In Support of Freebirth, Doulas and Birthkeepers

Are we finding ourselves in the middle of a modern day witch hunt?

I fear that this time it's the doulas and birthkeepers that are being targeted for their commitment to informing women of their right to ask questions, evaluate the information and decide for themselves how they wish to give birth.

Doulas and birthkeepers also have the audacity to add to the conversation without being 'properly trained' in birth and to stand by women without judgement regardless of their choices.

Even when nobody else will; when the official watchkeepers of birth have deserted.

Even in controversy.

I think that by default a doula's client base is representative of women who know that they want to avoid interventions. Not always, but mostly so.

Part of the doula's role is to signpost women and to provide information.

Having read the handbooks of two doula training providers in the last year, I know that the information that these providers' trainee doulas are going to share with their clients is well balanced and solidly evidenced. My impression is that doulas tend to be familiar with latest evidence or they know where to look if they aren't.

Doulas also provide information about current national and local maternity care guidelines and pathways. The problem is that many maternity care guidelines are not based on solid evidence and that modern maternity care is rooted in a medical view of pregnancy and so tensions between different paradigms start to arise. 

In the mainstream the opinion that doulas manipulate women by telling them 'unrealistic' things about birth seems to be quite popular and also the notion that 'doulas are dangerous' (the exact words expressed to one of my clients recently by a doctor). 

The fact that doulas charge for their services (imagine that!) seems to ruffle feathers, too. The idea that women choose freely where they spend their money (hello Gucci) depending on the kind of product or service they wish to enrol seems far fetched in the hospital corridors. 

Women are not seen as equal partners engaging in adult transactions that involve the exchange of money, no, they are seen as being exploited. 

Over the years I have heard many midwives express that they are worried that the relationship element of the midwife's role is being impeded by doulas.

I think that some midwives feel threatened by doulas. Doulas have stepped on the territory of midwives by filling in the gaps that are inevitable in the current maternity landscape. The midwives's scope for providing emotional support is becoming more and more restricted mostly by time constraints. 

Doulas are familiar with the works of obsetricians and family doctors like Dr Michel Odent and Dr Sara Buckley who have written extensively about the protective mechanisms of undisturbed primal birth or Dr Kirsten Small who continues to educate about the limitations of continuous foetal monitoring. They refer clients to the works of midwives such as Dr Sara Wickham and Dr Rachel Reed who are fluent in birth physiology and who put in perspective the many interventions that are offered to women in today's maternity landscape. And some doulas share with their online audiences examples of families who experienced detrimental harm because of interventions. 

On the other end of the spectrum doulas will also encourage women to ask for interventions if they assess the information and feel that this is more suitable for them and their bigger picture.

Occasionally I observe a post about an intervention gone wrong on social media that, though true, might be scaring women who are not ready to step outside the box. And while I understand why doulas share these stories (because otherwise women are unlikely to be told about those kinds of possible outcomes), this is where I think doulas make themselves vulnerable. Personally I have decided to stay away from mirroring the tactics that are used by mainstream providers and instead focus on how I think change can be made and that is by shifting the perspective on pregnancy and birth entirely. I have come to believe that by arguing and fighting about the same thing we might be missing out on the solutions that present themselves outside of our field of vision. 

I'll share more about that on my podcast.

Given that doulas can provide the relationships that women crave around the time of pregnancy and birth and that doulas commit to endless weeks of on-call when the average midwife generally doesn't, women place a lot of trust in doulas and doulas are becoming more and more popular. 

As a former midwife I know that there are not many opportunities for midwives to develop the kinds of relationships with women that doulas are free to form. Here in Northern Ireland we are being promised that the continuity of midwifery care teams will continue to be implemented and that that will make a difference. I hope that this is true and that those teams will attract midwives who know birth physiology and support women in opting out of aspects of their care if they wish to do so and, most importantly, I hope that those midwives will then be supported within the hierarchical structure.

At the moment, sadly, this is not what I hear from women or midwives. Far more often I hear of coercive language when women, after educating themselves, start declining aspects of routine care. It's not easy for women or midwives to step out of guideline in an age where compliance with care pathways is becoming more important than actually listening to women. In an environment where most women will be happy to go along with what the expert says, the occasional woman who wants to do things differently whilst still enlisting the support from midwives appears like a troublemaker. 

'She's one of them! Have you seen her birth plan?' 

Or, 'She's got a doula!' (eyeroll).

What does this kind of judgement do to the integrity of this birth experience?

Collectively, I think it is safe to say, midwives are biased towards medicalisation. Many of my former colleagues are not getting the perspective that Dr Wickham and other scholars have to offer and I know that some of them won't have heard of them and simply aren't interested or feel that they don't have the time to explore. And knowing how much work it is to  stay on top of what you need to do to remain on the midwifery register, I get it.

I also get that under those circumstances, when midwives rarely get to see the same woman twice, trust is an issue.Trust is earned and in order to gain it, maternity professionals must be willing to engage in conversations with women without pursuing the agenda of getting them to comply.

Needless to say the voice of doulas and birthkeepers disrupts the current maternity landscape and like many other disrupters doulas are portrayed as villains in the mainstream media. 

On June 22nd, 2024, The Sunday Times published a poorly researched hit piece aimed at doulas titled ‘Rise of the doula: a helping hand or a danger to mothers?’.

In it doulas are portrayed as dangerous proponents of homebirth.

Any journalist worth their salt would have had to come across the Lancet home birth series whilst researching for a piece like this. The global studies published in this series show that, compared to hospital birth, planned homebirth - that is homebirth with a midwife in attendance - is safer for healthy women and their babies for every variable that was measured. Furthermore, there's a Cochrane review stating that doulas may improve birth outcomes overall through the relationships that they form with women. 

So the combination of homebirth + doula + midwife makes total sense!

There's an amazing independent midwife in Germany who supports women with all kinds of 'risk factors' at home and in her birth centre. She has excellent support from the obstetricians she works with and the birth stories that her clients share are refreshing to read. Her clients trust her because she listens to them. Vaginal examinations are rarely used and if women decline auscultation, she'll respect that choice.

She'll be present in whatever way the woman wants her to be.

When things get hairy, she knows what to do and I know of one occasion where she and her colleague provided immediate life support to a baby with an unknown heart defect which I am certain made the difference between life and death for this baby.

She supports unassisted birth, sure, but women in her area love having her at their births. She works with doulas and obstetricians. The obstetricians she works with value the input that doulas can provide, too. Her focus is on overall family health and the model of care that has evolved in her clinic is exemplary. 

This is what can happen when there is true partnership in birth and when the mother and her family are right at the centre with their care team (whoever this may be) circling around them.

But instead of giving a true and well balanced reflection on doulas and their role in birth, the Sunday Times went for a divisive piece and I saw that many midwives and doulas took the bait. The advertising algorithms keep offering me a subscription to The Times via this headline (they clearly haven't got me sussed).

It appears that bashing doulas sells.

Sadly, in the week following this publication, three women died in childbirth in Ireland and it was easy to observe how fractured and divided the birth space has become in the days that followed the news.

For three women to die in one week in a country as small as Ireland is unheard of and I cannot even try to imagine what the families of these three women are going through.

In Ireland this kind of tragedy happens in about seven out of 100000 pregnancies, but how rare this is will not matter to the families concerned.

A mother is a new baby’s ecosystem, the primary point of comfort and as children grow, generally their mother remains the main source of nurture. Being bereft of a mother must be one of the most difficult situations that any family unit could possibly have to endure and my heart goes out to all of the families who have to live through such a loss.

Sadly the focus on social media was mostly with one family. It was with the family who made counter cultural choices and with those who supported them in those choices.

The mother who chose to birth at home unattended by midwives was singled out and the social media posts sharing the sad news of her death was re-shared over and over. Then a newspaper article came out and it stated that the woman had chosen a 'freebirth' with a doula and it even reported on the supposed complication that she died of.

This newspaper article got shared a lot, too.

In the various reposts I read comments as heinous as ‘It was her own fault’ or the more subdued version of the same sentiment: ‘This did not need to happen’.

I saw it implied that the woman was brainwashed, that women are manipulated by doulas and that doulas and birth keepers distribute misinformation.

I saw the doula accused.

I saw this woman villainized and blamed for dying and leaving her children without a mother. She should have thought of her children and not been so selfish.

Really?

Could it be possible that someone makes the choice to birth at home against medical advice to safeguard their mental health in order to protect her children? 

One of the comments belittled a reference to previous birth trauma as a reason for women opting to step away from maternity services. It suggested that birth trauma is not always avoidable and that it didn’t justify what the woman did.

This commenter obviously hasn’t read the last Confidential Maternal Death Enquiry in Ireland Report for 2019–2021 according to which the leading direct cause of maternal death was suicide.

Like everything in birth, the questions that these three recent tragedies in Ireland bring are complex and what we need is to huddle around everyone who has been affected by these tragedies.

Choices for women in Ireland are extremely limited and what happens 'Down South' really can't be compared to what happens 'Up North' on the island of Ireland.

Whilst in the UK women technically have the option to give birth at home outside of guidance, this seems to be impossible for women in Ireland. I frequently speak to women who find themselves abandoned by home birth midwives last minute or who have to endure even more patronising attitudes than women in Northern Ireland. Those women are yearning for support, they would love a midwife like the one in Germany present. When a woman decides to stay at home regardless of this lack of service and despite factors that may increase her chances of complication, her birth outside of the medical system isn't really down to 'choice' is it? 

And because typically the women who feel this way will have had encounters previously that have left them wanting or - worse - hurt, it is likely that there will be 'risk factors'.

Arguably it would be those women who need their midwives most but instead of being 'with woman',  midwives frequently get argumentative during conversations with women who seek their support to give birth at home despite 'risk factors'. This is the case particularly if women have traced routine interventions such as vaginal examinations or 'breaking the waters' back to the issue they encountered previously.

There's an increasing amount of women who don't want vaginal examinations routinely and I hear from women from all over the world whose midwives are offended by the idea that women ask them to simply be present 'just in case of an emergency' but to do nothing unless it arises. Very few midwives are comfortable to sit in a different room or somewhere nearby while a woman gets down to it with only her family members in her immediate field.

Why? What's the problem? 

When having these types of conversations it is possible to be honest and say things like: "I fear that in the worst case scenario the way in which I am equipped to help you or your baby might not be enough. All I can do is x,y and z and if the ambulance was at all delayed then the outcome could be tragic." This information delivered compassionately and lovingly along with some data about high likely this outcome actually is is all that is needed but quite frequently the conversation goes into questionable territory. One of my clients repeated to me the words that were uttered to her by a midwife: "How will you feel if your baby dies in this living room?". I figured that this must have been coming from someone who had recently done the training on how to alienate women.

There's another branch of freebirth, too, and that's when women choose right of the cuff, in their very first pregnancies even, not to engage with mainstream maternity care because they don't want to expose their babies to ultrasound for example or to the pharmaceuticals that will be offered to them throughout their journey. Those women never engage with mainstream maternity systems at all throughout the pregnancy, birth and postpartum timeline and, as I see it, this is where freebirth is being chosen in its own right.

Regardless of the circumstances leading to the out of system birth. there is usually meticulous deliberation. Women pay endless attention to detail in tending to their bodies, minds and spirits. 

To me contemplating freebirth is about balancing the potentially protective aspects of physiology against the potential disadvantages of getting into an emergency scenario without immediate access to medical staff as well as the possibility of an emergency being caused by the attendant in the first place. 

This calculating, weighing up and intuiting into what feels like the right choice for us is all we have. 

Freebirth is the right thing to do for some women and counter to what the newspaper article said, freebirth is not a new trend.

It's always been around and it will stay around. 

The first time I encountered it was in the late 90s. There was a little baby born in one of my friends' house shares. At about five hours old, this baby was the freshest new human I had ever seen at that point. I was in my early twenties at the time and everything around this birth was so matter-of-fact that I never questioned any of it. I couldn't take my eyes of this beautiful new mum and her brand new naked baby. 

Ultimately no matter what you choose, tragedy can strike (and most likely it won't).

Singling out one woman for her choices and claiming to know the one reason for this family’s loss before the routine process of formal investigation has even started reveals a short sightedness and a lack of kindness and compassion that I find hard to relate to.

The comments I saw exclusively came from other women.

I recognised some midwives among the commenters on social media. Most of them expressed their heartfelt condolences, others wagged their fingers.

See what happens when you don’t listen?

What purpose does this serve?

Midwives know the due processes that follow a mother's death and as members of a graduate profession that claims to provide evidence based information I don't think they should draw any conclusions in the absence of an investigation report. And most certainly a newspaper article is a questionable source of information to make any kind of assessment from. 

I don’t personally know the circumstances surrounding these three tragedies, I have been reading between the lines and it appears that at least one of the women died of a complication that occurred after a caesarean section. Even if the caesarean section were a risk factor for whatever complication this was, it would be jumping to conclusions to declare the caesarean to be the single one reason for this mother’s death. 

Why can't we give each other credit for our ability to make decisions? 

Why portray each other as vulnerable victims, deer in the headlights who can easily fall prey to 'misinformation'?

The very concept of 'misinformation' is counterproductive and hinders honest discourse. The word 'misinformation' is thrown at us mostly by mainstream media. A compelling headline and the implication that a certain group distributes 'misinformation' is enough to keep us from engaging with what they have to say in the first place.

Don't fall for it! Look further, go to the source, evaluate and come to your own opinions. Then, if you feel compelled to share at all, rather than sharing a headline, share your thought process and your conclusions. 

The only way to move forward is by being willing to remain unattached to being 'right' and to hear what other people have to say with an open heart. 

Personally, I don't simply hand myself over to the next best practitioner wether they are mainstream or not. (I'd test a doctor's or midwife's statement for validity as much as a doula's, wouldn't you?)

I reserve the right at any junction to favour the statistically more 'risky' choice at my own discretion. It's enough if I know know why, I don't feel the need to justify any of my choices to others.I trust myself to evaluate data and to make decisions that are right for me.

I also know that other people's decisions are none of my business (even if it is my job to support them).

Medicalisation is not the answer for everything.

Primal physiology is not the answer for everything.

Routine interventions put some women and babies at a disadvantage and they are beneficial for others.

Being undisturbed is safest for some women.

In an emergency situation a pair of skilled hands and the use of modern technology can save lives and yet there are also documented instances for the intervention being the reason a mama or baby died.

There is value in the medical resources that we have available to us in birth, that's undeniable.

It is also undeniable that losing sight of nature’s original design is a major factor in how we got here.

Women will continue to birth freely.

Let's not judge them and those of us who support them.

Regardless of the circumstances, a mother's or baby's death is always a tragedy. 

Let’s not allow ourselves to be divided.

Let’s not allow our bodies to be politicised.

Let’s care for each other as women and respect each other in our choices.

That's midwifery!