A Line in the Sand: Thoughts on Unassisted Birth

I have heard that a midwife’s stance on “unassisted birth” can tell you a lot about her beliefs about the birth process and how she practices.  I tend to agree with this.  In a neonatal resuscitation class, Karen Strange remarked, “Birth was set up to work in case nobody was there.”  That comment was very significant to me at that time.  I was at the very beginning of my journey to becoming a midwife and those words resonated well with me.  I have quoted her a lot since then, but attending an Ancient Art Midwifery Skills Lab changed things even more for me.  Kristi Zittle described the kind of midwife she was when she was a practicing, and those who know her know that Kristi would not do ANYTHING unless the mother specifically asked her to do it.  She didn’t check heart tones routinely (and certainly not with a Doppler), she didn’t check dilation, she didn’t check for nuchal cord.  In fact, she has a strong belief that absolutely NO ONE except the father or mother should touch the baby’s head during labor and birth.  I loved all of the new information I received during this skills lab and I loved how much more I trusted birth because of it.  When I came home from the lab, I sat down with my stack of books on my night stand.  Unassisted Childbirth by Laura Shanley stood out in the pile.  What I began reading was a perfect continuation of the education I had just received.  It is an insightful and spiritual book that can be life-changing.  When I was finished, I wanted so much to join the ranks of women who have birthed alone.  I sat down to write this position paper, starting with Karen’s quote, and then I realized that I can’t completely agree with the statement anymore as it was stated in the class (although I realize she may have meant it differently).  I would restate it as this:  “Birth was designed to work whether or not anyone else was there.”

The words “just in case” are a problem in the care of women during childbirth.  Very little data we have at this point in history is based on completely natural childbirth.  We simply don’t know how all of the actions of an attendant during labor and birth affect the process.  I have enjoyed working with 5 different midwives during my midwifery journey.  Most of them fundamentally “trust birth”, but I have witnessed most do a lot of things “just in case”.  I see massages of the perineum with olive oil just-in-case the mom’s tissue isn’t flexible enough.  I have seen babies suctioned with a bulb syringe immediately after birth just-in-case they need help with those first breaths.  I’ve seen hats put on babies immediately after birth just-in-case their mother’s body and a blanket don’t keep them warm enough.

To be critical of any of this elicits the response, “Well, this is so much less medical and invasive than what it would be like in the hospital.”  I know it must appear that I am just being picky.  These procedures ARE so much more gentle for mom and baby compared to the hospital alternative.  But there is another alternative for which we have very little data:  unassisted or unattended childbirth.  And these “just in case” procedures are so much more invasive than that alternative.

In relation to birth, thee terms “unassisted” or “unattended” can mean two different things depending on who you talk to.  To some, unassisted childbirth means that mom gives birth completely alone.  To others, unassisted childbirth means that dad is the only other person present at the birth and together they bring their baby into the world.  To others, unassisted childbirth can mean there is a trained attendant at the birth but is only there “just in case”.  For most, unassisted birth or unattended birth are interchangeable.  The idea of differentiating these terms was introduced to me by Kristi Zittle at an AAMI Midwifery Skills Lab, and it was introduced to her by Pamela Hines-Powell, a midwife in Oregon.  When describing the type of midwife she was to women when she was a practicing, it was important to Kristi to acknowledge those mothers who brought their babies into the world with only their body and their hands, but felt more comfortable having someone close by to help if they found a need.  She considers these moms to have had “unassisted births”.  For me, it resonated well with the kind of midwife I hope to be.  I have wrestled with the concept of unassisted or unattended childbirth because although I believe it is a wonderful way to bring a baby into the world, I couldn’t figure out where my desire to be a midwife fit into the idea.  What I want most for moms is to support their complete control in their birth.  I want them to know that they don’t need me.  They don’t need to be rescued from this incredible journey.  I want them to come away from their births NOT saying “I couldn’t have done it without you”, but rather “I DID IT!”  (This idea originally came from Carla Hartley, founder of AAMI)

Therefore, in order to honor those mothers whom I hope to support, I prefer to clarify the two terms in the following way: Unassisted childbirth means mom and dad bring their baby into the world on their own, but there is a trained attendant available to assist them if help is requested or required.  Unattended childbirth means there is no trained attendant available at the birth.  Mom (and possibly, dad) brings baby into the world completely alone.  This clarification meant a lot to me.  What it means is that, as a midwife, I can help parents have unassisted births.  I can still be a tool in ensuring that the power of birth is in the right hands:  the mother’s.

In Unassisted Childbirth, Laura Shanley writes a chapter called “The Case for Autonomous Birth”.  Only six pages of her book are dedicated to “proving” or “making a case for” unassisted childbirth.  The bulk of Shanley’s book consists of her story, discussions on the dangers of intervention, the influences of beliefs, expectations, dreams, impulses and intuition on birth, and stories of unattended births.  In 1994, when this book was originally written, there was limited data, and today, there is little more.  I imagine this is primarily because parents who give birth unattended aren’t part of any statistics simply by the nature of the act. The sources Shanley uses to make her case are books such as The Nature of Birth and Breastfeeding by Michel Odent (written in 1992), Husband-Coached Childbirth by Robert Bradley (written in 1965), and Come Gently, Sweet Lucina by Pat Carter (written in 1957).  Odent and Bradley compare human birth to the births of other animals and Carter writes about her own experience of unattended births.  For all of these authors, the case must be made by simply coming back to how birth was originally intended to work.  We were not given blankets, hats, or fur to keep our babies warm.  We were given a highly sensitive epidermis that can respond to warmth from another.  We weren’t given thermometers, stethoscopes, warm compresses, dopplers, or synthetic oxytocin.  And somehow we survived so well, we have the potential of over-populating the planet.  An internet search on unassisted childbirth leads me primarily to Shanley’s website titled Born Free!  Articles are posted there, but none of them can give statistics on the safety of unattended childbirth.  Again, it is the nature of the act.  It is one of those things that requires a leap of faith.  Extensive articles are abundantly available giving data on the dangers of intervention, and in the end, a mother has to believe that she has been given all of the tools to perform this most natural act.  Whether “unassisted” or “unattended”, she holds the power in her own hands.

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