Experiences of Women Who Have Planned Unassisted Home Births: a Systematic Review Protocol

SYSTEMATIC REVIEW PROTOCOL

Experiences of women who have planned unassisted home births: a systematic review protocol

1 1 2,3 Danielle Macdonald Josephine Etowa Melissa Helwig

1School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada, 2W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, Canada, and 3Aligning Health Needs and Evidence for Transformative Change (AH-NET-C): a Joanna Briggs Institute Centre of Excellence

Review question/objective: The objective of this review is to identify, appraise and synthesize the qualitative evidence on the experiences of women in high resource countries who have planned unassisted home births. This qualitative review aims to answer the following question: what are the experiences of women who have planned unassisted home births? Keywords Freebirth; unassisted birth; unassisted home birth JBI Database System Rev Implement Rep 2019; 17(1):16–21.

Introduction urging of physicians for reasons such as safety and 11 here are many decisions that women and family hygiene. This new, innovative medical model of birthing in hospitals slowly became normative after T members face as they prepare for the birth of a 12 new child. Place of birth and the type of healthcare World War II. As women and families came to provider for perinatal care are two common consid- associate hospital birth with safety, their interest and erations for women and families. For many women, trust in home births dwindled. In countries like a hospital is the preferred location for labor and Canada and the United States, in the 1970–80 s delivery, attended by a physician.1 Increasingly, in the home birth movement emerged in response to high resource countries,2,3 women and families are the misuse of obstetrical interventions, less than ideal birthing experiences and lack of choice for non- choosing to have midwifery care and home births 12 attended by midwives.4 normative ways of birthing. With the home birth For an unknown number of births, women and movement came renewed interest in choice of birth their families are choosing to have home births place and choice of healthcare provider, with women without the assistance of a healthcare provider. and parents deciding where and with whom they These births are referred to as; unassisted wished to have their birthing experience. 1,5-8 1,5,9 1 The term ‘‘unassisted birth’’ was first coined by births, free births, autonomous births, 13 unhindered births,1 and do-it-yourself births.5 For Laura Kaplan Shanley. Unassisted birth can be described as birth where there is an ‘‘absence of this systematic review of qualitative literature, the 1(p.54) term ‘‘unassisted birth’’ will be used as it is the most an expert, rather than complete solitude’’. commonly used term across countries in the global Unassisted birth has also been described as ‘‘a unique north to refer to this phenomenon.1 phenomenon, whereby women make an active choice not to utilize the maternity services that are Prior to the early and middle twentieth century, 7(p.4) depending on the high resource country, most available to them’’. It is very important to women gave birth in their homes.10,11 Birthing care distinguish unassisted birth from the phenomenon moved from taking place in homes to taking place in referred to as ‘‘born before arrival’’ which occurs hospitals in many high resource countries with the when a birth happens with the unintentional absence of attendance by a healthcare provider.7 An example of a ‘‘born before arrival’’ birth would be if a woman Correspondence: Danielle Macdonald, experienced an extremely fast labor and did not have [email protected] time to seek assistance from a healthcare provider. There is no conflict of interest in this project. This is different from an unassisted birth because DOI: 10.11124/JBISRIR-2017-003654 ’’born before arrival’’ birth occurs as a result of not

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having enough time to access healthcare, whereas in process, iii) autonomy, and iv) agency.7 The first two the case of an unassisted birth, there is an active reasons are self-explanatory. The third reason has to choice not to seek care from a healthcare provider. It do with the preservation of a woman’s autonomy is also important to understand that although an and her control over the birthing experience, which unassisted birth often takes place in the home, it was often related to a previous birthing experience should not be confused with a home birth. A home during which the woman felt a lack of control.7 The birth is a birth that is attended by a healthcare final reason had to do with a woman maintaining provider, usually a midwife, who is present during agency over her own body and the birthing process, labor, delivery and the immediate postpartum. through the decision to reject a medicalized birth.9 It is difficult to know the exact prevalence of This synthesis7 focused on what influenced women unassisted birth throughout the world because of to choose to have an unassisted birth; however, it did the nature of it taking place at the margins of the not explore and synthesize the literature1,8,9,14,15 healthcare system. Plested and Kirkham14 stated the about the actual experiences that women had during lack of data regarding unassisted birth in the United unassisted births. Kingdom, while Lindgren, Nassen, and Lundgren8 For this systematic review, we are interested in stated that one in five home births in Sweden are understanding the experiences of women who unattended by a midwife or a healthcare provider. It choose unassisted birth in high resource countries.2,3 is difficult to know whether the lack of data on The reason for this is because in high resource unassisted birth is due to the methods for collecting countries, perinatal care is generally available to data on out-of-hospital birth or whether the lack of women. Thus, the women choosing to have unas- data reflects the low numbers of women and families sisted birth are making a choice that challenges the choosing this as a birthing alternative. mainstream expectations of birthing with the assis- Studies have suggested that there is stigma asso- tance of a healthcare provider. In under-resourced ciated with making healthcare decisions that contra- countries, women and families may birth at home dict mainstream healthcare, such as the decision to without the assistance of a healthcare provider due have an unassisted birth.6,9 The presence of stigma to a lack of perinatal services, shortage of skilled surrounding the decision to have an unassisted birth birth attendants, and financial or infrastructure bar- may contribute to the challenge in accounting for the riers to access any services that do exist. The differ- number of women and families choosing such alter- ences in the accessibility of perinatal care between natives as home birth or unassisted birth.6 According high resource countries and low resource countries to Miller,6 women who chose unassisted birth often may result in different reasons why women choose to strategized how they were going to address the birth at home without the assistance of a healthcare layered stigma of an unassisted birth. For these professional. In this qualitative systematic review, women, unassisted birth was associated with two we are interested in understanding the experiences of layers of stigma; the first layer was one from main- women who choose unassisted births, within a con- stream society for choosing to have a birthing expe- text of generally accessible perinatal care. rience outside of accepted norms, the second layer This systematic review will synthesize findings as was from home birth advocates who supported they relate to women’s experiences of unassisted home birth, but not home birth without the assis- birth. Understanding women’s experiences of unas- tance of a healthcare provider.6 Miller6 argued that sisted birth may assist us in our understanding of this double layer of stigma rendered women and what women value in their experiences of birth, families who chose unassisted birth invisible. generally. The findings of this review may also assist Through this example, we can see the challenges us in identifying important elements of care that are in accounting the prevalence of unassisted birth missing from mainstream perinatal services. within the general population. A preliminary search of MEDLINE/PubMed, A meta-thematic synthesis which examined why CINAHL, the Cochrane Database of Systematic women choose to have an unassisted birth revealed Reviews and the JBI Database of Systematic Reviews four main reasons.7 The reasons for choosing an and Implementation Reports revealed that there are unassisted birth included; i) rejection of the medical currently no published systematic reviews about and midwifery models of birth, ii) faith in the birth women’s experiences of unassisted birth. Both

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PROSPERO and the Campbell Collaboration were be utilized in this review. An initial limited search of also checked. In PROSPERO, two results were iden- PubMed and CINAHL will be undertaken followed tified regarding outcomes and place of birth.16,17 by analysis of the text words contained in the title Other results concerned decision making around and abstract, and of the index terms used to describe birth18,19 and during pregnancy and birth.20 None each article (see Appendix I for preliminary search of the results in PROSPERO examined the experi- strategy). A second search using all identified key- ences of unassisted birth. words and index terms will then be undertaken across all included databases. Thirdly, the reference Inclusion criteria list of all identified reports and articles will be Participants searched for additional studies. Studies published This review will include women who have planned in English will be considered for inclusion in this unassisted births in their homes. That is, women who review. Studies published beginning with the date of plan to birth at home without the assistance of inception of each of the databases will be considered healthcare providers. for inclusion in this review. The search for unpublished studies will be important to this review given Phenomenon of interest that the topic is often at the margins of health care. The phenomenon of interest for this review is women’s experiences of planned unassisted births at home. Information sources Unassisted births are defined as births that are The databases to be searched include: MEDLINE planned not to be assisted by professional healthcare (Ovid), Embase (Elsevier), CINAHL (EBSCO), Sco- providers.7 Healthcare providers are defined as pro- pus (Elsevier), Web of Science (Clarivate Analytics), fessionals who are trained and licensed to provide Sociological Abstracts (ProQuest), ProQuest Disser- healthcare to women and newborns throughout the tations and Theses (ProQuest) and Nursing and perinatal period, specifically during labor, delivery, Allied Health Database (ProQuest). and the postpartum period. Healthcare providers The search for unpublished studies will include: include, but are not limited to: nurses, midwives, Targeted Advanced Google searches physicians, obstetricians, and paramedics. Government websites: Canada, US, UK, EU Context countries, Australia, New Zealand The context includes planned unassisted births that International Confederation of Midwives occur at home in high resource countries. For this International Council of Nurses review, high resource countries will include: Canada, Association of Women’s Health Obstetric and United States of America, Australia, New Zealand, Neonatal Nurses Japan, countries located in Europe and countries of Canadian Association of Perinatal and Women’s the former USSR.2,3 Births of any kind that occur in Health Nurses low resource countries will be excluded. For this Dona International - https://www.dona.org/ review, low resource countries will include; countries Association of Radical Midwives – www.mid- located in Africa, countries located in Asia (not wifery.org.uk Japan), and countries in Latin America.2,3 Births Unassisted Childbirth – www.unassistedchild- occurring in a hospital or birth clinic will be excluded. birth.com Free Pregnancy and Free Birth – www.freepreg- Types of studies nancyandfreebirth.com/ The review will consider studies that focus on quali- Freebirth Australia - http://freebirth.com.au/. tative data including, but not limited to: designs such as; phenomenology, grounded theory, ethnography, Study selection action research and feminist research. Title, abstract and full text screening will be con- ducted independently by two reviewers. Disagree- Methods ments that occur during these processes will be Search strategy solved by consensus or consultation with a third The search strategy aims to find both published and reviewer. Search records will be collated and man- unpublished studies. A three-step search strategy will aged using the citation management software

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Covidence (Covidence, Melbourne, Australia). Summary of Findings includes the major elements Duplicates will be removed and recorded. Reasons of the review and details how the ConQual score is for exclusion during the full test screening and the developed. Included in the table is the title, popula- critical appraisal process will be included in an tion, phenomena of interest and context for the appendix in the completed review. specific review. Each synthesized finding from the review is then presented along with the type of Assessment of methodological quality research informing it, a score for dependability, Qualitative papers selected for retrieval will be credibility, and the overall ConQual score. assessed by two independent reviewers for methodological validity prior to inclusion in the review Acknowledgments using standardized critical appraisal instruments We wish to gratefully acknowledge the continued from the Joanna Briggs Institute System for the support of The Centre for Translational Research: A Unified Management, Assessment and Review of Joanna Briggs Institute Centre of Excellence in Fort 21 Information (JBI SUMARI). Specifically, the JBI Worth, Texas. Critical Appraisal Checklist for Qualitative Research will be used, any studies with a score less References than 6/10 will not be included. Any disagreements 1. Miller AC. ‘‘Midwife to Myself’’: Birth Narratives among that arise between the reviewers will be resolved Women Choosing Unassisted Homebirth. Sociol Inq through discussion or with a third reviewer. 2009;79(1):51–74. 2. Solarz MW. North–South, Commemorating the First Brandt Data collection Report: searching for the contemporary spatial picture of the global rift. Third World Q 2012;33(3):559–69. Qualitative data will be extracted from papers 3. Solarz MW. The birth and development of the language of included in the review using the JBI Critical global development in light of trends in global population, Appraisal Checklist for Qualitative Research from international politics, economics and globalisation. Third 21 JBI SUMARI. The data extracted will include World Q 2017;38(8):1753–66. specific details about the phenomena of interest, 4. Canadian Association of Midwives. Midwifery in Canada is participants, context, study methods and the phe- growing! The Pinard: Newsletter of the Canadian Associa- nomena of interested relevant to the review question. tion of Midwives. 2015; 5(1):6–7. Findings, and their illustrations, will be extracted 5. Vogel L. ‘‘Do it yourself’’ births prompt alarm. CMAJ and assigned a level of credibility. 2011;183(6):648–50. 6. Chasteen Miller A. On the Margins of the Periphery: Unas- Data synthesis sisted Childbirth and the Management of Layered Stigma. Sociol Spectr 2012;32(5):406–23. Qualitative research findings will, where possible, be 21 7. Feeley C, Burns E, Adams E, Thomson G. Why do some pooled using JBI SUMARI. This will involve the women choose to freebirth? A meta-thematic synthesis, aggregation or synthesis of findings to generate a set part one. Midwifery 2015;13(1):4–9. of statements that represent that aggregation, 8. Lindgren HE, Na¨sse´n K, Lundgren I. Taking the matter into through assembling the findings rated according to one’s own hands – Women’s experiences of unassisted their quality, and categorizing these findings on the homebirths in Sweden. Sex Reprod Healthc 2017;11:31–5. basis of similarity in meaning. These categories are 9. Feeley C, Thomson G. Tensions and conflicts in ‘choice’: then subjected to a meta-synthesis in order to pro- Womens’ experiences of freebirthing in the UK. Midwifery duce a single comprehensive set of synthesized find- 2016;41:16–21. ings that can be used as a basis for evidence-based 10. Lewis CH. The Gospel of Good Obstetrics: Joseph Bolivar practice. Where textual pooling is not possible the DeLee’s Vision for Childbirth in the United States. Soc Hist Med 2016;29(1):112–30. findings will be presented in narrative form. 11. Thomasson MA, Treber J. From home to hospital: The evolution of childbirth in the United States, 1928–1940. Assessing certainty in the findings Explor Econ Hist 2008;45(1):76–99. The final synthesized findings will be graded accord- 12. Rooks JP. Midwifery amid the social movements of the ing to the ConQual approach for establishing confi- 1960s and 1970s. In: Midwifery & childbirth in America. dence in the output of qualitative research synthesis Philadephia, Pennsylvania: Temple University Press; 1997; and presented in a Summary of Findings.22 The p. 45–78.

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13. Shanley LK. Unassisted childbirth. 3rd ed. Laura Kaplan from: http://www.crd.york.ac.uk/PROSPERO/display_re- Shanley; 2016. cord.php?ID=CRD42015017334. 14. Plested M, Kirkham M. Risk and fear in the lived experience 19. Steel A, Wardle J, Lauche R, James P. Women decision of birth without a midwife. Midwifery 2016;38:29–34. making process with regards homebirth: a systematic 15. Lundgren I. Women’s experiences of giving birth and mak- review. PROSPERO [Internet] 2018. [cited 2018 August ing decisions whether to give birth at home when profes- 21]. Available from: http://www.crd.york.ac.uk/PROSPERO/ sional care at home is not an option in public health care. display_record.php?ID=CRD42018088102. Sex Reprod Healthc 2010;1(2):61–6. 20. Yuill C. Exploring informed decision-making during preg- 16. Scarf V, Rossiter C, Vedam S, Dahlen H, Ellwood D, Forster D, nancy and in birth: a meta-synthesis of women’s experi- et al. Maternal and perinatal outcomes by planned place of ences. PROSPERO [Internet] 2017. [cited 2018 August 21]. birth among women with low-risk pregnancies in high- Available from: http://www.crd.york.ac.uk/PROSPERO/dis- income countries: A systematic review and meta-analysis. play_record.php?ID=CRD42017053264. Midwifery 2018;62:240–55. 21. The Joanna Briggs Institute. Joanna Briggs Institute 17. McCourt C, Cartwright M. A review of facilitators and Reviewers’ Manual: 2014 edition [Internet] The Joanna barriers to the implementation of evidence-based practices Briggs Institute; 2014 ; [cited 2018 August 21]. Available in labour and childbirth in obstetric settings. PROSPERO from: https://joannabriggs.org/assets/docs/sumari/Revie- [Internet] 2017. [cited 2018 August 21]. Available from: wersManual-2014.pdf. http://www.crd.york.ac.uk/PROSPERO/display_record.ph- 22. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. p?ID=CRD42017081891. Establishing confidence in the output of qualitative 18. Shneerson C, Taylor B, Kenyon S. A systematic review to research synthesis: the ConQual approach. BMC Medical examine the evidence regarding discussions by midwives, Research Methodology [Internet] 2014. [cited 2018 Jun 11]; with women, around their options for where to give birth. 14. Available from: http://journals.scholarsportal.info/detail- PROSPERO [Internet] 2015. [cited 2018 August 21]. Available sundefined.

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Appendix I: Search strategy - CINAHL

# Search terms Results S1 (MH ‘‘Focus Groups’’) 26,285 S2 (MH ‘‘Qualitative Studiesþ’’) 87,976 S3 (MH ‘‘Interviewsþ’’) OR (MH ‘‘Thematic Analysis’’) OR (MH ‘‘Meta 160,924 Synthesis’’) OR (MH ‘‘Narratives’’) S4 TI ((semistructured or semistructured or unstructured or informal or indepth 79,895 or indepth or facetoface or structure or guide) N3 (interview or discussion or questionnaire)) OR ((semistructured or semistructured or unstructured or informal or indepth or indepth or facetoface or structure or guide)N3 (interview or discussion or questionnaire)) S5 TI (focus group or qualitative or descriptive or ethnograph or fieldwork or 122,333 field work or key informant or grounded theory or phenomenological) OR AB (focus group or qualitative or descriptive or ethnograph or fieldwork or field work or key informant or grounded theory or phenomenological) S6 S1 OR S2 OR S3 OR S4 OR S5 256,003 S7 (home OR unassisted OR free) N3 ((MH ‘‘Birth Place’’) OR birth place OR 418 birthplace) S8 (home OR unassisted OR free) N3 (birth OR child birth OR childbirth OR 4276 born OR newborn) S9 TX freebirth OR unassisted birth OR high risk home birth 226 S10 S7 OR S8 OR S9 4601 S11 S6 AND S10 698

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