Courtesy Christopher Briscoe

Jennifer Margulis (shown with Leone, 17 months; Etani, age 6; Hesperus, 10; and Athena, 8) delivered her oldest child in a hospital and the other three at home.

Back in 2001, when Jennifer Margulis decided to give birth to her second baby in the comfort of her own home, most doctors were stridently opposed to any deliveries outside the hospital. They’d wag their fingers and lecture women on the dangers of home birth, often implying that anyone who refused to give birth in a hospital was a bad mother.

But that stance seems to have softened – at least a little bit - in the intervening decade. In a 2011 position statement, the American College of Obstetricians and Gynecologists said that while it still views the hospital as the safest place to deliver, it “respects the right of a woman to make a medically informed decision about delivery.”

In response to that statement - and the growing number of home births in the U.S.- the American Academy of Pediatrics released a set of guidelines Monday for the care of infants born at home. The guidelines were published in the AAP’s journal, Pediatrics.

“We felt that it needed to be stated that no matter where a baby was born, the care needs to adhere to the same standards,” said the guideline’s lead author Dr. Kristi Watterberg, a professor of pediatrics and a neonatologist at the University of New Mexico. “One thing we feel very strongly about is that there needs to be one person present at the birth whose primary responsibility is care of the baby. While it’s uncommon for both the mom and the baby to get into trouble, it does happen.”

The guidelines detail the care and monitoring an infant should receive in the first hours and days after delivery. For example, babies born larger or smaller than expected should be tested for high blood sugar; caregivers should make sure breastfeeding is going without a hitch; blood should be drawn and screened for genetic abnormalities like cystic fibrosis.

The fact that the AAP has issued guidelines doesn’t mean the group supports home births, Watterberg said. “We concur with ACOG that hospitals and birthing centers appear to be the safest settings for birth in the U.S., but respect the right of women to make their own decisions about delivery,” she added.

Simply telling pregnant women not to choose a home birth “doesn’t work and isn’t helpful or constructive.” she said.

When it comes to care of the infant after delivery, the guidelines closely follow what is done in the hospital. Watterberg and her colleagues hope they will help standardize the care babies born at home get, whether that care is provided by a pediatrician, a family practitioner, or a midwife.

“I suppose we as a society are moving towards a spirit of tolerance,” said Dr. Dennis Woo, an associate clinical professor at the David Geffen School of Medicine at the University of California, Los Angeles, and former chief of pediatrics at the UCLA Medical Center, Santa Monica.

If new parents are going to opt for a home birth, there are some things they need to consider, he said. “The article makes the point that the pregnancy should be low risk, that there should be an experienced, certified midwife in attendance, and there should be a Plan B ready as a back-up.”

Though still relatively uncommon, home births have been on the rise. Between 2004 and 2009, home births rose by 29 percent, according to the National Center for Health Statistics. The increase was driven mostly by a 36 percent increase for non-Hispanic white women. Among this group of women, one out of every 90, about 1.1 percent, will choose to have her baby at home.

Many doctors argue that moms who choose to give birth at home are putting themselves and their babies at risk. If labor becomes obstructed, both the mother and the baby can be at risk. And though it is rare, a woman can hemorrhage and, in some cases, lose blood so quickly that in minutes she can go into shock and suffer organ failure, said Dr. Sindhu Srinivas, director of obstetrical services at the Hospital of the University of Pennsylvania and a professor of maternal-fetal medicine at the Perelman School of Medicine at the University of Pennsylvania.

At least one midwife group, the Midwives Alliance of North America, welcomed the new guidelines.

“We are very happy to see that these new guidelines overlap completely with the standard of care that is expected of certified professional midwives,” said Melissa Cheyney, chair of the division of research at  MANA and an associate professor at Oregon State University as well as a practicing midwife. “It’s clear that [AAP] supports birth centers and hospitals, but they also acknowledge that home birth is on the rise and they state that if a woman chooses homebirth, this is the standard of care she should expect.”

Cheyney agreed that a woman should expect two midwives to attend the birth, one to focus on the mom and one to focus on the baby. “Having two at the birth is essential,” she said. “The mother may need something at the same time as the baby. If the baby needs to be resuscitated, that requires two individuals.”

Margulis said that when she had her first baby in a hospital, she felt the experience was impersonal and insensitive. “There was a labor and delivery nurse who was physically rough with me,” said the 43-year-old Ashland, Ore., mother of four. “I was in labor for over 22 hours and she made us feel so rushed and stressed – and then we were left to sort of fend for ourselves. It was a joyless situation.”

After her health baby girl, Hesperus, was born, she was whisked away from her parents. “The staff insisted on taking the baby away from me and my husband,” Margulis said. “They took her to the nursery to wash her off and locked my husband out. But he saw how they were handling the babies – like they were little footballs.”

She was sure there had to be a better way. “The thing I wanted was for my babies to experience love and gentleness in the moments after they were born,” said Margulis, a senior fellow at the Schuster Institute at Brandeis University and author of “The Business of Baby.”  

Margulis has had three babies at home and feels she made the exact right choice in all three cases. “At home I felt totally at ease and comfortable,” she said. “No one was telling me what to do and I could just listen to my body and move around freely.” 

Shayna Marie Perkinson echoes those sentiments. The 27-year-old Ashland, Ore., mom, who gave birth at home to her son Milo 4 months ago, said “I felt like being at home I would be able to just allow the experience rather than being told what to do.”

One thing that made Perkinson comfortable with home birth was the family’s proximity to medical care: there is a hospital just five minutes away. The situation might be different if the hospital was a lot further away, she said, adding “I know families [who decided on home birth] who have come to stay with friends when the time was close so they’d be near the hospital.”

Watterberg and other doctors can understand how moms get turned off.

“Hospitals are where the vast majority of women give birth,” Watterberg said. “We need to continue to work on our hospitals to make the experience more gentle.”

Related links:

Home births rise nearly 30 percent, new report says

Childbirth takes 2 hours longer than 50 years ago

Repeat C-sections may be safer options for moms, babies

Pregnant women need whooping cough shot, CDC advises

By Trevor Stokes
Reuters
Group therapy can help women avoid risky and costly cesarean sections, especially first-time mothers fearful of childbirth, according to a new study from Finland. 

While nearly half of first-time mothers with an extreme fear of childbirth opted for C-sections before counseling, researchers found, only about a third ended up choosing C-sections after attending therapy sessions.

"Our study showed that group counseling is a very effective way to treat first-time mothers with intense fears of childbirth, in order to decrease the number of C-sections and to have more satisfactory delivery," lead study author Dr. Hanna Rouhe, clinical researcher at the Helsinki University Centralö Hospital, told Reuters Health.

"Many of these women with severe fear of childbirth don't come to any maternity clinic for consultation, they just come to deliver with all the anxiety and fear, so there will be problems in delivery," Rouhe said.

Previous research has shown that giving expectant mothers a forum to voice their fears reduced C-sections, but the Finnish researchers said their randomized clinical trial of a formal intervention to address those fears was a first. 

C-section is the most common surgery in the U.S., and accounted for a third of deliveries in 2010, according to the Department of Health and Human Services.

The C-section rate in Finland is half that of the U.S. Still, several medical groups have expressed alarm at the generally high number of C-sections performed in western countries, because the procedure both increases a woman's risk of bleeding, infection and infertility, and incurs higher medical costs.

It's been estimated that between six percent and 10 percent of C-sections may be scheduled by women with extreme fear of childbirth, according to the Finnish team.

"This study raises the issue that maybe we should pay more attention to why women are opting for primary cesarean sections," said Dr. Laura Riley, an obstetrician who specializes in high-risk pregnancies at Massachusetts General Hospital in Boston and was not involved in the new study. 

A number of initiatives aim to reduce the first cesarean section by waiting longer to induce labor and by allowing longer delivery times before C-sections are offered, she noted. But, Riley wrote in an email, "I am not aware of initiatives surrounding childbirth fear - maybe there should be."

Most hospitals include childbirth counseling in standard prenatal care, but when obstetricians discuss the C-section option, they give unsatisfactory treatment by not addressing any underlying fears, the Finnish researchers conclude.

For their study, which is published in the British obstetrics and gynecology journal BJOG, the team used a standard psychological questionnaire to screen a total of 4,575 first-time expecting mothers for fear of childbirth or a strong desire for C-section, and identified 371 with a severe fear of vaginal birth.

Symptoms of the intense fear included panic that affected daily life, nightmares about delivery and a strong desire for a C-section. 

The researchers then randomly divided the fearful expectant mothers into two groups: 90 women received six two-hour sessions of group therapy led by a trained psychologist and 240 received standard prenatal care.

When it came time to deliver their babies, 66 percent of the women in the therapy group chose to have vaginal delivery, while just 47 percent of the women in the control group chose vaginal birth. More than a third of women in the therapy group also reported afterwards that they had had a "positive" delivery experience, versus 23 percent in the control group.

Still, one expert questioned the study's design and said its results offer nothing new for doctors or pregnant women.

"Education and support of pregnant women works; it decreases C-sections, we already know that," George Saade, chief of the division of maternal-fetal medicine at the University of Texas Medical Branch, told Reuters Health. "That study doesn't prove much because the design is flawed."

Nearly half (106 out of 240) women not assigned to therapy in the study sought out their own support and therapy - including Lamaze classes and consultations with doulas and midwives - Saade pointed out, making the effect of the therapy intervention difficult to distinguish.

During the therapy sessions for the intervention group, would-be mothers underwent imaginary deliveries in calm settings and equated childbirth with peaceful images such as a flower opening. 

"I really do not see the value of the screening test or the intervention described in the study," Saade added.

The total therapy cost about 600 euros ($762) per mother, Rouhe countered. Vaginal birth plus the therapy cost 17 percent less than a 2,500-euro ($3,176) planned C-section, according to Rouhe, but the cost did not factor in the initial psychological test.

To date, three hospitals in Finland have adopted the screening system, which researchers aim to introduce across Finland. Most hospitals in Finland offer counseling, but don't screen and target fearful mothers for specific interventions. 

Fearful pregnant women have alternatives, Saade said, including talking with their doctors, childbirth classes that usually include a tour of the delivery room or using a midwife or doula who can help address the issue.

This month, professional medical associations and federal funding agencies published new guidelines for obstetricians intended to decrease C-sections.

Rouhe and colleagues plan to break down the cost effectiveness and longer-term impacts of the group therapy in future studies.

"We have to look at the larger problems in these women's lives," Rouhe said. Women with little social support and histories of abuse or mental health problems have increased childbirth fears, according to previous research.

"It's not only a problem of delivery," Rouhe said.

Jessica Wilcox thinks her in-laws still view her ideas about childbirth as kind of out there, but it’s hard to argue with success: In the last five years or so, Wilcox has given birth to two boys and two girls -- each weighing more than 10 pounds -- at her northern Virginia home. And she hopes to do it again one or two more times.

Wilcox is part of a small but growing trend. While home births are still rare in the United States, they've posted a surprising climb in recent years, according to a government report out Thursday.

Courtesy Julia Chemotti

Jessica Wilcox has given birth to her two sons and two daughters at their northern Virginia home.

After declining from 1990 to 2004, the percentage of U.S. births that occurred at home jumped 29 percent from 2004 to 2009, when it hit the highest level since researchers began collecting data 20 years earlier.

Non-Hispanic white women were most likely to give birth at home in 2009, with one in every 90 births, or about 1.1 percent, in that group taking place at home. That represents an increase of 36 percent over 2004.

Still, Wilcox’s children represent only a tiny minority. In 2009, 29,650 U.S. births, or .72 percent of total births, occurred at home. Compare that to, say, 1940, when 40 percent of births took place at home.  

Home births today tend to be more common among women 35 and older and among women with several previous children, according to the new report from the Centers for Disease Control and Prevention’s National Center for Health Statistics. They're most common in states with renegade reputations, such as Montana, which had the highest percentage of home births, nearly 2.6 percent, followed by Oregon and Vermont, with nearly 2 percent each.

“It’s women who are consciously rejecting the system,” says coauthor Eugene Declercq, professor of community health sciences at Boston University.

Although she's not older, that would describe Wilcox. Now 30, she delivered a baby in a hospital when she was 17 and gave him up for adoption. “It was a great hospital, but it was not a positive birth experience,” Wilcox says.

She didn’t like getting an epidural or an IV. She didn’t like all the poking and prodding by the nurses. And she didn’t like the fact she never saw the same doctor twice for her prenatal care. “I really wanted that personalized care that a midwife provides,” Wilcox says.

Her husband, Jeremy, 34, needed some convincing that it was safe to give birth at home, she says. “He was raised the same way I was: You get pregnant, you go to the hospital to have the baby.”

But now her husband likes to point out that he’s in good company: The son of Super Bowl-bound Tom Brady, New England Patriots’ quarterback, and his wife Gisele Bunchen, was born at home in 2010.

While the risk of death for a baby in a planned home birth is low, the scientific literature suggests it is two or three times higher than that for a newborn in a planned hospital birth, notes an opinion paper published last year by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice.

Home births actually had a lower risk profile than hospital births in 2009, though, according to Declercq and his coauthors. Hospital births were twice as likely to be low birth weight or preterm babies as home births. And just under 1 percent of home births involved more than one baby, compared with 3.5 percent of hospital births. In addition, women who opt for home births are less likely to be teenagers or unmarried. This all suggests that midwives who attend home births select low-risk women as candidates, the authors write.

“Home birth isn’t for anybody who walks in the door,” says Marsha Jackson, the certified nurse midwife who attended Wilcox’s first home birth. For example, Jackson says, her practice rarely accepts women who want to have a vaginal birth after a C-section, or VBAC, at home because of their elevated risk of a uterine tear.

Jackson cofounded BirthCare, a certified nurse midwife practice, back in 1987. Today, Jackson says, the group’s six midwives attend 25 to 30 births a month. About 60 percent are home births, while the rest are in BirthCare’s freestanding birth center in Alexandria, Va.

“The babies that we caught are now having babies with us,” she says. “That is wonderful. When we opened our practice, we never imagined that.”

Do you think home births are dangerous? Would you do it? Share with us on Facebook