Question: Where is the safest place for a woman to give birth?
- Home
- Hospital
- Birth Center
- None of the above
In discussions among women and health-care providers, the primary focus is on safety issues. The homebirth argues that ”birth is a safe as life gets”, and points to the frequency of doctor and hospital-caused complications of childbirth.
Those promoting hospital birth as the safest choice point out the uncommon, but deadly, complications that can occur in even low-risk births at a moment’s notice. They cite the capability of hospitals to immediately intervene surgically if necessary. The point to the distance the woman laboring at home or birth center may have to travel to reach emergency care, and the lack of emergency resources which may exist in a home or birth center setting.
Each side rests in smug confidence that they alone comprehend the truth.
But what is the truth? Can we know it? I believe the answer to the question of the safest place to give birth is ”none of the above”. Let me illustrate with true stories from own personal experience:
I was working on the labor deck one day, caring for two patient in labor, when I heard a yell, ”I need help in here!” coming from a nearby room. I rushed through the door and saw the anesthesiologist performing CPR on Elise, a patient we had admitted in active labor. “Get me a crash cart!” he yelled. I ran for the cart as other people hurried through the door. As the “code team” gathered around the bed, the anesthesiologist gave a rapid report: “We were placing the epidural, when suddenly she passed out. We need to intubate her now!” Heart monitor leads were slapped on her chest as the anesthesiologist slid a tube down her throat. A nurse led the protesting husband from the room and secured him in a private waiting room. As another nurse “bagged” Elise (breathed for her with a bag connected to the tube in her throat), the anesthesiologist pushed drugs through the IV, and watched anxiously until her heart rate increased to normal. Elise soon regained consciousness, but had to be sedated because the sensation of a large tube down her throat caused her to panic. For two hours, the staff had to “breathe” for her, until the numbness of her epidural gradually wore off and she could breathe on her own. A frightening experience that could have taken her life made me wonder if home would have been a safer place for Elise.
Cassandra was pregnant with her third baby, and planned a home birth. She’d had two low-risk, uneventful births and anticipated a quick, easy delivery with this baby as well. When labor began, she called the midwife right away once labor began, because her last labor had only lasted three hours. The midwife arrived and found Cassandra almost fully dilated, with her membranes still intact. Then her membranes broke. A large amount of water gushed out, and along with it, the baby’s umbilical cord. The midwife quickly took action to elevate the baby’s head off of the umbilical cord, but the head was firmly down in the pelvis and she had difficulty lifting it off the cord. Cassandra was quickly moved into a knee-chest position, but the baby’s heart tones remained in the 60′s. . .and then the 50′s. The assistant had already called 911, and the midwife had Cassandra start pushing as hard as she could, reasoning that since the heart rate was dropping, and Cassandra had had short labors, perhaps she could push the baby out faster than they could get to surgical services. Within minutes a floppy, unresponsive baby was delivered. Resuscitation efforts were begun, and continued in the ambulance on the way to the hospital. The pediatricians at the hospital worked on the baby for 30 minutes at the hospital, before finally declaring him dead. For Cassandra, birth in the hospital might have been safer.
Both the home-birth supporters and the hospital-birth proponents use anecdotes such as these to support their position. But are we missing the point? The point is that no one can know the safest place to give birth, because no one can know what will happen during their birth. Will they need emergency surgery? Will they be coerced into a unnecessary c-section that necessitates hysterectomy because the bleeding won’t stop? Will their emotional needs be ignored during labor, resulting in a slowing of contractions and leading to pitocin, forceps delivery, and post-partum hemorrhage?
The safest place to give birth is the place that has all the bells and whistles and emergency services available but a place where they are rarely needed or used. A place where the woman is viewed as a unique individual, first and foremost. Her needs are not identical to the needs of all the other women giving birth, nor can they be met by a cookbook approach that requires the same protocols for every woman. Secondly, the safest place to give birth is the place where the woman is viewed and cared for holistically. Recognition is given to the fact that the mind and body are closely intertwined, and when the woman is anxious or fearful, her labor and her baby will be affected. The woman must feel safe where she is. Third, the safest place to give birth is the place where the woman is treated as a valued customer. Good customer service includes respect, understanding of the customer’s needs, and a policy that ”the customer is always right”. Women in labor should not have to write birth plans. It should be standard of care for the woman to have a variety of choices available to her–laboring alone with her partner in a quiet, darkened room, undisturbed; laboring with an epidural and friends and family surrounding her; laboring with a doula who is welcomed by the staff; giving birth in the water; giving birth in any position of her choice; the list could go on and on. The question of every obstetric provider should be, “How may I help you have a safe and satisfying birth?”
The safest place to give birth today is just a dream. But at the start of a new year, is it a possible dream? Can we create a place like this? If enough of us demand it, can it be done?
The sad thing to me is that so many women believe they will be getting your dream scenario when they go to the hospital: “We are having a baby in the hospital just in case an emergency comes up, but they have promised me I can _____” (insert: move around as much as I want, use the tub, be monitored intermittently, go into labor on my own, etc. etc.). Or they believe they can make it so: “I will just decline the things I don’t want.” Then they arrive at the hospital and the cookbook approach begins and they have no idea how hard it is not to get steamrollered. I wish people really understood that as hard as they fantasize, 99% of hospitals are nowhere near the fantasy.
This is so, so true. I see this happen all the time. I try to tell my clients who truly want a non-interventive birth that their best chance is outside of the hospital, but few listen because of the fear that has been instilled in us in regard to birth.
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I think the other sad/ironic/maddening thing is that BOTH of these stories (and similar stories) are used to demonstrate that hospitals are “safer.” Because epidurals in particular, and interventions in general, aren’t truly considered optional or even *possibly* unnecessary, the first complication is seen by many in obstetrics as a complication of birth, not a complication of obstetrics.
The dream scenario, as presented, sounds great, but still sounds like it must take place in a hospital/birth center of some kind. Certainly a fabulous one! But I am still unsure that such would *necessarily* be superior to homebirth (for low-risk women) as long as homebirth were supported by these nearby fabulous hospitals. Basically, my dream scenario would have both, or all three– 1) a birth center attached to a hospital that did not push unnecessary interventions and allowed the entire rainbow of options, 2) an L&D unit within or attached to the hospital for higher-risk women, but one that also respected them and their choices and allowed a greater variety of family-friendly options, etc. and 3) greater and more integrated support for homebirths and potential homebirth transfers, as well as EVEN BETTER-educated and more well-respected HB midwives.
I didn’t intend for the first story to support the safety of homebirth. I believe if that woman had been at home, supported by family/doula/midwife, she very likely would not have needed an epidural. None of the rest of the scenario would have happened. The things we do to women in hospitals create the need for drugs and anesthesia the majority of the time.
Why does the “dream scenario” have to take place in a hospital, birth center, or home? Let’s think outside the box. We have mobile imaging vans, mobile dentistry vans, etc. Why not a mobile surgical unit so women who choose home birth but are not close to the hospital can have prompt medical attention if needed? Why not “maternity hospitals” which would be like a birth center but have surgical capability? I envision these places staffed and run by CPMs and CNMs dedicated to preserving normal birth and meeting the needs of the woman.
Now, that’s an interesting concept – the mobile surgical unit. I wonder if that’s something that could actually be logistically possible given the equipment needed?? Do you have further thoughts on that scenario? Because, if that were possible, emergency homebirth “transfers” would be dealing with half the time needed for care. Maybe, just maybe, paramedics should be trained in general anesthetics and emergency c-sections in ambulances. And maybe, midwives could be trained in the same.
I love that thinking out side the box:) It would be hard to do something like a mobile surgical unit that is available to everyone giving birth at home but I love the idea!! I think we need to do more of that thinking out side the box thing.
Yes, I like both ideas! Especially the mobile surgical unit!
I know that the first example was not meant to illustrate the safety of homebirth. But of course, neither does it illustrate the safety of hospital birth. My only point was that, unfortunately, stories like Elise’s are frequently used to justify hospital birth– just as often as stories like Cassandra’s. Which simply proves the extreme bias and lack of evidence-based… Well, not just evidence-based care, but evidence-based “common knowledge” among moms and other laypeople, unfortunately.
In the Uk if you are having a homebirth (at least in the area i lived in!) we had the ‘flying squad’ i think thats what they called them, basically paramedics on standby, but only for the emergencies, as we have transferrs to hospital of labouring women who were trying for a homebirth but ended in hospital, but were transferred slowly as it was just a long labour.
I have to admit, I don’t like the idea of a mobile surgical unit (except perhaps in for rural areas that could use something like that for things other than maternity issues). The thing is, birth is safe. It has risks, but they are different for each woman and each circumstance. There is nothing we can do to make pregnancy 100% safe — that’s simply the nature of life, as painful as it sometimes is.
Women need options, not a single solution that everyone must adhere to. Every intervention carries potential risks and potential benefits, and it shouldn’t be up to anyone but an individual woman to decide how she wants to weigh them, but in many states and countries, that right is taken away. The safety debate should be secondary to a woman’s right to autonomy.
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Look at the picture, and you ‘ll know my answer:)
Greetings from HOlland
Marianne
Great blog! Over many years I have thought about this obsession with safety, and find it helpful to think about it in terms of “what is safe enough?” The answer, of course , will vary from woman to woman, because it is not just about statistics, but also a reflection of our beliefs and values as individuals and couples. For thoughts that echo yours, with references, see http://cfmidwifery.org/pdf/SafetyinChildbirth2009cfm.pdf
Susan
I wish hospitals would be less intervention happy unless truly warranted. I have found some care providers and birth locations which come close to this. The problem is, you are never certain which doctor or nurse you will get. It is in some sense a crap shoot when you go to a hospital.
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