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“Outside the System”: Motivations and Outcomes of Unassisted Childbirth
November 19, 2016
By Katharine L. O’Day, NHCM, LM, CPM of Sacred Transitions Midwifery Institute
True informed consent and refusal cannot be offered to maternity patients without a clear understanding of the risks and benefits of childbirth options. Unassisted Childbirth, often abbreviated “UC” is a growing trend among birthers in the United States and other nations with similar maternity systems. In some areas the practice has increased more than 10% since 2004. (1) Many professional maternity organizations have come out to strongly discourage this choice, even though very little research has been done into UC safety and outcomes. Some assumptions have been made about the motivation for families seeking to birth unassisted, but very little is known about what is currently driving these families away from the system to birth on their own.
Data was collected anonymously and voluntarily from 857 individuals who had previously planned to birth unassisted, regardless of final birth location and attendant. Data was collected between December 1, 2014 and September 1, 2015 through Survey Monkey, an online, secure data collection tool. “Unassisted childbirth” was therein defined for the purpose of study as “willfully giving birth without a STATE LICENSED or REGISTERED professional individual present (someone who is permitted by state documentation and/or oversight to attend birthing women). In other words, you attempted or successfully birthed your baby without planning to have such a person on the premises at the time of your baby's birth. This definition means that no state recognized doctor, midwife, chiropractor, naturopath, nurse or any other professional individual was part of your plan for who would be present at your baby's birth. However, an unassisted birth plan may include the planned presence of one or more doulas, unlicensed or unregistered midwives (those unrecognized by your state regardless of their expertise or background), family members, friends, or any individual who was not licensed or registered by your state as being employed in the profession of attending childbirth.”
A total of 857 individual birthers took part in the research. The primary motivational reasons cited for seeking to birth unassisted were reported as 1) Personal intuition (80.24% of respondents), 2) A dislike of hospitals (77.32% of respondents), 3) Concern for their newborn’s safety within the confines of a hospital (72.20% of respondents) and 4) A desire to not repeat a prior bad hospital experience (51.83% of respondents). Collected demographics revealed a high percentage of lower middle class, white, married women who were college educated and had attended some type of birth or newborn certification or medical training. Among the 857 respondents, 1,444 pregnancies were reported, including 1,449 infants (five sets of twins were included). Out of these pregnancies, 1,333 pregnancies resulted in unassisted births. This reflected an unassisted delivery success rate of 92.32%. The failing 111 respondents transported into the care of a licensed or state regulated provider prior to delivery. Ultimately 1,339 babies were delivered unassisted. A perinatal mortality (2) rate of 2.2 per thousand was noted among the unassisted births which is comparable to the US rate of 2.97 per thousand. (3) The postpartum newborn complication transport rate was 2.17% within the first week of life, representing the immediate newborn morbidity rate. The postpartum maternal complication transport rate was 3.52%, overwhelmingly for postpartum hemorrhage. There were no maternal deaths reported. The total transfer rate to a licensed provider (regardless reason) was 12.93%. Final cesarean rate for all pregnancies, regardless of final birth location or attendant was 1.24%. There were 129 vaginal births after cesareans (34 of them had more than one prior cesarean) and the success rate among them was 100%. Newborn anomaly or abnormality rate was .62% and did not contribute to the perinatal death rate.
Further research that identifies those planning to birth unassisted and proceeds to follow them through their pregnancy and delivery would give a better understanding of the motivations and outcomes of unassisted births. This study could only rely on retrospective self-reporting. However, the low percentage of pregnancy and birth complications represented in this study should inspire an interest in further research. The low morbidity and mortality rates exist here despite factors that should raise those rates according to other research. Namely, that nearly one third of respondents reported having no prenatal care at all and 71.11% of respondents had no type of monitoring during their labor and birth. Participants also included five sets of twins, 26 vaginal breech deliveries, 96 vaginal births after one prior cesarean, and 34 vaginal births after more than one prior cesarean. These factors should be expected to induce a rise in poor outcomes, due to known rises in those groups when studied in a hospital setting. Preliminarily, planned unassisted childbirth appears to be a viable option for birthing families and the system’s propensity to discourage this choice appears to be based more on cultural bias than research. More research should be done to look at hospital attendance as an intervention on its own and how it affects maternal and newborn outcomes. Additionally, more research should be done into the role of maternal birth education and outcome instead of relying on prenatal visits alone in decreasing perinatal mortality and morbidity.
Unassisted childbirth is a growing phenomenon. Many medical organizations have come out to discourage its practice despite the lack of research. This bias serves to further push UCers (or “Free-birthers” as they are sometimes called) away from the system. This study sought to seek research regarding the safety or dangers of unassisted birth. It also sought to seek the motivation for the choice to birth without assistance. UC families appear to not be swayed by the lack of evidence to prove their choices are safe. As Helen Dahlen said "I think free-birth will continue to grow in popularity until we fix the system.” (4)
Participants were identified through social media, word of mouth and UC support groups. Prior to this study, it had been thought a difficult task to locate participants for such a study, but this task proved quite easy once trust was gained and anonymity assured. Any person who had previously planned an unassisted birth and wished to be involved was included (see “unassisted birth” definition elsewhere in this article). Due to the ease in locating participants, the UC growth rate of only 10% in the past 15 years is brought to question. It may be that UC participants are growing at a faster rate than previously thought.
Unpaid Sacred Transitions Midwifery Institute faculty, administration and students met to discuss, design and implement this survey. Participants were sought through social media channels, word of mouth and UC support groups and were not monetarily reimbursed for providing data. Respondent participation was strictly anonymous and voluntary. No monetary reimbursements were provided to anyone participating in, designing, writing, analyzing or publishing the research. Results were not incentivized by any business, government entity, corporation or nonprofit. Survey Monkey was used for the design and implementation and is a secure internet site that provided the survey technology and disallowed duplicate entries by IP recognition and blocking.
Data Collection Procedures
Data retained included socio-demographic variables, obstetric history, and health care seeking behavior during the antenatal and postnatal periods, delivery outcomes, maternal motivations, maternal and newborn complications, and support sought by the birthing individuals. Data were collected and entered through Survey Monkey and transmitted through secure methods to STMI for analysis. All analyses were performed Survey Monkey’s analysis platform.
“Unassisted Childbirth” was clearly defined for all participants as “willfully giving birth without a STATE LICENSED or REGISTERED professional individual present (someone who is permitted by state documentation and/or oversight to attend birthing women). In other words, you attempted or successfully birthed your baby without planning to have such a person on the premises at the time of your baby's birth. This definition means that no state recognized doctor, midwife, chiropractor, naturopath, nurse or any other professional individual was part of your plan for who would be present at your baby's birth. However, an unassisted birth plan may include the planned presence of one or more doulas, unlicensed or unregistered midwives (those unrecognized by your state regardless of their expertise or background), family members, friends, or any individual who was not licensed or registered by your state as being employed in the profession of attending childbirth.” Analysis of the data was performed through Survey Monkey’s analysis technology and reviewed by Sacred Transitions Midwifery Institute faculty, administration and students.
857 mothers responded to the request for planned UC data and successfully completed the survey. Among them, 1,444 pregnancies and 1,449 newborns were represented. There were five sets of twins.
Participants reported their age when they initially planned to UC for the first time. See Figure 1.1. Race demographics were reported and are displayed in Figure 1.2 with an overwhelming majority of those identifying as white. Respondents reported their household income. See Figure 1.3. Educational demographics were collected, and the majority of respondents had at least some college education. See Figure 1.4. Relationship status was overwhelmingly identified as “married.” See Figure 1.5. Sexual orientation was identified. The response was predominantly heterosexual, but the surprising outcome of this survey was the high level of participants identifying as “bisexual or pansexual” which was defined as “attraction for both genders or attraction regardless of gender.” Further research would be warranted to see if this is a growing trend universally or just among those choosing to UC. See Figure 1.6
Figure 1.1, Age at decision to UC by percentage responding
Figure 1.2, race by percentage responding
Figure 1.3, household income by percentage responding
Figure 1.4, education by percentage responding
Figure 1.5, relationship status by percentage of those responding
Figure 1.6, Sexual orientation by percentage as reported by participants.
Motivation and Predisposing Factors
The motivation for choosing to UC has not been deeply studied. The following motivations were unearthed with this research. The top five reasons were reported as 1) Personal intuition (80.24% of respondents), 2) A dislike of hospitals (77.32% of respondents), 3) Concern for their newborn’s safety within the confines of a hospital (72.20% of respondents) and 4) A desire to not repeat a prior bad hospital experience (51.83% of respondents). See Figure 2.1. Clinical education data was collected from respondents to understand the level of self-study in preparation for unassisted birth. The respondents appeared to be highly educated in birth assisting and a high percentage also reported having attended medical or nursing school. The majority of participants had been formally educated in some way related to birth. See figure 2.2. Prior trauma as experienced by the participants was collected. In most areas a higher rate of trauma was reported by respondents than among the general public as reported by the CDC. More research is needed to see if this is a more general, universal rise in trauma, or a rise specific to individuals planning to UC. The rate of substance abuse and prior cesarean delivery was lower than the general public, however. See Figure 2.3.
Figure 2.1, Motivation for
Figure 2.2, Birth education
Figure 2.3, Trauma experienced prior to
planning to UC
Transfer and Transport Rates Related to UC
Of the 1,444 pregnancies represented in the research, 111 pregnancies transferred into the care of a licensed provider prior to delivery. This reflects a successful UC rate of 92.31%. Thirty pregnancies transferred prior to the onset of labor and 81 transferred during labor but prior to delivery. See Figure 3.1. The overall final cesarean rate was 1.24%, drastically below the US national rate of over 32%. Reasons given for transferring or transporting prior to delivery are shown in Figure 3.2 and predominantly reflect a need for better support as opposed to medical indications. One baby died en utero and the mother transferred for hospital care prior to labor. 29 newborns were transported to a licensed provider for medical concerns within the first week and 47 mothers were transported for medical concerns postpartum. Reasons given for transporting newborns are shown in Figure 3.3 and reasons given for transporting mothers are shown in Figure 3.4. These rates reflect an overall transfer or transport rate of 12.93% for all respondents who originally planned to birth unassisted.
Figure 3.1, Transfer and Transport prior to Delivery and Outcome by Percentage of Respondents
Figure 3.2, Reasons respondents sought care from a licensed provider prior to delivery.
Figure 3.3, Reasons respondents sought care for their newborn from a licensed provider after delivery.
Figure 3.4, Reasons respondents sought care for themselves from a licensed provider after delivery.
Prenatal Care and it’s Effect on Outcome
472 pregnancies reported having had no prenatal care with a recognized provider, which accounted for 32.68% of all UC pregnancies. Of these, the respondents reported a lower transfer or transport rate in most instances See Figure 4.1. However, there were two perinatal deaths within the no prenatal care group and one perinatal death in the group which received at least some prenatal care. This is statistically insignificant due to the small number of parinatal deaths and should be looked at more deeply if access to a larger database becomes available.
Figure 4.1, Outcome by
Prenatal Care among UC birthers
Experiences of Unassisted Birthers
Respondents who successfully delivered unassisted were asked to list the types of labors and complications they encountered in their births. See Figure 5.1. This data was later analysed to compare types of complications and outcomes and will be discussed in the following sections.
Figure 5.1, Variations and
complications experienced by UCers
The UC Environment
The type of environment favored by UCers was examined, both in location and support. Over 96% of respondents understandably selected their own home to give birth in. A variety of preferences for those in attendance was noted and is shown in Figure 6.1.
Figure 6.1, Attendance at UC Deliveries
The inclusion of unlicensed/undocumented midwives was scrutinized. When the 152 deliveries that were attended by self-proclaimed midwives were isolated for analysis, it was discovered that the attendance of self-proclaimed midwives decreased the rate of perinatal death to zero. However, the sample size is so small that this would need follow up study with a larger group. Interestingly, the incidence of shoulder dystocia tripled in the midwife attended group (.098% vs .038% in the group without midwife attendance), the newborn transport rate doubled (.039% vs .019% in the group without midwife attendance), the maternal fever incidence doubled (.026% vs .011% in the group without midwife attendance), and the postpartum depression rate doubled (.092% vs .052% in the group without midwife attendance).
Length of Gestation
The topic of gestation length when not induced is of some interest. The length of gestation was recorded for each participant. See Figure 7.1. The perinatal death rate did increase with gestational age. There were no perinatal deaths prior to 41 weeks. There was one death between 41 and 41 weeks, six days and two deaths among babies born between 42 and 42 weeks, six days. See figure 7.2. Prematurity was recorded at 2% among respondents which is well below the national average of 10%. (5)
Figure 7.1 Gestational age at time of UC delivery
Figure 7.2, Perinatal death rate by gestational age among UCers
Newborn Delivery Weight
The weight of the newborns represented were collected and are shown in Figure 8.1. The concerns for blood sugar regulation appear to span the weight spectrum. One baby under 6lbs 8oz was transported for blood sugar regulation concerns two babies over 8lbs 9oz were transported for blood sugar regulation concerns. All three babies recovered.
Figure 8.1, Weight of UC newborns
Vaginal Birth After Cesarean
It appears that women seeking a vaginal birth after one or more prior cesarean sections make up a good number of those seeking to birth unassisted. There were 129 birthers in this category. They had a 100% success rate in achieving their unassisted births. This is remarkable, considering the VBAC success rate nationally is listed at between 60 and 80%. (6) Among VBAC UCers there were no perinatal deaths. Postpartum there was a 4.65% infant transport rate within the first week, which is four times greater than the overall UC newborn transport rate of 1.97%. Four birthers transported postpartum for hemorrhage, reflecting a 3.1% postpartum maternal transport rate for hemorrhage. This is double the rate for UCers as a whole. Among those who sought a VBAC in addition to a UC, 56% stated a primary reason for seeking this choice was due to the lack of access to their birth choices due to regulation in their area. This is up from 18% of the total respondent population and reflects a serious oversight in birth choice access in the United States.
Respondents reported 26 vaginal breech deliveries, 1.79% of the total pregnancies represented. This is approximately half of the expected 3-4% of term breech presentations. Among breech deliveries there were three newborn transports (two for respiratory concerns). This represented an 11.53% newborn transport rate, which is much higher than the 1.98% newborn transport rate among all UC deliveries. There was also one case of reported head entrapment that was resolved by the birther and did not require transport. There were no reported perinatal deaths among breech deliveries.
There were 82 UC deliveries that reported the presence of meconium stained amniotic fluid. Two babies transported postpartum and one baby died from infection. This represents a 12 per thousand perinatal death rate among babies with meconium stained fluid, which is exactly consistent with the national average. (7) The baby that died was further complicated by 24 hours of prolonged rupture of membranes prior to the start of labor.
Doppler Monitoring in UC
A total of 989 birthers attempted to UC without the use of any ultrasound monitoring. This appears to be related to a lower rate of transport during labor but a higher rate of perinatal death, though the perinatal death rate is so low as to make the findings less significant. See Figure 9.1.
Figure 9.1, Doppler use on UC outcome
Shoulder dystocia rates were collected and defined as the shoulders being “stuck and required extra maneuvering from me to release them.” Despite the difficulty in making a self-diagnosis of this nature, the reporting was consistent with national averages. A total of 61 were reported. One baby died, reflecting a 16 per thousand death rate with shoulder dystocia. The rate of occurrence appears to correlate with the US average. Among infants weighing under eight pounds, 9 ounces, UCers reported a 1.2% shoulder dystocia rate, above that weight the incidence was 3.3%. Shoulder dystocia is thought to occur between .6 and 1.4% of the time in babies under 8 pounds 13 ounces and 4-9% of the time in babies above that weight in the general public. (8) Positions reportedly used for successful delivery among UCers are shown in Figure 10.1 which compares the propensity to favor hands and knees with a shoulder dystocia versus the positions reported for all UC deliveries. Among those reporting a shoulder dystocia 26.22% reported an active labor longer than 24 hours and/or a second stage longer than two hours.
Figure 10.1, Maternal position at time of successful UC delivery, shoulder dystocia vs. all deliveries
Prolonged Third Stage
Participants reported 176 prolonged third stage placental deliveries. Prolonged was defined as more than one hour. Among these, only one birther transported for questionable blood loss. This constitutes a rate of .56% hemorrhage within the prolonged third stage group. Current U.S. hospital postpartum hemorrhage rate is 4.1%, which has risen from a rate of 1.5% in 1999.
Postpartum Follow Through
Three criteria from the immediate postpartum were investigated. Pediatrician follow up, breastfeeding success at 24 hours and postpartum depression rates after UC. Only 26.7% of UC birthers took their baby or babies to a pediatrician within the first week of life. It is surmised that the general distaste for the maternity system may carry over into patient satisfaction of the pediatric system. This should be further investigated in upcoming research. Respondents reported a successful latch within the first 24 hours after birth in 70.18% of births. This is consistent with hospital reports of between 40 and 75% successful breastfeeding rates at discharge. Postpartum depression rates for UCers are reported below the national average. UCers reported postpartum depression following just 5.26% of births as compared to 7.5% among birthers nationwide.
1. “A canary in the coal mine: the growing popularity of unassisted childbirth” by Amy Wright Glenn
2. “Perinatal mortality” is here defined as newborn deaths within the first 7 days of life so as to comply with the international standard.
3. CDC, perinatal mortality rates, http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_08.pdf
4. “A canary in the coal mine: the growing popularity of unassisted childbirth” by Amy Wright Glenn
5. CDC, http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm
6. Mayo Clinic, http://www.mayoclinic.org/tests-procedures/vbac/basics/definition/prc-20020457
7. Singh BS, Clark RH, Powers RJ, Spitzer AR, Meconium Aspiration Syndrome Remains a Significant Problem in the NICU: Outcomes and treatment patterns in term neonates admitted for intensive care during a ten-year period. J. Perinatol. 2009, July 29 (7): 497-503
8. Shoulder dystocia: an Evidence-Based approach, Salvatore Politi, Laura DʼEmidio, Pietro Cignini, Maurizio Giorlandino, and Claudio Giorlandino; J Prenat Med. 2010 Jul-Sep; 4(3): 35–42.