Home birth update
So it's been almost a year since I started attending home births with a CPM. This time has been one of incredible growth and education for me. I've been reading a lot about birth in general, and home birth (and its safety) in particular.
Unfortunately, the conclusion that I came to after all that intensive reading is that home birth with a midwife is as safe as hospital birth only if 3 conditions are met: 1. if home birth is well regulated, so it is extremely well defined who falls into a high risk vs low risk category and under what circumstances hospital transfers have to be made 2, if the midwife is well trained to recognize boundaries between normal and pathological, 3. if transfer conditions between home and hospital are good, which would include features like distance to transfer, cooperation of the hospital staff, or perhaps even access for the midwife to hospital resources to continue the woman's care.
If one of the conditions is not met, home birth becomes more risky than hospital birth in terms of neonatal mortality. This risk is relative, of course. In the US, in those states where the above 3 conditions are met, the risk of a baby dying in a home birth is 0.37 in 1000, which is the same as a low risk woman in a hospital, attended by a midwife. (Those attended by OB's have higher mortality rates, but there is a large confounding factor there of OB's attending complicated births, and midwives attending uncomplicated ones.) The risk of a baby dying in a home birth if those 3 conditions are not necessarily met (so, including all states, even those where home birth is either not regulated or illegal), is 1 in 1000.
The risk of giving birth in a hospital is the astounding rate of interventions used, which may or may not turn out to be without complications.
The question is whether a woman, if informed of the risks involved in hospital or at home, might still choose something that slightly elevated baby's risk but significantly reduced her own?
All of this is academic, of course. The fact of the matter is that if I attend enough births (about 1000), I will see a baby die. That's just statistics, whether I'm in a hospital setting or in a home birth setting.
The problem is that I am no longer confident in the judgment of the midwife that I work with. I think she is far too lenient and lax in her transfer policies. I admit some of this may be due to her experience - she's seen more than I have, so she maybe she knows better when transfers have to be made. But I think that especially in Hungary, where transfer conditions SUCK, primarily because often either the very fact that we're transferring a home birth, or some pertinent details of the case, need to be hidden, it just becomes outright dangerous. And I'm very unhappy with the fact that she herself doesn't accompany her clients to the hospital; that is a task left to one of her doulas. These days, this is most often me.
And once these two coincide; me accompanying the transferring woman to a hospital and a baby dying, I don't know how I'd handle that personally, and legally, I think I'd be in deep shit because of the unclear legal status of home birth in this country.
Add to this that she seems to have the fruit loop market cornered in Hungary. I really don't wish to insult anyone who believes in such things, but when we are talking about using crystals for pain relief or homeopathics or some undefined "Chinese herbs" to stem post-partum bleeding, I start getting antsy.
I've been spending a lot of time recently reading blogs by scientists and doctors about quackery and pseudoscientific practices, which they bundle up into a mockable package and call it "woo." I find their entire attitude to be profoundly disrespectful towards people who believe in different modalities, and yet very often I silently cheer them on because I happen to think that they are right. Not in the mocking, but in their assessment of the efficacy "woo."
However, I do see that people turn to "woo" because Western medicine has failed them in some major ways, the primary one being in terms of human interaction. That's another post in itself.
The point here is that the woo beliefs of many of my midwife's clients just adds to my apprehension concerning safety. Seriously, one of them actually claimed she consulted spirits concerning how much she should pay the midwife (she works on a sliding scale). These spirits must be ones of departed foreign currency traders, because they seemed to be quite up to date on current exchange rates - they suggested this client pay in Euros, and they got the amount just about right, too.
So the decision I made was to slowly distance myself from this midwifery practice, which I do with a lot of heartache. Especially since I am beginning to develop a closer relationship with some hospital-based midwives and attend more hospital births where I see another kind of "woo;" the one of accepted obstetric routines. Never mind that they are obsolete and have been shown to do more harm than good (case in point the 90% episiotomy rates for first-time mothers), this is the way we do things in this country! And if a woman wants something different? Then these midwives and doctors see it as MY role as the birth educator to convince my clients to just accept the unnecessary and harmful interventions "because they're in Hungary now." (A lot of my clients are foreigners.)
But fact of the matter is that I do not have fear when I accompany a hospital birth, but I have a knot in my stomach when I accompany a home birth. Okay, not the same kind of fear. I may be uncomfortable and angry and even traumatized by how women are treated and how hospital procedures can take a well-progressing birth and steer it completely off track, BUT I do not have the same crushing anxiety concerning my own responsibility for the lives of two people. And maybe that is selfish because I know at a hospital birth I will not be held responsible if something DOES go wrong, whether it was because of OR despite their best effort. But I also know that whether or not they created the complication in the first place, the hospital is better equipped to deal with it than we are in a home birth setting. And that I will not have to be the one doing that dealing.
It's easy to criticize hospital routines from the outside, without that weight of responsibility for two people's lives. I think it took me experiencing at least a little bit of that responsibility to really appreciate what it must feel like to be the one bearing it all, and I totally understand how under these circumstances, physicians grasp at whatever guard rails they have (hospital routines, even harmful ones), and whatever will cover their asses in case of trouble.
At any rate, my conclusion is that attending home births in this country is not safe. It's not as safe for the woman doing the childbearing, and it certain as hell is not as safe for me as an attendant. I could live with the woman's increased risk as long as she understood and accepted it (informed consent), but I cannot live with the risk to me, especially when I am not the one calling the shots. If I were going to be prosecuted for attending a home birth, I'd want to be the one making all the decisions for which I might be held responsible.
Unfortunately, the conclusion that I came to after all that intensive reading is that home birth with a midwife is as safe as hospital birth only if 3 conditions are met: 1. if home birth is well regulated, so it is extremely well defined who falls into a high risk vs low risk category and under what circumstances hospital transfers have to be made 2, if the midwife is well trained to recognize boundaries between normal and pathological, 3. if transfer conditions between home and hospital are good, which would include features like distance to transfer, cooperation of the hospital staff, or perhaps even access for the midwife to hospital resources to continue the woman's care.
If one of the conditions is not met, home birth becomes more risky than hospital birth in terms of neonatal mortality. This risk is relative, of course. In the US, in those states where the above 3 conditions are met, the risk of a baby dying in a home birth is 0.37 in 1000, which is the same as a low risk woman in a hospital, attended by a midwife. (Those attended by OB's have higher mortality rates, but there is a large confounding factor there of OB's attending complicated births, and midwives attending uncomplicated ones.) The risk of a baby dying in a home birth if those 3 conditions are not necessarily met (so, including all states, even those where home birth is either not regulated or illegal), is 1 in 1000.
The risk of giving birth in a hospital is the astounding rate of interventions used, which may or may not turn out to be without complications.
The question is whether a woman, if informed of the risks involved in hospital or at home, might still choose something that slightly elevated baby's risk but significantly reduced her own?
All of this is academic, of course. The fact of the matter is that if I attend enough births (about 1000), I will see a baby die. That's just statistics, whether I'm in a hospital setting or in a home birth setting.
The problem is that I am no longer confident in the judgment of the midwife that I work with. I think she is far too lenient and lax in her transfer policies. I admit some of this may be due to her experience - she's seen more than I have, so she maybe she knows better when transfers have to be made. But I think that especially in Hungary, where transfer conditions SUCK, primarily because often either the very fact that we're transferring a home birth, or some pertinent details of the case, need to be hidden, it just becomes outright dangerous. And I'm very unhappy with the fact that she herself doesn't accompany her clients to the hospital; that is a task left to one of her doulas. These days, this is most often me.
And once these two coincide; me accompanying the transferring woman to a hospital and a baby dying, I don't know how I'd handle that personally, and legally, I think I'd be in deep shit because of the unclear legal status of home birth in this country.
Add to this that she seems to have the fruit loop market cornered in Hungary. I really don't wish to insult anyone who believes in such things, but when we are talking about using crystals for pain relief or homeopathics or some undefined "Chinese herbs" to stem post-partum bleeding, I start getting antsy.
I've been spending a lot of time recently reading blogs by scientists and doctors about quackery and pseudoscientific practices, which they bundle up into a mockable package and call it "woo." I find their entire attitude to be profoundly disrespectful towards people who believe in different modalities, and yet very often I silently cheer them on because I happen to think that they are right. Not in the mocking, but in their assessment of the efficacy "woo."
However, I do see that people turn to "woo" because Western medicine has failed them in some major ways, the primary one being in terms of human interaction. That's another post in itself.
The point here is that the woo beliefs of many of my midwife's clients just adds to my apprehension concerning safety. Seriously, one of them actually claimed she consulted spirits concerning how much she should pay the midwife (she works on a sliding scale). These spirits must be ones of departed foreign currency traders, because they seemed to be quite up to date on current exchange rates - they suggested this client pay in Euros, and they got the amount just about right, too.
So the decision I made was to slowly distance myself from this midwifery practice, which I do with a lot of heartache. Especially since I am beginning to develop a closer relationship with some hospital-based midwives and attend more hospital births where I see another kind of "woo;" the one of accepted obstetric routines. Never mind that they are obsolete and have been shown to do more harm than good (case in point the 90% episiotomy rates for first-time mothers), this is the way we do things in this country! And if a woman wants something different? Then these midwives and doctors see it as MY role as the birth educator to convince my clients to just accept the unnecessary and harmful interventions "because they're in Hungary now." (A lot of my clients are foreigners.)
But fact of the matter is that I do not have fear when I accompany a hospital birth, but I have a knot in my stomach when I accompany a home birth. Okay, not the same kind of fear. I may be uncomfortable and angry and even traumatized by how women are treated and how hospital procedures can take a well-progressing birth and steer it completely off track, BUT I do not have the same crushing anxiety concerning my own responsibility for the lives of two people. And maybe that is selfish because I know at a hospital birth I will not be held responsible if something DOES go wrong, whether it was because of OR despite their best effort. But I also know that whether or not they created the complication in the first place, the hospital is better equipped to deal with it than we are in a home birth setting. And that I will not have to be the one doing that dealing.
It's easy to criticize hospital routines from the outside, without that weight of responsibility for two people's lives. I think it took me experiencing at least a little bit of that responsibility to really appreciate what it must feel like to be the one bearing it all, and I totally understand how under these circumstances, physicians grasp at whatever guard rails they have (hospital routines, even harmful ones), and whatever will cover their asses in case of trouble.
At any rate, my conclusion is that attending home births in this country is not safe. It's not as safe for the woman doing the childbearing, and it certain as hell is not as safe for me as an attendant. I could live with the woman's increased risk as long as she understood and accepted it (informed consent), but I cannot live with the risk to me, especially when I am not the one calling the shots. If I were going to be prosecuted for attending a home birth, I'd want to be the one making all the decisions for which I might be held responsible.