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February 10, 2010

What is the appeal of home birth?

I've never understood why anyone would choose to give birth at home, rather than in a birthing center attached to a hospital. a) Why not go somewhere where you don't have to wash the sheets? b) If there's even a remote chance that you need emergency surgery, why not arrange to be seconds away from an operating room rather than minutes, or longer? 

I know that childbirth isn't a disease. On the other hand, if I had a non-disease where there was a small chance that I'd need emergency surgery within the next 72 hours, I'd prefer to park myself as close to an OR as possible. 

I understand that every woman has the absolute right to make her own decisions about where and how to give birth. I'm not trying to influence anyone else. (Hivemind, be nice to each other, okay?)

Just to reassure people, like my mom, who might be following along at home, this is a purely academic question for me. I ask because Jill & Emjaybee's blog is thought-provoking.


Having done both I can safely say having a baby at home was the nicer option by far. And from some stories I've heard, the time it takes to get in to an OR or get and anesthesiologist is about the same amount of time it would take to get to the hospital. In addition, the stats on interventions in hospital births are pretty interesting...I don't have any handy of course but basically you are way more likely to have a cesarean, forceps, or some other form of "hurry that baby up I have a golf game" Also when you are hanging out in a little inflatable pool in your living room with a fire in the fireplace and some nice music...your body is relaxed, comfortable and way more likely to progress in a normal fashion...I guess if you have the option of fairytale birthing center that would be nice too but it's not the norm. I know at VGH even though they have a fancy birthing area, you still labor, deliver and recover in three separate areas...moving around is not so much what you want to do when birthin ' babies
anyways, that's just me

They don't trust the body of knowledge and practice they understand as 'medicine'.

They strongly value their comfort.

And they strongly consider the risks in hospital birth are high and risks in homebirth are low.

I know someone whose child almost died in homebirth, and is still very proud of the fact. I'd say that the two reasons above encapsulate

Not everyone who has homebirths distrusts medicine, though. Leah, you had a midwife and an OB both times, right? (Yay, Canadian health care system!)

There's one medical advantage -- less chance of iatrogenic infection than in a hospital. Birthing centers separated from general purpose hospitals are less dangerous in this respect, but you still have a lot of patients trooping through, and a lot of body fluids out in the world on their own. Infection control is difficult, and try as they might, hospitals never are completely successful at it.

Other than that it's mostly just being able to relax in a comfortable place customized to what the mother likes, and to have neither the mother nor any of her friends and family required to adjust themselves to the protocols and schedules of the hospital. The new birthing centers are much better than the old hospitals, but they're still workplaces and inevitably put some constraints on visitors, which aren't necessarily the constraints the mother herself would want.

The home-birth personnel I've known about all carefully watch for warning signs and refer difficult cases to hospitals. They also have backup for unexpected emergencies. Whether the risks form unexpected emergencies in normal patients outweight the positive benefits of home birth, I don't know. As I understand the European standard varies widely country to country, both in preferred methods and in results. Only the Netherlands has a high rate of home birth, 30% and declining.

The issue is highly ideologized and it's hard to Google good info, which I just tried to do. It seems, though, that without warning signs, home birth about breaks even compared to hospital birth. (Further study is required for the reason I just gave.)

Well-- I considered (and ultimately rejected) a home birth. I live in an area where there is not a nearby birth center. So my options were hospital or home birth. If you pick up a copy of Henci Goer's "Thinking Woman's Guide to a Better Birth" you get a really good look at some of the info about standard hospital interventions that may actually cause more problems than they are designed to prevent. It's hard to give birth in a hospital and have freedom of movement, for example, when the hospital wants to "require" an iv, etc.

How required all those policies really are varies a lot by practitioner. Ultimately I asked a lot of folks locally and found an OB (one of about *two* names in my relatively metro area that kept coming up) who was comfortable truly providing me with some autonomy and respect as to how I intended to birth. I found a doula who had a good working relationship with that OB. And I had the back-up of being at the hospital if anything sudden or bad happened.

But really? I feel like a bunch of that is luck. I went into labor afraid that I'd become another statistic, or be forced into things I didn't want to do. Having talked with a lot of women on this issue I feel like I got really, really lucky. I did leg-work, sure, but every woman in the area can't have those same two doctors, y'know? (And don't get me started on the OB I switched practices *away* from who insisted that she would "call the shots and be the captain of my treatment." eyeroll.)

I had my first one in a top-ranked hospital - feminist female OB/GYN with nurse midwife. When I had a minor leak in the amniotic sac, they treated me as high-risk and induced me five weeks early. My son almost died as a result of being born with immature lungs. That was it; I didn't want to lost my autonomy again and risk my next child's health.

As John mentioned, a normal home birth has a lower infection rate - and less chance of an episiotomy.

Experienced midwives monitored me closely; in fact, the quality of prenatal care was much better than my first pregnancy. And I didn't want to be cajoled into a C-section, as far too many women are. That's major surgery.

Oh, and I didn't have to worry about the hospital mixing up my baby with someone else's.

To me, the question, is why would anyone want to give birth in a hospital? My own bedroom was more relaxing and it felt safe. Yeah, you can pick a birthing center - and if you're lucky, you won't have a fever (even one degree above normal made you too high risk) and since they're small, sometimes they don't have enough beds. No, thanks. I was more than happy with my choice.

In a nutshell…

For many of us, it’s not necessarily the appeal of giving birth out of the hospital but because the hospital won’t allow anyone to attend our births and/or we’re given an inordinate amount of resistance that makes it a hostile environment (and I wouldn’t call a hostile environment conducive to birth). I gave birth the second time in a freestanding birth center that more or less ran under the auspices of the nearby hospital several miles down the road.

The fear of litigation and whatever else it is that drives physicians in their decision making process, which is not always the best scientific evidence available, precludes many women from giving birth vaginally in hospitals. One example is vaginal birth after a previous cesarean, which is safe. One highly regarded physician and long-time advocate of VBAC has said “the chance that a VBAC candidate will require emergency surgery is, for all practical purposes, no higher than that of any other pregnant woman.” Yet, women are denied the chance to just give birth vaginally because of hospital VBAC bans that are not supported by evidence.

Defensive medicine and the so-called litigation crisis sucks for pregnant women.

I had two c/s, a hospital VBA2C and now pregnant again, not one single hospital within a two hour drive will have me... not based on medical reasonings but based on liability. If I don't want another c/s, I'm forced to stay at home. Some women don't have the choice of being operated on or birthing at home.

Thanks for all the comments, everyone. I appreciate it.

Ultimately, I did not get to birth at home for a few reasons, but up until week 39, that had been my plan. I bought a set of $10 sheets at a discount store, and put them over a $5 plastic type liner...and UNDER both of those things, I had my own personal sheets. So after the baby was born (if it was born on the bed) the top stuff got ripped off and TOSSED! I didn't have to wash them. My mother birthed 3 children at home this way...and did the same. The one difference is that she found her sheets at goodwill and sterilized them. The goodwill was no longer around when it was my turn.

I actually don't know of any hospitals with birthing centers attached [available to ME] if I were going to birth in a center, it would not be at a hospital anyway. But being in the hospital for the possibility of an emergency is like saying you should have the police or ambulance follow you around b/c you might get into a car accident. (Which is actually probably more likely statistically...that you are involved in an auto accident versus a normal, healthy pregnancy presenting a last minute emergency during labor & delivery that can ONLY be fixed with an operating room nearby.)

Many midwives do have tools to stabalize mothers and babies in the event of an issue. And then they would wait for an ambulance to arrive. In *most* areas, an ambulance arrives in a few minutes (and with a skilled midwife, they will often see warning signs of problems to come and might even be prepared ahead of time by calling an ambulance in time) and in a hospital it takes time for the the correct announcement to be made about an emergency, the various people from different areas around the hospital come running...up flights of stairs, elevators, and it could be the equivalent of running a half mile for them to get to you to assist. My mother was a respitory therapist...and about 15 seconds before she clocked out, she got called to the furthest possible place from her location! It took her a full 2 or 3 minutes to get there, another minute or so for her to get the info and directions from the people already in the room...and only THEN could she act and do what needed to be done...all the while STILL waiting on someone else so they could move the patient to the necessary trauma area.

And no hospital would permit me to birth naturally when it was my time to go...and by the state law, I could not deliver in a traditional birth center. Home was the only way to go. The state basically said, "Do it our way, or do it without any real assistance." Pretty darn helpful, huh?

Because I don't trust anyone else. I want to birth without any interventions whatsoever. No watching the clock, VEs, stress. I don't want anyone else there hindering me. I also choose unassisted birth for those reasons.

Nicole, when you say unassisted, what does that mean for you? No OB or midwife? What about friends/family/partner?

I opted for a homebirth mainly out of fear. I was with my friend when she had her first baby in the hospital. She was induced at 39 weeks ultimately because the doctor wanted to be in Scotland for Thanksgiving. By the time she had her baby (by c-section of course) I had an intense feeling of "I'll squat in the woods before I ever let them do this to me!" You say, "If there's even a remote chance that you need emergency surgery, why not arrange to be seconds away from an operating room rather than minutes, or longer? " statistically, everytime you get in your car you are risking an accident that may require emergency surgery. I'm not willing to live my life in fear of "what if." That includes childbirth. Of course if you have health issues it makes sense to utilize the modern medical model of childbirth, but I had a healthy pregnancy. Its all a matter of perception. If you focus on the fact that automobile crashes are the sixth leading cause of death in America you will never get in a car.

The research that I did showed that home birth was a safer and more comfortable choice. There was no chance of unneeded interventions (that often cause other interventions, often ending in the all-too-common emergency c-section). Being in the comfort of one's own space with a trained professional and no distractions makes labor progress easier and faster.

I would question why anyone with a low-risk pregnancy that knows the facts about interventions and how the US ranks in terms of maternal and neonatal mortality would choose to birth in a hospital.

Given that studies consistently prove that homebirth is as safe if not safer than hospitals for low-risk women, it makes sense for a lot of women.

I contemplated homebirth - really wanted to do it. But given what I know about the two options I have for hospital transfer in the event I needed to, I decided to go with a birth center instead. The big drawback to me is that it is 45-75 minutes away from my house depending on traffic. The reason I picked such a long drive instead of doing a homebirth - the hospitals by my house have a cultural bias against natural birth that culminates in their abusing mothers who are homebirth transfers. They have abused mothers who have simply tried to birth in their hospitals without intervention as well. But a homebirth transfer has no hope in having an experience wherein she is respected as a human being. In fact, I know of two cases off the top of my head where they called DCFS on the mother simply to punish her because she had attempted a homebirth. I know another who is a sexual abuse survivor who chose homebirth to avoid power/control issues surrounding her genitals who had to transfer and ended up needing significant therapy to get past how she was treated.

These hospitals have a perfectly good reputation among the population of mothers who are fine with just going with the hospital flow. If people don't mind getting EFM, stuck in bed with no movement, pitocin, epidural, and probably eventually a c-section (and there are plenty of people who simply don't care about those things and therefore are perfectly happy with medicalized birth experiences), then those people generally have wonderful experiences at the hospitals I mentioned. But the second you do anything that involves bucking the system(wanting to move around, wanting to spend time in a shower or bath for pain relief, etc), they clamp down and make your life miserable.

My potential homebirth would have been somewhat compromised by anxiety over having to possibly transfer to these hospitals. So I chose to go to one with a great alternative birthing wing that is about an hour away. I am lucky enough to have that option, though, many people have the options of 1.) disrespectful hospital or 2.) homebirth. I would have gone with a homebirth in a second if I didn't have the birth center as an option.

I know it sounds like I have tons of anecdotes, but really sometimes you can get the feel for the culture of an institution by the experiences of your friends and acquaintances. I feel lucky that I heard about them before I just went with the closest place - I would have been miserable and likely scarred. Instead I had a decent mildly medicalized (epidural, forced pushing) birth at a different hospital first with a 9 lb 1 oz baby, then switched to the hospital/midwife group an hour away and had an amazing natural birth (with a super fast and easy recovery) of a 10 lb 6 oz baby. Particularly with the 2nd baby, my body would likely have fared differently had I been with most hospital-based care providers. I would not have been given time for him to turn before my water was actively broken, I would have been forced to push (and probably therefore not escaped without any tears), and really at the hospitals I was most nervous about I doubt I would have escaped without at least an episiotomy but probably a c-section.

A hospital-attached birthing center woul have to follow certain protocols that certain home birth midwives don't. I briefly considered going to one for my fourth birth (after three homebirths) because it's the first time I had insurace and thus it would have been the cheaper option (insurance would not cover my midwife). I decided against it when, in the early months of my pregnancy, a friend who was planning on a birthing center birth ended up risked out because her baby was breech. Her care was transferred to the hospital and she had a c-section that she felt was unnecessary. Personally, I didn't want to have to scramble around at the end of my pregnancy looking for a home birth midwife last minute if I ended up with a breech baby, or going past 42 weeks, or some other "complication" that would have risked me out of a birthing center but a home birth midwife would have attended. As it was, I did end up going overdue. Not only that, but my baby was enormous. I'm sure that I would have been pressured into a c/section or some form of induction if I'd had my care transferred to a hospital at 42 weeks. I wouldn't trade my 6-hour uncomplicated labor and my semi-standing birthing position in the comfort of my own home for all that hassle!

(This doesn't really answer why I chose homebirth for my first three births, but rather why I, retrospectively, would not have wanted a birthing center birth. Especially one attached to a hospital. To answer the former, it's because when I made my decision, I hadn't heard of any other options other than home birth or regular, run-of-the mill hospital birth, which I knew I definitely didn't want.)

I'd like to know why anyone would want to take a horrible car ride during labor. having to sit in an awful position for even 5 minutes sucks! but what about people who drive 2+ hours to get to a birthing center or hospital?! That whole time could have been spent relaxing, breathing, showering, bathing, or even napping, eating, or conserving energy!

That's only ONE of 100 reasons I chose to give birth at home.

Some people don't have the choice to deliver in a birth center attached to a hospital. For me, the nearest one would be several hundred miles.

I've had a wide variety of birth experiences...each one a little crunchier than the one before. My first 3 were born in the hospital. I was induced with my first, had the epidural with my first 2 and with my 3rd had a natural, med-free hospital birth. My 4th was born at home. I wish I could go back and have a do-over with the first 3 because they would all be born at home. There is something SO wonderful about birthing your baby and're already in the comfort of your own home. You don't feel like a guest somewhere, you aren't constantly interrupted and made to feel inadequate. You are free to labor and move and birth without being sujected to monitors, IV's and other unnecessary "policies". Oh and my midwife started the laundry before she left ;o)

Plus the interventions that you are subjected to at the hospital is ridiculous and often leads to more interventions up to and including ceserean delivery. Unfortunately hospitals are running birthing centers, in most areas, out of business. In the Phoenix metro area the only free standing birth center closed years ago.

To each her own but I'll have my babies at home!

Hey's actually Jill's blog, I am one of her guest writers.

I love the "clean the sheets" discussion that always comes up on homebirth, because the answer is actually kind of cool.

So here's what you do: you put your regular sheets on the bed. Over that, you put a plastic sheet or cloth. Over THAT you put some old ancient sheets you don't care about.

One of the things midwives and/or doulas do...unlike help you clean up after the birth. This also means that once you and baby are good, they will strip off the top two layers, leaving you and baby on dry clean sheets. They will also clean up the floor and other areas.

Of course many women homebirth in a birth tub, or standing up or on all fours over clean-able floors, towels, and/or chux pads, and so don't have to worry about mussing the bed anyway--giving birth in bed is not ideal for many women.

Medically speaking, a midwife monitors fetal heart tones, blood pressure, and other indicators of trouble; unlike an OB who's not been with you through labor, she has seen you pre natally and observed you throughout your labor; she is familiar with your "normal" in other words, giving her an advantage in spotting when something goes wrong. Many midwives are able to administer Pitocin in the event of a postpartum hemorrhage, if needed, slowing down any bleeding so that you can get to the hospital. It also takes on average 30 minutes to set up an OR for a woman who is already in the hospital; if they know you're coming, they can do that while you're in transit. Clearly, this is a risk many women still think is too high, and that's where choice comes in.

Homebirth is not risk free, but **neither is hospital birth.** Babies and mothers die in hospitals, after all; and in our current medical system, the too-high c/sec rate increases their mortality, prematurity, infection, and injury risks.

Humans are mammals; like mammals, we seek relaxation, security, and quiet during birth, and when (as in a hospital, and sometimes even in a birth center) these things are unavailable, we are tense and stressed, which can be a serious problem in a process that requires a woman to relax into the contractions to have more effective labor. Many women simply can't get into that mental state surrounded by strangers in a strange place.

Car rides during labor sound very uncomfortable. According to family lore, my mom and dad did a lot of strategic downtown window shopping at the very end of her pregnancy to make sure she was near the hospital where her doctor worked. They lived about 45 minutes away, otherwise.

I probably would have birthed in a freestanding birth center with my first child, except there aren't any within 3 hours of my town. In the end, I'm very happy with my decision to birth at home with both of my children. In my province, midwifery is regulated and the midwives work out of their own clinics with birthing priviledges at hospitals and home, so I had great care no matter where I chose to birth. I'm so, so proud and grateful that women in my area have such freedom to choose. I only wish it was the case in the rest of North America!
My first child's birth was a bit complicated (posterior baby, complicated tear and blood loss, but we didn't need to transfer), and my midwives were so skilled and confident and handled it so well that I had no qualms about birthing with them at home the second time around. My second birth was almost completely pain-free, something which I doubt would be possible in a hospital environment (without drugs, that is). It was almost a spiritual experience. It's very, very difficult to explain, I'm afraid. But I was only able to experience it that way because I had complete faith in my body and my baby to do what it should, and I was able to completely trust my midwives to catch any potential problems and treat us accordingly. At home, I could just go into myself and let it all go and just get on with it :)

Oh dear, well first off, I think it would take pages and pages to adequately describe why I prefer to stay away from the hospital. It is not as simple as one or two common stereotypes, but rather a complex interaction of dozens of factors, all weighing in on the discussion in their own way.

On a personal level, I choose to birth at home with my husband because I believe that birthing our child together is the culmination of our sexual relationship. This is in line with our Catholic Theology of the Body. (Those interested in these concepts can look at or read Marilyn Moran's Book "Pleasurable Husband/Wife Childbirth, the Real Consummation of Married Love.")

On an anthropological level, I am gravely concerned and alarmed at the obstetrical practices in America. Although I am passionate about science and technology (my field is Neuroscience) it is this very passion for accuracy and progress that drives me to criticise our current state. The more you know about this topic, the more disturbed you should become. A simple search on the internet will give you dozens and dozens of forums with women speaking out about the violence they experience when they walk into a maternity ward. We have not changed since the mid 1900s, when women were tied to their hospital beds with lambskin to prevent marks so the husbands wouldn't suspect.

Our obstetrical model is dehumanising, patronising and in many areas violent. Since a majority of the ACOG's members are male, there is an additional context of male to female violence. Perhaps this is why many women refer to their birth experience as "birth rape."

Moving onto the aspect of sciencet and those damned statistics. I have a favourite saying: "Doctor PRACTICE medicine." And no where else is this more obvious than in the maternity ward. Mothers and their neonates are one big social experiment. They are subjected to drugs, treatments and procedures, and only after much injury and death does the medical industry slowly begin to acknowledge the lack of science driving the practice. And then it takes even longer to eliminate the practice.

We see this with the medically inappropriate use of pitocin to augment labour, the off-label use of Cytotec, the increased number of c-sections, the prevalence of episiotomies, premature cord clamping, a loss of breech delivery training, etc etc etc. Everywhere you turn in this issue, doctors remain outdated, uninformed, and likely to rely on routine practices without scientific justification or basis.

As for the plea to preparedness: even an emergency c-section takes time. In many hospitals, it will take approximately 30-45 minutes from the time they decide to cut to the time they actually begin cutting. Clearly, a homebirth will not matter either way. The hospital can easily be phoned ahead of time and begin preparing while the mother is transported. Other severe complications such as abruption, have similar outcomes in the hospital or at home.

Those concerned about care for the neonate need to remember that midwives are trained in neonatal rescucitation (NRP) and can bring oxygen, pitocin and other tools and drugs with them, along with any homeopathic products they might think will help. To an extent, this is true for a freebirth. My husband and I are both CPR and NRP certified and will have some supplies on hand.

The thing is, the "change for emergency surgery" exists for ALL of us, EVERY DAY. It is not just pregnancy or labour that brings the risk of death. We ALL have a chance of injury or death. The chance of dying on the way to the hospital is higher than the chance of dying while birthing at home. Dig into this. Think about what this means when someone says they would prefer to be at or near the hospital "just in case." In case what? Our day to day activity, if you drive every day, is more dangerous than birthing. Should we all hang out around the hospital "just in case"?

It's hard, but during pregnancy a woman must reconcile the dichotomy of carrying life in her womb, life that will end in death. In our fear of death, we have created an entire industry and ideology that is simply throwing us closer to death as opposed to protecting us from it.

“The point here,” observes Dr. Marsden Wagner, former director of Women‟s and Children‟s Health, World Health Organization, “is there‟s not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why, if you really want a humanized birth, the best thing to do is get the hell out of the hospital.”

a)I didn't need to clean the sheets, because giving birth on your back in bed is counterproductive. I put a tarp and old sheet in the living room, which our midwife disposed of after the birth.

b) The routine interventions that occur from the moment you walk into a hospital each carry a risk, usually of more interventions... which can lead to an unnecessary c-section.

Giving birth is the most terrifying, powerful, exhilarating experience I could imagine. I've done it in a hospital and at home, and there is no comparison. Going through labor pains in the comfort my own living room, compared to a cold and sterile hospital surrounded by strangers? Snuggling up with my newborn in my own bed and taking a nap after birth? Best thing ever.

My mother's experience in giving birth to my older sister (a few decades ago now) involved sitting alone in a bed until a nurse walked in with a needle. She asked what was in the needle and the nurse stuck her and walked out without a word, returning some time later to say "You're not out yet?" and stick her again. That time she lost consciousness, and woke to a man she hadn't seen before telling her that she was a mother and she could have her baby in a couple of days. All of this was after she had requested minimal intervention and no medications without her consent, and told that her wishes would be respected.

I was born at home.

I'm not saying that her experience was typical even at the time (I hope not!), but it doesn't surprise me in the least that many women prefer being in a situation where they know they have control and can spend the whole time in comfort with loved ones present.

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