This isn’t a new thing, it’s the same old story
This morning the BBC shared an article online with the somewhat familiar headline “Medics warn of dangers of freebirth”. Of course we know what is coming because this kind of article comes out periodically in order to whip up some more fear around pregnancy and birth, as if women aren’t dealing with enough coercion as it is. Here are my thoughts on the themes of the article.
A maternity system that is scared of birth
“A senior obstetrician says she is “terrified” about women giving birth in a medically unsupervised environment”.
When we remember that freebirth is just normal birth, undisturbed and unobserved, then read the statement from the obstetrician we can clearly see the foundations on which the maternity system is built: fear. A senior obstetrician is terrified of normal birth. She believes that birth is inherently a medical event that needs supervision in order for it to be safe. Is this what women want to hear from a system that is simultaneously saying that they support normal birth? A system that tells women they have choices and that they will be respected and supported? These two things are incompatible.
The first line refers to women giving birth without medical supervision as a “trend” that risks “reversing [care] to the middle ages”. It’s funny, this “trend” has lasted since the beginning of time so I’m not sure we’re using that word right. In fact, to be more accurate, the medicalisation of birth was a trend. Marjorie Tew pointed out in her book Safer Childbirth; “In the 1980’s, with near total hospitalisation secured, there started to show signs of renewed interest in giving birth at home. Obstetricians could not make it a legal requirement to give birth in hospital, despite advocating for it, so instead they pushed the belief that birth was dangerous and that danger could only be reduced under obstetric control.” So since the 1980’s women have been pushing to de-medicalise birth again, it hasn’t been successful and, as a result, “a third of women describe their birth experience as traumatic.” – (Birth Trauma Inquiry Report – 2024)
Quite accurately, women in the Middle Ages were giving birth without being supervised or monitored, but this wasn’t what was causing death. The Black Plague had a lot to answer for, as well as general poor health, poor hygiene and a lack of good nutrition. When the idea that women and babies used to die all the time before we had midwives and obstetricians is thrown around it is to suggest that the medicalisation of birth is the reason less women and babies die now in comparison.
“Allowing women” to take risks…
“I just feel like freebirthing and allowing women to take that sort of risk with themselves, their bodies and their baby, is risking their baby dying and them potentially dying in that very unsupervised environment.”
- A senior obstetrician and gynaecologist
Let’s break that down. So if we replace the word freebirth with normal birth (because that’s what it is), she is again stating that normal birth is inherently dangerous and risky to the lives of both the mother and the baby, and that having a medical professional present will reduce that risk. She also uses the phrase “allowing women” which is unsurprising, given that this is the kind of phrasing that is used throughout the maternity system to give the illusion that women need permission from midwives to make choices about their bodies. She is completely ignoring the fact that there are huge risks involved in disturbing birth in the way the medical system does, including unnecessary interventions such as inductions, vaginal examinations, episiotomies, and also introduces the risk of trauma caused by obstetric violence leading to postpartum depression and PTSD. But the maternity system is happy for women to take those risks, because they won’t be held accountable for them.
What boundaries are doulas crossing?
“A woman was persuaded [by her doula] not to have a fourth degree repair in hospital.”
"We’ve had cases where the midwife has been asked to sleep in the car for 12 hours just in case."
Obviously I wasn’t there so I can’t speak to how much “persuasion” was taking place but I have been in situations at a home births where the woman has told me that she doesn’t want a certain thing, a midwife has told her that she needs that thing and I have reminded the woman that she gets to choose whether to have the thing. Where the midwife should be telling the woman that nothing is mandatory and telling her all of her options, that isn’t what happens. Coercive language is used instead, reeling off a list of risks (not backed up by evidence) of what the woman wants and none of the risks involved in having the intervention. A doulas role is to support the woman in her choices, and that involves her knowing that she has the option of saying no. That is not the same as giving advice or persuading her one way or another, but in my experience of interacting with midwives it is often taken as a personal attack or as if I am making life more difficult for her. The two options for a doula in that situation are A. to remind the woman that she has a choice because the midwife hasn’t told her that, or B. to say nothing which would probably lead to the woman being coerced into an intervention she did not want. I know which option many midwives would prefer, but what do women want?
The second example of a doula asking a midwife to stay in the car is likely simply the doula doing what the woman asks her to do. This comes up again in the article as Fionna Gibb from RCM says that she’s “heard about midwives being kept in a separate room by doulas, unable to monitor or assess the birthing mother.” Most of the women we speak to who are planning home births and planning on calling a midwife do not actually want her in the same room as her for the simple reason that being observed makes birth harder, like every other bodily function. So they want a doula who will protect her space from observation and disruption. We no longer attend births where midwives are present because protecting that space from a medical professional who feels entitled to be in the space, bound by policy and afraid of being sued or losing her job, proved to be an impossible task. Fiona also says “without regular access, they cannot assess if paramedic staff were needed for transfers.” If the maternity system trusted women they would know (and witness) that when something is wrong, the woman is the first person to know and she will make it clear. Instead what happens is that the woman’s intuition is constantly undermined throughout pregnancy and labour, and then she is not listened to during birth either.
Why should midwives have heard of us?
“In the last two years more doulas I have never heard of are appearing on the scene that don’t approach me or midwives caring for the woman. I don’t really know what they are advising women on."
- A senior midwife
This says a lot about the entitlement of this particular midwife, and the wider maternity system, believing that she deserves to know everything about a woman’s support team, that doulas should be seeking some kind of permission or approval from midwives. The reason doulas are so effective is precisely because we are not medical professionals, and we are not beholden to a system whose only measure of “healthy” is the presence of a pulse. We support women to raise that bar, and do what she feels is safest and healthiest for her, as a whole woman, and her baby. We would never assume that we care more about her or her baby’s life more than the woman herself. Women and babies coming out of births in the medical system are rarely whole and healthy.
With at-home medical services being suspended until further notice across Greater Manchester, women are expected (and being advised by midwives and obstetricians) to uproot their plans and give birth in hospital instead. It is a huge disservice to tell women that they must disregard their basic needs of privacy, safety and being undisturbed, to give birth in an unfamiliar, clinical environment with the attendance of strangers. The basic needs of women, of mammals, in labour are completely ignored by the medical system and the importance of the experience for both the mother and her baby isn’t even considered. Women are choosing to stay at home regardless of the presence of a midwife precisely because they feel it is safer and more comfortable for them, not because it’s some kind of trend. To call it a trend is to infantilise women and disregard their wants and needs.
We tend to find that midwives know specific doulas by their reputation, so either they are a compliant doula who doesn’t make a fuss and will side with the midwife if the woman wants to stray from what is being medically advised, or they are renegade doulas who are awkward and will make life difficult for midwives. We hear women being labelled as awkward by midwives and obstetricians for trying to assert their autonomy, so it’s unsurprising that doulas supporting women to do that are labelled as the same. We’ve been called dangerous by midwives before now, and this speaks volumes about the maternity system’s view on their own position. We listen to women, support their choices and provide emotional support. If the maternity system is labelling that as dangerous then there is a bigger problem here, because according to their own guidelines that is what they should be providing themselves.
Women should have the right to choose, within reason…
"Women should have the right to give birth in an environment in which they feel comfortable, and should be supported in their birth choice. However, safety is paramount and women should be given all the information they need to make an informed decision."
- The Royal College of Obstetricians and Gynaecologists
Women DO have the right to give birth in the environment of their choosing, and to be supported in that choice even where it goes against medical advice. Women should absolutely have access to all of the information they feel they need to make an informed decision. This isn’t how the maternity system is operating.
The senior consultant who is calling for regulation of doulas is maybe missing the irony in her suggestion. The reason midwives have gone from the supportive, wise women they once were, applying masterly inactivity in order to support birth to unfold naturally, to the medical staff they are now, incapable of allowing birth to unfold in its own time, is exactly because of regulation. Doctors in the 19th century recognised midwives as financial rivals and therefore were quite happy to attribute the high mortality rate to the incompetence of midwives. By claiming to offer a safer service, without any evidence to back it up, they increased the medicalisation of birth and attacked the skills of midwives. Midwives felt the need to regulate their profession to prove their worthiness, and in doing so sacrificed their true role. They became the very thing they were trying to protect women from: medical staff.
Doulas are not and should never be regulated. Being beholden to a regulator ahead of the woman herself is where women are being let down. I’m not saying that all doulas are working in the way that they should be, supporting women in their choices and not telling them what to do, but I believe that regulating doulas would lead to more of them telling women what to do. As things stand, women are able to find a doula or team of doulas who she connects with and trusts, she can weigh up her options for herself and she can choose who she wants to support her during pregnancy, birth and postpartum.
What choices are the medical system presenting to women?
Well for women in Greater Manchester they are being told that home births are off the cards (even though nobody can decide that except the woman herself, she can always give birth at home, regardless of the option of at-home medical services). They are told that their alternatives are to use a birth centre or an obstetric ward. Birth centres are often without staff, very few women actually get access to them and when they do it is only if they are ticking all the boxes. Obstetric units are understaffed, women have no privacy and are told to leave their dignity at the door. Out of the 56 services given ratings under the new inspection programme as of August 17th, 25 were given an ‘inadequate’ or ‘requires improvement’ rating. So women are being offered inadequate care, poor staffing levels, the intervention rate is always rising including inductions and c-sections, and that is being described as safer than being undisturbed at home. They’re simultaneously being told that freebirth is dangerous and, in some cases, wrongly told that it is illegal.
So are doulas causing deaths? And what are the dangers of freebirth?
“According to a report last year, of the 3,000 deaths of babies or mothers in childbirth, doulas were involved in 29 incidents, less than one per cent.
And of those cases, less than half involved doulas doing tasks that only midwives or doctors should do.”
The simple answer is no, or at least there is no evidence presented here to back that idea up. Of the 3,000 deaths of babies or mothers in childbirth mentioned (which should really be separated to give any useful insight into the causes), more than 99.03% of them happened where there was no doula present. It might be more useful to know how many of these deaths were outside of the medical system, how many were at home attended by a midwife and how many happened in hospital. Deaths are also just one measurement of birth outcomes. Being alive is one thing, being physically and mentally healthy is another.
The article didn’t actually give any evidence that points to the dangers of giving birth undisturbed. Neither did the midwives and obstetricians interviewed. The only point they made was that freebirth makes it harder for them to monitor and intervene, which is what women planning freebirths are trying to avoid. So the risks are that you’ll be undisturbed? You’ll be able to meet your basic needs easier? You won’t have to hire someone else to protect you from the intrusion of medical professionals on your very normal bodily function? If evidence was presented that compared truly undisturbed birth outcomes, not just being alive but being whole and healthy, to medicalised birth outcomes and suggested that freebirths have a higher rate of harm to women and babies, the headline might be justified. But that’s not the case.
In the Birth Trauma Inquiry Report (2024), of 1,311 personal submissions from parents, and 92 from professional bodies, every single story was in a medical setting despite the open call for evidence. The report summarised the main themes of the stories and every theme was about the way the woman was treated. Perhaps women should be being warned about the risk of harm at the hands of the maternity system.
Women are not following a trend or being led astray by doulas. Women are very aware that the medical system exists and can be used. They know that they can give birth in a hospital if they want to. Women are doing something that they’ve been doing since the beginning of time, giving birth intuitively. Stop treating them as if they are “silly little girls” who don’t know what is best for them.
If you’d like the support of doulas who believe that birth is a normal bodily function, who trust women entirely to make the best decisions for themselves and their babies, book a chat with us here.