Best-Laid Birth Plans

I am Canadian. New York magazine, therefore, hits my news stands three weeks late and I have only just read “Extreme Birth,” Andrew Goldman’s article about NYC home-birth midwife Cara Muhlhahn and home births in general. I have been wanting a good lead-in to a home birth discussion for a long time, so even though this article prompted much online buzz about home births from such big wigs as Jezebel and salon.com’s broadsheet weeks ago, I’ll throw my two bits in anyway.

A good friend, and one of the most unabashed, frank and honest people I know, is five months pregnant and on the wait-list for a midwife in her area. I was pretty surprised because  “Quick, easy, and pain free,” might as well be her motto. Both my kids were “delivered by” a midwife and I know that wanting to at least try for an unmedicated birth is really kinda the point. When I told her this, she replied that she has always been one to try the latest, trendy thing and thought she might as well see if she could go it au naturel. Is that really all this home birth talk is, then, a passing trend? Or does it represent a real backlash against the over-medicalization of childbirth and a general shift toward a less invasive approach to labour and delivery? Or could it be both?

In Ontario, where I live and birth, midwives have been regulated since 1994 and are fully integrated into the health care system. You can have a midwife assisted birth at home or in the hospital and have full access to all the standard prenatal diagnostic tests and procedures, should you want them. Midwives have hospital privileges and regularly consult with obstetricians over any deviation from a normal pregnancy. In most Canadian provinces, where midwifery is regulated, there is clearly a permanent, institutionally-grounded shift away from medical interventions during childbirth. That doesn’t mean we’re exempt from any general trends toward home birth, but it does mean that there is a already a basis for them.

In the United States, as I understand, midwives are independent practitioners whose legal status and base of operation varies from region to region. In “Extreme Birth,” Goldman’s focus is on Muhlhahn, the home-birth midwife catapulted to the lime light by the Ricki Lake produced The Business of Being Born. There are midwives in New York with hospital privileges as well, but Muhlhahn dismisses them with a roll of her eyes. “You might as well go with an obstetrician.” Aside from the actual birth, she conducts all pre and post-natal appointments at her clients’ home or office, too, which is convenient. (I had to trek to the midwives’ clinic for those appointment — except for the first couple postnatal visits at home.) She’ll also deliver breech births, twins, and VBAC’s (vaginal birth after c-section) at home which you absolutely would not be able to get with a regulated midwife in Ontario. I suspect that many American midwives would also recommend a hospital setting for these types of births. Would you be able to have a midwife-attended hospital birth, though? I imagine that depends on where you are. In instances where you cannot, the value of an experienced midwife for that type of high-risk home delivery is worth considering.

But why? What is the value of a home birth to begin with and does is merit any additional risk? The true value, I think, is that you are far more likely to succeed in having a natural birth if you plan for a home birth. This is because it is often easier to cope with labour pains in your own home where you can move around as you please and because pain relief is less readily available. You have to decide to ditch your entire plan and get up and travel to where you can get that epidural. (You’ll probably deserve one by that point, too, and should not feel badly at all.) Home births are also great because you get to rest and bond and establish breastfeeding right in your own bed. That is so much easier than in a hospital ward (and somewhat easier than in a private room).

Is there any risk, though? Not if you do it right. If you have a healthy, normal, low-risk pregnancy and are attended by a qualified mid-wife, studies show there to be no increased risk whatsoever. Even while arguing against the safety of home births in this NYTimes article, representative of the American College of Obstetricians and Gynecologists, Dr. Tracy, admits that, “The literature does say the majority of normal deliveries can be done at home. But I think, and others think, the stakes are too high.” The risks she and other doctors are concerned about are serious postpartum hemorrhaging and other emergencies that require immediate surgical attention. There is a much greater risk, however, of neonatal infection in hospital deliveries and, of course, infection along the incision where a c-section is performed.

Here’s what I think: Home births are a safe and responsible choice with any regulated midwife in Canada. They are also a safe and responsible choice with many American midwives, but you’ll have to do some research about what is standard in your area. They are safe if and when your midwife has been properly trained and there will be at least one fully qualified midwife plus an apprenticing midwife or doula or nurse or someone else experienced with home births present. Also, you need to have had proper pre-natal care and your pregnancy must be deemed low-risk. Yes, it is a shame that if you’ve had a c-section or if your baby is breech then a home birth is not an option, but there is definitely an elevated risk in those cases. (Breech presentations that won’t turn are an automatic c-section in Ontario.) You must also be willing to transfer to the hospital at the first sign of real danger and live within a reasonable proximity to a hospital. It is best if your midwives have privileges there, too, so there can be a continuity of care.

That said, both of my children were born at a hospital. We briefly considered a home birth the first time, but it seemed far too fringe to be safe. After a difficult labour and successful vaginal delivery (yay!) with the aid of two epidurals and oxytocin (boo!) and a retained placenta (boo! hiss!), all under the capable and superb care of midwife Elizabeth Brandeis, we really considered a home birth for our second baby. The odds of us having to transfer to hospital anyway if this birth were anything like my first, despite complete confidence in our midwives, led to another planned hospital birth. I will tell you now, though, that after a wonderful, all natural, three-hour labour and delivery the second time I will plan for a home birth if I ever have another.

I do understand why people are afraid of home births. I understand why they seem less safe and I believe they probably are less safe in some circumstances. One of the reasons I haven’t had a home birth myself is that I knew it would be a difficult and scary prospect for my family to contend with. Not because they are evil perpetrators of the North American medical establishment out to sever a woman’s connection with her newborn and rob her of her god-given birthing ability. But because they truly love and care for me and my children and worry about our safety. Regulated midwifery itself is a new enough choice and my own pregnancy is not the context for me to push a political agenda. Any of the benefits offered by a home birth would have been outweighed by the extra worry and concern my family would have (might have?) felt.

If all of this home birth talk is nothing more than a passing trend, then it is unlike the hippy-dippy waves of home birth popularity that have come before. Upper-middle-class professional women are choosing to deliver at home. Women who are otherwise squarely mainstream in their tastes and choices are opting to fore go the lab coats and IV drips and birth their babies in their own beds. As c-section rates continue to reach teetering new heights and fewer and fewer doctors see any reason to try to avoid pain medication, more women are looking elsewhere. This may be a trend, but let’s hope it leads to a safe, reliable alternative for the majority of women.

Lastly, let us not conflate safe, responsible, midwife-attended home birth with the unattended birth movement known as freebirthing. Let us not lump these together, as Summer from Wired For Noise does while citing a new Dutch study and referring to the loss of Janet Fraser’s baby: “Studies are showing us, once again, that home birth is safe. Do tragedies sometimes happen? Yes.” Grouping these under the same umbrella only serves to further mystify and distort the practice of standard home births. This is maybe what these radical freebirthers want? Sometimes it doesn’t matter if you are acting out of love or faith or whatever. Sometimes there are responsible choices versus irresponsible, negligent, and even criminal choices. This is one of those times. Planning to give birth by yourself, without so much as alerting a midwife, is selfish and stupid, irresponsible and incredibly dangerous. There. I said it.