The pros and cons of homebirth in the age of coronavirus

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I’ve received quite a few private messages asking whether homebirth is a better option than hospital birth in the age of coronavirus.

Let me start by acknowledging that I don’t know. No one knows; our lack of testing means that we don’t know how prevalent the virus is in the population or how likely a person is to catch it from another person. We also don’t know if coronavirus poses special risks to pregnant women and newborns although for safety’s sake, we must assume it might.

Homebirth midwives are providers, too. They are at much higher risk than average of having and transmitting the virus.

Since I don’t know, I can only list the pros and cons as I see them.

COVID-19 INFECTION RISK

Pro: There is no question that hospitals themselves are very high risk areas for COVID-19 transmission. They are filled with people who are severely ill and doctors and nurses who have been exposed to the virus repeatedly. That said, it is important to remember that hospitals are always full of sick people, so strenuous efforts are made to isolate labor and delivery as well as the postpartum floors from the rest of the hospital. The safest place within any hospital is almost always labor and delivery and the postpartum floors.

Con: midwives are healthcare providers, too. Unless they have stopped seeing all their other patients, they are at much higher risk than average of having and transmitting the virus. Moreover, they are unlikely to have access to the personal protective equipment that would reduce their risk. Keep in mind that a pregnant woman could have the virus already and SHE could pose a significant risk to her baby.

Con: If you need to transfer emergently during labor or after birth, you will be exposed to EMTS and emergency room personnel, the people who have the greatest risk of having been exposed to the virus and potentially exposing you and your baby to it.

INTERVENTIONS

Pro: Homebirth dramatically reduces your risk of unnecessary intervention.

Con: Homebirth dramatically increases the risk of death for baby and mother due to lack of necessary interventions.

COMPLICATIONS

Pro: There are no pros. Homebirths do not reduce the risk of complications; they increase the risks that complications will lead to brain injury for the baby or even death for the baby or mother.

Con: There is no access to an operating room for emergency C-section, no access to blood transfusions for hemorrhage and no access to the people who can perform advanced resuscitation and intubation of a baby who is born not breathing.

Con: Complications can often be prevented with early recognition and intervention. Homebirth midwives boast that they are experts in normal birth; they leave unsaid the fact that they are NOT experts in childbirth complications and often don’t recognize when they are developing.

Con: In the US (but not Canada, the Netherlands, the UK etc.) there is a second class of “midwife” known as certified professional midwife. They are not real midwives, merely lay people whose “education” is typically only a correspondence course. They lack the education and training of ALL other midwives in the industrialized world and they fail to meet the international standards of midwifery. They are barely better, and in some cases worse, than no midwife at all. They have NO training in managing serious childbirth and newborn complications. That’s why their death rate in much higher than midwives in other countries.

ACCOUNTABILITY

Pro: There are no pros.

Con: Homebirth midwives in the US, particularly CPMs, lack both malpractice insurance and accountability. If something goes horribly wrong, there is no one to sue and no way to hold them responsible for their errors.

THE BOTTOM LINE

There is one undeniable pro to homebirth in the age of COVID-19. It almost certainly lowers your risk of exposure to the virus compared to hospital birth but ONLY if you don’t need to transfer to the hospital. Your risk is not low, however, since your midwife is at high risk of carrying the virus.

There are a lot of cons but none greater than the fact that in the US, homebirth dramatically increases the risk of neonatal brain injury and death.

On balance, it seems to me that the risks of homebirth outweigh the risks of hospital birth, but other women may reach different conclusions and make different choices and that is their right.

  • Haley

    This is a change from your usual online persona and I like it. Thank you.

  • Blake Lee

    Wow, what a choice to make. I would have to pick the hospital because of previous csections but if I were low risk and had already had an uneventful vaginal birth…I’d be thinking long and hard. Not simply because of COVID-19 but because the baby friendly hospital initiative has made some hospitals down right dangerous for babies without an additional support person. No baby nursery and under staffed. The risk of falling asleep with the baby in your bed. I highly doubt they’ll drop the breastfeeding push. In fact if I had to bet, a whole lot of moms are going to be told breastfeeding will probably protect their baby from COVID-19. Imagine the pressure of that right now? No support person, baby friendly hospital, a pandemic…man, I’m glad I had my baby already so all of this is theoretically for me. For those people who this is reality, I’m so sorry!

  • Who?

    What do people think of this?
    https://www.abc.net.au/news/2020-03-24/powdered-breastmilk-technology-could-save-lives/12079406

    Also hope everyone is safe and well and has access to soap and (lots of) handcream.

    • rational thinker

      Freeze drying has been around for a long time now. They act like its a new process, and isn’t that how we get powdered formula which is more nutritious and safer than someone else’s body fluids.I wonder how much MONEY they will charge for this, they did not mention that. It totally sickens me when they act like there is no other choice than breast milk or donated breast milk.

      “I struggled to bond with him.” ” She said from there baby Elijah became constipated and irritable because the formula did not agree with him. As her new baby battled so did she, eventually grappling with depression.Ms Martin was not alone. A study of 2,500 women
      found those who had a negative experience with breastfeeding were more likely to endure post-natal depression two months after the birth of their baby.”—–

      Well, I wonder why so many women are getting depressed and have negative feelings about breastfeeding. Could it possibly be that you hammer into them how important breastfeeding is and how you won’t bond without it to the point that a mother feels she is a failure and a bad mother when breastfeeding doesn’t work out?

      “Ms Ryan said it was not unusual for mums to produce less milk as a result of stress and upheaval.She said the goal was to stop babies from having to go without, regardless of whether a family was fleeing a storm or were forced into isolation due to COVID-19.
      “When we go through things like floods, droughts
      or fires, they can have the breast milk there for these babies under 12months,” Ms Ryan said.”Because at the moment we have no contingency plans for emergency reserves of this essential food for babies.”—–
      I remember when a natural disaster hit, lactivist’s try to stop powdered formula from being sent using the excuse of water may be contaminated so formula is unsafe and women should get donor milk or try to relactate. So why would they think of sending powdered breast milk into a disaster zone because you know the water may be contaminated. These assholes are such hypocrites, if she wants to stop babies from having to “go without” in a natural disaster. Then I suggest she tell the lactivist’s that try to block formula donations to areas that need them to stop making babies go hungry for their ideology and in her own case their wallets.

  • Lurker

    Unfortunately, you missed a big pro: support. Hospitals in hard-hit areas are beginning to implement policies like this one from NY Presbyterian (which I just pulled from the website to be sure what I’d heard was true):

    “At this time, no visitors including birthing partners and support persons are permitted for obstetric patients. We understand that this will be difficult for our patients and their loved ones, but we believe that this is a necessary step to promote the safety of our new mothers and children.”

    As someone who has tried to talk people out of homebirth in the past, I still wonder, if I were pregnant now, with multiple quick, intervention-free births in my past, would I take the relatively low risk of something going wrong at a homebirth over the certainty of needing to go through labor and delivery ALONE, without my spouse or any other support person? I admit I would be tempted. They are asking a HUGE amount of women in labor to go through it all alone, and a lot of women aren’t going to be on board with that.

    • rational thinker

      Then they have to ask themselves which is more important, having someone hold their hand and keep them company or the life of their newborn baby. In the past support people/partners were not allowed in the labor room. If you look at the whole history of women giving birth in hospitals having your spouse/support person in the room while you give birth is a fairly new thing.

      • KeeperOfTheBooks

        To be fair, as important as emotional support is, it’s not only a case of needing emotional support in the age of coronavirus, but also someone who’s capable of caring for your newborn…’cos if you have the misfortune to give birth in a baby-friendly hospital, the chances are extremely good that the staff there won’t.
        I know two C-section moms who were absolutely in no position to care for their newborns postpartum, but with no well-baby nurseries and uncooperative nurses, they would have had to despite being incapable of remaining conscious, in one case, and not being able to control her arms and hands, in another. Both had support people with them who could care for the baby. With a policy like this, that would not have been the case.

        • rational thinker

          I do agree that one support person should be allowed especially in a BFHI hospital. Maybe a compromise could be made like once they come in with the mother they cant leave until mom and baby leave. So they wont be coming in and out of the hospital the whole time that would reduce some risk.

          If it came down to a choice between give birth at home with a few support people and give birth in hospital alone I would still opt for the hospital.

          On a personal note I do know how it feels not to have your spouse at the delivery. Especially when thats the one person in the world you want most at that time. It still hurts almost 18 years later. It was not by choice that my husband was not able too be there and it still upsets him too that he could not be there for the the birth of our first child.

          • Inmara

            One hospital in my country has such policy (father can come in and stay until discharge from hospital), but that doesn’t work if there are other children or other family members to be taken care of. The existing system in most hospitals is built around assumption that family or friends can help postpartum women a lot. I’m dreading that we will be thrown back in Soviet time practices when women were isolated in birthing hospitals, with no epidurals, no support from staff and limited options to cope with the birthing process. I still wouldn’t choose homebirth, but I’m now considering the hospital close to home which has not that many births and offer rather cheap epidural so I could labor alone.

          • KeeperOfTheBooks

            I’m sorry. 🙁 That’s a possibility for us with any future kids (ie, DH not being there) and it’s one reason I struggle with the idea of having another. I’m so sorry you had to experience that.

          • rational thinker

            What was more awkward was that when he could not be there his mom thought she should come to the hospital in his place. I was on my second hour of pushing when she showed up and I had never even met her before or talked to her over the phone.

          • KeeperOfTheBooks

            Good heavens. That had to have been…yeah, gonna have to go with “awkward,” though that’s the understatement of the year…
            My BFF had a vaguely similar situation in that when she had her first, her MIL, who she barely knew, showed up at the hospital about ten minutes after the birth and somehow got into the room. With a camera. While BFF was basically naked, bleeding, and trying to figure out breastfeeding. MIL decided this was an excellent time to take a bunch of pictures (“I know you must be tired! I’ll just take a few pictures and let you rest!”) and then disappear off into the hall announcing she couldn’t wait to post them on social media. *shudder* Friend informed her husband that if that happened, she’d kill him first and divorce him later.
            Wise man that he is, those pictures were deleted and never posted…

        • Grey Sweater

          Oops, just made a very similar comment. Totally agree with you: partners pick up so much slack in baby friendly hospitals.

        • E.C.

          Maybe this will force hospitals to do what they used to do, and what insurance companies are still paying them to do: take care of their patients. It’s ridiculous that a patient’s relatives are expected to do most of the care, just because the patient happens to be a newborn.

          • KeeperOfTheBooks

            Oh, I absolutely agree.

          • Grey Sweater

            Seriously. It’s so weird how little help new patients get. After most medical procedures, patients are expected to lay around and heal. Have a baby? Prepare to be woken up every two hours day and night and have approximately zero help.

      • Grey Sweater

        For me it wasn’t about emotional support or hand holding. After my daughter was born, I had a lot of complications and a surgery. The nurses came in every few hours day and night to physically force me to nurse but never helped with the baby. If my husband wasn’t there I don’t know what would have happened to us. I’m convinced I would have dropped her out of sheer exhaustion, at one point I hadn’t slept in 72 hours. Husband was basically the nurse. Not sure if someone would have picked up the slack if I was alone but this is a common experience among my friends.

      • Inmara

        We have the same situation in my country, support persons are banned from birth in two biggest birthing hospitals. And it’s not about “holding hands”, there is absolutely not enough midwives to ensure continuous monitoring of all birthing women (not even talking about helping to get through pain; I doubt that they will provide epidurals for everyone, and they are costly for patients, too) and absolutely not enough resources to ensure support postpartum (women are expected to care for newborns and themselves even after C sections). Also, if something goes wrong, there is no witness apart from birthing woman (who might not be in the state to understand what’s going on) and medical staff who is notorious for covering themselves and their colleagues from accusations in such cases.

        I’m due in October and I’m already worried about what restrictions will be in place then and what will be the overall situation surroinding healthcare (there are already problems with getting to “nonessential” appointments).

        • Grey Sweater

          I didn’t even consider the fact that a support person is also a witness. After my botched delivery, the clinic attempted to gaslight me by continually telling me that I was too hysterical to remember correctly. Surprise! My husband was there. And the doctor was forced to leave the clinic. If it had just been me I doubt anyone would have believed me.

        • Young CC Prof

          Yeah, giving birth without a partner is lonely, but being stuck in an understaffed postpartum ward alone with a fresh incision and a newborn can be unsafe. Somehow I doubt these hospitals banning dads have enough nurses to do the dad’s job.

          What they should do, and what some hospitals are doing, is require a temperature check for the support person, and then forbid him or her from wandering around the hospital, delivering meals for both people to the room.

        • KeeperOfTheBooks

          The witness thing is SO important. There was some pretty inexcusable behavior on the part of some nurses after Baby Books 3 was born, and it literally took me months to be able to put together exactly what happened and why it was unacceptable, in part because I was alone there. There was also no accountability because it was my word against two nurses.

          • Amazed

            Hey, an OT I think you’re going to like, from one book lover to another: I just posted a link to one of my best loved short stories, one about an infectuous disease, written 100 years ago. Bears much resemblance to what’s happening now. When you’re in the mood for being both appreciative and saddened, give it a go. I don’t know the person who translated it in English but it’s an amazing work of translation, even if I am not really in the position to say so since literary translations are TO maternal tongue for a reason.

  • AlexisRT

    Interestingly, I know someone whose homebirth was *cancelled* because of this. She was otherwise a good candidate (previous vaginal deliveries, lives two blocks from a hospital, history of fast labor). Unfortunately, that nearby hospital currently has a large number of Covid-19 cases, and her midwives (CNMs) don’t want to have to transfer her there in an emergency. They would prefer her to have a planned delivery in a different hospital.

  • fiftyfifty1

    I appreciate this systematic way you have laid it out. Including a frank acknowledgement of what we know and don’t know. This is so different than the fluff pieces I am seeing proliferate, with breathless titles like “Coronavirus forces pregnant women to change birth plans.” (maybe I shouldn’t have been surprised, this is like the 5th credulous article this same journalist has published on homebirth through a local NPR affiliate.)

    • Alia

      Well, not pregnant women exactly, but our national ob/gyn consultant (which would be like surgeon general for ob/gyn) is suggesting that women who were planning on getting pregnant postpone their plans until the end of the pandemics. So yes, many women may have to change their plans.

      • Grey Sweater

        We were planning to try for our second this summer. Definitely changing our plans completely. For someone who struggles with fertility, is worried about age, etc., this could be a huge game changer.

        • MelJor

          We were also about to start trying, and I just called in for birth control refill instead. We are young enough it isn’t major, but my husband is not very understanding about it—I get that he wants a baby, but I don’t want to die because I get pneumonia while pregnant during a pandemic 🙁

          • Grey Sweater

            We’re in the same boat! I’m thirty so not the end of the world, just disappointing.

      • Stella

        On the other side of the coin: I’m lucky. My Nexplanon is good till November next year. If it were due to be replaced now, I’d be SOL. Best I’d get is a phone consultation with my GP who’d send an e-script to my pharmacy for the pill. And I’d better’ve requested that consultation a good long while in advance of when my Nexplanon was due a change.

        This is better than nothing, but there’s a reason I chose LARC. Due to my shift work, I can’t reliably take the pill at the same time every day. *You* try taking a pill at the same time every day when your typical week is:
        Mon: 9-17 Tues: [s]Off[/s] Colleague called in sick, so 12-19 Wed: 6-14 Thurs: 14-22 Fri: Off Sat: 10-6 Sun: 13-21

    • Valerie

      Covid-19 changed my birth plans. I was going to have a 39 week induction for next week, as suggested by the ARRIVE trials. OB and hospital were totally on-board, but the hospital just changed their policy due to the virus. Now I have to wait for spontaneous labor, 3 cm dilation, or 41 weeks gestation.

      • fiftyfifty1

        That sucks and I hope you go into labor spontaneously at 39 weeks and have a textbook smooth delivery instead! It is stories like yours that I wish would be getting told: real stories of how COVID is changing procedures on L&D wards, OB offices, and fertility clinics. Instead I’ve seen a proliferation of fluff pieces that hold up homebirth as the supposed solution that women should be choosing. Anyway, best wishes for you and the rest of your pregnancy!

        • Valerie

          Thank you! Yes, I’m sure there are a lot of procedural changes. Eg, I learned they are discharging everybody a day earlier than usual after uncomplicated vaginal births and CS. I’m only hearing from my doctor about the policies that may apply to me specifically, and the hospital hasn’t made any news releases about coronavirus changes besides banning visitors (except one designated support person).

      • Young CC Prof

        How does that even make sense? Are they calling induction elective? Do they think that not inducing term women will let them stay pregnant until summertime?

        • Valerie

          My OB didn’t elaborate, but I believe it’s got to do with the chance the induction could take a much longer time where I would be occupying a bed and nursing staff. They want me to labor naturally at home as long as possible before they have to deal with me. I think they may be anticipating staff and PPE shortages, although there aren’t any yet in my area. It seems strange because it’s a maternity/gynecology hospital, and they won’t be treating pneumonia there, even if the other hospitals were overrun, but I don’t know how many resources are shared with affiliated hospitals. Or it could be that they see having us there any longer than necessary increases the chance of exposure in case somebody in the hospital turns out to be an asymptomatic carrier.

        • Desiree Scorcia

          when my friend was having her third, they wanted to schedule her c-section for the week before thanksgiving. I told her to ask them if they could push it past the new year. Ha!!

      • rational thinker

        A friend of mine had a vaginal exam on her 39 week appointment and her OB accidentally broke her water. If your OB is on board maybe he could arrange a similar “accident” for you.

    • Mel

      Right? After a lovely two month period of having Spawn at a preschool where his PT, OT and speech were being provided in-house, his school is closed and every option for services I can think of is closed.

      Well, all but one. We’re back to Therapist Mama who is collecting activities from his therapists to do at home.

      We’re doing fine – but my heart goes out to parents who really needed the support of the school districts for their ids.

      • Young CC Prof

        My son’s OT just today contacted us to offer videoconference appointments, and my health insurer is now covering telemedicine. Maybe your neighborhood will offer that, too.

        • Mel

          We live far enough out in the country that videoconferencing is a mess of poor stream quality and frequent dropped connections. I’ve been doing weekly email blasts to the various therapists and they send me back updated ideas that I then adapt.

          So far, we’ve been playing various games that encourage him to stand upright then squat – including “stretching” because he’s mimicking my daily stretching routine – and going for walks on dry days at a local park with paved bike paths to build up his endurance using his walker.

          He dislikes slimy and sticky textures – so we washed all of his metal toy cars today after they escaped from the toy box during nap time, found finger-paint, and gave themselves a new coat of paint! (Silly cars…..). Tomorrow is playdough day – which he hates – but he’s willing to place balls on top of each other to make snowmen. The next day, his toy animals are going to escape into a finger-paint mud puddle and will need baths again.