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Home birth from the view of orthodoxie

31 March 2009 5 Comments

I received the following comment from my posting related to the article Extreme Birth.  I thought I would post it as an entry along with commentary, rather than just add it as a comment, as I think it illustrates the conflated sloppy thinking that is so commonly associated with these topics.

Here are the comments by Tori Kropp RN along with my responses in ALL CAPS.

Birthing babies is what I love most in the world. The fact that I now have women ask me  –is it really bad for me to have my baby in a hospital? –breaks my heart and has forced me to come out swinging. Enough is enough. I can no longer sit back and listen to this dialogue about homebirth come up again and again without inserting some badly needed facts and a serious reality check.

The argument is always the same by homebirth advocates. Hospitals are loud, hectic, bright, insensitive, uncaring machines full of greedy doctors and overworked  – medical personnel – (I am pretty sure as a nurse, that means me) who are just waiting to hook women up to unnecessary medications and prevent them from  -trusting their bodies.

I FOR ONE HAVE NEVER MADE THIS ARGUMENT.   AND I BELIEVE THIS MISCONSTRUES THE DEBATE.  YES HOSPITALS ARE OFTEN PORTRAYED AS BEING INFLEXIBLE AND INHOSPITABLE TO BIRTH, AND OUR EXPERIENCE IN NEW YORK, AT LEAST, HAS BEEN GENERALLY CONGRUENT WITH THIS ASSERTION.    THIS IS NOT TO SAY THAT SOME HOSPITALS HAVE TAKEN STEPS TO UPDATE LABOR PRACTICES.

BUT IN GENERAL, THEY ARE INHOSPITABLE TO BIRTH ON BECAUSE THEY ARE FUNDAMENTALLY BASED ON A DIFFERENT MODEL OF CARE – BASED ON PATHOLOGY. THIS CREATES BARRIERS TO NATURAL BIRTH ON TWO FRONTS.

ONE IS PHYSIOLOGICAL — WHEN YOU ARE HOOKED UP TO A CONTINUOUS FETAL HEART MONITOR YOU ARE IMMOBILIZED.  DATA DEMONSTRATES THAT THE ADDITIONAL INFORMATION PROVIDED BY CONTINUOUS MONITORING DOES NOT LEAD TO BETTER OUTCOMES — INDEED IT PROVIDES TOO MUCH INFORMATION THAT LEADS TO UNNECESSARY INTERVENTIONS INT EH SAME WAY THAT MRI’S OF THE BACK DO.  FLUIDS AND FOOD ARE RESTRICTED IN ANTICIPATION OF SURGERY, EVEN THOUGH THESE PRACTICES IN FACT HELP TO PRECIPITATE A SURGERY.  HOSPITALS INSIST ON BEING HOOKED TO AN IV, FURTHER RESTRICTING MOBILITY, FURTHER HINDERING LABOR AND ADDING DISTRESS TO THE FETUS.  ONCE THE CHILD IS BORN, THERE IS OFTEN LIMITED CHILD-PARENT CONTACT.  VERNIX IS CLEANED OFF.  SO THEY ARE NOT JUST LOUD AND UNFRIENDLY, THEY ARE BAD FOR NORMAL BIRTH.

THE OTHER IS PSYCHO-SOMATIC IN NATURE.  WHEN YOU ARE IN AN UNFAMILIAR SETTING WITH STRANGERS COMING INN AND OUT OF YOUR ROOM, IT IS DIFFICULT FOR YOUR CERVIX TO DILATE.  THERE IS SIGNIFICANT DATA DOCUMENTING THIS, WHICH INA MAY GASKIN APTLY CALLED “THE LAW OF THE SPHINCTER.

I HAVE NEVER SEEN ANYONE DEPICT THE DRIVER OF THIS BEHAVIOR AS “GREEDY DOCTORS.”      INDEED THERE ARE DOCTORS OUT THERE WHO WOULD SIGNIFICANTLY MODIFY THE PROTOCOLS IN PLACE, BUT THEIR HANDS ARE TIED.  RATHER I HAVE SEEN THE INCENTIVES OUTLINED AS BEING DRIVEN BY THE LITIGIOUS NATURE OF OUR SOCIETY COMBINED WITH INSTITUTIONAL DRIVES TO MINIMIZE RISKS.  HOSPITALS AND INSURANCE COMPANIES ARE USING WORST-CASE SCENARIOS TO DRIVE PROTOCOLS.  THIS DRIVES BEHAVIOR THAT IS OPTIMIZED TO REDUCE INDIVIDUAL RISK AT THE EXPENSE OF OPTIMAL POPULATION-LEVEL OUTCOMES.

The argument goes on to state that homebirth is safer, more satisfying, more loving, more empowering, less interventive, healthier for the baby, more spiritual and on and on. Anyway you shake it that very implicitly pronounces that to give birth at home is…  – better -. Period. But always, at the end of any article, blog or comment about it by it’s proponents, are the words  – but a woman should be encouraged to give birth wherever she feels most comfortable, including a hospital.

THERE IS QUITE A BIT OF CLINICAL DATA THAT DOES BEAR OUT THAT HOME BIRTH IS SAFER FOR LOW-RISK PREGNANCIES.  NOW WHILE THE CLINICAL DATA MAY INDEED BEAR THIS OUT, THIS SAYS NOTHING OF THE MENTAL STATE OF A WOMEN WHO IS DUE.  MANY MANY WOMEN ARE FAR MORE COMFORTABLE GOING TO A HOSPITAL THAN GIVING BIRTH AT HOME, AND FEAR WOULD INTERFERE WITH BIRTHING AT HOME.  THE WRITER CONFUSES THE OVER-RIDING DESIRE TO SUPPORT WOMEN AND TRYING TO DRIVE A GRADUAL CHANGE IN PERCEPTION AND BEHAVIOR.  THIS SHOULD NOT BE CONFUSED WITH A DISCLAIMER.

Wait a minute. Is that what you just said? Let’s assume I am having my first baby. I am very excited and I want to learn everything I can, and of course, I want to do what is best for my baby and myself. Do I choose to have the  -scary, cold hospital birth – that I was told about or the  – loving, empowering, spiritually-fulfilling homebirth? I am very likely to make the choice to give birth in either a birth center or a hospital but wow – what a set-up for feeling badly about my choice.

Let’s look at some actual facts about birth in the United States:

Over 4 million women give birth each year

97% of women give birth in a hospital

2 million women live below the poverty line and have limited access to adequate maternity care

100 years ago, a woman had a significantly high chance of dying during childbirth . Medical advances, including the use of antibiotics, oxytocin to induce labor, safe blood transfusions and better management of hypertensive conditions during pregnancy, are directly responsible for the decline in maternal death rate.

WELL I AM NOT SURE WHAT CONCLUSIONS THE WRITER IS TRYING TO SURMISE AT THE NUMBER OF BIRTHS OR THE PERCENTAGE OF BIRTHS IN THE HOSPITAL.  BUT FALSE CONSENSUS IS NO ARGUMENT FOR WHICH PRACTICE IS BETTER FOR A POPULATION.   NOR AM I SURE WHAT THE AUTHOR IS TRYING TO SAY ABOUT POVERTY.  NO ONE IS ADVOCATING FOR WOMEN TO GIVE LABOR WITHOUT NECESSARY CARE (INCLUDING PRENATAL).

COMPARING INFANT AND MOTHER MORTALITY RATES NOW TO 100 YEARS AGO  TO ARGUE AGAINST HOME BIRTH IS A LITTLE STRANGE.  IT IS LIKE SHE IS EQUATING CONTEMPORARY HOME BIRTH TO BIRTH CONDITIONS 100 YEARS AGO.  HOW ODD.  THE DECLINE OF THE MATERNAL DEATH RATE IS NOT JUST DUE TO OXYTOCIN TO INDUCE LABOR BUT THE ENTIRE HOST OF PRENATAL CARE, PLUS GENERALIZED HIGHER NUTRITION, ETC..  WHAT A FALLACIOUS ARGUMENT…  IT DOES REVEAL HOW MANY PEOPLE VISUALIZE A HOME BIRTH, A LONE HOUSE ON THE PLAINS, A POT OF BOILING WATER ON A FIRE, A LEATHER BELT TO BIT ON…

Today, around the world, every 60 seconds, a woman dies during pregnancy or childbirth, often from an avoidable cause. There are no well-documented, large-scale studies that show that homebirth is either safer or more satisfying than hospital birth. We have  -far from perfect – health–care in this country when it comes to taking care of moms and babies. However, there is truly a disconnect with what is really important here. Perhaps those who exert so much energy on faulting the U.S. maternal/health care system could spend even ¼ of their time working to provide better access to care for the 2 million underprivileged women here who really need it.

THERE IS QUITE A LARGE AMOUNT OF CLINICAL DATA AND I HAVE POSTED SOME OF IT ON THIS BLOG, INCLUDING METASTUDIES.  THIS, OF COURSE, IS FOR LOW-RISK NORMAL PREGNANCIES.

NO ONE IS ARGUING THAT MEDICAL INTERVENTION IS NOT A VALUABLE TOOL TO IMPROVE THE HEALTH OUTCOMES OF THE POPULATION.  THE DEMONIZATION OF THE HOSPITAL SYSTEM, I BELIEVE, STEMS FROM THE ITS MIS-APPLICATION TO NORMAL BIRTH.

I AM NOT SURE HOW ADVOCATING FOR HOME BIRTH IS AT THE EXPENSE OF UNDERPRIVILEGED WOMEN.  HOME BIRTH IS MUCH CHEAPER THAN HOSPITAL BIRTH, AND THE MEDICAL SYSTEM WOULD CERTAINLY SERVE THIS POPULATION BETTER IF HOMEBIRTH WAS INCORPORATED.  HOMEBIRTH LIES MOSTLY OUTSIDE OF THE MEDICAL ESTABLISHMENT, SO THE INABILITY OF THE MEDICAL SYSTEM TO SERVE THE POOR HAS LITTLE RELEVANCE

I have shared in the births of several thousand women at homes, in birth centers and in hospitals. I have seen miracles, tragedies, difficulties and wonder in all of those places. What angers me so deeply is the direct insinuation that giving birth in a hospital denies a woman a safe, positive and life-affirming birth experience. What kind of support is that? A woman deserves to feel nurtured by other woman, not faulted, questioned or criticized. There is no  -better or best -way to give birth and I am no longer going to be quiet about it.

WAIT A SECOND.  THE WRITER IS FURIOUS THAT HOMEBIRTH ADVOCATES ALWAYS END WITH THE CAVEAT THAT YOU SHOULD HAVE THE BIRTH YOU ARE COMFORTABLE WITH.  BUT NOW SHE IS LIVID THAT THESE SAME ADVOCATES DENY THAT ANY HOMEBIRTH CANNOT BE POSITIVE FOR ANY WOMAN.  IS IT SAFE, WELL NOT AS SAFE AS A HOME BIRTH IF YOU ARE LOW-RISK.  SAFER IF YOU HAVE A HIGH-RISK PREGNANCY.  POSITIVE AND LIFE-AFFIRMING, WELL THIS DEPENDS ON HOW YOU WANT TO BE TREATED.  I AM SURE THERE IS QUITE A LOT OF VARIATION IN PATIENT CARE ACROSS HOSPITALS, AND THERE CERTAINLY IS A BIG QUALITATIVE DIFFERENCE BETWEEN BIRTH CENTERS AND HOSPITALS.

IT IS IRONIC THAT SHE SAYS THAT WOMAN SHOULD NOT BE CRITICIZED FOR HAVING A HOME BIRTH.  BUT AS SHE NOTED, 97% HAVE HOSPITAL BIRTHS.  THE FEW MOMS WHO GIVE BIRTH AT HOME ARE MADE TO FEEL LIKE PARIAHS.  THOSE WHO HAVE WONDERFUL NATURAL BIRTH STORIES HOLD THEIR TONGUES FOR FEAR OF MAKING OTHER WOMEN FEEL INADEQUATE ABOUT THEIR BIRTHS.  THIS IS THE TRAGEDY.  WOMEN SHOULD KNOW THERE IS AN ALTERNATIVE AND A HEALTHIER ALTERNATIVE.  ONE THAT IS BETTER ON MANY ACCOUNTS.

AND THE CLINICAL DATA IS WHAT IT IS.  THERE IS A BETTER WAY TO HAVE A NORMAL LOW-RISK LABOR.  AT HOME.  THE DATA FROM N AMERICA AND W EUROPE IS OVERWHELMING AND ROBUST.  SHOULD WOMEN FEEL BADLY ABOUT GIVING BIRTH IN THE HOSPITAL?  NO ONE IS ADVOCATING THAT.  IT IS IRONIC THAT THE WRITER FEELS OUTNUMBERED BY THE HOME BIRTH MOVEMENT WHEN THIS COMMUNITY IS CONFRONTING THE MEDICAL ESTABLISHMENTS INTERESTS.  HOSPITALS MAKE A LOT OF CASH OFF OF BIRTHS.  ACOG HAS AN INVESTED INTERESTED IN PREVENTING HOME BIRTH.  AND THEIR STATEMENT ON HOME BIRTH, WHICH IGNORED VAST AMOUNTS OF DATA THAT HAS SHAPED PUBLIC HEALTH POLICY IN MUCH OF WESTERN EUROPE, IS EVIDENCE OF THE BIAS.  MOST WOMEN DO NOT CHOOSE A HOME BIRTH BECAUSE THEY ARE SCARED INTO A HOSPITAL BIRTH.  WHO IS BEING IRRESPONSIBLE HERE?  HOW IS ADVOCATING FOR POLICIES THAT LEAD TO UNNECESSARY INTERVENTIONS AND ALL THEIR COMPLICATIONS?

THE BOTTOM LINE, IS THAT THERE IS A BETTER WAY.  YOU CAN STILL CHOOSE TO HAVE A HOSPITAL BIRTH BECAUSE YOU ARE MORE COMFORTABLE, BECAUSE YOU ARE AFRAID, BECAUSE YOU DON’T BELIEVE IN DATA.  BUT IT DOES NOT CHANGE THE FACTS.

5 Comments »

  • Alex said:

    This comment really struck me: “THOSE WHO HAVE WONDERFUL NATURAL BIRTH STORIES HOLD THEIR TONGUES FOR FEAR OF MAKING OTHER WOMEN FEEL INADEQUATE ABOUT THEIR BIRTHS.”

    I would love, love, love to share my birth story (an unmedicated birth at a freestanding birth center) and hear the birth stories of other women, including those who have had various interventions and even c-sections. I would never judge another woman’s experiences or preferences – I just want to share them. I think we would all gain so much from such an exchange because we would have a deeper understanding of the risks and benefits of every choice. But sadly, I feel like I must never volunteer anything about my experience. I hesitate to even confess that my daughter was not born in a hospital even when directly asked by other mothers for fear of them assuming that I do not support their choices or that I am judging them. I have been accused as much for answering questions that I did not myself initiate. This is such an unfortunate situation.

  • WendyCPM said:

    I really enjoy reading your blog — I have visited a few times now and am always struck by your reasoning. We’ve just started a blogroll on our Facebook page (http://www.facebook.com/business/dashboard/?ref=sb#/pages/Portland-OR/Vivante-Midwifery-Womens-Health/41471837073) — would you be willing to allow us to link to this blog? I’m sure that our dads would enjoy your posts too.

  • Juliet Grossman said:

    This is a fascinating topic. I think my experience defies categorization. I had both my daughters (now three and almost seven) at hospitals. I had drugfree deliveries with both. I did have what some people consider inducements both times. With my oldest, my water completely broke at home (at 39 wks) but I was not having contractions in much of any type of pattern. I’d been on 23.5 hrs a day bedrest for 11 weeks because I was 80% effaced from week 25 and at very high risk of preterm delivery.

    I’d talked with my doc a lot about ways to minimize chances of c-section, and when I arrived as I did, she explained why she recommended pitocin, and I took the pitocin, and that created contractions so my daughter was born a few hours later. After talking to my doc at length about it in my office visits before labor, I knew this was a use of pitocin that I felt positive about, and it worked out well.

    For my younger daughter, labor was going great but I was about 8 cm and my water still had not broken at all. It’s hard to describe why but this was incredibly uncomfortable and I knew that labor was going to fully progress once my water broke. On my request my doctor did break my water and my daughter was born about an hour later.

    How I did drugfree labor — breathing (I do a lot of yoga so I just used 2:1 yoga breathing) and the knowledge that “this too shall pass” – it’s painful, but eventually the pain does end. It was very psychological for me.

    Drugfree labors are so rare at Palomar Hospital (Escondido, CA) where my younger daughter was born that they brought nursing students into my room to see what a woman in natural labor looks like. (Talk about pressure to not freak people out! These girls were *young* so I tried to make it look like it didn’t hurt quite as much as it did.)

    If you have a baby at a hospital you really have to know what you want, do your own research, partner with your doctor, communicate with your doctor, choose a doctor who will listen and who is on the same page with you, and be assertive. The hospital where I had my older daughter (Riverside Community Hospital in Riverside, CA) is very, very old school. Believe it or not I had to fight for rooming-in after she was born (I didn’t trust that they wouldn’t give her glucose to keep her from crying. Sadly two nurses at the hospital I’d talked to before let me know this was a valid worry.) They actually came to my room at 2 a.m. and tried to get me to give them the baby so they could bring her to the nursery (yes, they have the old-school nursery with rows of babies lulled to sleep with bottles at this particular hospital.) She was crying and “disturbing others.” Well it’s a HOSPITAL! The LABOR AND DELIVERY wing of a hospital, no less. Women are SCREAMING and babies SHOULD be crying. What more welcome sound than a healthy baby crying. So sorry to disturb you IN THE HOSPITAL. (Sometimes people are stupid.)

    I will say about home birth and risk etc — I had a sudden emergency occur during Jane’s (younger daughter’s) birth. During pushing I began to bleed quite a lot. The doctor performed an emergency episiotomy (not as painful as it sounds, though I was looking up at the nurse and the look on her face as she realized and watched what he was doing was pretty horrifying.) He told me later there wouldn’t even have been time to do an emergency c-section. He also injected me with two different drugs that stop bleeding. Some midwives carry one of these but that one (most common one) didn’t work and the other one kind of did work. Women do sometimes die in childbirth even in the “first world” and I shudder to think that what turned out to be a nuisance (slightly anemic from losing blood and full episiotomy) could have been ME=DEAD.

    Sorry this turned into a novel – such a meaty topic.

  • Tori Kropp RN said:

    I so appreciate your response to my post. As I have mentioned, I have attended many thousands of births so my words on not based on my personal ideology but rather on what I have seen, learned and experienced first hand with laboring women around the world. I will address respectfully just of couple of your points for clarification.

    The actual research data shows that homebirth and hospital birth are EQUALLY the same in terms of low-risk, non-complicated births. One has not been shown to be better than another. Also, in the majority of countries where homebirth is the norm, they are attended by nurse-midwives or midwives who have been trained in solid educational programs rather than empirically by apprenticing with a lay midwife. They also have complete physician back up support and a strong relationship with a hospital, should the need arise.

    If hospital birth in New York is as you say ( and I do not know) than birth in California is vastly different. I currently practice in the largest hospital in Northern California where we birth over 6000 babies per year. Women without medical indication are not required to have continuous fetal monitoring and when they do, it can be by telemetry allowing complete freedom of movement. Women are also not prevented from eating and IV’s are certainly not required unless a woman requests pain medication or has a reason, based on either safety or that of the baby’s. Our primary ceserean section rate is 17% which includes a highly acclaimed high-risk perinatal practice.

    Unfortunately, your arguments are largely based on again, empirical data rather than solid studies. It is absolute nonsense that a woman’s cervix does not dilate because she is in unfamiliar surroundings. Tension certainly has an influence, however to say “what” that tension is is completely arbitrary. Equally, as often a woman’s cervix dilates easily when she has been relieved of pain that may, in fact, have been causing her tension. I have been to The Farm and respect Ina May Gaskin in a way you may not fully appreciate. I encourage you to base your opinions not on data that only supports your way of thinking but on all data. I welcome you to present large-scale studies that support several of your positions.

    I stand strongly by my statements that pain relief and birthing in an environment that provides potential safety for mom and baby does not preclude a woman from having an amazing, spiritual and fulfilling experience.

  • admin (author) said:

    Thank you for the comment Tori. I think that we both agree and disagree on a number of topics.

    Yes the current clinical data does demonstrate that intranatal and neonatal mortality rates are about the same for home births and hospital births. However, with a nation-wide c-section rates at around 30%, hospital birth carry an additional health burden. And extra costs. And this is incorporating the statistics of birth overseen by lay-midwives. So if you are arguing that lay-midwives are not qualified and lead to poor outcomes, excluding these births from the data would have to then show that home birth had better outcomes then hospital births.

    Fundamentally, I don’t think that many folks would argue that a hospital birth is by definition a bad thing. No one would argue that the technology and surgical skills cannot add value when complications arise. But the practical application of protocols in hospitals is driven by incentives other then optimal birth, from minimizing risk exposure to optimizing bed turn-around. California Pacific Medical Center in San Francisco is a great institution that I visited as a patient several times while I was in San Francisco. And I am glad that their rate of interventions is much lower to the national average and more in line with what the WHO would define as the optimal rate. But most hospitals are not so progressive.

    I suspect that you make a trade off in health benefits between home births and hospital births, as well as risks. If one could combine some of the beneficial practices of home birth (including familiarity and lack of pressure) with the technology and surgical expertise of a hospital, one would assume that optimal birth outcomes would be attained. This is exactly what birth centers try to accomplish. Unfortunately, New York only has one such center: http://www.nywomenshealth.com/birthing-center-st-lukes-hospital-new-york.htm. There is also the a second free-standing birth center planned: The New Space for Woman’s Health http://www.newspacenyc.org/

    I do not think that I am cherry-picking favorable studies. And not sure what you mean by saying that I am using empirical data rather than solid studies. Are these not the same thing? In terms of the “sphincer-law” that Gaskin discusses, she is simply stating that whatever makes you self-reflective and takes you our of the labor slows progress. This is not hospital specific. We experienced this exactly when our midwife came to our home to check on Tara’s labor. As soon as Tara was aware that she was being observed, her contractions all but ceased. When the midwife left, they resumed. It is true that I do not know of any clinical study of this effect, but is not hospital specific per se.

    Honestly, I do not think I know enough to argue specifically for or against pain relief. What I have argued, is that mobility, access to water, conformt with your surroundings, and feeling safe, all contribute to pain relief. If that can occur in a facility that has an OR available, all the better. Right now in NY, that is very hard to come by.

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