Friday, January 27, 2012

Home Births vs. Hospital Births: Who Gets Lost in Dichotomizing Rhetoric

Several news outlets--including CNN, NPR, and TIME--are reporting on the recent rise in home births in the U.S. And they've got something significant to report: home births are up nearly 30% since 2004.

These findings, of course, have fueled the ongoing divide between home and hospital births, which (almost always, in my experience) quickly falls into a debate between medicated and non-medicated births. 

These divides make some sense. Obviously, many of the medical options that come standard in a hospital (like pain medication) aren't going to be available during a home birth. 

Pregnant Lotus Smirk
From bettina n

Home birth advocates stress the importance of a woman's autonomy during the birthing experience and criticize the medicalized view of birth in the U.S. as limiting and restrictive to women. My own birth experience (non-medicated in a hospital), while ultimately positive (I got a healthy baby girl, and I didn't have meds), was frustrating because of the limits that were placed on me and the way I was treated as if control over my body wasn't mine to take. 

Hospital birth advocates claim that the risks of home births are too high, and that women who wish to birth at home are selfishly putting their own unrealistic expectations before the safety of their children. 

Both of these views are reflected in this quote from the TIME article:
A study published in 2010 in the American Journal of Obstetrics & Gynecology found that planned home births involved less medical intervention — fewer epidurals, episiotomies and infections and less emphasis on electronic fetal heart rate monitoring — but they were associated with three times the number of infant deaths. “Keep in mind that the absolute risk is still incredibly low,” says Macones. “But obstetrics is a risky business sometimes.”
These results have been disputed, with some saying there were design flaws in the study's meta-analysis approach.  Studies have also shown that increased risks disappear for low-risk, second (or more) pregnancies.

While there is plenty to unpack from this argument, I want to focus on the way that these studies and arguments get dichotomized and how that dichotomization hurts women who may not have some of the privileges of those driving the discussion.

Some recent posts on Feministing featured famed midwife Ina May Gaskin. The comments on these posts demonstrated the way that the home birth/hospital birth debate can become ugly in a hurry--and this is among a community of women who self-identify as feminists (and thus pro-woman). Even though many of these comments were respectful and well-stated, they still display the dichotomy in progress. Many of the women on this thread expressed that the home birth movement made them and their ideals feel attacked:

"I do have a problem with some of the home-birth movement’s sense of ideological purity, which sometimes goes so far as to shame women who choose to give birth in hospitals and who choose to have modern pain mitigation." -L. K. Lowe
"Can we please not confound feminism with the naturalistic fallacy? Just because birth is “natural” doesn’t mean it’s safe or de facto good. Kidney stones are natural, I don’t see people feeling they are somehow morally superior for passing those at home without medication or medical supervision." -Petra
I don't want to belittle L. K. Lowe's point that women feel judged for having a hospital birth--in fact, her point is kind of my point, too. However, women also feel judged for having home births. Take a look at this blog post that belittles women's attempts to have control in their births:
Home birth as a way to find a loving supportive environment and fight the enslavement of the patriarchy is absolute, utter nonsense.   It’s one of the only medical scenarios I can think of where women place health and welfare in jeopardy in order to feel “in control” and avoid intervention. 
And, of course, there's Amy Tuteur whose entire raison d'ĂȘtre is to demonize women who choose births outside of hospitals, demonstrated most clearly on her blog, but also--inevitably--in the comments of nearly every single major article on the subject (including the Feministing ones).

I fully support a woman's decision to have a home birth. I was very frustrated by my hospital experience and felt that I was not respected or treated with compassion. I hated the way the medical community made me doubt my own body, and I hated how much I had to fight just to give birth to my child. I completely sympathize with someone who doesn't want to have that battle and sees avoiding the battleground as the easiest way to do it. I also completely respect people who simply think that their homes are the best environment for birth. I think that women should be allowed to make sound judgments about their own birthing experiences, weigh any risks for themselves, and be informed advocates for their actions.  However, I think that the way this conversation gets framed is damaging all of us, and some of us more than others.

When we turn birth experiences into an either-or dichotomy, we miss the opportunity to join our voices and advocate for changes in medical policies and research. That hurts all of us, but it especially hurts women who may lack the socio-economic privileges that the women at the forefront of these arguments are granted.

Looking at the planned home birth statistics, it is clear that most of that 30% increase can be attributed to a narrow demographic: educated, well-off, older, white women.

The NPR article explains that "The increase in home births isn't occurring among all women. The trend appears to be being driven primarily by older white women, according to the report. Home births increased 36 percent among white women between 2004 and 2009."

Other statistics back up this trend. [Edit: I re-worded this section for clarity and added the comparative percentages for hospital births] One study looked at home births (link requires subscription access) across 19 states in 2006. The study aimed to compare the demographics of planned home births, unplanned home births, and hospital births.

  • 90.1% of planned home births were to white women, compared to 5.6% for Hispanic women and 2.2% for African American women (by comparison, the percentages for hospital births were 49.7% white, 32.2% Hispanic, and 11.9% African American)
  • 91.7% of planned home births were to married women (compared to 61% of women birthing in hospitals)
  • 54.9% of planned home births were to women with 13+ years of education (compared to 48.8% of women birthing in hospitals)
It's important to also understand that many of the risks associated with home births are particularly true for unplanned home births. The same study has the following statistics on these kind of births:
  • For unplanned home births 44.5% of the mothers were white, 25.4% were Hispanic, and 24.1% were African American (note that women of color have disproportionately high unplanned home births compared to the percentages for planned home births and hospital births)
  • Only 36.2% of unplanned home births occurred in women with 13+ years of education
  • Only 46.2% of unplanned home births occurred in married women 
A similar profile of births in Utah (a state not recorded in the previous study) had the following results about planned home births [Edit: I also added the comparative stats for all births to this section]:
  • 90.9% of planned home births were to married women (83.3% of women were married in all births recorded) 
  • 41.8% of planned home births were to women with post-high school education (compared to 37.9% of all births recorded) and 40.9% were to high school graduates (compared to 45.2% of all births recorded) (so about the same percentage of 13+ year education across the board in Utah)
What do these results tell us? They tell us that the women who are likely to choose home birth are more likely to be highly educated, married, and white. In other words, the women who choose home birth are the ones who benefit the most from privilege in our society. To me, this means that these are the women who have the greatest access to information and the greatest ability to go against societal standards for birth through informed self-advocacy. They are also the ones who are likely able to afford the services of a midwife or doula if their insurance doesn't cover it (and they're the ones more likely to have insurance to begin with). 

But what about women who do not have these privileges. What about women of color? What about women without a high school degree? What about women who are not married and may not enjoy the benefits of a two-income household? What about women who never even know that they have options on how they give birth?

To be clear, I'm not trying to say that women of color or unmarried women are incompetent and incapable of getting information about their birthing options, as I know many are. I'm just pointing out that privilege makes a difference, and when the privileged people in society (as they so often are) are the ones in charge of the narrative, those who don't benefit from privilege often suffer. 

In this case, they suffer because the dichotomy keeps us from enacting real policy changes in our birthing culture. Maybe many women don't feel comfortable with a home birth for whatever reason (it's outside of their cultural norms, they can't afford a doula, they don't have a home suitable for birthing, they don't have a supportive partner to help with the birth and recovery, they prefer a hospital out of safety concerns, etc.) These women still deserve to have options and autonomy in their birthing choices, and when we turn the debate into HOME="NATURAL" HOSPITAL=MEDICATED and then focus all our energy on deciding who is "right" in that debate, we lose sight of (in my opinion) the real goal: getting ALL women, regardless of their socioeconomic status and regardless of where they give birth, autonomy over their bodies, access to information, and the right to birth without fear and coercion. 


  1. Amen so many times over. Perfectly said.

  2. "To be clear, I'm not trying to say that women of color or unmarried women are incompetent and incapable of getting information about their birthing options, as I know many are. I'm just pointing out that privilege makes a difference, and when the privileged people in society (as they so often are) are the ones in charge of the narrative, those who don't benefit from privilege often suffer."

    There is an alternate explanation that you have not considered.

    You assume that if other women only knew what privileged white women know, they would want what privileged white women want. In other words, privileged white women are role models for everyone else. That is both racist and classist.

    They may have no interest in the fads that preoccupy privileged white women because they have more important things to worry about. For example, they may have medical problems and risk factors that privileged white women do not have to contend with.

    Homebirth is like following Martha Stewart. It's delightful to bake your own bread when you know that you don't HAVE to bake your own bread if you don't feel like it. Similarly, it seems delightful to privileged white women to avoid the hospital when they know that they don't HAVE to avoid the hospital if they change their mind. For other women, who don't have routine access to high quality medical care, who have medical risk factors, whose home is not a domestic paradise, who have enough unmedicated pain in their own lives that setting themselves the "goal" of enduring more pain without medication is unfathomable, homebirth is an affectation they have no interest in emulating.

    1. Nothing in this post was about women with less privilege needing to emulate those with more privilege by striving for a home birth. To the contrary, my point is that by turning the debate into "You can have a 'natural' birth at home or you can have a medicalized birth in a hospital," we remove all of the shades of grey. In doing so, we make it less likely that we'll have conversations about how hospital births can offer an environment where women have more autonomy or how home births can become safer.

      The privilege I'm pointing to isn't just in women who choose a home birth, but also that privileged viewpoints dominate the discussion--on both sides--and blind us to other perspectives.

      In fact, my whole point is that by turning it into a dichotomy where home birth becomes the only option for a woman who feels violated or oppressed by unwanted (and often unnecessary) medical interventions, then we also leave women who don't have or don't feel comfortable with that option behind. The alternative would be that we stop dichotomizing this discussion and allow for advocacy on both ends of the spectrum.

      Nowhere in that do I suggest that home births should become the wave of the future and that everyone should strive for them. In fact, I think that opening up the conversation and making hospital births less restrictive would actually support more women birthing in them, so I'm sorry that my views don't neatly fit into the narrow home birth advocacy you've made it your life's mission to attack.

    2. Oh, and I've also never suggested that the "goal" should be "enduring more pain without medication."

      I had a med-free birth because I didn't want limited mobility or to feel out of it from medication. I never thought there was anything glorious or praise-worthy in enduring the pain of birth, but it was a worthwhile tradeoff for me to have control over my own body.

      I understand and appreciate that other women feel differently (because they do feel the pain itself is an important experience, because they don't feel that the pain is a worthwhile tradeoff and opt for medication, or because of any other individual decision about their own bodies). That's their right, and I support women birthing how they feel is best for them.

      I want equal advocacy for all of us and for the conversation to include nuanced perspectives.

  3. "54.9% of planned home births [in the US] were to women with 13+ years of education"

    "41.8% of planned home births in Utah] were to women with post-high school education and 40.9% were to high school graduates (so 82.7% to women with at least a high school education)"

    OK, hang on a minute, these statistics are meaningless without context. As of 2006, 91.7% of 16-24 year old women in the US were NOT high school dropouts. (​programs/digest/d07/tables/​dt07_105.asp)

    And in 2010, among US women aged 25 years or older, 88% were high school graduates and 57% had attended at least some college. (​hhes/socdemo/education/​data/cps/2010/tables.html)

    This tells me that women choosing homebirth are LESS educated than their peers, not MORE educated.

    1. You're right. That was unclear. I added the comparative stats used in the studies (unplanned home births and hospital births for the first ones, all births recorded for the second one). Sorry, and thanks for pointing that out.

      Overall, education did have less of a correlation than ethnicity and marriage status, but the study across 19 states did find that 54.9% of the planned home births were to women with 13+ years of education while 48.8% of hospital births were to women with this level of education.

  4. I think you're implying that the middle ground, and the correct answer is to pressure hospitals to loosen their often too-strict policies and allow women more latitude and choice during labor and birth. I would agree with that, however, another major part of that is liability. When something goes wrong, and it can be demonstrated that it was because a woman was going against medical advice, she's going to sue and claim that she couldn't have possibly understood the risks and its all the doctor's fault for not clearly explaining everything to her and making her understand the full implication of her decisions. It usually works. Over and over. When hospitals and doctors no longer have to contend with that dynamic, they'll probably be a lot more willing to let women labor too long, avoid more csections, VBAC, deliver a breech vaginally, etc. Until then, when its the doctor assuming ALL the liability and ALL the blame, they will stonewall whatever they see as a risky decision, because its the most rational career move for them. It means they will most likely be practicing tomorrow, and paying off their mortgage and student loans and taking care of their own families. I can't blame them.

    1. I agree that liability is part of the issue, and I think it needs to be explored further. There are a lot of hospital policies, however, that seem (to me at least) to be less about liability and more about convenience for the staff.

      For instance, my nurse told me I couldn't get out of the bed to labor because it was against hospital policy. Some studies have found that maternal ambulation reduces the c-section rates. Even studies that suggest maternal ambulation doesn't effect length of labor or mode of delivery have found that mobility during labor doesn't pose any additional risks.

      I talked to an attending doctor who overturned the nurse and told me I was allowed to get out of the bed, but if I hadn't researched labor on my own before entering the hospital, I wouldn't have had the confidence or the knowledge to advocate for that change. It wasn't presented as a policy with risks I needed to weigh before making a decision; I was told flat out that I couldn't do it, and I really don't think that I would have made it through labor without pain medication if I hadn't been able to move around.

  5. I think another good example of that would be eating during labour. Most hospitals won't allow it, or at least don't tell you ARE allowed, and I'm pretty sure the evidence says it's fine. It's just a convenience for hospital staff, somehow easier for them to put a glucose drip in you.

  6. It's not just for the convenience of the hospital staff. You're not supposed to eat during labor for the same reason you're not supposed to eat after midnight if you're scheduled for surgery under general anesthetic the next morning.

    The anesthetist wants your stomach empty because she wants to reduce the odds that you will choke on your own vomit.

    There's some chance that you're going to need an emergency c-section under general anesthetic and they want you to have an empty stomach just in case.

    Most women who go in for a vaginal birth won't need a general anesthetic, and most people don't choke on their own vomit even if they have something in their stomach when they go under. But since aspiration is awful and eating during labor has no measurable benefit, it seems wise to err on the side of caution.

    One paper I read said that drinks like Gatorade could be a good alternative because they deliver calories and electrolytes and they are absorbed quickly.

  7. The sad thing about this debate is that people are trying to force their opinions on others. Amy Tuteur is entitled to her opinion as much as anyone else. And the great thing about our country is that you have freedom of speech, and for now you have freedom to have your baby anywhere you want.

    There are two questions that people are asking.

    1. Home Birth vs. Hospital Birth

    2. Home Birth with a licensed midwife or without a midwife.

    As to the first question there is lots of studies, blogs, mothers, fathers, doctors, midwives, and reading material to keep one occupied for years as to the safety numbers and the information that one needs to make a decision as to where they want to have their baby. That question doesnt need to be answered because its a personal choice. You can have your baby anywhere you want. You cant be forced to have a home birth or a hospital birth.

    Now for the second question. For those who have looked at the info and made a choice, the next question is should they have a Licensed Midwife or not. Licensed Midwives can be a nurse or non nurse midwife. Both Certified Nurse Midwives and Certified Professional Midwives are accredited by NCCA who also accredits Paramedics and EMT's. Some states only allow nurse midwives while others allow non nurse midwives.
    Access is the key. Having a Midwife makes home birth safer.

    If women have access to midwives for their home birth the outcomes are safer.

    So hopefully we can remain civil. We need to protect our doctors so that they can practice without fear of pointless lawsuits. We need to make sure that they can afford to practice. There is no reason for 100,000 dollar yearly insurance costs as many OB's pay. There is no reason a family needs a 140 million dollar settlement.
    We need to bring back some personal responsibility. Bad birth outcomes happen at home and at the hospital. Its not always the doctor's fault and its not always the Midwife's fault. Being respectful of other people's decisions is an important part of continuing the conversation and working toward the goal of having as safe a birth as possible where ever you happen to be.

    Jeremy Galvan