Nurse-Midwives Experiences with Planned Home Birth: Impact on Attitudes and Practice

Transcription

1 274 BIRTH 36:4 December 2009 Nurse-Midwives Experiences with Planned Home Birth: Impact on Attitudes and Practice Saraswathi Vedam, RM, CNM, MSN, SciD(h.c.), Kathrin Stoll, MA, Sarah White, FNP, MSN, Jessica Aaker, CNM, MSN, and Laura Schummers, BSc ABSTRACT: Background: Health care providers attitudes toward maternity care options influence the nature of informed decision-making discussions and patient choice. A woman s choice of birth site may be affected by her provider s opinion and practice site. The objectives of this study were to describe American nurse-midwives attitudes toward, and experiences with, planned home birth, and to explore correlates and predictors of their attitudes toward planned home birth as measured by the Provider Attitudes towards Planned Home Birth (PAPHB) scale. Methods: A survey instrument, which incorporates the PAPHB and assesses demographic, education, practice, personal experience, and external barrier variables that may predict attitudes toward planned home birth practice, was completed by 1,893 nursemidwives. Bivariate analysis identified associations between variables and attitudes. Linear regression modeling identified predictors of attitudes. Results: Variables that significantly predicted favorable attitudes to planned home birth were increased clinical and educational experiences with planned home birth (p < 0.001), increased exposure to planned home birth (p < 0.001), and younger age (p < 0.001). External barriers that significantly predicted less favorable attitudes included financial (p = 0.03) and time (p < 0.001) constraints, inability to access medical consultation (p < 0.001), and fear of peer censure (p < 0.001). Willingness to practice in the home was correlated with factors related to nurse-midwives confidence in their management abilities and beliefs about planned home birth safety. Conclusions: The results suggest that nurse-midwives choice of practice site and comfort with planned home birth are strongly influenced by the nature and amount of exposure to home birth during professional education or practice experiences, in addition to interprofessional, logistic, and environmental factors. Findings from this research may inform interdisciplinary education and collaborative practice in the area of planned home birth. (BIRTH 36:4 December 2009) Key words: attitudes, home birth, maternity care providers, midwifery, nurse-midwives, psychometrics Availability of choice and self-determination are core values in contemporary health care discourse. Global communication has enhanced public awareness of evidence-based maternity care options, including planned home births. In the medical literature, planned home birth refers to delivery by qualified birth Saraswathi Vedam is Associate Professor and the Director of the Division of Midwifery; Kathrin Stoll is the Research Manager; Laura Schummers is a Research Assistant with the Division of Midwifery, Department of Family Practice, at the University of British Columbia, Vancouver, Canada; Jessica Aaker is a Certified Nurse-Midwife on extended international leave; and Sarah White is a Family Nurse Practitioner at East Bay Family Practice in Oakland, California, USA. This study was initiated at Yale School of Nursing, New Haven, Connecticut, USA. The work was completed with the support of research funds from the Faculty of Medicine at University of British Columbia, Vancouver, British Columbia, Canada. Address correspondence to Saraswathi Vedam, RM, CNM, MSN, SciD(h.c.), Director, Division of Midwifery, Department of Family Practice, University of British Columbia, B Health Sciences Mall, Vancouver, BC, Canada V6T 1Z3. Accepted June 14, , Copyright the Authors Journal compilation 2009, Wiley Periodicals, Inc.

2 BIRTH 36:4 December attendants in the home setting. These births are planned during the prenatal course, when the women have met screening criteria for low perinatal risk. Standard labor and delivery equipment and medications, access to hospitalization, and physician consultation when necessary are included in the delivery plan. Public health care evaluations note safety, costeffectiveness, and improved resource allocation when normal birth occurs outside the hospital (1 9). Reports of demand for, and maternal response to, home birth indicate sustained public interest and high client satisfaction (10 18). Expert advisory panels in several nations recommend that home birth maternity services and informed choice of birth place be made available (19 24). However, in most developed nations, maternity care practitioners seldom provide intrapartum care in the home. Debate among maternity health care professionals and consumers about the advisability of planned home birth continues in the professional and lay literature (25). Women can only exercise the right to choose a birth place if they are offered a range of settings and have access to qualified providers in each setting. Provider Attitudes and Women s Choice The attitudes of medical providers toward maternity care options have been shown to influence the nature of informed decision-making discussions and women s choices (13,26 34). Home birth rates differ according to practitioner and may represent differences in his or her attitudes, practice setting preferences, or both. The recent government recommendations to offer a choice of birth site to all women in the United Kingdom (35) did not uniformly increase access to planned home birth. Changes in out-of-hospital birth rates were regionally differentiated (36,37), and many women were not offered a choice of birth site at all, leading researchers to suggest that care practitioners attitudes, resource availability, and community standards may influence the birth site options offered to women (35 37). In the Netherlands, where midwifery is the standard of care for lowrisk women, approximately 35 percent of all babies are born at home with midwives who practice in the context of endorsement and structural supports from the health care sector (7,14,38). In the United States, where professional bodies differ sharply on the appropriate settings for birth (19,21,25,39), planned home births represent less than 1 percent of all births (15). Measuring Attitudes toward Planned Home Birth Studies of provider attitudes with respect to home birth are scarce, and none used a quantitative instrument with validated psychometric properties to assess attitudes. In 1995, Floyd published a qualitative assessment of opinions and experiences with home birth among midwives in the United Kingdom (40). Factors that contributed to positive opinions were midwives experience with home birth, level of education, and personal beliefs that home birth improved the experience and well-being of women, babies, and midwives. The factors that contributed to negative opinions about home birth were a perceived Table 1. Provider Attitudes to Planned Home Birth (PAPHB ) Scale Items The home setting is an ideal birth environment for mother-baby bonding If it were possible, I would consider offering home birth as part of my practice A mother s cultural background is easier to respect at home births than hospital births First-time mothers should have the option of having a planned home birth A move toward more home births in this country would save our medical system a significant amount of money There is good scientific evidence demonstrating the safety of home births with certified nurse-midwives Because of the risk of hemorrhage, homes are not an ideal birth setting Women who give birth in the hospital are more likely to experience morbidity associated with medical interventions than women who give birth at home It concerns me when people I care about decide to have home births I am a home birth advocate Mothers who have home births are more likely to breastfeed than mothers who have hospital births Home birth is never as safe as hospital birth Home birth is more empowering for the mother than hospital birth Certified nurse-midwives who practice home birth have sufficient skills to handle emergencies safely I would feel comfortable if a close family member chose to have a home birth I am willing to collaborate with a certified nurse-midwife who offers home birth I am not as comfortable with home birth as hospital birth I would be willing to lobby for improved access to home birth in my state I would consider having my own (or my spouse s) planned home birth with a certified nurse-midwife Home birth clinical experiences within the nurse-midwifery educational programs are only important for those few students who plan to work in home settings These items were reverse scored.

3 276 BIRTH 36:4 December 2009 lack of skills specific to the domiciliary setting, lack of support by colleagues for home birth, beliefs about negative physician attitudes, and lack of access to specialist consultants. The small sample size (n = 44) and sole inclusion of current home birth providers limit the generalizability of the study to other contexts or jurisdictions. A second study in the United Kingdom (13) analyzed the responses to a self-administered questionnaire about home birth practice, with a sample of 226 midwives who practiced in the home. This study reported that 70 percent of all comments were favorable toward home birth, although little detail was given about how comments were judged or analyzed. A cross-sectional study of independent midwives in the Netherlands (n = 115) used two scaled instruments to evaluate midwives attitudes toward hospital and home birth, and a risk assessment of safety in each birth location (41). Participants expressed an overall preference for home birth. Midwives in larger practices and those with more home birth experience had significantly more favorable attitudes than those in small practices with few home births (p <0.05). However, since midwives in the Netherlands practice in the home in the context of collaborative support from general practitioners and consultants, the results cannot be used to generalize attitudes of midwives and physicians in North America. To date, attitudes toward planned home birth among North American maternity care providers have not been studied. We designed an instrument to examine practitioners attitudes and the factors that are associated with attitudes and practice site choices. A practitioner s educational background, clinical experience, or practice environment may influence the range of birth settings offered to women (13,27,28,37,40,42,43). The objectives of this study were, first, to describe the attitudes and experiences of American nurse-midwives toward planned home birth, and second, to explore evidencebased correlates and predictors of nurse-midwives attitudes toward planned home birth. Methods Instrument Development After completing a literature review, we developed a comprehensive survey, which included the Provider Attitudes towards Planned Home Birth (PAPHB) scale and variables that may affect attitudes. In the first section of the survey we asked nurse-midwives to provide information about sociodemographic, educational, personal, and professional factors, and external conditions (environmental, structural, economic, and logistical). In the second section, nurse-midwives rated PAPHB scale statements about planned home birth on a scale from 1 (strongly disagree) to 5 (strongly agree), with a neutral midpoint of 3. Psychometric testing (reliability and principal components factor analyses) indicated that the PAPHB scale measured the attitude to planned home birth construct with excellent interitem correlations (Cronbach s α = 0.94) (Table 1) in a national sample. Higher scores on the PAPHB scale indicate more favorable attitudes towards planned home birth. A detailed description of the development, content validation, and psychometric testing of this instrument is reported elsewhere (44). Survey Administration We distributed surveys electronically and by mail to all nurse-midwife members of the American College of Nurse-Midwives (ACNM) (approximately 5,000) in April We sent reminder s and postcards twice, and data collection ceased in July. The survey website was password protected and log-in time limited to protect the data and the anonymity of the respondents. Informed consent documents were made available in pdf format. All responses were exported into SPSS Version 16 (45). The institutional ethics review boards at Yale University, New Haven, Connecticut, and the University of British Columbia, Vancouver, British Columbia, approved this study. Data Analysis Descriptive statistics of sample characteristics and PAPHB favorability scores were computed. Using bivariate analyses (Student s t tests for dichotomous variables and correlational analysis for continuous variables), we examined the associations among demographic, practice, educational, and external barrier variables and home birth attitudes. We entered variables that displayed significant associations in the bivariate analyses into a linear regression model in four blocks (5 sociodemographic variables, 10 practice variables, 5 education variables, and 10 external barriers to home birth practice), with the PAPHB favorability score as the outcome variable. None of the predictor variables showed collinearity of r>0.6 with other predictor variables. We also identified PAPHB items that reflected regional practice conditions, ideas about safe practice, or professional relationships. We then correlated these factors with nurse-midwives willingness to practice in the home. Finally, a subset analysis of nurse-midwives who experienced different levels of exposure to planned home birth was performed to examine whether planned home birth attitudes became more favorable as level of exposure to planned home birth increased.

4 BIRTH 36:4 December Results Sample Characteristics Respondents returned 1,809 surveys electronically and 110 by mail. The response rate for electronic surveys (46%) was higher than paper surveys (10%). Once duplicate and incomplete survey entries were discarded, the final sample size was 1,893. Most respondents were female (99%), Caucasian (94.7%), educated at the master s level (78%), and ranged in age from 25 to 82 years (mean age = 48.6 yr). Close to one-half (48%) provided midwifery care primarily in urban centers, whereas 16.3 percent provided care in rural areas; the remainder practiced in a mix of rural and urban settings. The sample appears to be representative of this provider group, because nurse-midwives from all ACNM regions responded to the survey, and the age, education, ethnicity, and practice sites distribution were similar to those in published reports (46). The average PAPHB scale score for nurse-midwives was (range: , SD: 15.9), with 60 points indicating a neutral attitude toward planned home birth. Most study participants agreed that good scientific evidence exists demonstrating the safety of planned home birth (82%) and that the home setting facilitates motherbaby bonding (83%). Most also agreed that it is easier to preserve cultural congruence (70%) and an empowering experience (79%) for the woman at home than in the hospital. Seventy-nine percent believed that women who give birth in the hospital are more likely to experience morbidity associated with interventions. Practice and Personal Experience with Home Birth Most nurse-midwives (92%) had provided intrapartum care in the hospital. In contrast, 74 percent had never provided intrapartum care in the home. Twenty-two percent had cared for women in a hospital birth center, and 27.6 percent had provided care in a free-standing birth center. Five percent of respondents stated that they currently attend planned home births as primary midwives. A small minority of respondents (5.3%) were in practice as direct entry or traditional midwives before obtaining their nurse-midwifery education. Almost one-third of respondents with children (32.5%) planned a home birth for one or more of their children. Educational Exposure to Planned Home Birth When nurse-midwives described their midwifery education with respect to home birth, 27.2 percent responded that they had the option of attending a planned home birth as part of their curriculum, but only 10 percent reported actual planned home birth clinical educational experiences. Fifty-two percent believed that their nursemidwifery faculty had some experience with providing planned home birth, and 25.3 percent reported that faculty members were providing intrapartum care in the home during the time of the student s enrollment. Before going to nurse-midwifery school, 9.6 percent of respondents received midwifery education through another route, such as apprenticeship or direct entry midwifery school. External Barriers to Planned Home Birth Several external barriers to nurse-midwives home birth practice were identified. The most often cited barriers to home birth practice were a difficulty in obtaining liability insurance in a home birth practice (69%), lack of physicians in their region who would be willing to offer consultation or accept transfers from home birth midwives (48%), discomfort with approaching a physician for consultation (41.3%), restriction of home birth practice by state regulation (37.7%), the perception that home birth practice is too time-consuming (36.5%), concerns about good standing among peers (35%), and the perception that it is impossible to thrive financially in a home birth practice (31.2%). The impact of these external barriers on nurse-midwives favorability scores varied by region and may indicate regional differences in practice conditions. Factors Associated with Attitudes toward Planned Home Birth Thirty variables, including demographic, practice experience, educational experience, and external barriers, were significantly associated with attitudes toward planned home birth. A detailed list of these factors and associated scale scores is presented elsewhere (44). The mean difference in favorability scores was greatest when nursemidwives had different educational paths before nursemidwifery education (t = 9.977), p < 0.001; mean difference = 10.3 [95% CI: to 8.26]; different levels of home birth experience during nursemidwifery school (t = 9.39), p < 0.001; mean difference = 8.78 [95% CI: to 6.94]; and different amounts of experiences with out-of-hospital birth in a clinical role (t = ), p < 0.001; mean difference = [95% CI: to 11.66]. Among the significant external barrier factors, fear of lawsuits (r = 0.381) and different levels of comfort with enlisting physician consultation (r = 0.401) caused the widest variation in favorability scores.

5 278 BIRTH 36:4 December 2009 Table 2. Association between Exposure to Planned Home Birth and Attitudes Exposure Level Mean Planned to Planned Home Birth Attitude Home Birth Scale Score No. (%) No exposure at all 75 1, 384 (73.1) General exposure Ever been present at (4.9) planned home birth (excluding birth of own children and those you attended as a student or primary midwife) Educational exposure Attended planned home (9.9) birth as part of nurse-midwifery curriculum Professional exposure Ever provided (26) intrapartum care in home Provided intrapartum care (23.2) in home in clinical role Currently provide intrapartum care in home as primary midwife (5) When examining the mean scores on the PAPHB scale by levels of exposure to planned home birth, we found that attitudes became more favorable with increased exposure to planned home birth (Table 2). Predictors of Attitudes toward Planned Home Birth The 30 variables that were included in the linear regression model explained 40.2 percent of the variance in attitudes toward planned home birth. Practice variables accounted for 21.2 percent, external barriers accounted for 13.9 percent, sociodemographic variables accounted for 3 percent, and education variables accounted for 2.1 percent of the variance in home birth attitudes. Four of the 10 home birth practice variables significantly predicted more favorable attitudes toward home birth, including having attended planned home births in a clinical role (rather than a support or observer role), ever having attended a planned home birth before getting their degree, having provided intrapartum care in a freestanding birth center, and having provided intrapartum care in the home setting. Two of the five sociodemographic variables significantly predicted more favorable home birth attitudes, including being a younger nursemidwife and not being a member of ACNM region 5 (Arizona, Colorado, Iowa, Kansas, Minnesota, Missouri, Nebraska, New Mexico, North-Dakota, Oklahoma, South Dakota, Texas, Utah, and Wyoming). Two of the five education variables significantly predicted more favorable home birth attitudes, including having been exposed to nurse-midwifery faculty who had ever provided planned home birth as part of their practice and having attended planned home birth as an extracurricular activity while in nurse-midwifery school. Finally, 6 of 10 external conditions significantly predicted less favorable attitudes toward planned home birth, including perception that home birth midwifery practice is too time-consuming, discomfort with asking a physician to provide consultation or referral services for a home birth practice, perception that it is impossible to thrive financially in a home birth practice, perception that home birth nurse-midwives are looked down on by hospital-based nurse-midwives, and the belief that nurse-midwives who deliver at home are at higher risk for lawsuits than those who deliver in hospitals. Nursemidwives who agreed that it is too difficult to obtain liability insurance in a home birth practice had more favorable attitudes (Table 3). Nurse-Midwives Willingness to Practice in the Home Although as a group nurse-midwives were moderately favorable toward planned home birth, 41 percent would not consider offering it as an option for their own clients and another 13.6 percent were unsure or not motivated to do so. Willingness to practice in the home was most strongly correlated with factors related to nurse-midwives confidence in their ability to respond to complications in the home, beliefs about the safety of planned home birth, and comfort with asking a physician to serve as a consultant for their home birth practice. Concerns about financial and regulatory factors and peer opinion were also significantly correlated with willingness to practice in the home. A complete list of findings (rank-ordered by the size of correlational coefficient) is shown in Table 4. Discussion Maintaining a sufficient number of qualified maternity practitioners who routinely offer attendance at planned home birth is essential to meet consumer demand safely while maintaining fiscal responsibility in maternity health care. Nurse-midwives are the logical practitioners in the United States who could increase access to home birth, yet most do not practice in the home. As a group, nurse-midwives in this study had moderately favorable attitudes to planned home birth. They shared women s beliefs (12,16,18) about home birth

6 BIRTH 36:4 December Table 3. Predictors of Favorability toward Planned Home Birth Variable Standardized β Coefficient p Younger age <0.001 CNM is not a member of ACNM region CNM has attended planned home birth in clinical role <0.001 Before degree, CNM attended planned home birth (excluding own children and those attended as primary midwife or student) CNM has provided intrapartum care in home <0.001 CNM has provided intrapartum care in free-standing birth center 0.09 <0.001 CNM had faculty who had ever provided planned home birth as part of their practice CNM attended at least one planned home birth as an extracurricular activity <0.001 while in nurse-midwifery school CNM disagreed that home birth midwifery practice is too time-consuming for <0.001 the midwife CNM was comfortable with asking a physician to back her up in a home birth <0.001 practice CNM agreed that it is possible to thrive financially in a home birth practice CNM agreed that it is too difficult to obtain liability insurance in a home birth <0.001 practice CNM disagreed that home birth CNMs are looked down on by hospital birth CNMs CNM disagreed that CNMs who deliver at home are at higher risk for lawsuits than those who deliver in the hospital <0.001 ACNM = American College of Nurse-Midwives; CNM = certified nurse-midwife. Table 4. Correlation with Nurse-Midwives Willingness to Offer Home Birth as Part of Their Practice Attitude Item r I am not as comfortable with home birth as hospital birth Because of the risk of hemorrhage, homes are not an ideal birth setting CNMs who practice home birth have sufficient skills to handle emergencies safely There is good scientific evidence demonstrating the safety of home births with CNMs Resuscitation of the term newborn is more effective in the hospital setting than the home setting I would not be comfortable asking a physician to back me up in a home birth practice Women who give birth in the hospital are more likely to experience morbidity associated with medical interventions than women who give birth at home Women who choose home births tend to be risk takers It is very difficult to adequately manage labor pain in the home setting compared with the hospital setting Home birth midwifery practice is too time-consuming for the midwife Postpartum education is more thorough in the hospital than at home CNMs are able to identify women who are unsuitable for home birth CNMs who deliver at home are at higher risk for lawsuits than those who deliver in the hospital It would cost too much to start up a home birth practice CNMs who offer home birth are risking their licenses to practice Research on home birth outcomes is biased by the fact that women who choose home birth tend to be better educated and healthier It is possible to thrive financially in a home birth practice It would be too difficult to establish a home birth practice in my community Home birth CNMs are looked down upon by hospital birth CNMs It is too difficult to obtain liability insurance in a home birth practice CNM home birth practice is restricted and/or regulated by my state or country There are physicians in my area who are willing to offer consultation for, or accept transfers from, home birth midwives Putting home birth experience on my resume might hurt my chances of being hired at a hospital-based practice Correlation is significant at the 0.01 level (two-tailed). CNM = certified nurse-midwife.

7 280 BIRTH 36:4 December 2009 with respect to cultural and environmental benefits, reduced rates of intervention, and increased opportunities for the family to experience validation through shared decision-making. Yet most nurse-midwives were unwilling to consider home birth practice. The complex interactions among nurse-midwives professional experiences, practice environment, self-confidence, and autonomy clearly affect their ability to connect core attitudes to practice behaviors. Confidence and proficiency in professional practice naturally lead to an expanded ability to respond to patient requests. Differences in favorability scores between nurse-midwives who had clinical experiences with home birth and those who had no exposure were most striking. Even respondents who had only witnessed a planned home birth, or had planned a home birth for their own child, were more favorable than those who had never been exposed. Those with higher levels of exposure were both more favorable and more willing to offer home birth. The results also highlight the influence of preparation for home birth practice during the course of professional education. Mentorship and clinical role modeling from faculty who practice in the home may be as important as knowledge translation about data on safety or appropriate screening for planned home birth. Clinical rotations located in the home may increase confidence in the application of basic skills (e.g., management of postpartum hemorrhage or neonatal resuscitation) in any birth setting. A practitioner s comfort with appropriate site selection, screening for complications, and referral when necessary may also improve with increased clinical experiences with planned home birth for learners. The cumulative effect of such educational and professional experiences may increase both favorable attitudes and willingness to offer home birth to women (Table 4). In this study, attitudes that were correlated with perceived external barriers are a reflection of the normative cultural context in which American maternity care practitioners practice. In many American jurisdictions, they are subject to significant regulatory, logistic, and legislative barriers to the provision of home birth services. These restrictions may exist in part as a result of attitudes and beliefs that are particular to a professional culture. Those respondents who had less favorable attitudes to planned home birth identified that financial security, liability concerns, and lack of support from other maternity care providers (physicians and nurse-midwife peers) were barriers that affected the choice of practice setting. Several identified factors interact and compound to produce an environment that discourages home birth practice. Financial viability would be increased with an increased demand for home birth services and with the integration of home birth practitioners into mandatory health insurance schemes. Health insurance coverage for home birth may, in turn, increase consumer demand. Yet insurance coverage of any procedure or setting is dependent on the good will and endorsement of the health care sector. Similarly, the availability of affordable liability policies is a function of both demand or risk pool and the attitudes and knowledge base of the liability sector. The liability sector, like the payor sector, relies on panels of maternity professionals to set guidelines for access to coverage. Therefore, access to liability coverage for home birth practitioners is dependent on the attitudes of the panel members toward planned home birth. Finally, maternity care providers, like midwives, who are reliant on the collaboration of referral colleagues are subject to the inherent attitudes among these colleagues. The quality of interprofessional interactions ultimately affects both women s choices and quality of care across birth sites. Less than 1 percent of American obstetric and family physicians practice outside the hospital. Midwives are the sole maternity practitioners whose scope of practice and professional practice standards support planned home births. Yet, in the United States, only 6.4 percent of nurse-midwives are known to offer intrapartum care outside the hospital and just 3.7 percent practice in homes (46). In contrast, certified professional midwives (the other primary midwifery group in the United States) practice primarily in out-of-hospital settings. The differences among health professional curricula for maternity providers are likely to affect the development of attitudes. Medical educational programs throughout North America rarely offer theoretical or clinical education on appropriate care in out-of-hospital settings. Certified professional midwifery programs in the United States currently only offer home birth and birth center preparation. All American-based nurse-midwifery programs require hospital intrapartum experience, but home birth curricula and clinical experiences are rarely incorporated into core requirements. Findings from this research suggest that the formal inclusion of the theory and practice of home birth as core requirements for medical and midwifery students could increase overall favorability toward planned home birth. Interdisciplinary education about planned home birth could lead to best practice guidelines around collaboration in maternity care and remove significant external barriers to practice. Students may benefit from mandatory requirements for planned home birth clinical experiences, and out-of-hospital management and skills competency assessment, similar to those that exist in other nations. Given the scarcity of potential home birth clinical preceptors, educational programs may need to explore mentorship arrangements with certified professional midwifery clinical faculty or international clinical placements to facilitate acquisition of these skills and experiences. The development of curricula to prepare

8 BIRTH 36:4 December maternity practitioners for out-of-hospital maternity care will also improve preparation for practice in rural and remote settings, or during disaster conditions, and may be critical to the provision of essential health care services. Regional variations in the availability of liability insurance, willing physician consultants, health benefit reimbursement, and receptive hospital environments also affect practitioner attitudes and, in turn, willingness to practice. Evaluations that apply the PAPHB scale to other types of maternity practitioners may elicit information on how interprofessional attitudes affect the normative culture of practice. Regulatory requirements, such as written consultation agreements or liability coverage requirements, impede effective interprofessional communication and collaboration. They must also be addressed before women can expect increased availability of nurse-midwives who offer home birth as an option in the United States. Strategies to promote interprofessional experiences and understanding may reduce concerns about peer opinion, and ultimately allow for innovations in funding models and reimbursement schema. Limitations The survey instrument was sent to the entire membership of the ACNM, but problems with the distribution of paper versions to those members who did not have electronic addresses reduced response rates. Not all nurse-midwives are members of the ACNM, although the large majority of practicing nurse-midwives maintain membership. Moreover, the self-selected nature of study participants has the potential to introduce bias into the findings. In this case, the large sample (1,893), as well as the regional distribution of participants and sociodemographic and practice profile of respondents that reflect the core data set (46), increase the possibility that findings are generalizable to the entire population. The PAPHB as a quantitative scale may not have the ability to elicit nuances in attitudes that are affected by the individual s context. Comments and queries by study participants indicated a strong interest in elucidating their responses. Future applications will incorporate a qualitative assessment opportunity to better explore the complexities of attitude development. Future Directions Given that the provision of health care services and the regulatory framework related to home birth are distinct among different nations, the attitudes of maternity care practitioners are likely to be affected. Also, barriers to increasing women s access to home birth practitioners may be more comprehensively understood through studying attitudes and experiences in an interprofessional and interdisciplinary context. In a Canadian Institutes of Health Research-funded national, multi-site study, the authors are adapting the survey instrument to the Canadian context for administration to multidisciplinary maternity practitioners and to key informants from the health care administration and policy sectors. In Canada, both home and hospital birth clinical experience are required for successful completion of a midwifery degree. In addition, by regulation, all midwives must offer both options to clients, and access to physician consultation is facilitated by health authorities. Rates of planned home birth among midwives are somewhat higher than in the United States, but most Canadian physicians do not believe that planned home birth is a safe option (47). Conclusions This study indicates that while most American nursemidwives have favorable attitudes to planned home birth, their attitudes, choice of practice site, and comfort with home birth are strongly influenced by the nature and amount of exposure to home birth during professional education or practice experiences, and by interprofessional, logistic, and environmental factors. Acknowledgments The authors wish to thank the members of the two expert panels, one that evaluated background survey questions and the other that evaluated scale items, for their time and thoughtful consideration. References 1. Anderson RE, Anderson DA. The cost-effectiveness of home birth. J Nurse Midwifery 1999;44(1): Germano E, Bernstein J. Home birth and short-stay delivery. Lessons in health care financing for practitioners of health care for women. J Nurse Midwifery 1997;42(6): Chamberlain G, Wraight A, Crowley P. Birth at home: A report of the national survey of home births in the UK by the National Birthday Trust. Pract Midwife 1999;2(7): Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, : A retrospective cohort study. Birth 2009;36(3): Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009;181(6-7):

9 282 BIRTH 36:4 December Ackermann-Liebrich U, Voegeli T, Gunter-Witt K. Home versus hospital deliveries: Follow up study of matched pairs for procedures and outcomes. BMJ 1996;313: de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nihuis J, et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 2009; DOI: /j x. 8. Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: A prospective descriptive study. Obstet Gynecol 1998;92(3): Johnson K, Daviss B. Outcomes of planned home birth with certified professional midwives: Large prospective study in North America. BMJ 2005;330: Janssen P, Carty E, Reime B. Satisfaction with planned place of birth among midwifery clients in British Columbia. J Midwifery Womens Health 2006;51: Banyana JM, Crow R. A qualitative study of information about available options for childbirth venue and pregnant women s preference for a place of delivery. Midwifery 2003;19(4): Hildingsson I, Waldenstrom U, Radestad I. Swedish women s interest in home birth and in-hospital birth center care. Birth 2003;30(1): Davies J, Hey E, Reid W, Young G. Prospective regional study of planned home births. BMJ 1996;313(7068): Christiaens W, Bracke P. Place of birth and satisfaction with childbirth in Belgium and the Netherlands. Midwifery 2009;25(2):e11 e10 [Epub 2007]. 15. Curtin SC. Recent changes in birth attendant, place of birth, and the use of obstetric interventions, United States, J Nurse Midwifery 1999;44(4): Longworth L, Ratcliffe J, Boulton M. Investigating women s preferences for intrapartum care: Home versus hospital births. Health Soc Care Community 2001;9(6): Grzybowski S, Kornelson J, Cooper E. Rural maternity care services under stress: The experiences of practitioners. Can J Rural Med 2007;12(2): Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to give birth: Why women in the United States choose home birth. J Midwifery Womens Health 2009;54(2): Governing Council of the American Public Health Association. Increasing Access to Out-of-Hospital Maternity Care Services Through State-Regulated and Nationally Certified Direct-Entry Midwives.: Report No.: Washington, DC: American Public Health Association, World Health Organization. Care in Normal Birth: A Practical Guide. Geneva: WHO Safe Motherhood Technical Working Group, American College of Nurse-Midwives. Position Statement: Home Birth. Silver Spring, Maryland: American College of Nurse- Midwives, December, Accessed June 17, Available at: Canadian Association of Midwives. Position Statement on Home Birth. Montréal, Quebec: Canadian Association of Midwives, March, Accessed June 17, Available at: New Zealand College of Midwives. Consensus Statement: Normal Birth. Christchurch, New Zealand: Author, October, Accessed June 17, Available at: index.cfm/3,108,271/normal-birth-ratified-agm-2006.pdf. 24. National Institute for Health and Clinical Excellence (NICE). Intrapartum Care: Care of Healthy Women and their Babies during Childbirth. London, UK: NICE, 2007: Report No.: NICE clinical guideline Young D. Home birth in the United States: Action and reaction. Birth 2008;35(4): Finsen V, Storeheier AH, Aasland OG. Cesarean section: Norwegian women do as obstetricians do not as obstetricians say. Birth 2008;35(2): Lindgren HE, Radestad IJ, Christensson K, et al. Perceptions of risk and risk management among 735 women who opted for a home birth. Midwifery 2008 (In press). 28. Cheyney M. Homebirth as systems-challenging praxis: Knowledge, power, and intimacy in the birthplace. Qual Health Res 2008;18(2): DiGirolama AM, Gummer-Strawn LM, Fein SB. Do perceived attitudes of physicians and hospital staff effect breastfeeding decisions? Birth 2003;30(2): Hillebrand KM, Larsen PG. Effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians. Pediatrics 2002;110(5): Raisler J. Against the odds: Breastfeeding experiences of low income mothers. J Midwifery Womens Health 2000;45(3): Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol 1997;73(1): McGurgan P, Coulter-Smith S, O-Donovan P. A national confidential survey of obstetricians personal preferences regarding mode of delivery. Eur J Obstet Gynecol Reprod Biol 2001;97(1): O Boyle AL, Davis GD, Calhoun BC. Informed consent and birth: Protecting the pelvic floor and ourselves. Am J Obstet Gynecol 2002;187(4): House of Commons Health Committee. Choice in Maternity Services: Ninth Report of Session Volume I. London, UK: The Stationary House, July, 2003; Accessed June 17, Available at: cm200203/cmselect/cmhealth/796/796.pdf. 36. Hagelskamp C, Scammell A, Gray J, Stephens L. Staying home for birth: Do midwives and GPs give women a real choice? RCM Midwives 2003;6(7): Shaw R, Kitzinger C. Calls to a home birth helpline: Empowerment in childbirth. Soc Sci Med 2005;61: Wiegers T. Maternity care in the Netherlands: The changing home birth rate. Birth 1998;25(3): American College of Obstetricians and Gynecologists (ACOG). ACOG Statement of Policy as Issued by the ACOG Executive Board. Home Births in the United States. Washington, DC: ACOG, May, 2007; Accessed June 17, Available at: thestandardofcareindex.com/acogpolicystatements.pdf. 40. Floyd L. Community midwives views and experience of home birth. Midwifery 1995;11(1): Jabaaij L, Meijer W. Home births in the Netherlands: Midwiferyrelated factors of influence. Midwifery 1996;12(3): Brown JB, Smith C, Stewart M, et al. Level of acceptance of different models of maternity care. Can Nurse 2009;105(1): Peterson WE, Medves JM, Davies BL, Graham ID. Multidisciplinary collaborative care in Canada: Easier said than done. JOGC 2007;29(11): Vedam S, Aaker S, Stoll K. et al. Assessing nurse midwives attitudes towards planned home birth. J Midwifery Womens Health 2009 (In press). 45. Nie NH, Hull CH. SPSS Version Available at: Durnell-Schuiling K, Sipe T, Fullerton J. Findings from the analysis of the American College of Nurse-Midwives membership surveys: J Midwifery Womens Health 2005;50(1): Klein MC, Kaczorowski J, Fraser W, et al. Confusion in maternity care: How can practitioners see birth so differently? North American primary care research group, 36th annual meeting, November 17, 2008, Rio Grande, Puerto Rico.