Book Review: Unassisted Childbirth

An unassisted birth is one at which only the pregnant woman and the people she chooses to be with her are present. Unassisted births take place, by definition, in a private home, and are not attended by anyone with experience in supervising childbirth. Before moving to Rural, I had never encountered this childbirth practice but have several times since then among the women who receiving prenatal care at our clinic, women who transfer to the hospital after attempting an unassisted birth, and women who planned a hospital birth but ended up giving birth at home. Now I understand that unassisted childbirth is a recognized movement in the home birth community, and the major spokeswoman for it is Laura Kaplan Shanley, whose book entitled Unassisted Childbirth is a commonly-cited reference on the practice. This post examines the merits of Ms. Shanley's book and touches upon the practice itself.

I will disclose at the beginning of this review that the practice of unassisted childbirth makes me nervous. For the record, I believe every woman's birth should be attended by someone who has experience with the progress of normal labor and who will recognize when a labor deviates from normal. Note that this definition does not require a birth to take place in a hospital, although that is my preference. However, since moving to Rural I have worked side-by-side with home birth midwives and their pregnant clients and have come to respect the practice as a viable option for certain women. Home birth has been around for a long time and taking a rigid stand against it will do nothing to encourage women who are not good candidates for a birth at home to consider a hospital birth. I do not extend the same support to unassisted births. In an effort to better understand the motivation women have to pursue such a birth, I have been reading about midwifery, and cross-cultural and religion-based childbirth practices. This reading project brought me to Ms. Shanley's book.

Laura Kaplan Shanley is not a scientist, doctor or midwife, but a journalist. I don't know what her journalistic accomplishments are but she is widely cited in the midwifery literature. At the same time, the birth experiences she cites in her book are limited to her own and to verbal reports of other women's experiences, many of which are gleaned from other books about childbirth. However, apparently her own five unassisted births qualify her as an authority on the subject, and she presents an elaborate argument for the unfettered, natural unassisted birth. At the heart of Ms. Shanley's argument are the following assertions:

1. Childbirth is inherently painless.
2. Pain in childbirth is caused by false beliefs in the inherent painfulness of labor and unnatural emotions such as anger and anxiety.
3. It is possible to gain personal insight to control one's beliefs.
4. Reality is created by an individual's belief. Therefore controlling one's beliefs and expectations will change one's reality.
5. By turning to doctors and midwives to supervise their births, women are giving in to a false reality and experiencing the painful, dangerous birth they are led to expect.
6. The only way to be liberated from these false beliefs is to shun authority and give birth alone with only those people you choose to be in attendance.

To support the idea of pain-free childbirth, Ms. Shanley cites anthropologic studies of childbirth in non-Western cultures. She relies on Judith Goldsmith's cross-cultural study, in which Goldsmith describes a number of societies in which women give birth unassisted, in many cases hardly interrupting the work they were doing before the birth occurred. From this, Ms. Shanley concludes that there must be an underlying psychological reason for the difference in women's experience of the same physical event: birth. She does not pause to examine the possibility that cultural norms around the expression of pain differ greatly between the non-Western societies Goldsmith studied and our own. Neither does she discuss the physiology of painful stimuli. In Unassisted Childbirth, the perception of pain during childbirth is reduced to a purely psychological phenomenon.

Once Ms. Shanley has determined pain in childbirth to be a psychological construction, she goes about telling us how to control our beliefs and expectations so that we can control reality. Ms. Shanley is a student of the spirit guru Seth, who was channeled by the writer Jane Roberts:

"Seth teaches that we create our own reality according to our desires, beliefs, and intentions. Thoughts, he says, are not merely nebulous words floating about in our heads. The are actually electromagnetic particles, which, once conceived, have an intense desire to manifest themselves in the physical world. The stronger the thought, the more quickly it will come into our experience."--Shanley, Chapter 5

This belief, originating from a spirit guide channeled by another person, establishes the core of Shanley's belief. She cites a number of supporting statements from diverse classical and religious sources such as the New Testament and the teachings of Buddha, to the stoic emperor Marcus Aurelius. She cites more contemporary new-age thinkers such as Norman Vincent Peale and Bernie Siegal, M.D. as well, and cites the televised testimony of guests on the Sally Jessy Raphael and Geraldo Rivera shows as examples of women's mistreatment during childbirth in hospitals. Finally, she goes on to assert that meditating upon the ideal birth and active dreaming are two ways of retraining beliefs and creating reality. She gives the example of her own dental caries, which were originally going to require extensive dental reconstruction. Instead of proceeding with the recommended interventions, Shanley deferred treatment. During the next several months, she told herself "that I loved my teeth and was no longer attacking them." When she returned to the dentist, she was told there was nothing wrong with her teeth at all.

Believing absolutely in the power of her own mind, Shanley eschewed prenatal care with each of her five pregnancies:

"...when I was pregnant, every day I said to myself, 'I believe in my ability to give birth painlessly and easily. I believe I am deserving of a good birth. I believe I am not ashamed. I believe I am not guilty. I believe I am not afraid. I believe in love and I forgive myself.'"--Shanley, Chapter 6

All five births occurred at home, the first two in the presence of her husband and friends, the last three alone. One infant died within hours of the birth, from later-diagnosed congenital defects. Shanley's take on this neonatal death is interesting; she did not feel prepared for the pregnancy and had hoped for a miscarriage. Once the infant had died, she reasoned that her hope had been realized--only a bit later than expected.

Given her own success in retraining her beliefs, Ms. Shanley can't help sounding a bit critical of women who choose to accept help from doctors or midwives at the time of their deliveries. In one passage, she first acknowledges it is possible to have a good birth in the hospital:

"Of course, not all hospital births are horrendous. Many women are treated well in hospitals. Their wishes are respected. They have supportive birth attendants and are allowed to give birth in the way they desire."

Then she undermines the hospital experience and the women who endorse it, by implying those women have Stockholm Syndrome:

"Often, however, a woman who speaks glowingly about her physician and the interventions that he deemed necessary may not be facing up to the reality of the situation. According to one childbirth educator I spoke with, many women develop a 'hostage' mentality when in the hospital. As with hostages, they actually begin to identify with their 'captors.'...Many women simply feel more comfortable rationalizing their experiences than analyzing them and possibly coming to the conclusion that they and their trusted physicians did something wrong."--Shanley, Chapter 2

Apparently, women can control their reality by harnessing their beliefs, but only if those beliefs are consistent with Shanley's philosophy. All others, no matter how strongly held, are merely rationalizations or perhaps the result of medical brainwashing.

This is ultimately the greatest flaw in this very charismatic and inspiring book: although she would have women believe in their own inner strength and the power of their own minds, she dismisses any beliefs that contradict her own. In her firm, pro-woman language, she fails to disguise a fundamental desire to control natural processes, from childbirth to dental decay to metastatic cancer. The fact that this notion of control over nature has been the battle cry of patriarchy for centuries seems to escape Ms. Shanley. Her self-taught belief system is so pure and unassailable, it leaves the average woman out in the cold.

Comments

[dissertation]

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[amsty]

Living in a state where it is illegal to be attended at home, the only viable choices for women on budgets are to have an unassisted birth at home or submit to a hospital birth and try to fight for your rights to be left alone. Having done the latter twice already, I am tired of fighting, and although my current pregnancy is planned for the hospital with my CNM, it may just happen at home.

[Theresa]

I think you raise some great points, Rixa. I am trying to achieve some dialogue between homebirth and hospital birth advocates. Most of the UCs I've been peripherally involved with in Rural have been completely unattended births. I think I would feel much more comfortable with the idea of a nearby experienced midwife--someone who didn't have other distractions, but could be dedicated to helping the woman if needed.

I would love to discuss these topics further with you. I have your blog address now, will look for an email contact. Thanks for stopping here.

[Rixa]

I am a PhD student currently writing my dissertation about the unassisted childbirth movement in North America. I wanted to add that Laura Shanley's ideas, taken to their fullest, don't really represent most women in the UC community. I think a lot of women who have unassisted births do agree with many of her ideas (as so many in the natural childbirth/home birth community): the dangers of unnecessary medical interventions in birth, the importance of positive beliefs and visualization, the fear-pain-tension cycle, etc. But I haven't come across very many women at all who hold to the same beliefs that *all* reality is created. And the "healthy tribal woman" argument is something that Shanley is fairly alone in promoting. I think a lot of women just don't go there, because of all the colonialist and potentially racist implications of that argument (you know, native people never get sick, etc).

You would probably be interested to know that when Shanley published her book, the presence or absence of a birth attendant was peripheral to her message. In fact, the phrase "unassisted childbirth" was something her publisher came up with, not Shanley at all! Over time, she has become known as a figurehead in the unassisted birth movement, but that was not her original intention when she wrote her book.

The two books that probably represent UC ideas the best are "Birth Reborn" by Michel Odent and "Gentle Birth, Gentle Mothering" by Sarah J. Buckley. Now, these books aren't about UC specifically, but rather about the importance of the laboring woman feeling private, safe, and undisturbed. They are probably the most influential ideas in the UC community.

You might be interested in talking more with Pamela Hines-Powell, a CPM in Oregon who supports unassisted birth and works with UC families in a variety of capacities, including attending births she calls "unassisted but attended," where she sits in the other room or some other part of the house and only assists if asked.

Anyway, I'm glad you're having this conversation. I should add, too, that I had my first child unassisted. In an ideal world, we wouldn't have to fret over these categories of assisted/unassisted (or all the other "types" of birth that are so heavily contested) but the reality is that in many states, women do get cornered into either-or situations all to often. Either you have a midwife who does a lot of stuff at your home birth that the woman perhaps does or does not want, or you have a UC. Either you have a home birth with no physician willing to collaborate or back your midwife up, or you sign up for a hospital birth and all its bells and whistles.

For example, when I was pregnant I sent around feelers to the midwifery community in the state where I was living about getting some services such a postpartum exam to check for tears, having someone willing to be in another part of the house or "on call" down the street, etc. I was already assisting a home birth CNM, so I had an "in" into the community (since I lived in an illegal state). Midwives there were, understandably, very wary of doing anything out of the norm. For most of them, staying in another room and allowing a woman a private birth was outside their comfort zone in light of all the legal persecution they'd been going through lately. So I think the more pressing issues are: how to we accommodate some women's needs for privacy and autonomy, without perhaps forcing some of them into corners they don't wish to be in? Now, I think most women choose UC freely, but still many would love to have more open collaboration with midwives or physicians so it's not a "UC or ER" situation.

[Jessica Bond]

Home birthing...I just can't imagine what that would be like even if the birth was uncomplicated. I have a very high pain threshold and I offered the anesthesiologist cash for administering the epideral. Afterwards, it was indeed painless.

[perceval]

Disclosure: Even though I am pro-home birth, I had two planned C-Sections that I really enjoyed (huge cervical fibroid).

Personally, I am disgusted by much of what you report about Ms Shanley's book, even though I'm all for home birth.

I don't think it promotes a healthy, accepting attitude towards childbirth. Rather, it has the potential to plunge you into the deepest of depressions if things don't go according to plan. If things go wrong and you should (heaven forbid!) have an emergency C-Section, that happens because you must have subconsciously wanted it or because you didn't want a home birth strongly enough.

And the description of the still birth is just ... wrong. I know a few women whose babies were born asleep. I would bet that they would be up in arms at the slightest hint that their babies did not live because their mothers subconsciously did not want them to. I really, really hope that Shanley does not make that generalisation in her book.

What you want is a book that helps women make positive choices about childbirth and labour, and this does not seem to be it. Last, but not least, you can be fully in control by consenting to medical interventions that save your and baby's life. If both of you die just because you've become woefully attached to your dream birth, you've been played like a puppet on a string.

[Theresa]

Hi everybody,

Glad to have so many different voices and experiences leaving comments on this post. As I said, I am making a formal exploration into different types of birth practices, so I can understand where women and their midwives are coming from when they share their care with me. I believe in being open-minded and creating dialogue, but I will admit-this is not easy.

What I didn't get to write about in this review, and maybe will post about separately, is that I agree with Ms. Shanley on a number of points, including the power of a good attitude and unworried approach to birth. I have seen this life philosophy bring a calmness to a woman in labor.

However, I still believe an experienced childbirth attendant should be present to help a laboring woman. True, the attendant does not have to be trying to control every aspect of the experience, but can be a resource in case things don't seem or feel right. I agree that the attendant can be nearby, rather than in the room with the mother. I suspect that model is closer to the unassisted, non-Western birth traditions Ms. Shanley cites, in which women may withdraw to give birth, but have experienced women nearby, some of whom know she has withdrawn to labor alone.

Thanks for your thoughts.

[CJ]

Just to add a data point: I've had two babies in the hospital and two at home (one FP-attended, one CNM-attended) and I was astonished at the difference in the pain I experienced. The labors at home were hard work and uncomfortable, but between the two of them I had about sixty seconds of actual pain (I was lying down at the doctor's request for him to check FHTs and couldn't get up before the next contraction hit -- miserably painful).

It's possible that I'm remembering incorrectly, that I was in pain the whole time and just have forgotten, but I don't think so. I distinctly remember pacing and saying, "Gosh, I'm uncomfortable" the last time. I thought I was about 4cm at the time -- when the midwife arrived a few minutes later, I learned I was almost 9cm. "Gosh, I'm uncomfortable" isn't what I was saying at that point in my two hospital labors. ;-) FWIW, I don't have anything ideological riding on a pain-free birth experience, and I know that this next birth (planned for home with a CNM) could be very different from the last two.

While I know many women do have painful labors at home, my experience isn't all that unusual. This study is old but I find it intriguing. Oops, no HTML in your comments. Here's the link:

http://www.ncbi.nlm.nih.gov/pubmed/3399698?dopt=Abstract

Laura Shanley strikes me as dangerous and I do not understand unassisted birth, but I have to agree with her that birth setting has the potential to make a huge difference in experiences of labor pain.

[Hilary]

I have been enjoying your blog very much since I stumbled on it recently. I am a med student who trained as a lay midwife for two years and a mother who had two natural births. It is SO refreshing to see a physician who has such a balanced and fair treatment of maternity practices.

I have not read the book, but I completely agree with your position on unassisted birth. If you want, have your midwife or birth attendant spend the whole time in the next room. But have someone there who can diagnose or handle complications. I know of an unassisted birth turned cerebral palsy that happened near here, and I am sure there have been many other negative outcomes.

Not to mention the stillbirths and obstetric fistulas in these countries where the author is glorifying women who don't have a skilled attendant. She should go to a fistula hospital in Africa, look all these women in the eye and tell them it was their negative thoughts that brought them where they are.

[Evil HR Lady]

I have to agree with her assessment that childbirth is inherently painless. After I got my epidural, I hardly felt a thing. :>)

[enrico]

"I believe I am skinny. I am wealthy beyond compare. I am worthy of becoming a physician and know that elite institutions can't help but want me in their program. My body is a holy temple deserving of worship. I know that repeating this will make it all true, so sayeth Seth."

*opening eyes*

DAMMIT! SHIT! !@&#&!@#

[Paper Raisins]

I'm with you on this! I don't think it's a good idea to go without backup. I've checked out her website in the past, done my own research and reading. One thing that really bothers me, and it's probably semantics, but the wording "unassisted".

In my mind there is a vast difference between unassisted and unattended. I have no problem with the idea of a woman wanting to birth her baby without physical help... I get that someone might not want others to be closely involved, that it's an intimate experience for them and they just want to do it by themselves. To me this is "unassisted" .

But to choose NOT have someone who's appropriately skilled and educated there in case they are needed, I feel that's making an unwise decision. I don't think having someone there (if even in the other room) undermines confidence in yourself or the process, it's just being practical and careful.