Background
In the Netherlands and a number of other countries, birth centers are considered to be a relatively new type of facility and service through which birth care quality can be improved [
1‐
4]. In particular, hospital-based centers, or alongside centers that are located in close proximity to hospitals, are designed to provide an intermediate option of care between home and hospital birth. In these centers the mutual collaboration and/or affiliation with a hospital (for births with medical complications) is facilitated. Moreover, these centers are expected to provide a safe and easily accessible place of birth as well as personalized care that relies on meeting specific health needs. The premise of birth center care is to optimize the involvement of women in planning their own pregnancy and birth care by providing flexible options [
5‐
8].
Birth centers are emerging in countries such as Sweden, Germany and the United Kingdom and the demand for these healthcare facilities is increasing [
9‐
11]. A Dutch study showed that women are positive about birth centers because of the safe and convenient feeling, nice atmosphere and reassurance that medical help is directly available [
12]. Moreover, women who gave birth in a birth center felt in control, which is desired by many women and is known to be associated with higher satisfaction with the birth experience [
13,
14]. The same Dutch study, however, also showed that some women disliked their experience in a birth center either because of busy birth attendants or because they were expected to leave quickly after the birth [
12].
In the Netherlands, the first birth centers were established in 1883 in order to contribute to the education of midwives and to provide poor women with a safe place to give birth. Over the past century, the aim shifted towards a safe way to avoid ‘high-tech’ obstetrics in hospitals with low-risk pregnancies [
8]. In addition, during the beginning of the twenty-first century, many birth centers were established in the Netherlands as an answer to the problem of a shortage of midwives and a resulting increase in hospital births
1 [
8]. Despite the emergence of birth centers, the Netherlands still has a high percentage of home births, which is one of the features that makes the Dutch system of maternity care unique in the world [
15,
16]. To date, it remains unclear whether the expectations of female clients are better met in birth centers than in hospital or home births and if the offered birth care connects to the needs of different social groups, such as non-Dutch women, including first, second and third generation immigrants [
6,
8,
17].
In 2009, the Steering Committee on Pregnancy and Birth
2 [
18] advised the Dutch government to focus particularly on pregnant women in disadvantaged situations, e.g., non-Dutch women. Non-Dutch women could experience problems with regard to the use of health care due to their different cultural backgrounds and unfamiliarity with the Dutch maternity care system [
2,
19,
20]. This is accompanied by the problem that information about the necessity and possibilities of maternity care assistance
3 does not reach them sufficiently [
21,
22]. Consequently, these vulnerable groups underuse maternity care and, in addition, there is a mismatch between their specific care needs and the actual provided maternity care. This is problematic as non-Dutch women in the Netherlands face the highest risk of poor health outcomes for themselves and their (unborn) children [
2]. Health (i.e., pregnancy) outcomes for this group can be improved by narrowing the information gap and offering customized care with specific attention to their medical, psycho-social and social problems [
2].
Because of their adaptability to meet the needs of non-Dutch women in disadvantaged situations, birth center projects were mostly initiated in the urban areas of the Netherlands and cities such as The Hague. As the third largest city of the Netherlands, The Hague has a high proportion of Western (15.6%) and non-Western immigrants (34.4%). Many of them have a low socio-economic status (SES) and live in disadvantaged areas of the city [
23]. Moreover, the perinatal mortality figures are highest here compared to other cities in the Netherlands [
2].
The birth center project that was initiated in The Hague will be specifically focused on the collaboration between primary and secondary birth care
4 and on better meeting the needs of pregnant women in disadvantaged situations. The provided care will not only be focused on birth care provision during pregnancy and childbirth, but also during the postpartum period. Moreover, the project has the intention to engage all healthcare professionals who are involved in care during pregnancy, childbirth and the postpartum period to be able to offer the care that is needed; this will result in the best possible care in every situation. This means that a broad range of healthcare professionals such as gynecologists, midwives, general practitioners and maternity care assistants will actually be present in the birth center. Furthermore, other healthcare professionals who might be needed to support the women during pregnancy and childbirth such as physiotherapists and psychiatrists are available when needed. The birth center will offer comprehensive services and facilities during pregnancy and after birth to fulfill the individual wishes of different women. As a result of close collaboration with the hospital, anesthetic care is available. In case of medical complications, e.g., when the baby is premature or when a caesarian section is needed, the women will be transported to the hospital.
It is expected that women have high preferences for these features of the birth center as they make it possible to meet different needs (e.g., the possibility for the partner to stay overnight or an intimate atmosphere). The center will be unique as it will be established in the Medical Center Haaglanden, the clinical training hospital of The Hague, which ensures that women can immediately be transported to the hospital in case of medical complications. To reach its goals the birth center has three main objectives: (1) connecting the given care to the specific needs of different social groups; (2) providing prenatal and birth care, offering customized information about pregnancy and child birth to each social group and, ultimately, (3) countering the high perinatal mortality rates [
2].
Aim of this study
The aim of this study was to analyze the preferences of pregnant women living in the city of The Hague for services and facilities that could be offered in the new proposed birth center. Meeting the preferences of women in disadvantaged situations requires clarity about the factors that cause differences between ethnic groups. When such differences are found, it can confirm the need for specific birth care that fulfills personal wishes. Specifically, this study analyzed the influence of ethnicity in relation with education on birth center care preferences.
In this paper the three steps and objectives of this study were as follows:
(1).
To provide information about preferences among pregnant women for birth center care as proposed by the project;
(2).
To explore ethnic differences in the preferences for this specific form of birth center care, and finally;
(3).
To explore the mutual influence of ethnicity and education in the preferences for this specific form of birth center care.
Discussion
In this paper we investigated the preferences for a specific form of birth center care among pregnant women with different ethnic backgrounds living in The Hague, the Netherlands. The analyses were based on a survey conducted among 200 respondents, measuring preferences for three dimensions or aspects that are distinctive for birth care in the new proposed birth center: practical information, comprehensive care and comfortable accommodation. These dimensions were expected to match with the preferences and needs of Dutch and non-Dutch women. Non-Dutch or ethnic minority women were assumed to have stronger preferences for care offered in this birth center as they have specific needs and personal circumstances requiring customized and tailored services.
Overall, the women who participated in this study had relatively strong preferences for the proposed birth center care. These findings need to be interpreted with caution as it is difficult to categorize the results as positive or negative due to a lack of benchmark or norm. Our results seemed to indicate that, similar to women from other countries, women from the Netherlands were highly interested in the services that could be offered by a birth center [
9‐
11]. However, Borquez and Wiegers’ (2006) study [
12] showed that women in the Netherlands experienced home birth more positively than giving birth in a birth center; they perceived less pain, desired less pain-relieving medication, believed they knew their midwife better and rated their birth setting as ‘higher’. It is possible that, although women’s preferences are better met in a birth center, the actual experience of giving birth is better in their own trusted environment.
When focusing on the differences between ethnic groups, it showed that Non-Dutch women significantly judged the care in the proposed birth center to be better than Dutch women; this is because they had stronger preferences for the offered care during pregnancy, childbirth and the postpartum period. This can be explained by their different cultural customs and, as a result, their unfamiliarity with the Dutch healthcare system and the available home birth option. Besides, as some non-Dutch women do not speak sufficient Dutch, the offered maternity care does not always meet the health needs of these women and makes them in need of more guidance. The results of our study supports the expectation that for these specific groups, birth centers may provide personalized care, flexible options and the possibility to be involved in planning their own care [
6‐
8]. As the survey data used in this study specifically focused on
preferences for birth center care, it remains to be further researched whether or not the individualized care delivered in a birth center, in a culturally diverse urban area such as The Hague, will actually lead to improved birth outcomes. A study from the United Kingdom showed that care provided in a birth center positively influences pregnancy and child birth, e.g., women were less likely to have a C-section and more likely to carry to term [
24].
A second result from our analysis was that, among the higher educated, non-Dutch women displayed a significantly stronger preference for all three dimensions of birth center care, i.e., extensive practical information, comprehensive care and comfortable accommodation. Education stimulates critical thinking and increases the health literacy skills of individuals. While bearing this in mind, it can be assumed that higher educated women take more initiative in searching or asking for information and are more demanding. As result, higher educated women are less satisfied with the offered birth care and/or have higher preferences for birth care because they tend to be more critical [
25,
26]. This will trigger maternity care professionals to offer care in a dedicated and customized way for specific clients. In any case, it remains essential to educate non-Dutch women about pregnancy and childbirth to increase their involvement and to make them aware of the different settings in which they can give birth to their child.
It is important to bear in mind that this study was performed before the actual realization of the birth center in The Hague. The preferences of women were measured and analyzed for an as yet non-existing, proposed birth center in their city. Therefore, future (longitudinal) research should take a closer look at the advantages of birth centers and should examine to what extent birth centers actually fulfill the personal wishes of specific social groups such as ethnic minorities. When more insight into the contribution of different birth centers is available, evidence from policy evaluation research can lead to helpful suggestions concerning the design of birth centers in urban areas such as The Hague where inhabitants in disadvantaged situations are included.
Future research should also pay attention to factors other than ethnicity that probably play an important role in explaining women’s preferences for different aspects of birth center care. As our regression models showed, ethnicity and education were important determinants for preferences for birth center care. The low explained variance of the regression models also indicated, however, that many other explanatory factors are probably missing, e.g., household composition, income level, previous cultural and birth care experiences or the support received from family.
Strengths and limitations
A major strength of this study was the high response number, also by non-Dutch women. Of the 208 pregnant women that were invited for the survey, 200 women (96%) completed the questionnaire, which means an almost perfect response rate. This was possibly due to the role of the midwives in asking the women to participate in the study. Another strength was that, through the support of the telephone interpreter and the personal way in which respondents were approached, many non-Dutch women (66%, N = 186), who often are reluctant to participate in similar studies, could be included as well. The interpreter enabled non-Dutch women to participate and to fill in the questionnaire completely. This provided unique information, often not available in survey research on this scale, also allowing comparison of women from dissimilar cultural backgrounds.
This study also has limitations. Due to the fact that mainly women in a disadvantaged situation participated, the findings might not be easily generalized to other projects as it is not representative for the Dutch population. Still, we were able to analyze substantial variations in our sample of women, which provide useful information for our research aim. As a result, a recommendation for future research is to include more municipalities with different social compositions.
Second, this study only focused on preferences of women for different characteristics of maternity care that were presented as being provided in the proposed birth center. Knowledge about the current satisfaction levels of pregnant women in The Hague with birth care elements is lacking. Women could, for instance, be dissatisfied with the comprehensiveness of care because they want to receive care in another manner. As all interviewed women visited the same midwifery practice, it is possible that their preferences partly reflect the care they are currently receiving. Moreover, other aspects that are important to (non-)Dutch women remain unknown. Therefore, future studies should conduct qualitative research among focus groups or individuals from multiple practices to gain insight into other important aspects.
Finally, the questionnaires that were filled in with the help of an interpreter could have led to social desirability in the answers, thereby introducing bias. Women could have felt obligated to please the telephone interpreter. However, social desirability during a telephone interview is lower compared to social desirability during a face-to-face interview.
Acknowledgements
We would like to thank all the midwives for their assistance with recruitment and data collection.