Exploring home births in Catalonia (Spain): A cross-sectional study of women's experiences and influencing factors

J Adv Nurs. 2024;80:2363–2378. | 2363wileyonlinelibrary.com/journal/jan Received: 8 August 2023 | Revised: 9 November 2023 | Accepted: 13 November 2023 DOI: 10.1111/jan.15989 EMPIRICAL RESEARCH QUANTITATIVE Exploring home births in Catalonia (Spain): A cross-sectional study of women's experiences and influencing factors Lucia Alcaraz-Vidal1,2,3 | Fatima Leon-Larios4 | Gemma Robleda5,6 | Rafael VilaCandel7,8 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 1Department of Obstetrics and Gynecology, University Hospital Germans Trias i Pujol, Badalona, Spain 2Research Group on Sexual and Reproductive Healthcare (GRASSIR) (2021-SGR-01489), Barcelona, Spain 3Catalan Association of Home Birth Midwives, Barcelona, Spain 4Nursing Department. Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Sevilla, Spain 5Campus Docent Fundació Privada Sant Joan de Déu, School of Nursing, University of Barcelona, Barcelona, Spain 6Centro Cochrane Iberoamericano, Barcelona, Spain 7Faculty of Health Sciences, International University of Valencia –VIU, Valencia, Spain 8Department of Primary Health, Foundation for Promoting of Health and Biomedical Research in the Valencian Region (FISABIO-SP), Valencia, Spain Correspondence Fatima Leon-Larios, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Calle Avenzoar 6, 41009-Sevilla, Spain. Email: fatimale[email protected] Funding information Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, Grant/Award Number: II Call for Nursing R&D&I Grants. 2020; UGP-20-245 Abstract Aim: The study explores the experiences of women with low-risk pregnancies and no complications who planned a home birth. Design: A cross-sectional study was conducted using an online questionnaire. Methods: The questionnaire included socio-demographic, obstetric and perinatal variables. Birth satisfaction was evaluated via the Spanish version of the childbirth experience questionnaire. The study group comprised home-birthing women in Catalonia, Spain. Data were collected from 1 January 2019 to 31 December 2021. Statistical analysis was performed using SPSS. Results: A total of 236 women responded. They reported generally positive experiences, with professional support and involvement being the most highly rated dimensions. Better childbirth experiences were associated with labour lasting less than 12 h, no perineal injuries, no intrapartum transfers to hospital, euthocic delivery and the presence of a midwife. Conclusions: Women's positive home birth experiences were linked to active participation and midwife support. Multiparous women felt safer. Medical interventions, especially transfers to hospitals, reduced satisfaction, highlighting the need for improved care during home births. Implications for the Profession and Patient Care: Home births should be included among the birthplace options offered by public health services, given the extremely positive feedback reported by women who gave birth at home. Impact: Home birth is not an option offered under Catalonia's public health system only as a private service. The experience of home-birthing women is unknown. This study shows a very positive birth experience due to greater participation and midwife support. The results help stakeholders assess home birth's public health inclusion and understand valued factors, supporting home-birthing women. Reporting Method: The study followed the STROBE checklist guidelines for crosssectional studies. Public Contribution: Women who planned a home birth participated in the pilot test to validate the instrument, and their contributions were collected by the lead researcher. 2364 | ALCARAZ-VIDAL et al. 1 | INTRODUCTION High-quality, professionally provided healthcare services are crucial for women. It is essential to evaluate these services so they can be improved and tailored to meet women's needs (O'Brien et al., 2021; Olza et al., 2018). Childbirth stands out as one of the most significant events in a woman's life with both shortand long-term implications for her health. A crucial factor affecting the childbirth experience is the planned birth setting (Winter et al., 2022). In countries where home births are integrated into the national health service, such as Scandinavian countries and the Netherlands, women who opt to give birth at home report positive experiences related to the freedom to choose their companions, the intimacy and tranquillity, and the trust they have in themselves and their accompanying midwives (Hollander et al., 2019; Sjöblom et al., 2014). In Spain, hospital is the predominant setting for childbirth; home births are not integrated into the public health system (Ortega Barreda et al., 2017). To our knowledge, there are no quantitative studies comparing women's experiences based on the birthing environment in the Spanish context. Consequently, it is crucial to evaluate what aspects contribute to a satisfying birth experience for women, regardless of where they give birth. 2 | BACKGROUND Different authors have identified various elements related to childbirth experiences, such as the mother's individual factors (parity, experiences of female support during childbirth, cultural background and expectations of childbirth); interpersonal factors related to companions and healthcare professionals attending the birth, and factors related to the sense of control and perceived safety, both physically and emotionally (Chabbert et al., 2021; Leinweber et al., 2022; Vedeler et al., 2022). Positive birth experiences are linked with the perception of control over the process, the presence of chosen companions during labour, pain relief and the care provided by healthcare professionals, with special consideration given to continuous support from midwives (Chabbert et al., 2021; Downe et al., 2018; Perdok et al., 2018). Conversely, negative birth experiences are linked with labour induction (Place et al., 2022), medical or neonatal complications (Chabbert et al., 2021; Hosseini Tabaghdehi et al., 2019) and the unnecessary medicalization of childbirth, which undermines a woman's confidence in her own birthing ability (World Health Organisation, 2018). A negative birth experience is associated with an increased likelihood of developing fear or anxiety during subsequent childbirth (Viirman et al., 2023), post-traumatic stress disorder (McKelvin et al., 2021), postpartum depression and difficulties in bonding with the newborn (attachment difficulties) (Grundström et al., 2022; Yildiz et al., 2017). Moreover, a negative experience might influence a woman's choices regarding future pregnancies, birth options and even the timing of further pregnancies (McKelvin et al., 2021; Shorey et al., 2018). The planned birth setting also impacts the birth experience. Several studies have observed that women who planned a home birth had better experiences than women who chose to deliver in hospital. The home-birthing women's better experiences were linked to the factors already mentioned: a greater sense of control over the environment, the ability to make their own decisions about the process, continuous support from midwives, and a lower risk of unnecessary interventions or disruptions (Geerts et al., 2017; Gillen et al., 2023b; Hauck et al., 2020; Zielinski et al., 2015). Among the elements that influence the experience of planned home birth, notable factors include increased accessibility to midwives, the ability to involve family members and comprehensive postpartum care (Janssen et al., 2009). Another aspect is the sense of security related to knowing the midwife or midwifery team beforehand and having confidence in their competence and personalized care (Quattrocchi, 2022; Sandall et al., 2016). According to recent data, home births account for 1%–4% of all births in Europe, but the prevalence alters significantly from one country to another. For example, the Netherlands has a relatively high rate of home births at 16.3%, while Denmark, Germany and Belgium have lower rates (1.4%, 1.3% and 1.1% respectively) (Galková et al., 2022). The prevalence varies based on different healthcare systems, policies and cultural preferences in each country. In Spain, planned home births are generally offered as a private service, provided by midwives (Ortega Barreda et al., 2017). Expectant mothers contact midwives specializing in home births and establish a contractual, care-based relationship, involving continuous support and assistance throughout pregnancy to postpartum, following a model of care continuity. The Catalan Association of Home Birth Midwives (CAHMB) it is a scientific association, one of whose objectives is to conduct research on home birth, examining both maternal and neonatal The questionnaire gathered the participants' email addresses, and a commitment was made to disseminate the study's results through this means. KEYWORDS birth experience, birthplace, childbearing, home birth, midwifery, place of birth, women's health 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 2365 ALCARAZ-VIDAL et al. clinical outcomes, as well as women's experiences. CAHMB has 63 affiliated midwives, who provide care for both home births and births at the Migjorn Birthing Centre, a private facility in Barcelona, Spain. The Migjorn Birthing Centre is designed to provide the typical conditions and characteristics necessary for a home birth when a woman's usual residence does not meet the required criteria for a birth setting. Midwives affiliated with CAHMB follow a common set of guidelines endorsed by scientific societies, and their statutes mandate recording birth data in a shared database (Alcaraz-Vidal et al., 2021). The establishment of such guidelines and data-recording procedures ensures that the care provided by CAHMB midwives adheres to standard practices and allows the collection of valuable information for research and continuous improvement in the field of home births and care of the birth centre (Alcaraz-Vidal et al., 2018). According to Spain's National Institute of Statistics, there were 815 home births attended by healthcare personnel in Spain in 2019, comprising 0.22% of all births that year (Instituto Nacional de Estadística, 2023). Of these, 37.4% (305 of 815) were recorded in Catalonia; of the Catalan home births, 80.9% (247 of 305) were attended by CAHMB midwives (Instituto Nacional de Estadística, 2023). However, data on whether or not these home births were planned in advance are not available, as the INE does not collect information on intended birth settings. Similarly, it is not known how many intended home births eventually delivered in hospital (AlcarazVidal et al., 2021). The lack of specific data on planned and actual birth settings highlights the need for more comprehensive and standardized data collection in the field of home births to better understand and assess the results and experiences of women who choose this birth option in Spain. 3 | THE STUDY 3.1 | Aim The study's main objective was to explore the birth experiences of women with low-risk obstetric pregnancies and no associated complications who planned a home birth in Catalonia. 4 | METHODS 4.1 | Design This cross-sectional study sampled women who planned a home birth from 1 January 2019 to 31 December 2021. Participants completed the Spanish version of the childbirth experience questionnaire (CEQ-E) retrospectively, between 1 and 3 months after giving birth. 4.2 | Study setting and sampling The population was defined as women who wanted a planned home birth and were accepted after an initial evaluation, conducted by the midwives who would monitor the pregnancy and attend the birth. During the first home postpartum appointment, signed informed consent forms and personal contact information for further followup appointments were obtained from candidates who were willing to participate. The signed informed consent forms, along with the women's data, were sent by the midwives to the study's principal investigator. A sample size of 214 participants was determined using the EPIDAT 3.1 statistical programme to estimate a proportion with the following assumptions: a total of 700 births in the 2 years of follow-up, an 80% attendance rate, a 95% confidence level, 5% precision and an expected proportion of losses of 15% dropout rate. 4.3 | Inclusion criteria Convenience sampling was used, with the following inclusion criteria: (i) expectant mothers who could speak either Spanish and/or English, (ii) low-risk obstetric, (iii) singleton pregnancy and (iv) in the cephalic presentation. 4.4 | Validity, reliability and rigour The study collected the following data: the participants' socio-demographic information (age, level of education, country of origin, ethnicity and parity); variables related to childbirth (gestational age, type of birth, intrapartum transfers, pain rating using a numerical scale, use of non-pharmacological analgesia measures and duration of labour); maternal morbidity variables (perineal tear, episiotomy and admission to the intensive care unit) and neonatal variables (Apgar score, baby's weight, type of feeding in the first month and admission to the neonatal intensive care unit [NICU]). The duration of labour was defined as the time, in hours, that elapsed from the active phase of labour to the third stage of labour. The type of feeding in the first month was classified as (i) exclusive breastfeeding (including expressed milk and/or milk from a donor) (Vila-Candel et al., 2021; Winkvist et al., 2015), (ii) exclusive formula feeding or (iii) mixed if the bay's diet combined breastmilk and formula. The breastfeeding status was recorded at the same time the women completed the questionnaire (between the first and third month postpartum). 4.5 | Numerical pain scale Pain was assessed using a numerical pain intensity scale ranging from 0 to 10 (Nugent et al., 2021), where 0 represents no pain and 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 2366 | ALCARAZ-VIDAL et al. 10 represents the worst pain imaginable. This item corresponds to Item 20 on the CEQ-E. 4.6 | Degrees of perineal injury Perineal tears were classified as follows: first-degree tears involve injury to the skin only. Second-degree tears involve injury to the skin and perineal muscles but not the anal sphincter. Third-degree tears involve injury to the skin, perineal muscles and anal sphincter (subtypes A, B and C depend on the degree of involvement of the external and internal anal sphincters). Finally, fourth-degree tears involve perineal lesions that affect both the sphincters and the anal mucosa (Sultan et al., 2008). 4.7 | Childbirth experience questionnaire— Spanish version There are various validated instruments for assessing childbirth experiences across different dimensions. Of these, the CEQ has demonstrated higher validity than other tools (Nilvér et al., 2017). The Spanish version of the CEQ, known as the CEQ-E, was validated by Soriano-Vidal et al. (2016). While there is no specific instrument that addresses home birthing specifically, in previous studies conducted in other countries, researchers have used this questionnaire to measure satisfaction with planned home births (Handelzalts et al., 2016). The CEQ-E screening tool was self-administered and typically took approximately 5–10 min to complete. The questionnaire comprises 22 items related to the birth experience, categorized into four domains: self-capacity, perceived safety, professional support and participation. The first 19 items are rated on a 4-point Likert scale, enabling the assessment of each item based on the woman's level of agreement, ranging from strongly agree to strongly disagree. The last three items measure the remembered sense of pain, control and safety during the birth and are captured using a 4-point visual scale, which is then converted into categorical values ranging from 0 to 100. The final score ranges between one and four and is calculated following the initial version of the CEQ's guidelines. The CEQ-E demonstrated high reliability, with a Cronbach's alpha of 0.88. 4.8 | Data collection Participants completed the online questionnaire. A pilot test was conducted beforehand with 10 women to assess the feasibility of administering the questionnaire in a non-clinical environment; there were no doubts about its applicability. Participants were recruited by the CAHMB midwives using convenience sampling. All the women who were informed about the study chose to participate and provided their consent by signing the consent form. The questionnaire link was sent to them by email 30 days after they gave birth. Data were collated in an anonymized database that was periodically reviewed. The attending midwives contacted the research midwife each time a woman agreed to participate in the study, and the research midwife was responsible for sending the questionnaire link, reviewing the CEQ-E's completion, cleaning the data and ensuring anonymity. 4.9 | Statistical analysis The data analysis involved employing basic descriptive methods to calculate means and standard deviation (SD) for continuous variables, or medians and interquartile ranges (IQRs) for non-normally distributed variables. Categorical variables were summarized using absolute and relative frequencies. The normality assumption of the dependent quantitative variable, birth experience (CEQ-E), was assessed using the Kolmogorov–Smirnov goodness-of-fit test. Due to the non-normal distribution of the CEQ-E variable, the Mann–Whitney U test was utilized to compare the medians between this variable and the categorical variables in two independent groups. We analysed the obstetric variables between women intrapartum transferred to hospital via 2 × 2 tables and the chi-squared test (χ2) for qualitative variables. For categorical variables with more than two groups, the Kruskal–Wallis test was applied. The scores of each item in the CEQ-E were added or subtracted according to the authors' instructions to obtain a total score. A higher score indicates a better experience. Data analysis was performed using the SPSS v.28.1 statistical package (IBM Corp. Released 2018. IBM SPSS Statistics for Windows, Armonk, NY, USA). Statistical significance was considered when p < .05. 4.10 | Ethical considerations The study adhered to the Declaration of Helsinki's recommendations and was approved on 10 October 2018 by the clinical research ethics review board of Ethics Committee for Drug Research, Parc de Salut Mar (study registration number #2018/8120/l). All the participants were fully informed about the study, its voluntary nature and confidentiality. The research team recruited women at home in person and written informed consent was obtained in all cases. Anonymity and confidentiality were guaranteed. 5 | RESULTS 5.1 | Sample characteristics A total of 223 surveys were completed during the 2-year study period, resulting in an overall survey response rate of 100%. Table 1 shows the socio-demographic, obstetric and neonatal characteristics of the participants. Most of the women are Caucasian, 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 2367 ALCARAZ-VIDAL et al. of Spanish origin, multiparous, live with a partner and have a university education. Approximately 75% of the participants were aged between 30 and 39 years, with a mean age of 34.6 years (4.0). Regarding birth plans, 92% of women intended to give birth at home. Most of the births were full term; the 2.3% of births were between 36 and 37 weeks. The duration of labour varied widely, but approximately 73% of the women's labours lasted less than 12 h. The sample's self-reported pain levels ranged from zero to 10, with a median of nine. During labour, 59% of women were immersed in water. The majority opted for non-pharmacological pain relief, with only 0.9% choosing nitrous oxide and 9.9% opting for epidural analgesia. TABLE 1 Demographic, obstetrical and neonatal characteristics (N = 223). Demographic N% Maternal age 18–29 23 10.3 30–39 167 74.9 >40 33 14.8 Country of origin Spain 198 88.8 Foreign 25 11.2 Educational level Non-university 36 16.1 University 187 83.9 Lives in couple Yes 220 98.7 No 31.3 Ethnicity Caucasic 215 96.4 Other 83.5 Parity Nulliparous 87 39.0 Multiparous 136 61.0 Obstetrical Planned place of birth Home birth 206 92.4 Birth centre 17 7.6 Gestational age at birth* <37 52.3 37–42 211 95.0 >42 62.7 Duration of labour (h) <12 h 162 72.6 >12 h 61 27.4 Water immersion Yes 132 59.2 No 91 40.8 Nitrous oxide use Yes 20.9 No 221 99.1 Epidural Yes 22 9.9 No 201 90.1 Non-pharmacological measures Yes 174 82.1 No 38 17.9 Intrapartum oxytocin use Yes 19 9.0 No 193 91.0 (Continues) Demographic N% Postpartum oxytocin use Yes 33 15.9 No 175 84.1 Perineal injury Yes 120 53.8 No 103 46.2 Type of perineal injury Intact 103 46.2 I degree 63 28.3 II degree 44 19.7 III degree 31.3 IV degree 20.9 Episiotomy 83.6 End of labour Euthocic 208 93.3 Instrumental 83.6 C-section 73.1 Intrapartum transfer to hospital Yes 27 12.1 No 196 87.9 Neonatal Birth weight (g) <2500 20.9 2500–4000 205 91.9 >4000 16 7.2 Apgar <7 at 5 min Yes 16 8.2 No 178 91.8 Type of breastfeeding at 1 month Exclusive breastfeeding 202 95.7 Mixed breastfeeding 9 4.3 NICU admission Yes 20.9 No 221 99.1 *One missing value (N = 222). TABLE 1 (Continued) 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 2368 | ALCARAZ-VIDAL et al. Most of the respondents' births were simple and no oxytocin nor other medications were used during labour or postpartum. Perineal injury occurred in more than half of the births, with slightly more than 2% experiencing secondto fourth-degree tears, and 3.6% undergoing episiotomies. A total of 12% (27 of 223) were transferred to hospital during labour. Regarding neonatal characteristics, most of the newborns weighed between 2500 and 4000 g (median: 3459 g) and had an Apgar score greater than seven at 5 min after birth. Furthermore, no newborns required admission to the NICU, and 95.7% were exclusively breastfed. Quantitative analysis of the variables related to birth experience was performed. In general, the respondents rated their birth experiences positively, with a mean score of 3.5 (0.3). Of the dimensions assessed, professional support received the highest rating, with a mean score of 3.9 (0.3), followed closely by participation, with a mean score of 3.7 (0.5) (see Table 2). Contrastingly, own capacity received a low rating, with a mean score of 3.0 (0.4). TABLE 2 Overall CEQ-E score (N = 223). NMinimum Maximum Mean SD Own capacity 223 1.50 3.88 3.0 0.4 Professional support 223 2.00 4.00 3.9 0.3 Perceived safety 223 1.67 4.00 3.3 0.3 Participation 223 1.33 4.00 3.7 0.5 Total CEQ 223 1.72 3.91 3.5 0.3 Item number NMinimum Maximum Mean SD Own capacity Labour and birth went as I had expected 1 223 143.4 0.8 I felt strong during labour and birth 2223 143.6 0.6 I felt capable during labour and birth 4223 141.8 1.0 I was tired during labour and birth 5223 142.7 1.0 I felt happy during labour and birth 6223 143.5 0.7 I felt that I handled the situation well 19 223 2 4 3.7 0.5 As a whole how painful did you feel your childbirth was? (visual pain scale, VPS) 20 223 142.3 1.1 As a whole how much control did you feel you had during childbirth? (VPS) 21 223 143.2 1.1 Professional support My midwife devoted enough time to me 13 223 2 4 3.9 0.2 My midwife devoted enough time to my partner 14 223 143.8 0.4 My midwife kept me informed about what was happening during labour and birth 15 223 143.8 0.5 My midwife understood my needs 16 223 2 4 3.9 0.3 I felt very well cared for by my midwife 17 223 2 4 3.9 0.3 My impression of the team's medical skills made me feel secure 18 223 2 4 3.9 0.3 Perceived safety I felt scared during labour and birth 3223 141.6 0.8 I have many positive memories from childbirth 7223 143.7 0.6 I have many negative memories from childbirth 8223 143.7 0.6 Some of my memories from childbirth make me feel depressed 9223 143.6 0.8 As a whole how secure did you feel during childbirth? (VAS) 22 223 143.6 0.9 Participation I felt I could have a say whether I could be up and about or lie down 10 223 143.9 0.4 I felt I could have a say in deciding my birthing position 11 223 143.7 0.8 I felt I could have a say in the choice of pain relief 12 223 143.7 0.7 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 2369 ALCARAZ-VIDAL et al. Perceived safety was the lowest-rated dimension, with a mean score of 3.3 (0.0). The Mann–Whitney U test revealed significant differences between the women who transferred to hospital during labour and those who did not; the women who experienced intrapartum transfer gave lower scores across all the dimensions. These findings evince that intrapartum transfer is associated with notable differences in the variables evaluated, as summarized in Table 3. Table 4 presents a comparison of the obstetric variables of the women who experienced intrapartum transfer and those who gave birth at home. The analysis reveals several statistically significant variables associated with intrapartum transfer. Namely, labour duration exceeding 12 h, the use of nitrous oxide or epidural anaesthesia, intrapartum administration of oxytocin, dystocic birth, postpartum use of oxytocin, perineal injury and the absence of a midwife's assistance were all significantly related to higher rates of intrapartum transfer. On the other hand, variables, such as immersion in water during labour, an Apgar score below 75 min after birth, NICU admission and the type of feeding in the first month did not show significant associations with intrapartum transfer. These findings shed light on the factors that play a crucial role in determining the likelihood of intrapartum transfer during childbirth. 5.2 | Obstetric variables related to the CEQ-E Our objective was to perform a bivariate analysis to investigate the association between birth experience (considered the dependent variable) and other categorical variables of clinical interest collected in the study. The findings are presented in Table 5, which specifically focuses on the CEQ-E. The results revealed significant differences, indicating more positive birth experiences in certain scenarios. Specifically, better birth experiences are associated with labour lasting less than 12 h (p < .001), the absence of perineal injuries (p = .018), no intrapartum transfer to hospital (p < .001), euthocic labour and delivery (p < .001) and the presence of a midwife during the birth (p < .001). However, no statistically significant differences were found between the birth experience and immersion in water during labour (p = .556), the use of non-pharmacological pain relief measures (p = .765), postpartum oxytocin administration (p = .150), neonatal Apgar scores <7 at 5 min after birth (p = .887) and the type of feeding (p = .606). Regarding perineal injury, which ranges from intact perineum, firstto fourth-degree tears and episiotomy, statistically significant differences were observed concerning the type of injury (p < .001). Upon comparison of the groups, it was found that women with an intact perineum had a significantly better birth experience compared to those who underwent an episiotomy (p < .001). Moreover, women who experienced tears during childbirth reported a more favourable experience than those who had an episiotomy (p = .006). 5.3 | CEQ-E and parity Table 6 provides the item descriptions and statistical results of the CEQ-E for both nulliparous and multiparous women. The items are grouped into four domains: own capacity, professional support, perceived safety and participation. TABLE 3 Comparison of childbirth experience (CEQ-E) between intrapartum-transferred women and home birth (N = 223). NMean SD SE CI 95% Lower limit Upper limit Average rank Sum of ranks p-value Own Capacity Yes 27 2.5 0.5 0.09 2.3 2.7 48.2 1301.5 <.001 No 196 3.1 0.4 0.03 33.1 120.79 23674.5 Total 223 30.4 0.03 2.9 3.1 Professional support Yes 27 3.6 0.6 0.11 3.4 3.8 91.13 2460.5 .014 No 196 3.9 0.2 0.01 3.8 3.9 114.88 22515.5 Total 223 3.9 0.3 0.02 3.8 3.9 Perceived safety Yes 27 2.9 0.5 0.09 2.7 339.74 1073 <.001 No 196 3.4 0.3 0.02 3.4 3.4 121.95 23903 Total 223 3.3 0.3 0.02 3.3 3.4 Participation Yes 27 30.8 0.15 2.7 3.3 50.63 1367 <.001 No 196 3.8 0.3 0.02 3.8 3.9 120.45 23609 Total 223 3.7 0.5 0.03 3.7 3.8 Total CEQ-E Yes 27 30.4 0.08 2.8 3.2 30.15 814 <.001 No 196 3.6 0.2 0.01 3.5 3.6 123.28 24162 Total 223 3.5 0.3 0.02 3.5 3.5 Abbreviations: CI 95%, confidence interval 95%; SD, standard deviation; SE, standard error. 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 2370 | ALCARAZ-VIDAL et al. In terms of their own capacity, both nulliparous and multiparous women expressed satisfaction with their abilities during labour and birth. Nulliparous women reported higher levels of tiredness (p < .001), while multiparous women felt happier (p = .013) and more confident in handling the birth (p = .034). Similarly, multiparous women perceived childbirth to be less painful compared to nulliparous women (p = .043). Regarding professional support, both groups reported high levels of satisfaction with the support provided by their midwives. Multiparous women perceived greater care (p = .042) and support (p = .019). Additionally, they felt that their midwives dedicated more time to their partners (p = .045). Concerning the perceived safety, both nulliparous and multiparous women reported similar levels of fear during labour and birth. However, multiparous women had more positive memories (p = .031) of childbirth and fewer negative memories (p = .04). Both groups reported low levels of feeling depressed due to memories of childbirth, with mean scores of 3.4 and 3.7 respectively (p = .019). Lastly, regarding participation, multiparous women felt more empowered to make decisions about their birthing position and TABLE 4 Comparison of obstetric variables between intrapartum transferred (N = 223). Intrapartum transfer to hospital p-value* Yes No n%n% Duration of Labour (h) <12 h 622.2 156 79.6 .001 >12 h 21 77.8 40 20.4 Water immersion Yes 19 70.4 113 57.7 .207 No 829.6 83 42.3 Nitrous oxide use Yes 27.4 00.0 .001 No 25 92.6 196 100.0 Epidural use Yes 22 81.5 00.0 .001 No 518.5 196 100.0 Non-pharmacological measures Yes 24 88.9 150 81.1 .323 No 311.1 35 18.9 Intrapartum oxytocin use Yes 19 70.4 00.0 <.001 No 829.6 185 100.0 End of labour Euthocic 12 44.4 196 100.0 <.001 Dystocic 15 55.6 00.0 Postpartum oxytocin use Yes 939.1 24 13.0 .001 No 14 60.9 161 87.0 Perineal injury Yes 19 70.4 101 51.5 .066 No 829.6 95 48.5 Type of perineal injury Intact 829.6 95 48.5 <.001 I degree 6 22.2 57 29.1 II degree 725.9 37 18.9 III degree 00.0 31.5 IV degree 00.0 21.0 Episiotomy 622.2 21.0 Midwife assists birth Yes 14 51.9 196 100.0 <.001 No 13 48.1 00.0 Apgar <7 at 5 min Yes 00.0 16 9.3 .135 No 22 100.0 156 90.7 NICU admission Yes 13.7 10.5 .099 No 26 96.3 195 99.5 Type of breastfeeding at 1 month EBF 26 96.3 176 95.7 .877 Mixed BF 1 3.7 84.3 Abbreviations: BF, Breastfeeding; EBF, exclusive breastfeeding; NICU, neonatal intensive care unit. *Chi-squared test (χ2). 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 2371 ALCARAZ-VIDAL et al. mobility during labour than nulliparous women (p = .011 and p = .011 respectively). Both groups reported a sense of participation in the choice of pain relief methods, with no statistically significant difference observed. The analysis of perceived safety indicates that participants, regardless of parity, felt generally safe during labour and birth. They reported low levels of fear, positive and negative memories, and feelings of depression associated with childbirth. The findings suggest that the respondents perceived childbirth as a relatively safe and secure event. The analysis of domain scores in Table 7 reveals significant differences between nulliparous and multiparous women. In the own TABLE 5 CEQ-E score related to obstetrical and neonatal variables (N = 223). N n Mean SD Average rank Mann Whitney U Kruskal– Wallis p-value df Duration of labour (h) 223 <.001 — <12 h 162 3.56 0.19 123.32 3.107.00 >12 h 61 3.33 0.41 81.93 Water immersion 223 .556 — Yes 132 3.49 0.27 109.89 6.284.50 No 91 3.51 0.31 115.06 Non-pharmacological measures 212 .765 — Yes 174 3.49 0.31 107.09 3.203.50 No 38 3.5 0.22 103.8 Postpartum oxytocin use 208 .150 — Yes 33 3.43 0.33 90.68 3.343.50 No 175 3.53 0.22 107.11 Perineal injury 223 .018 — Yes 120 3.47 0.29 102.57 7.312.00 No 103 3.53 0.28 122.89 Type of perineal injury 223 <.001 2 Intact 103 3.54 0.28 125.18 17.461 Episiotomy 83.13 0.30 32.94 Injury 112 3.49 0.28 105.52 Intrapartum transfer 223 <.001 — Yes 27 3.01 0.44 30.15 4.856.00 No 196 3.56 0.18 123.28 End of labour 223 <.001 — Euthocic 208 3.54 0.24 118.43 222 Dystocic 15 2.95 0.37 22.8 Birth weight 223 .272 — <3400 97 3.52 0.25 117.40 5587.0 > = 3400 126 3.48 0.32 107.84 Apgar <7 at 5 min 194 .887 — Yes 16 3.52 0.22 99.41 15.395 No 178 3.5 0.30 97.33 Type of breastfeeding 211 .606 — Mixed BF 9 3.51 0.18 95.72 816.5 EBF 202 3.49 0.30 106.46 Midwife assists birth 223 <.001 — Yes 210 3.53 0.24 117.69 170.5 No 13 2.94 0.38 20.12 Abbreviations: BF, Breastfeeding; df, degrees of freedom; EBF, exclusive breastfeeding; SD, standard deviation. 13652648, 2024, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15989 by Readcube (Labtiva Inc.), Wiley Online Library on [09/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 2378 | ALCARAZ-VIDAL et al. Winter, C., Junge-Hoffmeister, J., Bittner, A., Gerstner, I., & Weidner, K. (2022). Planned Place of birth—Impact of psychopathological risk factors on the choice of birthplace and its postpartum effect on psychological adaption: An exploratory study. Journal of Clinical Medicine, 11(2), 292. h t t p s : / / d o i . o r g / 1 0 . 3 3 9 0 / j c m 1 1 0 2 0 2 9 2 World Health Organisation. (2018). WHO recommendations: Intrapartum care for a positive childbirth experience. World Health Organization. h t t p : / / a p p s . w h o . i n t / i r i s / b i t s t r e a m / h a n d l e / 1 0 6 6 5 / 2 6 0 1 7 8 / 9 7 8 9 2 4 1 5 5 0 2 1 5 - e n g . p d f ; j s e s s i o n i d = B 7 4 2 3 0 C F 9 B 1 B C 0 B E C D F 2 5 F F 3 6 4 C D 5 9 1 7 ? s e q u e n c e = 1 Yildiz, P. 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