If you are curious why anyone would choose an out-of-hospital birth, let me walk you through what parents planning VBACs in America can encounter.
Many women, especially those seeking VBAC, are between a rock and a hard place. Women are faced with hospital VBAC bans which mandate repeat cesarean sections and they don’t know what to do. They don’t want another surgery.
Or their local hospital technically allows VBAC, but the requirements in place greatly diminish the likelihood of success. Or their hospital says they can’t offer VBAC because they don’t have 24/7 anesthesia. Or an OB will tell them that they “Do VBACs all the time” when the reality is, they don’t. Or they felt deceived during their last birth and have subsequently lost all faith and confidence in the medical system. Trust is paramount between provider and patient and when that is so damaged, it’s difficult, if not impossible, to repair.
Other women report that their prior birth, either vaginal or cesarean, was so traumatizing that they developed Post Traumatic Stress Disorder and cannot step into another hospital again. Or they simply feel that physiological birth is impossible in a hospital. Or they want something simple like freedom of movement during labor and their local hospital requires VBAC moms, or all moms, to labor in bed. Or to deliver by 39 weeks. Or to give birth to a baby weighing less than 8 lbs. Or to dilate a 1 centimeter per hour.
Many women cannot travel 5-6 hours to birth at a VBAC supportive hospital, let alone move closer to the hospital, and away from their social support system, for the last weeks of their pregnancy.
Women simply want to birth normally after a cesarean and they want to avoid the risks associated with multiple repeat cesarean sections. Some women have found that the only way they can do this in their community is to birth at home.
National guidelines do not reflect access
The American College of Obstetricians and Gynecologists (ACOG, 2010) describes VBAC as a reasonable and appropriate choice for “most women” with one prior cesarean and for “some women” with two prior cesareans. The National Institutes of Health (2010) says “trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.” There was even a presentation at the 2010 NIH VBAC Conference discussing how there are not enough anesthesiologists in the United States to provide 24/7 coverage of all birthing units nationwide, but that VBAC could be offered safely nonetheless.
There are hospitals and hospital-based care providers who actively support VBAC. Yet not all women have access to such facilities and professionals. Even among women who do have access to a facility that attends VBAC, a recent study showed that the median VBAC rate at such facilities was about 10%. (Barger, 2013)
So increasingly, more women are opting to birth at home because they feel like they have no other choice or they simply prefer to birth at home. As the CDC recently reported, “After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009.” (MacDorman, 2012) Women feel like if they go to the hospital, they will ultimately have another cesarean because their OB or hospital administrators are not really supportive.
The great “what if”
The concern than many women have is “what if something happens.” Most women will be fine giving birth at home, but there will be women who have urgent, time sensitive complications at home that require immediate hospital transfer. If that hospital-based advanced medical care (i.e., drugs, surgery, blood products, etc.) is not reached in time, dire consequences could occur. This is the risk of home birth.
How a complication plays out depends on many variables:
- The type and severity of complication,
- How quickly it is diagnosed (based on the skills and experience of your care provider),
- If it is something that can be managed at home (based on the skills, experience, and supplies of your care provider) and if not,
- How quickly can you get to the hospital (based on the distance, driving conditions, etc), and
- How quickly the hospital personnel can respond to your complication.
- Does your home-based care provider have a good professional relationship with the hospital?
- Can s/he call ahead, inform them of your transfer, and have them ready the OR (if necessary)?
Uterine rupture and home birth
Some research on infant cord blood gases has suggested that if the baby isn’t delivered (almost always by cesarean) within 16 – 17 minutes of a uterine rupture, there can be serious brain damage or death to baby.
This is something to consider especially if you live in a rural area far from a hospital. You can watch a presentation from the 2010 NIH VBAC Conference entitled “The Immediately Available Physician Standard” by Howard Minkoff, M.D. for more information or read his presentation abstract.
The myth of the “unmessed with” birth
Some women believe the very false and dangerous belief that nothing can go wrong in a spontaneous “unmessed with” birth. I’m here to tell you that you can do everything “right” and still have a complication/ bad outcome.
While doing everything “right” decreases the risks that various interventions or restrictions introduce (such as elective induction, artificial breaking of the water, prohibiting movement during labor, etc), it does not eliminate the “naturally occurring” complications that are sometimes just the luck of the draw.
On Rights and Responsibilities
So when we talk about the “risks of homebirth,” it goes back to the question: Who decides what level of risk is acceptable?
And the answer is always the same: The mother. She is ultimately the one who will have a VBAC, repeat cesarean, uterine rupture, or placental accreta in future pregnancies… she needs to decide what is important to her.
Some women might say after reviewing the risks and benefits, “I want a home birth.” Other women might say, “I just want to be in the hospital in the event that I have one of those unlikely complications.” I don’t see any Right or Wrong answers here, just what is Right or Wrong for a particular parent.
I also think it needs to be stressed that with Rights comes Responsibility. Meaning, parents need to understand that if they choose to labor at home, understanding the small but real risk of uterine rupture and the potential impact of transfer time on outcomes, they can’t turn around and blame their provider if they become that statistic and have a bad outcome.
And this is true regardless of birth location.
Really, we need to be considering all of our citizens
The medical research on home VBAC is pretty limited due to the simple fact that it’s hard to collect the data on something that happens pretty rarely. Less than 1% of births in American take place at home and how many of these have a prior cesarean has not be tabulated.
I’d like to close with a quick two minute segment from the 2012 Human Rights in Childbirth Conference. It features Elselijn Kingma, Professor of Philosophy and Medical Ethics, UK & Netherlands during a session entitled, “Perinatal Mortality in the Netherlands: Facts, Myths, and Policy.”
She discusses how we interpret mortality data and what that says about our society.