It was recently suggested on a (mainstream) pregnancy forum that those who birth with a midwife at home or in a birthing center do it only for the “experience”, and that the safest place to give birth is in a hospital “just in case” anything goes wrong. When I replied that midwife-attended homebirths were statistically safer than OB-attended hospital births, I was asked why that was. So, in my typical concise fashion (ha!), I replied.
An obstetrician's training is in the pathology of pregnancy - finding and treating the things that go wrong with pregnancy. A midwife's training is in normal birth. The difference in training focus typically means a difference in the way the two caregivers approach birth.
OBs who provide maternity care for healthy women often apply unnecessary interventions to those healthy women, rather than solely to the complicated pregnancies for which said interventions would be appropriate and necessary. This is the case both during routine prenatal care and during the labour and delivery itself. These interventions often lead to complications that otherwise would not have arisen.
Midwives provide a far more holistic maternity care, viewing pregnancy and birth as a normal and healthy part of life rather than something to be micromanaged and intervened with. Intervention happens only when medically necessary, and midwives are trained to recognize complications which require transfer of care to an OB.
Family doctors typically have lower rates of obstetrical intervention than OBs do. (A family doctor was my caregiver of choice for my first pregnancy. A midwife is my preference this time, with temporary care being given by a family doctor as we are currently in between cities for the summer.)
North America is unique in its common use of obstetricians to provide prenatal care for routine low-risk pregnancies and deliveries. Most countries use OBs only for high-risk cases, with the bulk of prenatal care provided by midwives. These countries, incidentally, have lower maternal and newborn death rates.
Aside from the use of OBs in normal, healthy, low-risk pregnancies, the hospital environment itself is not conducive to the safest birth experience for the typical pregnancy. Fortunately, steps are being made to improve that, with some hospitals far ahead of others, but the typical hospital birth still involves being denied food and drink, having continuous fetal monitoring which requires being in bed during the labour and delivery, and giving birth lying down on your back with a doctor directing your pushing and breathing (the most inefficient way to give birth, but the most convenient way for the doctor). Episiotomies, forceps deliveries, and vacuum-extractor deliveries are all performed with little restraint. Pain relief is encouraged even though it commonly leads to problems with the delivery (inefficient pushing, fetal distress, etc) and thus in turn leads to a disappointingly high number of unnecessary c-sections. Time limits placed on the length of labour, coupled with the pressure of doctor hours, result in drugs frequently given to speed up labour, which again leads to more unnecessary c-sections. Any unnecessary surgery introduces risks that would otherwise not be present.
None of this is to say anything of the emotional state of a woman labouring in a hospital versus labouring at home. Most often, the woman feels that she and her labour are under the control of her doctor, becoming a passive participant rather than empowered to direct her own labour. The L&D room is often full of various nurses, residents, and doctors, any of whom may interrupt the labouring woman at any time. She labours under the constant threat of interventions and, ultimately, “failure to progress” (AKA, in many cases, your doctor wants to go home). None of this promotes the sense of comfort, security and focus that enables a woman to labour efficiently. Unfortunately, the connection between a woman’s state of mind and the ability of her body to labour is often ignored in the hospital setting.
Finally, there is concern about the safety of many prenatal tests and postnatal procedures performed, both for the mother and the child, as well as the difficulty a woman often has in declining any of those tests or procedures.
Any one individual midwife is not guaranteed to provide holistic maternity care, nor is any one individual OB guaranteed to encourage unnecessary interventions on a normal healthy pregnancy/birth, but the trends are there nonetheless. I am wholly confident in the care that a good midwife can provide, as I am wholly confident in my body to be capable of doing what women have been doing since the very beginning. On the (very low) chance that something does go wrong, I am grateful that hospitals are there to provide care where care is needed - in cases of disease and trauma, not in cases of normal, healthy, life-giving events.
So no, I have not planned a homebirth for the experience, for my own personal satisfaction, or because all the cool pregnant ladies are doing it. I have a planned a homebirth because for my low-risk pregnancy, a homebirth is the safest option.