Final Report Summary - CODEONBIRTH (An intercultural and Ethical Code on Birth. A dialogue between institutional directives and women's needs.)
SUMMARY DESCRIPTION OF PROJECT CONTEXT AND OBJECTIVES
This project proposes an anthropological medical analysis of out-of-hospital childbirth (homebirth and maternity home) in three European countries. It aims 1) to analyse the official medical, obstetrical and political discourses on this topic; 2) to compare and contrast birth policies and practices on out-of-hospital birth, especially with regard to maternity homes managed by midwives and the national health care system; and 3) to explore the experiences and perspectives of midwives and women on giving birth at home or in a maternity home.
The main objective is to construct an Intercultural and Ethical Code on birth to encourage better correspondence between the demands and expectations of women and the functioning of the medical system. This Code, produced by the dialogue between different approaches to the body, to health, and to reproduction as expressed by the actors (midwives, native and immigrant women, doctors, national and supranational institutions), is intended to serve as a point of reference for innovative birth policies and to contribute to resolving conflicts and misunderstandings regarding the exercise of reproductive rights.
A concern about the increasing medicalisation of birthing fosters this research—in particular, the rise in caesarean sections and excessive interventions during labour and delivery. Could birth at home as a model of care, which is increasing both at the public and the private level, be a superior alternative that actualises a more humanised model of birth while maintaining the benefits of biomedicine? Could there also be an intercultural model that is adequate not only for European women but also for immigrant women? Answering these questions entails re-conceptualizing the biomedical birth pathway according to what women and contemporary societies need. A prerequisite for implementing a participative and sustainable model of birth that is both culturally and socially adequate. An accurate analysis of the social actors’ perspectives will provide elements for a deeper understanding of how the medical system perceives women and the reproductive process, as well as of how women think of themselves and their own bodies. The employment of qualitative methodology based on in-depth interviews and case studies will allow for this accuracy.
DESCRIPTION OF THE WORK CARRIED OUT TO ACHIEVE THE PROJECT'S OBJECTIVES
Objective 1. The researcher carried out: a) a review of the World Health Organization documents on birth care since 1985 - the year in which the foundational document "Appropriate technology for Birth" was published; b) the collection of quantitative data on the subject; c) the analysis of the policies implemented at the national and local level, focusing on the organisation of birth-care services, guidelines and care protocols, obstetrician and midwives training and the engagement of women and couples in the decision-making process. The opinions of experts were collected, and the scientific literature on the subject were reviewed.
Objective 2. The researcher conducted the following case studies: 1) two maternity homes and the National Health Service homebirth services in the Emilia region of Italy, and 2) two maternity home experiences, one in Spain and one in the Netherlands.
Objective 3. The researcher interviewed women who gave birth at home and pregnant women who wished to give birth in a hospital.
In-depth interviews, focus groups, questionnaires and observations were used during the fieldwork in the three countries. The final sample was composed of 81 participants: 7 experts and health managers, 31 independent midwives, 9 hospitalized midwives, gynecologists and other health professionals, 11 women who gave birth at home, 8 pregnant women.
MAIN RESULTS
- The concept of “respect” emerged as a core argument in the dialogues and negotiations regarding the different approaches to the body, to health, and to reproduction as expressed by the actors involved in the study. More specifically, around this concept orbits the midwives and women’s visions of the process and all the practices that are deployed during the caring process at home or in a maternity home. It does not only refer to a general form of respect but also to the respect of the specific needs of a particular woman and a particular pregnancy. This concept includes respect for the woman (her personal story, her choices, her wishes, her knowledge, her feelings, her emotions, her body), respect for the mother and the baby, respect for the needs of the mother and father, respect for the triad (mother, father, and baby), respect for the place (the physical and social place that includes the entire process), respect for the practices and the tools available (the ability to not abuse them and to not intervene), and respect for one’s own profession (the skills, the roles and the ethics). The designing of the Intercultural and Ethical Code on Birth, the main objective of the project, is based on the concept of respect.
- The context within which this research was conducted is the gap between the WHO guidelines aimed at containing the over-medicalisation of delivery and birth and the implementation of routine hospital practices. Both in Italy and Spain, these practices, which are far from being critically examined at an adequate pace within the biomedical practice, are largely overlooked in the prevailing discourse despite the fact that there exist national policies aimed at these objectives in both cases. These issues are, instead, rather prominent in the conversations of those who make different choices, both at the personal and the professional levels, such as independent midwives and women who decide to deliver at home or in a maternity home. A dialogue between independent midwives, women who gave birth at home and hospitalized health professionals could reduce the gap between policies and practices and contribute to fomenting a respectful birth in the hospital.
- For low risk women, homebirth attended by independent midwives who are networked within a maternity care service is supported as safe by evidence-based medicine. However, risk perception about homebirth throughout society is high. From a medicalized perspective, “pregnancy and birth always have an element of risk”. Thus, a close monitoring of the process (i.e. monthly visits and ecographies) is necessary. Women who birth at home have a different perception from most women with respect to the risks and safety of the birthing process. For instance, they feel that the hospital is not the safest place to have a baby because of the high number of unnecessary interventions and the depersonalized and disrespectful environment. From their perspective, the concept of security is broader and covers aspects of social, family, and individual life in addition to the medical and clinical aspects. At home, they feel empowered and co-responsible for the birthing process. Taking into account these aspects in the planning of policies and practices, i.e. expanding the concept of safe beyond the biomedical perspective, could contribute to a more humanised method of birth in the hospital and could also prevent medicolegal contentious issues.
- The Emilia case study suggests that homebirth within a public model confers several advantages to the experience of birth for both women and professionals. In short, it actualises and legitimises a physiologically-centred and woman-centred birth model that maintains the benefits of biomedicine when necessary. This calls for politicians and administrators to dedicate more attention and resources to this service to make it accessible to more women.
- The social, a cultural and a political role of the independent midwives was highlighted. Independent midwives not only accompany women during and after childbirth, they are also the interpreters of the social and cultural changes brought about, in the last decades, by the increasing medicalisation of our lives. Moreover, they are the facilitators who are capable of encouraging and supporting women throughout the re-appropriation of agency on birth. The political nature of their role, therefore, is found in the ability to highlight, defend, and negotiate spaces of power that are both private and professional as well as individual and collective. They empower women and are the central node—according to the emerging data—of a different view on childbirth.
CONCLUSION
Main findings suggest that independent midwives’ visions and experiences contribute to maintaining the physiology and the re-appropriation of female knowledge and agency regarding the birthing process. Taking into account midwives and women’s experiences with out-of-hospital births can promote a more physiological and respectful approach to the birthing process, even in the hospital. This means, in contrast to the over-medicalisation of childbirth, re-thinking childbirth policies and practices beginning with the needs of the women and their babies and to include considerations of respect to all person, all cultures and all values within the context of a multi-ethnic society.
POTENTIAL IMPACT AND USE
The Code constitutes an innovative tool to find a less medicalised model of birth without renouncing the benefits offered by biomedicine when they are needed. Thus, it forms the basis of a voluntary code of practice covering the relationships between women and practitioners (midwives and doctors), and as such, it is intended as an aid to encourage better correspondence between the demands and expectations of women and the functioning of the medical system. A potential use of the Code involves transforming it into recommendations and strategies to implement good practices regarding birth management and innovative training pathways for health practitioners.
Research results will increase social actors’ awareness of the risks and benefits associated with the different models of birth (medical birth versus non-medical birth). They will also promote mutual communications between institutions and citizens and enhance collaboration between doctors and midwives with respect to hospital births and home births as well as private and public options regarding birth, while at the same time empowering women to exercise their rights regarding reproduction and birthing.
Research findings were disseminated by the researcher during academic events and outreach activities. While teaching activities constitute the core of the researcher’s development regarding her career, at the end of the fellowship, the researcher will continue to disseminate her results and discuss the Code as a lecturer on midwifery and health care professions at the University of Udine (host institution) and Trieste.
Results provided the researcher with knowledge of the concept of “obstetric violence”, which even exists as a legal term in some Latin American countries. It is an innovative issue at the European level. It is discussed by human rights organisations and social movements in order to fight for a more humane and respectful birth, but public and political debate is still weak. The issue represents a theoretical advancement in the state of the art and a new frontier for the researcher’s career development. Acquiring new skills and competences on the matter will provide the researcher with a wider range of experience in order to reinforce her position as an expert at European level. A new research project on obstetric violence is currently under evaluation (Marie Sklodowska Curie Action 2015-Global Fellowship).
This project proposes an anthropological medical analysis of out-of-hospital childbirth (homebirth and maternity home) in three European countries. It aims 1) to analyse the official medical, obstetrical and political discourses on this topic; 2) to compare and contrast birth policies and practices on out-of-hospital birth, especially with regard to maternity homes managed by midwives and the national health care system; and 3) to explore the experiences and perspectives of midwives and women on giving birth at home or in a maternity home.
The main objective is to construct an Intercultural and Ethical Code on birth to encourage better correspondence between the demands and expectations of women and the functioning of the medical system. This Code, produced by the dialogue between different approaches to the body, to health, and to reproduction as expressed by the actors (midwives, native and immigrant women, doctors, national and supranational institutions), is intended to serve as a point of reference for innovative birth policies and to contribute to resolving conflicts and misunderstandings regarding the exercise of reproductive rights.
A concern about the increasing medicalisation of birthing fosters this research—in particular, the rise in caesarean sections and excessive interventions during labour and delivery. Could birth at home as a model of care, which is increasing both at the public and the private level, be a superior alternative that actualises a more humanised model of birth while maintaining the benefits of biomedicine? Could there also be an intercultural model that is adequate not only for European women but also for immigrant women? Answering these questions entails re-conceptualizing the biomedical birth pathway according to what women and contemporary societies need. A prerequisite for implementing a participative and sustainable model of birth that is both culturally and socially adequate. An accurate analysis of the social actors’ perspectives will provide elements for a deeper understanding of how the medical system perceives women and the reproductive process, as well as of how women think of themselves and their own bodies. The employment of qualitative methodology based on in-depth interviews and case studies will allow for this accuracy.
DESCRIPTION OF THE WORK CARRIED OUT TO ACHIEVE THE PROJECT'S OBJECTIVES
Objective 1. The researcher carried out: a) a review of the World Health Organization documents on birth care since 1985 - the year in which the foundational document "Appropriate technology for Birth" was published; b) the collection of quantitative data on the subject; c) the analysis of the policies implemented at the national and local level, focusing on the organisation of birth-care services, guidelines and care protocols, obstetrician and midwives training and the engagement of women and couples in the decision-making process. The opinions of experts were collected, and the scientific literature on the subject were reviewed.
Objective 2. The researcher conducted the following case studies: 1) two maternity homes and the National Health Service homebirth services in the Emilia region of Italy, and 2) two maternity home experiences, one in Spain and one in the Netherlands.
Objective 3. The researcher interviewed women who gave birth at home and pregnant women who wished to give birth in a hospital.
In-depth interviews, focus groups, questionnaires and observations were used during the fieldwork in the three countries. The final sample was composed of 81 participants: 7 experts and health managers, 31 independent midwives, 9 hospitalized midwives, gynecologists and other health professionals, 11 women who gave birth at home, 8 pregnant women.
MAIN RESULTS
- The concept of “respect” emerged as a core argument in the dialogues and negotiations regarding the different approaches to the body, to health, and to reproduction as expressed by the actors involved in the study. More specifically, around this concept orbits the midwives and women’s visions of the process and all the practices that are deployed during the caring process at home or in a maternity home. It does not only refer to a general form of respect but also to the respect of the specific needs of a particular woman and a particular pregnancy. This concept includes respect for the woman (her personal story, her choices, her wishes, her knowledge, her feelings, her emotions, her body), respect for the mother and the baby, respect for the needs of the mother and father, respect for the triad (mother, father, and baby), respect for the place (the physical and social place that includes the entire process), respect for the practices and the tools available (the ability to not abuse them and to not intervene), and respect for one’s own profession (the skills, the roles and the ethics). The designing of the Intercultural and Ethical Code on Birth, the main objective of the project, is based on the concept of respect.
- The context within which this research was conducted is the gap between the WHO guidelines aimed at containing the over-medicalisation of delivery and birth and the implementation of routine hospital practices. Both in Italy and Spain, these practices, which are far from being critically examined at an adequate pace within the biomedical practice, are largely overlooked in the prevailing discourse despite the fact that there exist national policies aimed at these objectives in both cases. These issues are, instead, rather prominent in the conversations of those who make different choices, both at the personal and the professional levels, such as independent midwives and women who decide to deliver at home or in a maternity home. A dialogue between independent midwives, women who gave birth at home and hospitalized health professionals could reduce the gap between policies and practices and contribute to fomenting a respectful birth in the hospital.
- For low risk women, homebirth attended by independent midwives who are networked within a maternity care service is supported as safe by evidence-based medicine. However, risk perception about homebirth throughout society is high. From a medicalized perspective, “pregnancy and birth always have an element of risk”. Thus, a close monitoring of the process (i.e. monthly visits and ecographies) is necessary. Women who birth at home have a different perception from most women with respect to the risks and safety of the birthing process. For instance, they feel that the hospital is not the safest place to have a baby because of the high number of unnecessary interventions and the depersonalized and disrespectful environment. From their perspective, the concept of security is broader and covers aspects of social, family, and individual life in addition to the medical and clinical aspects. At home, they feel empowered and co-responsible for the birthing process. Taking into account these aspects in the planning of policies and practices, i.e. expanding the concept of safe beyond the biomedical perspective, could contribute to a more humanised method of birth in the hospital and could also prevent medicolegal contentious issues.
- The Emilia case study suggests that homebirth within a public model confers several advantages to the experience of birth for both women and professionals. In short, it actualises and legitimises a physiologically-centred and woman-centred birth model that maintains the benefits of biomedicine when necessary. This calls for politicians and administrators to dedicate more attention and resources to this service to make it accessible to more women.
- The social, a cultural and a political role of the independent midwives was highlighted. Independent midwives not only accompany women during and after childbirth, they are also the interpreters of the social and cultural changes brought about, in the last decades, by the increasing medicalisation of our lives. Moreover, they are the facilitators who are capable of encouraging and supporting women throughout the re-appropriation of agency on birth. The political nature of their role, therefore, is found in the ability to highlight, defend, and negotiate spaces of power that are both private and professional as well as individual and collective. They empower women and are the central node—according to the emerging data—of a different view on childbirth.
CONCLUSION
Main findings suggest that independent midwives’ visions and experiences contribute to maintaining the physiology and the re-appropriation of female knowledge and agency regarding the birthing process. Taking into account midwives and women’s experiences with out-of-hospital births can promote a more physiological and respectful approach to the birthing process, even in the hospital. This means, in contrast to the over-medicalisation of childbirth, re-thinking childbirth policies and practices beginning with the needs of the women and their babies and to include considerations of respect to all person, all cultures and all values within the context of a multi-ethnic society.
POTENTIAL IMPACT AND USE
The Code constitutes an innovative tool to find a less medicalised model of birth without renouncing the benefits offered by biomedicine when they are needed. Thus, it forms the basis of a voluntary code of practice covering the relationships between women and practitioners (midwives and doctors), and as such, it is intended as an aid to encourage better correspondence between the demands and expectations of women and the functioning of the medical system. A potential use of the Code involves transforming it into recommendations and strategies to implement good practices regarding birth management and innovative training pathways for health practitioners.
Research results will increase social actors’ awareness of the risks and benefits associated with the different models of birth (medical birth versus non-medical birth). They will also promote mutual communications between institutions and citizens and enhance collaboration between doctors and midwives with respect to hospital births and home births as well as private and public options regarding birth, while at the same time empowering women to exercise their rights regarding reproduction and birthing.
Research findings were disseminated by the researcher during academic events and outreach activities. While teaching activities constitute the core of the researcher’s development regarding her career, at the end of the fellowship, the researcher will continue to disseminate her results and discuss the Code as a lecturer on midwifery and health care professions at the University of Udine (host institution) and Trieste.
Results provided the researcher with knowledge of the concept of “obstetric violence”, which even exists as a legal term in some Latin American countries. It is an innovative issue at the European level. It is discussed by human rights organisations and social movements in order to fight for a more humane and respectful birth, but public and political debate is still weak. The issue represents a theoretical advancement in the state of the art and a new frontier for the researcher’s career development. Acquiring new skills and competences on the matter will provide the researcher with a wider range of experience in order to reinforce her position as an expert at European level. A new research project on obstetric violence is currently under evaluation (Marie Sklodowska Curie Action 2015-Global Fellowship).