But What If...?

Questions Commonly Asked of Homebirth-ers

As a homebirth mom myself, and then as a homebirth advocate, I have had many people question the wisdom of birth at home. Sometime by well meaning, but ill-informed friends and family. Sometimes by people who were just plain ignorant and rude.

Without second thought, people say things to home birth couples that, were the same comment directed at them in reverse, they would be highly offended. Here, I would like to address the most frequently heard comments.

I hope to provide couples who face this opposition every day with something fairly concise to work with. What I really wish is that I could buy a copy of Obstetric Myths vs. Research Realities and The Five Standards for Safe Childbearing* for every pregnant couple, friend/relative/co-worker of every pregnant woman, health care worker, nurse and doctor. These books are indispensable in dispelling the myth that there is any sort of scientific justification for the routine (i.e. in the absence of medical indication) use of technology in pregnancy and birth. They also illustrate how often the inappropriate application of technology is actually causative in compromising the lives of mothers and babies.

Actual Questions/Comments to Homebirth Couples

Question/Comment #1

"But what if something happens?"

Rarely can the questioner think of what actually might happen unless something traumatic happened in their own birth. This question sometimes comes combined with "You are so brave (or stupid) to give birth at home! I could never do it because my baby almost died (or did die)." In this case, the home birth parent is loath to suggest that the questioner might have made the unsafe choice.

There are very few medical emergencies of birth that cannot be handled by a competent midwife at home. Only about 10-15% of complications that occur at birth can't be predicted in advance through prenatal care. Of those, a very small percentage will actually need intervention that will require the surgical expertise of an obstetrician.

"Why take that chance?" is what some people may ask next. Here's why...

...because that chance is actually smaller than the chance a healthy hospital bound couple takes that their baby (or the mother) will be harmed by the use of technology that was meant for sick babies and mothers!

Consider this...

In a study entitled "Home Birth Versus Hospital Birth: Comparisons of Outcomes of Matched Populations", by Dr. Lewis Mehl in 1976 it was found that there was a three times greater likelihood of cesarean operation if couples gave birth in a hospital instead of at home with the hospital standing by. The data from the hospital population revealed twenty times more forceps, twice as much use of oxytocin to accelerate or induce labor, greater use of analgesia and anesthesia, and nine times greater incidence of episotomy (while at the same time having more severe tears in need of major repair). The hospital sample showed six times more infant distress in labor, five times more cases of maternal high blood pressure and three times greater incidence of postpartum hemorrhage. There was four times more infection among newborns and three times more babies in need of assistance in breathing. While the hospital sample had thirty cases of birth injuries, including skull fractures and severe cephalohematomas, there were no such injuries at home. The infant death rate of the study was low in both cases and essentially the same. There were no maternal deaths for either population. The main differences were in the significant improvement of the mother's and baby's health if the couple planned a homebirth, and this was true despite the fact that the homebirth participants of this study included those couples who began labor at home but ultimately needed to be transferred to the hospital.

All studies done to date have said the same thing...home birth is as safe or safer than birth in the hospital. Except for one. One study, done by physicians themselves, not surprisingly, said the opposite. What isn't often revealed about that study is that in order to come to the conclusion that it did, planned homebirths with midwives were not studied, but instead, "out-of-hospital birth" included: miscarriages after 20-28 weeks gestation (all stillbirths), accidental births in taxis (on the street, etc.), involuntary homebirths of impoverished mothers, and homicides by unwed mothers who did not want their babies and left them to die of exposure. Hardly comparable to homebirth with midwives.

Sadly, sometimes things do happen. But to think that any one place or caregiver can guarantee a perfect birth or perfect baby every time is unrealistic. Life itself has a 100% mortality rate. Birth has much better odds!

Unfortunately, too often if this question of something going wrong is being asked by someone who has chosen hospital birth for the safety they think it conveys, the story is something like...

"I needed an emergency cesarean due to cord prolapse (or transverse arrest, or infection, etc.)."

Definitely no choice but to have a cesarean done and quickly! But, how distressing to learn that the reason the cord washed down (or the baby dropped down and got stuck or the mother developed an infection, etc.) was because someone artificially ruptured the membranes? (or some other intervention routine intervention was done that commonly causes complications) Would a life saving operation been needed if nature had taken it's course? Who can say?

Sometimes emotional reactions take precedence over reason. I had one mother tell me that she could never have a homebirth because her baby died days after birth. This baby had multiple congenital abnormalities not compatible with life (not detected by all of the tests and ultrasounds she had in pregnancy) and would have died no matter where he was. It was tragic and I cried with the mother as I held her while she recounted her anguish. But the facts remain: technology didn't detect the problems; the hospital could not fix the problems or save the baby. It would have been no more or less grievous at home. The only difference is that the parents might have been able to spend those first and last days loving and saying good-bye to their little one instead of watching him in a box with tubes and wires. I respect her decision to not birth at home...it's the reasoning I don't understand.

Question/Comment #2

"How could you live with yourself if your baby died?"

The audacity of some people! This ranks right up there with the comment some reserve for after the birth "She's lucky nothing happened to that baby or I'd never let her live it down." The first comment was actually said by a nurse to my best friend within minutes of confirming her much anticipated pregnancy, the last was made to someone in my family by someone in my family after the birth of my baby.

Does anyone say this to a mother whose child becomes brain damaged from a vaccine reaction? Or to a mother whose child is disfigured by a scalpel in one of the millions of unnecessary cesareans? What about to the mother whose child dies due to a hospital acquired infection? Or needs to be in NICU for weeks because of preventable prematurity? A mother doesn't grieve any more or less because she makes the safest choice for her child, and home is the safest choice for most women. A loss is painful no matter how or where it occurs. If anything, a mother who as educated herself to the fullest extent will be more accepting of a loss, should it happen, because she knows that the hours she put into researching her options ensured that she made the choice that held the least risk. Not like the many mothers who follow the status quo, assuming no responsibility for their health care, too busy to ask questions or looks things up, who end up saying "If I had only known!" when/if they find out their complication was preventable. One has only to read Silent Knife or Open Season by Nancy Wainer Cohen to read the painful stories of many such women. She receives thousands.

Question/Comment #3

"How could you put your own comfort above the safely of your baby?"

Other parents aren't usually so brazen as to ask this one. Many homebirth couples have been asked this by physicians, nurses or other medical personnel who apparently had no compunction in soliciting unfounded doubt and guilt. Amazingly, I have yet to hear someone ask this where it is actually applicable - of a mother who declares that she will demanding her epidural or Demerol as soon as she steps foot in the hospital .

The fact is, homebirth couples do not make this decision on a whim, nor do they make it for such trivial reasons as comfort. By the time a couple has made the decision to birth at home, more than likely they have read as much (or more) about normal birth as the average med student. They have not made the decision because it's "in", "popular" or a passing "fad". Chances are they will take more heat for this decision than any other choice they have ever made and yet they will still make it. Why? Precisely because of the safety of their baby!

Question/Comment #4

"I couldn't do it without the drugs! What if you 'need' something?!"

First, the obvious. How can anyone know that they couldn't do it without the drugs if they never have? Second, this comment fails to take into account that birth in the hospital is usually more painful for many reasons.

  1. Use of pitocin makes a labor about ten times more painful (and induction/augmentation with pitocin is epidemic in our hospitals).
  2. Lack of sustenance due to restriction of food and water lowers the pain threshold.
  3. Being tethered to a bed by a fetal monitor or IV restricts the mother's natural instincts to find a more comfortable position (and has been proven to do nothing benificial for the mother or the baby outside of certain complications).
  4. Being in an unfamiliar environment causes stress hormones, such as adrenaline, to hinder the production of the hormones the mother should naturally make for birth, making labor longer and, you guessed it, more painful.

There are many other causes of increased pain perception in the hospital, and none are medically justifiable. Birth is the hardest work a woman will ever do. It isn't always comfortable but it can be. There are reasons Nature works the way She does. A marathon runner would not expect to be comfortable during the last leg of the race. It's absurd to think she could function in her capacity if she accepted that she needed drugs to dull the pain. Her sense of accomplishment, not to mention the endorphins her body would produce as she pushed past the pain, would not exist. Many women simply have no clue what is robbed of them when drugs are used non-medically in labor and birth.

There are many non-pharmacological methods of pain relief that are utilized at home, including (but not limited to) accupressure, herbs, hydrotherapy (hot tubs), ambulation (walking, rocking, position changes) and the comfort that comes from loving support. And of course, there are many women giving birth quickly and painlessly without the dangers of drugs thanks to Mongan Method HypnoBirthing(R).

Question/Comment #5

"Does your midwife carry malpractice insurance? Who pays if something happens to your baby?"

Sometimes stuff just isn't anybody's fault! This question goes with the mentality that doctors "owe" us perfect offspring. The mentality of midwifery clients is different for a number of reasons, so the assumption that if obstetrics is the most sued profession, midwifery must also be. Midwifery is not obstetrics! Obstetrics is a surgical specialty, midwifery deals with normal birth and healthy women. Sick women go to doctors. But I want to know a couple of things, anyway.

How did it come to be that, in our society, someone must always be at fault and everyone who has something bad happen to them gets to be compensated?! When there is true cause and effect, or real negligence, law suits are warranted as punishment for the incompetent caregiver who purposely hurt someone. I have no doubt some of these exist, but come on! When do we start taking responsibility for our own actions and stop placing blame? When do we admit that life isn't always 100% wonderful, and that humans don't always have control over all events?

When we hire a caregiver even though we know that provider does (or does not) "XYZ" but they have promised us they won't (or will) do "XYZ" to us, and then they insist they must (or mustn't) do "XYZ", and we let them, and we then have a complication due to "XYZ", why in the world should they then have to pay us for the choices we have made?! Why should a doctor or midwife have to pay parents money if they don't get the outcome that we all want and expect? Midwives and doctors don't grow babies for people. The are not omnipotent. Sometimes a complication can be detected and dealt with before it's a problem, and sometimes it can't, technology or not. Ultimately, God/dess has the final say. Take note that I am not defending practitioners who injure on purpose or don't respect their clients enough to practice informed consent. I'm simply saying that this thing has gotten way past common sense and decency.

I saw a saying years ago that sums it up, though I don't remember where. It said "We are midwives. We don't hold life and death in our hands. Nor do we give or take away life. We facilitate passages and respect life from birth to death. We are imperfect people with a perfect calling. We are midwives."

With cesareans having at least a five times greater mortality rate, it's ludicrous to say "If only she had had a cesarean, everything would be fine." That statement is only possibly true for a cesarean rate of about 12%. Since in the US our rate of surgical birth is twice that, the assumption that there is some magic technology that is instantly available and always supplies a happy ending must be curtailed or else the practice of defensive medicine will never end.

Question/Comment #6

"How will you know if you and your baby are OK if you are at home?"

This question usually comes out of a lack of information about what midwives do. Some people are under the impression that traditional midwives just show up and catch a baby, which just isn't so.

Midwives provide low tech prenatal care to healthy women. At each prenatal visit they check blood pressure, urine, fundal height, position of the baby, and fetal heart tones. Assessment of edema, maternal weight, hemoglobin, and fetal movement are made. Additional monitoring may be done, depending on the education and experience of the midwife, but the above are usually a minimum. If the mother or baby show any signs or symptoms of problems, the midwife will refer to a physician. Homebirth is only for healthy women and babies.

In labor, all of the same things are monitored. Baselines established in early pregnancy for pulse and respiration are noted and the mother is observed for any deviation from normal for her. If a problem arises, midwives are trained in emergency procedures for use until medical assistance can be procured. Midwives know normal pregnancy and birth, but also learn about variations of normal, like breech, or pathology, like ectopic pregnancy, so that they can recognize them early enough for a timely referral. Midwifery is prevention!

Question/Comment #7

"Does your insurance cover homebirth?"

While many companies are seeing the value in homebirth coverage, some will still only cover hospital birth. This shouldn't be unexpected since (as my own doctor explained to me) insurance companies were not developed to help people pay for health care, but were initiated by doctors to insure that they would be paid. Independent companies see that not only is it less expensive to pay for the homebirth, but there is less likelihood that there will be subsequent expenses due to iatrogenic (doctor cause) or nosocomial (hospital caused) complications. Homebirth parents also tend to make other health care choices, like breastfeeding, that lead to healthier (less expensive, in the eyes of the insurance provider) children.

Even if the insurance doesn't cover homebirth, couples are willing to pay out-of-pocket for the peace of mind the safety of midwifery provides. Most of the time, because midwives charge so much less than physicians, the out-of-pocket expense is similar to what the parents would be paying for their co-pay had they chose a hospital birth anyway.

Question/Comment #8

"Well, it sounds like it might be nice, but I'd want to have my first one in the hospital, just in case."

This usually ends up being either a self-fulfilling prophecy or an event to be healed. I have had people come to my class with this attitude. I support the right to be where ever they want to be, but it still makes me sad to see it happen over and over again.

They may have been promised by their doctor that none of the stuff on the birth plan is done anymore "Unless it's absolutely necessary." More often than not, somehow all of the things that lead to further intervention and complications are done anyway. The parents feel cheated and violated. Their trust broken. Especially because it wasn't going to happen to them...they trusted their doctor. Some of these women end up trying to get pregnant too soon, so that they can plan the homebirth that will heal their soul. Their hospital birth may be what the rest of our culture deems 'normal', but because they know there's a better way, it isn't 'right'.

Many (at least 24%, remember?) won't get the chance for anything different next time because they will have a cesarean that will risk them out of many homebirth practices for subsequent births. At least half of those will have been unnecessary.

Some will go on to have that homebirth. Are they glad that they gave birth in an institution the first time? Sometimes. If a true emergency developed and they really needed medical assistance, or if they had a hospital birth with good Certified Nurse Midwives and had an experience that they are happy with. Sometimes not. Because the two experiences are so vastly different, the sentiment is sometimes that they regret that they weren't at home the first (or second or third) time because they can't believe how much easier it was at home. One woman explained it this way, "Physically, it may be the same, but emotionally it is so different. It's like being a virgin and contemplating your "first time", but deciding you'd rather be raped first."

I have been a labor assistant at births where I knew exactly what she meant! But it isn't fair to put all hospital births in that category. I've seen some decent ones. Of the ones I witnessed, two couples had to work ever so hard to keep it normal and go several counties away, but it was their informed choice to be in the hospital. Another needed to be in the hospital due to medical complications (one of those times when hospitals are actually the only place to be!). Although she had many interventions, she knew that they were necessary ones that helped her to have as normal a birth as was possible for her for that baby. She was treated with the utmost respect and the minimum technology needed to help her and her baby was used. These three had no regrets as far as I know. I'm afraid they are the exception, though.

If the people who ask these kinds of questions or make these sorts of comments spent half as much time actually learning something about homebirth instead of jumping to judgment, they would never think of saying something so hurtful. I have been to almost an equal amount of home and hospital births, and I am admittedly a homebirth advocate, yet I still would not walk up to a hospital bound woman I barely know (or that I knew quite well for that matter!) and accuse her of trying to kill her baby! This is essentially what happens quite often to home birth-ers.

So, if someone you know is planning a homebirth and has sent you this link or printed this out for you, please take the time to read a few books and check out a few links on my home page before expressing your concern. You may just find yourself being their biggest supporter!
*Obstetric Myths vs. Research Realties, Henci Goer. Bergin & Garvey.
The Five Standards for Safe Childbearing, David Stewart, PhD. NAPSAC International.

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Created by Kim Wildner

Y2Kid Considerations...my musings on parenting in the new millenium
Pregnancy Matters...Enjoying the journey and growing a healthy baby
Discomforts of Pregnancy & Helpful Hints
Nutrition in Pregnancy


"Building a Mystery"
Sarah McLachlan