For most pregnant women, the onset of labor means it's time to jump in the car and ride to the hospital. For Sharon Levin, it just meant picking up the phone and calling her midwife.
Two of Ms. Levin's three children -- Seth, now 2 1/2 years old, and Daniel, 5 months -- were born at home.
"I really believe that women should be at home to have their babies," says Ms. Levin. "Just never leaving my home, it was so much more comfortable and so much more beautiful. I feel like my bedroom is holy because we had our babies up there."
Richard Santangelo speaks just as enthusiastically about his and his wife's experience with prenatal care and delivery at the Baltimore Birthing Center, which is run by midwives.
"People have been giving birth [since] way before hospitals were around," says the Baltimore chiropractor. At the center, he continues, "They tell you this is your birth, and that you do it your way. They always say, 'Let us know what you want. And if we're doing something you don't like, let us know.' "
Despite the enthusiasm of parents such as Ms. Levin and Mr. Santangelo, having babies outside hospitals is unusual in the United States -- and frowned upon by many in the medical community.
Less than 4 percent of births assisted by certified nurse-midwives are done in homes -- a percentage that has stayed constant during the past decade, according to Mickey Nall, manager of marketing and public relations for the American College of Nurse-Midwives. (Nurse-midwives are registered nurses with a year or two of specialized training.)
The number of birthing centers has increased slightly during the past decade, says a spokeswoman for the National Association of Childbearing Centers. Currently there are 135 in the country, with another 50 in the development stage.
The Baltimore Birth Center, which celebrated its 10th anniversary this month, has delivered more than 1,000 babies since it opened.
Many physicians, however, feel that out-of-hospital births -- especially those in the mother's home -- are simply too risky.
The American College of Obstetricians and Gynecologists is "strongly opposed to home births," says Kate Ruddon, spokeswoman for the American College of Obstetricians and Gynecologists. "They can be dangerous for the patient. Ten to 15 percent of pregnancies turn high risk during delivery."
Ms. Ruddon adds that the organization approves of birth centers, as long as they are connected to or affiliated with a hospital.
Why do mothers-to-be choose to take what some doctors describe as a risk to have their babies outside of a hospital?
Cheri Melomet, an Olney-based certified nurse-midwife who had her daughter at home, explains it this way: "Hospitals are for sick people. When you're pregnant, you're not sick."
For many women, fear of overmedication is a strong factor in deciding not to deliver in a traditional medical setting.
"They don't want the pressure of the hospital offering them a medication," says Gayne Barlow-Kemper, a "birth companion" who frequently assists midwives during home deliveries. "When a woman is in labor, she is exceedingly impressionable. She will accept an awful lot that she would rather not have."
Dr. Mary Jo Johnson, assistant professor of gynecology and obstetrics at Johns Hopkins Hospital, acknowledges that many women who deliver in hospitals feel they do not have enough say over what happens.
"Control is, I think, a very legitimate issue, having had two babies myself," she says. "But if the woman makes it clear what the issues are that are important to her during labor and delivery, then most of the time it can be accommodated."
One important distinction in delivering at home or in a birth center, instead of most hospitals, is that the baby stays with the family, rather than being taken to a nursery.
Following the hospital birth of her oldest child, Andrew, Ms. Levin says she missed bonding with her newborn because he was promptly taken to the nursery. "Breast feeding got off to a really lousy start because of it," she says.
Home and birth center deliveries also tend to get family and friends involved, providing emotional support for the mother-to-be. "You have who you want at your birth. It's a family affair," says Ms. Barlow-Kemper.
During her home birth, Ms. Barlow-Kemper's eldest son cut his new brother's umbilical cord. "That's something that will stay with him," she says. "He's seen what birth is like, what a natural process it is. He wasn't frightened."
There are several risk factors that prevent some women from giving birth in their home. If the woman has had a Caesarean section in the past, or if her fetus is in a breech position, she will probably be "risked out" and have to deliver in a hospital.
"Most pregnancies end in a normal baby, a normal delivery," says Dr. Johnson of Hopkins Hospital. "The problem is, most of the time we don't know which baby or which mom may have trouble right at birth."
Ms. Melomet says she addresses risk factors by screening families carefully. "I need to have people that are cooperative and that I can work with," she says. "The family needs to have its act together. They have to be emotionally ready for this baby."
In nearly 10 years of delivering babies at home, Ms. Melomet has had very few complications. "I've had two surprise breeches at home," she says. "Where it's a sudden life-or-death emergency issue, you almost never see that. First of all, you haven't given this person any drugs, and you've screened them real well. You already know that they've been eating well and they've had adequate weight gain."
Birthing centers offer a middle position between home and hospital births.
"We have a very homelike atmosphere, but we have all of the safety equipment available, even though it's in the background," says Eileen Pagano, co-founder of the Baltimore Birth Center.
Housed in a building on Park Heights Avenue, the birthing center also screens women carefully before they are permitted to give birth in one of its cozy rooms. However, if problems do develop during labor, Sinai Hospital is only minutes away.
Birth centers can also be an economical choice. The cost of having a baby in a birth center is usually half the price of a hospital birth, according to a survey done for the National Association of Childbearing Centers. Blue Cross and Blue Shield covers most of the costs, as long as the facility has a hospital backup.
Home birth, on the other hand, is becoming an increasingly out-of-reach option for many women, Ms. Barlow-Kemper says, largely because insurance companies are wary of covering midwives who do them.
Not all women can safely deliver their babies outside of a hospital setting. Here are some of the risk factors nurse-midwives may look for when screening prospective patients:
* A history of problem pregnancies.
* A history of hemorrhaging, diabetes, heart or kidney disease.
* A previous birth by Caesarean section.
* A baby in a breech presentation (buttocks-first position instead of the normal head-first).
* Multiple pregnancy (twins or triplets).