So your pregnant wife is starting to show an interest in homebirth… welcome to the club!
Give it to me simply: what does she want me to know?
The article before you is long, and I imagine that not everyone will have the patience to read the whole thing. So first I will summarize the main points, and then proceed to elaborate for those who are interested (including elaboration on the more technical aspects of homebirth in Israel).
- The decision regarding the location of the birth must be a mutual one.
- Under the right circumstances, homebirth is just as safe as hospital birth, but healthier; this is well-documented in medical research, and this is the accepted position in the WHO (World Health Organization) and in the health ministries of various developed countries.
- The opposition to homebirth that exists in the medical community of Israel and other countries stems from the nature of medical training, doctors’ subjective views, and sometimes, financial interests.
- Natural childbirth is beneficial to health and safety. Unnecessary medical intervention often leads to unnecessary complications and does not improve birth outcomes.
- Homebirth significantly improves one’s chances of giving birth naturally and without complication; it also constitutes a wonderful and empowering start to parenthood, and a much calmer and more natural transition for older siblings.
- Homebirth (as of today) is indeed expensive; however, it is not an excessive luxury, but a worthwhile investment.
Now let us begin.
There is no way I’m letting her do this
Imposing vetoes is not a healthy way to make decisions as a couple. A decision like this needs to be mutual, one that emerges from respectful dialogue and a desire to reach a solution that will satisfy both of you. If she sent you to me—this is probably a start. So here, make yourself a cup of coffee, si t down, make yourself comfortable, and hear where she is coming from. Who knows, maybe you’ll learn something.
Okay, let’s start with the most important thing: is homebirth safe?
The short answer is: yes. Homebirth, under the right conditions, is just as safe as hospital birth, and it is healthier. Meaning, the mortality risks in both locations are equal, but the risk of interventions and complications is much lower in a homebirth.
How do you know this?
In order to determine whether a certain medical treatment is effective and safe, we must turn to the science of medical research, which is called epidemiology. Epidemiology is a complex and advanced science, and if a study is undertaken carefully and methodically, the researchers can demonstrate pretty clear results. These results become clearer the more research done on the same subject—provided that those studies are also high-quality—shows the same results. These kinds of studies allow the medical establishment to check and approve use of medications and treatment methods for various medical conditions. Without epidemiology, we would have no way of knowing which treatments are safe or effective and what side effects or risks are associated with those treatments.
So what about homebirth? As of 2012, there were 12 high-quality studies done on homebirth throughout the world (see sources 1-12)—in the USA, Canada, Britain, Sweden, Holland, New Zealand and Israel. These studies compared the results of low-risk births that took place at home with similar births that took place in the hospital, and they concluded that the mortality rates were similar (and negligible, thank God), but the risk of complications and intervention was much higher in the hospital.
Five other studies (13-17) seem to conclude that homebirths are less safe, but these studies include high-risk births: preterm births (13-17), breech and twin births (13,14), births of babies with severe defects that made them incompatible with life (13,14), unassisted births (15,16), unplanned births (15,16), and births that were planned as homebirths but took place at the hospital due to a complication of pregnancy, but were still included in the homebirth group (17). Upon close examination, not only do the results of these studies not conflict with results of the “positive” studies—they strengthen them.
And those are only the studies that examined general safety. Other studies point to specific advantages of homebirth: for example, in November 2012 a study was published that showed that the risk of postpartum hemorrhage (PPH) was reduced in planned homebirths, even when those births were transferred to the hospital because of a complication (18).
The Cochrane Collaboration, associated with the WHO, conducts reviews of the medical research and publishes conclusions about all the research that exists about any particular condition or treatment. Their reviews are considered the gold-standard of evidence-based medicine. In 2012, they published a review of the research on homebirths, and concluded thus:
“It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications… Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.” (19)
Some countries have been putting this medical knowledge into practice for years and offer homebirth services as part of their national healthcare, for example: the UK, Canada, Australia, New Zealand, Holland and Japan.
In short: Yes, it is safe to give birth at home.
So why are all the doctors against it?
First of all, not all doctors are against it, but that is the general attitude in the medical establishment and particularly in the Israeli Ministry of Health. It’s important to understand that in every medical field—not just obstetrics—there are gaps, sometimes major ones, between the available evidence and clinical practices. It can take decades before the conclusions of medical research filter down to clinical practice. The reason for this is that most clinical physicians are not epidemiologists and are not familiar either with the field or with the current research in their fields (20. Dr. Wagner’s article is well worth taking the time to read.) Much of clinical medicine today is practiced out of habit (“this is how I learned and this is what I’ve always done”) or subjective experience (“This is what I’ve seen with my patients”) and not objective research, known as “evidence-based medicine”. Scary but true.
Furthermore, it’s important to understand what the doctor’s attitude towards birth is: in medical school, he (or she) is taught to search for problems and solve them. He is taught to treat the “interesting”, complicated and scary cases. Obstetricians are surgeons—this is their specialty. When it comes to a high-risk birth, this is precisely the right attitude: “to manage the birth”. For a low-risk birth, however, this attitude is not appropriate. The doctor didn’t go to medical school for so many years to sit on his hands and allow a woman’s body to do what it was built to do, which is exactly what should be done about most births… so he takes charge and manages the normal birth as well, and external management can bring about complications in many cases. We will elaborate on this later. Anyway, doctors see birth as a ticking bomb, something about to go downhill any second, because this is what they are taught and that’s what they see in practice during their work. So it’s no wonder they think homebirths are dangerous and crazy. If something is going to go wrong any minute, the birth should be in a place that can provide the fastest and most effective care in an emergency. Makes sense, no? But the facts and the research show us that this approach is inaccurate and not objective (more about the inaccuracy of the “ticking bomb” approach later). Many doctors have trouble understanding and internalizing this paradox.
It is a myth that the professional with the highest level of qualification is always the most appropriate care provider. Actually, in countries where midwives are in charge of low-risk prenatal care and deliveries and refer women to doctors if a complication arises—there are better maternal and neonatal outcomes than in countries where obstetricians are in charge of prenatal care and low-risk deliveries (21).
Obstetricians specialize in caring for complicated pregnancies and high-risk births. Midwives specialize in low-risk pregnancies and births. (Yes, there are no few Israeli midwives who are opposed to homebirth, but their training is also a product of the medical model of labor management, and many of them are not familiar with the current research.)
Of course, we can also mention financial interests: birth is a profitable industry. In Israel, hospitals receive approximately 11,000 NIS from Bituach Leumi for every birth that takes place within their walls, whether it is a complicated Cesarean birth or a straightforward, simple birth, following which the mother and baby are released after 24 hours. This is to avoid giving the hospital an interest in using unnecessary and costly interventions to make more money. But because most births are pretty straightforward and most women are released within two or three days of the birth, it turns out that the hospital makes a nice profit on each woman who chooses to give birth there (and let’s not even get into the fortune they make on women who are willing to pay an extra few thousand shekels to use the natural birth facilities). This is why hospitals market themselves aggressively to women. Have you noticed how many flyers, brochures, clubs and tours hospitals offer to pregnant women? Where are all the flyers for cancer patients?
It is these same individuals, with vested interests, who teach the courses to medical students, and unfortunately it is also the same individuals who sit on the boards and committees at the Ministry of Health. There is a serious problem of lack of separation of powers within the Ministry of Health, and as a result, policies and decisions are set in place that are not objective, and sometimes do not serve public health.
You will be hard-pressed to find any medical organization that more strongly and aggressively opposes homebirth than the American College of Obstetrics and Gynecology (ACOG). In the USA, as of today, healthcare is privatized, and the financial interests of doctors are very clear. By the way, healthcare costs in the USA are significantly higher than anywhere else in the world, but the maternal and neonatal outcomes are abysmal for a developed country. This shows that the connection between the cost of healthcare, the level of professional qualification, and positive outcomes is not nearly as direct as it seems.
Okay, all this research is all very nice, but in practice, there still might be a sudden complication that would be much better dealt with in the hospital with its staff and technology. How could I live with myself if something happened?
Yes. That could happen, and it is something that a couple must be aware of when approaching this decision. But it’s just as important to be aware of the other side: there is also a risk that a complication may arise in the hospital due to unnecessary intervention, which will lead to a bad outcome as well. There are births that would have been much better off starting at home. What we learn from the research is that statistically, the risk of a worst-case scenario in both locations is equal. That means that both choices are equally responsible and logical, at least from the perspective of irreversible disasters.
How will you live with yourself if you go to the hospital, the birth is complicated by the “cascade of interventions” (more on that later), your wife is rushed in for an unnecessary emergency C-section—and a rare and fatal complication occurs, God forbid? Or a case of criminal negligence (I don’t want to mention specific cases, but unfortunately they are not at all hard to find in the news)? A woman who contracts a violent infection in the hospital does not blame herself for one moment for her choice, even if it is clear that it would not have happened had she given birth elsewhere. She says to herself, “I am giving responsibility over to the doctors, and even if they are wrong and something happens because of negligent care or a complication that occurs because I am in the hospital, I know my choice was responsible. I don’t have control over what happens and what staff I run into, but I have control over my choice, and responsibility to make a choice that is statistically likely to lead to a good outcome”. On the one hand this is true. On the other, it’s no less true regarding homebirth.
However, it is more difficult to live with the decision—as correct, responsible and well-researched as it may be—when it is not “mainstream” or “generally accepted” with a stamp of approval from the Ministry of Health and Badatz hashgacha. The voices around us are disempowering, no doubt about it. This is the social reality. It is your choice whether the opinions of those around you is a good enough reason to choose not to give birth at home.
So wait, how does this even work?
In Israel there are a relatively small number of midwives who are qualified to attend homebirths and an even smaller number of doctors who do so. You can choose your attendant according to your location and your chemistry with him or her. I should note here there is no significant difference between a doctor and a midwife in terms of their training, equipment, and ability to handle an emergency situation.
Throughout the rest of this article I will refer to “homebirth midwives”, but I mean homebirth doctors as well.
Usually, homebirth midwives provide some level of prenatal care (how much and when depends on the midwife), and during this time you can talk about the birth, your preferences and your concerns.
But I don’t get it, what if something happens during the birth? I don’t have an operating table in my living room!
First of all, it’s important to understand that a vast majority of emergency situations that arise in childbirth are not sudden. There are warning signs that the midwife is trained to identify. She will measure the baby’s heartbeat using a portable Doppler approximately once every half hour, check your wife’s progress when needed and with her consent, and watch out for any sign of a problem, such as an unusual and sharp pain or excessive bleeding. The moment she suspects that there may be something to worry about, she calls an ambulance which will bring you to the nearest hospital for further treatment. In Israel, hospital transfer rates stand at around 10-12 percent, and out of these births, only a few end in C-sections (1-3 percent). If there is a reason to suspect that your wife may require a C-section, the hospital will begin to prepare an operating room as soon as they know you’re on the way. It’s important to realize that at the hospital, the “decision to incision” time for most “emergency” C-sections—that is, ones that were not planned ahead of time but arose out of a complication requiring immediate surgery—is thirty minutes or more. Thirty minutes is considered the safe standard even for urgent cases. For this reason, it is recommended that homebirths take place no farther than thirty minutes away from the nearest hospital.
Additionally, midwives bring a suitcase of equipment and drugs with them to every birth, and they are highly trained to respond in emergency situations like PPH or respiratory distress of the newborn.
You are welcome to ask the midwife of your choice about specific situations and how she handles them, as well as her personal statistics.
And what if the midwife doesn’t make it?! I’m really not into the idea of delivering my wife…
Well, if you decide to give birth at the hospital, there is still the chance of your wife giving birth in the car… which is a lot less fun than receiving a birth in a home that was prepared for it! If you see that the birth is progressing quickly and suspect that the midwife may not make it, she will guide you over the telephone, exactly as the emergency medical services would do if you had called an ambulance from the side of the road, only you already know her and she’s already on her way, and there will be no need to go anywhere in an ambulance.
And what if she’s attending some other lady when we call her?
When a midwife can’t make it for some reason or other, she sends a backup who she knows and trusts. In many cases, you will decide together with her which backup she should call.
What will we tell the neighbors? They’re sure to call an ambulance from the screaming…
In most cases, the couple is surprised at how little the neighbors hear of what’s going on on the other side of the wall. But if this concerns you, you can always warn them ahead of time, or hang a sign on your door: “Birth in progress, do not disturb”.
By the way, if we’re talking about screaming, just wait and see what the neighbors are going to hear after the baby is born…
And what about all the gunk from the birth, the blood and all that? Who cleans that up? I certainly hope it isn’t me…
Don’t worry. Before the birth the midwife will give you a list of equipment to prepare, among which will be a nylon sheet and large absorbent underpads that will absorb most of the gunk (which comes out together with the baby). The midwife will handle most of it, and will help you clean and organize the rest.
So while we’re here… what’s the deal with natural birth? Why suffer?
Every woman has different reasons for choosing a natural birth, and you should ask your wife what her reasons are. What’s important to know is that aside from the emotional reasons, natural birth has many advantages in terms of safety and health. Epidurals are relatively safe analgesics, but they are not without risk to the mother and baby. A physiological birth, in which a woman moves about freely and responds to the signals of her body, tends to be shorter, easier and less complicated than a “medical” birth.
I can promise you that there will never be prouder of your spouse than on the day she gives birth to your baby, regardless of the circumstances. Still, there is something else, something special and empowering about a homebirth, in that your wife did it herself, at home, without the aid of devices and medications.
What’s wrong with a little medical intervention? It saves lives, doesn’t it?
Yes. Medical intervention saves lives, no doubt about that one. The question is whether the life in question needed to be saved in the first place.
I’ll give you an example: in a typical hospital birth, the woman arrives at the labor and delivery ward and undergoes an admittance protocol that includes about twenty minutes of CTG (cardiotocography) monitoring that measures the baby’s heartbeat and the strength and durations of the contractions. That sounds reasonable, right? We want to be sure that the baby feels well and to see if the contractions are progressing, so what’s the problem?
There are two problems. The first is that the monitor traces are very difficult to interpret. It turns out that a doctor may interpret one trace as indicative of severe distress requiring an emergency C-section, and a few hours later, may look at the same trace and interpret it as being all right, instructing the woman to continue with a regular birth (22). Additionally, the apparatus itself is notorious for technical errors (and you won’t believe the stories I’ve heard about this). The second problem is that in most cases, the woman is instructed to lie on her back for the reading to be “good” and so the baby’s heartbeat doesn’t “run away” from the receiver. This act of lying down can create the exact problem the monitor is looking for: it causes the heavy uterus to exert pressure on the vena cava blood vessels which carry blood back to the woman’s heart, and this may cause heart rate decelerations and distress in the baby. Also, contractions usually feel stronger and more painful in the supine position, and the lack of movement can prevent the baby from descending and rotating correctly in the pelvis, leading to further complications and interventions. In contrast, the handheld Doppler apparatus used by homebirth midwives does not hinder the woman’s freedom of movement.
The bottom line is the Cochrane Collaboration’s summary (remember them?) of the subject: “We found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour [versus intermittent monitoring with a fetoscope or Doppler]. Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%… The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit. “ (23)
So worst comes to worst, she undergoes unnecessary surgery, what’s the big deal? The most important thing is that mother and baby are well…
That truly is the most important thing. But thank God, in our developed world instances where the mother or baby are not well are very rare, and therefore we have the privilege of paying attention to things of less importance.
The big deal is that Cesarean surgery is major abdominal surgery that is not without risk to the mother and the baby (infections, neonatal respiratory distress, damage to internal organs—and those are only the common ones). Even if everything is fine, the surgery affects your wife’s reproductive future, her functionality after the birth, breastfeeding, and bonding with the baby after the birth, to name a few.
This is just one example of a process we call the “cascade of interventions”. A process that begins with something small and routine like admittance CTG and ends with a highly medicalized, possibly traumatic birth. Sometimes this cascade is necessary and life-saving, but often it isn’t. You as parents have the privilege and responsibility of choosing your path, which in your opinion will bring about the best outcome for the mother and baby. For example, a couple that decides to have their birth at the hospital for various reasons, accepts that this choice brings with it some protocols and routine interventions that are part of hospital policy. A woman who chooses to have an epidural must accept that the epidural has some risks, with the understanding that the benefit of effective pain relief outweighs these risks. A couple who decides to have their birth at home decides that the benefits of a birth without unnecessary interventions and with lower risk of complication, outweighs the risks of the longer response time in event of emergency.
One last and important point (which relates to birth as a “ticking bomb”): It’s true that in pre-modern times women often died during childbirth, but think about it: the very existence of the human race is dependent on women being able to give birth. Evolution built the female and fetal bodies precisely for this purpose. If there was something inherently wrong with this mechanism, the human race would not have been so successful. Most of the fatalities were a result of infection (which nowadays we know how to prevent with good hygiene and treat with antibiotics) or problems that resulted from malnutrition (malformations in the pelvis, excessive bleeding etc.). These two things are pretty negligible in a developed country. Birth works. There’s no reason it shouldn’t work in most cases. Think how absurd it is that today we are so dependent on the medical establishment to save us from a process that is not only natural and normal, but that the entire existence of humanity hinges on its working right!
So fine, so let her give birth in an in-hospital natural birth center with a private midwife who won’t intervene. Why at home?
There are women for whom a natural birth center is an excellent solution, but it does have two major disadvantages: first, that it is still part of the hospital and therefore subject to its policies. Your wife will still have to go through hospital admittance to enter the natural birth center, and as we clarified above, that admittance may prevent her from having the birth she wants, and this may or may not be medically justified.
The second disadvantage is that giving birth at a natural birth center still involves leaving home, and the stress involved may interfere with the hormonal process required for the birth to progress normally. The hormone that causes the uterus to contract is called oxytocin. This hormone is released when the woman feels safe and loved. It is the same one that is released during sexual relations, and it requires a similar environment to be released adequately: low lighting, quiet, calm, safety, focus. These conditions are the exact opposite of what exists during the ride to the hospital or in the hospital itself, and her body responds to the stressful environment by releasing adrenaline, the “survival” hormone, which suppresses the release of oxytocin.
And we have still not mentioned the postpartum hospitalization. First off, the separation between the mother and baby after the birth, which is a whole story unto itself and policies vary from hospital to hospital. The hospital stay may also be the exact opposite of the rest and calm a new mother requires to recover from the birth. Many homebirth mothers describe how wonderful it was get up from the birth and go shower in her own shower, with her own soap and shampoo, to wrap herself in her own towels and blankets and get into her own bed with her baby and sleep the sleep of the just; no bustling nurse at 6 a.m. coming to check her temperature and blood pressure, no dealing with her roommates families and their noise, no beeps and announcements and slamming doors.
For the life of me I can’t understand how women who give birth at the hospital are able to rest at all…
Another thing: the trip home can trigger major breakdown, particularly for new parents with their first child. In the hospital the staff takes care of you and the baby, and you get the feeling that the nurses are the authority and take better care of your baby than you. And suddenly, the moment you walk out of there with that baby seat, you feel the weight of all the responsibility falling on your shoulders all at once. “Who abandoned this tiny, helpless creature in our care?!”
After a homebirth, the transition is more natural. The baby is born, and you immediately begin the process of learning how to care for him or her. You and not the nurse, you and not the doctor. With the gentle guidance of the midwife and your family or friends or whoever you choose to help you. Couples who give birth at home in the first birth emerge with greater confidence in their ability to care for the baby. This may contribute to lower rates of postpartum depression among women who give birth at home (24).
Okay, but this isn’t our first time, and last time she gave birth at the hospital and everything was fine. Why change a winning horse?
I think you might want to ask your wife about that “winning horse”, what she didn’t like about it and why she thinks it might be a good idea to go with a different “horse” this time around.
And what about older siblings?
What will you do with them if you have the birth at the hospital? You can ask Grandma/Grandpa/a friend/your sister-in-law to come over and take them while the birth is taking place, and then bring them back after the birth. There are also parents who choose to keep their kids at home, to watch the birth and take part in it. If you decide to do this, it’s a good idea to prepare your kids ahead of time so they know what to expect. It’s also a good idea to have another “staff member” who will be in charge of them and can take them out if you need a break from them or you change your mind.
Here I will mention that one of the big advantages of homebirth is that it makes the expansion of your family much more organic. The birth of a sibling is complex enough without Mom disappearing to the hospital for several days, lying there in bed like a sick person in a hospital robe with a tube in her arm,
and returning with a baby… you can’t compare this to waking up in the morning (or coming home from preschool or a fun day with Grandma) and discovering a new sibling in bed with Mom, who is smiling, calm and happy!
All right. How much does this whole thing cost?
A homebirth midwife charges about 6000 NIS for the prenatal care and the delivery. Unfortunately, as of today, Bituach Leumi does not compensate mothers for this expense.
Are you out of your mind?! Why would anyone spend that kind of money on a birth when we can have the birth at a hospital for free?! Low lighting, positive experience, blah blah, all great, but seriously! This is crazy!
Look, you’re right, it’s not fair at all that a woman needs to spend this kind of money to have the birth she wants. Particularly when the government pays twice that sum to a hospital whenever someone gives birth there. We hope that that will change soon and that the government will fund homebirths and natural birth centers in Israel, like in the UK, Australia, Canada, Holland and Japan. If you are interested in joining the fight for funding homebirths and natural birth centers in Israel, you can join the NPO “Nashim Korot Laledet” and see how you can help.
But I have a question: how much did you spend on your wedding?
Even if you are not married or you had a “folk wedding” in your backyard with Grandma Nechama’s catering and a dress that Aunt Malka sewed (and if so—good on you!), you are probably aware that most weddings today cost thousands if not tens of thousands of shekels. Why? Because it’s a once-in-a-lifetime event and people are willing to invest for it to be perfect and dreamy and for all their friends and family to join in the joy and remember the event forever (yes, there’s also an issue of social status and ego and all that, but let’s put that aside for now…).
All the more so it is worth spending money on the birth you want. Birth is not just a few-times-a-lifetime event (even if it’s 12…), it’s an event that affects the health of your wife and your child in the short and the long time: physical, mental, sexual and reproductive health. A wedding party does not have any of these repercussions. Birth does. I don’t call that a luxury, I call that an investment.
If you have difficulty getting the money together, there may be ways to find an arrangement. Midwives are flexible about payments. You can give up on fancy new baby gear and go with the simple and secondhand options. And you can ask your relatives to contribute to a “homebirth fund” as presents for your birthday/Chanukah/the birth.
Sheesh… how do I explain this to my mom…
Dealing with the reactions of your friends and family is indeed no small issue. Some couples choose not to tell anyone until after the birth, so the shock and the comments will come only after the fact and there are no dramas in the middle of the birth, like an aunt breaking into the house and trying to drag you to the hospital (though I must say, I haven’t heard of that one yet). Personally, I am a big fan of
honesty and don’t like hiding things. I feel that the more sure you are in your choice and the more you present it confidently and without wavering, people will understand that there’s no point in arguing. But you know your environment and yourselves, and you can use your judgment to decide how much, what, how and who to tell.
Okay… all this sounds a little more reasonable now, but I’m still not convinced.
The idea here is not to convince you, but to give you more information and food for thought. I suggest you mull it over on your own for a while, organize your thoughts and then sit down with your wife for a good, calm conversation in which you raise your questions and concerns. I think it is also advisable for both of you to meet with a midwife to ask your questions and see if you feel comfortable with her.
Still, it’s important to remember that at the end of the day this is your spouse’s birth. This baby is both of yours, but the womb in which he or she is ensconced belongs to your wife. In a healthy relationship, both sides must be considerate of one another and try to compromise. But the last word needs to be hers. It’s her body.
May you arrive at a solution that satisfies both of you and may it be a good and healthy birth!
The writer is an aspiring childbirth educator, had three homebirths and is currently the moderator of the “Active Birth and Homebirth” forum on the “Tapuz Anashim” website. You are welcome to approach her with any questions through the forum. A Hebrew version of this article is also available on the forum here.
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