Motivations and influences acting on women choosing a homebirth: Seeking a ‘cwtch’ birth setting

External influences

A great deal of health policy and professional discourse regarding homebirth reflects dominant ideas about childbirth being a risky event in a woman's life, which should be managed to mitigate potential harm. Coxon et al (2014) narrate that concepts of safety, risk, blame and responsibility constrain women's choices in maternity care. Burns (2015) argues that the home is often regarded as a place of risk, in contrast to the hospital, which is seen as a place of safety. Popular media compound this perspective with often dramatic portrayals of childbirth—which, in the absence of counterbalancing information, can affect how women engage with childbirth (Luce et al, 2016). Challenging this assumption is a formidable task for advocates of natural birth.

Ideas about risk are not neutral and how the language of risk is used and defined can shape decision-making (Scamell and Alaszewski, 2012). For example, couching debate about homebirth using the language of clinical risk alone fails to capture the many different aspects of safety, including the psychological, emotional and spiritual support that women consider when making choices regarding place of birth. Media attention sometimes castigates homebirth as a mere fashionable lifestyle choice on the part of some women (Lewis, 2015). This situation might explain the incredulity, censure and hostility some women face when choosing homebirth (Brailey et al, 2015; OBoyle, 2016), particularly when they are considered ‘high risk’ (Keedle et al, 2015; Lee et al, 2016).

In the UK, maternity policies extoll the need to ensure women have access to all types of birth setting (Scottish Government, 2011; Welsh Assembly Government, 2011; National Institute for Health and Care Excellence (NICE), 2016). Given the persistent variation in homebirth rates between different local authorities, from 0.5% to 14.2% (Nove et al, 2008; ONS, 2015), it is questionable whether this setting is being truly offered as a choice. Understanding why this is the case is complex as it is open to many differing explanations. Issues are numerous and include: the prioritisation of maternity services within the wider health economy, professional attitudes about birth and midwives' confidence in supporting homebirth. The Birthplace in England Research Collaborative Group continues to explore the effects of place of birth on pregnancy outcomes. Its initial reporting provided new evidence about the clinical safety of homebirth that, at the time, led to revisions in national policy (Brocklehurst et al, 2011). In contrast to previous statements, NICE (2016) advocates that women deemed ‘low risk’ should be routinely offered the full range of birth settings, including their home. The everyday realities of delivering this intention, however, are challenging.

McCourt et al (2011) highlighted that women's choices were affected by the availability of different birth settings in their locality and their own awareness about what choices were realistically available for them. Foremost in some women's considerations, if they opted for home birth, were the possibility of intrapartum transfer and concerns about delays in receiving help, rather than any eval uation of the likelihood of such an event (McCourt et al, 2011). Blix et al's (2014) review of 15 studies (n = 215 257 women) revealed emergency transfer rates to hospital from home of between 0.0% and 5.4% for planned home births. The reservations expressed by these women des pite the actuality of low rates of emergency transfer seemingly reveal the extent to which the ideology of birth as unpredictable and risky has been absorbed into everyday use.

Evidence surrounding the clinical safety of homebirth is varied. This might be because investigating the relationship between risk and outcome around homebirth is methodo logically complex. Consequently, results are often highly contextual and difficult to generalise (Zielinski et al, 2015). A further complication is that women who choose homebirth are demographically different from other mothers (Nove et al, 2008; ONS, 2015). One influential analysis suggested an increased risk of neonatal death following homebirth (Wax et al, 2010); its publication led to intense media coverage about the demerits of ‘risky’ homebirth. However, this study has been criticised as methodologically flawed and inaccurate in its conclusions (Zielinski et al, 2015). Cochrane reviews (Olsen and Clausen, 2012) and more recent research of nearly half a million planned homebirths (n = 466 112) in Holland (de Jonge et al, 2015) conclude that when planned homebirth is integrated into maternity services there is no increase in adverse perinatal outcome. For most low-risk women, with certain caveats, UK data support this conclusion (Brocklehurst et al, 2011).

In addition to positive evidence about maternal and infant outcomes, planned homebirth has numerous benefits for women, such as an increased likelihood of having a normal birth, less medical intervention, fewer complications (e.g. postpartum haemorrhage) and enhanced satisfaction with the birth experience (Nove et al, 2012; Zielinski et al, 2015). In their study of 28 125 mother–infant pairs in the UK and Ireland, Quigley et al (2016) found that homebirth was associated with greater breastfeeding uptake and exclusive breastfeeding up to 6 months after birth; the authors caution that this association is unlikely to be causal and further research is required. Despite this, the home vs hospital debate has a long and, at times, contentious history (Burns, 2015). The BJOG debate, ‘Home birth is unsafe’ (Cheyney et al, 2015; Grünebaum et al, 2015; Cohain, 2016; Grünebaum et al, 2016) illustrates the polemic and rancorous nature of this debate.

Opinions about homebirth can be a source of profes sional tension. Internationally, attitudes towards homebirth vary considerably (Roome et al, 2016), and in the UK opinions are mixed. This could be important as practitioners' views and attitudes might either positively or negatively affect the support women receive when making decisions about birth. McNutt et al (2014) surveyed opinions among health professionals in the east of England using a postal questionnaire. Midwives were generally more positively disposed and enthusiastic about homebirth than obstetricians and GPs, who were more antagonistic to homebirth and were opposed to government plans to increase the availability of this option.

Interpersonal influences

Midwifery is a relational service; midwives have a professional responsibility to provide information and support and articulate ways in which women can meet their desires around birth (International Confederation of Midwives, 2011). For women to make an informed choice regarding place of birth, midwives must provide accurate information regarding the choices available. Information provision about homebirth should move beyond just exposing the ‘facts’ and allowing women to decide for themselves; there should be consideration of what sort of information women need, what it says and how they understand it. Working within organisational constraints has the potential to make meeting this duty of care difficult (Hunter and Warren, 2014). Scamell and Alaszewski (2012) expressed concern that midwives in hospital settings can adopt a pathologising process to their work, which only determines normality in hindsight. If this is the case, then this could narrow the window of normality and advance a precautionary and interventionistic stance into practice, leading to fewer women meeting ‘low risk’ criteria.

Thomson and Downe (2010) highlight that in order to achieve a positive birth experience, it is crucial that there is an emotional connection between the woman and the midwife. In a model of continuity of care this connection is based on trust, mutuality and respect (Catling-Paull et al, 2011). Empowering women to give birth at home requires considerable interpersonal, cognitive and professional ability, as well as confidence, on the part of midwives. However, Bedwell et al (2015) suggest that midwives' confidence to provide intrapartum care is fragile and easily lost. Workplace culture, professional conflict and identity, censorious colleagues and notions of perceived autonomy can all affect midwives' abilities to support women (Bedwell et al, 2015).

Partners' and other social contacts' influences in pregnancy are pervasive and can have an impact on women's decisions about place of birth (Bedwell et al, 2011; Hildingsson et al, 2014; Martínez-Mollá et al, 2015; Lee et al, 2016), although the situation is not entirely unidirectional (Lindgren and Erlandsson, 2011). Most fathers in the UK attend the birth of their baby, but their role is often constrained (Hugill and Harvey, 2012). Some parents see homebirth as providing more opportunities for family members to be involved in childbirth than might otherwise be the case in institutional settings (Sweeney and O'Connell, 2015). In contrast, Hildingsson et al (2014) found that first-time fathers who expressed greater fears around childbirth often expressed a preference for hospital birth, and in some extremes wanted their partner to have a caesarean birth.

Personal motivations

Individual beliefs and values regarding birth and motherhood are often deeply held and manifest through various sociocultural influences (Grigg et al, 2015; Luce et al, 2016). In one study, Regan et al (2013) found that primiparous women with strongly held views about birth were highly selective in the information sources they used. This often involved rejecting information and other women's birth stories that conflicted with their own opinions (Regan et al, 2013). In contrast, Catling-Paull et al (2011) found that multiparous women with experience of normal birth relied less on others' opinions and drew on individual experience when making decisions about birth setting.

Various researchers have reported that women who have had a prior negative hospital birth experience, or anticipate one, often elect for homebirth in their next pregnancy (Thomson and Downe, 2010; Murray-Davis et al, 2012; Regan et al, 2013; Keedle et al, 2015; OBoyle, 2016); this suggests a link between poor experiences and choosing homebirth. It may be that negative institutional birth experience—or anticipation of such—motivates some women and explains why more multiparous than primiparous women choose homebirth. Such a relationship should be interpreted with caution, as few studies have explored women's decisions following positive birth experiences. It is also plausible that individual confidence after previous birth might be a factor.

Every woman's expectations surrounding birth are unique and reflect her own beliefs, personal circumstances and experiences. Hollowell et al (2016) summarised what women desire from their care providers during pregnancy. In essence, women want local care in a ‘homely’ environment that enables them to have a sense of control over decisions. Some women equate realisation of these desires with homebirth. Regardless of the setting, midwifery models that support continuity of carer can help to ensure high-quality maternity care (Grigg et al, 2015; Sandall et al, 2016). Ensuring this for every woman is challenging, and failure to do so contributes to dissatisfaction. A woman's sense of pride and accomplishment after normal birth can enhance her confidence and self-worth (Catling-Paull et al, 2011; Thomson and Downe, 2010). When women's negotiations about their desired childbirth experience fail, relationships with health professionals can flounder (Feeley and Thomson, 2016). In extreme situations, mainly in resource-rich settings, this can result in a woman rejecting all mater nity service models (including midwifery-led), leading to ‘freebirth’ where the woman gives birth without professional birth attendants (Feeley and Thomson, 2016; OBoyle, 2016).

To date, there is clear evidence which reveals that women's decisions about place of birth are dynamic and highly contextual. These decisions are informed by interplay between interpersonal and external influences and innate beliefs about motherhood and childbirth (Figure 1). Overall, women who choose to have a home-birth seem to have firm ideas about why they want to do this. Many are driven by a desire to have a better birth experience than they have had before, or imagine they will have, in a hospital setting. ‘Better’ is equated with being involved in making decisions, having continuity of carer without unwarranted intervention, and being in an environment that fosters feelings of emotional and physical security.