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Through networking and education, Midwifery Today's mission is to return midwifery care to its rightful position in the family, to make midwifery care the norm throughout the world, and to redefine midwifery as a vital partnership with women.
by Jill Cohen, Associate Editor, Midwifery Today
© 2003 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 50, Summer 1999.]
Homebirth as a Viable Choice
Planning a Homebirth
Regardless whatever law may be applied to the surface of women's lives, homebirth is a right. In a nod to this fact, lawmakers have carefully kept their hands off this right and gone after the homebirth attendant instead. Many women have had to go to great lengths to exercise their right, however, and homebirth midwives who are in the minority and sometimes practice illegally, work hard to help preserve it.
Women are becoming increasingly unhappy with their hospital birth experiences as the result of a multitude of factors, in particular the advent of health maintenance organizations (HMOs) and the proliferation of intervention that goes with hospital based modern health care.
The HMO system herds pregnant and birthing women through channels, leaving them without meaningful and conscientious individualized care. One-on-one care provides the physical, emotional and spiritual support so vital to good outcomes in birth, yet mainstream care continues to increase caseloads. This situation pulls away the safety net perfected over millennia and endangers women and babies daily. Increasing reliance on technology causes practitioners to lose the hands-on ability to ascertain what is really going on with a pregnant or laboring woman. The cascade of intervention that follows creates risks and events that would not have otherwise arisen.
Until recently, homebirth has been the natural mode of delivery since the beginning of humankind. It has only been in the last century that out-of-home birthing became the norm, a change engineered by ambitious men during a time when it was believed best to bring the natural world under control. What resulted in the birthing world was a surge into the hospital. It started with a fad, developed into a sign of prestige, then became pervasive when fear took over. With it came the inevitable spiral of cause and effect: the more intervention was introduced, the more it was needed, until birth was no longer recognizable as a natural process in human experience. Instead, it had been orchestrated into an assembly line procedure complete with time constraints, quotas, indifferent workers, procedures manuals, and loss of individual rights and autonomy.
Numerous side effects resulted, among them a woman's decreased ability to endure labor without drugs or direction. Over time the prevailing attitude developed that women did not have the power and ability to birth a baby naturally. Man's technology, it seemed, was better than nature's perfection. The truth is that a woman's body is designed to procreate and give birth. It produces hormones that act as pain relievers, contractions that come and go at intervals to offer respite, and many other perfect physiological responses that ensure a normal birth. Pregnancy and birth are the ultimate state of health!
If intervention arose out of need to "rescue" women from pain, results nevertheless show that under normal circumstances it is safer for mother and child to let the process of natural birth occur without medical intervention. Pain in childbirth is empowerment. Sure it may hurt, but the rewards that women recognize on a cellular level drive them. When all is said and done, that empowerment paves the path to parenthood, which is the ultimate task at hand.
Homebirth as a Viable Choice
In a homebirth situation, parents accept responsibility and help create the standards and protocols that will frame the birth experience. This prepares the family and the midwife for a natural, uneventful birth as well as for situations like premature rupture of membranes, breech presentation, postdates, twins and so on. In the hospital, those standards already exist, and each birth must fit into that already established framework. A natural process is immediately compromised when required to adhere to rigid structures devised by strangers.
Birth is a time to feel secure and safe. When a woman births at home she is in her own nest and is surrounded by colors, textures, lighting and sounds she loves. Her own bed, where she finds solace in rest and sleep, is available for birthing. She is in the place she will soon share with her baby. What better place is there to relax in the total way she needs to in order to give way to the birth process?
The holistic way to give birth is to let it happen. At home a woman has one or more care providers who monitor the progress of her labor and the well being of both she and her baby. Providing calm, watchful and intimate care, the midwives are there for the entire duration of labor and birth. The birthing woman knows this, depends on it and it helps her feel secure. She may also have her partner and family members with her—they know best what she likes and what soothes her the most.
In the hospital, on the other hand, the laboring woman is attended by strangers. She may not get the doctor she chose and if she does, he or she may go off call before she delivers. No matter how nice the birthing rooms are, the hospital is still an institution that functions in predetermined ways, with rules, standard procedures and time tables to abide by. In order to birth in a normal, healthy way a woman must be able to go within herself, calling up a lot of inner strength for the long process ahead of her. Encouragement is vital. But it is easy to become confused by someone else's procedures and stressed and discouraged when others' time constraints have to be adhered to.
At home, progress is assessed by taking vital signs and by watching the woman's self-paced unfolding. The midwife's presence is constant and she is the caretaker from start to finish. She monitors such things as blood pressure, temperature and fetal heart tones. She makes sure the laboring woman feels fearless and secure. She gives emotional support and offers touch therapies if the woman is comfortable with that. Time becomes secondary. Taking food and drink and getting rest and sleep are encouraged. How can a woman otherwise get through a long labor if she is not nourished and rested? Yet in many hospitals, food and drink are prohibited for fear that surgery and anesthesia may lie ahead. This protocol heads the cascade of intervention that is often inevitable at the hospital: an exhausted mom is given Pitocin to increase the effectiveness of her contractions, and from there it's a collision course of medical intrusions when a snack and a nap may have staved off any problems in the first place.
A woman feels in control of her birth process when she births at home. In the hospital, institutional standards are in control. It's hard to believe that most women would choose the latter. But fear of supposed consequences and fear of responsibility and one's own power seem to discourage a lot of today's expectant women.
One of the main concerns about homebirth voiced by many women is the lack of emergency care readily available if the need should arise. A good homebirth midwife, however, is well trained in avoiding and handling complications and performing neonatal resuscitation. She has the proper tools with which to control hemorrhage if the need arises. She is well versed in normal birth and is willing and ready to transport a woman to the hospital if it becomes necessary. Because she has come to know the woman on an intimate level, having done all the lengthy prenatals herself, she is well equipped to handle emotional issues that may arise during birth. Her intuition and instinct are consciously developed and their use is a priority in the kind of care she gives. She is comfortable with offering massage and hugs and cradling the woman in her arms. When a homebirth midwife follows these simple and practical standards and techniques, statistics on homebirth outcomes look very sweet indeed.
Obstetric Myths Versus Research Realities by Henci Goer presents statistics gathered worldwide that clearly demonstrate the safety of homebirth with a trained attendant. Yet even though research has validated its efficacy, homebirth is still seen as unsafe. Cultural trends, an overzealous media, clever marketing, power mongering, rumors and fear perpetuate that view.
Without a doubt it's time for a paradigm shift. Technology should be used only when it's absolutely necessary and non-interventive, with spiritually based trust in birth as the dominant concept. Practical, experienced midwifery would be the rule rather than the exception. Parents can help achieve this by recognizing and accepting their true responsibility, by reclaiming their right to choice, by educating themselves, being determined and organized, and by choosing a midwife or doctor who will honor and abide by their wishes.
Planning a Homebirth
Compared to the external issues that surround homebirth, the nuts and bolts of homebirth seem easy! Finding the right care provider is the number one priority. A woman can ask her friends and neighbors, look in the phone book, go online or ask other alternative practitioners for recommendations. An initial interview will tell both the midwife and the pregnant woman whether the match will be a good one. In almost all cases a woman will find just who she needs. The care provider will set up regular visits, talk about pregnancy, labor and birth and possibly make referrals to childbirth classes. Classes help a couple learn about birth and parenting and can provide a network of new friends and families who are going through the same miraculous process.
As a midwife, I make a large library of books and videos available to my families to check out. Some people are avid researchers and want to know everything. But there are also those who prefer simply to live the experience. They should be honored for their own way of learning. The parents who don't want any responsibility or say in birth, however, are not homebirth candidates. They need the institution to fulfill their needs. Homebirth is a partnership in which parents and practitioners work together.
Homebirth midwives provide excellent prenatal care, spending an average of forty-five minutes to an hour on a prenatal visit. This gives us an opportunity to attain all the clinical information necessary and still have plenty of time for chatting and getting to know each other. This one on one care builds trust and friendship which will serve the birthing process well when the time comes. We take a personal interest in making each woman's pregnancy, birth and postpartum the best it can be, and because of that, our caseloads are usually small.
On the other hand, typical clinics maintain a high caseload to cover high overhead. Time spent with a client must be kept to a minimum: the average time spent on a prenatal is ten to fifteen minutes. Bonds of familiarity and trust are not a priority; volume is. But low risk is tied to thorough, multifaceted care, and clinics often do not provide it. Homebirth midwives familiarize themselves with both the physical and emotional facets of the women they serve. The acumen they gain through power of observation is an essential tool that keeps birth both normal and safe.
A plethora of instruments, drugs, apparatus, operating rooms, machines and even special clothing await a woman who births in the hospital. By contrast, homebirth midwives travel light (see sidebar). I have a rule not to carry anything I don't know how to use. This defines my standard and parameters of care. For instance, if I do not carry IV setups, then I call in help or transport if the need arises for their use. I personally make sure all my equipment is in proper working order. I check before, during and after births. I make a note of what gets used and what must get replaced. I keep my instruments sterile and ready for birth at all times. I also keep an extra set. I always have plenty of gas in my car. I check my pager to be sure everyone has access to me at all times.
The homebirth parents are well prepared too—it's part of their responsibility and their active participation in the process. By the time the woman is thirty-four to thirty-six weeks pregnant, they have their sterile packs ready and all their supplies in order. Their midwife has provided them with concise lists of what is needed, and together they review everything at a home visit well before the due date. This helps the parents feel ready and relaxed. Lists of phone numbers posted by the telephone ensure that attendants and others are just a call away when the woman goes into labor, and help can be called in an instant should it be needed during the birth. The lists should include the hospital emergency room number, labor and delivery NICU and any doctors who may provide backup.
Birth is a profound experience. While it includes basic physical functions like contractions, dilation, descent and emergence, the emotional and spiritual aspects play a major role in outcome. The two main models of birth—allopathic and holistic—diverge greatly in all these areas. Allopathic care, centered in the hospital, is based on institutional standards which promote separation. Holistic care, based in homebirth, promotes connection in all aspects of its care and ultimately between mother and baby. There are times when allopathic and holistic modalities collaborate effectively, such as in high risk situations. For instance if a woman is transferred from home to hospital she can bring her music or special power pieces if she wishes. She can bring a favorite nightgown, photos, blanket and pillow. She can retain her familiar holistic attitudes and a positive outlook, and stay centered and secure while using technologies that are well applied.
Once a woman is transferred to the hospital, the degree to which a midwife can continue to participate in the birth depends on individual hospital attitude toward homebirth midwives. At the least, she can remain at the hospital as a supportive presence. The midwife can be proactive by staying with the woman and encouraging her while being respectful of hospital staff, not confrontational. She should be familiar with interventions in order to help the woman make choices to take the least interventive path first. She should know the patient bill of rights. She can be most supportive by being nonjudgmental of what the woman may have to experience in order to birth her baby.
In most homebirth cases, birth will simply occur. In most cases of hospital births, the birth will be tampered with to some degree. This is fact. Hospital practitioners are trained to perform—it's commonly held that only action brings about results. At home we believe that if all is well, let it be.
Going into the new millennium, we have an opportunity and an obligation to create birth change. By educating the public, promoting homebirth, informing one woman at a time, and confronting the media when they get it wrong, we can enhance the homebirth movement and preserve its kind of care. Balance will be a key issue. Keeping birth normal while using technology wisely can become a true art. Guarding choice can become a priority. Midwifery care can expand and progress to answer growing consumer demand. And rightfully considerate care for all women can set the pace for better birth outcomes and healthier generations to come. I may be dreaming, but along with many, many others, I have dedicated my entire life to these visions in honor of and respect for all mothers, babies, families and the future.
- Arms, Suzanne. (1984). Immaculate Conception. Toronto, NY: Bantam Books.
- Dick-Read, Grantley. (1959). Childbirth Without Fear. New York: Harper & Row.
- Ehrenreich, Barbara & English, Deirdre. (1973). Witches, Midwives & Nurses: A History of Women Healers. New York: Feminist Press.
- Frye, Anne. (1995). Holistic Midwifery Volume 1. Portland, OR: Labrys Press.
- Gaskin, Ina May. (1990). Spiritual Midwifery (3rd ed.). Summertown, TN: The Farm Pub. Co.
- Goer, Henci. (1995). Obstetrical Myths Versus Research Realities. Westport, CT: Bergin & Garvey.
- Goldsmith, Judith. Childbirth Wisdom. Brookline, MA: East West Books.
- Harper, Barbara RN. (1994). Gentle Birth Choices. Rochester, VT: Healing Arts Press.
- Wagner, Marsden. (1994). Pursuing the Birth Machine. Campertown, Australia: ACE Graphics.
- Ward, Charlotte & Fred. (1976). The Homebirth Book. Washington DC: Inscape Publishers.
Ten Questions to Ask When Giving Birth
- Who can be with me during labor and birth?
- What happens during a normal labor and birth in your setting?
- How do you allow for differences in culture and beliefs?
- Can I walk and move around during labor? What position do you suggest for birth?
- How do you make sure everything goes smoothly when my nurse, doctor, midwife or agency need to work with each other?
- What things do you normally do to a woman in labor?
- How do you help mothers stay as comfortable as they can be? Besides drugs, how do you help mothers relieve the pain of labor?
- What if my baby is born early or has special problems?
- Do you circumcise baby boys?
- How do you help mothers who want to breastfeed?
Editor's Note: These questions and their recommended answers are based on the Mother-Friendly Childbirth Initiative which was created by a coalition of fifty organizations and experts on childbirth representing many thousands of educators. For a copy of a brochure with the questions and more information about the issues the questions raise, contact the Coalition for Improving Maternity Services (CIMS) at 2120 L St, NW, S-400, Washington, DC 20037; 202-478-6138; www.healthy.net, email@example.com.
Characteristics of the Technocratic Model of Care
Basic Principle = Separation
- Mechanization of the body
- Isolation and objectification of the patient
- A focus on curing diseases, repairing dysfunction
- Aggressive, interventionist approach to diagnosis and treatment
- Alienation of practitioner from patient
- Reliance on external diagnosis
- Supervaluation of technology
- Hierarchical organization, the patient as subordinate to practitioner and institution
- Authority and responsibility inherent in the practitioner
Characteristics of the Holistic Model of Care
Basic Principle = Connection
- Views the body as an energy system interlinked with other energy systems
- Insistence that total healing requires attention to the body-mind-spirit-emotions-family-community-environment
- A focus on creating and maintaining health and well-being
- Nurturant, relational approach to diagnosis and treatment
- Essential unity of practitioner and client
- Respect for the value of inner knowing
- Technology at the service of the individual
- Lateral, webbed organization-networking
- Authority and responsibility inherent in the individual
Thanks to Anne Frye, Holistic Midwifery, Volume 1: Care during Pregnancy. Labrys Press, 1995.
How to Choose a Midwife
The following questions may help the pregnant woman to select a midwife who is perfectly suited to her and her family:
- How did she become a midwife?
- What training has she had?
- Is she certified or licensed with any organization?
- Does she belong to any midwifery organizations, attend conferences and workshops and subscribe to professional journals?
- What is her basic philosophy of childbirth?
- How many births has she attended as the primary midwife?
- What is the fee for her services, how must it be paid, what does it include?
- What kinds of services are included in prenatal care? (early detection of problem areas for the mother and baby; nutrition information, exercise recommendations, inhome care; recommendations for parent education via books, videos, or classes)
- Does she work with another midwife or assistant at births?
- What does she do if there are two births at the same time?
- How do you reach the midwife; does she have a pager allowing 24-hour access?
- Does she handle higher risk situations, such as twins or breeches?
- How does she handle other problems or complications that might develop during labor?
- What standard and emergency equipment does she carry? What herbs or medicine does she use?
- Which ones does she not carry and why?
- Does she have any affiliation with a physician who can answer unusual questions during the pregnancy or an emergency situation during labor?
- What is her policy for transporting?
- What medical facility would she use? Has she developed a good working rapport with the staff at that facility?
- What kind of postpartum care does she provide? (frequency of baby checkups; assistance with nursing)
In addition to asking these questions, it is important to be clear about what you expect from your potential midwife. Be prepared to share your vision of the birth and discuss any fears you may have. Tell her how knowledgeable you are about birth at present and how informed you would like to become.
Determine if the midwife's answers to your questions agree with your desires. If your heart trusts her and you are both in harmony physically, mentally and spiritually, then you have found your midwife.
Editor's Note: Adapted from the article "The Homebirth Choice" by Jill Cohen and Marti Dorsey.
Maybe women need to ask more questions in choosing a midwife. While a homebirth midwife can facilitate a positive birth experience for a woman, she cannot create it. That is up to the birthing woman. She creates her birth experience and sets the stage by choosing the cast who will help her meet her needs. Birth belongs to women. When women take responsibility for their birth experience, they are less likely to blame others.
— Lisa Boisvert Mackenzie, midwife, Saipan
How to Find a Midwife
Sometimes you have to be a private detective to find a midwife. Since the choice of a birth practitioner is one of the most important decisions you'll ever make, a careful search is worth the extra effort.
How Safe Is Hospital Birth?
"Doctors argue that the decrease in mortality and morbidity rates as birth moved into the hospital proves that the hospital is safer. Even if that statement were true, it would not mean hospital birth was responsible for the decline, but the claim is false. In the 1920s middle-class women began having babies in hospitals partly on grounds of safety. By the mid-1920s half of urban births took place there, and by 1939, half of all women and 75 percent of all urban women gave birth in hospitals. Despite this shift, maternal mortality did not drop below the 1915 levels of 63 maternal deaths per 10,000 births until the late 1930s, when sulfa drugs and antibiotics to treat infection were introduced and more stringent controls were placed on obstetric practices. During that same time period, urban maternal mortality rates, where hospitalization for birth was more common, were considerably higher than overall rates. Infant deaths from birth injuries actually increased by 40 percent to 50 percent between 1915 and 1929.
"…One of the more potent myths of obstetrics is that women and babies died in huge numbers until obstetricians saved them from the ravages of the natural process and the ignorance of midwives. Quite the contrary is true. The endless parade of procedures and drugs that obstetricians have inflicted on women and babies since that time, including the much-lauded forceps, have maimed and killed more women and babies than ever have been saved by their use."
Excerpted from Obstetric Myths Versus Research Realities: A Guide to the Medical Literature, by Henci Goer, Bergin & Garvey, 1995
"Do doctors deserve the credit for the fall in infant mortality over the past 70–80 years? Or perhaps, infant mortality was very low centuries ago when midwives delivered babies at home. When the female healer, including the midwife, was eliminated through the witch hunts of the 17th and 18th centuries, male doctors took over. They had one characteristic that midwives did not possess—they performed autopsies. And they had a nasty habit of going from the autopsy table to the mother in labor without washing their hands or…even changing their bloody gowns. Is it any wonder that childbirth fever-puerperal sepsis-became the great killer of these times?
"Finally…toward the end of the 19th century, Ignacz Semmelweiss told the doctors "wash your hands…" and as [they] began to wash their hands, childbirth fever began to disappear. Now, my concern is that modern medicine has taken credit for the decline in infant mortality, but understandably enough, has never considered assuming blame for its previous rise."
Excerpted from "Childbirth Alternatives and Infant Outcome: A Pediatric View," by Robert S. Mendelsohn, MD, in Safe Alternatives in Childbirth, NAPSAC 1977
- Doppler (optional)
- Watch with a second hand
- Blood pressure cuff stethoscope
- Curved hemostats (2)
- Scissors with blunt tips (one pair)
- Scissors with sharp tips (one pair)
- Needle holder (1)
- Mosquito forceps (3)
- Cord clamp or cord tape
- Stainless steel instrument tray and cover
- Sterile gloves
- Regular exam gloves (non-sterile)
- Chux pads (extras)
- Water-based lubricating jelly
- Syringes (5 cc and 3 cc with 21/23 gauge needles)
- Suture material (3-0 chromic absorbable)
- Tetracycline or erythromycin eye ointment
- Vitamin K for the baby
- Nitrazine paper
- Urine test strips
- Dell mucous trap catheters
- Bulb syringe
- Amnio hook (if you use them)
- Cord blood tube
- Betadine solution w/ scrub brush
- Alcohol prep pads
- Fleet enemas
- Gauze pads (4 x 4)
- Water bottle
- Heating pad
- Tape measure
- Infant scale
- Scale for adults
- Oxygen w/ infant resuscitator and adult mask
- IV equipment (if you use it)
- Herbs, homeopathics, Bach flower essences
- Bendable straws
- A car in good running order w/ full gas tank
- Blankets for transport
Birth Supplies Ordered by the Midwife
I order my supplies for each birth from Cascade Health Care Products in Salem, Oregon.
Following is my basic birth kit.
- Underpad (13)
- Polybacked sheet (2)
- Sanitary pads (1 pkg of 12)
- Peri bottle (1)
- Gauze pads (12 4 x 4)
- Alcohol prep pads (15 med)
- Straws (2)
- Bulb Syringe (1)
- Gloves (6 pair)
- Scrub brush w/ Betadine (1)
- Povidone solution (1 4-oz bottle)
- Oral thermometer (1)
- Baby cap (1)
Cascade Health Supply can be reached at 503-371-4445. You may want to investigate your area medical supply outlets to see if they can tailor a birth kit for you. It's less expensive than buying items individually.
Spirit-led Childbirth (888-683-2678, www.birthsupplies.com/ and Yalad Birthing Supply (330-493-3050, PO Box 8111, Canton, Ohio 44711) are other companies which offer birth supplies.
Parents’ Birth Supplies
I ask each pregnant woman to have the following supplies on hand six weeks before the due date.
- One set of clean sheets (for the bed after the birth)
- One white or light beige fitted sheet (to fit your bed)
- Two brown paper bags (for laundry and trash)
- One box of 10 to 15 plastic trash bags
- Washcloths (8 to 10, light color preferred)
- Towels (6 to 8, light color preferred, half hand and half bath)
- One unopened bottle of olive oil (one pint or more)
- Receiving blankets (10 to 12)
- Rubbing alcohol (one bottle)
- Hydrogen peroxide (one bottle)
- Cotton swabs (one box)
- Unscented maxi pads (one large box)
- Raspberry leaf (tincture or tea)
- Vitamin C (1,000 mg, one bottle)
- Echinacea tincture (one bottle)
- Food and juices for the mother and birth partner(s)
Prenatal care is what you do between your visits to your midwife. There can be no safe homebirth without first attending to the best way to prevent complications—nutrition. Nutrition is the key to a healthy baby, pregnancy and birth. Eat from a wide variety of natural food sources. Eat 80–100 grams of protein per day. Make sure you get plenty of carbohydrates as well, or your protein will be used for carbohydrates. Do not avoid salt. Cells are bathed in salt and you are building millions of new cells constantly. You can avoid the worst complications by eating adequate protein and salting your food to taste. You will give yourself your best chance to avoid preeclampsia or toxemia, prematurity, intrauterine growth retardation, low birth weight baby, and abruption of the placenta. Your good health will help prevent hemorrhage and long labor, and you will give birth to what research pioneer Tom Brewer, M.D., terms a "blue ribbon baby."
If you develop any of these complications, up your protein to 100–120 grams per day, add salt liberally, and watch your symptoms go away. Oh yes, being happy really helps your baby, too. Research bears this out.
Jill Cohen has been a community midwife in Eugene, Oregon for more than 20 years. She has been with Midwifery Today for 14 years, where she is associate editor of Midwifery Today magazine and senior editor of The Birthkit. Click here for more biographical information.
For more information on homebirth, please see Midwifery Today's reference page on homebirth.
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