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. Results: All 9 women who completed a birth plan found the experience highly satisfying, despite the fact that in some cases, their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners, but facilities often lacked space and financial incentives for birth plan programs. Conclusions: Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation. (BIRTH 34:1 March 2007)