The moral dangers of home birth: parents ... - Wiley Online Library

Sociology of Health & Illness Vol. 22 No. 6 2000 ISSN 0141±9889, pp. 792±814

The moral dangers of home birth: parents' perceptions of risks in home birth in Finland Kirsi Viisainen Department of Public Health, University of Helsinki, and STAKES, National Research and Development Centre for Welfare and Health

Abstract

This study explored Finnish home-birth parents' perceptions of risks in home birth through interviews. It was found that the parents considered three types of risks in their decision-making: medical risks of pregnancy and birth, iatrogenic risks of medical practice and moral risks of going against medical authoritative knowledge. While the parents' choice was guided by their image of the hospital as an iatrogenic environment for birth, they did not refuse prenatal examinations but, rather, negotiated the extent of their use to ensure the medical safety of their homebirth plan. Yet, they often concealed the plan from prenatal care staff in order not to be confronted with being labelled as a `risk parent'. It is argued that the authoritative medical definition of childbirth as risky and as requiring hospitalisation contains a moral subtext which defines home birth as risky behaviour, for which the parents can be blamed and stigmatised.

Keywords: Risk perception, home birth, Finland.

Introduction Risk is a pervasive concept in the medical organisation of perinatal care (Perkins 1994). It is the core concept around which medical services for pregnancy and birth are organised: in prenatal care the ultimate aim of medical screening tests is to be able to identify which women are in need of the assistance of higher-level medical technology during pregnancy and birth (Backett et al. 1984). The dilemma of medical risk discourse around birth is between the inaccuracy of risk classifications and the sense of security that surrounds medical technologies. Despite sophisticated screening technologies there are always complications which cannot be predicted (Baruffi et al. 1984, Alexander and Keirse 1989). Because of the possibility of mishaps, even in births classified as low-risk, it is argued that all births # Blackwell Publishers Ltd/Editorial Board 2000. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.

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need continuous hospital surveillance. This understanding of childbirth as inherently risky and unpredictable is the main premise of the medical view that all births should occur in hospitals. Also, women giving birth in hospital generally understand technology as being there to ensure that nothing can go wrong. How then do women who choose not to go to hospital for birth understand the risks in childbirth? The choice of home as a place of birth has been studied in the framework of alternative birth movements in which home birth has materialised as an extension of women's criticism of the standard medical birth care in hospitals (Shearer 1989, Mathews and Zadak 1991, O'Connor 1993, Chamberlain et al. 1991). In some countries, the alternative birth movements have been supported by a midwives' movement for an acknowledged independent position in the system (Kitzinger 1988, Burtch 1994, Bourgeault and Fynes 1997). The alternative models of childbirth have been described as differing from the medical model of childbirth in many aspects, e.g. in relation to use of technology, preferred location of care, locus of control in the birth process and the understanding of the locus of risks (Oakley 1979, Rothman 1982, Davis-Floyd 1992, Wagner 1994). While in the medical discourse the pregnant body is the locus of risk, in the alternative discourse the risk is situated in the medical interventions rather than in the pregnancy and birth process itself. Any intervention, either technological or psychological, which may intervene in or divert the normal process of birth, is considered to be a source of iatrogenic effects (Oakley and Houd 1990, Davis-Floyd 1994). Consequently, according to the medical model, physicians seek to control the inherently risky pregnant body, while in the alternative models women seek to control the risks of the hospital environment and interventions which they are subjected to in that location. It has been argued that this dichotomy in understanding the prime locus of risk as being between medical risks (pregnancy and childbirth as a risk to the life and health of the woman or her child) and iatrogenic risks (medical intervention that causes harm to the woman's or child's health and wellbeing, or threatens their lives) in childbirth is the key to understanding women's perceptions of the risks in childbirth and their decisions about place of birth and birth assistance (McClain 1983, Annandale 1988, Howell-White 1997). Within this framework, home birth has been stated to represent the choice of the natural birth idealist who completely resigns from the medical model (Martin 1989) and for whom medical risks are not important (O'Connor 1993). While the categories of medical risk and iatrogenic risk are a useful way to conceptualise risks in childbirth, this distinction perhaps focuses too narrowly on the perceived role of medical practice, and especially obstetrics, vis-aÁ-vis the definition of risks rather than on the way both the medical view and the alternative view approach childbirth through its risks. Lane (1995) claimed that the issue in childbirth is not the question of risk or no risk, but the way in which medical discourse assigns risk to pregnant bodies, largely ignoring structural and social conditions in risk production, and thereby # Blackwell Publishers Ltd/Editorial Board 2000

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realises social control over women. The authoritative position that medical knowledge has in defining risks needs to be considered when analysing the perceived risks in birth choices. Wrede (1997) has argued that the medical view localises risks as being either inherent in the pregnancy (risk pregnancy) or a result of the behaviour or lifestyle of the pregnant women (risk mothers). This differentiation of the risk-screening gaze in pregnancy and birth care is important because of its moral implications. Technologies are used to screen for risk pregnancies and their detection is considered to be the responsibility of the professionals. The woman's responsibility is to follow medical advice. If she does not do so and continues smoking, taking drugs or other harmful behaviour she is labelled a risk mother. Being a risk mother is potentially more morally stigmatising than carrying a risk pregnancy. Risk mothers have to be advised and controlled in order to protect the foetus from harm. Women whose risks in pregnancy and birth are related to their lifestyle choices can potentially be felt to have moral responsibility for their child's wellbeing. In risky behaviour in pregnancy, the moral danger described by Douglas (1992) is doubled because of the potential harm caused to the baby. Wrede's (1997) distinction between risk pregnancies and risk mothers in medical discourse can be used to highlight the moral dimension of the risk discourse about home as a place of birth. Not only does medical discourse define birth as risky and thereby requiring hospitalisation, but it also defines choosing home birth as risky behaviour. Those who go against medical advice for hospital birth have to deal with the moral danger of labelling and stigma consequent to their ìrresponsible' behaviour. I argue here that in order to understand the complexities of the perceived risks of home birth, it is useful to contextualise both the medical understanding of risks and its transformation into local policies and practices, and the home-birth parents' understanding of risks and the effect it has on their decisions about care. The following contextualisation of the current understandings of home birth in Finland reveals that there are three categories of risk that have importance to the parents' decision-making about the place of birth: medical risks of pregnancy and birth, iatrogenic risks of medical practice and moral risks of going against authoritative knowledge about safety. Medical knowledge has an important role in two of these categories since it defines the pregnant body as inherently risky (medical risk) and defines birth outside hospital as risky behaviour (moral risk). The context The Finnish maternity care system The Finnish maternity care system is built on a network of public maternity centres for prenatal care and public hospitals for birth care. These institutions have 99.9 per cent coverage of all pregnancies and births in the country. # Blackwell Publishers Ltd/Editorial Board 2000


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In the public maternity centres prenatal care is provided by public health nurses/midwives and general practitioners, and all births are assisted by midwives in hospitals. Obstetricians are generally only involved in care for complicated pregnancies and births. Hospitals have in practice been the only choice of place of birth since 1972 when the community midwife system was abolished with the Public Health Act and it was no longer possible to get a municipally paid midwife to attend a birth at home. By that time home births had for almost a decade already counted for less than one per cent of all births. The premise behind the policy of full hospitalisation was the interpretation that `Finland can boast some of the lowest infant and maternal mortality rates in the world, precisely because so much attention is paid to safety in Finnish hospitals' (NAWH 1994: 24). Clearly, when measured against maternal and perinatal mortality rates elsewhere the Finnish maternity care system is among the best in the world. Yet, to what extent the results are solely attributable to the safety provided by hospitals is hard to establish. Finnish obstetricians are also ready to admit that the high level of health care in general, the high level of education in the population and stable social conditions have contributed significantly to the good birth outcomes (Rutanen and Ylikorkala 1998). Home births in the current system are not recommended by health authorities, and are not provided with assistance in the publicly-funded system. Statistics confirm the rarity of home births: in the Medical Birth Registry only 0.01 per cent of all births between 1990 and 1995 were planned home births, which amounts to fewer than 10 births per year at the national level (Viisainen et al. 1999). Finnish midwives are currently trained to work only in the hospital environment. Older midwives who had had experience with home births in the 1950s and 1960s have mostly retired. Most midwives work in labour care in public hospitals and are only involved in prenatal care for those women who are detected to have complications and are therefore referred to the hospital prenatal clinic for monitoring. Women who wish to have a home birth cannot easily find midwives. Hospital midwives cannot go to a woman's home as part of their job. However, a handful of them occasionally assist in home births during their free time, often without the knowledge of their employer. The fact that most home births are assisted by `volunteer' midwives is potentially very problematic. Their service is not covered by any insurance or with backup by physicians. The assistance at home is often based solely on an oral contract between the parents and the midwife, and no monetary fees are officially paid, rather the compensation is given in the form of gifts. There is also a small group of privately practising midwives, but only six of the 50 members in their association have openly announced that they are willing to assist in births at home, while others only give prenatal care1. Home birth is not illegal, but privately practising midwives have found it difficult to get adequate liability insurance coverage from private insurance companies for home births. Nor are the parents compensated by the national health insurance system for the expenses of private # Blackwell Publishers Ltd/Editorial Board 2000

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midwifery care in home birth. The national health insurance board has taken a stand that birth at home is too risky (Telakivi 2000). In the 1990s more attention has been paid to choice in the Finnish maternity care system. The choices, however, exist only within the walls of the hospital. The hospital midwives have been active in introducing alternative forms of birth care in birth institutions. A range of care options exists now for the women in many hospitals: pain relief, ranging from acupuncture, water baths and reflexology to epidural analgesia; birthing positions from standing up or on all fours or sitting on birthing stools to the traditional prone position; family rooms where the whole family can stay after the birth, etc. (KlemettilaÈ 1998). The changes toward more options for the woman have been in the interest of midwives, while obstetricians have taken a stand on specific practices mainly if they have felt that the options increase medical risks, as in the case of less frequent foetal monitoring (Ekblad 1998). However, in a recent article reviewing the state of affairs in pregnancy and birth care in Finland, two leading obstetricians expressed their concern that Finnish women are planning births as èxperience journeys' and are already forgetting that birth involves serious risks. In their view `the obstetrician must respect the wishes of the mother and father, but only as far as it can be done without risking the health of the mother or the baby. Finally, the obstetrician must be the expert who dares to set limits on `èxperience hunting'' and takes full responsibility for the birth' (Rutanen and Ylikorkala 1998). Finnish medical and midwifery discourse on home birth The subject of home birth has not been much discussed in the Finnish medical journals since the 1960s. In 1997 there was, however, a short debate in a medical journal between an obstetrician, who saw home birth as a valid choice (Miettinen 1997), and a professor of obstetrics (Erkkola 1997). The view of the professor was probably representative of the general view of obstetricians in the country when he stated that the issue of home birth is not really relevant today because Finnish women have chosen hospital birth and think it is safe, and because reorganising to allow for home birth in the system would increase both risks and costs. While the obstetricians have openly voiced their rejection of the reappearance of home births in the country, the Finnish association of midwives has not taken any stand for or against home birth. Midwives have, however, shown some interest in the issue by keeping home birth on the agenda of national birth conferences which are attended mostly by midwives. For the 1985 conference there was a plan to bring in foreign speakers to introduce home birth as an example from abroad. At that point the objection by the Finnish Perinatology Association was so strong that they threatened to withdraw from the organising committee if such issues were discussed (Valvanne 1988). In the 1991 conference, however, it was possible to devote more time to alternatives, such as home birth and Swedish ABC care. Also, the Finnish Journal of Midwifery has been reporting on international conferences on # Blackwell Publishers Ltd/Editorial Board 2000


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home birth and publishing reports on home births in other countries, but has mostly kept quiet about the situation regarding home births in Finland. Finnish popular magazines for new parents (Kaks 'plus, Vauva) have followed the same careful trend; only in the 1990s have they published feature articles about home birth as an option chosen by rare individualists. The study The interviews I invited women who had planned for a home birth in the previous three years to participate in the study through announcements in the newsletter of a nationwide women's network called Àctive Birth' and in a popular magazine directed at new parents (Vauva). Twenty-one women and 12 of their partners volunteered. Most interviews took place in the women's homes, timed between two weeks and three years after the planned home birth had taken place. In the case of three women the interviews were initiated during pregnancy, and completed by phone or by another visit after the birth. The interviews covered the following themes: the reproductive history of the woman, previous birth experiences, reasons and motivations for choosing home birth, the process of decision-making about the place of birth, perceptions of risk, choice and responsibility in care, the practical issues of organising a home birth, the birth experience and choices about child health care. The interviews took place between March 1995 and March 1996. All interviews were recorded, transcribed and coded with support of a computer-assisted text interpretation programme. The coding framework was developed from the interview schedule and recurring themes. I report here the findings that are relevant to the manner in which the women and their partners perceived the risks in home birth and what kind of strategies they used to deal with them. The couples were interviewed together so that most of the questions were directed at them collectively, and the couples could choose which one of them would answer, or they would both give their own views. While in most interviews the woman did most of the talking and the man added his views, in some cases the men participated very actively in the discussion. There were only a few questions which were directed at the man alone. In this analysis, the subjects of the study are the women and men who participated in the interviews, to whom I refer collectively as the home-birth parents. The gender of the speaker in the quotations is indicated in the text. The background of the home-birth parents The average age of the women was 30 years (range 24±38) at the time of the planned home birth. One of the women was a single mother; all others were either married or cohabiting. Four of the 21 women had higher and seven had upper-secondary education. According to occupational classification # Blackwell Publishers Ltd/Editorial Board 2000

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the women belonged mostly to the middle class (upper and lower whitecollar occupations). Five of the women were unemployed at the time of the interview. The male partners were slightly older (average age 32 years), and better educated; eight of them had a higher education degree. Three of the women and two of their partners had a health-related profession (medical doctor, nurse and midwife), and one of the women was a medical student. Altogether there were five couples in which one or both partners were in a health-related profession. For eight of the women the planned home birth was their first. Of the 13 women for whom the home birth was their second or later birth, five had previously experienced home birth, ranging from one to three per woman. Three women had experienced an unplanned out-of-hospital birth earlier. Three women gave up their home-birth plan during pregnancy and instead gave birth in the hospital (one woman's husband did not support her idea of having a home birth, one could not find a midwife and one was ambivalent about the plan for both reasons). One woman went to hospital during labour (in the first stage of labour because of prolonged labour and exhaustion) and two during the third stage, one for manual removal of the placenta, and the other for suturation of a tear and for surveillance of the infant. Of the 21 planned home births, 15 proceeded through the three stages at home. All 21 babies born were healthy. One home birth was apparently complicated by shoulder dystocia, which the attending midwife successfully managed without using instruments or episiotomy. One mother took her newborn infant to the hospital for surveillance immediately after birth because she had rhesus antibodies during the pregnancy. The child however, was found to be healthy. Categories in analysis of parents' perceptions of risks In the analysis, the concept of risk was considered to include any fear or consideration of harm or hazard that the interviewed women and men felt to be important in their decision-making about the place of birth. Those risks which the women and men themselves referred to and discussed in their narratives about the pregnancy and birth were included in the analysis. I have classified the perceived risks using the earlier introduced categories of medical, iatrogenic and moral risks. While medical and iatrogenic risks were explicit in the parents' narratives about the decision-making process, the moral risks were more implicit. They were implied when the parents discussed the consequences of a home-birth decision in a context that does not generally approve it as a valid choice. Parents' perceptions of medical risks Generally the home-birth parents were aware of the medical argument about possible hazards involved in pregnancy and birth. The women and their partners considered the possibility of complications in pregnancy and birth and assessed their effect on their decision to give birth at home. The # Blackwell Publishers Ltd/Editorial Board 2000


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parents who were health professionals, especially, were very aware of the medical risk classifications of pregnancy and wanted to screen for any indications of a complicated birth, such as a low-lying placenta, or breech or transverse position of the foetus. In this respect, the health professional parents even sought extra prenatal diagnostic tests in order to make sure that there were no problems. Jaana2, a midwife, spoke about the last weeks before her birth: It was about the 38th week of pregnancy and my belly was really big, and I started thinking whether it was too big, and how to get a referral to the hospital for an extra ultrasound. I said to the GP [at the prenatal clinic] that I wanted an extra [ultrasound] check [at the hospital] because I was going to give birth at home. He did not agree at first but then did, only because of the home birth plan. When he was thinking of a possible indication for the referral, I suggested macrosomia, because I was indeed really big (P3: 408±14)3. Jaana stressed her own role in the decision about an extra ultrasound and also her definition that everything was fine: . . . When we then saw a heart with four compartments, stomach, bladder, and all organs in place in the examination, it felt good. Certainly the baby would not die of a heart condition right at birth. It was a good visit and I had a nice doctor. (emphasis added ) (P3: 430±5). Paula, a housewife, had to decide whether to go to the hospital for an induction because her pregnancy was past the expected delivery date, or whether to wait. She used the help of medical expertise to confirm her deciusion to stay at home: Yes, the baby was very late for the dates, 18 days, and that's quite a lot. When I was two weeks over, my midwife called and said this does not look good and proposed we change to plan B [hospital birth]. I said I must have counted wrong, let's wait. I went to the hospital maternity clinic to have the heartbeat monitored, they also scopied the placenta, tested everything and said that the baby did not seem as old as the number of weeks indicated. . . . Everything was OK, so I decided to wait further (P1: 358±84). Both Paula and Jaana were aware of the risks, but wanted to use the available medical services in order to make their own decision about the place of birth. Paula's husband, a physician, made a literature search to assess the risks in his wife's case. He used the medical risk analysis to counterargue the obstetric viewpoint that all women should give birth in hospital: # Blackwell Publishers Ltd/Editorial Board 2000

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When I read the literature, it became clear that in the birth process there are very few things that can be done to decrease the risks to the child. If the baby has a heart anomaly, then it is there even if you do a caesarean. . . . Paula had had three normal vaginal births and the baby was not too big this time so there was no reason to suspect that there would be problems (P1: 1366±84). For some lay parents, also, seeking medical information and second opinions was important, although sometimes confusing. Tommi, a self-employed educator, felt that with regard to medical knowledge he had to be more active and critical about what to believe: It is important that the woman and the man are informed because today there is more and more knowledge, and contradictory knowledge coming from everywhere, and you are supposed to act right. . . . You know, like the haemoglobin levels, the understanding has changed. Before if the haemoglobin went down you were supposed to start correcting it immediately and now it's thought that it's natural that it goes down in pregnancy, and one does not need to worry so much (P22: 1194±9, 1234±43). Another father, Osmo, also stressed the importance of analysing medical risks. He had also sought medical information together with his wife (a midwife) on the risks and safety of home birth: I think there is such a responsibility in home birth that you have to carry out the risk analysis so that risks are just about zero. All risks need to be eliminated, this is not some kind of sports game, or just seeking to be different from others, you can do it only if the risk analysis is zero (P22: 989±97). An important way to minimise medical risks, for both health professional parents and lay parents, was to follow the prenatal care provided by the public health care system in order to screen for complications. The lay parents would generally, however, not seek extra medical examinations to ensure safety, yet they also were eager to participate in decision-making on the meaning of the tests. They were not willing directly to accept the advice given by health care staff. Outi, a building contractor, had been planning to have a water birth at home and had openly discussed her plan with the public health nurse and general practitioner in the prenatal care centre. The prenatal care staff had generally not opposed the plan but when she developed a salmonella infection she was advised to give up her home-birth plan. She spoke about her own evaluation of the situation in the following way: # Blackwell Publishers Ltd/Editorial Board 2000


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K: I remember I called you when you were pregnant and you said nothing might come out of this [home-birth plan] because they suspected salmonella. Outi: Well, I had one positive test and then every week after that it was negative. ... K: What did they [the prenatal care staff] say about the salmonella, why did they think it is such a great risk? Outi: Well, this doctor said that the baby might get faeces in its mouth [during birth]. But then we thought about it ourselves and because all the tests had been negative there was not really much risk. Anyway the baby would have developed antibodies in the womb so that it could not get it (P11: 121±8, 159±67). She eventually had a successful water birth at home, and the baby was healthy. Apart from antenatal risk assessment the parents also relied on the assisting midwife's opinion on whether it was safe to give birth at home. Like many of the parents in this study, Anna and Heikki had been thinking that they would change their home-birth plan only if something unusual were detected during the pregnancy or actual birth. Anna felt, however, that even medical advice could be interpreted in many ways, but both she and her husband thought the midwife should have the last word if complications arose. K: Had you thought of conditions in which you would not give birth at home? Anna: We had not thought of it that much, we thought that she would be born at home, we had decided so, and nothing would go wrong. Of course if the midwife had insisted we would have gone [to the hospital]. We just generally thought that if something went wrong in the actual birth we'd go and fast. Heikki: We live only five minutes from the hospital here. I had driven the route every day, practised and checked the fastest route and looked which door is the entrance to use (P9: 96±111). Tanja, a medical student, had also considered the distance to hospital as a safety factor in her decision: I was thinking about all these things that can happen in birth, you know like in hospital the safety time limit for a caesarean is 10 minutes from labour ward to operation theatre. I thought I live so close here that I can make it (P12: 77±82). Sonja, an artist, had had two home births and had one transfer from home to hospital during labour. She felt that assessing risks during pregnancy # Blackwell Publishers Ltd/Editorial Board 2000

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was important but that one should not stress risks and pathology in the decision: Sonja: Every time I have been pregnant I have known everything is all right. If I have had any doubts I have asked the midwife to check. I have always been prepared to go to hospital. If one feels everything is not all right or the midwife says one should [go], then one should not take unnecessary risks. But not too much of that either because then home births would end. . . . Somehow people are too afraid of illness and death and everything is pathologised. K: What in your mind then is an unnecessary risk? Sonja: That is difficult to say because I have always been healthy. It has to be decided in the situation. If I'd have asthma or heart problems or suspect that the baby would be ill yes, then I, of course, would go to hospital (P20: 358±84). The parents in this study, both lay people and health professionals, accepted the medical view that complications can happen also in apparently normal births without prior signs of danger, but did not accept the conclusion that for this reason they should give birth in hospital. They used both their individual risk screening in prenatal care and the ambiguity of medical knowledge to assure themselves that they themselves would not be at risk. When actual risks were detected, the parents would however judge the medical opinion against their own experience and intuitive knowledge in the final decision. This was especially important for those parents who had an alternative worldview also on issues other than birth. Many of them were vegetarians and felt that living simply and close to nature was important for their lives. These parents would not search the Internet for medical references on the safety of home birth but rather read alternative or natural birth literature. Books by Janet Balaskas, Frederick Leboyer and the newsletter and meetings of the Finnish Active Birth movement were important sources for their thinking about birth. Self-care and self-reliance were stressed by these parents: the woman should take care of herself during pregnancy, eat well, exercise, practice yoga and trust her intuition about the birth. Helena, a university arts student, had developed rhesus antibodies in her pregnancies and was advised to give birth in the university clinic. She, however, decided to follow the development of antibodies in her fourth pregnancy with regular testing at the municipal prenatal clinic. The antibody count was not high, so she gave birth at home, but then took the baby in for hospital surveillance after the birth: I do not want to be induced in hospital; I want a natural birth. I am tired of discussing my decisions and what I would want others to do [in my births]. I'd rather make my own decisions and maybe take more of the risks involved (P17: 101±6). # Blackwell Publishers Ltd/Editorial Board 2000


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Sirpa, who is a nurse and a homeopathic practitioner, felt she knew better than to worry along with the prenatal care staff when her baby was suspected of being small: They said the baby is too small for the dates and my belly is too small. I said that listen, I am small and I have small babies. I never accepted the fears they wanted to lay on me, I only wanted to hear whether the heartbeat was OK but they would just say, but she is on this [low-weight] curve. . . I wasn't worried, I knew the baby was fine and I was fine (P4: 1008±18). Trusting one's intuition was not limited to parents with an outright natural lifestyle. Moreover, the health professional parents were guided by their intuitive knowledge and experience when they went against the norms of the system. Marja, a physician, had had a complication in an earlier birth. She acknowledged that she was considered to belong to a risk group and should therefore give birth in hospital, but decided to have a home birth in any case and trust her own judgement: I had had this manual removal of the placenta. After that one is not supposed to give birth at home, one is not a home birth case. I then realised that [even though] I have always said that if there is a reason I'll go to hospital, but now [when there was a reason] I still felt my threshold was higher. I would just prepare myself so well that I could still stay at home (P5: 1155±63). In most of the home birth pregnancies there were no detected medical risks. Yet, the parents had to deal with the general perception that still something could go wrong. In this they trusted their intuitive knowledge which helped keep fears away. Intuition in this respect was referred to by both lay parents and health professional parents, irrespective of how keen they were to have medical screening of the pregnancy. Tanja said: Of course I thought about the risks. But first I had what they call an intuition, I had all the time this very sure feeling that everything will go right. I don't know where it came from, but even when I thought of all the possible things that could happen, you know even if the cord would get twisted and the baby would die I did not find anything frightening. Not that I would have been afraid of the unknown, or had blind faith. I just naturally felt it would go well (P12: 642±53). Parents' perceptions of iatrogenic risks The women and men discussed risks in childbirth willingly, and, because of hospital birth being the norm, they often made a comparison between home and hospital regarding risks. A decision to give birth at home was generally # Blackwell Publishers Ltd/Editorial Board 2000

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not discussed entirely in its own terms, but in relation to `Why not in hospital?' Similarly, the risks of childbirth at home were contrasted to those in hospital. Anne, who had given birth to two children at home, said: There is no such thing as a completely riskless birth, one must remember that there is always a risk and something can happen even if you are in a highly equipped place, you never know. But then I thought that there are risks in hospital that are not at home. At home you can avoid strange bacteria, and interventions that can cause hazards. . .of course you have to be more careful at home, if something starts to go wrong you have to make a quick decision whether to go to hospital or not (P2: 1827±46). The possibility of medical interventions causing problems for the birth process was regarded as a tangible risk when the parents discussed the choice of a hospital birth, whether or not they had experienced a birth in hospital. Some health professionals discussed it using more medical terms, like Paula's husband Matti when he referred to the system's ability to cover up for the hazards it causes: OK, if your epidural anaesthesia goes into the spinal space, which in the worst case can paralyse you or cause other complications, the consequences will be dealt with discretely in the system and business goes on as usual. It has actually been the person's own choice, after all alternatives have been shown, and she has agreed to take the risk of the procedure . . . but then prenatal care starts from the assumption that everyone should get an epidural. Paula: Not anymore so much, it doesn't. The crazy years were in the late '80s. Matti: . . . Also, foetal monitors ± if unnecessary interventions are done because of monitoring, and they are just done, no questions, when you have a good baby by caesarean section they say it is good because of the caesarean. It is hard to prove that the operation was unnecessary (P1: 377±409). For most of the parents in this study the discussion of risks related to interventions was closely linked to the atmosphere in which the interventions were made. The hospital atmosphere was referred to by the parents as a factor which facilitated the possibility of complications arising from any medical procedure. It was not necessarily a matter of the interventions causing physical harm to the baby or the mother, but rather a matter of the institution taking control over the birth process and over the woman's will, and making her into a patient. What the women with earlier hospital birth experience resisted was not the use of technologies as such, but the lack of possibility to participate in decision-making about them. The women described their desire to decide over the flow of the birth, to concentrate on # Blackwell Publishers Ltd/Editorial Board 2000


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the labour without being disturbed and to be able to trust in their own ability to give birth. The risk that they would not be able to do so was one the women and men in this study associated with the expectation that women will take the obedient patient role. They felt the hospital atmosphere did not support their need for control over the birth process and for privacy. Many of the women with earlier hospital births concretely felt that the staff and technology had taken over in hospital, or that they had had to fight for their voice to be heard. As Mervi, an engineer, explained about her earlier experiences in hospital: [I do not want to go to hospital because of ] what happens to me there. I am such a good person I do what they ask me to. And they will ask a lot: `Let's have an enema, let's examine, all right lady, let's stay still we'll listen to the baby's heartbeat, we'll put this strap here and this string here, and let's break the membranes.' I do not want that. I want my birth to progress in peace on its own. . . . I have to relax and concentrate; I cannot fight with them at the same time (P18: 283±301). Tanja, a medical student, felt that the hospital atmosphere would have caused her to use technology unnecessarily: You have a lot of people running around and it's so restless. I do not tolerate pain very well and I know that if I had been in hospital I would have wanted a thousand and ten shots of analgesics. No, in this [home] birth my best analgesia was my attendant. I would not have had anything like that in hospital (P12: 87±90). Lena, whose first birth at home was transferred to hospital because of exhaustion, felt that the experience of not being able to control what happened to the baby after the birth was traumatic in her hospital stay, not the physical environment as such: Lena: . . . you see, it was the way they take the baby around. I cannot even remember clearly, of course I could have opposed it, but then, I couldn't. I did not even think of it; I just felt relieved. It was also traumatic because I had thought I could do things myself and decide [over the birth process] had I given birth at home. Now it was the contrary (P13: 1015±24). Not only the hospital milieu, but the atmosphere of prenatal care centres was felt stressful by some of the mothers, especially if the staff there would not support the home-birth idea. Outi related it to the authority of health care staff, which she felt difficult to confront: K: You said earlier that going to prenatal care was stressful, why did you feel that way? # Blackwell Publishers Ltd/Editorial Board 2000

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Outi: They have such authority that I get a feeling that I can't know anything myself, and the way they always say that I should think of the baby, too (P11: 150±7). She felt that when the prenatal care staff found anything that was wrong ± as, in her case, one positive test for salmonella ± they were eager to stress even the faintest possibility of complications to a sometimes quite considerable extent: Outi: I felt like they let you understand that if you don't do what they tell you and then something happens then they go: `Didn't we tell you so'. I don't know whether they really want to frighten you but one is very sensitive to such talk when pregnant (P11: 171±4). The way to deal with suspected iatrogenic risks was obviously to stay away from hospital altogether and avoid going to prenatal care as much as possible. None of the women, however, stepped completely outside the prenatal care system because they still wanted the security given by the risk screening done there. Avoidance of hospital was an important motivation for the home-birth decision for those who had had a traumatic hospital birth experience earlier. For most parents in this study the image of the hospital as an iatrogenic environment supported their decision to stay home. The moral risk of a home-birth decision The medical and iatrogenic risks were, indeed, discussed to a great extent by the home-birth parents when they described their decision-making about home birth. Nevertheless, another level of risks was implied when the parents discussed the way they dealt with the general perception that home birth is risky. The home-birth parents' recountings of discussing their plan with their friends, relatives and health professionals were stories of being confronted with astonishment, worry and clear opposition. The parents referred to a general perception, held by others, of home birth as something dangerous or forbidden. Some of their friends or relatives even suspected home-birth parents to be breaking the law: Osmo: When I told my friends about our plan, they usually first asked: Ìs it legal?' Next they thought about the risks, you know, what if something would happen and so on (P7: 1131±7). Being aware of the general opposition to such plans the parents did not expect to get any support from the staff in prenatal clinics and in hospitals. If the staff was supportive or at least not openly against the plan the parents were generally surprised, but pleased. However, doubt and accusations of irresponsibility were more common. Paula explained how she had discussed # Blackwell Publishers Ltd/Editorial Board 2000


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her choice of place of birth with a nurse in the prenatal clinic. The nurse had tried to persuade her to go to hospital. Paula quoted her: `You're not really thinking of giving birth at home, are you? Think about how you live here in the country and how long it takes to get to the hospital, and doesn't the safety of the baby mean anything to you? What if your placenta does not come off, then what? You'll bleed to death before you are in hospital'. And then the nurse stressed terribly that the hospital has this intensive care unit right there. But to my knowledge local hospitals do not have them either, and in that case you could call irresponsible all women who give birth in a local hospital just because they are far away from university clinics. They [health staff] try to scare you. But of course home birth has its limits too. If there were any sign of complications. . . I at least would not consider home birth worth dying for (P1: 295±313). Paula did not acknowledge that the choice of home birth would inherently be more risky just because of the lack of intensive care capabilities at home. Also Anna had found that the medical staff used risk language to keep her and her partner from choosing home birth: Anna: If you ask them [hospital staff] everything is a risk [at home]. Someone said that even breech babies have been born at home, so it really is not so clear cut when to go to hospital (P9: 1106±10). Anna's partner Heikki, pointed out that there nevertheless was a limit to their engagement to have a home birth: Heikki: You have to keep rational about it. When it feels that you cannot handle it anymore, when things develop into medical things, I give up and let professionals handle it (P9: 1118±21). The parents felt that they were or would be treated differently as soon as the health staff knew about their home-birth decision. Therefore many of the parents chose not to reveal their plan at any stage. Mia and Jorma were suspicious about the way health staff would interpret findings if they knew they were planning a home birth. Jorma described their strategy about prenatal examinations: K: When you decided that your second child would be born at home you said you certainly would not tell anyone. How so? Jorma: Well, because we sensed that it was felt to be so dangerous. So when all the ultrasound screenings and doctor's exams were normal during the pregnancy Mia did not tell anything [about the plan] there. It was enough for us to know that everything was OK. We thought that if # Blackwell Publishers Ltd/Editorial Board 2000

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they had known about our home-birth plan we could not be sure they would give us honest information, they would start finding things. We have the experience with our children that if you want something alternative they [the health staff] start finding problems (P16: 361±78). In Jorma's and Mia's experience they felt they would not get honest information if they revealed their home-birth plan, they also felt felt that they could not trust the health staff because they would try to keep them under the surveillance of the system: Mia: When I visited the prenatal care nurse I did not say anything about the plan because I wanted to protect myself. She [the nurse] later admitted that she would have tried to persuade me out of it had she known (P16: 880±4). Helena and Seppo had also learned not to listen to expert opinions but to make their own decisions and keep their plans to themselves, because they did not trust the authorities, either: Helena: I did not want to tell about our plan because I simply did not trust them in this issue and did not want to hear again, no that is not possible. I was tired of fighting. Seppo: Earlier, we openly said what we wanted and expected others to say: great, we will help you. But through experiencing obstacles we learned to tack the wind. When the clinic suggested we do something we said: oh yes, and then did what we wanted. . . .Maybe this is wrong but we are tired of battling (P17: 685±707). The parents spoke about the stigma involved, mostly indirectly, although one of the women summed up in a phone conversation after the interview, às soon as you mention you have given birth at home [the hospital staff] treat you like a leper.' More often they referred to the stigma indirectly when they described the necessary characteristics of a home-birth parent by saying that one has to be strong and know what one is doing. The possibility of being blamed was seen as a factor that hindered others from making the same decision. Seppo, a teacher and father of four, explained that home birth is not an option just for anybody, one has to be ready for the consequences, and be ready to be different: People think about alternatives, but are not ready to do anything. Especially with the first child people are very unsure what to do and then it is easiest to do what everybody else does. People do not want to stand out from the rest, especially not Finns. They want to do exactly like others, so that no one can say that they are different (P17: 2208±15). # Blackwell Publishers Ltd/Editorial Board 2000


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Susan, a housewife who had moved to Finland from abroad, thought that her idea of having home birth was tolerated partly because of her foreignness: People say that it is so brave to give birth at home but in my mind it is braver to go to hospital. Many [Finnish friends] said to me `How do you dare, I would never', others said, `No, it would not be for me, I want an epidural'. All kinds of comments have come. Others think it is just a crazy foreign idea, somehow exotic (P5: 1269±80). In the parents' narratives, taking acknowledged risks was inherently connected with taking responsibility. The women and men often turned the discussion on risks into a discussion on responsibility. They wanted to disclaim the health authorities' control and responsibility over their birth process irrespective of the place. Having made a conscious decision about the place of birth they felt they could not be less responsible if they decided to give birth in hospital: Sonja: I have come to the conclusion that even in hospitals things happen, and even more such mishaps. . . but it would not be a better choice for me that I could then blame a doctor or a nurse because if the baby died that would not bring it back. It would be awful if it would happen but life is so that such things happen. . . . I think I have always been the one who is primarily responsible for my own births (P20: 1442±64). Paula: Yes, the responsibility [of birth] is ours and it should be. The hospital functions in a way that it takes away all responsibility, even from a healthy person they take away everything, even your clothes and your identity and then you have no choice (P1: 634±40). The parents also referred to their intuition as a power which helped them face the accusations, as well as fears raised by others' judgements and negative opinions about their decision. Eero, a first-time father, described his feelings: Yes, especially towards the end [of the pregnancy] a lot of people tried to raise fears in us. . . even after we had made up our minds [about home birth]. But still we had this strong inner feeling that nothing bad will happen. K: Where did that feeling come from? Eero: It somehow came. . . it is just such a feeling inside. Such a strong feeling that this is what we have to do and this is what we do (P11: 1525±36). # Blackwell Publishers Ltd/Editorial Board 2000

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Discussion As in earlier studies (McClain 1983, Howell-White 1997), the parents in this study assessed both medical and iatrogenic risks when making a decision about the place of birth. But contrary to what has been suggested in the earlier studies, knowledge and awareness of the possibility of medical risks did not avert parents from a home-birth decision. The home-birth parents in this study were not all natural birth idealists for whom medical risks were not important. On the contrary they felt that medical risk screening was important, but they did not leave the conclusions to be drawn by health care staff alone. The parents who were more familiar with medical thinking, especially health professionals, would consider and prepare for medical complications more carefully, confronting the medical risk discourse with its own ambivalent knowledge base. The parents who were more inclined to follow an alternative birth-ideology did not think of medical risks as specific tangible risks but rather trusted their intuition about what is the right thing to do. What was important for all the women was a trust in their own ability to give birth, irrespective of how carefully they screened for medical risks. Even though medical contra-indications for a home birth in some cases had been detected, the women still preferred to trust their own bodies and intuitive knowledge. Beyond the medical and iatrogenic risks the Finnish home-birth parents' narratives reflected how in their decision-making they had to consider the moral risk of going against a social and cultural norm of hospital birth. The parents felt strongly that the moral danger (Douglas 1992) of having to go against authoritative knowledge limited others from making the same decision, and it also led them to conceal the home-birth plan from health authorities and even from friends. The three identified categories of perceived risks in childbirth at home indicate the multiple meaning of risks in everyday life. For an individual who is making decisions, risks are not clear-cut numerical probabilities of danger but ambiguities with which one has to live (Gifford 1986). According to Carter (1995), the authority of risk assessors lies in their power to make the distinction between safety and danger ± this separation constitutes a boundary which defines a space in which the dangers are more controllable. Finnish obstetricians and policy-makers clearly had drawn the safety boundary line between hospital and home. In hospital the medically acknowledged uncertainties and risks of childbirth are under the control of the professionals. Parents who give birth at home deliberately cross this socially and culturally constructed boundary. In the medical discourse they are defined as a `risk group' because of their non-compliant behaviour. The language referring to home birth as risky can be seen as a social coercion technique to keep everyone in compliance with the system (Douglas 1985). The parents felt a deep mistrust of the system, seeing it as capable of deceit # Blackwell Publishers Ltd/Editorial Board 2000


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in order to acquire compliance. Lupton has called attention to the need to analyse the moral subtexts of individualised risk discourse (1993). The parents felt that in the context of the system their decision was interpreted as morally wrong, and the possibility of being blamed for the consequences had to be dealt with in the decision-making process. The home-birth parents celebrated their ability to decide for themselves and to take full responsibility. In the parents' view, crossing the boundary between hospital and home made the birth process and the perceived uncertainties involved more controllable: in their own hands. In this study the midwives were not interviewed, but it came up in the parents' stories about looking for a birth attendant that most midwives they had contacted felt that assisting in a home birth was a great risk, and they were not ready to take on the responsibility of a home birth. For the midwives the risks involved in home birth meant not only the risk of being blamed for the possible outcome4, but also the risk of being stigmatised within the profession for flaunting the medical definition of home birth as risky and unacceptable. Health professionals formulate their view of risks using not only medical knowledge but also their own experiences. It is common for health professionals to feel very strongly that they carry the ultimate responsibility over all decisions irrespective of whether the client has participated in decisionmaking or not (e.g. Rutanen and Ylikorkala 1998). It has been argued that in medical and midwifery practice the clients are increasingly seen as generators of risk for the professionals and the fear of litigation is guiding actions (Enkin 1994, Annandale 1996). While litigation by clients is rare in the Finnish maternity system5, the social control within the professional groups is strong and keeps individual midwives and obstetricians from deviating from the norm of universal hospital birth care. The fact that the health professional parents felt so strongly that they had to screen for medical risks was, perhaps, related to the felt intensity of the moral risk of a decision to go against the authoritative knowledge of one's own professional group. Such a decision has to be well grounded to be defendable in front of others. As has been pointed out by social scientists examining the social construction of risk, the concept of risk is never neutral or value free (Douglas 1985, Lupton 1993, Carter 1995, Gabe 1995, Rhodes 1997). The perception of risk depends on the particular situation in which people are, therefore they view risks from their own context. For Finnish parents who wanted to have a home birth, the medical risks were not there simply to be accepted or discarded, but to be balanced against other issues they felt as important for their decision. When the parents considered the medical risk discourse they interpreted it in the light of their previous experiences and intuitive understanding of what they needed and were able to do. They wanted to negotiate the limits of action to be taken to minimise medical risks. The women's trust in their bodies' ability to give birth had for them the status of authoritative knowledge (Jordan 1997) which gave them strength to decide against the # Blackwell Publishers Ltd/Editorial Board 2000

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advice of medical professionals. The home-birth parents could be seen as true representatives of what Giddens (1994) calls post-modern reflexive individuals: they challenged authoritative knowledge by assessing for themselves what was valid and important in medical risk discourse. They chose to use the medical practice to the extent they felt necessary to ensure the medical safety of their plan, counter arguing against the pervasive risk discourse either with the ambivalence of its own knowledge base, or by trusting their intuition. Address for correspondence: Kirsi Viisainen, STAKES, PO Box 220, 00531, Helsinki, Finland e-mail: [email protected] Notes 1 2 3 4 5

Personal communication with M. Parviainen, chairperson of the association. All names are pseudonyms. P1±P22 are transcript files, with the numbers in the parentheses referring to lines. When I have presented results of this study in seminars in Finland the risk of litigation has almost always been raised in the discussion if there are midwives in the audience. Only two malpractice trials arose from 801 obstetric patient injury claims to the National Patient Insurance Association between 1987±1995 (Kurki 1997).

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Chamberlain, M., Soderstrom, B., Kaitell, C. and Stewart, P. (1991) Consumer interest in alternatives to physician centred hospital birth in Ottawa, Midwifery, 7, 74±81. Davis-Floyd, R.E. (1992) Birth as an American Rite of Passage. Berkeley: University of California Press. Davis-Floyd, R.E. (1994) The technocratic body: American childbirth as cultural expression, Social Science and Medicine, 38, 1125±41. Douglas, M. (1985) Risk Acceptability According to Social Sciences. Cornwall: Sage. Douglas, M. (1992) Risks and Blame. Essays in Cultural Theory. London: Routledge. Ekblad, U. (1998) `RaÈaÈtaÈloÈity synnytys' ± tasapainoilua aÈidin elaÈmysten ja sikioÈn hyvinvoinnin vaÈlillaÈ, [`Tailor-made birth' ± balancing between experience of the mother and wellbeing of the foetus] (in Finnish), Duodecim, 114, 2215±19. Enkin, M.W. (1994) Risk in pregnancy: the reality, the perception and the concept, Birth, 21, 131±4. Erkkola, R. (1997) Kotisynnytykset lisaÈaÈvaÈt riskejaÈ ja kustannuksia, [Home births increase risks and costs] (in Finnish), Duodecim, 113, 2218±19. Gabe, J. (1995) Health, medicine and risk; the need for a sociological approach. In Gabe, J. (ed) Medicine, Health and Risk. Sociological Approaches. Oxford: Blackwell Publishers. Giddens, A. (1994) Life in postmodern society. In Beck, U., Giddens, A. and Lash, S. (eds) Reflexive Modernisation. Politics, Tradition and Aesthetics in the Modern Social Order. Cambridge: Polity Press. Gifford, S.M. (1986) The meaning of lumps: a case study of the ambiguities of risk. In James, C.R., Stall, R. and Gifford, S.M. (eds) Anthropology and Epidemiology: Interdisciplinary Approaches to the Study of Health and Disease. Dordrecht: D. Reidel. Howell-White, S. (1997) Choosing a birth attendant: the influence of a woman's childbirth definition, Social Science and Medicine, 45, 925±36. Jordan, B. (1997) Authoritative knowledge and its construction. In Davis-Floyd, R.E. and Sargent, C.F. (eds) Childbirth and Authoritative Knowledge. CrossCultural Perspectives. Berkeley: University of California Press. Kitzinger, S. (ed) (1988) The Midwife Challenge. London: Pandora. KlemettilaÈ, S. (1998) Suomen synnytyssairaaloissa kuunnellaan synnyttaÈjaÈn toiveita, [Parturient women are listened to in Finnish maternity hospitals.] (in Finnish), Vauva 10/98, 42±57. Kurki, T. (1997) Patient insurance in perinatal medicine in Finland. Abstract. XV Nordic Conference of Perinatal Medicine 22±24 May. Turku Finland. Lane, K. (1995) The medical model of the body as a site of risk: a case study of childbirth. In Gabe, J. (ed) Medicine, Health and Risk. Sociological Approaches. Oxford: Blackwell Publishers. Lupton, D. (1993) Risk as moral danger: the social and political functions of risk discourse in public health, International Journal of Health Services, 23, 425±35. Martin, E. (1989) The Woman in the Body. Boston: Beacon Press. Mathews, J.J. and Zadak, K. (1991) The alternative birth movement in the United States: history and current status, Women and Health, 17, 39±56. McClain, C.S. (1983) Perceived risk and choice of child birth service, Social Science and Medicine, 23, 1857±65. Miettinen, A. (1997) Synnytyspaikka on osa synnytyskulttuurin kehittymistaÈ, [Place of birth is part of birth culture development] (in Finnish), Duodecim, 113, 2217±18. # Blackwell Publishers Ltd/Editorial Board 2000

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