Emotions and childbirth

The notion that it is safe to give birth without the presence of healthcare personnel must be treated like any other form of misinformation: with caution.

In March, the Norwegian Broadcasting Corporation (NRK) published the results of a survey showing that one in ten women believe it is safe to give birth at home without the presence of healthcare personnel (1). Around the same time, a doula (unlicensed birthing assistant) was reported for violating the duty to provide assistance in connection with a birth (2). The debate quickly escalated – partly driven by clear and informative warnings about the dangers of unassisted childbirth, but also by accusations against women who choose to give birth without the safeguards of modern health care. They were portrayed as spoiled and irresponsible – and, as I read it, as though they ought to be ashamed of themselves (3, 4). Spokespersons for 'freebirth' are standing their ground (5). This is perhaps not so surprising considering the mechanisms at play.

Childbirth stirs emotions. The idea that a child's death or permanent injury might have been preventable is a painful one, especially for healthcare workers who do their best every day to prevent such outcomes. For most of us who have been through it, childbirth is an intense and dramatic experience – and it can be traumatic, even within the structure of the public health service.

Giving birth with the assistance of healthcare personnel is much safer for both mother and child than giving birth without such support. Anyone who believes otherwise is either misinformed or misguided. Misinformation is when someone believes something to be true when it is not, whereas disinformation is the deliberate spreading of falsehoods (6). It is unlikely that women are trying to convince others to give birth in a manner they themselves consider dangerous; they likely want to give birth in the way they believe is safest for the baby (and for themselves). The mechanisms behind the conviction that an unassisted and 'natural' birth is best are probably the same as for other types of misinformation, and they affect us all.

Giving birth with the assistance of healthcare personnel is much safer for both mother and child than giving birth without such support

Such mechanisms largely govern what we believe to be true and the (health) choices we make in life – at least according to Sara and Jack Gorman, the psychologist and psychiatrist who published the book Denying to the Grave in 2017 (7). Through classic examples of misinformation (e.g. that vaccines and genetically modified food are dangerous, that HIV does not cause AIDS, or that having firearms in the home protects the owner from being killed by an intruder), they explain why we cling to our beliefs, even when science has long since reached a different conclusion.

Access to accurate information and the ability to engage in critical thinking are crucial. However, our education level does not necessarily correlate with how susceptible we are to misinformation or what health choices we believe are best or safest (7, 8). Psychological mechanisms also play a key role. Some factors are linked to our limited ability to understand risk, especially when negative outcomes are relatively rare (we are more afraid of flying than driving), and we tend to seek information that supports our own views (confirmation bias). Other factors involve traits that have helped us survive as a species but are counterproductive in this context. We look up to and follow charismatic leaders, avoid standing out from our peer group, and are reluctant to change our positions, even when presented with new information (7). This applies to everyone, including doctors and researchers. Take the Norwegian debate on COVID, for example: after five years and countless research articles, the opposing sides remain virtually unchanged.

We look up to and follow charismatic leaders, avoid standing out from our peer group, and are reluctant to change our positions, even when presented with new information

What can we do if the goal is to get as many people as possible to make the best health choices? Early in the pandemic, Gorman and Gorman cautioned against the use of ridicule and war metaphors (9). Facts alone are rarely enough to change someone's mind. Scaremongering and information campaigns have a limited effect. The same goes for trying to sway those firmly entrenched in their positions – the spokespersons and charismatic leaders (7). Instead, Gorman and Gorman suggest an empathetic approach, drawing on elements from motivational interviewing, where the goal is for the person to come to their own reasoned decision through constructive dialogue (10). Perhaps such an approach could help women who are reluctant to give birth in a hospital, or who do not want assistance from healthcare personnel, to have an open dialogue with their midwife or general practitioner.

Perhaps there are not so many of these women – at least not yet. There is a fundamental difference between thinking something is safe and believing it is the safest or best option. We know that certain quarters promote the idea that giving birth without healthcare personnel is best for mother and child, and we are familiar with their arguments. Misinformation must be addressed quickly to prevent it from taking root within the population (11). And we need to employ the right tools. Condemnation is not one of them.