August 22, 2001
Volume 3, Issue 34
Midwifery Today E-News
“Homebirth”
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Quote of the Week:

"Medical birthing knowledge is based on absurd observations of women attempting to give birth in cages."

- Leilah McCracken


The Art of Midwifery

How many of you doulas were once baby-wearers and have a rebozo in your birth bag to show new mothers? I use mine for a birth ball carrier. It allows me to keep the ball inflated and clean when transporting it to interviews and to births.

- Jane McClanahan

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News Flashes

Anderson R. Greener D
A descriptive analysis of homebirths attended by CNMs in two nurse-midwifery services, Journal of Nurse-Midwifery. 36(2):95-103, 1991 Mar-Apr.

This study examined outcome data from two nurse-midwifery-operated homebirth services in Texas. All clients who planned a homebirth within the two services during 1987 comprised the population. Analyses revealed that women choosing homebirth with these nurse-midwives were more frequently married, usually white, and more educated when compared with the overall U.S. childbearing population. Analgesia, episiotomy, and cesarean delivery were all found at lower rates than is reported when birth occurs in a hospital setting; complications occurred less frequently or at similar rates to those reported in the homebirth literature and national statistics. Research, educational, and clinical implications of the study are discussed.
www.changesurfer.com/Hlth/homebirth.html


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Homebirth

Therefore the midwife acts without doing anything
And teaches without saying anything.
Things arise and she lets them come;
Things disappear and she lets them go.
She has but doesn't possess,
Acts but doesn't expect.
When her work is done, she forgets it.
This is why it lasts forever.

- paraphrased from the Tao Te Ching

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Tew, M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35(277): 390-94

Using the raw perinatal mortality rates (PMRs) from a 1970 British national survey, the hospital PMR was 27.8 per 1000 births versus 5.4 per 1000 for homebirths/general practitioner units (GPUs). This was not because hospitals handled more high-risk births. When PMRs were standardized based on age, parity, hypertension/toxemia, prenatal risk prediction score, method of delivery, and birth weight, adjusted hospital PMRs for each category ranged from 22.7 per 1000 to 27.8 per 1000 while homebirth/GPU rates ranged from 5.4 per 1000 to 10.5 per 1000.

The 1970 survey assigned a prenatal risk score to predict the likelihood of problems during labor. When PMRs for hospital versus home/GPU for the same level of risk (very low, low, moderate, high, very high) are compared, the hospital PMR was lower only at the very highest risk level. All differences, except in the "very high risk" category, were significant. The PMR for high-risk births in home/GPUs (15.5/1000) was slightly lower than that for low-risk births in the hospital (17.9/1000). Moreover, the PMRs in home/GPUs for very low, low, and moderate risk births were all similar, but hospital PMRs increased twofold between categories, which suggests that hospital labor management actually intensified risks.

The percentage of infants born with breathing difficulties (9.3% versus 3.3%), the death rate associated with breathing difficulties (0.94% versus 0.19%), and the transfer rate to neonatal intensive care units for infants with breathing problems who survived six hours (62.0% versus 26.2%) were all higher in the hospital (all p<0.001), further evidence that hospital interventions do not avert poor outcomes.

Although no national study has been undertaken since, smaller studies confirm that increasing use of hospital confinement is not the reason for the overall drop in PMR since 1970. In fact, those years when the proportional increase in hospital births was greatest were the years when the PMR declined least and vice versa.

- Henci Goer, Obstetric Myths Versus Research Realities, Bergin & Garvey 1995

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Women experience less pain at home

It is well understood that sensations of pain in labour are regulated by hormones released by the woman's body. During labour, oxytocin--the hormone that causes contractions and helps the baby be born--works in harmony with endorphins--the body's own pain relieving hormone. During a homebirth, the woman's body will release these hormones according to her needs and she will usually cope well with the sensations of labour.

When a woman attempts to give birth in another environment such as a hospital, however, this process may not work as well. Even if a woman feels rationally that hospitals are "safer" places in which to give birth, her subconscious mind knows that this is not the case, and she feels insecure. This causes her body to secrete the hormone adrenaline, which causes the levels of both oxytocin and endorphins to drop. She experiences far more pain than she would in her own home.

Women experience lower levels of intervention at home

There are two main reasons that women experience lower levels of intervention at home. The first concerns the hormones described above. Adrenaline inhibits the release of oxytocin, and labour may well slow down. Although this slowing of labour is a natural safety mechanism designed to let the woman know she needs to find another environment, it is interpreted by many medical professionals as "failure (of her body) to progress." Rather than suggest that the woman talk about her fears or find a different environment, they will turn instead to drugs to speed up the labour. This drug can cause distress in the baby, among other effects, and often itself leads to a "cascade of intervention" which may result in an instrumental delivery or a cesarean.

The second reason is that hospitals are systems that need to run efficiently. They need to have procedures in place for workers to follow so that chaos does not ensue. Unfortunately this often means that hospitals have policies where a certain number of interventions are carried out on all women who choose to give birth there. Often there is no evidence to support these interventions, and many of them are known to be harmful when used routinely. Every intervention is useful to a small number of women when used appropriately, but when applied to all women they often cause far more harm than good.

- Sara Wickham, excerpted from "Homebirth: What Are the Issues?", Midwifery Today Issue 50

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HOMEBIRTH is the theme of Midwifery Today Issue 50. It also includes one of the loveliest Photo Albums of a birth we've ever published!

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Birth is a lot like swimming. In my hospital delivery, I felt like there was a panic-stricken nonswimmer hanging on my back, pushing me under, and it took all my energy to keep my head above water. I managed to survive. In my homebirth I glided along, buoyed by my pregnancy and thrilling at the flow of liquid labor over my body and soul. I came out of the water beautiful and refreshed. I had grown into the woman I always knew I could be.

- Jennifer Schulz, The Birthkit Issue 23

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One of the most important things I accomplish at in-home prenatal care is an adjustment of attitude. I remind myself that I am a guest. As a care provider this puts me in my proper place with the family. I want to be able to sit on a pregnant woman's bed with her and have her feel so comfortable and relaxed that she can talk about anything with me. I want her children, dogs, cats, and partner to view my presence as a normal occurrence so that when it's time to birth, I'm just part of the family. It's a psychological thing. It creates an opportunity for care that is intimate, observant, focused, and humbling. Women love to be nurtured in their own environment. It shows my dedication to them when I honor their right to be at home. In-home care empowers mothers-to-be, reaffirming that it's good to be home. It gets them used to being there, prepares them for the time after birth, and allows them to relax and enjoy their nest.

For the midwife it offers a golden opportunity to see the family in process and progress. We can observe the stages of development during the childbearing year, what that creates, and learn how to make it fun and safe and empowering.

- Jill Cohen, The Birthkit Issue 20

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THE BIRTHKIT back issues

THE HEART AND SCIENCE OF HOMEBIRTH, a Midwifery Today book. A compelling combination of the heart of homebirth--the emotional and social reasons homebirth is desirable, and the science of homebirth--the research that has consistently found homebirth to be every bit as safe, and in some cases more so, as hospital birth. Over 90 citations of specific journal articles, discussion papers, books, and studies form the backbone of the book.


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A Web Site Update for E-News Readers

HOME SWEET HOMEBIRTH T-SHIRTS are available from Midwifery Today. Pretty cross stitch design!

HOMEBIRTH PACKAGE includes 6 conference audiotapes with teachers such as Ina May Gaskin, Elizabeth Davis, and Mabel Dzata; The Heart and Science of Homebirth, a Midwifery Today book; The Homebirth Choice, a Midwifery Today booklet.

FIRST DO NO HARM, SECOND DO SOME GOOD, conference audiotape featuring homebirth midwife Judy Edmunds.


Midwifery Today's Online Forum

I am a doula, childbirth educator and mother of three. This fall I start back to school to get my RN and will go on to midwifery. I may have to work as an RN for a while to pay off some loans before going to graduate school. I am a little worried about that.

I know that I will be a great midwife but don't know what kind of nurse I will make. In my mind the two professions have very little in common. Any comments, thoughts?

To share your thoughts and experience, go to Midwifery Today's Forums. Click on "Aspiring Midwife Chat" and "from doula to ob nurse to midwife."
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Question of the Week (Repeated)

Q: What are midwives doing when women test positive for group beta strep in pregnancy? What protocols are midwives implementing at the birth and postpartum?

- Anon.

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Question(s) of the Quarter for Midwifery Today Issue 60

What do you see as the strengths and weaknesses of your path to becoming a midwife? How does the current controversy over the various pathways to becoming a midwife affect your practice or your hopes for a practice? Do you have any specific thoughts about midwifery education?

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Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

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International Connections

In Thailand we have tried for alternative birth care at Charoenkrung Pracharak Hospital, Bangkok, for three years. Ms.Pisuit Patumasute, head of the labor-delivery unit, has given much thought to how nurse-midwives can give the most valuable care to mothers. She has tried primary nursing system and active birth approach at LR. It is very difficult to change because the medical model practice is dominant in Thailand. However, she is doing good work right now. I had worked in that LR from 1981-1992, so I appreciate the advances that have been made. There are nearly 5,000 births per year in this LR. Last week I interviewed six mothers regarding their birth experiences. I found that what they appreciated in their births was nursing support. I think it is time for birth care to change to the midwifery model. For more information and sharing, please contact tel. 66 2 2891479 or email me. I would like to hear the experiences of someone who has changed birth care.

- U.C.
Reply to: usa_chuahorm@hotmail.com

To make more international connections, join the International Alliance of Midwives (IAM)! IAM is an online directory of birth enthusiasts. To learn more, go to: www.midwiferytoday.com/iam

~*~*~*~*

In response to Lauren McGinley's letter concerning her mother-in-law's statement that midwives wouldn't know when to transport [Issue 3:32]: A study was published in the Dec 28, 1989 New England Journal of Medicine (probably the most prestigious medical journal in the U.S.) titled "outcomes of Care in Birth Centers." It goes into great detail about not only the excellent outcomes and safety of birth centers but the transports and why they were done. Perhaps you could ask to find out what the transport rate is at the birth center where you had your baby for a more close-to-home picture.
In addition, many comparisons of physician and midwifery care have shown that outcomes for women and babies of comparable risk levels are as good or better with midwives.

I am also curious about your sister-in-law's birth: How low did the heart rate go and for how long? What was done to facilitate birth? How many things were done before they got to the birth which might have decreased baby's reserve (such as Pitocin augmentation, directed "purple pushing," pain medications or lying on her back) or made the birth more difficult (not feeding her, keeping her in positions which did not favor baby coming down, or giving pain medications that decrease contractions)? Having a cord around the neck seems to be a focus of birth fear for many people, but 20% of babies have it, and rarely is it a big deal. One reason we listen to heart tones is for those rare cases when it IS a big deal.

I just heard a talk by Holly Powell Kennedy about research she is doing to define what it is that makes midwifery what it is. How is it that we get the good outcomes that we do? How do we think? How do we make decisions about what to do next? In her research, she has asked questions of both midwives (CNMs and direct entry) and women they have cared for. One overarching concept that emerged from extensive input from the group about what makes for exemplary midwifery practice: what's important is not *never intervening* but *knowing when* to intervene (and of course the converse of that is knowing when not to).

- Bernice Keutzer, homebirth CNM
IL

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Re: Lauren McGinley's letter: Your stepmother is not likely to want to read much that is in favor of midwifery. May I suggest leaving a copy of "Pocket Guide to Midwifery Care" by Aviva Jill Romm somewhere that she may pick it up if she chooses? Others in your family may also benefit and it will save you the stress to trying to "explain" to them anymore.

What should be important to them is how you feel about it and your birth choices. If they are more educated on the subject, they may be more supportive. But if they haven't listened to you up to now, I'd let them read at their own pace.

If there is any openness at some point, the education of others might be further assisted by offering a copy of "Obstetric Myths vs. Research Realities" by Henci Goer or her book "The Thinking Woman's Guide to a Better Birth." Then, if you really want to clarify some of the things midwives are trained to do (or not do), you might keep one of the major midwifery textbooks around--such as "Varney's Midwifery" 3rd edition by Helen Varney or even "Understanding Diagnostic Test in the Childbearing Year," 6th edition by Anne Frye. Many other books and textbooks are even more geared toward homebirth. Providing subtle learning opportunities may get some awareness going.

- Julia

UNDERSTANDING DIAGNOSTIC TESTS in the Childbearing Year and HOLISTIC MIDWIFERY Vol. I, both by Anne Frye, are available from Midwifery Today.

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To Lauren McGinley: We were doing a waterbirth and everything was going according to the book. I had been in labor for 25 hours when our baby presented butt first. My midwife was keeping check on the baby's breathing and recommended that we go to the hospital for an emergency c-section. (She had also said if I could push her out past her bellybutton that she would be able to deliver her, but I could not. She told me that if she was able to get her out the baby would need to be resuscitated, a procedure she was certified in.) After the c-section, we found out that the cord had been wrapped around the neck twice.

Having a midwife is like having a lifeguard, like insurance. I'm glad I tried for a natural birth and I wish it had worked out for me because the recovery from the c-section has been awful even though the doctor did an excellent job and things went well.

As in any profession, some people are better educated, experienced or more responsible than others, so just ask a lot of questions and read everything you can and you will be confident in your decisions and the midwife you choose.

- Linda

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EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.


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