"I got to catch my own baby": a qualitative study of out of hospital birth.

BACKGROUND: About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse. METHODS: This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling. RESULTS: All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth. CONCLUSION: Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA.

This study shares information from qualitative interviews with Black women and women who are survivors of abuse regarding their choice to have a planned out-of-hospital birth, or to choose an unassisted birth (UAB) with no midwife or other professional birth attendant. Black women are less well represented among those who choose OOHB, and little is known about the reasons that they may choose OOHB. Previous studies show that women who have experienced childhood physical or sexual abuse may prioritize having a sense of control and autonomy during their birthing experiences; however, little is known about their specific choice for OOHB. Our study recruited 18 women who had an OOHB or UAB and who identified as either Black and/or survivors of trauma to participate in in-depth interviews concerning their choice to give birth out of hospital. Through qualitative research methods, we analyzed transcripts of these interviews and developed a theoretical model about women's decision making related to OOHB or UAB. We found that women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition, and that choosing OOHB or UAB allowed them to have more control during the process of giving birth. Understanding the role that previous trauma and experiences of discrimination play in birthplace choice may help birth professionals to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as important factors in their clinical interactions with birthing women.

Preference, knowledge and utilization of midwives, childbirth education classes and doulas among U.S. black and white women: implications for pregnancy and childbirth outcomes.

This secondary analysis explored preference, knowledge and utilization of midwifery care, childbirth education and doula care among 627 black and white women at three Midwestern U.S. health clinics. Women who were white, more educated, not living in a high crime neighborhood, and privately insured were more likely to attend childbirth classes. Sociodemographic factors that predicted having heard about doula care included being more educated and having a partner. None of the sociodemographic variables predicted midwifery care. Education about existing childbearing resources and availability of low-cost options should be expanded, particularly for black women and those with low resources.

Where Do You Feel Safest? Demographic Factors and Place of Birth.

INTRODUCTION: The vast majority of planned out-of-hospital births in the United States occur among white women; no study has addressed whether black women prefer out-of-hospital birth less or whether this racial disparity is due to other causes such as constrained access. This study sought to answer the question of whether white and black women feel safest giving birth in out-of-hospital settings at different rates and whether this answer is associated with other socioeconomic indicators. METHODS: An interview of 634 nulliparous women during the third trimester of their pregnancy in Michigan provided data regarding where women felt safest giving birth. Feeling safest giving birth out-of-hospital was examined in relation to socioeconomic factors including race, age, household income, education, residence in a high-crime neighborhood, partnered status, and type of insurance. RESULTS: This study found that black and white women say they feel safest giving birth in out-of-hospital settings at similar rates (11.5% and 13.1%, respectively). Logistic regression results showed that poverty and having education beyond high school were the only sociodemographic indicators significantly associated with feeling safest giving birth out-of-hospital. DISCUSSION: Disparities evident in planned home birth and birth center rates cannot be explained by racial differences in feelings toward out-of-hospital birth and should be addressed more specifically in public policy and future studies.

Ecological salivary cortisol specimen collection--part 1: methodological consideration of yield, error, and effects of sampling decisions in a perinatal mental health study.

BACKGROUND: Current health research strives to integrate biological, psychological, and social factors consistent with ecological models. Home-based biomarker specimens are consistent with an ecological approach, but deviations from laboratory norms could affect validity of results. OBJECTIVE: This article uses salivary cortisol specimens collected early in a perinatal mental health study to describe (a) return rate and returner characteristics, (b) adherence to procedures, (c) sources of laboratory error, (d) effects of deleting specimens with "nuisance" factors, and (e) effects that selection bias could have on cortisol concentration distribution. STUDY DESIGN: This includes methodological analysis of collection, assay, and preanalysis decision components. RESULTS: Rates of return do not differ by participants' sociodemographic, perinatal, or psychiatric characteristics. Excluding smokers affects representativeness. Selection bias in favor of more or less disadvantaged participants affects cortisol distribution. CONCLUSIONS: The large yield of useable specimens permits multivariate modeling of cortisol level in association with health outcomes, potentially enhancing ecological validity. J Am Psychiatr Nurses Assoc, 2008; 14(4), 273-284. DOI: 10.1177/1078390308322944.

Sex steroid hormones, growth and puberty in children with portal hypertension.

Perturbations in sex hormones occur in adults with liver disease; however, little is known about how liver disease affects hormone levels in children. To address this issue, we recruited 19 patients with portal hypertension and 21 non-hormone-deficient short children as controls. Serum sex hormones, sex hormone binding globulin (SHBG), IGF-I, IGFBP-3, gonadotropins, and thyroid hormones were measured; growth and pubertal status were recorded. There was no significant difference between groups for any of the sex hormones, SHBG, gonadotropins, or thyroid hormones. In contrast, IGF-I and IGFBP-3 were significantly lower among patients than controls, despite the fact that height SDS for the control group was significantly lower. We conclude from this cross-sectional study that children with portal hypertension do not have clinical evidence of growth failure or abnormal puberty, despite subtle changes in the growth axis.