The safety of selected birth locations according to women and men

● JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE ● No.2/2016 ●
● JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE ● No. 2/2016 (45-50)
●
The safety of selected birth locations according
to women and men
(Bezpieczeństwo wybranych miejsc porodu w opinii kobiet i mężczyzn)
G Iwanowicz-Palus 1 A,D,E,F, , M Król 2 A,B,C,D
Abstract – Introduction. The birth of a child is an important event
in the parents’ life, and therefore the high quality of birth is crucial. The vision of giving birth at a chosen location is often obscured by concerns about potential complications. Research on
out-of-hospital birth safety demonstrates that the risk is not any
higher than in hospital provided that the woman is with
a low-risk pregnancy and that the parents, place of birth and
equipment have been prepared properly. The purpose of this
study is to learn about the opinions of women and men concerning the safety of selected birth locations.
Materials and methods. The study has been conducted using the
diagnostic survey method with the application of the author’s
own survey questionnaire in the period from October 2011 to
April 2012, among 217 women and men inhabiting centraleastern Poland.
Results. As a result of the study conducted, a statistically significant correlation has been established between the opinion on the
safest birth location and age, education and maternal experience.
According to the respondents, the possibility of taking life-saving
actions and monitoring the well-being of the foetus exists, above
all, in a hospital setting and at a birth centre.
Conclusions. In the opinion of the women and men taking part in
the study, the safest birth setting is the hospital. Moreover, the
study has revealed a positive attitude of the respondents towards
midwife-led birth centres. A comprehensive approach to perinatal
care is necessary, in which the key role is played by natural birth
without fears of pain and complications, and where safety and joy
of childbirth would not be mutually exclusive.
Materiał i metody. Badania przeprowadzono metodą sondażu
diagnostycznego przy użyciu autorskiego kwestionariusza ankiety
w okresie od października 2011 do kwietnia 2012 roku, wśród
217 kobiet i mężczyzn z regionu Polski środkowo-wschodniej.
Wyniki. W wyniku przeprowadzonych badań stwierdzono istotną
statystycznie zależność pomiędzy opinią na temat najbezpieczniejszego miejsca porodu, a płcią, wiekiem, wykształceniem i
doświadczeniem macierzyńskim. W opinii respondentów możliwość podjęcia działań ratujących życie oraz czynności z zakresu
monitorowania stanu płodu istnieje przede wszystkim w szpitalu
oraz w domu narodzin.
Wnioski. Według kobiet i mężczyzn biorących udział w badaniach najbezpieczniejszym miejscem porodu jest szpital. Ponadto
badania pokazują pozytywne nastawienie ankietowanych do domów narodzin prowadzonych przez położne. Konieczne jest holistyczne podejście do opieki okołoporodowej, w której kluczową
rolę odgrywać będzie poród w zgodzie z naturą, bez obaw przed
bólem i powikłaniami, a bezpieczeństwo i radość rodzenia nie
będą wzajemnie się wykluczać.
Słowa kluczowe - bezpieczeństwo, poród, miejsce porodu.
Author Affiliations:
1.Independent Unit of Midwifery Skills at the Faculty of
Health Sciences of the Medical University of Lublin
2. Member of the Student Research Club at the Independent
Unit of Midwifery Skills of the Medical University of
Lublin
Key words - safety, birth, birth location.
Authors’ contributions to the article:
Streszczenie – Wstęp. Narodziny dziecka są znaczącym wydarzeniem w życiu rodziców, dlatego ważna jest ich wysoka jakość.
Wizję porodu w wymarzonym miejscu przysłaniają często obawy
o możliwość wystąpienia komplikacji. Wyniki badań dotyczących
bezpieczeństwa porodu w warunkach pozaszpitalnych wykazują,
że nie występuje ryzyko większe niż w szpitalu, w przypadku gdy
kobieta jest w ciąży niskiego ryzyka oraz dokona się właściwego
przygotowania rodziców, miejsca narodzin i zaplecza sprzętowego. Celem prowadzonych badań było poznanie opinii kobiet i
mężczyzn na temat bezpieczeństwa wybranych miejsc porodu.
A. The idea and the planning of the study
B. Gathering and listing data
C. The data analysis and interpretation
D. Writing the article
E. Critical review of the article
F. Final approval of the article
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Correspondence to:
Prof. Grażyna Iwanowicz-Palus MD, PhD Independent Unit
of Midwifery Skills at the Faculty of Health Sciences of the
Medical University of Lublin, Staszica 4-6 Str., PL-20-081
Lublin, Poland, e-mail: [email protected]
Accepted for publication: March 18, 2016.
I. INTRODUCTION
hildbirth is an important event for the parents and a
breakthrough in their personal life. They wish for their
physical, mental and spiritual needs to be appreciated.
Women want to be treated with due respect, and therefore
they demand an individual and respectful approach from
the healthcare workers as well as free choice and the possibility to make decisions about themselves. The vision of a
comfortable childbirth at a place of choice is often obscured by concerns that complications may occur in labour,
which has a significant influence on the selection of the
birth setting [1-3].
The results of research conducted in the scope of assessing
birth safety in a non-hospital setting demonstrate that the
risk is not any higher than in the case of childbirth in hospital. However, specific criteria must be met; namely, the
woman must be with a low-risk pregnancy and it is crucial
that a specialist should qualify the candidates properly beforehand, which significantly minimizes the risk of impairing the health of the mother or child. In addition, the woman should maintain a good psychophysical condition, be
subject to medical control and undergo the medical examinations recommended in pregnancy [4-9].
Childbirth should be planned properly. The delivery must
be conducted by a competent, experienced and qualified
person possessing the necessary equipment and cooperating
with other specialists. Appropriate organizational conditions must be ensured which include securing and preparing
the birthplace and providing the possibility of transferring
the mother and newborn to hospital in emergencies. Moreover, it is necessary to furnish the parents with the necessary knowledge – the midwife should inform them about
the proper conditions and course of labour [6,7,10 -13].
The Regulation of the Minister of Health of 20 September
2012 specifies the standards of conduct and medical procedures when providing health services in perinatal care of a
woman in the period of physiological pregnancy, physiological labour, postpartum period and neonatal care. The
determination of particular elements of perinatal care has
C
the objective of maintaining the well-being of the mother
and limiting the scope of medical interventions to the minimum. The above-mentioned standards should be applied in
each birth location selected by the woman in labour – both
in hospital (public and private) as well as at home and at
the birth centre run by midwives. The implementation of
patient’s rights in the scope of care of women in pregnancy
and labour comprises, among others, respecting her right to
make decisions related to the tasks and activities during
delivery, the option to choose a midwife or physician exercising care and the right to choose the birthplace [9].
The Polish people have become accustomed to the idea that
childbirth may take place in hospital only, and therefore
there has been a long-standing debate on the safety of giving birth in an out-of-hospital setting. Also, ever more frequently the issue of comprehensive care of the woman and
child is discussed, which is composed, among others, of the
sense of autonomy in choosing the place of childbirth [14].
The purpose of this study is to learn about the opinions of
women and men concerning the safety of selected birth
locations.
II.
MATERIALS AND METHODS
The study was conducted in the period from October
2011 to April 2012 among 217 women and men inhabiting
central-eastern Poland. The study has been conducted using
the diagnostic survey method with the application of the
questionnaire technique. The research tool was the author’s
own survey questionnaire applying a Likert scale, concerning the subject of the study and covering the characteristics
of the participants. The respondents were informed about
the voluntary and anonymous nature of their participation
in the study and that the information obtained would be
used solely for scientific purposes.
The database and statistical research have been executed
based on STATISTICA 10.0 software (StatSoft, Poland).
The values of the measurable parameters analysed have
been presented using the mean value, median and standard
deviation, and for non-measurable parameters – using numerical amount and percentage. For measurable features,
the normality of distribution of the parameters analysed
was assessed using the W Shapiro-Wilk test. In order to
compare two independent groups, the U Mann-Whitney test
was selected, and for more than two groups, the KruskalWallis test was used. For the assessment of correlation between the variables, the Spearman’s R correlation test was
used; the chi-square test of homogeneity was used for unrelated qualitative parameters in order to detect differences
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between the groups compared, whereas the chi-square test
of independence was used to investigate the correlation
between the parameters analysed. The significance level
adopted was p<0.05.
The majority of respondents were women (72.35%), young
people aged 25 or less (54.38%), people with a secondary
education or a lower level of education (43.31%), inhabitants of the provincial capital (37.33%), single respondents
(62.67%), individuals without any maternal experience
(63.59%), and students (53.46%), (Table 1).
Table 1. Socio-demographic data of the study group
Socio-demographic data
Female
Male
Sex
N
157
60
31.34
23.04
25.81
19.81
Provincial capital
Another city
Village/settlement
81
74
62
37.33
34.10
28.57
Education
Elementary/secondary
Post-secondary
Higher vocational
Higher master’s degree
94
27
46
50
43.31
12.44
21.21
23.04
Civil status
Single
Married
136
81
62.67
37.33
Yes
No
145
72
66.82
33.18
Maternal experience
III.
Statements
Public
hospital
Private
hospital
Birth
centre
Home
Definitely yes
45.16%
64.06%
32.72%
6.91%
Rather yes
41.01%
25.35%
35.02%
18.43%
I have no
opinion
6.91%
5.53%
21.66%
29.95%
Rather no
5.99%
3.23%
9.68%
28.11%
Definitely not
0.92%
1.84%
0.92%
16.59%
72.35
27.65
68
50
56
43
Place of residence
Alternative birth locations
%
<20
21-25
26-40
>40
Age
Table 2. Respondents’ opinion on the safest conditions for
childbirth
RESULTS
According to the respondents, the best conditions for
childbirth by all means were in a private hospital (64.06%),
then in a public hospital (45.16%), and a birth centre run by
midwives is regarded similarly (35.02%). In turn, almost
one-third of the respondents (29.95%) did not have an
opinion on the safety of their own homes (Table 2).
As a result of the research conducted, a statistically significant correlation has been established between the opinion
regarding the safest birth location and sex, age, education
and maternal experience. Respondents declaring willingness to give birth at a public hospital were convinced to a
significantly greater degree than respondents wishing to
give birth at a private establishment or in a non-hospital
setting that a public hospital (p<0.000001), birth centre
(p=0.007) and a private hospital (p=0.03) were the safest
places for childbirth. A person’s own home is the safest
birth location for the group of respondents with postsecondary education (p=0.03) and for persons with maternal experience (p=0.04). The male respondents were more
convinced that the safest place of birth was hospital (public
p=0.02) and a birth centre (p=0.002). A similar belief was
held by people aged under 20 (public hospital p=0.03 and
private hospital p=0.0001; birth centre p=0.0001) and by
respondents with an elementary/secondary education (public hospital p=0.0002; private hospital p=0.006; birth centre p=0.0001), (Table 3).
In the respondents’ opinion, the possibility of taking lifesaving actions definitely exists at a public hospital
(75.12%) and at a private hospital (75.12%), and it rather
does at a midwife-led birth centre (34.10%). In turn, actions in the scope of monitoring the foetal well-being
(CTG, foetal Doppler) may definitely be taken at a public
hospital (76.04%), private hospital (77.88%) and birth centre run by midwives (45.62%). According to one-third of
the respondents, a person’s own home rather does not allow
for taking life-saving actions (32.26%) or actions in the
scope of monitoring the foetal well-being (31.80%), (Table
4).
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1.78
3.33
1.00
1.00
4.00
St. dev.
0.79
0.78
0.99
1.11
Z
2.39
1.75
3.16
-0.38
0.02
0.08
0.002
0.70
1.50
1.22
1.50
3.35
Median
1.00
1.00
1.00
3.00
St. dev.
0.66
0.59
0.84
1.10
Mean
1.90
1.56
2.44
3.44
2.00
1.00
2.50
3.00
St. dev.
0.97
0.88
0.93
1.18
21-25
p
Mean
1.98
1.66
2.55
3.29
2.00
1.00
2.00
3.00
St. dev.
1.05
1.07
0.99
1.16
Mean
1.74
1.84
2.12
3.02
Median
2.00
2.00
2.00
3.00
St. dev.
0.79
0.87
0.88
1.18
Z
8.75
20.57
48.28
2.72
>40
elementary
/second
ary
postsecondary
master’s lbachelor’s
no
yes
Public
hospital
Private
place
Analysis
Analysis
p
0.03
0.0001
0.0001
0.43
Mean
1.50
1.31
1.64
3.13
Median
1.00
1.00
1.00
3.00
St. dev.
0.67
0.66
0.85
1.12
Mean
1.63
1.59
2.19
3.04
Median
1.00
1.00
2.00
3.00
St. dev.
0.93
0.93
0.92
1.19
Mean
2.07
1.70
2.59
3.67
Median
2.00
1.00
3.00
4.00
St. dev.
1.02
1.03
1.07
1.16
Mean
2.06
1.78
2.52
3.38
Median
2.00
1.50
2.00
3.50
St. dev.
0.96
1.00
0.86
1.12
Z
20.04
12.37
43.96
8.98
p
0.0002
0.006
0.0001
0.03
Mean
1.71
1.39
2.02
3.42
Median
2.00
1.00
2.00
3.00
St. dev.
0.82
0.75
0.99
1.11
Mean
1.88
1.83
2.29
3.03
Median
2.00
2.00
2.00
3.00
St. dev.
1.02
1.05
1.01
1.20
Z
-0.70
-3.05
-1.80
2.07
p
0.49
0.002
0.07
0.04
Mean
1.97
1.61
2.22
3.40
Median
2.00
1.00
2.00
3.00
St. dev.
0.85
0.89
0.91
1.09
Mean
1.38
1.39
1.91
3.08
Median
1.00
1.00
1.00
3.00
St. dev.
0.84
0.86
1.14
1.25
Z
5.56
2.19
2.70
1.66
p
0.000001
0.03
0.007
0.10
Monitoring of foetal
well-being
1.37
1.00
Life-saving actions
1.53
Monitoring of foetal
well-being
Mean
Median
Assessment of the possibility of monitoring the foetal well-being and taking lifesaving actions
Alternative birth locations
Public hospiPrivate hospiBirth centre
Home
tal
tal
Life-saving actions
1.17
Monitoring of foetal
well-being
0.98
Life-saving actions
0.91
Mean
Age
Education
0.91
3.27
3.00
Median
Analysis
Maternal experience
St. dev.
Home
Median
Analysis
Declared birth location
Mean
Median
26-40
<20
Analysis
Alternative birth locations
Private
Birth
hospital
centre
1.60
2.24
1.00
2.00
Public
hospital
1.85
2.00
Monitoring of foetal
well-being
M
Sex
F
Variables
Table 4. Respondents’ opinion on the possibility of taking
life-saving actions and monitoring the foetal well-being
depending on the birth location
Life-saving actions
Table 3. Assessment of the safety of selected birth locations considering selected variables
Definitely
yes
75.12
76.04
75.12
77.88
32.72
45.62
6.45
21.20
Rather yes
22.12
18.89
20.74
16.59
34.10
26.73
18.8
11.52
I have no
opinion
1.84
3.69
3.23
4.15
23.04
23.50
24.88
24.42
Rather not
0.92
0.92
0.92
0.92
7.37
3.23
32.26
31.80
Definitely
not
0.00
0.46
0.00
0.46
2.76
0.92
17.51
11.06
Statements
(%)
IV. DISCUSSION
Childbirth is considered to be one of the most important
events in the parents’ life, and therefore it is crucial that its
quality should be proper. Safety is the main criterion for the
high quality of care of a mother-to-be and her newborn [1].
The results of research in the scope of assessing the safety
of birth at home indicate that when childbirth is properly
prepared and conducted, the risk is not any higher than in
hospital conditions [4,5]. The British Medical Journal has
presented the results of an analysis carried out by Ackermann-Liebrichet et al. [4] in the years 1989-1992 on two
groups of women – one declaring eagerness to give birth at
home and another being proponents of hospital delivery. As
a result of the study, it has been found that in the case of
women with low-risk pregnancies, delivery out of hospital
does not contribute to the increased possibility of complications and risk to the health of the mother and child [3,12].
De Jonge et al. [16] published one of the most extensive
results of a cohort study covering 529,688 low-risk births.
The study group comprised women under midwife-led care,
from whom 60.70% planned childbirth in a home setting,
whereas 30.80% wished to give birth in hospital. In the
analysis of complications, taken into consideration were
intranatal mortality rates and neonatal mortality rates in the
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first day and week of life, maternal mortality rates and the
index of admissions to neonatal intensive care units. The
research has not demonstrated significant differences between childbirth at home and hospital delivery. On that
basis, it has been concluded that the place of birth does not
impact perinatal mortality rates [16]. Furthermore, research concerning the quality of care, conducted by Wiegers et al. using the Perinatal Outcome Index tool, has shown
that among women with a normal course of pregnancy, the
health risk associated with delivery planned in hospital and
at home was similar [17]. In the conclusion of the metaanalysis of research carried out by Olesen, which jointly
concerned over 24,000 pregnant women, it has been found
that childbirth out of hospital is an alternative acceptable
for selected women [18].
In turn, the research of Dziedzic et al. among Polish midwives revealed that 50.00% of them considered home births
to be safe. 16.45% of the respondents believed the opposite. The remaining part of midwifes did not express an
opinion on that issue [15].
However, according to the respondents involved in the present study, the safest conditions for childbirth existed in
hospital (private – 89.41%; public – 86.17%) and at midwife-led birth centres (67.74%). As far as birth at one’s
own home is concerned, the respondents failed to provide
an opinion (29.95%) or they claimed that it was not a place
safe enough (44.70%).
A midwife conducting birth out of hospital cooperates with
other specialists and institutions and consults them to a
relevant degree. The specialists and institutions comprise –
a gynaecologist/obstetrician, neonatologist/paediatrician,
hospital, laboratory, intranatal medical transport service
and other [12,13]. The midwife providing care to a woman
giving at home is obliged to possess an appropriately
equipped community midwife bag including an anti-shock
kit, equipment for measuring the vital signs, a foetal Doppler, disposable materials for injections, liquid transfusions
and dressings as well as other materials enabling the proper
care of the mother-to-be and infant [11,13]. The present
study has revealed that the respondents are not aware of the
fact that the midwife in charge is obliged to have the appropriate equipment not only in hospital but also in a home
setting. When asked whether it was possible to use CTG or
a foetal Doppler in each of the alternative birth locations,
the respondents univocally believed that only a public hospital (94.93%), private hospital (94.47%) and a birth centre
(72.35%) provided such conditions. The respondents expressed a similar opinion on the possibility of taking lifesaving actions (yes: public hospital – 97.24%, private hos-
pital – 95.86%, birth centre 66.82%, no: family home –
49.77%).
Midwives involved in out-of-hospital care of women in
labour are not against medical technology in the event that
a relevant intervention is necessary and they do not negate
the need to apply it in practice. However, they do not favour the medicalisation of maternity as well as abusing and
routinely executing certain operations (e.g. episiotomy,
labour induction). Above all, their efforts are based on preventing undue risk, which is why the criteria for nonhospital childbirth have been established – a strict classification and suitable standard of care of the mother-to-be,
taking into account when and how to intervene if complications occur [19].
In the second half of the 20th century, the Polish society, as
opposed to the German people, the British and the Dutch,
became unaccustomed to giving birth in out-of-hospital
settings. As many as 99% of Polish women give birth in
hospital where specific medical interventions are used (also
routinely), even though statistically ca. 80% of deliveries
happen unaided and without any complications [10,20].
Polish perinatal care is still a long way from the western
standards, yet in some establishments tentative steps have
already been taken towards altering the attitude to physiological labour. Gradually, interest is being taken in the foreign systems of independent midwives, which in addition to
granting professional autonomy to the midwives themselves, provide women with a sense of support and safety
associated with pregnancy, labour and maternity [21].
V. CONCLUSIONS
 According to the respondents, the safest place of
childbirth is the hospital.
 The study conducted demonstrates a positive
attitude of the society to midwife-led birth centres.
Such places, as an alternative to hospital, have
been considered safe for the mother and child not
only by the general public but also by individuals
declaring willingness to give birth at a public
hospital.
 It is necessary to strive for comprehensive perinatal
care, in which the key part will be played by
natural birth without fears of pain and
complications, and where safety and the joy of
childbirth will not be mutually exclusive.
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