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 clichés
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.
References
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