Influencers and Implications in Choice

In the past few decades modern hospitals have experienced great technological advancements

and patient-centered innovations, culminating in a far-reaching and powerful medicalized

framework of care. This process of medicalization sees medical practices becoming the method

for controlling problematic experiences and defining specific conditions in terms of medical

procedures. Additionally, this application of medical jargon increased the likelihood that medical

remedies would be applied to these conditions. This phenomenon affects the maternal health

realm in particular with childbirth being “the most common reason for hospitalization in U.S.

hospitals” (Healthcare Cost and Utilization Project, 2008). Prior to the mid-20th century, most

“American women gave birth at home under the care of midwives” (Boucher, D., Bennet, C.,

McFarlin, B., Freeze, R., 2009). Incidentally, with the growth of the specialty of medical

obstetrics, the rate of hospital-based births greatly increased and home-births saw a decline. “In

1950, the percentage of hospital births soared to 88%, rising to more than 99% by 1969, where it

remains today” (Boucher, D., et al., 2009). Even though the percentage of births within the

home has remained below one percent, the percentage has seen an increase in recent years.

According to a brief from the Centers for Disease Control and Prevention, U.S. home births saw

an increase “by 27 percent, from 0.56% of births in 2004 to 0.72% in 2009” (2012).

Several studies have found that safety rates are relatively equal when comparing hospital births

to home births. Despite comparable levels of safety, the choice to deliver one’s child at home is

not one a majority of American women are making. A closer look into what factors influence

this decision and sway expectant mothers to the technological-dominate mode of hospital birth,

uncovers a few specific implications. The first is that home birth is “not well supported in the
United States by the government, professional organizations, the insurance industry, or society”

(Boucher, D., et al., 2009). This is due in large part to government regulations that inhibit

practitioners from offering home services for childbirth with limits on licensure. Boucher, et al.

expands on this idea by commenting that all states in the U.S. license physicians, but there are

only 23 states that allow licensure of “nonnurse certified midwives who are more likely to attend

home births” (Boucher, D., et al., 2009). The American College of Obstetricians and

Gynecologists further dilute this choice of birth at home with policies that oppose home births

and even admonish “physicians from practicing home birth and from providing back-up support

for home birth providers” (Boucher, D., et al., 2009). Comments from such a reputable source

certainly influences mothers researching their birthing options but also, maintains the control of

the medical market which the college is a part of. This control manifests in small numbers of

home birth providers, and a lack of reimbursement of provider fees for home birth from most

insurance companies.

As suggested earlier, “factors related to the availability of birthing facilities may also play a role

in the choice of birthplace” (Centers for Disease Control and Prevention, 2010). This is the

regional or geographical implication that has a strong association to mode of birth delivery. As

explained by the CDC, the percentage of home births is typically higher in the northwestern

region of the country and lower in the southeastern region (Centers for Disease Control and

Prevention, 2012). According to the CDC brief, in 2009, the western state of Montana had the

highest percentage of home births (at 2.55%) and states like Texas and North Carolina of the

southeastern region had among the lowest rates of home births (at less than .50%) (2012).

Women in rural areas may not have access to a large array of healthcare options, the knowledge
to explore other choices, or the states within which they reside may be lacking in a licensing

system for midwives, all of which impede a woman’s choice for planning birth at home.

Another important implication that influences one’s childbirth options is the race and ethnicity of

the mother. There are significant percentage differences for home births according to maternal

race and ethnicity, something the CDC explains has only widened over time. In the 2009 brief

from the CDC, the percentage of “homebirths was three to five times higher for non-Hispanic

white women than for any other racial or ethnic group” (Centers for Disease Control and

Prevention, 2010). Furthermore, the percentage of natural births within the home for non-

Hispanic white women increased “by 14% from 1990 to 2004, and more rapidly, by 36% from

2004 to 2009” (Centers for Disease Control and Prevention, 2010). Race and ethnicity obviously

factors greatly into this choice, as in contrast the percentage for American Indian or Alaska

Native, Asian or Pacific Islander, Hispanic and non-Hispanic black women all saw a percentage

decline (Center for Disease Control and Prevention, 2010).

A third implication into this childbirth choice is the risk profile of the pregnancy and subsequent

birth. Home births typically have a lower risk profile; meaning they are not typically high-risk

pregnancies such as preterm, low birth weight or multiple birth pregnancies. “The lower

percentages of multiple, low-birthweight, and preterm deliveries for home births, compared with

hospital births, suggest that prenatal risk assessments are being done to identify low-risk women

as candidates for home birth” (Centers for Disease Control and Prevention, 2010). On another

note births taking place at home are not usually among populations of greater risk such as

teenagers or unmarried women.

The final implication that should factor into one’s choice between hospital and home births is the

cost of each venture. According to a brief from the Healthcare Cost and Utilization Project in

2008, childbirth continues to be the most common reason for hospitalization and totals about

“$16.1 billion in hospital costs, 4 percent of all inpatient costs” (2011). American women with

complication free pregnancies tend to get more services, necessary or not, from blood test to

ultrasound screens, and then they have to pay for each service individually, all of which adds up

quickly (Rosenthal, 2013). This does not even account for those families who deal with

significant complications that require further intervention. The brief from the Healthcare Cost

and Utilization Project, went on to summarize the costs of childbirth related hospitalization by

mode of delivery, and found that on average hospital deliveries cost $3,800 per stay, but the

mean cost varies by type. Cesarean sections “tended to be more costly than vaginal deliveries at

$4,770 vs. $2,900 without complications, and $6,500 vs. $3,800 with complications,

respectively” (Healthcare Cost and Utilization Project, 2011). According to another study, this

one on Medicaid claims in Washington State, it was determined that hospital deliveries cost

about $3,00 more than at-home births, accounting for complications (Gebelhoff, 2015). Despite

these findings women choosing to give birth at home in the United States are a minority

population, due to the previously mentioned compounding implications. Altman et al., puts it

best, “with more than 98% of women giving birth in the hospital setting, these women are at an

increased risk for added interventions and, therefore, added costs and burden to the health care

system (Altman et al., 2017). The systemic domination of technology and application of medical

practices, despite non-necessity, keeps the medicalization framework intact and prevents more

women from choosing a more natural childbirth approach.