title: Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on 'birthing outside the system'.
abstract: OBJECTIVE
  to identify and analyze literature exploring women׳s motivations to 'birth outside the system'.
  
  
  METHODS
  scoping review and thematic analysis of (mostly) qualitative studies.
  
  
  RESULTS
  fifteen studies of women choosing an unassisted birth, homebirth in countries where homebirth was not integrated into the maternity care system, or a midwife-attended high-risk homebirth were identified from Sweden, USA, Australia, Canada and Finland. Five main themes emerged as the most important factors: (1) resisting the biomedical model of birth by trusting intuition, (2) challenging the dominant discourse on risk by considering the hospital as a dangerous place, (3) feeling that true autonomous choice is only possible at home, (4) perceiving birth as an intimate or religious experience, and (5) taking responsibility as a reflection of true control over decision-making.
  
  
  CONCLUSIONS
  concerns over consent, intervention and loss of the birthing experience may be driving women away from formal healthcare. There is a lack of fit between the health needs of pregnant women and the current system of maternity care. Biomedical and alternative ׳outside the system׳ discourses on authoritative knowledge, risk, autonomy and responsibility must be negotiated to find a common ground wherein a dialogue can take place between client and health professional.
  
  
  CONCLUSIONS
  more research is needed to explore the scope of the phenomenon of women birthing outside the system and the experiences of midwives and obstetricians in the care of such women. This knowledge can be used to improve the maternity care system, so that fewer women will choose to withdraw from it.
authors.affiliation: Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, Vlaardingenlaan 1, 1059 GL Amsterdam, The Netherlands. Electronic address: Lianne.Holten@inholland.nl.
authors.forename: Lianne
authors.initials: L
authors.lastname: Holten
authors.affiliation: Department of Obstetrics & Gynaecology, Academic Medical Center, P.O.B. 22660, 1100 DD Amsterdam, The Netherlands. Electronic address: e.demiranda@amc.uva.nl.
authors.forename: Esteriek
authors.initials: E
authors.lastname: de Miranda
mesh_terms: D002755:Choice Behavior; D036861:Delivery, Obstetric / Q000523:psychology*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006700:Home Childbirth / Q000523:psychology*; D006801:Humans; D008427:Maternal Health Services / Q000639:trends; D008880:Midwifery / Q000639:trends; D036801:Parturition / Q000523:psychology*; D010349:Patient Compliance / Q000523:psychology*; D011247:Pregnancy
keywords: Autonomy; Homebirth; Maternity Care; Risk; Unassisted Childbirth