The Story of (Dis)Integration: A Biocultural Analysis of Midwifery Integration and Home-to-Hospital Transfer in the United States

The percentage of home births is small but increasing in the United States, with approximately 30,000 birthing people choosing to attempt a home birth every year before the COVID-19 pandemic, with the number of home births increasing significantly during and after the pandemic. An important aspect of home birth is home-to-hospital transfer, which occurs when the maternal parent and/or newborn needs to transfer care from the home to the hospital. Transfer rates, outcomes, and experiences are differential between U.S. states due to varying levels of midwifery integration, which is described as 1) the degree to which midwifery care is incorporated into state-level legislation and hospital policy, and 2) how people have integrated their transfer experiences into their lived experience. To examine midwifery integration, this dissertation uses a biocultural approach founded on evolutionary theories of human childbirth practices, as well as cultural theories around midwifery and biomedical models of care. Furthermore, this dissertation uses a multimethod approach to home-to-hospital transfer in the U.S. using the Midwives Alliance of North America (MANA) Stats 4.0 database and interview data from birthing people, doulas, and midwives in the Midwestern U.S. The first chapter, “Now it’s safer to stay home”: Home birth, transfer, and risk during the COVID-19 pandemic” uses transfer narratives and interviews from birthing people, doulas, and midwives who attempted a home birth in the Midwestern U.S. during the COVID-19 pandemic. The second chapter, “Midwifery Integration and Home-to-Hospital Transfer Rates in the United States” uses the Midwives of North America (MANA) Stats 4.0 database to examine how integration and midwifery legislation impacts intrapartum, postpartum, and newborn transfer rates in the U.S. The third chapter “Comparison of Outcomes Between Birthing People who Transferred and Those Who Did Not Using the MANA Stats 4.0 Database” compares the outcomes of individuals in MANA Stats 4.0 who transferred care to the hospital and those who stayed at home. Finally, the fourth chapter Holding the Space for Doula Integration in the United States explores my own experiences as a birth doula in Indiana, and how I have experienced instances of (dis)integration within my own practice. Using my own narratives, I offer suggestions for midwifery and doula integration for more caring, better integrated futures for birthing people and their families in the U.S.