I recently read an article posted by Spotsylvania Regional Medical Center on the safety of “alternative” birthing. It was a good article, especially considering it was written from a medicalized perspective, discussing home- and birth center births and different types of midwives. That said, the term “alternative” birthing rubbed me the wrong way.


I called a midwife friend, who just sighed and braced herself for the forthcoming rant. “What, I ask you, is ‘alternative’ about pushing a baby out the chute, unmedicated, with  no unnecessary interventions, in the setting and with the attendants of your choosing? Isn’t that how most of humankind got here? Almost all of humankind prior to the last 75 years? Actually, that’s still how most people get here, worldwide, and it almost always works beautifully. So isn’t that the mainstream way to birth? Isn’t a birth with all the usual hospital interventions, or a surgical delivery, actually ‘alternative’?  And how safe is all that? How many women are actually good candidates for highly medicalized births, versus the number who get them just because of some hospital’s or doctor’s routine? They’ve got it all backwards!”


“That sounds like a blog post,” my friend said.


I get calls from moms who want to know if they can safely birth at home. Often they’ve been led to believe their pregnancies are “high risk” because they are over 35 (how I love the term “geriatric uterus”), they ‘re overweight, they’ve had a prior cesarean, they weren’t supposed to be able to get pregnant in the first place, they have had more than 5 babies, their OB told them they are too petite to give birth <massive eye roll>, etc. Now, granted, midwives only provide care for clients who are healthy and have low-risk pregnancies, but none of the above issues makes a mom automatically “high risk” from a midwifery perspective. Still, most women who come into care with us and fall into those categories have been led to believe that they’ll need extra monitoring, will need to see a perinatologist throughout pregnancy in addition to regular OB care, will require every form of prenatal testing under the sun, and will need immediate access to every intervention during labor “just in case,” while they are denied simple requests that would help keep things normal and natural.


Out-of-hospital birth with a midwife–which I’m tempted to rename “old-fashioned birth”– is a viable option–I would say the best option– for healthy, low-risk pregnant women.  Even ACOG (the American College of Obstetricians and Gynecologists) has finally admitted this, although they’re still reluctant to acknowledge CPMs as legitimate care providers (but who do they think they are, anyway? That’s the self-interested and rather uninformed opinion of a trade organization, not a scientific research group,)


There are definitely certain circumstances that could risk a woman out of old-fashioned birth.  There are certain pregnancy complications or preexisting health conditions that make out-of-hospital birth more likely to be unsafe for a few women. Different midwives vary in their policies (based on skill, experience, and comfort level, and in some states, legalities) regarding breech or multiple deliveries and VBAC. The reality is that most women are relatively healthy and most pregnancies are uncomplicated, so most women are nothing like “too high-risk” to give birth out-of-hospital if that is their preference. Most women are great candidates for out-of-hospital births.


When I first meet with a woman for a consult, not only is she interviewing me to see if she’d like me to be her care providers, I am also deciding if I think she’ll be a good candidate for a homebirth. Some of the things I take into consideration include:


-I look at her general health and her obstetric history to make sure she doesn’t have any of those risk factors that truly would make an out-of-hospital birth likely to be unsafe.


– What is her family situation? Does she have a good support network? Are there a bunch of naysayers tearing down her confidence in her ability to birth, breastfeed, or parent? How does she handle them? Is her partner 100% on board with a homebirth? (If not…well, what that can look like is that topic of another post, but it’s a major red flag for me.)


– How well does she take care of herself? Does she take responsibility for eating well, exercising, resting enough and getting some downtime? How does she deal with stress? She doesn’t need to be perfect and have it all together (I couldn’t work with her if she did!), but I like to work with moms who are making a conscious effort toward the good in those areas.


– What is her nutritional status? There is literally no health issue that is not affected by nutrition, and there is no other single factor that influences the outcome of a pregnancy more than how the mom eats. Again, perfection isn’t necessary (we’d all fail that test!),but on the other hand, I have risked women out of care for eating a truly crappy diet.


-What is her philosophy about her health in general, and pregnancy and birth specifically? One of the hallmarks of midwifery care is that we are guides, consultants, lifeguards, but ultimately, the client has to be willing to own responsibility for her decisions. I want clients who are open to my recommendations (otherwise why hire me?), but I never want clients who are passive and want to hand over all decisions to their care provider.  I expect that women in my care will inform themselves (I’m happy to help) and make their own decisions. If not, they belong in OB care and need to deliver at the hospital.


-Does she truly feel safest and best delivering at home? Is she really motivated to have an old-fashioned birth for its own sake? I try not to take on clients who are delivering at home because it’s the fashionable thing to do, or because they’re uninsured and it’s cheaper than being in the hospital, or because they just hate hospitals, but aren’t really secure anywhere else, either. These moms tend to wind up in the hospital, anyway. In my experience, they have a high transport rate.


-Where does she live, and how long will it take to get to her? Is she comfortable with that? How far is she from the nearest rescue squad and hospital? Is her home environment conducive to a calm, safe birth? I don’t care much about the size of the home ( I’ve attended births in RVs, hunting cabins and renovated barns) and it doesn’t need to pass a white-glove inspection, but it should be safe and comfortable for the mother. There should be reasonable access to emergency services. Indoor plumbing is nice, too, although I’ve done without it. (Really.)


-Are there any other physical or emotional red flags, things that don’t add up or just worry me? Intuition is something most midwives learn to make good use of; sometimes there’s just a sense that a woman might be better off in a hospital setting. I try to get to the bottom of that before anyone makes a definite decision about their care.


Every woman has her own unique history and situation, and therefore it’s impossible to list every single factor that comes into play in deciding where and with whom she should give birth, but these are some of the biggest concerns.


If you are considering midwifery care and homebirth, and wondering if you’re a good candidate, I suggest you think about how the above questions apply to you. That decision is about a lot more than just what you weigh, how old you are, or how your last delivery went. Most midwives; myself included, offer a free consult of some kind, where you can meet and get your questions answered, and assess whether you’re a better candidate for old fashioned birth or the hospital alternative.


Heidi Horner CPM LM