Between Worlds: A Birth Story, Part 3

When we left me, I was kneeling on the bathroom floor brushing my teeth. I was still needing to find a comfortable position. We tried putting a stack of pillows on the floor so I could kneel leaning forward on the bed, but that didn't work for me either. Kim suggested I get on the bed and lean forward on the birth ball. That position was perfect. I used the ball to help me rock, sometimes back and forth, sometimes side to side. I started saying "peace" out loud during the pressure waves. Kim said that when I had gotten off the birth ball, the waves had suddenly gone from about 6 minutes apart to 3 minutes apart. They also let me know that Lorri was in about 25 minutes away, and Kristin was coming and bringing the assistant, Kelly, who was a nurse. I felt some strange sensations above my pubic bone--I wonder if it was the baby's head rotating or moving down. I suddenly wanted my t-shirt and pajama pants off, so I took them off, and was wearing my swimsuit top (which I had put on under my shirt after my shower that morning) and some mesh panties I found in my birth kit. Then, I sat up on the bed. It seems like a strange choice of position, but it was really comfortable at the time.

My midwife Lorri arrived. She said she would check my vitals before I got in the tub and went to get supplies. I got off the bed to go to the bathroom and then Lorri came back and took my blood pressure and temperature, and listened to the baby’s heartbeat, and all was well. I got in the tub. The tub was big and deep and I loved how I could get into all different positions in it. I took off my headphones and we played Hypnobabies out loud because I didn’t want to accidently get anything wet that wasn’t supposed to get wet. I reminded my team about the video camera, and my husband filmed me in the tub, including one pressure wave, and then went out of the bedroom and filmed the other people in the house The water in the tub was pretty hot, but I like hot water, so I didn’t really mind, until I had a few pressure waves in the tub and got really hot during them. Kim brought me a cold washcloth to put on my neck to keep me cool, but eventually I just had to get out. I think I went to the bathroom again, and then I was leaning on the side of the tub during a wave and I felt the need to yell at the peak of it. Lorri heard this, and came in. I told her I thought I was feeling pushy. She said to just try to let my body do most of the work and only push when I couldn’t help it. She asked if the water was too hot and I said yes, so she and my husband dumped in a few bowlfuls of cold water. I got back in and the temperature was much better.

Kim was filming now, and my husband knelt near the tubKristin and Kelly must have arrived around this time and came into the room and set stuff up. They were behind me and very unobtrusive. I remember turning around to make sure they were there a few times, because I guess knowing they were there was reassuring for me.

I remember reading once that in some tradition somewhere (I can't remember where), the birthing woman is thought to have to travel to the underworld to claim her baby. The beginning of pushing was definitely the most challenging part for me. Feeling that much power moving through my body was overwhelming, and I didn't quite know how to respond to it. At the peaks of the waves, when I couldn’t help pushing, I would vocalize loudly, because that seemed like the best way to release that intensity. I changed positions a lot, and loved the ease of movement in the water. I usually knelt low in the tub or was on all fours between the waves, and often during them, I had to go to a high kneel and throw my arms around my husband. He gave me Hypnobabies cues which helped me relax better. I remember apologizing for getting him wet. At one point, I was on hands and knees and lowered my face so close to the water that my bangs got wet.

Soon, I felt the baby’s head coming down and I said something like, “The baby is coming out! The baby is coming out!” It was almost like I didn't really expect the intense part to actually end, but the baby moving down meant it was definitely going to. Lorri, who was next to the tub on my left, turned to my husband and asked if he wanted to catch his baby, and he must have said he would because she started giving him instructions on how to do it. I switched from kneeling to a deep squat. With the next wave, pushing just happened. I roared, and the head became visible. I remember saying something about how excited I was that we were almost there. As the head crowned, I leaned back, letting my legs float forward in the water and my head rest against the edge of the tub, supporting myself with only my arms and head, while the rest of me floated. With the next wave, the head was out, and with the one after that, I eased the shoulders out, and out came our baby at 8:39 pm!

My husband lifted the baby out of the water, and I sat down in the tub and took my baby into my arms. He looked to see if it was a boy or girl, and exclaimed, “It’s a girl!” I was shocked because I had myslef convinced it was a boy! She gave a small cry and then got quiet and looked around.

My mom brought our two older kids in. It was neat for them to get to meet her so soon after she was born. Our son, who is 21 months, was a little more interested in the water, though, and put his hand in it (someone washed his hands), and he wanted to take his pajamas off and get in, too, but we didn't let him. The cord was short, so I was limited to holding her against me with her head on my chest, just out of the water. Lorri encouraged me to talk to the baby, so I babbled to her about all kinds of things as we waited for the placenta.

I had to push pretty hard to get the placenta out, and the membranes were trailing and full of clots. Then my husband cut the cord and Kristin helped me get out of the water and into the bed with the baby and then the baby had her first nursing. No one but me held her for over an hour after the birth. It was so peaceful and wonderful. When we weighed and measured the baby, she was 6 lbs 11 oz and 20 inches long. And perfect.


I was amazed at how minimal the damage to my body was. I didn’t tear with my second birth either, but this was even better. My vulva wasn’t even swollen and the little bit of soreness I had went away in a few days. I think it was mostly because I did mother-directed pushing this time and because the water acts as a big warm compress.

One of the names we gave our new daughter is shared with my mother-in-law’s sister, who passed away a few days later, in my mother-in-laws arms, soon after she arrived at her bedside. I am struck with the similarities between their transitions, one into, the other out of this world. I am so blessed to have been able to give my daughter a transition into this world that was gentle and loving as well as safe. Perhaps when we come out on the other side, we will be gently lifted into peace and parental love.

End? No, the journey doesn't end here. Death is just another path, one that we all must take. The grey rain-curtain of this world rolls back, and all turns to silver glass, and then you see it . . . White shores, and beyond, a far green country under a swift sunrise. -Gandalf the White, Lord of the Rings: The Return of the King (film version)

Between Worlds: A Birth Story, Part 2

Thrilled and terrified at the same time, I woke my husband up in a panic and told him I needed his help to handle these waves. I texted my midwife and she said to let her know when they had been consistent for about half an hour, and I texted my doula, Kim and told her that I was ready for her to come. The time stamp on that text is 3:35 pm.

I grabbed the Hypnobabies Birth Partner Guide and opened it to the birth prompts I went to the music on my phone and turned on Easy First Stage. I wanted to get into hypnosis as fast as I could and make this easier. I switched to the relaxation music for a while and we tried the birth prompts, but it wasn't really working for us, so my husband suggested I go back to Easy First Stage since I had found it so helpful in our last birth, and he would just do the "Relax" cue during the waves. I was sitting on the birth ball leaning forward onto our bed. I felt like the ball needed more air in it, so I asked my husband to blow it up for me. It was much more comfortable when it was fully inflated. My doula got there and she timed the waves and gave me encouraging words. My husband brought me some headphones and suggested I try using them to help me focus. At first I said no, but then I decided to try it and he was right, it did help. She and my husband were kind of tag teaming making sure the kids were okay in the other room. I stayed in "OFF" between waves, except to talk or to drink my poweraid. This helped me get deeper faster. For some of the waves, I would switch to "CENTER" and bounce gently on the ball, because it felt better. As I got deeper, I tended to stay in "OFF" and breathe deeply and use my peace cue. It didn't completely relieve the discomfort, but it helped enough that I felt calm, relaxed, and in control. This was Kim's first experience with a Hypnobabies birth. She was very impressed. I finally found my confidence, just in time.

After it had been about half an hour, someone called Kristin to let her know these things were not stopping. She said the other midwife, Lorri, was on her way, and she'd also be coming shortly. I stayed on the birth ball, except to go to the bathroom, which was just a few feet away. Whenever I got up, I would have extra pressure waves that were not as strong. Whenever Kim heard me start breathing deeply, she would write down the time, then come put her hand on my shoulder. My mom called at 5:40 pm. I told her I was in labor. She had been up very early and traveling all day and wanted to go to bed, but I kind of wanted her to come over and take care of the kids, so she said she would come. She came over and that freed up my husband and doula to both stay with me.

At some point, I noticed my legs were starting to feel stiff from sitting in the same position on the ball. I let my support team know that I wanted to change positions. We tried putting pillows on a chair so I could kneel leaning forward onto the bed, but when the next pressure wave started, that wasn't comfortable and I got up and did the slow dance position with my husband. When that one was over, I exclaimed, "Nausea!" my husband asked if I wanted a bucket and I said yes, but then I just walked to the toilet and threw up there. I heard my husband explaining to Kim that in the past, vomiting has been a sign that I was getting very close. They asked me how I felt, and I said I felt better after throwing up. My husband gave me my toothbrush with toothpaste on it and a cup of water so that I could brush my teeth and rinse my mouth out. My team decided to check with the midwives again, to make sure they'd be here soon, since it looked like I was in the transformation phase.

Between Worlds: A Birth Story, Part 1

At about 5:00 am on Wednesday, December 7, I woke up to a leaking sensation. It felt like a period, or rather, it felt just like when I leaked amniotic fluid before my first birth. I got up and put on a pad and laid back down. At about 6:30, I felt a gush. Not a gush like all my fluid was coming out, but a definite gush. I texted my midwives and let them know this, and that I was not having pressure waves yet. I woke up my husband a little while later and told him that my water broke but it could still be a while before the baby came. He said that he would stay home from work. I also texted my mom, who told me she would get a flight for the next morning, thinking that if I had the baby that day, she would be there in time to take care of everything I would need postpartum. My midwife Kristin called and said she would come take my vitals and give me a Doppler so I could keep an eye on the heartbeat. She came by and she also drew some blood because she was planning to do a re-check on my iron level at my appointment on Friday. She instructed me to eat and drink well, to rinse with a hibiclens solution whenever I used the bathroom, and to take my temperature and check the hearttones every hour and just let her know when pressure waves started. She said she thought it would probably be that day.

My husband spent the day cleaning up the house, buying food for after the birth, and doing last minute homebirth set up preparations. I helped a little, but didn't want to wear myself out. Pressure waves started by that evening and were about 10 minutes apart for a while. Around 10:30 pm,still thinking the baby would come that night, I decided to try lying down and listening to Hypnobabies to try to get some rest, or at least get myself into hypnosis. I ended up in and out of sleep all night because they spaced out, but didn't completely stop. I had my ipod on a playlist of Hypnobabies tracks so that it would just keep playing while I slept. I probably would not have gotten any sleep at all that night if I had not had Hypnobabies to listen to. The pressure waves were manageable when I was awake and listening, but when one would hit while I was asleep and I was woken up by it, it was extremely uncomfortable.

I got up around 5:00 and took a shower to see if that might do something, but waves were very far apart, so I ended up going back to sleep for a while. Husband was up around 7:00 am. I was kind of getting frustrated with the waves because they seemed to be far apart but strong when I was lying down, weak and close together when I was standing up, and seemed to almost completely disappear when I was sitting. I told him I was having some fears about being able to handle it because the waves seemed stronger than in my last birth (my theory is that the difference had something to do with my water not breaking until 9 cm plus last time) and I think with them being so far apart, yet so strong, I wasn't able to get deeply into hypnosis like I had with my last birth where waves started consistently 10 minutes apart and gradually got closer and closer together. I also was a little worried that it could still be a long time before active birthing started and I would be exhausted from not getting enough sleep by then. I was conflicted--I wanted birthing waves to come consistently so that I would have energy for the birth, but I also was a little afraid of the birthing waves. I asked my husband to give me a priesthood blessing for strength and comfort and to help me know what to do.

We could tell the kids needed to get out of the house (preschool group had been cancelled both days that week, so they had been home all day most of the week), so my husband took them to the store with him to get some things. It took a while to get them ready and get out of the house, and there were a few other things he needed to take care of. We ended up needing to eat lunch before they could go. Before they left, he was also on the phone with his mom. His mom's adopted sister had recently gone into a coma due to a brain infection and she was given a very small chance of survival. My mother-in-law wanted to go to Tahiti to be with her family during this difficult time, but did not have the funds. We offered to help pay for a plane ticket for her to go. My husband wanted to get out the door with the kids, so he had her talk to me to get our credit card information and she and I had a sweet conversation. There I was, with my birthing in limbo, waiting to bring a new life into this world, while she knew she was waiting for one to leave it. Perhaps my child and his or her great aunt were both delaying their transition. Maybe there is a place between our world and the world of spirits, and they were both there, together?

After I got off the phone, I decided a nap was a good idea (it was early afternoon by this point). I got in bed and listened to Hypnobabies again. I think I did the Fear Clearing track. I knew I needed that. I got some sleep. I woke up and my husband and the kids came home. I decided to try some activity to see if it might kick start things. My husband tried to take a nap himself. I mopped my kitchen floor. Then,I stood in front of the mirror in my kids' bathroom and remembered something I had learned at the Dancing For Birth&trade Training Workshop: asymmetry. Asymmetry of the pelvis can help position the baby and bring it down. The move I started doing wasn't exactly one we learned in the training, though it was sort of similar to the mighty mama (sumo) move--I alternated raising each knee up, quickly, one and then the other, over and over, and then a strong pressure wave came, and a few minutes later, another. They were strong and they weren't stopping. This was it!

Pregnancy Update: 36 weeks!

I really have been in denial about this baby coming! Two nights ago, I had some serious feeling pre-birth pressure waves (Hypnobabies lingo for false labor), and I think that made me finally start to accept that this is really going to happen!

I have had two midwife appointments since I posted my last pregnancy update. At my 32 week appointment, I learned that the results of my glucose screen were excellent. I also learned that there had been a mistake with the tube the blood was drawn in for the CBC I had drawn at the same time. I decided to re-draw it because I really wanted to know what my iron level was. The midwife and I discussed the supplements I was taking, and she told me the vitamin D I was taking (2,000 IU) was probably not high enough. A recent study found that routine supplementation with 4,000 IU in pregnant women (ten times the current recommended daily intake) resulted in no harm and better outcomes. Considering that my level was very low in my prenatal blood work (and that was in the spring time), I need to be taking a much higher dose, so I have upped it to 10,000 IU a day.

A couple days later, my midwife let me know the results of my CBC--my iron was low. Not dangerously anemic low, but low enough for me to feel tired. I started taking Floradix, and feel so much better. I realized that the amount of sleep I was needing to function (about 9-10 hours in a 24 hour period) was not normal, and I have so much more energy now. I am keeping my house clean while busy with preschool and Hypnobabies and feel like I'm staying on top of things pretty well! I took it in my last pregnancy when my iron came back a little low at the same time and I thought it increased my energy level then, too. Why didn't I start taking Floradix earlier? Probably partly because Floradix is really expensive...

My 35 week appointment was a nice, long one. We talked about everything we need to do to set up for the birth. I asked about placenta encapsulation, and how I am interested in it but I'm not sure because there doesn't seem to be much definitive evidence out there. She said that everything she had seen about it is very positive. I have a friend who does encapsulation, so I might just have her do mine. The midwife said that they will make sure to take care of the placenta if I decide I want to have it encapsulated.

Somehow we got on the subject of cord clamping and I said that both of my prior two babies had their cords clamped earlier than I wanted. She said that they prefer to wait a long time, because even after all the blood has gone to the baby, there are stem cells that transfer from the placenta to the baby. I said that with my prior babies, they were taken away to be given oxygen, deep suctioning, etc. The midwife explained that it is possible to do those things in the mother's arms. She explained that at a recent neonatal resuscitation class she attended, she demonstrated, using the neonatal resuscitation doll, that the way that people instinctively hold newborns actually keeps their airways open.

The fee for my midwives is paid and the birth kit is ordered! My midwife will be giving me the birth pool next week, and I also ordered a liner to go in it along with my birth kit. I have a student doula who will be coming to the birth to help out with whatever we need--filming the birth, helping with the kids (who I plan to have present, as long as they want to be there and are not bothering me), helping with Hypnobabies tools, etc. I really want to capture this birth on film, which is something I didn't do with my others. I am really happy to give this opportunity to this student doula--I know I appreciate those who agreed to be my first few doula births! She is working on a nursing degree and hopes to eventually do a Masters in Midwifery at Bastyr, so I think seeing my birth will be great for her!

More Thoughts on Research

The comments on Homebirth Research: Another Side of the Story have been interesting. Thank you to everyone who has shared your thoughts or other information you found about the study. I think the letter to the editor from De Jonge that one anonymous commenter shared was interesting, especially the point about how the methods of data collection in the study may have inflated the perinatal mortality rate in the low risk group. If she is correct in this assessment, I believe it does call the validity of the study into question.

That said, I think that the Evers study raises a lot of questions that require further research.

• is midwifery care, with referral to obstetric care if complications arise, optimal care for low risk women?
• are there specific aspects the midwifery system in the Netherlands that are suboptimal (such as, protocols for intervals to check the fetal heart rate, as mentioned in the paper, or as one response to the study pointed out, the use of midwives assistants to watch over women until close to time of birth)?
• how might midwifery care be improved to result in better outcomes?
• how might collaboration between midwives and physicians be improved to result in better outcomes?

I think that many questions such as "Is homebirth safe?" or "Are midwives or obstetricians better caregivers for low risk women?" are questions that may never be fully answered with research. There will always be people who find a flaw in a study's design or some other way to discredit it, because most people have basic beliefs about birth that are not easily changed. There will always be people who focus (some because it is their job) on the cases where things go wrong and work their hardest to save those lives. There will also always be people who want put their primary trust in either a divine design for the process of birth or its thousands of years of improvement through natural selection (whichever is their belief, mine is these former) and who prefer to use the technology of the past hundred years or so as mostly a back-up. Most people find ways to dismiss "evidence" that does not support their basic view while accepting that which is in line with it. It is human nature.

The answer to safety in maternity care is not to convince one side that the other is "right." The answer is respectful collaboration. This is not the first time I have talked about this. In October 2010, I committed to make my blog a doctor-friendly zone, and I hope that I have held true to that promise. I believe now, as I did then, that peaceful dialogue between doulas/activists/midwives and obstetricians and other hospital providers is essential for improving our maternity care system to protect the lives and and best meet the needs of mothers and babies. I believe that hospital and out-of-hospital providers could learn a lot from each other, which I think could help improve the safety of the practice of homebirth and care in transfers, as well as improve the environment and the options available to women in hospital birth. I have started to see dialogue opening up a little more in the past months, as more physicians are creating online presences and the internet is becoming a larger platform for conversation. I'm curious also, to see where the upcoming Home Birth Summit will lead.

Homebirth Research: Another Side of the Story

Information about this has been showing up everywhere for me lately, though I have not sought it out intentionally, and I feel like I would be irresponsible not to write about it.

For a long time, I stayed away from the topic of homebirth, partly because it is such a controversial topic. I have only started writing about it recently because I am pregnant and currently am under the care of a team of homebirth midwives. My post titled "How Homebirth Benefits Babies" was the first post I wrote that "promoted" homebirth (with caveats!). It is also has been the most widely read, currently at 1,788 pageviews.

I have discovered that the evidence really is not clear on the most important point I make in that post when I talk about homebirth research. My words:

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).

It has come to my attention that the results of one of the studies I cite in that post has been called into question by the results of another study--a study that nobody in the online natural birth community appears to be talking about, even though it was published 9 months ago.

The study I cited in my post was the de Jonge study from the Netherlands, which compared outcomes of home and hospital births attended by Dutch midwives among women classified as "low risk" by the Netherlands maternity care system. De Jonge found no difference in mortality or severe morbidity in the home and hospital groups.

The Evers study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study was published in the British Medical Journal in November 2010. It compared outcomes of term births classified as "low risk" by the Dutch system attended by midwives (primary care) with outcomes of births classified as "high risk" and attended by obstetricians (secondary care). It found higher rates of perinatal mortality in the primary care group, and no difference in rates of level 3 NICU admission (the measure the study used for severe morbidity). Yes, you read that right. More low risk babies died. There were 26 delivery-related perinatal deaths out of 18,686 who began labor in primary care(a rate of 1.39/1000) and there were 10 delivery-related perinatal deaths out of 16,739 who began labor in secondary care (rate: 0.60/1000). The transfer rate from primary care to secondary care during labor was 22.9%, and 12 if the delivery-related deaths occurred in those who were transferred. The number of intrapartum stillbirths was also higher in the group that began labor in primary care. The study excluded all instances of congenial anomalies.

This study calls into question the belief that the best and safest care for low risk births is low-intervention care. From the Discussion section of the paper:

This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels. Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes. Delay can occur at three moments. Firstly, diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours. Secondly, transport can delay treatment in case of an emergency. Finally, a delay can occur because the obstetrician underestimates the problem as the referred woman is a “low risk” patient. In addition, essential information can be lost during the referral. These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted.

And this is in the Netherlands, where there is a universal standard for midwife education and there is supposedly to be a good system of transfer of care. Would having low risk women also be cared for by obstetricians be a better system for the Netherlands? That is basically what we have in the U.S., and we have a 33% cesarean rate. Cesareans increase the risk of maternal morality (see Deneux-Tharaux, 2006), though maternal mortality occurs much less frequently than perinatal morality does. Considering the increased risks associated with pregnancies and births in women with prior cesarean sections (see Kennare, 2007) , some of which impact both the mother and baby, I just don't see how this can be the optimal way to care for mothers and babies either. I'm not even going to try to answer the question of how many mothers (and any future babies they may have) should have to accept the risks of a cesarean section to save the life of one baby. It is something to think about.

The choices we have are between sets of risks. The absolute risk of a baby dying at all is low, especially if there is access to fetal monitoring and some level of emergency care (such as midwives who can perform neonatal resuscitation). When are talking about a rate of 1.39/1000, it means an individual has a 0.139% chance of it happening (and a 99.861% chance of it not happening)--and that's all primary care deaths in the Evers study, including ones who would have died no matter what kind of care they received. The risk of preventable death is presumably lower, though we don't know how much lower because there is no obstetrician-attended low-risk comparison group in the study. I don't want it to seem like I am trying to "explain away" the risk of preventable death. The statistics mean nothing when your baby is the unlucky one who dies. I believe in informed choice, and I believe you need accurate information to make informed choices.

After I wrote this post and was waiting to publish it (I usually space posts out further, but I moved this one up because I felt I needed get it out there), I saw this post from Birth Without Fear in my facebook newsfeed, and felt it applied to what I am trying to say. Like her, I am not here to advocate that you have a homebirth. I advocate that you look at the information, weigh your options, and make whatever is the best decision for you.

Homebirth Set Up Video

A common question people have about homebirth is that there will be a big mess in their house and they will have to do a lot of work to clean up. This video shows a midwife setting up a home for a birth by putting a shower curtain under some old sheets on the bed and a garbage bag between pillows and the pillowcases, which helps make post-birth clean up easy. It also shows supplies for the birth, including old towels, the birth kit, and a bowl for the placenta. At the end, it shows how the midwives leave the room after the birth.

A Homebirth Midwife's Supplies

This video shows and lists the supplies typically brought to a homebirth by a licensed midwife in Washington State.

Licensing vs Decriminalization

Hope everyone is enjoying their Independence Day weekend. This post seems appropriate for this holiday, as it addresses freedom and law in the U.S.

One commenter on my post, How Homebirth Benefits Babies, said that she feels decriminalization of midwives would be a better way to legalize midwifery than licensing. I am aware of the division within the midwifery support community on the issue of licensing. Here is the issue, as I see it.

The arguments for decriminalization
Licensing puts restrictions on midwifery practice. States that license midwives have laws governing direct-entry midwifery that determine the criteria for acceptance as a midwifery client and conditions that require transfer to hospital-based care. These criteria may categorize a woman as "high risk" who is not really very high risk at all. For example, Arkansas law states that licensed midwives may not treat women who have previous cesarean sections, multiple gestation, maternal age greater than 40, or previous infant weighing more than 10 pounds. It also requires transfer for non-vertex positions and gives a set number of hours a woman can be in labor before she has to transfer. Here, in the state of Washington, transfer is required for women who pass 42 weeks gestation. I most definitely do not believe that all women that fit into these categories are only safe birthing in a hospital. These kinds of restrictions put many women and their midwives in tough situations, where the midwife could risk losing her ability to practice legally if she choses to help a woman have the homebirth they may both feel is optimal for her.

In theory, decriminalization would give midwives the freedom to set their own standards without the fear of prosecution for practicing medicine without a license (something underground midwives in states where homebirth midwifery is not legalized in any way have to deal with) and without having to worry about being punished for not following the terms of the state that gives them a license.

The arguments for licensing
The Unnecessarean reposted a discussion from their facebook wall on a status update that they shared from Big Push for Midwives'. It is an interesting conversation between midwives, consumers, lawyers, and advocates that I recommend reading if you want a good grasp of the different points of view on the issue. Here are a couple of quotes that address why licensing appears to be the best course:

Just “make midwifery legal”? How? By pushing for a blanket “midwifery is legal” law? How do you define midwifery? How do you define a midwife? How do you define what is NOT covered? All of these things would have to be done in order to “make midwifery legal.” All of these things are the same exact things done with licensure.-Tara ANaturalAdvocate

[A]s a practical matter, simply legalizing midwifery — that is, decriminalizing the practice of midwifery by statute and/or getting the legislature to pass a law to officially declare that midwifery will no longer be considered unauthorized practice of medicine or nursing — would be politically impossible. Organized medicine, and often organized brainy, fight tooth and nail against efforts by consumer groups to regulate midwifery. They win over many legislators by claiming that licensed certified professional midwives are unsafe. Can you imagine the field day the OBs and medical society would have, or how skeptical the legislators would be, if the legislation simply allowed midwives to practice without any state oversight? Even if this legislative option may have worked ever in the past, it would be truly impossible today. Really truly impossible. Our state groups are there “in the trenches” and know how difficult it is already to get licensed regulated midwives.-Susan M. Jenkins

Why push for the licensing of midwives? Because licensing legislation actually happens. Because states have the right to regulate health care providers who practice there. Because the majority of professions require some sort of license/certification/official credential to do their job. Because in order to legally recognize midwifery, you have to define it, and by defining it, you necessarily have to determine what it is not, which by definition will "limit" midwifery.

Oregon is the one state I know of were there is "decriminalized" midwifery--midwives have two options--they can choose to obtain a license from the state (which allows them to file for reimbursement from the medicaid system) or they may legally practice midwifery without a license. However, practicing without a license means it is a felony for these midwives to use oxygen and pitocin, as the use of such drugs falls under the category of "practicing medicine." I believe that women and babies benefit when midwives have the ability to legally use life-saving medications in the home in the event of an emergency. It appears to me that there is definitely a trade-off. Either midwifery involves the occasional practice of medicine, or it does not. You can’t have it both ways.

Beyond the ability to have pitocin and oxygen available, licensing also ensures consumers a minimum standard for licensed midwives. No, being licensed does not guarantee that someone is a competent midwife, but it gives consumers some indication of the midwife's qualifications. When anyone can claim to be a midwife, it creates a confusing and unsafe environment for consumers.

Licensure also strengthens the credibility of midwives, both to consumers and to medical professionals. Knowing that licensed midwives have completed certain requirements may make physicians and hospitals more respectful of them, allowing for better collaboration, which also benefits mothers and babies.

Many states do have mostly good, evidence-based guidelines for the scope of practice of midwifery. It is not necessarily licensing that limits homebirth options, but rather certain state’s licensing laws. Those who are unhappy with their state’s licensing regulations are free to organize consumer efforts to change those laws.

I, personally, am quite convinced that licensing is the most feasible way to legalize midwifery and that it helps make homebirth safer for consumers. What do you think?

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:

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

Homebirth Midwifery Care Now More Accessible to Yakima Area Women

I hope my out-of-town readers will indulge my sharing some local news.

Homebirth is growing in popularity among pregnant women here in Yakima, Washington. In February 2010, KIMA news published a story about more Yakima women choosing to birth at home. Although no homebirth midwives reside in Yakima itself, the midwifery team of Kristin Eggleston, LM, CPM of Sunrise Midwifery in Prosser, and Lorri Carr, LM of Highland Midwife Birth Services in Goldendale travel to Yakima to attend homebirths. Dr. Virginia Frazer, ND, LM, of Blue Heron Naturopathic Care and Shannon Bennett, CPM, both located in Tri-cities, also attend homebirths in Yakima.

Although homebirth midwives come to women's homes for a few appointments and for the birth itself, it is more efficient for them to have women come to an office location for the majority of their prenatal visits. Until recently, Yakima women would have to travel 50 miles to the nearest homebirth midwife office for prenatal care visits with a licensed midwife. I am very excited to learn that Kristen Eggleston and Lorri Carr have recently started taking appointments one day a week (Friday) at the home of the Naturopathic Medicine and Accupuncture practice of Dr. Heidi Robel, ND, LAC, PC, located at 307 S. 12th Avenue Suite 11 (map) in downtown Yakima. This location will increase the accessibility of midwifery care for women seeking homebirth in Yakima. This may allow more women to use their services, and will make using those services more convenient for those who no longer have to travel.

Doulas and Homebirth

In a previous post, I discussed how doulas can benefit women with various different birth plans and support scenarios, but a commenter notified me that I left one out...

How can a doula benefit me if I'm having a homebirth?

Part of the answer to this question relates closely to another post I started a long time ago but haven't finished yet about the similarities and differences in the roles of doulas and midwives. I will try to get that finished soon so that it can complement this post. I believe that the role of a midwife is meant to encompass the role of the doula, but it doesn't always happen that way.

I think that the degree of necessity for a doula in a homebirth is going to vary depending on several factors. The following are some situations where it would be to your advantage to have a doula at your homebirth:

busy midwife: If your midwife is at another birth when your labor begins, she may send a partner to be with you. You should be given an opportunity to meet any partner your midwife works with before your birth, but you may not have the same relationship with her you you have with your own midwife, but you will have that relationship with your doula.

absent partner: If you are a single mom or there is a chance your partner may not be present for the birth, a doula can act as your primary birth partner. This may also apply if you have a husband who is uncomfortable with playing an active role in the birth, disturbed by blood, etc.

sometimes even homebirthers need to be protected from trauma: Unfortunately, not all midwives are as gentle and respectful as what most homebirthing moms are looking for. I recently came across some birth stories of women (the blogger at Mandala Mom and Dy at Complete Beginnings) who hexperienced trauma because of the way they were treated by their homebirth midwives. I will give the founder of the midwifery method implicated in these posts the benefit of the doubt, and say that I don't think she intended for her ideas to be used this way, but I think it is important to understand that things like this can happen, and would like to propose that a good doula can help you find your voice when a provider (even a midwife) is trying to do something to you that you do not want. The women in the stories above both said that they had no indication of their midwives having anything in their philosophy that they disagreed with. All birthing women need to watch out for themselves, and a doula can be your watchdog.

What if I want an unassisted birth?

I am by no means an expert on UC. I imagine that for some women, hiring a doula may not align with their reasons for choosing an unassisted birth. Others may see a benefit to having an extra person around who knows about unmedicated birth is experienced in birth support in case you need an another pair of hands for something.