According to Germaine Greer (1985: 6), ‘from conception, pregnancy is regarded as an abnormal state… an illness, requiring submission to the wisdom of health professionals and constant monitoring, as if the fetus were a saboteur hidden in its mother's soma.’ She further considered that ‘hospital birth takes place among strangers and is subordinated to their routine’ (Greer, 1985: 11). Confirming this bleak analysis of the 1980s birthing zeitgeist, Davis (2013) shows that ‘in England and Wales the years between 1985 and 1988 saw the lowest ever recorded rate of home births, an average of 0.9 per cent.’
For decades, the medicalisation of childbirth has persuaded pregnant women that the best place to give birth is in hospital. Today, what was once a social event has become a medical procedure. Perhaps this helps to explain why the issue of dignity remains to be addressed effectively. Prochaska (2013: 821), referring to the first ever national Dignity Survey of more than 1100 women undertaken by Birthrights—a charity established to promote human rights in maternity care—noted: ‘Women who gave birth in hospitals experienced less choice and respectful care than those who gave birth in birth centres or at home.’
Contemporary homebirth rates have improved since the 1980s; but although the Birthplace in England Collaborative Group (2011: 1) concluded that ‘women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes,’ it noted that only 2.8% of births in England in 2007 were at home. More recently, the National Maternity Review (2016: 19) stated that this had dropped to 2.4% in 2012. Perhaps these data reflect the fact that not all women are offered a choice of place of birth and type of birth. For example, the National Maternity Review (2016: 26) states: ‘16% of respondents to the 2015 CQC Maternity Survey reported that they had been offered no choice.’
It has been encouraging that the National Institute for Health and Care Excellence (NICE, 2014) recommends that health professionals ‘advise low-risk multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.’ Meanwhile, the National Maternity Review (2016: 102) aims that, by 2020: ‘Women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit after full discussion of the benefits and risks associated with each option.’
However, translating recommendations into reality by NHS Trusts, many of which are resource-poor, is a major challenge. Beverley Lawrence Beech, chair of the Association for Improvement in the Maternity Services, said: ‘The choice of a homebirth should not be a postcode lottery where, in most Trusts, women have to fight to get one.’ Referring to the ‘full discussion of the benefits and risks associated with each option’, as recommended in the National Maternity Review (2016: 102), Beech commented: ‘No woman has ever told me that when discussing where to have her baby the doctor or midwife has listed the risks of an obstetric unit delivery. So much for informed consent.’
Birthrights chief executive Rebecca Schiller believes that the increased focus on out-of-hospital birth in maternity policy is not yet matched by realistic service provision. ‘Some Trusts,’ she told BJM, ‘have suspended their homebirth services entirely, while others have inadequate staffing plans that make homebirth an unreliable option for local women. Long-standing Department of Health policy stipulates that women should be able to choose where to give birth. In addition to the dramatic reduction in intervention in home settings highlighted by the Birthplace in England Collaborative Group (2011) study, the Birthrights (2013)Dignity in Childbirth survey reported that homebirthing women felt their care was more respectful and birth impacted positively on how they felt about themselves, their babies and their partners. Homebirth should be available to all women who want to access it. A policy drive that highlights homebirth benefits with no implementation plans is harmful to women who attach real significance to the birth choices they wish to make. Birthrights is working with others to address these issues on a number of levels.’
The medicalisation of society and the socialisation of medicine have conferred on childbirth the status of a medical procedure. While some births need to be managed in hospital, midwives have a role in ensuring that the women in their care have an opportunity to experience childbirth as a rewarding event—taking place, should they wish, at home.