home birth: the choice is yours, or is it?
Home births are beginning to make a resurgence in the U.S., but still compose an extremely small percentage of births overall. Although home births are steadily increasing, stigma still surrounds the practice, and people continue to experience barriers to having a birth at home. Pregnant people should have equal access to all birth options and unbiased educational resources on birth should be available. This issue is a matter of social justice because pregnant people are being deprived of choices on where to give birth and from being able to make informed decisions about their birth.
Home birth is a birth method that has existed in the United States for centuries. In 1900 almost all births in the U.S. occurred outside of the now common hospital setting, with a large portion of those births occurring at home (MacDorman 2012). As time went on and modern medicine improved, out-of-hospital births, including births at home and at birth centers, began to decrease. By 1940 only 44% of births occurred out of the hospital and by 1969 the rate of out-of-hospital births decreased to 1 % of births and persisted at this rate through the late 1980’s (MacDorman 2012). From 1990 to 2004 the rate of out-of-hospital births continued to decline and then began its resurgence in 2004 and continued through 2017(MacDorman 2019). During this resurgence home births increased 77% (MacDorman 2019). Additionally, according to the American College of Obstetricians and Gynecologists (ACOG) 2017 committee opinion, of 1.61% out-of-hospital births that occurred in 2017, 0.9% of those were home births (“Committee Report” 2017). It is clear that research shows home births are increasing, but there hasn’t been much discussion as to why they decreased in the first place.
Though there are most likely multiple factors that contribute to the decline in home births and out-of-hospital births overall, one key factor is the transition of birth from being viewed as a physiological process to a medical procedure. Throughout the 19th and 20th century new forms of analgesia, anaesthesia, and safe blood transfusions were developed, which led to more use of these during birth (Johanason et al 2002). In addition, when sulfa drugs were developed in the 1930’s, doctors found that they were decreasing maternal mortality rates, which was occurring often during hospital births ( Thomasson and Treber 2008). As time went on rates of medical intervention began to rise, even for women for whom it wasn’t necessary. This included the use of oxytocin, fetal monitoring systems, epidurals, and increased rates of c-sections (Johanson et al 2002). Today, one in three births is by cesarean: nine in ten of cesarean births go on to be a repeat cesarean (Strauss 2015: “Home birth-Proceed with caution”2010). This medicalization of birth may be a compelling factor as to why home births decreased and became stigmatized.
The stigma around home birth may also exist because of the few medical risks correlated with home birth. The ACOG explains that women who have home births are two times more likely to have perinatal death and three times more likely to have neonatal seizures (“Committee Report” 2017). Studies also show that even when comparing planned out-of-hospital birth to planned hospital birth that rates of perinatal death and neonatal seizure were higher among planned out-of-hospital birth with 3.9 vs 1.8 per 1000 and 0.2 % vs 0.9 % respectively (Snowden et al. 2015:”Home birth-proceed with caution” 2010). Although the rates of both are overall low in either setting, the risks are slightly higher for out-of-hospital births. In addition to the medical risks of having a home birth, we as a country have created a culture that deems pregnant people irresponsible if they don’t give birth in the hospital because hospitals are seen as the safest places to give birth.
Pregnant people often choose not to have a home birth because of the culture of responsibility and fear around it. When we see birth in television and films, the pregnant person is almost always depicted going to the hospital and if they are not then the birth happens somewhere else only because they could not get to the hospital on time or the baby was coming too soon. If people consider the option of home birth they are typically asked questions such as: Why would you want to do that? What if something goes wrong? Is that safe? Is that sanitary?. The pressure is then put on that individual to give birth in the hospital to eliminate any chance of “something going wrong”. The problem with this ideology is that it removes any aspect of choice and disempowers pregnant people in their decision making.
Furthermore, we as a country have a healthcare system that doesn’t support equal access to all birth options. A study of birth trends from 2004 to 2017 revealed that home births are self-paid at a significantly higher rate than hospital births with â…” of home births being self-paid compared to only 3 % of hospital births (MacDorman 2019). Pregnant individuals may not have the option to have a home birth if they can’t afford to pay for a midwife and/or supply related cost out-of-pocket. Moreover, data from the National Vital Statistics report for all 2016 births exhibited that Black, American Indian or Alaskian Native, and Hispanic individuals were at least two times more likely to use Medicaid to pay for birth than private pay in comparison to white and Asian individuals (Martin et al. 2016). This disparity could prevent most women of color from being able to have a home birth if they are more likely to need to use insurance to pay for birth and if their insurance does not cover home births. Despite these barriers to accessing a home birth, they are resurging and this may be due to the positive outcomes correlated with the practice.
Home births may be increasing because of the significant amount of positive effects associated with them. A study of birth trends from 2004 to 2017 found that women who had a planned home birth or birth center birth were less likely to have a preterm or low birthweight child (MacDorman 2019). Studies also show that home birth is highly associated with spontaneous vaginal birth with a rate of 93.8% for out-of-hospital births and 71.9% for hospital births (Snowden et al. 2015). Further, according to the ACOG, home births are also associated with fewer interventions, with interventions including: inducing labor, using analgesia, using fetal monitoring systems, episiotomies, operational vaginal delivery, or cesarean section (“Committee Report” 2017). It is also highly correlated with shorter delivery, fewer lacerations, post-partum haemorrhages, retained placenta and decreased chance of infection (“Home birth-proceed with caution” 2010). Home births also have cost effective benefits for some since they are associated with decreased rates of cesarean and increased rates of vaginal delivery, and studies show that “caesareans cost 50% more than vaginal births when paid by medicaid and by private insurance, adding $6,898 and $8,199, respectively, to the total cost per birth in New York” (Strauss 2015:12). Although all these positive outcomes are associated with home births, it is not seen as an ideal option for everyone .
Home births are safe for those who are considered ideal candidates for an out-of-hospital birth. Despite the fact that the ACOG believes that hospitals and birth centers are the safest place for birth, they do believe that pregnant people should be informed on who is an ideal candidate for home birth (“Committee Report” 2017). The ACOG, along with other professionals, explain that home birth is acceptable for those who have low-risks or uncomplicated pregnancies, a midwife, and live relatively close to a birth center or hospital (“Home birth-proceed with caution” 2010). According to data from the National Center for Vital Statistics, home birth is more common for women who are white, over the age of 35, and who have had multiple pregnancies (MacDorman 2012: Grunebaum and Chervenak 2016). Further, studies show that white women are three to four times more likely to have a home birth than any other race and in 2014 82.3% of out-of-hospital births were to non-Hispanic white women (MacDorman 2019: Grunebaum and Chervenak 2016). Additionally, home birth candidates are less likely to be individuals who are teenagers, obese, pregnant with multiples, smoked during pregnancy, or has a preterm or low-birth weight children (MacDorman 2019:MacDorman 2012).
"Dependency should not be a reason to be deprived of choice and respect, and much of the oppression many marginals experience would be lessened if a less individualistic model of rights prevailed."
The rate of home births are steadily increasing in the U.S., however, they are still not practiced widely and people continue to have unequal access to make decisions about their birth. Iris Marion Young states in Diversity, Social Justice, and Inclusive Excellence “...The feminist model envisions justice as according respect and participation in decision making to those who are dependent as well as to those who are independent (20).” She makes clear in this statement that just because a group may be dependent on something, in this instance pregnant individuals on healthcare, does not mean that they should not be involved in making decisions. Young goes on further to explain that “Dependency should not be a reason to be deprived of choice and respect, and much of the oppression many marginals experience would be lessened if a less individualistic model of rights prevailed(20).” She justifies here how dependency is not a reason to strip away someone’s right to choice and respect and that everyone is entitled to respect and access to choices. In correlation with Young’s argument, pregnant individuals should be respected as a whole and not deprived of their choice of where to give birth.
Though the rate of home births continues to increase, the stigma around home birth and barriers to being able to give birth at home still persist. There are clear positive and negative outcomes associated with home births and controversy over the best place to give birth, however, pregnant people should have the resources to make educated choices for themselves and access to all birth options. Aside from the ACOG beliefs about birth safety, they still feel that everyone has the right to make informed decisions about their delivery (“Committee Report” 2017). In order for the U.S. to shift to a birth culture that supports access to all birth options for all, we need to have a healthcare system that supports birth outside of a hospital setting. This is an issue of social justice that needs to transformed because individuals are actively being prevented from having access to all delivery options and everyone should have the right to make informed decisions about their birth. In order for this issue to be changed there needs to be unbiased educational information available on giving birth at home, at a birth center, or a hospital and who is considered ideal candidates for each setting. In addition, insurance companies should cover birth related expenses outside of a hospital setting to increase the option of having a home birth for all. If these changes are made there would be less stigma around home birth because it would be seen as a regular option like birth center and hospital births and there would be less financial barriers to being able to have a home birth.
Citations:
“Committee Opinion .” 2017.www.acog.org. The American College of Obstetricians and
Gynecologists.
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Grunebaum, Amos, and Frank A. Chervenak. 2016. "Out-of-Hospital Births in the United States 2009-2014." Journal of Perinatal Medicine 44(7):845-849
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Henderson, Jane, and Stavros Petrou. 2008. "Economic Implications of Home Births and Birth Centers: A Structured Review." Birth: Issues in Perinatal Care 35(2):136-146
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“Home Birth—Proceed with Caution.” 2010. The Lancet 376(9738):303–306
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Johanson, Richard, Mary Newburn and Alison Macfarlane. 2002. “Has the Medicalisation of Childbirth Gone Too Far?” Bmj 324(7342): 892–895.
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MacDorman, Marian F., T.J. Mathews and Eugene Declercq. 2012. “Home Births in the United States, 1990-2009.” Centers for Disease Control and Prevention:1-8.
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MacDorman, Marian F., and Eugene Declercq. 2019. "Trends and State Variations in Out-of-Hospital Births in the United States, 2004-2017." Birth: Issues in Perinatal Care 46(2):279-288.
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MacDorman, Marian F., Eugene Declercq and Fay Menacker. 2011. "Trends and Characteristics of Home Births in the United States by Race and Ethnicity, 1990-2006." Birth: Issues in Perinatal Care 38(1):17-23.
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Martin, Joyce A., Brady E. Hamilton, Michelle J. K. Osterman, Anne K. Driscoll and T. J. Mathews. 2017. "Births: Final Data for 2016." National Vital Statistics Reports : From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 66(1):1.
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Snowden, Jonathan M., Ellen L. Tilden, Janice Snyder, Brian Quigley, Aaron B. Caughey and Yvonne W. Cheng. 2015. "Planned Out-of-Hospital Birth and Birth Outcomes." New England Journal of Medicine 373(27):2642-2653.
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Strauss, Nan, JD, Katie Giessler MPH, and Elan McAllister BA. "How Doula Care can Advance the Goals of the Affordable Care Act: A Snapshot from New York City." The Journal of Perinatal Education, 24(1): 2015, 8-15.
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Thomasson, Melissa A., and Jaret Treber. 2008. "From F: The Evolution of Childbirth in the United States, 1928–1940." Explorations in Economic History 45(1):76-99
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