Giving Birth at Home
By Ada Calhoun
For most pregnant women, a key part of their birth plan involves how they'll get to the hospital. But more and more moms-to-be are skipping that step and planning to deliver at home. Old-school birthing is back in style, with well-read women forsaking obstetricians for midwives and epidurals for warm baths. These women want to give birth in their own bed or tub, with none of the medical interventions that have become staples of modern childbirth, like contraction-inducing medication and C-sections, which now serve as the grand finale in nearly a third of U.S. births. "For a normal, healthy pregnancy, the hospital environment is overkill," says Jessica Reid, 27, a stay-at-home mom in Pasco, Wash.
Reid had her first baby in a hospital but plans to have her second--due in late August--at home. "Interventions that neither the mother nor father wish to occur are more likely when surrounded by people who view pregnancy as an illness or labor as inherently dangerous," she says. "I consider birth sacred and a joy, and I intend to birth my baby in a way that reflects that."
Not since Ina May Gaskin's natural-childbirth advocacy inspired a generation of home birthers in the 1970s has the practice been such a hot topic--or so hotly contested. While home birthing still accounts for less than 1% of U.S. births, there's a movement afoot to license more lay midwives to attend home births. Concerned by this development, the American Medical Association (AMA) is urging lawmakers to curb the home-birthing movement, including having the licensing of so-called direct-entry midwives--who do not have nursing degrees--overseen by a state medical-practitioner board.
One of the biggest champions of home birthing is former talk-show host Ricki Lake, who produced the 2008 documentary The Business of Being Born. Lake and other activists contend that fear of litigation has led to more women in labor being tethered to monitors and forced under the knife. And pro--home birthers are pushing the notion that choosing where and how to give birth should be regarded as a civil rights issue. "Legislating against home birth is totally un-American and unfair," says Joan Bryson, who has worked as a midwife in New York City for 17 years. "We rank 42nd in the world in live births, and we spend more money than anyone else. You can't blame it on home birth."
Most planned home births are assisted by a midwife, although some extremists favor so-called free birthing, with no attendant. Home-birth midwives say they accept only low-risk patients, which excludes women with diabetes, high blood pressure, multiple births or any other risky condition. Most midwives--who typically charge from $1,000 to $5,000 per birth, significantly less than the cost of a hospital delivery--travel with basic emergency medical equipment, including oxygen, resuscitation gear and medication to stop hemorrhaging. And all insist they practice preventively and know when--and how--to get a woman to a hospital.
Take, for example, the case of a prolapsed umbilical cord. In roughly 1 out of every 300 births, the cord slips down into the birth canal before the baby does and risks cutting off the baby's oxygen supply. Kitty Ernst, an expert on midwifery at the Frontier School of Midwifery and Family Nursing in Hyden, Ky., says midwives are trained to push the baby's head back up off the cord and hold it there--the same way an obstetric nurse would--and get Mom to the hospital as an operating room is being prepared for her. "Your hand gets pretty tired," she says of this emergency procedure, which she adds can take as little as five minutes if the hospital is across the street.
But it's those precious minutes that have obstetricians alarmed. "Unless there's ready access to certain emergency personnel and equipment and even surgery, you're potentially endangering babies' and moms' health and lives," says Dr. Erin Tracy, an ob-gyn at Boston's Massachusetts General Hospital who authored two anti-home-birth resolutions approved by the AMA in June. "We've all seen scenarios where mothers came in, after very major blood loss, in a very catastrophic state," she says. "By the time they arrive in the hospital, you're sort of behind the eight ball in trying to resuscitate these patients. The same thing with neonatal outcome."
Doctors argue that what may seem like a low-risk pregnancy can go very wrong at the time of delivery--and that making home birth easier to access could lead to a huge step backward. After birthing moved to hospitals en masse in the 1950s, the maternal mortality rate plummeted, from 376 per 100,000 live births in 1940 to 37.1 per 100,000 in 1960. The most recent statistics show 15.1 deaths per 100,000. Many doctors fear that mortality rates will go up with the rising incidence of home birthing, but there are conflicting data on this. A study published in 2005 in the British Medical Journal found that home birthing had a similar mortality rate to that of low-risk hospital births; other studies have suggested a two- or threefold increase in the incidence of neonatal death.
In the absence of clear data, obstetricians in the U.S. are concerned about the recent push by direct-entry midwives to receive licenses so they can practice their craft without fear of prosecution. This summer, Missouri reversed its 25-year ban on non-nurse midwives. Twenty states have similar legislation they are either introducing or planning.
Meanwhile, many obstetricians are trying to meet women halfway, through hospital-affiliated natural-birth centers. These centers are often located near regular hospitals and boast low episiotomy and C-section rates. The decision about where to give birth "is not black and white," says Lake, who is on the board of a $7 million birthing center set to open in Manhattan in 2010. "It's amazing, the technology we have. But we are losing the value of normal, natural birth." Nationwide, the number of birthing centers is growing by about 5% a year. But what might seem like an ideal solution has run into roadblocks, as a few prominent centers have closed in recent years because of high malpractice-insurance costs--which means many natural-birth seekers will still have to choose between hospital and home.