by Bela Fishbeyn, M.S.

In this month’s issue of AJOB, Howard Minkoff and Mary Faith Marshall argue that we ought to acknowledge the inherent complexity and personal nature of risks involved in childbirth, and thus defer, when possible, to the decisions made by autonomous mothers-to-be. They place this in opposition to the claim that, “women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk,” and discourage deference to the evaluations of clinicians and judges. However, for mothers-to-be to access autonomy presupposes access to options that may not exist in the world, and in our current system that overwhelmingly favors medicalized birth, access to other birth options is limited.

The discovery of my own pregnancy initiated my research into prenatal care and childbirth in Northern California. Without prior conscious effort, I had become convinced that childbirth will not only be the most painful experience I’ll ever go through, but that I apparently have no sense at all of how to give birth without the rescue of medical intervention. But as I began replacing my images of childbirth from those I had seen portrayed in our media with those informed by reading about more natural childbirth options, I grew to understand that pregnancy and childbirth is a normal, natural process that can be directed by the woman instead of a pathology requiring urgent medical care. This shift in thinking freed me from my fear and replaced it with a deep desire to experience pregnancy and birth, but I want it on my terms.

While the vast majority of births result in a healthy mother and baby, routinized medical interventions during labor and delivery have increased dramatically over time in the US. And as with most medical interventions, these are not without risk of harm. For example, inducing labor by using a synthetic form of oxytocin to cause contractions is often associated with contractions coming on too fast and too strong and can result in fetal distress; epidurals often result in drops in maternal blood pressure and insufficient oxygen supply to the baby; Electronic Fetal Monitoring (EFM), a medical intervention with no proven benefit to mother or baby, is directly linked with restricting a woman’s movement during labor and birth; and separating a newborn from the mother after birth for routine mother/baby care is correlated with lower success rates in breastfeeding and mother-baby bonding.

Well-trotted evidence demonstrates that outcomes of non-hospital births and midwife-led models of care for low risk women are at least as good as those of hospital births and medical-led models of care. Briefly, midwife care during pregnancy and birth is associated with an increased chance for spontaneous vaginal birth and reduced rates of medical interventions, including epidurals, episiotomies, cesarean sections, and instrumental births. Moreover, studies demonstrate higher rates of maternal satisfaction and identify no adverse effects when comparing midwife-led care to medical care. Looking at 15 studies involving 17,674 women at both low and increased risk, the surveyors concluded that most women “should be offered midwife-led continuity models of care” unless these women have substantial medical or obstetric complications. And though the women in these studies are self-selected and non-hospital births are not risk free, hospital births are not without risks of their own, and it ought to be up to an informed woman to balance these risks and ultimately choose her care and site of birth.

Yet access to non-medical led care and non-hospital births is not equal. I was shocked and disappointed to learn how limiting and cost-prohibitive these options can be. In fact, while my own insurance options advertise 100% coverage for midwives and a small co-payment for birth centers (the same co-payment as a hospital birth), adjusters informed me that they actually have zero in-network midwives or birth centers. In other words, despite advertising coverage, they offer absolutely none. So, even after making a well-informed decision based on the medical risks and benefits, the realities of medical insurance have forced me to decide between accepting easy access and a small co-payment for a hospital birth or fighting for access and paying the entire cost out-of-pocket for the birth experience that I have chosen for me and my family.

I am part of the 1.36% of childbearing women in the US wanting a non-hospital birth. My claims to the style of prenatal care and birth are at least as medically supported as the status quo of women giving birth yet they are completely rejected by insurers. It’s difficult to see this as anything beyond minority prejudice and an unjust discrimination between legitimate medical options. If we can all accept that medical considerations for hospital or non-hospital births are equal, insurance companies ought to provide at least some level of coverage for both.

Besides the constant support of my beloved husband, I often feel alone and isolated in my quest for getting the prenatal care and birth that I want. When I talk with others about my plan, I’m met with mixed reactions. Some, mostly women who’ve recently given birth, are amazed by my description of the care I receive and my birth plan and wonder whether this sort of care is even possible. Most give me weird looks and wonder why I’m putting my baby at risk for personal preferences–why not just suck it up and do it at a hospital, what’s the big deal? Some are supportive. Some are intrigued.

After weighing the options and trying both models of care, I’ve decided to bite the bullet and pay for the birth and prenatal and postpartum care I want. If all goes according to plan, I’ll be receiving my prenatal care and delivering my baby this April at a nearby birth center. Compared to my obstetric prenatal visits, my appointments with the midwives are about an hour long (instead of 20 minutes) and include detailed conversations about my psychological and physiological well-being. So far, I’ve found the midwife care to be more holistic than my obstetric care; a typical appointment will include not only collecting my vitals and checking the baby’s heart rate, but also discussing my emotions, nutrition and exercise, stress, anxieties, and the like.

And when the time comes, instead of rushing to a hospital room, I’ll transition to a birthing room that looks very much like a home bedroom – fully stocked with medical equipment, though discreetly stashed in the closet. These rooms promote a calm environment where the mother is in control and free to move (and eat and drink) as she pleases. I’ll be able to choose how and where I give birth, whether it’s in bed, standing or squatting, in a birthing tub, and so on. No one will rush me through labor, no one will offer me unnecessary medical interventions, and no one will tell me when to push. By following my body’s cues, under the care of a licensed midwife, I’ll know what to do.

Regardless of stylistic preference for prenatal care and birth, surely any woman ought to have scientifically sound information on the relative outcomes between birthing options and access to any mode with both the best outcomes and lowest actual cost. The results are clear and consistent. Midwives are at least as safe or safer than obstetricians, they are associated with better outcomes, and they cost less. Yet false notions that non-hospital births take away potentially life-saving technologies, resulting in worse outcomes for mothers and babies, continue to direct our attitudes towards midwifery. The bioethics community should examine the source of these perceptions and their effect on how the medical system approaches childbirth.

I’m lucky to have access to the information and resources to enable me to make a decision outside the medical model. But, for many pregnant women, their options may be limited and they may not even have the opportunity to consider the benefits of a non-hospital birth. Bioethicists express deep concern for patient autonomy and informed decision-making in other areas of medicine–pregnancy and birth shouldn’t be outliers. Indeed, the decision about where and how to give birth is one that women ought to feel excited, not fearful, about.