SAUSALITO, CA (ASRN.ORG) -- When Kelly Brown gave birth three years ago, she labored for 22 hours, much of the time hooked up to an IV line that restricted her movement. Repeatedly offered pain medication she did not want, she narrowly avoided getting a Caesarean section.
“I decided I would never have another baby in a hospital,” said Ms. Brown, 33 of Warrenton, Va., who manages a Web site for a private school.
Five months ago she gave birth to her next child at home, attended by a midwife and surrounded by family. She walked, ate and drank as she wished, and pushed out the baby underwater in a labor tub set up in her own bedroom.
“Everything was so low-key and so comfortable, it was amazing,” Ms. Brown said.
A small but growing number of American women are making the choice to deliver at home. From 2004 to 2008, the number of home births in the United States inched upward to 28,357 — still less than 1 percent of the 4.2 million births each year, but a marked reversal in what had been a long trend toward hospital births.
Home births are less expensive than hospital births, but insurance policies do not always cover them and out-of-pocket costs can be higher. Still, money is not usually the factor driving the decision to avoid the delivery room.
Torrie Trautman, 27, and her fiancé, Kyle Birkemeier, 33, will save money when their baby is born at their home in Tempe, Ariz., but their main motive is to assure a natural and “calm” childbirth.
“We’re not against medicine,” Ms. Trautman said. “But we have a lot of friends who go in to do a natural birth at the hospital, and end up getting all the things they didn’t want, and maybe a Caesarean, too.”
For most women, the first concern is safety. Several leading medical organizations, like the American College of Obstetricians and Gynecologists, have warned repeatedly that the safest place to deliver a baby is in a hospital or birthing center.
In a paper published in The American Journal of Obstetrics & Gynecology last year, researchers concluded that babies born at home are three times as likely as those born in a hospital to die before they are four weeks old. But the finding ignited a firestorm among experts and has been roundly questioned by critics.
One of the chief criticisms of the paper, which was a meta-analysis of previously published work, was that it seemed to have lumped together the outcomes of planned home births and much more dangerous unplanned home births, said Dr. Eileen K. Hutton, director of the midwifery education program at McMaster University in Hamilton, Ontario.
Unplanned home births cover a range of situations, like births to young women hiding a pregnancy, those who did not have insurance and have not received prenatal care, and those who go into labor unexpectedly.
Dr. Hutton’s own studies have compared the outcomes of planned hospital births to low-risk women and planned home births to low-risk women who were attended by the same midwives. That research found no differences in babies’ survival.
Dr. William Barth, chief of the division of maternal-fetal medicine at Massachusetts General Hospital and the immediate past chairman of ACOG’s committee on obstetric practice, said that in either setting the risk of a baby dying is small. Even the controversial meta-analysis calculated a death rate of 1.5 per 1,000 home births, compared with 0.4 per 1,000 hospital births.
But he noted that complications can develop suddenly in the course of labor and childbirth.
While the medical establishment and home birth advocates may be at odds on some issues, they agree on some advice for women considering home births.
THE RIGHT CIRCUMSTANCES Only women who are having smooth, uncomplicated pregnancies that go to term and who are free of diabetes, hyptertension and other obstetric complications should consider a home birth, experts say.
They should be carrying singletons, not twins, and the baby should be in the proper position, not a breech presentation. Both ACOG and the American College of Nurse Midwives agree that women who want to try to have a vaginal delivery after having had a first baby by Caesarean section (known as a VBAC) should be in the hospital.
PROPER ASSISTANCE Hire a skilled, licensed midwife, preferably a certified nurse midwife or certified midwife who has a relationship with an obstetrician and a hospital. Certified nurse midwives are licensed in all 50 states, though restrictions vary from state to state. Certified midwives have the identical training and education, but the certification is newer, and not all states have included them in the regulations.
Medicaid reimbursement for certified midwives is mandatory in all states; for patients without insurance, midwives will often agree to work out an installment or other payment plan for patients. The midwife’s fee typically includes prenatal care and the delivery, as well as a head-to-toe exam of the baby after birth and postpartum care to six weeks or even six months. (Cleanup after the birth is also often included.)
NECESSARY EQUIPMENT Patients are often responsible for purchasing a birthing kit, which includes such items as plastic sheets, disposable underpads, menstrual pads, a tape measure to measure the baby and a thermometer. Many will also rent a birthing tub with a disposable liner that can be set up in the home. Midwives bring their own tools and equipment that can be used to resuscitate the baby. The midwife or the patient is responsible for supplying an oxygen tank.
AN EMERGENCY PLAN Since complications can arise, there should be a plan in place for safe, quick transportation to a nearby hospital in case of an emergency. First-time mothers are more likely to need to be transferred to a hospital than women who have had a vaginal birth before.
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Charles L. Berman
Liz Di Bernardo