Eye Opener: The Nash & Associates Blog

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Many little girls grow up fantasizing about what they want to be when they grow up; perhaps they want to be the President, or an artist, or a doctor, or an architect. Others might be daydreaming about being a princess or an astronaut. However, I do not know of many little girls who grow up dreaming about how they would like to bring a child into this world. Yet once these girls grow up into adults, many of them feel strongly about having a birth plan that is just as magical as all of their other dreams. Images of a comfortable labor or a display of womanly strength may play a role; perhaps they want music or a particular image available to them. Some want as few interventions as possible, while others would prefer an epidural at the hospital door. No matter what vision of childbirth a woman has, the desired end result is almost universally a healthy child.

Home Birth Rates Decreasing for Years…Now Dramatically Increase

It is no wonder that women often have strong feelings about what they want for their birth experience and how to best accomplish their goals. Historically, women gave birth at home. That practice changed and by the early 1950s, almost all women in the United States gave birth in a hospital setting. According to an NPR article about a recent study published in Birth: Issues in Perinatal Care, “the percentage of home births in the U.S. had been dropping slowly but steadily every year” from 1989 to 2004. Surprisingly, the trends reversed dramatically in the four-year period between 2004 and 2008. The study found a 20 percent increase in the number of women in the United States who gave birth at home between 2004 and 2008. Despite this increase, we are still talking about a small percentage of total births – less than 1 percent.

Increase is Mostly in Non-Hispanic White Women

A twenty percent increase is still a very large amount in a 4-year period. I was interested in the implications of this change. First, one of the most surprising (to me) findings in the study was that the change was not seen across the board. The article explained that “[m]ost of the rise was due to an increase in home births among non-Hispanic white women.” A New York Times article said that:

[t]he turnabout was driven by an increase of 28 percent in home births among non-Hispanic white women, for whom one in 100 births occurred at home in 2008. That rate was three to six times higher than for any other race or ethnic group.

I did not find any explanation or hypothesis for why this particular segment of the population was increasingly choosing home births over hospital births. Though the study does suggest that it was a change by choice as the article explained that “[r]esearchers found among the 25 states that tracked planning status in 2008, 87 percent of births that occurred at home were planned.”

Are Home Births Advisable? Are they Safe?

So, is the increase in home births a good thing? Certainly, I support a woman being comfortable and happy in her choice for a birth plan. I have given birth twice and know that it can be both one of the more uncomfortable and simultaneously one of the most overwhelmingly joyous moments of a woman’s life. A home birth affords a mother a setting that is likely more comfortable and certainly more familiar than most hospitals. And yet, as I mentioned earlier, women really just want a healthy outcome for both them and their baby. Can a home birth accomplish this goal?

Most of the medical community, certainly most associated with hospitals, say that home births are not the safest option for babies; however, neither are all hospital births.

Leading members of the medical community respond that hospitals — where 99 percent of all U.S. births take place, according to the CDC — are the safest places to have a baby, with modern medical interventions available.

The newborn death rate is two to three times higher for planned home births than for those that take place in hospitals, said George Macones, chairman of the committee on obstetrical practice at the American College of Obstetricians and Gynecologists, which has long opposed home births. Some home-birth advocates say such studies are flawed.

“There’s no question that if you come to a hospital, there’s a one in three chance you end up with a C-section, and it’s certainly true that some of them aren’t medically indicated,” Macones said. But at home, where there is less monitoring of the baby, there is more chance of a bad outcome, he said. “Obstetrics can be a risky business. Things can go wrong.”

From a Washington Post article

Home births, even those attended by a certified nurse midwife, do not provide the medical technology and care that can be present at in a hospital setting. Perhaps this is what many women may be trying to escape when choosing to give birth at home. I know that normally I would rather stay out of a hospital at all costs since hospitals may raise the risks associated with medical interventions and infections. Additionally, the high C-section rate at hospitals may also subject women to unnecessary risks. This is one of the concerns mentioned in the New York Times article:

Other research has suggested many women choose home birth because of concern about high rates of Caesarean sections and other interventions at hospitals, said the new study’s lead author, Marian F. MacDorman, a statistician with the National Center for Health Statistics. “The two trends are not unrelated,” Dr. MacDorman said.

Additionally, the NPR article reports that the new study published in Birth: Issues in Perinatal Care found that birth outcomes are improving for babies born at home:

Researchers … found a statistically significant improvement in birth outcomes for babies born in the home. Infants who were born preterm fell by 16 percent. The percentage of home births that resulted in infants with a low birth weight also fell by 17 percent…One reason for the better outcomes could be that more women are planning to give birth at home. Researchers found among the 25 states that tracked planning status in 2008, 87 percent of births that occurred at home were planned. MacDorman also suggested that midwives could be getting better at choosing low-risk women to be candidates for home birth.

Are Birth Outcomes at Home Improving Because Lower Risk Mothers Are Delivering at Home?

Now this idea is one that resonated with me. Perhaps the key to the safety of home births is which women are giving birth at home. I remembered reading a story in the Washington Post a couple of weeks ago about a local midwife who was convicted in a baby’s death. What stuck with me about this tragic story was that the mother did not seem (at least to me) to be a good candidate for a home birth. A couple of small paragraphs late in the article explain:

It was a case most obstetricians would call high-risk: The first-time mother in Alexandria was 43, and the baby was breech, which essentially means upside-down from the normal head-first position.

The baby’s position wasn’t the problem, Carr said; the problem was that the baby’s head became stuck.

Two women who supported the mother during the September delivery said in interviews that both Carr and the mother knew the risks involved in such a delivery. They both said everything was going well, until it wasn’t.

This sounds like a horrible accident that could have happened even with the best of intentions. However, another Washington Post article explained the details surrounding how the midwife, Karen Carr, came to be working with this mother:

[Law enforcement officials] said Carr was unlicensed in Virginia, agreed to perform a high-risk breech delivery in a woman’s home after other care providers refused, and ignored warning signs that the delivery was not going well.

Ultimately, prosecutors said, Carr allowed the baby to remain with his head stuck in the birth canal for 20 minutes and then, after delivery, tried to resuscitate him for 13 minutes before calling for emergency medical help. The boy never gained consciousness or displayed brain activity, and he died two days later at Children’s National Medical Center in the District when life support was removed.

…

The parents sought out Carr in August after nurses at a licensed birthing center in Alexandria said they could not deliver at home because of the fetus’s position in the womb; breech births are most often delivered by Caesarean section because the risk of complications from a breech delivery — in which the baby is positioned feet-first — are high, according to medical officials.

Carr agreed to do a home delivery and, prosecutors said, declined to call for help when things got out of control. A medical examiner ruled that the death was due to complications from a breech birth at home.

While the midwife might have been performing outside the standard of care, my question in reading these articles is whether it is reasonable for a midwife to agree to a home delivery for a high risk mother, who is of advanced maternal age, whose child is breech, and who has already been turned down for delivery by a licensed birthing center based on the risks. It seems to me that the midwife and the family were taking a grave risk with this child’s life – a risk that the parents must have at least somewhat acknowledged since they sought out the home birth after being turned away by the birthing center. To what degree is it the midwife’s responsibility to assist a woman who insists on a home birth despite the risks? To what degree is it her responsibility to refuse to participate if the risks to the child are unacceptably high?

Does Insurance Matter?

Finally, I wonder what role insurance will play in the increasing number of mothers choosing to give birth at home. Vermont’s governor just signed a bill into law that will require private health insurance companies to pay for midwives during home births.  According to the Forbes article about the new bill, Vermont joins New York, New Hampshire and New Mexico in this requirement. Vermont’s rate of home birth is the highest in the country at 3 percent. The bill is expected to lower costs for low-risk births for women who choose to birth at home. I wonder, however, whether the choice to have a home birth that is reimbursed by insurance will open the door to additional mothers choosing to birth at home even if the risks are high.

What Do You Think?

At the end of the day, it seems that home births may be a good option for some low-risk women who have the support of a well trained midwife and accessible medical back-up in case of problems. That being said, for those at higher risk, perhaps there need to be other safeguards in place.

What do you think? Are you or have you been involved in home births? How are woman normally empowered to have the birth they want if they are high risk? What can be done to make the choice safer for the baby?

Related Posts:

The Grief of Losing an Unborn Child

Laughing Gas Making Its Way Back into the Labor and Delivery Department