What Drew Me To Home Birth and What Turned Me Away, Part 4

I feel so conflicted with how to wrap this up… I have so much to say, so much that was going on, so much that I was thinking about… hopefully I can get it out in a way that makes sense outside of my head...

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So here I was pregnant with baby #2… and go figure, options were wide open for a home birth, insurance is all set to cover it… and now I was actually leaning toward hospital birth. But I didn’t know. I still wanted a home birth – and partially for my pride at this point.

But the questions and concerns…. Oh so many…

I talked to my two good friends (doula friend and childbirth ed friend) about everything I was going through… I felt so conflicted… and now, to add more confusion for me, a recent birth of a dear family friend had me even more confused and conflicted. At dinner with them one evening, I told them as much as I could about what I was thinking and concerned about and what I had recently learned about that birth: "our family friends just had a baby with a diaphragmatic hernia, perfect low risk pregnancy, she would have been considered a perfect home birth candidate, this was her third vaginal birth with no previous issues in other pregnancies/children. The hernia developed after the 20 week scan so they had no clue their baby would be born with this huge issue. The baby couldn't breathe when born… she couldn’t get enough air… and oxygen wasn’t enough, she needed a ventilator to breathe/stay alive until surgery.... what if that baby were born at home?" I looked at them desperately wanting an answer as I was crying to them… and doula friend said nothing and childbirth ed friend hopelessly said “I don’t know…”

I knew the answer. The chance of that baby surviving had she not been born at a hospital was slim to none.

(On a side note, I was recently reading the Birth Center study that came out in 2013 and one of the babies that died had this exact issue: diaphragmatic hernia. Very similar circumstance as our family friend. It developed after the 20 week scan so they were unaware this would be an issue at birth. The baby in the Birth Center study did not survive. I couldn’t believe it when I read it.)

I went into my search for information on home birth and its safety coming from the perspective of someone who was already sold on home birth. I wanted to believe. I wanted everything to point toward home birth. Sometimes when your searching for the answers to something, the results you find can be tainted by your own personal desires... what I mean is, if you want to believe in something badly enough, sometimes you can find a reason to believe because your desire is so strong. I thought my search would bring me to the conclusion - an even more well-informed, well-rounded conclusion - that home birth is safe. As I felt before. But that's not where I ended up.

By now, I felt so... turned off by the home birth system as a whole in our country. It all felt like it was based off of misleading information, protection of the reputation of midwifery at nearly all costs, a stunning lack of accountability, and stifling those who brought up their concerns.

I had read too many stories of negligent midwives, home birth losses that were very likely preventable... and I realized I had no way of knowing who I'd be hiring as a midwife. It made me sick to my stomach over it... I loved and felt I could trust our midwives implicitly and I believed in their skills... but I have yet to hear a home birth loss story where the mother didn't feel the same about her midwives... midwives who later betrayed the trust by taking chances or with flat out negligence. I felt more confident going the CNM route because I know they have their nursing board to hold them accountable. But even then, there's no guarantee... even if they are completely ethical and do everything right, what if I am that small statistic that faces an issue that can only be resolved in a hospital..... my house isn't that close to a hospital. It would take quite a bit of time, especially if it were during rush hour. It just..... it felt like a gamble.

And I realize in the hospital, it is also a gamble. You never know the doctor or nurse you will get. You never know what kind of day they are having. You never know what their philosophy is. You never know how outdated their standards of care may be. To a certain extent, you have to put blind faith in a care giver. But at least in a hospital, you have accountability. Accountability is crucial. And I've looked at the numbers... vital statistics, hospital stats, studies, etc... our hospitals in the USA do a very good job of making sure our babies are born alive and safe and healthy.

I believe there is a certain element of childbirth that is mental. I, personally, wanted to take this into consideration as well. It's mental in that.... it's the woman feeling comfortable and safe and letting her body do what it needs to do. In that mode, that safe space, a woman's body functions at 100%, the hormones, the labor, everything... it just functions better. I think that there is a lot of propaganda out there in the home birth world that leads women (or maybe just me) to believe that being at home, in that familiar place, that that is where birth needs to happen to allow the woman to feel that way.

My own hospital experience was quite nice with our first. And I understand that it may not be the norm. I have experienced other hospital settings as a doula where things weren't as nice and where there was some fight needed by a mother/couple to get evidence based care. And like I said in my first post, I read many, many stories of hospital experiences that were not as nice at all. 

The childbirth ed midwife said to me once, during my first pregnancy: “you have to decide: where do you place your risk?” So that’s what I had to do. I had to decide where I would place my risk. I had to think about my options…

What are the true, unbiased risks?

What risks could happen at home that could only be remedied in a hospital?

What risks could happen at a hospital that could only be avoided by being at home?

I took everything into account that I could... infections that can be caught at home and/or in water (water birth), infections that can be caught in a hospital, childbirth risks that can happen to anyone/anywhere...

I had my answer.

In a hospital is where I needed to have our baby.

I felt I had the best of both worlds in the hospital, with my birth team: my husband and my doula. I can hope for another fantastic nurse, I can hope for another lovely doctor... but there is no guarantee. But there is a guarantee that my birth team that I trust will help me ask questions, help me ask for options, help protect my space, help me feel uninhibited and unembarrassed and safe and able to surrender to the process, help my experience to be as close to my desired experience as possible. The doctor and nurse(s) may add to that team or may make it a challenge for that team but regardless, they will be there to keep us safe. They will have the interventions and equipment if needed or wanted readily available.

This is what worked for us. I felt that while home birth can sometimes be a safe option (and I wrote a blog post where I put together a list of things, based on my fairly extensive research, of what makes for a safe home birth option). But it wasn't going to be the right fit for us.

By Spring/Summer (ish) of 2012, I was 100% confident in my choice to have another hospital birth. But not only that, I felt compelled to share my journey, through my blog, shared the things I learned along the way, to process it all, and to maybe even help others that may be in the same boat I found myself in.

I knew publishing my first blog post would change certain things for me in my life. Specifically, it would change certain relationships. And it has. As you can imagine, it ended certain friendships. Our doula backed out of being with us for our birth. I was told by a birth world friend that my blog was "too negative, too extreme, I was advocating that women live life in fear." But that's not what it was about for me at all. I had so many "what ifs" running through my head when I was in the process of making the decision of where to have our 2nd baby... so much fear that I'd make the wrong choice (and other fears, too)... I had to hash it out. I wanted to make an informed decision. I wanted to feel confident in my choice. This is how my blog earned it's name... it's not about living life in fear or in a constant state of being bogged down by "what ifs." It was about allowing those "what ifs and fears" to guide me to gathering more information so I could feel confident in my choice; feel empowered and well-informed.

My blog started me down the path of advocating for change.

I believe education and standards and insurance and transparency are so incredibly important for home birth midwifery. My advocacy comes from a place of not trying to limit options -- it's from a place of believing that women deserve the best options.

**If you'd like to read more about home birth in our country, birth centers, studies and statistics, and more, click here. 

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You are reading Part 4 of "What Drew Me To Home Birth And What Turned Me Away." Click to view:

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What Drew Me To Home Birth And What Turned Me Away, Part 3

I’m trying to be as thorough as possible without leaving anything important out… there's really no other way to describe the my change of mind/heart without filling you all in on the moments that all played their part, however small they may be. My apologies for being so long-winded. Especially for this entry...

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So I passed 40 weeks. My OB, trying hard not to crush my dreams by bringing up the "i" word (induction!!), wanted me to come in for an NST and ultrasound that week. So I did. When I got in the room, the nurse said “are we scheduling your induction today?” Ugh… great. Here we go. My OB came in and again brought up induction “I know you don’t want to and hopefully you won’t need to, but when you come back in a couple days for your 41 week appointment, we’ll at least need to put it on the schedule, ok?” Ultrasound tech also asked me if I was having an induction soon, too. Ugh! I was so hurt! I felt betrayed. I wouldn’t need an induction. There was no need. I promptly went home and had a little Facebook vent:

“doctor appt today for check up plus ultrasound & non-stress test. Induce, induce, induce is all I heard from doctor, nurses, techs, etc!! I don't care if I'm 3 weeks late w/ a 12 pound baby & they schedule me for one... this pregnant lady isn't going to show up. I am NOT getting induced unless baby is in danger, people! Ultrasound & NST both showed our baby is healthy & happy!”

(I’m cringing right now reading that. That’s exactly what I wrote a few years ago on Facebook – copy and pasted.)

Anyway. No need to worry more about induction because I went into labor that evening. I labored at home for 24 hours. Our doula joined us around hour 20.

We arrived at the hospital in the evening and I did not know it at the time, but I had 12 more hours of labor ahead of me. I thought I was nearing transition but was crushed when I found out I was only 4cm. I cried. 

My nurse was…. amazing. I couldn’t believe it. The hospital overall was so nice, people-wise. Our room was mellow, lights were dim, and I was in and out of the shower. I hated being monitored some times, but sometimes it didn’t matter because I was happy laying down anyway. I drank coconut water and was offered food but there was no way I could eat anything. No way.

I couldn’t believe how nice everything was for us. Aside from the monitoring, our nurse and the on-call OB (I’d never met her before) left us alone. And were kind to us.

I was so happy/overwhelmed when I had the urge to push (and nurse confirmed I was complete) but so, so tired. I had no idea where I would get the strength to push. I’d been in labor for over 34 hours now. I tried different positions… but my favorite – which was shocking to me – was on my back. My legs were jell-o at this point. All I wanted was to do was sleep in between contractions.

Our nurse stayed with me the whole time and encouraged me with every push. She brought in a fan that she would turn off or on, as I requested, because I kept going back and forth between being hot and cold. She held me up when I tried squatting. She dabbed my head with a cold wash cloth. She encouraged me to reach down to feel our baby's head when baby was crowning... I did and it gave me a boost of energy to keep going. She was so amazing. Her shift ended but she stayed with me until after the baby was born. I couldn’t believe it.

After an hour and a half of pushing, our baby was born.

He went straight on my chest where he stayed until I couldn’t hold him any longer… because of my postpartum hemorrhage.

I wasn’t fully paying attention as I had my new baby and he was nursing and I was in la la land so I didn’t really know what was going on. Though the crazy fundal massage snapped me back to reality. The new nurse said “OK Danielle, we are having a hard time getting your bleeding under control and we’d like to give you the Pitocin now.” I said “yes, ok, yes do whatever you need to do” and was getting freaked out. I got a shot in my thigh. More fundal massage. And now I was feeling woozy. I had to pass off our baby to my husband because I was getting too weak to hold him. And freezing cold. I was thankful for the hot blankets the nurses piled on top of me. It’s all a blur. I remember getting pretty scared and asking the nurse “am I going to die? Am I going to need a blood transfusion?” She said they were doing everything they could to keep me from needing a transfusion but I was still bleeding a lot and they didn't know why but I might need a transfusion. What?? I asked again if I was going to die and I told her I was scared. She said I wouldn’t die and was comforting me but all the while trying to help me, too. I now had an IV of Pitocin and Cytotec suppository and more crazy fundal massage.The doctor let out an "OK, here we go" / sigh of relief as two giant and gross clots came out. Finally the panic started to subside as the bleeding was slowing down / stopping. A boggy uterus and two large clots is not a good combination, apparently.

After that I was on heavy watch by the nurses for the remainder of our stay to make sure the bleeding didn’t pick up again.

I texted the yoga midwife later on the day of the birth and I told her about the postpartum hemorrhage. She told me that home birth midwives carry Pitocin with them, too.

I felt weird after all of that. Confused. I thought I had done everything right to avoid PPH. And I know home birth midwives carry Pitocin but that didn’t do the trick for me. The shot and fundal massage, it wasn't enough. Would I have ended up transferring after our baby was born if we were at home? That thought lingered. I didn’t focus on it because it worried me. So it just lingered.

I was happy that I had my unmedicated birth and my healthy baby. It all worked out at the hospital. I didn’t even have to fight. There were things I picked apart afterwards, thoughts like “well, this would have been better at home,” but for the most part, I knew my experience was good. I cannot lie and say that I didn't want to hate it, though.

Trying to fast forward a bit as I know this is such a long story… 

We changed our insurance at the next enrollment period so that our new insurance would cover future births at home. I started the official doula training process, aside from the book list which I had already started during pregnancy. I had my doula training workshop and met a new friend. Doula friend and I instantly clicked. She quickly became someone I would call one of my dearest friends. We became each other’s back-ups as doulas.

Around this time something else interesting happened… I was a member of a large, local doula group and someone sent out an email about hearing a woman named Dr. Amy, I believe she was on NPR (or some other radio station). Quite a few emails came through of people chiming in about her saying, basically saying she was awful and anti-home birth and her website is horrible. I was curious but vowed never to give her site the traffic. I asked about her here and there, though, to people I knew in the home birth community. More of the same responses. It was odd to me that someone would be “speaking out” against home birth. So I was very curious about this. It’s a safe option. Of course it was an obstetrician against home birth. Typical. Probably just doesn’t know or understand the normal process… Oh well. I let it go for the time being. 

I began doing an “internship” (with doula friend) with a local group of midwives – they were CNMs. During this time at the internship, my love of home birth midwifery only grew. I was attending births now, too, as a doula. At home, birth center and hospital. I knew I wanted to be a midwife for sure but didn’t know which route I wanted to go. It appealed to me to go the CPM or LM route because it would be faster. But I didn’t like that I wouldn’t be legally allowed to work in every state. What was with that?? As a CNM I would be legally recognized in all 50 states. It would be a lot longer route though and even with my 4 year degree I might still be starting from scratch, basically, since my degree was not science related at all. I went back and forth… I still had the impression that skill set and training was very similar, just different routes. One took longer because you had to earn a nursing degree – which I liked the idea of some days, and other days I didn’t.

I now struggled with the thought of which midwife to choose for future pregnancies. I now had these midwives I loved too, in addition to yoga midwife. How would I choose?

Doula friend and I met a new friend around this time, too. She was a childbirth educator. We became a quite the trio of birth lovers – a funny way to put it but our love of childbirth is what really formed that initial bond, that and the fact that we were just compatible as friends. I loved those two gals. Both are two of the most wonderful and kindest women I’ve ever met.

The last home birth I attended was one that was one of the biggest turning points for me. It was a home birth transfer for fetal distress. And it was very, very scary.

This was a low risk, young, fit, healthy mother. When she got to 9cm, the heart rate started dipping down very, very low. The CNM looked a little worried so she had the mom get into a different position. Heart rate, again, was not good. CNM told her to try her other side. Same. Then hands and knees. It was better for a bit then it dipped down again. As I’m typing it makes it seem like it happened so quickly but there were a few minutes tried in each position. It seemed like time had slowed down while we were listening to those little heart tones. Everyone seemed worried by this point. And now the heartrate wasn’t recovering in between contractions. Why?? What was going on? The CNM suggested we needed to transfer. She kept checking the heartrate and then said “yes, we need to go now.” The husband asked if he should call an ambulance but the CNM said it would take too long. Everyone was gathering their things quickly so we could go. Where are the keys? Where are clothes for the mom? Where are shoes? Etc, etc... rushing around. Keep in mind, the mom was 9cm at that point. Tiny, petite gal and even with her husband pretty much carrying her around, it was a process just getting out of the house. CNM gave a shot of muscle relaxer type meds to the mom to help the contractions slow down. I drove behind them in my car. The midwife stayed in the backseat monitoring the mom. Heart rate was better once the contractions stopped because of the muscle relaxer that she administered. I was sobbing in my car on the way there, called my husband and cried to him, I was so freaked out that the baby was going to die. Everyone was freaked out. Arrived at the hospital and they had her in a room, hooked up to monitors… Contractions started up again and down went the heartrate. They tried having her push because baby was low but it wasn’t going to be quick enough. Heartrate was not. good. OB rushed it, lots of commotion, episiotomy, vacuum, baby born.

I walked away stunned.

For a while I didn’t let it soak in completely. At the postpartum visit I had with the mother, our conversation left me shaken. There were just too many unanswered questions. I thought maybe her take on it would help me figure things out… as if she might offer up something that I missed, I don’t know. But it didn’t. So many questions. She didn't understand either. How did that happen??

After a while, I finally started really thinking about that birth. I couldn’t initially and it took me some time to get there. At first, I just sort-of… carried on. Went about life like nothing happened with my home birth midwifery friends and such. Though I did voice my concerns and worries a couple times to doula friend and childbirth ed friend.

I wanted to process what had happened, though. I wanted to make sense of it but I couldn’t. What if there had been traffic on our way to the hospital? Do all midwives carry such meds that the CNM had? Would a CPM or LM be able to carry those meds? What if that baby was in distress the whole way to the hospital without those meds… would that baby be alive? Or alive but with neurological damage? What if that midwife hadn’t been monitoring her so closely? I couldn't believe how long the transfer took... and we were going so fast... but it still took so much time... it felt like time stopped and was taking forever and yet it felt like it only took 5 minutes. But in reality it took much, much longer.

One night, my curiosity got the better of me and… I found myself at a website I swore I would never visit…

The Skeptical OB

Ugh! I hated myself for looking, for giving the traffic. But I just felt drawn. I had to see what she had to say. What if there are pieces to the puzzle that I’d find on her site? I don’t know. I don’t know why I went there other than my curiosity just had the better of me in that moment.

I thought I’d read one post and leave… but I didn’t. I stayed. And read quite a few. My face was burning red and my heart was racing. I will never forget it. Ugh. I felt mad at her. She was so…. mean with her posts. But I also felt confused. I read posts of hers that only were about home birth (because she covers other topics as well). One I read was about a home birth of twins where the second baby didn’t survive. One was discussing Doppler versus Electronic Fetal Monitoring. In other posts, I read about infant mortality versus perinatal mortality. There was more…

I read Hurt by Home Birth. Even then I made excuses like those midwives were just horrible… my midwives would never be so negligent. I was sobbing reading the stories though... and these stories, too, began to linger.

After a few hours of reading, I shut my laptop and tried to erase it all. But I couldn’t… I was so confused. And I did not like Dr. Amy. She was so harsh and so extreme.

Oh man did I have questions now… what the heck was all that??!

So I started asking questions to people I knew. I sent one of the blog posts by Dr. Amy to a couple of my birth world friends. I thought they could help me shed some light on it and say “no, this is false.” But that’s not what I heard. I heard “she’s too extreme, it’s unhealthy to be that extreme” and even heard “I’m having a hard time taking her seriously because there are grammatical errors in that post!” This did not give me any answers.

I read Dr. Amy's critique of the Johnson and Davis study (Outcomes of Planned Home Births with a CPM in the British Medical Journal) ---- a study that I loved and trusted and served as my "proof" of safety of home birth here in our country ---- I sent the critique to my cousin, she was in the process of becoming a home birth midwife. She didn't have any answers. She sent it to two of her midwife friends, she forwarded me the responses. Which I still have. I don’t know if it’s legal or not to post their responses so I will just paraphrase…

The first midwife said that Dr. Amy was the biggest anti-home birth doc in the USA. She twisted around stats to make things sound worse than they were. She comments on every home birth article that pops up.

The second midwife said that Dr. Amy was old news. She was way, way against home birth and is well-known and despised in the home birth community. As far as her critique of the Johnson and Davis study, all you need to consider is the source.

Again, no answers.

There was no resolve. So I looked at the numbers myself. It took a while. A long while. But… Dr. Amy was right… the study showed an increase risk, double to triple, at home with a CPM versus in a hospital.

And that wasn’t the only flaw in the study.

So now I had other things I just had to look at myself. Does infant mortality reflect childbirth or are we really supposed to look at perinatal mortality? So I looked up the definitions. I looked at what the World Health Organization had to say about it. I had my answer: perinatal mortality is the best indicator for childbirth / maternity care safety. It’s the only mortality rate that includes intrapartum deaths – deaths that happen during labor and delivery. It includes prematurity, antepartum mortality, intrapartum mortality and neonatal mortality. And the US does really well with perinatal mortality – tied with countries like France and Japan, and actually better than countries like the Netherlands and the UK. Next best measure is neonatal mortality. Infant mortality is not at all the correct mortality rate to consider.

So did the movies I had watched and books I had read know this and purposely try to mislead? Or did they all just not know what they were talking about?

I started looking at different perinatal and neonatal mortality rates, too, here in the US. Different papers and vital statistics data from as current as I could get all the way back to the 60s. I looked at the different studies for home birth and looked at their neonatal and intrapartum deaths… they shocked me.

That phrase I heard… that comment… “babies die in hospitals, too.” That comment was just… well, it was crap. It’s deceiving. Incredibly deceiving. Because the truth is: No. Full term babies don’t just die in hospitals here in the USA. And more importantly, they don’t die in hospitals at as high of a rate as they do at home. I stopped listening to the way the stats were cherry-picked and/or misrepresented and/or simply left out by home birth advocates and started looking directly at the statistics myself. Home birth in the USA is not a safe option. Not as it is currently offered (and there doesn't seem to be any real effort to improve it).

There was a lot that started going on during and after this time.

The group of CNMs talked to me about working part-time as a coordinator for them. I was excited at the idea of it and said yes, I was interested… but I was stressed out about it. I still had so many unanswered questions and I didn’t know if I was OK with home birth for us now… I just had more to figure out. And if I had a job with them, well then, how could I not have them as my hired care givers for future pregnancies? Thankfully, they ended up wanting someone full time and found someone else for the job. I felt so happy it all worked out. I felt so relieved.

Before all of this - before the transfer, before Skeptical OB - I never went in search of home births with bad outcomes. I had read so much, so many birth stories, but the bad stories… stories of death and injury… were missing. They are missing unless you pretty much seek them out. And it’s not because they aren’t happening.

There were other people out there voicing their concerns over midwifery here in the US… blogs like Navelgazing Midwife and The Reformed CPM. More blogs that left me with questions and concerns.

And now weird things were happening when I started asking questions. I started being censored. I asked a question on the blog of a very outspoken home birth advocate. My question was regarding safety and worries I had. And the comment was not only deleted but I was banned from ever being able to visit the blog again. What the heck?

That was the first time my comments questioning home birth safety were deleted… but it was certainly not the last.

And then there were home births that ended with death and certain stories that made it in the news… and I was appalled at the comments I read. Parents of babies that died were blamed by others in the home birth community! The midwife was protected, comments like “this midwife delivered my baby and was wonderful! The parents need to own up to this!” And this sort of thing… it was happening over and over and over again. Midwives were protected even if clearly negligent. This didn’t make sense to me! I thought having a home birth was all about having a passionate care giver who gave evidence based care, the best care… better than what you could find in a hospital. But how can we be certain we are getting the best care at home if accountability doesn’t exist?? When negligent midwives continue to practice without being reprimanded and without a track record that is made public… then how do we know who is negligent and who is not? And why are these midwives protected by the other midwives and the community as a whole? And the families that seek accountability, why are they vilified?

And the hypocrisy of this was astounding! An adverse outcome or bad experience in the hospital? The doctor and hospital were wrong! The community gathers around the mother. An adverse outcome or bad experience at a home birth? The community gathers around the midwife.

I also started looking deeper into the differences in midwives here in our country versus other countries. Majority of home births in the USA are attended by a CPM, LM or lay midwife. The education and training is so different than midwives in countries like Netherlands, where it is part of a 4 year university program, where midwives have earned hospital privileges. That is not so for CPM and LMs. But when I looked at websites like MANA and other home birth advocacy websites, they always site studies from other countries to show proof of safety of home birth here in the USA... but how did this make sense? How can we use studies based in other countries where the whole midwifery system and the education and training and health care as a whole is totally different than what we have here in the USA? 

I had more questions and concerns… more stuff I needed to figure out... and now we were pregnant with our second child... more to come in Part 4 on what the final decision was...

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What Drew Me To Home Birth And What Turned Me Away, Part 2

So I reluctantly met with a new OB. She was my friend’s OB – we were pregnant at the same time. The new OB was nice and I felt comfortable enough with her in our first appointment that I decided to continue going back to her.

But I wasn't giving up hope! The insurance fight continued.

In the meantime, I was learning even more about home birth midwifery and natural childbirth, too. It seemed like the resources were never-ending! I now knew there were different types of midwives, which I didn't know from the start. The childbirth ed teacher said this to me during one chat: “just make sure your midwife is certified.” So I knew there were at least certified midwives and non-certified midwives out there for home births. But as I dove deeper into learning about home birth, I learned there were more than just two different types. I learned there were CPMs, LMs and CNMs. There are more, actually, that I learned about after the birth of our first child. Anyway. At one point the insurance company was starting to bend the rules for us a bit by allowing the home birth but only if we had a nurse midwife from our network. I asked yoga teacher if she was a nurse midwife as well, because I knew someone could be both a nurse midwife and a CPM or LM. She told me she was not but wrote me a text message saying that if I wasn’t able to have a home birth with her but instead had a home birth with a nurse midwife it would be “the next best thing.”

Turns out we didn't have any nurse midwives in our network.

At that point in time, I wasn’t fully aware of the differences in education and training between Certified Nurse Midwives, Certified Professional Midwives, and Licensed Midwives - not as I am now. I also was not aware of the differences between our midwives here versus midwives in other first world countries, like the Netherlands. I made the assumption that the process to be called a licensed professional meant something… surely, not just anyone can be called a licensed professional and be able to “oversee” a woman in labor and a newborn baby. I trusted that a Licensed Midwife would be capable, that the certification meant a certain level of competency… I don’t mean the midwives we knew specifically, I mean the title in general. The certification. It’s a national certification. Surely it is a thorough process. It is birth, after all. As much as I believed in birth so much and the beauty of it and simplicity of the physiological process… so simple yet different every time… I knew it also was important to have a skilled care giver present, as birth can “rarely” mean life or death… and a skilled care giver can make that difference. Complications can necessitate someone trained in resolving them.

I had read about childbirth complications. Midwives are trained to handle them at home, though. And chances of experiencing them at home, without intervention, were less. If all else fails, you go to the hospital. Another film I watched at the time, I remember hearing the midwife say that midwives will know ahead of time, before it becomes an emergency. The film echoed what I had heard and read. And plus, we had the proof. We had the studies to show that home birth was just as safe, as far as numbers were concerned.

There’s no guarantee anywhere you give birth. This I knew. This I had read and been told. Safety was a huge priority to us. Pardon me, it was the priority for us. It’s why we were having a home birth. The USA doesn’t compare well at all to other countries for infant mortality. Our maternal mortality… yikes. Our obstetric system is flawed. Big time. That’s why hospitals aren’t a safe place for having babies. Home is. 

These are things I believed.

I had faith... I had my trust in birth, my low risk pregnancy, my impeccable diet (I learned so much about nutrition from the home birth midwives – especially the one teaching our childbirth ed class)… I knew the chances that anything would go wrong for us and our birth were so, so slim. We just needed to be home. If our baby was going to die at home, our baby was going to die at the hospital. It would be a rare situation, if that were the case. 

These are things I believed.

(Neurological and physical injury were not things I looked into much. I will be honest. I was trying hard to learn as much as I could but it’s a lot to take in in a short amount of time (9 months))

Back to my OB…

I’d have visits with her and she was lovely. I was, ummmm, a pain in the butt, to put it mildly. I didn’t think so at the time but looking back… yikes. I had so many assumptions and just this sour attitude because of my now fairly strong fear of OBs and hospitals. I distinctly remember discussing with her cutting the cord after birth and Pitocin after birth. I wanted delayed clamping and did not want Pitocin. As far as I was concerned, Pitocin was the Devil. I didn’t want it anywhere near me! Not even after the baby was born, unless I truly needed it. Delayed clamping was no big deal, though she was skeptical of its benefits. I told the childbirth ed midwife about what the OB said when she expressed her skepticism of delayed cord clamping and midwife replied “well your OB just doesn’t know. She just doesn’t know.”

My OB was concerned that I didn’t want the Pitocin after the birth. She said it was standard procedure at the hospital to do Pitocin after baby was born – an IM shot. No, no. Not unless I needed it. (And I was certain I wouldn’t need it. I was certain I wouldn’t need any interventions.) I could tell it might still be an issue so I wrote on our birth plan that I refuse Pitocin unless I need it and unless I give consent. There. It was in writing. I felt better. :)

The OBs kindness was unexpected for me. I appreciated it but still thought it was… I don’t know… maybe a trap? Maybe it wasn’t real? I sound crazy, I know… but I’d heard too many stories of OBs that seemed on board then it’s a different story at the hospital.

The midwives helped me put together my birth plan. Oh, and I had a doula, too, now! So she double checked the birth plan, too. The childbirth ed midwife said my first draft sounded too harsh. I’m glad she said that. It was too harsh. Thankful that we edited to sound nicer… not so militant in my demands. I should post it sometime on my blog.

Every time I looked at the plan it made me feel a huge mix of emotions: hopeful that I wouldn’t need it because a last minute miracle would come up and we’d have our home birth. Nervous and scared that one of our items would be ignored or purposefully dismissed by hospital staff. Worried that my baby would end up getting swept away after birth and poked with a shot that I didn’t want near my sweet baby. Angry that I needed the plan, that I'd need to fight for our experience... it was my body, my baby, my birth and I didn't need anyone interfering or taking away control of what was mine. And of course, I also felt excited for birth and to meet our baby.

Sometimes I look back and think I was so extreme in my views… like the fringe of the fringe… but then I hop on a childbirth forum geared toward home birth and/or NUCB and nope. I wasn’t extreme. I was right there in the middle.

I was starting to consider becoming a midwife around this time (something I am still set on doing to this day... when our kids are in school so I can be in school, too). I just had so much... I don't know... adoration for the midwives. I think that's the right word. They had an answer for me about everything birth-related and made it all sound so… easy/uncomplicated/normal/beautiful. I heard their stories of even high risk births like twins born at home. I was in awe. Twins run in my family and I was happy to know we could have our twins at home if we ever were pregnant with them. Breech births, too. As they say in the home birth and NUCB communities, just “variations of normal.” The birth stories were amazing. I felt I was on the path to my calling in life (still feel that way).

Sigh…

A letter back from the Department of Managed Healthcare sealed our fate. The fight was officially over. Our insurance company wasn’t budging and there was nothing we could do about it. We were stuck with the hospital and I was devastated.

I had become Facebook friends a while back with yoga midwife - our midwife - and after every birth she attended, she would give a Facebook shout out of congrats about the birth… the strong, empowered mama… the beautiful water birth. Usually a photograph was included, too. I loved seeing them. I remember thinking that I couldn’t wait for our shout out and water birth photo on Facebook! I know it sounds silly but I just felt it was an opportunity to inspire another mother to have a baby born at home… where they should be born. Now that fleeting little thought… that small way of inspiring another… it was lost. With each new birth post she shared, to accompany the awe and excitement I always felt, now came along a bit of jealousy and hopelessness. I was crushed.

I felt comforted that we at least knew what we needed to do going forward. We are fortunate to have other options of health insurance through my husband’s work and we made plans to switch insurance companies during the next open enrollment to one that would cover a home birth (and we did do so). As much as I felt sad about not having our home birth this time, I felt excited and at peace that it would be all squared away for our future births, knowing they’d all be at home.

By the end of the pregnancy, when I hit 39 weeks, I felt OK with the fact that we’d be in the hospital. Not thrilled by any means… but OK. I knew it would help me, actually, going forward as a doula and childbirth educator and midwife. A hospital birth would be good for me to experience. I felt confident with how badly I wanted to avoid interventions. I had my husband on board. We had an awesome doula. I was just ready to meet our baby. If I had to fight for it, I was ready because I knew my birth team would help me stay strong. And hopefully the See’s Candy I bought to take with us to the hospital would help the nurses get on “our side.”

****

You are reading Part 2 of "What Drew Me To Home Birth And What Turned Me Away." Click to view:

Part 1

Part 2 (currently reading)

Part 3

Part 4

What Drew Me To Home Birth And What Turned Me Away, Part 1

So how did I go from home birth lover to where I am now? I gave a short version in my first blog post but I shared the full scoop recently with a group of friends and felt encouraged to share it on my blog. Though it makes me nervous to do so as it is personal and I'm discussing people (without names) that once meant a lot to me, people that still hold a special place in my heart. And it's hard and well, it was heartbreaking, really. To go through. But..... you never know who might relate.

So first, I just want to say that “where I am now” is not a home birth hater. I am not anti-home birth at all. I think home birth is a wonderful option, actually. I think we are lucky to live in a country where we have many, many options for having a baby. The issue for us pregnant women here in the US is what is figuring out what options are safe, which are safer, and what options are dangerous. I do not agree at all with home birth in America being labeled “safe” as it stands now. So while home birth may sometimes be a safe option for women here in our country, as a whole it is not. 

Now that I have that out of the way… I’ll get to it… here's my story...

7 Home Birth Myths: No For Real This Time

photo courtesy of Edward Willett

I recently read a little article about myths about home birth. It was funny. Not so much like funny haha but funny in that full-of-misleading-information type of way.

So I thought I'd take this opportunity to tell 7 actual myths about home birth. The legitimate and dangerous myths, the myths that many home birth moms and advocates (and their family/friends) believe. Because I've been there. If you'd like to read more about my journey and why I am a former home birth advocate, click here to read for the full story. If you have any doubts on how well I researched home birth, that should clear it up for you.

Let's start with the biggest myth of them all.....

Myth #1: Home birth is as safe as hospital birth

While that may be true in countries like Canada or Netherlands or UK, it is actually NOT TRUE here in the USA. Not true at all. Not a single peer review study regarding home birth in the USA supports that idea that "home birth is as safe as hospital birth" -- they each, in fact, show an incredible increase risk for babies born at home versus in a hospital. (Click here for the studies) (and Click here for the *new* MANA study which yet again shows increase risk to babies born at home)

Under certain conditions - similar to the the way home birth is typically practiced in other first world countries (click here) - home birth may be as safe as hospital birth. But that's not how it typically goes here in the US. The US stands alone in our home birth practices -- which is why all studies point toward increase risk at home versus hospital. Even when you take things like rare hospital-acquired infections into account, the risk is still greater at home.

Myth #2: Home birth midwives are experts in normal birth

If you are seeing a Certified Nurse Midwife (CNM) or Certified Midwife (CM) that has current hospital privileges, then yes, you are seeing an "expert in normal birth." Mass majority of home births in the US are attended by a Certified Professional Midwife (CPM), Licensed Midwife (LM) or lay midwife -- these midwives would not be able to practice as a midwife in any other first world country because the requirements for becoming a CPM or LM are incredibly lacking compared to midwives in other first world countries (and especially compared to our American midwives that go through ACNM). And obviously, if you are seeing a lay midwife, who knows what training she has under her belt or what her real track record is.

If you feel like you are the exception and that your home birth midwife is incredibly well-trained and incredibly ethical and would never take chances (especially without you knowing), then you might want to read up on these midwives. Sadly, there is no guarantee and no way to know for certain what your midwife's training consisted of, what her real track record is and whether or not her own birth philosophy will trump what is ethical.

Myth #3: Home birth midwives carry with them everything needed, in case of an emergency

There is a huge difference in what you will find at a home birth versus a hospital birth. To some, this may sound obvious. But to others it might help to see it laid out, the difference what you would find at a home birth and a hospital birth. It's one thing to hear your midwife say "here's what I will bring -- it's everything you need in an emergency," and another to actually see equipment home versus hospital, and even ambulance. So click here to see the full lists and compare. Perhaps the biggest difference is the team you will find at a hospital that you won't have at home - especially if your midwife works alone. If both mother and baby are in need of immediate medical attention after birth, you have many hands and minds - not to mention equipment - to help them both at the same time. When will minutes matter? Read these stories and you'll get an idea of how low risk can turn into emergency in a matter of seconds.

Myth #4: If complications come up, home birth midwives will be able to identify and transfer before it becomes an emergency

There are circumstances when minutes can really be the difference in life or death (or serious neurological and/or physical injury). Shoulder dystocia, cord prolapse, placenta abruption to name a few... how will your midwife handle these situations at home? Ask her. What if what she tries doesn't work, then what? The reality is, those complications can be and have been deadly at home birth. If what she tries does not work, you will be transferring to a hospital and minutes. will. matter. I, unfortunately, know of 3 home births in just the past year that resulted in shoulder dystocias that were not resolved in time and the babies did not survive.

Myth #5: Home birth midwives give better care than OBs

Home birth midwives are afforded a little luxury that OBs are not. The luxury is called: no accountability. OBs must always err on the side of safety. If they do not, they have the hospital, their medical board and lawyers (lawsuits) expecting answers if something goes wrong. If their actions prove they were negligent and/or unethical, they are in big, big trouble.... like Dr. Fischbein or Dr. Biter. Home birth midwives, however, are able to push the envelope when it comes to potential disasters. Why? Because they aren't required to carry insurance and NARM (North American Registry of Midwives -- their governing body) is nothing short of a joke as a whole but especially in the accountability department. Here is one (of too many) home birth loss mom's story of seeking accountability after her midwives were incredibly negligent in the care they gave (which, tragically, ended in the death of their child). What an incredibly sad and frustrating ordeal it becomes for parents who expect accountability. Even if your child requires lifelong medical care after a home birth injury (which means medical bills for the rest of his or her life), without insurance, you won't get a dime from your midwives -- no matter how lacking their care was.

Myth #6: Home birth is more affordable

If you go bare bones home birth - meaning no "extras" - with a midwife who charges a pretty low fee and you do not need a hospital transfer, then yes, it might be more affordable. But if you start adding in some of the typical "extras" recommended by home birth midwives: herbs, supplements, chiropractic care, acupuncture, doula, etc then it can add up and fast. Not to mention if you transfer! Then you pay for a home birth and a hospital birth and maybe even an ambulance, too! And because certain conditions can worsen en route to the hospital, it may be a more complicated delivery, which means higher hospital bill (such as a postpartum hemorrhage that requires a blood transfusion because of all the excess blood lost during the transfer).

Myth #7: Home birth means no interventions

Nothing shocks me anymore in the world of home birth midwifery. Interventions, especially. From home birth midwives (illegally) using vacuums for delivery and Cytotec for induction, to more "natural" interventions like castor oil or black and blue cohosh or breaking the mom's water to home birth midwives even suggesting alcohol during labor (yikes!).... truth is, interventions exist at home births, too. And they can be offered (or sometimes they'll just be done without consent) at home and at hospital. They may seem more "natural" if it's an herb in a bottle versus a hormone in an IV but interventions are interventions. If you can't ask "why is this needed" or say "I'd rather not" at a hospital, what makes you think you'll be able to do so at home with your midwife?

And because it was too hard to stop with just seven:

Myth #8: Home birth means evidence based care

From lack of monitoring during second stage (meaning anything less than checking fetal heart rate every 5 minutes while the mother is pushing) to treating GBS with garlic and/or Hibiclens to VBACs without continuous EFM to breech and twins delivered outside of a hospital, there is a long list of common home birth practices that are not supported by any evidence at all. Click here for a longer list, which still does not include everything.

So there ya go. Those are the real myths about home birth in the USA.

Home Birth Guidelines for Safety

photo courtesy of debit72

Clearly there are issues in the home birth midwifery here in the States, as the numbers continue to show us the increase risk for babies born at home (you can read the studies by clicking here). In my opinion, based on what I have seen, it is because too many risks are taken -- risks that pregnant women may or may not be aware they are taking. What makes home birth safe? Here are my thoughts on the matter. My stipulations are based on the standards set by other countries where home birth has shown to be a safe option.

1. The mother is low risk and takes the proper screening measures to ensure that she remains low risk through the pregnancy and through labor/delivery -- otherwise care is transferred to an OB (or hospital, if during labor/delivery).

2. The birth attendant is a trained and certified midwife with current hospital privileges and OB back-up (which basically means your midwife is either a Certified Nurse Midwife or a Certified Midwife). I think it is important for a mother to meet with the back-up OB at least once during pregnancy. That way, if any complications develop later in pregnancy and she needs to transfer care, she can transfer to someone she has already met and to someone she knows her midwives trust.

3. A second attendant or midwife is present for labor/delivery -- someone that is trained to assist in birth (certified in CPR and neonatal resuscitation). In case mother and baby both need assistance after the birth there is one trained professional for each.

4. Close proximity to a hospital where the mother is preregistered in the event of a transfer (10 miles max -- even that seems too far, in my opinion)

5. Monitoring every 15-30 minutes during first stage of labor; monitoring every 5 minutes in second stage of labor. Anything less than that is falling outside the guidelines of evidence based care.

6. The midwife should have current insurance. This is to protect the family and the midwife in case something goes wrong. I know you can't imagine suing your home birth midwife if something went wrong. However, for example, if a birth injury occurs and the child needs lifelong medical assistance because of it, then you are certainly entitled to compensation to help pay for those medical bills.

7. The mother is not a first time mom. Home birth for a first time mother carries a higher risk for the baby.

Those are my suggestions. If you cannot check off all of these items for your home birth (or birth center birth), then it is not something I could get behind and call "safe." With the ever increasing interest in mothers wanting a home birth, I can only hope more midwives take reasonable measures like these to ensure only the safest options for their clients. I know there are home birth midwives that stick to these guidelines and that is wonderful!

Home Birth Safety

Link for above AJOG study

Edit 01/31/2013: I need to add the latest study offering up insight on home birth safety here in the USA. Click here to read it. It, yet again, shows increase risk for babies born at home.

I originally wrote this as a post in a forum online but I decided I wanted to share it here as well. This post addresses the peer reviewed studies regarding safety of home birth in our country.

It is important to know that studies done in other countries to "prove" the safety of home birth do not apply to home birth midwifery in the United States. Countries like the Netherlands, the UK, Canada, etc have home birth midwifery integrated into their health care systems. Their midwives have different education and training... more similar to a CNM or CM here in the USA. CPMs and LMs are a different story though, but they are the ones who attend majority of home births in the USA. CPMs and LMs do not have hospital privileges. They are not comparable to midwives in other first world countries in terms of education and training, as most CPMs and LMs go through a direct-entry process that has no education requirements (until September 2012 it did not even require a high school diploma). There are other differences as well that I have discussed in other blog posts (here and here).

For various other reasons, home birth in the United States cannot be compared to home birth midwifery in other first world countries. It's comparing apples to oranges.

Is home birth safe here in the USA? What we have for information to answer that question are 4 peer reviewed studies plus the CDC Wonder Database, all of which show an increase risk for babies born at home. Here are the 4 studies:

#1 -- Outcomesof planned home births with certified professional midwives: large prospectivestudy in North America by Johnson and Davis, 2005, British Medical Journal

This study is the most well-known study in the home birth community and the only study that supposedly shows the proof that "home birth is just as safe as hospital birth." But this study has two fatal flaws and it actually shows the opposite, that home birth increases the risk for babies.

First, the authors compared intervention rates between home and hospital for the same year, 2000. But when they compared mortality rates between home and hospital, they used the year 2000 for the home birth rates BUT for hospital rates, they used several papers dating back to 1969. Why didn't they compare hospital rates for the same year? Because if they would have, you find the rate to be double to triple the risk. The authors claimed that they did not have the hospital data available for the year 2000 when they published their study, which is why they used the dated papers. You can read a critique here which shows the numbers:

Science Based Medicine: A Critique of the Leading Study of American Homebirth

It is also important to note that crucial data is missing from this study. In Autumn of 1999, NARM contacted all registered CPMs regarding this study. Not everyone could be contacted, not everyone planned to re-certify, not everyone agreed to participate. So they were left with 409 midwives. All 409 midwives AGREED to take part in this study. Yet, 18 midwives ended up not having their births used in the study - those 18 midwives were not able to re-certify because participation was mandatory in order to do so.... however, this does NOT mean those midwives are not still practicing. Where is the data on those 18 midwives and their births? Why did they AGREE initially to take part? What if they each had an infant or mother die under their care and that's why they did not complete the process? This essentially means midwives who had bad outcomes could bow out after the fact and those outcomes would then not be included in the study.

These are two serious flaws. This is a study I once was totally behind.... this is what I had my husband (and others) read when we were planning for our home birth, this was my "proof" of home birth safety. I was completely unaware of these flaws at that time. I even wrote a response on the article in the British Medical Journal regarding the missing data on those 18 midwives but I have yet to hear a response.

#2 -- Maternal and newborn outcomes in planned home birth vs planned hospital births: ametaanalysis by Wax, 2010, AJOG

This study shows a triple neonatal mortality rate for babies born at home vs in a hospital but it isn't a high quality study because there are births included in the home birth group that did not have a midwife present (in other words, births that were intended to be hospital births that were accidental home births).

These last two are the most recent studies:

#3 -- Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting by Grunebaum, 2013, AJOG

#4 -- Selected perinatal outcomes associated with planned home births in the United States by Cheng, 2013 AJOG

These two studies both show the risk to babies is significantly higher for death, seizures or serious neurological dysfunction for babies born at home and freestanding birth center. Home birth and birth centers were compared to hospital births with OBs (which would include high risk pregnant women) and hospital births with CNMs. 

Hospital births with CNMs had the lowest rates (meaning, best outcomes -- which would make sense b/c it would be low risk women). Followed by hospital birth with a doctor. A fairly significant higher risk is midwife-attended birth center birth. The highest risk - by an incredibly significant amount - was home birth with a midwife.

Some home birth advocates are trying to say these studies are not valid because they use unplanned home births - this is NOT true. They used data ONLY from home and birth center births where a midwife was present. If it was not midwife-attended or if it was unknown whether or not there was an attendant, the data was not used.

One of the limitations in the studies is actually home birth transfers to hospitals that resulted in death... those would be counted in the hospital group. This would obviously make the neonatal mortality rate even higher for home births if those deaths were counted in the home birth group.

Here is the response from MANA regarding these two studies:

http://www.mana.org/blog/0/understanding-outliers-in-home-birth-research

This response from MANA could not provide a better example of why I have ZERO respect for that organization. It is full of lies and utter nonsense.

First, they try to dismiss the findings by saying birth certificates "are not very accurate when it comes to rare outcomes like very low Apgar scores, seizures, or deaths (Northam & Knapp, 2006)."

In the comments, someone wrote that the study they reference actually states the opposite, it states that APGAR scores are actually quite accurate on birth certificates. So I read the study. And it indeed does say that APGARs are reliable on birth certificates. Each time APGAR scores are mentioned in the study, it mentions that APGAR scores are one of the more reliable pieces of information on birth certificates. To quote the very study they reference exactly it says “Birthweight, Apgar score, and delivery method agreed 91.9% to 100%. The high-percent agreement supports the reliability of those variables.” So not only did they offer up completely false information, but then when someone pointed it out to them, they did nothing to edit or change it. 

Next, they say that it is a fatal flaw to use birth certificate info because birth certificates don't adequately capture intended place of birth. But intended place of birth doesn't matter for this study - actual place of birth is what is most important. And the place of birth is adequately captured. The data used in these studies was only midwife attended births at home or at freestanding birth centers. As I said above, if it was unknown whether or not an attendant was present or if there was no attendant at all, the data was not used. So again, their second “flaw” with the article is yet again, not actually a flaw.

Then they say this "In recent well-designed studies that captured planned place of birth and used better sources of data, there were no differences in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011)." How incredibly shocking!! Yet again, MANA is trying to prove a point about safety by using studies based in other countries -- the first two studies are out of Canada and the third is out of the Netherlands. How on earth does this apply to the findings of these studies? IT DOESN’T. It literally takes nothing away from the findings of these studies. 

Finally they offer this "They analyzed the rare occurrence of 5-minute Apgar scores of zero, which may be indicative of a number of possible events which may or may not have been related to the time, location or care provider at the birth. The authors note that stillbirths may have occurred in the third trimester, may have been due to lethal congenital anomalies, and other possibilities that are captured in a 5-minute Apgar score of zero." However, if you read the study, they address this. And although it is considered a limitation that antepartum deaths may be included, it likely wouldn't change the findings because intended home or birth center antepartum deaths would be transferred to the hospital for delivery. What midwife would keep a woman at home to deliver the baby if she couldn't hear a heartbeat at the beginning of labor?? The chances of any third trimester stillbirths being included in the home birth group are slim to none.

That covers their critique of the studies. They were grasping and officially grabbed onto nothing.

The fact is, these two studies are very high quality. No, not perfect. But the findings should certainly not be dismissed. They should be addressed. And they certainly should be considered for those looking into home birth.

****

So that’s that.

While home birth can be safe, the truly safe scenarios are the exception, not the rule. All evidence points toward an increase risk at home. I have no doubt it is largely due to the lack of training and education of the birth attendants.

I have more to say… including my thoughts on what situations I would call “safe” for home birth and thoughts on the CPM/LM credential… but I will end this particular post here. Stay tuned…

01/14/2013 Update:
I added a blog post addressing guidelines for having a safe home birth. Click here to read it.