In countries where there is organized professional attention to pregnancy and childbirth, free birth is a waiver: “free birthing is a planned homebirth that the parents arrange to be intentionally unattended by any registered midwife or obstetrically trained registered professional’. That is, a home birth is planned without assistance by qualified and authorized midwives or obstetricians, outside the formal system of obstetric care, either only with family help, or with informal professionals (unregulated birth workers such as doulas).
Why are women withdrawing from formal systems of maternity care? 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
Let’s see in their own words what women tell us in two examples of qualitative studies (interviews).
One in Australia, about free birthing with an unregulated birth worker (being Australia a country where the planned attended home birth by a register midwife is publicaly-funded by the health system but its implementation is irregular)
And another in the Netherlands, about free birthing with family help (being the Netherlands a country where the planned attended home birth by a register midwife is publicaly-funded by the health system and frequent and well organized)
Note 1. This paper is not about the outcomes of the free birthing.
Note 2. To know more, go to the references, at the end.
Note 3. Comments are grouped in a/ a traumatising and inflexible system and b/ doing it my way and alternative options when having problems with the access to midwifery models of care
A traumatising and inflexible system
“I had my first birth in a hospital and ended up a fourth degree tear, immediately after I had a postpartum hemorrhage and at the same time on the table holding my baby; I was being asked to sign forms saying I was being stitched and at the same time being told I would never be able to birth vaginally again. I would have to have a caesarean and probably be incontinent for the rest of my life by bowel and bladder…I was absolutely convinced I00% I was going to die… it was so traumatic”.
“In my homebirth I was treated like a person who was part of the process. The main difference for me was, at home I was treated with love and respect, like I was important; like I was part of the process. I was treated like I was a real person. Whereas in hospital, I was treated like, I was a non-person. I was invalid and unimportant, less important that the machines that were hooked up to me …In my hospital birth I was treated like an inconvenience to the point where my midwife told me to stop vocalising because I was stressing her out. I was treated like the vehicle, which produces the result and the result being the baby. The baby being what’s important, the baby being the only thing that we are there for, the baby’s the product of the process. The product is what matters. I’m the mechanical arm on the car assembly line”.
“I was appalled at the midwives in the hospital and this was a midwifery group practice. I was just appalled…they pushed her; they scared her into having drugs. She wanted to have no drugs. The midwife just kept on saying “well if you don’t hurry up we’ll be whipping you down for an emergency caesarean section so you’ve got an hour”. Putting pressure on her and just not supporting her…giving her so much pressure, forcing her to have examinations when she didn’t want them”. I just wouldn’t. I was so upset with the whole operation”.
“I’ve just been at a homebirth with a homebirth midwife from the hospital and again, I found them extremely rude, they were very pushy; they told the mother off for having the baby before they got there. They wouldn’t respect the fact that she wanted to be left alone to have time with the baby. She was just saying, we need to do this; we need to do that, your baby might die if you don’t have this injection. Reprimanding her for not calling them sooner, it’s just not nice. I just wouldn’t do it”.
“She wanted to do a vaginal examination and I just thought, just leave me. I was actually annoyed with her because I had a point of reference; a different one and she annoyed me. I realised in my heart this is not necessary…It was a really fast birth my second child but she wanted to check, she got a bit nervous at some point and wanted to do a vaginal examination to check how I was progressing. I really didn’t want her to and so ok I just let her do it so she calmed down. I didn’t have that feeling with (UBW, unregulated birth workers as doulas, ex-midwives ), it wasn’t intrusive at all and I really, really valued that”.
“I felt that I would probably be pushed into having more VEs (vaginal examination) and I didn’t want any VEs or have any monitoring, I didn’t want someone entering into my conscious space. I did speak to midwives and they all basically said from a legal stand point they are required to do all that sort of thing like for their own back up pretty much, which I understand. I didn’t want to put someone in the situation where I was asking them to go against what they had to do when it was something that was making me uncomfortable and when I knew I had another option”.
“Women’s births are being interrupted unnecessarily and the potential that women have to have an empowering birth was being ignored a lot of the time; but other times, usually in the hospital setting, there was no space for it with the rules and what is happening there”.
“You have to have a lot of tests that need to be done and you have to have an ultrasound and things with the registered midwife. I just really like it when I know the birth worker who is with me solely. It’s just me and her. There is not this higher control system that has all these rules that are a blanket rule for everyone… She doesn’t make decisions based on maybe fear of getting in trouble with the medical and legal problems and things like that”.
“They are so out of their comfort zone and it’s so clinical. You can hide the clinical stuff and make it homely and you can have a double bed so the husband can stay… Birth in water is so ok yet it’s so not achievable in standard hospitals. Labouring and birthing in the shower is almost unheard of here. It’s the simplest things that are so hard to achieve… Birthing in a hospital is so not appealing on so many levels”.
“I had a lotus birth; there was no way I could do that in a hospital; they don’t not allow a natural third stage; they don’t allow you to have any natural alternative medicines or anything like that”.
“UBWs [unregulated birth worker, as doulas, ex-midwives etc] are not bound by regulations to work and the book keeping and that accountability to a higher power and all that sort of stuff. That affects our scope of what we can do…it’s just not having boxes to tick. That’s what women are looking for”.
“The midwives I know that are registered, they often are talking about the frustration of the way they want to serve women to be able to fit into the registration criteria. So in that case, the UBW doesn’t have to have that controlling criteria in the way that she has to abide by. She is not controlled by that medical system”.
“Because she wasn’t associated with the medical system, there wasn’t that feeling that I needed medical support. There was that deep trust that this was a really natural process that was happening…I didn’t need her to have a medical degree behind her to give birth to a baby”.
“As in individual and on a personal level it was wonderful. She is an amazing woman and very, very supportive emotionally and caring, vary knowledgeable. She gives a lot of confidence to the birthing woman that she can do it”.
“[…] I had really called or approached every [midwifery] practice in [the city] and they all had the same story, so I felt like either you all have that same protocol that you follow to the letter, OR you have discussed me [between yourselves], but I noticed I could not get
[…]“Their [midwives] fear reaction [to her intention to give birth unassisted] was: ‘Yes, but then we are responsible for something we are not present for.’ Which I felt did not make sense, because you are not there, so you can’t be responsible either. But they were very afraid of repercussions if things went wrong, or that we would hold them accountable […].”
“[My midwife] wanted to know what was going on and she wanted to perform examinations, and I knew for sure that she would not be ‘hands off’. That was stressful for me and I became nervous every time I thought about it. […] I didn’t want someone who wanted to examine me and did not trust me and therefore I couldn’t trust my body and I would produce stress hormones.”
[…] “And he rammed that vacuum pump in, literally. Like that! He said: ‘I am not here for my own amusement, I am here to help you.’ And he rammed […] that vacuum pump in without consultation [with me]. […] And then it was a C section. […] And I think it is mostly because I had that C section. […] and if there would not have been that last traumatic part that doctor X [gynaecologist] came in…[…] then I don’t think that I would have necessarily ended up here [giving birth at home].”
“And [the gynecologist] said to me, ‘I can’t offer you that bath’, but if she had, I think that would have convinced me to choose the hospital. And it may be stupid to say, was it really just that water birth, that made you take all those risks […]? Yes, I did that. […] We did not take that decision lightly. […] An instinctive knowing that that is the way I could give birth AND that it was denied me last time and I let that happen.”
“In the hospital it was very likely that I would have to give birth lying on a bed, I was afraid of that too. […] and I felt a very strong fear: if I had to lie down I would not be able to get him out. I had to be able to move around. […] In our experience we were not impossible to talk to about this subject…[…] no.
“In between I had an unpleasant consultation, [the obstetrician said] ‘Yes, at 41 weeks it will be a C-section (cesarean section).’ I thought: why? And: ‘You don’t want a dead child and that we will end up across from each other in court?’ So within five minutes we had a grim discussion.”
“That CTG (cardiotocography) or that doptone is also based on fear. Yes, then you trust the machine more than what I tell you about how it’s going, or your own intuition. And I understand that you think, as a midwife, you don’t want to be sued, and you don’t want a dead child, and you feel responsible. I understand all that. But it takes away my control over my delivery and my body and what I want.”
Doing it my way and alternative options when having problems with the access to midwifery models of care
“I studied a lot of Leboyer birth and about what happens if you have a drugged birth…and what patterns you set for yourself if you have an induced birth and how that affects your life”.
“After doing a lot more reading from a variety of sources and ideologies and different perspectives and across different years of birthing, I came to appreciate that perhaps if left alone a bit more then I would perhaps get a lot further into birth, further into labour and make it a whole lot better and smoother”.
“I moved from a fear of ‘what if’ to a bit more trusting the body and that nature would take its course…, which is very hard in a very medicalised system. I think weighing it all up having a little bit more knowledge and trust really helped me”.
“I don’t feel the need for security of knowing where the baby is or security of what the heart rate is, I don’t feel that need … you just have to trust that you know, trust it’s going to go well and trust in your abilities that it will go well”.
“I just wanted to do my own thing, in my own way so I could really focus and be able to do what I need to do as a birthing woman without having all the intrusion… I felt that if something was going to go wrong, that I would know, I’d feel it”.
“Women know how to birth…and I trust in the natural process of birthing; women are actually capable and should not be told they can’t do it or that they are too slow…. These are the key things for me from my experience. The women can actually do it; they know how to actually give birth”.
“Women don’t want a midwife that has been trained in that technocratic model. They don’t want someone who has been trained in a hospital environment to observe hospital births and to manage birth using hospital resources and hospital mentality to come into their homebirth, which is counter, intuitive. They don’t want that”.
“I didn’t particularly want that outside person coming into my home and me feeling like I had to welcome them in… I wanted that experience at home with my family, I wanted it to be intimate, I wanted it to be personal; I wanted to feel in control”.
“I was out of the geographical area, I wasn’t even eligible for it…so I didn’t have access to a birthing centre, only to a hospital…In my State, the line up for the birthing centre, is ridiculous, so many women want to get into the birthing centres in this State, and can’t get in because the waiting list is too long. And so they go to the hospitals, and a lot of them have really shit births”.
“A VBAC (Vaginal Birth After Cesarean Delivery) mother, she just really felt she didn’t fit into the homebirth scheme because she had a caesarean and she was really determined to have the baby at home”.
“It was significant that she came to my house. So the visit I felt it was very much on my terms, what ever happened, I felt very much in control about everything. And I really valued that”.
“I was looking for someone who wasn’t going to make me feel rushed and uncomfortable; I wanted someone who was going to respect my wishes and that was going to respect my preferences”.
“A lot of birth workers who work as doulas, work as unassisted doulas and have a lot more trust in the birthing process. They are a lot more willing to allow the woman to make her own decisions rather than taking control and doing it themselves…So it’s passing the power back to the women rather than handing her power over to the midwife or the doctor or whoever, an obstetrician. Making sure the woman is empowered to make her own decisions. She knows what is best for her and her family if she is given the right information and allowed to make her own decisions”.
“I chose her because she was extremely experienced, she was very passionate about what I wanted, she was willing to support whatever I wanted to do during the birth, that was stay at home or the be transferred or whatever… and her beliefs were inline with mine”.
“There were a few experienced doulas in the area where I live who attended free births who I trusted, but if anything was happening anything went wrong, they had the knowledge to help get me to the transport I needed… I had two doulas… I knew she had birth knowledge and backup there instead of just me and my partner being there alone”.
“I was looking for moral support and someone out of the intensity of the moment to just recognise we need extra help or no you’re doing fine. I guess a professional opinion on how things were going. I would never attempt to birth without a knowledgeable person. I wouldn’t freebirth on purpose. I think having a doula provided me a bit of security that if something would be heading in the dangerous situation, off to the hospital we go”.
“I still like to call her a midwife and she says “I am not a midwife”, but the discussion we had was, I like to call you a midwife or lay midwife because in every sense of the word you are more a midwife than I am a registered birth worker. You can work with the woman whereas, of course the clinical stuff is very important… often it is seen as more important that the rest of the holistic care that the midwife does …I feel you are more of a midwife than I am because the expectation to use my clinical skills outweighs my right to practice my normal midwifery, which is being with the woman”.
“I loved the way she trusted birth completely and I liked the way she trusted birth so much she didn’t need to become a registered midwife… I felt very secure in her skills”.
“I chose her because I thought she certainly was in line with what I wanted. I thought she would support me 100% and I would be safe if I changed my mind or if something went wrong she would support me … It was amazing, she would do whatever so I could stay at home. She would come over at the drop of a hat, she would give me any information I wanted. She give me female companionship”.
“She was very available to everything and flexible in every way. I remember in one antenatal meeting she would talk to my partner too and say, “Look just in case things happen fast then this is what you need to do”. I found that very empowering. That approach, this is your birth; this midwife client relationship is maybe a different one; maybe the fact she is not registered midwife; it’s more on an equal social basis with her. That respect was more equal and I felt more empowered. I had more responsibility and this was reflected by the way she said, “if things go fast or if I am not there fast enough or if the shoulders get stuck you can take your finger and do this”.
“I think some people you meet you just get a vibe. You just get that feeling that it’s something special to be in her care. I just felt I want that, I wanted to be in her care…and you know the thing with my UBW, interestingly she really empowered me and gave me lots of autonomy but in the crucial moment of birth, I didn’t want autonomy, where just you were in that moment where you feel like your first child descending and like in that moment, she did mother me, you know. Yea, I am very lucky”.
“I found the risk of a uterine rupture of 0.4% acceptable. Because other than that I had absolutely nothing. […] [Weighed] against the risk of intervention or even another caesarean in the hospital. […] so I came to a 0.4 for me, individually” (vaginal birth after cesarean, second child).
“I believe that I could get some of the same answers with my intuition, that you could measure in the hospital with machines. […] Your own consciousness could also give you signals, a sense of what needs to happen next”
“I think many UC (unassisted childbirth) women believe, I know I do, that many problems growing up and being human (…) are rooted in how we are born. (…) When I look at society and how harsh and cold it has become and how individual, I think: yes, I am not surprised when you see how we are all born. I see a connection there.
“It can be so affirming, a delivery. It is such a lifelong effect, your experience. […] And yes, I have really become a different person through that delivery because I really faced all my fears. Because I really did it myself and it wasn’t the midwife who ‘did’ my birth.”
“I am the woman who is giving birth, so I am ultimately responsible, even if you are standing next to me, I am still responsible for what I decide to do.[…]”
“For me it feels very clear […]. That now my conscience does not bother me and that I can imagine that would be more the case if I had not been able to make my own decisions surrounding the birth.”
“[After finding out the baby was breech] And then I cried in the car. […] And then I thought: yes, now it won’t be a home birth any more. […] Then I cried for I think another hour. Then I went on the internet and joined the birth movement […]. And then within an hour I had somebody who said: ‘I will help you at home together with your [own] midwife.’”
“ I was about 34 weeks I think and then I joined the Free Birth Group on Facebook and there was [midwife] too. [A friend] said: [midwife] is first-rate. I could say whatever I wanted and she would do it. So I called [midwife].”
“[…] I had instructed my partner that if I…suppose I were to lose a lot of blood, really a great deal of blood….the bath fills quickly but you can certainly see the difference….if you couldn’t see my legs any more […]. But mostly that he had to pay attention to me. If I seemed somewhat distracted or sleepy, that he had to call [the alarm number].
In countries where there is an organized professional care for pregnancy and childbirth, free birth is a waiver and a complaint to such organization.
Birthing Outside the System: Wanting the best and safest. http://researchdirect.uws.edu.au/islandora/object/uws%3A29953/datastream/PDF/view
Birthing outside the system: Perceptions of risk amongst Australian women who have freebirths and high risk homebirths. https://www.midwiferyjournal.com/article/S0266-6138(11)00181-1/abstract
Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’. https://www.midwiferyjournal.com/article/S0266-6138(16)30010-9/abstract?code=ymidw-site
Tensions and conflicts in ‘choice’: Womens’ experiences of freebirthing in the UK https://www.midwiferyjournal.com/article/S0266-6138(16)30123-1/abstract?code=ymidw-site
Refusal of recommended maternity care: Time to make a pact with women? https://www.sciencedirect.com/science/article/pii/S1871519217307102
Deliberately unassisted birth in Ireland: Understanding choice in Irish maternity services. https://www.magonlinelibrary.com/doi/abs/10.12968/bjom.2016.24.3.181
Why do women choose an unregulated birth worker to birth at home in Australia: a qualitative study.https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1281-0
Why do some women choose to freebirth? A meta-thematic synthesis, part one. https://www.researchgate.net/publication/273336517_Why_do_some_women_choose_to_freebirth_A_meta-thematic_synthesis_part_one
Why do some women choose to freebirth in the UK? An interpretative phenomenological study. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0847-6
Women’s motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1621-0
Nous sommes les freebirthers. Enfanter sans peur et sans reproche. https://www.erudit.org/en/journals/rf/2014-v27-n1-rf01435/1025462ar/
Risk resistance: constructing home birth as morally responsible on an online discussion group https://www.tandfonline.com/doi/abs/10.1080/13698575.2017.1327038
“Midwife to Myself”: Birth Narratives among Women Choosing Unassisted Homebirth. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1475-682X.2008.00272.x
Unassisted childbirth: why mothers are leaving the system. http://jme.bmj.com/content/early/2013/04/09/medethics-2012-101150.short
Giving Birth Outside the Health Care System in New Brunswick: A Qualitative Investigation. http://med-fom-crhr.sites.olt.ubc.ca/files/2015/12/leblanc2015_giving-birth-outside-the-health-care-system-in-new-brunswick.pdf
Getting the ‘Comfortable’ to listen: a mixed methods study of refusal of recommended maternity care. https://espace.library.uq.edu.au/view/UQ:718630
Less or more? Maternal requests that go against medical advice. https://www.sciencedirect.com/science/article/pii/S1871519217307035
Unassisted childbirth. https://en.wikipedia.org/wiki/Unassisted_childbirth