Thesis advisor: Joyce K. Edmonds / Background: Midwifery-led birth centers (BC) provide positive perinatal outcomes for women and birthing people at low perinatal risk that exceed national outcomes in the United States. Yet, less than 1% of all births occur in BCs. The Coxon conceptual model of birth setting decision-making provides the most comprehensive research framework about how people decide where to give birth. Research is essential for the promotion of an informed decision-making approach regarding birth setting options and the facilitation of access to high value BC care. This dissertation aims to study birth setting decision-making, specifically decision-making about BCs, in the United States. Methods: Three methods were used to address the overall dissertation aim. An integrative review was conducted to evaluate factors influencing birth setting decision-making in the United States, examining research studies from 2011-2022. A secondary data analysis of the population- based Listening to Mothers in California survey identified factors associated with interest in BC care in a future pregnancy among respondents who experienced hospital birth in California. Finally, a hermeneutic phenomenological study was conducted to explore the decision-making experiences of participants with Medicaid health insurance and who chose to give birth in a freestanding BC in Massachusetts. Results: Four themes were generated from 23 research studies included in the integrative review. The themes represented factors influencing birth setting decision-making in the United States: Birth Setting Safety Versus Risk, Influence of Media, Family, and Friends on Birth Setting Awareness, Presence or Absence of Choice and Control, and Access To Options. In the Listening to Mothers in California survey, respondents (N = 1447) were more likely to express interest in future BC care if they had experienced pressure from health professionals to have an obstetric intervention, believed childbirth is a process that should not be interfered with unless medically necessary, sought information about hospital cesarean rates, had a doula in labor, and experienced mistreatment. Finally, qualitative data from participant interviews (N = 12) generated five analytic themes that described the BC decision-making process: Desire to Step Away From “the System,” Access to Birth Center Care, Influence of Partners, Family, Friends, the Media, and Birth Workers, the Built Environment of the BC, and the Temporal Dynamics of Decision- Making. Conclusions: The findings from this dissertation extend our knowledge about BCs as a unique and necessary decision process and choice for perinatal care in the United States. Illuminating why and how people decide to seek care at BCs is vital to expanding access and supporting informed, values-based decision-making about birth settings. By making specifications and refinements to the Coxon conceptual model about birth-setting decision-making, a novel pathway is now available for further research and discovery about how people decide where to give birth in the United States and how to best support their choice. / Thesis (PhD) — Boston College, 2023. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

No description available.

Este estudo de caso buscou caracterizar a clientela de camadas populares e médias de um serviço de saúde \"alternativo\", com uma proposta de parto ambulatorial realizado fora do hospital, assistido por obstetrizes. Seu objetivo principal foi o de compreender a forma como ambas as clientelas conheceram e passaram a freqüentar esse serviço e os motivos que as levaram a fazerem essa opção, buscando reconhecer semelhanças e diferenças entre elas. O serviço em estudo foi o ambulatório e a Casa de Parto da Associação Comunitária Monte Azul - ACOMA, associação antroposófica que tinha, por objetivo, prestar serviços de saúde, prioritariamente, a moradores de duas favelas e do bairro em que se situa. A análise parte de uma abordagem antropológica, na qual a parturição é vista como uma arena, em que concepções e práticas conflitantes e competitivas se confrontam e se articulam. Foram utilizados métodos e técnicas qualitativos e quantitativos. A realização de entrevistas semi-abertas, visando a apreender as narrativas dos sujeitos acerca de suas vivências de gestação e parto, ao lado da observação participante de consultas de pré-natal e parto foram os principais instrumentos da análise qualitativa empreendida. Foi usada metodologia quantitativa para caracterizar o cenário da investigação, em que se procurou traçar o perfil sócio-epidemiológico de 564 mulheres atendidas nesse serviço, no período entre abril de 1995 e março de 1998, e de seus recém- nascidos, a partir das Declarações de Nascidos Vivos. Os resultados do levantamento sócioepidemiológico indicam que a maioria de sua clientela (77,2%) reside fora da área de abrangência prioritária da ACOMA. Por outro lado, a grande maioria dessas mulheres (93,5%) pertence aos estratos mais pobres da população do Município de São Paulo. As maneiras pelas quais a clientela soube da existência desse serviço e padrões de freqüência ao pré-natal são descritas e analisadas, quantitativa e qualitativamente, apontando para continuidades e descontinuidades entre a clientela \"particular\" e de \"usuárias\". Destaca-se que, para muitas \"usuárias\", a ACOMA era o serviço de prénatal mais freqüentado na gestação, e 44,2% dessas, deram à luz no mesmo serviço. A tendência predominante entre as \"clientes particulares\", por outro lado, era a de realizarem o pré-natal, simultaneamente, nesse e em outro serviço, pois procuravam a ACOMA, com a intenção de evitarem um parto hospitalar e de conferirem a proposta de parto do mesmo. As razões apresentadas e que levaram à escolha desse serviço para realizarem o parto foram múltiplas e complexas e acompanhadas de constrangimentos de ordem sócio-econômica e cultural. Entre elas, destacaram-se, o relacionamento com profissionais de saúde, a percepção de riscos em relação ao parto e a possibilidade de contar com acompanhantes de sua escolha, no momento do parto. Entre as \"usuárias\", o maior temor em relação ao parto hospitalar era o de não ter acesso a um leito, na hora necessária, e, entre as \"clientes particulares\", temia-se a cesárea desnecessária. Questões que se colocaram e que merecem ser aprofundadas referem-se a certas noções e valores em relação à sexualidade e à maternidade e sua associação com noções de \"modernidade\" em relação à família e ao parto, bem como sobre o processo de constituição da autoridade cultural e social de profissionais de saúde. / This study describes some of the characteristics of lower and middle class clients of an \"alternative\" health care center in which midwives were assigned to maternity care in an out clinic. It\'s primary objective was to understand how clients became familiar with the proposal; the patterns of attendance; why they chose this form of maternity care in a context where hospital birth is predominant, and whether there were significant differences in these patterns according to social class. This study was conducted at the Monte Azul Clinic and Birth Center, administrated by the Monte Azul Community Association (ACOMA). The latter is an anthroposophical association, whose basic objective is to attend to demands of the inhabitants of two shanty towns and the surrounding neighborhood. An anthropological approach in which birth is viewed as an arena where conflicting and competitve concepts and pratices are articulated and confront themselves is adopted in analysis. Qualitative and quantitative methods and techniques were employed. Interviews focused on the experiences with respect to pregnancy and birthing among the subjects of this study. Participant observation of pre-natal consultations and of childbirths were also conducted. In order to characterize the context of the field of research, quantitative methodology was employed. A social and epidemiological profile was constructed of the 564 women (as well as their newborns) who gave birth between April 1995 and March 1998, receiving maternity care from midwives working at the Clinic and Birth Center during this period. For this purpose data was collected from the Declaração de Nascidos Vivos - Live Birth Form, a document from the Ministry of Health, filled out at birth by the birth attendant which records data concerning live births. Results indicate that the majority of it\'s clients (77,2%) did not live within the association\'s \"target\" community. On the other hand, data indicates that the majority of women attended (93,5%) belonged to the poorest segments of the population of Sao Paulo City. How clients were informed about the existence of this Clinic and Birth Center as well as patterns of attendance are described and analyzed using quantitative and qualitative approaches. Continuities and discontinuities with respect to these patterns among the Clinic\'s clients and the midwives\' private clients are described and analyzed. Many of the Clinic\'s clients, recurred to this service predominantly for their prenatal checkups and 44,2% of these women recurred to the midwives\' assistance for maternity care. Among the midwives\' private patients, on the other hand, the predominant tendency was to do prenatal checkups simultaneously at the clinic and at other clinics where they were attended by obstetricians. The latter wanted to avoid hospital maternity care and attended prenatal checkups so as to confer and perhaps adhere to the midwives\' proposal of maternity care. Reasons presented with respect to choice of care in childbirth are multiple and complex, involving social, economic and cultural constraints. Among the reasons referred to in the interviews, the most recurrent were the quality of the relationship established with the health professionals; perception of risks with respect to childbirth; and the possibility of having support persons of their choice present during labour and childbirth. Among the clinic\'s clients, the fear of not gaining access to a hospital bed in due time was their major concern with respect to hospital maternity care. Among the midwives\' private patients, the fear of being submitted to a unnecessary cesarean section was a major concern with respect to hospital maternity care. Themes which emerged in this study and require further research include notions of \'modernity\' and their association to concepts and values concerning sexuality and maternity as well as questions related to the construction of cultural and social authority.

Este estudo de caso buscou caracterizar a clientela de camadas populares e médias de um serviço de saúde \"alternativo\", com uma proposta de parto ambulatorial realizado fora do hospital, assistido por obstetrizes. Seu objetivo principal foi o de compreender a forma como ambas as clientelas conheceram e passaram a freqüentar esse serviço e os motivos que as levaram a fazerem essa opção, buscando reconhecer semelhanças e diferenças entre elas. O serviço em estudo foi o ambulatório e a Casa de Parto da Associação Comunitária Monte Azul - ACOMA, associação antroposófica que tinha, por objetivo, prestar serviços de saúde, prioritariamente, a moradores de duas favelas e do bairro em que se situa. A análise parte de uma abordagem antropológica, na qual a parturição é vista como uma arena, em que concepções e práticas conflitantes e competitivas se confrontam e se articulam. Foram utilizados métodos e técnicas qualitativos e quantitativos. A realização de entrevistas semi-abertas, visando a apreender as narrativas dos sujeitos acerca de suas vivências de gestação e parto, ao lado da observação participante de consultas de pré-natal e parto foram os principais instrumentos da análise qualitativa empreendida. Foi usada metodologia quantitativa para caracterizar o cenário da investigação, em que se procurou traçar o perfil sócio-epidemiológico de 564 mulheres atendidas nesse serviço, no período entre abril de 1995 e março de 1998, e de seus recém- nascidos, a partir das Declarações de Nascidos Vivos. Os resultados do levantamento sócioepidemiológico indicam que a maioria de sua clientela (77,2%) reside fora da área de abrangência prioritária da ACOMA. Por outro lado, a grande maioria dessas mulheres (93,5%) pertence aos estratos mais pobres da população do Município de São Paulo. As maneiras pelas quais a clientela soube da existência desse serviço e padrões de freqüência ao pré-natal são descritas e analisadas, quantitativa e qualitativamente, apontando para continuidades e descontinuidades entre a clientela \"particular\" e de \"usuárias\". Destaca-se que, para muitas \"usuárias\", a ACOMA era o serviço de prénatal mais freqüentado na gestação, e 44,2% dessas, deram à luz no mesmo serviço. A tendência predominante entre as \"clientes particulares\", por outro lado, era a de realizarem o pré-natal, simultaneamente, nesse e em outro serviço, pois procuravam a ACOMA, com a intenção de evitarem um parto hospitalar e de conferirem a proposta de parto do mesmo. As razões apresentadas e que levaram à escolha desse serviço para realizarem o parto foram múltiplas e complexas e acompanhadas de constrangimentos de ordem sócio-econômica e cultural. Entre elas, destacaram-se, o relacionamento com profissionais de saúde, a percepção de riscos em relação ao parto e a possibilidade de contar com acompanhantes de sua escolha, no momento do parto. Entre as \"usuárias\", o maior temor em relação ao parto hospitalar era o de não ter acesso a um leito, na hora necessária, e, entre as \"clientes particulares\", temia-se a cesárea desnecessária. Questões que se colocaram e que merecem ser aprofundadas referem-se a certas noções e valores em relação à sexualidade e à maternidade e sua associação com noções de \"modernidade\" em relação à família e ao parto, bem como sobre o processo de constituição da autoridade cultural e social de profissionais de saúde. / This study describes some of the characteristics of lower and middle class clients of an \"alternative\" health care center in which midwives were assigned to maternity care in an out clinic. It\'s primary objective was to understand how clients became familiar with the proposal; the patterns of attendance; why they chose this form of maternity care in a context where hospital birth is predominant, and whether there were significant differences in these patterns according to social class. This study was conducted at the Monte Azul Clinic and Birth Center, administrated by the Monte Azul Community Association (ACOMA). The latter is an anthroposophical association, whose basic objective is to attend to demands of the inhabitants of two shanty towns and the surrounding neighborhood. An anthropological approach in which birth is viewed as an arena where conflicting and competitve concepts and pratices are articulated and confront themselves is adopted in analysis. Qualitative and quantitative methods and techniques were employed. Interviews focused on the experiences with respect to pregnancy and birthing among the subjects of this study. Participant observation of pre-natal consultations and of childbirths were also conducted. In order to characterize the context of the field of research, quantitative methodology was employed. A social and epidemiological profile was constructed of the 564 women (as well as their newborns) who gave birth between April 1995 and March 1998, receiving maternity care from midwives working at the Clinic and Birth Center during this period. For this purpose data was collected from the Declaração de Nascidos Vivos - Live Birth Form, a document from the Ministry of Health, filled out at birth by the birth attendant which records data concerning live births. Results indicate that the majority of it\'s clients (77,2%) did not live within the association\'s \"target\" community. On the other hand, data indicates that the majority of women attended (93,5%) belonged to the poorest segments of the population of Sao Paulo City. How clients were informed about the existence of this Clinic and Birth Center as well as patterns of attendance are described and analyzed using quantitative and qualitative approaches. Continuities and discontinuities with respect to these patterns among the Clinic\'s clients and the midwives\' private clients are described and analyzed. Many of the Clinic\'s clients, recurred to this service predominantly for their prenatal checkups and 44,2% of these women recurred to the midwives\' assistance for maternity care. Among the midwives\' private patients, on the other hand, the predominant tendency was to do prenatal checkups simultaneously at the clinic and at other clinics where they were attended by obstetricians. The latter wanted to avoid hospital maternity care and attended prenatal checkups so as to confer and perhaps adhere to the midwives\' proposal of maternity care. Reasons presented with respect to choice of care in childbirth are multiple and complex, involving social, economic and cultural constraints. Among the reasons referred to in the interviews, the most recurrent were the quality of the relationship established with the health professionals; perception of risks with respect to childbirth; and the possibility of having support persons of their choice present during labour and childbirth. Among the clinic\'s clients, the fear of not gaining access to a hospital bed in due time was their major concern with respect to hospital maternity care. Among the midwives\' private patients, the fear of being submitted to a unnecessary cesarean section was a major concern with respect to hospital maternity care. Themes which emerged in this study and require further research include notions of \'modernity\' and their association to concepts and values concerning sexuality and maternity as well as questions related to the construction of cultural and social authority.