When Shannon Gibney went to bed the night before her due date, she guessed she had a week or more of waiting to do before she would meet her first child. But contractions woke her around 2:30 a.m., and by 4:30 a.m., she knew she was in labor. Instead of grabbing her bag and rushing to the hospital, Gibney — whose husband was in Liberia waiting for a visa — called a friend and her midwife and got back into bed.
She never left her Minneapolis home. By dinnertime, she was back in her bed, surrounded by friends, her midwifery team, dog, Nadine, with cat, Carmen, looking on — and her new son, Boisey, wrapped tightly in a blanket in his mother’s arms. And Vietnamese takeout for dinner.
While Gibney’s decision to give birth at home with the support of a midwife may go against the grain — more than 99 percent of births in the U.S. occur in hospitals — it puts her in a growing group of people who are choosing to give birth beyond the hospital walls.
“I never really liked hospitals,” says Gibney, whose mother is a neonatal intensive care nurse. “I always kind of knew I wanted to avoid it.” When a friend in Michigan had a home birth, Gibney says they became demystified to her, and she pursued it after exploring more traditional routes that Gibney says are respectable choices for some women, just not her.
“It’s really about safety and being somewhere you feel safe,” she says. “Some women feel safest at the hospital … but I know myself, and I feel better at home.”
Gibney is not alone. Women in Minnesota and around the U.S. are learning about their birth options and realizing the hospital is not the only one. Their own bedrooms, rented birthing tubs in their living rooms or one of a new crop of birth centers are becoming viable options for healthy moms with low-risk pregnancies — options that are prompting policy changes, modeling cost-effectiveness, and boasting outcomes that rival any hospital.
Looking forward means looking back
A hundred years ago, giving birth outside of the home would have sounded as strange to the average person as home birth does now. Overwhelmingly, most women in the U.S. gave birth in their homes in the early 20th century.
But the way babies are born in the U.S. has changed drastically over the past century, driven in large part by an increase in hospitals and private health insurance rules. By the late 1930s, only half of births occurred at home, and by the mid 1950s, the rate dropped to just 1 percent, where it has remained since. Now, slowly, it is rising.
The historic move to hospitals has undoubtedly been beneficial for some women, namely those with pregnancy complications. Better birth outcomes for both mothers and infants over centuries can be credited to these advancements — C-sections, for example, that drastically raise success in some high-risk pregnancies, according to the March of Dimes.
While these resources have proven invaluable to women with complications in labor and delivery, more and more women are questioning whether, for a normal, healthy pregnancy with the expectation of a normal labor and delivery, interventions need to be used at all.
The question is caused, in large part, by the cultural shift that took birth out of the home and changed the way we perceive it, says Tina Cassidy, author of Birth: The Surprising History of How We Are Born.
“We now have doctors and surgeons, and their brain were taught to look at [birth] as an emergency,” she says. “It’s a tragedy.”
The rise of birth centers
Cassidy and others hope the U.S. is beginning another cultural shift, this time in the direction of more birth options for women. Naturopathic doctor and licensed home birth midwife Amy Johnson-Grass is pushing for them in Minnesota.
In February Johnson-Grass, who has delivered more than 300 babies in Minnesota homes in the past five years, expanded her midwifery practice by opening the Twin Cities’ first freestanding birth center, on Grand Avenue in St. Paul. From the outside, Health Foundations Family Health and Birth Center looks like its neighboring 1920s homes. Inside, its homey, bed-and-breakfast feel features exam rooms, birthing suites, a yoga studio and space for workshops and classes.
While Health Foundations was a first in the Twin Cities, it was not alone for long. Menomenie, Wis.-based Morning Star Women’s Health and Birth Center opened a location in St. Louis Park in April, and a nurse-midwife-staffed birth center is slated to open in Minneapolis, near Abbott Northwestern and Children’s hospitals.
Birth centers, which were popular in the 1970s, are resurfacing nationally as a happy medium between giving birth in hospitals and delivering in living rooms for healthy, low-risk moms. In 2006, the most recent year for which data is available, 28 percent of all out-of-hospital births occurred in freestanding birth centers, according to the Centers for Disease Control and Prevention.
Melanie Klassen of Eagan, Minn. delivered two daughters in the hospital. During her first birth, she pushed for hours while her doctor was unavailable; her daughter spent the first five days of her life in the neonatal intensive care unit because she spent too long in the birth canal. The second time, a daughter was “evicted” because her doctor suspected the baby was large and didn’t want Klassen to wait any longer to deliver her. The scheduled induction, with epidural, went fine, but excessive bleeding for more than a week after birth landed Klassen in the emergency room where she was admitted for emergency surgery.
So when Klassen found out she was pregnant with a third child, she knew she wanted to do things differently and did her homework. “I realized, Oh, my God! There are options!” she says. “I’m taking advantage of this.” Ultimately Klassen decided she did not want to do a home birth and settled on Johnson-Grass’ birth center because of its home-like setting with the reassurance of being close to a hospital — the best of both worlds, she says.
But with the praise comes a debate about the safety of birth centers and whether their staff and equipment can keep moms and babies healthy. They have transfer plans in case laboring moms need to be taken to a hospital. The vast majority of the time, a transfer — which happens rarely — is precautionary and not an emergency, says Johnson-Grass, with plenty of time to make a plan, pack a bag, and answer questions. Even so, opponents say that in the case of some emergencies, even a five-minute ambulance ride may be too long.
In Minnesota, the rise in popularity of birth centers spurred legislation to ensure their safety; a movement led by birth center advocates themselves. Johnson-Grass, along with others, worked on a bill that passed this summer requiring the licensing of birth in the state. In order to be licensed, a center will have to go through a rigorous process to be accredited by the Commission for the Accreditation of Birth Centers.
Fewer costs, but from whose pocket?
Licensing isn’t just about safety. It’s a move that will make center births more affordable. Many of the moms Johnson-Grass sees pay out of pocket for at least a portion of their births because their insurance won’t. Many insurance companies reimburse for at least some prenatal care provided or ordered by Johnson-Grass. Few cover out-of-hospital delivery. At Health Foundations, that currently means a $5,500 price tag, including pre- and postnatal care, for those without coverage. (A Health Foundations home birth runs
about $4,000.)
What sounds like a hefty price, many parents say, is worth every penny. Andrea and Nate Rinehart of St. Paul, who welcomed their son into the world at Health Foundations in February, said getting a clear answer from their insurance company about what they would and would not cover was a headache. They decided to pay out-of-pocket, submit everything to insurance afterward and cross their fingers.
With copayments and partial payment responsibility, many parents find that even with no insurance coverage, the cost of a home or center birth might not be much different from the final out-of-pocket cost of a hospital birth. And in the end, Andrea says, “If I’m going to splurge on something, it’s going to be my birth.”
This year’s federal health care reform bill will also help birth centers receive insurance reimbursement. The version of the bill that passed included a section that allows Medicare to pay for birth center births, and many insurance companies follow Medicare guidelines in deciding what services to cover. Many supporters of birth centers believe this will help address rising health care costs, as births that occur in centers generally cost much less than those that happen in hospitals. The average uncomplicated vaginal hospital birth costs about $7,000, according to the March of Dimes. If a C-section is involved, the cost climbs to about $11,500. However, many believe those estimates to be markedly low.
The case for out-of-hospital births
Health care providers agree that high-risk births should happen in hospitals, but that is where the agreement ends. Some do not condone births that happen outside of a hospital, period. The American Congress of Obstetricians and Gynecologists does not support home births or births in unlicensed birth centers. However in 2007, they issued a statement accepting freestanding accredited birth centers as a safe option for birth.
Others believe that for healthy, normal births, delivering outside of a hospital is just as safe and healthy for moms and babies. The research is clear, says Dr. Rachel Rapacz, a family medicine physician who practices at Hennepin North Care and attends births at Hennepin County Medical Center. “Birth outside of a hospital — when you have … a healthy mom, a healthy baby and a healthy pregnancy — is just as healthy if not healthier than birth in a hospital.”
Certain studies, as well as mother’s experiences, raise the question of whether some of what happens in hospitals could be detrimental to mothers’ and babies’ health. The soaring C-section rate in the U.S. — one-third of all births — has experts concerned. Research shows C-sections carry with them increased risks of a variety of adverse outcomes, such as uterine rupture and infection. Study of other interventions is ongoing, but there is evidence to suggest medically inducing labor increases the risk of C-section. And research shows having a C-section significantly increases the likelihood of having a repeat C-section. Inducing labor with drugs may also increase the risk of an epidural. Yet epidurals can slow labor, increasing the need for those same drugs to speed it back up.
“You just get caught in the thing,” says Klassen. “You dilate to five or six centimeters on your own, then you get the epidural because everyone says, ‘You have to get the epidural!’ but that slows things down, so then you get the [labor-inducing drug] Pitocin.”
The case against out-of-hospital births
Birth can be unpredictable. That’s the biggest argument providers and professional organizations have against supporting out-of-hospital settings. Even if they agree with research that shows these births often produce good outcomes in healthy women with normal pregnancies, many said it is not worth taking the chance that an individual birth may have complications. Something abnormal could happen, they say, when a woman in labor is too far from medical equipment and specialists to get the care she and her baby need before irreversible damage or death occur.
“A safe, normal birth is a retrospective analysis,” says Janette Strathy, who has practiced as an OBGYN at Park Nicollet for 25 years and is active in the Minnesota chapter of the American Congress of Obstetricians and Gynecologists. “You only know it’s going to be safe and normal afterward.”
But the official numbers suggest the perception of problems is stronger than the reality. Complications during labor and delivery are routinely reported to the Minnesota Department of Health by both hospital-based and out-of-hospital providers by checking off items on a standard list of complications, including fetal distress, a baby in breech or another unfavorable position and abnormally short or long labors. According to the health department, about 30 percent of hospital births in 2008 had at least one complication reported, compared with 23 percent of births that occurred at the mother’s residence. Among the 504 births that happened at home, one mother and 11 infants were reportedly transferred to a medical center at some point in the process.
Yet although the numbers don’t suggest greater risk for non-hospital births, liability remains a concern for providers, “whether we like it or not,” says Strathy. “Even if an OB wanted to support birth center births or home births, you put your professional life on the line if you even pretend that might be a good idea.”
Toward a culture of choice
Reality TV shows such as TLC’s “A Baby Story” and Discovery Health’s “Birth Day” usually feature hospital births, and movies and TV shows frequently show laboring moms rushing to the hospital.
But media depicting other types of births have emerged in recent years. Former talk show host Ricki Lake widely publicized the home birth of her son in the documentary “The Business of Being Born” and book, Your Best Birth.
As for Klassen, whose center birth was set in motion after she saw Lake’s film, safety and comfort come in a different form. “I don’t usually do anything that’s risky,” she says. “And at this point, I think it’s riskier [to give birth] in the hospital.”
Cassidy’s hope is that women learn more about childbirth practices and what their options are. “If they took the time to see what natural childbirth was like, I think they’d be blown away,” said Cassidy, who after a traumatic C-section, delivered her second child at home with the help of a lay midwife. “I hope [women] will understand that birth is not an emergency waiting to happen. It is a normal physiological process and … it can be the most amazing experience of your life, not the most frightening and painful.”
