No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Praxis and guidelines for planned homebirths in the Nordic countries - An overview
Abstract
The objective of this overview was to investigate the current situation regarding guidelines and praxis for planned homebirths and also to investigate possibilities for comparative studies on planned homebirths in the Nordic countries (Denmark, Iceland, Norway, Finland and Sweden).
National documents on homebirth and midwifery and recommendations regarding management and registration of planned homebirths in the included countries were investigated.
Guidelines regarding planned home birth were found in four of the included countries. In Denmark any woman has the right to be attended by a midwife during a homebirth and each county council must present a plan for the organization of birth services, including homebirth services. In Norway and Iceland the service is fully or partly funded by taxes and national guidelines are available but access to a midwife attending the birth varies geographically. In the Stockholm County Council guidelines have been developed for publicly funding of planned home births; for the rest of Sweden no national guidelines have been formulated and the service is privately funded.
Inconsistencies in the home birth services of the Nordic countries imply different opportunities for midwifery care to women with regard to their preferred place of birth. Uniform sociodemography, health care systems and cultural context in the Nordic countries are factors in favour of further research to compare and aggregate data on planned home births in this region. Additional data collection is needed since national registers do not sufficiently cover the planned place of birth.
... An insufficient homebirth offer can be one reason why some women choose to give birth at home without skilled care [1,8]. If a homebirth offer exists, the guidelines usually require that women have low-risk pregnancies with no prior complicated births to be able to have homebirth with midwives [9]. Disagreement with the guidelines and strong desires to give birth at home even with pregnancies that are considered to be high risk may be reasons why women choose freebirth [3,10]. ...
... Intrapartum care is provided at three levels: 1) specialised units providing advanced obstetric, anaesthetic and paediatric services, including neonatal intensive care units; 2) units in smaller hospitals with obstetric and aesthetic services; and 3) freestanding and alongside midwifery-led units providing care for low-risk women. The majority of births take place in level 1 and 2 units [9]. Midwives attend all births, assist all spontaneous vaginal deliveries and are present at all operative deliveries. ...
... Norwegian health authorities do not organise homebirth as part of the public maternity care system [14]. The woman herself must find a midwife willing to assist at the birth at home [9]. She also has to cover the costs for the midwife, but she may receive a refund for a certain amount from the authorities [14]. ...
Aim
This study was aimed at describing Norwegian women’s motivations and preparations for freebirth.
Methods
This qualitative study involved 12 individual interviews conducted face to face or via Skype with women from different parts of Norway. The material was analysed using qualitative content analysis inspired by Graneheim and Lundman.
Results
Three categories describing the women’s motivations and preparations for freebirth were identified. Unsatisfied with the care offered today described how the women thought that hospitals did not support normal birth and made an inadequate homebirth offer. The category earlier uncomplicated and traumatic births influence freebirth choices described two different dimensions of motivations for freebirth. Trust in one’s own knowledge and capacity referred to how women viewed birth as a natural process, their faith in themselves, how this view and faith influenced their preparation and how they gained knowledge about the birth process to prepare. An overall theme emerged: deep trust in birth as a natural process and the women’s own capacity to give birth embedded in distrust of the maternity care system.
Conclusion
This study showed that motivations for freebirth were embedded in overall dissatisfaction with today’s maternity care, the inadequate homebirth offer and deep trust in the women’s own capacity to give birth.
... In British Columbia, the Netherlands, New Zealand, and Ontario, all or most midwives provide care in the home setting, all or some of the time, 7,[26][27][28][29] whereas, in Australia, England, Iceland, Japan, Norway, Sweden, and Washington State, a subgroup of midwives provide home birth care. 7,[30][31][32][33][34][35][36][37][38] In all jurisdictions, except for Sweden, the midwives' or nursemidwives' regulatory bodies outline in the scope of practice or standards for competence that midwives practice in home settings. 27,29,30,36,[39][40][41][42][43][44][45][46][47][48][49][50][51][52] In Sweden, a publication by the association of midwives mentions the importance of client choice of birth place. ...
... 53 In British Columbia, the Netherlands, and Washington State, there are regulations that permit and govern physicians conducting nonemergency home birth; we did not find similar regulations for physician home birth in other jurisdictions. [54][55][56] Midwives in the 11 jurisdictions are regulated, primary care practitioners of maternity care, 7,22,[27][28][29][30][31][32][33]35,[56][57][58][59][60][61] with some exceptions and variations. In Japan, midwives have the legal right to practice autonomously, but in practice, it can be limited; 14 decisions about client eligibility for midwifery care are made in collaboration with an obstetrician and clients have several examinations by an obstetrician throughout normal care. ...
... 64,73 3.2 | Home birth eligibility, guidelines, and client access Jurisdictional or national home birth guidelines address health assessment and/or eligibility criteria in Australia, British Columbia, England, Japan, the Netherlands, Norway, and Ontario. 8,26,31,35,45,[76][77][78] In New Zealand, choice of home birth is considered a right and there are no eligibility guidelines; however, there are referral guidelines and recommendations which may influence choice of birth place. 79,80 In Washington State, eligibility for home birth is based on general recommendations and guidelines for referral to physicians. ...
Background:
The purpose of this study was to develop assessment criteria that could be used to examine the level of integration of home birth within larger health care systems in developed countries across 11 international jurisdictions.
Methods:
An expert panel developed criteria and a definition to assess home birth integration within health care systems. We selected jurisdictions based on the publications that were eligible for inclusion in our systematic review and meta-analysis on planned place of birth. We sent the authors of the included publications a questionnaire about home birth practitioners and practices in their respective health care system at the time of their studies. We searched published peer-reviewed, non-peer-reviewed, and gray literature, and the websites of professional bodies to document information about home birth integration in each jurisdiction based on our criteria. Where information was lacking, we contacted experts in the field from the relevant jurisdiction.
Results:
Home birth is well integrated into the health care system in British Columbia (Canada), England, Iceland, the Netherlands, New Zealand, Ontario (Canada), and Washington State (USA). Home birth is less well integrated into the health care system in Australia, Japan, Norway, and Sweden.
Conclusions:
This paper is the first to propose criteria for the evaluation of home birth integration within larger maternity care systems. Application of these criteria across 11 international jurisdictions indicates differences in the recognition and training of home birth practitioners, in access to hospital facilities, and in the supplies and equipment available at home births, which give rise to variation in the level of integration across different settings. Standardized criteria for the evaluation of systems integration are essential for interpreting planned home birth outcomes that emerge from contextual differences.
... Within the Nordic countries, Denmark is where women can find stronger support to their right to choose the place of birth, followed close by Iceland. 18 Roughly three-fifths of all Nordic home births happen in Denmark, and the number of midwives attending births at home is much higher than in any of the other surrounding countries. 16 The rates of home births are now 2.2% in Iceland, 1-2% in Denmark, 1.5/1000 in Norway, and 0.7/1000 in Sweden. ...
... 16 It is not clear why neighbour countries with significant similarities at the social, economic, and historical levels present these important differences regarding their organisational conditions for home births. 18,19 In fact, they seem to share a common past regarding the place of birth: by the end of the 19th century, almost all births in the Nordic countries happened at home; by 1950 the decline of the rate of home births was evident; and by the end of the 20th century home births were already rare events. 18,19 Still, Denmark was one of the last Nordic countries to institutionalise hospital birth as the norm. ...
... 18,19 In fact, they seem to share a common past regarding the place of birth: by the end of the 19th century, almost all births in the Nordic countries happened at home; by 1950 the decline of the rate of home births was evident; and by the end of the 20th century home births were already rare events. 18,19 Still, Denmark was one of the last Nordic countries to institutionalise hospital birth as the norm. 19 Paradoxically, one of the most remarkable difference regarding this institutionalisation process is found between Denmark and Sweden, countries which are particularly similar in most aspects of their history, economy and social development. ...
... Since the 1950s, demographic changes have also occurred in Nordic women, such as the trend to postpone pregnancies (15,16) and the increase in body mass index (BMI) (17). Still hospital routines when monitoring the progress of labor are very much based on previously developed partograms. ...
... Some women, however, choose to give birth at home with the assistance of a midwife. The prevalence of home births in Denmark is 12/1,000 births, in Iceland 18/1,000 births, in Norway 1.9/1,000, and in Sweden 0.6/1,000 births (17). Women who give birth at home usually do so without any interventions. ...
... In Denmark, home birth is included in the public health system; in Norway and Iceland home birth is financed through taxes, but with varied access to midwifery assistance. In Sweden, women who opt for a home birth need to find a midwife willing to assist and usually women have to pay for the home birth themselves (17). Despite the fact that the organization of home birth care differs among the Nordic countries, the population is fairly similar in terms of health, and all Nordic countries have equal access to health care. ...
Objective:
Normal progress of labor is a subject for discussion among professionals. The aim of this study was to assess the duration of labor in women with a planned home birth and spontaneous onset who gave birth at home or in hospital after transfer.
Methods:
This is a population-based study of home births in four Nordic countries (Denmark, Iceland, Norway, and Sweden). All midwives assisting at a home birth from 2008 to 2013 were asked to provide information about home births using a questionnaire.
Results:
Birth data from 1,612 women, from Denmark (n = 1,170), Norway (n = 263), Sweden (n = 138), and Iceland (n = 41) were included. The total median duration from onset of labor until the birth of the baby was approximately 14 hours for primiparas and 7.25 hours for multiparas. The duration of the different phases varied between countries. Blood loss more than 1,000 mL and perineal ruptures that needed suturing were associated with a longer pushing phase and the latter with country of residence, parity, single status, and the baby's weight.
Conclusion:
In this population of healthy women with a low prevalence of interventions, the total duration of labor was fairly similar to what is described in the literature for multiparas, but longer for primiparas. Although the duration of the phases of labor differed among countries, it was to a minor extent associated with severe outcomes.
... Background 31 From an international perspective, home birth is a common phenomenon. More than half of 32 all children are born at home, often without help from midwives or other skilled attendants, 33 due to financial, organizational or geographical factors [1]. In Europe, most births take place 34 Page 2 of 18 in hospitals, and the rate of home birth differs by country. ...
... In Europe, most births take place 34 Page 2 of 18 in hospitals, and the rate of home birth differs by country. The highest rate of planned home 1 births in the Nordic countries -Denmark, Iceland, Norway, Finland and Sweden-is found in 2 Iceland, with about two percent [1]. The rate in Denmark is about one and a half percent in 3 Sweden and Norway about one per mille and in Finland about one in three thousand. ...
... In Europe, most births take place 34 Page 2 of 18 in hospitals, and the rate of home birth differs by country. The highest rate of planned home 1 births in the Nordic countries -Denmark, Iceland, Norway, Finland and Sweden-is found in 2 Iceland, with about two percent [1]. The rate in Denmark is about one and a half percent in 3 Sweden and Norway about one per mille and in Finland about one in three thousand. ...
Objective:
To describe the lived experience of being a homebirth midwife in the Nordic countries.
Methods:
Interviews conducted with 21 homebirth midwives from the five Nordic countries were analyzed with a phenomenological approach.
Results:
The essential structure of being a homebirth midwife in the Nordic countries can be understood as realizing altruistic values and fulfilling one's own desires for working life, by facilitating the desires of the women giving birth. By being "active-passive" - using all her senses and letting her intuition lead her - the midwife supports women during labor and birth. Medical skills, evidence-based knowledge and experience are important for providing the optimal care in each situation. Further this becomes the midwife's chosen lifestyle, which alters her own self, making her available to assist the mother-to-be in fulfilling her wishes for a good birth. Finally, being able to use one's own full potential during a home birth is experienced as the ideal way of working as a midwife, practicing the art of midwifery.
Conclusion:
The experience of being a homebirth midwife in the Nordic countries includes making an adaption to a lifestyle that is considered the basis for a satisfactory and rewarding way of working. A sense of fulfillment is achieved through experiencing the possibility to work according to one's own ideals concerning the art of midwifery. The beliefs about a woman's ability to give birth and understanding the importance of a positive birth for both the mother and the newborn baby are essential.
... During the time of the study (2005)(2006)(2007)(2008)(2009), the tertiary hospital was furnished with two birthing units, a high-risk obstetric unit and a low-risk alongside midwifery unit. In rural areas during the same period, one secondary and four primary hospitals offered services to low-, medium-, or high-risk women, in addition to the services of four low-risk units and home birth services (23,25). ...
... Home and hospital births in Iceland are attended to by midwives who obtain a license to practice after a 4year bachelor's of science course in nursing and an additional 2-year master-level course in midwifery. The independent practices of home birth midwives are publicly funded (25) and are regulated and supervised by the Icelandic Directorate of Health, which has issued national guidelines for choice in place of birth. Contraindications for home birth and indications for intrapartum transfer are listed in the guidelines (25,26). ...
... The independent practices of home birth midwives are publicly funded (25) and are regulated and supervised by the Icelandic Directorate of Health, which has issued national guidelines for choice in place of birth. Contraindications for home birth and indications for intrapartum transfer are listed in the guidelines (25,26). ...
Background
At 2.2 percent in 2012, the home birth rate in Iceland is the highest in the Nordic countries and has been rising rapidly in the new millennium. The objective of this study was to compare the outcomes of planned home births and planned hospital births in comparable low-risk groups in Iceland.Methods
The study is a retrospective cohort study comparing the total population of 307 planned home births in Iceland in 2005–2009 to a matched 1:3 sample of 921 planned hospital births. Regression analysis, adjusted for confounding variables, was performed for the primary outcome variables.ResultsThe rate of oxytocin augmentation, epidural analgesia, and postpartum hemorrhage was significantly lower when labor started as a planned home birth. Differences in the rates of other primary outcome variables were not significant. The home birth group had lower rates of operative birth and obstetric anal sphincter injury. The rate of 5-minute Apgar score < 7 was the same in the home and hospital birth groups, but the home birth group had a higher rate of neonatal intensive care unit admission. Intervention and adverse outcome rates in both study groups, including transfer rates, were higher among primiparas than multiparas. Oxytocin augmentation, epidural analgesia, and postpartum hemorrhage rates were significantly interrelated.Conclusions
This study adds to the growing body of evidence that suggests that planned home birth for low-risk women is as safe as planned hospital birth.
... Midwives' provision of PHB may increase women's access to skilled birth attendance, which is an indicator for the reduction of maternal and newborn morbidity and mortality ( World Health Organization, 2015 ). Lindgren et al. (2014) reported an increased acceptance of PHB in Norway (1.9/10 0 0 births), the Netherlands (20%; Zielinski et al., 2015 ), Iceland (18/10 0 0 births), and Denmark (12/10 0 0 births). PHB is also practiced in Australia (0.7% in 2012), the UK, and Canada (for 25-30% of clients) ( Vedam et al., 2014 ). ...
... In the US, about 35,0 0 0 (0.9%) women had a home birth; of these, a quarter were unattended/unplanned ( American College of Obstetricians and Gynecologists, 2017) . The society provides guidelines and funding from taxes to support PHB practice in Denmark, Norway ( Lindgren et al. 2014 ), and Australia. Similarly, England's maternity services and the Canadian Provincial Health Ministry pro-vide compensation to the caseload midwifery schemes to ensure access to midwives for PHB ( O'Connell et al., 2012;Vedam et al., 2014 ). ...
Abstract
Objective
Planned home birth may increase women's access to skilled midwives in all settings. Using theory to understand and predict midwives’ intention regarding planned home birth services is rare. Therefore, using the theory of planned behaviour, we determined the factors associated with midwives’ intention to provide planned home birth services to low-risk women.
Design
This cross-sectional study adopted a quantitative approach and a survey. Stratified random sampling was used to recruit 226 midwives in Sokoto, Nigeria. Data—including descriptive statistic and multiple linear regression analyses—were analysed using SPSS 23 and significant was set at 0.05.
Setting
Ten public health facilities in Sokoto, northwestern Nigeria.
Participants
Among all 460 midwives (women aged 20–60 years), working in the maternity wards of health facilities in Sokoto, a sample of 226 midwives was calculated using a power of 0.80 and a 95% confidence interval.
Findings
The multiple linear regression analyses confirmed that the major factors associated with midwives’ intention to provide planned home birth services were midwives’ attitude towards planned home birth (p < .001) and midwives’ previous experience with planned home birth practice (p = .008).
Conclusions and implications
The theory of planned behaviour is a useful framework for identifying factors that affect midwives’ intention to provide planned home birth services. While future research may employ a qualitative approach to explore other factors, planned home birth education campaigns should target information that enhances positive attitude and encourages midwives to provide planned home birth services.
Keywords:
Choice behaviour, Home childbirth, Intention, Midwifery, Pregnancy
... This was mostly possible because of the singularities of the Danish context, where research, the professional development of midwifery and the consumers' demands contributed to an uninterrupted history supporting women's right to choose the place of birth (Santos 2017). Planned home births seem to be increasing, and the rate is now around 1-2 per cent (Lindgren et al. 2014), although some data inconsistency suggests underreporting ). Some of the families interviewed mentioned having decided for a home birth not to avoid the hospital after balancing the risk perception in each setting, but just because a home birth seemed calmer, cosier and easier. ...
... In this case, midwives must make the woman aware of possible complications and recommend hospital birth, while also being required to provide midwifery care at home according to the woman's decision (Sundhedsstyrelsen 2013), without the risk of litigation in the case of a severe complication that could not be appropriately solved due to the limitations of the home birth setting. Unlike countries where guidelines for the practice of midwifery at home are inexistent or insufficient, in Denmark guidelines are broadly disseminated and protect professionals from liability (Lindgren et al. 2014). ...
Planned home births happen across Europe, but there are countries where informal and formal limitations can be found by families. This article draws upon a short research project conducted in Denmark in March 2014, which aimed to explore the organization of home birth in Denmark and to compare it to the Portuguese case. Private home births, in Portugal, and publicly funded home births, in Denmark, show interesting similarities when looking at the individual experience of choosing and planning a birth at home. However, through this comparative analysis, I argue that the limitations imposed around the option of home birth in Portugal raise important inequalities between women and families planning to give birth at home and those planning a hospital birth. The successful models found in Denmark can potentially serve as grounds for a broader discussion and as a trigger for change in Portuguese policies, to promote ethical and evidence-based practices among professionals, and the improvement in perinatal health outcomes for families who experience planned home births.
... In 1960, home births were taken out of the public health care regime and could only be conducted under private care [1]. Since home births are not covered by Swedish health care, women have to make arrangements with an independent midwife or obstetrician and finance the home birth themselves, except in Stockholm County, where multiparous women who meet certain medical criteria may qualify for public funding [2]. ...
... In Sweden approximately one woman in 1000 have a planned home birth, and about ten times more women would make that choice if home birthing was an option in the health care system [3]. There are only approximately 20 home birth-attending midwives in the country [2], and most of them have other jobs and are not always available when the woman goes into labour. In one study, 14% of women who had planned a home birth were transferred to hospital because of midwife unavailability [4]. ...
Objective: The aim was to describe Swedish midwives’ experiences of working with home birth. Methods: Two focus group interviews were conducted with eight home birth-attending midwives. Data were analysed with qualitative content analysis. Results: Four main categories were identified: the birth as a meaningful moment; to fully focus on the birth; to practise the craft; and not to be part of the health care system. The midwives viewed childbirth as a significant moment that should be conducted on the woman's terms. Working with home birth enabled them to work at their own pace and focus fully on the woman. During home births, they learned more about normal birth, and developed their practical skills and professional knowledge with little reliance on technology. They did, however, not feel fully accepted in the maternity care system. Conclusion: This study contributes to the discussion about midwives’ experiences of working with home birth in contexts where home birth is not covered by public health care. The study shows that the work environment influences how midwives perform their craft, how they follow and support normal birth, and how the birth setting influence valuing their work.
... About 1% of all births in Denmark are registered as home births [15]. All women in Denmark have the legal right to be attended by a midwife during a home birtheven in cases with any potential pregnancy or delivery complications [15]. ...
... About 1% of all births in Denmark are registered as home births [15]. All women in Denmark have the legal right to be attended by a midwife during a home birtheven in cases with any potential pregnancy or delivery complications [15]. Maternal and neonatal outcomes of Danish home births have not previously been examined. ...
INTRODUCTION: The safety of home births has been widely debated. Observational studies examining maternal and neonatal outcomes of home births have become more frequent, and the quality of these studies has improved. The aim of the present study was to describe neonatal outcomes of home births compared with hospital births and to discuss which data are needed to evaluate the safety of home births.
METHODS: This was a register-based cohort study. Data on all births in Denmark (2003-2013) were collected from the Danish Medical Birth Registry (DMBR). The cohort included healthy women with uncomplicated pregnancies and no medical interventions during delivery. A total of 6,395 home births and 266,604 hospital births were eligible for analysis. Comparative analyses were performed separately in nulliparous and multiparous women. The outcome measures were neonatal mortality and morbidity.
RESULTS: Frequencies of admission to a neonatal intensive care unit and treatment with continuous positive airway pressure were significantly lower in infants born at home than in infants born at a hospital. A slightly, but significantly increased rate of early neonatal death was found among infants delivered by nulliparous at home.
CONCLUSIONS: This study indicates that home births in Denmark are characterized by a high level of safety owing to low rates of perinatal mortality and morbidity. Missing registration on intrapartum transfers and planned versus unplanned home births in the DMBR are, however, major limitations to the validity and utility of the reported results. Registration of these items of information is necessary to make reasonable assessments of home births in the future.
FUNDING: none.
TRIAL REGISTRATION: not relevant.
... Less than one in a thousand births in Sweden is a planned homebirth [7]. There are no guidelines regarding planned homebirths and the health care system does not provide economic support for homebirths [8]. Prenatal care and birth care are publicly funded in Sweden. ...
... Prenatal care and birth care are publicly funded in Sweden. However, a woman who chooses to give birth at home has to find a midwife willing to assist her and usually must pay for the service herself [8]. There are about 20 midwives in Sweden who assist planned home births on a regular basis. ...
Objective:
There are no national guidelines or financial support for planned homebirths in Sweden. Some women choose to give birth at home without the assistance of a midwife. The objective of this study was to describe eight women's experience of unassisted planned homebirth in Sweden.
Design:
Women who had the experience of an unassisted planned home birth were interviewed. The material was analysed using a phenomenological approach.
Results:
The essential meaning of the phenomenon giving birth at home without the assistance of a midwife is understood as a conflict between, on one hand, inner responsibility, power and control and on the other hand insecurity in relation to the outside, to other people and to the social system. A wish to be cared for by a midwife is in conflict with the fear of not maintaining integrity and respect in this precious moment of birth.
Conclusion:
Some women may be more sensitive to attitudes and activities that are routinely performed during pregnancy and childbirth and therefore choose not to turn to any representatives of the medical system. The challenge should be to provide safe care to all women so that assistance from a midwife becomes a reality in all settings.
... 48 Decision-making around community birth relies in large part on assessments to find appropriate candidates. National guidelines on health status during pregnancy and potential need for referral exist in England, 49 Denmark, 50 Iceland, 51 Norway, 52 the Netherlands, 17 Australia, 53 and Canada 15 and are routinely used to assess eligibility for community birth. During this research period, no German guidelines existed that could be applied to the eligibility criterion for community birth. ...
Background
Over one‐third of nulliparae planning births either at home or in freestanding midwife‐led birthing centers (community births) in high‐income countries are transferred during labor. Perinatal data are reported each year in Germany for women planning community birth. So far, data sets have not been linked to describe time‐related factors associated with nulliparous transfer to hospital.
Objectives
To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer.
Methods
Perinatal data from 2010 to 2015 were linked (n = 26,115). Women were reviewed with respect to international eligibility criteria for community birth; 1997 women were excluded (7.6%). Descriptive statistics were reported; unadjusted and adjusted odds ratios with 95% confidence intervals (CI) tested the predictive effect of demographic and labor factors on rates of intrapartum transfer.
Results
One in three nulliparous women (30.6%) were transferred to hospital. Compared with community births, transferred women were significantly more likely to experience longer time intervals during labor: from rupture of membranes (ROM) until birth lasting 5 to 18 h (OR 6.05, CI 5.53–6.61) and 19 to 24 h (OR 10.83, CI 9.45–12.41) compared to one to 4 h; and from onset of labor until birth 11 to 24 h (OR 6.72, CI 6.24–7.23) and 25 to 29 h (OR 26.62, CI 22.77–31.11) compared to one to 10 h. When entering all factors into the model, we found the strongest predictors of transfer to be fetal distress, longer time intervals between ROM until birth and onset of labor until birth.
Conclusions
Nulliparous transfer rates were similar to rates in other high‐income countries; 94% of referrals were non‐urgent. Time was found to be an independent risk factor for the transfer of nulliparae planning community birth.
... Maternity care in Sweden is publicly funded and most babies are born in hospitals [18]. The labour ward in which this study was undertaken, served women with singleton, mainly uncomplicated pregnancies of ≥34 gestational weeks. ...
Objective
To evaluate if a birthing room designed with person-centred considerations improves labour and birth outcomes for nulliparous women when compared to regular birthing rooms.
Methods
A randomised controlled trial was conducted at a Swedish labour ward between January 2019 and October 2020. Nulliparous women in spontaneous labour were randomised either to a birthing room designed with person-centred considerations (New room) or a Regular room. The primary outcome was a composite of four variables: vaginal non-instrumental birth; no oxytocin augmentation; postpartum blood loss < 1000 ml; and a positive childbirth experience. To detect a difference of 8% between the groups, 1274 study participants were needed, but the trial was terminated early due to consequences of the Covid-19 pandemic.
Results
A total of 406 women were randomised; 204 to the New room and 202 to the Regular room. There was no significant difference in the primary outcome between the groups (42.2% versus 35.1%; odds ratio: 1.35, 95% Confidence Interval 0.90–2.01; p = 0.18). Participants in the New room used epidural analgesia to a lower extent (54.4% versus 65.3%, relative risk: 0.83, 95% Confidence Interval 0.71–0.98; p = 0.03) and reported to a higher degree that the room contributed to a sense of safety, control, and integrity (p=<0.001).
Conclusions
The hypothesis that the New room would improve the primary outcome could not be verified. Considering the early discontinuation of the study, results should be interpreted with caution. Nevertheless, analyses of our secondary outcomes emphasise the experiential value of the built birth environment in improving care for labouring women.
... The Nordic Obstetric Surveillance study reporting obstetric complications found that Sweden was the only Nordic country where information about PPH was not available and the necessity of uniform definitions and valid reporting to enable international comparisons was highlighted [9]. Public health care is similarly organized in the Nordic countries; maternity care is funded by taxes and there are national birth registers [10]. A study presenting the rates and causes of PPH in Sweden would thus enable future comparison between findings in these neighbouring countries. ...
Objective
To explore diagnoses of postpartum haemorrhage following vaginal birth, in relation to socio-demographic and obstetrical data from women who gave birth at term, in Sweden, during the years 2005 to 2015.
Study design
A register-based cohort study was carried out, describing and comparing socio-demographic variables, obstetric variables and infant variables in 52 367 cases of diagnosed postpartum haemorrhage compared to 353 569 controls without a postpartum haemorrhage diagnosis. Postpartum hemorrhage was identified in The Swedish Medical
Birth Register by ICD-10 code O72. Variables for maternal characteristics were dichotomized and used to calculate odds ratios to find possible explanatory variables for postpartum haemorrhage.
Results
Between 2005 and 2015 there was no statistically significant decrease in diagnoses of postpartum haemorrhage after vaginal birth at term. Primiparity was associated with the highest risk and women birthing their fifth or subsequent child were associated with the lowest risk of postpartum hemorrhage. Increased maternal age (> 35 years) and/or obesity (BMI > 30) were associated with higher odds of postpartum haemorrhage. The risk of postpartum hemorrhage was 55 % higher when vaginal birth followed induction as compared to vaginal birth after spontaneous onset. Some of the factors known to be associated with postpartum haemorrhage were poorly documented in The Swedish Medical Birth Register.
Conclusions
Birthing women in a Swedish contemporary setting are, despite efforts to improve care, still at risk of birth being complicated by postpartum haemorrhage. Primiparity, increasing maternal age and/or obesity are found to provoke an increased risk and the reasons for these findings need to be further investigated. However, grand multi-parity did not increase the risk for postpartum hemorrhage. Codes for diagnoses require correct documentation in the birth records: only when local statistics are sound and correctly reported can intrapartum care be improved, and the incidence of postpartum haemorrhage reduced.
... Þjónusta við heimafaeðingar er veitt á ólíkan hátt í ólíkum löndum en er að jafnaði sinnt af ljósmaeðrum (Benoit o.fl., 2005;de Jonge o.fl., 2015;de Jonge o.fl., 2009;Evers o.fl., 2010;Lindgren, Kjaergaard, Olafsdottir og Blix, 2014;McCourt, Rayment, Rance og Sandall, 2012;Perdok o.fl., 2015). AEskilegt er að ljósmaeður samþaetti heimafaeðingarþjónustu sína við aðra þaetti faeðingarþjónustunnar og hafi samstarf við aðrar stéttir til að veita bestu mögulegu þjónustu (Benoit o.fl., 2005;de Jonge o.fl., 2015;de Jonge o.fl., 2009;McCourt o.fl., 2012;Perdok o.fl., 2015). ...
Background: Icelandic midwifery services have changed considerably through the years. Home birth rates declined rapidly in the latter half of the 20th century but have been rising in the new millennium. Due to low morbidity rates among the neonates of healthy low-risk women, and the small group size in Icelandic home birth research, drawing conclusions on neonatal outcomes is problematic. The aim of this review was to detect patterns in the provision of home birth services and adverse neonatal outcomes, such as neonatal mortality and morbidity, low Apgar scores, or specialised care. The purpose was to collect information that can be useful in the development of midwifery services in Iceland.
Methods: An integrative review on research articles on neonatal outcomes in home birth and available literature on the way home birth services are organized in different settings.
Findings: In countries where home birth services are regulated, integrated into the health care system, and provided by midwives with a standardized education, neonatal outcomes in planned home births are either equally good or better than planned hospital birth outcomes.
Conclusions: The home birth services of Icelandic midwives are in many ways compatible with well-organized services in other countries. Improvements could be made by issuing national guidelines on intrapartum care in all levels of service, as well as guidelines on consultation and transfer of care.
Keywords: home birth, hospital birth, safety, service, neonate
... In Sweden and Norway it is 0.06 % and 0.019 % respectively, while home birth is more common in Denmark and Iceland with 1.5-1.8 % [26]. It is not known whether the observed benefit of opting for a home birth with regard to SPT and perineal injuries is due to differences in midwifery practice, the selected population of women or other factors, such as birth position. ...
Background:
Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries.
Methods:
A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data.
Results:
Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54).
Conclusion:
A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.
... Cesarean section rates are also low compared with other high-resource countries, ranging from 15 to 21%, remaining unchanged during the last 20 years. All Nordic countries provide publicly funded healthcare, with the vast majority of the deliveries occurring in hospitals and few home deliveries (10). For low risk pregnancies, standard obstetric care during pregnancy is provided by general practitioners and midwives, whereas pregnant women at high risk for complications are referred to public hospitals. ...
Fetal medicine is a subspecialty of obstetrics investigating the development, growth and disease of the human fetus. The advances in fetal imaging (ultrasonography, MRI) and molecular diagnostic techniques, together with the possibility of intervention in utero, make fetal medicine an important, rapidly developing field within women's healthcare. Therefore, a variety of specialists, such as neonatologists, pediatric cardiologists, medical geneticists, radiologists and pediatric surgeons, are necessary to adjunct in the diagnosis and treatment of the fetus as a patient. In this commentary, we provide a description of some organizational and educational aspects of fetal medicine in the Nordic countries, using examples on the management of specific conditions such as aneuploidy screening, red cell allo-immunization and fetal interventions. Clearly, there are several cultural, legal, organizational and practical differences between the Nordic countries, which are not necessarily negative, given the high standards of care in all Nordic countries. The scope of the newly founded Nordic network of fetal medicine is to enhance cooperation in clinical practice, education and research between the participant countries. Hopefully, this initiative will find the necessary political and economic support by the national authorities and bring a new era in the field of fetal medicine in the Nordic region. This article is protected by copyright. All rights reserved.
... In other Danish regions, she may be attended by a midwife from the nearest hospital, without any particular experience or interest in home births, and the woman and midwife have never met before onset of labor. Denmark, Norway and Iceland, but not Sweden, have national guidelines on how to manage planned home births (7). ...
Introduction:
Women planning for home birth are transferred to hospital in case of complications or elevated risk for adverse outcomes. The aim of the present study was to describe the indications for transfer to hospital in planned home births, and the proportion of cases in which this occurs MATERIAL AND METHODS: Women in Norway, Sweden, Denmark and Iceland who had opted for, and were accepted for, home birth at the onset of labor, were included in the study. Data from 3068 women, 572 nulliparas and 2446 multiparas, were analyzed for proportion of transfers during labor and within 72 hours after birth, indications for transfer, how long before or after birth the transfer started, time from birth to start of transfer, duration and mode of transfer, and whether the transfer was classified as potentially urgent. Analyses were stratified for nulli- and multiparity RESULTS: One third (186/572) of the nulliparas were transferred to hospital, 137 (24.0%) during labor and 49 (8.6%) after the birth. Of the multiparas, 195/2446 (8.0%) were transferred, 118 (4.8%) during labor and 77 (3.2%) after birth. The most common indication for transfers during labor was slow progress. In transfers after birth, postpartum hemorrhage, tears and neonatal respiratory problems were the most common indications. A total of 116 of the 3068 women had transfers classified as potentially urgent CONCLUSIONS: One third of all nulliparous and 8.0% of multiparous women were transferred during labor or within 72 hours of the birth. The proportion of potentially urgent transfers was 3.8%. This article is protected by copyright. All rights reserved.
... Low availability of home birth services may partly explain the gap between women's preferences and their choices. Even though home birth services are technically available to most women in Iceland, the overall proportion of independent midwives offering home birth services is low (Lindgren et al., 2014). With the exception of multiparous women living in Stockholm, home births of Swedish women are not governmentally funded (Lindgren et al., 2014), which creates a financial incentive for choosing hospital birth. ...
Objective:
to examine the relationship between attitudes towards home birth and birth outcomes, and whether women's attitudes towards birth and intervention affected this relationship.
Design:
a prospective cohort study.
Setting:
the study was set in Iceland, a sparsely populated island with harsh terrain, 325,000 inhabitants, high fertility and home birth rates, and less than 5000 births a year.
Participants:
a convenience sample of women who attended antenatal care in Icelandic health care centres, participated in the Childbirth and Health Study in 2009-2011, and expressed consistent attitudes towards home birth (n=809).
Findings:
of the participants, 164 (20.3%) expressed positive attitudes towards choosing home birth and 645 (79.7%) expressed negative attitudes. Women who had a positive attitude towards home birth had significantly more positive attitudes towards birth and more negative attitudes towards intervention than did women who had a negative attitude towards home birth. Of the 340 self-reported low-risk women that answered questionnaires on birth outcomes, 78 (22.9%) had a positive attitude towards home birth and 262 (77.1%) had a negative attitude. Oxytocin augmentation (19.2% (n=15) versus 39.1% (n=100)), epidural analgesia (19.2% (n=15) versus 33.6% (n=88)), and neonatal intensive care unit admission rates (0.0% (n=0) versus 5.0% (n=13)) were significantly lower among women who had a positive attitude towards home birth. Women's attitudes towards birth and intervention affected the relationship between attitudes towards home birth and oxytocin augmentation or epidural analgesia.
Key conclusions and implications for practice:
the beneficial effect of planned home birth on maternal outcome in Iceland may depend to some extent on women's attitudes towards birth and intervention. Efforts to de-stigmatise out-of-hospital birth and de-medicalize women's attitudes towards birth might increase women׳s use of health-appropriate birth services.
... They provide continuity of care from the 37th week of pregnancy through the first week postpartum. The midwives can transfer the women to hospital, if needed, but do not have licence to care for them after admission [10]. Through the 1970s, 1980s, and 1990s only a few midwives attended planned home births in Iceland [11]. ...
Background:
The rate of home birth in Iceland increased from 0.1% in the 90's, to 2.2% in 2012. As the media contributes to the development and public perceptions, engagement and use of health care, it is of interest to explore the media representation of planned home birth in Iceland.
Objectives:
The aim of this study was to explore the way in which the constructions of planned home birth are represented in the Icelandic media; the frequency with which planned home birth was discussed and by whom it was discussed; whether the discourse was congruent with practice development in the country; and if so, how such congruency was effected.
Methods:
Data from the main newspapers in Iceland published from the beginning of 1990 until the end of 2011 were explored using content analysis.
Results:
In total, 127 items were summarized and we identified five themes: approach to safety, having a choice, the medicalization of childbirth, the relationship between women and midwives, and the reaction of the pregnant woman's local community. Central in the analysis were the importance of being able to choose a safe place of birth and the need for woman-centred care.
Conclusion:
Overall planned home birth was not discussed with much intensity or frequency, but in general the discussion was shaped by a positive attitude. There was a distinction in the public media discourse among midwives and physicians or obstetricians who do not argue against planned home birth but who nevertheless speak with caution. The pregnant women who chose home birth found their own home to be safe and similar views were identified among women and midwives.
... In economically developed countries, Norway included, hospital medicalised births are the norm [1,2]. Modern medicine and improved standards of living have saved countless lives during the birthing process, and giving birth in Nordic countries is regarded as safe [3]. However, considerable concerns regarding the various implications of medicalised birth have been highlighted [4][5][6]. ...
Objective: In some economically developed countries, women's choice of birth care and birth place is encouraged. The aim of this study was to explore and describe the experiences of midwives who started working in alongside/free-standing midwifery units (AMU/FMU) and their experiences with labour care in this setting. Methods: A qualitative explorative design using a phenomenographic approach was used. Semi-structured interviews were conducted with ten strategically sampled midwives working in midwifery units. Results: The analysis revealed the following five categories of experiences noted by the midwives: mixed emotions and de-learning obstetric unit habits, revitalising midwifery philosophy, alertness and preparedness, presence and patience, and coping with time. Conclusions: Starting to work in an AMU/FMU can be a distressing period for a midwife. First, it may require de-learning the medical approach to birth, and, second, it may entail a revitalisation (and re-learning) of birth care that promotes physiological birth. Midwifery, particularly in FMUs, requires an especially careful assessment of the labouring process, the ability to be foresighted, and capability in emergencies. The autonomy of midwives may be constrained also in AMUs/FMUs. However, working in these settings is also viewed as experiencing "the art of midwifery" and enables revitalisation of the midwifery philosophy.
... Hospital-based obstetricians, assisted by nurses, can constitute the most common form of childbirth service in one country, while midwives make up the primary childbirth care in another, regardless of setting (Sandall et al. 2013). Although home birth services are organized very differently worldwide, the health professionals attending the births are usually midwives (Brocklehurst et al. 2011;de Jonge et al. 2013;Grunebaum et al. 2013;Lindgren et al. 2014). ...
This article examines one of the relevant concepts in the current debate on home birth-autonomy in place of birth-and its uses in general language, ethics, and childbirth health care literature. International discussion on childbirth services. A concept analysis guided by the model of Walker and Avant. The authors suggest that autonomy in the context of choosing place of birth is defined by three main attributes: information, capacity and freedom; given the antecedent of not harming others, and the consequences of accountability for the outcome. Model, borderline and contrary cases of autonomy in place of birth are presented. A woman choosing place of birth is autonomous if she receives all relevant information on available choices, risks and benefits, is capable of understanding and processing the information and choosing place of birth in the absence of coercion, provided she intends no harm to others and is accountable for the outcome. The attributes of the definition can serve as a useful tool for pregnant women, midwives, and other health professionals in contemplating their moral status and discussing place of birth.
... Maternity care in Sweden is free of charge and funded by taxes, except for some of those women who request a homebirth [20]. Consequently, almost all births take place in hospitals. ...
Background
Women's negative experiences in the delivery room can have significance for later fear of childbirth. Therefore, it is important to critically evaluate the care during childbirth. The aim was to gain a deeper understanding of women's negative experiences in the delivery room.
Methods
This study is based on original data from three qualitative studies on Swedish women's experiences of fear of childbirth. Data were collected from interviews with 21 women; 15 pregnant women (6 + 9) with intense fear of childbirth, and 6 women who had experienced intense fear of childbirth 7-11 years prior to the interview. The analysis had a hermeneutic approach, with focus on the women's descriptions of their previous negative birth experiences.
Findings
The interpretation showed that in the delivery room the women were objects of surveillance, and they endured suffering related to the care during childbirth. This involves experiences of midwives as uncaring, feelings of being suppressed, unprotected and lacking safety, of feeling disconnected and of the body as incompetent in giving birth. The birth environments are understood as power structures, containing views of women's birthing bodies as machines, and delivery rooms as surveillance environments, involving interventions such as fetal heart monitoring, induction and augmentation of labour.
Conclusions
The delivery room was, for these women, a place creating fear of childbirth. To avoid negative birth experiences and future fear, women must be offered not only medical, but also emotional and existential safety in the delivery room.
... Gissler, National Institute for Health and Welfare, personal communication, 2013). Overall, home births are less frequent in Finland compared with other Nordic countries (Lindgren, Kjaergaard, Olafsdottir, & Blix, 2014). In Europe, the prevalence of planned home births was highest in Netherlands, 16%. ...
The planned home birth has provoked discussion around the world. Home birth has been described as a positive experience, but results regarding the safety of home birth are controversial. To date, the phenomenon has mainly been examined from the mother's point of view, and there is only one previous study reporting fathers' perspective. The purpose of the present phenomenological qualitative interview study was to investigate fathers' experiences of planned home birth. Eleven fathers were interviewed, and the data were analyzed using Colaizzi's phenomenological method. The fathers followed the woman's wish in choosing the birthplace and set aside their own views. Furthermore, hospital birth was not an option for the fathers due to their own prior negative experiences of hospital births such as disturbing the natural progress of birth. The fathers' experience of home birth included sharing the responsibility, supporting the woman, and participating in the home birth process. The experience was challenging; fathers had to take the role of a midwife, and no support or information on organizing home birth was offered by public health services. The fathers felt that the home birth connected them as family, and the experience was empowering. Our study results suggest that the health care professionals need more education and information on home birth and that the families (including fathers) interested in home birth need greater support from health care professionals. There is a need for proper national home birth guidelines, while family-and client-centered care has to be improved in birthing hospitals.
This article explores how the political ideal of data interacts with the legal entitlement of autonomy in the care of pregnant people guided by feminist theory and critical approaches to data. Using Scandinavian legislation and administrative practice, it analyses how the presence or absence of data, namely scientific evidence, interacts with pregnant people’s legal autonomy in healthcare. Data –particularly scientific evidence - is shown as something that is not neutral but open to interpretation and misappropriation. First, administrative complaints illustrate that not only a lack of scientific studies on pregnant people but also patriarchal attitudes have implications for care. Second, Scandinavian legislation authorizes the involuntary detention of pregnant drug users despite an absence of evidence supporting such drastic actions. Third, complaints bodies are found to frame injury to pregnant bodies as a natural consequence of birth, despite clear evidence as to the duties of healthcare professionals in preventing harm. A relational approach that sees the pregnant body and fetus as integrated though quintessentially unequal is needed. Evidence is not the only answer; an approach that recognizes the dignity of pregnant people must be central. This requires eliminating coercion, recognizing the pregnant patient as the decision maker in healthcare choices and prizing the birthing patient’s voice as a valuable data source.
As we describe the progress of adoption of new perinatal practices, we will limit our report to the potential implications of common non-traditional practices on neonatal health outcomes and highlight contemporary viewpoints of academic and regulatory organizations [the American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG) and the Centers for Disease Control and Prevention (CDC)] to these evolving practices.
Background
The majority of women in Sokoto, Nigeria prefer homebirths, but midwives are reluctant to provide care in the home setting. As such, many women continue to give birth at home alone or assisted by untrained attendants, which is associated with an increased risk for maternal and neonatal morbidity and mortality.
Methods
A randomized controlled trial was conducted among 226 midwives from 10 health care facilities. The intervention group received an educational program on home birth. A validated questionnaire that evaluated knowledge, attitudes, norms, perceived control, and intention to provide planned home birth care was given at baseline, immediately after the intervention, and at three‐months follow‐up. Data were analyzed using linear mixed‐effect model statistics.
Results
Following the intervention, the intervention group demonstrated higher knowledge and more positive attitudes, norms, perceived control, and intention to provide planned home birth care compared with the control group (P < 0.05). No significant changes in the scores of the control group were observed during the study duration (P > 0.05).
Discussion
Educating midwives on planned home birth increases their willingness to provide planned home birth care. Health system administrators, policymakers, and researchers may use similar interventions to promote skilled home birth attendance by midwives. Increasing the number of midwives who are willing to attend planned home births provides women at low risk for medical complications with safer options for labor, delivery, and postpartum care.
The birthing room is a major workplace for midwives but how it influences them in practice is not enough investigated.
Purpose: This study aimed to explore midwives´ experiences of how the birthing room affects them in their work to promote a normal physiological birth.
Methods: A phenomenological reflective lifeworld research approach was used and included individual interviews with 15 midwives working at four different hospitals in western Sweden, and of which two also assisted at homebirths. The analysis focused on the meanings of the study phenomenon.
Results: A birthing room can by its design either support a normal physiological birth or support a risk approach to childbirth. Four opposing constituents complete the essential meaning of the birthing rooms, and to which the midwives need to relate in their roles as guardians for normal birth: i) a private or a public room; ii) a home-like or hospital-like room; iii) a room promoting activity or passivity; iv) a room promoting the midwife´s presence or absence.
Conclusions: The birthing room mirrors a pathogenic-oriented care approach. A presupposition for the work to keep the birth bubble intact is to protect the mother from disturbing elements both inside and outside the room.
We developed and psychometrically tested a Theory of Planned Behavior (TPB) questionnaire which focused on assessing the midwives’ intention to provide planned home birth (PHB) services. This is a quantitative, cross-sectional survey, conducted among 226 midwives working in ten participating health facilities. The reliability and validity of the theoretical constructs were assessed. The Cronbach’s alpha values were >0.8 for all scales, suggesting satisfactory internal consistency. Confirmatory factor analysis revealed sufficient convergent validity (the average variance extracted was >0.5 for each construct) and discriminant validity. The study gathered an evidence of the usefulness of TPB in the specific context of PHB.
Problem:
There is a knowledge gap regarding women's experiences of coping with labour pain when not soliciting or not having access to pharmacological pain relief.
Background:
How women manage labour pain is complex, multifaceted and only the woman giving birth can assess the experienced pain. Women in the Nordic countries planning for a homebirth have little or no access to pharmacologic pain relief during labour.
Aim:
The aim of this study was to explore how women experience and work with labour pain when giving birth in their own home.
Methods:
Quantitative and qualitative data was prospectively collected and altogether 1649 women with a planned homebirth answered closed and open-ended questions about labour pain and birth experience.
Results:
While labour pain was often experienced as positive or very positive, the intensity was experienced as severe or the worst imaginable pain. Two main themes arose from the womens´ descriptions of their birth experience regarding labour pain: An encounter with extremes and Being in charge at home.
Discussion:
Women perceived labour pain as severe but manageable and were dedicated to completing the birth at home. Being at home enabled the women to exercise autonomy and work with labour pain on their own terms, together with the midwife and support persons.
Conclusions:
This study provides knowledge about women's experiences of labour pain in a home birth setting who used varying strategies to work with labour pain. This is a subject that should be explored further since results could also apply to facility-based birth settings.
Objective:
to gain a deeper understanding of how midwives promote a normal birth in a home birth setting in Norway.
Design/setting:
a qualitative approach was chosen for data collection. In-depth interviews were conducted with nine midwives working in a home birth setting in different areas in Norway. The transcribed interviews were analysed with the help of systematic text condensation.
Findings:
the analysis generated two main themes: «The midwife's fundamental beliefs» and «Working in line with one's ideology». The midwives had a fundamental belief that childbirth is a normal event that women are able to manage. It is important that this attitude is transferred to the woman in order for her to believe in her own ability to give birth. The midwives in the study were able to work according to their ideology when promoting a normal birth at home. To avoid disturbing the natural birth process was described as an important factor. Also crucial was to approach the work in a patient manner. Staying at home in a safe environment and establishing a close relationship with the midwife also contributed positively to a normal birth.
Key conclusions:
the midwife's attitude is important when trying to promote a normal birth. Patience was seen as essential to avoid interventions. Being in a safe environment with a familiar midwife provides a good foundation for a normal birth. The attitude of the midwives towards normal childbirth ought to be more emphasised, also in the context of maternity wards.
Background:
The option of a planned home birth defies medical and social normativity across countries. In Denmark, despite the dramatic decline in the home birth rates between 1960 and 1980, the right to choose the place of birth was preserved. Little has been produced documenting this process.
Aim:
To present and discuss Susanne Houd's reflection on the history and social dynamics of home birth in Denmark, based in an in-depth interview.
Methods:
This paper is part of wider Short Term Scientific Mission (STSM), in which this interview was framed as oral history. The whole interview transcript is presented, keeping the highest level of detail.
Findings:
In Susanne Houd's testimony, four factors were highlighted as contributing to the decline in the rate of home births from the 1960s to the 1970s: new maternity hospitals; the development of obstetrics as a research-based discipline; the compliance of midwives; and a shift in women's preference, favouring hospital birth. The development of the Danish home birth models was described by Susanne Houd in regard to the processes associated with the medicalisation of childbirth, the role of consumers, and the changing professional dynamics of midwifery.
Conclusion:
An untold history of home birth in Denmark was documented in this testimony. The Danish childbirth hospitalisation process was presented as the result of a complex interaction of factors. Susanne Houd's reflections reveal how the concerted action of consumers and midwives, framed as a system-challenging praxis, was the cornerstone for the sustainability of home birth models in Denmark.
Background:
Sweden has an international reputation for offering high quality maternity care, although models that provide continuity of care are rare. The aim was to explore women's interest in models of care such as continuity with the same midwife, homebirth and birth center care.
Methods:
A prospective longitudinal survey where 758 women's interest in models such as having the same midwife throughout antenatal, intrapartum and postpartum care, homebirth with a known midwife, and birth center care were investigated.
Results:
Approximately 50% wanted continuity of care with the same midwife throughout pregnancy, birth and the postpartum period. Few participants were interested in birth center care or home birth. Fear of giving birth was associated with a preference for continuity with midwife.
Conclusions:
Continuity with the same midwife could be of certain importance to women with childbirth fear. Models that offer continuity of care with one or two midwives are safe, cost-effective and enhance the chance of having a normal birth, a positive birth experience and possibly reduce fear of birth. The evidence is now overwhelming that all women should have maternity care delivered in this way.
Objective: To compare perinatal outcomes, maternal outcomes, and
interventions in labour by planned place of birth at the start of care in
labour for women with low risk pregnancies.
Design: Prospective cohort study.
Setting: England: all NHS trusts providing intrapartum care at home, all
freestanding midwifery units, all alongside midwifery units (midwife led
units on a hospital site with an obstetric unit), and a stratified random
sample of obstetric units.
Participants: 64 538 eligible women with a singleton, term (≥37 weeks
gestation), and “booked” pregnancy who gave birth between April 2008
and April 2010. Planned caesarean sections and caesarean sections
before the onset of labour and unplanned home births were excluded.
Main outcome measure: A composite primary outcome of perinatal
mortality and intrapartum related neonatal morbidities (stillbirth after start
of care in labour, early neonatal death, neonatal encephalopathy,
meconium aspiration syndrome, brachial plexus injury, fractured humerus,
or fractured clavicle) was used to compare outcomes by planned place
of birth at the start of care in labour (at home, freestanding midwifery
units, alongside midwifery units, and obstetric units).
Results: There were 250 primary outcome events and an overall weighted
incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were
no significant differences in the adjusted odds of the primary outcome
for any of the non-obstetric unit settings compared with obstetric units.
For nulliparous women, the odds of the primary outcome were higher
for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86)
but not for either midwifery unit setting. For multiparous women, there
were no significant differences in the incidence of the primary outcome
by planned place of birth. Interventions during labour were substantially
lower in all non-obstetric unit settings. Transfers from non-obstetric unit
settings were more frequent for nulliparous women (36% to 45%) than
for multiparous women (9% to 13%).
Conclusions: The results support a policy of offering healthy women
with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home
experience fewer interventions than those planning birth in an obstetric
unit with no impact on perinatal outcomes. For nulliparous women,
planned home births also have fewer interventions but have poorer
perinatal outcomes.
OBJECTIVE: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. DESIGN: A nationwide cohort study. SETTING: The entire Netherlands. POPULATION: A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown. METHODS: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. MAIN OUTCOME MEASURES: Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. RESULTS: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system
Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians.
We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes.
The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00-1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00-1.43) among women attended by a midwife and 0.64 (95% CI 0.00-1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29-0.36; assisted vaginal delivery, RR 0.41, 95% 0.33-0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28-0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49-0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14-0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24-0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21-0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09-1.85).
Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
To investigate the relation between the intended place of birth (home or hospital) and perinatal outcome in women with low risk pregnancies after controlling for parity and social, medical, and obstetric background.
Analysis of prospective data from midwives and their clients.
54 midwifery practices in the province of Gelderland, Netherlands.
97 midwives and 1836 women with low risk pregnancies who had planned to give birth at home or in hospital.
Perinatal outcome index based on "maximal result with minimal intervention" and incorporating 22 items on childbirth, 9 on the condition of the newborn, and 5 on the mother after the birth.
There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables.
The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.
A meta-analysis of observational studies have suggested that planned home birth may be safe and with less interventions than planned hospital birth.
The objective of this review was to assess the effects of planned home birth compared to hospital birth on the rates of interventions, complications and morbidity as determined in randomised trials.
We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: September 1999.
Controlled trials comparing planned hospital birth to planned home birth in selected women, assisted by an experienced home birth practitioner, and backed up by a modern hospital system in case transfer should be necessary.
Trial quality was assessed and data were extracted by one reviewer and checked by the other reviewer. Study authors were contacted for additional information.
One study involving 11 women was included. The trial was of reasonable quality, but was too small to be able to draw conclusions.
There is no strong evidence to favour either planned hospital birth or planned home birth for low risk pregnant women.
Objective - To collect data from a cohort of women requesting a home birth and examine the experience and outcome of pregnancy, the indications for hospital transfer, and the attitudes of mothers, midwives, and general practitioners. Design - Follow up study with anonymised postal questionnaires. Setting - Northern Regional Health Authority area. Subjects - The 256 women resident in the Northern region who expected to deliver in 1993 and whose request for a home birth became known to one of the local supervisors of midwives. Limited cross validating information was also collected retrospectively on all other women delivering a baby outside hospital in 1993. Main outcome measures - Rate of and reason for transferred care; maternal, midwifery, and general practitioner views; perinatal outcome. Results - Five women miscarried, leaving 251 in the study, Of these, 142 (57%) delivered at home. There were 17 (7%) caesarean sections but no perinatal deaths. General practitioners had reservations about half of the booking requests. Two thirds of the women thought they had not been offered any option about place of birth, 74 (29%) were referred to hospital for delivery before the onset of labour, and 35 (14%) were referred to hospital during labour. Intrapartum transfers were uneventful, and half the mothers commented spontaneously that they valued having spent even part of their labour at home. Conclusions - Home birth is valued for its family setting. General practitioners' support is sought and influential but uncommon, possibly because of a lack of understanding of the responsibilities of the midwife and general practitioner.
to explores preferences, characteristics and motives regarding place of birth of low-risk nulliparous women in the Netherlands.
a prospective cohort study of low-risk nulliparous women and their partners starting their pregnancy in midwifery-led care or in obstetric-led care. Data were collected using a self-administered questionnaire, including questions on demographic, psychosocial and pregnancy factors and statements about motives with regard to place of birth. Depression, worry and self-esteem were explored using the Edinburgh Depression Scale (EDS), the Cambridge Worry Scale (CWS) and the Rosenberg Self Esteem Scale (RSE).
participants were recruited in 100 independent midwifery practices and 14 hospitals from 2007 to 2011.
550 low-risk nulliparous women; 231 women preferred a home birth, 170 women a hospital birth in midwifery-led care and 149 women a birth in obstetric-led care.
Significant differences in characteristics were found in the group who preferred a birth in obstetric-led care compared to the two groups who preferred midwifery-led care. Those women were older (F (2,551)=16.14, p<0.001), had a higher family income (χ(2) (6)=18.87, p=0.004), were more frequently pregnant after assisted reproduction (χ(2)(2)=35.90, p<0.001) and had a higher rate of previous miscarriage (χ(2)(2)=25.96, p<0.001). They also differed significantly on a few emotional aspects: more women in obstetric-led care had symptoms of a major depressive disorder (χ(2)(2)=6.54, p=0.038) and were worried about health issues (F (2,410)=8.90, p<0.001). Women's choice for a home birth is driven by a desire for greater personal autonomy, whereas women's choice for a hospital birth is driven by a desire to feel safe and control risks.
the characteristics of women who prefer a hospital birth are different than the characteristics of women who prefer a home birth. It appears that for women preferring a hospital birth, the assumed safety of the hospital is more important than type of care provider. This brings up the question whether women are fully aware of the possibilities of maternity care services. Women might need concrete information about the availability and the characteristics of the services within the maternity care system and the risks and benefits associated with either setting, in order to make an informed choice where to give birth.
Background: Home-like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth.
Objectives: Primary: to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward. Secondary: to determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre.
Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two published conference proceedings.
Selection criteria: All randomized or quasi-randomized controlled trials that compared the effects of a home-like institutional birth environment to conventional hospital care.
Data collection and analysis: Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated methodological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals.
Main results: Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women allocated to home-like settings were transferred to standard care before or during labour. Allocation to a home-like setting significantly increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval (CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials; n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10). Allocation to a home-like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99). There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38). No firm conclusions could be drawn regarding the effects of staffing or organizational models.
Authors’ conclusions: When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications.
Citation: Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000012.pub2. DOI: 10.1002/14651858.CD000012.pub2.
homebirth for low risk women attended by competent midwives who are networked within a responsive maternity care service is supported by research as safe. Concerns exist over the safety of homebirths which are unattended by trained health professionals, or for women with medically defined risk factors. Both these birth choices are unsupported by mainstream maternity care options in Australia and therefore represent birth choices considered to be 'outside the system'.
to explore the perceptions of risk held by women who choose to have a freebirth (birth at home intentionally unattended by a trained birth attendant) or a 'high-risk' homebirth (professionally attended home birth where a mother or baby has medically defined risk factors). Both of these choices are considered to be 'outside the system'.
twenty women were interviewed about their choice to 'birth outside the system', nine choosing freebirth and 11 choosing to have an attended homebirth despite the presence of medically defined risk factors; three were primiparous and seventeen were multiparous. Women intending to have, or having had a freebirth or high risk homebirth, were interviewed using semi-structured interviews. Interviews were transcribed and analysed using thematic analysis.
the three main themes about perceptions of risk that were evident in this study were: 'Birth always has an element of risk', 'The hospital is not the safest place to have a baby'; and 'interference is a risk'.
the participants acknowledge that birth is a time in life that carries an element of risk. They perceive that hospital represents a more risky place to give birth than at home and that interventions and interruptions during labour and birth increase risk. Women who birth outside the system perceive the risks of birth in hospital differently to most women. These women feel that by birthing outside the system they are making a choice that protects them and their babies from the risks associated with birthing in hospital and thus provides them with the best and safest birthing option.
in pursuing the best for themselves and their babies, women who birth outside the system spent a lot of time and energy considering the risks and weighing these up. For them birth in hospital is considered less safe than birth at home.
Alternative institutional settings have been established for the care of pregnant women who prefer and require little or no medical intervention. The settings may offer care throughout pregnancy and birth, or only during labour; they may be part of hospitals or freestanding entities. Specially designed labour rooms include bedroom-like rooms, ambient rooms, and Snoezelen rooms.
Primary: to assess the effects of care in an alternative institutional birth environment compared to care in a conventional institutional setting. Secondary: to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010).
All randomized or quasi-randomized controlled trials which compared the effects of an alternative institutional maternity care setting to conventional hospital care.
We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors evaluated methodological quality. We performed double data entry and have presented results using risk ratios (RR) and 95% confidence intervals (CI).
Nine trials involving 10684 women met the inclusion criteria. We found no trials of freestanding birth centres or Snoezelen rooms. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anaesthesia (five trials, n = 7842; RR 1.17, 95% CI 1.01 to 1.35); spontaneous vaginal birth (eight trials; n = 10,218; RR 1.04, 95% CI 1.02 to 1.06); breastfeeding at six to eight weeks (one trial, n = 1147; RR 1.04, 95% CI 1.02 to 1.06); and very positive views of care (two trials, n = 1207; RR 1.96, 95% CI 1.78 to 2.15). Allocation to an alternative setting decreased the likelihood of epidural analgesia (seven trials, n = 9820; RR 0.82, 95% CI 0.75 to 0.89); oxytocin augmentation of labour (seven trials, n = 10,020; RR 0.78, 95% CI 0.66 to 0.91); and episiotomy (seven trials, n = 9944; RR 0.83, 95% CI 0.77 to 0.90). There was no apparent effect on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or postpartum hemorrhage. No firm conclusions could be drawn regarding the effects of variations in staffing, organizational models, or architectural characteristics of the alternative settings.
When compared to conventional settings, hospital-based alternative birth settings are associated with increased likelihood of spontaneous vaginal birth, reduced medical interventions and increased maternal satisfaction.
To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care.
A nationwide cohort study.
The entire Netherlands.
A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown.
Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics.
Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit.
No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16).
This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
About 150 planned home births take place in Norway annually. Professionals have different opinions on whether such births are safe or not. The aim of the present study was to perform a systematic literature review on maternal and neonatal outcomes after planned home births.
A review was performed of literature retrieved from searches in MEDLINE, PubMed, Embase, Cinahl and The Cochrane Library and relevant references found in the articles. The searches were limited to studies published in 1985 and later.
10 studies with data from 30 204 women who had planned and were selected to home birth at the onset of labour were included. Three of the studies had control groups including women with planned hospital births. All included studies were assessed to be of medium quality. Between 9.9 and 23.1 % of women and infants were transferred to hospital during labour or after birth. There were few caesarean sections, other interventions or complications in the studies assessed; the total perinatal mortality rate was 2.9/1000 and the intrapartum mortality rate 0.8/1000.
There is no sound basis for discouraging low-risk women from planning a home birth. Results from the included studies do not directly apply to Norwegian conditions. Outcomes and transfers after planned home births should be systematically registered.
This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991. A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery home birth practices). It is estimated that 60-70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartum transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.
To collect data from a cohort of women requesting a home birth and examine the experience and outcome of pregnancy, the indications for hospital transfer, and the attitudes of mothers, midwives, and general practitioners.
Follow up study with anonymised postal questionnaires.
Northern Regional Health Authority area.
The 256 women resident in the Northern region who expected to deliver in 1993 and whose request for a home birth became known to one of the local supervisors of midwives. Limited cross validating information was also collected retrospectively on all other women delivering a baby outside hospital in 1993.
Rate of and reason for transferred care; maternal, midwifery, and general practitioner views; perinatal outcome.
Five women miscarried, leaving 251 in the study. Of these, 142 (57%) delivered at home. There were 17 (7%) caesarean sections but no perinatal deaths. General practitioners had reservations about half of the booking requests. Two thirds of the women thought they had not been offered any option about place of birth, 74 (29%) were referred to hospital for delivery before the onset of labour, and 35 (14%) were referred to hospital during labour. Intrapartum transfers were uneventful, and half the mothers commented spontaneously that they valued having spent even part of their labour at home.
Home birth is valued for its family setting. General practitioners' support is sought and influential but uncommon, possibly because of a lack of understanding of the responsibilities of the midwife and general practitioner.
To describe the outcomes of intended home birth in the practices of certified nurse-midwives.
Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established.
Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000.
Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.
To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.
Prospective cohort study.
All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.
All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.
Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.
655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.
Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
To describe documented intrapartal care in relation to the World Health Organization (WHO) recommendations for care in normal birth, and to compare intrapartal care for pregnant women at low and high risk in a conventional maternity unit.
Retrospective examination of 212 consecutive childbirth records using an audit instrument developed from WHO's recommendations.
A conventional maternity unit in Western Sweden.
Practices that are demonstrably useful and should be encouraged were mostly documented, except for physical assessments, such as pulse and temperature and emotional aspects. Vaginal examinations were carried out more often than recommended, and fetal heart rates were seldom monitored intermittently. Practices classified as harmful, practices with insufficient evidence and practices frequently used inappropriately, were used to a large extent. There were high rates of interventions regardless of the women's risk level. The interventions were carried out without a rational documented indication. According to the documentation, only two-thirds of the women were in active labour on admission to the labour ward.
The recommendations from WHO were only partly adhered to. The instrument is considered useful for systematic audit of documented intrapartal care, and may help to identify areas in need of improvement. Improvements suggested by this study were as follows: inclusion of emotional aspects in the documentation, differentiation in cardiotocographic (CTG) surveillance for women at low and high risk, documentation of explicit indications for interventions and guidelines for admission to the maternity unit.
to test the hypothesis that midwives working in higher intervention units would have a higher perception of risk for the intrapartum care of women suitable for midwifery-led care than midwives working in lower intervention units.
an initial retrospective analysis of the computerised records of 9887 healthy Caucasian women in spontaneous labour enabled the categorisation of 11 units as either 'lower intrapartum intervention' or 'higher intrapartum intervention' units. A survey of the midwives involved in intrapartum care in these 11 units, using standardised scenario questionnaires, was used to investigate midwives' options for intrapartum interventions, their perceptions of intrapartum risk and the accuracy of these perceptions in the light of actual maternity outcomes.
midwives working in maternity units that had a higher level of intervention generally perceived intrapartum risks to be higher than midwives working in lower intervention units. However, midwives generally underestimated the ability of women to progress normally and overestimated the advantages of technological interventions, in particular epidural analgesia.
variations in intrapartum care cannot be solely explained by the characteristics of the women. The influence of the workplace culture plays a significant role in shaping midwives' perceptions of risk, but it seems even more likely that the medicalisation of childbirth has had an influence on midwives' appreciation of intrapartum risks. Intervention rates for low-risk births are often higher than recommended by research. The level of interventions varies across hospitals and higher rates are associated with higher perception of risk by midwives. Attention needs to be given to the influence the workplace plays in shaping midwives' perception of risk; and to the effect of organisational culture on intervention rates.
The aim of this population-based study was to measure the risk of adverse outcome for mother and child in planned home births in a Swedish population irrespective of where the birth actually occurred, at home or in hospital after transfer.
A population-based study using data from the Swedish Medical Birth Register.
Sweden 1992-2004.
A total of 897 planned home births were compared with a randomly selected group of 11,341 planned hospital births.
Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared.
During this period in Sweden the neonatal mortality rate was 2.2 per thousand in the home birth group and 0.7 in the hospital group (RR 3.6, 95% CI 0.2-14.7). No cases of emergency complications were found in the home birth group. The risk of having a sphincter rupture was lower in the planned home birth group (RR 0.2, 95% CI 0.0-0.7). The risk of having a cesarean section (RR 0.4, 95% CI 0.2-0.7) or instrumental delivery (RR 0.3, 95% CI 0.2-0.5) was significantly lower in the planned home birth group.
In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.
1.oplag. Köbenhavn. Komiteen for Sundhedsoplysning, www.sundhedsoplysning.dk (National guidelines for maternity care. The National Board of Health. The Danish Comittee for Health Education
- Sundhedsstyrelsen Anbefalinger For Svangreomsorgen
Anbefalinger for svangreomsorgen, Sundhedsstyrelsen, 2009. 1.oplag. Köbenhavn.
Komiteen for Sundhedsoplysning, www.sundhedsoplysning.dk (National guidelines
for maternity care. The National Board of Health. The Danish Comittee for Health
Education 2009)
Handläggning av normal förlossning. State of the art. (Management in normal childbirth. National Board of Health and Welfare
- Socialstyrelsen
Socialstyrelsen. Handläggning av normal förlossning. State of the art. (Management
in normal childbirth. National Board of Health and Welfare) Stockholm 2001
Swedish Law of Health and Care; 1982:763. Ministry of Health and Social Affairs Available from
- Socialstyrelsens
Socialstyrelsens författningssamling. Swedish Law of Health and Care; 1982:763. Ministry of Health and Social Affairs. Available from: http:// www.notisum.se/rnp/sls/lag/19820763.HTM.
Guidelines for reporting births to the Medical Birth Registry Veiledning for utfylling av melding til Medisinsk fødselsregister, IK-1002
- Medical Birth Registry
- Norway
Medical Birth Registry of Norway. Guidelines for reporting births to the
Medical Birth Registry. Veiledning for utfylling av melding til Medisinsk
fødselsregister, IK-1002; 2004. Available from: www.fhi.no/mfr.
Villkor för ersättning vid planerad hemförlossning. Riktlinjer för Stockholms läns landsting. (Premises for accepting economical allowance in home births
- I Wiklund
- L Nordström
Wiklund I, Nordström L. Villkor för ersättning vid planerad hemförlossning.
Riktlinjer för Stockholms läns landsting. (Premises for accepting economical
allowance in home births) Stockholm 2003
Oslo: HOD; 2001. (Ministry of Health and Care Services. Law regarding patient's rights (LOV 1999-07-02 nr 63). Ministry of Health and Care Services
- Helsedirektoratet
- Lov
- Pasientrettigheter
Helsedirektoratet. Lov om pasientrettigheter. Oslo: HOD; 2001. (Ministry of
Health and Care Services. Law regarding patient's rights (LOV 1999-07-02 nr
63). Ministry of Health and Care Services.).
Faglige krav til fødeinstitusjoner. Oslo: Statens helsetilsyn; 1997 (The Norwegian Board of Health. Quality levels for birth institutions. Oslo: The Norwegian Board of health
- Statens Helsetilsyn
Statens helsetilsyn. Faglige krav til fødeinstitusjoner. Oslo: Statens helsetilsyn;
1997 (The Norwegian Board of Health. Quality levels for birth institutions.
Oslo: The Norwegian Board of health; 1997).
Outcomes of 11 788 planned home births attended by certified midwives
- Anderson Re Pa Murphy
Anderson RE, Murphy PA. Outcomes of 11 788 planned home births attended by certified midwives. J Nurse Midwifery 1995;40:483–92.
Outcomes after planned home births (Utfall etter planlagte hjemmefødsler)
- E Blix
- P Öian
- M Kumle
Blix E. Öian P, Kumle M. Outcomes after planned home births (Utfall etter planlagte
hjemmefødsler). Tidsskrift Nor Legeforen 2008;128:2436-9
The Swedish Medical Birth Register
- Newborn Pregnanciesies
- Infants
Pregnanciesies and Newborn Infants, The Swedish Medical Birth Register 1973–
2009. National Board of Health and Welfare, Stockholm 2011
Swedish Law of Health and Care 1982:763 Ministry of Health and Social Affairs http://www.notisum.se/rnp/sls/lag Preferred place of birth: Characteristics and motives of low-risk nulliparous women in the Netherlands
- Socialstyrelsens Författningssamling
- M Hendrix
- M Nieuwenhuijze
- L Budé
- R De Vries
- J Nijhuis
Socialstyrelsens författningssamling. Swedish Law of Health and Care 1982:763
Ministry of Health and Social Affairs
http://www.notisum.se/rnp/sls/lag/19820763.HTM
Van Haaren-ten H, Hendrix M, Nieuwenhuijze M, Budé,L, de Vries R, Nijhuis J,
Preferred place of birth: Characteristics and motives of low-risk nulliparous women in
the Netherlands. Midwifery 2012; 28:609-18
Safe motherhood Accessed 2011-11-05 Available from
WHO, 2011, Safe motherhood. Accessed 2011-11-05. Available from:
http://www.safemotherhood.org/priorities/index.html
Access to midwives, nurses, physicians and dentists
Access to midwives, nurses, physicians and dentists 2008. National Board of Health
and Welfare, Stockholm 2009
Antenatal care in normal pregnancy for healthy women. Clinical guidelines [ Meðgönguvernd heilbrigðra kvenna í eðlilegri meðgöngu. Klínískar leiðbeiningar]. Directorate of Health
- H Kristjánsdóttir
- Jd Kristinsdóttir
- Ab Aradóttir
- A Hauksson
- H Gottfreðsdóttir
- R Reynisson
- Ss Jónsdóttir
- Þ Og Steingrímsdóttir
Kristjánsdóttir H., Kristinsdóttir JD., Aradóttir AB., Hauksson A., Gottfreðsdóttir H.,
Reynisson R., Jónsdóttir SS. og Steingrímsdóttir Þ. Antenatal care in normal
pregnancy for healthy women. Clinical guidelines [ Meðgönguvernd heilbrigðra
kvenna í eðlilegri meðgöngu. Klínískar leiðbeiningar]. Directorate of Health, 2008,
accessed 16.12. 2011. Available from:
http://www.landlaeknir.is/lisalib/getfile.aspx?itemid=4407
Home versus hospital birth Cochrane Database of Systematic Reviews
- O Olsen
- D Jewell
Olsen O, Jewell D. Home versus hospital birth. Cochrane Database of Systematic
Reviews 1998, Issue 3. Art. No.: CD000352. DOI: 10.1002/14651858.CD000352
Att föda barn -från privat till offentlig angelägenhet. Förlossningsvårdens institutionalisering i Sundsvall 1900-1930. Avhandling vid Historiska institutionen (To give birth -from private to public matter. Thesis defended at the department of history
- M Wisselgren
Wisselgren M. Att föda barn -från privat till offentlig angelägenhet.
Förlossningsvårdens institutionalisering i Sundsvall 1900-1930. Avhandling vid
Historiska institutionen (To give birth -from private to public matter. Thesis
defended at the department of history) Umeå university 2005
The Icelandic Directorate of Health, Reykjavik Available from http:// www.landlaeknir.is/utgefid-efni/skjal
- Guidelines For
- Place
- Birth
Guidelines for choosing place of birth [Leiðbeiningar um val á faeðingarstað].
The Icelandic Directorate of Health, Reykjavik; 2007. Available from http://
www.landlaeknir.is/utgefid-efni/skjal/item2818/. [accsessed 10.10.2012].
Available from: http://www. sst.dk
National Board of Health and Welfare, Denmark; 2009. Available from: http://www.
sst.dk/Webudgivelser/~/link.aspx?_id=9091B099275F4B0E9EFB46219200DD2A&_z=z.
Swedish Law of Health and Care; 1982:763. Ministry of Health and Social Affairs Available from: http:// www.notisum.se/rnp/sls/lag
- Socialstyrelsens Författningssamling
Socialstyrelsens författningssamling. Swedish Law of Health and Care;
1982:763. Ministry of Health and Social Affairs. Available from: http://
www.notisum.se/rnp/sls/lag/19820763.HTM.
Safe motherhood Available from: http://www.safemotherhood. org/priorities/index
WHO. Safe motherhood; 2011. Available from: http://www.safemotherhood.
org/priorities/index.html. [accessed 2011-11-05].
National Board of Health
- Personlig Meddelelse
- Specialkonsulent Steen Rasmussen
Personlig meddelelse. Specialkonsulent Steen Rasmussen. National Board of
Health, Copenhagen, Denmark (personal communication: special consultant
Steen Rasmussen).
Outcomes of 11 788 planned home births attended by certified midwives
- R E Anderson
- P Murphy
Anderson RE, Murphy P A, Outcomes of 11 788 planned home births attended by
certified midwives. Journal of Nurse Midwifery 1995;40:483-92
og Steingrímsdóttir Þ. Antenatal care in normal pregnancy for healthy women. Clinical guidelines
- H Kristjánsdóttir
- J D Kristinsdóttir
- A B Aradóttir
- A Hauksson
- H Gottfreðsdóttir
- R Reynisson
- S S Jónsdóttir
Kristjánsdóttir H., Kristinsdóttir JD., Aradóttir AB., Hauksson A., Gottfreðsdóttir H.,
Reynisson R., Jónsdóttir SS. og Steingrímsdóttir Þ. Antenatal care in normal
pregnancy for healthy women. Clinical guidelines [ Meðgönguvernd heilbrigðra
kvenna í eðlilegri meðgöngu. Klínískar leiðbeiningar]. Directorate of Health, 2008,
accessed 16.12. 2011. Available from:
http://www.landlaeknir.is/lisalib/getfile.aspx?itemid=4407
Head of the Norwegian association of midwives
- Marit Heiberg
Marit Heiberg, Head of the Norwegian association of midwives, personal
communication, 03.05.2011
The Swedish Medical Birth Register 1973-2009. National Board of Health and Welfare
- Newborn Pregnanciesies
- Infants
Pregnanciesies and Newborn Infants, The Swedish Medical Birth Register 1973-2009. National Board of Health and Welfare, Stockholm 2011
Kvalitetskrav til fødselsomsorgen). National guidelines published by the Norwegian Directorate of Health
Safe births. Acceptable quality levels for birth institutions (Et trygt fødetilbud.
Kvalitetskrav til fødselsomsorgen). National guidelines published by the Norwegian
Directorate of Health.Helsedirektoratet. 2010
Oslo: Statens helsetilsyn, 1997 (The Norwegian Board of Health. Quality levels for birth institutions. Oslo: The Norwegian Board of health
- Statens Helsetilsyn
Statens helsetilsyn. Faglige krav til fødeinstitusjoner. Oslo: Statens helsetilsyn, 1997
(The Norwegian Board of Health. Quality levels for birth institutions. Oslo: The
Norwegian Board of health, 1997).