For most of human existence, childbirth was something that happened at home. Lots of women and even more babies died, but that's the way it was. In the early 20th century, childbirth moved to the hospital, not in small part because women wanted it to: They were advocating for a safer place to have a baby and trying to escape from the constant threat of death in childbirth.
But every pendulum in history swings, and this one has been swinging back for some time. Now, many women are advocating for childbirth to move outside the hospital — or even outside the medical system and, in extreme cases, any other help beyond that in a person's home. A recent NBC news feature story chronicled a series of the types of decisions that can lead to avoiding help for a birth and end in tragedy.
The thing about the modern medical system is that it is a massive series of institutions, a huge multi-tentacled bureaucratic experience.
The thing about the modern medical system is that it is a massive series of institutions, a huge multi-tentacled bureaucratic experience that is a different beast entirely from any earlier means of delivering health care. Because of that, it is amazingly powerful; we can do things, and do things safely, that have never before been imaginable.
For example, as a high-risk obstetrician, I can get a woman in her third trimester who comes in hemorrhaging into the operating room, safely anesthetized and ready to receive a blood transfusion within 20 minutes. I can have the baby out one or two minutes after that almost every time. That level of efficiency and success is a gift and a miracle, and I am grateful to be able to deliver it when I have to.
But to get to that high level of care, there are costs. We tend to make processes that good and that fast by standardizing much of what we do, by generating protocols and establishing algorithms. And although good obstetric and medical care is tailored to the individual case, the process overall can feel like one that progressively strips the patient's unique human body of it's individuality.
I frequently hear friends tell me things like "nobody talked to me, they just talked at me" or "no one bothered to explain what they were going to do in plain English." Receiving care in that standardized way can be really tough — especially when it comes during what should be one of the most special moments of your life, the origin of your family.
I think that's part of why pregnant women start to doubt and leave the medical system, retreating to the birthing style of centuries ago. There are other reasons, of course, chief among them a profound mistrust of science and authority that's opened up, demonstrated by the recent rise of opposition to vaccines. But unlike the issue with vaccines, the retreat from the institutionalized birth experience is something that modern medicine often contributes to directly.
And leaving the medical system entirely when giving birth is a problem. I say that not just because I'm invested in my role as part of that very health care system (though I do think that, on the whole, my work does much more good than harm). It's a problem because those women are often leaving behind more than they realize.
Sure, they're leaving behind burdensome monitoring, beeping machines and possibly unnecessary interventions; they're leaving behind hospital-acquired infections and gowns that don't quite close in the back and the feeling some have of just being a medical record number, rather than a person.
But they're also leaving behind centuries of wisdom and expertise and tons of qualified people who want to help — not to mention the vast resources society has devoted to these things via that modern medical system. They're leaving behind the safe pain control that many of us want and need during delivery; they're leaving behind a secure blood supply collected for the 1 percent to 5 percent of women who have postpartum hemorrhages; they're leaving behind skilled pediatricians who can resuscitate newborns who often need help adjusting to this world.
Safety is more assured when the home birth is performed by someone well integrated with the larger health system.
Planned home births can be safe for mom and for baby, but even the safest home birth needs a plan. There are a tremendous number of studies on planned home birth; these studies are hard to do well, and therefore they show a variety of outcomes — most show many fewer interventions for moms in home births, though some have shown a commensurate increase in poor neonatal outcomes or even neonatal deaths.
Safety is more assured when the home birth is performed by someone well integrated with the larger health system that I work in. And that makes sense, because even in the most committed birth centers with the lowest-risk patients, some number of women (around 15 percent in this large study) have unforeseen problems before, during or after labor and need to transfer out to a hospital.
Thankfully, there's a middle ground that allows women to give birth within the medical system while getting the advantages of being outside it. One wonderful asset for a patient who wants to be both within and without the system is a doula, or birth companion. A doula is a gentle advocate and companion for labor — someone whose job it is to reassure a worried laboring woman, to make sure the right music is playing, to try to alleviate pain with a back massage.
A doula performs tasks that are not medical and not part of the job of the rest of the medical staff in the hospital, but it can feel essential to the experience and provide support a pregnant woman needs. On the other hand, doulas aren't medical practitioners, so they can't dispense medical expertise and often aren't covered by insurance.
Another fantastic option for women who want something different from the traditional doctor-heavy system is a midwife. Unlike doulas, certified nurse midwives are trained medical health care providers. Midwives can work with doulas and often handle pregnancy care, labor and delivery without obstetricians (although generally with one aware and nearby in case of emergency).
Thankfully, there’s a middle ground that allows women to give birth within the medical system while getting the advantages of being outside of it.
The training and culture of midwifery puts the patient and her wishes at the center of the experience. And I trust that, because they are medical providers with medical training, they will recognize if a pregnancy develops problems and we can work together to take care of them in a medical framework. This also means that insurance is more likely to cover the care.
Usually, though, patients of midwives don't need someone like me. The vast majority go through labor and delivery with only their midwives — exactly as they wanted to, never needing to know that a doctor was hovering in the background ready to help. They had all the advantages of the system but hopefully just felt like a woman, having a baby, in just the way she wanted to.