Challenging the status quo: Women's experiences of opting for a home birth in Andalucia, Spain

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ Esta es la versión aceptada del artículo publicado en: This is an accepted manuscript of a paper published in: Midwifery (2019): March 2019 DOI: https://doi.org/10.1016/j.midw.2018.12.001 Copyright: © 2018 Elsevier Ltd. All rights reserved. El acceso a la versión publicada del artículo puede requerir la suscripción de la revista. Access to the published version may require subscription. “This is an Accepted Manuscript of an article published by Elsevier in Midwifery on March 2019, available at: https://doi.org/10.1016/j.midw.2018.12.001.” Challengingthestatusquo:Wwomen'sexperiencesofoptingforahomebirthinAndalucia,Spain FatimaLeon-Lariosa,⁎ [email protected] CristinaNuno-Aguilarb LuciaRocca-Ihenachoc FelipeCastro-Cardonad RamonEscuriete aNursingDepartment.,FacultyofNursing,PhysiotherapyandPodiatry,Avenzoar,6,Seville41009Spain bHospitalUniversitarioVirgendelRocío,Seville,Spain cCityUniversityofLondon,UnitedKingdom dBartsHealthNHSTrust,WhippsCrossUniversityHospital,Leytonstone,London,UnitedKingdom eMarSchoolofNursing,UniversityPompeuFabra,Barcelona,Spain ⁎Correspondingauthor. Abstract Objective Toexploretheperceptions,beliefsandattitudesofwomenwhooptedforahomebirthinAndalusia(Spain). Background HomebirthiscurrentlyanunusualchoiceamongSpanishwomen.ItisnotanoptioncoveredbytheSpanishNationalHealthServiceandwomenwhooptforahomebirthhavetopayforanindependentmidwife. Design Aqualitativestudywithaphenomenologicalapproachwasadopted.Allparticipantswhotookpartinthisstudyhadchosentohaveahomebirthandgivenwrittenconsenttotakepartinthestudy. Methods Datacollectionwasconductedin2015-–16.Face-to-face,semi-structuredinterviewswereundertakenwithwomenwhochoseahomebirthinthelast5years. Findings The sample consisted of thirteen women. Seven themes were created through analysis: 1. Getting informed about home birth; 2. Home birth as a choice, despite feeling unsupported; 3. The best way to have a personalizedandaphysiologicalbirth;4.Seekingahealingandempoweringexperience5.Theneedforemotionalsafety,establishingarelationshipandtrustingthemidwife;6.Preparingforbirthandworkingonfears;7. Inequalityofaccess(becauseoffinancialimplications). Conclusions Womenoptedtoplanbirthathomebecausetheywantedapersonalisedbirthandcontrolovertheirdecision-makinginlabour,whichtheyfeltwouldnothavebeenaffordedtotheminhospitalsettings.Andalusian maternitycareleadersshouldstrivetoensurethatallpregnantwomenreceiverespectfulandhigh-qualitypersonalisedcare,byappropriatelytrainedstaff,bothinthehospitalandinthecommunity. Keywords:Homebirth;Midwives;Privatepractice;Midwifery-ledcare;Phenomenologicalapproach;Qualitativemethodology Introduction Around4.7millionEuropeanwomengivebirtheachyear(Macfarlaneetal.,2016).Despitethestrongevidenceformidwifery-ledcareandbirthsettings(Scarfetal.,2018),mostEuropeancountriesstillofferwomenvery limitedchoiceregardingplaceofbirthandleadpractitioner,withreferraltoanobstetricunitbeingtheexpectedoption(Macfarlaneetal.,2016).InmanyEuropeancountriesobstetricunitsare,infact,theonlyavailablebirthing setting. Evidencesuggeststhatmidwifery-ledbirthsettings,suchashomeandmidwiferyunits(bothalongside(AMU)andfreestanding(FMU)),canofferhealthadvantagesforhealthywomenwithstraightforwardpregnancies,when comparedwithobstetricunits(Brocklehurstetal.,2011;NICE,2014;Borrellietal.,2017;Scarfetal.,2018).Benefitsarediverse,including:lowermaternalinterventionsassociatedwithmaternalpostnatalshort-andlong-term morbidity(Brocklehurstetal.,2011;Scarfetal.,2018),greatermaternalsatisfaction(Dahlen,2010;Overgaardetal.,2012;Macfarlaneetal.,2014a,b)andareductioninintrapartumandpostnatalcarecosts(Sandall,2013;Hodnett etal.,2010,Schroederetal.,2017). Background TheBirthplaceinEnglandStudy(Brocklehurstetal.,2011),reportedahigherincidenceofnegativeperinataloutcomesassociatedwithnulliparashavingahomebirth.Thisdifferencewasnot,however,detectedinthelarge cohortstudybyDeJongeetal.(2013)andinasystematicreviewbyScarfetal.(2018).Moreresearchisneededtostudytheimpactofmodelsofcareonthesafetyofhomebirth,asthewayinwhichmidwivesorganisetheirworkload andwhethertheyprovidecontinuityofcaremighthaveanimpactonsafety(McCourtetal.,2014).Formultiparas,theevidencesuggestsbettermaternaloutcomesforwomenplanningahomebirthandnodifferenceinperinatal outcomes(Brocklehurstetal.,2011;DeJongeetal.,2013)ascomparedwithobstetricunitbirth.The2014NICEIntrapartumGuidelines(NICE,2014)advisecliniciansinEnglandtorecommendhomebirthtohealthymultiparaswith uncomplicatedpregnancies;andmidwiferyunits(AMUandFMU)tohealthynulliparaswithuncomplicatedpregnancies. TheSpanishNationalHealthServiceonlyofferswomentheoptiontogivebirthinanobstetricunit.Womendonothaverealchoicesonplaceofbirth. HomebirthisanoptionchosenbyasmallnumberofwomeninSpainandassistedby‘matronas’,Spanishmidwives,whohaveadual-qualificationasnursesandmidwives.Asnationalroutinedatadonotcapturebirthplace,it iscurrentlydifficulttoascertainhowmanywomengivebirthathomeeveryyear.Ahomebirthassociationpublishedthatin2013,800womenhadahomebirthwhichresultedina0.2%homebirthrate.IntheSpanishregionof Catalonia,therehasbeenasubstantialincreaseinhomebirthsbyhealthprofessionals,with383homebirthsin2013(Educer,2017).ThereisalsoaguidelineabouthomebirthdevelopedbyOfficialCollegeofNursesinBarcelona,in responsetotheincreasingdemand. Incontrastwiththesenationalfigures,subnationalstatisticsofhomebirthreporta30%homebirthrateintheNetherlands(deJongeetal.,2013),arateof0.3%inAustralia(AustralianInstituteofHealthandWelfare,2015), and2.3%intheUKin2015(OfficeforNationalStatistics,2015). ThereisalackofnationalpolicyandcareprovisionbythenationalhealthserviceregardinghomebirthinSpain.Womenhavetoeitherpayaprivatefeefortheserviceorpayforprivatehealthinsurancethatcoverssome servicesofahomebirth,suchasantenataleducationorpostpartumcare,butnottheintrapartumcare. Midwiveswhopracticeprivatelyusuallyholdprofessionalindemnityinsurance,andallmidwivesemployedbyapublichospitalarecoveredbytheiremployer'sinsurance. NotallSpanishregionshavehomebirthguidelinesandtodateonlytheNursingCouncilinBarcelonahasdevelopeditsownguidancefortheentireregionofCatalonia. Thestudy Aim Thisstudyaimstoexploreperceptions,beliefsandattitudesofwomenwhoplannedahomebirthinAndalusia(Spain). Methods In this study we sought to study meanings in subjective experiences. We explored in depth the meaning that individuals attributed to their experiences. The data analysis was based on the description by Dahlberg and Drew(1997),influencedbyGiorgi'sphenomenologicalmethod(Husserl,1970;Giorgi,1985)whichfocussesonthedescriptionofaphenomenon:inthiscase,homebirthinAndalusia,Spain.Phenomenologyisaqualitativemethodof enquirythatseekstofinddeepunderstandingandmeaninginspecifichumanexperiencesorevents(Welch,2011).Wedescribedanobjectwithreferencetosubjects(womenwhoexperiencedahomebirth).Weincludedacritical reflectioninthewholeprocesstounderstandthephenomenon.Semi-structuredinterviewsweredesignedbytheresearchteambasedonpreviousliteraturepublishedinothercountries(Woodetal.,2016;Holten&Miranda,2016;Lee etal.,2016;Dahlen,2010).QuestionsincludedcanbeseeninFig.1. Reflexivityimprovesvalidityandtransparencyinresearchandcanbedescribedas‘theprocessthroughwhicharesearcherrecognises,examines,andunderstandshowhisorherownsocialbackgroundandassumptionscan interveneintheresearchprocess’(Hesse-Biber,2007).Reflexivityensuredissueswithpowerrelationsinthefieldwereaddressedandthattheresearcherswereawareoftheirpreconceivedideas.Discussionamongtheauthorshelped toaddresssomeoftheseissues.Aconsensusoninterpretationofthedatawasreachedviadiscussionsandreflections. Recruitmentandparticipants Weusedaconveniencesamplingstrategyfollowingasnowballsamplingstrategy(AtkinsonandFlint,2001).Womenwhoplannedahomebirthinlast5yearswererecruited,intotal13.Recruitmentwasundertakenthrough midwiveswhoattendedthosehomebirths.Inclusioncriteriaincludedwomenwhoconsentedtotakepartinthestudyandsignedaconsentformafterhavingreceivedcomprehensiveverbalinformationabouttheresearch.Allwomen werefluentinspeakingSpanish.TheareaofrecruitmentwasAndalusia.Allparticipantsinvitedtojoin,agreed.Thesamplesizewasdeterminedbydatasaturation. Datacollection Each participant was interviewed face-to-face by a researcher. Interviews were undertaken at the women's own homes. All interviews were recorded and transcribed verbatim to maintain participants’ anonymity and confidentiality. Interviewslasted roughlyonehour. Thesemi-structuredinterviewquestionsweredesigned,althoughbasedonpreviousresearch,bytheresearch team(Fig.1) andincludedparticipants’ sociodemographicaspects.The interviewerwasanewlyqualifiedmidwifewhodidnotparticipateinanyoftheparticipants’healthcare.InterviewstookplacebetweenOctober2015andJanuary2016.InterviewswereundertakeninSpanishandweretranslatedinto Englishafteranalysis. Ethicalconsiderations EthicalapprovalforthestudywasobtainedfromtheUniversityofSeville'sHumanEthicsCommittee.Writtenconsentwasobtainedfromparticipants,whowerefreetodeclineparticipationorwithdrawatanytime. Dataanalysis Thematicanalysiswithaphenomenologicalapproachwasusedtoanalysedataandidentifythemes.Therecordedinterviewsweretranscribedverbatim.Everyinterviewwasanalysedseparatelyforthemesandideas,the procedurewillbedescribedhereunder.Emergingthemeswerecoded.Theresearchteamdiscussedcoding,interpretationandconsistency.Afinalconsensusofinterpretationofthemeswasreached.Anumericalcodeidentifierwas usedforparticipants,inordertoguaranteeanonymity. First,adescriptivestepwascarriedoutdescribingexperiencesindetailandthescientificessencewassoughtasageneralstructureofthephenomenon(Giorgi,1997).InterviewswereinSpanishandtranslatedintoEnglish.In Fig.1Interviewguidewithmothers. alt-text:Fig.1. ordertoreducethelossofmeaningandtherebytoenhancethevalidityofcross-Englishqualitativeresearch,backtranslationtotheoriginalsourcelanguagewasundertaken.AsVanNesetal.(2010) recommends, the researcher operatedasatranslationmoderatorincooperationwithaprofessionaltranslator.Side-by-sideprocedure,inwhichtheresearcherandthetranslatordiscusspossiblewordings,wasperformed. Findings Women'sdemographicsaredescribedinTable1.Participants’medianagewas30yearsold.Theparityofparticipantsincludedsevenprimiparasandsixmultiparas.Multiparouswomenhadanobstetricunitbirthwiththeir firstbaby.Someofthemwereinastablerelationshipwiththeirpartnersandothersweresinglemothers.AllparticipantsspokeSpanishasfirstlanguageandwereofCaucasianethnicorigin.Someofthemhadpreviouslyhadahome birth.Twowomenwhoplannedahomebirthtransferredintrapartumtothelocalobstetricunit.Threehadahomebirthafteracaesareansection.EightwomenlivedinaruralareaandfiveinanurbanareainAndalusia. Table1Sociodemographiccharacteristicsofinterviewed. alt-text:Table1 Code Age Residence Education Birthat Typeofbirth E1 35 Urban HighSchool Homebirth Vaginalbirth Homebirth Vaginalbirth E2 31 Urban University Hospital C-section Home>transferredintrapartum Vacuum E3 30 Rural University Homebirth Vaginalbirth E4 29 Rural HighSchool Homebirth Vaginalbirth E5 37 Rural University Hospital Vaginalbirth Homebirth Vaginalbirth E6 31 Urban University Hospital Vaginalbirth Homebirth Vaginalbirth E7 33 Urban HighSchool Home > transferHospital Vaginalbirth E8 28 Urban HighSchool Homebirth Vaginalbirth E9 38 Rural University Hospital C-section Homebirth Vaginalbirth E10 29 Rural University Homebirth Vaginalbirth E11 39 Rural University Hospital C-section Homebirth Vaginalbirth Homebirth Vaginalbirth E12 39 Rural School Hospital Vaginalbirth Hospital C-section Homebirth Vaginalbirth E13 36 University Homebirth Vaginalbirth Homebirth Vaginalbirth Homebirth Vaginalbirth Themesthatemergedwereclassifiedinsixkeycategories.IdentifierswereusedforthequotesfollowingdescriptionshowninTable1. Gettinginformedabouthomebirth InformationabouthomebirthisnotusuallygivenouttofamiliesbycareprovidersintheSpanishNationalHealthService,sincethischoiceisnotavailablewithintheservice.Womenareusuallyinformedbyotherwomen,the internetororganisationsthatpromotealternativewaystogivebirthinSpain.Sincehomebirthisnotofferedasapublicservice,freeatthepointofdelivery,healthcareprofessionalsdonotusuallycounselwomenontheprosandthe consofthischoice.Spanishwomendonothavetodecidearoundplaceofbirthinthepublicsystem,becauseonlyobstetricunitsarereadilyavailable. “Ireceivedinformationabouthomebirthin“Birthisours”(Elpartoesnuestro)and“MilkCollective”(E2).1 “OntheInternet,Igoogledabouthomebirth,IfoundagroupinSevillewhosupportswomenwhowanttogivebirthathome”(E9). “Ihavealwaysbeensurroundedbyotherwomenwhohadabeautifulhomebirth,soIwasclearthatIalsowantedahomebirthformyfirstchild”(E7). Homebirthasachoicedespitefeelingunsupported Womenrecognisedthattheydidnotalwaysfeelsupportedbytheirfamilybecausetheythoughtthathomebirthwaslesssafethanatthehospital.Participantsfeltpressuredbytheirfamilyandfriends,buttheyfeltthattheir partnerssupportwasfundamentaltocarryonwiththeirplanstobirthathome.Beingsupportedbytheirpartnersenabledwomentofeelconfidentandincontrol. “PeopletoldusthathomebirthwasriskyanddoubtedifIwouldbecapableofit.Mypartnerwasmybestsupport”(E2). “Youhavetofeelconfidentthathomebirthiswhatyouwant,ifyoudonot,peopleblockyou”.(E11). “Everybodytriesyoutochangeyourmind.Theytellyouhowmuchriskisinvolvedwithahomebirth,thatitistheworstdecisionyoucanmakeforyouandthebaby,andthatyouwillbothdie.Myhusbanddisagreedwithahomebirthat thebeginningbutaftergettingmoreinformation,hewasmygreatsupporter”(E4). “MyparentstoldmethatmybabyandIweregoingtodie”(E3). “Nooneinmyfamilysupportedme.TheythoughtthatIwascrazy.Somefamilymemberswereupsetwithmebecauseofmychoice.Ikeptitquiet.Ijustinformedmyfamilywhenmybabywasborn”(E9). “ThesocialimageofhomebirthisnegativeinSpainsomyfamilydidnotsupportme.Theyweredrainingmypositiveenergieswiththeirnegativecomments”(E7). Onlyonewomanfeltsupportedbyherfamilydespitesomeinitialapprehension: “Myfamilywasunsupportive,buttheysawthatIwaswell-informedandthen,theysupportedus”(E6). Mostparticipantshadantenatalcareinthepublichealthcaresystem,sowhentheywereaskedaboutplansforbirthandtheytoldthecareprovideraboutthechosenoption,generally,theydidnotfeelsupported.Healthcare providersgenerallycensoredhomebirthandmadewomenfeelbadfortheirbirthchoices. “TheymademefeelthatIwasputtingmybabyatrisk.Ididnotfeelanyrapportwithmyhealthcareprofessionals,soIavoidedtellingthemmydecisionabouthomebirthwhenIattendedtheantenatalclinic”(E10). “Myparents-in-lawweregeneralpractitionersandhadattendedbirthsinruralareas,butwhenItoldthemaboutmychoiceofhomebirth,theywereagainstit”(E11). Thebestwaytohaveapersonalisedandaphysiologicalbirth Inmanycases,themotivationforahomebirthwasbasedonpreviousnegativeexperiencesofbirthoranapprehensionwiththemainstreammaternitycaremodelinAndalusia,ofteninvolvingroutineinterventionsanda generalisedlackofrespectforwomen'sautonomy.Participantsexpressedaviewofbirthasaphysiologicalprocesswhichmustnotbeinterferedwithunlessnecessary.Participantsfearedthattheywouldnotbetreatedwithrespect andthattheirautonomywouldnotberespectediftheyattendedtheirlocalobstetricunit. “Somewomen,includingme,trulythinkthatthemostphysiologicaloptionforbirthisahomebirth,becauseawomandoesnotneedanotherpersontogivebirth”(E13). “Birthisaphysiologicalprocessandwemustrespectit”(E2). “Ahomebirthempowersyourselfasawoman.Youfeelthatyoucandoitbyyourself”.(E13). “Thereisalackofhumanityandrespectforwomen”[speakingaboutmainstreamcareinobstetricunits](E1). Womencomplainedaboutthestrictprotocolsthatdisregardedpersonalisedcareinhospitals.Theyfeltthatbyoptingforahomebirth,theirautonomyandrighttochoosewouldberespected. “Protocolsdonotaccountfortheindividualityofwomen.Allwomenaredifferentandhavedifferentneedsintheirbirths”(E4). “Whenyouareatthehospital,thereareprotocolsthathealthprovidersfollowwithoutconsideringwomen'swishes.[theymightsay]Itistimetobaththebabywhilstyouareinthemiddleofbreastfeeding”(E9). “Ireadwomen'sexperiencesofhomebirthontheinternetandrealizedthatthatiswhatIwantedformybirth”(E11). Seekingahealingandempoweringexperience Participantswhohadatraumaticexperienceinapreviousbirthchoseahomebirthbecausetheywerelookingforahealingexperience.Womenmentionedthattheirnegativeexperiencewiththehealthcaresystemmotivated themtoseekotheroptions,eveniftheseoptionswerenotreadilyavailableinthepublichealthcareservice. “Myfirstbirthwashorrible.Tobeforgotten.Infact,foralongtimeIdidnotrememberthebirth.Ididnotwanttorememberit”[Firstbirthwasinanobstetricunit](E9). “Youarethere,andyouletthemtodostufftoyou…Suddenly,Ifelthowtheyopenedme,Ifeltpain…”[Firstbirthwasacaesareansection](E2). Women'sexperiencesoftheirhomebirthwerecompletelydifferentandhadapositiveimpactintheirmemories.Insomecases,theysubsequentlyoptedforanotherhomebirthforthefollowingpregnancy. “Fromeverypointofview,itwasspectacular.Icantellyouthatthesensationofgivingbirthathome,theself-confidenceofgivingbirththere….youdonotfeelstressedorscared”(E5). “Ilikedit.Theyrespectedmyintimacy,theyweretherebutrespectingmyspace”[inreferencetomidwiveswhoattendedherbirthathome](E3). Theneedforemotionalsafety,establishingarelationshipandtrustingthemidwife Whenwomenwereaskedaboutthephilosophyandskillsthatcareprovidersmusthave,womenemphasised“empathy”and“worthy”asveryimportantattitudes.Womenratedhigheracompassionateattitudethanahighly qualifiedprofessional(doctor).Womenconsideredmidwivestobefullyskilledandqualifiedtoattendbirths,buttheyalsoexpectedthemtohaveotherabilities,suchasempathy,compassionandafriendlyattitude. “Beingempathetic[inreferencetomidwives].Theyneedtoberespectful,tolistentowomenandtheirpartner.Theyneedtoknowwhentolead,becauseiftheylosecontrol,womenwilldoaswell.Theyhavetocalmwomen,containtheir fear”(E12). “WhenIcontactedthemidwife,Ihadnotdecidedforahomebirthyet,IcontactedherbecauseIwantedtohavearespectfulbirth,withoutepiduralanalgesia,andIwantedapersonwhorespectedthat.IknewthatIwasnotgoingtofind ahealthcareprofessionalwhorespectedmeinthisway[atthehospital]…”(E1). “Ineededcalmness,Ineededapersonwhopassedontomeasenseoftrust,respectandlove”(E10). “Empathyandrespectarefundamental”(E11). “Ineedtotrustmymidwife;IwanthertobemysupportwhenIfeelweak.ShehasmytrustandIputmyselfinherhands”(E7). “Theymustknowhowtobe…bequiet,butpayingattentiontoeverything.Theycannotprojecttheirfear,theymustbeacompanion.Theymustidentifyifrisksariseandaskforhelpifthingstakeawrongturn,”(E6). Womenwhohadtobetransferredintrapartumdeclaredexperiencesofdisrespectfultreatmentreceivedbysomecareproviders.Theyfeltjudgedbecauseoftheiroptionofahomebirth. “Theyaskedme:‘areyoucomingfromahomebirth?Well,donotcomplainsomuch.’Shewassorude!”[thehealthcareprofessional](E7). Preparingforbirthandworkingonfears Womenwhohadahomebirthreportedagoodexperienceandmostofthemwouldrecommendit,butweobservedthatwomenidentifiedthatnoteveryoneispreparedtohaveahomebirth.Theyconsidereditveryimportantto workonfears.Participantshighlightedthattogivebirthathome,womenneededtopreparephysicallyandmentally. “Yes,Iwouldrecommenditifawomanisreadyforit.Shehastoworkonherfears”(E2). “IfIseethatawomanisinterestedinitandsheshowsmeinterest,Iliketoencourageher”(E6). “Iwouldrecommendit,butawomanhastoworkonherfearandconfidence.Irecommendit,butIamalsoveryrespectfulofotherwomen'schoices,becauseitisanintimateandpersonaldecision”(E13). Inequalityofaccess(becauseoffinancialimplications) Womenrecognisedthathavingtopayforahomebirthprivatelyisexpensiveincomparisontohospitalbirthandnotaffordableforeveryone.Theystatedthatitshouldbeincludedinthepublichealthcaresystemprovision. “Iwouldrecommendhomebirthtoanyoneifitwasapublicly-fundedoption,becausenotallwomencanaffordit”(E5). “Idonotunderstandwhyitisnotanavailablechoiceforwomen,becauseIthinkthatitischeaperforthehealthcaresystem”(E6). “Notallwomencanaffordaprivatemidwife(…).Itshouldbeafreeoption”(E7). WomenreportedthattheywouldliketohavemorebirthplaceoptionsavailableinSpain,includinginhospitalandathome. “Iwouldrecommendahomebirthbecauseitisthemostphysiologicalwayofgivingbirth(…).Iwishwewouldhaveotherplacesofbirthavailable,apartfromourhouses,forexample,birthcentresoraspaceinthehospitalwithoutmany medicalinterventions”(E7). Discussion Ouraimwastoexploretheperceptions,beliefsandattitudesofwomenwhoplannedahomebirthinAndalusia,Spain.Wereachedsaturationat13interviewsandweidentified7themes.Theimplicationsforpolicyand practicearecentredonhowtochallengethestatusquo,whichislinkedtoempowermentandself-determinationinthewomenandtheneedforachangeincareproviders’attitudes. Challengingthestatusquo Thedataclearlysuggestedthatthenationalhealthcaresystemdidnotofferorsupportalternativebirthplaceoptions,butalsoactivelydiscouragedhomebirthasachoice.Womenhadtodemonstrateastrongself-confidence tooptforahomebirthagainsthealthcareprofessionals’,familyandsocietalviewsofbirthasa‘riskyprocess’.Thisviewofbirthoutsidehospitalas‘deviant’andriskyismatchedbyawideinternationalliterature(Hunter, 2003; Schuster,2006;Deeryetal.,2007,2010;Stone,2012;Ranzcog.edu.au.2017). Womenplanningtogivebirthathomeoftendescribedalackofsupportbytheirfamily.Womenhadtogatherinformationabouthomebirthina‘covertmanner’andavoiddiscussingwithhealthprofessionalsfromthepublic servicestoavoidfeelingjudged. Havingpeersupportfromotherwomenwhohadahomebirthalsoempoweredparticipantstofeelconfidenttogivebirthathome,despitewidersocietalnegativeattitudes.Thesefindingshighlighttheneedfornationalpolicy tosupportwomen'schoicesofbirthplaceandtoleadthewayforaculturalshiftincareprovidersaswellasinthepublic. Empowermentandself-determination Birthplacedecision-makingwasinfluencedbytheconstructofsafety,riskandself-confidenceandthiswasconsistentwithfindingsbyGriggetal.(2015).Womenwhofeltasupportivephysicalandemotionalenvironmentmade autonomousdecisionsbasedontheirpersonalneeds(Woodetal.,2016). Dahlenetal.(2010)foundthatwomenwhochoseahomebirthweremorewillingtotakeresponsibilityfortheirpregnancy,labourandbirthwhencomparedwithwomenwhooptedforabirthinanobstetricunit,wherethe responsibilityforthedecision-makingisdevolvedtohealthcareprofessionals. GivingbirthathomeinSpainwasaconsciouschoice,asitwasnecessarytoseekacareprovidertofindtherightmidwife.Thisfindingwasthisinlinewithotherstudies.Onlyempoweredwomenoptedforhomebirths(Regan etal.,2013;LindgrenandErlandsson,2010). Manyparticipantswhogavebirthtopreviousbabiesinhospitaloptedforahomebirthinsearchofahealingexperience.Manywomenweretraumatisedduringaprevioushospitalbirthandthisencouragedthemtooptfora homebirth.Similarly,widerinternationalevidencepointstowardswomenhavinghomebirthsbecausetheyperceivethehospitalasathreat(Jacksonetal.,2012;Dahlenetal.,2010). Thewomeninthisstudyreportedreasonsforoptingforahomebirthwhichwereconsistentwithotherstudies:continuityofcarer,avoidingamedicalmodelofchildbirthandseekingadifferentatmosphereandenvironmentto the obstetric unit(Grigg et al., 2015). In our study the rejection of the biomedical model was a common theme that emerged as women's motivation to birth out of the hospital setting. Dahlen et al. (2010) as well as Feeley and Thomson(2016)reportedthatamedicalisedcareapproachwithroutineinterventionscontributedtowomen'slackofsatisfactionwithpreviousbirthsandtothedrivetoseekalternativebirthplacesforsubsequentpregnancies.Women whohadahomebirthfeltthattheywerenotboundtoabiomedicalmodelofcare,whichwasthenormatthehospital(Lawsetal.,2011). All participantsin thisstudy agreedthat they did not want to besubjectto routine procedures and to be treated in an impersonal manner with disregard for theirhumanrights of autonomy and self-determination. In accordancewithwiderinternationalresearchfindings,ourresearchrevealedthatwomenwantedanapproachtocarethathospitaldidnotprovide,includingwomen-centredcontinuityofcare(McWhirter,2017;HoltenandDeMiranda, 2016;Borrellietal.,2017).Similarly,Walsh(2006)foundthatwomenwhopreferredhomebirthwantedtoavoidinterventionsandfeltmostrelaxedintheirhomeenvironment. Womeninourstudyfeltautonomousandexperiencedahighdegreeofprivacy,self-determinationandintimacyathome.Theparticipantswhooptedforandhadahomebirthdescribedtheexperienceasextremelypositiveand empowering.ManyofthemexpressedstrongopinionsregardingtheneedtohavebirthplacealternativestothehospitalobstetricunitandbelievedthathomebirthandmidwiferyunitsshouldbepartoftheSpanishNationalHealth Service.Twofindingsfromourstudyareconsistentwithotherpublishedliterature:ahigherlevelofeducationamongthegroupofwomenwhochosetobirthathome(Steeletal.,2015)andhighlevelofsatisfactionwiththecare receivedwhilehavingahomebirth(Hitzertetal.,2016). Theneedforachangeincareproviders’attitudes Thefindingssuggesttheneedforashiftincareprovider'sattitudestowardscare,powerrelationsandwomen'sautonomy.Allwomendescribedthephilosophyandattributes,whichtheyexpectedintheirbirthattendantas beingempathetic,abletoestablishrapportandsuggestingasenseoftrustworthiness,whichmadethemfeelsafe.Safetyforparticipantsmeantbothphysicalandemotionalsafety.Rocca-Ihenacho(2017)reportssimilarfindingsinher ethnographicstudyofanFMUinEnglandandthewiderinternationalliteraturehasalignedfindings(Schuster,2006;Stone,2012). Womeninthisstudydidnotfeelthatthehospitalofferedanenvironmentconducivetoaphysiologicalandundisturbedbirth.Thisisinlinewithotherstudieswhichreportapositiveinfluenceofthefamiliarenvironmentat home(BorquezandWiegers,2006)andwomenreportingabetterbirthexperience(Hitzertetal.,2016).Careprovidersneedtrainingtobeabletoofferpersonalisedcarewhichistailoredaroundwomen'sneedsandfocusedonfacilitating anundisturbedbirth(Rocca-Ihenacho,2017).Thewaycareprovidersarrangetheenvironmentandareabletorespondtowomen'sneedsiscrucialforafeelingofsafetyandasenseofcontrolbythewoman(Woodetal.,2016).Training inlegislationaroundfacilitatinginformedchoicesandwomen'sautonomyisessentialastheevidencesuggeststhatcareproviderslackanunderstandingoftheirroleandresponsibilities(Kruskeetal.,2013). Limitations ThisresearchislimitedtowomenfromasmallareaofSpain,inAndalusia.Serviceusersandthepublic(PPI)werenotinvolvedintheplanning,datacollectionandanalysisandwereonlyincludedasparticipants. Conclusion WomenwhooptedforahomebirthclearlyexpresseddissatisfactionwiththecareofferedaspartoftheSpanishNationalHealthServiceinhospitals.Incontrast,theywantedtohavepersonalisedbirthsandcontroloverthe decision-makinginlabour,whichwerenotofferedtotheminhospitalsettings. ThisstudysuggeststhatthereisaneedforclearnationalpolicyregardingbirthplaceandinformationdirectedtothepubliconhomebirthandmidwiferyunitsinSpain.Women'sexperiencesofhospitalbirthindicatean urgentneedfortrainingonpersonalisedcareandhumanrightsinhospitalsettings.Professionalbodiesandassociationsaswellaswomen'srepresentativegroupscouldbecomeinstrumentalinimplementingevidenceonbirthplacein Spainandfacilitatingashiftinpublicperception. Ethicalapproval UniversityofSeville.