Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
Our Bodies, Ourselves (79 page)
The environment, culture, and routine practices used in different birth settings can affect the process of labor and birth. If you are healthy and have not experienced complications in your pregnancy, you can choose from any of the options in your community, which may include giving birth at home, in a birth center, or in a hospital. Some communities have several hospitals that provide maternity services, so if you are planning a hospital birth you may want to evaluate each one.
Home birth is a good option for healthy women who have healthy pregnancies, a safe and supportive home environment, and easy access to backup medical care. Two critical characteristics of home birth are that you rely on your body's natural abilities (not technology or drugs) to get you through labor and that you can receive continuous support from attendants of your own choosing. Home birth is associated with a very low likelihood of having a cesarean, episiotomy, medications to speed up labor, and pharmacologic pain relief and with high rates of satisfaction.
ONLINE HOSPITAL AND CARE PROVIDER RATING SITES
Many websites allow health care consumers to rate and provide feedback on care providers and facilities. Other sites provide safety and performance data for hospitals. These sites, in turn, help consumers looking for health care evaluate the choices in their communities.
The Birth Survey is a grassroots project that aims to increase transparency in maternity care. The site invites women who have given birth to provide feedback about care providers and birth settings. Survey questions are designed to assess whether care is evidence-based and mother-friendly, as defined by the nonprofit Coalition for Improving Maternity Services. In addition, project volunteers have been working with state health departments to obtain and publish facility data such as rates of cesarean section, induction, and episiotomy. You can view consumer feedback and intervention rates for the providers and facilities in your area at thebirthsurvey.com.
Midwives are specifically trained to monitor mother and baby's well-being during labor and to handle complications that may arise. Sometimes complications or a desire to use pain medication may require transport to a hospital. Many home birth midwives carry equipment to help address these needs before and during a transfer. In most studies of planned home birth, 10 to 20 percent of women who begin labor at home will transfer to a hospital before birth, but most of these transfers are for nonurgent situations, such as exhaustion, slow labor progress, or need for pain relief.
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QUESTIONS TO CONSIDER ASKING MIDWIVES AND DOCTORS
⢠What is your philosophy of childbirth?
⢠How long have you been practicing? How many births have you attended as the primary attendant?
⢠Do you practice alone or with others? If with others, what is their experience? Do they share your beliefs and manner of practice?
⢠Who attends births for you when you are away?
⢠Where do you attend births, and can I take a tour?
⢠How can I reach you?
⢠How often will I see you during these next months?
⢠What kind of childbirth preparation do you recommend?
⢠What tests do you recommend for pregnant women? Why?
⢠How do you define and handle complications?
⢠Do you provide labor support and stay with women throughout labor? If not, do the nurses provide one-on-one care for women during labor?
⢠How do you feel about doulas, labor assistants, or family and friends being present?
⢠Do you support moving around during labor, changing positions, and eating and drinking?
⢠Will I see you after the birth takes place?
⢠If I want to hold my baby right after birth, breastfeed, and not be separated, will that be supported?
⢠If I plan to breastfeed and experience problems, what support will you offer?
⢠Under what circumstances do you recommend IVs, continuous electronic fetal monitoring, Pitocin, episiotomy, forceps or vacuum, cesarean section, or immediate clamping of the baby's umbilical cord? What is your cesarean rate? Episiotomy rate? Induction rate?
⢠What is your protocol for the birth of twins and breech births?
⢠Do you attend vaginal births after cesareans (VBACs)?
⢠How much do you charge? Are your services covered by my insurance?
Additional Questions for Care Providers Who Attend Home and Birth Center Births
⢠Are you licensed and certified?
⢠What are your requirements for accepting patients to give birth in this setting?
⢠What drugs and equipment do you have available?
⢠What are the qualifications of your birth assistant?
⢠Do you have a formal agreement with an obstetrician-gynecologist to provide care if complications occur?
⢠Do you recommend that I meet the physician who will assist me in case of a complication?
⢠What hospital will I be transported to if a complication occurs during labor? What about in an emergency?
⢠Under what conditions would we go to the hospital?
⢠Would you stay with me if we transfer?
⢠What percentage of your clients transfer to a hospital during labor?
⢠Are you trained in newborn resuscitation?
⢠What kind of postpartum care can I expect? Do you provide follow-up care for the baby as well?
Freestanding Birth Centers
Birth centers provide comprehensive family-centered care for women during pregnancy, childbirth, and the time following birth. In the birth center philosophy, pregnancy and birth are normal and healthy processes that should be interfered with as little as possible.
Usually birth centers are homelike places, in contrast to the more institutional setting of hospitals, with added comforts such as birth tubs and birthing balls for relaxation and to relieve pain. Midwives provide personalized, continuous care to laboring women. Birth centers have systems in place to deal with complications during labor and birth and to transfer you to a hospital if necessary.
As with home birth, at a birth center you can expect greater reliance on your own physiology rather than on technology, a focus on individualized care, and staff available to give you continuous support.
Birth centers vary in their rates of using tests and procedures, in their policies and restrictions, and in their medical backup arrangements. There are certain situations in which you may be required to switch to hospital care before or during laborâor even after giving birthâeither as a precaution due to complications or in the rare event of an emergency.
Not all women are eligible to give birth at a birth center, and each has its own screening guidelines. Most commonly, this affects women seeking vaginal births after cesarean sections (VBACs). (For more
information on VBACs.
) You can find out if there is a birth center in your area through the American Association of Birth Centers (birthcenters.org).
A birth center located within a hospital may have a philosophy and practice anywhere on a continuum between that of a typical freestanding center and that of a hospital. Though many hospitals call their traditional labor and birth units “birth centers” in marketing materials, an in-hospital birth center is separate from the general labor and birth unit and is designed for healthy women who desire midwifery-model, low-intervention care. In most cases, women who need medical interventionsâsuch as intravenous Pitocin or electronic fetal monitoringâor women who desire epidural analgesia will move to the general labor and birth unit for these procedures.
One advantage of in-hospital birth centers is the close proximity to surgical and anesthesia facilities, should they be needed. However, in-hospital birth centers are more likely than freestanding birth centers to place restrictions on laboring women, such as requirements for a period of continuous fetal monitoring before admission or certain routines for newborns.
A hospital is the standard setting for many women who prefer to be close to medical care while giving birth or who intend to use an epidural for pain relief. It is also the setting of choice for women and babies who have medical conditions that increase the chances of needing special care. Hospital care is considered safest for women with high blood pressure, diabetes, or seizure disorders; women carrying multiple babies; women who are delivering prematurely or who are more than two weeks beyond their due date; and women whose babies are not in a head-down position or have problems that have been identified during the pregnancy. If you have one of these conditions, you will want to be with practitioners and facilities with experience handling your situation.
IS IT SAFE TO GIVE BIRTH AT HOME?
The media tend to portray childbirth as a high-risk event where anything could go wrong at any time. It is therefore not surprising that most of us feel that the safest labor and birth setting is the hospital, where we can be constantly monitored for problems and an operating room and surgical staff are available in case anything goes wrong.
But the reality is that most complications that occur in labor and birth are predictable. They tend to occur in women with high-risk pregnancies, develop slowly, or are known side effects of labor interventions such as medications to strengthen contractions or reduce pain. Although urgent complications can occur without advance warning, these are the exception rather than the rule.
Still, many women wonder if home birth can be as safe as hospital birth. Researchers have been studying this question for decades. Until recently, virtually every study suffered from major flaws that resulted in promising data but no clear answer to the safety question. More recently, three studies have been published that meet the highest standard for home birth research.
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One of these, a study from the Netherlands, where home birth is common, looked at the outcomes of more than a half-million planned home births. These studies show no difference in death or serious injury to babies and much better outcomes for mothers in planned home births.
Importantly, the three recent studies came from countries where only healthy women at term, with no risk factors for complications, may plan home births. In addition, midwives in these settings are highly skilled and regulated and have established relationships with consultant physicians and hospitals, so women or babies who need hospitalization can access it easily.
For these reasons, the outcomes of the studies cannot necessarily be applied to the United States, where there are no standard eligibility requirements for planned home birth. Laws regulating midwifery vary across the United States, and some midwives work without any formal arrangements for consultation and referral. Still, the largest study of planned home births in the United States showed excellent outcomes for both mothers and babies with low rates of obstetric complications, although the study did not meet the rigorous standards of other studies because hospital data on low-risk women in the United States are inadequate.
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In practice, the safety of home birth depends on the health of the woman and fetus, the skill of the home birth care provider, the distance to a hospital, and the ability to get safe, timely care at that hospital should a complication develop. Consider each of these carefully when exploring the option of planned home birth.
For some women, there are disadvantages to giving birth in a hospital. Hospital routines, which are set up to promote efficiency and to facilitate emergency medical treatment, are sometimes not flexible enough to accommodate an individual woman's needs. Providers who work in hospitals, even if they believe in informed choice and supportive, low-intervention care, are often constrained by hospital protocolsâsuch as policies forbidding vaginal birth after cesarean section or restricting what women can eat or drink in labor. Interventions such as cesarean surgery, vacuum- or forceps-assisted vaginal birth, and episiotomy are significantly more common in hospitals than in birth centers or the home birth setting.
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If you don't have a doula or other knowledgeable support person, assistance with nonmedical pain management will depend largely on the skill and availability of the labor and delivery nurses. You may be able to request a nurse with such experience when you arrive at the hospital, if that is important to you.
There is wide variation among hospitals. Some adhere to best practices, attending to the emotional and physical comfort of women and honoring informed choice, while others impose rigid routines and impersonal care. Likewise, rates of procedures such as cesarean surgery and outcomes such as infection vary across hospitals. If you live in an area with more than one hospital, it is best to ask knowledgeable people, such as childbirth educators or doulas, for their opinions of area hospitals and to check published quality reports if these are available. (Search online for “maternity care quality” and your state or region, or contact your state department of health.) The Birth Survey (thebirthsurvey.com), a nationwide grassroots project, offers intervention rates (where available) and consumer feedback on hospitals as well as birth centers.
I almost never hear of the totally natural, completely positive hospital birth experience, and that's why I'd like to share our story. . . . We chose the hospital we did because of the fact that there were many nurse-midwives on staff that I hoped would be supportive of my desire to have a natural birth. I . . . felt very supported by my husband's medical knowledge and he knew how strongly I wanted to do it drug freeâhe would be my advocate. He also shared a very empowering piece of advice with our birth class: that should you be in a hospital and not comfortable with the plan, you are entitled to say that you understand the risks and benefits of a procedure and [you] can refuse it. That is your right
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