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Home Birth vs. Hospital Birth - Issues of Responsibility

Looking for The Lactivist? She's retired. But you CAN still find Jen blogging. These days, she's runs A Flexible Life. Join her for life, recipes, projects and the occasional rant.

Wednesday, March 08, 2006

Well, the pundits have spoken and thus far, they've all been in favor of the Lactivist branching out to include some information on home birth, so here we go! :)

One of the discussion forums that I frequent to talk about childbirth issues had a great thread recently about the issue of home birth verses hospital birth in regards to how mothers are viewed in the case of a poor outcome.

While every legitimate study ever done has shown that home birth with a qualified attendant for a low-risk mother is absolutely as safe as a hopsital birth (and in fact, safer in terms of morbidity), American culture still has an air of "danger" that it associates with home birth.

While I've been surprised at the support I've received from friends and family so far over our family's plan for a home birth, I've still heard the requisite "I just don't think I could be brave enough to do that..." and "I'd just worry that something would go wrong." We all know that both of these translate into "Do what you want, but sounds to me like you are taking risks with your baby's health."

Now in these cases, it doesn't matter what types of data or stats you throw at people, they still have a hard time realizing the reality of the safety of home birth. This is usually compiled by the stories of horrible things that can go wrong in birth. "My baby was born limp and not breathing" or "After they broke my water, the baby's heartrate dropped way off and I had to have an emergency c-section."

Now, I'll address the truth behing some of that in a future post and will explain the concept of iatrogenic problems then as well....what I want to hit right now is this...

Why is it that if a mom gives birth at home and something catastrophic DOES happen (let's say complete placental abruption) that results in the death of mom or baby, society is fairly quick to place the blame and guilt on the mother for her "poor choice." Let's not even consider the fact that complete placental abruption has a pretty hefty mortality rate even if you are in the hospital...

However, if a mom gives birth at the hospital and something happens (let's say failed induction and AROM resulting in prolapsed cord, deprivation of oxygen and ultimate brain damage despite an emergency c-section) it's either the fault of the Dr. or the fault of "no one."

Anyone know why that is? Anyone disagree with me? Do people find comfort in the hospital because they can "shift the blame" if something horrible does happen? Why are we so quick to blame a mom for her choices in a home birth but so quick to excuse the mom in the hospital that didn't take the time to educate herself about the risks associated with procedures. Is it because it's not supposed to be her job? It's supposed to be the Dr's job? That gives her an out?

Now let me state...the loss or injury of a child is tragic and horrible in either situation...I'm just trying to understand why society puts these different spins on the same outcome simply because of location.


  1. Blogger K | 10:16 AM |  

    Gulp. I'm one of those who is not brave enough for a home birth but hate the idea of having another hospital birth. And honestly my own fear is in no way a judgment against moms who choose home birth. Indeed, I am more envious than anything.

    As a recovering lawyer I am still very risk adverse. So I want the doctors and equipment available should something go wrong.

    My dream birth scenario -- a birthing center where unnecessary interventions are discouraged BIGTIME but are nonetheless available if there is real distress (not the routine distress that makes litigation fearful docs and hospitals take a intervention-happy approach hoping to ward off lawsuits).

    Jenn -- this will be an interesting discussion! Thanks for taking it on.

  2. Blogger Jennifer | 1:02 PM |  

    Ahh yes, that lawyer in you coming out. :) I totally get that...I totally get the risk averse too, because that's where I was.

    "gee, that'd be nice, but what if X happens."

    Here are the three things that made me change my mind...just to see if they have an impact on you...

    1.) Most of what we think of as going "wrong" in labor are actually caused by the routine interventions that happen in a hospital. Epidurals cause a drop in blood pressure, contribute to inability to push or to malposition for pushing, etc... Narcotics cause floppy babies that have trouble breathing... inductions causing stress on the baby and so on.

    Reading the Thinking Woman's Guide to a Better Birth and really learning about the Pros and Cons and the direct correlations of interventions made me see that if left alone, there aren't many things that do go wrong.

    2.) Continual monitoring by an actual human being. The beauty of a home birth with a skilled midwife is that even if something goes wrong, you're likely going to find out sooner than you would in a hospital. When I was in the hospital, I saw a nurse about every hour or two, other than that, I was on my own. That was fine with me, but it also meant that if something had started going wrong, it wouldn't have been picked up until that next nurses visit.

    Because a midwife can pick things up more quickly, you tend to be able to get to the hospital and get treated as quickly as you would have if you had been in the hospital in the first place.

    3.) The few things that go catastrophically wrong and that do so quickly have such high mortality rates anyway that your chances of survivial are not that much greater in a hospital. Things like full placental abruption, catastrophic hemmorage, etc... Those are very, very rare, whether at home or in the hospital and even more rare for low-risk healthy moms.

    Once I realized those three things and realized that at home, I'd have more control and less chance of things going wrong because we interfeared, I realized that that was the best choice for me. Thankfully I have a husband that's 100% on board with this and I've found a midwife that I really trust.

    I think that's the key too. I would take a Dr. that I don't trust in a hospital over a midwife that I don't trust at home any day. Mostly because in a hospital, even if a Dr. screws up, things can usually be fixed. The key is just to have a good midwife that won't screw things up. ;)

  3. Blogger Judy | 7:25 PM |  

    Most Americans have been raised to trust the medical model. Medical=scientific=true for most people. Artificial medicine is beneficial just like the sky is blue. It simply is not questioned. I told my sister that I was going to a chiropractor for the arthritis in my neck. She suggested I go to a "real" doctor, who would have given me pain killers or muscle relaxers and said to live with it, instead of actually fixing the alignment of my vertebrae that caused the problem.

    The medical model is based on Naturalism and humanism, while looking for more natural methods trusts that God created the universe and that he knew what he was doing when he did it.

    I think people feel comfort by being around fancy machines they do not understand and trained medical professionals they see as being way smarter than them. Contrast that with your cat jumping on you while you're pushing or ruining your comforter with afterbirth. (I know this ain't legit, but I think people think like this.) People also see it as a step back. People's great grandparents had kids at home in the dark ages.

  4. Blogger Amanda | 7:34 AM |  

    I had the wonderful care of a CNM and water immersion birth with #2. SO, becasue I wanted to have that personal care, and was too afraid to have a home birth, I did it in the hospital.
    You raise interesting points. Whose fault is it that with my transverse lay #3, that we were eventually able to manually turn (on the 2nd try, the first time he returned to transverse), and the induction that I consented to ended up in a prolapsed cord at 5cm, and an emergency section. My midwife's? Mine? The OB who performed the external version, and OK'd my induction? If I hadn't been induced, but the version was successful and I waited out the last 2 weeks to go into labor on my own, would anything have been different? Maybe, maybe not. Interesting to play those events out in the light of a home birth, or even just waiting to go to the hospital in labor. My midwife I had total trust in, and she could hav enever know the prolapse would happen so late into active labor.We knew it was a risk early in labor, as the baby was still pretty high, but had not expected it after he dropped, I was 5cm, and contractions were 90 seconds apart. They were wheeling in the tub, the cord was discovered at my last check before I was going to get in the water. Maybe it still would have happened, maybe not, but is anyone at fault? What if it had happened at home, would it be my fault then? Interesting...

  5. Anonymous Anonymous | 1:40 PM |  

    I have not read enough of the site to know if you've ever had an Ob Gyn post here, but I thought this discussion was interesting and balanced, and wanted to weigh in. One thing I completely agree with here is the idea that increased inductions and increased interventions can lead to problems with labor and delivery. The induction questions is another discussion entirely. However, the idea of "risk" and "blame" and how that plays into what happens to a typical woman in labor is intriguing to me. As a practicing Ob, I confess that there are certainly times where decisions are made, by myself and my colleagues, based on "how would this play out in court if something bad happens?" It is unfortunate, b/c as you all have so astutely pointed out, LABOR IS A NATURAL PROCESS, and pregnancy is not a disease! I had an attending physician when I was a resident who said that 90% (and maybe this is actually higher) of women could deliver their babies with no one around--it's only the other 10% that OBs are there for. Now because I have been privy to that other 10% so many times, I could never do a home delivery myself--I would simply be too stressed out.

    But, I cannot believe that you can't find doctors who will help take care of you if you are planning a home birth! I have done this several times for women in my community, and most times they have gone on to deliver healthy babies at home with their midwives. I have taken care of Amish women after their transfer to the hospital from lay midwives, and I have admitted patients with postpartum complications, but that is the exception rather than the norm, I think. I haven't checked with my malpractice provider, but if that is the motivating factor, I can't believe that denying care is a safer bet than helping to care for a patient who simply wants to deliver elsewhere! I'm appalled at that.

  6. Blogger Jennifer | 1:57 PM |  

    Welcome to the Lactivist Mystery OB. ;) Very glad to see you here and weighing in on the debate.

    I'd also like to personally thank you for being willing to serve as a backup to women planning a home birth. You have no idea how few and far between doctors like you are. You do a service to ALL women by taking on that type of care.

    I have since found ONE doctor in the entire metro area (about 1.5 million people) that is willing to do tandem care. I've decided at this point that I don't need it, as my midwife is doing an excellent job and I've stayed low-risk. That said, had I ended up with a stubborn breech, or PIH or something else that elevated me to a high risk status, it was good to know that I could call him and transfer my care.

    I completely understand and respect the limits placed on OBs by the med-mal industry...and I can imagine how frustrating those must be for most OBs. It's got to be a hard industry to be in right now and the amount of mother's that expect their doctors to be God and to deliver a perfect baby "no matter what" must be an enormous amount of pressure. I just wish that there was a way for all of us to work together to better the situation.

    OBs should not be forced by med-mal carriers to deny care to women planning home births, or to automatically c-section any baby that is breech...simply due to what will hold up in court. At the same time, women should be given honest information by their OBs and not fed a line of bull designed to make them comply with the med-mal line of care.

    It's a tough line to walk with no easy answer.

  7. Blogger Ethel | 5:28 PM |  

    I wonder if the "I wouldn't be brave enough" comments could also be referring to the fears of trying something new (for most of us)? I mean, a homebirth is something most women can't ask friends or family about. Not only that, but they have to deal with the fears that well-meaning but ignorant friends and family will raise over the decision. That lack of support is scary.

  8. Blogger karmamama | 8:56 PM |  

    Three months ago, I attempted a home vbac. After my baby's heartrate dipped the second time, my midwife wanted to transfer. I did. We had already agreed that she would not accompany me to the hospital should a transfer become necessary, but I knew that my doula would go. I also knew that a transfer meant a cesarean.
    When we got there, I asked for a cesarean but all the staff seemed to care about was the name of my midwife which we refused to divulge. They said everything was fine and I should be able to birth this baby. I thought I was going crazy and was begging for a cesarean but was in active labor and had been pushing for two hours by the time I got to the hospital. I didn't really know exactly why I was there and I'm not sure what the doula told them but they wouldn't listen to any of us, including my husband.
    I accepted an epidural because I wasn't progressing and was confused. This took two hours to receive. Then, about two hours later a nurse came running in saying that she couldn't hear the baby's heartrate. That's when they did an ultrasound and found the baby had died. They told us that they thought they were hearing the baby's heartrate but that it had been mine the whole four hours we were there waiting.
    During my cesarean they found that I had a posterier rupture, which I believe happened while I was under the epidural.
    The point of me sharing my nightmare here is to address the idea of the mother being blamed. Many people in my family have been unsupportive or minorly supportive during my recovery and in my grieving because they are angry about my choice to homebirth even though my baby died in the hospital. When I left my home, her heartrate was back up.
    I've experienced the trauma of losing my child, the trauma of being neglected at the hospital and the trauma of being blamed by my family for my daughter's death.

  9. Blogger Jennifer Laycock | 10:50 AM |  

    Oh KarmaMama, I am SO sorry to hear this!

    I can't even imagine how the pain of this loss would be compounded by the insensitivity of the people who have no idea what they're talking about.

    I'm not the litigious type, but I certainly hope you are considering a malpractice suit against this hospital.

  10. Anonymous Anonymous | 6:26 PM |  

    This is such an interesting article I just wanted to share my experience - apologies, this will be long winded as I don't do 'brief'.

    I am deeply sorry for KarmaMama's experience and loss. Sometimes I feel rather guilty about the incredibly good experience we had with my son's birth, but want to share this so others know these things are possible.

    I believe wherever you choose to birth you should have access to the best care and support for your choices. I live in NZ. I come from the UK where homebirths are not given much support and are discouraged for first pregnancies. I am lucky to live now in Christchurch where there is a superb homebirth midwives group with an enormous amount of experience between them. The agreement with this group is that you aim for a homebirth as this is the safest place to be, unless you need to transfer to hospital, in which case they go with you and ensure you get as close as possible to a 'homebirth' in hospital.

    Parents prepare a birthing plan expressing their wishes for their baby's birth and the midwife ensures the Registrar and hospital staff have read and understood this. Essentially your midwife defends you from unwanted intervention but ensures you get the care you need and ensures parents stay informed throughout.

    I was lucky to have a wonderful pregnancy with visits from my primary midwife and second midwife monthly, then fortnightly, then weekly leading up to the birth. My midwives knew me and my partner, the full history of the pregnancy, my state of mind, my home and so on. My son decided not to be born until the 43rd week, but apart from talking through induction options, as baby and I were healthy, there was no pressure.

    We had the hire of a birthing pool if we needed it to help ease the process - in fact I stayed in it throughout the final stages with my partner in too holding me and my son was born underwater into my midwife and partner's hands - an incredibly beautiful experience.

    Many people have talked about coping with the pain. Previously this scared me - I can say now, with total conviction, this is something your body is built to deal with and deal with well, if you are given support, good techniques for managing it and lots of extremely hot towels. Yes, hot towels seriously do work. Yes it is hard work and sometimes you will doubt your ability to do it, but pain in a good cause is OK - I believe now that feeling pain is OK, being numb is not!

    And above all this, beyond having a healthy baby without any other drugs going through his body than some great hormones, I feel empowered by what I accomplished. My antenatal group friends all said the same thing - "If I can do this (and I did), then I can do anything".

    We went from the birthing pool in our living room into bed in our bedroom with our little boy. Our support team (2 friends and 2 midwives) cleaned the house, did the washing and, after a sleep, our friends did the shopping!

    Several of my friends from this group ended up birthing in hospital. Almost all of them still experienced a positive and close-to-homebirth process because their two midwives were with them, to protect and support them. Those that had more drastic interventions did so because that was what was needed - I think they felt some depression that it hadn't been the birth of their dreams, but they recognised the need for the intervention in their case and received incredible care from their midwives and hospital staff.

    In Christchurch NZ, the tools that midwives have to hand is the same as those available to midwives in birthing centres. If we needed to go into hospital, it takes about 10 mins. That is less than the time it would take to queue to get into the operating theatre, even if we were already in hospital. Plus, after birth in the maternity unit here, women and babies must leave after 2 hours.

    Sorry to ramble on, but from my experience, the most important thing is to have the consistent ongoing support of experienced midwives you have come to know, throughout the pregnancy and birth and afterwards during your recovery. Second is to have the support of friends and family so that you can abandon all else but recovering and bonding with your baby. It hurts to think that you cannot get this in the US and the UK in many states, to give birth where you feel safest and in the manner that you decide.

    To be made fearful of birth and to be blamed for your informed choices is totally crap in my opinion. To be forced into hospital births or a cycle of intervention is destructive to everyone involved and counter-productive: surely it produces an increasingly dependent and fearful population.

    To be helped to recognise your innate strengths and to be supported to birth and bond to the best possible degree with your child for the benefit of your family and your community is surely the aim. That sounds a bit 'happy-clappy' and I'm not a hippy, but I can't find another way to express the incredible benefits of positive birthing experiences.

    KarmaMama - I hope you and your partner can find peace and joy and your friends and family come to their senses, stop judging and simply start loving you for being brave and courageous people.

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