Up until the early nineteenth century, nearly every mother gave birth in her home supported by a midwife and surrounded by family. The Industrial Revolution shifted that paradigm and created new challenges, namely a rise in disease and injuries, sending more and more Americans into the burgeoning hospital system. During this time, male doctors with very little experience supporting childbirth began to offer diethyl ether, chloroform, and scopolamine morphine (“Twilight Sleep”) to address pain in childbirth. It comes as no surprise that the promise of a “pain-free” birth (and the waived expense for wives of servicemen) was appealing to many women, leading to the popularization of hospital birth in the twentieth century. By 1938, half of all births took place in hospitals, and by 1945, that number grew to eighty percent.
As the first wave of feminism arose, so did the belief that suffering through childbirth did not have to be endured. Unfortunately, the shift from home to hospital did not deliver on the promise of safe and satisfying birth experiences. Twilight Sleep wiped a mother’s memory of her birth but ultimately did not take away her pain. In Tina Cassidy’s book, Birth: The Surprising History of How We Are Born, she writes, “Once she was under the spell of Twilight Sleep, the doctor would bandage her eyes with gauze and stuff oil-soaked wads of cotton in her ears so her own screams wouldn’t wake her up. Her arms would be strapped down in leather thongs.” Hospital birth practices often led to poor birth outcomes, infections, and easily preventable complications, which inspired the widespread campaign to replace midwives with doctors. In the wake of this campaign, infant mortality jumped fifty percent from 1915 to 1929.
Believe it or not, many doctors completed their training without ever witnessing a vaginal birth. Midwives, who carried centuries of birth wisdom that was seldom taught in medical school, were gradually phased out of the new system.
As hospital birth became synonymous with wealth and prestige, many rural Americans didn’t have the means or access to see a doctor. This was especially true in the American South. Below the Mason Dixon line, Black midwives, known as “granny midwives,” safely delivered a majority of babies of all races up until the 1970s. In fact, the first slave boat that came to America in the 1600s brought with it a wealth of West African midwifery wisdom that delivered healthy birth outcomes for disenfranchised communities for centuries to follow. The industrialization of maternal care not only devalued traditional wisdom, but midwifery became outlawed in many states contributing to a maternal health crisis for women of color in the US.
Today, black women are also disproportionately affected. Black women are four times more likely to die in childbirth in the US. These disparities exist regardless of socioeconomic status. They stem from the aforementioned racial bias and long standing institutional racism within our health care system (including the criminalization of midwifery in the South).
Today, midwifery is regulated state by state and in some cases, traditional midwives are criminalized for practicing without a nursing degree or license. Although some would say these regulations were intended to make homebirth safer, others would argue they place a governing body between a midwife and her client that interferes with her ability to fully support her client’s autonomy.
Unfortunately, out-of-hospital birth is not accessible to many women across the US. Although hospital birth is exponentially more expensive than homebirth, most insurance companies don’t cover homebirth, making it financially inaccessible to many.
Today, around two percent of women choose to give birth outside of the hospital but the number has been increasing since 2004 according to a recent study. The documentary Why Not Home follows the stories of medical professionals whose thoughtful research and personal experiences as clinicians led them to opt for homebirth. Celebrities such as Hillary Duff, Gigi Hadid, Cindy Crawford, Elsa Hosk, Alanis Morissette, and Demi Moore have all spoken publicly about their decision to give birth at home, sparking curiosity and conversation about what is often considered an unorthodox thing to do. It turns out it’s not just radical hippies and the Amish who choose to give birth at home.
Over the past year and a half, pandemic restrictions have limited access to doula support and even taken away many partners’ ability to be present at the birth of their child. Concerns of being at a hospital during a pandemic, birthing in a mask, or without desired support, have all contributed to a recent renewed interest in homebirth.
Back in May of 2020, after receiving dozens of calls from concerned expecting parents, I hosted an Instagram series called Giving Birth at Home. During these discussions, mothers shared personal stories and offered advice about out-of-hospital birth. Cindy Crawford tuned in to talk about her two homebirths over twenty years ago:
“Pregnancy is natural…it is normal, you’re not sick, it’s not a condition. We are not weaker when we are pregnant. In fact, we are stronger.”
What I took from these conversations was that many people are wildly misinformed about the realities of homebirth and the qualifications of midwives. The perception of homebirth has been distorted by its dramatized portrayals in Hollywood and in the media. A common misconception about homebirth is that there is something inherently dangerous or spontaneous in this choice. Homebirths attended by midwives are well prepared for. They build relationships with clients through pregnancy and work closely with them to get an idea of their individual physical and emotional health, guide them through healthy pregnancy practices, and keep a close eye on any factors that may risk them out of a safe homebirth.
Midwives trust in physiological birth, approaching the process as a healthy function of the female body that, for the most part, does not require medical intervention. They believe that the body will know what to do and when — making midwives less likely to intervene unless medically indicated.
This approach creates a more comfortable atmosphere for the laboring mother and limits the need for labor augmentation and pain medication. Without the pressures of hospital policy, women can labor at home as long as they are comfortable, as long as no complications arise.
Despite all this, it’s still important to acknowledge that homebirth isn’t for everyone. Although eighty-five percent of women are considered low-risk and eligible for homebirth, many women prefer to utilize the epidural which is not offered at home. Others feel a sense of safety being in the hospital which is a very important factor that should not be overlooked in the decision-making process. Feeling safe is a key contributor in the flow of labor hormones.
A 2009 study found that the top four reasons women choose to birth at home were: the belief that homebirth is safer, a desire to avoid unnecessary intervention, a previous traumatic hospital experience, and a desire to avoid strict hospital rules that impact their decision making. Since homebirth midwives do not answer to hospital policy, mothers are given more control over their care. When we look at the standard of care in most hospital practices, they don’t always align with what the current evidence suggests. In practicing true informed consent, midwives present to their clients the risks and benefits of their options and allow parents the dignity of making their own informed choices. These options include the ability to labor and birth in water, move around freely, eat, drink, and have privacy to name a few.
When women labor on their own time without unnecessary medical intervention, they reduce their likelihood of cesarean birth. The World Health Organization states that an appropriate use of this potentially life saving procedure should approach a national average of twelve percent. The US cesarean rate sits at about thirty percent and is as high as fifty percent in some states, like Texas. Our cesarean rates do not appear to be due to increase in need, but rather to changes in practice. In a study of nearly forty-thousand first-time cesarians, the number one reason given for the C-section was “failure to progress,” or labor not proceeding in the expected amount of time. These are not medical indications for a cesarean. Of course, planning a homebirth does not eliminate your chances of having a cesarean, however it can greatly reduce your chances of an unnecessary cesarean. Without the cascade of intervention, cesarean rates drop to around six percent.
The controversy that often swirls around the conversation of homebirth comes from a misunderstanding of the research of homebirth safety. The American College of Obstetricians and Gynecologists states that hospitals are the safest place to birth but also recognizes that it is the right of a mother to make her own informed decision about where she chooses to give birth. They also recognize that to date, there have been no adequate randomized clinical trials of planned homebirth. However, in the UK, homebirth is recommended for low-risk women since it “often produces better outcomes” according to the Royal College of Midwives.
Although some studies suggest a small but significant increase in neonatal death and adverse outcomes, most studies across a range of countries have shown no increase in neonatal morbidity and mortality for planned homebirth.
Maternal outcomes are consistently better for planned homebirth, including less intervention and fewer complications. Maternal satisfaction with the birth experience is also high in the homebirth setting.
What happens if there are complications? It is important to note that there is no such thing as a risk-free birth regardless of location and circumstance. Like doctors, Midwives are trained to recognize and anticipate potential complications. Although it is rare for complications to happen suddenly and without warning in a low-risk pregnancy, midwives come equipped with a doppler, blood pressure cuff, emergency medications, oxygen, and the skills necessary to handle an emergency situation. If a complication is to arise that would require another level of care, having a hospital transfer plan in place is important.
Although a vast majority of US births take place in hospitals and the US spends the most money on obstetrics in the world, we rank the lowest on birth outcomes amongst the developed world.
In an interview with NPR, Harvard Obstetrician Dr. Neel Shah states, “We’re taking excellent care of high-risk women,” he says, “and leaving low-risk, normal women behind. We’re the only country on Earth with a rising maternal mortality rate.”
In 2008, Ricki Lake and Abby Epstein set out to make a documentary about giving birth in America. This documentary, The Business of Being Born, exposed the unfortunate realities of our maternal care system inspiring thousands of women to demand better. This film has changed the lives of many women including my own, inspiring me to become a birth doula where I have the privilege of getting to support women both at home and in the hospital. Feeling heard, supported, and empowered in your decision making is important no matter where one chooses to give birth. Afterall, parenthood isn’t a one size fits all model.
Carson Meyer is a genuinely multi-faceted entrepreneur, healer, and artist. She is a certified birth doula, birth photographer and the founder of the clean skincare line, C & The Moon. In 2016 she graduated from New York University’s Gallatin School of Individualized Study where she pursued studies in child development, art therapy, and alternative medicine. Carson returned to her home in Malibu, California and began her journey as a doula supporting parents through a healthy and peaceful pregnancy, birth, and postpartum period. If you’re interested in her virtual birth prep classes you can find more information here. Also, make sure to check out our most recent pod episode with her!