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Is It Safe? Asking the Wrong Question in the Home Birth Debate

11:47 am in Uncategorized by RH Reality Check

Written by Miriam Pérez for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

A recent heated dialogue between journalists Michelle Goldberg and Jennifer Block about the safety of home birth has been the latest in a recent media flurry about the rise in home births reported by the CDC in January. A New York Times Magazine profile of Ina May Gaskin, arguably our nation’s most famous home birth midwife, was just one of the most mainstream of the recent articles, and seems to have stirred up much scrutiny of the practice. 

I feel compelled to dip my toe into the conversation, if only to try and steer it in a different direction. The source of the back and forth between Goldberg and Block centers on this question: “Is home birth safe?” It’s not a new question; in fact it has been debated since the beginning of obstetrics and hospital birth at the turn of the 20th century. 

Unfortunately, though, it’s exactly the wrong question to which to be devoting so much air time. A scant share of all women giving birth in the United States do so at home. Despite the reported 29 percent increase in home births nationally between 2004 and 2009, fewer than one percent of births happen out of hospital. While home birth gets much scrutiny, particularly when wealthy white women are seen as forging a new trend by choosing it, the place where the majority of women give birth in the United States — the hospital — goes largely un-scrutinized. 

Hospital births do get a lot of attention in birth activist circles (where I spend significant time, as part of my work at Radical Doula). Midwives and doulas will quickly recite the problems with hospital birth, e.g., why high intervention rates (c-sections, inductions) are bad for mother and baby. But outside of that arena, where it’s arguably most needed, the conversation is stalled. 

Here is the reason this matters: we are in the midst of a maternity care crisis. I’ve said it before, but I’ll say it again: our maternity care system is broken. Why? Because our maternal and fetal mortality rates are worse than 40 other countries worldwide, despite the fact that we spend more money than anyone else on maternity care. And where is  almost all that care being delivered? In hospitals. 

More than thirty percent of all births in the United States are through c-section – a rate twice what the World Health Organization identifies as a dangerous level of c-sections. Maternal mortality is actually on the rise — more mothers are dying from childbirth-related causes now than thirty years ago. I could go on, but I’ve said this all before. 

I realize that things which are deemed “new trends” often get attention, despite the fact that we are only talking about a small minority of people. But there is another reason I think this crisis isn’t getting the air time it deserves — it disproportionately affects women of color. Black women are four times more likely to die in childbirth than white women. And remember, these are hospital births we’re talking about here. While CDC data showed an increase in home births from 2004 to 2009, non-Hispanic White women accounted for 90 percent of this increase. Women are dying from childbirth in our hospitals at alarming rates, under the care of obstetricians and nurse midwives. Something is wrong here.

I don’t hide the fact that I’m a supporter of the midwifery model of care. I do think home births can be a safe and viable option, given adequately trained providers and a relationship with emergency back up services if necessary (something that because of the history of hostility between midwifery and obstetrics is hard to come by). But I’m interested in seeing our energy and scrutiny focused on the vastly dominant portion of our maternity care system: hospitals. While some people know well what challenges arise in that environment, the stories of parents who’ve lost children or mothers in hospital aren’t often publicized in the same way as are those of that small share of home births. We know they happen — mothers and babies are dying from childbirth-related causes in our hospital system. Malpractice rates for OB-GYNs may be high, but the stories of what sometimes happens under their care doesn’t get the same level attention. Why? Because doctors practicing in hospitals have an army of institutional supporters that protect them legally, financially, and in the media.  

As I’ve said before, we desperately need innovation and new approaches to maternity care. Whether you think midwifery and home birth are viable alternatives or not, it’s hard to ignore the statistics that say what we’re currently doing isn’t working. We should be able to guarantee better (not perfect, but better) outcomes for parents and children. If I were to play the blame game, I’m going to look to where almost everyone is giving birth — the hospital. It’s likely that we’re not going to find just one solution that will reverse our rising maternal mortality rate, or our infant mortality rate (not to mention the less discussed, but also important, disability from childbirth-related causes); we will need a range of solutions.

I do think maternity care provided out of hospital by trained providers (yes, even midwives without nursing degrees) deserves our attention. I think evidence-based care should be the standard across maternity care disciplines, but right now it seems that the scrutiny spotlight is unfairly trained in only one direction. It’s the direction that affects very few people, and this imbalance undercuts efforts to do the work of improving birthing outcomes in all settings.

Midwifery, particularly Certified Professional Midwifery, the focus of Goldberg and Block’s conversation, is an under-resourced and extremely marginalized movement. It’s a movement with almost no institutional support, little lobbying power, and with a number of powerful groups (the American Medical Association, American College of Obstetrics and Gynecologists, even the American College of Nurse Midwives) working against it. It’s hard to imagine a movement so maligned being able to prove its worth in that kind of climate, even if Rikki Lake and the New York Times Magazine choose to promote it. 

Let’s focus our scrutiny on the system that is failing us, and figure out how we can make it better. A few things that would help greatly in this matter: transparency about c-section rates from hospitals, an independent body investigating deaths from pregnancy-related causes, and real pressure on the obstetrics community to follow their own advice on practicing evidence-based medicine. 

Home Births Rise in U.S. And It’s Not Because of Ricki Lake

6:40 am in Uncategorized by RH Reality Check

Written by Amie Newman for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

For women who choose to go through pregnancy and childbirth, the freedom to choose where and with whom to birth is not always immediately accessible. Before childbirth in hospitals became the norm, women birthed at home, under the care of a midwife. It wasn’t until the 1950s that childbirth care shifted significantly from midwives and homebirth to physicians and hospital birth. However, birth for healthy mothers and their babies does not necessarily have to be medicalized.  And because it was becoming increasingly clear that birth was drifting, quickly, from the hearts and hands of women to the more medicalized, economic model put forth by hospitals, women’s health advocates interested in natural birth created a movement.

There is nothing inherently wrong with hospital birthing, of course (written from the heart of a mother who birthed two beautiful children in a hospital birthing center). It is the focus on economics, while having lost our sense of what birth is all about by straying far away from trusting women and women’s bodies, that is the "wrong." We now have a cesarean section rate in this country of 30 percent – one out of every three births in this country is via c-section -  that dangerously exceeds the World Health Organization’s recommended rate of 5 to 10 percent of all births. With a cesarean rate of over 15 percent, the WHO says, we’re in the realm of doing "more harm than good."

We are not providing women with the optimal enivornments for birthing, or giving women the chance to choose where they wish to birth and with whom. There are of course many reasons for this, not the least of which is access. Women who have no health insurance are not in a position to "choose." Pregnant women who live in a small town with one hospital that forces c-sections upon women who have had a previous c-section are not in a position to "choose." Women who live in a state where midwifery, essentially homebirth, is illegal are not in a position to "choose."

This cannot be what our mothers want or what we want for our mothers.

Things are looking up. According to a new report by the Centers for Disease Control (CDC) released this week, more women in the United States are opting to birth at home or out-of-hospital, when they are able, mostly out of a desire for a low-intervention birth or because of cultural or religious reasons, and sometimes because of lack of transportation.  

The report also identifies reduced costs associated with out-of-hospital maternity care as a factor in the increased demand. 

Over the last five years, out-of-hospital births (which includes home birth and birthing at a free-standing birth center) rose 3 percent and home births rose 5 percent after having sharply declined between 1940 and 1969 and then remaining static over the last few decades.

Approximately 17 percent of these home births recorded were unplanned – either because of transportation issues for women who live in rural areas or emergency scenarios.

The report acknowledges that home births were "less likely than hospital births to be preterm, low birthweight, or multiple deliveries."

Out-of-hospital birth and home birth has been treated with more than a raised eyebrow by the media as well as some professional medical associations (specifically the American Medical Association (AMA) and American Congress of Obstetricians and Gynecologists (ACOG)) over the last few years.

The AMA passed a resolution in opposition to home birth stating that hospital births are the safest route for mothers and babies.

In a poorly reported segment on The Today Show a few months ago home birth was treated as a perilous fad spurred on by celebrities who birth at home with hordes of pregnant women clamoring to "do what Ricki Lake did."

However, the report makes a point to note that in contrast to the AMA and ACOG, the organizations that represent physicians who facilitate birth in hospitals, "the World Health Organization, the American College of Nurse Midwives, and the American Public Health Association all support home and out-of-hospital birth options for low-risk women."

As for midwives who attend home births and birth center births around the country?

The Big Push for Midwives Campaign Manager, Katie Prown, says, “Those of us who have been advocating for increased access to Certified Professional Midwives and out-of-hospital maternity care have long known that the research shows that AMA and ACOG statements about the safety of home birth and the reasons why women choose out-of-hospital delivery have no basis in the evidence,“ said Prown. “It’s great to be able to cite even more research on the safety of out-of-hospital birth and to be able to point to data showing that women in the United States do not, in fact, make decisions about where to have their babies for frivolous, selfish, or trendy reasons.”