Being Pregnant
Maybe Home Birth Vs Hospital Birth is the Wrong Question?
Lots of home birth in the news this week. First we learn from the CDC that since 2004 it’s gone up 29% in the US. Then over in Australia a home birth advocate dies after her own home birth. We don’t know what happened but of course speculation ensued. Perhaps she could have been saved in a hospital setting, but maybe not.
The debate over where to give birth has been revived and the usual arguments are being made from both sides of the issue.
I’ve been reading them all but there’s one article at Slate.com that caught my eye.
It’s by Emily Willingham a developmental biologist/science writer who given birth in a hospital and at home. Though the piece is called, “There’s No Place Like Home… To Give Birth,” Willingham– who writes with a refreshingly clear-headed logic–points out the flaws in both the hospital and home birth scenarios as they are played out in the US.
“What choices do women in the U.S. have that empower the woman and offer a safe, stress-reduced birthing environment? Harriet Hall, a doctor who is a considerate and calm proponent of hospital birth, has noted that integrating a ‘kinder, gentler, less-interventionist midwife approach into a home-like hospital birthing facility’ would increase patient satisfaction without sacrificing safety… Hall also has said, ‘We need to figure out (with science)’ what is ‘beneficial, to improve the safety of both homebirths and hospital births.’”
Yes! I’ve been saying this for years. Even if home birth was a real option for a segment of the population in the US, we still need to work on improving hospital care and outcomes! Fewer women would be opting out of hospital births if they didn’t feel their births would be overly medically managed to the point of introducing new risks from medications and surgery. Hospitals have much to offer in terms of emergency care, and a lot less to offer a low-risk mom who would prefer a birth with few interventions.
But Willingham also points out that home births in the US could use some improving too. There are various levels of midwives in the US and when we lump together data about poorly trained assistants and highly trained certified nurse midwives, we get skewed results. And without more focus on the training of home birth midwives, we will see adverse outcomes. She concludes:
“The obvious solution to the controversy is to offer choices that reduce perinatal stress, minimize interventions, and personalize birth—the great appeal of home birth and midwives—while ensuring a safe outcome with well-trained attendants and access to emergency facilities. The absence of options in the United States leaves this solution elusive, especially where hospitals lack a homey, low-stress environment and local midwifery care fails to meet the gold standard. Strange, isn’t it, that our nation, in the 21st century, can’t offer more uniformly safe choices for a low-risk pregnant woman seeking a healthy, low-stress birth for her child … and herself?”
How we can move forward in terms of safety in BOTH settings. Too often the home vs hospital debate gets mired in which (flawed) side is right? We could all use some help, frankly.
What do you think? Do you feel you have real choices?
Ceridwen is the co-author of From The Hips: A Comprehensive, Open-Minded, Uncensored, Totally Honest Guide To Pregnancy, Birth and Becoming a Parent.
Follow Ceridwen’s pregnancy and birth blogging on Facebook.
Photo courtesy of Rachel Zucker
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31 Comments
Hannah commented on Feb 02 12 at 1:21 pmAll I have to say is, ‘yes, please’.
Sarah Partain commented on Feb 02 12 at 1:24 pmYes. Our midwife in Seattle had hospital privileges and it was an awesome blend. I wish that kind of care was more common.
ceridwen commented on Feb 02 12 at 1:28 pmSarah– That’s so great to hear! The Pacific Northwest has a reputation for providing a more midwifery-based care for low risk women in a hospital setting. Here’s an Oregon Hospital, for ex, that’s making strides to lower the c-section rate: http://blogs.babble.com/being-pregnant/2012/01/11/oregon-hospital-bucks-status-quo-with-vbac-promotion-vaginal-breech-births/
Emily Willingham commented on Feb 02 12 at 2:10 pmThanks for talking about the Slate piece here. I have to confess, you managed to put the whole issue more concisely than I did…which I greatly appreciate.
Rachel Zucker commented on Feb 02 12 at 2:25 pmI’m glad you wrote this. When you tweeted about the death of the home birth activist I wanted to tweet back about the death of Michal Lura Friedman who died last December after complications following a cesarean birth. But this seemed in horrible taste — both deaths are tragic and upsetting and neither should be used to proselytize. We should all be working to make birth safer for all women and to make ALL our medical care more humane, responsible and respectful. Women do NOT have enough safe, accessible, affordable, legal options. We need to stop fighting amongst ourselves and work together to fix the problems. And, let’s be honest that mostly even when we’re talking about these “choices” we’re talking about the choices of white middle and upper class women. Hospital v. home certainly is not the primary question relevant in the discussion of why women of color are given sub-standard maternity care.
Jeanne Garbarino commented on Feb 02 12 at 2:39 pmI am in total agreement with Emily Willingham (author of the Slate article). I believe that this is a conversation that needs to be had.
Emily Willingham commented on Feb 02 12 at 3:48 pm@rachel One thing that would improve maternity care across socioeconomic classes is if CNM services *were* available more widely, as CNMs tend to cost considerably less than hospital or standardized OB care. In several cases of which I’m aware, the home birth choice was not only about the substandard hospital available in the area but because of cost.
ariela commented on Feb 02 12 at 5:41 pmI agree that the questions Emily Willingham is asking are the right ones. But I disagree that it’s possible to “ensure a safe outcome” – at least not 100%. Birth, whether at home or in hospital, has its risks and while they are very small and should definitely be minimized by ensuring access to emergency care and capable attendants, we shouldn’t pretend that it’s possible to prevent absolutely all maternal or neonatal deaths. Sometimes really bad stuff just happens and there is nothing that could have been done, regardless of where it happens or who is in attendance.
Emily Willingham commented on Feb 02 12 at 6:47 pmI don’t think anyone has asserted that it’s possible for a 100% surety of a safe outcome (?). You can *try*, but that doesn’t mean it will work, regardless of conditions. There are no 100% in human health and medicine, except that death will happen eventually. I said “ensuring a safe outcome” as the other half of the equation, but that’s not meant to imply some kind of 100% assurance. It just means to ensure its possibility by having appropriate contingencies in place. At any rate, certainly didn’t mean to imply some 100% surety of any kind.
KSK commented on Feb 02 12 at 9:17 pmI plan to deliver with a nurse midwife in a hospital (possibly a water birth) and to me, it’s the best of both worlds. Giving birth at home just didn’t appeal to me, but I wanted a supportive and natural birth experience. I wish everyone had more options.
Brieanne commented on Feb 03 12 at 7:11 amI stayed home for as much as my labor as possible. I ended up having back labor and went to the hospital when my contractions got to be about 3-5 minutes apart. I was very happy with my delivery. My midwife was absolutely amazing.
It was the after care that I wish would have been better. Next time, whether its at home or in the hospital, I’m going to have my own personal LC/doula to help me. I don’t remember how many times I begged the nurses to help me figure out how to breast feed. When we took the hospital tour we were assured it was a pro-breastfeeding facility. Hah what a joke that turned out to be. The only person who was trained in breastfeeding was the head nurse. After she tried for 10 minutes. She said to me, “you know sometimes breastfeeding just doesn’t work for everyone.” I was devastated. I felt like such a failure and was so frustrated with the hospital and staff. I tried and tried. My mom didn’t breastfeed so she had no idea what to do but at least she tried to help me. Needless to say my son’s and my breastfeeding relationship was never established. I pumped like a maniac for 3 months to assure myself that he will get the best for as long as I can supply it.
In the end, it was a lesson learned on my part. The only reason a home birth sounds appealing to me is because of the personalized options and the fact that I can choose who have there.
Eva commented on Feb 03 12 at 4:46 pmBirthing centers IN hospitals! Best of both worlds! I’m giving birth (if all goes well) at the birthing center at Saint Luke’s Hospital in NYC, with my midwives. I don’t understand WHY there isn’t more birthing centers – women get personalized midwifery care, birthing tubs, commitment to a natural child birth – as long as the situation warrants it. And if a woman wants an epidural, needs a c-section, if something goes wrong, well, they’ll wheel you up on the floor above to the Labor and Delivery ward – but your midwife goes with you! My husband and I are insanely lucky that this option is available to us, I wish it were for everybody!
Emily Willingham commented on Feb 03 12 at 5:37 pm@eva…me, too. It does sound like the best solution.
Also… Brieanne…I’m sorry about those breastfeeding problems. I felt all experienced when our 3rd was born, having done a couple of rodeos…and it turned out, he couldn’t do it because of motor problems, so I pumped around the clock for him. We had the midwife and two breastfeeding consultants in, and nothing worked. In the end, you do what you can, and that’s the best any of us can do.
ceridwen commented on Feb 04 12 at 7:31 amI just want to call your attention to a terrific follow up Emily Willingham has written on her own blog. http://biologyfiles.fieldofscience.com/2012/02/do-women-matter-in-childbirth.html It’s a great extension of this conversation. And, as Jeanne Garbarino noted above, it’s one we need to have!
ceridwen commented on Feb 04 12 at 11:23 amThis Slate piece has inspired so much productive discussion. Here is Meredith Fein Lichtenberg’s response which ends on a practical note: What can expecting parents do *in the meantime* to ensure they give birth under circumstances that best suit their situation? Some good and useful tips. http://amotherisborn.com/post/17031993890/getting-away-from-an-either-or-mentality-about
Becky commented on Feb 04 12 at 2:50 pmI think it is important to give women a real choice, and to respect their real desires. When talking about maternity care reform, I hear a lot of pushing for lower interventions. Most women I talk to, however, want the intervention — at least if we are talking about pain medication. Our focus should be an objective look at the evidence, in terms of best health care practices and when to intervene, not a focus on preserving “normal” or “natural” birth for its own sake. Whether a woman wants to sign up for the epidural ahead of time or wants to aim for a low-intervention unless needed delivery, she needs to be treated with respect and be given good information and real choices.
Emily Willingham commented on Feb 04 12 at 7:25 pm@becky Absolutely. What I’m writing about isn’t an effort to tell a woman what to do, and I make no mention of “natural” or “normal” because…good Lord, what would that be anyway? Women need choices so that they can determine what is the *best* for them and their baby. As I say in that second, more personal post I wrote (I think I say it there…I’ve said so much in the last two days)…if I were to have another child (I’m not), I’d go for that hospital where we had our third. I was kind of fond of the epidural I got.
Becky commented on Feb 05 12 at 11:06 amJust commenting, because when I hear a push for “low intervention,” that is almost always coupled with a stated belief in the importance of birth remaining natural and normal. Up until just recently Lamaze International was promoting “normal birth,” for instance, although I see they changed the name of the “Lamaze Institute for Normal Birth,” to the “Lamaze Institute for Safe and Healthy Birth.” Their stated beliefs didn’t change, though, which emphasize avoiding intervention and pain medication. The UK’s Royal College of Midwives actually has a “Normal Birth Campaign” which promotes “normal” birth. To me, arguing for low intervention doesn’t necessarily make sense without a strong belief and intervention is mostly bad. I’d prefer to see an emphasis on “true informed consent, real choice and safe and respectful treatment” or some such, which doesn’t assume a value judgement about intervention, if that makes any sense.
Or maybe you just mention “minimize intervention” because there is already a high intervention option available in most hospitals? My worry is that focusing on “minimizing intervention” will lead to the push for low intervention birth as the norm, and lead to denials of maternal request ceseareans or other interventions, as is happening in Canada and the UK.
Chelsea Bailey commented on Feb 06 12 at 9:41 pmI have friends that have had successful home births. The hospital here in northwestern NC has midwife and doula privileges. For me a home birth was not something I would consider, but at the time I was pregnant with my second son a lady I met in our children’s music class was pregnant with her third. She was planning a home birth as she had for her first two. I explained I was having a c section. She said “when you go to a hospital they make you have a c section??!!!!” so….education could go both ways. I had a wonderful experience. I didn’t feel the doctor was intrusive. I believe he had our best interest at heart, and we had a wonderful experience and produced two beautiful sons. My sister in law had a perfectly normal pregnancy but found my nephew had an undetected serious heart defect. If she had attempted a home birth he would not have survived. Only because he was born in a hospital with a NICU and received immediate intervention was he able to pull through. Now they are expecting their second child.
Kristen commented on Feb 06 12 at 9:45 pmLove LOVE that comment by Eva about birthing centers IN hospitals! The thought never occurred to me! It really would be the best of both worlds. I am very aware that birthing babies is a business and that its the maternity wards that bring in the most revenue for hospitals. However, I can’t say that I would be quite ready to have a home birth – or even at a birthing center – just yet (pregnant with my second child now). But a birthing center IN a hospital? I love it! Now to find one in Houston that offers that…
CK commented on Feb 06 12 at 10:04 pmI have never understood why the birthing center model has not been adopted by more hospitals. I birthed in an in-hospital birthing center with a CNM and could not have had a better experience. I birthed in a regular double bed (not a hospital bed) and had a jacuzzi tub, rocking chair and birthing balls, all available in the room. No continuous fetal monitoring–a nurse made very unobtrusive regular checks with a doppler (I think it’s a doppler, anyway. But in any case, I did not have to be strapped to a monitor at all after they did a 20 minute strip when I first arrived.) No IVs, no medical apparatus in the room, low lighting, my own food, drinks and music. My baby was never taken from me and put in a nursery–all pediatric checks were done on the bed next to me. And, best of all Labor and Delivery was only one floor away. If something had gone horribly awry, I could have been in an OR in minutes. If my baby had needed a NICU, there was one in the building. How lovely to have all the comforts of home and a natural, midwife assisted birth, without giving up the hospital safety net. What’s wrong with this? Why don’t more hospitals have birthing center facilities as well as traditional L&D units? They should. I think many, many more women would feel a lot safer of having a natural, midwife attended birth if they could have the comfort of knowing that all the obstetric procedure you could ever need was right there–but only if you need it.
Bantle commented on Feb 06 12 at 10:17 pmI agree. This IS the experience I got to have with my second birth though…my particular OB was extremely supportive of all of my natural choices, and my nurse kept the environment very comfortable for me. Together, (along with myself and my husband), we made it an ideal birth…no pressure, no interventions, nothing that I felt like I needed to change. :)
Venise commented on Feb 06 12 at 10:25 pmWell the article never stated the percentage of mothers that die in the hospital and how significant the comparison is vs home birth. Which to me does not really give a good comparison? I have experienced both Hospital and Home Birth. I would recommend anyone who is having a healthy pregnancy to go for the home birth it is way more intimate. Further more Midwives go to school just to study pregnancy and child birth does a DR spend even whole semester learning about pregnancy and child birth? That’s like asking your plumber to put on a new roof on your house! My first hospital born child almost died because of the Dr and shift change and info not getting passed along affectively I was ill for two weeks and could hardly look after my newborn. After my home birth I cooked food went to the laundry mat and did groceries all in the same day I gave birth I felt like a million bucks a lot of that had to do with being in my comfort zone. Child Birth is not something new, all the drugs they put in to a birthing mom are! Go natural Midwives are the best!
Sophie commented on Feb 06 12 at 10:30 pmI’m currently planning a home birth with a Certified Nurse Midwife with my second child after having a negative experience in the hospital with my first child. As a healthy, low-risk patient, I felt like too many interventions were pushed on me and my wishes for a natural birth weren’t respected. After an hour of pushing my Dr. started threatening me with a C-section for no good reason. I definitely feel that if hospitals were able to adopt more of a birth center model then we wouldn’t have to worry about “home birth vs. hospital birth”
Samira commented on Feb 06 12 at 10:32 pmwhere I am in NY home birth is not allowed because of stupid laws however the local hospital here though it is “lovingly” nicknamed the butcher shop or the vampires castle just remodeled its maternity ward and the birthing rooms look like a small bedroom from home they even have dimmer switches so if you don’t want your baby blinded by the bright lights of a normal hospital setting you can turn them down all midwives here have to work under a doctor and thus have hospital privileges as well I do however agree that both home birth and hospital birth needs improvement and one day I may like the option of birthing at home though I wasn’t exactly high risk or I would ave had to have the doctor care for me I was gestational diabetic and spent most of my time in the hospital with ivs to keep me hydrated so I am glad for the hospital’s more homey environment and would not have done my first experience differently… except maybe if I had known I would have opted to stay home the night before and get more sleep rather than go to my nephews birthday party… but since it was 1 week before my due date and most labor is sudden and unexpected I had only about 4 hours sleep before I went into labor and thus had little energy to push and fell fast asleep shortly after my shower and baby’s first feeding
Beauty21 commented on Feb 06 12 at 11:02 pmI thank goodness every day that I live in Canada, specifically Toronto, where midwifery is supported and I was able to have my son born at the hospital down the road with a midwide, nurses and an OB. I had GD the first time, hence the OB. I had a mix of everything including an epidural, so kudos to you Moms who can do it without pain management.
I am due again in June, but this time no GD, but I am still going to the hospital with my midwife but in a new maternity wing with birthing pools if I so choose. The atmosphere is supportive, relaxing (as can be!) and you are allowed to focus on the delivery and taking acre of yourself during the birth and after. The after care by nurses here is exceptional as well. I just wish every mother had this option.
renee0123 commented on Feb 07 12 at 1:12 amIs that baby ok? Ive never seen a newborn si gray I have 2 kids of my own and I understand all babies look diff it just seem awefully gray
caitie commented on Feb 07 12 at 1:13 amI had my son at home and will be having our second son at home this april as well. It would be perfect to be able to have a birth completly natural without so many interventions in a hospital setting in case of emergency but for me that was not an option. After visiting My local hospital would not allow me to take any phitis or videos of my son being born, eould not allow me to refuse an iv. They would HAVE to stick a needle in my arm just incase i needed one and they also would not allow me out of bed after my water broke.
Antje commented on Feb 12 12 at 4:37 pmYes, I luckily have the choice. Just booked a flight to Germany to give birth at a midwife-center. (http://www.geburtshaus-eilenriede.de/Geburtshaus_Eilenriede/praxisraeume.html)
jzzy55 commented on Feb 16 12 at 1:06 pmI also wondered what Renee0123 did about the scary-looking baby in the photo. He or she looks like a boiled kielbasa because of that mottled colorless skin. Presumably that’s normal in the seconds immediately after birth, or this image wouldn’t have been used to illustrate this article. Is this an appealing image for those contemplating a home-based water birth? I’m past my childbirth years but this photo is a huge turnoff for me.
ceridwen commented on Feb 16 12 at 4:09 pmYes, this picture is quite astonishing but it’s totally within the realm of normal fr a newborn to be covered in that white stuff at birth– it’s called vernix and it’s a waxy, oily substance that protects the baby’s skin while in utero surrounded by fluid. This baby in this picture was born 100% healthy. :)
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