Factors Associated with Health Care Access for Ohio Mothers Who Chose Home Birth

Factors Associated with Health Care Access for Ohio Mothers who Chose Home Birth

THESIS

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University

Martha Catherine Nieset

Graduate Program in Rural Sociology

The Ohio State University

2013

Master's Examination Committee:

Professor Joseph Donnermeyer, Advisor

Professor Cathy Rakowski

Copyrighted by

Martha Catherine Nieset

2013

Abstract

Every year in Ohio and throughout the United States women of childbearing age are increasingly making the decision to forgo the hospital setting and give birth at home.

The evidence has shown that women’s decisions to birth at home are highly influenced by their desire for greater control over their birth process in order to avoid unnecessary, technology-intensive interventions in the normal birth process. The body of research has demonstrated similar safety ratings for both the mother and child in planned low-risk home and hospital births attended by skilled providers. Compared with low-risk hospital births, outcomes of intended home births have consistently shown considerably lower rates of medical intervention in episiotomy, electronic fetal monitoring, caesarean section, and vacuum extraction with home birth care providers receiving higher client satisfaction ratings than their in-hospital counterparts. Currently over half of U.S. states regulate home birth midwife practice (most commonly the Certified Professional

Midwife, CPM) through some form of licensure or statute. Ohio currently does not regulate the practice, leaving women seeking a midwife for a home birth without a legally recognized care provider. Recognizing home birth as an option, tracking down a home birth midwife, and going through an entire pregnancy planning a home birth are not highly visible options for the majority of women in part because of the uncertainty

around home midwifery practice and the potential for it to be construed as “practicing medicine without a license” and prosecuted as such. Though prosecution is infrequent in

Ohio, most midwives practice with caution, receiving clients by word of mouth and association rather than advertising online or from a public business model. Beyond the fact that we know home birth is happening in Ohio and that it is increasing at a high rate, very little has been demonstrated in the research about how women find their midwives and their experiences with that care. This research was carried out using an online, anonymous survey distributed through social media and email community lists. Surveys sought participation from Ohio mothers who had planned a home birth for their child in the previous 5 year time period. The results yielded participation by 365 women, an estimated 10% of the potential sample size. While demographically the sample was similar to prior studies of U.S. home birth populations, new information and characteristics of the population and their choices were revealed. The results of the study painted a picture of women planning and seeking home birth, somewhat contrary to the risk-taking, anti-doctor, technology-averse, picture of which home birthing women are typically painted in American popular culture. A majority of the women who planned home births were highly educated, concerned with safety, sought a backup or collaborative healthcare physician, and participated in ultrasound testing. Other findings revealed the difficulties the women faced in obtaining an appropriate care provider: traveling longer distances to receive care, few care provider options, paying fees out of

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pocket, and hiring midwives later in their pregnancy. The results of the study indicate the need for policy in Ohio to improve access to qualified home birth health care providers.

Acknowledgments

I would like to personally thank all those who have supported me along the way in my graduate work and for this thesis in particular. It has been a long journey and would not be coming to completion without the support of many good people. Thank you most of all to my advisor Joe Donnermeyer, the countless hours you’ve spent meeting with me reading and discussing the research has been a major support for me in this step by step process. Thank you for your time and patience and most of all your encouragement.

Next I’d like to thank my family members, friends, and colleagues who have also been a major source of encouragement for me. I couldn’t have done it without you. Thank you also to Cathy Rakowski my committee member and teacher for your suggestions, the program coordinators in the School of Environment and Natural Resources, and The

Ohio State University for your direction and the opportunity.

Vita

May 1993 ...... St. Joseph Central Catholic High School

1998...... B.A. Psychology, Bowling Green State

University

2000 to 2003 ...... Software Administrator, Center for

Information Services

2003 to 2013 ...... Information Analyst, College of Arts and

Sciences, The Ohio State University

2013 to present……………………………….Enrollment Analyst, Office of Institutional

Effectiveness, Columbus State

Community College

Fields of Study

Major Field: Rural Sociology

Table of Contents

Abstract ...... ii

Acknowledgments...... v

Vita ...... vi

List of Tables ...... xi

List of Figures ...... xviii

Chapter 1: Introduction ...... 1

Purpose of Study ...... 2

Research Objectives ...... 4

Significance of Study ...... 5

Chapter 2 - Literature Review and Study Framework ...... 8

Home Birth Safety ...... 9

Home Birth Choice...... 15

Researching Accessibility ...... 18

Health Policy ...... 18 vii

Characteristics of the Health Delivery System ...... 21

Utilization of Health Services ...... 22

Characteristics of the Population at Risk ...... 22

Consumer Satisfaction ...... 22

The following is a short glossary of terms used throughout this thesis...... 23

Chapter 3 - Methods...... 27

Research Design ...... 27

Subject Selection ...... 29

Instrument Construction ...... 30

Data Collection ...... 31

Process and Timeline for Data Collection...... 31

Sample Limitations ...... 41

Chapter 4 – Results ...... 43

Reasons for Home Birth ...... 43

Characteristics of the Population...... 51

Characteristics of the Health Delivery System ...... 58

Utilization of Health Services ...... 68

Consumer Satisfaction...... 79

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Data Analysis ...... 80

Age...... 82

Education ...... 89

Income ...... 98

Metro/Non-metro Residence ...... 106

Chapter 5 - Discussion ...... 114

Introduction ...... 114

Summary of Conclusions ...... 116

Home Birth Population ...... 116

Characteristics of the Home Birth Delivery System ...... 117

Utilization of Services ...... 119

Satisfaction ...... 121

Research Limitations and Recommendations ...... 122

Instrument Limitations ...... 125

References ...... 127

Appendix A: Survey Instrument ...... 136

Survey: Ohio Women who have had a Planned Home Birth...... 136

SECTION 1 ...... 138

SECTION 2 - (Please answer Section 2 if your most recent planned home birth was

midwife-assisted ...... 147

SECTION 3 - Please answer Section 3 if your most recent planned home birth was

unassisted (others please skip to Section 4) ...... 155

SECTION 4 - (Everyone please complete) ...... 157

Appendix B: Write-in Responses to the Question “How did you first become aware of home birth as a birthing option?” ...... 161

Appendix C: Write-in Responses to the Question about Midwife/Midwife-team Training and Credentials...... 175

List of Tables

Table 1. Top Referrers (Summary provided by Bit.ly) ...... 35

Table 2. Organizations Through Which the Survey Link was Promoted ...... 39

Table 3. Primary Reasons Provided by Respondents for Choosing to Home Birth ...... 46

Table 4. Comments Reflecting Reasons Given for Choosing to Birth at Home (in Table

3) ...... 48

Table 5. Comments Reflecting New Themes for Choosing to Birth at Home ...... 49

Table 6. Mother’s Level of Education at the Time of Most Recent Planned Home Birth 52

Table 7. Mother’s Age at the Time of Most Recent Planned Home Birth ...... 52

Table 8. Mother’s Race/Ethnicity ...... 53

Table 9. Zip Code or City/State Where Mother Lived at the Time of Most Recent Planned

Home Birth...... 54

Table 10. Mother’s Perception of her Economic Status ...... 55

Table 11. Participating Mother’s Family Income ...... 55

Table 12. Mother’s Residency in Ohio ...... 56

Table 13. Total Number of Children Birthed by the Mother ...... 57

Table 14. Mothers Surveyed with Prior Cesarean Section ...... 57

Table 15. Primary Ways Indicated by Mothers’ of How They Came in Contact with Their

Midwives...... 58

Table 16. Themes from Comments Reflecting How Mothers Came in Contact with Their

Midwives...... 60

Table 17. Midwives Available in the Mother’s Area ...... 62

Table 18. Mother’s Distance from her Midwife or the Nearest Midwife-team Member . 63

Table 19. Credentials/Training of Midwife(s) Attending the Birth ...... 64

Table 20. Fee Charged by Midwife for Services ...... 65

Table 21. How the Midwife Fees were Paid ...... 66

Table 22. : Location for the Majority of Prenatal Check-ups ...... 67

Table 23. Planned Birth Location Distance from Nearest Hospital ...... 68

Table 24. Intended Type of Home Birth ...... 69

Table 25. Intended Home Birth Location (In/out of state) ...... 69

Table 26. Intended Home Birth Location ...... 70

Table 27. Actual Home Birth Location...... 70

Table 28. Month that Mother Hired Midwife ...... 71

Table 29. Social Pressure Affect on Hiring Midwife ...... 72

Table 30. Number of Non-midwives in the Birthing Room with Mother (Adults) ...... 72

Table 31. Number of Non-midwives in the Birthing Room with Mother (Children) ...... 73

Table 32. Number of Midwives Who Attended Home Birth...... 74

Table 33. Approximate Number of Prenatal Check-ups with a Midwife ...... 74

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Table 34. Approximate Number of Postnatal Check-ups with a Midwife ...... 75

Table 35. Switched Midwives During Pregnancy ...... 76

Table 36. Ultrasound During Pregnancy ...... 76

Table 37. Prenatal Check-ups with a Doctor ...... 77

Table 38. Reason for Prenatal Check-ups with a Doctor ...... 78

Table 39. Approximate Number of Prenatal Check-ups with a Doctor ...... 78

Table 40. Had a Specific Back up Doctor Planned ...... 79

Table 41. Satisfaction Level with Midwife Services ...... 79

Table 42. Would Hire a Midwife Attendant Again ...... 80

Table 43. Respondent's Age and Planned a Specific Back up Doctor for the Birth...... 82

Table 44. Respondent's Age and Contacted the Midwife through Online Resource...... 83

Table 45. Respondent's Age and Contacted the Midwife Through a Network or

Organization...... 83

Table 46. Respondent's Age and Contacted the Midwife Through an Interpersonal

Contact...... 84

Table 47. Respondent's Age and Distance to Nearest Hospital...... 84

Table 48. Respondent's Age and Number of Midwives or Midwife-teams Available to

Choose From...... 85

Table 49. Respondent's Age and Whether the Respondent Saw a Doctor During the

Prenatal Period...... 85

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Table 50. Respondent's Age and Whether the Respondent Saw an Obstetrician

Gynecologist (ObGyn) Doctor During the Prenatal Period...... 86

Table 51. Respondent's Age and Whether the Respondent Saw a Doctor that was Not an

Obstetrician Gynecologist (ObGyn) During the Prenatal Period...... 87

Table 52. Respondent's Age and Location of the Majority of Prenatal Appointments. ... 87

Table 53. Respondent's Age and Ultrasounds During Pregnancy...... 88

Table 54. Respondent's Age and Month that She Hired Midwife or Midwife-team...... 89

Table 55. Participant's Education and Planned a Specific Back up Doctor for the Birth. 90

Table 56. Participant's Education and Contacted the Midwife Through Online Resource.

...... 91

Table 57. Participant's Education and Contacted the Midwife Through a Network or

Organization...... 91

Table 58. Participant's Education and Contacted the Midwife Through an Interpersonal

Contact...... 92

Table 59. Participant's Education and Distance to Nearest Hospital...... 92

Table 60. Participant's Education and Number of Midwives or Midwife-teams Available to Choose From...... 93

Table 61. Participant's Education and Whether the Respondent Saw a Doctor During the

Prenatal Period...... 94

Table 62. Participant's Education and Whether the Respondent Saw an Obstetrician

Gynecologist (ObGyn) Doctor During the Prenatal Period...... 95

xiv

Table 63. Participant's Education and Whether the Respondent Saw a Doctor that was

Not an Obstetrician Gynecologist (ObGyn) During the Prenatal Period...... 96

Table 64. Participant's Education and Location of the Majority of Prenatal Appointments.

...... 96

Table 65. Participant's Education and Ultrasounds During Pregnancy...... 97

Table 66. Participant's Education and Month that She Hired Midwife or Midwife-team. 97

Table 67. Family Income and Planned a Specific Back up Doctor for the Birth...... 99

Table 68. Family Income and Contacted the Midwife Through Online Resource...... 99

Table 69. Family Income and Contacted the Midwife Through a Network or

Organization...... 100

Table 70. Family Income and Contacted the Midwife Through an Interpersonal Contact.

...... 100

Table 71. Family Income and Distance to Nearest Hospital...... 101

Table 72. Family Income and Number of Midwives or Midwife-teams Available to

Choose From...... 101

Table 73. Family Income and Whether the Respondent Saw a Doctor During the Prenatal

Period...... 102

Table 74. Family Income and Whether the Respondent Saw an Obstetrician Gynecologist

(ObGyn) Doctor During the Prenatal Period...... 103

Table 75. Family Income and Whether the Respondent Saw a Doctor that was Not an

Obstetrician Gynecologist (ObGyn) During the Prenatal Period...... 103

Table 76. Family Income and Location of the Majority of Prenatal Appointments...... 104

Table 77. Family Income and Ultrasounds During Pregnancy...... 104

Table 78. Family Income and Month that Mother Hired Midwife or Midwife-team. .... 105

Table 79. Respondent's Residence at time of Most Recent Planned Home Birth and

Whether the Respondent had a Specific Back up Doctor Planned for the Birth...... 107

Table 80. Respondent's Residence at time of Most Recent Planned Home Birth and

Contacted the Midwife Through Online Resource...... 107

Table 81. Respondent's Residence at Time of Most Recent Planned Home Birth and

Contacted the Midwife Through a Network or Organization...... 108

Table 82. Respondent's Residence at time of Most Recent Planned Home Birth and

Contacted the Midwife Through an Interpersonal Contact...... 108

Table 83. Respondent's Residence at Time of Most Recent Planned Home Birth and

Distance to Nearest Hospital...... 109

Table 84. Respondent's Residence at Time of Most Recent Planned Home Birth and

Number of Midwives or Midwife-teams Available to Choose From...... 109

Table 85. Respondent's Residence at Time of Most Recent Planned Home Birth and

Whether the Respondent Saw a Doctor During the Prenatal Period...... 110

Table 86. Respondent's Residence at Time of Most Recent Planned Home Birth and

Whether the Respondent Saw an Obstetrician Gynecologist During the Prenatal Period.

...... 110

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Table 87. Respondent's Residence at time of Most Recent Planned Home Birth and

Whether the Respondent Saw a Doctor that was Not an Obstetrician Gynecologist

(ObGyn) During the Prenatal Period...... 111

Table 88. Respondent's Residence at Time of Most Recent Planned Home Birth and

Location of the Majority of Prenatal Appointments...... 111

Table 89. Respondent's Residence at time of Most Recent Planned Home Birth and

Number of Ultrasounds During Pregnancy...... 112

Table 90. Respondent's Residence at time of Most Recent Planned Home Birth and the month She Hired the Midwife...... 112

xvii

List of Figures

Figure 1. Certified Professional Midwives CPMs Legal Status By State...... 15

Figure 2. Total Clicks on Survey Link by Date ...... 35

Figure 3. Total Surveys Completed by Date ...... 36

Figure 4. Approximate Locations of Survey Participants……………………………….41

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Chapter 1: Introduction

For thousands of years, home birth has been the norm in all societies. In the last

100 years, however, that has changed. The advent of medical technology fueled the growth of the OBGYN profession, birth became a male profession, and female midwives were pushed out. Birth in a hospital with the use of high-priced and sophisticated medical technology has become the new normal for child birth in the United States and other countries with advanced economies. Fear of the pain of childbirth has been promoted and the use of the epidural as a saving force with little concern for its side-effects is widely accepted. Today giving birth at home in the United States is considered by many to be an exceptional alternative, something done by people on the fringe of society, such as “earthy-hippy” types, Amish, or fundamentalist Christians.

Recent research has shown us that people beyond these stereotypes are choosing home birth too. Educated women, women who reject technology, women who are looking for options and want a care provider who understands what a normal birth looks like and can support it rather than intervene in it, and women who want to gain control over their birth experience – all are seeking out midwives or going it alone in home birth

(Boucher, Bennett, McFarlin, Freeze, 2009). Common among these women is the belief

1 that the best birth is one that happens naturally and at its own pace with little intervention, something difficult to achieve in today’s hospitals (Boucher et.al., 2009).

The leading question in home birth research for the last 20 years has been: “Is it safe?”. More than 30 research articles support the claim that home birth is a safe birth option (Cheyney, 2011). In fact we have learned that many women choose it because of its safety (Boucher et.al., 2009). It is not my intention to focus on the question of safety as there already exists much research about this issue. Instead, one goal of this thesis research is to examine the ways in which women have discovered the option for home birth care, considering that practicing home birth midwives are few and far between and often difficult to access when the desire for a home birth exists. A second goal of this research is to examine the characteristics surrounding the women’s home birth experiences as well as how many utilize home birth services in conjunction with mainstream medical services. Characteristics of women who chose home birth and their level of satisfaction with those services are the third goal of this research.

Purpose of Study

In the United States today, births most commonly take place in the hospital setting, with the home birth option accounting for around 1% of all births. In Ohio these statistics are similar, with recent research showing that home births are on the rise

(MacDorman, Menacker, & Declercq, 2010). Hospital births in the US are most commonly attended by Ob/Gyns while home births most commonly are attended by midwives (MacDorman, et.al., 2010).

We have learned from existing research that women choose midwife support for their births for many reasons and that midwives provide care to women with low intervention and high satisfaction rates (Johnson & Daviss, 2008 & Declercq, Sakala,

Corry, Applebaum, & Risher, 2002). We know that an even smaller number of women reject not only hospitals and doctors but also midwife care and choose the option for unassisted birth (also known as “free birth”), that is, to give birth without a health care professional. “For these women, a natural birth is the ideal, and the only truly natural birth is one experienced without the guidance of any professional” (Miller, 2009).

Statistics on the number of women who birth unassisted in the United States are uncertain, but researchers have estimated that between 500 and a few thousand women each year choose and plan for this option (Freeze, 2008).

Although today home is the non-traditional choice of birth place in the United

States, planned births at home are on the rise. Between 2003-04 and 2005-06, for example, Ohio had a 37% increase in the number of planned home births (MacDorman, et.al., 2010). Home birth with a professional care provider has been demonstrated to be a safe and prudent decision for low-risk pregnant women (Johnson & Daviss, 2008).

Despite the favorable safety rates for planned home birth, it is not well supported in the

United States by the government, professional organizations, the insurance industry, or society (Boucher et.al., 2009; Cassidy, 2006). The government prevents the growth of home birth practitioners by limiting licensure. All states have licensed physicians, advanced practice nurses, but only just over half allow licensure of non-nurse certified midwives who most commonly attend home births (Boucher et.al., 2009; MANA, 2013).

In recent years the American College of Obstetricians and Gynecologists have issued news releases in opposition to home birth which warns physicians away from home birth and providing back-up support for home birth providers (Boucher et.al., 2009; ACOG,

2006; 2008). The result of the lack of support for home birth is that there are only a small number of home birth providers, and women have great difficulty finding a provider for their home birth (Boucher et.al., 2009). In addition, insurance companies rarely reimburse providers’ fees for home birth (Hartley & Gasbarro, 2002; Boucher et.al.,

2009). Within society, women who make the choice to home birth are often questioned about the perceived risk they are taking (Boucher et.al., 2009), leading many women to simply not share their home birth plans out of concern for judgment. Considering all that is stacked against women who plan home birth, how then, do they find care providers, how do they navigate the health care system, and what characterizes there experience?...Herein lies the purpose of my study.

Research Objectives

With home birth being the non-typical choice for place of birth in the United

States today, I was seeking to learn more about the accessibility of home birth care by examining how and why some women go about choosing home birth, finding a midwife, or avoiding the health care system altogether. Hence, I designed a survey to learn more about the characteristics of women from Ohio who chose the home birth option.

This study focused on women in Ohio who chose to have a home birth in the prior

6 years (January 1, 2005, through March 21, 2011). The majority of the survey responses took place between 7/25/10 and 9/25/10 though I left the survey open online and 4 continued to receive responses, with 16 more trickling in between 9/26/10 and 3/21/2011.

The objectives of this study were focused around issues of accessibility and the type of health care that these women sought for themselves in their pregnancy and childbirth.

The survey questions will sought to clarify how women recognized or learned about the option to home birth, their ease or difficulty in finding and hiring a home birth midwife, and why some women chose to home birth without midwife or doctor assistance.

Through this study I sought to learn more about the options available for planned home birth care providers, associated costs, distances travelled, and other factors involved with hiring a midwife for home birth. I included questions on personal demographics such as age, ethnicity, birth location, income and socio-economic status in order to compare results with previous national studies of women who chose home birth and to understand how those demographic variables may be related to the choice to home birth.

I expected that women from rural areas would differ from women who live in urban communities on how they found or connected with their home birth midwives, depending on the number of midwives who practiced in their respective localities. I collected data on birth location of women seeking the home birth option in order to compare the different experiences of rural and urban women. I looked to see if rural and urban women had similar or different levels of access to midwife home birth care because of their location.

Significance of Study

I reasonably expected to obtain useful results because the body of research available includesd very little discussion about the accessibility of midwife care in the 5

United States today. By initiating a study that looked directly at accessibility, I expected to increase knowledge around how women in Ohio have gone about planning for a home birth, choose a care provider and the barriers to access they faced. The studies I reviewed followed standard research procedures, were approved by an Institutional Review Board, and guaranteed anonymity to survey participants in order to prevent any undue risk to the human subjects involved.

Data about midwife access provides valuable information to many professions which have the ability to guide allocation of resources and reflect how members of the professions can influence access to health care for women and their families. These professions include health care managers, educators, policy makers, legislators, and professional organizations. Home birth research can affect community health policy, individual freedom of choice, power and wealth, quality of care and cost effective alternatives in birth care. Community or state policy around midwife licensing and home birth can be affected by research on the safety and experiences of home birth mothers and children. “Policy ramifications include important changes in state regulation of medical and alternative health personnel, the allowance of the home as a medically acceptable and legal birth setting, and reimbursement of this low-cost option through private and public health insurers (Hafner-Eaton, Pearce, 1994)”. Currently twenty-eight of the fifty U.S. states recognize Certified Professional Midwives who provide home birth care (MANA,

2013) and many other states have legislation in process.

There is a special concern for home birth public policy in states where direct- entry midwives are not regulated through licensing. Doctors and nurse midwives are the

6 current licensed providers of maternity care in all 50 states, and primarily practice in hospitals. Mothers in these states are left with no licensed care provider for out-of- hospital maternity care, a choice which impinges on their freedom of choice in birth location. Women who choose home birth in these states have no means by which to verify the skill level or training their midwives possess, no way to seek retribution for grievances, and have few midwife choices.

Chapter 2 - Literature Review and Study Framework

Increasing numbers of mothers have choosen the out of hospital birth option in

Ohio (MacDorman, et.al., 2010), while the state continues to ignore the need for licensing that would provide a recognizable standard of education for midwives providing home birth services to these women. Besides assisting expecting parents in recognizing who is skilled “enough” to provide quality care to women and children, licensing would create a system of accountability for midwives who provide prenatal care and home birth services in Ohio. Licensure for midwives who attend home births is the first step in creating a system where midwife care is also affordable by low income women.

Most of the current knowledge around access to midwife care (how women find midwives, who they find, how far they travel for care, etc.) is through anecdotal information shared in birth professional organizations, or shared person-to-person through word of mouth in home birthing circles and communities. Information shared in this way may be potentially biased, misrepresented, or inaccurate. The goal in this research is to examine how Ohio women go about finding a midwife and the information and situations that affect their decisions for care. Considering the increasing numbers of home births in Ohio, this state is a valuable context in which to explore the above research questions. 8

Home Birth Safety

Jimmy Carter was the first of our U.S. presidents born in a hospital. All presidents until then, from George Washington to Gerald Ford, were born at home. We know that until well into the 20th century, most people were born at home (Cassidy,

2006). Along with the growth of the field of medical obstetrics came the growth of in- hospital births (Sears, 1994). The transition from almost all births taking place at home to almost all births taking place in the hospital took just over two generations to complete

(Rothman, 1982). Though not based on specific evidence, at the core of this change is the widespread belief that births in a hospital are far safer than births at home (Rothman,

2011). Recognizing this gives explanation to why safety has been a foremost concern of home birth research and why many misconceptions still remain about the safety of home birth by the general population.

Older studies of home birth have shown mixed results with regards to maternal and neonatal outcomes. Four studies from North Carolina, Missouri, Australia and

Washington State between 1980 and 2002 showed increased neonatal risk for home births

(Burnett et.al., 1980; Schramm et.al., 1987; Bastian et.al., 1998; Parrish et.al., 2003).

When comparing home and hospital births between 1994 and 1999, six studies from the

United Kingdom (2 studies), Switzerland, Netherlands, and the United States (2 studies) showed similar perinatal outcomes but lower obstetric interventions for home births

(Pang et.al., 2002; Northern Region Perinatal Mortality Survey Coordinating Group,

1996; Chamberlain et.al., 1999; Ackerman-Liebrich et.al., 1996; Weigers et.al., 1996;

Murphy et.al., 1998).

Most flaws in home birth studies have fallen into one of three categories: (1) failing to reliably differentiate between planned and unplanned home birth; (2) failing to distinguish between attendance by qualified and unqualified attendants; and (3) having a basis in birth certificate data that did not accurately provide information about birth attendants or did not specify inclusion of low-risk women (Vedam, et al., 2010). A recent study comparing the characteristics of planned and unplanned home births in 19 states concluded that the two types of births differ substantially, with unplanned home births more likely to involve mothers who are non-white, younger, unmarried, foreign- born, smokers, not college-educated, and with no prenatal care (Declercq, et.al., 2010).

Several recent studies provide evidence that supporting the safety of planned home births for low-risk mothers with a skilled care provider. The safety of home birth is commonly measured by perinatal mortality and morbidity of mothers and babies in the labor and birth process and comparing the home birth rates with hospital birth rates. Four recent studies show equivalent or lower rates of mortality and morbidity for planned home births compared to planned hospital births, after accounting for low maternal and fetal risk levels and care by qualified attendants (DeJong, van der Goes, Ravelli,

Amelink-Verburg & Mol, 2009; Hutton, Reitsman & Kaufman, 2009; Janssen, Saxell,

Page, Klein, Liston & Lee, 2009; Johnson & Daviss, 2005).

DeJong and colleagues conducted one of the largest studies so far (N=529,688), comparing perinatal mortality and severe perinatal morbidity between planned home, planned hospital births, and “unknown location” of birth, all where labor began with a midwife. The study used the national perinatal and neonatal registration data from 2000-

2006 in the Netherlands. It concluded that there was no increased risk of perinatal mortality and severe perinatal morbidity among low-risk women planning a home birth

(deJong, 2009).

Hutton and colleagues compared maternal and perinatal mortality and morbidity and intervention rates for women attended by Ontario midwives who planned a home birth, compared with similar low-risk women who planned a hospital birth between 2003 and 2006. (Hutton 2009) Their study used the Ontario Ministry of Health database and matched women with similar characteristics (N = 6,692) from the home birth and hospital birth cohorts. The outcomes of the study showed that all measures of serious maternal morbidity, including cesarean section, in the planned home birth group were lower.

Janssen and colleagues compared the outcomes of planned home births attended by midwives (N=2,889) with planned hospital births attended by midwives (N=4,752) or physicians (N=5,331). They also included in their study all home births attended by registered midwives, and all planned hospital births meeting the eligibility requirements for home birth from 2000 to 2004. They included a matched sample for physician- attended planned hospital births. Comparisons were made on perinatal mortality, obstetric interventions, and adverse maternal and neonatal outcomes. The study showed that planned home births with a registered midwife were associated with low rates of perinatal death, reduced rates of obstetric intervention, and adverse maternal and neonatal outcomes compared with hospital births attended by a midwife or physician.

These studies are consistent with the results of the 2005 study by Johnson and

Daviss comparing outcomes of planned home births with Certified Professional

Midwives and planned hospital births in North America (98% United States, 2% Canada)

(N=5,418). The study found that a planned home birth for low risk women was associated with lower rates of medical intervention, and similar intrapartum and neonatal mortality to that of low risk hospital births in the United States (Johnson & Daviss,

2005).

A meta-analysis (Wax et al., 2010) of 12 studies on home and hospital birth showed conflicting results and provoked a great deal of debate and criticism upon being published. In one example, Wax and colleagues (2010) used data from four of the studies in the meta-analysis to conclude that babies born in home births had triple the neonatal death rate (death in the first 28 days of life) of babies born in hospitals. An important criticism was their inclusion of birth certificate data to make this claim. The birth certificate data from the studies had been previously discredited on the basis that it could not distinguish between home births that were planned and attended and those that were unplanned and unattended (Cohain, 2010-2011), such as emergency cases in the backseat of a taxi or on the bathroom floor, which are known to have worse outcomes

(Declercq, et.al., 2010). Many studies that show equivalent neonatal outcomes for planned home and hospital births suggest that part of what makes home birth safe is the presence of an attendant trained to handle emergencies and who is capable of transferring to obstetric care should the need arise.

The August 2010 issue of the British Medical Journal published a letter from the authors of the 2005 North American home birth study describing the Wax meta-analysis as misleading (BMJ 2010;341:c4699). The December 2010 issue of the journal Birth

12 published a commentary on the Wax research stating, “The actual data on which these estimates were based demonstrate that meta-analysis can be developed into an art that suits whatever purpose its authors hope to achieve” (Keirse, 2010). A series of letters critiquing the study have been published in the April 2011 edition of the American

Journal of Obstetrics & Gynecology. Critiques have highlighted the hand picking of home birth studies that contributed to the conclusion, while a significant study, the largest to date, was left out of the meta-analysis and ultimately would have changed the authors’ conclusion on neonatal death. It is significant to note that the authors also concluded that perinatal mortality (stillbirths and deaths in the child’s first week) were the same for home births and hospital births.

Official statements and critiques of the research by Wax and colleagues have been published on the websites of many reputable organizations in response as well. The

American College of Nurse Midwives (2010), The Coalition for Improving Maternity

Services, National Association of Certified Professional Midwives (2010), Midwives

Alliance of North America (2010), Our Bodies Ourselves, and the UK’s National

Childbirth Trust – each have issued responses describing flaws in the study. News and political commentaries have called the study flawed and politically motivated, considering the known issues with the data included in the meta-analysis and responding to states where home birth midwifery legislation has been pending in the previous year.

Similar rates of mortality between home and hospital births are not new in the research. A strong history of research from the last 18 years comparing home and hospital births show similar mortality rates with fewer labor interventions. (Janssen, Holt,

Myers, 1994; Janssen et al, 2002; Durand, 1992; Murphy & Fullerton, 1998; Schlenzka,

1999; Chamberlain, Wraight & Crowley, 1999; Ackermann-Liebrich, Voegeli & Gunter-

Witt, 1996; Amelink-Verburg, Verloove-Vanhorick , Hakkenberg, Veldhuijzen,

Gravenhorst & Buitendijk, 2008).

Disagreement over the appropriate research methods for determining safety of home births has split some medical professional organizations in the United States from other national public health, midwifery, and international medical and public health organizations. The American Congress of Obstetricians and Gynecologists (ACOG) published a policy statement in 2008 supported by the American Medical Association and the American Association of Pediatrics, which questions the safety of home birth (Vedam et al., 2010). “The leadership of the organizations have suggested that only a large North

American randomized prospective controlled study can answer the safety question.

However, despite attempts to design a randomized controlled study, to date sufficient numbers of women have not consented to be randomly assigned according to birth site”

(Hendrix M, Van Horck M, Moreta D, et al., 2009; Olsen O, Jewell M. , 2000). Other

North American professional groups have issued policy statements in support of planned out-of-hospital births and rely on evidence from investigations that review outcomes from controlled observational cohort studies with credible comparison groups, including

The Society of Obstetricians and Gynecologists of Canada, the Canadian Association of

Midwives, various American midwifery professional societies (American College of

Nurse-Midwives, Midwives Alliance of North America, and the National Association of

Certified Professional Midwives), consumer groups (Lamaze International, Childbirth

Connection), and public health bodies (World Health Organization, American Public

Health Association, American Association of Birth Centers) (Vedam et al., 2010).

Figure 1. Certified Professional Midwives CPMs Legal Status By State. Reference: The Big Push for Midwives

Home Birth Choice

Choosing home birth depends on many factors that extend far beyond the simple preference of a birthing mother. In the United States, the laws surrounding home birth midwifery vary from state to state with laws that specifically prohibit the practice, uphold the practice, license the practice, or ignore the existence of the profession (MANA,

2010). Figure 1 highlights those states where Certified Professional Midwives are authorized to practice through licensure, permit, certification or registration. Therefore, the choice of birth place for women can only be exercised when they have a range of

15 available options and unrestricted access to qualified care providers and resources that provide her assistance in assessing birth site options based on her health status and vicinity to maternity care resources (Vedam et al, 2010). Since there are few places in the

United States where all birth settings and practitioners are integrated into the full spectrum of maternity care, home birthing women (and their midwives) often face a lack of receptivity and hostility when they transfer to hospital-based services (Vedam et al,

2010).

Several previous studies provide evidence on the reasons that women in developed countries choose to stay home to give birth. The most recent study based on responses from 160 women in the United States identified 26 unique themes in response to the question “Why Did You Choose Home Birth?” (Boucher et.al., 2009). The top five most common themes included: 1) safety; 2) avoidance of unnecessary medical interventions common in hospital births; 3) a previous negative hospital experience; 4) more control; and 5) a comfortable, familiar environment (Boucher et al., 2009). Other top themes included: privacy; dislike of doctors or hospitals; trust in the home birth process; better for the baby; midwives as the preferred caregivers; a desire for a drug-free birth; family involvement; a preference for a more natural birth; and various psychological benefits (Boucher et al., 2009).

Another study of 559 Canadian women asked them to respond to an open-ended question about their home birth experience, “Please use this space for any comments you would like to make about your pregnancy care, including those aspects you liked or those areas in which you would like to see improvement.” (Janssen et al, 2009). They reported

16 eight themes that were most consistently raised, and understood these to mean they were the most important aspects of their decision to home birth. The themes most commonly observed included: (1) client confidence in midwives knowledge, skills and abilities; (2) women felt empowered to participate in the decisions surrounding their care; (3) women felt a strong sense of being emotionally supported by their midwife; (4) women received good informational support and reported that time was spent getting to know them and answering their birth questions; (5) women received holistic care that was characterized by their familiar surroundings, viewing birth as family-centered, with less intervention in the normal birth process; (6) women believed their midwives to be accessible to them;

(7) women felt that they received comprehensive postpartum care at home; and (8) women who transported to hospital felt supported during that process (Janssen et al,

2009). The responses were overwhelmingly positive with only 7 negative responses noted.

The patterns of women who consistently choose home birth have remained similar in the research over the last 20 years. Women who choose home birth, when compared with the average childbearing woman in the United States are more often older, of a lower socioeconomic status and a higher educational level, and are more likely to be married and white (Declercq, et.al., 2010; Johnson and Davis, 2005).

A study of satisfaction among women who planned home and hospital births in

Canada found women who planned a home birth to be more satisfied with their experience than women who planned a hospital birth (Janssen et al, 2006). Both groups had high rates of satisfaction, but among the home birth women who were able to

17 complete the birth at home, the satisfaction was significantly higher than the hospital group (Janssen et al, 2006).

Researching Accessibility

Studying accessibility requires an in depth look at the many variables involved in a health care delivery system and how each is measured. In this research, I have used

Aday and Andersens’ (1974) framework for the study of accessible medical care which includes five key areas: (1) health policy; (2) characteristics of the health delivery system; (3) utilization of health services; (4) characteristics of the population at risk; and

(5) and consumer satisfaction. The survey in this research was created for home birth mothers in Ohio and included questions from each of the five areas in the framework of accessibility.

Health Policy

Health policy relates to the national, state and local laws that affect factors, such as who can provide care or services, when and where they can provide it, and how they may deliver it. The policies or lack thereof around home birth midwifery care create many examples of how central health policy is to the accessibility of health care services.

Health policy is central to this research because the laws around midwife care in a home birth setting are not well defined in Ohio. Much of my knowledge in this area was already known prior to beginning this study. We know that midwives who provide home birth services to Ohio women run the risk of being classified as practicing medicine or nurse midwifery without a license because there currently exists no option for a license in

18 the state. By their action of providing quality care, monitoring the vital signs of the pregnant mother and child while taking heart rate and blood pressure measurements, these midwives fall under the policies that currently exist to define what it means to practice medicine as a doctor or nurse in Ohio. In the last ten years, two Ohio midwives have been arrested for providing services to mothers who chose home birth, unrelated to any type of negligent care by them. In 2003, Holmes County midwife Freida Miller served jail time for refusing to reveal who provided her with a drug to stop the post- delivery bleeding of the mother she was caring for (Horton, 2002). In 2008 a Certified

Professional Midwife in Butler County was charged with the felony, practicing nurse midwifery without a license because she provided care to a woman who chose home birth. She later pleaded guilty to two misdemeanors (Crane, 2010).

The American College of Nurse Midwives is supportive of a woman’s option to choose home birth, Certified Nurse Midwives (CNMs) can legally attend them, but few

CNMs in Ohio do. CNMs are required to have a Standard Care Agreement with a collaborating obstetrician in order to practice. Obstetricians willing to collaborate or support a CNM who attends home births are rare because of the high liability insurance rates for home birth practitioners. Lack of physician back-up and high liability insurance have become the major factors that preclude CNMs from attending home births in Ohio.

I recently spoke with one CNM who regularly attended home births in Central Ohio up until about 20 years ago. I learned that she stopped attending home births after the doctors who provided her back up moved away or retired, and high insurance premiums

(at 2-3 times the normal rates) prevented other doctors from providing her with back up agreements (personal communication, March 27, 2011).

The current lack of state regulation around midwife care leaves Ohio’s low income women with reduced access to midwife services. According to a representative from the North American Registry of Midwives, Medicaid, a state assistance program that provides medical benefits to low-income persons, currently cannot be used to provide payment for most home birth midwife services. In order for midwife services to be Medicaid reimbursable they would have to be licensed and appended to the state’s list of reimbursable Medicaid providers. Some states that have licensed midwives have also gotten approval for them to be Medicaid providers (I. Darragh, personal communication,

March 13, 2011).

Recently, the MAMA Campaign (a collaborative effort by the National

Association of Certified Professional Midwives [NACPM], Midwives Alliance of North

America [MANA], Citizens for Midwifery [CfM], International Center for Traditional

Childbearing [ICTC], North American Registry of Midwives [NARM], and the

Midwifery Education Accreditation Council [MEAC]) has worked with legislators to get a federal bill (HR 1054: Access to Certified Professional Midwives Act of 2011) introduced in Congress. HR 1054 would add Certified Professional Midwives to the federally mandated list of Medicaid providers thereby requiring states that license them to also allow them to become Medicaid reimbursable providers. The end result of health policy is that it affects who can afford to use particular health services and what their options are for receiving that service.

Characteristics of the Health Delivery System

When considering the characteristics of the health care delivery system for home birth care, we must include two main elements: resources and organization (A&A, 1974).

Resources typically include the health personnel, structures where service is provided, education, equipment, and materials used in providing health services (A&A, 1974). The resources component includes both the volume and the distribution of medical resources in an area (A&A, 1974). In evaluating the home birth delivery system in Ohio, it is important to gain a better understanding about how women learn of the option to home birth and to find a midwife, how many midwives they have to choose from, the distance they travel to see their midwife, the training and skills of the midwife, and the costs associated with midwife services. In a state like Ohio that is without specific laws around home birth midwifery there are midwives of varying skill level and experience carrying or not carrying lifesaving equipment or drugs based on their desire to be a midwife rather than having demonstrated a responsible level of care provision. Also characteristic of the home birth delivery system in Ohio is that many home birth midwives do not openly advertise their services out of concern of prosecution. We know from past home birth research that US women in small towns (28%), rural (32%) and urban (35%) areas choose home birth. It seems likely that Ohio, considering its large rural and urban populations, will also display a difference in the patterns of mothers who choose home birth based on geographical location.

Utilization of Health Services

When assessing access to home birth care through utilization of health services, birth location, number of prenatal care visits and their location, use of other medical services, or co-care with a physician are all necessary variables to measure. These areas will help to characterize how women who ultimately choose home birth go about using or not using the system of services that are available to them. In Ohio, we do not know if women who choose home birth also utilize other types of medical services commonly used by mothers who choose hospital birth. Research about the types of medical services that home birth mothers select as either preventive or illness-related can help to conceptualize the demands placed on the system by this group.

Characteristics of the Population at Risk

The framework for accessibility explains that the characteristics of the population at risk are related to their likelihood of using services, their means to use the services, and the illness levels that affect how services are utilized. Means can refer to elements like people’s insurance coverage, income or rural-urban location. Other characteristics linked to use of services include age, education, race, economic status, training, previous experiences and values concerning health and pregnancy.

Consumer Satisfaction

Women’s attitudes about their experience with home birth midwives and about their past experiences with hospitals or doctors influence their continued and future use of those services. Several dimensions of satisfaction are relevant to research on access

22 including the convenience of care, its coordination and cost, level of courtesy shown by the midwife, the information given to the women by the midwife during her pregnancy and delivery, and the overall quality of the care provided (A&A, 1974).

Aday and Anderson (1974) point out that it is implicit in the concept of accessibility that categories of people have more or less (access) than others. I expect that through this research I will uncover the characteristics of the categories of women with more or less access to midwifery care. The attributes that facilitate or hinder medical care fall into one of two categories: socio-organizational or geographic (Aday &

Andersen, 1974). Socio-organizational attributes of accessibility are those that are non- spatial such as fees for care or services, training, and insurance coverage (Aday &

Andersen, 1974). Geographic attributes consider the distance to hospital care or physical barriers to care. Access is tied to the properties of the individual and the system (Aday &

Andersen, 1974).

The following is a short glossary of terms used throughout this thesis.

Apprentice: A midwife in training

Certified Midwife (CM): A Certified Midwife is an individual educated in the discipline of midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives. Certified Midwife is also used in certain states as a designation of certification by the state or midwifery organization (MANA website,

1/15/2012).

Certified Nurse-Midwife (CNM): A Certified Nurse-Midwife is an individual educated in the two disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives (MANA website, 1/15/2012).

Certified Professional Midwife (CPM): A Certified Professional Midwife is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwifery model of care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings (MANA website, 4/16/2011).

Direct-Entry Midwife (DEM): A direct-entry midwife is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing.

A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings (MANA website, 4/16/2011).

Doula: The word "doula" comes from the ancient Greek meaning "a woman who serves" and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period (DONA website, 1/15/2012).

Intrapartum Mortality: Refers to and includes only deaths that occur during labor and delivery.

Licensed Midwife (LM): A licensed midwife is a midwife who is licensed to practice in a particular jurisdiction (usually a state or province).

Maternal Morbidity: Any departure, subjective or objective, from a state of physiological or psychological well-being (Last, A dictionary of epidemiology, 1995)

During pregnancy, childbirth and the postpartum period up to 42 days or 1 year (i.e. uterine rupture and uterine scar, infertility, perineal or low abdominal pain, anemia, uterine prolapsed, Fecal and urinary incontinence).

Neonatal Mortality: Includes only deaths in the first 28 days of life.

Obstetric Intervention: Any disruption of the normal labor, birth, and post-partum processes. I.e. (typically) the use of forceps or vacuum to pull a baby from the birth canal, caesarean section, use of episiotomy, Pitocin, epidural, narcotics or drugs that augment labor; (historically) shaving of the mother's pubic region; mandatory intravenous drips; enemas; hand strapping of the laboring women; 12 hour monitoring of newborns in a nursery away from the mother.

Perinatal Mortality: Includes only deaths between the fetal viability (22 weeks gestation) and the end of the 7th day after delivery.

Planned Home Birth: Home births that are intended to happen at home. It is important to differentiate between planned and unplanned home births because they have substantially different characteristics.

Vaginal Birth After Cesarean (VBAC) – The common term for birthing a child vaginally rather than by a repeat cesarean surgery.

Unschooling Yahoo Group: A discussion and support group for unschoolers and those learning about the unschooled learning style, a home-school education with the child taking the primary responsibility instead of a parent or teacher; also called child-directed learning or self-learning.

Chapter 3 - Methods

Research Design

The purpose of this study is to explore and describe the accessibility of home birth medical care for women in Ohio who chose a home birth in the past 5 years. I did this by surveying mothers who had planned a home birth. In my review of the existing literature on home birth I have found no other research that specifically surveyed mothers about their experiences with planning a home birth or the accessibility of care providers they sought (or chose not to seek and why) for their care. The survey included 45 total questions of which 26 were for all women answering the survey, 14 were only for women who hired or used a midwife, and 5 were focused on women who chose to birth unassisted.

I focused the research time frame on planned home births that have taken place in the 5 years and 6 months (i.e., not beyond 5 years when rounded to the nearest year).

There exists no survey like this in the existing body of research, leaving me without a precedent or research design to model. Using the total number of home births in the Ohio dataset for the 2010 National Vital Statistics Report (MacDorman, et.al., 2010) I estimated the number of home births in the past 5 years, allowing me a base number for my possible sample.

The accessibility of home birth care is in large part affected by the laws at the state level regarding the licensing of non-nurse midwives, primarily Certified

Professional Midwives. In 26 states, CPMs are authorized to practice, in 13 states they are outlawed, and in 11 they practice in a grey climate where there are no laws surrounding or acknowledging their practice (MANA, 2011). Though this so called grey climate leaves midwives open to prosecution for practicing medicine (or nursing or nurse midwifery) without a license, and midwives in Ohio have been prosecuted for this. For this reason it is highly relevant to focus the research on accessibility of care (which tends to be by midwives) for women who planned for a home birth in a single state. Much of my knowledge and familiarity with home birth is tied to my experience of living, working, volunteering and having chosen to plan a home birth in the state of Ohio, which therefore led me to focus on the accessibility of care in my own state.

My experience as a member of the board of directors for Ohio Families for Safe

Birth, an organization dedicated to improving access to mother and child friendly care in all settings is currently focused on licensing Certified Professional Midwives to practice in the state. My work with this organization allowed me to learn about the many varying and complex scenarios and issues surrounding home birth, care, practice, licensing and politics. There are even stories shared among this group about women intentionally leaving Ohio to give birth in a state where home birth midwives are licensed to practice. I therefore included all mothers who were residing in Ohio and planned to give birth here, or who went elsewhere in order to have a home birth.

Subject Selection

This study was conducted in the form of a survey that included both forced-choice questions and several open-ended questions. The universe of potential respondents is not fully known but has been estimated based on those who are known and the groups and organizations to which we knowingly provided the survey invitation. The plan for participant recruitment included posting the survey invitation to various online websites where home birth mothers are known to frequent. This included blogs, Facebook pages and groups, e-newsletters, message boards, and sending it directly to e-groups and the email addresses of Ohio Families for Safe Birth (OFSB) supporters. The survey invited those who saw the survey to participate if they meet the criteria and to share the survey invitation with other home birth mothers or groups they knew.

I requested the email addresses of families on the Ohio Families for Safe Birth and Ohio Midwives Alliance (OMA) databases. These two organizations have partnered to propose licensure legislation for Certified Professional Midwives (CPMs) in Ohio and many of the members on their lists were previous clients of Ohio midwives. I sent a letter to Stephanie Beck Borden, the Chair of OFSB at the time, requesting the email addresses of people in their database of supporters in order to email them the survey invitation. Stephanie sent a letter of response on behalf of the board of OFSB approving my use of their database emails for the study.

I sent an email to Audra Phillips, President of OMA at that time, asking for permission to use the email addresses of those in their database of supporters in order to directly email them the survey invitation. After discussion with their board of directors

29 they declined my request and offered instead to send the survey to the midwife members of their organization asking them to invite their home birth clients to participate in the survey.

Instrument Construction

The survey instrument was designed, drafted and reviewed for optimal face validity. Knowledge gained from my experiences with the OFSB board over the last two years creating community meetings, lobbying events, strategizing communications language, participating in various national e-groups related to home birth and midwives, and hearing the stories of other home birth mothers around the state – all helped to provide me a basis from which to begin drafting relevant questions about the accessibility of home birth care and the reasons why some women choose to birth unassisted. More than ten drafts of the survey were reviewed and edited with my research advisor. A final draft of the survey was shared with five members of the Ohio Midwives Alliance Board of Directors who provided critical feedback on several of the questions in the survey based on their experiences with home birth clients. They suggested alternative wording on the midwife fees question and informed me that many of their clients see a chiropractor during their pregnancy, suggesting that chiropractor be included in the doctor related questions. After completion of the survey instrument a completed application and materials were submitted to the Institutional Review Board and received

IRB exempted status upon review.

Data Collection

The collecting of participant responses was completed using Google forms online spreadsheet/web form. The forms spreadsheet allowed the participants’ responses to each question to be entered directly into a spreadsheet for later retrieval and analysis. All responses were time stamped based on when the participant submitted the form. No personally identifying information was captured about the participants allowing responses to remain anonymous. After creating the survey and posting it online, Google provides a long unique link to the survey form which I took and made a personalized link for the survey http://bit.ly/homebirthohio using the Bit.ly web service. Bit.ly

(http://bit.ly/) is a free web service that functions to shorten, share and track the link that is created. The shortened web link was used with all investigator survey invitations.

Process and Timeline for Data Collection

The research survey was open and collected responses for one month while communications and survey invitations were staggered primarily over the first week of the survey window with a direct invitation halfway through the window. To improve the survey response rate, it was begun on a Wednesday evening so as to avoid the busy weekends and avoided known holidays when people are less likely to be on their computers and the internet. The survey instrument can be found in Appendix A.

The e-groups, Facebook pages, blogs, and websites where the survey invitation was posted and shared are advocacy, resource, and professional organizations related to birth, home birth, doulas, midwives and natural parenting primarily in Ohio. Some national groups were included because of their sheer numbers and were invited to share 31 the link with only women in Ohio who they knew. The survey invitation was directly sent to a number of personal acquaintances and friends who were birth professionals or home birth mothers. Their names were omitted from Table 2, which lists only organizational contacts.

The estimated number of people reached (17,383) in the survey invitation is known to be inflated for several reasons. Women in the various groups were most likely members of more than one group and therefore received the survey multiple times. Many groups received the survey prompts in multiple ways and therefore received the same survey invitation many times. For example, I am on the Ohio Families for Safe Birth e- group, Facebook page, web news group, and at least three other organizations that received the survey. Many women would have received the survey as many as 5 times

(while others may have received it only once) because of the many and varied ways that it was advertised to reach the widest possible audience. It is not possible to know how many unique individuals there are across the numerous organizations and groups where the survey was advertised and shared, hence, I am not able to give a true estimate of the number of people reached with the survey invitation.

Table 2 lists the name of the organization and type of media by which I advertised the survey invitation, the type of organization it is (Advocacy, Resource, Both Advocacy and Resource, Professional), the number of members to that group and media, the date the survey invitation was sent or posted, and a description of the group. The survey commenced on August 11, 2010, with the first email sent to the Ohio Families for Safe

Birth e-group. The official closing of the survey took place on September 13, 2010, after

32 a thank you message was posted on several of the most prominent Facebook pages included in the survey, acknowledging my appreciation to those who had participated, and announcing the survey closure. The survey was re-opened a few weeks later to allow for the addition of several newly-known home birth mothers who had not yet had a chance to participate and then was left open on the web. In the period from September

27, 2010 to March 30, 2011, 17 new responders were added to the total number of participants in the survey.

The survey’s final response total was 365. A majority (243) of the responses took place within the first 7 days of the survey opening. Another 100 responses were added by the end of the 3rd week, while the last 20 responses were spread out over the remaining open days. The email initiating the survey on August 11 was sent around 11pm and by midnight the survey had already received 13 responses. In the first 24 hours of the survey, 41% (148) of the final response rate had been collected.

The email responses I received following the opening of the survey gave me an indication of how the survey was accepted by the greater home birth community. These responses tended to fall into one or more of four categories. Several women wrote me because they wished they meet all of the criteria of the survey so that they could participate and give input about their own experiences with home birth. These responses included women who had home births prior to the time period of the study, planned a home birth in another state before moving to Ohio, and who wanted to have a home birth but could not (for unspecified reasons). Many women asked if I would provide feedback to them about the results and conclusions of the study. Other women offered support to

33 the research I was doing. One woman said, “I completed your survey. If you have any additional questions or need more qualitative research, feel free to email me. I'd be more than happy to help!” One other woman offered to give me the names of contacts in other parts of the state to help spread the survey. A nurse midwife who had previously practiced as a home birth midwife in Ohio wrote offering to explain to me the history of medical liability insurance in Ohio for nurses who provided home birth services and why so few of them do so today. Many of the emails I received included appreciation for doing “much-need research” in the field that might help support midwifery options.

Considering the multitude of cross postings of the survey many women surely received the same survey invitation numerous times. In all the postings and emails sent I received, only one email asking me to take their email off my list because she did not have a home birth. The tracking service from Bit.ly provided summary data on how often and through which sources the survey link was shared over the internet. Figure 2 shows the web traffic for the survey link by the number of times it was clicked on. The high points in the graph on Figure 2 correspond to the commencement of the survey

(Aug. 11), the sending of the invitation through the Athens (Ohio) Birthcircle newsletter

(Aug. 22), and the direct invitation to the Ohio Families for Safe Birth email addresses

(Aug. 28). Table 1 highlights the top sources from which a person clicked on the survey link demonstrating the top ways in which the survey was promoted.

Figure 2. Total Clicks on Survey Link by Date (Summary Provided by Bit.ly)

Table 1. Top Referrers (Summary provided by Bit.ly)

Figure 3. Total Surveys Completed by Date

The originally estimated possible sample size for this study was 5,364 for the period January 1, 2005, through September 8, 2010. The 2010 National Vital Statistics

Report (MacDorman, et.al., 2010) from 2003-04 to 2005-06 showed a two-year total number of home births for Ohio of 1,888 (or an average of 944 each year). Factoring in the same percent increase for the subsequent years, I arrived at an estimate of 5,364 home births for the time period of the study (2005 = 944, 2006=944, 2007=972, 2008=972,

2009=1001, and 2010=531, 2010 includes only the portion of the year that was included in the study). Understanding the response rate and totals for the study is important for two reasons: (1) recognizing communities known to prefer home birth that do not use internet technology (and not included in the survey); and (2) factoring in mothers who had multiple home births in the study time period. We must account for the women in

Amish and conservative Mennonite communities who prefer home birth and do not use

36 the internet and therefore would be unable to participate in this study. I can speculate based on what I do know about these populations in Ohio, though an estimate of the births would be difficult to determine. We know that Ohio’s Amish population is larger than any other state (over 60,000 in 53 separate communities) and a large number of

Mennonites and other plain, Anabaptist groups as well (Donnermeyer, personal communication, 2011). There are 3 birth centers in the Greater Holmes County that serve

Anabaptists (Mt Eaton Care Center – Mt. Eaton, OH; New Bedford Care Center –

Fresno, OH; Blessed Beginnings Family Center – Greenwich, OH). Holmes County and vicinity (i.e., includes four other counties) is the largest of all Amish communities in

Ohio and anywhere else.

I predicted that a response rate of 10% (or 536) would provide useful data on

Ohio. This original estimate of 536 did not factor in my later realization that many women who completed the survey had also had another home birth during the five-year period for which I estimated, meaning that the 5,364 births could likely have been from far fewer women whom I was only allowing one response to the survey (for their most recent planned home birth in the last five years.) I know from the responses to the fourth question in the survey that 41% (143) of women who took the survey had a previous home birth; I just don’t know when that birth took place. My predicted response rate of

10% therefore, might have been achieved with actual response total of 365. To know this for sure is not possible in this study since our question does not indicate if their previous home birth was also within the 5 years. Anecdotal evidence suggests that a number of

37 home births are never recorded and therefore may not be represented in the 2010 National

Vital Statistics Report.

Name of the organization/type of media Type Date Members Group description A statewide email group working to improve access to safe, appropriate, evidence-based care Ohio Families for Safe Birth (OFSB), 11- during pregnancy, labor, delivery and listserv A Aug 209 postpartum.

A non-profit, grassroots,email group of dedicated to supporting and promoting midwifery, Ohio Friends of Midwives (OFOM) 11- particularly direct-entry midwifery, also known listserv A Aug 55 as "lay midwifery",

Facebook page used by Ohio Families for Safe Support Licensing of Certified Birth and Ohio Midwives Alliance in their Professional Midwives in Ohio, 11- advocacy to license Certified Professional Facebook page A Aug 941 Midwives 11- Martha Nieset, Facebook page B Aug 467 personal Facebook page of co-investigator Ohio Midwives Alliance (OMA), 11- listserv P Aug 30 Professional Organization for Ohio Midwives Center for Humane Options in Central Ohio based practice of Home birth Childbirth Education (CHOICE) email 11- midwives, doulas and childbirth educations list and Facebook page R Aug 372 services

Birth Network of Cleveland, Facebook 12- Local chapter of a national organization in page B Aug 130 support of educating women of their birth options Cincinnati Natural Parent, listserv B 12- ? Parents in SW Ohio united by interest in using Aug natural practices around parenting Cincinnati area doulas, listserv P 12- ? Professional group for doulas in Cincinnati area Aug Cincinnati Home Birth Circle, Facebook R 12- 171 Parents in SW Ohio united by interest in using or page Aug supporting home birth practices Home Birth Option of Cleveland, B 12- 145 Parents in NE Ohio united by interest in using or Facebook page Aug supporting home birth practices Beginnings to Birth, Facebook page B 12- 246 Facebook page created by a Columbus area doula Aug to support her practice and share knowledge about childbirth practices All for Normal Birth in Akron Ohio, A 12- 34 Parents in Akron, Ohio area united by an interest Facebook page Aug in using or supporting normal birth practices Toledo Maternity Network, Facebook R 12- 21 Network of maternity services and people who page Aug use them in the Toledo area. La Leche League of Ohio, Facebook A 12- 400 Local chapter of a national organization that page Aug provides support to breastfeeding women The National Preservation of Traditional A 12- 249 A national group of people working to preserve Midwifery, Facebook page Aug traditional midwifery practices Birthing Beautiful Ideas, Facebook page B 13- 410 Facebook page created by a Columbus area doula Aug to support her practice and share knowledge about childbirth education. Continued Table 2. Organizations Through Which the Survey Link was Promoted

Table 2 continued

Name of the organization/type of media Type Date Members Group description Posted to safebirthohio.org website news A 13- ? repeat section Aug Spoke at Ohio Midwives Alliance P 14- 12 repeat quarterly meeting 8/14/2010 (gave Aug handout cards with the invitation and link)

International Cesarean Awareness B 15- 64 Local chapter of a national organization that Network (ICAN) of Central Ohio, Aug provides support to breastfeeding women Facebook page Birthing Beautiful Ideas, blog post B 16- ? Blog created by a Columbus area doula to Aug support her practice, increase knowledge and debunk myths about Vaginal Birth After Cesarean The Big Push for Midwives (new site), A 17- 5,237 A national email group for people working to Facebook page Aug license Certified Professional Midwives (CPM) in all 50 states. Email to Big Push, listserv A 17- 160 repeat Aug Ohio Families for Safe Birth, Facebook A 17- 292 repeat page Aug Athens Birthcircle, newsletter B 22- 450 Parents in Athens, Ohio area united by an interest Aug in using or supporting normal birth practices?????check mission on their site Ohio Families for Safe Birth email A 28- 952 repeat addresses Aug The Big Push for Midwives (old A 30- 6,336 repeat Facebook site) Aug Closed Survey Officially on Sept 13, 17,383 2010…though re-opened it in October for 4 late responders

Figure 4. Approximate Locations of Survey Participants

Sample Limitations

This study provides great value by helping those interested in home births to understand the accessibility of care and factors associated with it for women who choose home birth. During the study there were several recognizable limitations that should be noted.

A large community known to prefer home birth was excluded from the study because of the chosen method for data collection. Amish and conservative Mennonites 41 are known for their chosen lifestyle that minimizes the use of technology and so were unlikely to have participated in the survey. From the beginning of this study it was understood that the scope was more on the engagement of non-Amish in the practice of home birth and the options for care that they found. Future studies on home birth could focus more specifically on the accessibility of care for Amish populations in Ohio.

This study’s sample is of women who found or who intentionally chose not to have a care provider for her home birth. I recognize that women who wanted to have a home birth but could not find a midwife and who did not desire an unassisted birth were excluded from participating in this study and therefore creates a known limitation to understanding the overall accessibility of home birth care. It is important to the research of accessibility that all women who desired to have a home birth, including those who would have chosen it if they would have found a care provider, those women who would have considered it, had they known of the option, had the support, known of licensed care providers, or known of the proven benefits to home birth, be considered in future research of the accessibility for home birth care.

Chapter 4 – Results

The survey in this research was created for home birth mothers in Ohio and included questions from four of the five areas in the Aday and Anderson (1974) framework of accessible medical care. I will review the questions in the survey following their framework, and in this order: characteristics of the health delivery system, utilization of health services, characteristics of the population at risk, and consumer satisfaction. The fifth part of the framework, health policy, is not included since there were no questions included in the survey for this topic, and legitimately were impractical considering Ohio’s policy information is available without surveying home birth women.

I recognize that my study has implications for health policy, which I discuss in the final chapter. I begin this chapter by reviewing the reasons women indicated for choosing home birth, before proceeding to the four topical areas I included from the Aday and

Anderson (1974) framework.

Reasons for Home Birth

The second question of the survey read, “For my most recent planned home birth

I chose the home birth option because”. There were 13 options to choose from and I left room for open-ended responses. The responses to this question (Table 3) revealed that

43 the majority of mothers believed they would have greater control over their birth while at home (92%), and that they feared unnecessary medical interventions by giving birth in a hospital (91%). Several write-in responses illustrate these two most frequent responses,

“I didn’t want to have to negotiate and argue with hospital personnel”, and … “I gestate on the longer end of average (42-43 weeks) and was being hounded by my OB and CNM to induce despite being healthy (both baby and I were doing great; as very frequent BPPs and NSTs showed as well as several times daily kick).” Five of the top six responses for why women chose home birth in my study were also within the top six responses found in a recent qualitative study about why women in the United States select the home birth option (Boucher et.al., 2009).

The next two most frequent responses revealed that more than 87% wanted to give birth in a comfortable environment without the use of drugs (88%). Write in responses illustrate these frequent answers, including: “Hospitals are for the sick and/or injured. Birth is neither an illness nor injury. It is a normal”; and “Home births gives mothers the ability to experience birth in all its wonder, and make the birthing experience an unexplainable, wonderful thing. Hospitals take away that ability and make it more stressful”.

Most (78%) women also indicated that a home birth would be safer than a hospital for themselves and/or their baby. As one woman also wrote in, “I wanted to be in charge of my baby’s birth; not a doctor. I trusted my midwives, husband, and myself more than I would trust a doctor. I felt safer at home!”

The sixth most frequently mentioned response was privacy. Of those who were surveyed, 71% responded that privacy was a consideration in their choice to home birth.

One respondent to this question explained that she wanted “To be myself and not worry about what the nurses thought if I screamed or wanted to be in an unusual position”.

Rounding out the top ten reasons are the following: Over 60% of women responded that they were concerned about avoiding a cesarean section; having other children or family members present for the birth of their child was a consideration for

43% of respondents; having had a negative previous hospital experience (36%); and witnessing a negative hospital experience of someone else was a factor (22%) for some women in their decision to choose a home birth.

There were three other reasons mentioned by at least ten respondents. The cost of home birth was a factor in the decision of some women. Nearly 22% of the respondents agreed that it was less expensive than a hospital or birth center, while 11% said that not having health insurance made it more affordable. Finally, about 3% said that birthing at home was part of their culture or religion.

Reasons for choosing to birth at home n % I believed I would have greater control over my birth at home 336 92.31 I feared unnecessary medical interventions birthing in a hospital 333 91.48 I wanted to give birth in a comfortable - familiar environment 323 88.74 I wanted a drug-free birth 321 88.19 I believed it would be safer than a hospital birth for myself or my baby (ies) 284 78.02 It was more private 260 71.43 I wanted to avoid having a cesarean section 220 60.44 I wanted my child (ren) or other family members to be present 158 43.41 I had a negative previous hospital experience 130 35.71 I witnessed a negative hospital experience of someone else 81 22.25 It was less expensive than a hospital or birth center 79 21.70 I didn’t have health insurance and home birth was more affordable 39 10.71 birthing at home is part of my religion or culture 10 2.75 Total 364 Table 3. Primary Reasons Provided by Respondents for Choosing to Home Birth

Women cared so much about explaining their reasons for choosing the home birth option that there were more than 70 write-in responses for this question, as seen in Table

4. These write-in responses were grouped according to topic. Many fell under similar themes to the ones listed above, such as a desire to have control over their own birth rather than being at the mercy of someone else. However, several new themes also came up, including interest in having a water birth, concerns about having a peaceful, comforting or sacred space, and the desire to avoid a repeat cesarean section (wanting a

VBAC). Several women also indicated that having had previous experience with home birth, they preferred this option. The responses to these questions show the level of

46 thoughtfulness by the mothers around planning for the birth of their child. Women were clearly concerned about being in a safe, comfortable environment, where they could limit interventions, and maintain a level of control of their surroundings and support the naturalness of the birth process.

CONTROL OVER OWN BIRTH ( 15 comments) Control over baby after the birth I believed I would have greater control over the care of my baby. I knew that I would be the one making all the decisions; without being pressured by the medical community. I felt I would be given the “space” to birth the way that i needed to birth I did not want to have to “fight” to have a natural hospital birth I didn’t want my baby to stay with me vs. going to the nursery I didn’t want to have to negotiate and argue with hospital personnel. I wanted to be in charge of my baby’s birth; not a doctor. I trusted my midwives; husband; and myself more than I would trust a doctor. I felt safer at home! I never wanted to be separated from my baby We object to extreme medical intervention. I wanted to be able to recover at home without nurses checking in on us every two hours. It was also important to me that my prenatal care be unobtrusive and completely within my control. Two more reasons: (1) I gestate on the longer end of average (42-43 weeks) and was being hounded by my OB and CNM to induce despite being healthy (both baby and I were doing great; as very frequent BPPs and NSTs showed as well as several times daily kick I wanted to leave the cord attached for a long time I was able to eat during labor.

IT' S NATURAL ( 10 comments) My body knows what it’s supposed to do and having a child is not an illness nor a horrible emergency Physiological event and should be treated as such It's NOT a medical event. I trusted that my body was able to give birth naturally at home. I believe birth is natural and safe for women and babies that are in good health. Hospitals are for the sick and/or injured. Birth is neither an illness nor injury. It is a normal Did not have a reason to have baby at hospital. It’s just the way it should be for many women Towards our children and towards institutions of power--nonviolence; love; home- centered life; non-dependency on institutions; recovery of our own knowledge. My husband wanted to participate more than a hospital would have allowed AND I was present when my mom gave birth to my 3 younger sisters at home so it seemed both safe and natural. Table 4. Comments Reflecting Reasons Given for Choosing to Birth at Home (in Table 3)

PAST HOME BIRTH (8 comments) I had a great home birth experience before I had 2 previous positive home birth experiences My two previous births were at home. Positive previous home birth experience Previous home birth experience was so positive Previous home birth was great! I had both before: a hospital birth that was very low intervention and a home birth and the home birth was by far more comfortable (with less pain) and even though I had some minor complications that could have caused me to have 3rd degree tears if I was in Family history of birthing at home

WATERBIRTH (8 comments) I had a waterbirth which is not available at local hospitals I wanted to have a water birth. I think water birth is cool I was set on having a water birth and no hospitals offered it Easy access to water birth I wanted my baby to enter the world peacefully and have a water birth. I have 2 hour labor/deliveries and need a water birth to manage the pain

PEACEFUL, RELAXED EXPERIENCE, SACRED EXPERIENCE (7 comments) I wanted to give birth in a comfortable, familiar environment I wanted to be more relaxed I wanted to create a sacred space so that birth could be a spiritual experience. I wanted to be able to honor the sacred aspects of birth and didn’t feel that a hospital experience would do this. To be myself and not worry about what the nurses thought if I screamed or wanted to be in a unusual position I wanted both of us to have a peaceful experience. Continued Table 5. Comments Reflecting New Themes for Choosing to Birth at Home

Table 5 continued

Home births give mothers the ability to experience birth in all its wonder. Making the birthing experience an unexplainable wonderful thing. Hospitals take away that ability and make it more stressful. Bonding time

Vaginal Birth after Caesarian (6 comments) After 2 sections - no hospital would let me birth vaginally I was not allowed to have a VBAC at our local hospital VBAC - especially with twins is too difficult to obtain in a hospital VBAC in a hospital isn’t an option VBAC is more likely at home. The distance to a hospital that would permit a planned VBAC was too large.

SANITARY CONCERNS (3 comments) I wanted a germ and chemical free environment Not being exposed to nosocomial infections Hospitals are dirty and I did not want to stay the night there or eat there

CONSISTENT CARE Better quality of care and support with my midwife than with hospital rotating cast of doctors. Consistency of care - I wanted my pre-natal mw to be my birthing mw and Cleveland Clinic midwives did not provide that guarantee.. You go who was on call.

DIDN’T WANT TO TRANSPORT DURING LABOR I didn’t want to ride in a car while in labor I didn’t want to transport while in labor; and avoid the transition to home after the birth

MIDWIVES I’m training to be a midwife myself I am a midwife Continued

Table 5 continued

HAD A GREAT MIDWIFE I love my home birth midwife! I was provided with an amazing midwife.

PERSONAL CARE Personalized prenatal and postnatal care provided by midwives. Birthing centers are not an option in the area. Mutual respect and support from my midwives throughout the pregnancy and birth. free to do what I needed to birth my baby and 100% support by same people throughout whom I had built a relationship with and who were highly trained and understanding of the

Other Responses I believe birthing practices should reflect our values and attitudes I believed it would be as safe as a hospital birth. I didn't have health insurance and home birth was more affordable Don’t trust Doctors

Characteristics of the Population

The most recent and largest study of women planning home births with Certified

Professional Midwives in North America included 5418 women (Johnson & Daviss,

2005). The study was published in 2005 and based on data from the year 2000. It included information on formal education, age, ethnicity, socioeconomic status, and geographic location. Their results on formal education showed a less educated cohort than mine. Nearly 40% of the mothers in their study had a high school degree, while my sample contained only about 20% who had never gone beyond high school (Table 6). In

51 my sample, nearly 40% had graduated with a 4-year college degree, and more than 22% had earned a post-graduate degree (Johnson & Daviss, 2005).

Education Level n % Doctorate degree 13 3.62 Masters or professional school degree 68 18.94 Four-year college degree 137 38.16 Two-year college degree 69 19.22 High school diploma or GED 72 20.06 Total 359 No response 6 Table 6. Mother’s Level of Education at the Time of Most Recent Planned Home birth

The age distribution from the Johnson and Daviss (2005) study was similar to mine in that the largest number of respondents was in the 26-35 age range, and overall looked much like a bell curve (Table 7). Nearly 16% of my respondents were less than

26 years of age, with about 17% who indicated that they were older than 35 years. Only

1.37% of the respondents did not answer this question.

Age n % 46-50 2 0.56 41-45 4 1.11 36-40 54 15.00 31-35 107 29.72 26-30 136 37.78 21-25 52 14.44 18-20 5 1.39 Total 360 No response 5 Table 7. Mother’s Age at the Time of Most Recent Planned Home birth

A recent study of the prevalence of home birth by the CDC found that a 29% increase in home birth among all women has been led by white, non-Hispanic women who have increased at the rate of 36%, and whose percentage of home births are three to five times higher than for any other racial or ethnic group (McDorman et.al., 2012).

Consistent with my study, previous studies of home birth in the US (Johnson & Daviss,

2005) have shown similar overall breakdowns for racial and ethnic groups (Table 8). My cohort was slightly less diverse than other samples perhaps due to the less diverse nature of Ohio in comparison to the country overall. My sample was overwhelmingly white – slightly over 93% in my study while the previous study by Johnson and Daviss (2005) was about 89% white. Of the remaining respondents in my study, about 1.7% indicated that they were Hispanic/Latino women, less than 1% said that they were African

American, and slightly over 2% said Asian American, American Indian or some “other” responses. Finally, 7 respondents did not answer this question.

Race/Ethnicity n % White/Caucasian 341 95.25 Hispanic/Latino 6 1.68 African American 3 0.84 other 8 2.23 Total 358 No response 7 Table 8. Mother’s Race/Ethnicity

My data on location looks very different from the Johnson and Daviss (2005) study. As seen in Table 9, my sample was more urban, while their data showed a more diverse population by place (City 35%, Small town 28%, Rural 32%). Over 60% of my

53 sample lived in a metropolitan area of 1 million or more persons, with about 19% residing in metropolitan areas of 250,000 to 1 million. Most of the remainder lived in a non-metropolitan county that was next to a metropolitan county.

Location n % County in metro area with 1 million population or more 226 62.43 County in metro area of 250,000 to 1 million population 71 19.61 Nonmetro county with urban population of 20,000 or more, adjacent to a metro area 42 11.60 County in metro area of fewer than 250,000 population 10 2.76 Nonmetro county with urban population of 2,500-19,999, adjacent to a metro area 10 2.76 Nonmetro county with urban population of 2,500-19,999, not adjacent to a metro 3 0.83 area Total 362 No response 3 Table 9. Zip Code or City/State Where Mother Lived at the Time of Most Recent Planned Home birth

My question on perceived economic status showed results similar to Johnson and

Daviss (2005), despite having slightly different categories. My study included 5 possible responses – Upper, Upper-Middle, Lower-Middle, Working, Poor/Lower – while their study included only 3, namely, Upper, Middle, Lower class. Middle class was the largest segment of the population in both studies. The results for my study are displayed in

Table 10. Nearly half of the sample regarded themselves as lower-middle class, with nearly 30% identifying themselves as upper-middle class. Only two respondents said they were upper class, and nearly 24% indicated that they were either working or lower class.

Economic Status n % Upper Class 2 0.56 Upper-Middle Class 108 30.00 Lower-Middle Class 164 45.56 Working Class 64 17.78 Poor or Lower Class 22 6.11 Total 360

No response 5

Table 10. Mother’s Perception of her Economic Status

Related to the question on self-identification of social class was a question on family income. Respondents could choose from 11 options that included ranges in

$10,000 increments, “$0-$10,000” to “Over $100,000". As indicated in Table 11, about

9% reported their income as exceeding $100,000, and nearly 11% said either 80,001-

$90,000 or $90,001-$100,000. The majority of respondents indicated their income was in a range from $30,001 to $80,000. Matching closely the self-rating on social class, slightly over 20% said their income was $30,000 or less.

Income n % $0-$10,000 8 2.25 $10,001-$20,000 24 6.76 $20,001-$30,000 39 10.99 $30,001-$40,000 43 12.11 $40,001-$50,000 55 15.49 $50,001-$60,000 37 10.42 $60,001-$70,000 47 13.24 $70,001-$80,000 29 8.17 $80,001-$90,000 24 6.76 $90,001-$100,000 16 4.51 Over $100,000 33 9.30 Total 355 No response 10 Table 11. Participating Mother’s Family Income

The third question in Section 1 of the survey asked participants to confirm that they were residents of Ohio. It was important to ask this question so I could be sure that survey participants were within the scope of the research because my research question was looking specifically at Ohio women and their access and experience with a home birth. Eight women from outside of Ohio responded to the survey though they were mostly from nearby states. Their responses were reviewed and then removed from my final data set. Of the remaining 365 respondents included in the data set, 362 said that they lived in Ohio, as indicated in Table 12. The three who did not respond were reviewed separately and I was able to determine from their responses to other questions in the survey that they were indeed Ohio residents.

Resident of Ohio at time of most recent planned home birth? n % Yes 362 100.00 Total 362 No response 3 Table 12. Mother’s Residency in Ohio

Also in Section 1, women were asked about the total number of children to whom they had ever given birth. The most common response, as found in Table 13 was 2 at

36%, next was 3 at 23%, then 1 at 20%. Just over 21% of the mothers had given birth to

4 or more children.

Number of children n % 1 72 19.78 2 130 35.71 3 84 23.08 4 45 12.36 5 17 4.67 6 6 1.65 7 4 1.10 8 4 1.10 9 1 0.27 10 1 0.27 Total 364 No response 1 Table 13. Total Number of Children Birthed by the Mother

The sixth question in Section 1 asked if mothers had, previous to their most recent birth, ever had a cesarean section. Earlier questions about why the women chose the home birth option indicated that over 60% of the respondents were motivated in order to prevent having a cesarean section, so I thought it was important to be able to distinguish from the group how many women may also have been concerned with avoiding a repeat cesarean. Eleven percent of mothers in my survey responded they had previously had a cesarean section, while 88% responded that they had not, and 1% provided no response to the question.

Previous Cesarean Section? n % No 321 89.17 Yes 39 10.83 Total 360 No response 5 Table 14. Mothers Surveyed with Prior Cesarean Section

Characteristics of the Health Delivery System

The following questions were designed to help provide a better understanding of the system in which home birth health care operates. The majority of these questions come from Section 2 of the survey in which I asked the women who hired a midwife (or midwife team) to answer questions about that experience. Considering the fact that overall, very few women select birthing at home today, statistically only around 1%, I first asked all the women (in Section 1) how they learned of home birth as an option.

This was designed as an open-ended question with no limit to the number of words.

Discovered Midwife Through f % Interpersonal contact 261 75.65 Through a network or organization 70 20.29 From an online listing or website 62 17.97 In the phone book 7 2.03 Total 400 No response 20 Table 15. Primary Ways Indicated by Mothers’ of How They Came in Contact with Their Midwives

Because of their unclear, legal status in Ohio, home birth midwives, unlike most health care providers, are not listed on a health insurance provider list. It is important, therefore, to learn more about how women have found their midwives since they are not found in typical ways, like on insurance provider lists, in the phonebook, or on the internet. The eighth question in Section 2 asked: “Please tell me how you first came in contact with your midwife/midwife-team members. I found my midwife/midwife-team”.

As shown in Table 15, the most common response was “through a friend” at 43%. At

19% each, the second and third most common responses were “through another child birth professional” and “through a network or organization”. The fourth most common response, at 17%, was “from an online listing or website” from which many were described as online social or organizational networking sites, such as Facebook groups or home birth networking sites. The next most common responses were word of mouth options through someone they knew. Six percent of responses indicated “through a colleague or acquaintance” and 3% indicated “through a family member”. The option with the fewest responses, at 2%, was “in the phone book”.

There were many write-in responses to this question, showing the multitude of ways that women have found the midwives who provided their care. At least 4 women wrote in to explain that they were directed to their midwives through their doctors (an

OB/GYN, family doctor, or Chiropractor).

MEDICAL/HEALTH SPECIALISTS (11 comments) Through our family practitioner Through my family doctor OB/GYN Through my chiropractor Through CHOICE referral Midwives Care in Cincinnati Midwives Care could not deliver me at home - suggested *midwife name removed to protect identity* Through another CPM Recommendation from another midwife From my previous midwife that had quit working due to the tightening of the laws in Ohio and her worry that with now having a young child of her own she could end up in jail because she helped someone with their home birth Through another midwife in a different area

WEBSITE (5 comments) Facebook An unschooling Yahoo group I posted on a local online forum looking for information and a woman responded giving me some names Under the advice of my sister and via the web Local home birth site

BIRTHING NETWORKS/ORGANIZATIONS (7 comments) Homebirth Option of Cleveland MANA (Midwives Alliance or North America) Word of mouth through an organization La Leche League Homebirth circle meeting recommendation Homebirth Circle Dar a Luz Network Continued Table 16. Themes from Comments Reflecting How Mothers Came in Contact with Their Midwives

Table 16 continued

OTHER SOURCES (12 comments) Asking Amish women for local midwives Through the doula I'd recently hired Through another home birth mother We were already friends She is a personal friend She birthed me! Total stranger Mother was my midwife Local health food store I used my midwife team with my first and second child. I originally came into contact with them through the phone book. From the book "Spiritual Midwifery" Finding a midwife is like traversing the underground railroad - you really have to know the secret handshake

Important to understanding accessibility is the number of midwives that the women had to choose from in their area. The first question, in Section 2 of the survey, asked “During the pregnancy for your most recent planned home birth, how many different midwives or midwife-teams did you have to choose from in your area?”

Responses are summarized in Table 17. The most common response showed that 49% of women had 3-5 midwives to choose from, 42% had 1-2, and 7% had a choice of 6-8 midwives. Less than 1% responded to the “9-15” and “more than 15” options. Women who chose to birth unassisted did not answer this question.

Number of midwives (or Midwife teams) n % available 1-2 145 41.91% 3-5 170 49.13% 6-8 25 7.23% 9-15 3 0.87% More than 15 3 0.87% Total 346 No response 19 Table 17. Midwives Available in the Mother’s Area

The vicinity of the midwife to the respondent was also investigated. The ninth question in Section 2 asked “At the time of my most recent planned home birth, my midwife/nearest midwife-team member lived (…).” The responses to this question were somewhat evenly distributed among the options. Less than 5% of the respondents said that their midwife/midwife team lived within a mile of their homes (Table 18), with nearly 10% indicating a proximity of 5 miles or less. This was followed by slightly over

13 percent for a distance of 10 miles, and nearly 13 percent within 15 miles and 20 miles, respectively. The remainder, nearly 50% of all my respondents, showed a midwife team that was more than 20 miles away, including almost 10% who indicated a distance exceeding 60 miles.

Distance n % Within 1 mile of my home 18 5.19% Within 5 miles of my home 35 10.09% Within 10 miles of my home 49 14.12% Within 15 miles of my home 47 13.54% Within 20 miles of my home 48 13.83% Within 30 miles of my home 28 8.07% Within 40 miles of my home 48 13.83% Within 60 miles of my home 42 12.10% More than 60 miles from my home 32 9.22% Total 347 No response 18 Table 18. Mother’s Distance from her Midwife or the Nearest Midwife-team Member

Included in the survey were questions about the level of training of the midwife or midwife-team that cared for the women. For this question women were instructed to choose all that apply, which could mean that they selected multiple options for a single midwife or that they indicated multiple options for the various midwives who attended to them. The results of this question (see Table 19) help us to understand the level of training of the midwives who provide care. The responses were summarized under two broad categories, namely, certified or not certified. Ninety-four percent of responses indicated attendance by a midwife who was certified (CPM, RN, CNM, CM, LM or RM) while 67% indicated attendance by a midwife whose training was not certified. Another

7% were unsure of their midwife’s level of training. Many women wrote in explanations about the training of midwives who attended them. One explained that, “My midwife was in training (1 CPM and 1 working toward CPM)” showing that she had responded about the credentials of both midwives who attended to her, one who was certified and one who was not certified.

Certified credential / training f % Certified 322 93.60 Not Certified 232 67.44 Apprentice 6 1.74 I'm unsure if my midwife/midwife team members held any professional 7.27 credentials 25 Total 585 No response 20 Table 19. Credentials/Training of Midwife(s) Attending the Birth

Two questions in Section 2 of the survey investigated the cost and affordability associated with hiring a midwife. The first asked “What did the midwife/midwife team charge for midwife services? (or what were her fees?)” and the second “The costs associated with hiring the midwife/midwife-team were (…).” Both questions sought to learn more about how fees were generally negotiated and who made the payments. As seen in Table 20, the most frequent response to the question about the midwife’s fees was

$1501-$2000 at 23%, though the next three most frequent responses were not far behind.

Midwife fees were most commonly indicated to be between $1001-$2000 (42%) and

$2001-$3000 (35%). Only 10% of the women were charged less than $1000 and 10% were charged more than $3000 for the midwife’s services.

Fee n % $0-$500 15 4.32 $501-$1000 21 6.05 $1001-$1500 67 19.31 $1501-$2000 79 22.77 $2001-$2500 51 14.70 $2501-$3000 71 20.46 $3001-$3500 28 8.07 $3501-$4000 6 1.73 $4001-$4500 1 0.29 $4501-$5000 2 0.58 Other 6 1.73 Total 347 No response 18 Table 20. Fee Charged by Midwife for Services

The affordability of home birth midwife services can depend on several factors which include: insurance coverage, cost of the service, and personal income. Women in the study who hired a midwife, were asked how their midwife expenses were paid and were allowed to respond with more than one answer. More than 75% of the responses

(Table 21) indicated that the midwife’s services were paid out of pocket by the mother and her family. Other responses indicate that the cost of the midwife’s services were

“based on a sliding scale” (13%), were partially covered by health insurance (12%), mostly covered by health insurance (8%), were bartered with the midwife (7%), were provided at no cost (3%), or were left unpaid (1%). Three responses indicated that the midwife costs were fully covered by insurance. Several women also wrote in comments explaining various other situations surrounding the payment of the midwife fees. Six responses described that they were waiting to hear back about possible insurance reimbursement for the fees. One woman explained that a friend had paid for her home birth costs. Another explained that her insurance provider covered far less of the fees 65 than originally promised while one explained, “Our insurer DID apply our midwife expenses to our family's in-network deductible, after I wrote them a kind letter explaining that because such care wasn't even offered, it wasn't that I was choosing to go "out of network", I was forced to.” It is evident by these responses that women who choose to have a home birth, take on a great deal of the financial burden for the service.

How fees were covered f % Paid out of my own pocket 260 75 Were based on a sliding scale (per my income) 44 13 Were partially covered by my health insurance provider 43 12 Mostly covered by my health insurance provider 29 8 Were bartered with my midwife (total expenses or partial) 23 7 The midwife did not charge for her services 11 3 Unpaid 3 1 Fully covered by insurance 3 1 Other Comments 12 3 Total 428 No response 1 Table 21. How the Midwife Fees were Paid

Women were questioned about where the majority of their prenatal checkups took place. Nearly 22% of responses indicated that a prenatal check-up occurred in the mother’s home (Table 22), with 9 responses indicating that the mothers performed their own check-up. About 4 percent of responses indicated that the check-up occurred within a mile of their home and over 11 percent indicated that the check-ups took place within 5 miles of their home. The remaining responses indicated that mothers traveled distances greater than 5 miles, with about 4 percent indicating a check-up occurred over 60 miles from the mothers home. There were 24 “other” responses. Most of these indicated that

66 they had traveled various distances for prenatal check-ups with one or multiple care providers, or simply did not indicate a specific distance at all.

For my most recent planned home birth, the majority of my prenatal n % check-ups took place In my home, my care provider came to me 70 19.34 In my home, I performed my own prenatal check-ups 9 2.49 Within 1 mile of my home 13 3.59 Within 5 miles of my home 41 11.33 Within 10 miles of my home 35 9.67 Within 15 miles of my home 29 8.01 Within 20 miles of my home 38 10.50 Within 40 miles of my home 49 13.54 Within 60 miles of my home 40 11.05 More than 60 miles from my home 14 3.87 Other responses (self-described varying combinations of locations of 24 6.63 appointments) Total 362 No response 3 Table 22. : Location for the Majority of Prenatal Check-ups

Distance from a hospital is important to understanding the geography of the intended birth location. Research has shown that this is an important factor when emergencies happen and being within a reasonable distance of a hospital improves outcomes. In this study, the results of which can be found in Table 23, a large majority

(84%) of births took place within 10 miles of a hospital, with over 50% of the total within

5 miles of the hospital. The remaining births took place at a distance greater than 20 miles of the hospital.

Distance n % 5 miles of the nearest hospital 183 50.83 10 miles of the nearest hospital 119 33.06 20 miles of the nearest hospital 39 10.83 30 miles of the nearest hospital 10 2.78 40 miles of the nearest hospital 3 0.83 I'm not sure 6 1.67 Total 360 No response 5 Table 23. Planned Birth Location Distance from Nearest Hospital

Utilization of Health Services

The following questions were created to improve insights into how women who chose the home birth option for their pregnancy and childbirth navigate the system and make decisions on the care they receive. These questions also provide insight into how the patterns of home birth women overlap with women who choose more mainstream birth options.

Understanding the type of home birth a mother planned is important to the study of access because it may affect whether or not she utilizes midwife services. In this section, questions pertaining to utilization of the midwife (or midwife team) have been summarized for the 347 women, as shown in Table 24, who indicated they planned a midwife-assisted home birth, and excluded the 18 who planned to birth at home without a midwife. Questions of utilization that were not midwife related included all 365 survey participants.

I planned n % An unassisted home birth (without midwife assistance) 18 4.93 A home birth with a midwife 347 95.07 Total 365 Table 24. Intended Type of Home Birth

While it was expected that most mothers residing in Ohio would also give birth in

Ohio, I had heard of women leaving the state for various reasons, including Ohio’s lack of licensed home birth-providing midwives. In this study, 96% of women planned to birth their child in Ohio, while only 2% planned to leave the state to give birth. These results are displayed in Table 25.

Response n % No - planned to give birth in Ohio 352 98.32 Yes - planned to give birth outside of Ohio 6 1.68 Total 358 No response 7 Table 25. Intended Home Birth Location (In/out of state)

Most women (97%) in the study planned to give birth in their own home (Table

26). A few others planned to give birth in the home of a friend (1%), relative (1%), or their midwife’s home (less than 1%).

Location n % My own home 353 96.71 The home of a friend 4 1.10 The home of a relative 3 0.82 My midwife's home 1 0.27 Total 361 No response 4 Table 26. Intended Home Birth Location

The experience of most women (89%) who participated in the study was that their birth went as planned and they gave birth at their intended location. These results are shown in Table 27. For nearly 8% of respondents, their baby was born in a hospital, and one women said that she gave birth in a birthing center. Other mothers wrote in to explain that their baby was born at the intended location but before the midwife/midwife team arrived (1%), or to explain that the baby had not yet been born (2%).

Response n % Yes, everything went according to plan with my home birth 321 89.42 No, the baby was born in a hospital 28 7.80 The baby has not yet been born 6 1.67 The baby was born at home before the midwife arrived 3 0.84 No, the baby was born in a birthing center 1 0.28 Total 359 No response 6 Table 27. Actual Home birth Location

As indicated in Table 28, over two-thirds of all respondents had contacted and hired a midwife or midwife team within the first 3 months (first trimester) of their pregnancy (70%). This finding is contrary to previous research by Johnson & Daviss

(2008), which found a much lower rate, less than half of all women who planned a home

70 birth in their study had begun prenatal care with their midwife in that same time frame.

Others hired their midwife even before they were pregnant (5%). The most frequent month of hire was a tie between the first month (21%) and second month (21%) followed closely by the third month (20%). The remaining respondents indicated a month closer to delivery.

Time period n % Before I was pregnant 18 5 First month of pregnancy 78 22 Second month of pregnancy 78 22 Third month of pregnancy 73 21 Fourth month of pregnancy 39 11 Fifth month of pregnancy 27 8 Sixth month of pregnancy 16 5 Seventh month of pregnancy 9 3 Eighth month of pregnancy 5 1 Ninth month of pregnancy 4 1 Total 347 Table 28. Month that Mother Hired Midwife

Considering that most women in the United States today hire a doctor or obstetrician for a hospital birth, it is likely that women in my study encountered questioning, or concerns expressed by family members or other people they knew about their decision to hire a midwife and birth at home. The third question in Section 2 asked if concerns expressed by people they knew about home birth delayed them in hiring their midwife, the results of which are found in Table 29. The majority of women responded

“No” (91%) to this question, while about 8% indicated that those concerns did in fact delay their decision.

Response n % No - social pressure did not delay me hiring a midwife 317 91.35 Yes - social pressure delayed me hiring a midwife 29 8.36 Total 346 No response 1 Table 29. Social Pressure Effect on Hiring Midwife

In the first section of the survey I asked “How many people (non-midwives) attended your most recent planned home birth? (I.e. Who was in the birthing room with you)”. I asked the women to indicate the number of adults and children who attended separately. As can be seen in Table 30, two respondents indicated no one, which likely meant that they gave birth before the midwife/midwife team arrived. About 33% indicated one adult was present, and 29% said 2 adults. The remaining had 3 or more adults present. Although I did not specifically ask, I suspect that anyone with 3 or more adults present at the time of the birth included the father, another adult member of the family, a labor support person, or a friend.

Number of adults n % 0 2 1 1 118 33 2 104 29 3 67 19 4 (or more) 69 19 Total 360 No response 5 Table 30. Number of Non-midwives in the Birthing Room with Mother (Adults)

The responses about children in attendance varied much more than the adults (see

Table 31). Most women indicated that they had no children in attendance at the birth

(34%). This part of the question had a high no response rate at (33%) which may also likely indicated that they had no children in attendance at the birth. Starting with the next highest responses were women who had 1 (18%), 2 (10%), 3 (3%), and “4 (or more)”

(3%) children in attendance at the birth.

Number of children n % 0 123 50.00 1 65 26.42 2 37 15.04 3 11 4.47 4 (or more) 10 4.07 Total 246 No response 119 Table 31. Number of Non-midwives in the Birthing Room with Mother (Children)

As seen in Table 32, when asked how many midwives attended their most recent planned home birth, the most frequent response was two midwives (41%), one midwife

(37%) and three midwives (6%). Another 16 respondents (4%) said their birth was unassisted. In addition, 32 (8.5%) respondents described various combinations of a midwife and at least one apprentice or assistant, or that they gave birth before the midwife/midwives arrived, who then helped with post-natal care.

How many midwives attended your most recent planned home birth? n % 1 134 37.02 2 149 41.16 3 21 5.80 Other responses (self-described varying combinations of midwife(s) and 42 11.60 apprentices) Not Applicable, my most recent planned home birth was unassisted 16 4.42 Total 362 No response 3 Table 32. Number of Midwives Who Attended Home Birth

Women were asked for the approximate number of prenatal and postnatal checkups with a midwife (Table 33). Nearly half of all respondents indicated that they had approximately 9-15 (49%) prenatal checkups with a midwife. The remaining responses indicated that 26% had 6-8 appointments, 11% had 3-5, 6% had more than 15, and 3% had 1-2 prenatal checkups with their midwife.

For my most recent planned home birth, my approximate number of n % prenatal check-ups with a midwife was 1-2 10 2.92 3-5 38 11.08 6-8 95 27.70 9-15 180 52.48 more than 15 20 5.83 Total 343 No response 4 Table 33. Approximate Number of Prenatal Check-ups with a Midwife

Postnatal checkups involve important health checks for both mothers and babies.

The norm for one local home birth practice is to have checkups at 1 and 3 days, and again 74 at 2, 4 and 6 weeks postpartum to check for things like: jaundice, breastfeeding, postpartum depression, baby weight gain, appropriate bleeding from the mother. Most women indicated (Table 34) that they had 3-5 (61%) postnatal checkups with their midwife. The next highest response was 1-2 postnatal checkups for 33% of women.

Three percent indicated they had 6 or more postnatal checkups with their midwife. Two percent indicated that they had no postnatal checkups and 1 person indicated that the child had not yet been born.

For my most recent planned home birth, my approximate number of n % POST natal check-ups with a midwife was 1-2 115 33 3-5 209 61 6-8 10 3 9-15 1 0 there were no postnatal checkups 8 2 baby not born yet 1 0 Total 344 No response 3 Table 34. Approximate Number of Postnatal Check-ups with a Midwife

I was interested to know if women hired and then changed home birth midwives or midwife-teams at any point during their pregnancy. As can be seen in Table 35, most women (92%) indicated that they did not switch midwives or midwife-teams at any time.

Only 8% said that they made a switch at some time during their pregnancy.

During the pregnancy for your most recent planned home birth, did you n % switch midwives/midwife-teams at any time? No 318 92 Yes 29 8 Total 347 Table 35. Switched Midwives During Pregnancy

Women who chose the home birth option often mention a preference for less intervention and more natural methods. I was interested to see to what extent this type of preference carried over to their decision to have a prenatal ultrasound, as they might see this as less than natural. As it turns out, the majority of the women surveyed had some type of ultrasound during their pregnancy. Thirty-nine percent had 1 and 34% had 2 prenatal ultrasounds while twenty-seven percent indicated that they had no ultrasounds during the pregnancy.

During the pregnancy for my most recent planned home birth, I had n % 1 prenatal ultrasound 141 39 2 or more prenatal ultrasounds 122 34 I had no ultrasounds during the pregnancy for my most recent planned home 98 27 birth Total 361 No response 4 Table 36. Ultrasound During Pregnancy

Included in the survey were questions about the woman having had prenatal checkups with any type of doctor. More than 45% of the women surveyed had seen an

OB/GYN at some point during her pregnancy. Thirty-three percent of women saw no

76 doctors during their pregnancy. The third most frequent response was 19%, of women having had a prenatal appointment with a Chiropractic doctor. The next most frequently mentioned response was Certified Nurse Midwife, CNM (9%). CNM was not a check box option for the question so responses were received in the write-in comment section.

In hindsight, the question should have been included as an option in the selection because

CNMs in Ohio practice with obstetricians and this type of response would be as relevant as seeing a doctor (for the purpose of this question). The remaining responses included

“Doctor-MD” (8%), “Doctor-DO” (2%), and Nurse Practitioner, Neurologist and

Perinatologist each at less than 1%.

During the pregnancy for my most recent planned home birth, I had prenatal f % check-ups with a Doctor-OB/GYN (Obstetrician and Gynecologist) 167 45.75 I had no prenatal check-ups with a doctor 121 33.15 Doctor of Chiropractic - DC (Chiropractor) 68 18.63 Doctor-MD (or General Practitioner) 28 7.67 Certified Nurse Midwife - CNM (write-in) 33 9.04 Doctor-DO (Doctor of Osteopathy) 6 1.64 Nurse Practitioner (write-in) 1 0.27 Neurologist (write-in) 1 0.27 Doctor-Perinatologist (write-in) 1 0.27 Total 426 Table 37. Prenatal Check-ups with a Doctor

Women who saw a doctor during their pregnancy responded the most frequently that their reason for seeing a doctor was that they wanted to have a back up doctor that they knew in case of going to the hospital (30% of responses). Another 18% of responses indicated that they saw a doctor because they believed that chiropractic adjustments were

77 important for theirs or their babies’ health. Fifteen percent indicated that the reason the mothers saw a doctor was because they hired a midwife late in their pregnancy (15%).

Five percent of the responses indicated that the mother had some concern about complications in the pregnancy and therefore went to see a doctor.

During the pregnancy for my most recent planned home birth, I had prenatal check-ups with a doctor because f % Not Applicable - I had no prenatal check-ups with a doctor 146 40.00 I wanted to have a back up doctor I knew in case I decided to go to a hospital 111 30.41

66 18.08 I believed that chiropractic adjustments were an important part of my health and my baby's I hired my midwife late in my pregnancy 56 15.34 I was concerned about complications 18 4.93 Total 397 Table 38. Reason for Prenatal Check-ups with a Doctor

The women indicated the approximate number of prenatal checkups they had with a doctor. The responses, beginning with the most common were 3-5 (19%), 6-8 (15%),

1-2 (11%), 9-15 (9%), and “more than 15” (4%).

For my most recent planned home birth, my approximate number of prenatal f % check-ups with a doctor was there were no prenatal checkups 120 32.88 1-2 38 10.41 3-5 69 18.90 6-8 53 14.52 9-15 32 8.77 more than 15 13 3.56 Other responses (self-described varying combinations of numbers of visits with 35 9.59 doctors, CNMs in ObGyn practices, or not having seen a doctor at all) Total 360 No response 5 Table 39. Approximate Number of Prenatal Check-ups with a Doctor 78

I was interested to see if the women who planned a home birth also planned for a specific back up doctor in case they needed medical care. Half of women surveyed responded that they had a specific doctor planned, 45% indicated that they did not have a specific doctor planned, and 5% did not respond to the question.

My midwife/midwife-team or I had a specific back up doctor n % planned in case I needed medical care Yes 181 52 No 165 48 Total 346 No response 19 Table 40. Had a Specific Back up Doctor Planned

Consumer Satisfaction

Satisfaction overall with midwifery services was very high. Ninety-five percent of women who hired a midwife responded that they were satisfied (Strongly Satisfied,

86%) with the midwife/midwife team for their most recent planned home birth. Three percent of respondents replied that they were dissatisfied with the service they received.

How would you rate your satisfaction with your midwife or n % midwife team for your most recent planned home birth? Strongly Satisfied 299 86.17 Moderately Satisfied 29 8.36 Slightly Satisfied 3 0.86 Satisfied 5 1.44 Slightly Dissatisfied 4 1.15 Moderately Dissatisfied 4 1.15 Strongly Dissatisfied 3 0.86 Total 347 Table 41. Satisfaction Level with Midwife Services

When asked if they would hire a midwife again 96% of respondents who had previously hired a midwife, said they would do so again. Two percent of the women responded that they would not hire a midwife again and 1.44% was unsure.

Given the opportunity, I would choose to hire a n % midwife/midwife-team for a planned home birth again Yes - Definitely 321 92.51% Yes - Probably 13 3.75% Unsure 5 1.44% No - Probably 4 1.15% No - Definitely 3 0.86% Total 346 No response 1 0.29% Table 42. Would Hire a Midwife Attendant Again

Data Analysis

A chi-square test was used to determine if any of the categories within each of the dependent variables were different from chance, based on the four independent variables, namely: age, education, income, and metro (urban) vs. non-metro (rural). The chi-square test for relationship significance was chosen because I was examining two categorical variables for a possible relationship.

Chi-square is a test of relationship between two categorical variables and checks to see if a relationship exists between the two variables. Chi-square cannot detect the direction of the relationship, whether it is negative or positive, and it also does not look at differences within the variable itself. Chi-square is simply looking at the difference between the expected and the observed values for the two-way table as a whole. Chi- square is calculated by taking the sum of the squared differences between the observed

80 and the expected values, divided by the expected values. The expected value is calculated as the marginal row and column totals for each cell, which are multiplied and divided by the total number of cases. Hence, each cell has an expected value that represents what would happen by random chance. Any difference between the observed and the expected value, added up – cell by cell – creates the chi-square value and indicates if there is a difference that is statistically significant. For this measure I have used the standard rule of .05 for establishing whether or not a value was significant.

The dependent variables analyzed included: If the respondent planned a specific back up doctor for the birth; how she contacted her midwife (through an online resource, network or organization, or an interpersonal connection); the distance to the nearest hospital, the number of midwives or midwife-teams available to choose from; whether the respondent saw a doctor during the prenatal period (ObGyn or a doctor of another type); the location of the majority of prenatal appointments; the number of ultrasounds during pregnancy; the month that respondent hired midwife or midwife-team.

Two additional statistical measures of association were used to supplement the chi-square, namely, Cramer’s V and Phi. These two measures are appropriate to measure the strength of the relationship between two nominal (or nominal and ordinal) variables.

Phi is appropriate for 2x2 tables and Cramer’s V for larger tables. Both tests display a value of 0 when there is no relationship and a value of +1 when the variables are perfectly associated. A high value for v, or close to +1, signifies a strong relationship in both tests.

Age

The ages of the mothers who participated in the study were organized into 4 categories (i.e. 18-25, 26-30, 31-35, 36+). Differences are possible by age because societal experiences vary based on the norms, values and experiences prevalent at different points in time. In planning a home birth there are decisions that a woman makes and options she considers in her utilization of health services and her experience of the health delivery system which may help to reveal social nuances by age. Tables 43 through 54 present the statistical findings of a chi-square test regarding age and the various dependent variables previously listed.

Had a Specific Respondent's Age Back up Doctor Planned for the Birth 18-25 26-30 31-35 36+ Total No 25 (46.3%) 70 (53.4%) 43 (41.7%) 26 (47.3%) 164 (47.8%) Yes 29 (53.7%) 61 (46.6%) 60 (58.3%) 29 (52.7%) 179 (52.2%) Total 54 131 103 55 343 Chi-square=3.23 (df=3; p=.357), Cramer’s V=.097 Table 43. Respondent's Age and Planned a Specific Back up Doctor for the Birth.

Having a planned and specific back up doctor for the birth was not much different across each of the four age categories. There was no relationship between the respondents’ ages and whether they planned a back up doctor for the birth. Just over half of all women, regardless of their age, had planned a back up doctor in case they needed to transfer care while in labor.

Contacted Midwife Respondent’s Age Through an Online Resource 18-25 26-30 31-35 36+ Total Yes 10 (17.5%) 30 (22.1%) 16 (15.0%) 6 (10.0%) 62 (17.2%) No 47 (82.5%) 106 91 (85.0%) 54 298 (77.9%) (90.0%) (82.8%) Total 57 136 107 60 360 Chi-square=4.817 (df=3; p=.186), Cramer’s V=.116 Table 44. Respondent's Age and Contacted the Midwife through Online Resource.

The relationship between the respondents’ ages and how they contacted their midwives were not statistically significant, as reported in Tables 44 through 46. In each case, how they contacted their midwives: through an online resource, a network or organization or through an interpersonal contact, did not vary by the respondents’ age.

Contacting a midwife through an interpersonal connection was the most common way that women got in touch with their midwives, with between 55% and 71% of each age group indicating this option.

Contacted Midwife Respondent's Age Through a Network or Organization 18-25 26-30 31-35 36+ Total Yes 8 (14.0%) 26 (19.1%) 24 (22.4%) 11 (18.3%) 69 (19.2%) No 49 (86.0%) 110 (80.9%) 83 (77.6%) 49 (81.7%) 291 (80.8%) Total 57 136 107 60 360 Chi-square=1.731 (df=3; p=.630), Cramer’s V=.069 (p=.630) Table 45. Respondent's Age and Contacted the Midwife Through a Network or Organization.

Contacted Midwife Respondent's Age Through an Interpersonal Contact 18-25 26-30 31-35 36+ Total Yes 33 (57.9%) 96 (70.6%) 59 (55.1%) 38 (63.3%) 226 (62.8%) No 24 (42.1%) 40 (29.4%) 48 (44.9%) 22 (36.7%) 134 (37.2%) Total 57 136 107 60 360 Chi-square= 6.811 (df=3; p=.078), Cramer’s V=.138 Table 46. Respondent's Age and Contacted the Midwife Through an Interpersonal Contact.

Distance to Nearest Respondent's Age Hospital 18-25 26-30 31-35 36+ Total 5 miles of the nearest 26 71 55 29 181 hospital (48.1%) (53.4%) (52.9%) (49.2%) (51.7%) 6 to 10 miles of the 17 52 29 20 118 nearest hospital (31.5%) (39.1%) (27.9%) (33.9%) (33.7%) more than 10 miles from 11 10 (7.5%) 20 10 51 (14.6%) the nearest hospital (20.4%) (19.2%) (16.9%) Total 54 133 104 59 350 Chi-square=10.143 (df=6; p=.119), Cramer’s V=.120

Table 47. Respondent's Age and Distance to Nearest Hospital.

Across the respondent’s ages there was little difference in their distance to the nearest hospital. There was no difference between age and distance, and none of the tests were statistically significant.

Number of Respondent's Age Midwives or Midwife-teams Available to Choose From 18-25 26-30 31-35 36+ Total 1-2 22 (41.5%) 54 (41.2%) 43 (41.7%) 23 (41.8%) 142 (41.5%) 3 or more 31 (58.5%) 77 (58.8%) 60 (58.3%) 32 (58.2%) 200 (58.5%) Total 53 131 103 55 342 Chi-square =.009 (df=3; p=1.000), Cramer’s V=.005 Table 48. Respondent's Age and Number of Midwives or Midwife-teams Available to Choose From.

The number of midwives or midwife-teams available to choose from showed little difference across each of the four age categories. The relationship between the respondents’ age and the number of midwives or midwife-teams from which they had to choose was not statistically significant. A little over half of all respondents, regardless of their age, said that they had 3 or more midwives or midwife teams to choose from in their area.

Whether subject Respondent's Age saw a doctor during the prenatal period 18-25 26-30 31-35 36+ Total No 19 (33.9%) 54 (39.7%) 45 (42.5%) 21 (35.0%) 139 (38.8%) Yes 37 (66.1%) 82 (60.3%) 61 (57.5%) 39 (65.0%) 219 (61.2%) Total 56 136 106 60 358 Chi-square=1.567 (df=3, p=.667), Cramer’s V= .066 Table 49. Respondent's Age and Whether the Respondent Saw a Doctor During the Prenatal Period.

Just over 60% of respondents indicated they saw a doctor during the prenatal period. The observed values were not significantly different from the expected values.

The relationship between age and seeing a doctor during the prenatal period was not statistically significant.

Whether subject saw Respondent's Age an Obstetrician Gynecologist (ObGyn) doctor during the prenatal period 18-25 26-30 31-35 36+ Total No 31 (55.4%) 79 (58.1%) 62 (58.5%) 32 (53.3%) 204 (57.0%) Yes 25 (44.6%) 57 (41.9%) 44 (41.5%) 28 (46.7%) 154 (43.0%) Total 56 136 106 60 358 Chi-square=.552 (df=3, p=.907), Cramer’s V=.039 Table 50. Respondent's Age and Whether the Respondent Saw an Obstetrician Gynecologist (ObGyn) Doctor During the Prenatal Period.

Forty-three percent of respondents said they saw an ObGyn doctor during the prenatal period. The relationship between the respondents’ age and whether they saw an

ObGyn during the prenatal period was not statistically significant.

Whether subject saw Respondent's Age a Doctor that was not an Obstetrician Gynecologist (ObGyn) during the prenatal period 18-25 26-30 31-35 36+ Total No 37 (66.1%) 89 (65.4%) 75 (70.8%) 41 (68.3%) 242 (67.6%) Yes 19 (33.9%) 47 (34.6%) 31 (29.2%) 19 (31.7%) 116 (32.4%) Total 56 136 106 60 358 Chi-square=.845 (df=3, p=.839), Cramer’s V= .049 Table 51. Respondent's Age and Whether the Respondent Saw a Doctor that was Not an Obstetrician Gynecologist (ObGyn) During the Prenatal Period.

Over 67% of respondents said they saw a doctor who was not an ObGyn during the prenatal period. There was little variation in the proportion of those who consulted an

ObGyn by age. In fact, the percentages fell within a narrow range of 66.1% for women

19-25 years and 70.8% for women who were 31-35 years old.

Location of Respondent's Age Majority of Prenatal Appointments 18-25 26-30 31-35 36+ Total in my home 7 (14.0%) 29 (22.1%) 28 (27.7%) 16 (28.1%) 80 9 (23.6%) within 1 to 10 miles 15 (30.0%) 32 (24.4%) 27 (26.7%) 16 (28.1%) 90 (26.5%) of my home within 11 to 20 12 (24.0%) 25 (19.1%) 21 (20.8%) 9 (15.8%) 67 (19.8%) miles of my home more than 20 miles 16 (32.0%) 45 (34.4%) 25 (24.8%) 16 (28.1%) 102 (30.1%) from my home Total 50 131 101 57 339 Chi-square= 6.658 (df=9; p=.673), Cramer’s V=.081 Table 52. Respondent's Age and Location of the Majority of Prenatal Appointments.

Table 52 shows the distribution for distance traveled for a prenatal appointment and age. The expected values were not significantly different from the observed values.

However, even though age and location of the majority of prenatal appointments was not statistically significant, there was a marginal level of association apparent with age.

Older women were more likely to have had the majority of their appointments in their home, and to travel a shorter distance than younger women. Perhaps the results show that women who give birth at a younger age were more likely to live in rural areas.

Ultrasounds During Respondent's Age Pregnancy 18-25 26-30 31-35 36+ Total 1 or more 43 (78.2%) 106 (77.9%) 71 (67.0%) 39 (65.0%) 259 (72.5%) No Ultrasounds 12 (21.8%) 30 (22.1%) 35 (33.0%) 21 (35.0%) 98 (27.5%) Total 55 136 106 60 357 Chi-square = 6.229 (df=3; p=.101), Cramer’s V=.132 Table 53. Respondent's Age and Ultrasounds During Pregnancy.

The Chi-square test for age and ultrasound during pregnancy showed that the expected values and the observed values were not significantly different. Despite the lack of significant association between the two variables the number of ultrasounds was slightly higher for respondents under the age of 30. Overall, more than 70% all the women surveyed, regardless of their age, had an ultrasound during their pregnancy. Even though age and having an ultrasound, was not statistically significant, there was an association apparent with age, as older women were slightly less likely to have had an ultrasound. A very weak relationship may exist between the two categorical variables because of the high adoption and use of the ultrasound technology for youth. Despite the

88 choice to go “all natural” with their births, younger women may be slightly more likely to incorporate the use of technology into their pregnancy as they are also more likely to incorporate technology in other areas of their life (Becker, 2000).

Month Hired Respondent's Age Midwife or Midwife-team 18-25 26-30 31-35 36+ Total First Trimester 35 (64.8%) 95 (72.5%) 76 (73.8%) 38 (69.1%) 244 (71.1%) Second or Third 19 (35.2%) 36 (27.5%) 27 (26.2%) 17 (30.9%) 99 (28.9%) Trimester Total 54 131 103 55 343 Chi-square=1.637 (df=3; p=.651), Cramer’s V=.069 Table 54. Respondent's Age and Month that She Hired Midwife or Midwife-team.

The month in which a midwife was hired was not much different across each of the four age categories. In other words, there was no significant relationship between age and the month a midwife was hired.

There were no significant relationships evident between the independent variable, age, and the dependent variables for the Chi-square test of significance. However, a noticeable trend between age and the use of ultrasound technology during pregnancy may signify that younger women were more likely to include technology in the form of ultrasound use in pregnancy.

Education

Education may be an important factor in the experiences of women seeking the home birth option. Midwives who offer this type of care are so few compared to today’s mainstream options that research and education are necessary to simply know about

89 alternative birthing options. Previous home birth research has shown that women with higher educational attainment are more likely to make the home birth choice (Johnson &

Daviss, 2005). I was curious to see if increased educational attainment within the home birth cohort was also associated with additional decisions and characteristics surrounding the home birth choice. The education level of the survey participants is represented by 4 categories (i.e. High School, Two-year, Four-year College Degree, and a Graduate

Degree). Tables 55 through 66 present the statistical findings of the chi-square test for education and the various dependent variables.

Had a Specific Back up Participant's Education Doctor Planned for the High Birth School Two-year Four-year Graduate Total No 34 (53.1%) 34 (53.1%) 60 (45.1%) 36 (44.4%) 164 (48.0%) Yes 30 (46.9%) 30 (46.9%) 73 (54.9%) 45 (55.6%) 178 (52.0%) Total 64 64 133 81 342 Chi-square=2.201 (df=3, p=.532); Cramer’s V=.080 Table 55. Participant's Education and Planned a Specific Back up Doctor for the Birth.

Participants chose to plan a specific back up doctor for their birth at very similar rates across each of the four education categories. There was no relationship evident between the respondents’ ages and whether they planned a backup doctor for the birth.

Contacted Midwife Participant's Education Through an Online Resource High School Two-year Four-year Graduate Total Yes 15 (20.8%) 13 (18.8%) 19 (13.9%) 15 (18.5%) 62 (17.3%) No 57 (79.2%) 56 (81.2%) 118 (86.1%) 66 (81.5%) 297 (82.7%) Total 72 69 137 81 359 Chi-square=1.957 (df=3, p=.581), Cramer’s V=.074 Table 56. Participant's Education and Contacted the Midwife Through Online Resource.

The relationship between participants’ education and whether they contacted their midwife through an online resource was not statistically significant, as indicated in Table

57. As well, the results in Tables 58 and 59 show no statistical significance for educational level and contacting a midwife network/organization and or through an interpersonal channel.

Contacted Midwife Participant's Education Through a Network High or Organization School Two-year Four-year Graduate Total Yes 9 (12.5%) 13 (18.8%) 32 (23.4%) 15 (18.5%) 69 (19.2%) No 63 (87.5%) 56 (81.2%) 105 (76.6%) 66 (81.5%) 290 (80.8%) Total 72 69 137 81 359 Chi-square=3.637 (df=3, p=.303), Cramer’s V=.101 Table 57. Participant's Education and Contacted the Midwife Through a Network or Organization.

Contacted Midwife Participant's Education Through an Interpersonal High Contact School Two-year Four-year Graduate Total Yes 42 (58.3%) 41 (59.4%) 89 (65.0%) 54 (66.7%) 226 (63.0%) No 30 (41.7%) 28 (40.6%) 48 (35.0%) 27 (33.3%) 133 (37.0%) Total 72 69 137 81 359 Chi-square=1.744 (df=3, p=.627), Cramer’s V=.070 Table 58. Participant's Education and Contacted the Midwife Through an Interpersonal Contact.

Participant's Education Distance to Nearest High Hospital School Two-year Four-year Graduate Total 5 miles of the nearest 29 (41.4%) 34 71 46 180 hospital (51.5%) (53.8%) (56.8%) (51.6%) 6 to 10 miles of the nearest 30 (42.9%) 22 40 26 118 hospital (33.3%) (30.3%) (32.1%) (33.8%) More than 10 miles from 11 (15.7%) 10 21 9 (11.1%) 51 (14.6%) the nearest hospital (15.2%) (15.9%) Total 70 66 132 81 349 Chi-square=5.102 (df=6, p=.531), Cramer’s V=.085 Table 59. Participant's Education and Distance to Nearest Hospital.

In Table 59 the expected values are not significantly different from the observed values of respondents’ education and the distance to nearest hospital. There was no apparent relationship between the two categorical variables.

Number of Midwives or Participant's Education Midwife-teams Available to High Choose From School Two-year Four-year Graduate Total 1-2 35 28 46 32 141 (54.7%) (43.8%) (34.8%) (39.5%) (41.3%) 3 or more 29 36 86 49 200 (45.3%) (56.3%) (65.2%) (60.5%) (58.7%) Total 64 64 132 81 341 Chi-square=7.261 (df=3, p=.064), Cramer’s V=.146 Table 60. Participant's Education and Number of Midwives or Midwife-teams Available to Choose From.

The relationship between the number of midwives or midwife-teams available to choose from in their area and the participant’s education was at best marginally related to educational level. The chi-square value was nearly significant at .064, and the Cramer’s

V, with a coefficient of .146 revealed a very week relationship. As the table shows, women with only a high school degree were slightly less likely to have indicated that they had three or more midwife teams from which to select. As the participants’ education increased so did the number of midwives or midwife teams available, except for the Graduate-level education category where it drops slightly. Participants in the

Four-year and Graduate categories were 20% and 15%, respectively, more likely to have had 3 or more midwife options to choose from than participants in the High School category. Perhaps women with higher educational attainment were more likely to live in urban areas where home birth midwife options are more plentiful. If this is the case, it suggests a need for more midwifes in rural areas so women of all educational levels could access them and eliminate any disadvantage by educational level.

Whether subject Participant's Education saw a doctor during the prenatal period High School Two-year Four-year Graduate Total No 38 (53.5%) 33 (47.8%) 42 (30.7%) 25 (31.3%) 138 (38.7%) Yes 33 (46.5%) 36 (52.2%) 95 (69.3%) 55 (68.8%) 219 (61.3%) Total 71 69 137 80 357 Chi-square=14.610 (df=3, p=.002), Cramer’s V=.202

Table 61. Participant's Education and Whether the Respondent Saw a Doctor During the Prenatal Period.

The relationship between participant education and whether they saw a doctor during the prenatal period was significant at the .01 level. The data shows that for participating mothers, the more education they had, the more likely they were to have seen a doctor at some time during their prenatal period. About 69% of participants with a graduate education saw a doctor while less than half of participants with a high school education saw a doctor during their pregnancy.

Whether subject saw Participant's Education an Obstetrician Gynecologist (ObGyn) doctor during the prenatal High period School Two-year Four-year Graduate Total No 50 (70.4%) 44 (63.8%) 67 (48.9%) 42 (52.5%) 203 (56.9%) Yes 21 (29.6%) 25 (36.2%) 70 (51.1%) 38 (47.5%) 154 (43.1%) Total 71 69 137 80 357 Chi-square=10.821 (df=3, p=.013), Cramer’s V=.174 Table 62. Participant's Education and Whether the Respondent Saw an Obstetrician Gynecologist (ObGyn) Doctor During the Prenatal Period.

The relationship between participant education and whether they saw an ObGyn doctor during the prenatal period was also significant, but at the .05 level. The data shows that for participating mothers, just like in the previous table, the more education they had, the more likely they were to have seen an obstetrician at some time during their prenatal period. About 48% of participants with a graduate education versus 30% of participants with a high school education saw an obstetrician during their pregnancy. For each of these questions it could be that women with advanced education are more likely to be employed, be a student, or have a spouse who is employed or a student, and therefore have health insurance. Having health care coverage may make this cohort more likely to see an ObGyn since they are the most common pregnancy care provider covered under health insurance plans. It could be that women who have health insurance are more likely to seek out a doctor for their earliest pregnancy checkups even though they eventually choose to deliver with a midwife. Future research should include a question that determines whether the participant has health insurance.

Whether subject saw Participant's Education a Doctor that was not an Obstetrician Gynecologist (ObGyn) during the High prenatal period School Two-year Four-year Graduate Total No 54 (76.1%) 50 (72.5%) 87 (63.5%) 50 (62.5%) 241 (67.5%) Yes 17 (23.9%) 19 (27.5%) 50 (36.5%) 30 (37.5%) 116 (32.5%) Total 71 69 137 80 357 Chi-square=5.054 (df=3, p=.168), Cramer’s V=.119 Table 63. Participant's Education and Whether the Respondent Saw a Doctor that was Not an Obstetrician Gynecologist (ObGyn) During the Prenatal Period.

The relationship between respondents’ education and whether they saw a doctor who was not an ObGyn (MD, DO, DC) during the prenatal period was not statistically significant. The table shows only a small increase in the likelihood of seeing one of these non-ObGyn doctors among participants as education level increases.

Location of Majority Participant's Education of Prenatal High Appointments School Two-year Four-year Graduate Total in my home 15 (22.7%) 13 (20.0%) 32 (24.4%) 20 (26.3%) 80 (23.7%) within 1 to 10 miles 16 (24.2%) 17 (26.2%) 38 (29.0%) 19 (25.0%) 90 (26.6%) of my home within 11 to 20 12 (18.2%) 15 (23.1%) 22 (16.8%) 17 (22.4%) 66 (19.5%) miles of my home more than 20 miles 23 (34.8%) 20 (30.8%) 39 (29.8%) 20 (26.3%) 102 (30.2%) from my home Total 66 65 131 76 338 Chi-square=3.315 (df=9, p=.950), Cramer’s V=.057 Table 64. Participant's Education and Location of the Majority of Prenatal Appointments.

The test of relationship for the DV, location of majority of prenatal appointments, and IV, Participant’s Education, was not statistically significant and the values are very similar across the different categories. Simply put, there was no variation in the location for prenatal appointments and the educational level of respondents.

Participant's Education Ultrasounds During High Pregnancy School Two-year Four-year Graduate Total 1 or more 49 (69.0%) 50 (72.5%) 100 60 (75.0%) 259 (73.5%) (72.8%) No Ultrasounds 22 (31.0%) 19 (27.5%) 36 (26.5%) 20 (25.0%) 97 (27.2%) Total 71 69 136 80 356 Chi-square=.749 (df=3, p=.862); Cramer’s V=.046 Table 65. Participant's Education and Ultrasounds During Pregnancy.

The expected values were not significantly different from the observed values for the two ordinal variables, participant’s education and ultrasounds during pregnancy.

Across all educational categories, about the same proportion of women hired a midwife or midwife team during the first trimester.

Month Hired Participant's Education Midwife or Midwife- High team School Two-year Four-year Graduate Total First Trimester 46 (71.9%) 49 (76.6%) 92 (69.2%) 56 (69.1%) 243 (71.1%) Second or Third 18 (28.1%) 15 (23.4%) 41 (30.8%) 25 (30.9%) 99 (28.9%) Trimester Total 64 64 133 81 342 Chi-square=1.339 (df=3, p=.720); Cramer’s V=.063 Table 66. Participant's Education and Month that She Hired Midwife or Midwife-team.

The relationship between participant’s education and the month they hired their midwife or midwife-team was not significant. The percentage of participants who hired their midwife in the first trimester vs. the 2nd/3rd trimester tended to be very similar no matter the participants education level.

Two significant relationships were apparent between the independent variable, education, and the dependent variables for the Chi-square test of significance.

Educational level and seeing any doctor and seeing an ObGyn doctor during the prenatal period were related to some extent. In both cases, more educated women were more proactive on seeking an M.D., indicating that they may be more concerned about health related issues of the home birth option or that they can afford the check-up due to insurance provided by their employer or their spouse’s employer. However, the difference by educational level, though statistically significant, was not strong, suggesting a need for more research on this issue.

Income

Family income may be an important factor in the home birth option. Income plays a role in access to health care in the United States already because of our fee-for-service system that is mostly accessible through employer provided health insurance. Having insurance coverage or an income that negates the need for insurance may affect ones use of mainstream and alternative health care options. Survey respondents’ family income is presented in 3 groupings (i.e. $0-$40,000, $40,001-$70,000, $70,001+). Tables 67

98 through 78 present the statistical results for the tests of the relationship between family income and the various dependent variables.

Had a Specific Back up Family Income Doctor Planned for the Birth $0-$40,000 $40,001-$70,000 $70,001+ Total No 56 (54.4%) 60 (45.1%) 47 (46.1%) 163 (48.2%) Yes 47 (45.6%) 73 (54.9%) 55 (53.9%) 175 (51.8%) Total 103 133 102 338 Chi-square=2.261 (df=2, p=.323); Cramer’s V=.082 Table 67. Family Income and Planned a Specific Back up Doctor for the Birth.

Respondents in the lowest income group were slightly less likely to have indicated having a specific back up doctor planned for the birth than participants of higher incomes. However, the difference between family income and planning a backup doctor for the birth was not statistically significant.

Contacted Midwife Family Income Through an Online $40,001- Resource $0-$40,000 $70,000 $70,001+ Total Yes 15 (13.3%) 30 (21.4%) 16 (15.7%) 61 (17.2%) No 98 (86.7%) 110 (78.6%) 86 (84.3%) 294 (82.8%) Total 113 140 102 355 Chi-square=3.147 (df=2, p=.207); Cramer’s V=.094 Table 68. Family Income and Contacted the Midwife Through Online Resource.

Participants in the middle income category were the most likely to have contacted their midwife through and online resource. However, the test of the relationship between family income and contacting a midwife through an online resource overall yielded no 99 statistical significance. Given the low proportion across all three groups who contacted a midwife through an online resource, the results in Table 68 reveal no firm pattern by income.

Contacted Midwife Family Income Through a Network or Organization $0-$40,000 $40,001-$70,000 $70,001+ Total Yes 15 (13.3%) 28 (20.0%) 25 (24.5%) 68 (19.2%) No 98 (86.7%) 112 (80.0%) 77 (75.5%) 287 (80.8%) Total 113 140 102 355 Chi-square=4.477 (df=2, p=.107); Cramer’s V=.112 Table 69. Family Income and Contacted the Midwife through a Network or Organization.

Though the highest income group was most likely to contact their midwife through a network or organization, the expected values are not significantly different from the observed values for family income and contacting midwife through a network or organization.

Contacted Midwife Family Income Through an Interpersonal $40,001- Contact $0-$40,000 $70,000 $70,001+ Total Yes 68 (60.2%) 89 (63.6%) 66 (64.7%) 223(62.8%) No 45 (39.8%) 51 (36.4%) 36 (35.3%) 132 (37.2%) Total 113 140 102 355 Chi-square=.527 (df=2, p=.768); Cramer’s V=.039 Table 70. Family Income and Contacted the Midwife through an Interpersonal Contact.

Each income category showed about a 60-65% of the survey participants as having contacted their midwife through an interpersonal contact. The relationship 100 between family income and contacting a midwife through a network or organization was not statistically significant.

Family Income Distance to Nearest Hospital $40,001- $0-$40,000 $70,000 $70,001+ Total 5 miles of the nearest hospital 57 (52.8%) 69 (49.6%) 51 (52.0%) 177 (51.3%) 6 to 10 miles of the nearest hospital 31 (28.7%) 50 (36.0%) 37 (37.8%) 118 (34.2%) more than 10 miles from the nearest 20 (18.5%) 20 (14.4%) 10 (10.2%) 50 (14.5%) hospital Total 108 139 98 345 Chi-square=4.027 (df=4, p=.402); Cramer’s V=.076 Table 71. Family Income and Distance to Nearest Hospital.

The expected values are not significantly different from the observed values in table 71. The relationship between family income and distance to the nearest hospital was not statistically significant.

Number of Midwives or Family Income Midwife-teams Available to $40,001- Choose From $0-$40,000 $70,000 $70,001+ Total 1-2 51 (50.0%) 48 (36.1%) 39 (38.2%) 138 (40.9%) 3 or more 51 (50.0%) 85 (63.9%) 63 (61.8%) 199 (59.1%) Total 102 133 102 337 Chi-square=5.065 (df=2, p=.079); Cramer’s V=.123 Table 72. Family Income and Number of Midwives or Midwife-teams Available to Choose From.

The table on family income and number of midwives/midwife teams available to choose from showed a slight increase with family income. The expected values and the

101 observed values however were not statistically significant. Level of education was also almost weakly significant at the .05 level and we may speculate that increased family income and increased education are slightly associated with an increase in the number of midwives/midwife team options from which women can select.

Whether subject saw Family Income a doctor during the $40,001- prenatal period $0-$40,000 $70,000 $70,001+ Total No 50 (44.6%) 55 (39.3%) 32 (31.7%) 137 (38.8%) Yes 62 (55.4%) 85 (60.7%) 69 (68.3%) 216 (61.2%) Total 112 140 101 353 Chi-square=3.778 (df=2, p=.151); Cramer’s V=.103 Table 73. Family Income and Whether the Respondent Saw a Doctor During the Prenatal Period.

There was no relationship between reported income and consulting a doctor during the prenatal period, as shown in Table 73. The lowest income group saw a doctor at about 55% while the highest income group did so at just over 68%. This 13% difference, however, was not statistically significant.

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Whether subject saw an Family Income Obstetrician Gynecologist (ObGyn) doctor during the $40,001- prenatal period $0-$40,000 $70,000 $70,001+ Total No 72 (64.3%) 78 (55.7%) 50 (49.5%) 200 (56.7%) Yes 40 (35.7%) 62 (44.3%) 51 (50.5%) 153 (43.3%) Total 112 140 101 353 Chi-square=4.809 (df=2, p=.090); Cramer’s V=.117

Table 74. Family Income and Whether the Respondent Saw an Obstetrician Gynecologist (ObGyn) Doctor During the Prenatal Period.

The relationship between family income and whether the participant saw an

ObGyn doctor in the prenatal period was not statistically significant. In other words, family income and consulting an ObGyn were not related.

Whether subject saw a Doctor that Family Income was not an Obstetrician Gynecologist (ObGyn) during the $40,001- prenatal period $0-$40,000 $70,000 $70,001+ Total No 80 (71.4%) 93 (66.4%) 66 (65.3%) 239 (67.7%) Yes 32 (28.6%) 47 (33.6%) 35 (34.7%) 114 (32.3%) Total 112 140 101 353 Chi-square=1.071 (df=2, p=.585); Cramer’s V=.005 Table 75. Family Income and Whether the Respondent Saw a Doctor that was Not an Obstetrician Gynecologist (ObGyn) During the Prenatal Period.

As well, the relationship between family income and whether the participant saw a non-ObGyn type of doctor during the prenatal period was not statistically significant.

The percentage values for each successively higher income group increased slightly, but not enough to warrant a claim of statistical significance.

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Family Income Location of Majority of $40,001- Prenatal Appointments $0-$40,000 $70,000 $70,001+ Total in my home 24 (23.3%) 29 (21.8%) 27 (27.6%) 80 (24.0%) within 1 to 10 miles of my 26 (25.2%) 36 (27.1%) 27 (27.6%) 89 (26.6%) home within 11 to 20 miles of 15 (14.6%) 34 (25.6%) 17 (17.3%) 66 (19.8%) my home more than 20 miles from 38 (36.9%) 34 (25.6%) 27 (27.6%) 99 (29.6%) my home Total 103 133 98 334 Chi-square=7.601 (df=6, p=.269); Cramer’s V=.107 Table 76. Family Income and Location of the Majority of Prenatal Appointments.

The expected values were not significantly different from the observed values for family income and location for a majority of prenatal appointments. The largest percentage of women who traveled more than 20 miles for the majority of their prenatal checkups did occupy the lowest income bracket (37%) when compared to respondents in the middle income bracket (25.6%) and the highest income group (27.6%). But like all previous comparisons, reported income does not seem to make a difference in women’s experience with a home birth option.

Ultrasounds During Family Income Pregnancy $0-$40,000 $40,001-$70,000 $70,001+ Total 1 or more 71 (64.0%) 111 (79.9%) 73 (71.6%) 255 (72.4%) No Ultrasounds 40 (36.0%) 28 (20.1%) 29 (28.4%) 97 (27.6%) Total 111 139 102 352 Chi-square=7.863 (df=2, p=.020); Cramer’s V=.149 Table 77. Family Income and Ultrasounds During Pregnancy.

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Family income and having an ultrasound during pregnancy were positively correlated, although the relationship is weak at best. Respondents who reported lower incomes were less likely to have had an ultrasound, and both the chi-square value and the

Cramer’s V were statistically significant. About 80% of participants in the middle income category and nearly 72% in the highest income category had 1 or more ultrasounds during pregnancy, which was true for only 64% of participants in the lowest income category (who earned $40,000 or less). This suggests that respondents reporting higher income were more likely to have an ultrasound because they could afford it, or because they had insurance that covered such a visit.

Month Hired Family Income Midwife or Midwife- team $0-$40,000 $40,001-$70,000 $70,001+ Total First Trimester 70 (68.0%) 100 (75.2%) 71 (69.6%) 241 (71.3%) Second or Third 33 (32.0%) 33 (24.8%) 31 (30.4%) 97 (28.7%) Trimester Total 103 133 102 338 Chi-square=1.686 (df=2, p=.430); Cramer’s V=.071 Table 78. Family Income and Month that Mother Hired Midwife or Midwife-team.

The middle income group participants (75%) were most likely to have hired their midwife in the first trimester but they were only 5-7 % more likely to do so than the other two income groups. Hence, the chi-square value was not statistically significant. As well, the Cramer’s V was not statistically significant.

The independent variable, income, was significantly related to the number of ultrasounds that survey participants had during their pregnancy, otherwise, income was

105 not important in the way respondents reported their home birth experience on the survey.

The pattern to this finding, plus the previous comparisons by educational level, is important because it shows the home birth option is not simply for women who are disadvantaged by income or education. Instead, the home birth option appears to be a conscious choice of women across a variety of socio-economic backgrounds.

Metro/Non-metro Residence

The respondents’ residence location may be an important difference in the home birth option. Previous research shows that people in rural areas face greater barriers to health care access than their urban counterparts. Rural areas have higher poverty and therefore higher uninsured rates (Lenardson, et.al, 2009), difficulty recruiting and retaining health care providers (GAO, 2003), and longer travel times to receive health care services (Hart & Goodman, 2006).

The residence of each survey participant was categorized by the county in which they lived, based on US Bureau of Census designation as either metropolitan or nonmetropolitan. Specifically, on the survey, they were asked for the zip code where they lived at the time of their most recent planned home birth. Tables 79 through 90 present the statistical findings of a chi-square test regarding metro/non-metro residence and the various dependent variables. Statistically significant relationships were discovered in two of the following cross tabulations.

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Had a Specific Back up Respondent's Residence Doctor Planned for the Birth Non-metro Metro Total No 28 (54.9%) 137 (46.8%) 165 (48.0%) Yes 23 (45.1%) 156 (53.2%) 179 (52.0%) Total 51 293 344 Chi-square=1.154 (df=1, p=.283), Phi=.058 Table 79. Respondent's Residence at time of Most Recent Planned Home Birth and Whether the Respondent had a Specific Back up Doctor Planned for the Birth.

The response percentages in each cell of table 79 were nearly the same. The relationship between respondent’s residence and having a specific back up doctor planned for the birth was not statistically significant. Hence, there were no rural versus urban differences.

Contacted Midwife Respondent's Residence Through an Online Resource Non-metro Metro Total Yes 11 (20.0%) 51 (16.6%) 62 (17.1%) No 44 (80.0%) 256 (83.4%) 300 (82.9%) Total 55 307 362 Chi-square=.377 (df=1, p=.539), Phi=.032 Table 80. Respondent's Residence at time of Most Recent Planned Home Birth and Contacted the Midwife Through Online Resource.

The next three tables (Tables 80 through 82) show possible differences in how a midwife/midwife team was contacted based on the residence of the respondents. None of the results were statistically significant, indicating little rural versus urban variation in how women contact a midwife. This is an important finding because it indicates there is little disadvantage to rural residence. Since the home birth option is a self-conscious 107 choice made as an alternative to the hospital option, rural women who seek a midwife/midwife team were as likely to have made first contact via an online source, a network or organization or through an interpersonal source as urban women.

Contacted Midwife Respondent's Residence Through a Network or Organization Non-metro Metro Total Yes 12 (21.8%) 58 (18.9%) 70 (19.3%) No 43 (78.2%) 249 (81.1%) 292 (80.7%) Total 55 307 362 Chi-square=.256 (df=1, p=.613), Phi=.027

Table 81. Respondent's Residence at Time of Most Recent Planned Home Birth and Contacted the Midwife Through a Network or Organization.

Contacted Midwife Respondent's Residence Through an Interpersonal Contact Non-metro Metro Total Yes 32 (58.2%) 194 (63.2%) 226 (62.4%) No 23 (41.8%) 113 (36.8%) 136 (37.6%) Total 55 307 362 Chi-square=.499 (df=1, p=.480), Phi=-.037

Table 82. Respondent's Residence at time of Most Recent Planned Home Birth and Contacted the Midwife Through an Interpersonal Contact.

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Respondent's Residence Distance to Nearest Hospital Non-metro Metro Total 5 miles of the nearest hospital 24 (43.6%) 158 (53.0%) 182 (51.6%) 6 to 10 miles of the nearest 12 (21.8%) 107 (35.9%) 119 (33.7%) hospital more than 10 miles from the 19 (34.5%) 33(11.1%) 52 (14.7%) nearest hospital Total 55 298 353 Chi-square=20.891 (df=2, p=.000), Cramer’s V=.243 Table 83. Respondent's Residence at Time of Most Recent Planned Home Birth and Distance to Nearest Hospital.

In table 83 comparing respondents’ residence and distance to nearest hospital, I found a statistically significant difference. Unlike all previous comparisons by age, education, and income, this one showed a clear and moderately strong association, and in a direction that makes sense. In other words, rural women must travel a longer distance to access services at a hospital. Hospital consolidation has concentrated medical services in cities, and the experience of rural women to my survey demonstrates the distances they now must travel.

Number of Midwives or Respondent's Residence Midwife-teams Available to Choose From Non-metro Metro Total 1-2 27 (52.9%) 119 (40.5%) 146 (42.3%) 3 or more 24 (47.1%) 175(59.5%) 199 (57.7%) Total 51 294 345 Chi-square=2.766 (df=1, p=.096), Phi=.090

Table 84. Respondent's Residence at Time of Most Recent Planned Home Birth and Number of Midwives or Midwife-teams Available to Choose From.

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Over 59% of metro respondents indicated that they had 3 or more midwives to choose from while only 47% of non-metro respondents indicated the same. The expected values for the table, however, were not significantly different.

Whether subject saw a Respondent's Residence doctor during the prenatal period Non-metro Metro Total No 24 (43.6%) 116 (37.9%) 140 (38.8%) Yes 31 (56.4%) 190 (62.1%) 221 (61.2%) Total 55 306 361 Chi-square=.644 (df=1, p=.422), Phi=.042 Table 85. Respondent's Residence at Time of Most Recent Planned Home Birth and Whether the Respondent Saw a Doctor During the Prenatal Period.

In table 85 the non-metro and metro categories were very similar for the yes and no responses. It appears that seeing a doctor during the prenatal period shows no difference by rural versus urban status of the county where respondents lived at the time of their home birth.

Whether subject saw an Obstetrician Respondent's Residence Gynecologist (ObGyn) doctor during the prenatal period Non-metro Metro Total No 36 (65.5%) 169 (55.2%) 205 (56.8%) Yes 19 (34.5%) 137 (44.8%) 156 (43.2%) Total 55 306 361 Chi-square=1.987 (df=1, p=.159), Phi=.074 Table 86. Respondent's Residence at Time of Most Recent Planned Home Birth and Whether the Respondent Saw an Obstetrician Gynecologist During the Prenatal Period.

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There was a bout a 10% difference between the responses in the non-metro and metro categories for table 86. The relationship between respondent’s residence and seeing a doctor during the prenatal period was not statistically significant. Hence, rural versus urban differences in access to an ObGyn were minimal.

Whether subject saw a Doctor that was Respondent's Residence not an Obstetrician Gynecologist (ObGyn) during the prenatal period Non-metro Metro Total No 36 (65.5%) 209 (68.3%) 245 (67.9%) Yes 19 (34.5%) 97 (31.7%) 116 (32.1%) Total 55 306 361 Chi-square=.173 (df=1, p=.677), Phi=-.022 Table 87. Respondent's Residence at time of Most Recent Planned Home Birth and Whether the Respondent Saw a Doctor that was Not an Obstetrician Gynecologist (ObGyn) During the Prenatal Period.

Location of Majority of Prenatal Respondent's Residence Appointments Non-metro Metro Total in my home 16 (30.8%) 64 (22.1%) 80 (23.4%) within 1 to 10 miles of my home 5 (9.6%) 86 (29.7%) 91 (26.6%) within 11 to 20 miles of my home 7 (13.5%) 61 (21.0%) 68 (19.9%) more than 20 miles from my home 24 (46.2%) 79 (27.2%) 103 (30.1%) Total 52 290 342 Chi-square=14.590 (df=3, p=.002), Cramer’s V=.207 Table 88. Respondent's Residence at Time of Most Recent Planned Home Birth and Location of the Majority of Prenatal Appointments.

There was a noticeable and statistically significant difference between distance for a prenatal appointment and metro/non-metro residence. Like the previous finding on distance to a hospital, rural women must travel a greater distance. The largest response

111 was for non-metro respondents (46%) who travelled more than 20 miles from their home for the majority of their prenatal appointments. Like the other significant result for residence (distance to nearest hospital) traveling longer distances to a care provider is a common occurrence for non-metro (rural) residents tied to the reality that there are simply less care providers located in their areas. The Cramer’s V value show, however, that the association of distance and metro/nonmetro status was not very strong.

Ultrasounds During Respondent's Residence Pregnancy Non-metro Metro Total 1 or more 40 (72.7%) 223 (73.1%) 263 (73.1%) No Ultrasounds 15 (27.3%) 82 (26.9%) 97 (26.9%) Total 55 305 360 Chi-square=.004 (df=1, p=.952), Phi=-.003

Table 89. Respondent's Residence at time of Most Recent Planned Home Birth and Number of Ultrasounds During Pregnancy.

The number of ultrasounds during pregnancy showed little difference across the two residence categories. The relationship between the respondent residence and the number of ultrasounds during pregnancy was not statistically significant.

Month Hired Midwife or Respondent's Residence Midwife-team Non-metro Metro Total First Trimester 36 (70.6%) 211 (71.5%) 247 (71.4%) Second or Third 15 (29.4%) 84 (28.5%) 99 (28.6%) Trimester Total 51 295 346 Chi-square=.019 (df=1, p=.891), Phi=-.007 (p=.891)

Table 90. Respondent's Residence at time of Most Recent Planned Home Birth and the month She Hired the Midwife. 112

The month the respondents hired their midwife showed little difference by metro/nonmetro status. The relationship between the respondent’s residence and the month she hired her midwife was not statistically significant.

The independent variable, residence, had two expected, significant relationships.

For the two dependent variables most tied to geography, the distance to the nearest hospital, and distance traveled for prenatal appointments, I expected to find a strong relationship for the known challenge for rural people, that they must travel further distances for care than their metro counterparts, because they are simply located further away from care providers and institutions.

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Chapter 5 - Discussion

Introduction

Birthing at home is a choice that women in the United States are increasingly making, in large part, as a rejection of the overuse of routine technological interventions found in the hospital setting (Boucher et.al., 2009). The choice to give birth at home is increasing at such a high rate, 29% from 2004-2009 (MacDorman et.al, 2012), that these days access to quality care providers for births in the home setting must be called into question. The increase is across all states though some states at a higher rate than others.

Midwives remain the care providers that most commonly attend (62%) home births

(MacDorman et.al, 2012), yet many states still have not licensed or regulated the midwives who specialize in home birth care (MANA 2013). Midwives who provide home birth care in states like Ohio are not legally authorized to practice, yet do so in order to provide a service to pregnant women that very few (possibly no other) licensed care providers in the state will, and they do so at the risk of prosecution.

The purpose of this study was to explore and describe the accessibility of providers for women in Ohio who have decided to birth at home, a choice they can legally make, yet have no licensed providers who provide the service. The study was also particularly concerned with any variation based in social difference. The study focused

114 on a self-selected, online sample of Ohio mothers who planned a home birth between

January 2005, and October 2010. The survey contained questions focused around four measurable areas of accessibility: characteristics of the health delivery system, utilization of the health services, characteristics of the population, and consumer satisfaction.

The responses to the survey provided an enhanced understanding of how women find and select a care provider despite their limited options and how they select and participate in services that interweave both mainstream and alternative providers.

Questions about why women utilize home childbirth services in the United States, as well as their levels of satisfaction with that care, brought forth responses largely consistent with previous research in this area (Boucher et.al., 2009; Johnson & Daviss, 2008;

Declercq, et.al., 2002).

The specific objectives of this study were: 1) to describe the population of women who have chosen to birth at home by (a) age, (b) level of education, (c) income level, (d) perceived socio-economic status, (e) race/ethnicity, (f) rural/urban geographic living location; 2) to describe how women go about finding and hiring a midwife and various characteristics of the home-health delivery system; 3) to describe how women utilize the health services that they have available to them when they choose to have a home birth, and. 4) to describe their level of satisfaction with their home birth care providers

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Summary of Conclusions

Home Birth Population

Like previous studies, women who chose the home birth option in Ohio tended to be white, of an advanced age, highly educated and living in a metropolitan area. Over

95% of women who completed the survey responded they were white/Caucasian (Table

8) while 85% were 26 years or older (Table 7). Eighty percent had a 2-year college degree or higher, 60%, a 4-year degree or higher (Table 6). Eighty-five percent of women surveyed lived in an urban setting (Table 9). Seventy-six percent of women considered themselves to be in the middle or upper class (Table 10), while eighty percent had a family income of $30,000 or more (Table 11). Eighty percent of women surveyed who planned a home birth had previously given birth to another child (Table 13). It is important to note that the population of Ohio women who chose home birth is similar in its social make up to previous US studies of home birth. Most interesting about the makeup of this population is that it is very much different from the stereotype of home birthing mothers who in popular culture are often characterized as under-educated, hippy freaks who care only about their own experience of the birth. Despite the evidence that increases in home birth is led by white, middle to upper class women there is little variation in the reasons for choosing to home birth by women with different backgrounds.

In short, women from all social classes are making the decision to birth at home for very similar reasons: to avoid unnecessary intervention and maintain control over their birthing environment. As the home birth movement spreads to other classes of women it is possible that the reasons for home birthing may expand. It would be interesting to 116 follow the diversification of motivations for seeking the home birth option as womens’ backgrounds by social class and other demographic characteristics becomes more variant.

Characteristics of the Home Birth Delivery System

Women who planned a home birth had few options when it came to care providers they could hire. Over 90% of women in the survey responded that they had five or less midwives/midwife-teams to choose from in their area (42% had no more than

2 options) (Table 17).

Seventy-five percent of women surveyed responded that they found their midwife through an interpersonal contact (Table 15). Twenty percent said that a network or organization helped them find their midwife, and 18% said an online listing or website also helped them find their midwife (Table 15). These responses overlap and that is not surprising as it is understood that people can refer friends to an organization by sharing that organization’s website or online network.

Geography plays a major role in home birth access. Rural women in my study travelled greater distances for their midwife prenatal checkups and were significantly further from the hospital than their urban counterparts. Women who choose to birth at home and live far away from their care provider must travel longer distances or wait longer for their care provider to arrive for their birth. One of the risks of this characteristic is that of giving birth without a provider because the midwife cannot get to the mother in time for the birth. Several mothers in the study noted that they gave birth at home before their midwife arrived. Nearly 50% of all the survey respondents had a midwife (or team) whose nearest member lived more than 20 miles away, including 117 almost 22% who indicated a distance exceeding 40 miles. Twenty-seven percent of mothers reported travelling 20 miles or more for the majority of their prenatal appointments with the midwife. The concern here is that women in rural areas are at higher risk for poor outcomes when it comes to situations in need of transfer to a hospital.

Home birth is a considerably more affordable option for mothers without health insurance and includes alternative options of payment for care such as barter, sliding scale, and low cost providers. Compared with the least expensive hospital birth, the majority of home births are a savings of more than $9000. More than 75% of women reported paying out of pocket for their home birth (Table 21), while 20% reported partial or full coverage for their home birth services by their insurance provider.

The majority (94%) of women who planned home births identified at least one of their midwives as being certified as a nurse or midwife. Seven percent of women said they were unsure of their midwife’s level of training (Table 19).

Future policy makers should pay close attention to these important characteristics of the home birth delivery system and the serious lack of structure it contains. As increasing numbers of women are making the choice to birth at home, they are finding themselves faced with few home delivery care providers for which they are limited to discovering though their interpersonal contacts and their organizations to help them find those providers who are available. Women in rural areas face additional concerns about the distance they must travel to receive care. Most women report being able to find certified care providers, though a small number do not know the level of training of their provider. Improving policy around home birth care providers could introduce structure to

118 the system that would support improved numbers of home birth care providers in all geographic areas, make their training an assured and transparent safety standard, and lead to other forms of payment for home birth provider fees.

Utilization of Services

Women who chose home birth in my study were not technology averse. More than seventy-two percent of women who planned to birth at home had at least one ultrasound during the pregnancy (Table 36). Income however, was a factor tied to incidence of having an ultrasound. Respondents from lower incomes were significantly less likely to have had an ultrasound (Table 77). It is likely that the women who reported higher income were more likely to have an ultrasound because they could afford it, or because they had insurance that covered the procedure.

The relationship between mother’s education and whether she saw a doctor (also true for OBs specifically) during the prenatal period was significantly related. The more education the mother had, the more likely she was to have seen a doctor at some time during the prenatal period. About 69% of participants with a graduate education saw a doctor while less than half of participants with a high school education saw a doctor during their pregnancy. It could be that women with health insurance are more likely to seek out a doctor for their earliest pregnancy checkups even though they eventually chose to deliver with a midwife. Future research should consider how insurance plays into these relationships while also exploring more in depth their reasons for seeing a doctor.

Many women received dual care with mainstream medical practitioners (hospital and clinic based) and home-based midwives during their pregnancy. When asked if they 119 had a prenatal checkup with a doctor (or nurse-midwife – who practice with obstetrician oversight in Ohio) during their pregnancy, over sixty-five percent of the women said they had at least one (Table 37). Forty-six percent of women reported seeing their doctor for prenatal checkups 3 or more times in the pregnancy (Table 39). Forty-six percent of the women had a prenatal checkup specifically with an ObGyn doctor (Table 37). Thirty- five percent of women reported that the reason they saw a doctor during their pregnancy was so they’d have a backup doctor they knew in case they had complications or decided to go to the hospital (Table 38). Fifty-two percent of women said that they or their midwife/midwife-team had a specific back up doctor planned in case medical care was necessary (Table 40).Women who birthed at home typically had 1 or 2 care providers who attended the birth, while many had apprentice midwives attending in addition to their primary provider (Table 32).Sixty-one percent of women indicated (Table 34) that they had 3-5 postnatal checkups with their midwife or midwife-team.

Both future research and policy should also be concerned with how women utilize the services they have available. Unlike the stereotypes of women who home birth, the women in my study were highly engaged in the use of technology, and very concerned about safety for both themselves and their children. While around half of women reported planning a specific back up doctor for the birth about the same numbers also saw a doctor for care in addition to their home care provider. However, for the purposes of my study, I regret that my questions were somewhat shallow and in retrospect should have probed more deeply about this issue. Hence, I recommend that future studies look closer at these relationships in order to learn more about how women are navigating these dual care

120 systems and relationships. It would be important to look more closely at how much home and hospital providers know of the other, how they do or do not work together and how best they can provide optimal care. Creating policy around home birth care providers may support the building of a more collaborative system of care for home to hospital transfers when emergency and non-emergency services are needed at the hospital.

Satisfaction

Over ninety percent of women who planned a home birth were successful at having the birth at their intended location (Table 27). Midwives were highly rated as a health care provider by women in our survey. Ninety-seven percent of women responded that they were satisfied with the care they received (Table 41) and would hire a midwife again (Table 42). The implications of these results are that women are likely to continue seeking out midwives as providers, including both those who had a prior home birth experience and women who have talked to mothers who were satisfied with their midwife services and the home birth experience. Policies should support the legal practice for care provider types who have demonstrated high safety and high satisfaction in a home birth setting. Future research should delve into what is at the center of factors for these high ratings of midwives, and health care administrators should look more closely at how their prenatal and birth providers can model midwife technique and care in order to improve their own satisfaction levels.

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Research Limitations and Recommendations

I encourage future research in other states, or nationally, so that differences in the level of accessibility can be compared and contrasted between states. How does a state like Washington that has had home birth midwives practicing under license for nearly 20 years, an established midwifery training school, and Medicare coverage for low-income women, compare with Ohio which has none of these institutions in place? State-level laws that govern midwife licensure and practice and Medicare coverage for services affect how midwives advertise their services, how their services are paid, who can afford or take advantage of their services and how well they integrate into the overall healthcare system. It would be valuable to study relationships between the accessibility of home birth care providers and overall birth outcomes.

Eighteen of the women in my survey, or nearly 5%, chose to birth at home without the service of a midwife or any other care provider (unassisted births). Future studies should look more in-depth at the reasons and characteristics surrounding unassisted birth and what sets this group of women apart from women with midwife- supported home births. Though few in numbers, the percentage of women choosing unassisted birth in my survey of Ohio women is high compared to previous research estimates that put unassisted births in the United States at only 1% of all home births

(Freeze, 2008). Further research could help us understand what makes Ohio unique or possibly higher in its cases of reported unassisted birth.

I would encourage future research to analyze differences in accessibility for women who plan a home birth for a first birth and those women who plan a home birth

122 for a second or subsequent child. When considering an alternative option such as home birth, a point such as this would most likely affect exposure to resources in the home birth community and therefore accessibility to home birth as an option.

Most of the research available today in the United States points to the re-adoption of home birth being led by mid to upper class white women, yet African American women of all socio-economic statuses have the highest rates of pre-term and low birth weight babies, and maternal mortality of all ethnic classes in the U.S. Future studies should look at the health outcomes for women of color who choose to home birth and the potential advantages and disadvantages of the home birth alternative for them and their babies’ health.

This study of accessibility only looked at women who actually planned for a home birth which leaves out those women who thoughtfully considered the home birth option. Future studies should include women who are aware of the choice to home birth but for reasons unknown, make the decision to birth in a hospital or birth center instead.

If there were other options, like birth centers staffed by midwives, how might this affect their choices about where to give birth?

This study should be conducted again in the next five years as the next generation of women comes into the birthing age. How is the rapid increase in women choosing to birth at home influencing what is learned about the home birth option as it becomes more widely discussed, researched, and adopted by other ethnic groups, will the accessibility change?

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Due to the nature of this study (online, directed at women) there are many aspects of the home birth choice that I did not explore that should be considered in future research. Do the partners of pregnant women influence the choice to birth at home or not?

How is the influence apparent and what does it affect? The group of women targeted was online and meant that women who participated in the survey were those active with communities around birthing style and also may be more technically savvy. This could have influenced findings about the use of technology around birthing practices but is not of great concern considering the high adoption of social media and technology used by the general population as well.

How does the integration or segregation of the schools of thought around childbirth and its adopters affect outcomes for mothers and babies who are most commonly treated by mainstream care providers. More specifically, does the divisiveness between medical doctors and midwives affect the care of women who have planned a home birth and who are looking for back up care or who transfer to a hospital during labor? These are important questions for further research.

Future studies about access to care should include more in-depth questioning about marriage, relationships, sexual orientation and full or part time employment (field), student status, and health insurance coverage for birth in the hospital. Learning more about these characteristics of the population would help to inform understanding on the financial implications of the decision to birth at home. Future research should include the new universal healthcare and consider how it will affect the accessibility of home birth in the near future.

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Instrument Limitations

When developing a survey tool from scratch there are of course lessons learned in the process that can help to eliminate and guide future surveys questions of similar topic.

I have identified several questions that could be improved for future research. One of the primary paths to becoming a Certified Professional Midwife includes a formalized apprenticeship with another certified midwife. Questions about midwives in attendance should include a separate option that lists midwife apprentices. My questions did not include the apprentice options and it resulted in many women describing their additional midwives as apprentices in the comments field.

Information describing the women sought to participate in the survey should be clear with regards to wanting mothers who have given birth already or mothers currently planning a home birth. A few women identified that they had not yet given birth meaning that they could not provide any insight into questions related to post-birth care, satisfaction, and outcomes. These women were included in the survey responses as their experience with the birth planning could help to inform the research, but not as fully as other respondents could.

My question about the number of midwife options available in their area could have been more specific by limiting the definition for their area to “within a 60 miles radius”. This would have provided a more clear response option since beyond 60 miles is not a very accessible option for a midwife it could have skewed the responses for women in rural areas. I recommend that future studies define “the local area” more clearly in their survey questions so that women have a definitive end point for their area.

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The questions about prenatal check-ups with a midwife and with a doctor should have specified the practice scopes and the types of providers. Some women acknowledged having seen a Certified Nurse Midwife (CNM) at some point in their pregnancy. CNMs in Ohio typically practice in conjunction with an ObGyn practice and provide care in the hospital setting for birth. The responses to the questions targeted at gathering data on home birth midwives could have been skewed since they asked for

“prenatal checkups with a midwife” and some women could have interpreted that to mean the home birth midwife or the CNM that provided them. This data would have been valuable, along with the data on seeing a doctor. Further, it would have added a dimension of understanding to how women utilize the current health delivery system.

In conclusion, this research reveals the need for policy in Ohio to improve access to qualified home birth health care providers. This is achievable by first developing a system to license certified midwife providers so they can advertise through more traditional channels, they can be incorporated with the insurance industry, and work more collaboratively with the other providers. Incorporating these areas may help to level the playing field for women from various social groups with regards to accessing ultrasound technology and midwife providers for home birth.

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References

Ackermann-Liebrich, U., Voegeli, T., & Gunter-Witt, K. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcomes. British Medical Journal, 313, 1313-1318.

American College of Obstetricians and Gynecologists (2006). ACOG statement of policy: Out-of-hospital births in the United States.

American College of Obstetricians and Gynecologists (2008). ACOG statement on home births.

Amelink-Verburg, M., Verloove-Vanhorick. S., Hakkenberg, R., Veldhuijzen, I., Gravenhorst, J., & Buitendijk, S. (2008). Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. British Journal of Obstetrics and Gynecology. 115, 570-578.

American College of Nurse Midwives. (2010). ACNM Expresses Concerns Regarding Recent AJOG Publication on Home Birth. Retrieved from http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf

Anderson, R., & Anderson, D. (1999). The cost-effectiveness of home birth. Journal of Nurse Midwifery, 44, 30-35.

Anderson, R., & Murphy, P. (1995). Outcomes of 11,788 Planned Home Births Attended By Certified Nurse Midwives: A Retrospective Descriptive Study. Journal of Nurse Midwifery. 40, 483-492.

Amnesty International. (2011). Deadly Delivery: The Maternal Health Care Crisis in the USA – One Year Update. Retrieved from http://www.amnestyusa.org/sites/default/files/deadlydeliveryoneyear.pdf

Bastian, H., Keirse, M., & Lancaster, P. (1998). Perinatal death associated with planned home birth in Australia: population based study. British Medical Journal, 317, 384-388.

Block, J. (2007). Pushed: The painful truth about childbirth and modern maternity care. Cambridge, Massachusetts: Da Capo Press. 127

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: Why women in the United States choose home birth. Journal of Midwifery and Women’s Health. 54(2), 119–126.

Burnett, C., Jones, J., Rooks, J., Chen, C., Tyler, C., & Miller, C. (1980). Home delivery and neonatal mortality in North Carolina. Journal of the American Medical Association, 244, 2741-2745.

Cassidy, T. (2006) Birth: The surprising history of how we are born. New York: Atlantic Monthly Press.

Centers for Disease Control. (1995). Trends in lengths of stay for hospital deliveries- United States, 1970-1992. Morbidity and Mortality Weekly Report. 44,17, 335-337.

Chamberlain, G., Wraight, A., Crowley, P. (1999). Birth at Home: A Report of the National Survey of Home Births in the UK by the National Birthday Trust. The Practising Midwife. 2, 35-39.

Chan, L., Hart, L., & Goodman, D. (2006). Geographic Access to Health Care for Rural Medicare Beneficiaries. Journal of Rural Health. 22:140-146.

Cheyney, M. (2008). Homebirth as Systems-challenging Praxis: Knowledge, Power, and Intimacy in the Birthplace. Qualitative Health Research, 18(2), 254-267.

Cheyney, M. (2011). Born at Home: The Biological, Cultural and Political Dimensions of Maternity Care in the United States. Wadsworth Cengage Learning.

Hodges, S., & Goer, H. (2004). Effects of Hospital Economics on Maternity Care. Citizens for Midwifery. Retrieved from http://cfmidwifery.org/Resources/item.aspx?ID=32

Cohain, J. (2011). Response to Wax Meta-analysis. Midwifery Today International Midwife. Winter. 96, 50.

Crane, M. (2010, June 19). Midwives looking for state regulation. The Columbus Dispatch. Retrieved from http://www.dispatch.com/content/stories/local/2010/06/19/midwives-looking-for- state-regulation.html

Davies, J., Hey, E., Reid, W., & Young, G. (1996). Prospective regional study of planned home births. Home Birth Study Steering Group. British Medical Journal, 313:1302–6.

128

Davis-Floyd, R., & Johnson, C. (2006). Mainstreaming Midwives: The Politics of Change. New York: Routledge, Taylor, and Francis.

Daviss, B. & Johnson, K. (2010) Recent meta-analysis is misleading. British Medical Journal. 341:c4699

Declercq, E., MacDorman, M., Menacker, F., & Stotland, N. (2010). Characteristics of planned and unplanned home births in 19 states. Obstetrics & Gynecology, 116(1):93-99.

Declercq, E., Sakala, C., Corry, M., Applebaum, S., & Risher, P. (2002). Listening to mothers: report of the first national US survey of women's childbearing experiences. Retrieved from www.maternitywise.org/listeningtomothers/

De Jonge, A., van der Goes, B., Ravelli, A., Amelink-Verburg, M., Mol, B., Nijhuis, J., … Buitendijk, S. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. British Journal of Obstetrics and Gynecology, 116(9), 1177–1184.

Durand, M. (1992). The safety of home birth: The farm study. American Journal of Public Health, 82(3).

Fordham, S. (1997). Women’s views of the place of confinement. British Journal of General Practice. 47(415): 77–80.

Freeze, R. (2008). Born free: Unassisted childbirth in North America. (Doctoral dissertation.) University of Iowa. Retrieved from http://ir.uiowa.edu/etd/202.

Frey, R. (2008, February 14). Ohio criminalizes midwives wanting to help women deliver at home. CityBeat. Retrieved from http://www.citybeat.com/cincinnati/article- 3848-news-legalizing-birth.html.

Goodman, S. (2007). Piercing the veil: The marginalization of midwives. Birth, 65(3), 610-621.

Boulvain, M. (2011). Geneva Foundation for Medical Education and Research. Maternal Morbidity. Retrieved from http://www.gfmer.ch/Endo/Lectures_08/maternal_morbidity.htm.

Guise, J.M., Eden, K., Emeis, C., Denman, M.A., Marshall, N., Fu, R., Janik, R., Nygren, P., Walker, M., McDonagh, M. (2010, March).Vaginal Birth After Cesarean: New Insights. Retrieved from http://archive.ahrq.gov/clinic/epcsums/vbacsum.htm.

129

Gyte, G., & Dodwell, M. (2008). Safety of planned home births: An NCT review of evidence. MIDIRS Midwifery Digest, 18(3), 376–385.

Hafner-Eaton, C., & Pearce, L. K. (1994). Birth choices, the law, and medicine: Balancing individual freedoms and protection of the public's health. Journal of Health Politics, Policy and Law, 19(4), 813-835.

Hartley H., & Gasbarro C. (2002). Forces promoting health insurance coverage of homebirth: a case study in Washington State. Women Health, 36, 13–30.

Hart, G. (2010). Midwifery Today Responds to Study Questioning Homebirth Safety. Retrieved from http://www.midwiferytoday.com/articles/ajog_response.asp.

Health Management Associates. (2007, October 31). Midwifery Licensure and Discipline Program in Washington State: Economic Costs and Benefits. Retrieved from http://www.washingtonmidwives.org/assets/Midwifery_Cost_Study_10-31- 07.pdf

Hitt, E., (2010, July 16). Home Birth Study Findings Raise Controversy. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/725358

Horton, J. (2002, October 24). Midwife sent to jail. The Plain Dealer. Retrieved from http://www.collegeofmidwives.org/collegeofmidwives.org/news01/FM%20case%20 Oct%2029.htm

Hutton, E., Reitsma, A., & Kaufman, K. (2006). Outcomes of planned homebirths compared with a matched cohort of planned hospital births in women attended by Ontario midwives from 2003-06: a retrospective cohort study. Birth, 36:180-189.

Janssen, P.A., Holt, V.L., Myers, S.J. (1994) Licensed Midwife-Attended, Out-of- Hospital Births in Washington State: Are They Safe? Birth, 21(3)

Janssen, P.A., Lee, S.K., Ryan, E.M., Etches, D.J., Farquharson, D.F., Peacock, D., et al. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Canadian Medical Association Journal, 166:315–23.

Janssen, P.A., Saxell, L., Page, L.A., Klein, M.C., Liston, R.M., & Lee, S.K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Canadian Medical Association Journal, 181(6–7), 377–383.

130

Janssen, P.A., Carty, E.A., Reime, B. (2006). Satisfaction with planned place of birth among midwifery clients in British Columbia. Journal of Midwifery & Women’s Health, 51(2):91-7. doi: 10.1016/j.jmwh.2005.10.012

Johnson, K. C., & Daviss, B. (2008). Outcomes of planned home births with certified professional midwives: Large prospective study in North America. British Medical Journal, 330(1416).

Jolivet, R., Corry, M. P., & Sakala, C. (2010). Transforming maternity care: A high- value proposition. Women's Health Issues Journal, 54-56.

Keirse , M., (2010). Home Birth: Gone Away, Gone Astray, and Here To Stay. Birth, 37:4

Kleiverda, G., Steen, A.M., Andersen, I., Treffers, P.E., & Everaerd, W. (1990). Place of delivery in The Netherlands: Maternal motives and background variables related to preferences for home or hospital confinement. European Journal of Obstetrics & Gynecology and Reproductive Biology, 36:1–9.

Kringeland, T., Daltveit, A.K., & Möller, A. (2010). What characterizes women who want to give birth as naturally as possible without painkillers or intervention? Sexual & Reproductive Healthcare, 21–26.

Kukulu, K., & Oncel, S. (2009). Factors influencing women’s decision to have a home birth in rural Turkey. Midwifery, 25(1), 32-38.

Lee, V. (1996). Granny Midwives and Black Women Writers: Double-Dutched Readings. New York: Routledge.

Lenardson, J.D., Ziller, E.C., Coburn, A.F., Anderson, N. (2009). Profile of Rural Health Insurance Coverage: A Chartbook. Portland, ME: University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center. Retrieved from http://muskie.usm.maine.edu/Publications/rural/Rural-Health- Insurance-Chartbook-2009.pdf.

Lothian, J. A. (2007). Advancing Normal Birth. Journal of Perinatal Education- Supplement, 16(1).

MacDorman, M. F., Menacker, F., Declercq, E. (2010). Trends and characteristics of home and other out-of-hospital births in the United States, 1990-2006. National Vital Statistics Reports, 58(11).

MacDorman, M. F., Mathews, T.J., Declercq, E. (2012). Home Births in the United States, 1990–2009. NCHS Data Brief, Number 84. 131

Macfarlane, A., & Campbell, R. (1994). Where to be born: the debate and the evidence. Oxford: National Perinatal Epidemiology Unit.

Macfarlane, A., McCandlish, R., Campbell, R. (2000). Choosing between home and hospital delivery. British Medical Journal, 320(798).

Merrill, C.T., Elixhauser, A. (2005). Hospitalization in the United States, 2002: HCUP Fact Book No. 6. AHRQ Publication No. 05-0056. Agency for Healthcare Research and Quality, Retrieved from http://www.ahrq.gov/data/hcup/factbk6/.

Michal, C.A., Janssen, P.A., Vedam, S., Hutton, E.K., de Jonge, A. (2011). Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong . Medscape Ob/Gyn & Women's Health. Retrieved from http://www.medscape.com/viewarticle/739987.

Midwives Alliance of North America. (2010). Press Release RE: Maternal and Newborn Outcomes in Planned Home Birth Vs. Planned Hospital Births: A Meta- Analysis, Wax JR, Lucas FL, Lamont M, et al., Am J Obstet Gynecol 2010. Retrieved from http://mana.org/pdfs/MANA-Response-AJOG-Article-7-6-2010.pdf

Miller, A.C. (2009). Midwife to myself: Birth narratives among women choosing unassisted homebirth. Sociological Inquiry, 79(1):51-74.

Murphy, P., & Fullertion, J. (1998). Outcomes of intended home births in nurse- midwifery practice: A prospective descriptive study. Obstetric sand Gynecology, 92(3), 461-470

Mushinski M. (1994). Average charges for uncomplicated cesarean and vaginal deliveries, United States, 1993. Statistical Bulletin, Oct-Dec:27-36.

National Association of Certified Professional Midwives. (2010). Press Release RE: Maternal and Newborn Outcomes in Planned Home Birth Vs. Planned Hospital Births: A Meta - Analysis, Wax JR, Lucas FL, Lamont M, et al., Am J Obstet Gynecol 2010. Retrieved from http://www.nacpm.org/documents/070610-NACPM- Press-Release-Wax-etal.pdf.

North American Registry of Midwives. (2013, August 1). Direct Entry Midwifery State-by-State Legal Status. Retrieved from http://narm.org/pdffiles/statechart080213.pdf

Northern Region Perinatal Mortality Survey Coordinating Group. (1996). Collaborative survey of perinatal loss in planned and unplanned home births. British Medical Journal, 313:1306-1309.

132

Ohio Revised Code. (2012). 4723-8-04 Standard care arrangement for a certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist. Retrieved from http://codes.ohio.gov/oac/4723-8-04.

Olsen, O. (1997). Meta-analysis of the safety of home birth. Birth, 24, 4-13.

Olsen, O. & Clausen, J.A. (2012). Planned hospital birth versus planned home birth. The Cochrane Library, Issue 9

Our Bodies Ourselves Blog. (2010). A Letter to “Time” on Home Birth. Retrieved from http://www.ourbodiesourblog.org/blog/2010/10/a-letter-to-time-on-home-birth.

Pang, J.W., Heffelfinger, J.D., Huang, G.J., Benedetti, T.J. & Weiss, N.S. (2002). Outcomes of planned home births in Washington State: 1989-1996. Obstetrics Gynecology, 100:253-259.

Peterson, C. (2010). Midwifery and the crowning of health care reform. Journal of Midwifery & Women's Health, 55(1), 1-88.

Rooks, J.P., Weatherby, N.L., Ernst, E.K., Stapleton, S., Rosen, D. & Rosenfield, A. (1989). Outcomes of Care in Birth Centers: The National Birth Center Study. New England Journal of Medicine, 321(26):1804-1811.

Rooks, J. P., Ernst, E. K., Norsigian, J., & Guran, L.A. (2008). Marginalization of midwives in the United States: New responses to an old story. Birth, 35(2): 158-161.

Rothman, B. K., (1982). In Labor. New York: Routledge.

Rothman, B.K. (2011). Health Vision - Giving Birth in the United States (#407). Interview with Barbara Katz Rothman. Retrieved from http://www.youtube.com/watch?v=QsZjh5DvE34.

Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. Co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund. Retrieved from http://www.milbank.org/uploads/documents/0809MaternityCare/0809MaternityCare. html

Schlenzka, P.F. (1999). Safety of Alternative Approaches to Childbirth. (Doctoral dissertation). Retrieved from http://vbfree.org/docs/schlenzka.htm#dnload.

Schramm, W., Barnes, D., & Bakewell, J. (1987). Neonatal mortality in Missouri home births, 1978-84. American Journal of Public Health, 77:930-935.

133

Sears, W. & Sears, M. (1994). The Birth Book. Boston: Little Brown and Company.

Simonds, W., Rothman, B. K., & Norman, B. M. (2007). Laboring on: Birth in transition in the United States. New York: Routledge.

Sjoblom, I., Edberg, A., & Nordstrom, B. (2006). A qualitative study of women's experiences of home birth in Sweden. Midwifery, 22(4), 348-355.

Soderstrom, B., Stewart, P.J., Kaitell, C., Chamberlain, M. (1990). Interest in alternative birthplaces among women in Ottawa-Carleton. Canadian Medical Association Journal, 142:963–9.

Springer, N.P. & Van Weel, C. (1996). Home birth. British Medical Journal, 313, 1276-7.

Starr, P. (1982). The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. Basic Books.

Suarez, S. H. (1993). Midwifery is not the Practice of Medicine. Yale Journal of Law and Feminism, 5(2), 315-364.

U.S. Government Accountability Office. (2003, October 31). Physician Workforce: Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted. Retrieved from http://www.gao.gov/products/GAO- 04-124.

Vedam, S., Stoll, K., White, S., Aaker, J., & Schummers, L. (2009). Nurse-Midwives' experiences with planned home birth: Impact on attitudes and practice. Birth, 36(4), 274-282.

Vedam, S., Janssen, P.A., & Lichtman, R. (2010). Science and Sensibility: Choice of Birth Place in the United States. Retrieved from http://www.medscape.com/viewarticle/717516

Vickers, Andrew J. (2010, September 27). Home Birth Triples the Neonatal Death Rate: Attention-Grabbing No Doubt, But Uninformative. Medscape. Retrieved from http://www.medscape.com/viewarticle/729137

Wax, J.R., Lucas, F.L., Lamont, M., Pinette, M.G., Cartin, A.,& Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. American Journal of Obstetrics & Gynecology, 203(3):243.e1- 8.

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Wax, J.R., Pinette, M.G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births. American Journal of Obstetrics & Gynecology, 202:152.e1-5.

Wells, S., Nelson, C., Kotch, J. B., Weiss, S. H., & Gaudino, J. (2001). Increasing access to out-of-hospital maternity care services through state-regulated and nationally-certified direct-entry midwives. American Public Health Association. Retrieved from http://www.apha.org/advocacy/policy/policysearch/default.htm?id=242

Wiegers, T.A., Keirse, M., van der Zee, J., & Berghs, G. (1996). Outcome of planned home and planned hospital births in low risk pregnancies: Prospective study in midwifery practices in the Netherlands. British Medical Journal, 313, 1309-1313.

World Health Organization. (1996). Care in Normal Birth: A Practical Guide. Retrieved from http://www.who.int/making_pregnancy_safer/documents/who_frh_msm_962

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Appendix A: Survey Instrument

Survey: Ohio Women who have had a Planned Home Birth

We are seeking Ohio women (18 years of age or older) who have had a planned home birth since January 1, 2005. If you meet these criteria please consider taking this survey by first reading the Consent to Participate in Research below. ------

------The Ohio State

University Consent to Participate in Research Study Title: Factors Associated with

Health Care Access for Mothers who Choose Home Birth in Ohio Researchers: Dr.

Joseph F. Donnermeyer, Martha Nieset This is consent information for research participation. It contains important information about this study and what to expect if you decide to participate. YOUR PARTICIPATION IS VOLUNTARY. You are being asked to participate in a study conducted by Martha Nieset, a student in the Masters program in

Rural Sociology at The Ohio State University. In this study you will complete a survey about various factors associated with your access to health care when you chose to have a home birth. PURPOSE: The purpose of this study is to understand the factors around health care accessibility for Ohio mothers who choose home birth TASK: Your participation in the study will involve completing a set of questions about your most 136 recent planned home birth using an online survey. DURATION: The survey should take approximately 15 minutes to complete. You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your future relationship with The Ohio State University. RISKS AND BENEFITS: A benefit of participation in this study is your ability to contribute to the scholarly research of home birth that is available to our society. By participating in the survey, the research will be enriched by the sharing of your experiences and values. You will not receive any compensation for completing the survey. There are no known risks associated with completing this study. CONFIDENTIALITY: Confidentiality will be maintained by not collecting your name or any identifying characteristics directly related to the results of the survey. Your answers cannot be linked to you, and all data will be reported in summary form only. PARTICIPANT RIGHTS: You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled. If you are a student or employee at Ohio State, your decision will not affect your grades or employment status. If you choose to complete the survey, you may discontinue at any time or choose not to answer a question without penalty. CONTACTS AND

QUESTIONS: For questions, concerns, or complaints about the study you may contact

Dr. Joseph F. Donnermeyer via e-mail at [email protected] or Martha Nieset via e-mail at [email protected]. For questions about your rights as a participant in this study or to discuss other study-related concerns or complaints with someone who is not part of

137 the research team, you may contact Ms. Sandra Meadows in the Office of Responsible

Research Practices at 1-800-678-6251.

* Required

I have been given information about this research study and its risks and benefits. I have had the opportunity to have my questions answered to my satisfaction. By checking this box, I acknowledge that I am 18 years of age, or older, and I freely give my consent to participate in this research project. *

I consent

SECTION 1

I planned a (your most recent planned home birth)

home birth with a midwife

an unassisted home birth

For my most recent planned home birth I chose the home birth option because Please

choose all that apply

I feared unnecessary medical interventions birthing in a hospital

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it was more private

I wanted to give birth in a comfortable, familiar environment

birthing at home is part of my religion or culture

I believed it would be safer than a hospital birth for myself or my baby (ies)

I didn't have health insurance and home birth was more affordable

I wanted a drug-free birth

I wanted my child (ren) or other family members to be present

I had a negative previous hospital experience

I witnessed a negative hospital experience of someone else

it was less expensive than a hospital or birth center

I wanted to avoid having a cesarean section

I believed I would have greater control over my birth at home

Other:

At the time of my most recent planned home birth, I was an Ohio resident

Yes

139

How many home births, with a midwife or unassisted, have you ever planned?

This was my first planned home birth

This was my second planned home birth

This was my third planned home birth

This was my fourth planned home birth

I've had five or more home births

How many children have you ever given birth to?

140

Other:

Prior to your most recent planned home birth, had any of your births been by

Cesarean Section?

Yes

How did you first become aware of home birth as a birthing option?

At the time of my most recent planned home birth, I lived in this zip code or city/state

(please enter 5-digit zip code of your birth location or the city/state if the zip code is unknown)

For my most recent planned home birth, I planned to give birth outside of Ohio

141

Yes

For my most recent planned home birth, I planned to give birth in

my own home

the home of a friend

my midwife's home

a birth center

the home of a relative

Other:

Did your most recent planned home birth occur at your intended location?

Yes, everything went according to plan with my home birth

No, the baby was born in a hospital

No, the baby was born on the way to the hospital

No, the baby was born in a birthing center

No, the baby was born in an unintented non-medical location

Other: 142

The planned location for my most recent planned home birth was within

5 miles of the nearest hospital

10 miles of the nearest hospital

20 miles of the nearest hospital

30 miles of the nearest hospital

40 miles of the nearest hospital

50 miles of the nearest hospital

60 miles of the nearest hospital

More than 60 miles from a hospital

I'm not sure

For my most recent planned home birth, the majority of my pre natal check-ups took place

in my home, my care provider came to me

in my home, I performed my own pre natal check-ups

within 1 mile of my home

within 5 miles of my home

143

within 10 miles of my home

within 15 miles of my home

within 20 miles of my home

within 40 miles of my home

within 60 miles of my home

more than 60 miles from my home

there were no pre natal check-ups

Other:

How many people (non-midwives) attended your most recent planned home birth?

(I.e. Who was in the birthing room with you)

4 (or 0 1 2 3 more)

Adults

Children

How many midwives attended your most recent planned home birth?

144

4 (or more)

Not Applicable, my most recent planned home birth was unassisted

Other:

During the pregnancy for my most recent planned home birth, I had pre natal checkups with a Please choose all that apply

Doctor, MD (or General Practitioner)

Doctor, DO (Doctor of Osteopathy)

Doctor, OB/GYN (Obstetrician and Gynaecologist)

Doctor of Chiropractic, DC (Chiropractor)

I had no pre natal check-ups with a doctor

Other:

During the pregnancy for my most recent planned home birth, I had pre natal checkups with a doctor because Please choose all that apply

I hired my midwife late in my pregnancy

145

I wanted to have a back up doctor I knew in case I decided to go to a hospital

I was concerned about complications

I believed that chiropractic adustments were an important part of my health and my baby's

Not Applicable, I had no pre natal check-ups with a doctor

Other:

For my most recent planned home birth, my approximate number of prenatal checkups with a doctor was

1-2

3-5

6-8

9-15

more than 15

there were no prenatal checkups

Other:

During the pregnancy for my most recent planned home birth, I had

146

1 pre natal ultrasound

2 or more pre natal ultrasounds

I had no ultrasounds during the pregnancy for my most recent planned home birth

Other:

During the pregnancy for your most recent planned home birth, did you switch midwives/midwife-teams at anytime?

Yes

Not Applicable, my most recent planned home birth was unassisted

SECTION 2 - (Please answer Section 2 if your most recent planned home birth was

midwife-assisted

Please answer the questions in this section for your last midwife or midwife-team who helped you in your most recent planned home birth.

During the pregnancy for your most recent planned home birth, how many different midwives or midwife-teams did you have to choose from in your area?

1-2 147

3-5

6-8

9-15

more than 15

For my most recent planned home birth, I hired my midwife/midwife-team in my

first month of pregnancy

second month of pregnancy

third month of pregnancy

fourth month of pregnancy

fifth month of pregnancy

sixth month of pregnancy

seventh month of pregnancy

eighth month of pregnancy

ninth month of pregnancy

before I was pregnant

148

Did concerns expressed by people you knew (i.e. family / friends) about home birth delay you hiring a midwife for your most recent planned home birth?

Yes

For my most recent planned home birth, my approximate number of pre natal checkups with a midwife was

1-2

3-5

6-8

9-15

more than 15

there were no prenatal checkups

Other:

For my most recent planned home birth, my approximate number of POST natal check-ups with a midwife was

1-2

149

3-5

6-8

9-15

more than 15

there were no post natal checkups

Other:

For my most recent planned home birth, my midwife/midwife-team members had which of the following credentials or professional training? Please choose all that apply

Registered Nurse (RN)

Certified Professional Midwife (CPM)

Certified Nurse Midwife (CNM)

Certified Midwife (CM)

Registered Midwife (RM)

Licensed Midwife (LM) in another state

My midwife was in training

an academic program of study in midwifery

150

completed an apprenticeship with another trained midwife

I'm unsure if my midwife/midwife team members held any professional credentials

My midwife held none of these credentials

Other:

My midwife/midwife-team or I had a specific back up doctor planned in case I needed medical care

Yes

Please tell me how you first came in contact with your midwife/midwife-team members. I found my midwife/midwife-team Please choose all that apply

through a friend

through a colleague or acquaintance

through a family member

from an online listing or website

in the phone book

from another type of advertisement 151

through a network or organization

through another child birth professional (I.e. Doula or Child Birth Educator)

Other:

At the time of my most recent planned home birth, my midwife/nearest midwife-team member lived

within 1 mile of my home

within 5 miles of my home

within 10 miles of my home

within 15 miles of my home

within 20 miles of my home

within 30 miles of my home

within 40 miles of my home

within 60 miles of my home

more than 60 miles from my home

What did the midwife/midwife team charge for midwife services? (or what were her fees?)

152

$0-$500

$501-$1000

$1001-$1500

$1501-$2000

$2001-$2500

$2501-$3000

$3001-$3500

$3501-$4000

$4001-$4500

$4501-$5000

Over $5000

Other:

The costs associated with hiring the midwife/midwife-team were Please choose all that apply

mostly covered by my health insurance provider

were partially covered by my health insurance provider

paid out of my own pocket

153

were bartered with my midwife (total expenses or partial)

unpaid

the midwife did not charge for her services

were based on a sliding scale (per my income)

Other:

How would you rate your satisfaction with your midwife or midwife team for your most recent planned home birth?

Strongly Satisfied

Moderately Satisfied

Slightly Satisfied

Satisfied

Slightly Disatisfied

Moderately Disatisfied

Strongly Disatisfied

Given the opportunity, I would choose to hire a midwife/midwife-team for a planned home birth again

154

Yes - Definitely

Yes - Probably

Unsure

No - Probably

No - Definitely

SECTION 3 - Please answer Section 3 if your most recent planned home birth was

unassisted (others please skip to Section 4)

I preferred an unassisted home birth because

Given the opportunity, I would choose an unassisted home birth again

Yes - Definitely

Yes - Probably

Unsure

No - Probably

No - Definitely

155

How many people were at the residence during your most recent planned home birth?

(somewhere near by if you wanted them)

4 (or 0 1 2 3 more)

Adults

Children

I had a specific back up doctor planned in case I needed medical care

Yes

We'd be interested to know, in your own words, why you chose an unassisted home birth and how you planned it.

156

SECTION 4 - (Everyone please complete)

Please answer the following questions about your personal background at the time of your most recent planned home birth

What was your level of education at the time of your most recent planned home birth?

Less than high school diploma

High school diploma or GED

Two-year college degree

Four-year college degree

Masters or professional school degree

Doctorate degree

What was your age at the time of your most recent planned home birth?

18-20

21-25

26-30

31-35

36-40

157

41-45

46-50

Over 50

How would you perceive your economic status at the time of your most recent planned home birth?

Upper Class

Upper-Middle Class

Lower-Middle Class

Working Class

Poor or Lower Class

What was your family income at the time of your most recent planned home birth?

$0-$10,000

$10,001-$20,000

$20,001-$30,000

$30,001-$40,000

$40,001-$50,000

158

$50,001-$60,000

$60,001-$70,000

$70,001-$80,000

$80,001-$90,000

$90,001-$100,000

Over $100,000

I held the following credentials or training at the time of my most recent planned home birth Please choose all that apply

Registered Nurse (RN)

Certified Professional Midwife (CPM)

Certified Nurse Midwife (CNM)

Certified Midwife (CM)

Registered Midwife (RM)

Licensed Midwife (LM) in another state

I was a midwife in training

I had completed an academic program of study in midwifery

I had completed an apprenticeship with another trained midwife

159

I held none of these credentials or training

Other:

With which race/ethnicity do you most closely identify?

African American

American Indian

Asian

Hispanic/Latino

White/Caucasian

Other:

Do you have any other comments or thoughts you'd like to share about home birth?

Never submit passwords through Google Forms.

160

Appendix B: Write-in Responses to the Question “How did you first become aware of

homebirth as a birthing option?”

In preparing for my first birth & reading about different birthing options. A professor and his wife at OSU talked about their daughter having one in Columbus with a local midwife. I was doing research for a project while I was in nursing school and happened across the idea of water birthing. I'd known one person in my life (under the age of 80) who was born at home. He was one of 3 children born at home and his mother had nothing but good things to say about it. I thought she was crazy at the time. That is, until I started researching the waterbirthing option and felt more at ease with that idea than I had ever been while thinking about birthing in a hospital environment. In naturopathic medical school Talking to other women with the interest of avoiding another cesarean. I had read about homebirth. I first became aware of homebirth on a message board for moms but it wasn't something I considered at that time. During my second pregnancy we moved to the Columbus area, I joined a community of moms, and *** was influential in helping me choose homebirth. I was born at home. I've always known. But of 3 other siblings, only one has chosen out-of-hospital birth for herself. There is/was no pressure that homebirth was the only right way. I moved, and the midwives that I used for my 2nd birth had shut down, a friend I knew through an AP group suggested it. Many of my relatives including my parents were born safely at home and shared their experiences of witnessing the birth of their siblings or the births of their children. I learned it was available to me personally in the 6th month of my first pregnancy. Not sure, really. Internet +quality books + good references members of my church as well as my own research into options that facilitate natural childbirth. Dar A Luz Network members Talking with friends then lots of research. Had friends who had had a HB My mother had my brother at home. An Attachment Parenting web board. Through La Leche League when my first child was a newborn. Through friends When I was pregnant with my first child I read Spiritual Midwifery, and that led to many other wonderful birth books and then a midwife. Local homebirth support group and my hospital midwife who I was doing co-care with gave me information. Friends A family friend had unassisted homebirths with all five of her children. 161

I went to high school with a girl who talked about being born at home. Out of curiosity I looked it up and found Ina May's books. I have always been familiar with it, but became intimately acquainted with the option when I was present for the homebirth of one of my best friends. I first became aware of homebirth as an option when I was searching for hospital facility in my area that allowed attempting labor after a cesarean. Unfortunately only one out of five local hospitals at that time allowed VBAC's. I started looking for a doula in my area to hire so they could be present at the hospital with my husband and I during the birth and be a sort of advocate for me. I knew my husband would go along with what ever the doctors said and I knew that I would not be in a state of mind or spirit to be arguing with doctors. The doula gave us a few suggestions on book and movies to see and thats when my desire for a homebirth started. I knew that would be the only way I'd be able to deliver my baby in a stress free, quiet, calm, and spiritual environment. friend recommended her midwife Twelve years ago, when I was in college, my best friend from high school had a planned homebirth. From then until my daughter's birth 18 months ago I educated myself through various sources on birthing options, focusing on those that are natural and noninvasive. My brother was born at home. Several friends and family members also have had homebirths. A good friend used a homebirth midwife and hers was the only birth story I had ever heard that lacked major drama and trauma of mom/baby. When I took training to become a professional childbirth assistant/doula. Women at Dar a Luz Magazine article I became aware of homebirth in 2001, but didn't pursue it as an option for my family until 2007/2008 with my 4th child. I am a midwife I grew up in a more conservative Christian enviornment where several friends of my mother's had given birth at home. I also have several relatives and friends that have given birth at home. There are many women in my community who choose to have homebirths. It is a part of the vocabulary in my birthing community. I became part of an online community, and there were many midwives and doulas there. I was aware before that, that some women birthed at home, but I thought they were crazy. The women on the message board normalized it for me, that's when it became a real option. My mother had my two younger brothers at home, so I've known about homebirth most of my life. My mom homebirthed my younger brothers. Since I met my husband, he was born at home Meeting another mother planning a homebirth at a yoga class. From a friend who had had a homebirth. The doula we used with our first birth had mentioned it as an option. when i had my first child, i was aware of the option. because my husband's family was uneasy, we had a midwife assisted birth in the hospital. even though we had no problems, we were not completely satisfied with the experience. subsequently, we chose homebirth as a better choice. When my mother gave me the book Gentle Birth Choices by Barb Harper I had done a lot of research of better birthing options. My CNM in Florida told me about how she had a homebirth. We were coworkers and friends (since I was an L&D nurse), and she told me that it was the most wonderful experience she'd ever had, though she was never willing to attend one as a midwife.

162

One of my friends invited me to attend and photograph her second homebirth. After that, I really couldn't imagine giving birth another way. My mom is a homebirth Midwife. I grew up around homebirth. It was always very clear to me that is what I would do. The thought of giving birth in the hospital scares me and makes me feel very uneasy. At home, I am in control and my babies are brought into a calm, loving enviroment. i am a doula and saw dramatic differences between the two. that led to lots off research and really found that homebirth would be the safest opiton I always knew that was an option but the midwives that helped delivered my first two could only practice in a hospital mandated by their malpractice insurance. After a successful natural hospital birth I had the idea that I could have done that at home. my mother had had one homebirth out of eight and so i was aware women did it. in my teenage years i became more intrigued with it and knew i wanted to try it when i got married and started having babies. Friends I've heard about homebirth over the years. I didn't think it was possible for me in this area, until I started to do a little research. Through the search, I found the Cincinnati Homebirth Circle. I had a friend who had had a homebirth with her son. Several friends had used birthing centers with midwives, an option I investigated, but which wasn't available to me. Then one of these friends used a midwife at home for her second child (in Massachusetts). This was shortly before I became pregnant, and I almost immediately began looking into my homebirth options in Ohio. A friend had one where I lived in Tennessee, so I sought it out when I moved to Ohio. My husband suggested it jokingly and out of curiosity I looked it up. We spoke with a midwife and were very impressed. I had friends in other states that had homebirths. My aunt had 3 homebirths 20+ years ago. After a bad hospital experience, I did more research and had a homebirth with my 2nd child. I've known about it since I can remember. Women's Studies classes in college at Ohio University. Through my La Leche League group--other members had homebirths My mother had my twin bother and sister at home when I was 4. friends After my bad experience with my first birth in a hospital, I started researching and saw there were other options out there. As a teenager, I was a babysitter and worked with a family with 6 children--several of whom had been birthed at home. The mother and I talked about this quite often, as I was very curious, and she shared with me an opinion about childbirth and the homebirth option that made sense to me. She also informed me about the organization CHOICE. When I became pregnant, homebirth seemed like the obvious choice. I read books about natural childbirth and Mothering magazine. I talked with other mothers who had given birth at home. A friend told me about homebirth, midwives and doulas while I was in college (approx. 19 years old). I became aware of homebirth as a birthing option when I was a Women's Studies student at Ohio State. That was my first exposure to the birthing options that a woman has in Ohio, and it was before I even considered having children. A friend of mine had a homebirth with a midwife. Through a friend studying to be a midwife. I had 2 friends who had had homebirths. I discovered homebirth from a group of women who had or desired to birth at home.

163 community groups. online chat forum Friends In 2003, we began attending a new church. Some of the members had given birth at home with a midwife. I became pregnant with my first child a few months later. A web article written by a HBAC (homebirth after cesarean) mother A friend. Through word of mouth internet My older sister was a midwife many years ago in another state. When I was about 4 years old, my sister was born at home. I then attended 3 more homebirths as an observer throughout my childhood. Homebirth has always just been a way of life for me. Through a local attachment parenting mom's group. Read about it while pregnancy with my first child. I always have been aware that this is an aption, even though it is not widely accepted. my father and all six of his siblings were born in the house i grew up in. i have always seen birth as normal and natural. It was always in the back of my mind, but I never considered it a real option until all of my previous children were born via unnecessary c-section in hospitals. With each c-section, the option became more and more relevant until I made the decision that this time, I was having MY birth, and actually GIVING BIRTH to my child. I am now confident enough with my body and it's ability to give birth without needing a doctor/hospital environment to feel safe.

When I was reading about pregnancy and birth during my first pregnancy -- it didn't really get on my radar though until I moved to Ohio and met friends who had had homebirths. meeting a group of parents, reading spiritual midwifery, mothering magazine all slowly made me more aware... I am from California, and out there natural birth out of the hospital is more easy to come by. I wanted a natural birth in a birthing center for my second birth, but when I got to Dayton there were no freestanding birth centers. I did not want to birth in a hospital, and through much research and networking I met a group of women who taught me about homebirth. It was not easy to find local information when I first started looking, so I got most of my information from books (about the safety of homebirth).

My friends mom gave birth to her at home 27 years ago. I am part of a community where birth options are freely discussed and with more information at my disposal homebirth seemed to be a good fit for my family. From friends who had their own homebirth experiences. During my first I took child birth classes.(bradley method) That is when I learned about homebirthing. After I had a negative birth experiance.. I looked for something more. my mom was a midwife Through some women I had met in the local ICAN chapter, who had had HBACs.

164

My mother had four safe, healthy homebirths after two negative hospital experiences. She first pursued homebirth in 1976 to avoid unnecessary interference with her labor and the mistreatment of her infant that had occurred in both hospital births, but the relative cost, which would have been out of pocket, decided it. Paying five times as much to be abused wasn't appealing.

Homebirth midwifery wasn't legal in her area at the time, but she was able to find an experienced nurse-midwife who had been helping women from the Central and South American immigrant community, and delivered a 10lb6oz posterior infant with no tearing.

I never doubted that I was going to pursue homebirth if my pregnancies were low-risk, and followed homebirth research for years before I became pregnant. My husband had no experience with the concept but did some research and chose to support me. I have known people who have had children at home since I was a child. through friends and parenting groups interviewing a duola, she mentioned that i should consider it. i didn't know you could do it until i was 4 months pregnant. I have a friend who has had her babies at home. A friend researched it and I became interested. I believe it was by reading the book, "Gentle Birth Choices," but I was reading a lot of books about natural birth at that time so it could have been any of them. Growing up, I knew women who chose to have babies at home. I also read Ina May's Guide to Childbirth by Ina May Gaskin. I chose homebirth with my second child 13 years ago after a brutal hospital experience. I found a local child birth advocacy group and met my lovely midwife there. I am planning my 10th homebirth (11th child) with that same midwife in November. A local community of friends connected me to both midwives I have used. I became aware of the homebirthing option while watching a tv program. My husband's mother had some of her children at home.

I researched homebirth/birthing center options while pregnant with our 1st child. My mother was a Doula and assisted women through the birthing process at both hospitals w/doctors or midwives and at homes w/midwives. online forums I was a homebirth in Ohio in 1978. My involvement with online parenting support groups which emphasized natural and attachment parenting ideals led me to homebirth as an option. When I became pregnant with my son in 1997 I was looking into options. Homebirth immediately seemed like the perfect option for me and my family. I wouldn't have it any other way unless complications arose that the midwife felt would put someone in danger. I enjoyed all 3 of my homebirths. I guess I've always known that women have had births at home. I did my research on the internet and determined that I wanted a water birth at home with a midwife. The hospital protical and interventions really made me nervous. I am a doula, RN, and childbirth educator and was aware of the different options available. Books, Friends from friends who had had home birhts a friend mentioned it, then i researched it. The book Pushed 165

I have friends and family that have had homebirths. As a result of my own research as a childbirth educator and doula. A doula I was interviewing mentioned it to me when I told her I was currently searching for a hospital that would support the natural birth I wanted. I was born at home, as was my younger brother. Ina May Gatskin Book Spiritual Midwifery Friend Friend from chiropractic college. I, myself, was born at home over 25 years ago. My mother had 2 of my brothers at home as well. My sister had one birth at a midwife's home in Germany and then in the US, she had a midwife come to her own house. Research at the bookstore led me to the Natural Childbirth the Bradley Way by Susan McCutcheon. In the book she mentions homebirth. I knew immediately that was what I wanted to do. My mother talked about it when she became a doula. I also have a boss who had 4 babies at home in the 80's. I have another friend who had her baby at home in the 90's. At my Bradley Method of Childbirth class. through my doula

My first birth in a hospital was a horrible experience. I left the hospital thinking, "there has got to be a better way." I began researching childbirth and learned all about the normal, physiological process of birth. I realized that the interventions forced upon me in the hospital where not only unnecessary, but dangerous. I also learned of out-of-hospital birthing options, including birthing centers and homebirths. At first a birthing center appealed to me, but Ohio does not have any free-standing birth centers, so that was not an option. I began researching homebirth specifically and realized that this was my only true option. I gave birth to my second child at home less than 2 years later and will have it no other way! After having my second child in 1994. Not sure.. have always known a few people who did homebirths. My daughter had a homebirth. When I decided to go with a midwife instead of an OBGYN doctor, people started asking me if I was going to have the baby at home...then I learned more about it through our birthing class instructor. By reading Shiela Kissinger (sp?) publications. My husband is a chiropractor and he believes in homebirth, he told me about it. My mother wanted to birth my sister and I at home (London, England at the time), but was rushed to the hospital near the end of labor. Through friends that had healthy and joyous homebirths. My sister did it in California 15 years ago. More recently, I heard about it in Ohio through friends who are active in the doula community. A friend of mine decided to have her first child at home with a midwife. I had had two kids at the time and even though I wanted to stay home for their births, I didn't know it was an actual option. After researching with my third baby, I used a nurse midwife and delivered in the hospital. I finally found a DEM after many hours online to deliver my fourth at home. I worked at a health food store in my teens and found out about water births and homebirths then. This would have been ten years prior to my first child (who was also born at home). After becoming a doula, I got hooked into the homebirth community through another doula. From a friend and from the "Miami Maternity" show on Discovery health channel My sister gave birth to all 3 of her children at home with her mother-in-law being her midwife. When it was my turn it only seemed natural. my best friend had a homebirth

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A friend told me that homebirth was the best, safest way to go. She had six babies at home (some unassisted) and two of them were twins. I was born at home and my mother is a midwife. I have always known about homebirth. I had a friend who had several homebirths and it seemed like a wonderful option. I knew of them but I had a hard time finding a midwife. I found out about a local midwife through a friend. Its hard, you ahve to know someone who knows someone usualy. motheringdotcommune.com I Googled "birthing center Columbus Ohio" and found CHOICE. a friend Online, I found a midwife in my area. The prenatal care is 100% better compared to a physician. She cares, she listens, and she gives advice. Internet research, Ina May Gaskin books I read a ton during my first pregnancy and kept coming across it in books by Sheila Kitzinger, Ina May Gaskin and Henci Goer. My sister and friends shared their stories. I also read a TON about it. I lived in an apartment complex with a neighbor/friend who gave birth in her apartment to her first child at 18 years of age with a midwife. I chose that midwife, and she was wonderful at all 4 of my homebirths. Through a friend who taught Bradley Method of Natural Childbirth. My sister-in-law has had 5 homebirths. Reading and research after the birth of my first child. Word of mouth through friends. My aunt had 3 homebirths From an internet website for the magazine Mothering. My mother in law had homebirths. About 30 years ago when a cousin had her children at home. A friend in Michigan had a homebirth and got me thinking about it, then I did my own research. RESEARCH INTO THE FACTS ABOUT HOW IT CAN BE SAFER. I heard about it from friends. I use to coach gymnastics. One of my kids' moms was a Bradley teacher. I was at the time planning to become an Obstetrician and was pre-med in college. I asked her about becoming a childbirth instructor and she recommended some books including "Gentle Birth Choices" and "Natural Childbirth the Bradley Way." After reading those books, I became very interested in homebirth and natural child birth. I chose a free standing birth center for my first birth to appease my mother and husband. Watching the Business of Being Born and then asking around at the local health food stores. As it turns out, I've come to realize that I know a number of people who have had homebirths! friends I just never was aware of the converse. Researching VBACs online I noticed that many women turned to homebirth as their best option to avoid a repeat c-section I became aware in Miami, FL through my birth doula Through friends. Traveling the US as a young woman I met women that had homebirths. Ten years before becoming pregnant with my first child, I first learned about midwifery, homebirthing, etc. during a women's studies class at OSU called Issues In Women's Health. After reading a lot of material on the medicalization of women's natural body processes, etc., I became convinced that if I ever decided to have a child, I would pursue a midwife-assisted homebirth.

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Through my training as a doula. my mother is a midwife Internet Due Date Club Through friends and the internet. During my second pregnancy I became aware of the option but didn't have a homebirth until my fourth child. through chiropractic schooling, we discussed different birth options that were available to women in an obstetrics class. A friend had a homebirth about a year before I had my first Graduate school I always knew about it, I was just too scared the first time. I attended a local ICAN meeting for support from my c/sx and learned that it would be possible to VBAC at home with a midwife. I have studied midwifery for four years; homebirth has always been the natural and best choice for me. Growing up my father (who has read a huge variety of books) talked about the fact that for centuries women gave birth at home and that when birth was moved to the hospitals the death rate increased. I've always remembered that. Also, I have had bad experiences with doctors and don't trust them to do what is best for me. through friends, women and colleagues and research and study.

Some reading/study that was highly beneficial: Ina May's Guide the Childbirth and Spiritual Midwifery; Pushed; The Thinking Women's Guide the a Better Birth; Active BIrth; Natural Pregancy; Prenatal Yoga; Calm Birth; Hynobirthing; The Mind of Your Newborn Child by Chamberlain; Pre and Perinatal Birth Psychology and Reseach; Birthing from Within; What Babies Want; Being with Babies & Welcoming Conciousness by McCarty... Internet research. Mothering magazine One of my closest friends had two homebirths, and invited me to be present for one of them. It was one of the most beautiful things I was able to experience with her and I knew I couldn't have it any other way for myself when the time came to have children. My mother had several homebirths, so I grew up knowing it was a healthy and safe alternative. I really don't remember when I became aware, however it was something we considered with our first child even though I ended up having him at the hospital. Talked with a chiropractor and met with midwives that do homebirth through a friend who had a homebirth Can't remember the initial introduction but it was something I firmly believed in prior to my first pregnancy. It only makes sense to enter the hospital with a medical condition. Birth is not a medical condition. Working with a Doula during my first delivery 9 yrs ago. I've always planned on having a homebirth as my mother is a homebirth midwife. Reading childbirth education material I became aware of homebirth as an option during my first pregnancy when my mother-in-law sent me a copy of Spiritual Midwifery by Ina May Gaskin. At that time I was not comfortable with having a homebirth though. After my experience at the hospital though, I knew that any future children would be born at home. I felt that my care was poorly handled while in the hospital and despite asking directly for help in dealing with post-partum depression, I received no information or support. I felt a midwife would deal with these issues in a more compassionate manner. A friend of mine had all 3 boys at home in Ohio... and said it was wonderful!! So, I researched it and found it to be the BEST option for us. La Leche League after the birth of my first

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I read some books about homebirth as a teenager, which led me to an interest in homebirth. Then, as an adult, some friends gave birth at home, which cemented my idea that it was a safe and legitimate option. I had had friends plan a natural birth and I started to research options and eventually I discovered homebirth as an option. I waned my first birth to be an intimate, safe and powerful experience for my husband and I and our baby. I had friends who had given birth at home. I had always known it was an option, but had never considered it for myself until after my second hospital birth. My OB/GYN had tried to strip my membranes during a check-up (about a week before my due date) without first asking me. I was shocked at the lack of respect for my body being my own and felt violated. Also, during labor for this same pregnancy, I was given pitocin, which led to the need for an epidural, and eventually led to my blood pressure dropping. This is a side effect of the epidural, but I was not made aware of it beforehand. It was very scary and I did not want to be wheeled into a C-section because of it. All of the interventions (that were out of convenience for them) caused a trickle down effect that could have ended in a C-section. Thankfully, my blood pressure normalized, and I had my baby vaginally. These reasons led me to look for a doctor that would allow me to have a birth without pushing me into different interventions. I soon found there was not anyone in my area that I could trust to give me what I desired, and instead found my current midwife. I am now very glad that I ended up making this decision. I lived in Vancouver, Canada where midwifery/homebirthing is more acceptable and more widely known. Upon moving back to Ohio, I had a friend who was a doula for a midwife and contacted her based on my previous knowledge of homebirthing. Laura Shanley's website, Freebirth.com I had wanted a homebirth with my first pregnancy, but did not know how to go about it. I joined an online local parenting community where I found other parents that were able to share their experiences with me. I became aware of the option prior to becoming pregnant, as I educated myself on conception, pregnancy and labor options through books, internet and community organizations. Through a friend sharing her experience with me. A family friend delivered her children at home. Watched Business of Being Born at a preview party in Solon. I always knew it was an option, but after moving to OH while pregnant with my first child, I did not know where to look for a homebirth midwife. I did not know about Midwives Care that was in Cincinnati at the time so I went to the hospital for that birth. I ended up with a c-section and didn't want to repeat that with subsequent children. Friends Through friends at church. Friends. While researching options for a VBAC I came across stories of women who used midwives or birthed at home and I discovered Ina May and the Farm. My sister had a homebirth with her second child after having had a negative hospital birth experience with her first. online forums Met another mother who was doing so back in 1990 when I was pregnant with my oldest. She loaned me a bag of books about homebirth, and the rest is history. first through acquaintances who have had homebirths, then my own research on the subject. Through a friend. My LLL leader mentioned having an hbac after a meeting. The Web, searching for birthing alternatives/more natural births. My mother had 6 kids and only the first, myself was born at home. She made it sound like such a great experience that I wanted to do it as well.

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During the labor of my fourth child (the first four were born in the hospital), my nurse was also pregnant with her fourth child. She said her best friend was a midwife. She treated me with SO much respect. She was super knowledgeable about labor and birth. She helped me through the whole process. After I had my child, I started looking into midwives. I ended up finding one in the area. She did homebirths. My husband and I interviewed with her. She was wonderful and knowledgeable. I think I was always aware of homebirth as an option, but it did not become a real option to me until after the birth of my fifth child. Doula Quite a few years back when we were without health insurance we were considering starting a family and I started researching homebirth as an alternative to hospital birth because I knew it would be more affordable. I saw the documentary the business of being born' I knew that I didn't want a hospital birth so I started looking for other options and found a Birth circle support group in my area. Through the birth circle I found my mid wife. I was a homebirth child myself and watched four brothers get born at home, so when I think of birth, it is done at home. I did my masters thesis project on Midwives and how clients manage privacy/disclosure needs during their pregnancies and after the birth of their child. I always knew midwives existed, but through that project I became much more aware of options and more educated on the birth experience. (I really hope that this project helps you do the same). My fathers sister had done one. I had several friends who did homebirths. My mother had considered it with me, I just ALWAYS knew it was an option. A friend told me about it. While I was pregant with my first child I read everything I could get my hands on about birth. A friend had a homebirth. Through my birthing class for my first child in 2006. We had classes on Hypnobirthing and our instructor had a homebirth. Brother, Lewis Mehl my husband was born at home in 1980 My best friend was born at home. I talked to a friend who knew a Midwife. Then I contacted her and talked about my options. Exploring options for non-traditional birth, i.e. waterbirth at a hospital, birth center, etc. Stumbled upon CHOICE midwives in my area and went from there. Saw a doula at CHOCE, ***, who opened our eyes to homebirthing. It seemed we could have a better birth at home than we had had at St. Ann's in 2007. I've heard of it for years and am not really sure when or where was the first time. A professor in a college course spent a lecture discussing and displaying videos of homebirths and hospital births. His own wife had given birth to their three children at home and he talked about some of the things that were involved in their decision. This sparked my interest, and within a year I met a few women who had also had midwives assist their birth and took the opportunity to discuss their experiences with them. Reading books while pregnant. I attended a meeting of La Leche League, saw a book called _Creating Your Birth Plan_ by Dr Marsden Wagner, and heard the experiences of other women who had had homebirths. I knew several other women whom had planned homebirths as well as read books regarding homebirth. I researched on the internet and found my midwives as well as had references from other women who'd use them as well. My sister-in-law had a homebirth My husband told me about his sister's homebirth in Michigan. 170 i had some friends that had given birth at home. My husband was born at home along as well as his 6 brothers and sisters and since I never had any desire to ever have any drugs or assistance during birth, I researched it and decided it was right for me and my baby my partner encouraged me to explore this option. Reading birth books, and through my friend who was considering one at the time and told me about a homebirth midwife in the area. I had a friend give birth at home about 8 years ago. She had a previous 'bad' experience in the hospital and talked about how wonderful her homebirth had been. My mom had my 3 younger sisters at home. When I became pregnant and presented my husband with the homebirth option we knew it was for us. Internet An acquaintance asked me if I had ever considered it when I was pregnant with my first. I talked to her about it and then her midwife. Once I met the midwife I was convinced it was for me. It was common knowledge to me, but I know many people who are not aware of the option. Other moms. I was asked by a friend "Where I would give birth to my baby?" My response was in a hospital because that was all I was familiar with. She handed me two books: The American Way of Birth and Immaculate Conception. These books combined with my belief of birth being a natural process was all it took for me to choose a homebirth. I have always been very educated about childbirth since my first pregnancy when I took a Bradley class. During child birth education (Bradley) of my first child I learned about it. I wasn't a candidate because of a fibroid surgery, and first timer's fear. A friend of mine had a homebirth and told me about it. Through books at the library through a friend looking for reading material while pregnant with my second child, i read ina may gaskin's spiritual midwifery. When I was pregnant with my first and the obgyn would not consent to trying to let me go all natural with no intervention. I then met a woman who delivered her two children at home. my brother Bradley childbirth classes Word of mouth in my community. Research when pregnant into birthing options. The Business of Being Born (movie). My Great Grandmother gave birth to all of her children at home, on their farm. La Leche League friends, research I had friends who had had homebirths. internet blogs and forums word of mouth from other like-minded moms I feel like I always have known. After my first child was born via cesarean, I became involved with ICAN (Int'l Cesarean Awareness Network), and met other parents who had chosen homebirth. A friend of mine had a homebirth, I was present, in Denver, CO, 1996 my best freind had a homebirth with her first child 10 years ago - i thought she was crazy at first but i was with her through it and after and it seemed natural and right. i did not see the need to be at a hospital or have a doctor present unless there was risk. A friend told me of her experience with her first homebirth and I became interested then. As a doula I say a few homebirths and wanted to have one when I had my son. Word of mouth had a doula with my first son and she recommended homebirth 171

Before my first birth but the circle of people I was involved were negative towards the option. We didn't have the money to hire private care so we just let the possibility go. Simply through the grapevine of mothers, talking about their birth experiences. Read a book when I was 18 about the work life of a German homebirth midwife, given to me by a friend when I lived in Germany. Thought that would be the type of birth to keep in mind when childbearing came into the picture. I was born at home and I attended the homebirths of my two little brothers. After my first birth I knew there was something that wasn't right about my birth. I talked to someone I knew who had a birth in a birthcenter. She encouraged me to have a midwife next time and go to a birthcenter. In Ohio, there are no birthcenters and after having talked to the local midwives, I was convinced to have my babies at home. I knew that people did it before hospital births, and when I was at an art show a couple of years prior to being pregnant, I was introduced to a woman that was planning a homebirth. I asked her how you go about finding a midwife and she told me that you have to know the right people/ I have family members who have given birth at home over the past 30 years. A co-worker had given birth at home and it just hit me that it was right for me because I had always had problems with the medical model of care. I asked my OB/GYN about it and he warned me not to do it and not to use CHOICE, a local group of midwives. I had never heard of CHOICE and so thanks to his warning, I was able to find them and interviewed them and subsequently used them for my homebirth. Also, when I told the nurse at the OB/GYN office that I wanted to have an all natural birth, she looked at me quizzically and said "Why?" I knew then that the medical model was not for me. Friends Word of mouth through friends. In an article about Midwives Care during my first pregnancy when I was looking to an alternative to the OB/GYN's I;d been seeing. I heard a presentation given by a practicing doula in Ohio. She was outlining birth options available as well as their pros and cons. I called her and asked for a recommendation for a midwife. became friends with a woman who is a homebirth midwife, as well as having multiple friends who had had homebirths chiropractor through midwife at birthing center I don't remember! Many years ago- before I was even thinking about children- I picked up Christiane Northrup's book: Women's Bodies, Women's Wisdom. In it I read about a woman who chose a homebirth for the birth of her second child (I believe) after an unhappy experience in a hospital with her first child's birth. I am a firm believer in our evolution from animals, and as such, we have within us all the knowledge needed to live. And giving birth is part of life. So that was my first exposure to any discussion about birthing, really. I was, in fact, so ignorant (unaware of the raging debate) that I scheduled my first midwife appointment after I found out I was expecting without asking if the office assisted with homebirths! Even in the waiting room, reading the sign that said something along the lines of "We do not approve of homebirths". My mother pointed the words out to me, and I said, "Well, I think they must mean unassisted homebirths" I couldn't believe when they said they didn't condone ANY type of homebirth, and I began to lose hope. But I give thanks that one of the midwives in the practice recommended to me- since I was insistent on a homebirth- a midwife in Temperance who accepted homebirth clients. I am not sure how I would have found her name otherwise (Linda Johnson, CNM, Mother's Own Birth Center), though I was able to find her phone number in the phone book after being given her name. I did research online to find a midwife who offered out-of-hospital births. My midwife offers both birth center and homebirths. I became even more interested in homebirth after taking Bradley classes. Through a friend that had a homebirth with a midwife and loved it. From friends 172

Friends

I was always aware of homebirth as an option-and joked about it while pregnant w/ my first child. At that time I was an RN working in a very 'good' L&D unit, and knew as both a pt and a staff member that I would have little to no opposition while aiming for a natural, unmedicated birth. Doula care was part of my hospital charge-just like my nurse. And so there was no point to the 'risk' of homebirth.

With my second, now living in Ohio, and also working as a RN in two local hospitals, I feared I could not expect the same care from the nurses in these local hospitals, and it became clear to me that homebirth was the safest option for me, my baby, and family. through an internet search As a young child, I knew of friends who gave birth at home. I researched the option as an adult. I had read about it while pregnant with my 1st child and spoken to other mothers, both before my first was born and after, about their experiences giving birth at home. I was a single girl living in Atlanta, Ga in 1991 with three friends who were having homebirths. I was able to be at the end of one of them and thought it was an amazing, beautiful, peaceful and normal thing to be able to give birth in the comfort of your own home. I decided then that when I got married I would have homebirths. through a friend who became aware of it through a friend. my childrens fathre was born at home and I learned alot from his mother. I became more interested in the natural homebirthing way after a birth with rude hospital attendants who caused me and my first child un-needed hea;th issues. In 2005 when my sister was pregnant. A CNM mentioned it to us! Online research In the childbirth preparation class that we attended during my first pregnancy, the doula/teacher emphasized natural birth and consciousness of institutional statistics, medical traps, and abuses of power by hospitals, doctors, insurance companies. I did an Internet search of birthing centers and found homebirthing in the search. Through our doula whom we used for our first birth (hospital)...she was not associated with the Center for Humane Options In Childibirth Experiences (CHOICE), but shared their information, including website with my husband and me. Also, I saw bumper stickers on various cars in our city for CHOICE. Before I had children, I knew of a family member in Pennsylvania who had her children at home. I'd heard my fiance say that his mom had all three of her kids at home with a midwife, so I guess that's how I first heard about it. Then I saw a couple documentaries on the current obstetrics fiasco in America and that's when I decided I would want a homebirth for myself. My in-laws are home-birthers. A friend of my mothers had a homebirth in 1996 that I attended as a babysitter. Friends, "Spiritual Midwifery" A friend on a website fertilityfriend Through mothers I met at a breastfeeding support group and through my first midwife practice who had a birthing center and homebirth options. My sister-in-law told me I first really considedred it while attending our Bradley Method classes. Friends first, then I read the Dr. Sears Birth book, where he highlights all the options of birthing. A friend. I don't remember I had family members who homebirth, and I didn't view hospital birth as an option for my family. I had attended both home and hospital births, and I did not view the hospital as a safe alternative for me, and I did not see the reason to have a normal birth in a hospital. 173 books and internet sites about birth A friend of mine had a homebirth for her first child. I did not understand why any woman would have a homebirth. It seemed unsafe. I decided to do a little research and found that a homebirth seems like the safer option. I had my first child in the hospital setting. It was not pleasant. I was put on pitocin which caused excruciating contractions. I asked for an epidural which made me itch. Then, I was given something for the itching which made me sleepy. I couldn't walk, I couldn't pee. The hospitals have nursing students and medical students with no experiences handling your care. This is typical in the hospitals. When I found out I was pregnant the second time I was happy but also very concerned that I might have to go though something like that again. So, I started looking up information about doulas and midwifes. I switched from 4 prenatal care providers before I realized that I did not want another hospital birth. I talked to my friend and a few local doulas who gave me information on homebirth midwifes. I found a CPM who lived over 2 hours away to help me give birth to my second child. It was the best decision I could have made. Research project from school. With my first pregnancy Online research through a friend Friends of mine had homebirths and then I became friends with a midwife and got to know more women who had homebirths. When I discovered the book, "Spiritual Midwifery", while in college 18 years ago. Family member. Through an ICAN support group. Childbirth education classes via a hypnobirthing class I have been aware of homebirth as an option since I was pregnant with my first son. I read many books about natural childbirth and also read mothering magazine. Friends A friend who had birthed her children at home. My mother gave birth to me at home, and I didn't know if I would be able to until a friend told me about a local midwife who I then contacted. While studying HypnoBirthing for the birth of my second child. We were looking at a birth at a birthing center, but there were no birthing centers in our area. We came across the idea of homebirthing and looked into that option.

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Appendix C: Write-in Responses to the Question about Midwife/Midwife-team Training

and Credentials

For my most recent planned homebirth, my midwife/midwife-team members had which of the following credentials or professional F % training? Certified Professional Midwife (CPM) 170 46.58% completed an apprenticeship with another trained midwife 126 34.52%

Registered Nurse (RN) 64 17.53% Certified Nurse Midwife (CNM) 54 14.79% My midwife was in training 48 13.15% an academic program of study in midwifery 47 12.88% I'm unsure if my midwife/midwife team members held any 25 6.85% professional credentials Certified Midwife (CM) 17 4.66% Licensed Midwife (LM) in another state 13 3.56% My midwife held none of these credentials 11 3.01% Registered Midwife (RM) 4 1.10% lay midwife 3 0.82% emt 2 0.55% Neonatal Resuscitation 2 0.55% had attended homebirths previously with an MD-many years 1 0.27% before-for many years. emergency medical background 1 0.27% CPM application 1 0.27% 15 yr experienced lay midwife 1 0.27% 2 CPM's and an apprentice 1 0.27% Certified lay midwife 1 0.27% 2 CPMs and 1 in training 1 0.27% 2 CPMs and 1 intern 1 0.27% had delivered 500+ babies for 25 years 1 0.27% 175

30+ years of experience! 1 0.27% I'm not sure - CHOICE Midwives 1 0.27% assistant was lactation consultant 1 0.27% but 30+ years experience as a lay midwife 1 0.27% CNM in another state 1 0.27% LC 1 0.27% with a master's in midwifery 1 0.27% She worked with CNM's for several years 1 0.27% She had submitted her NARM and taken the test but I'm not sure if 1 0.27% she was certified yet Retired OB nurse 1 0.27% paramedic 1 0.27% one was a direct entry and the other was training with her 1 0.27% No credentials 1 0.27% I know she trained for many years 1 0.27%

My midwife was in the process of completing the CPM paperwork 1 0.27% has credentials and went to school out of state and was apprenticed 1 0.27% by both cnm and lay midwives Lay midwife with 30+ years expereince 1 0.27% lactation consultant 1 0.27% is looking forward to getting her certification when Ohio allows it 1 0.27%

IBCLC 1 0.27% Working towards CPMmbut had no completedi it yet 1 0.27% I think she was actually a CPM in the state of Illinois 1 0.27% 100s of births experience 1 0.27% I can't remember which midwife certification she has 1 0.27%

My midwife was in training (1 CPM and 1 working toward CPM) 1 0.27%

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