Being Honest about Childbirth Preparation

More on the homebirth debate blog, which is increasingly just an anti-natural-birth blog...

Normally I wouldn't give much weight to the problem of women who want natural births but find that labor is more intense/painful than they expected. I don't instinctively think that natural childbirth education classes bear responsibility for this kind of disappointment, based on the knowledge that all women experience labor differently.

I think that calling natural childbirth educators "liars" based on this discrepancy is inflammatory and nothing more.

But I tried to understand the intentions of writing a blog like this. I gave the author the benefit of the doubt, and I reached an understanding that I think is very important:

If a woman goes into labor, a normal labor (no posterior position, uncomplicated), with the idea that it's going to be a cake walk because she took a class, then she has been duped. The whole idea of childbirth education is to educate. This means making a strong effort to prepare women for what her labor will probably be like.

It does no one any good to attend a class where only ideals are taught. It gives no one any skills for dealing with even small deviations. Women need honesty - that doesn't mean horror stories, things that are going to frighten her into choosing certain options over others. It means telling women that there is an entire range of normal, and that some of it is painful, yes, but here are things you can do to get through it.

Any good childbirth education class - especially, but not exclusively, for women planning on having a natural birth - will tell women that labor is usually painful, but will also educate them on handling the pain. They will be honest about the entire issue. Their goal is to prepare the pregnant woman for labor, not to take shortcuts and present only a very limited view of labor and birth.

This goes both ways. I object to educators who tell women "labor is entirely pain-free if you're relaxed enough" as much as "since most of you will be getting epidurals, I won't go over relaxation techniques". Both approaches are wholly objectionable and are setting women up for failure.

Scrutiny

After spending much of my time looking at studies, researching different statistics, and making lists comparing references and outcomes, I've arrived at a different conclusion regarding homebirth safety.

I feel much more educated now than I was previous to the homebirth debates. I'm not where I would like to be, but I certainly feel more confident in my opinions.

I've reviewed countless studies, and what I've found can be summarized thus: Some studies show a slightly lessened risk of mortality for home birth. Some show a slightly greater mortality rate. Often, when the hospital and home group comparisons are restricted to similar risk profiles, the homebirth group shows a slightly lower risk.

The data is spread out, ranging for both homebirth and hospital mortality to all numbers between 0.5 and 3.5, according to many studies.

In all studies, the mother and baby had fewer interventions (instrument delivery, episiotomy, etc.) in the homebirth group, regardless of risk profile (meaning, the low-risk hospital groups had many more interventions than the low-risk homebirth groups).

This brings me to a good question. What is the definition of safety in childbirth?

Does "safe" just mean that no one died?

I believe it's broader than that. I believe that we must include the whole person, the whole mother and baby. We must examine their physical well-being as well as their psychological and emotional health as a crucial factor for a good outcome. If mother and baby are both alive, but the mother bears an unnecessary cesarean scar and feels violated and deprived of her womanhood, that is not necessarily a good outcome. She may be less likely to bond well with her baby, less likely to continue breastfeeding, and more prone to postpartum depression.

For care of the entire person, addressing all issues of wellness for both mother and baby, which I believe is an essential part of safety, homebirth is far superior. This is well supported in everything I read.

The mortality numbers are basically inconclusive, but honestly, I can't say that they lead me to believe there is anything inherently more dangerous to birthing at home. (I cannot say enough that in my area, laboring women are far safer, in every aspect, at home than at the hospital here...but that is another topic.)

Trying to Understand

This is from Birth as an American Rite of Passage:

After much research and more questioning, I had reached the conclusion that American hospital birth rituals are medically damaging and psychologically
disempowering and degrading to women. Once I had arrived at this conclusion, I had a good deal of trouble understanding why anyone would want a technocratic birth. Although it is true that I did not encounter many women who really wanted a highly technocratic birth, I kept running into woman after woman who felt generally comfortable with such a birth...I must take seriously the notion that American women do not rise up in protest against technocratic birth because it is in fact what most of them want.

Why? To ask why women want technocratic births is, in a broader sense, to ask what technocracy has done for women that they should value it so. The answer to that question seems clear: in the early years of this century technology began to give women the power to expand beyond the "natural order" that made so many of them, in an industrialized society, appear to themselves to be slaves to their biology. Ever since the invention of the bottle - the "war cry" of a generation of women - technology has increasingly offered women a way out of the home and into participation in the wider social world. And this trend has not slowed. Women's continued expansion beyond the "natural order" that kept them in "women's domain" is increasingly facilitated by technology, which women therefore have special reason to value and to seek.

This makes sense to me. I have wondered why so many women reject nature in favor of technology, and now it finally makes sense. People who are not hoping for a natural birth, or people who say "I want a natural birth, but we'll see" - they have an entire belief system that relies on doctors and medicine to alleviate their fears of the dangerous and bewildering natural birth process, to make it mechanical and predictable. I had thought for a long time that it was simply fear of pain, but it is more than that. It is fear of, among other things:

* physical danger
* exile from culture/social expectations
* being enslaved to unpredictable biological rhythms

and has little to do with birth itself. What we believe about birth is part of a larger system of beliefs, and these beliefs affect how we labor and where and how we deliver our babies. "What we believe is what can come true for us...If a woman believes on the deepest emotional level that the hospital is the only safe place to birth, then if she tries to deliver at home she won't be successful" (Lewis Mehl).

The Meaning of Scientific Research vs. Personal Experience

In many debates regarding homebirth (I can specifically think of two blog debates), the same progression of events, with the same heated emotional overtones, occurs. Doctors question the safety of homebirth, and the homebirth supporters retort with a long series of heartfelt insistence, personal stories, and talk about how much homebirth has meant to them personally. The docs list some studies and statistics, and while those might be discussed in a little more detail, most of the response is again anecdotal. All comments are delivered with increasing conviction, passion, and sometimes name-calling and utter defensiveness.

To this point I wish to discuss what kind of resolution we can gain from debating these topics, where doctors and birth practitioners have such different ways of approaching the same issue.

First of all, it should be immediately apparent that no one is likely to change their minds. I have been devoting a great deal of time to consideration and reconsideration of the points being made, and while I want to contradict some of the stronger arguments, I am unable to, and I am offering a possibly premature concession while I do more research. Yet my original stance remains unchanged.

This leads me to realize something inherent in these debates: Scientific research is not going to be the basis for change.

I do not believe that anyone truly bases their opinion of any topic, exclusively on the scientific conclusions of research. I do not think that those who argue against it have done this, though they will probably argue otherwise. Their opinions were forged elsewhere, probably in the OR, in medical school, or in the L&D unit of a hospital. We are reasonable creatures, but we do not use reason in this manner.

Because of this, we are never going to agree. We will always be in conflict.

That does not mean that change will not occur, but it will not originate in the broadcast or propagation of scientific studies.

Change will have its roots in three places: social influence, intellectual pursuits, and political muscle.

The homebirth/natural birth movement is a direct response to the horrid treatment of birth in modern hospitals. It is a protest of the management of healthy women in labor, a defense against the obstetricians who schedule cesareans so they can attend a barbeque at 4 pm (that is a real example). Many homebirthers are women who are recovering from a terrible hospital experience, having received a waterfall of interventions that made them feel violated, and stirred in them the desire to reclaim their bodies and their births. Certainly this does not encapsulate the motives of all homebirth advocates, but it does represent many of them.

The power of this birth movement is its social power. Homebirthers are not women in rural areas without access to hospitals; they are neighbors, sisters, urbanites. They have an affect on the women around them; their sharing of nightmare experiences makes other women reconsider their care. Doctors may dismiss the anecdotal as meaningless, but social change occurs anecdotally and not scientifically.

However, and not unimportantly, doctors have most of the political influence over childbirth. Most people trust doctors. Many women believe that doctors will never recommend a course of action that will harm them. And doctors are more capable of lobbying to influence change within the medical community than anyone, whether it is based on science or not.

So while women gather and share positive or negative birth experiences (stories that leave a deep mark on childbearing women), and doctors are digging deep into studies to back up their claims with a number, we are sitting at our computers debating our stances. Meanwhile, change is already happening around us.

The Problem of Birth Philosophies

You'd think forming a consistent, reasonable philosophy of birth would be easy, but you'd be wrong. I haven't decided anything for certain, and I am still working through my thoughts on the subject.

Yesterday I was considering how a practitioner's outlook on birth affects how they treat laboring women.

Medical: The general medical view is based on handling the complications that may arise during childbirth. I suppose this is because they deal with the major problems of births, and they see firsthand the damage and terror of a birth that does not go well. However, this view results in seeing a normal, uncomplicated birth as a retroactive diagnosis; in other words, they treat all births as if they are likely to become high-risk at any moment. Many women believe the medical view, that even in uncomplicated deliveries, hospitals are a necessary part of the childbirth experience, that the birth process is inherently flawed. All births are dangerous, and only some proceed without medical need. That there is a risk at all of something going wrong means that all births should take place in a facility where caretakers are able to address the most serious of complications. This will save lives, and that is the most important thing.

Midwifery: The midwifery model of care (MMOC) sees all births as normal, unless a complication occurs. But midwifery believes that the normal is by definition the most prevalent circumstance. I should note that it is part of the MMOC to transfer any situation that is deviating from normal to medical care, resulting in midwives recognizing and caring for low-risk pregnancies and labors. Midwives see the process of birth as a healthy event, which is reinforced by witnessing mostly births that go well. They are highly trained to recognize any problem that falls outside their scope of practice and will act quickly to procure the appropriate medical care, but only if necessary.

That these two approaches result in significantly different care is a problem. Medical care providers, those who have the skills and training needed in case a complication arises, assume that deciding to give birth in any other environment than their own is irresponsible. They criticize midwives for not being able to handle serious complications (a premise not entirely justified, as midwives have extensive training in birth complications - it would be irresponsible to be a birth attendant who does not know what to do in case of, for example, maternal hemorrhage or infant respiratory difficulties), as if the only person qualified enough to be present at a birth is an obstetrician in a hospital. This fear of and mistrust in birth is not without consequences, as even normal birth is then treated as a perilous event. Interference in childbirth, distorting the birth process so that it fits the medical model, is part of the medical standard.

But how often do complications occur? If they are naturally rare, then perhaps the medical model is incorrect in treating all childbirth as life-threatening. The midwives would be justified in assuming that labor will go well, unless it doesn't.

The problem with the midwifery model is the unpredictable nature of some complications. Even low-risk, healthy women sometimes have unexpected trouble during labor, and require immediate medical assistance. For the most part, I believe this situation may not be as much of a dilemma as it is, if obstetricians and midwives were able to agree on how to work together. Often midwives fear to transfer care to a doctor because of the disdain many doctors have for midwifery - they see midwifery as a dangerous trend, one which erroneously convinces women that birth is safe, that they may not need medical care during birth, and when a complication does occur, it is blamed on the midwives for not recognizing the appropriate channels of care (women in labor belong in hospitals, and nowhere else). "Another mismanaged home birth!" the doctors will say, shaking their heads, believing that with the proper education, the woman would have come to the hospital first and avoided a bad situation.

But the problem with treating all births as potentially complicated, is that the care received is motivated by fear and not by best practice. What I mean is, at most hospitals labor is not respected as a healthy process. If labor fails to begin within an arbitrary timeframe, it is stimulated with dangerous drugs. If labor is not progressing as quickly as outdated gauges (since proven to be mistaken and unrealistic themselves) say it should, the labor is controlled by chemicals which have repeatedly been shown to cause fetal distress and severe maternal discomfort. But doctors have solutions for those complications, treatments for the very complications their active management of labor has caused. And if too many complications occur, they have the means to surgically remove the baby from the dangerous womb environment.

This model is accepted by many women, because of the doctor's ability to deal effectively with complications. Yet, how many labors, left to progress on their own, with women freely moving about and eating and drinking at will, would have a complication? We are so removed from the idea of birth being a good, healthy process that we cannot be certain. Yet it is reasonable that treating a healthy woman as if she has a life-threatening condition is not good practice. In no other field of medicine is pathology addressed before it occurs.

Hospital treatment of childbirth is laden with tension and discomfort. But out-of-hospital birth does carry the risk of unpredictable problems that might not receive medical attention quicjly enough.

This supports my previous ideal: a hospital with a birth center attached as the standard for maternity care. Obstetricians run the hospital part, while midwives are in charge at the birth center. All normal births are handled by midwives, and if something should go wrong, medical attention is down the hallway. No interference without medical need. All births are treated as normal and healthy unless they are proved otherwise.

I can think of no better way to manage childbirth. It is certainly several steps beyond where we are right now.

My position is changing

I have spent much of my time recently examining numerous studies comparing hospital birth to homebirth and other out-of-hospital birth. I am not a scientist, and I struggle to make sense of a lot of the data.

But in the spirit of intellectual honesty, I have noticed a trend that is disturbing to me. I have found the following:

1. Comparisons of hospital births to homebirths consistently show a marginally greater number of neonatal deaths (that's death of the baby within the first 28 days of life) in the homebirth groups. When perinatal mortality (includes the neonatal rate plus all fetal deaths from 20 weeks of gestation) is calculated in, the mortality rates between hospital birth and homebirth are nearly the same. However, there does appear to be a higher risk of neonatal death in homebirth.
2. To find these figures, you generally cannot use homebirth supporters as resources. The problem is that one person might have used the perinatal rate of homebirth from a study to compare to the neonatal rate of hospital birth, which might make the homebirth group look more favorable but is a misrepresentation of the findings of the study. Then other homebirth supporters quote that person instead of reading the study themselves. When I tried to research homebirth, I found the same unsubstantiated quotes used again and again.

I have said before that I am not at heart a homebirth supporter though I find myself in sympathy with their cause, because they oppose the hospital routines and invasive, unnecessary procedures I also find objectionable. But finding the above to be compelling and, through my unlearned, unscientific eyes, evidently true, I have had to look closely at my position.

Neonatal deaths can occur for a variety of reasons, but it is reasonable to assume that more complications can be addressed favorably in a hospital instead of at home, at the very least because of surgical capacities in the hospital not available elsewhere. So if you have even one childbirth complication that can be successfully resolved by cesarean section, the homebirth group is at a disadvantage.

Does this make homebirth unsafe? I think by definition it makes homebirth less safe than hospital birth.

My position on homebirth is much more cautious now. As a doula I will still support women who opt for homebirth, especially in my current community, because our health care situation is a sorry one, and our single small-town archaic hospital here may very well be doing more harm than good on the whole. But for myself, I find the risk too much to bear.

I support the birth center attached to the hospital option, and that is where my fervent support will henceforth be directed.

Perhaps once I am further along in my schooling and have taken a statistics course or two, I will be better able to analyze the data at hand. As it is, I am disheartened by what I found, but I am committed to being honest about what it says.

How did you get to your present position?

It shouldn't be a surprise to anyone that our views are based on our experiences. We have emotional ties to our perspectives, and that makes argument or debate inherently difficult. Even if presented with evidence to the contrary - say, just for a random example, a study that shows that homebirth is more dangerous than hospital birth, that mortality rates are higher at home - those who find their practice meaningful on some level will not be convinced that the numbers are correct.

I originally decided to prepare for a natural birth because I wanted to avoid having a c-section. Most of the first-time moms I knew had had c-sections. So I did research on how to avoid it if it wasn't necessary. What I read said that the best thing was to allow labor to progress on its own, without intereference (like inductions, epidurals, staying in bed, etc.). I had a doula and had a wonderful experience. I treasure my birth and am sure that it was the best thing for me and for my baby. I am in awe that I actually did it - I didn't know I would be able to have a natural birth, until I did.

I support and admire homebirthers because they accept what I take for granted, that birth is a positive and normal event, that birth should occur where women feel safe, and that women are capable of amazing things.

I find myself feeling defensive of homebirth, because I am scared that the medical industry will succeed in removing the option, those of us who support natural birth will be silenced, and we will be streamlined into an arrogant, crappy system more interested in numbness and detachment than the joyous experience of giving birth. I am afraid that the trend is toward ignorance ("the doctor will handle everything for me") than toward empowerment. Even if "empowerment" took the form of education about birth plus the reliance on medicine, that would be a step beyond where most women are now. I resent the belief that "I'm going to get an epidural so I don't need to know anything about birth." There is nothing good about willful ignorance. When I defend the issue of homebirth, I am actually defending education and natural birth in the face of the message that women can't do this on their own and need the technology, no matter the circumstance.

What I wanted to ask was, How did you come to your current stance? Was it through your own experience, witnessing others' experiences? Was it in reaction to a bad experience? Why do you feel the way you do about birth?

On Water Birth

Being immersed in a warm pool of water during labor and/or birth is a wonderful way to provide non-pharmaceutical pain relief and give ease of movement and comfort. I used water in both of my labors and delivered one baby in the tub.

Water birth is perfectly safe so long as some basic principles are followed:

• Filters and water supplies are clean;
• Do not keep the baby under the water after delivery;
• Do not re-immerse the baby after the birth;
• Do not pull on the umbilical cord to raise the baby up, especially if the cord is short;
• The baby will sometimes try to take a breath if the umbilical cord is exposed to the air;
• Babies in distress (heart tones or presence of meconium) should be delivered on land.

You might ask how I can reconcile this stance with my personal experience, where my second baby was born underwater not breathing. Let me be specific about what happened:

My labor was very quick. I got in the water at 6 cm and was pushing an hour later. My water broke at 9 cm and it was clear. Fetal heart tones were monitored periodically and were perfect throughout labor. I never got the rest-and-be-thankful part of pushing; I was thrown from transition into pushing with no break and no difference in how the contractions felt. I was not aware of when the baby was born; she came quickly and with only a few pushes, with no head-molding. She was taken from me right away when she did not breathe on her own. The only indication of something being wrong was what I experienced, what I now think was a fetal ejection reflex. She was born so quickly that I think somewhere I knew something was wrong, and got her out fast. Her condition had nothing to do with her being born in the water; if anything, being in the tub helped me deliver her more quickly and got her into the hands of professionals much faster than would probably have happened otherwise. The water helped me to relax, and I loved being able to move around easily during labor, as I could in the tub.

I frankly do not understand the prohibition against water birth in US hospitals and wish they were more commonplace. At least allowing women to labor in the tub should not be an issue, but there is a lot of resistance to it. Safety issues are simply not issues with some common-sense precautions.

General Views on Homebirth

While I was trying to work this blog out in my head, I felt that I had little to say on the matter, and what I did have to say was common sense and seemed silly to say aloud.

The question at hand is whether homebirth is safe, as safe as hospital birth. The answer, as I see it, is of course it is - for low-risk women. This means healthy women who have uncomplicated pregnancies, their babies are head down (not breech or transverse), and who are being attended by a qualified midwife.

Women who have a history of hemorrhage, have twins, are carrying breech or transverse babies, or who have health problems (diabetes, epilepsy, congenital heart or kidney disease, anemia, smoking, etc.), should not deliver at home.

I see absolutely no reason why low-risk women should not be fully supported if they decide to give birth at home.

I feel that this barely needs saying aloud, because there are so many qualifiers. Is homebirth safe? Yes, with low-risk women whose babies are in the right position and being attended by a qualified midwife, yes.

But homebirth is not my ideal. It scares me.

I wish that birth centers within hospitals but run by midwives, like I had for my births, were the standard of care for labor and delivery. I think women generally feel that health care options are dichotomized: either go to the hospital where you're at risk for every possible intervention, or stay at home where you are truly in charge of what occurs. I haven't yet given birth in my current area, but I dread the day when I have to decide where it's going to be. I know if I go to the hospital, I will fight with the staff about IVs and constant external monitors and what position I want to use for pushing. I want to catch my own baby. I want to move freely and eat and drink as needed. But here, these things are restricted. It is an IV-standard, EFM-continuous, episiotomy-giving, lithotomy-only hospital. We have no birth centers of any kind, no midwives except homebirth midwives. We are indeed polarized. And with this kind of polarization, I feel more comfortable with the option of homebirth than going to this archaic hospital.

About ME

First, I am not a homebirth advocate.

Homebirth frightens me, though I understand that for most women the risks for birth at home taking a life-threatening turn are very, very low. I have studied birth for about four years, since my first pregnancy, and I have found that while not very much can go wrong during a normal low-risk birth, when it does, it is serious. I admire the women who trust in themselves so much that they want to be at home. For many of these women, they have never considered that birth should occur any other way. Many others have been scarred by horrific hospital experiences. I sympathize with them but I still feel like an outsider.

I have had two natural births.

My births were both midwife-attended in a birthing center which was hooked to a hospital. Let me be clear about this arrangement, because it is an important one. It was not a floor or a handful of rooms within the hospital; it was a separate building, attached by only a hallway, which was run by nurses and midwives. The birthing center had labor tubs and birth balls and encouraged unmedicated births for low-risk women. If anything should go wrong, the doctors were down the hallway, but they were otherwise not involved. To me this was an ideal arrangement, since I was low-risk and wanted no medical interference, I did have occasion to be grateful for the availability of medical help, during my second birth. I had a water birth, which was not exactly a gentle experience, because it was a very fast labor and my baby was born not breathing. She was given oxygen and rubbed with a towel and in a few minutes was fine, but this experience is the main cause for my mixed feelings about homebirth. A qualified midwife would have the necessary skills to handle this situation at home, though I felt safe in an environment where emergency care was quick and reliable, and I am grateful I was there instead of at my house.

I am a doula.

I became a doula because of my satisfaction with my births. I wish all women the same confidence and joy in their births that I experienced through mine. I believe that women have a lot to learn from birth, that it turns out best when left alone, and I truly believe that most women would not require pain medication if they had education before childbirth and the right amount of support during labor. But I would not condemn any woman for choosing pain relief. You can't be judgmental and be a good doula; women are always going to make choices that you don't agree with. I have never attended a homebirth; all my knowledge about it is from research and the experiences of friends and associates who have. I have nothing against attending a homebirth - I would be honored to. The opportunity hasn't yet arrived. I am still a very green doula.

I believe in birth.

Fear is the largest obstacle between women and a satisfying birth. We have been taught that birth is like pushing a watermelon out of a hole the size of a pea, that it is the worst pain you will ever feel, that major surgery is a reasonable escape from the misery of birth. No wonder our epidural rates are so high and that elective cesareans are increasing! Women are terrified of birth. Even though they were made to give birth, they have been frightened away from it.

I wish all women could have the experience of working with their bodies to bring babies into the world. I wish there was not so much focus on the pain of labor. I did not have what I would call easy labors, nor do I have a particularly high tolerance for pain. I learned relaxation skills, and during labor, I felt the difference between being completely relaxed during a contraction and tensing up against it. The pain was sometimes very high, but it was completely unbearable if I was tense. I believe that women have much to learn from childbirth, and it is knowledge we cannot gain anywhere else. We need to learn to trust. We need to learn to sacrifice. We need to do hard things to prove our strength to ourselves - we are indelibly strong and tough. That is what we have to gain from childbirth. And I can see no better preparation for motherhood than learning to work through difficulty.

You can tell from this that I certainly have my biases, but I believe I can be even-handed and rational on the topic of birth. I am a student of birth and hope to never assume I am no longer teachable.

The Reason for this Blog

This blog was inspired by Amy Tuteur's Homebirth Debate, which began as a forum for advocates and opponents of homebirth to debate their views. I followed the discussion with great interest, but found myself getting increasingly frustrated by the debate. I wish to have a different kind of forum.

In this blog:

I will not delete any comments for the sole reason that I do not agree with what is being said or because I am feeling defensive.

I will not dismiss valid reasoning or information on the grounds that I don't like it.

I ask that all who participate have a commitment to intellectual honesty. I am more interested in fairness and good reasoning than I am in defending any emotional stance.