Home Birth, Birth center, hospital …

birth quotesHome birth 

What is home birth?

Home birth is defined as giving birth to a baby in your place of residence. Home birth can be planned (87% of U.S. home births) or unplanned (13%). It can be attended by a midwife (62% of U.S. home births), a physician (5%), or others, such as family members or emergency medical technicians (33%) (MacDorman et al., 2012). In this article I will be focusing on planned home birth with a midwife.

Who is a good candidate for a home birth?

There is a lot of controversy over who should be eligible to give birth at home. Many countries have standardized “lists” of what makes a woman a good candidate for a home birth, but the U.S. does not. The list below is taken from the criteria used in Janssen’s (2002; 2009) studies on home birth in Canada.

Women who are considered “low risk” and may be good candidates for home birth include the following (this should not be considered an exhaustive list):

  • A woman who is pregnant with a single baby and has made an informed choice to birth at home
  • Baby is head down at term
  • Between 37 and 41-42 weeks pregnant (researchers differ on the 41-42 weeks)
  • No serious medical conditions (heart disease, kidney disease, blood clotting disorders, type I diabetes, gestational diabetes managed with insulin, preeclampsia, or bleeding)
  • No placenta previa at beginning of labor
  • No active genital herpes
  • No thick meconium
  • *No prior C-section
  • *Spontaneous labor

How do you find a midwife?

There are 2 main types of midwives who attend home births in the U.S. A certified nurse midwife (CNM) has a nursing degree plus at least a master’s in midwifery, and is certified by the American College of Nurse Midwives. These midwives are legal in all 50 states and can deliver babies in hospitals, birthing centers, and homes. However, the majority of births attended by CNMs take place in hospitals.

The majority of home births in the U.S. are attended by direct-entry midwives—these are midwives who are directly trained in midwifery and did not go through a nursing training program. A common type of direct-entry midwife in the U.S. is a certified professional midwife (CPM).  CPMs are educated through class and clinical experience. The clinical component consists of an apprenticeship under the supervision of one or more preceptors.  The average apprenticeship lasts 3-5 years. The CPM certification is offered by the North American Registry of Midwives. CPMs have legal status in 26 states and attend births in hospitals, birthing centers, and homes.

There are several other types of midwives, including certified midwives (CM), direct-entry midwives, and lay midwives. You can read definitions of these types of midwives here.

Advantages of home birth…

  • Statistics show that home birth is as safe or safer than hospital birth for low-risk women with adequate prenatal care and a qualified attendant.
  • At home a woman can birth in the privacy and comfort of the familiar surroundings of her own home, surrounded by loved-ones. in whatever positions and attire she finds most comfortable.
  • The birthing woman maintains control over everything impacting her baby’s birth. Meeting her needs is the only focus of all those present. Nothing is done to her without her consent.
  • Birthing time is allowed to progress normally, without interference and unnecessary interventions.
  • Studies show that the risk of infection is reduced for both the mother and the baby.
  • During birthing time the woman is encouraged to eat, drink, walk, change positions, make noise, shower, bathe, etc.
  • Care-givers are invited guests in the birthing woman’s home. She can have anyone she desires present: family, friends, children, etc. Her medical team (midwife and birth assisiant) do not go home because their shift has ended or because it was supposed to be their day off or because it is a holiday or because they planned something else.
  • She doesn’t have to worry about when to go to the hospital since her care-providers come to her.
  • Continuous one-on-one care is given by the midwife, providing ongoing assessment of the baby’s and mother’s condition throughout the birth process and postpartum period. Her care provider knows her well and she knows her care provider. They have established a trust relationship.
  • Women are supported through the hard work of birth, and encouraged to realize the insights, and experience the personal growth as a human being to be derived from such a powerful, life-changing event.
  • Bonding is enhanced and includes everyone who has contact with the baby including neighbors and relatives. Breast feeding is facilitated by the baby remaining with the mother.
  • Cesarean Section and forceps deliveries are unavailable – transportation to the hospital is necessary if these interventions are required. However, rates of both, as well as episiotomy, are very low.
  • The cost of a home birth may be less than a hospital birth, and is often covered by insurance if a CNM is utilized.
  • Pregnancy and birth are viewed as normal, natural body functions and not as an illness or disease.

Disadvantages of home birth…

  • Client’s must assume a greater level of responsibility for their own health: physical, mental and spiritual. This requires active ongoing participation in decision making in all aspects of their care, and a willingness to accept the consequences of those choices and decisions.
  • Since the hospital is the currently socially acceptable location for birth, choosing otherwise may result in negative judgments and lack of support.
  • Cesarean Sections, forceps deliveries and neonatologists are not available at home, transport is necessary for these and other medical interventions.
  • Personal arrangements must be made for postpartum care, such as meals, housekeeping, child care etc.
  • The cost of a home birth may not be covered by the client’s insurance.
  • Analgesics are not readily available with a home birth.

How much does it cost ?

$5000 and up in Los Angeles. That includes all the prenatal care (without blood tests, ultrasounds etc), the birth, and generally 1-3 postpartum visits. Most of the midwives accept payment plans and check with your insurance for reimbursement. Some insurances accept home birth but do not have any midwives « in network » so you have to write a letter to them for an « exception gap ».  If they do not accept home birth (you can still do it, but you can’t claim any of the bills), you can also write a letter to tell them how cheap and safe home birth is in your case. They sometimes will accept to make and exception and cover it.

Free standing birth center 

Birth centers are pretty much the same than home birth, except that it’s like going to someone else’s house. Like home birth, only low-risks pregnancies are accepted.

Advantages of a birth center birth…

  • The facility is usually only provided for pregnancy and birth events.
  • In a birth center, pregnancy and birth is considered a natural and healthy process.
  • During pregnancy and birth, women are encouraged to take charge of their own health care.
  • It provides an alternative to parents not comfortable with home birth, yet do not want to give birth in a hospital.
  • It has many of the same advantages as home birth, such as greater parental control, non-interventive obstetrical care, freedom to eat and move during birthing time, and to give birth in any position, and to have any number of family and friends attend the birth.
  • The parents are usually encouraged to bring family members to their prenatal visits.
  • It offers personalized care at much lower costs than traditional hospitals.
  • In most centers, parents can meet the entire staff prior to the birth.
  • The rate of Cesarcan and forceps deliveries is considerably than a hospital.
  • The discharge time after birth is normally measured in hours, not days.

Disadvantages of a birth center birth…

  • Rigid screening criteria often eliminates healthy mothers, i.e.; VBAC, mother over 35 (depending of facilities).
  • The mother is moved to birth center during birthing time
  • Many centers have rigid rules concerning transporting of the mother to the hospital i.e.; prolonged labor, ruptured membranes. Mother may have to be moved during birthing time.
  • There are usually no pediatricians on staff if the baby has special needs after the birth.
  • The mother cannot remain at the birth center for a two or three day rest; discharge is usually within 4 to 24 hours.

How much does it cost ? 

In Los Angeles the cost of a free standing birth center is $6000 and up. That include the same as the home birth. It often include some classes (breastfeeding, newborn care, nutrition, baby wearing…). Birth center have a better coverage than home birth but there is insurance that refuses them too. You can also write a letter to try an exception gap. My insurance didn’t cover my birth center, they had another one in-network. However, that one was 1:30hrs away from my home. So I asked for an exception gap and we were covered 85%. The downside is that you start your coverage only after it has been accepted. I didn’t know that so I asked for the exception gap a little late in my pregnancy.

Some birth centers accept Medical. Contact me for more info.

Hospital

Giving birth in a hospital is the most common choice in the US. Hospitals accept both low risks and high risks pregnancies. They are well covered by insurance and some of them accept medical.

Advantages of a hospital birth…

  • Many mothers feel safest birthing in a hospital.
  • It is the safest environment for the mother at risk for medical complications during labor.
  • Emergency personnel and equipment is available if the mother develops complications or needs medical attention.
  • It avoids the rush of a last-minute transfer to the hospital (from home or a birth center) if medical problems arise.
  • Anesthetists are available 
  • It is the only option available in the event a cesarean section is necessary.
  • Immediate pediatric attention is available should the newborn need medical care. Baby does not need to be taken off site to be routinely examined by a pediatrician.
  • It has round-the-clock help for the mother and baby (food, diaper changes, medical assistance and information.)

Disadvantages of a hospital birth…

  • The parents are not on « home ground » and do not have the same control they would at home.
  • Hospitals are primarily associated with illness.
  • Hospitals can seem impersonal and intimidating.
  • As a large institution, the hospital has rules, policies and red tape; they are rarely altered to accommodate an individual.
  • Less privacy is available.
  • The partner is often less actively involved in a hospital setting, and may fell like an « outsider ».
  • The mother’s birth is usually managed by experts trained in pathology, not normal births.
  • The risk of iatrogenic complications and infection to the mother and baby is greater among mothers who deliver in hospitals, than among those who give birth at home or in a birthing center.
  • The mother is at a significantly higher risk of having an unnecessary cesarean section.
  • Some routine separation of the mother and baby is almost unavoidable.
  • Most hospitals do not allow the mother much rest.

How much does it cost ?

The cost vary greatly between vaginal birth, length of stay, medical care etc. In the US, an average birth in a hospital cost $30.000. That does not include any prenatal care, and generally 24 hours of post partum care while in the hospital. Fortunately, insurances cover the cost of it and you generally have to pay your maximum annual out-of-pocket. It can be entirely free if you have mediCal. 

source (evidence based birth)
source #2 advantages/disadvantages (modified for hypnobabies language)

Read next article about (walking) epidurals

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