Exactly how dangerous is an unassisted birth?

[grude]

First off I know a whole lot of things can go wrong for mother or child no matter what at any time.

But I have seen claims that the idea that birth almost a death sentence is skewed by two things.

Corsets tight enough to deform a woman's body.

Midwives of the time spreading disease by not washing their hands

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

With those things not a factor just what would be the chance of a serious or fatal outcome to unassisted birth to either mother or child? Assuming lets say a well fed hunter gatherer woman who will probably find some shelter when contractions start?

There was a show on TLC called I Didn't Know I Was Pregnant and it surprised me how many of those women basically with no assistance have a healthy delivery. Several believed they just had a very large bowel movement that needed 12 hours of effort to pass.

[dracoi]

Wikipedia says that the natural (i.e. nonmedical, unassisted) rate of death from labor and delivery is 1500/100,000 with a current rate of about 10/100,000 with modern medicine. It says that about 1/3 of pregnancies and deliveries have some kind of complications, but most of those are clearly not fatal.

As for TLC's show... I take everything on it with more than a gain of salt. I think it should be renamed "Denial is not just a river in Egypt." (Which fans can shorten to DINJARIE. It kind of rolls of the tongue.)

[md2000]

Originally Posted by dracoi

Wikipedia says that the natural (i.e. nonmedical, unassisted) rate of death from labor and delivery is 1500/100,000 with a current rate of about 10/100,000 with modern medicine. It says that about 1/3 of pregnancies and deliveries have some kind of complications, but most of those are clearly not fatal.

As for TLC's show... I take everything on it with more than a gain of salt. I think it should be renamed "Denial is not just a river in Egypt." (Which fans can shorten to DINJARIE. It kind of rolls of the tongue.)

No, I saw a woman interviewed about 2 or 3 years ago in Newfoundland. She had 2 other kids, so she knew what a pregnancy felt like. Apparently she had "deciduous bleeding", or fake periods, for all 9 months. (It happens quite often, especially for the first few months apparently). Plus, a lot of women are irrelgular. Also, one doctor theorized the placenta attached to the front wall of the uterus, so that any kicking that did happen was not as obvious.

Finally, she was about 300lb., so that kind of made the situation less obvious absent other signs.

I suppose the difference is that in many third-world countries, yes, they have midwives, but unless the problem is "someone needs to pull" or "Shake some stuff out to clear the lungs", there probably is not a lot medically the midwife can do. Based on the number of unsassisted births that survive, I guess tying of the umbilical is not mandatory? based on the number of births in hospitals that are routine (or unnecessary C-sections) the odds of survival alone would be pretty good. Even if the mother dies of sepsis, that may take a while... the baby would survive.

[dracoi]

Originally Posted by md2000

Based on the number of unsassisted births that survive, I guess tying of the umbilical is not mandatory?

It's not mandatory. Once the baby starts breathing on its own, blood flow through the umbilical cord begins to stop. It will have stopped entirely before the placenta can be delivered. You only have to clamp it if you want to cut right away, like they do in hospitals. (Though I suspect that clamping and tying also helps to prevent infection).

[Surreal]

I don't have information about unassisted births but home birthing with the assistance of a midwife has been shown to be very safe:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2352715/

OBJECTIVE: To investigate the relation between the intended place of birth (home or hospital) and perinatal outcome in women with low risk pregnancies after controlling for parity and social, medical, and obstetric background. DESIGN: Analysis of prospective data from midwives and their clients. SETTING: 54 midwifery practices in the province of Gelderland, Netherlands. SUBJECTS: 97 midwives and 1836 women with low risk pregnancies who had planned to give birth at home or in hospital. MAIN OUTCOME MEASURE: Perinatal outcome index based on "maximal result with minimal intervention" and incorporating 22 items on childbirth, 9 on the condition of the newborn, and 5 on the mother after the birth. RESULTS: There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables. CONCLUSIONS: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.

http://www.commonwealthmidwives.org/...mj%20study.pdf

Objective To evaluate the safety of home births in North
America involving direct entry midwives, in jurisdictions where
the practice is not well integrated into the healthcare system.
Design Prospective cohort study.
Setting All home births involving certified professional
midwives across the United States (98% of cohort) and Canada,
2000.
Participants All 5418 women expecting to deliver in 2000
supported by midwives with a common certification and who
planned to deliver at home when labour began.
Main outcome measures Intrapartum and neonatal mortality,
perinatal transfer to hospital care, medical intervention during
labour, breast feeding, and maternal satisfaction.
Results 655 (12.1%) women who intended to deliver at home
when labour began were transferred to hospital. Medical
intervention rates included epidural (4.7%), episiotomy (2.1%),
forceps (1.0%), vacuum extraction (0.6%), and caesarean section
(3.7%); these rates were substantially lower than for low risk US
women having hospital births. The intrapartum and neonatal
mortality among women considered at low risk at start of
labour, excluding deaths concerning life threatening congenital
anomalies, was 1.7 deaths per 1000 planned home births,
similar to risks in other studies of low risk home and hospital
births in North America. No mothers died. No discrepancies
were found for perinatal outcomes independently validated.
Conclusions Planned home birth for low risk women in North
America using certified professional midwives was associated
with lower rates of medical intervention but similar intrapartum
and neonatal mortality to that of low risk hospital births in the
United States.

And here's one from the Cochrane Review:

http://onlinelibrary.wiley.com/doi/1...751D0ED.d03t01

No strong evidence about the benefits and safety of planned home birth compared to planned hospital birth for low-risk pregnant women.

In some countries almost all births happen in hospital, whereas in other countries home birth is considered the first choice for healthy and otherwise low-risk women. The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women. The review found only one small trial, which provided no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women.

[Hello Again]

There's an enormous, gigantic difference between planned homebirth with a midwife and an unassisted birth, where you're alone.

There's only one study I know about about unassisted birth in a healthy, western population (among a religious sect in Indiana where members forswore all medical attention and unassisted birth was the norm) , and it found maternal death rates 97x greater than in the general population of the state.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00000345.htm

[Yllaria]

Originally Posted by Hello Again

There's an enormous, gigantic difference between planned homebirth with a midwife and an unassisted birth, where you're alone. . . .

Especially since I'd take "unassisted birth" to mean any random person and the midwife would only accept someone for homebirth who didn't have many risk factors.

Grude, it sounds like when you say "unassisted birth" you mean no prenatal medical checkups, no vitamins, no nothing. That's a lot more risky than, say, a pregnant woman trapped in an elevator, whose blood tests and ultrasounds all say that everything is going fine. Let alone a woman using a midwife, with access to hospital backup if needed.

A few quibbles with the OP. Corsets were only used by a subset of well-off women for a short time, historically. And they were only tightened enough to deform by the very fashionable, who would be among the relatively wealthy.

The hand washing habits of midwives weren't nearly as deadly as the handwashing habits of doctors. Either one was safer if they were in your home, as opposed to in a hospital.

The women most at risk in pre-modern times were women who had experienced starvation as children and/or malnutrition as adults, especially during the pregnancy. All kinds of things can go wrong when growth is interrupted or stunted at the wrong time.

And here's where I wish I could remember some details. I remember reading about how if a woman were starved at exactly the wrong time in her development, she could later give birth to a daughter whose body was unable to provide the gestational support to her own daughters to allow them to develop ovaries with ripenable eggs. So the woman would be fine. Her daughter would be fine. But any granddaughters via daughters* would be sterile. That's how specifically starvation can affect developing bodies and leave them with hidden weaknesses.

*This wouldn't affect granddaughters via sons, as long as her sons mated with healthy women.

[Zsofia]

The problem with all those modern midwife homebirth studies is that 1) so few women are taking this option that it's hardly statistically significant, and b) no responsible midwife would ever take a homebirth client who was any kind of risk. And obviously that's quite a different matter from a taxicab birth.

[Surreal]

Originally Posted by Zsofia

The problem with all those modern midwife homebirth studies is that 1) so few women are taking this option that it's hardly statistically significant, and

Nonsense. The first study looked at 1836 women, the second study looked at 5418, and the third was published in the prestigious Cochrane Review.

Originally Posted by Zsofia

b) no responsible midwife would ever take a homebirth client who was any kind of risk.

This was controlled for. The studies only looked at healthy, low-risk pregnancies.

[AmberS]

Originally Posted by Hello Again

There's an enormous, gigantic difference between planned homebirth with a midwife and an unassisted birth, where you're alone.

There's only one study I know about about unassisted birth in a healthy, western population (among a religious sect in Indiana where members forswore all medical attention and unassisted birth was the norm) , and it found maternal death rates 97x greater than in the general population of the state.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00000345.htm

That study does not examine the safety of unassisted birth, however. Those women were not typical freebirthers. Those women were women who do not believe in seeking medical assistance when needed which is an entirely different situation from what other unassisted birthers are in.

You have to consider the fact that there are many types of unassisted birth. There are the women in the study above who seek NO medical attention whatsoever in any situation. Then there are accidental unassisted births in which medical attention is sought immediately. There are unassisted births worldwide which frequently have poor outcomes because the women in those situations live in extreme poverty meaning they are malnourished, starving and frequently diseased. You are going to get vastly different outcomes from these groups. It's like comparing healthy low-risk women who give birth in the hospital with extremely high-risk women who give birth in the hospital. There are just no similarities other than where they gave birth, so you cannot compare them.

If you are discussing healthy first world women who choose to birth unassisted, then you are looking at an entirely different demographic. I am assuming that this is what the OP is questioning. "Freebirthers," as they are commonly called, do seek medical assistance. They believe that unassisted birth can be safer in some cases and seek unassisted birth if they find it is the safer option. Women who plan unassisted births do get prenatal care, sometimes from a doctor or midwife, and sometimes performing the care for themselves. Should any problem whatsoever arise, these women seek medical help. They do not shun hospitals, they simply believe that hospitals are for when you have a problem. It's not the same as birthing unassisted "no matter what." Most people mistakenly believe that mothers choose unassisted birth because they do not believe in hospitals which is untrue.

Unfortunately, there have been no official studies done at all on this demographic, so it is hard to say. Judy C. Snelson has begun her own informal study which can be located here: http://www.unhinderedliving.com/stats.html
But with this study, you have to consider the fact that these are women who came to offer their information after the birth, so results are likely to lean toward positive stories.

There is also a group of unassisted birthers on Mothering.com and about three or four years ago, one woman who was curious and wanted to know began her own informal study. All members of the boards who were planning unassisted births gave their name and due date. They were then contacted at the end of their pregnancies to give information about their outcomes. There were almost 500 women that signed up at the beginning of their pregnancies. There were no maternal fatalities and four infant fatalities, two of which could not have been prevented, even in hospital and two of which there was a small possibility that the baby might have survived if birthed in-hospital. There were hospital transfers as well as births which resulted in cesarean. I would love to share this study but have not been able to find it this evening. I'd love it if there were someone who knows where to locate it on the Mothering.com boards. It was as close to a real study as anyone has accomplished thus far.

There is also a very well-known French obstetrician, Michel Odent, who has devoted his life to researching childbirth and his findings are a bit surprising. He is a proponent of home birth and unassisted birth (though he prefers a woman to have a low-profile midwife on-hand) after decades of scientific research and study. Odent's studies reveal that women birth much the same as any mammal and that, like any other mammal, the physical functions of birth are hindered when the woman is observed. Observation, he warns, can lead to complications. Of the many thousands of births that he has seen in his lifetime (he is in his 80s), he claims that the births he has seen with the best results are those where the woman is unobserved. "It's simple," he says. "The baby just comes out. Just like that."

I have spent the last twelve years deeply researching home birth, specifically unassisted childbirth and women do share their negative stories, though babies that die before, during or after unassisted births rarely die from complications from the birth itself but from severe malformations of the heart, resulting in a baby which is frequently unlikely to have been saved in a medical environment which is a horrible tragedy not only because the baby dies but because the families must grieve the loss of their very-much-wanted child in the face of criticism of others who blame the parents based on their birth choices.

Are there ever emergencies in unassisted childbirths? Definitely. But you are not going to find much solid evidence in print to either prove or disprove the safety of unassisted birth. Personally, I find that Odent's research is the most sound and I feel that unassisted birth is a good choice for women who are healthy, low-risk, not to far from a hospital, are not afraid and who have basic first-aid skills and someone such as a partner or husband in attendance.

[Hello Again]

Actually, the question in the OP assumes no access to medical care, and no one "on call" to assist. Thus, I feel the Indiana numbers hold the closest thing there is to an answer to the OP's question.

Originally Posted by the OP

say a well fed hunter gatherer woman who will probably find some shelter when contractions start

Note that the vast, vast majority of women had a sucessul birth despite no access to medical care and no assistance.

Odent's studies reveal that women birth much the same as any mammal and that, like any other mammal, the physical functions of birth are hindered when the woman is observed.

And with this, the thread takes sharp left into Nutterville. Company during birth is common for highly intelligent social mammals, including dolphins and elephants, who receive assistance from their social group with the birthing process (a dolphin birth helper is known as an "auntie" but can be male). Herd animals like horses and giraffes need the safety of numbers during birth, for to go off alone is quite dangerous in any circumstances. Horses stay with the main herd, while giraffes go to birthing grounds but synchronize their births so that no one group member will be alone. The statement that "all mammals birth alone" is overbroad and unsupportable.

[md2000]

Stillborn used to be a common problem - even today, google meconium aspiration...

One problem that doctors do address is inducing when the pregnancy has gone too long. The risks go up tremendously if the baby is significantly late.

[phreesh]

Originally Posted by Surreal

This was controlled for. The studies only looked at healthy, low-risk pregnancies.

This is an important consideration that many (not all) home birth advocates gloss over. These statistics are only applicable to a smaller subset of pregnancies where everything is highly likely to go smoothly.

For many pregnancies there are complicating factors that should encourage mothers to seek hospital care. And home birth advocates should ensure that this message is transmitted. Home birth is not for women who are outside the 'low risk' category.

[Chief Pedant]

Term births for healthy babies and healthy women are very safe under even primitive circumstances.

Humans have been procreating successfully--big heads, fragile babies and all--for a long time.
Any modern statistic regarding neonatal mortality needs to be carefully evaluated. We get older and more fragile women to pregnancy in the first place, and we are able to get them to carry less-viable offspring to much later stages. All of this skews statistics.
For example, if you try to save a 500 gram fetus and it dies, your mortality statistics are skewed according to what you've decided is a potentially viable fetus. Equally so, assisted births are remarkably safe, with the statistics once again skewed negatively by various factors. Maternal and baby mortality are almost unknown for a term birth to a healthy woman with a healthy baby in a modern Hospital.

I suspect in ancestral times, women with less gynecoid pelvises or other such complicating factors did not fare as well in the reproduction game, so to some extent the less-capable birthers were weeded out naturally. With modern medicine, one of the reasons you have more risk is the improvement in reproductive capability for women who might not have been able to reproduce in the past.

[AmberS]

Originally Posted by Hello Again

Actually, the question in the OP assumes no access to medical care, and no one "on call" to assist. Thus, I feel the Indiana numbers hold the closest thing there is to an answer to the OP's question...

Company during birth is common for highly intelligent social mammals, including dolphins and elephants, who receive assistance from their social group with the birthing process (a dolphin birth helper is known as an "auntie" but can be male). Herd animals like horses and giraffes need the safety of numbers during birth, for to go off alone is quite dangerous in any circumstances. Horses stay with the main herd, while giraffes go to birthing grounds but synchronize their births so that no one group member will be alone. The statement that "all mammals birth alone" is overbroad and unsupportable.

It wasn't clear to me from the OPs post, but I see what you mean when they mention "hunter-gatherers."

As for mammals, dolphins only sometimes have a partner when giving birth and I'm not able to find any information about giraffes birthing in synchronized breeding grounds. All I have ever heard and am able to find info for now is that they go off entirely on their own and return two to three weeks later with calf in tow. I'm not insisting it's incorrect, just hoping you can point me in the right direction for info on that. Mares also will stay behind of the herd to foal and will return to the herd afterwards.

Of course, it isn't to say that humans should all give birth alone - absolutely not. Many women do prefer to give birth with an assistant. There are aboriginal cultures which give birth both with and without assistance, so it's hard to say what humans would do in a more natural setting. We have cultures which do both.

[The Second Stone]

Originally Posted by dracoi

Wikipedia says that the natural (i.e. nonmedical, unassisted) rate of death from labor and delivery is 1500/100,000 with a current rate of about 10/100,000 with modern medicine. It says that about 1/3 of pregnancies and deliveries have some kind of complications, but most of those are clearly not fatal.

As for TLC's show... I take everything on it with more than a gain of salt. I think it should be renamed "Denial is not just a river in Egypt." (Which fans can shorten to DINJARIE. It kind of rolls of the tongue.)

So modern medicine precautions reduce the chance of dying by a factor of 150. Impressive. Win for medicine.

[MLS]

I know that anecdote does not equal data. However, despite the claims above, I myself know of one birth that would not have gone well if unassisted: My grandchild's. My daughter developed a blood pressure spike that was heading toward eclampsia. The birth was induced. It was very possible that without this inducement we could have lost both mother and baby. Today both are fine and healthy.

I say this not as a doctor but only as a person who has given birth twice. My personal experience is that I would probably have done fine with only minimal assistance. Regardless of statistics, even with low-risk pregnancies it's entirely possible for things to go very wrong very quickly.

[kob09]

my kid would have died or at least have severe mental damage if I didn't go to the hospital to give birth, as he had a heart malformation that caused him to not get any oxygen in his body. I had been thinking about home-birth and am glad I did not go through with it and my baby got immediate intensive medical care..

[cornflakes]

Originally Posted by grude

Midwives of the time spreading disease by not washing their hands

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

Nitpick: Semmelweis found that midwife assisted deliveries were roughly three times safer because his doctors weren't washing their hands between performing autopsies and assisting in childbirth (Yllaria touched on this.)

[md2000]

Originally Posted by phreesh

This is an important consideration that many (not all) home birth advocates gloss over. These statistics are only applicable to a smaller subset of pregnancies where everything is highly likely to go smoothly.

For many pregnancies there are complicating factors that should encourage mothers to seek hospital care. And home birth advocates should ensure that this message is transmitted. Home birth is not for women who are outside the 'low risk' category.

The OP question involves - What do you mean by "smaller subset"? 99%? 95%? 60%?

Based on the number of people I know of over the years giving birth, and how many reported real complication, I would be surprised if more that 1 in 20 fell in the category of "should seek medical assitance during birth" or "good thing they had assistance". Also, many many of the tragic "smothered baby" or "left in dumpster" stories, the birth itself, entirely unassisted, went ok.

[Farmer Jane]

I only came in here to say that Arab doctors were washing their hands long before we were. So did the ancient Greeks, but that was all banned in Europe.

[md2000]

Originally Posted by Farmer Jane

I only came in here to say that Arab doctors were washing their hands long before we were. So did the ancient Greeks, but that was all banned in Europe.

I recall some quote from about 1700 where the city planner says something like "the Romans were obsessive about drains and sewers in their cities and camps because they thought poor drainage caused disease; fortunately we know better."

The whole doctors-washing-hands thing was apparently a class issue. The doctors resented being told they should wash up, because that implied they were dirty, and as upper class gentlement they thought they were being equated with common ditch-diggers withmudy hands.

(Anecdote - I was on a vacation in Egypt and Jordan, and even with the 30-plus temperatures every day, and the locals dressed in layers of robes or western long pants and full shirts - nobody at all smelled. One of the tenets of Islam is to wash before each prayer. As a guide explained - that's a bit much, but most Moslems did try to wash 2 or 3 times a day... OTOH, by the time I got back to the hotel after a day dripping with sweat, I'm sure I reeked to them. Yes, the Arabs are very clean.)

[drachillix]

Originally Posted by The Second Stone

So modern medicine precautions reduce the chance of dying by a factor of 150. Impressive. Win for medicine.

Yet obstetricians still have some of the ugliest malpractice insurance rates, talk about no good deed goes unpunished .

[VOW]

Most childbirth occurs without incident. The doctor or the midwife simply makes it to the end of the delivery table and catches the baby.

But when something goes wrong, it goes HORRIBLY wrong, and incredibly fast, too. The uterus has a supercharged blood supply during pregnancy, and once the baby and placenta are delivered, the inside of the uterus is like a huge, open wound. Until it clamps down and clots begin to form, there will be blood. Without the clamping and clotting, there will be a LOT of blood, and mom can quickly bleed out.

Reminds me of that poem:

"There once was a girl
Who had a curl,
Right in the middle of her forehead.

When she was good,
She was very very good.
And when she was bad,
She was horrid."


~VOW

[Yllaria]

Originally Posted by cornflakes

Nitpick: Semmelweis found that midwife assisted deliveries were roughly three times safer because his doctors weren't washing their hands between performing autopsies and assisting in childbirth (Yllaria touched on this.)

Ah, but I didn't have a cite (besides I heard it in something that James Burke did). This is much better.

And I'm wondering exactly how well Dr. Odent observed those unobserved women. Because if I had needed to go be alone to give birth and a doctor asked me how it went, I'd say fine even if I was still bleeding heavily weeks later, even if labor took three days, even if the baby was a little sluggish, etc.

[Filbert]

My cousin attempted a home birth, with midwife, and birthing pool, all OK'ed as she was low risk.

I'm not sure on details (don't really want to ask, y'know?), but I do know she probably would have died if the hospital hadn't been as close, or if someone had been a bit slower deciding to call an ambulance; she lost a terrifying amount of blood and would up in hospital for a week or so as it was. Just an anecdote- it's fairly safe if you have good fallbacks available.

Incidently, regarding animals 'falling back' from the group to give birth- I'm sorry, but that's rubbish; most social animals (including wild horse species) will do their very best to stick to the group, for the simple reason that predators tend to follow herds seeking out sick or young animals. Elephants especially have been recorded as forming a complete protective ring around females giving birth. Chimpanzees and gorillas both generally stay with their troupe.

Animals which are more solitary in general will find somewhere to hide, but it makes no sense for normally social creatures to leave the safety of the group at such a vulnerable time, and they will not do so if at all possible. The exceptions to this are mainly predators, or other species where there is a real chance of the other members of the group attacking or eating the babies.

[monavis]

Originally Posted by grude

First off I know a whole lot of things can go wrong for mother or child no matter what at any time.

But I have seen claims that the idea that birth almost a death sentence is skewed by two things.

Corsets tight enough to deform a woman's body.

Midwives of the time spreading disease by not washing their hands

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

With those things not a factor just what would be the chance of a serious or fatal outcome to unassisted birth to either mother or child? Assuming lets say a well fed hunter gatherer woman who will probably find some shelter when contractions start?

There was a show on TLC called I Didn't Know I Was Pregnant and it surprised me how many of those women basically with no assistance have a healthy delivery. Several believed they just had a very large bowel movement that needed 12 hours of effort to pass.

I had 7 children and had 5 of them with out assistance, as a matter of fact i had 2 that I had to push the nurse and my husband away because the doctor told the nurse not to let me deliver without him. She was trying to push the baby back! Others' I had in the labor room, because they didn't believe me, and one getting off the elevator. I had almost no labor pains to speak of, I did work hard during my pregnacies, I helped remodel houses etc., and the 6th one I left the house at 9:30 and delivered at 10 minuets to 10. I had her one day, left the hospital the next, and went to the one house and did the finishing of the wood work. The nurses couldn't believe any one could deliver with out pain. The old lady that we bought the house from used to tell me I was going to have a terrible time,because i was doing such hard work,then after the delivery of my child when she heard of how fast i delivered she said"From now on when I hear a woman is pregnant I am going to tell her to work her fool head off"!