What if your baby dies?

Boy, doctors sure love to scare women who dare to question their judgment.

Via Susie Bright, here's an issue close to my heart. My first son was born in a hospital with a obstetrician and a nurse-midwife. They induced labor for what I found out later was a weak reason, he was born prematurely with hyaline membrane disease and he almost died.

I told my husband: "If I have to go back in the hospital, I'm not having another one." Fortunately, we located a supportive doctor and some good lay midwives, and my second child was born uneventfully in our bedroom. (On a bean bag chair.)

"What if something went wrong?" well-meaning people kept asking. "Being in the hospital saved your first kid's life." I tried to explain to them he would have been born full-term if I'd been at home, and no life-saving would have been necessary, but there's no talking to people about this. They're just too well indoctrinated with fear tactics.

Most complications of labor are identified with good pre-natal care. Obviously, if you have high blood pressure, an infection or similar factors, you should be in the hospital. There are very few conditions that are the proverbial "bolt from the blue" - and there are enough things that go wrong in hospitals.

What I avoided: An unnecessary episiotomy, low blood sugar (because I could eat in labor), hospital-bred bacterial infections, a higher risk of C-section (often brought on by staying in bed so the ultrasound monitor would work, causing compression on the umbilical cord -- or by an impatient doctor with a tee time, or by Pitocin-induced contractions) and being separated from my other kid. I felt so good after delivery, I got up and made breakfast for seven people.

Women should have real choices in childbirth. (In European countries, home delivery is no big deal.) But labor and delivery is the biggest cash cow American hospitals have, OB-GYNs are often reluctant to share power with their patients, and medical consumers have been trained to follow a doctor's authority without question:

The collapse of New York's legal home birth midwifery services has come as a result of the closure two weeks ago of one of the most progressive hospitals in the city, St Vincent's in Manhattan. When the bankrupt hospital shut its doors on 30 April the midwives suddenly found themselves without any backing or support.

There are 13 midwives who practise home births in New York, and under a system introduced in 1992 they are all obliged under state law to be approved by a hospital or obstetrician, on top of their professional training.

St Vincent's was prepared to underwrite their services, but most other doctors and institutions are not, and they now find themselves without the paperwork they need to work lawfully.

Miriam Schwarzschild, one of the 13, is now in the invidious position of either abandoning her clients or operating illegally. "Apparently by taking a woman's blood pressure I am committing an illegal act," she said. She has no doubts about what she will do: she will stand by the six to eight women she helps in labour every month, law be damned. She said she intends to "fly under the radar", but is anxious about what would happen should she be reported to the state authorities. "At any time a nurse or doctor could report me, and once that happens they could go after my licence and shut me down."

Jitters are spreading among the tiny community of home birth midwives. The rumour has circulated that one of them has already been shopped to the authorities by an obstetrician at a hospital where she transferred one of her clients in need of medical attention.

The crisis of home birth in New York city is an extreme example of a pattern found across America. Fewer than 1% of babies are born at home in the US, and in New York that figure is as low as 0.48% — about 600 babies every year out of 125,000. That compares with a rate of about 30% in the Netherlands.

he crisis of home birth in New York city is an extreme example of a pattern found across America. Fewer than 1% of babies are born at home in the US, and in New York that figure is as low as 0.48% — about 600 babies every year out of 125,000. That compares with a rate of about 30% in the Netherlands.

In much of Europe, midwives play the lead role in assisting most low-risk and healthy women to give birth, handing over to a specialist doctor or surgeon only when conditions demand. In the US, that relationship is reversed.

Obstetricians, who are trained to focus on interventionist methods and often have never even witnessed a natural birth, are in charge of about 92% of all cases. As a body, they are fiercely resistant both to midwives – who under the private medical system in America are their competitors – and to women choosing to remain at home.

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You can't really talk about serious health care reform without looking at major changes in the American way of childbirth. The L.A. Times this morning points out that one of the things driving costs ever upward is the U.S. Cesarean rate, a major surgical procedure now performed in almost one-third of hospital births:

Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

With that surge has come an explosion in medical bills, an increase in complications -- and a reconsideration of the cesarean as a sometimes unnecessary risk.

It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.

"We're going in the wrong direction," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the "perinatal paradox," in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, "is a microcosm of the entire medical enterprise."

As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation's $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.

Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)

Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.

"The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large," the report said. "Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets."

Are there other options, other solutions? Yes. Off-site birthing centers and home deliveries have lower C-section rates and healthier outcomes for mothers and babies. For decades, the all-powerful American College of Obstetricians and Gynecologists has managed to prevent any truly rigorous review of statistics here (preferring to use data that counts miscarriages as home deliveries), but the Netherlands have done it for us.

They found that births where women actually prepared to deliver at home (as opposed to precipitous labors where sudden complications forced them to deliver there) were just as likely to have a safe delivery and healthy baby as those who delivered in a hospital under the care of a midwife.

The group who chose to give birth in hospital rather than at home were more likely to be first-time mothers or of an ethnic minority background - the risk of complications is higher in both these groups.

[...] But Professor Buitendijk said the study did have relevance for other countries like the UK with a highly developed health infrastructure and well-trained midwives.

In the UK, the government has pledged to give all women the option of a home birth by the end of this year. At present just 2.7% of births in England and Wales take place at home, but there are considerable regional variations.

Louise Silverton, deputy general secretary of the Royal College of Midwives, said, the study was "a major step forward in showing that home is as safe as hospital, for low risk women giving birth when support services are in place.

Here are just some of the things you can avoid in a home delivery: Hospital "supergerms"; birthing positions that actually make fetal distress (and thus, a C-section) more likely; the use of powerful labor-inducing drugs that not only increase the likelihood of a C-section, but also of uterine rupture; and an episiotomy that may be painful for years.

I did it both ways: A hospital birth with a doctor and nurse-midwife, and a home delivery attended by lay midwives. (I told my then-husband I would "never" have another child in a hospital after they almost killed my first-born and then bragged about how they "saved" him.) Not only did I give birth at home with my youngest, I was up cooking breakfast for everyone just a few hours later. It was an experience I wouldn't trade for the world. It was better in every possible way.

For more info on home deliveries, see Rikki Lake's documentary "The Business of Being Born" on YouTube.