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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.

Comments

I came back to add that a homebirth was my only shot at giving birth vaginally. I had an unnecessary Cesarean with my first that left me both emotionally and physically traumatized when the OB goofed up during surgery and then lied to me about it. I nearly bled out a week later which was ten times worse than the actual Cesarean. For insurance purposes, I saw the same CNM practice during my second pregnancy (I would rather pay the $2K for a homebirth out of pocket and let my insurance cover a Cesarean if I Needed one), and I was fed a constant stream of fearmongering and lies regarding my VBAC wishes. I knew without a doubt that they would railroad me into another C-section, and frankly I couldn't deal with the possibility of having to endure that nightmare again. My midwife, on the other hand, truly believed in me and my body's ability to give birth. Where my first birth had been demeaning, terrifying, depressing, and traumatic, my home VBAC was triumphant, empowering, gratifying and peaceful. I wouldn't have stood a chance in the hospital. Even if they would have been more accomodating, simply the horrible memories would have shut me down as soon as I walked in the door.

The benefits to my children should be considered as well. My firstborn was taken from me and I did not see or hold him for four hours. I had to page a nurse and ask her to please bring him to me after sitting in my room alone all morning. He was given eye ointment without my consent, even though he was a Cesarean birth. He had trouble nursing and was never very enthusiastic about it for the rest of his 13-month stint at breastfeeding. He is now a wonderful, intelligent, sensitive 5 year old boy, but I still think I could have given him a more gentle welcome into the world. My second son was as peaceful as could be at birth - he did not cry or even so much as whimper. He gazed around the room with wide eyes and happily latched on to my breast like an old pro, where he stayed throughout the night. He slept between me and my husband, and never left my side from the moment he was born. I was so proud that I was able to give him such a gentle, loving birth.

My daughter was truly a life-or-death cesearean after she settled into a funky position with her cord compressed under her arm, blocking her blood & oxygen flow. They had her out in 16 minutes and I was lucky I happened to be at the hospital or she would have died. I wasn't in labor, but I was two weeks overdue & there only for a routine NST.

Even after that horrifying & traumatic experience, I chose to have my son at home instead of in a "safe" hospital or scheduling a "convenient" repeat surgery. I wasn't afraid of giving birth, I wasn't even afraid of surgery, but I was afraid of being out of control. Birth is the most out of control situation you will ever be in, the best thing you can do in labor is to "let go." So why was I worried about control? I'd already been through one birth where something went drastically wrong and yet everyone did everything right and my baby & I were just fine. I had nothing to do during those 16 minutes except to keep breathing, talk to my baby, don't let her know anything is wrong, there was nothing I could do, no decision I could make, and it was a terrifying experience that I never want to go through again.

I needed to have a birth where things weren't done to me without my consent (yes, they were absolutely necessary and I wouldn't have said no, but still....) and where things weren't done to my baby without my consent (even after it was determined she was no longer at risk, but my husband still hadn't been let into the OR & I'd been put to sleep) and where I was a person with a name, not The Code Blue in Room 5, that's literally how two hospital staff addressed me after I woke up.

My son ended up being another c-section after 3 days of labor. It was a beautiful & loving & wonderful experience. I felt good, I was well-supported, and I welcomed the waves that were bringing my baby to me. When things started not going well at the end (meconium, a premature urge to push, and a cervix that didn't quite dilate enough) my midwives & I & my husband all discussed the options. I'm the one who decided to go to the hospital, and 8 hours later I'm the one who said, "Let's do a c-section." It was the right decision, and it was MY decision.

In reality, most "birthing centers" are just fancy maternity wards. They are run by a hospital, and staff is subject to hospital policy & procedure protocols. A laboring mom usually gets a hospital experience, just with fancier bed linens & prettier pictures on the walls. There are very few truly stand-alone birthing centers in the U.S.

I had a natural birth in a hospital, and it was awesome. It helped that the hospital was natural-birth friendly -- they had a wireless external fetal monitoring unit, for example, so that I could walk around while in labor. It also helped that my OB did not push for an induction (I was at 41w 5d when I went into labor naturally -- most OBs do not let patients go past 41w 3 d).

If I have another kid, my first choice would be to give birth at a birth center. But if there isn't one around -- and there isn't one near my current home -- I would choose to give birth at home with a midwife over at an intervention-happy hospital.

On a related note, now that I've had a natural birth, the thought of having an epidural and other interventions, and laying on my back during labor, waiting to push, seems very strange to me.

An L and D nurse I know said that it takes at least 20 minutes (and sometimes far longer) to get a c-section team assembled, so even an "emergency c" takes a while. A proper home birth midwife will come equipped with drugs to stem any bleeding while you are en route to the hospital--the same ones you would get in a birthing center or a hospital.

That said, she advised to not attempt a home birth if you live more than 20 minutes away from a hospital (and if it's not an attempted homebirth friendly hospital, you have to be very cognizant of what you might get yourself into).

So, since I currently live five minutes from a very alternative birth friendly hospital (where we had number 1 fully naturally in their "alternative" rooms), the next one will definitely be a home birth barring any complications! The whole getting in the car and getting to the hospital sucked, as did getting transferred out of the alternative room to a (dirty, cold, and dusty) regular room and then a second (dirty and dusty, but at least not cold) regular room, as did having to get in the car to go home, as did the food...would much rather just stay home. There was nothing my midwife and the nurse did at the hospital that they could not have done in my home.

According to a survey published by the Journal of Midwifery & Women's Health last year, the major reasons for choosing home birth are because it is perceived as safer, because the woman wishes to avoid the risks posed by routine hospital interventions, and because of a prior negative experience giving birth in a hospital. This Journal is published by the American College of Nurse-Midwives, 97% of whose members practice in hospitals (2% in freestanding birth centers and 1% home birth), and the Journal is a highly-respected peer-reviewed scientific journal, so this article was not based on a home birth bias by the publisher. It's a copyrighted article so I cannot reproduce it here, but here's the abstract:

Volume 54, Issue 2, Pages 119-126 (March 2009)

Staying Home to Give Birth: Why Women in the United States Choose Home Birth

Debora Boucher, CNMCorresponding Author Informationemail address, Catherine Bennett, RNC, BSN, Barbara McFarlin, CNM, PhD, RDMS, Rixa Freeze, PhD, MA

Approximately 1% of American women give birth at home and face substantial obstacles when they make this choice. This study describes the reasons that women in the United States choose home birth. A qualitative descriptive secondary analysis was conducted in a previously collected dataset obtained via an online survey. The sample consisted of 160 women who were US residents and planned a home birth at least once. Content analysis was used to study the responses from women to one essay question: “Why did you choose home birth?” Women who participated in the study were mostly married (91%) and white (87%). The majority (62%) had a college education. Our analysis revealed 508 separate statements about why these women chose home birth. Responses were coded and categorized into 26 common themes. The most common reasons given for wanting to birth at home were: 1) safety (n = 38); 2) avoidance of unnecessary medical interventions common in hospital births (n = 38); 3) previous negative hospital experience (n = 37); 4) more control (n = 35); and 5) comfortable, familiar environment (n = 30). Another dominant theme was women's trust in the birth process (n = 25). Women equated medical intervention with reduced safety and trusted their bodies' inherent ability to give birth without interference.

With respect to the types of hospital interventions that these women wish to avoid, I suggest checking out an October 2008 study reviewing the existing scientific evidence regarding a number of common interventions in nearly all hospitals, such as routine electronic fetal monitoring, induction of labor, episiotomy, laboring in bed, and others. The study, called Evidence-based Maternity Care: What It Is and What It Can Achieve, was published by the prestigious Milbank Foundation, and written by the highly-respected health care think tank, Childbirth Connection, which has been in existence for over 80 years. The link to the study, as well as a synopsis of its findings, can be found at:

http://www.childbirthconnection.org/article.asp?ck=10575

One risk of hospital childbirth is the skyrocketing increase in cesarean section, major abdominal surgery which is 3 to 4 times more likely to result in maternal death and maternal morbidity than vaginal delivery and at least 3 times more likely to result in neonatal death or morbidity. Groups as mainstream as the March of Dimes and the Center for Disease Control have expressed alarm as the U.S. c-section rate has increased to approximately one-third of all births. In some areas of the country and in some hospitals, it has gone as high as 40 to 50%. Just last week, the California Maternal Quality Care Collaborative released a report showing that the materal death rate in California had actually increased since a rate of 5. 6 per 100,000 in 1996 to 16.9 per 100,000 in 2006. In part, the increase is ascribed to the increase in c-sections over the same period. The CMQCC is made up of the California Department of Public Health, Maternal, Child and Adolescent Health Program(CDPH-MCAH) and the California Perinatal Quality Care Collaborative (CPQCC) , with representation from the American College of OB/GYNs and other mainstream professional groups. An article about the report, which appeared in California Watch last week, can be found all over the internet, but here it is at the RH Reality Check blogsite:

http://www.rhrealitycheck.org/blog/2010/02/04/more-women-dying-pregnancy-complications

I'm an attorney, and represent the American Association of Birth Centers, the trade association for free-standing (NOT hospital-affiliated) birth centers. My client's membership has great statistics on safety and high quality care, and pride themselves on providing woman-centered care for low-risk women experiencing normal pregancies. Our website is www.birthcenters.org. We welcome further dialogue.
Susan Jenkins

Hello.
I birthed at home with #1 and am planning to do so again with #2 in June. Reasons:
1. I am more comfortable in my own space than anywhere else, and I believe a woman needs to feel safe and comfortable to have her best labor and delivery. Labor to me was largely mental / emotional.
2. Homebirth midwives are very, very attentive.
3. The midwife, helper and doula took care of cleaning everything up. When they were done, you couldn't tell that a baby was born there. We used vinyl tablecloths, chux pads, and old towels everywhere. And never once did I feel like laying on my back in my bed; rather I delivered my daughter in the living room. But the bed was prepared as described above, with old sheets and a vinyl tablecloth, just in case.
4. I live 10 minutes from the hospital. If there were an emergency, we'd have plenty of time to get there. They can't even prep the OR in 10 minutes, and we'd call ahead.
5. There aren't any birthing centers where I live.
6. This was the biggest reason: I didn't want to be arguing with nurses and doctors about interventions I may or may not need and trying to go against hospital policy while I was simultaneously trying to do the single most challenging physical/emotional/mental thing I had ever done. I didn't want to be asked my pain scale, and didn't I want to be offered "something for the pain," and be told I've only progressed x cm in y minutes, and perhaps we should speed things up with some drug or intervention. I wanted to be loved and supported and encouraged in the natural birth I wanted.

I was fantastically pleased with my choice to birth at home. I felt fully supported and very empowered, and my daughter entered the world very gently and in her own time. I found strength I never knew I had. Anyone who feels safe in her own home and wants a natural birth would be wise to consider midwife-attended homebirth.

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.

Yeah, this is totally the experience we were confronted with when my wife went into labor (after a completely normal and healthy pregnancy). From the minute she checked into the maternity ward and they knew she was having contractions, the standard baby extraction protocol was set into motion. Intervention 1, they broke her water and told her what they were doing almost as an afterthought. After that, since her water was broken, they said the baby must be born within a few hours or they would do a c-section.

During her continued labor (in which she was not allowed to walk around since she was strapped to a fetal heart monitor), they pressured her to take pitocin to speed up the process, which gave her even worse pain, stressed out the baby, and led to yet more intervention in the form of some sort of sedative that left my wife dazed and unable to do the controlled breathing we had practiced. The doctor basically told my wife that she wasn't doing a very good job and was taking too long. She was crushed.

She finally gave birth vaginally after a too-late epidural and increasingly high doses of pitocin and threats of c-section. The doctor actually walked out about a half-hour before the baby was born to do a quick c-section before coming back to tell my wife to push. The actual birth ritual was surreal--the doctor had me glove up and stand there waiting to receive my rightful property as it was being expelled from its incubator, and they had me cut the cord I guess to symbolize my ownership of the new baby.

The process just seemed to be about extracting babies, with little regard for the mother. In fact, I think they may have seen my wife as an *obstacle* efficient childbirth. Our next child won't be born at home, but we'll certainly look around for a good birthing center and have a doula or some other advocate around to push back against this kind of intervention.

a) birth hormones which dull pain and cause the birth "high" that many women experience when giving birth without drugs, do not function as effectively in an unfamiliar environment
b) there is less risk of infection from germs and viruses that you can catch in a hospital
c) you are more likely to have continuity of care from a midwife you knw if you go the home birth route, even if you end up needing ot go to hospital
d) less complications happen out of hospital. It's called the spiral of intervention...

Good question. Having had both hospital and home birth experiences, birthing in the familiar surroundings of my home with my family close at hand, was much less stressful than the hospital environment, where I felt that I had to spend a LOT of energy being constantly vigilant about interventions. And I think the risk factor of emergencies has been way over-promoted by the hospitals. There is no doubt that a birth can turn from nornal to a birth that requires medical intervention. But there is no quick walk to the OR. The average time to set up the OR is half an hour, about the same amount of time as it would take to transport a woman from home to hospital. The salient question is what makes the woman comfortable. If being in a hospital and near an OR give a woman piece of mind, then that might be the best birth environment. But for women, like myself, who feel that unwanted interventions are lurking at every turn in the hospital, then a home birth is much less stressful for both mom and baby.

I have four children, three girls and a boy, 23, 21, 19, & 17. (Daughter #2 turns 21 in four days, on Feb 16th.)

My son was born at home. At the time we lived roughly 40 minutes from the nearest hospital, and it wasn't a very good hospital. The nearest decent hospital was roughly an hour away. The nearest even close to good hospital was at least 90 minutes, and the nearest first-rate hospital was two hours. That's in good weather, dry pavement. But we were out in the country, western Washington State, and it rained all the time. Sometimes it snowed or we had ice storms.

In addition, my then (now ex-)wife's birth pattern from initial hard contraction till delivery had dropped by an hour with each delivery -- four hours with daughter #1, three hours with #2, only two hours with daughter #3...all of whom were born in a birthing suite in the best birthing hospital in Berkeley California. It made sense that this birth was going to come in roughly one hour and that the odds were high we might not make it to the hospital.

In addition, we didn't have health insurance right then -- I was selling health insurance, but we couldn't afford it ourselves. So we planned for a home delivery with a mid-wife. The other good news was, I was a retired paramedic/flight paramedic with ten years of experience in big-city inner-city (ghetto) emergency medicine and many years of flying in helicopters as well as fixed-wing aircraft, and I'd delivered or assisted in the delivery of roughly 250 babies during my training and practice. (I was fortunate to have done the equivalent of a "paramedic fellowship" in OB/GYN early in my career, where I worked at a high-risk obstetrical unit for four or five months.) Delivering babies pre-hospital was one paramedic skill at which I felt very comfortable.

The delivery of my son took 54 minutes from the first contraction to delivery. His 1/5 minute APGAR was 8/10. He was a big jaundiced after birth, so the midwife took care of my wife and gave my son low-flow oxygen; all of the girls -- whom all had been in the room to see their baby brother be born -- climbed into their car seats and I drove us all in the 30 minutes to the hospital. Twelve hours later we took my boy home.

Was home birth the right call? Yes, I think so. I can't imagine having tried to race to the hospital with my wife in hard labor. It would have put the entire family at risk. Plus frankly I didn't (and still don't) trust the doctors at that hospital. To warm up my kid, give him so O2 after birth, no problem. But for birth emergencies, I preferred my own care and that of the midwife, plus knowing I could call in Lifeflight from Seattle and have it land on the field outside -- which I had set with lights for a helicopter to land at night if necessary (remember, I was a flight paramedic).

Would this solution work for everyone? No. But it worked great for us. My boy is now a Senior in High School and graduates this spring.

Hi Lindsay,

I know you were making light about the cleaning the sheets thing, since it is doubtful any mother who has given birth at home had that on her to do list for that evening. With midwives, assistants, doulas, etc...sheets are no issue.

I wrote an article on the subject on my blog that covers many of the reasons why a mother/couple/family would choose a homebirth, and the statistics have not changed much at all since the date of the study. On top of that the chance of a caesarian section has continued to rise each year since 1965.

Please take a look at the statistics I pulled out of the study:

Homebirth study statistics

For my family and I it has come down to what type of lifestyle do we want to live? That lifestyle for us is one that is as drug and medication free as possible. Not because we are weirdos, but the more we learn about these drugs, and the more time goes by, the worse they end up being for us.

Thanks for bringing up the topics.

A quick point of view from a male perspective. My wife had her first child (my stepson) at a birthing center (pool birth) here in Phoenix. That experience was very positive but with the closing of the center and because she was in her early thirties she was willing to go with a more traditional hospital birth. Until we went to the hospital for the tour. By the time the tournurse got to the big light in the ceiling that drops down for the birth my wife could barely conceal her panic. Myself, I was a bit dismayed at the laundry list of people who would be taking my baby away from us immediately post birth for a barrage of tests etc.

As we were driving home and my wife was sobbing "I..don't...want...a...big light..coming out of the ceiling" we decided to go with a home birth. Luckily our OB/GYN was completely ok with the idea (my wife was healthy, good pregnancy, everything as normal as possible) and she gave us the name of a GREAT midwife. At our first meeting the midwife told us that her only requirement was that if she said we were going to a hospital, we were going to a hospital. She said the only baby she ever lost (in the course of over 2000 births) was because the mother wouldn't allow herself to be transported. When she said that I immediately knew we were in the hands of a professional. After that my wife immediately felt better (though I was a bit nervous, it was my first and quite possibly my only baby) and we spent the next four months getting ready. Near the due date my wife was already at 3cm dialation and our midwife said it was time. She let us know that, if the baby hadn't come by Friday she would help us induce. Which we did with castor oil, baking soda and orange juice (much healthier than hospital options I would assume).

After that everything went smoothly and having our baby in our bed (where we made her) was so stunningly wonderful I can't be grateful enough for the opportunity. Hearing my wife's friend call out "Oh my god, she's a girl" was... damn, I have no words. And knowing they were both safe and healthy and asleep in our room made me the happiest man on earth. A state that lingers still today.

As my wife used to say "I'm pregnant, not sick." I personally believe that that is a statement that should be in the minds of both our new mothers and the people who treat them.

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