Birthing Outside the System

Dr Sheena Byrom OBE

When I listen to or read accounts from women who feel distressed or destroyed by their childbirth experience, my usual positive optimism turns to rage, and intermittent gloom. I know, first hand, that having a baby has a life changing impact on women and can make or break their lives forever. When I read CITCM I revisited the anguish and anger; women are increasingly dissatisfied and disturbed following institutionalised childbirth, and they are choosing to reject it. And then there are the birth workers. They are the onlookers and actors also responding with adrenaline fuelled fight or flight responses and continuously jumping to the beat of the fear drum. This text splits open the shell of cover-ups to reveal a plethora of hidden agendas, underlying causes of harm – the impact that beaurocratic patriarchal maternity systems, based on risk agendas, have on women and families. Using the metaphor of the canary in the coalmine, this book not only shares research and personal accounts of violations of women’s rights, but it offers solutions for a better way. I feel relieved that truths are being shared in a way that touches my spirit, my soul and my human being to the core, and that give me the impetus to continue to lobby for change. The research evidence is compelling, the stories are heart rendering. We have to sit up, rise up and speak up for maternity services to change. We need to create a storm around this book, encourage others to read it, inhale it in then exhale it out as forcefully as a dragon’s breath. Eternal thanks to the editors for turning their frustrations into action, and to the chapter authors who share their lived experiences and knowledge for a better world. I salute you all.

Dr Sheena Byrom OBE

Midwife Consultant and Director – All4Maternity

Dr Michel Odent

Today, whatever the topic, we are in unprecedented situations. Homo has reached the limits of the domination of nature. A significant example: love hormones have been made redundant to deliver babies. It is as if we were close to the edge of a precipice. It is too late for procrastination. The only relevant strategy is to take other directions. What can we learn from mothers who find ways to escape from the dominant way of thinking? We must thank Hannah Dahlen, Bashi Hazard and Virginia Schmied for helping us to urgently clarify vital questions.

Dr Michel Odent, Obstetrician, Director of the Primal Health Research Centre, Author of The future of Homo, Do We Need Midwives, The Scientification of Love and many more

Dr Robbie Davis-Floyd

This book takes an innovative look at what are culturally considered birthing extremes. It asks, why do so many women and families in varied cultures choose to birth completely outside of hospitals and clinics where the technocratic approach is hegemonic? These people’s choice of unconventional "freebirth" or even of culturally accepted homebirths in low-resource countries where those are still normative constitutes a radical critique of the dominant system. That critique intensifies with the accounts of childbearers with complications medically considered high-risk—such as VBACs, breech and twin births—who resist this medical classification, redefining such births as simply variants of normal. A chapter on birth trauma demonstrates the emotional devastation that too often accompanies the inhumane and unnecessary interventions imposed on women who birth inside the technocratic system, and how freebirthers and others seek to avoid that trauma by utilizing normal physiologic birth as a vehicle for self-empowerment and healing. Critiques of "the system" are multiplying; to them, this "out-on-the-edge" book adds the telling perspectives of those who reject that system entirely. I highly recommend hearing their voices as spoken in these pages!

Dr Robbie Davis-Floyd PhD, FSfAA

Senior Research Fellow, Dept. of Anthropology, University of Texas Austin

Author, Birth as an American Rite of Passage and Ways of Knowing about Birth: Mothers, Midwives, Medicine, and Birth Activism

Professor Soo Downe OBE

The fact that this well-written, comprehensive, thought provoking book is so timely is both shocking and reassuring. Shocking because it reveals the degree to which maternity services around the world have become blind to the impact of extreme risk aversion on the wellbeing of women and babies. Reassuring because, finally, the blindfolds have been removed: and because, rather than just pointing out the problems, the authors also provide solutions. I hope as many people as possible read the book, and that they conclude that the time has come to act. Now.

Professor of Midwifery, UCLAN

Rhea Dempsey

#MeToo as a cultural moment inspires us to courageously speak and act in defiance of old ‘power over’ paradigms. It calls us to shape a new paradigm that honours respectful relationships and personal agency. Its reverberations are being felt in the birth culture.

Refusing to be constrained within wounding power over structures some women – canaries – are birthing ‘outside the system’ and thereby warning us of an urgent need for change.

Heeding the canaries’ warnings, the contributors to this book are shaping the new paradigm by powerfully documenting the issues and mapping the necessary path forward.

Rhea Dempsey, author of Birthing with Confidence

Dr Sarah Buckley

How do women perceive risk in childbearing? Do women really make dangerous choices for themselves and their babies? What is a safe birth? And how can we help women to feel safe? These critical questions are addressed by midwives, obstetricians, lawyers and birthing women themselves in this illuminating and important book.

Dr Sarah Buckley

GP and author of Gentle Birth, Gentle Mothering

Dr Rachel Reed

‘Birthing Outside the System: The Canary in the Coalmine’ shines a light into the coalmine of modern maternity care. The editors have brought together a diverse group of eminent authors whose contributions create a comprehensive analysis of the current global situation. The editors deliver on their promise - the book is indeed a ‘political opus’ that will ‘upend thinking and disburse assumptions’. However, the content also offers inspiration and practical guidance about how to create and sustain woman-centred maternity care. This is a call to action. We all need to work together to release the canary from her cage.

Dr Rachel Reed, Senior Lecturer in Midwifery, University of Sunshine Coast, Australia Author of Midwife Thinking Blog and Why Induction Matters

Professor Mary Renfrew

This book is a wake-up call that we cannot ignore. It raises essential questions for those who work in health care, in education, in research, and in policy. Perhaps most importantly, it raises questions for the whole of society - all human beings are born, one way or another, so this concerns all of us.

Health professionals may think that women who birth outside of the mainstream health system, with or without a carer, are being negligent or careless of their safety and the safety of their baby. What this book shows is that those decisions are often a response to previous damaging experiences of healthcare, and are not lightly taken. Women making these decisions may have the courage, or the support, or the total desperation to do so. But devastatingly, this book shows that these women are indeed the canaries in the coal mine, the visible sign of something much bigger. Many, many more women in many countries are giving birth inside systems that have not been designed to meet their needs, perhaps with staff who do not have the necessary knowledge, skill, or kindness. Women and their babies experience physical or psychological trauma as a result. This cannot – must not – continue.

Why, and how, have such systems developed across the world? International, multidisciplinary chapter authors explore this and many other fundamental questions with evidence, intelligence, and illuminating personal stories. Causes are both systemic and individual. One factor is a lack of good quality education. Another is a narrow interpretation of safety and quality in which physical outcomes and the routine use of interventions are prioritised over respect for the rights of women and children, optimising normal physiology, and considering the full spectrum of physical, psychological, social, cultural, and spiritual aspects of health and well-being. The imbalance of power throughout the system prevents effective challenge and change.

What can be done? Some national governments, regulators, and global organisations are already stepping up with shifts in policy and education, informed by evidence and with the significant input of women, families, midwives, and others, , . But this book demonstrates that more, much more, is needed if women, babies, and families everywhere are truly to receive respectful, kind, and effective care. Societal and professional barriers must be removed so that well-educated and effectively supported midwives are available and accessible for all. Service and education redesign must be informed by a radically different research agenda and co-created with women and families.

Righting the widespread and longstanding wrongs that have caused this damage will take time and coordinated cross-sectoral action. This book makes an important contribution to informing, motivating and shaping such action.

Mary J Renfrew BSc RN RM PhD FRSE

Professor of Mother and Infant Health

University of Dundee, Scotland

Professor Holly Powell Kennedy

Birthing outside the system: The Canary in the Coal Mine is a compelling and practical examination of health care which too often does not meet women’s needs – it forces the reader to confront that we have failed mothers and babies with the imbalance of care and interventions, as Miller notes "too much too soon" often in high income countries and "too little too late" for those who truly in need. It echoes the saying "if you’ve dug yourself into a hole, then stop digging" – in other words in maternal health care, seriously consider actions to change systems to meet the World Health Organizations directive to assure a positive birth experience and using interventions only when supported by evidence and clinical needs. Bravo to the authors for their courage, critique, and intellectual expose!

Professor Holly Powell Kennedy

Helen Varney Professor of Midwifery

Milli Hill

"For too long women who birth outside the system have been portrayed as mad, dangerous and irresponsible. This book finally turns the spotlight on the dangers of the system itself - in short, it moves us away from the default position of ‘woman blaming’ and forces us to ask what it is about the current mainstream birth system that feels so very unsafe to gathering numbers of women. This is a vitally important and deeply feminist book, that takes the radical step of actually listening to women’s voices and suggesting that the maternity care system does so too, and as a matter of urgency."

"A vital book, built on the deeply feminist idea that we should trust and listen to women rather than portraying them as mad and irresponsible."

Milli Hill, author of Give Birth Like a Feminist and founder of the Positive Birth Movement

Associate Professor Denis Walsh

I highly recommend this informative and ground-breaking book about women choosing to birth outside formal maternity care systems. This slowly increasing trend in high-income countries is telling the maternity services something hugely significant about current provision. The authors, with first-hand experience of women choosing this option and with decades of involvement in maternity services in Australia and internationally at a practice, research and strategic level, are ideally placed to lead us on this journey. Their book examines critical underpinning ideologies that are infiltrating maternity care and need to be exposed and reformed. Among the most significant are patriarchy and neoliberalism which are both disenfranchising childbearing women choices, undermining their agency and channelling them down a path of inappropriate medicalisation. This is a ‘must read’ for anybody involved in childbirth services.

Denis Walsh

Retired Associate Professor in Midwifery,

University of Nottingham, UK

Nicky Grace

Canary in the Coalmine by Hannah Dahlen, Bashi Hazard and Virginia Schmied is a collection of writings that address the central theme of why some women reject, or are rejected by, mainstream maternity services. The accounts and analyses shine a light not only on the motivations and experiences of those who give birth outside the system, but on the system itself. Dahlen, Hazard and Schmied have succeeded in creating a text where scholarly, political and personal perspectives on birth are intertwined. We are called to take action, to react to the global maternity emergency, to take heed of the canary in the coalmine: the birthing mother who needs to be cared for, listened to, worked with. As I read, I wept and raged at the violence and oppression that women are routinely subjected to within mainstream maternity care. I also found myself – a radical, home birth midwife – questioning and challenging my own perceptions of midwifery history and my own practice. This is a good thing. We midwives and other maternity care providers must never become complacent but should be willing to adapt and change as new information comes to light. ‘Canary in the Coalmine’ helps us to do this, to work with women rather than against them, to provide what they need and not what we think they need.

The text avoids the ‘toxic positivity’ that pervades so much of midwifery culture and is so damaging for midwives. But while realistic about the extent of the challenges and inequities we face, possibly the most brilliant aspect of ‘Canary in the Coalmine’ is that we are given practical, evidence-based solutions for change at local, national and global levels. This book can be used by women and their midwives, by politicians, maternity managers and policymakers to guide change in maternity services. I loved this book. Its sound intellectual and research-based roots mean it will be an essential academic midwifery and obstetric text, while the lively quality of the well-chosen writing ensures a wider readership for those involved in childbirth in all capacities.

Nicky Grace

Association of Radical Midwives

Editor of Midwifer