An open letter to expectant mothers on the safety of homebirth

Dear Mama,

You may have read an opinion piece in the New York Times by a non-practicing obstetrician who typically saves her rants for Twitter fights against homebirth, midwives, breastfeeding and even certain parenting practices. Perhaps you were as surprised as I was to read her views in a respected mainstream publication at a time when:

• The governments of many developed countries (such as the UK) are doing more to promote homebirth as a safe option for low-risk women
• Harvard-trained practicing OBs are talking about the faults and dangers in our current hospital maternity system
• And although they are still a small number, home births have doubled over the last decade.

The number of women giving birth at home is less than 2 percent of the 4 million or so annual births in the U.S.  And yet, according to the Lancet, America is only one of eight countries in the world where the maternal death rate is increasing, nearly doubling since 1987.  These awful numbers are rising for a few reasons-- including that hospital births have become so medicalized that they often introduce complications into what is otherwise an unchanged ancient physiologic process -- not because home birth has taken off like a rocket.

All of the gains our healthcare system made throughout the 20th century to fight infection, perfect anesthesia and cesareans, and provide better prenatal care are being eroded because doctors are introducing complications that don’t need to exist. To be clear, I’m not here to bash doctors. They mean well and often practice in an environment of fear where the saying goes like this: you get sued for the c-sections you don’t do, not the ones you do.  So the system is skewed toward intervention, which is now so common, it is one the key reasons why more American women are choosing to stay home! Oh, the irony. Another reason more moms are choosing to stay home is because the data shows it is safe, especially for low-risk mothers, and even for those who have had a cesarean.

Instead of focusing on what hospitals and OBs could do to lower their complications in birth -- beginning with reducing the outrageous national cesarean rate in the double digits that is as high as 50 percent in some hospitals -- the author of this confusing out-of-the-blue-except-that-she-is-promoting-a-book diatribe against homebirth instead chose to turn her sights on midwives who attend home births.

That angle makes me even more angry.

In the late 19th century, the all-male medical profession began launching campaigns to eradicate midwives. Massachusetts was at the forefront of this movement as we churned out doctors seeking to claim market share in childbirth. These campaigns portrayed midwives as illiterate, often because the women were immigrants who spoke languages other than English. And yet these midwives carried generations of wisdom and decades of hands-on practice that gave them the ability to gently ease breeches into the world or guide a mother into a position to minimize shoulder dystocia. As home birth midwives were pushed to the brink of professional extinction, this knowledge also faded. How has that helped women?

In the Netherlands and other countries that recognize the value of integrating home birth midwives into the maternal health care system, families have access to physician consult when needed, and smooth transfers from planned home births to the hospital during the small percentage (about 10 percent) of births where additional care is needed. In the U.S., this integration fluctuates widely. In some areas, physicians and midwives collaborate and transfers occur seamlessly, ensuring families receive the appropriate level of care when complications arise. In other communities, physicians refuse to consult with midwifery clients or families describe hostile treatment when they transfer to the hospital.

The bottom line is, the debate around home birth statistics as it has been portrayed in the mainstream media is only serving to confuse expectant parents trying to decide what is safest for their family. The headlines have focused on research highlighting the relative risk rather than the absolute risk, which is still quite small.

Continuing to blame midwives of any stripe for the lack of safety in the U.S. maternity care system is an utter farce. It is not the path to making birth safer. Women need more options, and more ways to integrate midwifery into mainstream care. Right now, midwifery lives in the realm of women who can pay for it like the luxury item that it is. That is also wrong. Expanding access to midwifery care -- whether at home or in the hospital -- benefits all of us.

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. 

"Birth, Breath & Death:Meditations on Motherhood, Chaplaincy and Life as a Doula," a book by Amy Wright Glenn

It's a slim memoir, about 100 pages long, but Amy Wright Glenn's memoir "Birth, Breath & Death," has stayed with me log after I finished it. The book is about how, as a young woman, she eschewed Mormonism to find her own spiritual path. She sought to understand all religions, and their commonality. She also put herself in challenging situations to learn about the two most important and spiritual aspects  life -- the birth and death parts -- which many of us find too personal and difficult to face with others (or even ourselves.)

Becoming a doula, even when she was unsure she wanted to be a mother herself, takes a wide-open mind and heart. Still, I can see why one might become a doula. To help a woman in labor is to be present at a miracle. But to help individuals and their family and friends meet the end is to surround yourself with sadness. That takes a kind of mettle that I cannot fathom, but am certainly grateful exists. Amy's willingness to confront death in many forms, with fortitude and grace, is mind-bending. The one exception to her willingness is when someone asks her to perform an exorcism. This scene becomes a form of comic relief in the book, though I don't think she wrote it to be funny.

"We dance between form and formlessness," she writes. These words made me pause. Yes, so much exists before we are born and after we die. If we're not dancing in between we are wasting time.

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. 

Call the Midwife: A historical guide to outdated birth practices

Call the Midwife on PBS is not only a well-written show based on a real-life British midwife’s work in the years shortly after WWII in London’s East End. It is also an excellent way to understand the true nature of midwifery, how childbirth has changed, and how it has not. I’ll be posting several pieces about the series as it unfolds.

One thing that is fascinating to me is seeing birth anachronisms – methods and instruments that are no longer used (for good or bad). And Episode One contains a wealth of examples. First, the midwives give mothers enemas. This practice thankfully fell out of favor decades ago. The rationale behind them was that by cleaning out the mom, the baby would have more room to maneuver and help the labor progress more quickly (as well as prevent soiling during labor). The technique was called “high, hot and a hell of lot,” referring to where to hold the container of hot water and how much to use. But enemas can be painful during labor and they were found to be of no benefit.

Episode One also contains a scene with pubic hair shaving, which midwives and doctors used to do in an effort to make the area more antiseptic. However, many studies later revealed that small nicks from shaving actually introduced germs into the mom’s bloodstream and could cause infection, so it is no longer recommended, except sometimes in c-sections. Phew.

Finally, perhaps the most awful of all of the outdated interventions seen in Episode One is the episiotomy – a scene that will make anyone cringe! -- where a cut is made to make the birth opening larger. These were once routine, but again, many scientific studies have debunked the method, showing that introducing a cut could make a mother tear more deeply and have more pain later when she might not tear at all if left alone.

Understanding Pelvic Organ Prolapse and Its Treatment Options

Below is a guest post about pelvic organ prolapse, which recalled for me some historical case studies where uneducated birth attendants would, after the baby was born, yank on an umbilical cord to remove the placenta more quickly, and cause the uterus to come out as well. At the Mutter Museum in Philly, devoted to medical oddities, there were even some gruesome examples of what women had to use as pessaries (including potatoes)!

Anyway, good information and sound advice below, especially as it relates to "mother directed pushing," which means, you push -- or don't push -- as your body feels most comfortable; not when someone else tells you to.

GUEST POST:

Pelvic Organ Prolapse (POP) is a common condition that affects women between the ages of 50 and 70. In fact, approximately 50 percent of women will be diagnosed with the condition during menopause, when decreasing estrogen levels cause pelvic tissues to become thinner and weaker. The symptoms of POP range from very mild to severe, as do the treatment options. It is important that women understand what POP is, how it can be prevented, and the variety of treatment options available.

Some treatments are significantly more risky than others, so women should become educated to understand the risks and benefits associated with each.

Pelvic Organ Prolapse

Although decreasing estrogen levels during menopause can be the final trigger for POP, there are additional contributing factors. The primary causes of POP are pregnancy and childbirth, although smoking, obesity and a genetic predisposition can also lead to a diagnosis of POP. The condition occurs when weakened pelvic tissues begin to sag, or drop, in the pelvic cavity. In mild cases of POP, a woman will not experience any symptoms. Her doctor usually diagnoses it during a routine pelvic exam.

In moderate to severe cases, connective tissues will begin to detach from the pelvic structure, causing pelvic organs to drop completely and begin to prolapse into the vaginal canal. The organs most commonly affected by POP include the bladder, uterus and rectum.

Some symptoms of POP include:

·        -- an inability to insert a tampon

·        --  a feeling of bulging, or sagging, in the pelvic cavity or vagina

·       --  difficulty beginning to urinate and/or weakened urine stream

·       --  unusual constipation

·        -- pain or discomfort during intercourse

·       --  spotting or light bleeding

Preventing Pelvic Organ Prolapse

There is evidence that POP can be prevented — or the symptoms can be significantly reduced — by maintaining a healthy weight, eating well, exercising and quitting unhealthy habits such as smoking. Women who are pregnant should discuss "Mother-Directed Pushing," as well as their options for delivery positions during their labor. Research has shown that working with a woman's natural birth physiology can reduce conditions like POP and incontinence.

Kegel exercises are also beneficial in promoting pelvic floor health. Women who do Kegel exercises on a daily basis during and after pregnancy have a lesser chance of developing incontinence and/or POP later on.

Treatment for Pelvic Organ Prolapse

Once POP has been diagnosed, women should discuss treatment options with their doctor. They should try non-invasive methods before opting for more risky surgical interventions. Non-invasive methods include:

·        --Physical therapy

      -Electrical stimulation of pelvic floor muscles

·        --Vaginal pessary

More invasive methods should only be used for moderate to severe cases of POP in which symptoms are uncomfortable and/or debilitating. One surgical method used to correct POP uses a material called transvaginal mesh. It has been linked to thousands of cases of severe health complications. The mesh product can erode into vaginal tissues, causing pain, infections and even organ punctures (organ perforation). These complications can be impossible to reverse.

There are alternatives to transvaginal mesh surgeries that can be successful in treating POP. Women should discuss their full range of surgical options before choosing the safest and most effective treatment for their symptoms.

Author Bio: Elizabeth Carrollton writes about defective medical devices and medication safety for Drugwatch.com.

Why becoming a doula is important now

Today, I present a guest post from Gina Forbes, the Workshop Coordinator at toLabor.

Becoming a doula is important now, more than ever.   With the current political climate and the recent attacks on women's health care and civil rights, it seems very clear that this is a precarious time in American culture.  Yet, I also feel that we are on the cusp of something bigger and better.  Every day, I learn about more individuals making greener, healthier choices for themselves and the planet.  People are beginning to rise up and live consciously.  This gives me hope.

As a birth advocate, doula, childbirth educator, and Workshop Coordinator for toLabor, I have thought long and hard about the role of a doula in this cultural and consciousness shift.  What is the greater significance of being a doula?

The answer is this: that EVERY person deserves to have autonomy over their bodies, their babies, their families, and their choices.  It is a human right, a civil right.  Every person who becomes pregnant, gives birth, and becomes a parent deserves to have high-quality, loving and compassionate care around this incredible time in their lives.  Doulas are people who are trained to respect that principle as the basis for all other work they do in their role as birth professionals.  Doulas ideally embody the role of empowered human being, facilitating a process of transformation and support for each and every client.  No matter what the birth experience looks like, doulas should be there to create the space for their clients to claim their choices, their autonomy, and their unique voice.  If done successfully, this paves the way for those individuals to become empowered, healthy, confident parents, which will have a direct impact on the quality of future generations' lives.  Birth matters!

I am an advocate for toLabor, the Organization of Labor Assistants for Birth Options and Resources, because toLabor exemplifies these beliefs in their doula training and certification program.   toLabor aims to return the focus of control to the laboring woman, to create the space and support for her to have her own voice, to be included and central in her birthing process.  toLabor understands the importance of empowering families, honoring birth, and changing lives.

Join the Community of Change.

toLabor will be having a doula training workshop in Jamaica Plain, MA on May 18-20.  For more information on that workshop, please contact local sponsor Catherine McKeown-Lindsey at catstamatos@yahoo.com or at 617-817-5397.  For other workshop listings and more information on toLabor, please visit the website at www.tolabor.com.

An amazing birth-artifact

This is an amazing image for two reasons: First, it was found by a man who is legally blind. Second, it shows a common position women gave birth -- standing up, supported by ropes or vines -- before doctors determined it was more convenient for women do to deliver on their backs. Which, it turns out, is the worst possible position because it is more difficult for both baby and mother. Thanks to Carey Goldberg at the CommonHealth Blog for pointing it out to me.