A new analysis by Dr. Joseph Wax comparing home births and hospital births, which was published in the recent issue of the American Journal of Obstetrics and Gynecology, not only presents misleading conclusions, it drives a wedge between two groups that cannot afford a greater divide: medical doctors and midwives.
The study documents similar perinatal (or the period immediately surrounding birth) mortality rates for home and hospital births, but claims a three-fold increase in neonatal (measured up to 28 days after delivery) mortality for home deliveries. Yet this analysis contains serious limitations and concerns those of us who practice midwifery in an out-of-hospital setting.
Beyond the issue of the flawed methodology, which has been addressed by several national organizations, including the Coalition for Improving Maternity Services and the Midwives Alliance of North America, there are serious cultural implications to this study.
As a medical anthropologist, I am concerned with the chasm with doctors and the medical establishment on one side, and midwives and the home birth movement on the other. In Oregon, where we have both licensed and unlicensed midwives working in home and in birth center settings, research has shown deep mistrust between doctors and some midwives. Many doctors have expressed the belief that only hospital births are safe, while midwives say they often feel marginalized and disrespected.
Such studies only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate across a cultural divide. Instead of a maternity system based on fear and misinformation, we need a system based on collaboration and mutual respect.
The United States is already the butt of jokes in the international public health community. We spend more on health care than any other high-income nation, while simultaneously serving the lowest percentage of pregnant women, as several of our key health indicators continue to decline each year. According to Eugene Declercq of the Boston University School of Public Health, the U.S. now has the highest number of maternal deaths relative to all other high-income nations, and we also rank second worst for perinatal deaths.
The U.S. has not reported a significant decrease in maternal mortality rates since 1982, and the Center for Health Statistics indicates that the rate of cesarean section in this country is now at a whopping 32 percent, marking the 11th consecutive year of increase. As the incidence of cesarean section rates rise, so do medical complications for mothers and babies, along with associated health care costs. The World Health Organization recommends a cesarean rate of no more than 10 to 15 percent, so our rate is two to three times higher than it should be.
The answer among the U.S. medical establishment has been to throw more expensive technology at the problem rather than retracing our steps to see where we went wrong. Instead of admitting that something is fundamentally broken with the system, organizations like the American College of Obstetrics and Gynecology continue to endorse the idea that medicalized hospital births are the only safe route for women.
We know that 99 percent of women in the U.S. are giving birth in hospitals, yet the United States has one of the highest infant mortality rates of any developed country, with 6.3 deaths per 1,000 babies born. Meanwhile, the Netherlands, where one-third of deliveries occur in the home with the assistance of midwives, has a lower rate of 4.73 deaths per 1,000.
While maternal mortality rates decreased among our peer nations between 2000 and 2005, they increased by more than 54 percent in the United States during the same time period. The two major differences between the U.S. and other nations, which have superior maternal and infant health outcomes, are that the latter offer universal health care and rely more extensively on cost-effective midwives as a public health strategy.
Consider the economics of the situation. The cost of a cesarean in the United States is about $15,000 and an uncomplicated vaginal birth averages $8,000 (without prenatal or postpartum care), while homebirth midwives charge $2,000 to $4,000 -- a fee that includes care from conception through the postpartum period. Exploring the option of home and birth center birth with midwives for low-risk women should be at the core of national health care reform and research. Instead, several generations of high-tech, low-touch birth and a pervasive cultural belief that birth is imminently dangerous -- even in healthy, low-risk women -- has led to powerful cultural blinders that limit options for women.
In anthropology, we say that "normal is simply what you are used to." The power of socialization and the dominance of biomedicine have kept us from systematically examining a variety of birthing environments and providers as viable alternatives to the expensive and interventive hospital delivery that has become the norm in the U.S.
Finally, I must briefly address the study by Dr. Wax and his associates. Let me first say that their study found no difference between home births and hospital births when measuring perinatal death, which is the primary indicator for evaluating the safety of a mode of delivery. Yet, the study chose instead to focus on neonatal death, generally accepted as death within the first 28 days of birth and to emphasize this part of their research. A complex mix of psychosocial and clinical factors, including congenital anomalies, Sudden Infant Death Syndrome, unsafe home environments, and poverty, can all contribute to death in the first month of life. As Dr. Michael Klein of the Child and Family Research Institute in Vancouver, B.C. points out, after removing low-quality studies and out-of-date statistics, the Wax study actually demonstrates no difference in outcomes between home and hospital-based delivery, even for neonatal mortality.
Yet the authors included faulty data in their total analysis, comparing apples to oranges by mixing different types of data sets, such as grouping low-risk with high-risk mothers, and including babies born unintentionally at home.
As an anthropologist, I see a study like this as harmful to women and as having a much larger social impact than the authors possibly intended. For instance, there are many women in rural areas and women who are uninsured, or under-insured, whose only option is to give birth under the care of a midwife. How does this study affect these women? A study like this only exacerbates and undermines often already negative and tension-fraught relationships, making it more difficult for out-of-hospital midwives and physicians to work together when needed.
There is something to be learned from the centuries-old traditions of midwifery, and I believe that if doctors and midwives, including those who work in the home setting, could be willing to learn from and respect one another, women and babies in our country would benefit. After all, we are all working for the same end result: a happy and healthy mother and baby. Our differing visions of how to get there will require an attitude of cultural humility and a willingness to listen. Studies like the Wax study take us in the wrong direction.
Melanie Batley: Time to Reconsider Whether the NHS Should be Encouraging Home Births
Joan Liebmann-Smith, PhD and Jacqueline Egan: Baby Health Quiz: 6 Questions to Test Your Knowledge
Amie Newman: Is Refusing a C-Section Child Abuse?
Home Birth : American Pregnancy Association
The Homebirth Choice - by Jill Cohen
http://www.ncbi.nlm.nih.gov/pubmed/19249657
There are problems on both sides.
Irrespective of the argument about the safety of the baby - which is hopelessly deluged in propaganda on both sides of the argument, the "elephant in the birthing room" is the gynecological morbidity faced by the mother 5-10 years after her first baby.
Injuries to pelvic nerves in a first labor result in endometriosis, adenomyosis, fibroids and many other painful gynaecological problems. Medicalised childbirth with high rates of induction of labor expose women to prolonged and difficult labors that cause gynecology. Natural childbirth with prolonged labors and straining in the second stage, expose the woman to similar injuries.
Prevention requires proper pre-pregnancy diets, proper pre-pregnancy exercise, proper coaching for labor, and spontaneous onset of labor in a "safe" environment - probably within 30 minutes of delivery by Caesarean section.
There is much room for some anthropology.
you can see similar rates of chronic pain, neuropathic pain, musculoskeletal pain and other medical disorders (urovaginal fistulas, urocutaneous fistulas, rectoceles, rectovaginal fistulas, bladder/bowel incontinence) after both home birth and hospital birth (including c-section).
If I ever do have children, which the mere thought of is mystifying to me.(not really the right word, kind of like a mix between gross, scared, how the blank is that supposed to fit out of that,I mean I know how it's supposed to come out, but it confounds me how it can come out, etc) .
I want drugs, I want so many drugs that I'm numb. I would like you to drug up my vagina, and me, and in the most painless way possible ( because I really, really hate pain) take he or she out.
So, when someone tells me they want a home birth, I don't get it. Why? Why? Why?
We created these great buildings, called hospitals, with special people, who have these magical drugs to make it better for you, the mother, the most important existence in this world. Mothers give life, so what's wrong with making one of the most dangerous procedures in their lifetime, a little more safe and pain free.
It's unavoidable. If you 'really, really hate pain' so much, how would
you deal with the bumps and bruises and occasional broken bones ?
People who can not feel pain (a rare disorder) are very vulnerable.
I just don't like it, and I've never broken a bone. I've had bumps and bruises, but that's what OTC pain medicine is for. And as for kids getting injured I deal with it when I take care of my cousins all the time. I don't have a problem with others peoples pain. I can be very sympathetic. My cousin broke his foot, tripping over a tree branch (yeah I teased him, after I knew he was OK), and I was the one taking him to all the doctors appointments, etc. Even some of the nurses laughed.
Why did I choose to have my last baby at home? Because I like to be in control, and in a hospital you are not. Because I had a crappy hospital birth experience, I couldn't move, eat or drink, had tons of interventions and drugs and ending with an episiotomy and forceps extraction (for a TINY baby)...23 hr labor from hell. And I DID have the 'magical drugs' as you call them (which made my labor stop, made me shiver and nauseous, made my baby's heartrate drop and which prevented me from bending over for the next 6-8 mos).
with my second I refused to go to that 'great building' until the last minute to give those 'special people' less opportunities to boss me around and annoy the shit out of me. My daughter was born 5 mins after I arrived.
My last was a no brainer: home water birth - clam, relaxed, I could move, drink, walk, listen to music and just let it happen. 5 pushes and baby was out. I would NEVER give birth in a hospital again if I had a choice.
I got care from a lovely CNM who works out of the hospital did every thing she told me to do and had my friend who is a CPM come to my house to labor with me got in the van when I was supost 5-6 centimeters. promptly threw up over and over asked them not to leave the driveway till I was done and quietly started pushing while I threw up. had a baby in 20 minuets and headed straight for the hospital. half way there I started to bleed. My friend the CPM who had thought we were going to the hospital had not brought her bag but still managed to get stopped by the time we got to the hospital 15 minuets after birth. went in to the ER. (they had 2 of us that night alone) we were then taken to the postpartum recovery where I got codeine and drugs to help with the bleed. best birth yet.
In short have your baby in a conversion van if you want the best of both worlds.
My mom had friends who did it in the hospital parking lot in the 80's.
works great
and a birthing tub, and so forth, and a stretcher for wheeling you into your
emergency c-section in the rare event, that wouldn't be a bad idea at all.
as far as the tub I hate water when I'm in labor so that's fine to.
the van has a queen size bed, very comfy.
7. Lastly, contrary to the prevailing opinions and viewpoints shared here and in many other inflammatory forums, I have found that in many hospitals, mine included, women are partners in care, and assist in making decisions after being carefully explained risks and benefits. I am sure the opposite can be found, but reading prior posts there seems to be a scarcity of vocal individuals relaying this perspective. Gone are the days where paternalistic medicine is the norm, the modern medschool curriculum specifically teaches patient autonomy, how to partner with patients and respect and work from within the patient's set of values.
I would love to see universal availability of home birthing in the US attended by a regulated body of certified nurse midwives, with careful selection criteria, as it exists in other countries. Unfortunately, we are still behind the times on this here in the US, and this is not available.
If shopping for a home birth experience, please 1) make sure you have a certified nurse midwife, 2) request documentation of their relationship with hospital providers in the case of an emergency. Do not settle for a lay midwife with a certificate from a lay midwife organization, do your research; they do not have the training necessary to tell you whether or not your are a good candidate for a home birth, and you and your babies health interest may not be fully served.
4. MDs and certified nurse midwifes in the US are not in a turf battle, not at my hospital, not on a national level. In Brittain certified nurse midwifes do all the low risk deliveries - it would be great if it were the same here. I think the perceived "turf battle" is between lay midwives and the greater regulated medical community. Understand that lay midwifes are providing a paid service in most cases, and for most of them it is a business. Just because they are engaged, excited, and interested makes it no less of a business.
5.In my hospital for cesarean deliveries, the baby is brought right onto the mother's chest, and can breastfeed while the operation is ongoing, and rides back to the room with the mother.
6. The rates of neonatal mortality and morbidity in US regulated vs unregulated (lay midwife) births would be very hard to acertain for a number of reasons, but biggest being that the baseline rates of events are low enough that the number of participants required to show a difference in outcome would be huge. In two years of practicing in Michigan where certified nurse midwives are not permitted to attend home births (so they are all lay midwives) I have seen two horrendous lacerations, and two hypoxic babies, one of which died and one which spent a month in the NICU, all because the home practitioner did not know their limitations.
1. In other countries with regulated home births, the attendant is the equivalent of a certified nurse midwife. In the US, we have lay midwifes as well, whose training and experience and safety vary widely. Applying information from studies from other countries to the US is comparing apples to oranges. If you wish to rest you and your babies safety on that, so be it, but understand the difference. There is a selection process to determine who are good candidates for a home birth in other countries, which is set up in collaboration with doctors; this is absent in the US.
2. Most insurance companies pay for a pregnancy in a lump sum, regardless of the services rendered during the pregnancy; it's about $1500 whether you deliver vaginally or by cesarean.
3."Bad" fetal heart rate tracings only predict a hypoxic fetus 50% of the time. So a C section for a non-reassuring tracing will have a happy normal baby %50 of the time. It's a known limitation, but the best we have.
Are you sure that's not just the room charge ?
For, like, one day ?
and though comparing studies of homebirthing between countries shouldn't be a reason to shift how we do things here i think our infant and maternal mortality rates DO. Maybe we rely too much on gizmos and gadgets and not enough on guts. meaning wisdom from being with a birthing mother from beginning to end, not just the last 10 minutes. making more time for the prenatal visits that focuses on building trust with your doctor so you feel safe asking questions and not rushed because the doctors' hand is on the door anxious to catch up on their appt schedule. talk to us about past abuse, fear and nutrition. SO much of your Self is revealed in becoming a mother. everything you thought you had under "control" comes back to rear it's head, leaving you vulnerable, sadly too often with little support.
Can any ladies on here share the positives and negatives of their experience(s), please and thank you!
Excellent magazine with many thoughtful articles,
which are available online.
Several recent ones describe waterbirths.
DVD's are also available.
positives:
- decreases pain, especially in the latent phase of labor; it is not as effective in the active phase, but does continue to help some
- others may speak to benefits of fetal transitioning, etc, I don't know of any particular long term fetal benefits
negatives:
- water gets disgusting (some of our certified midwifes hate doing them) - feces, amniotic fluid, blood are all normal parts of labor. they all end up in the water in a nice swirly.
- if you actually deliver in the water, the ability to quick intervene in the rare case of a shoulder distocia is hampered - takes a little extra time to get you into proper positions to be able to get the baby out. this is rare, though, but as an obstetrician, I am always preparing for the worst, and that's my biggest fear in a water birth.
oh wait...they DO have that.
People who opt for home birth, though, have to be prepared for the chance that something could go terribly wrong so quickly that there is no time for transfer to the hospital. It may not happen frequently, and sometimes hospital deliveries end tragically as well, but the risk is there -- if you suddenly need a c-section, you might not get it in time. My sister was one of the relatively few people who was a healthy woman with a normal pregnancy -- just the situation that works for home birth, but it was not legal where she lived so she went to the hospital as planned when she went into labor. Everything progressed, she was pushing, and then the baby crashed. She was delivered by emergency c-section, but has suffered from some learning deficits that are possibly attributable to oxygen deprivation during the delivery. Had my sister been at home, the baby would have died, and her own life could have been in danger as well. I'm very grateful that she was at the hospital and received quick, lifesaving treatment.
How do you know that is true? Did everything progress in the hospital exactly the same as it would have in a home birth? Was she being monitored by a real live person or by a machine? There are hundreds of variables to take into account in the two situations, making it impossible to claim such a thing as fact. In truth, no one knows what would have happened, or if the need for the emergency c-section would have arisen in a home birth setting, because the labor would not have been treated exactly the same way as it was in the hospital setting. I see people make these fallacious claims all the time, and it draws attention away from the real matter at hand.
You seem convinced that she would have been fine at home, and that she must have been lied to in the hospital. Agenda, much??
I did NOT say that nobody should have their babies at home. If people want to, fine. All I'm saying is that if you do so, you must be absolutely prepared for the chance that there will be a bad outcome. And yes, you can have a bad outcome in the hospital as well. Personally I'd rather risk losing a baby despite medical intervention than to lose one at home or in the car on the way to the hospital.
If the medical powers that be would support instead of hinder women who want to give birth at home, it could be safer for every one!
Despite the c-section drugs still trying to impede me, I had a natural boost of adrenaline and love hormone that gives a mom the passion and energy to take care of her newborn. At times, this modern way of giving birth can be barbaric and giving birth at home seems to appear healthier and the more civilized choice.
As I was being c-sectioned, my obstetrician was teaching residents how to slice, and sew. By being an experiment for these young minds, I knew I was contributing to the needless near 50% c-section rate. Birth is supposed to be a private event with the mother being surrounded by a couple of loving, supportive people. When animals give birth, they go to a private place in the woods and hide. How opposite maternity care is in modern times of being sometimes humiliated, exposed and just about tied down.
My firstborn was deposited on a cold metal scale rather than into my warm, loving arms. I realized why many women consider home birth a wonderful option. There are enormous benefits for mother and baby to be together during that precious time after birth, such as not losing weight like babies do in hospitals.
did you not sign consent papers for the surgery?
all babies lose weight during the first month...not just those in hospitals.
your firstborn (and all other babies) was hopefully NOT deposited in a cold metal scale but taken to an incubator, assessed for need of resuscitation, and then given to you. had you had a home delivery, i would hope that the midwife would also assess the baby before leaving him/her in your care, so that any necessary resuscitation could be done and you could have a healthy baby.
all mothers are given their babies immediately after birth, barring any medical needs for the baby or mom. it's not a matter of separating the two just to be cruel; the two are separated only in emergency situations.
as much as we'd want it, the role of medicine isn't to provide spiritual meaning. it's to provide healthcare.
this is a great example of the cultural values inherent in any medical system. it sounds like your cultural values would guide you towards home delivery. no physician would force you to do otherwise, because we have to get pt consent to do anything.
that being said, please don't confuse the issue by citing research as a reason to have home deliveries. i've looked, and can't find any valid, scientific studies that demonstrate home delivery is a safer option for deliveries. if you have such a study, please post it.
Women are looking into homebirth because they aren't happy with their hospital experiences. Instead of blaming women here, maybe it would be wiser to listen and try to find a solution that is both satisfying and safe.