I've been trying to look for the source of a pithy quote I heard a while ago comparing the environment for labor and sex, but I haven't been able to find it...so I'm going to quit searching for it and just paraphrase. It goes something like...
A good labor requires the same kind of setting as is necessary for a good intimate experience:
love,
safety,
and privacy.
A beautiful sentiment that I think is so true. Choosing a setting for birth that aligns with these ideals is something specific for a laboring woman and her family. For many, it is a simple decision. For others, it requires delicately balancing the three elements that makes a beautiful birth.
Popular practice
To quote the 2008 Milbank Report on Evidence-based Maternity Care:
Evidently, birth is a big deal...but it could be simpler than the complicated mess we've made it out to be. So let's find you a place that works out best for your family.Childbearing is a major life passage for over 4.3 million mothers, newborns, and families annually in the United States. Within the U.S. health care system, childbirth is the leading reason for hospitalization. About 23 percent of all individuals discharged from hospitals are mothers or newborns. The current style of maternity care is procedure-intensive, and six of the fifteen most commonly performed hospital procedures in the entire population are associated with childbirth. Cesarean section is the most common operating room procedure in the country. Only three reasons for outpatient visits involve more visits annually than maternity care (prenatal and postpartum visits combined): general medical examination, progress visit, and cough.
So, what are our options? Hospital, birth center, or home. Let's look at these options individually:
Hospital
As mentioned in the last post and evidenced by the above quote from the Milbank report, this is by far the most popular option in the U.S. For women whose pregnancy and impending births are considered to be "high risk" (e.g., pre-eclampsia, baby has a congenital heart problem, severe oligohydramnios, etc.) it is most likely that they are recommended a hospital birth. That makes good sense.
There are other cases where a woman, under the care of midwives, was planning to give birth at home or at a birth center but she and/or the newborn is determined to need higher level care, she would also go into the hospital. That also makes good sense.
But normal birth hasn't always taken place in the hospital. When did this change happen? In 1900, less than 5% of American women gave birth in hospitals. At the turn of the century was when a whole slew of events took place to sway more families into giving birth in the hospital setting. These events included:
...just to name a few.
- better roads, which made the trek to the hospital easier
- employee medical programs were established, incentivizing the use of licensed medical professionals and hospital facilities
- the "twilight sleep" birthing trend became popular and women [who could afford it] thought, "If I could do this without pain, heck, what's stopping me?!"
- poor public hygiene due to overcrowding made the home a less favorable environment for birth and this caused the rate of infant and maternal mortality to rise
- the American Medical Association grew in size and power in the political arena
With upper class women heading the movement of hospital births, their less financially fortunate counterparts see the trend as being a positive thing. The same kind of thinking applies to the trend shifts for breastfeeding (i.e., the use of wet nurses and the eventual use of formula). Furthermore, these trends are not only contained in the West, but are also perpetuated through colonialism. Even though the imperialism era is considered "over," we continue to see some of these practices (e.g., hospital births, routine episiotomies, lithotomy positions, routine cleaning of the uterine cavity during a Cesarean section, etc.) in areas affected by colonialism long after colonists have moved out of the area.
As an aside, I have heard that labor and delivery units in hospitals receive the most funding to "make things pretty and pleasant" because studies have found that moms are usually responsible for making decisions regarding health and where to go for care. So if moms have a good experience during birth at a certain hospital, they are more likely to choose that facility as a care place for their whole family. Interesting, huh? Lots o' money to be made, m'friends!
Anyhow, to summarize, we can look at some of the pros & cons of hospital births:
Pros:
Cons:
- "If something goes wrong, the most advanced help is readily available."
- Staff ready for normal and complicated/high-risk births.
- More options for pain management
- Insurance more likely to cover hospital births than births in other settings.
- "If something goes wrong, it was probably the hospital-based interventions that caused it."
- Higher likelihood of continuous monitoring and interventions (e.g., augmentation of labor by pitocin, forceps, etc.)
- Requires travel from home
- Because of the high number of healthcare staff present (OBs, L&D nurses, baby nurses, students, etc.), family's wishes may not be honored because of convoluted communication.
- If you give birth in a teaching hospital, you'd better believe your vajayjay is going to be poked and prodded by lots and lots of strangers.
Birth center
If you want to give birth in a peaceful, home-like environment but don't want to wash the placenta remnants out of your bedsheets, a birth center might be a good option for you. All birth centers come equipped with IV fluids, isolettes with a warming mechanism for newborns, resuscitation equipment, and most will have glorious, glorious bath tubs for your labor. (You can read more here about the Washington State requirements for the equipment and supplies that a birthing center must have.)
Birth certificate data on nearly 2.3 million singleton births in 2008 in the United States showed that about 10,700 women, or less than 1 percent (0.47 percent), delivered in a birthing center, usually a standalone facility staffed by a midwife and in close proximity to a hospital in case of emergency. The number of birth center births and home births in the U.S. in recent years are pretty comparable.
A growing trend these days is birth centers that exist within a hospital. Do you know what these birth centers were called before? Uh, maternity wards. That's right. But because of more evidence/marketing data showing that women feel better with a big ol' laboring tub and less interventions, hospitals are shifting the way their maternity wards operate. Some of the things that qualify a labor & delivery department in a hospital to be called a "birthing center" could include queen-size beds, jacuzzi tubs, maybe some sort of separation from the rest of the sick part of the hospital, and a large midwifery practice.
Onto the pros and cons of birth centers:
Pros:
Cons:
- Without health insurance, costs less than hospital birth.
- Less interventions than hospital setting and more freedom in moving around during labor and even birth.
- You can choose who attends the birth (including children).
- No need to do the laundry. :)
- So, did I already mention awesome bathtubs?
- Requires travel from home. And after you have given birth, you can only typically stay for 4-6 hours (which is usually not a problem with most families).
- In case of an emergency, delays caused by the transport might prove to be costly.
- Less options for pain management. Your midwife can offer IV pain killers but no epidural.
- Insurance may not cover it.
Home
A 2003 study of nearly 3,000 birth center births versus hospital births found that not only did both places resulted in equally safe outcomes for both mothers and babies, but the women who gave birth in birth centers wound up with fewer epidurals and cesareans (each having varying high rates of associated complications).
A more recent study found that babies born at home have a higher risk of complications, including lower Apgar scores, unless the birth was attended by a Certified Nurse Midwife. Being trained as both a nurse and a midwife, these professionals have a well-rounded knowledge of medicine as well as the science of birth to equip them for dealing with emergent situations. This study also found that birth outcomes were similar for babies born at the hospital as compared to birthing centers.
In general, however, I have found that it is difficult to track down an honestly good research study to fairly compare birth in these three settings. Data is often convoluted with home births that were not intentional, those that were unassisted, c-section rates that do not appropriately attribute emergent home/birthing center transfers, etc.
The documentary Business of Being Born was when I first heard the phrase "cascade of intervention." Take a look:
From my experience in the labor & delivery departments of several area hospitals, I have seen this cascade far too many times. It doesn't always end up in a C-section, but interventions are almost guaranteed in a hospital setting and when things go South, the phrase, "We need to do what is best for your baby" gets tossed around a lot...
As a final note, I want to point our attention to this number: 41. That is the position the U.S. is in with the maternal mortality ranking. This means that if you are giving birth in the top 40 countries, you have a better chance of surviving childbirth. The CDC further states that many of the maternal deaths in the U.S. are completely preventable.
Does that make any sense? How do we spend the most money and get such sh*tty outcomes?!
Our experience
We chose to have both Penelope and Camille (and eventually Marcus) at the Family Beginnings "Birthing Center" at Group Health Central in Seattle. In an effort to piss off a large number of people in one single shot, I have been heard comparing the choice of birthing at a birth center to buying a townhouse, using a hybrid cloth diaper, or driving a hybrid car. And, ha! I've bought a townhouse-ish condo, used hybrid cloth diapers, and recently bought a hybrid vehicle! So, really, joke's on me. What I meant with the comment above is that birth centers serve as a safe compromise between hospital and home birth. My criticism here is that sometimes these middle-ground compromises are neither satisfying nor are they the best option for you and your family. Nonetheless, you need to make the decision that is best for your family. And oftentimes that involves a lot of compromising.
For me, I would like to have a home birth. As much as I like to go out, I am not a fan of traveling when I am in pain. I like to be in a comfortable home environment where I know that nobody has C.diff or that a colostomy bag had busted just down the hall. A friend of mine (who is now a Certified Nurse Midwife) once said that she would like to have a home birth because that is where she knows she has no option for an epidural, which she is well aware is associated with many complications. Another reason for a home birth is that after I gave birth to Camille in the hospital, I was given a UTI by a not-so-careful nurse who failed to catheterized me in a sterile manner. This wouldn't have happened at home...where I think I would feel more naturally in my element and in control of the situation so that I could refuse unnecessary procedures.
Chin is less keen with the idea of a home birth because of the "just in case sh*t happens" scenario.
I get that. I'm pretty cautious, too.
"What if something unforeseen happens? Like baby needs a lot more extra help." We opted not to do any prenatal screening for genetic abnormalities (despite of, or perhaps because of, what happened with Penelope). So what if baby has some strange complication that we weren't aware of? What if I run a high fever and need an immediate administration of an IV antibiotic? I don't want to be transferred! Not all of these concerns are rational, but they are feelings...which are not always based on logic but are valid all the same.
As kind of an aside, one thing to consider if you are giving birth in the hospital is what kind of care is available should your newborn require special medical attention. There are three types of nurseries available:
Anyway...
Weighing our pros and cons, we decided to give birth at the Group Health Central birth center because:
My opinion is that when we choose the care provider or setting for birth, too many women and families operate out of fear instead of rationally thinking through the evidence. We are already irrational beings to begin with. Throw in birth hormones and family pressure and pain...and we are a mess! It's a very vulnerable time, really. Which is not surprising that when the sacred bubble of this birthing experience is breached, some women refer to it as "birth rape."
My best advice to those who are trying to choose a birth setting: choose a provider/group of providers that you trust. I think it is paramount that in this vulnerable scenario, women are surrounded by people who (1) know their stuff and (2) are truly supportive of her and her family. From there, consider your options and, with the help of those you trust, make an informed decision about the birth setting that is the most ideal for your family.
I wish you the best birth!
Acknowledgements & Resources
The same 2008 study with singleton births as cited above in the birth center section found 12,400 women (0.54 percent) gave birth at home intentionally. This number has been rising by nearly 30 percent in recent years. Nonetheless, home births in the U.S. is still a very controversial topic. Listen to these discussions between Ricki Lake and the cast of The Doctors.
Part 1
Part 2
*shudder*
[I know many of my friends watch this show. But my humble opinion is that The Doctors sucks on many, many levels...beginning with evidence-based practice vs. opulence-inspired health. Anyway...]
More controversial yet is the movement of unassisted home births. Unassisted home birth is exactly as it sounds: birth at home without the assistance of any trained professionals. This topic is controversial because birth without assistance not only puts mom at risk but also the fetus/newborn. If complications arise, a lay person who's in that chaotic birthing time may not have the capacity to get help in time.
But just the idea of home birth is squeamish to many Americans. We allow Hollywood to educate us on the practice of home birth and birth in general...like in this recent movie, The Backup Plan, for instance. I wonder if the movie was funded by ACOG.
Anyhow, pros & cons of home birth:
Pros:
- No need to leave home and risk shifting the flow of labor. And once you're done, you're already home!
- Without health insurance, home births cost the least out of the three options.
- Least amount of intervention.
- There is a lot of freedom in moving around in labor (no continuous monitoring), you can eat and drink freely, and you can choose who attends the birth (including children).
- Most home birth midwives are cool with water births. If giving birth in a hospital setting (or even some birthing centers), water births are often not allowed due to the pediatric team's discomfort with the idea of baby being born into water.
- If your home is decently clean, chances are you have a much lower risk of infection giving birth there as compared to at a hospital environment. The hospital is where sick people go!
Cons:The evidence
- Requires a decently clean environment...and you'd have to do the laundry. Doh!
- In case of an emergency, delays caused by the transport might prove to be costly.
- You have a smaller team of care providers with you (one midwife, possibly two, and hopefully a doula). It is crucial that they know what the heck they're doing in the case of an emergency. If the main midwife in charge is clueless, you are not in an environment where there could be a quick turnaround in getting other experienced staff involved.
- Even less options for pain management.
- Not all insurance plans will cover home births.
A 2003 study of nearly 3,000 birth center births versus hospital births found that not only did both places resulted in equally safe outcomes for both mothers and babies, but the women who gave birth in birth centers wound up with fewer epidurals and cesareans (each having varying high rates of associated complications).
A more recent study found that babies born at home have a higher risk of complications, including lower Apgar scores, unless the birth was attended by a Certified Nurse Midwife. Being trained as both a nurse and a midwife, these professionals have a well-rounded knowledge of medicine as well as the science of birth to equip them for dealing with emergent situations. This study also found that birth outcomes were similar for babies born at the hospital as compared to birthing centers.
In general, however, I have found that it is difficult to track down an honestly good research study to fairly compare birth in these three settings. Data is often convoluted with home births that were not intentional, those that were unassisted, c-section rates that do not appropriately attribute emergent home/birthing center transfers, etc.
 |
The documentary Business of Being Born was when I first heard the phrase "cascade of intervention." Take a look:
Changing into the hospital gown
Putting on the hospital gown shifts the balance of power from woman to hospital. Her perception of herself shifts, and she sees herself as a patient, in the care of “experts,” rather than as a woman confident in her ability to birth on her own terms. This simple act may also make the woman feel less comfortable, feel cold or she may be concerned about modesty as well, which increases stress and makes relaxation harder.
Putting on the hospital gown shifts the balance of power from woman to hospital. Her perception of herself shifts, and she sees herself as a patient, in the care of “experts,” rather than as a woman confident in her ability to birth on her own terms. This simple act may also make the woman feel less comfortable, feel cold or she may be concerned about modesty as well, which increases stress and makes relaxation harder.
Continuous Electronic Fetal Monitoring (EFM)
The major effect of continuous EFM is that it keeps the mother immobile in bed. The use of EFM is not evidence-based, and has had no effect in improving outcomes for babies. Evidence shows that Intermittent EFM with a handheld Doppler is just as effective as continuous EFM at identifying babies in distress. The only effect continuous EFM has had is that it has increased the cesarean section rate.
The major effect of continuous EFM is that it keeps the mother immobile in bed. The use of EFM is not evidence-based, and has had no effect in improving outcomes for babies. Evidence shows that Intermittent EFM with a handheld Doppler is just as effective as continuous EFM at identifying babies in distress. The only effect continuous EFM has had is that it has increased the cesarean section rate.
Getting the IV
IV’s restrict a woman’s mobility and make it easier to administer fluids and medications that interfere with natural birth. Women need to be free to move their bodies throughout labor, and should be encouraged to change positions frequently. Having an IV can hinder that. The IV is also simply uncomfortable, annoying and may interfere with her focus on relaxing with contractions as well and make holding hands with her support person more uncomfortable or impossible. Even a hep lock can be bothersome in the same ways. The perception that having an IV readily available is helpful in an emergency is not evidence based. Many times this IV port is not working well enough to handle an emergency and must be restarted.
IV’s restrict a woman’s mobility and make it easier to administer fluids and medications that interfere with natural birth. Women need to be free to move their bodies throughout labor, and should be encouraged to change positions frequently. Having an IV can hinder that. The IV is also simply uncomfortable, annoying and may interfere with her focus on relaxing with contractions as well and make holding hands with her support person more uncomfortable or impossible. Even a hep lock can be bothersome in the same ways. The perception that having an IV readily available is helpful in an emergency is not evidence based. Many times this IV port is not working well enough to handle an emergency and must be restarted.
Labor augmentation with Pitocin®
The use of synthetic oxytocin (Pitocin®) makes labor more painful for the mother, and more difficult for the baby to tolerate. There are studies that show pitocin may interfer with the body's natural ocytocin hormone production which may hinder the mother's natural efforts in the pushing stage, may contribute to postpartum hemorrhage and may interupt her bonding with her baby, contributing to postpartum depression. http://www.birthresourcenetwork.org/resources/54-pitocin-the-whole-story-
The use of synthetic oxytocin (Pitocin®) makes labor more painful for the mother, and more difficult for the baby to tolerate. There are studies that show pitocin may interfer with the body's natural ocytocin hormone production which may hinder the mother's natural efforts in the pushing stage, may contribute to postpartum hemorrhage and may interupt her bonding with her baby, contributing to postpartum depression. http://www.birthresourcenetwork.org/resources/54-pitocin-the-whole-story-
Pain relief
Because the contractions are so intense with Pitocin®, the mother frequently will choose to receive an epidural for pain relief.
Because the contractions are so intense with Pitocin®, the mother frequently will choose to receive an epidural for pain relief.
Restriction of movement
An epidural keeps a woman confined to bed for the duration of the labor and birth. Being unable to move restricts the woman’s ability to help her baby get into a good position for birth. It may also hinder the baby's ability to move, too.
An epidural keeps a woman confined to bed for the duration of the labor and birth. Being unable to move restricts the woman’s ability to help her baby get into a good position for birth. It may also hinder the baby's ability to move, too.
Contractions slow down
Epidurals can slow labor progress, which results in increasing dosages of Pitocin® to increase contraction intensity and frequency, which can lead to an even greater need for pain relief and greater risk of fetal distress.
Epidurals can slow labor progress, which results in increasing dosages of Pitocin® to increase contraction intensity and frequency, which can lead to an even greater need for pain relief and greater risk of fetal distress.
Progress slows or stops
Assuming the woman reaches full dilation, the epidural can interfere with the woman’s ability to push effectively.
Assuming the woman reaches full dilation, the epidural can interfere with the woman’s ability to push effectively.
Fetal distress
Hard contractions, combined with reduced blood pressure and the lack of blood flow to the baby, cause the baby to go into distress.
Hard contractions, combined with reduced blood pressure and the lack of blood flow to the baby, cause the baby to go into distress.
Cesarean section
After having exhausted all of the tools at the obstetrician’s disposal, this one option remains.
After having exhausted all of the tools at the obstetrician’s disposal, this one option remains.
(from novabirthcenter.com)
As a final note, I want to point our attention to this number: 41. That is the position the U.S. is in with the maternal mortality ranking. This means that if you are giving birth in the top 40 countries, you have a better chance of surviving childbirth. The CDC further states that many of the maternal deaths in the U.S. are completely preventable.
Does that make any sense? How do we spend the most money and get such sh*tty outcomes?!
Our experience
We chose to have both Penelope and Camille (and eventually Marcus) at the Family Beginnings "Birthing Center" at Group Health Central in Seattle. In an effort to piss off a large number of people in one single shot, I have been heard comparing the choice of birthing at a birth center to buying a townhouse, using a hybrid cloth diaper, or driving a hybrid car. And, ha! I've bought a townhouse-ish condo, used hybrid cloth diapers, and recently bought a hybrid vehicle! So, really, joke's on me. What I meant with the comment above is that birth centers serve as a safe compromise between hospital and home birth. My criticism here is that sometimes these middle-ground compromises are neither satisfying nor are they the best option for you and your family. Nonetheless, you need to make the decision that is best for your family. And oftentimes that involves a lot of compromising.
For me, I would like to have a home birth. As much as I like to go out, I am not a fan of traveling when I am in pain. I like to be in a comfortable home environment where I know that nobody has C.diff or that a colostomy bag had busted just down the hall. A friend of mine (who is now a Certified Nurse Midwife) once said that she would like to have a home birth because that is where she knows she has no option for an epidural, which she is well aware is associated with many complications. Another reason for a home birth is that after I gave birth to Camille in the hospital, I was given a UTI by a not-so-careful nurse who failed to catheterized me in a sterile manner. This wouldn't have happened at home...where I think I would feel more naturally in my element and in control of the situation so that I could refuse unnecessary procedures.
Chin is less keen with the idea of a home birth because of the "just in case sh*t happens" scenario.
I get that. I'm pretty cautious, too.
"What if something unforeseen happens? Like baby needs a lot more extra help." We opted not to do any prenatal screening for genetic abnormalities (despite of, or perhaps because of, what happened with Penelope). So what if baby has some strange complication that we weren't aware of? What if I run a high fever and need an immediate administration of an IV antibiotic? I don't want to be transferred! Not all of these concerns are rational, but they are feelings...which are not always based on logic but are valid all the same.
As kind of an aside, one thing to consider if you are giving birth in the hospital is what kind of care is available should your newborn require special medical attention. There are three types of nurseries available:
- Level 1 nursery - This is the nursery you see in the olden days where nurses will swoop in to save the pooped-out parents by taking the healthy newborn away for a number of hours during the postpartum period. The overwhelming evidence for better outcomes in rooming-in has more or less made these simple type of nurseries obsolete.
- Level 2 nursery - aka progressive or special care nursery (PCN/SCN). Instead of having a full-on neonatal intensive care unit (NICU), some hospitals only have a Level 2 nursery where they can take care of mildly complicated cases. Here, babies can be given supplementary oxygen, be tube-fed, and receive some IV therapy.
- Level 3 nursery - aka a NICU. A NICU is equipped to take care of basically all your little baby problems from needing sugar water to being on a ventilator.
Anyway...
Weighing our pros and cons, we decided to give birth at the Group Health Central birth center because:
- Our insurance will fully cover it. (Since Marcus will be born in 2012, our insurance will still cover everything at 100% and does not require a co-pay. After 2012, all bets are off.)
- Our families would flip if they hear that their grandchild was born somewhere outside of a hospital. And the headache that would cause is not worth it for us.
- We are working with a fantastic team of midwives who we trust and who we believe will honor our wishes.
- We are educated individuals and we are [mostly] aware of our rights, options, and the evidence behind perinatal practices. Should something come up in the hospital setting where we felt like we are strong-armed, we fully know we are the health care consumers and we are the ones ultimately making the decision. (Easier imagined in theory, I think.)
 |
| Thrilled |
My opinion is that when we choose the care provider or setting for birth, too many women and families operate out of fear instead of rationally thinking through the evidence. We are already irrational beings to begin with. Throw in birth hormones and family pressure and pain...and we are a mess! It's a very vulnerable time, really. Which is not surprising that when the sacred bubble of this birthing experience is breached, some women refer to it as "birth rape."
My best advice to those who are trying to choose a birth setting: choose a provider/group of providers that you trust. I think it is paramount that in this vulnerable scenario, women are surrounded by people who (1) know their stuff and (2) are truly supportive of her and her family. From there, consider your options and, with the help of those you trust, make an informed decision about the birth setting that is the most ideal for your family.
I wish you the best birth!
Acknowledgements & Resources
- Read more about the Milbank Report on Evidence-based Maternity Care here.
- A good guide to choosing a birth setting that is appropriate for your family plus the evidence behind the different birth setting options. Another nice one here. One more here. And there is yet another one coming soon.
- An interesting article on the importance of privacy in labor and how a good labor support system could help build this privacy for a laboring woman, even in a hospital setting.
- Great website on revealing the medicalization of birth with tangible recommendations of how to reduce your chances of getting into these situations.
- Take a survey and/or look up survey results from real people who reviewed providers (ObGyns and midwives) and birth settings (hospitals, birth centers, and home birth services).
- An extensive timeline of birth in America and its criticism.
- Some resources for each setting:
- Hospital:
- Here are the C-section rates for Washington hospitals and here are rates for Oregon hospitals (click here to see rates for hospitals in other states).
- An article written by my good friend Vina on how to increase your chance of giving birth naturally in a hospital setting.
- Birth center:
- Home:
- A blog on the safety of home births
- A blog on home birth horror stories and a critique of the pro-home birth evidence.
- A few short videos worth your time here, here and here. But you can find a lot more on YouTube, including footage of home births!
- I think this is a great article on the topic of "If I were home, I/my baby would have died." Not just an opinion piece, but an article that critically examines the evidence behind what people consider emergent situations and the causes of these disasters.
- The pictures are from here, here, here, and here.
2 comments:
You are awesome Bao! I'm totally with you on child birth options. I had never heard of C. diff until I picked it up having #1. Thank goodness he didn't get it too. That is why #3 was a "run through" delivery. I figured the faster in and out the less chance for infection in the hospital. 45 minutes in L&D and 8hrs in maternity (darn slow paperwork!). Can you/will you deliver in the water? I loved my waterbirth.
I do wonder who provided accurate APGAR scores for the home births that weren't attended by a CNM. Some are obvious, others are subject to interpretation, for instance I was surprised my very purple water baby scored well in coloration. The midwife knew that was healthy for a water birth. Of course I wouldn't advocate the giving birth alone in the woods idea anyway, I have great respect for nurse midwives and their skills.
Happy third trimester to you! I hope your family is well now.
No water birth for me since the pediatric staff at the hospital is not so keen on that idea. I can labor as long as I want in water, though. Not sure how long I want to spend laboring at the hospital...and considering that Camille's birth was super fast, I might just use the tub for postpartum soaking :)
Post a Comment