Place and space in relation to childbirth: a critical interpretive synthesis

Figures & data

Figure 1. Flowchart of literature search and selection

Table I. Characteristics of studies included in the critical interpretive synthesis (N = 27)

Authors, year, country	Objective	Data collection	Design and data analysis	Findings
Abel and Kearns (1991), New Zealand.	To explore women´s opinions and experiences of home births.	Individual interviews with 6 women, who had experienced planned home births. Two primiparas, 4 multiparas.	Interpretive method with a feminist geography approach.	The place of birth women’s ability to assume control and to have continuity of care and continuity of place.
Bernhard et al (2014), USA.	To compare and contrast individual women´s home and hospital birth experiences.	Interviews in focus groups with 20 multipara who had had at least one hospital birth followed by at least one planned home birth.	A qualitative descriptive methodology with a qualitative content analysis.	Five themes emerged; Choices and empowerment, interventions and interruptions, disrespect and dismissal, birth space, connection.
Blix (2011), Norway.	to explore midwifery practice in homebirth settings in Norway especially practice assumed by the midwives to promote normal birth.	Individual or group interviews with 12 midwives who regularly attended home births.	Grounded theory.	The core category, avoiding disturbance meant that midwives prevented the woman from being disturbed and protected her from disturbance.
Borrelli et al. (2016), UK.	To conceptualize first time mothers expectations and experiences of a good midwife during childbirth in the context of different birthplaces.	Individual semi-structured interviews with 14 women before and after birth. The women had given birth in three different planned places of birth (home, Freestanding Midwifery Unit and Obstetric Unit).	Grounded theory.	A conceptual metaphor, the kaleidoscopic midwife illustrated how the midwife adapts to each woman´s individual needs in the context of each specific labour.
Borrelli et al. (2017), UK.	To explore first-time pregnant women´s expectations and factors influencing their choice of birthplace.	Individual semi-structured interviews with 14 women during pregnancy. The women had the option to give birth in three different birth settings. (home, Freestanding Midwifery Unit and Obstetric Unit).	Grounded theory.	Three main themes were identified; influencing factors on the choice of birthplace, expectations on the midwives being and doing roles, perceptions of safety.
Burns (2015), Australia.	To move the theoretical debate beyond the home/hospital dichotomy.	Individually interviews with 58 participants. 51were women who were pregnant and planning or had had a home birth in the last three years. 7 were professional doulas and independent midwives.	Burns (2015), Australia.	To move the theoretical debate beyond the home/hospital dichotomy.
Carlsson (2016), Sweden.	To generate a theory based on where women choses to be during the early labour process.	37 individual interview transcripts from 37 women who had given birth. 18 of these women had sought and been admitted to hospital during the latent phase of labour and 19 women had remained at home until active labour.	Carlsson (2016), Sweden.	To generate a theory based on where women choses to be during the early labour process.
Chadwick and Foster (2014), South Africa.	To study risk constructions in relation to choice of birth at home or via an elective Caesarean section.	Individual interviews with 24 pregnant women who were planning to undergo either a homebirth or an elective caesarean.	Discourse analysis.	Women choosing elective Caesareans positioned themselves within biomedical forms of knowing about childbirth. Choosing caesarean section was itself constructed as a form of risk management.
Coxon et al. (2014), UK.	To provide an understanding of what accounts for birthplace preferences.	Narrative interviews were performed with 41 pregnant women.	A prospective, longitudinal study with a narrative methodology.	Women who preferred to give birth at obstetric units (25 of 41 women) viewed birth as a medical risk. Those who planned birth in alternative settings also emphasized their intention and obligation to seek medical care if necessary.
Davis and Homer (2016), Australia.	To explore the way that birthplace impacts on midwives in Australia and the United King	12 midwives were interviewed by focus groups.	A qualitative descriptive study with a thematic analysis.	Place shapes midwives practice and the way they feel. Place also shapes the midwives ability to be with the woman.
Davis and Walker, (2010a), New Zealand.	To explore the way in which case-loading midwives in New Zealand construct midwifery and given these constructions to examine their practice within obstetric hospitals.	Individual interviews using semi-structured questions with 58 case-loading midwives.	A post structural feminist theoretical framework was used with NVIVO.	Midwives employ strategies to make space for childbirth. These include re-constructing the maternal body as a competent body, re-positioning the woman at centre of care, disrupting the obstetric gaze and creating an oasis of privacy, calm and women- centeredness within the birthing room.
Davis and Walker (2010b), New Zealand.	To explore the social production of space and place in relation to childbirth.	Individual interviews using semi-structured questions with 48 case-loading midwives.	Discourse analysis.	Places play a significant role in shaping midwives understanding of childbirth and thus their decision-making and clinical practice.
Hammond et al. (2014a), Australia.	To explore the impacts of physical and aesthetic design of hospital birth rooms on midwives.	6 filmed labours. 8 midwives participated in video-reflected interviews	A video ethnographic study with thematic analysis.	Midwives were strongly affected of the design of the birth rooms, which challenged the provision of care.
Hammond et al. (2014b), Australia.	To explore the relationship between the birth environment and the practice of midwifery using the theoretical approach of critical realism.	Individual interviews with 16 practising midwives.	An explorative descriptive methodology with thematic analysis.	Midwives cognitive and emotional responses indicated a relationship between hospital birth environments and midwifery practice.
Hammond et al. (2017), Australia.	To identify and describe the design characteristics of hospital birth rooms that support midwives and their practice.	21 face-to face photo-elicitation interviews with 16 midwives were conducted.	A qualitative descriptive methodology by the theoretical approach of critical realism with a thematic analysis.	Three design characteristics were identified that supported midwifery practice; friendliness, functionality and freedom.
Hastings-Tolsma et al. (2018), South Africa.	To describe the experience of women receiving care during childbirth.	Individually interviews with 12 women who recently had given birth.	A qualitative descriptive methodology with a thematic analysis.	Four themes were noted: Cocoon of compassionate care, personal regard for shared decision-making, beliefs about birth and protection
Kennedy et al. (2004), USA.	To expand knowledge of the process and outcomes of midwifery care	Individually interviews with 14 midwives and 4 recipients of midwifery care.	Narrative analysis.	Three themes were identified; the midwife in relationship with the woman, orchestration of an environment of care, and the outcomes of care.
Kuliukas et al. (2016), Australia.	To explore midwives experiences of intrapartum transfer.	Individual interviews with 17 midwives who cared for women in birth centres who were transferred to the tertiary obstetric unit during labour.	A descriptive phenomenological study.	Midwives find transfer in labour challenging both emotionally and practically. Midwives acknowledged the challenge of finding balance between fulfiling parents ‘birth plan wishes with hospital protocol and maintaining safety.
Lock and Gibb (2003), Australia.	To describe the power that place holds over the postnatal-care experiences of women.	Conversational interviews with 5 women birthing in hospital.	A phenomenology approach with thematic analysis.	Four major constructs of experience were revealed through analysis and include spatiality, corporeality, temporality and relationality.
Lee, Ayers, and Holden (2016), UK.	To examine decisions regarding place of birth among a group of high-risk pregnant women. The intention was to consider differences and similarities between the groups in the factors they considered and emphases they placed on these when deciding on place of birth.	26 participants with high-risk pregnancies, at least 32 weeks pregnant were interviewed with semi-structured questions. Half the participants were planning hospital births and half were planning homebirths.	Thematic analysis	Both groups were concerned about safety but they expressed different concerns. Women planning homebirths displayed faith in the natural birth process and stressed the quality of the birth experience. Women planning hospital births believed the access to medical care outweighed their misgivings about the physical environment.
Mondy et al. (2016), Australia.	To explore the concepts of domesticity within the birth space. The specific objectives were to explore, describe and compare birth spaces with different domestic characteristics and subsequently, how labouring women worked within these spaces during the labour process.	Filming of 6 births in two different birth locations (territory hospital n = 5 and a stand-alone birth centre n = 1). Video footage of women labouring at home was used to compare and contrast women’s experiences. 9 Interviews were performed with the women or their attended people and 8 interviews were performed with their midwives.	Video ethnography and reflexive interviewing analysed with latent content analysis.	In general women labouring in conventional hospital acted and interacted with the environment in a passive way. In essence, all but one of the women labouring and birthing in these spaces took on the role of a “patient”. Domestication of the space’ was the mechanism this woman used to retain a sense of ownership within the birth space.
Newburn (2012), UK.	To explore the model of care provided at a birth centre from the perspectives of midwives and parents.	114 hour of observation at the birth centre observing antenatal, intrapartum and postnatal care. 14 individual interviews with parents after birth (seven with women and seven with women and their partner together) and 11 interviews with staff (9 midwives and 2 maternity assistants).	An ethnographic study.	Most women and men at the Birth centre perceived it as offering the best of both worlds based on its proximity to the labour ward.
Nilsson (2014), Sweden.	To gain a deeper understanding of women’s negative experiences in the delivery room.	Individual interviews with 21 women (15 pregnant women with intense fear of childbirth, and six women who had experienced intense fear of childbirth 7–11 years prior to the interview).	A hermeneutic approach.	The delivery room was, for these women, a place creating fear of childbirth. The birth environments are understood as power structures, containing views of women’s birthing bodies as machines, and delivery rooms as surveillance environments.
Nilsson et al. (2010), Sweden.	To describe the meaning of previous experiences of childbirth in pregnant women who have exhibited intense fear of childbirth such that it has an impact on their daily lives.	Individual interviews with 9 pregnant women with intense fear of childbirth who were pregnant with their second child and considered their previous birth experiences negative.	A descriptive phenomenological study	The women felt as if they had no place in the delivery room, that they were unable to take their place and that even if the midwife was present, she did not provide support. The experience remained etched in the women’s minds and gave rise to feelings of fear, loneliness, and lack of faith in their ability to give birth and diminished trust in maternity care.
Parrat and Fahy (2004), Australia	To explore what affects birth space has on women´s birth experience and outcome and how can midwives provide a holistically safe birth place.	A total of 6 women who were considered “low risk” at the beginning of labour, participated in individual interviews. Three of the participants had homebirths experiencing continuity of care in partnership with a midwife. The remaining three participants had the fragmented care of medically managed childbirth in hospital.	Feminist constructivism with grounded theory.	A “holistically safe” space is jointly constructed by midwife and woman. This model enables the woman to feel in control of her birth space, respond intuitively and facilitate her potential for a safe, natural birth.
Seibold et al. (2010), Australia.	To explore and describe midwives perceptions of birth space and clinical risk management and their impact on practice both before and after a move to a new facility.	18 midwives, including graduate year midwives, caseload midwives and hospital midwives working normal shifts, employed within a hospital were observed and interviewed in focus groups.	An explorative descriptive study utilizing a modified participatory approach.	Midwives desire to create the ideal birth space was hampered by a prevailing biomedical discourse which emphasized risk. Midwives in all three groups saw themselves as the gatekeepers, “holding the space” or “providing a bridge” for women, often in the face of a hierarchical hospital structure with obstetricians governing practice.
Townsend et al. (2016), Australia.	To describe midwives’ perceptions of the birth bed.	Individual interviews with 14 midwives from one Queensland maternity.	A qualitative descriptive design. Thematic analysis.	A common feature of the modern birth space is the bed. The themes highlight differences in how the midwives conceptualized the use of a bed within a birth space. While some avoided the use of the bed altogether others would only conceive of women moving off the bed if everything was “normal”. How the bed was culturally constructed appeared to dictate clinical practice.

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