Light and Momentary

Eliminate Aluminum Millinery

Betcha can't say that five times fast.  This is a post about faith and facts and tinfoil hats, sparked by the assertion that homebirth advocates are driven by the first and disregard the second.  Amy Tuteur, in particular, thinks that we are determined to ignore the evidence in favor of hospital birth.

I disagree.

The first time I heard about a friend who had a homebirth I was appalled.  She did what? I exclaimed.  What?  It was the evidence that changed my mind.  Friends' homebirth stories were intriguing -- they're the reason I looked at the evidence -- but the stories alone wouldn't have persuaded me that homebirth was a good idea.  I didn't read the full texts of the research at that point, but I read lots of abstracts and editorials -- all I could find, pro and con.

There's not much con out there.  I've been looking -- is homebirth controversial among epidemiologists?  Is the public health community arguing about its position on homebirth?  In developed countries where homebirth is a larger part of the landscape, are women being encouraged to move to hospitals because too many babies have died at home?

Best I can tell, the answers are no, no, and no.

During the Neonatal Doc discussion I emailed Mark Durand, author of the 1992 study comparing birth outcomes at The Farm with birth outcomes for a control group.  When he wrote me back two weeks later the thing that most stood out to me about his reply was its subtlety.  It made the whole conversation at Neonatal Doc look like something out of a Warner Bros. cartoon, with Elmer Fudd yelling, "Incweased pewinatal death wates!" and Bugs Bunny replying, "Naaaaah -- homeboith, Doc!"  [insert several minutes spent wondering if it is rude to make the other side be Elmer Fudd since he always comes off worst -- I can be Elmer Fudd if anyone prefers, talking about the muthah's bawth expewience.]  With Dr. Durand's permission, I am pasting the text of his email down below in the comments.

I have never claimed to be a statistical sophisticate.  (Another tongue-twister!  I'm on a roll.)  But neither, as far as I can tell, is Dr. Amy.  Now the point of this post is not to trash Amy Tuteur, a smart woman with whom I agree about some important issues, but I have to say that there have been some statistical clunkers in her assertions about homebirth safety.  And as I consider her re-analysis of studies that found homebirth safe for low-risk women, I have many unanswered questions.

For instance:  could you cite a definition that distinguishes intrapartum death and intrauterine fetal demise, since the distinction is central to your revision of the Murphy-Fullerton study?

[crickets chirp]

What does the epidemiological literature say about including or excluding deaths from congenital anomalies?  Can you show some support for your contention that excluding congenital anomalies is a "hide the bodies" strategy?

[crickets continue chirping]

Where are the data to support your assertion that the intrapartum death rate in hospitals is "vanishingly small"?

[I wonder idly if the monkeys/typewriters/Hamlet idea has a crickets/stridulation/Paganini analog]

Homebirth spawned a 250+-comment thread at the NHSblogdoc.  An obstetrician calling himself M said, "Look, the Cochrane reviewers say homebirth is dangerous and that BMJ study is worthless anyway since it's retrospective."  I have not been participating in that discussion, but I had to post a response to M.  I said, "In the report you cite the Cochrane reviewers were talking about 'home-like birth centers...in or near conventional labour wards'; they reached different conclusions about homebirth.  Furthermore, the Johnson & Daviss study, whatever its weaknesses may be, was prospective." He said, Yeah, well, we can't call homebirth safe without RCTs.

The problem is, we can't do randomized controlled trials for birth site.  It's not ethical to assign women randomly to deliver at home or in the hospital.  If you say the only thing that would change your mind is research that's never going to happen, to my ear it sounds a lot like, "Don't confuse me with the facts."  It makes me wish briefly for a tinfoil hat, the better to contain the fragments of my exploded head. 

Make no mistake, there are crazy homebirthers out there.  Like the Zion Birth people, who say the only acceptable response to a postpartum hemorrhage is calling on the name of Jesus.  (I hope you don't have to read much of this blog to see reverence for the name of Jesus; if I hemorrhage, I'll also be calling on the midwife to administer oxytocics pronto.)  Or the unassisted childbirth folks who say that if a baby's cord prolapsed they might just try to birth through it.  (Shudder.  I read that on one of the UC boards a few weeks ago and it haunts me.) 

So yeah, there are some tinfoil-hat people on my side of the conversation.  I am troubled, though, by resolute and irrational opposition to homebirth despite good science in support of the choice.  In her comment on my last birth post, Amy said, "I understand the attractiveness of making the homebirth debate about your opinion vs. my opinion."  This is not about my opinion.  Please, whoever you are out there, do not plan a homebirth because Jamie Gladly said it was a nice idea.  I urge you, if you are interested in homebirth, to do your own homework.

I think it is a mistake for anybody, on any health-related issue, to presume that he (or she) knows the truth forever and ever amen.  I think it's critically important to look at new evidence with an open mind -- not to assume results that challenge our assumptions must be flawed somehow.  I have written thousands of words about breastfeeding in this space, but one word never appears:  asthma.  Right now there's some ambiguity about the effects of breastfeeding on the subsequent development of asthma.  I could complain about the studies that don't confirm my point of view; I could mutter darkly about formula company funding.  But I think the wiser choice is to wait and see what happens with future research.  I will never tell you that the verdict is in when the jury is still out. 

But the jury isn't out on planned attended homebirth.  With one exception (the badly done 2002 study by Jenny Pang), every recent paper on the topic concludes that it's a safe option for low-risk women and their full-term vertex babies.  If you redefine terms, recalculate results, and rewrite conclusions, you can try to make the papers say something other than they actually say.  On which tactic, I must refer you to Benjamin Disraeli.

Amy objects to conspiracy-theorizing among homebirth advocates, and I have tried to avoid it in our conversations.  It's true that making midwifery care the norm for low-risk pregnancies would displace a lot of obstetricians, but I'm happy to talk about the data and not possible financial motivators.  In talking about the data, though, Amy seems to be driven by a conspiracy theory of her own, in which a lone non-practicing obstetrician with one semester's coursework in statistics and epidemiology can see The Truth that has eluded the authors, peer reviewers, and editors of every paper on the topic (save the magical mind-reading Jenny Pang) and the public health researchers who have published statements supporting homebirth.  Somehow they've all been duped by the Vast and Alarming Cabal Understating Out-of-hospital partUrition's Scariness.

Marsden Wagner, who spent 15 years as director of Women's and Children's Health for the WHO?  VACUOUS pawn.

Peter Schlenzka, whose Stanford sociology dissertation concluded that "...apparent disadvantages of the obstetric approach have such large order of magnitude, that in any clinical trial it would be considered unethical to continue with the obstetric treatment"?  VACUOUS tool.

Faith Gibson? Sheila Kitzinger? CIMS (perhaps they're secretly the Coalition to Increase Mortality Statistics)?  VACUOUS, baby.

Or maybe not.

I am going to stay in the conversation at Homebirth Debate for a while, making my Bugs Bunny-level contributions, even though sometimes I'm pretty sure I took a wrong toin at Albuquoique.  And if in the future there's solid new research showing a statistically significant difference in mortality for home-born babies, you can bet I'll re-examine my position.  I would be disappointed if homebirth were shown to be less safe than hospital birth, but I recognize that something might change to make it so.  I don't think it's likely, but it's possible.

One other important question remains unanswered at Homebirth Debate:  I asked Amy what evidence it would take for her to think homebirth was as safe as hospital birth.  ...And the crickets play a steady ostinato, but no answer is forthcoming.  Somewhere in that silence I start to suspect I'm sensing the singular susurration of a sizable silvery sombrero.  And I could be mistaken -- please tell me if you think I'm mistaken -- but I'm pretty sure it's not on my head.

My Son, the Homilist

We were ten minutes early for Mass this morning.  I said hello to the priest on our way in, and he said, "Happy Mother's Day, Jamie!  What a beautiful family you have."  Things have been going much better for us at Mass since I wrote this post; in fact, when Danielle posted recently about kids' behavior in church I just skimmed through the comments thinking, "Wow, I'm glad to be in an easier stage."

[cue rueful laughter]

The deacon preached this morning.  He's a stiff and formal guy, usually, but he invited all the kids to come and sit on the steps so he could talk directly to them.  My three big guys sat front and center, with Joe, who is almost four, right next to the deacon.

Joe is the most sociable of my four children and he was pleased to see that this homily was going to be a conversation and not a monologue.  "Do you know my name?" he asked the deacon.  "No, I don't know your name," said the deacon.  He plunged into the story of St. Isidore.

Now Joe is not a kid who likes to have the subject changed on him, and so he redirected the conversation.  "My name is Joe Gladly," he explained.  The deacon nodded.  "Gladly," he said into the microphone.  "St. Isidore lived near Madrid..."  "And when I grow up," Joe interrupted, "I want to be a policeman."

Joe's mouth and the deacon's mouth were roughly equidistant from the deacon's body mike, which meant that snippets of Joe's comments were amplified and projected through the PA system.  Little titters began sweeping through the congregation.

The rule in our house is that everybody dresses up for Mass, but we're not rigid about it.  Joe was playing outside in a King Kong T-shirt and sweats, and we decided that just for today we'd scoop him up and put him in the van instead of going in to change him into church clothes.  He stood up proudly next to the deacon and held his T-shirt by the shoulders.  "Do you know who King Kong is?"  "Yes," the deacon replied shortly into his microphone, "I know who King Kong is."  Big laugh from the congregation.  Big problem -- Joe loves to make people laugh.  The deacon was plowing ahead with his story of the saintly farmer, while Joe sang beside him, "He's a big gorilla and he lives in the jungle in the jungle in the jungle."  "In the jungle," echoed the deacon.

Mercifully, Joe was quiet for a minute while the deacon asked the kids to list the sacraments.  But not for long.  "And how can we talk to God?" was the next question.  "By praying!" answered a meek and quiet girl nearby.  Joe leaped to his feet.  "Hey!" he burst out. "I know about that!"  "Tell us about praying," the deacon encouraged him.

"Preying is when one dinosaur eats another dinosaur!" he exclaimed into the microphone.

...And it went downhill from there.  The nadir was Joe dancing and singing, "Stinkhead, stinkhead" -- I am writhing at the memory.  I was leaning into the aisle, pressing one finger to my lips and beckoning to him with my other hand.  He wasn't looking.

The deacon asked the kids to stand and extend their hands in blessing to their mothers.  "Even though some mothers might be embarrassed," he said, his smile no longer merely stiff but approaching rictus territory.  At this I felt myself shriveling like a slug under a cascade of salt, too mortified to pay attention to the prayer.  "Amen," ended the deacon.  "A-stink," a familiar voice added.

During the early part of this I wasn't too worried.  If you invite kid participation in your homily, you may get more than you bargained for.  Soon, though, I began praying for divine intervention.  Recently I read about a pastor who prayed for angels to quiet noisy children during Mass.  It never failed, he said.  I have to say it was not an effective strategy for me today, but maybe I shouldn't have been praying for an angel with a heavenly burlap sack and some celestial baling twine.  I asked God, too, that someday I might hear Joe tell this story from the altar as a priest -- "You know, the first time I was part of a homily I was only three years old...."  From where I'm sitting, though, that sounds like a pretty ambitious prayer.

It's been a long time since the best prayer I could think of in Mass was that I might grow in humility, but that's where I found myself today.  There's a reason humility and humiliate have the same root, I reminded myself.  I can't really think of today's preaching as a homily now -- in my head I keep calling it a humily instead.

But maybe one small good thing can come from it.  My friend whose mother died last November has been on my mind today -- I am hoping this Mother's Day has been peaceful for her.  I have resolved that every time I am tempted to wince at the memory of Joe chanting "stinkhead!" I will pray for her instead, remembering that it is a gift to be here with my children even when I wish momentarily to be far away instead.  Will you say a quick prayer for her too?

Here's a picture of my boys and me from my niece's baptism last month.  Happy Mother's Day, everybody.

Why Would You Do That At Home? Part One: Home and Hospital

You might think that being pressed for time would push me toward brevity and not prolixity, but you'd be wrong.  Remember the homebirth discussion from Neonatal Doc's blog?   It was mentioned in the first Pediatric Grand Rounds and I asked the host, Dr. Clark Bartram, for his opinion on homebirth. He gave a courteous and thorough response that included several questions.  Instead of responding in a novel-length comment over there, I am posting here.  (And posting.  Aaannd posting.)

Just to recap, I have given birth four times:  one hospital birth with an avalanche of interventions, one very nice hospital birth, one physician-attended homebirth, and one CNM-attended homebirth. I suspected that giving birth at home would be quite different, but I could not have imagined the reality.  It made me wonder:  why don't more women know what a great option homebirth can be?  Why is there so much resistance to the idea in this country, when the evidence shows it is no less safe than hospital birth? 

Right from the get-go, let me be clear that throughout this post I am talking about planned, attended homebirth by low-risk women carrying full-term vertex babies.  Plunging in, then:

Going to the hospital can alter the course of labor.

When I first posted here about the debate at Neonatal Doc's, I said homebirth was like cross-country skiing and hospital birth was like ski-jumping.  The birth stories we hear in this country are often litanies of intensifying woe:  stalled labor! IV! pitocin! pain! analgesia! wait, there's still pain! anesthesia! catheter! fever! antibiotics! slow descent! worrisome monitor tracings! episiotomy! hasty instrumental delivery! baby snatched from the jaws of death by the hospital staff! And people say, "How could you ever do that at home?"  Short answer: you don't.  You just don't get on that train.

Summer observed, rightly, that sometimes hospital birth can be "a swoop down the bunny trail."  And make no mistake:  sometimes in a homebirth a crevasse opens up in the trail before you.  But as a general rule, Homebirth = Less Drama. 

In a hospital you can see lifesaving interventions used appropriately (transverse babies being delivered via C-section); you can also see potentially harmful interventions used inappropriately. My college roommate talks about her surprise, as a med student, at hearing orders like, "Go to 1732 and break her water.  We're going to need that bed for someone else."  The advantages of hospital admission are accompanied by disadvantages (MRSA, anyone?). 

Another consideration:  the hospital environment can have unpredictable effects on individual women.  Many women can tell you what a drag it is to get in the car and drive to the hospital during active labor.  Does the interruption have as-yet-unquantified consequences?  As much as your conscious brain may think that the hospital is where you want to be for birth, what happens in your unconscious when you walk into a place that smells, to many people, like disease, death, and uncertainty?  Is that part of why so many women undergo pitocin augmentation in the hospital?  I just learned about a study that confirms my own experience -- women report that hospital birth is significantly more painful than homebirth.  Most women in a hospital request pharmacological pain relief, and labor analgesia and anesthesia are not risk-free.

Hospitals can only go so far in providing "home-like" care.

It's possible to have a home-like birth in a hospital, but it's not easy.  It's not the norm for women to deliver without intervention in hospitals, and that reality is reflected in staff preferences and practices.  In my post on the interplay of birth interventions and breastfeeding problems, I wrote about a friend who was told at crowning that she couldn't stay on her hands and knees for delivery.  Eight months later, another friend in another state had the very same experience.  The nurse said, "I know your doctor thinks this is okay, but I'm not comfortable with it."

I wish I had been there to say, "She has a head in her vagina, and you're uncomfortable?"

In some cases I can see the hospitals' point.  During my last birth, I wanted emphatically to be on my hands and knees with something firm beneath me.  I found vocalizing to be an immensely helpful pain-management strategy -- it was like my voice was a valve and the pain just sprayed out of my mouth as I groaned.  But if you're an L&D nurse in a typical hospital, do you want me crawling around on the floor while you're trying to assess me?  No.  Do I want to be crawling around on a hospital floor?  No.  Does anybody want me making that kind of noise when every other patient has an epidural?  I assure you the answer is no.  Safe and effective pain management strategies for mothers laboring at home may not translate well to the hospital L&D wing.

The issue is not only hospital culture but hospital economics as well.  Homebirth midwifery is not focused on efficiency.  My youngest son took some time to settle down after his birth, and the midwife watched him closely, with unobtrusive vigilance, to make sure his elevated respiratory rate was a function of his agitation and not an indication of a problem requiring intervention.  She charted the decrease in breaths per minute while keeping a careful eye out for nasal flaring or blanching or chest retractions or whatever else.  She stayed right beside us for more than three hours, making sure we were both doing well.  A hospital nurse doesn't have that kind of time -- does she send him for assessment just in case? does she leave us to monitor his breathing while she tends to her other responsibilities?  I much preferred knowing that my trusted midwife, licensed as an advanced-practice nurse and certified in neonatal resuscitation, was at hand to tell us if we had a problem.

Midwives bring something special to the table (or the floor, as the case may be).

I posted last year about how much I loved my midwife, but it bears repeating: she provided me with a fabulous blend of trust-the-process reassurance and appropriate watchfulness.  Last April I sent her a wigged-out email -- "Itching! Cholestasis! Stillbirth!" -- and she wrote right back saying, "Here are the risks; here are your options.  What do you want to do?"  (Then it rained and I stopped itching.  Allergies, not liver malfunction.)

During the pushing stage of my last birth I had a similar wigged-out moment, when the brief pause between delivery of head and shoulders made me think, "Overdue! Macrosomia! Shoulder dystocia!"  But even in the moment, I knew that I was in the right position and that she knew what to do. (Turns out the shoulders were not stuck; she was just easing a loose loop of cord over baby's head.) Throughout my labor, she stayed quietly beside me on the floor, watching, waiting, encouraging.

Homebirth midwives practice physiological management of childbirth, which reduces the risk of some of Dr. Bartram's concerns.  As an example, a baby whose mother was free to eat during labor is less vulnerable to hypoglycemia than a baby whose mother was restricted to a glucose IV.  Another example -- mothers who can move freely often choose positions that allow minor malpresentations (occiput posterior or asynclitic) to resolve.  Midwives spend a lot of time on patient education:  how's your diet? what can we do about this hemoglobin? have you lined up postpartum support?  After the birth we were given excellent when-to-worry guidelines that made clear whether to call the midwife, the doctor, or 911.

One reason I felt confident planning a homebirth is that my midwife is operating legally and had nothing to fear from a transfer to hospital care.  When homebirth is driven underground, who benefits? Some mothers will wish to consider homebirth despite the opprobrium of mainstream obstetrics.  Surely mothers and babies are better served by accredited midwives with a clearly defined scope of practice.  Surely we can all agree that seamless, timely transfers, without added stress about legal trouble for the midwife, improve the odds of a good outcome.  If you're opposed to licensing homebirth midwives, why?  Who benefits when unlicensed midwives are the only available homebirth attendants?

A parenthetical note about mess:

Some people say, "Ewww, giving birth on your own mattress?  Birth makes such a mess."  My friends, go to the bath accessories aisle at Target.  Behold:  the shower curtain.  Buy one.  Buy two -- they're cheap.  Make your bed and spread a shower curtain over it.  Put something absorbent, either newspaper or chux pads, over the shower curtain, and put an old sheet on top of it all.  Make a second nest in the living room floor if you think you might be a floor birther.  After the baby is born, roll up all the squishy stuff in the shower curtain and sink into fresh sheets on your own bed.  Bask in the cozy rightness of it all.

Since you will doubtless be breastfeeding and have no need of a Chief Cook & Bottle Washer, designate a Chief Cook & Towel Washer instead.  CC&TW can chuck all the laundry in for a cold soak, followed when convenient by a cold wash.  Check for any stubborn bloodstains before drying and spot-treat before a second cold-water wash if needed.  Not a big deal.  On to more pressing concerns.

(I am closing comments on this post so we can all talk down below.)

Part Two: Risks and Outcomes

Part One of this post is here.

Birth is about more than perinatal death rates.

In the debate at Neonatal Doc's, Dr. Amy said over and over that homebirth increases perinatal death rates for babies born to low-risk women.  I found her manipulations of the data unconvincing (do read the discussion yourself if you're interested -- these are some of the articles discussed), but just suppose she's right.  Suppose you goose the numbers hard enough to rewrite an author's conclusions, or suppose you ignore the methodological flaws of the Pang study and take it at face value -- suppose you do that and you conclude that homebirth raises perinatal death rates by one- or two-tenths of one percent. 

Does that mean no one should have a homebirth?

Erin posted on this question and I think it's worth addressing.  Who decides how big a risk is acceptable for a pregnant woman?  Would you say that obese women shouldn't attempt vaginal deliveries because they're at higher risk for shoulder dystocia?  Where would you draw the line, personally, on delimiting another woman's birth choices?

Another philosophical question for those of you who find Dr. Amy's statistical maneuvers persuasive:  is there some number of maternal morbidities that can be said to offset a fetal mortality?  Obviously, if the choice is an intact perineum or a live baby, you can go right ahead and slice up my perineum.  I'll hand you the scissors.  But the number of women giving birth over an intact perineum at home is far higher (68.8% for women at The Farm) than the number who do so in the hospital (Alicia? maybe half that? a third?).  A fourth-degree laceration isn't the worst thing in the world, but it's no picnic either.  Ina May Gaskin reports a fourth-degree laceration rate of 0.1% among women giving birth at The Farm.  How do hospital outcomes compare?  How much does it matter?

This question quickly becomes less theoretical, with much higher stakes than comfortable sitting or sex.  For instance:  if we estimate that a low-risk woman planning a hospital birth faces a 20% chance of having a C-section while a low-risk woman planning a homebirth has a 5% risk of same, we can expect to see a corresponding increase in maternal morbidity and mortality for women planning hospital birth.  The effects won't all be immediately apparent, either.  Prior C-sections raise a mother's risk of stillbirth and abnormal placentation in future pregnancies, and in the long term the resulting abdominal adhesions can cause illness and occasionally death from bowel obstruction.

I deal regularly with another casualty of mainstream obstetrics:  I can't tell you how many times I've spoken with crying mothers saying, "I wanted to breastfeed so badly but I just don't think it's going to work."  Complicated birth is often followed by complicated breastfeeding, and complicated breastfeeding is often followed by premature weaning.  (Kroeger & Smith lay it all out, with a great bibliography, for anyone who's interested in the details.)

If you took a thousand low-risk women planning a homebirth and a thousand low-risk women planning a hospital birth, all of whom described themselves as "highly motivated to breastfeed for a year," I would stake my IBCLC credential that breastfeeding rates would fall off more quickly among the women planning hospital births.  Only some of the difference would be a result of birth interventions. Homebirth is empowering -- it's a wonderful feeling for a woman to see her body do something so amazing -- and the confidence can spill over into breastfeeding.  Homebirthing women tend to find each other, either online or in real life, and they tend to seek out breastfeeding-friendly HCPs; readily available breastfeeding support from friends and doctors makes it much easier to sustain a nursing relationship.  Regardless of how the reasons break down, babies born at home often get their mothers' milk for longer than babies born in a hospital.  And that's an important consideration for anyone interested in public health.

Premature weaning exacts an immediate toll, both in healthcare costs (measured in billions per year) and in children's well-being [a huge but fascinating download].  It has a long-term cost as well. Long after infancy is over, bottle-fed children are at higher risk of respiratory and gastrointestinal illness and of some types of childhood cancer.  As adults they appear to be at higher risk of alcoholism, breast cancer, heart attack, and stroke.  Their mothers may be more vulnerable to osteoporosis, ovarian and endometrial cancer, and -- new information -- type II diabetes. 

Human milk makes a difference, both now and in years to come. It's usually easier to breastfeed if you give birth without unnecessary intervention, and it's usually easier to give birth without unnecessary intervention at home. 

Intangibles matter.

I hesitate to write about the subjective experience of homebirth because it provides fodder for people who say, "See? It's all about YOU and your EXPERIENCE and if you CARED about your baby you'd go to the hospital."  But I have to tell you:  my homebirths blew me away.  They were almost sacramental, by which I mean that the ordinary (here I am in my living room...) was transected by the extraordinary (...and here is this little face no one has ever seen before) in an event that filled me up with transcendent joy and with solemn resolve to be the finest mother I can manage to be.  My homebirths were like glimpses of heaven.

That will sound completely over the top to the skeptics among you, but it was a singular experience.  (If you have a singular experience twice, does that make it a doubular experience?)  Anyway, it was an experience I wish more women could have. 

On a more practical note, the postpartum transition was much easier after my homebirths than after my hospital births.  Some of it was the effect of homebirth on our marriage.  My husband was a perfectly capable labor coach in the hospital but he came into his own as a labor companion at home.  It was easier for him to love me through my labor here in our own house.  And those memories, of the tenderness in his touch as I moved through a tough contraction and of the elation in his voice when he said, "Another boy!" -- I will always hold them close.

We also found a marked difference in the sibling adjustment after the homebirths.  There are some confounding factors there -- one, I think it's easier to have a spring baby than a cold-weather baby and two, it gets easier to mother a newborn and an uncertain toddler as you become more practiced -- but I do think the births made a difference. There was less disruption in the older kids' routine; they didn't have to go visit me in a strange-smelling hospital.  The home-born babies just eased right into our family.  I was on such a high after the births, too, and when mama is happy -- well, we can't say with certainty that everybody's going to be happy, but it boosts the odds. 

On the subject of odds:

Many people don't think sensibly about relative risk.

We live in this country where people say, "Oh, I want to buy an SUV so I'll be safe on the road," even though SUVs are associated with a higher risk of accidents.  People don't observe basic food safety precautions, like washing up carefully after they handle raw meat, but they worry (as they spread pathogens far and wide) about whether cell phones might cause brain cancer.  Many, many people find emotional arguments more persuasive than rigorous epidemiological research.

The World Health Organization says a low-risk woman should give birth wherever she feels safe, whether that's her home, a freestanding birth center, or a hospital. For most American women, the clear choice is a hospital.  For most doctors, the risk of a congenital heart anomaly requiring immediate treatment looms larger than the risk of a fatal iatrogenic complication.  You have to choose the set of risks you're comfortable with.  I'd like to encourage everyone reading this, though, to find out more about the real risks involved.  The first comment on Neonatal Doc's post stated that 10% of the time homebirths are "a parent's worst nightmare and the scourge of neonatology."  As far as I can tell, that claim is simply unsupportable.  And if the worst happens?

A bad outcome may or may not mean that you regret planning a homebirth.

Anecdotally, I know two women whose babies died while they were laboring at home.  Though they were both heartbroken, neither regretted the choice to attempt a homebirth.  (In both cases, the death was judged unpreventable.)  Also anecdotally, I know two women whose planned homebirths changed course dramatically -- one because of a partial placental abruption and the other because of an undiagnosed congenital heart defect.  Both times the transfer to hospital care went quickly and smoothly, and both babies are fine.  And one more anecdote:  I know a woman whose baby's life was probably saved by her plans to give birth at home.  Because she had an attendant at her home in early labor, the cord prolapse was detected immediately when her water broke.  The attendant overrode the EMTs who wanted my friend flat on her back in the ambulance, and her daughter is now a smart and healthy 10-year-old.

Anecdotes, however, are of limited value here.  As Jo Leery Polyp wisely says, the plural of anecdote is not data.  Something you have to think about seriously when you consider homebirth is the small chance that your baby could die a death that a hospital might have prevented. Consider, too, the chance that people around you will blame you for the outcome whether or not the death was preventable.  Can you live with that?  Are you more comfortable with the risks that attend hospital birth?  In absolute terms, they are no smaller.  But you have to decide which ones you'd rather face.

I'm curious about the incidence of malpractice suits among women whose homebirths went wrong -- it's hard for me to imagine suing either of my two homebirth providers.  With homebirth, you know your provider can't offer you any sort of magical deliverance from the problems inherent in childbirth.  You own the pain, even though she can give you lots of coping strategies and sympathy as you stare it down.  And you own the risk that is inextricably bound up with bringing a child into this world.  Together you and she will do everything you can to reduce it, but you both know it's there.

Of course informed consent is important at home.  A woman considering a homebirth needs to ask good questions and consider the answers carefully.  What will this midwife do if there's meconium when your water breaks?  What does she carry to manage postpartum hemorrhage?  How long has she been certified?  Is she licensed?  The licensure department in your state probably maintains online records of complaints against licensed practitioners.  (While you're checking, you might want to check your OB's record too.)  I think informed consent is equally important for women in the hospital.  How many women get epidurals believing that the drugs won't affect their babies, when the anesthesiology literature shows otherwise?  How many women have consented to Cytotec induction without realizing that it could cost them their babies, their uteri, their lives?

In sum: 

If anybody ever tells you that homebirth is safe because it's natural, I urge you to run (shrieking is optional) in the opposite direction.  Please run right to your computer and tell me about it in an email, because I am mystified by Dr. Amy's repeated assertion that homebirth advocates start from that premise.  By the same token, if anybody tells you that homebirth can't be as safe as hospital birth, ask to see his references.  If they're persuasive, send them my way. I'd like to know more.

If you choose to deliver at home, the odds are excellent that you will deliver a healthy baby.  Statistics also suggest that you will find birth highly satisfying, less painful, and significantly cheaper than a hospital delivery.  The World Health Organization, the Cochrane reviewers, the American Public Health Association, and the American College of Nurse-Midwives, among others, support homebirth as a safe option for low-risk mothers.

In the end, though, I'm not talking about homebirth just because it looks good statistically.  I talk about my homebirths because I wish more women could know what it's like to scoop up a wee slippery baby and hold him close while he gets his first glimpse of home.  I talk about them because I will never forget the joy of saying, You are right where you belong, little guy.  Welcome home.

Spring Tide and Charlotte's Web

There's an ebb and flow to mothering -- sometimes it's not so hard and sometimes it kicks my butt.  Right now it's high tide, as Pete moves into toddlerhood.  He is so busy:  there are carpets to write on and magnets to eat and giant dump trucks to propel down the stairs.  There are also three erupting molars to kvetch about, and much clinging to Mom that needs to happen in between adventures.

When my oldest was this age I remember being so discouraged.  Didn't he know he was supposed to get easier after he turned one?  When was I going to be able to get something done?  I know, this time, that the tide goes out again.  Eventually.

I am working on another birth post, but I am only able to write in five-minute snatches.  (So far in this post, Pete has nursed, dumped all the diapers out of their bag, and wandered into the bathroom.  Must make sure the toilet brush is not being used for oral hygiene.  Back in a minute.)  Today here's a quickie instead.

Marty and I just read Charlotte's Web, a book I like better as an adult than I did as a kid.  This time through I was musing about its title -- the book's not as much about the web, I thought, as it is about the friendship between Charlotte and Wilbur. 

But then White describes the way Wilbur tries to be "some pig," and "terrific," and "radiant," even though he doesn't think he's really any of those things, because Charlotte says that's how she sees him.  That's one of the beauties of a good friendship:  your friend sees things in you that you can't see yourself.  You stretch yourself to be the person your friend sees, and you grow in the process.  The web that was woven to trick the humans became something more.

Something else I'd never noticed until this reading is the contrast between Charlotte and Templeton at the fair.  She empties herself for her babies and for Wilbur; Templeton stuffs himself.  It made me think of Christ's kenosis, and of the generosity that's a hallmark of genuine love.

In the end Charlotte says, "By helping you, perhaps I was trying to lift up my life a trifle.  Heaven knows anyone's life can stand a little of that."

Indeed.