Extreme childbirth: Freebirthing* 06 January 2007 * From New Scientist Print Edition. * Anna Gosline*
ONE HOT afternoon in August 1977, heavily pregnant Laura Shanley felt the early twinges of her first labour. Instead of calling a midwife, she calledover some friends. When her waters broke, she didn't dash for the hospital, just the bedroom. On hands and knees she gave birth to her son, John, in oneswift push. Ready to catch him was the only other person in the room, herhusband, David. Over the next few years Shanley, who lives in Boulder,Colorado, went on to have four more babies in the same way.Giving birth at home instead of hospital is not all that unusual. What setsShanley apart is choosing to go it alone without any professional help. Sheis part of a movement that advocates unassisted childbirth, or"freebirthing". The backlash against the perceived overmedicalisation of childbirth in the west has already seen some women reject hospitals infavour of a low-tech home birth with a midwife. Freebirthing proponents gofurther still, shunning even midwives. Almost all doctors and many midwives condemn unassisted childbirth asdangerous. The small but growing number of freebirthers, however, say it isperfectly safe for a woman to give birth alone, or at most, accompanied by apartner or friend. They believe that advice from medical staff interfereswith the normal birth process, and that women have easier labours if leftalone "as nature intended". "Birth is inherently safe and relativelypainless," Shanley claims, "provided that you don't interfere by usingdoctors or midwives."Freebirthers do have a point: childbirth has never been so medicalised. Formost of history women gave birth at home, possibly attended by a midwife ordoctor, but with little to no medical help. In the 20th century,city-dwelling and new, potent painkillers brought women into hospitals to deliver their babies.Here a growing number of interventions were introduced. In difficult laboursit became common for doctors to ease out the baby with forceps, or, later, asuction cup known as a ventouse. Syntocin, a synthetic form of the hormoneoxytocin, came to be used to trigger labour or speed it up. Once a lastresort, the ultimate intervention of a Caesarean section now accounts forabout one in four UK births. There is no doubt that these and other interventions have saved the lives ofmillions of women and children the world over. But campaigners and even somedoctors say they are overused and may even do more harm than good. Syntocin,for example, often makes contractions more painful.The countermovement began in the 1960s, spearheaded by the NationalChildbirth Trust in the UK and the Lamaze Institute and the InternationalChildbirth Education Association in the US. Today such groups lobby forchildbirth to remain as simple as possible, with the management of low-riskbirths ceded to midwives, who have only relatively low-tech forms of help attheir disposal. So far this has extended to the promotion of home births, with a midwifepresent but the nearest doctor an ambulance-ride away. The safety of homebirths is still hotly contested, but some want to progress to what could beseen as the natural childbirth movement's logical conclusion - completelyunassisted childbirth.Freebirthing has no formal organisations, so charting its growth isdifficult. When Shanley wrote a book on the subject in 1994, she says thepractice was nearly unheard of. Now most freebirthers use the internet tospread the word and swap tips. Shanley runs a website for these purposes andover the past decade she has heard from many other women who have givenbirth without help.Linda Hessel, who lives in Corvallis, Oregon, and had her third childunassisted, collects freebirthing stories from the website Mothering.com. About 160 mothers post from the US, Canada, the UK and Australia on the site's unassisted childbirth forum. It is a very small but growing movement,she says.Freebirthing is also growing in Australia, possibly influenced by pooraccess to midwives and the closure of some rural maternity wards over thepast few decades. The high rate of Caesarean sections in hospitals may alsobe a factor, says Sarah Buckley, a general practitioner (GP) in Melbourne.Six years ago, Buckley had her fourth child unassisted - a differentprospect for a GP, to be sure, but she supports the right of all mothers tofreebirth, making her one of the few doctors to do so.So do the freebirthers' claims stack up? Are they in fact giving birth thenatural way? In some ways nature has dealt humans a poor hand when it comesto giving birth. As early hominids evolved an upright walking posture, thepelvis had to pivot up, narrowing the birth canal. And the price we pay forour huge brains? Huge heads. No wonder the passage of a full-term babythrough the birth canal is a tight squeeze. "Birth is not as simple orstraightforward as it is in other animals," says Wenda Trevathan, a medicalanthropologist at the New Mexico State University in Las Cruces."Freebirthers say birth is inherently safe and relatively painless providedyou don't interfere by using doctorsor midwives"The shape of the pelvis may have led to another feature of human births.Thanks to the twisting and cramped interior of the birth canal, humanbabies, unlike those of other primates, tend to turn mid-birth and exit thevagina facing their mother's spine. This makes it harder for the mother toclear mucus from the baby's mouth after its head emerges. And if she pullsthe baby out too forcefully she may bend the spine and neck against itsnatural curve.That's why Trevathan argues that some form of birth attendant may have been de rigeur since bipedalism began to evolve 5 million years ago. "In mostcases, the mother and the baby benefit from some form of assistance," shesays.A glance through anthropological studies reveals that in almost allhunter-gatherer cultures, women tend to have some form of birth attendant.Even among the !Kung people of southern Africa, who say the ideal birth is asolitary (and silent) one, in practice women usually have help, at leastuntil they have a previous birth or two under their belt.Of course a birth attendant who merely helps the baby out and clears theirairways hardly requires midwifery training. But it does suggest thatfreebirthers who set their hearts on complete privacy may be striving forsomething that rarely happens "in nature".What does happen in nature? The World Health Organization estimates thatworldwide 15 per cent of labours have a life-threatening complication. Ithas also been estimated that the "natural" rate of maternal death fromchildbirth is between 1 and 1.5 per cent. The biggest risk is uncontrollable bleeding, even when women give birth in hospital.Birth is even riskier if it is you that is being born: in some developingcountries the neonatal death rate can be 10 per cent. The chief danger tothe baby is lack of oxygen, for example due to blood flow through theplacenta being restricted in a long and difficult labour.It is unclear, however, how these risk estimates apply to modern-day westernwomen who are generally healthy and well nourished. In fact freebirthersclaim it is better general public health that has led to the dramatic dropin maternal and infant deaths over the past century (see Graph).There is some evidence to support this claim. In the late 1970s, MarjorieTew, then a research statistician at the University of Nottingham in the UK,analysed the national birth statistics from 1958 and 1970. She found thathospitals had far higher infant death rates than either home births orindependent birth centres run by GPs, both of which used fewerinterventions. Contrary to the prevailing views, Tew concluded thatobstetric interventions hindered, rather than helped, the already fallingdeath rates. The underlying cause of the drop, she said, was better publichealth, nutrition, living conditions and infection control. It was arelatively low-tech medical intervention, the use of antibacterialsulphonamides to treat post-birth infections, that caused the biggest dropin maternal mortality over the past century.Home advantageThe accuracy of Tew's controversial conclusions hinge on whether heranalysis took adequate account of the fact that women would be more likelyto go to hospital if they were at higher risk in the first place. Tew didadjust for many risk factors including having a multiple pregnancy, a babyin the breech or head-up position, high blood pressure, previous Caesareans,and bleeding during pregnancy. However, there may have been other riskfactors omitted from the data.Tew's findings were so radical that it was many years before her work waspublished in an academic journal, and even then it was largely ignored. Inthe meantime the push for hospital births continued, and today they are thedefault setting for childbirth in the west.In most western countries even a standard home birth with a midwife presentis seen as a risk. In the US - where even uncomplicated hospital deliveriesare carried out by doctors, not midwives - most obstetricians are againsthome births. Two past presidents of the American College of Obstetriciansand Gynecologists have equated home births with child abuse. At one of itsmeetings last year the college gave out car bumper stickers saying: "Homedelivery is for pizza"."US obstetricians gave out car bumper stickers saying: 'Home delivery is forpizza'"The UK government has recently voiced support for making home births aneasier option, but they still account for only 2 or 3 per cent of births. InEurope only the Netherlands stands out, with a 30 per cent home-birth rate.The big question, of course, is whether home births are safe. On the onehand, there is the lack of doctors and their sometimes lifesavinginterventions. On the other, hospitals can be stressful places. Adrenalin(epinephrine in the US), the fight-or-flight hormone produced in response tostress, seems to slow labour, which could explain why decades of researchhave linked stress and fear to longer and more difficult births.The best way of answering the question would be to randomly assign a largenumber of women to either home or hospital births. But few would put up withhaving their care chosen for them. Instead, researchers can only study theoutcomes of the choices women make for themselves. This risks home birthsappearing safer than they really are because they tend to be selected bywomen who are white, well-off and well-educated - all factors that lowertheir risk of difficult births - as well as being at low medical risk.One of the biggest and best studies in this field was published last June,(BMJ, vol 330, p 1416). It attempted to follow every North American womanplanning a home birth under the care of a certified midwife in the year 2000and ended up including 5418 births.No mothers died and the infant death rate was 1.7 per 1000 - a similarfigure to low-risk hospital births in the US. Home-birth campaigners havehailed these results as vindication of their stance. Critics, on the otherhand, point out that 12 per cent of the women had to be transferred tohospital, usually for maternal exhaustion or because their labour wasn'tprogressing. And 3.4 per cent were admitted as an emergency, mainly forfetal distress or maternal haemorrhage.While this debate seems likely to run and run, many of even the staunchesthome-birth supporters shun freebirthing. Marsden Wagner, the WHO's formerdirector of Women and Children's Health, says it is a step too far. "Thereare a very few cases when things go bad," he says. "Midwives are trained toknow when things are going in the wrong direction."If the evidence on the safety of standard home births is unclear, it isalmost non-existent for freebirthing. There seems to be only one study ofwestern women who intentionally had unassisted births, published in 1987.This looked at a strict Christian community in Indiana called the FaithAssembly Church, who refused all medical attention for religious reasons. Itdocumented 344 births over seven years.The figures make grim reading. The neonatal death rate was 19 per 1000 livebirths, compared with 7 per 1000 for the rest of Indiana. Maternal mortalitywas 8.7 per 1000, 20 times higher than for other women in Indiana.Studies published in medical journals seem unlikely to influence thefreebirthing community, however. From their websites and message forums itis clear that these women reject orthodoxy in numerous ways. Many advocatelong-term breast-feeding and home-schooling; some also shun infant vaccinesand prenatal medical care. Without ultrasound scans and other checks,someone could unwittingly plan an unassisted birth while carrying twins or abreech baby - as happened with Laura Shanley's third child. Even that maynot deter the most radical freebirthers, who scorn medical assistance evenfor serious complications. But not all go so far. "These variations aresomething that I would want to know about," says Hessel, "and I might makedifferent plans accordingly."Freebirthers' attitudes to emergency back-up also vary; some women areprepared to head to hospital if the labour goes awry, others don't. Hesselknows of three infant deaths that might have been prevented if the mothershad sought help soon enough.Naomi Stotland, an obstetrician at the University of California, SanFrancisco, has stopped trying to understand the freebirthers. They feel, shesays, "that they are very in touch with their bodies and they can tell whensomething is right and something is wrong".There will never be a randomised trial of freebirthing. "It's not somethingthat is easy to prove or even study scientifically," says Stotland. "These are belief systems about birth." And belief is a powerful thing.
Anna Gosline is a science writer in Vancouver, Canada
From issue 2585 of New Scientist magazine, 06 January 2007, page 40-43