"I knew there has to be a better way": Women's pathways to freebirth in Poland.

BACKGROUND: Each year a small number of women decide to birth at home without midwifery and medical assistance despite the availability of maternity services in the country. This phenomenon is called freebirth and can be used as a lens to look into shortcomings of maternity care services. AIM: By exploring women's pathways to freebirth, this article aims to examine the larger context of maternity services in Poland and identify elements of care contributing to women's decision to birth without midwifery and medical assistance. METHODS: A qualitative methodology was used employing elements of ethnographic fieldwork, including digital ethnography. Semi-structured interviews with twelve women who freebirth, analysis of online support groups, secondary sources of information and elements of participant observation were used. FINDINGS: Women's decisions to freebirth were born out of their previous negative experiences with maternity care. Persistent use of medical technology and lack of respect from maternity care providers played a major role in pushing women away from available Polish maternity services. While searching for a better environment for themselves and their babies for the subsequent births, women experienced a rigidity of both mainstream and homebirth services and patchy availability of the latter that contributed to their decisions to freebirth. CONCLUSIONS: Freebirth appears to be a consequence of inadequate maternity services both mainstream and homebirth rather than a preference. Women's freebirth experiences can be used to improve maternity care in Poland and inform similar contexts globally.

Experiences of Dutch maternity care professionals during the first wave of COVID-19 in a community based maternity care system.

BACKGROUND AND OBJECTIVE: During the COVID-19 pandemic the organization of maternity care changed drastically; this study into the experiences of maternity care professionals with these changes provides suggestions for the organization of care during and after pandemics. DESIGN: An online survey among Dutch midwives, obstetricians and obstetric residents. Multinomial logistic regression analyses were used to investigate associations between the respondents' characteristics and answers. RESULTS: Reported advantages of the changes were fewer prenatal and postpartum consultations (50.1%). The necessity and safety of medical interventions and ultrasounds were considered more critically (75.9%); 14.8% of community midwives stated they referred fewer women to the hospital for decreased fetal movements, whereas 64.2% of the respondents working in hospital-based care experienced fewer consultations for this indication. Respondents felt that women had more confidence in giving birth at home (57.5%). Homebirths seemed to have increased according to 38.5% of the community midwives and 65.3% of the respondents working in hospital-based care. Respondents appreciated the shift to more digital consultations rather than face-to-face consultations. Mentioned disadvantages were that women had appointments alone, (71.1%) and that the community midwife was not allowed to join a woman to obstetric-led care during labour and subsequently stay with her (56.8%). Fewer postpartum visits by family and friends led to more tranquility (59.8%). Overall, however, 48.0% of the respondents felt that the safety of maternity care was compromised due to policy changes. CONCLUSIONS: Maternity care professionals were positive about the decrease in routine care and the increased confidence of women in home birth, but also felt that safety in maternity care was sometimes compromised. According to the respondents in a future crisis situation it should be possible for community midwives to continue to deliver a personal handover after the referral of women to the hospital, and to stay with them.

Out-of-Hospital Birth.

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

[Home births: A growing phenomenon with potential risks]. / Parto domiciliario: un fenómeno creciente con potenciales riesgos.

Home birth is a controversial issue that raises safety concerns for paediatricians and obstetricians. Hospital birth was the cornerstone to reduce maternal and neonatal mortality. This reduction in mortality has resulted in considering pregnancy and childbirth as a safe procedure, which, together with a greater social awareness of the need for the humanisation of these processes, have led to an increase in the demand for home birth. Studies from countries such as Australia, the Netherlands, and United Kingdom show that home birth can provide advantages to the mother and the newborn. It needs to be provided with sufficient material means, and should be attended by trained and accredited professionals, and needs to be perfectly coordinated with the hospital obstetrics and neonatology units, in order to guarantee its safety. Therefore, in our environment, there are no safety data or sufficient scientific evidence to support home births at present.

Adapting the 2015 Mother-Baby Friendly Birth Facility Guidelines for Semi-nomadic Pastoralist Communities in Laikipia and Samburu Counties of Kenya.

Purpose To adapt the 2015 International Federation of Gynecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM), White Ribbon Alliance (WRA), International Pediatric Association (IPA), and WHO auspiced Guidelines on Mother-Baby Friendly Facilities to a particular sub-population; seminomadic pastoralist communities of Laikipia and Samburu Counties, Kenya. We anticipate an increased utilization of childbirth services by improving their acceptability. Description We drafted a Pastoralist Friendly Birthing Facility Checklist based on the FIGO/ICM/WRA/IPA/WHO guidelines and previous research in this context. We employed mixed methods to finalise the adaptation: a workshop with 27 local stakeholders; interviews with ten health planners and skilled birth attendants (SBAs); and ten focus group discussions (FGDs) with health committee members, community health workers, mothers and traditional birth attendants (TBAs). A facility audit of dispensaries across five group ranches was also undertaken. Assessment The final Checklist was divided into: characteristics of care and the environment; care during labour and birth; post-partum care; and community staff relationships. It was endorsed by the Ministries of Health in the relevant counties, and by women, SBAs and TBAs. No facility currently satisfies all the criteria specified in the Checklist. Conclusion The FIGO/ICM/WRA/IPA/WHO Guidelines were successfully adapted and can be used to ensure health facilities meet the needs of pastoralist women.

Enacting Homebirth Bodies: Midwifery Techniques in Germany.

Building on insights from science and technology studies-inspired anthropological research on reproduction, this paper uses a praxiographic approach to analyze homebirth midwifery practices in Germany. I show that such practices are syncretic, and that techniques of routinizing and multiplying obstetrical interventions are combined in more or less coherent ways to configure pregnancies and births as physical, emotional, and social becomings. In the process of attending, homebirth bodies learn to co-respond to each other, to the midwifery techniques, and to the homebirth environment. Understanding how and with which aims midwives and women invest in those longterm engagements specific to homebirth surroundings may inform clinical practices.

"We need good nutrition but we have no money to buy food": sociocultural context, care experiences, and newborn health in two UNHCR-supported camps in South Sudan.

BACKGROUND: Determinants of newborn health and survival exist across the reproductive life cycle, with many sociocultural and contextual factors influencing outcomes beyond the availability of, and access to, quality health services. In order to better understand key needs and opportunities to improve newborn health in refugee camp settings, we conducted a multi-methods qualitative study of the status of maternal and newborn health in refugee camps in Upper Nile state, South Sudan. METHODS: In 2016, we conducted 18 key informant interviews with health service managers and front-line providers and 13 focus group discussions in two Sudanese refugee camps in Maban County, South Sudan. Our focus group discussions comprised 147 refugee participants including groups of mothers, fathers, grandmothers, traditional birth attendants, community health workers, and midwives. We analysed our data for content and themes using inductive and deductive techniques. RESULTS: We found both positive practices and barriers to newborn health in the camps throughout the reproductive lifecycle. Environmental and contextual factors such as poor nutrition, lack of livelihood opportunities, and insecurity presented barriers to both general health and self-care during pregnancy. We found that the receipt of material incentives is one of the leading drivers of utilization of antenatal care and facility-based childbirth services. Barriers to facility-based childbirth included poor transportation specifically during the night; insecurity; being accustomed to home delivery; and fears of an unfamiliar birth environment, caesarean section, and encountering male health care providers during childbirth. Use of potentially harmful traditional practices with the newborn are commonplace including mixed feeding, use of herbal infusions to treat newborn illnesses, and the application of ash and oil to the newborn's umbilicus. CONCLUSIONS: Numerous sociocultural and contextual factors impact newborn health in this setting. Improving nutritional support during pregnancy, strengthening community-based transportation for women in labour, allowing a birth companion to be present during delivery, addressing harmful home-based newborn care practices such as mixed feeding and application of foreign substances to the umbilicus, and optimizing the networks of community health workers and traditional birth attendants are potential ways to improve newborn health outcomes.

Midwife-assisted planned home birth: an essential component of improving the safety of childbirth in Sub-Saharan Africa.

Hospital births, when compared to out-of-hospital births, have generally led to not only a significantly reduced maternal and perinatal mortality and morbidity but also an increase in certain interventions. A trend seems to be emerging, especially in the US where some women are requesting home births, which creates ethical challenges for obstetricians and the health care organizations and policy makers. In the developing world, a completely different reality exists. Home births constitute the majority of deliveries in the developing world. There are severe limitations in terms of facilities, health personnel and deeply entrenched cultural and socio-economic conditions militating against hospital births. As a consequence, maternal and perinatal mortality and morbidity remain the highest, especially in Sub-Saharan Africa (SSA). Midwife-assisted planned home birth therefore has a major role to play in increasing the safety of childbirth in SSA. The objective of this paper is to propose a model that can be used to improve the safety of childbirth in low resource countries and to outline why midwife assisted planned home birth with coordination of hospitals is the preferred alternative to unassisted or inadequately assisted planned home birth in SSA.

Task shifting Midwifery Support Workers as the second health worker at a home birth in the UK: A qualitative study.

OBJECTIVE: Traditionally two midwives attend home births in the UK. This paper explores the implementation of a new home birth care model where births to low risk women are attended by one midwife and one Midwifery Support Worker (MSW). DESIGN AND SETTING: The study setting was a dedicated home birth service provided by a large UK urban hospital. PARTICIPANTS: Seventy-three individuals over 3 years: 13 home birth midwives, 7 MSWs, 7 commissioners (plan and purchase healthcare), 9 managers, 23 community midwives, 14 hospital midwives. METHOD: Qualitative data were gathered from 56 semi-structured interviews (36 participants), 5 semi-structured focus groups (37 participants) and 38 service documents over a 3 year study period. A rapid analysis approach was taken: data were reduced using structured summary templates, which were entered into a matrix, allowing comparison between participants. Findings were written up directly from the matrix (Hamilton, 2013). FINDINGS: The midwife-MSW model for home births was reported to have been implemented successfully in practice, with MSWs working well, and emergencies well-managed. There were challenges in implementation, including: defining the role of MSWs; content and timing of training; providing MSWs with pre-deployment exposure to home birth; sustainability (recruiting and retaining MSWs, and a continuing need to provide two midwife cover for high risk births). The Service had responded to challenges and modified the approach to recruitment, training and deployment. CONCLUSIONS: The midwife-MSW model for home birth shows potential for task shifting to release midwife capacity and provide reliable home birth care to low risk women. Some of the challenges tally with observations made in the literature regarding role redesign. Others wishing to introduce a similar model would be advised to explicitly define and communicate the role of MSWs, and to ensure staff and women support it, consider carefully recruitment, content and delivery of training and retention of MSWs and confirm the model is cost-effective. They would also need to continue to provide care by two midwives at high risk births.

Initiation of traditional birth attendants and their traditional and spiritual practices during pregnancy and childbirth in Ghana.

BACKGROUND: Prior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana. METHODS: The design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings. RESULTS: The findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood. CONCLUSION: Although, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.

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.

Committee Opinion No 697 Summary: Planned Home Birth.

In the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately one fourth of these births are unplanned or unattended. Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives' Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

Committee Opinion No. 697: Planned Home Birth.

In the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately one fourth of these births are unplanned or unattended. Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives' Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

From hospital to home: Australian midwives' experiences of transitioning into publicly-funded homebirth programs.

BACKGROUND: Over the past two decades, 14 publicly-funded homebirth models have been established in Australian hospitals. Midwives working in these hospitals now have the opportunity to provide homebirth care, despite many having never been exposed to homebirth before. The transition to providing homebirth care can be daunting for midwives who are accustomed to practising in the hospital environment. AIM: To explore midwives' experiences of transitioning from providing hospital to homebirth care in Australian public health systems. METHODS: A descriptive, exploratory study was undertaken. Data were collected through in-depth interviews with 13 midwives and midwifery managers who had recent experience transitioning into and working in publicly-funded homebirth programs. Thematic analysis was conducted on interview transcripts. FINDINGS: Six themes were identified. These were: skilling up for homebirth; feeling apprehensive; seeing birth in a new light; managing a shift in practice; homebirth-the same but different; and the importance of mentoring and support. DISCUSSION: Midwives providing homebirth work differently to those working in hospital settings. More experienced homebirth midwives may provide high quality care in a relaxed environment (compared to a hospital setting). Midwives acceptance of homebirth is influenced by their previous exposure to homebirth. CONCLUSION: The transition from hospital to homebirth care required midwives to work to the full scope of their practice. When well supported by colleagues and managers, midwives transitioning into publicly-funded homebirth programs can have a positive experience that allows for a greater understanding of and appreciation for normal birth.

Banning traditional birth attendants from conducting deliveries: experiences and effects of the ban in a rural district of Kazungula in Zambia.

BACKGROUND: In 2010 the government of the republic of Zambia stopped training traditional birth attendants and forbade them from conducting home deliveries as they were viewed as contributing to maternal mortality. This study explored positive and negative maternal health related experiences and effects of the ban in a rural district of Kazungula. METHODS: This was a phenomenological study and data were collected through focus group discussions as well as in-depth interviews with trained traditional birth attendants (tTBAs) and key informant interviews with six female traditional leaders that were selected one from each of the six zones. All 22 trained tTBAs from three clinic catchment areas were included in the study. Content analysis was used to analyse the data after coding it using NVIVO 8 software. RESULTS: Home deliveries have continued despite the community and tTBAs being aware of the ban. The ban has had both negative and positive effects on the community. Positive effects include early detection and management of pregnancy complications, enhanced HIV/AIDS prevention and better management of post-natal conditions, reduced criticisms of tTBAs from the community in case of birth complications, and quick response at health facilities in case of an emergency. Negatives effects of the ban include increased work load on the part of health workers, high cost for lodging at health facilities and traveling to health facilities, as well as tTBAs feeling neglected, loss of respect and recognition by the community. CONCLUSION: Countries should design their approach to banning tTBAs differently depending on contextual factors. Further, it is important to consider adopting a step wise approach when implementing the ban as the process of banning tTBAs may trigger several negative effects.

Factors influencing place of delivery for pastoralist women in Kenya: a qualitative study.

BACKGROUND: Kenya's high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women. METHODS: Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo. RESULTS: Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women's place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing. CONCLUSIONS: Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings.

Self-reported practices among traditional birth attendants surveyed in western Kenya: a descriptive study.

BACKGROUND: The high rate of home deliveries conducted by unskilled birth attendants in resource-limited settings is an important global health issue because it is believed to be a significant contributing factor to maternal and newborn mortality. Given the large number of deliveries that are managed by unskilled or traditional birth attendants outside of health facilities, and the fact that there is on-going discussion regarding the role of traditional birth attendants in the maternal newborn health (MNH) service continuum, we sought to ascertain the practices of traditional birth attendants in our catchment area. The findings of this descriptive study might help inform conversations regarding the roles that traditional birth attendants can play in maternal-newborn health care. METHODS: A structured questionnaire was used in a survey that included one hundred unskilled birth attendants in western Kenya. Descriptive statistics were employed. RESULTS: Inappropriate or outdated practices were reported in relation to some obstetric complications and newborn care. Encouraging results were reported with regard to positive relationships that traditional birth attendants have with their local health facilities. Furthermore, high rates of referral to health facilities was reported for many common obstetric emergencies and similar rates for reporting of pregnancy outcomes to village elders and chiefs. CONCLUSIONS: Potentially harmful or outdated practices with regard to maternal and newborn care among traditional birth attendants in western Kenya were revealed by this study. There were high rates of traditional birth attendant referrals of pregnant mothers with obstetric complications to health facilities. Policy makers may consider re-educating and re-defining the roles and responsibilities of traditional birth attendants in maternal and neonatal health care based on the findings of this survey.