Changing the Climate around Birth: A Kickstarter campaign for 'Why Not Home?'

I'd like a share a guest post by Jessicca Moore, a family nurse practitioner and filmmaker in Petaluma, CA, where she lives with her husband, two children, and two sheep. I met Jessicca in Boston recently, where she was screening a not-yet-finished feature-length documentary, “Why Not Home?” The film follows hospital birth providers who chose to give birth at home. You can watch a trailer and get more information here to support the project on Kickstarter, as I did.

(photo by Erin Wrightsman)

By Jessicca Moore

Our current system of birth is unsustainable. A system that spends 111 billion dollars on maternity and newborn care annually is not sustainable. A 33% c-section rate, while sustainable in some sense, is not without significant consequence.

As a family nurse practitioner, I’ve done work in healthcare improvement over the past 10 years. “Every system is perfectly designed to get the results it gets,” is a common saying in improvement work. Keeping this in mind, it’s not surprising that we have ended up here.

I am not a conspiracy theorist. I don’t believe there is one player at fault. The factors at work in the system are complex.

Instead of looking at hospitals, doctors, or insurers, I’m interested in how we as a culture have colluded with the system to sustain it and how we might change the cultural conversation around birth.

Currently the message many women hear about birth is, “Birth is painful. You can’t do it. The experts know what to do, let them handle it.” What if instead women heard something like this, “Birth is an intense transition to motherhood. You are powerful and capable. You have everything you need within you to do this. If you need help, a trusted guide is here to help you.”

We live in a culture that values technology and progress, speed, efficiency, and expert advice. While these values have led to significant improvements in many areas of science and medicine, they don’t translate very well when it comes to birth. Our outcomes have made this evident. The judicious and appropriate use of technology is too often replaced with a one size fits all overuse of technology. Still, there is reason to hope.

There is a growing movement that questions these cultural assumptions and the way they are broadly applied. We have the power to change the climate around birth. We can choose to slow down and honor birth and it’s place in the family and community. We can do this at home and in the hospital while improving quality outcomes and the experience for women and families.

Why America Is at a Crossroads With Childbirth Education

Earlier this month, the closing of Isis shocked families across all of its locations in Greater Boston, Dallas and Atlanta who had come to depend on it as a place that supported their transition into parenthood, from childbirth education, to lactation support and mommy-and-me circle time.  But despite a steady class business, the company needed its retail sales to stay afloat, and online encroachment from the likes of Diapers.com and Amazon spelled its doom.

Meanwhile, on the West Coast, a chain called Day One Center that also provided birth and breastfeeding classes recently closed, too. It seems as though few companies have figured out the right business model for birth-related support services in the digital age.

Even single-store independents are not immune to the struggle, from Crunchy Granola Baby in Salem, which closed in 2011, to Mothers and Co. in West Boylston, which shuttered in 2012 and whose owner, Jeanette Mesite Frem, now teaches in a cozy space above a pediatrician’s office.

While every business has its own nuances, do these failures say something about what they are selling or our willingness to buy it or perhaps both? What about the cultural shifts: more moms working who are too busy to devote their time to classes, or the seismic technology changes involving everything from online communities and YouTube pregnancy videos to apps for timing contractions?

Historically, women never needed childbirth or lactation classes because they would have been surrounded by other experienced women throughout pregnancy, birth and the postpartum period, providing support through each stage. In modern times, when birth moved from the home to the hospital, women were cut off from that network’s information, leaving a void.

The first childbirth education class in the U.S. happened in New York City, after American Marjorie Karmel gave birth in Paris attended by Dr. Fernand Lamaze, who was famous for his principles of painless, natural childbirth during a time when women were routinely heavily drugged during labor in hospitals. Karmel came home to the U.S. and teamed up with Elisabeth Bing in 1960 to offer childbirth classes in an apartment on the Upper West Side. A decade later, about 10 percent of hospitals sponsored prenatal classes. By 1975, most did – as they do today.

“It was a consumer movement,” Bing told me in an interview years ago in the very space where she taught thousands of parents how to handle contractions. “The time was ripe. It was a time when the public doubted everything their parents had done.”

That is a very different mindset than today, where consumer priorities seem to be less about questioning authority and more about having a fancy stroller. In fact, only about one-third of all moms (59 percent of first-timers) take birthing classes today, according to the Childbirth Connection’s Listening to Mothers III report.

To have a big impact, about 75 percent of first time mothers should have access to maternity classes, experts say. But even at a place like Isis, where the classes were fed by a hospital referral pipeline, they could not charge enough to keep the doors open. The lesson is that that either parents don’t want to pay all that much for education, or they expect their health insurance to cover it, like every other aspect of birth; and most insurance will only pay a fraction of it.

“Right now, the way it’s covered through insurance, it’s not highly valued either,” says Lamaze International executive director Linda Harmon. “It doesn’t provide full fee for service.”

In addition to concerns about cost, expectant parents are pressed for time. With many women giving birth later in life when they may be more firmly established in their careers, making time for classes spread out over several weeks may be too much.

And then there’s the internet. Blogs, websites, YouTube, twitter, Facebook groups. It seems everyone is an expert or has experience to share, which is great but can it really replace the personal touch that teaches women about things they may not even know they should be Googling for?

Frem says no: “It’s hard to learn online for something so physical and emotional.” While she has started a podcast and is considering video, she says her clients would rather meet wither in person. 

At the national policy level, there are pressures to improve maternal and neonatal outcomes as well as lower costs by reducing cesarean section rates and pre-term birth. Broader access to education would help achieve all of those goals – but access to and interest in class-based education appears to be waning.

Which begs the question: In the age of ‘massive open online courses’ -- or MOOCs -- do we even need classes anymore?

Lamaze International, the nonprofit leader in childbirth education that Elisabeth Bing co-founded, has been watching the cultural shift and is now focused on “meeting women where they are,” Harmon said. That includes their Push for Your Baby campaign; mobilizing social media to help mothers connect, which is the channel through which many are asking for help; a blog that contains evidence-based information; a 40-week education email; and even webinars.

“We’re pushing out information to reach them whether they come to class or not,” Harmon said, adding that they are also committed to teach sound business practices to independent teachers who leading classes in converted barns, church basements and hospital meeting space.

Robin Elise Weiss, an author and heavily credentialed childbirth educator, lactation consultant, doula and mother of 8, agrees that embracing change is essential but says that there are benefits from face-to-face sessions.

“It’s hard to teach relaxation through Facebook or twitter,” she says, though she is an avid user of both and creates a Facebook group for each class so they can teach each other. 

The Two Most Important Things in Episode Three of 'Call the Midwife'

Episode Three of PBS’ 'Call the Midwife' was another great show, with two interesting points relevant to the history of childbirth. (You can read my takes on Episode One and Episode Two, as well.)

First, an exuberant expectant husband who is craving information about his wife’s pregnancy comes home with a book written by Grantly Dick-Read (below), a British doctor who, like the midwives in the show, rode around London’s poor neighborhoods on his bike in the fog to help deliver babies. This was after World War I. Having grown up in the country surrounded by farm animals, he watched many mammals give birth and approached a woman doing the same without the fear that many other first-time mothers – and even obstetricians – brought/bring to the process. He considered birth normal, not an accident waiting to happen.

His first book, Natural Childbirth, was published in 1933. His second book, commonly called Childbirth Without Fear, came out in 1942 – right at the time of America’s great migration of birth moving from the home to the hospital. Many women, however, were shocked by how they were treated in the maternity ward, and they embraced Dick-Read’s second book like a bible for how to have a natural birth.

He arguably set the stage for the natural childbirth movement in American in the 1960s and ‘70s, though doctors Bradley and Lamaze are more often associated with that time.

The second point of interest for me in the show was the midwife’s use of a Pinard horn (below), a low-tech but effective instrument for listening to the baby’s heartbeat. 

Even today, midwives like to use these – or the fetoscope (below) – because they don’t pester the baby with bothersome noise like that which ultrasounds make in-utero.

Breeches and rickets: Lessons from Episode Two of the PBS Series Call the Midwife

Episode Two of PBS’ Call the Midwife gave us two births that most contemporary pregnant women don’t have to deal with. (You can read my post on Episode One here.)

The show included a woman with rickets, which is a vitamin D deficiency that was common among poor women who did not have a proper diet. The affliction can cause bones to bend – often noticeable in bowed legs, as in below – but can cause the pelvis to be misshapen as well. Sometimes the deformity could be so bad that there was no way for a baby to be born vaginally.

The mom in Episode Two had had a fatal outcome with a previous pregnancy but was able to have as c-section this time around thanks to the National Health Service covering the costs. If there is ever a time for a c-section, that would be it.

The other interesting birth was a breech, shown coming out “ass first,” as nurse Chummy (below) deadpans during the delivery. 

The scene shows how breeches can be born safely if patience, wisdom, experience and the right birth positions are applied. Today, sadly, very few women with breech babies are allowed to give birth vaginally by their doctors – mostly due to a lack of experience in knowing how to gently guide the baby out. It’s an artful midwifery practice we are losing – and shouldn't.  I’ll leave it to the sage midwife Ina May Gaskin to explain why.