The Homebirth Difference for Birth Trauma, Video Illustration

In a very short time, my post How Homebirth Benefits Babies has jumped to the #1 most viewed spot on my blog stats. I am working on a couple of posts inspired by some things that were said the comments on it, with respect to how we view the mother and baby's needs, as well as some thoughts on homebirth midwifery legislation.

In this post, I would like to illustrate one way homebirth causes less trauma to babies with some videos. Hospital births often involve the medical provider being very hands-on with the baby as it is born, pulling it out of the birth canal. The obstetrics textbook I had to read for my Hypnobabies Instructor training described the procedure of how to "deliver" a baby with, what seemed to me to be a lot of pushing and pulling on the baby. I had a homebirth midwife tell me that her goal is to "touch your baby as little as possible." In a birth with minimal disturbance, the baby will almost always emerge spontaneously, needing only to be caught, or, in a waterbirth, lifted out of the water. Of course, there are times when a pair of skilled hands is needed, for example, to help get a shoulder unstuck, but in most cases, avoiding pulling on the baby is ideal.

This video is made by chiropractors to explain the benefits of neonatal chiropractic adjustments to correct trauma caused by common birth practices. Some may find the angle the narration takes to be extreme, but the video footage itself is quite powerful. Some of the births it shows are typical hospital births, and some involve more extreme measures, which may be disturbing to some (TRIGGER WARNING).

Birth Trauma from Centre Quiropràctic Molins on Vimeo.

Contrast that with these homebirth videos

This is a home waterbirth video of a first baby, where you see the baby just slide out.



This video shows a homebirth in a sidelying position, where the midwife gently catches the baby:

The True Beauty of Motherhood

A big thank you to Women in the Scriptures for sharing the link to Beauty Redefined, a project seeking to help women discard society's myths about beauty and focus on recognizing that true beauty is more than skin deep. They are preparing to launch a billboard campaign in Salt Lake City. I haven't been to Salt Lake in a while, but apparently, there are a lot of billboards advertising plastic surgery these days, and those plastic surgery businesses are very successful. So successful, in fact, that Forbes classifies Salt Lake City as the "vainest city in the nation." In Mirror Mirror on the Wall, Salt Lake City is Vainest of them All?, Beauty Redefined discusses one plastic surgeon's explanation:

One SLC plastic surgeon, Dr. Brian Brzowski, told hypervocal.com he believes the intense interest in breast implants can be attributed to both the fact that women have babies at a younger age than the rest of the nation and that Utah women lead an active lifestyle. “A thinner, fitter populace tends to have less breast fullness. This can complicate clothing choices and make fitting into swimsuits and the use of padded bras more of a reality,” he says.

While his point about young mothers is very accurate, the latter point about the thinner, fitter populace and their troublesome small chests is a bit off the mark, in our opinion. Sure, it might be true that a fitness-oriented population might not have as much ”breast fulness” as the rest of the population, but the assumed “complicat[ions]” of that fact are what’s bothersome. Women shouldn’t need to “fit into” swimmingsuits – swimmingsuits should fit THEM. And why the use of padded bras? Why the unquestioned, unchallenged pressure to visually enhance the parts that have likely been instrumental in nourishing the babies they’re so proud of? Why is the appearance of breasts such a dominant concern?

(And no, the emphasis is not mine, it is bolded in the original, though I wholeheartedly agree with the emphasis.) I could write a lot about this topic, but I want to expand on something briefly touched on here--the focus on appearance over function. I believe that a very large part of true feminine "positive body image" involves appreciating not the way the female body appears to the world, but all of the wonderful things the female body can do.

My breasts may not be up to some ridiculously unrealistic standard of "beauty," but I appreciate them for comforting and exclusively feeding my two children for six months each, being their primary source of nutrition for six additional months, and continuing to be a source of supplemental nutrition and comfort for a few months further. Breasts that can nourish children are, no matter the size or shape, far more beautiful than the perkiest, silicone-filled, sex objects on the market. Breasts are beautiful because of what they do.

My own husband was once trying to explain how I was still "sexy" to him when pregnant. But in the course of explaining, he discovered that it wasn't really "sexiness" but actually real beauty. Even though at the time I did not have the same body I have while not pregnant, which he is very attracted to, I was beautiful to him in a different way. It was beautiful to him that I was carrying his child--the beauty of true love manifested in physical form, the beauty of motherhood. The beauty of me as "pregnant wife" is more than the outward appearance. It stems from my husband's deep love for me and appreciation of who I am--his wife and the mother of his children, which, during pregnancy, happens to be obvious in my physical appearance.

This conversation shows me a lot about what true beauty really means. True beauty may sometimes be visible on the outside, but usually not in ways that society recognizes as beautiful, with our distorted, unrealistic images of what a beautiful woman is. True beauty is who you are.

"[F]or the Lord seeth not as man seeth; for man looketh on the outward appearance, but the Lord looketh on the heart." (1 Samuel 16:7)

How Homebirth Benefits Babies

EDIT 8/28/11: Things are not always as simple as they first appear. There are multiple sides to every story. I have written a follow up post to this one that looks at another study that is relevant to the homebirth research I cite here: Homebirth Research: Another Side of the Story. It is important that you read it as well because what I talk about there has implications for everything I wrote about here.

I believe that having a good birth experience is and should be a factor in women's decision-making about where to give birth. But I don't believe it should be the primary factor, and don't believe it is for most women, including those who chose homebirth. There is no doubt that for a women who wishes to avoid medical intervention as much as possible, the experience will almost always be better in her own home where she can feel more in control of what is done to her and it is easier to relax. However, some women (myself included) would be willing to give up these advantages to themselves if it equated to better outcomes for the baby.

So, the question is, how does homebirth affect babies? Does being born at home harm them, have no effect, or help them? Theoretically, homebirth is a "more peaceful transition" and the baby "benefits from the mother's lack of trauma," but is there anything clinically measureable? What follows is my attempt to answer these questions with research. I have included citations and links to all the studies I cited so you can look at them yourself and make your own judgments about them. What I have linked to is what I read--in some cases full studies, and in others an abstract or the results cited in another article.

Clinical benefits of homebirth for the baby:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6). Babies of mothers who plan homebirths also:

• are less likely to require resuscitation at birth (2, 3, 4)
• are less likely to take longer than 1 minute to establish respiration (4)
  
• may have higher 5 minute APGAR scores (4, 6)
• are less likely to need oxygen therapy beyond 24 hours (2)
• are less likely to experience meconium aspiration (2)
• may be less likely to be admitted to the NICU (1, 3) though in one study (1) this difference disappeared when the data was controlled for risk factors
  
• are less likely to be born by cesarean, forceps or vacuum extraction (4, 5)
• are less likely to have birth trauma (2)

Why the differences?

Some possible explanations for the differences in neonatal outcomes:

• Women who plan homebirths are less likely to have obstetric interventions, including electronic fetal monitoring, augmentation of labor, assisted vaginal delivery, cesarean section, and episiotomy (2).
  
• Women who give birth at home feel more free to move and be upright during labor, which can promote progress without the use of oxytocin augmentation (7), thereby avoiding pitocin's potential side effects on the baby.
• Women who give birth at home are not under any pressure (direct or subliminal) to push in a bed. Studies show that upright birth results in a shorter pushing phase (8), higher APGAR scores, and lower arterial pCO2 with unchanged pO2, which indicates less transient cord compression (9).
• Women who give birth at home are not given any pain medications that have effects on the newborn's breathing or that increase the need for assisted delivery (10, 11). The vacuum extractor, the most common method of assisted delivery used today, is associated with slightly higher rates of neonatal cephalhaematomata and retinal haemorrhages (12)
  
• Babies born at home do not have their cords cut immediately. Academic OB/GYN has covered the research about cord clamping timing--see this post and these videos. In my experience, delaying cord clamping in most hospitals is much easier said than done, though hopefully this is changing.
  
• Babies born at home are almost never separated from their mothers. Most hospitals fail to implement immediate skin-to-skin contact as standard practice, despite the well-documented benefits for the newborn, including a positive impact on breastfeeding rates, breastfeeding duration, temperature regulation, cardio-respiratory stability, and infant crying (13).

It could be questioned whether the good outcomes were more related to midwifery practices than the place of birth. Some argue that midwives working in hospitals where there is immediate access to emergency care could get better results than they get at home. One study (2) found better outcomes for homebirths when comparing between home and hospital births with the same cohort of midwives. The difference could be attributed to different patient preferences in the two groups, such as a desire for pain medication in the hospital group. However, as I learned in my first birth, sometimes women who desire low-intervention births find that the hospital environment and protocols make this more difficult. Hospital policies often require providers to intervene in certain situations, such as slow or stalled labor, prolonged rupture of membranes, or a certain amount of time passing between full dilation and birth of the baby. Homebirth protocols are usually less restrictive, allowing more women to birth without intervention (without compromising results, if the protocols they are using are appropriate). Theoretically, women who birth at home will need intervention less often because being in a low-stress environment with minimal disturbance will promote optimal labor hormone release, resulting in less protracted labor and better natural pain control. And the research I've cited here indicates that when birth can safely occur with less intervention, better outcomes for babies result.

baby boy two hours after homebirth
(image originally uploaded by Fretwurst)

Some Caveats

Of course, it is important to recognize that we are talking about low risk birth here. Some higher risk women probably are taking an increased risk to their baby by choosing homebirth. I don't think all of them are necessarily "all about the experience" either. Most of them, I believe, are in a situation where they are certain or nearly certain to have a cesarean if they birth in a hospital, and they believe that the risks of surgery do not outweigh those of vaginal birth with their increased risk situation. However, these higher risk births would be much safer if they had immediate access to emergency care while still being able to give birth vaginally. While I am saddened by the lack of options for these women, homebirth is not meant to be a last resort for those in unusual circumstances that cause them to feel that the safest birth for them (vaginal birth in a hospital) is not an option.

It is also important to note the qualifiers "under a supportive system" and "with a qualified attendant." I believe it is very important to have a well-trained person you can trust to help you determine when intervention is truly necessary for the safety of you or your baby. The majority of homebirth research I have cited here is international. Many other countries have different requirements for midwife training than what we have in the U.S. In most of the countries where large-scale homebirth research has been done, homebirth midwifery is integrated into the maternity care system, allowing for smooth transfer in the event of an emergency. In the U.S., it is very important to ask questions about your midwife's qualifications, and be familiar your state's laws about direct entry midwifery (see Citizens for Midwifery) and requirements for licensure. Twenty-two states currently do not license direct entry midwifes. If your state is one of these, The Big Push for Midwives, is a resource that may help you get involved if you are interested. The requirements for the national direct-entry midwifery credential (Certified Professional Midwife or CPM) have been criticized for not being extensive enough, and are currently going through a revision process. It is also important to take into account the attitudes towards homebirth in hospitals in your area, as many in the U.S. are not supportive, which may interfere with transfer and care after transfer, should it become necessary.

Please review the the studies below, and, as always, consult with a qualified medical provider to help you make decisions about your care.

References:

• Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
  
• Outcomes of planned home birth with registered midwife vs. planned hospital birth with midwife or physician
• 3. Ontario study, outcomes cited in this article
• 4. A matched cohort study of planned home and hospital births in Western Australia 1981–1987
• 5. The Farm Study
• 6. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
• 7. Ambulation vs. oxytocin in protracted labor: a pilot study
• 8. The Squatting Position for the Second Stage of Labor: Effects on labor and on Maternal and Fetal Well-being
• 9. A comaparision of fetal outcome in birth chair and delivery table births
• 10. Epidural vs Parenteral Opiod Anestheia on the Progress of Labor
  
• 11. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid anesthesia: systematic review
• 12. Vacuum extraction versus forceps for assisted vaginal delivery (Cochrane Review)
  
• 13. Early skin-to-skin contact for mothers and their healthy newborn infants

Here is the link to the follow up post again: Homebirth Research: Another Side of the Story

Blessingway Traditions

(I have accidentally posted this post twice before when I didn't want to. Sorry for any confusion or RSS feed issues!)

A blessingway is a gathering to honor a pregnant woman. It is loosely based on the Navajo blessingway, which is a religious ceremony to celebrate various life passages, of which giving birth is only one. The natural childbirth community has adapted this idea to develop their own celebrations, which are very different from a traditional Navajo blessingway. Out of respect for the Navajo, some choose to use alternative terms for the gathering, such as "Mother Blessing."

A blessingway is different from a baby shower because the focus is on supporting the woman as she prepares to give birth. There are no gifts for the baby and no melted candy bars in diapers (I've always found that game disturbing). Sometimes the mood is one of a fun and lighthearted girl party and sometimes it is more spiritually-focused, depending on how the mother wants it to be.

I fell in love with the idea of blessingways when a mom planning a HBA2C on my natural childbirth forum told about hers. I later read the book Birthing from Within, which also discusses blessingways and gives ideas for activities to do at them. I would have loved to have one with my last pregnancy, but we moved here when I was about 3 months along and I didn't feel like I had formed friendships close enough with people here to invite them to something that seems so much more intimate than a traditional baby shower. I also assumed I couldn't throw a blessingway for myself, but needed to convince someone else to do it for me (I have since learned that self-hosted blessingways appear to be acceptable.)

With this baby, I will probably not have a traditional baby shower, since we already have everything we need for the baby. I think this is a perfect opportunity for a blessingway, and I have been looking into some various activities that could be included.

Some common blessingway activities, with links to pictures:

• Each guest is asked to bring a bead with some sort of meaning, and then the beads are strung on a necklace for the mother to wear during labor (see Rixa's necklaces she made from her son's blessingway. See also Busca's story about her necklace in Surrender, Part 2)
  
• Making a Quilt for the baby from squares made by each guest (See Rixa's quilt from her son. She also made one at the blessingway for her second daughter. )
  
• Sharing Poems or Positive Thoughts, which can be collected in a scrapbook for the mother to re-read later (A slideshow of Gina's scrapbook can be seen at the bottom of this post at Feminist Breeder)
• Making Flags (see this post and this one)
• Sharing Positive Birth Stories
• Honoring the pregnant woman by braiding or putting flowers in her hair, bathing or massaging her feet, making a belly cast, or painting her belly (see Rixa's blessingway for her son's birth, this post and this post for some pictures)
• Belly Dancing
  
• Making Birth Art
• connecting everyone's wrist with a string, then cutting the string and having each woman keep the string tied there until the baby is born and the umbilical cord is cut (a picture of this is found here, along with lots of other pictures)
  
• making a phone tree so that everyone can receive a call when the mother goes into labor, and they can all light a candle for her
• drinking herbal tea
  
• eating yummy food and enjoying the company of other women (great pictures here, here and here)
  

Some other ideas that I have sort-of come up with myself:

• Making hand-dipped candles for guests to take home and light when they get the call that labor has started
• Decorating a t-shirt or sarong with everyone's handprints and/or positive words for the mother to wear during labor to have their support with her
  

Baby Signing Time giveaway at Enjoy Birth

I first heard of Signing Time before I had kids. One of my really good friends in college was a Special Education major. She took American Sign Language for "foreign language" credit and she showed me one of the videos, explaining that they were produced by well-known LDS producer and composer Lex D. Acevedo (whose arrangements of instrumental hymns I listened to while in labor with my daughter). She also told me a little about the inspirational story behind Signing Time.

Soon after, I was in a language development class required for my Early Childhood Education major, and someone asked the professor about infant sign language. He admitted that he didn't know much about it, but he suspected that teaching children to sign would delay their speech because they would sign instead of talking. He obviously didn't know much about it, so he should have not answered the question. Research indicates that babies who learn sign language have significantly more advanced speech development than their non-signing peers when measured at 24 months and 36 months. There are many other benefits to baby signing, including reduction of aggression in toddlerhood and higher scores on IQ assessments at age 8.

Although I hadn't looked at the research, I was fortunate enough to have my negative conceptions of infant sign language challenged by my wonderful fellow daycare/preschool co-workers who used a few simple signs ("more" and "all done") to communicate with the one- and two-year-olds at mealtimes. I saw that it made it a lot easier to know what they wanted, and my mind was opened to the idea.

When my daughter was a baby, I read a little more about infant signing, and decided it was a good thing to do. I taught her some signs, including "more," "all done," "hot," and "music." (There were a few more I tried to teach, but didn't have enough opportunities to practice them for her to learn to use them). With my son, I have use the sign for "milk" to refer to breastfeeding, which he uses (which cuts down on him trying to pull down my shirt). He also uses "more," though he won't sign "all done" for some reason, though I think he tries to say it. He doesn't have any discernible words yet, but he can communicate some things to me. I want to teach him more, but feel I don't know enough signs to be able to teach him as much as I would like.

Recently, we rented a Signing Time DVD from our local library. Most of the signs were not really useful for a baby, but my three-year-old daughter really enjoyed the songs. She watched it over and over and will show me the signs she learned from it. I think it would be precious if someday she were to meet a child who uses ASL and could communicate some with him or her.

I was excited to see that Sheridan at Enjoy Birth is giving away her used Baby Signing Time DVDs, CDs, and a used BabySigns book. I think these materials would definitely get use at our house--I think my kids and I would all enjoy them! If you think you would like some great resources for signing with your baby, visit her blog to learn how you can win!

Why you still need to take a childbirth class if you're planning an epidural

I hear it all the time. "I hear childbirth classes are a waste of time. I know I'm going to get an epidural, so, what's the point?" Here are the reasons I think women who are planning on getting an epidural should take a childbirth class:

Take pain management into your own hands.
Most women will have to experience some labor before getting an epidural. You never know how long that will be. You may not be able to rely on an epidural to take away all of the pain because:

• You may have a long, uncomfortable early labor. Some providers prefer to wait until active labor (usually 4cm+) when contractions are regular and strong before giving an epidural to reduce the risk of cesarean.
  
• The anesthesiologist may not be immediately available when you ask for the epidural.
  
• If your labor goes very quickly, there may not be time.
  

People always tell women who are planning natural childbirth that unexpected things happen, and it's important to be flexible, but no one seems to mention this to women planning epidurals--why not be prepared for natural childbirth, just in case? Pain management techniques taught in natural childbirth classes are often things you can do alone or with your partner, without having to rely on another person and you don't have to be in the hospital to use them--you can use them at home waiting for contractions to get regular, and in the car on your way to the hospital.

Epidurals Don't Always Work
Two of my first interviews with potential doula clients were with women who had negative epidural experiences where the epidural did not provide the pain relief they were looking for. These women had no other coping techniques prepared. They were both looking for a doula because they wanted other options for pain coping and were hoping to have natural childbirths rather than risk having a non-functional epidural again. I believe every woman who wants an epidural should be able to have one, and that it will work goes without saying, but this is not always what happens. If these women had prepared some natural pain reduction techniques, it is possible that their births would have been less traumatic

Also, it is important to take into consideration that pushing usually works best if the mom can feel something. Without some sensation, it is difficult to know when to push. The dose of the epidural is often turned down or off during pushing. It can be hard to know exactly how much medication is needed to achieve the right balance. If your goal is to feel nothing, an epidural may not actually live up to that promise.

A Good Childbirth Class Might Change Your Mind
I have said before that it is a common problem to "not know what you don't know." For the majority of my first pregnancy, I was absolutely positive that I wanted an epidural. I wasn't exposed to any good reasons why I might want a natural childbirth until late in that pregnancy. Once I discovered those reasons, I had an extreme paradigm shift. I had to scramble to try to prepare for a natural birth at the last minute. A good childbirth class will explain why many women consider natural childbirth desirable and help you gain confidence in your abilities not only to cope with labor, but also to make informed decisions for yourself and your baby.

What Makes a Good Childbirth Class?
In my opinion, you are not getting your money's worth if your childbirth class doesn't cover

• the normal course of an undisturbed childbirth and why medically interfering in this process (to start labor, to speed labor, or to remove sensation) leads to the need for more and more medical procedures,
  
• honest information about the benefits and risks of common obstetric interventions (such as pain medications, labor induction, labor accelerating medications, artificial rupture of membranes, restricting food and drink, intravenous fluids, continuous electronic fetal monitoring, episiotomy, etc.),
  
• how to make sure your provider and place of birth will support you in the kind of birth you want,
• your rights as a patient to informed consent for medical treatment and, in some cases, to refuse treatment,
  
• more than one class period spent on pain management/reduction techniques. If you go over two or three breathing techniques and do one guided relaxation in class and then get a handout with some more ideas to practice at home, this is not enough!
  

Why not?
So, why not take a natural childbirth class? If you end up deciding to make natural childbirth your goal, the class will have given you valuable information and techniques to give you the best chance of meeting that goal. And if you decide you still want an epidural, you will be confident that you made that decision after truly considering all your options, and you will have good coping techniques to use in the time before you get the epidural, and to help you do the best you can if unexpected circumstances arise and the pain relief you want is not available to you.