Thirty-five years ago I gave birth to my first baby at home, followed by three more children via three more home births in the ensuing decade. My four births were beautiful, meaningful, empowering events that supported my smooth transition into natural mothering. Admittedly, this was long before I was a physician.
In fact, I was a home birth midwife.
Having home births – and being a midwife – were congruent with how I lived: as close to nature in my lifestyle choices as possible. During labor I felt the most comfortable being in my home, walking on the golf course behind my house, squatting during contractions, and eating & drinking freely to maintain my energy and stamina. It was where I felt the safest and could take the path of least resistance to how I wanted to birth. I also knew I was making an educated decision based on extensive research into the history of birth in many cultures, and the evidence for obstetric practices at the time.
But what about now that I am a Yale-trained physician and a family doctor with a specialty in obstetrics? Would I still have my babies at home? Come take a journey with me…
Home Birth: More Than a Romantic Choice
Where we choose to have our babies actually has to do with more than simply personal preference, spiritual beliefs, and romantic notions. It’s a public health and safety issue.
Just skimming the surface, we know that planned home births lead to substantially fewer unnecessary cesarean sections than do hospital births. We also know that prenatal care and birth attendance provided by a midwife are more likely to help pregnancy and birth stay on a natural trajectory, and are much less likely to result in unnecessary interventions of any type.
There are very real health reasons for women to consider birthing at home. These include mom’s safety, baby’s safety, and the economic sustainability of our health care system.
What’s The Big Deal About Cesareans, Anyway?
The national cesarean section rate is a shocking national average of 34%. At some major teaching hospitals in the US, including one of the ones in which I trained, the rate exceeded 40%. In fact, interviewing at some of these institutions when considering a residency in obstetrics, I was assured that there would be no shortage of cesareans for me to do!
Yet the World Health Organization states that C-section rates in an average, healthy population should never need to exceed 14%! When medically necessary, the benefits outweigh the risks and become acceptable. Unfortunately, most cesareans done in the U.S. are UNNECESSARY, making the risks unacceptable.
Clearly the US obstetrics system missed the memo on appropriate birth intervention rates!
There are not only immediate risks to the mother; we know that babies born by cesarean section miss out on the benefits of exposure to the vaginal flora that they’d otherwise come in contact with if born vaginally – and this lack of exposure can predispose a baby to disrupted gut flora and significant consequent health problems. Additionally, babies born by cesarean get a dose of antibiotics before birth via mom’s system, adding to the double hit on gut flora!
Birth by cesarean can make it more difficult for mom to breastfeed successfully because of physical discomfort. And let’s not forget that it is major abdominal surgery with much higher risks of harm for mom than with natural, vaginal birth.
Hospital Birth & Loss of Autonomy
During the years when I was having my own babies at home, people would comment that I must be incredibly brave to birth my babies at home. My response was always the same:
I wasn’t brave at all – I was simply terrified of having my babies in the hospital!
By the mid 1980s the cesarean section rate was escalating and had reached what then seemed to be an astronomical 18%. In retrospect I wouldn’t have believed it could get to where it is now, and the American Congress of Obstetricians and Gynecologists (ACOG) has stated that the rate will likely reach 50% before hitting a plateau!
At that time the episiotomy rate was approximately 99% and the epidural anesthesia rate was not far behind. Every woman was required to be strapped to a monitor and to have an IV line placed “in case of emergency.” One OB actually told me that he considered all pregnant women “disasters waiting to happen.”
I was just having a baby, not an emergency appendectomy! I didn’t want all of these potentially dangerous interventions for something that was almost always natural and safe. It sort of reminds me of those commercials for a medication for something benign like a foot fungus. You know, you’ve got a little athlete’s foot so treat it with something that can cause “heart problems, coma, and death.” It’s just overkill for something that’s usually just not that big a deal in a healthy person.
As a midwife I’d observed the loss of autonomy that too often occurred when a woman set foot in the hospital – the transformation that occurred with the ritual of shedding her “real person” clothes in favor of the hospital johnnie, and with it the shift of going from being an independent, capable woman into “a patient” – which culturally equates with being dependent, helpless, and sick – qualities that are a far cry from feeling empowered and strong.
Now, having been through obstetrics training I can honestly say that I’d feel even more concerned about having my baby in the hospital – unless absolutely medically necessary.
Aside from the astronomical cesarean section rates, numerous other complications are occurring in record numbers. One of these is chorioamnionitis, an infection in the “bag” that holds the water around the baby, leading both mom and baby to need antibiotics during labor and after birth – sometimes leading to separation of mom and baby after birth so the newborn can be observed in the nursery. This infection is due almost exclusively to bacteria acquired in the hospital, and is commonly transmitted to the mother when excessive vaginal examinations are performed to assess labor progress.
Women are expected to labor according to the “Friedman curve,” an obsolete measure of how many centimeters she should dilate per hour, and are given medications to stimulate labor when things are not going according to that archaic and inaccurate plan. Pitocin, the most commonly used medication, can cause the baby to go into distress, and in a domino effect, culminate in a cesarean section. This is just a small glimpse of what can – and generally does – go wrong in the hospital setting, leading to the high and inappropriate level of interventions we have in birth.
What should be used as lifesaving techniques, applied routinely, have become dangerous interventions for mom and baby. Yet we are told this is what we are supposed to do for the sake and safety of our babies. Because we are good moms, and trust the medical establishment to be looking out for our best interests and acting on the basis of scientific evidence, we acquiesce – sometimes against our better judgment, and sometimes only to discover later that we were bamboozled into the agenda of the profit-driven behemoth called the health care system.
Obstetric Evidence Reliable Only 30% of the Time
Are obstetrics practices reliable?
Well, the 99% episiotomy rates have declined dramatically in the wake of ACOG admitting that what they previously professed to be necessary was actually harmful. At the same time, rates of most other birth interventions from inductions to vacuum extractions have escalated.
We are just now seeing a leveling off of the preterm birth rate in the US. Until recently, inductions and scheduled cesareans have been a leading culprit in the high incidence of preterm births in the US. The costs of the high rates of preterm babies to individuals and society has been so overwhelming that mandated changes in hospital policies now prohibit cesarean sections prior to 39 weeks of pregnancy unless absolutely medically necessary for mother or baby. Again, what was previously deemed safe by ACOG has been recognized to be harmful.
Do we have a theme here?
Indeed, a report by ACOG itself acknowledged that only about 30% of the obstetrics practices in the US are based on reliable medical evidence. Thirty percent have poor evidence, and the rest, well, mezza mezza, as my grandmother would have said.
Let’s take the external fetal monitor, for example. Used ubiquitously in US hospitals, this annoying machine with its two tight belly belts, one to measure the amplitude of contractions, the other to measure baby’s heart beat during labor, not only keeps laboring moms virtually tethered to the hospital bed, it dramatically increases the rates of unnecessary cesareans, without improving any meaningful outcomes for mom or baby. This is well documented in the annals of the obstetrics and family medicine professions, yet its use persists. Why? It’s one of a limited number of forms of evidence that can protect obstetricians and hospitals in the event of a lawsuit.
Now that I am a physician many women ask me if I would still have my babies at home.
My answer is unequivocally: “Absolutely.”
While you might say, “Well that’s easy for you to say since you’re long past your childbearing years” and don’t have to make that choice, the proof is in the pudding in that I was the midwife to my granddaughter, born at home, to my public health specialist son and pediatrician daughter-in-law – after I’d already become an MD! While I had in no way suggested, encouraged, or even broached the topic of home birth with my Harvard-trained daughter-in-law, who by the way, also has an MPH from Harvard, her own experiences during the course of prenatal care led her to approach me. She’d concluded that home birth would be the safest option for her and her baby.
There are Some Terrific Docs But…
Now don’t get me wrong, there are a lot of terrific doctors doing a spectacular job attending births in hospitals. In fact, growing numbers (though still not the majority) of OBs are women who would like to see birth practices be democratized and evidence-based. And many women do experience empowered, beautiful, natural births in the hospital. It’s just a bit of a roulette, happening against the odds that fewer than 60% of women will even birth vaginally if in the hospital.
The problem does not lie solely or even primarily with individual doctors. Hospital risk management teams, insurers, and legal committees ultimately determine how your doctor is allowed to practice. And a lot of it comes down to preventing litigation against doctors and hospitals – and has absolutely nothing to do with your best interest.
Residency training instills the practice of “defensive medicine” early on. Many obstetricians exit residency not knowing what a truly natural birth even looks like, and have come to believe that birth is a dangerous event that must be contained and controlled. I have even heard some obstetrics’ residents describe women who choose to birth at home as irresponsible, and even lunatics.
On the other hand, growing numbers of obstetricians have become so disenchanted with and stressed by the medico-legal environment of their profession that they have stopped attending births and instead are focusing solely on gynecology. Recently I've even had several OBs contact me to learn how they might be able to practice in a more “holistic” woman-centered way. They want to love and trust birth again!
To Be Fair, The Home Birth Model is Not Perfect, Either
Lest you think I am on a doctor-bashing rampage here, please let me remind you, I am a physician. I've seen birth from unique vantage points. I’ve been through conventional medical training and am part of “the doctor club.” And I'm also a midwife. I really have no agenda other than to see women receive the best possible, most respectful care available, and to see us be able to receive that in the setting in which we feel safest giving birth. I do believe this can happen in hospitals. I recognize the many women prefer to birth in hospitals, and some must for medical reasons. These women still deserve to retain their autonomy, and to have unnecessary interventions minimized and safe and respectful practices maximized. Women can be partners in their care, not subjects of it.
As a midwife with 30 years of experience in the birth community, I will also readily admit that there are quite a few not so great home birth midwives contributing to not so great birth outcomes. In fact, in reaction to the problems found in medicalized birth settings, there’s a bit of a midwife ‘wild west' out there – anyone can get “the calling,” attend some births, and call herself a midwife. Caveat emptor! It’s not black and white. A poorly planned home birth or a less than competent midwife (or physician, though most home births are attended by midwives), in the rare event of a complication, can be disastrous. There’s no romanticization about that from me – I’ve been in the birth trenches for 3 decades and I know some firsthand horror stories from the mouths of the moms and midwives themselves!
Can The Birth Climate Change?
A healthy, respectful atmosphere could exist in which the choice of birth place is depolarized and women are supported in making the choice that is best for them and their babies. In fact, ACOG and the American Association of Pediatrics have recommended that this be the case amongst their members. Honest informed consent, with accurate disclosure of the best available evidence to pregnant and laboring mothers could occur. Midwives and OBs alike should honestly disclose their beliefs, practices, competing demands, experience levels, and outcomes. Women can be respected as intelligent clients capable of making smart choices, rather than being treated as helpless patients.
Critical self-reflection and communication with a common goal of providing optimal maternity (and neonatal) care in all settings is key — and achievable — if we can remove emotional hyperbole and actually listen to the concerns of all involved. I believe there is more common ground than difference.
Birth can be seen as a healthy, natural, normal experience – unless evidence-based medical indications demonstrate otherwise, and in those cases, the least amount of intervention necessary could be judiciously provided. And romantics aside — medical interventions are sometimes needed even in healthy moms who have eaten all the right foods and thought positive thoughts!
Healthy relationships could be established between the medical community and the midwifery community, and women could be supported in their choice to have babies at home, while being welcomed seamlessly into a medical setting should problems arise necessitating that care be transferred to a medical team. Better yet, there could be continuity of care in which there is no separation between birth models – where the only care offered to women is compassionate, respectful, and centered on the woman’s wishes, needs, beliefs, and best interests.
In fact, this is the type of care I have tried to provide my midwifery clients and my medical patients alike – and I know it is entirely possible! All choices and options can be respected. And birth itself can be respected as a natural process that offers women a powerful opportunity for empowerment. It is my hope that your birth experience can leave you feeling empowered and whole, regardless of where or how you bring your baby into the world.