Taken from the March/April 2012 issue of the Women's Health Activist Newsletter.

For one thing, I was thinking about the process of giving birth when I was in grade school – which is apparently not typical! And, when I did think about birth, it seemed like a normal part of life, not a potentially life-threatening medical crisis.

As an adult, when my friends and I started to talk about this, I learned that many of them are “terrified” of giving birth… and I don’t mean they are nervous, I mean petrified. Several have even said that, although they would like to have children, they may not because they are too scared of giving birth. While other young women seem able to empathize with this position, I have trouble doing so; I just can’t identify with birth as they describe it. And, as an advocate working on women’s health policy, I worry about what this seemingly common perspective says about quality of the care that mothers-to-be receive in the U.S. today.

My mother had three planned homebirths that were all attended by a lay midwife. Throughout my childhood on each of our birthdays, my mom gathered us together and told us the story of our birth. Again, this wasn’t something I realized was uncommon until high school, when I learned that not only did my peers not know the story of their births, but they also weren’t born at home — and thought it strange that I was.

But, my siblings and I didn’t think it was strange at all. We grew up knowing that my mom made tuna fish for my older brother’s lunch while she was in labor with me, and that he ran home from school to be there for my birth. We knew that it was raining the night my younger brother was born and that my mom listened to Frank Sinatra in the car while taking me over to my aunt’s house. We knew that my aunt was the midwife’s assistant for my younger sister’s birth, and I remember being woken up as a four-year-old so I could watch my sister’s birth. I know all these things because my mother talked about them with us, thereby normalizing these parts of life for my siblings and me. She didn’t gloss over the physical aspects of birth; she talked about breathing, walking, contractions, dilation, and feeling her baby transitioning into the birth canal. They weren’t scary stories to us, they were exciting – we used to ask to hear our birth stories.

Let me be clear: my mom didn’t have us at home because she’s opposed to modern medical care or because we lived in a remote part of the world. In fact, she’s a health care provider who runs a hospital in Philadelphia. She chose homebirth because she believes that birth is a normal part of life. She felt her body was made to give birth and that, for her — a healthy young woman with healthy pregnancies — medical intervention wasn’t necessary for safe birth. In 2012, however, this attitude is quite rare and it’s not just the apprehension I hear from my friends that makes me say that. Although there are no U.S. data available, surveys of British women show that nearly 87 percent of women report that they are “frightened of giving birth.”¹ My question is, why?

The fact is that giving birth in developed countries, in any setting, is incredibly safe for a woman who has access to healthcare. The maternal mortality rate in the U.S. is 12.7 maternal deaths per 100,000 live births² compared to 500 per 100,000 in South Asia, and 920 per 100,000 in Sub-Saharan Africa (the highest regional rate).³ A report on American women’s experiences with birth sums up the situation quite well: “In the United States, the great majority of pregnant women are healthy and have good reason to anticipate uncomplicated childbirth.”⁴ Again I ask, given these facts, why are so many women so scared of birth?

An article in the Journal of Perinatal Education offers one explanation: its negative portrayal in the mainstream media. The author provides examples of births as they are portrayed on TV and explains how such shows “can single-handedly convince most women that their bodies are incapable of birthing without major medical intervention and that they would be crazy not to want all the technology they can get their hands on.”⁵ On TV, pregnant women are usually shown in a state of panic as they are rushed to the Emergency Room. Once at the hospital, the woman screams about the pain and demands drugs, which usually elicits a laugh in comedies. In dramas, as often as not, some life-threatening medical emergency arises that requires a team of personnel to rush the woman to the operating room where she, her baby, or both, nearly die but are miraculously saved by some combination of modern medical technology and an attractive doctor. I’d be willing to bet that most people have seen some, if not many, variations of this chain of events on their favorite medical-themed TV show.

With this as the most common exposure women have to the birth process, it is easy to understand both women’s fear of childbirth and their discomfort with homebirth. If all births were like those portrayed on TV, maternal mortality rates in the U.S. would be much higher than they actually are, and homebirth would be a pretty dicey prospect. I’m glad I know that’s not the case, but I wish more women understood how safe childbirth is in the U.S. today.

In the hospital, even for what doctors describe as a “normal birth” where nothing goes wrong, the medical model relies on technology to manage the birth process. Consequently, most women who give birth in hospitals are connected to machines throughout their labor in order to allow continuous electronic fetal monitoring. Nearly half of all women who experience a hospital birth are given intravenous medication to speed up their labor; many also get an epidural for pain relief. Additionally, in the U.S., nearly one in three pregnant women deliver via a Cesarean section (C-section), although the World Health Organization estimates that C-sections are necessary in only five to ten percent of births.6 The extremely high rate of C-sections in the U.S. is cause for serious concern; according to a recent study, a national C-section rate of over 15 percent results in more harm than good for women and their babies.⁷ While this surgery can be life-saving when needed, current practices are subjecting many, many women to major abdominal surgery that they don’t need.

When a woman gives birth at a birthing center or at home, as my mother did, the experience is usually very different. Non-hospital births typically rely on a midwifery model that treats pregnancy and birth as normal life events. This model includes minimizing technological interventions while identifying women who might need obstetrical attention; a model that has been shown to reduce the incidence of birth injury, trauma, and C-section.⁸ But, less than one percent of births in the U.S. occur outside a hospital⁹ and only a tiny fraction of non-hospital births occur at home.

Women who have homebirths often describe with appreciation the experience of going through labor in the comfort of their own home. At home a woman can eat, drink, go for a walk and if, like my mother, she wants to continue with some of her typical routines, make lunch for her son — all while in labor. Some of these activities aren’t allowed in hospitals, such as eating or drinking during labor, and some just aren’t possible, like cooking in your own kitchen. But, one of the key differences is that, without the constraints of the hospital setting, a woman’s labor can proceed at the pace established by her body, rather than the pace established by institutional policies. This, among other things, makes unnecessary C-sections much less likely.

Homebirth is not an option (or the right option) for every woman, however. Even a woman who has a healthy, uncomplicated pregnancy might encounter a problem during labor. For this reason, it’s important that women planning homebirths have the option of a safe, smooth transition to a hospital when necessary.

Recently, I attended a national summit to discuss the status of homebirth in the U.S. maternity care system, convened by a group of health care providers and advocates seeking to ensure safe maternity care. Although the summit attendees held many different views on homebirth — ranging from those who believe it is never a wise choice to those who think maternal and child health outcomes would be vastly improved if the majority of women gave birth at home — the summit focused on how to ensure safe homebirth for the women who choose it. With that shared goal, we developed and agreed on several key elements that can make homebirth a better, safer option for women, including validating midwives within the maternity care system and better integrating the maternity care system to ensure smooth transitions of care between the home and hospitals.¹⁰ (See box.) These steps have the potential to improve maternity care for all women, and are vital to giving every woman the chance to have a happy, healthy and safe birth when, where, and how she chooses. (To learn more, see: http://homebirthsummit.org/summit-outcomes.html.)

I feel lucky that my mother introduced me to the idea of pregnancy and birth in such a natural way, although I know that homebirth isn’t for everyone. I left the summit more convinced than ever that making homebirth safer not only expands women’s options for childbirth, but also can improve the whole spectrum of birth experiences and outcomes. Helping more people learn about birth as a normal part of life, not a made-for-TV drama, will change women’s expectations dramatically. And, a more integrated maternity care system can make birth in a range of settings, with fewer unnecessary medical interventions, an accessible option for more women. Together, these changes can reduce the fear that is so common today and increase women’s chances of having an uncomplicated and healthy birth experience.

BOX: Summary of Key Elements for Safe Homebirth

1. Recognizing the value of women-centered care in all birth settings and the importance of shared decision-making between a women and her provider
2. Integrating the maternity care system to ensure smooth transitions of care between the home and hospitals
3. Ensuring equitable, culturally appropriate maternity care in all birth settings without disparities in access, delivery of care, or outcomes
4. Validating midwives within the maternity care system
5. Increasing participation of consumers in initiatives to improve homebirth services within the maternity care system
6. Improving collaboration among all practitioners in the maternity care system by ensuring all practitioners learn about maternity care in all birth settings
7. Improving the medical liability system as a way to increase choices in pregnancy and birth including access to homebirth
8. Improving the collection of patient level data on pregnancy and birth outcomes in all birth settings
9. Recognizing the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence

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Kate Ryan is the NWHN Program Coordinator.

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References:

1. UK National Birth and Motherhood Survey, Mother & Baby Magazine, October 2002. Available online at http://news.bbc.co.uk/2/hi/health/667444.stm.

2. U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration, Maternal and Child Health Bureau, Women's Health USA 2010, Rockville, MD: HHS, 2010. http://mchb.hrsa.gov/whusa10/hstat/mh/pages/237mm.html

3. UNICEF, Progress for Children: A Report Card on Maternal Mortality, New York, NY: UNICEF, 2008.http://www.unicef.org/factoftheweek/index_50177.html.

4. Declercq, Eugene R., Carol Sakala, Maureen P. Corry, et al., Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences, New York, NY: Childbirth Connection and Lamaze International, October 2006.

5. Lothian, J A and A Grauer, ““Reality” Birth: Marketing Fear to Childbearing Women”, The Journal of Perinatal Education 2003; 12(2): Pgs. 6-8.

6. Declercq, Eugene R., Carol Sakala, Maureen P. Corry, et al., Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences, New York, NY: Childbirth Connection and Lamaze International, October 2006.

7. Althabe F and JF Belizan, “Caesarean section: the paradox”, The Lancet October 28, 2006; Volume 368, Issue 9546:Pgs. 1472-3.

8. Midwifery Task Force, Midwives Alliance of North America, “Midwives Model of Care”, 2011. Available online at: http://mana.org/definitions.html#MMOC

9. MacDorman M, Menacker F, Declercq E.“Trends and characteristics of home and other out-of-hospital births in the United States, 1990–2006.” National Vital Statistics r \Reports; Vol 58, No 11. Hyattsville, MD: National Center for Health Statistics. March 3, 2010.

10. Home Birth Consensus Summit, The Future of Home Birth in the United States: Addressing Shared Responsibility. Common Ground Statements, 2011. Available online at:http://www.homebirthsummit.org/summit-outcomes.html