Norwegian women’s motivations and preparations for freebirth—A qualitative study
Introduction
It is called freebirth or unassisted childbirth if women that have access to skilled birth attendants actively choose to give birth without the support of offered by maternity care [1]. Studies in Sweden, the United Kingdom, Australia and the Netherlands have shown that women who choose to give birth outside the official care system often view hospitals as places with increased risk for complications due to unnecessary interventions [1], [2], [3], [4], [5]. Other reasons may be distrust in the health system and a feeling that the women’s needs are not being met [1], [4]. Studies have also indicated that some women choose freebirth after prior traumatic birth experiences [1], [4], [5], [6]. The prevalence of women who choose freebirth is difficult to assess due to its covert nature. Consequently, the prevalence is unknown [1].
In high-income countries, the majority of pregnant women give birth in hospitals, and homebirth has become the exception [7]. Homebirth is often not organised by the maternity care system and is viewed as unsafe in some obstetric settings [7]. An insufficient homebirth offer can be one reason why some women choose to give birth at home without skilled care [1], [8]. If a homebirth offer exists, the guidelines usually require that women have low-risk pregnancies with no prior complicated births to be able to have homebirth with midwives [9]. Disagreement with the guidelines and strong desires to give birth at home even with pregnancies that are considered to be high risk may be reasons why women choose freebirth [3], [10].
Maternity care is part of Norway’s public health system financed by taxes to ensure equal access to health care [11]. All women can access maternity care free of charge. Intrapartum care is provided at three levels: 1) specialised units providing advanced obstetric, anaesthetic and paediatric services, including neonatal intensive care units; 2) units in smaller hospitals with obstetric and aesthetic services; and 3) free-standing and alongside midwifery-led units providing care for low-risk women. The majority of births take place in level 1 and 2 units [9]. Midwives attend all births, assist all spontaneous vaginal deliveries and are present at all operative deliveries. Midwives are the primary caregivers for low-risk women during birth, no matter where the planned place of birth is [12]. The prevalence of planned homebirths is about 1 per 1,000 births, with 100–170 occurring every year [13].
Norwegian health authorities do not organise homebirth as part of the public maternity care system [14]. The woman herself must find a midwife willing to assist at the birth at home [9]. She also has to cover the costs for the midwife, but she may receive a refund for a certain amount from the authorities [14]. The refund does not cover the total costs of having a midwife on call, so the woman has to cover some of the expenses herself. The expenses the woman bears are approximately 500–800 Euros. Evidence-based guidelines applied by the Norwegian health care system with selection criteria for homebirth exist [9], [14]. In short, to fulfil the criteria for a homebirth, a woman must have a low-risk pregnancy, had prior normal pregnancies and births, give birth at term and have a contract with a midwife who can assist at home [14]. Even if a woman has that contract, she is not guaranteed that the midwife will be able to come when she is in labour as midwives offering homebirth usually hold part-time positions in birth units or antenatal services. Studies have shown that planned homebirth is a safe option for low-risk women [15], [16], [17], [18]. Approximately 30 midwives attend homebirths in Norway.
From a global perspective, the lack of skilled care during birth is a problem, and one strategy to reduce maternal morbidity and mortality is for all women to receive help from skilled carers [19]. Choosing to give birth without skilled professionals when access is available, therefore, is considered to be controversial [1]. There is no overview of freebirth in Norway, but with a homebirth offer that is arbitrary and costly for women, it is likely that freebirth is something that happens. To our knowledge, no Norwegian studies have examined why women choose this option. Such insight could help understand women’s views on maternity care that make them want to give birth outside the system. The aim of this study was to examine women’s motivations and preparations for freebirth.
Section snippets
Methods
A qualitative approach with individual semi-structured interviews was chosen for data collection. This method was chosen to gain deeper insights into personal experiences, reasons and thoughts regarding freebirth because it may be a sensitive topic [20]. This method was also preferred instead of, for example, a survey with qualitative responses because it is possible to elaborate on and examine answers during interviews, if needed. Twelve women were purposively recruited through posts on five
Characteristics of the study participants
Twelve women who lived in Norway participated in this study. Two women lived abroad at the time of the interviews due to work and family reasons and planned the freebirth outside Norway. The women came from both cities and smaller places in all parts of Norway, except northern Norway. Their ages ranged from 23 to 42 years, and their education levels from primary to higher education. One of the women was a midwife, and two were doulas. Table 1 gives an overview of their parity and freebirth
Discussion
This study gained insights into Norwegian women’s motivations for choosing freebirth and how they prepared for it. One main theme emerged from the data: deep trust in birth as a natural process and women’s own capacity to give birth embedded in distrust of the maternity care system. In addition, three categories were identified: unsatisfied with the care offered today, earlier uncomplicated and traumatic births influence freebirth choices and trust in one’s own knowledge and capacity. One
Conclusion and recommendations for practice
This study contributes to the body of knowledge on why women choose freebirth and constitutes the first study to examine this topic in a Norwegian setting. The participating women had deep trust in themselves and their capacity to give birth. The study shows that their motivations for freebirth were embedded in overall dissatisfaction with today’s maternity care and the inadequate homebirth offer. Having an affordable, feasible homebirth offer could prevent women from having freebirth in
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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