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Home birth: a universal fear?

Midwives magazine: Issue 4 :: 2012

As medicalised birth becomes more prevalent across the world, many women are finding themselves trapped in a system that prevents true freedom of choice. But birth advocates around the world are fighting to restore that freedom.

Cover feature Issue 4 2012
Agnes Gereb
If you’ve haven’t heard of Ágnes Geréb already, you will certainly be familiar with her story by the end of this year. Her plight is the focus of a new film, Freedom for Birth, which is due to be screened at 1000 locations around the globe on 20 September and, much like the successful ‘Who is Joseph Kony?’ YouTube campaign earlier last year, it is hoped to go viral soon after.

But unlike Kony, Hungarian midwife Ágnes Geréb is viewed as a hero by her peers as she has helped more than 3500 women achieve a safe home birth. Yet if the Hungarian authorities have their way, Ágnes may never be able to help another woman again; she is currently serving a two-year prison sentence for medical malpractice and has been handed a decade-long ban on practising midwifery.

Ágnes was initially taken into custody in October 2010 after she attended to a woman who had gone into labour unexpectedly – at the time, Hungarian law prevented midwives from attending births outside hospitals (Free Ágnes Geréb Campaign, 2012). However, her supporters believe that the arrest had nothing to do with her capabilities as a healthcare professional, but rather the fact that she’s an outspoken advocate of home birth and fully supports the woman’s right to choose how she gives birth.

Speaking at the time of her arrest, RCM chief executive Cathy Warwick said ‘Ágnes Geréb is a woman who has been attempting to work in the interests of women. Her treatment at the hands of the authorities is disproportionate and inhumane’ (RCM, 2010).

As well as alerting the world to Ágnes’ struggle, Freedom for Birth will give a overview of how childbirth is viewed around the world. It has been produced by film-makers Toni Harman and Alex Wakeford as part of their One World Birth campaign.

Toni and Alex’s campaign began four years ago following the difficult birth of their daughter who, after a series of medical interventions, was delivered by emergency caesarean section. Spurred on by the traumatic birth experience, the couple decided to put their film-making skills to good use by documenting real birth stories from around the world.

 ‘Our eyes were open to what is actually happening with birth on a global level, and we wanted to do something to make birth better,’ says Toni.

‘Women aren’t being given the choice to decide how and where to give birth, and that’s an abuse of human rights.’

Human rights
As part of their research for Freedom for Birth, Toni and Alex went to the International Human Rights Childbirth Conference at the Hague earlier this year, and were shocked to hear stories from women across the world who had been denied the right to choose how and where they give birth.

‘In many countries around the world, home birth is outlawed, so we heard about people who have literally been frogmarched by police into hospitals to have a caesarean,’ Toni recalls.
Childbirth experts – from midwifery professors and obstetricians to social anthropologists – have spoken out condemning these practices. One expert who has been fighting for decades for women’s right to choose how and where they give birth is author and birth activist Sheila Kitzinger. ‘This is not just about how nice it would be for a woman to have a midwife, or how nice it would be to have a home birth, it is a human rights issue, and a major feminist issue,’ she says.

Sheila, a staunch supporter of the RCM, was delighted when its new president, Lesley Page, lent her support to the campaign for Ágnes Geréb’s freedom by paying a visit to Budapest and also by writing a letter to Hungarian president Dr Janos Alder in April to request a full pardon and cancellation of all criminal charges against Ágnes. ‘It is our hope that the granting of clemency will help create the conditions for further reforms of maternity care in Hungary,’ wrote Lesley. (RCM, 2012).

Sheila also believes that the RCM’s work in linking up with midwives in other countries will help pave the way for change. ‘I think this opens all sorts of doors in other countries,’ she says. ‘I know, for example, that there are midwives in the Czech Republic who want change, and in parts of Spain and Italy too, where there are pockets of strong, autonomous midwife activity.’

Women around the world are also making a stand to protect their human rights. In the same year Ágnes was arrested, a high-profile test case, brought about by Hungarian mother Anna Ternovszky, was fought in the European Court of Human Rights. Anna won the case, meaning she was granted the right to choose where she gave birth to her second child – she chose a home birth.

More significantly, the court ruled that ‘the right concerning the decision to become a parent includes the right of choosing the circumstances of becoming a parent’ and that it was ‘satisfied that the circumstances of giving birth incontestably form part of one’s private life’ (NIHR, 2010).

 This ruling meant that Anna’s case would pave the way for home birth to be viewed as a legal right for women across Europe. New test cases are currently being fought in Croatia and the Czech Republic, places where home birth has historically been feared and actively discouraged (Strancansky, 2011).

Developments are also happening further afield. A report in the Canadian Medical Association Journal has found planned midwife-assisted home births to be as safe as hospital births (Janssen et al, 2009), and the Australian College of Midwives issued guidelines which support the choice of midwife-attended home birth as a safe option for women with uncomplicated pregnancies (ACM, 2011).

Back in Europe, there has already been a breakthrough in the Czech Republic. In January, a Prague court ruled that women should have the right to choose how and where they give birth. However, so far the verdict has done little to change the stance of healthcare professionals in the country. Speaking after the hearing, the head of the Czech Gynaecological and Obstetrical Society, Vladimír Dvořák, said: ‘Our attitude has not changed at all. Our utmost concern is to ensure maximum safety for the mother and the newborn, and we still maintain that home births are non legae artis. This means that doctors planning to deliver the baby in the mother’s home would not be following the latest medical standards’ (Richter, 2012).

Birth in the UK
In contrast, the RCOG is more accepting of home birth and midwife-led care for low-risk births. In response to the 2011 Birthplace study, RCOG president Dr Tony Falconer said: ‘We now have good evidence on the risks and benefits of each birth setting, information that is important to help women and healthcare professionals make informed choices on the place of birth’ (RCOG, 2011).

But despite the fact that Birthplace highlighted the low risks associated with home birth – especially for multiparous women – only about 3% in the UK opt for a home birth every year, indicating that there is maybe a level of distrust around the practice.

According to the National Childbirth Trust, this could be caused by misleading statistics surrounding home birth. In its online resources for parents, it points out that premature babies that are born on the way to the hospital and women who have concealed their pregnancy and given birth in secret are counted as home births in official data, which could make the risks of poor outcomes appear higher than they actually are (NCT, 2012).

Dr Mary Steen, in her book on home birth, points out that a medicalised birth is not necessarily an easier option for women who are worried about the risks. ‘There will always be an element of uncertainty around giving birth at home but being in a hospital setting does not prevent this either. Absolute safety cannot be guaranteed in any birth environment. However, good preparation and planning will help to minimise the risks associated with birth’ (Steen, 2012).

However, human rights lawyer Elizabeth Prochaska believes that not all women in the UK are being given the option to make an informed choice about their birth plan.

‘Obviously, it’s standard DH policy that women should have the right to choose between home, birth centre and hospital, but the reality is that birth centres are being closed all over the country as a result of austerity measures, and home birth services are being suspended frequently as part of cuts to staff, so they basically don’t have access to these services,’ she says.

While it is a legal obligation for home births to be an option for all women, less than a 10th of trusts offer a full range of birthing locations. 
 
As reported in the Birthplace study, in 2010 almost half of trusts in England (49%) only offered obstetric units for mothers-to-be (NPEU, 2011).

While those offering the full compliment of obstetric unit, freestanding and alongside midwifery unit was just 8.8% (NPEU, 2011). Elizabeth also believes women are being put off home birth by ‘scaremongering on the part of health professionals’. She has first-hand experience of this. Two years ago, when she was pregnant with her daughter, she called on the service of an independent midwife to attend her home birth after she found ‘bureaucracy’ was preventing her having the birth experience she desired.

‘[Some health professionals often don’t] understand the concept of informed consent. They tell women what they are allowed or not allowed to do rather than asking them what they want to do. You wouldn’t tell a cancer patient that they have to have chemotherapy.’
Elizabeth, who in her capacity as human rights lawyer has been working on the Free Ágnes Geréb Campaign for the past two years, is now using her legal expertise launching an online resource called ‘Birth Right’. Due to launch later this year, the service will provide support and advice to everyone involved in the birth process – from mothers to health professionals and doulas.

Birth Right and One World Birth are both positive steps in the fight for women’s freedom of choice, and giving the women the freedom to make those choices could change the world. As Ágnes Geréb herself summarised when the One World Birth team interviewed her shortly before her incarceration: ‘The freedom of a country can be measured by the freedom of birth.’


Who’s fighting?

A few ways people around the world are fighting for women’s freedom of choice:

In the US, an organisation called Where’s My Midwife? (wheresmymidwife.org) is campaigning for better access to midwives in hospitals, freestanding birth centres and for home births. The group is also working in Canada to raise awareness of midwife-led care.

Last September, the campaign group Homebirth Australia (homebirthaustralia.org) wrote to the Australian College of Midwives, proposing that they work in collaboration to promote safe home birth.

In Ireland, where the home birth rate is just 1%, the organisation Home Birth Association of Ireland (homebirth.ie) is available to advise women about their legal right to choose where they give birth.


References

ACM. (2011) Guidance for midwives regarding home birth services. See:  www.midwives.org.au/lib/pdf/documents/NSW/Guidance%20for%20midwives%20about%20homebirth%20services_08112011.pdf (accessed 7 August 2012).

Free Ágnes Geréb campaign. (2012) A black day for home birth in Hungary. See: www.freeÁgnesgereb.com/2012/02/20/Ágnes-persecution-continues-a-black-day-for-homebirth (accessed 7 August 2012).

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. (2009) Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 181(9): 617.

NCT. (2012) Is a home birth safe? See: www.nct.org.uk/birth/home-birth-safe (accessed 7 August 2012).

NIHR. (2010) Ternovzsky vs Hungary. See: http://sim.law.uu.nl/sim/caselaw/Hof.nsf/1d4d0dd240bfee7ec12568490035df05/30b9a2d7ebbbd8c4c12577f9004aa476?OpenDocument (accessed 7 August 2012).

NPEU. (2011) Birthplace in England Research Programme (Birthplace). See: www.npeu.ox.ac.uk/birthplace (accessed 7 August 2012).

RCM. (2010) RCM calls for release of imprisoned Hungarian midwife. See: www.rcm.org.uk/college/about/media-centre/press-releases/rcm-calls-for-release-of-imprisoned-hungarian-midwife-23-11-10 (accessed 7 August 2012).

RCM. (2012) The RCM calls for presidential pardon for sentenced Hungarian midwives. See: www.rcm.org.uk/college/about/media-centre/press-releases/the-rcm-calls-for-presidential-pardon-for-sentenced-hungarian-midwives-27-04-12 (accessed 7 August 2012).

RCOG. (2011) RCOG statement on the results of the NPEU Birthplace study. See: www.rcog.org.uk/what-we-do/campaigning-and-opinions/statement/rcog-statement-results-npeu-birthplace-study (accessed 7 August 2012).

Richter J. (2012) Prague court delivers landmark ruling in home births advocates’ battle with the state. Cesky Rozhlas. See: www.radio.cz/en/section/curraffrs/prague-court-delivers-landmark-ruling-in-home-births-advocates-battle-with-the-state (accessed 7 August 2012).

Steen M. (2012) Supporting women to give birth at home: a practical guide for midwives. Routledge: Oxon.

Strancansky P. (2011) East Europe: midwives struggle to deliver home births. Inter Press Service. See: www.ipsnews.net/2011/01/east-europe-midwives-struggle-to-deliver-home-births/ (accessed 7 August 2012).