When I gave birth to my first son in 2001, the labor pains were nothing compared with the trauma that we both experienced because of the hospital environment. The half-dozen yelling strangers, random people wandering in and out, the fluorescent lights, the 12 unnecessary blood draws from my healthy, full-term son’s heel: All of it left my husband, our newborn son, and me disoriented and upset. The two days in the hospital and the hospital-acquired infection I contracted interfered with my breast-feeding and made it hard for both my husband and me to bond with our firstborn.
The next year, in contrast, I chose to labor at home with a certified nurse midwife in attendance. My second son was full-term to the day, and his delivery was uncomplicated, not to mention fairly quiet. Were I less scientifically minded, I’d probably wonder whether those intensely (and unnecessarily) distressing earliest days with our firstborn caused my oldest son’s autism.
As a developmental biologist, though, I’m not given to such unscientific leaps or to detours away from evidence-based medicine. I know that the medical community is strongly biased against home birth. Many doctors, particularly OBs, think it is an unforgivably dangerous practice. Yet the data suggest that this mindset does not match the science—at least, when home birth is done a certain way. The variability of home birth practices in the United States means that the discussion requires more nuance. It’s not a matter of choice only between a dangerous but mother-oriented delivery at home with an untrained attendant or a safe but traumatic hospital delivery. At least, it shouldn’t be.
A CDC report indicates (PDF) that a growing but still tiny percentage of U.S. women are turning to home birth. The CDC identified a 29 percent increase in home-birth rates from 2004 to 2009 in the United States, a finding that angers people who view home birth as a child-endangering scourge. But recent large studies suggest that the experience and training of birth attendants and proximity of emergency intervention are more relevant to safety than birth location, while the birth environment is important to the level of stress the mother and infant experience.
A 2011 large U.K. study focused on birth location, monitoring outcomes of 64,000 low-risk births from 2008 to 2010. The researchers found that home births or births in a midwifery unit (the U.K. equivalent of a birthing center) were just as safe as a hospital delivery for women who’d already had a child, but not for women having their first birth. Further, births among first-time mothers were as safe in a midwifery unit as in an obstetric unit. Experienced midwifery care can, it seems, be comparable to hospital-based OB care for low-risk pregnancies and births.
In contrast, home-birth opponents like to cite an earlier 2010 analysis of 12 studies from six industrialized countries (developing nations have different, more fundamental issues). This analysis concluded that planned homebirths with healthy and low-risk mothers carried a 0.2 percent risk of newborn death versus a 0.09 percent risk for in-hospital births, a greater than two-fold increase. That increase sounds frightening and tragic, but the main factors associated with it were poor midwife training and a lack of access to hospital equipment.
“Poor training” takes me directly to the fact that home birth in the United States is, in practice, several different entities. The spectrum runs from women birthing unattended—which is both dangerous and counter to a long, multicultural tradition of woman-supported birth—to what I’d consider the gold standard: certified nurse midwife, backup from a hospital-affiliated OB, and a well-equipped hospital nearby. The 12-study analysis was not confined to that gold standard or to the newest practices. For example, one U.S. study that the authors included was “Outcomes of a rural Sonoma County homebirth practice: 1976-1982,” while the other U.S.-based study focused on the years 1989-1996. A Lancet editorial about the 12-study analysis noted, “In the USA … only a third of homebirths are accompanied by a certified midwife.” Achieving safer births overall in the United States clearly means having experienced, well-trained birth attendants, regardless of the setting.
Good training is important, but so is the birth environment. We shouldn’t separate the mother from the child, literally or figuratively, without attention to stress. Stress is a normal part of birth, but there is such a thing as too much. Read birth stories on parenting and pregnancy websites, and you’ll find women describing lingering mental trauma from hospital experiences, trauma that clinicians may not have even registered. Women may undergo an unfamiliar humiliation, a loss of all control at a transformative moment in their lives when that sort of stress can have lasting effects. If they’re like me, they turn to home birth with the hope that it will limit stress for everyone involved, in part because of familiar surroundings and the very personal care a midwife provides for her and the baby.
Obviously, a healthy child is paramount, but the woman is important, too, and safety and a reduced-stress environment are not mutually exclusive in a country where medical care should be exceptional. There are important reasons to consider a birthing woman’s needs. Some studies indicate that anxiety is no friend to labor progression. And then there are the longer-term outcomes. For example, experiencing “pressure to have an induction and epidural anesthesia” has been linked to post-traumatic stress disorder in women. Another large analysis of several PTSD and childbirth studies found that risk factors for PTSD included “obstetric procedures, negative aspects in staff-mother contact, [and] feelings of loss of control over the situation.” Maternal distress may be a risk factor for PTSD later in the child, and those early experiences between mother and child may matter for a lifetime. In other words, maternal stress is relevant, and having some say in this transformative experience is important to reducing that strain so that a mother can parent her new baby effectively.
What choices do women in the U.S. have that empower the woman and offer a safe, stress-reduced birthing environment? Harriet Hall, a doctor who is a considerate and calm proponent of hospital birth, has noted that integrating a “kinder, gentler, less-interventionist midwife approach into a home-like hospital birthing facility” would increase patient satisfaction without sacrificing safety. Indeed, the hospital where we had our third son offered such a setting, the elusive “just-right” balance for us. Hall also has said, “We need to figure out (with science)” what is “beneficial, to improve the safety of both homebirths and hospital births.”
True. But many women in the United States who don’t live in “progressive” areas continue to have little more than a binary choice between a heavily medicalized hospital experience and whatever limited midwifery option is available near them, which can range from lay midwives with little formal medical training to well-trained, experienced certified nurse midwives with hospital backup. Science-based conclusions about what really constitutes “safe” homebirth remain unobtainable without an infrastructure of certified nurse midwives available across the United States. Non-U.S. data tell us that birth attendant training and experience carry considerable weight, regardless of location, and that with a well-trained attendant, nonhospital births can provide a lower-stress environment and still be safe.
The obvious solution to the controversy is to offer choices that reduce perinatal stress, minimize interventions, and personalize birth—the great appeal of home birth and midwives—while ensuring a safe outcome with well-trained attendants and access to emergency facilities. The absence of options in the United States leaves this solution elusive, especially where hospitals lack a homey, low-stress environment and local midwifery care fails to meet the gold standard. Strange, isn’t it, that our nation, in the 21st century, can’t offer more uniformly safe choices for a low-risk pregnant woman seeking a healthy, low-stress birth for her child … and herself?