AIMS Journal, 2011, Vol 23 No 1
Jo Dagustun's personal reflections and a call to action
At the end of 2009, swathes of Primary Care Trusts - probably including your own - were quick to claim, in response to Maternity Matters, that they were offering local women a choice in where they gave birth, including at home. I'm sure many readers, at that point, joined with me in wishing that it were so simple. In this article, I reflect on my own feelings towards home birth as they have developed over twenty years and four births. In doing so, I suggest there has to be a personal acceptance of home birth before the option becomes credible, and the real challenge is thus how to create this 'credible option' environment for women.
During my first pregnancy in the late 1980s, I had read up about home birth and active birth, and I was keen on both (to the extent that I specifically remember working out whether I could have a pool in my flat). But I didn't raise the issue with my midwife, as I didn't want to get into a fight about it. So I did the usual thing of transferring to hospital in labour. I recall the journey being unpleasant; I was presumably feeling the contractions as painful as well as regular. Following what I believed to be a fairly 'ordinary bad birth' (I resented in particular the routine catheterisation, and the experience was only active insofar as I was invited to climb onto a hospital bed), I gave birth eight hours later and then stayed in the hospital for a good five days (on what I recall to be a lousy postnatal ward, but at least I could put my feet up and ring the bell anytime I wanted breastfeeding support - which was generally most useful at night, from a kind and knowledgeable woman in green, who was always willing to put down her broom to come and help ...)
Fifteen years later, I clearly had the desire to try for a home birth lodged firmly in my mind. The lousy car journey of my first labour was one motivator; not actually having a car in which to get to the local hospital was another. A home birth was planned and a large paddling pool procured. In the event, however, I was politely asked to present myself to the local hospital under the local PROM protocol. For my third and four th births, however, I stayed at home to give birth, attended by NHS midwives.
For some time, perhaps between birth two and three and a little time thereafter, I was quite an advocate of home birth. For me, home is not just the obvious default option, most likely to support a good birth experience. It is also, barring pathological indications to the contrary, the politically correct option. I am no braver than anyone else: I have experienced the usual fearful feelings associated with labouring and giving bir th far away from the 'safety kit' of the hospital. But the strength of my political motivation has led to my position that I should 'feel the fear and do it anyway'. I realise that this is not the most inspiring motto with which to encourage other women to seriously consider the option of home birth. But it was the best one I had, until I realised last year that I was no longer even very interested in advocating home birth.
During this time, I also chose to focus on the topic for a Masters dissertation. Whilst talking to women for that piece of research, I was surprised to discover how little many women actually knew about the most basic arrangements for giving birth at home. Most didn't know, for example, that the local norm was that two midwives would attend (both of whom are there to give you their full attention rather than just looking in now and again between other ward tasks); that the midwives take responsibility for clearing up any mess and serving the postnatal cup of tea and toast; that as much gas and air as you like (and even pethidine) could be accessed at home. As well as a lack of information about the home birth option, I also heard much dissatisfaction with the hospital experience. I therefore saw a clear opportunity - based on improved information and consciousness-raising - for more women to make a decision in favour of home. All in all, I believed - and liked to suggest to whoever would listen - that, if there are no indications to the contrary and all goes well, home birth has to be the jewel in the NHS maternity service's crown.
A few months after birth four, I was given the opportunity to talk about giving birth at home in a postnatal yoga class. I had an ideal and captive audience. I would have relished the opportunity a few years earlier. But, in the moment, I just couldn't muster up the enthusiasm to say anything much at all. I just couldn't be bothered to engage with the situation, and mumbled something rather incoherent about being happy to talk to anyone who had a specific question. Having puzzled over that experience, I have lately come to the conclusion that it reflected a key turning point in my own attitude towards giving birth at home. Through my own experience, I believe I had only then got to the point where I had really normalised home as the obvious place to give birth, to such an extent that I just found it strange that anyone would star t from the per spective of not thinking that giving birth at home was the best option.
In UK contemporary culture, home birth is generally viewed as a marginal, and even suspect, activity. The idea that we can seriously promote home birth simply by asking women 'if they've thought about it', whether at a booking clinic or later during the antenatal period, just doesn't ring true. My own experience points to the deep internal resistance to home birth prevalent amongst women (including myself), where we are generally exposed to decades of socialisation in favour of the hospital as the 'correct' place for giving birth. Increasing choice, then, is clearly not just about implementing overnight a policy decision to henceforth 'offer' or 'allow' the choice. It also has to be about working long-term - against a powerful dominant culture and a set of longinternalised beliefs - to support women to see home birth as a credible option for themselves. Incidentally, I believe that this is a really important goal in its own right, for wherever a woman then decides to give birth this outcome is bound to reinforce the notion of a woman's body as strong and capable of giving birth, a notion too often buried too deep for many women to access but perhaps key to improving bir th experiences and to ridding us of the phenomenon of 'ordinary bad birth' (or 'ordinary bad care', as a midwife friend has suggested).
If it is the case that whole-scale change is needed to implement this small part of the Maternity Matters agenda, I believe that it is essential for every PCT, local midwifery team and Maternity Services Liaison Committee to properly interrogate how they offer home birth 'on the ground', and to check that a single question at booking and a reference to the choice in a - possibly unread - leaflet, or at a poorly attended workshop, isn't the extent of local efforts to promote home birth. For it must surely be misguided to think that the existing huge barriers to such choice - whether personal or cultural - can be dismantled with such a simplistic approach. If we are really serious about extending the known benefits of home birth to larger numbers of women, then we really need a serious plan of action. One starting point might be to commission an in-depth audit of the beliefs of local midwives on this issue - and for the results of such an audit, and ensuing plan of action, to be discussed by the local MSLC. Because any option of home birth, if suggested by a professional who herself does not feel comfortable with the option, is highly unlikely to be read as either a credible or well-supported option by women.
Jo Dagustun is a PhD student in the School of Geography, University of Leeds, where she is exploring the potential for the lay community - as distinct from policy or the professional community - to improve women's experiences of birth in contemporary Britain. Jo is also a lay member of her local MSLC (Tameside and Glossop, Greater Manchester) and would welcome linking up with other MSLC members interested in extending choice of birth location to all women. Jo can be contacted via email at email@example.com.
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