Abstract
Background:
The COVID-19 pandemic resulted in an increased number of out-of-hospital births in the United States and other nations. While many studies have sought to understand the experiences of pregnant and birthing people during this time, few have compared experiences across birth locations.
Objective:
The purpose of this study is to compare the narratives and decision-making processes of those who gave birth in and out of hospitals during the pandemic.
Design:
We conducted semi-structured narrative interviews with 24 women who gave birth during the COVID-19 pandemic.
Methods:
Interviews were transcribed and coded, and a thematic narrative analysis was employed. Final themes and exemplary quotes were determined in discussion among the research team.
Results:
Results from narrative analysis revealed three themes that played into participants’ birth location decisions: (1) birth efficacy and values, (2) diverse definitions of safety, and (3) childcare and other logistics. In each of these themes, participants who gave birth in birthing centers, at the hospital, and at home describe their individualized approach to achieving a supportive birth environment while mitigating the risk of labor complications and COVID-19 infection.
Conclusion:
Our study suggests that for some childbearing people, the pandemic did not change birthing values or decisions but rather brought enhanced clarity to their individual needs during birth and perceived risks, benefits, and limitations of each birthing space. This study further highlights the need for improved structural support for birthing people to access a range of safe and supportive birthing environments.
Introduction
The COVID-19 pandemic drew increased attention to the experiences and decisions of pregnant and birthing people. After the World Health Organization declared COVID-19 a global pandemic, policies to prevent the spread of the virus were implemented in outpatient offices, labor and delivery units, and postpartum units, as with all other areas of healthcare. 1 Studies of prenatal and intrapartum care early in the pandemic suggest decreased in-person management of pregnancy, increased intervention during hospitalization, and decreased access to postpartum care.2 –6 For many pregnant people, the fear of restrictions on visitation, requirements for masking, and fear of perinatal exposure to COVID-19 increased worry and prompted them to reconsider where they would give birth.7,8 Although there have been several qualitative studies about the experiences of pregnant and birthing people during this time,9 –13 none of the currently published studies have captured the decision-making processes of patients as they determined where and how to give birth.
In the United States, the majority of births take place in a hospital, with approximately 1.6% of births taking place out of the hospital in either free-standing birth centers or at home. 14 By the middle of 2020, increased requests for out-of-hospital births were being reported with a study of Google searches during spring of 2020 showing increased interest in home birth. 15 Debates regarding the safety of out-of-hospital birth, especially for higher-risk births, were rehashed by midwives and obstetricians.8,16 Some clinicians called for increased structural support for those who choose to have out-of-hospital birth, while others suggested the risk of out-of-hospital birth outweighed the risk of potential COVID-19 infection.17,18
Research has investigated birth experiences during COVID in a variety of birth settings. While some studies have suggested that birth satisfaction decreased during COVID, particularly for Black and Latina individuals, others noted that family-centered care efforts such as skin-to-skin and lactation support remained.3,19 While few studies have compared those who chose in-hospital to out-of-hospital birth, some research suggests that those who chose out-of-hospital birth had less childbirth fear, were more likely to view childbirth as a natural process, and were less likely to fear infection with COVID-19 when compared to those who chose in-hospital birth, but often experienced barriers to executing this choice due to their own health needs or lack of access to care.20,21
While several studies have sought to understand the experiences of birthing people in the hospital or out of the hospital, we were not able to identify any qualitative study that examined these narratives side by side. Furthermore, although several qualitative or mixed-methods studies have been published on similar topics, few have used narrative methods to capture the lived experiences of these individuals. 12 This study aimed to understand the nuanced decisions of pregnant and birthing people during COVID-19 who gave birth in a variety of birth settings (hospital, birthing center, or at home) and to document the lived experiences of these individuals during this challenging time.
Materials and methods
We conducted a cross-sectional qualitative study of people who were pregnant and gave birth during the COVID-19 pandemic in a variety of birth settings (hospitals, birthing centers, and at home) in the United States. This research was determined exempt by the University of North Carolina Institutional Review Board (IRB). Participants responded to our study flier posted online in family-support group pages, or physically in OB/GYN, family medicine, or pediatric clinics. This flier outlined the purpose and goals of the research, in addition to study requirements. Participants were further recruited using snowball sampling. Potential participants were asked to fill out an online screening survey, including demographic information, date of recent birth, and birth location. Inclusion criteria included any person who gave birth after March 2020. The only exclusion criterion was non-English-speaking status, as interviews were all completed in English.
This study was conducted in a mid-sized city in the southeastern United States with a large tertiary medical center; however, participants were recruited from across the country with the majority of patients located in the northeast, southeast, and midwest. The initial recruitment period was from June 2021 to December 2021 and resulted in 20 participants. Due to limited racial and ethnic diversity present in the original sample, in addition to the need to recruit more participants who had an out-of-hospital birth, the research team decided to extend the recruitment period. Participant recruitment ended in March 2022 after theoretical saturation was reached within a more diverse and representative sample. For this 3-month period, targeted recruitment of these demographics was achieved by advertising the study in specific parenting Facebook groups.
Interviews were conducted via telephone or Zoom video conferencing depending on participant preference. S.H. conducted a single semi-structured interview with each participant according to an interview guide. No other members of the research team were present during interview. Questions addressed birth location decision-making, risk mitigation during COVID, and overall experience of being pregnant and giving birth during a global health crisis (Appendix 1). Interviews averaged 45 min in length. Following the interview, participants were asked to fill out an additional online demographic survey to capture age, race, gender, education level, partner status, parity, and gestational age at time of delivery.
Data analysis
All interviews were audio recorded, transcribed verbatim, and transferred to Dedoose (v9.0.78) for coding. Quality and completeness of transcription was confirmed by S.H. and L.C. Data analysis began before participant recruitment was complete. An inductive thematic narrative analysis was used to analyze the interviews using open and axial coding. S.H. and L.C. completed line-by-line coding of all interviews independently, and met regularly to discuss code application and resolve discrepancies. Following line-by-line coding, S.H. and L.C. met to generate and refine themes. Theoretical saturation was reached after the research team began seeing similar codes and themes within transcripts from participants who gave birth in either birth setting. Final themes and exemplary quotes were identified and agreed upon among the entire research team.
The research team comprised three cis, white women with varying levels of experience with qualitative research within maternal and child health. S.H. has graduate-level training in qualitative research and was a medical student when interviews were conducted. All researchers on the team have experience working in hospital-based labor and delivery in a medical or support person role and have a vested interest (or faculty appointment, A.L.) in social medicine. This positionality may have impacted participant recruitment, data collection, and analysis; however, S.H. and L.C. were cognizant of this positionality and attempted to mitigate bias through continuous personal reflection and discussion among the research team.
Results
A total of 24 participants who gave birth between March 2020 and August 2021 completed the study. The average age of participants in this sample was 30, and a quarter of them had an out-of-hospital birth. Demographic and birth characteristics of the participants are represented in Table 1.
Participant demographics and birth characteristics.
Our analysis revealed three themes. The first, birth efficacy and values, describes how birth values and decisions informing birth location did not change significantly despite the pandemic, but rather allowed pregnant individuals to more easily act upon such values. Second, diverse definitions of safety describes the various ways that participants balanced their perception of safety during birth with their perception of the risk of COVID. Finally, childcare coordination and other logistics examines how coordination of childcare may have swayed participants to choose one birthing location over another. In each of these themes, participants who gave birth in-hospital and out-of-hospital noted different methods of managing the challenges of being pregnant and giving birth during the COVID-19 pandemic. Exemplary quotes used to describe each theme are identified with each participant’s unique ID in addition to an acronym indicated birth location (IH = in hospital; OOH = out of hospital).
Birth efficacy and values
Narratives from our sample revealed that birthing values, such as a desire for medical pain relief or to birth in a comfortable and familiar space, were not altered by the pandemic, but rather more easily acted upon when making a decision about birth location. For example, many participants noted that they had never considered an out-of-hospital birth, and despite the risk of contracting COVID in the hospital, continued to feel more supported in the hospital setting. Conversely, those who had always desired or considered an out-of-hospital birth, even if they had not had one previously, felt that the pandemic made the decision to move forward with birthing at home or in a birthing center easier. Often, prior experiences with birth, either personal or familial, played into participants’ perceptions of their own abilities in birth and shaped the values that informed their labor plans.
Participants who gave birth in the hospital frequently used language that suggested they had never considered another location to give birth. Some participants were healthcare workers themselves and had established community and support within the hospital setting. One participant who was not a healthcare provider described her desire for medical pain management and desire for continuity of care with her medical provider: “I knew I wanted some kind of pain management during labor. I knew I wanted an epidural so that played a lot into it, and then also I really liked my OB. I wanted him to deliver the baby” (701, IH). Others described diagnoses associated with their pregnancy or prior pregnancies that inclined them more toward hospital birth. One stated,
In April, I was diagnosed with gestational diabetes, so now not only is this my first pregnancy and we have to worry about COVID, we have to worry about it with a high-risk situation. At that point we were even more cautious. (701, IH)
Another had a history of placental abruption during her first pregnancy, which made her “anxious about this (current) pregnancy from day one” (502, IH).
Participants who chose out-of-hospital births were more likely to be multiparous and have prior positive experiences with birth, although some described negative experiences with hospital births. Both translated to increased confidence in their bodies and belief that they could give birth at home or at a birth center. Many noted that COVID did not necessarily change this decision, but made them stronger in their conviction to enact it. One participant stated,
I mean, COVID-wise, it worked out in a sense because I wanted to have birth center care and a birth center birth to begin with, so that was already my plan . . . But it worked out well. I didn’t have to deal with the whole, “Oh, you can only have one person” regimen. I could have whoever I wanted with me and it was just me and my husband and the doula, and then we had a birth photographer as well. (1201, OOH)
Another described similar convictions:
I wanted to be at home. You know, I wanted privacy. I didn’t want lots of people. I didn’t want anything that I considered unnecessary medical interventions. You know, I didn’t want the hustle and bustle of a hospital with people in and out of the room who I didn’t know. I didn’t want someone telling me how to push, or like any of that kind of stuff. (1001, OOH)
Finally, one participant who experienced a prior traumatic forceps-assisted delivery with a third-degree laceration stated, “So after dealing with that, I refuse to give birth in a hospital” (302, OOH). In both groups of participants, the risks that felt more salient (potential medical complication versus potential for unwanted intervention) facilitated their birth choice.
Diverse definitions of safety
An important component of birth location decision-making was the participants’ definition of safety during labor. While all participants mentioned safety in some form or another, their definitions of “feeling safe” were often vastly different. Risk of contracting COVID-19 was only one component of safety for participants, as they also considered bodily autonomy, access to medical options for pain relief, and access to emergency intervention if necessary.
For those who gave birth in the hospital, the risk of exposure to COVID was often overruled by other birth safety considerations. For example, one participant noted,
I mean I was gonna be in a hospital anyways so it was really more about trying to understand the risk of being in the hospital. I didn’t consider anything like home birth or anything like that. I’m advanced maternal age so . . . I was high risk enough anyways. I didn’t want to complicate anything. (402, IH)
Similarly, one participant who gave birth at home described a different birthing complication that pushed her to choose home birth. She stated,
I had a very rapid um pushing phase with my first, and so there was just the chance that if it was another rapid labor, and second labors are usually faster at least . . . the birth center was a distance from our house and in the metro area that can be a 20 min drive or a 1.5 hour drive. (1011, OOH)
Others who gave birth in the hospital did briefly consider out-of-hospital birth, but found reasons to continue with an in-hospital birth. For example, several participants described wanting to maintain a COVID-free home and therefore did not want a midwife entering that space. One stated,
When COVID started and it started getting worse we discussed the whole home birth thing, but honestly aside from the whole, “something goes wrong, can the ambulance get here fast enough to fix it?” issue, we thought we didn’t want anyone to come in our house because of COVID, so we didn’t want to have a midwife or anybody like that coming to actually deliver. (701, IH)
Conversely, one participant who gave birth at home felt that having only a few healthcare providers enter their home would minimize risk. She stated, “The other piece that played into that was, you know, it was COVID and we could control more of our home environment” (1011, OOH).
COVID safety precautions that hospitals, birthing centers, and midwives were taking also played into participants’ birth location decisions. One participant who gave birth at a birthing center stated, “Oh I felt way safer at the birthing center. The entire time that I was there, it was just my midwife, her assistant, my husband, and me” (302, OOH). Another who considered a birthing center at first described how their COVID safety precautions seemed riskier than the local hospital’s:
The local birthing center, they were allowing people in that were not passing health screenings and so that made me feel like they were not taking as many COVID precautions as the hospital so it wouldn’t be any safer COVID-wise and maybe it would be less safe, and you also wouldn’t have all the support of the hospital. (1101, IH)
Childcare coordination and other logistics
Another topic that came up regarding birth location decision-making was that of childcare and logistics surrounding birth. COVID made accessing childcare during labor more difficult, as babysitters or family members who previously would have watched older children or been present as support people were unable to time quarantine around unpredictable labors. For those who gave birth in the hospital, this logistical concern led some participants to choose planned inductions in order for family members to safely quarantine before they were needed. One participant stated,
We scheduled an induction because of the childcare issue which I wouldn’t have done normally. Another reason was that at like 37 weeks she was breech and so we kinda set up scheduling the induction but they went in early to try to flip her, and she had just flipped on her own between week 37 and 38. So at that point I could’ve canceled the induction, but it was easier if it was planned when you don’t have reliable childcare. (1101, IH)
Others did not necessarily plan for induction but felt it made it easier to coordinate childcare when it happened. Another participant stated,
I was kinda at that point anticipating going to my induction date, which did end up happening. So [my sister] was in town for two weeks prior so I kinda felt pretty good about that. She had been isolated prior to coming and then she was going to be in our house for two weeks probably before I had the baby. (1002, IH)
Overall, many multiparous participants voiced that coordinating childcare for their birth was complicated by COVID, which factored into some of the birthing decisions they made.
Conversely, childcare was also a reason some participants chose out-of-hospital birth. One participant stated,
I was kind of comforted at the same time because I was doing it at the birthing center, and I had already talked to my midwife about it. My concern was my daughter. At the time she was four years old, and I was told that if I had given birth in a hospital, she couldn’t be there with us, and so I was really worried about having someone there with her, but because we were doing it at a birthing center, and that wasn’t a concern, my midwife was like, “Yeah, bring her. We’ll have the other helpers here, the doulas will help to keep her entertained.” (302, OOH)
Another participant who was GBS+ and would have required a longer hospital stay noted,
Especially with potentially being in the hospital for several days, we started looking at the birth center. I would be discharged 6 hours after birth and that was a game changer right, because one: it’s much more restricted about who is gonna be in the facility. And two: even if I have to do this by myself, I’m gonna be gone max you know 12 hours and then I’ll be right home with my family. I won’t be separated from the older two for so long and I won’t be by myself. That was another fear, that I would be by myself in a hospital for 3 days. (1102, OOH)
In these cases, not only were logistics at play, but also the need for support and connection from loved ones and desire to avoid isolation during birth.
Discussion
The results of our study suggest that participants decided on birth locations during the COVID-19 pandemic by factoring in their values around birth, their individual sense of safety in each location, and their ability to balance other logistics outside of birth, such as childcare or quarantine. Our narrative results add a unique perspective and depth to previously published qualitative studies on COVID-19 and birthing, as prior studies have not compared decisions regarding home and hospital birth and used different methodologies.9 –11,13 By capturing the narratives and lived experiences of participants, this study further informs the observed shift toward out-of-hospital birth in the United States during the COVID-19 pandemic.
Recent literature has proposed reasons for the increase in out-of-hospital births during this time. 22 Some literature has suggested that limited communication about ever-changing hospital policies about masking and having partners present during labor may have contributed.23 –25 This pattern held true across the globe with one study of Danish women showing that limited communication and concerns about contracting COVID-19 increased the desire for out-of-hospital birth, but the right to out-of-hospital birth was newly restricted due to national staff shortages during the pandemic. 26 DeJoy et al. 20 report that those who chose out-of-hospital birth often had previously considered it and that their own perception of susceptibility to COVID was an additional factor. This supports our findings; however, we found perceptions of susceptibility led others to choose hospital birth as well. Preis et al. 21 describe increased medicalization present during hospital births during COVID and add that perception of birth risk also led some to choose out of hospital; our study again found that this consideration inclined women toward both in-hospital and out-of-hospital birth. This suggests that frequently the decision-making process and central considerations for birthing people are similar for the range of delivery locations. Lyerly 27 found this to be true in a large qualitative study of childbearing people and argued that the “birth wars” that pit midwifery against obstetrics are primarily professional debates with adverse consequences for childbearing women. Instead, providers should aim to understand a patient’s values surrounding birth, helping them parse through their own individualized perception of risk, and empowering them to anticipate a positive birth experience in their chosen birth location (even where hospital transfer is required). This holds true even outside of a global pandemic.
Implications for practice or policy
For providers to accomplish such a patient-centered approach, systemic change is necessary. Combellick et al. 28 have described the changes that would have better supported pregnant people during COVID, such as increased accessibility to out-of-hospital birth, access to midwives, the right to an advocate at bedside during birth, and more transparent communication between providers and patients. Other studies similarly suggest that supporting a patient’s autonomy in birth while also building community and hospital systems prepared to triage and support patients to deliver safely is key. 29 This system must take into account the experiences of those historically marginalized and harmed during childbirth in medicalized settings, such as Black and Brown women and those of trans or non-binary gender identities, and work toward building more inclusive birth settings for all patients. Our study emphasized the subjective nature of perceived safety during birth, and that perceptions of safety (and risk) are often influenced by prior experiences in healthcare systems, family experiences with birth, exposure to informal birth support communities, and medical diagnoses. By gaining an understanding of an individual’s unique risk perception during birth, providers may be better able to support patients to navigate both healthcare systems and community resources in order to have a safe and fulfilling birth experience regardless of birthing space or medical comorbidities.
Furthermore, our study revealed that familial responsibilities and childcare could impede and certainly shape pregnant individuals’ access to their birth location preference. Caregiver burden increased during the COVID-19 pandemic, which had a direct impact on physical and mental health.30 –33 While it is well established that access to childcare can be limiting for parents returning to the workplace, it is notable that a similar pattern was seen in our study before family leave even began for participants. Therefore, effective change that supports birthing people also requires addressing childcare and family leave policies.
This study has several limitations. While we recruited an overrepresentative sample of participants who gave birth outside of the hospital compared to the national rate, our sample does not have an equal number of participants from either group that might facilitate a more direct comparison of in-hospital to out-of-hospital births. Furthermore, despite efforts to recruit a diverse sample, our sample was largely white and well-educated. Participants were predominantly multiparous and slightly older than the U.S. average age at first birth. While our sample may be representative of those who are frequently able to access out-of-hospital birth, it is also exemplary of a larger problem regarding equitable access to birth choices. More research is needed to understand how the COVID-19 pandemic impacted the birth choices of people of color and those from a range of socioeconomic backgrounds. The recruitment challenges our team faced were likely due to a variety of factors, including, but not limited to, time limitations of working parents or full-time caregivers, hesitation to participate due to the study’s backing by a large medical institution, larger cultural hesitation to participate in research due to prior harm done to institutionally marginalized communities in our country, and the identities of the research team. These factors should be taken into consideration during future research.
Finally, our work is also limited by the quickly changing nature of the pandemic, as participants were recruited across several different waves and strains of the virus, and with some giving birth before and after the introduction of vaccination. It is important to acknowledge the way that these temporal factors may have impacted participants’ experiences throughout pregnancy and influenced their birth location decisions.
Conclusion
This study provides a nuanced perspective on the experiences of birthing people during the COVID-19 pandemic in a variety of birth settings. Our results suggest that birthing people share common desires and take into account several similar factors when deciding when and how to give birth—even those whose choices about birth location diverge. For those who chose an out-of-hospital birth, the COVID-19 pandemic provided extra motivation to act on desires to give birth in a birth center or at home. Risk perception and familial responsibilities often factored into these decisions regardless of where participants chose to give birth. While the COVID-19 pandemic did increase out-of-hospital birth in the United States and in other nations, the call for increased structural support for birthing people to be able to choose an individualized, safe, and supportive birthing environment could improve birth outcomes and maternal and child well-being both during and outside of global healthcare crises.
Footnotes
Appendix 1
Acknowledgements
The authors would like to thank the providers and community members who shared the opportunity to be a part of this work with potential participants. Additionally, we would like to thank the participants for taking time out of their busy lives to share their meaningful stories.
