Women's childbirth preferences and practices in the United States

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Abstract

Over the past two decades, research on childbirth worldwide has documented women's varied perceptions of and decision-making regarding childbirth. Scholars have demonstrated the impact of medical authority, religion, perception of risk, and access to care providers on the decisions women make about where to have their babies and with whom. Virtually all research on how women make these choices, however, has focused outside the United States. To address this gap in the literature, we analyze data collected during 2004–2010 through 135 in-depth interviews with women in the U.S. who have had hospital births, homebirths with midwives, and homebirths without professional assistance to explore the factors that led them to the births they had. We supplement these interview data with archival analysis of birth stories and ethnographic data to offer additional insight into women's birth experiences. In our analysis, we utilize Pierre Bourdieu's concepts of “habitus” and “field” to examine the ways women's preferences emerge and how a sense of risk and safety shape their decision-making around pregnancy and parturition. Our findings indicate that while women's birth preferences initially emerge from their habitus, their birth practices are ultimately shaped by broader structural forces, particularly economic position and the availability of birth options.

Highlights

► Examines the meaning of childbirth and definitions of childbirth risk. ► Presents data from a multi-year study of women choosing homebirth with a midwife, hospital birth, and unassisted childbirth. ► Identifies distinct frameworks underlying birth preferences: scientific-medical, natural family, and religion-centered. ► Utilizes Bourdieu's concept of habitus to examine the interface of women's preferences and social structures in the U.S. ► Points to ways that availability of birth options and economic position constrain women's agency in birth choices.

Introduction

Over the past two decades, research on childbirth has burgeoned in social science fields (Carter, 2010; Craven, 2010; Howell-White, 1999; Ivry, 2009; Martin, 2003). This growing literature on childbirth delves into the perspectives of women on their pregnancies and births, revealing the impact of technology, the authority of biomedicine, the role of spirituality, and women's efforts to gain autonomy and agency in childbearing (Fox & Worts, 1999; Lazarus, 1997; Namey & Lyerly, 2010; Rapp, 2000; Root & Browner, 2001). A smaller body of work also focuses specifically on women's decision-making during pregnancy and parturition. Options exist for women regarding care providers, place of birth, care during pregnancy (including prenatal testing), and birth itself. Virtually all research on how women make these choices, however, has focused outside the United States, primarily in the United Kingdom (Longworth, Ratcliffe, & Boulton, 2001), Australia (McGrath & Ray-Barruel, 2009) and Scandinavia (Nieminen, Stephansson, & Ryding, 2009), but also in India (Van Hollen, 2003), Morocco (Obermeyer, 2000), and Brazil (McCallum, 2005).

Renner, Eden, Osterweil, Chan, and Guise (2007, p. 515) point out the National Institutes of Health claim that “there is increasing interest in and a paucity of evidence for patient preferences for childbirth” specifically in the United States. As van Teijlingen, Wrede, Benoit, Sandall, & DeVries (2009) has noted, American childbirth is “exceptional” in a global context because of the reliance on obstetricians for even routine deliveries. In addition, the striking social inequality in the United States and the litigious cultural climate also shape its organization of maternity care. In this paper, we analyze data from a large, multi-year qualitative research project on women's childbirth practices and preferences in this unique context. Data collected over a six-year period from women in the United States who have had hospital births, homebirths with midwives, and homebirths without professional assistance allow us to explore women's birth preferences and choices. Specifically, we address two questions: How do women develop particular preferences about birth locations and care providers? And what factors increase or decrease the chances that they will give birth where and with whom they prefer?

We utilize Pierre Bourdieu's (2005) concepts of “habitus” and “field” to examine the ways women's preferences emerge and shape their decision-making around pregnancy and parturition. A woman's habitus grounds her decision-making about birth within a larger framework of assumptions about motherhood, risk, and health; the habitus suggests particular courses of action as safest, but women must make decisions within a larger set of economic and cultural realities shaping her choices. Our analysis explores how women seek to manage risk and maximize safety, as they define it, within the constraints of their environment. In doing so, we are able to see the ways in which women's particular habitus interface with the structural context in which they live.

Section snippets

Preferences and practices in childbirth

Cross-cultural research on childbirth decision-making reveals clear variation in the meanings of childbirth, the assumed need (or lack thereof) for technological and medical intervention in delivery, and the role of a care provider in the birth process (Davis-Floyd & Sargent, 1997; Hunt, Namino, & Halperin, 2002; Ivry, 2009; Jordan, 1983; Lewallen, 2011; McCallum, 2005). Concerns about safety and the risk of birth are fundamental to many decisions women make about pregnancy and parturition.

Data and methods

From 2004 to 2010, we researched three difference types of childbirth practices – 1) homebirth with a midwife, 2) unassisted homebirth, and 3) birth with a physician in a hospital. All three phases of the research were approved by the appropriate Institutional Review Boards, at the first author's university and/or the hospital where research was conducted. The first research phase focused on contemporary midwives and their clients. We utilized several avenues to recruit respondents for the

Findings: birth preferences and birth practices

The data analyzed here focus on both women's preferences for childbirth and also the actual experiences of childbirth that they have. Not all women who wanted a homebirth ended up having one, but all of the women who wanted a hospital birth did so. Table 1 illustrates the frequency with which women with each type of articulated preference ended up having the birth they desired.

Given the normalization of hospital birth with a physician, it is the easiest preference to fulfill structurally and

Conclusion

Extant research on women's childbirth decision-making highlights the centrality of women's definition of risk in choices women make during pregnancy and parturition. Global research on women's decision-making in childbirth has documented dramatic variation in definitions of risk and safety, access to options in childbirth, and perceptions about what is a normal, healthy, and wise course of action for a woman having a baby. Our findings indicate clear differences in what women saw as “safe” or

Acknowledgments

An earlier version of this paper was presented at the 2011 Southern Sociological Society meetings in Jacksonville, Florida. The authors are grateful to Dr. Julie Reid, who provided helpful critiques of earlier versions of this manuscript, and to the four anonymous reviewers and the journal editor for their insightful and useful feedback.

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