Yesterday, the New York Times ran a short and sweet piece about a father who "watched a couple of YouTube videos" about how to catch a baby when his wife was about to give birth to their fourth child and there was no time to get her to the hospital. Last month, Jill at The Unnecesarean Blog posted a link to a news story about a 911 call from a husband whose wife was giving birth in their bathroom - who didn't even know she was pregnant! Another light-hearted NPR piece that ran in 2007 described three cases of births en route to hospitals that all occurred on the same stretch of highway in the same month. Stories like this pop up in the news often, although this is probably the first time we've seen the YouTube angle. But is there another, deeper story behind these puff pieces?

In the United States, we've seen a move toward "perinatal regionalization" for a couple of decades. (See Perkins' The Medical Delivery Business: Health Reform, Childbirth, and the Economic Order for an excellent analysis of perinatal regionalization and other topics.) This means maternity care services have been concentrated into fewer and fewer hospitals (or "baby factories") and the average childbearing woman lives farther from a maternity care setting. Even if the care at these large perinatal centers was top-notch (which it isn't), the health benefits are squandered if women can't get there in time.

When I was reviewing the research on rural birth centers for the next edition of Obstetric Myths versus Research Realities I came across two studies that provide indirect evidence that, in the absence of a community-based facility, considerable numbers of women would give birth en route to hospitals or would have unplanned or unassisted home births, both of which increase the risk of poor outcomes. In one study from Norway, in addition to the 999 women who gave birth as intended in birth centers, another 218 women who planned hospital births gave birth in the centers because rapid labor progress or difficult weather conditions made travel to the hospital unsafe. A study of a rural birth center in New Mexico did not specify how many unplanned births took place there, but they describe a case of a woman with placental abruption who, despite plans to give birth at the referral hospital because of a history of prior cesarean surgery, presented to the maternity unit with vaginal bleeding. She was urgently transported and had a precipitous vaginal birth soon after arrival at the referral hospital. Despite low Apgars, a neonatal seizure and evidence of intracranial bleeding, the infant had normal neurologic and developmental evaluations at 15 months. It is possible that presenting to the maternity unit instead of going directly to the hospital delayed the woman s access to emergency obstetric care. However it is perhaps more likely that prompt diagnosis and ready access to urgent transport at the community-based maternity unit averted a worse outcome by helping the woman reach the hospital prior to birth, where her infant could then receive immediate intensive care.

Most of the news stories about babies born accidentally at home have happy endings, but when we think more broadly about how best to serve the population of childbearing women, these stories should serve as a warning of a maternity care system that doesn't function as well as it could. In an era when home birth and birth centers are under attack, while a possible flu pandemic is making hospitalization a risky proposition, shouldn't we be talking about how to make sure all communities have access to trained birth attendants and prepared birth settings? Supporting the expansion of home birth services and birth centers could do just that.

Citations:

Leeman L, Leeman R. Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability.

J Fam Pract 2002;51:129-34.Schmidt N, Abelsen B, Oian P. Deliveries in maternity homes in Norway: results from a 2-year prospective study. Acta Obstet Gynecol Scand 2002;81:731-7

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