I would never presume to challenge a woman's personal choice of the manner in which she will give birth, as I would not challenge any other type of choice she makes for her own body. However, I just want to comment that young women's fears of C-sections are totally overblown. My experience is forty years old, and I suspect C-sections are managed even better today. I was over thirty, having a first child who was in a frank breach position, and two different obstetricians recommended a C-section. They explained the risk of the baby's head compressing the cord during a breach delivery, but it was totally my choice. I chose the C-section and had a very healthy baby with a 9 Apgar score. There was pain sufficient to need powerful analgesics afterwards, yes, but no pain before. It was definitely not a traumatic experience, particularly compared to the natural birth experience of a friend who needed an emergency nine-inch episiotomy without anesthesia. For other good reasons, I had a second C-section four years after the first. Practices had improved and this second child was handed to my husband immediately on her birth and "roomed in" with me--a great birth experience. My sister-in-law chose to deliver at home, far from a hospital, and also had a healthy baby. Each woman should be free to make her own choice, and no one should shame her for her choice, or blame her for a difficult or tragic outcome. Life offers no guarantees.
1
It drives me crazy when people say "birthing is a natural process", as if "natural" were equal to "ideal." All kinds of things are natural: having babies when we are 13, dying of the flu, walking into trees if we're severely nearsighted. We do not say, "hey, it's natural, so don't mess with it." Why must we do this with the historically dangerous process of giving birth?
Birthing is inherently risky and difficult for humans. The vaginal canal is far from ideal. This is due to evolution, plain and simple. At some point, being upright became more beneficial than easy childbirth, and as a result, our hips are narrow, meaning the birthing canal is as well. Like many things chosen by natural selection, it works well enough but not well. Evolution compensated for the high rate of death by making sure women could birth year-round.
Yes, the body adapts during labor, with dilation, etc, but the process remains risky and painful, and before modern medicine women and infants died in huge numbers, up to 30%. This is still the case in places where Western medicine isn't the norm.
The whole "natural is best" movement is deeply ignorant. If our bodies really had been designed, as the Creationist crowd thinks, then we'd give birth through our bellies, just above the uterus, which is what a C-section mimics. The answer to the higher rate of infection, etc., is not to move birthing into the home, but to keep working on reducing those rates, which many hospitals are doing.
Birthing is inherently risky and difficult for humans. The vaginal canal is far from ideal. This is due to evolution, plain and simple. At some point, being upright became more beneficial than easy childbirth, and as a result, our hips are narrow, meaning the birthing canal is as well. Like many things chosen by natural selection, it works well enough but not well. Evolution compensated for the high rate of death by making sure women could birth year-round.
Yes, the body adapts during labor, with dilation, etc, but the process remains risky and painful, and before modern medicine women and infants died in huge numbers, up to 30%. This is still the case in places where Western medicine isn't the norm.
The whole "natural is best" movement is deeply ignorant. If our bodies really had been designed, as the Creationist crowd thinks, then we'd give birth through our bellies, just above the uterus, which is what a C-section mimics. The answer to the higher rate of infection, etc., is not to move birthing into the home, but to keep working on reducing those rates, which many hospitals are doing.
2
Unfortunately the evolutionary 'evidence' this author cites is wrong. Actually evolution designed the female body as well as it could given the size of a neonates head, and the human female is one of the best adapted birthers on the planet---given our brain and head size. So just as we were 'born to run' we were also born to birth in a certain way that has been largely overlooked by modern medicine since the 18th century, when doctors across Europe killed more women than midwives did, while taking birth out of the hands of midwives as the doctors' increasingly specified which births (most) were their alone to manage. its a story of patriarchy, business, ignorance, and widespread maternal and fetal neglect that all too few know.
Working on Labor and Delivery for a couple of decades, I have seen everything, including moms who have had more than one previous uncomplicated birth needing to be rushed to the OR (which takes about 30 seconds) for either bleeding or fetal distress which would have resulted in a dead baby and/or dead mother in minutes otherwise. Yes, this is rare, but if it happens to you, your percentage is 100%. Other complications, such as post-partum hemorrhage or amniotic fluid embolism can also be quickly fatal.
My first baby (over 9 pounds) was born in the hospital with zero intervention and zero complications. He easily could have been born at home in retrospect, but we say "retrospective vision is 20/20." My second baby was also born in the hospital in the evening with an incredibly easy delivery and no complications. I felt great afterward, and all I wanted to do then was go to sleep. If I had been at home, I would have been dead by the morning from septic shock and my children would have had no mother. You just CANNOT know these things ahead of time. (PS it was NOT a hospital-acquired infection---it was my own normal flora that got inside during the 12 hours since my water broke, which is really not considered a prolonged amount of time.)
My first baby (over 9 pounds) was born in the hospital with zero intervention and zero complications. He easily could have been born at home in retrospect, but we say "retrospective vision is 20/20." My second baby was also born in the hospital in the evening with an incredibly easy delivery and no complications. I felt great afterward, and all I wanted to do then was go to sleep. If I had been at home, I would have been dead by the morning from septic shock and my children would have had no mother. You just CANNOT know these things ahead of time. (PS it was NOT a hospital-acquired infection---it was my own normal flora that got inside during the 12 hours since my water broke, which is really not considered a prolonged amount of time.)
3
When evaluating outcomes of a home birth vs hospital birth, studies need to look at the entire hospital stay until a baby and mother are discharged (rather than only what happens at the actual birth). Mother's and babies contract infections simply by being in a hospital, babies are subjected to countless procedures that are unneeded and have unintended consequences. I had my first baby with a midwife in a hospital. By the time baby two came, the hospital had changed their policies and every baby had to spend time in the nursery whether there was a problem or not--no exceptions. After my mom lost a baby years ago to a hospital acquired infection, there was no way I would send my newborn to a nursery with 15 other babies and countless folks in and out of the nursery. While it was a dangerous hospital policy that forced me to choose a home birth, I am forever thankful for the decision.
1
People have the right to choose a medical treatment other than the one that is recommended by their physician, even if there is good scientific evidence to support the physician’s preferred treatment. This is a result of the principle of patient autonomy, which is one of the ethical foundations of modern medicine. It is unclear, however, if it is ethically acceptable to allow a parent to make a choice for their child that puts the child at risk.
The perinatal death rate is significantly higher for planned home births. It therefore does not make any sense that parents put their baby (and the mother) at a higher risk of morbidity and mortality for the sole purpose of having a better “birth experience.”
The perinatal death rate is significantly higher for planned home births. It therefore does not make any sense that parents put their baby (and the mother) at a higher risk of morbidity and mortality for the sole purpose of having a better “birth experience.”
3
Why don't we pull our teeth at home now too? Because, come on, I think it would be a more pleasant experience, and we wouldn't be subjected to unnecessary pain relief measures or being forced to get back in our car afterwards when we could already be at home. And then I would have the choice of handling my extracted tooth however I wanted to afterwards, as well. I don't know why women want to go backwards. And it seems to me that having a home birth would create a lot of laundry to be dealt with afterwards, which would probably end up on the new mother's own to-do list as well. And your family would still be looking at you, despite having delivered an hour earlier, asking you what's for dinner. Why not escape to the hospital for this event, where all your needs are taken care of, and and any life-threatening emergencies can be dealt with by an expert immediately? Trust me, you will be at home with this baby for a long, long, long time.
7
I am a nurse-midwife and have attended thousands of births in both hospitals and freestanding birth centers. It is time to move the conversation from the place of birth being “good” or “bad” to how can we optimize the quality of the experience for each woman in the setting best for her. Not all hospitals, and not all community birth services (home and birth center) are created equal!
As mentioned by Dr Carroll, the United Kingdom has a maternity program that offers both birth center and home birth for healthy women, with clinical outcomes as good or better than planned hospital births for healthy women. The differences are likely several: they have an integrated system of care, their maternity system is midwifery based in collaboration with obstetricians, their midwives are all professionally trained, and they have quality improvement measures in place.
An exciting and encouraging development in the United States is the growing number of nationally accredited freestanding birth centers (www.birthcenteraccreditation.org). This site of birth for low risk women seeking an alternative may be the perfect compromise between unregulated home birth and hospitals geared more toward the care of the woman with complications than healthy women.
As mentioned by Dr Carroll, the United Kingdom has a maternity program that offers both birth center and home birth for healthy women, with clinical outcomes as good or better than planned hospital births for healthy women. The differences are likely several: they have an integrated system of care, their maternity system is midwifery based in collaboration with obstetricians, their midwives are all professionally trained, and they have quality improvement measures in place.
An exciting and encouraging development in the United States is the growing number of nationally accredited freestanding birth centers (www.birthcenteraccreditation.org). This site of birth for low risk women seeking an alternative may be the perfect compromise between unregulated home birth and hospitals geared more toward the care of the woman with complications than healthy women.
7
I agree. We need to make hospitals friendlier and more receptive to natural, uncomplicated birth. Let families make choices of how they want their labor and birth to proceed within the safety of a hospital. This is our challenge. Many women choose to have birth at home out of fear of being in a hospital. We need to help reduce that fear by making hospitals more 'user-friendly'. Unfortunately some home-birth midwives feed into that fear by representing the hospital as a hostile environment for birth. Women who have lost babies at home births are often told that the deaths were caused because they 'didn't trust their bodies or the birth process enough'. They are essentially blamed for their loss. There is a website for mothers who have lost babies at home births and most of them say they were made to feel responsible for the death of their babies. What a tragedy! We need to work on making hospitals friendlier and reassuring women that they can be safe in a hospital during the birth process. In addition, those midwives who choose to attend home births need to have emergency back-up plans well thought out and well-planned.
Can we please keep the terminology consistent? The relevant denominator is births planned for delivery at home vs planned for delivery at a hospital. The author variously refers to statistics for both births planned at home and births at home, which are two very different things. I certainly hope that the rate of children /born at home/ via cesareans is 0.
In both this article and the study, there is a surprising lack of consideration for risk indications that would affect birth plan, the need for hospitalization, and outcome. Women who plan to give birth at home have a very different demographic and health profile than those who plan to give birth at a hospital, and the analysis should have been limited to matched low risk populations.
In both this article and the study, there is a surprising lack of consideration for risk indications that would affect birth plan, the need for hospitalization, and outcome. Women who plan to give birth at home have a very different demographic and health profile than those who plan to give birth at a hospital, and the analysis should have been limited to matched low risk populations.
1
This idea has floated around for years and should be over by now but there is a group of anti-science women who are determined to have their own way and make a living off midwifery. It is the 2lst Century with all the amazing and helpful ways to have a healthy baby in the safety of a hospital. The hospitals have responded by providing a more homey atmosphere and welcomed families to be part of the whole process including kids. Why can't these women leave this idea behind insisting that their antiquated ideas are correct.
6
Betsy, I had my first child at a famous hospital in Los Angeles in 1986, delivered by c-section following every sort of intervention. The promised homey atmosphere was anything but, my labor nurse was new (straight from a career in surgery), and the hospital had a 60% c-section rate, their preferred method of delivery. I was emotionally traumatized by the way I was treated by the nurses and residents, as if I were just a hull around the thing the hospital wanted (no lawsuit). I worked hard to prepare for a vaginal birth after cesarean and delivered my second son in water (myself) at a freestanding birthing center (across the parking lot from a hospital) with a board-certified obstetrician in attendance. The difference between the two births was night and day, and the second birth is still one of the highlights of my life.
I come from a medical family (grandfather, father, stepfather, uncles, cousins and brother), so you would think I'd feel more comfortable having my baby in a hospital. But after my first experience, there was no way I'd consider it.
I come from a medical family (grandfather, father, stepfather, uncles, cousins and brother), so you would think I'd feel more comfortable having my baby in a hospital. But after my first experience, there was no way I'd consider it.
7
My mother and father had older sibs who were born at home in the early 1930s; they were both born in a hospital. The birth of my father's older sister was difficult and she suffered brain injuries that caused her to be disabled. That experience caused both my parents to be quite adamant about my children being born in a hospital where immediate intervention was available.
I have to wonder if, like vaccinations where people have no experience with the consequences so they think it's more risky to vaccinate than to not vaccinate, the success in reducing birth injuries has created a situation where the risks of a birth with intervention are over weighted.
A child disabled by a birth injury is forever. I feel like hospitals have responded to criticism of their practices with birthing centers and changed practices, but that they're still where I would want to be.
I have to wonder if, like vaccinations where people have no experience with the consequences so they think it's more risky to vaccinate than to not vaccinate, the success in reducing birth injuries has created a situation where the risks of a birth with intervention are over weighted.
A child disabled by a birth injury is forever. I feel like hospitals have responded to criticism of their practices with birthing centers and changed practices, but that they're still where I would want to be.
4
I have a friend (with an otherwise totally unremarkable low risk delivery and labor up to that point) who had a placenta previa. A resident noticed the umbilical cord coming out and put her hand inside the cervix to hold the baby's head up. She was rushed into an emergency c-section and 10 minutes later her baby was born, all the while with the resident's arm up her vagina. The bottom line is, if she was at home her baby would have died. To me that is too much risk, even if this is a "zebra" not a "horse". It's just not worth it.
4
This reminds me of the story, "My daughter's baby would've died in a home birth. The placenta stopped working 1 hour before the baby was born, and the baby was fine because it was born in the hospital." You see how silly this story is. Placenta previa is when the placenta implants over the cervix and causes a good deal of bleeding prenatally/or at the birth. What you describe is a cord prolapse. A midwife can hold the head up long enough to get to a hospital by ambulance, just like any resident or nurse can.
1
The fact that you so casually blow off a cord prolapse (or previa) is terrifying. I imagine this is because you have never seen either first hand. I have. I have seen a baby out in less than 3 minutes from prolapse to section removal of the baby - so fast that mother was put under crash anesthesia and the OBs did not even fully scrub but just put on gowns and threw antiseptic everywhere. It is not simply a matter of "holding the cord back in"- that is a temporizing measure meant for several minutes only to get the baby out immediately, this is probably why historically death rates for cord prolapse in home birth is 40%, versus 1-3% for in hospital. Even in that 3 minutes, I watched the baby's heart rate tank and needed to be resuscitated at birth. A few minutes later and it would have been a stillbirth. And I gather you have never seen that episode of The Knick, where the turn of the century surgeons attempt repeatedly to figure out a way to tamponAde the bleeding of women with preview delivering vaginally - where they bled out in about 90 seconds. OBs screen for this because that is not something that you want to be surprised by, including God forbid in an out of hospital setting, and it is an indication to have a c section. And no, not all cases present with antepartum bleeding.
8
We must remember that babies die in childbirth in hospitals, too, but only in homebirth do we blame the mother, shame her for being selfish and irresponsible, when her baby dies. The judgement leveled again women who consider or choose to give birth outside of a hospital setting is horrendous.
Each woman should have the right to give birth where she feels safest. For some women, that means a hospital. For others, that means at a birth center, or at home in the bedroom, the bathroom, the kitchen! We need to stop telling women that the only important thing is to deliver (not “birth”—“deliver,” we say, like a pizza or a package from Amazon) a healthy baby, no matter what the cost to a mother’s body or psyche, in a room full of doctors and nurses with needles and drugs and scalpels at the ready.
Each woman should have the right to give birth where she feels safest. For some women, that means a hospital. For others, that means at a birth center, or at home in the bedroom, the bathroom, the kitchen! We need to stop telling women that the only important thing is to deliver (not “birth”—“deliver,” we say, like a pizza or a package from Amazon) a healthy baby, no matter what the cost to a mother’s body or psyche, in a room full of doctors and nurses with needles and drugs and scalpels at the ready.
4
Yes, delivering a health baby and having a resulting healthy mother should be the primary goals. The bathroom or the kitchen is ridiculous. I don't like hospitals at all- but I made that choice, for the baby.
3
And yet, the safety of the baby and the mother should be everyone's primary objective. It really should be. Rhetoric about where the woman "feels" safe, or women needing to do "what is right for them" is off point. The safety of the baby (and the mother) should not be controversial. Thus, I'm left with less sympathy for the "Mother should do whatever she FEELS" line of thought.
4
Right, silly me! I forgot: Women's experiences don't matter when it comes to pregnancy and birth. Even when that experience includes unnecessary interventions—e.g., episiotomies, pitocin, major abdominal surgery—that compromise her own health. Even when a traumatic hospital birth leads to postpartum depression and anxiety. Who cares about her, so long as she has eliminated the very, very tiny chance—we're talking less than 1 in 10,000 for abruptio placenta or cord prolapse, two of the rare events that can happen without warning—that something could go wrong during the birth that would require immediate care.
Great article. I am curious whether the author and his wife would choose the in-hospital option if they could NOT selectively manage the course of their medical treatment that his professional status and knowledge allow (in other words, if he was like everyone else).
If he would still do this, I would question whether he has considered the skewing of studies, such as the Oregon one, in which transfer complications are included in the out-of-hospital group, given the higher than average propensity for in-hospital complications (i.e. the alternative) in rural states and counties where home births tend to occur. Given the overall low number of home births compared to hospital births, around 1%, the 4% plus regional variances could greatly skew these statistical comparisons.... as I see it.
If he would still do this, I would question whether he has considered the skewing of studies, such as the Oregon one, in which transfer complications are included in the out-of-hospital group, given the higher than average propensity for in-hospital complications (i.e. the alternative) in rural states and counties where home births tend to occur. Given the overall low number of home births compared to hospital births, around 1%, the 4% plus regional variances could greatly skew these statistical comparisons.... as I see it.
1
My first child was just over 6 lbs and a frank breech. She was a high forceps extraction. My 2nd was 7.5 lbs and popped out just like squeezing a grape. Had I chosen to have a 3 rd, I probably would have opted for a trial of home delivery. Would have been easier on the other 2 and more comfortable for me. I should add that this was the Lamase era and I had ho anesthesia for either delivery
Both of my parents, born in the early 1900's were delivered at home.
Why does anyone want to return childbirth to the 19th century?
While physicians find it better medical practice to first see horses, and not zebras; this is not the case with responsible mothers. Their job is to see zebras all the time and then to ascertain if it is really a horse.
Statistics are great, but not if you and your child are on the wrong side of one.
Why does anyone want to return childbirth to the 19th century?
While physicians find it better medical practice to first see horses, and not zebras; this is not the case with responsible mothers. Their job is to see zebras all the time and then to ascertain if it is really a horse.
Statistics are great, but not if you and your child are on the wrong side of one.
4
After a traumatic hospital birth of my son last year, I absolutely plan to have my second child at home as long as there is no medically pressing reason for me to go back to the hospital.
But you know what? I think I'll hire a midwife educated in modern medicine, not one who practices the sort of care women received in the 1800s. Your comparison is irrelevant.
But you know what? I think I'll hire a midwife educated in modern medicine, not one who practices the sort of care women received in the 1800s. Your comparison is irrelevant.
8
I'm sorry you had a traumatic hospital birth. But, I think having a baby at home with only the assistance of a midwife is an invitation to disaster. A midwife does not have sufficient training or tools to cope with an emergency. How about a hospital birth with a good doctor?
3
For your information, midwives absolutely have sufficient training to cope
with emergencies. Please don't pass judgement on something you are obviously unfamiliar with!
with emergencies. Please don't pass judgement on something you are obviously unfamiliar with!
1
I would like to see the statistics broken out for first-borns versus subsequent deliveries, for both home and hospital; I think those numbers would be important to know.
3
I live in a place in Canada where midwives have privileges at hospitals. I was also able to choose between several midwife practices. I can feel confident giving birth in a hospital, because I know that my birth professionals share the same goals and values, and will protect me from unnecessary interventions. At another midwife practice I interviewed, the midwife told me they had a high rate for homebirths in this area: 40%. And that is at a more 'political' midwife practice. In the US, where I'm from, the tendency is too much to hector women for making alternative choices, instead of working to make sure what is supposed to be the safest choice, is truly as safe as it can be. Thanks for this reasonable article!
7
I cringe at the "home birth" movement. Here's why: If you need an immediate C-section or other hospital available intervention to save the baby (or mother) you may not be able to access that service in time. One always needs a plan B that you can put into operation as soon as you assess the need, not several hours later after you finally get to the "worried enough" stage. I fear that lay midwives and women they are caring for have too high a threshold of transitioning to hospital/birthing center when appropriate.
Tragedies that would likely be prevented in the right setting DO happen.
Tragedies that would likely be prevented in the right setting DO happen.
5
Cringe all you want, but birth is a 100% natural thing that has been taken over by corporations who want to profit on "scariness". From personal experience the hospital birth on our first was impersonal, loud, and with lots of pressure to induce and take drugs. And this was a highly-rated hospital.
Our second was delivered at home with a mid-wife. It was quiet and intimate. We were in our bed with our baby soon after the birth. Birth is meant to be a beautiful, natural event, not one with masked nurses, countless monitors, and pressure to take unneeded drugs.
Our second was delivered at home with a mid-wife. It was quiet and intimate. We were in our bed with our baby soon after the birth. Birth is meant to be a beautiful, natural event, not one with masked nurses, countless monitors, and pressure to take unneeded drugs.
Two good friends lost their first son related to an attempted home birth. The pain for the family and there friends was huge. I have a family member who is a certified nurse mid-wife and has delivered hundreds of babies. She would never deliver at home for the reason that you always need to have a plan B to transition to immediately.
I'm glad you had a good experience but it is a risk, a big one as far as I am concerned.
I'm glad you had a good experience but it is a risk, a big one as far as I am concerned.
1
My first child was born in a hospital, with multiple interventions starting early because my water broke early, and in the end I felt lucky to have avoided a C-section. I was in a state of high-alert in the hospital--not conducive to giving birth. Animals do not give birth when in imminent danger, which is what the hospital can feel like. My next two children were born in quick labors at home. Had anything gone wrong, we were within ten minutes of a hospital for emergency care. My home-birth midwife had a long-term transfer rate to the hospital of about 10% of her deliveries. Home/Hospital birth is not either/or. Low risk births, for which there are clear criteria followed by my midwife (and which comprise the majority of births), can be attempted at home. If any complications develop, that's what emergency care at hospitals is for, and in that case it is a miracle and a lifesaver.
5
10 minutes to the hospital plus the few minutes it would take to get from the front door to the OR in an emergency = dead baby and/or dead mother. Even if this happened only 0.01% of the time, if it happens to you it's 100%. Safety trumps "birth experience."
2
Ideally, I think birth centers should be located close enough to the hospital that the mother could be taken to an operating room on a gurney in case of emergency. Otherwise, though, run by midwives and left to deliver babies naturally without interference in whatever way the mother and midwife want.
4
Dr. Carroll is being disingenuous. The rates for intervention, procedures, C-section, etc. are higher for births in hospitals than for home births because only low-risk births are deemed safe enough to attempt a home birth. If there is a reasonable risk of complication (baby too large for small mother, older mother, mother with high blood pressure, low amniotic fluid, etc.), home births are not recommended. All of these cases are sent to the hospital, creating two very different sets of potential data. So he is comparing apples and oranges.
I do not contest that some physicians probably over-recommend interventions/procedures. Some no doubt are driven by greed or convenience. I would venture that most are driven by fear of getting sued in the U.S., the country with the most lawyers per capita. I have read comments where the writer crows that they resisted the doctor's recommendation for a C-section and both baby and mother were fine. But what if the doctor did NOT recommend a C-section and things turned out badly? He would no doubt sue the doctor and the hospital. If you are the doctor, and you estimate a 25% chance of complication, what would you do?
I think home births are great for some people/circumstances, and it is surely good to have both home births and hospital births. However, this article does not seem balanced and I am surprised it is written by a physician, who should know better.
I do not contest that some physicians probably over-recommend interventions/procedures. Some no doubt are driven by greed or convenience. I would venture that most are driven by fear of getting sued in the U.S., the country with the most lawyers per capita. I have read comments where the writer crows that they resisted the doctor's recommendation for a C-section and both baby and mother were fine. But what if the doctor did NOT recommend a C-section and things turned out badly? He would no doubt sue the doctor and the hospital. If you are the doctor, and you estimate a 25% chance of complication, what would you do?
I think home births are great for some people/circumstances, and it is surely good to have both home births and hospital births. However, this article does not seem balanced and I am surprised it is written by a physician, who should know better.
12
SYJ: Your "apples and oranges" critique is ill-informed; it seems you have not read the studies in question. When comparing home and hospital birth outcomes, usually only normal, low-risk births are considered in both locations. For example, a recent well-publicized study "included 79,727 cephalic, singleton, term, nonanomalous deliveries in Oregon in 2012 and 2013," of which about 4% took place at home. The Oregon study also accounted for how the home vs. hospital populations differed in age, race, financial status, and other potentially confounding variables. (http://www.nejm.org/doi/full/10.1056/NEJMsa1501738#t=articleMethods) This is Scientific Method 101, and a peer-reviewed study would be seriously remiss not to account for these variables.
2
I am a CNM, PhD. Thanks for citing the research and saving me the trouble- Canadian studies also have compared mothers with equal risk profiles who choose hospital or home- and there are more interventions in the hospital. See this: http://www.ncbi.nlm.nih.gov/pubmed/26696622
The physician writing this article makes many valid points.
The physician writing this article makes many valid points.
The statistics cited here suggest that there may be a tradeoff between higher infant mortality in home births and higher maternal morbidity in hospital births.
For planned hospital births, the original article reported 25.3% are C-sections, which this piece says is associated with a maternal morbidity rate of 27/1000, leaving 74.7% as vaginal births which have a general morbidity rate of 9/1000, for an average expected morbidity rate of 13.54/1000 for planned hospital birth. For planned home births, 5.3% are C-sections and 94.7% are vaginal births, so mean morbidity is 9.94/1000. That comes out to 3.5 /1000 extra incidents of maternal morbidity for planned hospital vs. planned home births. Maternal morbidity is defined in this piece as "permanent harm or significant temporary harm."
The original cited article didn't actually examine maternal morbidity, which seems like a real oversight, and something that should be corrected in future work. After all, a birth involves a mother and a baby, and the health outcomes of both are critical to evaluate birth practices.
For planned hospital births, the original article reported 25.3% are C-sections, which this piece says is associated with a maternal morbidity rate of 27/1000, leaving 74.7% as vaginal births which have a general morbidity rate of 9/1000, for an average expected morbidity rate of 13.54/1000 for planned hospital birth. For planned home births, 5.3% are C-sections and 94.7% are vaginal births, so mean morbidity is 9.94/1000. That comes out to 3.5 /1000 extra incidents of maternal morbidity for planned hospital vs. planned home births. Maternal morbidity is defined in this piece as "permanent harm or significant temporary harm."
The original cited article didn't actually examine maternal morbidity, which seems like a real oversight, and something that should be corrected in future work. After all, a birth involves a mother and a baby, and the health outcomes of both are critical to evaluate birth practices.
2
I wonder if the maternal morbidity measurement takes into account short- and long-term mental health issues triggered by conventional, allopathic treatment of pregnancy as disease, including the postpartum reactions to trauma like depression & anxiety, as well as long term consequences like PTSD from the dehumanization of being treated as a piece of meat, deprived of agency over one's own body, and forced separation and forced invasive procedures of one's newborn???
Much hubbub has been recently made in my small'ish midwestern community because the teaching hospital has been 'certified' as 'baby friendly'. (side-eye, huge sigh) Apparently what makes hospitals 'baby friendly' are exactly those used by the midwifery practice that supported me while delivering my babies 18 & 24 years ago. These practices are extremely 'DUH' practices. Not using them was obviously never about the safety of babies and always about institutional perceptions of convenience, efficiency, and thus, profitability.
And a quick decoding of the language of 'baby-friendly' makes it very clear that, while the market has driven allopathic medicine toward some better practices, it continues to refuse to acknowledge women delivering babies as adults with agency who are both customers and fully human with an innate right to control what happens to their own body. Being pregnant and giving birth is not disease and it is not mental incapacity.
There are zebras. There are horses. And there are jackasses.
Much hubbub has been recently made in my small'ish midwestern community because the teaching hospital has been 'certified' as 'baby friendly'. (side-eye, huge sigh) Apparently what makes hospitals 'baby friendly' are exactly those used by the midwifery practice that supported me while delivering my babies 18 & 24 years ago. These practices are extremely 'DUH' practices. Not using them was obviously never about the safety of babies and always about institutional perceptions of convenience, efficiency, and thus, profitability.
And a quick decoding of the language of 'baby-friendly' makes it very clear that, while the market has driven allopathic medicine toward some better practices, it continues to refuse to acknowledge women delivering babies as adults with agency who are both customers and fully human with an innate right to control what happens to their own body. Being pregnant and giving birth is not disease and it is not mental incapacity.
There are zebras. There are horses. And there are jackasses.
4
I gave birth in a "baby-friendly hospital" and I have never felt so disrespected as a woman with agency and choice. After a very difficult delivery with my undergoing general anesthesia, I was handed a baby immediately after awakening and told it was "my responsibility" to care for him while I was still semiconscious, while I was begging the nurse to take him because I was afraid I was going to drop him on the floor. This was because of the policy about immediate skin to skin. I was in bed with a baby in a bassinet across the room with paralyzed legs and a catheter in, not having slept for 2 straight days, and was told the baby could not be taken by the nurses for any respite care at all- if I had not had my husband staying overnight, I don't know what I could have done- all because the nursery had been eliminated, and continual rooming in was mandatory. When my babies each needed one bottle of formula due to medical reasons (note, it was their ONLY bottle they ever got of formula ever) despite being a physician myself and discussing it in conjunction with the pediatrician, I still got a lecture by the nurse about milk supply even by the second time around where I had just exclusively nursed my first and knew what I was doing. When I asked for a pacifier, which is supported by current data to probably PROMOTE breastfeeding and reduce SIDS, I was told they were unavailable. Just a list of no-nos, with no individual choice on the woman's part. No thanks.
1
The statistics game is dangerous here. Pick your favs and make your argument.
No mention in this piece about the long term health effects on babies born by the unnecessarily high C Section rate in the US. They are huge, and include allergies, asthma, increased upper respiratory infections, etc. The physician who treats these maladies has conveniently left them out.
I am a physician who believes my babies born out of hospital with nurse midwives received more attentive care than they would have in hospital, and are better off for it.
No mention in this piece about the long term health effects on babies born by the unnecessarily high C Section rate in the US. They are huge, and include allergies, asthma, increased upper respiratory infections, etc. The physician who treats these maladies has conveniently left them out.
I am a physician who believes my babies born out of hospital with nurse midwives received more attentive care than they would have in hospital, and are better off for it.
2
Can this statistic possibly be right?
It’s important to remember that the rates of severe morbidity (permanent harm or significant temporary harm) and death in women are 27 per 1,000 for planned (or “low-risk”) C-section deliveries versus 9 per 1,000 for planned vaginal deliveries.
That's nearly 3 in 100 - 3%! The difference is 2 in 100 or 2%. If C-section rates are 5 times as high, that means about 0.4% of women, or 1 in 250, suffers permanent harm due to having a hospital birth rather than a home birth. So we essentially sacrifice two mothers per baby. (Article cites 1 in 500 fatality rate due to home birth.)
It’s important to remember that the rates of severe morbidity (permanent harm or significant temporary harm) and death in women are 27 per 1,000 for planned (or “low-risk”) C-section deliveries versus 9 per 1,000 for planned vaginal deliveries.
That's nearly 3 in 100 - 3%! The difference is 2 in 100 or 2%. If C-section rates are 5 times as high, that means about 0.4% of women, or 1 in 250, suffers permanent harm due to having a hospital birth rather than a home birth. So we essentially sacrifice two mothers per baby. (Article cites 1 in 500 fatality rate due to home birth.)
1
No, it is not true. "Planned" does not equal "low-risk." It just means no trial of labor first, so not an urgent c section. Lots of ill and high risk women may have planned c-sections. This includes women with preeclampsia, women with diabetes, etc, of which there are quite a lot. So of course, their morbidity would be higher. Really you would want to subdivide out planned c-sections in low risk women (for example, take for breech only with no other high risk factors) and compare that morbidity statistic to planned vaginal deliveries.
It does not cease to amaze me that somehow there is a crisis in our country of obesity, hypertension, and diabetes which is trumpeted everywhere, including on these health pages, but somehow commenters in this article think that this magically skips women of childbearing age. These illnesses lead to higher risk births and to high risk babies, and hence higher risk of c-sections. There is a way to reduce c-section births, and that is to improve the overall health of people, including young women, before they get pregnant.
Also, you are comparing apples and oranges. Morbidity doesn't mean the same as mortality. You are talking about complications of delivery, not all of which are permanent, compared with a dead baby. It is fine to make that decision if it is best for you, but just make sure you understand what you are talking about and not only couch it in euphemisms.
It does not cease to amaze me that somehow there is a crisis in our country of obesity, hypertension, and diabetes which is trumpeted everywhere, including on these health pages, but somehow commenters in this article think that this magically skips women of childbearing age. These illnesses lead to higher risk births and to high risk babies, and hence higher risk of c-sections. There is a way to reduce c-section births, and that is to improve the overall health of people, including young women, before they get pregnant.
Also, you are comparing apples and oranges. Morbidity doesn't mean the same as mortality. You are talking about complications of delivery, not all of which are permanent, compared with a dead baby. It is fine to make that decision if it is best for you, but just make sure you understand what you are talking about and not only couch it in euphemisms.
5
If the doctor "on call" lives 20 minutes away when an obstetrical emergency happens, a catastrophic shoulder dystocia, how is a hospital birth safer than a homebirth?
2
Are you kidding? Are you comparing the doctor already being with the mom, at the hospital, with getting a phone call and being 20 minutes away when trouble first occurs?
3
A former President of the American College of Obstetricians & Gynecologists was quoted in the College Journal in the sixties from memory, "One day home births will be seen as the earliest form of child abuse."
7
The U.K. and Holland have demonstrated how to make homebirths safer than hospital births. That should be the end of the argument. Why do we continue to give US women two substandard options - hospital births with excessive complication rates, or homebirths that are unsafe?
5
Not true. Holland is moving away from home birthing precisely because it has shown itself to be considerably less safe.
This is really the only statistic that matters: "In 2012 and 2013, researchers found that the rate of perinatal death was significantly higher for births planned at home: 3.9 versus 1.8 per 1,000. That would be an additional death for each 500 births at home." 4 million babies were born in the US last year. It doesn't take a mathematician to realize that more home births will mean a lot of dead babies. Perhaps as a matter of 'statistics' it will be negligible, but for those dead infants it's a 100% loss.
8
The statistic that matters is that in the UK and Holland, home births are as safe as hospital births.
5
The issue is not to make a home birth "safer". It is to make it safe, so no more babies have to die because of the place where they were born. Home birth can never be made as safe as a hospital birth because of the location and the midwife not being able to provide the services a hospital can provide. Telling women considering a home birth is misleading them
4
After age 30, the older the mother, the more likely for there to be birth complications. And mothers are giving birth at older ages all the time.
Both my grandmothers gave birth to a combined 15 children at home (the last child each had was born in a hospital as the oldest sibling was mature enough to insist their youngest sibling wasn't born at home). In one case, home was Brooklyn, and in the other case, home was either the Lower East Side or Brooklyn (so these were not rural births). Even though these women were initially in their early 20's and in good health when the babies started coming, one lost a child because the family could not get the baby to the hospital soon enough.
I personally think that birthing centers (usually in a separate but nearby building) affiliated with hospitals are a good compromise.
Both my grandmothers gave birth to a combined 15 children at home (the last child each had was born in a hospital as the oldest sibling was mature enough to insist their youngest sibling wasn't born at home). In one case, home was Brooklyn, and in the other case, home was either the Lower East Side or Brooklyn (so these were not rural births). Even though these women were initially in their early 20's and in good health when the babies started coming, one lost a child because the family could not get the baby to the hospital soon enough.
I personally think that birthing centers (usually in a separate but nearby building) affiliated with hospitals are a good compromise.
2
I had an obstetrical compilation at home, not during labor. My water broke and the cord prolapsed. I had no contractions prior to my water breaking. I was planning on birthing in a hospital. I knew, because of my profession, what had happened. I also knew that my baby was very much in trouble. I called an ambulance and the EMS crew was so ignorant of obstetrical issues that they were taking the time to fill out paperwork when we should have been all sirens blaring tearing down the road. It was only because I started kicking the EMS guy that they left and got me to the hospital. My daughter was born with Apgars of 1-3-3 and had a full body hypothermia treatment for several days to try and prevent brain damage. Miraculously she is fine. My point? Better obstetrical transfer is just a good idea, home birth or not. You shouldn't need a graduate degree in maternal health and a hard right kick to get decent emergency obstetrical transfer. We have a lot of work to do to improve maternal and child health outcomes. Let's stop arguing over how people give birth and just make it ALL safer.
18
My only advice is if you decide to home birth make sure that your midwife has malpractice insurance because there is no accountability if something goes wrong at home. I have been blogging about home birth safety for years. I lost a baby to home birth and I just don't think women know really what they are getting into when birthing at home. Things can go wrong real quick at home. Midwives do not have to carry malpractice insurance and I think that is terrible. Just an opinion from a mother that had a home birth disaster. Blessings to you all.
10
I had three babies at home, and was a doula for 32 hospital births. I am convinced that with my low-risk profile, the babies and I were all better off away from the hospital, and the temptations for unnecessary intervention that abound there. My midwives can no longer do home births because no doctor will back them, due to new state regulation. I agree with a previous comment that what we need is better coordination between home-birth providers and hospitals, including transport when necessary. It is the refusal of the medical establishment to support home birth which often causes complications.
5
I'm probably a wimp, but since just last year a woman at my office died because she had complications at a midwifery clinic (apparently excessive bleeding) and even a transfer to a larger hospital didn't save her, I'd vote for the larger hospital from the start. Her baby survived, but it's motherless, and her husband lost his wife - and we all lost a young, talented colleague. Very sad.
15
"Probably a wimp?" No, sounds like you are smart and realistic. Proving that you are "tough" is an absolutely lousy reason for homebirthing or even for going through natural labor. If you want to prove you are tough, run a marathon. I don't get why birthing seems to be a competition/extreme sport for some people.
6
Shall I now tell you the few times I have seen mothers die in the hospital while
giving birth from medical errors?
giving birth from medical errors?
1
I suspect that self-selection plays a strong role in patterns like "the risk of admission to an intensive care unit was significantly lower for those born at home" - those with lower risk pregnancies will select themselves out of the population who go to the hospital for birthing.
On the other hand, those with known risk factors will choose to go to the hospital.
I strongly suspect that if we compared folks with similar risk factors, the difference between home births and hospital births would be greatly diminished.
On the other hand, those with known risk factors will choose to go to the hospital.
I strongly suspect that if we compared folks with similar risk factors, the difference between home births and hospital births would be greatly diminished.
7
"babies not born in hospitals were significantly more likely to die....." - having trouble getting past this fact. Any chance that some of the increased interventions in hospital prevented infant harm or death? In other words, it is a trade off. Yes, interventions always need to be justified- the benefits (prevention of harm/death) do need to outweigh the risks. Filling up empty NICU beds doesn't justify admission to NICU, but having a home birth just to avoid these interventions (whether well justified or not) is really throwing the baby out with the bath water.
4
When the zebra happens to your baby all is what matter is that your have zebra wrangler. Homebirth midwives do not know how to do that. http://www.skepticalob.com/2016/01/homebirth-is-a-business.html
12
Our first child was born in hospital. During labor my wife was tethered to to a monitor, which did not allow her to move freely; ended up using nitrous oxide to dampen the pain, and was subjected to an episiotomy. At the end of this experience I understood why they call this labor. We decided to use the services of an independent midwife for the birth of our second child. The midwife was excellent and did much to prepare my wife for a home birth. On the day, the birth process moved swiftly and I ended up delivering our baby girl (with the midwife passing some last minute instructions down the phone). Birth is a natural process and the vast majority of women can do this at home with the assistance of a midwife, or in my case, someone who can catch the baby.
5
Stories like these are midwifery's bread and butter. The truth is that first labors are just generally longer and physiologically more difficult than second labors. Let's face it -- having a baby for the first time can be a very unpleasant experience, no matter where it happens. So women unhappy with a first birth turn to midwifery for the second one and -- voila, it's easier! What do you know? Hurrah, hurrah and all that. The midwife is happy to take the credit even though she likely had zilch to do with the relative ease of the second birth compared to the first. Had you gone to the hospital again, your wife would have probably still had an easier birth, just within the safe proximity of doctors and equipment in case anything had gone wrong.
8
Tethered to a monitor! The horror! Glad it worked out for you - but hope some mother-to-be who reads your endorsement doesn't end up on the sad side of the statistics.
1
Heart attacks are also a natural process, but I would not recommend staying home for one.
3
My blood boils when I read/hear people who, having never done the research, opine about giving birth at home. I have successfully had two home births, and it was absolutely the best decision for our family. Women have lost faith in their ability to give birth and the medical community does not help with it's incessant interventions and nonexistent training on how to help women give birth. My first midwife, b/c of years of training and experience, got my labor started again after it stalled at 24 hours. (BTW, she was able to track the baby's vital signs the entire time.) At a minimum, women should know the option exists, it is very, very safe, and no delivery is without risk. Not all babies who die during home birth would live in hospital, and not all babies who die in hospital would die at home.
10
Good for you. I don't judge you, so don't judge us who decide that modern paint relief is the way to go.
5
@ROK: She's judging you? I didn't get that from her comment. I read it a second time and still didn't get that.
1
I had my first child in a hospital and I am glad I did. My entire pregnancy was totally normal and healthy, as was my child. However my placenta bled during labor and I needed an intervention. What if I had been at home when that happened? I may not be here right now. Neither would my baby.
5
If you are at home with an experience midwife, they are watching you and know signs of things going wrong. My midwife intervened in my hemorrhage before it was problematic. I bled and lost a lot of blood, but she had the skills to take care of me and my baby. When you are searching for a midwife, ask what their back up plans are. Ask if they've ever had transfers to the hospital or other bad experiences and how they dealt with them. A ton of midwifes are just as (sometimes even more) capable as doctors. They have the experience and they are actually present the entire birth and able to see if anything is going wrong or slowing down or becoming irregular. They catch things early and have dealt with more things without having "c-section because insurance!" shoved down their throat.
4
Had a teacher in HS many years ago, whose wife and he tried a home birth. There was a problem and the baby did not make it. It was sad to see hope and anticipation crushed like that. 3.9 to 1.8 in a 1000 are pretty good odds unless it happens to you.
7
In my opinion there is too much emphasis on the " birthing experience" in this country. Labor and delivery is such a minute part of a mothers life. Good or bad its the end result that matters. Why take any risk having a baby at home ? It is just common sense to have your baby in the safest place and that is in the hospital, contrary to all these fancy statistics.
24
I hope you realize that not everyone feels the way you do. Many woman are concerned about unnecessary interventions that are so common in U.S. health care and rightly so. As I learned, these "interventions" can have real and lasting consequences. Reliable studies show that, the more health care available in a community, the more health care consumed. That means unnecessary and often unwanted procedures are being foisted on patients, including pregnant and laboring women and newborns. In my case, the premier women's hospital in my city admitted my healthy, but slightly underweight newborn to the step-down NICU five minutes after delivery to "fill a bed" as the article says. They immediately started feeding him formula from high-flow bottles without regard for my desire and intention to breastfeed...they said his blood sugar was low. Nevermind that the best treatment for low blood sugar in newborns is being on mom's chest and breastfeeding! He was in for four days and force-fed formula around-the-clock at strict four hour intervals. Of course, I won't ever know if it was the stress, separation or the bottle feeding that made it impossible for me to breastfeed. I can say that it was devastating in a way I couldn't have imagined. Certainly, I cannot compare it to the loss of a child, but the experience was unnecessary. Our pediatrician confirmed the admission to the NICU was not needed, but common. He said he was sorry it had happened. Cold comfort, even three years later.
10
I don't understand the logic. I'd much rather have my child placed unnecessarily in intensive care than have my child need intensive care and not have it.
To me, the solution seems clear and it's not have more births take place at home. It's make hospital maternity wards more homey.
http://fewbricksshy.blogspot.com/
To me, the solution seems clear and it's not have more births take place at home. It's make hospital maternity wards more homey.
http://fewbricksshy.blogspot.com/
10
Whenever my Indian grandmother passed a pregnant woman, she used to say a prayer. For my ammuma and all the women who came before her, all births were home births, and they came with a strong possibility of death.
So recalls my mom, who grew up in Kerala (a part of India with a remarkably low infant and maternal mortality rate). My mom went on to practice medicine in the U.S. for over 45 years, but because of her childhood and medical training in India, I grew up hearing enough stories about the myriad potential complications of childbirth, many of which she had witnessed during her training: obstructed labor, placenta previa, post-partum hemorrhages, breech birth, eclampsia...the list goes on.
For those of us with access to decent healthcare, the blessings of modern medicine — and yes, the "medicalization" of birth — have made dying from such complications a thing of the past. When I got pregnant, I had a lot of people tell me that giving birth is a normal part of life, that we humans have been doing it forever, and that home births are safe. I opted for a hospital birth (and an epidural), thinking all of the while of my foremothers, for whom there was no such choice.
So recalls my mom, who grew up in Kerala (a part of India with a remarkably low infant and maternal mortality rate). My mom went on to practice medicine in the U.S. for over 45 years, but because of her childhood and medical training in India, I grew up hearing enough stories about the myriad potential complications of childbirth, many of which she had witnessed during her training: obstructed labor, placenta previa, post-partum hemorrhages, breech birth, eclampsia...the list goes on.
For those of us with access to decent healthcare, the blessings of modern medicine — and yes, the "medicalization" of birth — have made dying from such complications a thing of the past. When I got pregnant, I had a lot of people tell me that giving birth is a normal part of life, that we humans have been doing it forever, and that home births are safe. I opted for a hospital birth (and an epidural), thinking all of the while of my foremothers, for whom there was no such choice.
26
Thankfully, we were able to use a well-equipped birthing center (actually, a converted house), staffed by highly experienced and empathetic mid-wives, for the natural births of our children. Wonderful experiences.
Sadly, since then, the birthing center we used has had to close. Despite an exemplary record, the birthing center was overwhelmed by rapidly rising insurance costs and ever-increasingly burdensome regulations which were the handiwork of medical industry lobbyists.
Birthing centers staffed by mid-wives seems like a great middle ground between a home birth and a hospital birth, truly providing the best of both. Unfortunately, this option has largely become unavailable, a casualty of the medical industry's determined undermining of anything which takes away their profits.
Sadly, since then, the birthing center we used has had to close. Despite an exemplary record, the birthing center was overwhelmed by rapidly rising insurance costs and ever-increasingly burdensome regulations which were the handiwork of medical industry lobbyists.
Birthing centers staffed by mid-wives seems like a great middle ground between a home birth and a hospital birth, truly providing the best of both. Unfortunately, this option has largely become unavailable, a casualty of the medical industry's determined undermining of anything which takes away their profits.
3
I was born when a 2lb 2oz baby was considered unable to live. It was a sudden birth at home, and the doctor, my grandfather, commented "That thing can't live." He sat up all night feeding me and tried to get me admitted to a hospital. Even as a MD, he could not convince any hospital to take me for fear it would count against their statistics. I was put in a box with a lamp...a good thing it was not one of these modern lamps or I would really have died!! Lesson: a hospital birth is not always available, even for those who can pay for it.
9
I'm so glad you made it, George. Your grandfather sounds like a wonderful, compassionate physician and human.
Reduce the risks of excessive interventions and maternal morbidity and even mortality in hospitals - we know how to do it. Reduce the risks of inadequate screening and infant death and damage out of hospital - we know how to do that too. It's not either/or- we have to do both. For the sake of ALL our families.
6
Here's the best option:
An in-hospital delivery, with a Certified Nurse Midwife (CNM) as the attending OB provider.
As a nurse, and later as a nurse practitioner, I wanted the resources available in-hospital, with the support and improved care only available when attended by a CNM. I chose a midwifery group at Albert Einstein Hospital in The Bronx. I had excellent outcomes with all 3 deliveries, even when the last child had meconium, late decelerations, and the MDs were calling for a section, it was because my CNM, completely unflappable, said, "let's try one more thing", that I avoided that section, and delivered a perfect baby boy, who celebrates his 21st birthday today.
An in-hospital delivery, with a Certified Nurse Midwife (CNM) as the attending OB provider.
As a nurse, and later as a nurse practitioner, I wanted the resources available in-hospital, with the support and improved care only available when attended by a CNM. I chose a midwifery group at Albert Einstein Hospital in The Bronx. I had excellent outcomes with all 3 deliveries, even when the last child had meconium, late decelerations, and the MDs were calling for a section, it was because my CNM, completely unflappable, said, "let's try one more thing", that I avoided that section, and delivered a perfect baby boy, who celebrates his 21st birthday today.
9
If OBs and hospitals would stop scaring women with all the high tech interventions, maybe more women would be willing to come to the hospital. As the article said, women are more likely to have inductions and c-sections which cause babies to be admitted to the NICU.
There was a program on TLC called Maternity Ward. It was at a Yale affiliated hospital. Some of the babies were delivered by doctors who rushed in at the last second to catch the baby and take the credit. In the very next room, women were assisted in labor by Nurse Midwives. The difference was unbelievable. It was hard to believe that some women were subjected to all the high tech bullying in one room while tethered to their beds by wires and IVs, while the patient in the next room had a completely different experience as the midwife assisted her in the delivery.
The US is not a shining example of low infant and maternal mortality. I find the numbers of deaths in the hospital to be suspiciously low considering that is where the high risk women go to deliver. We also have the most expensive system in the world where going the hospital to have a baby puts a lot of financial pressure on those who don't have good health insurance. What we need is a system to bring a well equipped ambulance to the women when they are in active labor and it can be used as needed. It is a lot less expensive than going to a hospital which over-charges for everything and exposes the patients to germs and medical errors.
There was a program on TLC called Maternity Ward. It was at a Yale affiliated hospital. Some of the babies were delivered by doctors who rushed in at the last second to catch the baby and take the credit. In the very next room, women were assisted in labor by Nurse Midwives. The difference was unbelievable. It was hard to believe that some women were subjected to all the high tech bullying in one room while tethered to their beds by wires and IVs, while the patient in the next room had a completely different experience as the midwife assisted her in the delivery.
The US is not a shining example of low infant and maternal mortality. I find the numbers of deaths in the hospital to be suspiciously low considering that is where the high risk women go to deliver. We also have the most expensive system in the world where going the hospital to have a baby puts a lot of financial pressure on those who don't have good health insurance. What we need is a system to bring a well equipped ambulance to the women when they are in active labor and it can be used as needed. It is a lot less expensive than going to a hospital which over-charges for everything and exposes the patients to germs and medical errors.
10
You are absolutely correct to bring up the US ranking in birth outcomes compared to birth outcomes in the rest of the 'developed' world. We do a horrible job that is replete with unnecessary, expensive interventions.
Hhhhmmm, what could be the difference at a structural level???
If we take the profit out of healthcare, our mothers and babies will do better across the socio-economic spectrum, have better choices, and have more control over their choices.
Our birth outcomes are a direct result of our access and affordability failures.
Hhhhmmm, what could be the difference at a structural level???
If we take the profit out of healthcare, our mothers and babies will do better across the socio-economic spectrum, have better choices, and have more control over their choices.
Our birth outcomes are a direct result of our access and affordability failures.
Thank you for your recognition that there is more than one right answer. Different people have different priorities and, as in Britain, it is possible to offer a system that recognizes this. It might also help if women and their partners were reminded that they don't have to acquiesce to everything proposed. They can refuse care. And if ever there were an argument for certified nurse-midwives, your notation of the rates of severe morbidity and death in women with planned c-section deliveries speaks for itself.
5
The U.S. is ranked #58 in infant mortality rates, far behind the Netherlands and the UK where home birth is common place. Sure, there will be complications with some home births, but most of of American births are in hospitals and look how poorly we rate.
11
Just realize that we save 24 week premies, if they die they go into our infant mortality rate. Other countries don't save infants with this gestational age. So it really isn't a meaningful stat.
3
An ill-informed statistic without context. Infant mortality rates are high in the US because the US has a heterogenous population 6 times the size of UK or the Netherlands. The poor as a percentage of our population is also greater with a huge new immigrant an illegal immigrant population that increases with decreased access to healthcare and a host of medical problems. Alos, with 35% of the us population obese or morbidly obese this increases the risk of obstetric and neonatal complications. You cannot compare the Netherlands a country radically different from the US to anything that isnt similar. If you compared neonatal outcomes in Seattle they would be drastically different from Loredo, TX or BIrmingham AL.
5
NO other countries save 24 week preemies? Your bias is showing, Dr. X.
2
I'm interested in the post below which states that midwives don't carry insurance. Is this true? I read years ago about a very prominent midwife in NYC who didn't have insurance. I find this interesting because the actuaries who work for the insurance companies really crunch the numbers in terms of risk. If someone can't get insured for the work that they do, doesn't that tell the consumer something?
1
Yes, in most states, it tells you that it's unavailable to home birth midwives. I recently retired after 20 years attending out of hospital birth and in my state it was not an option. In another answer to your question, it also told me AND the consumer that we needed to be very honest and aware of the risks and we both needed to take responsibility because we did not have, if time was of the essence, that luxury. I was never sued (which they could have done) and my outcomes and relationship with my clients was the reason. It's a far different model than in the hospital.
2
They do not because they do not want to spend money on malpractice insurance. It is all abut $$$ for home birth midwives. They have workshops and books on how to make themselves judgement proof.
So, if OB makes an error and baby has brain damage, at least the family will get money for care. But if Home birth "midwives" damages the baby, the parents are stuck paying for it all. http://www.skepticalob.com/2012/06/if-homebirth-midwives-want-to-be.html
So, if OB makes an error and baby has brain damage, at least the family will get money for care. But if Home birth "midwives" damages the baby, the parents are stuck paying for it all. http://www.skepticalob.com/2012/06/if-homebirth-midwives-want-to-be.html
4
Dr. Carroll, you as a pediatrician should know that if a newborn is experiencing distress, seconds matter, not minutes. There is no way you can get the newborn to a hospital fast enough to prevent brain damage, even if the hospital and midwife are part of a system. Transferring laboring women of course is another situation, but I'm referring to fetal distress and anoxia during delivery.
So why risk it? The best option is to have midwife assisted deliveries in hospitals; where the low-tech approach is the first approach but if a crises ensues, it can be easily managed.
So why risk it? The best option is to have midwife assisted deliveries in hospitals; where the low-tech approach is the first approach but if a crises ensues, it can be easily managed.
10
As a home birth midwife I was trained in neonatal resuscitation and performed it for for primary apnea at home several times with good outcomes and no need for transport. CPR is another required training for Certified Professional Midwives and luckily, I never had to perform that. Detecting fetal distress in labor is a crucial skill by midwives so that a timely transport can be initiated. Does it every happen so fast that one loses a baby? Yes, sadly. The time it happened to my client's baby, we transported very fast and were told by hospital staff that the baby's death could have happened in the hospital, too. We will never know and it's a difficult thing to accept but the mother understood the risks and has made her peace with it.
Exactly. The two groups need to work together to make birth more humane and SAFE. People like to wax poetic about the old days of childbirth but women routinely died. Clearly there needs to be a middle ground. The best bet would be to go with a CNM who worked in a hospital for low risk patients. That way you get a decent birth with accountability. I'm not looking for a perfect birth, I'm pretty sure for most of human history birth has been horrible, so it's weird that we want it to be so romantic now. I'm just looking for dignity and safety in an environment that is not paternalistic.
Leo,
My wife deliver both of our children (31 years old and 26 years old) at a nurse mid-wife clinic in East Tennessee. Hospital back up was available but not needed. To my knowledge the clinic is still operating and the rate of successful births is equal to hospital births. The rate of complications, infections and interventions is higher in a hospital. Just depends on what survey you refer too.
My wife deliver both of our children (31 years old and 26 years old) at a nurse mid-wife clinic in East Tennessee. Hospital back up was available but not needed. To my knowledge the clinic is still operating and the rate of successful births is equal to hospital births. The rate of complications, infections and interventions is higher in a hospital. Just depends on what survey you refer too.
6
I was born in a country where home births were common but, because my family had the finances, my father intentionally picked the best hospital and ob/gyn possible in our city. Which was fortunate because despite my healthy mother having had a son already and an uneventful pregnancy, I ended up being tangled in my umbilical cord and at risk of choking myself. Fortunately, our ob/gyn, with decades of experience, was able to get me out of that situation using forceps and not a surgical delivery. I was then put in a specialized care unit just in case. I recovered fine, without any health issues. Thus, my view on this is it's better to be safe than sorry.
5
" ... while also ensuring that more intensive care is available when needed."
Sometimes needed within minutes or seconds.
Would mean mobile hospitals in the driveway or curbside? How many would a large city need?
Obviously the species survived without hospitals. And high tech medicine gets costlier yearly. And there may be greedy abuses.
But--like you and your wife--parents should give the kid its best shot. Not to mention wasting a nine month investment.
Sometimes needed within minutes or seconds.
Would mean mobile hospitals in the driveway or curbside? How many would a large city need?
Obviously the species survived without hospitals. And high tech medicine gets costlier yearly. And there may be greedy abuses.
But--like you and your wife--parents should give the kid its best shot. Not to mention wasting a nine month investment.
2
"May have legitimate reasons"? There are PLENTY! I don't have fear around the death of my baby during birth. I am a healthy, low risk individual that successfully had 1 homebirth and am planning my second in December. Fear is not in my birth plan. However, a safe and secure birth certainly is.
To be clear, I would not choose a homebirth without a Certified Nurse Midwife (CNM), a distinction that the author puzzingly leaves out. A CNM holds a master's degree in Nursing (nurse practitioner), and typically have years of in-hospital training. Further, they can perform a wide range of interventions (short of a c-section) and she had an oxygen tank, was prepared to offer an emergency episiotomy, stitches, and even had pitocin in case of bleeding on my side.
I paid out of pocket for my wonderful, clean, healthy home birth because my insurance wouldn't cover the location even though my CNM in an IN-NETWORK provider for them. She wrote prescriptions and ordered blood screenings. But I will pay again because 1) I am a mammal and deserve a warm, quiet place to birth. 2) Relocating during labor is non-inituitve. 3) I want zero interventions. 4) I want to take a nap in my bed after.
Distinguishing between CNM and "professional" midwives is essential and a missing component of this article and the general conversation. Our midwife was well-trained and knowledgeable - no hocus pocus and perfect bridge to western medicine right in our home. We can't wait to do it again.
To be clear, I would not choose a homebirth without a Certified Nurse Midwife (CNM), a distinction that the author puzzingly leaves out. A CNM holds a master's degree in Nursing (nurse practitioner), and typically have years of in-hospital training. Further, they can perform a wide range of interventions (short of a c-section) and she had an oxygen tank, was prepared to offer an emergency episiotomy, stitches, and even had pitocin in case of bleeding on my side.
I paid out of pocket for my wonderful, clean, healthy home birth because my insurance wouldn't cover the location even though my CNM in an IN-NETWORK provider for them. She wrote prescriptions and ordered blood screenings. But I will pay again because 1) I am a mammal and deserve a warm, quiet place to birth. 2) Relocating during labor is non-inituitve. 3) I want zero interventions. 4) I want to take a nap in my bed after.
Distinguishing between CNM and "professional" midwives is essential and a missing component of this article and the general conversation. Our midwife was well-trained and knowledgeable - no hocus pocus and perfect bridge to western medicine right in our home. We can't wait to do it again.
13
I was interested in a freestanding birth center birth/home birth. I've since changed my mind because even though doctors and hospitals have huge egos regarding the practice of medicine, at least they are taught to be cautious by default. This is a quality that you are not certain to find in a midwife. Second, the midwifery system here trails behind other countries, like Britain. I can't be sure that a midwife that I hire will adhere to certain standard protocols and not follow her own ego or pride. In short, in the United States midwives are a grab bag; you could get Ina May Gaskin, II, or you could get some uninformed schmoe who wants to get her birth numbers up. I can't take that chance. Also, midwives don't often carry malpractice insurance; it is too expensive for most of them to do so. That means, if something should happen to you or your child, you can't sue because she'll likely claim bankruptcy. The organizational bodies for midwives have no teeth. They can suspend or revoke creditation, but how does that help you if your child has died due to negligence?
I'm going to try going with a doctor who respects my decisions. I'm going to exercise in order to bring on labor. I'm going to do most of my my laboring at home and not rely on the epidural, because that is seemingly where they get you. If something is to happen to me or my child, I'll know that I'm in a place where everything can be done.
Ideally, all birth centers would be in hospitals.
I'm going to try going with a doctor who respects my decisions. I'm going to exercise in order to bring on labor. I'm going to do most of my my laboring at home and not rely on the epidural, because that is seemingly where they get you. If something is to happen to me or my child, I'll know that I'm in a place where everything can be done.
Ideally, all birth centers would be in hospitals.
1
Certified nurse midwives are probably what you're looking for.
6
I'm curious why you believe an out of hospital, non nurse provider would not be cautious?
2
I would have no problem going with a CNM who was affiliated with a hospital and who ideally worked in/for one. The goal is to make birth safer and more pleasant for the mother and child, not to give birth in my house. I'm not trying to recreate Little House on A Prarie, I just want to have choices and be treated with dignity.
Better collaboration between hospitals and non-clinicians such as midwives / doulas is definitely important. The UK has this in place and that is a good thing.
What is not so good in the UK, however, is the lack of choice afforded to women. If you want a low-cost home birth the system is in place to let you do that. If you want care from an obstetrician with a preference for a C-section instead of an instrumental delivery with forceps, that choice is not available to you. Forceps are preferred in the UK because they are cheaper for the hospital than C-section.
So for all those advocating 'low intervention' births and lamenting the high C-section rate, keep in mind that the UK system uses forceps for about 11% of births (at least in Scotland). This is what keeps the C-section rate down. Yet forceps are barely used in the US anymore because they are associated with birth injury to both mother and baby.
From personal experience, the US allows greater freedom of choice to women. Sometimes in an irresponsible way, in that it is much easier for a woman here to have a home birth entirely independent of the hospital system if that's what she wants. But often in a good way, in that if you find the right OB-GYN s/he will respect your choices as a woman. Not so in the British system where the NHS protocols, laid out by NICE and driven by cost concerns, determine everything.
What is not so good in the UK, however, is the lack of choice afforded to women. If you want a low-cost home birth the system is in place to let you do that. If you want care from an obstetrician with a preference for a C-section instead of an instrumental delivery with forceps, that choice is not available to you. Forceps are preferred in the UK because they are cheaper for the hospital than C-section.
So for all those advocating 'low intervention' births and lamenting the high C-section rate, keep in mind that the UK system uses forceps for about 11% of births (at least in Scotland). This is what keeps the C-section rate down. Yet forceps are barely used in the US anymore because they are associated with birth injury to both mother and baby.
From personal experience, the US allows greater freedom of choice to women. Sometimes in an irresponsible way, in that it is much easier for a woman here to have a home birth entirely independent of the hospital system if that's what she wants. But often in a good way, in that if you find the right OB-GYN s/he will respect your choices as a woman. Not so in the British system where the NHS protocols, laid out by NICE and driven by cost concerns, determine everything.
2
I just did an emergency cesarean on a mom with her third baby. Two prior normal deliveries and no risk factors. Her placenta abrupted-came off the wall of the uterus. If she had been home they both would have died.
How much risk is it worth to your baby to stay home. I agree most will be fine, but if things go badly that is a lot of grief and guilt to carry the rest of your life.
How much risk is it worth to your baby to stay home. I agree most will be fine, but if things go badly that is a lot of grief and guilt to carry the rest of your life.
26
This article discusses home birth in Britain without including vital information about what that means. A 'home birth' in Britain doesn't mean you have a baby outside the medical system. Home births are attended by a highly-qualified nurse midwife provided by the NHS. Compare that with the patchwork of regulation (or lack thereof) for midwives and doulas in the US. S/he can provide pain relief, including nitrous oxide, which is not available in the US (even in most hospitals). S/he will administer eye drops and other vital health care to the infant immediately after birth. By omitting this information the author provides a false impression about the safety of home births.
2
British midwives are not nurses. They are direct entry midwives who take a 3 year university degree.
2
Some British midwives are also nurses. It is possible to be a British nurse who trained in nursing then applied for a midwifery program (or vice versa). But it's also possible to only complete a midwifery program.
1
You are mistaken. Eye prophylaxis and even nitrous oxide are available, as well as other legend drugs and devices are required to be administered by home birth midwives in many states. We need uniform laws, for sure so that mothers and babies receive the best care.
2
Possibly the rates of intensive care admission etc are higher for in hospital births because parents sensibly don't plan to have a home birth unless they believe the baby will be healthy and all aspects of the delivery normal.
1
Since c-section carries a much higher risk for maternal health and mortality the fact that it happens ~5x more often in a planned hospital birth than a planned home birth suggests to me that more mothers would die in the hospital even if more babies die at home. So I find it interesting that the headlines all tout the risks to babies but not the benefits to moms. I know babies die in childbirth ~10x more than moms but still it seems important to note. Some people would prioritize the health and life of a fetus they'e never met over themselves or their partner. However, plenty of people are more attached to mom who may include her other children.
7
So my choice is to either risk my own health with an unnecessary or premature medical procedure, or risk my child's health while preserving my own, and maybe saving some money giving birth in my own home. I find it difficult to believe that woman are unable to find obgyns that respect their choices, barring medical necessity. Regardless, I'll go to the hospital. As a mother and the adult in the room, I'LL take the risk to my own body and health. But I WILL NOT allow any additional risk to my unborn child for my own comfort or an idealized vision of "natural birth." I cannot believe that people are more worried about a C-section than their baby's health and safety.
3
Well, people evaluate risk individually. Some people will risk an unlikely event over a much more likely event- for example, many accept the additional risk of driving in a car each day, rather than accept the risks of isolation that not having individual transportation may bring.
3
Yet another article that throws around statistics without probing their significance. If planned home births are almost all self-selected healthy, low-risk women while hospital statistics include even the most high-risk cases and yet the statistics are still 3.9 deaths at home versus 1.8 per 1,000 in a hospital that is hardly an argument that home birth is safe. In fact, that leads me to believe that if we exclude high-risk births in a hospital and compare apples to apples the perinatal mortality rate for home births would be significantly higher than hospital births.
7
This whole debate is ridiculously polarized. In countries where midwives and OBs and birthing centers and hospitals see themselves as partners and not adversaries, women have all good choices from which to pick. Can't we stop the fight and cooperate?
20
Not when the taxpayer picks up the tab from dealing with a child who might have been healthy if born in a hospital, but who was not.
Insurance reasons. I worked with an IN-NETWORK certified nurse midwife who could charge all aspects of my pre- and post-natal care. But the birth HAD to take place in a hospital (average $16K) for it to be covered. I paid the $3000 out of pocket to have the birth experience I deserved, but its annoying because I pay so much for insurance in the first place
3
Totally agree. There have been several important Homebirth Summits lately that suggest ways hospitals could cooperate with local community midwives. Hospitals have the power to make births in their communities safer by working with local midwives.
This is a totally irresponsible article and this doctor is playing to the anti-vax mentality which is morally reprehensible.
I was one of those no sweat, no-risk mothers UNTIL I WASN'T. Then out of the blue my baby went to fetal distress and I became an EXTREME EMERGENCY. This was my second baby so I was shocked at the turn of events.
If I wouldn't have been at the hospital, there is a high probability that I wouldn't have survived, but my baby under no circumstances would've recovered...a tragedy that was avoided simply because the hospital was prepared for these dire situations.
And it was pointed out to me my innumerable doctors at the hospital that I had a major lawsuit on my hands, because the attending doctor had failed to see the warning signs because, as this doctor pointed out, aren't most births horses and not zebras?
And no I didn't sue because my baby survived, but that's only because I was in the hospital!!!!
I was one of those no sweat, no-risk mothers UNTIL I WASN'T. Then out of the blue my baby went to fetal distress and I became an EXTREME EMERGENCY. This was my second baby so I was shocked at the turn of events.
If I wouldn't have been at the hospital, there is a high probability that I wouldn't have survived, but my baby under no circumstances would've recovered...a tragedy that was avoided simply because the hospital was prepared for these dire situations.
And it was pointed out to me my innumerable doctors at the hospital that I had a major lawsuit on my hands, because the attending doctor had failed to see the warning signs because, as this doctor pointed out, aren't most births horses and not zebras?
And no I didn't sue because my baby survived, but that's only because I was in the hospital!!!!
12
I am surprised that most people seem NOT to be mentioning important factors which influenced my interest in home birth: respect and control. I think/hope attitudes have improved in the 30-40+ years since my children were born, but I was badly bothered by the lack of status and respect I felt in the hospital setting. Forget your knowledge and intellect, your experience and status -- during L and D it seemed any nurse or intern could talk down to me, order me about, tease me, and ask me questions in a tone and matter that insinuated I was an ignorant child or a guttersnipe. I think it takes judgment to know what sort of person you're dealing with via their words and ideas, and when I meet medical types who fail to detect my intellect, I doubt ALL aspects of their judgment -- besides feeling insulted. During childbirth I had no extra energy to address these issues. which for me were very real and did not disappear into the background no matter what pain and strain I was experiencing.
11
This still happens. My cousin just gave birth less than 2 weeks ago and they took the baby out of room without explaining to them what was going on and took her to the NICU because they thought she had some fluid in her lungs. My cousin didnt get to hold her for over 24 hours and she feels completely betrayed by the system. She doubts there was anything wrong and thinks instead they were overly aggressive in protecting themselves from a lawsuit instead of thinking about what is really best for mom and baby.
4
This is endemic in American healthcare. I had a surgery in Costa Rica this past year and was amazed at how much more respected I was. All 3 of my children were born at home and I did it because I had seen the stats and believed it was safer overall. We also lived very close to good hospitals and had a transport plan. Had I lived far from emergency care I doubt I would have had mine at home. At least this article seems to think that women should make this decision themselves. Abortion is completely legal, but the minute we decide to bring a baby to term many think our bodies are no longer our choice. Such hypocrisy.
3
Lauren, did it ever occur to you that maybe the reason no one explained what they were doing was because the baby was in trouble and they were trying to save his/her life? I can tell you when I. M running a code my priority is the patient in front of me, not stopping and explaining everything as it happens. Trust me, you want my focus on saving the person, not trying to hold hands, at least in the immediate moment.
We should instead ask "How do we make hospital births less stressful, less medicalized, less unnecessarily invasive, and more risk-tolerant and family-centric"? The stressful environment and aggressive push for c-sections and inductions are among the primary reasons why women opt for home births (not to mention the costs). The difference between "emergency" and "difficult delivery" appears to be a fine line that shifts based upon a doctor's schedule and personal preferences. One can only blame medical malpractice suits but so much.
16
Dr. Carroll should have looked closer to home. In Canada we have a much more coordinated system for birth. I'm always amazed at how in the U.S. it's a choice between a hospital birth (which in the U.S. has higher rates of C-section than elsewhere) or the dangers of an untrained, unaccredited midwife in a home birth with no hospital support. In Canada, I had a choice between a family doctor or a midwife. Either would have worked fine -- as the midwives are accredited and affiliated with hospitals. I chose to go with my family doctor, but it's also totally normal to choose a midwife, because the medical system supports rather than stigmatizes it. (OB/GYNs don't come into it unless you're high-risk or need surgery.) I'm pretty sure the more holistic approach used outside the U.S., in which birth practitioners are trained, accredited and affiliated with hospitals (I've lived in Canada & Germany and seen both) would lead to better outcomes than this U.S. study is showing.
10
Your information about women's choices in the US is incomplete. It is actually quite normal for women in the US to choose a midwife for their prenatal and delivery care. Licensed, certified midwives work at both of the hospitals where I gave birth, and women are free to choose a midwife instead of an OB for their care.
4
If only those options were available everywhere in the U.S. They are not.
4
Bubbles, there are many types of midwives in the US. I would venture to say that those that practice at a hospital are certified nurse midwives with full hospital backup. Midwife licensing and minimum qualifications vary greatly by state.
My state requires a pre-existing relationship between practicing midwives offering home births with an OB/GYN and hospital as backup. My understanding is it is difficult for midwives practicing in people's homes to find OB/GYNS willing to work with them. So that is not good, but the requirement is quite reasonable and must be followed.
So what happened here? A nurse midwife with no OB/GYN or hospital backup and no liability insurance arranged to deliver a child of a well-educated professional couple at home. Mom labored a long time and child and mom experienced serious distress. So the midwife called 911 and the mom was taken to a university hospital-- as a patient about whom the hospital had no information, no medical or pre-natal history. A C-section was performed but the child has severe disabilities. What did the parents do? Sue the hospital contending that the staff waited too long to do the C-section and that the child's disabilities are the hospital's fault. They DID NOT sue the midwife. Guess what? They won a huge judgement against the hospital!
What happened is truly a tragedy but who is ultimately at fault here? Yes, coordinate but understand the varied practices that are in place.
My state requires a pre-existing relationship between practicing midwives offering home births with an OB/GYN and hospital as backup. My understanding is it is difficult for midwives practicing in people's homes to find OB/GYNS willing to work with them. So that is not good, but the requirement is quite reasonable and must be followed.
So what happened here? A nurse midwife with no OB/GYN or hospital backup and no liability insurance arranged to deliver a child of a well-educated professional couple at home. Mom labored a long time and child and mom experienced serious distress. So the midwife called 911 and the mom was taken to a university hospital-- as a patient about whom the hospital had no information, no medical or pre-natal history. A C-section was performed but the child has severe disabilities. What did the parents do? Sue the hospital contending that the staff waited too long to do the C-section and that the child's disabilities are the hospital's fault. They DID NOT sue the midwife. Guess what? They won a huge judgement against the hospital!
What happened is truly a tragedy but who is ultimately at fault here? Yes, coordinate but understand the varied practices that are in place.
4
My family. 6 children.
1 hospital - horrible
1 birthing center - better
4 birthed at home - awesome!
1 hospital - horrible
1 birthing center - better
4 birthed at home - awesome!
13
Hospital birth in the US is a wildly over-medicalized practice driven not by mothers, midwives, or empirically-supported practice, but by obstetricians who have lost sight of the most basic elements of the birth process (a woman flat on her back while laboring will "fail to progress" and the cascade to surgery begins), who rely on unsupported techniques (e.g., fetal monitoring does not predict outcome), and who are terrified of liability (hence C-section rates 3 to 4x WHO recommended guidelines).
Remember, obstetricians are surgeons, most surgeons do surgery, C-section is major surgery with all related and nontrivial risks (to mother and baby)
Remember, obstetricians are surgeons, most surgeons do surgery, C-section is major surgery with all related and nontrivial risks (to mother and baby)
14
there is a huge push in the medical system to decrease the cesarean rate. you may not realize this - but we now have battery operated fetal tracing monitors connected via wifi to a computer so that we can see the fetal tracing at all times and still allow the patient to walk. more practices are incorporating midwives to help labor with the patients. they primarily are in charge of the labor and us obstetricians are there in cases like when your baby's heart rate is down in the 70s for ten minutes and not coming back up... more hospitals and practices (that can afford to do so) have OB's in the hospital 24 hours a day so we are not constantly looking at the clock when a patient is in labor. you can not make a blanket statement like this. at this point in the "ob world" we are being trained on how to reduce cesarean section rates, more research is being done currently to help figure out what is the best type of monitoring for the baby that actually does predict outcome. we are working on it. we want to help a mother have the most natural birth possible and still ensure a healthy baby. there has been a shift in the ob culture. it is not going to happen overnight.
6
Dear anonymous ob, thank you for your detailed, informative comment. I am grateful every single day for my ob and the hospital staff who saved my child after my 33-hour, walking (most done at home) non-progressing, unmedicated labor aided by a doula and my husband. My beautiful boy was delivered by emergency c-section--he was head down but spine-to-spine, and by the time our doctor took him he was almost transverse and had his arm wedged over his head. My kind, skilled doctor told me there was nothing I could have done differently and the only way my son could have been born at that point was by c-section, although that was not in my "birth plan." I am a small woman and my son was large, almost nine pounds. Neither of us diabetic and I was a very fit and flexible yoga teacher, really confident the birth would be uncomplicated. Sometimes the unpredictable occurs and for sure, I am so thankful for my doctor and the hospital. My beautiful boy is 14 y.o. now and almost 6 feet tall, slim, healthy, athletic, smart, and a kind and compassionate person. I am so grateful.
One of the most (terrible) memories of delivering children occurred with a first pregnancy for the couple. Perfectly normal prenatal, with a very fit and concerned but not over the top mother-to-be. Exceptional support from family and husband.
Ten minutes before we were going to the delivery room (back then we didn't convert the room beds to delivery beds, we still went to the delivery room) the baby's heart stopped. Fortunately, an OB/GYN was also in the hospital and within five minutes we had a C-section completed. The baby was dead, with the cord wrapped around the neck tightly.
Even in the best of circumstances, tragedies happen. The next few hours as the previously happy, expectant couple began to deal with the loss was so humbling and hard to deal with it made me consider that such terrible mental grief wasan't worth the just being around when most of the other babies' deliveries sort of happened on their own.
To be sure, the father later told me that if that would have happened at home, they would never been able to cope with their guilt. That doesn't mean every delivery should be in the hospital to help assuage those concerns, but in this rare but tragic case it helped make their next few years until choosing to try again for a child less of a burden.
Ten minutes before we were going to the delivery room (back then we didn't convert the room beds to delivery beds, we still went to the delivery room) the baby's heart stopped. Fortunately, an OB/GYN was also in the hospital and within five minutes we had a C-section completed. The baby was dead, with the cord wrapped around the neck tightly.
Even in the best of circumstances, tragedies happen. The next few hours as the previously happy, expectant couple began to deal with the loss was so humbling and hard to deal with it made me consider that such terrible mental grief wasan't worth the just being around when most of the other babies' deliveries sort of happened on their own.
To be sure, the father later told me that if that would have happened at home, they would never been able to cope with their guilt. That doesn't mean every delivery should be in the hospital to help assuage those concerns, but in this rare but tragic case it helped make their next few years until choosing to try again for a child less of a burden.
7
I "interviewed" doctors 30+ years ago to find one who would use only the medical technology necessary. Taking a recommendation from the local midwife organization, we hired an OB in a town an hour away to get the promise (no internal monitors, no ultrasound - he only insisted on a saline IV as a safety issue - hard to get a line in if mom is seizing) of care we wanted. I delivered in a hospital with a plan for the next birth to be at home. The next pregnancy was twins, so back to the hospital we went. We still drove an hour to our OB/hospital as our local hospital's C-section rate for twins was insane. We DID have ultrasounds with the twins, but otherwise that birth was as easy and without unnecessary intervention as the first. Every family must weigh the risks and get good information before making decisions.
3
As a nurse practitioner and a home birth mom the thing that surprises me about all the discussion around outcomes and informed consent for home birth is the lack of informed consent and honest discussion about risks and outcomes in hospital birth. In my experience home birth midwives are very up front about the risk of infant death. It's a risk in any setting, but because of the additional social stigma and judgement around home birth midwives have frank discussions about this with clients. I've never known a doctor to tell a low risk mother planning a hospital birth that there is a chance that her baby will die--but it happens--and parents are surprised. No one ever told them this was a possibility. This not to mention the other risks mentioned in this piece. Regardless of your chosen place of birth providers have a duty to be transparent and honest with the families they are caring for. Informed consent is more than signing a piece of paper.
10
But isn't it obvious that a baby can die in any setting? I'm sure parents are surprised if a baby dies at all, probably more surprised in a hospital where the death rate is lower, but that doesn't mean they thought it was impossible. If an expectant mother is going into the lowest risk setting, what is the point of someone saying to her, "Just so you know, your child might die"? There's no better choice for her to make, so it would just be upsetting, not productive.
2
To make birth experience nicer for women, hospitals should start with the beds. Hospital beds are made for the benefit of the doctors and not women in labour. They are too narrow and too high. Falling off the bed should not be one of your worries while you are having a baby.
6
I seriously considered home birth, found the "culture" of institutional OB/GYN appalling and had little confidence in NYC hospitals based on long experience as a caregiver. Thank God, I found a wonderful midwife/OB-GYN collaborative practice that overcame my objections--because I was one of that tiny percentage who would have had a disastrous outcome at home: a super-fast labor and footling breach presentation. The hospital stay itself at Brooklyn's Methodist was textbook insensitive and awful--but thanks to an emergency C-section (with the team literally RUNNING down the halls to the ER with me and my still-inside-me kid on the gurney), we both did fine.
3
People know if their baby in breach well in advance of giving birth.
4
Not always. Some babies do somersaults until labor is underway. I had one of each -- a son in position for a good six weeks and a son who waited until the last minute to make up his mind. Both are healthy adults, but as births go, the somersaulting babe fared a little better.
2
People are allowed to smoke cigarettes if they feel it is a good thing to do, I suppose birthing at home makes at least as much sense as thant. But why stop there? Find a birthing center with a field and a team of mules. Light plowing would let you walk while the baby settles into postion, and then you could squat in the field for delivery! What could be more natural?
5
Have a hospital birth because your baby might need the medical help a hospital can give. Your baby probably won't need the help, but you want to make sure the help is there if needed.
Yes - the hospital was noisy, impersonal, and I had 2 C-sections. But I came home with 2 healthy babies and, frankly, remember almost nothing about the few days I spent in the hospital, except the total joy of getting the baby. As to the actual delivery, I clearly remember seeing the baby for the first time, but that's about it. They say that most women forget the pain (or they wouldn't do it again) and I believe it.
The baby lasts a lifetime. The hospital lasts a few days. And C-sections aren't that bad. You might never wear a bikini again, but you'll be walking the next day and more than able to care for your newborn. The only thing that really matters is maximizing the odds that the baby is healthy.
Yes - the hospital was noisy, impersonal, and I had 2 C-sections. But I came home with 2 healthy babies and, frankly, remember almost nothing about the few days I spent in the hospital, except the total joy of getting the baby. As to the actual delivery, I clearly remember seeing the baby for the first time, but that's about it. They say that most women forget the pain (or they wouldn't do it again) and I believe it.
The baby lasts a lifetime. The hospital lasts a few days. And C-sections aren't that bad. You might never wear a bikini again, but you'll be walking the next day and more than able to care for your newborn. The only thing that really matters is maximizing the odds that the baby is healthy.
11
So, if I deliver in a hospital, I have a 7 in 1000 chance of severe damage due to a C-section to ME, the mother, who btw might have other children to worry about (I get this from 0.25 chance of c-section and 27 in 1000 chance of severe damage), but only a 2 in 1000 chance of my baby dying... but at home I have a substantially lower chance of permanent damage to me, while the chance of damage to my baby goes up only 4 in 1000 (ie still less likely than me suffering permanent damage from a hospital c-section)? Hmmm. Can't imagine why women would choose home birth if they could...
11
Your comparisons are off. Risk of death to low risk mother from c-section is 0.13 % (that is, 13 per 100,000). Granted, this is about 3 times the risk of a vaginal delivery, which is 3.5 per 100,000) but overall also very safe. Risk of overall complications is 9%, slightly higher than that of vaginal delivery which is 8%, in low risk cases. Most of these are minor and not permanent, certainly not as high as you are quoting, also in that you are ignoring tha fact that vaginal delivery has its own risks of permanent damage as well which is NOT 0/1000. Also, although the DEATH rate for babies is what you are quoting, you are also comparing to damage, which is much higher number. The Oregon study indicated the rate of neonatal seizures was four times higher in homebirth than hospital birth. Neonatal seizures are a marker for potentially very serious brain damage, which can lead to lifelong issues for these children. I say this as someone who sees people with brain damage for a living. So you really need to take the numbers overall and not cherry-pick and compare like to like.
10
While discussing Zebras, the big Elephant in the room is the epidemic of C-Sections. The primary cause of admissions to Neonatal Intensive Care Units (NICUs) are C-Sections. In the 1970s, the rate of "medical necessity" for hospital based deliveries according to the college of Obstetrics and Gynecology (ACOG) was 7.5% in the US. Since then the ACOG rate has more than doubled to 16%. In the same time, the actual is 32.5 and, in some populations above 40% with worse outcomes for infant and mother. At birthing Centers, the rate is 7.5%, about the same as other developed countries. In the Scandinavian countries the rate is under 5%. If your talking about birthing options locations, why not compare to a medically supervised birthing center with a more home-like environment with immediate access to medical assistance as necessary?
5
What is the rate of obesity now in mothers versus 1970s? What is the average age of a woman giving birth now versus 1970s (hint, it is much higher?) What is the rate of pre-pregnancy diabetes and hypertension now versus 1970s (hint, also much much higher?) With the introduction of IVF in 1978, what percentage of births were twins or higher order multiples now versus 1970s (also much much higher)? With modern medical advances, what percentage of women with serious chronic illnesses in general are now able to get and stay pregnant versus the 1970s (much higher)? And if comparing to Scandanavian countries, what are their rates of the aforementioned complicating factors, most notably obesity, diabetes, and hypertension, compared with the U.S.? All of these factors I listed above are medical reasons which carry a higher rate of c-section for mothers due to high risk pregnancy, and all have greatly increased by many orders of magnitude in the past 40 years. As far as birthing centers, most of these women who have any of these risk factors will not be allowed to go there, keeping the c-section rate artficially low and the hospital (where they are referred) rate higher.
14
It is not about "the experience" and selfishness. Cesarean births carry a 20-30% higher risk of type 1 and type 2 diabetes, asthma, allergies (as well as obesity), according to the Danish National Birth Cohort. Any intervention that increases the risk of C-section increases these risks. But OB's cannot be sued for adverse health outcomes which appear years later. C-section babies also have an immediate risk of respiratory distress and necrotizing fasciitis, both life-threatening.
Certainly, some C-sections can be life-saving, but with a 30% rate, it is certain that many are done to reduce doctors' risks (and also their fees and convenience) not babies' or mothers'.
Human beings are mammals. Ask any vet--mammals give birth in dark, quiet, private areas, and if disturbed are for more likely to have adverse outcomes.
It's about weighing very likely serious negative outcomes against very unlikely catastrophic outcomes. Here is a somewhat trivial analogy: Per mile traveled, walking is far more likely to result in a fatality than driving. Does that mean no one should ever walk?
Women seek home-births because they feel they cannot trust our hospital based ob's. It is shameful that our medical system does not support women in childbirth as is done in the Netherlands and Scandinavia, where outcomes are far better.
Certainly, some C-sections can be life-saving, but with a 30% rate, it is certain that many are done to reduce doctors' risks (and also their fees and convenience) not babies' or mothers'.
Human beings are mammals. Ask any vet--mammals give birth in dark, quiet, private areas, and if disturbed are for more likely to have adverse outcomes.
It's about weighing very likely serious negative outcomes against very unlikely catastrophic outcomes. Here is a somewhat trivial analogy: Per mile traveled, walking is far more likely to result in a fatality than driving. Does that mean no one should ever walk?
Women seek home-births because they feel they cannot trust our hospital based ob's. It is shameful that our medical system does not support women in childbirth as is done in the Netherlands and Scandinavia, where outcomes are far better.
24
Simply put, Elaine is being misleading.
There's just no way humans are mammals. The rest is all true though, for sure.
There's just no way humans are mammals. The rest is all true though, for sure.
2
You can have a hospital birth and still insist on a vaginal delivery. I don't know where the above statistics are coming from, but if a baby is in enough distress that an emergency C-section is required, it's possible the distress that led to the C-section also leads to health problems down the road. Also, twins are more often delivered by C-section and just sharing a uterus may lead to future health issues. Women with diabetes have disproportionately more C-sections, so their kids are already predisposed to diabetes for genetic reasons. Etc. There's a lot to control for before that argument makes sense.
3
Not true. Women are essentially wards of the hospital once they admit themselves. They can be (and are) forced into c-section surgery at the discretion of the physician and hospital protocols. If they try to leave, they can be arrested. And if they're obstinate and argumentative - including attempting to keep the hospital from forcing invasive procedures on the newborn, the hospital will very likely be (at least initially) successful in using the state's child welfare system to take their newborn away from them to be placed in state custody.
Pregnant women, from conception to postpartum, are not legally considered fully equal adults in today's political, legal and medical culture. We are living a Handmaid's Tale.
Pregnant women, from conception to postpartum, are not legally considered fully equal adults in today's political, legal and medical culture. We are living a Handmaid's Tale.
I notice little comparison here of different home and hospital situations. My first birth was in a small rural hospital that employed one OB, who was attending a party in another city when I went into labor. My labor was fast, and he barely made it back before I started pushing. There was no NICU--the closest was 45 minutes away. There was no in-house anesthesiologist--their policy was to start with Demerol before calling him in to do an epidural--which could be quite a wait. The nurses attending the birth were freaking out--one of them had never seen an unmedicated birth. The OB (who I really liked, by the way) left the hospital less than an hour after the birth. Flash forward to my third birth at home in a large city. My first two births had been uneventful. My house was a 5 minute drive to two major hospitals. I was attended by a highly experienced nurse midwife, who had no trouble dealing with the cord around my son's neck. She had both oxygen and oxytocin with her (we didn't need either) and hospital admitting privileges. She was there before I started pushing and stayed for several hours after. Given that my home birth avoided standard but risky interventions, the local hospital's 40% cesarean rate, and a potential unneeded NICU stay for my son, my home birth seems like a much safer situation. Each person has to consider the benefits and risks of her own situation.
14
What most people don't understand, including this writer probably, is that in a planned home birth with a great midwife, everything is different from a hospital birth. For instance, the writer mentions induction. When a woman shows up at a hospital in labor, sometimes the travel and change of scene and nerves may make her labor stop. To get it going again labor may be "induced" with drugs. Now the contractions will be stronger and more painful, so she may ask for pain relief when that wasn't in the plan originally. And things can go downhill from there. Everything will be different. The time a midwife spends with you per visit is typically an hour. She will make housecalls near the end. She wants to visit you in your environment and where the baby will be born... There's so much to say about the wonderful practice of home birth. I had my 3 babies at home and each experience was wonderful. Actually that's an understatement!
16
I think the key here is "great" midwife. Midwives in America are not regulated enough for my liking. You could get someone who is awesome or you could get a hack. Because the lay public is uninformed when it comes to medical issues, they don't know who they have contracted with until it is often too late.
2
38 years ago, I gave birth to my 4th child in a planned home birth. I was in the care of GP who had been delivering babies at home for literally generations. The doctor required that I agree to abide by his medical judgement if at any time during the pregnancy or delivery he saw trouble with this plan, and that I would agree at that point to deliver in hospital.
This baby's birth was the smoothest, easiest, least stressful birth experience I'd ever had, I slept through the entire first phase of labor, rather than rushing about, getting a sitter, counting the minutes between contractions, wondering whether to leave for the hospital, waiting for a room, being examined multiple times to determine my "progress", etc. etc. etc. Just sleep...And then, waking at 5:30 a.m., calling the doctor who arrived with his nurse at 6:30 and the baby came at 7:30, to a welcoming family. Scrambled eggs and Asti Spumante were had by all. Daughter weighed in on a bass fisherman's scale at 10.5 lbs.
This was almost 40 years ago. It is astounding to me that we are not utilizing the resources of licensed, trained nurse/midwives and doctors to manage more births at home, rather than fewer. Yes, there are horror stories, but largely because home birth is conducted as a clandestine thing. With proper communication and support, as well as access to major medical facilities should the need arise, home births can be safe and satisfying experiences.
This baby's birth was the smoothest, easiest, least stressful birth experience I'd ever had, I slept through the entire first phase of labor, rather than rushing about, getting a sitter, counting the minutes between contractions, wondering whether to leave for the hospital, waiting for a room, being examined multiple times to determine my "progress", etc. etc. etc. Just sleep...And then, waking at 5:30 a.m., calling the doctor who arrived with his nurse at 6:30 and the baby came at 7:30, to a welcoming family. Scrambled eggs and Asti Spumante were had by all. Daughter weighed in on a bass fisherman's scale at 10.5 lbs.
This was almost 40 years ago. It is astounding to me that we are not utilizing the resources of licensed, trained nurse/midwives and doctors to manage more births at home, rather than fewer. Yes, there are horror stories, but largely because home birth is conducted as a clandestine thing. With proper communication and support, as well as access to major medical facilities should the need arise, home births can be safe and satisfying experiences.
19
No epidural, no thank you.
5
I had my kids in army hospitals here and overseas. The only way to get an epidural was from an anesthesiologist if one was available. In my case none were. I would have liked some pain relief if given a choice.
4
ROK, why? I had an epidural during a labor that went south when my BP shot up and could not be lowered by meds and my baby seemed in distress, and during which my blood volume was too low to do the C-section that was needed. I ended up 10 centimeters dilated and my condition was stabilized enough that they literally ran to the OR and delivered my baby within minutes.
I only had the epidural, was awake during the C-section and had my little guy placed on top of me right away and even called him by the nickname I had used during pregnancy. I did need transfusions afterward and my recovery was difficult but the epidural during the crisis and birth made it bearable.
The bottom line--there is no uniform right or wrong in all of this. Would I have liked to have had a calmer birth? Sure. But the stress wore off and I certainly bonded with my child. Some of these hard and fast rules are part ideology.
I only had the epidural, was awake during the C-section and had my little guy placed on top of me right away and even called him by the nickname I had used during pregnancy. I did need transfusions afterward and my recovery was difficult but the epidural during the crisis and birth made it bearable.
The bottom line--there is no uniform right or wrong in all of this. Would I have liked to have had a calmer birth? Sure. But the stress wore off and I certainly bonded with my child. Some of these hard and fast rules are part ideology.
1
So sorry you had a bad experience. However, why? Because not being in pain is better than being in pain. And a beautiful healthy baby to boot.
We'll know that homebirth is safe when neonatologists start recommending it.
10
They never will. There is no money in it for them.
4
When I was a licensed practicing midwife, I delivered babies at home for several NICU nurses & NICU respiratory therapists from both Women's Hospital and Tampa General.. and I considered that the highest compliment. They certainly, more than many people, know risks vs. benefits. That the nurses at Women's Hospital (many years ago - it may be better by now) would not give birth at the hospital they worked at, told me everything I needed to know about the quality of care they expected to receive.
11
Neonatologists have other worries these days. One that I know, talking about the difficult cases he's handed, says "What used to be a miscarriage-- now it's my patient! And every parent wants a perfect outcome or they sue."
9
My daughter was born with a midwife in a birthing center just adjacent to a full-service hospital. We were out of hospital but moments away from Ob care and an OR if needed. It wasn't but this was an ideal plan for us.
Midwifery and Obstetrics can collaborate successfully.
Midwifery and Obstetrics can collaborate successfully.
11
Thinking about risk means considering both the probability that something will go wrong, and how bad things could get if they do go wrong. Sometimes births do go horribly badly for mother and baby. I want to be in a hospital for that reason, even if I expect everything will be fine. The phrase "died in childbirth" used to be much more common for a reason.
9
If a couple plans a home birth and antenatal care reveals no significant problems that increase the risk, then they still can go to the hospital generally if things turn sour.
So, the actually morbidity and mortality statistics may become biased in favor of home births unless an "intent to treat" analysis is done in addition to an actual outcome analysis.
I wonder if the calculated mortality rates for home and hospital delivery take this into account.
Stephen Rinsler, MD
(Retired pediatrician)
So, the actually morbidity and mortality statistics may become biased in favor of home births unless an "intent to treat" analysis is done in addition to an actual outcome analysis.
I wonder if the calculated mortality rates for home and hospital delivery take this into account.
Stephen Rinsler, MD
(Retired pediatrician)
6
Can you please say more about this for those outside the medical and statistics fields?
The Oregon study attempts to address this to some degree. Recommend taking a look at the actual numbers and avoid the "spin" put on it by many.
3
Women who are healthy and likely to have uneventful pregnancies are the ones most likely to seek and go through with homebirths whereas those who are high-risk for whatever reasons (older, multiple medical problems, baby with health problems as predetermined by ultrasound or other testing, etc.) are less likely to choose and undergo homebirth. Also, responsible and experienced midwives or other professionals would likely steer them away from homebirths if they feel it would be unsafe for the mother/ child. Thus, better outcomes from home births might be a function of healthier women and babies to begin with. Alternatively, those women and babies with risks might be overwhelmingly directed/ choose to have hospital-based births.
Consequently, unless these factors are adjusted for, the deck is already stacked beforehand and conclusions might be skewed. It's like comparing college grades between someone who has completed high school vs. someone who did not (if colleges admitted such people). Would it be a surprise if the former did much better?
Consequently, unless these factors are adjusted for, the deck is already stacked beforehand and conclusions might be skewed. It's like comparing college grades between someone who has completed high school vs. someone who did not (if colleges admitted such people). Would it be a surprise if the former did much better?
While I fundamentally respect a mother's right to decide what happens with her body among safe options (which is complicated to define), I have always found the emphasis on the birth experience itself both mystifying and frustrating. In most cases, it is the least important part of having a child. The real work has only just begun.
18
Have you ever seen a completely calm newborn who stares into your eyes with absolute wonder? I do think my children benefited from their peaceful, quiet, low-lit, low-stress home births.
5
Trilby, I had an emergency C-section after a horrendous labor during which I almost stroked. Guess what? I was awake during the section and my baby was placed on top of me and looked into my eyes, once they were assured he was OK. I even called him the nickname I had during my pregnancy and, for the life of me, it sure seemed he recognized it. I loved him then, I love him now, and it sure seemed like he felt loved and recognized from the get go....
2
Yes, my first child did. After an emergency csection where he and I almost died, and where the nurse practitioner saved his life by resuscitating him while I was unconscious. After I woke up from the anesthesia they put him right in my arms and he was just the way you described, that is, as I was breastfeeding him as well. I guess we could have had a natural birth and my husband could have planned two funerals instead, though.
1
As an OB/GYN, in the past, I supported women having choices. However, my position has changed. I simply do not feel an informed discussion is being had with the women who choose homebirth. First of all, the provider/midwife is not subject to regulations or in the event of bad outcomes, no entity will necessarily reevaluate the credentials or practices of this provider. The reality is, there are aspects of labor which are unforeseen, even in the hospital setting, and potentially disastrous, even in low risk pregnancies. If you choose a homebirth, are you willing to accept that possibility? Are you even being told of this potential? This discussion is not alarmist, it is reality. That said, I have two patients in labor, the infant and mom. When I tell a mom her infant has no heartbeat, when her provider has not listened in the past 4 hours, it is heartwrenching. Chances are even with proper intermittent monitoring IN the hospital, this infant could have been saved. It only takes one case for me, I do not need to hear the stats or anti hospital rants. Forever, I will be guided by the infant, and mother who needs immediate attention. There ARE hospitals with sound midwives, doctors and nurses, who will respect all patient's wishes. May those who opt for homebirth, know all the risks, research their providers and make a real informed choice.
17
In that instance, it's malpractice on the part of the midwife. My midwife did frequent fetal monitoring all through both of my homebirths. She also carried pitocin in case of bleeding, oxygen, etc.
2
Dear Sheeba:
With respect, as a member of the medical establishment the paternalism inherent in your belief that women shouldn't have choices regarding where they give birth (and by extension the protocols they and their babies are subjected to during the birth process), is part of the reason that home birth is increasingly appealing to many women, myself included. I agree with you wholeheartedly that home birth providers should be subject to better education/training, licensing and practice standards to ensure that everyone who chooses home birth is attended by a competent attendant who is accountable for the care they provide. But rather than attempting to marginalize women who choose home birth and the providers who attend them, I think that the medical establishment (in the U.S. in particular) needs to accept that home birth is here to stay and direct efforts to improve safety toward better integration of home birth into our medical system. As a well-educated, practicing attorney and two-time home birthing mother, I can tell you unequivocally that the fact that I was choosing an option with overall higher risk as compared with hospital birth did not escape my notice. My midwives and I had many discussions about risk, informed consent and the pros and cons of many aspects of my care that I believe far exceeded the type of information my friends who were planning typical hospital births received from their OB/GYNs.
With respect, as a member of the medical establishment the paternalism inherent in your belief that women shouldn't have choices regarding where they give birth (and by extension the protocols they and their babies are subjected to during the birth process), is part of the reason that home birth is increasingly appealing to many women, myself included. I agree with you wholeheartedly that home birth providers should be subject to better education/training, licensing and practice standards to ensure that everyone who chooses home birth is attended by a competent attendant who is accountable for the care they provide. But rather than attempting to marginalize women who choose home birth and the providers who attend them, I think that the medical establishment (in the U.S. in particular) needs to accept that home birth is here to stay and direct efforts to improve safety toward better integration of home birth into our medical system. As a well-educated, practicing attorney and two-time home birthing mother, I can tell you unequivocally that the fact that I was choosing an option with overall higher risk as compared with hospital birth did not escape my notice. My midwives and I had many discussions about risk, informed consent and the pros and cons of many aspects of my care that I believe far exceeded the type of information my friends who were planning typical hospital births received from their OB/GYNs.
9
I am not saying women should not have choices. I feel not all women are being well informed of the choice they are making. If you know the risks and are willing to accept them, then as a grown adult, proceed at your own risk. Keep in mind, your background may have helped you into making the choice that you did and asking the poignant questions. As a physician, if a bad outcome occurs, there are consequences, a state entity exists to monitor providers. With a homebirth provider, this monitoring does not exist. Should it not be so? Why should that provider be treated any differently? There is no paternalism in my held beliefs. If you have seen and managed the bad outcomes, more than once, over 20 years, you too may lean towards what is best for patient safety.
2
As America's closest neighbour, here is a perspective from Canada, which offers free care by midwives in several provinces. The program replaces care by a regular physician.
My wife has had 3 babies at home (in British Columbia), attended by at least 2 licensed midwives (one for my wife, and one as backup for the baby), and for our last birth, a doula and trainee midwife as well. It was a much less stressful experience than a hospital would have been. She delivered the babies in a children's pool in our living room (more relaxing and therefore less painful), in less than 3 hours -- the fear, and traumatic transfer to a hospital would likely have caused a much longer labor. No pain medications were administered, although the midwives can administer them if requested.
The births were not free of complications. Our first birth, my wife became dehydrated and the midwife hooked up a saline drip. The baby came out blue -- the midwife administered oxygen and our girl is now a healthy 3 year old! Our 2nd birth involved a hemorrhage, which the midwife competently handled and my wife recovered within a couple weeks. She also stitched up any tears so there was no need for any follow-up hospital visit. The first few weeks of followups happened at home -- much easier than having to travel to a hospital for a checkup! Things like initial nursing advice the midwife helped with.
Midwives here go through a 4 year program, including on site training. This training is highly specialized.
My wife has had 3 babies at home (in British Columbia), attended by at least 2 licensed midwives (one for my wife, and one as backup for the baby), and for our last birth, a doula and trainee midwife as well. It was a much less stressful experience than a hospital would have been. She delivered the babies in a children's pool in our living room (more relaxing and therefore less painful), in less than 3 hours -- the fear, and traumatic transfer to a hospital would likely have caused a much longer labor. No pain medications were administered, although the midwives can administer them if requested.
The births were not free of complications. Our first birth, my wife became dehydrated and the midwife hooked up a saline drip. The baby came out blue -- the midwife administered oxygen and our girl is now a healthy 3 year old! Our 2nd birth involved a hemorrhage, which the midwife competently handled and my wife recovered within a couple weeks. She also stitched up any tears so there was no need for any follow-up hospital visit. The first few weeks of followups happened at home -- much easier than having to travel to a hospital for a checkup! Things like initial nursing advice the midwife helped with.
Midwives here go through a 4 year program, including on site training. This training is highly specialized.
19
We don't have specialized midwife training in the states. Literally anyone can be a midwife. Until such a time when they are actually trained and certified no one should rely one one. Also, we are a litigious society, when something goes wrong, and it will, who will be sued? Do the midwives have malpractice insurance?
Mark, please google "licensed midwife". It varies by state, but in most of the USA it is completely false that anyone can just decide to practice midwifery with no training, credentials, or licensing.
And yes, they usually do carry malpractice insurance.
And yes, they usually do carry malpractice insurance.
4
This is completely untrue and misleading.
Certified nurse-midwives (CNMs) are highly-trained and licensed advanced practice registered nurses. This pathway requires at least 6 years of undergraduate and graduate education (4 years for the bachelor of science in nursing, 2 years for the master's degree in nursing with a specialty in midwifery), as well as many hours of supervised clinical experience. CNMs must pass a national certifying exam.
See the following for more information:
https://en.wikipedia.org/wiki/Certified_nurse_midwife
Here's a description of the midwifery program at UCSF, one of the finest health care graduate schools in the country:
http://nursing.ucsf.edu/programs/specialties/nurse-midwifery-womens-heal...
Certified nurse-midwives (CNMs) are highly-trained and licensed advanced practice registered nurses. This pathway requires at least 6 years of undergraduate and graduate education (4 years for the bachelor of science in nursing, 2 years for the master's degree in nursing with a specialty in midwifery), as well as many hours of supervised clinical experience. CNMs must pass a national certifying exam.
See the following for more information:
https://en.wikipedia.org/wiki/Certified_nurse_midwife
Here's a description of the midwifery program at UCSF, one of the finest health care graduate schools in the country:
http://nursing.ucsf.edu/programs/specialties/nurse-midwifery-womens-heal...
4
The vast majority of births occur in hospitals, which is why there are so many commenters whose births would have been problematic had them been at home, and they are glad to have been at a hospital. That's called "anecdotal fear." However, as one commenter pointed out, the Oregon study showed an increase of risk for home births from 2/thousand to 4/thousand. In other words, negligible for those who see value in home birthing. Please consider the significant downside of hospital births from my experience:
While my wife was in labor at a NYC hospital, I was mostly stuck in the hallway arguing with various doctors who demanded we have a c-section. At one point a doctor said, "Are you willing to risk your wife's life to avoid a c-section?" The happy news is that, other than a prolonged labor, my child's birth went fine -- WITHOUT the c-section! No complications.
Hospitals are kind of like the military: They have a lot of sophisticated equipment that costs billions of dollars, and they want to play with it whenever possible. Just having all those toys (and medications) at hand greatly increases the likelihood of using them.
We have cultivated a fear-based society in the U.S. in which we are afraid the bogeyman is hiding behind every corner waiting to leap out and get us. The fact that The Netherlands has 50% of births at home with no increased risk is the kind of rational evidence one needs to know what is best for their family.
FEAR = False Evidence Appearing Real
While my wife was in labor at a NYC hospital, I was mostly stuck in the hallway arguing with various doctors who demanded we have a c-section. At one point a doctor said, "Are you willing to risk your wife's life to avoid a c-section?" The happy news is that, other than a prolonged labor, my child's birth went fine -- WITHOUT the c-section! No complications.
Hospitals are kind of like the military: They have a lot of sophisticated equipment that costs billions of dollars, and they want to play with it whenever possible. Just having all those toys (and medications) at hand greatly increases the likelihood of using them.
We have cultivated a fear-based society in the U.S. in which we are afraid the bogeyman is hiding behind every corner waiting to leap out and get us. The fact that The Netherlands has 50% of births at home with no increased risk is the kind of rational evidence one needs to know what is best for their family.
FEAR = False Evidence Appearing Real
46
I agree with you that doctors are likelier to recommend a C-section than may be strictly necessary. But if the doctor didn't push hard enough and you went the natural birth route and there was a problem -- what then?
The doctors are trying to minimize the risk. When my sister gave birth, they said they could try to do natural birth but the baby's heart rate was stressed and it might be more prudent to do a C-section rather than attempt natural and rush into a C-section if necessary. I think you could view that both ways depending on your viewpoint. That sounds to me like minimizing risk -- it probably sounds to you like they wanted to do the more dangerous operation so they could "play with their toys".
The doctors are trying to minimize the risk. When my sister gave birth, they said they could try to do natural birth but the baby's heart rate was stressed and it might be more prudent to do a C-section rather than attempt natural and rush into a C-section if necessary. I think you could view that both ways depending on your viewpoint. That sounds to me like minimizing risk -- it probably sounds to you like they wanted to do the more dangerous operation so they could "play with their toys".
Doubling the risk of death is not negligible! 1 in 256 babies die at home. Keep in mind, this is a low risk population. The higher risk hospital patients, preemies, moms with comorbidities have a 1 in 555 chance of death. In what world is doubling the risk of death in a healthier population okay?
1
Agree! I secretly roll my eyes when people say "Oh well it would have been great to have a homebirth but thank god we were in the hospital because....." the baby's heart rate spiked, or i needed to be induced, or the baby took in a touch of fluid, or labor was going on too long.... Its like, really? I think these incidences are highly correlated with the fact that you went there in the first place and let them start over-monitoring you like crazy. Its not good for babies either - they end up exposed to antibiotics, in stressful birth situations, exposed on the examination table, and worst of all - sometimes separated from the mother. Low risk with a well-trained (masters-level in nursing) midwife, and eliminating fear from the labor process will result in completely safe home births. And the parents can be lounging in their bed and skyping with their family within the hour! Our midwife even started a load of wash and then left.
3
As an Anesthesiologist who has attended well over 3,000 deliveries of all sorts, my bias is to see women have a safe birth. Midwives attending home birth need to be licensed and 100% responsible from a both professional credentialing and financial standpoint for any mishaps. The pregnant woman should have an assigned Obstetrician who will be responsible if things should go awry, and who should meet and know the woman beforehand. No more laboring women coming for life-saving help after waiting too long at home with an overly- aggressive midwife. Above all, do no harm.
12
I always nod politely when someone mentions having a home birth. The reality is, I think it's nuts. I had a perfectly "normal" pregnancy with zero complications. After delivering a healthy baby, the medical staff attempted to staunch heavy bleeding, after they were unable to remove the placenta from my uterus. For 30 agonizing minutes (I was awake because I had a C-section- which was fortunate, because they were able to see what was happening), they attempted transfusions and manual removal. It was futile. I ended up having an emergency hysterectomy and was later diagnosed with having placenta accreta. Had I chosen to have a home birth, I most certainly would have died, with no access to a blood supply or immediate surgical intervention.
11
Even when all systems are dilated and ready to go, there's no way of telling if you'll have a problem birth. My son's was a problem, and thankfully we were in the hospital. We opted for a midwife when a nurse told us that my wife's OBGYN was known for inducing labor on Fridays to get to his country house for the weekend. The midwife gave us the home birth option. Instinctively we opted for the maternity ward. On the slim chance that anything went wrong, we'd rather be in a hospital.
As it turned out, something did go wrong. My son descended into the birth canal only to get stuck. His heart rate fell precipitously. The midwife stepped aside and the on-duty physician took over. It was touch and go - he was too far down the canal for a C-section. Instead, we had a horrendous forceps birth, with the force of the doctor's pulling literally moving the delivery table. I thought for sure my son's head would come off.
Thankfully, he was arrived healthy. This kind of intervention would not have been possible at home -- an ambulance would not have arrived quickly enough. It turns out one of my son's arms had been twisted over his head and his elbow was jammed sideways into the birth canal, wedging him in. No way to predict that.
I recommend the safe route. I shudder to think what would have happened with a home birth.
As it turned out, something did go wrong. My son descended into the birth canal only to get stuck. His heart rate fell precipitously. The midwife stepped aside and the on-duty physician took over. It was touch and go - he was too far down the canal for a C-section. Instead, we had a horrendous forceps birth, with the force of the doctor's pulling literally moving the delivery table. I thought for sure my son's head would come off.
Thankfully, he was arrived healthy. This kind of intervention would not have been possible at home -- an ambulance would not have arrived quickly enough. It turns out one of my son's arms had been twisted over his head and his elbow was jammed sideways into the birth canal, wedging him in. No way to predict that.
I recommend the safe route. I shudder to think what would have happened with a home birth.
12
We had planned a NJ hospital birth. My son had other plans. I had a home birth, at the front door with the car running. My mother caught while I was supported by my partner. I was extremely lucky. My doctor did not force me to go to the hospital, she came to my house! It was a wonderful experience that I shared with my own mother who was the first to hold her grandson.
I can't say a home birth is for everyone but more importantly, hospitals should stop harassing women in labor. While still pregnant, we "toured" the hospital maternity ward. There I was instructed on three procedures they would do prior to calling my doctor. My sister's two hospital births ended in cesarean sections after complete harassment by the nurses and doctors.
I can't say a home birth is for everyone but more importantly, hospitals should stop harassing women in labor. While still pregnant, we "toured" the hospital maternity ward. There I was instructed on three procedures they would do prior to calling my doctor. My sister's two hospital births ended in cesarean sections after complete harassment by the nurses and doctors.
8
Do you think the 'harassment' was because they were maybe worried about the baby?
1
What would the baby vote for!!!! I have had personal and observational experiences which given me this simple answer for home births vs hospitals. Enough of this selfish crap about what is best for the family. Have your warm and fuzzy feelings when you get back home. Get that human being out of the womb with as much help and technology as you possibly can.
8
The baby would undoubtedly vote for being immediately placed on its mother and remain there, with its cord intact, for as long as possible.
In which scenario is that most likely?
In which scenario is that most likely?
9
The baby would vote for getting out of the womb as safely as possible (no nuances, here) and when out, be in an place where all up to date technology was there to save him/her in case of any abnormality. There is no proof that the after birth scenario you show has any effect other than to give the mother comfort. Better the baby come out alive and well.
2
That's nice and all but for the baby to have it done, he/she needs to get safely out of the birth canal first.
1
I work in OB. When things go wrong they usually go very very wrong and it can happen very quickly. I don't know why anyone would want to take even a small chance that their baby would have a bad outcome because of a home birth. There are obstetricians out there who are willing to work with women who want very low intervention births and then there are others who have very high c-section rates. You have to do your research and find an OB you are comfortable with and who is willing to work with your birth plan as long as you and your baby are not in danger.
17
I can't believe someone is actually vying that midwifery lobbyists are the cause of an upswing in home births. I live in New York City and I have never once encountered midwifery lobbyists or anyone recommending me to them, but I have had two home births here-- why? Because I wanted it and had to seek it out myself. For the millions of people in this city, there are only a handful of homebirth midwives. And the statistics in this article proclaiming death is more likely at home--where does this come from? From what I understand, they include in those statistics every single child born outside of the hospital, not discriminating between say a homeless woman on the street and a woman who has planned her homebirth. My first birth required some intervention because I hemorrhaged from what I understand--quite dangerously--but my midwife was fully prepared, and I did not need to go to a hospital. Midwives also carry oxygen, they have pitocin with them to counteract hemorrhages, they stitch up expertly, and primarily--they do not interfere unless absolutely necessary. I would rather no articles at all be written about home birth than these skewed perspectives--at best, the home birth community can continue unperturbed, at peace, so as to be available to informed women, but at worst--the medical community will prevent and hinder all licensed midwives from their practice, cutting into the possibility of insurance coverage, among other things.
13
We just had our second baby in a hospital in London 2 weeks ago. It was actually fine and my wife used a birthing pool to give birth to our healthy daughter without any medication or interventions at all. That said, they did try to induce her a few days earlier once she hit the due date as apparently the baby "wasnt growing" (based on a cursory estimate with a tape measure) and was "moving less" (even though my wife - and the midwife in fact - had no real idea what that meant). Since the baby's movements do often change in the last few days of pregnancy, I suggested we give it a little more time to see if the baby would come naturally (which my wife agreed with). And I'm so glad we did. After our first baby was induced on the encouragement of the midwives/nurses in Sydney (where he was born), he ended up in ICU for over a week dealing with jaundice and other problems that admittedly may not have had anything to do with the induction (but happened nonetheless). No such problems this time and just a much more pleasant experience all round. I think it is often harder to do a "natural" birth the first time because of the mom's lack of experience (and consequent vulnerability to hospital-encouraged interventions which make labor quicker and hence midwives'/doctors' lives easier, and not to mention more profitable though not such an issue in Europe) but the second time, third time etc she may have more confidence to resist the "intervention culture".
4
Thank you for this more balanced discussion. While the risk of infant death (although not fetal) was significantly different, that is significant using the scientific definition of that word. Here is an excerpt of the actual study: "Here is the actual reporting of results in the study: "The rate of fetal death did not differ significantly between groups before reclassification (1.3 per 1000 deliveries among in-hospital births vs. 0.6 deaths per 1000 deliveries among out-of-hospital births, P=0.30). After hospital transfers were reclassified as belonging to the planned out-of-hospital birth category, the rate of fetal death was higher (though not quite reaching the level of significance) among out-of-hospital births than among in-hospital births (2.4 vs. 1.2 deaths per 1000 deliveries, P=0.05) . . . Similarly, rates of perinatal and neonatal death did not differ significantly before transfers were reclassified (P>0.1 for all comparisons) but were higher in the case of planned out-of-hospital births than in the case of planned in-hospital"
This debate often makes women the scapegoats. In fact, it is the medical profession that is failing (both midwives and hospitals). The choice shouldn't be, reduced the risk to baby v. risk to mother. An option that protects both is needed. Transfers need to be improved. Midwifery needs to be recognized as a legitimate choice that should be supported for women who want that route.
This debate often makes women the scapegoats. In fact, it is the medical profession that is failing (both midwives and hospitals). The choice shouldn't be, reduced the risk to baby v. risk to mother. An option that protects both is needed. Transfers need to be improved. Midwifery needs to be recognized as a legitimate choice that should be supported for women who want that route.
16
As an OB/GYN, I believe I have some perspectives. Mid-wives are wonderful option for low risk pregnancies where women want the opportunity to have a low intervention delivery. The idea of home birth however is a complete anathema to me. I have taken care of 5 women in the last 3 years who have labored at home under the care of an aggressive midwife (some not formally trained) who have had either their babies die or be born with significant neurologic defect, including one women who labored at home and almost bled to death in the hospital from a protracted labor. In 1900, the mortality for a women in labor was 25%, not complications, actual death. Human physiology has not evolved to allow for easy gestation and the evolution of obstetrics as a speciality has decreased maternal and fetal mortality 1000-fold. Anything can happen in labor- bleeding, fetal distress, seizures and being in a hospital can allow for interventions to save both mom and baby's life. Why anyone would take a risk with this is beyond me and is tantamount to neglect/child abuse. The consequences for a complication (permanent neurologic disability) are too great. By all means use mid-wives and birth centers attached to hospitals- but please dont delivery at home. You risk far too much.
44
Thank you for excellently articulating the dangers inherent in authors viewpoint. Yes hoof sounds should be first related to horses than zebras, but the consequences of misinterpreting the hoof sounds should be taken into account as well. The impact of a mishandled home birth, which may be a low probability event is grave for mother and baby. As you have pointed out, birthing process is an inherently risky even due to human physiology, and unless we are comfortable with a high maternal mortality rate and life long damage for the child, in our pursuit of reducing hospital bills, homebirths should be strictly discouraged.
6
What would the baby vote for?!!
1
The maternal mortality rate was most certainly not 25% in 1900. It was less than 1%, and most deaths were due to postpartum infections caused by poor sanitation which would have been treated with antibiotics.
6
I have responded to many home births gone a wry in my years as a paramedic. Some babies made it and all was well and some did not. Five or six minutes without oxygen is a long time and that is about the average response time for an ambulance.
Fast forward a number of years and I was having my own child. I developed HELLP syndrome. I am lucky to be alive and very lucky my daughter survived. Had we stayed home we would surely have perished. Things can go bad in an instant. Better safe than sorry.
Fast forward a number of years and I was having my own child. I developed HELLP syndrome. I am lucky to be alive and very lucky my daughter survived. Had we stayed home we would surely have perished. Things can go bad in an instant. Better safe than sorry.
10
Any good midwife has both oxygen and an ambu bag, and knows how to use them.
3
Midwives carry oxegyn, so you must not have been responding to planned homebirths.
5
You need a lot more than oxygen if you have a truly distressed infant. You need to be able to do a true resuscitation, which is complex and should not be done in the home. Your responses, oxygen, and Phil's (ambu bag) just show that you have zero idea about what happens when in newborn is in severe distress.
4
I'll save other people from having to read all these comments, and summarize:
"My sister-in-law/neighbor/self had a scary birth- I shudder to think what would have happened had we not been in the hospital!"
Or- "someone I know had a complicated home birth and their baby was injured- only a selfish idiot would ever consider birthing outside the hospital"
"My sister-in-law/neighbor/self had a scary birth- I shudder to think what would have happened had we not been in the hospital!"
Or- "someone I know had a complicated home birth and their baby was injured- only a selfish idiot would ever consider birthing outside the hospital"
17
Balanced by the medicine haters who call women who have epidurals selfish and women with induced labor sheep.... six of one, half a dozen of the other.
4
Let me make it simple for you. When deciding on taking a course of action, do not be fooled by low probability of failure, multiply the probability of failure with the impact of failure. In case of event as serious as childbirth, the consequences of failure are make homebirth an unwise choice, especially, when the most advanced care is available to almost everyone in this country.
9
Don't forget the all-knowing doubters with their retrospectoscopes:
"That life-threatening complication you described was not really a big deal. The doctors just made a big fuss to upset you/trick you into a c-section/get to the golf course faster/make more money. Homebirth midwives deal with hemorrhages/hypoxia/infection/seizures all the time -- no problem!"
"That life-threatening complication you described was not really a big deal. The doctors just made a big fuss to upset you/trick you into a c-section/get to the golf course faster/make more money. Homebirth midwives deal with hemorrhages/hypoxia/infection/seizures all the time -- no problem!"
5
Well, the home birth haters are out in droves as usual. I hate to tell you folks, that cord around the babies neck? Very common, and only rarely serious. Any midwife can deal with it. Except the doctors made a big deal out of it, and scared you.
Fluid broke and you didn't go into labor right away? Not a big deal unless you get a fever. Mine broke two days before I went into labor and had a home birth.
If the rate of mortality in a home birth in 1 out of 250 children, that is safer than almost any activity in life, certainly including crossing the street, driving a car, living in certain neighborhoods....
I am curious about one aspect of these differing mortality statistics. Is some of the statistical difference due to babies with birth defects, diseases etc needing extended ICU or extended lifetime care? If so, I don't call that much of a victory. Please don't take offense if you are the mother of a severely handicapped child - but most parents would not take it on willingly, or a severe premie if they knew the difficulties that followed - not the least of which in this country - are financial.
Fluid broke and you didn't go into labor right away? Not a big deal unless you get a fever. Mine broke two days before I went into labor and had a home birth.
If the rate of mortality in a home birth in 1 out of 250 children, that is safer than almost any activity in life, certainly including crossing the street, driving a car, living in certain neighborhoods....
I am curious about one aspect of these differing mortality statistics. Is some of the statistical difference due to babies with birth defects, diseases etc needing extended ICU or extended lifetime care? If so, I don't call that much of a victory. Please don't take offense if you are the mother of a severely handicapped child - but most parents would not take it on willingly, or a severe premie if they knew the difficulties that followed - not the least of which in this country - are financial.
4
Sure, feel free to go to the days of Midwives, with high maternal mortality, and life long consequences for babies. This zeal for reducing healthcare expenditure is promoting dangerously underqualified professionals like Midwives, nurse practioners, and their ilk.
4
1 out of 250, you say? Prove it.
1
Amazingly little information about which period of time you are referring to. What studies are you using? What were the causes of maternal mortality? Without information you sound kind of hysterrical.
4
The best of both worlds. My friend had her baby in a motor home, parked in the hospital parking lot.
9
Babies more likely to die! What about the mother? You'd be crazy to return to the days of high maternal mortality for some fuzzy fantasy. Do the smart thing; if your midwife won't or can't deliver where they have staff who can save your life, find a better one. My female ob/gyn (2nd child) was just as good and caring as my in-hospital midwife (1st child).
5
Please note; the study compared planned home births to hospital births. It did not compare licensed midwife-attended home births to hospital births. That's a big difference. I am a former midwife; it has been years since I practiced; but a majority of our training focused on prenatal care, and screening for risks. At the time that I trained in the 1980s, I really wanted to train in yhr Netherlands, which at the time had the lowest infant mortality rate in the world for births, but they were not accepting non-Dutch students at that time. Holland still outranks the US for having better infant mortality outcomes, but about 1/3 of their births are home deliveries, attended by highly-trained midwives. See http://www.bbc.com/news/health-22888411
12
The training of midwives in the US is different than other developed countries. We have CNM's: Certified Nurse Midwives with University education/degrees and a wealth of training and we have CPM's: Certified Professional Midwives who are not required to have ANY education (maybe a correspondence course) and clinical training with another (perhaps unlicensed) CPM. If this study is based on the Oregon statistics, this is a state which has no licensing requirements for midwives, anyone can call themselves a midwife and deliver babies. This is the outcomes you get. That is one reason other countries have better outcomes for home birth.
3
I was not enthusiastic about giving birth in a hospital, just because of the risk of unnecessary interventions. However, I live more than an hour away from a hospital with a labor and delivery ward or a NICU, so home birth just wasn't a viable option for me. Unfortunately, the birthing center in Austin refused to take me as a patient, despite my totally normal pregnancy, just because my work schedule had me traveling while I was pregnant. It seems like birthing centers are only an option for high-income women who don't need to work, or have jobs with generous maternity leave policies. For the self-employed mother who can't possibly stop working without plunging her family into real poverty, birthing centers are an inaccessible luxury. So my only choices were a hospital birth or a really dangerous home birth. I choose the hospital birth, and all my worst fears came to pass. Doctors decided I needed to be induced six weeks before my daughter's due date because they suspected IUGR (which turned out to be false). I spent six days enduring every single induction procedure there is, except stripping the membrane, which I vetoed over strenuous objections from the doctors. After day two I had to fight off a c-section, even though I was on constant monitors, and neither me or my child were ever in distress for second. It was basically a nightmare. To top it all off, I've now got 10K or hospital bills in collections that I can't possibly hope to pay.
18
Please note that the Snowden et al article which compared risks was not an "apples to apples" comparison. For births intended to occur outside the hospital, both those that actually occurred at the intended site and those that did not were included in the risk calculation. For intended hospital births, only those that actually occurred in the hospital were included. Also, the public is misled when accredited birth centers are lumped with other sites.
3
For a woman in her childbearing years, I cannot think of an experience that could be more intimate, personally spiritual or carry more gravity, than that of giving birth. Expectant parent(s) fervent desire is the birth of a healthy baby that will live a long and happy life. Where the baby makes this journey, is a most personal decision that only the parent(s) can make. No matter what is decided, it is made after (hopefully) deeply careful consideration. It is imperative that parent(s) feel safe and secure in their decision.
Women have been giving birth since the dawn of humanity. It is a natural process. Most babies will survive their births, some will not, that is the law of nature.
Our four children were born at home, in the 70's and 80's, with "lay" midwives attending. (In our state "lay" midwives are now licensed Certified Professional Midwives.) My prenatal care was three pronged, involving my family practice MD, my very experienced midwives and a great deal of research and self education on my part. Were a transfer to the hospital to be required, my MD agreed to be our "back-up". All births were uneventful and beautiful.
I now work in healthcare. I flinch at the term, "failed" home birth. A transfer to hospital care from home is the result of a knowledgeable decision on the part of the midwives and parents, not a failure.
Thank you, Dr. Carroll for your respect for, and recognition of, the value of alternatives and integrative care, in childbirth.
Women have been giving birth since the dawn of humanity. It is a natural process. Most babies will survive their births, some will not, that is the law of nature.
Our four children were born at home, in the 70's and 80's, with "lay" midwives attending. (In our state "lay" midwives are now licensed Certified Professional Midwives.) My prenatal care was three pronged, involving my family practice MD, my very experienced midwives and a great deal of research and self education on my part. Were a transfer to the hospital to be required, my MD agreed to be our "back-up". All births were uneventful and beautiful.
I now work in healthcare. I flinch at the term, "failed" home birth. A transfer to hospital care from home is the result of a knowledgeable decision on the part of the midwives and parents, not a failure.
Thank you, Dr. Carroll for your respect for, and recognition of, the value of alternatives and integrative care, in childbirth.
14
I'm in my seventies, had two children, both at hospitals. In 1960, there was no such thing as a "home birth" or a certified midwife, or any midwife at all, except in the way way backwoods. My first child was born in a university hospital, where no one listened to me when I said I was in second-stage labor, though the OB knew my father was also an OB. My son was delivered by myself and a wonderful nurse, sans OB, sans drugs. Despite the frantic scene, it was an intensely satisfying experience, even though my husband was not allowed in the delivery room (and probably would not have come in if invited). Later that day, I began to bleed in a gush - I rang for a nurse. If I hadn't known what to do to stop the bleeding, I would have bled to death waiting for that nurse. I lived because my father had taught me something about childbirth. My second child was born in one of New York's finest hospitals and the OB was cold and uninterested, and again, paid no attention to me when I said I was going into the second stage of labor. When it was clear I was right, that crew anesthetized me and who knows how my child was delivered? It was not a happy experience, though I was a healthy, normal young woman with no problems during pregnancy. Today's choices are so much better. So, mothers, rejoice in the progress over the past 50 years! Enjoy the presence of your child's father and the fact that you can decide on so many levels how to shape the experience for your whole family.
16
What we don't understand in this country is that in the rest of the world, including the countries with the safest statistics re newborn mortality, birth is led by midwives. Doctors are always at the ready and work as partners, but obstetricians play a rarer role and most mothers don't see one. My personal experience is from the UK, and as an American, I was so glad to be over there! I had two children in London, 15 and 20 years ago. One in a hospital and the second one at home. As an older mother, I did have obstetric care although most of my prenatal care was midwife led. I had an excellent midwife who had seen me throughout my maternity care (most of my appointments were AT HOME!) so when my labor turned unproductive and I faced a c-section, she advocated for me. I trusted that this surgery was for the good of my child and me, not for the convenience of the doctor or hospital. For my second child I wanted to avoid a c-section. I felt this was probably more likely if I at least labored at home as long as possible. I had a midwife team with me, who consulted with the chief of obstetrics by phone as my labor progressed. In the end, I stayed there. The obstetrician ok'd me for a home birth, and so I stayed there. No way would this have happened in the US, where I certainly would have had another surgical birth. By the way, i didn't pay a dime under the UK's amazing National Health Service!
11
The home birth argument is multifaceted in our current health care environment. As a perinatologist- I look at this question from a completely clinical perspective. The fact that the risk of newborn death is higher in women who deliver at home, albeit a very small number (1.5 vs. 0.4/1000), is the fact that women need to make a decision regarding. The neonatal increase in risks for home birth are very similar to the risks that a woman takes by attempting vaginal birth after cesarean section (VBAC). Most practitioners agree that VBAC is reasonable thing especially in patients who have the best chance at success.
Early in my career - I couldn't understand why on earth any woman would consider home birth. Now, with the amount of data demonstrating planned home birth's relative safety and possible decrease in maternal harm -I feel that, in the right patient, with the right counseling and the right Plan B (i.e hospital close by) - home birth is a reasonable option.
Early in my career - I couldn't understand why on earth any woman would consider home birth. Now, with the amount of data demonstrating planned home birth's relative safety and possible decrease in maternal harm -I feel that, in the right patient, with the right counseling and the right Plan B (i.e hospital close by) - home birth is a reasonable option.
20
When I was a medical student, another phrase I learned was that obstetrics is 99% boredom and 1% panic. It makes little sense to me to subject a newborn to the risk of harm, even if it is low, because the price is ultimately paid by the child who must live with the consequences of the mother's choice.
6
My wife has delivered seven babies with minimal intervention - but always in a hospital. We were fortunate to have seven pregnancies with no complications but still preferred the safety of a hospital. My sister has delivered seven babies safely at home. So I am well acquainted with that viewpoint as well.
What I can't agree with in this article is that the NHS in Britain is being held up as a model to be followed. Five of our children were born in the US, one was born in Britain (at a birthing centre adjacent to the hospital) and the last one was born in Germany. The experience in Britain was by far the worst: starting with the pre-natal care all the way to the delivery. My suspicion is that the health services in Britain are encouraging home deliveries because their health system is in such disarray that keeping people out of the system improves the chances of a better outcome.
What I can't agree with in this article is that the NHS in Britain is being held up as a model to be followed. Five of our children were born in the US, one was born in Britain (at a birthing centre adjacent to the hospital) and the last one was born in Germany. The experience in Britain was by far the worst: starting with the pre-natal care all the way to the delivery. My suspicion is that the health services in Britain are encouraging home deliveries because their health system is in such disarray that keeping people out of the system improves the chances of a better outcome.
4
We hired a doula for my first labor and delivery, and planned to deliver at our local hospital. It was a good balance -- the doula provided the support I needed to have the low-intervention birth I was hoping for, but when our baby struggled to breathe after birth, a team of pediatricians appeared instantly to help him. Also, I tore fairly badly during delivery and needed to be sewn up right away. I was grateful for both the low-tech one-on-one attention of the doula during labor and the instant high-tech medical attention of the hospital staff at and after delivery. I think that providing laboring women with more options for in-hospital support, including trained doulas and midwives, would probably strike a much better and more cost-effective balance than asking them to choose between the benefits of one approach or the other.
5
I personally know six or more delightful healthy babies that were born at home in the last few years. My two children were born in a birthing center that offered water birth and we born in the water without complications.
Many people do this because they value the psychological benefits of a more gentle birth for the baby as well as the mom. This article only mentions the physical experience of birth. Birth also has a mental and spiritual dimension. If you are looking for a holistic approach, you probably will not find it in the regular hospital.
It seems the Oregon report is good and suggests that, like our friends up north, the US would benefit from better integration between midwives and hospital practices. For many years it has been an all out professional war between midwives and doctors. This turf battle is part of the reason home birth is not as safe as a hospital birth. If other countries can make this option safe, we can in the US as well.
Many people do this because they value the psychological benefits of a more gentle birth for the baby as well as the mom. This article only mentions the physical experience of birth. Birth also has a mental and spiritual dimension. If you are looking for a holistic approach, you probably will not find it in the regular hospital.
It seems the Oregon report is good and suggests that, like our friends up north, the US would benefit from better integration between midwives and hospital practices. For many years it has been an all out professional war between midwives and doctors. This turf battle is part of the reason home birth is not as safe as a hospital birth. If other countries can make this option safe, we can in the US as well.
8
I had my baby at home 25 years ago. What occurs to me, as I compare my experience to the many many other people I have known have babies, is how incredibly lucky I was to choose to work with a midwife. My midwives were nurse practitioners, with a full time practice, and the support of an OBGYN. What worked about the experience was that during my prenatal care, I was educated about pregnancy and babies. I see that experience is missing for a lot of new moms. Lots of the other new moms who were seeing the midwives ended up having their baby in a hospital, but still benefitted from all the attention and experience of the midwives and the community of mothers they created in their office every day. I had my baby at home. The labor was only five hours long and the midwives called it a "dutch birth" which means the baby came out on it's own - they just were there to catch it. I gave birth on all fours, and spent those five hours taking baths, swearing at my husband (and digging my finger nails into his palms ever five minutes or so) and pacing around the house. My next door neighbor was a fireman and had participated in way too many home birth emergencies, so he stocked up on an oxygen tank and put the squad on alert when labor started. Luckily, we didn't need it and I am also grateful for how my whole community supported me through my pregnancy - it was hard.
13
As an ICU nurse who is also part of the Code Blue team I can tell you that when a birth goes bad, SECONDS count. A happy experience can turn tragic in an instant and you have only minutes to save both mother and baby. Sadly, even a highly trained Code Blue team with years of experience handling such situations may lose one or both. Horribly horribly sad.
But we also rescue one or both, time and time again. Mothers and babies who absolutely positively would have died had we not been there to intervene.
Home births? Sure, they are often successful. But if there is any chance at all that they might not be, err on the side of safety. The ultimate goal is a safe birth for both Mom and baby. The "birth experience" is important but, IME, far less important and, when all is said and done, the risk is not worth it.
But we also rescue one or both, time and time again. Mothers and babies who absolutely positively would have died had we not been there to intervene.
Home births? Sure, they are often successful. But if there is any chance at all that they might not be, err on the side of safety. The ultimate goal is a safe birth for both Mom and baby. The "birth experience" is important but, IME, far less important and, when all is said and done, the risk is not worth it.
19
My children were born in the late 70s, when fathers weren't allowed in the delivery rooms and women had no say in any aspect of the highly medicalized birthing policies and procedures. They (we) were treated as though they were idiots if they expressed a wish for natural, or more natural, childbirth. It was dehumanizing. I lived in a rural area where home births and midwifery were beginning to be practiced and was lucky enough to find one doctor who was willing to attend a home birth, so I had a doctor and a nurse practitioner present for the birth of my first child at home. It wasn't perfect but it was better than the hospital option, and we were prepared for contingencies and the possibility of needing to go to a hospital. By the time my second child was due, the doctor had stopped attending home births on the orders of the local hospital. I went to the small town where my mother lived and where the one obstetrician, when presented with what I wanted (no medical "prepping", father present, going home the following day, no meds unless I said so, etc.), grinned and said, "I've never done that before - I'd love to!" This time, it WAS perfect. Things have changed a lot since then, but it's very interesting to me that this discussion continues to be, largely, "either/or", instead of a real effort to combine the best aspects of both kinds of birth settings.
11
I have experienced both hospital birth and home birth as the father of three children. Our first was born in the hospital. The care (At a very reputable hospital) wasn't bad, but it wasn't good either. It was very stressful and focused on procedures and streamlining the process for the staff. The focus was not on mom or the baby.
To my fellow posters, I respect your opinions, but you are quite ignorant about midwives. I have met many and I have found them to be quite simply amazing health care providers.
No one who supports home childbirth is asking that everyone be forced to have a home birth, only that they be allowed that right for those who choose that path. In the Bradley classes we took, the instructor talked rationally about the range of options and to know when switching to a hospital birth is the right thing to do.
Personally I found home birth in our own bed in a quiet room to be fantastic and would recommend it as an option to pregnant mothers who are in a low risk category and who would be more comfortable giving birth there.
To my fellow posters, I respect your opinions, but you are quite ignorant about midwives. I have met many and I have found them to be quite simply amazing health care providers.
No one who supports home childbirth is asking that everyone be forced to have a home birth, only that they be allowed that right for those who choose that path. In the Bradley classes we took, the instructor talked rationally about the range of options and to know when switching to a hospital birth is the right thing to do.
Personally I found home birth in our own bed in a quiet room to be fantastic and would recommend it as an option to pregnant mothers who are in a low risk category and who would be more comfortable giving birth there.
13
The safety of child trumps your sense of quiet and convenience.
3
So every pregnant woman should be forced to birth in a hospital with an OB and an epidural in case an immediate c-section is needed? Think about what you are advocating.
2
Why do those that dislike home birth think that you must be treated horribly at a hospital to have a safe birth? Could it be possible to be treated like a human being with choices and dignity and still have a safe birth? Not in most hospitals, so women are stuck with choosing dignity or safety. An easy choice for some, a very difficult choice for others.
1
Part of the issue here comes from women not speaking their minds and following their instinct. Both midwives and doctors can be "bullies", it's up to the patient to recognize that early in the pregnancy and switch practitioners.
When pregnant with my first child I asked my OB a laundry list of questions regarding her stand on planned inductions, C-sections etc. Her stance was that she and her partners didn't do "optional" inductions or C-sections. It wasn't a matter of convenience but of mom and baby health. That seemed like an eminently reasonable answer. When asked about "birth plans" she just smiled and said "you can plan all you want but I encourage you to be flexible bc babies tend to have their own plans and they don't usually mesh with yours." It's the patient's job to ask these questions. If you doctor or midwife isn't willing to answer them or you don't like the answers, CHANGE DOCTORS.
Fast forward several months and I had a medically necessary scheduled induction. Despite being in great shape, active, didn't gain too much weight etc I developed pre-eclampsia. Baby and I were both healthy. Because I had a good relationship with my dr, I trusted her when she said I needed to be induced asap. I doubt a midwife would have tried to deliver me at home but I definitely wouldn't have take the chance. Plus, the last thing I wanted to do after having either of my kids was to clean up the mess that having a baby makes. Thanks but I'm happy to leave that to the hospital.
When pregnant with my first child I asked my OB a laundry list of questions regarding her stand on planned inductions, C-sections etc. Her stance was that she and her partners didn't do "optional" inductions or C-sections. It wasn't a matter of convenience but of mom and baby health. That seemed like an eminently reasonable answer. When asked about "birth plans" she just smiled and said "you can plan all you want but I encourage you to be flexible bc babies tend to have their own plans and they don't usually mesh with yours." It's the patient's job to ask these questions. If you doctor or midwife isn't willing to answer them or you don't like the answers, CHANGE DOCTORS.
Fast forward several months and I had a medically necessary scheduled induction. Despite being in great shape, active, didn't gain too much weight etc I developed pre-eclampsia. Baby and I were both healthy. Because I had a good relationship with my dr, I trusted her when she said I needed to be induced asap. I doubt a midwife would have tried to deliver me at home but I definitely wouldn't have take the chance. Plus, the last thing I wanted to do after having either of my kids was to clean up the mess that having a baby makes. Thanks but I'm happy to leave that to the hospital.
4
LK, usually the midwife cleans up the mess as part of her services.
But it sounds as if you needed to deliver in the hospital, and I'm glad all turned out well for you.
But it sounds as if you needed to deliver in the hospital, and I'm glad all turned out well for you.
1
I also changed doctors during my first pregnancy. Not everyone has such an option. Many docs won't take on late transfers because it is believed we independently minded types carry a greater risk of lawsuits. As it turned out, my second care provider wasn't any better than the first. The second just knew how to tell me what I wanted to hear. When I went into labor, they changed their tune completely, which is not uncommon. (For example, see Marjorie Karmel's Thank You, Dr. Lamaze.) I ended up with an iatrogenic c-section and, as a direct result, complications for my daughter.
With respect to pre-eclampsia, most midwives focus pretty intensely on pro-active nutritional practices from the beginning of pregnancy or earlier. Many believe nutrition--especially taking in higher amounts of protein in early pregnancy--plays a role in preventing certain kinds of pre-eclampsia, among other complications. The importance of nutrition and other preventive practices are often overlooked in care models that rely on in-hospital technology as the primary fail-safe.
That said, you are absolutely correct that any midwife would have transferred you to obstetric care as soon as you began to show signs of pre-eclampsia. They look for signs at every prenatal visit, of course. They are well-educated, highly experienced professionals whose sole focus is the health of the mothers and babies under their care. And, happily, they don't leave parents of newborns to clean up after a birth.
With respect to pre-eclampsia, most midwives focus pretty intensely on pro-active nutritional practices from the beginning of pregnancy or earlier. Many believe nutrition--especially taking in higher amounts of protein in early pregnancy--plays a role in preventing certain kinds of pre-eclampsia, among other complications. The importance of nutrition and other preventive practices are often overlooked in care models that rely on in-hospital technology as the primary fail-safe.
That said, you are absolutely correct that any midwife would have transferred you to obstetric care as soon as you began to show signs of pre-eclampsia. They look for signs at every prenatal visit, of course. They are well-educated, highly experienced professionals whose sole focus is the health of the mothers and babies under their care. And, happily, they don't leave parents of newborns to clean up after a birth.
3
Fear not LK, the midwives clean everything up, do the newborn exam and even make you a cup of tea, if so desired!
I would think that mothers likely to choose a home birth would be those less likely to experience complications, no matter where they gave birth, which would have a tendency to make home birth look "safer" and less complication-prone.
If there IS an unexpected complication in a "low-risk" birth, I'd much rather it happen in a hospital.
If there IS an unexpected complication in a "low-risk" birth, I'd much rather it happen in a hospital.
5
It is important to keep up front the objective in all of this - getting a healthy undamaged baby and a healthy undamaged mommy. If you believe that some sort of joyous birthing experience is really important, try to keep in mind the primary objective. If you believe that doctors do too many operations just to generate income, I truly feel sorry for you.
3
Hospital control also carries risks of damage to mothers and babies. A hospital is far from a safe place.
2
The zeal for reducing healthcare expenditure is leading even rational people into dangerous territories. Rather, than cutting away the administrative and insurance bloat, and control criminal pharma sector, the focus is to replace professional care with decades of science behind it with quakery. The financial overlords will like to create a 2-tier system, with the ill-informed relegated to midwives/nurse practioners and their ilk, while keeping the fat cats happy.
2
You do realize that the US spends so much more money for pregnancy, labor and birth care and has some of the worst outcomes (dead and damaged babies) in the whole world. Your comment is very uninformed, we are not trying to cut costs at all in the US, yet we still have worse outcomes than most of the developed (and under developed) world.
1
"Recently, a new study comparing the safety of home or birth-center deliveries with hospital deliveries led to headlines proclaiming that babies not born in hospitals were significantly more likely to die. I have no trouble believing that’s the case."
Proclaiming??? Boy, talk about biased writing in this article.
Proclaiming??? Boy, talk about biased writing in this article.
1
The key isuse is not safer, it is safest. In this case, common sense suggests hospital delivery......
4
It's safer to never drive a car, take a plane or cross a street in NYC. Never leaving your house your entire life, ever, is probably the "safest" option. But it is not living.
3
If hospitals were more flexible about allowing natural birth and midwives to attend births and doctors were less eager to schedule births and intervene in them, people would be more inclined to consider hospital births and less inclined to choose home births.
21
Home birth is common, safe and integrated into the health system in the UK and the Netherlands. There is no reason it couldn't be for the majority of women in the US given the right safeguards, e.g proximity to a hospital.
But perhaps the US healthcare system is exceptional? It may well be with the push for profit, double the c-section rates as recommended, and the marginalization of midwifes.
Mother and baby come second.
But perhaps the US healthcare system is exceptional? It may well be with the push for profit, double the c-section rates as recommended, and the marginalization of midwifes.
Mother and baby come second.
11
Average UK or Dutch citizen is far healthier than average US citizen because of better dietary and exercise habits. Thus it is understandable that risks of home births will be lower in those countries. Wholesale lifting of one segment of healthcare from Europe, while ignoring the structural differences will be dangerous.
1
As a certified nurse midwife and experienced home birth attendant, I still feel that we may be ignoring some crucial aspects of the statistics that potentially create strong bias.
1) Not all midwifery education promotes or adheres to the same standard.
2) Experience and credentials might account for some of the differences in outcome between settings, or even between midwives in the same setting.
3) Perhaps most importantly, there are no standard practices for facilitating the transfer of care into a hospital setting. This lack may make the out of hospital options appear more dangerous than they would otherwise be in a less adversarial system of care.
I would welcome further research that examines outcomes, using basic risk screening as the starting point, and following through the path of care in a system designed to minimize the impact of hospital transfer.
1) Not all midwifery education promotes or adheres to the same standard.
2) Experience and credentials might account for some of the differences in outcome between settings, or even between midwives in the same setting.
3) Perhaps most importantly, there are no standard practices for facilitating the transfer of care into a hospital setting. This lack may make the out of hospital options appear more dangerous than they would otherwise be in a less adversarial system of care.
I would welcome further research that examines outcomes, using basic risk screening as the starting point, and following through the path of care in a system designed to minimize the impact of hospital transfer.
24
Perhaps you should conduct such a study. Please do!
But also please be careful of what perhaps sounds like a bias against CPMs. The CPMs I've worked with have been more medically-oriented than the CNMs. I myself prefer less intervention.
Which reminds me that communication about values between mother and provider might also contribute to the quality of outcome.
But also please be careful of what perhaps sounds like a bias against CPMs. The CPMs I've worked with have been more medically-oriented than the CNMs. I myself prefer less intervention.
Which reminds me that communication about values between mother and provider might also contribute to the quality of outcome.
1
Never mind the death rate: having grown up next to a cousin brain-damaged during a planned home delivery, I would be curious to see a comparison of non-fatal, but permanent, damages between home deliveries and hospital deliveries.
I delivered twice in hospital. Yes there were probably a couple of unnecessary procedures, yes it was less comfortable than being at home. But I barely remember those details: what really mattered in the end was having two beautiful and perfectly healthy babies back home.
I am wondering if we are focusing too much on what is, at most, a couple of days. What really matters is the next 20 years!
I delivered twice in hospital. Yes there were probably a couple of unnecessary procedures, yes it was less comfortable than being at home. But I barely remember those details: what really mattered in the end was having two beautiful and perfectly healthy babies back home.
I am wondering if we are focusing too much on what is, at most, a couple of days. What really matters is the next 20 years!
14
And I have 3 beautiful and perfectly healthy children who were born at home. The only non-fatal, permanent damage I've seen in children is in children born in hospitals.
3
But brain damage happens as a result of hospital births as well.
I myself regret having birthed my oldest in a hospital. Her complications haven't been as dire as those you describe, but they are a direct result of hospital interventions. She could have been better off. Her three younger siblings, born at home, have been wonderfully healthy and happy from the first moment.
I myself regret having birthed my oldest in a hospital. Her complications haven't been as dire as those you describe, but they are a direct result of hospital interventions. She could have been better off. Her three younger siblings, born at home, have been wonderfully healthy and happy from the first moment.
4
Of course they do. In all of these cases, we talk about RISKS and COMPARISONS. In the Oregon study, the RISK of having a baby with neonatal seizures in a home birth was higher than in hospital birth. It didn't mean there were none in the hospital, simply fewer. Just like if you wear a seatbelt, it doesn't mean you won't die or be injured in car crash, it's just less likely.
3
You state: "I, and my wife, feared the deaths of our babies during delivery so much that we chose in-hospital births."
You are letting your fear drive your decision, and that is of course common for new parents.
However, trust that your wife and your baby know how to get the birthing done. It is, after all, a very small event relative to the nine months prior and 80+ years post delivery.
Your wife and your baby come from a long, long line of people who have done this before.
You are letting your fear drive your decision, and that is of course common for new parents.
However, trust that your wife and your baby know how to get the birthing done. It is, after all, a very small event relative to the nine months prior and 80+ years post delivery.
Your wife and your baby come from a long, long line of people who have done this before.
2
My family tree is littered with babies, siblings of living ancestors, who died during delivery. My great grandmother died delivering my great uncle, who died too, leaving my grandfather motherless.
Don't confuse luck with skill.
Don't confuse luck with skill.
3
No, he has the correct understanding of fat tail events in statistics, it is not only the probability which counts, but the impact of wrong decision as well.
My great grandmother died in childbirth as did her baby, my great aunt, that she delivered at St. John's hospital in Tulsa on Christmas Day in 1928. Her husband insisted she birth in the newly-opened hospital labor and delivery ward though she had previously successfully birthed my grandmother and another aunt safely at home. When her mother and my great grandfather went into collect the bodies, my great grandmother had been covered by the hospital staff but the baby's body was left naked and with the umbilical cord attached on a sink drainboard with the medical waste from the failed birth.
So, 'my great grandmother died delivering my great aunt, who died too, leaving my grandmother motherless'.
Don't confuse anecdotes (or small and biased sample size) with population statistics.
So, 'my great grandmother died delivering my great aunt, who died too, leaving my grandmother motherless'.
Don't confuse anecdotes (or small and biased sample size) with population statistics.
I think the ideal is high-quality birth center with highly quality midwife and RN staff, state-of-the-art rescucitation equipment and proximity to a high level newborn nursery.
4
Consider, as the author wrote, that "increased neonatal intensive care use is a possible example of supply-induced care." The closer the baby is to a NICU, the more likely he or she is to be admitted to it, independent of other factors that better indicate true need.
2
There are a lot of misconceptions about midwives out there, and maybe it's much much worse in the States than up here in Canada, but let me fill you all in on some facts.
Midwives, at least here in Canada, are "Modern Medicine". They practice in hospitals as well as out of them, in birth centers, and yes at planned home-births (where the mortality rate is statistically insignificantly different from hospital birth here in Canada http://www.cbc.ca/news/technology/home-birth-with-midwife-safe-as-hospit....
Midwives are an integrated part of our health care system. They are paid for by our single-payer government health care provider, which means anyone, regardless of income, can seek the care of a midwife. In fact, midwifery is becoming so popular, and has so many advantages, that waiting lists are common for women merely planning to have children soon, who aren't even pregnant yet.
Also, midwives have so much respect as health practitioners in our country that one is the HEAD OF OBSTETRICS at one of the countries most renowned hospitals.
Midwives absolutely support hospital births, which still make up 90% of the births here in the great white north. In particular a hospital birth is recommended for anyone who might have the slightest inkling of a complication. It's just plain smart.
But for women with no complications there is indeed, NO INCREASE IN RISK, for a professional midwife attended planned home birth, within a certain proximity to hospital. The facts.
Midwives, at least here in Canada, are "Modern Medicine". They practice in hospitals as well as out of them, in birth centers, and yes at planned home-births (where the mortality rate is statistically insignificantly different from hospital birth here in Canada http://www.cbc.ca/news/technology/home-birth-with-midwife-safe-as-hospit....
Midwives are an integrated part of our health care system. They are paid for by our single-payer government health care provider, which means anyone, regardless of income, can seek the care of a midwife. In fact, midwifery is becoming so popular, and has so many advantages, that waiting lists are common for women merely planning to have children soon, who aren't even pregnant yet.
Also, midwives have so much respect as health practitioners in our country that one is the HEAD OF OBSTETRICS at one of the countries most renowned hospitals.
Midwives absolutely support hospital births, which still make up 90% of the births here in the great white north. In particular a hospital birth is recommended for anyone who might have the slightest inkling of a complication. It's just plain smart.
But for women with no complications there is indeed, NO INCREASE IN RISK, for a professional midwife attended planned home birth, within a certain proximity to hospital. The facts.
28
Log on to the NARM (North American Registry of Midwives) website for the education/training of CPM's (Certified Professional Midwife) in the US. You can be a High School Graduate, no University education, no education whatsoever (the PEP program) and be a CPM in the US. You have to know who you are dealing with and who is calling themselves a midwife. A midwife isn't always a midwife like you may think they are. Most home birth midwives in the US are CPM's. They couldn't practice in other developed countries because of their lack of training/education.
2
We have 4 kids - all delivered at great hospitals. I still remember what happened for my first one during the final pushes. His heart rate dropped to less than half. All the sudden doctors and nurse appeared out of nowhere. In seconds the birthing room was transformed with all sorts of equipment. The doctor then decided to help pull my newly born son out. Then came a out a beautiful alien-looking son. His head was so big that it was all stretched out in the birthing canal.
20 years later, he's a healthy 6' tall sophomore at NYU. Maybe he would've been fine being born at home. Maybe there was an equipment issue in the heart rate monitor. Glad we didn't have to find out.
20 years later, he's a healthy 6' tall sophomore at NYU. Maybe he would've been fine being born at home. Maybe there was an equipment issue in the heart rate monitor. Glad we didn't have to find out.
3
It seems that much of the dualism between home vs. hospital has to do with patient education and empowerment (related issues). I had three hospital births because my husband is an ER doctor and has seen first hand the complications that can arise from home-births (where a woman or baby has come into the ER from a home birth). I had a "birth plan" for all my births. All were supported by a midwife - I never saw an Ob during any pregnancy - and all involved only the interventions I ok'd. I never felt pressured to do anything, and when the midwife had a suggestion, I knew enough to make an informed decision. After all three births, my babies were in bed with me nursing immediately, and then I checked out of the hospital earlier than the required 24 hrs. postpartum by signing an AMA ("against medical advice") form and went home. I was fortunate to have relatively straightforward births, so could leave the hospital comfortably within 12 hrs. The hospital setting was a practicality for me; everything I needed in case of emergency was right there, but my birth plan was to behave as if I was at home. I wonder about the statistics for C-section and intervention and how those correlate to patient education and empowerment.
Doctors are still in a position of great power in our culture. If one is not well informed before-hand, I can imagine how one could be frightened into feeling pressured. This is, I believe, at the heart of home vs. hospital
Doctors are still in a position of great power in our culture. If one is not well informed before-hand, I can imagine how one could be frightened into feeling pressured. This is, I believe, at the heart of home vs. hospital
38
It sounds as though you're saying that you believe it's easy for anyone to have a perfectly empowered birth experience in a hospital. And that the problem of too many c-sections in this country is due to a lack of education of the mothers giving birth. Surely you must know that because your husband is an ER doc you were among a privileged elite to whom the hospital staff might actually have shown some deference. More often, they do everything they can to establish and enforce dominance. And there are more of them and they aren't in the midst of giving birth themselves, so those factors also contribute to their overwhelming success.
4
If you believe doctors have great power in our culture, I have some beachfront property in Nebraska for sale.
1
Gently, women without a direct connection to hospital staff or high status professional positions in the industry generally are going to have a better experience than women without those connections.
Home births terrify me for a few reasons. Objectively, the article included this frightening statistic:
In 2012 and 2013, researchers found that the rate of perinatal death was significantly higher for births planned at home: 3.9 versus 1.8 per 1,000. That would be an additional death for each 500 births at home.
I'm not sure how anyone can read that and conclude that it represents an acceptable risk. The same people who do though would probably never consider letting their one year old ride in a forward facing car seat -- for which there is no evidence nearly as compelling. This outcome is in no way a "zebra."
On a personal note, my 4 year old would have had a terrible outcome were it not for his resuscitation by the neonatologist at birth, and his pregnancy was as low risk as they come.
In 2012 and 2013, researchers found that the rate of perinatal death was significantly higher for births planned at home: 3.9 versus 1.8 per 1,000. That would be an additional death for each 500 births at home.
I'm not sure how anyone can read that and conclude that it represents an acceptable risk. The same people who do though would probably never consider letting their one year old ride in a forward facing car seat -- for which there is no evidence nearly as compelling. This outcome is in no way a "zebra."
On a personal note, my 4 year old would have had a terrible outcome were it not for his resuscitation by the neonatologist at birth, and his pregnancy was as low risk as they come.
4
I don't see a discussion of the elephant in the room. The safest option (for those wanting it) would be home birth supervised by a physician with hospital stand-by. But because of the horrendous malpractice complications with billions in payouts for complications, this scenario has largely been abandoned. We need effective malpractice reform (no-fault payments for children born compromised[in most cases, not the fault of anybody anyway])
5
Untrue. For the very ill neonate and mother, the availability of the resources of an OR and NICU would be necessary for it to be safest. A physician can only carry so much. Even an ambulance can only carry so much. You can't apply anesthesia or do an emergency c-section in an ambulance, never mind on someone's kitchen table.
7
You mistook my meaning. It is true from a medical perspective that hospital births are probably safer; but misadventure is really fairly uncommon. At present, a midwife in some states delivers on her own. In the rare event of a complicated birth, the physician is drawn into the case at the last minute without knowing the patient. I feel it far preferable to have the physician know the patient and be prepared to intervene. This has worked well in the past but the malpractice liability is too great.
MDMD, thank you for finally the voice of reason. The cause of our terrible outcomes in the US is because physicians cannot practice medicine the way they were taught, the way their experience tells them, the way their "gut feelings" implore. They practice medicine the way the lawyers tell them they can practice medicine (and lawyers don't have a medical degree). Why wouldn't we have bad outcomes here? Oh, and in the 70's with the advent of electronic fetal monitoring, people thought it would decrease the number of brain damaged, (CP) babies and it hasn't done that. But lawyers like it, so we keep monitoring babies and having more and more C-sections for fetal distress.
1
Women need more safe choices. In many parts of the U.S., we have the choice between homebirth with a "certified professional midwife" (less medical training than certified nurse midwife) and hospital birth with a full slate of mandated routine procedures, from hep lock to constant electronic fetal monitoring. My hospital offered lots of concierge options for things like past-delivery champagne, but nurses + OB were unpleasant when I chose to push while lying on my side. Attitudes like that are part of the problem.
10
This would be a tough call, but having experienced numerous routine pelvic exams that were unpleasant, cold and dehumanizing, I can certainly understand the allure of home births and midwives.
12
As my old attending used to say, home delivery is for pizza, not babies.
5
I regret I must inform you that it is mothers who give birth to babies. They are no more "delivered" by doctors than they are by storks. Your tiresome attempt at an aphorism is misogynistic at best.
8
My wife and I attended a birth class at a home birth center, and found it to be absolutely infuriating. We were there to see if it was the right thing for our baby, but everyone else seemed to have an ideological axe to grind. We were ridiculed by the instructor, and any safety concerns were dismissed with "well, if you have complications, then of course you should go to the hospital." The fact that a woman can bleed out after childbirth in less than two minutes was just dismissed as "big medical" propaganda.
My wife needed hospitalization for the birth, and in a follow-up class at the home birth center, we were treated as if that was something to mourn.
So, I view home birth advocates as irresponsible and anti-scientific.
My wife needed hospitalization for the birth, and in a follow-up class at the home birth center, we were treated as if that was something to mourn.
So, I view home birth advocates as irresponsible and anti-scientific.
35
Patrick, wouldn't you agree that it is a bit unfair to characterize all home birth advocates as "irresponsible" and "anti-scientific," because you had a negative experience with one home birth center?
There are certainly crazy people out there, but for the most part, advocates of home birth are just as reasonable and scientific as the author of ths article.
There are certainly crazy people out there, but for the most part, advocates of home birth are just as reasonable and scientific as the author of ths article.
4
Well said; For all of the rubbish I have read on here about "obgyn's not wanting to lose money" there are an equal number of midwives and birthing centers who are taking money by allowing parents to dictate every part of their delivery. No one is doing this for free or out of the goodness of their heart.
1
I've had two uncomplicated homebirths and would consider doing it again. I'm not a medical professional, but I do have a master's degree in a statistics-heavy field. Early in my second pregnancy and read through all the research again to make sure that a homebirth was still the right option.
I'm comfortable with a homebirth under 3 conditions:
1. Low risk pregnancy . I wouldn't homebirth with hypertension, twins, a breech baby (although I would try for a vaginal breech birth in hospital).
2. My midwife is highly trained, professionally accredited, experienced, and legal in my state.
3. I'm close to a hospital and can easily transfer if needed.
With those three caveats, the best available data told me that, while there was still an extremely small risk of a catastrophic outcome, I was also hugely lowering my risk of morbidity by not stepping into the hospital.
In the last ten years, I have seen some hospital practices improving. A lot of hospitals are installing birth tubs, which are amazing for pain relief (hydrotherapy is considered a no-brainer in sports medicine, why has it taken so long to catch on in obstetrics?) More hospital-based midwifery practices are popping up. And many practices are allowing VBACs, moving away from excessive use of pitocin, monitoring that leaves the mother immobile, unneeded inductions, etc.
I agree that home birth can be made safer (legalization and licencesure is a good start) but hospitals also need to improve their standard of care.
I'm comfortable with a homebirth under 3 conditions:
1. Low risk pregnancy . I wouldn't homebirth with hypertension, twins, a breech baby (although I would try for a vaginal breech birth in hospital).
2. My midwife is highly trained, professionally accredited, experienced, and legal in my state.
3. I'm close to a hospital and can easily transfer if needed.
With those three caveats, the best available data told me that, while there was still an extremely small risk of a catastrophic outcome, I was also hugely lowering my risk of morbidity by not stepping into the hospital.
In the last ten years, I have seen some hospital practices improving. A lot of hospitals are installing birth tubs, which are amazing for pain relief (hydrotherapy is considered a no-brainer in sports medicine, why has it taken so long to catch on in obstetrics?) More hospital-based midwifery practices are popping up. And many practices are allowing VBACs, moving away from excessive use of pitocin, monitoring that leaves the mother immobile, unneeded inductions, etc.
I agree that home birth can be made safer (legalization and licencesure is a good start) but hospitals also need to improve their standard of care.
20
Informed consent! The medical establishment needs to start listening to what women (and many fathers) are telling them about how hospitals treat laboring women. A certain kind of person is thick on the ground in obstetrics and L&D nursing: women and men who went into their profession because they just love babies and the miracle of life. Notice I didn't say they love women? Most don't think women should have the right to decide whether to carry a fetus in the first place, and they don't think a pregnant woman should be allowed to make decisions about her medical care, her diet, her lifestyle, her pain relief, or how and where she delivers. They view women as incubators, not people, and when the incubator goes off script - starts talking and asking questions, mouthing off and expressing opinions, it makes them very, very angry. They retaliate, hurt, punish, and control.
Start listening to the stories from women who have been abused, assaulted, bullied, and denied informed consent. These stories – thousands of them - get dismissed as "hysteria" or "hysterical propaganda" - well, Cosby's victims were dismissed too until the numbers started to reach the dozens. Or you hear, "At least you had a healthy baby." As though a good women would understand her place and never think about her own pain or trauma. These doctors and nurses are not the majority, but they are far, far, far more common than anyone wants to admit. They are a big driver of the home birth movement.
Start listening to the stories from women who have been abused, assaulted, bullied, and denied informed consent. These stories – thousands of them - get dismissed as "hysteria" or "hysterical propaganda" - well, Cosby's victims were dismissed too until the numbers started to reach the dozens. Or you hear, "At least you had a healthy baby." As though a good women would understand her place and never think about her own pain or trauma. These doctors and nurses are not the majority, but they are far, far, far more common than anyone wants to admit. They are a big driver of the home birth movement.
43
My first child would have been born either severely brain damaged or dead had I not been in the hospital where a c-section, arranged in record time, saved his life. My second child was breach, so I opted for a c-section, this time planned.
Modern medicine has its advantages, I highly recommend it.
Modern medicine has its advantages, I highly recommend it.
40
Both my children were normal deliveries, but only because the nursing staff at the hospital I was at were truly experienced and great at their jobs.
My first child was very big, musical and had really broad shoulders. The nurses pushed her out, and I didn't have C-section.
My son was in fetal distress and the nurses massaged his scalp, reducing stress and keeping blood flow strong, until the doctor arrived. The cord was around his neck, and causing distress. I was fully grateful to have the hospital and the skilled staff there: no brain damage is goal we all look for.
I don't quite understand why the dichotomy exists between full intervention hospital delivery and full non-intervention home birth. Why don't we set the standard at supervised, low intervention maternity centers, with skilled staff and doctors readily available to prevent tragedy? Sometime the happy medium is a great place to start.
My first child was very big, musical and had really broad shoulders. The nurses pushed her out, and I didn't have C-section.
My son was in fetal distress and the nurses massaged his scalp, reducing stress and keeping blood flow strong, until the doctor arrived. The cord was around his neck, and causing distress. I was fully grateful to have the hospital and the skilled staff there: no brain damage is goal we all look for.
I don't quite understand why the dichotomy exists between full intervention hospital delivery and full non-intervention home birth. Why don't we set the standard at supervised, low intervention maternity centers, with skilled staff and doctors readily available to prevent tragedy? Sometime the happy medium is a great place to start.
28
Not musical. Never musical .... Muscular! I truly loathe autocorrect.
1
Cathy,
Having the umbilical cord around the baby's neck is normal, and not a cause for concern. After all, a baby inside the womb is not breathing through its neck, it is breathing through the cord. However, it is such powerful imagery that when doctors see it (like a noose), and say it to the mother, fear sets in, stress levels rise, and interventions begin. The baby is now seen as being in "distress", and here begins procedures to mitigate it. This, like many other things, is a false negative. Heart-rate monitors are also misread, causing other reactions/interventions.
Having the umbilical cord around the baby's neck is normal, and not a cause for concern. After all, a baby inside the womb is not breathing through its neck, it is breathing through the cord. However, it is such powerful imagery that when doctors see it (like a noose), and say it to the mother, fear sets in, stress levels rise, and interventions begin. The baby is now seen as being in "distress", and here begins procedures to mitigate it. This, like many other things, is a false negative. Heart-rate monitors are also misread, causing other reactions/interventions.
3
Having the umbilical cord wrapped around the baby's neck during birth is *not* normal...ask my aunt, who lost a baby that way.
1
Isn't it likely that the reason intensive care units are utilized more frequently with in-hospital births is because the babies born outside the hospital don't make it there in time to take advantage of the intensive care the hospital affords? I'm really asking honestly, from a statistical standpoint, isn't that a likely explanation?
Based on the comments it sounds to me like the people who gave birth at home with no complications love home birth, and those who had complications are a little more cautious about that endorsement. Just an observation.
Based on the comments it sounds to me like the people who gave birth at home with no complications love home birth, and those who had complications are a little more cautious about that endorsement. Just an observation.
7
Also, all high risk pregnancies are hopefully going to be done in hospital, with a higher rate of sick babies and mothers, hence needing a neonatal intensive care unit.This would include almost all premature babies, as well. It is not a fair comparison because you are comparing things that are not equivalent. What you would ideally do is compare LOW RISK full term women with planned home births with LOW RISK full term women without induction,etc, giving birth planned at the hospital and compare ICU admission rates. For example, while this was not directly studied in the Oregon study mentioned here, the rate of neonatal seizures (which require ICU care and are a marker of significant brain injury) was four times higher in planned homebirth in that group. This is an avenue for further study.
For a blogger on economics, the author doesn't understand the basic of risk management, and as a doctor doesn't know know much about delivering babies. The fundamental essence of modern delivery of babies is the reduce the incidence of unpredictable, but traceable catastrophes. This involves turning uncertainty into some small but manageable risk. That's what happens in a hospital birth. You have a higher chance of a minor problem, but a much lower chance of a huge problem.
No person ever has enough experience in their life to make statistical inference of the safety of childbirth. We are falsely assured by the "white swans" of natural birth into thinking we can't experience an unpredictable catastrophic "black swan" delivery.
That's why there are scientific professionals, Obstetricians, who help us with the procedural part, but more importantly, the estimation and mitigation of risk. Obstetrician know the actual science and statistics. They're the ones I trust.
I recommend reasoned some Kahneman and Tversy or Nassim taleb before writing another opinion piece in the NYT or before blogging on economics.
No person ever has enough experience in their life to make statistical inference of the safety of childbirth. We are falsely assured by the "white swans" of natural birth into thinking we can't experience an unpredictable catastrophic "black swan" delivery.
That's why there are scientific professionals, Obstetricians, who help us with the procedural part, but more importantly, the estimation and mitigation of risk. Obstetrician know the actual science and statistics. They're the ones I trust.
I recommend reasoned some Kahneman and Tversy or Nassim taleb before writing another opinion piece in the NYT or before blogging on economics.
18
Have you ever heard of a thing called an ambulance.
Most cities up here in Canada have them, where midwife attended homebirths have a statistically nil difference to births in the hospital.
The reason for this is the superior Canadian health system, which co-ordinates efforts between medically trained midwives, and labour and delivery nurses, and obstetricians.
John has clearly never had a midwifery experience, cuz if he had he would know that they do not push home birth, and in fact do the opposite, clearly laying out any increase in risk factors, and obviously suggesting hospital births for women with any complications.
Midwives are indeed scientific professionals. At least here in Canada they are. No less so than OB's. Really, you can start thinking of them as doctors of child birth.
Most cities up here in Canada have them, where midwife attended homebirths have a statistically nil difference to births in the hospital.
The reason for this is the superior Canadian health system, which co-ordinates efforts between medically trained midwives, and labour and delivery nurses, and obstetricians.
John has clearly never had a midwifery experience, cuz if he had he would know that they do not push home birth, and in fact do the opposite, clearly laying out any increase in risk factors, and obviously suggesting hospital births for women with any complications.
Midwives are indeed scientific professionals. At least here in Canada they are. No less so than OB's. Really, you can start thinking of them as doctors of child birth.
9
Two very wise men told me long ago:
"The public does not understand the concept of relative risk"
and
"The plural of anecdote is not data"
"The public does not understand the concept of relative risk"
and
"The plural of anecdote is not data"
2
haha good one. What happened to the nation that once put people on the moon with slide rules? We sure have changed. We don't have a common language of science or rationalism anymore.
1
I had planned a home birth for my first child. At each visit, the midwife assured me that everything was normal. However, in the back of my mind was a nagging thought. What if everything didn’t go normally? My water broke at 4am on a Sunday. The midwife said to call when my contractions were coming at a certain interval, but they were consistently irregular. She “tested” for amniotic fluid, and said there was none. She suggested I had peed on myself and said to wait. By Tuesday, I was in so much pain and so exhausted, my husband called the midwife, and she suggested that this could go on for a while. My husband insisted we speak to the doctor. He had us come in the next morning, and immediately confirmed my water had broken and was down to a low level. He told us to head straight to the hospital. The relief I felt was indescribable. After 12 hours at the hospital, my son was born. Afterwards, I lost a significant amount of blood. I learned this could have gone very badly if I had not been in the hospital. My son turned out fine, but I learned that while childbirth for some could go perfectly smoothly, for others like me, it can be serious. And there is no way to know beforehand. I do think hospitals should do more to make hospital births more like home births, in terms of allowing the process to go more naturally. Perhaps having more midwives working in the hospital WITH doctors would help. It shouldn’t have to be such a stark choice.
76
You had a midwife who didn't listen to you. I'm sorry for that. You shouldn't paint all home birth midwives with the same brush. I'm a home birth CNM and when I was in school, the latest motto then was, "Listen to women." I have never stopped doing that.
3
Imagine someone was talking about driving a car, and they said, "Drivers who don't wear seatbelts actually have fewer accidents. They are more relaxed, they react quicker, and they are more in touch with the road!" I wouldn't necessarily doubt them. But if they said, "Therefore, not wearing a seatbelt is safer, because you're less likely to get in an accident," I would not be convinced by that logic. You don't wear a seatbelt because it makes an accident less likely. You wear one because if you do have an accident (whether it's your fault or not), you are much more likely to survive it. The same is true for hospital births. They may be less comfortable (much like wearing a seatbelt is less comfortable) -- but they are much, mure safer when things go terribly wrong.
I understand the logic of women who use the "seatbelts cause fewer accidents" logic when discussing home births and talking about "fewer interventions." I understand it, but I think it is bad logic. Because when things go wrong in childbirth, much like in driving, it can happen very fast, and often for reasons that are completely unexpected.
I don't think home births should be illegal, but I think they're foolish, particularly for those who are far from a hospital. I guess the best we can do with these people, as this doctor notes, is to make their choice as safe as possible.
I understand the logic of women who use the "seatbelts cause fewer accidents" logic when discussing home births and talking about "fewer interventions." I understand it, but I think it is bad logic. Because when things go wrong in childbirth, much like in driving, it can happen very fast, and often for reasons that are completely unexpected.
I don't think home births should be illegal, but I think they're foolish, particularly for those who are far from a hospital. I guess the best we can do with these people, as this doctor notes, is to make their choice as safe as possible.
72
I am glad to see an article that looks behind the much publicized statistical conclusions of the Oregon study (2x greater risk for births out of hospital) and considers more carefully the pros and cons of each option. The Oregon study, or more accurately the news coverage of it, was, for me, an example of our excessive and uncritical reliance on statistics in assessing medical risks. Sure, the study concluded that the risk of infant death out of hospital was twice as high as for in-hospital births. But, the absolute numbers in both cases were tiny (tragic for those involved, but perhaps irrelevant for the great majority of women): 2 per 1000 vs. 4 per 1000. Yet the study was often headlined as "double" the risk: "double" is not always "double". Doubling a 0.2% risk still leaves a tiny risk; doubling a 5, 10, or 25% risk is quite different. The numbers of cases studied were wildly different: about 76,000 hospital births, about 3000 out of hospital. Doesn't it make sense to use such a study, not to disseminate overall statistics, but to focus on what circumstances led to this small, but tragic, number of deaths. Sometimes, the results of statistical studies (and this should apply equally in areas like cardiovascular medicine where we are bombarded with statistical risk assessments) should lead us to more qualitative, case-by-case assessments to explain, not just measure, the risk and to address the specific problems that led to a bad outcome.
20
I have two little girls both whom were born at home. Both pregnancies were low risk and we were assisted by a very professional mid-wife. We were prepared in advance to rush to the hospital of need be. On both occasions we actually did end up going to the hospital after the fact because of tearing. I would rate the experience very highly except that we had to go to the hospital afterwards. That was the worst part. The first time was not too (younger doctor) bad but with the second child the obstetrician who stitched up my wife was very condescending and reminded me why I didn't want to be there in the first place.
6
Hospital birth is a low, but predictable risk. Birth at home has higher variability, and if you have a disaster, you're SOL. It just depends on if you believe that statistics apply to yo, or believe you are magically excluded---or you just like to roll the dice. If we hadn't had our first child in the hospital, he would have died.
61
21 1/2 years ago, I was 27, healthy, not overweight, very low risk, and had a perfectly normal pregnancy. Committed to a drug-free and natural childbirth, my husband and I chose a birth center and midwife who had a doctor on-call as a backup in case of complications. Four to five months before my due date, the backup doctor left and the midwife gave us two options: home birth or find a new midwife/doctor. I found a new midwife but she had admitting privileges at a hospital. We figured it was a good compromise. After four hours of routine labor without drugs or any interventions at the hospital, things went badly...quickly. When my daughter was delivered, limp and not breathing, there was a team of doctors and nurses ready in the delivery room to help her. Her first Apgar was a 2; her second was an 8 (on a scale of 1-10). If we had had to wait for a doctor or ambulance to arrive at a birth center or our home, my beautiful, intelligent, and very healthy 21-year-old daughter, about to graduate from college, would have been brain damaged due to lack of oxygen from a cord wrap. Yes, childbirth is a natural process. But I'd rather be in a hospital with all the resources of modern medicine available in case that "natural process" goes badly.
120
Two of my children were born in hospitals and the third with a midwife in a birth center. As with most things there are advantages and disadvantages to both. I don't believe greed is a factor in the treatment of either doctors/hospitals or midwives. I think people believe what they believe about the process and try to make patients fit that. I wanted to do a midwife birth for the first child but my husband was skittish. The birth was uneventful but I had to be very forceful in declining pitocin (to speed the delivery along). Pitocin is routine and common, but also associated with increased c-sections. I figured she would come on her own time and she did. Because the first two births were successful at the hospital, and our insurance did not have maternity coverage for the third baby, my husband was open to the idea of a midwife. The experience was mostly positive, but my midwife was not any more responsive than my doctors to my knowledge of my body (we ultimately ended up delivering the third baby by ourselves--the midwife arrived about 15 minutes later). Both the midwife and the hospital staff were entrenched in their own ideas of how babies are supposed to be born and did their best to impose that on me.
7
Actually, there is absolutely no data linking pitocin with an increased C section rate. Idaho MD
10
But there is a correlation with induction and increased C-section rate. However, in the hospital, it is often written as an "augmentation" not an "induction", when it really was an induction.
3
As a father with two children born at home (in New Zealand) and two in hospital (Canada and the USA), I fully support the families who choose to give birth a home for low risk pregnancies. The first challenge to home birth in the US is the almost complete lack of any coordination between midwives, doctors, hospitals and insurance companies. The second issue, in part related to the first, is the highly variable training of people acting as midwifes and doulas. Many home birth practitioners are well trained and have immense experience. Others are effectively lay practitioners who may support or even encourage families to avoid medical intervention even when its necessary. Hospital and home birth are both legitimate alternatives for women and families seeking the best for themselves and their baby. However the hostility by the US medical system to home birth (and birth centers) places mothers and babies at risk. Similarly, the demonization of hospital birth by some in the home birth movement is equally harmful. Progressive states should seek to address these challenges and create a much more supportive and safer infrastructure for home birth and birth centers. Britain, the Netherlands and New Zealand provide different models for doing this.
62
Great post!
Thank you for this article, Dr. Carroll! What a welcome and needed relief -- a call to end the either-or of home/hospital births and move to a model of collaboration and support among mothers, caregivers of all kinds, doctors and hospitals. Let's do it!
30
News Flash! If you go to the hospital with appendicitis you are more likely to get an operation than if you stayed home. Home delivery is great provided that you have all the emergency capability of a hospital - oh wait.
39
having a child is not like having appendicitis.
2
Pregnancy is not an infection or an illness of any sort. Unfortunately, in this culture, we still treat it as such.
2
Both my children were born in the Netherlands, a country that dos not believe in the medicalization of child birth -- after all we humans have been birthing children for quite some years. In the Netherlands, the bias is for home birth unless a medical condition of either the mother or the foetus requires a hospital birth. Some 50% of births in the Netherlands occur at home supervised by a midwife and with little to no anethstesia). Midwives in the Netherlands (who are fully trained via a medical degree) attend most of the births (Dutch midwives attend births some 10x more than Dutch obstetricians). No one there thinks about zebras nor horses, child birth is a natrual part of life.
73
Childbirth is a natural part of life, and so was maternal death before modern medicine.
10
"after all we humans have been birthing children for quite some years..."
In 1900, prior to the "medicalization" of pregnancy and delivery, the reported rate of maternal death was 6-9 per 1000 live births--in 2000 this rate was 0.1 per 1000 live births. Childbirth is a "natural," but frequently dangerous part of life, which can end in heartbreak for families if the appropriate precautions are not taken.
In 1900, prior to the "medicalization" of pregnancy and delivery, the reported rate of maternal death was 6-9 per 1000 live births--in 2000 this rate was 0.1 per 1000 live births. Childbirth is a "natural," but frequently dangerous part of life, which can end in heartbreak for families if the appropriate precautions are not taken.
8
How is little to no anesthesia for 50% of women a good thing? Are women given a choice in this, are they coached that they are somehow "lesser" if they want it (a big problem with shaming with this here in the US), or is the hospital and its anesthesia availability only for those with high risk pregnancies? More power to women who decide a nonmedicated birth is not for them, as long as there are no overt or implied denial of anesthesia whenever requested as long as it is medically safe, even if the woman changes her mind. Sometimes ideology and/or economics can be a block, either by "reminding" a woman about what she said before the pain started, or playing up the trouble of transfer, or like in the UK, where the decreased cost of a nonmedicated home delivery to the system is taken into account. Don't forget that midwives are also medical providers and a laboring woman may not have the energy or desire to argue with them either.
3
This is a very tricky subject. I had my first child in a birthing center and the second at home with a certified nurse midwife. In both cases I was low risk and I had wonderful births, free from any of the typical hospital interventions. My children were completely healthy and my recovery was fast and easy compared to friends who had hospital births. In the birthing center and at home we had a back up transfer plan if necessary. This is not for everyone or even for most people, but the routine procedures at hospitals make that type of birth unappealing for many. I wish we had more birthing center options within hospital settings so that women could opt for a natural birth in a setting that supports their decision while being close to medical facilities if needed.
43
Roosevelt/Mount Sinai on the west side, to my knowledge, is the only hospital in New York City that has a birthing center within the hospital. It would be great if more hospitals followed suit to reach this middle ground.
1
Agree with Dr. Scherr. It's a total non-sequitur to note higher morbidity in planned C-sections and then say you're more likely to get a C-section in a hospital. If you have a planned C-section, you are 100% likely to have a C-section! (well not exactly but you get my point...)
5
Why the push for home births? Because of the knowledge that, however well-meaning and trusted, your obstetrician is primed -- financially and for lifestyle reasons -- to bully you into induction and a c-section. In this case, the credential conferring expertise also confers blinders as to how infuriating and sad it is for women -- like me -- to be essentially forced to give birth using medical procedures we don't want or need. That women have to even consider giving birth at home to escape this medical imprisonment is yes, sad, but doctors have only themselves to blame.
68
Barbara clearly you don't know how much an obstetrician gets paid for a C-section. If it is a Medicaid patient the reimbursement doesn't even come close to covering the cost incurred for malpractice premium by that obstetrician.
I don't know any obstetrician who got wealthy "forcing" women into inductions and c-sections.
I don't know any obstetrician who got wealthy "forcing" women into inductions and c-sections.
4
My OB charged the same for a C-Section as for a Vaginal Delivery, there was no financial incentive. Also if you go to a group practice--there is no "lifestyle" reason for an unnecessary C-section , the next doctor will come on shift and wait until that baby decides to arrive. Barbara, you have no idea what you are talking about. I think that the reason we do not have birthing centers in hospitals is that the doctors who are trained OB/GYN feel that they do not want to come in only at the end of the process when mother and baby are in some distress, a good OB and nurse team are well equipped to assist in a comfortable, "home like" delivery in a hospital where in seconds the "bedroom" can be turned into a full medical facility and the doctor and nurse have been monitoring everything from the beginning of the journey months before and are fully involved with the birth of that child. You can shop for an OB and find a practice that you like. In my family women gave birth at home back in the "olden" days--it is the modern age--empower yourself and own your hospital birth with the best care available.
Exactly. As an NP 27 years ago in Boston it was very evident to me that the only way I could be safe from intervention would be to hide out laboring at home. My healthy (now full grown) daughter was the result after 36 hours of labor. The cord wrapped around her neck was expertly flipped over her head and she got oxygen immediately with quick pinking up and crying. I would have been induced for sure, for the convenience of the MD in hospital.
My home birth was not driven any more by midwives than a medical birth is driven by hospitals and physicians. I chose to have my two sons at home because I wanted to avoid the traditional interventions of the medical professions. The boys were born in the early 1980's at the cost of $300 which included all pre-natal care. If this is a midwife driven by money to pay for her second or third vacation home, I would be surprised. The experience did not involve p-drips, medications, cuts any other medical procedures. We had a physician on call if I needed to have extraordinary attention. I highly recommend it for those who have an of the concerns I listed above - health or fiscal.
17
And if you had had an emergency, that physician on call for you would have been able to do nothing separated from all the support facilities a hospital provides. You were lucky, that's all.
19
This is such a tough one. My sister in law gave birth to her third child and all was 100% normal with the pregnancy. At the last minute while in the early stages of labor at the hospital, she developed a fever and an infection and needed an emergency C-section. What would have happened has she been at home? No easy calls here.
16
I have similar thoughts and reservations as you. My mom and I both had easy, healthy pregnancies and run of the mill hospital births. My sister, who is very healthy and in great shape, also had an easy pregnancy and thankfully was at the hospital to give birth, because something happened and she almost had a heart attack. She did have a C-section, but no one is arguing the validity of that decision.
We have all these statistics to show us that at-home births are growing, but do we have any firm data on the frequency of medically serious events for which mother or child require hospital services? Anecdotal, but as you say when it's your loved ones, tough call.
We have all these statistics to show us that at-home births are growing, but do we have any firm data on the frequency of medically serious events for which mother or child require hospital services? Anecdotal, but as you say when it's your loved ones, tough call.
6
If she had developed a fever at home, she would have been transferred to the hospital. That is a normal procedure for planned out of hospital deliveries. In the hospital, I have seen women with fevers given IV antibiotics. I do not remember any being given a C-section for it. I do not know your sister-in-laws history so cannot speak to that, however, a fever is not usually an emergent situation calling for a C-section.
4
Elizabeth,
They would have brought her to a hospital for a c-section.
They would have brought her to a hospital for a c-section.
1
All very good points. But to say women are more likely to have c-sections, inductions and babies in the ICU if they choose to have their baby in the hospital, is twisting some of the data. How many women plan home births who have planned c-sections? Zero. How many women have planned home births who have planned induction? Zero. How many women have a planned home birth and have a high risk delivery, increasing the risk of needing the ICU for the baby? Very few (I hope). We have too many c-sections and inductions in the US, but these are decisions that are made independent of the site of delivery, sometimes for the convenience of the patient or doctor. While just under 2 babies more per 1000 births die at home vs in the hospital may be a zebra. The impact it has on the family is louder than hoofbeats. We should more extensively study which mothers/babies do not have a higher risk of neonatal death/seizures so women that fit that profile can feel confident in their decision to have a home birth. www.lakesidemedicalmusings.com
34
Read the Oregon study before you call it a "zebra." It's very well done based on good data.
1
The statistic that 2 infants per 1000 births die at home is probably distorted when mothers choosing a home birth get into trouble during their home delivery and are emergently transferred to the hospital. The death is then credited as occurring at a hospital location when the reality is it was caused by home birth.
Then the hospital and their personal can also be held responsible for the infant death, opening up deep pockets for the lawsuit.
Then the hospital and their personal can also be held responsible for the infant death, opening up deep pockets for the lawsuit.
7
And in Canada, well, just read this
http://www.cbc.ca/news/technology/home-birth-with-midwife-safe-as-hospit...
http://www.cbc.ca/news/technology/home-birth-with-midwife-safe-as-hospit...
2
Years ago our children's pediatrician who was from Amsterdam told us that in that country, as the labor progresses in the home, an special medical van comes and parks outside the house, in case of trouble. If nothing goes wrong, the van goes on to the next birth. (She also told us that for two weeks after the birth, the government provides a caretaker who does all the housework - preparing meals, laundry, etc. - so the parents can concentrate on taking care of the baby.) I never verified this, but it sounds very sensible.
54
Ah, sensibility. I "caught" both our babies in a warm bathtub by candlelight, in a beautiful room, surrounded by beautiful people (a team of 3 expert midwives) and mellow music with my wife in my arms. There was a king sized bed waiting for us, menus from local resturaunts to order our meals from, and a pleasant waiting room for family to relax in. It was a "bed & breakfast of birthing" and it was amazing. Slightly more expensive it was as insurance companies are still not covering it the same as hospital births, but worth every penny x 100! Shout out Alma Birthing Center!
Had there been trouble, the hospital was 10min. away with all its lights and noises and symptomizations. The most dangerous part of our experience was being forced by law to drive across town to check with a Dr about some minor concern. Talk about stressful. Ever tried finding parking at a hospital with a woman in labor?
Home and center births are not for everyone, but I feel that after several hundred thousands of years, the women have it pretty well figured out. I wouldn't have traded our experience for any hospital, anywhere, for (most) any reason. And I know I'm biased, but I can't really see why anyone, would who didn't need to, would.
Had there been trouble, the hospital was 10min. away with all its lights and noises and symptomizations. The most dangerous part of our experience was being forced by law to drive across town to check with a Dr about some minor concern. Talk about stressful. Ever tried finding parking at a hospital with a woman in labor?
Home and center births are not for everyone, but I feel that after several hundred thousands of years, the women have it pretty well figured out. I wouldn't have traded our experience for any hospital, anywhere, for (most) any reason. And I know I'm biased, but I can't really see why anyone, would who didn't need to, would.
7
Dr. Tuteur - I have to respectfully disagree about lobbying being the reason women choose midwives. I switched to a midwife in my seventh month of pregnancy after all the doctors in the ob-gyn practice I was going to basically laughed in my face when I said I wanted natural childbirth. One actually laughed and told me condescendingly that I would definitely change my mind, another snorted and said, "Ugh, why?" I switched to a midwife who was very clear with me about what I was in for with natural childbirth while also encouraging me. She assumed I was an intelligent, educated person who had done her research, which I was.
In terms of home births -- it cuts both ways. What about the hospitals that don't allow midwives or doulas? That forces women who want both a midwife and a hospital to choose. I was fortunate to have a hospital nearby where our midwife was affiliated. But if I had to choose, I would have chosen the midwife, no question. P.S. Even at what the medical community considers my "advanced" age of 38, I had a perfect natural delivery with zero complications.
In terms of home births -- it cuts both ways. What about the hospitals that don't allow midwives or doulas? That forces women who want both a midwife and a hospital to choose. I was fortunate to have a hospital nearby where our midwife was affiliated. But if I had to choose, I would have chosen the midwife, no question. P.S. Even at what the medical community considers my "advanced" age of 38, I had a perfect natural delivery with zero complications.
14
I am from Amsterda, and I had a home-birth there. The care-taker is correct, that is included in insurance. The van is incorrect. In case of emergency an ambulance is called.
1
Homebirth is a fringe practice driven not by mothers but by midwives.
Most women have no interest in increasing their baby's risk of death. Even in the UK, where homebirth is promoted aggressively, the homebirth rate has never reached 3%. In the US, it's closer to 1%. In contrast, the proportion of midwives who favor homebirth far outstrips the proportion of women who favor it. Why? Follow the money.
Natural childbirth in general, and midwifery in particular, are industries complete with trade organizations and lobbying groups. In a never ending effort to increase market share, midwives demonize anything doctors can do (C-sections, epidurals) and insist that anything they can do keeps birth "normal."
Homebirth may decrease treatment intensity (and thereby increase deaths) but it increases midwifery employment and midwifery autonomy, two paramount goals for the midwifery industry. Whereas one UK midwife can care for multiple women in a hospital, TWO midwives are required to care for one woman at homebirth.
The midwifery lobby is very powerful in the UK and the results have been catastrophic. There have been multiple high profile scandals involving the deaths of DOZENS of babies and mothers because midwives insisted that high risk patients were low risk (to maintain patient control and market share). Payments for dead and damaged infants have soared and liability payments no represent fully 20% of maternity expenditures. This is not a system we should be trying to emulate.
Most women have no interest in increasing their baby's risk of death. Even in the UK, where homebirth is promoted aggressively, the homebirth rate has never reached 3%. In the US, it's closer to 1%. In contrast, the proportion of midwives who favor homebirth far outstrips the proportion of women who favor it. Why? Follow the money.
Natural childbirth in general, and midwifery in particular, are industries complete with trade organizations and lobbying groups. In a never ending effort to increase market share, midwives demonize anything doctors can do (C-sections, epidurals) and insist that anything they can do keeps birth "normal."
Homebirth may decrease treatment intensity (and thereby increase deaths) but it increases midwifery employment and midwifery autonomy, two paramount goals for the midwifery industry. Whereas one UK midwife can care for multiple women in a hospital, TWO midwives are required to care for one woman at homebirth.
The midwifery lobby is very powerful in the UK and the results have been catastrophic. There have been multiple high profile scandals involving the deaths of DOZENS of babies and mothers because midwives insisted that high risk patients were low risk (to maintain patient control and market share). Payments for dead and damaged infants have soared and liability payments no represent fully 20% of maternity expenditures. This is not a system we should be trying to emulate.
73
Thank you Dr. Tuteur for speaking up for women and babies. You are completely right - very few mothers would choose to triple the risk of their baby's death, if they were properly informed of it. Women are being given the short end of the stick in this whole push toward home birth, and it makes me sad how advances of the last century are being reversed as a result. You are right to call the midwifery lobby out for what it is. Women should demand the best care for themselves and their babies, and the option with 1/3 the chance of the baby's dying in the process (not to even mention better pain relief...) has to be the best option by most people's standards.
14
A doctor telling us to follow the money! If we want to follow the money, we need to compare midwive's salaries to obstetricians.
42
"Homebirth is a fringe practice driven not by mothers but by midwives."
This was definitely not the true in the case of our daughter-in-law who delivered both of her sons at home, one in Virginia and one in San Francisco.
Our daughter-in-law, who is very bright and very well educated, chose home delivery because she felt she had better control of her situation than she would in a hospital. She carefully researched and retained experienced and competent midwives, and in both cases the midwives had an emergency plan to get their patient to the nearby hospital quickly should it become necessary.
As an aside, my wife, a very experienced critical care nurse, was present to observe the second delivery. She was very impressed with how everything went.
Both of our grandsons are healthy and doing great. It seems to me that their mother made the right decision to have them at home for the reasons stated above.
This was definitely not the true in the case of our daughter-in-law who delivered both of her sons at home, one in Virginia and one in San Francisco.
Our daughter-in-law, who is very bright and very well educated, chose home delivery because she felt she had better control of her situation than she would in a hospital. She carefully researched and retained experienced and competent midwives, and in both cases the midwives had an emergency plan to get their patient to the nearby hospital quickly should it become necessary.
As an aside, my wife, a very experienced critical care nurse, was present to observe the second delivery. She was very impressed with how everything went.
Both of our grandsons are healthy and doing great. It seems to me that their mother made the right decision to have them at home for the reasons stated above.
19