Choosing a Birthplace for your Baby

By Janelle Durham, Great Starts Director of Education

 

Hospital Births

Advantages: Epidural anesthesia, and/or other pain medications, are available for women who choose to use them. Emergency equipment to deal with any complication is immediately available. Insurance coverage available.

Another possible advantage: Our culture generally assumes women birth in a hospital, so many American women may feel more comfortable doing so. If a woman feels safest in a hospital, birthing in a hospital may minimize anxieties, which can help labor to progress.

Disadvantages: Hospital policies often place restrictions on the choices laboring women can make; policies may affect mobility, eating and drinking while in labor, choice of position for birth, etc. Nursing staff may change throughout the labor, and are typically people the family has not met before. Interventions such as I.V.’s, electronic fetal monitoring, medical induction, and augmentation may be commonplace routines for low risk birth, as well as high risk birth. Birth is viewed as a medical event, where frequent assessments are performed to monitor for possible complications, and labor may be managed with medical interventions to prevent possible complications, as well as to treat them if they arise.

Additional considerations: Note that hospitals vary widely in their services, policies, attitudes about birth, and “homelike” atmospheres. Depending on your insurance coverage, and where you live, you may have several hospitals to choose from. Try to learn about your options through tours and other information sources, and choose the hospital which best suits your needs. (Look here for questions to ask at each birthplace as you explore your options for your place of birth.)

 

Birth Center Births

Childbirth centers are a middle ground between home and hospital births. They provide a ‘home-like’ setting for active labor, birth, and the first few hours after birth.

Advantages over homebirth: May feel safer than homebirth for some women (although the actual ability to manage emergencies is the same as at a home birth). May be closer to a hospital than the family’s home is, in case transfer is needed. Often covered by insurance. [Note that some families choose birth centers because they don’t want to worry about cleaning up their home after the birth. It’s important to know that midwives typically help clean up the birth space after the birth, whether it’s at home or a birth center. Midwives can also advise you on ways to reduce the “messiness” of home birth.]

Advantages over hospital: Less expensive. Fewer restrictive policies. Non-interventive care, with lower chance of cesarean section. May result in a more positive birth experience, if mom has more sense of control and comfort. Birth centers are positive environments centered on childbirth, not institutions focused on treating illness. They are similar in philosophy to homebirth, with a focus on birth as a natural event, and on empowering the mother to make choices about how to give birth.

Disadvantages: See the disadvantages for home birth. Plus, for birth centers: Early labor may be affected by anxiety over when it will be time to go to the birth center; active labor can be affected by anxiety about whether transfer to the hospital will become necessary. This uncertainty or fear can slow or disrupt labor progress. Most birth centers ask the parents to leave the birth center a few hours after the birth; some parents are ready to leave at that time, some wish they could stay and cocoon. There is a chance that women will have to move multiple times during labor, from home to birth center to hospital.

Washington state guidelines defining a low risk maternity client who is eligible for birth center birth can be found here.

 

Home Births

Advantages: Parents have more flexibility and choices regarding labor than they would have in a hospital. Mother may feel more relaxed and secure in her own territory. Personalized care - caregivers are guests in the home, and no unfamiliar people are present. Older children can be present for as much of the birth as desired. Mother is able to avoid ‘routine’ interventions, such as I.V.s, monitoring, and augmentation. Intervention rates are minimal, complication rates are typically low. Low risk of infection. Low cost. Birth is viewed as a natural event, and part of the on-going life experience of the family.

Disadvantages: Insurance coverage is possible in some states, not in others. Home birth services are not available in all areas. Pain medication availability varies by state; in Washington, no labor pain medication is available, but local anesthetic is available for episiotomies and/or stitches for tears. There is a chance of transfer to hospital during labor: 6% for mothers who have birthed before, 25% for first-time moms. Most transfers (96.6%) are for non-emergency situations, such as prolonged labor, exhaustion, meconium in amniotic fluid, prolonged ruptured membranes, or a desire for pain medication. (Johnson, 2005)

Additional considerations: Mother must be in good health, and experiencing a low risk pregnancy. Choosing a well-trained and competent caregiver is essential; as is a clear plan for hospital transfer. The home should be within 15-20 minute drive to a hospital.

  

Where do American women give birth?

Korte and Scaer estimate that 1% of all births are planned home births. Their rough estimate for out-of-hospital birth centers is 30,000 births a year, out of 4 million babies born each year in U.S. hospitals. In King County, in Washington State in 2005, 1.1% of babies were born in birth centers, and .9% were born at home.

 

How do costs compare?

Estimates of costs for births without complications are: hospital -  $5,000 - 9,000; birth center - $1500 for birth center + 2500 for midwives’ services; homebirth - $2000 – 3500 for midwives’ services. Note that medical insurance may cover a majority of the costs of hospital birth. Insurance may cover out-of-hospital birth fees, depending on the state.

 

How do rates of medical interventions compare?

	Home ††	Seattle area home and birth center †	Seattle hospitals - midwifery clients only †	Seattle area hospitals - all patients †
Induction/ Augment. %		0-8*	5-19	16-50
Pain Meds %		< 5*	30-75	60-90
Episiotomies %	2.1	0-1.6	0-5.5	3-20
Instrumental Delivery %	.6			7-25
C-section %	3.7	0-21*	0-19	21-32

 

†† Johnson, 2005. (examined records of 5418 planned home births in North America) † Data self-reported by providers, from Great Starts Guide - Seattle 2007. They are likely to reflect the differences in rates between hospitals, midwifery clients at hospitals and home birth clients in places other than Seattle. * Clients had to transfer to hospital for these procedures.

  

How Safe Are the Different Options? 

When asked why they chose hospital birth, most women say “Safety.” For a high-risk pregnancy, with high likelihood of severe complications, clearly the hospital is the best option. Lower-risk, healthy women, have the full range of choices available to them.

Several studies (e.g. Johnson, 2005) have examined outcomes for planned home births for lower-risk women and compared them to outcomes for similarly lower risk women planning to birth in hospitals. They indicate that women who plan home birth were less likely to have labors induced or augmented, less likely to have interventions such as cesarean, episiotomy, and forceps, and less likely to use pain medications.

The rates of infant mortality, maternal mortality, and need for special care for the newborn were similar, whether baby was born at home or in the hospital. For more details, see below.

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Information about Birthplaces in the Seattle Area

Contact Info for Tours of Local Birthplaces

Survey of local birthplaces (hospitals, birth centers, and home birth midwives: includes information on policies, services available, and intervention rates. Information for ordering the 2007 Consumer Guide edition. Full data (not as consumer friendly) from the 2004 edition.

Cesarean Rates, 2005.

Local Hospitals that provide maternity care:

Auburn Regional Medical Center, Evergreen Health Care in Kirkland, Group Health on Capital Hill, Highline Medical Center in Burien, Northwest Hospital in North Seattle, Overlake Hospital in Bellevue, Stevens Hospital in Edmonds, Swedish Medical Center on First Hill and in Ballard, University of Washington Medical Center, Valley General in Monroe, Valley Medical in Renton.

Local Birth Centers:

The Birthing Inn in Tacoma, Cascade Birth Center in Everett, Community Birth and Family Center in Montlake area of Seattle, Puget Sound Birth Center in Kirkland, Seattle Home Maternity and Birth Center, Seattle Naturopathy and Birth Center in Montlake neighborhood.

Midwives who attend home births:

Check the directory for Midwives Association of Washington state. Also, many of the birth center midwives also attend home births, so check on the websites for the birth centers.

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Research & opinions on safety of out-of-hospital birth

The American College of Obstetricians and Gynecologists stated in 2006: “The hospital is the safest setting for labor, delivery, and the postpartum period. ACOG strongly opposes out-of-hospital births. Although ACOG acknowledges a woman’s right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births.” In 2007, it revised that statement to refer only to home births, not to births at out-of-hospital birth centers.. (It should be noted that ACOG is a professional organization which represents members who primarily attend only hospital births)

However, the American College of Nurse-Midwives (ACNM) responded that ACOG’s implication that there is insufficient evidence to support the safety of planned out-of-hospital birth is unsubstantiated, and that they are not aware of any evidence supporting the assertion that the hospital is the safest setting for labor, birth, and the immediate postpartum period for low risk women. ACNM’s response was co-signed by CIMS, Lamaze, Citizens for Midwifery, American Association of Birth Centers, Midwives Association of North America, American Nurses Association, White Ribbon Alliance for Safe Motherhood.

World Health Organization states:  "It has never been scientifically proven that the hospital is a safer place than home for a woman who has had an uncomplicated pregnancy to have her baby. Studies of planned home births in developed countries… have shown sickness and death rates for mother and baby equal to or better than hospital birth statistics for women with uncomplicated pregnancies."

Here are summaries of some of those studies:

Johnson (2005) examined 5418 planned home births in North America. Women who planned to birth at home were much less likely to experience medical interventions than similarly low-risk women birthing in hospitals: episiotomy (2.1% vs. 33%), vacuum extraction (.6% vs. 5.5%), and cesarean (3.7% vs. 19%). Outcomes: No maternal deaths occurred. The incidence of infant death was 1.7 deaths per 1000, which is within the range of observed rates for low risk hospital births.  More details from this study here.

Janssen, et al. (2002) examined planned home births vs. planned hospital births in British Columbia. Planned home birthers were less likely to be induced, have labor augmented with oxytocin or prostaglandins, have an episiotomy, or have an epidural. Rates of cesarean, perinatal mortality, 5 minute Apgar scores, meconium aspiration syndrome, or need for transfer to a different hospital for specialized newborn care were very similar for both groups.

Olsen (1997) examined several studies of planned homebirths with hospital backup compared to planned hospital births. Nearly 25,000 births in 5 countries were studied. Fewer home-born babies were born in poor condition. Mothers were less likely to have had labors induced or augmented, or to have had c-sections, forceps, or vacuum extractor deliveries. There was no difference in survival rates for babies born at home, and no maternal deaths in either group.

An analysis of 4500 home births and 3300 hospital controls indicates that a woman who is appropriately screened for home birth is putting herself and her baby at no greater risk than similar mothers who deliver in a hospital. Chamberlain, et al, 1999.

976 planned home births were compared to 2928 planned hospital births in Australia. Planned home births appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births. Woodcock, et al. 1987.

National [U.K.] Perinatal Epidemiology Unit, 1994: “No evidence exists to support the claim that a hospital is the safest place for women to have normal births."