Thursday, February 11, 2010

This Far and No Further

I had another clinical observation day today, for my breastfeeding course. This was with a community based lactation consultant, which was very cool. It was great to see an L.C. in action (I wish i could do an observation day with my MOM--how cool would that be??!), and I know this L.C. from before, as I went to see her when I had my first bout of yeast last year, and we have kept in touch since then. She's very supportive of midwifery also, which is nice, and which makes logical sense, since there is so much overlap between natural childbirth and breastfeeding. But today she threw me a comment that surprised me [I'm beginning to get the impression that this shouldn't surprise me, ever, from anyone], about how she just can't bring herself to support home birth, 'because it is SO much safer to be in the hospital, where everything is there if you need it.'

I'm cautious in moments like these. You don't want to plow over people with your opinions, but I feel strongly about the safety and appropriateness of homebirths for low risk women, and support a woman's right to choose where to give birth with all my heart. So I just can't keep quiet. But how to approach in such a way that doesn't shut people down? Close their minds?
I pointed out the fact that in hospitals, the golden standard timeline from recognition of an emergency to in the operating room, performing surgery, is thirty minutes [I didn't point out that it is not uncommon for this to actually become 40 to 45 minutes]. Many midwives will stipulate that a woman's home, should she choose to give birth at home, be within a half hour of a hospital. This is comparable to hospital OR time, since in an emergency a midwife can phone ahead to the hospital, get the operating room ball rolling, and call an ambulance or get in the car and drive, and have a woman in the operating room within the same or similar time frame.
All of this is true. Some midwives will deliver a particularly low risk woman at home when she lives further from the hospital. But often people seem confounded by the idea of home birth because of its geographical distance from the operating room. That geographical distance isn't quite as far as we like to think. Operating rooms don't stand filled with staff and equipment at all times, ready to cut in four or five minutes. Even in hospital, even in an emergency, a cesarean takes time to prepare for. And even in a home birth, a cesarean is accessible.

I could also have pointed out that in Norway, 70% if women give birth at home, attended by midwives, and Norway has one of the lowest infant and maternal mortality rates in the world.

I could also point out that home birth statistics in Canada show that home birth is actually safer. Intervention rates are lower. Complications are lower. Surgical rates are lower. Infection rates are lower. Death rates are lower.

Women are screened for risk factors before being accepted as candidates for home birth. There is always a second medically trained person at a home birth in case of the need for resuscitation. But the statistics are inarguably in favor of home births for low risk women. Perhaps hospital based infection rates cause enough deaths to counter balance any home birth deaths in which a geographically proximal operating room or a larger resuscitation team would have made a difference.

The thing is, women should be free to choose. Birth is not dangerous. It is a vulnerable time in a woman and an infant's life, but it is not inherently dangerous. Nature is very good at directing birth, which is not a medical event until [unless] it becomes a medical event. Healthy women with adequate nutrition and access to clean water, good medical care, some degree of prenatal care, and access to accurate information regarding birth, can and do give birth with very little danger. Some women feel safer in proximity to a greater number of health care professionals. Wonderful! Give birth in hospital. Some women feel safer in their own homes, with their own family and bed and bathtub around them, exposed to the microflora that their bodies are accustomed to living with. Wonderful. They should be free to choose this, without judgement.

Such a long journey. So solitary sometimes.


ms emili louann said...

Since I had a cesarean first, will I always be considered too "high-risk" for a homebirth, even though I had a successful vbac with my second?

Dana said...

I'm with you all the way!!!

Asheya said...

Yes to homebirth! You hit the nail on the head with everything you said, and especially the part about women who have good nutrition, clean water, and access to health care professionals should they need it. With proper woman care, birth happens as nature intended 95% of the time--healthy baby, healthy mama.

Because of this, I am an advocate for women in remote communities who are properly informed of the risks, both of hospital and home birth, being given the opportunity to birth at home. There is research from Canada and Australia that indicates that making women birth (especially aboriginal women) in a large center outside of their community actually results in lower birth weight babies and less than optimal outcomes, as compared to birthing with a health care professional in the community, even though it is a great distance to surgical backup. This research is not extensive, but it is a start.

The reasons for better outcomes if women birth in their communities have to do with stress: emotional stress at being separated from family and community, financial stress on the family for her stay in a big center, frustration if the baby is 'overdue' leading to more induction rates. Also, these communities often lack adequate prenatal care, which means woman care during pregnancy is not very good, also leading to poorer outcomes.

As far as what you can say to people, I think that if you are talking to someone who is also in the health care field, it is entirely appropriate to pull out all the statistics and provide them with a mini education on the spot! If you are talking to a pregnant woman, I think this approach is also useful, with an emphasis on her choice. If you are talking to a spouse or a parent of a pregnant woman, then again, the research speaks! I think you have a very balanced view and are all about INFORMED choice, and people will get this as you talk to them.

You know I am passionate about homebirth, so you are not alone!

Rachel Clear said...

Awesome. You said exactly what I've been wanting to say and didn't quite have the smarts to say? Permission to copy? (With credit given to you, of course!)

melissa said...

permission to copy granted! Absolutely!

Matt and Colleen said...

Excellent post! I happen to be a freak who likes to be in the hospital but I am so supportive of my friends who have had amazing home births. Choice! Each mother having a say about the environment she feels most comfortable.

You are going to be an awesome midwife!

Looking forward to seeing you. Remind me to tell you a story about my Alaska Native Grandma giving birth 14 times without any "Westren" intervention.


nancy said...

as usual, your way with words is amazing! I'll forward a letter your dad wrote to the Sun newspaper to remind you where those writing genes come from.

I'm becoming more and more aware of the scary microbs we are exposed to in hospitals - as more and more of them become resistant to antibiotics.

Here's a scarey example I experienced at work yesterday. 4 women were using our 2 breast pumps. 2 of the babies had been readmitted to the hospital - one for a group B strep infection (bad enough to cause a repiratory arrest) and the other for jaundice (with mom who had a cold sore).
The other 2 women had delivered in the past 48 hrs. The 2 breast pumps were in and out of these 4 rooms off and on all day.
The potential for the brand new newborns being exposed to gr B strep or herpes simplex (which can be fatal in newborns) seems pretty high to me. It was crazy busy on the ward so the staff had no time to come up with the safest solution here-including me. Today I emailed my boss with my concerns.
Anyhow, all this to say....and people think hospitals are safer than home to give birth in? Give me a break!

Also, in my 35 years of working on maternity wards, even in emergencies, time is almost always on our side. Most obstetrical complications give plenty of subtle and not so subtle signs long before things get urgent. Its women who do not have one on one experienced knowledgable constant suport(aka midwives or labour nurses)who end up in trouble. Yes, interventions and c/s can save lives in the rare events of hemorraging or prolonged lack of oxygen but even then there are usually signs and symptoms that give you time to get the necessary help from home or the labour room.
And as you point out Melissa, despite what we see on ER, nobody just grabs a scalpel and starts to cut! The 30 min standard is quite realistic in hospital settings, and often takes longer. Very rarely, every second counts, but being in a hospital gives no garentee of a good outcome.

The emotional state and sense of safty a woman feels during labour effects how labour progrsses. So it just makes sense that women should be encouraged to give birth wherever they feel safest, emotionally and physically - be that home or hospital.

So ends my rant!