It’s funny. I’ve recently been told—by more than one person—that Sara and I are “brave” for planning to deliver our baby at home. This from people who are educated, intelligent and have my respect. And yet, they couldn’t have picked a worse way to characterize the decision. What’s going on here?
Read on, and then you tell me: isn’t it actually more courageous for a low risk mother-to-be to voluntarily walk into a hospital to give birth?
First, let me point out that:
A. No. If you’re a good candidate for home birth (and the majority of women are), then a planned, attended home birth is as safe, or safer, than a hospital birth.
A. Surprisingly easily.
If you’re giving birth and you’re low-risk, then simply checking into a hospital greatly increases the likelihood of unnecessary interventions–pitocin drip, epidural, episiotomy, cesarean section, et al.–with no corresponding increase in safety for mother or baby.
I can also tell you this: my home is more sanitary (with respect to virulent infectious agents) than the cleanest hospital maternity ward [11].
A. Evidence. Sara has searched through the medical literature, and every relevant study she has found has shown that home birth is as safe, or safer than, hospital birth. See references below.
The upshot of the research [1] is this:
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.
A. First of all, it’s worth noting that in the majority of cases, nothing goes wrong. Expecting that things will go wrong just isn’t rational. On the other hand, preparing for things that might go wrong, even if they’re unlikely, is wise.
Certified nurse midwives are trained, equipped and experienced at solving the most common (and remember, “common” is relative) problems. They’ll bring with them, into our home, oxygen, pitocin, resuscitation equipment, etc. Using instruments identical to those used in a hospital, they can stop hemorrhaging, perform an episiotomy, stitch tears, etc., as needed.
And, of course, a trained, experienced midwife will know if you need emergency intervention (e.g., cesarean), and in that case she will get you to the hospital and have the staff prepped and ready to receive you once you arrive.
Also, it’s important to note that you’re more likely to have one of these problems just by being in a hospital; birthing at home reduces the likelihood of many of them in the first place:
A study by Mehl compared a group of 1046 women giving birth at home with 1046 women having hospital births and found [8]:
- 9 times as many episiotomies
- 15 times as many women receiving analgesia or anaesthesia
- 3 times as many caesareans
- 2 times as many forceps deliveries
- 3 times as many postpartum haemorhages
- 3.7 times as many babies requiring resuscitation
- newborn infection rates 3 times higher
- respiratory distress 17 times higher
- lower Apgar scores
- mortality figures were the same for both groups.
A. I’ve heard and read lots of scary anecdotes about both home birth and hospital birth. At the end of the day, my decision is driven by evidence, not anecdote.
A. In some deliveries, yes. Obstetricians are trained as surgeons, so that they can c-section a woman who needs drastic intervention. Consequently, that’s what they’re best at. But most women do not need a cesarean, and in that majority of cases, going to a surgeon may not (and often does not) provide the best outcome. (Part of a “good outcome” is avoiding a c-section unless it’s truly necessary. Some are necessary; most are not.)
Certified nurse midwives, on the other hand, are trained to handle healthy, normal births, including several types of non-drastic interventions. This is their expertise. They make sure that things are progressing properly, and know when to transfer you to the hospital if an obstetrician’s expertise is indicated.
Okay, yours may have been. But most c-sections that take place (yes, the majority of them) are necessitated by earlier “routine” interventions, which, in many cases, were not required in the first place. Henci Goer describes this “cascade effect” clearly [3]:
Every intervention into the normal process [of labor] introduces risks as well as benefits…. When intervening becomes routine, meaning there is no reason for it, only risks remain. Moreover, because one intervention tends to lead to another, it produces a “cascade effect.”
So, for example, electronic fetal monitoring confines women to bed, which may slow labor. Doctors may then give oxytocin, which increases pain, causing women to want an epidural. The epidural may slow labor or cause abnormal heart rate patterns, ending the cascade in a cesarean section for poor progress or fetal distress.
The bottom line: many c-sections are made necessary by the routine protocols followed by hospital practitioners. [2]
A. That’s great. Most hospital births go well, and are safe. (Hey, I was born in a hospital, and my mother says I’m perfect, so…)
A. You can’t choose something if you don’t know it exists. Most of us in the U.S. (myself included) have been conditioned to go to a doctor when we get pregnant. I didn’t know the first thing about home birth until 12 weeks into our pregnancy; and even then, I thought it sounded crazy. That is, until I read the evidence about home births and hospital births, and their respective pros and cons, and realized that home birth was a wonderful option for us.
In the U.S. today, midwife-attended births are on the fringe. Not so in other developed countries. Holland is probably the best example of a country with a high rate of midwifery (and home births) and an excellent, low mortality rate (lower than the U.S. rate).
A. No. Every woman should learn about the home birth option (and all other options), but home birth only makes sense for pregnancies which meet certain conditions, e.g., low risk, singleton (no twins), no breech. [4] [But see reader comment #3 for an alternate opinion.]
A. Okay. An informed decision–either way–is a decision well made.
In the end, it’s not the location of [a low-risk] birth that dictates how good the outcome will be; it’s who’s running the show. The people running the show in a hospital are well-intentioned, but much more likely to take unnecessary (and unpleasant) actions. Period.
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Thanks for posting this.
My first child was brought into the world by a 100% All-American unneCaesarean, after the usual hospital routines (including forced withholding of food) gave me a migraine, which somehow led to the decision to give me an epidural, and the rest was pretty much typical of what happens with a cascade of interventions. And I had a nurse-midwife!
My second child was a hospital VBAC miserable enough that I perceived it as a rape. (We'd already picked out a direct entry midwife who had experience with the Amish, but severe gastroenteritis triggered premature labour, which I didn't know about until the paramedics insisted on taking me to the maternity ward - the maternity ward! - where I was told that I was ten centimetres dilated and coming out of transition. Oops. the less said about what happened next, the better.)
My husband caught our third child in the bathtub five minutes before our midwife and doula arrived. That was easily my best birth.
We're expecting another baby in August, and planning to birth the baby at home again. Of course.
Carol, I'm so sorry you lost your first baby. As a new father, it hurts me just to imagine the possibility. I have friends and family who have lost babies and I've seen how hard it is on them. (Just for the record: all my babylost friends were planned hospital births.)
I'd like to clarify a few things, because your comment may be taken by some readers as a backhanded argument against home birth.
I found your story in Mothering magazine, and from what I can tell, your baby died in the hospital, not at home; and it seems likely that she would have had the same sad fate even if you had planned on a hospital birth.
I agree with you: it's useless to speculate either way. All we can say is that (a) some babies die during birth (whether at home or in the hospital), and (b) low-risk babies die at the same rate in hospital births as in planned, attended home births. (See references, above.)
Carol, your story is moving, powerful and sad. In the end, though, I'm sure you'd agree that mothers-to-be should be driven by data, and not by anecdote. Your birth story is sad, and my home birth story is happy; but both are irrelevant to a pregnant woman who is deciding how to birth her child.
Thank you for posting and for furthering the discussion.
- ron
I am so envious of your beautiful homebirth... it would seem like the greatest dream to me to be able to give birth at home.
Sadly, my first daughter, on the 13th of May, 2003, died while I was laboring at home. I will never be able to not second guess whether being in a hospital could have saved her. Thus, I am now tied to the hospital, and technology is both my friend and a very effective tool for maintaining my mental health during birth.
However, I will add, that my two births that followed Charlotte's death were very independent, drug free (at least until the prolapsed cord was discovered at 10cm with my son) and very much guided by me. I feel fortunate to have access to a birthing center where mothers are always encouraged to take the upper hand and always get the last word in (at least if you are bossy like me!) It would be my hope that in the future women could be encouraged to take charge of their own births and not let hospital staff dictate the course of their births so as to draw in unnecessary complications.
I wrote about this on my blog a lot a while back, but really it comes down to this: once you become part of the babylost world, you have sympathy for those doctors: if you had the choice to maybe intervene and maybe save a baby's life, you should. Because having your baby die is an experience I would wish on no-one. I assure you pitocin, a c-section, or anything else you might be handed is better than waking up the day after you give birth to an empty womb, leaking breasts, and no baby to feed.
So, after that brief defense of hospitals and their staff, I do in all honesty congratulate you, and please know that I only wish I could have been so fortunate.
Editor's note: See Ron's response below.
!!!Yeah!!!
Congrats!
Update: We now have a wonderful son! (*)
There were some complications(!), but the midwives handled them perfectly.
But I do now realize that there's one major disadvantage to a home birth: I never got to speed to the hospital without any regard for traffic laws. I can honestly say that I'd been looking forward to that for many years.
It was great meeting you guys on Monday and I can't wait to hear about your birth!!
I am quickly becoming more and more educated about home births, thanks to a few message boards I am a part of, and a bit of research on the internet.
Both of my births were in the hospital, with not too much intervention, but I'm not so sure I would make it to the hospital the third time! (I'm not pregnant right now, but thinking of the future). I want to make sure I am totally ready for a home birth, and who knows, by then maybe I will have decided to go with a midwife. In Manitoba they are covered by health care, so I wouldn't pay a cent!
My first birth was quite traumatic for me, and I believe it was due to the Demerol that they gave me. I did ask for it, so it's not like it was their fault, but if I had known that I would only labour another hour or two til I was ready to push, I never would have taken anything.
With my second, I was already 7 centimeters dilated when I got to the hospital, and that was after only 1 hour of labour, so I knew I didn't have time for any intervention, which was totally fine by me! My second baby came into the world after 3 hours of labour and 10 minutes of pushing. I have an amazing family doctor though, who reminds me far more of a midwife. She knew to tell me to only give little pushes, and to let my body do most of the work. She calmly talked to me the whole time, holding my hand.
The one thing I would like to change is that for both births it was so intense that once I lay on the bed, I really couldn't move to get up again. I would like to try squating in a birthing pool. In our hospital, if you have a midwife assisted birth, you can use a pool, but a doctor assisted birth, you can't. So, I might have to do something about that!
Thanks for informing me even more. I'm going to continue my research.
I had a homebirth not to avoid medical care, but because homebirth provided me with *better* medical care. My midwife had 27 years of experience with all kinds of unusual circumstances (that would have been "emergencies" at a hospital), to say nothing of the confidence in natural birth that comes from attending hundreds. An obstetrician does not attend the labor, usually- s/he attends the "delivery." A midwife and doula are there for the whole process; this is what has been proven to make a concrete, biological difference in outcomes.
When I worked as a doula, I had one client whose doctor was late. The nurse assigned to her just happened also to be a homebirth midwife (who worked with my own). Unlike any other hospital birth I attended, the mother was comfortably seated on her husband's lap, the baby was guided out with only a small tear, and there was silence in the room. I looked up to see a horde of L&D nurses in the doorway, spellbound. They all rushed to the scene after hearing the nurse would handle the delivery; not one of them had ever seen a birth like that.
My midwife handled my friend's fourth birth, a footling breech in a birth pool at home. She called for emergency assistance (another common misconception is that midwives somehow do not know when to transport for medical intervention), but as the fire truck arrived, the baby was born. The firemen congratulated the family and took all the small children in the house for a ride on their truck. Renowned obstetrician Michel Odent says that the only way he will deliver a breech is if the woman is upright- in other words, there are techniques other than cesarean for delivering unusual presentations, if a practitioner is properly trained.
In regards to the cost, my comments were based almost completely on my experience here in Australia, which I thought mirrored the US, but apparently US insurance companies are more enlightened than Australian ones are.
In Australia, if you receive private care from a midwife (i.e. care from a midwife that is not an employee of the hospital while you are a patient there) then you bear the entire cost. Medicare doesn't pay anything and health insurance (with few exceptions) doesn't pay anything.
In contrast, if you book into a public hospital for your care, which is overseen by doctors even if you have many of your pre-natal visits with midwives, then the government pays for everything. With my first child my only out of pocket costs were for my prescriptions and the parking.
(Thanks to all who have commented!)
For what it's worth, we verified today that our medical insurance does cover home birth when attended by a certified midwife. Our midwife is out-of-network (are any midwives in-network?), which means we'll end up paying 30% (or about $1500) of the cost out-of-pocket.