- The Washington Times - Sunday, September 20, 2009

For Angela Hirsch, the decision to give birth to her second child at home was fairly easy. Her daughter was born in a hospital, and the experience had left her feeling that she wanted a more comfortable setting.

That’s something many home birth advocates cite when they talk about the advantages of home birth.

“All the prenatal care was done at home,” says Ms. Hirsch, a press officer with the Coast Guard who lives in Northwest Washington. She contacted the midwives at Metro Area Midwives Allied Services (MAMAS) at the midpoint of her second pregnancy.

“We had leisurely visits, I made tea, and they answered all my questions. You really got the sense that they love what they do,” she says.

Home birth has become a hot topic these days, thanks to a spate of high-profile celebrity interviews and a rush of recent media accounts. Actually, less than 1 percent of U.S. babies are born at home, but the question of home birth itself, whether it is safe, better for the baby or simply a recent fad, is contentious.

“There is definitely a resurgence of interest in home births,” says Alice Bailes, a certified nurse midwife and co-director of Birthcare and Women’s Health Ltd. in Alexandria.

Both the American Medical Association (AMA) and the American College of Gynecologists and Obstetricians (ACOG) have reiterated their opposition to home births, citing safety concerns and the expertise of the midwives who attend them. Nevertheless, a recent study of 13,000 births published in the Canadian Medical Association Journal, which prompted a number of the most recent news stories, says home births are as safe as hospital births for a low-risk population. Other studies make similar claims.

Both sides acknowledge that home births are not for everyone, especially if a woman has had a previous Caesarean section, is diabetic, has high blood pressure, or has given birth prematurely. But even low-risk pregnancies can have unforeseen complications.

“Everyone knows, and everyone understands, that there needs to be a mechanism to transfer a mother to a hospital setting,” says Ms. Bailes, who notes that about 11 percent of her clients end up being transferred to a hospital.

To be sure, a hospital experience can be daunting, especially these days when procedures such as episiotomies and enemas, IV hookups, and fetal monitors are routine. So are C-sections, once seen as a last resort, now performed with increasing regularity.

“The picture of birth in America today is startling,” says Jo Anne P. Davis, a certified nurse midwife and an assistant professor and midwifery tutor at Georgetown University School of Nursing. “One in three women are being surgically delivered. The maternal mortality rate has experienced a slight rise in the last decade, and the premature rate is going up.”

Yet Ms. Davis notes that the atmosphere around home births has changed as professional medical organizations “ratchet up” the rhetoric against birthing at home.

“The connection between home and hospital should be seamless,” she says. “There should be a flexible network of care that adjusts to women’s needs.”

Having babies in the hospital was not the choice for most women as recently as 70 years ago, notes Judith W. Leavitt, a professor of medical history at the University of Wisconsin and author of “Make Room for Daddy: The Journey From Waiting Room to Birthing Room.”

According to Ms. Leavitt, as late as 1938, only about half of American births took place in a hospital. Before 1920, only about 5 percent did. By 1955, fully 95 percent of Americans were being born in a hospital.

What moved women into the hospital, and made the hospital birth experience routine, Ms. Leavitt says, was safety, along with the availability of medicines and procedures not accessible to the midwives of the time. Today, she notes, many home birth advocates opt out of the hospital because there is “too much medicine.”

MAMAS and many other area midwife services are staffed by certified nurse midwives, who boast both a nursing degree and a certificate awarded after rigorous training and coursework in midwifery. Midwife certification is provided by the American College of Nurse Midwives and the North American Registry of Midwives, although practices and credentialing can differ from state to state. Not all midwives have a nursing degree, and some may undergo only a period of apprenticeship or self-study.

The type of training a midwife receives determines what she can do if complications arise during a birth. Certified nurse midwives come to the home with a veritable toolbox of equipment, including drugs, which they are authorized to administer if need be.

“All the equipment you would find at a birthing center, we bring with us,” Ms. Bailes says.

You also can expect to find certified nurse midwives in a variety of settings other than the home, including birthing centers, which function as a sort of middle ground between home and hospital, as well as hospital delivery rooms themselves.

For Emily Scherer, a physician’s assistant who works in an area hospital, a home birth was a more natural experience than the ones she had seen in the delivery room during her labor and delivery rotation.

“I was convinced that that was not how I wanted my baby to be born,” she says.

Like many Washington area women who choose to give birth at home, Ms. Scherer had two midwives and a “birthing attendant,” in this case also a midwife, present during her labor. Despite the fact that her labor was “off and on for three days,” and the reality of it all happening in a small Washington row house, three extra people in the bedroom seemed, well, “natural.”

Both Ms. Hirsch and Ms. Scherer ended up with healthy babies and a very positive birthing experience. Many physicians remain cautious, however.

“Sometimes a low-risk pregnancy can turn into a high-risk situation in very little time,” says Dr. Erin Tracy, an OB-GYN at Massachusetts General Hospital who is ACOG’s delegate to the AMA. “There are simply not the same resources at home.”

Dr. Tracy notes that 1 in 200 women are suddenly confronted with shoulder dystocia during delivery, a complication where the baby’s shoulder fails to deliver after the head because it is obstructed by the mother’s pelvis. And she says that the increasing number of C-sections can be linked to an older and more obese population of pregnant women, as well as the increased number of multiples.

“I’m a fan of natural childbirth so long as it’s safe,” she says. “But if you’re at home, there’s always the chance that something is going to go awry.”

Physicians also question the data that touts the relative safety of home birth, noting the small size of the samples and the fact that because the home birth population is self-selecting, it may already include factors that make home delivery safer.

For home birth advocates though, studies are only part of the story. So is the relative expense — home births typically are less expensive than a hospital delivery, although insurance companies often won’t cover as much of the cost.

“By the end of the process we were wishing that all medical professionals would be like the midwives,” says Aaron Hirsch, Angela’s husband. “How many times have you gotten a hug from a medical professional?”

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