In the past, most Americans were born at home with lay midwives attending. The mortality rate for both mothers and babies was higher in 1900, at 700 maternal deaths per 100,000 births (Korte and Scaer 97), than it is now. Babies also died at a significantly higher rate at that time, which decreased to 28.9 births per thousand by 1960 (Korte and Scaer 98). Obstetricians tend to emphasize that many women used to die in childbirth, implying that we should be grateful for current obstetric practice. However, even in 1900, the percent of women who died giving birth was only 7/10ths of one percent! One has to wonder how this percentage compares with our country’s current cesarean section rate of 22%. Are the surgeries performed on these mothers actually saving them from imminent death? Maternal and infant mortality are lower now than they were 40 years ago. But the assumption that hospital birth is safer for mother and baby has never been supported (Jones 6). Prenatal care, better nutrition, antibiotics and blood transfusion have played more of a part in the relative safety of birth now.

Sheila Kitzinger, British childbirth expert, states that planned home birth with an experienced lay midwife has a perinatal death rate of 3-4 babies per 1,000 births (51). Hospital births, by contrast, carry a perinatal mortality rate of 9-10/1,000. [Perinatal death rates include fetal deaths on and after 28 weeks gestation, whereas neonatal mortality rates only include deaths occurring in the first 28 days after birth (Jones 96,98)].

• A study in Australia found a perinatal mortality rate of 5.9/1,000 out of 3400 planned home births (Kitzinger 41).
• Joseph C. Pearce states in his landmark book Evolution’s End that homebirthed babies have a six to one better chance of survival than a hospital-birthed child (117).
• A study in the Netherlands done in 1986 on women who were having their first babies showed these results: out of 41,861 women who delivered in the hospital, the perinatal mortality rate was 20.2/1,000. Of 15,031 women who delivered at home with a trained midwife, the rate was 1.5/1,000 (Kitzinger 44). I know, I thought it must be a typo too.
• Marsden Wagner, formerly of the World Health Organization, states that every country in the European Region that has infant mortality rates better than the US uses midwives as the principal and only attendant for at least 70% of the births (Jones 2). He also states that the countries with the lowest perinatal mortality rates in the world have cesarean section rates below 10% (Jones 13). How does this compare with the US rate? Miserably.

Other studies:

• Dr. Lewis Mehl did a study comparing home and hospital birth with mothers from California and Wisconsin with matched populations of 2,092 mothers for each group. Midwives and family doctors attended the homebirths; OBGYNs and family doctors attended hospital births. Within the hospital group, the fetal distress rate was 6 times higher. Maternal hemorrhage was 3 times higher. Limp, unresponsive newborns arrived 3 times more often. Neonatal infections were 4 times as common. There were 30 permanent birth injuries caused by doctors (Jones 99).
• Dr. Mehl did another study comparing 1,046 home births with 1,046 hospital births. The groups were matched for age, risk factors, etc. There was no difference in infant mortality. None! However the hospital births caused more fetal distress, lacerations to the mother, neonatal infections and so on. There was a higher rate of forceps and C-section delivery and nine times as many episiotomies (Jones 110).
• Robert C. Goodlin reported in the Lancet on 1,000 births, half occurring in a hospital, half in a birth center. There were no IVs, monitors or anesthesia used in the birth center, but the babies were born in better condition. Besides that, three times as many cesareans were performed in the hospital (Korte and Scaer 37-38).
• In 1982, Anita Bennett and Ruth Lubic evaluated 2000 births that had happened in 11 freestanding birth centers. The neonatal death rate was 4.6/1,000. The authors were denied information on low-risk women delivering in hospitals (Korte and Scaer 45). One wonders why....
• I found these comments very interesting. A British research statistician, Marjorie Tew, did long term studies of the safety of birth in various settings during the 1980s. She found that among a sample of 16,200 births, the perinatal mortality rate was lower for out-of-hospital births, even for very high risk mothers! At a relatively high risk level, perinatal mortality was three times higher in hospital (Korte and Scaer 49). Tew then expanded her research by using information from the Netherlands, a nation where both obstetricians and midwives practice. The perinatal mortality rate was ten times higher in the hospital births there, even though the risk status of the mothers at the time of delivery was not much higher than that of mothers who chose midwives (Korte and Scaer 50).
• In the Netherlands, which has a significantly lower infant mortality rate than ours, the C-section rate is 7% (Jones 20). The episiotomy rate is 6%, whereas ours is 90% (Jones 19). Midwives attend most of the births in the Netherlands. (Midwives tend to allow time for the woman's tissues to stretch and to use perineal massage, warm compresses, and good head flexion to avoid both episiotomies and tearing; hence the lower Netherlands rate.)
• In 1988, the US ranked 19th among industrialized nations for low infant mortality rates. By comparison, Sweden, where all mothers receive midwifery care, even when they are high risk and may also require physician care, ranked second (Jones 95).
• Between 1978 and 1985, licensed midwives in Arizona had a perinatal mortality rate of 2.2/1,000 and a neonatal mortality rate of 1.1/1,000 (Jones 96).
• This stat is priceless. Read on: In Madera County Hospital in California, where there is a transient, high risk population, midwives did the best job. In 1959, when doctors did the deliveries the neonatal mortality rate was 23.9/1,000. During 1960-1963, midwives had a rate of 10.3/1,000. When OBGYNs took over again in 1964, the rate skyrocketed to 32.1/1,000 (Jones 98).

Another factor that is important in making the choice about where to give birth may surprise you. It makes common sense, but has also been documented by several studies. Women who give birth in a hospital are much more likely to experience postpartum depression or even post traumatic stress disorder. Kitzinger states that the more interventions a woman experiences, the more likely she is to be depressed, with C-sections obviously carrying the greatest risk of depression (193). She quotes 5 or 6 studies documenting the effects of this "institutional violence."

Aidan McFarlane, a British physician, notes that while 68% of hospital mothers experience postpartum depression , only 16% of home birth mothers do (Jones 24). On the Farm, a self-contained, alternative lifestyle community in Tennessee, the rate of postpartum depression was .03 percent (Korte and Scaer 183). Almost all mothers on the Farm had both a homebirth and a supportive, loving community of women to assist them postpartum. Depression, in itself, would be a major reason for mothers to consider giving birth in their own homes, if that is where they are most comfortable, especially if they had previously experienced postpartum depression and thus were at high risk for a repeat episode.

Aspects of hospital birth that may strongly contribute to the incidence of postpartum depression in our country are the way the moment of birth is handled and the routine separation of baby and mother. In a study which appeared in the New England Journal of Medicine in 1972, Marshall Klaus, the "bonding" expert, found that holding the baby close released "dormant intelligences" in the mother and caused "precise shifts of brain functioning and permanent behavior changes" (Pearce 115). In other words, bonding is not just an emotional thing that only mothers think happens. It is a biochemical process that forever changes the mother, so that she knows more instinctively how to relate to her baby. In the hospital, baby cannot see mom with all the bright lights and is often inspected and observed for several hours before mother can hold it for any length of time. This is not to say love can’t make up for this loss, but motherhood might come easier if we had those natural body changes to help us. Then babies are still routinely kept in the nursery, if not most of the time, at least part of the time. The routine separation of mom and infant makes baby frightened and mom depressed (Pearce 124). This may be why postpartum depression and difficult adjustments are so common in the US and rare elsewhere. Japan moved from midwifery to obstetrical handling of births approximately 25 years ago. When older Japanese recently asked Joseph Pearce why their mothers no longer "know what to do with their children," (129) one has to wonder how much the new hospital setting has to do with it.

Most homebirth studies also show a significantly lower rate of C-section than hospitals have. Most stats I have seen show a rate between 1-5%, with the above quoted lower mortality rates as well. Cesarean sections themselves carry a far greater risk of additional illness or death than most people realize. I think because they have become so routine in our society, everyone feels "It’s no big deal." However, C-sections carry a 2 to 4 times greater risk of death than do vaginal deliveries (Boston Women’s Health Book Collective 341).

Several studies on the risk of death from the surgery alone (i.e. factoring out the conditions the surgery was done for) have shown varying, yet consistently depressing, results. Errard and Gold found with eleven years of statistics that the risk of death from cesarean section was 26 times greater than from vaginal birth (Cohen and Estner 26). Cohen and Estner also cite a study done in Georgia showing a maternal death rate of 59.3 per 100,000 women who had cesarean section versus 9.7/100.000 for women who delivered vaginally (26). A California study showed a maternal death rate 2-3 times greater from C-section. Korte and Scaer state that obstetricians admit a maternal death rate four to six times higher with cesareans (162), and add that many believe the rate is higher, giving 1 in 1,000 as the true odds of death for a c-section mother (163). You should also be aware that death is not the only complication caused by cesareans; mothers commonly experience infection after a section. Infertility problems, organ damage, and paralysis from anesthesia complications are rare but possible risks. The pain at the incision site is no picnic either.

Another thing to think about is how a surgery like this will affect you, your child, and your society in the long run. When mothers "fail" to give birth naturally in hospitals, as they so often do these days, their self image is harmed despite well meaning friends telling them it doesn’t matter how baby came out. Especially if mothers are not certain their sections were absolutely necessary, there is often a hidden anger that can’t be overtly expressed in our culture. Mothers may take this unacceptable anger out on the only people they can--their children. "In 1979, the government of California funded the first scientific study ever made of the root causes of crime and violence. Their first report three years later stated that the first and foremost cause of the epidemic increase of violence in America was the violence done to infants and mothers at birth" (Pearce 126). The "little things" really do matter, just as a small pebble thrown in a pond makes ripples that travel a long, long way.

If you are a woman with no health problems or contraindications to safe labor and delivery, consider very carefully your place of birth. Your chance of having major surgery is one in four if you choose a hospital, regardless of your current health status. Those are very good odds. If you had the opportunity to buy a million dollar lottery ticket with odds that good, you would, wouldn’t you? Don’t assume that it won’t happen to you. Since the risks to you and your baby are lower at home, and your risks of having surgery are greater if you go to a hospital, please consider homebirth as an option.

Wherever you decide to give birth is up to you; just remember that you can make the decisions that need to be made when you have true information. It is your body, your baby, your money, and your life on the line, not the doctor’s or anyone else’s. You have the right to accurate information and the right to decide what is best for your baby. Don’t let anyone tell you otherwise. Also, when you ask for information, beware of health care providers who say they judge each case individually, so they can’t really give you their statistics. It probably means either they don’t know or they don’t want you to know. You will have to live with the consequences of decisions made during your labor, for better or worse. For more information or support, call me at 606/625-0185 or email me at griebenow@iclub.org

The author disclaims any liability resulting from the use of this information, and strongly urges you to use your own mind.

References

1. Boston Women’s Health Book Collective. The New Our Bodies, Ourselves. New York: Simon and Schuster, 1984.
2. Cohen, Nancy Wainer and Lois J. Estner. Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean. New York: Bergin and Garvey, 1983.
3. Davis, Elizabeth. Heart and Hands: A Guide to Midwifery. 2nd edition. Berkeley: Celestial Arts, 1992.
4. Jones, Carl. Alternative Birth. Los Angeles: Jeremy P. Tarcher, 1990.
5. Kitzinger, Sheila. Home Birth. London: Dorling Kindersley, 1991.
6. Korte, Diana and Roberta Scaer. A Good Birth, A Safe Birth. Boston: Harvard Common Press, 1992.
7. Mitford, Jessica. The American Way of Birth. New York: Dutton, 1992.
8. Pearce, Joseph Chilton. Evolution’s End: Claiming the Potential of Our Intelligence. San Francisco: Harper, 1992.
9. New Our Bodies, Ourselves. New York: Simon and Schuster, 1984.
10. Cohen, Nancy