Why be an autonomous consumer of the healthcare system?

In recent years as midwife-assisted homebirth has become more topical in the mainstream press, so too freebirth* or family birth, has also become more widely known. Our culture of control over women means that the shock value of women birthing autonomously is on a par with those women who chained themselves to parliament houses for the privilege of voting. The politicised nature of birth, and the heavily contested zone of women’s bodies, means that any choice outside of an external careprovider model is scrutinised, criticised and demonised. Those who birth in hospitals, with their poor outcomes and constant newsworthy crises are seldom asked to justify their decision despite the clear evidence that their choice is the suboptimal one. How refreshing it would be to see women in L&D quizzed over their reasons, research and capabilities to manage the system they’ve chosen.

*[Important nomenclature point: “Unassisted Childbirth” while a popular label, still epitomises the notion that the norm for birth is “assisted” and yet a woman birthing without a medical attendant is seldom actually “unassisted” just supported in different ways from assisted births.]

There are a number of broad reasons often given for those who choose freebirth – note that this is not the same as women speaking for themselves. Some reasons include the cost of private midwifery care, availability of midwifery care, fear of careproviders or previous trauma. All of these are still coming to us via a paradigm which assumes the only model for birth to be one in which women seek external care provision. This argument posits that only “damaged goods” or those without access to midwives would need or want to birth without an attendant, thus cementing the primacy of the external careprovider in birth. For some women, some of these factors do come into play. For many women these are not factors which they consider when planning a birth. Those living in major cities, for instance, have little trouble locating independent midwives.

The pressures on independent midwives are well known to those of us who work in birth and it cannot fail to be acknowledged as reprehensible that obstetricians who work without evidence or woman-centred care are favoured on every level over those who would seek to offer women something of benefit to them, their families and also the wider community. What some midwives fail to recognise however is that the very pressures on them from those bureaucracies which seek to stamp out homebirth are filtering down to clients in a very real way. The obstetric model of “care with strings” is the one promoted by these bureaucracies so women are forced to accept birthing under conditions which may indeed favour a midwife’s continued access to registration but does not support women to achieve the births they desire. However the end result is arrived at, some women are thus unable to find midwives to care for them and decide, given the demonstrable dangers of our hospital system, that they will be an autonomous consumer within the healthcare system and care for themselves.

Freebirth is thus not an attack on midwifery but for some women it is an indication that midwifery as it stands is unable to fulfil the needs of many consumers. Perhaps rather than viewing freebirthing women (and those who support them) as another enemy, it would serve some careproviders to use this information to reflect upon how to manage these issues without clients being affected. The use of freebirthing women’s stories to promote midwives’ campaigns for professional recognition is a misguided approach and only furthers the existing paternalism around birth. Midwives should be freely available to all women and to exploit some women’s decisions to birth without a midwife in order to further a very different agenda does not seem a deeply considered strategy. Increased availability of midwives, desirable as it is, will not alter every woman’s freebirth plans given the range of reasons women might choose freebirth in the first place nor should it since women’s right to choose within birth must be inviolable.

However a woman arrives at the decision to pursue freebirth, it almost always boils down to a desire for autonomy. Autonomy is not available to women in the hospital system, it is not available to all women choosing independent midwifery for complex reasons, some of which are stated above. In fact it is generally not available to (nor is it pursued by many) women in our lives outside of birthing. Some women want to truly make their own decisions around their bodies, births and babies. This can only be a radical concept in a world where women are seldom supported in their basic rights to bodily integrity.

Imagining women with an automatic right to full autonomy is disturbing to many of us, enculturated as we are to believe that women are communal property, subject to the invasive gaze of authorities both public and private. It seems a difficult concept for careproviders who come from a background of normal socialisation and through inherently misogynist training to grasp, but it is as difficult a concept for many women to grasp and those who do are a (maligned) minority. Some women even recognise that it is their response to the client/careprovider dynamic which leads them to choose autonomous birth and thus avoid their own socialisation to hand over their power. Careproviders might even find their own personal and professional satisfaction concomitantly increased by taking similar steps.

It would indeed be refreshing sometime to see the tables turned and women who choose birthing options known for poor outcomes, and venues in which their power is expected to lie dormant questioned about why they would make such dangerous decisions. Of course this can only happen in a world where it is no longer normal for women to unquestioningly accept what is offered as “care” in the maternity system and what passes for “choice” when you inhabit a faulty feminine body in a patriarchy.