In Ireland, some women who are unable to access a midwife-attended homebirth are choosing to give birth at home without assistance. This paper describes the experience of four such women, whose stories reveal the context and larger case of the Irish homebirth service. Background literature on unassisted or ‘freebirth’ is followed by an outline of current Irish homebirth services, illustrating the context of the women's decisions.
Freebirth
Deliberately unassisted birth, where the option of birth attended by a trained professional is freely available, has been called ‘freebirth’ (Shanley, 2012). Freebirth must be acknowledged as a ‘choice’ only in resource-rich contexts where access to hospitals and trained birth attendants is largely unproblematic (Lundgren, 2010).
In countries such as Ireland, the UK, New Zealand and the Netherlands, midwife-attended birth is the norm and, to varying degrees, homebirth is accommodated. Freebirth, however, is seen as an active rejection of cultural birth norms and is described as an explicit critique of the dominant maternity services (Miller, 2012; Worman-Ross and Mix, 2013).
Several studies have investigated women's reasons for choosing to freebirth, notably Freeze (2008), Brown (2009) and Miller (2009) in the US, Cameron (2012) in Canada, and Dahlen at al (2011) and Jackson et al (2012) in Australia. Women choose freebirth to increase their sense of control over the birth and avoid unnecessary interventions that occur more frequently in hospital birth.
The risks that professional birth attendance claims to monitor and manage may present themselves as real dangers for some women. This concern effectively reprises Percival's claim (1970) that no birth can be considered ‘normal’ except in retrospect, and allows professional discourse on risk in maternity services to overpower the principle of women's choice. Chervenak et al (2013), for example, argue that owing to evidence of risk in out-of-hospital birth in the US, there is a moral imperative to ‘prevent’ not just freebirth but homebirth in general. Examples of professional risk discourse overruling women's choice is also clearly evident in recent Irish legal decisions, which will be discussed further in the analysis.
Irish maternity and homebirth services
Hospitalisation and centralisation of birth in Ireland has been the norm since Comhairle na nOspidéal (1976), which largely reflected the UK Peel Report (Department of Health and Social Security, 1970). More than 99% of approximately 70 000 babies born each year in Ireland are born in hospital (Economic and Social Research Institute (ESRI), 2012). Four large urban maternity hospitals account for almost 50% of those births (ESRI, 2012). Free antenatal care is offered by the maternity hospitals but for many low-risk women, antenatal care is shared with their GP. Overall, intervention rates in Ireland (ESRI, 2012) are high compared to European median rates (Macfarlane et al, 2015): spontaneous vaginal deliveries are at 56.3% compared to 66.2%, birth by caesarean section 28.1% compared to 25.2%, and vaginal instrumental births are the highest in Europe at 16.4%.
Alternatives to consultant-led hospital birth are limited. There are only two alongside midwifery-led units (Begley et al, 2009) and one small hospital-outreach community homebirth midwifery scheme in south Dublin (National Maternity Hospital, 2015). Isolated midwife clinics, Domino (domiciliary care in and out of hospital) schemes and postnatal early transfer home schemes give a small degree of midwifery-led care to some women, but do not offer homebirth.
There are fewer than 200 homebirths per year in Ireland (< 0.5%). There is a nominally ‘national’ homebirth service (NHBS) (Health Service Executive, 2013) but it is entirely dependent on a very small number (< 20) of self-employed community midwives (SECMs), most of whom work only part-time (Community Midwives Association, 2015). Women must try to access one of these few SECMs or forgo a homebirth. The Home Birth Association of Ireland (2012) reports that demand for homebirth in Ireland far outstrips supply. There is no formal record of the number of homebirth requests that are not accommodated, so the unmet demand cannot be determined. Kenny and OBoyle (2015) demonstrated that the majority of women who failed to secure a midwife for homebirth went on to give birth in hospital (43 of 53 women, 80%). A significant proportion, however (7/53, 13%), decided to birth without professional assistance. In this Irish context, then, the decision to birth unattended needs to be explored.
Methodology
As there is no formal record of those who have had unassisted births, it is impossible to estimate or justify a representative sample. Case study involves the in-depth reporting of individual sociological cases, which allows their apparent peculiarities and unique setting to be purposefully examined (Yin, 2013). Stake (1995) describes the use of individual cases to explore a larger case as ‘instrumental case study’. The unit of analysis for this study, then, is not the individual women but rather the Irish homebirth service.
An online survey of unmet demand for homebirth between 2010 and 2013 was carried out in 2013 (Kenny and OBoyle, 2015). All seven self-identified unassisted homebirthers were invited as part of that survey to indicate whether they would be willing to be interviewed. Three of the these ‘freebirthers’ agreed to be interviewed. One further eligible freebirther in the period, who had not completed the initial survey, was known to and recommended by one of these three. She also offered to tell her story. Written informed consent was obtained to have interviews recorded and transcribed. Recordings were destroyed after transcription by the author.
The four women's transcribed interviews were coded to identify concepts and explored for common themes. The themes identified are used to examine the wider ‘case’ of Irish homebirth services. Other documentary material describing Irish homebirth services was drawn from the Department of Health (Ireland), the Health Service Executive (HSE), the Nursing and Midwifery Board of Ireland (NMBI), Irish and European legislation, and Irish judicial rulings on homebirth.
Ethical approval was granted by Trinity College Dublin (TCD) Faculty of Health Sciences Research Ethics Committee. All names have been changed and demographic details outlined will not enable identification of participants.
Results
Demographic details of the women and their stories are summarised in Table 1. They were all multiparous women who had wanted a midwife-assisted homebirth. When this option was not available, they actively considered and birthed at home without a midwife. Their primary motives for choosing homebirth were broadly the same as documented elsewhere (Edwards, 2005; Janssen et al, 2009a).
| Demographics | Case 1 Fidelma | Case 2 Florence | Case 3 Frances | Case 4 Felicity |
|---|---|---|---|---|
| Age | Mid-30s | Early 30s | Early 30s | Mid-30s |
| Ethnicity | White Irish | White Irish | White Middle European | White Irish |
| Marital status | Married | Partnered | Married | Married |
| Urban/rural | Rural | Rural | Urban | Rural |
| Parity | Para 3 | Para 3 | Para 2 | Para 3 |
| Previous birth history | SVD, MLU, water for labour (UK) |
SVD, epidural and augmentation, hospital (Ireland) |
SVD, epidural, hospital (Ireland) | SVD, homebirth (Ireland) |
| Antenatal care (this pregnancy) | GP shared care; antenatal hospital booking | GP, then did not attend; booked hospital, again did not attend | GP shared care | SECM, declined antibiotics in pregnancy |
| People present for birth | Partner | Mother-in-law, sister, partner | Partner, female friend | Partner |
| Labour care arrangements | ‘I imagine it'll just happen in the night, I can't imagine I'm going to end up in the hospital.’ ‘It was designed to a certain extent and an accident at the same time, we just dilly-dallied a bit much, when the birth came.’ | ‘It was, you know, kinda planned and it wasn't planned’ |
‘Didn't decide 100%’ |
‘Hoping all would be OK for homebirth’ |
| Postnatal care (this pregnancy) | Ambulance to hospital for baby notification (registered as hospital birth until asked to change); PHN care | GP locum | Ambulance to hospital for baby notification and perineal suture; discharge to PHN | SECM |
| Reason for choosing freebirth | Unable to access SECM/unavailable; aversion to hospital/intervention | Unable to access SECM/distance (Possible history of shoulder dystocia, likely unsuitable) | Not suitable for HSE scheme due to hepatitis C | Not suitable for HSE scheme due to Group B streptococcus during pregnancy. Keen to avoid routine antibiotics |
HSE–Health Service Executive, MLU–midwifery-led unit, PHN–public health nurse, SECM–self-employed community midwife, SVD–spontaneous vaginal delivery
Case 1
Fidelma had two previous babies, one in a midwifery-led unit in the UK and one in the Netherlands, a homebirth in water. She contacted many midwives asking for a homebirth under the NHBS but none was available. Fidelma discussed with her husband the possibility of birthing at home without the midwife. She ‘dilly-dallied’ in labour until it was too late to go to hospital. She transferred to hospital for postnatal care and later discovered that the baby had been recorded as a hospital birth.
Case 2
Florence had two previous births. The first was in hospital a considerable distance from her home, where she had many interventions she later regretted. The second was an attempted unattended birth but she transferred, after what she felt was a long and difficult labour, to a midwifery-led unit. Her story suggests she may have had a degree of shoulder dystocia, which might have made her ineligible for a subsequent homebirth. Nevertheless, she again preferred a homebirth. Florence was unable to access a midwife close enough to attend her. Florence's partner was present for the birth, and her sister and mother-in-law were on-hand. A locum on-call GP examined her and her baby postnatally.
Case 3
Frances, a doula, is from Eastern Europe, living in an Irish city. She had her first child in hospital but felt unsupported to birth without intervention. She has hepatitis C and so is ineligible for the NHBS. Antenatally, her care was shared between her GP and the hospital. She fully considered birthing at home but describes the final decision as ‘an accident’. Her partner and a female friend were present during labour. After birth she called an ambulance as she wanted to ensure notification and registration of the baby's birth.
Case 4
Felicity had two previous homebirths in Ireland. She was low risk in this pregnancy and secured the assistance of a SECM for a homebirth under the NHBS. During the pregnancy she developed a group B streptococcal infection. She therefore became ineligible for the homebirth service, which was rescinded by the HSE. The SECM was obliged to hand over to hospital care. Despite advice from the hospital, Felicity declined antibiotic therapy for herself antenatally or for her baby postnatally and decided she would rather avoid hospital birth. Felicity's husband was present at the birth, and the SECM who had attended her antenatally attended her for the postnatal period.
Themes
Three common themes emerged:
Theme 1: Midwife-attended homebirth was not available
The reasons reported for being unable to access a midwife varied. Among the four cases, two were unable to find a midwife available to attend them for homebirth. The inability of low-risk, eligible women to find a midwife has been noted by Kenny and OBoyle (2015) and demonstrates the inequity of access to the supposedly ‘national’ homebirth service (HSE, 2013).
One woman (Frances) was outside the suitability criteria for the HSE homebirth service so did not seek a midwife-attended homebirth. Another (Felicity) accessed a midwife but became ineligible for a midwife-attended homebirth. She said:
‘I can understand from her [midwife's] point of view that she didn't really have a choice on it. I mean she wanted to be there. She just couldn't facilitate me with the homebirth—insurance is through the HSE so they can only operate under these very stringent conditions… I felt completely abandoned at that stage in the process.’ (Felicity)
Unsuitability for the NHBS has been noted as limiting women's choice of place of birth. Seven multiparous women who had wanted a midwife-attended homebirth between 2010 and 2013 chose not to birth in hospital, even though five had been identified as being ‘unsuitable’ for the homebirth service (Kenny and OBoyle, 2015). Women's preference for a midwife-attended homebirth is not accommodated; indeed, the service obstructs attendance by a midwife for such women.
Theme 2: Reliance on emergency services
Despite the women's belief in their own power to birth successfully, they understood that birth might not progress normally.
‘I knew there was a risk involved.’ (Florence)
‘You feel yourself, you feel the baby inside and you can feel that there is something wrong—you cannot [know] but you can have this idea.’ (Frances)
When pressed, the women said they felt that delay in progress was likely the main reason they would transfer to hospital. Bleeding, or the baby failing to breathe, were particular reasons they anticipated as requiring emergency intervention. Without a midwife in attendance, they decided they could resort to emergency services, their GP or hospital, should the need arise.
‘And if something went wrong, then we were going to call the ambulance—that's the only thing you can do at the moment—but we didn't have any more plans.’ (Frances)
Distance, time delay waiting for an ambulance, and travel time to hospital were included in calculating the timing of any request for emergency assistance. The women felt that the subject of distance to hospital was diminished in their regular dealings with maternity services, but highlighted in the arguments against homebirth. They felt that access to hospital via emergency services ameliorated risks to themselves or their baby.
Theme 3: Social disapproval inhibits disclosure
All of the women identified a significant degree of disapproval from others, for out-of-hospital birth and even for planned midwife-attended homebirth. They were aware that some health professionals consider it risky, dangerous or unacceptable behaviour.
The women discussed how they were careful regarding to whom they disclosed their intention or consideration of unattended homebirth. Often, even their own mothers were not told. The women felt others would worry and try to talk them out of it. Non-disclosure among freebirthers is also described in the US (Miller, 2012).
Even after the event, the women were not entirely secure in the legal position of unattended homebirth:
‘In Ireland it's pretty hard to get the answers for your questions, for example in the [United] States in this situation you could get sued for putting baby in risk and I don't know if it is working the same in Ireland.’ (Frances)
‘I didn't know the legalities… I didn't want to go against the grain, go against the mould and do what I wasn't supposed to do… Definitely I got the feeling that it wasn't allowed.’ (Fidelma)
Many presented their outcome of an unassisted birth as an ‘accident’ or a result of failing to make the decision to go to hospital until too late. They nevertheless had been actively considering the possibility and consequences of birthing at home alone. Unassisted birth was not a thoughtless or unconsidered choice; it was apparent that they used this construction to avoid having to clearly signal their intent and suffer the anticipated opprobrium of others.
The larger case of homebirth services in Ireland
The themes derived from these four women's experiences of deliberately unattended homebirth will be used as instrumental cases (Stake, 1995) to reveal and explore the larger case, that is, the Irish maternity service context in which their stories unfolded.
Lack of choice in Irish maternity services
As demonstrated above, choice of place of birth is extremely limited in Ireland. SECMs were, for many years, the only professionals supporting women to have homebirths. Arising from women's unsuccessful petition for the right to homebirth, the Irish Supreme Court ruled that the HSE could not be obliged to provide homebirth (O'Brien v SWHB (South Western Health Board) [2003]). Nevertheless, the HSE continues to offer some support for homebirth (Meaney et al, 2013). A combination of recent EU directives (EU Directive 2011/24/EU) and Irish state legislation (Nurses and Midwives Act 2011) require professional indemnification. Individual midwives, however, are unable to access private indemnification on the open market. Evidence from the UK indicates that insurance premiums would be prohibitive (Department of Health, 2010; Royal College of Midwives and Nursing and Midwifery Council, 2011).
The NHBS was developed (HSE, 2008; Meaney et al, 2013) in the first instance not to give women choice but rather to secure a means by which SECMs could avail of state-based professional indemnification for their practice (HSE, 2004; 2012). The NHBS provides state indemnification of homebirth midwifery to low-risk women, but without making a commitment to providing that choice to all eligible women. By providing state indemnification of midwives the service has, to an extent, enabled homebirth midwifery practice. The HSE terms for indemnifying midwifery attendance at homebirth are, however, more restrictive than the UK's National Institute for Health and Care Excellence (NICE, 2014) guidelines. Whereas previously a midwife may have attended a woman who, fully informed of any risks to her and her baby, still chose to birth at home, the same midwife would now be criminalised for attending her. The Irish legislation is clear that paid midwifery attendance at birth without indemnification is illegal. If the woman has any risk, the HSE will not indemnify midwifery attendance at home. The HSE's refusal to facilitate that choice drives women and midwives apart. Some women cannot get the midwifery attendance they want because midwives feel unable to attend for fear of prosecution if they do (OBoyle, 2013; 2014).
Discussion
Unassisted birth as critique of institutionalised birth
Each of these women would have preferred to have been attended by a midwife in her own home. The women's preference to birth with a midwife at home was either unavailable or withheld from them, so they found themselves constrained by circumstance, rather than ‘free’ to birth without professional attendance.
These women differ, then, from freebirthers—as defined by Shanley (2012) or Miller (2012)—who explicitly express a preference to birth without professional assistance. Feeley et al (2015) also identify freebirth as a rejection of medical and midwifery care. The experience of these Irish women is certainly not a rejection of midwifery-attended homebirth, rather theirs is a critique of the lack of choice within Irish maternity services. The decision to freebirth is an extension of the motivation to homebirth (Edwards, 2005; Janssen et al, 2009a). They wanted a non-hospitalised birth and they believed, based on experience, in their own power to birth.
Risk, blame and subterfuge
Professional discourse on risk and childbirth is pervasive and persuasive, with women's discourse on choice apparently less authoritative, as evidenced in the Supreme Court decision (O'Brien v SWHB (South Western Health Board) [2003]) and a later High Court ruling which denied midwife-attended homebirth after caesarean section (Teehan v Health Service Executive & anor [2013]). The women interviewed here were very aware of the risk discourse in childbirth (Murphy-Lawless, 1998; Edwards, 2005). They perceived a degree of social opprobrium and stigma associated with the decision to homebirth generally, and certainly with regard to freebirth. They reported selective or non-disclosure of their intent either to homebirth or to freebirth. They had a clear concern not to implicate themselves or others when telling their freebirthing stories. They do not feel secure that legislation would not be used against those who were with them at their births.
The UK Nursing and Midwifery Council (2012) has reassured women that it is not illegal to have family members or doulas present at professionally unattended birth. In Ireland, the HSE and the NMBI have made no such assurance, while emphasising that professional attendance must be indemnified. Midwives ‘should support every woman to engage with maternity care’ (NMBI, 2015: 14)—which, presumably, includes advising against unattended birth. The HSE, however, has repeatedly neglected to address the safe and appropriate midwifery management of women who are, or become, ineligible for the homebirth service (HSE, 2004; 2012).
Conclusion
There is good evidence as to the safety of midwifery-led models of care, including homebirth (Janssen et al, 2009b; National Perinatal Epidemiology Unit, 2015). It is difficult to substantiate the real demand for homebirth and midwifery-led units in Ireland, but while they have been recommended in the Irish context (KPMG, 2008; Begley et al, 2009) they have yet to be rolled out nationally.
The case studies presented here demonstrate that there is a cadre of women who so strongly perceive the inadequacy of the maternity services in Ireland that they effectively opt out of the presumed benefits of professionally attended birth. These women clearly critique the quality and appropriateness of Irish maternity services. Homebirth has been identified as critique of hospital birth (Rothman, 1991; Freeze, 2008; Cheyney, 2008; 2011; Worman-Ross and Mix, 2013). In the UK, Wickham (2008) has similarly identified freebirth to be an explicit critique of formal maternity services.
Women's desire and repeated calls for choice in maternity services in both the UK (Department of Health, 1993) and Ireland (Kinder, 2001) have long been ignored. These individual cases critique the larger case of the Irish maternity service, making visible both its strengths and weaknesses. Strengths identified are the options, though limited, of midwifery-led models of care and homebirth, and the perceived reliability of the emergency services. Weaknesses identified are centralisation and unresponsive services; excessive birth intervention; lack of choice and access to a variety of services; and underutilisation of the scope of midwifery practice.
Hospitalisation and centralisation of birth in Ireland since Comhairle na nOspidéal (1976) may have served the acutely unwell and high-risk minority of women and babies, but it drastically reduces choice and freedom for the low-risk and medium-risk majority. The HSE should emulate its UK neighbours and respond to the evidenced demands for different models of maternity care in Ireland, rather than abandoning women to birth alone.