A growing amount of research suggests the rise in women choosing to freebirth is partly in response to the system not meeting the needs of women who want continuity of care and a non-medicalised birth (Feeley and Thomson, 2016; Holten and Miranda, 2016; Jackson et al, 2020).
Birthing outside of mainstream maternity services can be loosely divided into two categories: women choosing to birth at home with a registered midwife, even though they have medically defined risk factors that would class them as at increased risk of complications and/or exclude them from midwifery led care; and women choosing to freebirth. Freebirth, sometimes referred to as unassisted birth, is a practice where women intentionally give birth without healthcare professionals present in countries where there are medical facilities available (Mc Kenzie et al, 2020). Although the actual numbers of freebirths cannot be verified due to the birth taking place away from the health system and the required reporting system, freebirth is reportedly becoming more common.
Holten and Miranda (2016) analysed 15 studies from Sweden, the US, Australia, Canada and Finland, and found reoccurring themes within the literature. A total of five themes were identified as the most important factors to women's motivation to birth outside of the mainstream maternity services. Resisting the biomedical model of birth by trusting intuition describes how the biomedical model of birth is perceived as not meeting the needs of women.
Women are challenging mainstream maternity care by opting for freebirth
Women's own body knowledge and intuition were recognised as authoritative knowledge, the knowledge which forms the basis on which decisions are made and actions are taken, and superior to medical knowledge and professional care. Challenging the dominant discourse on risk by considering the hospital as a dangerous place described that rather than perceiving the hospital as a safe place to give birth, the women felt that the hospital itself posed a risk to them due to medical and professional intervention. The woman choosing to birth outside of the mainstream believed that birth was inherently safe and that risk was located in professional interventions.
Feeling that true autonomous choice was only possible at home was the third theme that arose from the literature. Some women believed that true informed consent was not possible in the hospital, that choices were limited and women's decisions were not supported. A more positive theme identified was the perception of birth as an intimate or religious experience, highlighting the importance of intimacy, privacy and comfort which could only be achieved at home. For women choosing to freebirth, the midwife's presence in itself was an intervention. The final theme taking responsibility as a reflection of true control over decision making described how women who choose to freebirth take full responsibility for the outcome of their decision-good or bad. Rather than placing responsibility in the hands of health professionals, they retain their power and autonomy (Holten and Miranda, 2016).
Research shows that some women are opting out of the mainstream because they are rejecting the dominant medicalised approach to birth. Jackson et al (2020) included 28 women's stories in their study of women's motivation to ‘birth outside the system’. A total of 20 women were interviewed from four Australian states; of these women, nine chose to freebirth and 11 chose home birth with a privately practising midwife, despite the presence of medically defined risk factors. A total of eight further stories were accessed through secondary publicly available resources, including submissions to the National Review of Maternity Services in Australia. The core category in this Grounded Theory study was ‘wanting the best and safest’. The women in this study did not believe the rhetoric that the biomedical approach to birth within a hospital setting was the safest option. These women held the counterculture belief that they, not the health professionals, held the authoritative knowledge that enabled them to choose to birth outside the system and that the hospital could not provide the best or safest care (Jackson et al, 2020).
Many of these women stated that a previous traumatic birth experience influenced their decision. The women discussed how staying away from the hospital would minimise the risk of intervention and increase their control of external factors in relation to their births. A key finding in this study was that these Australian women felt that the risk of going into mainstream care was a higher risk than birthing their babies at home, with or without a trained health professional's assistance (Jackson et al, 2020).
Women's perception of risk is sometimes at odds with what the mainstream maternity system defines as risky. Another Australian qualitative study by Davison (2014) of 14 women who chose a privately practising midwife in Western Australia found that women researched their options, believed mainstream services restrictive and focused on medical risk status rather than on the individual woman. Women in this study wanted a relationship with their midwife, they wanted a midwife who shared their philosophy that believed and trusted in women and supported physiological birth. All the women in this study stated that if the option to birth with a privately practising midwife was unavailable, no assistance in pregnancy and birth would be better for them than the option of mainstream care (Davison, 2014; Davison et al, 2015).
Until recently, the documentation on freebirth was mainly found in countries where home birth was not a mainstream option for women, such as North America and Australia. However, freebirth is also on the rise in the UK where home birth is more acceptable. Similar issues were noted in a UK study of freebirth conducted via an informal survey of 220 freebirthing women (Joy, 2013). Joy (2013) found that many women chose to freebirth as a direct response to the excessive medicalisation of birth and the lack of suitable maternity care options. The women in her UK survey acknowledged the benefits of continuous care through pregnancy with a trusted midwife, however, felt this was not an option within the free maternity care options. Women in this UK study believed that the option of a privately practising midwife would be the ideal choice but, for many, it was unobtainable due to the financial cost of this type of care (Joy, 2013).
Another UK study by Feeley et al (2016) explored why women chose to freebirth. Three themes were identified from the data from 10 women: violation of human rights, tactical planning, and unfit to be a mother. Violation of human rights described how even though all the women knew that they had a legal right to birth their babies unassisted, this was not understood by some health professionals. Some women experienced harassment, suspicion and prejudice, with some midwives suggesting that by opting out of mainstream care they were putting their babies at risk.
Tactical planning described how women carefully planned their births to avoid the risk of being reported to social services or the police. The concern regarding referrals to social services was not exaggerated as described in the theme unfit to be a mother. A total of four women in this study were referred to social services for ‘placing their child at risk’ following their decision to freebirth. Another woman in this study was referred after she declined to attend a consultant appointment at the hospital.
These studies again highlight the reduction in woman's autonomy during childbirth. If women do not comply with the mainstream maternity system, they are frequently seen as deviant, selfish or bad mothers (Feeley et al, 2016; Jackson et al, 2020). For many, the perception of women choosing to birth outside of the mainstream birthing system is that the women are not ‘truly’ informed of the risks or making an educated choice. However, two Australian studies found that the majority of women choosing to opt out of mainstream maternity care held a bachelor's degree or higher (Davison et al, 2015; Jackson et al, 2020).
Dahlen et al (2011) state that the rise of freebirth is in part a symptom and consequence of a broken maternity system. Rather than reflecting on why a woman would prefer to give birth unassisted, we should be asking ourselves why she is rejecting the mainstream system. Plested and Kirkham (2016) suggest, that for some women, their experience of the mainstream maternity system is one that is risk obsessed and driven by fear. The research clearly shows that women are making educated and informed decisions to reject the services that our mainstream maternity systems are offering. If maternity systems neglect to provide true evidenced-based care, support for undisturbed physiological birth, access to continuity of midwifery care and home birth, then women will continue to birth outside the system.