Torn: Birth Center after Home Birth???

[mum2sarah]

Tonight I attended an orientation at the only freestanding birth center in my geographical area.  I'm seriously considering a birth center birth, even though my last birth was a perfect homebirth... Mainly it's due to financial reasons: I don't think I can afford another homebirth.  Plus I'm a little nervous that it will have been 7 years since my homebirth & what if it's more complicated this time or my body forgets what to do?  And... we really want to know the sex this time....

I know those are all stupid reasons... Frankly I think I could have a successful unassisted homebirth, because essentially that's pretty much what my homebirth was.  We had planned for the midwife to be there, but she lived 1hr 30min away and we did not give her enough notice... We figured it would be another prolonged labor like with my first, so we waited and waited, and finally called her an hour before DD was born, so I pushed when I felt the urge to push and DD was born without complications.  The midwife arrived in time to deliver the placenta, cut the cord and help us get cleaned up.  But I don't know that I want to *plan* on a UC, yk?  I'd just feel better if I knew a midwife was on the way at least (like last time).  So I either have to pay out of pocket for another homebirth or go to the insurance-covered birth center, and those are tough choices....

At the orientation tonight the nurse said they listen to the baby during active labor every 15 min, which I thought seemed excessive and like it would be highly distracting to me and possibly even inhibit good progress.  Plus there's a lot of prenatal testing and such you have to do to be "eligible" to birth there instead of at the hospital...  In general, it seemed like they had an awful lot of hospital transfers (around 40%) and their overall c-section rate (which I guess only applies to the hospital transfers) was something like 17% which I was not all that impressed with in light of the WHO recommended 10%. ... It just seemed to me that the whole spiel was aimed at reassuring first time moms that the birth center is as safe as a hospital, but my concern is exactly the opposite.  I'm worried about it being too much like a hospital birth. The testing and monitoring and poking and prodding was exactly why I couldn't relax and let labor do its thing in the hospital.  OTOH, they have nice cozy rooms with jacuzzis, they let you leave 4 hrs after birth if all is well, and you can labor and birth in any position you wish, nor do they insist on regular vaginal checks during labor.  However, I spoke with the nurse afterwards, and she straight-up told me that women who've had home births already aren't as ecstatic about giving birth there, which didn't seem like a good sign to me...

*sigh* anyone else do a birth center birth after a homebirth?  Were you disappointed?  Do you regret the decision?

[msmiranda]

My question would be (well, one of them anyway):  what do they transfer for?  40% is a very high transfer rate.  I'm guessing that they get a lot of first-time moms who are interested in the idea of, but not really committed to, natural childbirth, and most of the transfers are for maternal exhaustion/desire for epidural.  Which wouldn't apply to you, so it might not be something to worry about.  Same thing with the c-section rate -- if those mamas who decide to transfer for exhaustion/pain relief are then in the hospital where they are put on a clock and subjected to OBs who just want to get them delivered, and they start the whole cascade of interventions, then that rate is not so surprising. You have a "proven pelvis" and a history of quick labor.  As for being risked out, you should find out what their parameters are and decide whether you think you might fall into them.  Some things (e.g. breech, placenta previa) cannot be predicted, but others (gestational diabetes, PIH, etc.) you may know whether you are at risk for or on the borderline.  

I would absolutely do a birth center birth after having had a home birth -- I don't think it's crazy at all.  But maybe you should try to meet with one or more of the midwives who staff this one to see whether you would be a good fit.  I wouldn't necessarily assume from the orientation that they would not be able to help you have the birth you want.  There are a lot of women out there who are interested in natural childbirth and having a midwife, but who are not "there yet" on the safety of OOH birth.  These are probably the women they are trying to woo as clients.  I had my first son with a midwife practice that delivered in a  birth center and a hospital.  They served a low-income clientele as well as (for lack of a better term) professional women, and they did most of their births in the hospital with 70% having epidurals.  But of course what they loved the best was assisting natural births, and especially birth center births.  They respected the wishes of their clients but they would have LOVED to have a mom like you come to them.  So you never know,

[Italiamom]

I'm sorry, I'm confused.  You said this is a freestanding birth center?  Why do they have nurses?  Or are they CNMs?

I think Ms. Miranda makes some really great points about the transfer rate potentially just being about first time moms, but honestly, those numbers seem OUTRAGEOUSLY high.  There are 3 freestanding birth centers in my area, and none of them come even close to those numbers.  I realize that you certainly want to respect a mother's wishes, but it seems like if that many moms are transferring, that maybe the midwives are dropping the ball a bit as far as support.  I know that probably half of my midwife's clients were first time mamas, and the transfer and cesarean rates at her birthcenter are so, so much lower than that.

That said, birthcenters do have the awesome tubs (NO SET UP!!  NO TAKE DOWN!!), and often times outrageously large showers (with seats!), and typically GIANT hot water heaters.  All of those things were sooooo nice to have, at least for me :)

[mum2sarah]

There are 5 CNMs (which is kinda too many IMO), and also a couple RNs that help out. Actually I was a little wrong about the transfer rate--it's closer to 30% but that still seems high to me.  I see what you mean about not having to set up or take down a birth pool, but on the other hand, we toured all their rooms and I felt their jacuzzis seemed a little on the small side.  When I did my homebirth I had a pretty big birth pool and I liked being able to sort of move around into different positions when I was in it, but I don't think there will be that much mobility in these jacuzzis.

I made a prenatal appt with one of the CNMs for next week, so I think I'll try to discuss some of my concerns with her and see if I feel reassured...  I also talked to a friend today who gave birth at the birth center and she insisted it was a very good experience (but then again it was over a decade ago that she birthed there and a lot of the CNMs are different now, and it's even in a different building now).  She went on to have a homebirth with her youngest (after having a birth at the birth center), and she said that she would do a birth in the birth center again, but part of that had to do with the fact that she didn't really hit it off with her homebirth midwife; whereas, I really loved mine...

I guess I don't need to decide yet, as I'm only 8weeks, but it's tough to know if I'll feel comfortable there or not... Maybe I'll have a better picture after meeting with one of the CNMs...

[msmiranda]

Yes, 30% is still a high rate, but I guess what I was trying to say is that there may be some self-selection issues that enter into the calculus.  If part of the selling point of the birth center is, "you can transfer to the hospital and get an epidural if you want it," then they may be getting a lot of moms who are not fully committed to going med-free and that would affect the transfer rate.  Now, if they are pushing mamas to transfer, that would be a whole different story and something to be concerned about.  I have just observed from my few years in the birth advocacy world that there is an intermediate category of women in between the hard core homebirthing types and the hard core hospital medicalized types.  From reading message boards and meeting folks around here, I have definitely gotten the impression that there are a lot of women who are interested in *trying* unmedicated birth but they want to have that feeling of having pain relief available and I think a lot of them end up going for the epidural -- especially first-time moms because their labors tend to be longer.  And it may not be a matter of whether the midwives give good support -- not to criticize anyone who gets an epidural, as I definitely would have gone for that if I had felt I needed it, but I think the level of commitment to not using meds varies and does affect whether an individual woman will choose to transfer.  So lumping those women in with you would be comparing apples and oranges, if that is indeed what is happening.  If they are really on top of things, they will have their transfer stats broken down (primips v. multips, reasons for transfers) so you can see them in detail. 

5 midwives is a lot, but pretty typical for a birth center practice -- there were 4 in the practice where I gave birth to my son, and there are 5 in the most popular birth center practice around here.  Even my homebirth midwife who did my second birth is now a practice of 3 because she was getting so busy.  (Fortunately I like all of them).  Your meeting with the CNM will probably go a long way in helping you decide if this is the right choice for you.  It definitely wouldn't be the same as a home birth, but it's not a hospital with an OB and it's covered by your insurance, so that's two things in its favor!

[Mama Metis]

I see that you're in PA. Have you considered a homebirth with a CNM? I am in PA too and my homebirth is covered by insurance. My midwife is a CNM with hospital privilege, but her practice is almost exclusively homebirth. Might be worth looking into. Good luck!

[sosurreal09]

I had a birth at a birth center and the only real reason I want to do a home birth with my next baby is b/c they wouldn't leave me alone with the damn 15 min heart checks! I had a hypnobirth and this was very distracting.

[MoonJelly]

As far as finding out the sex, you could get care from the birth center (or an OB for that matter) for the first half of your pregnancy if you like and then switch to a home birth midwife.  If you are 35 or over you are eligible for Level I and II sonograms and other pre-natal testing, some of which also tells the sex.  The birth center is probably required to refer you if you are over 35.  Or in the case of some insurance (incl. mine), you don't have to have a referral, you just have to be over 35 to have it covered.

Although I never did "concurrent care" (seeing two providers at once) my homebirth midwife was used to some women doing that throughout the entire pregnancy. 

In other words, I wouldn't let the desire for some amount of medical intervention during the pregnancy be the thing that stops you from having a homebirth. 

[klemomma]

I had a UC with baby #3. Then, I had baby #4 at a birth center that is located within a hospital (but it is an accredited birth center - just not freestanding). So, yes, I would have a homebirth and then a birth center birth :-)

Each birth is different, and circumstances are different every time. Finances can be a big concern. If the cost of a homebirth is a stress factor for you, that can be a substantial issue.

There were things about my birth center birth that annoyed me, yes. But, I knew going into it that none of my most important concerns would be an issue. I knew that, unless there was a serious, real medical issue, I would have a natural, very low intervention birth. No one would coerce me into an epidural. If that is something that goes on at a birth center, but you are firm in your natural birth, have done it before, etc., I really don't think that will be an issue.

Mostly, what annoyed me was people saying dumb things to me. For example, after birth, my baby was skin to skin on my body. I had a blanket over both of us. Her arm wasn't covered. A nurse rushed over to us and covered her arm and told me, "Cold babies crash quickly!" I was like, wth? Obviously, I knew she was warm - we were skin to skin under a blanket! But, really, whatever... It was mildly annoying, but not really a big deal in the grand scheme of things. 

I feel like, having had multiple natural births, I know my own body. I know my own birthing process. I own it, iykwim. It doesn't really matter where I give birth that much any more. I obviously choose a place where it will be as low intervention as possible. I know that I will make informed decisions whatever arises. I can do that at home, at a birth center, or even in a hospital. I don't choose the hospital, because I know I'll have to fight harder and there will be more interventions to turn down, more interventions that are expected, and more annoyance. But past that, I know I'll get a good outcome (obviously referring to my care and decisions, not that I am stating that unexpected or dangerous medical circumstances couldn't arise - of course they could).

Honestly, there were some benefits to the birth center birth also - jacuzzi tub, being fed, etc. All that being said, I plan to choose a homebirth whenever I have another baby.

So, I think you need to go with what feels right to you for *this* birth at *this* point in your life. If a birth center feels right to you, then go with it. You can also make arrangements for the birth center, and then when it comes down to it, UC, that way you have the option. I have heard of women doing that, then calling the birth center midwives and saying, "Oops, it happened too fast! Can you come check us out?" and the midwife coming to their home so that they don't have to transport at that point. Not saying this would definitely work / happen, but it is a possibility.

I would feel out the birth center a bit more, see if you "click" with the midwives, and get some more data on their c-section rates and transfer rates. Also know, though, that if you know your stuff and make informed decisions, you aren't likely to be a part of those rates without medical necessity. Also acknowledge that no arrangement is perfect - a birth center birth brings the possibility of more annoyance and intervention, but poses less financial risk. A homebirth may be a more ideal experience, but at the cost of very real financial stress. Don't feel bad for financial stress being an issue. If it is an issue, acknowledge that and allow yourself to factor that into your decision. We mamas often feel that cost and other factors *shouldn't* be factors, but that doesn't change the fact that in the real world, they are!

Good luck, mama! Trust yourself, and you will figure out what is right for you and this baby!

[mum2sarah]

Originally Posted by Mama Metis 

I see that you're in PA. Have you considered a homebirth with a CNM? I am in PA too and my homebirth is covered by insurance. My midwife is a CNM with hospital privilege, but her practice is almost exclusively homebirth. Might be worth looking into. Good luck!

Unfortunately there's a huge difference in homebirth climate in the western part of PA than there is in the eastern part.  While we're lucky in PA that it's in theory legal to have a CNM  homebirth, in practice, it can't be done in western PA.  In fact none of the CNMs in the area will do a homebirth, and many even spoke out in the papers against a CPM who jailed a few years ago for a neonatal fatality, after the county coroner pressed charges against the parents' will (http://www.pittsburghlive.com/x/pittsburghtrib/news/cityregion/s_595876.html).  There's a very anti-homebirth climate here, and the only midwives you can find to attend a homebirth are CPMs and even they have been driven out of Allegheny County (the county where Pittsburgh is situated).  For my last homebirth, I had a choice of only a couple CPMs and none were less than an hour from my home (thus the reason my midwife didn't make it in time), out in the surrounding countryside where there tends to be some Amish populations that they serve without as much fear of legal repercussions.
 

[mum2sarah]

Originally Posted by sosurreal09 

I had a birth at a birth center and the only real reason I want to do a home birth with my next baby is b/c they wouldn't leave me alone with the damn 15 min heart checks! I had a hypnobirth and this was very distracting.

See, that's exactly what I'm worried about...

[mum2sarah]

Moon Jelly and klemomma,

     Those are good thoughts.  I'm not quite old enough for the over 35 criteria (I'm 33 but will be 34 by the time the baby's born), but the birth center midwives did say that they would do an ultrasound if the mom wants it.  So I guess there's no harm in seeking prenatal care from them regardless of where I ultimately choose to give birth.  And I guess it's not as stupid of a reason as I let on to be worried about the financial impact of paying for a homebirth.  See, I am working right now as a graduate student researcher, but I will finish my masters just before the baby's born, and I'd like to then stay at home as long as possible.  My partner is also a grad student researcher but he's going on to his PhD so he'll have a steady income for at least 3 more years til he starts looking for postdocs/professorships/etc, but for now, his pay is very meager. I'll probably eventually re-enter the teaching field but I'd like to be at home at least for a year or two with the baby, depending on how far we can stretch things financially.  So it's hard to think about paying for a homebirth midwife when that could be another month or so of money that I could use to spend at home with the baby...  I had been pondering (similar to klemomma's example), though it may be somewhat dishonest, I might be able to get away with laboring at home and if I feel like things are going well and moving along efficiently, just do a UC and call the midwives and claim that I didn't realize how quick things happened til it was too late to transport to the birth center without risking giving birth in the car.  They do home visits for everyone a day or two after the baby's born anyway, so it might not be out of the question that they'd come and check up on us if I had the baby at home as an "oops."

[Mama Metis]

Wow I had no idea the environment was so hostile out there. I guess it's lucky that you have the birth center at all! Good luck - I hope you can find a solution that works for you. 
 

Originally Posted by mum2sarah 

Originally Posted by Mama Metis 

I see that you're in PA. Have you considered a homebirth with a CNM? I am in PA too and my homebirth is covered by insurance. My midwife is a CNM with hospital privilege, but her practice is almost exclusively homebirth. Might be worth looking into. Good luck!

Unfortunately there's a huge difference in homebirth climate in the western part of PA than there is in the eastern part.  While we're lucky in PA that it's in theory legal to have a CNM  homebirth, in practice, it can't be done in western PA.  In fact none of the CNMs in the area will do a homebirth, and many even spoke out in the papers against a CPM who jailed a few years ago for a neonatal fatality, after the county coroner pressed charges against the parents' will (http://www.pittsburghlive.com/x/pittsburghtrib/news/cityregion/s_595876.html).  There's a very anti-homebirth climate here, and the only midwives you can find to attend a homebirth are CPMs and even they have been driven out of Allegheny County (the county where Pittsburgh is situated).  For my last homebirth, I had a choice of only a couple CPMs and none were less than an hour from my home (thus the reason my midwife didn't make it in time), out in the surrounding countryside where there tends to be some Amish populations that they serve without as much fear of legal repercussions.
 

[MoonJelly]

Sadly this goes along with what I know from relatives from that area.  These ladies are afraid to lean away from their OB's on anything.  And the hogwash I have heard of what they have been told by their OB's throughout numerous pregnancies is so ridiculous and out-dated it's crazy.  My impression is that it is a highly conservative area when it comes to prenatal care to the point of just being stuck in conventional practices that have been tossed out by most everyone else. 

(edited to say I was referring to post 13)

[mum2sarah]

Moon Jelly, yes, there is a very medicalized culture here.  I think it has to do with all the hospitals and medical education programs in the area (UPMC, Children's Hospital, cancer research, all the nursing programs at Pitt, etc.).  I mean it's great that we have such facilities and expertise for life and death situations.  I was very grateful for Children's , for example, when DD got swine flu and suffered a febrile seizure.  But it makes it very difficult to have natural birth alternatives in the area.... Luckily, in most other aspects of life, there is plenty of diversity and open-mindedness in Pittsburgh... Just wish it would spill over to prenatal and maternal care.