"Fear of Flying" Issues of Safety and Control in Hospital and Home Birth

Part one is a look at what the real risks of childbirth in a hospital are versus birth at home. Why do physicians and many childbearing women feel safer in a hospital? Is a hospital birth truly safer than a home birth? Is the real issue safety or control of the birth process? Part two examines why one woman chose a home VBAC and how she viewed risk, homebirth safety, VBAC research and statistics on a personal decision making level.

The first part of this article may be a tad morbid, but please, stick with me! I am terrified of flying. Every time I step foot on a jet, scenes of previous airliner accidents I’ve seen on the news flash before my eyes. When I first walk onto the plane I imagine the gory details of each horrific crash that I remember. I think about how the people must have felt as they were going down. I think that dying in an airplane crash would be one of the most horrific ways to die. My fear tends to be irrational. Case in point: I’m somewhat afraid that by admitting this fear out loud I am jinxing myself into the death I hope not to have. Even more irrational is the fact that I would choose to drive to a destination, if the distance is not prohibitive, rather than to fly. This is quite irrational because statistically it is far riskier to drive than it is to fly.

I’ve asked myself many times why, being that the statistics are so clear, do I feel better about driving? After pouring over risk statistics for childbirth and reading multiple news stories about c-sections and uterine rupture one afternoon, the answer came to me. Because I feel more in control when I am driving a car. If something goes wrong, I have the power to correct and maneuver the car in such a way to avoid disaster. Whether I am actually as in control as I feel is another matter! Also, car accidents, though more common, are not always deadly. Airplane accidents, though far more rare, tend to be of the catastrophic nature. Ok, here comes the big analogy… I see childbirth in hospitals as an unpleasant series of fender benders with an occasional paralyzing or fatal crash. I see homebirth as a plane ride over beautiful landscapes to an exotic destination where fatalities are few and the rewards are worth the ride. Let me just be up front here… this analogy is quite flawed with regard to statistics because hospital birth and homebirth come out just about even with regards to risk. Riding in a car is clearly riskier than flying, though. OK, that’s out of the way, so let’s move on to what this analogy is really about: control.

Physicians would rather drive. They like to be in control. They have the power to start the car. (Translation: Start ‘er up with membrane stripping, synthetic prostaglandins, pitocin or scheduled c-section. Get ‘er on the road at a reasonable time and arrive before dinner. No night or weekend driving required.) They have control of the steering wheel. (Translation: They are masters of evasive maneuvers. Labor stalls, administer pitocin. Labor is painful, administer epidural. Baby appears to be in distress. Cut him out.) They can plan the route. (Translation: They determine hospital protocol. They direct the staff. They tell women what position to assume. They tell her when to push. They tell her when to breathe. They determine when it’s time to give up. They schedule the operating room.)

Physicians are afraid of flying. Physicians have seen and treated plane crash victims and they are afraid. There has been a lot of press recently about rising c-section rates and declining vbac (vaginal birth after c-section) rates. The underlying fear is uterine rupture. Uterine rupture can be a catastrophic, bloody complication resulting in the death or serious injury of the baby and/or the mother. It is the plane crash nobody wants to go through. It is also the plane crash no physician wants to be sued for. Physicians have everyone convinced, including themselves, that they are superior drivers, so in control. They are more often sued for “letting” a vaginal birth continue than for getting in the drivers seat by doing a c-section. Surely they could have done something. Physicians have convinced most people, including most child-bearing women that it is safer to drive than it is to fly.

I, along with a sizeable minority of other women, don’t think physicians are very good drivers on the childbirth journey. I’ve driven with physicians who have caused multiple fender benders and a couple of hospital stays. Neither my children nor I died, but it wasn’t pleasant and I still feel the pain. I learned the third time and decided to hop on an airplane instead. Yes, accidents happen and you won’t die in a plane crash if you are riding in a car. Both hospital birth and home birth come with unique risks. Physicians scare women with graphic, horrendous stories of rare plane crashes, but never disclose all of the fender benders they have been involved in nor the years of chronic pain and illness they have caused their unknowing passengers. Though they may have driven a woman into oncoming traffic, most people will not question a physician after a fatal accident because, after all, the doctor engaged in such heroic maneuvers to correct the situation that surely it wasn’t his fault. Many times a physician will drive a woman into oncoming traffic, but maneuver brilliantly out of the situation and is heralded as a hero. I have heard so many women say “if I weren’t in the hospital, my baby (or I) would have died.” I even said that myself after the birth of my oldest until I learned that more than likely my doctor caused the problem that had to be heroically treated.

Are there times when it is safer to drive? Most certainly! If my plane were broken you bet I’d like to hop in a car with a physician. Just as the mechanics of a plane are carefully evaluated before take off, women who choose homebirth, through good prenatal care and nutrition, take special care to make sure they are flying in a safe vessel. Physicians do have unique skills and maneuvers that have saved the lives of women and babies. Sometimes there are unknown mechanical difficulties and my plane could crash, and I hope that should there be an accident a physician would be readily available to help me. That is where much of the argument against homebirth arises; what about the unexpected? Again, the unexpected can happen at the hospital or at home. The unexpected scenarios are different, given the situation, but injury and mortality statistics tell the story of safety. Look at the statistics objectively and you will find that the control of a physician directed car ride (childbirth) is an illusion. Driving is not safer than flying a mechanically safe airplane.

Yadda. Yadda. Yadda. Ok, you’re thinking, cute analogy with the doctors and their cars, but how is homebirth like an airplane ride? And what if a woman wants to ride in a car? Homebirth is like an airplane ride because it requires trust. It is not blind faith, however. If you learn about the natural process of childbirth, you will be amazed and you will understand the marvelous design of childbirth and understand that the autopilot program works beautifully most of the time. I am a person of faith and believe that it is God who authored the program. We don’t have to agree on who authored the program, but we can see that it exists. You can objectively look at the statistics. When women fly, trusting in the process of childbirth, they and their babies arrive safely at their destination.

There are people along the way to help you along your journey. I see midwives and doulas as flight attendants (I know there has to be a more poignant analogy, but I’m at a loss right now). They can give you information about flying and can do certain things to help you during the flight. They are seasoned travelers. But they are not flying the plane. You are not flying the plane. The pilot is a process, a program that has been written in your body from the time of the first woman. Most women who fly would tell you that the flight was thrilling and beautiful. The chances are that they sought to understand, both scientifically and spiritually, what the process would entail before they embarked upon the journey. The understanding eliminates fear and it is fear that causes the most pain and most problems during the journey of childbirth. (No, that notion is not some hooey mystical thought. Just do a little research on fear and hormones and you will see a scientific basis.) Though there may have been turbulence, the destination, which can’t be reached by car, was worth the ride.

I am not saying that taking the car ride can’t ever be enjoyable or safe. Some women will choose the car ride because they are more comfortable driving and are afraid of flying. I have taken many a Sunday drive that I found to be perfectly pleasant. Sometimes taking the car may even be a better choice (ala my broken plane analogy). “So, what are you saying?” you may be thinking to yourself. (Something I’m sure my husband has wondered many times to himself.) I am saying look at the statistics objectively when deciding between a homebirth and a hospital birth. I am saying that the controlled environment of a hospital is not as safe as has been portrayed by the medical establishment. Conversely, homebirths aren’t dangerous as the medical establishment has portrayed them either. One of my favorite quotes is “birth is as safe as life gets.” I am saying that many of the “hot-button” birth topics, such as c-section, vbac, homebirth and midwifery, in our society today center around the issue of control, not safety. Despite my appeal for an objective look at the statistics, I am saying that statistics don’t tell the whole story; you must dig deeper because childbirth is not about a set of blanket statistics. It is about individual women and individual babies. If you are a woman today you must insist on the truth, not an illusion, and you are ultimately responsible for making the reasoned decision about whether to get in the car or hop on the plane.

Why I Chose to Fly…

I had a home VBAC (vaginal birth after cesarean) 6 months ago. I agonized over my decision. I poured over statistics. I read articles. I read medical journals. I even called experts in states as far away as New Mexico and New York. I have always believed that home is where babies receive the gentle welcoming into the world that they deserve. From the time I became a mother and became interested in the subject of birth I have known that homebirth is as safe or safer, statistically speaking, for normal pregnancies. However, with my most recent pregnancy, I was facing labor with one strike against me in the safety department- a previous c-section. I needed to investigate and find out for myself what my true risks vs. benefits were for who I am as an individual and for my specific situation. I wanted a homebirth and I wanted a safe birth. Anti-homebirth crusaders frequently accuse homebirthing moms of seeking an “experience” at the expense of their safety and their baby’s safety. Make no mistake, EVERY mother wants a safe birth for her baby, for herself, and for the sake of other children she might have who need her. It is laughable to think that a woman’s obstetrician, who knows her through a series of 5 minute office visits, cares more about a baby’s well being than it’s mother.

Uterine rupture is the primary fear with VBACs. The risks of UR are somewhat higher with VBAC. The risks are increased with induction and labor augmentation, but even naturally laboring mothers face a small increase in risk. Rupture can happen to any mother, even mothers without scarred uteruses (those ruptures actually tend to be more catastrophic in nature). Ruptures have even been known to happen before labor, just during the course of carrying the baby. I decided for myself that the increased risk was small enough that it did not warrant birthing in the hospital. I would not check myself into a hospital during my third trimester “just in case” I ruptured nor would I have checked myself into a hospital “just in case” if I were birthing without a scar.

Most recent statistics from the CDC have VBACs occurring in 9.2% of births. The chances of having a successful VBAC in a hospital are BLANKPERCENT. I believed that the risks for me in entering a hospital outweighed the risks of me staying at home. Some of the risks for a mother from a c-section are infection, organ damage, hysterectomy, painful scarring, and yes, even death. Some risks for the baby include respiratory distress, infection and death. Risks for future pregnancies include unexplained stillbirth and placental abnormalities such as previa, accreta and percreta. We plan to have more children, so I factored the health of my future babies into the risk/benefit analysis as well. An obstetrician can’t be sued for how his actions affect future pregnancies, so these are risks of c-section that are not often disclosed to patients.

My decision making process included factoring in intangibles that can’t be scientifically measured and presented neatly in research papers. Fear is an intangible. I felt that home was a safer, more comfortable, more supportive atmosphere that would allow me to relax through my labor and have a safer, healthier, more comfortable and spiritually whole birth. I do not find hospitals to be pleasant places and truth be told, do not have a great deal of respect for the standard practices of modern obstetrics. I felt that labor for me would be inhibited in a hospital and would interfere with my ability to give birth safely. I have faith in my intuitive abilities and sensitivity to signals my body is sending me. I believed that with a natural labor, I would feel physical changes and intuitive alarm bells that would signal rupture. I live within 10 minutes of two hospitals and felt that I was within a reasonable distance for transporting into an emergency room if I felt things were going wrong. Rupture during VBAC is not usually sudden and catastrophic as it is more likely to be in mothers with unscarred uteruses. I did not fool myself into believing that a rupture could not happen to me, even a sudden and catastrophic one. There are other risks with home VBAC as well, but rupture is the most feared one. That being said, there are risks with any birth in the hospital or at home. Look at infant and maternal mortality statistics. Babies die. Mothers die. Where do they die? They mostly die in hospitals! We don’t expect it to happen and we shouldn’t dwell on it, but to believe that everything is guaranteed to turn out fine in a hospital is delusional. The sense of security is false.

I took specific actions and made a plan to mitigate my risks. I took care of my body. I ate well, I exercised, and I prepared for birth. I verified the position of my placenta through an ultrasound. I decided I would take a conservative approach to any decision to transport to the hospital. If I felt any doubt, or any twinge of unusual pain during labor, I would transport. I wasn’t set on staying home at any cost and would not have allowed myself disappointment or regret for making a responsible decision to transport. I had a trained, experienced midwife. My midwife had attended hundreds of births, including VBACs, and had excellent outcomes. I also had a fantastic doula, a woman with wisdom and experience I very much admire. I verified the distances and travel routes to local hospitals. I called the fire department, asked about their protocols, and found out which hospital I would be taken to in case of emergency. My husband and I talked about all of the risks and potential emergency situations with our midwife. Those who birth at home are probably some of the most prepared, informed and proactive parents you will meet!

My decision to give birth at home was well thought out. This article has been about statistics and the risks of hospital versus homebirth, but my decision was much more than a risk/benefit analysis. My decision was also deeply personal and passionate. I gave birth to a beautiful, healthy baby boy in the private, intimate, comfortable and peaceful environment of my home. It was the birth he deserved. I will always treasure his birthday in my heart. And though he won’t remember it with conscious thought, I believe the gentle way he entered this world will be imprinted on his heart and soul forever.

Need references? See the surfliography.