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SECTION D: Selected Studies on Patient Choice & Satisfaction

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I: Studies of Patient Demand & Satisfaction, Autonomy & Experience

Each paper is linked to either its original abstract on PubMed or the full-text article if available; click on the title to be taken to the abstract/ article.

A) Jackson, M., Dahlen, H., & Schmied, V. (2012). Birthing outside the system: Perceptions of risk amongst Australian women who have freebirths and high risk homebirths. Midwifery, 28(5):561-7, doi: 10.1016/j.midw.2011.11.002.

A qualitative study using open ended questions examined 20 Australian women over 18 years of age who chose to have an unattended home birth (freebirth), or an attended high risk home birth despite having medically defined risk factors, or care provider recommendations for a hospital birth. Of note in this study is the participants’ average age (34) and level of education, where more than 70% of the women had tertiary qualifications. All were living in urban settings within 30 minutes of emergency care. 17 of 20 women were multiparous. Researchers found that the women who chose an unattended birth attributed this choice to a previous traumatic hospital birth or because of a belief that the interventions and interruptions of hospitals increase risk. The study found that women who freebirth tend to perceive risk differently, and that these women believe they are making a choice to protect their babies. For these women, birth in the hospital is less safe than birthing at home. The women in this study directly connected their experiences during labour and birth to their experience of mothering both immediately and long term. This study also aims to dispel a belief that women who freebirth are poorly informed and undereducated because study participants were more educated than the Australian public and had attended formalized training in obstetric emergencies and neonatal resuscitation.

B) Blix, E. (2011). Avoiding disturbance: Midwifery practice in home birth settings in Norway. Midwifery, 27(5):687-692.

Qualitative study of 17 Norwegian midwives to examine how midwifery care promotes and supports normal labour and birth and why these births are associated with lower rates of interventions compared with hospital births. The study highlights the connection between the calm, undisturbed environment available to women at home with fewer interventions in childbirth. Strengths of this study include its detailed discussion of how the home and its particular setting might augment “normal birth”.

C) Catling-Paull, C., Dahlen, H., & Homer, C. S. (2011). Multiparous women’s confidence to have a publicly-funded homebirth: a qualitative study. Women Birth, 24(3):122-8, doi: 10.1016/j.wombi.2010.09.001.

A qualitative study of 10 multiparous Australian women who chose a publicly-funded, planned home birth with the St. George Hospital Homebirth Program. The study found that multiparous women who have had at least one previous normal birth feel a strong confidence to birth at home. The women cite hospital back up, trust in the skill of their midwives, and their own personal strength as sources of confidence to have a normal birth at home. None of the women felt that they were at an increased risk of birth complications due to having a baby at home.

D) Stramrood, C. A., Paarlberg, K. M., Huis In ‘t Veld, E. M., Berger, L. W., Vingerhoets, A. J., Schultz, W. C., & van Pampus, M. G. (2011). Posttraumatic stress following childbirth in homelike- and hospital settings.J Psychosom Obstet Gynaecol, 32(2):88-97, doi: 10.3109/0167482X.2011.569801.

A qualitative cross-sectional study of 428 Dutch women who completed surveys 2-6 months post-partum to compare the rate of post-traumatic stress disorder (PTSD) in home-like settings to the hospital. The study found that women who had home deliveries had the lowest rate of PTSD symptoms compared to women who were either transferred to care in the hospital during labour but who remained in primary care (under the care of a midwife) or to those who gave birth in secondary or tertiary care (either under the care of an OB/GYN or at a university referral centre). Home deliveries also had a lower rate of PTSD compared to those with pregnancy or delivery complications at the hospital. However, no difference was found in the scores between women who delivered in primary care with a midwife either at home (planned home birth) or the hospital (planned hospital birth). The study also found a strong association between the development of PTSD and the reported intensity of labour pain, leading researchers to speculate whether there is a difference between women requesting pain medication and the role this might play in the development of PTSD for certain women.

E) Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: A follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4):280-7. doi: 10.1111/j.1523-536X.2010.00422.x.

A qualitative review using thematic analysis and grounded theory to examine the case notes of midwives involved in 15 instances of perinatal mortality at home births in the UK between 2002 and 2005. Researchers noted that in 13 of the 15 cases significant antenatal risk factors were present (4 sets of twins, 3 VBAC, 3 Breech, 5 maternal illness) and 8 of 15 women had declined some, or all, routine antenatal screening. Strengths of this study are that it provides a detailed examination into perinatal deaths at home and examines why some women might choose high-risk home births even after antenatal risk factors have been identified, or care providers have encouraged a transfer to the hospital. It illustrates the challenge that independent midwives face balancing informed consent/ refusal with providing care. This study also examines how issues regarding transfer of care, inter-professional communication, and a deep mistrust of NHS by some women can led to a delay in care and poorer outcomes. Limitations of this study are its small sample size, but also that it is only a study of the midwives’ notes and does not include hospital notes or family accounts.

F) Hendrix, M., Pavlova, M., Nieuwenhuijze, M. J., Severens, J. L., & Nijhuis, J. G. (2010). Differences in preferences for obstetric care between nulliparae and their partners in the Netherlands: A discrete-choice experiment. J Psychosom Obstet Gynaecol, 31(4):243-51, doi: 10.3109/0167482X.2010.527400.

A prospective cohort study to examine the differences between low-risk pregnant women and their partners’ preferences regarding obstetric care and place of birth and the extent to which these preferences are influenced by obstetric care and socio-economic factors. The study employed a method of “discrete choice” to assess preference. Data were collected at 32 weeks from 321 pregnant women and 212 of their partners. This study found that overall women prefer to be assisted by a midwife during birth and they also prefer to give birth in a home-like setting. Women also place importance on having influence over the decision making process and the possibility of pain relief (though the study does not specify what kind of pain relief). Their partners’ preferences where similar; high value was placed on a midwifery assisted birth in a home-like setting, and control over decision-making. Partners had a preference for no out-of pocket payments and a higher preference for access to pain relief.

G) Hildingsson, I., Rådestad, I., & Lindgren, H. (2010). Birth preferences that deviate from the norm in Sweden: Planned home birth versus planned cesarean section. Birth, 37(4):288-95, doi: 10.1111/j.1523-536X.2010.00423.x.

Descriptive and comparative study using data from questionnaires of women who had a planned home birth (n=671) and women who had an elective caesarean section (n=126) between 1997 and 2008. In Sweden, the current medical context neither promotes home birth nor elective caesarean section. The study found significant socioeconomic differences between the two groups of women. Compared to women who chose an elective caesarean, women who chose planned home birth were more educated, had a lower BMI, were less likely to smoke, felt less threat to baby’s life during the birth, felt more in control, and were more satisfied with their overall birth experience. Women in the home birth group reported a higher intensity of pain, but a more positive experience of that pain than women who gave birth via caesarean.

H) Lindgren, H. & Erlandsson, K. (2010). Women’s experiences of empowerment in a planned home birth: A Swedish population-based study.Birth, 37(4):309-17, doi: 10.1111/j.1523-536X.2010.00426.x.

Descriptive study using questionnaires of women who had one or more planned home births between 1992 and 2005 (n=735). Birth stories were analyzed using content analysis and descriptive statistics. Women who birthed at home felt empowered by their environment and the people who supported them (midwives, partners, family). Birth stories rarely mentioned pain or suffering and stressed the importance of an undisturbed space and sense of control. Surveys highlighted the importance of support, guidance and trust in their attendants to feel safe. Feeling disempowered was related to a poor choice of attendants and the absence of partner support. The response rate of the study was 99%. Limitations: small scale study might not be generalizable to general Swedish population or international context.

I) Lindgren, H. E., Radestad, I. J., Christensson, K., Wally-Bystrom, K., & Hildingsson, I. M. (2010). Perceptions of risk and risk management among 735 women who opted for a home birth. Midwifery, 26(2):163-72, doi: 10.1016/j.midw.2008.04.010.

Using data from a national survey of all women who birthed at home in Sweden between 1992 and 2005, this study aims to describe women’s perceptions of risk and risk management related to childbirth. Categories of perceived risk related to hospital and home births emerged. Perceived risks of hospital births included loss of autonomy, impersonal care, and subjection to interventions. Perceived risks of home birth centered around difficulty accessing emergency care in a worst-case scenario. The study found that women avoided discussing risks with care providers (other than their homebirth midwife) as a strategy to manage perceived risks.

J) Janssen, P. A., Henderson, A. D., & Vedam, S. (2009). The experience of planned home birth: views of the first 500 women. Birth, 36(4):297-304, doi: 10.1111/j.1523-536X.2009.00357.x.

K) Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery & Wom Health, 54(2):119-126, doi: 10.1016/j.jmwh.2008.09.006.

L) Christiaens, W., Gouwy, A., & Bracke, P. (2007). Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison. BMC Health Services Research, 7(109), doi:10.1186/1472-6963-7-109.  (full text)

M) Jannssen, P. A., Carty, E. A., & Reime, B. (2006). Satisfaction with planned place of birth among midwifery clients in British Columbia. J Midwifery Womens Health, 51(2):91-7.

N) Hildingsson, I., Waldenstrom, U., & Radestad, I. (2003). Swedish women’s interest in home birth and in-hospital birth center care. Birth, 30(1):11-22.

O) Harris, G. (2000). Homebirth and independent midwifery. Aust Coll Midwives Inc J, 13(2):10-6.

P) Davies, J., Hey, E., Reid, W., & Young, G. (1996). Prospective regional study of planned home births. Home Birth Study Steering Group. BMJ, 313(7068):1302-06.  (full text)

Q) Cunningham, J. D. (1993). Experiences of Australian mothers who gave birth either at home, at a birth centre, or in hospital labour wards. Soc Sci Med, 36(4):475-83.

R) Soderstrom, B., Stewart, P. J., Kaitell, C., & Chamberlain, M. (1990). Interest in alternative birthplaces among women in Ottawa-Carleton. CMAJ, 142(9):963-69.

S) O’Brien, B., Chalmers, B., Fell, D., Heaman, M., Darling, E. K., & Herbert, P. (2011). The experience of pregnancy and birth with midwives: Results from the Canadian Maternity Experiences Survey. Birth, 38(3):207-215, doi: 10.1111/j.1523-536X.2011.00482.x.