ron rothman.ron rothman
selectively conformist

Is Home Birth Courageous?

It’s funny. I’ve recently been told—by more than one person—that Sara and I are “brave” for planning to deliver our baby at home. This from people who are educated, intelligent and have my respect. And yet, they couldn’t have picked a worse way to characterize the decision. What’s going on here?

Read on, and then you tell me: isn’t it actually more courageous for a low risk mother-to-be to voluntarily walk into a hospital to give birth?

First, let me point out that:

  1. “Home birth” means planned home birth. The process starts at home, but in those cases where a doctor’s intervention is warranted, the mother is taken to a nearby hospital.
  2. A planned home birth is attended by a qualified, certified midwife.
  3. In this article, I’m simply answering the question, “Isn’t home birth unsafe?” I won’t focus on “Why is home birth better?”

Q. Isn’t hospital birth safer?

A. No. If you’re a good candidate for home birth (and the majority of women are), then a planned, attended home birth is as safe, or safer, than a hospital birth.

Q. Come on, how can a hospital not be safer?

A. Surprisingly easily.

If you’re giving birth and you’re low-risk, then simply checking into a hospital greatly increases the likelihood of unnecessary interventions–pitocin drip, epidural, episiotomy, cesarean section, et al.–with no corresponding increase in safety for mother or baby.

I can also tell you this: my home is more sanitary (with respect to virulent infectious agents) than the cleanest hospital maternity ward [11].

Q. How do you know that home birth safe?

A. Evidence. Sara has searched through the medical literature, and every relevant study she has found has shown that home birth is as safe, or safer than, hospital birth. See references below.

The upshot of the research [1] is this:

Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.

Q. What if something goes wrong at home?

A. First of all, it’s worth noting that in the majority of cases, nothing goes wrong. Expecting that things will go wrong just isn’t rational. On the other hand, preparing for things that might go wrong, even if they’re unlikely, is wise.

Certified nurse midwives are trained, equipped and experienced at solving the most common (and remember, “common” is relative) problems. They’ll bring with them, into our home, oxygen, pitocin, resuscitation equipment, etc. Using instruments identical to those used in a hospital, they can stop hemorrhaging, perform an episiotomy, stitch tears, etc., as needed.

And, of course, a trained, experienced midwife will know if you need emergency intervention (e.g., cesarean), and in that case she will get you to the hospital and have the staff prepped and ready to receive you once you arrive.

Also, it’s important to note that you’re more likely to have one of these problems just by being in a hospital; birthing at home reduces the likelihood of many of them in the first place:

A study by Mehl compared a group of 1046 women giving birth at home with 1046 women having hospital births and found [8]:

  • 9 times as many episiotomies
  • 15 times as many women receiving analgesia or anaesthesia
  • 3 times as many caesareans
  • 2 times as many forceps deliveries
  • 3 times as many postpartum haemorhages
  • 3.7 times as many babies requiring resuscitation
  • newborn infection rates 3 times higher
  • respiratory distress 17 times higher
  • lower Apgar scores
  • mortality figures were the same for both groups.

Q. But I heard a horror story about a home birth…

A. I’ve heard and read lots of scary anecdotes about both home birth and hospital birth. At the end of the day, my decision is driven by evidence, not anecdote.

Q. Midwives?? Aren’t obstetricians the experts at delivering babies?

A. In some deliveries, yes. Obstetricians are trained as surgeons, so that they can c-section a woman who needs drastic intervention. Consequently, that’s what they’re best at. But most women do not need a cesarean, and in that majority of cases, going to a surgeon may not (and often does not) provide the best outcome. (Part of a “good outcome” is avoiding a c-section unless it’s truly necessary. Some are necessary; most are not.)

Certified nurse midwives, on the other hand, are trained to handle healthy, normal births, including several types of non-drastic interventions. This is their expertise. They make sure that things are progressing properly, and know when to transfer you to the hospital if an obstetrician’s expertise is indicated.

Sidebar: “My c-section was necessary.”

Okay, yours may have been. But most c-sections that take place (yes, the majority of them) are necessitated by earlier “routine” interventions, which, in many cases, were not required in the first place. Henci Goer describes this “cascade effect” clearly [3]:

Every intervention into the normal process [of labor] introduces risks as well as benefits…. When intervening becomes routine, meaning there is no reason for it, only risks remain. Moreover, because one intervention tends to lead to another, it produces a “cascade effect.”

So, for example, electronic fetal monitoring confines women to bed, which may slow labor. Doctors may then give oxytocin, which increases pain, causing women to want an epidural. The epidural may slow labor or cause abnormal heart rate patterns, ending the cascade in a cesarean section for poor progress or fetal distress.

The bottom line: many c-sections are made necessary by the routine protocols followed by hospital practitioners. [2]

Q. But I had my child in a hospital, and we’re both fine.

A. That’s great. Most hospital births go well, and are safe. (Hey, I was born in a hospital, and my mother says I’m perfect, so…)

Q. If home birth is so good, how come more women don’t choose it?

A. You can’t choose something if you don’t know it exists. Most of us in the U.S. (myself included) have been conditioned to go to a doctor when we get pregnant. I didn’t know the first thing about home birth until 12 weeks into our pregnancy; and even then, I thought it sounded crazy. That is, until I read the evidence about home births and hospital births, and their respective pros and cons, and realized that home birth was a wonderful option for us.

In the U.S. today, midwife-attended births are on the fringe. Not so in other developed countries. Holland is probably the best example of a country with a high rate of midwifery (and home births) and an excellent, low mortality rate (lower than the U.S. rate).

Q. Should every pregnant woman have a planned home birth?

A. No. Every woman should learn about the home birth option (and all other options), but home birth only makes sense for pregnancies which meet certain conditions, e.g., low risk, singleton (no twins), no breech. [4] [But see reader comment #3 for an alternate opinion.]

Q. I’ve read what you’ve written. But what if I still don’t want a home birth?

A. Okay. An informed decision–either way–is a decision well made.

Conclusion

In the end, it’s not the location of [a low-risk] birth that dictates how good the outcome will be; it’s who’s running the show. The people running the show in a hospital are well-intentioned, but much more likely to take unnecessary (and unpleasant) actions. Period.

References

  1. [1] Outcomes of planned home births with certified professional midwives: large prospective study in North America, British Medical Journal, 2005;330:1416 (18 June)
  2. [2] Cesarean Birth in a Culture of Fear, Mothering Magazine, Issue 144, September/October 2007
  3. [3]Goer, H., The Thinking Woman’s Guide to a Better Birth, Perigree, 1999
  4. [4] Homebirth 101, ivillage.com
  5. [5] Collaborative survey of perinatal loss in planned and unplanned home births, BMJ 1996;313:1306-1309 (23 November)
  6. [6] Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study., J Nurse Midwifery. 1995 Nov-Dec;40(6):483-92.
  7. [7] Young, G. and Hey, E., Choosing between home and hospital delivery, BMJ 2000;320:798 (18 March 2000)
  8. [8] Responses to Home births or hospital? It’s baby who knows best by Karen Robinson, The Sunday Times (UK), 29 August 1999.
  9. [9] Joint Interregional Conference on Appropriate Technology for Birth, World Health Organization, Regional Office for Europe, April 1995
  10. [10] Home Birth vs. Hospital Birth – Issues of Responsibility, March 2006
  11. [11] Hospital Birth and Risk of Infection, June 2006
  12. [12] Cesarean Fact Sheet, Childbirth.org
  13. [13] Normal Birth – What are the Chances?, Sally Tracy
  14. [14] Ina May’s Guide to Childbirth, Ina May Gaskin

16 Responses to “Is Home Birth Courageous?” [Leave yours »]

  1. jessjgh1 said:

    Wow, this is an awesome summary of the issue. I sure wish I could have show my husband this when we were considering homebirth for baby #2. I was unable to capture the simplicity and logic of the issue- and you have done that very well.

    What a resource for others looking into homebirth! Especially those that need help convincing a husband or partner. This is a great place to start…. Read this, keep an open mind, do your own research.

    I had a hospital birth because I couldn’t relieve my husbands anxiety over homebirth… and I wish I had had an article like this- it would have helped. I was fortunate to find an alternative I was comfortable with… otherwise I would have pushed him for the homebirth. But the environment I found for our birth is (sadly) extremely rare amid the hospital culture.

    Homebirth is an extremely viable option. The only other good alternative is to create major change in hospital birth and culture– or in most cases, go in armed with information, support, and ready to demand respect for the birth experience that should be ‘normal’. Birth should not be a battle, but so often, in a hospital a woman wanting a normal natural birth has to be ready to fight for that right, and those that are not prepared are often taken advantage of. That’s how I felt my first birth experience went, and the 2nd time around I was much more aware of the choices and options I had.

    I didn’t let that happen a 2nd time, but again, I shouldn’t have had to do so much to arm myself against our birth culture

    Jessica jessjgh1

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  2. Ron, this is a great summary of the question of the safety of home birth. I especially appreciate the references.

    Birth is so mis-represented in the mass media (think of all those movies where the couple rushes to the hospital when the woman has the first contraction). Combined with the dislocation of the family and the fact that women are having fewer children than in the past, most people only have very limited exposure to what real birth is. Therefore they are highly susceptible to anecdotes, dramatizations, and scare tactics. Often these scare tactics are used by doctors to press their patients into complying with the interventions they recommend, but more often they are used by well meaning friends and family who just don’t know better.

    “Something could go wrong…” – well, yes, but something could go wrong at any point in your life and most people do not deal with that risk by living in a hospital. They go to the hospital once something is starting to go wrong.

    There is a huge misconception that if you use a midwife as your primary carer that you cannot have access to a doctor. People who plan a home birth also prepare a backup plan, that includes what hospital to go to in an emergency and what doctor to call. In fact, in Australia, where some people live very far from medical services, midwives will advise against a planned home birth if there is no hospital nearby, recommending instead that women relocate near a hospital for the time around the baby’s due date specifically because the midwives know that there are circumstances that require the intervention of a doctor and that they cannot responsibly do their jobs unless they make sure their patient is within reach of those services should they be necessary.

    Many people think that obstetricians are trained to deliver babies, but that is actually not true. Midwives are trained to deliver babies (or “catch babies” as many prefer to say). Obstetricians are trained to deal with births where the mother or the baby are unwell. They are trained to deal with emergencies. They are trained to do surgery. When birth is not an emergency (which is largely the case) then they are unnecessary, but if you entrust your labor to an obstetrician rather than a midwife, then it is likely to be treated as if something is going wrong. When you have a hammer, everything looks like a nail. You have done a good job of documenting that above.

    Furthermore, the method of dealing with emergencies is shifting more and more towards cesarean sections as doctors get less and less experience learning how to use forceps, vacuum extraction, and other age old techniques of coaxing babies down the birth canal. It is a common misconception that you can avoid the pain of childbirth by having a c-section. It is true that you may not feel labor pains, and you will almost certainly avoid tearing of the perineum or an episiotomy, but you will also endure major surgery, with risk of significant blood loss and infection, and a four to six week recovery period, all when you are required to provide round the clock care for your newborn baby. There is no doubt that the c-section is a valuable tool, but not one you want to endure unnecessarily. The New Yorker ran an interesting if slightly annoyingly celebratory article on the history of the c-section (apologies for all the adverbs there).

    It is worth noting that most women remember their birth stories very clearly, and generally feel they did what they had to given how their bodies reacted to being pregnant, but often women are duped into believing they failed labor and their doctor saved them, when in fact often it is the contrary case of the doctor’s actions creating medical complications that then need further medical intervention. Naomi Wolf’s book Misconceptions provides a detailed analysis of how the medical profession has disempowered women and midwives in the US over the past century.

    Finally, most births are attended by a midwife. The obstetrician whizzes in a few times for a few minutes while the mother is in labor and may be there for 20 minutes or so when the baby is actually born. The rest of the time it is midwives who are caring for the mother and helping her to progress the labor. If anything, having a doctor who expects you to respect that he is a very busy person interrupt this intimate and timeless experience creates tension when it is least appreciated. So avoid the tension, and the risks of intervention. Avoid the hospital rules (which neither of us has touched on – but are often used to force a woman into an intervention that she would otherwise decline). Have your baby at home.

    Caveat: there are a large number of conditions that really do require specialist medical treatment in pregnancy. If you happen to have one of these (multiple gestation, diabetes, etc.) then home birth is probably not appropriate for you – the important thing is to determine which category you fall into (and it’s not always straightforward).

    One last thing: the mingling of the medical and insurance industries have colluded to make home birth more expensive to the mother than a hospital birth, even though the actual cost of a home birth is much lower. This acts as a disincentive to women who might otherwise consider home birth. By reducing the incidence of home birth, the industries have kept home birth on the fringes of people’s consciousnesses, minimizing its ability to threaten the supposed supremacy of the medical industry.

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  3. tabitha said:

    i dig it! as a homebirth mom, of course, i agree. except:

    1) cnms and cpms are not the same thing. if i chose a midwife (as i did for my second child) i would choose a CPM [Certified Professional Midwife] over a CNM [Certified Nurse Midwife] any day. a personal choice, but everyone should know that the name midwife doesn’t always mean the same thing.

    2) planned homebirth is not always attended by a midwife. for instance, i homebirth unassisted. my births are planned and safe.

    3) twins and breech babies are often safely born at home. most DOCTORS do not know how to birth breech babies vaginally, it is true. but many, many, many an unnecessary cesarean has been given for both twins and breech babies. being at a hospital makes this almost inevitable. in many states you can find midwives who will help you deliver your breech or twins, or breech twins!

    anyway, i’m not just looking for something to disagree with, i promise. a very nice entry that i will surely pass on to others. -tabitha

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  4. Sara said:

    Tabitha,

    Thanks so much for your comments – we erred in not including CPMs along with CNMs. (I’ll try to get the webmaster to edit that. :) )

    We intentionally left out unassisted homebirths, simply because all of our references and source studies were limited to homebirths attended by either a CPM or CNM. Thanks for pointing out that twins and breech can be safely delivered at home. In our particular situation, (I think) our midwife will deliver twins at home, but she won’t do breech births at home – I think it varies by midwife? Thanks again!
    Sara

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  5. One more thought – perhaps people think you’re brave for facing all the people who would second guess your decision.

    [Ed. Note: Thanks for giving our friends the benefit of the doubt, :) but that’s clearly not what they meant.]

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  6. I found the link to this on mothering.com’s message boards. I homebirthed my 2nd & 3rd children with a CNM attending.

    Wonderfully worded article. I love to see this written from the father’s perspective. One thought in response to comment #2, last paragraph. It appears at first glance that a hospital birth (after insurance) is less money out-of-pocket than a homebirth (if the homebirth isn’t covered by insurance), but I have found this not to be the case for many women. I have seen women pay far more in the 10% insurance co-pay for the unnecessary (that is to say, preventable) hospital interventions, including epidurals, C-section, NICU stay, spinal tap on the baby, medicine for the “sick baby,” Bili-lights for the jaundiced baby (due to epidural sleepiness & not being allowed to nurse early & often), etc. Had they known from the beginning how much that hospital stay would cost them, both monetarily and in unnecessary risk, pain, and suffering, they might have gladly pursued that very affordable homebirth, even if it were 100% out-of-pocket.

    Incidentally, the insurance co-pay (our out-of-pocket pay) for my non-medicated, intervention-free, non-complicated vaginal hospital birth of my 1st child in 2002 cost about the same as a homebirth would cost 100% out-of-pocket, in my area ($2500-3500). Luckily, my homebirths were covered 80% by our insurance (would have been 90% but my MW was out of network) so my homebirths cost $600 out-of-pocket.

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  7. Ron [author of post] said:

    (Thanks to all who have commented!)

    For what it’s worth, we verified today that our medical insurance does cover home birth when attended by a certified midwife. Our midwife is out-of-network (are any midwives in-network?), which means we’ll end up paying 30% (or about $1500) of the cost out-of-pocket.

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  8. In regards to the cost, my comments were based almost completely on my experience here in Australia, which I thought mirrored the US, but apparently US insurance companies are more enlightened than Australian ones are.

    In Australia, if you receive private care from a midwife (i.e. care from a midwife that is not an employee of the hospital while you are a patient there) then you bear the entire cost. Medicare doesn’t pay anything and health insurance (with few exceptions) doesn’t pay anything.

    In contrast, if you book into a public hospital for your care, which is overseen by doctors even if you have many of your pre-natal visits with midwives, then the government pays for everything. With my first child my only out of pocket costs were for my prescriptions and the parking.

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  9. Elizabeth said:

    I had a homebirth not to avoid medical care, but because homebirth provided me with *better* medical care. My midwife had 27 years of experience with all kinds of unusual circumstances (that would have been “emergencies” at a hospital), to say nothing of the confidence in natural birth that comes from attending hundreds. An obstetrician does not attend the labor, usually- s/he attends the “delivery.” A midwife and doula are there for the whole process; this is what has been proven to make a concrete, biological difference in outcomes.

    When I worked as a doula, I had one client whose doctor was late. The nurse assigned to her just happened also to be a homebirth midwife (who worked with my own). Unlike any other hospital birth I attended, the mother was comfortably seated on her husband’s lap, the baby was guided out with only a small tear, and there was silence in the room. I looked up to see a horde of L&D nurses in the doorway, spellbound. They all rushed to the scene after hearing the nurse would handle the delivery; not one of them had ever seen a birth like that.

    My midwife handled my friend’s fourth birth, a footling breech in a birth pool at home. She called for emergency assistance (another common misconception is that midwives somehow do not know when to transport for medical intervention), but as the fire truck arrived, the baby was born. The firemen congratulated the family and took all the small children in the house for a ride on their truck. Renowned obstetrician Michel Odent says that the only way he will deliver a breech is if the woman is upright- in other words, there are techniques other than cesarean for delivering unusual presentations, if a practitioner is properly trained.

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  10. I am quickly becoming more and more educated about home births, thanks to a few message boards I am a part of, and a bit of research on the internet.

    Both of my births were in the hospital, with not too much intervention, but I’m not so sure I would make it to the hospital the third time! (I’m not pregnant right now, but thinking of the future). I want to make sure I am totally ready for a home birth, and who knows, by then maybe I will have decided to go with a midwife. In Manitoba they are covered by health care, so I wouldn’t pay a cent!

    My first birth was quite traumatic for me, and I believe it was due to the Demerol that they gave me. I did ask for it, so it’s not like it was their fault, but if I had known that I would only labour another hour or two til I was ready to push, I never would have taken anything.

    With my second, I was already 7 centimeters dilated when I got to the hospital, and that was after only 1 hour of labour, so I knew I didn’t have time for any intervention, which was totally fine by me! My second baby came into the world after 3 hours of labour and 10 minutes of pushing. I have an amazing family doctor though, who reminds me far more of a midwife. She knew to tell me to only give little pushes, and to let my body do most of the work. She calmly talked to me the whole time, holding my hand.

    The one thing I would like to change is that for both births it was so intense that once I lay on the bed, I really couldn’t move to get up again. I would like to try squating in a birthing pool. In our hospital, if you have a midwife assisted birth, you can use a pool, but a doctor assisted birth, you can’t. So, I might have to do something about that!

    Thanks for informing me even more. I’m going to continue my research.

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  11. Cheryl said:

    It was great meeting you guys on Monday and I can’t wait to hear about your birth!!

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  12. Ron [author of post] said:


    Update: We now have a wonderful son! (*)

    There were some complications(!), but the midwives handled them perfectly.

    But I do now realize that there’s one major disadvantage to a home birth: I never got to speed to the hospital without any regard for traffic laws. I can honestly say that I’d been looking forward to that for many years.

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  13. Jessica said:

    !!!Yeah!!!
    Congrats!

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  14. I am so envious of your beautiful homebirth… it would seem like the greatest dream to me to be able to give birth at home.
    Sadly, my first daughter, on the 13th of May, 2003, died while I was laboring at home. I will never be able to not second guess whether being in a hospital could have saved her. Thus, I am now tied to the hospital, and technology is both my friend and a very effective tool for maintaining my mental health during birth.
    However, I will add, that my two births that followed Charlotte’s death were very independent, drug free (at least until the prolapsed cord was discovered at 10cm with my son) and very much guided by me. I feel fortunate to have access to a birthing center where mothers are always encouraged to take the upper hand and always get the last word in (at least if you are bossy like me!) It would be my hope that in the future women could be encouraged to take charge of their own births and not let hospital staff dictate the course of their births so as to draw in unnecessary complications.
    I wrote about this on my blog a lot a while back, but really it comes down to this: once you become part of the babylost world, you have sympathy for those doctors: if you had the choice to maybe intervene and maybe save a baby’s life, you should. Because having your baby die is an experience I would wish on no-one. I assure you pitocin, a c-section, or anything else you might be handed is better than waking up the day after you give birth to an empty womb, leaking breasts, and no baby to feed.
    So, after that brief defense of hospitals and their staff, I do in all honesty congratulate you, and please know that I only wish I could have been so fortunate.

    Editor’s note: See Ron’s response below.

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  15. Ron [author of post] said:

    Carol, I’m so sorry you lost your first baby. As a new father, it hurts me just to imagine the possibility. I have friends and family who have lost babies and I’ve seen how hard it is on them. (Just for the record: all my babylost friends were planned hospital births.)

    I’d like to clarify a few things, because your comment may be taken by some readers as a backhanded argument against home birth.

    I found your story in Mothering magazine, and from what I can tell, your baby died in the hospital, not at home; and it seems likely that she would have had the same sad fate even if you had planned on a hospital birth.

    I agree with you: it’s useless to speculate either way. All we can say is that (a) some babies die during birth (whether at home or in the hospital), and (b) low-risk babies die at the same rate in hospital births as in planned, attended home births. (See references, above.)

    Carol, your story is moving, powerful and sad. In the end, though, I’m sure you’d agree that mothers-to-be should be driven by data, and not by anecdote. Your birth story is sad, and my home birth story is happy; but both are irrelevant to a pregnant woman who is deciding how to birth her child.

    Thank you for posting and for furthering the discussion.
    – ron

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  16. Sarah Dorrance-Minch said:

    Thanks for posting this.

    My first child was brought into the world by a 100% All-American unneCaesarean, after the usual hospital routines (including forced withholding of food) gave me a migraine, which somehow led to the decision to give me an epidural, and the rest was pretty much typical of what happens with a cascade of interventions. And I had a nurse-midwife!

    My second child was a hospital VBAC miserable enough that I perceived it as a rape. (We’d already picked out a direct entry midwife who had experience with the Amish, but severe gastroenteritis triggered premature labour, which I didn’t know about until the paramedics insisted on taking me to the maternity ward – the maternity ward! – where I was told that I was ten centimetres dilated and coming out of transition. Oops. the less said about what happened next, the better.)

    My husband caught our third child in the bathtub five minutes before our midwife and doula arrived. That was easily my best birth.

    We’re expecting another baby in August, and planning to birth the baby at home again. Of course.

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