Women’s choice over their birth location is a subject that has come to the fore in the public’s attention. There is a dearth of empirical research, which has addressed women’s experiences of giving birth at home.
Evidence Based Midwifery: March 2012
Ruth McCutcheon1 D Psych, MSc, Dip, MPhil, BA. Dora Brown2 PhD, BSc.
1 Counselling psychologist, South West London and St George’s Mental Health NHS Trust, Springfield University Hospital, London, SW17 7DJ. Email: firstname.lastname@example.org
2 Lecturer, Department of Psychology, Faculty of Arts and Sciences, University of Surrey, Guildford, GU2 7XH. Email: email@example.com
Women’s choice over their birth location is a subject that has come to the fore in the public’s attention. There is a dearth of empirical research, which has addressed women’s experiences of giving birth at home. A grounded theory method (Glaser and Strauss, 1967; Rennie, 1988) was applied to the experiences of nine women who had undergone, or had knowledge of, a home birth. The emergent theory described the overall perspective of the women on adopting a philosophy of control in planning and giving birth at home. This encompassed a dynamic relationship between the perceived three stages of having a home birth: preparing for the challenges, developing resilience strategies and the outcome of the home birth experience.
Key words: Grounded theory, holistic care, home birth, empowerment, qualitative analysis, evidence-based midwifery
Historically a shift from births managed naturally by midwives at home, to hospital, occurred in the late 19th century, as a pathological perception of childbirth was promoted via some anti-home birth, medical publications and obstetric opinion (Oakley, 1984; Savage, 1986). This perspective was challenged by consumer groups in the 1970s, such as the National Childbirth Trust (NCT), who promoted natural births (Oakley, 1984).
A recent positive media contribution on the issue of home birth was Rikki Lake’s (2008) documentary The business of being born. Nonetheless, giving birth at home remains a marginalised choice, available to privileged socio-economic groups (Edwards, 2005). According to data published on the BirthChoiceUK website, there was a decrease in the rate of home births in 2009 (2.57%) in comparison to the 2008 home birth statistic of 2.70% (BirthChoiceUK, 2011). Furthermore, the current picture of the NHS is one of over-stretched and under-funded maternity services where ‘choice’ is limited for women wishing to have a home birth (Dreaper, 2010).
Background literature was obtained using an Athens database search. In summary, this revealed that the detrimental effect of the technocratic model of maternity care has been a subject of continued debate in the literature (Davis-Floyd, 2001; Edwards, 2005; Stockill, 2007). In contrast, a number of researchers have demonstrated the efficacy of a humanistic model of maternity care, which aims to focus on enhancing relationships between medical practitioners and mothers (Kennell et al, 1982; Kleinman, 1988). These studies have demonstrated that having empathic, intensive one-to-one care has shortened and eased labour.
Similarly, a liberal strand of the obstetric literature focused on the beneficial experiences of an active birth (Odent, 1984). Likewise, a number of childbirth theorists have argued for non-intrusive birth conditions to create a climate that enhances a bond between mother and child (Odent, 1984; Kitzinger, 1992; Wagner, 2001). An alternative area of the literature has focused on the biological aspects of bonding at the moment of birth and the effect of natural opiates released in strengthening the mother’s feelings of goodwill; in addition to extended contact with the newborn (Trevathan, 1987; Klaus and Kennell, 1976).
Some research has honed in on the specific qualitative elements of the birth space. In particular, the way in which the birth location affects a woman’s sense of physical and emotional integrity (Ng and Sinclair, 2002; Parratt and Fahy, 2004; Edwards, 2005; Kornelson, 2005; Cheyney, 2008). These studies yield similar themes, namely that a home birth facilitates positive elements of the birth experience, such as retreating from the outside world to focus attention on processes that are occurring within the body, having a choice of people present, a sense of self efficacy and making an informed choice about medical interventions. These studies provide valuable information, but more research is necessary so that a more holistic perspective can be developed. Therefore this study was undertaken to add to the body of knowledge in this area.
A grounded theory (GT) method was used. A distinctive strength of this approach is its capacity to look at social context and the meanings inherent in social relationships. The focus of interest was exploring a group of women who engage in the marginalised practice of home birth and the implications for this in going against cultural norms.
Rennie’s (1994) version of GT was utilised in the research to analyse the data, deriving from the original GT model, which was developed in 1967 by Glaser and Strauss; this brought together three contrasting traditions of ‘positivism, symbolic interactionism and pragmatism’, which held opposing epistemological assumptions (Charmaz, 2006). A detached empirical stance was reflected in Glaser’s proposal to apply a rigorous systematic method, which would allow for ‘reality’ to be discovered (Charmaz, 2006). In contrast, Strauss, who drew on the theoretical tenets of symbolic interactionism and pragmatism, proposed that interaction is dynamic as humans actively engage in processes of creating and altering social meanings via language or exchanging ‘shared’ symbols (Fassinger, 2005).
The criteria for selecting participants was that women had experiences giving birth in a home setting or had knowledge of this topic. Selecting women for this sample was facilitated by the NCT, two independent midwives, and the Women’s Health and Family Service – a voluntary organisation offering support to women from ethnic minority groups. Women were recruited following the theoretical sampling strategy recommended by Charmaz (2006). In keeping with a GT approach, questions of a general exploratory nature were developed (Fassinger, 2005). The interviews were semi-structured and the questions were open-ended. The questions became more focused as the theoretical sampling strategy was followed. After the process of saturation, the researcher began to select new cases to deepen her understanding of the research. This included using a negative case analysis to question her assumptions about the emerging theory. For example, two women who had hospital births offered a different perspective on choosing a birth space.
Interviews were undertaken in the houses of seven participants and the remaining participants chose to be interviewed within their work settings. To ensure confidentiality, a private space was chosen in these instances. Four of the inquiry sessions lasted for one hour, in two cases, the interviews were 50 minutes, and in the remaining cases, the interview duration was one and a half hours. A total of nine women volunteered to participate. Demographics of the nine women can be seen in Table 1 (below).
Nine interviews were audio-taped and analysed. All transcribed data had a numerical line reference for ease of access (Rennie, 1988). Rennie’s (1988) technique of conceptualising categories was applied, where concepts were allocated to categories and there was no limitation to the number of categories. The process described above was aimed at finding commonalities and diversities in meaning within each account and across participants in a process of constant comparison (Rennie, 1988). A theoretical sampling strategy was used where the interviews started with a few participants. The data collected from these participants were then analysed and emergent insights were used to modify the interview schedule with a view to refining hypotheses and proceed with more interviews. The aim was to construct a theory by initially generating descriptive categories that stayed close to the language of the participant, which are later connected by constructed categories demonstrating how they are related. This process of compressing categories yielded key explanatory concepts to answer the research question.
This research gained ethical approval from a university in the UK, appropriate to using a non-NHS sample of participants. A requirement of the committee was that participants would be given a briefing on the procedure of the study and written consent would be obtained. It was made clear that participants could withdraw their consent at any stage. Further, confidentiality was protected and anonymity was aided through the allocation of a transcript number to substitute personal details.
Figure 1 (below) illustrates how the core category of ‘philosophy of control’ acts as the umbrella term for the three main categories. The model presents what is understood as a dynamic relationship between the perceived three stages of having a home birth: preparing for the challenges, developing resilience strategies and the outcome of the home birth experience, described as follows.
The philosophy of control
The core category ‘philosophy of control’ was developed as an overarching term for three main categories, as it describes the overall perspective of the pro-home birth participants on having a sense of control in planning and giving birth at home. The term ‘philosophy of control’ is explained here as the participants’ values and wisdom in relation to having power to direct their own experience of childbirth.Preparing for the challenges of a home birth
The first main category entitled ‘preparing for the challenges of a home birth’ pertains to potential obstacles that the participants encountered in planning a home birth and challenges that ensued.Service delivery unknown
Some of the women in the study found the ‘unknown’ aspect of their NHS maternity care anxiety provoking. This anxiety had different manifestations – for a few participants, part of the issue was that their unique hopes for the birth could be adversely affected by the values of the allocated midwife:“I’d never met this woman... and it could have gone horribly wrong... She might not have been a home birth person, she could have been somebody who thought I... should be in hospital.” Some women felt anxious due to not being guaranteed access to a midwife once in labour. As one participant stated:
“You’d ring up in labour and be told there were no midwives available and so you’d have to come in and that would have been my disaster scenario.”
This property described the negative judgements that women felt they had to contend with in planning a home birth. One participant commented:
“We were scared, you know, because it was the first and some people were trying to tell us, ‘you can’t have your first one at home’... and I obviously was a novice.”
Similarly, another participant identified a cultural narrative that women who have a home birth are unstable for taking perceived risks in giving birth at home:
“Culturally a lot of people think that you’re risking life and limb… and a bit mad, a bit crazy.”
In contrast, a few women identified negative judgements imposed by maternity professionals. One stated: “I just wanted to be at home, but I had a lot of cheek sucking from the midwife.”
Home birth viewed as unsafe
This property captures the ways in which giving birth at home was seen as an unsafe practice by a few of the participants. These women expressed views on this issue partly from their cultural perspective. One participant expressed that isolation and lack of extended family support was a risk factor for women having a home birth in the UK in the aftermath of giving birth:
“If you not got nobody, if you just had a baby... you get up, you dress up, you read this to the children... and sometimes you increase your bleeding.”
However, beyond the cultural management of birth, for one participant, home birth was seen as unsafe because of the unpredictable element of labour, such as complications:
“If I chose home birth, my pregnancy was so, everything was pretty OK… They would probably have allowed me to… and it didn’t turn out to be straightforward.”
Unwanted hospital birth
In contrast to the above, this property captures the pro-home birth participants’ views on having an unwanted hospital birth. An overarching sense of anxiety was described, which seemed to relate to loss of choice in the birth setting. A few women imagined that a hospital setting would impose a restriction on allocated time during labour before applying interventions. As one described:
“I was quite scared of going into hospital because then you get interventions… they’re kind of timing you, that’s the impression I get.”
A further issue for a couple of the participants who had unwanted hospital births was being in an ‘alien environment’, which meant being surrounded by strangers:
“There was always the option that someone could walk into the room by accident or... walk in and want to examine me.”
Medicalisation of birth
This property refers to a collective feeling among some pro-home birth participants that birth has become a medicalised construct. These participants expressed views that women were persuaded to focus on risk and regard hospital as a place of safety. One participant described this as follows:
“Before everyone started having babies in hospital, they were giving birth at home, and because pregnant women want to do right by their baby, people, especially professionals (were) saying ‘you want to be safe and you want to have doctors around you’, I know that I would be swayed by that.”
A few participants discussed the restriction of services faced by women using the NHS, such as the way in which labour wards dehumanised women in the level of care. As one described:
“Worst case scenario, going into hospital and not getting any personal treatment, where they come into the room and they don’t even speak to you, they just speak to your partner, and poke you about and start examining you just makes me feel I don’t know... it’s just very invasive.”
Overall the doubts expressed by some participants at the medicalisation of birth were with the political prioritising of resources over women’s needs and subsequent levels of competency in the care provided by doctors:
“I don’t want people to make decisions like giving me drugs… if you go into hospital, they give you a certain amount of time and I know they get worried because of litigation these days... so they’d much rather whip you in and do a c-section.”
A failed home birth
A further challenge to women planning a home birth is the possibility that there are complications that require an admission to hospital. One participant stated that the effect of being unable to fulfil her hopes of a home birth led to self-critical thinking:
“My ideals of the natural birth… my body didn’t seem capable of doing that.”
In the aftermath of not being able to have a home birth, this participant reflected that the care provided could have been essential in making a recovery:
“I think it all does start with having a positive birth and having the right care… if I’d had... continuous care, that could have helped me... and not made me feel like I was... being silly.”
Developing resilience strategies
The second main category is entitled ‘developing resilience strategies’. For the purpose of clarity, the term ‘resilience’ will refer to the ways in which participants described being able to positively deal with stressful challenges in the context of planning for and giving birth at home.
This property outlines the way in which women that planned home births developed resource strategies regarding the issue of potential risks. A few participants described the importance of having a flexible approach with the acceptance that they might need to access a hospital in the event of needing emergency care:
“I… trusted her (the midwife) to make the right medical decision. So if she’d said to me, ‘S it’s not going as it should be going, we need to go into hospital’, I would have gone to hospital.”
A second strategy to contending with risk was to question the assumption that a medical setting equated with total safety. One participant stated:
“Doctors… they’re just human beings and they can get things wrong and I like to think that I’m well read and well researched… I‘d rather make my own choices that are not their choices.”
In contrast, some women in the sample managed anticipated risks in planning their home birth through considering proximity to the hospital to have swift access to medical resources:
“I only live... ten minutes drive from the hospital so I felt if I had to go in… we’d take the decision early enough to get there.”
Creating a birth space
This property describes the way in which many participants wanted to influence the relationship between the outer space of their environment and their inner psychological space in preparing for a home birth. A number of the women in the sample valued being in their own environment and having access to their personal possessions, synonymous with privacy and personal space. As one participant commented:
“I would hate to be using somebody else’s bathroom... it was just very nice to be in one’s own environment really.”
Another participant related this to the comfort aspect of being in familiar surroundings:
“I hoped to get something therapeutic from having the baby at home, definitely… from being in my own environment, being able to have a bath in my own bath… get into my own bed.”
Acquisition of knowledge
This property refers to ways in which participants acquired knowledge regarding natural childbirth and new beliefs about coping with pain. These women described using approaches such as hypnobirthing and yoga to feel physiologically calm:
“Hypnobirthing, that was really positive, and it also said that there’s an attitude about, of fear… you can actually work with your body and not fight it.”
A further participant described being empowered though new knowledge:
“She (the midwife) was all for home births… I felt really empowered just going to that class... she told us how to breathe, how to get through.”
Further, one participant stressed the importance of understanding the relationship between the environment and its impact on physiology during labour:
“If you don’t get the environment right for birth, you are never able to release the hormones that make labour happen effectively.”
Seeking empathic relationship with the midwife
Most of the women in the sample viewed the collaborative and empathic qualities of the relationship with the midwife as important in feeling resilient. One participant stated:
“She was keen on you know not interfering, she was all the things that home birth is about really… very passionate about her job and really, really cared for the mums.”
Part of a collaborative relationship described by some participants was having a shared vision of the birth. One said:
“I did write a birth plan, but I didn’t need to because it was all in her head… because we discussed it all… She knew exactly where I was coming from.”
The outcome of the home birth experience
The main category – ‘the outcome of the home birth experience’ – describes the participants’ perceived sense of control over their bodies as the culmation of forseeing challenges and building resources in preparing for birth at home. Broadly, there was a sense that the participants who gave birth at home experienced a freedom of expression. Moreover, this sense of control appeared to impact on how they related to others in the birth space, and how they felt about themselves in the aftermath of the experience.
This property describes the way in which many participants valued giving birth at home as they were free to choose how they occupied their physical space. One participant stated:
“I felt in control… you know on the floor being on, over a ball and being over the arm of a chair, and... just listening to my body.”
Most of the pro-home birth women in the sample reported to value being able to take their time and trust their own judgement as to how they wanted to care for their baby:
“Freedom, it’s the freedom of being at home you know, because you can do what you like.”
Turning inwards and coping with pain
This property captures the views of the women who had a home birth on being able to turn inwards to enter an altered conscious state during labour. This seemed to be facilitated by a home setting in a number of ways. Some of the participants stated that turning inward required a process of deep relaxation:
“I was slowly internalising and you do lose your inhibitions.”
One participant described noticing her instincts and feeling a sense of the body’s wisdom of knowing how to give birth:
“I found that amazing really, that I knew when to push because I hadn’t been examined really, so I didn’t know how dilated I was, but I knew that it was the right time to push, and he came out very easily.”
Alternatively, one participant stated that positive thinking as a consequence of feeling in control helped to relax with the pain:
“I think it is, it’s a lot down to positive thinking on how your birth is. I think if you feel out of control, and you feel frightened, then it can only make you have more pain.”
This property captured the relationship between the imagery that women experienced and affect during labour in the birth space. In some instances the imagery was visual and, in others, it was sensory. The important thing to note was that it was strongly bound with emotion and influenced the way in which women felt able to cope with their labour.
In relation to a couple of the home birth experiences, positive images appeared to relate to pleasant affect. One participant described imagery during the transitional part of labour:
“I remember the transitional bit, you know when your contractions stop, it did happen, it really did happen. In my case the birds were singing and the sun was shining in the pool... and it was quiet… and I was like ‘oh this is lovely’.”
Another participant described an image of darkness and pain but this was perceived as manageable because the participant was in a warm place as she retreated into her body:
“I felt in control, dark just, just being with the pain… just listening to my body and letting my body do what was natural to it.”
Connection to the baby
This property outlined how there was a sense for those who had successful home births, of feeling emotional and physical wellbeing, which enabled a strong connection between mother and child. One participant viewed a positive connection as being able to keep prolonged close proximity with her newborns:
“All the way through delivering the placenta and stuff… they were with me the whole time feeding or just nuzzling.”
The confidence brought about by having a satisfying birth in a home setting led some participants to feel that they had positive associations with their babies. Some of the women attributed this partly to having agreeable perceptions of giving birth and feeling energised as a consequence of not having interventions:
“I was just like on... top of the world, which must mean that my frame of mind was such that I was positive towards my son.”
This property pertains to a sense of pride and confidence that the women who had successful home births in the sample felt as a result of giving birth naturally. One participant observed:
“I just wanted to get pregnant and do it again, like the next day. I felt like I’d achieved something.”
On a different note, a few women described a sense of achievement of feeling brave for coping with the pain of childbirth without needing medication. As one participant stated:
“I suppose I feel proud of myself that I’ve managed to give birth to two big babies.”
Another participant described the empowerment that a natural birth instills:
“I think probably a normal physiological birth… actually reconfirms your body’s ability to perform in that area, which I think probably gives you a lot more self confidence.”
Overall, the participants who gave birth at home reported an immense sense of achievement which remained with them after the birth:
“I think it’s something I carry along with me, chuffed to be able to have her at home. It was a case of being able to do everything that I’d planned.”
The emerging theory presents a dynamic relationship between the three stages of undergoing a home birth: preparing for the challenges, developing resilience strategies, and the outcome of the home birth experience. The core category ‘philosophy of control’ underpinned these stages of a home birth in constituting a set of values, which women in the sample developed in the process of feeling able to direct elements of this experience.
An aspect of this theory, which differentiated the home birth experience for this sample of participants from other home birth studies, was the dynamic process of reflecting upon obstacles to having a home birth. This acknowledgement of barriers constituted a catalyst for problem-solving and taking action to make the home birth experience happen; namely, expressing a belief that a natural physiological birth is possible. As such, there was a rejection of the medical model of maternity care that resonates with Cheyney’s (2008) study, which proposed that participants having a home birth created new ‘explanatory models’ as a process of ‘unlearning and relearning’.
The ‘developing resilience factors’ area of the model showed a process of women developing efficacious beliefs about giving birth at home, such as creating a satisfying birth and adopting a flexibility of expectations. In turn, the beliefs appeared to give the women the momentum to influence their behaviours, such as to implement the practical measures to make the home birth experience happen. This chimes with the notion that women who give birth at home acquire power through knowledge and action (Cheyney, 2008). Previous home birth literature has placed much emphasis upon the quality of the home birth experience (Parratt and Fahy, 2004; Kornelsen, 2005). In contrast to these studies, the ‘outcome of the home birth experience’ area of the model described elements of the home birth experience, which occurred as a culmination of women actively creating the conditions (cognitively, physiologically and behaviourally) of the desired home birth space.
As a consequence, all of the participants who achieved a successful home birth expressed a sense of choice and freedom in occupying this uniquely designed birth space. Consistent with existing home birth studies, the issue of choice in relation to the home birth space has been reported to be salient (Parratt and Fahy, 2004; Kornelsen, 2005). This suggests the importance for women of creating a birth space where there is choice over the medical interventions received to enable physical and emotional safety (Parratt and Fahy, 2004).
This study considers the psychological experience of giving birth at home with a view to providing insights to health professionals working with this group of women. The findings of this model suggest that women can adopt a number of resources to maximise their sense of actively creating a birth setting and coping with anxieties.
The findings suggest that women can adopt a number of resources to enhance their sense of actively creating a birth setting and coping with anxieties. Further research is needed to explore the use of imagery in internalising during the birth experience. This could usefully focus upon women who have planned for a home birth and had to deliver in hospital.