Saturday, December 29, 2007

The Best of Both Worlds?

Freestanding birth centers often advertise that they are the "best of both worlds." For example, the Connecticut Childbirth and Women's Center states that "the birthcenter provides women with the best of both worlds--expert care provided by certified nurse-midwives, while emergency care is just a stone throw away" at the nearby hospital. I've often wondered about freestanding birth centers. I think they are fantastic for women who have a need to birth in some kind of institution (whatever that need might be: mental, emotional, lack of a safe home environment) but don't want the whole hospital runaround. I wish that there were more birth centers, so that it would be an option for any woman who desired it.

However, in light of some of the discussion about the photo essay about "homelike" birthing spaces, I'd like to offer up another view of birth centers as the worst of both worlds. Here's why:

Freestanding birth centers offer no technological or pharmacological advantages over home births. Midwives in both settings carry nearly identical equipment. It might vary slightly from midwife to midwife, of course, but there is no additional technology available in FSBC's compared to midwife-attended home births. In both settings, women will likely have access to:
- anti-hemorrhagic treatments and equipment (ranging from herbal tinctures to Pitocin, Methergine, Cytotec, IVs to replace fluid loss and/or stablize in case of transport)
- maternal and neonatal resuscitation equipment and skills (bag & masks, oxygen tanks, suctioning equipment, possibly meds & intubation supplies)
- suturing equipment and local anesthetic
- fetoscopes/dopplers for listening to baby's heart beat during labor
- other equipment for monitoring vital signs (BP cuff, stethoscope, thermometer, etc)

Women in both settings will need to transfer to a hospital for interventions such as:
- operative deliveries (vacuum extraction, forceps, cesarean section)
- analgesia (except in rare cases where some birth centers supply IM narcotics)
- anesthesia (spinal, epidural, etc)
- continuous Electronic Fetal Monitoring (external or internal)
- blood banks if a transfusion is needed

In a home birth, a woman is on her own turf. The midwife is the invited guest. In a FSBC, however, it is the midwife's turf. Often birth centers have a set of protocols that govern when a woman must transfer to a hospital or to OB care. The midwife at the birth center has final say over whether or not the woman can use the facilities. Like Tabitha and others have commented, no matter how nice the decor, it isn't the same at someone else's place. You don't usually feel the same sort of liberty or comfort or lack of inhibition as you would in your own space.

So perhaps birth centers are the worst of both worlds. There is no additional safety or access to technology in a freestanding birth center compared to home, and the woman is not on her own turf and ultimately cannot make the final decisions of when to stay or transport like she could at home.

Thoughts on this?


  1. I couldn't agree more. And, I would add to the list of 'cons' of the birth center vs. homebirth: at home, the woman is surrounded by her own germs, to which her body and baby are acclimated. At a freestanding birth center, this most certainly isn't the case.

    Besides, for me, the last thing I would want to do is bundle up my brand new baby into a car seat to go home. That is one of the perks of homebirth, to me.

  2. But the overall rate of infections is four times higher for hospital births, and a woman who has active herpes should definitely not be having a home birth anyway - she should be having a c-section. Bringing herpes into the argument is specious.

    *If* you are screened for group B strep, and *if* you have it, it's still unlikely to affect the baby, and being in hospital and having IV antibiotics hasn't actually been shown to be effective. The RCOG Audit on the prevention of neonatal Group B Streptoccocal disease says "Antenatal screening and treatment have not yet demonstrated an effect on all cause neonatal mortality and may carry disadvantages for the mother and baby. These include potentially fatal anaphylaxis, the medicalisation of labour and the neonatal period, and infection with resistant organisms."

    You can give examples of two babies who died of sepsis, both with prolonged rupture of the membranes, I note, and not either group B strep or herpes. Both of these women should arguably have sought medical attention after 24 hours.

    What about all the women who successfully birthed their babies at home without sepsis? What about all the women in hospitals whose babies contracted respiratory syncytial virus or candida, or hib or enterovirus and ended up with sepsis?

    Two examples of women with ruptured membranes - for FOUR DAYS, which most women who want home births would think was a reason to check in with a doctor at least, do not cancel out the fact that women are less likely - four times less likely - to develop an infection in their own home.

  3. Oh, and Rixa, I agree completely about birth centres. The huge advantage of home is how comfortable we all feel in our own homes. Being relaxed, you don't have adrenalin countering the effects of oxytocin, and labour is generally more effective. You wouldn't get the same thing in a birth centre - no matter how nice the decor, it's still not as relaxed as being at home.

    And radical midwife, you've made me wonder about the relative safety concerns of car travel as opposed to home birth!!

  4. And finally (I wish I could get it together to say everything in one comment), the Center for Disease Control estimates that 90,000 Americans die each year from infections they acquired while inside a hospital. Since hospitals don't have to report antibiotic resistant infections, and stats from birth/death certs are difficult at best, it's very unlikely that we're going to know with any degree of accuracy how many babies are dying from infections in hospitals vs how many have died from planned homebirths with active herpes lesions (which imo you'd have to be pretty stupid to do) or strep B (very unlikely - 1/10,000 even if the mother is infected) or even prolonged rupture of the membranes resulting in sepsis.

    But I'd bet my bottom dollar a doctor will come along and claim deaths from home births are worse/more/the result of irresponsible irrational women who don't understand SCIENCE like doctors (ha!)

  5. anonymous:

    "do you have a link for the statistics verifying the following?

    "Of course the biggest infectious threats to the baby are maternal infections agents, and the baby is NOT acclimated to them. Group B strep and herpes kill and injure many more babies than hospital acquired infections."

    Of course I do; otherwise I would not have made the claim. The most common cause of neonatal sepsis in the US is Group B strep.

    According to Neonatal Sepsis:

    "The infectious agents associated with neonatal sepsis have changed over the past 50 years. S aureus and E coli were the most common bacterial infectious hazards for neonates during the 1950s in the United States. Over the ensuing decades, GBS replaced S aureus as the most common gram-positive organism that caused early-onset sepsis. During the 1990s, GBS and E coli continued to be associated with neonatal infection; however, coagulase-negative S aureus is now more frequently observed. Additional organisms, such as L monocytogenes, Chlamydia pneumoniae, H influenzae, Enterobacter aerogenes, and species of Bacteroides and Clostridium have also been identified in neonatal sepsis.

    Meningoencephalitis and neonatal sepsis syndrome can also be caused by infection with adenovirus, enterovirus, or coxsackievirus. Additionally, sexually transmitted diseases and viral diseases, such as gonorrhea, syphilis, herpes simplex virus (HSV), cytomegalovirus (CMV), hepatitis, HIV, rubella, toxoplasmosis, Trichomonas vaginalis, and Candida species, have all been implicated in neonatal infection. Bacterial organisms with increased antibiotic resistance have also emerged and have further complicated the management of neonatal sepsis. The colonization patterns in nurseries and personnel are reflected in the organisms currently associated with nosocomial infection. In today's neonatal intensive care units (NICUs), infants with lower birth weight and infants who are less mature have an increased susceptibility to these organisms.

    Staphylococcus epidermidis, a coagulase-negative Staphylococcus, is increasingly seen as a cause of nosocomial or late-onset sepsis, especially in the premature infant, in whom it is considered the leading cause of late-onset infections. Its prevalence is likely related to several intrinsic properties of the organism that allow it to readily adhere to the plastic mediums found in intravascular catheters and intraventricular shunts. The bacterial capsule polysaccharide adheres well to the plastic polymers of the catheters. Also, proteins found in the organism (AtlE and SSP-1) enhance attachment to the surface of the catheter. The adherence creates a capsule between microbe and catheter, preventing C3 deposition and phagocytosis."

    In other words, the most common cause of neonatal sepsis is group B strep. Since the advent of antibiotic treatment of mothers testing positive for group B strep, the incidence of group B strep sepsis has declined almost 70%. Most of other organisms on the list are also carried by the mother including E. coli and sexually transmitted organisms. Other organisms include infectious agents such as Listeria.

    You will notice that MRSA ("superbugs") are not even mentioned. MRSA (and meth sensitive staph) can be a problem in NICUs and babies who are premature are particularly vulnerable. To date, there have been rare reports of MRSA in well baby nurseries, most in Japan.


    "having IV antibiotics hasn't actually been shown to be effective"

    You have misunderstood your own reference. IV antibiotics are not particularly effective in the UK because the incidence of group B strep is much lower there. It has been quite effective in the US. The incidence of group B strep sepsis in neonates has dropped by 70% since antibiotic prophylaxis was started.

    "the Center for Disease Control estimates that 90,000 Americans die each year from infections they acquired while inside a hospital."

    Go back and look at the data. Almost all those hospital acquired infections occur in elderly, severely ill or immunocompromised patients. There are only rare cases of hospital acquired infections in term babies.

    I am not claiming that it is impossible to get a hospital acquired infection, just that the incidence of hospital acquired infections in term babies is rare, while the bulk of cases of neonatal sepsis and death are caused by maternal organisms.

  6. I think it depends on what state and what set of laws you're working with. In PA a homebirth midwife could be charged with practicing medicine without a license for a lot of the things that a CNM can do at a birth center, like administer pitocin or give sutures.

  7. Rixa, thank you for bringing out this side of the argument. I honestly had never thought of the idea of FSBC being the worst of both worlds. During our insurance snaffoos, I was considering a FSBC, but only for monetary reasons, certainly not for safety. Now that we have the money situation figured out, I have no reason why I would choose a FSBC over my homebirth. YAY!

  8. It's a moot point for me and other women in my community who have cesarean scars. Our BC disallows VBAC. I did just discover that they changed their mandatory transfer after ROM from 24 hrs to 12 hrs. Yikes!

    I agree that the benefit (if that's the right work) of birthing at a BC exists for people who don't want to start/end birth at a conventional hospital but lack the confidence in homebirth. And if they have lower transfer-to-cesarean rates, then that's a good thing.

    Amy's infection rant is drivel, IMO. It's up to the woman to decide to test for strep, herpes, and the like. The outcomes of her decisions... well, umm... are for her and her family to deal with. The supposition that homebirth outcomes due to infection are more alarming than hospital birth outcomes due to infection is ridiculous. Plus, aren't women/infants in hospital settings treated as immunocompromised anyway?

    Regarding accidents, injuries, and death related to homebirth - yes, they do happen. Women die, babies die, mistakes may be made. Midwives are crucified for them. A doctor may be sued or reprimanded for his/her mistakes (maternal death, maternal trauma, infant death, infant trauma, unnecessary intervention - nearly impossible to prove anyway, etc.), but rarely will this result in cessation of practice.

    Thanks, Rixa, for another excellent post.

  9. Dr. Amy may be annoying, but she is correct. Radical Midwife's statement that "the woman is surrounded by her own germs, to which her body and baby are acclimated" is simply not a correct scientific statement. The greatest risk to the baby is indeed group B-beta strep (roughly 70-80%, depending on the specific source) and the baby is by no means acclimated to this just because it resides in mama's body.

    And you can check my IP address to verify I am not Amy!!

  10. after erasing a long comment, i realize i have nothing nice to say.

    but great post, rixa!

    tabitha not karl

  11. Rixa
    I have a very different opinion on this. Not everyone has access to a safe, clean place to birth.

    The assumption that all women have an appropriate and supportive home to birth in, is very classist.

    I know many women who were for various reasons unable to birth in their own 'home' and a free standing birth center would have been a very welcome option. (we no longer have one in ottawa, canada)

    I have known young women living at home with unsupportive parents, women who live in very rural areas who were too far away for a comfortable transfer if necessary, and women in-between moves - so basically homeless to name just three examples.

  12. I don't even think it's a matter of choosing between a FSBC and a homebirth but rather between a FSBC and a hospital. We have to remember that this is a brainwashed society. And speaking as someone recently enlightened and trying to "deprogram" and trust birth, if I were planning where to give birth, I wouldn't consider a homebirth, because I'm just not mentally ready yet. And if a mom who didn't trust birth and trust herself fully was guilted into a homebirth, that could be just as impeding as the "discomforts" of a hospital or FSBC for a woman on the other side.

  13. Many mothers (I among them) wish there was a middle ground between homebirth and "old school obstetrics" intervention-happy hospitals. I am not comfortable with a homebirth because of my own circumstances and personal assessment of risk.

    Neither, however, does the research support the heavy use of interventions all too common in hospital births.

    It is sad that birth advocates so cavalierly dismiss scientific research in favor of their own perceptions and convictions. It is even more sad that medical professionals cannot see the harm caused by their knee jerk reliance on often unnecessary medical procedures. (Hello -- "First, do no harm" ring a bell?!)

    Free standing birth centers -- in a more perfect world -- could offer that middle ground. Sad to see the politics/agendas of "both sides" working against an option that may meet the needs of many women desiring safe normal births.

  14. i think the point is being missed=- or rather a different point is being inserted where it doesnt belong. this isnt about whether or not FSBCs should keep existing. 'birth advocates', at least none that i know, don't want birth 100% at home, 100% out of hospital or 100% out of FSBCs.

    can we not agree that all birthing places can be improved upon, and are not ideal in this culture? for example, hospitals need significant improvement in many areas, such as the environment, the medical training/ fear of birth and so on. FSBCs can also be improved to better serve mothers and babies. even home birth (both assisted and unassisted)needs improvement- one big area is access for all healthy moms, not to mention widespread education.

    tabitha not karl

  15. I want to reiterate that I wasn't at all saying that birth centers shouldn't exist--just that their advertising as having the "best of both worlds" is perhaps a misnomer. Notice in my original post that I strongly support them and think they're a great option.

    I've lived and worked with midwives in two states where DEMs aren't licensed, but almost all of them find a way to obtain emergency anti-hemorrhagic meds & oxygen tanks. But yes, that might be a slight difference between HB & FSBCs in theory, if not always in practice.

  16. Babies can also contract group B strep from nurses.
    Although I was fortunate enough to avoid GBS, my whole family caught a nasty virus from my hospital stay, me with a 103F fever and my 2 week old son with diarrhea. The hospital rooms just aren't cleaned well enough, and nursery workers don't always wash their hands enough. Prophylactic antibiotics can't help everything.
    I truly wish for more birthing centers, I think that they increase visibility of midwives in the community and also increase availability of midwives to women who do not have the option or knowledge of homebirth. The cool thing is, once a woman has had a birth center birth, many decide to homebirth afterwards.

  17. "...the woman is surrounded by her own germs"(radical midwife) - Huh?

  18. "...the woman is surrounded by her own germs"(radical midwife) - Huh?"

    This idea makes sense if you think about. None of us live in perfectly germ-free environments. We wouldn't want to. I'm not saying that we are all filthy and disgusting. What I am saying is that each of us are adapted to the germs that we live around on a daily basis. We have germs on our skin, in our mouths, on our bathroom and kitchen counters, on our floors. They are part of living. However, these germs don't generally make us sick because we are immune to them, or they aren't harmful in the first place. The problem with the kind of germs that live in hospitals is that hospitals use so much anti-bacterial stuff that the only germs that survive are the kinds that can't be killed easily. This is why the infections that can be caught in hospitals are so much worse than what you typically have floating around in your house. Personally, I'd rather deal with my own germs than worry about what I'm going to pick up from the hospital.

  19. While I agree that a birth center can seem superfluous to someone who could just as easily birth at home, for some it WOULD be a better option if it was available. There are no freestanding birth centers around here, and if there were, I would have rather gone to one of them than to the hospital for my first birth. I was a naive first-timer, I didn't think homebirth was a good option for me. And I suppose at that time in my life, it wasn't - I didn't know nearly as much as I do now, nor did I have a home that was an optimal birthing environment.

    Yes, a birth center that is "just like home" can seem silly when one COULD just do it at home anyway, but for some, that isn't an option. That peculiar mentality of having to GO SOMEWHERE to give birth is quite real, esp. among those who aren't well-versed in the idea of homebirth to start with.

  20. "That peculiar mentality of having to GO SOMEWHERE to give birth is quite real, esp. among those who aren't well-versed in the idea of homebirth to start with."

    FYI -- there are even women out there who are well-informed and very well-educated who do not want to birth at home. Nothing peculiar about it. Entirely reasonable.

  21. I know, K. I didn't mean to come across that way. I was mostly speaking from my own experience - that *I* wasn't confident enough in the concept of home birth and would have therefore chosen a birth center if there was one available.

    Like I said, there can be other factors that would make someone want to birth in a not-at-home-but-homelike environment. I would rather have given birth in a ditch than in the apartment I lived in when my first child was born!

  22. I gave birth to my first child in a FSBC nine months ago today. I chose the midwifery model of care and received all of my (largely elective) prenatal care at the BC with my midwives. I also attended some gatherings and classes there and felt free to walk my teacup into the kitchen to place it on the sink or to sit down in the common room to wait for my appointment. My husband and I live in a small one bedroom apartment where laundry facilities are not readily available, the bathtub is less than inviting, and honestly, I didn't want to have my first baby and then have to think about getting up to do the laundry. We arrived at the BC (which was blocks away) about an hour after my water broke, since I was having contractions hard and fast, and a little more than four hours later, my boy splashed down. I was very pleased with my decision, and while the jury is still out as to whether or not we will have another child, I am inclined to think that I would seek a similar experience. The midwives who attended my birth also attend many homebirths, however, so I could have it either way.

    I have never believed that babies should be born in hospitals, barring the need for emergency medicine. I did not for a moment consider giving birth in a hospital. I do not tolerate being messed with, and my memory of my birth experience is mostly of my husband and myself with one or two quiet encouragements from my midwives. And I didn't have to do laundry.

  23. Thanks for all of your input. I think, after all of the comments, that calling it the "worst" of both worlds is far too strong. I guess that I am mostly fascinated with the use of "homelike" to describe birthing spaces. If it isn't home, why are we so taken with describing things as "like" it?

    The comments have also raised a very important issue: that home isn't always this lovely, safe, snuggly haven for women to birth in.

    Anyway, I wish there were a lot more birth centers so that it weren't all-or-nothing for women who don't want the standard hospital treatment. My little sister has used an in-hospital birth center for her last two babies and had a fantastic experience. It wasn't freestanding, but it was located in a separate area in the hospital, had its own set of protocols such as no drugs offered, had a large queen size bed and a huge tub for laboring or birthing.

    The use of the term "birth center" as euphemism for a regular hospital maternity ward is an entirely different issue. I think some women might see the words "birth center" and think they're getting something different, when in fact it's just the standard hospital experience.

  24. I think that another very important reason why some women choose birth centers is that they have older children at home and they just don't want/can't labour freely at home with their children present.

    Some FSBC are really like beautiful B&B's. There is staff after the birth to make the couple comfort foods.

    FSBC's help support women in the freedom to choose what is best for their own births.

    I do wholeheartedly agree that hospitals should not say their L&D floor is a Birth Center.

  25. "I think that another very important reason why some women choose birth centers is that they have older children at home and they just don't want/can't labour freely at home with their children present."

    This is actually the reason I didn't want to go to a birth center. My 5yo has expressed a strong interest to watch this baby be born, and I'm thrilled with that idea, but I don't want to worry about keeping all three kids happy during the labor before the birth. That is why I am jumping for joy that we've found a way to have a homebirth. I know this isn't necessarily the prevailing idea of how childbirth should be done, but it works for us. I know many, many women who, for various reasons, would not be comfortable birthing at home, and that is fine. I do wish, though, that more women had the option without having to jump through the kind of hoops that we are having to right now. I don't think we would have for our first baby. We just didn't know enough at the time.

  26. "I do wholeheartedly agree that hospitals should not say their L&D floor is a Birth Center."

    Me too!!! It's not a birth center, it's a dang L&D ward just like all the rest. I dunno why that irritates me...maybe cuz they're trying to make it seem better by slapping a friendlier name on it?

    Also, as far as having kids at a birth...I think if we decide to have our eldest present, that it will be just another fabulous advantage of home: he can go wander off and play in his room if he wants, or have Dad help him fix a snack, or whathaveyou...he's not stuck fidgeting at mom's side in a strange environment where there's not much to do.

    Do some birth centers have play areas for children? That would be a great idea! Keep the older sibs occupied while mom births!

  27. Many forget or do not even realize that pregnancy is not an illness. And even the most unhealthy women go on to deliver perfectly healthy babies. When it is your time to deliver,the baby will come no matter where you are at. The majority of women can have their babies naturally. A few can not because of misshaped pelvises or prior traumatic injuries. I think most women need an attendant evn if just her mother form moral support and clean up. But we don't really need someone to deliver our babies. I have had 2 babies in the hospital that I caught myself. First one no one believed I was in labor because I was calm. Second the nurse tried to get me out of the wheelchair and into bed. I had already told her I won't make it because the baby will fall out and he did. The minute I stood up gravity assisted my birth.
    In this day and age with overuse of antibacterials and antibiotics given just in case..infections that are hospital acquired are hard to fight. Women testing positive for Beta strep need to research how to rid their bodies of it naturally prior to birth and then have they MDs retest them.

    What about all the women who successfully birthed their babies at home without sepsis? What about all the women in hospitals whose babies contracted respiratory syncyntial virus or candida, or hib or enterovirus and ended up with sepsis?These are very common nosocomial infections.

    I have had enough children in different hospitals to learn by experience that they are NOT the safest places to deliver. Even when you need surgery. How did I acquire a MRSA infection in my csection incision when I had my twins?
    When I had my vbac and told the doctor I needed to get on my hands and knees, I did not know it was to rotate my posterior baby, I just knew the feeling to do it was intense, the dr refused because he would not be at a proper angle to "deliver" my baby, we ended with a forcep suction delivery and my having a 4th degree laceration. My next delivery was a preemie. Why on earth did nurses cut my preemies lifeline?(the cord), before having resuscitation materials set up? Why with next child did nurses not get gloves on when I said baby WILL fall out when I stand?
    I won't even state my questions with my last delivery I talked a bit on those on dr amy site. I am a crazy joke there. I am concerned that we have accepted such mediocre care as normal. We don't really know what a normal delivery is anymore.If you want normally unhindered births you are considered weird or crazy.
    As far as women with STDs and delivery, it is individual. Don't punish all women for the problems of a few.As medical professionals Stop treating everyone alike because we are not.

    Statistics mean nothing to me because I consider them flawed because all doctors don't report what they should.
    My preemie acquired RSV in the hospital. I have copies of records and keep great notes and have noted things omitted from charts. Could be human error but it happens much to often. In our sue happy world I don't believe we will ever hear the truth reported. Malpractice insurance has put so many obs out of business also.
    If my post sound scattered it is because I am pregnant and tired!

  28. Back to radical midwife's original comment, OF COURSE one of the major benefits of homebirth IS being home with your own germs and not the freaky germs of the hospital. I heard recently that the 6th leading cause of death in Americans is Hospital-Accquired infection. Disgusting.

    I dont even go to see my freinds in the hospital when they have given birth if I am pregnant or have to bring a nursing baby, because it is just too gross there. The last place I want to ever, ever be "open" in.

  29. RIxa: I'm going to get into this on my own Blog very shortly but, I do want to respond to a comment you made about "even DEM's who are not licensed manage to obtain antihemmorhagic drugs etc that they need". Something that gets left out of these kinds of remarks is that the simple truth is it is illegal for direct entry, unlicensed midwives to obtain, possess or use drugs, the equipment to deliver them and we are risking midwifery and homebirth by continueing to break the law under a misguided understanding of "civil disobedience". Same thing goes for Midwives, and I am hearing about many such, who collect a cash fee from their clients and then also bill insurance using medical billing codes ( again, this is illegal. It is insurance fraud and it is prosecutable as a felony in most States ) because they think/believe that Midwifery and homebirth "should" be reimbursed by insurance. Unfortunately, just because we "think" so won't stand up in Court. I am on record as being against midwive billing insurance through "trickery" ie. using dishonestly procurred medical codes and the women doing it are going to get caught and when that happens; we're all in a very large vat of hot water! I would really like to see midwives/doulas etc. NOT making these statements so benignly; as though there is nothing wrong with a midwife getting/having and using prescriptions, syringes and medical devices "off license" as though there is no problem with that. There is a big problem with that and it's going to get a lot bigger.

  30. Kneelingwoman,
    Thanks for raising that issue. I meant my comment more as a statement of my own experiences in two illegal states than as a judgment (positive or negative) about whether or not I approve of it. I have mixed feelings about DEMs using meds that they can't obtain legally. It's a damned if you do/damned if you don't situation: if they don't carry things like anti-hemorrhagic meds or O2, then they will be called "unsafe" by the medical profession. But if they do they will be accused of practicing medicine without a license!

  31. I am a licensed midwife who works at a freestanding birth center in the Portland, OR area.

    I think the first problem with this discussion is that "birth center" can mean a lot of different things. Many hospitals call L&D a "birth center" now, and there are even L&Ds that are in a separate building (but still part of the hospital) called "freestanding birth centers."

    That aside, and only looking at true freestanding birth centers (by my definition, these are midwife owned and staffed, and not associated with a hospital in any way), these vary greatly from state to state and place to place. Where I work, the transport rate is under 7% and the Cesarean rate under 4% - same as our homebirths (we all do homebirths too). But other birth centers have transport rates over 20%, due to laws or "scrutiny" or style of practice. I think those are important questions for a client to ask: How many births does each midwife do per month (you don't want an exhausted midwife!), and what are the transport and Cesarean rates for the facility?

    Another important question to ask is: Are there different laws for homebirth vs birth center births? In Oregon, the difference is small, but it is there: I can do breeches, twins, and all VBACs at home. I cannot do breeches, twins, and SOME VBACs at the birth center (most VBACs I can do at the birth center). In other states, the dichotomy between what will happen at home and at a birth center can be much, much greater.

    This leads me into a reason that birth centers can be a benefit: In case of transport, some women prefer to be closer to a hospital. For women who live rurally, our birth center can be closer to emergency services than their homes. (Which is why it is completely idiotic that the riskier births can be done at home, and not at the birth center...but I'm working on changing that.)

    Many of my clients are what I can "one foot out of L&D." They come into their interviews often times not even realizing that they can't get an epidural at the birth center! (We of course fully inform them of everything we can and cannot do for them during that interview.) These women would never choose homebirth when they first walk through my door. But many of them change their mind on that issue later, and go on to have homebirths. Others don't. Either way, I am glad we are an option for them.

    There are benefits to homebirth and birth center births. It seems that others have already fully explained the benefits of homebirth, and I totally agree with all of that. That is why I do homebirths.

    Someone also mentioned that not everyone's home is the greatest place for a birth. That is also true. Some people also have partners that they can't get on board with a homebirth, but a birth center is a good "compromise" for the couple. At our birth center, they get super great food for up to 2 days after the birth, and a massage on the second day. Some mamas, especially first timers without a lot of support, really need/want that extra care.

    I don't think it is an issue of one being better than the other, but of different choices being better for different women in different situations. In my opinion, MORE choice is always good!

  32. Jesica, thanks for your input. It's really strange that you can do certain kinds of births at home but not at the birth center! It's good to know the kids of questions to ask, too.

  33. I birthed in a FSBC because I was VBACing and my home was over 45 minutes from the nearest hospital. Not to mention the m/w was 2+ hours from my home and needed to stay within a reasonable radius of the majority of her patients. I don't live in the outer edges of Alaska, I live in a very popular resort town, but hospitals are few and far between, so I'm not even really a special case in this instance.

    I never once felt like I wasn't on my own turf. It just never even occurred to me. My m/w is a homebirth midwife, but owns a FSBC as well. It was spectacularly spotless, offered a much better shower and space to put an Aqua Doula that the subfloor in my home may not have supported. I spent 35 hours in labor, 15 of which at the BC and never felt pressured. I loved the fact that the room had no windows and no clocks, so I never thought about how long I had been in labor or what time of day it was.

    The "types" of BCs run the gamut, and unless you've visited (and maybe even birthed) in all of those different types, you really can't make a blanket statement claiming they're all the same.

    If it hadn't been for the FSBC, I would have never had the opportunity to have an assisted homebirth. And to me it really was a homebirth because I felt completely at home. As if I was in my mothers bedroom...

  34. I know I am late to this conversation, but I just read this post for the first time. I mostly agree about birth centers. In many cases (if home is as close or CLOSER to a hospital), home is even safer than the FSBC.
    However, one thing I do think can be an advantage with FSBC is continuity of care. At the FSBC where I had my second baby, the midwives all had practicing privileges at the local hospital where they took their transfers when necessary. This means that even if you needed obstetric help and had to transfer, your midwife would remain with you and would be a respected presence in the hospital. Had I needed to transfer, that meant the world to me! I'm grateful that I didn't have to transfer during my homebirth either (my 3rd) because my homebirth midwife (CPM) would not have been allowed to stay with me in our hospital here and also most likely would have been treated poorly- as would I because homebirth is so unaccepted and frowned upon. So the continuity of care at the FSBC was fantastic and my midwife there told me that even when they do have to transfer for whatever reason, that the midwives can still be the primary attending for the women that are able to go on to deliver vaginally in the hospital! That is rare for homebirth transfers, unfortunately.
    However, your points about being on someone else's turf, and the midwives having all the same equipment- EXACTLY RIGHT! I felt that way about my birth center birth also.

  35. My wife was 2 mos pregnant when I got laid off. We weren't able to have a place of our own yet we knew we wanted a water birth and we DIDN'T want to go to a hospital. It was a compromise for us, and worked out OK, but we still didn't like the level of intervention that we knew we had to put up with like being forced to drink tons of water and then having to be Cath'ed when she wasn't comfortable enough to urinate, like she would have been at home. If we'd had a home, and enough money, we'd have had it at home hands down, maybe even a UC.

  36. I delivered our first at a fsbc, DH was literally terrified of the idea of a home birth, and I was terrified of a hospital birth (unless complications arised) so we went half way. It was awesome.
    This baby (due May 15, 2011) I wanted a home birth but insurance refused to pay and we have no extra money to pay out of now we live in an apartment with pretty thin walls, I wouldn't feel like I could relax and be vocal like I need to be. So again we decided on a FSBC birth, the same birth center. I pray we are living in a place and financially able to have a home birth with the next baby though.


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