I often get asked by expectant moms, how they can avoid pitfalls during labor and know if an intervention is truly necessary.  They want to set themselves up in the best way possible to have the natural birth they really want.  I think there are a few important steps that couples can take well before the birth to ensure the smoothest possible experience.  In Denver, we are blessed with many choices for how, where and with whom to birth.  Let's explore these options a little further.  

Step one: Your choice of birth location really matters and can influence the course of your labor!
The best birth location is the one in which the laboring woman feels most  secure and comfortable and offers her the greatest amount of safety, respect, patience and support.  Sometimes your choice of location comes along with your choice of your care provider or vice versa.  Sometimes it is influenced by insurance or costs (more on that later), location, amenities or necessity.  Sometimes it is a gut reaction to the feelings you have while exploring your options.  It just feels right.   Put some time and thought into your choice because it is one of the most important aspects of having a great birth experience.  

There are three main locations that women choose to give birth in:
Hospital
Birth Center
Home 

Each has advantages and drawbacks, but ultimately the choice is yours. Let's explore each option in the following blog posts:

Hospital
The most common choice for birth location in the United States is a hospital. There are some obvious advantages, but also many drawbacks to consider about your choice to give birth in a hospital.  Even if you ultimately decide to give birth in a hospital, it is important to be aware of the pitfalls and avoid hospitals with higher rates of intervention or greater restrictions placed on the laboring mother. Childbirth Connection provides really valuable resources for parents and has a great discussion on choosing your birth place.  No two hospitals are alike, so shop around... the closest isn't always the best choice. Ask friends and co-workers to tell you about their experiences.  Go on tours and ask questions about the hospital policies.  Don't judge a book by it's cover... a pretty room isn't that important during labor, but a supportive nurse and a deep jacuzzi tub may be all you need.  

Some of the advantages of a hospital birth may include: 

• Immediate access to medical technology, medications, and surgery if needed.
• Can be more safer for some women than a home or birth center birth
• Access to pain medications
• Assistance during the postpartum period (healing, breastfeeding, newborn care, etc)
• Safer for "high-risk" women

Some of the drawbacks to a hospital birth may include: 

• Typically encounter the Medical model or "managed" birth
  
• Subject to unnecessary interventions (routing I.V's, continuous fetal monitoring, time lines for progression or delivery)
• More likely to have an episiotomy.
• Small, but real risk of acquiring an infection while at the hospital.
• More restrictions on movement and positions with the use of medical equipment (EFM, I.V., epidural, etc.)
• Foreign environment that can make the mother more fearful, anxious or uncomfortable, which can slow or stop her labor. 
• More interruptions, less privacy and more variability of care. Parents may not know or have limited familiarity with the care provider on call.
• Food or drink may be limited or banned for the laboring woman.
• Many interruptions during the postpartum period. Mothers are more likely to be separated from the newborn. May be more difficult to establish breastfeeding.

Birth Center 
Birth Centers are great options for low-risk women who would like to be close to a hospital, but would like a more home-like and intervention-free environment.     Most birth centers are located near hospitals (for quick transfers if needed) and offer most of the comforts of homebirths.  Most are staffed by midwives and do not offer pain medication, but instead rely on a variety of other ways of comping labor.   In the Denver Metro area, Mountain Midwifery is the only Birth Center and has a wonderful reputation.   They do fill-up so don't delay in checking them out if you are interested in this option!

Some of the advantages of a birth center may include:  

• Comfortable environment that is more home-like than a hospital
• Usually more privacy and intimacy than a hospital
• Freedom of movement, mother led labor and birth
• Midwifery model of care
• Usually in close proximity to a hospital for transfer, if needed
• Less medical interventions (such as routine I.V.'s, continuous fetal monitoring, strict time lines for delivery, etc.)
• Often covered by insurance.  Usually significantly less total cost than an uncomplicated birth in a hospital.

Some of the drawbacks to a birth center may include: 

• Unlike a homebirth, it does require mom to change locations during labor.
• Limited access to life saving medical technology. Birth centers will have some equipment and supplies do deal with emergencies such as oxygen, medications for hemorrhage and resuscitation equipment. 
• Risk factors may make the birth center less safe or inadvisable (for example: high blood pressure, premature labor, breech, twins, etc.). Most Birth Centers are regulated and have strict guidelines for the type of care they can offer.  
• Birth center policy may only allow for a short postpartum stay. Parents are sent home shortly after birth which may be overwhelming for some.

Home Birth
Giving birth in your own home (or a friend or relatives home) is an increasingly popular option.  There are many factors that weight into the decision to have a home birth, with many who choose to give birth at home doing so because they feel it offers them the safest and most respectful environment for birth. 
 
Some of the advantages of a homebirth may include:

• Safer for the mother - Less chance of an episiotomy, postpartum hemorrhage, and cesarean
  
• No chance of developing a hospital acquired infection
• No unnecessary medical interventions (such as routine I.V's, continuous fetal monitoring, strict time lines for delivery, etc.)
• Comfortable and familiar environment for labor (which may make labor faster and easier)
• Freedom to labor as the mother sees fit and total control of the people present
• No access to pain medication (to avoid the temptation or pressure)
• Limited interruptions
• More peaceful environment after the birth, easier to bond and breastfeed.

Some of the drawbacks to homebirth may include:

• No access to pain medication without a transfer
• Greater parental responsibility for the preparation and safety of the birth
• Cost - Fees generally range from $2000-$4000+ and while some insurance plans cover all or part of the costs of a homebirth, even paying out of pocket this fee is just a fraction of the cost of most weddings, new cars, vacations, etc.  Don't forget to consider your co-pay and deductible costs for a hospital birth which can average $10,00-20,000+.  
• Limited access to life saving medical technology. Midwives have some equipment and medications and are trained in resuscitation, but could not preform an emergency cesarean or and do not have the range of equipment and medications that are available in hospitals.  
• Risk factors may make home birth less safe or inadvisable (for example: high blood pressure, premature labor, distance from a medical center, breech, twins, etc.). Each case should be evaluated individually and risk/benefits should be weighed.

There have been a few studies done which looked at the safety of homebirth in the U.S., Canada, the U.K. and other countries.  A national study of births in the Netherlands published in 2009 concluded:These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth. They show that planning a home birth is a safe option in a country with a maternity care system, which facilitates this choice through adequate numbers of well-trained midwives who assess the appropriateness of a home birth and through a rapid transportation and an integrated referral system.de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009;116:1177–1184.

While there is some debate about the research both confirming and dismissing the safety of home birth in the United States, there are some considerations to be aware of that can affect the availability and safety of this choice:

• There are several types of providers who attend homebirths (see this list for a definitions of acronyms), but the availability of providers varies greatly depending on where you live.  In Colorado, home birth are primarily attended by either Certified Professional Midwives (CPM) (certified by the North American Registry of Midwives (NARM)) or  Certified Nurse Midwives (CNM) (certified by the  American Midwifery Certification Board (AMCB)).  Occasional in others areas of the country, Family Physicians or Obstetricians attend home births.  
• Homebirth is safest for those having a healthy pregnancy.  Risk factors that increase the likelihood of complications should be considered carefully.  In many states, there are rules governing the ability for a care provider to attend a birth with certain risk factors.  Tips for maintaining a healthy pregnancy will come in a later post, but the usual suspects are important:  diet, exercise, reducing stress, and avoiding harmful substances (like smoking, drugs/medications, chemicals, etc).  
• Distance to the nearest medical facility should be considered.  Generally, a good rule of thumb a drive of is 20 minutes or less is usually considered reasonable.  Keep in mind that it is extremely rare for a woman to rapidly develop a life threatening emergency and most transfers for planned home births are not urgent.