Advertisement

Homebirth, freebirth and doulas: Casualty and consequences of a broken maternity system

      Summary

      In Australia private homebirth remains unfunded and uninsured and publicly funded homebirth models are not widely available. Doulas are increasingly hired by women for support during childbirth and freebirth (birth intentionally unattended by a health professional) appears to be on the rise. The recently released Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR) exclude homebirth from the funding and insurance reforms proposed. Drawing on recent research we argue that homebirth has become a casualty of a broken maternity system. The recent rise in the numbers of women employing doulas and choosing to birth at home unattended by any health professional we argue is in part a consequence of not adequately meeting the needs of women for continuity of midwifery care and non-medicalised birthing options.

      Keywords

      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

      WHO. The World Health Report 2005: make every mother and child count. World Health Organisation Geneva; 2005.

      Introduction

      On a recent visit to the Netherlands, the first author spent time experiencing the joys of fully funded and insured homebirth with privately practicing midwives. On asking Dutch colleagues about doulas and freebirth (birth intentionally unattended by a health professional) the intriguing response was, “Why would you need a doula when you have a midwife?” “Why would a woman have a freebirth when she has the option to birth at home with a midwife?”
      In Australia private homebirth remains unfunded and uninsured. Doulas are increasingly hired by women for support during childbirth and freebirth appears to be on the rise. It is important to note that we do not intend to argue against doulas or indeed freebirth. Rather these issues provide a lens through which we will view a maternity system that is not meeting the needs of all women in Australia. Too often we criticise women for their choices and do not stop to consider why they are making these choices. Recent research into the areas of homebirth, freebirth and doulas has given us some interesting insights into issues we need to address.
      The intervention rates during childbirth have increased dramatically over the past 10 years in Australia,
      • Laws P.
      • Hilder L.
      potentially leaving some women traumatised and fearful
      • Fenwick J.
      • Gamble J.
      • Nathan E.
      • Bayes S.
      • Hauck Y
      Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women.
      and seeking other options, such as homebirth and in some cases freebirth. In some models of care in Australia, such as the private obstetric model, first time mothers have a greater chance of having surgical intervention during their births than of not having it.
      • Laws P.
      • Hilder L.
      • Roberts C.L.
      • Tracey S.
      • Peat B.
      Rates for obstetric intervention among private and public patients in Australia: population based descriptive study.
      The recently released Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR)
      • Commonwealth of Australia
      Improving maternity services in Australia.
      excludes homebirth from the funding and insurance reforms proposed, despite 60% of the 832 publicly available submissions asking for this option to be expanded.

      Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth; in press (October 2010).

      We argue that homebirth has become a casualty of a broken maternity system. The recent rise in the numbers of women employing doulas

      Stevens J, Dahlen H, Peters K, Jackson D. Midwives’ and doulas’ perspectives of the role of the doula in Australia. Midwifery; in press.

      and choosing intentionally to birth at home unattended
      • Newman L.A.
      Why planned attended homebirth should be more widely supported in Australia.
      by any health professional, we argue is in part a consequence of not adequately meeting the needs of women for continuity of midwifery care and non-medicalised birthing options.

      Homebirth

      Homebirth is an option for only a few women in Australia through publicly funded models of care and for women who choose to hire a privately practicing midwife. The private models of homebirth remain unfunded and uninsured. A strong medical lobby against the mainstreaming of homebirth has contributed to its marginalisation in this country.

      Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth; in press (October 2010).

      An exemption on the registration requirement for insurance for intrapartum care at home has been granted until 2012. Recent maternity service reforms have excluded private homebirth from insurance cover and Medicare rebates.
      This is out of step with maternity service reforms in comparable countries such as New Zealand, the United Kingdom and Canada where home birth is supported as a mainstream option with public funding and affordable insurance and rates of homebirth range between 1 and 3%. In New Zealand our closest neighbour, 2.5% of births occur at home and this option of care is funded and insured.
      • New Zealand Information Service
      Report on Maternity Maternal and Newborn Information 2004.
      The Netherlands also stands in strong contrast, where over 25% of women continue to give birth at home with excellent perinatal outcomes.
      • de Jonge A.
      • van der Goes B.
      • Ravelli A.
      • Amelink-Verburg M.
      • Mol B.
      • Nijhuis J.
      • et al.
      Perinatal mortality and morbidity in a nationwide cohort of 529,688 low risk planned home and hospital births.
      As a result a small number of women (0.3%) choose to have a planned homebirth in Australia and a further 0.5% of women gave birth in places other than planned hospital or home. This group includes birth before arrival and freebirth.
      • Laws P.
      • Hilder L.
      The MSR was released by the Federal government in February 2009.
      • Commonwealth of Australia
      Improving maternity services in Australia.
      Over 900 submissions were received by the Department of Health and Ageing during this review and the majority (DOHA) (54%) were from consumers. Whilst the recommendations are very positive, excluding homebirth from the reforms and not addressing funding and insurance for homebirth services is its greatest weakness. Sixty percent of the submissions mentioned homebirth. Women described in detail the benefits and barriers in accessing this option of care.

      Dahlen H, Schmied V, Tracy S, Jackson D, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review? Too hot to handle? Women and Birth 2010, in press.

      The debate around homebirth is about more than place of birth, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model including a pathological paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth (children) and therefore should determine what is considered safe, the culture of childbirth in this country and the position and status of women within a society. Homebirth also represents starkly the different philosophical frameworks held by midwifery (essentially a social model of care) and medicine (essentially a biomedical model of care) and hence the debate over this issue is ideological, contested, longstanding and circumscribed by relationships of power.
      Despite the MSR claiming the aim was to expand birthing choices to women and prioritise safe evidence based care,
      • Commonwealth of Australia
      Improving maternity services in Australia.
      the expansion of homebirth as an option for women and privately practicing midwives in Australia was not recognised or supported. Most concerning is the possibility that the authors of the MSR were more concerned with ‘political safety’ than meeting the expressed choices of women and responding to the evidence.

      Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth; in press (October 2010).

      We therefore argue that homebirth has become the casualty of a broken maternity care system where medical dominance and misplaced fears over safety have robbed women of a choice that is considered a fundamental human right in most countries on earth. There inevitably will be consequences of this continued denial.

      Freebirth

      There were a number of submissions to the MSR that discuss having had or having considered a freebirth birth.

      Dahlen H, Schmied V, Tracy S, Jackson D, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review? Too hot to handle? Women and Birth 2010, in press.

      This was most often due to cost or inability to find a private midwife to provide care. Some women also seek to avoid hospitalised, medicalised care due to previous traumatic experiences (life, birth or other) and for some the fear is so great that they cannot contemplate returning to institutions they see as perpetrators of their trauma.

      Freeze RAS. Unassisted childbirth in North America. Iowa: Graduate College of the University of Iowa. Unpublished PhD Thesis; 2008.

      Other women find no ability to have choice in hospital and are met with refusal and hostility when they seek to have a breech birth, vaginal twin birth or vaginal birth after caesarean section.

      Freeze RAS. Unassisted childbirth in North America. Iowa: Graduate College of the University of Iowa. Unpublished PhD Thesis; 2008.

      As intervention rates rise in our country and more and more restrictions are placed around birth due to arguments about safety (often focused on medico legal concerns, rather than women's comprehensive health and safety) some women choose to flee the limited options of mainstream maternity care.
      There is no official data available regarding freebirths in Australia but it has been reported to be rising in an earlier publication
      • Newman L.A.
      Why planned attended homebirth should be more widely supported in Australia.
      and again more recently following the MSR.

      Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth; in press (October 2010).

      Detailed theories for why women choose intentionally give birth unattended have yet to be researched and very little academic literature exists on this topic. Our initial work into why women birth outside the system in Australia, indicate it is complex. Turton in the UK (2007) interviewed women who had had freebirths and concluded that there are three overarching motivations for women choosing to birth unattended, (1) to minimise interventions that they view to be unnatural, (2) a belief that a woman is her own best care giver, and (3) a previous traumatic birth experience (mostly in hospital) that was associated with a perceived loss of control for the mother.

      Turton H. An investigation into unattended birth in the UK and the USA and the clinical, ethical and legal issues surrounding it London: University College London. Unpublished Masters Thesis; 2007.

      Freeze in the USA (2008) also examined freebirth in her thesis and explains that the practice of intentionally birthing unassisted illuminates trends in maternity care practices that drive and sometimes force women to choose unassisted birth.

      Freeze RAS. Unassisted childbirth in North America. Iowa: Graduate College of the University of Iowa. Unpublished PhD Thesis; 2008.

      The rise in freebirths is being reported in two countries – Australia and the USA – both with the high intervention rates in birth and limited access to continuity of midwifery care.
      When medicalised hospital services do not meet a woman's emotional or social needs or their basic human rights then women will avoid these services.
      • United Nations Population Fund
      It is speculated that one reason mothers choose to freebirth is a general dissatisfaction with the birthing options offered within the mainstream maternity care system. We argue therefore that the rise of freebirth in Australia is in part a symptom and consequence of a broken maternity care system.

      Doulas

      Doulas are relatively new in Australia, nevertheless demand for them is increasing.
      • Cencighalbulario L.
      Doulas make an ideal choice – Mums, bubs and toddlers: a special advertising report.
      The rise in the use of doulas is thought to be due to increasing dissatisfaction with the current maternity health care system. Women are generally not provided the continuity of carer and emotional support they want within the maternity system, therefore there are reports that doulas are taking over this care and doing what midwives traditionally used to do or indeed should do.
      • Cencighalbulario L.
      Doulas make an ideal choice – Mums, bubs and toddlers: a special advertising report.
      The benefits of doula care include the provision of continuous labour support, reducing women's stress, provision of multicultural and religious support, support for women's partners, reduced interventions during birth and increased breastfeeding initiation.
      • Campbell D.A.
      • Lake M.F.
      • Falk M.
      • Backstrand J.R.
      A randomized control trial of continuous support in labor by a lay doula.
      • Dundek L.H.
      Establishment of a Somali doula program at a large metropolitan hospital.
      • Hodnett E.
      • Gates S.
      • Hofmeyr G.
      • Sakala C.
      Continuous support for women during childbirth.
      The role of the doula in Australia is unclear and almost no research has been undertaken into doulas in this country. Midwives in Australia are increasingly reporting concern and tension between themselves and the emerging role of the doula.

      Stevens J, Dahlen H, Peters K, Jackson D. Midwives’ and doulas’ perspectives of the role of the doula in Australia. Midwifery; in press.

      Our study into this issue showed that the broken maternity system is failing women and midwives and as a result doulas saw themselves as ‘filling the gap’ and midwives felt doulas were ‘taking our role’. Midwives often cannot provide woman focused care because the system is fragmented, overloaded and medically dominated. Hospital based midwives feel that doulas are being employed by women because midwives do not have the opportunity to provide continuity of care, they find it hard to advocate for women due to feeling powerless because they are aligned to the maternity system, and do not have the time to support women properly.

      Stevens J, Dahlen H, Peters K, Jackson D. Midwives’ and doulas’ perspectives of the role of the doula in Australia. Midwifery; in press.

      Doulas noted in this study that the current systems do not support the woman and her choices; everything is run by a clock; midwives are bound by the system.
      As homebirth remains largely unrecognised and unsupported by Australia's mainstream maternity system, and continuity of midwifery care is limited, doulas are fast replacing the lay midwife that flourished in the 1970s and 80s and becoming a more common presence at freebirths.

      Stevens J, Dahlen H, Peters K, Jackson D. Midwives’ and doulas’ perspectives of the role of the doula in Australia. Midwifery; in press.

      It is incorrect to criticise doulas for this however, as they may be better advocates than midwives in the current maternity care system because they are only accountable to the woman, whilst midwives are also legally accountable to the medicalised system, and are often not given time and the opportunity to provide continuity of care.
      • Finlay S.
      • Sandall J.
      Someone's rooting for you: Continuity, advocacy and street-level bureaucracy in UK maternal healthcare.

      International Confederation of Midwives. Definition of the midwife 2005: Available from: http://www.internationalmidwives.org/Portals/5/Documentation/ICM%20Definition%20of%20the%20Midwife%202005.pdf.

      • Kitzinger S.
      Letter from Europe: home birth, midwives, and doulas.
      • Stein M.T.
      • Kennell J.H.
      • Fulcher A.
      Benefits of a doula present at the birth of a child.
      • Rosen P.
      Supporting women in labor: analysis of different types of caregivers.
      This raises questions as to whether in fact making doulas legally accountable would diminish or enhance their role. The rise in doulas we argue is in part a consequence of a broken maternity care system.

      Conclusion

      Intervention rates during childbirth have increased substantially over the past ten years in Australia,
      • Laws P.
      • Hilder L.
      potentially leaving many women traumatised and fearful.
      • Fenwick J.
      • Gamble J.
      • Nathan E.
      • Bayes S.
      • Hauck Y
      Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women.
      This is not safe either physically or psychologically. It is expensive, has many consequences and is counterproductive to optimising normal birth and healthy mothers and babies. Options of care for childbearing women remain limited with around three percent of women able to access continuity of midwifery care and no funding or insurance for homebirth with a private midwife. This does not support the provision of evidence based services. The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care – especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and limited access for women to a hospital birth under a private midwife. The rise in doulas and the numbers of freebirths is ironically being seen in two countries – Australia and the USA – both with the highest intervention rates in birth and limited access to continuity of midwifery care. The answer to all this is not to demonise women for their choices or doulas for their practice but to stop and consider our responsibility as a society to mothers and babies. It is time we made our maternity care system accountable and really listened to what women are telling us and how in fact we are failing them.
      In Australia homebirth has become the casualty of a broken maternity care system that is medically dominated and bound by fear. The choice to exclude homebirth from the recent MSR reforms because it was deemed “a sensitive and controversial issue” (
      • Commonwealth of Australia
      Improving maternity services in Australia.
      , p.21) is testament to this fact.

      Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth; in press (October 2010).

      The rise in the use of doulas and numbers of women choosing to freebirth are in part the consequence. Women will always find ways to meet their needs and feel safe when it comes to giving birth. It is time we stopped blaming women for their choices and stop and examine how we may contribute to this broken maternity care system.

      References

        • Laws P.
        • Hilder L.
        Australian mothers and babies 2006. vol. 22. Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2009
        • Fenwick J.
        • Gamble J.
        • Nathan E.
        • Bayes S.
        • Hauck Y
        Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women.
        Journal Clinical Nursing. 2009; 18: 667
        • Roberts C.L.
        • Tracey S.
        • Peat B.
        Rates for obstetric intervention among private and public patients in Australia: population based descriptive study.
        British Medical Journal. 2000; 321: 137-141
        • Commonwealth of Australia
        Improving maternity services in Australia.
        The Report of the Maternity services review, 2009. Commonwealth of Australia, Canberra2009
      1. Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth; in press (October 2010).

      2. Stevens J, Dahlen H, Peters K, Jackson D. Midwives’ and doulas’ perspectives of the role of the doula in Australia. Midwifery; in press.

        • Newman L.A.
        Why planned attended homebirth should be more widely supported in Australia.
        Australian and New Zealand Journal of Obstetrics and Gynaecology. 2008; 48: 450-453
        • New Zealand Information Service
        Report on Maternity Maternal and Newborn Information 2004.
        2007
        • de Jonge A.
        • van der Goes B.
        • Ravelli A.
        • Amelink-Verburg M.
        • Mol B.
        • Nijhuis J.
        • et al.
        Perinatal mortality and morbidity in a nationwide cohort of 529,688 low risk planned home and hospital births.
        British Journal of Obstetrics and Gynaecology. 2009; https://doi.org/10.1111/j.1471-0528.2009.02175.x
      3. Dahlen H, Schmied V, Tracy S, Jackson D, Cummings J, Priddis H. Home birth and the National Australian Maternity Services Review? Too hot to handle? Women and Birth 2010, in press.

      4. Freeze RAS. Unassisted childbirth in North America. Iowa: Graduate College of the University of Iowa. Unpublished PhD Thesis; 2008.

      5. Turton H. An investigation into unattended birth in the UK and the USA and the clinical, ethical and legal issues surrounding it London: University College London. Unpublished Masters Thesis; 2007.

        • United Nations Population Fund
        UNFPA State of the World Population 2004. UNFPA, New York2004
        • Cencighalbulario L.
        Doulas make an ideal choice – Mums, bubs and toddlers: a special advertising report.
        The Daily Telegraph, 2008 (Sect. 48)
        • Campbell D.A.
        • Lake M.F.
        • Falk M.
        • Backstrand J.R.
        A randomized control trial of continuous support in labor by a lay doula.
        Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2006; 35 (26/2/08): 456-464
        • Dundek L.H.
        Establishment of a Somali doula program at a large metropolitan hospital.
        Journal of Perinatal and Neonatal Nursing. 2006; 20: 128-137
        • Hodnett E.
        • Gates S.
        • Hofmeyr G.
        • Sakala C.
        Continuous support for women during childbirth.
        Cochrane Database of Systematic Reviews. 2007; : CD003766https://doi.org/10.1002/14651858.CD003766.pub2
        • Finlay S.
        • Sandall J.
        Someone's rooting for you: Continuity, advocacy and street-level bureaucracy in UK maternal healthcare.
        Social Science and Medicine. 2009; 69: 1-8
      6. International Confederation of Midwives. Definition of the midwife 2005: Available from: http://www.internationalmidwives.org/Portals/5/Documentation/ICM%20Definition%20of%20the%20Midwife%202005.pdf.

        • Kitzinger S.
        Letter from Europe: home birth, midwives, and doulas.
        Birth. 2008; 35: 250-252
        • Stein M.T.
        • Kennell J.H.
        • Fulcher A.
        Benefits of a doula present at the birth of a child.
        Journal of Developmental and Behavioral Pediatrics. 2004; 24 (14/05/2008): 195-198
        • Rosen P.
        Supporting women in labor: analysis of different types of caregivers.
        Journal Midwifery Womens Health. 2004; 49: 24-31
      7. WHO. The World Health Report 2005: make every mother and child count. World Health Organisation Geneva; 2005.