Introduction

Although out-of-hospital birth is still a controversial topic, evidence-based literature shows that in high-income countries, in low-risk women, and in well-integrated health systems, homebirth and independent birth centers are associated with fewer obstetrical interventions and equal safety compared to hospital births [1,2,3,4,5,6, 7••]. Sometimes, it is even safer than hospital birth, because it provides fewer unnecessary interventions, offers personalized care, and enhances women’s empowerment [2]. During the COVID-19 pandemic, the interest in out-of-hospital births increased in high-income countries, and the number of women choosing the home or a birth center to deliver has grown considerably. This review aims to give a more in-depth understanding of women’s and health providers’ perspectives on and experiences of out-of-hospital birth services during the pandemic period. It also aims to foment the debate on the desirable better integration among different models of care in childbirth in high-income countries.

Methods

To perform this study, a qualitative synthesis was conducted [8]. The objective was to identify papers relating to out-of-hospital births and COVID-19 published in English or Spanish between 1 January 2020 and 30 June 2022.

Search Strategy and Study Selection

The database search was conducted on PubMed and SciELO. Interdisciplinary approach was taken into account: both databases contain citations and abstracts of biomedical and social sciences literature. Qualitative approach is well-represented in these sources. The following key words were used: “out-of-hospital birth,” “homebirth,” “planned homebirth,” “birth centre,” and “Covid 19” or “Sars-Cov-2.” In Spanish, “parto domicilio/domiciliar/en casa and Covid 19/Sars-Cov-2,” “casa de parto/casa maternidad,” and “Covid 19/Sars-Cov-2” were used. The inclusion criteria comprised primary data analysis characterizing women’s and health care providers’ perspectives on and experiences of out-of-hospital birth during the pandemic, written in English or Spanish and considering high-income countries. A total of 78 articles were initially obtained by data search. Each title and abstract were screened for inclusion. Following deduplication (33), 20 articles were excluded according to the following exclusion criteria: research conducted in middle- and low-income countries (12), systematic reviews (2), guideline and protocol studies (2), and articles addressing other topics (4) (Fig. 1). Twenty-five studies were included in the review. They were carried out in 9 countries (Table 1).

Fig. 1
figure 1

Flow diagram of search and study inclusion

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Table 1 Selected studies.
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Data Extraction

Twenty-five studies were included in the review (Table 1). Full texts were analyzed. A thematic synthesis approach [9] was used to synthetize the data. It was based on an initial coding of the texts and the subsequent development of first-order descriptive categories, a second order of analytical themes, and a third order of domains (Table 2). ATLAS.ti qualitative data analysis software was used to code and synthetize the studies into categories and themes. The analysis synthetizes findings from research conducted in the following countries: the USA (15 studies), Canada (1), Australia (1), Switzerland (1), the Netherlands (2), the UK (2 studies), Spain (1), Poland (1), Croatia (1). Sixteen studies included women, 4 studies included health providers (especially midwives), 1 study included both women and health providers, and 4 studies discussed policies and laws.

Table 2 Analysis: codes, categories, and domains.
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Quality Assessment

Qualitative studies were assessed for quality using the JBI Critical Appraisal Checklist for Qualitative Research (QARI) tool [10]. Threshold for inclusion was confirmation of questions 2, 3, 4, 5, 8, and 10.

Findings

The studies included in this review show the perspective and experience of women regarding home birth during the COVID-19 pandemic [11,12,13,14,15,16,17,18,19,20,21,22,23,24, 25•, 26,27,28,29,30,31,32,33,34,35]. A few case protocols or policies are also discussed [17, 19, 25•, 34]. In the qualitative synthesis, the following themes emerged as significative during the pandemic: (1) increased use of and interest in homebirth and independent birth centers by pregnant women (16 studies); (2) midwives’ perceptions and role (10 studies); (3) reasons of the preference of giving birth in an out-of-hospital setting (17 studies); (4) women’s experiences (10 studies); (5) barriers to access a no hospitalized birth (9 studies); (6) recommendations (12 studies).

Themes were aggregated into four domains: (1) data, (2) midwives’ perspectives and experiences, (3) women’s perspectives and experiences, and (4) policies (Table 2).

  1. 1.

    Data

    Increase of delivery in homebirth and independent birth centers. During the COVID-19 pandemic, more women desired and had a home birth. Most of the studies show a significant increase of out-of-hospital births during the pandemic period [12,13,14,15, 17, 22, 24, 25•, 26, 27, 30]. In the USA in 2020, one out of every 50 births (2.0%) was a community birth [2]. Community birth increased in every states in the USA, from 19.5 to 30% [12, 14, 24]. Homebirth increased from 23.3 to 30%, and birth center birth increased from 9.2 to 13.2% (2, 4]. Increases occurred for all racial and ethnic groups, particularly non-Hispanic Black mothers [12,13,14, 24]. An increase between 20 and 30% of out-of-hospital births is reported also in Poland, in the Netherlands, in the UK, in Australia, and in Croatia [15, 17, 25•, 26, 29, 31]. In Croatia during the pandemic period, the overall prevalence of unplanned out-of-hospital births was 0.4%, against the annual out-of-hospital birth rate reported in the last decade, consistently around 0.05–0.10% of all singleton gestations [17].

  2. 2.

    Midwives’ perspectives and experiences

    The perceptions of community midwives and midwives working in hospital-based care regarding the increasing birth rate in their country are reported [16, 19, 21, 24]. Midwives also reported increased interest in or desire for out-of-hospital birth, increase in the number of enquiries by women relating to homebirth, more confidence in giving birth at home, and better-informed choices about the place of birth [16, 19, 21, 24]. Women with high-risk pregnancies, such as those living with HIV, are increasingly investigating the option of home birth, according to the midwives’ experiences [24]. Findings also show the positive role of community midwives in supporting birthing women during the pandemic and their ability to find innovative ways to offer care in the pandemic situation. Flexibility and their ability to work when supplies or institutional support is limited were particularly useful during this period [13, 16, 19, 26, 27, 29, 31, 33,34,35]. Changes reported in their practices included more wearing of personal protective equipment (masks and gloves); sanitizing their workspace; fewer in-persons visits or childbirth classes; more video calls, phone calls, and virtual prenatal and post-partum visits; and sharing online documents to inform women [26, 27, 31, 35]. Strategies were developed to contrast the lack of PPE, for instance homemade sanitizer and cloth masks [29]. Some difficulties emerged, such as financial strain for independent midwives, due to the loss of job for many parents because of the pandemic [16, 27], and the inability to support women who needed transfer from home to hospital because of the restrictions (health professionals were seen as “support people” or visitors, not as professionals) [29, 31].

  3. 3.

    Women’s perspectives and experiences: the reasons for the choice

    • 3.1 Motivations/reasons for the preference of giving birth in an out-of-hospital setting. More women have chosen out-of-hospital birth due to (a) the perception of the hospital as a more dangerous place in the time of pandemic (greater chance of becoming infected) [15, 17, 20, 30]; (b) the restrictions implemented in facilities [15, 16, 18,19,20, 22, 26,27,28, 30, 31], especially restriction on birth partners and visitors, being separated from the newborn after birth, and restriction on doulas; and (c) fear of unnecessary intervention in response to the pandemic stresses and uncertain condition (i.e., unnecessary induction of labor, cesarean section, etc.) or lack of support [18, 26, 27, 30]. Interest in “freebirth” (giving birth without a professional present) is also reported, particularly for lesbian, bisexual, pansexual, and queer women [28, 31]. Many women had a preexistenting desire for community birth and used the pandemic to justify or consolidate their choice [19, 33].

    • 3.2 Women’s satisfaction. Women who choose to give birth at home or in an independent birth center reported significantly higher satisfaction: they reported to be better informed and less stressed during pregnancy; receiving care in their home kept them safe; fear of contagion was better managed; more autonomy and self-efficacy were also reported [10, 16, 19, 21, 27, 34]. Increases in the risk profiles in community birth (increase of women giving birth to twins, preterm births, breeched newborns, post-cesarean delivery, or persons living with HIV) were also reported [14, 23, 32, 33].

  4. 4.

    Policies

    • 4.1 Evidence reported some logistic, financial, and legal barriers to access an out-of-hospital birth setting, preventing women from a true choice [11, 12, 19, 21, 22, 25•]. Limited accessibility of birth centers (birth setting not close to the women’s home), high costs, and suspended services due to the emergency were reported during the pandemic period.

    • 4.2 Recommendations. According to many studies, the pandemic is an opportunity to restructure reproductive health care, particularly to better support out-of-hospital births [11, 18, 20, 22, 25•, 29,30,31,32,33, 35]. Findings stressed the pandemic served as a positive example of the need to recognize and better integrate in the broader health system home birth services and birth centers. This involves rethinking laws, policies, and practices in order to offer a real choice to all women regarding the model and place of birth. This is recommended due to the positive impact of out-of-hospital services in women’s and midwives’ experiences and in clinical outcomes.

Discussion

The impact of the COVID-19 pandemic had a profound effect on childbearing women, their families, and midwives [36••]. Evidence shows that restrictions and measures taken during the period disrupted the quality of care provided to women during labor and childbirth and respectful maternity care [37] and impacted the choice of the place of birth. On the one hand, fear of being infected or ill led some to perceive hospitals as no longer “safe” places for mothers and newborns. This occurred even if the risk was defined by scientific evidence as contained for pregnant women [38].

On the other hand, the implementation of rigorous protocols in a standardized way (in most cases, for all deliveries and birthing women) discouraged many women from delivering in hospitals and caused them to take interest in alternative models of care. The WHO, since the beginning of the emergency and throughout the pandemic period, has repeatedly recommended not to separate women in labor from their newborn and their companion of choice, even when suspected of or infected with SARS-CoV-2 [38]. Despite these recommendations, separation of mother–partner–child has been implemented all over the world [39]. The impact on the mother and newborn in terms of well-being and “positive birth” [40] has emerged in the literature [41, 42], as well as the lack of exercise of human rights in childbirth and the loss of women’s autonomy in reproductive health [43, 44].

Qualitative studies on out-of-hospital birth carried out between 2020 and 2022 in different countries are discussed within this context. The pandemic has accelerated the demand for homebirth and birth centers, increasing in the last decades in high-income countries (Macdormen and Declerq 2019 [45]. Women’s needs and expectations—well investigated in high-income countries also before the pandemic [46,47,48,49]—were highlighted during the COVID-19 emergency, involving more women and parents. The increasing rate of using homebirth and birth centers shows that out-of-hospital births have been a fundamental “safety valve” to manage fear, uncertainty, and stress during pregnancy and birth for both women and midwives; it has also offered women the possibility to maintain certain autonomy and freedom of choice in the reproductive process. This calls for novel social and political awareness for accessing different models of care (hospitalized or not) as a human right in daily life and as an efficient response strategy for present or future emergencies involving health systems. A novel policy effort to better support and integrate out-of-hospital services in health care systems is urgent in high-income countries. Lessons learned from these experiences during the pandemic represent an opportunity to rethink our models of care in childbirth, focusing on women’s needs and contrasting abuse and disrespect that can turn into forms of obstetric violence, which is well known in research [50,51,52,53,54,55,56] and recently addressed in the debate of international bodies [57,58,59]. Expanding biomedical concepts of safety and risk, while also considering social, cultural, and family dimensions—as clearly emerge from women giving birth at home or in birth centers also before the pandemic, is taken into account in this perspective [54, 60].

Conclusion

Interest in out-of-hospital births has increased during the COVID-19 pandemic. More women have delivered at home or in an independent birth center. Main reasons for this choice are fear of contagion in facilities and standardized protocols, such as restrictions during delivery and the post-partum period, especially women’s separation from their companion of choice and their newborn. Research findings suggest that homebirth and birth centers have conferred several advantages for both women and professionals during the pandemic period, maintaining the benefits of biomedicine when needed. This calls for renewed support for out-of-hospital models of care within a public model of care.