"My fondest memory is being in my own bed with nowhere to have to relocate to," says Pam Mandell, a Baltimore mom who gave birth twice in her own home. "It was so peaceful and intimate." ¶ Most pregnant women, when that fateful day finally arrives, lumber to their cars amid contractions with a bag that's been packed for weeks, and make the uncomfortable trek to the hospital. They will fill out paperwork and see dozens of nurses, doctors, and technicians before their baby arrives. Most will get an IV and an epidural, and about a third will have a Caesarean section, before they leave the hospital with their little bundle of joy.
But not Mandell or any of the other Baltimore moms who have decided to give up the drugs, the needles, and even the doctors in favor of a more traditional experience. "Several of my friends had home births, but I didn't understand it at that time," Mandell says.
It wasn't until she became pregnant for the first time that she started reading books about the midwifery model of childbirth and some of the potential drawbacks of hospital births. "These books convinced me that my home-birthing friends weren't fringe but on the right path," she adds.
So Mandell hired a midwife and a doula, who would provide emotional and logistical support during the birth. She went into labor early one evening, 12 days after her due date. She called her midwife, who told her to relax and try to get some sleep—she did, but was woken up at 2 a.m. by active labor.
At 6 a.m. she called her doula, who came right away. "The first thing I asked was if this 'looked right,' not knowing, unfortunately in our society, what birth and labor really looks like. She assured me that, yes, it looked right, and that I looked beautiful. That really resonated with me as I never considered what was happening as beautiful and right," she recalls.
Her midwife arrived soon and told her that she was doing just fine. "I thought that I couldn't do it," Mandell remembers. "They assured me that I was, in fact, 'doing it.'"
After about 12 hours of active labor and about 15 minutes of pushing, Mandell's son, Gitan, was born healthy and happy.
Obviously, this is a fond memory for Mandell. But it doesn't come without a catch: Home births in Maryland are sometimes illegal.
Maryland is one of 26 states where Certified Professional Midwives (CPMs) cannot be licensed, and one of 15 states where they are directly forbidden from attending home births. These "direct-entry" midwives—i.e, independent practitioners not affiliated with a hospital—do not have medical or nursing degrees, but most attend hundreds of births as an apprentice before earning certification and practicing on their own. Another type of midwife, Certified Nurse Midwives (CNMs), can attend home births in Maryland—but CNMs mostly work in hospitals, not with home-birthing moms.
A bill passed by the 2008 General Assembly gave more freedom to CNMs (they no longer must work directly with a physician), but there is no proposed legislation in Maryland geared toward legalizing CPMs. There have, however, been some efforts at raising awareness, such as the informal petition to legalize CPMs by the grassroots organization Maryland Friends of Midwifes. (At press time, they had 737 signatures.)
But the growing desire of moms to have their babies at home—national interest rose after Ricki Lake's 2008 documentary The Business of Being Born—has stretched the few legal CNMs who attend home births to their limits. As a result, many women go "underground" in search of illegal midwives to attend their births. Usually, this poses little trouble for the moms but could have drastic legal consequences for the midwives. If the state finds out that a CPM has attended a home birth, she risks legal prosecution and heavy fines for practicing without a license.
"Prosecuting Certified Professional Midwives is not the answer," says Debbie Pulley, who works for the North American Registry of Midwives (NARM), the agency that certifies CPMs. "Integrating them into the health- care system is."
There are other possible risks involved in using the services of an illegal midwife as well. It is possible that in some cases, fear of legal ramifications may affect a CPM's decision to transfer a mother to a hospital if complications arise during birth. This past May, for example, Baltimore-based CPM Karen Carr pleaded guilty to two felony charges after she attended a high-risk breech birth in Virginia, where complications resulted in a baby's death. While it was the state, not the family of the child, that brought the charges against Carr, her case raises questions about careful practices and selecting the safest candidates for home birth.
"If there's any chance that a baby is going to die because they're too far from a hospital to have a STAT C-section if something goes very bad, very quickly, I wouldn't want to take that risk," says a retired local OB-GYN who wishes to remain anonymous. "I think you'll probably find that most OB-GYNs don't feel comfortable with that."
Indeed, the American College of Gynecologists and Obstetricians (ACOG) released a formal statement earlier this year against the growing home-birth trend. ACOG maintains that the hospital is the safest place to give birth, citing a meta-analysis of 12 studies that showed home birth to be two to three times more likely to result in neonatal death. Critics of this statement, however—including two independent experts in meta-analysis working for Time magazine—concluded that this analysis was "weak and methodologically flawed."
Other studies have drawn the opposite conclusion, such as the 2009 study published in the Canadian Medical Association Journal, which concluded that women and newborns, after a planned home birth, were at a similar or reduced risk of death.
"I think one of the biggest misconceptions is that home birth is not safe," says Evelyn Muhlhan, a Baltimore midwife (CNM) who has attended more than 600 home births. "I always tell people I bring everything except the kitchen sink. I carry IVs; Pitocin in case there's a postpartum bleed; I carry oxygen; I use lidocane for a local [anesthesia] to repair a tear . . ."
The only thing she doesn't offer is pain medication, which mothers seeking a natural birth usually try to abstain from anyway. "If the things that we have now like pain medication and epidurals and spinals, if they were not made available to women, what do you think they would do?" Muhlhan muses. "They would have their babies! They'd have no choice!"
Tibeca Yao, a Cockeysville mom, says she was pressured into accepting interventions in the hospital. "After finally consenting to an epidural, I was pushed with Pitocin [a medication that causes contractions to intensify]. Looking back, I can see the cascade of interventions that began from the moment I consented to any pain medication," she says. "Further, they took my baby away to weigh her almost immediately. I realized at that moment that I would never again want to birth in the hospital."
Her second child was born at home.
The home birth can also be significantly less expensive than birth in a hospital. Rates for care at Muhlan's Alternative Birth Choices vary, she says, depending on the services requested (like lactation counseling), but are generally around $3,000. Compare that with the $15,000 cost of a hospital birth—a cost that can more than double if procedures like a Caesarean section come into play.
So why aren't more people taking advantage of the opportunity to birth at home?
Two of the primary reasons, Muhlhan says, are fear and lack of knowledge. "Even to this day, people are still saying, 'You're going to who? A midwife? Okay . . . and you're going to have your baby where?'"
The fear, she says, comes mainly from the prevailing view that birth is dangerous without the monitoring of doctors. "I think culturally we've done women a big disservice to fear birth," Muhlhan says. "I see that birth is not a medical event, and that in healthy women it's pretty normal."
Interestingly, despite the fact that 99 percent of American women give birth in hospitals, the U.S. is ranked second to last among developed nations in terms of neonatal and maternal mortality rates. That's below Qatar and Slovakia. The Netherlands, where 70 percent of women give birth with a midwife and 30 percent give birth at home, ranks consistently in the top five countries for best survival rates of both mothers and babies. In fact, birth with a midwife is the norm in almost all the countries with better infant and maternal mortality rates than the United States.
Of course, home birth isn't for everyone. Good midwives know which women are appropriate candidates for home birth and which would be safer with more medical technology on hand. For example, women with diabetes or hypertension or a baby in the breech position should probably deliver in a hospital where they can still be attended by a midwife but where medical technology is readily available in case of an emergency.
"My best advice for those who are thinking about starting a family," says Muhlhan, is that "they should do their homework." We don't buy the first car off the lot, or the first house we see, she says. "Why not educate yourself about pregnancy and birth, about the different practitioners, and then make an informed decision?"
Pam Mandell certainly does not regret her decision—she found her home-birth experience far more comfortable than most hospital births.
"During labor I was free to eat, shower, be in the privacy of my home," she says. "No fluorescent lights, no intrusive nurses or doctors, and no one telling me to do anything. My home is warm and clean, not sterile and impersonal. Being there made my birth experience mine. Ours."