Answering the Question of Homebirth

Editor’s note: This article first appeared in Midwifery Today, Issue 93, Spring 2010.
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It is inevitable. In every single childbirth education class and doula prenatal meeting I lead, I am asked “the question.” It never fails. Sometimes a particularly well-read mother or partner asks it at our first meeting before we even start getting down to business. Other times it doesn’t come up until the last meeting, after we’ve watched videos of particularly beautiful births and are saying, “Goodbye, until the baby comes.” But most often the question is asked when we talk about interventions.

So what is this powerful question? In some way, shape or form, my clients ask, “Can I have a homebirth?” And, sadly, my response is always along the lines of: “What county do you live in?” Because in Western Pennsylvania where I live, teach, and act as a doula, homebirth midwives are no longer attending births or, at least, they’re not advertising their services. You have to know someone who knows someone who can put you in touch with someone.

Because I am a doula and instructor of hypnosis for childbirth, the majority of my students and clients are seeking a natural birth experience. The majority also are low-risk, younger than 40, and somewhat knowledgeable about birth. They come to me because they want a different experience than they have had with a prior birth or than the horror stories they have heard in the media or from friends. I teach them about all the terminology, the tests and ways to negotiate to get what they want. I talk to them about strategies to get care providers to slow down and listen to them and that, when all else fails, to bring a man in a suit (perhaps the father or grandfather of the baby) to intimidate their care providers into taking them seriously. I also ask them to consider where they are birthing and with whom and explain the midwife’s model of care. During all this I know the best chance they have to achieve their desired gentle, natural birth, is to give birth at home. But, living in Pittsburgh, they do not have that option.

While homebirth is not technically illegal in the state of Pennsylvania, meaning currently no laws regulate birth in the home; it is “alegal”—tolerated in practice, but midwives (traditional as well as certified professional midwives) can be ordered to cease and desist for practicing without a license. This leaves it up to the discretion of the local law enforcement to pursue cases against midwives who attend homebirths that result in transfers to hospitals or result in poor maternal or fetal outcomes. The profession’s questionable status combined with the prominence of several major medical systems in Pittsburgh has led to the prosecutions of a number of Western Pennsylvania midwives, making it nearly impossible to locate a midwife willing to attend a homebirth in this part of the state. The birthing culture here is a conservative, medically managed model of care. When I began researching resources for my students and clients in 2007, I was able to find only three midwives within driving distance of Pittsburgh and none were willing to be put on my referral list. Instead, moms-to-be network on local attachment parenting and natural living e-mail groups, posting requests for information on midwives, and receiving referral information privately.

When I am with a birthing mother in her home, helping her relax and nest, watching her go from uncertain to confident and comfortable in her temporary role, I cannot help but think about what is to come. How we will soon interrupt this wonderful birthing dance and move her to a new place with new people, bright lights. and invasive exams and monitors. We are going to ask her to let go of her inward focus and answer questions about her pain level, contraction frequency and duration, and many other things so that “we” can figure out what her body is doing and how to “fix it” or make it go faster and “better.” How, when we arrive and check in, there is very little that I, as the doula, can do to stop the cascade of interventions if, for some reason, her body takes longer than average to dilate, her baby descends more slowly than desired, or her urge to push is delayed or takes longer than is deemed “necessary.” It feels like a crime that this mother is not allowed to remain in her own space, with a watchful and respectful birth attendant.

As a doula, the best solution I have found is to encourage my clients and students to stay at home as long as possible. However, the expectation of having to move can prolong a labor if the mother is holding back or fearful about leaving the comfort of her home to transition into a new place. If this anticipation of moving causes tension, the mother may arrive at her birthing location and find that she is not as far along as she had hoped—and the cascade of interventions begins.

For doulas, who are not able to perform dilation checks, it can be difficult, especially with first-time moms, to tell when the time has come to move from home to the birthing center or hospital.

A woman can experience transition-like sensations at different times during her birth, and it can be hard to gauge where she is without the luxury of additional time. While precipitous births in cars are rare, it is still something that can happen if the couple wait too long to transition out of the home. No doula wants to bear the responsibility of having suggested they wait longer.

The irrational “illegality” of homebirth robs women of the opportunity to birth unmolested. It robs babies of the opportunity to have a truly natural birth, and it robs families of the empowerment that comes from taking charge of their care. As a doula, I teach the ultimate contradiction: parents have the right and power to make decisions about their and their child’s care, but they don’t have the option to give birth in their own homes. But I’ve been getting “that question” more often, and more families here are beginning to stand up for their rights in hospital settings. My hope is that they will take this a step further and demand the right to birth at home.

How to Perform a Dilation Check without a Vaginal Exam

Editor’s Note: Sharon Craig of Kabul, Afghanistan, learned this trick from midwife Molly Caliger while studying with the Russian Birth Project in St. Petersburg, Russia. This “trick of the trade” originally appeared in Midwifery Today, Issue 78.

This technique is based on the fact that as labor progresses, the uterine muscle of the cervix (lower uterine segment) is pulled up and the muscle fibers in the uterine fundus increase and become larger. A practitioner who has mastered this skill can know how dilated the cervix is by how many fingers fit between the uterine fundus (the uppermost part of the uterus) and the xiphoid process (the lowest part of the sternum). Each finger that can fit indicates two centimeters of cervix that still needs to dilate before reaching complete dilation.

So, taking into account existing IUGR or preterm fundal sizes, if you can fit five fingers between the fundus and the xiphoid process, the cervix is closed. If you can fit two fingers, the cervix is six centimeters dilated. This technique is tricky to learn, but very helpful to use to determine progress without being invasive, and can be done at the same time as assessing intensity and timing of contractions.

About Author: Vanessa Turner

Vanessa Turner is a professional doula and childbirth educator in Pittsburgh, Pennsylvania. Normalizing homebirth and midwifery care as the standard for low-risk mothers is her passion and she hopes to become a CPM after her children are grown.

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