Freebirth - the evidence - Dr Sara Wickham

Freebirth – or unassisted birth – is a term used to describe a birth in which the woman/family has decided to give birth without the assistance of a professional midwife or doctor. They may or may not have care during pregnancy, and there are many different reasons and situations in which women freebirth. So, as with many things, one size doesn’t fit all and this can be a hard thing to define.

Freebirth is legal and no-one is under any obligation to consent to any medical appointment, treatment or procedure as long as they are conscious and have capacity. As I will show on this page, it’s also not hard to understand why some woman and families opt to birth without midwifery or medical assistance. But those who opt for freebirth often find that they are judged, shamed, coerced or subject to professional and/or systemic pressure.

Back in 2008, I wrote an article for a midwifery journal about unassisted birth, which was the term that was more commonly used at the time. At that point, only a handful of articles and studies had been published on this topic. They varied in tone, as you might expect.

Since that time, a number of studies have been published, and I created this page for those who are looking for academic evidence and conversations about freebirth. I add to it when I see something new, so it’s worth bookmarking if you are interested in this topic.

Before I go on, let me briefly explain my background and position, so you can decide whether to spend your time reading this.

Here’s where I’m at…

I am a midwife, yes. So I do see the value of midwives and midwifery. More on that in a bit.

But I’m a midwife who has worked outside of the system for almost her whole career. I totally understand that the system isn’t for everyone, for all manner of reasons. In fact, I became so frustrated with the lack of evidence-based care in some areas and settings that I began to write books about the evidence for different interventions so that I could help more women and families than I could care for directly.

So I’m passionate about women and families being able to make the decisions that are right for them. (I literally wrote the book on that too. It’s useful even if you are birthing outside the system.)

I believe that everyone should be able to access good evidence to help their decision making. It’s not the only thing you’ll want to take into account. But it’s often very enlightening, especially when it’s unpacked and explained by someone who knows their stuff.

Perhaps even more importantly if you’re reading this, I totally understand why some women and families opt for freebirth.

Why freebirth isn’t as extreme as some people would like us to think

I know that some people would like to put women and families who opt for freebirth into a metaphorical box along with other groups of people who they see as extreme and ‘out there.’

The thing is that there’s nothing particularly extreme about many of the freebirthing women that I have met. Some of them remind me of something Caitlin Moran wrote in The Times magazine in 2016 about how, in reality, feminists aren’t radical, bra-burning man haters. They are, she wrote, normal women going about their normal business muttering tiredly, “I’m so tired of this sh*t”.

Same goes, in my humble experience, for quite a few of the women who decide to freebirth.

They aren’t poster women for taking risks with your baby.

They’re not hippy, chanting, granola-eaters who don’t care whether their babies live or die.

Far from it.

Some of these women and families know more about the evidence (or lack of evidence) for birth interventions than their caregivers. As a result, they feel that their babies will be safer away from mainstream medicine and its conveyor belt of routine drugs, interruptions and interventions.

Different risks

This was confirmed by a research study by Jackson et al (2012). The researchers interviewed women who chose to have a freebirth or to birth at home even though they had been advised that they had ‘risk factors.’

The researchers found that:

“[T]he participants acknowledge that birth is a time in life that carries an element of risk. They perceive that hospital represents a more risky place to give birth than at home and that interventions and interruptions during labour and birth increase risk. Women who birth outside the system perceive the risks of birth in hospital differently to most women. These women feel that by birthing outside the system they are making a choice that protects them and their babies from the risks associated with birthing in hospital and thus provides them with the best and safest birthing option.

[I]n pursuing the best for themselves and their babies, women who birth outside the system spent a lot of time and energy considering the risks and weighing these up. For them birth in hospital is considered less safe than birth at home.” (Jackson et al 2012).

Weighing up risks and evidence

In other words, those who opt for freebirth are often caring and deeply committed women who are sick of being told how, when and where to give birth, worn down from hearing that their bodies aren’t up to the job and fed up with being told that professional perceptions of risk are more valid than their own worldview.

One really important study was carried out by Plested and Kirkham (2016), who explored “Risk and fear in the lived experience of birth without a midwife” and found that:

“[W]omen׳s lived-experiences of the maternity services in this study suggest a pervading mood of fear which finds voice in manipulative risk discourse and midwifery behaviours that can result in women avoiding maternity care. Fear based ׳risk-talk׳ is used as a scare tactic to coerce women into particular choices; if women do not comply they are labelled ׳risk-takers׳ and can become ostracised by the maternity care system.

[R]isk discourse and its emphasis on mortality and morbidity raises awareness of death and creates important existential concerns for women which are unaddressed by health-care professionals. This can lead to a loss of trust in health-care professionals and women sourcing positive support and a salutogenic approach to childbirth from outside the system.” Plested and Kirkham (2016).

Tired of being controlled

In fact, many of the studies on this page show the same as Jackson et al (2012). That is, women and families have weighed up the risks and the evidence. They’ve often spent many hours exploring this.

Some of them are tired from living in a world where, the minute you become pregnant, people think they have the right to tell you what you can and can’t do, eat, and drink. Where total strangers seem to feel they are allowed to touch your belly. And in which anyone who has the right bit of paper and a white coat or a blue tunic thinks they can put their fingers inside you anytime they deem it necessary.

In case you’re not aware: they can’t. That’s not legal either.

As a colleague of mine commented, “It’s a popular criticism to think that freebirthers exist as an isolated phenomena and are acting in a way that disregards safety and responsible parenting. They have come into existence as a response to the disjunctive relationship between authoritarian medical practice and individual client autonomy.”

It’s no wonder that some women and families opt out.

The issue with the evidence

In Your Own Time was written to help parents and professionals better understand the issues and the evidence relating to the current induction epidemic. Looks at the evidence relating to due dates, ‘post-term’, older and larger women, suspected big babies, maternal race and more.

In case you’re not already aware, there is a wide gap between what the evidence says is an optimal approach to birth and what is bring offered within mainstream maternity services.

For instance:

There are wide discrepancies between the evidence on induction and the current guidance. Although that post is about the UK, the same thing is going on in most if not all other high-income countries.

Evidence on labour progress is ignored.

Although we know that cervical recoil and labour plateaux are real phenomena, they aren’t accommodated for.

Women are instead subjected to intervention without this being an informed decision, and it can lead to negative birth experiences.

The lack of evidence to support fetal monitoring is ignored.

Women who are older or larger than average have a particularly difficult time if they want to opt for or out of certain things.

And there are a hundred other examples.

Not everyone who realises this opts for freebirth, of course.

I’m just explaining the fact that so many women can’t get the respectful, supportive, evidence-based care they want and need. Which is why some of them are looking elsewhere.

I want to add a quick caveat here. Whenever I write about freebirth, someone always wants to point out that not all women/families seek freebirth to avoid the system. Some see it as a positive decision. So let me acknowledge that up front. I already noted that it’s hard to define. It’s also important to say that there are as many reasons to freebirth as there are people doing it.

In fact, let’s look at the research on why women freebirth.

Why women freebirth

There have now been a number of studies looking at why women freebirth.

Here are a few examples:

Women’s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’.

In their review of the literature, Holten and de Miranda (2016) found that:

“Concerns over consent, intervention and loss of the birthing experience may be driving women away from formal healthcare. There is a lack of fit between the health needs of pregnant women and the current system of maternity care. Biomedical and alternative ‘outside the system’ discourses on authoritative knowledge, risk, autonomy and responsibility must be negotiated to find a common ground wherein a dialogue can take place between client and health professional.”

Why do some women choose to freebirth in the UK? An interpretative phenomenological study.

This qualitative (and freely available) study by Feeley and Thomson (2016) explores what influenced women’s decision to freebirth in the UK.

The authors concluded that:

“The UK based midwifery philosophy of woman-centred care that tailors care to individual needs is not always carried out, leaving women to feel disillusioned, unsafe and opting out of any form of professionalised care for their births. Maternity services need to provide support for women who have experienced a previous traumatic birth. Midwives also need to help restore relationships with women, and co-create birth plans that enable women to be active agents in their birthing decisions even if they challenge normative practices. The fact that women choose to freebirth in order to create a calm, quiet birthing space that is free from clinical interruptions and that enhances the physiology of labour, should be a key consideration.”

Why do women choose an unregulated birth worker to birth at home in Australia: a qualitative study.

In Australia, Rigg et al (2017) explored “…the reasons why women choose to give birth at home with an unregulated birth worker (UBW) from the perspective of women and UBWs.”

“Four themes were found: ‘A traumatising system’, ‘An inflexible system’; ‘Getting the best of both worlds’ and ‘Treated with love and respect versus the mechanical arm on the car assembly line’. Women interviewed for this study either experienced or were exposed to mainstream care, which they found traumatising. They were not able to access their preferred birth choices, which caused them to perceive the system as inflexible. They interpreted this as having no choice when choice was important to them. The motivation then became to seek alternative options of care that would more appropriately meet their needs, and help avoid repeated trauma through mainstream care.” (Rigg et al 2017).

Birthing outside the system: the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia.

Also in Australia, Jackson et al (2020) wrote more about why women chose freebirth or to have a homebirth with risk factors.

“The core category was ‘wanting the best and safest,’ which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was ‘finding a better way’. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies.” Jackson et al (2020).

The growth of freebirth

There are no official data on freebirth, and I’ll explain why it’s hard to research in the next section. But we can be confident from anecdotal evidence that more freebirths occurred during the Covid pandemic, likely because of the unevidenced restrictions that were placed on women and families. More on that here.

In 2022, a scoping review was carried out by Shorey et al (2022). They looked at freebirth studies carried out in low-, middle- and high-income countries (and more on why that’s important below). They highlighted some other issues as well:

“More women chose to give birth unassisted in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Overall, motivation for freebirth included previous negative birth experiences with health care professionals, a desire to adhere to their birth-related beliefs, and fear of contracting the COVID-19 virus. Included studies reported that study participants were often met with negative responses when they revealed that they were planning to freebirth. Most women in the included studies had positive freebirth experiences. Future research should explore the different motivators of freebirth present in LMICs or HICs to help inform effective policies that may improve birth experiences while maintaining safety.” (Shorey et al 2022).

There are growing numbers of international studies on freebirth as well. Shorey et al (2022) include a useful list of studies of freebirth in low- and middle-income countries. Researchers have also looked at freebirth in other high-income countries, including Poland, Norway, Denmark, The Netherlands and Malaysia.

The evidence for safety

There is also no direct evidence on the relative safety of freebirth. That’s not likely to change, because of the stark contrast between the type of research that evaluates safety – which involves being randomised to a type of care – and the reasons that women give for freebirthing. It’s incredibly hard to gather data on a group who often feel forced (through no fault of their own) to hide what they are doing. Some women/families pretend that they ‘accidentally’ gave birth before they could call a midwife. Others do their best to avoid contact with the system altogether.

Some of the professional, midwifery-focused organisations who have started to create resources about freebirth point out that there is a lot of evidence to support the value of midwifery care.

They point to research showing that, “Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths.” (Homer et al 2014).

They cite an important paper in The Lancet which shows the value of midwifery care worldwide.

They present evidence from the World Health Organization and The Cochrane Collaboration about the value of midwifery and how midwives make a difference.

And we do.

But these studies are global. Freebirth occurs everywhere in the world. While I have written mostly about freebirth in high-income countries, because I live in the UK and my readers live in high-income countries, more women opt for unassisted birth in low- and middle-income countries. However, their health and situation may be rather different from those who freebirth in, say, the UK or Canada or Australia.

Yet the studies cited include many of these women in low- and middle- income countries who are not comparable with most of the women who are opting for freebirth in high-income countries. The studies are sometimes comparing midwifery-led care with obstetric-led care, not midwifery care with freebirth. Setting – that is, whether you birth at home, in a birth centre or in hospital – also makes a difference. The research on midwifery care doesn’t take into account the additional knowledge (and sometimes, non-professional supporters) that freebirthing women and families may have.

And, even if these things weren’t an issue, the kind of midwifery care that was on offer in many of the studies upon which this data were based is not necessarily what is on offer today. In fact, it often isn’t, and that’s a huge part of the problem.

There is, as in so many areas, a lack of evidence, which means we need to make decisions in uncertainty.

Just as women and families have been doing for millennia.

More information and your rights

If you’re looking for more information about making birth decisions, I have a book which will help you look at these. It’s called What’s Right For Me? Making decisions in pregnancy and childbirth.

There are hundreds of pages of information on this website if you want to become more informed about the issues. If this is your first visit, this is a good place to start.

There are also some useful factsheets out there if you’re looking for information on your rights. For those in the UK, Birthrights have factsheets on Unassisted Birth and Consent to Treatment (which also includes discussion of capacity).