Monday, August 23, 2010

In defense of reproductive choice: homebirth

I've been reading comments lately on Facebook and elsewhere mocking women who choose homebirth. Many things disturb me about such comments, including their occasional MD provenance, but the most disturbing thing to me is the knee-jerk equation of homebirth with woo like homeopathy, chiropracty, and using eye of newt in stews. I've read dismissive and derisive words targeted at women who make this choice, including one in a UK article quoting an MD calling women selfish and reckless for choosing homebirth. Birth is birth, no matter where it happens. Location does not make it woo, and to equate this choice with practices that are patently woo is a form of uberstereotyping at its worst.

The women who choose to have a child at home represent a large spectrum, from those who insist on unassisted births for religious or other reasons to those who use a certified nurse midwife (CNM) who has OB backup minutes away. Just as there is no single profile of a woman or family who chooses homebirth, there is also no single monolithic reason that they do so. The reasons are complex, and as a woman who has had a child at home and has given a great deal of thought to this subject, I address those here in arguing in defense of homebirth as a valid reproductive choice.

Why did I choose a homebirth? I tried it three times. The first time [which was really in a birthing center not connected to a hospital], my CNM kicked me over to the OB because of high blood pressure, and I gave birth to our first child in the hospital, where nurses literally yelled in my face, the door to the delivery room was wide open so that total strangers could just stand there, watching everything, and they gave my newborn son a total of 12 medically unnecessary heel pricks for blood draws for blood sugar levels when he didn't have a single reading out of normal range. For those unfamiliar with this process, they clipped my son's heel with a tool that tore into the skin to make it bleed. As he screamed, they squeezed the blood out to sample the blood sugar levels. They did this to him twelve times in the first 36 hours of his life for no legitimate medical reason.

The trauma of that experience was so powerful that I had a form of PTSD that lingered long after. Five years later, when I returned to that hospital to have my thyroid removed, just driving into the parking garage brought on waves of nausea and adrenaline. To this day, I can't hear a click like the one the heel-prick tool makes without flashing back to those first two days of my son's life. That thyroid problem, by the way, was something my midwife detected--my OB and other doctors had not bothered to test for it.

This experience and form of PTSD following a hospital birth is not uncommon. Take some time to read birthing stories on the Web. You'll find women who aren't even articulating their fear, anxiety, or lingering feelings of trauma, yet it comes through in their stories. Some frankly describe their experiences as horrific or traumatic. Is it all about them? No. But it certainly is much about them, and anyone who discounts that is treating the woman herself as less than a person.

I'm guessing that no doctor wants their patient to come away from an experience like childbirth with this kind of persistent emotional distress. Add to that the physical sequelae of a hospital experience--such as the two hospital-borne infections my son and I had, the antibiotics and consequent infant and breast fungal infections that interfered significantly with breastfeeding--and the entire experience can snowball into something that I personally try to avoid recalling.

Our second son was born quietly and safely at home with a CNM who had OB backup, while our third was born at a different hospital with my OB, CNM, and husband the only people in the quiet, darkened, family room where labor, delivery, and post-partum recovery all took place. I don't know if those who mock homebirth realize it, but it's the women like my mother--the vanguard of the homebirth movement--who drove hospitals to realize that they needed to offer families these environments that were more like, well, home. To offer women and families a choice.

This shift from bright, loud L&D rooms full of masked strangers and a peeping public to a dark, quiet room with only family and familiar healthcare providers is an example of what could be achieved if MDs were more accepting of midwives and could bring themselves to listen without mockery or skepticism to why women choose homebirth. I didn't choose that route because I have a la-la attitude that childbirth is soooooo natural and soooo straightforward and something that will work out just fine as long as you do it right. I chose that route because it was what was best for our family, for my child, and because I knew that with the CNM and my OB backup, things were in all probability going to be fine. When I say "probability," that's really what I mean.

MDs can tell the horror stories and have seen babies die in terrible and avoidable ways, and as someone who engages daily with medical and health information, I know these stories, too. The doctors have seen the worst, and their minds can instantly pathologize any situation. They've got legitimate fears about women giving birth away from the emergency interventions a hospital can offer. For the record, I had those fears, too, but in my cost-benefit analysis, my home was the better choice of places for the one fully healthy pregnancy I experienced to reach its end. As a woman, a person, an adult, the pregnant woman, the mother, it was and remains my right to weigh the balance of these issues and make that choice.

The one thing that I or any mother can have in common is the goal of a healthy baby at the end of the process. MDs can stonewall women like me and make fun of us, or they can reach out and try to find ways to make all childbirth options as safe as possible (with the exception of the unreachable extremes). Had our community offered a home-like environment away from the death and sickness of the hospital with midwives aiding the birth and emergency interventions and MDs nearby (you know, like a birthing center), I'd've probably seriously considered that option. But it wasn't an option. Where I live--and where many American women live--the options occupy one end of the spectrum or the other.

The question is, Can we work together toward the goal of safe choices and safest births? As I've noted, the reasons women choose homebirth are complex. One thing that drives women away from doctors and the hospital-care environment is the condescension they experience. I'm not speaking for myself but based instead on the hundreds of birth stories I've read in which women express a feeling of not being heard, of being pushed to accept interventions, of being treated like children themselves. When I read comments from MDs mocking their own patient population, I have to take stories like this seriously. We cannot work together toward a common goal of a safe birth if one of the fundamental reasons women choose the homebirth route persists.

From what I understand from midwives in our community, OBs are reluctant to work with them. As backup for emergencies, the MDs may have liability concerns, which are legitimate given our litigious environment and the fact that any homebirths that come to them will likely by definition be emergencies and associated with complications. Yet, other countries have demonstrated that it is possible for MDs and midwives to work together to produce a safe, healthy, non-traumatic birth environment for mother and child. Even as that progresses in these countries, here in the United States, women in New York have in practice lost their choice of midwife-assisted birth.

I have known several midwives. Yes, they can be touchy feely. They can talk about woo-y type stuff that's just not my thing. One even meditated. But women turn to practitioners of this ancient profession because in their experience--and in mine--midwives listen. During prenatal visits, midwives do everything women experience in a doctor's office, with two exceptions: Midwives don't make the woman wait for an hour to be seen, and when they do see her, the appointments themselves can last as long as an hour as the midwife listens and notes everything the woman has to say. This art, the art of listening, is one that any MD would do well to practice. Studies indicate that many doctors aren't too great at listening, and if there's one thing a pregnant woman needs as badly as she needs a blood pressure check and to pee on a stick, it's to have someone really hear what she's saying.

A recent study has stirred up a great deal of controversy about homebirth because it found a higher rate of infant death during the month post-partum period among homebirths. These findings run counter to previous reports of relative safety of homebirth. I don't doubt the study authors' analysis, but I don't think that they pursued the potential reason for these deaths not during the birth but during that post-partum period. It may be--indeed, is likely--that the homebirth population is less inclined to seek standard medical intervention in general and that in the presence of infant symptoms of illness, they opted for home care, leading to higher rates of complications and deaths.

Some studies also indicate a higher rate of perinatal death with homebirth. These studies include the spectrum of homebirth options, and in my opinion, it's inaccurate to compare a birth with, for example, a lay midwife to one involving a CNM with OB backup. But many studies have found comparable rates between low-risk, CNM-attended homebirths and hospital births, and of course, many of these are international studies. Indeed, with the right safety mechanisms in place, even the World Health Organization countenances the choice for women.

What is the bottom line here? I would argue that the onus is on doctors to open up more to what women are saying about birth. The MDs may have heard it all a million times, but for the individual woman, the future mother, she's the only experience she has. If the medical establishment could expand the options, women could have reproductive choices that are safe for their babies and for them, and doctors would feel more comfortable about safety and access to necessary interventions.

Perhaps, some day, we can achieve the birthing nirvana that The Netherlands seems to have become, based on a study 529,688 women in that country. As the authors observed, "This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of welltrained midwives and through a good transportation and referral system." These words describe the goal. But to get there, a first step would be that MDs not mock their patient population, no matter how misguided the patient's thinking may seem. Women deserve that respect...and choice.