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What's So Scary About Home Birth?

Posted Sep 14 2009 10:22pm

"The Perils of Home Births" screams the title of the segment at the bottom of the screen in a Today show attempt to cover the realities of homebirth in the United States.

"Is avoiding the clinical nature of a hospital setting for a homebirth worth the risk?" asks the reporter. Never mind that the question seems in part to answer itself with the presumption that there is greater risk inherent in a homebirth. The answer further seems rooted in the devastating story of a young couple expecting their first child. As the story is reported, the couple employed a certified nurse midwife ("CNM") to birth at home. After a four-day labor, the frightening voice-over tells viewers, "overseen not by doctors but by the midwife's staff..."  the baby is born without a heartbeat, rushed to the hospital and dies from suffocation, a result of becoming entangled in her own umbilical cord. A devastating story with which we all sympathize, to be sure. 

Should this story, however, be used as a reason to employ scare tactics and to encourage non evidence-based decision making for pregnant women looking into their childbirth options?

As Alison Cole, midwife-in-training, notes in her RH Reality Check reader diary on the segment, "My heart aches for this family, but their experience does not shed light on the safety of birthing at home, just as the story of one family mourning the loss of a hospital-born baby is not evidence that all births should be removed from the hospital."

Coincidentally, the same day, I receive in my inbox a notification of a newly released study out of Ontario, Canada published in the most recent issue of Birth journal. The study examines the outcomes associated with planned home-birth compared to planned hospital birth, facilitated by midwives, in Ontario over a three-year period (from 2003-2006). The authors find that, in fact, there is no difference between planned home and hospital birth when comparing perinatal and neonatal mortality rates (or maternal mortality rates, either). 

This is not the first, nor will it be the last, compilation of data confirming the safety of homebirth facilitated by midwives. The results of a study will never comfort a crushed-hearted couple dealing with the death of a child whether born at home, in a birthing center or in a hospital. But the evidence as to the safety of planned home-birth and midwifery care is clear and getting clearer everyday. Unfortunately, with a tremendous lobbying effort and biased agenda, the American College of Obstetricians and Gynecologists (ACOG), continues to use its power to quash access to this kind of care for women in the United States.

Midwifery care, in Ontario, Canada, is regulated by the College of Midwives of Ontario and is widely accepted as optimal care for low risk pregnant women. In fact, in many ways, it is the kind of system many midwifery practitioners and advocates are pushing for in this country in hopes of providing women and their babies with the highest-quality prenatal, perinatal and postnatal care. 

According to the authors of the published study, 

Midwives are well integrated into the Ontario health care system; they have admission and discharge privileges at their local hospital(s), and access to other health care providers for consultation or transfer of care as required. Two midwives are in attendance at births either in the home or in the hospital.

Ontario is not alone in its support for homebirth - nor are the findings an anomaly. The UK's Royal College of Obstetricians and Gynecologists fully supports planned home birth for "women with uncomplicated pregnancies." Canada's Royal College of Obstetrics and Gynecology pursued research which concluded that planned homebirth results in positive health outcomes for both mother and baby:

"Women planning birth at home experienced reduced risk for all obstetric interventions measured, and similar or reduced risk for adverse maternal outcomes," writes Dr. Patricia Janssen from the University of British Columbia and coauthors. Newborns born after planned home births were at similar or reduced risk of death, although the likelihood of admission to hospital was higher. 

The evidence being uncovered regularly - from around the world - suggests that there is great benefit (for mother and newborn) to ensuring access to midwife-care, homebirth and other out-of-hospital birth options. As well, as Jennifer Block notes, there is a cost effectiveness to increasing access to a range of chidbirth options. When women are subjected to increased, unnecessary medical interventions, costs rise for all involved - families, insurance companies and hospitals. 

Unfortunately, there are significant obstacles to accessing this kind of care for many women in this country. Without regulation and licensure of certified midwives in all fifty states, birthing out-of-hospital with a midwife may be illegal or financially out-of-reach for most women, severely restricting a woman's freedom to choose to birth in the way she sees fit and forcing midwives into difficult, sometimes career-jeopardizing situations. 

In an attempt to address the reality of how and why midwifery care is out-of-reach for many women, the Today Show segment quotes a source citing the "elite" nature of out-of-hospital childbirth, comparing it to a "spa treatment." And while there is some truth to the idea that access to midwifery and homebirth remain options only for those who can afford to pay out-of-pocket, this is by far the whole story.

While The Today Show is busy running tabloidesque segments on childbirth, advocates and providers are hard-at-work attempting to expand safe, evidence-based options for maternity care for U.S. women and their families . If campaigns like The Big Push for Midwives are able to successfully ensure licensure and regulation of CPMs (and legislation to do this is currently pending in 18 states, according to The Big Push), the demand for this kind of care - no matter what a woman and her families' economic situation may be - can be met. It means that midwifery maternity care can be covered under various health insurance plans - including Medicaid. In some states, it's already happening - with impressive results.

In Washington state, for example, all births regardless of health care provider or location, can be covered under any insurance plan including Medicaid. As Miriam Perez writes for RH Reality Check, in Washington state, "around 45% of out-of-hospital births attended by midwives in the state are Medicaid births." Midwifery care becomes accessible for all women, and makes good economic sense, when we ensure safe and regulated care through licensure.  A cost-benefit analysis performed by the Washington Department of Health showed that licensed midwifery care saves the state $3.1 million per biennium.

Despite The Today Show's insistence on painting midwife-provided maternity care as a cause-celebre, a growing number of U.S. women are choosing to birth out-of-hospital under a midwife's care. Professional medical assocations like the AMA (American Medical Association) and ACOG are feeling the pressure. An ACOG representative's blinders were practically visible when she declares in The Today Show segment that "childbirth decisions shouldn't be dicatated by what's fashionable or trendy" - as if pregnant women who meticulously and thoughtfully prepare for a home birth, with the support throughout pregnancy from a midwife, are simply making their decision after flipping through fashion magazines, spotting a star's story of her homebirth and deciding to just "go for it" to be cool or hip. 

Last year, in fact, the AMA went on the offensive, targeting celebrity Ricki Lake's documentary, The Business of Being Born, in a resolution stating its opposition to homebirth. The outcry, however, was so great that the organization amended its resolution and deleted all references to Lake and her film. 

The Big Push for Midwives has this to say about ACOG's focus on homebirth as simply another celebrity led trend:

“ACOG clings to this ridiculous fantasy that women choose to deliver their babies outside of the hospital because they want to be like Ricki Lake, Demi Moore or Meryl Streep and that if women would only watch enough fear-mongering stories on morning television they’ll be brainwashed back into hospitals,” said Katherine Prown, Campaign Manager of The Big Push for Midwives. “Insulting our intelligence and promoting policies that deny us choices in maternity care are not exactly winning strategies for stemming the tide of women seeking alternatives to standard OB care.”

The Today Show segment does include an interview with a former head of Women's and Children's Health at the World Health Organization, Marsden Wagner, who talks about the tendency hospitals have to treat even low risk, healthy pregnancies as medical emergencies. The reporter also acknowledges the rise in unnecessary medical interventions - including a 50% meteoric increase in cesearean sections over the past decade. Jill who writes the blog TheUnnecesearean.com notes that according to the latest statistics from the CDC almost 32% of all births are via c-section in this country. 

What is most important to highlight, ultimately, is that women in the United States are increasingly seeking alternatives to hospital birth for a variety of excellent reasons. For some women it's a desire to experience their low-risk, healthy pregnancy not as a medical condition but as a natural state - a healthy state - with a provider who encourages them to trust their bodies. Maybe a woman doesn't wish to expose herself to potentially unnecessary medical interventions, but wishes to create an environment and experience that speaks to the ways in which she and her family envision welcoming their baby into the world - in a way that seems most compatible with midwifery and out-of-hospital care. Other women are distrustful of our health care system's tendency to treat pregnant women (or any seeker of health care) as merely a consumer or a number without a name, on the receiving end of depersonalized care. Some women view the mainstream medical establishment as patriarchal and demeaning, in general, and reject the idea that "doctor knows best" in any and all situations regarding pregnancy and childbirth.  This is not say that ob-gyns cannot be excellent, loving and responsive care providers. There are millions of us out there who are indebted to these kinds of ob-gyns, undoubtedly. Midwives understand the value and importance of a trusted, respectful physician as a partner in a woman's care, should she need it. 

The midwifery model of care may be an appealing option for many women because it starts from a place of empowerment - if you can envision it, you can do it. Start with an intention of the kind of birth you wish to have, my midwife and doula told me, and we'll go from there. Maybe you have a vision of birthing outside but never dreamt it was possible - as one woman on Ricki Lake's web site writes of her own desire: "I told my midwife of my dream. Her exact words were, “mmmmmm, that sounds beautiful. Is that something that you would like to do?” That floored me since I wasn’t at that point asking to have an outdoor birth." Or maybe you'll plan for the homebirth you've been expecting and midway through your pregnancy, or after hours of labor, your midwife tells you you'll need an emergency cesearean section, in a hospital. Birth doesn't always go the way we plan - no matter where or with whom we choose to birth. The issue at hand, however, is not that we can possibly know exactly how it will end up but why we wouldn't think that we deserve to do everything we can to experience pregnancy, childbirth and the days and weeks postpartum in a way that feels best and right for us - most importantly, winding up with a healthy newborn warm against our chest, asleep next to our body. The Today Show may present homebirth as an option to be feared but that's only because the unknown is often times a scary venture. If you look at the evidence and listen to women's experiences, It doesn't have to be that way.

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