The core category (Fig. 1) that emerged was ‘wanting the best and safest,’ which describes what motivated the women’s decision to birth outside the system; because they believed it was the best and safest for them and their baby. How they came to this belief is explicated through the subcategories: ‘previous birth experiences,’ ‘perspectives on childbirth,’ ‘perspectives on risk’ and ‘the hospital can’t provide the best or safest.’
The basic social process (which explains the journey women took as they pursued the best and safest) was ‘finding a better way’ (Fig. 2). This process is elucidated through the subcategories: ‘considering birth options,’ ‘managing opposition,’ ‘mitigating the risks of birth at home’ and ‘becoming the expert.’
Wanting the best and safest
This study found that what motivates women to birth outside the system is ‘wanting the best and safest’ for themselves and their babies. One participant who chose homebirth explained:
‘In an effort to want to make my own choices and to be in control and to feel safe, and like the decisions were truly mine and the decisions that are the best for not just you and not just your baby, not just your husband, but just the whole picture. It’s what’s best for me and this baby and my other children and my husband, it’s wanting the best and to get the best I feel like I need to be in control and for me to be in control and to be safe means I need to be at home’. (HB05).
Similarly, a woman who chose freebirth explained:
‘I want the absolute very best for all of my children, I would not ever, ever endanger them, I don’t want them harmed, I want them to have the very best outcome in terms of their physical health, mental health, emotional health, their complete and utter wellbeing and safety…so that’s where I was coming from’. (FB05).
There are three criteria by which the participants judge ‘best’ and ‘safest.’ These are: having a natural birth without intervention, having their family close and being respected as the authority throughout their care. If a birth option cannot cater to one of these criteria, it is not considered the best or the safest.
Previous birth experiences
The women in this study who had given birth previously described their previous birth experiences as a learning experience, which gave them insight into what they did and didn’t want for their next births, and many were also left feeling traumatised. After becoming traumatised by their previous birth experiences, the participants learnt that a birth inside the system could not offer them the standard of care they desired. One woman recounts:
'This male doctor and a nurse came in and he was saying, “I’m just going to examine you” ... I was saying “no” and he said “oh it won’t take a minute just slide back” and started, and I was like “stop it, stop it, get out of me: and he was like “just lie still,” and he ended up holding me down and a nurse held me up at the top …while he ‘examined me,’ that was so painful ... in the street, assault is assault, if you’re saying no and there’s a person still continuing doing what they are doing that is assault'. (FB01).
Another woman described her experience of caesarean section where she also felt disregarded as a human being, stripped of dignity and degraded:
'I was then treated like a piece of meat, my baby was handed to my partner and he was told to leave the theatre, I was then stripped of all coverings while the staff wandered around theatre cleaning up, I was then told that they were now going to clean my vagina, I was exposed for all to see. I was in such a state of shock by this stage that I was unable to speak, let alone object to what was happening to my body or to ask for my baby. I was stripped of all dignity and totally degraded'. (FB15).
These circumstances taught the participants that hospital birth could not offer them safety, because they had already proved psychosocially to be dangerous. For this reason, the participants perceived births inside the system to be a riskier and a less safe choice than a birth outside the system. This belief was accentuated by the impact birth trauma had on their lives. Some of the participants’ experience of birth trauma was life changing, an effect they were not willing to compound by returning to the place that was the source of their original trauma. So traumatic was the experience for some participants, that they reported outcomes such as the development of mental illnesses and pathological behaviors, Post Traumatic Stress Disorder (PTSD), the inability to embody the type of mothers they wanted to be, and the inability to function with their other relationships.
One woman asserted ‘that [the first] birth caused myself and my family significant distress and trauma for a long time afterwards’ (FB10). The presence of long-term effects after a traumatic birth left some participants questioning whether they would ever recover, with comments such as ‘I’ve never been the same since’ (HB11) and ‘it would change our family forever’ (FB11).
Perspectives on childbirth
The participants’ philosophical standpoint on childbirth played a particular role in their choice to birth outside the system. The participants believed that childbirth imprints on one’s life, is a normal process and needs ideal circumstances to work best. With the understanding that childbirth imprints on one’s life, participants pursued birth outside the system in the hope that the imprinting would be positive not negative. The belief that childbirth is a normal bodily function, predisposed participants to question the need for hospitalisation. Finally, the participants reported a detailed list of circumstances that they believe are required to ensure birth works best. These included: adequate hormonal function, an optimal environment, privacy and relaxation, active birth positioning and good physical, emotional and mental preparation. Based on their previous experiences, the participants believed that the hospital was not capable of facilitating the circumstances that birth needed to work best and was therefore incapable of providing the best and safest.
Perspectives on risk
Just as the participants’ perspectives on childbirth informed their choice to birth outside the system, so too did their perspectives on risk. The participants’ perceptions of risk were that birth always entails an element of risk, the hospital is not the safest place to have a baby, and that interference is a risk. The participants also believed that their chosen place of birth may not mitigate the risk inherent in birth. As one woman put it,
‘I always knew that there was no guarantee that the baby would be born alive or that it would live beyond the birth, but I think there is no guarantee with that in a hospital setting either’. (FB06).
They believed that the hospital is not the safest place to have a baby, citing additional and unique risks associated with this option. One woman commented:
‘Automatically walking into a hospital I’m exposed to hospital bugs, that to me is unsafe ... a neonate’s immune system is not fully developed, I don’t want my babies exposed to that, I don’t even want myself exposed to that. So, they can’t possibly offer me a safe birth’. (FB05).
Finally, the participants perceived that interference in the birth process is a risk. One woman commented:
'If you can stay away from the hospital system, then you can minimise the amount of interference. I look at interference a bit like risk, like every time someone new comes across you or does something that’s a risk that something goes wrong, every time you get a medication there is a risk it’s the wrong one, every time they do something, there is a risk that flows onto something else, so if no one is doing anything to you or giving you any drugs or performing any unnecessary tests, then there is no risk there'. (HB05).
Because the participants wanted the best and safest for themselves and their babies, they sought out birth options that would limit risk. Hospital was perceived to be riskier, and the most likely site where birth would be interfered with, so it was discounted as a suitable birth option.
The hospital can’t provide the best or safest
Participants’ previous experiences with the hospital system, paired with their beliefs on childbirth and risk, led them to assume that the hospital could not provide the best or the safest, because they could not cater to their personal criteria by which ‘safest’ and ‘best’ were judged. The participants cited multiple reasons why the hospital was incapable of providing the best or safest and these have been categorised under the headings, ‘not enough resources to cope with demand’, ‘the environment was not like home’, ‘it’s like a cattle yard’, ‘staff are bound by hospital policy’, ‘they intervene’, ‘they fear birth’, ‘there would be tension around my autonomy’ and ‘hospital management of birth is emotionally unsafe’.
One woman felt that the hospital system was inherently flawed, stating:
'I’m not sure they really could have done anything better for me just because of the mentality ... it’s a revolving door and they’ve got to get this baby out the quickest way possible, whichever way suits us and then get this baby fed, don’t care how just get it fed and then get you out the door. I don’t know if they could have done anything better'. (HB07).
Worse still, many women found hospital care traumatising, with one woman explaining,
'I decided that should I find myself unable to access a midwife, I would birth at home – alone. Nothing that can happen to me or my baby at home could be much worse than what my second baby and I experienced in hospital. I will never subject myself, my baby or my family to such an ugly, traumatic and dehumanising experience again'. (FB1).
The participants concluded that the hospital could not provide the best or the safest, and so they set out on the journey towards ‘finding a better way’, which ultimately led them to birth outside the system.
The basic social process- finding a better way
In explaining their choice to birth outside the system, the participants described making a considered decision after first exploring other birthing options. This process followed a typical path, with the women ‘discovering that there are multiple birth options’. They move on to ‘meet with a variety of care providers’ and then ‘weigh it all up.’ After making the decision to circumvent the system, the women ‘get informed about out-of-the-system birthing options,’ which for some leads to homebirth and for others ‘forces them to consider freebirth.’
Considering birth options
As the women investigated, they discovered many birthing options of which they had hitherto been unaware. In her pursuit of a better way, one participant said,
‘I just became more informed about my other choices ... [and this] just blew open a whole new world for me around another choice’ (HB04).
As the women met with care providers and weighed up all their options, they came to a realisation that giving birth in hospital would not cater to their desire for the best and safest. It was from this point women described immersing themselves in information about homebirth and freebirth; one woman explains:
‘I googled everything and anything that I could get my hands on…read Ina May Gaskins stuff and yeah so got a lot more informed about the alternatives’ (HB06).
For the women who chose homebirth with risk factors, their process of discovery of birth options stopped here; they hired a midwife and followed through with their midwife-assisted homebirth. For those who chose freebirth, the process of considering their options continued. In their quest to find a better way, some participants came to point where they were forced to consider freebirth. This was because other birthing options became either unavailable or unacceptable to them.
All but one of the women reported having made contact with a midwife or care provider in order to discuss their birth options. The one woman who did not make contact had completed a PhD on the topic of medicalisation of childbirth and during that process had connected with women who described their choice to freebirth. Prior to becoming pregnant, this woman decided she would freebirth and thus did not engage the counsel of a care provider in the pursuit of her plans to freebirth.
While the women choosing homebirth with risk factors chose to continue being cared for by a midwife and women who chose freebirth disengaged from this care, the two choices to give birth outside the system have their roots in a fundamental rejection of how maternity care is provided within the system. These two outside-the-system birth choices are united in their counter-cultural rejection of the care that is offered to women in mainstream maternity care services in Australia.
The majority of participants reported a preference to have a midwife in attendance, but ultimately freebirthed because they felt they had no other option, and so it was the best and safest option available to them at the time. One participant explained:
'Yeah, like, if that [a midwife] had been available, I would have been quite happy to have the midwife help me in my home have my baby, I never would have considered unassisted ... I mean like I said, I never would have chosen to go down that path had the decision – I kind of felt like the decision was made for me, by denying me that choice'. (FB03).
Managing opposition
In the process of finding a better way to birth, the participants realised that their chosen option subverted biomedical models of childbirth, and that they would have to formulate a strategy in order to manage opposition. The women anticipated that managing opposition within a hospital setting would be hard work, and they did not want to have face this task while in labour. As one woman put it, ‘I felt like it would be a constant struggle, my partner and I against the hospital staff’ (HB04). Another participant felt that managing opposition ‘seems like a lot of energy’ (HB06) to waste whilst trying to give birth.
The strategies employed in order to manage perceived opposition included: arming themselves with knowledge so they could effectively defend their choice, strategic engagement of care providers – avoiding those who would oppose their choice and engaging those who would facilitate it, selective disclosure of their plans to avoid conflict, having people on their side to help advocate for their choice, and ‘playing the game,’ which involved bartering with and manipulating the system to ultimately get what they wanted without having to compromise on the best and safest.
Mitigating the risks of birth at home
The participants made their birth choices based on their desire for risk reduction, therefore, they sought to mitigate the risk by focusing on their mental and physical preparation in order to experience the most optimal birth outcomes. One woman explained:
'I really feel like setting the scene for the freebirth for me was all about taking good care of myself and I invest a lot of time and money into having really good health care and I take really good care of myself'. (FB06).
They also gathered knowledge, skills and supplies to ensure that they felt adequately prepared to mitigate their unique risks, this preparation differed between women who chose freebirth and homebirth. The women who chose freebirth read about what they might need – as one participant noted, ‘we did a lot of research into what we would need to have the birth at home’ (FB01). Women who freebirthed collected equipment for resuscitation – ‘we had the little resuscitation kit’ (FB01) – and also equipment that would be required for an uncomplicated birth, ‘like sterilised scissors’ (FB05) to cut the cord after the birth. While, women who had hired a midwife did not make mention of specific items that they gathered in preparation for their homebirth, the women who freebirthed felt obliged to gather this equipment since they were taking full responsibility over what supplies would be available to them for their birth.
They also planned for all possibilities, so that they were clear in their minds about what plan of action would be taken in an unexpected circumstance. In the circumstance of an emergency, the participants believed that transferring to hospital became the new best and safest. One participant had prepared for:
'... everything from, if my waters break and there is staining in the meconium we are off to hospital, if you know, if I’m feeling unwell – you know we went through a – I listed all the situations with my husband and I sort of said if this happens, then we need to transfer to hospital, if that happens then we need to transfer to hospital'. (FB08).
Becoming the expert
Throughout the process of finding a better way, the participants simultaneously became the experts. They came to value their own ability to make informed and safe choices over that of their care providers. One woman described:
'I felt empowered to be able to take a certain amount of control over my own care ... I think really largely for me, it’s really been a progressive experience of feeling more confident the more skilled up as time passed'. (FB06).
Another woman spoke of how her previous birth experiences had turned her into an expert. Having gained confidence and expertise through her previous birth experiences, she felt confident to birth her breech baby at home:
'It was my third birth. I think that is a big factor. If it was my first birth, I probably would have listened to the obstetrician and just gone for the elective caesarean out of fear, so again I was very comfortable with birthing babies by this stage, very confident in my own ability'. (HB06).
The participants described themselves as different to other women because they are ‘always bucking against the system’, ‘take responsibility’, ‘investigate to ensure that they know’, ‘believe in their ability to ‘know,” ‘have a sense of entitlement to choose’, and ‘possess confidence in their ability to birth’. These characteristics facilitated the development of their expertise as they pursued a better way and ultimately led them to birth outside the system.