133: The Freebirth Movement: Choice, Risk and Accountability

In this episode of The Baby Tribe, Afif speaks with Irish Times journalist Ellen Coyne about her reporting on the rise of freebirth in Ireland: giving birth without a midwife, doctor or trained medical professional present. Ellen discusses what led her to investigate the movement, the concerns raised by senior midwives, the lack of clear data around unassisted births, and how online communities can frame freebirth as empowering while failing to fully engage with the risks. After the interview, Afif and Anne debrief the issue from neonatal and obstetric perspectives. They explore why some women may feel drawn away from maternity services, including previous trauma, poor communication, lack of continuity of care and fear of intervention. They also examine the role of social media, doulas, birthkeepers and unregulated advice in shaping decisions during one of the most vulnerable times in a woman’s life. This is not a conversation about shaming women. It is about safety, autonomy, trust and accountability. Birth trauma is real. Consent matters. But real empowerment is not being left alone with risk. It is having accurate information, respectful care and skilled support available when things change. Birth is not a purity test. There is no gold medal for suffering. https://www.irishtimes.com/health/2026/06/06/free-births-in-ireland-concern-grows-for-women-choosing-births-without-medical-help/ Learn more about your ad choices. Visit megaphone.fm/adchoices

Transcript

SPEAKER_03 0:01

This show is part of the Head Stuff Podcast Network.

SPEAKER_00 0:07

Welcome to the Baby Tribe. I'm your host, Afi Felkafash, Neonatologist, Pediatrician, and Lactation Consultant, and my co-host is Anne Doherty, obstetric anesthesiologist. Today we're talking about free birth. Free birth means giving birth without a midwife, doctor, or trained medical professional present. It is often presented online as empowering, instinctive, and liberating, and I understand why language like that appeals to women, especially those who have felt dismissed, pressured, or traumatized by maternity care. But we need to hold two truths at once. Women deserve respectful, compassionate, consent-based care. They deserve to feel heard, involved, and safe. But the answer to poor care is better care, not no care. Because birth can be beautiful and straightforward, but it can also change very quickly. A baby who is not breathing needs help. A mother who is bleeding heavily needs help. And in those moments, minutes can matter. In this episode, I will be speaking with Irish Times journalist Ellen Coyne about her reporting on free birth in Ireland. And then Anne and I will debrief what this means for mothers, babies, maternity services, and the online culture that cells risk as empowerment. Birth is not a purity test. There's no gold medal for suffering. Safe birth is care that respects the mother and protects the baby. Ellen, thank you so much for joining us on the Baby Tribe. Delighted to have you here.

SPEAKER_04 1:46

Thank you so much for having me.

SPEAKER_00 1:48

So can you tell us what made you look into free birth in Ireland?

SPEAKER_04 1:52

So maybe some of your listeners might have seen a really excellent investigation that The Guardian did at the end of last year. They had a podcast series and some articles that were taking a deep dive into the international free birth movement, particularly focused in the United States, which is, I suppose, the epicentre for some of this in terms of the social media content. And they found that there were some quite troubling trends that free births had been associated with, unfortunately, the deaths of some babies in cases where the investigation suggested had that happened in a hospital or had people sought help earlier, the outcome might not have been as severe. And I remember in one of the episodes of that podcast, there is they're talking about the women all over the world that have had an interest in the free birth movement, and there's audio of a woman saying, Oh yeah, I'm I'm based in Ireland. And I remember thinking, you know, post-COVID, after everything that happened here with maternity services and the fact that some people did have some unfortunately negative experiences in the public health service, it was probably worth taking a look at was this a trend here and was it something that doctors and consultants had been aware of and concerned about?

SPEAKER_00 3:03

And when you first started looking into it, did you expect to find adverse outcomes linked to free birth or did something else initially emerge?

SPEAKER_04 3:13

Honestly, I thought maybe it might be something where people in maternity hospitals had seen this coming up as a social media trend, or maybe they had heard women asking about it or querying if they could have a free birth or an unassisted birth at home. I was conscious, I suppose, that unfortunately our home birth cover in Ireland isn't great. There's a lot of people who, just by virtue of where they live, can't qualify for one, even though, in a different scenario, in a different county, maybe they would qualify for home birth. I didn't really expect to find what we did find, which was uh documentation from the heads of midwifery at all 19 of the maternity units that was quite conclusive that there have been adverse incidents that women and babies have died in this country in cases that were associated with free birth. I had no idea that it was that severe, and I had no idea that, well, the number of free births in this country are very small. I didn't really appreciate that they were rising as much as the midwife said that they were.

SPEAKER_00 4:13

Did you get a sense of the scale of free birth in Ireland?

SPEAKER_04 4:16

No, and that's really frustrating. I suppose by virtue of what it is, like a free birth is a birth that is deliberately outside of the system, we don't have figures. So all we're relying on is anecdotal reports. And obviously, if a midwife or a concert consultant hears about a free birth, it's probably because something has gone wrong, unfortunately. So we'll I don't know, will we ever know the true scale of it? But according to this forum of midwives, which convened in late 2024 because they were so concerned about free births, while the numbers are small, they described it as a notable rise in free births. So it is something that is out there, it's not quantified, but it is a concern.

SPEAKER_00 4:58

Outside of speaking to healthcare providers, what other people did you speak with about this?

SPEAKER_04 5:03

So I was quite interested in speaking to um midwives and doctors, obviously. I also spent some time online trying to talk to women and look at some of the social media content that's kind of driving this, and I did find that sometimes that could be quite difficult. Um I don't doubt that it we'll be, you know, we'll be seeing it in terms of the response to the Irish Times article, but there's definitely a sense in the in if you want to call it the free birth community, that the media and the medical system is against them, that there is kind of like a conspiracy to uphold what they would describe as like the patriarchal medical system, and that people who believe in and promote free birth won't get a fair hearing in the media. Um, now I don't know if that is it's a fair criticism, but it just made me appreciate really how when people decide to go down this route, they really have decided to opt out of the mainstream system altogether, and it be can be quite difficult then to kind of get them back. We did also, and people will read it in the piece, uh, we did speak to the brother of Naomi James, so people might be familiar with Naomi's story. She unfortunately passed away in the summer of 2024 after giving birth to her fourth baby, a baby boy, um, at home in Drohida, and she was taken to Our Lady of Lords hospital and unfortunately passed away following a hemorrhage. Since her death, her brother, despite the fact that he's obviously grappling with a blanket of grief, has become quite a prominent um advocate against free births. He described how Naomi was somebody who, and it's obvious from her social media presence, was spending a lot of time in these on-birth online birth activism, free birth communities. She was somebody who was coming from the perspective that with her with her two previous pregnancies, a twin pregnancy and uh a singleton pregnancy, she had had her babies via cesarean section, she hadn't been happy with that, and she really wanted a vaginal birth for this delivery. And as Adam described it to me, Naomi went from the position of wanting a vaginal birth to feeling that it was kind of her right to have a vaginal birth.

SPEAKER_00 7:20

I think as a healthcare provider, we need to look at ourselves and ask the questions why are women choosing to go for a free birth? And I wonder, I mean, I have my thoughts, but I wonder, did you get a sense? I guess you alluded to some of that is that um women may have felt not heard, um, not listened to, not involved in their own birth journey, and perhaps maybe coerced um or frightened of interventions in general. Also, I guess the lack of availability for alternative safe ways to birth your child outside of the hospital setting is lacking in Ireland, and it doesn't really um do any women a proper service. Was that the sense that you got?

SPEAKER_04 8:07

I think that is the number one most important thing that I found in the story, and it's the number one most important thing I would hope other people take from the story is that obviously when you are pregnant, you are psychologically wired to want to protect your baby and choose what is best for that baby. Women are not stupid and they're not taking high-risk decisions for no reason. And I think the fact that if there is a notable increase in free births, albeit from a low statistical base, obviously we need to ask what is it about the public health service and our maternity services that are frightening women and making women feel I would rather give birth without a medical professional around at home, maybe beyond the appropriate distance to a hospital, if God forbid something goes wrong, than go into a maternity hospital. And I think that obviously people bring up a lot the rate of interventions in Ireland, the rate of C-sections, inductions. Um, a lot of women who maybe go down this route are not first-time mothers. Maybe they've had a negative experience previously in a hospital. They felt that maybe their waters were broken without somebody actually talking to them about it first, even things like exams to see how dilated a woman is, if you feel like that's something that's kind of rushed and just kind of done to you rather than you being a participant in it, it can be quite traumatizing. And I think that that is the the most important story here, that if women are actively choosing to turn away from our maternity services at a point in time when there's been so much development and investment in maternity services over the last decade, what is it that's going wrong there that's making them want to take their chances at home rather than come into a hospital?

SPEAKER_00 9:47

And I think that is, as you said, the key question. And the hospital maternity service has a lot of work to do in order to change that perspective and because there has been two recent surveys, um, one done by the HSC, one done by an independent group, both had similar themes. The biggest thing that women who expressed negative um views about hospital care was that they uh expressed the lack of continuity of care, which you can get with a home birth or midwifery led care. Um they expressed the fact that communication was an issue, coordination between antenatal GP combined care with the hospital, you know, was lacking, that if you were in the public system, you had to retell your story every time because you're talking to a new doctor, and also um, you know, feeling unheard and not involved in the decision-making process. So these are real things that we need to work on. On the flip side, however, uh and I'm really interested in what you found um during your investigation, is uh people online capitalizing on this gap in the healthcare service to entice women away from hospital care for their own benefit. So, can you tell me a little bit more about that?

SPEAKER_04 10:59

Yeah, and I think that's really interesting because it's kind of like I don't want to use a trite term like a culture war, but spending some time in these online spaces, it would be very difficult to come away from it. I think any dispassionate analysis of it would say that it has kind of adversarial rhetoric between some birth activists and the hospital system, and of course there are negative things that happen in maternity hospitals sometimes, but I felt that some of these activism circles would go further than that and nearly start ascribing malice or blame to the hospital system, um, which I found quite interesting. Obviously, the investigation started with the issues around free births, but I did start looking at um some Irish activists, and there is an Irish group called the Irish Birth Movement that had a book out a couple of years ago. Um, so during the investigation, I had a look at that book and an introductory chapter that was written by some of the founders of the Irish Birth Movement, and I did find some kind of unusual claims in it. So one was that if you've had a C-section, C if you have a C-section, you will not be able to pick your baby up afterwards. I know that that's not true because I had an emergency C-section and I was able to pick up my baby afterwards. There were some references to how if you have a medicated birth, so an epidural or obviously the other anesthetic that would be used for a C-section emergency or elective gas and air, that anyone who avails of pain relief is, I quote, not fully present during the birth of their baby, which I think some women would find offensive.

SPEAKER_00 12:29

And obviously, most women would find offensive, and it's not true.

SPEAKER_04 12:33

It's a matter of opinion, it's not a that's not a medical perspective, and it's all it is it is offensive and it does kind of create a hierarchy where you know your birth wasn't real, it wasn't a real physiological experience if you weren't kind of suffering enough or in or in pain enough. And also the book kind of says to women explicitly, if you go into hospital and you ask for XYZ, maybe there's a certain thing in your birth plan that's very important to you that in a lot of cases you will be met with adversary, that um there's nearly like a model of coercion that doctors use to kind of push you into something that you might not be comfortable with. And I think if you were a first-time mother, if you are pregnant and you read that, it is kind of conditioning women to believe that the hospital is a scary place where the people who work there aren't looking out for you and you are, I suppose, one cog in a in a kind of baby factory line where um people want to just do inductions and cesarean sections for no good reason.

SPEAKER_00 13:36

Did you get from the conversation with individuals involved in that movement that they were presenting a balanced view of things?

SPEAKER_04 13:45

Well, no, I mean I did ask the the Irish Birth Movement um a number of questions about those those three uh claims that I just mentioned, and they didn't really respond to that. And I suppose as part of the article, I did speak to current and former consultants who were kind of pointing out that those claims were not correct. Um, the only response that I actually got from the Irish Birth Movement was when I asked them about the fact that this forum of midwives had said that there was um mortality and severe morbidity of women and babies associated with free births, you know, is that something that they would be concerned about? And the statement that they sent back was just to the effect of uh it is the legal right of women to choose um whatever birth plan they wish, a kind of reference to the HSC national consent policy, and that this isn't a matter of opinion or something that can be debated. So very firmly full that they were coming down on the side of autonomy, which is obviously very important in maternity care, but just kind of saying that a free birth is uh is something that someone can choose and not really engaging with the very real and severe health risks that can come with giving birth unassisted with with no medical professional around and and no midwife on call.

SPEAKER_00 15:00

You robbed my next question, Alint. This is what I was gonna ask. Did you get a sense that they were highlighting the potential risks of free births?

SPEAKER_04 15:08

No, because the entire I mean the entire online birth movement, and that's it's not just specific to Irish activists, um, it it is kind of all pointing you to the risks in a hospital. And, you know, people will talk about how, well, if people raise concerns about, you know, cases where something terrible has happened in a free birth, they will turn around and they will rightly say, you know, terrible things also happen in hospitals. That childbirth is obviously not a completely risk-free experience, and nobody can ever completely mitigate risk. But I suppose what I found interesting was a lot of the kind of free birth or physiological birth movement or natural birth, whatever label is put on it, will talk about the fact that for millennia uh women have been giving birth unassisted, which is true, but for millennia, women and babies have been dying from unassisted births as well. And there was a conversation I had with Rona Mahani from Hollistreet that I didn't unfortunately get the space to put into the Irish Times, but she was pointing out that there's parts of the developing world where free birth is the standard because there's no other maternity services available, and our maternity hospitals and our government, through foreign aid funding, is spending so much money trying to help women in countries who are suffering from preventable deaths from childbirth because they don't have access to the medical professional knowledge and to the basic medical standards that we have in Ireland. And I think that if you are somebody online who is actively encouraging somebody away from the medical system, there's no accountability for you if or when something goes wrong. And that's something that Fiona Hanrohan at the Retunda said to me as well. You know, people need to be careful about the advice that they take from people online because if and when something goes wrong, those people will will run from the hill for the hills and they will not be accountable and they will not be available.

SPEAKER_00 17:03

Yeah. And did you get a sense of the credentials of the people that you were speaking to that were part of the healthcare movement? Did you get a sense that they were presenting themselves as birth experts but without the clinical training or the regulation?

SPEAKER_04 17:18

It's quite mixed. So we're talking about like a global uh community here, and I found that what's quite common, particularly in the UK, where this is a trend as well, is that you will get a lot of jaded midwives who obviously were working as medical professionals within the system who then decided to leave because they were disenchanted with what they saw happening in hospitals. And we know that there's a lot of issues with obstetric care in the UK at the moment, and it is in the news at the moment. But what's really interesting is even when you are a trained midwife, a current or former midwife, if you are attending a free birth, the whole ethos and kind of like the rules of the free birth is that you're not attending that as a midwife. You are supposed to not intervene in any way, shape, or form. You don't have any medicine with you, you're not doing the things like having an ambulance on standby that a midwife would do for a home birth. All of that is kind of gone. So the whole point of a free birth is to not be medically qualified. The whole reason for it, the whole ideology behind it is that a woman is giving birth without a medical expert around. So despite the fact that people might not have medical qualifications that maybe some of us would hope someone would have if they were giving pregnant women advice, not having medical qualifications in the free birth world is nearly like a badge of honour because it means you're not part of this big bad patriarchal system that is doing bad things to women against their will.

SPEAKER_00 18:46

Yet there is some overreach, isn't there? I think. And for me, dabbling in that online space, you do get a sense that medical advice is being given. Um, you know, listening to the baby's heart rate is being done by doulas that shouldn't be doing that because they don't have any medical training, or birthkeepers or birth birthing partners that have no medical training, yet there is this kind of blurring of lines of what is being done for the women around the time of delivery or labour.

SPEAKER_04 19:15

And I've seen like there's one example that we do reference in the investigation where somebody who is a doula, who's obviously not a medically trained professional, um, was operating under the title of a midwife support worker. So when you have the word midwife in there, I think that does send a clear signal to a woman that there's some sort of medical qualification there. Like we all hold midwife in such high regard. That is obviously a protected title for a reason. And like you say, there is that kind of blurring where a lot of birth activists will deliberately use medical sounding language, they will point to research, they will point to um, like a lot of them will engage in what they call myth busting about what is a pro what is a necessary intervention and what isn't. So if you're in that online space, that can be quite, that can sound quite, it can sound like an authority. And what we also need to remember is when women go into these online spaces, they become seductive places to be because you've just come out of an antenatal appointment where a doctor has said to you, I don't think you should go for a vaginal birth, or I would advise against a vaginal birth, and that's quite hurtful if that's what you really want. And maybe you had a section last time that you weren't fully happy with or on board with, and you can log on to this place on your phone where these women will tell you, you are absolutely right, you deserve a vaginal birth. This is a symptom of a bad system that's not listening to you, that's not letting you do what your body is is naturally designed to do. I mean, why would you choose to listen to the consultant over those women? And I think that's where like the power is in this, in this online community, and it's why women find it so empowering to be in it, because they feel like someone is listening to them and validating any of their choices, regardless of whether those choices are necessarily medically advised. So that's almost an impossible thing for for midwives and doctors to compete against. Like, how can you how can you have a relationship that is stronger than the parasocial relationship that some people are forming with with birth activists?

SPEAKER_00 21:24

What stayed with you most while reporting this?

SPEAKER_04 21:27

I think it was just the day we got the the document back from the the the forum of midwives. So this is again the most senior midwives in the country. Because number one, as you well know, like the whole ethos of a midwife is you know supporting a woman's autonomy, um, supporting a woman, if possible, not intervening if it is not necessary. So for midwives to be adopting a position on free births, first of all, in Ireland, it was very significant, but to seeing it. The document in black and white, you know, the words um mortality and severe morbidity for women and babies, and just seeing this in a document that this has happened in this country, and we haven't really been aware of it in a national scale was really striking because I think we all assume that, God forbid, when something does go wrong for a woman or a baby, that that kind of meets the threshold of an inquest or some sort of scandal, and maybe it does when it happens in a hospital. But when these things are happening on the fringes outside the system, we're not hearing about when things go wrong, and those are not the stories that will be celebrated and coming up when we're scrolling on our timelines with all these kind of beautiful pictures of empowering free births, and it's very scary. Like the idea that some of these women or babies could have suffered preventable harm is it's very challenging and it's difficult to understand. But I think that as yourself and other medical professionals I spoke to demonstrate there is an understanding that obviously there's something wrong with the system, and that needs it's it is not an easy thing to fix, but for the sake of women and babies, it's an urgent thing that needs to be fixed.

SPEAKER_00 23:20

What do you hope pregnant women would take from reading the article?

SPEAKER_04 23:23

Well, I think the number one thing is to just be very judicious about who you take advice from. Like it is obviously quite difficult to end up working in a big maternity hospital as a midwife or a consultant. It's very easy to set up an Instagram account and you know to adopt all the right language and have all the right kind of uh visuals and images. And, you know, it's always worth asking: is this person giving you this advice because they really care about you and your pregnancy, or are they giving you this advice because it suits their personal political ideology for you to not go to a hospital? And where will that person be if, God forbid, something goes wrong? Like what recourse will you have, or what kind of accountability will you have? But the second thing I suppose, and I know that this conversation is happening at the same time as another conversation about private care in maternity services, and I think they're kind of like this in the free birth thing is kind of like two sides of the same coin because both of them are cases where women, for whatever reason, don't feel comfortable or don't feel like they entirely trust the public health service. And there have been dramatic improvements in Irish maternity services over the last decade or over the last couple of decades, but obviously something is missing in terms of that relationship between medical professionals and women. I know that COVID-19 did a lot of damage and there's probably some work to still be done to kind of earn back some of that trust. I'm conscious that there's a lot of women who maybe had their first pregnancy then who might be going through a second or third pregnancy now, and that will be a legacy problem. But I really think that, and I think Fiona Hanrohan put it quite well, that women need to feel comfortable to talk to doctors and talk to midwives and ask questions, and they should feel comfortable pushing back if they feel that they're being kind of pushed towards something that they don't feel comfortable with. So it's just, I know it's a big, it's like it's a big problem to solve, but I think that this rise in free births, it should be, we should all be really seeing it as a big red alarm bell.

SPEAKER_00 25:30

And finally, your message to policymakers and doctors.

SPEAKER_04 25:33

Well, I think that that is what is so interesting, is that obviously everybody has to recognise women's autonomy. And even in the document that I found, the midwives were saying that you know, obviously women have a right to choose an unassisted birth. So you can't regulate free births out of existence. And I think to do so would actually be counterintuitive because it would give credence to those who claim that the medical system is kind of out to get them. I think that the way to challenge this is to kind of start asking how is it in a in a country as wealthy and as modern as our as Ireland, people are still having negative experiences in maternity hospitals, that there's still such a postcode lottery, which is desperately unfair, which is driving women towards private care as well, especially in the Midlands and women who kind of choose to come to Dublin instead. You know, why is it that we can't kind of get the very basic things right? And socially and politically, you would imagine that even if you're not somebody who is a parent, if you don't have children, everybody should recognise that we all have a stake in making sure that having a baby is one of the most fulfilling, empowering, and happiest experiences that a woman can have within the reasons of mod within the remit of modern medicine. So what is it that we're doing that is making that a scary, an isolating, a disempowering, and an upsetting experience for women? And how do we change that? I know that doctors are obviously under a lot of pressure, there's a lot of capacity issues in hospitals that can't be helped. They're very, very busy and emergencies can happen as well. But what can we do on those day-to-day days where an emergency isn't happening to make sure that every time a woman walks out in an appointment, she feels that the person was on her side and the person was listening to her as well.

SPEAKER_00 27:20

Ellen, thank you so much, so much food for thought. I really appreciate you coming over to have a chat.

SPEAKER_04 27:25

No, thanks so much for having me. I really appreciate it.

SPEAKER_00 27:27

Thank you. So, I mean, you had a chance to listen to the conversation I had with Ellen about the Irish Times article that came out last Saturday. So, can you tell me your initial thoughts?

SPEAKER_02 27:45

Um, first of all, fair play to Ellen. I think she's done a phenomenal job in kind of unpacking the facts and the fictions around all of this. Um my first thought is always for the individuals um involved in trying to make that decision because I think it's really, really important that people who are making that decision are not villainized in any way or othered. Um and one kind of analogy came to me um as I was thinking about it, and if I said to you that a woman decided that her best place to deliver her child was up a tree, you would think that that's absolutely bananas.

SPEAKER_00 28:34

I would think that she's bonkers.

SPEAKER_02 28:36

Yeah, I think that you know, you'd be like, How, like, what the hell? Like, that's a banana's decision. But if I said to you that that tree was the only safe place in the midst of a massive monsoon and it was the only dry place you could get out of the water to actually try and birth her child, you'd say that that was a fairly sensible decision and such heroic measures. You know, so the context of all of these decisions are always really, really important, and it's not about the decision, it's about the context. And I think any decision that's made in relation to women trying to either are deciding to go against medical advice or as the synonyms that are used, you know, moving outside of guidance and all of this kind of stuff, the context has to be queried for that.

SPEAKER_00 29:23

So, what I'm hearing from you really is first of all, that's a really I think powerful analogy. And what it tells me is that we need to ask why are women walking away from hospital care?

SPEAKER_02 29:34

Yeah. And it like there's two lenses to look at it, I think. There's the microscopic lens, so the individual circumstances, but then there's a macroscopic lens about the narratives that are being superimposed on that decision or that potential decision to push that decision forward. And I think we have to look at all of those things through both of those lenses. Um, so like from an individual perspective, like you've got a woman who's in the midst of a very deeply vulnerable personal experience, we try and embed that trusted care of caregiver in an infrastructure and in a system that is evidence-based, but we need to get better at creating that warm blanket rather than the cold machine. And then when you superimpose the narrative from social media and from the internet, that you know you are at the forefront, this woman is at the forefront of you know generations of women, you know, fighting against the patriarchy for control over their bodies, and that you stand in your own sense of empowerment and your own femininity when you move against the machine. It becomes very seductive at a very vulnerable time, and then the algorithm feeds this to you repeatedly because that is how the algorithm is designed, and I can absolutely see where the monsoon comes from, so that she needs to decide that that tree is the safe place.

SPEAKER_00 31:07

Yeah, so I see this in two parts. The first part is us as healthcare providers and the medical system needs to first of all recognize what are the issues that are driving some women away from hospital care.

SPEAKER_02 31:21

When people are online on social media, etc., there's a huge amount of people from outside our healthcare system that are feeding narratives online, and people need to understand our healthcare system to see the differences because there's like there's influencers from North America who are an entirely different healthcare system. Over there, it can cost 20 grand to have a child, and also even in the UK, and there's a huge amount of inquiry and review on UK maternity services that is ongoing. Their maternity service is fundamentally different in terms of its structure and how it's delivered. And when you look at our own healthcare service here, over 80% of women in the last maternity service said that they were satisfied with their care. Now, that still leaves a significant number of women that we need to work harder to meet their needs. We can't let this narrative take legs and be fed from other jurisdictions that it is fundamentally unsafe or everyone is deeply unhappy. There is a significant number of women that we have to figure out how to meet their needs, and part of that is trying to develop options for them that they're happy with. We do have a multitude of options. We have like the maternity strategy has got low care, uh normal risk, um, increased risk and high risk pathways. And the normal risk pathway does option of for options for maternity uh midwifery-led and midwifery delivered care. The issue is that in Ireland, because of our infrastructure, home birth services are extremely limited. And there is a trend and a demand amongst women to be able to avail of that service. And that's a bigger issue with physical infrastructure in terms of rapidity of access to escalated care, but also indemnification, which is uh a statutory requirement for healthcare providers that they have some level of healthcare provider insurance. And that's limited by the level of liability payouts in the in the state and the structure of our medical legal system. So this is a huge piece of work that we need to address. But I really don't want our healthcare system and our issues being conflated with other jurisdictions because it muddies the waters and it doesn't really allow us to make the necessary change that women want.

SPEAKER_00 33:53

On the flip side, then let's talk about the individuals, the people that capitalise on this in the online space. Yeah. Be it doulas, birthkeepers, birth workers, all of these terms that may have a sense of authority behind them, yet when you dig deep, these people have no medical training, no understanding of research, but they know exactly what they're doing in terms of attracting women to this idea of free birth.

SPEAKER_02 34:24

Okay, so there's a couple of ways we can approach that, I think. In terms of like, if you want to give all of these people the benefit of the doubt, they truly believe that they are fighting bat a battle for female empowerment against a malevolent institution that is looking to disempower women. Let's work at it from that perspective. Then putting women into a situation where the evidence, the medical evidence, suggests that it is higher risk than the situation than the alternative, and they are not openly disclosing those risks, then that is a huge problem. And I think that is the reality, regardless of what their intention is. And I've looked into these podcasts and things online, I've listened to a few of them, and you know, they say things like a woman never hemorrhages at home. You know, they say things like, I've attended thousands of births and I've never seen a postpartum hemorrhage. In our healthcare system, it is a requirement that we do quantitative, gravimetric assessment of blood loss at each birth. So you can say that this woman lost 253 mils, this woman lost X amount, everything is weighed and measured, and we've moved toward that because of fundamental biases in estimations rather than measurement. None of the women who are attended by these practitioners have gravometric assessment of their blood loss, none of them have outcome objective assessment of their outcomes, none of them are reported unless there's a negative issue. And then these people say, Well, we're not actual medical protect practitioners, so we're not really accountable for any of this. And this is the issue. Anyone can go and do a course that involves supporting women, and I have no problem with that. I think women need all kinds of support available to them. But when they start giving medical advice and are part of bodies that are not regulated, overseen by disciplinary bodies, it's a problem. If you look at nurses, midwives, doctors, we are obliged and required by law to be registered and overseen by quality assurance bodies in terms of our practice and by disciplinary bodies that are overseen by the high court. Like the level of oversight and accountability that we are held to is appropriate, and the level of oversight and accountability that these people have online are who are not like over overseen by regulatory bodies is minimal. It's the same as going in and buying a coffee.

SPEAKER_00 37:18

Yes.

SPEAKER_02 37:19

That's all you are, you're consuming their services.

SPEAKER_00 37:21

Yes, and there are clear examples of the lack of accountability. For example, there has been recent deaths that have been quite prominent in the Irish media, and when you actually look at the circumstances surrounding them, these women were advised by those so-called practitioners on how to navigate and avoid taking advice from healthcare providers. Yet when the negative outcomes happen, you see a complete absence and lack of accountability. So this has been documented in newspaper reports and also accounts of the circumstances surrounding the death of these women that availed of free births. But then also, you know, about the statements that are being made that say I've never seen a woman die from a postpartum hemorrhage, or I've never seen a postpartum hemorrhage occur in a in a free birth environment. Those individuals we know cared for women that actually died from a postpartum hemorrhage. Yet they come out with these statements.

SPEAKER_02 38:17

One of the podcasts I listened to, somebody was talking about, you know, she she had some increased bleeding after her free birth at home, and she herself was a doula, and she was teaching her husband how to like manually massage her uterus from both inside and outside to try and rub up a contraction to limit the blood loss. And she said she felt it was her body's way of including him in every part of the birthing process, and that was how it was presented to people. Um, and if that's her view on it, that's fine. But I think that presenting, you know, what is a significant healthcare risk issue for a new mother as you know, an inclusive moment is pretty much muddying the waters again. And these are people who are part of a program that has moved internationally. And I think in 2025 it had been reported that they've made 11 million so far from people prescribing uh or uh subscribing to their program. So this has been monetized. This has been monetized on a global level. So let's be really, really clear on that.

SPEAKER_00 39:27

So Anne, you deal with you know high-risk situations all the time from a maternal side, and I do from a neonatal side. So what are the risks that women should watch out for?

SPEAKER_02 39:36

Like it's really interesting um when you try and drill down on on what the potential risks are risks are because we have no numbers. Um this is often done kind of um in a quite clandestine way, um, and often we only hear about it if there is a mortality, not even a morbidity, often a mortality. Um so so it's really difficult to know. So what I did was I actually looked back historically and I said, like, if we take away a lot of the immediate care that's offered to women in labor in terms of risks and in terms of historically, what were the outcomes and what were the risks, you know? So like from about 1870 onwards, there was really good reporting on maternal mortality rates, and up until about 1930, where we had better control, better medications, better presence at labor, better standardized approach toward labour, better accountability, antibiotics, all of those kind of things, then we saw an improvement. But prior to that time, you were talking about a maternal mortality rate of five per thousand, which would give us a maternal mortality rate of about 250 um a year, okay, or 500 per 100,000. Our current mortality rate is around nine per 100,000. So, like the difference is vast. Now, that's from all cause of mortality. In terms of like issues in labor itself, obviously the major one is going to be hemorrhage, and the reason for that is that it can happen so quickly and escalate so quickly, and it can be pretty occult, so pretty hard to spot in the beginning, which sounds strange because you think somebody bleeding should be very, very obvious, but you can have little tears that are relatively high up, you that can like literally nip off little vessels that start to bleed internally before it becomes apparent, and that is why we have reasonably high level of monitoring and all those kind of things as well. It's not just that you would see a huge gush of blood coming out somebody's uh vagina or anything like that. So it's it's more complex than just a straightforward, oh look, she's bleeding. Um, but often hemorrhage was one of the major causes of maternal mortality until we got those better drugs, better monitoring, and that escalated care quite quickly. And the other thing to you you'd look at would be sepsis.

SPEAKER_00 42:06

Unfortunately, the recent high-profile cases of maternal deaths in the community highlight that it can be very slow occurring and then all of a sudden get very fast. Get very fast, and the one can decompensate.

SPEAKER_02 42:18

I understand that, you know, from reading and listening to midwife practitioners in the community, you know, there is benefits in the initial period to trying to just let that woman have those moments with her babies, with her baby latching, all of those kind of things. And it does help with the body's natural progression toward improving uterine tone and all of those kind of things. But it's also at a time where you know increased vigilance is warranted. So you've got this tension between wanting to give that woman those golden moments with her child versus not intervening too much, and that's tension and that's a difficult situation, um, because it's hard to spot then the the early signs of something happening. But even even with escalated levels of monitoring, trying to spot the point where it's going to turn into something more significant that requires in more intervention immediately can be difficult.

SPEAKER_00 43:22

Yes, and I would also parallel that with what happens with the baby, in that sometimes there are subtle signs of a baby breathing fast or grunting or slightly pale, the colour not kind of coming around as fast as it should. And again, there is a point at which you have to decide, okay, should I maybe intervene, do a more thorough assessment to determine how well or unwell the baby is, or do I give it another few minutes? And sometimes things can spiral very, very quickly. And that tension that you described, sometimes we experience it in the labor and delivery setting when there is concern about the well being of mum and baby around delivery, and we're present in the room. My instinct is I want to take the baby away just for a few minutes. Yeah.

SPEAKER_02 44:03

To just make sure it's But you can't because it's really important that you don't intervene unless it's necessary as well. Absolutely.

SPEAKER_00 44:09

But sometimes it's hard to tell whether you should intervene or not until you have a couple of minutes with the baby and assess them and then give the baby back straight away.

SPEAKER_02 44:17

And you know, interesting, like I know we're talking a lot about maternal uh morbidity and mortality here, but in terms of neonatal or fetal morbidity and mortality in these in these births, like there's a lot of the higher profile people who have availed of free birth internationally who would have lost children, still burstillborn children and stuff. Um, and it's just it, you know, the thing is like you could turn around and say that wouldn't have happened in hospital, and we will never know.

SPEAKER_00 44:47

But what I think you can say is that at least in hospital there's a chance to intervene adequately.

SPEAKER_02 44:53

Yes, but the problem is that they're saying that the intervention is the problem. So then I think for any woman who's sitting trying to figure out, Am I going to avail of a free birth? We have to say it is probably it from the evidence that we can see and on balance of probabilities, it is of significantly higher risk for your well-being and the well-being of your child, and your life and the life of your child.

SPEAKER_00 45:24

Yeah. Before we finish up, can I um ask you to talk about and challenge this natural birth purity test? That's that that narrative that is being pushed by the free birth movement.

SPEAKER_02 45:36

Well, that that i i if if you avail of any painkillers, it's not a real experience.

SPEAKER_00 45:40

Well, that vaginal birth is ranked above cesarean, that no epidural is much better than epidural, spontaneous labor is better than induction, home wild birth ranked above hospital birth, trusting birth is ranked above above asking for help. All of these narratives that I think disempower women. You know, because when your body, and I'm doing this in quotation marks, fail you, fails you, you are a failure.

SPEAKER_02 46:05

Oh, look, it's the same to me, it's a parallel to the beauty narrative. It's a parallel to the size, how big is your body, how small is your body, are you a classic, what what shape is your body? It's it's literally a superimposed um competition of value on you as a woman. Yeah, you know, like the way I see it, right, is that all people, regardless of gender, are individuals who can make their own decisions for themselves. And superimposing a value system on people that involves something that is not always within their control, okay, to reflect their value as an individual in society is just horrible, horrible thing to do. And it is a mean of means of controlling that person. Um, so I think if somebody turns around and says that your birth experience wasn't valid to them because of a decision that you made where you took two paracetamol, or you decided that you wanted to have an elective cesarean section because it was right for you and your family, then again, the woman who gave birth up a tree made the decision because that's the decision she needed to make at the time. And they do not understand the context of the decision you're making. Yeah. And I know people kind of say, well, that's the same for free birthers. Yes, it is. So that's why I am actually trying to attack the context and give people evidence-based factual information to show where people are accountable for the context they're creating. Okay, we have to make it easy for people to call for help. We have to make it easy for people to turn around and go, I might be in trouble here. You know, we have to make it and it's safe for them to say that.

SPEAKER_00 48:03

Absolutely. And that was going to be my next point is the non-punitive re-entry pathway. That if a woman decides to come back into the system, that she should be welcome with open arms and not feel that she made a silly decision in the outset.

SPEAKER_02 48:16

It should be a case of the same as everything else. Welcome back, well done. Now, what are the issues that we can address with you?

SPEAKER_00 48:23

Yes, exactly. The other thing is we need to get better at trauma-informed maternity care. We've had episodes on this before, the importance of that.

SPEAKER_02 48:31

Well, there's a huge, there is a big push that's ongoing at the moment. Yes, and it's just in the midst in the process.

SPEAKER_00 48:36

And we need to expand our support options for mums.

SPEAKER_02 48:40

We have to get better at at making risk assessments with patients and understanding that they are there may be women who are happy to tolerate a much higher risk than the policy would dictate or then the evidence would dictate. And we have to figure out what to do about that and what to do with them about that, because the liability component is very difficult in terms of the medical-legal side of it, in terms of the state liability in the clinical indemnity scheme, and going outside of policy. So we have to figure out that medical-legal component much more as well, to actually enable doctors to be able to say to somebody, I understand you want to take on this increased risk and this increased potential for harm. So no woman should ever have her autonomy or a consent diminished because she's doing something against medical advice. But on the other flip side of it, the difficulty is encountered because of the liability of the risk. And that is a bigger, broader conversation that needs to happen as well.

SPEAKER_00 49:47

Well, Anne, thank you so much. That was a very difficult conversation, but I think it was an important one because the point of this episode, again, was not to shame women, not to tell mothers that their fears are silly, but that their experiences do not matter. Of course, they matter. Birth trauma is real, poor communication is real, as you said, and consent matters and trust matters. But trust cannot be rebuilt by replacing care with ideology. And I feel that the free birth movement is often sold as empowerment, as an ideology, but the real empowerment is not being left alone with risk, it is having accurate information, respectful care, and skilled support available when things change. So, the message is simple. You are not weak for wanting pain relief, you are not less powerful because you had an induction, you are no less of a mother because your baby was born by Caesarean, and you are not failing because you want trained professionals in the room. Because birth is not a purity test, there's no gold medal for suffering. What mothers and babies deserve is safety, dignity, honesty, and care. Thank you for listening, and we'll chat to you next week.

SPEAKER_03 50:59

This show is part of the HeadStuff Podcast Network, a hub for the creative and the curious. Shows are produced in association with HeadStuff and the Podcast Studios Dublin.com.