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THE M.D.

The right place to deliver: home or hospital?

It's a heated argument, and neither side has conclusive evidence. So how to decide?

November 09, 2009|Valerie Ulene | Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.

All three of my children were delivered in a hospital under an obstetrician's care. Fetal monitors tracked the babies' heart rates, and an EKG machine measured mine. When it came to discomfort, I opted out and embraced every pain-relieving intervention that was offered. For me, each of the experiences was blissful -- pain-free deliveries with beautiful, healthy outcomes: Kira, Jamie and Clay.

This type of birthing experience isn't right for every woman. Some pregnant women believe very strongly in a more natural birth process, striving to minimize the use of technological interventions. Some choose to give birth at home, opting to have a nurse midwife oversee their care and delivery.

Many doctors are, to put it mildly, not supportive of this approach. Calling home delivery unsafe, they say that women who choose it are placing personal preferences about the birth process ahead of the health of their child.

Last year, the American College of Obstetrics and Gynecology issued a formal statement -- one supported by the American Medical Assn. -- detailing its opposition to home births. The organization acknowledged a woman's right to make her own decisions about delivery, but it drew the line at delivering at home.

"Unless a woman is in a hospital, an accredited freestanding birthing center or a birthing center within a hospital complex, with physicians ready to intervene quickly if necessary, she puts herself and her baby's health and life at unnecessary risk," read the statement.

"Most women who have home deliveries don't realize what can go wrong and how quickly it can go wrong," says Dr. Erin Tracy, an attending physician of obstetrics and gynecology at Massachusetts General Hospital.

Babies can become trapped in the birth canal, for instance, or their oxygen supply can drop dangerously low, leading to brain damage. Women can experience life-threatening bleeding during labor or contractions so forceful that they rupture the uterus.

When these types of complications arise, immediate lifesaving interventions are required -- interventions that can be delivered only by a physician in a hospital or medical center. If a home birth takes an unexpected turn for the worse, both mother and baby must be transported to the hospital for treatment. Even under ideal circumstances -- when the problem is detected quickly, the ambulance arrives promptly and the transport time is short -- those inherent delays in treatment can have tragic consequences.

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Midwives respond

Midwives say doctors' fear and criticism are unwarranted. "Their position is based on emotional considerations and not really on fact," says Leslie Stewart, a certified nurse midwife in Los Angeles.

Midwives also point out that the interventions and procedures doctors use to ostensibly keep babies safe carry their own set of risks. Cesarean sections, for example, which are now performed in one of three hospital deliveries, increase the risk of several complications for both mother and child. Inducing women to deliver before they go into labor can result in a baby being born before its lungs have fully matured.

Evidence to support either side's case is spotty at best. The National Center for Health Statistics tracks the number of home births that are performed annually (24,970 in 2006), but it doesn't closely analyze outcomes of these deliveries.

"Assessing the safety of home birth is very complicated," says Marian MacDorman, a statistician with the center. The population of women delivering in the hospital is fundamentally different from those who have their babies at home. Only healthy women with low-risk pregnancies typically attempt home birth; hospital-based deliveries, however, include a large number of high-risk women. "It's like comparing apples and oranges."

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Home benefits?

Several studies conducted outside the U.S., however, have produced fairly consistent results: Home births performed on healthy women by highly qualified nurse midwives appear to be as safe as physician-attended, in-hospital deliveries.

One of the most recent studies, published in the Canadian Medical Assn. Journal in September, actually found the risk of death to be slightly lower among babies born at home (0.35 per 1,000, compared with 0.64 per 1,000 for those delivered in the hospital). The study suggested that home birth might offer other advantages as well: Women who gave birth outside of the hospital were less likely to experience certain complications, such as vaginal tearing, and their infants were less likely to require some types of supportive therapy after birth.

Although compelling, these latest results must be interpreted cautiously. Enormous discrepancies between the U.S. and Canadian healthcare systems make it difficult to extrapolate them from one country to another.

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No firm answers

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