An important starting point for any review is operational definitions of the concepts under review. Given the rise in literature reporting on unassisted or free birthing, on Babies Born before Arrival (BBA’s) to hospital, and the increased visibility of birthing supported by unregistered attendants, operational definitions of planned home birth and maternity care providers are central.
Operational definition of terms
We define:
Planned home birth
as an informed decision by women to birth their baby at home with the support of maternity care providers.
Maternity care providers
as healthcare providers involved in supporting women to plan their birth at home. These will include midwives, obstetricians, general practitioners, (G.Ps) anesthetists, paediatricians, and paramedics.
Rationale for focus on planned homebirth in middle- and high-Income Countries
The organisation of health care differs between countries and between low and middle-income countries and middle and high-income countries. The focus of this review is on middle and high-income countries. The classifications are provided below.
Country Classification
According to the World Bank classification 27 , high-income countries (also known as developed countries) are countries with per capital gross national income (GNI) of at least $12, 476 as of 2018. For example, Argentina, Australia, Barbados, Canada, Chile, Croatia, Denmark, New Zealand, France, Germany, Finland, Portugal, Spain, Sweden, Switzerland, United Kingdom, United States of America etc. Middle-income countries have per capita GNI between$1, 025 and $12,476 as of 2018. For example, Angola, Bangladesh, China, Cameroon, Ghana, India, Kenya, Indonesia, Nigeria, Pakistan, Philippines, Sri Lanka, Sudan, Tunisia, Vietnam, Zambia. Low-income countries are those with GNI per capita of $1, 025 or less as of 2018. For example, Afghanistan, Benin, Burkina Faso, Burundi, Central African Republic, Chad, Democratic Republic of Congo, Eritrea, Ethiopia, Gambia, Guinea, Guinea Bissau, Haiti, Korea, Liberia, Madagascar, Malawi, Mali, Mozambique, Nepal, Niger, Rwanda, Sierra Leone, Somalia, South Sudan Tajikistan, Syrian Tanzania, Togo and Uganda, Yemen Rep.
Search strategy
Using a systematic approach28, we will develop a search strategy to identify relevant research studies on women’s experiences of planning a home birth, with the support of their maternity care providers. Search terms will be iteratively developed using text words derived from the review aim, the PICO framework29 (Population, Intervention, Comparison and Outcome) (Table 1) and database-indexed terms. Broadly, search terms will be words related to: (home birth OR childbirth) AND plan AND experience (see appendix 1 for a detailed draft of the Medline search). We will test and refine the search strategy for accuracy on Ovid Medline prior to running it on other databases. This refined search strategy will be utilised on seven bibliographic databases: Ovid Medline, Embase, PsycInfo, and CINAHL plus, Scopus, ProQuest and Cochrane (Central and Library) from January 2015 to 26th May 2020. We decided on January 2015 as our cut off point for the searches as the publication of the NICE clinical guideline (CG190) on Intrapartum Care for Healthy Women and Babies was December 2014, which advocated for home birth as a choice of place of birth for women. In line with the Peer Review of Electronic Search Strategies (PRESS) guidelines30, we will develop the search strategy in consultation with an experienced subject librarian, which will be checked by at least two authors.
We will tailor the refined search terms to each database’s indexing requirement. Boolean operators ‘AND’ and ‘OR’ will be used to combine search terms as appropriate. We will also use quotation (“) and truncation (*) marks to capture possible variations of the search terms on each database. We will further conduct supplementary searches to identify additional articles, which we may have missed during the electronic database searches. This will include back chain referencing of included papers (hand searching of reference lists), consultation with members of the Regulation and Quality Improvement Authority (RQIA) Planning to Birth at Home in Northern Ireland12 guideline development group, professional networks and grey literature search (for example, OpenGrey). We will run the searches again on the selected databases prior to the final analysis in order to identify any article newly published since our last search. We will manage search results with the bibliographic databases Endnote, Refworks and Covidence. Deduplication of retrieved articles will be undertaken on Endnote and Covidence using a systematic method31. The review is registered on the International Prospective Register of Systematic Reviews (PROSPERO: Registration ID: CRD42018095042)
Table 1
Population | Inclusion Criteria • Women who planned or are planning a home birth within the context of a middle or high-income country in consultation with maternity care providers Exclusion criteria • Women who had an unplanned or unassisted/free home birth • Women planning a home birth without consulting with a professional maternity care provider • Women who planned or are planning a home birth within the context of a low-income country (low income countries are excluded because their healthcare provision or context is different to that of middle to high-income countries) |
Intervention/Exposure | Primary studies which: (1) focused on the planning phase of the home birth experience for women (planned home birth as defined above) and (2) reported on women’s experiences of planning their home birth with their maternity care providers |
Comparator | Not applicable |
Outcome(s) | (i) Women’s experiences of planning a home birth (ii) Women’s perceptions of their consultation with maternity care providers to plan a home birth |
Identification and selection of studies
Studies will be identified and selected based on the following inclusion and exclusion criteria:
Inclusion criteria
Primary studies, which investigated women’s experiences of planning a home birth within the context of middle and high-income countries, reported in English language and published between January 2015 and May 2020 will be included. Studies that report on women’s experience and/or perceptions of their consultation with maternity care providers when planning a home birth will be also be included.
Exclusion criteria
We will exclude grey literature, which lacks a clear methodology (for example, editorials and books), conference abstracts whose full papers cannot be accessed and PhD and MSc dissertations. We will also exclude studies focused on healthcare professionals’ or partners’ views on home birth planning. We will exclude home birth studies that lack clear separate data on women’s experiences of the planning phase of the home birth, and studies conducted in low-income countries.
Screening
Following deduplication on Endnote, we will upload the remaining articles into a systematic review management software by Cochrane32 to manage the screening process in a rigorous and transparent approach in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA)33. At least two reviewers (MH, OB or PG) will independently screen the titles and abstracts) of retrieved studies to remove irrelevant articles. Two authors will resolve any conflicts and if not possible, a third author will review and then all three authors will reach agreement. Two authors (MH, OB or PG) will then screen the full text of potentially relevant articles against the review’s inclusion and exclusion criteria. We will resolve differences in opinion through discussion (by a minimum of two authors) to reach a mutual agreement. We will report the study selection process on a PRISMA diagram (see Fig. 1).
Quality appraisal
At least two reviewers (MH, OB or PG) will independently appraise the quality of the included studies using an appraisal tool relevant to each study’s methodological design. We will appraise studies using the Critical Appraisal Skills Programme (CASP) tool34 suited to each study’s design. For example, qualitative studies will be assessed using the CASP tool for qualitative studies. We will appraise RCT studies (if included), using the CASP tool for RCTs, although we do not expect to find any RCTs due to the nature of the review question. We will assess other quantitative studies (non-RCTs), using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool35. Mixed Methods studies will be assessed using the Mixed Methods Appraisal (MMAT) tool36. We will assess risk of bias in RCTs (if included) using the Cochrane risk of bias tool37 and the Confidence in the Evidence for Reviews of Qualitative Research (CERQual) tool38 for qualitative studies.
Data extraction
At least two reviewers will extract data using a standardised form on MS Excel or MS Word. Conflicts will be resolved through discussion. We will systematically extract data on outcomes related to women’s experiences on planning a home birth with their maternity care providers. We will extract data on the study title, author(s) and year of publication, study setting, methodology, population, key findings, quality appraisal score and key conclusions. Where possible, we will attempt to retrieve missing data in relevant studies by contacting the corresponding author.
Data Analysis
At least two reviewers will analyse aggregate data from the final included studies and resolve any conflict through discussion. The approach for data analysis will be determined by the methodological design of the included studies. If the studies are not sufficiently homogenous (for example, inclusion of a mixture of qualitative and quantitative studies), we will conduct a narrative synthesis. If all studies included are qualitative studies, we will undertake a thematic synthesis39. NViVo 12 software will be used to manage the data analysis process where appropriate.