INTRODUCTION

A key principle of the midwifery model of care in Canada is the choice of birthplace.¹ In Ontario, midwives are the only primary care providers explicitly trained and authorized to conduct births in OOH settings such as birth centers or at home.² With up to 4,000 births per year in Ontario occurring at home,³ preservation of home birth as a safe and accessible option relies on the continued competence and confidence of midwives in home birth care.⁴ Assessing OMEP graduates’ preparedness to practice home birth is essential to informing curriculum development to meet midwifery students’ learning needs related to home birth education and training.

This article is the second of two companion articles in this issue that provide the first examination of OMEP alumni’s perceptions of their preparedness for home birth practice upon graduation. Part 1 provides a background and context for our research question and discusses the quantitative findings from our mixed-methods study. In Part 2, we provide a thematic analysis of the qualitative data and, through the words of our participants, explore the main factors that impact their learning to be competent and confident at home birth. An upcoming article will describe findings that explore the meaning of home birth to midwives through sensory experiences, metaphor, and imagery.

METHODS

Recruitment and screening

Participants were recruited through a survey link shared in online groups and on social media. Eligible participants graduated between 2018 and 2023 with a Bachelor of Health Sciences (BHSc) in Midwifery from one of three OMEPs: Laurentian University, McMaster University, or Toronto Metropolitan University (TMU). The TMU Research Ethics Board reviewed and approved this study (REB #2023-225).

Data collection

Seventy-four participants completed a survey, producing the quantitative data reported in Part 1 of the study. The survey also included short answer questions and 12 of the 74 participants opted to answer open-ended questions in Zoom interviews. The short answer questions and interviews provided the qualitative data presented in this article.

Data analysis

A professional transcription service transcribed Zoom interviews verbatim, omitting filler words and utterances. The transcripts were then verified and de-identified to protect participant confidentiality. A reflexive thematic analysis approach⁵ identified common themes in the short answer survey questions and interviews. The thematic analysis employed a combination of inductive methods deriving codes and themes directly from the data and deductive methods applying existing knowledge to inform and contextualize themes within the dataset.^6,7 Two authors independently coded five transcripts (ensuring diversity in participants), then worked together to establish an initial coding framework. All interviews were coded using the NVivo 12 software. As the analysis progressed, the framework was updated to accommodate new codes not aligned with the existing categories. These coded data informed the creation of thematic memos, wherein codes with similar content were consolidated into potential themes. These thematic memos underwent an iterative process of review and refinement by the two authors for consensus. Once refined, the memos were presented to the broader team for additional input. As a research team consisting of midwives who practiced in Ontario for over 30 years and current students in the OMEP, we were mindful of our personal experiences and perspectives on home birth and midwifery education throughout the data analysis process. Theoretical lenses of feminist pedagogy, situated learning, and Benner’s stages of clinical competence informed our analysis.^8–10

RESULTS

We identified six factors that shaped perceived competence and confidence in conducting home births and organized these factors into two theme categories: (1) preclinical courses and case-based tutorials and (2) clinical placements. After exploring these factors, we highlight three key recommendations identified by participants.

Preclinical and tutorial factors

In the first three semesters, OMEP students typically take preclinical courses that build foundational knowledge and skills. This is followed by six semesters of placements combined with in-person workshops and online tutorials designed to bridge theoretical learning with practical application.

Evidence-based curriculum normalized home birth

Early exposure to evidence supporting home birth played a crucial role in normalizing out-of-hospital (OOH) practice and shaping students’ confidence. Several participants explained that comprehensive research on the safety and benefits of home birth presented early in the program positively influenced them:

Professional guidance and peer learning

Participants benefited from insights about home birth from experienced midwives. Course instructors who shared positive home birth stories helped build comfort and confidence:

Participants valued tutors who spoke highly of physiologic birth, normalized it, and encouraged students to seek as many OOH births as possible. They felt they benefited from conversations or case scenarios involving home births and tutors prompting students to consider if transfers to the hospital could have been resolved at home.

Participants highlighted how OMEP’s design promoted peer-to-peer interactions with others in their cohort, such as “check-in” during the first hour of tutorials. For some participants, such collaborative learning environments enriched their educational experience by providing access to diverse perspectives and a shared pool of knowledge. However, several participants considered student-led learning during tutorials as missed opportunities to learn from experienced midwives.

Limitations on home birth coverage in the curriculum

Participants described the curriculum’s integration of home birth within the framework of midwifery principles as critical:

However, some participants reported gaps in the coverage of home birth throughout the OMEP curriculum that left them feeling inadequately prepared.¹¹ They described discussions about home birth in preclinical courses as superficial and sometimes relegated to a peripheral rather than fully integrated topic:

Some participants relied on personal past experiences rather than the OMEP curriculum for their understanding of home birth:

Several participants could not recollect any way in which tutorial sessions impacted their comfort in conducting home births. Instead, they recalled that it was mainly “preceptors who took on that role” (Laurentian, 2022) within their placements.

Focus on complications in birth education and the role of medicalization

Participants reported that increasing focus on complications during the prenatal, intrapartum, and postpartum stages as they advanced through the OMEP came at the expense of reinforcing the normalcy of birth, thereby making “home birth seem a little scarier.”

Many participants expressed that topics related to home birth were disproportionately centered on emergencies and when to transfer care, often leaving students feeling more equipped to handle complications than to support a typical home birth scenario.

Some participants perceived that the increased focus in senior courses on managing complications may stem from a growing medicalization of birth in the health system, coupled with legal pressures:

For others, the program’s depiction of the midwife’s role in home births was reported to be “romantic” and not aligned with the challenges of offering choice of birthplace in a medicalized system:

Participants pointed out the difficulties of navigating interprofessional relationships, outdated hospital policies, hospital politics, managing client expectations within the scope of professional practice, and the fear of legal liability. One participant perceived that new clinical practice guidelines had an increased focus on medical interventions, such as electronic fetal monitoring and neonatal resuscitation, which restricted their ability to embrace and confidently prioritize client choice of OOH birth.

Clinical placement factors

In the last six semesters of the OMEP, students participate in clinical placements, which serve as a critical nexus to apply theoretical learning. Participants reported that exposure to home births in placements was crucial in preparing them to conduct home births as new registrants.

Practice culture

Midwifery practice groups that presented a positive outlook on home birth provided learning opportunities considered invaluable by students and essential to building confidence. Such environments often included practice meetings focused on home birth, home birth information sessions for clients, and space in the clinic where clients could plan an OOH birth. One participant shared that at their clinic:

Students in these practices gained extensive hands-on experiences that built an invaluable skill set that they carried with them as practicing midwives:

The scope of OOH experiences varied across placements, and participants placed at clinics with low home birth rates noted a gap in their exposure and subsequent confidence:

Participants perceived that some practices leaned toward a medicalized model of midwifery practice and sometimes overtly discouraged home births because they were thought to be “dangerous and risky.” Some reported that clients who were planning home birth were “risked out” because of a low threshold for transferring care to hospitals:

Some clinics’ practices were influenced by prevailing attitudes and policies at their hospitals. One participant shared how they “felt that there was discussion in each of my placements around ‘community standard’, like being afraid of the obstetrician, being afraid of what would happen if you had to transfer in.” (TMU, 2022)

One participant emphasized that comfort in hospital settings may inversely affect confidence in home births, with a tendency to become more risk-averse and less tolerant of the normal birth process outside the hospital environment:

Preceptor attitudes and expertise

During placements, preceptors played a critical role in fostering students’ competence and confidence in conducting home births. The majority of participants highlighted the value of working alongside preceptors who not only demonstrated enthusiasm and confidence in OOH births but also actively involved them in the process.¹¹ These preceptors displayed a strong belief in the normal physiologic birth process and maintained a calm demeanor, instilling confidence through role modelling and reducing apprehensions about home births:

In environments with fewer OOH births, some preceptors created rich learning opportunities by involving students in prenatal informed choice discussions (ICDs), sharing home birth stories, reviewing cases, and involving students in setting up and refilling home birth equipment. In the absence of OOH experiences, preceptors who advocated for and exposed students to unmedicated physiologic births in hospital settings were also key to developing confidence.

Conversely, participants with preceptors who exhibited discomfort, anxiety, fear, and a low threshold for transferring care to hospitals during home births reported feeling diminished confidence and that their preceptors did not facilitate competence:

Recommendations identified by participants

Participants were prompted to provide recommendations to improve home birth training for current midwifery students. They suggested shifts in three fundamental areas: curriculum content and delivery, the role of mentors, and strategies for increasing OOH births.

Integrative strategies for home birth education in the curriculum

Reflecting on their time in the OMEP, many graduates advocated for increased emphasis on the physiological processes of childbearing and birth in all courses:

Participants acknowledged the importance of being prepared to handle complications that may arise during a home birth; however, they reflected that it would be “sometimes nice to just have those reminders that birth can be and is a natural process” (Laurentian, 2019), indicating a need for balance in education between managing emergencies and supporting normal, physiologic birthing processes:

The recommendation for integrated home birth education extended to more in-depth foundational education on supporting physiologic labor and birth:

Participants voiced the need for regular, detailed discussions that examined theoretical scenarios and also included practical management of situations that may arise during home birth. To better prepare students for conducting home births, participants widely recognized the value of simulation, especially when direct clinical experiences were scarce. Through simulations, participants appreciated the opportunity to be immersed in the practicalities of setting up for home birth, including becoming familiar with equipment and managing typical and emergency scenarios in an OOH setting. Participants suggested active learning techniques utilizing mock setups, role-playing, and realistic elements such as packing birth bags and creating home birth checklists and emergency drills. They elaborated that simulation classes or workshops should also focus on specific practical skills, including determining where to hang an IV and effectively communicating on 911 calls and with interdisciplinary teams for transfers. Participants also suggested preparation for nonclinical aspects of home birth, such as effectively being present in a client’s space.

While the value of simulation was undisputed, participants also acknowledged its limitations, as a simulated home birth cannot fully capture the pressures and emotional dynamics inherent to an actual home birth:

Mentorship and positive role modeling

Participants highlighted the indispensable and fundamental role of OMEP preceptors and educators acting as mentors and conveyors of extensive practical knowledge on home birth. Participants emphasized the critical need for direct learning from experienced midwives through case studies, story sharing, and workshops, with a focus on debriefing and reflective learning. Many students reported that their most invaluable lessons came from senior-year preceptors, who shared clinical wisdom along with practical insights:

To promote effective mentorship, participants recommended supporting preceptors with continuing education, including current evidence-based practices and mentorship skills specific to home birth. This training was highlighted as a necessity:

Participants extended the need for effective mentorship and role modeling to the importance of leveraging real-world experiences of practicing midwives within class-based content:

Participants also recommended involving birthing parents to help students understand the importance of supporting home birth:

Logistical and structural changes

Participants discussed the mandated minimum of 10 OOH births for registration, and that the diversity and scope of placements may not be adequate to ensure competence and confidence in home birth. The current CMO requirement, while ensuring basic exposure to OOH births, was described by some participants as insufficient for equipping future midwives to handle the complexities of home birth care. Some advocated for an increase in the minimum number of OOH births:

Others identified the minimum required OOH births as a source of stress, given the declining rates of home birth in Ontario.

To address these concerns, participants saw benefits in doing placements in high home birth practices and/or workshops specifically focused on rural or low-resource settings, birth centers, and other OOH settings. Such placements were viewed as opportunities to enhance students’ exposure to diverse care contexts:

Participants also emphasized the benefits of a variety of clinical experiences in building competence and confidence. Exposure to home births in diverse settings, including international placements, rural communities, and low-resource practices, enriched their learning:

DISCUSSION

The goal of this study was to explore the experiences of OMEP graduates to examine how the curriculum impacted the development of their competence and confidence in home birth practice. The short answer survey responses and interviews revealed key areas where students experienced gaps and inconsistencies, including perceptions of how home birth was covered in preclinical courses, tutorial sessions, and within placements.

Course factors identified by participants as negatively impacting the development of competence and confidence in home birth practice included limitations and inconsistencies in coverage of home birth and physiologic birth in the curriculum, particularly as the focus on managing risks and complications increases later in the program. Course factors identified as having a positive impact included evidence that normalized home birth early in the program and collaborative learning with tutors and peers who shared positive home birth experiences during case-based tutorials. These findings indicate a need to realign the OMEP curriculum to ensure consistent normalization of physiologic birth and to develop a structure that iteratively reinforces and builds students’ knowledge and practice of home birth as they advance through the program. For example, incorporating Benner’s levels of proficiency into midwifery training for home birth may provide a useful tool in supporting students’ incremental progression in knowledge acquisition and skill development, and aid in the assessment of proficiency at each stage of education.¹⁰

Given the OMEP curriculum was designed at a time when physiologic birth and OOH births were more common in most placements, it assumed that competence and confidence would flow from clinical experiences. Our research reinforces that as opportunities have diminished, taking a conscious and deliberate approach to learning about home birth and physiologic births in all settings is an increasingly urgent priority. Increasing opportunities for the utilization of simulations for practice in normal and complex scenarios in OOH settings is key. Participants recommended connecting with positive role models specific to home birth to debrief scenarios and provide expert guidance.

Participants hoped for placements in settings known for high OOH birth rates whenever possible but acknowledged that the alternative for many students may be attending comprehensive workshops focused on home and OOH birth. These recommendations reflected a desire to ensure that all OMEP students have adequate opportunities to participate in and debrief real or simulated home births. Simulation is widely recognized as a strategy to support healthcare learners gain confidence and competency^12,13 and is recommended as a way for midwifery students to acquire skills under the guidance of experienced instructors. Participants’ suggestions about debriefing home birth experiences with a mentor also corroborates previous studies that highlight debriefing as an important and valuable component of reflective learning and practice.^13,14 Our findings also align with a recent qualitative study in Spain that explores midwifery students’ experiences of training in planned home birth, which noted a need for better integration of home birth into midwifery education and encouraged the use of simulation with debriefing to provide midwifery students and midwives with increased opportunities to develop familiarity and confidence in home birth.¹⁵

The qualitative data, like the quantitative data, provide evidence of the positive impact of home birth experience before and during midwifery education, consistent with the strengths of situated learning.⁹ Our findings suggest, however, that many new graduates need ongoing mentorship for OOH birth in their first years of practice. In addition to strengthening mentorship during clinical placements, structured mentorship opportunities extending into the New Registrant year and early independent practice may also be beneficial.¹⁶ Peer networks, facilitated mentorship programs, or regular check-ins focused on building OOH birth confidence and competence could help mitigate the isolation some participants described when attending home births independently. From the perspective of Benner’s stages of clinical competence, most graduates enter practice as advanced beginners, able to perform tasks and apply learned principles, but still requiring guidance when navigating new, complex, or high-pressure scenarios.¹⁰ Targeted support during the New Registrant year can accelerate progression toward competence and proficiency, fostering the clinical judgment, autonomy, and confidence necessary for OOH midwifery care. This is particularly relevant given reflections that, in real-time scenarios, new graduates may feel they are “on their own,” without the immediate support typically available in hospital environments.

In addition, birth in Ontario is becoming more medicalized with high rates of complications and interventions.³ Despite overall evidence that midwifery care increases spontaneous birth and lowers interventions,¹⁷ midwifery practices vary. Placements in practices with a more medicalized approach to midwifery care impacted students’ confidence-building. In such settings, preceptors who hesitated to advocate for home births discouraged students from fully embracing home birth care as a safe and viable option. This hesitancy may also reflect a broader cyclical influence within communities, where low rates of OOH births may both create and be a consequence of discomfort with physiologic birth. The reverse may also be true; high rates of home birth can positively shape practice culture and foster approaches that normalize OOH care. A positive feedback loop, where increased exposure to home births fosters confidence and enthusiasm among midwives and students, promotes OOH birth as a safe and viable option. Both systemic and cultural attitudes within midwifery practices and the surrounding community may lead to hesitation about OOH birth or, conversely, support OOH care, influencing the opportunities available for students to gain hands-on experience in these settings. Much remains unknown about the decision-making processes surrounding home birth, including the influence of cultural norms, immigration status, and geographic location, but evidence from systematic reviews supports that the confidence and support of midwives is critical to access this choice.^18,19

Prevailing medicalized models of childbirth may also create a disconnect between the midwifery philosophy of care and the realities faced by Ontario midwives in practice and as they mentor students. Participants noted that the fear of being criticized, coupled with poor interprofessional dynamics, may contribute to a more medicalized approach. These dynamics can be understood through a feminist pedagogical lens which critiques how dominant power structures privilege certain forms of knowledge while silencing or marginalizing others.⁸ In this case, biomedical, intervention-focused models are positioned as authoritative within hospital systems, while the experiential, relational, and client-centered knowledge central to midwifery philosophy is devalued. The Canadian Birth Place study, which included obstetricians, registered midwives, and family physicians, found that biases against home birth and interprofessional tensions significantly impacted both patient choice and the quality of care provided.⁴ These systemic influences not only eroded confidence in OOH birth practices but also limited opportunities for midwives to fully embody the principles of midwifery-led care, such as informed choice and autonomy in the choice of birthplace. Our findings echo broader concerns in midwifery literature, which suggest that medicalization contributes to the marginalization of midwives and undermines their ability to act as autonomous care providers.²⁰ Support for midwives to effectively advocate for evidence-based low-intervention approaches to care will not only impact quality care but also support student experiences.

CONCLUSION

This study provides an initial qualitative examination of OMEP graduates’ perceptions of their preparedness for home birth practice. Participants appreciated instructors, tutors, and preceptors who fostered confidence by modelling best practices and emphasizing physiologic birth principles. They valued preceptors and tutors in clinical courses who demonstrated confidence in home birth, actively involved them in care, and modelled effective communication and decision-making in OOH settings. Based on these factors, recommendations to improve home birth education include better integration of physiologic birth and home birth education throughout the curriculum; incorporating simulation of physiologic birth and home birth; ensuring access to role models and mentors to debrief home birth experiences; and implementing strategies to increase exposure to OOH births. The results of our study provide a springboard for midwifery programs to consider optimizing home birth education in their curricula to enhance midwifery students’ competence and confidence in home birth practice as new midwives.