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.