Staying Home To Give Birth
Staying Home to Give Birth: Why Women in the United States Choose Home Birth
Debora Boucher, CNM, Catherine Bennett, RNC, BSN, Barbara McFarlin, CNM, PhD, RDMS, and Rixa Freeze, PhD, MA
Approximately 1% of American women give birth at home and face substantial obstacles when they make this choice. This study describes the reasons that women in the United States choose home birth. A qualitative descriptive secondary analysis was conducted in a previously collected dataset obtained via an online survey. The sample consisted of 160 women who were US residents and planned a home birth at least once. Content analysis was used to study the responses from women to one essay question: ”Why did you choose home birth?”Women who participated in the study were mostly married (91%) and white (87%). The majority (62%) had a college education. Our analysis revealed 508 separate statements about why these women chose home birth. Responses were coded and categorized into 26 common themes. The most common reasons given for wanting to birth at home were: 1) safety (n = 38); 2) avoidance of unnecessary medical interventions common in hospital births (n = 38); 3) previous negative hospital experience (n = 37); 4) more control (n = 35); and 5) comfortable, familiar environment (n = 30). Another dominant theme was women’s trust in the birth process (n = 25).
Women equated medical intervention with reduced safety and trusted their bodies’ inherent ability to give birth without interference. J Midwifery Womens Health 2009;54:119-126 Ó 2009 by the American College of Nurse-Midwives.
INTRODUCTION
Modern hospitals have undergone tremendous technological advances and patient-focused changes over the past 50 years, culminating in facilities that offer world-class care, patient safety, and compassionate attention. In particular, maternity units have been replaced with family-centered birthing suites outfitted with the latest machines and patient amenities. Despite this safe and seemingly comfortable environment, a small but steadfast population of American women chooses to decline the hospital setting to give birth in their own homes.
Before the mid-20th century, most American women gave birth at home under the care of midwives.1 As the specialty of medical obstetrics grew, the percentage of hospital-based births increased.2 In 1940, 40% of births to white women and 73% to nonwhite women in the United States occurred at home.3 Total hospital births were 56% in 1940.3 In 1950, the percentage of hospital births soared to 88%, rising to more than 99% by 1969, where it remains today.3-5 Therefore, the small percentage of the population of women choosing home birth in the United States today comprise a minority culture.
Although the percentage of home births has remained below 1% since 1960, the actual numbers are not trivial. National figures for 2005 show that 24,468 infants were born at home in the United States.4 The majority of women who chose home birth in the United States were white (n = 19,706) and were attended by midwives (n = 13,118).4
Numerous studies have shown equivalent safety rates when comparing home and hospital births.6-11 A recent inegrative review compiled data from 28 studies undertaken between 1969 and 2000.7 Fullerton et al.7 concluded that maternal and neonatal outcomes of planned home birth receiving first-level care were favorable when compared to planned hospital or birth center births.7 A meta-analysis of six studies comparing the birth outcomes of 24,092 low-risk pregnant women found that perinatal mortality was similar between the home and hospital birth groups.10
Olsen10 found that the home birth group had a decreased frequency of induction, augmentation, episiotomy, operative vaginal birth, and cesarean delivery.10 Despite favorable safety rates, the choice to have a planned home birth is not well supported in the United States by the government, professional organizations, the insurance industry, or society.1 Government regulations impede practitioners from providing home birth services by limiting licensure. All states license physicians and advanced practice nurses, but only 23 states allow licensure of nonnurse certified midwives who are more likely to attend home births.12 Recently, the American College of Obstetricians and Gynecologists issued a news release reiterating its opposition to home birth as stated in their 2006 Statement of Policy, which admonished physicians from practicing home birth and from providing back-up support for home birth providers.13,14 These regulations and policies result in small numbers of home birth providers and great difficulty for women in locating a provider. Some insurance companies do not fully reimburse providers’ fees for home birth.15 In addition, women who choose home birth are often asked questions about the perceived risk they are taking.
Studies from other countries where home birth is more prevalent examined reasons why women chose home birth. Common themes were control, comfort, freedom to move, and fewer interventions.16-20 In two of the four studies, women stated that they felt safer at home.16,20 In Turkey, although the main reason for choosing home birth was economic, almost 50% of the women stated that they feel more comfortable at home.20
Given that women choosing home birth in the United States are a minority population, and that their choice to birth at home is not well supported, the aim of our study was to describe the reasons why women choose home birth.
METHODS
Study Design
This qualitative descriptive study sought to examine why women in the United States choose home birth. The study consisted of a secondary content analysis of one question from a larger dataset collected for a study entitled, ”A New Look at Homebirth in the United States,” by Rixa Freeze at the University of Iowa. The Institutional Review Boards at the University of Illinois at Chicago (UIC) and the University of Iowa reviewed and approved the study’s intent and protocol. The online survey was advertised via e-mails and postings on Internet electronic mailing lists for childbirth professionals and via direct solicitations to known childbirth professionals who provide home birth services. Solicited home birth providers forwarded the advertisement to their patients, requesting volunteers to respond to the survey, which was made available online from August 2006 through May 2007. The data were collected in an Excel spreadsheet. After the survey was closed, the data were de-identified and provided to the UIC research team.
The conceptual framework that guided this research was Leininger’s cultural care diversity and universality theory.21 The goal of Leininger’s theory is to ”provide culturally congruent nursing care in order to improve or offer a different kind of nursing care service to people of diverse or similar cultures.”21 This theory applies to the subjects of our study because the small population of women who choose home birth could be considered a cultural group. Essential to Leininger’s theory is the need for nurses to appreciate how the individual woman views her own health status.21 This framework can be extended to include an understanding of why women would choose to give birth at home and not in the hospital. This project sought to identify the reasons why women choose home birth. We anticipated that several themes would emerge during data analysis, which may help health care providers provide culturally competent care to this cultural group.
Sample
A convenience sample of 160 women was selected from 272 respondents who completed an online survey about home birth conducted via a Web site (http://homebirth.study.googlepages.com). Responses were selected if the respondent was a woman who had planned to give birth at home in the United States at least one time. Responses were excluded if the respondent planned only to birth in a birthing center or hospital, was not a woman, or was not a resident of the United States.
Measures and Data Collection Procedures
The original online survey consisted of 30 questions authored by Rixa Freeze. The subset of data used for this study included one open-ended question ”Why did you choose homebirth?” and six demographic questions: ”State of residence,” ”Gender,” ”Age,” ”Your occupation and education level,” ”Place and manner of your children’s births,” and ”Involvement with birth.” The majority of responses to the question ”Why did you choose homebirth?” were brief; all 160 responses were analyzed.
Data Analysis
The de-identified data were collected using Excel, with rows representing the respondents and columns representing the questions. A coding subset was created containing only the respondent’s identification number and the responses to the key study question ”Why did you choose homebirth?” Content analysis coding proceeded in an orderly fashion from the top of the spreadsheet to the bottom.22
Responses were analyzed using the basic and fundamental method of qualitative description as described by Sandelowski.22 Content analysis was used to relay each respondent’s content without extensive interpretation. As each respondent’s statement was analyzed, the reasons for choosing home birth were identified, copied, and categorized into themes; the theme descriptions emerged out of the data.
A total of 508 reasons were coded into themes. Doublecoding of all 160 responses (100%) proceeded as follows:
one team member reviewed all of the content, extracted 508 distinct reasons from the 160 responses, and coded the reasons into themes which were identified from the data; then a second team member reviewed the 508 reasons and coded them into themes, using the list of themes that were previously identified. Disagreements were found regarding 37 of the 508 reasons (7.3%), which were then discussed and recoded. A matrix of the themes and the extracted reasons was created and distributed to two other team members, who reviewed the responses within the themes for consistency and accuracy.23 The matrix was also used to analyze the themes across respondents, combine them into 26 final common themes, and to identify common reasons why US women choose home birth.
RESULTS
Sample Characteristics
One hundred and sixty of the original respondents met inclusion criteria for this analysis. The mean age of the study participants was 35 years (range, 20-65 yrs). Most respondents planned a home birth in the recent past: 82% (n = 132) occurred within 5 years of the survey, and the overall mean was 3 years. The majority of the women in the sample were white and married. One-third of the women described themselves as homemakers or stay-at-home mothers. At the time of the survey, 32% worked as professionals; six of the 51 professionals identified themselves as health care practitioners. Other occupations represented were service workers and management. More than half of the women possessed at least a college degree and many also held advanced degrees. Respondents resided in 36 of the 50 states, with 28% residing in Illinois, 6% in Colorado, and 6% in Maryland. A complete list of the characteristics of the study sample is displayed in Table 1.
Themes
Responses to the study question ”Why did you choose homebirth?” were numerous. Most of the 160 respondents stated several reasons for planning a home birth (mean, 3; range, 1-11). Descriptions of the 26 common themes and the coding rationale are found in Table 2. The frequency distribution of coded themes is displayed in Figure 1.
The five most frequently identified themes will be discussed in this paper: ”safety and better outcomes,” ”intervention-free,” ”negative previous hospital experience,” ”control,” and ”comfortable environment.” Nine out of the 30 respondents who mentioned ”comfortable environment” also mentioned ”trust in birth”; therefore, the ”trust in birth” theme will also be discussed.
Safety and Better Outcomes
Twenty-four percent (n = 38) of the respondents reported that their reason for planning a home birth was their belief that home was the safest place to give birth and allowed the opportunity for better health outcomes. The following comments exemplified these beliefs:
”We felt [that] homebirth was the safest option for us.”
”Later, I learned about the risks of homebirth vs. [sic] hospital birth, and felt that in my situation I had a far better chance at a good outcome at home.”
Only three of the 38 women who listed safety and better outcomes as a reason for choosing home birth also reported a negative previous hospital experience. Seven of the 38 women reported that it was better for the baby’s health to birth at home.
Professionals represented the largest occupational group that reported safety and better outcomes (n = 14), and four of the professionals were health care practitioners. Other occupations represented in this theme were homemakers (n = 11), service (n = 5), management (n = 4), students (n = 2), and sales (n = 1). Most of the women had attended college (n = 36), and many had completed a bachelor’s degree (n = 14) or higher (n = 12).
Intervention-Free
The other most frequently identified theme involved the use of labor and delivery interventions. Twenty-four percent (n = 38) of the respondents discussed their desire to avoid medical interventions, routine procedures, and interferences that are common in hospitals. Some women described specific interventions that they would like to avoid, and other women referred to interventions that occurred during a previous hospital experience that they were hoping to avoid:
”No: monitors, IVs, drugs, laying on my back, family pushed away, baby taken away, baby given sugar water.”
Some women focused their comments on avoiding interference in the birth process:
”I believe birth proceeds best when uninterfered with.”
Twenty-four percent (n = 9) of the respondents who mentioned safety as a reason for choosing home birth also stated that they preferred their birth to be intervention-free. Women who expressed both safety and intervention-free themes shared this typical responses:
”I realized that *my* [sic] home.[is] a safer environment for my babies than a hospital room. .As far as I am concerned, lower intervention means higher safety for both mother and baby.”
Negative Previous Hospital Experience
Another theme that was frequently mentioned (n = 37) was a negative previous hospital experience:
”In my first birth experience, I felt bullied, robbed, cheated, and fearful in the hospital environment. I could not use my voice in the hospital and my doctor did not listen anyway. I was a passive patient, instead of an active participant.”
Many chose home birth after observation of someone else’s negative hospital experience:
”I had seen such bad experiences through family and friends of mine with hospital births that I really wanted to do a homebirth.”
Control
Many women (n = 35) wrote about wanting control of their birthing experience. They expressed a desire to be the primary person making decisions and choices regarding treatment and care:
”To create a situation where I had a great deal of freedom and control over the birth process without the restriction imposed by hospital policies.”
Comfortable Environment
Giving birth in an environment described as comfortable, calm, peaceful, loving, or familiar was a theme that was mentioned as a priority to many of the women (n = 30) in this study:
”I wanted to bring my baby into a peaceful and familiar environment surrounded by love and support.”
One-third of the respondents in this group (n = 9) also expressed the eighth most common theme, ”trust in birth.” They remarked that birth would proceed more normally in a home environment than in a hospital environment. We include this theme because of the frequency of its occurrence within this group’s statements:
”I knew [that] I’d feel more comfortable at home and I would therefore labor better.”
DISCUSSION
Previous studies have reported equivalent safety rates when comparing home and hospital births,6-11 the demographics of women choosing home birth,24,25 and the expectations of women choosing hospital birth.26 Women choosing home birth in several countries were described as wanting more flexibility, choice, and control,16-20 while those choosing a hospital birth have been described as being concerned about safety.17-19 These findings could be misinterpreted to mean that safety is not a concern for women who choose home birth. In this study, the concern for safety was mentioned by 24% (n = 38) of women as being paramount in their decision to plan a home birth; they considered home birth to be safer than hospital birth.
Avoiding unnecessary medical interventions and interferences that are part of hospital routine were also mentioned by 24% (n = 38). Listening to Mothers II
(LTM-II), a national US survey of women’s childbearing experiences, found that interventions have become routine in hospital settings, including electronic fetal monitoring (94%), medications for pain relief (86%), and epidural analgesia for vaginal deliveries (71%).26 Nearly one-third of hospital births in 2005 were cesarean deliveries.26 LTM-II concluded that ”large proportions experienced numerous labor and birth interventions of benefit for mothers with specific risk conditions, but inappropriate as routine measures.”26 Routine labor interventions experienced by women delivering in hospitals are not evidence-based and do not reflect best practice.27 It is not surprising, then, to hear women express a desire to birth at home to avoid interventions that they may have experienced or witnessed at previous births, especially when women do not feel that their preferences would be honored.
Many of the women’s responses specifically acknowledged the impact of former negative birth experiences. The hurt and frustration were apparent in their responses.
Also voiced in their comments was the positive impact that their decision to have a home birth had on their families, their babies, and themselves. This echoes the findings of LTM-II, which examined research focused on the lifelong implications and the impact of the birthing process on both infants and mothers.26
Institutions have policies and procedures intended to safeguard the well-being of the institution and those it serves. In some instances, the control of the institution comes in direct conflict with the power and control of the individual. In our study, 35 women stated that one of the issues that influenced their decision to have a home birth was their desire to have increased control of their birthing experience. Words used were: ”freedom, control, autonomy, and lack of hospital-imposed restrictions”- concepts that they felt were only available to them in their own home. In contrast, words used by women in LTM-II when describing their feelings about their hospital birthing experience were ”overwhelmed” (38%) and ”frightened” (33%), while only 17% described feeling ”powerful” during the labor process.26
Thirty of the women in our study remarked that their home birth decision was based on wanting to give birth in a comfortable, familiar, peaceful setting where they would be better able to relax during labor. Many of them also upheld their belief that this relaxed state contributed to a normal progression of labor, which results in shorter labors. Extensive research supports the hypothesis that increased epinephrine levels that occur with anxiety during labor are associated with an increase in the length of labor.28-33
LIMITATIONS
The nature of research conducted by online survey limits the availability of the survey primarily to individuals with access to the Internet. The demographics of our sample do demonstrate a lack of diversity. The sample may therefore not be representative of all women who choose home birth. However, similar to the women participating in our study, 19,706 of the 24,468 home births recorded in 2005 in the United States were to white women.4 The study is also limited to a self-selected convenience sample of women who came forward to discuss their home birth decision. These women may have been passionately biased about their choice. The original data included a small set of women who chose hospital births, but they were excluded from this secondary analysis. We sought not to compare hospital birth to home birth, but simply to describe why women choose home birth.
These limitations reveal an opportunity for larger studies of a prospective design to explore the reasons why women of diverse backgrounds desire to birth at home.
IMPLICATIONS
The goal of our study was to categorize and describe common themes among the culture of women choosing home birth and to provide an understanding of the depth of reasons included in this very personal decision. We used Leininger’s theory of cultural competence to explain the need for health care professionals to appreciate how the individual woman views her own health status.21 Through appreciation of the insight and personal expressions shared by women, the implications for practice apply to midwives, physicians, obstetric nurses, and perhaps most importantly, to women of childbearing age whose health status is affected by the childbirth process. Midwives and physicians who attend home births can use this information to further support the necessity for continuing the home birth portion of their practice.
There is clear evidence that hospital obstetric units in the United States are not providing evidence-based maternity care, appropriate care for low-risk women, labor support techniques for pain relief, nor support for the natural ability of low-risk women to give birth vaginally without technological interventions.26,27,34 The insight provided by the women in our study, combined with the responses from LTM-II,26 could provide motivation for hospitals to evaluate their current practices and begin to implement protocols that better reflect current evidence-based research and women’s desired preferences.
Our research can provide a framework to assist hospital obstetric nurses and physicians in providing culturally competent care to women who divert from their planned home birth when a transfer to the hospital is necessary. The women in our study were concerned about safety and interventions, not unlike the women of the LTM-II study who planned to deliver in the hospital.26 Unlike the women in LTM-II, who reported that they did not possess the knowledge to make informed birthing decisions concerning risks and benefits of interventions,26 many of the women in our study felt that routine obstetric interventions were not safe and made a careful choice to birth at home.
In summary, our data on ”Why did you choose homebirth?” and the data from LTM-II have shown that women in the United States who have a strong desire for a natural birth without exposure to technological or medical interventions have few alternatives.26 We know that more than 99% of births in the United States occur in a hospital,4 and more than 90% of those women experienced interventions, even though 50% of them believed that the birth process should not be interfered with unless medically necessary.26 Given these inconsistencies, one might be better able to understand why low-risk women who want to labor without interventions choose home birth.
CONCLUSION
The women in our study have provided thoughtful insight into the very personal reasons why they planned to deliver their children at home. Their survey responses illustrate that they do care about safety, that they desire a natural birth experience without medical interventions, and that they wish to feel that they are in control of their birth. Women in our study trusted the inherent abilities of their bodies to give birth without interference, in the environment of their own conception. According to our respondents, there is no place like home for a safe, comfortable, peaceful, relaxing birth.
Table 1. Characteristics of Eligible Respondents Planning a Home Birth (N = 160)
Characteristics n (%)a
Education
High school degree 10 (6.3)
Some college 33 (20.6)
2-year degree, certificate, or technical school degree 7 (4.4)
Bachelor’s degree 63 (39.3)
Graduate or doctorate degree 37 (23.1)
Not specified 10 (6.3)
Ethnicity
Asian 2 (1.3)
Hispanic 9 (5.6)
White 139 (86.9)
Not specified 10 (6.2)
Occupation
Homemaker 53 (33.1)
Professional 51 (31.9)
Service 21 (13.1)
Management, business, and financial operations 11 (6.9)
Sales and office 4 (2.5)
Unemployed 2 (1.3)
Other 18 (11.2)
Marital status
Married 146 (91.2)
Partnered 4 (2.5)
Single 4 (2.5)
Divorced/separated 4 (2.5)
Not specified 2 (1.3)
Age, y (Mean, SD) 35 (8)
Age, y (Range) 20-65
a
Given as n (%) unless otherwise noted.
Table 2. Descriptive Coding Criteria for 26 Themes that Emerged from the Analysis of the Question, ”Why Did You Choose Home Birth?”
Theme Description
Safety, better outcomes ~Respondents stated their belief that home birth is safer than hospital birth, or has better health outcomes.
Intervention-free ~Respondents stated a desire to avoid medical interventions, routine procedures, and interferences that were common in hospitals.
Negative previous hospital experience ~Respondents described negative previous hospital experiences either during their own hospitalization for a birth or an illness, or when they witnessed the negative experience of someone else in a hospital.
Control~ Respondents stated a desire for autonomy or control over childbirth decisions and choices, or desired avoidance of restrictions and rules.
Comfortable environment~ Respondents stated a desire to give birth in a comfortable, familiar, peaceful, relaxing, calm, or loving environment.
Do not like hospitals, doctors ~Respondents stated a dislike or distrust of doctors, hospitals, or the concept of managed birth.
Privacy ~Respondents stated a desire for privacy, to be left alone, to be in an uninhibited place, to avoid strangers, or to avoid staff interruptions.
Trust in birth~ Respondents stated a belief in the natural process of childbearing, that labor will progress better at home, or a belief that at home, birth is treated like a normal event, not an illness.
Better for baby ~Respondents stated a desire to do what is best for baby: no separation from mother, no medical interventions, better breastfeeding initiation, or quiet home environment.
Preferred caregiver~ Respondents stated that they had a specific caregiver that they trusted and therefore preferred, or they stated a preference for home birth caregivers or midwives.
Options ~Respondents stated a desire for specific options including delayed cord cutting, water birth, freedom to move around and choose positions, or freedom to eat and drink during labor.
Drug-free~ Respondents stated a desire for a drug-free birth.
Family involvement ~Respondents stated a desire for family participation in the birth and bonding between the various family members.
Natural~ Respondents stated a desire for a natural experience: not necessarily drug-free per se, but an overall natural quality to the birth.
Psychological benefits ~Respondents discussed psychological issues, spirituality, or feelings such as empowerment, joy, or satisfaction.
Peaceful experience Respondents stated a desire for a birth experience that was calm, low stress, gentle, peaceful, positive, etc.
Rights vs. fights ~Responses discussed birthing rights, feminist issues, violence against women, or desires to avoid fighting for their rights or for the birthing experience they desired.
Avoid cesarean ~Respondents stated a desire to avoid a primary or repeat cesarean section.
No car ride ~Respondents stated a desire to avoid a car ride in labor or in recovery.
Time limit Respondents stated a desire to avoid time limits in labor and delivery.
Family history ~Respondents reported a family history of home birth or that home birth was the norm in their community.
Miscellaneous These responses were vague or did not answer the question.
Cost ~Respondents stated that home birth cost less or that they did not have insurance.
Infection ~Respondents stated a desire to avoid hospital-acquired infections.
Fear ~Respondents stated various fears related to hospitals, staff, child abduction, or children switched in the hospital.
History of fast labor~Respondents reported a history of precipitous birth, or increasingly faster labors with each birth.
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