Wednesday, November 11, 2009

Letters to a young homebirther

I got permission to share a recent exchange with a several-degrees-removed family member, a terrific, sharp, lovely young woman who is expecting her first baby by the end of November. Her recent training as a physician's assistant included a rotation in labor and delivery - and the experience made her extremely disillusioned and uncomfortable with a hospital setting for her birth unless it becomes medically indicated. We talked about all this for a while while I was visiting family this summer, and exchanged a few emails as well. She had found a great midwife and things were going smoothly. And then, like many moms experience, especially first-timers, she went through a questioning period. Here's what she sent me:

Okay, Anne. I need your help. I am having a hard time feeling 100% confident with the home birth. Did you ever second guess- what if her heart rate drops and I need a c-section in 2 minutes instead of 10? This is my biggest obstacle. [The father] and I met an awesome midwife and I honestly feel really good and at peace with the whole thing. And the thought of going to the hospital just makes me, well, not want to deal with it. Can you help me out. Since you had your first at home too, maybe you could give me some good advice...

Now, before I share my responses, I want to make clear that I would never, EVER try to "talk someone into" a home birth. At least I hope I never come off that way. I would never want someone to feel pressured, and women should absolutely give birth where they feel the most authentically comfortable. And for some women that is going to be the hospital, period. I can help support their informed choices no matter where they are. IF, however, a mom is intrigued, and curious and, maybe eventually, leaning towards a home birth, I can share my own reasons why it was the right choice for me, and why it is a good choice for many others.

So! My responses, in two parts:

PART ONE

Hey there!

I just wanted to let you know I DID get this, and plan to reply to it in more detail, but I am just in the middle of an insane week, starting with my first postpartum doula client, and tomorrow I start a 3 day weekend of doula training! Yikes! Anyway, absolutely I have some thoughts for you and will elaborate soon.

Hang in there! I'm so glad you met an awesome midwife. In the meantime, before I can write some more, here are some other links [I had emailed her a bunch before] you might find interesting and reassuring:

Recent Canadian study, the most comprehensive yet: http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20090831/home_birth_090831/20090831?hub=Health

And here's another study that came out earlier than the Canadian one, from the Netherlands: http://www.nhs.uk/news/2009/04April/Pages/HomeBirthSafe.aspx

You also might really like this blog, it's one of my favorites: Stand and Deliver. The author happens to be LDS, too, and is a PhD in the study of American medical care and environmental issues. Browse around!

More to come . . .

Anne

PART TWO:

Okay! The dust has settled a bit. Sorry, you just caught me at a particularly crazy time!

Did you have a chance to look at those studies and the blogs? How did you feel about them?

But ya know, I can inundate you with tons of compelling blogs and studies and articles, and it still may not quell the deep-seated fear you're worried about. Right? I totally get it, I do. Like, yes, it may have been shown in a number of studies (and it is) that for low-risk women with qualified CPMs, home birth outcomes are just as good if not better than their hospitalized counterparts - but . . . what if YOU are the one exception? WHAT IF? And that's a valid question, and I think it does a disservice to both you and, less importantly, to home birth advocates to act as though it's not, or, even worse, pretend to give you any kind of guarantee.

The first thing I would tell you is to talk about it with the great midwife you said you found, or, if you've already talked about it, heck, talk about it with her some more, seriously. Midwives are very used to this, and any good one should be willing to take their time with you on this matter (or any matter that concerns you - this is one of the best things about midwifery care; I got a MINIMUM of an hour per visit, often more, as opposed to the 5-10 minutes you typically get with an OB*). I talked with Nancy quite a few times about transfer and how that would work, and under what circumstances.

Nancy's rate of transfer was about 15%, and most home birth midwives, from everything I've read, average between 10 and 15%. I was actually kind of pleased to hear that she was on the conservative side - to me, that meant I could be reassured that she wouldn't be taking any chances. Really, I think that CPMs who do "take chances" are extremely rare, but it's always good to talk to your own and find out what her rate is, and what that means. Many CPMs will share their statistics right up front. With Nancy it was right in the materials she gives out to every client on the first visit. (Try getting an OB to disclose the same.*)

We talked in detail about what kinds of things would warrant a transfer. Some things are absolutely non-negotiable and obvious, like the rarity of a prolapsed cord (I can give you examples of when and how a transfer under this circumstance would work if you like). Some are very common, such as persistent late decels; it's just a matter of timing, and deciding when to leave. There are a few things that actually will vary: Nancy would transfer any time there was meconium in the amniotic fluid, even if there were zero other signs of distress, whereas some other midwives don't feel that this is always necessary. Again, talk to your midwife about this! I think it's important to feel comfortable with her philosophy, not to mention that you can always tell her, as well, that you absolutely want to err on the side of caution (which they do anyway, but you know what I mean).

One thing Nancy also made clear to me is that within that 15%, very, VERY FEW of these transfers are actual emergencies. She has only had to call for an ambulance a few times in her entire career, and she's extremely experienced. MOST transfers can be done in a calm, if not exactly leisurely fashion. Ask her about this as well.

That reminds me of one other point: I blogged recently about the difference between a freestanding birth center and a home birth,. A midwife wrote this: "When a dad/partner/relative tells me s/he/they would have no problem having a baby in a birth center, but wouldn't be comfortable at home, I let him/them know that I carry the same equipment that is at the NACC-certified birth center downtown (minus the sedatives). The difference is *I* carry the equipment into their house instead of them getting up, in labor, and heading out into the elements, driving to the birth center. It often comforts them to know this. I have even gone so far as to open my kit up to show a skeptical nursing relative. It is very important for everyone (who will be at the birth) to feel 100% comfortable with the parent's choice to have their baby at home."

So it's the same 'stuff'. Either they schlep the stuff to you, or you schlep yourself to them. And thus, forgive me for quoting myself, but I think it's relevant: "I could see myself choosing a birth center for one of two reasons: if it were closer than my home to a good hospital; or if my home at that moment were not a good setting for whatever reason - recent move leaving the place in a shambles, tiny apartment with thin walls, something along those lines." So I would factor the former into your decision as well. Is a birth center closer to the hospital than your home, by more than a few minutes? If so, that IS something to consider.

Still, the central fear in your gut: What if you need a c-section in 2 minutes instead of 10? Okay. Again, I feel you. It's so hard to distinguish sometimes, how much of that is a real, genuine, authentic gut feeling, and how much of that is the fear that comes from our conditioning and our culture, and the medicalized model of care that has been so deeply ingrained in us all? That's not easy to shake off. I CAN tell you, as I suspect your midwife would, that a real, out-of-the-blue, code RIGHTNOW - without ANY prior warning - is very rare. In the vast majority of cases, there are going to be signs, and a qualified midwife will be vigilantly watching for them (you know that intermittent auscultation is every bit as effective as cEFM, and in fact reduces morbidity resulting from increased c-section rates) and will recognize when to make a timely transfer.

But does it happen? Yes it does. INCREDIBLY rarely, but it does. So what happens if you're in a hospital? Let's say there is a cord accident (soooooo rare), and, as you said, you need a section in 2 minutes instead of 10? Well, you've spent time in a hospital rotation. What's the minimum amount of time it takes to scrub in and set up? Rixa of Stand and Deliver (which I mentioned to you earlier) wrote this (in the comments on that thread):

It's important to know that not all hospitals can respond similarly to obstetric emergencies. It's not like there's a generic "hospital" experience when you need a crash c-section. ACOG's rule is that you need to be able to perform an emergency c/s in 30 minutes or less.

My local hospital does not have an in-house OB or anesthesia; if there's an emergency, they have to be called in. During my hospital tour, the nurses said the fastest they have ever seen a c/s done is 10 minutes from decision-to-incision (for a cord prolapse). That's probably not typical nor normally reasonable; it depends how far away the OB and anesthesiologist are at the time of the emergency. Really, if the only "safe" way to give birth is to have access to a crash c/s in 10 minutes or under (and really, if the baby's oxygen supply is totally cut off, 10 minutes is too long), then all women should have to give birth in a tertiary care center with 24-hour in-house OB and anesthesia (which ACOG has recommended for women doing VBACs, despite the lack of evidence that this round-the-clock access improves VBAC outcomes). Of course that's not feasible or reasonable at all. In short, the public has this impression that if you're in a hospital, the staff can immediately respond to any emergency--which is not the case. It takes time to set up the OR, to assemble the surgical team, to prep the mother.



So, from decision to incision, you're not going to get a c-section in 2 minutes no matter where you are. These are the extreme minority cases where, sadly, being in the hospital would not make a difference.

But here's the practical: So, let's say you are going to need a c-section, because such a need does sometimes happen, of course. Much of that setup and scrub-in can be taking place while you are en route to the hospital. Yes, there is prep that needs to happen to you, physically, but again, you've seen it yourself. A lot has to happen besides what happens to the mom. Talk to your midwife about how such transfers take place when they arise for her. This is one of many reasons good relationships between midwives and doctors/hospitals are so important, and they do need to be improved, no doubt, in some areas more than others.

How about one other scenario that is often raised as a concern? Let's say baby is born and doing fine, but mom has a postpartum hemorrhage? The immediate response from a CPM is the same as it would be in a hospital, including Pitocin (intramuscularly) and fundal massage, and if necessary, bimanual compression, which can be maintained during transfer if transfer is deemed necessary. From there transfusion could be done (if needed), etc. I am totally not trivializing this - it needs to be taken seriously, but do be aware that a common cause for PPH is cord traction (forcibly removing the placenta by intentionally pulling on the umbilical cord), causing placental separation before it detaches normally on its own, which happens far too often in an actively managed third stage. (Yeesh, right?) Again, talk to your midwife about what steps she would take.

Marsden Wagner (himself a perinatologist) wrote in "Born in the USA" that saying that you need to have an OB for a low risk, uncomplicated pregnancy is like saying that you need to hire a pediatric surgeon to babysit a normal, healthy kid. Because what if something goes wrong?? We get in our cars every day, with our children, knowing that there IS a risk that we will get into an accident. To say that there's not is just untrue, but we have weighed the risks and benefits and decided that in the context of our lives, it is worth the risk to be able to drive.

As I've said before, can you imagine if, every time you went to get into your car, people ran up to you and told you about the worst accident they've ever seen or heard of? Yet people do exactly that to pregnant women all the time. People choke to death eating food, but we don't go to the hospital every time we eat a meal, "just in case", because eating is a normal bodily function that, most of the time, goes just fine. But to deny that choking IS a possibility is dishonest. I can go on with analogy after analogy, but you get my drift.

I hope this all helps you sort this out! I really can understand having the concerns you describe, and I want to emphasize that though I tried to address your concerns and some specific scenarios, I still cannot give any guarantee. It really does boil down to recognizing that there ARE risks in either choice, as with life in general, and what you and you alone have to decide is which set of risks you are comfortable with.

Keep me posted! I wish you the best no matter what!

Anne


* P.S. I don't mean to rag on OBs too much - please know I'm aware that MOST of them are good people who genuinely believe they're doing the best thing for women, and I'm grateful we have them when we DO need them in high risk situations or with complications, i.e. when their care is most appropriate, even if I do disagree with many of their beliefs and practices regarding low risk, normal childbirth, a.k.a. "active management". There are many brilliant and wonderful ones out there, despite a few bad apples.

*****

I hope my fellow birth advocate readers out there approve! Especially any midwives or scholars - I pray that my information was accurate and fair as much as it was encouraging.

9 comments:

  1. I wish I would have talked to my midwives more. I chose mine because there is only one birth center where I live and my health insurance would only cover hospital or birth center midwives, not homebirth. My midwives treated me fairly inconsistently with how I would expect midwives to operate. There was one midwife and one student midwife present. The head midwife kicked out my support team except for my husband (who happend to be drunk and fell asleep) she then left the room leaving me to labor for 5 hours ALONE! After the baby was born, the cord was tractioned 12 minutes pp and that led to a pph If that wasn't bad enough the midwife let me bleed out fo 2.5 hours and never once checked to see if I tore (had a second degree tear when I got to ER). I lost 4 pints of blood and received 3 blood transfusions. I developed an infection and spent the first 9 days of my daughter's life in the hospital hooked up to 17 wires or IVs. I am still pro home birth and believe that if I had been choosier about a midwife that this would not have happened to me. I know that sometimes these things happen but I really feel that in my case it was mis(or over) managed birth. I will definitely be having a home birth next time around. I have been assured by other midwives and an OB that I am not high risk because of previous pph. I just want women to research their midwives just like they would OBs. I made the assumption that midwives all followed a mother centered model of care and I was wrong. Midwives like the one I had give midwives everywhere a bad name.

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  2. "Midwives like the one I had give midwives everywhere a bad name." I couldn't agree more! I'm so sorry you got such crappy treatment. Midwives are definitely not all created equal, that's for sure - it is always worthwhile to interview any potential care provider thoroughly.

    I hope you have a positively transcendent experience next time!

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  3. Anne, I think your information was fantastic, and actually answered some of MY questions about home birth - like what if I start bleeding or what if there's a prolapsed cord? Thank you. I hope the information helped your family member.

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  4. That's great that she found a midwife. Doing a birth at home with a competent, skilled, and compassionate midwife sounds wonderful.

    I hope she feels more comfortable with her decision as the time gets closer, and that she and her baby both have an awesome and safe birth!

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  5. I like how you handled this. I think that you can definitely support your position with out trying to "talk someone into it."

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  6. Deanna, glad to be of service, in some small way!

    Thanks you guys. I'm always hyper-conscious of the often fine line between making a strong case for something and standing by your beliefs, and being overbearing and pushy. I'm sure I won't always succeed, but I'll always try.

    Morgan, I hope so too! Perhaps, if she's inclined, I can have her guest post her birth story.

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  7. I did have a transcendent experience :-) I had to find the strength within myself because I didn't have any one else helping me through it. I have my birth story on my blog although I have yet to write about the aftermath because it is still too painful.

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  8. I just read your story, such a great one! Thanks for sharing that! If you ever do decide to write out the aftermath and want to share, let me know. I'd love to read that too.

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  9. I know I'm late commenting on this but I just found this blog. I think this was a good letter and hope your relative found it helpful. One thing that I always do when describing to people why I choose homebirth over hospital birth (my whole family is obsessed with the worst case senarios) is break it down into something non birth related (and usually abstract) so they understand the statisical nature of it. One example I've used:
    You have two boxes in front of you and you must put your hand into one. The left box has a 1:100 chance your hand will be hit with a hammer. The right box has a 1:75 chance your hand will be hit. Even though it makes sense to choose the right box (homebirth/midwife/birthcenter) there is still a chance you might get hurt, but you've choosen the situation that puts you at the least risk of that.
    It doesn't make any sense to choose the left box (hospital) just because I MIGHT get hurt on the right box, I'm MORE LIKELY to be hurt on the left one! With birth we don't have a choice of a 'perfect choice' any choice we make has some statisical likelihood of injury/death, the 'right' choice is a balance between what makes a woman comfortable and what is least likely to cause injury/death. Of course, I'm overly logical, so to me, the 'facts' on a matter ARE what make me comfortable. :)

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