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May 04, 2006

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Jamie, you are so intelligent that I freak out just thinking about talking to you.

You are very VERY well researched. If I was at all inclined to homebirth, you would sway me in an instant.

That said, I can't for a few reasons. First off, we don'thave legal midwives here. Second, the one underground midwife said she wouldn't touch me, as I bleed out profusely, to the point of transfusion, after birth. We've done pit, then moved to methargen, and now we've gone to cytotec. It's the only thing that works, and so I will be in the hospital for any more babies.

Plus, I'm just greedy enough to want a few days to myself. I like to let The Hubster stay home with the other kids for a few days, so he can get a greater appreciation for me, and what I do.

I agree with every single word of both of your posts, and I applaud you for your knowledge and passion.

I want to be Jamie when I grow up!!

Yes, you are amazing. I was just utterly blessed to have non-interventional hospital births. If I ever decide to have another baby, I know where I can send my recalcitrant husband to read about home-birth! :)

Quick question, I'm about to turn 35, would that make me less of a candidate for a home birth if I were to have a baby in the next few years?

Oh, sorry, it's me again... I just wanted to say that every time I read about your home birth experiences I just feel like I *need* to have one more baby so I can have him/her at home :)
Giving birth twice was amazing, but I just wanted to be able to experience it fully, like you did, and one can't do that in a hospital setting.

Well... right now we can't even think about it, but who knows what the future will bring to our family!

I've had a hospital birth, a midwife-attended water birth at a birth center, and a midwife-attended water birth at home. Really, all three birth experiences were great, but unquestionably, the home birth was the greatest of all--and the labour and delivery was the most difficult (OP baby, with face-first presentation, 15 hours of labour opposed to the 4.5 hours of the previous two, and over 1.5 hours to push him out).

I was so much more comfortable at home. I was able to nap in active labour, move how and where I needed, eat when and what I chose...and I felt so wonderfully well taken care of through the entire process.

My hospital experience left me feeling lucky that I avoided major interventions. After labouring for just a few hours and progressing very rapidly, my OB broke my water "to speed things along." It was almost time for him to see his first appointments of the day, you see--mustn't keep the other ladies waiting.

The birth center was a definite improvement, but it was a long drive, which is no picnic in active labour. My husband and I did not sleep well on uncomfortable beds, and there wasn't a bed big enough for us to share. I loved the water birth, but we were happy to go home, about six hours later.

I'm still on a high from the homebirth experience--it was just eight days ago!--and I'm so very glad this difficult labour was here rather than a hospital setting. I'm quite sure an OB would have felt it necessary to "help", which could so easily lead to more drastic interventions. Instead, things progressed exactly as they should have, and I delivered without even a minor tear. I really think I can credit homebirth, and my awesome midwife, for my intact perineum, as well as for this baby who nurses so spectacularly (really, you should see his latch!). How different would things be now if we'd been in a hospital?

Although I'm content to be finished with my three kids, I kind of wish I could have another homebirth. I wish everyone had this option.

I'm curious as to what your older children did while you were in labor - just simple curiosity, not any judgment! My sister and I spent the day with friends while our brother was born (I was 7, she was 3) and I wonder what my parents would have done had the birth been longer, at night, etc. - guess I should ask my mom. Did you have a plan? Play it by ear? My 3-year-old godchild is about to become a big sister so this has been on my mind.

So what if you are strep-B positive? Are you disqualified?

Jamie, this was an excellent set of posts. I think homebirth is a wonderful option and I would love to give birth in our home. My husband doesn't feel quite the way I do (read: not at all). I do, however, hope I can bring him around to this way of thinking. That's why I showed him your posts. :)

Jamie- these are some of the best things I've ever read on desirability and safety of homebirth. I have three kids - first was a c/section, 2nd and 3rd were homebirths with midwives. I agree with you entirely about the profundity of the birth experience at home - and the safety.

I was in grad school (technology management) while pregnant with my third. Researched and presented my findings on the safety of homebirth to a class full of mostly male engineers and other technical managers. I like to hope I changed a few minds :-)

Great, great, great post. Posts. Thank you!

I have had one baby, at home. It was rough going, as first babies often are. I'm sure that I almost could have transfered for "maternal exhaustion." If I had been in the hospital for that birth, who knows what interventions would have been done to me. I had a very odd (read: non-textbook) labor, and the baby took a long time to engage, even in active labor (could be diagnosed as "CPD"!!). And yet, with a wonderfully capable midwife, and the help of my husband and mother, we had a perfectly safe and miraculous homebirth (one year ago tomorrow!).

Thanks again for your insightful and intelligent writing!

Wow. So, first off, I'm sending my mum ('homebirth-is-irresponsible') to read these posts. Thank you.
Second, my husband told my mum last year that after our son's birth, he now realizes that my birthday is not really about me but about her. So, in that spirit, a belated happy birthday to Pete but also a happy - what? anniversary? Birth Day? - to you.

Jamie, your comments at Neonatal Doc's were absolutely incredible and intelligent as are your posts here. I always read your writings with awe and gratitude that we are on the same "side." At times I wish I had your gift with words so I could adequately convey how much this means to me (but then I try to remember not to covet ;-)).

I am going to take the liberty of replying to some of the other comments. I had my 4th baby last year attended by a direct-entry midwife and assistant at home when I was nearly 39. I had tested positive for Group B Strep. At least in Alaska neither age nor GBS are issues. Things went too fast for the IV antibiotics (for the GBS) which rather appalled my sister-in-law (a nursing student) who was attending to mainly support my daughters (11 & 13) who wanted to attend the birth.

My 7-year-old son was downstairs watching cartoons (his choice). I imagine if I didn't have a history of quick births and/or had other children younger than that I would have had more of a plan for them.

The effect on siblings was a factor in my homebirth decision though of course my priority was the safety of the baby. My heart is still torn at how it felt 13 years ago to leave my 2-year-old for the hospital birth of my 2nd child. She was lovingly cared for by Grandma and an aunt but my heart was screaming "this is wrong; if I can help it - never again!" I was blessed to be able to birth my 3rd baby at a birthing center a mile from my house which allowed minimal separation from home and children (I wanted the birthing tub :-), at that time the girls wanted nothing to do with a birth).

This time I said, "no more riding in a car while in labor, no more being away from our own bed." And it turned out to be the best thing for every single one of us.

Thank you, Jamie - you make a wonderful difference!

Jamie, the intact perineum rate in hospitals is enormously variable and tends to be provider dependant. I know that in the hospital where I practice, almost everyone tries really hard to avoid having to put in stitches. I haven't looked at the stats for a while, though. The residents are always asking for 'midwife' tips.

The real downside of the hospital, in my opinion, is also the greatest 'advantage'. It is that the interventions (sometimes life saving, sometimes annoying, and sometimes downright dangerous)are readily available.
There is some truth to the saying that if your only tool is a hammer, everything looks like a nail. In a teaching hospital it can get even worse - there is a saying that the indication for various procedures is RADNO (resident ain't done one). So a mom who is pushing OK despite her epidural might end up with a forceps or vacuum delivery as a learning experience for the resident. We try hard in my setting not to let that happen, as I think that part of the learning process is to learn just when an intervention is needed. But I can only speak for myself.

I so wish that I were in a financial capacity to have my own practice and to attend moms at home, in a birth center, and in the hospital. There is truly nothing like being in your own space. However, I had 2 hospital births after my 2 home births, and I personally found that the people around me made more of a difference than the furnishings. Having a midwife in the hospital was a definite improvement over having a doctor in the hospital.

BTW - the small rural hospital where I practiced for 3 years (Florence OR) had a breastfeeding success rate (including continuation into the second year) that approached that of home birthers. One thing that made a real difference was that the care of the newborn was not turfed to the peds as soon as the cord was cut, but the midwife or family doc also became the baby's ped's provider. I followed my babies until the 2 month check-up and then helped them transition to the FP docs, all of whom also really supported breastfeeding. The OB to Peds model is another factor that interferes with successful breastfeeding in the hospital.

Hi, everybody, and thanks for your comments. Carmen, do not freak out about talking to me. We will have lots of fun together if we ever get the chance to meet up. Lilian, I'm always glad to hear about women who are happy with their hospital experiences, and I don't imagine your age alone would disqualify you as a homebirth candidate.

Nicole and Rosie Kate, best wishes to you both on the respective birthdays. Thanks for your stories.

Jess, my big kids were with grandma during the birth. Lauren, my midwife had a great GBS handout that laid out the risks and the options.

Katy, thank you for contributing your perspective and for your kind words. Alicia, it's always helpful to hear from someone in the trenches.

Rachel, Ariella, Leslie, good to hear from you too.

Jamie, WILL YOU MARRY ME????

Oh, wait...you're married, I'm married and we're both ladies. Hmmm...well, I guess I just think you're terrific. Thanks for yet another really wise couple of posts. I was reading over at Neonatal Doc (after most of the posting was done) and felt like I was at a football game...maybe a wrestling match. Thank you for your courage and intelligence.

One caution on homebirths...I had a homebirth on the UK NHS and got stuck with a not-so-good midwife. I'm sure she was technically competent, but she had a hard time getting her head into the game and spent several of my very-close-together-contractions looking for a pen. We assured her that we had pens, pencils, markers, crayons, cray-pas and even watercolors if she desired! She found her pen and then needed to find her apron. *sigh* She found that and then was able to attend to me. The baby was born a few minutes later.

My labor was an interruption to her evening/life. She was just the on-call midwife and I hadn't met her before. It seemed an awful lot like an HMO-type birth.

However, I was still at home and all went well and now my friend and I have some good laughs about it. I'm glad this was my fifth kid and not my first, as I really missed the good relationship I had had with my first homebirth midwife (with baby #4).

Again, thanks and keep 'em coming!

Lauren, what I was told about Strep B was that if I was positive the midwives would come at the first sign of labor (instead of waiting until I was in "active" labor) to assess me and give me a course of antibiotics.

Jamie, this is wonderful.

Jamie, you're one of my homebirth heroines, in addition to being super smart and dedicated to the research, my god woman, where do you find the time?

You are really doing your part to normalize homebirth and that is so important for so many women. Thank you so much!

I nominate Jamie for the next leader of Citizens for Midwifery!

Thanks for every last brain cell you have exerted on your very thoughtful posts in the "debate" and for this topic on your blog. They really are gifts.

Jamie:

I saw your post at Neonataldoc and followed your links. I understand the attractiveness of making the homebirth debate about my opinion vs. your opinion because it tends to blur the safety issue. The debate then looks like my opinion (subject to my biases) against your opinion.

I have a suggestion, though. Why not submit the data to a statistician or an epidemiologist who has not previously studied the issue? That could be extremely helpful to others who are reading the debate but cannot follow the statistical intricacies. If you are truly confident that the data shows that homebirth is not more dangerous for babies than hospital birth, I would guess that you would welcome independent confirmation of this fact. It would certainly go a long way toward strengthening your argument.

Jamie:

People on both sides of the issue express a passion and commitment that are very refreshing. How about a forum where we could debate this issue? I set up a Homebirth Debate page to continue our discussion from Neonatal Doc and hopefully expand it to more participants.

If you are interested, you can write the first post detailing your position and people can comment on it.

LOL, I for one am happy to see the Google Ads up and running! Perhaps you an use the money you raise to fund another study on the safety of home birth.

Frectis:

Why don't you write your thoughts and I will publish them, so others can comment? You seemed pretty committed to your point of view and you had quite a few supporters.

Excellent arguments, well made.

Only one major criticism: You managed to write two posts on home births (I linked here from Pedie Grand Rounds at Unintelligent Design) without mentioning fathers, or men full-stop for that matter.

Do you do only parthenogenetic births?

best,

Flea

My two babies were both born in hospitals.

My first labor came on suddenly around 10 p.m., after a late dinner - it went straight to contractions every 3 1/2 minutes. After some indecision, by about 1 a.m. I had made it into the hospital. The hospital midwives said I was still a long way from birth, and the two labor beds were already full - wouldn't I like to go home and sleep for the night, and then come back? Me: Sleep!!?? (by now I had strong contractions every 3 minutes or so) Them: well, maybe your husband would like to get some sleep... So finally I gave in and went home, arriving about 2 a.m. After 3 hours of torture (while my husband slept), I woke him up at 5 a.m. and said I couldn't take it anymore, and called the hospital and went back there, arriving back about 6 a.m. All three of these trips were by taxi, about 10-15 minutes each way. The midwives said I was ready to push, and put me straight onto one of the two delivery beds. After a bit, one of the moms on the two labor beds came in, and was put on the other delivery bed. Our babies were born 3 minutes apart, mine at 8:08 and hers at 8:11 a.m. The mom in the other labor bed had a long labor, and her son was born about 2:30 in the afternoon.

I can understand the talk about a hospital birth being safer, but with hindsight, I don't think it was really very safe for me to have spent 8 out of my total 10 hours of labor being shuttled around in a taxi, briefly being monitored by the hospital, and then lying at home for 3 hours of strong contractions, completely unmonitored and unwatched, for the whole middle part of my labor. Luckily nothing went wrong, but I do think having a midwife watching and monitoring me the whole time at home would have been safer.

I am definitely a believer in monitoring the baby's heartbeat during labor, because my second baby had a very slow heartbeat during contractions (again, this was in hospital, where I arrived 2 hours into a 4 hour labor/birth). It turned out that his cord was stuck somewhere and needed to be adjusted. No other interventions were needed, and this could have been done just as easily (and perhaps earlier) at home I guess, but anyway I am just glad he was monitored. Of course, no one was bothering to monitor my first baby during most of my first "hospital" labor.

Since I'm not planning any more children, I don't have to decide now whether hospital births are really for me! I guess with a 3rd birth, no hospital would send me back home midway, though!

Hi, Dr. Amy, and thanks for stopping by. I will continue to be interested in the responses of epidemiologists to the question of out-of-hospital birth safety. Actually, I think I have one more post brewing on that question, but I'm mostly talked out on homebirth. (After 5000 words, one would hope I'd be talked out.)

Flea, no parthenogenesis here. My husband did get a paragraph in the "Intangibles" section of this post, though you're right that in thinking about birth I'm mostly thinking about mothers and babies. It didn't even cross my mind until you mentioned it. I think your comment shifted the overall female-male commenter ratio for this blog from 466:1 to 389:1 -- not usually too many men hanging out here. Got any thoughts on homebirth from a father's/ped's perspective? (My husband's verdict after the first homebirth: "This was very civilized. People should do this more often.")

Lisa C., you don't even want to know what my laundry backlog looks like. Moxie and Frectis, thank you. Kirsty, that sounds awful! And Sandy, what a story!

Aaaaa! Someone else to preach besides me (albeit, I don't do it online)! Bliss!

We have very similar birth stories: #1 intervention up to wazoo, #2 very nice un-intervention hospital waterbirth, #3 new-state, no midwives, intervention hosp birth, #4+5 at-home waterbirths in different state (just to get around the legalities).

These posts are just excellent. I shall send all "thinking about it's" your way, so they know that I'm not the only "crazy" one out there!

(BTW: as irony would have it, my friend just transferred to the hosp tonight after trying a homebirth. The DRAMA begins....sigh.)

I wanted a home birth very badly, and did everything right that you are supposed to do in planning one - I educated myself thoroughly about the process and risks of childbirth, I made sure that my wonderful ob-gyn approved of my health and understood my plans, I pre-arranged support care with her, I got a highly qualified lay midwife with excellent references which I checked out thoroughly.

What I did not and could have anticipated was the degree of fear which my lay midwife had of being prosecuted for attending homebirths (homebirthing and lay midwifery are of questionable legality in Ohio).

Because of her fear, she did not tell me when she noticed signs that I was developing preeclampsia. She believed herself - and perhaps might have been - competent to manage my pregnancy through to the birth.

I, being one sharp cookie, also noticed that I was developing symptoms of preeclampsia, spoke with my midwife about it, was un-reassured by her insistance that it was nothing I need to contact my ob-gyn about, fired the midwife and contacted my ob-gyn.

Support care and the possiblity of transfer had been already arranged with my wonderful ob-gyn, who put me on bed rest for the remaining two months of my pregnancy, and provided wonderful care through to a safe (if slightly complicated) hospital delivery.

My daughter will turn six next month.

I still would like to believe that home birth can be a safe and healthy experience for both mother and child -- but I no longer think it is a safe option unless one lives in a state where medically trained and licensed care providers can legally attend and provide pre-natal care for homebirths. The risk that fear of legal repercussions will damage patient care is too great.

I had my first homebirth two months ago (second baby). Barring being risked out or transferred, I won't have another hospital birth. That is not to say that my first experience was horrid; for a hospital birth I think it was actually pretty good, but mostly that's because the OB on call was busy doing sections and my doula and labor nurse were able to help me through the.most.hideous. contractions ever.

I'd have been transferred regardless, because I developed a fever and Perp's heartrate was exceedingly high with no variability. She was absolutely fine, but had I been at home, we would have erred on the side of caution and gone in for more monitoring and fluids/abx.

I'm beta strep positive and went to pretty crazy lengths to get the ampicillin I needed to cover the colonization, but since I went into labor two minutes away from the hospital and then had to drive home (ah, the irony), and because my labor was so fast (first ctx at 1, baby at 4, 30-minute drive), I never got the meds nor would I have had the time for the critical second dose CDC recommends. I didn't have any of the risk factors, however, as I did with my first labor, so we tracked AMP's temps for the first 24 hours and kept a Very Careful Eye on him. If anyone needs 5 grams of amp, let me know, ;)

We sent Perp to my ILs (MIL actually drove me home as we were in the middle of lunch when labor kicked in. Marathon Spaghetti seems to have done the trick, fwiw), so it was easy peasy for me to hop (edit: waddle) out of the car and send the two of them on their merry way. Perp was fast asleep in her car seat so I might have done the same anyway.

My OB dropped me at 38 weeks because she wasn't comfortable with my plans for homebirth. This after I told her *at our first visit* what I wanted. After calling the patient relations department at the clinic and casually mentioning that I was pretty sure it was illegal for her to do this without directly transferring me to another doc, I got a call from the head of OB who said he'd be happy to cover me, but I was endangering my life and my baby's in like 17 different ways. We met exactly once before I decided that was enough OB care thankyouverymuch.

I ended up cold-calling a family practice doc who said I was "in good hands" with my midwife, and to call her pager if we needed anything, and she'd be happy to attend if we ended up at the (other) hospital. Now *that's* service!

I did not manage to deliver with an intact perineum; it seems that my babies' shoulders do me in every time. Even so, I never felt a thing with either tear and healing was a breeze.

The biggest problem I had with getting ready for the birth was getting my head around it. I got copies of my L&D report from the hospital and learned that I'd had a pretty good case of chorioamnionitis, which the docs NEVER mentioned to me, despite the fact that my WBC was still twice normal the next day, even with two or three doses of amp on board during delivery. So I was scared of a repeat of the fever, AROM, and general hastiness of Perp's birth. It took a few days of Completely Freaking Out before I got comfy again with the idea of delivering at home, something I'd been panting over from the minute I POAS and got that little pink line. Once I got over that hump, though, it was one of the most amazing (and I hesitate to use the word, given recent discussions) experience of my life. Even Husband, the Republican lawyer, opined that this is how it ought to be done (with the caveat that it helps if you know nothing is going to go wrong. Yeah, 'cause you know that in a hospital...).

I had my wonderful homebirth, in the most fabulous tub which we set up in our bedroom. Not a drop of blood or gore spilled, not a sheet or towel stained, and my daughter was home with us the next morning. I was able to crawl into my cozy hatch immediately after catching my baby. Think of it, my hands were the first to touch him, not some stranger's. There was no frenzied cord cutting, no doses of Pit without my knowledge (or consent), just a joyous welcome into into the heart of our little family. I can't understand what's so wrong with that.

Given proper screening and a qualified attendant, I think this is how birth ought to be. We don't have the option of midwife-attended birth at the local hospitals, and there is no free-standing birth center closer than three hours away. I'd have had AMP in the car. THAT would have led to some stains.

FTR, my midwife is a CPM/Naturopathic physician and I worship the ground she walks on. None of our prenatal visits were shorter than an hour, and we spent plenty of time talking about ME, the WHOLE me, not just my body from the navel down. I don't think you can put a price on that.

I'm so glad I stumbled onto this discussion (thanks, Tertia!) and that all the responses are so civilized and cogent. It's a breath of fresh air in this debate, believe me.

YI think the home birth people need to be doing more work to support the position.

1) You're talking about the wrong population of infants.

Few people are denying that a safe home birth is "better" than a safe hospital birth. Why would they? Assuming you produce a safe infant, it's a great thing: you get choice, comfort, etc.

The anecdotes and the posts tend to focus on the great experiences of mothers who gave birth at home. Which is relevant... not at all.

2) You're making unfounded "slippery slope" arguments.

A typical home birth "slippery slope" claims, exaggerated for clarity, goes like this:

As soon as you're in a hospital, you'll get pitocin. Then you'll always get a C section. Or an episiotomy. And after your episiotomy, you won't want to breast feed. That means your baby wil be undernourished, unconnected to you as a mother, and generally in poor shape. Doomed from birth, as it were; any other medical interventions will only make things worse. And if you DO have a C-section, chances are it wasn't necessary, which can lead to post partum depression, and then you take drugs, which lead to addiction, and you'll end up dying down the road, accompanied by your sadly neglected and now-suicidal child--all because you gave birth in a hospital!

Does that sound ridiculous? I hope so.

If you're going to make a chain of claims, you need to provide support for EACH one, and they need to be linked. And if you can't prove that (for example) there's any link between hospital births and depression, don't keep saying it.

Note that the medical folks don't really do that. This is why we sound a bit "dry" or "impersonal".

When I say, for example "a baby who is delivered at home, with a pressing and undetected condition which can only be treated in a hospital, will die if a hospital is not available" this is factual, not theoretical.

3) You don't understand the statistics.

OK, let me restate that: Some of the home birth people don't seem to realize that just because a procedure turns out not to have been necessary DOES NOT mean you should not have performed the procedure.

This follows from two theories: First, the statistics in question apply to groups, not to individuals.

Procedures are developed to benefit the group as a whole. The group benefit may not accrue to any individual in particular--in fact, some people will almost always be HURT by the procedure. (Vaccines are an excellent example of this). This does NOT mean the procedure is faulty. It doesn't even necessarily mean it can be improved, though most things usually can.

Second, the relative risks of an unecessary procedure may be smaller than the risks of the reverse. Chemo is a good example of this: You may not need it after surgery, and it has a set of risks. Bit if you don't take it and you DID need it, you're screwed. So you usually go for the chemo--a smart choice.

Similarly, C section rates are extremely high. And C section present their own risks. Of course, C sections also PREVENT other risks--so the fact that one was not needed after alll doesn't mean it was the wrong choice, any more than the factthat one was performed means it needed to be done.

4) You seem to be playing statistical games.

What I mean by this is that there are a lot of factors which are correlated with neonatal and perinatal survivability. A VASTLY incomplete list might include income, race, gestational age, drug and/or alcohol use, type and length of prenatal care, etc.

I can't say this for sure. Bit there seems to be a tendency--and maybe I'm imagining this, but I don't think so--to cherrypick.

Midwives already try to cherry pick, insofar as it's only an "approved" method for vertex full term babes. But you need to be sure to compare those statistics with equivalent hospital births: equivalent in ALL the factors.

Why is this important? Well, here's a good example: Most midwives provide excellent prenatal care. In many respects, they're probably better than many OBs.

So, for example, do you think good prenatal care is related to lower rate of neonatal death? If so, and you think midwives are better at prenatal care, this is probably an argument against home birth

(explanation: If a) death rates are similar, b) prenatal care affects death rates, and c) midwives give better prenatal care; then you must correct for the prenatal care. Thus, it may be the safest method is midwife prenatal and hospital birth.)

If you didn't understand this in theory, please let me know--I'll explain it.

5) You use the wrong experts and/or draw the wrong conclusions from their comments.

Yes, California loves home birth. And guess what? The FDA says Plan B isn't safe. You still on board with the "laws are right" crowd? Governmental action doesn't mean it's right.

As for the WHO: "safe" is a relative term, as is "preferred". It is logically consistent to say "home birth is safe" if your clients would otherwise have an unassisted birth. It is logically consistent to say "midwives are safe" if your client would otherwise not have professional help, or if her local hospitals are atrocious. These statements do not prove your position. (moreover, the WHO, like California, is surprisingly political. Are you surprised by that?).

6) You try to change the "rules", without given reason for the exception.

Look, scientists are fairly predictable folk. It's as if we all come from the "show-me state" (I forget which one that is).

You want to change our current belief on procedure, which we have developed through research?

Show us.

The whole setup is designed to AVOID the idea of "let's assume it's true until it is shown to be wrong". Yet home birth seems to be asking for an exception.

Youy know the studies we want. You know how to make them happen. If you want us to believe them, go do the damn studies right.

I might add that the home birth movement is often bedfellows with other "alternative" therapies. They've got the same problem.

7) You fail to concede where you have a problem.

Look, i spent ages arguing with home birthers just to get them to concede one point: In SOME births at home, there will be a problem which you can't detect, and a baby will die because he wasn't in a hospital. The operative word is "some".

If you can't concede something simple like that--and I felt like I was pulling teeth--how the hell can you expect to have a conversation?

I don't have anything to say that hasn't been said already:

Thank you for this wonderful post!! Your research is excellent. Your writing is strong. Thank you!

I have referenced your posts on my blog. Good work!!

Thanks for these posts, Jamie. I read last week's condemnation of homebirth (and most, but not all of the comments), and shook my head at the information that I felt was missing. There were so many assumptions about what a home birth means, and what a woman's reasons might be for choosing one.

I initially chose homebirth for a pretty lame reason: finances. As a single woman whose pregnancy was very unexpected, I certainly didn't have health coverage for pregnancy and birth. I earned too much income to qualify for any assistance, but too little to absorb what looked to be about a $10k (possibly more) out of pocket expense, assuming I had no complications or c-section.

Once I made the choice I started reading. And reading. By the time my daughter was born, I was pleased with the choice I'd made. Her birth was textbook, and I was able to relax at home right away to bond with my new little girl.

The best part of working with a direct-entry midwife was, IMO, the touch-time that I would have never gotten from a traditional practice. With each prenatal visit, I got a full hour (often more) of my midwife's time. I was able to ask her question about what I'd learned, and she was able to help me in some non-medical ways (emotional support, for instance) that I wouldn't have found elsewhere.

After the birth, she was still invaluable to me as I struggled to establish breastfeeding. So many of my friends were utterly lost for the first couple of weeks post-partum. In contrast, I saw my midwife daily at first, then every couple or three days. She provided PP care to both me and baby until six weeks post-birth.

If we'd had a complication, absolutely we would have transferred. My midwife was a professional who went out of her way to establish good relationships with the local hospitals, but I'm sure I would have encountered someone who would have looked down his/her nose at me -- that seems to be common. That said, if I'd had to transfer, the benefits I saw both before and after the birth would have outweighed the shortterm awkwardness of dealing with new healthcare professionals for the birth itself.

Thanks again for a great pair of posts.

I followed this over from the adult and pediatric Grand Rounds. Allow me to say that your post has really made me think more positively about home birth. And it certainly has made me more aware of the risks of medical intervention, which frankly is part of hospital culture. Scientists can be just as prejudiced as dock workers--we're all people, and we're all prone to habitual thinking.

Thank you very much for these posts. I found them fascinating to read, intelligent and well-written, and very thought provoking. One thought that I had... it seems that, when doing the cost-benefit analysis, a lot (most?) of the "costs" in the hospital column are not immutable, inherent, inevitable qualities that arise from the setting itself (although some are), and so they could be reduced or eliminated. It does not necessarily follow from the fact that at a hospital your health care providers have the ability to give pitocin/an epidural/episiotomy/c-section that they use these tools, or that they use them more often than necessary. Essentially what you describe is bad medical decision-making on a mass/systemic level. I wish that, in addition to leaving the homebirth option open, since some women will always be more comfortable at home, we could also improve hospitals. The hospital that I gave birth at, St. Luke's-Roosevelt in Manhattan is, in my opinion, already there in many respects and these posts really make me count my blessings.

You might note that the argument over at neonataldoc was NOT about "home birth vs. fully surgical birth".

You might think it was, but you'd be wrong.

It was actually about "home birth vs. in-hospital birth of all kinds", which includes (for example) birthing centers in hospitals, midwife-assisted births in hospitals, and so on.

This is a VERY important distinction. The home birth folks sometimes seem to think Dr. Amy and others are advocating for a "no midwives, doctors-only" approach, or an "as many epidurals and interventions as necessary" approach. This is a straw man.

Our last child, and our next (for example) was/will be delivered in a hospital, by a CNM. All the benefits of a midwife, and all the benefits of a hospital. The only difference was that it wasn't at home--which, knowing the risks involved, was probably a factor in decreasing tension.

Different hospitals, different states, different midwives... surely this can't be impossible to acheive elsewhere.

I had a homebirth with my twins 10 years ago. My 12-year-old was born in a hospial via the "necessary" c-section for "failure to progress". I so agree with your analysis of home birth vs. hospial birth. The sad thing is that most women that have hospial births are iggnorant to the mechanics of birth. They just aren't ready take control of their own bodies. They think Dr's are all mighty. Also, as far as pain medications goes, they say, "If I were getting my appendix out, I wouldn't do it without any pain medication". Some women think that if they can do it pain free then why wouldn't they. I was ready for the pain. I wanted to feel the experience of birth. Some people just aren't into the wonderous joy of birth and that's sad.

Sailorman,
But isn't this discussion also about CNM care vs lay midwife care? What if, for example, a kind of bacteria so virulent and resistant to antibiotics was going around the hospitals that physicians and CNMs began choosing to deliver babies at home? For those in the discussion who believe homebirth is fundamentally unsafe, my question is what exactly do you think makes it unsafe? Is it direct-entry midwives with questionable training and experience? Or is it access to more technology in the hospital? The baby who died in Wisconsin in March had a direct-entry midwife rather than a CNM. I think this is an important and relevant distinction (but then, I'm in nursing school so I'm biased).

Generally i think more training is better, but I have no particular issues with lay midwives.

I think the discussion, though, is focusing on the question:

For ANY person who is delivering a child (lay midwife or CNM) is it safer to have a planned home birth or a planned hospital birth?

Whether a CNM is more capable than a law midwife is secondary IMO.

Inciedentally, I am a stats geek. and I keep seeing the Farm study come up. For an extremely, extremely, detailed analysis of the Farm study, and why it has an enormous host of problems, see here:

http://moderatelyinsane.blogspot.com/

"Statistics for believers" # 1, 2, and 3.

I would be interested to hear your specific responses to the issues I raise with the Farm study.

Jamie,

EXCELLENT postings. I am impressed and honored to read what you write.

I will be linking to these posts and to your blog.

Hh

Ah, Jamie. Fighting the good fight. I applaud you (and I am in awe of you).

The idea that a CNM-attended hospital birth is "all the benefits of a midwife, and all the benefits of a hospital" is a faulty one, though it's a good compromise in care for people for whom homebirth isn't appropriate.

Argh. Good studies exist already, demonstrating the safety of homebirth for normal infants, and statistical risk of intervention (and sequelae, including subsequent interventions) in hospital birth. Blustering about "knowing the risks involved" and "misinterpreting statistics" makes me tired. Anti-homebirth people who go around hollering about how hospitals practice exclusively evidence-based medicine make me alternately laugh and weep.

I know enough doctors (otherwise mainstream MDs) who have chosen homebirth for themselves that I don't put much stock in any "we medical folk" talk.

Wow. Just wow. I take a break from blogs for a while, and look what I miss!

Having had one hospital birth that went pretty darn well as those things go, and one at home, I would tell you that you couldn't pay me enough money to give birth in hospital, unless there were a true emergency.

Why is it that we, as a society, are just fine with so many other reproductive choices made by women, with their accompanying risks--various forms of contraception, abortion, sterilization--and not with the choice of the place to give birth? It seems so ironic to me.

Sailorman, I'm still reeling from the scorn and lack of good faith in your first response. I'm guessing more of us would be willing to engage with you if you hadn't completely misjudged and indulted your audience here. I'd love to do a point-by-point response to your post, but just don't have the energy to fight with someone who clearly doesn't want to have discussion. I have no interest in bludgeoning you with my ideas. I only wish I could trust that you felt the same.

Moxie,

I am sorry you think I have misjudged the audience here. I don't think I have, if it's the same audience on neonataladoc and homebirthdebate.

I remain extremely interested in your ideas. In fact, one of my main frustrations is that many homebirth advocates' posts seem to mainly attack their opponents, instead of presenting their own altrnatives.

So I'll happily read anything you have to write.

Thanks to everybody who read and commented. I'm working on one more post in response to the comments from Dr. Amy and Sailorman -- I'll get it up as soon as I can.

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