The baby buggy, trundling along to homes in all parts of the city and its far-flung suburbs, is becoming a familiar sight to residents of Phoenix, Arizona. It is a huge, 24-foot-long GMC motor home, completely outfitted with first-class equipment as a mobile obstetrical unit. Two remarkable women—Gladys McGarey and Barbara Brown, a doctor and a nurse practitioner—have transformed a good idea into a reality, one that could revolutionize the rapidly growing home-birth movement.
Why do some women, rejecting the presumed benefits of a modern hospital, choose to have their babies at home—even going so far as to give birth unattended when they cannot get trained help? "It's the freedom they want," explains Ms. Brown, "they want to be able to do their own thing." And in this case, that means being able to select who will be present at the birth—not only the father, but children, other relatives, and friends. It means being able to move about during labor, have snacks, and be unrestricted in movements during delivery—all of which is difficult in a hospital setting, if not prohibited. It means control over one's own experience of giving birth. Yet many people see home birth differently.
Opponents of home birth, who include most members of the medical profession, object to it on the grounds of possible danger to mother and child. Citing statistics and horror stories, they argue that a woman who chooses home delivery is playing a kind of Russian roulette, not only with her own life, but with that of her baby. Medical organizations generally follow the line laid down in 1975 and reaffirmed in 1979 by the 19,000-member American College of Obstetricians and Gynecologists (ACOG): the "potential hazards" of birth, both to mother and child, "require standards of safety which are provided in the hospital setting and cannot be matched in the home situation."
More blunt and direct is an editorial in the ACOG Newsletter, in July 1977. Titling his piece "Home Birth Crisis," Warren H. Pearse, executive director of ACOG, spared no hyperbole: "Home delivery is maternal trauma—home delivery is child abuse!" He attributed what he called "the rising tide of demand for home-delivery" in part to the trend toward natural childbirth and noninterference and in part to an "anti-intellectual, anti-science revolt, of which the non-drug Laetrile is another current example."
To back up its position, in January 1978 ACOG issued a press release announcing that data collected from 11 state health departments show that "out-of-hospital births pose a 2 to 5 times greater risk to a baby's life than hospital births." Critics, however, were quick to point out that the survey is not an adequate or accurate evaluation of the safety of elective home birth, for included in the statistics are all out-of-hospital births: unplanned home births, unattended home births, late spontaneous abortions, etc. It is far from a convincing report.
Home-birth enthusiasts counter that the risks attributed to it have been greatly exaggerated. They point to several studies by Lewis E. Mehl, MD, especially one conducted in 1976 that matched over 2,000 women—1,046 home deliveries, 1,046 hospital births, in a comparison study. The women were matched for age, risk factor, gestational length, parity (previous deliveries), education, and socioeconomic status. Data were from seven home delivery services and two hospitals. "There was no significant difference in the incidence of fetal, intrapartum or neonatal deaths," Mehl reported. Provided the woman has been selected as medically low-risk and is attended by a midwife or physician, he concluded that "home delivery is an alternative that cannot be dismissed because of unacceptable high risk to maternal and infant health."
Besides claiming that home birth is a safe experience for the vast majority of women, supporters go on to make an even stronger case—that it is actually safer than hospital delivery, because hospital practices put mother and child in danger. To illustrate, they cite horror stories, the validity of which is occasionally acknowledged even by opponents. For example, Dr. Saul Lerner, a participant in a 1979 ACOG-sponsored round table on home versus hospital delivery, admitted that there are two sides to the issue. "I did a survey for a debate on the home vs. hospital delivery issue," he said, "and came across a major public health problem. I came up with a book of horrendioma on home birth. But if I'd been assigned the other side I could have called hospitals and come up with horrendioma that would make us look sick."
Now if the members of ACOG, or any other medical organization, wish to proselytize for hospital delivery, issue policy statements, and present evidence to document the reasons for their views, that is their right. But they go much further, threatening and intimidating those who do not agree with their stand. Many doctors are refusing to give prenatal care to women who are planning an out-of-hospital delivery. That is the doctors' prerogative, of course, but often their refusal comes from a fear of reprisal—loss of hospital privileges or withdrawal of insurance coverage—rather than from genuine acceptance of ACOG's policy on home birth.
And physicians' reluctance is not the only obstacle to home birth. Hospitals are refusing emergency care to home-birth couples. The opening of independent birth centers is stymied by regulations and restrictions, and efforts to establish midwifery training programs are constantly impeded. Pressure is exerted through the legislatures, the courts, and the medical licensing boards.
Yet despite the opposition of a large part of the medical establishment, home birth continues to gain popularity. At present, only one or two percent of all babies born in the United States are delivered at home, but the number is increasing.
"Our arrogant opposition to home birth has been unsuccessful," admitted John Miller, Jr., MD, another participant in the ACOG round table. But "embracing" home birth "is unacceptable," he added.
But why must working with, rather than against, home delivery be regarded as unacceptably "embracing" it? Why not work to see that many alternatives in childbirth are available to a mother and that out-of-hospital birth is made safer, while hospital delivery is made more attractive and satisfying? Narrowing the margin of danger, however wide or slight and whatever the alternative chosen by a mother, should be welcomed.
The independent birth centers that are springing up throughout the country are one such alternative. They provide a sharp contrast—and competition—to the hospitals supported by ACOG as the only place in which a woman should give birth. A mobile obstetrical unit such as the "Baby Buggy" offers another alternative, and a highly feasible one. It is designed specifically to narrow whatever margin of danger is associated with home birth.
The idea is that of Dr. Gladys McGarey, a charter member of the American Holistic Medical Association and its first national vice-president. She and her husband, William McGarey, have been physicians in Phoenix for over 30 years. They founded the Association for Research and Enlightenment (ARE) Clinic, a nonprofit corporation that initiates research into the concepts found in the writings of Edgar Cayce. Along with other related activities, the clinic provides various out-patient services. "Dr. Gladys" has hospital privileges at two major hospitals in Phoenix and is on the Obstetrics and Gynecology Committee at one of them.
When the home-birth movement began to gather steam in the early 1970s, Dr. Gladys was not one of those who refused to provide prenatal care. While she did not want to do home deliveries herself, she was concerned that so many of her patients were determined to have a home birth anyway. There was no official back-up at the hospitals for mothers who might suddenly have difficulties. "It was getting pretty scary," she says. "It's not that they didn't care (about safety); they did care, but the important thing was that they were going to have home delivery."
So about seven years ago she began to formulate a home-birth program for the clinic. What was needed, she decided, was a paramedic van and a fully trained nurse-midwife, someone who could handle emergencies as well as normal births. Putting this plan into effect took Ms. Brown, a woman with more than 20 years of intensive obstetrical experience in England and Canada.
A nurse-midwife is a registered nurse who has had additional training in obstetrics and the actual delivering of babies. Ms. Brown had received her nursing degree and midwife training in England, where for seven years she did both home and hospital deliveries. Upon emigrating to Canada, where there wasn't any home-birth program, she worked entirely in hospitals. Besides her work as a midwife, she was responsible for setting up an obstetrical department at a hospital in Ottawa.
Then she found herself at a crossroad in her life. As she puts it, "I needed another challenge. I'm always looking for challenges." She came to the United States, intending to get involved with home births. A new program had been started at the University of Arizona in Phoenix, a program to train Family Nurse Practitioners, able to attend to a family's basic medical needs. She saw this as a way to broaden her medical skills.
To earn her FNP diploma, it was necessary to find and work with a tutor for six months. Purely by chance, she applied at the ARE Clinic, one of three recommended by the university. On walking in, "I felt I'd been here all my life," she exclaims. She was hired on the spot and began to do home births in January 1978. "She needed us, and we needed her," says Dr. Gladys.
THE BABY BUGGY IS BORN
Word went out to friends and associates that the ARE Clinic was looking for a suitable van. One was soon located in Santa Fe Springs, California. It had been built and outfitted as a paramedic unit but never used because the brakes were below-standard for California hills. Since Phoenix is flat, however, it passed inspection. For $21,000, borrowed from a bank and being paid off in installments, the clinic had its Baby Buggy. About the only modification was to remove the whirling yellow light from the roof and to paint the outside—cream, light blue, and pink—with the ARE logo on one side, a stork-with-baby on the other, and the name ("The Baby Buggy") and phone number.
The interior needed no alteration. Ms. Brown selected the type of equipment found in the "Flying Squad" ambulances, so important to the home-birth service in England. There is an isolette ("incubator") for babies in distress and two oxygen tanks. A portable fetal monitor can be brought into the house so that the baby's heart beat can be frequently and accurately checked. There is a small refrigerator for blood and urine samples, equipment for giving intravenous injections, and a stretcher for transporting the mother to and from the van if it is necessary to take her to hospital. A telephone has been installed beside the driver's seat. Everything, right down to the batteries, is checked thoroughly once a week.
As a family nurse practitioner, Ms. Brown is qualified and permitted to deal with a number of problems and to make decisions on medical matters. "Not every baby that needs a bit of oxygen or warmth needs to go into hospital." The isolette can be taken into the house for a delivery, warmed up, and made ready with oxygen—just in case it will be required.
Besides the paramedic equipment, the Baby Buggy contains several items for optional use during labor. A silk-screen print of the Nativity scene, a gift from a patient of Dr. Gladys, has been framed and may be used as a focusing point (part of the Lamaze "natural childbirth" technique). Recently a tape recorder was donated, for women who wish to hear music or to record the birth. And there is the famous "bean-bag" chair, stuffed with a kapok-like material, to give support for delivery in an almost-seated position—a position many women find far more comfortable than the supine position that is (or was until very recently) standard for hospital delivery.
Ms. Brown is on 24-hour call, seven days a week, fully prepared to attend a birth at any time. One of the advantages of home delivery, as opposed to hospital, is that a woman can give birth when it is her time. She is not given drugs to accelerate or impede labor for the convenience of the staff and obstetricians, a practice found in many hospitals. Asked what would happen if two women went into labor at the same time, Ms. Brown laughs. "Well, they don't dare. They're all under strict orders not to." Joking aside, to cover this possibility, the clinic has recently hired a family physician to be on stand-by for home births. Up to now Dr. Gladys was prepared to do occasional home deliveries. And since both she and the family physician have hospital privileges, hospital back-up is assured in cases of extreme emergency.
Patients come from all walks of life but tend to be well-educated and financially secure enough to afford the service. The cost is $750, which is about $550 more than a certified midwife's fee and slightly more than the least expensive hospital birth. The average cost for hospital delivery is around $1,000, which includes the obstetrician's $500 for pre- and postnatal care and the delivery itself. While the clinic's program is not the cheapest way to go, the people who use it are sure it is worth every penny.
The additional insurance of the Baby Buggy is frosting on the cake for those participating in the clinic's comprehensive program. The $750 charge covers the delivery itself, prenatal check-ups at the clinic, childbirth preparation classes, and several home visits—three before and two after the birth—by Ms. Brown and Ms. Mary Cosgrove, the nurse who assists her. They get to know the entire family—the children, friends, even the dog and cat.
To fully appreciate the service, you almost have to go to Phoenix and drive from one end to the other. The distances are vast, and Ms. Brown can put well over a hundred miles on her car just doing a round of prenatal visits. The original plan was to accept only women who live within 10 miles of the clinic, but that proved impossible. Word about the program spread rapidly, not through advertising, but by word of mouth, and the demand was too great. Ms. Brown was not really surprised: "All you have to do to be successful is to do a good job."
The success is not going unnoticed. Josephine Gibson, associate professor and director of the nurse practitioner and nurse-midwifery programs at the University of Arizona at Tucson, sent a warm letter of praise. Voicing concern over the growing number of home deliveries, and the potential danger, she wrote: "Various alternatives such as a birth or maternity center have been suggested, but such a facility is not yet available. Your proposed back-up system seems to be an excellent adjunct for those providing home deliveries. We applaud your proposal as a pilot project."
Such a response is heartening, indeed, and a far cry from the usual one of rigid opposition. But it is a proper attitude toward this fine service. "After all," says Dr. Gladys, "we're satisfying a need. We're not pushing or suggesting home deliveries. We're taking care of a situation that already exists." Whatever the reasons for the current popularity of home birth, it is refreshing to see a challenge to the medical profession being met in the marketplace—and with compassion, dedication, and imagination.
Sarah Foster's background is in anthropology, on which she has spoken before various professional organizations. Her article "S 1 in Sheep's Clothing" appeared in REASON in November 1978.