Home sweet home
Author: Sara Rider

Over the last few years, the combined number of babies born each year in Williamson and Travis Counties has been over 23,000 according to the Texas Department of Health Services. The vast majority of these infants began their lives in one of the area hospitals; this prevalence of hospital delivery follows a national trend. Since 1969, according to the Centers for Disease Control and Prevention (CDC), only one percent of births in the United States occurred outside a hospital. This marked a major change from earlier centuries – before 1900, says the CDC, almost all births in the U.S. occurred outside a hospital.

But while most women opt for hospital labor-delivery-recovery rooms as the place to welcome their newborn son or daughter, a small percentage of women select home birth. In 2004, the CDC reported that .56% of all births occurred at home, a number that rose to .72% in 2009, with midwives attending 62% of home births that year. According to Mary Barnett, a certified nurse midwife who began Heart of Texas Midwives in Austin in 2003, her patients have many reasons for choosing home delivery.

The power of choice
“Number one, to avoid routine interventions in the hospital, such as an IV and continuous fetal monitoring. We see women who don’t want to argue about what it is that they want – they want natural childbirth,” explains Barnett.

Overall, Texas has one of the lowest rates of home delivery in the U.S., with less than .50% of births occurring at home according to the CDC. This compares to states like Washington, Wisconsin or Utah, where home birth rates range between 1.5% and 2.59%.

Obstetrician/gynecologist Karen Swenson, M.D., of Women Partners in Health, who practices at Seton Medical Center, sees patients in her practice who want to deliver at home and people who are set on a hospital delivery.

“I see the whole spectrum. Some people come to me at the beginning of their pregnancy wanting home delivery because that is how they have always wanted to do it,” reveals Dr. Swenson. “Some people go out and have that experience and come back after their birth for their gynecological care. And I’ve had a patient who delivered at the hospital the first time, delivered at home the second time and came back and delivered in the hospital the third time.”

Deciding factors
So what are the factors that lead women to choose home delivery or decide on hospital delivery? Barnett believes that women are drawn to home delivery because of factors they cannot control in a hospital. “The lack of control, the lack of privacy, it’s huge. You can’t really control who walks in your door. They are in a more dependent position because they are not calling the shots. It’s not their territory. In their house they are calling the shots, and I think all of this makes a huge difference. It’s like the difference between standing in the middle of downtown and standing in a cow pasture.

A baby still comes out, but it’s so very different.”

Barnett also believes that the medical equipment used in hospital deliveries – IV, fetal monitors, continuous monitoring with blood pressure cuffs – “tethers” the woman during labor and can make labor more difficult and less natural as it restricts the mother’s ability to move.

Dr. Swenson asserts that it doesn’t have to be that way. “Patients can be admitted and not be continuously monitored or have an IV. A birth plan discussing these options is a great idea so that staff can accommodate the patient’s requests.” In general, she believes that the options of how a woman can labor and deliver in a hospital setting “are huge.” “You can be continuously monitored if that’s the best thing for you, or you can be intermittently monitored.”

Cautionary advice
Dr. Swenson says that people often choose hospital delivery because of the services they can call on in a hospital. “What I worry about in home birth is dealing with the emergent circumstances: when a heart rate goes down, not being able to recognize a baby that is deteriorating, not anticipating the risks to the mother, not anticipating infection. If you are laboring in a hospital, there can be a much more rapid response to a change in the mother or the baby.”

“I think birth is a natural process,” says Dr. Swenson. “But in the advent of technology, fortunately women don’t die in childbirth as often as they used to. I think birth is part of the spectrum that is normal for a woman. But there are potential risks and complications. We need to honor those and we need to be prepared for those.”

Barnett believes that home delivery is safe and that midwives take the precautions they need to protect both mother and baby. Just as is done in the hospital, the midwives in her group monitor baby and mother during a home delivery. “We listen to the baby’s heart beat with a Doppler, but we do it intermittently. We follow the guidelines from the American College of Obstetrics and Gynecologists for intermittently listening to the baby’s heart beat. And we follow the guidelines from the Association of Women’s Health Obstetrical and Neonatal Nurses in monitoring the mother.”

Who should home birth?
Both Barnett and Dr. Swenson believe that not all women are good candidates for home delivery.

“I think most people are pretty good at what is called self-selection,” says Barnett. “Most people with serious medical problems don’t want a home birth.” She adds that people who develop serious health complications during a pregnancy are also not people she would deliver at home. “Someone who has diabetes that develops during pregnancy and can’t be controlled with diet and exercise, we’re not going to deliver them at home.”

Dr. Swenson agrees that a woman “who has chronic hypertension, any kind of major medical problem, diabetes or any kind of rheumatologic disorder like lupus should not deliver at home.

Someone who has had a previous delivery that was complicated or who has had a preterm delivery in the past should not deliver at home.”

Of course it is the fear of the complications that can be at the heart of any decision for home delivery versus hospital delivery. Barnett makes it very clear that some complications will require a hospital transfer, but says that her personal rate of transfers during labor is only 11 percent.

“There is a different set of risks that can occur in the home than in the hospital,” explains Barnett. “If somebody had a prolapsed cord in a home birth setting, you don’t have ready access to an operating room like you do if that happens in the hospital. But there are also risks at hospitals that you don’t have at home,” she suggests, maintaining that there are more infections in hospitals than there are at home.

“Home birth can be a very good option,” encourages Barnett who emphasizes that women must choose good practitioners if they decide on a home birth. “I think midwives can be bad practitioners, just like any other profession. You can have bad doctors, you can have bad nurses, you can have bad priests, you can have bad midwives. So it is important that midwifery be professional, that we adhere to standards.”

At the heart of the decision about where to deliver is something of paramount importance: the health and safety of baby and mother.

“I think people have to be so very careful when they are making these decisions. Always the most important thing is thinking about the safety of your child. That should always be utmost in your mind,” stresses Dr. Swenson. “Sometimes that means you have to give up your dream of doing it a certain way.”

Sara Rider is a native Austinite who has worked with physicians and hospitals throughout Texas. She frequently writes freelance articles on health topics for newspapers and magazines

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