Light and Momentary

The answer is "it depends"

Ten years ago an internet pal sent me a link to an online discussion of homebirth safety, in which a couple of neonatologists and an infamous OB-GYN were congratulating themselves for their perspicacity in grasping its obvious hazards. "Aha!" said the naive Jamie of 2006. "Some people are wrong on the internet! Perhaps I will enlighten them." 

Over the next couple of months I read every research article about homebirth that I could get my hands on. I read the 2005 Johnson & Daviss study so many times that I wound up quoting it to myself in labor. I wrote some crazy number of words about homebirth that spring and spent an even crazier number of hours writing them. (They're all in the Birth category, if you're curious. They're probably some of the better pieces on this site, if you need a rabbit hole to fall down.) But guess what? Some people are still wrong on the internet. 2006 Jamie would be bitterly disappointed.

Here is a true statement about homebirth: in the right circumstances, homebirth can be as safe as hospital birth for babies and vastly safer (not to mention happier) for mothers. Here is another true statement about homebirth: in the wrong circumstances, homebirth can be a deadly act of folly, leaving heartbreak and fury in its wake. And here is one more true statement about homebirth: there is a big gray area between those first two true statements, and we in the US are doing a terrible job helping women to navigate it.

In 2009 an enormous study was published in the Netherlands, investigating perinatal death among low-risk women. The authors calculated an odds ratio, assessing the odds that a home-born baby would die vs. the odds that a hospital-born baby would die. If I were a betting woman, I would have predicted a marginally higher odds ratio for the women delivering at home -- something like 1.1, maybe as high as 1.2. But I would have lost that bet, because in that study of more than half a million women, the odds ratio was...1.0. Exactly the same odds of perinatal death for hospital-born vs. home-born babies. This is irrefutable evidence in support of my first assertion: in the right circumstances, home birth can be as safe as hospital birth.

Since I was immersed in the literature in 2006, there have been a spate of US studies published on homebirth. I haven't read them all, but many of them seem to have been written by OB-GYNs with an axe to grind. These findings do not invalidate the Dutch results described in the previous paragraph; instead, they illustrate the truth of my second assertion. Homebirth is only as safe as hospital birth in a limited set of circumstances: low-risk mother, singleton vertex baby, trained attendant, ready access to hospital care if needed. If any one of those elements is missing, the odds of an adverse outcome rise precipitously. Approximately 10% of the women who choose homebirth with CPMs in this country are Amish. They are more likely to be grand multiparae; their babies face a higher burden of potentially lethal genetic disease; they tend to live in rural areas where transport times are longer; they may choose birth attendants with limited expertise. The homebirth outcomes for the Amish women in my region have something to say about homebirth safety in the Midwest, but most of the women giving birth in Gladlyville are facing different circumstances. It would be a mistake to extrapolate too energetically from a higher-risk population about the risks that lower-risk women must confront.

And yet there's a lot of extrapolating. And finger-pointing. And polarizing. Which serves-- whom does it serve, exactly? 

In 2011 researchers published a really interesting set of findings from a large UK study: for women who've had babies before, homebirth is just as safe for babies and considerably better for their mothers. For women having their first babies, homebirth is associated with a statistically significant increase in the risk of some adverse outcome. (It's not accurate to say that their babies are significantly more likely to die -- the investigators only looked at a composite outcome because the study was underpowered to detect differences in rare events like perinatal death.) This could mean a big scary adverse outcome, like death or brain damage, or a less serious adverse outcome, like nerve damage. The absolute risk was low, but it was higher among women planning to deliver at home.

This is an intriguing finding, I think, and it raises questions I'd like to talk about. Does it reflect the UK midwives' idea of a "duty of care," by which they mean that they can't require a laboring woman to jump in an ambulance even if ambulance-jumping is clearly the best decision? Are there ways to make homebirth safer for women having their first babies? There are many, many questions worth talking about when it comes to homebirth. Here in the US, for instance-- what coursework should be required for CPMs? How important is it for them to take a pharmacology class? How much do they need to know about suturing before they start a practice? Are outcomes worse in states where CPMs are working underground? Should women have the right to choose a high-risk homebirth?

Unfortunately, measured discussions are rare. The notorious OB-GYN I first encountered 10 years ago has a book coming out next month; she has spent the past ten years broadcasting misinformation about homebirth. (It makes me sigh to think of all the stats classes she could have taken during those ten years.) I shut my Facebook tab to write this post, because the "bong" tone announcing another salvo in a friend's comments kept distracting me. It is unlikely that this post will change any minds, because "it depends" is not a very clickbait-y headline. 

But it's the most accurate one.

23

It's the twenty-third day of NaBloPoMo and my daughter is 23 months old today. This means...it's time for a guest post! My pal Jenny (Stella's godmother) was at her birth, and at Stella's baptism she gave me her account of it. Such a treasure! (All typos are my doing. Thanks again, Jenny!)

Ready for my close-up

It's probably predictable that this article would push my buttons. It's about women fixing their hair and makeup immediately after their babies are born so they'll look nice when the pictures are posted on Facebook.

In my view, the expectation that a woman will look just like she always does in the moments after she gives birth trivializes the event. If I had just finished a triathlon, would you be surprised to find I had untidy hair? (The people who know me in real life say, No, Jamie, the surprise is when your hair is not untidy.) I have never done anything as physically demanding as giving birth to my children. Their birthday pictures remind me that I poured my heart into something beautiful -- they could all be captioned "Mettle, tested." I love those pictures for their nakedness, even though I am clothed in all of them. Concealer is beside the point.

In this picture I am looking a little peaky even though I am on top of the world: that's because I hemorrhaged after my second son's birth. Sometimes birth can be brutal and dangerous. Honestly, I think the idea that a woman should be Facebook-ready twenty minutes afterward is one of the crazy expectations that contribute to the incidence of PPD in this country. Pregnancy weight gain = bad! Get back in those skinny jeans! Hurry up and go back to work! What's the matter with you that you can't get out of the house? "The matter" is that you just had a baby -- it's supposed to be a life-altering event.

Here's the thing I find most curious: what's going on with the baby while mom is blending her eyeshadow? Does it make more sense as part of the hospital birth scene, where it's not unusual for babies to spend some time being examined or bathed away from their mothers? I love that first postpartum hour or two, basking in the post-birth glow with the hard work behind us. I have held my babies greedily all through those hours, nuzzling their damp little heads and memorizing their faces. (I have been wrestling with this paragraph for an absurdly long time now because I think it might sound judgmental and that's not my intent. The tone is more puzzled than judgy, I promise.) I have never been happier than I was in this picture. And yeah, my face is red. So what? You propel a 9#12 baby with a 38+cm head through your pelvis, and then tell me if you're thinking about skin tone.

One of my college Greek classes was taught by an elderly professor with a quavery voice and silvery hair. We were reading the first chapter of the gospel of John and he taught us something I'll never forget about the word translated as "children" in verse 12. It's a word without an exact analogue in English -- a participle, teknon, that means "one having been born." It connotes, he said, the tender love a mother feels for the child she has borne, a love refined in the crucible of sweat and blood and pain. Irrevocable love. Transforming love.

By any objective standard I am not looking my best in this picture, taken in the first minute after my daughter was born. (That's meconium smeared on my pajamas. All the fashionable moms are wearing meconium this season.) But I see this picture and I remember that sometimes determination is costly. I remember that sometimes you have to lean into suffering to find a way through it. I remember that fear gets me nowhere. And I remember longing fulfilled, the joy beyond words of seeing that little face at last. It's a glimpse of a place between worlds: she is no longer contained within my body, not yet untethered from it.

I have spent hours writing about the lessons birth has taught me, as well as some time writing about beauty. I know that my views on epidurals and eyeliner (in a word: overused) are not the norm, and the point of this post is not to say "Women of America, UR DOIN IT RONG." I think it's worthwhile, though, to push back against the idea that we just want to erase the pain of birth along with any traces it might leave. I believe real beauty has nothing to do with mascara. I believe we're never more beautiful than when we say, "This is my body, given up for you."

Peonies

When I called to tell her that Joe was finally going to be born, seven years ago today, my friend Shannon brought me a peony from her garden. It had been tightly furled just that morning, she said, and now it was blooming beautifully. She wanted me to have the visual, so I could think "open open open" through my labor.

Our peonies have been blooming, spilling forth that same luscious pink. I can't look at them without thinking of Joe's birth, which might well have been the finest day of my life so far. It was my first homebirth and I was astonished at how joyful it was. Of course birth is joyful wherever it happens, but I did not know there could be so much joy in the process, joy in the laboring.

It was hard. He was 9#12 and his head was gigantic. But it was my pain and I was not afraid of it. (No matter how much it hurt, when it was over I wasn't going to be pregnant anymore. I was very tired of being pregnant.) I remember using a technique from Birthing from Within in which I tried to ride the pain, like a surfer. I remember seeing kaleidoscopic colors when I closed my eyes; I remember wave after tremendous wave. 

I also remember a confidence that was absent in my two hospital births. I was on my own turf on a glorious day in late spring, there with a doctor I trusted and a dear friend as well as my husband. We laughed all day long -- that's what I wrote about it when it was all over. I said I wanted to live my life, and eventually die my death, the way I had gone through that day -- "with courage and laughter even in the hardest places."

In each of my pregnancies I have asked the Blessed Mother to intercede for my unborn baby and me. Joe came along in late August, on one of the feasts of St. John the Baptist, and so for months I had prayed daily for the intercession of Our Lady of the Visitation. How fitting, then, to wake up in labor on her feast day. I still ask daily for the intercession of Our Lady of the Visitation, in hopes that my children will recognize the hidden presence of Christ whenever they encounter it -- that they might see the truth of their redemption written plainly in unexpected places.

That's what I think of when I see those tightly closed peony buds. You would not guess that they could contain such extravagant beauty, and yet they do. Tonight I am wishing my Joe -- my seven-year-old Joe -- a year full of joy and beauty, hidden in unexpected places.

The Really Long Conclusion

The next stretch of labor was -- there's no other word for it -- fun.

In Which I'm Not (Do You Hear Me? I Mean It!) Going To Have A Baby Tonight

On Monday afternoon, the 22nd, I loaded the two younger boys into the van for what I hoped would be my last prenatal visit. I was anxious, yet again.

I'd Hammer All Day

Yesterday I went to the doctor to check on Miss Olga's position.

An Earful

I wanted my insurance to cover chiropractic treatment for this symphysis trouble, which is much improved but still painful. (I am under strict instructions from my midwife not to do laundry, because carrying things up the stairs is a prime way to make it worse. Yes, ma'am! That's an instruction I'm happy to comply with. Now all I have to do is sustain an injury that sidelines me from washing dishes and I can kick back and lead a life of leisure.) I called my doctor's office to see about a referral, and they told me I'd need to come in first.

Today I saw the other doctor in the practice, and OH MY GOODNESS is she different from her partner. Remember my conversation with him about the risks of homebirth? Lather rinse repeat, minus the friendly. The weird part about both conversations is that they've focused on the risks to me: I could die because nine years ago I had a not-enormous and easily controlled postpartum hemorrhage. Neither doctor has mentioned the risks to the baby, which take up much more space in my head. The studies don't support the idea that the risks to babies are greater in planned attended homebirth, but things do go wrong sometimes. I find myself thinking about that a lot just now.

Since I've had this conversation before, I responded pretty calmly. Nine years ago I had clear risk factors for postpartum hemorrhage: untreated anemia, long first stage, long second stage. This time my hemoglobin is solidly in the normal range (up a whole unit from six weeks ago! I am practically Popeye!) and it is very unlikely that I will contract hard for 24 hours or push hard for two (please God). I have had more babies than the average woman, which is an additional risk factor, but I have also had two perfectly normal third stages, with not a glimmer of trouble, since that hemorrhage. Hm, I'm thinking I probably said all this in that earlier post and you guys aren't the ones I want to argue with anyway. I'll spare you the part about the drugs my midwife carries and how close I am to the hospital where I have already pre-registered.

I am still a little wound up about our conversation, though. It made me want to come home and blast Enya while brewing a pot of red raspberry leaf/shepherd's purse tea and soaking plaster strips for a belly cast. I don't actually own any Enya or any belly-casting materials, but I think I will put the kettle on.

Is that a threat?

I wrote a letter to my HMO. I said, "You should cover my CNM's services. It will save you a ton of money. Outcomes for low-risk out-of-hospital birth are just as good for babies and much better for mothers. Also: much much cheaper for you! Save money! Support great (and did I mention cost-effective?) care for women! Cover my homebirth!"

They said no. I figured they would say no, but I also figured it was worth a try. One sentence in their reply, though, gives me pause. It says that if I pay privately for her services, they will refuse to cover any resulting complications.

Now maybe that's just boilerplate for out-of-network denials, aimed at keeping in-network doctors from having to pick up the pieces after out-of-network poor outcomes. If I were to pay for a nose job that went wrong, say, they wouldn't want to get stuck with the cost of follow-up care. But I've been wondering all afternoon -- are they threatening to refuse to pay for a transfer to hospital care if that's needed? If I hemorrhage and need monitoring afterward, are they going to attempt to stick me with the bill? If the baby needs help, are they going to deny the claim?

The doctor who wrote the letter quoted the ACOG statement. (For you non-earthy-birthy folks, the ACOG statement said essentially, "We don't like homebirth, evidence be damned." They cited no literature, because there is no literature for them to cite -- not a single study supports their contention that planned attended homebirth is more dangerous for low-risk mothers or their singleton full-term vertex babies.) But the C-section rate in my town exceeds 40% -- wouldn't you think the insurers would be on a mission to cut costs while improving satisfaction? Isn't it silly for them to turn me down when I hand them just such an alternative?

Risks, Benefits, Looming Catastrophes

I saw my OB this morning. He is a very pleasant guy, UK-trained and personable, and he seems to be convinced that I'm going to have a catastrophic hemorrhage when this baby is born. My two younger sons were born at home, one with a family practitioner and one with a CNM. While I would go back to the hospital in a flash if this pregnancy turned high-risk, I plan to stay home this time too. We've had an HMO for a couple of years now, and along with prenatal visits to my midwife I'm seeing an in-network OB so I can have my tests covered. I was up-front with him about my plans to stay home as long as I stay low-risk.

He has spent a fair amount of time telling me I could bleed out and die.

When my second son was born in an Edinburgh hospital, I was quite anemic going into the delivery and the third stage was actively managed (i.e., more tugging on that cord than I was comfortable with). I lost an estimated 850 ml of blood, but the hemorrhage was easily controlled -- one shot of methergine and that was that. I have no wish to repeat the experience, since the recovery was rather grim, but I also don't think it's an enormous red flag in my obstetric history. I have since had two perfectly normal births with utterly unremarkable third stages, and while I accept that I could hemorrhage again, I'm not losing sleep over it.

When I met my midwife during my pregnancy with Pete, the first question I asked her was what she carried to manage PPH; she said she always had pitocin, methergine, Cytotec, and IV fluids. I live half a mile from the hospital. I will pre-register there, just in case. I will transfer in a heartbeat if there is a problem. My midwife is licensed and legal; she would accompany me, chart in hand.

It doesn't seem very likely to me that I'm going to exsanguinate under those circumstances. Hemorrhage, maybe; lose my uterus, remotely possible; die, improbable. Call me an optimist.

I spent some time this morning trying to respond to the doctor's concerns: I didn't have even a hint of uterine atony after Pete's birth. I'll reconsider my plans if I'm anemic in the third trimester. My midwife can take the same first steps to intervene at home that she can in the hospital. I think, though, he has it burned in his brain: Homebirth = Too Risky. (Oddly, he has focused exclusively on the risks to me, not the risks to the baby.) But I believe I have read every paper published in English on homebirth safety in the past 15 years, and the results are clear: planned attended homebirth is a safe option for low-risk women carrying full-term vertex singletons. (Don't even get me started on Amy Tuteur, who should serve as a caution to any would-be amateur epidemiologists.)

I  am feeling a little cranky today because I threw up my breakfast (at 16w5d! on Unisom! enough already!) immediately before going to the doctor to hear about my impending demise. But I will end on a happy note: I am grateful for this baby, whose kicks and flutters are making me smile every day now, grateful for a thus-far low-risk pregnancy, grateful for my midwife. My first visit with her was such a welcome contrast to my first OB visit. Afterward I told my husband, "I wish every pregnant woman could see someone like her." I'm glad I can.

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.

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.

The Perils of Skiing, the Value of Broccoli, and an Atypically Splenetic Rant from the Usually More Measured Jamie

When I spoke to those college students early last month about childbirth, I used an analogy that occurred to me during the Winter Olympics: I said that hospital birth is like ski-jumping and homebirth is like cross-country skiing. Ski-jumping is more dramatic than other events -- there are ambulances standing by for a reason. Cross-country skiing has its own risks. It's unusually hard work, and you could have a heart attack and die on the trail. But out there in the stillness some of us find an extraordinary beauty. A significant consideration, of course, is that in childbirth you've got a passenger along for the ride, dependent on you for protection. Your decisions matter, because we're talking about the potential for injury to or death of a baby. But I think most people hear "homebirth" and imagine ski-jumping solo, with no helmet and no EMTs, when it simply isn't like that. In both events you've got skis on your feet and you're heading to the finish line. But when you deliver a baby at home, the spiral of interventions that too frequently culminates in an emergency surgical delivery just doesn't get started. Why am I talking about skiing in April? Because Amie sent me a link to a blogging neonatologist's post on homebirth and I am frustrated. A few different MDs weighed in, asserting that homebirth is not safe, that last year's BMJ study was homebirth propaganda, that the problematic August 2002 Journal of Obstetrics and Gynecology study (critiqued here with additional links at the bottom of the page) was a landmark in homebirth research. My references were discounted (can't trust those Cochrane reviewers, you know); my requests for citations in support of dubious contentions have thus far been ignored. Which leads me, inexorably, to thoughts of broccoli. Let me explain. If you're an MD, you can probably diagnose cancer and prescribe narcotics. You can most likely explain whether a fluoxetine metabolite is psychoactive and how the Krebs cycle works. And hey -- more power to you. Somebody has to understand the Krebs cycle and it certainly isn't going to be me. If I were seized by a masked gunman who said, "Quick! Explain the Krebs cycle or I'll shoot!" -- well, tell my boys I loved them, folks, 'cause that's the end for me. But your MD degree doesn't qualify you to pronounce infallibly on the relative desirability of comparably safe options. Those decisions belong to patients. If you are skimming along here, thinking, "...skiing? ...broccoli? ...what?" this is the part where you need to pay attention. As far as I know, and I am not an expert but a curious layperson, there is no valid research to support the idea that hospital birth is safer than planned birth at home for low-risk women. If you have a full-term vertex baby and a qualified attendant, you won't increase your odds of a good outcome by going to the hospital. You will increase your odds of a surgical delivery, a cut or lacerated perineum, and a whole lot of hassle initiating breastfeeding, but probably that's not a constellation of facts the hospital's marketing department would choose to emphasize. I've heard a number of doctors say they're personally uncomfortable with homebirth. And that's fine by me: I would never suggest that anyone have a homebirth unless she's comfortable with the idea. But the doctors who say, "I'm an MD and no one should give birth at home" -- well, that's like saying, "I'm an MD and broccoli is icky." You're welcome to dislike broccoli. Maybe it gives you gas, or maybe you overcook it to drab sliminess every time because you get distracted thinking about the beauties of the Krebs cycle. Under certain circumstances broccoli can be indisputably icky -- or even dangerous, if you chop it up on the unwashed cutting board you just used for raw chicken. But an unqualified pronouncement that people who care about their families' health eat cabbage, and not broccoli, is ridiculous. When an MD says, "Homebirth is not safe," I'm skeptical. (Also irritated, but you probably figured that out by now.) When an epidemiologist says, "My analysis of a large number of homebirths leads me to conclude that..." -- then I'm all ears. That's exactly what happened with last year's BMJ study of homebirth safety (which confirmed that planned attended homebirth is a safe option for low-risk women and their full-term babies), and yet a commenter described it as pure propaganda passed off on an unsuspecting public as science. Ah, yes, the mighty homebirth lobby in action. Probably the entire BMJ editorial board quakes in its shoes at the thought of the powerful CPM contingent...or not.... I went back and forth a few times with one particular doctor, and our exchange left me highly exasperated. For one thing, she disagrees with me that homebirth can offer advantages to babies. But is it really best for babies when their mothers are pressured to use physiologically unsound positions (supine or lithotomy) for second-stage labor? Are routine pitocin augmentation and AROM good for babies? She disagrees that obstetric management can affect breastfeeding, though she offers no references to dispute the extensive bibliography of Kroeger and Smith. Most reprehensibly, she states in her final comment that fetal death is a feature of natural childbirth, not obstetrically managed childbirth. Maybe she works at the Fantasy Island Medical Center, where obstetric interventions have only benefits and no risks. But here in the real world, where I happen to live and give birth to my babies, there are unexplained IUFDs in the hospital as well as at home. There are HCPs who make mistakes in the hospital as well as at home. And, most troublingly, there are HCPs who do their level best to help babies arrive safely and still find themselves facing a bad outcome. It happens -- guess what? -- in the hospital as well as at home. To imply that good obstetricians don't see stillbirths is to demonstrate unbridled optimism -- or perhaps unbridled hubris. I was noodling around her website trying to find out more about her perspective, and came across this information on episiotomy: Episiotomy is one of the simplest and most common procedures performed in obstetrics today and, remarkably, one of the most controversial. It is difficult to understand why it is so controversial when you understand how and why an episiotomy is done. Episiotomy is designed to prevent uncontrolled, jagged tears during delivery.... Lately it has become fashionable for women to refuse episiotomy. There may be no harm in refusing an episiotomy, but it's important to understand that the consequences may very well include even more stitches and more postpartum discomfort than an episiotomy may cause. ...um...ooookaaay, maybe I shouldn't be holding my breath for references. Longtime readers will know, I hope, that I am not a commando homebirther. If either of my two homebirth attendants had said, "Jamie, we have to go to the hospital," I would have said, "Car or ambulance? Tell me more on the way." I have never intimated that homebirth is the best or purest or only right way to deliver a baby. But if I live to be a hundred, with the intervening 65 years crammed full of new and joyful experiences, I am certain that the days my sons were born into my living room floor will remain two of the four or five finest days of my life -- days when I was brimming with gladness at being alive in a woman's body, at being a mother to my boys. I am saddened that so few women in this country have the option of a legally attended homebirth. But! I have just learned from the good doctors that this is the viewpoint of a selfish woman preoccupied with having "an experience" at the expense of her baby's safety, and that I should have gone to dinner and a movie if I wanted "an experience" and bypassed the whole pregnancy/birth/motherhood thing. The things you learn in med school, I tell you. So these are my questions, gentle readers: one, should I call my confessor for an appointment tonight or can it wait until morning? Two, should homebirthing women be held to a higher standard with regard to informed consent? (By which I mean, if most women laboring in hospitals don't know that the shot of Nubain they gratefully accept can impede a baby's subsequent respiratory effort, should a woman at home be expected to be more conversant with the literature?) Three, Dr. Amy assures me she has a list of references as long as her arm to demonstrate the hazards of planned attended homebirth by low-risk women -- does this mean she is an amputee or just a person with unusually short arms? Four, would you consider a homebirth yourself, and why or why not? Talk to me. Regularly scheduled rant- and sarcasm-free blogging will resume shortly.

Doors

This is a post about birth, but it begins with a bit of travelogue.

We went to Rome in 2000.  I had hoped to get to Rome in 2000 from the minute I first heard about the Jubilee, and I was elated when we actually bought the tickets.  It was not an easy trip: the baby was teething and the 3yo did not -- just imagine! -- appreciate the walking tour of Bernini sculpture.  But it was wonderful regardless. 

When I am an old woman I will remember our day at St. Peter's.  Of course I will remember the Pietà and the great baldacchino.  I will also always remember walking through the holy door, flung wide in celebration.

A door is only a door:  its purpose is merely to get you from one place to another.  And a birth is just a birth; it gets you from pregnancy to motherhood.  But we seem to think, at this time and in this country, that births are meant to be more like the gates to the Emerald City than like Consorti's stunning door to St. Peter's. Absolutely, safety comes first.  If the lintel crashes on your head when you open a door, it doesn't matter that it was a work of art.  But I am saddened by the idea that beauty and welcome and celebration are just frills.  I am saddened that so many women in this country are seeing these doors, and thinking they have no other options.

This post has been brewing in my head since Pete's birth in April. I wanted to write it when I saw the NYT article on midwifery (the one that featured Moxie's midwife). Hospitals are cutting midwifery services, it reported.  They get reimbursed at higher rates when OBs attend births, so they want OBs attending births.  The question of what's best for most women -- a birth attendant whose training emphasizes finding and treating pathology, or a birth attendant who believes that childbirth is a robust process -- is taking a back seat to the question of what's most profitable. 

I wanted to write this post when Katie Allison Granju blogged about the recent study on home birth safety that found, just like every other good study on home birth safety, that planned, attended home birth is no less safe than hospital birth for low-risk women.  I got into an argument in her comments section (and now I can't find that post in her archives) with a woman who told me I should climb a mountain and say "om" if I wanted a sacred and empowering experience.  Her common sense, she said, told her that hospitals had to be safer than homes, the data notwithstanding.  (I didn't tell her that she should sell her car and take the bus if she was that worried about safety, since in the big picture attended childbirth, regardless of location, is safer for both parties than car travel.)

I wanted to write this post when BrooklynGirl posted about policies at the hospital where she will deliver:  no food or drink for laboring women, for instance.  She said, "Going to a high-intervention hospital and expecting low-intervention treatment seems a little like going to a French restaurant and ordering Eggplant Parmigiana."

But there's more at stake when we talk about birth choices than there is when we talk about ratatouille vs. caponata.  I remember hearing Ina May Gaskin and Naomi Wolf discuss their books on WFUV a couple of years ago.  Naomi Wolf was busy haranguing the medical establishment; Ina May Gaskin said, in her calm and matter-of-fact way, "In my community, women believe that their bodies are capable of bearing children.  And mostly, they are right." I do not mean for this post to sound like Naomi Wolf, berating the hospital staff who want birth to be safe.  I am only wishing that more American women could have the confidence that Ina May's neighbors do.  I am wishing for widespread recognition that safety in childbirth need not exclude beauty and tranquility.

This is supposed to be the era of evidence-based medicine, and yet circular thinking abounds.  We don't let women eat during labor because they might need emergency C-sections.  When they need emergency C-sections, we say, "Oh, good thing she was fasting."  It is not rocket science to see that fasting is part of the problem, not part of the solution.  Why isn't there more outrage in the face of a 27% C-section rate?  What if 27% of American women were told they needed surgical assistance to walk, or swallow, or breathe?  Childbirth is different in important ways, of course, and it certainly does have its dangers.  But it is a well-designed process essential to the survival of the species.  It is normal.  A 27% C-section rate simply doesn't make sense.

My frustration with irrational thinking is only one part of why I wanted to finish this post, though.  My home births verged on sacramental -- they were put-out-your-hand-and-touch-the-face-of-God experiences.  I wrote after Pete's birth about being fully engaged -- mind, body, and soul -- in cooperating with a miracle.  It is a fine thing to be alive, I wanted to say after my two home births, a fine thing to have a woman's body.  I wish there were less fear about birth in this country.

Home birth is not for everybody; unmedicated birth is not for everybody (though I want to say loud and clear, in case anyone reading this has suffered through a miserable hospital birth, or has pleaded for an epidural at 4cm after planning to go natural, that my two home births were far, far less painful than my two hospital births). High-tech obstetric care saves lives, and of course I'm grateful that it's there.  What's missing is the recognition that low-tech care for low-risk women, particularly home birth, need not be a choice made on the fringes.  Birth can be both safe and sacred. 

My posts about Pete's birth are absurdly long, but that's because I wanted to hold fast to the details.  It was such a happy day that I didn't want the memories to slip away from me.  Why is it commonplace for women to say, "I couldn't get pregnant again until I had forgotten just how horrific the birth was"?  To my ear that says something telling about mainstream birth practices.

I read a snarky piece on Naomi Wolf's Misconceptions -- a book that does invite some snarking -- in which the reviewer complained that Wolf talked about her births and not her children's births.  I think that complaint speaks volumes about the American view of birth:  we forget, too often, that parturition brings forth a mother as well as a baby.  I will call them my births without apology.  My children will never remember them; I will never forget.

Of course birth isn't just about me:  it is more than anything a call to selflessness.  And yet at the same time it is about me.  One of the hardest things about pregnancy and motherhood is the loss of control, the moments in which you realize you are not in charge.  (I posted about this very thing, hugely pregnant and sobbing, in April.)  In their efforts to improve outcomes, to give better answers to the scary "what if?" questions all pregnant women ask, many hospitals wrest away more of their autonomy [edited to acknowledge that many women willingly cede it].  The irony, the crashing, underappreciated irony, is that for the average low-risk woman such care offers no improvement in safety over lower-tech alternatives.

I believe that for many women home birth can restore a welcome, appropriate feeling of autonomy.  I believe, too, that a joyous birth experience lays an important foundation for new mothers.  With home birth it's your living room, your fridge, your applesauce and your choice to eat it.  It's your labor and you can climb in your own tub when it feels right to you.  It's your pain:  you own it, you ride it. It's your body, doing something astounding; it's your baby, whom you have yearned to meet.  It's your birth -- your very own everyday miracle.

"With Woman"

As my midwife was packing up after Pete's birth, she pulled an oxygen tank out from under the couch arm.  "I didn't see that!" I said, surprised that I had delivered three feet away without noticing it. "That's the idea," she said.  "We want it right at hand in case we need it, but out of sight otherwise."

It's a good emblem for midwifery care, I think -- the recognition that Pete might need help in a hurry coupled with the recognition that he'd probably be just fine, especially if I wasn't confronted with reminders of what might go wrong.

Back in September, Tiffany mentioned that she'd been satisfied with her family practitioner but would stick with midwives in the future. At the time I wondered why.  I had been so pleased with Joe's birth -- our family practitioner, Dr. Right, seemed to offer the best of both worlds.  If we needed to transfer to the hospital, he would be right there to run interference for us.  When my mother-in-law said, "I just feel better if the doctor's in the next room," I could say, "Actually, the doctor will be in the same room.  It will just be my living room."  During the birth he stayed out of the way, letting the process unfold on its own.  It was great.  But I wanted to tell you all a litte more about my midwife.

I've had a big increase in hits lately, which I am thinking is at least partly due to new readers rather than friends checking in 45 times a day because I am late answering their emails.  (Soon, I promise.  I'm having trouble staying caught up on both laundry and email.  I'm a little scared of what might happen if I let the dirty laundry gain momentum.) 

For those of you who are new and not motivated by my sparkling prose to tramp through the archives in search of the whole story, here's the recap:  miscarried in late May of '04; conceived again in late July despite my expectation that it would take a long time; felt many things including disloyalty to miscarried baby, unreadiness, wrenching uncertainty about pregnancy ending in a healthy baby, total inability to handle another loss, and buckets of guilt about all of the above; promptly turned a fetching shade of celadon and stayed that way, retching, until early October; found out as normal coloring returned that husband needed a new job; stressed and stressed and freaked; wailed and gnashed teeth when husband interviewed for a job two hours from the city; suddenly was suffused with serenity (at least briefly) about moving; spent six work weeks holding down the fort on my own in the city while my husband settled into his job here; found and purchased a house; moved in on the first day of my 36th week. 

I am tired just writing it all down.

I spent a lot of my pregnancy feeling ambivalent and vulnerable, saying, "I'm pregnant!" with the back of one hand pressed dramatically to my forehead.  As firmly as I believe in the sovereignty of God, I kept saying, "Lord, if you think I can handle this you are badly overestimating me."

At first we just didn't know what to do about the timing of the birth and the move.  Should I stay in the city with the kids until after the baby arrived?  Should we scramble to find prenatal care and a house here and get moved before the birth? Well, let me tell you:  if we hadn't scrambled, I would be so fried.  At the time, though, it was hard to know what was best.  One big question was answered when we found a CNM who could do a home birth in Gladlyville.

I left my first prenatal appointment with her saying, "I'm pregnant!"  But suddenly I was saying it with a much different tone of voice, one that said, "I am this baby's home, his refuge.  I am his whole world right now.  And no matter what my opinion might be on the timing of this pregnancy, I can still be glad for the chance to be his mother."  I found a good radio station and sang all the way home, beating a tattoo on the steering wheel.  I kept looking down at the speedometer and seeing that the needle had edged up past 80 again.  "If I get stopped," I wondered, "can I plead happy?"  The moon was full that evening, and I wondered if two more full moons might find me in labor.  (Ha! snorts the voice of hindsight, or is it the nose of hindsight if it is snorting?  The velum of hindsight, perhaps.)  Anthropomorphizing aside:  moonrise ahead of me and sunset behind, and a delicious inner confidence that I could manage what lay ahead of me -- a confidence that surged again every time I saw my midwife. 

A friend of mine who is planning her fifth home birth was talking to me about how much she liked Dr. Right.  "Midwives do all that goofy backrub stuff," she said.  "I hate that!  I just want them to leave me alone."  But I loved all that goofy backrub stuff.  Whenever I voiced a need, and sometimes when I didn't, they were right there.  They didn't hover, but they helped any way they could.  I fretted; they reassured. I groaned; they encouraged.  "It's more show!  That's the way!" they would say.  (In the moment I thought, "Oh, come on, anybody can push out MUCUS -- it doesn't have any bones!")  Through the hard part of my pushing stage they would lean in and push on the top of my pelvis together as a contraction hit, making more room for Pete to descend. Oh, the relief.

Birth is at bottom a solitary undertaking:  nobody can drink that cup for you.  (I sound like a bluegrass singer here:  You gotta wa-alk that lonesome valley....  It's true, though.)  Dr. Right's approach was to give me plenty of space to do what I needed to do.  I appreciated that.  But my midwife came in close.  She couldn't walk that road with me, but she could stand right nearby and tell me she knew I could get there.  And get there I did.

She came back 36 hours later for my postpartum visit and asked how I was feeling about the birth.  I said, a little choked up, "It was such a nice birth."  She said, "It was a nice birth, the kind that fills me up and keeps me going."  Suddenly I didn't want her to go -- she had been such a welcome, sane-ifying (what is the opposite of crazy-making?) presence during the last few months.  I said, "Thank you."  She answered, "It was an honor.  Thank you for inviting me."

For a few days I couldn't even think about that without tearing up. An honor?  To follow me around as I crawled on the floor mooing?  To wipe up the blood and mucus and excrement?  An honor?  But I thought more about it, and realized that she was the person who first saw my little guy's face.  She shared in one of the best moments of our marriage.  She listened in as we got acquainted with the baby we had waited eagerly to meet.

And it made me think again about the paradox of birth.  From what St. Paul calls my "less presentable parts," along with all the flushable stuff, have come my greatest treasures.  The most physically demanding work I have ever done has opened the door for the most spiritually demanding work I have ever done, work that is fitting me for heaven.  The most intense pain I have yet experienced has yielded to the richest joy I will know until the last great passage.  On that day, too, I hope to see a Face -- deeply beloved and heretofore hidden.

Here we are together, just a little while after Pete (hiding in towels) was born.  I am on top of the world.  (Perhaps some people can get to the top of the world with tidy hair; I cannot.)  She, I think, is enjoying the view with me.

Into His Wonderful Light

The books all say you shouldn't push until you have to, but I ignored them.  I had been doing a lot of reading on second-stage labor, and I wanted a chance to think about how it felt to try some new ideas before I stopped being able to think clearly.  The midwife had brought a length of fabric for me to pull on during pushing, and I gave it a tentative try from the birth ball:  chin tucked, jaw relaxed, thighs relaxed, pu-u-u-ull on the fabric and push gently.

"I think that'll work," I said.  "I need to be able to plant my feet a little more securely.  And first I need to use the bathroom."

We trooped into the bathroom, and here things begin to get kaleidoscopic.  I have been mulling over the best way to tell the end of this story because there was so much happening.  Maybe I'll lay out the separate threads and you can imagine them interwoven.  Here's what we had going:

Body.  My contractions became more painful quickly.  But there was an important difference between this pushing stage and my others:  it was not nearly as overwhelming.  I don't know how well I've conveyed the intensity of my previous pushing stages, but they were crazy -- like a bullet train, like an F5 tornado.  The urge to push was like the urge to breathe after someone had been holding my head in a barrel of water for a minute or two:  Push or Die.  It sounds dramatic, I know, but it's true.  This time around it was more like a freight train -- it's still a big powerful thing, but it's not as scary to see it bearing down on you.  And it gets where it's going.

You know, that's a bad analogy, actually, because in this country right now freight trains get where they're going more reliably than high-speed passenger trains.  Maybe this is a better one:  have you ever been out walking on a summer's night and been caught in a storm?  The thunder is loud and the rain is heavy and you think, Boy, am I getting wet and I wish I were at home.  But when you get home and towel off your hair you remember the power of the thunder and the warmth of the rain and you think, Wow, that was amazing.

And wow, it was amazing.  I felt for the first time like I could choose how much to push instead of going flat-out with each contraction.  Less bearing-down effort meant more pain, but I could pick my spot on that curve.  I could ride it instead of running away from it.

Mind.  I don't remember anyone coaching me about pushing while I was doing it, but my mind was busy talking me through it.  Keep your weight forward in hopes of triggering a fetal-ejection reflex, thighs relaxed, don't hold your breath, jaw loose.  "Oh, Dr. Odent?" I remember thinking, "what does a person have to do to get a baby to fall out around here?"

Heart.  The most extraordinary thing about this stage was the peace I felt going through it -- I felt enfolded in love, secure in the goodness of God. For a few years now I had prayed regularly for JP2, for a gentle death in God's time.  I asked him to intercede for me now, for a gentle birth in God's time.  I remember praying little snippets of familiar prayers -- Queen of Heaven, rejoice! Alleluia!  I said, God, were you listening to Renee's prayer for me?  But I was okay with taking it slowly.

As the contractions intensified my voice got lower and lower and louder and louder, until the neighbors must have wondered, "Is there a livestock exhibition at the Gladlys' house tonight?"  One of my favorite memories of this birth is of a contraction when as my throat poured out a tenor moo my heart sang out, "Glory to you, Lord God!"  I thought about an image I love -- of all creation, from angels and archangels to rocks and trees, giving glory to God -- and I laughed to myself at the thought of my contribution to the blend.  I am forever telling my children, "God can use anything you give him," but it still makes me chuckle to think of my birthing noise as part of the celestial music.  The next morning I got an email from a friend saying, "I will pray for you, that you can give glory to God in the midst of your pain."  Isn't that cool?

Probably I should add a fourth thread:  mouth.  Another thing I am always telling my children is "out of the overflow of the heart the mouth speaks," but my mouth took on a life of its own during this birth.  "I hate this part," it said with feeling a few times; also, "who brought the plunger?"  They asked me whether something -- maybe warm compresses? -- felt right and I bleated, "There's a head in my pelvis -- nothing feels right."  They said something encouraging -- maybe "just a little more work"? -- and I bellowed forlornly, "THAT'S EASY FOR YOU TO SAY."

So here we are:  relax your jaw and glory to God and I hate this part all spliced together with an overlying haze of pain.  (But please, if you are considering a natural birth, don't be put off by the pain bit.  I am usually a wuss about pain but Ina May Gaskin is right:  labor pain is clean pain.  It is gone forever now and I honestly cannot remember how it hurt, only that it did hurt but that I could handle it.  You can too!)  I pushed in the bathtub, remembering Renee's experience and hoping my baby would ease out in one push (no dice), and I pushed on the toilet seat.  I squatted on the bathroom floor and pulled down on my husband's arms while he pulled against me.  I headed back to the living room and pushed some more -- hands and knees, semi-squatting, combinations thereof. 

It seemed like I'd been pushing for a while when the midwife checked me again.  Baby was only at 0 station and I had a moment of discouragement.  "I can't do it," I thought.  "Let's just go to the hospital so they can pull the baby out."  But then I realized I hadn't been pushing very hard; I had wanted to see what happened if I let my uterus do the work.  I began to put a little more of my back into it.  "It'd be faster in a full squat," said my mind, so I did one contraction that way and BANG my water broke, nice and clear.  I wasn't really in a hurry, though, so I didn't stay in a full squat for long.

A little while longer and the midwife checked me again. "I can only get one knuckle in before I feel the baby's head," she said excitedly.  All right then, I thought, let's do it.  She and her assistant were going to check the baby's heart tones again, but I called out sharply, "Crowning!" 

My Joe slid out in a whoosh once his big head was ready to go, but this time there was a lag.  I thought, "I bet the baby's shoulders are sticking.  But I'm in the right position and she knows what to do."  Turns out there was a loose loop of cord around baby's neck, easily passed over his head.  A shoulder was born, and a second shoulder, and --

-- and there was a new little person in the room.

He is nursing as I type this, his face already engraved on my heart.  But oh, I wish I had the words to tell you about that first moment when I scooped him up, still tethered to me, and held him close as his little purple body pinked up.  I am crying too hard to see as I remember, but in the moment there was no room for tears -- only joy, and elation, and relief.  Is there any moment more precious than that one, when the pain evaporates and the groans give way to coos of welcome?

And maybe that's where I'll leave it for today.  Welcome, baby, welcome.  We're so glad you're here.

Out of Darkness

I'm not sure how to start this story because it doesn't have a clear beginning and the middle is a little fuzzy.  With my other births I could say, "I woke up having contractions at x time and they were y minutes apart and z hours later etc." but on Sunday I had decided that my uterus and I were no longer on speaking terms.  I'd feel a contraction and think, "Tell it to somebody else, girlfriend, because I am not listening, do you hear me?  Not listening.  Talk to me when you've got something worth my time."

So all I know is that there was a change in the contractions in the small hours of Wednesday morning, because I remember thinking vaguely as I went to answer Joe's call that it finally felt like we might be getting somewhere, but la la la I was pointedly not listening.  And I remember feeling not quite myself on Wednesday morning -- I knew that I just wasn't up for the half-mile walk to the library -- but I thought I might just be tired from finishing that poultry post the night before.  My husband says I called him around eleven to say I was suspicious that this pregnancy might actually be a temporary condition, but this puzzles me because I was at the library at eleven, resolutely not listening.  (Maybe he got a call from my uterus -- "She won't listen to me!  Will somebody listen to me?!")

After lunch I took a nap, thinking that it might be wise to get some rest, and a couple of times I had to roll out of bed to stand up and move with a contraction.  (By the way:  does anyone else hate lying down for contractions?  The Bradley books recommend sidelying for maximum relaxation but ouch does that make it more painful for me.  With my first labor I got panicky because it hurt so much lying down.  "This is supposed to be the most comfortable position and I'm miserable!" I thought fretfully.  I wish I had known to go wash the dishes instead of lying in bed trying to pretend it didn't hurt.)  When I woke up I called the midwife.  "What do you say to a Thursday baby?" I asked her.

At that point, I thought we might have a baby sometime after midnight, or maybe the next morning.  In the next 24 hours is my guess, I said.  I told her I was going to pick up my husband and drop off the kids at a friend's house, and I'd get back to her in a couple of hours about how things were progressing.  All right, she said.

Snag A:  the friend who lives right by my husband's office wasn't home.  Snag B:  my neighbor had class Wednesday night and I couldn't see asking her husband to watch my three in addition to his four.  Snag C:  the other friend I was going to call lives in a subdivision I've never been to and the thought of trying to navigate twisty subdivision streets with rhyming names made me a little queasy.  Snag D:  Joe fell asleep in the car on the way home from picking up my husband.  We decided we'd just keep the kids at home until my mother-in-law arrived to take them to her house for the night.  She left for PCT at 4.

I had thought a lot about how I hoped the birth would go, and the verse that kept coming to me was "in my flesh I am filling up what is lacking in the afflictions of Christ on behalf of his Body, which is the Church."  It has always struck me as a rather audacious claim, but I figure the Apostle Paul knew whereof he spoke.  I had envisioned myself beatifically offering up the sufferings of labor for the needs of the world, but beatific proved to be a lofty goal.  For one, the kids were grating on me.  In the car they had been fighting about the baby's name.  "It's going to be a girl and we'll call her Rayquaza," said the oldest.  "No! A boy! Peter-the-pickup-driver George Spider!" insisted the youngest.  "Rayquaza and that's final!" shouted the oldest.  Oh, my word, it gives me a headache just remembering.  "Listen!" I burst in.  "I am IN LABOR.  I am trying to drive and I am already distracted.  Stop it right now."  Usually, that would have done the trick -- my oldest is a compassionate kid who listens reasonably well.  Not on Wednesday, though.  "Rayquaza!" he interjected once more, sullenly, prompting shouts of "Peter-the-pickup-driver George Spider!" from the 2yo and lobbying for "Starfire!" from their brother.  Thankfully, my husband was waiting out front for us and he drove us home before I could cause any property damage.

They continued to squabble at home, and I continued to be exasperated with them.  I remember thinking, "Boy, am I edgy.  I skipped right over that happy excited part of labor this time."  I was also getting more uncomfortable physically.  I wondered if the baby was posterior, because the contractions required more of my attention than I expected them to at that point.  Maybe some music will help, I thought.

I put in a CD I hadn't listened to in years, a recording of Newman Center choirs from ten years ago.  I put on our little choir's first song and suddenly flashed on a memory.  The months after our first miscarriage took a heavy toll on our marriage, and I remembered leaving the recording session and complaining bitterly about my husband to my friend Kate -- the same Kate who has given me so much long-distance love and encouragement this last month.  Then as now, she patiently encouraged me that things would get better.  And she was right both times, as it turns out.

So I was thinking about this as the song changed, to John Michael Talbot's "Magnificat."  Kate had started us out with a solo, and it was so comforting to me to hear her voice, clear and true, singing, "My soul proclaims the greatness of the Lord, and my spirit exults in God my savior."  The other women's voices joined hers, and I thought about my friend who delivered a daughter last week, down on the alto part, and another friend, also a mother now, who sang soprano with me.  I remembered gathering around the piano with them, working out the harmonies, and I felt comforted again thinking about my women friends around the country praying for me.

I was pacing around our downstairs and trying to pray:  a contraction in the kitchen, offered for the conversion of Robert Mugabe and peace in Zimbabwe; one in the music room, for an end to abortion; one in the living room, for the souls in purgatory.  I thought about the saints who were mothers, like Monica and Elizabeth Seton, and about saints who had no children but offered their physical suffering for the glory of God, like Perpetua and Felicity.  And I thought one more time of Kate, who gets a giggle out of that particular pair of names, and smiled to myself. 

I headed into the dining room, knowing I needed to eat between contractions to fuel up for what I thought would be a long night.  I nibbled at some cottage cheese and a slice of toast, but I wasn't very hungry.  In the kitchen I happened to notice the clock:  contraction at 5:11, one at 5:13, one at 5:16.  After the third one I called the midwife again.

We're having a baby tonight, I said.  Oh? she asked.  Not right now, I told her, not in the kitchen floor as we speak.  But with my other labors I've known things were cooking when I started getting flushed after a contraction, like my uterus was hogging all the blood it could during the contraction, and that's where we are now.  It's probably better if you come sooner rather than later.  She had a couple of quick things to take care of, she said, and then she'd head right down.

I wanted to write what should have been a quick post, but the interruptions kept coming.  I would get up to sway through a contraction and the boys would say, "Can't we use the computer now?"  As soon as I hit "publish," I started looking out the window for my mother-in-law.  I needed the boys to go.  At 6:15 I called her.  "Where are you?" I asked curtly.  "Oh, about 15 or 20 miles away," she said.  I asked M to start a bath for me so I could hop in once the kids were out the door.

The midwife's assistant got there soon afterward and we chatted for a few minutes.  She told me a little bit about herself (she's a mother of four sons), but I had to ask her to tell me most of it again afterward because I seemed to have Teflon ears at that point.  I don't think I'm very far along, I told her, but I'm pretty uncomfortable.  I'm worried about pushing, I said, and I don't want to make this stage of labor harder than it needs to be because I'm thinking ahead.  Can you help me stay where we are?  Sure, she said.  She asked if she could rub my back while I rocked on my hands and knees, and I said yes gratefully. 

Finally my mother-in-law pulled in.  I said a quick hello to her and hugged and kissed the boys goodbye.  I had tried to get them to help me make a labor nest a little earlier, but they wanted to play Darth Vader instead, with the shower curtains as cloaks.  Penny and I double-made the bed, and spread a shower curtain over the living room floor.  I headed for the tub.

I had labored in a tub twice before and found that it made an immediate difference for me, so I was surprised that I was still uncomfortable in the water.  It was too hot at first, and even when the temperature was right I just didn't feel the relief I expected.  My husband joked gently, "If you have the baby tonight, we'll have to have another so we can hit the 28th." [The three oldest boys have birthdays on the 29th, the 30th, and the 31st.]  "Don' t talk to me about that right now," I snapped at him.  "Wow," I thought to myself, "you are awfully cranky."

The midwife arrived and I climbed out of the water.  "Can we see how things are going?" I asked.  Baby sounded great, but I was more curious about my cervix.  She checked me and said, "Jamie, how did you get that Studebaker in your uterus?"

Okay, okay, she said nothing of the sort.  But I could not have been more surprised by a Studebaker than by what she actually said, which was this:  "My fingers are stretching, stretching [I interpreted this as "you're not very far along but at least your cervix is stretchy" so imagine my shock when she concluded by saying] --I'd say eight, almost nine."

Can we have a moment of collective jaw-dropped-ness?  Can we laugh out loud with relief and surprise?  I spent the next ten minutes trying to get my mind around that number.  I wanted to say, Are you sure?  What units are you using?  Does the baby have such a big head that I have to dilate to 17?  How can I possibly be almost complete?  I said, Okay, God, I asked for a gentle birth but I never imagined it would be this easy to get here.

My husband came down the stairs with the pair of sweats I'd asked him to bring me.  "How far along do you think I am?" I demanded.  "I'd say about four," he guessed.  (That's exactly what I would have said.)  "Nope," I said.  "I don't think I'm going to need those pants after all."

I climbed on the birth ball (I had been looking forward to the midwife's arrival because rocking on the ball sounded so good) and relaxed through the next couple of contractions.  Of course I'd been uncomfortable -- I was in transition!  No wonder the kids were bugging me!  No wonder I didn't want to be talking about having another baby!  I am having another jaw-dropped moment just remembering.  Lucky for you I can type with my jaw on the floor, or I'd never get this post written.

It wasn't very long at all before I began to have the beginnings of a pushing urge.  I said to the midwife, "I'm worried about pushing this baby out.  But you think I can do it, right?"  She looked into my eyes and said steadily, "Yes.  I think you can."

The Gray Lady Says No

Twice in the past month I've written to the NY Times.  They didn't publish either letter -- can you believe it?  How I hate it when my brilliance and insight go unrecognized.  (I hope it's clear my tongue is so far in my cheek that I sound positively dysarthric.)  But hey -- who needs a cooperative letters editor?  I have a blog! 

The first letter was a response to a Science Times blurb about that study on changes in frozen human milk.  Too much detail, I know, but the confusing spin I saw everywhere (breastmilk gets less nutritious! formula stays just the same!  --that's because formula is dead, folks, whereas human milk is living tissue) made me mad.

 

Your summary of the changes in antioxidant capacity in stored human milk obscured a critical detail:  at every stage, human milk has a higher antioxidant capacity than formula.  While it's true that this study reported a 19.3% drop in antioxidant capacity in human milk frozen for seven days, from 1.66 to 1.34 units, you failed to mention that formula has only 1.07 units of antioxidant capacity no matter how it's prepared.  In other words, breastmilk has a 25.2% higher antioxidant capacity after a week in the freezer than formula has when it's fresh.

Without those numbers, it's easy to infer that stable formula is a wiser choice than mutable human milk.  That would be like saying that since orange juice from frozen concentrate has a lower vitamin content than fresh-squeezed orange juice, we should just drink Tang.  After all, its nutritional profile is more constant.

Many employed mothers must overcome a variety of obstacles to express milk for their babies.  Those mothers deserve complete information about the importance of their milk to their babies.

The World Health Organization has said for years that if breastfeeding is impossible, human infants should receive their mother's expressed milk as a second choice, donor human milk as a third option, or formula if no human milk is available.  The results of this study confirm that fresh breastmilk is better than expressed breastmilk which is better than formula.  It's a shame the study is being misinterpreted in some quarters as casting doubt on the value of expressed human milk, when its findings clearly point in the opposite direction.

 

For the curious, study results are available here and the WHO statement on infant feeding is here or on page 11 of this longer document.

On Monday of last week there was a front-page story on the difficulty of VBACing in this country.  I found it outrageous but I saw not a single letter published in response.  Mine is too long but here it is:

 

In your Nov. 29 article on the difficulties many women face when they attempt to avoid repeat Caesarean sections, Dr. Gerrit Schipper quotes his patients as saying, "...Who am I as a lay person to go against what you think?"

Who are you?

You are the woman who gives -- or withholds -- consent for surgery after assessing its attendant morbidity and mortality risks.

You are the mother of the baby in question, a baby whose risk of breathing difficulties increases with Caesarean delivery.  If you are considering VBAC, you are the mother of at least one other child, whose adjustment to life with a new sibling may be made more difficult by a lengthier post-Caesarean hospital stay.  Perhaps you hope to be the mother of future children, whose gestations and deliveries may be complicated by unnecessary surgery this time around.

You are the source of the food your baby was designed to receive, and the person who will have to deal with the positioning difficulties and delayed milk production which often go hand in hand with C-sections.

You are a patient entitled to straight answers about why American obstetric practice deviates from World Health Organization statements on C-section.  You are a participant in a health care system that was already creaking and groaning before this avalanche of repeat Caesareans began.

You are, as I am, a citizen of a nation impoverished by the malpractice epidemic and the associated changes in doctor-patient relationships -- and impoverished, too, by widespread refusal to acknowledge that childbirth is a normal, robust, and profoundly beautiful physiological process. 

And I don't know about you, but I am a woman so frustrated by mainstream American obstetric care, in which "First, don't get sued" seems to have supplanted "First do no harm," that I want nothing to do with it.  My fourth baby is due in the spring.  I'm planning another home birth.

 

There, I feel better now.

It's (Not) Only Natural

"You couldn't pay me to have an epidural," I used to say dramatically.  This was after my second son's birth, when I was floating so high on my flocculent cloud of mother-love and birth empowerment that my connection to the planet seemed rather tenuous at times.  I don't say it anymore, in part because I try to squelch my tendency to be irksomely earnest.  More importantly, though, it wasn't getting my point across.  The birth junkies knew what I meant already.  And the mainstream moms -- well, they probably wished somebody would smack a little sense into my smug self.

I wasn't feeling smug, even though I'm sure it seemed that way.  I was contrasting my two birth experiences:  the first a cascade -- a veritable Iguaçu Falls -- of high-tech "help" (if you look closely at that picture you might see Alex and me going over in a barrel), the second more like a trip down West Virginia's Gauley River.  Sometimes it was a wild ride.  I was glad we had a guide.  (Hey, that rhymes.  It's a poem about my son's birth.  My husband will say, "Keep your day job, Jamie.")  But even in the roughest spots there was no panic and the scenery was astounding.

I wanted to know why no one was saying bluntly what seemed so obvious to me:  pharmacologic pain relief in labor is overrated.  It comes at a cost, measured in intangibles as well as dollars.  It doesn't guarantee that the pain will go away.  And it can cause problems that linger long after the contractions are gone.

One day when I was seven months pregnant with my oldest son I was talking to a patient's mother about birth.  She said she'd opted for an epidural.  "You must have one," she gushed.  The first time, I did.  Suddenly I was not a normal woman moving through a normal process; I was a patient, immobile and tethered to multiple beeping things.  I spiked a fever and needed antibiotics in my IV.  They weren't sure how the baby was doing and placed an internal monitor.  I tried to push and could not get that 37cm head to budge.  I could go on and on but I won't, in part because I don't need to.  It is the litany of American birth today:  fetal monitoring, IV, pitocin, epidural, catheter, antibiotics, assisted delivery, laceration repair, forever and ever, amen.

This post began in response to Alicia's question about why some lactation consultants leap to techno-solutions for breastfeeding problems.  I believe we are seeing so much medicalized breastfeeding in part because we are seeing so much medicalized birth. I believe too many of us don't trust women's bodies to birth and nourish their babies -- "us" meaning both the mothers themselves and those who help them.

Earlier this year I attended one of La Leche League's Lactation Specialist Workshops, featuring Linda Smith and Mary Kroeger, co-authors of Impact of Birthing Practices on Breastfeeding:  Protecting the Mother-Baby Continuum.  Virtually any birth intervention can affect breastfeeding.  If you were yanked by the head through a tight passageway, would you be in the mood to work for your dinner afterward?  Neonates, with their immature livers and kidneys, are routinely exposed to narcotics during birth -- how can they be expected to coordinate sucking and swallowing with breathing when their respiratory function is depressed as a result of the drugs?  Is it any wonder that some of them just don't try?

Even interventions that seem innocuous can have unexpected sequelae.  Many lactation consultants report a loose correlation between the volume of IV fluids a mother receives during labor and the degree of areolar edema she experiences in the postpartum period.  Antibiotics given to a mother during labor can lead to thrush and premature weaning.

LCs, who are under pressure to fix breastfeeding problems in the brief hours before mom's insurance stops paying for her hospital room, inherit complications from L&D.  But it's not that simple.  Most mothers are clamoring for epidurals.  Probably some of the LCs have a techno-orientation to begin with.  At bottom it's the culture, the whole technophilic culture.

Some of the problem begins at conception:  women are getting pregnant who never could have conceived thirty years ago.  Polycystic ovarian syndrome is a major cause of infertility and it can also cause major problems with breastfeeding.  Some women who require significant help to conceive may also need significant help to breastfeed.

As breastfeeding initiation rates increase, breastfeeding problems increase too.  LCs are stretched thin at most hospitals.  If a techno-fix seems faster, they may rely on the techno-fixes.  As members of a fledgling profession (so new I'm not even sure what to call it despite being certified in it -- lactation consulting? lactation consultancy?) they are still establishing a place in the medical community.  In the American medical establishment, whizbang technology equals credibility.  (Okay, I am exaggerating.  But is it so far off the mark?  If It Is New And Expensive It Must Be Better, no?)  Are some of these LCs throwing technology at problems because that's just what American HCPs do?

LCs are like lifeguards on duty while the tide is changing.  Few of today's grandmas breastfed for very long; a mother who did not watch babies being breastfed when she was a child has missed something that should be a part of American girlhood.  No LC can infuse her with the inner understanding of how you hold a hungry baby and guide him to the breast that little girls acquire when they watch their younger siblings nurse.  Maybe that's another reason why the LC breaks out the nipple shields instead.

We live in a quick-fix culture and the quick fix for breastfeeding problems is formula.  We don't have the attitude that breastfeeding is simply what you do, even when it's tough.  With a roomful of voices chorusing "just give him a bottle," the LC may be scrambling to pull a rabbit out of her hat.

Another component of the problem is the paternalistic attitude of some HCPs, coupled with unwillingness to acknowledge that birth interventions and artificial feeding can have undesirable consequences.  Why would you suffer when you don't have to, honey?  The myth that epidurals don't affect a baby is widespread.  It's nothing but a myth, though; the anesthesia literature documents that epidural medication gets through the placenta.  Similarly, a shocking number of doctors withhold information about the health effects that attend infant feeding choices because they say they don't want mothers to feel guilty.  Let's pretend, they seem to say (the data notwithstanding), that epidurals and bottles are perfectly harmless.

Normal birth choices in our culture are simply not normal physiologically.  Last week a friend of mine was saddled with a random OB resident when her midwife was unavailable.  While her baby was crowning, the doctor was demanding that my friend roll over from her hands-and-knees position onto her back.  (Crowning, I kid you not.  What say we tell that doctor to do some gymnastics while she has a head half out of her vagina?  Because we all know women are supposed to compress their aortas when their babies most need oxygen, and push uphill while they're doing the hardest work of their lives.)  The doctor was rough during the post-birth exam, and my friend protested.  The response?  "Well, if you had had drugs, this wouldn't hurt."  (At that point my friend invited her to leave.)

So many women talk about unmedicated birth and breastfeeding in the same way:  I'm going to try it, they say.  And really, that's all anyone can say -- the most diehard natural birther can end up with a transverse baby and the most dedicated breastfeeder can birth a baby with an inborn error of metabolism.  The best-laid plans gang oft agley and all that.  Far far far be it from me to suggest that new mothers just aren't trying hard enough to do things in The Right Way.  But there is an unfortunate misperception in this country that natural birth and natural feeding are optimal but optional.  Nice if you can manage it, but don't knock yourself out.

And yet -- and yet.  From my own first birth experience I have beaucoup de sympathy for anyone who feels she simply cannot manage the pain of birth any longer.  I know, too, that breastfeeding can be excruciatingly painful and difficult.  This is not a post questioning any woman's individual decisions, decisions made during some of the most vulnerable and volatile days of her life.  But I wonder (quietly, because it is not a popular curiosity) what it does to us as a culture when so many women give birth without sensation and feed their babies at a remove.  What happens when we as a nation are numbly watching "Malcolm in the Middle" reruns during one of the most intense moments of human experience?  I guess my answer to Alicia boils down to this:  I think the average American birth experience explains a lot about the average American breastfeeding experience.

I feel a bit like a foreign-language speaker when I talk with women who plan, before the first contraction strikes, on having epidurals.  For me, the calculus is straightforward:  the number of minutes of pain between 5cm and birth is a far more manageable problem than the annoyance of numb and useless legs, the risk of a sepsis workup and possible thrush after an epidural fever and antibiotics, the prospect of weeks of painful sitting and who knows how much uncomfortable sex as a result of trying to thread a watermelon through a thimble without being able to feel what I'm doing.  There are studies on the psychological effects of epidurals (these may include a spectator role for the mother, less interaction with baby, and less mastery of the mothering role a year later -- references available if you'd like them), but I'm not thinking just about the science here.

I am thinking about reading the first chapter of the gospel of John in one of my college Greek classes, and about the professor who said something I will never forget:  the word "child" in the verse "...to become children of God" is a participle, teknon, meaning "one having been born."  It connotes, he said, the tender love of a mother for the child she has labored to bring forth with sweat and blood and anguish and cries from a place beyond words.  I believe the rending groans of an undrugged mother (the ones that cause cranky L&D nurses to poke in their heads and say, "Pipe down! You're scaring the other women on the floor!") are an analog to her baby's birth cries:  they signify the birth of a mother. 

I cannot explain the alchemy of my younger sons' births.  But they took me to a place I had never been, a place from which my heart has never quite returned.