There has been much discussion in recent years of the importance of women exercising their right to choose where to give birth (American Congress of Obstetricians and Gynecologists (ACOG), 2011; Birthplace in England Collaborative Group, 2011; Snowden et al, 2011; Hadjigeorgiou et al, 2012; Olsen and Clausen, 2012). The European Court of Human Rights has recognised that it is the right of all women to be the ultimate decision-makers regarding the circumstances in which they give birth. However, in many Western societies, women's choices associated with the right to choose place of birth are often framed by sociocultural factors. These include a dominant medical model of maternity care, which underpins the arguments surrounding safety of birth outside of hospital (De Jonge et al, 2009; Wax et al, 2010; Jomeen, 2013; Cheyney et al, 2014). The debates concerning medicalisation and safety of childbirth continue, despite considerable evidence suggesting that choice and control are important factors in promoting positive birth experiences for women (Department of Health (DH), 2004; 2007; Snowden et al, 2011).
The argument for supporting women's choice of birthing place is strengthened given that birth at home presents a similar, and in some cases reduced, risk to mothers and infants as giving birth in a hospital setting (Ackermann-Liebrich et al, 1996; De Jonge et al, 2009; ACOG, 2011; Birthplace in England Collaborative Group, 2011; Olsen and Clausen, 2012; Cheyney et al, 2014). Some countries, such as the Netherlands (De Jonge et al, 2009), emphasise the need for a well-organised national infrastructure to support women's choice. This includes specially trained midwives and the implementation of a good transportation and referral system. However, in most European countries where hospital births are the norm, such an infrastructure is sometimes only marginally provided. In such countries, for example, Switzerland, women who want a homebirth have to ‘buck the system’ to be able to choose their preferred place of birth.
Background
Switzerland and its system of health care
Switzerland is a federalist country, located in central Europe and consisting of 26 states (known as cantons). The federalist structure of the country means that a central government is in place, but most decisions are taken at a decentralised, cantonal level, or delegated to municipalities. This structure applies to the organisation and provision of health care, which is only partially regulated by national laws (European Observatory on Health Care Systems, 2000).
An important factor influencing Swiss health care is cost. Health-care expenditure in Switzerland is high (10.8% of gross domestic product), which implies that the Swiss health system is one of the most expensive in Europe (AngloInfo, 2015). Private health insurance has been mandatory since 1996, and certain health-care packages are defined within the national law (De Graeve et al, 2001). Health insurance companies are important partners in the organisation of health care and are organised at both national and cantonal level.
Traditionally, medical involvement in health care is high. Choice of care provider is highly valued by the Swiss population. However, information about different health-care options and alternatives to medical care is not often not provided.
Maternity care in Switzerland
In 2013, the crude birth rate in Switzerland was 10.2 per 1000 population (Swiss Federal Statistical Office, 2015). A few years earlier, the Euro-Peristat report (2006–2010) reported a perinatal mortality rate of 4.3 per 1000 total births and a maternal mortality rate of 5.5 per 100 000 live births (Zeitlin et al, 2010). This was in comparison to the UK, which recorded a crude birth rate of 12.1 per 1000 population (2013) and a perinatal mortality rate of 4.3 per 1000 live births in 2010 (Office for National Statistics, 2015). The maternal mortality rate in the UK (2010–2012) was 10.12 per 100 000 maternities (Knight et al, 2014).
There are similarities and differences in the delivery of obstetric care in Switzerland in comparison to other European and non-European countries. As in the UK, Swiss GPs have their own practice or working group practices. Similarly, medical specialists, such as obstetricians, are either employed by a hospital or provide care in a private practice. Obstetricians working in private practice can refer women to either a public or private hospital to give birth, and are eligible to use the facilities and personnel in either system (Luyben et al, 2014). However, unlike many other European countries approximately 90% of pregnant women attend antenatal care with their gynaecologist, whom they have usually visited before pregnancy for family planning and reproductive health (Luyben et al, 2013; Schmidlin, 2014).
Most midwives work within a hospital system, with a few choosing to work independently or in a birth centre. While women have the freedom to choose whichever health provider they wish, they are often provided with little information about alternative options available (Luyben, 2008). Differentiation between those women deemed ‘low obstetric risk’ (indicating the need for primary care only, provided by a midwife or general practitioner) and ‘high obstetric risk’ (indicating the need for secondary care led by a gynaecologist) is rare (De Vries et al, 2001; Luyben and Gross, 2001).
Women's experiences of Swiss maternity care
Little information is available on Swiss women's experiences of their maternity care. In contrast to the UK, Switzerland has no tradition of formal systematic involvement of consumers in designing or planning their health care, which also affects women's voices in the construction of maternity care (Hofmann et al, 2003; Frei, 2005; Brunold-Bigler and Preisig, 2006; Blöchlinger, 2008; Kurth et al, 2010; Haueter, 2012; Hölzli Reid, 2012; Meier Magistretti et al, 2014). Both an existing personal relationship with their care providers and a long tradition of biomedicine as an expertise in the German-speaking regions are considered to have influenced women's health beliefs to have become medical-authority-based (Brezinka, 1997; Brezinka, 1998; Luyben, 2008).
Women interviewed about their individual experiences of maternity care in Switzerland, therefore, expressed surprise that their personal views were sought (Luyben, 2008; Luyben et al, 2011; 2013). Consequently, issues surrounding women's choice and control in childbirth have only marginally been addressed (Brailey, 2005), and the development of such projects is still in its infancy. For example, in 1999, the German Association of Midwives launched a project called Informed Decision-making, based on the MIDIRS initiative in the UK (O'Cathain et al, 2002; MIDIRS, 2005). However, the project had to be stopped after a few years, owing to a lack of funding.
Even fewer studies have explored the tension between dominant cultural and social expectations and safety in childbirth, for example homebirth. In the 1990s, a regional study was conducted in Switzerland involving an international advisory expert panel, which addressed the evidence-base for choice of place of birth (Ackermann-Liebrich et al, 1996). This prospective matched-pair study involved a 214 paired sample, which could not be randomised because women choosing homebirth were more likely to be from a higher socioeconomic group. Through the matched-pair design, factors for bias could be limited as much as possible. Although the sample did not have sufficient power, the indicators showed that giving birth at home in Switzerland with an experienced midwife and adequate environmental conditions was as safe as giving birth in a hospital for women with a low-risk pregnancy (Ackermann-Liebrich et al, 1996). Despite these findings, medicalised birth continued to increase in Switzerland and, as in other countries, there is a growing number of women who decide to ‘free birth’—that is, give birth at home without professional attendance (Wichmann, 2015).
Within the dominant medical childbirth paradigm, homebirth in Switzerland is still a possible, but unusual, option for women. Since the 1990s, the number of women who choose homebirth has been monitored through national midwifery statistics (Schweizerischer Hebammenverband, 2015). However, little is known about the experiences of women who choose this option and who could be seen to be opposing cultural childbirth norms. With this in mind, the aim of this study was to explore the factors that influence decisions of Swiss pregnant women who choose to give birth at home.
Method
A qualitative descriptive approach (Neergaard et al, 2009) was chosen as an appropriate methodology to capture the rich experiences of women around place of birth in Switzerland. Pregnant women, who were planning a homebirth and who lived in or near the capital of Bern, Switzerland, were invited to participate in the study. As women in Switzerland traditionally make decisions about place of birth early in pregnancy, women who had recently had their pregnancies confirmed were recruited to ensure the minimum time had elapsed between their decision of where to give birth and participation in the study.
The lead researcher was living and working as an independent midwife in this area of Switzerland and therefore it was convenient to recruit women from this area of Switzerland. Midwives who were members of the Swiss Midwifery Association and who were known by the lead researcher facilitated recruitment of women. Midwives distributed information sheets about the study to women in the Bernese region who were planning to give birth at home. Those women who were interested in participating were asked to contact the lead researcher directly, where they would be given further information. Women were asked to give written consent before interview. The aim was to recruit as diverse a sample of women as possible with regard to age, socioeconomic background, parity and ethnic background.
The inclusion criteria for taking part in the study were pregnant women planning a homebirth who lived in or around the city of Bern. Women were interviewed shortly after agreeing to participate in the study, therefore ensuring the memory of the decisions they made was vivid. The reasons why some women expressed interest in the study but subsequently did not participate, is unknown. No women were excluded from participation in the study. Participants are listed in Table 1.
| Pseudonym | Age | Gestation | Parity | Professional background | Nationality |
|---|---|---|---|---|---|
| Jane | 40 | 22 weeks | Para 2 | Physiotherapist | Swiss |
| Eve | 30 | 38 weeks | Para 1 | Midwife | Swiss |
| Claire | 35 | 39 weeks | Para 2 | Housewife | American |
| Lea | 32 | 35 weeks | Para 2 | Nurse | Swiss |
| Lyn | 28 | 38 weeks | Para 0 | Social worker | Swiss |
| Tina | 33 | 29 weeks | Para 3 | Psychologist | Swiss |
Ethical approval
Permission to conduct the study was granted by the ethics committee of the Canton of Bern Switzerland (Kantonale Ethikkommission Bern).
Data collection
Semi-structured interviews were conducted to explore women's reasons for choosing a homebirth. A semi-structured interview guide, based on existing literature of women's experience of homebirth, was used to support the interview. The semi-structured interview has been described as a managed conversation, using a set of fixed and additional questions to facilitate exploration of issues relating to the research topic (Cachia and Millward, 2011). The objective of the interview was to offer women the opportunity to express their own feelings and experiences. Six interviews with women took place in 2010 over a period of 6 weeks; the study was part of an MSc dissertation, therefore there were time constraints on what could be achieved. However, it is believed that data saturation was achieved as many of the issues discussed were common to women interviewed and at the final interview no new themes were identified.
Interviews focused on three questions:
The interviews were conducted in Swiss German, a dialect of the German language, and were digitally recorded. All interviews were transcribed into Swiss German and then translated into English by the lead researcher before data analysis. Women were not excluded from participating in the interviews because of language or dialect.
Data analysis
Data were analysed using thematic analysis, a process of coding and thematic grouping (Braun and Clarke, 2006). Data were analysed at the end of each interview and then collectively after data collection was complete. A sub-section of interviews were analysed independently by an academic member of staff at the host university. The findings from both analyses were then compared and agreement reached regarding interpretation of the data (Sandelowski, 1993). Participants were not invited to read through interview transcripts or analysis of data to verify the accuracy and interpretation; however, women were asked if they wished to receive a copy of the final MSc dissertation.
Findings
Four themes were identified from analysis of the data:
Previous hospital experience motivated a desire for homebirth
Previous experience of hospital birth, either personal or from others, was influential in women's decision to give birth outside hospital. Some women had given birth in hospital and their prior experiences proved a strong motivator in choosing a homebirth. Women found much of what hospital care offered to be unacceptable and this contributed to their choice for homebirth. For example, lack of privacy and a high number of professionals being present at the birth negatively affected their experience of birth.
‘I think there were about eight or ten people in the room, in the middle of labour… “Can I watch?” And I am like, “Who are you?” “Oh I am going to be a doctor and would like to see a twin birth…”’ (Claire)
One woman, who was a midwife, expressed concern at the unexplained and high rate of intervention she saw during hospital childbirth.
‘There's just too much intervention for no reason, I didn't want to give birth like what I had seen at work.’ (Eve)
For another woman, previous experience made her lose confidence in hospital care.
‘I think if my first birth would have been good, we wouldn't have gone for the homebirth, but my first birth was so awful that I didn't think it was brave having a homebirth, I thought it couldn't be any worse.’ (Tina)
Those assisting with labour and birth in hospital seemed to disregard women's individual needs. One woman spoke of not being listened to or respected.
‘…and they said “you can push if you want.” I said “but I feel nothing so why do I need to push?” So I am pushing and pushing for an hour, I was so tired that I couldn't push so I said “Can I stand or squat?” because I am laying on my back, but the doctor says “no, you can't do that…”’ (Claire)
Personal and societal influences
Influences on women's decision to give birth at home
A woman's decision to have a homebirth was influenced by significant people in her life, for example, a midwife or partner.
The midwife's influence
Women felt the support they received from their midwife was crucial in their decision to choose a homebirth. The trusting relationship women had with their midwife was an important factor in increasing their confidence. One woman commented:
‘…with Jane I really feel we are in perfect hands, I really feel she knows exactly what she is doing, that's my expectation of a homebirth, competent care, and to know that someone knows when to make decisions.’ (Tina)
Another woman also commented on the importance of support from her midwife:
‘It was important to me that the same midwife cared for me from beginning to end, that we could build a relationship, that I was not going unprepared into an unknown situation.’ (Lea)
Partner support
In addition to the support received from midwives helping women decide on homebirth, women also believed their partner was influential in their decision of place of birth.
‘That my partner supported a homebirth was important to me [in influencing my decision], and if he hadn't wanted it we would have found another solution.’ (Lyn)
Another woman commented on the support she received from her partner:
‘For me, the most important factor in deciding on a homebirth was Dave [partner]. I knew he completely supported me.’ (Jane)
Information on childbirth
Another area that influenced women was the information they received about childbirth. Written information was obtained from both health professionals and other women and was readily available for the women.
‘It's a good thing I read these, you know the birthing experiences from other women and the midwives’ points of view… so I thought, “OK, I can do this.” It gave me confidence.’ (Claire)
Other women's experiences
The final influencing factor on the women's decision-making on homebirth was talking to other women. Some of the women were alerted to the possibility of a homebirth by hearing about other women's experiences. When hearing about other women's experiences, they felt that their decision to have a homebirth had been reinforced.
‘A colleague of mine had a homebirth and talked a lot about it. That's where I got the idea from.’ (Lea)
‘A woman in the same block had a homebirth and then there are four women around me who had homebirths, that gave me confidence.’ (Lyn)
Although the interviews focused on the factors that influenced women's decision to request homebirth, women's discussion sometimes indicated both positive and negative factors and influences. The negatives included those who had tried to change or alter their decisions.
Expectations of a homebirth
Women expected homebirth would guarantee them an intimate environment, free from distractions and disturbances, which was the opposite of what they had experienced in previous hospital births or perceived happened in hospital.
‘That's what I like about a homebirth; there are no distractions, nobody opens the door and disturbs you. You can just be.’ (Lea)
‘…in hospital everything is so impersonal, you've got people going in and out while you are giving birth, I find that very disturbing.’ (Jane)
Women expected homebirth would allow them to have control over the environment in which they gave birth. This was an important aspect of the women's decision for a homebirth. The women talked about preparing the house to be ready for the birth, enabling them to create their special area in which to give birth. This personalised area would optimise privacy, control and comfort for women, facilitating optimal physiological function and thereby promoting normal birth. Women acknowledged this, commenting on how they felt that the home environment meant it was more likely that they would be able to have a normal birth, something that was highly prized.
Safety
Other aspects of expectations of homebirth were issues around safety. Although not asked about in the interview, safety was something the women felt had a major influence on their decision to have a homebirth.
‘I will try not to resist if there isn't a homebirth. You need to have that flexibility and understanding.’ (Jane)
‘I was never afraid that something may happen, I always said to myself, then you need to transfer.’ (Eve)
Women who considered safety in their decision to give birth at home were reassured that they could transfer to hospital easily, if necessary.
Women's attitudes to birth
The decision to birth at home was strongly influenced by the women's attitude towards birth. All of the participants trusted the birthing process, believing birth to be a universal female experience and best left undisturbed.
‘I had the basic trust [in giving birth at home and the ability of my own body]; hundreds of thousands of births have already taken place, why shouldn't it work?’ (Jane)
Although the study did not suggest that women's choice and attitude was in contrast to the childbirth culture they lived in, women in the study acknowledged that by choosing a homebirth they were rejecting societal norms. One participant referred to herself as ‘alternative’, while others recognised that they ‘didn't fit in’ or that they went ‘against the mainstream’. These women acknowledged that they were ‘different'and realised that this was reflected in other areas of their lives, not just birth. For example, women in the study did not always adhere to a various social norms or societal values. They talked about seeking out other like-minded people in an attempt to reaffirm their views of birth, as well as for solidarity and social support. One participant spoke about how choosing homebirth was a
‘contribution against the current, a way of not taking part’ (Lyn)
Thereby displaying an awareness of the political nature of deciding to birth at home.
Discussion
Women in the current study reported several influences in choosing a homebirth. For example, consistent with other studies, women spoke of how their midwife strengthened their decision by reinforcing their trust in birth (Kontoyannis and Katsetos, 2008; Murray-Davis et al, 2012). This would support Fahy's concept of ‘midwifery guardianship’, which describes midwives' empowerment of women through promotion of their innate power to give birth (Fahy et al, 2011: 224). Fahy and Parratt (2006) suggest that midwives act as guardians when they support women in their birth choices. Midwifery guardianship has the potential to create an environment where women feel safe and relaxed. Women spoke of the competence of their midwife as an influencing factor.
Support, information and knowledge about homebirth
Consistent with the work of other authors (Madi and Crowe, 2003; Barber et al, 2006), women in this study believed midwives to be a crucial influence on their choice of place of birth. Women also spoke about the importance their partners played in supporting their choice to give birth at home. This important role that partners play in helping women choose birth at home has previously been identified by Madi and Crowe (2003) and Andrews (2004). Many women in this study spoke of how homebirth could potentially be more pleasant for their partners (Houghton et al, 2008). Giving birth at home meant partners could stay with the women after they had given birth. Partners of women who give birth at home tend to feel empowered, more confident in their own home environment and with a more defined role in the birth experience (Hildingsson et al, 2011; Johansson et al, 2015; Jouhki et al, 2015).
‘For some women, the decision to have a homebirth was an intuitive reaction. Women's inherent knowledge enabled them to challenge more positivist forms of knowledge that inform the medical model of care’
Women described the importance of knowledge, both formal and experiential, in their decision-making. Women obtained information from talking to other women (Andrews, 2004; Lothian, 2010) from reading books and from the internet. Acquiring knowledge and information provided women with the confidence to think about alternative birth options and challenge cultural and social norms. Knowledge also gave women the insight to recognise occasions when they might need intervention. For example, women were aware that if there were complications during the birth, they would need access to a hospital. The women, therefore, did not reject the prospect of medical intervention entirely.
Similar to other studies (Luyben, 2008; Luyben et al, 2011; 2013), a number of women in the current study reported the influence of friends in their decision regarding where to give birth. Speaking with friends had made women aware of alternatives to hospital birth (Andrews, 2004; Lothian, 2010). For other women, however, the decision to have a homebirth was an intuitive reaction. Women reported that ‘it just felt right’, demonstrating the importance of tacit and innate knowledge. Women's inherent knowledge enabled them to challenge more positivist forms of knowledge that inform the medical model of care (Davis-Floyd and Davis, 1997). In Switzerland, women's innate knowledge of childbirth is still culturally inclined towards medicalisation (Maillefer et al, 2015). A recent study showed that, despite having confidence in midwifery care during birth and postpartum, women still believed obstetricians were the key professional in obstetric care (Maillefer et al, 2015).
Women's attitudes to birth
Women spoke of birth as a universal female experience and believed it was best left undisturbed and with minimal intervention (Boucher et al, 2009). Many of the women spoke of trusting the birth process and trusting their bodies to give birth. This was important in their decision-making.
However, the women's decision could be seen as opposing social norms, and ‘swimming against the tide’. Women reported feeling ‘different’ and felt outside the normal jurisdiction of childbirth (Andrews, 2004; Catling et al, 2014). As a result, women avoided discussion of birth plans with health providers for fear of repercussions (Bernhard et al, 2014). These views were supported in a recent study by Maillefer et al (2015), where Swiss obstetricians appeared opposed to the development of midwife-led maternity units.
Negative attitudes toward their choice of place of birth affected the confidence of some women; for others, however, it strengthened their resolve. Women reported seeking their ‘own kind’ in choice of birth, which gave them a sense of connection and reaffirmed their decision.
Limitations
Participants were largely from similar socio-economic, educational and ethnic backgrounds, which could restrict transferability of findings to other populations. However, women of different age groups and gestation were included and were believed to be representative of those women who choose to give birth at home (Hildingsson et al, 2006). Although women were invited to participate regardless of parity, only one primiparous woman was recruited to the study. Including more women who were experiencing their first pregnancy might have provided different views.
The findings from this study might have been enhanced by obtaining views from those women opposed to homebirth, or who would not consider it an option. Additionally, obtaining the views of obstetricians and midwives working in the Swiss health-care system might have furthered our understanding of women's choice regarding place of birth.
Implications for practice
Women's motivation for homebirth in Switzerland came from dissatisfaction with hospital maternity care. Women objected to a lack of privacy, limited control regarding their birth experience and limited involvement of partners. Women sought care that was woman-focused and believed that care at home with a midwife was more likely to provide this than hospital care. Many of these factors could easily be achieved within hospital care.
Women's experience of care might be improved if medicalisation of childbirth in Switzerland was used more appropriately. In contrast to other European countries, Swiss women are socialised into a medical model of reproductive health from an early age. In the UK and Scandinavia—countries where there is less medical intervention during childbirth—midwives play a significant role in reproductive health services, with obstetricians involved only in complex cases. In order to change a culture reliant on medical care, it may be necessary to review obstetricians' role in reproductive health and include midwives more in the provision of this service. With the promotion of ‘keeping birth normal’, a key strategy for the International Confederation of Midwives (ICM), and recognition of midwives as the advocates of normal childbirth (ICM, 2014), involvement of midwives in Swiss maternity care may facilitate a more normalised view of reproductive health.
Conclusion
This study aimed to identify factors influencing the decisions of pregnant women living in Switzerland to give birth at home. The women in the study sought more autonomy, less medical intervention and a more relaxing environment when giving birth. Women were not confident that they would find these in a hospital setting. In their choice for homebirth, women were seen to be ‘swimming against the tide’ of cultural and social norms. In light of findings that suggest homebirth is often a safe (if not safer) option for women in developed countries, maternity care should focus on facilitating women's choice and offer homebirth as a viable option.