It is nearly midnight on a Saturday, and Katie Harrison* is walking up and down the sidewalks of Astoria, Queens. Rushed from her apartment, she is wearing a makeshift outfit of zebra-striped pajama pants, “dorky” running shoes, and an old coat that no longer cinches across her belly. The walk, down the four flights of stairs instead of the elevator, and then outside, up and down her block, is meant to expedite her labor.
Every few minutes Harrison feels the clench of a contraction and braces herself against the walls of the buildings to “vocalize” her pain as it erupts from her abdomen. She oohs and ahhs loudly with each wave.
It is a crisp March night, and 30th avenue is buzzing. Young professionals and Greek immigrants mingle in outdoor sidewalk cafes, chatting over cooling cups of coffee. Pedestrians stream up and down the block, to the elevated tracks of the N/Q train, in and out of 24-hour fruit strands, and past Italian bakeries with dry, colorful pastries propped up in the windows. On nights like this, the street pulsates to New York’s peculiar rhythms, its constant come-and-go, its vibrant sidewalk culture.
The pedestrians glide past Harrison, many, perhaps, wondering just when the woman so evidently in labor might stop pacing the busy sidewalks and flag down a cab for the hospital. But Harrison has no such plans now, or ever. She has chosen to have her baby without a doctor, epidural, IVs, beeping machines, or bulky monitors. Instead, she will deliver in her Astoria apartment, attended by a certified nurse midwife, a doula, and her husband.
A woman passing by pauses next to Harrison, wishing her well in a slight European accent: “Congratulations! And, well, good luck!’” Harrison smiles at the recollection. “I just thought, how cool is that? I’m outside on the streets of New York about to have a baby and some woman is just like, ‘Way to go, good luck.’” Soon it was time to go inside, to alternately labor in the inflatable birthing pool and pace around the kitchen as the night slowly wore on.
And then, at dawn, when bright, blue-ish light was just beginning to seep into the apartment windows, Lucy, at a healthy nine pounds and 20 inches, entered the world on the kitchen floor, her father holding her mother in his arms in a supportive squat. The new family went into the bedroom and curled up under the blankets for their first night together. In the morning, for breakfast, there was champagne and birthday cake.
Planned home births like Harrison's, in March of 2009, have started to gain surprising ground in the past decade, both in numbers and in cultural acceptance. Last year, the CDC reported that home birth had grown 29 percent between 2004 and 2009. Though it was an impressive growth spurt, it did not bring the number of home births up to even one percent of total births in the United States. Nonetheless, home birth advocates find the statistical uptick heartening. They interpret it as a step towards wider acceptance and evidence that the practice has started to shed its anti-establishment aura.
Along the way, home birthing has nudged its way into the mainstream maternity conversation, rallied by the influential 2008 documentary The Business of Being Born, and by celebrities and models gushing about their experiences on Twitter and in glossy issues of Vogue. The pop-culture realm soon followed: a Pampers ad featured a water birth, and Kourtney considered birthing at home in an episode of Keeping Up With the Kardashians. Home birth stories, musings, and recommendations for birthing kit products (think plenty of plastic sheets and pads) now plaster mom message boards.
Aside from the unintended car or subway emergency, out-of-hospital births currently account for only one in every 100 mothers’ experiences. But largely thanks to The Business of Being Born, produced by Abby Epstein and Ricki Lake (the talk show host turned birth advocate), expectant mothers are far more likely to at least now consider the option.
And yet, despite this evolving discussion and mainstream rebranding, daunting obstacles remain for those who wish to avoid the hospital. Midwives who will attend births at home remain scarce (as do birthing centers), even in large urban areas. The choice continues to trigger medical opposition, harsh stereotypes, headache-inducing pushback from insurance companies, and abiding resistance from family and friends. And by no means does the choice to birth at home come risk-free.
Rixa Freeze is a visiting professor of English at Wabash College in Crawfordsville, Indiana, who doubles as a doula and home birth advocate. Her academic research is on the home birth movement and she runs a popular blog on the subject, Stand and Deliver. Freeze points to Lake’s film as a key turning point. The documentary "really brought it into the radar of most normal people," she said. "A lot of people who don’t care about birth issues now at least know that this exists."
The new rise in acceptance, declared New York magazine in 2009, has "de-radicalized home birth." That the magazine would spot home birthing as a trend was an early indicator of its widening acceptance. The movement’s epicenter -- once the crunchy commune of legendary midwife Ina May Gaskin in Summertown, Tennessee (population 866) -- was now shifting to the grand metropolis.
Whitney Hardie is one sign of the urban shift. A photographer, Hardie moved to New York City in 2010. Her first child had been born in a Utah hospital, an experience she found frustrating and “combative” -- a constant struggle with her doctors over what she did and did not want. As she contemplated another pregnancy, Hardie was unaware of what other birthing options she might have. “I occasionally heard about home birth before,” she said, “but it was kind of fringy, like, ‘Oh, that’s weird and scary.’” She thought she might decide on a birthing center (a medical facility designated for natural birth), but she and her husband had moved to Upper Manhattan, where no such centers existed.
Once settled in New York, however, Hardie met women who had delivered at home and who rattled off anecdotes of their positive experiences. “I feel in New York City it’s gaining popularity,” she said. “People definitely don’t have the reactions they have outside of New York -- they’ve heard of home birth before and know people who have done it.” Though at first she doubted she would ever consider it -- and her husband protested that he didn’t want to be “some hippy!” -- they were persuaded after discussing the possibility with a midwife. Their second daughter was born at home, in the tiny tub of their bathroom.
Unrestricted by hospital beds and protocols, Hardie was free to choose whatever position or room she determined most comfortable. Now, feeling relaxed in her own apartment, surrounded by her husband and trusted midwife, she found the home birth filled with noticeably less anxiety and pain. “We don’t ever want to go back to the hospital,” Hardie and her husband agreed.“This was the best thing ever.”
Today, there are 21 home birth midwifery practices in the city -- a number that increased 20 percent between 2010 and 2012. "They are actually turning people away now," said Sally Mendelsohn, who herself is a midwife in the city. At the same time, the type of women attracted to the method has evolved. Vanessa Aja-Sigmon is a Brooklyn mother who chose a home birth for her second child. Sitting in her midwife’s waiting room, she noted the diversity of the women around her. "You do have your hippies," she said, "but you also have your metropolitan high-heeled-business-suit kind of power people. Everyone’s got their reason and it’s unique -- and it doesn’t necessarily mean that you are going against the grain. You just want to feel supported and safe about your birth."
As demand has grown, expectant New York mothers who hope for a home birth are now scrambling to book their midwives as soon as they learn they are pregnant. Harrison herself has 10 friends who also opted for home deliveries. Even back in 2009 when Lucy was born, midwives were in such demand that Harrison simply had to choose the single city practice without a booked-up schedule, “the only option left.”
Headquartered on the 19th floor of an office building on Lexington Avenue is Choices in Childbirth. CiC, as it calls itself, is one of the main leaders of the alternative birth movement. Its mission statement: "We help women make informed decisions about where, how, and with whom to birth."
CiC’s program manager is Grace Rice, a young woman with short, neatly cropped blonde hair and a master’s degree in Public Health. “There’s been a lot of talk here about just reaching the tipping point in general,” Rice said. “Reaching the point where in the United States this movement isn’t the fringe -- that it becomes normal for women to want to have a doula, or to have a home birth, or the word ‘midwife’ isn’t still thought of as someone who just shows up at your house with a bucket.”
Abigail Adams, a New York City mother and Upper East Side native, is part of that growing group of women whose perception of midwifery and home birth has changed. Until relatively recently, the only time she recalls hearing the word "midwife" was in the title of a children’s novel she had read in third grade.
And yet, when Adams gave birth in the summer of 2011, at age 24, she chose to do so at her apartment in Upper Manhattan, attended by a nurse midwife. Positive input from friends and the growing number of books, media attention, and documentaries about the “Midwifery Model of Care” had her convinced.
Of course, midwifery and home birth are far from new. A birth at home was certainly the norm up until only about a century ago. In the 1900s, an estimated 95 percent of all births occurred at home. But in those days, the definition of “midwife” was loose. Many of the women -- and it was almost always women -- who attended births had no formal education. Skills were informally passed on, and there was little government regulation.
Today, all licensed midwives must undergo extensive formal education and are regulated by national accrediting associations, like any medical profession. Modern midwives provide prenatal care, general well-woman gynecological care, and they attend low-risk, natural deliveries (most in the hospital, although at home and in birthing centers as well). In general, they spend more time with their patients and take a more holistic approach than medical doctors. They focus on facilitating a low-intervention birth.
Yet in the past, the widespread lack of prenatal care or testing, the high rates of poverty, and the absence of antiseptic practices made home births particularly risky. Mortality rates were high. At the turn of the century, between 6 and 9 of every 1,000 pregnant women died of birth-related complications. Soon, those who could afford to do so began electing to birth at the hospital with a physician in attendance. The shift came quickly. By 1938, about half of all American births were in the hospital. Just 17 years later, by 1955, almost no babies were born at home.
The statistics have largely remained the same since. With 99 percent of American women birthing in the hospital, the idea of an out-of-hospital birth became tagged as a risky choice confined to radicals, the uneducated, and the poor. What was once considered a natural rite of passage became a medical procedure, and depictions in films and television shows solidly reflect the overall American perception of birth -- a medical emergency involving fits of screaming, pain, and interventions.
These interventions, hospitals, Caesarean sections and extensive prenatal care have, in the time since the 1900s, certainly saved lives. But many now wonder if the medicalization of birth has gone too far. Today, almost one out of three American babies, or 32.8 percent, has a Caesarean delivery -- despite a suggestion by the World Health Organization that a reasonable rate is likely no more than 10 to 15 percent.
Further, artificial induction of labor has more than doubled in the past few decades. Many women have expressed disappointment with the over-medicalization and lack of dignity in what they felt should have been a focus on the new life entering the world. "I do in some ways understand the rebellion against the medical establishment," said Dr. Chris Creatura, a New York City-based obstetrician and gynecologist. "We really haven’t done a good job of respecting women’s autonomy and making this experience a positive one."
This growing acceptance of home birth also parallels the larger trend to favor the natural and organic foods once only associated with fringy granola types. Breastfeeding rates continue to rise and the number of certified doulas (a nonmedical assistant and coach during childbirth) has spiked dramatically in recent years. Alternative medicine no longer seems dubious. As Michael Spector wrote recently in The New Yorker,
The era of paternalistic medicine, where the doctor knew best and the patient felt lucky to have him, has ended. Our healthcare system has become impersonal, mechanized, and hollow, and it has failed millions of people, many of whom want to find a way to regain control of their own medical decisions.
After all, it is not only the home birth rate that has reflected this shift. Though midwives are often associated only with the home, 96 percent of all midwife-attended births actually occur in hospitals, and that overall rate has increased every year for the past two decades. In 2009, the latest year for which data is available, midwife-attended births reached an all-time high, with midwives attending 1 in every 8 vaginal births in the United States.
Increasingly, to give birth outside of a hospital or with a midwife in a hospital is considered a privilege, a new "status symbol," especially among the urbane. It is an opportunity to avoid crowded, hectic florescent-lit hospital wards and cascading medical interventions, to receive more personalized attention from healthcare providers, to take a more active, deliberate role in the labor process, and to welcome an infant into the world in the relaxed, boutique environment of the home.
Many of the movement’s legacy leaders, who entered the field when it was far from hip, have been surprised by this new classification of “status.” At the same time, the newfound cool has doctors and some health organizations worried. Could the same risky home birth practices of the more distant past simply have a new PR spin?
“Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre,” declared a press release of the American Congress of Obstetricians and Gynecologists in 2008. “Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.” It’s hard to imagine that Ricki Lake’s documentary, released at about the same time, did not help to incite ACOG’s issuing of such a statement.
Rice, of CiC, also pointed to the film’s influence on the current trend. “I think The Business of Being Born -- and lots of people say this -- did the most for getting this issue into the mainstream, that has never been done before, in a way that wasn’t hippie and disenfranchising,” she said. “So many mainstream moms have seen it and said, ‘Oh, I saw The Business of Being Born and it changed my life.’”
What the film did, besides prompting obstetricians to raise eyebrows, was offer a more conventional reference point to mothers considering an alternative birth. The film had high production values and was stocked with experts. It steered clear of the radical taint that proved dissuasive in the past and presented the complicated issues of modern maternity care in a visual, easy-to-digest, and convincing manner; images of escalating medical interventions and bleak hospital rooms are set to alarming music and coupled with eye-popping statistics.
In the documentary’s sequel, More Business of Being Born, the supermodel Gisele Bündchen blissfully enthuses over the spiritual, relaxed experience of her home birth, which, she has said, “didn’t hurt in the slightest.” She was not the only celebrity mother featured. “Women have been giving birth naturally for gazillions of years,” a sun-kissed Cindy Crawford reminds us. “When you’re home, you have much more inner resources to draw on. You’re not dealing with a new environment and strange people -- you turn in.” Crawford adds, “And I think that’s where you really need to be to birth.”
Almost all of the mothers I interviewed, whose children were not born in hospitals, mentioned the film. They summoned it to help convince their partners or to explain their decision to skeptical family members and friends. For some, the film was utterly determinant. Harrison’s husband, for example, was finally swayed after seeing the documentary. She said it left him “1000 percent convinced.”
In the sequel, Lake and Epstein, the film’s director, trumpeted how successful the original documentary had been. “Women -- and men -- have taken this film and just run with it,” said Epstein to the camera, as Lake sits next to her, beaming. “It just struck a cord in these women where they are like, ‘Yeah, that’s right. Why are we putting up with this?’”
Most hospitals no longer routinely perform the distasteful procedures of an earlier era. No more are enemas, pubic shaving, and episiotomies pro-forma. Maternity wards are no longer anti-breastfeeding or quick to pull a baby away from the mother. And hospital professionals are keen to encourage the involvement of the other parent during the birth itself.
But what has become the major turnoff for many prospective mothers is the inordinately high incidence of C-sections. In the film, and in my interviews with local midwives and mothers, the subject came up again and again as a primary reason for women opting out of the hospital choice. Jana Branson, a Park Slope woman who is pregnant with her first child, may be one of them. “As soon as I’m in a hospital, then the possibility of C-section goes up a lot,” she said. “That’s just what my brain jumps to, I guess.”
Her concern is not unfounded. Not only are one in three hospital births by Caesarean, but it has also become the most common surgery performed in the United States, rising an astonishing 60 percent in the 13 years between 1996 and 2009. And yet, it has not produced the logical result -- a similar decrease in mortality rates. In fact, the maternity mortality rate for women in New York City -- those who die in childbirth or from pregnancy-related complications -- has actually increased 30 percent over the last 10 years for which data is available. And the decline in infant mortality rates in the United States has come at a slow, stagnated rate, especially in comparison to similarly developed countries. When compared to its 16 "peer countries," the U.S. ranks worst in infant mortality. The Department of Health and Human Services has now called for a 10 percent reduction in the C-section rate among low-risk women by 2020.
“There is not a single OB in the United States that could really look at you and say that our C-section rates are really natural or OK,” said Rice. “It’s great that we have OBs who can perform Caesarean sections in emergencies, but 35 to 50 percent are not emergencies.”
While factors such as elective surgeries, growing rates of obesity, and the age of mothers have likely helped lead to more C-sections, natural birth advocates argue that the bulk of the rise is largely unnecessary. Instead, many see excessive induction of labor (which has been shown to significantly increase the odds of a C-section) such as the liberal administration of Pitocin, a form of synthetic oxytocin used to facilitate labor, as a factor that has likely contributed to the increase.
A quick labor -- or even quicker, a C-section -- is also, of course, more efficient for both hospitals and doctors (and incidentally, more profitable). It’s also what experts call America’s move towards "defensive medicine," where medical decisions are increasingly dictated by liability risks. Obstetrics pays some of the highest damages among medical practitioners, and residents of places like New York City can be especially litigious. In a 2012 survey of New York area obstetricians, 21.1 percent of respondents admitted that liability had influenced their decision to increase the number of Caesarean deliveries they performed.
The usual stereotype sees home birthers, midwives, and advocates as strictly anti-medicine, but most insist they are not -- as long as interventions are used properly. As Rice of CiC explained, “Just because we have the technology and we have the medication doesn’t mean that we have to use it in every case. They are for moms who are high-risk and all of these interventions that happen immediately when a woman enters a hospital -- there’s no thought as to ‘Well, does she even need Pitocin, or do we just want to give her Pitocin because we need that bed in 12 hours?’”
Midwives generally recommend that women who do not qualify as low-risk should plan for a hospital delivery with a doctor, and those who are accepted by midwives should still be prepared to transfer to the maternity ward in the case of stalled labor or complications. The prenatal period is filled with testing and checkups (at either the home or the midwife’s office), much as it is with a traditional OB/GYN. And most midwives and mothers are quick to add that although the home was the best choice for them, they do not believe it is right for everyone. “Notwithstanding my saying that 90 percent of women could give birth normally at home, I would never say that they ought to,” Mendelsohn, the nurse midwife mentioned earlier, said. “I think everybody needs to deliver where they are most comfortable. If she wants to be in the hospital, she ought to be in the hospital.”
Midwives are not surgeons. Their speciality relies on natural, low-intervention techniques, and they tend to call in a surgeon for a C-section as a last resort. Julia Lange-Kessler sees this as one of the profession’s top selling points. She is a certified midwife and coordinator of the Nurse Midwifery Program at New York University. “I like to think that when you have a birth with a midwife, if you are having a C-section, you are having a necessary one as opposed to an unnecessary one. And that midwife is going to try every trick in her bag that she can before you have to go that section,” she said.
New York mothers interviewed expressed particular concern about practices in their city’s hospitals. Although C-section rates in New York City, at 32.3 percent of all births, are no higher than the national figures, mothers feared their risk of having to submit to the procedure was greater than elsewhere, where crowded wards in the boroughs might make efficiency more pressing. Hardie, the photographer mother, ruled out city hospitals for her second child when, during a photoshoot of a client’s birth, she noticed how liberally Pitocin was administered. “The whole system just felt like you really needed to have your baby as fast as possible,” she said. “I thought even what I had experienced in Utah, it would be even more so in New York City.”
Risa Klein, a prominent city midwife, echoed the feeling. She lives and keeps an office in Manhattan but deliberately attends deliveries at hospitals in New Jersey in order to avoid the "rules, stress, and fear that permeates and runs rampant" on the labor and delivery floors of the city. She has a C-section rate of just 5 percent.
Jeanette Breen, a nurse midwife on Long Island, estimates that half of the women who engage midwives like herself do so after an appalling hospital experience they vow never to repeat. After all, it’s not just a possibly unnecessary surgery that can scar an expectant mother. A hospital is never a place one wants to be. We go because we have to, because we are sick, and pregnant women, home birth advocates insist, are certainly not sick. Taking a natural, positive process and twisting it into a medicalized moment of rushed interventions and cold, sterile rooms often seems, to many New York City home birthers, to be the more radical choice.
“To me, the hospital is for sick people, and not for healthy people giving birth,” said Adams, the Upper Manhattan mom. “Hospitals freak me out anyway, so I didn’t want to go into one.” She was worried about the risk of infection, believing that by delivering at home she was at least surrounded by her own germs.
Although a desire for a low-intervention, unmedicated birth is common to all who chose home birth, others were also swayed by comfort. “One of my fears was actually needles,” said Aja-Sigmon, who delivered once at home and once at a birthing center, and later became certified as a childbirth educator and doula. “The idea of a needle anywhere on my body -- an IV, my back -- it’s like, that’s enough to make me not want to give birth in the hospital.” Women found other aspects of the out-of-hospital experience equally alluring. They enjoyed ditching the hospital gown in favor of a favorite T-shirt, or nothing at all. They welcomed the absence of that rushed, stressful ride to the hospital, and being able to shower or blast a playlist at will. The wanted the freedom to choose whatever laboring position was most comfortable and conducive to labor, and they looked forward to cozying up in their own sheets immediately after the birth, with a new baby who has never been taken from their arms.
Harrison also expressed an unexpected reason why the hospital is sometimes avoided. “I have been sexually assaulted and that’s something that has come up for a lot of people who are sexual assault survivors,” she said. “I just have a lot tied up in the idea of consent, just even in the medical sense.” The possibility of a C-section terrified her. “Having something really scary happen to you, kind of without your consent…I was so freaked out by that idea that I was having PTSD flashbacks.”
To another mother who had endured a sexual assault, but declined to allow her name to be published, the personal care she received when she gave birth at home in 2010 was paramount. “I’m a rape survivor and one of the conversations that came up with my midwife and doula -- and never with the gynecologist -- was asking that question of if I had ever had sexual trauma, as it can come up during birth. That was really important,” she said. “[A natural home birth] wasn’t something that was going to be done to me or things that were going to happen to me. It was something I was a part of.” Turned off by the experience with her gynecologist, she found comfort in the Midwifery Model of Care: “I didn’t get eye rolls when I was asking questions about my medical care, which is what I first got at Beth Israel, like, ‘Oh, you don’t need to worry about that,’ or, ‘That’s for us to decide.’ I wasn’t feeling like my voice was heard.”
Others agreed that this extra personal attention midwives tend to offer was the most important factor. Aja-Sigmon said her decision didn’t involve “a major philosophical reason at first. It was just the idea that midwives tend to spend more time with each patient. In terms of most things I don’t need that, but in terms of something as intimate and intense as giving birth, that made a lot more sense to me.” Midwives don’t have their hand on the door to get to the next patient, is how one New York midwife put it.
In the past few years, New York City, and the state, have been working to increase accessibility to birth choices and lessen the obstacles to non-hospital options.
Prior to 2010, home birth midwives were legally required to carry a written agreement with doctors willing to "back up" their practice. But securing a signature from a doctor became increasingly difficult. "There are very few doctors who are willing to be associated with the model. It’s a threat to them," said Alice Gilgoff, a licensed midwife and advocate in New York, as well as the author of Home Birth. The required signature was largely considered a pointless bureaucratic law anyway, since in the event of a needed transfer, a midwife would likely bring the mother to the nearest hospital, not to the doctor with whom she had signed an agreement.
The restrictions of the law became alarmingly apparently when St. Vincent’s Hospital closed in 2010. Seven out of the 13 city home birth midwives at the time had signed agreements with doctors at St. Vincent’s. The hospital’s closure effectively made it illegal for almost half of the city’s midwives to practice. That same year, despite strong opposition from ACOG, New York passed the Midwifery Modernization Act, repealing the requirement of a doctor’s signature and simultaneously expanding midwives’ independence in the medical field.
New York state is also now among the few that doesn’t require midwives to hold a nursing degree before being licensed, a move that many hope will open up the field to more midwives. “New York is unique in the country," Gilgoff said. “It’s considered a leadership state among other states where they actually want to increase access to midwifery care.”
But even with legal advancements, the home birth choice is still, in reality, far from an accessible choice for many families who might otherwise be interested. Indeed, it requires considerably more effort, time, money, and knowledge than it does to simply follow one’s obstetrician to the hospital where he or she practices.
In theory, a home birth -- avoiding lengthy hospital stays and costly procedures -- ought to be the more economical choice. And this was largely true in the past. Yet wrangling with the insurance company to cover the cost of the birth can be difficult and can today often carry higher out-of-pocket costs than a hospital birth. Further, some policies stipulate that if a planned home birth results in an emergency transfer to the hospital, no hospital expenses will be covered. It poses heavy financial risk that few low income families could reasonably accept.
Medicaid in New York does reimburse for home births1 -- but only up to a certain point -- and even though New York insurance laws theoretically cover2 the practice, many mothers found that fine print and exceptions were exasperating enough to be a deterrent. “Our insurance didn’t cover it; we fought them,” said Aja-Sigmon. “We entered the repeal process and it was a pain in the butt. It took months of diligence, and hours of our life, and time, and calling and writing letters.”
In the end, after the birth, Aja-Sigmon had every penny covered, but she, and many families like hers, had to go ahead without a clear sense of what the out-of-pocket expenses might be. The time and knowledge needed to navigate and appeal the complicated insurance process is one reason why home birth might have started to become associated only with the wealthy.
“‘The birth movement is so like Park Slope moms and Upper West Side -- middle and upper class women who have time on their hands to do research about birth options and do want an empowered birth,” said Rice of CiC. “And then there are all these other women who are too busy working three jobs and trying to get food on the table -- it’s not even on their radar.”
When Hardie, the mother who gave birth in her bathtub in Upper Manhattan, first called her insurance company inquiring about information on coverage for her home birth, she instead got a lengthy lecture on the dangers of the practice. The representative explicitly noted that the company did not support home birth and ticked off a long list of reasons why. This, of course, is the spiel that many women choosing home birth have heard before, perhaps most vehemently, in a doctor’s office as they inform their OB/GYN of their choice.
ACOG accepts the role of licensed midwives in hospitals and birthing centers, but nowhere else. Its 2007 statement on the issue is clear: "ACOG does not support programs or individuals that advocate for or who provide home births." Although the organization’s overall position has largely remained unchanged, a new statement released in 2011 drew more on the new language of the movement -- emphasizing choice -- while still denouncing the practice:
Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.
(In late April of this year, the American Academy of Pediatrics also revised their statement, concurring with ACOG’s new acknowledgment of birthing options.) But sounding the alarm on home birth, the ACOG committee added that it "is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth."
And yet, the committee acknowledged that “high-quality evidence to inform this debate is limited. To date, there have been no adequate randomized clinical trials of planned home birth.”
The fact is, it is almost impossible to devise a randomized controlled study that adequately compares home to hospital birth. Some studies that concluded the risks at home were higher had included unplanned births, those performed by unlicensed midwives, or those involving mothers with high-risk factors, such as breech birth (where the baby is abnormally positioned feet first) or twins. Most licensed midwives would not take on these patients.
Studies that tend to favor home birth are similarly flawed. Most women who choose home birth are very low-risk to begin with, while hospital data include some of the most high-risk patients whose birth experience is more likely to lead to death. And sometimes, even if complications began at home, a home birth transfer to the hospital can be counted against the hospital. Some home birth advocates cite studies from places like the United Kingdom or the Netherlands that indicate better outcomes with home birth. Yet physicians argue that this is comparing apples and oranges. Not only are the medical systems in those countries radically different, with better prenatal care, but they are also more accustomed to home birth. They thus have organized transfer systems between the home and the hospital which likely lead to better outcomes. (This is one example of the ways some midwives feel the American hospital system, by being so unaccepting of home birth, actually hampers its safety.)
Dr. Creatura, the New York City OB-GYN, delivered babies until recently at New York Presbyterian Hospital. Although she says she is not as intensely anti-home birth as many of her colleagues -- she has friends who have chosen to birth at home -- she still insists that the practice presents too many risks. “Birth is a life-threatening process,” Dr. Creatura said. “Yes, it may be natural, but it’s also life-threatening and body-altering.”
Many midwives and advocates contend that home birth is safe when limited to low-risk women with minor chances of complication. “The beautiful thing about birth is that there is so much information you get in advance about whether you are going to have a problem,” Mendelsohn said. But Dr. Creatura disagrees. “You can certainly eliminate a lot of troubles, but in some of the most horrendous cases -- you didn’t expect something bad to happen. The people who came close to dying were the ones who weren’t supposed to,” she said. “The nice thing about birth is that it almost always turns out OK. But the problem is that it is not plannable.”
It is an assertion that contradicts the dialogue of the new birth movement. You can have Your Best Birth -- the title of Lake and Epstein’s follow-up book -- if only you methodically plan for it. “I don’t want to not have the birth I want just because I’m scared,” the actress Alyson Hannigan insists in More Business of Being Born, on her decision to have a home birth despite sharp caution from her doctor.
Dr. Creatura stopped delivering babies, in part, because of her disappointment with hospital protocols, largely dictated by the legal department. They restricted her practice of medicine and aggravated her patients: “Certain protocols are meant to protect patients,” she said, “but it ends up hurting them.” She understands how hospital policies and poor experiences can lead women to explore other options. And yet, Dr. Creatura urges that the hospital still must be chosen, simply for its safety. Home birth, she said, “is an unnecessary risk for women of great options and privileges. Most of the time it turns out great. But when the outcomes are bad, there is a lot of blame -- and women then feel very guilty that they made that wrong choice.”
Harrison, for the first three months of her pregnancy, continued to see her regular OB/GYN. But when she finally informed her doctor that she was planning a home birth, the relationship soured. “She was just very judgmental. Very, very judgmental. She said ‘that’s not safe’…and like, ‘You should let a doctor make that decision, because you’re not educated enough and you’re not old enough’” Harrison remembered. “I was like, I’m 26, a grown woman. I have a master’s degree. I wasn’t a doctor, but I was treated like I was an 8th grader.”
To counteract doctors’ negativity, many women who chose home birth rely on their own research, common sense, and what they feel they know about their own bodies. As Hardie explained, “I was definitely not worried about what the OBs were saying because I had been through that process before, and . . . I often thought that my OB was trying to scare me or get me to do something that I didn’t want to do, like induce because it was better for his schedule. I didn’t feel like I could trust them as much as I could trust my midwife. Common sense as well as documented studies show that it is safe, but we just have a culture of doing it differently. And I think OBs have a livelihood to protect.”
In recent years, as home birth has become more common, doctors and organizations have become more vocal in opposition to the practice. A recent study in the American Journal of Obstetrics & Gynecology went so far as to call home birth a “compelling example of what happens when ideology replaces professionally disciplined clinical judgment and policy.”
Dr. Creatura agreed. “I feel like it’s so important in women’s health care to be sure that we are really conscious of what is actually good -- not just for the movement, but for the individual,” she said. “In the name of empowerment, there is a lot of lying.”
Klein, the Manhattan midwife who practices in New Jersey hospitals, was a television news producer before she swapped careers after the birth of her first child. “That was the greatest production ever,” she said, in the office she keeps among a cluster of medical suites on First avenue in Gramercy. “I knew I could help other people, because it was the best thing that ever happened in my life.” Klein began her career as a lay home birth midwife -- prior to receiving her degree in Nurse Midwifery from Columbia University -- but she is increasingly finding real problems with the home birth movement. (She now only accepts one or two home births a year, and her barriers for acceptance are high -- mothers must be extremely low-risk, as well as well-versed in the process.)
Films like The Business of Being Born were a “blessing” in generating more awareness of the work of midwives, Klein said. But she laments some of the other effects the film had on women, believing the documentary creates the mistaken impression that anyone could have a home birth. She saw the outcome in her own practice, noticing a surge in women making appointments with her who wouldn’t qualify. “They’d ramble off reasons and I’d look at them and say, ‘I’m sorry, I can’t work with you…I’m sorry, but I don’t buy it. You want a home birth because of The Business of Being Born, but you’re really not even a home birth candidate.’ And then they’d sit there and cry.”
As a hospital midwife, she is often on the frightening hospital end of home births, dealing with transfers brought in by midwives and trying to “fix” the problems before it leads to a C-section. “Not every woman can have a home birth, for medical reasons, and many midwives take them and then I see them,” Klein said. “Just because it’s a choice -- it’s not for everybody.”
As a midwife who has an official, professional relationship with an obstetrician and perinatologist, she also takes issue with the way the film, and the language of the new movement in general, slams doctors and C-sections without recognizing that, in many cases, the need for both is valid.
Aja-Sigmon agreed that the film might have oversimplified the conversation. “It kind of says ‘midwife, good; OB, bad’ when there are lots of amazing hands-off OBs and other midwives who don’t exactly follow the Midwifery Model of Care.” “People were more aware with what midwives do,” she said. “But they also automatically equated having a midwife with having a great birth, an empowered birth -- and then you see people who are really disappointed.”
Others found the film’s birthing boosterism derisive to women who elected to give birth with an epidural or a doctor, or who underwent a C-section. It conveyed an undertone of elitism and judgment, leaving some of those who ended up in the hospital with a sense of not having cared or tried hard enough. The model Miranda Kerr drew fire from some mothers when, in the August 2010 issue of Harper’s Bazaar UK, she called babies born with an epidural "drugged up," and said that her choice to birth her son naturally was to "give him the best possible start in life."
Doctors and nurses sometimes remind those who choose an unmedicated birth that “there’s no gold medal for going without medication,” a saying that hints at the idea that mothers who decline an epidural do so for the bragging rights. Though home birthers and unmedicated birthers insist that this is far from the truth, there is, nonetheless, a sense of perceived pride that surfaces. In More Business of Being Born, Laila Ali, the daughter of Muhammad Ali, spoke of other mothers requiring epidurals to birth: “I know most women feel that way -- I’m not the average woman,” she said.
It’s part of the dialogue that can turn others off of the movement. “There is this friction between natural birthers and medicated birthers,” Hardie agreed. “This feeling that maybe it’s this ‘status symbol’ in terms of how good of a woman you are.” It’s due to this that Hardie, and many of the other unmedicated and home birth mothers interviewed, say they purposely steer clear of bringing up their experience unless asked. They do not want to impose a choice, or make others feel defensive about their decision.
Stephanie Krause is an artist and mother of two in Brooklyn. When Krause and her husband first learned they were expecting, “home birth wasn’t really even on the radar.” But after touring hospitals and learning that even birthing centers came with restrictions and risks of intervention, they decided the home was their best option. Resistance from family and friends was strong. “In my circle, I was such a pioneering move,” she said, “I was so excited to be the token successful home birth that would make all my friends interested in home birth.”
Instead, after 72 hours of excruciating “back labor,” Krause ended up with an emergency transfer to the hospital. She was fully dilated and had been pushing for hours, but the baby was in a posterior position and was simply not transcending. By the time she arrived at the hospital, she was thoroughly depleted. “If you could have gotten the baby out by now, you would have,” the doctor said. “I think you should have a C-section.”
It was a result, albeit necessary, that Krause found “crushing.” She cried throughout the procedure. “I wanted this peaceful home water birth and here I was in the operating room and [my daughter] was suctioned and taken from me, and I didn’t even get to hold her,” Krause said. “I just learned so much from this experience about lack of control.”
For days after returning from the hospital, she was in shock. The outcome -- so different from the natural, home birth ideal -- made her to “feel lesser.”
As a home birth mother who ended up with complications and a Caesarean, she found she was now considered “the shameful secret” of the home birth community -- as experiences like her own, she said, are often upheld as the reason why women shouldn’t choose home birth in the first place. “I just felt so guilty,” she said. “Especially with The Business of Being Born, that movie is very heavy-handed about how harmful C-sections are to the baby, so that was hanging over my head too, like, ‘Oh my god, I’ve ruined her.’ It’s not just a loss of your dream. It’s all this guilt about what you’ve done to your child and their horrible entrance into the world.”
The scar that results from a section can lead to an increased risk of uterine rupture during subsequent labors. "Once a Caesarean, always a Caesarean," is the maxim, and vaginal births after a section -- they are referred to as VBACs -- are relatively rare. It is one reason why many women want to avoid a first Caesarean. ACOG has recently modified its statement to be more open to VBACs for low-risk women, but many doctors -- and midwives, depending on how high-risk the woman is -- still will not accept them, especially not for a home birth.
But when Krause became pregnant with her second child, she chose home birth again. “I did so much work to make it work, it was actually ridiculous,” she said, recounting the number of books she studied and the body work she did on fetal positioning. But in the end, complications from her first C-section led to a second emergency transfer to the hospital.
Krause now wishes that the home birth community were more open about mothers like her, whose labors end in complications. “Midwives [need to] bring it up more blatantly during the prenatal care, even if they say, ‘Look, you have to realize this is something that can happen,’” she said. During her pregnancy, she had been so engrossed in her ideal birth, that she knew she herself wouldn’t have wanted to hear anything that questioned it. But when things didn’t go as planned, she had been so unprepared for the possibility that she found the fallout devastatingly worse.
“You can trust the process, but it’s better to do it without being Pollyannaish about it. Birth is still a very primal, unpredictable thing, and you can plan and trust until your stomach is content but that doesn’t mean it’s going to happen that way,” she said. “The fact is [The Business of Being Born] doesn’t even consider the home birth Caesarean moms. It’s just you’re either a home birth mom or you’re one of those moms that goes to the hospital and has interventions.”
Klein, the hospital-based midwife, agrees that this can be one of the assumptions that the birth movement has created. “No woman should feel that she can’t have a joyful, bonding birth if she has a C-section,” she said. She explicitly blames The Business of Being Born. “People shouldn’t feel that if they don’t have a home birth that they’re not good enough -- and that’s what that documentary does,” she said. “We have to give up this notion of home birth as ‘status symbol.’”
Instead, Klein holds that the future of maternity care ought to be more midwives in maternity wards. She often tells mothers who come to her hoping for a home birth that she can create a similar experience in the hospital. “You can have a home birth with a caring, skilled midwife, with the lights dimmed low -- rent a tub, bring your own pillows, and have a beautiful birth in the hospital,” she said. “If we have everybody trying to be a home birth midwife, then we are not really doing a service to reducing the high, rising C-section level. I think that if we have midwifery centers in hospitals then we are creating an opportunity for people to get the Midwifery Model of Care -- and also be in the hospital if their baby is going to need help.”
But not everyone can deliver with midwives like Klein, who admits that as a professional with a private practice in New York City, she often deals with “the lifestyles of the rich and famous.” And it is the perceived lack of options in having a natural birth in any other setting that might be factoring into the home birth rise. Rice, of CiC, said, “Home birth is a great option for many women, but I think that it’s actually the worst part of the situation we are in right now. There are just so few other options. There is this huge portion of the population that would love something between a home birth and a C-section -- and there’s nothing.”
Many mothers interviewed said they would have remained in the hospital if they were certain their desire for minimal intervention would be respected. “[These mothers] know they don’t want drugs,” said Breen, the midwife on Long Island. “And a lot of them are not really as comfortable with home birth as they are fearful of the hospital.” It is, of course, certainly allowed to have an unmedicated, vaginial delivery in the hospital, with a doctor. But many women are skeptical at how achievable this actually is, with doctors much more familiar with medicated birth, and hospital staff quick to recommend Pitocin and epidurals.
Branson, the Park Slope woman considering a home birth, toyed with the idea of a unmedicated birth in the hospital, but soon gathered that “it’s practically impossible.” (As Aja-Sigmon, the doula, phrased it: “You buy a hospital ticket, you pay for the ride.”) Even with a hospital midwife, some worried that simply due to strict hospital protocols -- like limited movement, required fetal monitors, or restrictions on doulas -- the birth experience they wanted wouldn’t be possible.
And still, those who do achieve an unmedicated birth in a hospital can find the experience such an exhausting yes-and-no battle with hospital staff -- Hardie is one such example -- that they are repelled just the same.
Women looking for a natural birth do have a third option: Birthing centers. These freestanding or hospital-affiliated medical facilities for natural birth are staffed by midwives and sometimes also by obstetricians -- the middle ground between the maternity ward and the home. Like home birth, birthing center intervention rates are typically much lower than that of hospitals (although the fact that they only accept low-risk pregnancies certainly helps to drive down this number).
Mothers often look to the centers for the same increased options that a home birth provides. Frances Cheung, who gave birth at the Brooklyn Birthing Center in May 2012, was one of them. “I can’t imagine if I were to go back into a traditional hospital setting,” Cheung said. “I can’t imagine lying on my back and laboring that way -- because gravity really helps, the birthing pool really helps, being able to walk around really helps.”
By keeping low-risk women out of costly hospital beds and the hands of highly paid obstetricians better suited for high-risk patients, births at the centers often cost much less than hospital births -- at an average of $2,277 per birth, compared to $10,166 for a vaginial birth at the hospital. On the whole, the medical community accepts them, and many have established relationships with nearby hospitals if complications arise. In the last five years, the number of freestanding birthing centers has grown 30 percent across the country.
Gilgoff, the licensed midwife and advocate in New York, sees the centers as a vital part of the modern maternity system, especially those that are freestanding. She notes that hospitals have at times tried to attract expectant mothers drawn to home birth by creating quasi-“birthing rooms” in their wards. But because they were still in the hospital environment, the same interventions and restrictions remained in force. (“It would just be like the room with the potted plant,” Gilgoff said.)
In New York, alternatives outside the home are not only few, but dwindling. Specific urban challenges like rising malpractice insurance rates, and perhaps also a general New York medical culture that prioritizes the efficiency of hospital birth, have led to a city with very few birthing centers now left. It’s another reason why home birth may be steadily rising.
In 1991, Gloria Perez, a dental assistant living in the west Bronx, gave birth to a baby boy at Morris Heights Women’s Health Center and Birthing Pavilion. She returned home in less than 24 hours, and avoided both a "frightening" epidural and Caesarean section. "I wouldn’t have had my baby anywhere else," Perez said. "I love knowing that I pushed that baby out by myself."
Today, the Morris Heights Birthing Pavilion is closed. Though it still maintains an active women’s health clinic, Morris Heights has not accepted a birth since last January. The shuttering of birthing centers is a decision that has been made repeatedly in the city over the past decade or so, even as interest in out-of-hospital birth grows. SoHo Midwives Center closed in 2002; Elizabeth Seton Childbearing Center in the West Village in 2003. The Bellevue Birthing Center -- once celebrated by The New York Times as a "landmark achievement" -- closed in 2009.
“The insurance crisis,” as many in the medical field call it, is likely one of the most devastating culprits in the blow to New York’s birthing centers. In the early 2000s, malpractice insurance rates began to increase dramatically. “A Birthing Center Falls Prey to Rising Insurance Costs,” declared a New York Times headline when Elizabeth Seton closed. Kate Bauer, the Executive Director of the American Association of Birth Centers, said some centers saw their malpractice insurance rates increase between 100 and 200 percent in just one year. But the increased rates were not necessarily linked to increased malpractice suits; in many cases it was simply a matter of location, as highly litigious areas like New York City were slammed with increments from which most of the country was spared.
Further, many of the problems with in-hospital centers, like Bellevue, grew out of struggles with efficiency. With a natural birth, there is inherently a lot of “waiting around.” But a busy New York City hospital is incentivized to avoid this; midwives and nurses who weren’t attending births in active labor were often pulled from the birthing centers and sent to standard Labor and Delivery units. With no staff left, the centers would close for the day. “It’s so difficult when we know there’s a demand,” Rice said. “There are people who say ‘I went banging on the door to have my baby there and they said they didn’t have enough people to staff it, and so we were forced to go have a hospital birth.’”
There has been no indication when -- if ever -- the Morris Heights Birthing Pavilion will reopen. For now, everything remains frozen in place. The three birthing rooms boast crisply made king-sized beds, artwork remains framed on the wall, and medical equipment lies clandestinely in the corner. The closed center -- once a symbol of ecumenical birthing options for women of all classes -- now simply serves as another sign of the city’s lack of access to natural birth.
For Morris Heights mothers who express interest in an unmedicated birth, the closest birthing center is now a difficult 20-mile drive away. Others now turn to the home. In October, two mothers who had previously birthed at Morris Heights chose home birth when they learned the Birthing Pavilion had closed.
Today, only one freestanding center and one in-hospital center remain in the entire metropolitan area of New York City. In a city of 8 million people, this largely means that a birthing center is far from a viable option for most women looking for a natural birth. Brooklyn Birthing Center , on Ocean Avenue in Midwood, can be too lengthy of an in-labor commute for a woman anywhere outside of the borough. And the in-hospital center at St. Luke’s-Roosevelt, in Midtown Manhattan, has often been criticized for its strict hospital policies.
With overcrowded, intervention-friendly hospitals and a lack of birthing centers, many New Yorkers might see home birth as their only chance at a natural birth. It is a reality that Branson, and many women like her, found The Business of Being Born, in the midst of its gushing over natural birth, noticeably left out. “They didn’t necessarily talk about the fact that, actually, there aren’t that many options for New York women,” Branson said. “If you go to St. Luke’s, like yeah, maybe Christy Turlington delivered her baby at St. Luke’s. But of course she did, they’re not going to say ‘no’ to Christy Turlington's birthing plan.”
Birth centers might be especially vital in New York, where tiny apartments and paper-thin walls can rule out the practicality of home birth. “I definitely want to have a natural childbirth, but you know, we live in a 450-square foot apartment in a 16-unit building, so New York definitely adds a different layers to things,” Branson said.
Rachel Stoklasa, a Brooklyn mother, wanted a natural birth, knowing that all her mother’s and sister’s births resulted in C-sections that, to her, seemed unnecessary. But she wasn’t keen on the idea of a home birth (“I can’t imagine giving birth in the middle of, like, dirty dishes in the sink and laundry piles”), choosing to birth instead at the Brooklyn Birthing Center.
And of course, others simply don’t feel safe at home. Benedicte Chidaine, a mother who moved with her family from France to Park Slope, Brooklyn, found natural birthing in her new neighborhood to be “really, really popular.” She had had her first two children in a hospital in France, but desired something “more quiet and less stressful than the hospital.” “Home birth in France is much more of a hippy thing,” she said. “Here, you have your hippies too, but I think it is more mainstream.”
But like Branson, she was frustrated by inaccessibility to natural birth: “People do it at home, but that’s scary for me.” She ended up choosing to birth at Brooklyn Birthing Center, achieving the natural, relaxed experience she was looking for, at the same time feeling secure in a medical facility. “And they are not too ‘granola,’ you know? We did all the tests and the examinations that are required anywhere else,” she said.
Although more and more women, like Chidaine, may be realizing that a midwife-attended birth -- whether in the hospital, in a birthing center, or at home -- isn’t quite the same anti-establishment statement of the past, interviews with midwives, mothers, and advocates indicated that overcoming stereotypes is still an uphill struggle. Said Klein, “The ACNM -- the American College of Nurse Midwives -- hasn’t done the best job at helping people understand that midwives aren’t only down in the South working with poor people. The word ‘midwife’ should be as common as the word ‘Kleenex.’ Why don’t people know what we are?”
Lange-Kessler, the midwife at NYU, said she and her colleagues are doing more deliveries than ever before. “And yes, the number of home births is definitely increasing,” she said. “But if you are looking at an increase between 1 and 2 percent of the population -- how could that possibly be trendy? I think most people don’t even know what a midwife is. That’s my reality.”
It’s not just midwives who still encounter misinformation and stereotypes. “People either think that you’re superwoman, or they think that you’re this super-crunchy granola weirdo,” said a home birth mother who declined to be named due to her public job -- a decision that itself speaks to the negative perceptions of the movement that endure. “One home birth does not kale-chip-eating make,” she insisted.
Hardie encounters crunchy stereotypes as well, but says she can brush them off. “I feel like when people know me as a person, they know I’m not, like, living off the grid” she said.
Choices in Childbirth strives to correct misconceptions about midwives and alternative birth options as part of its advocacy work, but accepts that lingering stereotypes will likely always remain. “Even though we try to portray a different attitude, people will be like, ‘Oh that’s hippie stuff,’ and that’s almost always how they want to portray us,” Rice said. “We really struggle with that. And I think we will be fighting that for many years.”
It is a reality that leads many to think that home birth will never manage to be acceptable to more than a very small minority. Still, many advocates speculate that, while home birth may never reach significant numbers, midwife-attended and more natural birth practices -- whether in the hospital or at birthing centers -- will certainly hold a place in the future of maternity care. As Rice said, “I think that the film . . . coupled with the rise in unnecessary C-sections and unhappy women afterwards -- I think all of it is kind of combining into the perfect storm. And hopefully we will be able to come out over the tipping point. But we will see.”
For now, that one percent remains committed in their decision to stay home, and the choice remains an important aspect of their identities, even after their children are born.
“Being able to have my kid on my kitchen floor, I feel like I can do anything,” said Harrison. “And I tell myself that whenever I have to do something scary, like a job interview or something like that. I say, ‘You know what? You had your babies at home. You had giant babies and it was awesome and you did it. You can do anything.’”
*Name has been changed to protect the identity of the subject.