"I knew there has to be a better way": Women's pathways to freebirth in Poland

Exploring women's motivations to freebirth and their experience of maternity care: A systematic qualitative evidence synthesis

BACKGROUND

Freebirth is currently defined as the deliberate decision to give birth without a regulated healthcare professional. Previous reviews have identified factors influencing women's decision to freebirth, yet there is limited evidence on what is the care experience for women who opt to freebirth.

AIM

To synthesise the qualitative evidence on women's motivations to freebirth and their experience of maternity care when deciding to freebirth.

METHODS

We conducted a qualitative evidence synthesis using a sensitive search strategy in May 2022 and August 2023. Twenty-two publications between 2008 and 2023 and from ten different high-income countries were included. Thematic synthesis, underpinned by a feminist standpoint, was used to analyse the data.

FINDINGS

Three main analytical themes were developed in response to each of the review questions. 'A quest for a safer birth' describes the factors influencing women's decision to freebirth. 'Powerful and powerless midwives' describes women's perceptions of their care providers (mostly midwives) and how these perceptions influenced their decision to freebirth. 'Rites of self-protection' describes women's care experiences and self-care practices in the pregnancy leading to freebirth DISCUSSION: Freebirth was rarely women's primary choice but the result of structural and relational barriers to access wanted care. Self-care in the form of freebirth helped women to achieve a positive birth experience and to protect their reproductive self-determination.

CONCLUSION

A new woman-centred definition of freebirth is proposed as the practice to self-care during birth in contexts where emergency maternity care is readily available.

Freebirth, the only option for women who do not fit into common practice- A Swedish national interview study

OBJECTIVE

To explore women's experience of freebirth, as giving birth without the presence of a skilled healthcare professional such as a midwife.

METHODS

Online semi-structured interviews with nine multiparous women in Sweden. A qualitative experiential approach, as described by Burnard, was followed for data analysis.

RESULTS

The five main categories explored were: (i) previous negative experiences of hospital care as a reason for freebirth; (ii) receiving support for the decision of freebirth was crucial; (iii) longing for individual midwifery-assisted home-birthing support; (iv) to give birth in peace and in self-control, in the safe home environment; and (v) helpful support during labor and birth was appreciated.

CONCLUSIONS

The women in the study had a powerful and positive experience of freebirth, but individual midwifery birthing support was also requested. Easily available and respectful midwifery support should be offered to all childbearing women.

Did everyone change their childbirth plans due to the COVID-19 pandemic? A web-based cross-sectional survey of Polish pregnant women

BACKGROUND AND AIM

With the worldwide outbreak of coronavirus, a significant impact has been observed on the functioning of healthcare systems and the process of childbirth. Women probably did not even have a choice to adjust their plans accordingly to the current situation. The aim of the study was to examine how the outbreak of the SARS CoV-2 pandemic state affected the decisions of pregnant women about their childbirth plan.

DESIGN

This cross-sectional study was performed using a web-based survey published on social media in Poland.

METHODS

The cross-sectional study was performed using web-based questionnaires. The study group included Polish women who changed their childbirth plans, compared to a group of women not sure about delivery plan change and those whose plans had not changed. The data were collected from 4 March 2020 to 2 May 2020, when the first rising count of new infections was observed in Poland and worldwide. Statistical analysis was performed using STATISTICA Software, Inc., 13.3 (2020).

RESULTS

Of 969 women who completed the questionnaire and were enrolled into the study, 57.2% had not changed their childbirth plans (group I), 28.4% had changed their plans (group II), and 14.4% of respondents answered "not sure" to this question (group III). The majority of women changed their birth plans during the pandemic because of the potential absence of their partner during labour (56% of women who had changed their plans and 48% of those whose answer was "I am not sure", p < .001). Another reason was the fear of separation from the child after delivery (33% of women who had changed their plans and 30% of those whose answer was "I am not sure", p < .001).

CONCLUSION

Restrictions due to the COVID-19 outbreak have influenced the childbirth plans of pregnant women. The changes were independent of women's vision of birth before the pandemic.

IMPACT

The restriction on births with accompanying person and the risk of separation from their infant after childbirth significantly influenced the decision-making process. As a result, some women were more likely to opt for a home birth with or even without medical assistance.

PATIENT OR PUBLIC CONTRIBUTION

The study participants were women who were pregnant at the time of completing the questionnaire, were over 18 years old and spoke Polish.

Midwives' experience of personal/professional risk when providing continuity of care to women who decline recommendations: A meta-synthesis of qualitative studies

PROBLEM

Women's autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife's willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines.

BACKGROUND

Women's reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives' and their perception of personal/professional risk in such situations.

AIM

To synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations.

METHODS

Systematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings.

FINDINGS

Eight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women's rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of 'being torn', and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to.

CONCLUSION

Maternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women's right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies.

Trends and motivations for freebirth: A scoping review

BACKGROUND

Even when maternity care facilities are available, some women will choose to give birth unassisted by a professional (freebirth). This became more apparent during the pandemic of coronavirus disease 2019 (COVID-19), as women were increasingly concerned they would contract the virus in health care facilities. Several studies have identified the factors that influence women to seek alternative places of birth to hospitals, but research focusing specifically on freebirth is limited.

METHODS

Eight databases were searched from their respective inception dates to April 2022 for studies related to freebirth. Data from the studies were charted and a thematic analysis was subsequently conducted.

RESULTS

Four themes were identified based on findings from the 25 included studies: (1) Geographical and socio-demographic determinants influencing freebirth, (2) Reasons for choosing freebirth, (3) Factors hindering freebirth, and (4) Preparation for and varied experiences of freebirth.

DISCUSSION

More women chose to give birth unassisted in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Overall, motivation for freebirth included previous negative birth experiences with health care professionals, a desire to adhere to their birth-related beliefs, and fear of contracting the COVID-19 virus. Included studies reported that study participants were often met with negative responses when they revealed that they were planning to freebirth. Most women in the included studies had positive freebirth experiences. Future research should explore the different motivators of freebirth present in LMICs or HICs to help inform effective policies that may improve birth experiences while maintaining safety.

Why freebirth in a maternity system with free midwifery care? A qualitative study of Danish women's motivations and preparations for freebirth

OBJECTIVE

Even in maternity care systems with free midwifery care, some women intentionally choose to birth unattended by any health professional (freebirth). Women who choose freebirth represent an enigma for many, and a provocation to some. However, people who do not conform to dominant medical practices are a source of valuable insights that can reveal shortcomings in the mainstream health care system. Thus, the aim of this study was to explore and understand women's motivations and preparations for freebirth.

METHODS

The study was informed by the theoretical lens of the 'undisciplined patient'. Qualitative, in-depth interviews were performed with ten Danish women, who for their most recent birth had planned to freebirth. Data were analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. "The standard system is not for me" describes negative experiences during previous births and the desire for more individualised support. "Re-establishing trust in myself" describes the women's quest for recognizing their own needs and re-building autonomy and inner strength. "I do my research" describes how the women sought new ways of knowing and prioritised experiential knowledge. And finally, "I create my safe space" describes the women's efforts to create the best possible physical and emotional space for themselves and their babies in order to have a safe and autonomous birth experience.

CONCLUSION

Freebirth is not undertaken lightly or without preparation by women. Improved continuity of care as well as greater flexibility in hospital guidelines could accommodate some of these women's demand for autonomy in birth.