The Adirondack Daily Enterprise recently ran an article from North Country Public Radio, “Meet the only St. Lawrence County midwife who delivers babies at home,” comparing home births in St. Lawrence County with hospital births at Canton-Potsdam Hospital and Claxton-Hepburn Medical Center.

We’re writing to remind readers about the maternity services available locally at Adirondack Health, but also to provide feedback about the reporting, some of which was disappointing to see in our hometown newspaper.

The article both overestimates the risk of hospital deliveries resulting in cesarean section (c-section) and underestimates the risk that mothers attempting to deliver at home will require a transfer to the hospital. That’s because the data cited in the article effectively compares apples to oranges. While the article quotes midwife Sunday Smith as saying only 12% of home births result in hospital transfers, the transfer rate for first-time mothers is two to three times higher — ranging from 23 to 37%, according to the American College of Obstetrics and Gynecology. Likewise, the statistics provided for hospital c-section rates omit important context. The rate cited in the article applies to hospitals’ overall c-section rates — which include mothers who are having planned repeat c-sections due to prior history of c-section, mothers carrying multiple babies, c-sections indicated for fetal position such as when the baby is breech and cesarean births required for complications such as placenta previa.

A much more objective measure of the likelihood for c-section would look at the primary cesarean rate for mothers with singleton pregnancies (one baby in the uterus as opposed to twins/triplets/etc.) in vertex presentation (head down), which is often much lower than the overall c-section rate. And even this number is an overestimate, because higher risk patients are more likely to receive care in a hospital setting and already have higher baseline risks of cesarean section.

Had we been asked, we could have told NCPR that our primary cesarean section rate of singleton vertex pregnancies was 15.6% in 2023 and 14.6% in 2022.

When discussing risks of homebirth in the article, there was also no mention of the increased risk to newborns ­– who face double the risk of perinatal death and three times the risk of neonatal seizures and serious neurologic dysfunction, compared to newborns delivered in hospitals. Mothers also face serious risks due to potential delays in care, should complications arise. The worst postpartum hemorrhage Dr. Burns ever treated was with a patient who was considered low risk. Sometimes minutes matter — they certainly did to that particular patient.

Mothers dying in childbirth, stillbirths and neonatal death all used to be more common phenomena than they are today. Things are different now, thanks to modern medicine, tools and management protocols. These tragedies are still more commonplace in parts of the world that lack immediate access to lifesaving measures like c-section, operative vaginal birth and blood transfusions. While we can understand the attraction to homebirth — to create your own birth experience in familiar surroundings — in many cases it involves more risk than is necessary, particularly when mothers can be supported in hospitals, as they wish, provided everything is going well. The Adirondack Health Women’s Health Center has certified nurse midwives and obstetricians, working together, to provide prenatal and birth services centered around patient preference and comfort, while, at the same time, offering expertise and emergency services when needed.

Our larger issue with the article, however, is that it perpetuates an overly idealized notion of what the best birth experience “should be” — a notion that can create a lot of pressure on moms-to-be, and ultimately a sense of failure if things don’t go as planned, even when the outcome is a safe mom and baby. Ultimately, when it comes to giving birth, the body is in charge, not the mind. Even with one’s best intentions and efforts, sometimes birth is very difficult, and it is no one’s fault. As caregivers, we are there to offer support, information and guidance when things become difficult. It is a partnership and a trusted relationship.

It is sad that the article seemed to promote an antagonistic relationship between women and medicine, rather than explore the real barriers to women receiving the best healthcare.

The article we were hoping to read would have focused on the fact there are more maternity deserts developing nationwide, as smaller hospitals close maternity units to save costs and patients are left with fewer and fewer options. A report from the Center for Healthcare Quality and Payment Reform found that 55% of rural hospitals in the United States do not offer labor and delivery services, due to financial challenges and staff shortages. More than 200 rural hospitals have stopped delivering babies within the past decade. Residents in rural areas travel at least 30 minutes, on average, to reach a hospital with obstetric services, compared with less than 20 minutes in most urban areas.

At the Women’s Health Center in Saranac Lake, we are currently caring for families from Essex, Franklin, Clinton, and St. Lawrence counties. We have cared for people coming from as far as Warren and Herkimer counties. People need to travel farther and farther for care. This puts pregnant people and babies at risk. That problem is increasing across the country as well as here in the North Country, but the solution is certainly not to convince women they don’t need those hospitals.

If someone is contemplating where they should give birth, they should be informed. They should think about what is most important to them. Bring these values and wishes to your care team and see if they can be accommodated in a hospital setting. Most of the time they can.

We want families to have good experiences and good outcomes for moms and babies. We are all on the same team.

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This commentary was co-signed by Dr. Eve Burns, DO, FACOG; Sarah Updegraft, MSN, CNM, PMH-C; Mary Rooks, MSN, CNM; Dr. James Pate, MD, FACOG and Dr. Jeffrey Dodge, DO, FACOG of the Women’s Health Center at Adirondack Health in Saranac Lake.

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Sources

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The American College of Obstetricians and Gynecologists Committee Opinion Number 697 Planned Home Birth April 2017. Reaffirmed 2023.

Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Women’s Health 2014; 59: 17-27.

Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metanalysis. Am J Obstet Gynecol 2010; 203: 243.e1-8.