Autonomy in place of birth: a concept analysis

Rethinking the birth plan after the pandemic: A qualitative study of the view of Spanish midwives

Background

The birth plan promotes women's autonomy allowing them to express their care preferences and to participate actively in decision-making. During the Covid-19 pandemic, concerns about infection placed limitations on women's decision-making and infringed upon some of their rights. The role of the birth plan, after the pandemic, needs to be reassessed to protect women's rights and ensure high-quality maternity care.

Research aim

To explore Spanish midwives' perspective on the principle of respect for autonomy and how this is reflected in the birth plan, and to identify aspects that can be improved in the new post-pandemic scenario.

Methods

A descriptive phenomenological study of the experiences of Spanish midwives before, during and after the COVID-19 pandemic that addresses the use of the birth plan and the impact that the pandemic has had on women's rights. Individual online interviews and face-to-face focus groups were used.

Results

Prior to the pandemic, midwives felt that birth plans had problems related to the unrealistic expectations of some women as well as to a lack of awareness of their usefulness. During the pandemic, women mobilized to challenge restrictive regulations, but faced problems with information dissemination and professional coordination, leading to continued infringement of women's rights post-pandemic.

Conclusion

To enhance the effectiveness of the birth plan in supporting women's autonomy, a deliberative approach is needed, along with improvements in midwives' ethical and communication skills. The COVID-19 pandemic has created a new scenario in which the discussion about the possibility of increasing the number of birthing centres or offering home birth care funded by the public system, should be debated.

An online survey of women's views of respectful and disrespectful pregnancy and early labour care in the Czech Republic

OBJECTIVE

To ascertain and explore the views of women and their partners, giving birth in the Czech Republic, of the level of respectful or disrespectful care provided during pregnancy and early labour.

DESIGN

Ethical approval was granted for a descriptive, online anonymous survey of 65 questions, with quantitative and qualitative responses.

SETTING

The Czech Republic.The survey was completed by 8,767 women and 69 partners in 2018.

MEASUREMENTS AND FINDINGS

Descriptive statistics and thematic analysis were used to present results. The majority of women were aged 26-35 years. Most had birthed in one of 93 hospitals, with 1.5% home births. Almost 40% never had an abdominal examination.in pregnancy. Quantitative data analysis revealed that less than half were given information on place of birth, or how to keep labour normal or non-interventionist. Almost 60% did not get information on positions for birth. Most (68%) commenced labour naturally, 25% had labour induced, 40% of them before term, and 7% had an elective caesarean section; 55% stated they had not been given any choice in the decision. Over half of those who had a membrane sweep said permission had not been sought. Half (54%) only had 'checking' visits from the midwife in labour.

KEY CONCLUSIONS

Findings reveal a lack of information-giving, discussion and shared decision-making from healthcare professionals during pregnancy and early labour. Some practices were non-evidenced-based, and interventions were sometimes made without consent.

IMPLICATIONS FOR PRACTICE

The examples of disrespectful care described in this study caused women distress during childbirth, which may result in an increased fear of childbirth or an increase in free-birthing.

Respectful maternity care and women's autonomy in decision making in Iceland: Application of scale instruments in a cross-sectional survey

OBJECTIVE

To explore how maternal factors are associated with women's experiences of respect and autonomy in Icelandic maternity care.

DESIGN

An online survey was developed including two measures assessing the quality of perinatal care: the Mothers on Respect Index and the Mothers' Autonomy in Decision Making Scale. Median and interquartile ranges were calculated for both scales. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals to investigate the relationship between maternal factors and perceived low levels of respectful care and perceived low levels of autonomy in decision making.

PARTICIPANTS AND SETTING

A total of 1,402 women participated. Requirements were: Age ≥ 18 years; antenatal care and childbirth in Iceland 2015-2021; and fluency in Icelandic, English or Polish.

MEASUREMENTS AND FINDINGS

Perceived lower levels of respect were reported by migrant women [aOR 2.16 (1.55-3.00)], women with at least one social complication [aOR 2.52 (1.92-3.31)], primiparous women [aOR 1.72 (1.26-2.36)], women with at least one pregnancy complication [aOR 1.63 (1.22-2.18)] and those who gave birth by caesarean section [aOR 1.75 (1.25-2.45)]. Perceived lower levels of autonomy were reported by migrant women [aOR 1.42 (1.02-1.97)], women who had at least one social complication [aOR 2.12 (1.63-2.74)] and those who gave birth in a hospital setting [aOR 1.62 (1.03-2.55)].

KEY CONCLUSION

The results shed light on inequity in Icelandic maternity care and suggest that data from such surveys can provide valuable information on the changes that must be made in maternity health care services to ensure equity.

IMPLICATIONS FOR PRACTICE

Action must be taken to increase provision of respectful, woman-centred maternity care with an emphasis on informed decision making. Strategies to improve services for groups that have been socially marginalized, such as migrant women and women affected by social determinants of health, should be implemented and monitored.

Conflicting attitudes between clinicians and women regarding maternal requested caesarean section: a qualitative evidence synthesis

BACKGROUND

Caesarean section (CS) can be a life-saving operation but might also negatively affect the health of both the woman and the baby. The aim of this study was to synthesize and contrast women's and clinicians' attitudes toward maternal-requested CS, and their experiences of the decision-making process around CS.

METHODS

The databases of CINAHL, MEDLINE, PsycInfo and Scopus were screened. All qualitative studies that answered the study question and that were assessed to have minor or moderate methodological limitations were included. Synthesised findings were assessed using GRADE-CERQual.

RESULTS

The Qualitative Evidence Synthesis included 14 qualitative studies (published 2000-2022), involving 242 women and 141 clinicians. From the women's perspectives, two themes arose: women regarded CS as the safest mode of birth; and women's rights to receive support and acceptance for a CS request. From the clinicians' perspectives, four themes emerged: clinicians were concerned about health risks associated with CS; demanding experience to consult women with a CS request; conflicting attitudes about women's rights to choose a CS; and the importance of respectful and constructive dialogue about birthing options.

CONCLUSION

Women and clinicians often had different perceptions regarding the right of a woman to choose CS, the risks associated with CS, and the kind of support that should be part of the decision-making process. While women expected to receive acceptance for their CS request, clinicians perceived that their role was to support the woman in the decision-making process through consultation and discussion. While clinicians thought it was important to show respect for a woman's birth preferences, they also felt the need to resist a woman's request for CS and encourage her to give birth vaginally due to the associated increases in health risks.

Women's decision-making autonomy in Dutch maternity care

BACKGROUND

A positive childbirth experience is an important outcome of maternity care. A significant component of a positive birth experience is the ability to exercise autonomy in decision-making. In this study, we explore women's reports of their autonomy during conversations about their care with maternity care practitioners during pregnancy and childbirth.

METHOD

Data were obtained from a cross-sectional survey of women living in The Netherlands that asked about their experiences during pregnancy and childbirth, including their role in conversations concerning decisions about their care.

RESULTS

A total of 3494 women were included in this study. Most women scored high on autonomy in decision-making conversations. During the latter stage of pregnancy (32+ weeks) and in childbirth, women reported significantly lower levels of autonomy in their care conversations with obstetricians as compared with midwives. Linear regression analyses showed that women's perception of personal treatment increased women's reported autonomy in their conversations with both midwives and obstetricians. Almost half (49.1%) of the women who had at least one intervention during birth reported pressure to accept or submit to that intervention. This was indicated by 48.3% of women with induced labor, 47.3% who had an instrumental vaginal birth, 45.2% whose labor was augmented, and 41.9% of women who had a cesarean birth.

CONCLUSIONS

In general, women's sense of autonomy in decision-making conversations during prenatal care and birth is high, but there is room for improvement, and this appeared most notably in conversations with obstetricians. Women's sense of autonomy can be enhanced with personal treatment, including shared decision-making and the avoidance of pressuring women to accept interventions.

A true choice of place of birth? Swiss women's access to birth hospitals and birth centers

While the place of birth plays a crucial role for women's birth experiences, the interest in out-of-hospital births has increased during the Covid-19 pandemic. Related to this, various international policies recommend enabling women to choose where to give birth. We aimed to analyze Swiss women's choice between birth hospitals and birth centers. Employing spatial accessibility analysis, we incorporated four data types: highly disaggregated population data, administrative data, street network data, addresses of birth hospitals and birth centers. 99.8% of Swiss women of childbearing age were included in the analysis (N = 1.896.669). We modelled car travel times from a woman's residence to the nearest birth hospital and birth center. If both birth settings were available within 30 minutes, a woman was considered to have a true choice. Only 58.2% of women had a true choice. This proportion varied considerably across Swiss federal states. The main barrier to a true choice was limited accessibility of birth centers. Median travel time to birth hospitals was 9.8 (M = 12.5), to birth centers 23.9 minutes (M = 28.5). Swiss women are insufficiently empowered to exercise their reproductive autonomy as their choice of place of birth is significantly limited by geographical constraints. It is an ethical and medical imperative to provide women with a true choice. We provide high-resolution insights into the accessibility of birth settings and strong arguments to (re-)examine the need for further birth centers (and birth hospitals) in specific geographical areas. Policy-makers are obligated to improve the accessibility of birth centers to advance women's autonomy and enhance maternal health outcomes after childbirth. The Covid-19 pandemic offers an opportunity to shift policy.

Maternal attitudes towards home birth and their effect on birth outcomes in Iceland: A prospective cohort study

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.

Home birth constructed as a safe choice in Iceland: A content analysis on Icelandic media

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.