Of the many questions that surrounded my children’s births, “where” was simply not one of them.
There was my house, with its carpeted floors and plush interiors, its tight corners and two flights of stairs. And there was the local hospital, a sterile purpose-built environment. The former I considered a place where people live and watch TV and cook dinner. The latter I considered a place where people go to have medical procedures as safely as possible. Because I counted birth as an essentially medical procedure—a procedure, that is, during which lives are at stake—the distinction between the two locales couldn’t have been clearer in my mind.
So when Jessica Smock approached me with the idea of a feature-length article on the topic of home birth, I was dubious. Jessica and I had already written a pair of essays that turned on the issue of what constitutes a “good” delivery, a debate that illuminated the divide between those of us who view a baby’s entrance into the world as a means to an end and those of us who place a primacy, often a high one, on the process itself. As a woman who is firmly in the means-to-an-end camp, I had to admit to conceptualizing home birth as a rather extreme option on the “process” side, lingering somewhere at the far end of the natural-birth continuum alongside lavender candles and placenta-berry smoothies.
And yet it so happened at the time that a friend of mine was pregnant. This friend, Maria, is one of the most moderate mothers I know, a far cry indeed from the stereotype home birth tends to conjure. She vaccinates her children. They sleep in their own beds; they will attend the school down the road. She is not, in other words, a champion of the kind of anti-institution, “DIY” (do-it-yourself) parenting Emily Matchar describes so well in her book Homeward Bound, the introduction of which contains this gem: “From home births to diaper-free infants to hand-mashed baby food to extended breast-feeding, today’s parenthood often seems to take its cues from Little House on the Prairie.”
Which is why you might be able to imagine my surprise when, on a visit to Maria’s house for tea and cake in the late stages of her second pregnancy, she casually pointed out the pile of birth equipment stashed in the corner of her spare room. It sat there rather ceremoniously, a promise of the major event set to take place a few weeks later in that very spot. It would be an understatement to say I was shocked. But I also became very curious, very quickly. All of a sudden I wanted to understand: what is the motivation to have a baby in your own home?
And this is exactly what Jessica and I set out to discover. We found that home birth, for a certain segment of the population, is not really about answering the question: “Where will my baby be born?” It is about imbuing the birth experience with some sort of meaning that transcends the pragmatic task of getting a baby out of its mother’s womb. Often it is about control and demedicalizing the process of giving life. For once you remove yourself from the hospital setting, with its myriad of medical interventions, there is an inimitable opportunity to let your body lead the way.
Which sounds wonderful, of course, until your body doesn’t quite know the right way to go. Women have been pushing out babies since the beginning of time, fair enough. But women have also been dying in childbirth since the beginning of time, as have infants, in much greater numbers than they do now. A successful home birth might be statistically likely and it’s all well and good if you are in that majority. It can be catastrophic, however, if you are not. And the twist of the knife is that you simply cannot know ahead of time into which group you will fall, however straightforward your pregnancy has been. My sister-in-law, for example, suffered a prolapsed umbilical cord during her labor, a completely unpredictable setback. Had she not been in a hospital, her baby would have been lost.
Risk should be at the center of any discussion of home birth, though as we concluded in our piece, it is a subject about which it is near impossible to draw hard and fast lines. As such, the safety of delivering a baby in your house is one of the fiercest battlegrounds of reproductive medicine: the same data are interpreted variably depending on who is doing the interpreting; new studies with different protocols are drawn up to counterbalance previous studies. Home birth is also an arena that is handled differently in different countries, which affects the perception (and also perhaps the reality) of its safety.
In an astonishing development, announced after our article went to print, the UK has changed its guidelines on home birth and has done so rather drastically. In 2007, the guidelines advised women to be “cautious” about home birth in the absence of conclusive risk assessments. But as of last month the National Health Service is now advising healthy women that it is “particularly suitable” for them to have their babies at home as opposed to in a hospital. That in optimal conditions—low-risk pregnancies of women who have already given birth with no complications—delivering at home is safer because of the lower chances of surgical intervention, accident and infection.
Welcomed here is the idea that certified nurse midwives should play an increasingly important role in childbirth. More suspect is the notion that these midwives should be delivering 45% of Britain’s babies in an environment devoid of certain life-saving techniques should an emergency transpire. According to Amy Tuteur, who goes by the online persona “The Skeptical OB,” “homebirth is no safer than it ever was.” She considers the British development a matter of putting babies’ lives at risk for reasons of political expediency and economic cost-cutting. So too the chairman of the committee on obstetrics practice for American College of Obstetricians and Gynecologists has reiterated the college’s position in respect of the US, a country with a significantly different medical system from the UK: “We believe that hospitals and birthing centers are the safest places for birth, safer than home.”
What kind of practical effect the NICE guidelines will have is unclear. The home birth rate in the UK has been falling in recent years (2.3%), as it has been rising in the US (1.36%). Whether the new recommendations will ultimately put Britain on a par with a country like the Netherlands (where about 25% of births take place at home) is yet to be seen, as is whether the changes in policy on one side of the Atlantic will have any cross-cultural impact on the obstetric practice of the other side. And while home birth is still something I would never choose for myself, I will now be watching with interest as to whether it becomes a more common occurrence among my friends.