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Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE

Lately, with the publication of data on almost 17,000 planned American home births, the “home birth debate” has been reignited, sparking all kinds of conversation – some polarizing, some rational, and everything in the middle. A glaring oversight I see in this conversation, though, is that, while statistics are helpful, what’s most important to families making decisions about where to give birth is what is safest for each woman and her baby, in their unique circumstances.

 

The variability in options and quality of care across the country is stunning.  In Southern California, a low-risk woman might have access to several high-quality hospitals, a lovely birth center, and a dozen respected midwives who enjoy good relationships with the local medical community.  This woman has the luxury of considering what large data sets may say about the optimal location for her birth.

 

But this is not reality for too many American women.  For them, options may look more like this:

 

A Kentucky woman has two children at home; one car, which her husband takes to work 6 days a week for 13 hours at a time; and zero wiggle room in the budget. The nearest hospital, which is over 90 minutes away, has a Cesarean rate of over 50% and this woman knows from friends and relatives that admittance there means she loses any say over how she gives birth. While the children’s grandparents are happy to help with childcare when they can, they work full-time, too. For this family, an unnecessary surgery and extended hospital stay or re-hospitalization would be devastating. In Kentucky, 76 out of 120 counties have no obstetricians and many areas where women must drive at least an hour to reach one; there are zero birth centers, and few legal home birth midwives. Because home birth options are so limited by law, there is little transparency about who this family might hire to assist them outside of the hospital.

 

 In Arizona, a woman is pregnant with her fifth baby.  Her first baby was a C-section after a 39-week induction for “suspected big baby,” and she’s regretted agreeing to that non-evidence based induction ever since.  Her next three babies were born vaginally with a different, wonderful doctor at that same hospital.  After her family moved across the state, she found out the only hospital in her area does not allow vaginal birth for anyone who has ever had a C-section.  She’s not willing to have non-medically indicated surgery.  Even if she and her husband could afford to travel to another hospital three hours away, they can’t imagine the logistics and expense of taking their four children there to stay for an indefinite amount of time waiting for labor to happen.  (Today in Arizona, legislators are debating whether to prohibit women from having supported home birth if they have had a prior C-section or are carrying a breech baby or twins.  A seemingly reasonable safety measure?  In context, this means a good number of those women will face mandatory surgery at their local hospitals if this bill passes.  Some will submit to the surgeries; some will leave the state to give birth; some will have unattended or illegal home births.)

 

 In Delaware, a woman has experienced a traumatic hospital birth with a doctor who left her feeling sexually abused after forcefully penetrating her several times, although there was no medical emergency.  She’s still paying bills from that hospital visit, which ended in PTSD and a failure by the doctor and hospital to respond to her complaints about her mistreatment.  She cannot imagine ever entering that facility unless there were a life-threatening emergency.  Because of her family’s financial situation and the fact that she has other small children requiring care, it’s not possible for her to travel to another local hospital or to the single birth center in the state.  Home birth there is essentially “underground,” with only one legal midwife in the whole state, which translates to a measure of uncertainty about who this woman might hire illegally and how seamless a transfer to the hospital would be, if there is an emergency. 

 

 In Louisiana – the state with the worst infant mortality rate in the U.S. – a woman is pregnant for the fourth time, having had one prior Cesarean, followed by two uncomplicated vaginal births in another state.  There is one birth center in Louisiana, but it did not offer vaginal birth after Cesarean as of January 2014, and the only hospital within driving distance has a 47% C-section rate, a ban on vaginal birth after Cesarean, and a local reputation for being unsanitary, poorly staffed, and, based on a Consumer Reports publication, rife with medical safety issues.  They don’t allow doulas at all.  She applies to the state for permission* to have a well-respected licensed midwife (one of eight in the whole state) attend her at home instead, and is denied because of her previous C-section.

 

 A woman in New York has her first baby at the local hospital, unmedicated and without intervention.  However, she has to fight every step of the way to avoid risky interventions (like this) and must compromise on some things in order to get others.  Hospital protocol includes a number of non-evidence-based practices, including routine admission stripcontinuous electronic fetal monitoring, restriction to bed on the backprohibition of anything by mouth except ice chips, and a 12-hour time limit to give birth.  Staff is irritated that she has a doula, and upset with her for declining routine procedures.  They insist on keeping her healthy baby “in observation” for four hours after he is born despite an Apgar score of 9 and no medical indication.  When she begs to meet her new baby, she is told that observation is mandatory.  Her husband then attempts to advocate for her and is told CPS could be called if he continues to try to see their baby.  Later, the family meets with a lawyer and is told that there is nothing that can be done legally either about the attempt to force certain interventions or to withhold the baby.  Both parents realize that entering a hospital again means they have no meaningful right to say “no” to anything. 

 

 In California, a woman who has had a C-section faces a hospital ban of vaginal birth after Cesarean.  Her insurance refuses to pay for her to go elsewhere, citing the “lack of medical necessity” of vaginal birth.  She spends her entire pregnancy fighting with the insurance company over this policy and is denied six times in her appeals. 

 

These are the hard choices real women are faced with.  We hear from them at ImprovingBirth.org every day.  They are not making purely statistical calculations among sterilized ideals of birth locations.  They are making difficult, individual analyses among limited options – and among providers who practice very differently.

 

Recently, someone asked why a woman might choose to give birth outside of a hospital, and I replied, “Because I am less afraid of my body than I am of non-evidence-based hospital protocols.”

 

I truly don’t know if I would choose a home birth, but I do know that the hospital across the street from me has a 40% C-section rate and will call CPS if I decline a routine, non-evidence-based newborn procedure on my baby.  I know, from speaking to other mothers, that I “must” give birth by 41 weeks, and if I decline an epidural or medications to speed up labor, I could face ridicule from my caregivers or even a punitive episiotomy if I get unlucky with who is on call.

 

Knowledge like that complicates these decisions immensely.  The question for me isn’t so much, “Is home birth safe?” but, “Is home birth less dangerous than hospital birth?”

 

The truth is that there’s no such thing as “safe” or risk-free birth in any setting.  For each of us, “safety” and “risk” are complicated calculations made within limitations of our individual circumstances and the options at hand.  For mothers and families making these important decisions, statistics are helpful, but statistics only illuminate the corners of our own unique sets of certainties and uncertainties.

 

Polarizing arguments and digging in our heels about these issues don’t make birth safer.  Insisting that one location is always safe and one location is never is ridiculous. Pretending that all women are making decisions based on a full set of good options or the same set of health circumstances is unrealistic.  Making judgments about someone else’s personal circumstances is nonsensical.  We can never know all of the factors that go into those complicated decisions.

 

Home birth has been around since humans have been, and it doesn’t look like it’s going anywhere.

 

Hospital birth is where 99% of American birth takes place, and I doubt it’s going anywhere, either.

 

For real people making real choices, let’s open up the discussion with compassion instead of trying to choke it to death.  Transparency and collaboration can make birth safer in all of these settings, but it can’t happen in a hostile environment.  If we can let go of our own biases of where women “should” give birth, maybe we can start making birth safer in all of those locations.

 

* Louisiana is the only state that requires some individual women to seek permission from a state agency (the State Board of Medical Examiners) to hire a midwife for home birth.

 

Author Cristen Pascucci is Vice President of ImprovingBirth.org, and she’ll be in Los Angeles on March 23 to host “Stand On Your Rights L.A.: Demystifying Legal Rights in Childbirth & How to Use Them.”  

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More articles from Cristen here.

 

Want to support ImprovingBirth.org’s mission? Like us on Facebook, participate in our history-making 2013 Rally to Improve Birth, and donate to the cause.


60 Comments

  1. Those examples are quite sad and make me feel very lucky to live in Australia. I have had two public hospital births and, if anything, the midwives were more enthusiastic about natural birth and no intervention than I was.

    I was open to the smorgasboard of drugs, epidurals and even a caesarean, but they talked me out of it. They were strong natural birth advocates despite working in a mainstream public institution (not a birthing centre).

    So, I just wanted to share that experience so hospitals and medical staff weren’t all stereotyped as such scary non-negotiable interveners.

    • Barbara Wilkey

      Most American hospitals won’t allow midwives in th lo ugh, let alone hire them along side doctors(as they should) and as your hospital did.

      • Brenda Osborne

        Barbara, Sure they do! American hospitals have CNMs (certified nurse midwives) which are great resources for low risk women seeking low-intervention births. Let’s stop the spread of misinformation about hospital birth. People need to know what instead of meekly delivering at home, you can actually just go to the hospital and tell them what you want.

      • eyecatcher

        @Barbara – RE: “Most American hospitals won’t allow midwives in”
        WRONG. EVERY American hospital allows *qualified* midwives in with adequate training and education. They’re called CNMs. And guess what? CPMs aren’t allowed in hospitals in any other 1st world nation either.

        It’s not about turf wars. It’s about qualifications.

        • Cristen Pascucci

          I’m afraid it’s not true at all that every hospital allows midwives. In fact, one of the three hospitals in my own town (I wrote this article) does not allow them, CNMs or otherwise.

    • There are hospitals in Australia that are guilty of providing poor care too. I can relate to two of those cases and have only had one hospital birth, it pushed me to have a free birth the second time round and now we are having another homebirth but with a midwife. It all depends on who you get when you are in labour, I am just not going to risk it again!

    • Out of interest where in Australia was this experience because I have yet to witness this !!!!!!

  2. Stephanie Austin

    Hawaii just stopped 3 bad legislative bills which would have effectively curtailed home birth as an option for mothers. Now, a ‘task force’ has bee proposed with 19 members, including home birth mothers, native practitioners, CPM’s, CNM’s, obgyns, Dept. Of Health, hospital, neonatologist and others – most likely weighted on side of hospital birth. My question: can your organization provide an opinion of which existing state laws. (Idaho ? Oregon?) provide the best options for mothers seeking home birth and the most support forodwives? Don’t know if you or any other group has done a side by side analysis. This could save a lot of time and help deflect those who will use this opportunity to try to severely limit home birth. Thank you -

  3. There is one birth center in Louisiana. It is Gentle Choices, located in Lafayette, and is CABC accredited. However, it is also quite expensive for cash-pay clients and cannot accept Medicaid, which pays for around 70% of births in Louisiana. Also, the board of medical examiners never approves or denies VBAC requests. A more likely scenario would be this woman can’t find an obstetrician to say she is low-risk, which is mandatory before a midwife can take on her care. Or that after she has to lie to an obstetrician about her birth plans in order to be seen by a midwife, who then must send her private health information to the board with a VBAC request they will never answer and she and her midwife must assume no answer=permission (which is a huge assumption).

    • Charlotte, thanks for the info! That’s funny – I have never met a Louisiana woman who knows about that birth center! Will be sure to pass that along.

      I have seen the documentation for this woman. Not only did her OB “approve” her request, she actually RECOMMENDED it because this woman has a history of precipitous labor. Her last baby was born on the floor just as EMTs arrived; she wasn’t even able to get out the door to go to the hospital! I have a copy of the letter from the state board, and the re: line is “Request for VBAC approval.” Interesting side note: they took four months to process the application and deny her, and another month after that to notify her in writing, which left her in quite a bind at the end of her pregnancy!

    • Charlotte, as a mom who had a cesarean in baton rouge, hospital vbac,and then a Hbac my OB and I most definitely has to submit a letter to the medical board of examiners for their approval of my midwife my on, and I to have an Hbac. It is in the rules and regs.

    • Sherri Daigle

      Charlotte, while I would not agree that LSBME has a right to ‘grant permission’ for VBAC’s, I would still have to say that no client of mine has ever been denied a HBAC with me. They have never failed to answer. I can’t speak for anyone else. My understanding is that they are rethinking and drawing away from VBAC’s at home. For that particular case, they claimed the woman had other dubious reasons for high risk??? Quandary, LA

    • Louisiana Midwifery is constrained by our ancient Midwifery Law, archaic Rules and Regulations and the dominance of the Louisiana State Board of Medical Examiners who govern Licensed Midwives. Doctors don’t want to take the controversy on, and so remain opposed or otherwise apathetic to the out of hospital VBAC issue. My OB refuses to support out of hospital VBAC because of pressure from his colleagues not to cover him for backing the birth center.

      In order to provide low risk midwifery care, I respect the collaborative agreement with my OB/GYN that limits my practice from VBAC at the birth center where I am Clinical Director. Doctors put pressure on one another not to participate around the country, thus more and more birth centers are backing down from providing VBAC services because they will loose their essential relationship with the transferring hospital and OB collaboratives.

      While we are an Accredited birth center, we must continue to follow low risk guidelines determined and approved by the LSBME. Unlike other states we do not have a specified Birth Center Licensure Law, that allows VBACs in their facility. The current opportunity to provide safe ongoing midwifery care to low risk mothers, educating midwifery students and helping to enable the development of more birth centers around the state is more important to me than battling a weakly supported VBAC issue. Midwifery in this state has a long way to go to gain the confidence and respect of the already skeptical medical community and reluctant consumer community without endangering their hard earned trust in us by rallying for out of hospital VBAC privileges. There are not enough midwives, or numbers of women seeking midwifery care in this state to rattle change. Not enough consumers to support our struggle over the years, and not enough of them lobbying openly to be heard.

      Other states with flourishing midwifery practices, birth centers and consumer activism make thunderous changes, but as Louisiana steadily lags behind in almost every benchmark nationwide; we are ridiculously overlooked and entombed in our efforts to shift the old ideas that midwifery is substandard care. So, don’t criticize the process unless you make thunder, support midwifery education, midwifery presence in the hospitals and clinics and by all means get your fingernails dirty in the politics of this state and help. Blogging at best is a passive voice, instead be visible and rally in numbers and prove that Midwifery matters here! ~ That’s just my opinion!

      • Lynette, thank you so much for your honest comment and insight. I actually called Gentle Choices earlier today to ask for input on this before I updated the article to refer to the one birth center in Louisiana! I agree 110% with what you say here. Louisiana is representative of many classic problems in care: few options, outdated laws/regs, a culture that seems to encourage low expectations and little education/participation on the part of women about birth, and a lack of autonomy and respect for midwives – oh, and sky-high costs. As far as we are concerned, LA is a special case, and we’re making many efforts there in all of the ways you mentioned, including four rally locations around the state for last year’s Rally to Improve Birth. I will send you a separate email, as well.

        • The American Association of Birth Centers is working with Lynette and several groups who wish to open birth centers in the state to pass legislation that will license birth centers in the state. Once licensed, birth centers can accept Medicaid clients, thus making birth centers an option for the nearly 50% of pregnant women in most states whose care is paid for by Medicaid. It is an uphill battle, with opposition from many local hospitals, that don’t want competition from freestanding birth centers. We could have new birth centers in Baton Rouge, New Orleans, and maybe also northwestern LA if the state facility-licensing agency would support our bill. But, also, as Lynette point out, it is absolutely essential to amend the state midwifery law and get out from under the Medical Board’s iron control. Change requires advocacy and advocacy requires people to step forward and join consumer grassroots movements to lobby for needed changes in birth options.

          • Medicaid pays for 70% of births in Louisiana and LA has some of the highest healthcare costs in the country.

  4. Michelle A.

    I have great sympathy for the women in the scenarios you describe above and certainly feel these women deserve better. However, these circumstances are not the norm and it would be a disservice to scare women into believing all births within hospitals would go this way.
    The debate is not about safe vs. not safe, the debate is over what is safer and I think when looking at the data there can be little doubt that when looking specifically at infant death rates, hospital birth is safer in this country. Now, every person must do their own risk assessment, but the hard thing is, while a woman’s risk of a c/s is certainly higher in a hospital and no one would doubt that for women who want to birth naturally, they are more comfortable in their own homes, the increased risk in a home birth is an increased risk to their baby’s life. That pretty much supercedes all other risks that we are talking about. Not that I don’t think the other issues you are talking about are really important but we must be careful to not quite literally throw the baby out with the bath water.
    I for one am working hard to change birth within the hospital setting and try to create the best of all works. I am an OB and I fully support naturally laboring women, VBAC, and limit interventions to those medically necessary. I deliver in a hospital with an over 40% c/s rate, but my rate stays around 15% even caring for high risk women. It is not the hospital or even the practitioner that matters, it is about changing the culture in which we care for women.

    • Michelle, thank you for your comment, and I so appreciate your efforts. I’m glad you are here. I think you misunderstand when you say this might “scare women into believing all births within hospitals would go this way.” I wouldn’t assume that by talking about the reality of what does happen in some places that readers would assume all hospital birth is this way. My point, actually, is that we can’t use the word “all” at all. It is impossible to say “all hospital birth is safer” or “all home birth is safer” when these variations exist to such extremes. Certainly, different hospitals have different policies which cover quite a range (for example, requiring women to give birth by a specific gestation), and each hospital has a different culture (we hear from nurses all the time who work in places that are everything from loving to hostile toward women).

      For hard numbers, check out some of the statewide rates on cesareanrates.com for C-sections and VBACs. These numbers, of course, don’t account for the stories we hear from women all over the country about the treatment they received, hospital policies/protocols, and micro-cultures.

    • A huge part of the problem with the debate is that we only look at physical outcomes, and seem to forget that emotional outcomes are important too. I’ve seen the devastated woman after a birth goes poorly…how it really sucks the life out of them, even though they still live and breath physically.

      I definitely agree that there are good care providers out there-I can name many in my local community. But even the best OB care provider can not always overcome an individual woman’s situation that makes a hospital a poor option for her for birth. We must work to make homebirth safer by making continuity of care between home birth providers and hospital birth providers as seamless as possible.

    • Michelle, thanks for being a doctor who walks the talk when it comes to supporting women in labor, no matter their choices about what kind of birth they have. I think you are right about the need for a culture change, and I think that change needs to take place most desperately in hospitals. The crux of the change: treating women like they matter in the birthing process, specifically in the area of informed consent. I truly believe that fewer people would choose homebirth if they believed they’d be listened to and respected in birth. I trusted my OB and the she and the hospital really let me down (and screwed me up) by doing things without my consent. I would never have considered a home birth for the reasons you mentioned. Now, if I became pregnant again, I’d explore the options for homebirth even knowing the risks because of the way I was treated in the hospital. My story is extremely common. Please continue to work with your colleagues to change the culture at your hospital — and others if you can — if you truly believe hospital birth is safer for babies.

    • Melinda Toumi

      Nope. I had three c/s and the maternal death rates on fourth cesareans vs. Vbac was my deciding factor. Slightly higher death rate of baby? Sorry buddy. The duty I have to my existing children and my life both come before a new baby. I don’t expect everyone to make decisions with that same paradigm, but wanted to share that I don’t think the same way. (Btw my hba3c was the most awesome thing I’ve ever done.)

    • Hi Michelle,

      I think you are very privileged to work where you do. I have lived and worked in MA professionally (I am a CPM)for the past 14 years and have had a lot of hospital interaction in transferring clients, acting as a doula at births, and hearing many women’s stories. The stories included in this article are very much what I have seen and heard. I have also seen wonderful practitioners in hospital, but, unfortunately they are few and far between. There are no vbac’s in hospital in my region. One of the three hospitals in my area defied the vbac ban by having moms who wanted them sign waivers. This worked for 3 years or so when the hospital board threatened to fire all the ob’s and the midwife if they didn’t stop all together.

      It sounds like you are one of the very caring and evidence based practitioners. I am so glad you are here to join this discussion and I am so glad to hear you are trying to make changes in the culture. I truly believe that homebirth / midwifery model should be offered in all birth settings so women have full options.

      On another note, I have to wonder if you have really done due diligence on reviewing the information you believe to true about infant mortality and homebirth. For example, if you had to research a treatment option would you carefully look at the studies, or just go with what your colleagues seemed to be doing around you? I am guessing your review of the stats in the area of homebirth has been lacking. Birth certificate data is not high quality and does not differentiate between planed and unplanned homebirth or type of provider (trained?), if any. You might also know that the studies published in this area are by the same controversial researcher. I think it would be more fair for you to look at the research more closely before making such an inflammatory and very unfair statement. Also, you can talk to all researchers involved in the debate easily to answer your questions about research quality. Here is a start: http://midwifery.ubc.ca/files/2014/01/HomeBirth_AnnotatedGuideToTheLiterature.pdf and this, published by a nurse-midwiery journal regarding the latest CPM study http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12165/abstract

    • Whitney Adams

      I researched for this article I wrote about home birth. It is full of sited research material and may be of interest to you.
      http://firehorsemomma.hubpages.com/hub/My-Homebirth-Journey

  5. Wow, this article makes me very thankful to live in an area with many varied options for expecting mamas. From birth centers within “baby friendly” hospitals to free standing birth centers and plenty of freedom and choice for home birth providers we are truly blessed with an abundance of riches within an hour’s drive in the DFW metroplex.

    • Some areas in Texas have excellent options! In a place with such great options, here are two telling incidents about the variations. It’s a big state… This past weekend, a VBACing woman switched providers/hospitals at the last minute to avoid a forced surgery. There’s also this story, from October: http://www.improvingbirth.org/2013/10/tanya/

      • Texas has one of the very best midwifery practice laws and also one of the very best birth center licensing laws in the US. There are more than 60 birth centers in Texas at present and more opening all the time. I strongly recommend TX laws as models for Hawaii advocates to consider.

  6. alisa west

    I’m sorry but I have been.a.doula for over 20years and am now an.apprenticing midwife and these are the norms! Hospital birth is almost never safer with the exeption of high risk pregnancies. its great thada your trying to change the system.from the “inside ” but you first have to get real.with the truth and stop defending a broken.system.

  7. There is an accredited birth center in Lafayette, Louisiana.

    • Thank you! Updating the article

    • Gentle Choices, as of last fall, however was not taking VBAC. Perhaps that has changed. By my understanding from the midwives, doulas, and mothers in the Lafayette area is that one never knows with VBAC if they will be an option at the birth center.

  8. I am a PhD working in maternal child health and fight to have women’s rights and health recognized in pregnancy and birth. These stories are heartbreaking because they show how little women’s humanity is respected. I have a recent posts about informed refusal
    http://humanwithuterus.wordpress.com/2014/02/08/informed-refusal/
    and the right to “high risk” homebirth
    http://humanwithuterus.wordpress.com/2014/02/09/the-right-to-high-risk-homebirth/

    in the coming weeks, I hope to discuss some of the situations/stories here as well.
    Thanks so much for all you do!

  9. Thank you collecting and retelling stories. As a doula I sit down in homes and at coffee shops and hear stories all the time. It’s a priveldge, and slow tideous work. Linking the stories told over time and in safe places to the policy makers in large busy offices is at the heart of solutions.

  10. Marie Pearce

    I am so grateful to live in the UK where real choice is always a legal option (European Court of Human Rights Ternovszky ruling, see http://www.freedomforbirth.com/), even if birth is often over-medicalised in hospital. If a woman doesn’t have rights over her own body at all times, what worth are her rights?
    It astounds me that basic human rights are not respected in the US, it shocks me that a person doesn’t have bodily integrity, the most basic human right there is. Reading this article makes me realise why routine infant circumcision is still practiced – if women have no choice then it’s unsurprising that infants rights are also not respected. I see these two thing as absolutely related and relevant to a discussion on rights and choice in birth.
    Every woman in the world should have the right to a safe birth, supported by skilled practitioners using evidence-based care, every infant should have a right to that same care.

  11. I understand the “need” to be in control.(whatever that is supposed to mean). I flat out would have died if I had chosen to give birth at home. My son would not have lived either. I had a wonderful healthy pregnancy. All looked great. My natural birth plan was going great, and then all of a sudden we were in crisis. My blood pressure almost flatlined and the cord was wrapped around his neck. And that was the beginning of the danger. If not for being in the hospital we would not be here. I know the idea of a c section sucks, but us dying would have been much worse. My second baby could have been an easy home birth, but there was no way I was going to risk her life or mine!

  12. I would like to point out another scenario related to this debate. I have been a labor and delivery nurse for the last 27 years mostly working in low risk and Ldrp units. I also spent 2 years in a high risk l&d unit. In all those years i have never seen a doctor take the c/section road lightly. I suppose I have been lucky in that the doctors I worked side by side with always gave the woman every chance possible to have a vaginal birth, The piece that is missing here is liability, not only for the doctors and nurses but for the hospital also. It is unfortunate, but it is difficult to have it both ways.

    Most of the women advocating for home births have never seen a baby die that did not get the proper intervention. Most of you will say, yes, but what are the odds? I say it only takes one. Besides being a nurse all these years I am the mother of four children, three born in the hospital and the last at home. My son was born at home, with an extremely tight nuchal cord, both his eyes at birth were filled with blood from the broken blood vessels caused by the cord being so tight, my midwife was able to listen to his decreased heart rate via her feta scope but we both knew there would not be time to get an ambulance and get me to the hospital in time for a c/section. My midwife stretched my 8cm sized cervix to complete and encouraged me to push, my son was born with a low 1 minute apgar and subsequently
    appeared to be ok. He is in his twenties now and suffers from epilepsy, birth trauma? no one knows for sure but for me it doesn’t matter, I have to live with my decision. Do I still advocate for home birth? yes and no. Being on both sides of this debate makes it extremely hard, and yes there are babies born all the time at the hospital who die, or have some sort of birth trauma, it just that I would like to know that for me I would like the best of both worlds, access to emergency c/section, access to fetal monitoring to diagnose problems that can be acted on quickly and efficiently.

    What needs to change is our attitudes regarding the home birth and encourage more hospitals to opt for a more “natural” environment within the safety net of a hospital, for more incentives for doctors to hold off performing unnecessary c/sections and to look into more support from a legal stand point to support these doctors. Home birth is fine, but be prepared to live with the outcomes good or bad.

    • Terry, I appreciate your view very much. I am sorry to hear about what happened with your last son’s birth and I hope you have found healing in that time.

      Liability is an interesting animal. From my perspective, the liability climate itself is misaligned based on some fundamental, historical problems with legal rights and practical responsibilities in childbirth. Birth is often seen as the provider’s job, rather than the woman’s – which translates to “by any means necessary” during the process and “the ultimate responsibility” for the outcome. With that responsibility comes liability. That liability is mis-assigned, however, when a care provider is put in the untenable position of delivering a perfect outcome in a scenario that carries inherent risk. And for the woman, her rights are taken right out of her hands along with the responsibility – and the liability. It’s a lose-lose. What is missing there is a recognition of the woman as the legal decision-maker, which would require informed consent as a much more robust process, and help to relieve the provider of expectations that are impossible. Here is a really good discussion of this as it relates to birth: https://www.improvingbirth.org/2013/07/informed-consent-in-childbirth/

      To your last sentence, I would say we should be prepared to live with the outcomes good or bad, regardless of the setting. :) Sometimes, no one is to blame. Birth is not risk free.

    • Terry, thank you for sharing your story and perspective. Your words are powerful, and no one can imagine what it means to ‘live with the outcomes’ of the decision to give birth at home as you do. The risks may be small, but they are real, and they have consequences. I think your words of caution should be heeded. Those of us who’ve had to live with the outcomes of our normal, healthy, straightforward home births would be wise to listen to the voices of women and families who’ve not had these same outcomes. These voices matter. Your voice matters. Thank you for sharing.

  13. After having a vaginal hospital with my son, I became pregnant with twins. My doctor was willing to allow me to try and give birth vaginally, but only if I agreed to a epidural. I did and was able to deliver both twins vaginally and safely. I’m not sure why I HAD to have an epidural in order to have a vaginal birth.

    Getting permission from insurance or the state for how to deliver a baby strikes me as absurd.

    • you were likely required to have an epidural in case the second twin had to be delivered by cesarean for decreased heart tones, flipping to transverse or breech, etc. otherwise in order to do an urgent cesarean you would have had to have general anesthesia and miss your second twin’s birth. that is usually why epidurals are recommended in hospital for twins w mom planning on vaginal delivery.

  14. Midwifery and all home births are illegal here in Alabama unfortunately and I think the closest hospital with a birthing tub is in Birmingham a far distance to travel…I wanted to pursue a career as a midwife until I found out that it was impossible unless I became a CNM

    • Amber, please look into the Alabama Birth Coalition (www.alabamabirthcoalition.org and there’s also a Facebook page). They have a bill which would legalize and license the practice of Certified Professional Midwives. This is a grassroots consumer movement and can use all the members and supporters it can get. The only way to make home birth accessible to women who want a home birth in AL is to pass this law in the state legislature. Join them and help to change birth options in your state.

  15. You forgot Alabama. It’s one of the few states that actively prosecutes midwives. Families are left with the choice to cross state lines, birth alone or find a midwife willing to risk prosecution.

    • This wasn’t meant to be a comprehensive list, by any means. It would be longer by a couple of dozen states :)

    • Lauren, please see my comment to Amber about joining the Alabama Birth Coalition to work for legislative change.

  16. While I greatly appreciate the premise of your article, I fear that you have fallen into the same script that is part of the growing trend. Had this truly been an article about opening up the discussion about birth choices, you would have included testimony about great hospital experiences and traumatic home births alongside your examples of negative hospital options. You are absolutely right in that birth is a unique experience for every woman and we all deserve to have safe and well educated choices. As a society we must move in this direction. Unfortunately, I believe we are swinging in the other direction in that now we are to fear hospitalsand think of medical staff as the enemy. New moms feel guilty for admitting that they want a hospital and maybe drugs.
    Though I ultimately had a c section due to preeclampsia, my experience through labor (yes, labor) was one of love and support from the staff. My doula was not only welcomed but was encouraged to take a very active role until it was time to go into the OR. The epidural did not paralyze me and I was able to nurse within 30 minutes of leaving the OR.
    Again, this was a unique experience that was right for me. Had I known that the epidural wouldn’t be so bad and that the nurses would be as loving as they were, I would have felt far more confident going into it.

    I understand where you are coming from, but please remember that there is a fine line between making a point and fear mongering.

    • Camille, it’s wonderful to hear stories of supported, respectful births like yours. I don’t see it as fear-mongering to speak the truth about the variations in our system. This article was meant to shed light on the reality of the choices some women face, to introduce some context into the larger debate. This is their reality – and the reality of many, many others – which includes references to home birth climates that are not as safe as they should be, either.

      If women were having wonderful hospital experiences across the board, I wonder if we’d see such a growing trend for out-of-hospital birth.

      • I, too, was hopeful that this article, unlike the usual ones on this theme, might touch on good hospital birth stories. For a variety of reasons, I have never been a good candidate for home birth, as many women aren’t. If we really want to talk about improving birth, we should be talking about hospitals and OBs that do a good job, not just the kinds of stories above. You refer to the reality that hospital birth isn’t going anywhere and that having choices in where to give birth is in large part a function of economic and other privilege. Given that, it is incumbent upon the movement for better birth to not just argue in favor of access to home birth but also for making birth in hospitals better, which is not, contrary to the tone of much rhetoric on the topic, impossible.

        • Cristen Pascucci

          Bionic, we focus almost exclusively on improving birth in hospital settings, since that’s where most women give birth. I actually wasn’t arguing in favor of any setting, other than to say it doesn’t make sense to remove options from people who may already have such few options. It’s a shame that women don’t have better alternatives wherever they choose to give birth.

    • I agree with your statement that if a fair argument were being made here that all sides would be addressed and examples from each. I feel this is biased. I married into a family that is very adamant about home births and although I think it is a nice idea and one of my two births was at a poor hospital (my first), I have learned to research hospitals as well as discuss my desire to have a natural birth with the doctor I am considering laboring and delivering with. My second birth was amazing and the hospital I went to fully supports natural childbirth. They even were encouraging me to get out of bed and walk around. It is a common misconception among women who are “home-birth-only” that all hospitals are bad and anti-natural birth. It is also a common misconception that home-births are all unsafe, and I get that. But for me, the peace of mind of being in a safety net of time-sensitive medical options in a place that is not going to pressure me to go against my desire to birth naturally and drug-free far outweighs all of the hype I’ve been fed about the negativity I would have otherwise encountered. I realize that not all hospitals are like this just as I realize that not all hospitals are like the ones mentioned above, but the argument above seems to me to be suggesting that more are bad than good.

  17. Hi Cristen,
    Thank you for this important contribution to the national discussion of how we -all of us – should work to improve maternity care in the United States. The Big Push for Midwives Campaign is a coalition of state grassroots consumer groups who have joined forces to work, with their midwives, for laws that will license Certified Professional Midwives (CPMs) in all 50 states and the District of Columbia. At the present time, only 28 states have laws that permit CPMs to practice legally in home and birth center settings. Our member state organizations are working in many of the states you have spotlighted – Arizona, where consumers and midwives are working to defeat a bill that will prohibit out of hospital VBAC and breech births, Kentucky and Delaware, where midwives can be arrested or otherwise forced out of practice. Many of the changes in birth options that we so desperately need will involve making changes in state law, whether to require more hospital transparency, to require hospitals to grant autonomous privileges to nurse-midwives, to license midwives and birth centers and to remove restrictions on the midwife’s scope of practice. Improving magernity care in the US will require a combination of direct advocacy to the hospital-medical establishment, and legislative and regulatory advocacy with the state and federal governments, but to accomplish any of these goals we need women and their families to commit themselves to advocacy for change. We need a national movement, like MADD for drunk driving, for women to regain control over their birthing and maternity care options. I am so pleased to know that Improving Birth and other consumer movements have begun this process.

  18. E Matthews

    I had 4 of my 5 children in the UK, each at a different facility. The one attended by a dr.(the first) was by far the WORST; I should have been put on Pitocin, but wasn’t and it lasted 36 hrs. In all the other cases, they were delivered by midwives at hospital; you could do just about anything you wanted. If you wanted a water birth, you did have to “reserve” it in advance, and hope nobody else was using the pool at the same time. (They had only a limited number of pools.) I had all my kids after the first in an easy chair. Archaic practices such as episiotomy as routine, shaving, enemas, etc. were nonexistent. They only use epidurals at certain places, and only if you ask–they don’t try to push you. Depending on where you deliver, you can even order food while having contractions. I believe they use the best of both worlds: modern interventions when needed but also giving the pt. what SHE wanted. For example, my 2nd labor looked to be like the first; water broke, no contractions. When we arrived at the hospital, they wanted me to “walk up and down” as with the first, but I said “NO WAY, you’re giving me Pitocin and that’s it. They did that with my first and all it did was exhaust me.” And they LISTENED. My 5th was in a US hospital, and I was worried about the interventionist attitudes here, but she arrived before the dr. so it was OK

  19. i believe the issue of hospitals and/or practices not “allowing” VBACs is one of the most important issues as to why some women are choosing homebirth instead and that hospitals and ob practices and licensing boards need to address this; in our state the birth centers and definitely the licensed homebirth midwives cannot attend VBAC births. and of course, reducing the primary cesarean rate is also of paramount importance to prevent the VBAC issue in the first place; see the new ACOG/SMFM joint statement on preventing/avoiding the first cesarean. and having practiced in mostly rural states, the issue of finding a hospital that “allows” VBACs as in your examples is very very real.

  20. I had 4 home births because I felt it was safer than a hospital. My daughter just had her first baby (natural) we also had to fight the entire way through the labor for no intervention. After the birth, every nurse on the floor came in and told her they were so proud of her that she did it “natural.” But, I wondered, why couldn’t they have been supportive during labor????

  21. If I had read this article as a first time pregnant woman,I would have been terrified of approaching any hospital in America. My first child’s birth was not what I had hoped for (induction,pitocin,epidural) and yes,the annoyances of repeated questions such as “on a scale of 1 to 10,how great is your pain” were real. But the nurses were kind to me. They listened to my requests and did their best to respect my wishes within the tight restrictions they had to follow. No one tried to take my baby from me or inflict a punitive episiotomy. What a terrifying prospect! My second child was born in a birth center and my third child at home. I wanted to avoid another hospital birth but it was not because of heartless,vindictive hospital staff. I was low-risk,live in TX and weighed the pros and cons and RISK and made my choice. I would like to see the hospital birth presented in a more fair light and the emphasis placed on joining together to fight for a woman’s right to weigh her risks and make her choice.

    • Beth, I agree that reality is terrifying for some women. I’m glad you had the options you had. But I would like to point out some language you used: the nurses, who were kind, “did their best to respect my wishes within the tight restrictions they had to follow.”

      That is no ideal, either. Pregnant women, like everyone else, have the right to autonomy, to informed consent and refusal. What you describe is a system in which a woman has none of those rights, and her advocates (the nurses) appear to have too little power on her behalf.

      Women’s choices in childbirth are not meaningful when they are choosing within a system that does not recognize their most basic rights as citizens.

      Who stands to gain, and who to lose, in that scenario?

  22. This is the best article I’ve read that explains some of the tough choices I had to make birthing my son in NY. While not nearly as bad as the Kentucky or Louisiana cases mentioned, I very much feel we were stuck in a situation without any good options. I hired the only full time home birth midwife on Long Island, but due to rising pressure she wouldn’t deliver a breech at home. No hospital would allow me a natural delivery and due to a fluke, no doctor would take me as a patient. I had to enter the hospital through the clinic and had a new doctor every day. I ended up with a 37 week c-section and a baby that spent more than a week in the NICU as a result. It was the polar opposite of the birth I wanted. It was the opposite of everything. More than two years later I’m still upset that the options so freely available elsewhere were not available to me.

  23. Living in Africa it is very strange to hear Americans and even some Europeans talk the way they do about birth. Humans are not animals, but our bodies are “animal” and never more so than when we give birth to our young. I think in America you have allowed your government, your police and your medical industry to brainwash you that birth is something that there can be laws about, because it falls under “medical event.” In many parts of the world we look at America and shake our heads and laugh (and sometimes cry) that people have allowed such a normal thing as welcoming a new family member to become this hotbed of debate and fear and legal issues. Those of us who know many, many families who had what the first world calls “free-births” can honestly not understand the fear, the coercion, the panic, the dependence on technology, the involvement of parties that have no right to interfere. To be honest, the fact that the people of America have allowed birth (something which is normal and natural to every mammal since the dawn of time) to become subject to legislation, makes them seem totally insane to the rest of us. I feel for these people in the examples, what a travesty of social control, blatant fascism. God help us all.

  24. I’ve had three very positive hospital births. I never felt pushed toward having a C-section. I chose not to have any pain medications and they never tried to influence me any different. I felt safe having my babies in an environment that god forbid, if anything went wrong, had everything available to do what they needed to do quickly to protect me and my baby. I’m sure there are many successful home births. I have a friend who lost her full term baby at home during delivery. By the time they got her to the hospital the baby had died. That just wasn’t worth the risk to me. She has regretted her decision for home birth ever since. There are many great hospitals and doctors and thousands upon thousands of great hospital births too. It’s an individual’s choice and I know I made the right choice for me and my babies.

  25. eyecatcher

    You mentioned the MANA study. That study showed that 5 out of 222 breech babies died at homebirth and a 50% C-section rate. Since this site is about “Improvingbirth” what recommendations do you have for improving the safety of breech babies at homebirth?

    • Cristen Pascucci

      eyecatcher, did you mistake my mentioning the existence of a study as endorsing that study or the results of that study? This article isn’t about my recommendations for specific circumstances in specific locations. This article is meant to bring a dose of reality into the discussions around home vs. hospital birth – that, in fact, each family must weigh the relative safety or non-safety of their own hospital access or home birth support in order to make decisions. It is impossible to make decisions about safety without taking into account the actual facilities, providers, and options available to a specific woman and baby. In some areas in the U.S. — too many — the quality of those facilities, providers, and options is extremely limited.

Trackbacks/Pingbacks

  1. Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE, Cristen Pascucci , - Birth Balance - […] Lately, with the publication of data on almost 17,000 planned American home births, the “home birth debate” has been …
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  4. The Best Birth for Mom and Baby | Women's Wellness Of New Jersey - […] and babies better. Improving Birth’s article takes the opposition out of the conversation. http://www.improvingbirth.org/2014/02/versus/ Different schools of thought …
  5. Birth Centers Change the Conversation on VBAC - Improving Birth | Improving Birth - […] More articles from Cristen here, including her most recent, “Home Birth vs. Hospital Birth: YOU’RE MISSING THE POINT, PEOPLE“ […]
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  7. How we decided on a birth center. | Optimistic Heathen - […] [great article] Came across this article on Improving Birth, and think it’s a great place to start if […]

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