A canary in the coal mine: the growing popularity of unassisted childbirth

A very small percentage of American women intentionally choose to birth at home without the presence of a midwife, doctor, or nurse. According to Shira Segal, professor at the University of Colorado at Boulder, this is a "radical sub-movement within homebirth ideologies." Why would women choose to give birth without the presence of medical professionals? For some, this action stems from religious conviction. For others, it's a philosophical choice. However, a growing number of women are turning to unassisted childbirth (UC) as a result of feeling powerless and mistreated during a previous birth experience. They have lost faith in American obstetrics.

In 2013, The Journal of Medical Ethics featured an article entitled "Unassisted Childbirth: Why Mothers are leaving the System." The authors argue that health care professionals must understand the growing popularity of UC. Why? The authors claim that contemporary hospital protocols such as "procedural intervention" are "driving women away from formal health care."

Like a miner's canary, this small but growing trend towards UC -- also called "free" or "undisturbed" birth -- should not be ignored. As a doula, I've never attended a UC. As a mother, I would not choose one. Nevertheless, the practice both intrigues and concerns me. As a society, we would be wise to study this phenomenon and reflect upon its meaning.

Variations within UC

The name Marilyn Moran means very little to the average American. Yet, for many in the UC community, she is regarded as a beacon of insight. In 1981 Moran authored "Birth and the Dialogue of Love" wherein she argues that expectant couples only need each other to birth "the fruit of their love." For Moran, birth is potentially a deeply sexual experience and its medicalization removes women from the capacity to enjoy the sensual or orgasmic dimensions of birth as nature intended. After delivering her tenth child at home alone with her husband, Moran devoted the rest of her professional life advocating a couples approach to free birthing.

Not all UC proponents share Moran's couples-only philosophy. There are disagreements within the movement as to what support a laboring mother can receive and still call her birth unassisted. Most agree that no one should be timing contractions or checking cervical dilation. In order to attain the ideal pain-free and highly pleasurable birth, some women chose to birth completely alone. Others surround themselves with close friends or hire a doula to offer emotional and physical comfort. The Doula Organization of North American (DONA) "does not take a stand or position on UC." DONA International's official statement on unassisted births attended by doulas states: "DONA International doulas support a woman's right to autonomy and freedom of choice." The repeating mantra of UC advocates I interviewed is that "women should do whatever makes them comfortable."

What does autonomy, freedom, or comfort look like for UC proponents? In seeing themselves as honoring intuitive and primal birth wisdom, the practice of non-human mammals secluding themselves in preparation for birth is often highlighted. Also, UC advocates idealize birthing practices that existed before the advent of modern medicine. In particular, tribal customs that emphasize birth as a rite of passage that women face alone are held in high esteem. Today, some tribal communities, like the Piraha of Brazil or the San Bushmen people in South Africa, regard birthing alone as the ideal. However, birthing alone is the exception not the norm in human experience.

Throughout recorded history, the vast majority of birthing women have sought out the support of birth attendants. There always have been women more skilled than others when it comes to assisting the safe delivery of a newborn. These proto-midwives from our past "have been around since the dawn of human consciousness because women become intrinsic seekers of help or support during childbirth," states Tina Cassidy author of "Birth: The Surprising History of How We are Born." According to Cassidy, UC will appeal to what "has always been and will always be a very small minority of women."

Why birth unassisted?

Like advocates of assisted home births, UC adherents oppose the routine privileging of medical or technological knowledge over the intuitive and lived experiences of laboring women. However, unlike assisted home birth advocates, UC proponents claim that intuitive wisdom best emerges -- or only emerges -- in the absence of medical authority figures including home birth midwives.

For Christian UC adherents, God created the human body to "speak" and pregnant and laboring women are encouraged to listen to their bodies' wisdom and "rest in Him." Jeanine Baker, the founder of the website "Christian Unassisted Childbirth" writes, "it is my hope that more women who are dissatisfied with their own previous birth experience(s) will stumble onto this site and find what they've known in their heart all along." Birthing unassisted is growing in popularity among fundamentalist Christian subcultures particularly within the Quiverfull movement that eschews the use of birth control. The most extreme version of Christian UC comes from the work of Carol Balizet, a leader in the Home in Zion Ministries based in Tampa, Florida. According to Balizet, Christians who place their faith in the "false high priests" of medicine risk delivering their children via cesarean section -- a surgery she regards as being under the authority of Satan.

Most women who plan a UC birth don't do so for religious reasons and Balizet's extremism is controversial even within fundamentalist Christian circles. However, all involved in the movement recognize the name of Laura Shanley, author of "Unassisted Childbirth" first published in 1993. Shanley's website is a go-to reference for women considering UC. She is deeply respected within UC circles and often regarded as the voice of the unassisted birth movement.

According to Shanley, physical health or disease is rooted solely in a person's state of mind. For example, if a pregnant woman has placenta previa -- wherein the placenta grows over the cervical opening making vaginal delivery very dangerous -- it is because the woman harbors unexamined fear or stress. "In order to heal this condition the woman needs to ask herself why she created the condition in the first place," states Shanley. Perhaps the woman is having marital, family, or work related problems. Perhaps she didn't want the pregnancy. Perhaps she was feeling, as Shanley puts it, "overwhelmed."

Furthermore, a person's psychological state is deeply influenced by the dominant culture. For Shanley, birthing in a way that "goes against society" is stressful and can cause a birthing mother to face complications as she attempts a UC. According to Shanley, if our society were to fear birth less then "women will no longer trigger the fight/flight response in labor and many of the problems we now see in birth will disappear."

Shanley birthed all five of her children at home unassisted. She sought no prenatal care during her pregnancies. Instead, she relied on her intuition, dreams, and positive thinking practices to guide her choices. Her second birth was a footling breach. "I didn't know he was breech until his foot came out," she recalls. Trusting a guiding inner voice, Shanley skillfully delivered him herself. "I knew that if I truly felt there was something wrong I would seek medical help," she states.  Her fourth child was born unassisted in her bathroom five weeks premature. He died within hours due to a congenital heart defect. The medical coroner stated that his death would have occurred regardless.

What advice does Shanley offer to Americans upon encountering UC? "Do your own research," she recommends. This is exactly what a small but growing number of women are doing.

Some women are drawn to the privacy and autonomy of UC due to previous birth or sexual trauma. Studies confirm that women can develop post-traumatic stress disorder (PTSD) after experiencing a particularly difficult or interventionist birth. For sexual abuse survivors, being poorly or insensitively treated by their care providers can trigger a great deal of fear and deep resistance to working with medical professionals in future births. Shanley's work also speaks to women who are frustrated with the medical models available to them. "A large percentage" of women coming to UC are doing so as a "counter surge to what is happening in obstetrics" states Florida midwife and birth activist Adriana Algieri.

A Lack of Options

Up until the 1930s, most Americans were born at home with the assistance of a physician, midwife, or birth attendant. Then a hospital based model of care favoring the presence of, at the time, an all male obstetrical profession pressured lawmakers to ban midwifery. In just a few decades, most Americans were born in hospitals where birth was commonly regarded as something to manage and control.

Beginning in the 1970s, well-known natural birth advocates, including the legendary Ina May Gaskin, turned to each other for support in delivering their babies. Basically, they self trained as lay midwives. Midwifery care was non-existent in most of the US and hospital-based care favored practices, like routine episiotomies or forceps deliveries, which were antithetical to a respect for the natural process of birth. Leaders in the natural birth movement helped establish the formation of programs to formally train midwives who could legally practice at home, in birth centers, and in hospitals. While the natural birth activists of the 1970s were delivering "unassisted" in one sense, overall they were not guided by the current UC philosophy that rejects the presence of all medical support.

Today, America's dominant hospital based model of birth remains quite interventionist despite improvements from the routine episiotomy days. Instead of fully focusing on the well being of the mother and child, care providers often feel obligated to monitor the clock in order to conform to set rules concerning the time allotted to women for labor. Given this, it's no wonder that one in three babies in the US are born via cesarean section. For women seeking to birth with assistance outside of the hospital setting, viable options aren't always easy to find. In more than two-dozen states, assisted home birth by Certified Nurse Midwives and/or Certified Midwives remains illegal and birth centers can be hard to come by.

For women seeking a vaginal birth after a previous cesarean (VBAC), choices can be particularly limiting. Some hospitals don't allow them and in many states midwives can't legally attend a home birth after cesarean (HBAC). Outside of scheduling another surgery or delivering in another location, some women begin to consider an unassisted birth after cesarean (UBAC). Online, they will find inspiring stories celebrating the power of UBACs to encourage them. Given the rare but life-threatening complications that can occur in the event of a uterine rupture, this is troubling.

The Question of Safety

Several medical organizations strongly oppose UC. In the US, formal statements against the practice have been issued by the American College of Obstetricians and Gynecologists. The American College of Nurse-Midwives also warns against birthing unassisted. Given its underground nature, statistics are hard to come by. Nevertheless, one study reported in the magazine New Scientist examined the neonatal death rate for 300 UC births in a religious community in Indiana. It was 19 per 1000 births. This stands in contrast to the rate of seven per 1,000 characterizing the rest of the state. The US Centers of Disease Control and Prevention (CDC) analyzed the rates of maternal mortality in two Indiana counties where the majority of this same religious community reside. They found the maternal mortality rate was 872 per 100,000 births compared to the rate of 9 per 100,000 for the rest of Indiana's residents. The difference is staggering.

UC advocates are quick to highlight the fact that mothers and babies also die in hospitals. This point particularly hits home for American women as the US currently ranks 50^th globally -- behind every other industrialized nation -- with regard to maternal mortality. However, despite serious flaws in the American obstetrical system, the above-mentioned studies in Indiana suggest that the rate of such tragedies only increase with the removal of all medical support.

It's vital to distinguish UC from assisted home birth when assessing the question of safety. Too often the two are lumped together. Roughly 1.3% of American women plan home births and the majority of these women desire the presence of a skilled midwife to assist the delivery.

The 2014 study on assisted home birth by the peer-reviewed Journal of Midwifery & Women's Health clearly puts to rest the debate about the safety of assisted home birth for low-risk women. The study -- the largest of its kind -- examined the outcomes of 17,000 planned and assisted home births and found that on every level, low-risk women had better outcomes at home in the care of a trained midwife than their counterparts in the hospital. For example, the cesarean section rate for these births was 5.2%. A concern about UC doesn't mean that the safety of planned and assisted home birth is in question.

Not all unassisted births are planned. Birth can happen quickly before the arrival of an attending professional or a trip to the hospital. According to the CDC, one-third of the unassisted home births documented in 2006 were unintentional. Whether planned or not, according to the National Center of Health Statistics, the number of UCs went up 10% between 2004 and 2006. The movement continues to gain adherents. In a 2013 interview, Helen Dahlen, a professor of midwifery at the University of Western Sydney, stated: "I think free-birth will continue to grow in popularity until we fix the system."

Barbara Herrera from San Jose, California is doing her best to fix a broken hospital system. Herrera is a Licensed and Certified Professional Midwife. She worked for years as a home birth midwife and once supported the UC movement. In fact, she delivered her daughter unassisted and led workshops for mothers planning UCs on how to handle medical emergencies. Today, Herrera chronicles her journey from being "pro-UC to anti-UC" on her blog "The Navel Gazing Midwife." The untimely deaths of acquaintances attempting UCs precipitated her shift.

Herrera understands that some women in the US are unable to obtain the quality of care they so desire. She gave up her home birth practice to work as a doula with the hope of providing sensitive and personalized support to birthing women in hospitals. Herrera feels strongly that all women should have a medical professional present at their births -- even if this means delivering in a less than ideal setting or undergoing another major abdominal surgery. "It's far worse to offer condolences because of a dead baby," she states.

Not all medical professionals agree. Two well-respected voices in the natural birth community, Dr. Sarah J. Buckley MD and Dr. Aviva Romm MD, both had planned UCs. These women are not anti-medicine. They practice medicine. Some UC advocates argue that as long as medical support is lined up and "waiting in the wings," the experience of delivering one's own child is beyond extraordinary.

The Canary

It is unlikely that UC ideologues will change their minds about the practice even if provided with convincing evidence that UCs are statistically more dangerous than birthing assisted at home or in an American hospital. For the religiously motivated, a UC death indicates a lack of faith, God's will, or a karmically correct outcome. Shanley argues that even if she encountered compelling statistics regarding an increase risk to mother and child in UC, they "wouldn't prove [to her] that [UC] is dangerous." For Shanley, an increase in UC mortality rates would reveal that our culture continues to regard birth as dangerous. This belief then "becomes a self-fulfilling prophecy."

I imagine that most women drawn to UC are not ideologues in the religious or philosophical sense. They simply have lost faith in the medical models available to them. They also are enamored and encouraged by the powerful testament of UC births that have unfolded with wonder. Given the challenges facing birthing women in America, is it surprising that a minority movement would herald a retreat from the system writ large?

Honoring the wisdom of a natural birth is beautiful. However, sometimes dangerous and life-threatening events unfold naturally in labor and delivery. A wise and judicious use of medical intervention in such situations saves lives. The small but growing number of women who choose to sidestep all medical support is concerning. Like a miner who observes a sick canary, it is in our best interest to do more than notice.