I wrote this as an indirect response to two family members (who will probably never read it and would not change there opinions anyway). If anyone feels like reading it I'd love to hear some opinions or suggestions. I tried to tone down the soap-box-ish-ness of it and I know I don't *need* to defend our choice, but anyway...
Homebirth?
I feel very lucky that our family and friends are generally supportive of our plans to have a home birth. I also know that some of them do have concerns about this which is understandable because they care about us and our growing family. It also seems that some of them regard this as a poorly considered or risky choice. Perhaps I am being too defensive, but to me that basically implies they must think either DH and I got caught up in some hippie naturalist trend or that we take the lives of myself and our baby lightly, neither of which could be farther from the truth. In fact I began researching pregnancy and birth over two years ago when we were just beginning to consider trying to conceive. I have read literally thousands of pages from sources such as medical books, anthropological studies and academic research. I don't think I have approached any decision in life more cautiously than I have this one. Although the decision belongs only to me and DH, I still do wish that those close to us at least would understand how we came to make this choice.
There are two ways to consider our birth plans. We have chosen to have a homebirth with a midwife. We have chosen not to have a hospital birth with an obstetrician. There are reasons for looking at it both ways but inevitably it becomes a comparison: midwife versus obstetrician and home versus hospital. In some countries the decision is not so polar but where we live it becomes that way since midwives can not be in charge of a birth in a hospital, due to the nature of privatized medical and liability insurance. Even if that were an option I'm not sure I would take it because simply being in a hospital brings with it some baggage such as the risk of secondary infection and usually a more limited set of options for natural pain relief in labor. So in the end the comparison is between two very different models of care and two very different settings for birth. A planned home birth attended by a trained midwife is statistically as safe or safer than an obstetrical hospital delivery for full-term babies born from a healthy pregnancy. This is encouraged by the World Health Organization and is reflected in the birthing practices of the countries with the lowest rates of maternal and neonatal mortality (the U.S. does not rank in the top 10).
The midwife model of care centers on normal pregnancy and natural birth without unnecessary medical intervention. A midwife provides prenatal counseling and testing as well as support through the entire labor and delivery offering a continuity of personal care that is rarely matched with obstetricians. Midwives can skillfully handle the many variables of a natural birth and can effectively assess if a situation is developing that requires transfer of care to the hospital, rarely under emergency circumstances. Studies of populations matched for lack of risk that compared birth outcomes of healthy pregnancies have shown babies born under the care of a midwife have lower mortality, higher apgar scores, less frequent need for resuscitation, fewer infections and reduced failure to thrive. The mothers also benefit with fewer complications and a faster recovery than their counterparts who birthed in the hospital.
Despite the advantages, midwifery care and homebirth do not make sense for everyone. Midwives are experts on normal birth but obstetricians are trained to handle the complications that arise more commonly if the mother has high risk factors or if unhealthy conditions develop during pregnancy. There is an in depth screening process to be accepted as a client of a midwife and this evaluation of health continues all through the pregnancy. If any conditions develop which seem questionable, the mother must see an obstetrician to receive medical care if needed. Even with a perfectly healthy little baby, it is imperative that the mother also be completely healthy because both are very active participants and need the ability to handle the stress and exertion of a successful labor and birth. Factors such as diabetes, smoking, high blood pressure, malnutrition or heart problems can compromise a mother's ability to birth naturally. In a pregnancy with such risk factors an obstetrician's expertise is essential and the hospital has medical technology on hand to enable the safest delivery. The technology available in hospitals today saves the lives of many women and babies and for that it is invaluable.
This does not mean that a hospital is also the safest place for someone with a healthy pregnancy and no risk factors to give birth. Certain hospital or obstetrical policies and the availability of technology and have lead to a major overuse of medical intervention and a resulting rise in complications. The chance of something going wrong for a healthy mother and baby at home is actually smaller than the chance that something will go wrong at a hospital as a result of over-treatment. Complications that actually require the medical expertise of an obstetrician during a birth which has proceeded naturally are very rare. Prenatal care can predict 85 - 90% of birth complications, very few of which can not be handled by a competent midwife at home. The techniques used by a midwife are equally effective at resolving unforeseen problems and have less risk associated with them than the hospital procedures for handling the same issues. One example of a situation that can not be predicted but can safely be handled at home is shoulder dystocia, when the baby gets stuck in the birth canal. The midwife handles this situation with specific maneuvers that usually involve repositioning the mother onto hands and knees and carefully manipulating the baby to release the shoulder. The methods used by obstetricians tend to be more invasive (such as use of vacuum or forceps) and have greater associated risks. Repositioning is generally not done in the hospital because most obstetricians insist on the mother being on her back. Most women will also have an epidural so they may not have enough mobility to actively participate to that extent anyway. Without the epidural and with freedom to move and birth in whatever position feels best, qualified midwives are able to work through complications in birth to ensure the health of mother and baby. It is extremely unusual that a midwife will need use emergency equipment, but they come prepared with oxygen, resuscitation gear for both mother and infant and other items that can help stabilize a problem for transport to the hospital.
I understand where a lot of the doubts originate, especially for those who feel that they would have lost their baby (or the mother) if they had not given birth in the hospital and had immediate access to a complete medical facility. I certainly do not think they should have had a homebirth - there is value in the comfort they found in the availability of medicine and some had unhealthful conditions during the pregnancy. However, what is generally not recognized when somebody shares this experience is that the vast majority of urgent birth situations following a healthy pregnancy are the product of a prior obstetrical intervention that had an unintended side effect. It is impossible to say that the outcome would have been worse at home because the whole process would have proceeded so much differently. Statistically, these emergencies hardly ever occur under natural birthing circumstances. Interventions such as artificial rupture of the membranes, artificially induced labor and epidurals all have legitimate reasons for use. For example, epidurals can be a valuable option and bring many women a lot of comfort in labor, affording them a better birth experience than they would have otherwise. They also are associated with an increased incidence many negative conditions including fetal distress, maternal hypotension and fever, prolonged labor and malpresentation of the baby's head, all of which require further, sometimes urgent medical treatment. Many women find great benefit from an epidural and the choice to have pain relief is completely valid. The problem is that in a hospital natural alternatives are usually not available or promoted and it is very difficult to find a doctor who truly advocates natural birth.
Actually, comparison study shows that mothers report experiencing more pain with a hospital birth than a home birth. One reason is that in the hospital, pitocin is often used to augment or induce labor and is thought to make contractions about ten times stronger and much more painful. Another contributing factor is that the threshold of pain is lowered when food and water are limited which is a common restriction in hospitals. The unfamiliar environment also causes the body to release stress hormones which work against the production of the birth hormones, making labor both longer and more painful. There are also many non-medical options for pain relief that are utilized at home and often unavailable at a hospital such as a warm tub of water, accupressure or massage, and regular movement like walking. Some hospitals permit mothers to move around during labor but an IV or a fetal monitor can inhibit the mother's natural instinct to find a comfortable position for labor. In addition to being restrictive, studies have shown that continuous fetal monitoring does not improve the outcome over intermittent fetal monitoring and may in fact make it worse by increasing the rate of unnecessary cesarean deliveries for false alarms. Continuing with the theme, it is another intervention that has not been shown to have a beneficial effect on birth outcome for a normal pregnancy.
Giving birth is not risk free anywhere. Our choice to give birth at home with a midwife was made with safety as the primary consideration. We made this choice after a lot of research and consideration of the risks and benefits of different birth options. If I develop any risk factors during the pregnancy or if I go into labor too early or late we will have a back up obstetrician. We will also deliver under the obstetrician's care if our baby is breech or if this were to be a multiple pregnancy. Our midwife we has a transfer rate of 7% with an eventual cesarian rate of 3%. The only mortality that ever occurred under her care was a baby born with severe congenital birth defects that simply was not viable. DH and I have complete confidence in my body's ability to birth naturally and in the care provided by our midwife. I am writing this because I want our family and friends to recognize that this is a careful, informed decision. I hope that those concerned about us understand and respect the reasons behind our choice, even if it differs from their own inclinations. I welcome discussion and questions on this subject and I can provide abundant information or references if anyone is interested.
Homebirth?
I feel very lucky that our family and friends are generally supportive of our plans to have a home birth. I also know that some of them do have concerns about this which is understandable because they care about us and our growing family. It also seems that some of them regard this as a poorly considered or risky choice. Perhaps I am being too defensive, but to me that basically implies they must think either DH and I got caught up in some hippie naturalist trend or that we take the lives of myself and our baby lightly, neither of which could be farther from the truth. In fact I began researching pregnancy and birth over two years ago when we were just beginning to consider trying to conceive. I have read literally thousands of pages from sources such as medical books, anthropological studies and academic research. I don't think I have approached any decision in life more cautiously than I have this one. Although the decision belongs only to me and DH, I still do wish that those close to us at least would understand how we came to make this choice.
There are two ways to consider our birth plans. We have chosen to have a homebirth with a midwife. We have chosen not to have a hospital birth with an obstetrician. There are reasons for looking at it both ways but inevitably it becomes a comparison: midwife versus obstetrician and home versus hospital. In some countries the decision is not so polar but where we live it becomes that way since midwives can not be in charge of a birth in a hospital, due to the nature of privatized medical and liability insurance. Even if that were an option I'm not sure I would take it because simply being in a hospital brings with it some baggage such as the risk of secondary infection and usually a more limited set of options for natural pain relief in labor. So in the end the comparison is between two very different models of care and two very different settings for birth. A planned home birth attended by a trained midwife is statistically as safe or safer than an obstetrical hospital delivery for full-term babies born from a healthy pregnancy. This is encouraged by the World Health Organization and is reflected in the birthing practices of the countries with the lowest rates of maternal and neonatal mortality (the U.S. does not rank in the top 10).
The midwife model of care centers on normal pregnancy and natural birth without unnecessary medical intervention. A midwife provides prenatal counseling and testing as well as support through the entire labor and delivery offering a continuity of personal care that is rarely matched with obstetricians. Midwives can skillfully handle the many variables of a natural birth and can effectively assess if a situation is developing that requires transfer of care to the hospital, rarely under emergency circumstances. Studies of populations matched for lack of risk that compared birth outcomes of healthy pregnancies have shown babies born under the care of a midwife have lower mortality, higher apgar scores, less frequent need for resuscitation, fewer infections and reduced failure to thrive. The mothers also benefit with fewer complications and a faster recovery than their counterparts who birthed in the hospital.
Despite the advantages, midwifery care and homebirth do not make sense for everyone. Midwives are experts on normal birth but obstetricians are trained to handle the complications that arise more commonly if the mother has high risk factors or if unhealthy conditions develop during pregnancy. There is an in depth screening process to be accepted as a client of a midwife and this evaluation of health continues all through the pregnancy. If any conditions develop which seem questionable, the mother must see an obstetrician to receive medical care if needed. Even with a perfectly healthy little baby, it is imperative that the mother also be completely healthy because both are very active participants and need the ability to handle the stress and exertion of a successful labor and birth. Factors such as diabetes, smoking, high blood pressure, malnutrition or heart problems can compromise a mother's ability to birth naturally. In a pregnancy with such risk factors an obstetrician's expertise is essential and the hospital has medical technology on hand to enable the safest delivery. The technology available in hospitals today saves the lives of many women and babies and for that it is invaluable.
This does not mean that a hospital is also the safest place for someone with a healthy pregnancy and no risk factors to give birth. Certain hospital or obstetrical policies and the availability of technology and have lead to a major overuse of medical intervention and a resulting rise in complications. The chance of something going wrong for a healthy mother and baby at home is actually smaller than the chance that something will go wrong at a hospital as a result of over-treatment. Complications that actually require the medical expertise of an obstetrician during a birth which has proceeded naturally are very rare. Prenatal care can predict 85 - 90% of birth complications, very few of which can not be handled by a competent midwife at home. The techniques used by a midwife are equally effective at resolving unforeseen problems and have less risk associated with them than the hospital procedures for handling the same issues. One example of a situation that can not be predicted but can safely be handled at home is shoulder dystocia, when the baby gets stuck in the birth canal. The midwife handles this situation with specific maneuvers that usually involve repositioning the mother onto hands and knees and carefully manipulating the baby to release the shoulder. The methods used by obstetricians tend to be more invasive (such as use of vacuum or forceps) and have greater associated risks. Repositioning is generally not done in the hospital because most obstetricians insist on the mother being on her back. Most women will also have an epidural so they may not have enough mobility to actively participate to that extent anyway. Without the epidural and with freedom to move and birth in whatever position feels best, qualified midwives are able to work through complications in birth to ensure the health of mother and baby. It is extremely unusual that a midwife will need use emergency equipment, but they come prepared with oxygen, resuscitation gear for both mother and infant and other items that can help stabilize a problem for transport to the hospital.
I understand where a lot of the doubts originate, especially for those who feel that they would have lost their baby (or the mother) if they had not given birth in the hospital and had immediate access to a complete medical facility. I certainly do not think they should have had a homebirth - there is value in the comfort they found in the availability of medicine and some had unhealthful conditions during the pregnancy. However, what is generally not recognized when somebody shares this experience is that the vast majority of urgent birth situations following a healthy pregnancy are the product of a prior obstetrical intervention that had an unintended side effect. It is impossible to say that the outcome would have been worse at home because the whole process would have proceeded so much differently. Statistically, these emergencies hardly ever occur under natural birthing circumstances. Interventions such as artificial rupture of the membranes, artificially induced labor and epidurals all have legitimate reasons for use. For example, epidurals can be a valuable option and bring many women a lot of comfort in labor, affording them a better birth experience than they would have otherwise. They also are associated with an increased incidence many negative conditions including fetal distress, maternal hypotension and fever, prolonged labor and malpresentation of the baby's head, all of which require further, sometimes urgent medical treatment. Many women find great benefit from an epidural and the choice to have pain relief is completely valid. The problem is that in a hospital natural alternatives are usually not available or promoted and it is very difficult to find a doctor who truly advocates natural birth.
Actually, comparison study shows that mothers report experiencing more pain with a hospital birth than a home birth. One reason is that in the hospital, pitocin is often used to augment or induce labor and is thought to make contractions about ten times stronger and much more painful. Another contributing factor is that the threshold of pain is lowered when food and water are limited which is a common restriction in hospitals. The unfamiliar environment also causes the body to release stress hormones which work against the production of the birth hormones, making labor both longer and more painful. There are also many non-medical options for pain relief that are utilized at home and often unavailable at a hospital such as a warm tub of water, accupressure or massage, and regular movement like walking. Some hospitals permit mothers to move around during labor but an IV or a fetal monitor can inhibit the mother's natural instinct to find a comfortable position for labor. In addition to being restrictive, studies have shown that continuous fetal monitoring does not improve the outcome over intermittent fetal monitoring and may in fact make it worse by increasing the rate of unnecessary cesarean deliveries for false alarms. Continuing with the theme, it is another intervention that has not been shown to have a beneficial effect on birth outcome for a normal pregnancy.
Giving birth is not risk free anywhere. Our choice to give birth at home with a midwife was made with safety as the primary consideration. We made this choice after a lot of research and consideration of the risks and benefits of different birth options. If I develop any risk factors during the pregnancy or if I go into labor too early or late we will have a back up obstetrician. We will also deliver under the obstetrician's care if our baby is breech or if this were to be a multiple pregnancy. Our midwife we has a transfer rate of 7% with an eventual cesarian rate of 3%. The only mortality that ever occurred under her care was a baby born with severe congenital birth defects that simply was not viable. DH and I have complete confidence in my body's ability to birth naturally and in the care provided by our midwife. I am writing this because I want our family and friends to recognize that this is a careful, informed decision. I hope that those concerned about us understand and respect the reasons behind our choice, even if it differs from their own inclinations. I welcome discussion and questions on this subject and I can provide abundant information or references if anyone is interested.
