Unassisted birth and doulas is not without risk to all involved. Unassisted birth, sometimes referred to as freebirth or unattended birth, refers to a planned birth that takes place without a qualified birth attendant present. While doulas are birth experts, doulas are non-clinical. A qualified birth attendant refers to a properly trained midwife, obstetrician, or family physician.
At the International Doula Institute, we pride ourselves in always staying within our scope of practice. For this reason, we do not condone IDI certified doulas attending unassisted birth. Doing so puts doulas in a position to easily slip into medical or clinical tasks which fall outside our scope of practices.
Unassisted birth typically means:
- The person giving birth intentionally chooses no medical provider to attend the birth.
- Support may include family, friends, or a doula, but no professional midwife, obstetrician, or trained nurse-midwife is present. IDI does not condone IDI certified doulas attending unassisted births
- It is not the same as unplanned unassisted birth which sometimes occurs when birth is faster than anticipated. In these cases, proper prenatal care has typically occurred and a qualified birth attendant will arrive or parents will go to them shortly after the birth. The providers will examine baby and ensure placenta has safely detached.
- Many professional bodies and maternity care organizations issue strong cautions or warnings against unassisted birth because of the inherent risk. Birth often unfolds very well, but when it does not, a skilled professional saves lives.
Women choose unassisted birth for various reasons: desire for autonomy, distrust of medical systems, previous traumatic birth experiences, philosophical or spiritual beliefs about birth, or belief in the body’s inherent capability without intervention. (PubMed)
However, the absence of a skilled attendant means that if complications arise, delays in diagnosis or treatment can result in serious maternal or infant mortality and morbidity.
Unassisted Birth and Doulas – Why IDI Doulas Are Not Trained to Attend Unassisted Birth
At IDI, our role as doulas is to provide continuous emotional support, evidence-based education, advocacy, and companionship during pregnancy, labor, birth, and postpartum. As doulas, we are non-clinical, and we do not provide medical interventions or make clinical decisions.
Here’s why unassisted birth lies outside the doula scope of practice:
- Risk management requires clinical training.
Complications during labor and birth (e.g. hemorrhage, fetal distress, cord prolapse, shoulder dystocia, postpartum hemorrhage) may occur without warning. Recognizing, diagnosing, and intervening in such situations requires medical skills, judgment, and equipment that doulas are not trained or licensed to provide. - Ethical and legal boundaries.
Doulas must remain within their professional scope. Attending an unassisted birth could implicate liability risks, as interventions or observations you make could be interpreted as medical advice or actions. Maintaining clear boundaries protects both the client and the doula. - Supporting safe transfer requires planning.
In a birth attended by a qualified midwife or provider, there is often a system for timely transfer to a higher level of care if needed. In unassisted birth, that pathway may not exist or may be delayed, increasing risks. - It conflicts with evidence-based practice.
Because unassisted birth is not supported by high-quality evidence as a safe option across populations, it’s inconsistent with our commitment to offering clients information grounded in research and clinical guidelines.
In short: doulas can support, inform, and accompany families during birth, but we do not replace skilled medical care. Unassisted birth is beyond what we can ethically or safely offer.
Regardless of written contracts or agreements with families, in the absence of a midwife or physician, a doula could be seen as the “birth professional” in attendance. If things do not go well,
How Unassisted Birth Differs from Planned Home Birth with a Qualified Attendant
It’s helpful to know the difference between unassisted birth and a planned home birth attended by a qualified midwife or physician. While home birth (with a qualified attendant) is still a subject of debate in some medical circles, it is fundamentally different from freebirth in critical ways. Research supports home birth with a qualified attendant within a close proximity to a hospital with maternity as a safe option for low to moderate risk mothers expecting healthy full term babies.
What the Research Says about Planned Home Births
What does the research say about births planned at home, with professional midwifery care, in low-risk populations?
- Lower intervention rates. In a meta-analysis covering 500,000 intended home births, women intending home birth (in well-integrated systems) had significantly lower odds of cesarean section (OR 0.58), operative vaginal delivery (OR 0.42), epidural analgesia (OR 0.30), episiotomy (OR 0.45), and maternal infection (OR 0.23), compared with hospital births. (The Lancet)
- Good perinatal and maternal outcomes. Studies show that when home birth is properly supported, low-risk mothers may have comparable perinatal outcomes to hospital births. (PMC)
- Some degree of hospital transfer is common. For example, in a study of midwife-assisted home births, about 12.1% of intended home births were transferred to hospital care during labor or delivery. (PMC) It’s important to note that most of these transfers of care are not due to emergency but rather a need or desire for pain medication or labor augmentation.
- Low rates of intervention and high rates of physiologic birth. In Washington State’s planned community births, cesarean rates were low (4.7%) and physiologic (non-intervened) birth rates were high (85%), with a breastfeeding rate of 93%. (Lippincott Journals)
- Caution regarding neonatal risk in some settings. Some studies show higher risks of neonatal issues in planned out-of-hospital settings. One Oregon study of nearly 80,000 deliveries found that out-of-hospital births had about 3.9 per 1,000 perinatal deaths versus 1.8 per 1,000 in hospitals (i.e. approximately double the risk) even among low-risk singleton births. (UT Southwestern Medical Center)
Important Note:
It’s important to note that many of these studies emphasize that the safety of planned home birth depends on careful selection of low-risk clients, professional attendant support, and timely access to transfer to hospital. (PMC)
One of the most challenging aspects of tracking out of hospital births with qualified attendants in the US is that there is no one federal definition of midwife. There are highly qualified direct entry midwives who have trained in a traditional apprenticeship, but someone without that training might call themselves a midwife as well. There are advanced practice nurse midwives, certified midwives, certified professional midwives, and more. Because of the lack of singular definition, tracking safety and outcomes becomes a challenge.
However, overall, research does show that midwife attended births outside the hospital while also being within 15 minutes of a maternity hospital, is a safe option for many low risk mothers. Due to the nature of unassisted birth, there is no way to truly track all outcomes.
Why It Matters That Doulas Don’t Attend Unassisted Birth
- Family safety is paramount. While supporting autonomy is important, we must prioritize reducing avoidable harm. If a birth becomes complicated, a skilled birth attendant is vital. Doulas simply do not posses the skills to intervene while remaining within their scope of practice.
- Clear professional boundaries promote trust. Families benefit from knowing exactly what doulas can and cannot do. Our strength lies in nonclinical support, not in medical responsibility.
- Liability and ethical integrity. Staying within scope helps protect both the doula and the family from misunderstandings or legal risk. Even if you explain your role as non-clinical, if an emergency arises there may be the expectation that you will intervene.
- Respect for the shared care model. In ideal birth models, doulas, midwives, obstetricians, and other professionals each contribute safely within their scope of practice. Unassisted birth removes the safety net of collaboration.
Unassisted Birth and Doulas – Can I Attend an Unassisted Birth?
While there are doulas who will attend unassisted birth, it is the position of IDI that our doulas do not attend unassisted births. While we believe in birth autonomy and that all families deserve support during labor and birth, we do not promote doulas working outside their scope of practice. To protect birthing communities and doulas, we advise against attending unassisted births.
Birth almost always unfolds quite well, especially without elective interventions. However, when birth does not unfold safely, there is often only a matter of minutes between complication and needing a complication resolved. To protect families and doulas, doulas should not be in a position of being the most knowledgeable birth expert in a birthing space.
Author: Aliza Juliette Bancoff
Aliza Juliette Bancoff is a well-known doula and doula trainer who has been providing doula services to families for over a decade. She is the founder of Main Line Doulas, a doula group providing doula support in the great Philadelphia area for the last decade, the International Doula Institute, which provides online doula training and lactation training and certification programs and the International Breastfeeding Institute which provides lactation training and certification. She is the co-founder of United Birth, a company devoted to increasing access to doulas across the country to make the perinatal time safer both physically and emotionally. “Every birthing person deserves access to quality doula support. And we are working to make that a reality across the country. The work we are doing to get doulas to every birthing person will decrease the black infant and maternal mortality rate significantly by 2030.” Says Bancoff. Aliza is known for her compassionate and empowering approach to doula work, and she has been featured in numerous media outlets, including United Nations Maternal Health Report, Parent Magazine, CafeMom, theBump and many more. Aliza's journey into doula work began when she gave birth to her first child and felt a strong calling...