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Homebirth vs hospital birth for the number cruncher

I’m a hard number cruncher. But there are major limitations if you are going to rely solely on case controlled studies to decide between home and hospital birth. There are so many variables and nuances that haven’t been “number crunched” to that extent but make a HUGE difference in the how your birth progresses and the ultimate outcome. For example does your labor slow down, or even stop, or do you experience reverse dilation when:

  • you transfer to the hospital
  • you put on a hospital gown
  • the nurse puts an IV in your arm
  • the fetal monitor requires constant readjustment
  • people you don’t know perform vaginal exams on you
  • people you don’t know see you naked
  • all your privacy disappears
  • nurses wait outside the door as you use the restroom
  • you are limited to laboring in bed
  • you have to fight to decline procedures
  • you are put on a timeline saying that if you don’t have the baby by X o’clock, you will have a cesarean
  • you are told if you don’t “progress” at 1 cm/hr, you will have a cesarean
  • you are in a place that feels unsafe

All of these things play into the stress of hospital birth. I think this plays a huge role in the “failure to progress” diagnosis. Of course women aren’t “progressing” in the hospital, it’s not a calm, peaceful place to give birth especially when women are put on timelines. To be told that if you don’t make ABC progress by X o’clock or you will have a cesarean is very stressful.

Judith A. Lothian, RN, PhD, LCCE, FACCE in Do Not Disturb: The Importance of Privacy in Labor says:

Women choose to give birth in hospitals because they believe it is “safer” than birth outside the hospital. In fact, laboring and giving birth in most hospitals create a set of physiologic responses that actually occur when we feel unsafe and unprotected. In the typical hospital environment, women are disturbed at every turn—with machines, intrusions, strangers, and a pervasive lack of privacy. The shadow of “things going terribly wrong at any moment” follows women from one contraction to another. Together, these fears contribute in powerful ways to the release of stress hormones, moving women into an attitude of physiologic fight or flight. On an intellectual level, a woman may believe that the hospital is a safe, protected environment, but her body reacts quite differently. No matter what her head says, her body gets the message loud and clear. Her body responds on a primal, intuitive level, kicking automatically into fight-or-flight mode and dramatically altering the process of labor and birth. In choosing modern medical “safety,” women are stressed physiologically, which makes labor and birth more difficult. The lack of attention to women’s inherent need to not be disturbed in the typical hospital environment has set the stage for an almost 27% cesarean rate, the routine use of epidurals in labor, the high rates of augmentation of labor, and the high incidence of instrument deliveries in the United States.

When women are in the hospital and their contractions slow down or stop, they are often given drugs, such as Pitocin, to start it back up.  This is called augmenting labor and comes with a variety of risks including hyperstimulation of the uterus, uterine rupture, amniotic fluid embolism, post-partum hemorrhage, cesarean section, fetal distress, and the very worse, yet thankfully rare risk of infant or maternal death.  Unfortunately, many women are not aware of the risks of augmentation.  They are just told that this will help their uterus work better.

I think one risk of hospital birth is experiencing an otherwise avoidable repeat cesarean. I think three important questions to ask are:

1. Do hospital mandated procedures, policies, and timelines interfere with the progression of labor resulting in an otherwise avoidable “failure to progress” repeat cesarean?

The answer to this question could be a whole book. I think Judith Lothian’s article Do Not Disturb: The Importance of Privacy in Labor nods possibly yes by examining the impact of the lack of privacy available in the hospital setting. Books like “Gentle Birth, Gentle Mothering,” “Born in the USA” and movies like “The Business of Being Born” touch on this question as well. The bottom line is, 99% of women give birth in the hospital and 92% of women have repeat cesareans (Martin, 2009).  Many women feel like the only way they will have a successful VBAC is to do it out of the hospital which comes with its own risks.

2. Are women more likely to need the advanced emergency equipment available at the hospital because in addition to naturally occurring unavoidable complications, they are at an increased risk for otherwise preventable compilations resulting from cascading interventions?

In other words, are OBs and hospital based nurses more likely to perform frequent vaginal exams, because they have the medications and facilities to perform an “emergency” cesarean if an infection does develop? Are OBs more likely to perform episiotomies, even though women who have had episiotomies are more likely to tear into their rectum (4th degree tear) (Jandér 2001, Klein 1994, Signorello 2000), because they have the skill set to suture that severe of a tear?

And are women aware that frequent vaginal exams, especially once their water has broken, are linked to higher infection rates or that they are more likely to tear into their rectum if they have an episiotomy? Or are they just thankful that they were in the hospital so when the infection developed or the tear occurred, they had access to advanced medical techniques?

3. How does fighting your way through labor with an OB who is not supportive of vaginal birth impact the progression of labor, if at all?

There are OBs who will patiently wait for labor to unfold provided that mother and baby are OK. Most recently, a doctor at Good Samaritan in Downtown LA, attended a woman in labor who was at 8cm for over 8 hours. Many OBs (the majority?) would have diagnosis a “failure to progress” and recommended/required a cesarean. Counter that with the hospital-based birth stories featured in VBACing Against the Odds and Hospital VBAC turned CS due to constant scare tactics.  There are also wonderfully positive hospital births like The Birth Story of James Liam.  How your labor plays out depends greatly on your care provider’s personal birth philosophy and your hospital’s standards and policy.

Let’s now look at the primary risk of home birth which, in my opinion, is experiencing a 3% chance of a complication (Johnson 2005) that is outside your midwife’s scope of practice or training and requires emergency transfer to the hospital. The primary question here is:

1. Does your midwife have the knowledge and skill set that will enable her to quickly diagnose complications, such as uterine rupture, placental abruption, umbilical cord prolapse, placenta previa, severe post partum hemorrhage, and coordinate rapid hospital transfer?

I talk about this more in the article, I’m pregnant and want a VBAC, what do I do?:

The most important thing when interviewing midwives is experience. You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.) I am a full supporter of non-nurse midwives, but please do your homework. If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.

Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees. You and your baby’s well being should come well before her possible discomfort. In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.

It’s important to note that some complications can be handled safely at home. I had a home birth and I did have a complication – a post-partum hemorrhage (PPH), which is the leading cause of maternal mortality in the USA. I was fine and my baby was fine. (This article from eMedicine discusses PPH at length including hospital protocol.) I’m glad I was home, but my story might have ended very different if my midwife didn’t have Pitocin and Methergin and was able to act quickly. This is a testament to hiring a good, experienced midwife and ensuring that they have drugs to manage PPH. I was the statistic and I had a good outcome.

It’s also important to note that sometimes complications cannot be managed at home and without immediate access to drugs, surgery, or blood products there could be dire consequences. Here is one mom’s story of placental abruption at home.  She survived, her baby girl Aquila did not.  Her midwife was a CPM who had attended less than 150 births.  Her midwife did not recognize the symptoms and they did not get to the hospital in time.  This illustrates how important it is to hire a qualified care provider when you are birthing at home.

People talk about trusting birth.  I think “respect birth” is a better phrase.  I trusted the skills of my midwife to diagnosis my PPH and I trusted those drugs to make my bleeding stop quickly when birth veered off course.  Complications do happen at home and when interviewing a homebirth midwife, I suggest asking her how she handles complications as well as hospital transfers. (Read more about home birth here: Why Homebirth?)

Conventional wisdom states, if you are at home and a problem happens, you are out of luck… but that if you are in the hospital, everything will be ok. The truth is, there are real risks to each location.

Women plan home births because they wish to avoid the stress, pressure, and hospital policies which will almost certainly put them in that 92% repeat cesarean category. Here are some examples that illustrate the struggles women endure in the hospital:

This woman had to engage the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women because her OB group, who said they would support her plans of a VBA2C, withdrew support at 37 weeks giving this mom few options. With the quick help of these legal organizations, this mom was able to have a trial of labor.

This woman managed to VBAC at a hospital despite lies, lies, and more lies and only because she was willing and able to fight her entire labor.

This woman wanted to VBAC at a hospital, but after many lies from her OB, she consented to a repeat cesarean, which virtually guarantees her cesareans in the future unless she has a home birth or manages to find one of the handful of OBs who attend VBA2C in a hospital.

This woman had a scheduled repeat cesarean under the advice of her OB only to have a hysterectomy due to complications from the surgery. No more kids for her. Very sad.

This woman had a scheduled repeat cesarean under the advice of her OB, only to realize that recovering from elective major abdominal surgery while caring for multiple children is the pits and regretting that decision.

This woman had a scheduled repeat cesarean under the advice of her OB, only to have her baby born to early. Her baby had respiratory problems and spent 10 days in the neonatal intensive care unit.

This woman had a cesarean because she was pregnant with triplets. She experienced complications and died. She left five young children for her husband to raise.

How about all the women who can’t get private medical insurance because they have had a cesarean?

How about the women who have cesareans for reasons other than the health of the baby or mom?

Or all the moms who aren’t even given a chance to VBAC because they are outright lied to and told that VBAC is illegal in their city, county, or state?

Or the moms who think all they have to do is find a hospital that “allows” VBAC and they will be successful?

There are real risks to hospital and home birth.

It is unfortunate that so many OBs and hospitals are not supportive of VBAC because they are forcing women to either choose an unnecessary repeat cesarean or pushing them into home birth which comes with its own set of risks.  This is not an easy question to answer.  It is important when choosing your birth location, that you understand the risks. The number one thing you can do to have a successful VBAC is hire a VBAC supportive care provider. Read more here.

I wish you the best wherever you chose to birth your children.

I urge people who are anti home birth, to please put that energy into reversing VBAC bans and making hospitals a more hospitable place to birth.

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15 comments to Homebirth vs hospital birth for the number cruncher

  • I had this sent to me a few days ago:

    http://www.indiebirth.com/2008/09/02/a-vbac-story/

    Change is coming… :)

    Keep spreading your message.

    -Maryn

  • Amy Tuteur, MD

    “Women choose to give birth in hospitals because they believe it is “safer” than birth outside the hospital. ”

    Birth in the hospital is safer. The only people who appear to be unaware of this are homebirth advocates. All the existing scientific evidence and the existing state and national data show that homebirth has an increased rate of neonatal death compared to hospital birth for comparable risk women. Sure, there are papers that claim to show that homebirth is as safe as hospital birth, but they do that by comparing low risk homebirth to high risk hospital birth, or low risk homebirth to hospital birth in decades past. The Johnson and Daviss BMJ 2005 study ACTUALLY shows that homebirth with a CPM in 2000 had a neonatal death rate almost triple that of hospital birth in 2000.

    According to the Linked Birth Infant Death 2003-2004 dataset recently released by the CDC, the most dangerous form of PLANNED homebirth in the US is homebirth with a DEM.

    Dr. Amy, Thank you for your comment. My reply is a little long, so I’ve included it here. Best, Jen

  • Shari

    I have had one C (42 weeks after long labor / failure to progress). Then one VBAC (41 weeks, pitocin induced chubby 9 lb 2oz girl!) I had my heart set on another VBAC and have made it clear to my OB from day one. He gave it lip service. I have very well controlled gestational diabetes, no insulin, baby is not apparently big yet at 34 weeks. Well, at my 33 week appt my OB told me they no longer do pitocin inductions under any circumstances for VBAC. I’m an engineer and huge number cruncher, not usually prone to “new-agey” things like home births. I understand exactly the increased risk but still believe a woman should be able to choose that risk versus choosing the risks of a c-section. My problem is that I’ve never dilated or gone into labor on my own, and was thinking Pitocin was probably my only chance. Right now I am seriously considering a homebirth just so I will be given the full 42 weeks to try, instead of the new “40 week 3 day” rule they are starting to propagate before trying to force a c-section. I also am so tired of FIGHTING! I had to fight so hard for my first VBAC, and now I will have to fight even harder because of the new rules. I believe both my baby and I are healthy, and assuming there is not a huge problem in the end game, I should be able to push out another gorgeous little baby in the privacy of my home. Still a little chicken to try it. Main worries are potential of uncovered insurance costs and of course emergencies. Am seriously considering and meeting with a midwife for the first time tomorrow. Thank you for the articles, recent updates, and encouragement.

  • Gigi

    I had one C section-primary- after coercion of my doctor to induce me at week 38, for no reason apart his convenience. He said week 38 was the optimum week to give birth, so why wait?
    I found that in the hospital Mitera in Athens, Greece that is common practice. They induce week 38, allow you to labour for 4-5 hours and if you do not give birth by then, they c sect you!
    What a wonderful birthing culture!

  • Catherine

    I just want to thank the woman who created this website — every article is so well written that even the really long ones, I have to just bookmark and come back to when I have a second. I have had two c-sections now, both unplanned (first was after baby was found to be breech, water broke naturally; second was due to decelerations and the hospital/doctor policy to not induce with a previous c/s — which I don’t disagree with, though I’m sad it had to happen). I would love to have a third child, but am now caught trying to find the healthiest safest way to birth after two cesareans. I would love it if you could add a VBAMC article somewhere in here — I know the research is a bit more complicated, but you seem to sleuth out the best parts and make it digestible. Thank you!

  • What a great article! I could not agree more. I will have to make sure moms I work with are aware of this resource.
    Kate, very HBAC friendly CPM

  • Ladya

    Hello to all the women who are making strides for all the womqn across the globe. i support vbac 1000% and more. I had a VBAC after 2 c’s it was wonderful but Drs were difficult. I am pregnant again due in two weeks and ready , I would like to a home birth but we dont have midwives that does home birth in the bahamas. All the smae women search , be confident and believe.

  • Thank you for everything you are doing to change the state of birth in the US. I had a home birth after two cesareans and I am working to empower mothers to find out the truth about their choices and their ability to bring their babies into the world. I am always referring people to your articles because you bring logic and statistics to issues that are emotionally charged. Thank you so much!!

  • Angie

    You give statistics but don’t list any of the sources. If you want to lend any kind of credibility to this article you really should consider actually posting where you got your information from. Not to mention some people consider it plagiarism :)

    All I see in this article is “I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.” You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up. If I was a true number cruncher interested in only facts and unbiased information then I most definitely would find this article completely useless. Numbers are supposed to be unbiased information, though they can be twisted, and this article is anything but. I would be far more impressed by an article that can show numbers AND an unbiased point of view. If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.

    Nice try though, E for effort.

  • Emma Mckay

    Thank you so much for all the information, I am in tears.

    I have held off having another child, due to a 52 hour labour and a c-section.
    Fear took over me, as doctors lied and told me different stories.
    My ‘natural contractions stopped because of fear and lies.
    One doctor looked at his watch and told me he wanted to go home.
    I live in a small town, so the nearest hospital is 60 kms away, the doctor here told me I had to go to the hospital, as my waters had broken and I had no contractions within 24 hours,so I was ‘high risk’ for infection.
    No-one wanted to help me here, plus it was late, I already called the doctor from her warm bed.She sent me off to hospital as a high risk, when I arrived at the ‘big’ hospital, a nurse walked in and said, “take your clothes off, we’ll induce oyu and get ready for a c-section”….No hello or how are you can I get you anything.
    There were rips in the curtains, it was lit with fluorescent lights and I had to share a bathroom with the lady next door who I had to listen to give birth.
    I was so afraid at this stage, that I had no choice…If I was a weak woman, I would have said “okay” and not known any thing ‘un natural about this.
    When I said “NO” to the nurse, that I was having a vaginal birth, she walked out and 5 minutes later in came a doctor, who said and I quote “What are you doing here then if you think you are to have a vaginal birth considering your waters broke over 24 hours ago, and you have had no movement as yet”….then he said, “Oh let me guess the Doctor in your town was^$#$&^**>> and she couldn’t be bothered with you so she sent you here, am I right that it was doctor #@#%&$^*&&>>??”
    I fell apart after I asked him to “**ck off and get me a new doctor”!!!!

    There was no hope for me, I was scared by this stage, I was quite happy at home with my partner and doula, my best friend….We lay around eating and preparing and we went for a walk.
    If I had of known that I could have been given antibiotics; against the possibility of having an infection, due to my waters breaking in my small town from the doctor on call that night, perhaps I would have stayed calm and in my space rather than panicked and fearful that I had the infection and I must go straight to hospital to get rid of it,otherwise my baby could die…

    I am so disgusted with Doctors, and even more disgusted with the lack of choices women have with something that should be and can be so beautiful, therefore it should be out decisions on ho and where we choose to birth.

    After I had my c-section, I came home with ‘golden staff’ which I had got from the hospital, my weeping cut was getting worse, I had to go on antibiotics for nearly two months, finally the doctor said that I had to go back to hospital and they were to re-open my scar and sew it up again as the puss from the infection and the hole was getting too big, not to mention that my poor little baby girl was taking in so much of my pain and fear and drugs, I was bed ridden.
    I refused and stopped the antibiotics and went onto homeopathies, a concoction I made up myself, one for wounds one for fear and one getting better. Within 3 days my wound was healing and getting smaller, with in 1 week it had closed, all the puss was gone…

    Anyway, my partner and I are trying now for another baby, as my little girl now 4 tells me “she is ready for a baby sister”, I just hope that through this pregnancy I will cure myself from the trauma that I had to endure unnecessarily.
    This has shattered my world, my being for so long, I want to be free and positive and know that it wasn’t my fault or my bodies fault, that I am a strong woman who can give birth vaginally with out doctors interfering and telling me differently.
    I want the old me back….GO VBAC………I can do this!!!!!!
    Thanks for letting me use this site for letting go a little more…
    Emma Mckay from Denmark Western Australia.

  • [...] and want a VBAC, what do I do?, * The Three Types of Care Providers Amongst OBs and Midwives, * Homebirth vs hospital birth for the number cruncher, # VBACing against the odds, and # Comparing fetal death and injury: VBAC vs. [...]

  • Jennifer

    Here is an article which crunches the numbers from the “triple the neonatal death rate” study. http://www.medscape.com/viewarticle/739987

  • [...] Of 5,418 women in the Johnson 2005 planned home birth study, 185 (3.4%) women needed urgenttransfer to the hospital. Please read more here. [...]

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