Unassisted birth: listening and learning from the minority

This is the text of a 2008 article that I wrote about unassisted birth, or freebirth.

Please bear in mind that this was written very early on in the unassisted birth debate and there are far newer references available, some of which I discuss here.

It is the assumption of most people who live in modern, Western societies that, at some point after a woman becomes pregnant and before she gives birth, she will avail herself of the services of a professional birth attendant.

Most often, her birth attendant will be working within organised maternity services.

Yet, since the inception of professional birth attendance and organised maternity services, there have always been women who, for one reason or another, have given birth without professional assistance.

There are probably as many reasons for women having unassisted births as there are women, but, as Gaskin (2003) pointed out, it is important that we distinguish between births that are intentionally unassisted and those that are unintentionally unassisted.

The latter category is wide and it includes a huge range of women.

Most of us have met the woman who went to every antenatal visit and class but whose baby arrived before her midwife did, and, if we haven’t met the women who didn’t know she was pregnant until she birthed her baby into the toilet, then we have read about her experience in the newspapers.

Neither of these women necessarily wanted to birth without help.

Nor did the young woman who suspected she was pregnant but was too scared to tell anybody, the woman who did not know whom to tell, perhaps because she faced barriers in language or understanding, or the woman who was bullied by someone else into not telling.

As different from each other as these women who have unintentionally unassisted births might be, they are different again from the women who are actively choosing unassisted birth, unattended birth or, as some prefer to call it, freebirth.

Yet, like Gaskin, I believe that this distinction is important, in the same way that it is important to distinguish planned from unplanned homebirth in order to assess the safety of homebirth in research studies without the confounding that is caused by the mixing together of data from all homebirths.

A Range of Attitudes

The decisions that we make about our pregnancy and childbirth journeys can shape our experiences, health and lives, as well as those of our families. But those decisions can be complex. This book is a guide to the different perspectives and approaches that exist, and it offers tips, tools and ways of thinking which will help you make the decisions that are right for you.

The unassisted birth movement is a very difficult issue to research, by virtue of the fact that these women are actively seeking to avoid the kind of systems that gather data, but it seems to be a movement which is growing.

This is not to suggest that women are choosing this option in their thousands, but the level of discussion of this phenomenon on the internet alone would suggest that a significant and increasing minority of women are deliberately choosing to ‘go it alone’.

This is, then, an issue which is worthy of midwives’ attention.

The issue, however, is controversial, and a range of opinions exists among midwives.

With a few exceptions (e.g. Hughes 1997), much of the initial debate occurred in the United States (US) and, although there are significant differences between US and UK maternity care, two US authors have neatly encapsulated two of the main standpoints in this area.

The first standpoint argues that women have always sought out midwives, and that midwives play an important part in keeping birth safe.

A few years ago, Ina May Gaskin responded to an article published by one of the leaders of the unassisted birth movement in the United States.

Citing stories of unassisted births that had gone awry, she criticised the authors of freebirth websites for, “promot[ing] unassisted birth without taking into account the possible consequences of such a decision” (Gaskin 2003: 40).

Other midwives, however, take a different standpoint, arguing that being with birthing women is a privilege rather than a right and suggesting that, by taking on some of the elements of the medical model, midwives have played a part in fuelling the unassisted birthing movement.

Midwives taking this position try to look through the eyes of women and suggest that, if women do not want midwives, then this is because midwives cannot be offering women what they want (Hart 2003).

“Are we so untrusting of birth that we must carry and recommend a bagful of herbs and medications, put our clients on special diets, dictate food, herbs and supplements, tell them how and when they must labour, frighten them with a long list of rules, regulations and “protocols” and force them to fit into our schedules? Do we horrify them with our talk of risks, consequences, worries and fears? Do we reassure them with our tests, or do we frighten them?” (Hart 2003: 41)

These questions can be asked of birth attendants working in any country or setting.

Women who choose options that differ from the norm tend to be seen as noncompliant, and efforts are made to try to get as many of these women as possible to comply with the system and its norms.

Yet some women do, indeed, choose unassisted birth because they do not believe that professional or systemic maternity care will meet their needs (e.g. McCracken 2000, Schrock 2002).

A Range of Needs

This really seems to be the heart of the problem.

We have built maternity care systems and institutions, and these systems are good at attending lots of women at the same time, but they are not always good at being able to meet the needs of the woman who wants something quite different.

This is not the fault of the people working in the system. There are some amazing midwifery managers out there; they bend over backwards to accommodate individual women’s needs and to put right their complaints, and neither they nor individual midwives are the problem.

The problem may lie more in the way that maternity care is given according to guidelines, by people who are not necessarily known to the woman, and in a way that pays more heed to the needs of the system than to the feelings of the individual.

Many of the women who choose unassisted birth understand that there is little evidence supporting much of what they are being “offered” in the system and yet they know that they have no guarantee that they can get around it. As midwives, we have been challenging the appropriateness of interventions in birth for many years now. How can we blame women for doing the same?

I believe that both of the midwives quoted above are right. It is important that women have full information about the choices that they are making, whatever kind of birth they are seeking.

It is also important to continually question our own practices, and those of the services for which we work.

It may be uncomfortable to realise that “we” can also be seen as an intervention, but, if we can find ways of listening carefully to what this minority of women are saying, we may be able to find ways of improving the experiences of all women.