European Journal of Obstetrics & Gynecology and Reproductive Biology, 36 (1990) 1-9 Elsevier
EUROBS 00939
Place of delivery in The Netherlands: maternal motives and background variables related to preferences for home or hospital confinement Gunilla Kleiverda ‘, A.M. Steen 2, Ingerlise Andersen 4, P.E. Treffers ’ and W. Everaerd 3 Departments of ’ Obstetrics and Gynaecology, 2 Department of Informatics and 3 Clinical Psychology, Academisch Medisch Centrum, Amsterdam, and 4 Faculty of Social Sciences, University of Utrecht, Utrecht, The Netherlands Accepted for publication 12 September 1989
The decision-making process regarding the preferred site for confinement was investigated in a total of 170 nulliparous women with initially uncomplicated pregnancies. Of these women, 100 had a preference for delivery at home and 45 for hospital confinement. The remaining 25 women were in doubt about the preferred location. Interviews were held at the 18th week of pregnancy. Motives for choosing either a home or a hospital confinement were analysed. Preferences for either home or hospital confinement were predicted by a stepwise discriminant analysis. Educational level, psychological well-being, anxiety concerning complications at birth, and attitudes towards female social roles accounted for 78.6% of the variance. Fear that something might go wrong during labour together with an older age predicted for 62% the group of women doubtful about the place of confinement. Home delivery; Hospital delivery; Antenatal booking
Introduction
Dutch women are in an unique position: provided there are no medical contra-indications, they may choose either to give birth at home or in a hospital. When no complications occur, in both cases the confinement is guided by a midwife. In contrast with most other Western and Eastern European countries, where the Correspondence: G. Kleiverda, Department of Obstetrics and Gynaecology, Centrum, Meibergdreef 9, 1105 AZ Amsterdam, The Netherland. 0028-2243/90/$03.50
Academisch
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
Medisch
2
hospitalization of birth has become the norm, 35% of confinements still take place at home. A consequence of this selection system, which allows only women with low-risk pregnancies to deliver at home, is that home confinements show a much lower perinatal mortality rate than hospital births, which also includes outcomes of high-risk pregnancies attended by obstetricians [1,2]. Adverse perinatal outcomes in home deliveries in some other countries are influenced by a relatively high percentage of unplanned home births [3] or by midwifery practiced by people without obstetric qualifications [4]. In The Netherlands, research concerning home and hospital confinements has mainly focused on: the evaluation of the obstetrical care system and the safety of home confinements [1,2,5,6]; perinatal mortality [7,8] and perinatal morbidity and neurological follow-up [9-131. Women’s experiences concerning the place of birth have hardly been a matter of study [14]. Studies in other countries comparing home and hospital confinements have mainly focused on mortality rates [15-171. A few surveys compared women’s perception of home births with perception of hospital births [18]; some authors looked into the reasons why either of these locations was being preferred [19]. Other research has focused on differences in intervention procedures and neonatal morbidity [20]. Little is known about the decision-making process regarding the place of birth. In countries where domiciliary confinements are difficult to arrange, women who prefer birth at home are often highly biased towards domiciliary confinements because of previous unsatisfactory hospital experiences [21,22]. Despite these methodological problems, generally women who had experience with both locations of birth preferred home confinement [18,23,24]. With regard to control over personal health and the childbirth setting women who chose home births were more internally oriented than women who preferred hospital confinements [25,26], As part of a prospective study on the tradition to parenthood, we explored women’s motives and background variables with regard to the preferred place of birth in a country where free choice of location of confinement is available. Subjects and methods Description of the sample
The study included 170 nulliparous women. All women received prenatal care from midwives at the beginning of their pregnancies, which were regarded as low-risk in terms of pregnancy outcome. At the beginning of their pregnancies, 100 women preferred birth at home, 45 preferred the hospital, and 25 had no initial preference and were in doubt about their place of confinement. Procedure
Through eight independent midwives’ practices in Amsterdam and its surrounding areas nulliparous women were recruited at their first antenatal visit. Interviews reported on in this article, were held at the 18th week gestation.
3
Open-end questions were used to elicit the women’s motives for choosing a particular place of confinement. A l-5 point Likert-type scale was developed to measure attitudes towards home and hospital confinements. Two factors, each including items favouring one type of place of confinement, could be discerned using factor analysis. Semi-structured questions were used to obtain information about influence by ‘important others’. Standardized scales were used to classify information pertaining to demographic background variables: age, occupational [27] and educational [28] levels and to health [29], psychological well-being [30] and self-esteem [31]. A scale to evaluate attitudes towards female social roles was described previously [32]. Besides, a scale measuring specific anxieties related to pregnancy and labour was completed. Statistical analyses were performed using &i-square tests and univariate and multivariate analyses of variance. In this article, first the more qualitative data obtained in answer to the open-end questions concerning preference for either home or hospital confinement are described. The various opinions are illustrated using scoring rates on an attitude scale. Second, the significance of ‘important others’ is evaluated. Third, quantitative data are presented; these concern the univariate and multivariate analyses used to predict the desired location of birth. Results I. 1. Reasons for preferring home delivery The reasons most frequently mentioned
by the women with a preference for home confinement can be classified in two categories: advantages pertaining to the home environment (97%) and disadvantages noted concerning the hospital environment (86%). The advantages of the home environment were described by the women as follows: “I feel most at ease and I can relax best in my own home”. “Having a child at home is the most normal way.” The home environment is cosier.” “At home I can decide myself how things are going.” “ In my own house I have more privacy.” Disadvantages of hospital confinement, even though their own midwife would assist them there during the confinement, were expressed as follows: “There are many rules; you are not allowed to do what you like.” “Other people make decisions for you.” “ People, who you don’t know, just walk in and out.” “I can’t have my friends with me during delivery.” “ My husband cannot do anything during delivery. ” “Technology will be used too easily.” “ It seems terrible to me to go to the hospital by car while in labour. ” “I’m scared of the hospital: it reminds me of the sick and dying.” “ It seems terrible to stay alone for a night in hospital after delivery.” Other arguments (29%) mentioned spontaneously were: “I live close to the hospital. In case of need, it would take the obstetrician as long to get to the hospital as it would take for me to be transferred there.” “ Besides, hospital confinement is more expensive.” “ My husband doesn’t like hospitals at all.” “I was present when my sister gave birth at home, it was such a wonderful experience.”
4
1.2. Reasons for preferring delivery in hospital The reasons most frequently mentioned by the women preferring
hospital confinement can also be classified in two categories: advantages pertaining to confinement in the hospital (76%) and disadvantages noted concerning birth at home (38%). Advantages related to confinement in hospital were mostly described in terms of more safety: “If something goes wrong, expert knowledge is present.” “I don’t have anything against home deliveries, but I think that giving birth in the hospital is just safer.” Disadvantages related to home confinement were described less frequently. “I don’t like the mess of delivery in my home, it’s nice to have it happen in the hospital and then when everything is over, it will be nice to come home again with my baby.” “It seems awkward to me to have to be transported to the hospital at the last minute in case of complications.” Other arguments not falling into the category of advantages or disadvantages were mentioned more often by women preferring hospital confinement (47%) than by the women who preferred delivery at home (29%). “This is my first baby; I don’t know how things will go and how I will react, so I think the hospital is better.” “I would like to give birth at home, but my partner prefers the hospital.” “If this delivery takes place without complications, I will give birth at home next time.” Housing conditions were mentioned only twice as a reason for a hospital confinement. 1.3. Women without an initial preference
regarding place of delivery
The women in doubt about the place of confinement mentioned the same kinds of arguments as the women who had made an initial choice. However, deciding on either home or hospital confinement seemed to be more difficult for these women. “At this point I do not know. When I hear about positive experiences with home deliveries, I think ‘at home’; when I hear about negative experiences with home deliveries I think it would be better to give birth in hospital.” Sometimes their partners initially had a different opinion, thus making it more difficult for these women to reach a decision. 1.4. Opinions concerning home and hospital confinements
In addition to different answers on open-end questions, the three groups of women also diverged significantly in their opinions as measured by the two factors-scores of the attitude towards location of confinement scale, favouring either home or hospital confinement (analysis of variance, F, respectively, 43.68 and 21.43, df = 2, p < 0.001). The women planning a hospital birth did not consider domiciliary confinement to be unsafe: 78% of these women agreed upon that it is as safe to deliver at home as it is to deliver in the hospital if pregnancy is uncomplicated. However, 58% of these women assessed the hospital location as being safer. Even by 38% women preferring hospital birth disadvantages of this location were noted, as many unknown people around, making one feel less at ease than one would at home.
5
The differences found between women preferring either a home or a hospital confinement were most marked in the influence which the location of birth was expected to have on their behaviour during labour: 61% of the women who preferred home birth compared to only 17% of the women preferring hospital delivery agreed upon a positive influence of the home environment in coping with pain, while, respectively, 69% and 16% were anxious for loosing self-confidence in hospital. 2. The influence of “significant others” The experienced influence of other women’s histories with regard to the location of birth, and the opinions of the partners and midwives was investigated next. The following percentages of familiarity with other women’s locations of birth for the total group of women were found: home birth (86%), voluntary hospital (93%) transfer during labour to hospital (57%). The women who preferred hospital confinement were more familiar with the other women’s experiences concerning this location than the other two groups (&i-square = 11.92, df = 2, p < 0.05). Also, to a lesser extent, more women planning to have home birth were familiar with domiciliary confinements than the other groups (&i-square = 5.63, df = 2, p = 0.06). Knowledge of women who had been transferred to hospital during labour did not differ significantly among the three groups of women. Positive reinforcement was experienced more often by women preferring to give birth at home (46%) than by women who planned to deliver in hospital (18%) (&i-square = 9.19, df = 1, p < 0.01). Negative emphasis on either place of delivery was observed in 23% of cases with no differences between the two groups. The 25 initially doubtful women were positively reinforced towards home confinement six times (24%), one of these women (4%) was negatively influenced concerning home confinement. We also asked the women if their partners’ view on the place of confinement affected their decision regarding the place of delivery in any way. In only eight cases (5%) the women experienced to be strongly influenced in their decision by their partners’ view. In the remaining cases the women felt that the partners left the decision to them (53%), did not influence them because they had practically the same opinion (39%), or the woman was single (3%). With regard to the influence of the opinion of the midwife, more influence was experienced by the doubtful women (32%) than by the other women (14%) (chisquare = 5.12, df = 1, p -C0.05). 3.1. Demographic and other background variables The demographic and attitudinal variables related to the preferred location for giving birth are summarized in Table I. Significant differences between the three groups were found with regard to age (analysis of variance F = 3.38, df = 2, 167, p -z 0.05); educational levels (&i-square = 37.59, df = 6, p < 0.001); occupational levels (&i-square = 21.12, df = 4, p < 0.001); plans with regard to postpartum employment (&i-square = 25.93, df = 2, p < 0.01); and attitudes towards female social roles (analysis of variance, F = 5.80,
6
TABLE I Demographic and attitudinal variables related to preferred location for giving birth Home (n = 100)
Hospital (n = 45)
Doubtful (n = 25)
Total (n = 170)
29.22 (3.63)
27.80 (3.86)
29.96 (3.61)
28.95 (3.74)
Educational level (low-high) 11% l-3 22% 4 43% 5 24% 6
44% 38% 11% 7%
16% 44% 24% 16%
21% 29% 32% 18%
Occupational level low medium high
82% 16% 2%
64% 12% 24%
58% 24% 18%
Plans regarding paid work after confinement 62% 74% continue 8% 19% in doubt 30% 7% quit
76% 5% 19%
71% 14% 15%
Attitudes towards female social roles (high = traditional) 27.33 (7.73) 22.86 (7.30) mean (SD)
24.24 (6.58)
24.25 (7.52)
Age mean (SD)
45% 31% 24%
df = 2, 167, p < 0.01). In the univariate analyses, no significant differences were found between the groups either with regard to level of self-esteem or health or psychological well-being. Some differences were found regarding fear that something might go wrong during labour. This was affirmed by 60% of the women doubtful about the location of confinement, 49% of the women preferring a hospital birth and 44% of the women planning a domiciliary confinement (not significant). 3.2. Prediction of the preferred location of confinement by two stepwise discriminant analyses
In order to predict the preferred location of confinement, two multivariate analyses were performed, including the above-mentioned variables of the univariant analyses. The home and hospital delivery groups were included in the first analysis. Four factors appeared to predict for 78.6% the preferences of these two groups; educational level was by far the most important variable. The others were psychological well-being, fear that something might go wrong during labour and attitudes towards female social roles. The standardized canonical discriminant function coefficients were, respectively, 0.92, 0.43, 0.16 and 0.24. A high educational level, relatively low psychological well-being as measured by the Bradburn Scale, though little anxiety concerning birth, and less traditional attitudes towards female social roles predicted a great chance of preference for domiciliary confinement.
In the second analysis, the group of women doubtful about the location of birth was compared with the other two groups taken together. Fear that something might go wrong during labour together with age predicted the preferences of the two groups for 62.1%. The standardized function coefficients were, respectively, 0.83 and 0.57. So, women doubtful about the place of confinement were in general older and more anxious about complications during labour than women with a clear preference for location of birth. Discussion
As a part of a prospective study on the tradition to parenthood in the Netherlands, where domiciliary confinements are freely available, motives and demographic background figures with regard to the choice of the place of confinement were studied. In an urban research area, the educational level of women was the main predictor for the location of confinement: women with a higher level of education more often preferred home confinement than women with a lower educational level. Besides, women preferring a domiciliary confinement had higher age and occupational levels and less traditional attitudes towards female social roles. This high socioeconomic status (SES) contrasts with results from studies in other countries, where it mainly are women with low SES who give birth at home [3,20,23]. When we take a look at the motives and attitudes presented by women preferring a home or a hospital confinement, we found that even a great part of the women preferring a hospital confinement agreed upon some negative aspects of this location and agreed upon the safety of home confinements. However, major differences between women opting for either a home or a hospital confinement were found in the expected influence of the environment on own behaviour during labour. Apart from an expected positive influence of the home environment in coping with pain, and anxiety for loosing self-confidence in hospital, arguments were noted as: “At home I can decide myself how things are going.” These arguments about the possibility of being in control during labour indicate a more internally oriented locus of control in the women planning home delivery, in contrast to answers such as: “I don’t know how I will react” or “something might go wrong” which indicate a more externally oriented locus of control in the women preferring hospital confinement. Also arguments about “more safety” fit in this last kind of argument. As an internally oriented locus of control is correlated with higher SES [33], we can explain why it on the older, higher educated women who choose for a home confinement. The third group of women, initially in doubt about the preferred location of giving birth, could be predicted to a lesser extent by older age on the one hand and fear of complications during labour on the other hand. This group of women experienced more frequently than the other groups of women influence of the midwife in their decision on the location of confinement. Although partners are nearly always present at deliveries in the Netherlands, the decision on the location of confinement seems to be mainly one taken by the woman
8
herself. Knowledge of women who had been transferred to hospital during labour did not scare off women to opt for a home confinement, while positive experiences of other women at home further reinforced the decision for a domiciliary confinement. The impacts of these findings are, that when we compare outcomes of women voluntarily giving birth in hospital with those giving birth at home, we have to do with two different groups with regard to age and SES and with regard to attitudes towards control in labour. In a next article we will present the results from our study with regard to actual location of confinement and obstetric outcomes in relation to the preferred place of birth. Acknowledgements
This study was supported by the Dutch Ministry of Social Affairs, the Dutch Ministry of Health and the World Health Organization. References 1 Kloosterman GJ. The Dutch experience of domiciliary confinements. In: Zandler L, Chamberlain G, eds. Pregnancy care for the 1980s. The Royal Society of Medicine. London: Macmillan Press Ltd, 1984:115-125. 2 Van Alten D, Eskes M, Treffers PE. Midwifery in the Netherlands. The Wormerveer study; selection, mode of delivery, perinatal mortality and infant morbidity, Br J Obstet Gynaecol 1989;96:656-662. 3 Murphy JF, Dauncey M, Gray OP et al. Planned and unplanned deliveries at home: implications of a changing ratio. Br Med J 1984;288:1429-1432. 4 Schramm WF, Barnes DE, BakeweIl JM. Neonatal mortality in Missouri home births, 1978-84. Am J Public Health 1987;77:930-935. 5 Huygen FJ. Home deliveries in Holland. J Roy Co11Gen Pratt 1976;26:244-248. 6 Damstra-Wijmenga SMI. Home confinement: the positive results in Holland. J Roy Co11 Gen Pratt 1984;34:425-430. 7 Treffers PE, Laan R. PerinataI mortality and hospitalization at delivery in The Netherlands. Br J Obstet Gynaecol 1986;93:690-693. 8 Hoogendoom D. Indrukwekkende en tegelijk teleurstellende daling van de perinatale sterfte in Nederland. Ned T Geneeskd 1986;130:1436-1440. 9 Lievaart M, De Jong PA. Neonatal morbidity in deliveries conducted by midwives and gynecologists. A study of the system of obstetric care prevailing in The Netherlands. Am J Obstet Gynecol 1982;144:376-386. 10 Treffers PE, Van Alten D, Pel M. Condemnation of the obstetric care in The Netherlands? Letter to the editor. Am J Obstet Gynecol 1983;146:871-872. 11 Berghs GAH, Spanjaards EWM. De normale zwangerschap: Bevalling en beleid. Thesis. Nijmegen, 1988. 12 Eskes M, Rnuist M, Van Alten D. Neurologisch onderzoek bij pasgeborenen in een verloskundigen praktijk. Ned T Geneeskd 1987;131:1040-1043. 13 Rnuist M, Eskes M, Van Alten D. The pH van het arteriele navelstrengbloed van pasgeborenen bij door vroedvrouwen geleide bevallingen. Ned T Geneeskd 1987;131:362-365. 14 Schuil PM. De client in de verloskundige zorgverlening. Thesis. Oldenxaal: Verhaag, 1975. 15 Barron SL, Thomson AM, Philips PR. Home and hospital confinement in Newcastle upon Tyne, 1960-1969. Br J Obstet Gynaecol1977;84:401-411. 16 Fedrick J, Butler NR. Intended place of delivery and perinatal outcome. Br Med J 1978:i;763-765. 17 Campbell R, MacDonald Davies I, MacFarlane A et al. Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery. Br Med J 1984;289:721-724.
9 18 O’Brien M. Home and hospital confinement: a comparison of the experiences of mothers having home and hospital confinements. J Roy Co11Gen Pratt 1978;28:460-466. 19 Gordon I, Ellias-Jones TF. The place of confinement: home or hospital? The mother’s preference. Br Med J 196O;i:52-53. 20 Mehl LE. The outcome of the home delivery research in the United States. In: Kitzinger S, Davis JA, eds. The Place of Birth. Oxford: Oxford University Press, 1978:93-117. 21 Fraser CM. Selected perinatal procedures. Scientific basis for use and psychosocial effects. Acta Obstet Gynecol Stand Suppl 1983;117:11-12. 22 Campbell R, MacFarlane A. Place of delivery: a review. Br J Obstet Gynaecol 1986;93:675-683. 23 Alment EAJ, Barr A, Reid M et al. Normal confinement: a domiciliary and hospital study. Br Med J 1967;ii:530-535. 24 Kitzinger S. Women’s experiences of home birth, In: Kitzinger S, Davis JA. eds. The Place of Birth. Oxford: Oxford University Press, 1978:135-157. 25 Fullerton JDT. The choice of in-hospital or alternative birth environment as related to the concept of control. J Nurse-Midwif 1982;27:17-22. 26 Fleming AS, Ruble DN, Anderson V, et al. Place of childbirth influences feelings of satisfaction and control in first-time mothers. J Psychosom Obstet Gynaecol 1988;8:1-17. 27 Van Westerlaak JM, Kropman JA, Collaris JWM. Beroepenklapper. Nijmegen: Instituut voor Toegepaste Sociologic, 1975. 28 Central Bureau of Statistics. Arbeidskrachtentellingen, 1979. 29 Luteijn F, Kok AR Hamel LF et al. Hopkins Symptom Checklist. Lisse: Swets & Zeitlinger B.V., 1984. 30 Bradbum N. The structure of psychological well-being. Chicago: Aldine, 1969. 31 Rosenberg MJ. Analysis of affective-cognitive consistency. In: Hovland C, Rosenberg MJ, eds. Attitude organization and change. New Haven: Yale University Press, 1960:15-64. 32 KIeiverda G, Slot-Andersen I. Eerste kind en baan: een onderzoek naar gezondheid en welbevinden. Ministerie van Sociale Zaken en Werkgelegenheid. The Hague, 1988. 33 Halfens RJG. Locus of control. Beheersingsorientatie in relatie tot ziekte- en gezondheidsgedrag. Thesis. Maastricht, 1985.
EUROBS 00939
Place of delivery in The Netherlands: maternal motives and background variables related to preferences for home or hospital confinement Gunilla Kleiverda ‘, A.M. Steen 2, Ingerlise Andersen 4, P.E. Treffers ’ and W. Everaerd 3 Departments of ’ Obstetrics and Gynaecology, 2 Department of Informatics and 3 Clinical Psychology, Academisch Medisch Centrum, Amsterdam, and 4 Faculty of Social Sciences, University of Utrecht, Utrecht, The Netherlands Accepted for publication 12 September 1989
The decision-making process regarding the preferred site for confinement was investigated in a total of 170 nulliparous women with initially uncomplicated pregnancies. Of these women, 100 had a preference for delivery at home and 45 for hospital confinement. The remaining 25 women were in doubt about the preferred location. Interviews were held at the 18th week of pregnancy. Motives for choosing either a home or a hospital confinement were analysed. Preferences for either home or hospital confinement were predicted by a stepwise discriminant analysis. Educational level, psychological well-being, anxiety concerning complications at birth, and attitudes towards female social roles accounted for 78.6% of the variance. Fear that something might go wrong during labour together with an older age predicted for 62% the group of women doubtful about the place of confinement. Home delivery; Hospital delivery; Antenatal booking
Introduction
Dutch women are in an unique position: provided there are no medical contra-indications, they may choose either to give birth at home or in a hospital. When no complications occur, in both cases the confinement is guided by a midwife. In contrast with most other Western and Eastern European countries, where the Correspondence: G. Kleiverda, Department of Obstetrics and Gynaecology, Centrum, Meibergdreef 9, 1105 AZ Amsterdam, The Netherland. 0028-2243/90/$03.50
Academisch
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
Medisch
2
hospitalization of birth has become the norm, 35% of confinements still take place at home. A consequence of this selection system, which allows only women with low-risk pregnancies to deliver at home, is that home confinements show a much lower perinatal mortality rate than hospital births, which also includes outcomes of high-risk pregnancies attended by obstetricians [1,2]. Adverse perinatal outcomes in home deliveries in some other countries are influenced by a relatively high percentage of unplanned home births [3] or by midwifery practiced by people without obstetric qualifications [4]. In The Netherlands, research concerning home and hospital confinements has mainly focused on: the evaluation of the obstetrical care system and the safety of home confinements [1,2,5,6]; perinatal mortality [7,8] and perinatal morbidity and neurological follow-up [9-131. Women’s experiences concerning the place of birth have hardly been a matter of study [14]. Studies in other countries comparing home and hospital confinements have mainly focused on mortality rates [15-171. A few surveys compared women’s perception of home births with perception of hospital births [18]; some authors looked into the reasons why either of these locations was being preferred [19]. Other research has focused on differences in intervention procedures and neonatal morbidity [20]. Little is known about the decision-making process regarding the place of birth. In countries where domiciliary confinements are difficult to arrange, women who prefer birth at home are often highly biased towards domiciliary confinements because of previous unsatisfactory hospital experiences [21,22]. Despite these methodological problems, generally women who had experience with both locations of birth preferred home confinement [18,23,24]. With regard to control over personal health and the childbirth setting women who chose home births were more internally oriented than women who preferred hospital confinements [25,26], As part of a prospective study on the tradition to parenthood, we explored women’s motives and background variables with regard to the preferred place of birth in a country where free choice of location of confinement is available. Subjects and methods Description of the sample
The study included 170 nulliparous women. All women received prenatal care from midwives at the beginning of their pregnancies, which were regarded as low-risk in terms of pregnancy outcome. At the beginning of their pregnancies, 100 women preferred birth at home, 45 preferred the hospital, and 25 had no initial preference and were in doubt about their place of confinement. Procedure
Through eight independent midwives’ practices in Amsterdam and its surrounding areas nulliparous women were recruited at their first antenatal visit. Interviews reported on in this article, were held at the 18th week gestation.
3
Open-end questions were used to elicit the women’s motives for choosing a particular place of confinement. A l-5 point Likert-type scale was developed to measure attitudes towards home and hospital confinements. Two factors, each including items favouring one type of place of confinement, could be discerned using factor analysis. Semi-structured questions were used to obtain information about influence by ‘important others’. Standardized scales were used to classify information pertaining to demographic background variables: age, occupational [27] and educational [28] levels and to health [29], psychological well-being [30] and self-esteem [31]. A scale to evaluate attitudes towards female social roles was described previously [32]. Besides, a scale measuring specific anxieties related to pregnancy and labour was completed. Statistical analyses were performed using &i-square tests and univariate and multivariate analyses of variance. In this article, first the more qualitative data obtained in answer to the open-end questions concerning preference for either home or hospital confinement are described. The various opinions are illustrated using scoring rates on an attitude scale. Second, the significance of ‘important others’ is evaluated. Third, quantitative data are presented; these concern the univariate and multivariate analyses used to predict the desired location of birth. Results I. 1. Reasons for preferring home delivery The reasons most frequently mentioned
by the women with a preference for home confinement can be classified in two categories: advantages pertaining to the home environment (97%) and disadvantages noted concerning the hospital environment (86%). The advantages of the home environment were described by the women as follows: “I feel most at ease and I can relax best in my own home”. “Having a child at home is the most normal way.” The home environment is cosier.” “At home I can decide myself how things are going.” “ In my own house I have more privacy.” Disadvantages of hospital confinement, even though their own midwife would assist them there during the confinement, were expressed as follows: “There are many rules; you are not allowed to do what you like.” “Other people make decisions for you.” “ People, who you don’t know, just walk in and out.” “I can’t have my friends with me during delivery.” “ My husband cannot do anything during delivery. ” “Technology will be used too easily.” “ It seems terrible to me to go to the hospital by car while in labour. ” “I’m scared of the hospital: it reminds me of the sick and dying.” “ It seems terrible to stay alone for a night in hospital after delivery.” Other arguments (29%) mentioned spontaneously were: “I live close to the hospital. In case of need, it would take the obstetrician as long to get to the hospital as it would take for me to be transferred there.” “ Besides, hospital confinement is more expensive.” “ My husband doesn’t like hospitals at all.” “I was present when my sister gave birth at home, it was such a wonderful experience.”
4
1.2. Reasons for preferring delivery in hospital The reasons most frequently mentioned by the women preferring
hospital confinement can also be classified in two categories: advantages pertaining to confinement in the hospital (76%) and disadvantages noted concerning birth at home (38%). Advantages related to confinement in hospital were mostly described in terms of more safety: “If something goes wrong, expert knowledge is present.” “I don’t have anything against home deliveries, but I think that giving birth in the hospital is just safer.” Disadvantages related to home confinement were described less frequently. “I don’t like the mess of delivery in my home, it’s nice to have it happen in the hospital and then when everything is over, it will be nice to come home again with my baby.” “It seems awkward to me to have to be transported to the hospital at the last minute in case of complications.” Other arguments not falling into the category of advantages or disadvantages were mentioned more often by women preferring hospital confinement (47%) than by the women who preferred delivery at home (29%). “This is my first baby; I don’t know how things will go and how I will react, so I think the hospital is better.” “I would like to give birth at home, but my partner prefers the hospital.” “If this delivery takes place without complications, I will give birth at home next time.” Housing conditions were mentioned only twice as a reason for a hospital confinement. 1.3. Women without an initial preference
regarding place of delivery
The women in doubt about the place of confinement mentioned the same kinds of arguments as the women who had made an initial choice. However, deciding on either home or hospital confinement seemed to be more difficult for these women. “At this point I do not know. When I hear about positive experiences with home deliveries, I think ‘at home’; when I hear about negative experiences with home deliveries I think it would be better to give birth in hospital.” Sometimes their partners initially had a different opinion, thus making it more difficult for these women to reach a decision. 1.4. Opinions concerning home and hospital confinements
In addition to different answers on open-end questions, the three groups of women also diverged significantly in their opinions as measured by the two factors-scores of the attitude towards location of confinement scale, favouring either home or hospital confinement (analysis of variance, F, respectively, 43.68 and 21.43, df = 2, p < 0.001). The women planning a hospital birth did not consider domiciliary confinement to be unsafe: 78% of these women agreed upon that it is as safe to deliver at home as it is to deliver in the hospital if pregnancy is uncomplicated. However, 58% of these women assessed the hospital location as being safer. Even by 38% women preferring hospital birth disadvantages of this location were noted, as many unknown people around, making one feel less at ease than one would at home.
5
The differences found between women preferring either a home or a hospital confinement were most marked in the influence which the location of birth was expected to have on their behaviour during labour: 61% of the women who preferred home birth compared to only 17% of the women preferring hospital delivery agreed upon a positive influence of the home environment in coping with pain, while, respectively, 69% and 16% were anxious for loosing self-confidence in hospital. 2. The influence of “significant others” The experienced influence of other women’s histories with regard to the location of birth, and the opinions of the partners and midwives was investigated next. The following percentages of familiarity with other women’s locations of birth for the total group of women were found: home birth (86%), voluntary hospital (93%) transfer during labour to hospital (57%). The women who preferred hospital confinement were more familiar with the other women’s experiences concerning this location than the other two groups (&i-square = 11.92, df = 2, p < 0.05). Also, to a lesser extent, more women planning to have home birth were familiar with domiciliary confinements than the other groups (&i-square = 5.63, df = 2, p = 0.06). Knowledge of women who had been transferred to hospital during labour did not differ significantly among the three groups of women. Positive reinforcement was experienced more often by women preferring to give birth at home (46%) than by women who planned to deliver in hospital (18%) (&i-square = 9.19, df = 1, p < 0.01). Negative emphasis on either place of delivery was observed in 23% of cases with no differences between the two groups. The 25 initially doubtful women were positively reinforced towards home confinement six times (24%), one of these women (4%) was negatively influenced concerning home confinement. We also asked the women if their partners’ view on the place of confinement affected their decision regarding the place of delivery in any way. In only eight cases (5%) the women experienced to be strongly influenced in their decision by their partners’ view. In the remaining cases the women felt that the partners left the decision to them (53%), did not influence them because they had practically the same opinion (39%), or the woman was single (3%). With regard to the influence of the opinion of the midwife, more influence was experienced by the doubtful women (32%) than by the other women (14%) (chisquare = 5.12, df = 1, p -C0.05). 3.1. Demographic and other background variables The demographic and attitudinal variables related to the preferred location for giving birth are summarized in Table I. Significant differences between the three groups were found with regard to age (analysis of variance F = 3.38, df = 2, 167, p -z 0.05); educational levels (&i-square = 37.59, df = 6, p < 0.001); occupational levels (&i-square = 21.12, df = 4, p < 0.001); plans with regard to postpartum employment (&i-square = 25.93, df = 2, p < 0.01); and attitudes towards female social roles (analysis of variance, F = 5.80,
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TABLE I Demographic and attitudinal variables related to preferred location for giving birth Home (n = 100)
Hospital (n = 45)
Doubtful (n = 25)
Total (n = 170)
29.22 (3.63)
27.80 (3.86)
29.96 (3.61)
28.95 (3.74)
Educational level (low-high) 11% l-3 22% 4 43% 5 24% 6
44% 38% 11% 7%
16% 44% 24% 16%
21% 29% 32% 18%
Occupational level low medium high
82% 16% 2%
64% 12% 24%
58% 24% 18%
Plans regarding paid work after confinement 62% 74% continue 8% 19% in doubt 30% 7% quit
76% 5% 19%
71% 14% 15%
Attitudes towards female social roles (high = traditional) 27.33 (7.73) 22.86 (7.30) mean (SD)
24.24 (6.58)
24.25 (7.52)
Age mean (SD)
45% 31% 24%
df = 2, 167, p < 0.01). In the univariate analyses, no significant differences were found between the groups either with regard to level of self-esteem or health or psychological well-being. Some differences were found regarding fear that something might go wrong during labour. This was affirmed by 60% of the women doubtful about the location of confinement, 49% of the women preferring a hospital birth and 44% of the women planning a domiciliary confinement (not significant). 3.2. Prediction of the preferred location of confinement by two stepwise discriminant analyses
In order to predict the preferred location of confinement, two multivariate analyses were performed, including the above-mentioned variables of the univariant analyses. The home and hospital delivery groups were included in the first analysis. Four factors appeared to predict for 78.6% the preferences of these two groups; educational level was by far the most important variable. The others were psychological well-being, fear that something might go wrong during labour and attitudes towards female social roles. The standardized canonical discriminant function coefficients were, respectively, 0.92, 0.43, 0.16 and 0.24. A high educational level, relatively low psychological well-being as measured by the Bradburn Scale, though little anxiety concerning birth, and less traditional attitudes towards female social roles predicted a great chance of preference for domiciliary confinement.
In the second analysis, the group of women doubtful about the location of birth was compared with the other two groups taken together. Fear that something might go wrong during labour together with age predicted the preferences of the two groups for 62.1%. The standardized function coefficients were, respectively, 0.83 and 0.57. So, women doubtful about the place of confinement were in general older and more anxious about complications during labour than women with a clear preference for location of birth. Discussion
As a part of a prospective study on the tradition to parenthood in the Netherlands, where domiciliary confinements are freely available, motives and demographic background figures with regard to the choice of the place of confinement were studied. In an urban research area, the educational level of women was the main predictor for the location of confinement: women with a higher level of education more often preferred home confinement than women with a lower educational level. Besides, women preferring a domiciliary confinement had higher age and occupational levels and less traditional attitudes towards female social roles. This high socioeconomic status (SES) contrasts with results from studies in other countries, where it mainly are women with low SES who give birth at home [3,20,23]. When we take a look at the motives and attitudes presented by women preferring a home or a hospital confinement, we found that even a great part of the women preferring a hospital confinement agreed upon some negative aspects of this location and agreed upon the safety of home confinements. However, major differences between women opting for either a home or a hospital confinement were found in the expected influence of the environment on own behaviour during labour. Apart from an expected positive influence of the home environment in coping with pain, and anxiety for loosing self-confidence in hospital, arguments were noted as: “At home I can decide myself how things are going.” These arguments about the possibility of being in control during labour indicate a more internally oriented locus of control in the women planning home delivery, in contrast to answers such as: “I don’t know how I will react” or “something might go wrong” which indicate a more externally oriented locus of control in the women preferring hospital confinement. Also arguments about “more safety” fit in this last kind of argument. As an internally oriented locus of control is correlated with higher SES [33], we can explain why it on the older, higher educated women who choose for a home confinement. The third group of women, initially in doubt about the preferred location of giving birth, could be predicted to a lesser extent by older age on the one hand and fear of complications during labour on the other hand. This group of women experienced more frequently than the other groups of women influence of the midwife in their decision on the location of confinement. Although partners are nearly always present at deliveries in the Netherlands, the decision on the location of confinement seems to be mainly one taken by the woman
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herself. Knowledge of women who had been transferred to hospital during labour did not scare off women to opt for a home confinement, while positive experiences of other women at home further reinforced the decision for a domiciliary confinement. The impacts of these findings are, that when we compare outcomes of women voluntarily giving birth in hospital with those giving birth at home, we have to do with two different groups with regard to age and SES and with regard to attitudes towards control in labour. In a next article we will present the results from our study with regard to actual location of confinement and obstetric outcomes in relation to the preferred place of birth. Acknowledgements
This study was supported by the Dutch Ministry of Social Affairs, the Dutch Ministry of Health and the World Health Organization. References 1 Kloosterman GJ. The Dutch experience of domiciliary confinements. In: Zandler L, Chamberlain G, eds. Pregnancy care for the 1980s. The Royal Society of Medicine. London: Macmillan Press Ltd, 1984:115-125. 2 Van Alten D, Eskes M, Treffers PE. Midwifery in the Netherlands. The Wormerveer study; selection, mode of delivery, perinatal mortality and infant morbidity, Br J Obstet Gynaecol 1989;96:656-662. 3 Murphy JF, Dauncey M, Gray OP et al. Planned and unplanned deliveries at home: implications of a changing ratio. Br Med J 1984;288:1429-1432. 4 Schramm WF, Barnes DE, BakeweIl JM. Neonatal mortality in Missouri home births, 1978-84. Am J Public Health 1987;77:930-935. 5 Huygen FJ. Home deliveries in Holland. J Roy Co11Gen Pratt 1976;26:244-248. 6 Damstra-Wijmenga SMI. Home confinement: the positive results in Holland. J Roy Co11 Gen Pratt 1984;34:425-430. 7 Treffers PE, Laan R. PerinataI mortality and hospitalization at delivery in The Netherlands. Br J Obstet Gynaecol 1986;93:690-693. 8 Hoogendoom D. Indrukwekkende en tegelijk teleurstellende daling van de perinatale sterfte in Nederland. Ned T Geneeskd 1986;130:1436-1440. 9 Lievaart M, De Jong PA. Neonatal morbidity in deliveries conducted by midwives and gynecologists. A study of the system of obstetric care prevailing in The Netherlands. Am J Obstet Gynecol 1982;144:376-386. 10 Treffers PE, Van Alten D, Pel M. Condemnation of the obstetric care in The Netherlands? Letter to the editor. Am J Obstet Gynecol 1983;146:871-872. 11 Berghs GAH, Spanjaards EWM. De normale zwangerschap: Bevalling en beleid. Thesis. Nijmegen, 1988. 12 Eskes M, Rnuist M, Van Alten D. Neurologisch onderzoek bij pasgeborenen in een verloskundigen praktijk. Ned T Geneeskd 1987;131:1040-1043. 13 Rnuist M, Eskes M, Van Alten D. The pH van het arteriele navelstrengbloed van pasgeborenen bij door vroedvrouwen geleide bevallingen. Ned T Geneeskd 1987;131:362-365. 14 Schuil PM. De client in de verloskundige zorgverlening. Thesis. Oldenxaal: Verhaag, 1975. 15 Barron SL, Thomson AM, Philips PR. Home and hospital confinement in Newcastle upon Tyne, 1960-1969. Br J Obstet Gynaecol1977;84:401-411. 16 Fedrick J, Butler NR. Intended place of delivery and perinatal outcome. Br Med J 1978:i;763-765. 17 Campbell R, MacDonald Davies I, MacFarlane A et al. Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery. Br Med J 1984;289:721-724.
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