Healthcare and birthing in Chile.

Chile is a country located on the southwestern coast of South America. Considered a developing country by the World Bank, Chile has the highest gross domestic product (GDP) per capita in its region [27, 28] and its political and economic histories are marked by the well-known fact that it was the first Latin American country to enact a neoliberal dictatorship during the 1980s. That circumstance paved the way for the privatisation of healthcare, positioning it as a consumer good. A mixed public-private healthcare system was established in which public insurance (Fondo Nacional de Salud, FoNaSa) and private insurance (Instituciones de Salud Previsional, ISaPres) coexist. This system is still in place today [29].

The implementation of this model gave rise to a technocratic, commodified view of healthcare processes, including the healthcare provided during childbirth. According to recent statistics, 99.6% of births in Chile have taken place at a healthcare institution and have been attended by healthcare professionals, namely, OB/GYNs and midwives [30]. Within the public system, 33% of birth are by caesarean delivery and 63% of those in private system are by caesarean, positioning Chile as a country with one of the world’s highest rates of C-sectioning [31].

In contrast, the number of home births has increased significantly. In 2017, 0.15% of births took place in the home with an attending healthcare professional [3], while in 2020, approximately 1% of home births were attended by a midwife [32].

Participant context.

Chile is divided into 16 administrative regions. The women interviewed for this study live in the regions of Norte Grande (‘Far North’), Zona Central (‘Central Chile’) and Zona Sur (‘Southern Zone’) (Fig 1).

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Fig 1. Political map of Chile showing its administrative and geographical regions.

https://doi.org/10.1371/journal.pone.0249224.g001

These regions were selected to enlarge the geographical scope of home births by women in both rural and urban areas of Chile. This aspect an important consideration due to the fact that women described difficulties finding a midwife who was able to attend births in locations far away from urban areas because of the low availability and quantity of midwives in rural areas. Moreover, a mandatory provision within the protocols established by midwives attending home births requires that childbirth take place in a location that is closer than 20 minutes’ drive from a hospital in case an emergency transfer becomes necessary.

In light of each of these considerations, Chile’s extensive geographical expanse and the diversity in expertise that this breadth occasions means that residence in rural areas or places outside of the capital’s centralising sphere of influence is a crucially important circumstance that must be taken into account during participant screening and selection.

1.1. Making the decision to give birth at home.

According to the women interviewed, one of their hardest moments was making the decision to give birth at home, mainly due to lack of knowledge, or more frequently, the negative ideas surrounding home birth. Social representations of home birth are predominately negative. They are based on claims that home births are unsafe and unsuitable, and therefore women who give birth at home are correspondingly categorised as irresponsible women. One woman expressed it as follows in an interview:

‘My mum went crazy. She said that, if it was about the money, she would pay for the birth, and how could I do that, and that I was irresponsible’.

(P: 6:7).

As a source of objective knowledge validated by science, biology and medicine, hygienist discourse has positioned and represented home birth as an unsafe form of childbirth because it is carried out outside of the safeguards of a healthcare institution. This idea has taken deep root in society’s conceptual framework of childbirth despite and separately from the vast international scientific evidence that exist on the subject. Women who choose to give birth at home feel obliged to inform themselves about its advantages and disadvantages, both for their own sakes and to generate socially acceptability in their personal surroundings. A participant described it this way:

‘It terrified them all, but nobody asked me anything either, except for my dad, who took me aside and said, “Alright, so you want to have [the baby] at home. I want you to explain everything you are doing to have [the baby] at home, what the pros and cons are, what the risks are…” so I explained everything to him, and he said “Ah, OK”, and relaxed about it’

(P:2:21).

Society’s entrenched hygienist discourse creates a situation wherein women who decide to give birth at home have to educate themselves about this option, which entails the complex process of acquiring information from a critical perspective that will allow them to problematise the predominant contemporary way of giving birth and subsequently develop a solid discourse with which to defend and justify their decision. To that end, in order to make and reaffirm their decision based on the benefits of home birth, women’s strategies include reading, watching documentaries, attending workshops and dialogue with other women who have given birth at home. Some participants described it as follows:

‘I started to read, I started to get informed, and I started to collect lots of information on the benefits of a natural birth in a place I knew, where I was protected, and it started to make a lot of sense to me to have my daughter at home’

(P:3:5).

‘I started getting together with friends who had given birth at home, so in that way, yes, a feminine structure helps, such as having close female friends who have gone through this, so like getting information by word of mouth, through sharing. On top of that, at the beginning of my first trimester, I did a workshop about home birth with a midwife’

(P:15:4).

While the women interviewed describe this process of acquiring information and educating themselves as necessary, especially during their first pregnancy, some expressed that, after their second time giving birth, they preferred to let their own experiences be their guide and thereby avoid creating unreal expectations for themselves about a ‘perfect’ birth that didn’t reflect the reality a woman might experience. One interviewee described it as follows:

‘During my first pregnancy, I read a lot and I collected a lot of information. I also think that by studying so much, I had created this idea of a perfect birth. So, on my second pregnancy, I said I wasn’t going to read or study anything, and I was just going to let it all happen however it was going to’

(P:12:30).

And so, making the decision to give birth at home reflects the successive situations participants must face during their life journeys, from starting to educate themselves to their firm decision and its reaffirmation to others.

1.1.1. Why do I need to give birth at home? The biomedical model is currently the predominant model on labouring and childbirth. The unequal power relationships in this healthcare provision format mean that individuals play passive, secondary roles in their own disease and health processes. Furthermore, this model is part of a technocratic paradigm, an important consideration in the dynamics of the healthcare institution culture, wherein the human body is understood as if it functioned like a machine [15]. Through this metaphor, the technocratic paradigm mechanises physiological processes with a series of procedures and technologies that estrange the idea that women have an autonomous capacity for giving birth. The women interviewed were referring to this situation when they described the excessive medicalisation of births that takes place inside hospitals. From the moment they are admitted, a complete array of technological apparatuses is deployed for application during labour. One participant described it as follows:

‘It’s quite a nasty situation, a Machiavellian business, medicine is, if you think about, for example, medical machinery. But in the gynaecological area, I have the impression that it’s all about being a woman. I feel like right there, something happens, like “women’s bodies are defective and we’re helping out the woman’s body”‘

(P:6:14).

This statement expressly addresses the question of sex. At the core of the biomedical model, women are seen as having defective bodies that are insufficiently prepared for giving birth on their own [12], so they need outside intervention to have a ‘successful’ birth, which is defined solely and exclusively as culmination with a live mother and newborn. But, when birth does not go as expected, the biomedical system attributes this to the inability of women’s bodies to give birth according to the established standards, thereby blaming women and making them feel as if they had failed to reach their goal of being mothers [39]. In its zeal to compensate for the deficiencies of women’s bodies regarding childbirth, the biomedical system justifies practices and procedures including unwarranted episiotomies, directed pushing, the Kristeller manoeuvre and unnecessary caesarean sections in the name of ‘saving’ the life of the baby to be born because the mother was unable to give birth by herself. A participant described it this way:

‘They made me consent to a C-section I didn’t want. They induced me at 8 am and at 1 pm, they told me, “Enough, you never dilated, so we’re going to do a C-section on you” as if it were my fault: “you didn’t dilate and we can’t keep waiting on you”, like they were blaming it on me’

(P:12:7).

We observed that the main reason that the women interviewed who had given birth before [in a hospital] gave for wanting home births was negative hospital experiences during their prior pregnancies. Along with ill-treatment and the excessive medicalisation of birth, these situations have been researched extensively by several different authors [39, 40], who have theorised and conceptualised these acts as ‘obstetrical violence’, defined by the Venezuelan Fundamental Law on the Right of Women to Live Free of Violence, is ‘the appropriation of women’s bodies and reproductive processes by healthcare staff’ [41]. One participant said:

‘I wanted to give birth at home because I was afraid of obstetric violence more than because, “Oh! I wanted to connect with the earth” or something like that. I’m telling you, now that I have given birth at home, if I had another kid, I would do it at home. I recommend it to everyone’

(P: 1:11).

The acts of obstetric violence the participants refer to originate in a system structured such that the rights of women and their families are impinged upon. Multiple factors intersect to cause these manifestations of violence against women in that the women subjected to them coincide in sex and their condition as pregnant individuals; both circumstances place them in vulnerable situations [40].

The experiences the women recount reflect a perinatal trauma that persists in the participants’ memories throughout their lives. Despite having had positive experiences with childbirth later on, the emotional and symbolic damage inflicted by perinatal trauma impedes these women from generating and recalling positive feelings about the birth of their children.

A participant described it this way:

‘Lots of things happened and a lot of them were really sad. Look, I feel like crying as I’m telling you this right now, even though I later gave birth at home, twice. People say I’ve already healed from that, and I feel like I won’t ever heal because of how they snatched [my child] away from me. They ripped my child from my womb in a violent way. It shouldn’t have been like that. And there were a thousand more things, during the C-section, during hard labour and while I was hospitalised. They treated me badly for four days. I was subjected to violence and traumatised so much that I wanted nothing more to do with (the hospital). In fact, I was even scared of going for check-ups’

(P: 12:9).

Thus, opting to give birth at home is a resilience strategy that women adopt in the face of obstetric violence and, simultaneously, an act of emancipation from the current dominant healthcare culture surrounding birth. However, obstacles are not only created within institutional settings. On occasion, they are found among family as well.

1.1.2. The people around me don’t support me: obstacles to home birth. Support and companionship during pregnancy, labour and birth are essential. However, managing their desire to give birth at home, on the one hand, and feeling that they had to persuade their loved ones that this was an informed, safe and responsible decision, on the other, was a significant source of tension for the women interviewed. Sometimes, childbirth outside of institutional regulatory frameworks was interpreted by the families of the women interviewed as an offensively unsafe decision that incurred risk. Families recurred to negative cultural representations such as fear and pain to reverse or question a woman’s decision to give birth at home. Biomedical discourse is so entrenched in society’s subconscious that it becomes impossible to think about birth in a different, autonomous way that doesn’t involve surgery or treatment provided by an institution. One participant described it as follows:

‘I felt extremely criticised by my whole family, but not family like my dad, mum and sisters, but my female cousins and my aunts. Actually, I remember a comment one of my cousins made, which I said I wanted to forget because she told me, “I want to see you when you’re screaming in pain”‘

(P:14:22).

Likewise, giving birth, especially at home, is not a frequent topic of conversation among family members. When someone comments on birth in a family setting, they cautiously and discreetly say that their grandmother or great-grandmother gave birth at home with a birth assistant. Yet rather than being a mere memory or anecdote, these situations intimate that home births are not perceived as a safe model for birthing in the modern age. Technological advances in medicine have given rise to a social discourse that validates and depicts birth in healthcare institutions as the exclusive model, and this rhetoric is intergenerational, as indicated by the following participant:

‘My father […] told me he wanted nothing to do with it, that he didn’t understand, with all the technology we have, why I would put myself at risk, why I would put my baby’s life at risk’

(P:1:14).

In response to these obstacles, some women interviewed chose to hide their decision from their families and thereby avoid complicated interrogations and the possible collapses of family relationships. This selective silence can be understood as a strategy that women use to placate the biopolitical punishment [13] represented by their families as they question and create tension about her decision to give birth outside of the social established norms. A participant described this situation as follows:

‘I told my aunt and she said, how could I, with all of the advances we have now, how could I take such a risk? So, I finally told her that OK, I would have [my child] in a hospital and I said the same thing to the whole family, just like I did to my family on my father’s side, who are more traditional. I told them my child was born at home afterwards’

(P: 15:18).

On the other hand, the support that women sought was reflected in their partners’ active participation. From the very first moment that the interviewees expressed interest in a home birth together with their partners, their partners supported them, although they did have a few questions because they didn’t know about labour in a non-institutional context. Partners felt fear and worry about a situation that they neither knew about, nor understood nor even know how to react to. One participant described it as follows:

‘I think my husband had a few concerns because he didn’t know much about what I wanted to do or what would happen, so we went to check-ups together with the midwife and every time he had questions, I told him, “Ask, ask, so you won’t be worried, and you can give me the support I need”. So, in the end, we persuaded him’

(P:27:9).

The women interviewed thus described how important their partners’ presence was for them while in labour. However, that presence was valued from a household logistics point of view more than for emotional and physical contact. They felt it was much more important for them to have everything under control and play a protective, precautionary role than be together with them during labour. For instance, some interviewees assigned their partners tasks such as keeping the house warm or ensuring they had water or towels on hand. In this sense, Odent [16] comments on a similarity between home births and birth in other mammals, in that the female mammal makes sure she gives birth away from others and the male mammal makes sure that no threats or predators are around. One participant described it this way:

‘Before the birth and during labour, he was busy making sure I was alright, like “I need to make sure the house is nice and warm, so she and the baby aren’t cold. I need to give her the flowers when she’s in pain, I need to massage her…”—and maybe I didn’t let him give me massages. He made the hole in the ceiling for the cloth. He focused on those issues, resolving material concerns so we could be alright’

(P:14:20).

Despite the family obstacles described by the women interviewed, they experienced the respectful companionship of their partners first as a challenge, and later as support in preparing for the exact time and setting in which they would give birth.

1.2. Giving birth: (Re)birth.

For the women interviewed, childbirth was not only a continuation of a physiological process but a state that transcended rational comprehension [42]. They experienced emotions that washed over and overwhelmed them as a true re-birth and a sublimation of detachment from worldly concerns. As they gave birth, they felt re-born as women and mothers. One participant described the level of intensity that she experienced as follows:

‘It’s like you yourself are born again […], when you give birth, you that was before dies, and you are born as a mother, as a powerful woman and that is the most beautiful thing about births. [weeps] I get emotional about it!’

(P: 8:30).

Together with this sensation, the women interviewed expressed that, while in labour, and especially during the more advanced stages, they experienced a trance-like sensation. Some women even compared this sensation to the effects of hallucinogenic substances insofar as sensations of joy, body heat and even a great deal of pleasure. Casilda Rodrigáñez [14] calls this ‘orgasmic birth’. She indicates that it ‘happens because uterine movement itself produces pleasure, and this happens during natural birth’ [14]. She also says that ‘the type of movements uterine smooth muscle bundles make during labour is the same as during an orgasm’ [14]. Some participants characterised this moment as follows:

‘When I wasn’t having contractions, I was in a state of pleasure. It was as incredibly intense thing, very sensory and good. I made strange noises and it was like I was in a trance, an exquisitely beautiful trance, like a decadent feeling, very warm. I remember sweating a lot’

(P: 3:13).

‘I had taken trips on plants and giving birth is the same. It’s like taking some mushrooms or like taking cactus. I don’t know what it’s called—your sanity, you in your normal state of mind—it’s like letting go of that, as if the brain turns off, something like that’

(P: 12:20).

And so, some participants felt sensations and emotions during labour that are totally different from society’s negative representations of tragedy and, particularly, pain as a source of suffering. This reveals the possible transition to positive emotions during a home birth.

1.2.1. Shifting emotions during home birth. The transcendent understanding beyond rationality as described above is the result of a series of emotions that converge to allow birth to happen. For the women interviewed, home birth was something they had never felt before. They experienced multiple emotions during that time, yet their overall sentiments were satisfaction and joy, so much so that they even recommend home birth to other women. One participant described it as follows:

‘Giving birth at home, it’s possible. It’s beautiful. Beauty isn’t always comfortable or easy, but it’s worth it, the whole time, and I recommend it to all women. Every woman should try it, really and if they can’t, that’s OK, but they should try it’

(P:1:48).

The women interviewed describe pain as a primary sensation throughout most of their time labouring, among the multiple emotions they felt throughout the process. The women do not understate the intensity of the pain; in their opinion, it is the most difficult thing to endure. Pain management and the nature of its representation have been the subject of much study [14, 43, 44]. However, the women reinterpreted the pain of childbirth based on the knowledge they had acquired during pregnancy as more closely resembling a necessary emotion for a home birth to take place than as suffering. They describe it as follows:

‘It hurts, but you don’t suffer. I think that’s what you learn from reading and researching until you’re sick of reading and researching. At the heart of it, this is not suffering. This is physiological pain, the only time in your life that something is going to hurt because everything is the way it should be’

(P:26:12).

To paraphrase Spinoza [45], no one knows what a body can do, nor what it can achieve. Thus, and contrary to the dominant discourse of ‘suffering through birth’, emotions such as happiness even coexist with pleasure during home birth despite the pain. These sentiments are a recurring theme among interviewee’s stories. Their feelings are made possible because of the fluidity pregnant woman experience giving birth in a place that is familiar and comfortable to them, surrounded by people they have chosen to be there. This is essential.

The more the woman knows and is comfortable with the setting in which she is going to give birth, absent the hostility that occurs in hospitals, the better her body will be able to progress through its physiological process without interruptions or intervention by external agents. In this context, a woman will be able to experience positive emotions and advance through labour and childbirth. As this participant described it:

‘Being able to have your baby without someone bothering you, without being interrupted, without anyone getting in the way, and doing it in a private space with your family, being able to have that memory, for your children (if you have other children and they participate in it) to have that memory: the arrival of a sibling. That’s priceless’

(P: 7:39).

During a home birth, women embark on a journey through diverse emotions, mainly experiencing birth as satisfaction, confidence and wisdom. However, sometimes they prefer to experience such an important moment in their lives in introspective solitude over having company.

1.2.2. I (don’t) want to be alone. The intensity with which emotions appeared during labour was apparent in the women’s contradicting and imperative desires to be alone or to have someone else present. This feeling varied among birthing stages. During the initial phases, the prevailing sentiment was the desire for company. Participants expressed that the most meaningful companion for them during that stage was their partner, even if the latter didn’t always act the way the women expected them to. Participants felt that their partners transmitted a sense of protection and support in addition to them taking care of home birth logistics. One participant described it this way:

‘He came in all of a sudden, all worked up. It annoyed me, but at the same time, I wanted him there. I couldn’t imagine him not being there. I had always wanted him to be there during the birth’

(P: 11:9).

Contrarily, during more advanced, active stages of labour, participants expressed having been more comfortable alone, with no one touching or talking to them. It is very important to respect this evolution and refrain from intervening in any way. At this point, the woman and her bodily state play the most important role; any external interposition could impede labour. One participant described it this way:

‘The first two hours, I wanted to be alone. I told my husband, “Leave me alone”. Like horses go off by themselves, I went to a room and I hugged a cushion. There I was, thinking, alone. During the birth itself, the midwife told him, “Caress her” and I told him, “Don’t touch me”!’

(P: 8:8).

Parallel to how important their partners’ support was for women, midwives also played an essential role in home birth. The women interviewed said that their midwife’s presence transmitted not only a sense of support but also, and in particular, a sense of safety and protection. They perceived the midwife as a professional technical expert and trusted fully in their midwives’ knowledge and skills, above all, to know what to do in the event of the unexpected. In the words of one interviewee:

‘I needed the midwife to be there to know that everything was going to go well and that if something didn’t go well, she would know what to do. She fulfilled that role and took care of my health and my baby’s health perfectly’

(P: 5:7).

Midwives played this important role in home births. The women interviewed assessed that their presence meant added value in that, through their attitude of compassion and sisterhood, the midwives represented feelings that are mutually expressed among women who help other women to give birth. One woman described herself in these words:

‘I had the feeling that I preferred to be with another woman who would understand the process and what was happening to me better, a woman who could help me’

(P: 9:12).

In this way, the women interviewed recognise the midwife not only an expert woman with technical and scientific knowledge, but also, they identify a true active partner in the birth process. Their company, understanding and contentment was fundamental, both for them and for their partners and families. Consequently, the figure of the midwife in home birth represents the political and active sisterhood that women need and that challenges midwives to change the world for more just, dignified and humane births [46].