Abstract
While many Western countries do legally permit homebirths under certain conditions, in the Slovak Republic they exist in a legal vacuum – they are neither permitted nor prohibited. In the present study, we aimed to explore how Slovak women who deliberately delivered at home perceive the reason for this decision and the subsequent homebirth itself. We interviewed eight women aged 21 to 36 and analysed the transcripts using the interpretative phenomenological analysis framework. The analysis revealed four major themes – (1) the sacredness of childbirth, (2) the aspiration to be the director of your childbirth, (3) homebirth as an expression of the need for intimacy, and (4) the struggle with one’s social circle. Childbirth is seen as an ultimate act of nature defined by its beauty and purity, but these qualities are tainted by biomedical approach of healthcare providers. The results of this study suggest that women’s needs of autonomy, relatedness, and inclusion are not properly met by Slovak health care and obstetrics. Stricter adherence to the principle of informed consent during hospital births, and legalisation and regulation of homebirths could reduce medical risks during childbirth and improve women’s mental well-being during and after a pivotal moment in their life.
1 Introduction
For a long time through humanity’s history, childbirths belonged to the domain of the home and community. Since the 1940s, along with medical advances with regards to antibiotics, blood transfusion, and safe anaesthesia, they were being transferred to the hospital setting, resulting in lower maternal mortality (Sanchéz-Redondo et al., 2020). However, it can also be argued that this led to the medicalization, denaturalization, and masculinization of childbirth. The biomedical care model, which became the status quo, gave power to medical doctors at the expense of women’s autonomy (Rodríguez-Garrido & Goberna-Tricas, 2021). Even though there have been slight shifts in paradigm in recent decades, respect towards women’s autonomy during labour is still a relevant issue (for instance, see Van der Pijl et al., 2021). Apart from being emotionally harmful on its own, stress caused by feeling treated as an object can also impact natural physiological processes during labour (Odent, 2009).
Therefore, a demand for a different approach to childbirth was arising. Much earlier paper by Wolfson (1986) already reported a growing interest in homebirths in the US. This trend does not diminish in the present and it appears to be especially true for more economically developed countries (Johnson et al., 2013). In many Western countries, such as USA, UK, Australia, Sweden or Spain, homebirths are legally permitted. They are especially popular in the Netherlands, where they constitute about 20% of all childbirths, and must be attended by direct entry midwives (Sanchéz-Redondo et al., 2020). The common argument in favour of homebirth legality is that they can be regulated and therefore, unlike underground homebirths, standards in medical procedures can be met (Starr, 2009). The conflict at the heart of the issue is between the mother’s autonomy and the child’s right to life (Wolfson, 1986), but a vast body of empirical research shows that the medical risk to both mother and child in homebirths attended by midwives is negligible compared to in-hospital births (Grünebaum et al., 2015). Risk factors for homebirths include multiple gestation, malpresentation, history of caesarean surgery, gestational age over 41 weeks, and first birth. These are typically evaluated and considered when homebirths are authorised in countries where they are legal (Grünebaum et al., 2015). In Slovakia, homebirths exist in a legal vacuum. Neither Act No. 311/2002 of the Slovak Collection of Laws, which regulates the work of nurses and midwives, nor Draft Act No. 22/1988 of the Ministry of Health, which regulates births and abortions, contain any reference to the place of birth. Therefore, homebirths are not permitted, but they are also not explicitly prohibited.
Expectant mothers’ preference for homebirth may have various reasons, but several findings seem to be universal across studies from different countries (Descieux et al., 2017). One of the frequently mentioned motives is a need for personal autonomy and control, which drives pregnant women to gain information on their own rather than just accept medical personnel’s perspective (Murray-Davis et al., 2012). They are especially likely to choose homebirth if they come to a conclusion that birth is best kept as a natural physiological process, and thus perceive many medical interventions as excessive, unnecessary, or even harmful, which can include procedures such as unindicated use of cesarean section, induction or augmentation of labour with oxytocin, epidurals, Kristeller’s procedure etc. (Bernhard et al., 2014; Boucher et al., 2009; Ďurnová & Hejzlárová, 2021; Leon-Larios et al., 2019; Murray-Davis et al., 2014). The heart of the issue is not use of these interventions per se, but rather the fact they are used routinely. Women are either pressured to agree or the information are tailored to them to make them conform to hospital policy, which makes achievability of informed consent questionable (Happel-Parkins & Azim, 2016; Newnham et al., 2017). However, there are also other forms of interference with women’s autonomy, such as not allowing close relatives to be present, not allowing choice of health care provider, or not allowing woman to properly bond with her newborn immediately after delivery (Bernhard et al., 2014; Boucher et al., 2009; Ďurnová & Hejzlárová, 2021).
Other driving factors are linked to attributes of the environment. Physical attributes such as room temperature, lightning, ventilation, or presence of birthing tub, are not negligible, but also not the most significant (Morison et al., 1998). The presence of chosen loved ones and having a birth managed by a midwife perceived as warm and supportive are essential for birthing women to feel at greater comfort (Bernhard et al., 2014; Skrondal et al., 2020), especially to women who previously had a bad experience with labour in a hospital (Beck & Watson, 2010). When it comes to homebirths, women can occasionally resort to spiritual language and speak of home as something more than just four familiar walls (Burns, 2015). The spiritual language bears traits of pantheism, since the spiritual blends with nature into a wise entity guiding the process of childbirth, which is consequently a sacred and transcendental act (Galera‐Barbero & Aguilera‐Manrique, 2022; Sjöblom et al., 2006). Reports of this kind support the idea that women do not just choose to deliver in a place other than the hospital, but strive for homebirth specifically due to intrinsic qualities of the home. However, the spiritual dimension is not necessary for homebirth to be a place of choice – simply striving for a familiar and emotionally supportive social environment is a huge factor on its own (Buitendijk, 2011). Home is an ideal place for childbirth because it offers a sense of connection, rootedness, and ownership.
Homebirthers can be considered a marginalised group even in Western countries (see Vedam et al., 2014), and this fact appears to be even more true in Czech and Slovak settings. A large survey in the nearby and both legally and culturally similar Czech Republic revealed that homebirthers are predominantly urban and well-educated women. Most of them are aware of the risks associated with homebirth and have thought of a hospital they could go to as a back-up plan (Ďurnová & Hejzlárová, 2021). They cannot legally exercise their birthing autonomy, and public discourse suggests that they are viewed unfavourably by the local medical community (see e.g. Čepelíková, 2019).
Besides possible stigma homebirthers can face from healthcare workers, there is the issue of Slovak healthcare system, which is underfunded and lags behind other Western countries (OECD, 2021). Although there is a lack of peer-reviewed studies on obstetrics in Slovakia, a book published by the Slovak civic organisations Citizen, democracy and responsibility and Women’s circles comes to similar conclusions based on interviews with Slovak women who have had personal experience with the obstetrics system. According to the authors (Sekulová et al., 2015), women are not adequately informed about the procedures conducted by medical personnel, procedures with long-term consequences for women’s health are used routinely and without their consent, their need to eat and drink are not always respected, they are verbally assaulted and humiliated, their wish to bond with the child after birth is not adequately respected, etc. All of the aforementioned complaints are contrary to the recommendations of the Technical Working Group and World Health Organization (1997).
To our best knowledge, no scientific research has been conducted with regard to social and psychological aspects of homebirths in Slovakia. Therefore, we find it worthwhile to inspect the lived experience of Slovak homebirthers as someone who has decided to go against societal norms and expectations to have such an intimate experience as childbirth on their own terms. The aim of our study was to phenomenologically examine the making of the decision, preparation, childbirth itself, and subsequent early parenthood. Previous research on this subject often focused solely on decision making and preparation phase (Andrews, 2004; Leon-Larios et al., 2019; Murray-Davis et al., 2012; Sanfelice & Shimo, 2015) or on the act of childbirth itself (Morison et al., 1998; Sjöblom et al., 2006; Skrondal et al., 2020). We decided to conjoin these aspects along with early parenting to follow the example of studies painting a more holistic picture of homebirthers’ perspective (Bernhard et al., 2014; Galera‐Barbero & Aguilera‐Manrique, 2022; McCutheon & Brown, 2012).
2 Methods
2.1 Sample and Data Collection
We interviewed eight women (aged 21–36 years) with a history of planned homebirth. A combination of convenience and snowball sampling was used to collect the data. The first set of data (four participants) was obtained in person in 2019. The emergence of the COVID-19 pandemic meant that the remaining interviews were realised via online calls the following year. For ethical reasons (i.e. to avoid re-traumatisation) and also to ensure greater homogeneity of data, we did not want to include women whose homebirth had long-term health consequences for them or their expected off-spring when recruiting participants. However, no potential respondent had to be excluded due to this requirement. The length of the interviews ranged from 55 to 130 min. Participants were informed of their right to refuse to answer any of the questions asked or to end their participation in the research at any time during the interview. They were also encouraged to reach out to the researchers and offered support if they experienced any psychological problems as a result of the interview. Even though planned homebirths are not explicitly permitted in Slovak republic, no ethical standards were breached when conducting this study since they are also not explicitly prohibited. Besides, the law no. 154/1994 of Slovak Collection of Law recognizes the possibility of childbirth outside hospital. Therefore, our respondents did not commit any criminal activity and furthermore, the interviews were realized after the childbirth had already taken place.
The interviewees were asked about the incubation period of their decision to deliver at home (i.e. what they had experienced prior to pregnancy that they felt influenced their decision), the process of decision-making and committing to that decision, the process of homebirth itself, and subsequent parenthood. In accordance with interpretative phenomenological analysis (IPA) as a qualitative research method, the interviewer used phenomenologically-laden questions (for instance, “What was your homebirth like? Can you please describe this experience to me?”). The interviews were then transcribed word-for-word. In the interview transcripts, the data was anonymised by changing the participants’ real names. Basic information about our participants can be found in Table 1.
List of interview respondents.
| Name | Age | Age at the time of homebirth | Primipara at the time of homebirth |
|---|---|---|---|
| Catherine | 36 | 30, 33a | Yes |
| Veronica | 29 | 27 | No |
| Michelle | 33 | 29 | No |
| Diana | 27 | 25 | Yes |
| Alice | 28 | 27 | Yes |
| Jane | 27 | 27 | Yes |
| Isabelle | 21 | 19 | Yes |
| Emma | 33 | 29 | No |
-
aCatherine had two homebirths as the only respondent in this study.
2.2 Data Analysis
The analysis of the interview transcripts followed the IPA framework (Smith et al., 2009). Each interview was analysed independently by two researchers, highlighting important text passages and using analytical comments. Following the idiographic principle of IPA, the discussion between the researchers created a series of themes for each of the participants. The researchers then looked at the similarities between the participant-specific themes and drew up more abstract themes and sub-themes to summarise the findings across all cases. In the presentation of our results, we have also tried to preserve inter-individual specifics and nuances from case-by-case analysis.
3 Results
The analysis has identified 4 major themes and 9 corresponding sub-themes (see Table 2). Initial analysis led to 6 major themes and 15 subthemes, but some of them were conjoined based on semantic affinity. The following paragraphs present our findings theme by theme, describing them in more detail and illustrating them with quotes from our participants.
Themes and sub-themes emergent from the analysis.
| Themes | Subthemes |
|---|---|
| Sacred act of childbirth | Duality of artificial and natural Homebirth as a beautiful experience |
| Aspiration to be the director of your childbirth | Studying and preparing for homebirth Delivering the baby on “my own terms” – controlling the physical and social environment of childbirth Absolute control is not possible |
| Homebirth as an expression of need for intimacy | Being together as an integral part of the experience of homebirth Preference for attachment parenting |
| Struggling with one’s social circle | Being doubted and argued against by friends, relatives, and medical personnel Isolation from doubt-inducing interpersonal experiences |
3.1 Sacred Act of Childbirth
3.1.1 Duality of Artificial and Natural
The distinction between natural and artificial was very present in the language of our respondents. According to our respondents, nature is a force for good. Their perception of nature often had mystical qualities, which was evident when they referred to their impulse to give birth at home as “subconscious” or “intuitive”, implying there is something preverbal and outside the realm of rationality about their decision and the act of childbirth itself. The woman’s body knows at this primordial level how to birth a child and all she has to do is listen to it.
You just need to give yourself up to that subconscious instinct. You just know everything about it on a subconscious level. Someone calculating the date of your delivery? That’s absolute nonsense. Do not look for logic in childbirth, no, no. (Veronica, 29 years old)
Our respondents also frequently expressed the sentiment that humanity has forgotten to live in harmony with nature, which comes at a high price.
Birth is a simple, natural thing. We should not make it a ceremony. Does a mother bear go to a hospital when she’s gives birth? No, she gives birth in the woods, in her natural habitat. She bites off the umbilical cord and gets on with her life. And in what way are we different from animals? In no way, except for being more stupid. (Veronica, 29 years old)
On the other hand, professional medical treatment, perceived as unnatural, cold and uncaring, played a significant role in their decision. In the perception of our participants, homebirth was unanimously seen as “natural”, in contrast to hospital birth, which was characterised by coldness and artificiality. The duality presented here corresponds with a traditional good/evil dichotomy in religious and moral doctrines. Because nature is the force for good and childbirth is an act of nature, this gives childbirth an aura of sacredness – something to be valued, cherished, and protected. Impressions of artificiality and aversion to hospital environment either came from a personal negative experience of the first delivery in hospital for Veronica, Michelle, or Emma, or a close friend or relative had had such an experience, as was the case for Catherine and Alice. The nature of the negative experience could vary. It could involve a lack of care for mother’s needs, unempathetic communication, or unwarranted medical procedures like intravenous cannulation, administration of oxytocin (to speed up the labour), pressure on fundus or episiotomy, which can be used routinely and without the permission of the women. The consequence of this is distrust or sometimes even resentment toward obstetrical system.
The gauze through which I was allowed to drink fell out of my mouth and the nurse shouted at me whether I made such a mess at home. I was just like ‘what the hell‘. Why do people who can’t act human do this job? (Michelle, 33 years old)
You know, [you’re not allowed] spontaneous expressions in the hospital, like when you wanna make sounds, they say ‘stop screaming, hysterical woman!‘ and stuff like that. So, you suppress yourself and you don’t … you don’t wanna cause them any trouble. And they wouldn’t even allow me to drink. (Emma, 33 years old)
Unlike Michelle and Veronica, Alice did not have her own experience of labour in hospital, but her sister did. Alice believed that her sister’s childbirth had not been handled well by the medical personnel and also spoke about her sister’s postpartum depression, which she attributed to the hormone treatment she had been given to induce labour. The intensity of respondents’ negative attitude towards hospitals varied and they were not a priori opposed to hospital births, but rather to specific procedures or attitudes of medical personnel. Jane specifically mentioned that a positive attitude towards homebirth, rather than a general fear of hospitals should be the primary motivation for a woman to give birth at home.
3.1.2 Homebirth as a Beautiful Experience
Since nature was presented as a positive spiritual force, childbirth has quasi-religious qualities and consequently, the hospital environment is inappropriate for the sacredness of this act. This perception underlines the notion of childbirth as something that lies outside the realm of cold rationality and thus belongs to a kind of higher dimension described as sacred, mystical, otherworldly, or sublime.
I did not even think about giving birth at the hospital. Hospitals always seemed so unpleasant and so … I don’t want to drag spirituality into this, but childbirth seems like such a sacred moment to me. It’s so sacred and beautiful … and I don’t think that a place like a hospital is suited for this. (Isabelle, 21 years old)
While for some of our respondents the core of their experience with homebirth was safety and intimacy, for others, like Alice and Isabelle, who reported being “shocked” or “caught off balance” by the experience, the transcendental aspect was in the forefront. They were emotionally overwhelmed and out of control, but in a way they remember fondly. Isabelle attributed this sensation of being overwhelmed to the fulfilment of the woman’s “higher purpose”, which seems to be related to the perceived sacredness and spirituality of homebirth mentioned earlier.
You know what, it was essentially a shock for me. I remember all of it. I remember it as scenes from a different dimension, because it was totally … there’s just nothing you can compare it to. It went as I hoped it would, but it was somehow different from anything I’ve ever experienced. The pain was horrible (laughter), truly awful. But the baby … my little one was so calm. So beautiful. (Alice, 28 years old)
Him [the baby boy] coming to this world. I couldn’t even conceive it. It gave me so much joy that I was able to smile despite to pain. She [the midwife] said she’d never seen a woman laugh when she’s in so much pain. (Isabelle, 21 years old)
However, the transcendence of homebirth was not echoed by everyone. For Veronica, Jane and Emma, the homebirth was beautiful in its ordinary simplicity and comfort. Rather than a vast and all-encompassing experience of transition to motherhood, their description was more akin to a rural idyll. While they also often used words such as “natural” or “nature’s wisdom”, giving the childbirth the same spiritual background as the other respondents, the beauty laid out by them was of a different kind.
Homebirth for me means … well, for me, it was an ordinary day. People might expect from all those videos [on the internet] something grandiose, something extraordinary, right? You decorate the room, candles everywhere and who knows what else. But it was all simple for me, it was about the comfort of my home. I could be dressed however I liked, make whatever sounds I feel like. (Emma, 33 years old)
3.2 Aspiration to Be the Director of Your childbirth
3.2.1 Studying and Preparing for Homebirth
The need for control over one’s own delivery was also one of the central driving forces in the decision to deliver at home, but the flip side of this coin is a lot of preparation and studying, as our respondents claim. Because responsibility was not passed onto medical personnel, but taken on by themselves, it was necessary to actively think about different scenarios. Although homebirth was surrounded by an aura of spiritual mysticism, idyll and sacredness in the eyes of our respondents, some of them also maintained a sceptical position. It did not automatically reject the mystical position, but rather coexisted with it. For instance, Emma voiced her opinion that the decision for homebirth should not be made impulsively or purely out of fear of medical personnel.
Not many women opt for homebirth when the pregnancy is somehow complicated, it’s not typically an impulsive choice. Mostly, women do their research … and think extensively, because you’re taking the responsibility and they wanna know both pros and cons. You have to take all possibilities into account, you need to think of more than just one scenario. (Emma, 33 years old)
Given my interest in the topic, I had been in an online homebirthers’ group two years before (I found out about my pregnancy) and I had come across stories of these women, and these stories were inspiring, because quite often there were also stories where it was not all sunshine and rainbows. (Emma, 33 years old)
From the sceptical position, respondents assessed the risks associated with homebirth, included the course of their pregnancy as a factor in their decision making, and emphasised the importance of having a Plan B (i.e. being prepared for transfer to a hospital in case of medical complications).
My pregnancy being unproblematic was a big factor. I’m really grateful for that, because if it were risky, I would probably choose the hospital where you are in the care of doctors. (Jane, 27 years old)
3.2.3 Delivering the Baby on “My Own Terms” – Controlling the Physical and Social Environment of Childbirth
Once homebirthers had assurances that alleviated their anxieties, they could think about how they wanted to arrange both their physical and social environment. Attributes of the physical environment such as light and music were mentioned, but respondents talked about the social environment much more extensively. This could include the closest relatives (see next theme), but the choice of midwife was also mentioned with great emphasis when the issue of control over the environment was raised. Midwife was not only the person who assisted the labour, but was involved in planning of its scenario as well. Each of our respondents placed some value on their choice of midwife, but the greatest value was probably placed by Diana, who made it her secret mission to befriend her midwife before the birth. All the effort so that the person attending to her labour was a source of warmth and trust, rather than a foreign element disrupting her comfort.
I had this all thought out. My secret mission (laughter). It was weird at times, building friendship with her [the midwife], it was even unpleasant at times to intrude onto her life, but it was worth it. … Her presence during my labour was not uncomfortable, so mission accomplished (laughter). (Diana, 27 years old)
Having built trust with her midwife, she was confident that there was someone who would respect her plan, her needs and her wishes. Diana also continued to criticise the lack of predictability of hospital childbirth (“it depends on the doctor who is on duty right then”) and on the other hand expressed satisfaction with the possibility of coming up with one’s own script for home childbirth, which made her feel more at peace. In her own words, “even an actor is lost without a script”, which was a fitting analogy to explicate her need for structure. Similar attitude was expressed by Emma, who also highlighted the comfort that comes with having control over the environment and flow of the birth:
Everything was adjusted to me, my tempo, the baby’s tempo … and not the other way around, not me adjusting to changes, to personnel, the hospital. I had my intimate atmosphere, my comfort. (Emma, 33 years old)
3.2.3 Absolute Control is Not Possible
Even though it was very important for our respondents to be in control and to have a plan, it was not possible to have absolute control. As they reflected, body movements and sensations during labour cannot be predicted or scripted. If they were primipara and thus had no reference point for their own previous experiences, they could not even imagine it before it happened. This was experienced as being out of control, but at the same time was connected to the transcendence of the experience mentioned in the previous theme. Also, not everything went according to their script, at least not for all of them. Catherine had two homebirths, but after the first one, she started bleeding and an ambulance had to be called. However, being “scolded like a dog” for her decision by the ambulance and hospital personnel did not discourage her from having a second homebirth. On the contrary, it confirmed her in the decision she had made in the first place. Other respondents did not report any medical complications during or after their homebirth.
Before my first labour, I had been totally convinced ‘it’s gonna happen like this and this’, and then before my second one, I just told myself delivering well and in good health is all that matters. I accepted that the process cannot be influenced solely by my plans and decisions. (Catherine, 36 years old)
3.3 Homebirth as an Expression of the Need for Intimacy
3.3.1 Being Together as an Integral Part of the Experience of Homebirth
For all our respondents, the moments immediately after the birth were of great importance. And for some of them, they were even more important than the process of birth itself. Moments of belonging, intimacy and mutual presence, as they described it. For Alice, Jane, Emma and Diana, it was mainly about establishing the dyadic connection with the newborn, while for others the need for intimacy included their partner and their remaining offspring.
When we were lying together, all four of us, I was breastfeeding our baby girl, our son was stroking her head … that was the most beautiful thing I’ve ever experienced. I was immensely happy. So yes, you can bring a child into this world and be happy in that moment, not five days later when you come home from the hospital. (Michelle, 33 years old)
Hospital birth as a point of reference was pervasively present throughout all themes, including this one. For instance, Diana doubted that she could experience this much intimacy in a hospital setting, where the mother has to adapt to the demands of medical personnel and accept that she is not allowed to be with the baby whenever she likes.
I fell in love with her immediately, infinitely. I had no idea you could love someone so much, the intensity of it took me by surprise. I doubt I could experience such a thing in a hospital environment. It would taint it. … The intimacy and silence of her birth, nothing stressed me out. I could focus on her and savour those moments. (Diana, 27 years old)
3.3.2 Preference for Attachment Parenting
Respondents also continued to explain how their decision to be close to their newborn in the first minutes of its life outside the womb was related to their general philosophy of motherhood. Most of them referred to it as “attachment parenting”, but even if they did not have a name for it, the philosophy focused on the emotional and physical presence of the mother with the child. Therefore, homebirth was typically not an isolated choice, but one that resulted from their deeply rooted attitude towards parenthood.
It’s not like you come up with the way you wanna raise your child after you deliver at home. The decision for homebirth is tied to your philosophy of upbringing. (Veronica, 29 years old)
3.4 Struggling with One’s Social Circle
3.4.1 Being Doubted and Argued Against by Friends, Relatives, and Medical Personnel
The decision to give birth to their child at home was often met with signs of disapproval by our respondents, because it is considered as something out of the ordinary, if not borderline criminal, in the Slovak cultural setting. A woman who makes this choice can be seen as a “hippie” or a “New Age enthusiast”, or as childish and naive, because delivery is something that is supposed to be painful and stressful. Our respondents felt that this notion of labour as something to struggle through rather than enjoy and be elevated by was being imposed (although only through words, not direct action), leading them to feel doubted, unvalidated, and unsupported.
Everybody thinks that because I’ve laboured at home, I must have dreadlocks, smoke weed and walk barefoot outside. … Surely I must grow vegetables and not shave my legs, because I’m a homebirther (laughter). (Catherine, 36 years old)
People would be asking questions like what if something goes wrong … you know, the people who see nothing but fear and stress when they think of childbirth. Like, you gotta go through that, that’s the way it is, everyone was brought into this world like this. (Alice, 28 years old)
Due to doubtful and disapproving reactions, and lack of validation from their own social circle, some of the respondents felt the need to communicate their story and their experience of homebirth to us, the researchers, as a means of satisfying their need for an empathetic listener and sending a message to the outside world.
This whole thing is educational (i.e. the respondent’s testimony), so that people can see how messed up our obstetric system is. Everyone who is in any way connected to the pregnant woman. Husband, parents, in-laws, but first of all, she has to see it. Women need to see that they have the right to get what they want, that the way things are working is wrong. I hope that many women will read what you’re working on. (Catherine, 36 years old)
I would like people, but especially men, to hear of this work, because … I mean, it didn’t work out with my partner, but some other men perhaps. I want to share this story, not only with you. And I’m grateful for this opportunity. (Alice, 28 years old)
Alice expressed her need to specifically address men with her message, which was related to her experiences with her own (ex)partner. At the time, he showed no interest in her pregnancy and future parenthood, which was “heart-breaking” for her. Shortly after the childbirth, he left her and their daughter, and pursued a relationship with someone else. She did not seek or find another relationship with a man.
He was like ‘whatever’, like men are when they don’t care. He just … he didn’t even know … he didn’t even want to do his research on it, sit down and talk it through, like partners should do. I think a man’s respect … his support for the woman matters, because he cares about her and doesn’t want her to feel hurt. (Alice, 28 years old)
For Diana, the lack of support from her partner was also an important issue. In her case, however, this conflict had a satisfactory resolution. She had initially felt his lack of support as “humiliating” and interpreted it as him not being interested in her needs, but when she realised that her partner had thought of hospitals they could go to if medical complications arose, and also consulted a doctor friend about her pregnancy and childbirth, her perspective changed. She saw her partner as someone who did not agree with her decision but respected it, and cared for her and their offspring. In retrospect, she saw her anger towards him as unjustified and also reflected that her pain from his lack of support was rooted in long-held resentment towards her original family, which was only exacerbated by her decision to deliver the baby at home.
That distrust of his. He was afraid of homebirth, had catastrophic scenarios in his head. It made me uncomfortable, I woke up in the middle of the night in sweat during my pregnancy. I had terrible dreams, that he was screaming at me after the homebirth, that I was crazy and stuff like that (laughter). (Diana, 27 years old)
I have to say though, I was very dramatic (laughter) because I regretted expecting a baby with him at that time because of his doubts. It further undermined my trust [in other people] because even my own family never trusted me. Just like when I was a child, I rebelled against my parents and wanted to show them I could do this. And I did, I gave birth at home. (Diana, 27 years old)
Diana further explained how her resentment towards her parents became less intense after she had forgiven her husband. She acknowledged his right to be worried and to have a say in the matter of childbirth. Disagreements with her original family about this decision were also mentioned by Isabelle, with emphasis on her mother as the most important woman in her life:
The one thing that caused doubts in me was when my close ones did not take my side. I mean my parents, when they didn’t tell me, ‘yes, we believe in you if you think this is the right choice’. They did not support me. My father maybe a bit, but mum didn’t. And in this particular situation, when you’re about to do something your mother once went through, as did your granny, … it’s a woman’s thing. So, it was supposed to be my mum who would stand by me in this matter. (Isabelle, 21 years old)
3.4.2 Isolation from Doubt-Inducing Interpersonal Experiences
Disapproval and doubt expressed in one’s social circle, whether they were actually experienced or anticipated, led our respondents to pre-emptively isolate themselves from such experiences by not telling anyone about their decision, avoiding the topic, mentally distancing themselves from negatively perceived comments or seeking support elsewhere. Despite these efforts not to let the critical and disapproving outlooks get to them, it was difficult to find reassurance and comfort as these comments were coming from the most significant others.
We only told the people who supported us. I did not feel the need to share it with a wider circle, which was also based on the experiences of other women I’ve come across. Even family members and many others who find out will give unsolicited advice and opinions, and cast their fears upon us. I had no need for any of that. (Emma, 33 years old)
Catherine was also one of those who decided to share her decision to give birth at home for the second time only with people she was confident would support it. She also mentions having a support group of homebirthers, which was mentioned not only by her but also by several other respondents. These communities, which were mostly online, offered a safe retreat and affirmation that was lacking in their social environment. The importance of the support group for Catherine was highlighted by the fact that she informed them of the onset of labour and she felt encouraged by their support during the birth itself.
When I was expecting my second [child], I only told those who were convinced [it is the right decision], so that I would only have positive thoughts and everything would go well. And so it did. … When I went into labour, I informed the girls from the support group. They lit a candle for me and I even had a childbirth song, so I really felt what used to be very important for women, which was the community of other women supporting you. (Catherine, 36 years old)
Another way of dealing with uncertainty caused by disapproval and social stigma, which is more intrapersonal rather than interpersonal in character and is alluded to by Catherine in the aforementioned quote, is to believe in the power of a positive outlook on homebirth, not affected by thoughts of negative scenarios. This sort of magical thinking, which likely helped our respondents to cope emotionally with uncertainty and lack of control, is also clearly expressed by Jane in the following quote. It illustrates not only the nature of this coping mechanism, but also the fact that she found herself going back and forth, once focusing on positive outcomes only for fear of negative scenarios to come back later. Therefore, the effect of this strategy could only be temporary.
When I was thinking about it [the impending childbirth], I tried to imagine things in a positive light. I also tell myself to think positively, because that attracts positive stuff. So that means avoiding (thinking about) any kind of negative scenarios. Because I’m quite an expert at that, if I don’t check myself, I can instantly think of the worst possible thing. (Jane, 27 years old)
A more permanent change in experience often came once the baby was delivered. If the homebirth was successful and there were no medical complications (which was the case in all but Catherine’s first homebirth), there could be a change in the women’s feelings – belittlement was replaced by empowerment and affirmation. This was particularly mentioned by respondents who described their homebirth as a transcendental experience.
4 Discussion
Phenomenological analysis of the interviews with eight Slovak homebirthers revealed four major themes of their lived experience – the perceived sacredness of the act of childbirth, strong desire for autonomy and control in this act, atmosphere of connection and togertheness, and the struggle against disapproval and judgement of other people.
Sanctification is an act that elevates an object, idea or practise from the realm of the ordinary into the world of the extra-ordinary and although typically associated with religion, it also occurs in non-theistic contexts (Pargament & Mahoney, 2005). Haidt and Graham (2009) emphasised that the integral aspect of sacredness is purity, which means that what has the status of sacred must not be subject to pragmatic thinking and compromise, otherwise it becomes tainted. Defilement of the act of childbirth by the hospital setting was explicitly mentioned by one of our respondents, but was implicitly hinted at by others. Hospital childbirth was perceived by our respondents as tainted because of its artificiality, technicality, coldness and one-size-fits-all approach. On the opposite side, the actual process of labour during homebirth was experienced as transcendental (“being in awe”, “otherworldly”, “sublime”, etc.). According to Bonner and Friedman (2011), such experiences are characterised by profoundness (i.e. significant and moving), connectedness (being part of something larger) and existential awareness (simply being present as opposed to doing). All of these characteristics were present in our respondents’ description of the experience.
Perceiving childbirth as a sacred act is not a very common finding in qualitative studies examining reasons for and experience of homebirth, although few studies do report it (Burns, 2015; Galera‐Barbero & Aguilera‐Manrique, 2022; Sjöblom et al., 2006). While for some women that participated in our study the sacredness had clear spiritual connotations (e.g. higher forces or energies), for others, the core aspect of it was love and connection with one’s family. This is similar to how women in study by Galera-Barbero and Aguilera-Manrique (2022) frame homebirth as a transcendental experience – a moment of intimacy with the partner and their children. However, our respondents did not just reminiscence about their homebirth with a kind of appreciative wonder, but in a few cases, also with puzzled apprehension, which both constitute a sense of awe according to Schneider (2017). They referred to this experience as being “caught off balance” or “shocked”, especially by one’s own bodily sensations during labour. In retrospect, they interpreted these sensations as nature at work. “Nature” or “women’s higher purpose” were also mentioned a kind of deities behind the sanctity of childbirth. In the study by Sjöblom et al. (2006), homebirthers often referred to “natural forces” present in women’s body which the woman needs to attune to. This corresponds with the idealisation of nature as a force for good, which could reach the point of naïve optimism in some cases (e.g. the belief that a woman’s body has all of needed intuitive knowledge for successful childbirth). The concept of natural childbirth is a subject of critique not just from biomedical (see Dietz & Exton, 2016), but also from feminist perspective, because it is intrinsically saturated by gender essentialism – something that appeals to “good mother” image and paints women as caring, connected to nature, intuitive, and emotional (see Brubaker & Dillaway, 2009; Malacrida & Boulton, 2012). Essentialist beliefs, which were expressed by our respondents, can serve to strengthen one’s sense of identity, which is psychological mechanism of dealing with perceived threats (Ryazanov & Christenfeld, 2018). Since homebirthers in Slovakia often have to face disapproval, stigma, and uncertainty, this could have helped them to deal with challenges such as these. Their declarations of empowerment and assurance in their femininity after successful homebirth support this understanding.
While the idealisation of nature was a powerful element in homebirthers’ narratives, the contempt expressed toward obstetrical system was on the opposite pole. It is likely that the view of hospital births held by our respondents is not influenced solely by their spiritual tendencies, but is also a product of this system. The emphasis on criticism of the obstetric system and medical personnel is quite unique among studies on this subject, with the exception of work by Sanfelice and Shimo (2015) who collected data in Brasil where healthcare and obstetrics are also far from ideal state. Some of our respondents alluded to the quality of the medical system compared to more economically developed countries, even outright saying that some obstetric procedures used by Slovak medical personnel, such as routine episiotomy, are outdated and not performed in these countries.
The power structure and inflexibility of the Slovak obstetric system leads to the suppression of women’s need for autonomy, one of the basic psychological needs according to the self-determination theory (Ryan & Deci, 2008). Turning away from this system and taking control of one’s own childbirth is therefore not entirely unexpected, which was another major theme of our analysis. Emergence of this theme is however not exclusive to this study – on the contrary it is the most prevalent finding in previous studies on homebirthers’ motivation and experience (see Galera‐Barbero & Aguilera‐Manrique, 2022; Leon-Larios et al., 2019; Morison et al., 1998; Murray-Davis et al., 2012; Sjöblom et al., 2006). We have replicated the finding of preference toward natural childbirth without pharmacological or other medical interventions, but the cited studies also mention homebirthers’ position of wanting to have a choice over which interventions are used (meaning interventions were not dismissed per se). This can be attributed to the fact that the other studies were conducted in countries where homebirths are legally permitted, which means they are attended to by midwife with compulsory medical equipment. In Slovakia, this is not a possibility. Not only through choice that goes against societal norms and obstetric system, but also through desire to master and control their body did the homebirthers assume their individual agency.
In accordance with the need for autonomy, arranging physical environment to one’s liking was of unquestionable importance (i.e. creating intimate atmosphere with lightning and music), but having control over social environment was even more vital, which is closely related to the next major theme. To have the opportunity to bond with the newborn without forced interruptions, or just to be surrounded by people with whom one is close and comfortable, were manifestations of a need for intimacy, or in the language of basic psychological needs theory, a need for relatedness (Ryan & Deci, 2008). Respondents emphasised the importance of immediate skin-to-skin contact with their newborn and the general atmosphere of intimacy, which they felt was not possible in a maternity clinic. The preference for the intimacy of the moment could co-exist with the perceived sacredness of the act mentioned earlier, but there was also a group of women in our sample for whom childbirth was “beautiful in its simplicity”, with no mention of the vastness and otherworldliness of the experience. For multiparous women in our sample, intimate atmosphere also involved their other children, which is not unusual preference (Sjöblom et al., 2006). Wanting to give birth in intimate atmosphere, early bonding with the baby or having a good relationship with the midwife are common findings in empirical literature on homebirthers (Bernhard et al., 2014; Jouhki, 2012; Leon-Larios et al., 2019; McCutheon & Brown, 2012; Skrondal et al., 2020).
In the decision-making and preparation phase, women had to endure struggles in their social circles and with medical personnel caused by their inclination towards homebirth. They were stigmatised (a form of social exclusion) and disapproved of, thus their interpersonal needs for inclusion and affection were frustrated (Schutz, 1966), so they had to find a way to cope. Homebirthers feeling unsupported, disapproved or disrespected, whether it comes from significant others, healthcare workers, or broader social circle, is not unique to Slovak settings (for instance, see Bernhard et al., 2014; Leon-Larios et al., 2019; McCutheon & Brown, 2012). Similarly to what Bommarito (2018) and Galera-Barbero and Aguilera-Manrique (2022) found in their studies, women we have interviewed tended to share birth plans exclusively with those with accepting attitudes and avoided dismissive attitudes. Disapproval from the closest to them, such as their partner or mother, was perceived as particularly hurtful, but doubts expressed by others could also cause anxiety about risks of homebirth. To cope with the anxiety, our respondents tended to create a sort of bubble, in which only positive thoughts were allowed, in accordance with the saying “What you don’t know can’t hurt you”. The coping mechanism described above corresponds with repressive coping which is defined by downplaying problems and misfortunes and maintaining artificially positive view. It consists of two more specific mechanisms: attentional deployment from negative stimuli and positive cognitive reframing (Koole, 2009). Positive cognitive frames used by homebirthers took the form of affirmations which were often rooted in naturalistic spiritualism we have described in greater detail when discussing the theme of sanctity of childbirth (e.g. “the nature knows best, I just need to trust it”). However, unlike successful repressive copers, most women still had their doubts and swayed back and forth between confidence and doubts. Because they were not completely isolated from reality with uncertainty and risk, they also implemented strategies to manage risk which are similar to homebirthers’ strategies in study by McCutheon and Brown (2012) – having a plan B (i.e. transfer to a hospital), preparation (e.g. breathing techniques), and having a script which they talked through with their doulas. Most of them attended regular check-ups with their gynaecologist and also claimed they would not choose homebirth if their pregnancy was problematic, but we acknowledge that the degree of naivety/scepticism in deciding to have a homebirth might vary among individual women.
Along with contribution, our study also has its limitations. We are aware that the women we interviewed represent only a very small sample of homebirthers and half of them were interviewed online, which could have impacted quality of the data. In addition, results may provide distorted picture of homebirthers due to self-selection bias and possible retrospective optimism of the respondents to avoid cognitive dissonance. Not including women with negative experience with their homebirth is an additional source of bias that contributes to the overly romantic picture of homebirths. One respondent with history of two planned homebirths had to be transferred to a hospital during her first homebirth, but in the end, this did not end with any long-term health consequences for her or the child. It can also be argued that our study lacks the representation of father’s perspective about which a couple of studies have been conducted separately (Jouhki et al., 2015; Lindgren & Erlandsson, 2011), but it could also emerge as theme in discussions with female respondents (Galera‐Barbero & Aguilera‐Manrique, 2022). We wanted to remain focused on mothers while also giving them the space to talk about their partners, which they mostly did. Partners were either present as a vital part of intimate atmosphere or as an obstructive element if they expressed disapproval of homebirth. For further research on this topic, we believe a longitudinal approach would be beneficial to assess changes in women’s phenomenology from the first days of pregnancy to early parenthood.
5 Conclusions
In our study, we gave voice to women whose childbirth preferences are not reflected in the law. Homebirth as a spiritual choice, an expression of autonomy and intimacy, and a bearer of social stigma was already to some degree demonstrated in previous studies. However, the qualitative analysis of our data has revealed an unusual importance and further elaborated the theme of spirituality/transcendence. The specifics of Slovak obstetrics – homebirths not being allowed, but also not forbidden – could play a huge part in this, because unregulated homebirths mean that standards regarding equipment and healthcare provider qualifications are unlikely to be met. Therefore, homebirth in Slovakia is not a suitable option for those women who just wish minimal intervention. Consequently, all respondents wished for natural childbirth and most of them mentioned some form of spiritual naturalism as a basis for this wish. However, self-selection bias when recruiting respondents could also play a role in this. Besides putting spiritualism/transcendence at the forefront, the emphasis on intimacy, or a sense of togertherness and connectedness, is also noticeable.
We believe that our findings not only present a picture of lived experiences of Slovak homebirthers, but also point to areas of the Slovak healthcare system and obstetric care that can be improved for the benefit of all women, including those who do not consider homebirth as an option. It was not our aim to glorify homebirths, although under certain circumstances and regulations (such as the need for a certified midwife to be present) they can be a viable option for pregnant women. For those who choose traditional birth in a maternity clinic, their basic psychological needs for autonomy, positive affection and social inclusion should be held in higher regard. Women could be granted greater autonomy in choosing who is present in the delivery room, especially in the absence of complications. Compassionate communication that respects women’s rights and needs and does not make intrusive interventions without their consent should be required of medical personnel. We hope that the results of our study will make a positive contribution to the discourse and conditions of childbirths in Slovakia and Czechia.
Funding source: Vedecká Grantová Agentúra MŠVVaŠ SR a SAV
Award Identifier / Grant number: 2/0083/22
Acknowledgments
We thank all our respondents for taking part in this study and we thank Mgr. Janka Horehájová for transcripting the interviews.
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Research funding: This research was supported by grant agency VEGA, project no. 2/0083/22, Strategies, resources and consequences of emotion regulation in the provision of health care.
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