The novice birthing: theorising first-time mothers' experiences of birth at home and in hospital in Australia

Objective

to explore first-time mothers’ experiences of birth at home and in hospital in Australia.

Design

a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes.

Setting

Sydney, Australia.

Participants

19 women were interviewed. Seven women who gave in a public hospital and seven women who gave birth for the first time at home were interviewed and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once.

Findings

three categories emerged from the analysis: preparing for birth, the novice birthing and processing the birth. These women shared a common core experience of seeing that they gave birth as ‘novices’. The basic social process running through their experience of birth, regardless of birth setting, was that, as novices, they were all ‘reacting to the unknown’. The mediating factors that influenced the birth experiences of these first-time mothers were preparation, choice and control, information and communication, and support. The quality of midwifery care both facilitated and hindered these needs, contributing to the women's perceptions of being ‘honoured’. The women who gave birth at home seemed to have more positive birth experiences.

Implications for practice

identifying the novice status of first-time mothers and understanding the way in which they experience birth better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing. It demonstrates how midwives can contribute to positive birth experiences by being aware that first-time mothers, irrespective of birth setting, are essentially reacting to the unknown as they negotiate the experience of birth.     

‘Just waiting to be hauled over the coals’: Home birth midwifery in Ireland

Objective

to describe the context of Irish home birth midwives' practise experience.

Design

ethnography derived from participant observation, unstructured interview and documentary analysis.

Setting

women and midwives' homes and meeting places in Ireland.

Participants

21 self-employed community midwives.

Measurements and findings

choice of place of birth is extremely limited in Ireland. Structural and professional supports for home birth and midwifery are lacking. Home birth midwives highly value midwifery professionalism but are professionally isolated. They promote women's birthing autonomy and choice of place of birth. However, they experience and anticipate negative, even punitive, responses from their own and other professions. This ethnography describes a particularly volatile period in Irish home birth midwifery practice.

Key conclusions

Irish home birth midwives are professionally isolated which, given wider cultural antagonism to home birth, perfuses their practice with an element of defensiveness. Strong midwifery association is a key pillar of professionalism globally. In Ireland, the lack of a strong professional body undermines autonomous midwifery practice in all settings but particularly in the home. The midwifery philosophy of ‘being with woman’ appears to run contrary to professionalising discourses where the professional ‘knows best’. Contemporary cultural expectations of professionalism such as clinical indemnification and risk averse practice protocols, bring challenges to autonomous midwifery practice.

Implications for practice

place and context of birth effects not only the woman's birth experience but the midwife's professional autonomy. Without supports for autonomous midwifery, autonomous birthing is under threat. Place of birth effects birth experience and birth quality, not least because it is that context which also influences, for good or ill, midwifery autonomy.     

Factors influencing women's decision to have a home birth in rural Turkey

Objective

to ascertain the reasons why mothers choose to have a home birth and the factors that influence these reasons.

Methods

this cross-sectional study involved 392 women and was conducted between June and September 2003 in a rural setting in Turkey. The data were collected using a questionnaire developed by the authors. The questionnaire included demographic information, obstetric background, the reasons for deciding to give birth at home as well as questions on who encouraged the decision to give birth at home and who assisted in the home births.

Findings

the decision to have a home birth is related to economic difficulties and the desire to benefit from the assistance of neighbours. Women who had experienced both planned and unplanned home births reported that home birth was unsafe.

Conclusion

preliminary information is provided about women having home births that may inform practitioners’ educational efforts and future research.     

Low use of medication in home deliveries in the Netherlands.

OBJECTIVES: In view of the growing concern for de-medicalizing childbirth, the aim of this study is to give detailed figures on the use of medication during home deliveries in the Netherlands. METHODS: A prospective study of medication use by 68 community midwives during 716 home births in the Netherlands. RESULTS: Medication was used in 58.4% of the home deliveries, with an average of 1.4 drugs per delivery. The drugs used were mostly oxytocin (in 35.6% of all deliveries) and local anesthetics (in 32.9%). When medication was used, it was administered before cutting the umbilical cord in 16.7% of the cases. Prophylactic or routine administration of local anesthesia, postpartum hemorrhages, and retained placenta were the most frequent indications for using medication. CONCLUSIONS: The use of medication during home deliveries in the Netherlands is low and newborns are minimally exposed to medication. This illustrates the Dutch birth culture, which tends to minimize the medical aspect of childbirth.     

Outcomes of independent midwifery attended births in birth centres and home births: A retrospective cohort study in Japan

Objective

the objective of this study was to describe and compare perinatal and neonatal outcomes of women who received care from independent midwives practicing home births and at birth centres in Tokyo.

Design

a retrospective cohort study.

Settings

birth centres and homes serviced by independent midwives in Tokyo.

Participants

of the 43 eligible independent midwives 19 (44%) (10 assisted birth at birth centres, nine assisted home birth) participated in the study. A total of 5477 women received care during their pregnancy and gave birth assisted by these midwives between 2001 and 2006.

Methods

researchers conducted a retrospective chart review of women’s individual data. Collected data included demographic characteristics, process of pregnancy and perinatal and neonatal outcomes. We also collected data about independent midwives and their practice.

Findings

of the 5477 women, 83.9% gave birth at birth centres and 16.1% gave birth at home. The average age was 31.7 years old and the majority (70.6%) were multiparas. All women had vaginal spontaneous deliveries, with no vacuum, forceps or caesarean section interventions. No maternal fatalities were reported, nor were breech or multiple births. The average duration of the first and second stages of labour was 14.9 hours for primiparas and 6.2 hours for multiparas. Most women (97.1%) gave birth within 24 hours of membrane rupture. Maternal position during labour varied and family attended birth was common. The average blood loss was 371.3 mL, while blood loss over 500 mL was 22.6% and over 1000 mL was 3.6%. Nearly 60% of women had intact perinea. There were few preterm births (0.6%) and post mature births (1.3%). Infant’s average birth weight was 3126 g and 0.5% were low-birthweight-infants, while 3.3% had macrosomia. Among primiparas, the birth centre group had more women experiencing an excess of 500 mL blood loss compared to the home birth group (27.2% versus 17.6% respectively; RR 1.54; 95%CI 1.10 to 2.16). Multiparas delivering at birth centres were more likely to have a blood loss over 500 mL (RR1.28; 95%CI 1.07 to 1.53) and over 1000 mL (RR1.75; 95%CI 1.04 to 2.82) compared to women birthing at home.

Conclusion

our results for birth outcomes with independent midwives at birth centres and home births in Japan indicated a high degree of safety and evidence-based practice. This study had some limitations because of its incomplete data and low response rate. However, this is one of the few studies that reported outcomes of Japanese independent midwives and the safety of their practice. A birth registry system would provide us with more accurate and complete information of all childbirths with which to evaluate the safety of independent Japanese midwives.     

Experiences of women who planned birth in a birth centre compared to alternative planned places of birth. Results of the Dutch Birth Centre Study

Objectiveto assess the experiences with maternity care of women who planned birth in a birth centre and to compare them to alternative planned places of birth, by using the responsiveness concept of the World Health Organization.Designthis study is a cross-sectional study using the ReproQ questionnaire filled out eight to ten weeks after birth. The primary outcome was responsiveness of birth care. Secondary outcomes included overall grades for birth care and experiences with the birth centre services. Regression analyses were performed to compare experiences among the planned places of birth. The study is part of the Dutch Birth Centre Study.Settingthe women were recruited by 82 midwifery practices in the Netherlands, within the study period 1 August 2013 and 31 December 2013.Participantsa total of 2162 women gave written consent to receive the questionnaire and 1181 (54.6%) women completed the questionnaire.Measurements and findingswomen who planned to give birth at a birth centre:(1) had similar experiences as the women who planned to give birth in a hospital receiving care of a community midwife.(2) had significantly less favourable experiences than the women who planned to give birth at home. Differences during birth were seen on the domains dignity (OR=1.58, 95% CI=1.09–2.27) and autonomy (OR=1.77, 95% CI=1.25–2.51), during the postpartum period on the domains social considerations (OR=1.54, 95% CI=1.06–2.25) and choice and continuity (OR=1.43, 95% CI=1.00–2.03).(3) had significantly better experiences than the women who planned to give birth in a hospital under supervision of an obstetrician. Differences during birth were seen on the domains dignity (OR=0.51, 95% CI=0.31–0.81), autonomy (OR=0.59, 95% CI=0.35–1.00), confidentiality (OR=0.57, 95% CI=0.36–0.92) and social considerations (OR=0.47, 95% CI=0.28–0.79). During the postpartum period differences were seen on the domains dignity (OR=0.61, 95% CI=0.38–0.98), autonomy (OR=0.52, 95% CI=0.31–0.85) and basic amenities (OR=0.52, 95% CI=0.30–0.88). More than 80% of the women who received care in a birth centre rated the facilities, the moment of arrival/departure and the continuity in the birth centre as good.Key conclusions and implications for practicein the last decades, many birth centres have been established in different countries, including the United Kingdom, Australia, Sweden and the Netherlands. For women who do not want to give birth at home a birth centre is a good choice: it leads to similar experiences as a planned hospital birth. Emphasis should be placed on ways to improve autonomy and prompt attention for women who plan to give birth in a birth centre as well as on the improvement of care in case of a referral.     

Avoiding disturbance: Midwifery practice in home birth settings in Norway

Objective

to explore midwifery practice in home birth settings in Norway, especially practice assumed by the midwives to promote normal labour and birth.

Design

in-depth interviews transcribed verbatim and analysed using a grounded theory method.

Setting

home birth settings in Norway.

Participants

12 midwives who regularly attended home births and who had assisted a minimum of 30 home births between 1990 and 2007.

Findings

the core category ‘avoiding disturbance’ was identified during the analyses, indicating that the midwives prevented the woman from being disturbed and protected her from disturbance if it occurred during labour. The core category must be understood in the light of the midwives’ attitudes towards and beliefs about labour and birth. The labour process could be disturbed by the midwife, the birthing woman, the partner and other supporting persons, and older children. The midwives regarded labour as work to be done by the woman, as a sexual process, and had a basic understanding that labour and birth usually had good outcomes.

Key conclusions

factors regarded as beneficial for the woman and her labour, like a partner, friends and helpers supporting the woman and doing important and necessary work, and a midwife observing the woman, fetus and course of labour, could also be perceived as sources of disturbance.

Implications for practice

the effect of a calm, undisturbed environment on the labour course should be explored further.     

Nature works best when allowed to run its course. The experience of midwives promoting normal births in a home birth setting

Objectiveto gain a deeper understanding of how midwives promote a normal birth in a home birth setting in Norway.Design/settinga qualitative approach was chosen for data collection. In-depth interviews were conducted with nine midwives working in a home birth setting in different areas in Norway. The transcribed interviews were analysed with the help of systematic text condensation.Findingsthe analysis generated two main themes: «The midwife's fundamental beliefs» and «Working in line with one's ideology». The midwives had a fundamental belief that childbirth is a normal event that women are able to manage. It is important that this attitude is transferred to the woman in order for her to believe in her own ability to give birth. The midwives in the study were able to work according to their ideology when promoting a normal birth at home. To avoid disturbing the natural birth process was described as an important factor. Also crucial was to approach the work in a patient manner. Staying at home in a safe environment and establishing a close relationship with the midwife also contributed positively to a normal birth.Key conclusionsthe midwife's attitude is important when trying to promote a normal birth. Patience was seen as essential to avoid interventions. Being in a safe environment with a familiar midwife provides a good foundation for a normal birth. The attitude of the midwives towards normal childbirth ought to be more emphasised, also in the context of maternity wards.     

After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada

Objective

to describe in detail the emotional support techniques employed by birth doulas during labour.

Design

grounded theory methodology was utilised in collecting and analysing interviews given by doulas and mothers who had doula care. By using both informants, a clearer picture of what constitutes emotional support by doulas emerged.

Participants

10 mothers from three different states in the Midwestern USA and 30 doulas from 10 different states and two Canadian provinces were interviewed. Two doulas worked in hospital-based programmes whereas the others had independent practices. Doulas usually attended births in hospitals where medical attendants spent little focused time with the mother.

Findings

nine different strategies were distinguished. Four strategies (reassurance, encouragement, praise, explaining) were similar to those attributed to nurses in published research. Five were original and described as only being used by doulas (mirroring, acceptance, reinforcing, reframing, debriefing).

Conclusions

emotional support by professional birth doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labour.

Implications for practice

the doula’s role in providing emotional support is distinct from the obstetric nurse and midwife. Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive ‘doula effect’ on obstetric and neonatal outcomes in certain settings.     

Literature review: The ‘logics’ of birth settings in Arctic Greenland

Objective

to review literature on the physical place of childbirth in Greenland between 1953 and 2001, using a narrative review theory and a content analysis framework, the paper seeks to describe and analyse the change in perinatal health care structure in Greenland.

Design

findings were discussed within the framework of Daviss' Logics bringing into account scientific, clinical, personal, cultural and intuitive logics as well as economic, legal and political ‘logics’ concerning perinatal health care policies.

Setting

the literature study concerns the place of birth in Greenland, a self-governing constituency of 57,000 people, the world's largest island and with a predominately Inuit population with its own language and culture. Inuit population with its own language and culture.

Findings

the place of birth in Greenland has changed and focus has moved from birth as a personal and community act to birth within the private and political arena. New policies and guidelines for pregnancy and childbearing decisions are seldom negotiated with the women, families and their communities.

Conclusions

policy changes have an influence on the social and cultural development of Greenland and it poses a challenge and a counter weight to the political and economic limitations that the government works within. Women and children are vulnerable groups and are directly affected by the changing perinatal health care and policy. It is important that when changing policy, the women and their families are part of the dialogue around change.     

Labour augmentation and fetal outcomes in relation to birth positions: A secondary analysis of an RCT evaluating birth seat births

Objective

the aim of this study was to compare the use of synthetic oxytocin for augmentation, duration of labour and birth and infant outcomes in nulliparous women randomised to birth on a birth seat or any other position.

Study design

a randomised controlled trial in Sweden where 1002 women were randomised to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The outcome measurements included synthetic oxytocin augmentation, duration of the second stage of labour and fetal outcome. Analysis was by intention to treat.

Setting

southern Sweden.

Findings

the main findings of this study were that women randomised to the experimental group had a statistically significant shorter second stage of labour than women randomised to the control group. There were no differences between the groups for use of synthetic oxytocin augmentation or for neonatal outcomes.

Conclusions

women allocated to the birth seat had a significantly shorter second stage of labour despite similar numbers of women subjected to synthetic oxytocin augmentation in the study groups. The adverse neonatal outcomes did not differ between groups. The birth seat can be suggested as non-medical intervention used to reduce duration of second stage labour and birth. The birth seat can be suggested as a non-medical intervention that may facilitate reduced duration of the second stage of labour. Furthermore it is recommended that caregivers, both midwives and midwifery students, should learn skills to assist women in using a variety of birth positions.

Trial registration

unique Protocol ID: Dnr 2009/739 (register.clinicaltrials.gov).     

Birth preparedness and skilled attendance at birth in Nepal: Implications for achieving millennium development goal 5

Objective

to assess birth preparedness in expectant mothers and to evaluate its association with skilled attendance at birth in central Nepal.

Design

a community-based prospective cohort study using structured questionnaires.

Setting

Kaski district of Nepal.

Participants

a total of 701 pregnant women of more than 5 months gestation were recruited and interviewed, followed by a second interview within 45 days of delivery.

Measurements

outcome was skilled attendance at birth. Birth preparedness was measured by five indicators: identification of delivery place, identification of transport, identification of blood donor, money saving and antenatal care check-up.

Findings

level of birth preparedness was high with 65% of the women reported preparing for at least 4 of the 5 arrangements. It appears that the more arrangements made, the more likely were the women to have skilled attendance at birth (OR=1.51, p<0.001). For those pregnant women who intended to save money, identified a delivery place or identified a potential blood donor, their likelihood of actual delivery at a health facility increased by two to three fold. However, making arrangements for transportation and antenatal care check-up were not significantly associated with skilled attendance at birth.

Conclusions

intention to deliver in a health-care facility as measured by birth preparedness indicators was associated with actual skilled attendance at birth. Birth preparedness packages could increase the proportion of skilled attendance at birth in the pathway of meeting the Millennium Development Goal 5.     

The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death

This paper identifies a number of methodological difficulties associated with the comparison of home and hospital birth in terms of the risk of perinatal death, and suggests ways in which these problems can be overcome. A review of recent studies suggests that most available data sources are unable to overcome all of these challenges, which is one of the reasons why the debate about whether perinatal death is more likely if a home birth is planned or if a hospital birth is planned has not been satisfactorily resolved. We argue that the debate will be settled only if perinatal mortality data from a sufficiently large number of maternity care providers over a sufficiently long period of time can be pooled and made available for analysis. The pooling of data will bring about its own difficulties due to variations over time and between providers and geographical areas, which would need to be taken into account when analysing pooled data. However, given the impracticality of a randomised controlled trial and the rarity of home birth in most of the Western world, we argue that more effort should be made to pool data for perinatal mortality and other rare pregnancy outcomes, and share them between health providers and researchers. Thus, high-quality analyses could be conducted, allowing all women to make an informed choice about place of birth. However, pooling data from countries or states with very different maternity care systems should be avoided.     

Childbirth at home: A qualitative study exploring perceptions of risk and risk management among Baloch women in Iran

Objective

to explain how women who choose to give birth at home perceive and manage the risks related to childbirth.

Design

a qualitative, methodological approach drawing upon the principles of grounded theory. Data were gathered by in-depth interviews with women who had given birth at home.

Setting

the study was conducted in Zahedan, the capital of Sistan and Balochestan province in southeast Iran.

Participants

21 Baloch women aged 13–39 years who had a planned home birth were interviewed. Nine had been attended by university-educated midwives, eight by trained midwives, and four by traditional birth attendants.

Findings

concerning perceived risks, women perceived giving birth in hospital to be risky because of medical interventions, routines and ethical considerations. The perceived risks for home birth were acute medical conditions. Women made their decision to give birth at home based on existing verbal, visual, and intuitive information. The following two categories related to risk management were identified: (1) psychological preparation and (2) medical and logistican preparation. All of the women relied on their own intuition, their midwife and the sociopsychological support of their families to transfer them to hospital in the case of complications.

Key conclusions and implications for practice

the women who chose to give birth at home accepted that there was a risk of complications, but perceived these to be due to fate. Technical risks were considered to be a consequence of the decision to give birth in hospital, and were perceived to be avoidable. In addition, the women considered ethical issues as risks that are sometimes more important than medical complications. Women's perceptions of risk, and the ways in which they prepare to manage risk, are central issues to help providers and policy makers adjust services to women's expectations in order to respond to the individuality of each woman.