In a tiny basement living room in southwestern Virginia, two women and their husbands listen to Joanna Davis talk about what might go wrong during their births.
“So this is an Ambu bag, and if your baby was in trouble and needed help breathing this is what we would use,” she begins.
Davis is a home birth midwife based in southwestern Virginia, but serves a significant swath of central Appalachia. Several months ago, she held a birthing class for two families interested in using her services.
During the class, Davis and an apprentice went over every instrument and scenario - both good and bad - that could possibly occur during a birth. Davis says she requires all families to attend the classes so they know exactly what they are getting into.
Despite a nationwide increase in home births in the last few years, the percentage of women choosing this option remains less than 1 percent throughout most of Appalachia. But many who turn to home birth, like the two women in Davis’ living room, cite the desire to control their birthing experience and eliminate what they perceive as unnecessary medical interventions.
“Most of my philosophy of practice is that moms and dads do a great job of getting babies in there and they do a great job of getting babies out,” said Davis. “I really love when the dads catch the babies, when they are super in-tune and involved and all of that. I’ll step in when they need me to, but most of the time I feel like my job is to create a safe place where they can do their work.”
Davis worked for about ten years as what’s called a direct entry midwife - she didn’t have official training - but learned through careful studying, researching and shadowing other midwives. In January of 2015 she decided to pursue licensure and passed the necessary requirements to become a certified professional midwife - a designation recognized in Virginia, but not in Kentucky and West Virginia, although both Kentucky and West Virginia are currently working on legislation that would change that.
She said when she first started, the women she served were “super conservative on one end and super ultra liberal hippie, crunchy ('those people'), and now we really are finding people that [are along that] whole spectrum [who] are much more interested in owning the experience of their own birth and wanting to be more comfortable and in control of their own births.”
Stereotypes May No Longer Fit for Families Choosing Home Birth
At a pretty, upper-middle class Morgantown home, Cassandra Harvey’s baby is gurgling happily.
“My husband is a physician - he’s trained to deliver babies - but most OBs that work in a hospital setting, they’re actually surgeons, so they are trained to deal with things that come up that are not part of the normal birthing process,” she said.
Harvey has three children - the first was born in a birthing center, the second in a hospital, and the third at her Morgantown home. Harvey did later clarify that her husband is a general practitioner, not an obstetrician, and that his training in birth occurred as part of an obstetrics rotation in medical school.
“I will say that at first he was a little unsure about the whole home birth process, which is why we had a midwife even though he’s a doctor and could have handled it on his own,” she said. “But he said it was important to him that he get to just play the dad and not have to play the medical provider as well.”
Harvey was adamant that having a homebirth doesn’t mean she’s uneducated or reckless - two accusations she heard over the course of her pregnancy - but rather that she was hyper-educated - she knew exactly what she wanted, what the risks were and how to choose a provider who would help her achieve her goals.
“Most women, if they are low risk, can have a healthy delivery without any kind of intervention,” she said. “But in a hospital they are looking for those things. So when you have a intervention it can snowball and when I say on my terms I want it to be completely the way nature intended it to be without someone looking for a reason to create or have an intervention.”
This is not to say that all home births always go well or that everyone has a good experience with it. Almost all the mothers I talked to I met through the midwives who served them. So consequently, the population sample was enthusiastic about home birth.
Obstetricians Urge Caution
Doctor Dara Aliff is a Charleston-based OB/GYN. “I currently have in my practice two women who have documented PTSD from home births gone awry and are seeking care for that,” she said. “And so I think the idea that it can’t go wrong just because it’s in your house is completely false.”
While Aliff says she isn’t totally against home birth like some of her colleagues, she strongly cautions against what she calls “home birth at all costs,” and urges women to choose their providers carefully.
“I can’t think of a situation where I would say to someone, ‘Gosh you are just an ideal candidate to do that,’ because you never know who’s going to be the one, who’s going to be the one who all of a sudden isn’t. And that can happen quickly.”
The official viewpoint of the American College of Obstetrics is that “hospitals and birthing centers are the safest setting for birth.” However, the College “respects the right of a woman to make a medically informed decision about delivery.”
A little data to further muddy the waters. According to the Committee on Obstetric Practice, women who have planned hospital births are twice as likely to have a C-section as those who have chosen to give birth at home. However, planned home births are also associated with a two to threefold increased risk of neonatal death when compared with planned hospital birth.
Midwife Joanna Davis, whom we talked to at the beginning of this story, says she attends 12-24 births a year. This past year was her busiest year on record. Still, home births in the three states that she serves - West Virginia, Virginia and Kentucky - account for fewer than 1 percent of all births, according to the Centers for Disease Control and Prevention.
Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Benedum Foundation.