Field, L.

Hands On or Hands Off: The Baby’s Coming, but Who’s in Control?

“…The process of birth provides a structure around which the social and cultural forces
can guide its expressions” – Esposito (Behruzi 2013)
Childbirth is an event experienced daily by women all over the world shaped by

the culture and society which they reside in. Traditionally, the ‘event’ of childbirth can be

experienced in a few different settings – either at home with a midwife, in a medical

birthing center staffed by midwives and other health care professionals, or in hospitals

staffed by Doctors and nurses, with all of these options having the potential for the

additional presence of a doula. Each of these settings inherently will contribute to the

amount of control and autonomy the woman giving birth will consequently experience,

contingent upon her choices of location, staff, procedures, attendees, and specific

unpredictable factors related to the nature of how her birth will proceed. Though this

‘event’ for women falls under umbrella terms of childbirth, labor and delivery, and

‘bringing new life’, it is by no means experienced the same way by each. Each birth

comes with its own set of risks, complications, length, ease, and unforeseeable events,

which are unable to be, replicated even when the same woman gives birth to multiple

children. Each event is unique and specific to its occurrence and dependant upon the

framing of the location in conjunction with the cultural and societal structures in place:

“The setting for birth, whether it is home, birth center, or hospital, can have a direct

impact on the choice, control, and power a woman has over what happens to her during

her birth process” (Gibson 2014:154). Thus, we will explore how the technology-based

and individualized culture of the United States infiltrates and affects the birthing process

of the women who live here by looking at the subjectivity women experience when
 Field, L. 2

delivering in different spaces and how those spaces impact the woman’s amount of

control and autonomy she has during pregnancy and childbirth.

Women’s level of autonomy and control experienced during childbirth, based off

of the location of delivery and those attending, are explored through existing literature

and six interviews I conducted which included three mothers who have given birth in a

hospital setting and three who have given birth at home. Common themes, in-vivo codes,

and interpretations of their childbirth experiences are combined with existing literature on

control and autonomy during childbirth in order to draw out the specific ways they have

experienced their autonomy, agency or control. The concept of ‘humanized birth’,

“refers to women-centered care, choice, control, and continuity of care”(2013:6)1 directly

sums up how each facet within agency, autonomy and control contribute to the same

purpose: Women feeling safe, confident, cared for, and in control of their bodies,

childbirth and babies throughout their pregnancy and delivery. Though I will be

comparing both hospital and home births, it is important to recognize that ‘humanized

birth’ can and does occur in each location, though at different levels based on the

variability of individual situations. I will be exploring the similarities and differences

between women who choose to give birth at home or in hospitals to elicit their

conceptualizations of autonomy and control influenced by location and procession of

childbirth.

Note: I use the terms ‘women’ and ‘mothers’ to refer to biological females who
experience pregnancy and childbirth while understanding not all with female anatomies
may self-identify as ‘women’. For the purposes of fluidity in addressing this topic, I will
use the term ‘women’ to refer to those who participate in pregnancy and childbirth.

REVIEW OF LITERATURE
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The material I have reviewed palls in comparison to the amount of material that

exists on this topic. Thus, this collection of information is not comprehensive, but the

material reviewed here plays a part in contributing to the highly contested topic of patient

autonomy and a woman’s position in society during her experience of childbirth.

Background
Women in the United States are allowed a small number of socially accepted and

expected spaces to give birth, with hospitals, culturally, being widely utilized. Though

homebirth is viable, it is often perceived as a looked down upon option in the U.S..

Within these modes of childbirth, control and autonomy can be located in these three

entities: [1] Individual; [2] Location; [3] Caregiver. A combination of each variable in

each unique instance of childbirth manifests a different level of a woman’s control and

autonomy.

First, the individual must be considered since it is essential to acknowledge that

each woman’s delivery experience and autonomy/control levels is contingent upon her

own specific set of preferences, desires, history, and culture that is embedded within her

reality: As Behruzi (2013) states, “From the feminist cross-cultural studies, we realize

how differences between birthplace, race, ethnicity, and the religion of women play a role

in their decision-making on medicalized birth” (5). Yet, not all approaches to childbirth

conceptualize patient autonomy and control as stemming from life situations specific to

the individual being cared for. There are many differing perceptions on patient position

and limitations placed on their autonomy while under care. Thus it is imperative for both

the woman herself and her practitioner to consider the ideals and desires they each may

hold surrounding her impending childbirth – “Issues of control, pain management, stress,
 Field, L. 4

and roles of the practitioner in the birth process are all important factors that contribute to

the beliefs held by the woman” (Gibson 2014:152). The largest inhibitor of the

individual’s realization of their beliefs is education. Education plays an essential role in

whether or not autonomy and control can be exercised to full potential during childbirth:

Education allows a woman the ability to critically evaluate different options of location

and practitioner and models of childbirth, as well as the differing options within each

overarching model. When a woman is not exposed to alternatives, it raises the possibility

that she will potentially be inducted into childbirth as a passive participant of her own

labor versus an active and prepared player, as “It seems that the medicalized birth system

is more embedded in US culture, as US women are less likely to question the use of

particular procedures in hospitals” (Behruzi 2013:5) than if they had been educated prior.

Once a woman achieves education on her options, abilities, and rights to her body she

will be able to establish mental preparation and a support system for whatever birthing

institution she finds herself within.

Options of location for childbirth are largely contingent upon the financial ability

of the individual, limiting some women to fewer options than others. For homebirth, both

geographical location and financial ability affect those seeking out home delivery, since

only 27 states out of 50 legally allow midwives to practice in home (Gibson 2014:150).

Though legality does make it easier to locate a midwife, it is finances that are the real

blockade to access to homebirth, as “Some insurance companies do not fully reimburse

providers’ fees for home birth” (Boucher et al. 2009:119). Though homebirth may be

cheaper in the end, it is unavailable to those who need it most due to laws and constraints

on practitioners and financial means. When deciding upon location, finances aside, there
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are two polar ends of the birth location spectrum – hospital birth and home birth. – Inside

of these ends fall birthing centers, which incorporate both opposing methodologies into

their practices to allow a blending of ideals. On the hospital end exists the

‘technocratic/biomedical model’ of childbirth that governs the practices and

interventions of the physician by “…requiring the woman to release a significant degree

of personal power and control to receive the support of the physician-dominated

technology” (Gibson 2014:153). This model is rooted in the particular culture women are

embedded within in the U.S. via normalization of the model in “…prenatal visits,

childcare classes, and through the popular media” (Gibson 2014:153). On the other end,

“The holistic/midwifery-based model of care incorporates the body/mind connection

and focuses on the individual” (Gibson 2014:154). Many women choose homebirth due

to “Common themes [of] control, comfort, freedom to move, and fewer interventions”

(Boucher et al. 2009:120). The major differences between hospital birth and homebirth is

the amount of interventions utilized and the amount of control and autonomy the woman

is able to exercise, which are both dependent on the location of birth selected. Thus,

individual education is imperative for women to be able to align their ideals with their

location choice.

Location also impacts the type of caregiver selected for childbirth services. Thus,

if a woman’s pregnancy ideals line up with a specific model of pregnancy – either

holistic or technocratic – it will influence her choice of location and inevitably will

predict the attitude and operation of her caregiver. Caregivers were positioned last since,

I believe, they should be a direct expression of the woman’s desires, preferences,

background, support system, and culture she has chosen to experience her delivery
 Field, L. 6

within. Yet this is not always the case due to the individual woman’s restraints on

education and financial ability in combination with the training that some practitioners

receive since “Economics, social class, knowledge, race/ethnicity, language, and

geography may limit a woman’s choice of practitioner” (Gibson 2014:150). Gibson

(2014) also notes, “These authors have highlighted the need for clinicians to understand

the belief models of their clients in order to help provide effective care that is utilized by

the client” (157). In order to provide the most autonomous enabling care, the provider

that exists within the chosen location must be kept in communication with the woman’s

desires, instead of expecting the woman to adhere to theirs. Unfortunately women often

discover during their childbirth that “The way that labor is handled through these

different protocols [either hospital or home birth] can drastically affect women’s

experience of birth, whether she wants a natural or highly technological birth” (Gibson

2014:152), which can ultimately lead to loss of her autonomy and control.

Overall, the individual woman, the location of her delivery, and the selection of

her caregiver are major contributors to levels of personal autonomy and control

experienced within childbirth. ‘Humanized care’, defined as “…birth without any

unnecessary medical intervention” (Behruzi et al. 2013:2), has the potential exist within

all frameworks of labor and delivery. Caregivers should represent a culmination of each

piece of ‘humanized care’ through the expression of their treatment of women in labor in

delivery by providing “A woman-centered care approach in which women are respected

regarding their values, beliefs, autonomy, choices, and their control over their bodies and

births…” (Behruzi et al. 2013:2). I believe that ‘humanized care’ can flourish in all

models of birth, yet currently homebirth and midwifery are more inclined to provide it
 Field, L. 7

versus hospital birth, by being generally more willing to share the power in their position

of knowledge than the other. In the end,

“If women are educated about the different practitioners available and the models
of pregnancy, birth, and care associated with midwives and doctors, they will be
better informed when selecting a practitioner for their care if choice is available”
(Gibson 2014:172).

History
In order to understand the market that exists today, within which women make their

childbirth decisions, we must look at the past. Historically, tracing back to the records

18th century (and presumably prior), “At a time when around 99% of deliveries were

home-births, there were no hospital transfers…” (Shelton 2012:719) and women gave

birth at home with trained midwives. D.C. Shelton (2012) takes issue with the murky

trajectory of modern Obstetrics and Gynecology that began with history of ‘man-

midwifery’ and William Smellie and William Hunter, the supposed ‘Founding Fathers’ of

the field (718). They were responsible for rudimentarily constructing the ideology of

hospital delivery that has grown to today’s popularity; “In 1950, the percentage of

hospital births soared to 88%, rising to more than 99% by 1969, where it remains today”

(Boucher et al. 2009:119). They created ‘lying-in’ houses, which eventually became

hospitals, where low-income women could give birth in exchange for allowing student

teaching observation (Shelton 2012:721) to draw women away from delivering at home.

This was not for the benefit of the patient, but in order for them to engage in the

disgusting and lucrative work of the murder-for dissection of pregnant women: Shelton

(2012) states that the creation of these early hospitals allowed for “…A ready supply of

vulnerable pregnant women for murder and dissection with little fear of detection” (721).

Pregnant women who delivered in these early ‘hospitals’ from 1730 to 1930 were not
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only at risk of death via murder, but infection, since at the time “The risk of death from

infection was far less for home-births, in stark contrast to rising MMR [maternal

mortality rates] at hospitals” (Shelton 2012:721). The risk of infection within hospital

birth still exists today, which is the leading contributor to the ideology of a ‘24-hour’

birth, “…where women ideally dilate one centimeter per hour, give birth within 24 hours

of the onset of labor, and experience more technological intervention than those giving

birth outside of the hospital” (Gibson 2014:154). These deaths were directly related to the

usurping of “the pre-1730 structure of maternal home-care provided by trained

midwives” that ultimately resulted in “around 1 million human deaths connected to man-

midwifery initiatives of the 18th century” (Shelton 2012:723). This is not information that

should be disregarded, as much of the literature glosses over the ‘humble’ beginnings of

Obstetrics and Gynecology by omitting its life threatening origins, for example when

Boucher et al. (2009) states, “Before the mid-20th century, most American women gave

birth at home under the care of midwives. As the specialty of medical obstetrics grew, the

percentage of hospital-based births increased” (119). This notably does not give the same

connotations.

It is also imperative we highlight how Obstetrics/Gynecology and Midwifery

serve women differently based on their racial and class backgrounds, both historically

and today, since “a woman’s class background together with her race, profoundly affects

the kind of birth experience she will have in the hospital” (Martin 2008:148). Note that

Martin mainly refers to hospital birth experiences since “The majority of women who

chose homebirth in the United States were white and were attended by midwives”

(Boucher et al. 2009:119). This is reflective of the class barriers low-risk pregnant poor
 Field, L. 9

women of color face, since homebirths are not covered by insurance, making them

mainly upfront expenses that are unaffordable to many low-income populations. This is

not to say all women of color are impoverished, because this is not the case, but

institutionalized racism has disproportionately placed women of color in a financially

disadvantaged position. Not only are low-income women of color barred from homebirth

options, but are potentially faced with medicalized racism in hospital settings – “…The

ways in which racism is explicitly used in medical school culture as a way of further

entrenching the superior standing of doctors over the rest of the population…” (Martin

2008:153) leading to greater possibility of mistreatment of women of color by their

caregivers. Though women of color can and do experience racism in hospital settings,

there is potential for doctors to empower women through race, as was evident in the

experience of Lisa who gave birth in a hospital setting. She self-identified as Black and

commented that she had an exceptionally good experience with her first delivery, stating

– “The medical staff, all the doctors in the practice are females. I think they’re all Black

women actually… I had never realized that the entire practice was all African-American

women, and I’m like, I like that, you know?” (Lisa, 1 Hospital Birth). This was a source

of comfort, power, and control for her that ultimately impacted her in a positive manner.

While we know power invoking experiences are possible, until women can be

empowered in all systems of care, we need to be cognizant of how women of color are

currently doubly at odds with the systems of birth in place – they are disadvantaged

within the hospital setting and are also kept out of the market of homebirth due to the out-

of-pocket price tag. Chrisler (2014) states “ ‘Our ability to control what happens to our

bodies is constantly challenged by poverty, racism, environmental degradation, sexism,

 Field, L. 10

homophobia, and injustice in the United States” (205), with different combinations of

these variables adding to the stress and fight for autonomy pregnant women already face

in navigating the terrain of labor and delivery.

This is not to position hospital birth in a negative light, but to give an informed

history on the creation of why hospital based labor and delivery is widely accepted today

as normative in our culture. Our current climate ultimately posits hospital birth as the

preferred, expected, and presumed safest method of labor and delivery for women, even

though “Numerous studies have shown equivalent safety rates when comparing home and

hospital births” (Boucher et al. 2009:119). Yet, the dominant cultural expectancy of for

women to deliver in hospitals helps to maintain that a majority of women give birth in

hospital settings; As Boucher et al. (2009) states, “We know that more than 99% of births

in the United States occur in a hospital, and more than 90% of those women experienced

interventions, even though 50% of them believed that the birth process should not be

interfered with unless medically necessary” (125). This is a direct threat to women’s

autonomy and control over their labor process when delivering in hospital settings, and

must be addressed for optimal control and autonomy. Behruzi et al. (2013) sums up the

historically non-working relationship between hospital and home birth by stating,

“Social scientists have argued that medicalized birth is determined by embedded

cultural ideas in which progress and technological birth practices are defined as a
victory of civilized society over the ancient feminine nature of birth.
Consequently, women are controlled through more and more medical practices in
order to prevent any risk to themselves and their babies (3).
This is important to remember as we examine, compare and contrast women’s

experiences of childbirth and labor in home and hospital locations.

METHODS
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Women selected for interviews were currently living in Baltimore, Maryland.

Using semi-structured questions, I interviewed six females in-depth, spanning from 30

minutes to an hour and a half in length, who had given birth to at least one child either

within a hospital or home birth setting. I planned to interview three who had delivered

within hospitals and three who had delivered at home or in a birthing center. Three of the

six women had only ever delivered in a hospital setting, whereas the other three had all

delivered in a hospital setting and had also delivered in a homebirth. Thus the women

who had delivered both in hospital and at home offered both of their experiences of birth

avenues, contributing more to the hospital birth stories than the home birth stories

overall. The hospital birth interviewees were Lisa, a Black 29 year old mother of one,

Beth, a white 40-year-old mother of two, and Rosie, a white 38-year-old mother of three.

The homebirth group consisted of Aidana, a white 34-year-old mother of four, Rachel, a

white 35-year-old mother of three, and Kallie, a white 37-year-old mother of two. All

births took place between 2006 and 2016. All identified as financially able to secure the

birth their desired birth methods besides Kallie who objected to the idea of ‘affordability’

of homebirths. From these interviews themes were produced leading to instances

occurring only in hospital births, only in homebirths, and then the intersection of the two.

All names and identifying variables have been changed to protect the identities of the

interviewees. All verbatim quotes have been edited for clarity.

FINDINGS
It is important to recognize that “In all scenarios and contexts, women expressed a desire

for control over their childbirth experience. Clearly, the issue of control in childbirth is

unique for each woman” (Meyer 2012:219), which was relevant in all interview cases.
 Field, L. 12

Though experiences of hospital and homebirth have varying outcomes of control, what

matters is women’s choice and control over their birth process, since “Women who

actively wanted technology and highly managed birth were equally as happy with their

care as those who desired a more natural birth experience” (Gibson 2014:172).

Hospital Birth
“I’m just much more in favor of being in a hospital and having that medical attention.
[The heart rate drop] could have gone wrong if we were home. Since we were at a
hospital with a staff that knew exactly what they were doing, its like I barely even
remember that that happened” (Rosie, 3 Hospital Births).
Stress & Medical Interventions & NRT’s
Stress was clearly present when medical interventions and New Reproductive

Technologies (NRTs) were utilized in the hospital setting. For mothers giving birth in

hospitals, common medical interventions were of fetal monitors, ultrasounds, and more

extreme intervention of cesarean section. While medical interventions, and potential for

these interventions, pushed some of the women away from hospital care, both Lisa and

Rosie had the most positive experiences overall with the hospital care that they received

While Rosie’s 3 hospital experiences were positive, she did address the

unnecessary stress fetal testing and monitoring produced when reflecting upon the birth

of her first child who was born with autism – “I thought a lot about whether I wished I

had known ahead of time, and I don’t think I would have wanted to know because I think

it just makes for a really anxiety filled pregnancy”. This influenced her choice not to

undergo fetal testing for her other pregnancies. Beth also experienced worry over fetal

testing due to her second child’s ‘short femurs’; “It was super stressful that third trimester

because I didn’t know if there was going to be something wrong with her…but they

couldn’t really say why they were concerned, [but] that it was abnormal, it was atypical”.
 Field, L. 13

Chadwick and Foster (2014) state that often in hospitals, “To minimize risk, childbirth

must therefore be managed by experts constantly monitored and is subject to a series of

investigations in order to probe dysfunction and abnormality” (76). This statement was

also true for Beth and Aidana who struggled with constant fetal monitoring during their

hospital births. Beth also desired a v-bac for her second birth stating, “I wanted to wait

and not go to the hospital so I could give my body a chance to go into labor before, so I

could possibly not have another C-section” (2 Cesarean Hospital Births). This shows the

additional stress placed upon her during her hospital experience due to fetal testing,

constant monitoring, and undergoing a second c-section. Cahill (1999) comments,

“Ironically, it seems that the very technology that was developed to decrease fears of

infant and maternal death…have combined to increase those very practitioners’ fear of

birth” (502). These sentiments are echoed by Rachel, a midwife who labored both at

home and in hospitals; “If anything remotely small changes, then you have the nurses and

the doctor who have the ultimate control…these things are completely different at home”

(2 Hospital & 1 Homebirth). There is evidence for greater autonomous support outside of

the technocratic system due to these experiences of additional stress from monitoring,

testing, receiving undesired interventions and modes of birth that are ultimately placed

out of a woman’s control by the hospital.

‘24-Hours’, Labor Progression & Fear

Many of the women delivering in hospitals feared not progressing quickly enough during

their childbirth. They combated this fear by staying home longer in order to stave off

potential of having technological interventions and c-sections. Many of the women in

hospital births experienced interventions of being induced or having their membranes

 Field, L. 14

ruptured in order to speed up their labor process allowing all, but one of them, to avoid a

cesarean. Both of Beth’s modes of birth were heavily contingent on the idea of ‘time’

during labor, as she states, “I was there for so long and not being in active labor, I had

some contractions but nothing really. So the doctor came in pretty early just to check

[dilation]…and I was not ‘making progress’ in their terms” (2 Cesarean Hospital Births).

This is related to Gibson (2014) speaking about the expected progression of 24-hour

labor that exists in hospital births made possible by the use of technological interventions.

When Kallie, the only woman who had planned all homebirths, needed to go to the

hospital due to regression of dilation, she stated, “…I think we told them my water had

broken at a different time, because we didn’t want to be on the clock of ‘the broken

water’ that the hospital will put you on” (1 Hospital & 1 Home birth), in order to avoid a

c-section. This fear of not progressing during labor and the interventions that take place

during the 24-hour time period greatly reduce the amount of control women have over

their labors and bodies.

Privacy, Vulnerability & Power

Levels of control are also heavily contingent upon experiences of vulnerability and

privacy during childbirth; Chadwick and Foster (2014) state that “[Women] are classified

by biomedical discourse as bodies at risk of complication, abnormality and death but are

also positioned as vulnerable bodies at risk of exposure, loss of dignity and

objectification, particularly in medicalized settings” (79). Rosie, Lisa, Beth, and Rachel

commented on their issues with privacy and vulnerability during their hospital

experiences. Rosie delivered her first child in the UK and found that she missed the

privacy a single occupant room in the U.S. provided, adding to her stress of processing
 Field, L. 15

the complications of her first birth. Lisa commented on her fear of getting an episiotomy

during her delivery and worried of being vulnerable to that procedure but was reassured it

would not be used. Beth discussed her experience of vulnerability during her second c-

section stating, “I was basically lying by myself on the table…naked from the waist

down, and I’m just lying there. And to them, you’re just a patient, but it’s my body, you

know? I was completely exposed here” (2 Cesarean Hospital Births), the feeling of loss

of dictation over her body greatly influenced her feelings of autonomy and control over

her situation. Rachel directly commented on vulnerability stating, “In a hospital birth you

really have no idea who’s going to be in your room. It’s a very vulnerable time. I mean

definitely, there’s informed consent and they ask you, ‘Is this ok if I do this to you?’ but

you don’t really have a choice to say no…” (2 Hospital & 1 Homebirth). These are clear

instances of loss of autonomy, which as Brione (2015) states, could be better mediated

and potentially remedied from the top down:

“[Physician’s] should be alert to the powerful position they hold, and the ability of
this power imbalance to restrict a patient’s exercise of skills necessary for
exercising autonomy, and lead patients into making decisions that do not fit with
their own preferences” (80).

Home Birth
“The homebirth is very autonomous, you really call the shots. You decide who’s going to
be there, what’s going to happen” (Rachel, 2 Hospital & 1 Homebirth).
Hands Off – Facilitated Birth
In contrast to hospital birth, I found that many of the women who delivered at home

experienced both minimal interventions as well as minimal physical contact with their

midwives; directly in opposition to the amount of contact experienced by women in

hospitals via insertion of IVs, constant vaginal dilation checks, fetal monitors, cesarean
 Field, L. 16

sections, and more. Two of the current homebirthers switched from hospital to home after

disliking their hospital experiences, relating to the insight Boucher et al. (2009) offers:

“Routine labor interventions experienced by women delivering in hospitals are

not evidence based and do not reflect best practice. It is not surprising, then, to
hear women express a desire to birth at home to avoid interventions that they may
have experienced or witnessed at previous births, especially when women do not
feel that their preferences would be honored” (124).
Rachel, Aidana, and Kallie all commented on the participation of their midwives stating

that they were very hands off, ultimately waiting and usually sitting quietly until each

began to push, before assisting. Rachel summed up the midwife’s position by stating,

“In a hospital, the midwife or the doctor is running the show. At home its [the
woman’s] territory, its her house and the midwife is just the facilitator and is just
there to make sure everything is going well and to step in if there is any problems,
but really isn’t in charge of much at home” (2 Hospital & 1 Homebirth).
Reduction of Stress & No Time Limit
Gibson’s (2014) statement that “Out-of-hospital births attended by midwives proceed at a

more relaxed pace, according to the needs of the woman’s body rather than the staff, and

with fewer interventions” (154) is echoed by the experiences of the women interviewed.

There was no stress over time limits at home; only the homebirth to hospital transfer

experienced ‘timed’ stress. Aidana described her afterbirth saying, “Even delivering the

placenta wasn’t a rush, it was ‘whenever you feel the urge, tell me’. No timetables, no

pressure. Peaceful” (2 Hospital & 2 Homebirths). Rachel also describes the lack of

disruption laboring at home provided her; “I just labored and had a baby. I didn’t have to

go through all that upheaval of the car ride and registration and getting an IV band – all

of these things that are very disruptive to the labor process.”(2 Hospital & 1 Homebirth).

This clearly influenced the autonomy and control experienced by homebirthing women.
 Field, L. 17

Comfort & Control

All of the homebirthing women discussed the control and comfort birthing at home

provided. Boucher et al. (2009) examined reasons women chose homebirth, with

“Common themes [being] control, comfort, freedom to move, and fewer interventions”

(120). These themes were all very present, as women described the various spots and

positions they labored in, the limited participation of their midwives, and their ability to

dictate the experience of their own births. Aidana described the differences between her

hospital and homebirths, stating “I felt completely out of control for some points [in both

my hospital births], but I felt with my homebirths it was a big contrast. I felt very, very

calm, very empowered, and not fearful. [I] just let it happen. It was healing” (2 Hospital

& 2 Homebirths). Beth felt that, if she were to be pregnant again, “I think I would do the

birthing center. There’s more of an emphasis on walking and not so ingrained in this

schedule and the process that comes with the biomedical model” (2 Cesarean Hospital

Births). These sentiments are related to speculation that women may choose homebirth

“…as a form of resistance against the hegemonic technological model of birth. The

women’s own personal experiences may override the dominant cultural model, allowing

them to seek out other ways of knowing about pregnancy and birth” (Gibson 2014:153).

Intersections & Implications of Hospital & Homebirth

Preparation for Birth & Birth Plans
Preparation for birth was discussed by all women, with a portion of them having either

mental or written birth plans laid out, and all of them taking childbirth classes or

engaging with reading material. These birth plans included desires about the birthing

process, attendees and visitors, and their support systems. Kallie, a homebirther,
 Field, L. 18

emphasized the necessity of preparation for birth, having designed parallel care plans for

both of her pregnancies; one for home and one if her homebirth went to the hospital:

“When I’m talking to new moms…they don’t get the ramifications of how much
they should prepare for having the birth that they want and being in a safe place
after the delivery and having the support systems in place that they’ll need and
knowing who to invite and who not to invite and just holding that sacred space
because it is such a sacred time” (1 Hospital Birth & 1 Homebirth).
The U.S. birth system essentially does not support and empower the mother in allowing

her to consider the implications of place, people, and mode, but instead operates by

valuing a consumer mindset of entering care and leaving with a child, by all means

necessary. Lisa discussed that she may reconsider who to invite to her delivery a second

time, relating to Behruzi el al. (2013) comment that, “There was a lack of knowledge

among women, particularly those expecting their first baby, about what they should

expect from the specific hospital that they chose for their birth setting” (5). Rachel’s

feelings back up these findings, as she stated “I think for any birth you need to have some

type of preparation, but a hospital birth, just because there might be more interventions”

(Rachel, 2 Hospital & 1 Homebirth).

Recovery & Postpartum Support

Within the hospital birth system women are not receiving the care postpartum they need

in order to recover quickly and efficiently. Midwives provide both childbirth and

postpartum care in almost all cases. Both Kallie and Rosie recall the ease of using the

provided in-home postpartum care, and in Rosie’s case, feeling more comfortable with

being assisted with breastfeeding and personal recovery questions by the home health

aide provided in the UK. Lisa, a hospital birther, reflects on her struggles surrounding

recovery – “There might be handouts, and there might be a 24-hour hotline for nursing
 Field, L. 19

issues, but I think then it becomes so much about taking care of the baby, that you’re not

told ‘This is what you should do to take care of yourself’”. Behruzi et al. (2013) reports,

“Previous research has shown that a hospital’s policies and procedures, inadequate

staffing, technology-focused care, and lack of continuity of care are barriers to a more

humanized birth approach in specialized hospitals” (2), leading to a greater difficulty in

recovery as well. Many of the women’s hospital birth experiences reported struggling to

manage their own recovery while providing care for their infant. Rachel highlights the

way postpartum care has been devalued for women, by stating,

“I think the postpartum period is the most important and that’s what’s most
neglected in American health systems… I feel moms after birth need a lot more
support than before…and that’s really neglected and I think that leads to
postpartum depression and a lot of stress following the birth” (2 Hospital & 1
Homebirth).
While hospital birth postpartum care may be more centered on the infant, Aidana felt that

homebirth care was also very supportive for her; “I would recommend a homebirth to

anybody…my hospital births were a little disappointing, sad to say. [Homebirth] was

very empowering and it was a much easier recovery for both” (2 Hospital & 2

Homebirths).

Personal Attention & Reliability of Practitioner

There was a lot of emphasis on the necessity of individualized and reliable care provided

by caregivers during birth. It was more likely for women delivering in hospitals to end up

with a care provider they had never met before, in addition to the multiple nurses, as well

as being left for periods of time while the doctor attended to other women’s births. This

directly contrasts with the care of a midwife who, when present, are ultimately there to

provide care only to the woman who’s home they’re in. Lisa, Rosie, Beth, and Aidana all
 Field, L. 20

experienced hospital professionals they had never met before, which led to Beth and

Aidana’s birth plans and goals not being followed or met. Gibson (2014) also interviewed

women who experienced both hospital and home deliveries, found women who decided

to deliver in a hospital “…for access to technology later reported that if they had to

choose again that they would give birth with the midwife due to her personal relationship

and commitment to the women” (169). Of the four women I interviewed, both Aidana

and Beth felt abandoned and frustrated, while the other two were not as bothered due to

ease of their childbirth processes. For Rosie, she experienced control by “Having a

receptive doctor. I never felt they weren’t listening to me or that I wasn’t in control of

how I wanted it to go, and I trusted them.” (3 Hospital Births). While Aidana’s

experience influenced her to switch to homebirth; “I was priority one to my midwife, it

was all about me and my baby. Best outcome for me physically and emotionally, I felt

cared for” (2 Hospital & 2 Homebirths). Women not only need to be able to physically

rely upon a practitioner, but “For true autonomy to exist, women’s knowledge and beliefs

must be valued…On this basis, midwives and medical professionals play a significant

role in facilitating or restricting choice and autonomy” (Church 2014:231). The necessity

of reliability and personal attention is emphasized by Beth’s words; “Because the

outcome was so not what I wanted that, I really felt like I had no control. My power,

whatever agency, was usurped” (2 Cesarean Hospital Births).

Control & Pain Mediation – Epidurals & Affirmations

Women in hospital births relied predominantly on epidurals while homebirthers used

affirmations, self-hypnosis, and birthing pools. It is clear that efforts to mediate pain

influenced the levels of control over their experiences. Lisa and Rosie both commented
 Field, L. 21

on the clarity their epidurals provided them, allowing them to relax and be present in the

moment of childbirth: “[An epidural] was definitely the right decision. At that point, I

was just like ‘ok, I’m just going to sit here and enjoy this peaceful moment while I can”

(Lisa, 1 Hospital Birth). Women who were induced with pitocin all described their need

for an epidural, as the contractions are made much stronger and more painful. Overall,

use of epidurals were very positive cognitive experiences for control felt in hospital birth,

as Cooper et al. (2010) states, “One might expect good pain relief to increase the amount

of control experienced. Conversely, immobility as a result of epidural analgesia may

reduce the amount of control felt” (32). Both Beth’s and Aidana’s experiences represent

the latter half of the statement, that pain was managed but immobility reduced their

amount of control over their bodies. All three homebirthers engaged in affirmations and

attempted self-hypnosis, though it was not always as successful, as a means to mediate

their pain. Both Aidana and Kallie engaged in committed affirmations, such as “Positive

thoughts, like this is a natural thing, and this will happen and everything will be fine”

(Aidana, 2 Hospital & 2 Homebirths). Kallie describes her experience of childbirth as

productive ‘pain’ saying, “I just remember when he came out, like the feeling of him in

the canal, just kind of like moving and sliding through and just being like ‘whoa! That is

insane’, like I don’t remember that being painful…” (1 Hospital & 1 Homebirth). Thus

the contrast of the experiences of women with highly technocratic births – such as Beth

who felt entirely uncomfortable from the ‘tugging’, as she described it, during her

cesareans – to holistic births, represented by Kallie’s experience of productive labor

‘pain’, are each influenced by location, caregiver, and knowledge base of the individual.

Kallie also highlighted her doula as an invaluable influential resource for her, (with only
 Field, L. 22

two women of the six utilizing a doula), as it contributed to the positivity and control

over her experience.

“Good Outcome”
All of the women reported that they had experienced a good outcome in the experiences

of childbirth overall, which proved to be interesting. Even women who had experienced

multiple unwanted interventions during birth reported their outcome as good. This seeks

further research and potentially more pointed questions to women to help delve deeper

into separating out their own experiences of childbirth and their experiences of taking

home a healthy baby. Beth’s feelings show this potential, which could have been

obscured by the way the questions were posed, stating, “I guess I’d say it was wonderful

in the sense that I have two healthy children, but also in the sense that kind of, like,

disappointing and maybe alienating in a lot of ways. Just feeling a lack of control over

the outcome” (2 Cesarean Hospital Births). Thus there is need for further research on the

idea of what a positive or good outcome of experience of childbirth actually constitutes

and how it relates to overall feelings of autonomy and control.

CONCLUSION
I have established an argument for discovering the differences in levels of

autonomy experienced between women who have delivered at home and those who have

delivered in hospital. Despite the differences recorded here, I believe that overall it is

most important – in whichever model a woman decides is right for her – that she receives

the best support, care and genuine autonomy and control over her body, her pregnancy,

her baby, and her childbirth. The research that I have done here indicates that a greater

level of autonomy is experienced via homebirths when the woman is the one to ultimately
 Field, L. 23

direct her care and the type of childbirth she has. I also understand that homebirth may

not be feasible for all mothers who wish to have complete control and autonomy over

their childbirths, as homebirths are currently still not covered by insurance directly, if at

all, and therefore may not be a viable option to all women, necessitating change in

insurance policies. Second, since

“There is clear evidence that hospital obstetric units in the United States are not
providing evidence-based maternity care, appropriate care for low-risk women,
labor support techniques for pain relief, nor support for the natural ability of low-
risk women to give birth vaginally without technological interventions” (Boucher
et al. 2009:124),
additional research is needed on hospital policies or practices which take away women’s

power over their bodies and their births. There should be allowance of movement during

labor and birth, redevelopment of fetal monitors or switching over to solely wireless

devices which are only used if necessary, abolishment of the mandatory IV upon arrival,

and cease to multiple vaginal exams. Another large issue is giving the woman’s body the

necessary time in order to be ready to give birth and being able to discern what has been

too long and what has not, not simply by basing every woman’s body off of the ‘24 hour’

clock the hospital births run on. I believe women should have access to the medical

procedures they desire, such as an epidural or pitocin, without having to sacrifice their

autonomy and control in order to receive them.

Overall there is a lot to be done in order to ensure women are cared for without

compromising their autonomy and control throughout their entire pregnancies – including

the postpartum period. Instead of continually engaging in a culture of fear perpetuated by

the biomedical model and training of medical professionals, comprehensive information

needs to be made readily available to women outlining medical procedures, their rights
 Field, L. 24

within the hospital and to their bodies, and in setting up the comparison of pros and cons

between homebirth or birthing center birth and hospital birth. These lifesaving procedures

should not cost a woman agency over herself, and until that is changed women will

continue to be subjected to the odds of experiencing their childbirth in a dehumanizing,

traumatizing and confusing way within hospitals, while also policing women who choose

to deliver outside of this imposed model.

Limitations & Further Research

There is great need for further research into the intersection between homebirth,

hospital birth and the levels of control and autonomy experienced by women during

childbirth. This data is not conclusive since it took place over one semester time period

and is based from six interviews – five of them being white women and one being a black

woman. Further research to be done on the levels of control and autonomy needs to

examine experiences by women from different socioeconomic, racial, and class

backgrounds. All of the women interviewed were able to ‘afford’ or financially obtain the

childbirth that they desired, from either hospital or homebirth, so more research needs to

be done on women of lower class backgrounds who may not have access to alternative

forms or information. Further research should be done on the ways education and access

to information influences women’s experiences, location, choice of caregiver, and overall

autonomy and control of their childbirths; as Kallie made clear,

“[Women] don’t realize the choices they have, they don’t realize that they are in
control of their bodies, that they get to say what can or can’t be done to them, and
I can’t see it changing too much until women, and men, realize that that’s the
better way to do it” (1 Hospital & 1 Homebirth).