Birthing Outside the System

The Canary in the Coal Mine

Hannah Dahlen, Bashi Kumar-Hazard, Virginia Schmied, Hannah Dahlen, Bashi Kumar-Hazard, Virginia Schmied

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429953149
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería

This book investigates why women choose 'birth outside the system' and makes connections between women's right to choose where they birth and violations of human rights within maternity care systems.

Choosing to birth at home can force women out of mainstream maternity care, despite research supporting the safety of this option for low-risk women attended by midwives. When homebirth is not supported as a birthplace option, women will defy mainstream medical advice, and if a midwife is not available, choose either an unregulated careprovider or birth without assistance. This book examines the circumstances and drivers behind why women nevertheless choose homebirth by bringing legal and ethical perspectives together with the latest research on high-risk homebirth (breech and twin births), freebirth, birth with unregulated careproviders and the oppression of midwives who support unorthodox choices. Stories from women who have pursued alternatives in Australia, Europe, Russia, the UK, the US, Canada, the Middle East and India are woven through the research.

Insight and practical strategies are shared by doctors, midwives, lawyers, anthropologists, sociologists and psychologists on how to manage the tension between professional obligations and women's right to bodily autonomy. This book, the first of its kind, is an important contribution to considerations of place of birth and human rights in childbirth.

Part 1

Understanding the problem

Introduction

Hannah Dahlen, Bashi Kumar-Hazard and Virginia Schmied

The question should not be why do women not accept the service that we offer, but why do we not offer a service that women will accept?

(Fathalla, 1988)

Introduction

This book has had a very long gestation. It was conceived many years ago, even though we did not realise it at the time. As you will see below, your editors (Hannah, Bashi and Virginia) came together by chance, three very different women with different expertise and backgrounds, who connected through a common focus and a powerful synergy in our research, work and personal experiences.

This book is about women who choose to birth ‘outside the system’. We defined birthing outside the system as either ‘freebirth’ – where women plan a birth at home with no registered health provider in attendance (also known as unassisted birth or unhindered birth) – or ‘high-risk homebirth’ – where the presence of significant risk factors cause most health providers and guidelines to recommend hospital birth as the safest option (for example, breech and twin birth). Essentially, women who birth ‘outside the system’ are making a choice of birth place (usually home) or provider (such as unregulated birth workers), or both, in circumstances that would not be recommended by the majority of health professionals and fall outside health service guidelines. Note that we refrained from saying ‘evidence-based guidelines’ because it will become apparent, as you read this book, that the guidelines commonly used within the system are not necessarily evidence-based or woman-centred.

This book is a political opus, and we make no apologies for that. If you think you can sit back and be entertained, think again. We intend to upend thinking and disturb assumptions. We intend to shock, at times distress and most certainly to exasperate. Finally, we hope to inspire you to be a part of the change we so desperately need. We guarantee that you will think differently after reading this book and hope you will join a revolution to humanise childbirth for every woman, everywhere. We have a challenge on our hands in maternity care today, but we also hold the answer to that challenge.

The state of childbirth in the world

Women are not choosing birth outside the system because they are spoilt for choice; far from it. They choose to birth outside the system because what we offer is hurting them and we are simply not listening to their concerns. The world authorities are now taking this issue very seriously, in the face of mounting scientific evidence of harm.

Recent world reports

Medical intervention in childbirth has reached unprecedented levels. While it is sometimes necessary to save lives, it is apparent we have gone too far with little consideration given to short- and long-term consequences on health (Dahlen et al., 2013; FIGO, 2018; WHO, 2018). The 2018 Lancet Series on Caesarean Section warned against excessive use – now reaching epidemic proportions – of obstetric interventions like caesarean section (Boerma et al., 2018). The authors called for a reduction in overuse of interventions causing avoidable harm and leading to a cascade of interventions that cause even further harms that are not being adequately monitored. The authors also found, based on data from 169 countries that included 98.4% of the world’s births, that nearly 30 million caesarean sections had occurred in 2015 (21%) – almost double the rate since 2000 (12%) (Boerma et al., 2018). Many countries reported caesarean section rates significantly higher than the World Health Organisation (WHO)-recommended rates of 10–15% (Betran et al., 2015; WHO, 2015). For example, caesarean section was up to 10 times more frequent in Latin America and the Caribbean region (44.3%) when compared with the west and central African region (4.1%) (Boerma et al., 2018). By contrast, the rate in Africa is too low. There was significant variation between countries with similar socio-demographics; for example, Cyprus has a rate of 55% while the Netherlands was at 16% in 2016 (OECD, 2018). The Nordic countries not only have the lowest caesarean section rates in the developed world, they also have some of the best maternal and perinatal outcomes. Caesarean section use is almost five times higher in the richest countries when compared to the poorest (Boerma et al., 2018). High caesarean section use was also seen among low-risk births, especially among women who are more educated (Brazil and China). Caesarean section use was at least 1·6 times more frequent in private facilities than in public facilities (Boerma et al., 2018). Similar findings were reported in Australia (Dahlen et al., 2014).

Caesarean section is not without significant consequences. The Lancet Series on Caesarean Section (CS) states:

The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose–response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported.

(Sandall et al., 2018, p. 1349)

Related obstetric intervention rates are also rising across the globe. In 2016, the Lancet Series on Maternal Health reported high rates of induction of labour, described as care that is ‘too much, too soon’ (Miller et al., 2016). The Lancet Series on Midwifery (Renfrew et al., 2014) and the WHO recommendations: intrapartum care for a positive childbirth experience (WHO, 2018) also call for a reduction in unnecessary birth intervention. These major reports offer a simple solution: a move towards relationship-based models of care, the gold standard being continuity of midwifery care for all women, regardless of risk. In the Lancet Series on Midwifery, the authors found over 50 outcomes were improved with midwifery care, including reductions in maternal and neonatal mortality and morbidity, stillbirth, preterm birth and unnecessary interventions, and improved psychosocial outcomes. Homer and colleagues (2014) showed that the effect of scaling up midwifery to 95%, in countries with the highest incidence of adverse maternal and newborn outcomes, could avert 61% of maternal and perinatal deaths. The Quality Maternal and Newborn Care framework (Renfrew et al., 2014) emphasised the importance of care that is respectful and tailored to a woman’s individual needs within her context in her community.

A global network of researchers recently published a research priorities paper calling for the need to recognise the importance of positive experiences for women during pregnancy, birth and the postpartum period alongside the reduction of adverse events. This is leading to a critical change in the conversation and prioritisation of research in this space (Kennedy et al., 2018). The paper called for three inter-related research themes: (1) examination and implementation of models of care that enhance both well-being and safety; (2) investigating and optimising physiological, psychological and social processes in pregnancy, childbirth and the postnatal period; and (3) development and validation of outcome measures that capture short- and longer-term well-being (Kennedy et al., 2018). These first steps may well herald a new era in childbirth research and policy that will actually improve care for women, babies and their families.

Birth trauma and mental health

In the first study on freebirth and high-risk homebirth in Australia undertaken by our (Hannah and Virginia) PhD student Melanie Jackson (see Chapter 2), 85% of the women interviewed had given birth previously, most in hospital. Many reported highly negative previous birth experiences involving interventions without informed consent. For some, the treatment they received was emotionally and physically devastating (Jackson, Dahlen, & Schmied, 2012). It was clear that these women wanted what was the best and safest for their baby and were highly educated (70% had university degrees). They perceived the intervention and interference they had previously experienced in hospital as a greater risk. They also understood that the health system would not respect or support their choices, so they chose to disengage from, and birth outside, the system (Jackson et al., 2012).

Once we add the complexities around mental health concerns to mistreatment in childbirth, the vulnerabilities women with mental health issues face in birth are compounded and exacerbated. Worldwide, maternal mental health problems are considered one of the most significant public health issues, with several developed nations, including Australia, now reporting maternal suicide as the leading single cause of maternal death (Ellwood and Dahlen, 2019). One in five women experience high levels of anxiety in pregnancy and this appears to be increasing (Kingsbury et al., 2017; Dahlen et al., 2018), with significant and enduring impacts on women and their babies (Austin et al., 2017). The American Psychiatric Association (2018) found that anxiety had increased in the population by five points in just one year on a 0–100 scale, to reach an average of 51 points. In Australia, the 2018 Women’s Health Survey reported that 66.9% of the 15,000 women interviewed felt nervous, anxious or on edge during several or more days over a four-week period (Women’s Health Survey, 2018).

Risk factors for perinatal anxiety and depression include: (a) previous history of depression or anxiety (Clavarino et al., 2010; Rubertsson, Hellström, Cross, & Sydsjö, 2014; Dennis, Brown, Falah-Hassani, Marini, & Vigod, 2017); (b) birth interventions associated with post-traumatic stress disorder (PTSD) in the mother (Rubertsson et al., 2014; Dennis et al., 2017; Simpson, Schmied, Dickson, & Dahlen, 2018); (c) difficult socio-economic circumstances, with low-level social support, or migrant and refugee backgrounds (Rubertsson et al., 2014); and (d) women who report perfectionist characteristics (i.e. striving to meet the ‘good mother’ ideal) (Hays, 1996; Liamputtong, 2006; Maher and Saugeres, 2007; Goodwin and Huppatz, 2010; Pedersen, 2012). In this book, you will read that a past traumatic birth and/or PTSD is a major reason motivating women to leave our maternity system (see Chapter 12).

When military personnel return from war with PTSD, we do not send them back to the same battlegrounds where the trauma was first triggered. By contrast, with childbirth trauma, we not only require women’s exposure to the same trauma, we bully and coerce them into accepting it, again and again. When traumatised women seek to avoid further trauma (in hospital), care providers accuse them of being selfish, journalists portray them as bad or stupid mothers and laws are proposed to ‘criminalise’ their efforts to protect themselves. Demonising and criminalising women to control and herd them back into an abusive environment is coercion and, in itself, a form of violence against women. It serves as an easy, duplicitous distraction for health professionals who want to ignore their contribution to the mistreatment of women.

Recent evidence demonstrates that respectful care has an impact on physical and psychological health. A Cochrane review of routine uptake of antenatal services across 41 countries (high-, medium- and low-income) found women were more likely to access antenatal care if they saw care as individualised, positive, reflecting their cultural values and beliefs, accessible, affordable and flexible. Women in the review valued good information and advice, and wanted to feel safe, respected, and be treated with kindness (Downe, Finlayson, Tuncalp, & Gulmezoglu, 2019).

Obstetric violence

A review on ‘obstetric violence’ reported that public...

Table of contents

• Cover
• Half Title
• Series Information
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• # ENOUGH
• List of Figures
• List of Tables
• Notes on contributors
• Foreword
• Part 1 Understanding the problem
• Part 2 Working towards a solution
• Glossary of terms
• Index