INTRODUCTION

The Australian media is experiencing a consistently heated and emotional debate about the death of babies delivered in unassisted birth settings. In April of 2012, the ongoing legal case of an established ‘unassisted birth’ advocate once again brought the question of the safety of unassisted births to the public's attention. In this case, her baby daughter had died, in 2009, as a result of delivery difficulties.1 More recently, in June 2012, a more complex case evolved. Here a ‘deregistered’ midwife was involved in several infant deaths, allegedly related to unregulated home birthing.2 This has sparked coronial recommendations for law reform which may, among other things, ‘render it an offence for a person to engage in the practice of midwifery, including its practice in respect of the three stages of labour, without being a midwife or a medical practitioner registered pursuant to the National Law’.3

Along with raising safety and ethical issues, these recent events have prompted fears that new legislation may drive proponents of unassisted childbirth further from medical advice through fear of litigation. Although particularly topical in the Australian media recently, this is a subject that is of interest worldwide. Herein, unassisted childbirth is defined, the evidence surrounding it probed, the reasons for its existence investigated and the ethics around the topic explored.

What is unassisted childbirth?

Unassisted childbirth (also known as free birth, UC and others) is a planned process where a mother elects to give birth in a chosen setting without a health professional present. For the purpose of our discussion, it must be stated that this is being evaluated as separate from an emergency home birth, or a home birth with a health professional (usually a midwife) attending. Although the internet is full of discussion, formal, reliable statistics pertaining to unassisted birth are difficult to come by. Data from the US Centre for Disease Control suggest that in 2009, 32% of 29 650 (9522) home births were unattended by a physician or midwife.4 In the USA, in 2006, 65% of these births not attended by a physician or midwife were reported as planned.5 In Indiana, USA, a study investigated the perinatal and maternal outcomes of a religious group who abstained from all medical care. Between 1975 and 1982, the investigators found perinatal mortality was 2.7 times higher and the maternal mortality rate was 97 times higher than the state average.6 There is some evidence that unassisted childbirth may be practiced by a significant number of the worldwide population and may also be associated with poor outcomes.

Does modern medical care result in better obstetric outcomes?

Unassisted childbirth is not a mainstream practice across the developed world. It is said that natural maternal mortality may be around 1500 per 100 000 (1.5%) without any intervention.7 Obviously, this number may also include societal factors where mothers are malnourished or exposed to high rates of infectious diseases. Great strides have been made in medical care in an attempt to kerb these naturally high mortality rates. The World Health Organisation (WHO) uses maternal and under 5 mortality as key health characteristics of communities. In 2010, Australian maternal mortality was 7 per 1 00 000 (0.007%) live births and the under 5 mortality rate was 5 per 1000 (0.5%) live births.8 Also in 2010, the Western Pacific regional rate was 49 per 1 00 000 (0.049%) and 19 per 1000 (1.9%), and the global average was 210 per 1 00 000 (0.21%) and 57 per 1000 (5.7%) for maternal mortality and under 5 mortality, respectively.8 As Australia has a larger per capita expenditure on healthcare, a larger proportion of healthcare workers per capita and a larger income per capita compared with regional and global averages, it may be inferred that Australians subsequently have access to advanced medical care.8 At least statistically, access to advanced medical care has certainly made an impact on what is a risky event for both the mother and the baby.

In what setting do women typically give birth?

In the Western world, mothers generally have several options for the delivery of their baby. These options are usually dependent on cultural norms and the setup of healthcare facilities. In Australia, for example, the vast majority of women deliver in hospitals. Assisted home birth, which enables mothers to give birth at home with a registered health professional present, makes up a large number of deliveries worldwide. As it is a largely regulated occurrence, home birth trends are better known. Some countries such as the Netherlands have home birth rates of around 30%,9 backed by their own study of the safety of home births in low risk pregnancy, within their system.10 Countries such as Australia (0.4% in 2008)11 and the USA (0.65% in 2005) have extremely small rates of home birth.12 Home births remain controversial, and have been shown in certain settings to triple the rates of neonatal mortality, but reduce intervention rates.13 Overall, the research into home births suggests the success of the practice is highly dependent on the setting in which it occurs. Factors such as pregnancy risk stratification, emergency hospital access and specific training of health professionals are all considerations when interpreting the success of a home birthing programme.

Why are some mothers avoiding healthcare support entirely?

While the choice between a delivery at home or in the hospital is readily available, it needs to be discovered just what drives some mothers away from healthcare support. Proponents quote reasons of unnecessary intervention and disruption of the ‘natural’ process of birthing. Some say the hard to measure spiritual, emotional and even sexual aspects of childbirth are destroyed in the hospital setting. A recent American study suggested greater comfort and control as reasons for selecting home births.14 This may parallel reasons for selecting an unassisted birth. Online forums for discussion reveal that women's motivation in avoiding the medical system is varied. Many had traumatic experiences involving procedures where adequate communication and consent were not attained. Others spoke of generally losing control due to ‘unnecessary intervention’.15 A recent Australian study interviewed 20 women about their choice to ‘birth outside the system’. Nine mothers chose unassisted birth and 11 chose to have a home birth (despite the presence of medically defined risk factors). The three main comments about the perceptions of risk were: ‘Birth always has an element of risk’, ‘the hospital is not the safest place to have a baby’ and ‘interference is a risk’. The group of women interviewed were highly educated, and four were practicing midwives. Furthermore, 16 of the 20 women had previously delivered in a ward setting.16

Unnecessary intervention seems to be a real concern for some pregnant women. Whatever the reason, increased intervention in the medical setting is a fact. Although the trend has slowed in recent years, in 2006 the caesarean section rate had increased to 30.8% across Australia compared with 20.3% in 1997. Rates were even higher in Australian private hospitals.17 This, along with increased use of interventions, such as induction and augmentation of labour, has not resulted in significant improvement in perinatal or maternal mortality during the same time period. Critics of the rapid rise in caesarean sections report fear of litigation, physician preference and repeat caesareans as being major factors for the increased rate.18 Others suggest the rates are increasing due to a rise in the age of mothers, and increasing obesity.19 The fact is, caesarean section rates are increasing globally and are as high as 46% in China where a quarter are not even medically necessary.20 Caesareans not medically indicated are said to be associated with increased morbidity.20

The significant rise in interventions is not only due to physician choice. The respect for patient autonomy has certainly contributed to the increased rates of caesareans and interventions for analgesia. Furthermore, opinion varies on the risks and benefits of caesarean section,21 and many believe the long term adverse effects of vaginal delivery are not well detailed to patients.22 Physicians are more likely to discuss the risks of caesarean section over vaginal delivery.23 Risks with vaginal births, such as faecal and urinary incontinence, pelvic organ prolapse and increased labour complications in older women, are all very compelling arguments for elective caesarean section. The lack of information, in this instance, is the cause of fear among pregnant women.

Traumatic experiences during childbirth seemed to be a very solid motivation in turning mothers to unassisted childbirth. The experiences mostly involved situations where there was a seeming lack of consent, active involvement and/or a communication breakdown. Informed choice is a complex issue, particularly pertaining to obstetrics. A large study from the UK in 2002 aimed to quantify women's perception of informed choice in maternity care.24 Women from 12 maternity units in Wales were surveyed in both the antenatal and postnatal periods. They found several patients felt they had not exercised their informed choice overall in their maternity care. Specific decisions performed better than others. Decisions such as whether to breast or bottle feed, and whether or not to have screening for Down syndrome were perceived as well-informed choices. Interestingly, whether to have their baby at a hospital or at home, and whether or not to have an epidural scored poorly, where only 45% and 46%, respectively, of women perceived they had exercised an informed choice. Informed decisions should be facilitated by health professionals and any practice based solely on institutional routine should be resisted.

What about the child (and mother)?

Recent cases have certainly alluded to safety issues surrounding unassisted childbirth. Autonomy versus non-maleficence, critical obstetric ethical issues, is raised once again. In other words, how should the importance of self-determination versus doing no harm be balanced? Autonomy is a key argument for unassisted birth. However, importantly, an essential precursor to autonomy is informed consent. Choices made by parents throughout the birthing process are often made without adequate information.25 In some cases, procedures are performed and equipment used with no information of the risk and benefits.26 Further complicating the issue are the conflicting medical opinions about various interventions and their effectiveness. This results in the confusion of many new parents and means that a uniform experience in the healthcare system can be difficult to achieve.

Although it is an emotionally loaded topic, the unborn baby's safety in all cases needs to be considered. Supporters of unassisted birth, on the whole, seem to believe the risk to the baby is a calculated one.16 The lack of quality data and the recent media coverage suggest otherwise. Although unborn babies have few legal rights, there are views that propose they have a moral right to be born in the safest possible setting.27 The argument will surely continue, even in light of further future evidence. What is certain however is that until new evidence supporting certain practices is disseminated across healthcare, informed consent and therefore patient autonomy will be elusive. Even then, cultural ideals, health organisations and lifestyle pressures inform consent. When the evidence is clearly against a practice, to what extent should autonomy be respected?

Implications

The topic of unassisted childbirth is much more complex than weighing up the potential health risks and assessing medical reasons for its occurrence. Although there is limited evidence to create a solid argument against unassisted childbirth, the available evidence does suggest that regulation and support of the birthing process result in more positive outcomes. Furthermore, evidence, other than anecdotal, supporting unassisted childbirth will not eventuate without a relationship to formal healthcare. With this in mind should we blanket the practice with governmental legislation, promote and sell ‘baby friendly’ healthcare innovations, or just ignore the practice and accept the consequences?

Despite differing opinions, it has been shown that access to neonatal resuscitation facilities results in a significant improvement in perinatal mortality.28 This highlights the importance of childbirth occurring in a regulated environment, where established protocol exists and access to emergency services is available. Recognising birthing can occur in an institutional setting, or at home (assisted or unassisted), legislation inevitably needs to play some role in the regulation of birthing. This is difficult because the stakeholders, mothers, physicians, midwives and bureaucrats, have differing opinions about the issue. Opinions also differ drastically depending on worldwide geographical location. Recently, in Hungary, a well-qualified midwife was jailed for assisting in home births.29 In Canada, home birth is encouraged30 and supported by local research.31 In the USA, the laws around home birth are somewhat fragmented. Although home birth is legal, in some states it is illegal for some types of midwives to assist childbirth.32 In the UK, however, there are few legal barriers around home birth.33 Although it is currently legal in Australia, coronial recommendations following recent incidents include it being an offence for someone to practice ‘midwifery’ (or the like) when not formally registered. Furthermore, recommendations extend to health professionals having a legal duty to report any planned home births that may have an ‘enhanced risk’, and have those cases receive consultation from an obstetrician. These recommended laws could discourage unassisted birth, but some believe that they may only push the practice further away from healthcare.34 In a move for further supervision, others have suggested a system based upon the UK's ‘supervisor of midwives’ position.35 This would enable further support for midwives’ development and enable easier dissemination of standard evidence based medical practice.36

As well as legislation, creating more attractive birthing environments may encourage mothers to deliver in a formally regulated setting. Encouraging deliveries at home and in birthing centres allows more freedom of choice. Both methods have been demonstrated to be safe, and even result in favourable outcomes. Importantly, outcomes are highly dependent on the cultural setting and supporting healthcare infrastructure.37 ,38 Choice for delivery method is important, but mothers need to be updated with the latest evidence based recommendations. As demonstrated with many other health issues, mass media is also an important tool to be used. Evidence based recommendations could be disseminated to further encourage informed decisions by mothers. It is certain that any approach to encourage maximal engagement of mothers with healthcare will require a coordinated, well-resourced, multimodal approach to achieve the full effect.