What On Earth is a ‘Hybrid Freebirth'?

Last month we finally saw the publication of a long and eagerly awaited document entitled “Enabling Safe  Quality Midwifery Services and Care in Northern Ireland”. The report is authored by Professor Mary Renfrew and in it we see examples of manipulation and tactics that parents often describe as “fear mongering”. The report points to power imbalances between parents and practitioners and it lists, yet again, the familiar examples of coercion that have become endemic to today’s maternity landscape.

Luckily the report also acknowledges the exemplary midwifery care that I know exists on many wards and in many community midwifery teams as well.

And most importantly Professor Renfrew offers a five-year pathway that she hopes would improve maternity services in Northern Ireland. 

Once more we are reminded of the importance of language.

The words we use to talk about pregnancy and birth are important not only in how each pregnant mama experiences her pregnancy but they also shape our collective consciousness.

Language has long been a priority in birth activism.

At the start of my career I was mainly invested in the positive reframing of the vocabulary used in labour as it is advocated in hypnobirthing. I remember being a birth partner for one of my friends 18 years ago and I introduced her to the idea that it might be helpful not to relate to her sensations in labour as “pain”.

She loved it and thought it made total sense until she was in labour.

I will never forget the moment during the birth of her first baby when she looked at me with disgust after a particularly strong contraction (or wave or surge or whatever name you want to give the beautifully designed rhythmic movement of your uterine muscle in labour) saying:

“I don’t know what the f*ck else you could call this other than pain!”

I have since known many women who say that they didn’t feel pain, only intensity. 

The problem was that I didn’t know much else about hypnobirthing then and so I didn’t know that my friend needed to re-program her mind with affirmations and regularly practice a breathing strategy like the one my colleague Tara and I teach in our couple’s hypnobirthing and movement program “Born Through Yoga”. 

Later in my career I got more interested in other harmful vocabulary that women commonly hear in relation to their experience of pregnancy and birth such as “failure to progress” or the idea of being “allowed” to do x,y or z.

Of course no doctor or midwife is in a position to “allow” or “disallow” you anything and women are well within their right to call out such language.

It's refreshing to see this mentioned as an example of poor language in the Renfrew Report.

When the report was still being written, Northern Ireland saw the emergence a new term in the birth world:

“Hybrid Freebirth"

It has been used by midwives in recent weeks and months and it seeks to describe a scenario where a woman asks midwives to be present in her home but to omit most or all of the observations they would normally do. Instead of inviting the midwives into their birth space directly, they might ask them to keep themselves available in an adjacent room instead “just in case”.

Though I absolutely agree that it is very important to find out what "just in case" means to a woman, I do feel that the term “Hybrid Freebirth” is an attempt to institutionalise and take ownership of language that women have used for decades to describe their experiences of unadulterated birth.

Those midwives who disagree with “Freebirth” seem to disagree with “Hybrid Freebirth” just as much and I have heard a number of accounts where women tell me that the midwives’ disapproval is evident in the tone of voice in which they educate women about the fact that they are ultimately asking for a "Hybrid Freebirth".

This is further evidence for the power imbalances that Professor Renfrew outlines in her report and I wonder what she would make of this innovative use of language. 

Here’s what I think:

“Hybrid Freebirth” is a contradiction in terms. 

The word “hybrid” suggests an interdependence between two systems for the hybrid model to work and “freebirth” is a term that women use to describe a completely autonomous unassisted birth.

A freebirth generally occurs outside of the realms of maternity institutions and freebirthing women rely on the workings of one system alone:

Their Reproductive System!

Many women who experienced freebirth come come back from their journeys telling us that birth can be an ecstatic, expansive experience—a spiritual journey offering a momentary glimpse into creation, a merging with universal consciousness.

Others think of it in mpre practical terms. They describe it as uncomplicated and simple; not easy but simple. Just a day at home pottering about until they gave birth.

They might choose to share the experience itself only with their partner or they might invite another woman into the space. Maybe a doula or a birthkeeper or their mothers, but it is widely understood that the birth belongs to the woman, anyone who enters the birth space must trust the process of birth as an innate mechanism and they answer only to the mother.

Trust is paramount in freebirth.

Trust in the process, yes, but also a much deeper trust in the mother herself and trust between all the people involved.

There’s a lot of conversation about safety among freebirthing mothers and those who support them and I have never witnessed as much insight and self reflection in all my years of birth work as I have among women who choose out of system pregnancy and birth. Counter to popular believe those women do not reject medical interventions in principle and they are open to seeking help from within the medical system if they need it. They simply question routine interventions and the policies that regulate them.
 
Occasionally women prepare for a homebirth with registered midwives but then don’t call them to the birth.

If that was the plan all along, women will generally refer to this as a freebirth as well.

Those arrangements might have been made to avoid issues around birth registration or even social work referrals.

This is different from the scenario where the baby accidentally arrives before the midwives make it to the home or where a birth occurs so fast that a trip to a birth centre or hospital was impossible. 

The difference between this scenario and freebirth lies in the intention. 

Freebirth can take many forms but it is not defined by keeping your doppler in your bag and your hands in your pockets, nor is it defined by the mere absence of a registered midwife. 

In days gone by, any women alongside the birthing mother was, by definition, a “midwife” (from "mid-wyfe”, meaning with woman) but not anymore. Today only those registered with the NMC may call themselves midwives and if you are allowed to call yourself a “midwife” you will find it very difficult to truly align with a mother who asks you to forego the observations your regulator asks you to make.

Although the lip service of “freedom of choice”, “right to informed choice” and “woman centred care” is present in many maternity documents, the system as it is is rigged against birth physiology, women and midwives alike. 

There simply is no version of “freebirth” that can include the presence of a registered midwife.

Once a registered midwife is on the scene neither the woman nor the midwife are free to simply witness the birth in its unfolding.

Midwives have allowed themselves to become compromised.

Midwives no longer have the luxury of answering only to the woman, they bring with them an obligation to practice within the confines of strict policies and they answer to their regulators, their employers and increasingly their underwriters for implementing them.

Yes, we have entered an era where women are being restricted in their choices by various industrial complexes and the insurance and legal industries play a major part in the landscape of maternity systems today.

Most importantly though, the midwifery model is indistinguishable from the medical model of birth and midwifery guidelines sit entirely within the medical paradigm.

It took me a long time to figure this out and even longer to accept it.

There are aspects to our amazing physiology that get overlooked entirely in the medical model.

“Normality" as it is understood in medical midwifery is defined by rigid parameters and “normality” is not equal to “physiology”. 

An autonomous woman led birth doesn’t resemble a birth observed within the confines of “normality" much. 

A physiological unfolding of birth does not occur in rigid stages and although there are definite commonalities in the progression of a physiological birth, nobody watches the clock .To the onlooker looks surprisingly different to birth within the institution and parents who have experienced institutional and autonomous birth (unsurprisingly) say that there is no comparison.

Most midwives are uncomfortable with supporting the full arc of a physiological birth without “knowing what’s happening”. "Knowing what’s happening" is defined by various parameters that were originally defined by doctors who eventually managed to dominate the sphere of birth. They gave traditional midwives a bit of the territory if they agreed to get trained in their methods and become regulated. 

In some ways, we’re seeing the very early stages of a similar dynamic unfold between doulas and midwives in various parts of the UK. Let's hope that doulas remain steadfast in their position next to the woman and don't get drawn in to becoming the midwives' messengers in the same way that midwives allowed themselves to ally with the medical establishment. 

I've been pondering what words I would use instead of "Hybrid Freebirth"  and here's my train of thought: 

A woman who has made an informed choice to have a hombirth with a midwife present and decline any amount of interventions clearly does not want a freebirth. She is opting for an out of guideline birth at home and there is a pathway for that.

At least in theory, all a midwife has to do is inform the woman of the rationale for her suggested interventions in an unbiased way, give her the available data to support decision making, document the discussion, accept the woman's choice, and then support it. 

This is not new and when I was still on the register I supported this without question as long as I had done my duty of informing the woman of the rationale for the policy that suggests a different path to the one she's choosing.

I've been at births after 42 weeks gestation, I've supported home VBACs and I have been at homebirths where I was asked to sit next door. I've been at homebirths when the waters had released for longer than 24 hours and I have held off on transfers when the woman said that she wasn't ready to leave. 

I simply documented the discussions though I do think this used to be easier in days gone by.

When a woman feels safer with a midwife present in her home to help in those rare instances where a registered midwife might make a difference by using her training or the pharmaceuticals she is licensed to administer, that woman does not have to accept the other interventions by default. Any intervention should only ever be OFFERED to the woman and it can only be carried out with the woman's explicit consent.

If there truly are legal and regulatory obstacles to granting a woman full autonomy over her own body, then those should really be hashed out with the regulatory body, the NMC, and not with the women. 

At risk of stating the obvious: Particularly when it comes to vaginal examinations, no means no. There’s a sensitive way of exploring situations where a vaginal examination might shine light on an unusual situation but this does not mean that the woman has to comply either.

That, too, is captured in maternity policy and it is also the law!

The new term “Hybrid Freebirth” is telling of a lack of understanding of the ever expanding grassroots movement among women who don’t want to view themselves—or be viewed—through the narrow lens of obstetrics. 

Out of guideline birth at home is a hybrid of institutional homebirth, not of freebirth and I think it would be wise to keep the distinction alive for women’s sake but most importantly for the sake of the registered midwives who are being asked to attend the birth. 

Given the generally negative attitudes towards freebirth within the midwifery community and society as a whole, midwives are creating unnecessary tension in the profession. A midwife could feel apprehension if we start calling an out of guideline birth any kind of “freebirth”.

There is already enough fear around supporting out of guideline birth at home and midwives worry about adverse outcomes and their standing with their regulators when guidelines were not followed to the T. Midwives have been the subject of sensational news headlines when a birth ends in tragedy many times and they are understandably fearful of that. In this context I think that midwives need to be mindful not to evoke language that associates them with the practice of freebirth which is still seen as wreckless by many members of society and by the press, too.

Just like the "stages of labour",  "failure to progress", "incompetent cervix", "inadequate contractions", "preventable death", "spontaneous vaginal birth" or even the concept of "reproductive freedom",  "hybrid freebirth" is a construct imagined by the representatives of the medical establishment and they ultimately serve to keep our perceptions within a narrow frame of reference.

Imagine knowing that you don't have to engage in any kind of trade off when it comes to your bodily autonomy. That you don't have to trade dependency on pharmaceutical contraception for reproductive freedom for example and that you don't have to give birth within the confines of the rigid construct of "normality". 

When you apply curiosity, trust, acceptance and love the entire conversation shifts.

Authentic midwifery is all but dead within the institutions but it is seeing a revival in the grassroots. I love seeing women take ownership of the territories of their bodies, not by demanding change from the institutions but by being the change. 

In the last couple of years I have met some inspirational women who are moving forward fearlessly and in the birth keeper movement in Ireland there is so much love among the different practitioners who are witnessing each other not only in birthing their babies and birthing their families but in birthing their vision of being with woman. 

Is there a world where birth keeping can exist alongside the medical model? Is it possible for medical practitioners to welcome women who are living a holistic lifestyle with open arms when they truly need medical intervention.

Can the institutions earn back all women's trust?

Here in Northern Ireland change is coming. Let's hope that Professor Renfrew's roadmap for the next five years is going to help to heal our maternity services.

What do you think?