Home births on the rise, but not always an option

“Hard to Deliver” is a three-part series about maternal health care barriers in Southeast Iowa, as told by the mothers and families who’ve had to navigate them. This article is the second installment.

RIVERSIDE — For a growing number of soon-to-be moms, especially in rural Southeast Iowa, home births present a more attractive option than a hospital’s labor and delivery floor.

Those who hire in-home midwives say they prefer the simplicity of a single professional for all their pregnancy-related needs. While hospital visits would usually send an expecting family to a variety of providers over the course of a pregnancy, midwives can offer consistent, personalized care at every step. Also appealing is the option to give birth from the comfort of home rather than facing the stressful drive to a faraway hospital after labor starts.

The decision was simple for rural Riverside resident Chelsey Montgomery-Gusta. She lived 40 minutes from an appropriately equipped hospital, she appreciated the familiarity of a small group of professionals, and she expected a more comfortable experience in her own house.

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She also worried about the mortality rate for women of color like herself in a hospital’s less personalized setting. Medical research nonprofit KFF found last year that pregnancy-related mortality rates in the U.S. were three times higher for Black patients than white patients. A CDC report released in February had the same findings, based on nationwide data gathered in 2022 and ‘23.

Montgomery-Gusta said the experience of home birth was everything she’d hoped for.

“It was a magical, unforgettable experience that I still like talking about today,” she said. “My husband and I got to learn how to be parents without a bunch of doctors coming and poking and prodding, and asking questions while I’m hooked up to an IV, it was none of that. It really empowered me, I think.”

The overwhelming majority of mothers still opt to give birth under a physician’s care. The American College of Nurse-Midwives reports physicians were present for all but 12% of the births in Iowa in 2023. Several parents who spoke with The Union said they preferred the peace of mind that came with fully equipped, robust hospital staff, or hadn’t considered midwives in the first place, despite having low-risk pregnancies.

But the tide may be turning. A study published in the Journal of Perinatal Medicine in May of 2024 reported a 60% increase in planned U.S. home births from 2016 to 2023.

There were a number of factors at play in the trend for Iowa, including concerns about COVID-19 exposure, interest in newly state-sanctioned midwifery licensing, and the continued closures of rural birthing centers according to Bethany Gates, a licensed midwife who operates in Eastern Iowa.

“I think it was just a perfect storm for home births to rise,” Gates said. “I think we’re going to see home births continue to rise, because we’ll get more providers coming into the state to offer those services. And as you get more providers in those areas that are rural, and away from hospitals, it just becomes an easier option.”

Many parents prefer a hospital

While midwives have helped relieve the travel burden on some families in Southeast Iowa, they’re not necessarily the best fit for every expecting parent.

For one thing, insurance doesn’t always facilitate home births, and the level of coverage for midwives varies greatly from one plan to the next, compared to that for a trip to the delivery room.

Medicaid currently reimburses for midwives in Iowa, but not for doulas, according to the Iowa Hospital Association. And Chelsey Montgomery-Gusta said her family’s private provider denied requests for reimbursement after her first two kids, but hoped for better luck after a recent swap to a new insurance plan.

And even as in-home births grow more popular, some patients have had bad experiences with them.

Months ahead of her delivery in May of 2024, Washington resident Brookelyn Schwartz hired certified midwives after interviewing them personally. She said she formed a friendship with the pair of providers over the course of her pregnancy, which was normal, healthy and seemingly low-risk right up until the home stretch.

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But complications arose in the last few days of the term, and Schwartz was disheartened by her midwives’ responses to unexpected complications shortly before and during the roughly 18-hour labor.

Her child started aspirating during birth, and struggled to inhale after the process finished. A family member called 911 and the baby was rushed to Washington’s emergency room in an ambulance, before transferring by helicopter to the University of Iowa Hospital for more intensive care. Schwartz’ son ended up with a 31-day stint in the NICU.

The first-time mother, meanwhile, had to stay home and recover for a day. Her family helped her make the trip to Iowa City once she could get into a wheelchair, but apart from some brief contact immediately after birth, she wasn’t able to hold her child for about another week.

Schwartz said she grappled with guilt during that period, second-guessing her decision to give birth at home despite knowing she couldn’t have predicted the complications.

“Once I was finally able to go up to the university, I was able to be there, but it was very emotionally taxing,” she said. “I tried to do my best to really process, and not blame myself for anything that happened … but going up to the university, every single day basically for 31 days and watching your baby, that was not fun. That was really, really hard.”

Interviewed in January, Schwartz said her son was happy and healthy, but doctors warned the complications during his birth may lead to problems later in life, with symptoms not presenting until age three or four.

Physicians in Iowa City also told the young parents their child’s aspiration was caused by distress during birth, and could have been prevented with the right procedures after certain warning signs appeared a few days before his delivery. The news was disconcerting, and Schwartz remains frustrated with the care she received at home.

“This was totally avoidable and I could have been listened to,” she said. “Once I learned that, I started really processing the anger side of things. Like, ‘OK, I trusted you, I trusted your education and your responsibility,’ … I was in my most vulnerable state and I trusted these people, and there were little signs that got disregarded.”

Midwives can’t fill the gap alone

In general, midwives are equipped only to handle low-risk pregnancies. When a parent-to-be or their newborn requires advanced medical intervention during or immediately after delivery, a fully equipped hospital is the only safe choice.

While they have considerable discretion over their patients, midwives are expected to turn down high-risk clients likely to face complications, referring them instead to hospitals. Louise Zook, a midwife who operates in Williamsburg and Kalona among other places, said about 10% of her prospective clients “risked out” of services, either before they began or once complications arose a few weeks into their pregnancies.

“Midwives have a lot of free rein over how they decide if something is high-risk or not,” she said. “I try to, in my personal practice, align fairly closely with what a hospital would consider high-risk.”

Midwives can’t perform Cesarean sections or administer anesthesia. Most say they don’t accept patients with diabetes, or whose children test positive for trisomy, a genetic condition that ultrasounds can screen for.

That means that even for those interested in giving birth from home, it’s not always a viable option. And on a community-wide scale, even the best in-home provider can’t replace a hospital’s obstetric unit.

“Midwives are a tremendous asset to these rural areas, and communities that are lacking hospitals,” Zook said. “But still, there’s no way they’re going to be able to handle all of it, or take care of every single case.”

That leaves some families in a bind.

During her third pregnancy in 2019 and 2020, Wellman resident Amy Allen tested positive for Group B strep, a fairly common occurrence affecting about 30% of women. The bacteria poses virtually no risk to healthy adults, but it’s dangerous to newborns and can be transmitted to them during childbirth, necessitating antibiotics in the delivery room.

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That finding, combined with her slightly higher-than-average age for pregnancy, led Allen to opt against a midwife. While UI’s facilities were about 40 minutes away, the robustness of a modern hospital offered some welcome peace of mind.

“In the case that there were complications, I would prefer just to be there,” Allen said. “I know a lot of people in the area have been choosing to do home births, I just worry about the complications, especially as I get older.”

But the drive from Wellman to Iowa City proved just a few miles too far. An evening blizzard didn’t help matters as Allen and her husband rushed from their home to the university around midnight.

Allen’s frustration grew as the contractions sped up. She had come to the hospital earlier that day expecting to give birth, but was sent home as early labor progressed slowly. While she was hesitant to travel too far from Iowa City, she figured she’d be more comfortable at home in the meantime, and expected a few hours of wiggle room if labor started overnight, given the process with her previous kids.

That hope faded shortly after her water broke, right around midnight.

“This is a moment I’ll never forget,” she said. “The garage door opened, and it was nearing 12 o’clock at this point, and there is snow everywhere … that’s the moment that I’m like, ‘We are never going to make it. We’re never going to make it to the hospital. There’s no way.’”

When it was clear Allen couldn’t hold out any longer, her husband quickly pulled into a Casey’s Parking lot on Highway 1, and she gave birth to her daughter in the passenger seat. An ambulance arrived about 10 minutes later, transporting mother and child to the E.R.

The baby’s temperature was colder than ideal, due to the winter weather and limited climate control in the Chevy’s passenger seat. Otherwise, Allen said there were minimal complications, and the child is happy and healthy today.

Ambulances are backup, not substitute for obstetric professionals

When nonhospital births go awry, the obvious backup plan is to call an ambulance.

Far from a perfect solution, it’s the only option for some parents. Syndey Bowlin, a mom from Hedrick, went into labor two weeks earlier than expected while attending the Keokuk County Fair in 2023.

An ambulance arrived promptly and rushed her from the scene, only for Bowlin to give birth pulled over on the side of Highway 92 a few minutes later, about half a mile away. Her spouse was unable to meet her there until after the fact.

“It was definitely a crazy thing to experience,” she said. “I didn’t exactly know where I was, I just knew that the person that was supposed to be with me, I sent him on a trip to go get our stuff, and probably shouldn’t have.”

Paramedics say the backs of their vehicles have the most essential, immediate lifesaving supplies needed for virtually any medical emergency, enough to help patients through natural births in a pinch. But even more so than a hospital ER, an ambulance lacks sufficient temperature control, sterility or equipment needed to care for newborns after the fact.

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“If you have to put an IV in a baby, it’s the absolute worst environment humanly possible,” said Washington County Paramedic Scott Atkins, who said he’d delivered five or six babies in his roughly 30 years of experience. “Delivering in the back of an ambulance is never going to be the best-case scenario, but it’s an option that we have to think about.”

While emergency medical responders are trained for the situation and can work with newborns, they’re hardly specialists.

Continuing education helps paramedics brush up on procedures, but with labor and delivery calls being relatively rare, professionals say it’s easy to fall out of practice. Proficiency with obstetric principals can vary from one crew member to the next.

“When you’ve done it as long as we have and you don’t have neonatal, infant calls that often, you tend to lose even what you’ve learned in school,” said Melissa Handy, another longtime paramedic in Washington County. “Most often, we get calls where babies are already delivered by the time we get there. Like, they have them on the floorboard driving to the hospital, or a toilet. That’s what we deal with more.”

Bowlin’s story is case in point: she said she was assisted by an off-duty paramedic with some experience delivering babies, who, in a miraculous coincidence, happened to make her acquaintance a few weeks prior and happened be at the fair for a concert the day she unexpectedly went into labor.

The man managed to hop into the ambulance before it pulled away, bringing a massive relief to Bowlin who said the rig’s on-duty staff seemed out of their depth.

“When the others weren’t sure what to do and I found out he was there, I was like, ‘Get him, get him!’” Bowlin said. “Had it not been for him, though, I’m truly not sure what I would have done … I’m scared thinking what would’ve happened if I didn’t have this specific person in there with me.”

Paramedics encourage expecting parents to read up on their local EMS system if they plan to give birth at home. There are best practices people can take to help ensure an on-duty ambulance is ready where and when they need it.

Handy said families should let local operators know when they plan to have a home birth, especially if they live far from an ambulance barn. It also helps for dispatch to have an early heads-up about high-risk pregnancies, even when residents don’t plan to give birth at home.

“Typically, we’re not involved until the last minute, when it’s bad,” Handy said. “But if you have a birth plan with your midwife, we can be part of that plan … the more time we have to prepare, the better.”

Comments: Kalen.McCain@southeastiowaunion.com