“The underlying belief in midwifery is that birth is a physiological process…versus the more medical view…that birth is something that can be high-risk at any moment and it’s sort of a disaster waiting to happen.”Dr. Robyn Lamar
National Public Radio
During my OB/GYN residency back in 1975, we were taught that home births with midwives were bad and hospital births with physicians were good. Today, some people say the risk of infant death for home birth is two times greater than it is for hospital births. But I have learned over the last 46 years that hospital births are not necessarily safe or good, and that home births are not necessarily risky or bad. The primary question each woman must ask herself is where she will feel more comfortable: at home or in the hospital?
It is not uncommon for labor to stop for a while when women check into a hospital for a delivery because of hospital-associated anxiety. If labor stops for any length of time, your obstetrician may want to begin induction processes to speed things up to meet the requirements of insurance companies, or you may be sent back home for a while. I have always tried to manage patient anxiety by promoting confidence and comfort in my patients, giving them the autonomy and respect they would have at a home birth within the safety of the hospital.
If you want a delivery with the least amount of technological intervention, you will probably need to work with a midwife and have a home birth. Many people feel that birth is a natural process and should be allowed to progress without a lot of technological intervention. This is especially true in the developed countries with lower maternal mortality rates.
In a hospital, even with a “natural” delivery, you will probably have an IV, monitors (sometimes even internal monitors), a blood pressure machine, and a Foley catheter. You may well be tied to the bed with monitoring equipment. Walking is good for a natural labor, but in a hospital hooked up to numerous pieces of electronic equipment, arranging to walk around to help your delivery is difficult.
Then there is the issue of whether you want to be subjected to an induction. Pitocin creates a very painful labor which will require an epidural. Patients are not always aware that it’s the Pitocin which creates a level of pain requiring an epidural. In natural labor, the period of strong uterine contractions lasts a shorter period of time and the mother is more likely to deliver her baby without anesthesia.
The American College of Obstetricians and Gynecologists (ACOG), the professional group for physicians in this specialty, opposes home births, as would be expected. However, they offer suggestions for making home birth as safe as possible:
- Home birth should be less than 15 minutes from a hospital.
- No previous cesarean section or other uterine surgery.
- No multiple births such as twins.
- No breech births.
You also need to consider whether you are willing to have a cesarean section. Obviously, midwives do not do cesarean sections, but if you have complications with your delivery the midwife believes would be better handled in a hospital, you may find yourself in a position of being offered a cesarean section.
The issue between a hospital and home birth is really that the hospital is a safer place in case of an obstetrical emergency such as hemorrhage. Obviously, a team of specialists readily available to address childbirth emergencies is “safer” than having to try to get to a hospital while hemorrhaging.
Dr. Neda Ghaffari specializes in high-risk pregnancies. She will tell you, though, that “it’s very hard to determine which patients are going to have an obstetric emergency.” Dr. Ghaffari recommends that if a woman with a low-risk pregnancy does choose a home birth that she live within 15 minutes of a hospital. If she has had a previous cesarean section, is carrying twins, or has a breech baby, she should opt for a hospital birth. These are virtually the same recommendations as those of the American College of Obstetricians and Gynecologists.
When I was in medical school, I observed that with obstetrics, there is an opportunity to choose your outcome. In other medical specialties, the ability to choose an outcome may reside only in a choice of one treatment over another, with the outcome in neither the patient’s nor the doctor’s control. There is also in obstetrics a responsibility to a second patient, the baby. This was the reason I found obstetrics so compelling as a specialty. Those choices of outcome, however, should belong to the mother and not be solely the jurisdiction of the obstetrician. A basic human need is the need to feel autonomous. This couldn’t be more true than when giving birth. There’s much talk about the risk of home births as compared to hospital births, but the real underlying issue which prompts women to consider home births is having more say in their birthing process.
About 20 years ago the state of Minnesota decided to license lay midwives. I felt this was a smart move because the license gave the state some oversight of the lay midwives. Some states, such as North Dakota where I practice, have an opposite perspective. States like North Dakota do not license lay midwives. In fact, some time ago the North Dakota medical board actually punished a doctor for supplying a lay midwife with Methergine, a drug that has been used for decades to contract the uterus and decrease blood flow.
I have worked closely with midwives and they knew that their mothers could choose to be admitted to the hospital for their delivery even without complications, with the midwife present for the delivery in the role of a doula. Both the midwives and I knew this was the best of both worlds for our mutual patients. Yet the hospital made it plain they did not like my working with midwives.
From my perspective, we need to combine the concept of the hospital and the home birth. Create specialty birthing hospitals so there is the hospital safety net, with nurses, doctors, and an operating room combined with the autonomy, comfort, voluntariness, and respect that mothers would get with a midwife at a home birth. Ideally, the labor, delivery, recovery, and post-partum should actually be like home, not just give the appearance of home with pretty drapes and wall coverings.
Assessing your situation as to comfort, your autonomy, necessary support, risk, and state law can help you choose whether to be at home or a hospital to have your baby.
About the author: An obstetrician and maternal mortality expert, “Rural Doc” Alan Lindemann, M.D. teaches women and their families how to create the outcomes they want for their own personal health and pregnancy. A former Clinical Assistant Professor at the University of North Dakota, he is currently a clinical faculty member available to serve as preceptor with medical students in rural rotations. In his nearly 40 years of practice, he has delivered around 6,000 babies and achieved a maternal mortality rate of zero! Learn more at LindemannMD.com.