You’re Giving Birth WHERE?

So you’ve decided on a birth team and birth place and you’ve started to share your decisions with family, friends and colleagues. Their response? “You’re giving birth where??” Or maybe you get the wide-eyed stare. Or the laughter! Or the jaw drop. Or even the very concerned brow furrow.

Immediately you feel as though you need to defend your choice, or at the very least politely sit through someone’s laundry list of concerns, or stories they’ve heard, or a barrage of questions about every possible danger you could conceivably encounter as a result of your choice to birth there.

Homebirthers typically get the “You’re brave” comment, which is often a thinly veiled way of implying crazy. After all, choosing to birth in an environment where pain medications are not readily available means you’re setting yourself up for actually feeling labor. Or it may even be a disparaging comment implying that you’ve made a dangerous ill-researched decision and are putting your life and your baby’s life at risk. From the homebirther’s viewpoint, it’s usually the hospital birthers who are brave. After all, choosing to birth in an environment where a national figure of 32.9% of pregnancies end with caesarean surgery (local rates may top 40%) and where interventions are often routine seems daunting to those who do indeed wish to experience a natural birth in a comforting environment.

According to the CDC’s data brief issued in January 2012, there were 29,650 home births in the United States in 2009: the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009. That still means that fewer than 1% of women gave birth to their babies at home that year and it was the highest level since data on this item began to be collected in 1989. (Of course, the vast majority of babies were born at home before birth became medicalized in this country.) Those figures blow me away, because I birthed all four of my children at home. It just seems natural to me and I loved not having to drive anywhere in labor, having the midwives I’d chosen and trusted come to my home and being able to recover and bond with my baby without the interruption of returning home. I know it’s not the right choice for everyone, but it still surprises me that I’m among just 1% here in the U.S. and that I’d be among the 30+% who give birth at home in The Netherlands, where my parents were born and raised. And the Dutch have better perinatal mortality and morbidity rates than we do in the States. Hmmm.

It’s important to recognize that for some, a hospital truly is the best place for their labor and birth experience. If a woman is not comfortable with an out-of-hospital environment for birth, then that is not the right place for her and she should not try to force it to be so. She can, however, increase her chances of having a natural birth and positive labor experience by hiring a doula. For others, having a birth at home is the most comfortable, appropriate and safe option. For still others, birth at a birth center is an ideal compromise and can offer the best of both worlds. Fortunately for many healthy and low-risk pregnant women, birth at a birth center or at home with professional licensed midwives is a safe and available option.

It is the right and responsibility of every woman to educate herself about birth and make the choice that is most appropriate for her. Whatever that choice may be, it should be respected!

If you have a relative who is persistently ‘sharing their concerns’ with you about your choice of birth place or birth team, it may help to bring them along to one of your prenatal visits or childbirth classes. Sometimes it helps for them to meet your knowledgable and professional midwives and to see for themselves that the birth center is in fact equipped with oxygen, resuscitation equipment or whatever else it is that they are worried about, that it does have a telephone and protocols in place for transfer when necessary, and that it is run by competent and trained professionals (and not a bunch of barefoot hippies catching babies out in the woods somewhere). If that doesn’t put their mind at ease and they cannot respect the decision that you have made and their misplaced concerns are causing you stress, then it may be best to minimize contact with them until after your birth.

If you’re still considering a certain hospital or birth center, or even an individual care provider, and you have questions or concerns about safety, you may want to ask about their specific statistics. Knowing what the national caesarean rate is one thing, but what matters more is knowing if your local hospital’s rate is 70% or 15%. Even within the same hospital, different care providers have different practices, comfort levels, philosophies and rates so ask about their statistics for what matters most to you: episiotomies, caesareans, use of pitocin for induction/augmentation, use of analgesia/anesthesia, rate of infection, rate of forceps/vacuum use, and rate of birth injuries, perhaps. You are perfectly within your rights to ask those questions. Sometimes you get more information from what they won’t tell you than from what they do tell you.

Time and again, studies have shown that a midwife-attended birth at home or in a birth center is as safe as birthing in the hospital, but with fewer interventions and more satisfying experiences for the parents.

For more information on the safety of out-of-hospital birth, check out:

Outcomes of planned home births with certified professional midwives: large prospective study in North America

Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.

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

Technology in Birth: First Do No Harm by Marsden Wagner, MD

“An important decision to make is whether to have your birth at home, a freestanding birth center or a hospital. Overwhelming scientific evidence shows that the home is a perfectly safe place to give birth if you are one of the more than 80 percent of women who have had no serious medical complications during pregnancy. The evidence indicates that it is important to have a trained birth attendant for your homebirth, be it non-nurse midwife, nurse-midwife or doctor. Your place of birth should also be within 30 minutes of the nearest hospital. The single most important advantage of homebirth is that the birthing woman is in control. Another important advantage is that in homebirth there is far less unnecessary use of technology.”

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician

Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births 

Results  No significant differences were found between planned home and planned hospital birth. [….]

Conclusions This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.”

Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study 

“There were no maternal deaths. [….] The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartum transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.”

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia 

Results: Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14–0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22–0.43). [….]

Interpretation: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife.”

Homebirth 101 an article by Henci Goer, author of Obstetric Myths Vs Research Realities

“What are some advantages of homebirth?

You are much less likely to be subjected to potentially problematic procedures, drugs and restrictions. Every obstetric intervention carries risk as well as benefit. When interventions are used with women who don’t need them, on a routine or “just in case” basis, or on women whose problem could be resolved by waiting or by simple, risk free measures such as: walking, change of position, talking over worries, or a warm bath, than those women are exposed to the risks without any chance of benefit. The end result is that some women and babies will develop complications, minor or major, that never would have occurred had they not been subjected to the intervention. This truth is why numerous studies examining individual procedures, drugs and restrictions have consistently concluded that outcomes are equally good and often better with restricted use of the intervention.

Likewise, numerous studies comparing outcomes between low-risk women receiving standard obstetric management versus similar women receiving the less interventive, midwifery style of care have found that women and their babies receiving the midwifery style of care did equally well or better.”

 

Where did you give birth? 

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