Taking the matter into one's own hands - Women's experiences of unassisted homebirths in Sweden.

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.

Transfer to hospital in planned home births: a systematic review.

BACKGROUND: There is concern about the safety of homebirths, especially in women transferred to hospital during or after labour. The scope of transfer in planned home births has not been assessed in a systematic review. This review aimed to describe the proportions and indications for transfer from home to hospital during or after labour in planned home births. METHODS: The databases Pubmed, Embase, Cinahl, Svemed+, and the Cochrane Library were searched using the MeSH term "home childbirth". Inclusion criteria were as follows: the study population was women who chose planned home birth at the onset of labour; the studies were from Western countries; the birth attendant was an authorised midwife or medical doctor; the studies were published in 1985 or later, with data not older than from 1980; and data on transfer from home to hospital were described. Of the 3366 titles identified, 83 full text articles were screened, and 15 met the inclusion criteria. Two of the authors independently extracted the data. Because of the heterogeneity and lack of robustness across the studies, there were considerable risks for bias if performing meta-analyses. A descriptive presentation of the findings was chosen. RESULTS: Fifteen studies were eligible for inclusion, containing data from 215,257 women. The total proportion of transfer from home to hospital varied from 9.9% to 31.9% across the studies. The most common indication for transfer was labour dystocia, occurring in 5.1% to 9.8% of all women planning for home births. Transfer for indication for foetal distress varied from 1.0% to 3.6%, postpartum haemorrhage from 0% to 0.2% and respiratory problems in the infant from 0.3% to 1.4%. The proportion of emergency transfers varied from 0% to 5.4%. CONCLUSION: Future studies should report indications for transfer from home to hospital and provide clear definitions of emergency transfers.

Transfer in planned home births in Sweden--effects on the experience of birth: a nationwide population-based study.

OBJECTIVE: More than 10% of all planned home births in high-income countries are completed in the hospital. The aim of this study was to compare the birth experiences among women who planned to give birth at home and completed the birth at home and women who were transferred to hospital during or immediately after the birth. METHODS: All women in Sweden who had a planned home birth between 1998 and 2005 (n=671) were invited to participate in the study. The women who agreed to participate received one questionnaire for each planned home birth. Mixed methods were used for the analysis. RESULTS: Women who had been transferred during or immediately after the planned home birth had a more negative birth experience in general. In comparison with women who completed the birth at home, the odds ratio for being less satisfied was 13.5, CI 8.1-22.3. Reasons for being dissatisfied related to organizational factors, the way the women were treated or personal ability. CONCLUSION: Being transferred during a planned home birth negatively affects the birth experience. Treatments as well as organizational factors are considered to be obstacles for a positive birth experience when transfer is needed. Established links between the home birth setting and the hospital might enhance the opportunity for a positive birth experience irrespective of where the birth is completed.

Fear causes tears - perineal injuries in home birth settings. A Swedish interview study.

BACKGROUND: Perineal injury is a serious complication of vaginal delivery that has a severe impact on the quality of life of healthy women. The prevalence of perineal injuries among women who give birth in hospital has increased over the last decade, while it is lower among women who give birth at home. The aim of this study was to describe the practice of midwives in home birth settings with the focus on the occurrence of perineal injuries. METHODS: Twenty midwives who had assisted home births for between one and 29 years were interviewed using an interview guide. The midwives also had experience of working in a hospital delivery ward. All the interviews were tape-recorded and transcribed. Content analysis was used. RESULTS: The overall theme was "No rushing and tearing about", describing the midwives' focus on the natural process taking its time. The subcategories 1) preparing for the birth; 2) going along with the physiological process; 3) creating a sense of security; 4) the critical moment and 5) midwifery skills illuminate the management of labor as experienced by the midwives when assisting births at home. CONCLUSIONS: Midwives who assist women who give birth at home take many things into account in order to minimize the risk of complications during birth. Protection of the woman's perineum is an act of awareness that is not limited to the actual moment of the pushing phase but starts earlier, along with the communication between the midwife and the woman.

Perceptions of risk and risk management among 735 women who opted for a home birth.

OBJECTIVE: home birth is not included in the Swedish health-care system and the rate for planned home births is less than one in a thousand. The aim of this study was to describe women's perceptions of risk related to childbirth and the strategies for managing these perceived risks. DESIGN AND SETTING: a nationwide study including all women who had given birth at home in Sweden was conducted between 1 January 1992 and 31 July 2005. PARTICIPANTS: a total of 735 women had given birth to 1038 children. Of the 1038 questionnaires sent to the women, 1025 (99%) were returned. MEASUREMENTS: two open questions regarding risk related to childbirth and two questions answered using a scale were investigated by content analysis. FINDINGS: regarding perceived risks about hospital birth, three categories, all related to loss of autonomy, were identified: (1) being in the hands of strangers; (2) being in the hands of routines and unnecessary interventions; and (3) being in the hands of structural conditions. Perceived risks related to a home birth were associated with a sense of being beyond help: (1) worst-case scenario; and (2) distance to the hospital. The perceived risks were managed by using extrovert activities and introvert behaviour, and by avoiding discussions concerning risks with health-care professionals. CONCLUSION: women who plan for a home birth in Sweden do consider risks related to childbirth but they avoid talking about the risks with health-care professionals. IMPLICATIONS FOR PRACTICE: to understand why women choose to give birth at home, health-care professionals must learn about the perceived beneficial effect of doing so.

Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study.

OBJECTIVE: 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. DESIGN: A population-based study using data from the Swedish Medical Birth Register. SETTING: Sweden 1992-2004. PARTICIPANTS: A total of 897 planned home births were compared with a randomly selected group of 11,341 planned hospital births. MAIN OUTCOME MEASURES: Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared. RESULTS: 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. CONCLUSION: 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.

Transfers in planned home births related to midwife availability and continuity: a nationwide population-based study.

BACKGROUND: Planning a home birth does not necessarily mean that the birth will take place successfully at home. The object of this study was to describe reasons and risk factors for transfer to hospital during or shortly after a planned home birth. METHODS: A nationwide study including all women who had given birth at home in Sweden between January 1, 1992, and July 31, 2005. A total of 735 women had given birth to 1,038 children. One questionnaire for each planned home birth was sent to the women. Of the 1,038 questionnaires, 1,025 were returned. Reasons for transfer and obstetric, socioeconomic, and care-related risk factors for being transferred were measured using logistic regression. RESULTS: Women were transferred in 12.5 percent of the planned home births. Transfers were more common among primiparas compared with multiparas (relative risk [RR] 2.5; 95% CI 1.8-3.5). Failure to progress and unavailability of the chosen midwife at the onset of labor were the reasons for 46 and 14 percent of transfers, respectively. For primiparas, the risk was four times greater if a midwife other than the one who carried out the prenatal checkups assisted at the birth (RR 4.4; 95% CI 2.1-9.5). A pregnancy exceeding 42 weeks increased the risk of transfer for both primiparas (RR 3.0; 95% CI 1.1-9.4) and multiparas (RR 3.4; 95% CI 1.3-9.0). CONCLUSIONS: The most common reasons for transfer to hospital during or shortly after delivery were failure to progress followed by the midwife's unavailability at the onset of labor. Primiparas whose midwife for checkups during pregnancy was different from the one who assisted at the home birth were at increased risk of being transferred.

Characteristics of women giving birth at home in Sweden: a national register study.

OBJECTIVE: The objective of the study was to estimate the proportion of planned home births in Sweden and to identify maternal characteristics of women giving birth at home. STUDY DESIGN: This case-control study included register data of births from 1992 to 2001 in 352 women giving birth at home and 1760 women giving birth in a hospital. RESULTS: Four hundred thirty-nine out-of-hospital births were found during the study period, and the proportion of planned home births was less than 0.5/1000. Women with home birth were more likely to have 4 children or more (odds ratio 3.7 [1.4 to 9.9]), be born in a European country outside Sweden (odds ratio 3.5 [1.8 to 6.8]), have a family income below the median (odds ratio 2.9 [2.0 to 4.1]), not work outside the home (odds ratio 2.4 [1.7 to 3.5]), have a high level of education (odds ratio 2.1 [1.5 to 3.0]), and be older than 35 years (odds ratio 1.7 [1.1 to 2.5]). CONCLUSION: Women with planned home births appear to be a group having a different lifestyle, compared with Swedish women in general.