By Lauren Apfel and Jessica Smock
The first time Maria Fletcher gave birth it wasn’t traumatic, but it wasn’t what she had hoped for, either. After an uneventful pregnancy, Fletcher arrived at the hospital in Glasgow, Scotland, where she lives, in what felt like the beginnings of active labor. She would later learn that particular March evening was one of the maternity ward’s busiest of the year … but at the time, she was simply placed on a gurney, as the contractions mounted, and told to wait. And wait she did until several hours later when, quite suddenly and with no medical staff in attendance, she was overwhelmed by the urge to push. At that point she hadn’t yet even been internally examined.
“I was one of these women,” Fletcher says, “who wasn’t a screamer. I wasn’t drawing attention to myself and I was clueless as to how far along I actually was.” When it became evident to one of the midwives on call that the baby wasn’t coming imminently, Fletcher was wheeled into a birthing suite, which, by a stroke of luck, had just become available. From then on the care was good, she says, and the baby was delivered safely after a long spate of pushing. The aftercare, on the other hand, and the reality of being one of four bed-and-bassinet pairs in the hospital room to which she was assigned, was not so good. Spending two nights with her newborn daughter on a bursting ward was, she says, “rather awful.”
Reasons for home birth
Two years and two weeks later, Fletcher wakes in the wee hours of the morning with a steady tightening across her abdomen. She is 39 weeks pregnant with her second child, a boy. This time, however, she is planning to have the birth at home. The arrangements have been very straightforward: in the UK, the home birth or Community Midwifery Service is intimately linked with the National Health Service (NHS). When Fletcher arrived for her first prenatal appointment at around 12 weeks, as is standard with the NHS, she explained that she was “considering” a home birth. With no difficulty or judgment, she says, she was then transferred to the home birth team, who oversaw the remainder of her care.
Fletcher describes the day she successfully gave birth to her son in the spare room of her spacious Bearsden farmhouse as “the most productive of my life.”
“I made my son’s birthday cake,” she says. “I wrote and submitted a book proposal. The cable guy came, and my husband and I watched a cowboy movie.” Knowing there was no mad dash to the hospital in the cards allowed her to relax into labor, in a familiar setting, with all of the home comforts at hand. This was exactly the scenario she was looking for.
Fletcher cites two reasons why she chose a home birth in the first place, one negative and one positive. The negative reason hinged on the experience she had in the hospital delivering her first child: the waiting, the lack of control over her environment, the overflowing and understaffed postnatal ward. The positive reason was of a different, more nebulous nature. After giving birth to her daughter without an epidural, Fletcher says she was amazed at “what my body and my mind were capable of.”
Fletcher’s reasons align with what the limited recent research has found regarding women’s motivations for home birth. According to a 2009 study published in The Journal of Midwifery and Women’s Health, for example, the most common reasons why women chose to give birth at home were: the belief that home births are safer than hospital births; the desire to avoid unnecessary medical interventions; previous negative hospital experiences; and the preference for a comfortable and familiar setting. Another reason cited, though less frequently, was a trust in the birth process or a woman’s belief that her body instinctively knows how to give birth without medical interference.
The birth of Fletcher’s son, as it panned out at home, spoke to several of these reasons. The delivery itself was very intense, she says, and very painful—shockingly so. The labor progressed quickly once it kicked off in earnest, and the first home birth midwife arrived on the scene at 6:00 p.m.
By 7:00 p.m., she was accurately predicting the baby would make his appearance within the hour. That hour was agonizing, Fletcher recalls. But being in her own space, surrounded by her own things, had its benefits. “I remember writhing in pain, I was beside myself, and then seeing our copy of Touching the Void on the bookshelf. There’s a passage where the main character repeatedly sings Brown Girl in the Ring, to get himself through a particularly trying time. So that’s what I did. Over and over again.”
Until the baby was born just after 8:00 p.m. The time immediately following birth was the best part, Fletcher says. She had decorated the birthing room with pictures of her daughter and both her mother and her mother-in-law, who have eight children between them. “There was a real sense of ‘girl-power’ in the room,” she says, from which she was able to draw strength. And once her son arrived, she felt surrounded by all that love. “It was a real party atmosphere. There was cake, there was a lot of laughter.”
“Informed choice”
Jessica Pearlman also gave birth to her second child at home, in Seattle, Washington, and she too had strong reasons that influenced her decision. Unlike Fletcher, who delivered her first child vaginally, Pearlman had had an emergency C-section. From the earliest days of the second pregnancy, she was determined to attempt a VBAC (Vaginal Birth after Caesarean), having found the recovery from the surgery of her first birth to be “very slow” and a trial she wanted to avoid.
But it wasn’t until, stuck on strict bed rest, she watched the 2008 documentary The Business of Being Born—a film highly critical of the US medical system for its rate of medical interventions during childbirth—that she became “wistful” about the prospect of a home birth.
“Watching this movie,” she says, “what really appealed to me was seeing women laboring as their bodies were directing them to do so, not as some hospital protocol dictated.” Pearlman’s reaction to the film is not surprising, as this is precisely how it aims to inspire women, with both celebrity and non-celebrity mothers sharing stories of their empowered birth experiences. One of the trailer’s tag-lines is: “Have your baby the way you want.”
Which is what Pearlman ended up doing. “As soon as I came off bed rest at 36 weeks,” she says, “that very evening I drove myself to the monthly meeting of my local ICAN chapter, where my eyes were opened to the fact that I could have a home birth despite a prior C-section.” At that point, she hired a team of private midwives for the delivery, which, unlike in the UK, was a totally out-of-pocket expense. This is not uncommon: according to the American Pregnancy Association, approximately one-third of home births are paid for with no insurance reimbursement (in contrast to 2% of hospital births).
Pearlman made contact with her midwives through ICAN, which is The International Cesarean Awareness Network, Inc., a nonprofit organization whose mission is to “improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).” The existence of organizations such as this—as well as the NCT (National Childbirth Trust) in Britain and Choices for Childbirth, whose goal is to help “women make informed decisions about where, how and with whom to birth”—illustrates the extent to which the idea of “informed choice” has come center-stage in the reproductive process. So too Anne Tourish, the midwife in charge of Glasgow’s home birth team who delivered Maria Fletcher’s baby, identifies this as exactly what she is offering the mothers-to-be who request her services.
Since more than 98% of US births today take place in a hospital, according to the Centers for Disease Control and Prevention, the notion of choice has become closely bound with a more “natural,” less medicalized experience. More specifically, for many women, the decision to give birth outside of a hospital is coupled with the desire not to have a Cesarean section, as it was for Pearlman.
The hospital setting itself, these women feel, kick-starts a domino effect—or what natural birth advocates call “a cascade of interventions”—whereby one medical intervention gives rise to another which, in turn, leads to a potentially unnecessary C-section. Opting for the birth to take place at an alternative birthing center or, better yet, in the confines of your own home (the logic goes), makes a surgical delivery less likely. One of the Internet’s most widely cited “birth affirmations” is a quotation by feminist writer Brooke Sanders Purves, which underlines the point: “The best way to avoid a Caesarean is to stay out of the hospital.”
Control, trust, and birthing at home
Pearlman is adamant she wasn’t seeking out a natural birth for natural birth’s sake. Nor is she sentimental about her delivery. “For me, birth is no ‘Enya’ song—I was terrified early on and in extreme pain throughout.” But she still relished some of the more natural elements the home location was able to afford: “At no time,” she says, “was I checked for dilation, at no time was I ordered what to do, at no time was I given any medications whatsoever.” What was “natural” to her, and what made her delivery a good one and preferable to her C-section, was the aspect of “not being controlled” that home birth offered.
The meaning of “control” in the context of the birth experience, however, is not the same for all women, as Dr. Anne Lyerly, researcher and Ob/Gyn, discovered during interviews for her book, A Good Birth: Finding the Positive and Profound in your Childbirth Experience. Lyerly found that how women talked about control fell into five distinct categories. For some women, like Pearlman, control meant a sense of agency or involvement in the birth process. For others, it meant physical or emotional safety, emotional connectedness, or knowledge and preparedness. For others still, it meant dignity and respect.
Some cultural critics see this more complex definition of “control” as reflecting a larger trend in parenting and motherhood. According to Emily Matchar, author of Homeward Bound: Why Women Are Embracing the New Domesticity, the increasing numbers among certain populations of white, college-educated women who choose to deliver at home can be primarily explained by the rise of what she calls “DIY-parenting.” This parenting culture is skeptical of most communal institutions, including hospitals, schools, research institutes, and public health organizations. And it argues for the superiority of “natural” maternal instinct over the authority of experts.
“The growing home birth movement reflects the larger cultural shift away from trusting in ‘experts’ and towards self-reliance, especially when it comes to parenting,” Matchar says. “There’s an enormous amount of dis- trust in the medical system. Some completely justified, some quite paranoid and anti-science. And for many people, choosing home birth is a result of this distrust.”
It is worth noting that control and trust are not the only considerations on which the decision to have a home birth might turn. There is a growing portion of mothers-to-be who have their hearts set on a particular kind of birthing experience, which goes beyond the desire simply to hold the reins or to be informed about, and connected to, the process. Anna Wharton, for instance, wanted to give her first child a “memorable” and “peaceful” entry into the world. To this effect, she writes in the UK Times, “I chose to birth at home in a pool…I wanted to labour in a dark- ened room practising the hypno-birthing techniques I’d been learning for months. I even wanted to add a small amount of my placenta to a berry smoothie.”
When home birth goes wrong
Wharton had a birth plan that included details about how to make her delivery special and natural. “Yet nowhere in my birth plan did I write the word ‘safely.’” Ideally, in the realm of birth, “natural” and “safe” would be adjectives that never came into conflict with one another. But the reality is that they can, especially when you are having a baby in your own home. Home birth by its very nature means that certain medical interventions will not be available at the moment of de- livery. If either the baby or the mother is in need of a more sophisticated treatment, the protocol is to phone for a transfer to the hospital. For Anne Tourish, Glasgow’s home birth midwife, this is a rare occurrence: she has only had two “major emergencies” in the past five years.
And yet, home births do go wrong, because the cliche about birth is true. Despite the best-laid plans and the lowest-risk pregnancy, it remains an inherently unpredictable event. In the UK, according to research by the British National Birthday Trust, about 40% of first-time mothers who attempt a home birth and 10% of mothers who have previously given birth end up transferring to a hospital. The reasons vary from exhaustion and a labor that fails to progress to more serious and much less common issues, such as maternal hemorrhage. In the US, The Midwives Alliance of North America reported this year that 10.9% of women who attempt home birth end up transferring to the hospital, with the rates among first-time mothers three times higher.
Erin McLennan, a registered nurse and midwife with ten years’ experience, has been on the receiving end of a failed home birth more times than she would have liked. “There are certain labor and delivery emergencies where everything is about timing,” she says. “Placental abruption, uterine rupture, sudden fetal distress, or any type of prolapse falls into this category. If the time it takes for you to receive emergency care is too great, you have compromised safety for access to your sitting room.”
McLennan remembers an especially gruelling incident in this vein, a woman trying to birth in her own home who suffered from a prolapsed umbilical cord. “To get her to the hospital safely, this woman required somebody applying constant counter pressure to the cord through the cervix,” McLennan says. “She needed to be lying down on a stretcher, in a position where her head was lower than the rest of her body, with the midwife in front of her.” Removing the mother and the midwife from the apartment in tandem, however, proved difficult. Obstacles including a tight corner and a narrow set of stairs made the evacuation extra time-consuming, further threatening the life of the unborn baby.
Anna Wharton’s home birth was also life-threatening. After forty hours of labor and a session of unproductive pushing when she wasn’t yet fully dilated, Wharton was rushed to the hospital, sirens and all. There, her baby was delivered as quickly as possible by forceps. “There was no cry from my baby,” she writes. “And the only words uttered were the pediatric team shouting medical terms, only one of which I recognised: cardiac arrest.” Wharton’s daughter is fine now, a reality she credits, in no uncertain terms, to the fact that she was in a hospital. “We all want a healthy baby, safely delivered. And there is only one place where you can—almost certainly—be guaranteed of that happening. And it’s not your living room.”
Wharton is not the only woman who would describe her home birth as a “disaster,” nor is she the only one who heralds her personal experience as a warning to others. There is an entire website, created by Amy Tuteur, MD, dedicated to the phenomenon of having been “Hurt by Homebirth.” The website, a harrowing read, show- cases stories written by the women themselves who have sustained harm and/or loss as a result of choosing to give birth in their own homes.
Tuteur, who runs another online enterprise called The Skeptical OB, explains the mission behind these websites as “to debunk the many pseudoscientific claims of advocates of home birth and natural childbirth.” Tuteur believes that all women are entitled to make an informed decision about where they give birth. But the problem, as she sees it, “is that the homebirth industry works over-time to make sure that women are supplied with inaccurate information.” A veritable blizzard of it, she says. “If a woman chooses home birth because she thinks it is safe, she deserves to know that she’s been misled.”
Despite her sometimes provocative and inflammatory rhetoric on social media, Dr. Tuteur’s stance on home birth is actually not so different from leading medical groups’ positions, such as the American College of Obstetricians and Gynecologists (ACOG). ACOG’s most recent policy statement about home birth (and one that is more tolerant than those it has made in the past), for instance, supports a woman’s right to decide the type of birth she feels is best for her, based on accurate medical evidence. But it affirms that a hospital is statistically the safest place for a birth to happen.
The safety question
And yet, there still does not appear to be a straightforward answer to the question: is home birth safe? For a pregnant woman considering other options besides the typical hospital birth and who doesn’t want to make an irresponsible decision that puts her baby or herself at risk, it is easy to see how she may become confused and frustrated in the face of the available information.
While medical researchers might equate the danger of having a home birth to driving while “not putting your child’s seatbelt on,” midwives’ professional organizations often argue that it is actually more dangerous for low-risk women to give birth in a hospital, due to the risk of unnecessary surgical and other medical interventions.
The fallout from a study released last winter demonstrates how home birth research has become one of the most divisive areas of reproductive medicine. The paper concluded that, “Low-risk women in this sample experienced high rates of normal physiologic birth and very low rates of operative birth and interventions, with no concomitant increase in adverse events.” Home birth, in other words, for this sample of 16,000 women, was concluded to be safe: it did not result in increased complications or deaths, and it lead to fewer C-sections and other medical interventions. The study, published in the Journal of Midwifery and Women’s Health, was quickly publicized by pro-home birth advocates as hard evidence of the unequivocal safety of home births for certain populations of women.
Just as rapidly, however, doctors’ organizations and leading medical researchers responded to the study as well. They argued that the study’s statistics instead showed a dramatic increase in the number of newborn death rates associated with home births, possibly by as much as 450%. Dr. Amos Grunebaum of Cornell’s Weil Medical School criticized the study’s design and released his own study the same week that found that babies born at home by midwives were four times more likely to die than those delivered by midwives in a hospital. Grunebaum further contended that a first-time mother can reduce the chances of her infant’s death by 85% by delivering her baby in a hospital with a midwife rather than at her home.
This type of skirmish is typical after studies related to home birth are published. As Emily Oster, an economist who examined the research surrounding pregnancy in last year’s Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong—and What You Really Need to Know, writes: “For every study that found an increased risk of death in home births…there is one that found no increased risk.”
Oster concludes that there is probably a very small additional increase in the risk of death or complications from home birth deliveries, but it is not possible to state from the current medical literature how much bigger that risk is. Home birth may be a tiny bit riskier but is still generally safe, for women with low-risk pregnancies, as long as those deliveries are supervised by a highly trained, experienced certified nurse-midwife. (For higher-risk deliveries, such as multiples, women who had prior C-sections, breech pregnancies, and women with complications such as gestational diabetes, most caregivers and researchers—even midwives—will concede that there is at least a slightly greater chance of a bad outcome.)
Absent a study with a very large sample size that directly compares a cohort of women who planned home birth deliveries to another cohort that planned hospital deliveries, while also controlling for all the ways in which mothers who choose home births may differ from those who choose a hospital birth, it is nearly impossible for anyone to claim a definitive answer about what is certainly safe, what is a little risky, or what is too risky. It is also difficult to make international comparisons between the United States and other nations, since many European countries, such as the Netherlands (where home births make up about 30% of all births, according to the Dutch National Institute for Public Health and the Environment), have national health plans supportive of home births and their birth systems. These national services coordinate care between hospitals, doctors, and midwives, as was the case with Maria Fletcher’s birth on the NHS.
The future of home birth
Despite the intractable positions of those involved in the debate surrounding the safety of home birth, women are opting to have babies at home in ever greater numbers. While home births still only account for less than 1% of all deliveries in the United States, the total number of home births has risen 59% from 2004 to 2012, according to the Centers for Disease Control and Prevention, and is at a nearly 40-year high. The increase in home births is mostly explained by the growing number of white women who are selecting this route, now about one in 74 delivering at home, a rate two to four times higher than for any other ethnic group.
The rise in the number of women choosing home birth seems to be a long-term trend rather than a statistical blip, since many of the factors that are responsible for this pattern show no sign of disappearing: current cultural trends in parenting, dissatisfaction with an increasingly expensive and flawed medical system, gaps in insurance coverage that cause some to think hard about delivery costs, and the expectation that birth will be an event that is valuable and meaningful.
Even as common ground between home birth advocates and opponents remains elusive, it is clear that more and more women are taking their birth experiences into their own hands, as they take them into their own houses. Maria Fletcher and Jessica Pearlman are two such women, both of whom have said they would choose home birth again, unequivocally.
Lauren Apfel is the debate editor for Brain, Child Magazine. Connect with her at omnimon.net and on Twitter @laurenapfel.
Jessica Smock is the co-editor of The HerStories Project, a writing and publishing community for women, whose recent anthology, My Other Ex: Women’s True Stories of Leaving and Losing Friends, was released in September. She lives in Buffalo, New York, with her husband and toddler son.