Homebirth revisited

As part of my psychology course, we had to write a paper on the topic of our presentations for class. Since I presented on birth, this left me with a lot of good options. I was considering writing about VBAC but in the end, decided to focus on home birth safety.
I started researching and realized there were a lot of articles on the issue and got very involved contrasting and comparing different studies. Finally, I realized this was taking up too much of my time. The paper was only supposed to be 3 to 5 pages and I was getting carried away.
So I forced myself to focus only on two articles, including the infamous "Wax" study. After obsessing about my bibliography for way too long, I finally handed it in today. Now all I have left is my final and I will have successfully completed my first pre-requisite. 
The paper is too long to post but I will share some excerpts here. If you are interested, you can comment here or email me and I will send you the whole thing. Without further ado:

...The results showed that the rate of perinatal death per 1000 births was similarly low in all three groups.  It was .35 for planned home births, .57 for planned hospital births attended by a midwife, and .64 for planned hospital births attended by a doctor.

78.8% of the women who planned to give birth actually did, the other 21.2% were transferred to the hospital. The rate of interventions, including fetal monitoring, episiotomy and cesarean section, was significantly lower for the women who had planned to birth at home. Additionally, adverse maternal outcomes such as postpartum hemorrhage or third degree perineal tears were less common at home. The same goes for adverse outcomes for the newborn, such as birth trauma, required resuscitation at birth, meconium aspiration and others (Janssen et al., 2009, p. 379). The full charts comparing birth outcomes as well as level of intervention can be found on page 381 of the article....

In summary, Janssen et al.’s (2009) study showed that planned homebirth with a registered midwife is associated with “very low and comparable rates of perinatal death and reduced rates of obstetric interventions and adverse maternal outcomes compared with planned hospital birth attended by a midwife or physican” (p. 383)....

In conclusion, Wax et al. (2010) repeat that there is significantly less maternal and newborn intervention and morbidity in homebirths, especially if they are attended by highly trained and regulated midwives who are integrated into the healthcare system. Unfortunately, this is not always the case in the United States because midwifery is not regulated the same way in every state (p. 243.e7).

This rate of low intervention makes sense because women who chose homebirth do so in part to avoid the many interventions they may be subjected to in a hospital setting. Women who birth at home are considered to have low obstetric risk and so are more prone to having more favorable outcomes. Additionally, midwives have a different model of care than obstetricians, which has been shown to consistently lead to less medical interventions and improved perinatal outcomes (Wax et al., 2010, p. 243.e7)....

Giving birth is a very important milestone in the lives of all women. There are many physical, emotional and psychological aspects that need to be taken into account when choosing a care provider and a place of birth.  Most women feel that their needs will be best met in a hospital setting. Both articles state that there is an aspect of self-selection present in homebirth. Women who choose homebirth are looking for a different model of care and for a lower level of medical intervention that not all pregnant women are comfortable with.

While homebirth is not the right decision for all women and the United States will not be encouraging the midwifery model of care like other European countries, an analysis of the available data does indicate that planned homebirth with a highly trained and certified midwife is a safe and viable option for the women who chose it. 

Homebirth- Part 1

Before writing about homebirth, I want to stress that I am not trying to convince anyone to have a homebirth or that homebirth is the only/optimal way. I strongly believe every woman needs to educate herself and make the choices that work for her and her family. My aim is just  to show that homebirth is a viable and safe option for most low-risk women.
When discussing homebirth and its safety, I am referring to planned homebirths attended by certified and licensed midwives, whether they be CNM (certified nurse midwives) or CPM (direct-entry midwives). I do not mean accidental homebirth, where the woman did not make it to the hospital in time, or unassisted childbirth, which is a whole topic onto itself .
A certified nurse midwife has undergone rigorous training and can provide pretty much the same care as doctors- she can monitor the baby's heart rate, give IVs of fluid or antibiotics if necessary, repair any tears, administer pitocin to help postpartum bleeding, do newborn assessment as well as neonatal resuscitation. What a midwife cannot do is administer an epidural or perform a C-section.
Study after study has shown that homebirth is as safe, if not safer than birth in hospitals. The neonatal and maternal mortality rates at home are the same to those in hospitals. If you would like to see a study that backs this claim up, click here. Another study done in the Netherlands can be found here. You can find links to other studies in this post.  Intervention rates of home births, as you can imagine are much lower- To quote one above mentioned study
Individual rates of medical intervention for home births were consistently less than half those in hospital, whether compared with a relatively low risk group (singleton, vertex, 37 weeks or more gestation) that will have a small percentage of higher risk births or the general population having hospital births (table 3). Compared with the relatively low risk hospital group, intended home births were associated with lower rates of electronic fetal monitoring (9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean section (3.7% versus 19.0%), and vacuum extraction (0.6% versus 5.5%). The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women."
Additionally, here is a study that finds the midwifery model of care to be superior to the other models, in terms of outcomes for mothers and babies.
In case you are wondering what the Midwifery model of care is, here is an excerpt from the website of the Midwives Alliance of North America:

Midwives Model of Care™
The Midwives Model of Care™ is based on the fact that pregnancy and birth are normal life events. The Midwives Model of Care includes:

• monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle
• providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
• minimizing technological interventions and;
• identifying and referring women who require obstetrical attention

The application of this model has been proven to reduce to incidence of birth injury, trauma, and cesarean section.

The Midwives Model of Care definition above is Copyright © 1996-2001, Midwifery Task Force, All Rights Reserved.

I don't want to bore everyone here with statistics, and there is no need to reinvent the wheel. There are many excellent websites that have great information about homebirths, you just have to find them. Here are just a few:


Choices in Childbirth
NY Homebirth Midwives
Bring Birth Home
Why Homebirth- an article in midwifery today


Coming up in Part 2- "What if something goes wrong/Thoughts about Risk" and "How exactly does this work?"

Busy Day

Today was going to be the day when I finally post some info on homebirth...but it has been a busy day and my bed is calling. In my quest to get back to a normal schedule, here are some of the things I accomplished:
-buy Channukah presents for the kids, although I still need something for Y.
-buy a pretty sweater for myself (thanks Mom!)
-pick M up from school. This is totally worth it because he is so excited to see me. He says, " My Mommy's here with my new baby brother!"
-cook food for shabbos AND dinner
- pick up A from school as a surprise and have her proudly introduce Baby AY to her Morahs and friends
- the regular homework/dinner/bath/bedtime craziness
-finally order thank you cards on snapfish with this cute picture on them. Plus I had a 50 percent off coupon.

- hold this cute baby for about two hours straight because 8 30 to 10 30 seems to be his cranky time.
Now that he has finally fallen asleep, I am going to take this as my cue to try and get to bed too.
But to get things started a little bit, I'll share one great article about homebirth.- Why women should not fear homebirth  by Mayim Bialik. I hope some of you read it and share your thoughts

AY's birth story

My doula Leda came for a postpartum visit today and presented me with a lovely birth story. This inspired me to finally write down my own version. Note- if you do not like birth stories and do not want to read about mucous plugs, contractions and amniotic fluid, stop reading right now. Otherwise, consider yourself warned and read  on:
During this pregnancy, I started having Braxton Hicks/ pre-labor contractions pretty early on, around 34 weeks. I was surprised, but my midwife Miriam reassured me that it was normal for symptoms to appear earlier in subsequent pregnancies. On November 7th, in my 36th week, I had a day of more intense contractions and all around weird sensations and I thought I may be in labor and that my water had broken (it had not). The sensations went away in the evening though and for the next few weeks, I went about my regular business, having some days with more contractions, others with less. I tried to rest up more, especially at nights. I always knew the contractions were not real labor because they did not hurt that much and because they stopped when I was lying down.
I saw my midwife Wednesday before Thanksgiving and she said everything looked great. We scheduled our next visit for Thursday, December 1st, my due date. My husband laughed and said there was no way we were still going to be seeing her pregnant that day.
Friday November 25th started out as a pretty regular day. The kids were all home so we spent time at the park in the morning and then the afternoon getting ready for shabbos. A little bit after candle-lighting, I noticed that I was having a lot of discharge, more than usual. This continued on for most of the evening so I asked my husband if I could call the midwife just to check in and see if it might be amniotic fluid. I told her what was going on and she told me she thought it was my mucous plug and not amniotic fluid. She also told me how to check to be sure, to go to bed early and call her if anything changes.
I went to bed early and had a pretty good night's sleep although I just felt something was going on. I was not having a lot of contractions, but something felt different. I also remember having a few contractions lying down and thinking it was weird, because I had never had contractions in bed.
Shabbos morning I woke up and soon after started having real contractions. They felt different than the Braxton- Hicks because they were stronger, although still not very painful. They were coming about every 15 to 20 minutes. I told my husband to go to shul but to make sure the janitor would pick up the phone in case I needed him. I was not sure if I should go to shul, but once I saw that the contractions were still irregular and not hard to deal with, I decided to take the kids. I figured it would distract me and also keep them busy. It is hard for them to be home all day so I wanted to take them out.
Shul was pretty uneventful. We only went around 10 45 and left about 12  so we were not there for that long. I was able to daven and interact with people at the kiddush after, while every 20 minutes or so taking 45 seconds to surreptitiously breathe through a contraction. Around 12 I decided it was probably best to head home. We then had a pretty normal shabbos lunch. I wanted to go about with my routine as much as possible until I felt like I could not anymore. So I served everyone lunch and I ate a good meal to make sure I was well nourished and hydrated for labor. We sang songs and talked about the parsha with the kids.
The contractions started feeling stronger and coming closer together. At some point my husband walked into the kitchen while I was leaning into the counter and breathing/swaying. He shook his head and said something like, "It's a good thing you know about this stuff and are calm."
By now I knew this baby was coming that day, it was just a question of when. We discussed dropping the kids off by friends but there were some teenage girls coming over to play with them around 3, so we decided to wait and see what was going on once the girls left. Maybe we could stall till bedtime or at least till shabbos was over when we could distract the kids with the iPad.
We finished lunch around 1 45 and I told my husband to go rest because I could not sleep with contractions anyway. I decided to read on the couch while the kids played. The contractions were closer together when I was actively moving around so I was trying to stall a bit by staying lying down. The contractions were more uncomfortable that way. The kids still had no idea anything was going on. They did not really notice me breathing through contractions and I wasn't doing anything else at this point.
When the girls arrived to watch the kids around 3, I excused myself to go lie down. I called Miriam to tell her what was going on. Because the contractions were still spaced out when resting, she thought I probably still had some time but told me she would be close by, awaiting my call. I was a bit disappointed because I thought she would come right over, but decided Miriam was probably right and there was still more time.
I tried to lie down and rest a bit, but I was too excited by all the happenings. Plus I could not stay lying down during the contractions which were now 7-8 minutes apart and getting stronger.
The turning point came at 3 45 when I went to the bathroom and all of a sudden, started having contractions every 2-3 minutes. I stayed in the bathroom for a bit because I felt more comfortable there but when I saw that they were not slowing down and also thought my water might have broken, I realized I needed to call Miriam back.
I called Miriam around 4 10 and told her I was ready for her to come ASAP. I also called my doula Leda who happened  to be on her way to the West Side anyway. She said if I was calling her on Shabbos, something must really be going on. It was a little strange making all these calls on Shabbos, but I knew it was the right thing to do. If anything I probably should have called earlier!
From here, everything went really fast. My husband asked the girls to stay so he could daven mincha. He would watch the kids till the end of shabbos and then put on a video for them. There was only 45 minutes left till the end of Shabbos so that seemed to make sense.
He also brought me some water. Meanwhile I decided to get in the shower to cope with the contractions. By now they were really intense but thankfully they were very short, maybe 30 seconds or so. Maybe 45. I wasn't timing anything at this point, just trying to get through one at a time. The shower was incredibly helpful. I let the water run down my back while leaning into the wall and moaning.
I could have just stayed there. I did not really want to move but I realized I was close to pushing and decided to call Miriam again to make sure she was really coming! Just as I came out of the bathroom, Miriam walked in. It was 4 45 and I was so relieved to see her. I told her I thought I was almost ready to push and she took one look at me and agreed. She checked the baby's heartbeat and said it sounded great.
About two contractions later, Leda walked in and I started to feel a real urge to push. At 4 57, with one of my first pushes, my water broke. At first I was pushing standing up but then I decided to move onto my bed. This was my first time pushing self-directed rather than the counting way they do in the hospital. It felt better this way to push when I felt the need to, rather than when the doctor tells you to. I could feel the baby moving down, although I could not see anything because of the position I was in.
At this point, Leda asked if she should go get my husband and take over the kids. I was very much in the moment and did not want her to leave my side. I also was not sure how he could be in the room for modesty reasons. Looking back, I regret that decision. I did not realize how soon the baby was going to be born and I wish he could have been there. I was also just really focused on getting the baby OUT. Throughout my labor I had been pretty calm and in control, even through what must have been transition while I was in the shower. But now I was starting to lose it and just wanted it to be over. With every push I kept asking if the head was crowning yet. I actually only pushed for 10 minutes but it felt like forever at the time. Finally I felt the baby crowning and the head emerged. I was assuming that from that point on, he would slide right out like the others did, but instead I felt incredible pain as his shoulders and the rest of his body came out. It was the only time in my labor when I actually screamed really loud. I remember saying, "What's going on?" because I thought something was wrong.
But then the baby was here! Miriam and Leda helped me turn from my knees onto my back and handed me the baby. They covered us in towels so we would be warm and I got my first look at the baby. I checked the gender and announced "It's a boy". He was covered in vernix and cried right away. In fact, Miriam said he started  making sounds before his whole body was even out. She also told me that the pain I had felt was him coming out straight with both shoulders, as opposed to rotating one shoulder at a time, so she had helped him along a bit. Even so, I only had a minor tear that did not need any repairs. The baby looked great. His APGARS were 9 and 10.

As soon as the baby was born and I was covered, Leda went to get my husband so he could meet our new baby. It was a very special moment. We were waiting to cut the cord until the placenta was out so I just lay there with the baby on me, getting to know him. I felt the cord pulsating, which was pretty cool. The baby cried a bit and at first he was not so interested in nursing but after 20-30 minutes, he latched on like a pro.
Soon after,I delivered the placenta and we cut the cord. The kids came in at some point to meet their new baby brother. They were very excited.

After about an hour, Miriam examined me to make sure my bleeding was normal (it was) and did a newborn exam on the baby. He measured 21 inches and weighed in at 8lbs 6 oz, although I think Miriam's scale might have been a bit off and he was probably more like 8 lbs 2 oz. He passed his newborn exam with flying colors- his color was good, all his reflexes were in order and, as a bonus,  he was beautiful!
I could not believe how normal everything had felt. I also was feeling very good for just having given birth. When I told Miriam that my perineum felt a bit sore, she laughed and said, "Well you did just have a baby come out of there!"  I got up to take a shower, while Leda and Miriam changed the sheets and cleaned up the room. The mess was pretty contained and it was easily done. I also got dressed so we could take some pictures with the baby.
Miriam left around 6 45 after making sure we were all settled and okay. She told me to call her anytime if I had any questions and that she was available to come back if I needed her. Leda stayed for a bit longer. She got some laundry started and brought me dinner- orange juice and cereal.
My husband put the kids to bed and called our parents to share the news. By 8 pm, everyone had left, the kids were sleeping and I was lying in bed with the baby. I marveled at him and at how smoothly things had gone. It's truly a miracle how one moment you are pregnant and then all of a sudden there is this little person. We felt incredibly blessed.

PS: I know a lot of you are curious about the logistics of home birth. I plan to do a more comprehensive post about it in the next few weeks, including frequently asked questions, the safety of homebirth, etc. so stay tuned!

Homebirth

For those of you who have been up at night worrying about the future of midwifery in New York, I am happy to announce that the Midwifery Modernization Act has passed and now just needs to be signed by the Governor. Homebirth is once again legal in New York.
In that spirit, I would like to share a video of a homebirth that I came across on the lovely internet. This video is part of "A Baby Story" and features an orthodox Jewish couple having their second child at home with the help of , you guessed it, a skilled midwife.
No worries, the filming is done very modestly and there are no close ups of the baby being born. Still a wonderful video that shows how normal and safe homebirth can be. I am including the first part, and the rest of it can be found on youtube. Enjoy!

Support the Midwifery Modernization Act

I haven't really blogged about this but there has been a lot going on in NYC in the midwifery field. The closing of St Vincent's Hospital a few months ago was a big blow to the natural childbirth community as it was the hospital most supportive of intervention-free birth. Additionally, it was the back up hospital for the NYC homebirth midwives. Any women who had to be transferred were usually sent to St Vincent's because the staff had a good relationship with the homebirth midwives.
In New York State, midwives are not allowed to practice without a WPA- written practice agreement that is signed by an Obstetrician. This is a document stating that the midwife has a relationship with this specific doctor, and that the doctor takes responsibility for the midwife's patients if complications arise. The midwives who attend homebirths had WPAs with the doctors at St Vincents. When the hospital closed, the homebirth midwives lost their WPAs. No other doctors in other hospitals were willing to sign a WPA for them, so for the past few months the midwives have essentially being practicing illegally. Nothing has changed about these midwives' skills in delivering babies, they are just missing a form.
Over the past few months, doulas, birth advocates and midwives have been lobbying hard for the Midwifery Modernization Act (MMA) which would give certified midwives the ability to practice without a WPA. It has gone through several rounds and revisions and will hopefully be brought to a vote on Monday in the New York State Assembly.
This is exciting news. While home birth is definitely not for everyone, it should be a legal option for the women who want it. Even for midwives practicing in hospitals, this act would give them more independece and legitimacy as valued providers of care for women.
I am curious to see what will happen on Monday- for more information and to find out how you can support the bill, check out Free Our Midwives.