I would like to birth in the comfort of my home or a freestanding birth center

The debate surrounding out-of-hospital birth either at home or in a freestanding birth center could very well fill a book on its own; however, it is impossible to discuss birth plans without acknowledging the small percentage of women who, no matter how much hospital birth changes, will never be comfortable with hospital-based care. Several studies have examined the reasons women decide to birth out-of-hospital, even if it means a skilled attendant is not available to deliver their child. Some common motivations expressed by many women who have had out-of-hospital births were a strong desire to maintain control over their birth, as well as avoid a traumatizing hospital experience and remain in a loving, supportive family friendly environment. Many women expressed more fear of hospital interventions than complications during childbirth, with a common theme being that they wanted to trust their body and the process of birth.^1–3

The question is whether or not it is safe. Until recently, there was little research available on the safety of home birth in the United States, as it was only in 1991 that nonmedical midwives formed a credentialing organization and registry of nonmedical midwives and their outcomes began to be tracked.⁴ Home birth was also such a rare event prior to the last two decades that it generated little attention for study, as it had no significant contribution to public health outcomes and was regarded as simply a fringe practice. Furthermore, the research that did exist out of countries where home birth was more common was reassuring. For example, in the Netherlands where one-fourth of the deliveries occur in the home, no difference in perinatal mortality, which includes fetal loss after 20 weeks, intrapartum fetal death, and neonatal death up to 28 days after birth, or other significant complications were observed in the over 400,000 women who planned a home birth, compared to over 250,000 who planned to deliver in hospital.⁵ Research out of the United Kingdom, where home birth represents 8% of the total births, showed similar results.⁶ Even in Canada where home birth is less common, the most recent study by Hutton et al.,⁷ comparing 11,493 planned homebirths and 11,493 planned hospital births, showed no significant difference in rates of perinatal mortality or significant morbidity and need for resuscitation with intended birth location and a lower rate of obstetrical interventions in the planned home delivery group.

In the United States, as home birth rates have been increasing and more data about American home birth has become available, there has been much debate about whether home birth is as safe in the United States as it appears to be in other countries. Data released by the Midwives Alliance of North America (MANA) in 2014, which analyzed the outcomes of 16,924 women who intended home birth, cared for by nonmedical midwives, was initially determined to be consistent with the European and Canadian data on home birth, demonstrating low rates of obstetrical intervention without an increase in adverse outcomes.⁸ However, reexamination of this data with a logistic regression of risk factors to maternal and neonatal outcomes found significant increases in perinatal mortality, especially in the setting of home birth among first-time mothers, mothers with a previous cesarean, mothers with a breech baby, and mothers with multiple gestations.⁹ A separate retrospective cohort study of all Oregon births from 2012 and 2013 examining planned out-of-hospital births and planned in-hospital births demonstrated higher rates of perinatal mortality in planned out-of-hospital births (3.9 vs. 1.8 deaths per 1000 deliveries). It also showed higher rates of neonatal morbidity for home births, including neonatal seizures consistent with neurological injury and admission to the neonatal intensive care unit.¹⁰

There are many explanations for why American home birth is more dangerous than home birth in other countries and approximately three times more likely to result in perinatal death than hospital birth. As discussed previously, home birth is not integrated into obstetrical system. It is predominantly performed by non-nurse midwives with varying degrees of experience, education, and expertise. In the countries where home birth has comparable safety to hospital birth, out-of-hospital births are performed by nurse midwives who follow strict risk stratification guidelines and have specific protocols for transfer. In Canada, that transfer rate is as high as 25% and approaches 50% for first-time mothers. In the United States, in part because obstetricians have been so reluctant to offer any validation of homebirth, there are no such guidelines or transfer protocols, and MANA has been equally reluctant to define any limitations to home birth, instead stating those decisions should be between each woman and her midwife. Consequently, as the MANA data shows, there are significant numbers of high-risk births being performed at home, contributing to poorer outcomes.¹¹

However, despite these facts and ACOG’s strong statement opposing home birth, there are many who feel home birth should be considered a reasonable option for women, including the American College of Nurse Midwifery.¹² This is because the absolute risk of home birth is small, even if higher than hospital birth, and is comparable to other risks that obstetricians would consider acceptable, such as VBAC.¹³ Thus, in the same manner that personal autonomy and reasonable representation of risk should be promoted in maternity care in regards to other non-interventions, home birth should be regarded and presented in a balanced way. As long as patients are being counseled about the small but increased risk, they should not be unduly pressured out of a planned home birth and providers should instead work to make home birth rare, but as safe as possible. Efforts toward that goal should include standardization of midwife credentialing and training, proper physician oversight of midwifery care, clearly defined inclusion criteria for home birth and indications for transfer, and integration of home birth into the maternity system.

In terms of out-of-hospital delivery within freestanding birth centers, this is generally less controversial. Freestanding birth centers are staffed with certified nurse midwives to a much greater degree than home births, thus minimizing some of the concerns surrounding this type of out-of-hospital birth. Furthermore, certified freestanding birth centers must meet state licensing standards, as well as standards set by the American Association of Birth Centers, the Joint Commission, and the Accreditation Association for Ambulatory Health Center. While there are certainly emergencies that can occur even in low-risk births that could be more appropriately treated in a hospital, with the ability to perform an emergency cesarean, the regulations over birth centers offer proper risk stratification as well as guidelines and protocols concerning transfer to hospital that home births lack. For this reason, both ACOG and the ACNM support birth within certified freestanding birth centers.¹²

I would like lights to be kept dim, voices to be kept quiet, personnel to be kept to a minimum, and the music of my choice to be played

A calming birth environment is a goal listed in nearly every natural birth plan. Interestingly, it is only within the more recent history of hospital births that this could even be addressed or determined by women, as it is only within the last thirty years that private labor and delivery rooms became widespread. Prior to this, women labored in large wards or shared rooms, alongside other laboring women and without the support of their spouse or family. Women were only taken to a private space when delivery was imminent. There was little concern for the labor experience and birth, like any other hospital function, was handled in a utilitarian manner. Today, having babies has become big business. Hospital administrators have discovered that where a woman delivers her children has a large association with where her entire family will seek future care, as women typically direct health care utilization in most families. Women will readily seek out the hospital which can provide the nicest maternity environment and, to attract women to their hospitals, maternity units are frequently updated and renovated and hospitals are increasingly providing private rooms throughout a woman’s stay. Hospitals also invest generously in large marketing campaigns where decor is emphasized as much as quality of care. Women often make the choice of hospital based on appearance, privacy, and perceived comfort. Interestingly, hospital choice frequently trumps the decision regarding their care provider, with women often specifically selecting doctors or midwives who deliver at their preferred hospital.

Wood paneling and nice art work on the walls may professedly have little to do with quality healthcare and conversations about labor and delivery ambiance perhaps seem better suited to playgrounds and mommy blogs than medical journals. Nonetheless, multiple studies have been performed exploring the effect of environment on laboring women. For example, the PLACE pilot trial in Canada demonstrated that women who labored in an “ambient clinical setting,” where the hospital bed was not a center of focus in the room and additional design features that promoted relaxation, mobility, and calm were implemented, were less likely to receive pitocin augmentation for labor dystocia and reported less time spent in bed and greater overall satisfaction.² Another recent study showed that women who viewed nature images throughout their labor had higher patient reported quality of care scores, lower heart rates throughout labor, and higher APGAR scores in their infants.³ While the studies to date have been small in scale, they support what women themselves have been saying: environment does matter.

The extent that environment is thought to benefit or inhibit the labor process is related to the perception of safety, comfort, and sense of personal control that it evokes in the laboring woman. Most natural labor texts discuss this in the context of the fear-tension-pain cascade, a concept that originated in the 1940s with Dr. Grantly Dick-Reed and his book Revelation of Childbirth, which was retitled Childbirth without Fear. According to Dr. Dick-Reed, when women anticipate pain in childbirth and fear the process, their muscles become constricted in response to the sensations of labor and that tension produces pain, which then justifies and reinforces the woman’s fear response, promoting an endless cycle of suffering. Through his observations of patients who expressed little discomfort during labor, he proposed that if women could be taught to relax during labor and not be fearful, much pain during labor could be prevented as well (Figure 4-1).¹⁴

Ina May Gaskin, in her book Spiritual Midwifery, and Marie Mongan, who originated the HypnoBirthing Method, expanded on this idea. They theorized that the elimination of fear not only prevented pain in childbirth, but was also essential to the process of cervical dilation. They proposed that the cervix functions in pregnancy and labor like sphincters, which are structures in the body composed of circular smooth muscles that perform the dual functions of constricting a body passage and relaxing to permit the flow of liquids and solids through that passage as required for natural physiological functioning. In the case of the cervix during pregnancy, the circular smooth muscles remain constricted to maintain the pregnancy, while during labor they relax in response to longitudinal muscle contractions in the body of the uterus to effect the release of the baby.^15,16

In fulfilling these dual functions, Gaskin holds that the cervix obeys several “Sphincter Laws.” In her laws, Gaskin states that the cervix needs privacy and intimacy to open and that the process is hindered by time limits and commands. She describes several situations where the cervix can open only to close again if the mother is stressed and also where a closed cervix opened easily in response to positive emotional stimulus after a long, protracted labor. She also observes a connection between a relaxed, open jaw and cervical and vaginal stretching and opening.

While many of Gaskins observations about the cervix may be true, her theory of the cervix as sphincter is inherently flawed and simplifies an incredibly complex process. The cervix is actually composed mostly of connective tissue, with only 8% of the distal portion of the cervix being composed of circular smooth muscle.¹⁷ The strength of the cervix during pregnancy is determined by the extracellular matrix of collagen fibers, rather than the level of contraction of the smooth muscle. When the cervix begins to ripen, the process by which the cervix softens and thins in the days and weeks that precede active labor, it is due to a decrease in the collagen concentration rather than a relaxation of the smooth muscle. This change in cervical composition is caused by a relative increase in hydrophilic glycosaminoglycans and non-collagenous proteins which increase the tissue’s hydration and, in turn, break up the collagen fibers which create the cervical tensile strength. What exactly initiates this process is still poorly understood.

However, if a woman’s psychological state is not impacting the cervix directly, as Gaskin proposes, then what is going on? Why is the emotional state of laboring women observed to impact labor progress? Likely, relaxation of the other muscles in the abdomen and pelvis contribute to the process by allowing for more optimal descent of the fetal head into the pelvis. That descent and resultant pressure on the cervix is what is aiding the labor process in the ways that Reed, Gaskin, and Mongon observe in their texts. Though there are no direct studies that demonstrate this, epidurals in the later stage of labor have been shown to aid in the labor process in this manner, so it is a reasonable to theorize that muscular relaxation in an unmedicated birth would function in a similar fashion. The psychological state of the laboring mother also impacts the intricate balance of hormones that bring about labor, as it does in other mammalian species. Mammals universally seek out environments of darkness and safety for birthing and the labor process can be observed to halt or speed up in response to external stimuli that produce stress or comfort. Hormones, such as adrenalin and cortisol, which are released when a laboring woman enters a “flight or fight” stress response, inhibit the release of oxytocin and, by extension, slow the progression of labor. Vasopressin, also released during a stress response, directs blood flow away from the uterus, contributing to fetal distress and preventing the muscles from contracting effectively.¹⁸