Out-of-Hospital Birth

“We have a secret in our culture, and it’s not that birth is painful. It’s that women are strong.”
– Laura Stavoe Harm

Why Choose Out-of-hospital birth?

Giving birth naturally can be an experience of transformation and empowerment for everyone involved, and yet the intensity of the process can be challenging for many women. The key to a birth that is both healthy and minimally painful is the ability to relax, as it allows the spontaneous rhythms of labor to progress without interference. The greatest obstacle is fear, for it generates tension and resistance and makes coping with contractions more difficult. In general, the more relaxed the mother, the easier the birth.

Mothers birth best where they feel the most comfortable. For many healthy, low-risk mothers, home provides a supportive and safe environment in which to give birth. For others, a free-standing birth center offers all the comforts of home and none of the responsibility for set-up and clean-up. Moreover, when a newborn baby is perceived to be a conscious, cognizant being, the manner in which he/she is born can have far reaching effects both psychologically and spiritually. In the privacy and sanctity of the out-of-hospital setting, a mother can surround herself with those she loves and trusts. Assisted by capable, experienced practitioners, the family has more freedom to create the experience they desire and welcome their new child with love and dignity.

“Where would all the specialists and producers of medical technology and drugs be if it were suddenly ‘discovered’ that when women eat well in pregnancy, eliminate drugs and stop substance abuse, almost all complications disappear?” – Anne Frye

Advantages for Mother

  • Childbirth has the potential to be a profound, life-transforming experience for the woman, one which may facilitate emotional healing, strengthen and deepen her relationships to all aspects of herself–with far reaching effects to her children, her mate and family members.
  • She is not subjected to routine procedures such as continuous electronic fetal monitoring, IVs, and episiotomy.
  • She can eat, drink, walk, and rest freely, working with her own natural body rhythms.
  • She has continuous care with the same attendant throughout the prenatal, labor, delivery and postpartum periods, facilitating trust and competent decision-making based on full informed consent and confidence in her providers.
  • She is more likely to deliver without drugs, vacuum extractors or cesarean section when supported by caregivers who feel that birth is a normal physiological function.
  • The woman and baby have less risk of infection in their own home.
  • She is free to explore a variety of creative birthing options such as waterbirth, birthing stools, delivery positions like squatting or hands and knees, and may utilize comfort measures like candles, incense, inspiring music, and aromatherapy.
  • She is less likely to experience postpartum depression when she has not been separated from her baby. In addition, when childbirth takes place outside the hospital, it becomes an integral part of family life, with father and/or siblings able to participate in as complete and appropriate a manner as possible. This assists postpartum adjustment for all family members.
Emily

Emily reaches for her son as he emerges from her body.
There is no more amazing moment……..

Advantages for Baby

  • The baby’s experience at birth can be made as gentle and loving as possible, and routine procedures such as deep suctioning, bright lights and artificial warming can be avoided unless medically necessary.
  • The healthy baby remains with the mother, preserving the mother-infant bonding so crucial to the development of attachment parenting.
  • The baby is more likely to be born vaginally without breathing difficulties so often associated with anesthetics and cesarean birth.
  • Breastfeeding is easier to establish when the baby can nurse on demand, and the mother is given immediate encouragement and instruction in proper technique.
  • Baby is less likely to develop an infection at home.

Disadvantages

  • Requires a higher level of effort and responsibility on the part of the parents, and may not be supported by medical doctors/society.
  • While midwives are trained in emergency measures, access to some equipment may be delayed, and transport to a hospital may be required.

In urban areas, access to emergency medical services are expeditiously obtainable, and most midwives work in consultation and collaboration with an obstetrician who is willing to assume care of their patients if necessary.


Safety of out-of-hospital birth

There have been a number of clinical studies on the safety of out-of-hospital birth for normal, low-risk women receiving good prenatal care. Practically all of them show that out-of-hospital birth is either as safe, or safer, than hospital birth – for low risk, healthy pregnant women with normal pregnancies. The main study describing out-of-hospital birth as more dangerous is a study that was done by the American College of Obstetricians and Gynecologists in 1978 called “Health Department Data Shows Danger of Homebirths.” This study included all out-of-hospital births, including unattended births in the home, births en route to the hospital, mothers who may have been high risk, had received no prenatal care, and babies who were pre-term. This factor, which skewed the results, was not widely acknowledged. In fact, this report also included miscarriages in its data showing the risks of out-of-hospital birth. Clearly, this report is not representative of the kind of service that midwives are offering. And interestingly enough, it seems to be the ONLY study that showed out-of-hospital birth to be less safe than hospital birth, although many studies have tried.

To read more about the safely of out-of-hospital birth with skilled midwives, read The Five Standards for Safe Childbearing, by David Stewart, Ph.D. It cites study after study that detail the statistics that prove the safety of midwife-attended out-of-hospital birth.

 


 

The Philosophical Assumptions of Home Birth Parents and Attendants*

Because pregnancy and birth are natural physiological events, normal birth does not belong in hospitals.
The natural course of labor is already perfect, and should be interfered with as little as possible. Pain is part of an essential and healthy feedback mechanism in labor, which women can learn to cope with, with proper encouragement and support.
Medical management of pregnancy and birth should be limited to those that are medically complicated.
Unnecessary medical interventions complicate normal labor, creating additional risk and the need for more intervention.
*excerpt taken from Birthing from Within by Pam England, CNM, MA, and Rob Horowitz, Ph.D.

 


“There is, in fact no scientific support for the vast majority of interventions that are commonly used in maternity care today.”
– Doris Haire, President, American Foundation for Maternal and Child Health

 

How Safe is that Hospital Anyway?

Information compiled by Jennifer L. Griebenow 4/97

In the past, most Americans were born at home with lay midwives attending. The mortality rate for both mothers and babies was higher in 1900, at 700 maternal deaths per 100,000 births, than it is now. Babies also died at a significantly higher rate at that time, which decreased to 28.9 births per thousand by 1960. Obstetricians tend to emphasize that many women used to die in childbirth, implying that we should be grateful for current obstetric practice. However, even in 1900, the percent of women who died giving birth was only 7/10ths of one percent! One has to wonder how this percentage compares with our country’s current cesarean section rate of 22%.

Are the surgeries performed on these mothers actually saving them from imminent death? Maternal and infant mortality are lower now than they were 40 years ago. But the assumption that hospital birth is safer for mother and baby has never been supported. Prenatal care, better nutrition, antibiotics and blood transfusion have played more of a part in the relative safety of birth now. Sheila Kitzinger, British childbirth expert, states that planned home birth with an experienced lay midwife has a perinatal death rate of 3-4 babies per 1,000 births. Hospital births, by contrast, carry a perinatal mortality rate of 9-10/1,000. (Perinatal death rates include fetal deaths on and after 28 weeks gestation, whereas neonatal mortality rates only include deaths occurring in the first 28 days after.) A study in Australia found a perinatal mortality rate of 5.9/1,000 out of 3400 planned home births.

Joseph C. Pearce states in his landmark book Evolution’s End that homebirthed babies have a six to one better chance of survival than a hospital-birthed child.

A study in the Netherlands done in 1986 on women who were having their first babies showed these results: out of 41,861 women who delivered in the hospital, the perinatal mortality rate was 20.2/1,000. Of 15,031 women who delivered at home with a trained midwife, the rate was 1.5/1,000 . I know, I thought it must be a typo too.

Marsden Wagner, formerly of the World Health Organization, states that every country in the European Region that has infant mortality rates better than the US uses midwives as the principal and only attendant for at least 70% of the births. He also states that the countries with the lowest perinatal mortality rates in the world have cesarean section rates below 10%. How does this compare with the US rate? Miserably.

Cesarean section and hospital birth is not doing for women and their newborns what doctors and hospitals claim it is! Ask for statistics and studies when your doctor claims hospital birth is safer than planned (not accidental, unattended) home birth. He will be unable to provide them. If your doctor says, “That’s common knowledge,” you would be wise to seek another health care provider. If you can find studies that claim hospital birth is safer, you will find that they included deaths occurring in unplanned, unattended births that occurred at home, rather than comparing normal, low-risk women. And more often than not, the study will have been funded by (guess who?) ACOG (The American College of Obstetricians & Gynecologists). Other studies:

Lewis Mehl did a study comparing home and hospital birth with mothers from California and Wisconsin with matched populations of 2,092 mothers for each group. Midwives and family doctors attended the homebirths; OB-GYNs and family doctors attended hospital births. Within the hospital group, the fetal distress rate was 6 times higher. Maternal hemorrhage was 3 times higher. Limp, unresponsive newborns arrived 3 times more often. Neonatal infections were 4 times as common. There were 30 permanent birth injuries caused by doctors.

Dr. Mehl did another study comparing 1,046 home births with 1,046 hospital births. The groups were matched for age, risk factors, etc. There was no difference in infant mortality. None! However the hospital births caused more fetal distress, lacerations to the mother, neonatal infections and so on. There was a higher rate of forceps and C-section delivery and nine times as many episiotomies.

Robert C. Goodlin reported in the Lancet on 1,000 births, half occurring in a hospital, half in a birth center. There were no IVs, monitors or anesthesia used in the birth center, but the babies were born in better condition. Besides that, three times as many cesareans were performed in the hospital.

In 1982, Anita Bennett and Ruth Lubic evaluated 2000 births that had happened in 11 freestanding birth centers. The neonatal death rate was 4.6/1,000. The authors were denied information on low-risk women delivering in hospitals. One wonders why….

A British research statistician, Marjorie Tew, did long term studies of the safety of birth in various settings during the 1980s. She found that among a sample of 16,200 births, the perinatal mortality rate was lower for out-of-hospital births, even for very high-risk mothers! At a relatively high-risk level, perinatal mortality was three times higher in hospital. Tew then expanded her research by using information from the Netherlands, a nation where both obstetricians and midwives practice. The perinatal mortality rate was ten times higher in the hospital births there, even though the risk status of the mothers at the time of delivery was not much higher than that of mothers who chose midwives.

In the Netherlands, which has a significantly lower infant mortality rate than ours, the C-section rate is 7%. The episiotomy rate is 6%, whereas ours is as high as 90%. Midwives attend most of the births in the Netherlands. (Midwives tend to allow time for the woman’s tissues to stretch and to use perineal massage, warm compresses, and good head flexion to avoid both episiotomies and tearing; hence the lower Netherlands rate.)

In 1988, the US ranked 19th among industrialized nations for low infant mortality rates. By comparison, Sweden, where all mothers receive midwifery care, even when they are high risk and may also require physician care, ranked second.

Between 1978 and 1985, licensed midwives in Arizona had a perinatal mortality rate of 2.2/1,000 and a neonatal mortality rate of 1.1/1,000. o In Madera County Hospital in California, where there is a transient, high-risk population, midwives did the best job. In 1959, when doctors did the deliveries the neonatal mortality rate was 23.9/1,000. During 1960-1963, midwives had a rate of 10.3/1,000. When OBGYNs took over again in 1964, the rate skyrocketed to 32.1/1,000.

Carl Jones says, and I concur, “No one can tell a mother she is perfectly safe giving birth at home. Whether she is safer at home than in a hospital, however, is another question”. There is always going to be some risk when giving birth, as in all of life, and women should be carefully screened for any health problems that could be dangerous during labor and delivery. For certain women in rare instances, obstetric care is essential. However, for most women, better, healthier results are seen when mothers choose birth centers or home births. As far as the risk of home birth goes, Our Bodies, Ourselves states, “The times when hospital care unexpectedly becomes instantaneously necessary are rare”.

In A Good Birth, A Safe Birth, Diana Korte and Roberta Scaer quote Tew, the research statistician, who says, “The danger of home as a place of birth does not lie in its threat to the healthy survival of mothers and babies, but in its threat to the healthy survival of obstetricians and obstetric practice”.

Another factor that is important in making the choice about where to give birth may surprise you. It makes common sense, but has also been documented by several studies. Women who give birth in a hospital are much more likely to experience postpartum depression or even post traumatic stress disorder. Kitzinger states that the more interventions a woman experiences, the more likely she is to be depressed, with C-sections obviously carrying the greatest risk of depression. She quotes 5 or 6 studies documenting the effects of this “institutional violence.” Aidan McFarlane, a British physician, notes that while 68% of hospital mothers experience postpartum depression, only 16% of home birth mothers do. On The Farm, a self-contained, alternative lifestyle community in Tennessee, the rate of postpartum depression was .03 percent. Almost all mothers on the Farm had both a homebirth and a supportive, loving community of women to assist them postpartum. Avoiding depression, in itself, would be a major reason for mothers to consider giving birth in their own homes, if that is where they are most comfortable, especially if they had previously experienced postpartum depression and thus were at high risk for a repeat episode.

Aspects of hospital birth that may strongly contribute to the incidence of postpartum depression in our country are the way the moment of birth is handled and the routine separation of baby and mother. In a study that appeared in the New England Journal of Medicine in 1972, Marshall Klaus, the “bonding” expert, found that holding the baby close released “dormant intelligences” in the mother and caused “precise shifts of brain functioning and permanent behavior changes”. In other words, bonding is not just an emotional thing that only mothers think happens. It is a biochemical process that forever changes the mother, so that she knows more instinctively how to relate to her baby. In the hospital, baby cannot see mom with all the bright lights and is often inspected and observed for several hours before mother can hold it for any length of time. This is not to say love can’t make up for this loss, but motherhood might come easier if we had those natural body changes to help us.

Then babies are still routinely kept in the nursery, if not most of the time, at least part of the time. The routine separation of mom and infant makes baby frightened and mom depressed. This may be why postpartum depression and difficult adjustments are so common in the US and rare elsewhere. Japan moved from midwifery to obstetrical handling of births approximately 25 years ago. When older Japanese recently asked Joseph Pearce why their mothers no longer “know what to do with their children,” one has to wonder how much the new hospital setting has to do with it.

Most homebirth studies also show a significantly lower rate of C-section than hospitals have. Most stats show a rate between 1-5% for planned homebirths, with the above-quoted lower mortality rates as well. Cesarean sections themselves carry a far greater risk of additional illness or death than most people realize. They have become so routine in our society that everyone feels “It’s no big deal.” However, C-sections carry a 2 to 4 times greater risk of death than do vaginal deliveries (Boston Women’s Health Book Collective). Several studies on the risk of death from the surgery alone (i.e. factoring out the conditions the surgery was done for) have shown varying, yet consistently depressing, results. Errard and Gold found with eleven years of statistics that the risk of death from cesarean section was 26 times greater than from vaginal birth. Cohen and Estner also cite a study done in Georgia showing a maternal death rate of 59.3 per 100,000 women who had cesarean section versus 9.7/100.000 for women who delivered vaginally. A California study showed a maternal death rate 2-3 times greater from C-section. Korte and Scaer state that obstetricians admit a maternal death rate four to six times higher with cesareans, and add that many believe the rate is higher, giving 1 in 1,000 as the true odds of death for a c-section mother.

You should also be aware that death is not the only complication caused by cesareans; mothers commonly experience infection after a section. Infertility problems, organ damage, and paralysis from anesthesia complications are rare but possible risks. The pain at the incision site is no picnic either. Another thing to think about is how a surgery like this will affect you, your child, and your society in the long run. When mothers “fail” to give birth naturally in hospitals, as they so often do these days, their self image is harmed despite well meaning friends telling them it doesn’t matter how baby came out. Especially if mothers are not certain their sections were absolutely necessary, there is often a hidden anger that can’t be overtly expressed in our culture. Mothers may take this unacceptable anger out on the only people they can–their children. “In 1979, the government of California funded the first scientific study ever made of the root causes of crime and violence. Their first report three years later stated that the first and foremost cause of the epidemic increase of violence in America was the violence done to infants and mothers at birth”.

The “little things” really do matter, just as a small pebble thrown in a pond makes ripples that travel a long, long way. If you are a woman with no health problems or contraindications to safe labor and delivery, consider very carefully your place of birth. Your chance of having major surgery is one in four if you choose a hospital, regardless of your current health status. Those are very good odds. If you had the opportunity to buy a million dollar lottery ticket with odds that good, you would, wouldn’t you? Don’t assume that it won’t happen to you. Since the risks to you and your baby are lower at home, and your risks of having surgery are greater if you go to a hospital, please consider homebirth as an option.

Wherever you decide to give birth is up to you; just remember that you can make the decisions that need to be made when you have true information. It is your body, your baby, your money, and your life on the line, not the doctor’s or anyone else’s. You have the right to accurate information and the right to decide what is best for your baby. Don’t let anyone tell you otherwise. Also, when you ask for information, beware of health care providers who say they judge each case individually, so they can’t really give you their statistics. It probably means either they don’t know or they don’t want you to know. You will have to live with the consequences of decisions made during your labor, for better or worse. For more information or support, call me at 606/625-0185 or email me at griebenow@iclub.org

The author disclaims any liability resulting from the use of this information, and strongly urges you to use your own mind.