Helena Lindgren

Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study

Objective. The aim of this population‐based study was to measure the risk of adverse outcome for mother and child in planned home births in a Swedish population irrespective of where the birth actually occurred, at home or in hospital after transfer. Design. A population‐based study using data from the Swedish Medical Birth Register. Setting. Sweden 1992–2004. Participants. A total of 897 planned home births were compared with a randomly selected group of 11,341 planned hospital births. Main outcome measures. Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared. Results. During this period in Sweden the neonatal mortality rate was 2.2 per thousand in the home birth group and 0.7 in the hospital group (RR 3.6, 95% CI 0.2–14.7). No cases of emergency complications were found in the home birth group. The risk of having a sphincter rupture was lower in the planned home birth group (RR 0.2, 95% CI 0.0–0.7). The risk of having a cesarean section (RR 0.4, 95% CI 0.2–0.7) or instrumental delivery (RR 0.3, 95% CI 0.2–0.5) was significantly lower in the planned home birth group. Conclusion. In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.

Maternal and infant outcome after caesarean section without recorded medical indication: findings from a Swedish case–control study

To compare maternal complications and infant outcomes for women undergoing elective caesarean sections based on a maternal request and without recorded medical indication with those of women who underwent spontaneous onset of labour with the intention to have a vaginal birth.

Perceptions of risk and risk management among 735 women who opted for a home birth

OBJECTIVEnhome birth is not included in the Swedish health-care system and the rate for planned home births is less than one in a thousand. The aim of this study was to describe womens perceptions of risk related to childbirth and the strategies for managing these perceived risks.nnnDESIGN AND SETTINGna nationwide study including all women who had given birth at home in Sweden was conducted between 1 January 1992 and 31 July 2005.nnnPARTICIPANTSna total of 735 women had given birth to 1038 children. Of the 1038 questionnaires sent to the women, 1025 (99%) were returned.nnnMEASUREMENTSntwo open questions regarding risk related to childbirth and two questions answered using a scale were investigated by content analysis.nnnFINDINGSnregarding perceived risks about hospital birth, three categories, all related to loss of autonomy, were identified: (1) being in the hands of strangers; (2) being in the hands of routines and unnecessary interventions; and (3) being in the hands of structural conditions. Perceived risks related to a home birth were associated with a sense of being beyond help: (1) worst-case scenario; and (2) distance to the hospital. The perceived risks were managed by using extrovert activities and introvert behaviour, and by avoiding discussions concerning risks with health-care professionals.nnnCONCLUSIONnwomen who plan for a home birth in Sweden do consider risks related to childbirth but they avoid talking about the risks with health-care professionals.nnnIMPLICATIONS FOR PRACTICEnto understand why women choose to give birth at home, health-care professionals must learn about the perceived beneficial effect of doing so.

Transfers in planned home births related to midwife availability and continuity: : a nationwide population-based study

BACKGROUNDnPlanning a home birth does not necessarily mean that the birth will take place successfully at home. The object of this study was to describe reasons and risk factors for transfer to hospital during or shortly after a planned home birth.nnnMETHODSnA nationwide study including all women who had given birth at home in Sweden between January 1, 1992, and July 31, 2005. A total of 735 women had given birth to 1,038 children. One questionnaire for each planned home birth was sent to the women. Of the 1,038 questionnaires, 1,025 were returned. Reasons for transfer and obstetric, socioeconomic, and care-related risk factors for being transferred were measured using logistic regression.nnnRESULTSnWomen were transferred in 12.5 percent of the planned home births. Transfers were more common among primiparas compared with multiparas (relative risk [RR] 2.5; 95% CI 1.8-3.5). Failure to progress and unavailability of the chosen midwife at the onset of labor were the reasons for 46 and 14 percent of transfers, respectively. For primiparas, the risk was four times greater if a midwife other than the one who carried out the prenatal checkups assisted at the birth (RR 4.4; 95% CI 2.1-9.5). A pregnancy exceeding 42 weeks increased the risk of transfer for both primiparas (RR 3.0; 95% CI 1.1-9.4) and multiparas (RR 3.4; 95% CI 1.3-9.0).nnnCONCLUSIONSnThe most common reasons for transfer to hospital during or shortly after delivery were failure to progress followed by the midwifes unavailability at the onset of labor. Primiparas whose midwife for checkups during pregnancy was different from the one who assisted at the home birth were at increased risk of being transferred.

Women’s Experiences of Empowerment in a Planned Home Birth: A Swedish Population‐based Study

BACKGROUNDnChildbirth can be an empowering event in a womans life. However, little is known about womens own perceptions of power and empowering sources during childbirth. This study aimed to describe the factors experienced as empowering during a planned home birth.nnnMETHODSnThe inclusion criteria were women in Sweden who had a planned home birth between 1992 and 2005. All the women (n = 735) who agreed to participate received one questionnaire for each planned home birth. A total of 1,038 questionnaires were sent to the women. The written birth stories were analyzed using content analysis and descriptive statistics.nnnRESULTSnIn the analysis of the participants birth experience four categories and one overall theme emerged from the stories. The categories identified were sensations, guidance, tacit support, and identification of needs. Greater emphasis was put on guidance among first-time mothers than among multiparas, for whom tacit support was identified as the most empowering factor. The overall theme was identified as resting in acceptance of the process. The empowerment women expressed by achieving and maintaining a sense of control allowed them to rest in acceptance of the efforts that are part of a normal birth.nnnCONCLUSIONnWomen who choose to give birth at home find empowering sources within themselves from their environment and from the active and passive support of persons they have chosen to be present at the birth.

Transfer to hospital in planned home births: a systematic review

BackgroundThere is concern about the safety of homebirths, especially in women transferred to hospital during or after labour. The scope of transfer in planned home births has not been assessed in a systematic review. This review aimed to describe the proportions and indications for transfer from home to hospital during or after labour in planned home births.MethodsThe databases Pubmed, Embase, Cinahl, Svemed+, and the Cochrane Library were searched using the MeSH term “home childbirth”. Inclusion criteria were as follows: the study population was women who chose planned home birth at the onset of labour; the studies were from Western countries; the birth attendant was an authorised midwife or medical doctor; the studies were published in 1985 or later, with data not older than from 1980; and data on transfer from home to hospital were described. Of the 3366 titles identified, 83 full text articles were screened, and 15 met the inclusion criteria. Two of the authors independently extracted the data. Because of the heterogeneity and lack of robustness across the studies, there were considerable risks for bias if performing meta-analyses. A descriptive presentation of the findings was chosen.ResultsFifteen studies were eligible for inclusion, containing data from 215,257 women. The total proportion of transfer from home to hospital varied from 9.9% to 31.9% across the studies. The most common indication for transfer was labour dystocia, occurring in 5.1% to 9.8% of all women planning for home births. Transfer for indication for foetal distress varied from 1.0% to 3.6%, postpartum haemorrhage from 0% to 0.2% and respiratory problems in the infant from 0.3% to 1.4%. The proportion of emergency transfers varied from 0% to 5.4%.ConclusionFuture studies should report indications for transfer from home to hospital and provide clear definitions of emergency transfers.

Playing second fiddle is Okay-Swedish Fathers' experiences of prenatal care

INTRODUCTIONnIn Sweden, prospective fathers are encouraged and welcome to attend prenatal visits, and pregnant women assess their partners involvement in prenatal care as very important. The aim of this study was to describe expectant fathers experiences of and involvement in prenatal care in Sweden.nnnMETHODSnData were drawn from a 1-year cohort study of 827 Swedish-speaking fathers recruited during their partners midpregnancy and followed up 2 months after childbirth.nnnRESULTSnThe participants reported that the most important issues in prenatal care were the womans physical and emotional well-being and the support she received from her midwife. However, care was identified as deficient in nearly all aspects of information, medical care, and fathers involvement. Excessive care was also reported and related to how the father was treated by the midwife, mainly in terms of attention to his emotional well-being.nnnDISCUSSIONnAlthough fathers prioritize the needs of their pregnant partners, it is important for caregivers to assess fathers needs and incorporate a family-oriented approach to prenatal care.

Birth Preferences that Deviate from the Norm in Sweden: Planned Home Birth versus Planned Cesarean Section

BACKGROUNDnOpting for a home birth or requesting a cesarean section in a culture where vaginal birth in a hospital is the norm challenges the health care system. The aim of this study was to compare background characteristics of women who chose these very different birth methods and to see how these choices affected factors of care and the birth experience.nnnMETHODSnThis descriptive study employed a secondary data analysis of a sample of women who gave birth from 1997 to 2008, including 671 women who had a planned home birth and 126 women who had a planned cesarean section based on maternal request. Data were collected by means of questionnaires. Logistic regression with crude and adjusted odds ratios (OR) with a 95 percent confidence interval (95% CI) was calculated.nnnRESULTSnWomen with a planned home birth had a higher level of education (OR: 2.3; 95% CI: 1.5-3.6), were less likely to have a high body mass index (OR: 0.1; 95% CI: 0.01-0.6), and were less likely to be smokers (OR: 0.2; 95% CI: 0.1-0.4) when compared with women who had planned cesarean sections. When adjusted for background variables, women with a planned home birth felt less threat to the babys life during birth (OR: 0.1; 95% CI: 0.03-0.4), and were more satisfied with their participation in decision making (OR: 6.0; 95% CI: 3.3-10.7) and the support from their midwife (OR 3.9; 95% CI: 2.2-7.0). They also felt more in control (OR: 3.3; 95% CI: 1.6-6.6), had a more positive birth experience (OR: 2.9; 95% CI: 1.7-5.0), and were more satisfied with intrapartum care (OR: 2.3; 95% CI: 1.3-4.1) compared with women who had a planned cesarean section on maternal request.nnnCONCLUSIONSnWomen who planned a home birth and women who had a cesarean section based on maternal request are significantly different groups of mothers in terms of sociodemographic background. In a birth context that promotes neither home birth nor cesarean section without medical reasons, we found that those women who had a planned home birth felt more involvement in decision making and had a more positive birth experience than those who had a requested, planned cesarean section.

Waiting in no-man's-land - mothers' experiences before the induction of labour after their baby has died in utero.

OBJECTIVEnCarrying death instead of life is beyond understanding and a huge psychological challenge for a pregnant mother. The aim of this study was to investigate the mothers experiences of the time from the diagnosis of the death of their unborn baby until induction of labour.nnnMETHODnIn this qualitative study, in-depth interviews were conducted with 21 mothers whose babies had died prior to birth. The interviews were then analysed using content analysis.nnnRESULTSnThe overall theme that emerged from the mothers experiences is understood as waiting in no-mans-land, describing the feeling of being set aside from normality and put into an area which is unrecognized. Four categories were established: involuntary waiting describes the sense of being left without information about what is to come; handling the unimaginable concerns the confusing state of finding oneself in the worst-case scenario and yet having to deal with the birth; broken expectations is about the loss not only of the baby but also of future family life; and courage to face life describes the determination to go on and face reality.nnnCONCLUSIONSnThe mothers experiences during the time after the information of their babys death in utero until the induction of labour can be understood as a sense of being in no-mans-land, waiting without knowing for what or for how long.

Praxis and guidelines for planned homebirths in the Nordic countries – An overview

OBJECTIVEnThe objective of this overview was to investigate the current situation regarding guidelines and praxis for planned homebirths and also to investigate possibilities for comparative studies on planned homebirths in the Nordic countries (Denmark, Iceland, Norway, Finland and Sweden).nnnDESIGN AND SETTINGnNational documents on homebirth and midwifery and recommendations regarding management and registration of planned homebirths in the included countries were investigated.nnnFINDINGSnGuidelines regarding planned home birth were found in four of the included countries. In Denmark any woman has the right to be attended by a midwife during a homebirth and each county council must present a plan for the organization of birth services, including homebirth services. In Norway and Iceland the service is fully or partly funded by taxes and national guidelines are available but access to a midwife attending the birth varies geographically. In the Stockholm County Council guidelines have been developed for publicly funding of planned home births; for the rest of Sweden no national guidelines have been formulated and the service is privately funded.nnnKEY CONCLUSIONnInconsistencies in the home birth services of the Nordic countries imply different opportunities for midwifery care to women with regard to their preferred place of birth. Uniform sociodemography, health care systems and cultural context in the Nordic countries are factors in favour of further research to compare and aggregate data on planned home births in this region. Additional data collection is needed since national registers do not sufficiently cover the planned place of birth.