Home II
Many moons ago, when I was relatively new to the blogosphere, I wrote a post critical of home deliveries, and it gave me my first introduction into how volatile the "commentsosphere" could be. In a comment on a post a few weeks ago, cj brought up the subject of home deliveries again and wondered what my feelings were on them now. Since I'm always looking for ideas for posts, I thought why not write about them again? Now I know how to cut off comments if I have to (just kidding!)
I should say that in the two disasters I saw from home births, both were done by uncertified midwives who kept the mother in labor at home way too long when other intervention was called for, resulting in dead or severely brain damaged babies. Not surprisingly, this did not give me a good impression of home deliveries. It's only fair to admit, though, that there is a difference between uncertified and certified midwives, and perhaps things would have been different with certified midwives who knew what they were doing.
Still, though, I'm not quite ready to give my full blessing to home deliveries. Like most neonatologists, I've seen babies come out bad unexpectedly from supposedly low risk deliveries, and when that happens, frankly, it's good to have a neonatologist around. Sure, midwives are trained in newborn resuscitation, but unless you resuscitate depressed babies all the time - like neonatologists do - you're not going to be that good at it.
In the comments to that long ago post, several people cited literature about the safety of home versus hospital deliveries, both pro and con. Normally I'm a big fan of evidence based medicine and making decisions using data, but this might be one time where the literature is not that helpful. The problem is that disasterous deliveries, whether at home or in the hospital, are very low frequency events, so a study would have to be almost prohibitively huge to give a fair comparison of home versus hospital outcomes. I'm simply not convinced that any of the studies cited were big enough.
I still think that the best solution is for hospital based deliveries to get better, to ditch the impersonal and degrading garbage associated with them. I think deliveries done in a dedicated birthing center, perhaps in a separate building on a hospital campus, with nice rooms and quiet delivery personnel, yet connected to the hospital in case rapid action is needed before, during, or after delivery, is the way to go.
Come on folks. Both sides have to give a little in this debate. Pro home-birthers need to acknowledge that it's about the baby, not the experience, and that homes are simply not as well equipped to handle bad babies as hospitals are. Anti home-birthers, though, need to acknowledge that too many hospital deliveries have too many unnecessary impersonal and obtrusive things, ranging from yelling obstetricians to lousy, stirruped posture, to normal babies being whisked away from their mothers right after delivery. It's too bad; it shouldn't be that hard to give a good birthing experience in a hospital - but apparently it is.
I should say that in the two disasters I saw from home births, both were done by uncertified midwives who kept the mother in labor at home way too long when other intervention was called for, resulting in dead or severely brain damaged babies. Not surprisingly, this did not give me a good impression of home deliveries. It's only fair to admit, though, that there is a difference between uncertified and certified midwives, and perhaps things would have been different with certified midwives who knew what they were doing.
Still, though, I'm not quite ready to give my full blessing to home deliveries. Like most neonatologists, I've seen babies come out bad unexpectedly from supposedly low risk deliveries, and when that happens, frankly, it's good to have a neonatologist around. Sure, midwives are trained in newborn resuscitation, but unless you resuscitate depressed babies all the time - like neonatologists do - you're not going to be that good at it.
In the comments to that long ago post, several people cited literature about the safety of home versus hospital deliveries, both pro and con. Normally I'm a big fan of evidence based medicine and making decisions using data, but this might be one time where the literature is not that helpful. The problem is that disasterous deliveries, whether at home or in the hospital, are very low frequency events, so a study would have to be almost prohibitively huge to give a fair comparison of home versus hospital outcomes. I'm simply not convinced that any of the studies cited were big enough.
I still think that the best solution is for hospital based deliveries to get better, to ditch the impersonal and degrading garbage associated with them. I think deliveries done in a dedicated birthing center, perhaps in a separate building on a hospital campus, with nice rooms and quiet delivery personnel, yet connected to the hospital in case rapid action is needed before, during, or after delivery, is the way to go.
Come on folks. Both sides have to give a little in this debate. Pro home-birthers need to acknowledge that it's about the baby, not the experience, and that homes are simply not as well equipped to handle bad babies as hospitals are. Anti home-birthers, though, need to acknowledge that too many hospital deliveries have too many unnecessary impersonal and obtrusive things, ranging from yelling obstetricians to lousy, stirruped posture, to normal babies being whisked away from their mothers right after delivery. It's too bad; it shouldn't be that hard to give a good birthing experience in a hospital - but apparently it is.
posted by neonataldoc at 7:52 PM
54 Comments:
Pro-homebirther here, I fled from the hospital based infirmary system to protect the baby, not for the experience. In all my reading I've only seen pro-hospital folks think we did it for the experience.
After reading Henci Goer, Obstretric Myths vs Research realities, I knew that the interventions cause the majority of the depressed babies. Even the IV was shown to delay labor. It dilutes the hormones in your bloodstream that the baby put there to say, "Now". The intake forms dismiss labor. Literally we get scared and shut down labor. Animals need a safe quiet place to labor, if they are threatened, they can delay labor until safe.
Thanks for acknowledging that hospitals must change if we want fewer dead babies. How 'bout if we start by forbidding the docs to say, "We must break your water or you have to go home"?
Doc, you did a nice job on this piece. Currently pregnant, I'm immersed in reading of the two camps on this subject - and the only one I want, doesn't exist apparently (a pleasant, hands-off hospital birth).
I'm terrified of delivering at home because of those "What-Ifs" and how I'd never be able to forgive myself not having every medical intervention available for my baby. On the other hand, my last 23 hr pitocin driven labor, pushy nurses, and protocol, with an eventual C-section was horrible.
I want a healthy baby foremost; but surely I ought to be able to find a happy medium between my previous highly invasive birth and squatting my baby out in my own living room.
In my small town in rural America, it seems unlikely. The best I can do is to continue to educate myself and make clear and confident choices when the time comes.
stockingup99, if doctors didn't tell my mother they needed to induce and eventually do an emergency cesarean - Neither my mother nor I would be here today. That is something that couldn't have been done at home and if it was at home by the time she would've gotten to the hospital which was over an hour away, we'd have been gone.
As for the hormone, Neonatal Doc can definitely correct me if I'm wrong but I *thought* what they give you is oxytocin (cuddle hormone) to help labor along. I've also heard that rubbing ice on a laboring woman's nipples helps release more oxytocin and speeding the delivery. The only drugs I can think of that would help reduce uterine contractions are given for early labor and are ritodrine and terbutaline (Bricanyl). Of course though there are probably others but these are the ones I know of. Again Neonatal Doc, correct me if I am wrong :)
I would rather have a hospital birth, if I were to ever miraculously get pregnant, even if I had the option of a midwife. Certified ones are great but I'd feel safer inside a hospital.
NeoDoc, there definitely needs to be a happy medium but the option of a private, out-of-the-way wing for private deliveries and a warm, comfortable setting sounds too good to be true for the lower to middle class mother-to-be, especially if that mother-to-be is located in an urban setting. Anyone with enough money can secure a private room with attentive hospital staff and a comfortable decor, but what about the non-wealthy? Hospital stays are expensive! (note: I am not a militant pro home birth-er, I just wish to bring up the ever-present issue of class)
Can't we all just get along...? ;)
Seriously though, one thing I have learned is that everyone is different and there is rarely one thing that works for everyone. I think that is the same for birth. I am in the middle and can see both sides to the argument. For some women, home births are wonderful experiences. For others, the hospital is where they choose/need to be. In both situations, it is possible for things can go well or badly...
What I would like to see is both sides working together so that whatever birthing experience a mother may choose, we can make it as safe and healthy as possible.
Just my 2 cents...
Interesting post. I like your ideas. I'm a "pro-hospital" person myself, but I do understand others' needs and wants.
When I was a nursing student, I actually did an honors project working in an Amish Birthing Center here in Ohio. It was built specifically to care for these women who wanted a home like setting, but also for the doc (yes, there was only one!) who needed access to life saving equipment if needed. Plus, it made it so the doc did not have to make house calls to women ready to deliver (remember, they have no phones to call the doctor so someone would have to go retrieve him and bring him back!) It was very much set up like a home with couches and tubs and kitchenettes. All "medical" equipment was very well hidden. The births were very low key and quiet. The mom directed what she wanted done or not done. It really is a lovely place and our current hospital settings could learn from this center.
A good CNM at a birth center knows when transfer is necessary, and in our case that happened long before delivery. I've had an OB attended delivery with the usual interventions and I should have gone in better informed - my fault. Second baby we chose a midwife at the hospital and had to fight to avoid interventions, then had to fight the nursery to get our baby back into my room. And the midwife didn't even arrive in time, my husband & the nurse delivered our daughter.
Then we decided to try a CNM at a birth center in close proximity to a hospital. She transferred me to a perinatologist when complications developed and I delivered by c-section under general at 23 weeks. The peri advised me to return to my midwife for prenatal care and try for a VBAC delivery with our next baby, though new guidelines suggest all VBACs be attended by an OB w/anesthesiologist present?
After a lot of research and discussion and consultations w/our CNM, OB & peri, we decided to sign all the waivers and deliver at the birth center. I was home less than 3 hours after delivery and it was one of the most amazing experiences of my life. Was it a risk? Yes. But I trusted our medical team, and that was a trust they had worked hard to earn over the years. So maybe it's less about location and more about trusting the people we chose to help us bring our children into the world?
As for cost, our birth center works w/medicaid and uninsured families. The fee is less than that of a hospital delivery. Moms can get a free consult to determine if they are good candidates to deliver out of the hospital and she does not hesitate to transfer, as we know from personal experience. I don't presume that all birth centers are equal - I know that ours is exceptional! I think too often we go into pregnancy not well informed and that's something we can all work to change.
Heidi
I agree with stockingup99....I also had homebirths to protect the baby AND to protect myself from an unnecessary or "convenient" (for the OB) cesarian surgery.
(BTW: Henci Goer also has another excellent book: "The Thinking Woman's Guide to a Better Birth")
I asked my certified midwife about HER statistics regarding troubled babies and births. Forgive me for not knowing the exact number of people in the "study" (over 1000 easily), but over a 24 year period, her stats were that only 2% of the women who labored under her care actually needed her to intervene on either their behalf or their baby's.
And in that time frame, only ONE baby has died. And the doctors at the local hospital said that the baby would've died THERE too--the case was so rare. But she DID save the mother's life by her quick thinking.
Those are stats that I can live with, personally.
BUT, I do agree with you. I think that birthing centers are a wonderful "compromise", and more women would use them, if they were available. There are none in my state, that I know of. It's really too bad.yehewkih
I appreciate your tone on this one doc. I think you make several good points that I agree with. Hospitals have a lot of room for improvement, and there are safer choices than home for the baby.
I know many people who think freestanding birth centers are the middle ground. Freestanding so that they are not under hospital protocols, yet either close to a hospital or (better yet) with docs on staff. Nobody can argue that the purpose of most hospital protocols are for protecting the hospital from possible litigation, not for the good of the individual birthing woman. (EFM anyone?) Hiding the medical equipment has no benefit if it’s trotted out and used in a non-evidence based way.
Home could be made safer by regulating midwives in all states, (people who have a concern about the training of midwives could focus on changing that) and by making it easier and faster to get help when it’s needed. Not everyone lives within 10 minutes of a level 3 hospital, and some people who do still can’t get help from that hospital in a timely manner.
While I agree that larger studies need to be done (and that will take time with the small numbers of home births happening currently) one thing that does stand out from these studies is that out-of-hospital is safer for Mother. Far fewer interventions result in far less morbidity (incontinence, sexual dysfunction, hospital acquired infections, surgery resulting in future miscarriages and infertility) out of hospital. For now, it’s safer for me to avoid a hospital. I would love to see some work done on lowering intervention rates in the hospital setting, it may bring me back to the hospital for a future birth.
We also need to work on the attitude of the staff in a hospital. Hearing someone standing behind a curtain giggling about the size of my areolas isn’t exactly the kind of respect I wish to receive when I’m doing the most important work of my life. I suppose if the staff were more accustomed to seeing a naked woman give birth, perhaps standing or on hands and knees instead of lying on her back, hearing the sounds an unmedicated woman makes (very sexual, it can be embarrassing to those who aren’t accustomed to hearing it). A little exposure to ‘normal’ and it’s variations would do hospital staff a ton of good. If I hadn’t felt badgered, disrespected, laughed at and just generally railroaded, I might not have felt the need to look for an alternative. Tolerance for all women and their unique personalities/choices would go a long way to boosting the hospital image. You could learn a lot from midwives in this area.
I applaud everyone who is keeping communication on this issue open and respectful. I wish more docs were open to learning from and teaching midwives. Maternity care in this country has a long way to go. Sadly, I can’t wait around for all this to happen. So for this pregnancy, I’m planning a home birth.
I had my two births with certified nurse-midwives at University Hospitals. The first was very long and would certainly have resulted in interventions without the care & patience of the midwife.
The second went much more quickly but had shoulder dystocia. The Midwife & their doc (head of family medicine at the Uni & a paediatrician) worked as a team to get my daughter out quickly, with great apgar's - 8 & 10). She had temporary Erb's Palsy (brachial plexus injury) but is now a competitive swimmer and gifted student who has been grade accelerated.
I thought the care was terrific, and really valued the fact that it was a team - your midwife didn't disappear just because you needed MD involvement. Although it was in-hospital, the interventions were minimal; only what was truly required.
i have seen severl home births gone wrong like you. i guess it is because where we work. they are truly heartbreaking for all involved.
i have attended a home birth of a friend as her friend. the certified nurse midwife was very professional and answered my curious questions matter of factly without any defensiveness. it was an interesting thing to witness.
my own experiences (g6p4) are in the hospital birthing in a birthing chair . all were wonderful experiences for me. two of my babies were sent to the nursery at my direction were further evaluation (thick, chunky meconium suctioned below the cords and a floppy, stunned girl after a precipitous delivery) but soon returned back to me. i do believe a freestanding birthing center is the way to go as well as doula support and lots and lots of education for moms prenatally. my deliveries took place the way i wanted and directed because i was empowered enough to ask "why" and "why not".
i am truly saddened when i hear some expecting mothers today discuss their planned epis and even sections, all, they explain and defend, so they can avoid pain.
Great post doc.
As someone who's been judged and scrutinized because of certain decisions (midwifery care, delayed vax, etc), I try to be non-judgmental of other parents and their choices.
It's pretty hard, however, not to have a strong opinion on unnasisted childbirth. I frequent altie forums just because some of the principles and values that they espouse resonate with me but reading birth stories, specifically the unassisted ones whose babies ended up dead just make me a little bit angry.
I chose to give birth not in a hospital but a freestanding birth center (although it was just across the hospital), but by God, if there is something, other than normal, I would not hesitate to be brought to a hospital which was what happened (water broke, no labor within 24 hours). Kudos to my midwife who did not hesitate and did not make me feel bad for the transfer and who stayed with me throughout. Kudos to my doc who let my midwife guide me through labor without intervening much.
I agree, there should be a happy medium. When homebirthers notice some meconium when their water breaks I think it is very criminal not to call 911 and get a hospital transfer.
I think unassisted childbirth should be carefully monitored and if possible should have some legislation attached to it. Maybe it's one way to prevent otherwise healthy babies from dying.
It is unclear if -r- realizes the difference between unassisted birth and attended home birth. Unassisted means the family has chosen not to have a childbirth professional attend their birth, wheras an attended homebirth has a professional attendant (usually midwife)
There has been quite a bit of data to show there are large differences in safety between the two. Having a qualified attendant (and the medical equipment such as hemmorage drugs and infant resus equipment) is what makes planned home birth safe.
A certified and licensed midwife has the capability to manage meconium and other issues that may come up.
The safety issue arises in states where midwives are either not regulated or illegal. With that environment home birth becomes less safe because the midwife may hesitate to transfer, or the family may fear a transfer, both slowing down an emergency response. When midwives are legal and regulated/licensed they can work together with the local medical facilities for the benifit of babies born out of hospitals.
An interesting note is that the large CPM 2000 study reciently published in the BMJ includes CPM statistics from both legal and illegal/unregulated states. Even with these known safety issues the study shows that home birth with a CPM attendant is appox as safe as hospital.
We should be thinking of ways to increase safety in both hospital and out.
All these people with their hate for hospitals. I delivered at two different hospitals and found the staff at each to be solicitous of my wishes, supportive of breastfeeding and rooming-in, careful to explain what was happening and why, everything people say they want. I guess it's a shame there are some hospitals out there giving all the rest a bad name.
Nobody has yet addressed the question: Is childbirth an illness? A pathology? Or is it not? IF childbirth was really an illness, or very dangerous,how did the human race continue into modern times?
My personal belief is that childbirth is a normal "bodily function" or skill---as in "Your body KNOWS how to have a baby."
The much-inflated c-section rate, now close to 30% in some medical centers, does NOT reflect the element of risk and danger inherent in childbirth. The element of risk and danger is much less than 30%---probably less than 10%, which is the c-section rate in the inner city hospital where I work.
I myself have had 2 kids born at home. I have attended home births as a lay midwife, before I was a nurse. I have worked for a home birth doctor and I have worked with the lay midwives, attending at home births.
The lay midwives cannot get licensed in my state. They are a-legal, neither legal nor illegal. There are no laws that address their status/work. Their response to this Catch-22 is to get their certifications in other states.
The percentage of people who want home birth has stayed a pretty steady 1% for many many years---at least 25 years in my area. The lay midwives, together with the birthing parents, find a doctor who will work with them, offering them back-up should some problem arise. The back-up doc gets them access to a hospital, should they need to go.
However, the 1% are a self-selected, extremely conscientious and safety-conscious group. They are the lowest of the low-risk population. Their nutrition is impeccable; they keep their dates for prenatal care. They all commit to breastfeed---some for prolonged periods of time, to enhance their kids' immune status, etc.
A very big difference in home and hospital birth is the atmosphere. As a birth attendant, I go in to someone's home, and I am on their "turf." I am not taking over and "managing" their labor and birth. I am/was doing watchful waiting. I am monitoring progress. I am labor-coaching.
My training came mostly from the ladies, the lay midwives, some of whom were trained in Marin County in the 60's and early 70's, when home birth was a natural logical consequence for the hippies. In my area, lay midwives also received training from a lay midwife who had a large birthing center in El Paso for illegal Mexican farm workers, who didn't dare show up at a hospital. Midwives from my area travelled to El Paso, and spent some time there, because they were able to see a lot/learn a lot in a short period of time---that is how busy the birthing center in El Paso was in those years. The training I received from the ladies was far more intense than the training I received about childbirth in nursing school, by the way.
I worked for a home birth doc, too, and received NO training from him---he counted on the training I got from the ladies.
I have never seen the level of joy and elation, the spontaneous and raw emotion surrounding childbirth in the hospital. Nor do I see the woman's self-confidence in the hospital. Most women, my own daughter included, state that they couldn't have done it without an epidural . . . and they act as if they have been brought through a cataclysm by the medical people. But I know different. I know that a woman's body knows how to birth a baby. I have seen it done, in its natural state (I finally said the "n" word!) at the home births.
Here is how my husband and I decided on home birth. A what-if thinker asked us "What if something happened to the baby?" My answer was, "If something happened to the baby, you'd need to put me in a rubber room---my grief would be boundless." That would be true at home OR at the hospital . . . Knowing what I know about hospital deliveries and medical errors in general, I see how much risk and danger exists in hospitals. So, like many others, I choose my poison---er, risk. Home is for me.
cherrie,
i actually do know the diff between the two. i was merely pointing out an example on how some women in search for the best childbirth experience can take it
to an extreme.
addendum:
i totally agree with neonataldoc on how sometimes in the zeal to have a good, intervention-free birthing experience some lose sight of the fact that in the end it is the well-being of both child and mother that should be topmost priority.
Here in Australia I think we *have* managed to achieve a happy medium. I gave birth to both my daughters in a large public hospital where anyone can (and does) give birth, and I had excellent experiences with minimal medical intervention. The deliveries and subsequent hospital stays were 100% covered by our national medical insurance scheme, as they are for anybody, rich or poor.
All the delivery suites at the hospital are private and include large bathrooms with baths and showers that labouring women can use for pain relief (and for birthing, if that's what they want). Birthing balls are availabe and women are able to have an active birth. There are no routine IVs. Nobody is forced to lie on her back on a bed (although that's what I felt like doing for my first, so I did).
All the standard drug pain relief is available - gas, pethidine, epidural - if you want it. I had a little gas, and a lot of screaming. The midwives weren't concerned by my vocalising - one helped me to use the grunts and yells to help the pushing, not to oppose it. Rooms are sound-proofed, so there aren;t concerns about "upsetting the others".
Midwives attend the births, with obstetricians on call if needed. I only saw an obstetrician when I was being stitched up after delivery the first time; the second time I didn't see an OB at all (as a public patient, I didn't have "my own" OB; if I had opted to use my private health insurance to be admitted as a private patient, I could have had "my" OB on call).
Both times, after my baby was born, I held her straight away. She was briefly weighed, then wrapped up and returned to me to breastfeed. Then a midwife brought in a sandwich and a cup of tea and left my husband, our daughter and me alone for some bonding. After a while I got up and had a shower, then we took our baby upstairs to the post-natal ward, where I shared a room with one other woman and her new baby.
Neonatal Doc, I've been horrified by some of your stories of what seems to be standard practice in the US - from TVs in delivery suites to, yes, doctors who are apparently shocked at women giving birth naked. Given that I spent most of my labour under the shower both times, clothing was a little redundant; although I then put a nightshirt on for second stage labour I wouldn't have had any qualms about taking it off if I'd been too hot.
Having read what you have written about hospital births in the US, I'm not surprised that more women prefer home births there than here. Here it seems the choice is not so stark.
Interesting post, thanks. I'm very far from being an expert in this area, but I have been lucky enough to find an OB/GYN whose bias is against intervention as long as the mother is healthy, who has a C-section rate of maybe 5%, who will actually let mothers try to deliver breech (as long as it's not transverse), who listens to his patients and tries to give them what they want. If more doctors were trained like this, maybe the issue would be less Manichean, less us-vs.-them. I wish more women had the opportunity and the education to look for OB/GYNs with this kind of approach. As for myself, I'll opt for a hospital birth every time -- not least because I know from experience that I bleed heavily after delivery, but also because I trust my doctor.
superstenogirl,
Haven't we done this before?
Oxytocin is the feel good natural hormone. Pitocin is the artificial version of the get labor going hormone I was talking about the IV diluting.
In my example, the docs don't shut down labor with drugs, I was talking about mother's natural response to delay labor in fearful situations. That is why most sponatanious labor births end up being induced anyways in most hospitals. Induced can be read as pitocin.
Choosing to birth out of the hospital for my third birth actually made it safer. In a peaceful setting with professional attendants who knew how to judge if the seven minute ride to OR was warranted. The OR would be prepped and ready at the same time I arrived. In many hospitals it takes much longer than that from decision to cut to the arrival of the doc, from his home.
Oh, and this hospital had a level four NICU. Under the docs care (which I fled), he had a level one NICU, and recommended labor at home unatttended. In case of any trouble with the baby they would airlift it to a different county without either parent, and not release mom to follow for at least 24 hours. No food during labor, and they made a big deal you could have water. Imagine running a marathon without water. For my first two births, they didn't let me have water in the hospital. No food for 25 hours during my first birth. How draconian.
I was definately safer out of the hosptial. At least around here. Maybe in other places the hospitals aren't so mean. For my first the Surgical OBstetrician continued to cut an episiotomy while I was reminding him that he agreed that I preferred not to have one. He took that knife to me, even though he had agreed not to, and I was asking him to stop.
Great post, Doc. I was involved last fall in a code for a botched homebirth that resulted in the baby's death.
I came home tired and upset and fired off an angry post about it--and it got the most comments of any post I've written.
But I later realized that of course I only see the bad outcomes. Duh. If homebirth goes as planned and is successful, I wouldn't be involved.
Neonatal Doc,
There is a lot wrong in hospitals and birth is only part of it. Medicine as we know it is imploding because of managed care, malpractice, and cost constraints. There is tremendous room for improvement in the way that hospitals care for all patients, including pregnant women.
That said, the hospital is still the safest case to give birth for exactly the reasons you described. As you know, that original thread spawned my blog on homebirth and we have been continuing the argument for many months. During that time, I have read, learned and thought about many things.
First of all, a truly comprehensive review of the literature shows that homebirth is not as safe as hospital birth. A detailed analysis can be found in the report on Intrapartum Care produced by NICE, the National Institute for Health and Clinical Excellence in the UK, an independent healthcare watchdog. The report points out that the quality of the studies on homebirth is poor, but that the evidence suggests that homebirth has an excess rate of neonatal death in the range of 1-2/1000.
I also learned that many of the studies that claimed to show that homebirth was safe played fast and loose with the data. For example, the most widely quoted study on homebirth by Johnson and Daviss does NOT show that hospital birth is as safe as homebirth. Johnson and Daviss compared the neonatal death rates at homebirth in 2000 with some out of date homebirth papers to make their statistics look good. However, the actual neonatal death rate in the hospital (white women, singleton babies, term) is 0.72/1000 (National Center for Health Statistics). This is quite a bit less that the homebirth neonatal death rate of 2.6/1000 (white, singleton babies, term). Johnson and Daviss simply neglected to mention that in their paper.
Finally, I have learned that homebirth advocacy represents a particular philosophy that favors the "natural" over the technological, expands the definition of "natural" arbitrarily to include things like waterbirth which is decidedly not natural, and venerates the experience of labor pain. Most women simply don't share those philosophical beliefs.
A small factual correction of Amy's post. Johnson and Daviss neonatal+intrapartum deathrate is 1.7, neonatal alone is about 1.
Here is a quote from the study.
"After we excluded ... three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period. This was a rate of 2.0 deaths per 1000 intended home births. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded."
For those complaining about the high C-section rate...if you look at the data, the rate has climbed since the 80s along with the number of malpractice suits...with todays litigenous society, if I was an OB, I'd probably play it safe too if I thought something was not "right"
I didn't realize this blog spawned Homebirth Debate. What do I know.
Anyway. The higher C-section rate is also a result of many women choosing it electively, which was not offered so much in the past.
I was very surprised at how hard it was to figure out my options far enough in advance. I chose my OB when I was pregnant (I needed a positive pregnancy test for my low cost health care plan to authorize me to use an OB).
I tried to ask the right questions about my OB at the begining (how often do her paitients deliver naturally, etc.), but I had so little time to talk to her about her usual protocols surrounding birth instead of just my measurements and symptoms during the pregnancy!!
I didn't realize until 9 months just how strongly my OB felt that anyone over 41 weeks should be induced--and I didn't realize until I was being induced just how strongly my OB felt that I really needed the epidural, etc. And nobody thought to mention when they were presuading me to have the epidural that I would no longer be allowed to sit up in bed after the epidural was administered.
I read all the books, took the classes, thought I'd asked all the right questions about my OB...and I still wound up having all the interventions I'd hoped to avoid. I really don't know what I should have done differently
We went home from the hospital with a beautiful healthly little baby, and I realize that this was the most important thing of all...but a year later, I still have the nagging feeling that things went very differently than they should have gone...
Time is one big benifit of hiring a midwife. Midwives usually schedule an hour per prenatal appointment, and will spend as much time as you wish answering questions, even if you go beyond an hour.
Anonymous 1:07:
"A small factual correction of Amy's post. Johnson and Daviss neonatal+intrapartum deathrate is 1.7, neonatal alone is about 1.
Here is a quote from the study.
"After we excluded ... three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period. This was a rate of 2.0 deaths per 1000 intended home births. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded.""
This illustrates what I mean about manipulating the statistics. It is absolutely essential to compare like with like. So in the case of the US statistics for homebirth in 2000, the rate of 0.72/1000 applies to white women with singletons at term (in other words, it includes congenital anomalies, breech, pre-existing medical problems and complications of pregnancy). The appropriate comparison statistic from the Johnson and Daviss study is therefore 14 deaths out of 5418 homebirth deliveries (2.6 neonatal deaths/1000). This would mean including congenital anomalies and breech, which Johnson and Daviss tried to subtract.
Rather than showing that homebirth has neonatal death rate comparable to hospital birth, Johnson and Daviss ACTUALLY showed that homebirth has a neonatal death rate almost 3 times higher!
Most people don't realize that, because most people don't realize that Johnson and Daviss compared the homebirth neonatality rate to a bunch of out of date studies, not to the hospital neonatal death rate in the same year.
Neonatal Doc,
What is your experience with vaginal delivery babies vs. C-section babies?
I had my first and only daughter in a hospital about two years ago. I never once considered how I could make the experience more enjoyable for myself, I just wanted to get my daughter here safe and sound. I was fortunate to have the expertise of a medical doctor and I’m glad my daughter was able to be checked out by a qualified medical team. I think we take common things for granted too much of the time.
They call it labor because it’s work. It wasn’t meant to be enjoyed. I would so sacrifice my life for the life of my child. Labor and delivery should be about the safety of the child and not the comfort of the mother.
Pro home-birthers need to acknowledge that it's about the baby, not the experience, and that homes are simply not as well equipped to handle bad babies as hospitals are.
On the survey our clients complete for their out-of-hospital birth plans (be it home or birth center) I have yet to see "experience" as their reason for seeking our services and certainly have never heard that from their husbands. It's respect, their perception of safety, personalized care, unhurried appointments, a lower fee, and our absolute promise to transfer them to the hospital in the event of complication (among other reasons).
That being said, you are absolutely right about hospitals improving their customer service and I am not sure how Dr. Amy's ongoing "debate" (more like a soliloquy with comments) fixes that problem. For as much as she apparently thinks she is accomplishing in setting the "record straight" we all know less than 1% of babies are born out of the hospital, planned or not. Why not fix the problems of the mainstream rather than beat down the fringe with a couple of studies?
I feel compelled to comment on this topic. I started out as a pro-homebirther, but after two complicated births (one complete placenta previa with hemorrhage and pre-term labor, plus a partial previa with numerous bleeds) I am really fed up with the "any intervention is evil" talk. I hemorrhaged at 32 weeks and was on hospital bedrest for four plus weeks until baby was ready for a c-section. A doula "friend" questioned why I consented to continuous fetal monitoring during that time and why I would allow an IV during the section. That talk, to me, is just crazy. I will not risk another pregnancy, but if I did, I would not consider anything other than a hospital birth presided over by an OB. Give me an epidural, give me an episiotomy, give me pitocin - I don't care. As I told my OB, you can cut me in half with a chainsaw as long as the baby is healthy. I have read blogs (naval-gazing midwife, for one) that really touch me -- she appears to put the safety of mom and baby ahead of anyone's need for an "experience," so I don't discount home births or midwives completely. I just think people have to be realistic about the dangers of childbirth to both mother and child.
As the mother of two children, now ages 11 and 13, I think that all of the time and energy I put into reading books and putting together a "birth plan" had nothing to do with where we are now. Bottom line, whether you take the epidural the moment you feel your first contraction at a hospital or go drug-free at home on the couch...when your child is 13, he/she will still frequently stomp down the hall, slam his/her door and loudly announce that he/she hates you. He/she will dismiss out of hand any suggestion that you make about what he/she might like to do. He/she will take eye-rolling to a level you never believed possible, etc.
A healthy baby is the desired outcome whether you choose to give birth at home or in a hospital. When people arguing against epidurals (and btw, I was given my first epidural when I was 4 centimeters and 30 minutes later I was at 10....so the whole "slowing down labor" thing didn't work with me) say things like, "Women delivered babies for millenia without anesthesia!" My response would be, "Yes, and teeth were pulled without novacaine...but thanks, I'll take the new technology! Would you refuse chemo if you had cancer? Refuse medication if you had diabetes? All of those conditions could have the same argument...I know, I know...giving birth isn't an "ailment" or "illness"...but it isn't a garden party either.
I just hope that new Moms know that their kids won't give a rat's a** how much pain they endured giving birth to them...they still won't clean their rooms, will hate the dinner you lovingly prepared and will lie to you about whether or not they have done their homework!
It's not the 18 hours of labor that is so important...it's the next 18 years!
Amen di!!
To me this is just one more argument that pits women against each other, when we need to be supporting one another and celebrating the huge amount of choice that we enjoy in this country. I don't have an issue with women who choose a homebirth, but I would ask the same grace from them.
I chose to give birth in a hospital, and had very positive experiences (with the exception of the premature birth and death of my twins, but even then the hospital staff was outstanding to me). I had an evil epidural with all three of my living children, and they all came out pink and perfect, latched on with no trouble and breastfed beautifully for their entire first year of life. The first is a strapping 12 year old who is passionate about skateboarding, dotes on his baby sister and struggles with math. The eight year old has boundless energy, loves any sport involving a ball and still loves it when I read him stories at night. And our almost two year old worships the older two, loves doggies and FINALLY sleeps through the night. They don't care how and where they were born- they are just glad to be here!!
I agree that practices need to change in the hospitals. I apprecitate your view but I have to ask:
Neonatal Doc, what are you willing to do to help change the culture of the hospitals/OBs and make births a less invasive/intervention place? Could you be an advocate for families who want a hands off birth in the hospital using intervention only when NEEDED?
Many homebirthers and midwives are trying to be change agents and advocates for the culture change. I think homebirthers, hospital, and birth center mamas agree that they desire a healthy baby and healthy mama.
There are a lot of stories and experiences out there where the interventions caused a disappointing and traumatic birth for the baby and/or mama. A few have mentioned it already but many women feel safer at home having their babies rather than fearing how interventions (of course they have their time and place--it is when they are overused and abused that causes trouble) and lack of informed consent will harm their baby.
I'm glad that you're willing to take a look at both sides and realize that there are valid points to both arguments. I read your first homebirth post when I discovered your blog and was tempted to leave a nasty comment, but I resisted because it never does anything to forward the cause.
It's great that you realize that hospitals do need to change the way they approach birth, but that is something that will most likely never happen so women like myself, low risk, will continue to birth at home.
Both of my children were born at home. I wouldn't have it any other way as long as I'm low risk and I have a skilled midwife in attendance.
Great comments, everyone. I can only reply to a few. Laina makes a good point. Poor people might not have enough money to go to a nice place, and frequently they might not feel empowered to speak up for what they want, either.
Chris and Vic, I don't really care whether we call childbirth an illness or not, as long as we recognize that without modern medicine it can be a dangerous process. Let's not go back to the days of huge maternal and infant mortality and morbidity that occurred before modern medicine. The species survived throughout the ages - but a lot of individuals did not.
I like the point that di and lori make. When they're 15, neither the kids nor mother will care much about the birth experience. Amy Tuteur, thanks for the support.
Finally, Amelia asks what am I prepared to do about it. I can't do much about the prebirth things, but I am trying to make newborn care more family centered, with kids not being whisked away from mom right away. It's not easy.
Vaginal versus cesarean babies? A big topic. Maybe some other post.
Neonatal Doc, I am sorry you don't think the distinction about childbirth being an illness vs a skill/art is important. I, obviously, think it is important.
If it is an illness, it is within the purview of the doctors and other medical people. If it is an art, skill and a normal life transition, it is not within the purview of medicine.
If it is not within the purview of medicine, then who "attends" to childbirth? Other women, who know it intimately---in history, called midwives. Midwifery skills are vast and they are not necessarily medical skills, though they ARE safe-passage skills. Safe passage skills acknowledge that there is some risk and danger, depending upon the circumstances.
Example: A laboring woman who has been pushing for a while, with little progress, may change positions. She may actually have fashioned a "birthing chair," or may use the toilet as a place to push (My midwife friend used to call this "re-shuffling the deck"). She augments her labor with re-positioning rather than with Pitocin. Her midwife is, meanwhile, reading the mother's cues re: fatigue, and watching the clock on the mother's behalf. When pushing has gone on a very long time---depending on the circumstances, more than 2 hours---the midwife and the woman and her household make a decision. The midwife weighs in on whether or not it is safe for the baby to go on pushing; and if the mother has the stamina or not. They may decide together on a time limit. Oxygen may be brought out, to enhance the mother's stamina (and it may help the baby's as well). If heart tones are questionable---the midwife has a feto-scope and a doppler, as well as oxygen---the mother avoids pushing and oxygen is used. It is possible that a decision is made jointly to go in for a hospital birth. These problems are observed and assessed early-on (prevention is important). The midwife is there every minute and for some hours following the birth and she is back again within 24 hours. The woman is drug-free, and clear-headed enough to really participate in decision-making.
During the pushing phase, the woman is asked to stop pushing, while perineal support and even warm compresses are applied, in order to avoid an episiotomy, in order to birth the baby gradually, with minimal trauma to the perineum and cervix. I cannot remember thinking, "Let's hurry up and get this baby out" because we believed in the process and believed that it was basically sound and safe, and that we were alert to when danger signals presented themselves. There was excitement, but not pressure to get through it quickly. There was a great calmness in anticipation. We often held our breath and pushed with the woman. We were with her. So was her husband/partner, and her household. It is support like you have never seen in another venue, such as a hospital. When we went in to the hospital, on rare occasions, everything changed. It got scary and "cold." Fear was in the air. The midwife had the skill, if they would let her in to the delivery, to continue to support and encourage the mother and father through the birth. She stepped back a little, but was still the labor coach. Hospital people would look at us midwives with extreme suspicion, however.
Perhaps if you looked at home birth and home birth believers as a different cultura---if you are into the beauty of cultural diversity, that is---then this would make more sense to you.
I am asking for you to get into my mind-set, and to be fair, I must try to get into yours. This I have never done, in spite of working in the NICU for many years. Like Darwin, I believe that some individuals are not fit enough to survive. And there is some sense to the survival of the fittest on a global scale. I read the book, The Thrall's Tale, just before Christmas, and in this book, a premature baby is left out in the elements, "exposed," to die. This was very long ago, in a Scandinavian island location---historical fiction. Yes, we are beyond that---but have we thought it through very, very well? Have we looked at the other side, where it makes some sense to "let go"? To see how things play out on their own, without extreme intervention?
Chris and Vic (CAK)
It seems that the only statistic you've looked into is the infant mortality rate for home vs hospital birth. There are other statistics to consider.
My home birth midwives had lifetime cesarean rates in the 4-5% range and my backup midwife, who ran a birth center, was 7-8%.
Their initiation of breastfeeding rates were essentially 100% and the one who kept track had a one year breastfeeding rate of about 75%.
I once asked a midwife who had been practicing for 30 years her episiotomy rate and she named 4 women she had cut and then started apologizing for having cut one of them because in hindsight it wasn't really necessary.
Certainly you see in your NCCU what we do to mothers in our 40% c/sec rate hopsitals. You see them wheeled in, doped up on Percocet, unable to lean over to pick their baby up.
I scrubbed for a stat section last night, fetal distress but no scalp pH confirmation, APGARs 9/9, mother got 4 liters due to a pesky uterine artery. Caused by Cytotec hyperstimulation, for an "elective" induction. Thank goodness she was in a well-equipped American hospital with an OB, ready to eviscerate her at a moment's notice. Not.
Yes, IATROGENIC!
Caused by the interventions we do to promote safety and stave off risks and danger in the birth process. Caused by us, the well-educated, who make decisions that are fear-based, and in the end become the heroes? Say what?
It is a**-backwards. We need to think hard and long about what we set in motion by our interventions.
Please remember: I am you. I am a medical professional, too, and I share the responsiblity to reverse these iatrogenic insults.
CAK
Thank you someone for mentioning the real iatrogenic risks of hospital birth. These, and unnecessary intervention, are why many smart, informed people do in fact believe that out-of-hospital birth with a qualified attendant is safer for healthy, low-risk women.
Some feel that hospitals are safer because of the presence of OBs and anesthesia, but I need to remind everyone (again) that unless you're in a large metro area, relatively few hospitals offer that 24/7. In my rural area only one hospital within 50 miles has in-house staff. So where is the benefit exactly?
There is always risk to childbirth, no matter the setting, and every parent and both "camps" must acknowledge that things can go wrong. Sometimes a baby would have been better off in a hospital, sometimes a mother would have been better off out-of-hospital.
The point for me is that it comes down to a simple matter of reproductive choice. Truthfully, I don't really care WHAT you or you or you think about out-of-hospital birth, as long as a woman has the legal and protected right to choose to do with her uterus and vagina. If you support reproductive rights for women, how can you not support the right to the option of out-of-hospital birth??
That is not to say that I am a homebirther at any cost. There is presently a local lay midwife on trial in my state. Many rally to her defense in the spirit of support-a-sister-midwife no matter what. I know this midwife is unsafe, and so I do not. I do support restricting her right to practice, but do not support restricting a woman's right to choose whatever she wants to.
Because I know someone will respond with "well what about the baby" -- it IS about the baby. Safety is always first. From working eight years in hospital and almost six years out of hospital (home and birth center birth), I honest to goodness believe that OOH is just as safe as, or safer than, hospital birth, for the majority of moms and babies.
should we return to all the deaths we saw 100 yrs ago? that is the question being posited. all for an "experience' ? yes,an 'experience'.let's keep our moms and babies safe. it only takes one tragedy .... if you've evr seen one you will become physically ill.change can come in the hospital,it already has.dads were not allowed at deliveries until recently.mom's perineum was shaved,until recently.enemas were given,until recently.etc,etc.etc,. change in the unfriendly,techno-oriented present hospital manner can and should be done.but come on,no one wants to return to the appalling death rates of 100 yrs ago. let's support the family and stop this bickering.we can argue statistics all day,the truth is birth is a very serious undertaking,not an 'experience' and some of us see the end results of some very sad 'experiences'
Anonymous 4:00 pm, did you read what shamhat or cak wrote? It's disingenuous, not to mention impossible, to compare today to 100 years ago, because a lot more has changed other than the location of birth. There are horror stories on both sides (several moms in the past year have DIED from botched epidurals, for example), so it's NOT just about an experience believe it or not. As for hospitals changing, yes, it's great that they can and have, but should today's women be forced to accept substandard conditions until hospitals decide to make more changes? Some of the "until recentlys" aren't-- they're "they stills." It depends on where the woman lives, what hospitals are local to her, and what their policies are.
People who give birth at home do so for many reasons. It's monstrously unfair to ascribe the need for a better experience to all of them.
and yet,the desire for an 'experience' is the main focus of the homebirthers,and that is truly 'disengenuous'
Wow, anonymous, you didn't read my whole post either. You read the first two or three lines and stopped.
If you do bother to read the rest of this, I'll keep it short:
It's NOT all about the experience, or even mostly about the experience. That's something anti-homebirthers make up. It's impossible to ascribe the same motivation to hundreds of thousands of women.
It's not MAINLY about the experience. It MAY be, it depends on the woman.
Thank you. Somebody needs to say the truth from an educated point of view. Keep it up! As a family doc who did obstetrics only during residency, I still had opportunity to see two home births go very wrong, with disastrous, heartbreaking results. I wouldn't recommend my patients have appendectomies at home, either, but at least only one person might die.
poor babies,it's quite a crap shoot for them,eh? and what if mom and baby crump at the same time? one pair of hands is just not enough...and all for an 'experience' the baby's brain can die in 4-6 minutes without oxygen.it really takes at least 2 people to resucitate a baby that's trying to check out,drying,warming,intubating,cpr.add to that a mom that's bleeding out,well,it can all go south in less than 5 minutes.then what have you got? a tragedy.......
With professional homebirth midwives, there are two attendents at every birth, both certified in neonatal resuscitation. And I have not seen any response to the fact that most hospitals DO NOT have in house OB, anesthesia, or OR teams. So tell me, what's the difference (other than more germs and interventions?)
FD, you have expereince with two homebirths "gone wrong". How many hospital births went bad during that same time frame? You do recognize for the two you saw there were thousands that went fine, right? I invite you to come attend homebirths with me anytime, to heal these experiences if you'd like.
With professional homebirth midwives, there are two attendents at every birth, both certified in neonatal resuscitation. And I have not seen any response to the fact that most hospitals DO NOT have in house OB, anesthesia, or OR teams. So tell me, what's the difference (other than more germs and interventions?)
My local hospital has no neonatoligist on staff. Nor is there an anesthesiologist or OB present at night (although they are on call). So if I was birthing at home and something went wrong, I would probably arrive at the hospital before the OR was even ready and the various doctors had been rounded up. And if a neonatologist is needed, you have to be transferred via ambulance or helicopter to another hospital.
The local OBs and midwives work together, and home births are encouraged. Midwives are covered by our provincial health plan, and are heavily regulated in what kinds of births they are allowed to attend (any risk factor = no home birth). At least two midwives are present at every homebirth (usually there's also at least one student as well), and they carry the same equipment or equivilent equipment to that in my local hospital.
I really don't see how there's much difference between birthing at home with midwives and birthing at my little local hospital. If I needed to transfer to hospital, the midwives would call ahead and the process of getting the appropriate personnel ready would begin. If I was in the hospital, it would probably take the same amount of time to get from 'oh no' to c-section (or whatever) as it would if I was at home and the midwife made the call to transport.
If every birth is thought of in terms of the worst case scenario, we should all be birthing at big hospitals with Level 5 Nicus and specialists available 24/7. But for many of us, the local hospital is pretty much the same as giving birth at home, especially in the situation we have here where the midwives and OBs are fairly integrated and there are no turf wars between them.
*I actually gave birth at the hospital (with no problems or issues) since the midwives didn't have full priviledges at that time, and I'll probably give birth at the hospital again because I could use the 3 days vacation away from home!
Great post, NeoDoc.
To the commentors: Spoilt, the lot of you.
Have your cake and eat it, too.
Wish you would be willing to share it with the less fortunate though, instead of arguing about which flavour is better.
From, a med student who has just come back from Africa dealing with mothers who choose between drunken traditional birth attendants and serious post-partum infection versus paying their entire monthly money for transport to a very basic hospital which may or not have electricity and certainly doesn't have running water.
With love. And frustration.
> The more I practice and study medicine, the more I realize we need to learn. <
Please allow me to begin by quoting your own words. They make a great deal of sense!
I am the mother of a 20-year-old daughter named Rebecca. She has a tranlocation trisomy consisting of part of the long (q) arm of chromosome 13 and part of the long (q) arm of chromosome 15. She was born with Trigonocephaly, a funny-sounding heart (due, the pediatric cardiologist said, to one wall of her heart being thicker than the other). This was discovered via echocardiogram. Rebecca also had an extra toe (complete with bone and joints), severe jaundice, clenched fists, lowset ears, and several of what the doctors termed "strawberry hemangiomas." Shortly after birth she developed a large umbilical hernia. For reasons known only to God, no genetic testing was ordered, though we were in one of the largest hospitals in the country. The repeat "echo", performed at about 8 weeks showed no sign of a heart problem. We give God the glory for this! The Trigonocephaly was corrected at 8-and-1/2-months-of-age. The extra toe was removed by a hand/foot surgeon. The umbilical hernia gradually healed over time without surgery. Rebecca also developed strabismus in early childhood, which was corrected at age 5. Her scoliosis never reached the point of requiring surgery.
Other issues have involved sleep pattern problems, autistic tendencies (possibly connected to the trisomy for 15q), and developmental delay.
Let's skip to the present. Rebecca functions about like a mid-to-upper elementary schooler. She reads on about a fifth-grade level, can do arithmetic up through basic fractions (including counting money and telling time). Her cursive handwriting is beautiful. She loves to sing in church, to play baseball on a special needs team, and can hit the ball out of the air when pitched from a machine. her autistic tendencies have lessened over time, especially in her late teens and this first year of her 20's.
Yet, I know enough people with surviving T-13 kids, many of them Full T-13, to know that, had I found out prenatally, I would have been encouraged (even pressured)by many doctors to abort. Had I found out in the newborn period, her first really bad cold may have been occasion for a talk about signing a DNR.
I am so thankful that I was allowed for 12 wonderful years to raise my daughter without such input. She was finally diagnosed after testing was suggested by a sleep clinic pulmonologist who wanted to know why she had such an involved medical history.
If you want to see other long-term survivors of various forms of T-13 who are bringing great joy to their families, and often accomplishing things far beyond medical predictions, please visit www.livingwithtrisomy13.org. There is a Treasured Memories Album on that website also to honor those T - 13 youngsters who came to brighten the lives of their families for awhile and have gone on to be with the Lord.
Glenda Parkman
I noticed in this blog you said "I still think that the best solution is for hospital based deliveries to get better, to ditch the impersonal and degrading garbage associated with them." and yet, in a previos blog, you talk about how you and someone else present at a delivery giggled because a mom chose to labor without clothes. Seems a bit hypocritical, doesn't it?
I was 27 when my daughter (second child was born).
Low risk. Drug-free birth.
Healthy baby
At 35 mins she crashed. The cardiac team (it was a small private hospital) spent some time resucitating her. She was very unstable and they suspected a cardiac condition and she was transferred to Level 4 NICU. Ended up being PPHN.
8 weeks later a friend still chose to birth at home. I have always felt somewhat offended by her choice. Did she think she was immune? No single midwife no matter how skilled can replace the value of having any number (there were 10-15 in the delivery room responding to our daughter's crash) of doctors working on your babe. My daughter may not have had the 10 mins for a hospital transfer. For us, being at a hospital almost certainly saved her life.
This is so late now that I doubt anyone will read it, but I just wanted to add that I would LOVE to have the same midwife-attended hospital birth I had with our first, but the midwifery practice in question faces an uncertain future... thanks to administrators' not finding them profitable enough, and pressure from other local obstetricians on the OB practice that the midwives are part of. So we're considering a homebirth as one of two not-very-good options (the other being a switch to one of two huge anonymous obstetrics practices at 33 weeks, where we know ahead of time that my preference to have freedom of movement and eat and drink to comfort during labor won't be honored.)
Personally, I can't stand the more militant natural-birth types -- who ignore the fact that for centuries maternal and fetal death were serious dangers every time a woman gave birth, who seem to think that every woman who chooses an epidural and doesn't breastfeed for three years is a selfish ogre, and who are content to tell me what my body was "designed" (!) to do without ever getting to know me first. (And the fact that they do so while calling themselves feminist is too funny.) But I feel much the same way about the obstetricians who *also* never get to know me, are *also* content to look at my body as a collection of mechanical functions... and who take all of two minutes for a prenatal appointment, btw.
So basically it's two less-than-ideal choices. With one there's a sizeable chance that I'll be disrespected, cut open, and separated from my baby. With another there's an increased (though still small) chance that something will go disastrously wrong and our choice to birth at home rather than a hospital will end up causing our baby's or my morbidity or death. Great.
The two camps are at each other's throats, the "best of both worlds" option I wanted isn't there because of politics, and at this point I just want to have the damn baby and be left alone, KWIM?
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