Should More Women Give Birth Outside The Hospital?

A recent recommendation from doctors in the United Kingdom raised eyebrows in the United States: The British National Health Service says healthy women with straightforward pregnancies are better off staying out of the hospital to deliver their babies.

That's heresy, obstetrician Dr. Neel Shah first thought. In the United States, 99 percent of babies are born in hospitals.

"There's really only one way of having a baby in the U.S.," says Shah, who works at Harvard Medical School and Beth Israel Deaconess Hospital. Here, he says, delivering at home or at independent birthing centers is still not considered mainstream.

Shah was asked by the New England Journal of Medicine to respond to the British recommendation. He compared birth outcomes here in the U.S. and Britain, especially the cesarean rates, which average 33 percent in the U.S. compared with 26 percent in the U.K. And he started to think the British were on to something.

"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."

There are lots of reasons for the rise — increased obesity, a lack of consistent prenatal care, older women having babies. Shah also blames hospital infections, and the rise in emergency and elective C-section deliveries.

Rather than rebut the British, Shah argues in his New England Journal editorial that the practice of giving birth outside a hospital with a midwife can be safer.

"Choose the right patients," he says. "And you need to be able to link those birth centers to hospitals, like mine, that have blood banks and three operating suites and everything else."

The American College of Obstetricians and Gynecologists has been supportive of midwife-led births. But it draws the line at home birth.

"I don't recommend home birth, and as an organization ACOG suggests that a hospital or birth center is the safest option," says Dr. Jeffrey Ecker, an obstetrician at Massachusetts General Hospital and chairman of ACOG's committee on obstetrics practice.

Women and babies are in real danger, Ecker says, if something goes wrong during a home birth. Compared with births planned for delivery in a hospital or birthing center, planned home births have a significantly higher rate of infant mortality in the U.S., studies show, though the absolute risk of the baby dying is relatively low in both cases.

Also, Ecker says, the British and American health systems are simply too different for the British recommendation to make sense for the United States.

"The system that supports home birth in the U.K. is much different than the system that currently exists in the U.S.," Ecker says. "In fact, I would argue that there is no system in the U.S."

The U.K. has universal health care, and British women are generally referred to a midwife as soon as they know they're pregnant.

Though the percentage of American women who choose a midwife-led birth is still only about 9 percent, the total is on the rise, recent statistics suggest. Most midwives work in hospitals or birthing centers.

Yinka Sokunbi worked as a midwife in London until her husband's work transferred her to Dallas last year. She was stunned at the different attitudes toward childbirth in the U.S.

"A lot of people do not know what midwives do," she says. "They have this vision of old ladies with potions and herbs."

From her training and practice, Sokunbi says, she can handle a host of common childbirth scenarios.

"I am suitably trained to recognize when things aren't going as they should be going and what to do about it," she says.

The bag Sokunbi takes to a home birth has no potions, but does have: a fetal Doppler device for monitoring the baby's heartbeat; certain medications; and oxygen for reviving a blue baby.

And at the first sign a delivery could be running into trouble, she sends her laboring patient to the nearest hospital, she says. That handoff to an obstetrician is one of the major differences between the U.S. and the U.K. It's very smooth in the United Kingdom, where doctors and midwives have a close partnership, Sokunbi says.

"In the States, the way I see it so far, it seems there are midwives on one side and obstetricians on the other — and there's this opposition," she says.

Shah warns against "thinking of midwifery as a silver bullet" aimed at fixing problems with childbirth in the United States. Rather, he hopes that obstetricians and midwives can work together, as they do in in the U.K., to give many women a cheaper, safer and more pleasant experience of labor and delivery.