Informed Choices: Place of Birth

I recently shared my birth story on the blog and the podcast- and if you read or listened, you’ll know I had a home birth this time. My first birth was a hospital birth. These are two options when it comes to place of birth. The third is usually a birth centre – I will discuss each option more below, including current evidence. Please be advised that I am writing this primarily from the perspective of someone who lives in Ontario – where midwives are regulated healthcare professionals who are integrated within our healthcare system.

Also – I know there is often confusion between doulas and midwives. In Ontario especially, they are very different. I’ve previously written about doulas here and I’ve had a former Ontario midwife on the podcast before here (the difference between midwives and doulas was discussed on the episode).

Disclaimer: this is not medical advice. This blog is for informational purposes only. Please seek medical advice from your trusted healthcare professional.

A Note for High Risk Pregnancies

So I think it’s important to start off by recognizing that choosing place of birth sometimes can be limited by the status of a pregnancy. A high risk pregnancy (generally) cannot be safely supported in the home, or sometimes even a birth centre because these places are not hospitals (though a birth centre may be connected to one so it’s worth discussing your unique situation with your provider).

So, if your pregnancy is considered high risk – you may need to deliver in a hospital. Although this can be upsetting for those who maybe dreamed of a different setting for their birth – know that this is because of the resources a hospital and modern medicine have to offer. I know people love to say “we were meant to do this” when it comes to labor and delivery, and while it’s true that are bodies are supposed to support being able to get pregnant and carry a baby and deliver it – a quick look at history and even the current world around you can tell you that this is not always the case. Sometimes, people do need help conceiving, carrying or delivering their baby and that is okay. I hate when people say that our bodies are meant to do this because it can cause an immense amount of guilt and frustration when your body doesn’t do what you think it’s “meant” to do. Our bodies are also supposed to produce insulin and that does not always happen (see: Diabetes) – and the same can be said of many other bodily actions or functions. So please don’t feel as if you or your body has done something wrong or ‘failed’ because you need support, assistance, etc in any of these tasks. You are amazing no matter what!

Modern medicine is very important when it comes to birth. Do I think there can be too much intervention at times? Yes absolutely. I do also know that there are times when intervention and monitoring are needed and save lives. If you haven’t – check out Angela Garbes book “Like a Mother”(fyi- affiliate link, I may earn from your purchases as an Amazon associate). This is a great balanced look at the science of pregnancy and birth, and also the culture and expectations – a good read for any expecting mother (or parent). It talks a lot about the evolution and history of birth and birth practices and is very informative.

ANYWAYS – point of this is – if you are high risk, you may have to birth in hospital. This doesn’t always mean that you can’t make your birth what you want it to be. I read recently about a mom bringing little Christmas lights for her hospital room and the nurses loving it. Make your space your own. Bring music. Advocate for the parts of your birth you want to include – if they are possible, discuss them with your provider. Get a doula to help with advocacy, support and education. And remember to always be open and flexible – practice this in the days leading up to birth with everything else in your life so it becomes a habit. Being high risk does not mean your birth experience cannot still be positive – you may just need to make some adjustments to your “ideal” birth. Hopefully you will have the support to do that.

What are my options for place of birth?

If you are considered a “low risk” pregnancy, you will have more options in terms of birth place – depending on where you live. Accessibility is still an issue with birth centres primarily, but it could also be an issue with hospitals if you are very rural! Lets review the 3 options for place of birth:

Hospital

This is likely your default option because of the times we live in. Though there is certainly an increase in births in other locations now, hospital is by far the most popular choice (although I think some people don’t know there are sometimes other options, or have a provider who only delivers at the hospital so choice may not be the right word).

I don’t think I need to explain what a hospital is – if you give birth in a hospital you’re usually admitted through labor and delivery and deliver your baby with your preferred provider (midwife or nurse/obstetrician or GP team). Sometimes you have to stay afterwards in postpartum – actually I’d say most people do, unless you deliver with midwives then you will often have the option to go home several hours after your birth as long as all is well.

Hospitals boast medical technology, certain medications/pain control options or procedures that cannot be done at home, and life-saving surgeries. All very important.

Birth Center

Depending on where you are, your birth centre will be slightly different – but I’d consider it an in-between option. It is not quite a hospital birth (but as I mentioned is often connected to or associated with one) yet it is also not a home birth. It’s a happy medium option for people who may want to have a more “holistic” birth experience – I refrain from use of the word “natural” because all birth is natural. Additionally, they are known for being more culturally sensitive and supportive of different birth preferences. They also usually take on a more “at home” vibe, with comforts and surroundings that can help support relaxation.

In Ontario, midwives deliver babies at birth centres. There are two types – Aboriginal Midwife led and Registered Midwife + Aboriginal Midwife led. You can read more about the two types here.

Notably – Ontario only has two birth centers and they are in two major cities – Toronto and Ottawa. I mentioned accessibility before and this is mainly what I was talking about. Some people will travel to be close to a birth center because it’s their preferred birth location, however this is not possible or feasible for everyone. So, birth centres for a lot of people are not in the cards because of this – which is unfortunate, but there are likely many logistical and staffing factors (and financial – although birth centers ?may reduce costs) that contribute to them not being more widespread.

Home

Finally, in Ontario, low-risk pregnancies have the option of delivering at home with midwives. The option of home birth of course exists in other places too – for example, the UK has quite a robust and positive history of home births with midwives. Similarly, they have criteria laid out for those who are more appropriate for birth at home like Ontario does.

You can obviously give birth at home anywhere – but whether or not where you live has good home birth outcomes and regulated health professionals that attend these births is another story entirely. I simply cannot cover this information worldwide – so I’ll focus on the data that exists in Ontario primarily, but I’ll try and provide references and links to other information (mainly for the US, since most of my readers are Canadian and American). The data I mention about safety is in reference to home births attended by regulated health professionals – specifically, midwives. In Ontario, midwives are integrated with the healthcare system and deliver in hospitals, birthing centres and at home. In the US, midwives are often not integrated in the same way so outcomes and data are different. Please see ACOG’s statement on Planned Home Birth here to see which factors and providers increase positive outcomes for home births in the US.

Low risk pregnancies are appropriate for home births, with a cephalic (head down) presentation at 37+ weeks gestation. Again – criteria in different areas may vary, and the decision should be made after a thorough discussion with a healthcare provider about risks and benefits.

Big sis meeting little bro @ home!

Risks and Benefits

Lets Talk Benefits First

Many people are aware of the notable benefits of hospital birth – major ones being access to resources and speciality care, surgery, and pain control options not available in other locations.

For certain birthing persons, a hospital may boast even more benefits. If you are high risk for any reason – the hospital will hold many benefits by giving you the care you and your baby need. Sometimes that is life-saving care. Some may also just feel more comfortable in a hospital setting for whatever reason (probably because of the above reasons) which is also fine. The best thing we can do for ourselves is give birth in: 1) a place where we can safely do so and will be cared for as is needed/appropriate; and 2) somewhere where we feel comfortable. Sometimes you might not get the comfortable option unfortunately and I recognize that – as I mentioned above, there may be things you can do to make the hospital comfortable for you. Sometimes it’s having coping methods that keep you calm; a support person to be your rock; etc.

Sometimes we’re put in an emergency situation and comfort gets robbed from us in those momentsI hope that healthcare providers do their best to make birthing people who deliver under these circumstances as comfortable before and after as possible. From listening to so many people’s birth stories I can say that it really can make a big difference in their overall experience. This can be considered one of the “risks” of hospital birth. I’m not going to get too much into what I think is sometimes (I say that lightly because I am not an expert) the overuse of interventions – but I will say this is why it’s important to be informed about your options, your birth and everything else so that you or your support person can advocate for not only what you want, but for what is best based on evidence-based information. Notably, it can also be considered a risk of birth in general. In any place of birth, we may have emergencies or things that occur that may even be traumatic. We may have a negative experience in any place of birth and this is a risk. Things we can do to minimize this risk is having a provider we trust (big one), having a good support person willing to advocate when you cannot, and being informed. It’s not a promise – but these things may help.

In terms of benefits of birth centers and home births – comfort, which I mentioned above, is a big one. I truly believe (and this is just my opinion) in a comfortable environment, for most people, labor goes smoother. I know it certainly happened to me – I mean, this could have been a first vs second birth scenario, but with my second labor I coped better too. I had everything I needed at my fingertips at home. My husband even preferred it because he could eat if he wanted to without needing to “leave” me or have someone else bring him food. Other benefits for me were: no commute to hospital; had everything for me/baby available (no risk of forgetting something due to pregnancy brain); no risk of my spouse not being able to be there due to COVID precautions; minimized risk of contracting COVID; already at home after birth; and, my daughter got to meet her brother right away.

There is evidence to suggest that women choose home births to increase feelings of control over their environment, but also because many women reported feeling like they lacked choice in the hospital setting. So often, women will pursue home birth after a first birth experience in a hospital for these reasons – to be involved in decision-making (which, should also be happening in any setting however reports from women don’t always reflect this) and to reduce interventions which many felt were unnecessary.

If you want to read more about the benefits (or risks) of planned home births, I have been citing from this study by Zielinski et al. (2015).

I found a great Canadian study by Hutton et al. (2016) looking at and comparing outcomes for planned home or hospital births. They found no significant differences based on planned place of birth, but did find that planned home births in places like Ontario had fewer interventions. You can see more comparative statistics between planned hospital and home births on this page. This is certainly a benefit.

Other benefits of home birth include: higher rates of exclusive breastfeeding; fewer postpartum complications such as hemorrhage or 3rd and 4th degree tears; and a better overall experience and higher satisfaction for women.

Notably, intervention rates were also shown to be low for Ontario’s birth centers in their first year, in a study done by Sprague et al. (2018). But more research is needed – birth centres in the province don’t have enough births recorded yet to provide the same level of data as we have on Ontario home births. International research on the topic show great outcomes for low-risk births at centers in places like the UK. Hopefully increasing births in these locations will provide us with similar Canadian results – because they really are a great option for those who want an “in-between” option.

Risks

These should be discussed with you by your healthcare provider – because each person’s situation is different. High risk pregnancies hold a variety of different risks – which is why the recommendation is for high risk births to happen in hospital so that any risk or issue that may arise can be addressed. It’s possible that a high risk pregnancy has a totally smooth birth – but there is just no way to know that in advance, so being prepared is likely the best and safest option.

The risks of home birth – in Ontario specifically, when attended by a registered midwife – are essentially the same as for a hospital birth with a low-risk pregnancy. There doesn’t seem to be much if any difference in the data. One thing that is seen from the data is the decrease in interventions with a planned home birth (including if the person ends up going to the hospital).

When you look at home birth data outside of Ontario, in places like the US, things get more cloudy. Lower APGAR scores in home birth babies have been reported in US studies – however, there is often not differentiation between the type of midwife delivering the baby (and in the US it’s not just one type like it is in Ontario). Different US studies have also reported higher neonatal mortality rates and greater risks if delivering at home after 41 weeks gestation.

From reading the data, it seems that a lot of the issues in the US with home births stem from a lack of consistency with midwifery licensure and education. There are so many types of midwives and not all are trained the same. They also are often not as integrated into the healthcare system and the hospital system as Ontario midwives so luckily are.

Zielinski et al. (2015) note that having eligibility criteria for a home birth contributes to the safety of home birth. Home birth may seem like it’s only available to a limited number of people in a way, but it appears it is for a good reason. I think this is why Ontario maintains such good outcomes.

One thing I got asked a lot when telling people I was having a home birth was what if I needed pain management or had an emergency? Not having access to medicated pain control options may be a risk for some – as it can negatively impact their experience. Some things that happen in labor may require a hospital visit – non-emergent or emergent. If someone knows they will need pain management (like an epidural), planning a hospital birth may be a good idea – however, transfer from home to hospital can happen if you want to try without it. As someone who had an epidural the first time, I was definitely concerned I wouldn’t be able to birth without one – to my surprise, I never felt I needed one but remember that pain tolerance and experience is different for all of us. There is nothing wrong with wanting something more to make your experience more comfortable (remember I said that was important?!).

Transfers are also facilitated for both non-emergent and emergent reasons (if needed). A risk here would be if you live in more of a rural area – and have a further distance to travel to arrive at a hospital. When you discuss home birth with your midwife, this will be a consideration for them as well as things like the weather, which could impact travel time or ability. There may still be options if you wish to pursue a home birth, which can be discussed with your midwife in detail.

In regards to emergency management – I was told I would be alerted at a “yellow light” and not a red one, when it came to signs of any potential change in course. Midwives in Ontario are monitoring you during your home birth for any changes that may require a hospital visit. They actually have the training to manage many complications and even some emergencies in the home. So if something were to happen, you’re not just waiting until you get to a hospital to deal with it. Your midwives and emergency services (if needed/applicable) will be responding immediately. You can read (and watch on Youtube) about emergency transfers to hospital here.

Are there any increased risks to a hospital birth? As I mentioned above, women do report issues with hospital births such as feelings that they are not included in decision-making. Data mentioned above also shows an increased risk of unnecessary intervention (obviously a necessary intervention is not a negative). And emergencies are always risks, no matter where you birth.

If we look at the “bigger picture”, racism and resulting disparities increase risks for certain birthing persons, like Black or Native American birthing persons, who experience high rates of morbidity and mortality in birth. Things like access to education or access to thorough health education, may limit ones knowledge of birth and all of these things create risks. More interventions, less informed choice and so on. There are so many systemic factors that contribute to risk – and sometimes, these are increased in the hospital where women feel they have less choice and sometimes, less personalized care (which is sometimes the result of another issue – nursing shortages, staffing ratios, nursing pay, no sick days, ETC – the list goes on).

Other risks may be things like infection risk when attending a hospital – which is a particular concern during the pandemic, where we now have to worry about COVID on top of other illnesses we normally found in a hospital. The pandemic also increases anxiety for many – which I see as another risk. Stress and anxiety are not fun to have (though they don’t seem to prolong labor as some believe).

So: all birth comes with risk, despite what some may want you to believe. Although we can be “built to have babies”, this is not a hard and fast rule like.. at all. Many people do need to assist their babies arrival into the world – in different ways, and nothing is wrong with that. Some people have narrow pelvises, or conditions which make a safe vaginal or unassisted birth impossible. Even those who seemingly have everything they need to deliver safely may find themselves in an emergency situation where they require intervention because birth and the human body itself can be unpredictable.

When it comes to place of birth – what matters most is that you are birthing somewhere that is safe for you, and that is in line with what you value and care about.

A planned home birth with a regulated midwife for a low-risk pregnancy, at least in Ontario, is considered a safe option comparable to a hospital delivery when it comes to outcomes. Midwives can respond to complications and emergencies, and are monitoring constantly to ensure you get the care you need if anything changes. A birth centre would be similar under, again, regulated midwife care. A hospital birth boasts the resources needed to respond to emergencies – and the benefit is that you’re already there for quick access. It may also be where you are most comfortable – you don’t need a reason, just follow your gut. It is also the safest option for those with certain conditions of pregnancy, or who are considered high risk (discuss with your provider if you have concerns). If you are low-risk – place of birth is an individual choice, really, based on your preferences and eligibility. Be informed, talk to your provider and remember that there is always the option to transfer to hospital if anything changes (including your mind or coping abilities!).

Additional Resources

Home Birth Safety – Association of Ontario Midwives

The Safety of Home Birth – JOGC

Statistics Canada Info on Place of Birth

ACOG Planned Home Birth Statement

SOGC Statement on Planned Home Birth

Home Birth FAQ

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