Friday, July 13, 2012

Take on Home Birth, Part II

I just want to quickly mention a few things.....

1. I don't think every woman has had a perfect hospital experience. I know some women have had some downright horrible experiences in hospitals. I don't mean to gloss over those. But for the same reason that we can't assume that every baby at a home birth will die, we can't assume that every hospital experience will be horrible. Not every midwife practices negligently, not every OB pushes interventions. There is no black or white. All I can base my opinion of hospital births on is my own experience, now that I've had one.

Watching the movie Business of Being Born scared me. Talk about trying to instill some fear in women! I had never given birth in a hospital before so when I saw that, I thought, "YIKES! That's how it happens in majority of the hospitals in the US? I don't want that!!" It was pretty much all I knew of hospital birth at that time until I had my own.

After our birth, my opinion changed. It changed based on my own personal experience.

No one bases their decision to have a home birth on experience alone (or, at least, I hope they don't). I, personally, no longer had "fear of hospital birth experience" on my list of reasons for wanting a home birth. So I continued on down my list..... I took into consideration as much as I possibly could. If I missed anything, please tell me. Honestly, what else can I consider? I am not basing my decision solely on a desired experience, or solely on anecdotes, or solely on any one thing... I can't imagine that any woman does... I am basing my decision taking into account everything I knew to consider. 

2. I'm not suggesting that home birth all of a sudden become illegal in all 50 states. But what I think we should all be striving for is for regulation of home birth midwifery in the US to ensure it is being practiced as safely as possible. If people want to continue to compare the US to other first world countries to show how we are failing with childbirth and they are thriving with childbirth b/c they have more home births with midwives than we do, then the US should have a home birth midwifery system that is somewhat comparable to those other countries - but we don't at all. Our home birth midwifery system in the US is flawed.

I think it would be wonderful if we had a home birth midwifery system like they do in the Netherlands, where home birth is an option for low-risk pregnant women and the home birth midwives are an integrated part of the hospitals.

Some things I think that could help:
  • That the title "CPM" not include such a wide range of education and training. As it is now, you could have a CPM that never received a high school diploma or you could have a CPM that has her masters in a health-related field. You could have a CPM that apprenticed for 2 years or one that apprenticed for 5 years. And etc. Perhaps CPMs don't want hospital privileges, I don't know... but for the sake of consistency of care for their clients who need to transfer in labor, I would think it would be something they would like. Why not set the standards for education and training so that they can have hospital privileges?
  • Mandatory reporting of records and outcomes to the state, signed off by the parents (to ensure accuracy).
  • Mandatory malpractice insurance - if they want to be considered health care professionals, why would they be an exception to this?
As I mentioned in one of my comments, perhaps if midwifery were more regulated, then more states would legalize it and maybe even more insurance companies would provide coverage for it... therefore, giving more women the option of having a home birth. 

While I don't see myself ever seriously considering home birth again, I am not trying to take away that option from anyone who wants it. I am just advocating for a safer home birth midwifery system here in our country.

3. Why didn't I add neonatal death rates? Because, just like infant mortality, neonatal mortality does not include stillbirths. Regardless, I didn't leave them out on purpose - I simply did not look up the most recent ones. If anyone would like to add them in the comments, please feel free. Even if we considered neonatal statistics, what would it tell us about home birth safety in the US? Nothing. Perinatal mortality rates, neonatal mortality rates and infant mortality rates of the US vs other first world countries tells us nothing about the safety of home birth in the US. Even if the US was #1 for safety for each of those rates, would that mean every woman would want to give birth in a hospital? No.

Until we have some accurate data of home birth outcomes in the US, we're never going to know how safe or not safe it is.



Monday, July 9, 2012

A Birth Doula's Take on Home Birth


I fell in love with the idea of a birth at home when I was pregnant with our first child. 

Here's us, with my preggo belly :)





I had devoured Ina May’s Guide to Childbirth, watched the movie The Business of Being Born, read that 2005 Johnson and Davis article in the British Medical Journal, met some amazing midwives that seemed to have an answer for me about everything childbirth-related, and was introduced to this new, wonderful community of women that all doted on home birth and its safety. I was sold. I wanted a home birth. I wanted empowerment, water, privacy, minimal interventions, and the safest, most peaceful entry into the world that I could possibly give my child.

So during my pregnancy, along with studying to become a birth doula, I spent my time fighting our insurance company (because they wouldn’t pay a dime for a home birth), reading more books about natural childbirth and information that supported the safety of home births, and trying to prepare myself, my husband, and our home for our first child. A few weeks into my third trimester, I got one final letter back and it sealed our birthing fate. Our fight was over… the insurance company was NOT going to pay for our home birth. We were covered 100% for our OB care and hospital birth – I didn’t even have co-payments; our home birth would have cost $4500+. A baby on the way, buying a new house... OB and hospital it was. I was devastated and scared.

To make a long story short, I’ll fast forward about 2 years and give some highlights along the way: we had a baby boy in the hospital and it was a really good experience (I was actually shocked but our nurse and doctor were both very kind and I somehow managed to get out of there with a med-free birth as I had hoped and a healthy baby who was breastfeeding like a champ); a few months later, we switched our insurance companies to one that would pay for 80% of a home birth (our hospital birth was great, so can you imagine what our home birth will be like for our next child? Can we start on Baby #2 now, please?!); I started to attend births as a doula at home, birth center, and hospital; I became a certified birth doula through DONA and began the process of becoming a childbirth educator through ICEA; I was a part of an emergency home birth transfer that left me with many questions; I started to go outside my comfort zone by reading material and information that was against home birth; I started to doubt some of the things I had learned – and swore by – regarding home birth; I got pregnant with Baby #2 and started debating if I was really convinced of the safety of home birth; my husband and I ultimately decided we did not want to give birth at home; I decided I could no longer support mothers as a doula at home births because home birth here in the USA was no longer something I supported at all.

Talk about a 180! And that’s where I am today. I am a birth doula who does not support home birth. You won’t find a lot of women in my community who aren’t all about home birth let alone someone who doesn’t support it at all. Not so long ago, I was like the majority who support home birth and like the majority of mothers who have a home birth: I was a non-expert who read enough material and talked to enough of the right people in the home birth community that had me convinced of its safety.

What changed?

Do I Really Need to Fear my Hospital?
I can’t lie; a huge source of my hospital fear came from watching the movie The Business of Being Born. It wasn't just that movie - but being a film it painted a very real, and scary, picture of what I was reading about all over the place -- it shares that same message regarding hospitals that is echoed loudly in the home birth community, even the natural childbirth community. I didn’t want some passionless OB who had some kind of hidden agenda. I didn’t want to be stuck in a bed to labor. I didn’t want to be swept up in the “cascade of interventions” that could possibly lead to an unnecessary c-section. I didn’t want to end up with drugs in my and my baby’s systems. I didn’t want extra hurdles that would make breastfeeding more challenging. I didn’t want any of it and I was surely scared of it. What I knew at that time was that childbirth would be just as safe at home or in hospital, so then why not be in a place where I can avoid all those discomforts and interventions? I could be in the comfort of my own home and have someone taking care of me that I knew would be truly passionate about childbirth.

But then we had our hospital birth. And it was really nice. I didn’t even end up with my OB, I had one of her partners on call – whom I’d never met – and she was great. No one pushed interventions, I wasn’t stuck in bed when I labored, I could squat when I pushed, and I held my baby the second he was born. And the hospital births that I attended as a doula, those were pretty awesome, too. Wow, there are actually some fantastic OBs and nurses out there who love what they do. What was all this? Was avoiding interventions really such an impossible task? Were hospitals and OBs really all that scary? Maybe hospitals circa now aren’t so shabby after all?

Experts in Normal Birth
The whole idea behind having an “expert in normal birth” for my pregnancy and birth sounded so right-on: I wanted someone who knew how to attend to a woman in a labor and allow me to give birth vaginally with as little intervention as possible. I believed (and still do) that pregnancy is a normal and healthy event usually… but, I couldn’t help but wonder, maybe I should think about this from another angle? What if things become not-so-normal? What then? Yes, a home birth midwife is trained to identify when things become complicated, but maybe I want someone who can not only identify any issue but someone who can also remedy any issue with any technology or equipment needed to do so (or immediately turn over my care to someone who can, say if I was under the care of a CNM in a hospital).

So what about OBs? As our c-section rate in the US proves to us, most of the deliveries an OB oversees are vaginal, not surgical (though some or many think too many are surgical). Yes, majority of them may not be “normal” due to interventions but is that the OBs fault? Or is that the woman’s choice? Most women want an epidural (an intervention). Are OBs supposed to deny a woman an epidural so they can attend only “normal births?” Of course not.

OBs see and deal with and train for every type of scenario that can come up during childbirth: from “normal” to post partum hemorrhage to vasa previa to newborn diaphragmatic hernias to amniotic fluid embolism to cardiac arrest to much, much more. They are experts in all things birth-related.

Telling myself “that won’t happen to me… complications are rare… birth is almost always normal” wasn’t going to work. What if my next birth veers outside of that range of “normal?” Or what if it veers way outside of that range? If we transfer to a hospital, from a financial perspective, I then have to pay my home birth midwife plus a hospital (and potentially an ambulance, too). And, no, I completely understand it’s certainly not all about money. You can’t put a price tag on the safety of you or your baby. But the truth is, many women have a home birth because it’s the more affordable route… and if they transfer, what then? They end up with two (or more) bills to pay instead of one.

I have met some of the most amazing, well-educated, caring home birth midwives that exist in the US (CNMs and CPMs). Their track records are astounding. There’s no doubt they love what they do and they are good at what they do. But my what if’s had officially run wild and there was no reeling them back in without something concrete. I truly love the midwifery model of care so I considered a hospital CNM but they aren’t offered through our hospital – and I actually really liked our hospital now. Plus, my OB and I developed a really great relationship. My office visits with her are personal and I don’t feel rushed. I started to feel so torn… my gut was telling me I should go with my OB but my heart was still leading me toward home birth with a midwife.

So now what? Statistically, which is safer: home birth or hospital birth?

The Confusing Statistics and Many Types of Midwives
If you try to look at this statistically - home birth safety vs hospital safety - it’s more confusing than trying to understand a debate in a foreign language. One study will show that home birth is just as safe as hospital birth (the 2005 Johnson and Davis Study in the British Medical Journal) and another study will show that home birth has triple the death rate of hospital birth (the 2010 Wax Study in the American Journal of Obstetrics and Gynecology). Which study is better? Which is more thorough? Which is more accurate?

How was I to know if the authors of the study haven’t made any errors? What if they are coming from a biased standpoint, could that affect their outcomes? There are critics on both sides of the home birth debate that will point out the flaws in both of those studies - or in any study (or even data) that you will be able to find. Basically what we’re left with is this: in the United States, we don’t have any studies that have been performed to accurately assess how safe or unsafe home birth is. It truly doesn’t exist. For various reasons it doesn’t exist… from the way death certificates vary from state to state to the fact that home births midwives aren’t required by law to report their outcomes (except in Colorado). A thorough and accurate study of the safety of homebirth in the US versus hospital birth in the US, does not exist.

So what about comparing childbirth-related death rates in the US where the majority of births take place in a hospital, to childbirth-related death rates in other first world countries where home birth with midwives is much more common? This could be a good indicator of whether or not home birth is safe, right? Well, there are two big problems there:
1.      Which type of death rate do you consider?
2.      If we compare midwives in foreign countries to midwives in the US are we comparing apples to apples?

I’m using the most recent data that I could find. Since home birth advocates often compare the US to the Netherlands, that’s what I will do.

Often when people refer to safety of childbirth, they use the infant mortality rate. If you consider infant mortality, then yes, the US doesn’t do so well when compared to other first world countries that have a higher rate of home births with midwives - the US infant mortality rate is higher than the Netherlands.1 But what is infant mortality?

Infant mortality refers to the death of a baby within the first year of life.2 Infant mortality does not include intrapartum fetal deaths (when a baby dies during labor and delivery). Again, infant mortality refers only to babies born alive that die before they turn one. If a baby dies at 4 days old or 364 days old it will affect the infant mortality rate. So yes, it includes pregnancy and birth-related issues that may later cause a death like birth defects, low birth weight and neonatal hemorrhage but also includes things like accidents, disease, and SIDS… those are all encompassed (and more) in the infant mortality rate.

Makes you wonder… is comparing infant mortality rates between countries really the best way to determine if childbirth in that country is safe or not? Is there another mortality rate that is more specific to childbirth? Yes, there is. Actually, there are two: perinatal mortality and neonatal mortality.

Perinatal mortality refers to death around the time of delivery and includes both fetal deaths (of at least 20 weeks of gestation) and neonatal deaths (death during the first 28 days after live birth – neonatal deaths obviously then determines the neonatal mortality rate).3 Neonatal mortality is encompassed within perinatal mortality. Seems to me that perinatal mortality is the more accurate way to assess the outcomes of pregnancy and childbirth… that’s because it actually is.

So, how does the US compare to other countries in this regard? We do quite well! The US perinatal mortality rate is actually lower than the Netherlands.4

Now you have to compare the types of midwives they have in other countries to what we have here in the US. Again, I’ll stick with the Netherlands.

The midwives in the Netherlands must first be accepted into one of four higher education academies. Each academy follows a strict four-year curriculum and is for full-time students only. Approximately half of the curriculum is practical internships and the other half is studying science-based medicine. Once you graduate and become a professional midwife, you can work either as a midwife who attends home births or who attends hospital births. A home birth midwife in the Netherlands has hospital privileges even if that is not where they primarily work. Low-risk pregnant women have an option of home birth or hospital birth with a midwife but if the woman becomes high-risk or if complications arise during pregnancy, labor or delivery, she is referred (or transferred) to an obstetrician.

In the US, it is very different. There are three main types of midwives in the US: Certified Nurse Midwives (CNM), Certified Midwives (CM), and direct-entry midwives. Direct-entry midwives refers to Certified Professional Midwives (CPM), Licensed Midwife (LM; which is essentially a CPM that has been licensed to work in a particular state); and, lay midwives (no certification, education or training requirements - technically anyone can call themselves a midwife). 

Though some CNMs and CMs attend home births, most work in hospitals - the training and education of a CNM or CM is more similar to the training and education of a midwife in other developed countries. 

Mass majority of home births in the US are attended by some sort of direct-entry midwife (a CPM, LM or lay midwife). The typical route to become a CPM or LM (and most popular route of all currently practicing CPMs and LMs) is the Portfolio Evaluation Process which consists of an apprenticeship program and passing a skills assessment and one written exam. The time length to become a CPM varies on an individual basis. 

If a CNM or CM has current hospital privileges, then she may be able to continue care alongside the hospital staff in the event of a transfer. CPMs and LMs do not have hospital privileges and are legally regulated in only 26 states.

When you consider education and training requirements in addition to hospital privileges, you aren’t comparing apples to apples at all when you’re looking at home birth midwives from one country to the next.

After taking all of this into account, I was no longer sold on the safety of home birth based on any of the studies or data or comparisons of rates or midwives from country to country. The whole idea of having some sort of statistical proof to back up our home birth beliefs flew right out the window. I suddenly felt like I was grasping at straws… was I?

What else can I consider? If I stayed low-risk in my pregnancy, I believed the odds would be in my favor. And if things were starting to veer into not-so-normal-land at our home birth, my midwife would catch it and we’d just go to the hospital, right? But…

Is Our Hospital Really Close Enough?
Have you ever heard a woman defending her choice to have a home birth by saying “we only live 5 minutes from the hospital if something comes up.” Well… is that really the case?

Have you ever seen a woman in active labor? They don’t move very fast. Even if you live across the street from a hospital, it’s going to take you longer than 5 minutes to get her there – or simply just to get her out of the door. Now if it’s a situation where the midwife sees a potential emergency happening before it actually becomes an emergency, then getting to the hospital in time might not be a big deal at all. But what if it’s a situation where every minute matters (which it can be – and with little to no warning – even for a low-risk mom with previous vaginal births)?

Things to consider if it becomes one of those every-minute-matters situations: Do you know approximately how long it will take for an ambulance to arrive at your home? Is traffic something you need to worry about? Does your midwife have complete and accurate records for you and will she have them when you’re in labor to take to the hospital (blood type record is important)? If you don’t go via ambulance, the hospital likely won’t even know you’re coming (unless someone calls ahead) so do you know what your hospital’s protocol is when a woman comes in during active labor in an emergency situation? Depending on the type of hospital it is, that can make a huge difference in how fast they can get you the help you need.

One of the home births I attended as a doula was a hospital transfer. For that particular transfer, it took over an hour from the time the decision was made to go to the hospital until the baby was delivered… and this was one of those every-minute-matters emergencies. One second everything was great and the next, it wasn’t. The midwife said an ambulance would take too long, so that idea was quickly vetoed (and for good reason). On the way, the midwife called the charge nurse at the hospital in the Labor and Delivery unit to let her know we were coming so they could be ready for us. The mother had also seen an OB during her pregnancy so the hospital already had her records. We were only 6 miles away from the hospital, it was mainly freeway, and we hit zero traffic. The baby was stationed low enough that the OB was able to use a vacuum to get the baby out (if a c-section were needed, it would have taken more time). All those things considered, it still took over an hour from the time the midwife said “we need to go to the hospital” until that baby was out.

Be honest with yourself. How long do you really think it will take for you to get to a hospital? We’re not just talking door-to-door here. We’re talking from bed or bath or where ever you are laboring in your house all the way into a hospital and in the right hands at the hospital. An emergency in childbirth can happen with little to no warning even for a low-risk mother, even with the most skilled caregiver in attendance. If it’s an emergency for something like cord prolapse and if that baby is being seriously deprived of oxygen and blood, then you can see how every single second becomes precious. Is cord prolapse common? No (it is more common if your baby is breech, though). But is “not common” good enough for you when it comes to your baby’s life? Or what if your baby just goes into distress for no reason? The home birth transfer I mentioned above was for a young, healthy mother with a textbook low-risk pregnancy. Baby just stopped tolerating labor for no apparent reason and went into distress (perhaps his cord was being compressed? Changing positions did nothing to help so who knows what it was).

Just a quick side note… Your midwife isn’t going to have a vacuum with her and neither is an ambulance. Nor will your midwife or an EMT be able to perform an emergency c-section. Believe it or not, there are many that do not know this.

When we really took into account our distance from a hospital, it scared the crap out of me… could we really get to a hospital in time? Even if my body was pumping out enough adrenaline for me to fly there, would that be fast enough in an emergency? What if minutes matter for my child’s life or well-being? What if it matters for my own life or well-being?

BUT… “Babies Die in Hospitals, Too”
Yes, they do. And this was something I, too, once argued to defend home birth. But again - putting things into perspective - when, in the past 10 (even 20) years, is the last time you heard of a full-term baby who died in a hospital born to a low-risk mother? 

More importantly, I had to ask myself: how many healthy, full-term babies are dying in hospitals that otherwise would have lived had they been born at home?

I’ve heard plenty of stories of babies that were born prematurely that died in a hospital, or babies that died in a hospital because of severe congenital defects, and etc. So yes, it’s very sad but true: babies die in hospitals, too. But for full-term babies, it’s not often. Not often at all.

A Woman’s Right to Choose
Yes, I know… ultimately, what it all comes down to is that women should be allowed their own choice of where to give birth and with whom. After all, it’s “her baby, her body.”

The HUGE problem with that is: in order for a woman to make an informed decision about her baby and her body, she needs to have all of the information in front of her. She needs to know what is considered high-risk and needs to know why it is considered high-risk. Even if the mother is low-risk and a “perfect home birth candidate” it doesn’t mean that birth can’t be dangerous to a point where minutes can mean the difference between life and death… or life and severely physically or mentally injured.

I recently had a conversation (via Facebook commentary) with a home birth supporter (she may even be considered a home birth activist to some, perhaps even to herself – I don’t know). In her comments she wrote, “yes, there are bad midwives out there- I have no idea how many. No one does. But I do know that there are also many midwives who are cautious and do not deserve to be lumped in with the reckless ones. And the women who proceed cautiously when choosing home birth also don't deserve to be lumped in with those who take on many risks… A quick google search and you can find all sorts of information that lets you know that giving birth at home when you are high-risk is a bad idea…. Some people don't want to know the reality of a situation and that is their deal. What can you do if they are not willing to listen? And I am speaking for myself because I can't speak for anyone else. But if you are choosing to do a VBA3C twin birth at 42 weeks at home.. I mean, come on, you better own that choice.”

That’s just it. That right there hits the nail on the head for me and is the number one reason I have a huge issue with home birth in the US. Doesn't every woman think she is proceeding cautiously when choosing home birth and her home birth midwife? How does a woman know her midwife isn’t one of those “bad midwives” who simplifies very high-risk situations? How do you know your midwife is giving you true informed consent? A woman trusts her midwife implicitly – no woman would knowingly risk her child’s life!

Homebirth midwives in the US vary so greatly in their training, their education, and their philosophy of childbirth. There are many, many midwives in the US - and well-known ones like Ina May Gaskin - who take on high-risk mothers. What may be considered high-risk to one midwife may just be considered a “variation of normal” to another. Even if a midwife acknowledges a high-risk situation, if she tells her client that she knows exactly how to handle it, what is the client supposed to do? No matter how well-read a woman (and/or her partner) may be, she is not expected to know what her midwife does. If you can't trust your professional caregiver to tell you when things become too risky, then who the heck can you trust? Google?

There seems to be a very fine line between "proceeding with caution" (which is apparently what women are supposed to do) and "living in fear" (which is apparently what women are not supposed to do). How does a woman know on which side of the line she falls?

No midwife or OB wants to see anyone harmed of course. But at least an OB has the fear of a lawsuit, fear of losing their job, and fear of losing their license to keep them in check. A home birth midwife doesn’t. You could essentially be a midwife’s guinea pig and not even know it.

Not For Me My Baby
I was filled with doubt about the safety of a home birth and the proof I once believed in, no longer existed. I was done grasping. All those sayings and ideas that once meant so much to me: home birth midwives are “experts in normal birth,” high-risk situations like breech presentation are just a “variation of normal,” we should all “birth without fear,” and of course, just “trust birth,” did they really mean enough to me anymore? What once sounded so profound to me eventually became more like horrible clich├ęs than anything else.

I do believe that birth is normally safe for low-risk pregnant women but that was not enough for me. It did not matter how many amazing home births I could witness or read about. I couldn’t base my decision on anecdotes alone. My baby’s life deserves more consideration than just anecdotes. That proof… that proof of safety… I couldn’t find it. I still can’t. The appeal of home birth is still there… I don’t think it will ever go away. But how could I choose a home birth now? How could I even attend one as a doula?

I know some will think that I just don’t know enough about home birth or that I just don’t “trust birth” enough. Well, the latter is certainly true. If all it takes is to “trust birth,” why do some babies die at home births from issues that were very likely preventable or treatable in a hospital? I can’t help but think of the woman whose labor ended with a placental abruption at her home birth and her baby who didn’t survive it – and she was a perfect home birth candidate: low-risk, previous vaginal birth, healthy… or the woman whose attempted breech delivery at a home birth also ended with the death of her child after his head became stuck for more than 10 minutes... or the many others. I read their stories, I saw their photos, and I cried. Did those babies die simply because those moms didn’t “trust birth” enough? No. No, of course not.

I promise you that you are going to find anecdotal stories to support either side of this debate: scary hospital births, scary home births, happy hospital births, happy home births. You’ll find studies and statistics and data that seem to support either side. So how do you choose? When you find yourself confused about what to believe or who to believe and your baby’s life is at stake, perhaps fear is just your instinct in disguise.


Please see my two follow-up pieces:

Take on Home Birth, Part II
Murphy's Law


References
1 “Country Comparison:: Infant Mortality Rate,” The World Factbook, Central Intelligence Agency, 2011, https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html
2  “Definition of Mortality, Infant,” MedicineNet.com, 2012, http://www.medterms.com/script/main/art.asp?articlekey=14274
3  Marian MacDorman, Ph.D. and Sharon Kirmeyer, Ph.D., “National Vital Statistics Reports,” U.S. Department of Health and Human Services, 2009, http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_08.pdf
4  “Neonatal and Perinatal Mortality,” World Health Organization, 2006, http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf











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