Planned Place of Birth—Impact of Psychopathological Risk Factors on the Choice of Birthplace and Its Postpartum Effect on Psychological Adaption: An Exploratory Study

The choice of birthplace may have an important impact on a woman’s health. In this longitudinal study, we investigated the psychopathological risk factors that drive women’s choice of birthplace, since their influence is currently not well understood. The research was conducted in 2011/12 and we analyzed data of 177 women (obstetric unit, n = 121; free standing midwifery unit, n = 42; homebirth, n = 14). We focused antepartally (M = 34.3 ± 3.3) on sociodemographic and risk factors of psychopathology, such as prenatal distress (Prenatal Distress Questionnaire), depressiveness (Edinburgh Postnatal Depression Scale), birth anxiety (Birth Anxiety Scale), childhood trauma (Childhood Trauma Questionnaire), and postpartally (M = 6.65 ± 2.6) on birth experience (Salmon’s Item List), as well as psychological adaption, such as postpartum depressive symptoms (Edinburgh Postnatal Depression Scale) and birth anxiety felt during birth (modified Birth Anxiety Scale). Women with fear of childbirth and the beginning of birth were likely to plan a hospital birth. In contrast, women with fear of touching and palpation by doctors and midwives, as well as women with childhood trauma, were more likely to plan an out-of-hospital birth. Furthermore, women with planned out-of-hospital births experienced a greater relief of their birth anxiety during the birth process than women with planned hospital birth. Our results especially show that women with previous mental illnesses, as well as traumatic experiences, seem to have special needs during childbirth, such as a safe environment and supportive care.

The paradox of contemporary midwifery practice: Promoting an out-of-hospital birth setting

<p>In New Zealand women choose their place of birth in partnership with their Lead Maternity Care (case loading) midwife, with most choosing a hospital regardless of their lack of risk factors. The reasons why most women in western countries choose to birth in hospital have been widely investigated. Risk aversity is most commonly implicated. For both women and health professionals this powerful discourse persists despite consistent research findings indicating higher rates of normal birth, and lower rates of maternal morbidity associated with interventions for healthy women who birth in out-of-hospital (primary) maternity units, with no difference in neonatal outcomes. There is however a gap in the literature regarding what is known about how midwives might positively influence the choice to birth in a primary unit. A qualitative descriptive design through an appreciative inquiry lens enabled insight from 12 midwives who have a higher ratio of women within their caseload who choose to birth in a primary unit. Four focus groups were formed with these midwives to explore their perspectives and approaches as they assist women to make their place of birth decisions. From thematically analysed data, five themes emerged, Ways of knowing: woman, art, science and research; Trusting in you, me, and the process of childbirth; Setting boundaries as a ‘primary birth midwife’; and Delaying and diverting, a malleable approach, centered around the theme When it matters what we say: reframing safety and risk. Alongside supporting current research, this study adds to the body of knowledge about birthplace choice by bringing to the fore the notion of paradox in practice, setting boundaries whilst remaining malleable for example. In a contemporary maternity context, these midwives dance between two worlds fundamentally at odds with one another, effectively managing contradiction, complexity and uncertainty to achieve a high primary unit caseload. The experience of what works to promote the primary unit for a cohort of New Zealand midwives is uncovered in this research. The social recalibrations needed to adjust the hospital birth norm are much broader issues than midwives alone can change, but in this study, we see they are staying the course in order to protect and promote normal birth. How midwives might inform decision-making for place of birth choice is described.</p>

The paradox of contemporary midwifery practice: Promoting an out-of-hospital birth setting

<p>In New Zealand women choose their place of birth in partnership with their Lead Maternity Care (case loading) midwife, with most choosing a hospital regardless of their lack of risk factors. The reasons why most women in western countries choose to birth in hospital have been widely investigated. Risk aversity is most commonly implicated. For both women and health professionals this powerful discourse persists despite consistent research findings indicating higher rates of normal birth, and lower rates of maternal morbidity associated with interventions for healthy women who birth in out-of-hospital (primary) maternity units, with no difference in neonatal outcomes. There is however a gap in the literature regarding what is known about how midwives might positively influence the choice to birth in a primary unit. A qualitative descriptive design through an appreciative inquiry lens enabled insight from 12 midwives who have a higher ratio of women within their caseload who choose to birth in a primary unit. Four focus groups were formed with these midwives to explore their perspectives and approaches as they assist women to make their place of birth decisions. From thematically analysed data, five themes emerged, Ways of knowing: woman, art, science and research; Trusting in you, me, and the process of childbirth; Setting boundaries as a ‘primary birth midwife’; and Delaying and diverting, a malleable approach, centered around the theme When it matters what we say: reframing safety and risk. Alongside supporting current research, this study adds to the body of knowledge about birthplace choice by bringing to the fore the notion of paradox in practice, setting boundaries whilst remaining malleable for example. In a contemporary maternity context, these midwives dance between two worlds fundamentally at odds with one another, effectively managing contradiction, complexity and uncertainty to achieve a high primary unit caseload. The experience of what works to promote the primary unit for a cohort of New Zealand midwives is uncovered in this research. The social recalibrations needed to adjust the hospital birth norm are much broader issues than midwives alone can change, but in this study, we see they are staying the course in order to protect and promote normal birth. How midwives might inform decision-making for place of birth choice is described.</p>

A Qualitative Study to Explore the Barriers for Nonadherence to Referral to Hospital Births by Women with High-Risk Pregnancies in Nepal

Maternal and neonatal morbidity and mortality tend to decrease if referral advice during pregnancy is utilized appropriately. This study explores the reasons for nonadherence to referral advice among high-risk pregnant women. A qualitative study was conducted in Morang District, Nepal. A phenomenological inquiry was used. Fourteen participants were interviewed in-depth. High-risk women who did not comply with the referral to have a hospital birth were the study participants. Participants were chosen purposively until data saturation was achieved. The data were generated using thematic analysis. Preference of homebirth, women’s diminished autonomy and financial dependence, conditional factors, and sociocultural factors were the four major themes that hindered hospital births. Women used antenatal check-ups to reaffirm normalcy in their current pregnancies to practice homebirth. For newly-wed young women, information barriers such as not knowing where to seek healthcare existed. The poorest segments and marginalized women did not adhere to referral hospital birth advice even when present with high-risk factors in pregnancy. Multiple factors, including socioeconomic and sociocultural factors, affect women’s decision to give birth in the referral hospital. Targeted interventions for underprivileged communities and policies to increase facility-based birth rates are recommended.

A Risk Calculator to Predict the Need for Maternal or Neonatal Hospital-Based Peripartum Intervention: Modelling National Surveillance Data

Objective: Given growing interest in alternatives to hospital birth, particularly given the COVID-19 pandemic, we developed a peripartum intervention risk calculator (PIRC) to estimate maternal and neonatal risk of requiring hospital-based peripartum intervention. Design: National cohort study. Setting: United States. Sample: Hospital births captured by the Pregnancy Risk Assessment Monitoring System from 2009-2018. Methods: The cohort was stratified by receipt of hospital-based interventions, defined as: 1) operative vaginal delivery (forceps or vacuum), 2) cesarean delivery, or 3) requiring neonatal intensive care unit admission. Gravidas with prior cesarean delivery or fetal malformation were excluded. Main Outcome Measures: Risk of requiring hospital-based intervention. Results: A total of 63,234 births were evaluated (72.6% full-term, 48.5% nulliparous) including 37.9% who received one or more hospital–based interventions. Gestational age was the most predictive factor of requiring hospital-based intervention, with lowest odds at 400/7-406/7 weeks. Previous live births (Ref: none; 1, OR 0.41; 2, OR 0.35; ≥3, OR 0.29; p<0.05 for all) were protective. Other predictors included advanced maternal age, high pre-pregnancy body mass index, maternal diabetes, maternal hypertension, and not exercising during pregnancy. The resulting seven-factor model demonstrated strong discrimination (optimism corrected C-statistic=0.776) and calibration (mean absolute error=0.009). Conclusions: We developed and validated the PIRC for predicting individualized risk for hospital-based intervention among gravidas based on seven readily accessible prenatal factors. This calculator can support personalized counseling regarding planned birth setting, helping to close a critical gap in current clinical guidance and providing an evidence-based risk assessment for those contemplating alternatives to hospital birth.