Monday, May 23, 2011

Home birth on the rise in the U.S.

When I heard Eugene Declercq speak at the CIMS forum, I jotted down some notes on his data, but it was one of those "scribble it on the back of the conference program because you forgot to bring a notepad" situations, and he talked about so much interesting stuff I didn't have room or time to write it all down. One thing I was intrigued by was his statement that 1% of all births to white women are now happening at home. That seemed high to me, but he co-authored a new article out in the journal Birth, and it has that statistic plus a lot more info.

Some excerpts that were particularly interesting to me:

Large differences occurred in the percentage of home births by maternal race and ethnicity, and these differences widened over time... In 2008, 1.02 percent of births to non-Hispanic white women were home births, representing a 28 percent increase from 2004, when 0.80 percent of births to non-Hispanic white women were home births. In contrast, the percentage of home births declined slightly for non-Hispanic black women from 0.30 percent in 2004 to 0.28 percent in 2008. In 2008, the percentage of home births was 0.20 for Hispanic women and 0.38 for American Indian women, statistically unchanged from the 2004 figures. In 2008, the percentage of home births was 0.27 for Asian or Pacific Islander women, up from 0.24 percent in 2004. Approximately 94 percent of the increase in the overall percentage of home births from 2004 to 2008 was because of the increase for non-Hispanic white women. In 2008, 83 percent of home births were to non-Hispanic white women, compared with 54 percent of hospital births. [emphasis mine]

In 2008, Montana had the highest percentage of home births (2.18%), followed by Vermont (1.96%) and Oregon (1.91%). Three other states (Alaska, Pennsylvania, and Wisconsin) had a percentage of home births of 1.50 percent or above. An additional 10 states had 1.00 to 1.49 percent of home births. In contrast, 18 states had less than 0.50 percent of home births.

Interestingly, the recent increase in home births in the United States began before the release of a series of documentaries and newspaper articles about home birth... Such a development is not without precedent. In the United Kingdom, a government-endorsed movement called Changing Childbirth has been credited with leading to a growth in home births that has continued until the present. However, the home birth rate in the United Kingdom had already been increasing for five consecutive years before Changing Childbirth came into being... Women choosing home birth may be a harbinger, as much as a result, of increased activism related to childbirth...

These make me think about the highly culturally specific nature of the homebirth movement in the U.S. White women (in states with small minority populations) are accessing, promoting, and creating change around homebirth, and I would say I see a culture of normalcy arising around out-of-hospital birth in a certain segment of the population. (Overheard outside a prenatal yoga class: "Well, you don't have to pack a bag since you'll be staying at home, but what are YOU packing to bring to the birth center?") There is clearly a lot of privilege at work here...there are so very very few voices speaking to the non-educated-middle-class-white-woman demographic. I often think some of the Hispanic women I work with in CenteringPregnancy would be interested in having their babies in a setting other than the hospital - out-of-hospital birth with midwives being the standard in many countries they/their families come from - but there is simply no way for them to even know that homebirth is possible in the U.S., much less sort through the complicated process of finding and accessing it, insurance-wise. (And I can't pitch homebirth to them in my role, unfortunately!)

It comes back to my frustration that the people with privilege seek out the nurturing, mother-friendly, midwifery care; and the people who need that care the most, so frequently get a prenatal care through a health department or community health center, every visit with a different provider and then labor and delivery with another set of strangers, usually the general OB service at the hospital. I see basically zero outreach to low-income/minority communities from the birth community, and walking my delicate line between working in the system right now, I am guilty of that too. How do we fix this??


Elita said...

I live in South Florida and I have a midwife and she rents a room at a local birth center for prenatal visits. When I go for my appointments, I'd say almost all the women I see in the waiting room are low income women of color. The birth center takes Medicaid (as does my midwife for home births) but I have no idea if the birth center is promoting its services to the community, and if so, how. I always hear too about how the home birth movement is being driven by mainly middle and upper middle class white women and I see that reflected online. However in real life, I know and see a lot of women of color, particularly poor women, choosing birth centers and home births. Maybe it is the location of the facility? No idea. Have you ever seen that old show House of Babies on TLC? It is about the Miami Maternity Center, a birth center in Miami. If you watch the episodes you will see a lot of the families having babies there are minorities and lower income.

I guess birth is like anything else in our country's history, it goes in cycles. Poor folks get things right (cloth diapering, breastfeeding, home birthing, growing own food, etc), rich people fuck it up for convenience sake (disposables, good drugs at the hospital, tv dinners) then those convenience items become status symbols. At first even white women wanted to be attended by a black "granny midwife" at home. Then white women ran to the hospital in droves and black women followed. Now the white women are running from the hospital and I think slowly but surely minority and lower SEC women will follow.

Rebecca said...

Elita, thanks for your comment! Almost all birth centers seem to take Medicaid and I have seen how they really fought for this. My sadness is that it is not always reflected in the population they serve. But you're right - the "House of Babies" show features a great birth center that serves a lot of Medicaid/low-income families. Morris Heights Birth Center in the Bronx is another example of this. I think (although I could be wrong) that those are birth centers founded with a specific mission to serve those populations and really focused on outreach. Or maybe birth centers just find their initial clientele and then are recommended via word of mouth, so they just end up at a particular spot on the socioeconomic scale and stay there. It would be a fascinating topic for a research study!

I think to some extent you're right about people following suit as something becomes a status symbol. But of course it makes me sad because it shouldn't work like that! And because it can become something that gets very class- and race-delineated and those divisions can really stick. I see that happening with breastfeeding to some extent.

k. emvee said...

Elita - I think you're definitely right about the work on the ground looking different than who's having the conversations on the internet. And Florida is doing a lot of things right that other states aren't doing. I know more midwives of color from Florida than from any other location in the US.

To answer your original question, Rebecca, I think one of the most important things that we can do as birth workers is to build our practices from the very beginning with the goal of serving women of color (or start making changes now if not just starting out). Thinking about where in town you have your office, who you partner with in your community (if you're a white midwife, do you recommend doulas, acupuncturists, massage therapists, or lactation consultants of color to your clients?), and how you build community. I work with two white midwives right now, but they have done an excellent job of building community and when you attend their events, you see clients of color are well-represented. Thinking through things like this and others are all things we can do on an individual practitioner level that make a big difference and hopefully help influence other practitioners.

Other than that, I think one of the biggest keys is Medicaid and insurance reimbursement. Hopefully, we're moving in that direction.

Rebecca said...

k. emvee, thanks for your thoughts! You are so right that a big part of this is about being intentional in building community. It makes me think about my responsibility as a lactation consultant (albeit new). I know that there are a lot of wannabe LCs out there looking for preceptors. When I am recertified and able to offer mentorship hours (4.5 years from now, so not anytime soon!) I would like to do outreach to aspiring LCs who come from communities that are underrepresented in the profession.