麻豆传媒

ONE HOT afternoon in August 1977, heavily pregnant Laura Shanley felt the early twinges of her first labour. Instead of calling a midwife, she called over some friends. When her waters broke, she didn鈥檛 dash for the hospital, just the bedroom. On hands and knees she gave birth to her son, John, in one swift push. Ready to catch him was the only other person in the room, her husband, 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 sets Shanley apart is choosing to go it alone without any professional help. She is part of a movement that advocates unassisted childbirth, or 鈥渇reebirthing鈥�. The backlash against the perceived overmedicalisation of childbirth in the west has already seen some women reject hospitals in favour of a low-tech home birth with a midwife. Freebirthing proponents go further still, shunning even midwives.

Almost all doctors and many midwives condemn unassisted childbirth as dangerous. The small but growing number of freebirthers, however, say it is perfectly safe for a woman to give birth alone, or at most, accompanied by a partner or friend. They believe that advice from medical staff interferes with the normal birth process, and that women have easier labours if left alone 鈥渁s nature intended鈥�. 鈥淏irth is inherently safe and relatively painless,鈥� Shanley claims, 鈥減rovided that you don鈥檛 interfere by using doctors or midwives.鈥�

Freebirthers do have a point: childbirth has never been so medicalised. For most of history women gave birth at home, possibly attended by a midwife or doctor, 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 labours it became common for doctors to ease out the baby with forceps, or, later, a suction cup known as a ventouse. Syntocin, a synthetic form of the hormone oxytocin, came to be used to trigger labour or speed it up. Once a last resort, the ultimate intervention of a Caesarean section now accounts for about one in four UK births.

There is no doubt that these and other interventions have saved the lives of millions of women and children the world over. But campaigners and even some doctors 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 National Childbirth Trust in the UK and the Lamaze Institute and the International Childbirth Education Association in the US. Today such groups lobby for childbirth to remain as simple as possible, with the management of low-risk births ceded to midwives, who have only relatively low-tech forms of help at their disposal.

So far this has extended to the promotion of home births, with a midwife present but the nearest doctor an ambulance-ride away. The safety of home births is still hotly contested, but some want to progress to what could be seen as the natural childbirth movement鈥檚 logical conclusion 鈥� completely unassisted childbirth.

Freebirthing has no formal organisations, so charting its growth is difficult. When Shanley wrote a book on the subject in 1994, she says the practice was nearly unheard of. Now most freebirthers use the internet to spread the word and swap tips. Shanley runs a website for these purposes and over the past decade she has heard from many other women who have given birth without help.

Linda Hessel, who lives in Corvallis, Oregon, and had her third child unassisted, collects freebirthing stories from the website . About 160 mothers post from the US, Canada, the UK and Australia on the site鈥檚 unassisted childbirth forum. It is a very small but growing movement, she says.

Freebirthing is also growing in Australia, possibly influenced by poor access to midwives and the closure of some rural maternity wards over the past few decades. The high rate of Caesarean sections in hospitals may also be a factor, says Sarah Buckley, a general practitioner (GP) in Melbourne. Six years ago, Buckley had her fourth child unassisted 鈥� a different prospect for a GP, to be sure, but she supports the right of all mothers to freebirth, making her one of the few doctors to do so.

So do the freebirthers鈥� claims stack up? Are they in fact giving birth the natural way? In some ways nature has dealt humans a poor hand when it comes to giving birth. As early hominids evolved an upright walking posture, the pelvis had to pivot up, narrowing the birth canal. And the price we pay for our huge brains? Huge heads. No wonder the passage of a full-term baby through the birth canal is a tight squeeze. 鈥淏irth is not as simple or straightforward as it is in other animals,鈥� says Wenda Trevathan, a medical anthropologist at the New Mexico State University in Las Cruces.

鈥淔reebirthers say birth is inherently safe and relatively painless provided you don鈥檛 interfere by using doctorsor midwives鈥�

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, human babies, unlike those of other primates, tend to turn mid-birth and exit the vagina facing their mother鈥檚 spine. This makes it harder for the mother to clear mucus from the baby鈥檚 mouth after its head emerges. And if she pulls the baby out too forcefully she may bend the spine and neck against its natural curve.

That鈥檚 why Trevathan argues that some form of birth attendant may have been de rigeur since bipedalism began to evolve 5 million years ago. 鈥淚n most cases, the mother and the baby benefit from some form of assistance,鈥� she says.

A glance through anthropological studies reveals that in almost all hunter-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 a solitary (and silent) one, in practice women usually have help, at least until they have a previous birth or two under their belt.

Of course a birth attendant who merely helps the baby out and clears their airways hardly requires midwifery training. But it does suggest that freebirthers who set their hearts on complete privacy may be striving for something that rarely happens 鈥渋n nature鈥�.

What does happen in nature? The World Health Organization estimates that worldwide 15 per cent of labours have a life-threatening complication. It has also been estimated that the 鈥渘atural鈥� rate of maternal death from childbirth 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 developing countries the neonatal death rate can be 10 per cent. The chief danger to the baby is lack of oxygen, for example due to blood flow through the placenta being restricted in a long and difficult labour.

It is unclear, however, how these risk estimates apply to modern-day western women who are generally healthy and well nourished. In fact freebirthers claim it is better general public health that has led to the dramatic drop in maternal and infant deaths over the past century (see Graph).

There is some evidence to support this claim. In the late 1970s, Marjorie Tew, then a research statistician at the University of Nottingham in the UK, analysed the national birth statistics from 1958 and 1970. She found that hospitals had far higher infant death rates than either home births or independent birth centres run by GPs, both of which used fewer interventions. Contrary to the prevailing views, Tew concluded that obstetric interventions hindered, rather than helped, the already falling death rates. The underlying cause of the drop, she said, was better public health, nutrition, living conditions and infection control. It was a relatively low-tech medical intervention, the use of antibacterial sulphonamides to treat post-birth infections, that caused the biggest drop in maternal mortality over the past century.

Home advantage

The accuracy of Tew鈥檚 controversial conclusions hinge on whether her analysis took adequate account of the fact that women would be more likely to go to hospital if they were at higher risk in the first place. Tew did adjust for many risk factors including having a multiple pregnancy, a baby in the breech or head-up position, high blood pressure, previous Caesareans, and bleeding during pregnancy. However, there may have been other risk factors omitted from the data.

Tew鈥檚 findings were so radical that it was many years before her work was published in an academic journal, and even then it was largely ignored. In the meantime the push for hospital births continued, and today they are the default setting for childbirth in the west.

In most western countries even a standard home birth with a midwife present is seen as a risk. In the US 鈥� where even uncomplicated hospital deliveries are carried out by doctors, not midwives 鈥� most obstetricians are against home births. Two past presidents of the American College of Obstetricians and Gynecologists have equated home births with child abuse. At one of its meetings last year the college gave out car bumper stickers saying: 鈥淗ome delivery is for pizza鈥�.

鈥淯S obstetricians gave out car bumper stickers saying: 鈥楬ome delivery is for pizza鈥欌��

The UK government has recently voiced support for making home births an easier option, but they still account for only 2 or 3 per cent of births. In Europe 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 one hand, there is the lack of doctors and their sometimes lifesaving interventions. On the other, hospitals can be stressful places. Adrenalin (epinephrine in the US), the fight-or-flight hormone produced in response to stress, seems to slow labour, which could explain why decades of research have linked stress and fear to longer and more difficult births.

The best way of answering the question would be to randomly assign a large number of women to either home or hospital births. But few would put up with having their care chosen for them. Instead, researchers can only study the outcomes of the choices women make for themselves. This risks home births appearing safer than they really are because they tend to be selected by women who are white, well-off and well-educated 鈥� all factors that lower their risk of difficult births 鈥� 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 woman planning a home birth under the care of a certified midwife in the year 2000 and ended up including 5418 births.

No mothers died and the infant death rate was 1.7 per 1000 鈥� a similar figure to low-risk hospital births in the US. Home-birth campaigners have hailed these results as vindication of their stance. Critics, on the other hand, point out that 12 per cent of the women had to be transferred to hospital, usually for maternal exhaustion or because their labour wasn鈥檛 progressing. And 3.4 per cent were admitted as an emergency, mainly for fetal distress or maternal haemorrhage.

While this debate seems likely to run and run, many of even the staunchest home-birth supporters shun freebirthing. Marsden Wagner, the WHO鈥檚 former director of Women and Children鈥檚 Health, says it is a step too far. 鈥淭here are a very few cases when things go bad,鈥� he says. 鈥淢idwives are trained to know when things are going in the wrong direction.鈥�

If the evidence on the safety of standard home births is unclear, it is almost non-existent for freebirthing. There seems to be only one study of western women who intentionally had unassisted births, published in 1987. This looked at a strict Christian community in Indiana called the Faith Assembly Church, who refused all medical attention for religious reasons. It documented 344 births over seven years.

The figures make grim reading. The neonatal death rate was 19 per 1000 live births, compared with 7 per 1000 for the rest of Indiana. Maternal mortality was 8.7 per 1000, 20 times higher than for other women in Indiana.

Studies published in medical journals seem unlikely to influence the freebirthing community, however. From their websites and message forums it is clear that these women reject orthodoxy in numerous ways. Many advocate long-term breast-feeding and home-schooling; some also shun infant vaccines and prenatal medical care. Without ultrasound scans and other checks, someone could unwittingly plan an unassisted birth while carrying twins or a breech baby 鈥� as happened with Laura Shanley鈥檚 third child. Even that may not deter the most radical freebirthers, who scorn medical assistance even for serious complications. But not all go so far. 鈥淭hese variations are something that I would want to know about,鈥� says Hessel, 鈥渁nd I might make different plans accordingly.鈥�

Freebirthers鈥� attitudes to emergency back-up also vary; some women are prepared to head to hospital if the labour goes awry, others don鈥檛. Hessel knows of three infant deaths that might have been prevented if the mothers had sought help soon enough.

Naomi Stotland, an obstetrician at the University of California, San Francisco, has stopped trying to understand the freebirthers. They feel, she says, 鈥渢hat they are very in touch with their bodies and they can tell when something is right and something is wrong鈥�.

There will never be a randomised trial of freebirthing. 鈥淚t鈥檚 not something that is easy to prove or even study scientifically,鈥� says Stotland. 鈥淭hese are belief systems about birth.鈥� And belief is a powerful thing.