For decades, childbirth has been the most common reason for hospital admission, a statistic only recently surpassed by COVID-19-related admissions in the heaviest-hit states. Urgent need to preserve hospital capacity prompted our health care system, aided by technology, to rapidly transition to caring for people in the safety of their homes. Once considered old-fashioned, home-based medicine is now the standard-of-care, begging the question: Are home birth midwives onto something (”Obstetrician: Home birth is not a good idea given the risks involved,” May 11)?
Even prior to the pandemic, home birth midwives specialized in providing prenatal, labor-and-delivery and postpartum care at home. The once-ancient art of midwifery now leverages modern technologies while remaining committed to the continuity-of-care that hospital-based obstetrics typically lacks. Our cultural norm of hospitals as the safest places to give birth reflects both medical and sociological assumptions that may no longer hold up.
Meanwhile, over-medicalization of normal birth, partly a byproduct of being under the purview of surgeons and institutions, is implicated as a driver of adverse outcomes. In response, there have been widespread efforts to reclaim natural birth, such as emphasis on non-pharmacological interventions for labor pain. Planned home birth has also been increasingly popular, including among trendsetting influencers.
Demand for home birth rose sharply in the early days of the pandemic. While fear of COVID and of birthing alone due to visitor restrictions drove many to suddenly reconsider their hospital plans, the majority found themselves stuck due to lack of universal access to safe alternatives. Simultaneously, the American College of Obstetricians and Gynecologists doubled down on its stance against home birth, citing evidence of increased infant morbidity and mortality. Notably, this evidence is controversial and inconsistent with data from other high-income settings where planned home birth for low-risk individuals is an integrated option. It also does not account for maternal health benefits, as the vast majority of hospital transfers are not emergencies, but rather for labor that is not progressing or epidural pain relief.
COVID-19 has made hospital birth more medicalized than ever with universal screening protocols and patients and staff alike shrouded in personal protective equipment. Restrictions on visitors, including essential advocates such as doulas and interpreters, increases the risk for traumatic birth and medically unnecessary cesarean delivery. The fact that Latinx and Black birthing persons are more likely to be COVID-positive, and therefore more likely to birth alone in the hospital, drives this point home.
The pandemic forces us to scrutinize the necessity of many routine hospitalizations: Why haven’t we taken a closer look at childbirth? Home-based midwifery can show us how to safely untether low-risk birth care from hospital settings. We call upon providers and payers to urgently adapt our health systems to incorporate home birth as an option. This would decompress hospitals when they need it most and may even improve birth outcomes.
Dr. Marielle S. Gross and Ryann Morales
The writers are, respectively, a practicing OB/GYN physician and professor of bioethics at the University of Pittsburgh and Johns Hopkins Berman Institute of Bioethics; and a home birth midwife and attorney.
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