My rant about the homebirth vs hospital-birth debates.

I think it is wonderful that we are living in a time and place when debates like this are happening. We have access to research and opinions, professional and personal ideas, anecdotal and evidence-based practices in our country's medical system.

I would challenge everyone interested in this issue, standing on any part of the spectrum, to read the Johnson and Daviss studies previously mentioned. Dr. Tuteur, as always is comparing apples to bananas by pointing out low-risk hospital-births compared to ALL home births (planned or not, attended by a midwife or unattended, etc). It has been shown time and again, in this an other countries, that homebirth is just as safe, if not a safer alternative to hospital birth for a low-risk mother with a trained midwife. Could hospital births be just as safe as home births? Yes, but they're statistically not.

This debate is all subjective, however. If a woman lives in an area where all the local hospitals have a 50% cesarean rate (a method of obtaining a child which is more than twice as likely to result in death of the mother as a vaginal birth), you can safely bet that a low-risk mother, and perhaps even high-risk mothers, would be better off birthing at home or going to another state to have their babies.

If a woman lives in an area where the closest hospital is 2 hours from their home, she may be in a difficult predicament for choosing her birth place. In the state of Colorado, where I live, a homebirth must occur within 30 minutes travel time from the home to the hospital. This implies an inherent safety of birthing for low-risk women attended by a CPM.

This debate isn't about making all low-risk women birth their babies at home or making all women birth their babies in hospitals. At least, it shouldn't be that way. It should be about finding the options that result in the most satisfying results, including safety to mother and baby. Of course, we are not all the same and we do not all birth the same. Some women have the best outcomes in a hospital, some at home, some in a freestanding birth center, some in other locales altogether. We can't make decisions based purely on other people's experiences, even when those people are doctors.

We need to be informed consumers and look at the scientific evidence presented to us and listen to our hearts and souls and bodies. If after you have done the research, your heart and soul tells you that the hospital is the place for you, then you're right. Choosing your birth place because everyone else does it that way or because of reasons you haven't researched is asking for trouble. If we find ourselves outright stomping on an alternative we've never looked into, we should challenge ourselves to look into it. We may find that we're right or we may find that we're wrong and our culture has taught us something that is not true or is no longer true.
Yes, mothers and babies in the US suffer from lower mortaliity from birth today than they did in the early 1900s. Why is that? Well, we learned about germs, for one thing, We stopped letting doctors go from cleaning out cadavers to using forceps on birthing women, ungloved and unwashed. When birth went to hospitals, it was more dangerous than homebirth. Read "Brought to Bed" for more on the transition from home to hospital and the numbers associated with this transition. There are plenty of books on the topic and all of them point out that moving births to hospitals was NOT the big change that made birth safer in this country. It was germ theory and penicillin. There were places where birthing in a hospital meant a 50% mortality rate due to infection. It was horrific. No, hospitals are not that bad now, but with 20-50% cesarean rates, you have to wonder.

Speaking of cesarean rates, lets point out that the World Health Organization has proven a cesarean section rate above 10-15%, for industrialized countries, puts women and babies at greater risk of morbidity and mortality than a physiological birth. I already mentioned that mothers are more than twice as likely to die when they have a cesarean as when they have a vaginal birth. And someone said people never die because the doctor is there "in case." Hm... A doctor is trained to see problems and fix them, he or she is not trained to let well-enough alone and see normal variations as normal. An obstetrician is very good at what he/she does, when it is necessary. It is not always necessary, however, and it is certainly not necessary for women to have cesarean sections more than 10% of the time they are just wanting to bring their babies into the world.

Women should not be coerced or forced into having unnecessary interventions in labor and birth, especially when there is evidence to say those interventions are dangerous when used without very careful application. These are the things people should be upset about, not the decisions of some women to birth their babies at home.

First, my definition of safety: your relative chances of suffering physical and psychological damage. This is comparing two cars. They both have 5-star safety ratings under certain circumstances, but they're not the same circumstances.

Is homebirth safe? Yes, but your safety factor depends on some things! Is it safe for a low-risk mother who is attended by a trained midwife with a plan for transfer if mom and midwife decide to go? Yes, this scenario places mom and baby at the same safety level as this same mom in a hospital with a midwife, and if the mother has had babies before, she is safer than at a hospital.

Is it safe for a high-risk mother with the same midwife? Yes, but not as safe as a hospital might be for her and her baby.

Is hospital-birth safe? Again, yes, but it depends! Is it safe for the same low-risk mom as above, who is attended by a hands-off nurse-midwife? Yes, but not as safe as the homebirth would be if she has had babies before. How about the low-risk mom attended by an OB? Hm... this is a tricky one because it greatly depends on the OB's practices. Generally, however, the low-risk mother and her baby, with an OB at a hospital, will be in greater danger of suffering physical and psychological damage than the same mom and baby at home or with a midwife in the hospital. And the high-risk mom in the hospital? Generally safer than at home, still dependent upon her provider, however.

So, it's not all black-and-white. It depends on the mom, the baby, the birth place, and the healthcare provider. That's why it's so important to shop like a consumer when it comes to birth choices. Don't just choose the same car everyone else is going for... sometimes you'll find out that your car isn't worth anything in a few years and you'll need to trade it in. And remember, you can always exchange your car for a better model, sometimes for a lot less money! Plenty of women have changed doctors or switched to a midwife or a homebirth at 8 months pregnant or even later. It's your body and your baby. You should do what feels right for you.

Cesareans (10/12/07)

The cesarean section rate in the U.S. is 30.1%. W.H.O. guidelines state they should never rise above 10% for developed countries. This means that 2/3 of all U.S. cesareans are unnecessary. W.H.O.'s guidelines are based on when the risks begin to outweigh the benefits of this major abdominal surgery. This means that babies and especially women are actually being unnecessarily harmed by this cultural practice.

Why no outcry? Why no laws being made against unnecessary cesareans? Why no required guidelines for hospitals and maternity healthcare providers to follow to reduce their cesarean rates?

I joined the ICAN (International Cesarean Awareness Network) Yahoo group and read experience after experience of women who felt robbed, raped, devastated, devalued, lied to, and more because they had a cesarean that they later found was unnecessary. I read stories of doctors and nurses presenting vulnerable, laboring women and their spouses with the "option" of cesarean, or worse yet, tossing the "dead baby" card on the table when there was no reason to believe the baby was in danger. After months of physical recovery and years of emotional anguish, postpartum depression, and cases of post-traumatic stress disorder, these women go over their medical reports, talk with other medical professionals, talk with other women, and learn that their cesareans weren't necessary. They learn, three children later, that the repeat cesareans they were "offered" during pregnancy were not also not necessary, but because their doctors presented it like the first option, they took it. Doctors say, "You can have another cesarean," and refer to a VBAC as a "trial of labor," instead of telling women, "There is good reason to have a VBAC, in your case." When a woman wants to have a "trial of labor," they're not only given the consent form, but they're also given the lecture of all the risks of the "trial," whereas mothers who choose to schedule a repeat cesarean are not usually told of the risks of thier second (or third or fourth) cesarean when they sign the consent form. It's not until they've had three or four cesareans that their doctors get a little worried and tell them that they shouldn't get pregnant again because another cesarean would be risky, and they won't attend a VBAC after a woman has had that many cesareans because it would be risky... so a woman is told not to have any more children. TOLD. Who is this person who plays God over you as a woman? Who thinks you should just get a hysterectomy with your next cesarean? What angers me the most this is that these women wouldn't be "at risk" with subsequent cesareans or VBACs if their doctors hadn't suggested they take the second cesarean, and better yet, if they hadn't had an unnecessary cesarean in the first place.

Yes, I'm getting carried away on a scenario where women have bad doctors or simply feel under-educated. Yes, cesarean sections are necessary and life-saving in some circumstances. It is utterly horrifying to me that the cesarean rate is what it is in the U.S. I cannot express the horror I feel at the idea that one in three live births delivered in the United States of America are removed from their mother's splayed abdomens while they lie behind sterile shields with their arms tied down and their spouses nowhere to be seen. It's the thing of horror novels to imagine women with their babies ripped from their bellies, and yet we do it. To me, it is equally horrifying when the surgery does not save lives and livelihoods. No, not all obstetricians are evil surgery-mongers who want to cut open every woman who comes through their practices. I've never been one to think it's okay being satisfied and passive because things are "okay" or because it's good more than it is bad.

The big questions are why are so many unnecessary cesareans being performed and how do we stop it?

The Healthy People 2000 objective of reducing the cesarean rate to no more than 12% for primary cesareans, no more than 65% for women with previous cesareans, and no more than 15% overall not only failed, but failed miserably. The rate didn't go down, but went up and continues to do so. So, making objectives to make people healthier doesn't work.
The Coalition for Improving Maternity Services created the Mother-Friendly Childbirth Initiative, which states that mother-friendly maternity services will have a cesarean rate of less than 10% for low risk and 15% for high risk women (http://www.motherfriendly.org) was established in 1996 and hasn't worked in reducing the cesarean rate overall.

This is just the beginning of my thoughts.

Christina