About Birth And WhiskeySep 02, 2023
On May 26, 2022 at 11:00 am I was sitting in front of my computer eagerly awaiting the start of an information session. The session was hosted by an organisation that offers an insurance solution which supports out of guideline care for independent midwives.
You may or may not be aware of the fate that befell independent midwives in the UK when the UK government implemented a European Directive to mandate all healthcare professionals to hold appropriate Professional Indemnity Insurance (PII) for the scope of their practice. Independent midwives had thus far been providing labour and birth care without insurance because there wasn’t a product available that provided appropriate cover. Historically independent midwives had arrangements with the families they served and operated on a basis of trust. The IMUK (independent midwives UK) notified the government of the absence of a PII package for self employed midwives and asked for assistance. The government stated that the request was ‘not a good use of public funding’.
I'll leave that hanging there for you to ponder.
IMUK found a package but that was investigated and challenged by the Nursing and Midwifery Council (NMC) between the years of 2014 and 2017. Different groups of independent midwives found underwriters for labour and birth care. The problem here was that those underwriters did not cover out of guideline care. As guidelines are constantly narrowing the midwife’s scope of practice as risk factors are added on in reaction to isolated incidences (not evidence), families are frequently referred back into mainstream care by their independent midwives, often at the very end of their pregnancies. This could be on the 7th day ‘overdue’ in an otherwise ‘normal’ pregnancy, their plans for homebirth smashed at the very last minute.
To my knowledge this affected Northern Ireland only very briefly. I’ve only ever witnessed the attempt of one company at setting up an independent midwife service here but it didn’t blossom into existence but, remember, I *was* going to be an independent midwife someday, and I was still searching for a way to make it work.
You can see that the matter of childbirth and our reproductive choices will always be political because it requires a commitment from the government and from the health service to prioritise funding one way or another. Our bodies have always been politicised and used to polarise the opinions of voters and we've had a new taste of this over the last few years. For the longest time I believed that it required sustained activism to provide choice to families. If the main players saw that it made total sense to start a family off healthily, they would fund that. We just had to show them. I have changed my mind about this, governments are interested in playing into the hand of the medical industrial complex and campaigning is a waste of energy (IMHO).
Okay, now that we have set the record straight, back to May, 2022. Here I was, waiting for the zoom session to start. I looked at a screen full of participants' faces. One of my friends, a fellow midwife, was in the same meeting. Our eyes met on the screen - or at least I imagined that they did. We knew that the product wasn’t available in Northern Ireland yet but I had exchanged a few emails with the manager of the company expressing that I was keen to help get it off the ground here and so I found myself with a bunch of eager independent midwives in England and my friend in this by now very familiar newly normal setting for a meeting. I was keen to hear about this product and how one could support women out of guideline as an independent midwife.
We were greeted by a midwife, a doula and an administrator, all lovely. They ran us through how the product worked and how you could get on board. If a woman was out of guideline for a homebirth then the midwife would submit the details to the team who would then present it to the underwriters. The underwriters would get back with a decision and let us know if they would insure us.
Hold on a minute! So now the underwriters get to decide? Should this not be entirely up to the woman? I am ‘with woman’. We have a conversation and we talk about the special considerations that bring her off guideline for a homebirth and then the family decides. I am here to provide the information and then the care.
The conversation that ensued was interesting. I asked this question and I was told that we were keeping women ‘safe’ and that generally women were ‘reasonable’ and therefore there shouldn’t be much of an issue.
I messaged my friend: ‘So coercion then?’.
I asked the question ‘What is safety? How do you and the underwriters define it?’ and ultimately we were back to guidelines and women being reasonable and midwives needing to protect their registrations. I asked the practical question of how we would figure out if we were still covered if a woman had a ‘prolonged labour’ and declined transfer at 4am and because there hadn’t been any examples of any of this happening this question couldn’t be answered.
I didn’t pursue any of it further but I truly wish the company and all the midwives who are successfully using it to truly serve women only the best. I hope it’s a success and I see some really amazing services pop up in England as a result.
For me the meeting left me with these questions:
Who owns birth?
What is safety,
and what does risk actually mean?
It’s hard to find a woman who wants a homebirth and doesn’t have her baby’s best interest at heart. In fact I would say that every single woman wants the best for her baby and women choose homebirth because they want the best for their babies. Sadly women are often deemed as selfish when there is a risk factor and they still want to go ahead with their home birth. What is entirely reasonable to one family might be totally unreasonable to another and, indeed, the midwife or doctor. There are few circumstances where I could not imagine to at least be able to find a way to understand the reasoning a family presents to me, I don't have to agree, I just have to support. In this dynamic we would have had some honest conversations, made plans for possible scenarios specific to the situation. Midwife - with woman!
Practitioners commonly interpret risk by the worst possible outcome. Very few practitioners can clearly communicate how coming to a hospital instead of staying at home (in this particular equation) improves outcomes for a specific risk factor. That's because sticking with the guidelines is less likely to disrupt one’s sleep but also, it's not usually very clear cut. 'High risk' does not describe the same odds in each scenario. In fact most common risk factors in a second pregnancy (apart from a previous caesarean section) don't render a mother or baby at any higher risk than they ever were first time around and yet, they might be out of guideline for a homebirth and therefore they have to advocate strongly for their choices.
The language used to get women to comply is often coercive and patronising. One of my clients recently declined an induction of labour. Her baby 'is big’ and she was approaching 41 weeks. She was told that she was risking stillbirth by declining the induction of labour and so she asked how likely an outcome this was and how the induction of labour would improve the potential outcome. The doctor simply said: ‘One stillbirth is one too many.’
You don't say, doctor!
How much more obvious a statement could you make to the parents of the very baby we are talking about here? Parents are seeking unbiased information in order to make the best decision on behalf of their baby. This type of coercive language is not okay! Health care providers need to work on their biases and get perspective on the risk factors they coach parents about. 'One baby is one too many' implies that all babies can be 'saved' if women just do what they are told and that is simply not true!
I get that this perspective can be lacking in the general population but health care providers who operate on this shallow level of understanding are remiss in their duty. Very often, families who wish to give birth at home or in a midwife led unit despite a risk factor will have thought about the worst possible outcome in great detail. They will have looked at statistics. Families frequently say that if there truly was an acute issue, they would, of course, want the help of doctors and modern medicine. This is what informed choice should mean and yet women face judgement for their ‘unreasonable’ choices every day.
During the months and years of the pandemic my head was full of questions about how I could still fit into the birth world. I loved being a midwife but I couldn’t deal with this preparedness to railroad people into decisions without providing good evidence anymore. Have you read my blog post from two weeks ago where I elaborate on what was going on in my mind then? Despite the many beautiful colleagues around me who are advocating for women on a daily basis, I couldn’t see past these bigger issues anymore. I couldn’t see past how weak the very foundations of midwifery practice truly were either. What’s a due date in the first place? Where’s the evidence for routine ultrasound scanning or CTG monitoring? How had we ended up with a measuring tape and customised growth charts? With section rates soaring and the scope of midwifery narrowing I had had enough.
I was in turmoil and so I booked a consultation with a woman called Yolande Norris-Clark. She lives in Nicaragua now but has spent most of her years as a birth worker in New Brunswick, Canada. Yolande has given birth to nine babies, all outside the system, most of them wild pregnancies and freebirths. She has witnessed and supported hundreds of births as an authentic midwife. I had encountered one freebirth back in the late 90s in Germany, I even met the baby once she was born. I have read books about unassisted birth and I have spoken to mamas who had given birth without a registered midwife or doctor but I had never spoken to anyone supporting women in pregnancy and birth without a state registration. I was curious to learn how birth was different in Yolande’s world from what I had observed over the years and I found that birth itself wasn’t different. Birth is just birth. The difference lies in the ownership. Women who don’t outsource any part of the responsibility for themselves or their babies own birth and that’s incredibly powerful. It's impossible to politicise because it it can't be controlled. Yolande suggested that I get in touch with a woman called Faye. Having given birth to two of her three children with her husband by her side and nobody else, Faye runs @birthfreedomproject uniting freebirthing families from all over Ireland. Despite currently living in Austin, Texas to help her husband expand his business, she still manages to create community here on the island of Ireland. Have you heard of Natterjack Irish Whiskey? No? Go, check them out on Instagram! You'll see Faye's husband Aidan there. Just a guy who makes whiskey and stands by his woman in birth!
I had just parked my car in a Lidl car park ready to get my groceries for the week when Faye returned my call. We spent over an hour on the phone talking about pregnancy, birth and babies. We discovered many shared values and we have stayed in touch ever since. When Faye announced that she would be in Ireland in August and that she would arrange a gathering in Blessington on the 23rd, there was no question in my mind. I would be there to finally meet her in person!
The program for the day:
Birth and Whiskey!
What a great day filled with beautiful stories about birth. The women spoke of how they prepared for their pregnancies; good, wholesome food, movement, deep breathing, meditation and conscious conceptions. They called their babies in, got glimpses of who they were bringing into the world before their babies were even here. I listened to their birth stories, to how they moved through their labours. There were many commonalities and yet each story was unique. All of them were challenging and liminal journeys.
Hearing the accounts of the men brought me an entirely new insight. We heard from three men who talked about the births of their children. All of them had experienced hospital birth, each of them experienced some degree of trauma as a result. Seeing the way in which their women were disowned of their birth experiences opened them to the possibility of out of system birth the next time.
Each of the men described how they confronted their fears of supporting their women in labour and birth. The responsibility they were taking on was huge and none of the men went there lightly. All of them asked themselves the same questions: What if something happens to the baby or what if there is an emergency? How would they know what to do? In the end it came back to trusting their women and the process...and to trusting themselves. It was a privilege to listen to these men being vulnerable and sharing such intimate emotional processes with a room full of mostly women.The men and women who had decided that they would take full responsibility for the birth of their children all grappled with difficult questions. They all went through a process that involved gathering information, evaluating evidence, getting read up on how birth works and knowing the types of problems that can occur in a labour and how to look out for them.
It’s hard to describe what I learned that day. For the first time in my life I think I truly understood the potential power of undisturbed birth for family integrity. I think it awakens the archetypical instincts in both parents. The men described feeling intuitively that their role was to protect the birth space and then, once the baby was born, to protect the space of the mama/baby. They facilitated their women’s rest, cooked for them, looked after the older children and took care of all the housework. There was the most beautiful conversation when one of the women spoke about how much she appreciated her man giving her this space and caring for her in this way. She spoke of how important it was to acknowledge this, how important it was that there were opportunities for the fathers to rest, too. The men spoke about how close they felt to their women after this experience of bringing life into the world in such an intimate way. All of it stood in such contrast to the narrative that is so popular today; that men are oppressors of women, that we live in an unhealthy patriarchy. I have been a liberal for all of my life and I appreciate all kinds of family makeups and that afternoon, there in Blessington, Co. Wicklow, Ireland, sitting among these people from all walks of life talking about freebirth, I got a new insight. I truly understood the conservative value of ‘family’ as the foundation of a strong society. I saw that these families had created a canvas for loving relationships that are impermeable by ideology and divisive narratives.
I am beyond grateful for this experience.
Some families invited a birth keeper or doula to the birth and others didn’t. Despite those extraordinary stories of life unfolding, there was a consensus that, when all was said and done, birth was just an ordinary life event. In hindsight, some of the families felt that if you were considering spending money on support, it was best invested in arranging for help in the first few weeks postpartum so that the parents can get some time together with the new baby.
Of course, out of system birth is not for everyone. People don't necessarily know it's an option. Many people consider it ‘unsafe’, and they are right. Like driving your car or riding your motorbike, freebirth is just as 'unsafe' as it is 'safe'. I think it is fair to say that most midwives and doctors don't support the idea, many don't support the idea of homebirth attended by a midwife, let alone freebirth. There's no statistic to compare outcomes, so I can't see it ever being presented as an option among your 'informed choices', and yet it is. All the families I have ever spoken to opted for it because they felt it was the safest option for them. They felt that disrupting physiology regularly in labour in order to perform observations was in itself risky, we have never measured what that does to the process. Stepping into an unfamiliar clinical environment with an elaborate birth plan and potentially feeling judgement from practitioners for declining routine observations was unsafe in their estimation. Some parents reported experiences of outright hostility towards them both in Ireland and in Northern Ireland, too. One young woman was laughed at and told her birth plan was 'unacceptable'. That's not 'safe'.
‘Risk’ and ‘safety’ can only be defined by the families themselves and birth is owned by whoever you allow to claim ownership of it.
Parents, doulas, midwives and doctors, I encourage all of you to listen to some stories of freebirth. It's a great way to expand your understanding of birth physiology even if you feel firmly rooted in the medical paradigm of birth.
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