Doula support during Unassisted Childbirth(UC)

Unassisted childbirth (UC) is defined as “births that are planned not to be assisted by professional healthcare providers”(MacDonald et al.), and an “absence of an expert, rather than complete solitude”.  This is different than, what is called, “born upon arrival“.  This is when a mother gives birth without a provider unintentionally.  An unassisted birth, in contrast, is actively chosen.  It should also not be confused with a homebirth, which is attended by a midwife.

While there is only a small percentage of mothers who choose to have an unassisted birth, doulas are sometimes asked to attend these births.  There is some confusion as to whether or not this is within the scope of a doula, and it may vary by organization as to whether or not they feel it is acceptable for their certified doulas to attend unassisted births.  The purpose of this post is to clarify the New Beginnings Standard concerning this issue.

Why Mothers Choose UC

Five reasons for choosing UC have been identified. (Holten et al, 2016)  These include:

1. Rejecting the medical and midwifery model of care.
2. Feelings that giving birth in the hospital is risky.
3. Belief that true choice can only happen at home.
4. Perceiving birth as being intimate.
5. Wanting to take full responsibility on themselves.

This choice appears to be made,  based off of the idea that mothers have been left without a voice in the medical model of care that predominates our maternity care system in most western cultures.  It is also based on a worldview that birth is inherently safe, and that medical interference actually poses more risk to normal births.  Lack of trust appears to be an essential element for many women who choose to have an UC.

The Practice of UC

There is no clear research that shows exactly how many women are having unassisted childbirth.  About 1% of births are at home, and UC comprises a very small percentage of that 1%.  In Sweden, that estimate is as high as 1 in 5 homebirths (Lindgren et al).  A best estimate has been between 5,000 and 8,000 births within the US each year. There are also varying definitions of UC beyond what was used above.  Some feel that just having no medical provider is enough to establish a birth as unassisted, while others within that community will argue that hiring anyone to be at the birth, including doulas, is creating an unnatural environment in which to give birth, thus it disrupts the birthing process.  (Freeze, 2008)

Doulas and UC

Attending an unassisted childbirth has been a controversial topic for many doulas and organizations.  In an online poll done in 2007, when asked whether or not they would attend a UC, almost 70% of doulas said they would, but only 30% said they would only attend a UC if they knew the mother well.  The rest cited legal, certification, or safety reasons for not attending according to the  poll.  While many doulas will acknowledge that they support a mother’s decision to choose where they birth and that having labor support may be beneficial, they are cautious about whether or not they would themselves attend a UC.  As the only birth professional there, it is questionable whether they would be held accountable for any action or inaction should an emergency arise, and obtaining liability insurance to cover out of hospital births is difficult.

New Beginnings and UC

As a training company, New Beginnings takes no stance on the safety of UC, but does respect the rights of women to choose who and where they will give birth.  While New Beginnings does not place restrictions on doulas who practice within their scope of practice, they are advised to take into consideration the legal and ethical problems that may come from attending an unassisted childbirth.  We advise that no medical information be given at all.  Since women will have no care provider to discuss medical concerns with, the information from a doula may constitute as medical advice.  We also advise that the doula do not touch the baby at all until it has been medically evaluated. Do take into account that we do not know in what circumstances a doula would be held accountable for practicing medicine without a license.  It may not happen if you follow the scope of practice and these few other rules listed here.  However, we have no guarantee, and you may still be prosecuted.  Even if you are proven innocent, you may waste  time, money, and reputation.

References:

1. Holten, L. (2016). Women׳s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’, Midwifery , Volume 38 , 55 – 62
2. Nolan M. (2008). Freebirthing: why on earth would women choose it? Practicing Midwife. 11(6):16–8.
3. Freeze, R. (2008).  Born free: unassisted childbirth in North America. University of Iowa Retrieved online: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1387&context=etd
4. Miller AC. “Midwife to Myself”: Birth Narratives among Women Choosing Unassisted Homebirth. Sociol Inq 2009; 79 1:51–74.
5. Feeley C, Burns E, Adams E, Thomson G. Why do some women choose to freebirth? A meta-thematic synthesis, part one. Midwifery 2015; 13 1:4–9.
6. Macdonald, Danielle1; Etowa, Josephine1; Helwig, Melissa2,3 Experiences of women who have planned unassisted home births: a systematic review protocol, JBI Database of Systematic Reviews and Implementation Reports: January 2019 – Volume 17 – Issue 1 – p 16-21
   doi: 10.11124/JBISRIR-2017-003654
7. Lindgren HE, Nässén K, Lundgren I. Taking the matter into one’s own hands – Women’s experiences of unassisted homebirths in Sweden. Sex Reprod Healthc 2017; 11:31–35.
8. Feeley, C., Thomson, G. Why do some women choose to freebirth in the UK? An interpretative phenomenological study. BMC Pregnancy Childbirth 16, 59 (2016). https://doi.org/10.1186/s12884-016-0847-6