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.

A Stack of Books

Just thought I would share a photo of the backstairs leading to my kitchen. They are painted to look like the covers of my two books -- Birth: The Surprising History of How We Are Born; and Jackie After O -- and the middle three that my husband Anthony Flint wrote. If you look closely, you'll see that there's room for one more. Taking bets as to which one of us will claim it. Regardless, we're grateful to Boston artist Jane O'Hara for doing an amazing trompe l'oeil stack that makes our home even more special to us.

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. 

10 reasons why I am running the Boston Marathon

       1. Because I have two legs.

       2. Because I am alive.

       3. Because I don’t take #1 or #2 or so many other lesser things for granted.

       4. Because it’s for the GREATEST possible cause.

       5. Because Boston is my home.

       6. Because I’ve been a spectator for long enough.

       7. Because if not now, when?

       8. Because I’d like to experience a marathon as more than just a metaphor.

9     9. Because I don’t want my sons’ most poignant marathon memory to involve a lock-down.

       10.  Because I need the exercise.

Please consider donating any amount here and join me in being an ambassador for peace.

"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 Case for Midwives at Birth and Death

Episode Four of Call the Midwife (see reviews of the other episodes below) was among the saddest yet, with a mother dying of eclampsia, not knowing her headaches were a classic sign of the affliction. Eclampsia remains one of the most confounding mysteries in childbirth. No one really knows why it occurs or how to prevent it. But the only way to end it is through delivering the baby before the mother’s life is threatened.  Unfortunately in this case, the baby was delivered and the mom still died. The midwife who first met the mother – but never had a chance to care for her – sat by her bedside as the woman lay dying, a reminder that historically, midwives ushered in new life and ushered it out as well. They typically cared for the ill and dying – not just pregnant women.  There are “midwives of death” – hospice workers and others  who help people pass peacefully at home. I think we need more midwives at both ends of the spectrum of life.