Normal birth rates before and after the merging of mixed-risk and low-risk maternity wards in Iceland: A retrospective cohort study on the impact of inter-professional preventative measures.

BACKGROUND: In 2014, the National University Hospital of Iceland (NUHI) merged a mixed-risk birth unit and a midwifery-led low-risk unit into one mixed-risk unit. Interprofessional preventative and mitigating measures were implemented since there was a known threat of cultural contamination between mixed-risk and low-risk birth environments. The aim of the study was to assess whether the NUHI's goal of protecting the rates of birth without intervention had been achieved and to support further development of labor services. METHODS: A retrospective cohort study of all women who had singleton births at NUHI birth units in two 2-year periods, 2012-2013 and 2015-2016. The primary outcome variables, birth without intervention, with or without artificial rupture of membranes (AROM), were adjusted for confounding variables using logistic regression analysis. Secondary outcome variables (individual interventions and maternal and neonatal complications) were analyzed using descriptive statistics, t test, and Chi-square test. RESULTS: The rate of births without interventions, both with and without AROM, increased significantly after the unit merger and accompanying preventative measures. The rates of AROM, oxytocin augmentation, episiotomies, and epidural analgesia decreased significantly. The rate of induction increased significantly. There were no significant differences in maternal or neonatal complication rates. CONCLUSIONS: Interprofessional preventative measures, implemented alongside a mixed-risk and low-risk birth unit merger, can increase rates of births without interventions in a mixed-risk hospital setting. However, it is necessary to maintain awareness of the possible effects of a mixed-risk birth environment on the use of childbirth interventions and examine the long-term effects of preventative measures.

Concerns about transmission, changed services and place of birth in the early COVID-19 pandemic: a national survey among Danish pregnant women. The COVIDPregDK study.

BACKGROUND: The outbreak of the COVID-19 pandemic caused great uncertainty about causes, treatment and mortality of the new virus. Constant updates of recommendations and restrictions from national authorities may have caused great concern for pregnant women. Reports suggested an increased number of pregnant women choosing to give birth at home, some even unassisted ('freebirth') due to concerns of transmission in hospital or reduction in birthplace options. During April and May 2020, we aimed to investigate i) the level of concern about coronavirus transmission in Danish pregnant women, ii) the level of concern related to changes in maternity services due to the pandemic, and iii) implications for choice of place of birth. METHODS: We conducted a nationwide cross-sectional online survey study, inviting all registered pregnant women in Denmark (n = 30,009) in April and May 2020. RESULTS: The response rate was 60% (n = 17,995). Concerns of transmission during pregnancy and birth were considerable; 63% worried about getting severely ill whilst pregnant, and 55% worried that virus would be transmitted to their child. Thirtyeight percent worried about contracting the virus at the hospital. The most predominant concern related to changes in maternity services during the pandemic was restrictions on partners' attendance at birth (81%). Especially nulliparous women were concerned about whether cancelled antenatal classes or fewer physical midwifery consultations would affect their ability to give birth or care for their child postpartum.. The proportion of women who considered a home birth was equivalent to pre-pandemic home birth rates in Denmark (3%). During the temporary discontinue of public home birth services, 18% of this group considered a home birth assisted by a private midwife (n = 125), and 6% considered a home birth with no midwifery assistance at all (n = 41). CONCLUSION: Danish pregnant womens' concerns about virus transmission to the unborn child and worries about contracting the virus during hospital appointments were considerable during the early pandemic. Home birth rates may not be affected by the pandemic, but restrictions in home birth services may impose decisions to freebirth for a small proportion of the population.

Barriers to women's access to alongside midwifery units in England.

BACKGROUND: Alongside midwifery units (AMUs) are managed by midwives and proximate to obstetric units (OUs), offering a home-like birth environment for women with straightforward pregnancies. They support physiological birth, with fast access to medical care if needed. AMUs have good perinatal outcomes and lower rates of interventions than OUs. In England, uptake remains lower than potential use, despite recent changes in policy to support their use. This article reports on experiences of access from a broader study that investigated AMU organisation and care. METHODS: Organisational case studies in four National Health Service (NHS) Trusts in England, selected for variation geographically and in features of their midwifery units. Fieldwork (December 2011 to October 2012) included observations (>100 h); semi-structured interviews with staff, managers and stakeholders (n = 89) and with postnatal women and partners (n = 47), on which this paper reports. Data were analysed thematically using NVivo10 software. RESULTS: Women, partners and families felt welcome and valued in the AMU. They were drawn to the AMUs' environment, philosophy and approach to technology, including pain management. Access for some was hindered by inconsistent information about the existence, environment and safety of AMUs, and barriers to admission in early labour. CONCLUSIONS: Key barriers to AMUs arise through inequitable information and challenges with admission in early labour. Most women still give birth in obstetric units and despite increases in the numbers of women birthing on AMUs since 2010, addressing these barriers will be essential to future scale-up.

Impact of Socio-Economic Factors and Health Information Sources on Place of Birth in Sindh Province, Pakistan: A Secondary Analysis of Cross-Sectional Survey Data.

Medical facility birth with skilled birth attendance is essential to reduce maternal mortality. The purpose of this study was to assess the demographic characteristics, socio-economic factors, and varied health information sources that may influence the uptake of birth services in Pakistan. We used pooled data from Maternal-Child Health Program Indicator Survey 2013 and 2014. Study population was 9719 women. Generalized linear model with log link and a Poisson distribution was used to identify factors associated with place of birth. 3403 (35%) women gave birth at home, and 6316 (65%) women gave birth at a medical facility. After controlling for all covariates, women's age, number of children, education, wealth, and mother and child health information source (doctors and nurses/midwives) were associated with facility births. Women were significantly less likely to give birth at a medical facility if they received maternal-child health information from low-level health workers or relatives/friends. The findings suggest that interventions should target disadvantaged and vulnerable groups of women after considering rural-urban differences. Training non-health professionals may help improve facility birth. Further research is needed to examine the effect of individual information sources on facility birth, both in urban and rural areas in Pakistan.

Improving the quality and content of midwives' discussions with low-risk women about their options for place of birth: Co-production and evaluation of an intervention package.

OBJECTIVE: Women's planned place of birth is gaining increasing importance in the UK, however evidence suggests that there is variation in the content of community midwives' discussions with low risk women about their place of birth options. The objective of this study was to develop an intervention to improve the quality and content of place of birth discussions between midwives and low-risk women and to evaluate this intervention in practice. DESIGN: The study design comprised of three stages: (1) The first stage included focus groups with midwives to explore the barriers to carrying out place of birth discussions with women. (2) In the second stage, COM-B theory provided a structure for co-produced intervention development with midwives and women representatives; priority areas for change were agreed and the components of an intervention package to standardise the quality of these discussions were decided. (3) The third stage of the study adopted a mixed methods approach including questionnaires, focus groups and interviews with midwives to evaluate the implementation of the co-produced package in practice. SETTING: A maternity NHS Trust in the West Midlands, UK. PARTICIPANTS: A total of 38 midwives took part in the first stage of the study. Intervention design (stage 2) included 58 midwives, and the evaluation (stage 3) involved 66 midwives. Four women were involved in the intervention design stage of the study in a Patient and Public Involvement role (not formally consented as participants). FINDINGS: In the first study stage participants agreed that pragmatic, standardised information on the safety, intervention and transfer rates for each birth setting (obstetric unit, midwifery-led unit, home) was required. In the second stage of the study, co-production between researchers, women and midwives resulted in an intervention package designed to support the implementation of these changes and included an update session for midwives, a script, a leaflet, and ongoing support through a named lead midwife and regular team meetings. Evaluation of this package in practice revealed that midwives' knowledge and confidence regarding place of birth substantially improved after the initial update session and was sustained three months post-implementation. Midwives viewed the resources as useful in prompting discussions and aiding communication about place of birth options. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Co-production enabled development of a pragmatic intervention to improve the quality of midwives' place of birth discussions with low-risk women, supported by COM-B theory. These findings highlight the importance of co-production in intervention development and suggest that the place of birth package could be used to improve place of birth discussions to facilitate informed choice at other Trusts across the UK.

Birthplace choices: what are the information needs of women when choosing where to give birth in England? A qualitative study using online and face to face focus groups.

BACKGROUND: Current clinical guidelines and national policy in England support offering 'low risk' women a choice of birth setting. Options include: home, free-standing midwifery unit (FMU), alongside midwifery unit (AMU) or obstetric unit (OU). This study, which is part of a broader project designed to inform policy on 'choice' in relation to childbirth, aimed to provide evidence on UK women's experiences of choice and decision-making in the period since the publication of the Birthplace findings (2011) and new NICE guidelines (2014). This paper reports on findings relating to women's information needs when making decisions about where to give birth. METHODS: A qualitative focus group study including 69 women in the last trimester of pregnancy in England in 2015-16. Seven focus groups were conducted online via a bespoke web portal, and one was face-to-face. To explore different aspects of women's experience, each group included women with specific characteristics or options; planning a home birth, living in areas with lots of choice, living in areas with limited choice, first time mothers, living close to a FMU, living in opt-out AMU areas, living in socioeconomically disadvantaged areas and planning to give birth in an OU. Focus group transcripts were analysed thematically. RESULTS: Women drew on multiple sources when making choices about where to give birth. Sources included; the Internet, friends' recommendations and experiences, antenatal classes and their own personal experiences. Their midwife was not the main source of information. Women wanted the option to discuss and consider their birth preferences throughout their pregnancy, not at a fixed point. CONCLUSIONS: Birthplace choice is informed by many factors. Women may encounter fewer overt obstacles to exercising choice than in the past, but women do not consistently receive information about birthplace options from their midwife at a time and in a manner that they find helpful. Introducing options early in pregnancy, but deferring decision-making about birthplace until a woman has had time to consider and explore options and discuss these with her midwife, might facilitate choice.

Birth place preferences and women's expectations and experiences regarding duration and pain of labor.

INTRODUCTION: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women. METHODS: A prospective cohort study (2007-2011) of 454 women who preferred a home birth (n = 179), a midwife-led hospital birth (n = 133) or an obstetrician-led hospital birth (n = 142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth. RESULTS: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2-0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2-0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1-0.7). Women who preferred a midwife-led birth - either home or hospital - were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9-9.8 resp. 3.4, 95%CI 1.5-7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1-6.0). DISCUSSION: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women's expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.

Understanding the preference for homebirth; an exploration of key barriers to facility delivery in rural Tanzania.

BACKGROUND: There is limited information on the effect of expectant parents' socio-cultural perceptions and practices on the use of skilled birth attendants (SBAs) in rural Tanzania. The purpose of this study was to explore the socio-cultural barriers to health facility birth and SBA among parents choosing home birth in rural Tanzania, specifically in the Rukwa Region. METHODS: This study used a descriptive exploratory methodology. Purposive sampling was used to recruit study participants for both in-depth interviews (IDIs) and focused group discussions (FGDs). Qualitative research methods, including FGDs and IDIs, were utilized in data collection. The respondents were men and women whose youngest child had been born at home within the prior 12 months. A thematic approach was used for data analysis. RESULTS: The main themes that emerged regarding barriers to the use of health facility were 1) limited decision-making by men on place of delivery; 2) low risk perception by men and its interference with health facility birth; 3) men's limited resource mobilization for health facility birth and 4) females' perceptions that pregnancy and childbirth are low-risk events. CONCLUSION: This qualitative study demonstrates that apart from well-documented structural barriers to skilled birth attendance in rural Tanzania, the low risk perception among both men and women plays a substantial role. The low risk perception among both men and women affects the use of SBAs in two ways. First, women become negligent and take risk of delivering at home. Second, male partners do not seriously mobilize resources for health facility childbirth. These findings reinforce the urgent need to implement creative programs to increase genuine male participation in facilitation of health facility childbirth.

Factors related to choice of place of birth in a district in Nepal.

OBJECTIVE: In Nepal, both percentage of women giving birth at health facility and proportion of birth assisted by skilled birth attendant is very low. The purpose of this research was to identify predictors for choice of place of birth: either at home, primary health care facility (including birthing centres) or at tertiary health care facilites (hospitals and clinics). METHODS: A cross-sectional household survey was conducted in seven village development committee of a district lying in plain area of Nepal: Nawalparasi. A structured interview questionnaire was developed and administered face-to-face. Descriptive analysis along with chi-square test and multinomial logistic regression was used to identify the predictors of giving birth at a health care facility. RESULTS: Women were significantly more likely to give birth at health care facilities compared to home if the distance was less than one hour, belonged to advantaged caste, had radio, television and motorbike/scooter, decision maker for place of birth was husband, reported their frequency of antenatal (ANC) visits at 4 or more and belonged to age group 15-19. CONCLUSION: The analysis indicates that husbands of women giving birth influence the choice of place of birth. The findings highlight importance of having four or more ANC visits to the health institutions and that it should be located within one-hour walking distance. Inequity in utilisation of childbirth services at health institutions exists as showed by low utilisation of such services by disadvantaged caste.

A comparison of intrapartum interventions and adverse outcomes by parity in planned freestanding midwifery unit and alongside midwifery unit births: secondary analysis of 'low risk' births in the birthplace in England cohort.

BACKGROUND: For low risk women, there is good evidence that planned birth in a midwifery unit is associated with a reduced risk of maternal interventions compared with planned birth in an obstetric unit. Findings from the Birthplace cohort study have been interpreted by some as suggesting a reduced risk of interventions in planned births in freestanding midwifery units (FMUs) compared with planned births in alongside midwifery units (AMUs). However, possible differences have not been robustly investigated using individual-level Birthplace data. METHODS: This was a secondary analysis of data on 'low risk' women with singleton, term, 'booked' pregnancies collected in the Birthplace national prospective cohort study. We used logistic regression to compare interventions and outcomes by parity in 11,265 planned FMU births and 16,673 planned AMU births, adjusted for potential confounders, using planned AMU birth as the reference group. Outcomes considered included adverse perinatal outcomes (Birthplace primary outcome measure), instrumental delivery, intrapartum caesarean section, 'straightforward vaginal birth', third or fourth degree perineal trauma, blood transfusion and maternal admission for higher-level care. We used a significance level of 1% for all secondary outcomes. RESULTS: There was no significant difference in adverse perinatal outcomes between planned AMU and FMU births. The odds of instrumental delivery were reduced in planned FMU births (nulliparous: aOR 0.63, 99% CI 0.46-0.86; multiparous: aOR 0.41, 99% CI 0.25-0.68) and the odds of having a 'straightforward vaginal birth' were increased in planned FMU births compared with planned AMU births (nulliparous: aOR 1.47, 99% CI 1.17-1.85; multiparous: 1.86, 99% CI 1.35-2.57). The odds of intrapartum caesarean section did not differ significantly between the two settings (nulliparous: p = 0.147; multiparous: p = 0.224). The overall pattern of findings suggested a trend towards lower intervention rates and fewer adverse maternal outcomes in planned FMU births compared with planned AMU births. CONCLUSIONS: The findings support the recommendation that 'low risk' women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of 'straightforward vaginal birth' compared with planned birth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs.

First-time mothers' choice of birthplace: influencing factors, expectations of the midwife's role and perceived safety.

AIM: To explore first-time pregnant women's expectations and factors influencing their choice of birthplace. BACKGROUND: Although outcomes and advantages for low-risk childbearing women giving birth in midwifery-led units and home compared with obstetric units have been investigated previously, there is little information on the factors that influence women's choice of place of birth. DESIGN: A qualitative Straussian grounded theory methodology was adopted. Fourteen women expecting their first baby were recruited from three large National Health Service organizations that provided maternity services free at the point of care. The three organizations offered the following birthplace options: home, freestanding midwifery unit and obstetric unit. Ethical approvals were obtained and informed consent was gained from each participant. METHODS: Data collection was undertaken in 2013-2014. One tape-recorded face-to-face semistructured interview was conducted with each woman in the third trimester of pregnancy. FINDINGS: Findings are presented as three main themes: (i) influencing factors on the choice of birthplace; (ii) expectations on the midwife's 'being' and 'doing' roles; (iii) perceptions of safety. CONCLUSION: Midwives should consider each woman's expectations and approach to birth beyond the planned birthplace, as these are often influenced by the intersection of various influencing factors. Several birthplace options should be made available to women in each maternity service and the alternatives should be shared with women by healthcare professionals during pregnancy to allow an informed choice. Virtual tours or visits to the birth units could also be offered to women to help them familiarize with the chosen setting.

Freestanding midwifery units: Maternal and neonatal outcomes following transfer.

BACKGROUND: the viability of freestanding midwifery units in Australia is restricted, due to concerns over their safety, particularly for women and babies who, require transfer. AIM: to compare the maternal and neonatal birth outcomes of women who planned, to give birth at freestanding midwifery units and subsequently, transferred to a tertiary maternity unit to the maternal and neonatal, outcomes of a low-risk cohort of women who planned to give birth in, tertiary maternity unit. METHODS: a descriptive study compared two groups of women with low-risk singleton, pregnancies who were less than 28 weeks pregnant at booking: women who, planned to give birth at a freestanding midwifery unit (n=494) who, transferred to a tertiary maternity unit during the antenatal, intrapartum or postnatal periods (n=260) and women who planned to give, birth at a tertiary maternity unit (n=3157). Primary outcomes were mode, of birth, Apgar score of less than 7 at 5minutes and admission to, special care nursery or neonatal intensive care. KEY FINDINGS: the proportion of women who experienced a caesarean section was lower, among the freestanding midwifery unit women who transferred during the, intrapartum/postnatal period compared to women in the tertiary maternity, unit group (16.1% versus 24.8% respectively). Other outcomes were, comparable between the cohorts. Rates of primary outcomes in relation to, stage of transfer varied when stratified by parity. DISCUSSION: these descriptive results support the provision of care in freestanding, midwifery units as an alternative to tertiary maternity units for women, with low risk pregnancies at the time of booking. A larger study, powered, to determine statistical significance of any differences in outcomes, is, required.

Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study.

BACKGROUND: In several developed countries women with a low risk of complications during pregnancy and childbirth can make choices regarding place of birth. In the Netherlands, these women receive midwife-led care and can choose between a home or hospital birth. The declining rate of midwife-led home births alongside the recent debate on safety of home births in the Netherlands, however, suggest an association of choice of birth place with psychological factors related to safety and risk perception. In this study associations of pregnancy related anxiety and general anxious or depressed mood with (changes in) planned place of birth were explored in low risk women in midwife-led care until the start of labour. METHODS: Data (n = 2854 low risk women in midwife-led care at the onset of labour) were selected from the prospective multicenter DELIVER study. Women completed the Pregnancy Related Anxiety Questionnaire-Revised (PRAQ-R) to assess pregnancy related anxiety and the EuroQol-6D (EQ-6D) for an anxious and/or depressed mood. RESULTS: A high PRAQ-R score was associated with planned hospital birth in nulliparous (aOR 1.92; 95% CI 1.32-2.81) and parous women (aOR 2.08; 95% CI 1.55-2.80). An anxious or depressed mood was associated with planned hospital birth (aOR 1.58; 95% CI 1.20-2.08) and with being undecided (aOR 1.99; 95% CI 1.23-2.99) in parous women only. The majority of women did not change their planned place of birth. Changing from an initially planned home birth to a hospital birth later in pregnancy was, however, associated with becoming anxious or depressed after 35 weeks gestation in nulliparous women (aOR 4.17; 95% CI 1.35-12.89) and with pregnancy related anxiety at 20 weeks gestation in parous women (aOR 3.91; 95% CI 1.32-11.61). CONCLUSION: Low risk women who planned hospital birth (or who were undecided) more often reported pregnancy related anxiety or an anxious or depressed mood. Women who changed from home to hospital birth during pregnancy more often reported pregnancy related anxiety or an anxious or depressed mood in late pregnancy. Anxiety should be adequately addressed in the process of informed decision-making regarding planned place of birth in low risk women.

Women's birth place preferences in the United Kingdom: a systematic review and narrative synthesis of the quantitative literature.

BACKGROUND: Current clinical guidelines and national policy in England support offering 'low risk' women a choice of birth setting, but despite an increase in provison of midwifery units in England the vast majority of women still give birth in obstetric units and there is uncertainty around how best to configure services. There is therefore a need to better understand women's birth place preferences. The aim of this review was to summarise the recent quantitative evidence on UK women's birth place preferences with a focus on identifying the service attributes that 'low risk' women prefer and on identifying which attributes women prioritise when choosing their intended maternity unit or birth setting. METHODS: We searched Medline, Embase, PsycINFO, Science Citation Index, Social Science Index, CINAHL and ASSIA to identify quantitative studies published in scientific journals since 1992 and designed to describe and explore women's preferences in relation to place of birth. We included experimental stated preference studies, surveys and mixed-methods studies containing relevant quantitative data, where participants were 'low risk' or 'unselected' groups of women with experience of UK maternity services. RESULTS: We included five experimental stated preference studies and four observational surveys, including a total of 4201 respondents. Most studies were old with only three conducted since 2000. Methodological quality was generally poor. The attributes and preferences most commonly explored related to pain relief, continuity of midwife, involvement/availability of medical staff, 'homely' environment/atmosphere, decision-making style, distance/travel time and need for transfer. Service attributes that were almost universally valued by women included local services, being attended by a known midwife and a preference for a degree of control and involvement in decision-making. A substantial proportion of women had a strong preference for care in a hospital setting where medical staff are not necessarily involved in their care, but are readily available. CONCLUSIONS: The majority of women appear to value some service attributes while preferences differ for others. Policy makers, commissioners and service providers might usefully consider how to extend the availability of services that most women value while offering a choice of options that enable women to access services that best fit their needs and preferences.

Midwifing the notion of a 'good' birth: a philosophical analysis.

OBJECTIVE: to ponder afresh what makes a good birth experience in a listening manner. DESIGN: a hermeneutic approach that first explores the nature of how to listen to a story that is already familiar to us and then draws on Heidegger's notion of the fourfold to seek to capture how the components of a'good birth' come together within experience. SETTING: primary birthing centre, New Zealand PARTICIPANTS: the focus of this paper is the story of one participant. It was her second birth; her first birth involved a lot of medical intervention. She had planned to travel one hour to the tertiary birthing unit but in labour chose to stay at the Birth Centre. Her story seems to portray a 'very good birth'. FINDINGS: in talking of birth, the nature of a research approach is commonly to focus on one aspect: the place, the care givers, or the mode of care. In contrast, we took on the challenge of first listening to all that was involved in one woman's story. We came to see that what made her experience 'good' was'everything' gathered together in a coherent and supportive oneness. Heidegger's notion of the fourfold helped reveal that one cannot talk about one thing without at the same time talking about all the other things as well. Confidence was the thread that held the story together. KEY CONCLUSIONS: there is value in putting aside the fragmented approach of explicating birth to recognise the coming together of place, care, situation, and the mystery beyond explanation. Women grow a confidence in place when peers and community encourage the choice based on their own experience. Confidence of caregiver comes in relationship. Feeling confident within 'self' is part of the mystery. When confidence in the different dimensions holds together, birth is 'good'. IMPLICATIONS OR PRACTICE: one cannot simply build a new birthing unit and assume it will offer a good experience of birth. Experience is about so much more. Being mindful of the dimensions of confidence that need to be built up and sheltered is a quest for wise leaders. Protecting the pockets where we know 'good birth' already flourishes is essential.

A systematic review to examine the evidence regarding discussions by midwives, with women, around their options for where to give birth.

BACKGROUND: Discussion of place of birth is important for women and maternity services, yet the detail, content and delivery of these discussions are unclear. The Birthplace Study found that for low risk, multiparous women, there was no significant difference in neonatal safety outcomes between women giving birth in obstetric units, midwifery-led units, or home. For low risk, nulliparous women giving birth in a midwifery-led unit was as safe as in hospital, whilst birth at home was associated with a small, increased risk of adverse perinatal outcomes. Intervention rates were reduced in all settings outside hospital. NICE guidelines recommend all women are supported in their choice of birth setting. Midwives have the opportunity to provide information to women about where they choose to give birth. However, research suggests women are sometimes unaware of all the options available. This systematic review will establish what is known about midwives' perspectives of discussions with women about their options for where to give birth and whether any interventions have been implemented to support these discussions. METHODS: The systematic review was PROSPERO registered (registration number: CRD42015017334). The PRISMA statement was followed. Medline, Cochrane, CINAHL, PsycINFO, Popline and EMBASE databases were searched between 2000-March 2015 and grey literature was searched. All identified studies were screened for inclusion. Qualitative data was thematically analysed, whilst quantitative data was summarised. RESULTS: The themes identified relating to influences on midwives' place of birth discussions with women were organisational pressures and professional norms, inadequate knowledge and confidence of midwives, variation in what midwives told women and the influence of colleagues. None of the interventions identified provided sufficient evidence of effectiveness and were of poor quality. CONCLUSIONS: The review has suggested the need for a pragmatic, understandable place of birth dialogue containing standard content to ensure midwives provide low risk women with adequate information about their place of birth options and the need to improve midwives knowledge about place of birth. A more robust, systematic evaluation of any interventions designed is required to improve the quality of place of birth discussions. By engaging with co-produced research, more effective interventions can be designed, implemented and sustained.

Does fear of childbirth or family history affect whether pregnant Dutch women prefer a home- or hospital birth?

OBJECTIVE: It is a generally accepted idea that women who give birth at home are less fearful of giving birth than women who give birth in a hospital. We explored fear of childbirth (FOC) in relation to preferred and actual place of birth. Since the Netherlands has a long history of home birthing, we also examined how the place where a pregnant woman׳s mother or sisters gave birth related to the preferred place of birth. DESIGN: A prospective cohort study. SETTING: Five midwifery practises in the region Leiden/Haarlem, the Netherlands. PARTICIPANTS: 104 low risk nulliparous and parous women. METHOD: Questionnaires were completed in gestation week 30 (T1) and six weeks post partum (T2). MEASUREMENTS AND FINDINGS: No significant differences were found in antepartum FOC between those who preferred a home or a hospital birth. Women with a strong preference for either home or hospital had lower FOC (mean W-DEQ=60.3) than those with a weak preference (mean W-DEQ=71.0), t (102)=-2.60, p=0.01. The place of birth of close family members predicted a higher chance (OR 3.8) of the same place being preferred by the pregnant woman. Pre- to postpartum FOC increased in women preferring home- but having hospital birth. KEY CONCLUSIONS: The idea that FOC is related to the choice of place of birth was not true for this low risk cohort. Women in both preference groups (home and hospital) made their decisions based on negative and positive motivations. Mentally adjusting to a different environment than that preferred, apart from the medical complications, can cause more FOC post partum. IMPLICATIONS FOR PRACTICE: The decreasing number of home births in the Netherlands will probably be a self-reinforcing effect, so in future, pregnant women will be less likely to feel supported by their family or society to give birth at home. Special attention should be given to the psychological condition of women who were referred to a place of birth and caregiver they did not prefer, by means of evaluation of the delivery and being alert to anxiety or other stress symptoms after childbirth. These women have higher chance of fear post partum which is related to a higher risk of psychiatric problems.

Women׳s birthplace decision-making, the role of confidence: Part of the Evaluating Maternity Units study, New Zealand.

OBJECTIVE: to explore women׳s birthplace decision-making and identify the factors which enable women to plan to give birth in a freestanding midwifery-led primary level maternity unit rather than in an obstetric-led tertiary level maternity hospital in New Zealand. DESIGN: a mixed methods prospective cohort design. METHODS: data from eight focus groups (37 women) and a six week postpartum survey (571 women, 82%) were analysed using thematic analysis and descriptive statistics. The qualitative data from the focus groups and survey were the primary data sources and were integrated at the analysis stage; and the secondary qualitative and quantitative data were integrated at the interpretation stage. SETTING: Christchurch, New Zealand, with one tertiary maternity hospital and four primary level maternity units (2010-2012). PARTICIPANTS: well (at 'low risk' of developing complications), pregnant women booked to give birth in one of the primary units or the tertiary hospital. All women received midwifery continuity of care, regardless of their intended or actual birthplace. FINDINGS: five core themes were identified: the birth process, women׳s self-belief in their ability to give birth, midwives, the health system and birth place. 'Confidence' was identified as the overarching concept influencing the themes. Women who chose to give birth in a primary maternity unit appeared to differ markedly in their beliefs regarding their optimal birthplace compared to women who chose to give birth in a tertiary maternity hospital. The women who planned a primary maternity unit birth expressed confidence in the birth process, their ability to give birth, their midwife, the maternity system and/or the primary unit itself. The women planning to give birth in a tertiary hospital did not express confidence in the birth process, their ability to give birth, the system for transfers and/or the primary unit as a birthplace, although they did express confidence in their midwife. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: birthplace is a profoundly important aspect of women׳s experience of childbirth. Birthplace decision-making is complex, in common with many other aspects of childbirth. A multiplicity of factors needs converge in order for all those involved to gain the confidence required to plan what, in this context, might be considered a 'countercultural' decision to give birth at a midwife-led primary maternity unit.

Autonomy in place of birth: a concept analysis.

This article examines one of the relevant concepts in the current debate on home birth-autonomy in place of birth-and its uses in general language, ethics, and childbirth health care literature. International discussion on childbirth services. A concept analysis guided by the model of Walker and Avant. The authors suggest that autonomy in the context of choosing place of birth is defined by three main attributes: information, capacity and freedom; given the antecedent of not harming others, and the consequences of accountability for the outcome. Model, borderline and contrary cases of autonomy in place of birth are presented. A woman choosing place of birth is autonomous if she receives all relevant information on available choices, risks and benefits, is capable of understanding and processing the information and choosing place of birth in the absence of coercion, provided she intends no harm to others and is accountable for the outcome. The attributes of the definition can serve as a useful tool for pregnant women, midwives, and other health professionals in contemplating their moral status and discussing place of birth.

Determinants of prakriti, the human constitution types of Indian traditional medicine and its correlation with contemporary science.

BACKGROUND: Constitutional type of an individual or prakriti is the basic clinical denominator in Ayurveda, which defines physical, physiological, and psychological traits of an individual and is the template for individualized diet, lifestyle counseling, and treatment. The large number of phenotype description by prakriti determination is based on the knowledge and experience of the assessor, and hence subject to inherent variations and interpretations. OBJECTIVE: In this study we have attempted to relate dominant prakriti attribute to body mass index (BMI) of individuals by assessing an acceptable tool to provide the quantitative measure to the currently qualitative ayurvedic prakriti determination. MATERIALS AND METHODS: The study is cross sectional, multicentered, and prakriti assessment of a total of 3416 subjects was undertaken. Healthy male, nonsmoking, nonalcoholic volunteers between the age group of 20-30 were screened for their prakriti after obtaining written consent to participate in the study. The prakriti was determined on the phenotype description of ayurvedic texts and simultaneously by the use of a computer-aided prakriti assessment tool. Kappa statistical analysis was employed to validate the prakriti assessment and Chi-square, Cramer's V test to determine the relatedness in the dominant prakriti to various attributes. RESULTS: We found 80% concordance between ayurvedic physician and software in predicting the prakriti of an individual. The kappa value of 0.77 showed moderate agreement in prakriti assessment. We observed a significant correlations of dominant prakriti to place of birth and BMI with Chi-square, P < 0.01 (Cramer's V-value of 0.156 and 0.368, respectively). CONCLUSION: The present study attempts to integrate knowledge of traditional ayurvedic concepts with the contemporary science. We have demonstrated analysis of prakriti classification and its association with BMI and place of birth with the implications to one of the ways for human classification.