Background
Methods
Research team
Study design
Maternal characteristics | N |
---|---|
Indication for secondary care | |
VBAC (1 also diabetes type I) | 21 |
Breech (1 also post term) | 8 |
Twins (1 also preterm) | 5 |
Previous postpartum hemorrhage (>1000 ml) or | 3 |
manual placenta removal | 2 |
Prelabor rupture of membranes > 24 h | 1 |
High body mass index (> 35) | 1 |
Treatment with low molecular weight heparin | 1 |
Unassisted childbirth (UC) | 7 |
Age at delivery (years) | |
20-25 | 2 |
> 25-30 | 18 |
> 30-35 | 8 |
> 35-40 | 7 |
Parity during relevant delivery | |
1 | 8 |
2 | 13 |
3 | 8 |
4 | 4 |
5 | 1 |
6 | 1 |
Employed | |
Yes | 19 |
No | 9 |
Highest education | |
High School | 4 |
Vocational training | 4 |
College | 6 |
University | 14 |
Marital status at time of relevant delivery | |
Married | 20 |
Living together | 8 |
Perinatal death | 2 |
Breech | 1 |
VBAC | 1 |
Data analysis
Results
Discrepancy in the definition of superior knowledge
The other group used a nature-oriented framework, wherein a pregnant woman’s intuition is considered superior knowledge. They deemed childbirth only safe if left alone and taking place undisturbed in an atmosphere of relaxation (usually at home), where the woman can follow her intuition. However, giving birth in the stressful environment of a hospital, or even at home in the presence of a midwife, would lead to more interventions, making the situation less safe.“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” (R18, home VBAC (vaginal birth after cesarean), second child)
Several participants also believed that the way a child was born and the atmosphere it was born into would have an effect on its development in later life.“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” (R1, home breech birth, first child)
“I think many UC 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. “ (R6, UC, second and third child)
Need for autonomy and trust in the birth process
Participants also mentioned the need to feel safe, loved and respected during their delivery, and be surrounded by people who trusted in their ability to give birth unaided, which they felt would not be possible in the regular system.[…] “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].” (R18, home VBAC, second child)
For some, the process of an undisturbed natural birth was (almost) equally as important as the outcome, as it was part of the personal development of the mother in becoming who she wanted to be: an autonomous woman without fear. Most participants believed that a birth without interventions would be more likely to lead to the desired outcome of an (emotionally and physically) healthy mother and baby.“[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.” (R2, home breech birth, first child)
Some participants who had chosen a UC indicated that, in their experience, health care providers believed they were responsible for the outcome of a delivery, whereas the participants themselves insisted that true autonomy was only possible when they were allowed to take full responsibility for their own decisions and whatever outcome that would lead to.“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.” (R3, UC, third child)
When discussing her midwives’ reaction to her intention to give birth unassisted, the same participant later said:“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.[…]” (R5, UC, fourth, fifth and sixth children)
Noticeably, none of the participants regretted their choice to birth outside the system, not even the two whose baby did not survive.[…]“Their fear reaction 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 […].” (R5, UC, fourth, fifth and sixth children)
“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.” (R28, home breech perinatal death, first child)
Conflict during negotiation of the birth plan
Another participant, who experienced a perinatal death during a home breech delivery, stated:“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.” (R23, attempted home VBAC, second child)
Also, some participants desired to waive certain parts of the protocol, for example continuous CTG (cardio-tocography) monitoring during VBAC. Most participants felt they encountered insufficient flexibility on the part of their provider. According to them, discussions about the birth plan often involved manipulation on the part of their providers, including threats of perinatal mortality if protocol was not followed. This has become known amongst many participants as ‘playing the dead baby card’, also known as ‘shroud waving’ in English literature [7].“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.” (R28, home breech, perinatal death, first child)
This negotiation then led to feelings of anger, disappointment and stress on the part of the participants. In quite a few cases, the decision to go against medical advice had negative consequences for the women involved. Some had child protective services forced on them, and many felt they had to operate in secret because of this and the stigma it involved.“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.” (R15, home VBAC, second child)
Search for different care
Some participants quickly found a likeminded new caregiver, others searched for quite some time and experienced rejection (of their wishes) by yet another midwife or obstetrician.“[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.’”(R17, home breech birth, first child)“ 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].” (R20, home VBAC, second child)
Some participants proceeded with their pregnancy without medical help. They checked their own blood pressure, measured their own abdominal circumference, or had an ultrasound done to check for placental location. Some of those who planned a UC devised emergency plans for the most common critical situations, like shoulder dystocia or post partum haemorrhage, whereas others notably did not, since they trusted that an uninterfered-with birth would not go awry.“[…] 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 a foot in the door.” (R11, high BMI (body mass index), home birth second child)
Many of the participants spent a significant amount of time preparing for birth. They read books, took antenatal classes (often hypnobirthing) and talked with family and friends about their decision. Although every participant discussed her situation with her partner at length, it is noticeable that most stated that their partner left the search for information and the final decision completely up to her.“[…] 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].”(R5, UC, fourth, fifth and sixth children)
Fear
The participants in the feedback focus group acknowledged the four main themes as generally fitting with what they had told the interviewers, although several had difficulty with the term fear. They were concerned that fear as an overarching theme would make them appear to be weak and afraid, whereas they viewed themselves as strong, enlightened and determined. The authors therefore emphasize how the theme fear does not just reflect on the participant’s fear of unnecessary interventions, but much more on the medical approach of childbirth at this time, with its fear of bad outcome, peer pressure and legal measures.“That CTG 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.” (R6, UC, second and third child)