What's right with freebirthing?

Jo Dagustun suggests how reflecting on the marginal pursuit of independent birthing can improve maternity services for all

What's the first thing that comes to your mind when you think about independent birthing (also known as unassisted birthing or freebirthing), where a woman prepares to give birth in her own home with support that excludes the presence of a midwife or other medically-trained person?

I was working with the issue of home birth when the media debate on freebirthing took off a couple of years ago, following the Channel 5 TV programme 'Outlaw Births'. Like most people, I had my doubts about freebirthing, but I quickly 'grabbed' what I needed from the debate: I concluded that this media coverage was an incredible opportunity for supporters of home birth. At a single stroke, it was possible to envisage home birth being shifted from the margins of birth practice into the mainstream imagination ('how middle-of-the-road and sensible to invite midwives to attend your home birth'). And mainstream it really is, given the very 'hospital-like practice' that – in my personal experience – too quickly seeps into NHS home birth protocols.

For many people interested in improving maternity services, however, the feeling that the issue of freebirthing primarily brings forth is a feeling of disappointment: 'it's a shame that the maternity services can fail so badly that some women will choose to give birth without their support'. It is seen foremost as a commentary on wellknown problems in our maternity services: midwifery staff shortages, poor hospital facilities, the lack of time available to midwives to properly support women with complex psychosocial needs, pressures on a universal home birth service... If such issues were resolved, the argument goes, a woman would have no need to opt out of the system in this way, risking her and her baby's health – as well as their lives.

But I would like to suggest that such knee-jerk reactions – reflecting more our existing agendas than the new information we have received – distract us from some important principles at the heart of the practice of independent birthing. We might pause, for example, on a key assumption generally made – but rejected by independent birthers – that on-hand medical support is vital for safe childbirth. Of course, midwives might be excused for making this assumption; indeed, the professional identity of midwives is in some sense closely allied to it. But we all know that it is perfectly possible to give birth, with good outcomes for mum and baby, without on-the-spot medical assistance. It happens frequently, whether planned or not (not least, of course, because of our peculiar insistence that women should travel during the late stages of labour).

Related to this is the way in which the practice of independent birthing forces a focus on the physiological, on the belief that female bodies are designed to give birth and that childbirth is an inherently safe, normal bodily function. The idea that women's bodies are strong and capable (as opposed to the culturally more dominant notion that women's bodies are frail and at risk of failure) is part of the rhetoric of the now-mainstream normal birth campaign, with its mantra that 'midwives are the experts in normal birth'. But – against a backdrop of our wider culture that insists on the devaluation of and domination over nature and the body – do enough of us really believe in this immense power and capability of the female body? Do you? Reflecting on our own attitudes towards independent birthing, I would suggest, can usefully provide a key to unlocking our personal and deep-seated attitudes, perhaps revealing less confidence than we like to assert.

Furthermore, the practice of independent birthing might encourage deeper reflection on the role of the paid birth supporter. In any population of women, there are likely to be a range of different images that women hold of their ideal labour and birth support. One woman, for example, might see her ideal supporter as a medically trained person who is present (perhaps in an adjoining room) on a strictly 'just-in-case' basis, for what is otherwise an undisturbed birth. Another woman, perhaps less experienced and less confident in her body's ability to birth, might welcome the reassuring presence of someone throughout her labour, to coach her as the birth unfolds and to remind her that her body is capable and strong. (This might not necessarily be a midwife, of course.) These ideas challenge the notion that 'a midwife is a midwife', and that the midwife – rather than the woman – is entitled to decide what support should be provided at any individual birth. All this engages with important debates about the need for a diverse and flexible range of maternity service workers to offer every woman truly individualised support during her transition to new motherhood, including some tough debates on the useful role of birth supporters other than midwives.

This is clearly linked to the way in which independent birthing powerfully suggests a necessary shift in the power relations between birthing women and paid birth supporters. Independent birthing can serve to remind us need for a diverse and flexible range of maternity service workers of the intense taken–for–granted professionalisation of birth. But it really should be up to women – not the professionals involved – how, where and at what pace they want to birth. Too often we lose our focus on this key point as we repeatedly enact our familiar roles within a high-volume institutionalised service delivery machine. To enable women to claim power within a traditional birth setting is an immense challenge, and is a debate that gets us into difficult territory, given our observations that many women today seek to use any increase in power, perhaps paradoxically, to opt for a low level of personal autonomy within the birth-room and to seek a more medicalised route than many of us would think preferable for her or her unborn baby. But this again is something that needs to be tackled, rather than ignored, within the popular mantra of choice, and reformed antenatal arrangements would be a small step in the right direction.

We need to completely rethink our current approach which does little to encourage women to learn about and prepare for the incredibly powerful process of physiological birth, which is then too often overwhelming and [not] surprisingly 'like hard labour' fortoo many women 'in the moment', with the inevitable cascade of intervention that results. This would be an important element in a broader programme of cultural change aimed at restoring value to the practice of undisturbed physiological birth.

Whenever I come across an idea that seriously challenges my established ways of thinking, it often turns out that I have uncovered an unexpected opportunity for learning. By taking seriously some key issues raised by independent birthing – beyond those that simply support my own immediate agenda – my own deliberations have been immeasurably strengthened. As fellow members of the Association for Improvements in the Maternity Services, I hope yours will be too.

Jo Dagustun

Jo is a lay-member of AIMS, and is currently researching contemporary UK birth cultures for a PhD (based at the School of Geography, University of Leeds). Jo has four children, two of whom were born at home (supported by NHS midwives).

This piece was inspired by a recent PhD thesis on the topic of unassisted birth in North America by Rixa Freeze, which powerfully documents changes in professional practice made possible through an exposure to the phenomenon of independent birthing. Rixa's thesis is freely available online at rixarixa.blogspot.com