In the fall of 1975, my mother pushed me into the world in our dining room while perched atop the communal birthing table passed around for decades among the pregnant women of the remote island of Vinalhaven, Maine, where we lived. My parents’ favorite song played in the background.
Every time my maternal grandmother called me on my birthday, she recounted the joy of witnessing her first birth—my own. Even though she was the mother to nine children, she had given birth unconsciously to my mother and her siblings during the era of twilight sleep. My birth was a moment of intergenerational healing, and when we moved back to the mainland, my parents chose to birth my little brother at home. It’s an uncommon origin story for an obstetrician. It’s also the foundation of my belief that pregnant women and birthing individuals should have support from obstetricians to choose where and how they give birth.
There is a misconception both in my field and popular culture that to have a home birth is to deliberately forgo proper care. The recent Netflix movie Pieces of a Woman, by Hungarian screenwriter-director team Kata Wéber and Kornél Mundruczó, opens with one of the most riveting childbirth scenes ever captured on film. Martha, the character portrayed by Vanessa Kirby, loses her baby during a planned home birth. As Martha struggles with her loss, her mother compels her to testify in a wrongful death lawsuit brought against the midwife by the state. The film is a richly nuanced reading of a mother’s grief. It also highlights, and in some ways perpetuates, stigma that harms midwives and those they care for who deserve comfort and dignity when giving birth outside of a hospital setting.
The reality is that a planned home birth with a midwife is a safe option for low-risk pregnancies and can limit unnecessary medical interventions. It’s essential for people in rural areas who lack hospital access. It can also be a more supportive and comfortable option for women who face mistreatment, abuse, and racism at the hands of the U.S. maternity system, which often fails to meet the complex and diverse needs of all Americans. The ongoing COVID-19 pandemic at times overwhelms hospital birthing units, causing some to wonder whether more birthing services should be thoughtfully moved into the community. Some hospitals restrict the number of visitors who can attend a birth, adding yet another compelling reason why people may prefer to give birth at home. Midwives are extensively trained, skilled professionals who in the best of circumstances work in collaboration with OB-GYNs and hospitals to manage emergencies—something that Pieces of a Woman’s harrowing birth scene obscures.
While we don’t know the outcome of the legal case in Pieces (it’s a secondary story line) we do know the outcome of the case on which the film is based—that of Hungarian obstetrician-turned-midwife Ágnes Geréb. I became familiar with Geréb’s court case when I was a visiting Fulbright research scholar at Semmelweis University in Budapest. Geréb built a thriving home birth practice in the city and over the course of her career experienced three perinatal losses during home births. The obstetric profession pursued Geréb with criminal charges for these stillbirths. In 2010 she was convicted of negligent homicide. Geréb ultimately spent about four years under house arrest and is restricted from the practice of midwifery until 2022. In the United States, midwives have recently been subject to criminal prosecution, in part due to our inheritance of a patchwork of state-by-state regulations that themselves were a response to the near extinguishment of midwifery as a profession. This heavy-handed approach can have a chilling effect, creating an unfriendly and unsafe environment for people to practice.
I cannot help but contrast these midwives’ treatment with my own experience. Forty years after my own home birth, I was working as a practicing obstetrician at a hospital in San Francisco. I accepted the transfer of a woman who attempted a home birth and eventually needed an emergency cesarean. Sadly, her baby’s health declined immediately after the birth and eventually died. Everyone involved was devastated and heartbroken. In the aftermath, we all searched for answers. I still do.
When such a tragedy happens under the care of an OB-GYN, it’s often treated as a risk of the profession. When a midwife is in charge, especially in a home birth, people are quick to cast blame and assume they made a grave error. In the hospital, I had access to legally protected and confidential peer review where the entire clinical team could debrief the event and implement process improvements. If I were a midwife, I may well have instead faced criminal charges.
It’s my job as an obstetrician to explain risks and work collaboratively to build a safe birth plan in the context of the hopes, fears, and desires of pregnant women and birthing individuals who I serve. During prenatal care, I have supported pregnant women in making an informed decision to give birth at home or in a birth center. For these women, I always keep an open door should they need access to specialized tests or ultrasounds. When I accept a transfer into the hospital from a home birth, I strive to maintain a continuum of care, for example, by reviewing the home-birth midwife’s records. Sometimes, after a comprehensive evaluation, women transferring into the hospital do need obstetric interventions. It’s entirely possible to walk the path from home birth to an unplanned cesarean in a way that is respectful and collaborative. In my opinion more women would choose home births if doctors better supported this option by discussing and implementing best practices for home-to-hospital birth transfers.
Those cases when risks thwart a patient’s ideal birth plan are exceptions rather than the rule. There are also times when, no matter how well you plan, things go wrong. Despite best efforts, tragedies can happen in any birthing circumstance, In some of these instances, the answer is not to blame but rather draw lessons and use them to optimize best practices. I’m certain the answer is not the general stigmatization of women who attempt a home birth, nor the incrimination of midwives who assist them.
Pregnant women and birthing individuals get the best care when midwives are respected and integrated, and not marginalized, from the medical system. My fellow obstetricians must see midwives as partners in providing the safe care that our patients deserve. The stigma against home birth is unwarranted, and it ultimately deprives people of the supportive birth experience they deserve.
Update, March 18th: A detail about the death of the baby following the emergency c-section has been removed from this piece, as it could potentially be used to identify the patient.