In all nine cases, the women felt that they were safer giving birth at home than in the hospital, and most had a strong aversion to birthing in a hospital. In two cases, the women had experienced previous hospital admissions as extremely stressful.
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In six cases, the women had had a negative experience during a previous birth.
These were not related to a poor obstetrical outcome (there were no cases of previous perinatal deaths or major maternal or neonatal morbidity). The women explained that they had experienced a lack of autonomy during medical interventions during birth (e.g. an induction of labor, instrumental delivery or cesarean section) as traumatic.
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In four cases, an experience during the current pregnancy was also perceived as traumatic. These situations involved a lack of autonomy as well.
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Some health care professionals we interviewed were aware of the fact that many women who birth outside the system have had a previous traumatic experience LQWKHKRVSLWDO7KH\EHOLHYHGWKDWWKLVPDGHFDULQJIRUWKHVHZRPHQGLFXOW
because of the extra time needed to ameliorate previous trauma, and that they were placed at a disadvantage by a pre-existing lack of trust.
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Community midwives and obstetricians often understand that previous trauma FDQLQÁXHQFHDZRPDQ·VFKRLFHVEXWWKLVGRHVQRWQHFHVVDULO\PHDQWKDWWKH\
want to attend a high-risk home birth.
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Weighing the evidence.
After having had a negative experience in regular care, and vowing not to lose their autonomy again, the women started gathering information. They used websites, internet fora, and medical journals to increase their knowledge of REVWHWULFV DQG KHLJKWHQ WKHLU WUXVW DQG FRQÀGHQFH LQ WKHLU DELOLW\ WR ELUWK
naturally.
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Some health care professionals have noticed a shift to a more empowered clientele. They feel that there is a growing awareness among women that they have the right to refuse medical advice.
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With their newly gained knowledge, these women critically appraised the UHOHYDQWSURWRFROVDQGJXLGHOLQHVDQGWKHVWDWLVWLFVWKH\ZHUHEDVHGRQ2IWHQ
they decided that the risks did not apply to them or that they were willing to take their individual risk.
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Several health care professionals were also critical of the evidence many protocols and guidelines they were expected to adhere to were based on:
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After weighing their risks, women decided that the interventions they feared would take place in the hospital posed more of a risk to them and their baby than a home birth did.
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Some women also felt that the risks they took having a home birth in a high-risk SUHJQDQF\ ZHUH RXWZHLJKHG E\ WKH SRVVLEOH QHJDWLYH HͿHFWV RI URXWLQH LQWHUYHQWLRQV$VRQH2%*<1FRQFXUUHG
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The women stepped into the consultation with their health care professional with this (alternative) risk perception and aversion to the hospital.
Paternalistic decision-making and a perceived lack of autonomy (again).
Most health care professionals were of the opinion that the style of counseling pregnant women has changed over time and that this is a good development.
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However, in 8/10 cases, the women felt that there had been no SDM during health care provider consultations in which they discussed their wishes for giving birth. They experienced a paternalistic style of counseling and a lack of autonomy.
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The women felt there was no room for their wishes and that they had limited choice, as one woman’s partner articulated:
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Yet most health care professionals were convinced that they had counseled the woman adequately and did not understand where it had all gone wrong, as the following quote by an obstetrician counseling in the case of a breech presentation illustrates:
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In this case, the obstetrician was convinced that the consultation had gone well.
The woman however, experienced a complete lack of autonomy, which led her to abandon plans for a hospital birth in favor of a home birth. This is how the woman experienced the same encounter:
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counseled in the hospital. In one case, the woman who was pregnant with twins and desired a home birth, had a consultation in a clinic that specializes in consultations with women who want to birth outside the system. The other case was a woman who wanted a VBAC at home. She was counseled by an obstetrician who also involved the community midwife in SDM.
Inflexibility: conflict in negotiation.
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midwives and obstetricians with regard to deviating from guidelines or protocol.
In three cases, health care professionals threatened to call child protective services, and two actually did. In two other cases, the obstetricians lodged a formal complaint against holistic midwives for attending high-risk births at home. All this caused a great deal of stress for the women involved.
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In some instances, the women had been in contact with more than one obstetrician from the same clinic and had encountered two very distinct YLHZSRLQWV7KLVGLGQRWLQFUHDVHWKHLUFRQÀGHQFHWKDWWKHFOLQLFZRXOGUHVSHFW
their wishes during their labor. In one case, an obstetrician expressed his negative views on women who chose home birth in a high-risk pregnancy in a telephone conversation with a community midwife, as she explained:
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However, another obstetrician from the same department, who saw the woman later on, had other ideas, and was very set against involving child protection services.
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In consultations, health care professionals often felt that they had done their EHVWWRUHDFKDFRPSURPLVHEXWWKDWWKHZRPHQWKHPVHOYHVZHUHWRRLQÁH[LEOH
in their wishes.
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At the same time, this community midwife’s client had experienced their QHJRWLDWLRQRIKHUELUWKSODQDVLQÁH[LEOH
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regular care without giving their health care professionals an explanation.
The partners’ role in the negotiation of the birth plan seems limited. In all cases, partners left it up to the woman to inform them of her choices and they respected her choice.
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In one case, the partner was not aware that his wife was considered to have a high risk pregnancy (twins):
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women to search for care outside the system.
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Holistic care: a last resort/second best choice.
In all 10 cases, the women started care with a midwife and decided during their pregnancy to go against medical advice and protocol by choosing a home delivery. The women found that the wishes they had for their birth could only be met by a holistic midwife, since the community midwives and/ or obstetricians were unable or unwilling to help them. Holistic midwives were more accommodating to the women’s wishes. These midwives had other criteria for
In all 10 cases, the women started care with a midwife and decided during their pregnancy to go against medical advice and protocol by choosing a home delivery. The women found that the wishes they had for their birth could only be met by a holistic midwife, since the community midwives and/ or obstetricians were unable or unwilling to help them. Holistic midwives were more accommodating to the women’s wishes. These midwives had other criteria for