Process lessons from evaluating a combined continuity of carer and home birth scheme.

INTRODUCTION: Continuity of midwifery carer improves outcomes, but there is significant variation in how such schemes are implemented and evaluated cross-culturally. The Angus home birth scheme in Scotland incorporates continuity of carer throughout pregnancy, labor, birth, and the postnatal period. METHODS: Manual maternity case note review to evaluate the 80% continuity of carer and 3% planned home birth rate targets. RESULTS: Of 1466 women booking for maternity care, 69 joined the scheme. Forty-four had a planned home birth (3% overall), of whom seven were originally deemed ineligible. Of the 44, eight (18%) also achieved 80% continuity of carer with the primary midwife; by including a home birth team colleague, the continuity rate rose to 73%. Women whose care achieved home birth and continuity targets had lower deprivation scores. Eligibility issues, women's changing circumstances, and data recording lapses were complicating issues. CONCLUSIONS: Targets must be both feasible and meaningful and should be complemented by assessing a broad range of outcomes while viewing the scheme holistically. By expanding eligibility criteria, the home birth rate target was met; including input from a home birth team colleague in the calculation meant the continuity target was nearly met. With dedicated and competent staff, adequate resource and political support, and when considered in the round, the scheme's viability within local services was confirmed. Other generalizable learning points included the need to standardize definitions and data recording methods. Comparability across schemes helps grow the evidence base so that the links between processes and outcomes can be identified.

Cultural Care of Pregnancy and Home Birth: An Application of the Sunrise Model.

BACKGROUND AND PURPOSE: The role of older women close to the pregnant woman may be relevant when conveying information. The use of theories/models can guide the development of nursing practice. PURPOSE: To explore beliefs and practices related to pregnancy and childbirth from the perspective of older women who gave birth at home, applying Leininger's Sunrise Model. METHODS: Qualitative approach, using semi-structured interviews with 24 older women who gave birth at home (rural area, Spain). Manual content analysis of the data was used, and Sunrise Model guided to explore the role of culture and the factors affecting maternity care. RESULTS: Two main categories emerged: beliefs/practices related to physiological aspects (subcategories: minimal intervention, hygiene, pain control, rest, feeding) and to psychosocial aspects (subcategories: spiritual well-being, company). IMPLICATIONS FOR PRACTICE: The experiences of older women who gave birth at home helped us to understand some beliefs that survive in some pregnant women, similar in different cultures, and divided into physiological and psychosocial aspects. Older women have a relevant role as transmitters of information, and can provide some keys to plan health interventions, as companions or counselors. Applying the Sunrise Model, we verified the weight that culture has in maternal health care, and the multiple factors that interfere with the way of caring. The application of models helps us to improve nursing practice: not only should we focus on knowing the physical aspects, but also the social and cultural circumstances surrounding the pregnant woman.

[Home births: A growing phenomenon with potential risks]. / Parto domiciliario: un fenómeno creciente con potenciales riesgos.

Home birth is a controversial issue that raises safety concerns for paediatricians and obstetricians. Hospital birth was the cornerstone to reduce maternal and neonatal mortality. This reduction in mortality has resulted in considering pregnancy and childbirth as a safe procedure, which, together with a greater social awareness of the need for the humanisation of these processes, have led to an increase in the demand for home birth. Studies from countries such as Australia, the Netherlands, and United Kingdom show that home birth can provide advantages to the mother and the newborn. It needs to be provided with sufficient material means, and should be attended by trained and accredited professionals, and needs to be perfectly coordinated with the hospital obstetrics and neonatology units, in order to guarantee its safety. Therefore, in our environment, there are no safety data or sufficient scientific evidence to support home births at present.

Seeing birth in a new light: The transformational effect of exposure to homebirth for hospital-based midwives.

OBJECTIVE: The aim of the study was to explore hospital-based midwives' experiences of providing publicly-funded homebirth services in Australia. DESIGN: A qualitative descriptive study using a constructivist grounded theory methodology was undertaken. SETTING: Five different states or territories of Australia where publicly-funded homebirth services were operating. PARTICIPANTS: Interviews were conducted with 21 midwives and midwifery managers from eight different public hospitals who had recent experience of working in, or with, publicly-funded homebirth models. FINDINGS: Witnessing undisturbed birth in the home setting transformed midwives' attitudes towards birth. Following exposure to homebirth, many midwives felt they were seeing undisturbed birth for the first time. This led them to question their current understanding of physiological birth and develop a new awareness of the powerful influence that the environment has on labouring women. This new understanding resulted in changes to their practice. KEY CONCLUSIONS: For midwives accustomed to working in hospital settings, exposure to homebirth deepened their understanding of physiological birth, resulting in a perspective transformation and subsequent shift in practice. IMPLICATIONS FOR PRACTICE: Exposure to homebirth may motivate midwives to alter their practice in both home and hospital settings in order to shift the power dynamic between women and caregivers and protect women from unnecessary disturbance during labour.

Intrapartum-related perinatal deaths in births planned in midwifery-led settings in Great Britain: findings and recommendations from the ESMiE confidential enquiry.

OBJECTIVE: To review quality of care in births planned in midwifery-led settings, resulting in an intrapartum-related perinatal death. DESIGN: Confidential enquiry. SETTING: England, Scotland and Wales. SAMPLE: Intrapartum stillbirths and intrapartum-related neonatal deaths in births planned in alongside midwifery units, freestanding midwifery units or at home, sampled from national perinatal surveillance data for 2015/16 (alongside midwifery units) and 2013-16 (freestanding midwifery units and home births). METHODS: Multidisciplinary panels reviewed medical notes for each death, assessing and grading quality of care by consensus, with reference to national standards and guidance. Data were analysed using thematic analysis and descriptive statistics. RESULTS: Sixty-four deaths were reviewed, 30 stillbirths and 34 neonatal deaths. At the start of labour care, 23 women were planning birth in an alongside midwifery unit, 26 in a freestanding midwifery unit and 15 at home. In 75% of deaths, improvements in care were identified that may have made a difference to the outcome for the baby. Improvements in care were identified that may have made a difference to the mother's physical and psychological health and wellbeing in 75% of deaths. Issues with care were identified around risk assessment and decisions about planning place of birth, intermittent auscultation, transfer during labour, resuscitation and neonatal transfer, follow up and local review. CONCLUSIONS: These confidential enquiry findings do not address the overall safety of midwifery-led settings for healthy women with straightforward pregnancies, but suggest areas where the safety of care can be improved. Maternity services should review their care with respect to our recommendations. TWEETABLE ABSTRACT: Confidential enquiry of intrapartum-related baby deaths highlights areas where care in midwifery-led settings can be made even safer.

Providing Care for Infants Born at Home.

The American Academy of Pediatrics (AAP) believes that current data show that hospitals and accredited birth centers are the safest settings for birth in the United States. The AAP does not recommend planned home birth, which has been reported to be associated with a twofold to threefold increase in infant mortality in the United States. The AAP recognizes that women may choose to plan a home birth. This statement is intended to help pediatricians provide constructive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize appropriate care for newborn infants born at home that is consistent with care provided for infants born in a medical care facility. Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care consistent with that highlighted in this statement, which is more completely described in other publications from the AAP, including Guidelines for Perinatal Care and the Textbook of Neonatal Resuscitation All health care clinicians and institutions should promote communications and understanding on the basis of professional interaction and mutual respect.

All that I need exists within me: A qualitative study of nulliparous Norwegian women's experiences with planned home birth.

OBJECTIVE: The aim of this study was to gain knowledge regarding how Norwegian nulliparous women experience planned home birth and why they choose this route of giving birth. DESIGN: A qualitative approach was used, and the study data were derived from semi-structured individual interviews, which were analysed through systematic text condensation. PARTICIPANTS: Ten Norwegian women aged nineteen to thirty-nine years were interviewed. They had each gone through with a successful planned home birth of their first child within the last two years. These women all resided in the middle, western and eastern areas of Norway. A certified midwife was present throughout the labour and birth, and no transfer to the hospital was necessary. FINDINGS: The following two main themes were identified: 'inner motivation' and 'giving birth in safe surroundings'. The women in this study had a strong inner faith in the normal physiological processes of labour and birth and had educated and prepared themselves carefully for their planned home birth. To be able to enter one's own inner world was considered crucial for labour, and the trusting relationship they had with their midwife made this possible. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Planned home birth may be experienced as a very positive occurrence for nulliparous women, and the care those women in this study received contained several elements that can help to promote normal labour and birth at a time in which reducing interventions in maternity care is of importance. Their positive birth experiences gave the women confidence both in their transition to motherhood as well as in other aspects of life.

Planned home birth in Slovenia-Are we ready?

Nowadays, women want a more intimate and familiar atmosphere during labour, which results in increased planned home birth rates. Every woman has the autonomy to decide where she will give birth; however, it is important that she is informed of risks and advantages beforehand. Home births can be distinguished between planned and unplanned home births. Planned home births can be conducted by professional birth attendants (licensed midwives) or birth assistants (doulas, etc). The rates of Slovenian women who decided to deliver at home are increasing year by year. Researches on home births still present discordant data about home birth safety. Their findings have shown that the main advantage of home birth is a spontaneous birth without medical interventions, especially in multiparous low-risk women. The main disadvantage, however, is a higher risk for neonatal death, in particular on occurrence of complications requiring a transfer to hospital and surgical intervention. Global guidelines emphasize careful selection of candidates suitable for home birth, well-informed pregnant women, education of birth attendants, and strict formation of transfer indications.

Mothers´ experiences in relation to a new Swedish postnatal home-based model of midwifery care-A cross-sectional study.

BACKGROUND: The goal of postnatal care is to provide the highest possible quality of care and medical safety with the least possible intervention in order to optimize health and wellbeing of the new family. The aim of the study was to describe mothers´ experiences in relation to a new postnatal home-based model of midwifery care. METHODS: The current study uses a cross-sectional mixed method design to assess a new postnatal home-based model of midwifery care in Sweden. Healthy women with an uncomplicated pregnancy and childbirth, and with a healthy baby answered an online questionnaire one week after birth. Data were collected during one year (2017-2018) and analyzed using descriptive and inferential statistics for quantitative data, and manifest content analysis for qualitative data. FINDINGS: In total, 180 mothers with one to six children were included. They were most likely to have been discharged between six and 12 h after childbirth (56%) and 90% reported that the time for their discharge was good. The postnatal check-ups included were telephone contact (100%), home visit(s) (94%) and hospital visit(s) (98%). Most mothers had a positive postnatal care experience from using the new postnatal model of midwifery care (mean VAS 8.74, Std. Deviation 1.438). For 75%, of the participants, home-based postnatal care would be preferred for their next childbirth. CONCLUSION: Home-based postnatal care is well accepted by mothers who were discharged early after childbirth. Mothers with a positive experience of the new postnatal model of midwifery care would prefer home-based postnatal care for their next childbirth. Midwifery care should include home-based postnatal care.

Integrative power in Swiss home-like childbirths: A qualitative multiple case study.

OBJECTIVE: To increase understanding of integrative power in decision-making in home-like childbirth from midwives' and women's perspectives. DESIGN: A qualitative multiple case study. SETTING: Two regions of Switzerland, a French and a German-speaking. PARTICIPANTS: Twenty interviews with midwives and 20 with women and some partners who had experienced complications in home-like births. METHODS: Data were collected from in-depth interviews relevant for casestudy. Four cases during second stage of labour were carefully selected using literal replication logic. Interview transcripts were analysed in developing case descriptions and in interpreting mechanisms related to perception of power in making decision. FINDINGS: The analysis of each case and a cross-case comparison showed that mechanisms for building integrative power, such as creation of relationships, cooperation, loyalty, legitimacy and respect, were highly visible in midwifery decision-making activities. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The study highlighted the visibility of integrative power mechanisms in decision-making in homelike settings. Until now, mechanisms of positive power in midwifery have been poorly described in literature. Integrative power could be a promising strategy to reinforce decision-making strategies. Therefore, clinical and policy measures explicitly addressing the positive aspects of power should be developed and evaluated.

Utilization of institutional delivery and associated factors among mothers in rural community of Pawe Woreda northwest Ethiopia, 2018.

OBJECTIVE: In most of sub-Saharan African countries the significance of delivering in health institution and threats of death is still little known. This study is to assess utilization of institutional delivery and associated factors among mothers who gave birth in the last 12 months prior to the study in rural community of Pawe Woreda, Benishangul-Gumuz, northwest Ethiopia, 2018. A community-based cross-sectional study was conducted on 623 mothers. RESULTS: Overall deliveries 60.5% were assisted at health facilities. Multivariable logistic regression showed that Mothers educational status, Antenatal Care visit during their recent pregnancy, delivery plan of recent pregnancy, maternal knowledge on benefit of institutional, decision power about place of delivery and distance to reach the nearby facility on were significantly associated with utilization of institutional delivery. The utilization of institutional delivery services among rural women in Pawe Woreda had improvements but still low. Intensifying women education, up taking Antenatal Care potential services, address health education for mothers about benefit of institutional birth and counseling danger sign of labor and delivery, involving couples decision power of facility birth and expanding health facilities in the community are recommended interventions.

Challenging the status quo: Women's experiences of opting for a home birth in Andalucia, Spain.

OBJECTIVE: To explore the perceptions, beliefs and attitudes of women who opted for a home birth in Andalusia (Spain). BACKGROUND: Home birth is currently an unusual choice among Spanish women. It is not an option covered by the Spanish National Health Service and women who opt for a home birth have to pay for an independent midwife. DESIGN: A qualitative study with a phenomenological approach was adopted. All participants who took part in this study had chosen to have a home birth and given written consent to take part in the study. METHODS: Data collection was conducted in 2015-16. Face-to-face, semi-structured interviews were undertaken with women who chose a home birth in the last 5 years. FINDINGS: The sample consisted of thirteen women. Seven themes were created through analysis: 1. Getting informed about home birth; 2. Home birth as a choice, despite feeling unsupported; 3. The best way to have a personalized and a physiological birth; 4. Seeking a healing and empowering experience 5. The need for emotional safety, establishing a relationship and trusting the midwife; 6. Preparing for birth and working on fears; 7. Inequality of access (because of financial implications). CONCLUSIONS: Women opted to plan birth at home because they wanted a personalised birth and control over their decision-making in labour, which they felt would not have been afforded to them in hospital settings. Andalusian maternity care leaders should strive to ensure that all pregnant women receive respectful and high-quality personalised care, by appropriately trained staff, both in the hospital and in the community.

Birthplace in Australia: Processes and interactions during the intrapartum transfer of women from planned homebirth to hospital.

OBJECTIVE: the aim of the study was to explore the views and experiences of women, midwives and obstetricians on the intrapartum transfer of women from planned homebirth to hospital in Australia. DESIGN: a Constructivist Grounded Theory approach was taken, to conceptualise the social interactions and processes grounded in the data. SETTING: urban and regional areas in four states of south-eastern Australia. PARTICIPANTS: semi-structured qualitative interviews were conducted with 36 women, midwives and obstetricians who had experienced an intrapartum homebirth transfer within three years prior to the interview. Interviews were audio recorded and transcribed verbatim. FINDINGS: women who were transferred to hospital from a planned homebirth made physical and psychological journeys out of their comfort zone, as they faced the uncertainty of changing expectations for their birth. The trusting relationship between a woman and her homebirth midwife was crucial to women's sense of safety and well-being in hospital. Midwives and obstetricians, when congregating in the hospital birthing rooms of transferred women, also felt out of their comfort zones. This was due to the challenges of converging with others who possessed conflicting paradigms of safety and risk in birth that were at odds with their own, and adapting to different routines, roles and responsibilities. These differences were derived from diverse professional, social and personal influences and often manifested in stereotyping behaviours and 'us and them' dynamics. When midwife-woman partnerships were respected as an inclusive part of women's care, collaboration ensued, conflict was ameliorated, and smooth transfers could be celebrated as successes of the maternity care system. KEY CONCLUSIONS: supporting woman centred care in homebirth transfers means acknowledging the social challenges of collaborating in the unique context of a transferred woman's hospital birthing room. Understanding the power of the midwife-woman partnership, and its value to the health and well-being of each woman and her baby, is key to facilitating a successful transfer. IMPLICATIONS FOR PRACTICE: the midwife-woman partnership played a central role in providing the necessary support and advocacy for women transferred out of their comfort zone. When midwives worked together in an integrated system to provide the necessary care and support for women who were transferred, greater levels of collaboration emerged and women's perceptions of their quality of care was high. In practice, this meant health professionals respecting each other's roles, responsibilities and expertise, and ameliorating 'us and them' dynamics.

A cross-sectional study of traditional practices affecting maternal and newborn health in rural Nigeria.

INTRODUCTION: Certain traditional practices which have negative effects on maternal and child health continue to be practiced in sub-Saharan African countries. A survey was carried out in a rural village in Nigeria to understand the scale and range of these practices. METHODS: This was a cross-sectional study in which trained interviewers administered pre-tested questionnaires on child-bearing women using questionnaires embedded on android devices. RESULTS: The median age of marriage and pregnancy were 15 and 16 years respectively. Home births were high (90.4%) while non-skilled birth attendant was 87.4%. The community had a son preference index ratio of 1:4.1. Up to 81.5% of mothers responded that one form of unhygienic traditional procedure or the other was performed on their children. Time to initiation of breast feeding was in hours in the majority (76.3%) of mothers, with a high rate of use of prelacteal feeds (85.2%). Being an adolescent mother (AOR 0.403, 95%CI 0.203, 0,797) and utilizing a skilled provider at birth (AOR 0.245, 95%CI 0.088, 0.683) were associated with less likelihood of having an unhygienic procedure performed on children. CONCLUSION: The findings of our study suggest that traditional practices which could have negative effects on maternal and child health are still ongoing in the study community. Child protection laws and safeguarding principles could help to reduce these practices and would need to be developed and implemented in these settings where these practices are still prevalent.

Giving birth on our own terms-Women's experience of childbirth at home.

BACKGROUND: home births are quite rare and are not supported as part of mainstream health care services in most European countries. Women who choose home as the place of birth often do so because maternity services in hospitals do not offer the options that they want. The aim of the present study is to describe women's experiences of giving birth at home and to produce a comprehensive structure of meaning regarding giving birth at home. DESIGN: a phenomenological study based on analysis of open-interview transcripts using Colaizzi's approach. PARTICIPANTS: women who gave birth at home FINDINGS: women who have given birth at home experience having control over their own body, the care they are given, and the practical arrangements surrounding the birth. However, they also experience negative attitudes from other people about their decision to give birth at home, and challenges because of worries about how they and their baby will cope. During the birth women feel a sense of connection to their own body, which they trust to tell them what to do. They experience great happiness on successfully giving birth and feel connected to nature and the circle of life. Being able to celebrate with family members and be pampered by them after the birth made the women feel 'like queens'. CONCLUSIONS: women's experience of childbirth at home is one of having control over the birthing process and its environment. The main challenge is exposure to negative attitudes from others, including health care professionals. Overall, the experience was full of happiness and good feelings. We conclude that more attention should be paid to the quality of birth experiences and women's individual needs and wishes within maternity care provision.