Most women, especially from educated and urban settings choose to have child birth at a hospital. But an amazing fact is that- just a century ago in 1900, almost all U.S. births were at home and by 1930 two-thirds of U.S. births were still at home (Davis-Floyd, 2004). By 1960, however, 97 percent of U.S. births were in the hospital, with the largest change occurring between 1935 and 1944, when the proportion of hospital births more than doubled from 36.9 percent to 75.6 percent (DeVries et al, 2001). This was mostly due to growth in hospital infrastructure in the United States, the development of hospital insurance and the development of pain free child birth technologies such as Twilight Sleep. In these circumstances, child birth was portrayed as unnatural and dangerous for mother and baby. Hence obstetrics, a new science of birth, evolved in the hospitals and science institutes. Most women having home births in the 1940s and 1950s were rural and nonwhite and were doing so because of a lack of hospitals or because racial segregation closed local facilities to them. The tremendous emphasis in the United States on new medical technology makes hospitalization of birth a requisite for quality care It is only more recently, as a result of the growth of women’s movement and the natural childbirth movement, that home birth is again openly discussed as a birth option. According to a study by Andrews (2004), the decision to have a home birth is based on previous birth experience, the desire for a familiar environment and concerns over childcare.
Kathlaeen Doherty Turkel (1995), who has spent over ten years of research on childbirth, says that many women who had child birth in hospitals have told her that they felt totally out of control in unfamiliar settings. They felt they should not make too much noise, should do what they were told, and should be as cooperative as possible. The women whom she interviewed felt that hospital procedures were unnecessary intrusions into the birth process and none of them every went back to the hospital for subsequent births. Kathleen Doherty Turkel reveals that often, in a hospital the requests of women are ignored. She also rues the fact that episiotomy is done for many women during hospital delivery even when they don’t really need it. She cites the fact that there is a lack of evidence that routine episiotomy prevents either perineal trauma or pelvic floor relaxation, but there is evidence which associates perineal trauma with episiotomy (Edwards and Waldorf, 1984, p. 143).
Dwinnell ( 1992) argues that the treatment which many women receive at the hands of doctors in hospitals is a form of violence against women. He says that some aggressive clinical procedures include: vaginal exams and other procedures done without permission or explanation to the woman, telling a woman she is hurting her fetus if she questions or refuses tests or procedures which the doctor sees as necessary; threatening to use various tests, procedures, or drugs if the woman does not cooperate, maintain control, or birth fast enough; and using intimidation supported by professional status. However, the fact remains that most women continue to birth in hospitals with doctors in attendance.
According to Jane Dwinell, the midwifery model holds that birth is a womancentered activity, that it is gentle and peaceful, and comes about at its own speed. Thus, Dwinell opines that in a home birth, a woman is respected, her questions and ideas are respected, and she gives birth when, where, and how she chooses. The midwife merely guides her, answers her questions, listens to fears and concerns and offers different solutions to problems such as using medical technology or the use of herbs,visualization, massage, counseling, and caring.
The way a society conceptualizes birth is the most significant indicator of how birth will be organized and carried out in that society. In the United States, birth is defined primarily as a medical event. Therefore, in the United States, pregnant women are seen as “patients.” Pregnancy is viewed as a “condition” requiring treatment from physicians, technicians, and nurses who make use of a variety of procedures, tests, and high-tech diagnostic tools to assess the health of the pregnant woman and of the developing fetus and the overall progress of the pregnancy. Birth itself takes place in a hospital setting under the direction of a physician and the assistance of nurses and technicians who rely upon an array of technologies to assess the progress of the event ( Arney, 1982; Davis-Floyd, 1992; Eakins, 1986a; Jordan, 1993; Rothman, 1982, 1989).
Contrary to child birth in home settings, in a hospital birth, the woman is subjected to many high-technology devices and procedures. Most labors in the United States are monitored with electronic fetal monitors, and laboring women usually receive some type of anesthetic or analgesic for pain relief. Jordan (1993) maintains that 80 percent of women birthing in hospitals in the United States have their labors augmented with Pitocin. Other common practices include artificial rupturing of the amniotic sac to speed up labor and the routine use of episiotomy, a cut in the perineal tissue to enlarge the vaginal opening ( Harrison, 1982; Rothman, 1982; Stewart and Stewart, 1976). Cesarean sections are also a common occurrence in U.S. hospitals. The current rate of Cesarean sections in the United States is 22.7 percent ( Ruzek, 1993). According to Jordan, 80 percent of birthing women receive epidural anesthesia and 80 percent of all labors are augmented with Pitocin. Epidurals often have the effect of slowing down labor. These labors are then speeded up with Pitocin. Episiotomies are done in over 90 percent of all first-time births ( Jordan, 1993, p. 143).
Home births are not advocated by doctors mainly because midwives are commonly viewed as less well trained and less competent than physicians. But researchers have found evidence that contradicts this statement. A study of nearly twelve thousand births in free-standing birth centers, where most births are attended by nurse-midwives, showed very little intervention and excellent outcomes ( Rooks et al., 1989). A study done by Lewis Mehl in 1977 compared 1,046 planned home births with 1,046 planned hospital births and found home births, which are usually attended by midwives, to be safer than hospital births ( Mehl, 1978). More recent studies on home birth show similar positive outcomes ( Sullivan and Weitz, 1988).
The British Medical Journal (2005) reports the largest prospective study of planned home birth with a direct-entry midwife. The study shows that homebirth is as safe as hospital birth for low risk women, and also carries a much lower rate of medical interventions, including Cesarean section. Canadian researchers Kenneth Johnson and Betty-Anne Daviss (2005) studied over 5,400 low-risk pregnant women planning to birth at home in the United States and Canada in 2000. The researchers analyzed outcomes and medical interventions for planned home births, including transports to hospital care, and compared these results to the outcomes of 3,360,868 low risk hospital births. According to the British Medical Journal the findings were: 88% of the women birthed at home, with 12% transferring to hospital; planned home birth carried a rate of 1.7 infant deaths per 1,000 births, a rate which is consistent with most North American studies of low risk hospital births and out of hospital births; there were no maternal deaths; medical intervention rates of planned home births were dramatically lower than of planned hospital births, including: episiotomy rate of 2.1% (33.0% in hospital), cesarean section rate of 3.7% (19.0% in hospital), forceps rate of 1.0% (2.2% in hospital), induction rate of 9.6% (21% in hospital), and electronic fetal monitoring rate of 9.6% (84.3% in hospital).97% of over 500 participants who were randomly contacted to validate birth outcomes reported that they were extremely or very satisfied with the care they received. This study supports the American Public Health Association’s resolution (2001) to increase access to home births attended by direct-entry midwives and also the World Health Organization’s 1996 position: “Midwives are the most appropriate primary healthcare provider to be assigned to the care of normal birth
(1996).” Finally, the study concludes that planned home birth conducted by a trained midwife is a safe, high-quality, satisfying, cost-effective choice for healthy women and their babies that results in superior outcomes. Based on this test, the Midwives Alliance of North American (MANA) recommends that midwifery care should be made the gold standard in maternity care in North America.
The study titled “The safety of home birth: the farm study” by A M Duran also vouches for the safety factor in the case of home births. In this study pregnancy outcomes of 1707 women, who had home births between 1971 and 1989 in rural Tennessee, were compared with outcomes from 14,033 physician-attended hospital deliveries derived from the 1980 US National Natality/National Fetal Mortality Survey. The results of this study show that under certain circumstances, home births attended by lay midwives can be safe if not safer than physician-attended hospital deliveries. An interim analysis (Olsen 1995) of a subset of four of the six studies in the meta-analysis showed that the total number of complications, the frequency of fetal distress, the frequency of neonatal respiratory problems and the frequency of birth trauma were significantly and consistently lower in the home birth group.
In her article Judith Lothian (2001) says that the woman needs to have confidence in her ability to give birth. Since birth is a “normal, natural and healthy process”, (Lothian, 2001, p19), the author stresses the importance of the mother’s participation in home birth setting and holds that the birth experience boosts her strength and energy. Generally in the case of home birth, pregnancy and birth are considered as healthy processes, not pathological conditions. Hence, attending women in childbirth cannot be viewed as the practice of medicine.
The medical model of birth focuses on those factors which can be measured and technologically managed, most notably mortality and morbidity rates. But there are other factors which are not so easily measured which are equally important. Birth is an important personal and family event and a life altering one at that. The experience of birth extends far beyond the event itself and affects not only mothers and babies, but fathers, siblings, extended family members, and friends. In home birth, the experiential knowledge of birthing women is seen as equally important as, or more important than, technical knowledge. They are allowed to express themselves freely through talk, touch, laughter and tears. Feelings and communication are central to the birthing activity. The physical and emotional health of the mother is seen as essential for the health of the baby (Turkel, 1995).
Another important aspect of home birth is the important role played by the midwives. Midwives and mothers work closely together and midwives become an intimate part of the birthing process. Oakley and Houd offer a clear example in this description of labor: “The woman gets on her knees. The midwife is sitting in front of her, also on her knees. The woman puts her head on the midwife’s shoulder, who then holds her head in her hands. They are finding a rhythm together” ( Oakley and Houd, 1990, p. 72). In the case of complicated pregnancies, however, when intervention may be necessary, midwives provide a source of emotional support and can work along with obstetricians to provide care. By constantly teaching and explaining, midwives enable women to make informed choices about medical care. Even when the situation warrants technological intervention, the midwife can act as an advocate for birthing women and families, maintaining an emphasis on the human aspects of birth. Midwives view birth as more than a medical event. Many authors talk about the importance which midwives attach to the emotional and social aspects of birth in addition to the physical aspects. Birth is physical, but it is also emotional, spiritual, and sexual. The tradition of midwifery has demonstrated a sensitivity to all the aspects of birth. Midwives work to see that parents are able to experience the fullness of birth. Finally, home birth offers family-centered care which recognizes the diversity of families. Families come in a variety of forms and from a variety of backgrounds. Home birth, then, contrary to hospital birth is based not upon surveillance and control, but rather upon the desire to offer support and to meet the needs of each individual birthing woman (Turkel, 1995).
It is interesting to note that today in most developed countries, the home birth rate is about 1 percent. This could be larger if made more readily available has been proved by Netherlands where the home birth rate has never dropped below 30 percent (Weigers 1997), and New Zealand, where in recent years it has risen to 12 percent as the result of a strong support from midwives, consumers and government. In Europe as in the United States, home births are today discussed as a viable option, with variable success.
Bibliography
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- Eakins Pamela S. 1986a. “The American Way of Birth.” in The American Way of Birth, edited by Pamela S. Eakins. Philadelphia: Temple University Press
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- Dwinell, Jane. Birth Stories: Mystery, Power, and Creation. Bergin & Garvey. Westport, CT. 1992.
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- Duran A. M. (1992). The safety of home birth: the farm study. American Journal of Public Health, Vol. 82, Issue 3. Pages 450-453
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- DeVries et al (2001). Birth by Design: Pregnancy, Maternity Care, and Midwifery in North America and Europe. Routledge. New York. 2001.