Monday, March 24, 2014

My Changing Thoughts on Homebirth

Everyone loves a good I've changed my mind post, right?  Well, I haven't totally changed my mind, but I've sorta changed my mind.  Close enough for a blog post, right?

When I was pregnant with Heidi, homebirth wasn't even on my radar.  I didn't consider it at all, and actually sorta thought that people who did it were crazy.  Although I was interested in natural childbirth and knew I didn't want an epidural or any other interventions. I was the crazy one who showed up at the hospital with a long birth plan that I'm sure the nurses proceeded to totally ignore.

I had a completely problem-free pregnancy.  I went into labor all on my own at 38.5 weeks, went to the hospital way too early, ended up with artificial rupture of the membranes, they gave me staidol (which was terrible, as it didn't take the pain away, but made me feel loopy).  She was born just fine after about an hour of pushing (6 lb, 12 oz.) problems during birth, no problems during breastfeeding.

When I got pregnant with Greta, I was in a totally different place.  I had gotten a lot more immersed in natural family living culture...I was into cloth diapers, baby-wearing..the whole she-bang.  So, I had definitely come across the idea of homebirth and it was always portrayed in a positive light.  Since my first birth went off just fine, I decided to try it.  Our insurance at that time was such that it was almost as cheap to pay a homebirth midwife out of pocket as it was to pay the 20% co-insurance for the hospital birth.  We hired a homebirth midwife (the first one I interviewed and I honestly had no idea about checking credentials.).  I was with her until around 25 weeks pregnant, when we moved from TN to NH because Ben got a new job. Well, his new job had fantastic benefits, everything was covered at 100%, so we couldn't justify paying out of pocket for a homebirth midwife when the hospital was free.  So, instead we found an OB (a big teddy bear of a guy) and "hired" a doula (actually she worked for free, because she was in training).   Again, the pregnancy was smooth and problem-free.

I  went into labor all on my own at 38.5 weeks. Labor started with my water breaking, but contractions started on their own a few hours later.  We went to the hospital way too early again, but still everything was fine and I gave birth to 7 lb 14 oz. Greta after about 10 minutes of pushing.  Totally natural childbirth.
She wasn't too pretty when she first came out due to all the brusing and she ended up back in the hospital with jaundice at four days old, but ultimately all went well.

When I got pregnant with John, I chose a CNM (certified nurse midwife) that practiced at a hospital 45 minutes away from our house, because I had heard fabulous things about her.  And, she was fabulous.  I had another super smooth, complication- free pregnancy.  I went into labor all on my own at 38.5 weeks.  His labor however was long and difficult and the heart monitor started picking up heart decelerations after they artificially ruptured my membranes.  He had a hard time descending down and I was pushing for a long time (probably about an hour and a half). Finally he came out, without any assistance, right about the time they started talking about doing something to pull him out.  And ultimately he was fine.  He was born sorta gray and limp at 8 lb. 1 oz, but pinked up and starting screaming right away.  The midwife said he had a shorter umbilical cord which made it harder for him to descend and caused the heart decelerations.  I gave birth to him on my hands and knees, which looking back probably wasn't the best position with a short cord.  Anyway, we went home only a day later and all was well.

When I got pregnant with Elsa, we were living in Florida while Ben was in law school and I had to be on medicaid.  There is a law in Florida that states all licensed midwives have to accept medicaid.  So...finally....a homebirth was financially accessible.  I interviewed and chose the only homebirth midwife (who was a CPM..certified professional midwife) that serviced our town.  Another completely smooth and complication free pregnancy.  I went into labor all on my own at 38 weeks (notice a pattern uterus apparently sends out the eviction notice at 38 weeks).  This was by far my easiest labor and delivery.  I wrote about it here.  I had a few minor contractions off and on all day, but it wasn't until 5:30 or so that I realized I might be in labor.  We called the midwife at 6:30, she got to our house around 7:15.  At that point, contractions were fairly intense but still 10-15 minutes apart.  At 8:40, I had to go to the bathroom (yes..*that* way) and suddenly I entered transition, with contractions basically back to back.  I was in there dealing with back to back contractions for about 10 minutes...walking through them the whole time as that was the only way I could deal with them.  Finally, I managed to come out, call Ben and the midwife for help...just as they walked into the room, my water broke, I started pushing and Elsa was born 2 pushes later (6 lb, 15 oz.) just before 9 PM.  Totally healthy and fine. I almost felt like I hadn't had a baby.  I kept looking at her and thinking where did you come from, because her birth was so fast, and so much less painful and difficult than my other ones.  Oh...and she was born with a short cord as well..but this time it didn't cause any problems at all (I think because I was standing up and basically walked/stood though the whole labor and pushing part).

Despite the fact that her birth was so easy and quick...I felt really unsettled by it for some reason.  I loved giving birth at home, but I hated being home after birth.  I actually missed being in the hospital with cable TV (we don't have cable) and the ability to watch anything without a bunch of kids around. Not to mention the meals they just bring you and the nurses that are always checking on you.  I am such a Nervous Nelly about my babies when they are newborns, I am constantly checking their breathing and looking for chest retractions.  I think I would have really appreciated a professional set of eyes looking at her.  Sure, the midwife did come back about 1 1/2 days later to check on her, and obviously I could have called her if I was really worried, but it's hard to tell real worry, from just Amelia is crazy worry.  And, in fact, when Elsa was two weeks old, I took her to the ER for what I thought were chest retractions.  The doctors were all....she's fine, that's normal, those aren't retractions.  So, I don't always trust my worry radar.

Anyway,  after Elsa's birth, I spent a lot of time reading up on homebirth and thinking about if I would do it again.  We would like to have at least 1 or 2 more children, so it may come up in the future.  And, I'm pretty sure the answer is no.  No, I wouldn't.  If/when we are blessed with another child, I think I would go the hospital route.  Hopefully with a good CNM, because I really did love the midwife experience I had with John, but I also appreciate that if there is an emergency, you are already are in the hospital.

Anyway, here are the reasons why I wouldn't have another homebirth, even though the one I had was basically fantastic.

I don't really think my midwife was all that qualified.  From what I understand, the CPM (certified professional midwife, which is different from the CNM (certified nurse midwife credential) isn't that riguous of a program.  You don't need to have a degree in anything medical.  When I interviewed my midwife, she told us that she had attended about 450 births with 2 infant deaths. The first death was an infant that died in early labor for no explained reason.  The second death was a baby that died at 7 days old from an undiagnosed heart condition. When I heard about those, I blew them off...thinking, oh, those could happen in the hospital too.   It wasn't until I started thinking more critically about homebirth (after Elsa was born) that I realized maybe those infants *could* have been saved if they had been born in a hospital.  Maybe the baby with the heart condition could have had that picked up on earlier, and received life-saving treatment or surgery in the first few days after birth? Newborns are tricky.  It's easy to tell if my older kids are sick or can see if they are acting normally, playing normally, eating normally, etc.   Newborns are harder...they sleep all the time, they make funny noises, they cry a lot.  I can see how it would easy for parents to miss respiratory distress or other problems in a newborn.

And, the first baby, the one that died during early labor.  I have no idea what happened there. I have no idea how may weeks she was.  Who knows if the mom had undiagnosed diabetes or pre-eclampisa or something else?  Maybe there was nothing that could have been done to prevent it.  I don't know, but I will say that my midwife was not rigorous in testing.  She did take my blood pressure every visit (and during labor). However,  I had the diabetes *test* at 23 weeks pregnant (4-5 weeks earlier than it is usually done) and the test consisted of nothing more than a finger prick to test blood sugar after I ate *my normal breakfast* (which is not high in carbs or sugar). No glucose tolerance test or anything.  Now, clearly, since I gave birth to a 6 lb baby, *I* didn't have gestational diabetes, but her "testing" for it was fairly atypical and I'm not even sure it was all that accurate, because it was done so early.

Now, maybe those babies still would have died if the mother had given birth in the hospital.  I have no idea..this is all pure speculation.  And, maybe other midwifes are more qualified, I'm sure many are. However, I do think there is a problem with the CPM credential as a whole.  It's just not nearly as regulated or rigorous of the education of a CNM.  In Florida, where I had Elsa, midwives are licensed and regulated and they carry malpractice insurance.  Even with that, I feel as though my midwife did not have as much experience, with only seeing 450 births in 14 years of practice, considering that a midwife or OB working in a hospital could easily see that many births in a year.

While it's rare, there are babies that have died at homebirth that could have been saved if they were in the hospital.  It's tragic and sad, but it does happen.  Not all that often,  Most of the time things go just fine (as my homebirth did).  But, it can and does happen and I don't know that I could live with myself if it were to happen to me.   When I was thinking about homebirth with Elsa, I read an article saying that there were really only two emergencies that are dangerous and where the mom would be better off in a hospital (placental abruption and pulmonary embolism). However, I think there are more emergencies than that (ie. shoulder dystocia, meconium, cord accidents).  When I was deciding on a homebirth, my thinking basically went like this.  I'm weighing the small chance of a life-threatening emergency happening against the large chance of unnecessary interventions.  Except that I don't think the chance of a life-threatening emergency is as small as I had previously thought.  Still small...but not as small.  And, ultimately, I'd rather have a c-section that was unnecessary than have needed one and not have it available.  To be perfectly blunt, a dead baby is way, way worse than an unnecessary c-section. And, to be totally fair, if I'm counting on my history of super low risk pregnancies and births to make a homebirth safer than I have to count on it making a hospital birth smoother and less likely I would have any unnecessary interventions.  After all, I've managed to have three babies in the hopsital without ever being induced, put on pitocin, getting an epidural, or having a c-section,   And, even if those do happen, it's not all that terrible in the grand scheme of things.  Not to belittle anyone who felt traumatized in the hopsital by having those things done, I'm just trying to explain *my* thought process here

I liked being in the hospital after birth.  I really did.  I liked that time to relax (without other kids around) and having a professional set of eyes looking at the baby.  By the second day, I was more than ready to go home, but I always really enjoyed that first day, with lots of good food and cable TV.

My decision to homebirth was based on fear.  Fear is generally not a good way to make a decision.  A big part of my decision is that we didn't have anyone to watch our other kids without imposing on friends, so it was easier to just stay home.  Plus, being on medicaid, I was worried about being treated poorly in the hospital.  That sounds silly, but I was worried about being looked own upon, or hassled because I was on medicaid.   Plus, I  had a fear of hospitals. We had a bad experience at the ER with my husband about a year prior...I felt like the hospital was all oh, just leave your brain here at the door when you walk in. You won't need to think anymore, we'll do all your thinking for you and do whatever we want to you and you don't get any say and then we're charge you an arm and a leg for it.  I don't like that.  But that's not necessarily a reason to avoid the hospital...just a reason to be more assertive and ask more questions.

If I were to homebirth again, would everything go fine? More likely than not..yes.  I've always had healthy, smooth pregnancies. I have smaller babies. I go into labor spontaneously at 38 weeks.  It seems fairly unlikely that I would suddenly have a big baby with shoulder dsytocia that waited until 42 weeks to come out, when all my other babies were small-avg. and born at 38 weeks.   But, you never know and I am now considered "advanced maternal age".   Plus, one thing I've learned is to never take good health for granted.  I've never been GBS+, I've never had meconium, never had pre-eclampsia or diabetes or any other issues..but that's not to say that those things coudln't happen in the future.

However, If an emergency were to happen..things would not go smoothly.  My midwife couldn't work at a hospital, I'd get stuck with some random doctor.  And, it would be an emergency..which is never good.  They'd have to do all the paperwork and intake. I would hate to transfer.  It just sounds like a nightmare.  Worst of all, it just might not be *soon enough" to avoid tragedy. However, if an emergency were to happen and I already was at the hospital, I think it would be less traumatic, a better experience and quite possibly a better outcome.

The experience of birth doesn't mean all that much to me.  I choose natural childbirth because I hate drugs and I hate the way they make me feel.  I really do.   When I had my wisdom teeth taken out, I thought the nausea and drowsiness and loopiness of the pain medication they gave me was worse than the pain of the teeth.  And, I've had similar experiences with other pain relieving drugs.  Most of the time, I'd rather have the pain and not deal with drug side effects.   I found my homebirth to be the easier and least painful of all my births, but not the most meaningful.  I didn't find it "empowering".  I actually found it unsettling, I seriously felt like Elsa just fell out of me and I barely did anything.  My most "empowering" birth was my third...the difficult one with John at the hospital.  That was hard and long and painful and I felt like I had run a marathon after it was over.  I'm still a big fan of natural childbirth *for me", I realize it's not for everyone.  But, I personally prefer to just deal with the pain than deal with the drugs and side effects.

Do I regret my homebirth? Obviously not.  Everything went fine, and I feel like I learned a lot from it.  I learned why I want to be a hospital next time, and I learned what *I* need to do to have a smooth and easy labor (lots of walking around and moving through contractions and standing during pushing).

Do I think homebirth should be made illegal? No! I can definitely understand the desire to birth at home, surrounded by familiar surroundings.  Birth DOES go best when the mom is comfortable and feels safe.  And, I definitely think a big part of the reason that homebirth was so fast and easy is that I was in safe, comfortable surroundings and didn't have to move in the niddle of labor.   However, I do think there needs to be reform.  I think it should be better regulated, I think the CPM credential needs to have a more rigorous educational training associated with it and I do think moms who choose homebirth should fully understand thte risks involved.  I think there needs to be better cooperation between homebirth midwives and hospitals and OB's.  I certainly didn't fully understand the risks involved in homebirth the first time I chose it (with Greta, where were ended up switching to OB and hospital birth anyway).  I don't think midwives should work alone. I think it's safer to have two professionals at a birth. I also think there needs to be hospital reform, so hospitals are more amenable to moms who choose natural childbirth.  A big part of the reason I chose homebirth with Elsa is because we lived in an area where the hospitals were notoriously unfriendly towards natural childbirth.  Most importantly I think there needs to be more frank discussion of the risks and benefits of any birth location.  I didn't feel like I was properly informed of the risks and benefits of homebirth, nor of the risks and benefits of certain procedures (like artifical rupture of the membranes) in the hospital.   I'm thankful that I never had a bad hospital experience, and I'm thankful that I never had a bad homebirth experience.

Birth is a touchy and personal subject and I DO think the birth experience matters.  But, ultimately safety matters as well.  This is why *for me* I would likely choose the hospital should we be blessed with another baby. I guess you could say I've come full circle on this matter, although I no longer think people who choose homebirth are crazy.  I totaly get it.  I just don't think I would choose it again.

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  1. Another great post Amelia! You're very wise and humble.

  2. Even though homebirth is not an option for us with this baby, it still intnrigues me. I'm always amazed at the women who do it but know that I personally would prefer to be at the hospital just in case. It's nice we live in a country where we have lots of options!

  3. Wow! This was a really interesting read; thanks for sharing your thought process and conclusions, Amelia. I've gradually realized over the course of this pregnancy the importance of my own gut instincts. It's so easy to fall into this, that, or the other camp not only with child birth, but also with child raising and education! But ultimately, it comes down to what you feel comfortable with at the time, based on your experiences and research and with the help of your spouse of course.

    1. Yes...gut instincts are so important!!

  4. Thank for this post. I thought about home birth, but my body does not go into labor, so the first was induced at 42 weeks, had shoulder dystocia, and was 9lbs 11oz after 4 hours of pushing. The second was induced at 39 weeks and was only 6lbs 10oz. The problem is that I always have bleeding complications. There are to many risks for me to not be at a hospital.

    1. Thank you for sharing your experience. Glad you liked the post!

  5. I think it's really awesome that you wrote this post so honestly, even though it sets you apart a bit from the crunchy community. :)

    Homebirth has never really appealed to me...sometimes I think about it, but it just doesn't seem like fun.

    What do you think of births at a birthing center? That's where I had Zuz, and I found it a really nice middle ground. The birthing center that I went to is staffed by two CNMs, several LPNs to help them, and an MD. Everyone has privileges at the hospital down the street. I guess I felt like it was a good happy medium for me...

    The most important thing in discussions of birth is a focus on balancing competing interests, and ensuring that we are respectful of the people who have these interests. I think this post really moves that conversation in a good direction - thanks again.

    1. Hi Martha, I think it really depends on the birthing center. I think a lot of birthing centers are no different than a homebirth, it's just like giving birth at *someone else's home*. However, I do think the one you used is different, because it has CNM's, LPN's an MD and they have hospital privileges. I would definitely consider a center like that, it sounds fantastic (was just too far away for me when I was in Naples). A big factor is there would be a better continuation of care if you needed to go to the hospital and they have an OB. The one right in Naples is not like that (it has a CPM, a RN (who does home visits after birth) and then birth assistants...but no CNM's or MD's or hospital privileges and I don't think the RN attends birth, just does home visits afterwards. So, birthing centers....I think it just really depends on the center who staffs it.

  6. I just had a home birth a few months ago and loved it but I do think home birth is not for everyone. I did a lot of research and choose a team of midwives all of whom were also naturopathic doctors well experienced in birth and all medical aspects as well. They have working relationships with hospitals and if I transferred would have stayed with me throughout birth. They were very cautious and would not have agreed to a home birth if there were any possible complications. I also live within 5 to ten minutes from several hospitals so the time it would take for me to transfer would be fairly equivalent to time spent transfering from maternity ward to o
    Operating room in event of emergency anyway.I'm also a person who hate hospitals and constant monitoring. I love being in my own space and loved sleeping in my own bed. I also am lucky enough to have a mom with the ability to come stay for several weeks to help with offer kids and house stuff as well as feeding me. And my insurance covers 100% of labor and delivery but sticks us with facility fees so home birth was free for us. We had a perfect set up for home birth. In different circumstances I may not have chosen it. Safety of mom and baby should always come before an ideological belief about birth.

    1. Congratulations on you baby! So glad the birth went well!

  7. I think I'd like a home birth, but the husband isn't on board, so we do the natural in the hospital route, and then go home as soon as possible. I do not enjoy being awakened for blood pressure tests or people chatting in the hallways.

    I am with you 100% on pain medication. I just hate the way they make me feel.

    1. Yeah...I'm not a huge fan of the blood pressure checks either. I like the people chatting in the hallways though....just cause I'm nosy. LOL

  8. For what it's worth, I have a dear friend whose baby needed emergency heart surgery at 10 days old for a heart defect that was not detected at the hospital. The baby wouldn't nurse for 10+ hours, was very sleepy and his temp dropped. So they took him to ER. I don't know if I would have taken a baby in at that point. Thank goodness they did though.

    I deliver at the hospital too. For lots of reasons. I cannot imagine going through transition and hearing the 2 year old crying for me. Or even worse, trying to touch me. I know it doesn't mean much, but I've always given birth right in the middle of the day so it's how I imagine it will always go. I don't really want birth to be a family experience. Not at this point. And I like the hospital. Just me and baby, nothing else but me and the baby. Its wonderful.

  9. This is a really thoughtful post and I think everyone needs to figure out where the best place is for them to birth. My only comment is in response to this
    "While it's rare, there are babies that have died at homebirth that could have been saved if they were in the hospital."
    True. But it's also true that there are many many babies who have died at the hospital that could have been saved if they were home. Infections, use of cytotec, premature inductions that result in a distressed baby...and that's not taking into account the countless lifelong injuries because of unnecessary medical intervention.
    In the end, with every birth we have to come to terms with the fact that there are no guarantees and there are risks and benefits to each choice. And bluntly put, there are neonatal and maternal deaths that occur in both places. Surrendering to that reality and making the best choice you can with the information and resources available to you is very hard indeed!

  10. Great post! I've read a ton on homebirths in the last year and have come to very similar conclusions as you. It just isn't worth the risk. No matter how safe it is (and it really doesn't seem very safe since the majority of homebirth midwifes are not as well educated or as experienced as they think they are), it will never be as safe as the hospital. Thank you for explaining your thoughts!

  11. Another great post! I have done a very similar turnaround on homebirth. We had our second at home, and while it went well (almost too well--midwife almost didn't make it in time!) it wasn't until about 5 years later that I started to feel uncomfortable about how fly-by-night the whole thing felt.

    Now I've had two happy natural hospital births since and doubt I'd ever consider a homebirth again.

  12. Just a thought...few seem to bring up the fact that there are complications or even deaths that occur at the hospital that might not have happened with a home birth. Oftentimes unnecessary interventions, switching care givers during labor, infection, or any of a number of complications that are more common or specific to a hospital birth can cause serious problems. There are risks with birth in any circumstance. There are bad doctors and bad midwives (though I would not discount a CPM's qualifications....hands on is probably the best kind of training as far as the birth process is concerned. Just look at Ina May Gaskin (CPM) and her AMAZING birth stats and knowledge). Ultimately it is up to YOU as a mother to weigh those decisions. There is no decision you can make that will take away all your risks. You can only educate yourself, go with your gut and pray for the best. All that aside, I really enjoyed your post and you honesty. My mother had 6 home births with an incredible midwife and I think she would love to see me do the same. Right now I'm happy with my free standing birth center across from 2 hospitals (-;

  13. Liked this one too :) Sorry to bombard you with "I like it" comments, but I just wanted to let you know I'm appreciating your writing months after the fact!


  14. This is just so awesome. I loved your post; I am going to drop by again and again. Thanks

  15. Good to read articles being balanced! One factor that you didn't mention is how well the personnel are trained on the actual birth process. Having had an induction that ended up with lots of interventions and OB that didn’t seem to trust my body to deliver as well as hospital births with no interventions (different doctor who was very trusting) & home births with different midwives (& deliveries @ 3 different hospitals as well as at home) the ability to understand a woman during labor process is important. Sadly hospital births tend to focus less on birthing process to the detriment of outcomes. With my home births I also was concerned about being able to rest afterwards and had quick foods as well as lined up friends to help bring food. Not being kept up by lights and nurse checks was a perk though) I do think my home birth children were more safe for many situations because I had someone trained to work with my body. 2 hospital births, the child had cord around their neck, Drs cut cord right away and children had poor circulation/blue on arms or legs and one even had to be recesistated. 1 home birth had cord around neck so tight child had bloodshot eyes after delivery. Midwife worked to unloop the cord and he has zero breathing or circulation issues. I think based off my previous hospital births that it would've been much more traumatic in a hospital and I am so thankful the properly trained person was at his birth. Dr's may be present when more babies are delivered at hospitals but that doesn't necessarily mean they learn how to help wih or even understand the birthing process


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