This paper reports findings from a phenomenological study seeking to understand women’s lived experience of planned home birth.
This paper reports findings from a phenomenological study seeking to understand women’s lived experience of planned home birth.
Midwives magazine: February 2002
The hospitalisation of women in childbirth has become the societal norm in the UK. A major factor influencing the move from home to hospital-based childbirth was the assumption of hospital’s greater safety. This has been consistently defended by the medical profession and various Government bodies over the years. However, this view has been altered with the publication of the Winterton Report (House of Commons Health Committee, 1992), which concluded that the policy of hospitalising childbirth could not be validated on a safety basis alone. The use of data from quantitative studies using mortality and morbidity rates as outcome measures have been used extensively over the last four decades to examine the status quo of birth being hospital-based. Despite constraints and difficulty in drawing firm conclusions from these studies, Buitendijk’s (1993) and Campbell and Macfarlane’s (1994) extensive literature reviews provide collaborative evidence pointing to the conclusion that, for low-risk women, there is no justification for the suggestion that hospital is safer than home for birth.
Review of literature
The literature presents midwives’ attitudes toward home birth as being negative and a number of contributing factors have been identified. These include midwives’ fear of being inadequately prepared for the management of home births, i.e. having insufficient skills and lack of competence due to the small number of women seeking home birth (Davies et al, 1996), fear of home birth because of extensive hospital training (Lawrence-Beech, 1991) and reluctance to return to flexible working hours (Davies et al, 1996).
The growth of the medical model paradigm purports the view that birth is risky and that hospital and technology are necessary for childbirth (Hafner-Eaton and Pearce, 1994). Research by Davis-Floyd in 1994 portrays women who choose home birth as being different from other women. She believes they have a innate sense of their own bodies’ power to accomplish birth without intervention. West (1988) would argue that most modern women and society consider hospital and technology as necessities for a safe birth outcome.
Kleiverda et al (1990) reported women’s perceptions of the advantages and disadvantages of home birth. Women considered birth at home to be natural, taking place in a relaxing atmosphere of privacy, with family involvement and more control for the birthing woman. Disadvantages of hospital birth included a lack of privacy, reduced involvement of their partner, inappropriate use of birth technology, fear of hospital and restrictions on personal freedom. McDonald in 1994 summed up women’s motives for seeking home birth as ‘practical, philosophical and political’. The concept of control has also been identified as a major factor in home birth by Wesson (1995) and Davies et al (1996).
The literature did not reveal any data on women’s lived experience of planned home birth and therefore this study was designed to let women tell their birth stories.
Research design and methods
This study focused on women’s experience and to do this a phenomenological approach was selected to reveal the ‘essence’ of their home birth experience. The purpose of phenomenological research is to provide rich, insightful reflections with which the reader may identify (Morse and Field, 1996).
A purposeful sample of nine women consented to participate. Contact was established through Trust and verbal consent to interview them was obtained over the telephone. Ethical approval was obtained from the local Ethics Committee.
Sorrell and Redmond (1995) identify that the purpose of phenomenological interviewing is to understand shared meanings by drawing from the respondent a vivid picture of the lived experience, complete with the richness of detail and context that shape the experience. Each interview commenced by asking women to tell the researcher about their birth experience. The interviews were in-depth, unstructured and face-to-face, and took place in the woman’s own home. Each interview was audiotaped with consent. Data saturation was achieved when the narratives began to be repetitious and there was no new information emerging.
Each of the interviews was transcribed verbatim. The procedure of bracketing was used when listening to recordings of the interviews and in reading the nine transcripts. Data analysis was carried out in keeping with Giorgi’s (1985) method.
Oiler (1982) recognises that bracketing is the strategy used to control bias in many phenomenological studies. However, the use of bracketing has been greatly debated. Munhall (1994: 62) stated: ‘… the aim of bracketing is to set aside our own beliefs for a period of time so that we can “hear” and “see”, as undisturbed as is possible by our own knowing. This unknowing allows for openness and also allows us to converse with participants without attempting to validate our own presuppositions and beliefs.’ Giorgi (1988) purported that, because of bracketing, the meanings intuited by the researchertranscend his/her consciousness and it is therefore not essential to check to see if the same meanings arise in another’s consciousness. He argues this is the reason that consensual judges are not needed. Instead, every reader becomes a critical evaluator of the investigator’s essential intuition. For Giorgi too, using the participant as evaluator overlooks the fact that participants describe experiences from an everyday perspective and that the phenomenologist seeks the meaning of everyday experience. Giorgi (1988) concluded that validity, in a phenomenological sense, has been achieved if the essential description of a phenomenon truly captures the ‘intuited essence’.
Findings: The logical and intrinsic nature of the decision to climb
Participants described many factors influencing their decision to labour at home. They had thought through their decision-making process carefully. One woman justified her decision as follows: ‘We decided that home is safer, causes less fear for me also, it’s better for breastfeeding, it’s where babies belong, it’s a whole experience, it’s a family event, and interference from doctors, really, it's wrong.’
Women often had a poor perception of hospital birth that had influenced their decision-making: ‘It was a completely different experience from the hospital birth with my first, you know ... I felt like a queen ... I never felt that with my first in hospital.’
Women perceived home to be natural and giving birth to be natural: ‘Having children is one of the most natural things in the world ... it’s the most natural thing having them at home.’
Inner forces also drove these women toward home birth, giving an intrinsic desire of having to undertake the event: ‘I was so adamant, even before we got pregnant ... that I really wanted to do this, it was very important to me.’
Telling others of the decision
Disapproval from professionals was expected by many of the women, yet midwives were often described as being ‘mostly encouraging’, with occasional reference to midwives’ disapproval. Women preferred to cooperate with professionals as much as possible, rather than resorting to confrontation and ‘rights’ language: ‘I was very much, in my inner mind … I’m having this baby at home, come what may.’
The choice of birthplace was ultimately the woman’s own, yet participants discussed embarking on the climb with their partners: ‘Well, my husband took a bit of coaxing with the first home birth. I think he was frightened, you know, of anything happening. For me it was different, it’s my body you know ... I eventually convinced him.’ Women also described supporting their partners in coming to terms with the decision and in living through the experience. Descriptions suggested that family members and friends were generally supportive of the woman’s choice. However, negative reactions were reported and most of these focused on perceived safety.
Women coped with these negative attitudes assisted by their knowledge of the literature on home birth and felt that they somehow ‘knew better’: ‘If the conversation came up and people asked where I was having the baby, I’d say, actually I was having the baby at home ... With my second, I never said anything, because I was so sick of people saying these stupid things to me. I mean you don’t sort of go up to people and say God, you must be stupid having it in the hospital, you know. It’s a very personal thing and it’s very insulting ... They say God, you must be mad, or either mad or very brave. People don’t actually believe you when you say that the statistics show that it’s actually safer, they can’t conceive of how it possibly could be.’
A positive perspective on the outcome from the climb
Descriptions revealed a self-determination element among participants when they relived their experience: ‘I thought, right, I’m sticking to my guns here, I’m doing this, I’m not going to be intimidated out of it.’ ‘I felt so confident, the whole way through, I just felt so strongly ... that it was going to be a good labour, I could do this, my body could do this.’
These women felt they were doing something that was perfectly safe. ‘Back up’ services and the possibility of transfer had been considered by all of them. However, they perceived the chances of complications as being very low: "I always thought if anything did go wrong, then the midwife would be with me. I trusted her to know and I wouldn’t have argued about going to hospital. I also felt that, in myself, I would have known.’
From the participants’ perspective, they were the people who fully considered and accepted liability for the outcome of their decision to have a home birth. One said: ‘I think if anything had went wrong, if anything did happen, I would have been the one to be blamed … my fault ...’
The ascent itself: requirements for the actual climb
One of the primary requirements of women ‘climbing the mountain’ was the need to be in control of self and circumstances: ‘I was always asked, you are on your own home ground, the midwife is the guest in your home and it’s a different balance I suppose in power ...’ ‘It was a case of, it’s my house, my body, I’ll do what is right at the time ...’
A sense of control was also linked to being in one’s own familiar environment: ‘You don’t feel as relaxed and comfortable anywhere as you do in your own home.’
A supportive partner was also important. Several women described how partners shared the home labour experience in practical and supportive ways. Women also indicated a need to feel support from health professionals during their experience: ‘The midwifery staff were supportive once they had thoroughly grilled me about why I was doing this and that I knew what I was taking on.’
For others, support was given unconditionally and a relationship of friendship and trust developed: ‘What I liked about having her at home was the midwives, we all knew the midwives, because they kept coming out and we got to know them.’
It was clear from the accounts the difference a supportive, understanding midwife could make during the difficult ‘climb’ through the home birth experience. Descriptions implied that birth experiences were affected positively or negatively by the presence of particular midwives: ‘I thought, please, please God, make her be on duty the day I give birth ... The midwife just filled me full of confidence about home birth, she was so good ... It all worked out very well and a lot of it had to do with that one particular midwife. There was another one ... she was very off-putting too and she came out a few times ... she just made comments that I felt was implying that I was, like, courting danger ...’
Approaching the summit
Women went about their usual routine when labour was beginning. They contacted the midwife and noted the time of their contractions. Women provided details about mobility during labour, as well as their birth positions during labour. These descriptions provided strong memories of midwives’ influence in the birthing process: ‘No matter what I said, this one midwife said Noproblem … do you want to stand up? However, another midwife wanted me to lie on my back to be examined and I wouldn’t do this ...’
Some women highlighted individual difficult aspects of their labour experiences (the final part of the climb). These impinged upon their own particular labour experience and subsequent births: ‘The backache was in between contractions, when the contractions ended, the backache started and it was nearly worse than the contractions.’ ‘With each subsequent birth, it’s a different part of the birth that sticks in your mind that you not dread, but you know, have to work through again.’
One mother of six said: ‘I think I went in for home birth also because I thought, it would be more pain-free and nice. The first birth taught me that’s not necessarily so.’
The wish to avoid or keep pharmaceutical analgesia to a minimum was an important aspect of the experience. Women believed in their bodies’ and minds’ ability to manage their pain: ‘In labour too, I think the adrenaline thing gets you through far more efficiently than any interventions, or drugs, or I was asked if I wanted a TENS machine and the thought of these things strapped to me, I said no, you just trust yourself.’
Some of the women recalled their previous experience of taking analgesia. For example: "The pethidine just made me vomit and really scared me [with first birth in hospital].
It made me so drowsy, but I don’t think it helped the pain ... whereas with the two at home, I never had anything ... I don’t think it’s explained very well, what the pain is for, people just get frightened of the pain, if they could see it as something useful and there’s going to be an end product, and the pain is there so as you can help them out, it’s not frightening at all.’
It was frequently stressed that home was ‘easier’ in terms of pain than hospital by eight women who reflected on a previous hospital experience.
Reaching the peak
Women described their birthing positions vividly and they indicated a need to be in control of the event. One woman described her immediate feelings after her five home births: ‘Of the births, no two were anyway the same ... It was great, I remember seeing the baby when she was born ... and thinking Oh, she’s so beautiful [first home birth] ... The feeling when he was born was just sheer relief (laughs) [second home birth] ... then when it came to the next baby, that’s when I had “the” home birth experience that people talked about (laughs), it was very different ... it was a gorgeous … birth, I thoroughly enjoyed it [third home birth] ... Anyway, the birth wasn’t a picnic again [fourth home birth] ... The last one was very messy [fifth home birth].’
Descriptions of general emotions experienced immediately after the birth provided images of great joy: ‘Everybody was absorbing this fantastic atmosphere that there was around.’
Celebrations at the End of the Climb
All the women emphasised their excitement (both verbally and non-verbally) at their other children coming in soon after the birth to see the new baby. Important aspects of the experience from women’s perspectives were that mummy would not have to leave for hospital and the children’s lives would continue largely unaffected, together with the benefits of a gentle introduction to the new family member: ‘I think once you have other children it just seems normal to them, it isn’t a big wrench and you know, the baby’s there.’
Close family and friends were involved soon after the birth, which then became a social event rapidly focusing around the woman’s home: ‘As soon as I had the baby, I’d had my bath and everything and my mum and everybody arrived ... we were all in the garden with the baby.’
The excitement and the wish to tell others of the baby’s arrival was a vivid memory and women described their happiness at receiving visitors from the family circle. This was considered to be a very important feature of their post birth experience.
Triumph over the mountain
After the climb, there was a feeling that this had been a unique conquest and descriptions revealed a sense of amazement at the speedy removal of any traces of the birthing process or the actual birth. The return to normality was sudden: ‘Everything was gone, you know, like 20 minutes and they had the whole place back to normal, it was just amazing ... we were having cup of tea with this beautiful baby.’
Even though the descent had been made and a sense of normality was externally returning, internally this also seemed to emphasise the uniqueness of the experience for the women. One woman stated: ‘By three o’clock [am], everybody had left, except for just ourselves, the four of us, the whole family, we were just tucked up across my bed and I think in some ways, that was the moment that felt that this is absolutely right, there’s nothing more right in the world, it was just all … so peaceful, so … why would you do anything differently kind of feeling to it.’
This sense of restoration to normality and the family being left alone after the event was synonymous with the ‘grande finale’ of the ‘mountain climb’. After this perceived unique and ‘normal’ event, women wanted to return to routine quickly: ‘After that [day two], you slip back into your own routine, getting back into domestic routine is much easier.’
All of the women felt empowered by their experience and they would repeat it again despite the hardship of the climb: ‘When I’d had one at home, there was no going back.’
Women also wished to tell others about home birth: ‘I would be saying to people: would you not fancy a home birth? (laughs) But I would never really push it … you have to really want it.’ Women’s birth memories were overwhelmingly positive: ‘a wonderful experience’, ‘really lovely’, and ‘brilliant’.
The findings from this study suggest the decision to birth at home was the result of thorough reasoning, acceptance of responsibility for the decision and an ability to withstand various social forces.
Schneider (1986) also identified that women do not take the decision to have a home birth lightly and accept responsibility for its outcome. Davis-Floyd’s (1994) study also demonstrates that women who choose home birth make a conscious effort to oppose the social forces that propel them into hospital. For the women in this study, the choice to birth at home was not an easy one. It requires remarkable ‘strength’, ‘self-determination’ and a ‘non-conformist perspective’ to withstand the various opposing forces identified.
Women in the study believed birth to be a ‘normal physiological event’ and they expected a safe outcome, accepted responsibility for their choice and trusted in their own body’s ability to complete the climb. They also perceived home to be the ‘natural’ place to labour, a view upheld by Davis-Floyd in 1994.
Being at home gave them more control over events and their environment. For the actual climb, participants needed to feel a sense ofcontrol over events. Green et al’s (1990) and Simkin’s (1991;1992) studies have also found a correlation between feeling in control and positive psychological outcomes. However, Green et al (1990) caution that an inherent danger in a woman’s desire to be in control over events during childbirth is that it may lead to conflict with midwives and doctors, who also want to be in control. For example, some midwives tried to exert subtle control over these women, such as influencing positions used in labour or by requiring justification from women regarding their birth place decision.
If a woman perceived the midwife attending as supportive of her choice and wishes, it could make a positive contribution to the woman’s lived experience. In contrast, a midwife considered by the women to be unsupportive may have resulted in a negative effect on the experience. Floyd’s (1995) study demonstrated that some community midwives wish to retain control over the home birth situation and it has been suggested by Green et al (1990) that midwives may feel threatened by women’s behaviour in relation to control — which may be interpreted as aggression — and poor interactions may result. Davies et al (1996) also provides corresponding evidence regarding professionals’ ‘opposition’ to women who wish to birth at home. However, further research is required to investigate this issue in depth.
The findings demonstrated that participants had a positive perspective on pain when living the experience of home birth. Waldenstrom (1996) purports that labour pain has a different meaning than pain related to disease — it can be viewed as being part of nature and therefore related to mastery, which women may value as important. Humenick (1981) suggests that a mastery model may be more successful in explaining women’s satisfaction with childbirth than a pain management model, where pain requires relief. Humenick goes on to suggest that long-term benefits to women are greatest when they are able to meet the psychological tasks they set themselves in labour and actively participate to the extent they desire. Hence, ‘mastery’ over labour pain (with minimal or non-use of analgesia) may be linked to participants’ perceptions of pain.
‘Mastery’ may also explain the sense of achievement at the end of their home birth experience. These women had mastered labour pain with minimal analgesia and also mastered the home birth experience itself, so they had met the psychological tasks they initially set themselves and actively participated in all aspects of their birth experiences to the extent they wished. However, it is recognised that the pain experiences of women are individual and extremely complex, warranting further investigation.
The outcome of the birth experience for these women was more than that of a healthy mother and baby. Women achieved something deep and meaningful through the uniqueness of the motherhood experience — and there was a realisation of achievement, triumph and mastery over the difficult mountain climb.
Maslow’s (1987) classic theory regarding personal growth towards self-actualisation may also be linked to these personal aspects of the ‘culmination of the climb’ for participants. Each of the five areas of need set out in Maslow’s pyramid may be suitably linked to living through the experience of planned home birth, where basic physiological, safety and support needs must be met on the lower mountain slopes before the growth needs of esteem and selfactualisation can be reached at the culmination of the climb.
Van Manen (1984) argues that a phenomenological study cannot be concluded or summarised, just as a poem cannot be summarised, the wholeness is the result.
Margaret Ng is a community midwife sister at the Causeway Trust, Northern Ireland
Marlene Sinclair is a Senior Lecturer in Midwifery at The University of Ulster at Jordanstown and Professional Editor of the RCM Midwives Journal
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