Objective: to examine the reasons for the variation in home-birth rates between midwifery practices. Method: multi-level analysis of client and midwife associated, case-specific and structural factors in relation to 4420 planned and actual home or hospital births in 42 midwifery practices. Findings: women's choice of birth location and the occurrence of complications 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 practice characteristics. Higher home-birth rates were associated with a positive attitude to home-birth, a critical attitude to hospital birth for non-medical reasons, and good co-operation between midwifery practices and hospital obstetricians. Conclusions: the proportions of planned hospital birth and of referral to specialist care are the most important predictors of the actual hospital-birth rate of women receiving midwifery care. Both can be influenced by the midwife 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 make about home or hospital birth. © 2000 Harcourt Publishers Ltd.
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