Access across birth settings: Examining sources of conflict and controversy among maternity providers

Background: The US maternity care system is failing to reliably offer high-quality, cost-effective maternity care to all populations, even when women have access to tertiary care centers. Planned home births are associated with excellent outcomes, high patient satisfaction, and cost savings. However, in North America controversy among maternity care providers around appropriate birth setting is pervasive, and research has demonstrated that provider opinion influences patient choice. Methods: Mixed-methods study (survey and focus groups) of attitudes towards home birth among Canadian obstetricians, registered midwives and family physicians. Regression analyses revealed covariates of attitudes (as measured with a 17 item scale); qualitative findings explicated the context and etiology of attitudes. Results: Type of care provider accounted for 84% of the variance in attitudes towards home birth. Scale scores for midwives indicated very favorable attitudes towards home birth, whereas physician attitudes were largely unfavorable. Age, birth centre experience, size of practice, and community demand were significantly associated with attitudes among midwives (n=451). Among family physicians (n=139) covariates of attitudes were age, province of practice, exposure to planned home birth during medical education, and/or perceived peer censure. Obstetricians (n=245) universally had no exposure or only negative exposure to home birth during their education. Findings were strongly reinforced and explicated by qualitative findings obtained via multi-disciplinary focus groups. Implications for health professional education, interprofessional collaboration, and access to high quality maternity care will be discussed. Application of the Provider Attitudes Towards Home Birth Scale in international settings will be described.