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OPB's Think Out Loud tackles home v. hospital births ~ Th 5.7.09 @ 9

823157770_ee5173e61d_m In case this topic interests you, OPB's Think Out Loud show on Thursday 5.7.09 is about birth choices.  Here's how they describe the show:

Oregon State University says a new study describes a "pattern of distrust" in the relationship between hospital physicians and midwives who transport their patients to hospitals due to complications during homebirths.

The study (led by OSU assistant professor and midwife Melissa Cheyney) looked at birth records in Oregon's Jackson County from 1998 through 2003 to determine whether a correlation existed between poor health outcomes and homebirths.

While the study didn't find a link between the two factors it did reveal ongoing conflicts between doctors and midwives with physicians asserting that only hospital births were safe. This finding is in line with a 2008 American Medical Association resolution (pdf), which stated:

"The safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex."

Listen up! Call in!  Speak Up! Or join the conversation on the show's active blog.  It's on from 9 to 10 am, then is re-aired again at 9 pm the same night.  And of course podcasted forever.  

If you listened, did you like the show? 

[Photo courtesy of cafemama]

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All three of my children were delivered in the hospital. Different sets of emergency conditions attended all three deliveries. If the babies were delivered outside the hospital, none of them might have survived.

The safest place for my husband was in the hospital...GIVE ME THAT EPIDURAL NOW!;O)

I personally find home births foolish. Why not have a midwife at a hospital? n my case, I ended up with an emergency c-section with absolutely no indications during pregnancy. If I had been at home, sure everything MIGHT have gone okay, we might have made it to the hospital in time, but then again what if not? That would be hard to live with.

I guess I just don't get the whole "natural, it's a beautiful experience thing." To me it seems more of a selfish act then being in a situation that could prevent something terrible from happening. That said I know a lot of great people who have had home births with perfectly healthy babies but even with that small risk...it's just worth it to me.

I Think it is hard for anyone to lead a logical argument that says a homebirth is safer than a hospital birth. I think it might be less invasive and different choices may be made in a home birth situation. For me, the choice was easy, hospital! Did I enjoy being hooked to monitors the entire time? Of course not. Would I have liked to walk around? Sure. But in the end my baby was in the safest situation possible. I have diabetes, so their was the potential for many complications. My first son was born vaginally, but my second was a planned c-section due to size. If I had insisted on a homebirth with my second (who weighed 10.5 lbs) there could have been major complications leading to the possibility of death (greater risk than I was willing to take, that's for sure.) I'm not sure that others are necessarily aware of this. Humans are a young species that is still evolving. We are the only species of mammal that gives birth through the pelvis rather than behind it. Since this is the case, humans actually have a very high incidence of maternal and fetal death due to babies not fitting through the pelvis. Since we now have medical intervention, many women with narrow pelvises are successfully surviving childbirth and passing these genes along to their daughters. These means our pelvises are not getting wider, as they have been for the past 2 million years. I think I will trust the doctors, not the evolutionary history of humans!

I heard the show and found it pretty interesting. I did hospital births, so I've not looked into this with much depth. I was really surprised to hear how simple it is for someone to lead a birth with pretty minimal training. I find that pretty concerning, but less so than the idea of homebirth with a very well-trained professional. I agree with the sentiment about having folks licensed and having oversight if they're going to practice in this manner.

I almost wanted to call the program- but alas was at work. I have to say that I was very happy with my natural birth at OHSU with midwives- except for the hospital setting- I could have been a home birth. To me, this was the best of both worlds- and I didn't have to clean my house!

Meg, I really encourage you to examine this study: http://news.bbc.co.uk/2/hi/health/7998417.stm which compares the safety of home birth vs. hospital in the UK. It is the largest of its kind to date.

The US has one of the worst infant mortality rates of any western industrialized country. The most recent year I could find information for percent of home births was 2003. In that year, .57 percent of deliveries were home births. Often those statistics include unplanned or emergency births that happened at home without having been prepared for, I'm not sure if that is the case with the figure quoted.

I encourage anyone who believes that making an argument in favor of home birth is a fool's errand, or anyone who believes that home birth is only about some selfish desire to experience some sort of mythical natural experience to do some research into iatrogenic complications in childbirth. There is some good information in the comments section on the Think Out Loud website, there are many good books, among them, Pushed, and The Thinking Woman's Guide to a Better Birth (an unfortunate title that at least borders on condescending, but an excellent resource), and of course the internet is full of information.

I truly believe that taking an attitude that actively discourages other women from learning about birth, their bodies, and the choices that they can make is doing a terrible disservice to women and their children everywhere.

I often hear the argument that "if my baby were born at home they would have died" and I really understand that people who've had some pretty urgent birth situations might not think homebirth is a wise idea. However, there is more to it than that.
The thing we dont realize is that the prenatal care in midwifery is so much more extensive and indepth that problems are discovered and prevented prenatally far more than is even possible in a hospital setting. The intensive focus on nutrition and wellness in midwifery care prevents problems from occurring. In homebirths midwives are in attendance for the entire birth from beginning to end and are more likely to catch problems early and transport.
Statistically no more babies or mamas die in low risk homebirths than low risk hospital births.
In the end though, that is besides the point. Hopefully whatever birth you choose, whether home or hospital, it is an informed choice that is right for you. The point is the availability of the informed choice. Women need to be able to make their own educated decisions about their place of birth, and need to have those options be safe and supported. Therefore as a mama who has chosen to have a homebirth you have the right to receive quality care when being transfered to the hospital in the case of an emergency or perhaps just for wanting pain medication.
That is the core of the issue, not for everyone to have a homebirth but for them to be available to women who make the educated choice to have them.
Its like if someone said "YOU MUST BOTTLE FEED YOUR BABY" or "YOU MUST BREASTFEED YOUR BABY" Regardless of which you think is best it must be the mamas choice based on her information and education that decides that.
Homebirth is a womans rights issue. We are clever beings so let us make the decisions for ourselves.

As a physician, I am fairly biased regarding this issue.

I must point out something from this piece on the BBC website:

"The study did not compare the relative safety of home births against low-risk women who opted for doctor rather than midwife-led care. This is to be the subject of a future investigation."

Furthermore, it states that one-third of the woman ended up being transfered to the hospital "as complications arose"

I have not looked into the article myself, but I am very interested to know the age of the mothers that were included in the study. Anyone aged 35 or over is "high risk", so I would think that they were having their babies in the hospital.

I know that women have been having babies since the beginning of time, and that it is a natural process. What I think is probably a little less natural are the societal changes of recent times that have resulted in many more women not having their first child until they are in their 30's. Given this to be the case with me and most of my friends, and knowing how the majority of them had abnormal glucose tolerance tests, difficult pregnancies, difficult deliveries (I myself had ended up with an emergency C section), I am of the mind that it may likely have to do with our older age. I would like to see a study comparing rates of these types of things in 30-something year old moms to 20 -something year old moms.

And one last thought. I would speculate that the high infant mortality rate here in the US is secondary to minorities who have no adequate prenatal care. I can not tell you how many babies I saw be delivered in the urban poor county hospital of Atlanta GA to mothers who never saw an MD prior to that day. Some of them even denying they were pregnant as the head was crowning! I think that concentrating on free access to healthcare through socialized insurance is more important way to decrease infant mortality...not encouraging home births.

My son didn't breathe for 8 minutes after he was born. I was so glad he was delivered at home, where my midwives calmly massaged and resuscitated him with his cord still attached, encouraging us to sing to him and call out to him to help him come into his body. His cord supported him and his heartbeat remained strong throughout, and when he was breathing stably we snuggled our alert, wide-eyed baby and got to know him in our cozy bed. The midwives stayed for several hours to make sure he was okay, but gave us time together as a family to rest and bond as they cleaned up their equipment, did the laundry, and brought us hot soup and bread pudding.

In the hospital, I think it would have been a very scary experience. The baby's cord would have been cut immediately, depriving his body of oxygen. Afterward, he would have been whisked away from us for monitoring and tests, and we would have missed wide-eyed curiosity as he took in the world for the first time, searching for the mom and dad whose voices he'd been hearing from inside.

It was a pretty easy decision for us to give birth at home for a lot of reasons. We did some research, and found midwives who were very experienced in home births, and also certified nurse-midwives through OHSU with hospital experience. We chose them explicitly because of their comfort with both worlds, and enjoyed a relatively uneventful pregnancy, luxuriating in thorough pre-natal care in the comfort of our own home.

And then, at about 34 weeks, I was diagnosed with mild pre-eclampsia, and the decision was quickly made that my care should be transferred to an OB, and delivery should take place in the hospital. The midwives eased our transition to an awesome OB, and served as doulas for the birth, so we had that continuity,which was wonderful.

I have to say, though, that even though we started at the hospital, and did not transport to the hospital during labor, word got around at the hospital that we had been (up until 5 weeks earlier) planning a home birth, and both my husband and I felt, time and again, with each new set of nurses, each new doctor, that we had to prove that we were rational people, willing to accept medical intervention.

It felt almost as though someone had flagged our charts, as people to watch out for. Time and again, we proved ourselves "worthy", beating back the prejudice against that "home-birthing crowd". But it was an extra stress that really did not help anything about our situation, and I can only imagine how much more that same energy must be felt by people who do end up in emergency transports. I think there is a lot to be gained by doctors and midwives sitting down and educating each other in their respective areas of expertise.

There is good in both places, and this is such a personal (not to be read "selfish") choice, that I think it's dangerous to generalize too much from our own experiences.

Happy mother's day to all you warrior mamas!

Hi Rebecca! Happy Mother's Day--I hope that the sun has been shining in your part of the world today.

I had my first (and so far only) child at the age of 32, after an uncomplicated pregnancy. I delivered him in a free standing birth center here in Portland, attended by a CPM with a vast amount of experience, her intern, and an apprentice. We were in a small apartment at the time and I was not comfortable birthing there, so we traveled a few blocks. If we have another, the plan is to have a home birth, barring any complications.

There may be some truth to the idea that later pregnancies are more prone to complications, or that may be entirely anecdotal--not discounting statistical information for women over the age of thirty five, although there is some issue with the setting of a limit for "high risk" at 35. Either way, the point of midwifery care and birth outside of a hospital setting is that for low risk women who have had a healthy, uncomplicated pregnancy it is as safe an option as birthing in a hospital setting. Possibly safer. According to the WHO, our cesarean rate of greater than 30% is such that the risks associated with cesarean section to that number of women effectively exceed the benefits (the implication being that the number of c-sections performed therapeutically and the benefit derived therefrom is negated by the risks taken on by the 15-20% of c-sections performed outside the bounds of more strict indications). The risks associated with c-sections are greater than those associated with vaginal delivery; it's a major surgery, not an alternate route.

It is well documented that labor augmented with pitocin is a seriously risky business. Williams Obstetrics: "Oxytocin is a powerful drug, and it has killed or maimed mothers through rupture of the uterus and even more babies through hypoxia from markedly hypertonic uterine contractions." Yet pitocin is a routine part of labor and delivery in a hospital. More simple interference such as confining a woman to bed for first or even just second stage labor and the use of the lithotomy position for delivery (let's just make that pelvis smaller, shall we? and how about we work against gravity for a bit, hmmm?) can have profound effects. Those are only three of a number of routine interventions that one can expect in a standard L&D hospital setting, the vast majority of them working against, rather than with the physiology of birth.

I am certainly not suggesting that emergency medical care does not save the lives of mothers and their babies, but I am saying that medically managed births are by design more likely to include complications, some of them very serious, each one potentially requiring more intervention to fix what was not originally broken.

I am a little shocked every time I hear what I believe to be scare tactics and misinformation generously scattered around when the subject of women choosing to inform themselves about the physiology of birth and options that they have (or have not, in many cases) with regard to where how and with what kind of support they will labor and birth is raised. It disturbs me that the risks of arom, pitocin augmentation/induction (let's not even get into cytotec), continuous fetal monitoring, enforced immobility, routine and multiple cervical dilation checks, and npo orders to name just a few are not made plain to women who however inadvertently choose that course; but a woman who chooses to inform herself, has a plan in place to deal with an emergency should one arise, has a care provider on hand with oxygen, pitocin in case of hemorrhage, neonatal resuscitation skills, suturing skills and an understanding of the normal physiological process of labor and birth as well as the ability to determine what is outside the range of normal and may require medical assistance, is either an infanticidal moron or an ignorant sentimentalist.

I have had both a hospital and home birth. My first daughter was born in a hospital with a great midwife and the experience was just fine. The nurses and staff were great and even supportive of my choice to have a natural birth. When I got pregnant with number two I did more research and asked more questions. I wanted to really know my midwife and not rotate through 6-10 for each visit. I wanted a waterbirth. I wanted to be able to be with my older child after the birth. I wanted a comfortable environment. We found a midwife with over 30 years experience and felt like a home birth was the right choice for us. Yes, it helped that we are only a few miles from a hospital and yes we had an emergency plan, but I felt confident that with the care of my midwife (who was so completely more knowledgeable then the 6 we worked with during my first pregnancy)the chances of a problem arising were very slim. I am so thankful that we chose to birth at home. In the hospital, with a midwife, I had a great emotional support ("you're doing great") at home, I was surrounded by women, on the floor with me, rubbing my back, holding my had, etc. helping me breath through each contraction. Not to mention the comfort of my home vs. a cold hospital bed and floor. Afterward, I was in my own bed with my older daughter and was able to rest peacefully. I didn't miss the nurses coming in every hour to weigh the baby, the photography people wanting to take pictures and all the other staff that stop in to check this or do that or the few hours wait to get the paperwork in order to send me home.

As for safety, there is plenty of info that talks about the safety of home births. I wanted to have a safe birth for my baby without any unnecessary medical interventions. And, as they say, "The first medical intervention is leaving for the hospital." Ina May Gaskin's Guide to Childbirth is a wealth of information. She has collected data on her births for a very long time. The C-section rate from her and her partner's births was less then 2% while it was 25% at the time in the hospitals (now over 30%). I applaud any Mama that takes the time to research the topic and use that information to make a choice that is best for her and her family.

Camellia,
Thanks for sharing. That is a beautiful story.

First off Meg I am not sure where you got the information that humans are the only ones who birth through their pelvis. All Mammals that I know of, and I live on a farm birth through their pelvis not behind it. Believe me when you see a cow or horse birth their babies (and they are big) by themselves you believe that birth can truly happen naturally for humans as well.

I am both an RN and a Student Midwife. I am a student planning to become a CPM not a CNM for many reasons. As both a nurse and a doula I have watched many families be convinced that their baby is in imminent danger and a c-section should be performed. Most all of those cases presented a baby born in NO distress and an APGAR score of 9 at 1 minute. Many of these where also performed 2-3 hours after the decision was made. To me this signifies there was not imminent danger, within that 2-3 hours the mother could very well have dilated more and be close to birthing her baby vaginally. On the other note, there are definitely reasons for intervention and I am glad they are there when needed, but sadly those interventions are overused based on liability, insurance and personal convenience reasons.

Most births can safely occur at home, and should not be considered selfish. Woman should have the choice to birth where they want without being told it is wrong or selfish. I could say that having an epidural is selfish as well as there is a lot of documentation showing the dangers to baby from epidural medications.

I just attended a homebirth of a diabetic mom to an 11lb 8oz healthy baby with no perineal tearing. Both Mom and baby are happy and very healthy. Personally I don't think this birth is a fluke, I think it is what can happen often, and woman should all have that choice.

I feel stri

I am certainly not comparing the US to Sierra Leone..but what an interesting piece. He does not mention the source, but Kristof quotes that 1/10 women worldwide need a C-section. I know that in the US it occurs in about 1/3 which is obviously wrong...but food for thought anyway!

http://www.nytimes.com/2009/05/17/opinion/17kristof.html

Just like the vaccination issue, things occur in African countries, like death in childbirth and death from pneumococcal pneumonia, which may you thankful to have access to the medical care we have here in the US.

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