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The Home Birth Debate Heats Up

The New York Times Magazine published an article this week on Ina May Gaskin, a leading advocate and pioneer of the homebirth movement in the US that emerged during the late 1960s and early 1970s out of the hyper-medicalized (and sedated) birthing ethos that preceded it. Gaskin is still delivering babies, and she’s still writing books (she wrote Spiritual Midwifery, which describes as “the classic book on home birth that introduced a whole generation of women to the concept of natural childbirth,” in 1975). Gaskin is a fascinating figure who, although she fell into midwifery accidentally, has had a dramatic impact on childbirth in America.

The singer/songwriter Ani DiFranco (who I was a HUGE fan of when I was 14… Fancy running into her again in my Natural Parenting writing life!) writes in her forward to Gaskin’s newest book, Birth Matters, “What if the medical establishment that purports to be saving women from the specter of pain and danger is instead ejecting them from the seat of their power?” Referring to the many strong, healthy female friends who tell DiFranco they could never have delivered their babies naturally, as she did, DiFranco continues, “How could all of these otherwise empowered young women go so unquestioningly into the role of damsel in distress when it comes time to have their children? How were they convinced they ‘couldn’t do it’? Ms. Gaskin is a bright light shining into a dark chasm of forgetting.” DiFranco’s praise is echoed by many, but Gaskin and her practices are not, as the online comments section following the NYTimes article clearly reflect, lauded by all. Home births fall under subject matter territory more divisive than whether or not toddlers should breastfeed. The NYTimes piece is pretty fascinating, wherever you stand, and represents both sides of this issue. Give it a read; you’ll like it. Then, let’s talk about these comments, and where all of this debate might be going. Although many of the responses represent extreme adherence to one side of the issue or another, others represent some common priorities, and seem to open onto new ideas around how birthing can be made better in our nation, for babies and mothers alike.

Voluntary C-section rates are unduly high – and largely unquestioned – in the United States today, but home births are also on the rise, in large part due to women's (especially, statistically, middle-class, white women with the means for the best hospital care available) increasing awareness of natural birth options, and increasing dissatisfaction with the medical establishment’s approach to reproductive care and childbirth (high-intervention, sub-par results… the US ranks 41st in neonatal mortality and 50th in maternal mortality, worldwide). Home births for low-risk pregnancies, and performed with the support of experienced, capable midwives show comparable positive outcomes to hospital births, and countries like the Netherlands are oft-referenced examples of nations that have normalized these types of deliveries and rank far above the US on those neonatal and maternal death rosters. But for many American women who choose not to deliver their babies at home – which is most of them – and some who swear they’d never consider it an option at all, the crucial question isn’t one of female empowerment or even a positive birth experience (women who give birth without interventions generally feel better about their experiences than those who got the meds), but of risk-management. IF something goes wrong during childbirth, these women (and many men, too) feel a hospital is the best – if not the only -- place to be.

I’ve pulled out a few of the comments on the NYTimes site that caught my eye, to give a sense here of the range of perspectives on this topic. Hold on tight. Here goes:

J. Curtis, from San Jose, California, gives a brief, gut-wrenching account that represents the risk factor many moms aren’t comfortable with (including the NYTimes’ article’s author, and, on a level, me):

“In 1991 my son was born in a hospital five weeks early with undeveloped lungs. He spent his first ten days of life in the neonatal intensive care unit. One night, when I was in the NICU rocking him, a baby arrived via ambulance and bypassed the emergency room to be taken straight up to the NICU. They did their best to save him, but it was too little, too late. He was born at home, where the mother had given birth to healthy babies three times before. I was very sad when the family came to say their goodbyes. My OB doctor told me that sometimes during births, situations can go from good to bad very, very quickly.”

Of course, situations can, and do, make turns for the worse in hospitals, too, and when babies (or moms) die there, as Gaskin points out in the NYTimes piece, people don’t tend to question the very concept hospital births... or the medical interventions that introduce risk into birth processes.

BrittaLouise, from Brooklyn, offers her perspective, from the other side:

“My hospital births I felt were much more dangerous to me with one of them resulting in emergency surgery post-birth and blood transfusions for a hemorrhage that got out of control. I am completely convinced that if I had been in a birth center or in my home that would not have happened because I would have had a midwife that was FULLY present with me and not multi-tasking or going off/coming on shift. I am not at all convinced that a hospital birth is safer for the mom or the baby.”

Interesting, right?

Let’s keep going. Feminism is a topic that came up in the NYTimes piece, and seems to emerge fairly frequently around natural parenting in general. Stephanie, from Washington DC, had a positive C-section experience, and, feeling judged by pro-home-birthers, reminds readers that a real feminist perspective respects all women’s choices:

“For those of you who call yourselves feminists for your choice to birth your children at home, that is fine, but please refrain from judging women who choose to take advantage of the advancements of modern medicine. True feminism is about freedom of choice without judgement. Freedom to choose whether to become a mother, freedom of how to deliver your child, freedom to choose whether to work or stay at home, and freedom of equality in all aspects of your life. If we, as women, start attacking each others’ choices on how to birth children--the most fundamental aspect of our womanhood--I think that the advancements of feminists before us will be greatly diminished.”

I totally agree that attacking each other is NOT helpful; for one thing, it diverts attention from the prevailing institutions that must improve policy and practices to better serve women and kids (like, for instance, the American medical system). Stephanie may be forgetting, however, that one of the reasons people choose home births is because they don't feel they are offered sufficient choices regarding their own health – or that of their babies -- in hospital settings. And, many high-profile feminists railed again Gaskin’s camp during the 1970s, because they believed childbirth to be a purely biological process that women were subjected to, rather than voluntarily active in, and wished it to be as mechanized as possible. Women who birth at home today are doing so against the (often hostile) mainstream, and many women who’d like to have a home birth can’t even do so legally. The re-emergence of home birth as an option represents the push (so to speak) for a full spectrum of choices for all women. But yeah, no one should be judging, from either camp, that's for sure.

Here’s a cool one from a dad-to-be (Jon, in Brooklyn):

“We obviously have a fairly broken health care system if it's the most expensive in the world yet 40th in neonatal mortality, and this rise in home births, however small (there are only 2-3% in the US!), is a response to that system, however risky or unorthodox it may be. But what gets on my nerves is when people call natural births a "selfish" choice. For me, it's not about some kind of psychedelic high or orgasmic thing or even some coolness factor in saying "screw you" to hospitals. It is first and foremost about making a connection with another being and providing it a great springboard into a healthy life, which, for us, happens to be a natural home birth. It's also about supporting my wife who wants to do a home birth, and I'm all about it if she is, so let's do this. That, to me, doesn't seem selfish.” (Awww.)

Concerned Citizen, from “Anywheresville, USA”, has a lot to say (brace yourselves, if you’re gonna go in there and read the rest); here’s a little snippet that reflects the nuts and bolts of his perspective:

“’Natural’ is to die in childbirth, or die of puerperal fever, or an infection. ‘Natural’ is to lose a full term baby to a breech birth. ‘Natural’ is to get pregnant 20 times in your lifetime, miscarry 5 times, have 5 dead babies and then lose another 5 in early childhood, and see only 1 child in 4 live to adulthood. This is why people used to have 5, 6, 7 children -- because most never lived to grow up!”

As entertaining, if not enlightening, as the extreme opinions on either side can be, there are also lots of comments in the mix from people who fall somewhere in the middle on all of this, who wanted healthy babies and got them, one way or another, and can see the pros and cons of home and hospital births alike. In fact, I’d venture to say (although I didn’t count) that the majority of comments, especially once the super pro- or anti-homebirth positions were aired, reflect an intelligent willingness on the part of the public to consider the range of childbirth choices and experiences (which vary tremendously; as one commenter said, there is no ‘one size fits all’), the system in which they exist in our country, and the ways in which they might be improved.

Carol Livingston, in Walnut Creek, California, offers some unique insight into that system, and how it promotes, rather than bridges, the divide between opposing options:

“As an OB/Gyn who has been supportive of home birth and acted as physician backup for a home birth practice I see the biggest problem is the polarization between home and hospital practices. In 1st world countries where home birth is routine there is a seamless transition if a mother needs to transfer to the hospital. There is a protocol and an accepting staff and plan of care. In the US home birth is regarded as dangerous and transfers are often treated with open hostility. Mothers often endure scoldings and punitive attitudes when they present to the hospital and often present as "no doc" patient because homebirth is ‘extralegal.' Therefore mothers and their midwives are reluctant to go to the hospital until things have totally deteriorated.”

And here’s the voice of a former hippie, turned (now longtime) doctor, Jimraker, in Maine, advocating for a solution, a middle ground, which does exist in some places and is therefore definitely possible. (In fact, another commenter shared that her hospital birth experience in Canada included birthing balls, bathtubs, dim lighting, and doctors... #NationalHealthCare, #BestOfBothWorlds). Back to you, Jimraker:

“I believe the ideal solution is a "birthing" center run by the mid-wives but with instant access to the hospital should anything go wrong. I've seen them. One of my son's was born in one. Completely autonomous but connected to a hospital by subtle swinging doors just in case...”

Lastly, Kim L, in Washington DC, has had one negative C-section experience but has found that middle-ground positive variety for her second baby (arriving soon):

“Having a healthy baby is the most important thing, but not the only important thing in birth.

With our second, I feel confident and lucky to be delivering with the Wisdom Midwifery practice at George Washington University Hospital in DC. The midwives are incredibly competent, confidence-building and gentle. My hope is for an uncomplicated, normal, vaginal delivery, but going in I feel best that I am partnered with practitioners (the midwives and the rest of the GW medical staff) that empower their patients to leave it all on the field. If a medical intervention is needed, it's right there, but that need is truly the determinant. My fervent hope is for this model of care to spread and become a real option for peaceful, confident and healthy births nationwide.”

This strikes me as the potentially super-positive outcome of debates like this, which is to say, a pendulum-swing back in Gaskin’s direction which also incorporates the positive aspects of hospital birth (namely major emergency care) into the big birthing picture. I ultimately contend that if women present low-risk pregnancies, want to deliver at home, and have capable midwives (plus quick hospital access) on board for that, then they should absolutely be able to do so, stigma-free (remember that births don't need to be problem-free for midwives to handle them; most midwives are very capable in semi-emergency situations, and most also know exactly when it's hospital time). I find the statistics from the Netherlands very compelling. But I also feel that home births shouldn’t be the only option for women who desire less intervention, more choice, and, hey, a little mood music if that's their thing... even if they do want the security of a medical team on hand, or end up needing an intervention. American birth statistics speak for themselves in terms of our neonatal and maternal death rankings, and I believe we can do better through dialog like this, which moves closer to making all (and new, and better) birth options safe, appealing and available for every mom.

So what do you think? Does Gaskin’s Farm sound just your speed? Are you C-section or bust? Somewhere in the middle (I was all “Hand me a healthy baby, and let’s make this fun!”)? What do you think of this emerging combo-birthing center and hospital idea? Have any of you had positive experiences with in-hospital midwives? How about home-births that rocked your world? Hospitals that hit the spot? What’s working in these different approaches? What’s not? How can we do better?