Introduction
There are many decisions that women and family members face as they prepare for the birth of a new child. Place of birth and the type of healthcare provider for perinatal care are two common considerations for women and families. For many women, a hospital is the preferred location for labor and delivery, attended by a physician.1 Increasingly, in high resource countries,2,3 women and families are choosing to have midwifery care and home births attended by midwives.4
For an unknown number of births, women and their families are choosing to have home births without the assistance of a healthcare provider. These births are referred to as; unassisted births,1,5-8 free births,1,5,9 autonomous births,1 unhindered births,1 and do-it-yourself births.5 For this systematic review of qualitative literature, the term "unassisted birth" will be used as it is the most commonly used term across countries in the global north to refer to this phenomenon.1
Prior to the early and middle twentieth century, depending on the high resource country, most women gave birth in their homes.10,11 Birthing care moved from taking place in homes to taking place in hospitals in many high resource countries with the urging of physicians for reasons such as safety and hygiene.11 This new, innovative medical model of birthing in hospitals slowly became normative after World War II.12 As women and families came to associate hospital birth with safety, their interest and trust in home births dwindled. In countries like Canada and the United States, in the 1970-80 s the home birth movement emerged in response to the misuse of obstetrical interventions, less than ideal birthing experiences and lack of choice for non-normative ways of birthing.12 With the home birth movement came renewed interest in choice of birth place and choice of healthcare provider, with women and parents deciding where and with whom they wished to have their birthing experience.
The term "unassisted birth" was first coined by Laura Kaplan Shanley.13 Unassisted birth can be described as birth where there is an "absence of an expert, rather than complete solitude".1(p.54) Unassisted birth has also been described as "a unique phenomenon, whereby women make an active choice not to utilize the maternity services that are available to them".7(p.4) It is very important to distinguish unassisted birth from the phenomenon referred to as "born before arrival" which occurs when a birth happens with the unintentional absence of attendance by a healthcare provider.7 An example of a "born before arrival" birth would be if a woman experienced an extremely fast labor and did not have time to seek assistance from a healthcare provider. This is different from an unassisted birth because "born before arrival" birth occurs as a result of not having enough time to access healthcare, whereas in the case of an unassisted birth, there is an active choice not to seek care from a healthcare provider. It is also important to understand that although an unassisted birth often takes place in the home, it should not be confused with a home birth. A home birth is a birth that is attended by a healthcare provider, usually a midwife, who is present during labor, delivery and the immediate postpartum.
It is difficult to know the exact prevalence of unassisted birth throughout the world because of the nature of it taking place at the margins of the healthcare system. Plested and Kirkham14 stated the lack of data regarding unassisted birth in the United Kingdom, while Lindgren, Nassen, and Lundgren8 stated that one in five home births in Sweden are unattended by a midwife or a healthcare provider. It is difficult to know whether the lack of data on unassisted birth is due to the methods for collecting data on out-of-hospital birth or whether the lack of data reflects the low numbers of women and families choosing this as a birthing alternative.
Studies have suggested that there is stigma associated with making healthcare decisions that contradict mainstream healthcare, such as the decision to have an unassisted birth.6,9 The presence of stigma surrounding the decision to have an unassisted birth may contribute to the challenge in accounting for the number of women and families choosing such alternatives as home birth or unassisted birth.6 According to Miller,6 women who chose unassisted birth often strategized how they were going to address the layered stigma of an unassisted birth. For these women, unassisted birth was associated with two layers of stigma; the first layer was one from mainstream society for choosing to have a birthing experience outside of accepted norms, the second layer was from home birth advocates who supported home birth, but not home birth without the assistance of a healthcare provider.6 Miller6 argued that this double layer of stigma rendered women and families who chose unassisted birth invisible. Through this example, we can see the challenges in accounting the prevalence of unassisted birth within the general population.
A meta-thematic synthesis which examined why women choose to have an unassisted birth revealed four main reasons.7 The reasons for choosing an unassisted birth included; i) rejection of the medical and midwifery models of birth, ii) faith in the birth process, iii) autonomy, and iv) agency.7 The first two reasons are self-explanatory. The third reason has to do with the preservation of a woman's autonomy and her control over the birthing experience, which was often related to a previous birthing experience during which the woman felt a lack of control.7 The final reason had to do with a woman maintaining agency over her own body and the birthing process, through the decision to reject a medicalized birth.9 This synthesis7 focused on what influenced women to choose to have an unassisted birth; however, it did not explore and synthesize the literature1,8,9,14,15 about the actual experiences that women had during unassisted births.
For this systematic review, we are interested in understanding the experiences of women who choose unassisted birth in high resource countries.2,3 The reason for this is because in high resource countries, perinatal care is generally available to women. Thus, the women choosing to have unassisted birth are making a choice that challenges the mainstream expectations of birthing with the assistance of a healthcare provider. In under-resourced countries, women and families may birth at home without the assistance of a healthcare provider due to a lack of perinatal services, shortage of skilled birth attendants, and financial or infrastructure barriers to access any services that do exist. The differences in the accessibility of perinatal care between high resource countries and low resource countries may result in different reasons why women choose to birth at home without the assistance of a healthcare professional. In this qualitative systematic review, we are interested in understanding the experiences of women who choose unassisted births, within a context of generally accessible perinatal care.
This systematic review will synthesize findings as they relate to women's experiences of unassisted birth. Understanding women's experiences of unassisted birth may assist us in our understanding of what women value in their experiences of birth, generally. The findings of this review may also assist us in identifying important elements of care that are missing from mainstream perinatal services.
A preliminary search of MEDLINE/PubMed, CINAHL, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports revealed that there are currently no published systematic reviews about women's experiences of unassisted birth. Both PROSPERO and the Campbell Collaboration were also checked. In PROSPERO, two results were identified regarding outcomes and place of birth.16,17 Other results concerned decision making around birth18,19 and during pregnancy and birth.20 None of the results in PROSPERO examined the experiences of unassisted birth.
Inclusion criteria
Participants
This review will include women who have planned unassisted births in their homes. That is, women who plan to birth at home without the assistance of healthcare providers.
Phenomenon of interest
The phenomenon of interest for this review is women's experiences of planned unassisted births at home. Unassisted births are defined as births that are planned not to be assisted by professional healthcare providers.7 Healthcare providers are defined as professionals who are trained and licensed to provide healthcare to women and newborns throughout the perinatal period, specifically during labor, delivery, and the postpartum period. Healthcare providers include, but are not limited to: nurses, midwives, physicians, obstetricians, and paramedics.
Context
The context includes planned unassisted births that occur at home in high resource countries. For this review, high resource countries will include: Canada, United States of America, Australia, New Zealand, Japan, countries located in Europe and countries of the former USSR.2,3 Births of any kind that occur in low resource countries will be excluded. For this review, low resource countries will include; countries located in Africa, countries located in Asia (not Japan), and countries in Latin America.2,3 Births occurring in a hospital or birth clinic will be excluded.
Types of studies
The review will consider studies that focus on qualitative data including, but not limited to: designs such as; phenomenology, grounded theory, ethnography, action research and feminist research.
Methods
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe each article (see Appendix I for preliminary search strategy). A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published beginning with the date of inception of each of the databases will be considered for inclusion in this review. The search for unpublished studies will be important to this review given that the topic is often at the margins of health care.
Information sources
The databases to be searched include: MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), Scopus (Elsevier), Web of Science (Clarivate Analytics), Sociological Abstracts (ProQuest), ProQuest Dissertations and Theses (ProQuest) and Nursing and Allied Health Database (ProQuest).
The search for unpublished studies will include:
* Targeted Advanced Google searches
* Government websites: Canada, US, UK, EU countries, Australia, New Zealand
* International Confederation of Midwives
* International Council of Nurses
* Association of Women's Health Obstetric and Neonatal Nurses
* Canadian Association of Perinatal and Women's Health Nurses
* Dona International - https://www.dona.org/
* Association of Radical Midwives - http://www.midwifery.org.uk
* Unassisted Childbirth - http://www.unassistedchildbirth.com
* Free Pregnancy and Free Birth - http://www.freepregnancyandfreebirth.com/
* Freebirth Australia - http://freebirth.com.au/.
Study selection
Title, abstract and full text screening will be conducted independently by two reviewers. Disagreements that occur during these processes will be solved by consensus or consultation with a third reviewer. Search records will be collated and managed using the citation management software Covidence (Covidence, Melbourne, Australia). Duplicates will be removed and recorded. Reasons for exclusion during the full test screening and the critical appraisal process will be included in an appendix in the completed review.
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).21 Specifically, the JBI Critical Appraisal Checklist for Qualitative Research will be used, any studies with a score less than 6/10 will not be included. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data collection
Qualitative data will be extracted from papers included in the review using the JBI Critical Appraisal Checklist for Qualitative Research from JBI SUMARI.21 The data extracted will include specific details about the phenomena of interest, participants, context, study methods and the phenomena of interested relevant to the review question. Findings, and their illustrations, will be extracted and assigned a level of credibility.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI SUMARI.21 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Assessing certainty in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.22 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the table is the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review is then presented along with the type of research informing it, a score for dependability, credibility, and the overall ConQual score.
Acknowledgments
We wish to gratefully acknowledge the continued support of The Centre for Translational Research: A Joanna Briggs Institute Centre of Excellence in Fort Worth, Texas.
Appendix I: Search strategy - CINAHL
References