Interesting article on homebirth, natural birth, birth interventions and cesarean from our neighbor to the south!
Inside Baltimore's Home-Birth Underground
Like any 8-day-old baby, Jimmy Gaffney spends most of his time either nursing or sleeping. Peacefully alternating between the two while cradled in his mother's arms in the family's sun-dappled Hamilton backyard, the robust newborn looks like a promotional photograph for parenthood. And yet, so far as the state and city of his birth are concerned, this baby does not officially exist.
He was born at home, in May, with only his mother and father, Alana and Matt Gaffney, in attendance (his two excited siblings, who had slept through most of the five-hour labor that culminated in his 4 a.m. birth, came in just as their father was placing the freshly born baby on his mother's chest). The family is in no rush to notify the authorities about Jimmy's birth; they have been taking it easy for the past week, sticking close to home and bonding with the new addition while Alana recovers. A call to register his birth with the Baltimore City Health Department will summon a visit from a home nurse, and the Gaffneys are not quite ready for outsiders, particularly bureaucrats asking a lot of questions about a process they regard as utterly natural--and completely private.
Although they have health insurance that would have paid for a hospital delivery, Alana and Matt managed Jimmy's birth entirely on their own; Alana even administered her own prenatal care. Neither is a doctor; she is trained as a nurse and Matt is a wildlife biologist, so there is a certain amount of medical/scientific experience between them, but it's hardly the job experience most people look for when hiring a birth attendant. In fact, 99 percent of women in the United States give birth in a hospital; the remaining one percent of births include all births outside the hospital, including accidental births (as in, say, the back seat of a taxi).
Thus it is impossible to say how many of the nation's annual 4 million births take place at home. Not all states track births outside of hospitals, and those that do typically classify intentional home births together with the kind attended by taxi drivers. Furthermore, in Maryland and other states where certified professional midwives cannot legally practice, many midwife-attended births end up being recorded as unassisted to keep the midwife off the bureaucratic radar.
Disenchanted with a medical system that treats birth as an emergency instead of an emergence, seeking an alternative to the tubes and wires and monitors of a high-tech birth, some women are stepping outside of the hospital to have their babies. And some say their numbers are growing.
But is home birth safe? No studies exist for unattended births like Jimmy Gaffney's, but there are dozens demonstrating that, in low-risk pregnancies, home births attended by a midwife are as safe for mother and baby as going to the hospital. The largest and most scientifically rigorous home-birth study to date, sponsored by the Canadian government, followed all 5,418 planned home births across the United States and Canada attended by Certified Practical Midwives in 2000. The authors concluded that babies are born as safely at home as they are in the hospital, and with vastly fewer interventions like cesarean section, the use of forceps, or episiotomy; other recent studies, including a 1995 study of 11,788 intentional home births under midwife care published in the Journal of Nurse Midwifery, have reached the same conclusion.
Despite evidence that it is safe, "I think some people shy away from home birth because of the responsibility," Alana Gaffney says. "If you're at home, attended or unattended, and something happens to the baby, it's your fault for not seeking appropriate medical care. But if you go to the hospital and something happens, you're guilt free. No one is going to say anything to you--it's just one of those things that happens."
The Gaffneys' decision to have an unassisted birth was not made lightly. The births of their first two children, Joseph, now 10, and Keira, now 3, took place in medical facilities; Joseph was born in a hospital, Keira in a birth center. "We are pretty mainstream," Alana says. "We own our home. We drive a minivan." But when she became pregnant with Jimmy, Alana knew she wanted to do things differently.
"The first two times there were a few issues with both my care and the baby's care," she says wryly. While in labor with Joseph, Alana says she was given pitocin (a synthetic hormone that speeds up contractions) without her knowledge or permission, and another drug caused her to hallucinate. During Keira's birth at a now-defunct birth center, each time Alana's labor plan diverged from birth-center policy the staff threatened to transfer her to the hospital for a cesarean section; even worse, immediately after Keira was born, they took action that potentially endangered the neonate. There was meconium stain--feces passed by the baby in utero, which happens in approximately 13 percent of births--when Keira was born, and, as Alana explains, "studies show that if the baby is alert and crying, suctioning in the presence of meconium will do more damage than good--it can cause pneumonia. I repeatedly told them not to do it, and even gave them the reference number of the article, but they just did it anyway. It was maddening."
So for Jimmy's birth the Gaffneys sought a setting where no one would be threatening them, giving medication without consent, or performing potentially harmful treatment on the baby: their own home. In deciding to do it themselves, they skipped right over the usual alternative to a hospital delivery: birth at home under the care of a midwife.
"We did initially consider using a midwife," Alana explains during a visit shortly before Jimmy's birth. "But if we were looking for something that was truly intervention-free, and we knew what we wanted and we knew how to do it, then we finally decided we should do it ourselves" A daunting proposition to some, perhaps, but not to Alana, who has attended births as a nurse. "I don't have any apprehension about the birth, or about labor," she says. "In 95 percent of births there is no special equipment but two hands to catch the baby. While there are things that could happen, it doesn't take a rocket scientist to deal with those things."
It's a decision that mystifies Evelyn Muhlhan, who has worked as a Certified Nurse Midwife for 22 years. "If you want to be left alone while you labor, that's fine, but have an attendant in the next room," she says. "For the most part, birth is normal and very few women will have problems, but when a problem does arise are you going to be equipped to handle that?"
A veteran of a recent unintentional unassisted birth, Brigitte Jacobson wishes that Muhlhan could have been in the same room when her son Noah was born in September 2007. Jacobson's plan for the home birth of her second child definitely included the presence of her midwife, but labor progressed more quickly than anticipated, and Brigitte began pushing Noah out before Muhlhan could get there. Although everything ended well, Noah's shoulder got stuck, and Jacobson, along with husband Mike and doula Bobbie Humphrey, spent a terrifying couple of minutes trying to dislodge the baby before he suffered oxygen deprivation. Noah's birth was one of the 5 percent where complications arise, but Jacobson is confident that her animal instincts saved the day: Although her helpers urged her to remain on her back, she says, "I just felt the overwhelming urge to stand up--when I finally did, he just fell out of me. Bobbie actually dove down and caught him!"
Despite the drama of Noah's birth, Jacobson says she has never regretted her decision to birth at home: "If I had encountered the same shoulder dystocia at the hospital, I may have ended up with an injured baby or a C-section."
The American College of Obstetricians and Gynecologists (ACOG) strongly opposes home birth--at its annual conference in 2006, the organization gave out bumper stickers reading home deliveries are for pizza. The official ACOG statement on home birth says in part, "Unless a woman is in a hospital . . . with physicians ready to intervene quickly if necessary, she puts herself and her baby's health and life at unnecessary risk."
Unlike the majority of his ACOG colleagues, Dr. Robert Atlas, chief of obstetrics and gynecology at Mercy Medical Center in downtown Baltimore, is not against home birth per se. "I think in the correct patient demographic, home birth is an acceptable alternative," he says. However, he explains, "the problem most obstetricians have with home birth is that [at the point] when we get involved, nothing is good, things have gone awry, so we have a bad taste in our mouths because of being placed in that situation."
On the other hand Dr. Victor Khouzami, chairman of obstetrics at the Greater Baltimore Medical Center in Towson, agrees wholeheartedly with ACOG's anti-home birth stance. And, although he confirms Alana Gaffney's contention that the incidence of complications in a normal, low-risk pregnancy is 5 percent or less, he looks at this statistic from the diametrically opposite view. "The incidence is low, yes, but the severity--the `what if'--well, in medicine we do a lot of testing to find that one in a thousand," Khouzami says. "And I don't think that anyone is willing to be that one in a thousand. It's fair to say that anyone doing a home birth is taking at least a 1-in-1,000 risk."
Advocates for home birth, however, argue that in always looking for that one in 1,000, that 1/10th of 1 percent, has resulted in hospitals treating every birth, even in low-risk mothers, as a potential emergency. Instead of trusting the human body to bring forth babies as they have for millennia, requiring mainly time and a supportive atmosphere, risk management has transformed birth into a heavily medicalized event where the laboring woman, bristling with IV tubes and multiple probes and monitors, must remain on her back in a hospital bed--which may be the worst possible position for effectively pushing out a baby.
Well, yes, says Khouzami. "If you are here long enough, we are going to do something to you. It's a matter of time. I will be the first one to admit that," he says. "The trade-off is that I am going to make sure that nothing happens to you or to the baby.
"So which risk do you want? You can't have it both ways."
Khouzami oversees Maryland's most prolific labor and delivery hospital ward: GBMC physicians and staff delivered nearly 5,000 babies in 2007. Almost half--42 percent--of those babies arrived via surgery.
The cesarean section is unquestionably one of modern medicine's greatest achievements. Still, it is major surgery and carries risks that for the mother include death, hemorrhage, infection, organ damage, uterine rupture, and threats to future fertility. Nor are babies necessarily better off: Studies show that the risk of post-cesarean infant death rate is double that of babies delivered vaginally. Long-term side effects include substantially elevated rates of asthma and severe food allergies in cesarean babies. (Researchers are beginning to understand that the cruise down the birth canal serves a biological purpose, squeezing amniotic fluid from the baby's lungs to facilitate breathing, and colonizing the baby's digestive tract with healthy bacteria that help protect against future food allergies.) Other neonatal risks include, according to ACOG's own research on cesareans performed in low-risk pregnancies, "increased fetal hemorrhage, asphyxia, birth trauma, electrolyte abnormalities, and use of mechanical ventilation, suggesting that high cesarean delivery rates themselves are not protective."
Overall, Maryland hospitals had an average C-section rate of 32.2 percent in 2006; nationwide the same-year average was 31.1 percent. In plain terms this means one in three of babies in our state is now born via surgery. (According to Atlas, Mercy's 2007 overall cesarean rate is 30 percent, though the cesarean rate for deliveries by its staff midwives is "5 to 10 percent at most.")
Both Maryland and U.S. cesarean rates are double the World Health Organization's recommended proportion (for developed countries) of 15 cesareans per 100 births. Beyond that number, a 2005 WHO survey reports, "the maternal injury and death consequent to major abdominal surgery begins to eclipse the lives and health saved."
There are, of course, births where a cesarean is medically necessary, and even the most ardent birth activist readily admits that properly administered C-sections have saved the lives of countless women and their babies. What is startling, however, is the rapidly increasing number of cesarean deliveries in the United States experienced by low-risk pregnant women who have uncomplicated labors. According to the National Center for Health Statistics, "Twenty-four percent of first births to low-risk women in 2003 were cesarean births, an increase of one-third since 1996."
"There's always a reason to cut," says Barbara Stratton, a former doula who now leads the Baltimore chapter of the International Cesarian Awareness Network ( ICAN). "Your labor's too early, your labor's too late. Your baby's too little, your baby's too big, you're too little, you're too big. You have too little amniotic fluid or you have too much amniotic fluid. They come up with reasons sometimes verging on the bizarre about why they have to section." And many women, she says, are not properly notified of the risks to their health, fertility, or life.
Mercy's Atlas says that obstetricians are in a tough position. "What we're held to now is the expectation that every patient who delivers a baby should have a perfect baby," he says. "Cesarean rates keep rising because obstetricians can't practice in a safe environment legally." Fetal monitoring during labor produces a paper trail and, Atlas explains, "any time you have a bad outcome you then go back and say, `It was here, this drop in the heart rate right here that caused the baby to suffer.' So most likely any time there's an abnormal fetal heart rate tracing they're going to do a cesarean section." In other words, when doctors perform a cesarean it is seen as doing everything they can--they get sued for the C-section they don't do.
Escalating cesarean rates have grabbed headlines in recent years, but one trend behind the trend--a corresponding jump in the artificial induction of labor--has garnered less attention. Induction occurs when, rather than waiting for labor to start on its own, medical personnel jump-start things by administering pitocin, a synthetic version of oxytocin, the "birth hormone" secreted by the body during naturally occurring labor. The Centers for Disease Control and Prevention report that in 2005 the rate of induction of labor was 22.3 percent, a number that has more than doubled since 1990.
"I can't tell you how many times people asked me during this pregnancy, `So when are you getting induced?'" Alana Gaffney says. "One woman even told me, `The last two weeks don't count.' Inductions and interventions have totally just become how we, as a society, picture giving birth."
"Don't. Be. Induced," Mercy's Atlas says emphatically. "Inductions themselves increase the rate of cesarean twofold."
Beyond creating contractions in an otherwise nonlaboring woman, pitocin is also used to speed up existing labor that is not progressing quickly. That goes against everything one Baltimore midwife believes in.
"Some women just take a long time to have their babies," says "Denise," a midwife who has practiced locally for years and who asked that her real name not be used to protect her from possible arrest. "Birth is a normal bodily process. It's not a medical event. When you treat it like one you're creating problems. Lots of times what I see with hospital births is them tinkering around the edges, cranking up this thing and that thing, to move everything along according to their outline of how a birth is supposed to go.
"They tweak the labor until there is a problem, and then they `rescue' the woman from that and say, `Aren't you glad you were here?'" Denise contends. "It happens all the time. And the woman feels sure that something terrible would have happened if they hadn't had their baby in that hospital. But the truth is if she hadn't gone, none of those problems would have arisen."
Nichole Kirby could be a poster child for the process of one intervention leading to a series of interventions resulting in an unwanted cesarean. The March 2006 birth of her first baby, Alana, at a local hospital, was artificially induced and turned into a grueling 30-hour marathon of suffering and fear. "I got the epidural and all progress stopped," she recalls. "I had at least eight or nine internal exams. I had doctors coming in in pairs of two to do exams. They didn't really talk to me or even introduce themselves. It felt incredibly violating--there were at least 15 different people in that 30-hour period poking around my genitals, and that's not cool."
Although the baby was not in distress, Kirby says, "They did the C-section as a policy decision--it was 24 hours after my water had broken. It was so traumatizing, I was crying and begging them not to give me a C-section. They just started tying me down to the table--I had no idea that it's part of surgery. I was terrified, and they didn't explain anything. I was hyperventilating and shaking so much they thought I was having a seizure." The surgery proceeded, and Alana was quickly born.
"I heard her crying and asked if I could see my baby, and they said I couldn't see her. So I tried to ask how she was doing, what color eyes does she have, what color hair, and nobody would even answer me. They were just busy doing what they were doing to my body, but it's like I wasn't there. I was so exhausted after 30 hours of not sleeping or eating and then the surgery that I just passed out and woke up half an hour later when they were done with my stitches." It was another hour before Kirby got to hold her baby, she says, "because even after I got to the recovery room I was shaking so badly from the epidural I couldn't control my muscles."
Ultimately, Kirby says, "It was a really, really horrible experience, but it's the standard way things are done, and what a lot of women are told is that this is what you have to go through to have a baby, and you just have to suck it up for the baby's sake."
Perhaps it is not a surprise that when Kirby became pregnant for the second time she was reluctant to return to a hospital. Initially, she says, she wanted a midwife-assisted home birth but was told "because of the [previous] cesarean, no nurse-midwife would deliver me at home." Ultimately, Kirby saw no other option except to do it herself: "I had a friend who was studying to be a midwife one day, and she had an unassisted birth herself, so I had her come and keep me company. I did a lot of reading and research to learn about possible complications, how to handle it if something went wrong."
But this time, in September 2007, at home instead of the hospital, everything went smoothly. "I had a 14-hour labor at home," she says. "I could move around, eat and drink. Lying in the tub with a hot towel over my stomach took away a good portion of the pain." Kirby's baby boy Robbie arrived without incident and, she says, this time the experience was exhilarating: "I wanted to do it again, right away!"
Is there any scenario where women can have it both ways--freedom to labor and birth in their own time and their own way, yet do so within the medical safety net?
"There are a lot of people who believe that all you need are midwives and high-risk obstetricians," Mercy's Atlas says. "The reality is, many midwives have been driven out of practice themselves because of the difficulty of being able to afford malpractice insurance. What's sad is that midwives, dollar for dollar, get paid less than obstetricians for doing more. They spend more time with their clients, they have better interactions with their clients, and they get paid less."
Local midwives and doulas have good things to say about Mercy's support of alternative birth choices. "I think that it has been helpful to our institution to have women come in who do want to do things differently, because it makes the team have to think differently," Atlas says. Mercy prides itself on its in-house midwifery practice, where women can move about--"We have multiple telemetry units, so you can walk around and still be on the monitor," Atlas notes--and eat during labor, as well as choose any position, including in a water tub, for pushing.
"We just had a woman deliver a 12-pound infant with a midwife, and she would never have delivered vaginally with an obstetrician," Atlas says. "The question is, did she get the correct care? Or was that too risky to have allowed that patient to have delivered vaginally? The fallacy is, `Ooh, doctors say we gotta get this baby out before it gets too big,' and there's no data suggesting that is of benefit." Atlas says, whenever possible, "labor should be natural. It is not a pathologic process but a natural process and should be treated that way."
In many other hospitals, however, all bets are off. "An issue with natural birth at the hospital is, if you ask most hospital staff what that means, they think it just means labor without an epidural or painkillers," Kirby says. "Natural birth is so much more than that. It is birth unfolding in its own time, without a deadline, without pitocin, without monitors, without IVs, without being stuck in a bed or deprived of food."
"Doctors will say that they support natural birth," local nurse-midwife Evelyn Muhlhan says. "I think they think they support natural birth, but when it comes down to it they really don't. In the majority of hospitals, the system is really set up to handle one kind of birth, and the pressure is on to get with the program."
Atlas, Kirby, and Muhlhan all agree that the best thing that women can do is educate themselves about birth, and then seek out a health-care provider that will support their birth plan. "Be an advocate," Atlas says. "Make it clear when you come through the door: This is how I'd like things to go."
Actually, it appears that the majority of women would like things to go as painlessly as possible. In the 1990s, birth centers became a popular alternative: home-birth comfort and freedom with a medical safety net. Recently, however, birthing centers have been going out of business at a brisk rate. Due partly to slim profit margins--"Vaginal deliveries are not a moneymaking enterprise," Barbara Stratton observes--and partly to ever-rising liability insurance, birth centers are losing out to hospitals that have wisely co-opted the birth-center ambiance (comfortable homey setting, complete with mood lighting, Wi-Fi, and iPod docks) while also providing epidurals.
Ahh, the epidural. Epidural pain relief is an anesthetic/narcotic cocktail administered continuously into the lower spine via catheter. Ideally, when administered at the right level at the right point during labor, the epidural dulls the pain of contractions while allowing the laboring mother enough sensation to be able to push the baby out when the time comes. When administered in the wrong amount or at the wrong point during labor, however, epidurals can slow or even stall contractions altogether, leading to pitocin or a C-section for "failure to progress." It can also leave a woman too numb to push, necesitating a vacuum extraction device to help the baby out through the birth canal.
GBMC's Khouzami reports that, among women birthing there, demand for epidurals is such that "we had to create a dedicated OB anesthesia department to make sure epidurals are given 24-7. . . . I would say the majority, certainly more than 90 percent, want an epidural."
"In our world today we are very comfortable," midwife Denise muses. "People just don't do anything that's hard anymore. We don't even have to suffer the heat or the cold anymore, we drive everywhere. You don't really get that challenge that helps you to grow, to mature--avoiding those challenges seems to be the order of the day. And I think that is translating to how we give birth in this society."
But birth in the sweaty, grimacing model--birth that puts the labor into labor--still holds attraction for some. "I got interested in home birth because when I talked to women who had done it, they all talked about how it was so incredible, a peak experience like nothing else," Brigitte Jacobson says. "I had never heard anyone talk about their hospital birth like that and I wanted that experience."
Having had it, she describes it as "incredible--like the best drug in the world, free and nonaddictive."
For those up to the challenge of a no-pain-relief birth, midwives Evelyn Muhlhan and Denise are at your service. For home birth in Baltimore they are the two to see--pretty much the only two.
In Maryland, only Certified Nurse Midwives (CNMs) like Muhlhan are allowed, under state law, to "attend births habitually or for hire." CNMs have nursing degrees with graduate-level training in delivering babies; due to burdensome regulations and skyrocketing liability insurance, nearly all of them work in hospitals or as part of a medical practice. As an independent practitioner, Muhlhan sees about 100 patients each year through her Catonsville practice, Alternative Birth Choices. She works with clients who want a hospital birth with her as their midwife, but she says the vast majority of her caseload is home-based.
A lay midwife, on the other hand, always works outside the medical system. "We learn from other midwives, we don't work in hospitals. It's mostly a lot of self study and apprenticeship," Denise says. "I call myself a lay midwife, but technically I do have a Certified Professional Midwife certification." Passing the CPM test is a way for independent practitioners to get professional recognition through the North American Registry of Midwives, and in some states a CPM can practice legally. Virginia recently started allowing CPMs to be licensed, but, Denise says, "I will be perfectly honest, I don't mind being illegal.
"The reason women come to us in the first place is that the licensed practitioners' hands are tied in many ways," she continues. "Hospitals are now discouraging VBACs [vaginal births after cesarian], not delivering breeches, and doing everything they can to give you that first C-section, and the midwives who work there are bound by hospital policy. It's very distressing. People come to me because they need to get outside the system to birth appropriately."
Denise sees about 120 patients a year: "Sometimes it's people who have had previous traumatic experiences in hospitals, but I do have a lot of religious women and women who are just very comfortable giving birth. I think I get a lot of religious ladies because they don't deify doctors as much as the rest of us might--they feel like they can trust a different kind of power to see that their birth goes well. I do get all different persuasions: Christian women, Orthodox Jewish women, Muslim ladies that come here in the whole burka business." Furthermore, she has seen "nurses who have home births, physicians, wives of physicians. They are intimately familiar with the medical model and realize that it is a better choice to birth at home.
"In my opinion the only reason to give birth in a hospital is to get pain medication," she says. "There's really nothing else they have to offer you. It's safer at home, or at least as safe, and some studies show it's significantly safer. People always say, `Well, what if something happens?' Nobody ever asks that same question about hospitals, because they assume that if you are at the hospital then they are going to take care of it. We have one of the highest infant mortality rates in the developed world, and it's not because of home births--how could it be, there are so few--it's because of hospital births."
With only 1 percent of births in this country taking place outside a hospital, that means when mothers and babies die in the United States, the vast majority are doing it hospitals. "Well, when 10 percent of my patients who come through my door have no prenatal care at all, that would give some of the answer," Mercy's Atlas explains. "Other industrialized countries give prenatal care. I think the fact that the US doesn't have universal health care is the main factor [in elevated maternal and fetal mortality and morbidity rates]."
Muhlhan and Denise each end up transporting less than 5 percent of their laboring home-birth patients to the hospital. They report cesarean rates of 3.5 percent, meaning that 95 out of 100 patients in their care will deliver at home and 97 percent will deliver vaginally.
Denise's low C-section rate is one reason Barbara Stratton chose Denise to deliver her second baby at home after a traumatic C-section with her first. The other reason was she had little choice: "I wanted a VBAC and I didn't trust that I would get it in the hospital."
As liability-leery hospitals increasingly limit or even ban post-cesarean vaginal deliveries, home births after cesarean are becoming increasingly common.
"It's not like I thought, Woo-hoo, I have a scar on my uterus, let's go give birth at home!" Stratton says. "I knew that risk of uterine rupture was there, and if you rupture in labor, the best place to be is not at home. But in my mind the risk of what they could do in the hospital to actually raise my risk of rupture, like artificially breaking my bag of waters, using induction or augmentation drugs, ending up with an unnecessary C-section, I felt that outweighed my risk of the very small chance of having a uterine rupture at home."
Mary Haber also chose Denise to deliver her second child, in April. "I am not radical" she says. "I really want to be safe. And I chose home birth with [Denise] because I knew she would transport the moment she suspected a problem. She is not going to take that risk for me, for the baby, or for herself." Haber had given birth to her daughter Ella in a birthing center; the closest one to Baltimore, it was still an hour away. "I loved the place and loved the midwives, but I did not love the drive," she says.
So for Haber's second birth, she sought options closer to home. "It just came down to I don't want to disappear from Ella's life for two days, or even 12 hours, and come back with a new person," she says. "It would be the biggest shock of her life, not being part of that experience. I didn't want her to be there so much as to have the choice to be there. And it turned out--this is the irony--that I was making such loud horrific noises that she didn't want to come anywhere near."
As soon as Caleb came out, however, Haber felt nothing but "pure bliss.
"When I tell you it was the perfect experience, that doesn't mean that it didn't hurt," Haber says. "There were moments I thought I might die, that's how bad it hurt. But birth is such a paradox, because it is simultaneously the most blissful and most painful experience.
"It still hurts like hell, no matter where you give birth."
© 2008 Baltimore City Paper