Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey Beth Murray-Davis, RM, PhD (Assistant Professor)n, Helen McDonald, RM, MSc (Associate Professor), Angela Rietsma, RM, MSc (Lecturer), Melissa Coubrough, RM, MSc (Research Assistant), Eileen Hutton, RM, PhD (Assistant Dean, Director Midwifery Education Program) McMaster University, Canada
art ic l e i nf o
a b s t r a c t
Article history: Received 23 July 2013 Received in revised form 23 January 2014 Accepted 29 January 2014
Objective: decision-making autonomy regarding where to give birth is associated with maternal satisfaction with childbirth but how women decide their location of birth is poorly understood. The aim of this study was to understand how pregnant women in Ontario, Canada decide to give birth at home or hospital and why they choose one birthplace over another. Design: a mixed methods survey completed by midwifery clients in Ontario pertaining to sources of information about choice of birthplace and decision-making priorities. Findings: decisions about choice of birthplace are made before becoming pregnant or during the first trimester. Books and research are important sources of information for women when deciding where to give birth. Women who planned home birth wanted to avoid interventions and felt most comfortable at home. Those who planned hospital birth wanted access to pain medication and found the idea of home birth stressful. Questions about the safety of home birth are a critical barrier to those who are undecided about where to give birth. Key conclusions: beliefs and values about birth and the desire for pain relief options play significant roles in women's decisions, but are balanced with views of safety and risk. Regardless of where they have their baby, midwifery clients believe that birth is a natural process. Implications for practice: the findings provide health care providers and women with a deeper understanding of the factors for consideration when deciding where to give birth. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Choice of birthplace Decision-making Women's choice Survey research
Introduction Choice and autonomy to determine where to give birth are significant factors in maternal satisfaction with childbirth, yet little is known about what motivates women to choose one place of birth over another (Hadjigeorgiou et al., 2012). Previous literature, focused on the decision to give birth in hospital, highlighted women's belief that hospital was safer than home should complications arise (Madi and Crow, 2003; Houghton et al., 2008; Pitchforth et al., 2008). Other motivations for having a hospital birth included feeling ‘protected’ by the medical environment, wanting easier access to pain medication and increased monitoring, and the belief that it is cleaner than home birth (Houghton et al., 2008; Pitchforth et al., 2008). For many women, hospital n Correspondence to: Midwifery Education Program, McMaster University, 1200 Main Street West, MDCL 2210, Hamilton, Canada L8N 3Z5. E-mail address: [email protected] (B. Murray-Davis).
birth was seen as the ‘default’ choice due to lack of availability, lack of information, or due to a higher risk pregnancy (Madi and Crow, 2003). All midwives in the province of Ontario, Canada offer a choice of birthplace of home or hospital thus providing an ideal setting to study women's decision-making around choice of birthplace. Our review of the existing literature on choice of birthplace revealed that most studies focused on either home or hospital in isolation, rather than comparing or contrasting the choice for one over the other. Much of the research on choice of birthplace was based on retrospective satisfaction with one's birth experience and did not consider decision-making prior to birth. Satisfaction with birth was not consistently higher in one birthplace or another, but was more closely associated with the woman's perception of her involvement in shared decision-making about the birth, feelings of control and having adequate information (Christiaens and Bracke, 2007; Christiaens et al., 2007; Cheyney, 2008; Houghton et al., 2008; Christiaens and Bracke, 2009; Hadjigeorgiou et al., 2012).
http://dx.doi.org/10.1016/j.midw.2014.01.008 0266-6138 & 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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There was also limited research from the Canadian context with the exception of a study from Ottawa in 1987 that considered women's preference for giving birth in hospital, birth centres or home (Soderstrom et al., 1990). The authors described demographic characteristics for women choosing home or hospital, and provided a description of the rationale for women's choices. However, the study was done prior to legislation and regulation of midwives in Ontario. At that time, women wanting midwives as care providers were only able to have home births and paid for midwifery services out of pocket. Thus, these findings may not reflect current options where women can choose midwives as their primary care provider paid for by the health care system and can choose to have either a home or a hospital childbirth. The purpose of our study was to understand how pregnant women in Ontario decide to give birth at home or hospital and why they choose one birthplace over another.
Methods Ethical approval was obtained from the McMaster University Research Ethics Board. Data were collected between January and July 2012 using a mixed methods survey design. Data collection was done using a self-administered questionnaire. Questions were developed based on the themes identified in our previous qualitative study which investigated motivations for choosing home birth and focused on sources of information, influential factors in decision-making and the role of health care providers (MurrayDavis et al., 2012). The questionnaire was structured in three sections. The first addressed sources of information used to make a decision. The second section had three separate subsets of questions unique to the identified choice of birthplace – home, hospital or undecided. Many questions overlapped across the three subsets, but there were some unique questions relevant only to the specified location of chosen birthplace. The final subsection asked those planning home or hospital to rank their top three decisionmaking priorities. The questionnaire included seven-point Likert scales with options from ‘very important’ to ‘very unimportant’, open-ended questions. The questionnaire was tested for face validity by convenience sample of 10 women and five midwives. Minor revisions were made to questions following their feedback but full testing of validity and reliability of the tool was not done. The sample was drawn from 85 midwifery practices in Ontario. Using six geographical regions in the Province, as determined by the Association of Ontario Midwives, nine practice groups were randomly selected per region and invited to participate as recruitment sites. Recruitment sites were sent posters and survey packages to distribute to all eligible women. 600 surveys were distributed in total, with 100 per region. Recruitment in midwifery practices was variable with some sites making the poster visible, whereas at other sites the midwife or the practice administrator informed the women about the study. Women at greater than 24 weeks gestation, older than 16, who had an equal opportunity to give birth at home or hospital, and who had no contraindications to vaginal birth were eligible to participate. The questionnaire was filled out on paper and sent back by postage paid envelope or online using SurveyMonkey. Women were asked where they planned to give birth and were provided with the following options: home, hospital or undecided (at the time of survey completion). The data will be presented in these three cohorts. Data analysis of Likert scales were done using Excel to generate descriptive statistics, and open-ended questions were analysed thematically. Findings Twenty-four of the 54 midwifery practices invited agreed to participate as recruitment sites. Two hundred and nineteen surveys
were returned and 214 were included in the final analysis. Five surveys were excluded from the final analysis, four because the woman had already given birth at the time the survey was completed, and one because the woman was pregnant with twins and was therefore not able to make a choice to have a home birth (College of Midwives of Ontario, 1999). One hundred twenty-two (57%) surveys were completed on paper and 92 (43%) surveys were completed online. Demographics of participants are listed in Table 1. Of the 24 recruitment sites, three (14.3%) practices were designated rural/ remote and the other 85.7% designated as urban. This is somewhat reflective of the distribution of midwifery practices in the province of Ontario where 19 of 85 (22%) are designated as rural/remote. The majority were aged 30–34 (54%), married (85%), had completed college or university (65%), and described their income bracket as ‘medium’ (69%). Eighty-two (38%) were nulliparous, 130 (61%) were multiparous and two participants did not answer. The mean gestational age at the time of survey completion was 32 weeks. Seventy-eight respondents (36.4%) indicated ‘home’ as their choice of birthplace, 123 respondents (57.5%) identified ‘hospital’ and 13 respondents (6.1%) were still undecided. Most participants indicated choice of birthplace was decided either before becoming pregnant or within the first trimester. The questionnaire was divided into three sections: sources of information used when deciding about birth place (Table 2), reasons for choosing place of birth (Tables 3 and 4), and decision-making priorities (Table 5). Results are presented here according to the three sections of the questionnaire and then described more fully for each cohort – home, hospital and undecided at the time of completing the questionnaire. Participants were asked to also identify their top three reasons for choosing home or hospital birth. Five women from the hospital group selected more than three reasons when completing this question. The cohort of women who had not yet made a decision about where to give birth was excluded from this question. The top three decision-making priorities were that they felt safer and more comfortable in their chosen location and they believed that birth was a natural process. Those planning a home birth most frequently identified: birth as a natural process (65.7%); wanting to avoid interventions (46%); and feeling more comfortable at home (34.2%). Those planning hospital birth most frequently identified feeling safer in hospital (74.7%) as their decision-making priority. Other top priorities included wanting access to pain medication (38.2%) and feeling more comfortable (35.7%). Those planning a hospital birth were more likely to identify a history of a complicated birth as a factor in their decision-making (19.5%) over those planning home birth (0%). Concerns about the mess of home birth (30%) and previous positive hospital experiences (20.3%) were identified by women planning hospital birth, whereas neither were identified by those planning home. Eighteen per cent of those choosing home birth cited wanting to have water births and to control their surroundings compared to 2% in the hospital group. Participants were invited to identify additional decisionmaking priorities in an open-ended question. Several women planning hospital births expressed a desire for access to interventions and services only provided in the hospital. Also, they stated that living one to two hours from the nearest hospital played a role in their decision. Participants in all cohorts (77%) expressed a desire to have access to birth centres in Ontario (72% home group, 79% hospital group, 85% undecided group): Best of both worlds, less clinical, busy, stressful than hospital, more comfortable. Participants expressed a belief that birth centres would provide an environment for labour and birth without intervention and
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 1 Demographics of sample population. Total
Home
Hospital
Undecided
n ¼ 214
n ¼ 78
n ¼ 123
n¼ 13
n
(%)
n
(%)
n
(%)
n
(%)
Age o 20 20–24 25–29 30–34 35–39 40–44 >45 Not identified
0 7 61 115 28 2 0 1
(0) (3.3) (28) (54) (13) (1) (0)
0 5 18 36 17 1 0 1
(0) (6) (23) (47) (22) (1) (0)
0 2 40 71 9 1 0 0
(0) (2) (32) (58) (7) (1) (0)
0 0 3 8 2 0 0 0
(0) (0) (23) (61) (15) (0) (0)
Marital status Married Common law Single Same-sex married Same-sex common Law
181 30 1 2 0
(85) (14) (0.5) (1)
68 9 0 1 0
(87) (11) (0) (1)
106 15 1 1 0
(86) (12) (1) (1)
7 6 0 0 0
(54) (46) (0) (0)
Education Elementary school High school College/university Graduate studies Not identified
1 18 137 56 2
(0.5) (8) (65) (26)
0 10 47 20 1
(0) (13) (61) (26)
1 6 84 31 1
(1) (5) (69) (25)
0 2 6 5 0
(0) (15) (46) (38)
Income bracket High Medium Low Not identified
34 145 31 4
(16) (69) (15)
11 51 15 1
(14) (66) (19)
20 87 14 2
(16) (72) (12)
3 7 2 1
(25) (58) (17)
Parity Nulliparous Multiparous Not identified Mean gestation (weeks) at survey completion
82 130 2 32.0
(38) (61)
27 50 1 31.9
(35) (65)
49 73 0 32.0
(40) (60)
6 7 0 30.7
(46) (54)
29 36 32 42 37 38
(14) (17) (15) (20) (17) (18)
12 19 10 11 10 16
(15) (24) (13) (14) (13) (20)
17 16 19 26 24 21
(14) (13) (15) (21) (19) (17)
0 1 3 5 3 1
(0) (8) (23) (38) (23) (8)
Region of Ontario North East West South Central South West South East
exposure to infection. Yet, some assumed that birth centres would have access to epidural analgesia, on-call Obstetricians and emergency operative capabilities: If the BC (birth center) was medically prepared to address complications with the baby, or with myself. A Birth Centre would combine the best of hospital and home; i.e. without the ‘medical’ environment of a hospital, yet with medical options and services unavailable at home, and with greater freedom of choice (i.e. more conducive to family and friends being part of the birthing process; more focused on flexible needs/desires of mothers and families, than to adhering to hospital policy and procedure)
Home birth cohort The majority of women choosing home birth ‘strongly agreed’ with the statements: I feel more comfortable in my own home (88.4%); I feel more relaxed in my own home (87.2%); I want to be able to move freely in labour (85.9%); and I want to avoid interventions (79.5%). Over 90% of women also ‘strongly agreed’
or ‘agreed’ with the following rationales for wanting to be at home: I want my partner involved in the birth; I want to be involved in decision-making; I want to be able to eat and drink freely in labour; I want to control my surroundings; and I want to avoid an epidural. When asked which statements best reflected their beliefs about choosing a home birth participants ‘strongly agreed’ that: birth was a natural process (91%); recovery afterward was easier at home (45.5%); and labour would progress faster at home (42.3%). More than 80% of women ‘strongly agreed’ or ‘agreed’ that birth in the hospital was too medical. Perceptions of risk and safety were also explored. All participants ‘strongly agreed’ or ‘agreed’ that they had trust in their midwife's skills. They also overwhelmingly ‘agreed’ that they felt safe at home (96.1%) and that home birth was safe for mothers and babies (94.8%). Home birth provided an opportunity for optimal health for the woman and her baby for the majority of participants. When asked about their perceptions of the role of health care providers in decision-making they ‘strongly agreed’ that their midwife supported their decision (59.2%). Yet, 51.2% of respondents expressed strong agreement or agreement with the statement ‘I dislike differing opinions from hospital staff.’
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 2 Sources of information used when making decisions: % of respondents identifying information source as ‘very important’ or ‘important’. Home n¼ 78
Media, popular culture Research Books Newspaper Videos Friends and family I have friends and family I have friends and family I have friends and family I have friends and family I was born in hospital I was born at home
who who who who
have have have have
had had had had
positive hospital experiences negative hospital experiences positive home birth experiences negative home birth experiences
Health care professionals My midwife talked about options for place of birth I attended a home birth information session My midwife recommended hospital birth My midwife recommended home birth My doctor recommended hospital birth My doctor recommended home birth My doula recommended hospital birth My doula recommended home birth My naturopath recommended hospital birth My naturopath recommended home birth
Thematic analysis of qualitative answers revealed a common belief that hospital birth was riskier due to the higher likelihood of interventions during labour. The women commented on negative aspects of the hospital environment such as lighting, smell, noise, interruptions, and restrictive policies. Other recurring themes were the desire to avoid being on the ‘hospital clock’ during labour as well as the belief that home offered a better environment for post partum recovery: I want the opportunity to bond with my baby immediately following birth, with people (my midwives) near who appreciate the importance of the bonding experience after birth. Having spent time researching how to meet the needs of my baby, I prefer to have people accessible to me for assistance as needed, yet if possible work from this knowledge I've been gaining to be empowered to care for my baby in the initial hours after birth, uninterrupted by checks, policies, restrictions, and guidance I may not agree with. Hospital birth cohort There was only one statement from the list of rationales for choice of birthplace that was selected as ‘strongly agree’ by the majority of women choosing hospital birth: ‘I want my partner to be involved in the birth’ (65.6%). The role of a woman's partner in making this decision was also highlighted when 70% ‘agreed’ or ‘strongly agreed’ that their partner wanted a hospital birth. When the strongly agree and agree rankings were combined most women identified that they: wanted to be involved in decision-making (89%); felt more comfortable in hospital (78.7%); wanted an epidural (64%); and wanted to be in control of their surroundings (63.1%). Most also ‘agreed’ they wanted to avoid the mess of home birth (60%) and found the idea of home birth stressful (53%). The majority of this group ‘strongly agreed’ that birth was a natural process (65.8%). This group neither ‘agreed nor disagreed’
Hospital n ¼ 123
Undecided n¼ 13
n
(%)
n
(%)
n
(%)
72 57 7 32
(93.3) (73.3) (9.6) (41.3)
69 49 9 22
(56.4) (40.1) (7.5) (18.2)
10 7 3 4
(76.9) (53.8) (23.1) (30.8)
32 57 63 23 4 2
(41.6) (73.1) (80.8) (29.5) (5.2) (2.7)
87 65 63 45 39 4
(71.3) (53.3) (52.9) (37.2) (32.5) (3.5)
9 7 10 5 5 0
(69.2) (53.8) (76.9) (38.5) (38.5) (0)
61 33 3 24 1 0 1 3 0 2
(79.2) (42.9) (3.9) (30.8) (1.3) (0) (1.3) (3.9) (0) (2.7)
91 11 17 10 14 4 10 5 7 4
(75.8) (9.2) (14.3) (8.4) (11.6) (3.3) (8.3) (4.2) (5.8) (3.4)
13 8 6 5 1 1 0 0 0 0
(100) (61.5) (46.1) (38.5) (7.7) (8.3) (0) (0) (0) (0)
that labour would progress faster in hospital (52.9%) or that recovery afterward would be easier in hospital (46.2%). When asked about risk and safety, all participants identified that they had trust in their midwife's skills. The hospital felt safer to these women (89.2%), and was seen as a safe choice for both mothers and babies (78.4%, 81.7%). However, 41% neither ‘agreed nor disagreed’ that hospital provided an opportunity for better health for mother and baby. At the same time, the same number felt that home birth was risky (40.8%). The majority (94.2%) felt supported by their midwife for their decision. Seventy-five per cent trusted hospital staff and did not appear concerned with differing opinions from hospital staff. The need to please their midwife, the desire to have children involved in the birth, and concerns about discrimination were not important factors in the decision to have a hospital birth. The open-ended questions provided opportunity to describe why they chose a hospital birth. Overall, birthing in the hospital with a midwife was described as ‘the best of both worlds’. Women reported increased feelings of security from having quick access to clinicians or emergency services due to a fear of potential complications in labour: I feel more comfortable in a hospital, knowing that if something goes wrong, I can get immediate help (i.e. emergency C-section). Some women who had chosen hospital birth stated they did not plan a home birth due to their belief that their home environment was unsuitable due to renovations, size constraints, poor emergency access, lack of childcare, or the presence of a pet. Similarly, some women felt they lived too far from the hospital. Other women commented on the influence of their previous birth experience and stated they would be more likely to choose home birth if they were not attempting a vaginal birth after caesarean, or if they had a history of uncomplicated labour.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 3 Reasons for choosing – rationale and beliefs: outcomes by cohort identified as ‘very important’ or ‘important’. Home n ¼ 78
Rationale for place of birth I want my partner involved in the birth My partner wants a home/hospital birth I want my children involved in the birth I want my friends and family at the birth I had a previous fast labour I want to be involved in decision-making I had a previous hospital birth I want to control my surroundings I live far from the hospital I live close to the hospital I feel more comfortable in hospital I feel more relaxed in hospital I want pain relief options I had a previous birth complication I find the idea of home birth stressful My house is not suitable for home birth I want to avoid the mess of home birth I want to avoid/have an epidural I cannot afford home/hospital birth I find hospital policies restrictive I find hospitals stressful I want a water birth I want to avoid infection risks I am worried about travelling in labour I want to avoid interventions I feel more comfortable in my home I want to be able to move freely in labour I want to eat and drink freely in labour I feel more relaxed in my home
Undecided n ¼13
n
(%)
n
(%)
n
(%)
75 46 15 23 32 78 27 70 6 48
(96.1) (60.5) (19.5) (30.2) (41.6) (100) (34.6) (89.8) (7.7) (63.2)
104 84 5 21 27 109 57 77 18 72 96 63 77 32 64 35 72 25 4
(85.3) (70.3) (4.2) (17.6) (22.5) (89.3) (47.2) (63.1) (14.8) (60.5) (78.9) (51.6) (63.7) (26.5) (52.4) (29.2) (59.5) (20.7) (3.3)
13 5 0 3 3 7 4 12 1 10 2 7 5 2
(100) (40.7) (0) (23.1) (23.1) (53.8) (30.8) (47) (7.7) (77) (15.4) (53.8) (38.5) (15.4)
n n n n n n n
Beliefs about birth I see birth as a natural process I believe labour will progress faster at home/hospital/comfortable environment I believe recovery afterward is easier where I am comfortable I am worried I will be discriminated against I want to honour my cultural and religious traditions n
Hospital n ¼123
70 1 63 47 37 65 28 75 76 77 73 76
(89.7) (1.3) (80.7) (60.3) (47.4) (83.3) (35.9) (96.2) (97.4) (98.7) (93.7) (97.4)
77 51 63 10 12
(98.7) (65.4) (82) (12.9) (15.3)
n n n n n
n
n
n
n
n
n
n
n
n
n
n
13 9 13 10 10
(99.9) (69.2) (99.9) (76.9) (76.9)
13 12 13 1 1
(100) (92.3) (100) (7.7) (7.7)
n n n n
113 10 21 6 12
(94.1) (8.4) (17.6) (5.1) (10.1)
:‘Not asked’ for this participant group.
Table 4 Reasons for choosing – safety and role of health care providers: outcomes by cohort identified as ‘very important’ or ‘important’.
Perceptions of risk and safety I trust my midwife's skills I feel safe in hospital Hospital birth provides opportunity for better health for me and my baby Hospital birth is safe for mothers Hospital birth is safe for babies I feel home births are risky I feel birth is risky I feel safe at home Home birth is safe for mothers Home birth is safe for babies Home birth provides better health for me and my baby I feel hospital births are risky I am a safe distance from hospital if needed Role of health care professionals I want to please my midwife My midwife supported my decision Hospital birth was my midwife's idea I trust hospital staff I dislike medical staff I dislike differing opinions from hospital staff Home birth was my midwife's idea n
‘Not asked’ for this participant group.
Home
Hospital
Undecided
n¼ 78
n ¼123
n17 ¼13
n
(%)
n
(%)
n
(%)
78
(100)
119 107 55 94 98 49
(99.2) (89.2) (45.4) (78.4) (81.7) (40.8)
13 10 8 10 9
(100) (76.9) (61.5) (76.9) (69.2)
n n n n n n
n
75 74 74 61 26 77
(96.1) (94.9) (94.8) (78.2) (33.3) (98.7)
n
2 70
(2.6) (92.1)
17 112 7 76
n n
10 39 3
(13.2) (51.2) (3.0)
n
5 11 11 5 4
n n n n
n
n
n
(14.4) (94.2) (5.9) (63.9)
2 12 n n
n
n
n
n
n
n
(38.5) (84.6) (84.6) (38.5) (30.1)
(15.4) (92.3)
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 5 Top 10 decision-making priorities: outcomes by cohort. All participants (n¼ 195)
I I I I I I I I I I
feel safer feel more comfortable see birth as a natural process want access to pain medication feel more relaxed want to avoid interventions am worried about the mess at home had a previous positive hospital experience had a previous complicated birth want a water birth
Home (n¼ 78)
Hospital (n ¼ 123)
n
(%)
n
(%)
n
(%)
99 69 54 45 38 36 35 24 24 16
(50.7) (35.3) (27.6) (23.0) (19.4) (18.4) (17.9) (12.3) (12.3) (8.2)
7 26 50 0 17 35 1 0 0 14
(9.2) (34.2) (65.7) (0) (22.3) (46.0) (1.3) (0) (0) (18.4)
92 44 4 47 22 2 37 25 24 2
(74.7) (35.7) (3.2) (38.2) (17.8) (1.6) (30.0) (20.3) (19.5) (1.6)
Undecided cohort Those who were undecided about choice of birthplace ‘strongly agreed’ or ‘agreed’ with the statements; I want my partner involved in the birth (90%); I want to be able to move freely during labour (99%); I want to avoid interventions (100%). However, there were several statements where the responses in this group were mixed. For example, when asked if they wanted pain relief options, 38% ‘strongly agreed’ or ‘agreed’, 23% ‘disagreed’ and 39% were neutral. When asked where they felt most comfortable and most relaxed, over 60% felt more comfortable and relaxed at home. Only 46% ‘agreed’ to feeling relaxed in hospital. Many saw birth as a natural process (77% strongly agree), and believed that both labour and recovery would be easier in a comfortable environment. Trust in their midwife's skill was unanimous. This group was mixed in the perception of safety between home and hospital. Specifically, 76.9% ‘agreed’ to feeling safe in the hospital, and 84.6% felt safe at home. The women ‘agreed’ that hospital birth was safe for mothers and babies (61% and 54% respectively). They ‘agreed’ that home birth was safe for mothers (77%), but only 38.5% agreed home birth was safe for babies. When asked whether home or hospital afforded better opportunity for the health of mother and baby, the undecided respondents agreed hospital was better over home (61.5% versus 30.1%). When the role of health care providers was explored those in the undecided group agreed that they trusted health care providers (92.3%) and that their midwife supported their decision (92.3%).
Discussion The goal of this study was to explore the factors that influence a woman's decision about where to give birth. Key decision-making priorities identified by all women in the study were the belief that birth was a natural process and the desire to feel safe and comfortable in their chosen birthplace. The most influential sources of information for decisionmaking were books and research about choice of birthplace. The internet and popular media were also identified as key resources. This is similar to the findings of the Canadian study conducted by Klein et al. (2011). The views of family and friends, and especially a woman's partner were important when making the decision. The role of partners in decision-making about place of birth was explored in more depth in a recent study. The authors found that, whereas women's partners may have a preference for one birthplace over another, typically hospital birth, they view the
woman as holding a better ‘bargaining position’ in decisionmaking (Bedwell et al., 2011). They described that the onus was on the woman to educate the partner and justify her decision to have the baby at home (Bedwell et al., 2011). The authors hypothesised this was due to the lack of communication between the partner, the woman, and health professionals. As such, involving partners in discussions regarding choice of birthplace may empower them, reducing feelings of vulnerability and increasing their comfort level with home birth (Bedwell et al., 2011). The results of our study indicate that these conversations should occur during the antenatal visit as attending a home birth information session was not a highly valued component of the decisionmaking process. The women's beliefs and values about birth played a significant role in shaping their decision about where to have their baby. Those planning home birth wanted to avoid interventions such as epidural and felt that hospital birth was too medical. They also felt more comfortable and relaxed, and able to control their surroundings at home. They expressed a desire to eat and drink freely, to have their partner involved during the birth and to be involved in decision-making. Those planning a hospital birth identified a desire to have their partner involved, to be involved in decisionmaking and to have pain relief options. They felt most comfortable in hospital and found the idea of home birth stressful. The majority of women in the study, regardless of their chosen place of birth believed that birth was a natural process. This is an important finding as it may indicate a shared value among midwifery clients. The universality of this belief among study participants may also indicate that women perceive the natural process of birth can occur regardless of their chosen birthplace with a midwife-attended birth. The data on midwifery births in Canada supports this finding with midwifery clients being more likely to have a vaginal childbirth, less likely to be induced and seven times more likely to have a medication free birth when compared to women under the care of Obstetricians (O'Brien et al., 2011). Further, there is recent Canadian evidence that women who choose to receive care from a midwife may have different attitudes and expectations about care than women who choose to see an obstetrician or family doctor, when a choice of care provider is available (Klein et al., 2011). Specifically, Klein et al. (2011) found that midwifery clients are less supportive of the use of technology during labour and value the role of the woman in her own birth. Perceptions of safety and risk were critical factors that shaped decision-making. Safety was a priority across all groups, but was the strongest determining factor among those choosing hospital birth. It became clear that the women in the home birth group valued safety, but they considered home birth to be a safe option and were more likely to see that hospital birth carried its own set
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
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of risks. All participants felt confident in the care provided by midwives regardless of place of birth. The intersection between beliefs about birth and views of safety and risk was most acute in the group of women who were still undecided about where to give birth. This group shared beliefs about birth that closely matched the home birth group, yet their views of safety and risk were more closely aligned with the hospital group. Specifically, with respect to their values and beliefs they wanted their partner involved, they wanted to be free to move and to eat/drink freely, and to avoid interventions. Yet, at the same time, they gave mixed responses about the desire to have pain relief options. In terms of views of safety, they felt safer in hospital than at home. For example, undecided women more strongly agreed that hospital birth was safe for both mothers and babies, but they were less likely to agree that home birth was safe for babies. Those who are undecided about where to give birth face a unique challenge to reconcile conflicting beliefs and priorities in order to select a birthplace where they feel both comfortable and safe. Their responses also highlighted that the desire for pain relief options is a central decision-making issue. Finding a balance between values and risk perception may be challenging in pregnancy. It has been described as a time where women need to make risk calculations (Lindgren et al., 2010). Women find themselves weighing perceived risks against actual risks, mediated by the perceived likelihood that the risk may occur and the perceived seriousness of the outcome. These perceptions and risk calculations are unique for each woman, but are informed by societal values (Lindgren et al., 2010). Both home and hospital births may feel risky to women: at home, women worry about being too far away from help and are concerned about the ‘worse case scenarios’ (Lindgren et al., 2010). At hospital, women see the loss of autonomy, characterised by the involvement of strangers, and the emphasis on routines and interventions, as being risky. Understanding a woman's views of these risks may help health care providers to review evidence and address the issues of likelihood and severity of adverse outcomes. This conflicted decision-making process found in the undecided group may be confounded by a lack of prior birth experience as this group had the highest percentage of nulliparous women. This raises the issues of the impact of parity on decision-making for where to give birth. A greater proportion of those planning home birth identified themselves as multiparous. With more multiparous women planning home birth, they may have spent more time thinking about how their labour will progress based on their prior birthing experience. This mental preparation along with their prior experience could lead to greater feelings of confidence in their bodies' ability to labour, increasing their comfort level with birthing at home. With respect to the role of health care professionals during the decision-making process, women revealed that midwives were supportive of their chosen birthplace but did not recommend one place over another. Apart from midwives, other health care providers' ‘recommendations’ for place of birth, be it home or hospital, were not influential in their decision-making process. This is in contrast to previous Canadian literature that identified that health care providers' attitudes regarding maternity care can influence a woman's choice (Vedam et al., 2012). Yet, it is well established that health care providers do not agree on the safety of home birth and that health care providers other than midwives do not have education or knowledge related to the screening for or management of birth outside of hospital (McNiven et al., 2011; Vedam et al., 2012). Given the lack of importance ascribed to non-midwifery providers' recommendations as well as the timing of participants' decision regarding birthplace, it appears that once a woman has decided on her birthplace, there
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is little importance placed upon recommendations made by a non-midwifery provider. Also, there may be a tendency among those interested in home birth to avoid discussing this decision with other health care providers as it may represent a choice outside of the accepted norms and expectations of traditional medical care (Lindgren et al., 2010). As midwives are the only care providers in Ontario who offer both home and hospital births to clients, women who choose midwifery care are more likely to plan and anticipate a home birth, leading to the lack of importance placed upon recommendations from other health care providers. Women from all groups expressed a desire for an alternative to home and hospital birth and overwhelmingly agreed they would access birth centres if they were available. However, there were many misconceptions about what services would be available at birth centres across all groups. Women planning home birth were less likely to indicate they would utilise a birth centre, expressing a belief that birthing anywhere other than their home would be like birthing in a hospital. Those who stated they would not utilise birth centre facilities still supported the availability of an alternative to birth at home or in hospital. The results of this study shed light on some of the important factors when considering choice of birthplace. The results are limited by the small sample size and by the typical sources of bias in self-administered questionnaires such as self-report and selection bias. The sample may not be representative of the wider Ontario population, due to the over representation of educated, married, Caucasian women, however, this may be an accurate reflection of the midwifery population in the province. Yet, some key groups remain under-represented such as nonwhite, same-sex couples, single mothers and those whose are new to Canada and who may not have English as a first language. Twenty five per cent of midwifery clients choose to give birth at home in the province of Ontario, yet there was a 37% rate of planned home birth in this study. This over-representation is likely attributable to a self-selection bias as women choosing home birth may be more motivated to describe their thought process and rationale for choosing a birthplace that is not the societal norm. Also, although the proportion of rural/remote practices participating in the study is similar to that across the province, travelling time to the nearest hospital may be given greater priority in the decision-making process among women in these areas.
Conclusion The Ontario Choice of Birthplace Study has identified influences, beliefs, rationales and decision-making priorities considered by women when selecting where to have their baby. The study also identified a unique challenge faced by those who are undecided about place of birth, as they share beliefs with women planning both home and concerns about safety similar to those planning hospital birth. Women in all groups expressed a strong preference for the availability of birth centres in the province. From a policy perspective, this finding comes at a critical time as the province is exploring the availability of options for out of hospital birth. It is hoped that the results of our study will assist health care providers when providing information to women about where to have their baby. For women, the findings identify key issues for consideration when deciding where to give birth. Exploration of these key issues are hoped to facilitate effective decision-making based on each women's values and priorities. With this in mind, the development of a decision aid may be a useful next step from this research.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
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References Bedwell, C., Houghton, G., Richens, Y., Lavender, T., 2011. ‘She can choose, as long as I'm happy with it’: a qualitative study of expectant fathers' views of birthplace. Evid. Based Midwifery 6, 59–64. Cheyney, M.J., 2008. Homebirth as systems-challenging praxis: knowledge, power, and intimacy in the birthplace. Qual. Health Res. 18, 254–267. Christiaens, W., Bracke, P., 2007. Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective. BMC Pregnancy Childbirth 7, 1–12. Christiaens, W., Bracke, P., 2009. Place of birth and satisfaction with childbirth in Belgium and the Netherlands. Midwifery 24, e11–e19. Christiaens, W., Gouwy, A., Bracke, P., 2007. Does a referral from home to hospital affect satisfaction with childbirth? A cross national comparison. BMC Health Serv. Res. 7, 109–118. College of Midwives of Ontario, 1999. Indications for Mandatory Discussion, Consultation and Transfer of Care. College of Midwives of Ontario, Toronto Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopoulos, I., Martensson, L.B., 2012. Women's perceptions of their right to choose the place of childbirth: an integrative review. Midwifery 28, 380–390. Houghton, G., Bedwell, C., Forsey, M., Baker, L., Lavendar, T., 2008. Factors influencing choice in birthplace – an exploration of the views of women, their partners and professionals. Evid. Based Midwifery 6, 59–64. Klein, M.C., Kaczorowski, J., Hearps, S.J.C., et al., 2011. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. J. Obstet. Gynecol. Can. 33, 598–608.
Lindgren, H.E., Radestad, I., Christensson, K., Wally-Bystrom, K., Hildingsson, I.M., 2010. Perceptions of risk and risk management among 735 women who opted for home birth. Midwifery 26, 163–172. Madi, B.C., Crow, R., 2003. A qualitative study of information about available options for childbirth venue and pregnant women's preferences for a place of delivery. Midwifery 19, 328–336. McNiven, P., Klein, M.C., Baradaran, N., et al., 2011. Midwives' belief in normal birth: The Canadian survey of maternity care providers' attitudes towards labour and birth. Can. J. Midwifery Res. Pract. 10, 11–21. Murray-Davis, B., McNiven, P., McDonald, H., Malott, A., Elarar, L., Hutton, E.K., 2012. Why home birth? A qualitative study exploring women's decision making about place of birth in two Canadian provinces. Midwifery 28, 576–581. 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, 207–215. Pitchforth, E., Watson, V., Tucker, J., et al., 2008. Models of intrapartum care and women's trade offs in remote and rural Scotland: a mixed methods study. Br. J. Obstet. Gynecol. 115, 560–569. Soderstrom, B., Stewart, P.J., Kaitell, C., Chamberlain, M., 1990. Interest in alternative birthplaces among women in Ottawa-Carleton. Can. Med. Assoc. J. 142, 963–969. Vedam, S., Schummers, L., Stoll, K., et al., 2012. The Canadian birthplace study: describing maternity practice and providers' exposure to home birth. Midwifery 28, 1–9.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
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Midwifery journal homepage: www.elsevier.com/midw
Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey Beth Murray-Davis, RM, PhD (Assistant Professor)n, Helen McDonald, RM, MSc (Associate Professor), Angela Rietsma, RM, MSc (Lecturer), Melissa Coubrough, RM, MSc (Research Assistant), Eileen Hutton, RM, PhD (Assistant Dean, Director Midwifery Education Program) McMaster University, Canada
art ic l e i nf o
a b s t r a c t
Article history: Received 23 July 2013 Received in revised form 23 January 2014 Accepted 29 January 2014
Objective: decision-making autonomy regarding where to give birth is associated with maternal satisfaction with childbirth but how women decide their location of birth is poorly understood. The aim of this study was to understand how pregnant women in Ontario, Canada decide to give birth at home or hospital and why they choose one birthplace over another. Design: a mixed methods survey completed by midwifery clients in Ontario pertaining to sources of information about choice of birthplace and decision-making priorities. Findings: decisions about choice of birthplace are made before becoming pregnant or during the first trimester. Books and research are important sources of information for women when deciding where to give birth. Women who planned home birth wanted to avoid interventions and felt most comfortable at home. Those who planned hospital birth wanted access to pain medication and found the idea of home birth stressful. Questions about the safety of home birth are a critical barrier to those who are undecided about where to give birth. Key conclusions: beliefs and values about birth and the desire for pain relief options play significant roles in women's decisions, but are balanced with views of safety and risk. Regardless of where they have their baby, midwifery clients believe that birth is a natural process. Implications for practice: the findings provide health care providers and women with a deeper understanding of the factors for consideration when deciding where to give birth. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Choice of birthplace Decision-making Women's choice Survey research
Introduction Choice and autonomy to determine where to give birth are significant factors in maternal satisfaction with childbirth, yet little is known about what motivates women to choose one place of birth over another (Hadjigeorgiou et al., 2012). Previous literature, focused on the decision to give birth in hospital, highlighted women's belief that hospital was safer than home should complications arise (Madi and Crow, 2003; Houghton et al., 2008; Pitchforth et al., 2008). Other motivations for having a hospital birth included feeling ‘protected’ by the medical environment, wanting easier access to pain medication and increased monitoring, and the belief that it is cleaner than home birth (Houghton et al., 2008; Pitchforth et al., 2008). For many women, hospital n Correspondence to: Midwifery Education Program, McMaster University, 1200 Main Street West, MDCL 2210, Hamilton, Canada L8N 3Z5. E-mail address: [email protected] (B. Murray-Davis).
birth was seen as the ‘default’ choice due to lack of availability, lack of information, or due to a higher risk pregnancy (Madi and Crow, 2003). All midwives in the province of Ontario, Canada offer a choice of birthplace of home or hospital thus providing an ideal setting to study women's decision-making around choice of birthplace. Our review of the existing literature on choice of birthplace revealed that most studies focused on either home or hospital in isolation, rather than comparing or contrasting the choice for one over the other. Much of the research on choice of birthplace was based on retrospective satisfaction with one's birth experience and did not consider decision-making prior to birth. Satisfaction with birth was not consistently higher in one birthplace or another, but was more closely associated with the woman's perception of her involvement in shared decision-making about the birth, feelings of control and having adequate information (Christiaens and Bracke, 2007; Christiaens et al., 2007; Cheyney, 2008; Houghton et al., 2008; Christiaens and Bracke, 2009; Hadjigeorgiou et al., 2012).
http://dx.doi.org/10.1016/j.midw.2014.01.008 0266-6138 & 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
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There was also limited research from the Canadian context with the exception of a study from Ottawa in 1987 that considered women's preference for giving birth in hospital, birth centres or home (Soderstrom et al., 1990). The authors described demographic characteristics for women choosing home or hospital, and provided a description of the rationale for women's choices. However, the study was done prior to legislation and regulation of midwives in Ontario. At that time, women wanting midwives as care providers were only able to have home births and paid for midwifery services out of pocket. Thus, these findings may not reflect current options where women can choose midwives as their primary care provider paid for by the health care system and can choose to have either a home or a hospital childbirth. The purpose of our study was to understand how pregnant women in Ontario decide to give birth at home or hospital and why they choose one birthplace over another.
Methods Ethical approval was obtained from the McMaster University Research Ethics Board. Data were collected between January and July 2012 using a mixed methods survey design. Data collection was done using a self-administered questionnaire. Questions were developed based on the themes identified in our previous qualitative study which investigated motivations for choosing home birth and focused on sources of information, influential factors in decision-making and the role of health care providers (MurrayDavis et al., 2012). The questionnaire was structured in three sections. The first addressed sources of information used to make a decision. The second section had three separate subsets of questions unique to the identified choice of birthplace – home, hospital or undecided. Many questions overlapped across the three subsets, but there were some unique questions relevant only to the specified location of chosen birthplace. The final subsection asked those planning home or hospital to rank their top three decisionmaking priorities. The questionnaire included seven-point Likert scales with options from ‘very important’ to ‘very unimportant’, open-ended questions. The questionnaire was tested for face validity by convenience sample of 10 women and five midwives. Minor revisions were made to questions following their feedback but full testing of validity and reliability of the tool was not done. The sample was drawn from 85 midwifery practices in Ontario. Using six geographical regions in the Province, as determined by the Association of Ontario Midwives, nine practice groups were randomly selected per region and invited to participate as recruitment sites. Recruitment sites were sent posters and survey packages to distribute to all eligible women. 600 surveys were distributed in total, with 100 per region. Recruitment in midwifery practices was variable with some sites making the poster visible, whereas at other sites the midwife or the practice administrator informed the women about the study. Women at greater than 24 weeks gestation, older than 16, who had an equal opportunity to give birth at home or hospital, and who had no contraindications to vaginal birth were eligible to participate. The questionnaire was filled out on paper and sent back by postage paid envelope or online using SurveyMonkey. Women were asked where they planned to give birth and were provided with the following options: home, hospital or undecided (at the time of survey completion). The data will be presented in these three cohorts. Data analysis of Likert scales were done using Excel to generate descriptive statistics, and open-ended questions were analysed thematically. Findings Twenty-four of the 54 midwifery practices invited agreed to participate as recruitment sites. Two hundred and nineteen surveys
were returned and 214 were included in the final analysis. Five surveys were excluded from the final analysis, four because the woman had already given birth at the time the survey was completed, and one because the woman was pregnant with twins and was therefore not able to make a choice to have a home birth (College of Midwives of Ontario, 1999). One hundred twenty-two (57%) surveys were completed on paper and 92 (43%) surveys were completed online. Demographics of participants are listed in Table 1. Of the 24 recruitment sites, three (14.3%) practices were designated rural/ remote and the other 85.7% designated as urban. This is somewhat reflective of the distribution of midwifery practices in the province of Ontario where 19 of 85 (22%) are designated as rural/remote. The majority were aged 30–34 (54%), married (85%), had completed college or university (65%), and described their income bracket as ‘medium’ (69%). Eighty-two (38%) were nulliparous, 130 (61%) were multiparous and two participants did not answer. The mean gestational age at the time of survey completion was 32 weeks. Seventy-eight respondents (36.4%) indicated ‘home’ as their choice of birthplace, 123 respondents (57.5%) identified ‘hospital’ and 13 respondents (6.1%) were still undecided. Most participants indicated choice of birthplace was decided either before becoming pregnant or within the first trimester. The questionnaire was divided into three sections: sources of information used when deciding about birth place (Table 2), reasons for choosing place of birth (Tables 3 and 4), and decision-making priorities (Table 5). Results are presented here according to the three sections of the questionnaire and then described more fully for each cohort – home, hospital and undecided at the time of completing the questionnaire. Participants were asked to also identify their top three reasons for choosing home or hospital birth. Five women from the hospital group selected more than three reasons when completing this question. The cohort of women who had not yet made a decision about where to give birth was excluded from this question. The top three decision-making priorities were that they felt safer and more comfortable in their chosen location and they believed that birth was a natural process. Those planning a home birth most frequently identified: birth as a natural process (65.7%); wanting to avoid interventions (46%); and feeling more comfortable at home (34.2%). Those planning hospital birth most frequently identified feeling safer in hospital (74.7%) as their decision-making priority. Other top priorities included wanting access to pain medication (38.2%) and feeling more comfortable (35.7%). Those planning a hospital birth were more likely to identify a history of a complicated birth as a factor in their decision-making (19.5%) over those planning home birth (0%). Concerns about the mess of home birth (30%) and previous positive hospital experiences (20.3%) were identified by women planning hospital birth, whereas neither were identified by those planning home. Eighteen per cent of those choosing home birth cited wanting to have water births and to control their surroundings compared to 2% in the hospital group. Participants were invited to identify additional decisionmaking priorities in an open-ended question. Several women planning hospital births expressed a desire for access to interventions and services only provided in the hospital. Also, they stated that living one to two hours from the nearest hospital played a role in their decision. Participants in all cohorts (77%) expressed a desire to have access to birth centres in Ontario (72% home group, 79% hospital group, 85% undecided group): Best of both worlds, less clinical, busy, stressful than hospital, more comfortable. Participants expressed a belief that birth centres would provide an environment for labour and birth without intervention and
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
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Table 1 Demographics of sample population. Total
Home
Hospital
Undecided
n ¼ 214
n ¼ 78
n ¼ 123
n¼ 13
n
(%)
n
(%)
n
(%)
n
(%)
Age o 20 20–24 25–29 30–34 35–39 40–44 >45 Not identified
0 7 61 115 28 2 0 1
(0) (3.3) (28) (54) (13) (1) (0)
0 5 18 36 17 1 0 1
(0) (6) (23) (47) (22) (1) (0)
0 2 40 71 9 1 0 0
(0) (2) (32) (58) (7) (1) (0)
0 0 3 8 2 0 0 0
(0) (0) (23) (61) (15) (0) (0)
Marital status Married Common law Single Same-sex married Same-sex common Law
181 30 1 2 0
(85) (14) (0.5) (1)
68 9 0 1 0
(87) (11) (0) (1)
106 15 1 1 0
(86) (12) (1) (1)
7 6 0 0 0
(54) (46) (0) (0)
Education Elementary school High school College/university Graduate studies Not identified
1 18 137 56 2
(0.5) (8) (65) (26)
0 10 47 20 1
(0) (13) (61) (26)
1 6 84 31 1
(1) (5) (69) (25)
0 2 6 5 0
(0) (15) (46) (38)
Income bracket High Medium Low Not identified
34 145 31 4
(16) (69) (15)
11 51 15 1
(14) (66) (19)
20 87 14 2
(16) (72) (12)
3 7 2 1
(25) (58) (17)
Parity Nulliparous Multiparous Not identified Mean gestation (weeks) at survey completion
82 130 2 32.0
(38) (61)
27 50 1 31.9
(35) (65)
49 73 0 32.0
(40) (60)
6 7 0 30.7
(46) (54)
29 36 32 42 37 38
(14) (17) (15) (20) (17) (18)
12 19 10 11 10 16
(15) (24) (13) (14) (13) (20)
17 16 19 26 24 21
(14) (13) (15) (21) (19) (17)
0 1 3 5 3 1
(0) (8) (23) (38) (23) (8)
Region of Ontario North East West South Central South West South East
exposure to infection. Yet, some assumed that birth centres would have access to epidural analgesia, on-call Obstetricians and emergency operative capabilities: If the BC (birth center) was medically prepared to address complications with the baby, or with myself. A Birth Centre would combine the best of hospital and home; i.e. without the ‘medical’ environment of a hospital, yet with medical options and services unavailable at home, and with greater freedom of choice (i.e. more conducive to family and friends being part of the birthing process; more focused on flexible needs/desires of mothers and families, than to adhering to hospital policy and procedure)
Home birth cohort The majority of women choosing home birth ‘strongly agreed’ with the statements: I feel more comfortable in my own home (88.4%); I feel more relaxed in my own home (87.2%); I want to be able to move freely in labour (85.9%); and I want to avoid interventions (79.5%). Over 90% of women also ‘strongly agreed’
or ‘agreed’ with the following rationales for wanting to be at home: I want my partner involved in the birth; I want to be involved in decision-making; I want to be able to eat and drink freely in labour; I want to control my surroundings; and I want to avoid an epidural. When asked which statements best reflected their beliefs about choosing a home birth participants ‘strongly agreed’ that: birth was a natural process (91%); recovery afterward was easier at home (45.5%); and labour would progress faster at home (42.3%). More than 80% of women ‘strongly agreed’ or ‘agreed’ that birth in the hospital was too medical. Perceptions of risk and safety were also explored. All participants ‘strongly agreed’ or ‘agreed’ that they had trust in their midwife's skills. They also overwhelmingly ‘agreed’ that they felt safe at home (96.1%) and that home birth was safe for mothers and babies (94.8%). Home birth provided an opportunity for optimal health for the woman and her baby for the majority of participants. When asked about their perceptions of the role of health care providers in decision-making they ‘strongly agreed’ that their midwife supported their decision (59.2%). Yet, 51.2% of respondents expressed strong agreement or agreement with the statement ‘I dislike differing opinions from hospital staff.’
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
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Table 2 Sources of information used when making decisions: % of respondents identifying information source as ‘very important’ or ‘important’. Home n¼ 78
Media, popular culture Research Books Newspaper Videos Friends and family I have friends and family I have friends and family I have friends and family I have friends and family I was born in hospital I was born at home
who who who who
have have have have
had had had had
positive hospital experiences negative hospital experiences positive home birth experiences negative home birth experiences
Health care professionals My midwife talked about options for place of birth I attended a home birth information session My midwife recommended hospital birth My midwife recommended home birth My doctor recommended hospital birth My doctor recommended home birth My doula recommended hospital birth My doula recommended home birth My naturopath recommended hospital birth My naturopath recommended home birth
Thematic analysis of qualitative answers revealed a common belief that hospital birth was riskier due to the higher likelihood of interventions during labour. The women commented on negative aspects of the hospital environment such as lighting, smell, noise, interruptions, and restrictive policies. Other recurring themes were the desire to avoid being on the ‘hospital clock’ during labour as well as the belief that home offered a better environment for post partum recovery: I want the opportunity to bond with my baby immediately following birth, with people (my midwives) near who appreciate the importance of the bonding experience after birth. Having spent time researching how to meet the needs of my baby, I prefer to have people accessible to me for assistance as needed, yet if possible work from this knowledge I've been gaining to be empowered to care for my baby in the initial hours after birth, uninterrupted by checks, policies, restrictions, and guidance I may not agree with. Hospital birth cohort There was only one statement from the list of rationales for choice of birthplace that was selected as ‘strongly agree’ by the majority of women choosing hospital birth: ‘I want my partner to be involved in the birth’ (65.6%). The role of a woman's partner in making this decision was also highlighted when 70% ‘agreed’ or ‘strongly agreed’ that their partner wanted a hospital birth. When the strongly agree and agree rankings were combined most women identified that they: wanted to be involved in decision-making (89%); felt more comfortable in hospital (78.7%); wanted an epidural (64%); and wanted to be in control of their surroundings (63.1%). Most also ‘agreed’ they wanted to avoid the mess of home birth (60%) and found the idea of home birth stressful (53%). The majority of this group ‘strongly agreed’ that birth was a natural process (65.8%). This group neither ‘agreed nor disagreed’
Hospital n ¼ 123
Undecided n¼ 13
n
(%)
n
(%)
n
(%)
72 57 7 32
(93.3) (73.3) (9.6) (41.3)
69 49 9 22
(56.4) (40.1) (7.5) (18.2)
10 7 3 4
(76.9) (53.8) (23.1) (30.8)
32 57 63 23 4 2
(41.6) (73.1) (80.8) (29.5) (5.2) (2.7)
87 65 63 45 39 4
(71.3) (53.3) (52.9) (37.2) (32.5) (3.5)
9 7 10 5 5 0
(69.2) (53.8) (76.9) (38.5) (38.5) (0)
61 33 3 24 1 0 1 3 0 2
(79.2) (42.9) (3.9) (30.8) (1.3) (0) (1.3) (3.9) (0) (2.7)
91 11 17 10 14 4 10 5 7 4
(75.8) (9.2) (14.3) (8.4) (11.6) (3.3) (8.3) (4.2) (5.8) (3.4)
13 8 6 5 1 1 0 0 0 0
(100) (61.5) (46.1) (38.5) (7.7) (8.3) (0) (0) (0) (0)
that labour would progress faster in hospital (52.9%) or that recovery afterward would be easier in hospital (46.2%). When asked about risk and safety, all participants identified that they had trust in their midwife's skills. The hospital felt safer to these women (89.2%), and was seen as a safe choice for both mothers and babies (78.4%, 81.7%). However, 41% neither ‘agreed nor disagreed’ that hospital provided an opportunity for better health for mother and baby. At the same time, the same number felt that home birth was risky (40.8%). The majority (94.2%) felt supported by their midwife for their decision. Seventy-five per cent trusted hospital staff and did not appear concerned with differing opinions from hospital staff. The need to please their midwife, the desire to have children involved in the birth, and concerns about discrimination were not important factors in the decision to have a hospital birth. The open-ended questions provided opportunity to describe why they chose a hospital birth. Overall, birthing in the hospital with a midwife was described as ‘the best of both worlds’. Women reported increased feelings of security from having quick access to clinicians or emergency services due to a fear of potential complications in labour: I feel more comfortable in a hospital, knowing that if something goes wrong, I can get immediate help (i.e. emergency C-section). Some women who had chosen hospital birth stated they did not plan a home birth due to their belief that their home environment was unsuitable due to renovations, size constraints, poor emergency access, lack of childcare, or the presence of a pet. Similarly, some women felt they lived too far from the hospital. Other women commented on the influence of their previous birth experience and stated they would be more likely to choose home birth if they were not attempting a vaginal birth after caesarean, or if they had a history of uncomplicated labour.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 3 Reasons for choosing – rationale and beliefs: outcomes by cohort identified as ‘very important’ or ‘important’. Home n ¼ 78
Rationale for place of birth I want my partner involved in the birth My partner wants a home/hospital birth I want my children involved in the birth I want my friends and family at the birth I had a previous fast labour I want to be involved in decision-making I had a previous hospital birth I want to control my surroundings I live far from the hospital I live close to the hospital I feel more comfortable in hospital I feel more relaxed in hospital I want pain relief options I had a previous birth complication I find the idea of home birth stressful My house is not suitable for home birth I want to avoid the mess of home birth I want to avoid/have an epidural I cannot afford home/hospital birth I find hospital policies restrictive I find hospitals stressful I want a water birth I want to avoid infection risks I am worried about travelling in labour I want to avoid interventions I feel more comfortable in my home I want to be able to move freely in labour I want to eat and drink freely in labour I feel more relaxed in my home
Undecided n ¼13
n
(%)
n
(%)
n
(%)
75 46 15 23 32 78 27 70 6 48
(96.1) (60.5) (19.5) (30.2) (41.6) (100) (34.6) (89.8) (7.7) (63.2)
104 84 5 21 27 109 57 77 18 72 96 63 77 32 64 35 72 25 4
(85.3) (70.3) (4.2) (17.6) (22.5) (89.3) (47.2) (63.1) (14.8) (60.5) (78.9) (51.6) (63.7) (26.5) (52.4) (29.2) (59.5) (20.7) (3.3)
13 5 0 3 3 7 4 12 1 10 2 7 5 2
(100) (40.7) (0) (23.1) (23.1) (53.8) (30.8) (47) (7.7) (77) (15.4) (53.8) (38.5) (15.4)
n n n n n n n
Beliefs about birth I see birth as a natural process I believe labour will progress faster at home/hospital/comfortable environment I believe recovery afterward is easier where I am comfortable I am worried I will be discriminated against I want to honour my cultural and religious traditions n
Hospital n ¼123
70 1 63 47 37 65 28 75 76 77 73 76
(89.7) (1.3) (80.7) (60.3) (47.4) (83.3) (35.9) (96.2) (97.4) (98.7) (93.7) (97.4)
77 51 63 10 12
(98.7) (65.4) (82) (12.9) (15.3)
n n n n n
n
n
n
n
n
n
n
n
n
n
n
13 9 13 10 10
(99.9) (69.2) (99.9) (76.9) (76.9)
13 12 13 1 1
(100) (92.3) (100) (7.7) (7.7)
n n n n
113 10 21 6 12
(94.1) (8.4) (17.6) (5.1) (10.1)
:‘Not asked’ for this participant group.
Table 4 Reasons for choosing – safety and role of health care providers: outcomes by cohort identified as ‘very important’ or ‘important’.
Perceptions of risk and safety I trust my midwife's skills I feel safe in hospital Hospital birth provides opportunity for better health for me and my baby Hospital birth is safe for mothers Hospital birth is safe for babies I feel home births are risky I feel birth is risky I feel safe at home Home birth is safe for mothers Home birth is safe for babies Home birth provides better health for me and my baby I feel hospital births are risky I am a safe distance from hospital if needed Role of health care professionals I want to please my midwife My midwife supported my decision Hospital birth was my midwife's idea I trust hospital staff I dislike medical staff I dislike differing opinions from hospital staff Home birth was my midwife's idea n
‘Not asked’ for this participant group.
Home
Hospital
Undecided
n¼ 78
n ¼123
n17 ¼13
n
(%)
n
(%)
n
(%)
78
(100)
119 107 55 94 98 49
(99.2) (89.2) (45.4) (78.4) (81.7) (40.8)
13 10 8 10 9
(100) (76.9) (61.5) (76.9) (69.2)
n n n n n n
n
75 74 74 61 26 77
(96.1) (94.9) (94.8) (78.2) (33.3) (98.7)
n
2 70
(2.6) (92.1)
17 112 7 76
n n
10 39 3
(13.2) (51.2) (3.0)
n
5 11 11 5 4
n n n n
n
n
n
(14.4) (94.2) (5.9) (63.9)
2 12 n n
n
n
n
n
n
n
(38.5) (84.6) (84.6) (38.5) (30.1)
(15.4) (92.3)
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 5 Top 10 decision-making priorities: outcomes by cohort. All participants (n¼ 195)
I I I I I I I I I I
feel safer feel more comfortable see birth as a natural process want access to pain medication feel more relaxed want to avoid interventions am worried about the mess at home had a previous positive hospital experience had a previous complicated birth want a water birth
Home (n¼ 78)
Hospital (n ¼ 123)
n
(%)
n
(%)
n
(%)
99 69 54 45 38 36 35 24 24 16
(50.7) (35.3) (27.6) (23.0) (19.4) (18.4) (17.9) (12.3) (12.3) (8.2)
7 26 50 0 17 35 1 0 0 14
(9.2) (34.2) (65.7) (0) (22.3) (46.0) (1.3) (0) (0) (18.4)
92 44 4 47 22 2 37 25 24 2
(74.7) (35.7) (3.2) (38.2) (17.8) (1.6) (30.0) (20.3) (19.5) (1.6)
Undecided cohort Those who were undecided about choice of birthplace ‘strongly agreed’ or ‘agreed’ with the statements; I want my partner involved in the birth (90%); I want to be able to move freely during labour (99%); I want to avoid interventions (100%). However, there were several statements where the responses in this group were mixed. For example, when asked if they wanted pain relief options, 38% ‘strongly agreed’ or ‘agreed’, 23% ‘disagreed’ and 39% were neutral. When asked where they felt most comfortable and most relaxed, over 60% felt more comfortable and relaxed at home. Only 46% ‘agreed’ to feeling relaxed in hospital. Many saw birth as a natural process (77% strongly agree), and believed that both labour and recovery would be easier in a comfortable environment. Trust in their midwife's skill was unanimous. This group was mixed in the perception of safety between home and hospital. Specifically, 76.9% ‘agreed’ to feeling safe in the hospital, and 84.6% felt safe at home. The women ‘agreed’ that hospital birth was safe for mothers and babies (61% and 54% respectively). They ‘agreed’ that home birth was safe for mothers (77%), but only 38.5% agreed home birth was safe for babies. When asked whether home or hospital afforded better opportunity for the health of mother and baby, the undecided respondents agreed hospital was better over home (61.5% versus 30.1%). When the role of health care providers was explored those in the undecided group agreed that they trusted health care providers (92.3%) and that their midwife supported their decision (92.3%).
Discussion The goal of this study was to explore the factors that influence a woman's decision about where to give birth. Key decision-making priorities identified by all women in the study were the belief that birth was a natural process and the desire to feel safe and comfortable in their chosen birthplace. The most influential sources of information for decisionmaking were books and research about choice of birthplace. The internet and popular media were also identified as key resources. This is similar to the findings of the Canadian study conducted by Klein et al. (2011). The views of family and friends, and especially a woman's partner were important when making the decision. The role of partners in decision-making about place of birth was explored in more depth in a recent study. The authors found that, whereas women's partners may have a preference for one birthplace over another, typically hospital birth, they view the
woman as holding a better ‘bargaining position’ in decisionmaking (Bedwell et al., 2011). They described that the onus was on the woman to educate the partner and justify her decision to have the baby at home (Bedwell et al., 2011). The authors hypothesised this was due to the lack of communication between the partner, the woman, and health professionals. As such, involving partners in discussions regarding choice of birthplace may empower them, reducing feelings of vulnerability and increasing their comfort level with home birth (Bedwell et al., 2011). The results of our study indicate that these conversations should occur during the antenatal visit as attending a home birth information session was not a highly valued component of the decisionmaking process. The women's beliefs and values about birth played a significant role in shaping their decision about where to have their baby. Those planning home birth wanted to avoid interventions such as epidural and felt that hospital birth was too medical. They also felt more comfortable and relaxed, and able to control their surroundings at home. They expressed a desire to eat and drink freely, to have their partner involved during the birth and to be involved in decision-making. Those planning a hospital birth identified a desire to have their partner involved, to be involved in decisionmaking and to have pain relief options. They felt most comfortable in hospital and found the idea of home birth stressful. The majority of women in the study, regardless of their chosen place of birth believed that birth was a natural process. This is an important finding as it may indicate a shared value among midwifery clients. The universality of this belief among study participants may also indicate that women perceive the natural process of birth can occur regardless of their chosen birthplace with a midwife-attended birth. The data on midwifery births in Canada supports this finding with midwifery clients being more likely to have a vaginal childbirth, less likely to be induced and seven times more likely to have a medication free birth when compared to women under the care of Obstetricians (O'Brien et al., 2011). Further, there is recent Canadian evidence that women who choose to receive care from a midwife may have different attitudes and expectations about care than women who choose to see an obstetrician or family doctor, when a choice of care provider is available (Klein et al., 2011). Specifically, Klein et al. (2011) found that midwifery clients are less supportive of the use of technology during labour and value the role of the woman in her own birth. Perceptions of safety and risk were critical factors that shaped decision-making. Safety was a priority across all groups, but was the strongest determining factor among those choosing hospital birth. It became clear that the women in the home birth group valued safety, but they considered home birth to be a safe option and were more likely to see that hospital birth carried its own set
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
of risks. All participants felt confident in the care provided by midwives regardless of place of birth. The intersection between beliefs about birth and views of safety and risk was most acute in the group of women who were still undecided about where to give birth. This group shared beliefs about birth that closely matched the home birth group, yet their views of safety and risk were more closely aligned with the hospital group. Specifically, with respect to their values and beliefs they wanted their partner involved, they wanted to be free to move and to eat/drink freely, and to avoid interventions. Yet, at the same time, they gave mixed responses about the desire to have pain relief options. In terms of views of safety, they felt safer in hospital than at home. For example, undecided women more strongly agreed that hospital birth was safe for both mothers and babies, but they were less likely to agree that home birth was safe for babies. Those who are undecided about where to give birth face a unique challenge to reconcile conflicting beliefs and priorities in order to select a birthplace where they feel both comfortable and safe. Their responses also highlighted that the desire for pain relief options is a central decision-making issue. Finding a balance between values and risk perception may be challenging in pregnancy. It has been described as a time where women need to make risk calculations (Lindgren et al., 2010). Women find themselves weighing perceived risks against actual risks, mediated by the perceived likelihood that the risk may occur and the perceived seriousness of the outcome. These perceptions and risk calculations are unique for each woman, but are informed by societal values (Lindgren et al., 2010). Both home and hospital births may feel risky to women: at home, women worry about being too far away from help and are concerned about the ‘worse case scenarios’ (Lindgren et al., 2010). At hospital, women see the loss of autonomy, characterised by the involvement of strangers, and the emphasis on routines and interventions, as being risky. Understanding a woman's views of these risks may help health care providers to review evidence and address the issues of likelihood and severity of adverse outcomes. This conflicted decision-making process found in the undecided group may be confounded by a lack of prior birth experience as this group had the highest percentage of nulliparous women. This raises the issues of the impact of parity on decision-making for where to give birth. A greater proportion of those planning home birth identified themselves as multiparous. With more multiparous women planning home birth, they may have spent more time thinking about how their labour will progress based on their prior birthing experience. This mental preparation along with their prior experience could lead to greater feelings of confidence in their bodies' ability to labour, increasing their comfort level with birthing at home. With respect to the role of health care professionals during the decision-making process, women revealed that midwives were supportive of their chosen birthplace but did not recommend one place over another. Apart from midwives, other health care providers' ‘recommendations’ for place of birth, be it home or hospital, were not influential in their decision-making process. This is in contrast to previous Canadian literature that identified that health care providers' attitudes regarding maternity care can influence a woman's choice (Vedam et al., 2012). Yet, it is well established that health care providers do not agree on the safety of home birth and that health care providers other than midwives do not have education or knowledge related to the screening for or management of birth outside of hospital (McNiven et al., 2011; Vedam et al., 2012). Given the lack of importance ascribed to non-midwifery providers' recommendations as well as the timing of participants' decision regarding birthplace, it appears that once a woman has decided on her birthplace, there
7
is little importance placed upon recommendations made by a non-midwifery provider. Also, there may be a tendency among those interested in home birth to avoid discussing this decision with other health care providers as it may represent a choice outside of the accepted norms and expectations of traditional medical care (Lindgren et al., 2010). As midwives are the only care providers in Ontario who offer both home and hospital births to clients, women who choose midwifery care are more likely to plan and anticipate a home birth, leading to the lack of importance placed upon recommendations from other health care providers. Women from all groups expressed a desire for an alternative to home and hospital birth and overwhelmingly agreed they would access birth centres if they were available. However, there were many misconceptions about what services would be available at birth centres across all groups. Women planning home birth were less likely to indicate they would utilise a birth centre, expressing a belief that birthing anywhere other than their home would be like birthing in a hospital. Those who stated they would not utilise birth centre facilities still supported the availability of an alternative to birth at home or in hospital. The results of this study shed light on some of the important factors when considering choice of birthplace. The results are limited by the small sample size and by the typical sources of bias in self-administered questionnaires such as self-report and selection bias. The sample may not be representative of the wider Ontario population, due to the over representation of educated, married, Caucasian women, however, this may be an accurate reflection of the midwifery population in the province. Yet, some key groups remain under-represented such as nonwhite, same-sex couples, single mothers and those whose are new to Canada and who may not have English as a first language. Twenty five per cent of midwifery clients choose to give birth at home in the province of Ontario, yet there was a 37% rate of planned home birth in this study. This over-representation is likely attributable to a self-selection bias as women choosing home birth may be more motivated to describe their thought process and rationale for choosing a birthplace that is not the societal norm. Also, although the proportion of rural/remote practices participating in the study is similar to that across the province, travelling time to the nearest hospital may be given greater priority in the decision-making process among women in these areas.
Conclusion The Ontario Choice of Birthplace Study has identified influences, beliefs, rationales and decision-making priorities considered by women when selecting where to have their baby. The study also identified a unique challenge faced by those who are undecided about place of birth, as they share beliefs with women planning both home and concerns about safety similar to those planning hospital birth. Women in all groups expressed a strong preference for the availability of birth centres in the province. From a policy perspective, this finding comes at a critical time as the province is exploring the availability of options for out of hospital birth. It is hoped that the results of our study will assist health care providers when providing information to women about where to have their baby. For women, the findings identify key issues for consideration when deciding where to give birth. Exploration of these key issues are hoped to facilitate effective decision-making based on each women's values and priorities. With this in mind, the development of a decision aid may be a useful next step from this research.
Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
B. Murray-Davis et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Please cite this article as: Murray-Davis, B., et al., Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.01.008i
