I read recently that the majority of women say they were offered a choice of place of birth, yet 98% are still having their babies in hospitals, despite a very large body of evidence which leads to the conclusion that home births are safe for mums, safe for babies, and have higher levels of satisfaction. A small number of women will have their baby in a birth centre, which can range from the amazing, free standing, autonomous resource centre to a corridor on an obstetric unit with similar practices and policies. However, these places are not geographically available to all women, and the acceptance criteria can be quite tight. So, why? How can Wales have a home birth rate of about 8%, how can places like Torbay and the axed Albany practice have home birth rates of 40% with outcomes as good (and even better) than the hospital?
This is because women generally are NOT being offered options, or not in a way which makes them real and accessible… Imagine asking a first time mum, who has been told (and believes) that birth is awful and that she should take every painkiller on offer, where she would like to have her baby. You pretend that you are offering her an open choice, but you offer her little or no information or chance to educate her decision making, and then when she says ‘hospital, where the drugs are’ you write down that she has ‘chosen’ hospital birth… You do this when she is about 12 weeks pregnant, and you set her expectations on a decision made at that point in time. Did she really have a choice of a home birth or a birth centre? The choice might have been there on paper, or even kind of asked, but the chances of this mum accessing that choice were virtually nil.
Imagine listing the hospital run places for birth like a menu, and then, with raised eyebrows and incredulous voice say ‘Or you *could* have your baby at home’ without making sure that the woman has understood the value of doing so. She isn’t going to be very likely to book it, unless she’d have been asking for a home birth even if you hadn’t ‘offered’ it. Did you really let her have a choice, or give her the information she needed to make an informed decision about how she wanted her baby to be born? No, you set her up to ‘choose’ hospital again.
Or how about when a woman books a home birth, without the security of knowledge and confidence from having a 1:1 MW, and then sees her GP, Obs, other MW even, who sucks her teeth, says home birth is dangerous, throws about a few incorrect statistics and says ‘and you wouldn’t want anything awful to happen to your baby would you, because it is horrible watching a woman bleed to death’ or any such claim. Interestingly, when you ask them when they witnessed that awful situation, you find it was whilst they were a student eons ago, or something that they didn’t even see for themselves, only heard about ……. When the woman then ‘changes her mind’ and ‘chooses’ to transfer her care to the ‘safety’ of the hospital, who can blame her!
Most women are OFFERED a choice, few are actually GIVEN one 😉
The places where women frequently and successfully give birth outside of the hospital system have very different choices. Usually the discussion begins with talking about how birth can be, and giving the woman true freedom to ask questions and to digest the information in a way that is accessible for her. She may or may not be ready at this stage to make a choice and work towards that goal, but no assumptions are made about her birth, and no ‘booking’ of a place made. The woman’s pregnancy progresses with the support of a caregiver the woman knows well and trusts because the communication is open. If there are complications, then the woman and her supportive caregiver address them, sometimes together, sometimes with the help of extra professionals. The woman gets to decide here how things will proceed, and she alone gets to decide which pieces of advice and information she wishes to act on, and her decisions are supported and respected, in the safe knowledge that she has made an informed decision. When she chooses to decline offered interventions, that is respected without pressure. There can be no choice, and no informed decision, unless you have the complete freedom to reject a choice or make a different decision from that recommended.
In that situation, when the woman finally begins to labour, she is supported at home and makes her decision as to whether or not she wishes to transfer her care to hospital at that point. She will make that decision based on the information about how well she and her baby are, and on her personal preferences. Whatever she chooses will be accepted, valued and supported. Interestingly, the majority of women in that situation seem to choose to stay within their nest, and birth happens smoothly and well, the outcomes are as good as in a medical facility, but the striking difference is how the woman feels about her birth. It is rare for women who have been through that experience to talk about birth being ‘painful’, ‘degrading’, ‘frightening’ or most telling of all, ‘worth all the pain and trauma because I have a baby.’ Her satisfaction levels are high, she is empowered and she is on top form to begin being a parent. Is that not the way it should be?
Choice is a funny thing, and the illusion of choice is one which will continue until we start to support and educate women so that they can make real choices and not just the ones that the system wants them to make.