Introduction: About sixty million of home deliveries occur worldwide every year. The vast majority of them in Low and Middle Income Countries (LMIC) where most of all out of health facility deliveries are attended by relatives and traditional births attendants . Poor hygienic conditions, ignorance of clean birth practices and lack of skills to manage the complications when they occur, make home deliveries unsafe for the mothers and their new-borns. Thus, getting pregnant women to give birth at health facility is critical in the efforts to improve reproductive health outcomes in many LMIC.

Background: Historically, the focus of the UK and international research exploring planned home birth decision making has been largely focused on understanding the experiences of women who decide to birth at home. As a result of high-profile research that suggests that non-OU birth locations are safe for low risk women, there has been a recent shift in focus resulting in research studies that aim to increase the rates of planned home birth, or more often the rates of all non-obstetric unit birth within the UK. However, despite this increased level of attention, the rate of home birth remains stubbornly low. Whilst there is some research to indicate why this might be the case, research that sheds a new light on the issue, and that develops an evidence base for new interventions is required. This thesis illuminates the factors that need to be considered in order to increase women’s abilities to make an informed decision about planned birth. Methodology: A pragmatic approach, using mixed methods, was used to explore the current way that we offer planned home birth to maternity service users, and to ultimately make suggestions about how this could be improved. The following studies have been undertaken: Study 1: Initial exploratory study: The case notes of one hundred and sixty nine women, from one health board and who had planned to birth at home, were audited. Non-participant observation of birth planning meetings at thirty-six weeks gestation were undertaken with seven community midwife and low-risk women dyads. These were followed by individual semi-structured interviews with the participants. Study 2: Scoping review: Qualitative and quantitative research, and non-research based literature, were analysed to produce a qualitative review of planned home birth decision making. Study 3: Active offer of planned home birth concept analysis The findings of the initial exploratory study and the scoping review, in addition to active offer literature that is predominantly applied to support the provision of services within minority official languages, were used to create an active offer of planned home birth. Study 4: Workshop study testing the findings of the concept analysis Narrative based exercises were used to explore the concept analysis findings with twenty previous service users who had birthed at home, nine previous service users who had chosen an institutional birth, and fourteen community midwives. Findings: Women will either take a ‘passive’ or ‘active’ approach to the offer of planned home birth, with a passive approach likely where no motivation for an active approach has been provided. Where a woman takes a passive approach, her ability to make an informed decision about planned home birth will depend on an active offer being made by her midwife. This will be most effective when it is supported by a midwife’s employing organisation. The findings of this thesis suggest that a two stage active offer of planned home birth (AOPHB) process, consisting of ‘Creating the conditions’ and ‘Positive reinforcement’ stages, can be used to underpin the offer of planned home birth. Discussion: There has previously been minimal understanding of how to facilitate the home birth decision making process, and a passive offer is routinely provided to women in the UK. The proposed two-stage AOPHB process provides a structured way for midwives to underpin their offer to women, in order that an increased percentage of women are able to make an informed decision about home birth and/or decide to birth at home. Where midwives apply the AOPHB, women who may take a passive approach could be ‘activated’ to engage in home birth decision making. A pilot intervention has been drafted to implement the AOPHB within clinical practice. The intervention provides support for the implementation of the two-stage AOPHB process through the use of individual components focused on midwives and their employing organisation; student midwives; and women, and their significant others. Implications: This thesis has contributed to the developing knowledge base about planned home birth decision making. The application of active offer theory to the offer of planned home birth has been undertaken for the first time, and this has generated a new and useful perspective on this area of midwifery practice. The resultant two-stage AOPHB process has the potential for developing midwifery practice in terms of supporting midwives to understand and facilitate women’s decision making around home birth, providing a flexible tool that can be used in clinical practice. This is the first approach that has been developed with the aim of increasing the ability of women to make an informed decision about whether they wish to birth at home. Additionally, the pilot AOPHB intervention has implications around the understanding of how employing organisations can best support midwives in this aspect of their role, and developing how student midwives are educated about offering home birth to women.

Thesis (Ph. D.)--UCLA, 2008. / Vita. Includes bibliographical references (leaves 387-400).

Thesis (M.S.)--University of Michigan, 1980.

Thesis (Ph. D.)--University of Washington, 1985. / Vita. Bibliography: leaves [507]-538.

Sedan början av 1900-talet har de flesta förlossningar skett på sjukhus och antalet hemförlossningar har minskat drastiskt. Idag är hemförlossningar ytterst ovanligt i Sverige och finns ej som ett vårdval trots att kvinnor har rätt till självbestämmande vad gäller sin graviditet och förlossning.  Syftet var att beskriva kvinnors anledningar till att välja hemförlossning.    En litteraturöversikt med ett systematiskt tillvägagångssätt utfördes som metod. Databassökning skedde i databaserna PubMed, CINAHL samt PsycInfo. Artiklarna kvalitetsgranskades och inkluderade artiklar analyserades med integrerad analys.   Studiens resultat mynnade ut i två huvudkategorier. Den första huvudkategorin var “på kvinnans egna villkor” med subkategorierna “egenmakt och kontroll”, “hemmet som en trygg plats”, “tron på den egna kroppen” och “den fysiologiska födseln” samt “val av närvarande personer”. Den andra huvudkategorin var “att undvika negativa upplevelser” med subkategorierna “tidigare negativa erfarenheter” och “viljan att undvika interventioner”.    Slutsatsen var att det finns olika anledningar till att kvinnor väljer hemförlossning där de främsta är att föda på sina egna villkor och önskan att undvika negativa upplevelser. Kvinnor vill ha inflytande över sin förlossning och ha möjlighet att välja personer som ska närvara och stödja kvinnan. Hon vill föda på en trygg och säker plats, hemmet, där hon har större möjlighet till en normal eller fysiologisk förlossning utan onödiga interventioner. För att främja kvinnors självbestämmande bör alternativ till sjukhusförlossning erbjudas. / Since the beginning of the twentieth century, the majority of births have taken place in hospitals, and the number of home births has decreased substantially. Home birth is utterly rare in Sweden, and it is not a publicly funded option for Swedish women, even though women should have the right to independently make decisions about their pregnancy and labor.   The aim of the study was to describe women’s reasons for choosing home birth.  A literature review with a systematic approach was the performed method. Databases used for this purpose were PubMed, CINAHL and PsycInfo. The articles were quality reviewed and analyzed through integrated analysis.    The findings of the study were presented in two main categories with appurtenant subcategories. The first main category was “the woman’s own terms” with subcategories “empowerment and control”, “the home environment is a safe space”, “belief in the body and the physiologic birth” and “choosing present people”. The second main category was “wanting to avoid negative experiences” with subcategories “previous negative experiences” and “wanting to avoid interventions”.  The conclusion was that there are various reasons why women choose home birth where the main reasons were to give birth on their own terms and a desire to avoid negative experiences. Women want to be able to influence their labor and have the opportunity to choose people who will be present and support the woman. She wants to give birth in a safe and secure place, her home, where she has a better chance for a normal and physiological birth without unnecessary interventions. In order to promote women's self-determination, alternatives to hospital birth should be offered.

Trata-se de um estudo descritivo, exploratório, cujo objetivo foi conhecer as vivências, preparação, sentimentos e motivações de mulheres que optaram por partos domiciliares. Participaram da pesquisa dez mulheres que tiveram, pelo menos, uma experiência de parto domiciliar, em Porto Alegre, nos últimos cinco anos. As informações foram coletadas por meio de entrevista semi-estruturada e analisadas segundo a proposta de Minayo, sendo organizadas em quatro grupos: motivações (decisão, influência familiar); preparação (preparo pessoal do ambiente); sentimentos (vulnerabilidades, fragilidades, medos); vivências (resgate da força feminina, parto e transformação pessoal, filho s). Os dados indicam que as mulheres que optaram por partos domiciliares não aceitam o que o sistema hospitalar atualmente oferece às parturientes e reconhecem que, para algumas, o parto hospitalar é a melhor opção, seja por questões que envolvem decisões pessoais ou de saúde. / This paper is aboul a descriptive exploralory study underlaken with the objective of getting acquainled wilh life experiences, preparalion, feelings and molivalions of women who opled for home delivery. The subjecls of lhe research comprised len women who had ai leasl one experience of home delivery in Porto Alegre, Brazil, in lhe lasl five years. Semi-structured inlerviews supplied ali of lhe informalion Ihal was analyzed according lo Minayo 's proposal and ciassified inlo four groups: molivalions (decision, family influence); preparation (personal and environmenlal preparalion); feelings (vulnerabilities, fragilities, fears) ; life experiences (rescue of women 's slrenglh, delivery and personal change, children). The dala indicate Ihallhe women, who opledfor home delivery, do nol accepl whallhe hospilal system offers lo women in labor ai presenl bul they do recognize thal, for a few women, hospilal delivery is lhe best choice for them, be il for reasons thal involve personal decisions or health ones. / Tratase de un estudio descriptivo exploratorio, cuyo objetivo fue conocer a las vivencias, preparación, sentimientos y motivaciones de las mujeres que eligieron parto en casa. Participaron de esta invesligación diez mujeres que tuvieron, por lo menos, una experiencia de parto en casa en Porto Alegre, Brasil, en los últimos cinco anos. Las informaciones fueron colecladas por medio de entrevisla semi-estructurada y analizadas a través de la propuesta de Minayo. Fueron enlonces clasificadas en cuatro grupos: motivaciones (decisión, influencia familiar); preparación (preparo personal y dei ambiente); sentimientos (vulnerabilidades, fragilidades, miedos); experiencias de vida (rescate de la fuerza femenina, parlo y transformación personal, hijos). Los datos indican que las mujeres, que eligieron parto en casa, no aceptan lo que el sistema hospitalar ofrece a las parturientas aclualmente pero reconocen que, para algunas mujeres, el parto hospitalar es la mejor opción para ellas, sea por razones que envuelven decisiones personales o de salud.

Trata-se de um estudo descritivo, exploratório, cujo objetivo foi conhecer as vivências, preparação, sentimentos e motivações de mulheres que optaram por partos domiciliares. Participaram da pesquisa dez mulheres que tiveram, pelo menos, uma experiência de parto domiciliar, em Porto Alegre, nos últimos cinco anos. As informações foram coletadas por meio de entrevista semi-estruturada e analisadas segundo a proposta de Minayo, sendo organizadas em quatro grupos: motivações (decisão, influência familiar); preparação (preparo pessoal do ambiente); sentimentos (vulnerabilidades, fragilidades, medos); vivências (resgate da força feminina, parto e transformação pessoal, filho s). Os dados indicam que as mulheres que optaram por partos domiciliares não aceitam o que o sistema hospitalar atualmente oferece às parturientes e reconhecem que, para algumas, o parto hospitalar é a melhor opção, seja por questões que envolvem decisões pessoais ou de saúde. / This paper is aboul a descriptive exploralory study underlaken with the objective of getting acquainled wilh life experiences, preparalion, feelings and molivalions of women who opled for home delivery. The subjecls of lhe research comprised len women who had ai leasl one experience of home delivery in Porto Alegre, Brazil, in lhe lasl five years. Semi-structured inlerviews supplied ali of lhe informalion Ihal was analyzed according lo Minayo 's proposal and ciassified inlo four groups: molivalions (decision, family influence); preparation (personal and environmenlal preparalion); feelings (vulnerabilities, fragilities, fears) ; life experiences (rescue of women 's slrenglh, delivery and personal change, children). The dala indicate Ihallhe women, who opledfor home delivery, do nol accepl whallhe hospilal system offers lo women in labor ai presenl bul they do recognize thal, for a few women, hospilal delivery is lhe best choice for them, be il for reasons thal involve personal decisions or health ones. / Tratase de un estudio descriptivo exploratorio, cuyo objetivo fue conocer a las vivencias, preparación, sentimientos y motivaciones de las mujeres que eligieron parto en casa. Participaron de esta invesligación diez mujeres que tuvieron, por lo menos, una experiencia de parto en casa en Porto Alegre, Brasil, en los últimos cinco anos. Las informaciones fueron colecladas por medio de entrevisla semi-estructurada y analizadas a través de la propuesta de Minayo. Fueron enlonces clasificadas en cuatro grupos: motivaciones (decisión, influencia familiar); preparación (preparo personal y dei ambiente); sentimientos (vulnerabilidades, fragilidades, miedos); experiencias de vida (rescate de la fuerza femenina, parlo y transformación personal, hijos). Los datos indican que las mujeres, que eligieron parto en casa, no aceptan lo que el sistema hospitalar ofrece a las parturientas aclualmente pero reconocen que, para algunas mujeres, el parto hospitalar es la mejor opción para ellas, sea por razones que envuelven decisiones personales o de salud.

Trata-se de um estudo descritivo, exploratório, cujo objetivo foi conhecer as vivências, preparação, sentimentos e motivações de mulheres que optaram por partos domiciliares. Participaram da pesquisa dez mulheres que tiveram, pelo menos, uma experiência de parto domiciliar, em Porto Alegre, nos últimos cinco anos. As informações foram coletadas por meio de entrevista semi-estruturada e analisadas segundo a proposta de Minayo, sendo organizadas em quatro grupos: motivações (decisão, influência familiar); preparação (preparo pessoal do ambiente); sentimentos (vulnerabilidades, fragilidades, medos); vivências (resgate da força feminina, parto e transformação pessoal, filho s). Os dados indicam que as mulheres que optaram por partos domiciliares não aceitam o que o sistema hospitalar atualmente oferece às parturientes e reconhecem que, para algumas, o parto hospitalar é a melhor opção, seja por questões que envolvem decisões pessoais ou de saúde. / This paper is aboul a descriptive exploralory study underlaken with the objective of getting acquainled wilh life experiences, preparalion, feelings and molivalions of women who opled for home delivery. The subjecls of lhe research comprised len women who had ai leasl one experience of home delivery in Porto Alegre, Brazil, in lhe lasl five years. Semi-structured inlerviews supplied ali of lhe informalion Ihal was analyzed according lo Minayo 's proposal and ciassified inlo four groups: molivalions (decision, family influence); preparation (personal and environmenlal preparalion); feelings (vulnerabilities, fragilities, fears) ; life experiences (rescue of women 's slrenglh, delivery and personal change, children). The dala indicate Ihallhe women, who opledfor home delivery, do nol accepl whallhe hospilal system offers lo women in labor ai presenl bul they do recognize thal, for a few women, hospilal delivery is lhe best choice for them, be il for reasons thal involve personal decisions or health ones. / Tratase de un estudio descriptivo exploratorio, cuyo objetivo fue conocer a las vivencias, preparación, sentimientos y motivaciones de las mujeres que eligieron parto en casa. Participaron de esta invesligación diez mujeres que tuvieron, por lo menos, una experiencia de parto en casa en Porto Alegre, Brasil, en los últimos cinco anos. Las informaciones fueron colecladas por medio de entrevisla semi-estructurada y analizadas a través de la propuesta de Minayo. Fueron enlonces clasificadas en cuatro grupos: motivaciones (decisión, influencia familiar); preparación (preparo personal y dei ambiente); sentimientos (vulnerabilidades, fragilidades, miedos); experiencias de vida (rescate de la fuerza femenina, parlo y transformación personal, hijos). Los datos indican que las mujeres, que eligieron parto en casa, no aceptan lo que el sistema hospitalar ofrece a las parturientas aclualmente pero reconocen que, para algunas mujeres, el parto hospitalar es la mejor opción para ellas, sea por razones que envuelven decisiones personales o de salud.

The topic of this thesis is woman's experience with natural childbirth and its potential for disruption of medical discourse, which is in the Czech Republic in obstetrics still dominating. Through the method of discoursive analysis I am trying to generate any behavior that may be in conflict with social expectations and may question norms and standards in the field of pregnancy and obstetrics. I am also trying to trace whether and how does the deepening and gaining of the birth knowledge lead to the transformation of woman's identity. Theoretically, the work is grounded in a post-structuralist paradigm and builds on the concepts of biopower, performative acting and authoritative knowledge. Data sources are stories written in support of a midwife Ivana Königsmarková and published on the internet (www.pribehyproivanu.cz).