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disagreement) during antenatal discussions with an obstetrician or midwife, which led to the participants’ decision to give birth elsewhere, alone, or with DQRWKHU RIWHQ´KROLVWLFµ PLGZLIH)UHTXHQWO\WKLVPLGZLIHZRXOGEHDVLQJOH
practitioner, often specializing in working outside the guidelines, and providing continuity of care both during pregnancy and delivery. Many participants indicated that they experienced a lack of continuity of care (-r) in regular care.
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their pregnancy. Some had started a previous birth in primary (midwifery-led) care, but were transferred during birth to a clinical setting due to a complication, DWZKLFKSRLQWWKHLURZQPLGZLIHOHIWWKHPLQWKHKDQGVRIKRVSLWDOVWDͿWKH\
had never met before.
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had already been made up.
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Some participants quickly found a likeminded new caregiver, others searched for quite some time and experienced rejection (of their wishes) by yet another midwife or obstetrician.
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Some participants proceeded with their pregnancy without medical help. They checked their own blood pressure, measured their own abdominal circumference, or had an ultrasound done to check for placental location. Some of those who planned a UC devised emergency plans for the most common critical situations, like shoulder dystocia or post partum haemorrhage, whereas others notably did not, since they trusted that an uninterfered-with birth would not go awry.
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They read books, took antenatal classes (often hypnobirthing) and talked with family and friends about their decision. Although every participant discussed her situation with her partner at length, it is noticeable that most stated that their SDUWQHUOHIWWKHVHDUFKIRULQIRUPDWLRQDQGWKHÀQDOGHFLVLRQFRPSOHWHO\XSWRKHU
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Women felt that their care provider’s version of superior knowledge, with its evidence based protocols, stemmed from fear. Most participants believed that an optimal birth could only be achieved through true autonomy and trust in the natural process, and that this was only possible without fear. According to the PDQ\RIWKHSDUWLFLSDQWVFRQÁLFWVRIWHQDURVHEHFDXVHRIIHDU ZKHUHKHDOWKFDUH
providers were afraid of a bad outcome or litigation (or both), women feared unnecessary interventions, being overruled and losing their autonomy, having their birth disturbed (by interventions), being reported to social services and EHLQJVWLJPDWL]HGIRUWKHLUFKRLFHV7KHVHFRQÁLFWVZHUHDQLPSRUWDQWIDFWRULQ
women’s search for a care provider and/or birth setting without fear.
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The participants in the feedback focus group acknowledged the four main WKHPHVDVJHQHUDOO\ÀWWLQJZLWKZKDWWKH\KDGWROGWKHLQWHUYLHZHUVDOWKRXJK
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overarching theme would make them appear to be weak and afraid, whereas they viewed themselves as strong, enlightened and determined. The authors WKHUHIRUHHPSKDVL]HKRZWKHWKHPHIHDUGRHVQRWMXVWUHÁHFWRQWKHSDUWLFLSDQW·V
fear of unnecessary interventions, but much more on the medical approach of childbirth at this time, with its fear of bad outcome, peer pressure and legal measures.
Figure 2 Code Tree
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• Biomedical perspective - Biomedical knowledge
. Risk (Individualisation, Guidelines) - Ethics
- Interventions
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• Nature oriented framework - Acceptance
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. Awareness . Body Knowledge - Natural process - Religion/spirituality/fate
. Supernatural
Need for autonomy and trust in the birth process
• Autonomy - Control
- Informed consent . Time
. Information - Personal choice - Responsibility
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Figure 2 Continued
• Emotional needs - Feelings of safety - Intimacy
. Love - Relaxation - Respect
• Personal development
- Process equally important as outcome - Motherhood - Birth positions - Water birth
• Negotiation
- Negative Feelings/emotions . Anger
'LVFXVVLRQ &RQÁLFW0DQLSXODWLRQ´'HDGEDE\FDUGµ - Mismatch
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Discussion
This qualitative study involved 28 in-depth interviews with women who made choices for their birth setting that went against medical advice. Four main themes and one overarching theme emerged. These will now be rephrased as positive recommendations and discussed with reference to the literature.