Women’s motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis

Abstract

BackgroundHome births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. Until now there were no qualitative data on women’s motivations for these choices in the Dutch maternity care system where integrated midwifery care and home birth are regular options in low risk pregnancies. We aimed to examine women’s motivations for birthing outside the system in order to provide medical professionals with insight and recommendations regarding their interactions with women who have birth wishes that go against medical advice.MethodsAn exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with 28 women on their motivations for going against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. A focus group was held for a member check of the findings.ResultsFour main themes were found: 1) Discrepancy in the definition of superior knowledge, 2) Need for autonomy and trust in the birth process, 3) Conflict during negotiation of the birth plan, and 4) Search for different care. One overarching theme emerged that covered all other themes: Fear. This theme refers both to the participants’ fear (of interventions and negative consequences of their choices) and to the providers’ fear (of a bad outcome). Where for some women it was a positive choice, for the majority of women in this study the choice for a home birth in a high risk pregnancy or an unassisted childbirth was a negative one. Negative choices were due to previous or current negative experiences with maternity care and/or conflict surrounding the birth plan.ConclusionsThe main goal of working with women whose birthing choices do not align with medical advice should not be to coerce them into the framework of protocols and guidelines but to prevent negative choices.Recommendations for maternity caregivers can be summarized as: 1) Rethink risk discourse, 2) Respect a woman’s trust in the birth process and her autonomous choice, 3) Have a flexible approach to negotiating the birth plan using the model of shared decision making, 4) Be aware of alternative delivery care providers and other sources of information used by women, and 5) Provide maternity care without spreading or using fear.

‘She convinced me’- partner involvement in choosing a high risk birth setting against medical advice in the Netherlands: A qualitative analysis

“…This is in line with other studies [18][19][20]22,33], where the pregnant woman initiated conversations about birth options that were against convention or medical recommendation. Often these plans originated in a previous traumatic experience in maternity care, where the women experienced a cascade of interventions and lack of shared decision making [18,20,24,28]. The overarching theme of 'fear' (of unnecessary intervention, loss of autonomy, provider's fear of bad outcome and legal ramifications) from our previous study on women's motivations [24] was not found to be an important factor in this current study.…”

“…All partners were contacted through the women. The interviews with the women were the subject of previously published research by this group [24]. All partners who were asked for an interview agreed to be interviewed.…”

“…Both choices are explicitly against medical advice. In 2017, we published a qualitative study among 28 women who made such a choice, examining their motivations for doing so [24]. The themes that emerged from these interviews centered around dissatisfaction with the regular system of maternity care, trust in nature and their own capacity for giving birth, conflict with maternity care professionals and a search for alternative care.…”

Women desiring less care than recommended during childbirth: Three years of dedicated clinic

“…7 Medical reasons for recommending hospital birth under supervision of an obstetrician are outlined in the Dutch national multidisciplinary list of recommendations, "the VIL. Their motivations to decline recommended care aligned with those of the women in our previous qualitative study, including disagreement about what constituted "superior knowledge," a need for autonomy and trust in the natural birth process, a conflict (elsewhere) in the negotiation of their birth plan, and a search for the type of care that they wanted.…”

“…Their motivations to decline recommended care aligned with those of the women in our previous qualitative study, including disagreement about what constituted "superior knowledge," a need for autonomy and trust in the natural birth process, a conflict (elsewhere) in the negotiation of their birth plan, and a search for the type of care that they wanted. 7 Medical reasons for recommending hospital birth under supervision of an obstetrician are outlined in the Dutch national multidisciplinary list of recommendations, "the VIL. "…”