Why Women Birth Outside the System: How a Group of Researchers Came to the Conclusions We In Birth Advocacy Work Have Been Saying For Years

In my usual scroll through Facebook I came across a post from Midwife Thinking. For those of you who don’t know, Dr. Rachel Reed is a midwife in Australia, where maternity care is even more polarized and politicized than here in Canada. I often look at what is happening in Australia and the UK when I consider how best to advocate for birthing people and what to watch out for. For some background information, the Australian health authority hates home birth and maternity care is very much in control of the obstetrician, with the more resistant birthing people and their families having their midwives taken away or otherwise feeling they have no option but to free-birth.

sam quote

Now, I have touched on this topic before many times on what happens when our choices are limited and we feel forced into a corner. It is my life’s work to ensure that every family who wants a midwife should be able to get one, or at least know where to find the support to birth outside of the system as it stubbornly clings to the notion that only the medical professional gets to be “in charge” of birth. In reading this study, nothing changed from what I have been saying all along, or what has been echoed by numerous other birth advocates, midwives, former nurses turned advocates, doulas, and other birth worker, birth researchers, and birthing people who have an invested interest in their birth outcomes. The reality is that those of us who birth outside the system do so because we have a different perspective on birth, we value more than just having “a healthy baby” and when pushed into a corner by the maternity care system there is a growing number of us who just opt out rather than put ourselves at risk.

With my first, I had planned a homebirth but had not yet learned that I had to be strong in my convictions and be willing to “go against the rules” in order to achieve the birth I had wanted. With my second child I was already an advocate for 2 years. I had made contacts within the outlying birth community and I knew a lot more than I had as a first time mother planning a birth that was completely outside of my family’s cultural normative, with no friends who had experienced a homebirth. Truthfully, I had been a pioneer in simply choosing a midwife instead of a doctor, and for daring to dream of birth outside the hospital. Ultimately while that first home birth didn’t happen, I had still adopted many of the beliefs that are reflected as driving influences for other mothers birthing outside the system.

Here were the key points that were made in the study and my thoughts on how closely they resemble my own reasons for choosing to birth my children outside the system:



Demographic information was collected from the 20 women who were interviewed. The median age of the women when interviewed was 34. The majority of women had their first baby within the system, with only two women birthing outside the system for their first baby. Nine out of the 20 women were employed at the time of interview. The most remarkable finding from these data was the participant group’s high level of education.”

At the time of planning my first birth, I was 27 years old. I had some formal education in research, critical thinking, Psychology, Sociology, and plenty of writing classes. I didn’t know much about birth, but as an avid reader I jumped right into learning all I could the moment I found out I was pregnant. I might also add that my father went to nursing school the same year I started college and I often read over his reports. I learned a lot of terminology from that in itself, but these experiences in college taught me that I could learn anything about anything I put my mind to, even if I never pursued a formal degree in it. By the time I had my second child I was 30, and had pursued informal education through reading many books and articles, including medical journals. Therefore I would classify myself as part of this demographic that was studied, even if my education level isn’t “formally” high level. One does not need a degree to be educated, they only need to be able to read and understand what they are reading.

 It was found that all of the participants lived within a 30-min drive to a hospital that provided maternity care. It is possible, therefore, that the choice to birth outside the system was considered more reasonable given the women’s relative proximity to emergency care. Four of the twenty participants in this study were midwives; one choosing freebirth and three choosing homebirth. This adds an interesting dimension, as these women had insider knowledge of mainstream maternity services.”

This was also true for myself, as I lived approximately 5-10 minutes from the local hospital. I wasn’t a midwife, however as a birth advocate and someone very much immersed in the birth culture with midwives, doulas, and nurses frequently part of my social circle, I did also have insider knowledge by the time I birthed my second child and continue to gain knowledge from those who work in the system and are actively trying to change it.

“Demographic information collected included the proximity of the place of birth to a maternity care service. This was collected to ascertain if access to hospital services was a factor in women’s decision-making process. By collecting this data we could determine that none of the research participants chose to give birth outside the system as a result of living remotely and not having access to a maternity care facility.”

This part is interesting to me that they didn’t also look at mothers who chose to birth outside the system because they did not have access to birth in a facility, however lack of access to birth in the system does not necessarily mean that those who have no options would choose homebirth or free-birth if given an alternative, just as those of us who choose homebirth and free-birth would do so even if the hospital was next door and they promised to “allow” us our autonomy.

For those who don’t know the founder of BeBaby, Samantha offers an excellent perspective as a nurse who has a passion for physiological birth and as a strong advocate for birth rights. I met her through my work in advocacy and when I shared the study with her to get her thoughts, she responded thusly:

” In order to ´decrease’ freebirth all women would need the flexibility to birth at home with a respectful attendant. If you somehow manage to ´fix’ hospitals (and frankly lets be honest that will never happen) you would see an increase in satisfaction in those choosing hospitals already. However women who choose homebirth or freebirth also do so because they recognize that home is where your body responds best to labour, the car ride to and the process of admitting to another area disturbs it. However many woman turn to freebirth because they can’t get a midwife like is the case here in Quebec, the cost of a midwife is too much (out of system midwives aren’t covered), or they have access to them but they turn out to be ‘medwives’. Which I hear a lot about in all of North America”

I couldn’t have said it better myself!

Reasons For Birth Outside the System

The study seems to have accurately identified that those of us who birth outside the system do so because we want what is best and safest for us and our children. The mothers interviewed all confirmed that our definition of “best and safest” differs from what the system has determined is “best and safest” for birth, and that our definition is more complex than a live baby being extracted from a live mother. This is a figure taken directly from the article I am referencing:

reasons for wanting best and safest



A quote directly from the study read:

“This study found that what motivates women to birth outside the system is ‘wanting the best and safest’ for themselves and their babies. One participant who chose homebirth explained:

‘In an effort to want to make my own choices and to be in control and to feel safe, and like the decisions were truly mine and the decisions that are the best for not just you and not just your baby, not just your husband, but just the whole picture. It’s what’s best for me and this baby and my other children and my husband, it’s wanting the best and to get the best I feel like I need to be in control and for me to be in control and to be safe means I need to be at home’. (HB05).

Similarly, a woman who chose freebirth explained:

‘I want the absolute very best for all of my children, I would not ever, ever endanger them, I don’t want them harmed, I want them to have the very best outcome in terms of their physical health, mental health, emotional health, their complete and utter wellbeing and safety…so that’s where I was coming from’. (FB05).

There are three criteria by which the participants judge ‘best’ and ‘safest.’ These are: having a natural birth without intervention, having their family close and being respected as the authority throughout their care. If a birth option cannot cater to one of these criteria, it is not considered the best or the safest.”


How We Come to The Conclusion to Birth Outside the System

Furthermore, there was a basic social process that led to the mothers in the study to choose free-birth or home birth that started with “finding a better way” and ultimately taking control of their births to avoid the trauma they perceived or had already experienced in hospital birth. Put simply, the options given in the medical system did not reflect what was truly felt to be safest for the individual mothers and in order to avoid the tension around autonomy they chose to opt out of the system. This was very much my thought process going into my first birth and when I ultimately was talked into a hospital birth I made the decision that I would not allow anything to interfere with my birth process. Ultimately I found that trying to protect my birth space in the hospital was stressful and was not willing to repeat such an experience next time. This desire for a better birth (which I called my “do-over homebirth”) was so strong for me that it led to further education on birth and an insatiable hunger for all the information I could possibly get my hands on. I actively interviewed care providers and settled on the most holistic midwife practice I could find, however I also knew that even the best midwives would have limitations in what they were “allowed” to do. So as a backup plan I also prepared myself for free-birth just in case I had to go against the “rules” for home birth. It is my belief, based on what I have already seen and heard from birth workers, that those families who plan home birth and free-birth are possibly more likely to seek as much information on physiological birth as possible, and therefore that is part of why we feel safer birthing outside of the system. Knowledge is power, and the more knowledge we gain on our bodies, our babies, and the birthing process, the more we realize that birth is safest where WE feel safest. If we don’t feel safe in the medical system for fear of unnecessary interventions or pressure when we decline interventions, then it makes sense that we would opt out.

social process


“In explaining their choice to birth outside the system, the participants described making a considered decision after first exploring other birthing options. This process followed a typical path, with the women ‘discovering that there are multiple birth options’. They move on to ‘meet with a variety of care providers’ and then ‘weigh it all up.’ After making the decision to circumvent the system, the women ‘get informed about out-of-the-system birthing options,’ which for some leads to homebirth and for others ‘forces them to consider freebirth.’”


Want to know more?

The study was very long, but I took the time to read through it and put the key points in purple lettering and boldfaced other sentences. I even used a highlighter near the end. I did this because I like to be able to find information I am looking for quickly, medical journals are notoriously wordy, and there is a lot of explanations as to how they do the studies that the average person isn’t going to be as interested in as what those studies actually say. I spent 2 years in college taking psychology classes and research classes. I also took a few classes on critical thinking, how to break down an argument,  and how to weigh facts presented in those arguments. I will be the first to admit I don’t know everything, nor will I ever learn everything. No one person will ever be able to learn everything there is to know, however we can read and we can learn to think critically. Therefore, I felt that rather than merely sharing my opinion on the study, I would also include the study itself for you to read and come to your own conclusions as to whether it accurately explains why people choose birth outside the system. I do encourage you to read the original journal article at your leisure because it is very interesting in how they broke down this study and the extent to which they looked at the responses given by the participants. There are also stories included by the participants that reflect a little of what is also happening in Canadian maternity care.

You can find the original study here (for as long as they allow it to remain public): https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-02944-6

Here is the document I slightly altered to emphasize certain points: https://docs.google.com/document/d/1wvU3veVVDpLqCK3Kk6OK7HQqcFj6Gj-5xNNTangzZd0/edit?usp=sharing



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