Friday, August 22, 2008

Questioning Safety: Hospital, Birth Center, and Homebirth

Where is it safe to birth your baby? Is the hospital the safest option? The only safe option? Are planned homebirths safe? Is it safer to have an OB/GYN (obstetrician, who is a doctor) as a care provider, or are CNMs (certified nurse midwife) and CPMs (certified professional midwife) safe options too?

First, I want to share a quote by Harriette Hartigan (midwife/photographer) that is commonly heard in the birthing community, "Birth is as safe as life gets". I wonder what the context of this quote originally was... to me, it suggests several important ideas:
  • Birth is a part of life. This is easy to forget when, in our culture, birth is so removed from life - usually taking place in the hospital, with only the birthing mother, her partner and maybe a female friend or relative. Very, very few of the pregnant mamas who take my classes have ever seen a real birth - human or animal. Contrast that experience with the one pictured below, where you can see birth really is a part of life:

  • While birth is safe, there are no guarantees. And that, I think, is the hardest thing. We've all heard horror stories, and I feel no need to put additional details in people's heads. Thankfully, in our country, most births conclude with a healthy mother and healthy baby (not that there isn't room for improvement!). But there are times, so sadly, when despite careful attention to mother and baby, something goes wrong. Sometimes with a warning, sometimes not. Even sometimes when the mother has had excellent prenatal care, an uncomplicated pregnancy, and highly qualified, experienced birth attendants. As sad as that is - it's life. People die. The struggle is to avoid medicalizing the experience of so many motherbabies in the name of preventing one or two deaths. Because doing that - continuous fetal monitoring, or not laboring at all and giving birth via a cesarean at 39 weeks - actually carries many, many more risks for mothers and babies, as well as the health of their future children. The struggle is to avoid lawsuits where something bad happens despite excellent care. This tendency has had the unfortunate effect of justifying doctors who practice defensive medicine: monitoring continuously for the paper trail, and the many cesareans that happen "just in case", because doctors know they will be sued over the cesarean they didn't do, not the one they did.

  • Choices we make can make birth safer. I wear my seat belt, and buckle my kids into booster seats. We wear life jackets. We get consistent check-ups by experienced, well-trained care providers. We eat lots of fruits and vegetables and whole grains etc. & etc. & etc. My husband and I make choices for ourselves, and for our children, that - to the best of our knowledge - enhance and protect our healthy bodies. Women can make choices for their birth experience that enhance and protect their bodies and their babies.

    One last point - while I wear a seat belt, I do still drive a car. I know that accidents happen, but that doesn't change my decision to drive on a daily basis. While I try to minimize the chance that something catastrophic happens while we're in the car, I understand that driving safely, while I'm not too tired, in a safe vehicle that gets routine maintenance, doesn't completely protect me. There are things that happen where no blame can be assigned - they just happen.
  • I believe birth is very similar to driving a car. Safe most of the time, even when people don't make the best choices; safest, but not perfectly safe, when they do. So, back to the original questions: where, and with whom, is it safe to give birth?

    Book after book that I've read reassures that quality care in a well-prepared home or quality birth center is as safe if not safer than a hospital birth attended by a doctor. Here are some excerpts that I found particularly helpful:

    From the Sears' Birth Book on birth center births, "In 1989 the New England Journal of Medicine reported a study of nearly twelve thousand women admitted for labor and delivery to eight-four free-standing birth centers in the United States. The study concluded that birth centers offer a safe and acceptable alternative to hospital births for low-risk women. The cesarean-section rate for the women in the study was 4.4 percent, far below the national average. There were no maternal deaths, and the neonatal death rate was well below average" (Sears 42). To find a birth center near you (as well as lots of other great information), check out American Association of Birth Centers . For questions to ask and things to think about, visit Childbirth Connections "Tips and Tools for Choosing a Place of Birth" page.

    While discussing homebirth, the Sears' write: "In 1900 fewer than 5 percent of births took place in hospitals. This increased to 75 percent by 1936, and by 1970 approximately 99 percent of mothers delivered in hospitals. But is this progress? Illustrating the differing perceptions of home birthing are these two mothers discussing their birth choices: 'You are brave to have a home birth,' said a concerned mother. 'You are brave to have a hospital birth,' replied the other" (43). They go on to discuss the safety of home births this way, "both sides of statistics to support their view. The people in white coats boast that the chances of a mother dying in childbirth was much higher in 1935 than in 1980, and that this is the result of technology available only in the hospital. Home-birth supporters argue that there is no reason to believe that there is a cause-and-effect relationship between birth in the hospital and lower mortality rates. Today's women have better access to prenatal care and more is known about safe birthing. Antibiotics are available to treat infections, and most aspects of health are better now than they used to be. Hospitals actually have higher mortality rates than home births, in part because mothers with the highest risk of life-threatening medical problems deliver in hospitals. Statistics that show poor outcomes in home births are equally misleading since these studies lump all out-of-hospital births together, whether they're planned, properly attended home births or involve foolhardy couples with no prenatal care doing it on their own [or happen by accident, at home or en route, mom has the baby earlier than anticipated]" (46).

    The more recently published book, Having a Baby Naturally, comes to similar conclusions. O'Mara asks "Which birth environment is safest? Surprisingly, home births, birthing in birthing centers, and hospital births are equally safe. Recent studies show definitively that there is no improvement in outcome, for mother or baby, in hospital births as compared to those that happen at home or in a birthing center . . . in fact, there is an indication that outcome is actually slightly better in low-risk births out of the hospital" (34). She goes on to explain that "home births, and births in birthing centers, have enjoyed a recent renaissance in the United States. However, there is still a lingering societal question about the safety of such births, and most women continue to go to the maternity ward of the hospital where their caregiver practices. Choosing to do something different may take real courage, as friends and relatives may be particularly concerned about the safety of your choice" (35).

    There is a great website that offers answers to many of the "What if" questions friends and family might ask. It does have some loud music that accompanies it, but if it bothers you, just mute it.

    The Home Birth Reference Site has some terrific information too, on the safety of homebirth, as well as home birth stories, reasons why people homebirth, how to plan a homebirth, more answers to "what if?" questions and other useful information. The North Carolina Homebirth website provides additional information on why homebirth, how to plan and prepare, and more birth stories.

    A few additional links include:
  • Citizens for Midwifery document comparing WHO recommendations, CIMS suggestions, and the reality of birth in the US as of 2004.

  • An article by Pam England (Birthing From Within), "No Place Like Home".

  • Childbirth Connections offers excellent information about the different care provider options, as well as information on questions to ask yourself in making a choice, and questions to ask during the interview process.
  • Finally, I want to mention that the United States is not the standard-bearer for safety for mothers and babies. Using 2008 statistics, the United States (6.3/1000) currently ranks BEHIND the following countries for infant mortality rates: South Korea (5.94/1000), Cuba, Isle of Man, Italy, Taiwan, San Marino, Greece, Monaco, Ireland, Canada, Jersey, New Zealand, United Kingdom, Gibraltar, Portugal, Netherlands, Luxembourg, Guernsey, Liechtenstein, Australia, Belgium, Austria, Denmark, Slovenia, Macau, Isreal, Spain, Switzerland, Andorra, Germany, Czech Republic, Malta, Norway, Anguilla, Finland, France, Iceland, Hong Kong, Japan, Sweden, and Singapore (2.3/1000).

    There is something many (but not all) of these other countries have in common: universal access to prenatal care, and more support and use of midwives and out-of-hospital births.

    Marsden Wagner's book Born in the USA offers some interesting critiques and comparisons of care in the US vs. care in other developed countries. He writes, "Whenever I discuss home birth with obstetricians in the United Sates, I need only ask, 'What about the Netherlands?' to see their faces fall. The Netherlands has a long tradition of planned home birth. As recently as thirty years ago, half of all births in the Netherlands were planned home births. The percentage fell to one-third in the 1980s, but the rate has been climbing for the last ten years and is now more than one-third - 36 percent. The Dutch do not have significantly more women and babies dying around the time of birth than other Western European countries, and they have lower mortality rates than the United States does" (144).

    Later he also discuss birth in Denmark: "Denmark also guarantees a choice of place of birth to all Danish families. Like every other highly industrialized country except the United States, Denmark also has a national health care system. In Denmark, midwives attend all low-risk births either in the hospital or in the family's home . . . The home birth rate varies within Denmark (it is around 10 percent of all births in some districts), and Denmark's mortality rates for birthing women and newborn babies are among the lowest in the world" (193).

    Wagner also explains that "In some areas of Western Europe and Scandinavia, a low-risk pregnant woman can choose a small group of midwives who share a practice. The woman will usually get to know all of the midwives during prenatal visits over the course of her pregnancy, and when she goes into labor, one of them will come to the home or hospital and assist for the entire time, even if the labor is thirty-six hours long. This allows the woman to receive one-on-one continuous care with a known midwife - so this scientifically proven ideal scenario is not pie in the sky, but quite feasible. All those countries in Western Europe and Scandinavia where midwives handle prenatal and birth care for low-risk women exclusively have lower mortality rates for birthing women and their babies than the United States does" (198).

    He goes on to use a few more examples - "a resurgence of birth houses in Japan began [after the Americans left post-World War II], and more and more midwives are leaving hospital practice to work as community midwives in birth houses. This Japanese experience confirms what we have seen in the United States, that in the end, attempts to eradicate midwifery are not successful. In every society, there will always be midwives working to maintain women's freedom to control their own reproductive lives, and there will always be women who will avail themselves of midwifery services" (199).

    And, "In New Zealand, the maternity system is similar to Scandinavia's, but a woman having a low-risk pregnancy can choose either a midwife or a family physician to provide her prenatal and birth care" (Wagner 199).

    Each of these countries have significantly better outcomes for babies: New Zealand (4.99/1000), Netherlands (4.81/1000), Denmark (4.40/1000), Japan (ranked third, at 2.80/1000), and Sweden (ranked second, at 2.75/1000).

    Another famous champion of birth, Barbara Katz-Rothman, explains that "Birth is not only about making babies. Birth is about making mothers - strong, competent, capable mothers who trust themselves and know their inner strength." Safety concerns should not limit women's options for where they give birth, and with whom. Women should be able to choose the options that feel safest to them - hospital or birth center or homebirth, obstetrician, family physician, or midwife. All care providers should encourage women to trust themselves, to participate in decision-making, and treat each birthing motherbaby as individuals. Your baby has only one birth experience; you will probably only have one or a few birth experiences - and each one is an amazing opportunity for growth and joy.

    There's a quote in Our Bodies, Ourselves For the New Century that I share with my clients: “When women go to caregivers for checkups, they should walk out from every visit feeling ten feet tall. Every site of care and style of care, no matter who gives it, ought not only give surveillance but should educate and empower, should enhance every woman’s feeling of ability to do what she’s doing well” (451). That sums it up beautifully for me, and I hope this blog entry helps you explore the options for care that surround you so that you enjoy education and empowerment on your journey to motherhood.

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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