We live in a world with many different perspectives on risk. Entire professions now exist to advise us on how to recognise, avoid and manage risk. And the maternity and obstetric professions are no different.
So how do mothers-to-be make decisions about the best birthing environment for them and their baby? And what prompts some women to give birth at home in situations that seem inherently risky to mainstream society?
How we evaluate risk is less to with logic and more to do with intuition, exposure to certain events in our lives, and societal norms. The risk of death from driving compared with flying is around 100 times greater. Yet fear of flying is more common and we rarely get into a car and consider the risk we are taking is unreasonable. Nor do we berate others for this choice.
Home birth remains an uncommon choice among many women in the western world: just 0.3% of births in Australia are planned home births. Where registered midwives are present, home birth for low-risk women is just as safe as hospital birth and is gradually becoming a more acceptable option via mainstream maternity services throughout Australia.
Free birth and high-risk home birth
But scientific evidence and health policy data show that intentionally birthing at home without a health professional (known as free birthing) and planning a home birth if you have a high risk pregnancy are less safe. We also know that when women choose to give birth outside the system, the resulting vitriol from the media and the public can be savage.
A desire to understand what motivates women to free birth and plan high-risk home births promoted my PhD student, Melanie Jackson, to lead a major study, the first paper from which has just been published online in the journal Midwifery.
We interviewed 20 women from around Australia about their choice to birth outside the system. Nine choose to free birth and 11 had a home birth despite the presence of medically defined risk factors; three were first-time mothers and 17 had previously given birth. Many of these women reported very negative previous hospital birth experiences that had been emotionally and physically devastating.
We found these women had different perceptions of risk and felt “birth always had an element of risk” regardless of where it occurred. They also believed “hospital was not the safest place to have a baby” and that “interference in birth is a risk” and this interference was most likely experienced in hospital.
It was clear these women weren’t deluded about the risk they took, but saw potential intervention in the birth, separation from their baby and abusive care providers as greater risks. They prepared extensively for their birth and felt their choice provided the best and safest birthing option for them and their babies.
Some commentators, such as Miranda Devine, have argued that women who choose to birth outside the system ignore or underestimate the risk of giving birth at home.
However, our study found that these women considered risk seriously but placed the iatrogenic risks of giving birth in a hospital under intense scrutiny. They challenged the assumptions that hospital birth must be safer and deemed the risks, such as a one-in-three chance of caesarean section, as unacceptable.
It is easy to demonise these women but, as health professionals, we must examine our role in driving some women to less-than-ideal choices. In 2005, the World Health Organisation challenged practitioners not to ask, “why women do not accept the service that we offer?” but to question “why do we not offer a service that women will accept?”.
While women in this study also accepted responsibility for their decision, they challenged the assumption that a hospital birth would have been a better option for them. Given that 16 of the 20 women who had their first baby in a delivery ward or birth centre pursued a radically different option for subsequent births, we have to question the impact of current maternity care on these decisions.
We need further research into how to maximise the safety and choice for women who choose to birth outside the system. But first we need to collect the data about how many women intentionally free birth in Australia so we can monitor the trends and outcomes.
More broadly, we health-care professionals need to consider our roles and responsibilities in providing services that meet all women’s needs.