Amid Fears And Controversy, A Doctor Chooses A Home Birth
2015; Project HOPE; Volume: 34; Issue: 6 Linguagem: Inglês
10.1377/hlthaff.2014.0531
ISSN2694-233X
Autores Tópico(s)Medical History and Innovations
ResumoNarrative Matters Health AffairsVol. 34, No. 6: Variety Issue NARRATIVE MATTERSAmid Fears And Controversy, A Doctor Chooses A Home BirthJessica Taylor Goldstein Affiliations Jessica Taylor Goldstein ( [email protected] ) is an assistant professor of family and community medicine at the Medical College of Wisconsin, in Milwaukee. She is also an assistant director at the Waukesha Family Medicine Residency Program. PUBLISHED:June 2015Free Accesshttps://doi.org/10.1377/hlthaff.2014.0531AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractA family physician who delivers babies discusses her decision to have a home birth, and the controversy and fear surrounding it.TOPICSMidwivesNursesPharmaceuticalsMaternal healthMedically necessaryDiabetesChildren's healthMy daughter Sage was born at home in the middle of the polar vortex in Wisconsin, in the winter of 2014. She arrived in this world at forty weeks and one day, weighing a healthy six pounds and thirteen ounces. She is my third child and my first home birth, either witnessed or experienced.Considering my occupation, I know many people found my decision to have a home birth surprising. I am a family physician at an urban community hospital and deliver babies as part of my practice, including performing cesarean sections. Family medicine allows me to take care of the pregnant woman, her baby, and her whole family, a calling that I find incredibly rewarding.I was still a resident physician when my first two daughters were born. What I wanted was a normal physiologic birth, or “one powered by the innate human capacity of the woman and fetus,” as defined by the American College of Nurse-Midwives and others. A birth that let my body do what it was meant to do, and with limited medical intervention. I considered a home birth for my first delivery but was afraid of the unknown and the risks. Instead, I labored at home for seventeen hours with the help of the bathtub and hypno-birthing tapes. Once in the hospital, I progressed without medication to eight centimeters, and then received an epidural, Pitocin to make my contractions stronger, two vaginally placed monitors, and a nurse who insisted that I stay flat on my back during labor. Finally, after thirty-five hours and threats of a c-section, I delivered a vaginally squashed and swollen six pound, five ounce baby girl that looked like E.T.That day, I was exhausted and mad at myself. Looking down at my baby, I felt to blame for my hard and “unnatural” labor. I was grateful that she was healthy, but I felt that if I had relaxed more or been stronger, I could have had the birth I wanted, with limited medication and medical intervention. Having witnessed hundreds of births, I knew some births are harder than others and all are different, but still I blamed myself. That feeling stayed with me until I had my second child.Predictably, the second was easier, and within ten minutes of reaching the hospital and one big push later, I had my baby. My husband delivered our little girl, as my doctor had not even been called yet, and the obstetrical resident took over the placental delivery. An intern, who only had been a physician for nine days, broke the cord on my placenta, and I had to have it manually removed. Although she looked healthy and vigorous, my baby was taken away to be examined very shortly after birth. My normal vital signs were checked more times than medically necessary, often interrupting bonding as I held my baby. I was physically shaken in the middle of the night while breastfeeding because the nurse was worried I was asleep with the baby in the bed. I was exasperated, but twenty-four hours later I was home.As a resident physician, I found providing obstetrical care to be an amazing but frustrating experience. While family physicians can handle complex medical problems such as hypertension and diabetes in general, patients who have these conditions in pregnancy are considered high risk and are often transferred to an obstetrician. I decided that it was important to get more training in order to be there for my patients even if their pregnancies became more complex. This led me to a fellowship in high-risk obstetrics, to learn not just how to perform c-sections but also how to avoid them.‘There Are No Failed Births’Between the births of my second and third children, I completed the fellowship at the University of New Mexico, where in the course of my work I performed vaginal deliveries and c-sections on high-risk obstetrical patients. Our group was the backup for a freestanding birth center, a type of care setting that provides a more home-like environment and an alternative to the hospital. Birth centers are often staffed by midwives but can include physicians as well, and they require hospital backup in case patients need to be transferred. Births that take place in these centers and at home are all included under the umbrella of “out-of-hospital birth.” As a fellow, I often handled complications from attempted out-of-hospital births that ended up back in the hospital. When talking with patients who needed to be transferred to the hospital, we were advised not to call it a “failed home birth.”“The birth is inevitable,” my fellowship director had told us. “No woman should feel like a failure during childbirth.”The midwives who brought these women to the hospital always stayed with them through labor. Often, the women went on to have vaginal births. In New Mexico I worked with several physicians and nurses who had positive home birth experiences, and I came to understand home birth better. We talked about the controversy and about risk profiles. I learned that some women are very good candidates, and, with proper backup, the process can be safe. In England national guidelines endorse choice of place of birth, supported by a 2011 study in the British Medical Journal by Peter Brocklehurst and colleagues that showed no significant differences in morbidity and mortality for mothers with low-risk, term pregnancies or for infants born to these mothers regardless of place of birth. Planning For Home BirthA year after moving back to Wisconsin after my fellowship, I became pregnant with my third child. I decided to look more seriously into home birth and was referred by another physician to a midwife who was in the process of opening a freestanding birth center. I asked her about my options. Over the course of the next few months, I learned what it was like to be a midwife’s patient. My midwife and her assistants were certified in newborn resuscitation, and all the medications needed in case of postpartum hemorrhage would be available, as well as medication and supplies if I needed a vaginal repair.“What happens during the birth?” I asked the midwife.“I will monitor the baby’s heart tones during labor and take vital signs, just as I would in the birth center,” she said. I felt comfortable with her.Delivering babies myself, I know what the standard of care is, and I know I received it throughout my pregnancy. Other than being more than thirty-five years old, I had a low risk profile. I had two previous vaginal deliveries and no history of hemorrhage, gestational diabetes, or any other risk factors. My midwife came to my home a few weeks before the birth to make sure I had everything I needed. I ordered a custom birthing kit online that included clamps and pads. Other than clean sheets and towels, not much else was needed.A Personal Decision I consider my decision to have a home birth a personal, not professional, one, yet I could not completely divorce the realities of my day job from my private choices. In the medical community, there is a great deal of opposition regarding home birth and an unwillingness on the part of some obstetricians to even discuss home birth as an option. One day during my pregnancy, I noticed an article pinned to the bulletin board on the labor and delivery floor at my job, with the title: “Planned home birth: the professional responsibility response.” It was a clinical opinion article from the American Journal of Obstetrics and Gynecology from January 2013, and it stated that “planned home birth should not be considered medically reasonable in professional clinical judgement.” It went on to state that “professional responsibility prohibits participation or facilitation of substandard care.” As I finished reading, I rubbed my belly and frowned. Given my profession, I was certainly an informed consumer. I knew that there was about a 10 percent chance of a medical emergency or lack of labor progress that could necessitate a hospital transfer. I was also aware that in a catastrophic emergency, being five feet away from an operating room or neonate intensive care unit could improve the outcome, although the absolute risk of infant death is exceedingly low (around 1 in 1,000). I understand how that risk may still be too high for some. For my third pregnancy, I believed that the benefits of a planned home birth outweighed the risks.When I was seven months pregnant with Sage, I talked with my sister on the phone about the delivery plan. She’d been my support person for my two previous births, flying in from California.“I can’t tell anyone you are planning a home birth,” I remember her saying.“Why?” I asked her. “It’s my birth, what’s wrong with wanting it to be a natural experience?” My sister had always been my rock, my voice of reason, and this statement threw me a little.“I get so many questions that I don’t know how to answer,” she said. My aunt, for instance, whose own daughter had two previous cesarean sections, could not understand why I would want to put the baby at risk.“She’s a doctor,” she told my sister. “Why would she do that?”It didn’t take long for word of my plans to spread on the labor and delivery floor where I work. Several labor nurses and obstetricians, some I did not know very well, questioned me about it. One obstetrician pulled me aside and said, “Do you mind if I ask what your backup plan is?”“I saw an obstetrician for my ultrasound,” I said. “He’s my backup.”This was only half true. I felt defensive, and, to be honest, this was the one part of my plan that concerned me. The doctor to whom my midwife referred me was a forty-minute drive from my house—not a very realistic alternative in case of emergency. Instead, my plan, if needed, was to take an ambulance to the nearest hospital, four miles from my home, and most likely be handed off to a doctor who knew nothing about me—a fact that I admit would have possibly delayed my care in an emergency and made it less safe. That possibility made me anxious, but I was not deterred.Gotta Get Thru ThisI went into labor at 3:30 in the morning on a Sunday. By 6:30 my contractions were getting stronger. I woke my husband as well as my sister, who had been in town for five days now, awaiting the arrival of my child. I called my midwife to let her know I was in labor, filled up the tub with warm water, and labored there for about an hour. My husband had covered the bed in old sheets on top of a shower curtain liner. After my bath I went to lie down in my bed and listen to music. I remember the pop song “Gotta Get Thru This” by Daniel Bedingfield, pumping through my headphones. Around 9:30 in the morning, the midwife arrived.She told me that if I felt pressure I could push. I remember crying in between contractions. I remember swaying and pacing next to the side of the bed, squatting, and standing. I remember my sister rubbing my leg and my husband holding my hand. I remember hearing my kids in the hallway—they decided to watch a Disney movie rather than watch the birth. I remember crying tears of joy as I realized I might have this baby at home, the way I planned.My midwife and her assistants waited in the hall when they were not taking my vital signs or listening for heart tones until the delivery. I pushed for eighteen minutes, and my daughter was born, crying, with all ten fingers and toes. She was beautiful.My husband kissed my forehead. “I’m so proud of you,” he told me. Sage was put directly on my bare skin and did not leave that spot until I was ready for her to. I remember my girls—ages three and four at the time—coming in and singing “Happy Birthday” to their new little sister. After she was all wrapped up, they sat on the bed with her, kissed her little hands and talked to her, welcoming her to the family. The midwife stayed for about two hours, and then over the course of the next three days, she came and visited me and the baby at my home. She checked the baby’s vital signs and weight, and looked for jaundice, while also examining me for signs of infection and bleeding. We visited our family physician a week after the birth, and Sage was back above her birthweight.I gave birth at home because I wanted to experience physiologic childbirth with limited medical intervention. To be at home, snuggled afterward in my own bed where I felt most safe, surrounded by the family that my husband and I created together, was a feeling like no other. I wanted to feel empowered by the experience, not belittled by it. I finally got to experience the birth I had envisioned was possible.Addressing The Values Of WomenMy daughter’s home birth was a calculated decision. I knew the benefits and the risks, and I had a backup plan. I am thankful that I did not need it.What I have learned in the process, and what I continue to learn, is that individual birth decisions and the controversy surrounding them are governed by fear on all sides.Patients fear losing control of their decisions to health care providers. Midwives fear unnecessary medical interventions that interfere with physiologic birth. Physicians, who carry all the liability when they provide backup for a midwife or another physician, fear unsafe practices and uninformed decisions. To say that physicians are afraid of getting sued is an oversimplification. As a physician, I fear the preventable bad outcome and losing my ability to practice medicine much more than I fear a lawsuit. This is my life’s passion, as it is for many physicians.According to the Centers for Disease Control and Prevention, out-of-hospital births are on a steady rise and are at their highest level since 1975. I am in the demographic most likely to choose out-of-hospital birth: white, college educated, mid-thirties, and having had children before. I believe that out-of-hospital birth is on the rise because the values of women are not always addressed in the hospital setting.I have seen firsthand why cesarean sections and other interventions are at times medically necessary: A baby’s heart tones drop suddenly because the umbilical cord delivers before the baby, requiring an emergency cesarean section; a mother hemorrhages after delivery and needs an emergency, life-saving hysterectomy; the baby comes out and unexpectedly makes no effort to breathe. I have been humbled by how unpredictable birth can be. But bad outcomes in low-risk pregnancies are rare and can happen regardless of place of birth.Yet it is also clear that in other circumstances, some interventions may be avoidable and can be reduced. Unfortunately, hospital culture is not always conducive to such a nuanced approach. Many physicians, not trained to allow for a physiologic birth, intervene unnecessarily. Hospital protocols, such as taking babies immediately to the nursery to be weighed and measured, or swaddling babies and not placing them skin to skin with their mother, can affect breastfeeding rates and interrupt bonding. As a patient, you might get the feeling that things are being done to you and your baby, instead of being done with you.In recent years the American Congress of Obstetrics and Gynecology (ACOG) has softened its stance against home birth. A 2011 ACOG committee opinion on planned home birth acknowledges that although the committee still believes that hospitals and birthing centers are the safest settings, “it respects the right of the woman to make a medically informed decision about delivery.” In November 2014 the Journal of Midwifery and Women’s Health published a review by Saraswathi Vedam and colleagues that concluded: “Regardless of one’s opinions of planned home birth, all clinicians and researchers can agree on the importance of interprofessional collaboration.” I believe that all stakeholders, and particularly ACOG, should continue to develop, recognize, and implement policies and guidelines for collaboration between midwives and physicians; facilitation of transfer of care; and standards of care across birth settings that enhance safety, ensure high-quality care, and support physiologic birth when possible. Summer 2014It is a beautiful day, and I am on call making my hospital rounds. The resident doctor calls me about her patient who is being admitted in labor. This patient is “special,” because she has had two previous c-sections. A trial of labor after cesarean with two previous c-sections is something that practice guidelines from ACOG say can be considered, but this is not very common. One of the more experienced nurses wants to hear me gain the patient’s consent. I make very clear to the patient the risks: most importantly, the risk that her uterus could open because of her previous scars. Usually, there is a 0.5–1.0 percent chance of this happening, but because she has had not one but two previous c-sections, the risk may be higher. Although the risk is relatively small, the recommendations require continuous fetal monitoring and having a surgeon (in this case, me) be available to manage complications. The nurse, feeling satisfied with my explanation, relaxes a little.The patient progresses fairly quickly to complete dilation, without epidural pain medication. I am supervising the resident physician, who, along with the nurse, is ready to tell the patient to hold her breath and bear down.“Wait, please,” I say. “Let her body tell her what to do.”Then we just watch.“How will we know when the baby comes down then, if we don’t check?” the resident says.“You’ll see the head,” I tell her. We all watch as the patient has her first vaginal delivery after three births. The resident catches the baby and lifts her onto her mother’s chest.That night, while I’m snuggled up with Sage, who is now six months old, I send a message via Facebook to my midwife. “Thought you’d be proud. I delivered a patient with two previous c-sections today without an epidural.” To which she responds, “Are you sure you aren’t part midwife?”I am not a midwife, but as a physician and a mother, I share a common goal with midwives: to empower women in their birth experience whenever possible. Women should be able to choose their birth settings and practitioners based on weighing the risks and benefits according to their own values. The system can and needs to be safer. Collaboration will make it safer, and placing blame on pregnant women is not the answer. Instead of resisting rising trends in out-of-hospital birth that are considered safe in other developed countries, practitioners in the United States must learn to work together to meet the needs of pregnant women. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 June 2015 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF downloadCited byThe Health Care Dimension: Delivering Care for High-Risk Pregnant Women and Preterm Infants29 July 2016
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