Home away from home: the alternative birth center

Reducing high maternal mortality rates in western China: a novel approach

Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity.

Reclaiming the Body, Birthing at Home: Knowledge, Power, and Control in Childbirth

In the following essay I draw on existing literature to suggest that homebirth represents the convergence of knowledge, power, and control during pregnancy, labor, and delivery. I pay particular attention to the ways in which working-class women are disadvantaged by the medicalized model of childbirth and are less likely to acquire extensive knowledge about birth, less likely to feel as though they have power over their own birthing experiences, and less likely to exercise control over obstetric interventions and their birth environments. This is a problem that is, on the one hand, caused by a problematic health care system and inadequately staffed public health clinics and, on the other, a model of childbirth that values medicalized birth knowledge over embodied birth knowledge. I argue that all women can and should be made more aware of the various birthing options that are available to them so they can make birthing decisions that are not based solely on fears of obstetric dysfunction. I also encourage birth activists to explore the relationship between social class and birth options so their advocacy efforts can better address women's needs.

Negotiating control and meaning: home birth as a self-constructed choice in Finland

Each society has its own consensual understanding of birth and its determinants: caregivers, location, participants and loci of decision-making, which in the Western world are based on biomedical knowledge. However, two competing cultural models of childbirth, the biomedical/technocratic model and natural/holistic model, mediate women's choices and preferences for the place and caregiver in childbirth. This article explores the way in which these cultural models of birth and the existing practical possibilities for choices shape women's and men's understanding of home birth. Based on interviews with 21 Finnish women and 12 Finnish men, the reasons for and experiences of planning and building toward a home birth are examined through an analysis of birth narratives. The analysis focuses especially on the women's definitions of what is 'natural' and their relationship with health services where biomedical practices and knowledge are the norm. The analysis shows that the notion of 'natural birth' holds various meanings in Finnish women's narratives namely self-determination, control, and trust in one's intuition. I seek to demonstrate that just as the biomedical management of childbirth exhibits distinct cross-cultural variation, so also does resistance to biomedical hegemony, as such resistance is strongly embedded in the local socio-cultural situation.

Midwife or doctor: a study of pregnant women making delivery decisions

Eighty-eight women from diverse educational backgrounds were interviewed as they made several important and related life decisions during their pregnancies. In this article, the focus is on the choice of birth attendant. There were few differences between those women who did and did not consider a midwife. Women who selected a midwife reported feeling more knowledgeable about birth attendants, more in control over the birth attendant decision, more satisfied about their delivery decisions, more in control of and satisfied with pain medication decisions, more autonomous in their pregnancy decision making, and more in agreement with "alternative birth" philosophies. and less in agreement with "conventional birth" philosophies. The participants also reported receiving more approval from spouse/significant other and friends, were more likely to use "gut instinct" and previous experience or habit to make pregnancy decisions, and were more ready to make these decisions than were women who had not selected a midwife as their primary birth attendant.

Choosing a birth attendant: the influence of a woman's childbirth definition

This study examines the impact of a woman's childbirth definition or beliefs on selecting either a Certified Nurse Midwife (CNM) or an obstetrician. The global hypothesis is that women who define birth as "natural" and "normal" are more likely to select a CNM than women who define it as "in need of medical attention." The quantitative and qualitative data were collected over a period of 2 years from 200 pregnant women enrolled in a central New Jersey health maintenance organization (HMO) which had contracted with an independent group of CNMs to provide midwifery care to its clientele. The findings indicate that after controlling for risk-eligibility, women who define childbirth as "risky" and requiring technical medical intervention are more likely to select an obstetrician, while those who define it as "natural" and "normal" are more likely to select a Certified Nurse Midwife. Additionally, a number of social characteristics such as expectation of information, support from the baby's father, and a low desire for control over the birth process are related to selecting a CNM. Anticipated choice, measured at the first prenatal visit, is positively related to eventual choice, indicating that early pregnancy definitions accurately predict service usage. Factors affecting birth attendant selections for first-time mothers were somewhat different than those affecting non-first time mothers. Namely, non-first-time mothers were less influenced by perceived childbirth risks and expectations of information than first-time mothers. The implication of these findings is that by selecting providers who share their varying childbirth beliefs, women evaluate and endorse particular profession's practice style as most appropriate.

Women's satisfaction with birth center care: a randomized, controlled study

This randomized, controlled trial compared women's satisfaction with care at an in-hospital birth center with standard obstetric care in Stockholm. Subjects were 1230 women with an expected date of birth between October 1989 and February 1992, who expressed interest in birth center care, and who were medically low risk. The intervention was the random allocation of maternity care at the birth center or standard obstetric care. Birth center women expressed greater satisfaction with antenatal, intrapartum, and postpartum care, especially psychological aspects of care. Of these women, 63 percent thought that the antenatal care had raised their self-esteem, versus 18 percent of the control group. Eighty-nine percent of the experimental group would prefer birth center care for any future birth, and 46 percent of the control group would prefer standard care. Birth center care successfully meets the needs of women who are interested in natural childbirth and active involvement in their own care, and are concerned about the psychological aspects of birth.

Birth places: a geographical perspective on planned home birth in New Zealand

In New Zealand until the 1920s, most births occurred at home or in small maternity hospitals under the care of a midwife. Births subsequently came under the control of the medical profession and the prevalent medical ideology continues to support hospitalised birth in the interests of safety for mother and child. Despite resistance from the medical profession, recent (1990) legislation has reinstated the autonomy of midwives and this has come at a time when the demand for home births is increasing. This paper locates these changes within the geographical context of home as a primary place within human experience. It is argued that the medical profession has been an agent of an essentially patriarchal society in engendering particular experiences of time and place for women in labour. Narrative data indicate that the choice of home as a birth place is related to three dimensions of experience unavailable in a hospital context: control, continuity and the familiarity of home.

The making of a medical tradition: vaginal birth after cesarean

By 1982, both the National Institutes of Health (NIH) and the American College of Obstetricians and Gynecologists had recommended that hospitals adopt policies favoring vaginal birth after cesarean (VBAC). Yet VBAC has since made only small inroads against repeat cesarean section and is primarily popular among progressive obstetricians and middle-class women wanting to experience natural childbirth and to avoid surgery. This study was undertaken to learn why, in hospitals permitting and ostensibly encouraging VBAC, some obstetrical patients choose 'trial of labor' for vaginal delivery, and others choose elective repeat cesarean section. Interviews with 100 women showed that the choice of a delivery method was largely influenced by the respondents' interactions with physicians, their reconstructions of the meanings of the previous cesarean section, and their personal ideologies about reproduction and motherhood. Ethnic minority women exhibited a greater preference for elective repeat cesarean than did white women. Caution is nevertheless urged in overinterpreting the significance of patient ethnicity for the continued popularity of elective repeat cesarean surgery.