For the last 25 years, the hospital has reigned supreme as the unquestioned place to have a baby. Within the last two years, however, there has been an increase in the number of medically supervised home births in the Washington area.
According to the Maternity Center in Rockville, headquarters for a group of certified nurse midwives who oversee prenatal care and attend home deliveries, the number of medically attended home births in the Washington area has grown from about five a month to 25 a month during the last two years.
Proponents of home delivery believe its attraction is the warmth and familiarity of the atmosphere and ability of the family to participate in a major family event. Fran Ventre, a lay midwife in Maryland, said that people who out for home births tend to be "people who are against medical interference where it is not necessary. Some live in the suburbs, some in communes. It's a middle class phenomenon only because a lot of people who are well educated and are into alternative life styles are becoming aware of these things first."
For some parents, cost is a factor. At Maternity Center the fee for prenatal care, home delivery, and one year post partum care is $550, while the fee for an obstetrician's prenatal care and delivery is around $650 plus a hospital fee of around $800 for an uncomplicated, typical three-day stay.
Prospective patients at the Maternity Center are screened for high risk factors. Those who fall into this category are advised to seek the care of an obstetrician and have a hospital delivery. Those in the low risk category receive regular prenatal care and are given a list supplies necessary for a home delivery. In Maryland, the Maternity Center's geographic [WORD ILLEGIBLE] Oxon hill to the south and [WORD ILLEGIBLE] to the north.
Two obstetricians oversee the Maternity Center's practice; they are on call should a home delivery patient need to be hospitalized.
Most obstetricians hold negative opinions on the subject of home births.
Dr. Donald Meek, an obstetrician practicing in Maryland and the district said, "They scare me to death. I did four myself many years ago, and I think the dangers outweigh any benefits because of the lack of life support systems."
Home Oriented Maternity Experience (HOME), an Arlington-based chapter of a national organization, responds to these views by noting that patients are screened in order to find the high risk mothers who need the sophisticated technology available in a hospital. Ninety per cent of deliveries are normal, they say, and do not require hospital life support systems.
Such statistics as exist are confusing. Neither obstetricians, nurse midwives nor public health officials are able to agree on statistics of infant and maternal mortality and morbidity related to home versus hospital setting.
Neonatologists - physicians specializing in the care of the newborn - are generally unenthusiastic about home births, pointing to emergencies and problems which cannot be predicted and which need the life-support systems of a hospital.
"Of all the high-risk pregnancies, 40 per cent will not be picked up by normal monitoring procedures until the time of labor," said Dr. Anne Fletcher, director of neonatology intensive care at Children's Hospital National Medical Center.
"What it boils down to is that things can happen which demand immediate intervention and at home that isn't available. The best equipped nurse-midwife doesn't have all the equipment of a hospital," said Dr. Mary Kate Davitt, director of nurseries at Georgetown University Hospital.
Certified nurse midwives practice in a variety of health care delivery settings, including hospitals, under the state's lay midwife laws and under the state's Nurses Licensing Act. The definition of nursing in the latter was amended in 1974 to provide for the expanded role of the nurse as a health provider. In addition, a joint statement of policy by the Maryland Nurses' Association and the Medical Chirurgical Faculty of the State of Maryland sets standards and requirements for practice.
The midwife law requires that a nurse midwife take a course of instruction from specified public health nursing personnel in the state or show a diploma from a school of nurse-midwifery. Both Georgetown University and Johns Hopkins offer degree courses in midwifery. Nurse midwives must also pass an examination given by two physicians named by the State Department of Health or submit proof of being licensed by another state or country in which licensure requirements are equal to those of Maryland. Licenses must be renewed bienually through the Maryland State Department of Health, Bureau of Preventive Medicine, 2411 North Charles Street, Baltimore, Maryland 21218. Lay midwives are non-professionals who must nonetheless meet state licensing requirements for lay but not nurse midwives.
A birthing center has some of the life support systems of a hospital but it has a home-like setting. Generally, nurse midwives provide prenatal and delivery care while obstetricians are on call for emergencies and once-a-pregnancy screening.
"The concept is one many of us have been toying with for years - an out-patient maternity center for normal uncomplicated deliveries. The hospital is a sophisticated, expensive institution geared to take care of the very sick, and if you could get away from their heart-lung machines and intensive care units, you could cut costs," said Dr. Thomas Gresinger, a Northern Virginia obstetrician involved in the planning of a birthing center near one of the three Northern Virginia hospitals with obstetric units.
One other option for families who are concerned about the safety of home births but object to the impersonal atmosphere of a hospital is an in-and-out delivery.Delivery is at the hospital and, if there are no complications, both mother and baby return home the same day.
"For those who object to a hospital stay it's of great value," said Dr. William Peterson, chairman of the department of obstetrics and gynecology at Washington Hospital Center. He said that between five and 10 patients a month deliver on an in-and-out basis at his hospital.
"If all goes well mother and child return home about five to six hours after delivery," Person said.
With the trend clearly towards a family centered childbirth experience, hospitals in suburban Maryland are creating a warmer atmosphere within the hospital setting. Holy Cross, Montgomery General, Prince George's General, and Washington Adventist Hospitals, those in Montgomery and Prince George's Counties with obstetrical service, all permit and encourage fathers in the labor and delivery rooms, and allow fathers to hold and care for their babies during the hospital stay.
Washington Adventist Hospital has a complete family-centered childbirth program including sibling visitation. Since the family-centered program began, the hospital's obstetric unit has gone from 42 per cent occupancy to 120 per cent occupancy. Gynecological beds are used for the overflow.
Obstetricians feel that with the improved atmosphere, hospitals are more suited than ever to be the perfect setting for childbirth.