Personal Beliefs and Alternative Childbirth Choices: A Survey of 552 Women Who Planned to Give Birth at Home

186 BIRTH 20:4 December 1993

Personal Beliefs and Alternative Childbirth Choices: A Survey of 552 Women Who Planned to Give Birth

at Home

Hilda Bastian

ABSTRACT In Australia, planning to give birth at home was unusual in the middle to late 1980s, a choice made by only about 0.5 percent of women. This study investigated the personal beliefs and circumstances of 552 women who planned to give birth at home. Results showed that these women came from diverse backgrounds and beliefs, although in general they were of higher than average educational and occupational status, and less likely to hold Christian beliefs relative to the Australian community in general. Their lives and experiences rejected both unconventional and more traditional choices, and the view that women who give birth at home characteristically belong to the counterculture could not be justiJied. Thejindings of this study suggest that stereotypes of women who give birth at home do not apply to the circumstances of substantial numbers of women. (BIRTH 20:4, December 1993)

Planning to give birth at home is an unusual choice in Australia. Only about 0.5 percent of women plan a home birth, just over 1000 each year, although the frequency in different parts of the country varies (1,2), and a small unmet level of demand for this option exists (3). Although much of the published debate about home birth in Australia, as elsewhere, has focused on the relative safety of this practice, in general woman do not make decisions about care in childbirth based solely on their perceptions of medi- cally designated benefits and risks (4).

Providing perinatal services in a pluralistic community requires understanding of diverse patterns of personal and health beliefs that may guide the preferences and needs of individual women. Devel- oping rapport between woman and caregiver is not likely to be assisted by judgmentalism or stereotyp- ing from health professionals. In the case of families

Hilda Bastian is a maternity consumer advocate and researcher. This survey was conducted through Homebirth Australia Inc, a national consumer organization, and supported by a grant from the Consumers’ Health Forum of Australia Inc.

Address correspondence to Hilda Bastian, PO Box 314, Ka- toomba, NSW 2780, Australia.

0 1993 Blackwelf Scientific Publications, Inc.

who may already be reluctant to seek professional help, encountering such attitudes may discourage appropriate referral and transfer for assistance, or jeopardize participation in care when it is sought.

It is also true that differences in the personal beliefs and backgrounds of women may contribute to their preferences and willingness to reject strong community pressure to give birth in a hospital. In the face of various stereotypical representations of women who give birth at home, an investigation of the beliefs and social circumstances of the women who make this choice was a central purpose of a survey conducted through the national home birth consumers’ organization, Homebirth Australia.

Methods

A three-page questionnaire including 36 items relating to family details, beliefs, and experiences of home birth was distributed widely through various channels, beginning in 1986. The questionnaire was circulated at home birth conferences, reprinted in the newsletters of several home birth groups around the country, distributed by some home birth practitioners to women in their care, and advertised through invitations to participate that were placed in several publications.

BIRTH 20.4 December 1993 187

Table 1. Education of Women and Their Partners ~~ ~

Women Partners

Home Australia Home Australia Level of Education (n = 545) 1986 (7) (n = 528) 1986 (7) ~ ~~~ ~

Less than tertiary (010) 30.1 71.8 31.6 52.3 Tertiary (%) 69.9 28.2 68.4 47.7

Home birth data relate to attendance to tertiary level; 1986 census data relate to tertiary qual$cations attained in couple families with dependent children.

A total of 586 completed questionnaires were re- ceived, of which 34 were excluded. In one questionnaire the woman involved was not yet pregnant, and in the remaining 33, women had completed more than one questionnaire. In each of the latter instances the questionnaire relating to the most re- cent home birth was included. A general description of the final 552 responses was published indepen- dently by Homebirth Australia (5).

All but 44 women provided the date of the latest planned home birth. Where the date was known, most births (65.5%) occurred from 1985 to 1987. The largest year of response was for 1986: 162 questionnaires (31.9%). The range of years was from 195’7 to 1992, but only nine questionnaires related to births before 1982. The timing of this study enabled comparisons to be undertaken with both the 1986 Australian census and the first national report on women who gave birth in the years 1985 to 1987 in Australia after beginning labor at home with the in- tention of giving birth there ( I ) .

By comparison, the women in this survey were slightly older than those in the national report. Their reproductive histories were similar, although they were somewhat more likely to be giving birth for the first time, 34.6 percent compared with 30.8 of women in the 1985-1987 report. They were less likely to have transferred to hospital during labor. The distribution of births through Australia’s states and territories was different from the national frequency of planned home births, with overrepresen- tation from the Northern Territory and New South Wales.

Results

Social Circumstances

Study women were older at the time of the current planned home birth than Australian women giving birth generally; only 0.4 percent were younger than 20 years, compared with 5.9 percent nationally. Nearly half (47.7%) were age 30 years or more, compared with a national average of 30.9 percent

(6). Women were less likely to be married than is average for Australian women giving birth: 31.1 percent were not married, compared with 16.8 percent nationally (6), but only 3.0 percent were single parents. The women in this group stayed home with their children at about the same rate as Australian women generally: 58.9 percent stated that they were currently at home caring for their child or children full time, compared with 59.0 percent of couples with dependent children who had at least one partner at home in 1986 (7).

Although family incomes for this group were somewhat lower than the country’s average, their socioeconomic status was particularly high with re- spect to their educational levels and occupations. Study women had especially high levels of tertiary education compared with Australian women with dependent children generally (Table 1). They were also much more likely to be in prclfessional or paraprofessional occupations (Table 2) (8). The occupations of women and their partners were coded in occupational status categories according to Najman and Bampton (9). The occupational status of the women and their partners was similar, with over 60 percent in upper-level occupations, and around 30 percent in middle-status occupations.

Among study women, 130 (23.6%) were health care practitioners, including 56 nurses, 32 midwives, 20 in therapist and paramedical occupations, 20 alternative therapists, and 2 medical practitioners; an additional 14 were childbirth educators (2.5%). This high proportion of health care practitioners reflects the large number of women in professional and paraprofessional occupations who work in health care: 44.2 percent of study women in those categories. Among women in these categories in Australia generally in 1986, 32.0 percent were registered nurses or health diagnosis and treatment practitioners (8).

Personal beliefs

Significant differences existed in the religious beliefs of the women and their partners, compared


Table 2. Occupations of Women and Their Partners

Occupations

Partners Women

% Home % Australia % Home % Australia ( n = 481) 1986 (8) (n = 495) 1986 (8)

Managers and administrators Professionals Paraprofessionals Tradespersons Clerks Salespersons and personal service workers Plant and machine operators and drivers Laborers and related workers

5.6 42.8 18.5 5 .O

14.8 11.6

1.7 -

7.6 12.3 7.2 3.9

32.8 19.7 3.4

13.2

12.5 39.8 12.7 17.0 6.3 5.1 1.8 4.8

14.9 12.0 6.3

23.4 7.6 8.3

11.7 15.8

Home birth data relate to occupations provided for women and their partners either currently in the workforce, or previous occupation if currently at home with children. 1986 Census data relate to the occupations of Australian women and men generally when provided.

with religious beliefs among all age groups as reported in the 1986 national census (10) (Table 3). People planning home births were less likely i o be Christian, and much more likely to have non-Chris- tian, nontheistic, or no religious beliefs. The number of people planning home births who held non- Christian beliefs followed a pattern different from that among the general population, with higher rates of Buddhists and Hindus. Most Australian Bud- dhists and Hindus were born outside the country, usually in Asia, whereas those in the home birth group were mostly born in Australia.

Australian individuals of non-Christian or no religious belief are much more likely than Christians to have educational qualifications at, or higher than, the university degree level. However, the 203 (86.1%) study women of Christian beliefs were more likely to have tertiary level education than the 287 (69.0%) with no or non-Christian beliefs (P < 0.0001, x 2 19.01). Women of Christian beliefs were more likely to be married (87.1%) than women of no or non-Christian beliefs (59.4%) (P < 0.0001, x2 43.90). Women with tertiary education were also

Table 3. Religious Beliefs of Women and Their Partners

more often married, but this was not statistically significant.

Almost half of the study women identified themselves as feminist (47.3%), with 30.8 percent of their partners considered feminist. A significantly lower number of women of Christian belief identified themselves as feminist (35.1%) compared with women of other or no religious beliefs (55.4%) (P < 0.0001, x 2 18.94). Unmarried women more often identified themselves as feminist, but this was not statistically significant.

Study women were much more likely to be vegetarian (23.9%), whereas nationwide in 1983, 3.4 to 4.7 percent of women age 25 to 44 were vegetarians (1 1). Only 13.8 percent of study women of Christian belief were vegetarian, compared with 28.9 percent of those of non-Christian or no religious beliefs ( P < 0.0001, x2 15.50).

Study women had a higher than average rate of breastfeeding, regardless of the place of birth of their children: 96.6 percent reported breastfeeding their first children, with higher rates for later children. In 1983,85 percent of Australian women were

Religion

Women Partners

Home Australia Home Australia (n = 552) (%) 1986 (%) (10) (n = 552) (%) 1986 (%) (10)

Christian 36.8 Non-Christian* 7.1 No religion 32.8 Nontheist 1.3 Inadequately described 10.7 Not stated 11.2

75.3 2.0

11.0

0.3 11.4

-

34.2 6.2

34.4 1.8 9.4

15.4

70.6 2.1

14.3

0.5 12.5

-

~~

1986 Census data relate to all Australian age groups. * Non-Christian incorporates Muslim, Buddhist, Jewish, Hindu, other Eastern, spiritualist, and some occult faiths.

BIRTH 20:4 December 1993 189

Table 4. Attitudes Toward Conventional and Alternative Medicine

Positive Undecided1 Negative Type of Medical System (%) Ambivalent (%) (%)

Conventional (n = 549) 54.3 17.1 28.6 Alternative (n = 550) 90.4 7.8 1.8

fully breastfeeding after the birth of their first child (12).

Attitudes Toward Health Care and Use of Medical Services

Considerable feelings of negativity and ambivalence toward the value of conventional medicine in health care were expressed by these women (Table 4). Many clearly distinguished their attitudes toward medical care in relation to illness or injury from that in relation to pregnancy and childbirth, as well as distinguishing between routine and emergency obstetric intervention. In all, 95.8 percent indicated that a reason for choosing to give birth at home was “wanting a natural birth,” with 96.5 percent reading two or more books in preparation for birth, and 56.7 percent reading eight or more. In 1989 in Victo- ria, a population-based survey found that 64.1 percent of women found reading extremely or very helpful in understanding and dealing with pregnancy (3).

More than half of these women had a backup hospital registration (56.3%); 45.3 percent lived 10 minutes or less from a hospital, and 91.0 percent less than 30 minutes. Attitudes toward hospitals in relation to childbirth were often negative: 62.0 percent indicated that a dislike of hospitals in general was one reason why they planned to give birth at home. Of women who had previously given birth in a hospital, 58.6 percent said that dissatisfaction with a previous hospital birth was a reason for planning home birth. Most women believed that home birth was safer than birth in hospital (60.2%), 29.2 percent believed it was similar, and only eight be-

Table 5. Use of Pennatal Services

lieved it was less safe. A further 9.2 percent rejected these options, and said that they believed the level of safety depended on individual circumstances.

In discussing why they planned home birth, women often mentioned that obstetric intervention could be harmful or disruptive to the woman and her baby, and that uninterrupted labor offered benefits.

Discussion

Research conducted in a special-interest group may or may not be representative of more general experiences (13). An inherent bias in this group is likely, since the questionnaire was distributed largely through the organized home birth movement, with an introductory passage indicating that the objec- tive of the study was to assist in promoting the option of home birth in the Australian community. In addition, the style of this study, conducted through a lengthy written questionnaire, would have influ- enced who participated. Nevertheless, the partici- pants were similar in measurable ways to women planning home births in Australia generally, and the large number provided a broad range of views and experiences. The findings call into question the basis of some frequently encountered stereotypes of women who give birth at home in Australia, and support others.

Perceived characteristics of women who prefer to give birth at home engender antagonism in the medical profession, but the stereotyped criticisms actually relate to personality traits, such as inde- pendence, that are highly valued (14). Yet charac-

Perinatal Service Doctor

(%)

Antenatal care Childbirth education* Birth attendancet

82.1 14.9 92.4

79.4

10.9 -

7.1 3.6 6.2

1.1 45.8 4.7

* In addition, 35.6% attended childbirth association, home birth group, other independent, or other unstated type of childbirth education classes. t Midwives and doctors as birth attendants at home, with care occasionally shared.


teristics that are valued by the community in other contexts may not be similarly positively regarded by health care practitioners when displayed by patients. Stereotypes regarding educated, middle- class pregnant women generate false assumptions among some perinatal practitioners and may inap- propriately affect interactions with them (15).

For women who give birth at home, the burdens possibly associated with being in a group labeled as antagonistic toward obstetric care have been exac- erbated by the “counterculture” stereotype that at- taches to this choice in some countries such as Aus- tralia. Perhaps because home birth has been embraced so strongly and promoted by counterculture groups and leaders, it has come to be regarded by some as being itself a product of the counterculture and therefore readily dismissed. However, a study that examined this issue in the San Francisco area in the early 1970s concluded that only about 10 percent of the couples giving birth at home could be characterized in this way (16).

In this group, indicators of a strong committment to what might be described as New Age or counterculture beliefs were a strong feature, but were shown by a similarly small minority of women, in terms of, for example, Eastern or theosophical religious beliefs. Only 14 families indicated that they were living in a communal setting. Women prefer- ring this lifestyle may be underrepresented in this survey, since a lower than average number were cared for by lay midwives, who in Australia might more commonly be supporting women living in ru- ral communities in particular. Nevertheless, this could only add a further small proportion of women to the group.

Perhaps the strongest stereotype that might apply more fairly to this group is that of individuals in professional and paraprofessional occupations. In examining the implications of alternative health care movements generally in the United States, it was suggested that one reason why these activities failed to attract more serious attention is because of their dual association with the New Age and patron- age by the affluent “baby boom” generation. This perspective may have led people to regard these alternatives as “indulgent and trivial,” despite their potential significance and social implications (17).

Support for alternative health therapies was the norm for this group of women, with some ambivalence about the value and appropriate role of medical, and particularly obstetric, care. Although ex- ploration of these issues is beyond the scope of this survey, others suggested that, in fact, an association may exist between these attitudes, and that frustration or dissatisfaction with conventional

medicine may be the most common reason individuals turn to alternative therapies. It is not, however, the only one, since the choice of alternative medicine may also originate from a belief in its basis and value, or simply be a preference for exploring all options (18). Although a suitable attitudinal survey for comparison was not located, there are indicators that the acceptance of alternative therapies may be widespread in Australia. Chiropractors, osteopaths, and naturopaths are registrable practitioners in at least parts of the country, and private health insur- ance commonly reimburses for different therapies.

Many of these women said they would consider giving birth at home unattended, although several specified that this did not mean they actually would do it. Unattended home birth rarely occurs in Aus- tralia. In this context, the high positive response to the question, “Would you consider going it alone?” may be more an expression of rejection of the hospital or commitment to home birth, rather than indicating actual intent. Although questioning the role and value of medical care was common in this group overall, it should be noted that there was also a high use of medical services antenatally. Medical practitioners were present at just over 10 percent of the births (presumably with hospital medical staff also present, although not always listed after an intra- partum transfer). Some women preferred medical to midwifery attendants, and some complained about the scarcity of physicians willing to be involved in home birth.

Even the choice of home birth, unusual as it is in Australia, cannot be regarded entirely as an indica- tor of a preference for alternative health care. A European survey reported that home birth is not an alternative form of perinatal care in all countries because it remains a major part of formal perinatal services (19). The study group consisted of more women born in The Netherlands and United King- dom, where home birth may still be regarded as more conventional.

Choosing to give birth at home cannot be considered as an undifferentiated phenomenon that can be easily characterized. The choice is made within a cultural framework that differs among individuals, communities, and countries. In Australia at the time of this survey, state-funded, hospital-based perinatal care and medical services were freely available to all citizens, whereas domiciliary midwifery care was a relatively expensive option generally available only within private, entrepreneurial practice. This may well have affected the extent to which home birth was a feasible option among various social groups. In contrast, a study of women in a wel- fare program in Oregon, for example, concluded

BIRTH 20:4 December 1993 191

that giving birth at home was sometimes associated with financial issues, and that it would be wrong to assume that it was always a philosophical choice, or one made only by middle-class women (20).

Even within a given community, women who give birth at home are not necessarily a homoge- neous group. This survey demonstrated major trends in beliefs and behaviors that were unconventional relative to Australian women generally, such as religious beliefs and dietary patterns. However, many women indicated beliefs and behaviors that were characteristically more conventional, such as the large number with Christian belief. Although they were significantly more likely to be married, but less likely to regard themselves as feminist or to follow vegetarian diets. They may be uncharacteris- tic of Australian Christian women in other ways that this survey could not adequately explore, as suggested, for example, by their educational status.

For some women, choosing to give birth at home may be an extension of a critical and nontraditional approach to life choices, as suggested by the high level of rejection of prevailing religious beliefs and marriage customs. For others, however, a planned home birth may be the only unconventional aspect of their lifestyle. Indeed, it may even be a choice that stems from traditional attitudes and values; rather than being primarily associated with a choice in terms of health care, it may be more directly and solely related to privacy and family issues. A small number of women stated that they gave birth at home for religious reasons.

In some instances a commitment to a belief system may also be accompanied by a rejection of medical care within that tradition, as for example, among women of Jehovah’s Witness background, some of whom indicated they chose home birth for religious reasons. A study of domiciliary midwives in Utah reported that most were strongly committed to the Mormon religion, and several held fundamen- talist beliefs (17). For adherents to this belief system, midwifery and home births were a traditional part of a lifestyle that emphasized female modesty and embraced alternative healing methods, as well as a commitment to individual responsibility and resistance to secular authority (17).

Personal beliefs play an important role in health- related behaviors in pregnancy and more generally. Established links exist between health status and religious belief, but it is not known to what extent this is attributable to social class or lifestyle differences, such as vegetarian diets and avoiding to- bacco and alcohol, or to “less tangible aspects of group affiliation” (21). Such studies highlight the need to consider women’s personal beliefs, values,

and life circumstances in understanding their health-related behavior and lifestyle choices. These interrelated factors warrant further examination to help gain a better understanding of the factors that shape the experiences of women in pregnancy, and influence their interaction with health care systems.

Conclusions

Women who plan to give birth at home in Australia come from diverse backgrounds and beliefs, both unconventional and more traditional. The belief that women who give birth at home belong predomi- nantly to the counterculture does not appear to be justified, although characterizing them generally as educated and middle class more closely reflects the norm from the middle to late 1980s in Australia. Nevertheless, stereotypes will be contradicted by the circumstances of many women, and are unlikely to assist in providing appropriate and responsive perinatal care to the women who make this choice, or in recognizing the various features of the home birth phenomenon. Understanding the characteristics of women who give birth at home in other communities and circumstances requires local study, because of the many influences and experiences that contribute to women’s childbirth choices and practices.

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Documents

Personal Beliefs and Alternative Childbirth Choices: A Survey of 552 Women Who Planned to Give Birth at Home