A Closer Look at Home Birth

By: Tema Flanagan Parents

When Meg, a nurse in South Philadelphia, had her first son, she planned to give birth in a very familiar setting: the hospital. Her goal was an intervention-free labor: she hired a doula and was even able to to use a midwife, but things didn’t go according to plan. “Ultimately I wound up with Pitocin, an epidural, and the threat of vacuum-assisted delivery due to prolonged pushing,” she said. “I felt like a lot of things were being done to me. I was scared, exhausted, but no one was really talking to me. Maybe it was just the stress and the lack of sleep, but it was one of the worst experiences of my life.

So when Meg had her second son two years ago, she knew she wanted a different experience. This time, she planned to hire a midwife and give birth at home. “I had researched home birth midwives during my first pregnancy, but it felt a little scary,” she said. “I work in a pediatric cardiac intensive care unit, so I know how sick some babies can be after birth. My work experience is not normal. Most babies are born perfectly healthy.” Nevertheless, she says, “I was paranoid that giving birth at home would cause me to compromise my baby’s health.” But after talking with a well-regarded local midwife at length about safety precautions, she decided to go for it.

“My home birth was such a different experience from my hospital birth,” reflects Meg. “It wasn’t by any means easy. But I felt a much more collaborative approach. There was lots of back labor and there was a moment that I wanted to give up, go to the hospital, and get the drugs! But the midwives were so encouraging and positive. And it felt so comforting to be around all of my things and in my own home. At the end of an exhausting 15 hours, my second son was born into my arms at the foot of my bed. I will never forget the happiness, relief, and pride that I felt at birthing my chunky eight-pound, eleven-ounce guy.”

Meg’s decision to pursue a home birth, while relatively uncommon in 2018, is certainly not unique. Several generations ago, home births were the norm. Now, though, the vast majority of births in the United States take place in a hospital or, less commonly, at a midwife-staffed birthing center. As of 2009, only a very small minority of births in the US (just 0.72%) took place at home. Yet even that small number represented an increase of 29% over 2004–2009.

Beginning with the rise of the natural childbirth movement in the 1970s, home birth has been passionately debated among doctors, midwives, women, and families on both sides. So who are the women who are choosing the home over the hospital delivery room? How did births move from homes to hospitals in the first place? Why are home births so controversial? And what are the pros and cons—and the health risks—of home births in America today?

A brief history of home birth

For much of history, individual homes were the natural setting for most births, with lay midwives often in attendance instead of doctors. Up until the nineteenth century, childbirth was seen as part of the women’s sphere. Women attended other women as they gave birth, and men (even family members) typically weren’t present.  

But this started to change as doctors (a career once reserved only for men) professionalized and increasingly specialized over the course of the eighteenth century and beyond. By 1900, half of births in America were attended by physicians, with midwives attending the births of those women who couldn’t afford a doctor’s services.

Shortly thereafter, hospitals became the preferred setting for childbirth, and women themselves led the charge, choosing hospitals over home birth because of the pain management options available. In fact, during the early twentieth century, feminists were at the forefront of efforts to move childbirth out of the home and help women gain access to drugs that put them in a “twilight state,” free of the pain associated with unmedicated labor. As a result, women often gave birth in a completely unconscious state well into the twentieth century.

At the same time, however, the move from homes to hospitals lead to major gains in safety: Infant mortality went down by 90% and maternal mortality reduced by a whopping 99%. Still, it wasn’t until much later in the twentieth century that hospitals became the setting for almost all births in America (in 1935, 36.9% of births were in the hospital; by 1973 the figure had risen to 99%).

The 1970s also saw the rise of the natural childbirth movement, spearheaded in large part by a midwife named Ina May Gaskin. Gaskin and her contemporaries advocated low-intervention, natural childbirth with the home as the primary setting. Then, as now, home birth was an extremely controversial topic, with midwives and obstetricians often at odds with each other. (The American College of Obstetricians and Gynecologists’ official stance is that while pregnant women have the right to make their own decisions, hospitals and accredited birth centers are the safest choices for childbirth.)

Who is pursuing home birth today and why?

Though the overall number of home births remains quite low, a small but growing group of women are actively choosing to give birth at home. “We do know that home birth is really a majority of white, educated women,” says Maureen Darcey, a certified nurse-midwife and executive director of the Women’s Birth and Wellness Center in Chapel Hill, North Carolina. (Incidentally, Maureen is also the midwife who attended my own birth 34 years ago.)

Like Ina May Gaskin, the women who seek home births are often drawn to it because they would like to have as little intervention as possible and pursue a totally “natural”—some say idealized—childbirth experience. For many of these women, the perception is that hospitals treat pregnancies more like illnesses than the natural processes they are and are therefore more inclined to pursue “medically unnecessary” interventions like induced labor, epidurals, and non-emergency C-sections. And it’s true that the U.S.’s overall C-section rate is astonishingly high. According to the CDC, the overall C-section rate rose 60% from 1996 to 2009; as of 2013, the rate of C-sections among low-risk pregnancies was 26.9%. This is nearly double the internationally accepted rates of C-section deliveries, according to the World Health Organization.

I had great trust in my body and the birthing process and never really considered the alternatives. Freedom of movement and freedom to birth how my body needed became areas of importance for me once I was pregnant and understanding what my options were.”

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Beyond that, there is the perception that hospitals arrange the labor and delivery experience for the benefit and convenience of doctors rather than the comfort or ease of women. For example, birthing mothers in hospitals are often required in the final stages of labor to push lying on their backs in the hospital bed, making it easier for doctors to catch the baby as it emerges from the birth canal. But many women believe that other positions (standing, squatting, or kneeling on all-fours) are more conducive to pushing and aid in the delivery of the baby. At home, under a midwife’s care, women are typically free to labor in the position that makes them most comfortable. Proponents of home birth are interested in an alternative philosophy regarding childbirth, one that seeks to empower the laboring mother and honor the body’s innate ability, in many cases, to handle the labor process.

“I chose home birth because I wanted a low-intervention birth,” explains Katherine Mann, who gave birth to her son, Elliot, in 2009 at her home in Shenandoah Valley, Virginia. “I didn’t want drugs or fetal heart monitoring or anything that would slow down the natural process. As long as I knew I could get to a hospital if needed, I wanted to try giving birth at home.”

While many women land on home birth after feeling dissatisfied with one or more hospital birth experiences, some go into their pregnancies knowing that home birth is their goal. Brita Nordgren of Weaverville, North Carolina, never considered anything but home birth for her two pregnancies. “My sisters and I were all born at home, and while my mother didn’t talk about it much, home birth was definitely part of our family culture,” she says. “I also had great trust in my body and the birthing process and never really considered the alternatives. Freedom of movement and freedom to birth how my body needed became areas of importance for me once I was pregnant and understanding what my options were.”

Six women shared their home birth stories with me, and each one spoke glowingly of her experience, from prenatal care to delivery. Many of them were struck by the amount of time their midwives spent with them during prenatal visits. Others mentioned how comforting it was to be surrounded by their own belongings while delivering at home. Still, others felt that by delivering at home they had avoided what they believed would have been unnecessary interventions. And, while some women pointed to a few “negatives” of home birth, like unsupportive friends or relatives or having less hands-on support in the days immediately following the birth, each of the women I corresponded with said they would choose to give birth at home again given the option.

The potential risks of home birth

So what makes home birth so controversial? After all, if the women I spoke with (all of whom were able to deliver healthy babies at home with no major health complications) are any indication, it seems like there are plenty of positives to successful home birth experiences. Proponents of home birth point not only to the improved experience for mothers, they also note the lower rates of episiotomies and vaginal tearing, as well as the reduced rate of interventions overall—and the cost savings that go along with it.

But when home births go wrong, there is a greater chance that they will go very wrong. While it can be hard to pin down data regarding the safety of home births (with both sides referencing studies that support their perspectives), it does seem clear that home births are, on average, riskier than hospital births. “The balance of data suggests that the risk of death for a full-term newborn is about two-fold higher,” says Dr. Kate Menard, Professor and Director of Maternal-Fetal Medicine and Vice Chair for Obstetrics at the University of North Carolina Chapel Hill’s Department of Obstetrics and Gynecology. “The other risk that’s documented is that when labor goes bad and there is oxygen deprivation, it can cause seizures and brain damage, and that risk is about two-fold higher, as well. All of that is rare in a term baby, but it’s more common with home birth.”

When it comes to both home births and birthing center deliveries, appropriate upfront risk-assessment plays a key role. “You need to have risk criteria for folks to deliver at home or a birth center, and they should be the same criteria,” Darcey says. “You should be no more than 30 minutes from ‘decision to incision,’ and you have to make decisions earlier if you live further. You shouldn’t be doing twins and breeches at home. If you really risk-screen your moms, there may be a small increase in admissions to NICUs, but home births can do just as well as the hospital.”

Even with proper risk assessment, however, low-risk births sometimes go awry, and in those cases speed of access to appropriate care is crucial. “‘Low risk’ can become ‘high risk’ with little warning,” notes Dr. Menard.

Obviously, proximity to the hospital in a true emergency may explain some of the differences in the documented risks. But another factor may have to do with the midwives themselves, who practice with widely varying levels of education and experience. There are two kinds of midwives: certified nurse midwives (CNMs) and certified professional midwives (CPMs). While CNMs have nursing degrees in addition to a standardized course of midwifery education, CPMs are far less uniform in terms of training. All CPMs receive certification through the North American Registry of Midwives (NARM), but there are several pathways to certification. Some CPMs attend midwifery schools, while others receive their CPM status without any formal education outside of an apprenticeship process (as well as the completion of a competency-based written exam administered by NARM).

For a number of reasons (including insurance coverage, state-specific laws requiring physician oversight, and liability concerns), nurse midwives are more likely to attend births in hospitals and birthing centers rather than in the home. So it is mostly CPMs who provide home birth services, and, since CNM-attended home births are illegal in a number of states, these services may be provided outside the law.

While many CPMs can and often do provide an excellent standard of care, at least one study indicates that CPM-lead home births are significantly riskier than CNM-lead home births in terms of infant mortality (both of which were found to be riskier than CNM-lead hospital births). Clearly, then, it is important for expecting mothers to be aware of the difference between CNMs and CPMs and to learn about a prospective midwife’s background and educational experience before making the decision to work with her, especially for a home birth.

What to consider when considering home birth

Women who are interested in home birth should first and foremost determine the legality of their decision. “You want to make sure it’s legal in your state,” Darcey says. “If not, you need to know the repercussions. In some cases, when things go wrong, parents can be charged with child abuse.”

Assuming home birth is an option, women should do their research both in terms of the midwives they are considering and the data regarding risk factors. In particular, Darcey recommends talking with prospective midwives to make sure they have infant resuscitation knowledge and equipment as well as the ability to administer certain medicines if needed, though she notes that the legality of bringing medicines to home births varies from by state.

Ultimately, the decision to have a home birth is highly personal and involves weighing the risks in addition to identifying your goals. Even as a midwife, Darcey went through this same process back when she was pregnant and considering home birth. “I thought, wait a minute, I’m confident going to other people’s home births, why wouldn’t I do that myself? But in doing that, my husband and I really had to sit down and understand that we were making that decision and we would have to deal with the consequences if something happened to the baby or me. We felt ultimately together that we could do it at home. We had a skilled provider, we were close to the hospital, we had everything we thought we would need.”

 

Birth is an olympic event, not a spa event.”

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For those on the fence about home birth, the good news is that many of the goals of the home birth movement, like lower interventions and the freedom to move freely throughout labor, can now often be achieved in a hospital or birthing center setting.

“My advice to women is to do their research,” says Dr. Menard. “There are certain hospitals where C-section rates are through the roof. Hospitals track and publish C-section rates, so look for C-section birth rates for first-time moms with a term baby who is head-first rather than overall C-section rates, which could be misleading.” Finding these figures specifically should give expecting mothers a sense of how a particular hospital approaches childbirth. She also advises women to talk with individual providers about their own approach. “Ask what’s your C-section rate? What is your practice related to labor management? Get a sense of whether they have a low-intervention approach,” she says. “The practices that incorporate midwifery tend to do better.”

Regardless of where women decide to give birth, it’s important to keep expectations of the experience realistic. One unintended consequence of natural childbirth advocacy may be that women whose births don’t go according to plan wind up feeling like the experience was a failure—even when a healthy delivery was the end result. The goal of reducing unnecessary interventions is a good one, but the goal of a healthy mother and baby is the most important of all

“Some of the material out there leads to a rainbows-and-unicorns idea about what home birth is like, and It might not end up that way,” Katherine says. Expectant mothers in every setting would do well to keep this in mind.

Darcey has a similar take. “Birth is an olympic event,” she says, “not a spa event.”


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