Four factors that affect birth setting decisions
In an analysis published in Birth, researchers identified four themes that impact people’s decisions about birth setting in the United States: safety, external influences, choice and control and access.
“I have practiced midwifery for 10 years in tertiary care, community hospital and freestanding birth center settings and have witnessed the lack of information many people have at their fingertips to pick a birth setting that meets their needs and preferences,” Erin K. George, CNM, MSN, a research fellow and nursing PhD student at Boston College, told Healio. “Additionally, many people face significant financial, health insurance and/or geographic barriers to sites of care that would be their first choice for labor and birth. I believe that increasing our understanding about what influences a person's decision about where to give birth and how people experience the birth setting decision-making process can improve overall quality and satisfaction of their births and increase access to birth setting options.”
George, who is also a certified nurse-midwife at Mount Auburn Hospital in Cambridge, Massachusetts, and colleagues reviewed 23 studies that included retrospective, cross-sectional or prospective data on birth setting decisions to identify themes that influenced decisions on birth setting.
The researchers determined that the studies were quasi-experimental or nonexperimental in design and were either high or good quality based on the Johns Hopkins Nursing Evidence-Based Practice model.
Safety
Participants in 18 studies cited their perceptions of the safety and risks of various birth settings as a major factor in their birth setting decision. Those who opted for home births explained that they felt they would receive unnecessary interventions if giving birth in a hospital.
On the other hand, participants in seven studies reported they chose to have a hospital birth because they believed hospitals to be the safest place to deliver. They also cited that labor discomfort and risks would be managed properly with doctors and interventions available.
External influences
There were 16 studies that examined external influences, such as exposure to media and stories and opinions from friends and family.
Those who chose home births or birth centers cited books, films and positively skewed articles on home birth as contributors to their decision. They also took the labor narratives of friends and family into consideration, and one study showed that participants who were born at home decided to have a home birth to carry on “family tradition.”
Participants who opted for hospital births reported having read negatively skewed articles on home birth.
Choice and control
Ten studies examined the presence or absence of choice and control over birth settings. Participants who opted for home birth cited autonomy, agency and empowerment as the main factors in their decision.
Participants who gave birth in hospitals reported a lack of control over their birth. Of note, those who had lower expectations for the choices they could make during labor and birth reported positive birth experiences regardless of whether they followed their birth plan.
Access to options
Having access to certain options was also a major contributor to birth setting decisions in the eight studies in which it was investigated.
“Because U.S. health care is a profit-driven, fragmented industry, the access to options component is significant in the U.S. context,” George said. “Too many people live in places where they have little to no access to birth providers and facilities, and health insurance plans do not have to cover births in all settings (birth center, home, hospital) or provide people with birth setting choice.”
George said that clinicians can use these findings to help direct patients to birth settings that best fit their needs and desires.
“These findings can lay the foundation for creating patient decision aids or decision support tools that can support decision-making about birth settings,” George said. “The findings also serve to raise awareness for birth providers about the different perspectives and experiences that contribute to how people decide where to give birth and decrease stigma associated with birthing outside of the predominant hospital-based birth settings in the United States.”
Moving forward, George suggested research should focus on learning more about what influences birth setting decisions, and she emphasized the need for “studies that are more inclusive of people from diverse backgrounds.”