On Homebirth

Planning a homebirth in the United States means constantly dealing with medical professionals who think you’re the scientific and moral equivalent of an anti-vaxxer.

I’ve come to the conclusion that while some doctors do take an active interest in the medical literature, others view themselves mainly as technicians. Unfortunately, most seem to fall into the latter category. Not that I blame them for it. With all they do, how can the average doctor be expected to keep up with current research as well? But the very structure of American medicine seems to encourage an over-reliance on the official positions of the various medical associations (even when they differ quite significantly from international medical opinion). “What do I think about homebirth? I don’t know, what does the ACOG say about it?”

Several weeks ago, we were told by one particularly condescending doctor:

I just want healthy babies and healthy mothers. There’s no reason for anyone to die in childbirth anymore and the hospital is really the safest place. You’re taking a big risk.

Uh, no we’re not. Read the literature.

The United States has a 32.2% C-section rate, much higher than medical necessity might dictate (and even higher among poor women of color). While the American College of Obstetricians and Gynecologists (ACOG) discourages homebirth, insisting that “hospitals and birthing centers are the safest setting for birth,” they nevertheless note that “planned home births are associated with fewer maternal interventions, including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and cesarean delivery.” (This still hasn’t stopped them from distributing anti-homebirth bumper stickers: Home Deliveries are for Pizza, not Babies.”)


Both babies and pizzas.

Given the mind-boggling numbers, the statistical possibility of one’s pregnancy ending in a C-section should in itself raise alarm. In addition to the standard risks associated with major abdominal surgery, women who undergo C-section are four times more likely to die from complications during or after childbirth. It is for this reason the World Health Organization (WHO) says the overall C-section rate should not rise above 10-15%.  When rates exceed this level, there is no indication that health outcomes improve. Yet C-section rates continue to climb… and women are dying.

Only about half the states bother to collect data on maternal death and there is no corresponding national effort. The World Health Organization estimates somewhere around 12-28 deaths in the United States per 100,000 mothers—or about 1200 annually. This is an astonishingly high figure for a technologically advanced country; higher than Iran, Turkey, or pre-revolutionary Libya.

Yet numerous studies show that an uncomplicated pregnancy is as safe or even safer at home than in a hospital, where one is much more likely to face medical intervention and its attendant problems.

recent study on planned homebirth indicates a very slightly higher rick of perinatal death compared to in-hospital births but a significantly lower chance of unwanted medical inventions:

Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings.

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This study is just the latest installment in a solid body of evidence that out-of-hospital births attended by qualified midwives are a safe option for women with uncomplicated pregnancies. So the argument that hospitals are the “safest setting” is certainly not as obvious as ACOG would like to suggest and the emphasis on risk tends to obscure the fact that, for the vast majority of women, childbirth is a normal physiological process—one for which their body has been well-equipped by the forces of human evolution. The cult of risk strips women of bodily agency. It presents a pregnant woman first of all as an emergency or at least a potential emergency. As City University of New York sociologist Barbara Katz Rothman writes:

Virtually any house can be struck by lightning: Do you care to think of where you live as being ‘low-risk’ for lightning? This is just what contemporary medicine has done to pregnancy. It has distinguished between ‘low-risk’ and ‘high-risk’ pregnancies, with the emphasis always on risk, and then gone on to define an ever-increasing proportion of pregnancies as ‘high-risk.’

Perhaps more than anything else, the obsession with risk is one expression of our deep cultural desire for scientific and technological mastery, for the attainment of absolute certainty over matters of life and limb—even to the point of irrationality and skyrocketing C-section rates. But whether at home or in a hospital, there is no such thing as “risk-free” childbirth. It’s likely there never will be such a thing.

This is not an argument against either hospitals or modern medicine. Hospitals are ideal for medical emergencies and the psychological comfort that provides makes hospital birth a no-brainer for many women. But pregnancy is not an illness. It’s not an emergency. Our midwife knows what she is doing and it’s really getting to be a drag constantly dealing with practitioners clearly less interested in keeping up with the scientific literature than in chastising us for defying the hospital monopoly. 


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