Where's a Baby to Be Born? A Midwife's PerspectiveBy Jennifer Hess, CNM


A precious new baby is on the way. Preparations of all kinds are made. Anticipation runs high. Whom will she resemble? Will he be an athlete like Mom, artistic like Dad?

Parenthood brings unimaginable joys and challenges. Among these is the responsibility to make myriad decisions on behalf of this little being that may have, variously, minor to far reaching implications. Cloth or disposable? Breast, bottle, or both? Family bed or separate sleeping? Vaccinations: now, later, never? And the list goes on. Each child and family are unique and we are indeed fortunate to live in a time of many options.

One of the first decisions parents make for their child is the location and circumstance of his birth.

Most adults in our society grow up with the idea that birth is an event that takes place in a hospital. Few parents about to welcome their first child have seen a baby born. Most have heard stories of great pain and of unpredictable emergencies resolved with the assistance of doctors, medicines and machines. Fear understandably runs high. New parents have faith that the hospital's labor and delivery unit will protect mother and child, providing the best outcome possible in this perilous undertaking. Their physician, thoroughly trained to anticipate disaster, assures them this is true.

Expectant parents in several other western nations, Great Britain, the Netherlands, and Belgium among them, grow up with the experience of birth commonly taking place at home. Chances are good that they arrive on the threshold of labor having witnessed the birth of one or more siblings, or recall that they played contentedly in the company of a close adult relative as their mother gave birth in another room of their home. Perhaps they recall the hard physical work their mother performed to bring forth the new baby, the sounds of her labor, and the family gathering close in the parents' bed immediately after the birth to welcome their newest member.

homebirth hospital home birth

They anticipate their labor will require much effort, that all will proceed successfully without the need for intervention, and that their midwife, an expert in normal birth, will be in watchful attendance.

Different cultural experiences, to be sure. But what of the outcomes - the simple numeric facts of how mothers and infants fare in these different scenarios? Childbirth comprises 1/5 of all healthcare expenditures in our country and the U.S. spends more per birth than any other country. Surely we Americans, with our technological prowess and our specialists at the ready have succeeded in making birth safer.

The fact is that the U.S. ranks 19thamong the nations of the world in terms of maternal-infant morbidity and mortality, i.e.: adverse outcomes and death related to pregnancy and birth.

Those nations with the most favorable statistical outcomes are those in which midwives attend the majority of pregnant and laboring women, and birth commonly takes place outside the hospital.

Studies have demonstrated that continuous fetal heart-rate monitoring, routinely used in U.S. hospitals, has not improved outcomes in normal labors but has served to double the cesarean rate, which now stands at over 20% nationwide. Some type of surgical intervention, such as forceps, vacuum delivery, episiotomy, or cesarean section are utilized in fully 50% of births in U.S. hospitals.

"Impressive (even scary) statistics," an expectant couple may think, "but what about the PAIN?" The anticipation of pain may frighten them more than statistics, which most of us believe apply to someone else. We all know labor is painful - enormously so, according to many. The hospital offers safe and reliable relief - and why, after all, should women suffer in this modern day and age?

In fact, medications and anesthesia produce measurable effects on infants as well as mothers. Neither is without risk. The subject of anesthesia could be an entire article in itself.

Expectant parents are encouraged to thoroughly investigate the implications of utilizing pain relieving medications and to familiarize themselves with other, highly effective means of managing the pain of labor.

Immersion in warm water, the continuous presence of loving, familiar support persons, the freedom to eat, drink and move about as desired, a calm and quiet atmosphere, massage, acupressure, and steadfast encouragement all play an enormous part in labors where women successfully give birth without medication.

Such success is the norm in home births and birth centers, while hospitals commonly have epidural rates of 50-90%, greatly increasing the chance of other necessary interventions, including Pitocin augmentation of labor, and instrumental or cesarean delivery.

Apart from outcome statistics, what are the experiential differences and considerations which factor into a choice between hospital, birth center, and home births?

Some differences are obvious: to give birth at a hospital or birth center the parents must travel to a location that is not their familiar personal space. Home is home - usually a comfortable, private, safe haven. Depending on individual circumstances, home could also be cramped, lacking in privacy, or too distant from emergency services.

In the event of transfer to the hospital from a home birth, it is common to encounter a hostile attitude from on-call hospital staff, who feel burdened and additionally liable for a patient with whom they are unfamiliar and in whose care they have not participated prior to the transfer.

A hospital will have many routine procedures which may be uncomfortable, of questionable value, and which contribute to a sense of powerlessness.

Parents may not be informed of, nor given choices about, routine procedures performed on the newborn. Parents may have little say in how their baby is handled or whether they are separated from their infant. Both mother and infant may be exposed to a vast array of pathogenic organisms they would not have encountered elsewhere.

A birth center will afford much the same freedom from routine interventions as home, while also having a clear and philosophically concordant backup arrangement in the event medical assistance is required. The stay after birth is typically six hours. Most parents feel ready to leave sooner, yet some report fatigue or trepidation about caring for their infant on their own so soon after birth.

Most notably, differences in home, hospital and birth center births relate to the over-all sense of participation and accomplishment with which families recall their birth experiences. Following a hospital birth, it is common to hear such comments as, "I never could have done it without that epidural," and, "My doctor did a great job." A more common exclamation following an out of hospital birth is, "wow-- look what I did!" or "that was harder than I expected, but I wouldn't have done it any other way."

In an ideal world, our healthcare system would provide for complete support for midwife attended home birth and easy access to medical backup for all birthing families. Since this is not the reality here, research and self-education are essential to making an informed decision about the complex topic of birth location.

Much information and many considerations stand before parents as they make their choice of where their child will be born. Hospital, birth center, or home: which is right for them? For their baby? If they have already chosen a care provider, are all three options available to them? If not, do they wish to find a new provider? How will insurance coverage influence their choice? How will their personal and family birth histories factor into their decision?

Consider all questions, examine all assumptions, and gather as much information as possible. In the end, trust your heart to lead you to the best choice for you, for this baby, at this time.

May your birth be blessed.

Jennifer Hess is a certified nurse-midwife who has served as the primary midwife at more than 1,000 births, both within and outside of the hospital. She is a partner in Motherwell Midwifery and attends births at home and at The Birth Home, a freestanding birth center in Pleasanton California.

Local midwives make a presentation on birth options and alternatives quarterly at The Nurture Center. See Classes for more details.
The birth tub pictured above is available for rent within the continental United States. For more information, see the Birth tub page