There's some back and forth going between Michelle Goldberg at The Daily Beast and Jennifer Block at Slate about home-birthing. (All the links are here.)
I have mixed feelings about all this. On the one hand, I come from a big midwifery family. My aunt, a former Midwife of the Year, gave me Lamaze classes in her basement, while I was pregnant with Jonah. I come fertile peasant stock. I figured that I would bend down in a field and my kids would pop out. There are way too many unnecessary, c-sections that happen in this country. Sometimes childbirth requires time and patience, which modern medical care does not provide.
On the other hand, Jonah would not come out of me naturally. I was two weeks overdue and big as a house, when I went to the hospital thirteen years ago. They pumped me full of petocin for 24 hours. I still wasn't dilating. They popped my water and still nothing. They stuck forceps in me and pulled me across the stretcher. Still no Jonah. I needed an emergency c-section. When they finally dislodged Jonah's skull from my pelvis, Jonah was really pissed off. He had two welts on his forehead from the forceps. He came out swinging and screaming. The nurses laughed that they never saw a newborn hit a doctor before.
We were also surprised that Jonah was a boy; a technician told us that we were having a girl two weeks before that, even though we told her that we didn't want to know the gender.
Then they realized that they had cut my bladder during the c-section. They shoved Steve in the hallway with the baby and bottle and spent six hours repairing my bladder. My bladder is no longer positioned in my body the way that God intended. That's okay. It works.
So, American medicine sucks AND a home-birth would never have worked for me.
Apt. 11d 
But let’s not conflate midwifery with home births. I don’t know about the US but here in Canada midwives practice in hospitals as well so you do have quick access to medical procedures in an emergency.
I had the girl in hospital with a doctor as it was a hard won pregnancy and I wasn’t about to take any chances. And I have friends who have done the home birth route too. The latter is not that common but I can appreciate that in certain circumstances where it is low risk, it’s a reasonable choice.
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I suppose you were too busy and not up to it at the time, but the traditional American thing to do after that sort of event is to sue-sue-sue. And you probably would have won, too, and quite justifiably.
A blogger’s wife recently lost one twin after an attempted home birth (they eventually went to the hospital). The same thing could easily have happened at a hospital, twins being twins, but still…On the other hand, a friend of mine had her fourth and fifth babies at home and they did fine. I’ve heard once or twice of women doing home births just because of the predictably huge expenses of a hospital delivery, especially after successfully delivering several older siblings without difficulty. In general, for a home delivery I’d want the hospital to be very close and there to be no complications at all and for it to be an experienced mother. My sister had her baby in Germany, and it sounded like their approach is very similar to a home birth. She did 16 hours of labor with no medication, but with goulash to keep up her strength, followed by one of those loooong European stays at the hospital or maternity home (I’m not positive that it was technically a hospital–that was Germany, but in Russia (which has a lot of Western European cultural influences), you’d traditionally have a baby not at the hospital, but at the “birth house” (roddom).) Here in the US, they’d be afraid you or the baby would pick up some sort of super bug at the hospital from a European-style long stay, and they’d be right.
I personally like hospital amenities quite a lot.
One thing I’ve picked up from recent perusal of internet forums is that it’s really bad to wind up in ER getting obstetrical care. I generally like ERs for other stuff but it sounds like the culture there is just very different from obstetrics, and they don’t have a well-developed bedside manner for dealing with obstetrical issues, plus the ambiance is iffy. So in case of a home birth, I think it would be very worthwhile to have plans in place to bypass the ER in case of emergency.
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I was really sick after the birth. It took me months to recover, so I probably didn’t work on the law suit hard enough, but I did talk to a couple of lawyers. They didn’t want to take the case, because my bladder healed. It’s much harder to sue, if they repair you properly.
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Here’s another consideration–there seem to be a lot of mega-babies these days, which is a possible complication. 10-pounders are quite routine among my generation of cousins.
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Sandra is right that we don’t hear about the other options available for birthing like a midwife in a hospital or birth center. These are probably more appealing to most women than home births but are much harder to vilify. I had a midwife in a hospital births and it was a good middle ground. All of the hospitals around here provide that option and it is growing in popularity.
I feel like home birth advocates assume that people will have robust support systems available to them to help out after the birth. I have a very supportive husband but not much else. I couldn’t walk for two days after my second and I know if it had been at home I would have been up and around early than I should have. Being in the hospital helped me feel like it was ok to not move and to ask for help with simple things like using the bathroom.
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A ferocious homebirth advocate would likely argue that you may have handled a homebirth just fine if you’d waited until you went into labor on your own instead of inducing. Few of these people have ever been 42 weeks pregnant.
I personally don’t understand the big debate. True emergencies where seconds matter are rare and sane midwives know when it makes sense to transfer to a hospital with different equipment and expertise. Yet many of us, myself included, are uninterested in homebirth; I wanted to go elsewhere for birth because that way I wouldn’t have to wash the sheets. A birthing center where I didn’t have to worry about doctors and nurses behaving badly would have been nice and it’s a shame that more energy isn’t focused on getting more of them going instead of criticizing other people’s choices between rocks and hard places.
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My friend who recently fired her old OB switched over to the midwives in the same practice. Interestingly, the midwives used the ultrasound machine more than the old OB. They’d roll it in and do an exam, which seems to be standard medical practice these days even very early (for my current pregnancy, my doctor did an ultrasound rather than a blood test to confirm the pregnancy). Meanwhile, my friend’s former OB didn’t use the ultrasound machine himself at all and would send her out for ultrasounds if anything concerning came up, unnecessarily increasing the worry involved.
It’s kind of weird to have an example of midwives who are more technically inclined than a doctor in the same practice, but he seemed to be phoning it in.
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From the first Goldberg article:
“She found a midwife she trusted, Tamra Roloff, a great admirer of Gaskin who owned the local health-food store, THC Organic Market. “She was just like, ‘Your birth is going to be amazing, it’s going to be so powerful,’” Bizzell recalls. “There was a lot of this earth goddess empowering stuff.””
Note to self: never hire a midwife who runs a health food store but moonlights as a midwife. There’s no way one person could both 1) be an experienced enough midwife and 2) run a successful retail operation.
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Also from the first Goldberg piece:
“The danger of a late miscarriage from amniocentesis, a prenatal test for genetic defects, is as high as one in 200, but many women opt for it anyway, with their doctor’s support.”
Goldberg makes it sound like women are pushing for amniocentesis, while their doctors meekly acquiesce. In my recent experience, it can be quite the other way around. I had a good 19-week diagnostic ultrasound with no indications of any abnormalities, but the ultrasound doctor was really quite pushy about urging me to do an amnio, even after I said no a couple different times during the same conversation. The funny thing about it was that given my age, the risk of having a baby with Down Syndrome and the risk of the amniocentesis accidentally causing a miscarriage were roughly equal. I guess either doctors are bad at math and/or this guy really didn’t want to get sued for “wrongful birth”.
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I consider myself someone who would have liked a home birth but was a big old chicken. I also knew I didn’t have good support, and that would have made a huge difference. Once doesn’t want to have to constantly justify one’s decisions, you know? For the first baby, there were some additional considerations, and for the second, I was in freakin’ Maine. I had no friends, much less any birth support.
I had midwives for both births, one ultrasound for each birth as well. Wait, I think I had a stress test including ultrasound at 38 weeks or so for the first. I had hypertension and they put me on bedrest.
My birth plan had two simple words: no cutting. No episiotomy, no c-section if either could be avoided. I took drugs (demerol for the first, stadol for the second). My labors were relatively short–10 for the first (pit-induced), 8 for the second.
The issues for the first child: I would have liked a homebirth and had some support nearby, but we moved 6 days before I gave birth and it was all too chaotic to make a homebirth plan. I didn’t even know where I was going to be living for most of the pregnancy.
Actually, funny story. I was put on bedrest because of hypertension (the fact that it was a heat wave and they made me go to an appointment in freakin’ Borough Park, where I didn’t live and which involved a lot more walking, and *then* they took my BP and it was high didn’t seem to matter to them) (That said, since I was working full-time and moving out of our apartment, I decided that bedrest would be a great excuse not to work). They kept doing bloodwork and one day got the results that said I should come in and be induced. This was the Monday after we moved. I said no, I wouldn’t come in as I didn’t think there was a good enough reason. I think that one midwife in the practice whom I spoke to that day hated me. 🙂 Fortunately, when my water broke Friday night at 3 am, the other midwife was on call. She let me stay home because contractions hadn’t started. But then I got a call at 10 am from the midwife who hated me, and she told me to get my ass to Methodist *immediately*. I said sure, then I took a shower, had some lunch, made some calls, and moseyed in about noon or so. 🙂 Her concerns and mine were different. She was worried about midwife stuff. I was concerned about contractions advancing quickly leading to my giving birth in a car on the side of the Jackie Robinson Parkway. Otherwise, I’d have stayed in Hicksville as long as I liked. What was she going to do? Drive to Hicksville and handcuff me and bring me in?
I guess this is a long way of saying that even though I didn’t have a home birth, I pretty much controlled my labor experience through force of will (pretty much the way I go through life) and choosing the right people to be around me. I was informed pretty well about everything (*except* the fact that I would be ice cold right after birth–no one told me that!!!), didn’t defer to the expertise of doctors or midwives, never really doubted myself and gave myself flexibility. And I’m pretty happy with my experience. I know I did the right thing in the situation I was given. I think a lot of people feel very much out of control, and that fuels a lot of the debate. When you feel like you’re in as much control as you can be, and you’ve done everything you can, it really doesn’t matter. But when choices are taken away from you and/or information is withheld, that’s when all the second-guessing – of yourselves and others – starts.
And sorry for the long comment. This is one of my hot-button issues.
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“but the ultrasound doctor was really quite pushy about urging me to do an amnio, even after I said no a couple different times during the same conversation. The funny thing about it was that given my age, the risk of having a baby with Down Syndrome and the risk of the amniocentesis accidentally causing a miscarriage were roughly equal.”
My feeling was, what would have been the point of an amnio? OK, so you tell me my kid has DS–it’s not like I’m going to have an abortion, so what’s the point of sticking a huge needle that would gross me out into my belly? So, no amnio, no ADP or whatever that was called. I did appreciate the 20 week u/s and finding out the sex and that the kid had 2 arms, 2 legs, major organs in the right places (a due-date-list friend had an omphalocele that required some care during delivery).
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Wendy I love and appreciate your comments and read your blog too.
That said I am taking a deep breath at both your motto and your statement that you controlled the outcome. Your motto was about the same as mine: Avoid a c-section.
I pushed for 4 hours in a (Canadian) hospital with a natural childbirth friendly, quite brand new birthing centre with natural childbirth special nurses all versed in various positions etc. etc. which was known for its low c-section rate.
Sadly my baby came out flat and died 4 days later. She had a tight 2x nuchal cord.
She had been an active, reactive baby in utero and I saw one of the LotR movies twice because she would jump at the Nazgul and it was so happy.
But in the NICU we learned she was deaf, blind, and would never be able to swallow her own saliva. First we stared down the tunnel of lifetime care for her. And then we took her off support and about 22 hours later she died.
So the idea that you controlled your outcome kind of gets to me.
On the one hand, yes, we had some poorly managed care – part of the issue was staffing and that when the distress was obvious, a c-section wasn’t available just then. But we had done research and thought we had good care. It was an outlier event.
The other half of the issue though was that that particular nurse was really really pro NCB and she either ignored or was ignorant about the pattern she saw on the strip (not a low heart rate per se but poor recovery and low variability) and was way more into protecting the low c-section rate than being conservative.
We eventually did not continue with a lawsuit and went through the ombudsman for some changes, so we didn’t really get to the part where you assign legal blame. But I pretty much give natural childbirth activism a good 20% of the blame, because it encourages people to frame their birth plans, like mine, “Avoid a c-section.” I don’t believe that the worst outcome, although gosh, Laura, that sounds pretty darn awful too.
Anyways. I am not anti-midwife in Ontario, where they are well trained, regulated and work as an integral part of the system. A midwife might have caught the distress, depending on her listening skills, or if she had been looking at a cEFM strip she would have for sure.
That said, as a homebirth because my daughter’s heart rate only dipped low at the end — about 5 minutes before it actually stopped — it would really really have depended on her ability to catch the slow recovery.
Having been in that situation and having been a person with a 1:1000 complication, and a 1:10,000 result (because most hospitals would have done a c-section), I have to say that am much more in line with Goldberg’s thinking on this whole movement.
And I think Americans settling for the CPM credential is frankly, crazy, for a lot of reasons.
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“My feeling was, what would have been the point of an amnio?”
So several years later, I’m not twisting a hanky in court, talking about how HARD it is to have a disabled child and how expensive it is and how I didn’t understand what I was doing when I said no and getting a bajillion dollars from a sympathetic jury who wants my life to be easier.
Or maybe doctors are just bad at math. Some of both, probably–isn’t medicine a haven for smart people who are good at memorizing stuff, but not very gifted at math or abstract reasoning?
“so what’s the point of sticking a huge needle that would gross me out into my belly?”
me to ultrasound doc (making appropriate gestures): I don’t want a big needle stuck into my tummy.
doc to me: We only put in as much as we have to.
I’m kind of over-budget here, comment-wise, but in partial defense of the crunchy home birth people, I’d like to paraphrase Gandhi on Western Civilization and say that evidence-based obstetrics is a wonderful idea, but it doesn’t really exist yet. I have a subchorionic hematoma, I was on bedrest for under two weeks, and I’ve since been on a schedule of reduced activity. I’ve done lots of prowling of online support groups and my husband has looked at abstracts of every article he could find on the condition. From the support group forums, I’ve learned that there is an enormous diversity of medical advice for these hematomas. Some doctors encourage restrictions of various kinds, others say that that’s just to make the mother feel better in case of miscarriage, so you might as well carry on normally, and a few prescribe medications in the hope of dissolving the blood clots. Some of the diversity in approach is due to difference in size, location, gestational age, etc., but also, as Wikipedia says helpfully, “There is no known therapeutic intervention.” My husband went through about 80 abstracts on SCHs and there was only one article on treatment. As I recall, it was a study of a couple hundred Israeli women, 30 of whom didn’t do bedrest and the rest who did (the bedrest had somewhat better results, but you can add all the usual qualifications to that statement–no one is going to be able to persuade several hundred normal pregnant women to participate in a randomized trial). Science hasn’t quite arrived on the scene yet.
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I wondered about the doctor who was insisting on an amnio, but if you really answered the doctor by citing a fear of big needles, I can understand why the doctor would feel the question wasn’t answered.
Doctors should say, in answer to the question: “why should I have the amnio?” that it detects Downs Syndrome with high accuracy and that 90% of the people who receive the diagnosis choose to end their pregnancies (I don’t think they actually say this, and it bugs me, but perhaps there’s some rational reason why they don’t, for example that people would interpret the comment as an encouragement of pregnancy termination).
Then, people who will not terminate their pregnancies for Downs can respond that they will not end their pregnancies and ask if there’s any other reason that they would want an amnio. Then, the doctor could offer information about treatment that could follow an amnio (if they are important enough — my impression is not for Downs, but there are a few ultrasound detectable fetal abnormalities that can sometimes be corrected/treated, though not usually the kind that are detected by amnio, i.e. genetic issues).
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True that, AmyP. I had bleeding (never found the source) in my last pregnancy and my OB was like “bedrest!” and I said “but the studies…” and he said “I know but given your history (see lengthy comment above) I’d rather it, both just in case and so you don’t feel like you walked too far.”
In fact (after much more PTL drama) I got off bedrest, walked to the car, into a restaurant, had a steak and caesar, and went immediately into labour. I do blame the anchovies.
On amnio: In Canada they really don’t care if you say no, so we did despite my AMA.
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I didn’t have anything like JennG’s very sad experience, but I also have learned to distrust the conventional hippie birthing advice to stay home as long as possible and have a shower. When my second was about to be born, I took that advice but the whole thing was only 4 hours from beginning to end. It took a long time for me to be seen and get a room and by the time my epidural was working (after half a dozen tries) it was just in time to interfere with the grand finale. (If the same circumstances arose again, I hope I would pass on the epidural–it so wasn’t worth it on that occasion.)
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Jenn, sorry for your loss and your comment.
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JennG – I am really, really sorry.
I said no to amnio, because I wouldn’t abort a Downs baby. Nobody gave me a problem about that.
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bj,
My first answer was “No.” He asked again and my second answer was “I don’t want a big needle stuck into my tummy.” By the third time, he was finally starting to catch on and asked something like, so you wouldn’t be terminating? and we were able to close the discussion. He was a tenacious son of a gun, though.
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Of course I meant thank you for the comment. Sometimes there are stories we don’t tell and the selective reports skew our perceptions of reality. I always appreciate hearing all the experiences people have.
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I had an amnio, because I did believe I would terminate a Down’s pregnancy. I never had to make the decision, so I only know what I thnk I would have done.
I gave birth in the crunchy coast, in a birthing center next to a hospital. They were equipped to do c-sections but not with high level nicu. For me, the advice to go home, after my water broke, take a shower, watch tv, go grocery shopping, visit the bookstore, take the other kid trick or treating (mind the spouse did that. I did waddle to the door with candy) worked out well. I live on the crunchy coast, so my births plan had to explicitly state that I had no particular priorities other then delivering a healthy baby (that I wanted to cede decision making on that t o the doctor, I didn’t mind , being monitored, having oxygen, being induced
if necessary, wanted an epidural). I was induced and did have an epidural (which was fabulous; I felt fully present mentally but only felt discomfort).
It’s no accident that my two were born @12:51, though
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“I was induced and did have an epidural (which was fabulous; I felt fully present mentally but only felt discomfort).”
I had a good first epidural, too (with a 13 hour labor) and had a really nice nap.
It’s so typical that I wound up having a good epidural when I was originally hoping to go unmedicated (stupid childbirth education!) and then just barely got an epidural the second time, when I was totally counting on getting it.
“It’s no accident that my two were born @12:51, though”
bj, is there more to that sentence?
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Jenn, I’m so sorry for your loss. I can’t even imagine what you’ve been through.
By controlling the outcome (and I don’t think I used those words, anyway), I didn’t mean that I through force of will had a particular kind of birth experience. What I meant was that I had a birth experience that I felt responsible for. The experience I had was the one I made happen; it didn’t happen to me. I don’t mean I was proactive in every aspect. I just mean that I own that experience.
I didn’t have a birth plan, actually; my comment was a joke (which I did say to the midwives a few times), but it reflected my fear–I don’t like being cut. Puncture-y, slice-y things freak me out. I would have had a c-section if I needed it, but I didn’t assume that having a 9 lb 14 oz fetus in my 5’2″ body meant that I needed a c-section.
I’m aware of the potential pitfalls of thinking one is smarter than the doctors. I don’t want to be my father. Despite several health problems, he always thought he knew better than the doctors, and he died at age 67 of complications from advanced prostate cancer, which supposedly doesn’t kill people any more. That will always be with me. But when I thought about giving birth, I thought less about what I wanted the midwives to do and more about the kind of patient I wanted to be.
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This seems to be the mothership for discussions of problems with licensing and regulation of midwives who do homebirths:
http://10centimeters.com/
Here’s a post on the problem of thinking “What can go wrong? The hospital is so close.”
http://10centimeters.com/friday-fallacies-the-hospital-is-just-minutes-away/
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“It’s no accident that my two were born @12:51, though”
bj, is there more to that sentence?
Yes, the editor wasn’t letting me add more! (on the iPad).
It wasn’t a coincidence because I went into labor for both a different number of hours before they were born, but since my labor wasn’t progressing, they started inducing (with pitocin)at the beginning of a nurses shift, and the babes were born predictably about 3.5 hours after they started the drip.
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“What I meant was that I had a birth experience that I felt responsible for. ”
This was very much what I experienced, too. But in my case, I think it was an active plan by the medical team at my facility. They guided decision making, broaching decisions as questions (even if they were strongly guiding). Mind you, my doctor thought I had more medical knowledge than I did, which created confusion occasionally, like when she handed me lab results not meant for patients, so maybe not everyone got the same gentle guidance. But I do think the center was set up with the goal of giving patients ownership of their treatment.
Sometimes it was very annoying, because I really didn’t want to be making the treatment decision. I think I recently read something somewhere complaining about this new trend of requiring patients to plan their own treatment protocols. So, both good and bad at different times.
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I had a good look at the archives from 10centimeters.com and learned a few things.
1. The US has a weird situation where the best-trained midwives (certified nurse midwives) work largely in hospitals while home births are primarily done by much less-credentialed midwives (certified professional midwives). Note also how very similar CNM and CPM would sound to the uninitiated–I had no idea until the past couple days that there was such a big difference between different kinds of midwives.
2. It can be really easy to get the CNM credential and a lot of CNMs just don’t have enough medical training to understand when a situation is becoming dangerous and more than they can handle–they’re overconfident because they’re ignorant.
3. The board that governs CNMs operate more as an advocacy group than a self-policing medical organization. CNMs tend to circle the wagons after a preventable tragedy rather than try to identify and expel dangerous midwives. It’s hard-to-impossible for expectant parents to discover if a CNM has a shady past, because there’s no central registry of complaints.
4. Lastly (but very importantly), CNMs are generally not required to carry liability insurance. Hence, if something goes terribly wrong (death or permanent disability or major medical expenses to repair injuries), there is nobody with deep pockets to sue. Requiring liability insurance would be a very important step toward cleaning up the midwife world, as it would hopefully push marginal practitioners out, while easing the financial situation of families that have been injured.
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