By Pam England
"I know that I'm healthy and everything's going well with my baby and I know everything's going to be fine."
Those words, uttered by an extremely pregnant Dawn Louro on CBS's Morning Show in February, sound more innocuous than momentous. But in some ways, they are revolutionary. Because Ms. Louro's calm assessment of her pregnancy came only weeks before she gave birth on television, before an audience of millions. At home.
In some circles, laboring or birthing at home is considered quite radical. Most first-time mothers probably doubt that they know enough to give birth anywhere, much less at home. They are surprisingly out of touch with the innate, miraculous processes involved in giving birth. Even though those mothers do not know birth technology either, they know it is out there. Daughters of our technological age, users of cellular phones and computers, understandably have faith in technology.
In addition, women who plan to labor and give birth at home typically get little support and a lot of anxious skepticism from those around them. Under such circumstances, it is not surprising that so few women today give birth at home.
But that may at last be changing and more than 20 years after Mothering first began writing about the possibility and the pleasures of delivering your child in his or her own home. Oprah Winfrey has done shows about alternatives to hospital birth. Chris Bohjalian's book Midwives has been a national bestseller. And then there was Ms. Louro's labor. "I just want it to be in my own home environment," Mr. Louro told the CBS correspondent. "I want to be able to get up, walk around, and have my whole family around me after the baby is born."
As a childbirth teacher, one of my greatest challenges is to inform people objectively about their choices and give them respectful support in their decision-making, so they are not left feeling coerced or guilty about whatever informed choice they eventually make. That is what I wish to do here. Homebirth may not be right for you, for reasons of physical health or personal philosophy. It also may be the perfect choice for you, but one you hadn't considered until now. In a childbirth class I taught recently, the topic arose spontaneously. A couple, one of whom was a physician, said they were thinking of a homebirth. The class erupted into animated discussion, provocative questions, and a sense of hopeful excitement.
At the end, one mother turned to me and sighed happily, "I feel more relaxed just knowing that a homebirth is a possibility," she said, "whether or not I choose it."
Is Homebirth Safe?
The Farm is a 1,700 acre commune in Summertown, Tennessee, founded in 1971 by Stephen and Ina May Gaskin. The trained and skilled midwives there have professional consulting relationships with physicians and refer mothers with complications or risk factors to the hospital.
In 1992, a major study compared 1,700 homebirths attended by The Farm midwives to a sample of 14,033 physician-attended hospital births. The findings were dramatic and heartening: The cesarean rate among mothers who received prenatal care at The Farm was only 1.5 percent compared to 16.5 percent in the doctor-attended group. The transfer-to-hospital rate was 13.5 percent. There was no significant difference between the two groups for perinatal death, bleeding, birth injury, or respiratory distress syndrome.
This excellent outcome for those choosing homebirths has been found in other studies as well. In a famous 1977 project, Dr. Lewis Mehl studied birth outcomes from the medical records of 1,146 elective homebirths in the San Francisco area. The results: the perinatal mortality rate among women who elected homebirth was 9.5 per 1,000 births and compared to a rate of 20.3 per 1,000 among California women who gave birth in the hospital. In other words, as Dr. Mehl concluded, "the [homebirth] outcomes were better than average and the complications rates lower than expected."
And then there are the subjective, anecdotal reports from women who have chosen a homebirth. According to a wide-ranging 1992 survey, "91 percent of . . . women who had had their last baby at home said that they would prefer to have their next baby at home, compared with 15 percent of those who had had their baby in a hospital. Among the few women who had experienced both a homebirth and a hospital birth, 76 percent preferred giving birth in their homes."
The Economics of Homebirth
Homebirth is significantly cheaper than a hospital birth. But that doesn't mean it will save you money. Why is that? Consider the following: In 1997, a normal hospital birth cost between about $4,000 and $6,000, with a complicated birth costing many thousands more. In comparison, most homebirth midwives have an inclusive fee of about $2,000, which not only covers labor and delivery but also all prenatal care and several postpartum visits.
In some states, homebirth midwifery is covered by private health insurance. Unfortunately most HMOs do not yet reimburse licensed homebirth midwives, which in effect limits consumers' freedom of choice. It is extremely difficult for some people to make a "choice" which requires substantially greater out-of-pocket expenses.
If your healthcare coverage is limited only to in-hospital birth, write the benefits manager at your place of employment; they seem better able to exert leverage on insurance companies and HMOs than can individual consumers. Issues like this also are being considered in some state legislatures. Write a letter to your local representative or call and make your opinion known.
Finding a Midwife
Rare is the doctor who will actually attend a homebirth. But a few do. To see if any practice in your neighborhood, contact HomeFirst Health Services through their Web site: www.homefirst.com.
It's extremely likely, however, that you'll need to find a midwife to attend your birth. Midwives come in several varieties. Nurse midwives have an RN and have completed postgraduate training at an institution accredited by the American College of Nurse Midwives (ACNM). Direct-entry midwives have trained as midwives but without obtaining an RN (which is the usual route of entry in many countries overseas, including most of Europe). The Midwifery Education Accreditation Council (MEAC) has begun accrediting direct-entry midwifery training programs. Two other organizations offer certification to direct-entry midwives: The ACNM and the North American Registry of Midwives (NARM). Not all midwives are certified.
How can you find a midwife who is compatible with your personality and birthing goals? Begin by asking friends or acquaintances who've had a successful homebirth for a recommendation. You can also contact one of the national midwifery agencies for referrals (see below). But most important is to meet and develop a rapport with any midwife you're considering. She will, after all, be key to the success of your home delivery. You should feel you can trust and rely on her. And, as her client, she will probably wish to feel the same towards you.
The Last Word
Almost every homebirth that I have attended has been a profound experience for everyone involved, including me. After the last such birth, I formulated a few principles regarding homebirth. They can, I think, stand as a summation of why the experience affects people so powerfully, and why it is a moment few new parents ever will forget:
- Pregnancy and birth are natural physiological events, so normal birth does not belong in hospitals.
- The natural course of labor is already perfect, and should be interfered with as little as possible.
- Pain is part of an essential and healthy feedback mechanism in labor. Women can learn to cope with it, especially with the proper encouragement and support.
- Medical management of pregnancy and birth should be limited to those which are medically complicated.
- Unnecessary medical interventions complicate normal labor, creating additional risk and the need for more intervention.
- Comfort and security help mothers cope with labor. Comfort and security exist at home.
Pam England is a certified nurse midwife in Albuquerque, New Mexico, where she directs the Art of Birthing Doula Training Program. This story was adapted from her book Birthing From Within (Partera Press, 1998). To order a copy, call Partera Press at 505-268-8206 or visit the Web site: www.birthpower.com
To Learn More
These are a few excellent books and articles that address homebirth:
Declercq ER, Paine LL, Winter MR. "Home Birth in the United States, 1989-1992. A Longitudinal Descriptive Report of National Birth Certificate Data," Journal of Nurse Midwifery, 1995; 40 (6): 474-82.
Duran, AM. "The Safety of Home Birth: The Farm Study," American Journal of Public Health, no. 82 (3):450-453.
Goer, Henci. Obstetric Myths Versus Research Realities: A Guide to the Medical Literature (Bergin & Harvey, 1995)
Hannon, Sharron. Childbirth: A Source Book for Conception, Pregnancy, Birth, and the First Weeks of Life (M. Evans and Company, Inc., 1990)
Mehl, Lewis, et al., "Outcomes of Elective Home Births: A Series of 1,146 Cases," Journal of Reproductive Medicine, no. 19 (5):281-290.
For help in locating a midwife or other labor assistant, contact:
American College of Nurse-Midwives
818 Connecticut Avenue NW, Suite 900
Washington, DC 20006
Association of Labor Assistants and Childbirth Educators
PO Box 382724
Cambridge, MA 02238
Midwives Alliance of North America
PO Box 175
Newton, KS 67114
North American Registry of Midwives
5257 Rosestone Drive
Lilburn, GA 30047