Tuesday, February 28, 2012

A Look at Home Births

Giving birth at home is once again gaining in popularity. Until the first part of the 20th century this is how women brought their newborns into the world, but as hospitals gained in popularity, especially in the 40's, home births went out the door for the more clinical style hospital birth.

I feel very blessed that we have an opportunity to have a home birth for our third child. I wish I could have done it with all three. Although, in all fairness, my daughter's birth was overall a good experience and one I would hope for again if I went the route of going to a hospital.

While home births are gaining in popularity, I think there is still a lot of confusion about them. I know I didn't fully understand how it worked when I first started looking into them several years ago. One benefit we have today is that now that home births are more popular there is more information easily available about them and finding an experienced midwife has also gotten easier.

Certainly there are many that would question why in the world you'd choose to have a child in your home. It doesn't take much searching to find passionate advocates for both hospital births and home births and both sides have a variety of statistics that they use to support their beliefs (see here and here for against home births and here and here for pro home births). For several generations now we have been trained to believe that hospitals are the only place to have a baby safely. There is a system that has been set up that we are to follow, starting with the beginning of pregnancy and one that continues forward through the life of a child. While I am not here to tell you that no one should have a hospital birth, that certainly isn't true in my opinion, I do think that home births should be considered as an option. Every woman should consider all of her options and educated herself to make the best decision for her baby and her. We were designed to have babies and have been doing so since humans first came into existence. Some people embrace the idea that our bodies can give birth without a lot of assistance and others feel lead to have as much help surrounding the birth as possible. Are either wrong? No. For me, the issue comes more about the freedom to decide what is best for my baby's and my body. Either route someone chooses to go, there are going to be not so perfect outcomes and even deaths. What would truly be fantastic is if the two styles of giving birth could more greatly overlap giving women a far greater advantage to delivering a healthy baby without the use of drugs or other unnecessary procedures.

When I first started looking into home births it was overwhelming to figure out how the whole process worked. If you follow the standard protocol, things are fairly simple and there doesn't need to be a lot of decision making. You find a doctor that is in your insurance plan and then follow what they tell you to do. Home births fall into a category of their own and depending on what state you live in, the laws that govern midwives and the freedom to have a birth at home varies.

Local Laws and Finding a Midwife
One of the first places to start your research is to find out what your state allows and doesn't allow for midwives and home births. Each state is different. Just because there may be midwives in your area that provide home birth services doesn't mean they are doing it legally. Perhaps the legal aspect doesn't matter to some, but I do believe knowing the laws are important and will only help in making a final decision on what path to follow. The laws in each state don't only govern if you can have a legal home birth, but also what type of midwife you are able to choose and what type of certification they must have. 

In the past couple of years it seems that more sights have popped up that give a list of midwives that are available in certain areas. One list I found to be helpful for the Twin Cities was on Minnesota Birth.com. Outside of lists though, try to get recommendations from friends and family. I was able to not only find midwives on the list above, but also had friend recommendation and the midwives themselves gave recommendations for women who may be located closer to the home we are moving to. In the end I interviewed one person I found on Minnesota Birth.com, one who was recommended by a friend and one who several other midwives recommended because of her proximity to where I'm moving.

The different Types of Midwives and How to Choose
There are three types of midwives. Depending on the state that you live in you may have the flexibility to choose the midwife of choice. The state of Minnesota has some of the most flexible laws surrounding midwifery care and we are blessed to be able to choose from any of the three types of midwives that are outlined below.

Jill Cohen shares an explanation of the different types of midwives in her articles The Homebirth Choice on Midwifery Today:
Certified Nurse Midwife (CNM): 
A Certified Nurse-Midwife is a registered nurse who is educated in the two disciplines of nursing and midwifery and has been certified by the American College of Nurse-Midwives (ACNM). She may work through a hospital, in a birth center or in an independent homebirth practice in collaboration with a physician. Only about 150 CNMs do homebirths, however, because they are required to have a written collaboration agreement with a physician.

Certified Professional Midwife (CPM): 
A CPM is certified by the North American Registry of Midwives (NARM). She has generally passed both a written test and a skills exam. Her training may be through an academic setting or it may be through the time-honored apprenticeship model, or even a combination of the two. Apprenticeship is encouraged. CPMs work in birth centers or at home. As of 2007, 24 states regulate the practice of homebirth midwifery through either licensure, certification or registration with the state.I In 11 states, the practice of direct entry midwifery is illegal (Source: MANA.org). More complete definitions and explanations can be found in Paths to Becoming a Midwife.

Direct Entry Midwife or a Lay Midwife:
A lay midwife is a woman who has apprenticed with an experienced midwife and may have attended school or workshops and classes to supplement her education. She attends births at home or in birth centers. She may be affiliated with a physician, but she is not under the physician's directive. She either chooses not to be certified or certification may not be available in her practice region.
When choosing a midwife, DO YOUR RESEARCH! Don't pick the first person you find, unless they are a good match and do plan to interview at least several people if possible. Talk to friends and perhaps look for recommendations through online communities. Have a list of questions and concerns ready for the interviews, but also be looking for a good personality fit.

Some questions to think about:
  • How many births have you attended?
  • What has your training been?
  • Are you certified?
  • Do you work alone or do you have assistants? 
  • What is your protocol if there is an emergency?
  • Do you know how to spin a baby (this is turning a breach baby before they are born)?
  • Have you had experience with a breach birth?
  • Are you familiar with how to use vitamins, herbs and homeopathy to help with issues in pregnancy? 
  • What aren't you comfortable with? 
  • What is your cost?
  • Do you accept insurance?
  • Where do we meet for prenatal and postpartum appointments? 
  • What happens if I have to go to the hospital?
  • Do you have references?
  • Do you offer ultrasounds, blood work and other tests?
  • If so, are they mandatory or can I decide what I do and don't want to do. 
  • What do you do if I start hemorrhaging?
  • What emergency supplies do you bring with you?
  • Do you have back-up help?
  • How many births do you book in a month and what happens if you have two births happen on the same day?
Don't for a moment hesitate to share your concerns and apprehensions during the interview process and throughout all your prenatal visits. It's important to have open communication and there are no dumb questions. If for any reason your midwife isn't prepared for you questions and doesn't seem interested in investigating to find an answer or looks down on you for what you've asked, than it's perhaps time to move on and find someone who is a better fit. Ultimately this is about your baby and you. While certainly people have given birth to healthy babies with no problems at all in a various number of ways, having a well trained, informed, knowledgeable person at your side is only going to be to your benefit if there is a problem. Just realize that this person doesn't need to be an OBGYN or an MD.

Each midwife is different and approaches the birth differently. Of the three women I interviewed, all three where unique in there own way. All three would have done an excellent job and where well experienced and knowledgeable, but I related to each of them differently.

Consider the care that the midwife has to offer. Despite the fact that your are giving birth at home, there is still certain basics that one would go to a doctor for that a midwife can do too. Many midwives do have ways for you to have ultrasounds, blood work completed and other tests done if it's your desire. They typical work with a clinic where you can go to have the test/ultrasounds done and then the results are sent to them. Some midwives can also draw blood and do many test in their own office. Don't assume that because you aren't going mainstream with your delivery that you can't still have some of the mainstream services. I think the biggest difference is that with a home birth midwife, the tests and ultrasounds can be optional. They also have a greater flexibility with how they test.
My Experience: 
I had no desire to do the standard test for gestational diabetes. First I'm not overly concerned about there being a problem because of the diet I maintain, but also I don't want to drink a syrup that is filled with ingredients that are terrible for my body. So, instead my midwife gave me a blood sugar meter to use for a week and test my blood sugar after fasting (first thing in the morning before eating) and after several meals during the day. I much prefer going this route, especially since I actual get to see what my blood sugar level is doing after certain foods I eat. It's for more educational than drinking a cup of syrup.
One other aspect that someone may want to consider is where prenatal and postpartum visits are going to be with the midwife.
My Experience:
All three of the midwives I spoke with had a different set-up. One had a specific office area built at home for appointments. Another had her appointments in her regular home and it was very relaxed. The third had an actual office space that I went to for visits. All three had me coming to them for most of the prenatal visits, except around 36 weeks when they would come to my home and become familiar with the setting. The first couple days of postpartum visits also would take place at my home and then the 2 week and other visits there after would be back on the midwife's turf. Some midwives do all visits at your home, which can be especially helpful if you have other children at home. 

Insurance and Cost
Many of us rely heavily on our insurance companies to cover our health care, and pregnancy and birth are no different. While perhaps in the perfect world it would be wonderful to be able to make our decision not based off of finances, it's the reality of the world we live in, especially in our struggling economy. Most insurance companies will likely not cover a home birth, but don't let this deter you right off, because this doesn't mean you'll actually spend more out of pocket money than in a hospital birth.

The average cost of working with a home birth midwife is $3,000 - $3,500 in the state of MN (and in most other states as well). This covers all of the prenatal visits, the birth and postpartum visits. What it often doesn't cover are extras like ultrasounds, blood work and the birthing kit. While insurance may not cover the midwife expenses, it is very likely that it will cover those extras, except perhaps the birthing kit.  The birth kit itself runs from $40-$100 depending on the midwife and where they order supplies. It includes the disposable items like pads, gauze, gloves and so forth that will be used when you give birth.

Many midwives do accept insurance and work with insurance companies, so at the very least they can submit claims for things like ultrasounds and blood work. Even if your insurance will not cover the costs, it's possible they will allow certain expenses to be applied to your annual deductible.
My Experience:
Our insurance covered all of our prenatal visits for our last two children as long as I saw a midwife that worked within the medical system (certified nurse midwife) at a regular clinic/hospital. Our insurance also covered the first two ultrasounds and all of the typical testing that is routinely done. However, in both pregnancies I was told to have more than two ultrasounds for various reasons. I felt like I had little option, but to go along with what I was told to do. Those extra ultrasounds cost us about $400 a piece out of pocket. So, although insurance may cover most things, be aware that you can be pushed/strongly encouraged to do more tests than necessary and more than what insurance will cover. With the actual birth at the hospital we had to meet our deductible before any of the expenses were covered. Our deductible is pretty high, higher than the cost of a home birth midwife, so by the time we paid our deductible (minding that in both of my last pregnancies our deductible reset itself sometime during pregnancy/birth and we had to pay even more out of pocket) we actually ended up paying more for a hospital birth, than a home birth, even with us not using our insurance at all.
Also, there is far more flexibility with what type of test/lab work you want to have done for a home birth (at least this is so in the State of MN). Some people may feel inclined to have nothing done, while others want the ultrasounds and so forth.

In the end, understanding how your insurance works, what it will cover, how much the deductible is and so on, will make a big difference in how much a hospital birth would cost versus a home birth.

Home births are not for every woman, even if she desires to have one. If there is concern that the pregnancy is high risk, than the hospital is likely the best place for your baby and you. The midwife can help discern what issues would lead for a hospital birth. This may vary from one midwife to another. Some are more comfortable and better trained in certain areas that may lead to a high risk situation. For instance, a mother with diabetes, twins or a breech baby won't be handled the same way by every midwife. It's important that depending on the personal situation, that the midwife you choose to work with is comfortable with these situation and has had first hand experience in what to do if there are complications and is very knowledgeable about when it's time for help and to have you go to the hospital.

Safety also plays an important part into why it's good to interview your potential midwife and get recommendations. You want to know that the person you are working with is experienced. I have run across some truly heartbreaking stories on the internet where things have gone wrong in the birth, that would have not been a problem if the midwife had been better trained and known what to do when certain signs started to appear. It must be said though, that this is also true with a doctor and a hospital birth. Not every professional has the same experience even if they have a certain title associated to their name. Sadly the US doesn't have the best statistics supporting it's infant mortality rate and these are based primarily off of hospital births.

A couple of articles that may be of interest about infant mortality rates in the US:

However, in comparison to the early 20th century and before, overall the infant death and maternal death rate are down significantly, both for hospital and home births. A great deal of this is likely due to better training, better cleanliness, and mothers receiving overall better care. Now why is the US struggling behind so many countries with our infant mortality rate? Take a look at our standard diet, especially in comparison to the countries who rank higher than the US and then see if you don't have a better idea of where at least part of the problem is coming from.

In the end if you choose to deliver at home, the hospital is a phone call and an ambulance ride away.
No matter where you decide to deliver, it's vitally important that you inform yourself of the different procedures that happen when the birth isn't progressing by either natures, a midwifes or the hospital timeline. Understand the pros and con's of things like petocin, epidurals, cesarean sections. Don't rely on your medical professional to give you all the information. I will attest to first hand experience, that I knew little of the repercussions of taking the drug petocin in my first pregnancy. The movie The Business of Being Born, dives into this subject a little bit. While I wouldn't recommend this movie for everyone, it does share a different perspective and can encourage a mother-to-be to ask more questions and be prepared for some of the different situations that may come up in her birth.

So some may be wondering, which birth place is actually safer, one that takes places at a hospital or one that takes place at home? Well, statistically speaking, from what I've read, home birth are technically safer, but that is likely because midwives don't typically take on high risk pregnancies. None of the midwives I researched or spoke with ever had loss a baby or mother, but I believe most of them had to transfer a woman to the hospital at one point in their careers. This is typically because of a first time pregnancy and things not progressing like the midwife would have liked. No matter where you look your are going to read or hear about sad, difficult stories whether the birth took place at home or at a hospital.

Basic Pros and Cons
  • You can deliver your baby in the comfort of your own home
  • There is usually complete flexibility with how you'd like to give birth; squatting, in a birth or bath tub, lying down
  • The birth process can be more flexible and it's less likely that you'll be forced to do a procedure you aren't comfortable with
  • You are giving birth in the same environment that your immune system has been accustomed to (This was a huge one for me. I have gotten very sick after both births, a great deal of this certainly has to do with over exhaustion from not being able to sleep at the hospital and what giving birth takes out of you, but I have truly questioned what we are opening our bodies up to in a strange environment that we've likely not been in before. This also means the baby is in the environment that their immune system has already begun to develop in and they don't have to fight off unknown illnesses or sicknesses from the strangers that they can come in contact with.)
  • You can sleep in your own bed
  • You get to eat your own food and eat it when you want it (I really needed to eat during my first birth and soon after my second. The first time around it was very difficult getting the nurses to understand that I knew my blood sugar had dropped significantly and them trying to get me to walk right after birth was almost impossible because I was so weak. Having food when you need it can be a huge benefit to keeping up strength and energy in the birth process. Also, if you aren't one for processed and questionable ingredients than having access to your own healthy food is a huge plus. I think having extremely nourishing food from the get go is essential for the health of the baby and mother and sadly hospital have yet to figure out what healthy food really is.) 
  • Your baby stays right with you the whole time. Even measurements can be taken with baby right next to you (This is very important for initial bonding.)
  • Baby doesn't have to go through any unnecessary test
  • If you have other children, you don't have to find childcare help and they can be apart of the process if you want them to be
  • There are no time restraints for how quickly you must have your baby (A 24 hour window is very typical at a hospital before the recommend induction or a cesarean section. The problem is that labor varies from woman to woman and sometime it needs to go longer. This isn't necessarily detrimental mother or baby as long as both are staying healthy.)
  • Insurance often does not cover the basic costs
  • You are further away from the hospital if something goes wrong or an emergency comes up
  • If you have children, they may be close at hand unless a friend or family member takes them. 
  • You are on your own soon after the birth is completed. (The midwife will be there for 3-6 hours after the birth, but then you have to kick it into mom gear. This would be a bigger deal for first time moms. However, the midwife is still available by phone and if a problem arose, she could certainly come back.) 
  • Your spouse or you need to be ready to either have meals on hand or be prepared to make then as needed. No hospital food waiting for you. 
  • There may be some extra clean-up after the birth, but the midwife will likely have most things done before she leaves
Other Things to Consider
While not customary in our culture, in many different places of the world the first hours, days and weeks of a babies life are extremely private. Many women have no contact with other people outside of their family so that the baby has time to build up it's immune system. It's also a strong time of bonding. In the movie The Business of Being Born, they discuss how vitally important having a vaginal birth is as well as how important those first hours are for the initial bonding and nursing. Home births allow for these first weeks of seclusion, if it's your desire, so that baby has time to build up it's immune system.

Having the support of your husband is very important. This isn't just your child, it's his too. Be considerate of your spouse if he isn't on board with a home birth. My husband wasn't at first, but after doing more research and gaining greater understanding, he now feels comfortable and is very supportive.  Remember, your husband loves you and it can be scary for him to think about something going wrong.  I think it's very important to respect our husbands. If your husband is completely against having a home birth, then consider looking at other alternative. Perhaps going to a birth clinic may work and can be a nice compromise. You can always continue to try to encourage him to change his mind by helping him become more informed. Normally you can change from a doctor or another midwife to a home birth midwife up until 26 - 28 weeks into the pregnancy.

Make sure to be taking good care of your body. What we put in our bodies directly affects our health and our babies health. Whether you are delivering in a hospital, at a birth clinic or at home you want your body to be strong and to be at it's peek for health. This means being very conscious through your whole pregnancy to take care of yourself. Don't binge on the processed junk foods, get the best sleep you can and try to exercise. You want to give your body and your babies body every advantage they can have for a smooth birth. It's hard work giving birth and it takes a lot out of the body. Think of it this way. You aren't going to eat fast food for nine months and not exercise and then expect your body to run a 10k effortlessly? Why would birth be any different? It takes effort on your bodies part, it's not a couple of pushes and baby comes out (well at least not normally). Birth is a whole body effort as the sore muscles will remind you a couple of days after giving birth. Your responsibility as a mother begins at the point of conception, not once your baby has made it's appearance. Do what you can to learn about nutrition and how to keep your body healthy. Before taking any particular medication that may be given, look and see if there are alternative ways to correct the issues that don't require putting questionable meds into the body.

In the end, don't let fear make your decision about where to give birth, but instead make your decision based off of wisdom and knowledge. As a born again Christian, I think being prayerful through each step of decision making is vitally important. Put our reliance on the Lord and trust Him to provide us with the Wisdom we need to make the right decision for ourselves and our families.

To read about my last pregnancies check out the links below:

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