NEW YORK CITY — In the United States since the 1940s, most births have taken place in the hospital, attended by obstetricians employing the full armament of modern drugs and technology.
In the last two decades, the rate of Caesarean surgical deliveries has shot up dramatically, to more than one in three births today. Partly in response, a home birth movement that began in the 1960s has sprung up again.
New York medical student Emilie Jacobs and her husband, Rowan Finnegan, parents of 22-month-old Elias, are planning another home birth for their second child. “If it’s a healthy pregnancy, and there’s no reason you would need more stringent medical care, more advanced procedures, then why not?” asked Jacobs.
The same licensed nurse-midwife will attend her, bringing along the emergency equipment of a paramedic, just in case. Although most problems in labor are detected in plenty of time, several top hospitals are only a few minutes away, Jacobs noted. Ten percent of planned home births do end up in the hospital, usually because labor has failed to progress. But if all goes well, Jacobs will have a peaceful, unmedicated birth - with no high-tech monitoring, surgery or drug-induced labor.
As a doctor in training, Jacobs has attended hospital births. She says they are determined more by hospital protocols, both medical and financial, than meeting the needs of women in normal labor.
“It’s not an illness to be pregnant. The hospital’s a place where people go when they’re sick,” she said. “There’s infection there, there’s a greater chance of having some kind of extra requirements placed on you, in terms of the speed of your labor and medications being offered or encouraged, and higher C-section rates. And higher procedure rates, such as episiotomies.”
Jacobs is one of about 30,000 women who will give birth at home in the U.S. this year. Although the numbers have risen in the last 10 years, home births still represent less than 1 percent of all U.S. deliveries.
The Business of Being Born, a 2008 documentary by Ricki Lake and Abby Epstein, helped publicize the movement, with scenes of uncomplicated midwife-assisted births at home, often in a tub of warm water to ease labor pains. Other advocates have spread the word with online video of their own water births - usually with fathers present, and often with older siblings, too.
Women who choose home birth over hospitals often say, like Jacobs, that they want to avoid hospital requirements, such as fetal monitoring or the need to turn over beds quickly, that can divert a normal labor into a surgical one. Caesareans are major surgeries, they note, with serious risks to the mother, including the chance of uterine rupture in future pregnancies.
However, there is disagreement among some experts as to whether home births are safe. A recent study in the American Journal of Obstetrics & Gynecology reported that babies delivered in planned home births in the U.S. are 10 times more likely to be stillborn and four times more likely to have seizures or other serious neurological problems. The study found that in about 60,000 planned home births from 2007 to 2010, 98 infants had no pulse and were not breathing five minutes after birth, a rate of 1.6 per 1,000 births. The rate in hospital births was .16 for every 1,000 infants.
Co-author Frank Chervenak, director of Maternal Fetal Medicine at New York-Presybyterian/Weill Cornell Medical Center, said that some of the deadliest complications in labor can happen with little or no warning.
“We here on our labor and delivery unit fight for seconds when an unexpected fetal distress occurs; we do drills, so we plan an emergency Caesarean and fight for seconds,” he said. “Because literally, seconds -- if someone is as much as one block away from this hospital, it’s too far,” he said.
Chervenak acknowledges that the incidence of serious problems in planned home births attended by midwives is rare, but argues that they are too grave to be risked, and that obstetricians should counsel "strongly" against them and refuse to participate.
Advocates say that is comparable to advising obstetricians not to perform the diagnostic test of amniocentesis, because of the 1 in 200 to 1 in 400 risk that it will cause a miscarriage.
Tina Johnson, director of professional practice and health policy for the American College of Nurse-Midwives, contends that the AJOG study was based on unreliable birth certificate data from the Centers for Disease Control.
“[It] used a lot of flawed data and drew a lot of conclusions that are inconsistent with all of the other research that’s out there currently, including another recent AJOG article, citing that planned home births with certified nurse-midwives are just as safe as midwifery deliveries in the hospital,” she said.
Jennifer Block, who recently gave birth to her own first child at home, is the author of Pushed: The Painful Truth about Childbirth and Modern Maternity Care.
“I knew from my own research that planning a home birth with emergency obstetric backup, if necessary, is the birth plan that was most likely to result in a spontaneous vaginal birth, with the least trauma to me and the best start for my baby,” Block said. “I knew that if things weren’t going well that we would transport to the hospital.”
“I think we forget when we focus on the perceived risks of home birth is that there are risks to being in the hospital,” she observed. In addition to the chance of contracting an infection or having a Caesarean, she said, there’s a risk of “having the baby end up in the NICU (Neonatal Intensive Care Unit) for days because labor was sped up, and hyper-stimulated, and the baby was in distress. So, I think focusing on those tiny rare risks, even though they’re very significant, doesn’t really give us the whole picture.”
Block notes that women choose home birth for the baby’s health as well as their own. “If the mother has a spontaneous vaginal birth, that’s absolutely the best-case scenario for the baby,” she said. “We know babies benefit from vaginal birth: their lungs, their respiratory health, their gut health; they are colonized with good bacteria; the breastfeeding relationship has a much better start.”
Both opponents and advocates of home birth point to the Netherlands and some other countries as support for their cause. In Australia and Britain, for example, most pregnant women are cared for by midwives, and see a doctor only if there is a complication or risk factor. “That’s the model that exists in the countries in Europe that have the lowest Caesarean rates,” Block notes.
Chervenak notes that in the Netherlands, where home births attended by midwives have long predominated, hospital births are on the rise. Many women there, however, also choose to pay extra to have midwives attend them.
He thinks the answer for the U.S. is to “let midwives either deliver in the hospital or adjacent to the hospital. Bring home births into the hospital.”
“You can get a much better experience in the hospital in northern Europe and the Netherlands than you can in the U.S., frankly,” Block says. “If I could go to the hospital and get into a birth tub, and not be told that I have to be monitored continuously [and be] in bed, then maybe I would do that.”