Imagine making love in a hospital room with bright lights and several onlookers urging you to hurry up. In adjacent rooms can be heard similar experiences and in the corridor are others waiting for you to vacate your room. What would the effect of this environment be on the hormones of love-making? During labor and delivery, the same love hormones build up in a woman's body: the oxytocin and prostaglandins that induce and accelerate the stages of labor; and the surge of endorphins that provide the unmedicated woman with strength, optimism and the resulting euphoria when it is all over.
Real-life home birth dramas
The optimum environment for giving birth is a quiet, safe, dark private room, attended by familiar people. Most animals seek this environment and spontaneously halt their own activities when disturbed. Humans are also territorial; in times of stress, they need familiar surroundings, quiet and privacy.
So why do women, as their contractions get stronger and their stress levels rise, leave their own beds, familiar homes and the people they love - possibly in the middle of the night - to go to a busy city hospital? They pass through corridors of the sick and ailing while experiencing the greatest miracle of harmony between body and soul.
The answer most women and their partners give is that they feel safer giving birth in a hospital. They need the reassurance of constant monitoring and the knowledge that experts are at hand if things go wrong. After all, the media does not publish the stories of the majority of women who have totally normal, uncomplicated births. The headlines only focus on the abnormal. And looking at the protocols of the average Israeli obstetrics department, it seems that the woman is a walking time bomb - attending a birth is accompanied by watching the clock to make sure each stage does not exceed the required time.
And what of the baby born in this hi-tech environment?
William James discusses the reaction of the newborn as a "buzzing booming confusion." Affected by medications given to his mother to accelerate the labor and for pain relief, the child is greeted into this world by strangers hurrying along the process, and loud voices urging the mother to push more. And if they don't keep to time, the infant is hauled out by suction or deprived of the stimulation of a vaginal birth because of the rising Caesarean rate.
It is true that during the past 10 years there has a been a vast improvement in hospital births in terms of attending to families' emotional as well as physical needs and accepting the rights of the laboring family based on informed consent.
Having established the Israel Childbirth Education Center 25 years ago, this writer and other veteran educators and counselors welcome the radical changes that have taken place. Midwives have been encouraged to attend courses on physiological birth and how to support the laboring woman with natural remedies such as massage, oils, baths and showers, more flexible positions, relaxation and breathing, use of herbs, etc. Some have learned the skills of shiatsu and yoga. In one northern hospital, the doctors are invited into a woman's room only if the midwife thinks it necessary, and midwives use their healing skills to try to avert interventions.
Hospitals are competing with each other to provide more esthetic conditions, natural birthing rooms, private baths or showers, dimmed lighting and state-of-the-art beds that can be adjusted for a woman to choose in what position she gives birth.
But many of these renovations are cosmetic. Until the mind-set of senior doctors and midwives in those hospitals changes radically, women are still subjected to the cycle of interventions that has contributed to Israel's 20-25% Caesarean rate, which is 10-15% more than that recommended by the World Health Organization.
Another improvement in recent years is the time that healthy babies are left with parents so that mothers can bond and start breastfeeding, and the option to request rooming-in. But even if a baby is in the room with his mother 24 hours a day, births in most hospitals are followed by a period of separation while a pediatrician and nursery staff check all the vital signs.
For the majority of women in labor, is this actually a safe way of giving birth?
Attempts to establish alternative birth centers have not been encouraged by the Health Ministry, and small maternity departments that lacked fully equipped intensive care neonatal units were closed down. Laniado Hospital in Netanya pioneered - and others are following - an innovative program where women, for an additional fee, can choose their midwife, who then undertakes to attend her for the duration of the labor - and not disappear at the end of her shift. This gives the woman and her support persons an opportunity to meet with the midwife of choice, discuss important issues and then be reassured by that familiar face when they come into the hospital for the birth.
There is no reason why every hospital in Israel should not implement a similar program - it simply needs some organizational skills and motivation.
With all this in mind, it is not so surprising that home birth is becoming more popular in Israel. There are now 12 Israeli licensed midwives and several others, licensed overseas, who are available for home births.
Public attitudes are still ambivalent toward birthing at home, partly because of the cost (hospital births are covered by the National Insurance Institute) and partly because couples fear that it is not safe to give birth out of a hospital.
But in countries where home birth has been part of the mainstream for many years, the safety statistics are in favor, providing there is compliance with criteria of accepting only healthy women with a single fetus and no history of complications in previous pregnancies and labors.
In the UK, for example, home birth was promoted by the government in the 1960s and 1970s because of a baby boom and a shortage of hospital beds. More hospitals were built in the 1980s, and the British government tried to phase out home birth. By 1990, home birth in Britain had dropped to 1%.
Since then, however, there has been an active movement to retain the rights of women to have safe home births with fully licensed domiciliary midwives. Unlike in Israel, home birth is paid for by the authorities, but logistically it is not always available because only midwives working with a National Health Service family doctor can be hired, and many family doctors have now opted out of supervising home births. This leaves the option of finding a private independent midwife.
The Netherlands, which traditionally has a strong track record for home births, still provides consistent state support.
Ilana Shemesh, who emigrated from New Jersey in 1973, was one of the first licensed midwives to offer home births in Israel. She has 25 years' experience in midwifery, having worked at Assuta and Misgav Ladach hospitals. A new edition of her book Home Birth (in Hebrew) will soon be published.
In the past, although the Caesarean rate was much lower, there were many unnecessary interventions, and the social and emotional needs of laboring women were not high priority in hospitals. There was also little support for breastfeeding. The two challenges faced by the Israel Childbirth Education Center when it opened in 1981 was to get the fathers or other support persons admitted into the labor ward and to have less separation between the mother and the newborn.
Shemesh recalls that she was extremely frustrated by hospital routines, even as conditions improved.
"I was really stressed trying to conform," she says, adding that she had a reputation in the establishment as a radical non-conformist.
For her first 10 years of accepting home births, she kept it quiet because the practice was considered so radical.
"I accepted only a few a year, but I was inspired by the demand. Home is the best stress-free environment, for the family and for me," she says.
Shemesh insists on criteria in accord with international protocols (see sidebar). She is a member of the Israeli Homebirth Midwives Association and has met with Health Ministry officials to negotiate accepted protocols for home birth.
"They would like to see us exclude [some] mothers because of the size of the baby, whereas I would rather assess each woman individually according to her size and previous obstetric history," she says.
Shemesh, like most home midwives, only attends births at homes no farther than a half-hour drive to the nearest hospital, so that if there is a necessity to transfer, she can do this herself or call MDA. "Most transfers are not emergency," she emphasizes when discussing the 10% of transfers she has experienced over the years.
Six out of every 10 transfers have been during labor because of failure to progress, which she feels is not yet critical but reaching the mother and baby's endurance levels. Of this six percent, only one in three needed a Caesarean section. More urgent transfer was required in the rarer four percent of postnatal complications of retained placenta or a distressed baby.
Since the remedies used for inducing labor and pain relief are non-medical, home birth midwives do not experience the complications caused by interventive remedies such as fetal distress because of aggressive inductions, dozy babies because of the use of pethidene, or the increase in vacuum births as a result of epidurals.
Who demands home birth? Shemesh says her clients are now more native-born Israelis. "It used to be the Anglos, then the hippies and yuppies," she says. "but now the demand comes from women who feel that they will have a safer birth without unnecessary interventions. The men are often more scared," she adds.
Listening to other midwives and mothers, it does seem that partners are more ambivalent about home birth. They have no control over labor and have to watch as their loved one endures what can be an arduous and painful experience. They may well prefer to be in the controlled environment of a hospital.
Some practical problems will only be solved when home birth is fully accepted by the government. Women only get their maternity grant if the baby is admitted to the hospital. For the first birth this is substantial at NIS 1,300 and needed to buy basic equipment.
Another problem is if the mother is Rh negative and needs the routine anti-D injection soon after the birth. If she is not in the hospital or her physician will not give her a prescription, it will cost NIS 350.
Also, health funds do not cover a check-up by a pediatrician because the baby does not yet have an identity number. "I like a baby to be checked within 24 hours," says Shemesh, explaining that this usually necessitates using a private pediatrician.
"The government could save so much money on safe low-risk home births. A hospital birth costs NIS 7,000, whereas a home birth including a pediatric check-up costs NIS 4,500 to NIS 5,000. With 140,000 births a year in Israel, the majority of them being low-risk, that could leave a lot of spare cash for fighting disease. The government pays for Caesareans on demand, operations requested by women without medical indications, and yet they will not pay for home births."
But more important, says Shemesh, is the better outcome.
Women are disappointed if Shemesh cannot accept them for home birth, but she is strict about screening. "We cannot get favorable insurance policies," she cautions, "but I have not yet had a court case."
Clients sign an informed consent form. "Israeli midwives' training is at a very high standard, but there is not enough focus on prenatal and postnatal care," says Shemesh. "All licensed midwives are qualified for home births, but they need to be special."
Mindy Levy, a former New Yorker in Israel since 1978, lives in Beit Lehem Haglilit near Tivon. She has been working with home births for nearly three years, after a long career in hospital midwifery. She trained at Rambam Medical Center in Haifa and worked for nine years at Bnai Zion Hospital in Haifa. During the latter part of that period, Levy was deputy head midwife and a clinical tutor. She also coordinated the midwives' training course at Rambam for two years and continues to teach midwifery at Tel Hashomer, Soroka, Ichilov and Rambam hospitals.
"Midwife educators need to be at the forefront of promoting home births," she declares. "After so much research and in-depth work in education, I understood the damage done by unnecessary interventions - and I was part of it! I was co-operating with something I didn't agree with."
It was research for her master's degree in women's studies. Levy's thesis paper was on the connection between trauma and birth, focusing on victims of terrorist attacks that led to a higher awareness of trauma in general and trauma created in the delivery room. "I wanted to attend births that were healing trauma, not causing it," she says.
It became clear that Levy had to leave the hospital system. "I was saving my own life," she says, explaining that her daily routine was making her sick. "This was no longer my idea of midwifery; it was too segmented. I would work with a woman for a few hours, part of a shift, and have to attend to more than one woman at a time."
Levy says that once she made a decision to attend home births, the demand snowballed. "For some women with special needs or suffering from trauma, home birth is not always appropriate," she notes, adding that she would offer the option of attending them privately in hospital. "Sometimes we would start a home birth, and I would see that the woman really wanted to be in the hospital."
In the period since Levy left the hospital labor ward, she has attended 42 births - 37 at home and five "dominos" (see sidebar). She will also attend a birth in her own home if the conditions are not right in the client's home. During this time, 20% of her clients were transferred to the hospital, mostly for non-emergency reasons.
"I have a deep belief in mothers and babies and their ability to birth without complications. I also believe in myself that I can identify situations that require a higher level of care," she says.
Clients are fully informed and take responsibility, she notes. Home midwives are not insured, so the women are required to sign a release form. "It's a formidable situation - there are two lives here."
Like all home midwives, Levy has back-up if she has two births coming up close together; but she also calls in a second midwife for the second stage of childbirth so that if the mother or baby needs extra attention, there is more than one pair of hands.
Home birth is time-consuming. Levy meets with clients regularly during pregnancy and is present throughout the labor. She stays for four hours after the birth, making sure that after the placenta is expelled, there is no excessive bleeding and that the blood pressure is stable. She helps the new mother to shower and breastfeed her baby, returns the next day to ensure that a pediatrician checks the baby, and keeps in telephone contact.
Levy observes that in a physiological birth - one without interventions - the second stage is far shorter than the average hospital birth, with less tearing or bleeding after the birth and an easier start to breastfeeding. In all the home births she has attended, there has only been one case of neonatal jaundice.
This bears out this writer's observations in the UK when home birth was common. Early and uninterrupted breastfeeding provides the newborn with valuable colostrum, which helps the baby to expel meconium at an earlier stage, which in itself prevents the build-up of the bilirubin seen in jaundice.
Asked if children might be present at a birth, Levy replies that she complies with the desires of the client but maintains a special awareness for the well-being of the child involved. "In one birth, as the mother started to breastfeed her newborn, her three-year-old climbed onto the bed and sucked from the other breast," she recalls.
Levy says she derives great satisfaction from attending women throughout the entire maternity experience, and not in fragmented segments. "The first meeting before the birth is so important," she says. "It's very emotional for the women. Sometimes the couple are at odds about the safety of home birth, so we can discuss the facts versus the myths."
She has also been a nurse in a neonatal intensive care unit, and shows her clients the emergency equipment she carries. However, in spite of the orientation meeting, if the father is adamantly against home birth there is no point in continuing in that direction. "Fear and negative vibrations arecontagious," she says.
Some midwives prefer not to attend first-time mothers at home, but Levy feels otherwise. "I believe that the first birth should be optimal, the very best of experiences - and then the other births will follow on in that pattern. Home birth is a feminist statement."
What is domino birth?
The combination of home and hospital birth is popular in the UK. British midwife Caroline Flint is the author of Know Your Midwife. She has a long track record in hospital births and runs an alternative birth center in London.
Flint has written extensively on the value of being attended by professionals with whom there has already been a dialogue. Women and their supporters meet with the midwife at home prior to the birth, invite the midwife home at the onset of labor, and together make the decision when to go to the hospital or birth center. In this way, the long early stage when there are sometimes false starts can be safely spent in the comfort of home; only when the active stage of labor progresses is there a need to go to the hospital. The same midwife continues to care for the laboring woman until she has given birth and recovered, with no time limitations of hospital shifts.
What the researchers say
Comparing the safety of home births against that of low-risk births in a hospital is controversial because some studies include the entire range of home births, even in countries where home midwives may not be fully qualified and do not always comply with the criteria.
Therefore, the fact that the prestigious Cochrane Database Review 2000 concludes that "There is no strong evidence to favor either planned hospital birth or planned home birth for low-risk women" is in fact a subtle statement of support for home birth because it hands the choice back to the women themselves.
Dr. Avner Shiftan of Poriah Hospital near Tiberias published a favorable survey on planned home births in the Hebrew medical-scientific periodical Harafuah. He investigated a total of 348 home births in 2005 as reported by licensed Israeli midwives, and found that 90.2% of the births took place without any complication. 9.7% of women were transferred to hospital during labor, of which 3.4% concluded with Caesarean section and 1.1% with an instrumental birth. 2.8% of mothers, and 0.28% of newborns were transferred to hospital after the birth. There were no maternal, fetal or neonatal deaths.
Shiftan concluded that planned home births with professional midwives complying with the criteria for low-risk pregnancies result in a friendly environment and less medical intervention.
On November 23, 1996, the British Medical Journal had as its main theme the study of home births. One of the articles compared hospital and home births in the Netherlands, a country with a strong tradition of home births. Researched by Prof. M. Keirse, Van der Zee, Berghs and Wiegers, a study was based on maximal result with minimal intervention and again showed that when home birth is conducted within the criteria for safety, the outcome is at least as good as that of planned low-risk hospital births.
British researchers Davies, Hey, Reid and Young observed that of the 14% of women who were transferred to hospital during labor, on no occasion was emergency intervention required in the first hour after transfer and that the women were appreciative that they had spent even part of their laboring time at home.
The UK-based National Birthday Trust published the most comprehensive study of that time in the UK in 1994, researched by British obstetricians Chamberlain, Wraight and Crowly. It should be noted that Prof. Chamberlain is a champion of the rights of the birthing woman who endeavors to achieve a reduction in medical interventions.
In the study, planned home births were compared with planned hospital births, matching risk factors, age, primaparas and multiparas. The authors concluded that "The hypothesis that social and environmental factors can affect progress of labor and mode of delivery is strongly supported by experimental evidence."
The research showed how continuous professional support during labor is associated with a reduced incidence of Caesarean section and instrumental delivery, concluding that low-risk women may labor better at home.
A more recent study by Johnson and Davis published in the British Medical Journal in 2005 showed the outcomes of planned home births with professional midwives in North America. A total of 12.1% were transferred, and true to other studies, the majority of them were during labor for non-emergency intervention in the hospital. The researchers did show that transfers for primips were four times as common as that for multips; but again, most of the reasons for transfer were not emergencies.
While there is no doubt that the priority for both parents and caregivers is a healthy mother and baby, these studies are only examining tangible complications. They are not looking at the number of mothers who have problems breastfeeding because of the medications received during labor. Nor do they examine prolonged labors because women are inhibited in the hospital environment from producing the love hormones, or the cases of post-traumatic stress disorder in women who felt that their birth was taken away from them. They are not even looking at the proven favorable outcomes in home birth where midwives are reporting shorter second stages, calmer babies, less bleeding after birth, fewer episiotomies, less medication, and fewer eventual vacuum births and Caesarean sections. This is because these are all cause-and-effect and cannot always be measured scientifically.
Criteria for home birth
*Home is within a half-hour ride to the hospital
*Full term - 37 to 42 weeks
*Good normal pregnancy
*No blood pressure problems
*Not VBAC - Vaginal birth after Caesarean (not all midwives comply with this clause)
The writer is president of the Israel Childbirth Education Center