Origins of the freebirth literature

One of the most important conclusions to be drawn from the first empirical and non-empirical texts is that, taken together, they largely incorporate all that scholars will subsequently ‘discover’ in empirical studies decades later. Interestingly, both sources have largely been forgotten by mainstream academic studies.

Coining the term ‘freebirth’

In a similar vein to Carter, Parvati Baker130 published the first edition of her book Prenatal Yoga and Natural Childbirth in 1974.131 The book consists of yoga advice, combined with the author’s personal views and experiences of childbirth. In a pattern arising in other autobiographical texts,132–134 the author experienced a hospital birth, before later having a homebirth, and finally two freebirths.

Parvati Baker claims to have been the person to have coined the term freebirth.135 When exactly she created the term is unclear. Griesemer sheds some light on this when quoting Parvati Baker’s earlier work, The Possible Family: Little House on the Edge of the Millennium (1995).136 Griesemer137 quotes Parvati Baker as writing:

Freebirth is giving birth in fullest freedom without paying anyone to be paranoid for you. There are no costs at any level as what is valued is core responsibility, rather than buying someone else to take on this primal opportunity to cultivate responsibility.

In Parvati Baker’s view, therefore, the term ‘free’ relates not only to a psychological mindset, but also to a financial situation. While in the USA maternity provision comes with a price tag, from a UK perspective this financial element of the term has less relevance.

Notably, Parvati Baker was a childbirth activist and conference speaker; therefore, she may have been using the term orally long before 1995. Nevertheless, this is likely to be the first published reference to freebirth and an explanation as to what it is. Although the original text is now unobtainable, the term has gained momentum enough to be used in much of the following literature over the next several decades.

In 1994 and within the same research tradition, Laura Shanley published the first edition of her book Unassisted Childbirth.138 The alternative term ‘unassisted childbirth’ or UC has also gained momentum, and along with freebirth it is these two terms from these two authors which feature most heavily in the later literature.

The notoriety of Born in Zion

Within the same research tradition but writing from a very different perspective is Balizet,139 the founder of Zion birth ministries and a non-freebirther who attends other women’s freebirths in a religious capacity. The first two editions of her book were unobtainable (1992 and 1994), and the third edition had to be sourced from the Library of Congress in the USA. The difficulty in sourcing the book may be due to its content and influence.

Not always considered part of the freebirth literature,140 Balizet stands far beyond the freebirth mainstream due to the author’s rejection of all medical intervention relating to both birth and illness, and her Christian belief in the power of prayer to resolve medical emergencies. Notably, in none of the other literature are her views and so called ‘Zion Births’ advocated, nor the rejection of all medical care promoted. In other autobiographical texts, writers are quick to highlight that freebirth is simply one legitimate option.141

Ironically, however, Balizet is a former nurse, and while prayer is her obstetric instrument of choice she does not remove herself entirely from the mainstream biomedical model of childbirth. Throughout the book there are references to her using a suction bulb to clear the baby’s airways immediately postbirth,142 weighing the newborn,143 using mouth-to-mouth resuscitation144 and manually extracting a baby from its mother (although on God’s instruction).145 Conversely, some of her views would not enter the biomedical paradigms. Examples of how Balizet believes labour can become slowed include the presence of a nearby nudist camp,146 and ornaments of frogs and owls in a woman’s home.147

Nevertheless, Balizet does share parallels with other freebirth literature. While religion is Balizet’s main focus, religion and spirituality do appear as lesser factors in other texts.148–151 Balizet also argues that fear affects birth.152 This aligns with Dick-Read’s influential work, which appears in many of the freebirth texts. In Balizet’s unique view, however, this fear is caused by a battle between God and Satan.

Although this work stands in contrast to its contemporaries, it has had some influence and has gained notoriety, due to its links to Christian fundamentalism and to a number of deaths. In his text When Prayer Fails: Faith Healing, Children and the Law, Peters dedicates a full chapter to exploring the legal cases pertaining to three members of a small religious denomination in Massachusetts known as The Body (also colloquially deemed the Attleboro Cult).153

‘Profoundly influenced’ by the teachings of Carol Balizet, the community eschewed all medical care.154 As a result, in 1999 a member of this community, Rebecca Corneau, freebirthed her son Jeremiah, who died at birth. The body was then buried in a local park alongside the remains of 10-month-old Samuel Robidoux, whose parents Karen and Jacques had starved to death based on an instruction from God.155 The cases drew national media attention. Jacques Robidoux was convicted of first-degree murder, and his wife exonerated ‘with her attorney arguing that she was a psychologically battered woman who had been victimized by a “bizarre, misbegotten group”’.156

Of most relevance however is that Corneau, who at the time of the proceedings was pregnant, was taken into state custody to ensure she gave birth with medical professionals present. This spawned considerable debate both within and outside of academia, raising legal, philosophical and bioethical questions,157 with legal scholars challenging the constitutionality of incarcerating pregnant women based on the risk of them committing a future crime.158, 159 Following later similar state incarcerations (unconnected to Balizet’s teachings), this reflects a growing trend in American scholarship to explore the parameters of state power in protecting an unborn fetus.160–163

Regardless of this notoriety, Balizet’s teachings remain in circulation. Her philosophy has been linked to the more recent Quiverfull movement in the USA.164 This movement espouses female submission to men, and the rejection of contraception in favour of pronatalism and large families.165 While freebirth has been linked to feminist discourse,166 this antifeminist stance is apparent in both Balizet and in the earlier work of Moran,167 highlighting that freebirth has not always been—nor does it always continue to be—rooted in typical feminist thought.

The midwifery research tradition

As the autobiographical freebirth literature reached its apex in the 1990s, an alternative research tradition came to the fore: midwifery. The earliest UK paper sourced was an opinion piece published in 1997,168 and the first narrative article appearing in the midwifery press was written by the husband of a freebirthing woman.169

In 2006, the first midwifery-based empirical study that includes freebirth was published. Kornelson and Grzybowski carried out an exploratory qualitative study of 44 women living in four rural communities in British Columbia, Canada. The aim of the study was to understand ‘the realities of maternity care faced by rural women’,170 particularly as the authors note that since 2000 there had been a significant decline in the number of Canadian rural communities offering maternity care. While not about freebirth per se, the cohort included three women who had freebirthed as a response to their reality of living rurally and ‘a lack of alternatives’.171

There are two points to note here. First, this empirical study is very different from the autobiographical texts. In combination with these, it begins to highlight a spectrum on which freebirthing women sit with regard to decision making. On one end are autobiographical authors such as Shanley who make a positive choice to freebirth, and on the other end are those women who, as Kornelson and Grzybowski note, due to various circumstances feel they have no other option.

The second point is that Kornelson and Grzybowski found that rural women who were expected to leave their communities to give birth often experienced psychological and financial consequences. In order to overcome this, they developed strategies—such as freebirth—as a form of resistance. In exploring this idea, they acknowledge the position of indigenous women. While it is unclear whether any of the freebirthers in the cohort were Aboriginal Canadians, this unique perspective is acknowledged in Australian freebirth literature, in particular with regard to Aboriginal women wanting to give birth ‘on country’.172 Similar points were raised in the anthropology research tradition with regard to indigenous women in Peru who freebirth for cultural reasons.173 Such arguments indicate the heterogeneity of women who freebirth and suggest that, in attempts to support these women, some maternity systems may face additional challenges that are not present within the UK.

From 2006, there was a noticeable increase in empirical studies pertaining to freebirth. It is unclear why this is so. However, around this time within academic discourse, the concept of birth trauma evolved from the idea of it being physical trauma that occurred during birth, to one which incorporated a woman’s psychological response to her birthing experience.174 Beck’s 2004 qualitative study of 40 women’s birth experiences and her argument that clinicians viewed their trauma as routine is the start of a body of work in which the psychological aspects of birth trauma have been explored empirically.175–177

As researchers began to explore the psychological impact of birth trauma, the phenomenon began to appear within the empirical freebirth literature,178 but not within the parameters of midwifery until 2012.179 Why midwifery is slow to explore the topic empirically is unclear. This may be linked to the status of the profession, particularly in the USA, and potential limitations in funding and publication platforms. However, there is some evidence—although very little—of a connection with birth trauma within earlier non-empirical midwifery literature.180, 181 As highlighted earlier, the freebirth–birth trauma link was also made outside of midwifery decades previously182 and had been argued in activist literature as early as 2001.183

While midwifery was slow to recognise the link, since 2012, midwifery studies from various countries have highlighted the connection, that is, from Australia,184, 185 Canada,186 the UK187 and the Netherlands.188 Similarly, as reflected in Kornelson and Grzybowski, midwifery has recognised issues relating to the maternity system as a motivating factor in women’s decisions to freebirth, for example, its inflexibility, homebirth rules, overmedicalisation and the risks associated with hospital births.189–195 This development may reflect a methodological shift whereby the lived experience captured via qualitative research is becoming more frequently employed within midwifery, suggesting more of this information is coming to the fore.

Two UK studies stand apart from the other empirical midwifery literature, as they shift the dialogue beyond freebirthing women’s motivations. Feeley and Thomson196 explore how women navigate the maternity system when attempting to carry out their decision to freebirth. In the same year Plested and Kirkham197 published a similar study but their emphasis was on how freebirthing women experience risk and fear within the maternity system. These papers highlight the stigma and condemnation women experience when they attempt to make birthing decisions outside of the norm. In particular, these two studies illuminate tactics employed by HCPs, who attempt to make women conform to their perception of appropriate behaviour. This can be contrasted with current maternity rhetoric relating to woman-centred care and choice in England.198 Most worryingly, tactics included referrals to social services in four out of ten participants in Feeley and Thomson, and three out of ten in Plested and Kirkham. All referrals were later dropped, with Plested and Kirkham describing the referrals as being ‘deemed inappropriate’.199 Unsurprisingly, the misuse of social services referrals has been noted much earlier in activist literature.200, 201

What can be gained from these studies is the tension between a pregnant women’s reproductive, legal and human rights, and the power of the state to ‘protect’ the unborn. These are the same issues seen in the legal and bioethical arguments triggered by the consequences of Balizet’s philosophy, and in the wider relevant American scholarship. Unlike in the USA, women in the UK are not being incarcerated, but there is a similar sentiment of control and retaliation, which raises ethical questions that remain as yet unexplored within the midwifery research tradition.

The medicine research tradition

The medical literature on freebirth can be divided into both empirical202–206 and non-empirical sources.207–209

In direct contrast to all other non-medical freebirth studies is Burnett et al,210 published in 1980, which serves as a fascinating insight into a biomedical analysis of freebirth at the time. This quantitative study explored the neonatal mortality rates of home deliveries in North Carolina between 1974 and 1976. Homebirths were grouped into various categories, for example, planned with a lay midwife or unplanned and precipitate. Of relevance to the present review was that the authors concluded that planned homebirths without an attendant resulted in a death rate of 30/1000 live births. In real terms this was 3 deaths out of the 100 freebirths, based on 244 544 overall births both within and outside of hospital during that time period. Notably, very little is explained with regard to the statistical power of the findings, with no discussion of confidence intervals or p values.

While these appear to be high rates, the article reveals much about the maternity system at the time. Written in an unempathetic way, the tragic deaths of some babies in non-freebirth circumstances highlight a society that displays an uncomfortable level of contempt for pregnant women and vulnerable mothers. Two babies died because ‘one mother…went to hospital but was turned away for lack of funds. The other…reportedly had been told not to go to the hospital without payment in hand’.211 Three deaths involved ‘unwed teenaged mothers charged with homicide’.212 The authors discuss two further homicides, ‘[o]ne infant was drowned in a canal and the other was grossly neglected’.213 In summarising these tragedies, the authors conclude that these ‘deliveries were judged to be either precipitate or intended without preparation for a healthy infant’,214 thus placing all blame on the mother’s decision making and none on wider society. These cases expose a sad underbelly of women either unable or unwilling to access US maternity provision.

Such tragedies raise questions about why the women who did freebirth did so. While Burnett et al highlight that they had a low-risk demographic profile,215 there is no qualitative exploration as to why they made this decision, nor consideration of, for example, their insurance status or socioeconomic background. This study therefore highlights the limits of a biomedical, quantitative approach to exploring freebirth, and demonstrates the importance of later qualitative studies to understanding this phenomenon.

Two further medical studies reignite the issues associated with religious denominations who eschew all medical care. Kaunitz et al 216 investigated the perinatal and maternal mortality rates of the Faith Assembly in north-eastern Indiana, USA from 1975 to 1982. They discovered that the group had a perinatal mortality rate three times higher and a maternal mortality rate 100 times higher than the state-wide rates. Similarly, Asser and Swan217 explored child fatalities from religiously motivated medical neglect between 1975 and 1995. Within their inclusion criteria were perinatal fatalities based on unattended homebirths. These numbered 59 out of 172 child deaths and were linked to a range of religious groups operating within a number of states. Commentary also included six maternal deaths.

While other freebirth writers have dismissed the relevance of these studies,218 they are important for the purposes of this review. It is unclear what the social circumstances of the women involved were, and the levels of autonomy and agency they were able to employ. Nevertheless, it would be unfair to automatically presume that these women were incapable of active decision making, or to suggest that their freebirth was not based on an honest belief that aligned with their religious and worldview. However different these motivations may be from the ‘mainstream’ freebirthers, and however unpalatable the mortality statistics, without evidence to suggest otherwise, these women appear to be making an active decision to step out of the existing maternity system and to freebirth. Consequently, these studies are important for a wider understanding of the phenomenon. What they also suggest is that the USA has an additional and more complex element to their freebirthing communities, which does not exist in literature from other countries and does not appear to be an issue within the UK.

Strengths and limitations of the review

The main limitation of the review is that only English-language papers were sought. This prohibits a full analysis of the literature, particularly that pertaining to other Western industrialised nations such as Germany and France. In addition, the inclusion of a Peruvian study suggests that there may be relevant literature published in Spanish. Of particular relevance is the consideration of indigenous women’s cultural needs within South and Central America. A more thorough understanding of this could have better contextualised the literature in relation to indigenous women in Canada and Australia.

Areas of future research

As noted at the beginning of this paper, current freebirth research has focused very broadly on women. Relevant studies published in the English language have only touched on how freebirth plays a role within the lives of very specific groups, for example those from particular indigenous or religious communities. It is unknown whether there are any trends based on, for example, ethnicity or socioeconomic background. As noted earlier, anecdotal suggestions of freebirth within the transcommunity did not materialise in the literature and therefore it is unknown whether some transmen are freebirthing.

The experiences of the partners of freebirthers are largely absent from the literature, as are the experiences of HCPs who come into contact with freebirthing women. While Feeley and Thomson219 and Plested and Kirkham220 begin to explore freebirthing women’s interactions with HCPs, the lack of perspectives from midwives and doctors means it is difficult to understand why some freebirthing women receive such a negative response. For policy and education purposes, it is important to know, for example, whether HCPs do not understand the rights of women with regard to their birthing decisions, and whether they have been appropriately taught how to support women who decline routine care.

The literature focuses heavily on good freebirth outcomes. With the exception of some insightful information provided by Spencer-Freeze,221 none of the qualitative research fully explores any negative consequences of freebirth. It is unknown whether this is because freebirthing women who experience difficulties seek help from HCPs, or whether women who do have negative experiences do not wish to speak out about their freebirths. From a quantitative perspective, the medical profession has made some attempt to understand outcomes. However, given the small number of freebirths and its clandestine nature, it would prove difficult to carry out a contemporary study as any results would likely lack statistical power.