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Women in the U.K. with low-risk pregnancies received some notable advice recently: Avoid giving birth in hospitals. The recommendation came from the National Institute for Health and Care Excellence (NICE), which updated its guidelines to encourage midwife-led care and births — either at home or in birthing centers — in about 45 percent of all pregnancies.
“In updated guidance, the evidence now shows that midwife-led care is safer than hospital care for women having a straightforward, low risk, pregnancy,” the NICE website announced on Dec. 3. “This is because the rate of interventions, such as the use of forceps or an epidural, is lower and the outcome for the baby is no different compared with an obstetric unit.” The guidelines call for supporting freedom of choice and providing unbiased information about all birth-setting options, noting that home births “are equally as safe as a midwife-led unit and traditional labor ward for the babies of low-risk pregnant women, except for first-time mothers,” for which home births have shown to carry a slightly higher risk of complications.
The news, to me, was cause for celebration: I had given birth to my daughter at home, in my tiny New York City apartment, after my instincts — as well as much research and trusted advice — told me I would be safer there, both physically and emotionally. And it was an incredibly empowering, life-altering experience that I’ve never regretted, to the point of sometimes yearning to go through it all again.
I know I’m not alone in reveling in the U.K.’s news on this side of the pond, where the percentage of out-of-hospital births increased from .87 percent of U.S. births in 2004 to 1.36 percent in 2012 — its highest level since 1975, according to the latest stats from the Centers for Disease Control and Prevention. Of those out-of-hospital births in 2012, two-thirds, or more than 35,000, occurred at home.
Of course the other pleased contingent in the U.S. is that of midwives. “It’s really nice to see the U.K. come out with such strong, supportive language about midwife-led care,” notes Tina Johnson, director of professional practice and health policy with the American College of Nurse-Midwives. She believes the chances are high that there will be a midwife-supportive stance in America, though others in the field have varying levels of optimism. That’s because roadblocks include a differently structured healthcare system that often pits obstetricians against midwives, a financial incentive for hospitals to remain the go-to birth providers, and what some believe is a powerful fear of birth in American culture. “It’s easy to scare women — it’s even profitable to scare women and girls about birth,” noted pioneering midwife Ina May Gaskin in a TEDx talk last year.
Organizational policies in the U.S. — including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics — unequivocally name hospitals as the safest settings for births, while “respecting the right of women” to make an informed choice. But recent studies, including a large one from 2013, have shown that midwife-led birth centers both improve birth outcomes and lower healthcare costs.
“I can’t imagine it happening here,” says Miriam Schwarzschild, a Brooklyn-based midwife who has been attending home births (including my own) for 25 years, regarding the U.K.’s new standards. “It’s mostly a financial thing. There’s no financial benefit to going to the hospital in England. Here, once you take a woman out of the system, I think the doctors feel threatened.” But the biggest obstacle to having non-hospital births becomes an accepted norm here, she says, is the frequent friction between ER doctors and home-birth midwives during sometimes-necessary transfers to the hospital. “We meet with so much hostility — we have places that won’t even talk to us, and we’re not respected for what we do,” says Schwarzschild, who has a hospital transfer rate of about five percent. “If someone shows up at the hospital for pain relief because they just couldn’t do it, they shouldn’t have to wind up with a C-section.”
Safe and smooth transfers from home birth to hospital birth are of utmost importance in the NICE recommendations — and a vital goal of the Home Birth Summit, which periodically brings together providers of maternity care with varying perspectives to work toward a common vision of autonomy and choice.
“I do feel like [what happened in the U.K.] could happen here, but there are many steps we’d have to take,” Home Birth Summit chair Saraswathi Vedam, a professor of midwifery at the University of British Columbia and advisor to the Midwife Alliance of North America, tells Yahoo Parenting. She says that reactions at hospitals to home-birth transfers vary by region, and that the way to make them smoother everywhere is to create informative guidelines. “Many times a woman in crisis shows up at the hospital, a physician has no information, and we live in a litigious society,” Vedam says. “I don’t believe most are motivated by finances, though, but by the fear of responsibility. Many believe it’s not reasonable to have attempted a home birth, and they’re not necessarily aware of the training that midwives have.”
On the flip side, she explains, planning to have a home birth doesn’t always mean it will wind up that way, and women often feel reluctant about changing their plan mid-labor; knowing they’d be transferring to a “receptive environment” would be hugely helpful, she says. Vedam notes that most transfers to the hospital — about 80 percent — are due to “prolonged labor,” not true emergencies.
Dr. Howard Minkoff, chairman of the department of obstetrics and gynecology at Maimonedes Medical Center in Brooklyn, NY, is one physician who is interested in the “receptive environment” approach — although he is not a proponent of home birth, and does believe it comes with a higher risk, regardless of recent study findings. “I’ve been in this business for long enough to know that a perfectly healthy woman can prolapse her [umbilical] cord and that 20 minutes to the hospital can be too long,” says Minkoff, who recently gave a talk on the ethics of various obstetrical practices, including home birth, at Columbia University.
Still, Minkoff adds, “Women have the right to say ‘I’m willing to accept that risk.’ …I tell physicians, it’s legal to have a home birth, people are going to choose to have home births, and our job is to make it as safe as possible so we can move in the same direction as England.” As far as all sides working together in that way in the U.S., Minkoff says he’s optimistic, noting, “I think there’s a movement afoot.”