bearing blog

I got an email in my box a little while ago from a reader who wanted to know how Mark and I decided to plan home births:

 I was really interested in finding out that you have homebirths. I was born at home, and would love to have my baby at home, but I have had no luck convincing my husband of it….He's a Navy guy with an engineering/risk assessment background, plus doctor & nurse family members.  But I'm more worried about being pushed into unnecessary interventions anda c-section in the typical hospital setting which is my only option where Ilive. … My question is basically, how did you and your husband come to decide on homebirth? Having your scientific/engineering background, Ithought maybe whatever convinced you might also be helpful…

I wonder if maybe home birth types have a reputation for not being of scientific/engineering background?  Most of the home birth couples I know IRL include at least one engineer or scientist, although I admit there is a significant sampling bias in that, um, that is the kind of person we tend to hang out with.  Engineers and the people who marry them.

It has been a long time since we were deciding whether to try a home birth or a hospital birth, and I had to go to Mark and ask him:  "Remind me again, back before I got pregnant with Oscar, when I brought up the idea of having a home birth, did you agree right away?"

"Not right away, no.  I figured we would do the 'normal thing' and have the baby in the hospital.  And then you showed me what you'd been reading and I decided that home birth made sense."

Here's a slightly edited version of what I emailed back to the reader.

My first thought is that there isn't anything about BEING an expert in risk assessment (or statistics, or possibly even perinatal medicine!) that ought to make a person more or less likely to choose homebirth. I would hope it would make a person more likely to assess the risks accurately and dispassionately, but that doesn't mean he or she would come to a different conclusion. 

I know that Mark and I, after gathering some information, came to agree that homebirth probably had a higher-than-hospital, but still small, risk of death or serious injury to myself to the baby; but that the hospital had a MUCH larger-than-home, and in fact, quite large risk of many, many comparatively less serious problems and not a few moderately serious ones. The research I've seen since then seems to have borne it out. 

• In both homebirths and hospital births there is a small risk of neonatal death, and this small risk seems to be greater in homebirths.  (Some homebirth advocates deny this, but at least what I've seen over the past few years whenever I've looked has given me a strong impression that the evidence supports it.) 
• There is a hugely increased risk, in hospitals, of many annoyances and lesser-to-moderately-severe complications.For example, hospital births carry higher risks of infection, and enforced policies like fetal monitoring and things can slow labor which can lead to induction which can lead to distress, yadda yadda yadda. None of these things are likely to be fatal, but they can and do create smaller problems.

 A more serious risk, to me, was the risk of winding up with an unnecessary Cesarean section. Giving birth in an American hospital, you're looking at a 20-40 percent chance of a C-section depending on the hospital. That to me is unacceptably high, because I do not take the complications and side effects of C-sections lightly, especially as a mother who hoped to (at the time) and now has gone on to have several pregnancies. VBACs are difficult to get, and the riskiness of C-sections increase exponentially after the second.   (A mother who expected to have only one or two children might rate the riskiness of Cesarean section lower, and be more willing to have one even if it were possibly unnecessary.)

I also take very seriously the proper onset of the nursing relationship, which is more difficult to establish in the hospital environment, once you add up the effects of drugs, maternal discomfort in the environment, and hospital policies (and assuming that the homebirth team provides better lactation support than the hospital lactation support, an assumption which may or may not be true depending on the available options).  

People brush these things off – Cesareans, nursing difficulties caused by hospital policies — because they're so common. But looked at objectively they are quite serious and it's sad that they are so common.

Nevertheless, it's still a judgment call that in my view is personal – whether to choose a small increased risk of something truly catastrophic and tragic, or  whether to choose a hugely increased risk of a whole lot of lesser but still significant problems. And that's just the "risk assessment" end of it, from statistical thinking.  There are many individual considerations — have you found a home birth attendant that is satisfactory to both of you?  how fast can you get to a hospital should an emergency occur? — that may change the calculation for your family.   Once you start considering your own feelings about the situation, it  gets even muddier. It isn't necessarily good to be in a place where the statistics say you are "safe" but where you don't FEEL safe — that could be hospital or it could be home — but FEELING safe, believing you are safe, is biochemically  important in giving birth. It's harder to do if you're stressed and fearful, which is at heart a hormonal response.

(And of course both father and mother need to come to some kind of agreement.  Including discussing the possibility of your worst fears coming true, in either situation.  Because when you face birth, you face death, too.  Best to face it together.)

OK, that aside.  I was also influenced and reassured by joining a mailing list — not sure if it still exists — about unassisted childbirth. Even though I didn't intend to "go UC," and have always opted to be well supported at home including with an experienced and compassionate midwife, I was inspired and given confidence by reading story  after story of births that happened at home, with no attendant at all, by choice. (Plus it made me feel less like an extremist by comparison!)  I was influenced by friends who had planned home births. 

I was influenced by Henci Goer's book Obstetrical Myths versus Research Realities:  A Guide to the Medical Literature.  Another book, Active Birth by Janet Balaskas (the latest version, which I haven't read, is here), gave me confidence with regards to natural pain management.  

I read other books, too, once we had made up our minds; and those tended to be the "crunchier" sort, which helped me understand what we were in for once we chose midwifery care.  Things like Heart and Hands:  A Midwife's Guide to Pregnancy and Birth by Elizabeth Davis.  When it came to general-info pregnancy and childbirth books, I tried to avoid those that took hospital birth for granted, and went for the ones that included homebirth as a birth choice.  Books by William and Martha Sears (The Pregnancy Book, The Birth Book –I didn't actually read that one– and  The Baby Book) and Sheila Kitzinger (The Complete Book of Pregnancy and Childbirth) are good examples.   

As for breastfeeding books, my two favorite are the LLL one (The Womanly Art of Breastfeeding) and So That's What They're For by Janet Tamaro, which is a little more lighthearted and thus good for lending to people who think La Leche League is a club for fanatics.  

Since I don't use contraception and want to get through lactational amenorrhea to regular cycles before becoming pregnant, I used Breastfeeding and Natural Child Spacing by Sheila Kippley (she has a couple other books on the same subject); the publisher, CCL, doesn't carry it anymore, and so these days the equivalent information is probably available in CCL's Art of Natural Planning:  Postpartum Student Guide (available here).  I continue to support CCL's work and one of these days I will have to sit in on the new NFP classes, which have been revised significantly since I took them years ago in marriage prep.

(Perhaps my readers know of some more books I've missed, especially some that have come out in the last few years — I haven't done much "how to have a baby" reading since my second.)

Natural family planning influenced us in another way  – we sort of were in a mindset of avoiding "interventions" in our intimate life, of generally trusting our bodies to tell us what we needed to know, and giving birth at home was a sort of natural outgrowth of that. There was a sort of weirdness to the idea that we should need medical assistance for something that ought to work fine if  we just left it alone. 

That's sort of a combination of "gut feeling" and logic – truthfully, the species wouldn't have survived if it didn't work most of the time, and if you read a bit about the history of birth in America, you'll see that a lot (not all) of the improvements in maternal/neonatal outcomes are from simpler things like antibiotics, nutrition, and prenatal care/screening, not so much from medical attention surrounding the birth itself. Obviously this isn't true  for functionally impossible vaginal birth, e.g. with complete placenta previa, but it's possible to rule out that kind of thing before birth if you want to get an ultrasound.

One thing we did the first time we went through it, is I doubled up on prenatal care — I had my homebirth midwife appointments, and I also had the full spectrum of prenatal appointments with a "standard" CNM practice.  (Except I declined the glucose tolerance test and the routine ultrasound). We felt  we were keeping our options open. But we never bothered with the regular doctor thing at the other births after that. With this my fourth pregnancy I chose to get a midterm ultrasound to rule out any musculoskeletal deformities or placental problems that might indicate I should consider a hospital birth.  I'm older now, and my babies tend to be large with sticky shoulders; it seems reasonable to me to check for extra problems that could exacerbate that.  I've already made up my mind based on my own birth history not to attempt a vaginal birth should the baby present breech.

That illustrates another belief of mine, that it's important to keep an open mind about the appropriateness of medical interventions (taken individually) and be willing to adjust your approach as information comes in about your physical health, the baby's physical health, and your own tolerance for different kinds of risk. Sometimes a C-section is a good idea, sometimes it's not. Sometimes an ultrasound is a ridiculous, expensive, unnecessary intervention; sometimes it answers questions that need to be answered. Same thing goes for glucose tests, fetal heart monitoring, epidurals, GBS testing and IVs, all that stuff — they are powerful tools that can be used or misused, they're not good for every individual or bad for every individual either.

If you're going to have a hospital birth, my standard two pieces of advice (especially to first-timers) are

• consider hiring a doula for your hospital birth, or else bringing along a  knowledgeable friend who can help advocate for you, or at least bringing along a close female friend who's given birth before and isn't scared of it.  The mere presence of a female support person (not part of the medical staff) in the delivery room significantly lowers your chance of a section. See here, here, here, and lots of links here.
• Do what you can to prepare yourself and your husband to advocate strongly against unnecessary cesarean section. This is, to my mind, the single greatest risk associated with giving birth in American hospitals. Understand why it's NOT a "no big deal" to have a cesarean, and why it's so important to try to avoid that "first" cesarean if you possibly can. Know the positive indications for a truly necessary section, know alternatives to non-necessary c-sections in advance, and know what you can do to avoid interventions that sometimes cause an apparent need for a c-section. 

I think that covers it.  Comments from readers are welcome as usual.