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Yes, we have decided to have a home birth with a midwife. I know that this causes you some concern, so I decided to tell you why we have decided on this course. I'd like to preface this by saying that I know that this is a difficult subject to talk about without seeming to criticize those who choose otherwise; please be assured that this is not my aim. I realize that home birth is not desirable or advisable for everyone for various reasons. All I am trying to do in this letter is explain to you why we have made our decision.
First of all, you need to realize that we're not going into this blind. I have been studying, gathering information, and weighing options for several years now. I have read extensively on both sides of the subject and have talked to many women who have experienced birth at home, both with and without midwives. I feel I am well qualified, with all of the information I have, to make such a decision.
Second, you want to know about the qualifications of Mary, the midwife we have selected. A lot of women at our church have used midwives, and I called around for references. Her name came up repeatedly. One elder's wife I talked to said she had her sixth (and last) child with Mary, and it was by far the best birth she had experienced. We interviewed Mary and found that she was exactly what we were looking for. She is licensed by the state of Arizona as a midwife; she went to a three-year midwifery school in Tucson; she runs a training center for other midwives; she has assisted at well over a thousand births; she has one doctor whom she regularly works with as backup; and her rate of transfer to the doctor is less than five percent. She's also very nice and has four homebirthed children of her own. (BTW, midwifery is pronounced with an "F" sound, not a "V" sound.)
And third, you want to know just why we have made this crazy decision, right? Well, basically, we feel that we have a better chance of having a safe and healthy birth, baby, and mother outside a hospital. The rest of this letter will be explaining how and why. We believe, with good reason, that there is less of a chance that a home birth will have complications necessitating removal to a hospital than the chance that a normal, low-risk hospital birth will have medical interventions causing complications and distress to mother and/or baby, thereby necessitating further and more drastic interventions.
Okay, here goes.
To begin, there is not a single medical study proving hospital birth to be safer than planned home birth for the healthy (that is, not high-risk) mother and baby. In fact, the opposite. Let me quote:
Because prenatal care, better nutrition, antibiotics, and blood transfusions for maternal hemorrhage have become widely available over the last few decades, the infant mortality rate has dropped. This decrease was paralleled by a higher proportion of mothers who gave birth in hospitals, leading to the assumption that birth in the hospital attended by a physician was safer than home birth for all mothers. However, no study has ever supported this assumption . In fact, each of the alternative birth options in this book is usually safer than conventional hospital birth. In the alternative birth setting, the mother is at a reduced risk (and often at no risk) of iatrogenic (doctor-caused) medical complications and nosocomial (hospital-caused) infection and other problems in childbearing. . . .
Though hospital birth is safe for most mothers, medical studies have shown that there is an increased risk of maternal and infant morbidity in the hospital as compared to home. The risk of infection to mother and baby is greater in the hospital (where there are more pathogenic organisms) than at home. Varying with the hospital, the mother and baby are also at higher risk of iatrogenic complications. These include such problems as fetal distress from overuse of oxytocic drugs to stimulate labor and from pain-relief medication, infections from too many vaginal exams, and unnecessary surgical birth."
from Alternative Birth: The Complete Guide, Carl Jones
It is often claimed that because far fewer mothers die around the time of birth than, say, 60 years ago when most mothers had their babies at home, hospital birth must be the cause of this decline in the maternal and perinatal mortality rates. But the fact that two things happen at the same time does not mean that one causes the other.
Nor should we compare statistics of home births in different historical periods. Many things change, including women's health, their access to contraceptives, and their socioeconomic condition. These things have a profound effect on perinatal mortality. As the standard of living rises, fewer babies die at birth in every country, whether or not home births are allowed, and whatever the obstetric practice is.
from Homebirth, Sheila Kitzinger
Of course we're all glad that we have access to wonderful, life-saving medical technology. It's great to have when you need an operation, a shot, or some other life-saving technology. However, allopathic (regular MD) medical technology is not by any stretch of the imagination the only or even always the best way to go.
We feel we're not at a disadvantage; as pointed out above and discussed in more detail below, things are much less likely to go wrong in births outside the hospital setting. And actually, they rarely go wrong quickly. A vast majority of problems are slow in building and call for discussion and decisions anyway, so there is plenty of time to get to the hospital if necessary.
Let's look at the most common problems during a normal, low-risk birth that cause doctors to reach for their bag of interventions:
Long labor with slow
dilation
Tiring, but not in itself dangerous. No risk of mental handicap, despite
doctor's boogie-man stories. But if you're in a hospital and have a labor of
more than 48 hours (and sometimes far less!), you are at very high risk
of forceps delivery, vacuum extraction, or C-section.
Cephalopelvic disproportion
Usually a misdiagnosis because of lengthy labor. If there is true
disproportion, the mother should certainly go to a hospital; however, this is
by no means a sudden emergency, but a decision made by all involved after much
discussion when no progress is being made.
Long second stage
Again, tiring, but not in itself dangerous.
Baby in distress
Frequently brought about by medical interventions such as pain-relieving
drugs, which slow labor down, or contraction-inducing drugs, which stimulate longer
and harder contractions than normal. Even if a normal birth is distressing the
baby, it rarely necessitates a split-second decision. Electronic fetal
monitoring, internal or external, has been conclusively proven to provide
no better outcomes than intermittent external monitoring by handheld
stethoscope or Doptone. To the contrary, breaking the waters to monitor
internally or forcing the mother to lie still on her back for external
monitoring have been proven to increase fetal distress.
Shoulder dystocia (head
out, shoulders stuck)
This can generally be prevented by slow birth, with plenty of dilation time.
(See below for more on slow births.) When shoulder dystocia is a problem, the
mother can turn on all fours and deliver from behind. If this still does not
work, an episiotomy can be made (one of the few true medical indications for
episiotomy).
Baby has breathing
difficulties at birth
Most likely to occur when mothers have had painkilling drugs in labor,
including Demerol, sedatives, tranquilizers, and epidural, or when a C-section
has been performed. Other than the biggies (such as an incubator), all methods
of resuscitation used in the hospital are available at home: clearing airways,
giving oxygen, massage, etc.
Postpartum hemorrhage
Again, most likely to occur when obstetric intervention has taken place. Often
a problem when doctors try to pull the placenta out before it has completely
separated. However, midwives can administer artificial oxytocin by injection
to cause the uterus to contract firmly and stop bleeding.
Very few women are at any sort of risk in childbirth; of those few who are, at least 85 percent have risks that are predicted (preeclampsia, high or low blood pressure, diabetes, etc); that is, it's not a surprise at the time of birth that the mother may have difficulties. That's why high-risk mothers give birth in hospitals. For almost all problematic situations (except for the most serious life-threatening ones), midwives generally have alternatives to medical interventions that are healthier for mother and baby and considerably more conducive to normal birth. A normal, low-risk pregnancy is not a medical condition; in fact, a normal, low-risk pregnancy has a good chance of becoming an abnormal, problematic delivery when it takes place in a hospital: hospital births are associated with a much higher rate of infant and maternal mortality, along with myriad other problems.
Simply not true. Midwife-attended births have better outcomes than hospital births for both baby and mother. That is true even correcting for the high-risk births that take place in hospitals and comparing only low-risk hospital births to low-risk home births. It is true that our infant mortality rate is much lower than it used to be, but did you know that the US is today 26th - that's twenty-sixth! - in the world in infant mortality rate? In a country with such wonderful hospital facilities, that is worse than shameful, it's criminal. And yet, in industrial countries that use midwives as primary birth care providers (Japan, the Netherlands, Sweden, Holland, among others), the infant mortality rate is much, much lower than in countries that use doctors and physicians as primary birth care providers (as in the US). More quotes:
In Britain, Marjorie Tew was the first person to challenge the assumption that the rise in hospital births was directly responsible for the drop in [maternal and infant] deaths. She expected that the published data would confirm the view that hospital birth is safest, but was amazed to find 'that maternal and fetal death rates for comparable groups were always higher in hospital than at home whether the predicted risk was high or low...'
As more and more women went into hospitals staffed by specialist obstetric teams, the majority of them low risk who would have previously given birth in a small general practitioner unit or at home, the number of babies dying in these hospitals went up. Marjorie Tew then analyzed the statistics produced by the British Birth Survey of 1970 and, using the risk scores employed by the survey's researchers, showed that, except for the women at the very greatest risk, birth was safer at home or in a GP unit than in a hospital.
from Homebirth, Sheila Kitzinger
This is nothing against doctors, but unfortunately, our doctors are trained to treat the birth process as an illness and not as a normal function of a woman's body. They have never seen a normal, unmedicated, un-intervened-in birth. They have been trained in what to do for emergencies in birth, without being trained in what to do for normal, low-risk birth. They have never seen nor been shown how to treat birth as a normal, nonmedical condition. They know of no way to treat birth other than as a serious medical condition; ergo they end up treating all births as emergencies. This creates a self-perpetuating cycle: The doctor performs an unnecessary medical intervention, which causes a medical problem, which both justifies the original intervention and creates a need for further intervention.
On the other hand, midwives are specially trained in what to do for normal, low-risk births where mothers just need time, attention, and a trust that their bodies really do know what they're doing. Slow birth is a specialty of midwives, while doctors usually do not even realize that it is desirable to slow a birth rather than rush it, much less that the attendant can help coach the mother into a slow delivery. This is usually accomplished through "breathing the baby out," a general unrushed atmosphere, no clock watching, and making sure the mother is comfortable and dealing as best she can with whatever she's going through.
Let's look at just a few problems. If a mother is put on a monitor, has drugs, or happens to have a Neanderthal doctor who still lives in the dark ages, she is put on a bed on her back (maybe even with her feet up in stirrups - a holdover from the days of the twilight sleep, when mothers were knocked out completely and unable to assist in giving birth in any way; the doctors had to do everything, and this is obviously the position that gives them the most access to the baby). Discounting only hanging by the heels from the ceiling, on the back is the very worst position possible for labor and delivery. Lying flat on the back puts the weight of the uterus on the major blood vessels behind it and impairs circulation, besides making the mother work against gravity to expel the baby. Here are just a few of the problems caused by labor while lying flat on your back:
With a drop in blood pressure or fetal distress, the doctor will want to monitor the baby (if not do an immediate C-section). This entails amniotomy (breaking the waters) to screw an electrode into the baby's scalp (increasing risk of infection to baby and mother), which may cause further fetal distress and even a prolapsed cord if the baby is still high when the waters are broken.
Painful labor can slow progress; slower progress means more painful labor. Painkilling drugs (Demerol, etc.) slow labor even more; drugs to speed up labor (Pitocin or other synthetic oxytocin, which causes contractions) make labor more painful; use of either drug frequently necessitates the use of the other to mitigate the effect of the first drug on the labor. Pitocin not only causes more painful labor to the mother, it causes problems for the baby, too. It causes contractions that are longer and much more intense than those caused by the body's natural oxytocin, and since oxygen to the baby is briefly cut off during each contraction, this means that it is cut off for a longer period of time. This, of course, can lead to further fetal distress.
The truth is, the first stage proceeds most quickly if the woman is upright and walking around, as midwives encourage (in fact, my midwife wants me to ignore the first stage as long as possible - just act normal). The second stage proceeds with the least effort if the mother is upright - squatting, kneeling, or standing - as this increases the mother's pushing power, uses gravity to ease the baby down, and also opens the vagina to the fullest extent possible while at the same time shortening the birth canal up to twenty percent. But of course, it's not as convenient for doctors to direct births, intervene, or catch the baby if the mother's not lying on her back. Midwives, on the other hand, realize that the mother is the one doing all the work and they can just get to wherever they need to be to make sure the baby doesn't fall headfirst onto the floor. My midwife admitted she often gets backaches from the strange positions she takes to catch babies, but cheerfully says that's just part of the deal.
Yes, "most C-sections are done at times of distress to the mother and/or baby" . . . at least, according to the doctors who perform them! Many hospitals have a C-section rate of 25 to 30 percent, which is very close to the national average. This number has been climbing steadily for decades to reach its present high - without changing outcomes in the slightest. Statistically, around 5, maybe 10, percent of C-sections are necessary (meaning that they save lives as shown by drops in maternal and infant mortality) and helpful for mother and/or baby. (Many natural childbirth practitioners, however, have rates of only 3 percent with no increase in mortality.) Those over 5-10% are indeed often "necessary," but only because unnecessary interventions caused some sort of distress to mother or baby, as discussed above; or sometimes are just plain old excuses to use that nice shiny equipment and charge you an arm and a leg (or a uterus, as the case may be), with the bonus that babies are born on schedule, during regular office hours. (Yes, that's a fact, too - a significant proportion of C-sections are performed just before it's time for doctors to go off-duty.)
Probably the most frequent reason given for a C-section is cephalopelvic disproportion - the baby's head is too big for the mother's pelvis. However, now that the archaic idea "once a C-section, always a C-section" has been chucked out the window and mothers are having VBAC (vaginal birth after C-section), many of them deliver bigger babies VBAC, when the reason given for their first C-section was that the baby was too big for the pelvis!
A close runner up for most frequent reason given is that labor is progressing too slowly. Again, there is no evidence that reducing the length of the second stage makes labor any safer, prevents baby deaths, or produces healthier babies. If a baby is truly too large to come through the mother's pelvis, there are many clinical signs to indicate this, not the length of the second stage alone.
And, last but not least, who do you think has the largest rate of C-sections? Poor, uneducated, less healthy, less well-prepared mothers; or rich, well-educated, more healthy, better-prepared mothers? Well, the rich, of course - they have the insurance to pay for the equipment! But guess who has the very highest C-section rate of all? Female lawyers! Doctors are always aware that they could be sued if they don't take every medical intervention available (whether it truly helps or not) to show that they did their best to save a baby, so the women most likely to sue have the highest C-section rates! I realize that I'm not a lawyer and therefore not at highest risk of C-section, but it goes quite a way toward showing the mindset of doctors: don't want to be sued, the equipment is there, might as well use it.
I've actually heard people say that C-section babies looks prettier because they weren't squeezed out through the tiny opening. However, the problem is that other things besides the face get squeezed. Uterine contractions and the passage through the birth canal squeeze excess fluid from the lungs and massage the baby, providing important respiratory stimulus. Babies who don't get squeezed through the tiny opening are much more likely to have breathing difficulties after birth. Not only that, but if the C-section is mistimed, the baby may be premature, which of course carries its own set of difficulties.
But it's not only bad for the baby! The mortality rate for C-section mothers is almost four times higher than for vaginal birth, largely due to the effects of general anesthesia. Plus, infection rate is much higher than with vaginal birth, sometimes 65 percent higher, and may occur in the lining of the uterus, the urinary tract, or the incision itself. Or, an adhesion can develop, even years later, on a perfectly healed C-section scar and cause illness in the mother (as happened to my own sister 7 years after her C-section). Physical problems aside, C-section mothers are much more likely to suffer postpartum depression - the baby blues - than vaginal birth mothers.
I'd like you to perform an experiment for me. Take a piece of paper and hold it so that the flat side faces you with the longest side horizontal. Hold it by the very edge of the top two corners. Now pull your hands gently apart, straight to the side, trying to tear the paper. Now pull harder. It takes quite a bit of traction to tear the paper this way. Now, take a second piece of paper and cut a snip into the center of the longest side. Hold the paper in the same way as before, with the cut facing up so that it is between your hands. Apply the same gentle pressure. Tears quite a bit more easily, doesn't it?
Left uncut, the vast majority of women who are having unrushed births (that is, without doctors timing the second stage) and who receive proper care of the perineum will not tear at all, or will sustain only a very slight first-degree (skin-only) tear. All episiotomies are second-degree (muscle) wounds at least, and many women subsequently tear much further than the original cut (sometimes into the rectum). A smooth cut may be easier for a doctor to stitch than a ragged tear, but the tear is usually smaller than the cut would be, and heals quite well on its own or with only a couple of stitches.
Doctors, unfortunately, are never taught how to guard the perineum against tearing. Again, they have only ever seen births with episiotomies, so they only know how to perform births with episiotomies. And actually, episiotomies, like C-sections, do become "necessary" in hospitals. Many mothers in hospitals would tear if they were not given episiotomies, because along with never having seen a birth without one comes the fact that doctors do not know how to facilitate a birth without one, by guarding and taking care of the perineum. Most doctors will wait until the perineal skin turns white (no more blood in the area) and stretched and shiny-looking, announce that the skin is about to tear (which indeed it is), then cut. But midwives don't let the skin get all white and stretched and shiny-looking in the first place. Slow dilation and birth, with perineal massage if necessary, keeps the blood flowing in the area, keeps the skin and muscles flexible, and keeps her from needing an episiotomy, because the skin won't tear or will sustain only a minor surface tear, much less traumatic than a cut. [Since I originally wrote this letter, I have sustained three midwife-assisted homebirths without the smallest tear - and my babies have big heads!]
Considering that out of over 1,000 births, my midwife has had to give only two episiotomies (both medically necessary, shoulders stuck or some such problem), and that a tiny minority of the rest of her mothers tore enough to even consider whether they should have stitches or not, I'll take my chances on tearing. Not only because I hope not to tear, though. There are sound medical reasons for not having an episiotomy. The risk to the baby is very slight, of course, other than a possible nick on the head. But to the mother, risk is much higher - it is, after all, a surgery. If done too early, before the tissues thin out, it can cause unnecessary heavy bleeding. Blood loss may cause anemia. Many episiotomy wounds become infected and sometimes a perineal abscess results. Repair of episiotomy can be as painful or more painful than birth or the episiotomy itself. Women with episiotomies are in much more pain while healing than women with minor - or no! - tears. Some women have pain that remains for years from the large knob of scar tissue. Last but not least, a really nasty one: some unfortunate women, even after painstaking and painful suturing, are left with a recto-vaginal fistula (a gap in the wall between the rectum and vagina), so that feces pass through into the vagina.
Well, we understand. You haven't been reading and studying and mulling it over for several years the way we have (me voluntarily, my husband by necessity). We actually had one friend tell us, in no uncertain terms, that it is "irresponsible and a disservice to your child not to provide it with every opportunity to have its life saved in a crisis situation; to stay home when you could afford other care borders on criminal" (yes, that's a direct quotation).
What we told him is that we think it is irresponsible and a disservice to our child not to provide it with every opportunity to have a safe, healthy birth, and to avoid all crisis situations if at all possible, and we believe the best way to do this is to give birth in a place that is proven to do the best job of preventing crisis situations from developing: in our home with a skilled caretaker who knows how normal birth should progress and who knows how to facilitate normal birth without medical interventions. We are fortunate in having a skilled, caring midwife, who also has a physician backup in case something does go wrong, and who is skilled enough to have to use him in less than 5 percent of her more than 1,000 births. Incidentally, in the few births she has had to transfer to the doctor, not a single mother or baby has been compromised in any way by the extra time taken to reach the hospital.
The bottom line is, we both really believe that home birth is the safest possible birth for mother and baby. We also believe (which I didn't address in this letter at all) that it provides for the best emotional environment for the whole family, with the least amount of stress and difficulty possible.
Well, that's about it. I want to reiterate that I'm not pointing any fingers or accusing anyone of anything. (Okay, I do accuse doctors of a few things, but I'm not accusing anyone of being a bad parent.) I am simply explaining why I have made the decision I have made, which I realize is not a decision all women will make or should make. It is definitely not a choice that any woman should make unless she is absolutely 100% convinced that it is best for her personally, and unless her husband is also behind her 100%. However, I think it's not too out of line for me to say that this is a choice worthy of investigation, and that it is unfair for anyone to condemn it out of hand without investigating it.
I wrote this letter while pregnant with my first child. I have subsequently had three extremely healthy homebirths with Mary, and have never torn even the least little bit.
Copyright (c) 2002 Carma Paden. All rights reserved. No portion may be reproduced in any fashion without express permission.