Objective: to examine the reasons for the variation in home-birth rates bet
ween midwifery practices.
Method: multi-level analysis of client and midwife associated, case-specifi
c and structural factors in relation to 4420 planned and actual home or hos
pital births in 42 midwifery practices.
Findings: women's choice of birth location and the occurrence of complicati
ons that lead to referral to specialist care before or during labour, were
found to be the main determinants of the home-birth rate,Yet, about 64% of
the variation between midwifery practices is explained by midwife and pract
ice characteristics. Higher home-birth rates were associated with a positiv
e attitude to home-birth, a critical attitude to hospital birth for non-med
ical reasons, and good co-operation between midwifery practices and hospita
l obstetricians.
Conclusions: the proportions of planned hospital birth and of referral to s
pecialist care are the most important predictors of the actual hospital-bir
th rate of women receiving midwifery care. Both can be influenced by the mi
dwife through a positive attitude to home-birth, a critical approach to non
-medical reasons for hospital birth, and good co-operation with specialist
obstetricians. It is, therefore, important for midwives to be aware of the
influence that their own attitudes may have on the choices their clients ma
ke about home or hospital birth. (C) 2000 Harcourt Publishers Ltd.