home birth

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Viewpoint: Doctors Respond To Home Births That End Up In Hospital

By Shirie Leng, M.D. and Cindy Ku, M.D.

As physicians we are concerned about a recent post on CommonHealth — “What to Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)” — that focuses on planned home births that end up in the hospital.

While we respect the right of women to labor and deliver in the environment of their choosing, requiring medical intervention in childbirth is neither shameful nor a moral failing. Life-threatening complications which, 100 years ago, would have meant a death sentence for mothers and babies, are now treatable and even preventable in the modern hospital maternity ward. Suggesting that women are unduly traumatized by transfer to and treatment in a medical facility does a disservice to the obstetricians, nurses, anesthesiologists, and neonatologists who work so hard to save these lives.

Here’s an example of the kind of case that could possibly result from a home birth that goes awry. While on a routine morning on the obstetrics unit, the usual routine was interrupted by a phone call from the emergency room. A laboring mother was in distress and needed an emergency caesarean, and she was about to arrive into the trauma OR. Since caesareans are not normally performed in the emergency room trauma room, everyone dropped their plans and hurriedly prepared the trauma OR. One minute later a petite young woman on a stretcher crashed through the door along with the obstetrician. “Get the baby out of me!” she screamed, writhing and crying in agony as the team transferred her to the operating table. Between her moans and her desperate outbursts, she could barely understand the questions as the anesthesiologist tried to ascertain three things: did she have heart or lung problems, did she have allergies, and did she have any potential problems with her airway?

 (meme_mutation/flickr)

(meme_mutation/flickr)

We had no other information to go by – no laboratory data, no history, not even her name. All we knew was the baby was in breech position (legs down, not head down) and was in distress. We had five seconds to decide how we would help to save the two lives in front of us. We told her as gently as we could (though it likely didn’t register with her at all) that she needed to breathe in oxygen for herself and her unborn child, that she would be unconscious for about an hour, and we would see her and her baby in the recovery room. Vaginal delivery is not the standard of care for breech presentations because of the significantly elevated risk of shoulder entrapment in the birth canal and stillbirth. Months after this case we all still wonder how we could have done better and what would’ve happened if she hadn’t arrived in time.

Thankfully, our team — the obstetricians, anesthesiologists, nurses and neonatologists — worked together successfully and both mother and child did well. We don’t know for sure if this case began as a home birth, but it does represent the sorts of difficulties that we medical staffs wrestle with when a home birth becomes complicated and ends up at the hospital.

Childbirth always brings with it an element of danger. While everything usually goes right, when it goes wrong it usually does so quickly and seriously. To expect the idealized experience in every case is to deny reality. In 1900, when women were having the arguably blissful natural birth experience home birthers seek, the maternal mortality rate was more than 800 deaths per 100,000 births. According to the CDC, in 1997 that number was 7 per 100,000. This statistic, an upwards of 99 percent decrease in mortality rate, was not achieved by midwives and doulas with the latest technology in birthing balls and labor tubs. It was achieved through advances in science and medicine. Continue reading

What To Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)

Screen shot 2015-03-20 at 9.07.11 AM

By Ananda Lowe
Guest Contributor

The term “homebirth cesarean” didn’t exist before 2011, when Oregon mother and student midwife Courtney Jarecki coined it. But now, a Google search returns almost 2,000 entries on the topic.

The term refers to a small but emerging community of mothers who have experienced the extremes of birth: They’d planned to have their babies at home, but ended up in a hospital, most often in the operating room having a cesarean section, major abdominal surgery. Needless to say, the effect of such a dramatic course change takes a toll, and can often be overwhelming.

(“Homebirth cesarean” can also refer to births that were planned to occur at a freestanding birth center outside of a hospital, but eventually were transferred to the hospital for a cesarean.)

How often does this happen?

Home births, though a small fraction of the approximately 3.9 million births a year in the U.S., are on the rise. Based on the most recent birth data from the National Center for Health Statistics, “the 36,080 home births in 2013 accounted for 0.92% of all U.S. births that year, an increase of 55% from the 2004 total.”

Eugene Declercq, a professor of community health sciences at Boston University School of Public Health, studies national birth trends. He said in an email that while there are no nationwide numbers on homebirth transfers to the hospital, “the studies that have been done usually report about a 12% intrapartum transfer rate.”

But beyond the numbers, what happens emotionally when your warm and fuzzy image of natural childbirth in the comfort of home suddenly morphs into the hard reality of a surgical birth under fluorescent lights?

A woman who'd planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

A woman who’d planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

Jarecki founded the homebirth cesarean movement to figure that out. She connected women who, like herself, shared the experience of giving birth through full surgical intervention, despite their original plans of having their babies at home or outside of the established medical system.

In Jarecki’s case, she labored at home for 50 hours until her midwives detected a rare complication known as a constriction ring, or a thickened band of tissue in her uterus that was impeding progress. Shortly after this, meconium appeared, and Jarecki knew it was time to go to the hospital. Her emotional response to the intensity of the situation, however irrational, was one of anger, shame and failure at her ability to give birth normally. A cesarean followed.

Over the next several years, Jarecki began helping other homebirth cesarean mothers emerge from the silence and shame they felt confronting their unexpected surgeries. Some of these women also report that their postpartum recovery was tougher because their unique needs were not adequately addressed by their home birth midwives or their hospitals.

Jarecki started by launching a (now busy) Facebook page as a support group for these mothers and their health care providers.

Childbirth Expectations vs. Reality

Rule number one in childbirth is that it rarely unfolds as you expect. Continue reading

Water Babies: Docs Challenge Growing Trend — Childbirth In A Tub

Lumina Gershfield-Cordova, after giving birth to her daughter in the water. (Photo: Erica Kershner)

Lumina Gershfield-Cordova, after giving birth to her daughter in the water. (Photo: Erica Kershner)

Earlier this month, Lumina Gershfield-Cordova gave birth to her healthy 8-pound daughter in a large tub of warm water.

And from that portable tub — set up in the bedroom of her Somerville, Mass., condo — came an atypical American birth story: Gershfield-Cordova describes the buoyancy of the water offering her delicious freedom to move, stretch, turn and, sometimes, relax in ways that are generally unavailable to a woman delivering a baby flat on her back in a hospital bed.

“It’s so wonderful the way the water supports your whole body,” she said. “You can assume positions you can’t get into when gravity is pulling down on you — it’s such a relief. You feel like a ballerina, or an athlete…I was able to work with my baby and together we found the right way for her to come out — there were actual moments of pleasure during her descent. It was amazing.”

Gershfield-Cordova, 35, is one data point in a growing trend. Actress Ricki Lake famously gave birth in a bathtub as part of her pro-natural childbirth documentary, “The Business of Being Born;” the movie created a kind of “Lake Effect” with more buzz around home birth in general, and water birth as well. One report recently quoted supermodel Gisele Bundchen saying her own child’s birth in the water was inspired by Lake’s film.

“It’s so wonderful the way the water supports your whole body…You can assume positions you can’t get into when gravity is pulling down on you — it’s such a relief.”

But it’s one thing to labor in the water, and quite another to actually give birth underwater, according to two prominent physician groups.

In a just-released joint opinion, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have come out squarely against childbirth in the water.

Their conclusion: laboring in water could be helpful for women as a way to reduce pain (and pain medication) and spend less time in labor, but giving birth underwater is too risky, with no peer-reviewed, randomized controlled trials showing benefits.

Despite such caveats from medical authorities, both water labor and water birth are becoming more popular around the world.

Consider: One percent of all births in the United Kingdom include some kind of immersion in water (one expert put the number closer to 5 percent); and in the U.S., according to a leading water birth advocate, most birthing centers and nearly 10 percent of the nation’s approximately 3,100 hospitals are now offering birthing tubs that allow women to either labor or deliver their babies in water.

Last year, in one private midwifery practice affiliated with a major medical center in Morristown, N.J., 50 percent of the 170 births were in water, says Lisa Lederer, president of the practice, Midwives of New Jersey. “The benefit is the ability to give birth naturally, without medication… it’s true pain relief without the side effects of epidurals or narcotics,” said Lederer, whose practice has been involved in about 1,000 water births since 2000. “Women will labor in the tub, and I ask them to get out to move around, to pee, or just for a change and they’ll beg to get back in and practically dive head first back in the water. This is not just nice or pretty — it actually helps them.”

Noting that water birth, along with home birth, is a growing trend in the U.S., Dr. George Macones, an obstetrician-gynecologist at Washington University in St. Louis, and chair of the committee that prepared the latest ACOG/AAP opinion, said: “I think there’s an important distinction between laboring in a tub and delivering in a tub. Most of us feel that laboring in a tub is fine, as long as the baby is doing well and mom is doing well. Delivering underwater is where there’s a bit more of a struggle — there isn’t a lot of data on this but there are a number of case reports of really bad things happening.” Mostly, he said, there are “concerns about the baby aspirating water.” Others cite infection as a potential problem.

Still, Macones said, at his hospital, where planning has begun for a new labor and delivery ward, “one of the hot topics is how many rooms will have tubs.”

The new ACOG/AAP opinion (which follows a 2005 AAP commentary on the risks of underwater delivery and 2012 ACOG guidelines on perinatal care) concludes that water birth should be considered an “experimental procedure ” and only performed as part of a clinical trial with informed consent — something that’s unlikely to happen in the U.S., according to Macones.

For comparison, here’s what the U.K. Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives stated back in 2006: “All healthy women with uncomplicated pregnancies at term should have the option of water birth available to them and should be able to proceed to a water birth if they wish.” The groups also also urged hospitals to support women in this pursuit: “…to achieve best practice with water birth it is necessary for organisations to provide systems and structures to support this service.”

Here’s more of the joint ACOG/AAP opinion, published online in the journal Pediatrics, and summarized in a news release:

Undergoing the early stages of labor in a birthing pool may offer some advantages to pregnant women. However, underwater delivery has no proven benefit to women or babies and may even pose a risk of serious health problems for the newborn…

“Many labor and delivery units are equipped with tubs to be used by laboring women, and immersion in water for relaxation and pain relief is appealing to some,” said Jeffrey L. Ecker, MD, chair of the College’s Committee on Obstetric Practice that developed the Committee Opinion. “But it is important to recognize that laboring in water is not the same as delivering underwater. Laboring in water may offer some potential benefits, but delivering underwater does not seem to have clear advantages, and the risk of rare, but serious, consequences to a delivering baby’s health is something women and providers should all be aware of.”

“The members of the committees conducted a thorough review of the literature, and came to the conclusion that there is no evidence to support delivering babies in water has benefits to the baby,” says Tonse Raju, MD, chief, Pregnancy and Perinatology Branch, the National Institute of Child Health and Human Development (NICHD), who served as the NICHD liaison to the AAP Committee on Fetus and Newborn.

The new recommendation acknowledges that there may be some positive effects of water immersion to pregnant women during the early stages of labor, such as decreased pain or use of anesthesia and shorter labors. However, there is no evidence that giving birth underwater improves newborn outcomes…

Potential risks of underwater delivery include a higher risk of maternal and neonatal infections; difficulty in the regulation of the baby’s body temperature; increased chance of umbilical cord damage; respiratory distress resulting from the baby inhaling tub water; and potential for seizures or asphyxiation of baby following birth.

The College and AAP say that underwater delivery should only be performed within the context of an appropriately designed clinical trial with informed consent.

Barbara Harper, an RN who founded the company Waterbirth International in the late 1980s after her two sons were born in water, has been called “the Billy Graham of water birth.” She says she’s personally attended around 600 water births and trained more than 7,000 physicians, nurses, medical students and others around the world — in Mexico, India, Israel, Malaysia, all over Europe, the U.K and U.S — on how to safely and effectively manage childbirth in the water. Based in Fort Lauderdale, Fla., Harper is currently in China conducting water birth training in medical schools and hospitals.

Harper refutes the ACOG assertion that water births are more risky than land births and cites a number of published studies and analyses that support her position, among them a 1999 British report that concluded: “perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally.”

Among water birth’s benefits, Harper says, are that it can speed up labor, give the mother more of a feeling of control, provide pain relief and reduce the need for drugs and inteventions such as epidurals, episiotomies and even cesarean sections. However, Harper says she has very strict criteria regarding who is eligible to give birth in a tub: “Anyone can labor in the water,” she says. “But if your labor goes into the pathology area and wanders out of normal physiology,” water birth should not be an option. She says, for instance, that women with preeclampsia, high blood pressure, abnormal bleeding or untreated infection or fever should not deliver babies in the water. Continue reading

New Home Birth Data: Numbers Rise A Bit, Controversy Remains Unchanged

A new CDC analysis of trends in out-of-hospital births from 1990-2012 found that home births are on the rise — but only a tiny bit.

The federal agency reports that 1.36 percent of U.S. births occurred outside a hospital in 2012, up
from 1.26 percent in 2011. Those new numbers mark the highest level of non-hospital births since 1975, according to the CDC.

In terms of actual births, that means 53,635 births in the U.S. took place out of a hospital in 2012, including 35,184 home births and 15,577 birthing center births, the CDC says.

(Source: CDC)

(Source: CDC)

Here are some more findings from the CDC news release:

• In 2012, 1 in 49 births to non-Hispanic white women were out-of-hospital births;

•The percentage of out-of-hospital births was generally higher in the northwestern United States and lower in the southeastern United States;

•Out-of-hospital births generally had a lower risk profile than hospital births.

Continue reading

Opinion: License Professional Midwives For More Childbirth (And Home Birth) Options

Home birth announcement (Courtesy Sarah Whedon)

Home birth announcement (Courtesy Sarah Whedon)

By Sarah Whedon
Guest Contributor

When I was expecting my first baby in 2009, I planned a home birth with a wonderful midwife. My pregnancy was healthy and normal, my prenatal care with my midwife was both empowering and attentive to my health needs and my labor began spontaneously at full term.

Everything was going according to plan, until about 20 hours into active labor at home when my midwife alerted me that my baby’s heart rate indicated a serious problem and we needed urgent medical attention.

In the amount of time it took the ambulance to arrive at my Somerville home, my midwife cut an episiotomy (a skill in which home-birth midwives are trained but don’t practice as a matter of routine) and performed an emergency delivery. My baby had aspirated meconium (the sticky tar-like substance in a newborn’s bowels that is occasionally expelled during birth) and was having trouble breathing even with the aid of the oxygen my midwife carried with her. She needed a transfer to the level III NICU at Children’s Hospital, where she made a complete recovery.

I had a home birth because I wanted the kind of low intervention pregnancy and birth that Certified Professional Midwives (CPMs) offer. But I tell my birth story publicly because it demonstrates something important that people don’t often realize about CPMs: they are skilled professionals who are prepared to handle emergencies, including facilitating transfer to medical care when needed.

CPMs are midwives who are specially trained in out-of-hospital care. They differ from Certified Nurse Midwives (CNMs) who are trained as nurses and typically practice in hospital settings. Currently, Massachusetts licenses CNMs but has no licensing system for CPMs, who provide care for approximately 500 women across the state each year.

So when I recently learned of a petition asking me to support licensing of CPMs in Massachusetts, I immediately wanted to get more involved. I found other moms who want this bill to pass and I’ve had the pleasure of lending my support to this work being carried out by a coalition of advocates from the Massachusetts Midwives Alliance, Massachusetts Friends of Midwives and others. More than 500 Massachusetts residents have now signed the petition.

The bills (HB 2008 and SB 1081) would require all midwives practicing out of hospital to become CPMs, create state licensing requirements for CPMs and establish a Committee on Midwifery under the Board of Registration in Medicine. The nine-member committee will include five CPMs, one obstetrician, one CNM and one consumer of midwifery services.

Supporters of the measures that would license and regulate home birth midwives were energized by an amazing turnout at a Committee on Public Health hearing last month, testifying to the professional skill of these midwives and the valuable ways they serve Massachusetts families. Several moms even brought their charming home birth babies along for the day at the State House.

I have heard from some midwifery supporters who oppose licensing, worrying that new regulations will hamper midwives’ ability to truly practice the midwifery model of care. But midwives themselves will be involved in determining details of regulation. Overall, licensing of our midwives would mean more moms will feel able to choose home birth, because they’d have the security of knowing that in order to hang out her shingle, a midwife must meet state licensing standards.

The Massachusetts Medical Society has also opposed the bills, expressing disapproval of any health care that is delivered outside the team context with immediate M.D. supervision. Continue reading

Pediatricians’ New Guidelines On Home Birth Rekindle Old Debate

Yesterday, the influential American Academy of Pediatrics issued, for the first time, a set of guidelines related to planned home births, a hotly debated practice (though not so much among women who do it) that has increased slightly in the past few years, mainly among highly educated white women.

 (meme_mutation/flickr)

(meme_mutation/flickr)

Specifically, the guidelines are on caring for infants born via planned delivery at home. The first line of the guidelines underscores the fact that the new statement is hardly radical:

The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery.

Time Healthland reiterates that the guidelines, published in the journal Pediatrics yesterday, are pretty straightforward, including these recommendations:

“…at least one person at the birth should be responsible for tending to the newborn infant; that person should also be trained in infant CPR. Medical equipment should be tested before the delivery. A phone line should be available; while you’re at it, check the weather forecast too, in case complications arise and a trip to the hospital is necessary. In case of emergency, have a plan to transfer the laboring mom to a hospital. And do all the stuff that nurses do in the hospital to brand-new babies: monitor their temperature and heart rates, keep them warm and cozy, administer vitamin K and heel-prick newborn screening tests that are sent to outside labs for processing, among other things.

Still, Time says:

More controversial is the academy’s advice that pediatricians endorse only midwives who are trained and cleared by the American Midwifery Certification Board. Midwives accredited by this board typically attend deliveries at hospitals and birthing centers. That position has upset certified professional midwives, who deliver the majority of babies born at home in this country but are accredited by a different body — the North American Registry of Midwives (NARM).

Robin Hutson, executive director of the nonprofit Foundation for the Advancement of Midwifery, based in Boston, says these guidelines are only useful if consumers also have access to data on the risks of giving birth in other settings. In a hospital, for instance, Hutson notes there’s a higher likelihood of infections, unnecessary use of medical interventions and prolonged separation of mother and baby which can deter breast-feeding. “No method of birth is risk free,” Hutson says.

One local doula told me that even though the statement is certainly not a full-blown endorsement of home birth, just the fact that the AAP put it out somehow offers the practice added legitimacy in mainstream circles.

Of course it’s also pragmatic for the AAP to acknowledge that all babies, regardless of where they’re born, deserve the same level of care, particularly since home birth has been undergoing a mini-resurgence. (It ticked up a bit after actress and home-birth advocate Ricki Lake gave birth in a bathtub and then produced the film, The Business of Being Born.)

As we reported in 2011:

After a 15-year decline, home births in the U.S. rose 20 percent between 2004-2008. Though the actual numbers remain tiny — out of about 4 million births, 28,357 happened at home in 2008 — the reversal of the long downward trend is notable. So are the demographics: much of the increase was driven by highly educated white women.

Continue reading

NYT: The Battle Over Home Births

http://www.youtube.com/watch?v=siLbqthiTWo

Before Ricki Lake gave birth in her bathtub and before “Orgasmic Birth” was a top movie pic among the doula set, there was Ina May Gaskin, the earth-mother-high-priestess-venerated-goddess of natural childbirth.

This weekend, The New York Times discovers what proponents of home birth have known for decades: Ms. Gaskin, a self-taught midwife who launched her communal birthing center, The Farm in Summertown, Tennessee, with her husband Stephen in the 1970s, has helped deliver thousands of healthy babies without any medical help.

Gaskin’s statistics are eye-popping: out of approximately 3,000 total births, The Farm’s C-section rate is about 2 percent, The Times reports (compared to a more than 30% rate in the U.S.) and epidural anesthesia has been used only once. “Failure to progress,” a frequent diagnosis for long-laboring moms in American hospitals (and often the trigger for a cascade of medical interventions, including C-sections) are virtually non-existent at The Farm. This less-medicalized approach is, once again, gaining momentum and Gaskin’s ideals are increasingly going mainstream.

Samantha Shapiro writes:

Unmedicated home birth is being chosen by a growing minority of women. Between 2004 and 2009, giving birth at home increased 29 percent. Most of this rise is among white women. Recent pregnancy documentaries like “Pregnant in America,” “Orgasmic Birth” and “The Business of Being Born” — all of which feature Gaskin — present hospital birth as profoundly disempowering to women.

Continue reading

Two-Year Prison Sentence For Hungarian Doc, Home-Birth Advocate

Dr. Agnes Gereb, obstetrician and home-birth advocate, was sentenced to two years in prison.

Home births are up in the U.S. according to the CDC, due in part to organized efforts by groups like The Big Push for Midwives to educate the public and help legalize midwives in more states.

But things don’t look so great for home-birth supporters in Hungary. This week, Dr. Agnes Gereb, an obstetrician and home-birth midwife who had been sentenced to two years in prison for malpractice, lost her appeal and got hit with even tougher sanctions, CBS News reports. (Her supporters say she has been singled out for punishment due to her role assisting and championing home-births.)

Budapest’s Court of Appeals also banned Dr. Agnes Gereb from working in her profession for the next 10 years, increasing last year’s court ruling, which had banned her for five years. Continue reading

Report: Gynecologist Imprisoned For Assisting With Home Births

Dr. Agnes Gereb was imprisoned for championing home births, supporters say

This is a little far afield but worth checking out:

The Guardian (U.K) reports that Hungarian authorities have imprisoned gynecologist and midwife Agnes Gereb for helping women give birth at home (Ricki Lake, where are you??). The Oct. 22 article begins:

Twenty minutes after the expectant mother went into labour, the police were knocking at the door. While mother and child were taken to hospital and treated well, the midwife at the birthing centre was thrown in jail. Dr Agnes Gereb is now being kept in maximum security conditions in a Budapest prison, facing a five-year prison sentence.

Gereb, founder of the Napvilág birthing centre, is a highly experienced gynaecologist, midwife and internationally recognised home birth expert. She has successfully helped deliver 3,500 babies at home. But her reputation means nothing to the authorities in Hungary, a country that has, campaigners say, relentlessly pushed to criminalise home births and make hospital deliveries compulsory…

Held for a further week without charge, (Gereb) finally appeared in an open court on 12 October, shackled in leg chains and handcuffs, accused of negligent malpractice. She also faces several other charges, including one for manslaughter relating to an earlier home birth when a baby died after a difficult labour.

Supporters from around the world have organized a “Free Agnes Gereb” campaign on two Facebook pages, here and here, and other sites, and are petitioning authorities to release her from prison.