Pregnancy and 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;  2) avoidance of unnecessary medical interventions common in hospital births; 3) previous negative hospital experience; 4) more control; and 5) comfortable, familiar environment. Another dominant theme was women’s trust in the birth process. Women equated medical intervention with reduced safety and trusted their bodies’ inherent ability to give birth without interference.


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. As the specialty of medical obstetrics grew, the percentage of hospital-based births increased. In 1940, 40% of births to white women and 73% to nonwhite women in the United States occurred at home. Total hospital births were 56% in 1940.  In 1950, the percentage of hospital births soared to 88%, rising to more than 99% by 1969, where it remains today. 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.  The majority of women who chose home birth in the United States were white and were attended by midwives.

Numerous studies have shown equivalent safety rates when comparing home and hospital births.  A recent integrative review compiled data from 28 studies undertaken between 1969 and 2000.  Fullerton et al. 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. 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. Olsen found that the home birth group had a decreased frequency of induction, augmentation, episiotomy, operative vaginal birth, and cesarean delivery.

 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.  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 non-nurse certified midwives who are more likely to attend home births.  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.   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.  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.  In two of the four studies, women stated that they felt safer at home.  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. 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. 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.’’ 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. 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 who completed an online survey about home birth was selected from 272 respondents who completed an online survey about home birth.

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?’’

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. Descriptions of the 26 common themes and the coding rationale and the frequency distribution of coded themes are found in Tables 1 and 2 in the study. 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 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.  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, and four of the professionals were health care practitioners.

Other occupations represented in this theme were homemakers, service, management, students, and sales. Most of the women had attended college, and many had completed a bachelor’s degree or higher.

Intervention-Free

The other most frequently identified theme involved the use of labor and delivery interventions. Twenty-four percent  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, it proceeds best when un-interfered with.’’

Twenty-four percent 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* 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 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 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 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 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.’’

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%). Nearly one-third of hospital births in 2005 were cesarean deliveries. 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.’’

Routine labor interventions experienced by women delivering in hospitals are not evidence-based and do not reflect best practice. 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.

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. 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.


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. 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. The insight provided by the women in our study, combined with the responses from LTM-II, 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. 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, 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. We know that more than 99% of births in the United States occur in a hospital, 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. Given these inconsistencies, one might be better able to understand why low-risk women who want to labor without interventions choose home birth.

Graph: Number of responses from each of the 26 themes that emerged from analysis of the question,
"Why did you 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.

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 'Behold, I will bring them from the north country, And gather them from the ends of the earth,
 Among  them the blind and the lame, The woman with child and The one who labors with child,  together,
 A great throng shall return there...And My people shall be satisfied with My goodness, says the LORD.'
 Jeremiah 31:8, 14~~~
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March 2009