Saturday, March 12, 2016

Why a Homebirth?

Having been duly insulted on the Internet, I wanted to examine why homebirth is becoming more popular in this country. It is still an unusual choice, but more and more women are opting for it. Why do you think this is? If the hospital is so great, why are so many women running away from them?

Being a veteran of three hospital births and one homebirth, I think I can offer an opinion. Why did I choose a homebirth after three medically uneventful hospital births? For the record, it was not so I could "give a water birth in <my> own bathtub" because Oh! Gross! I cannot imagine sitting in water surrounded by my own muck Touching! Me! It's bad enough that it's coming out of me. Must I have smeared all over my skin too? Shudder. It might be your thing, but sorry, I cannot go there. And yet I have given birth at home. What other reason could I possibly have?

My third hospital birth was outstanding. My doctor and I had a birth plan we mutually agreed upon. I was not hooked up to IVs and constant fetal monitoring. I could move freely. I was not forced to give birth on my back. By serendipity, I had an outstanding labor nurse who went over and above the call of duty. She embraced and supported my preferences. My preferences are not extreme, but include not being treated like a trauma patient about to die and laboring in positions where the mechanics of birth are the priority instead of the convenience of the attending's view.

I am confident that if I ever give birth in a hospital again, I have the knowledge and experience to negotiate a birth similar to my third birth. It only took me two hospital births to get there. This fact of requiring prior experience is ridiculous and, really, is the problem. A pregnant woman should not have to endure several less-than-ideal births in a hospital to figure out the myriad ways the hospital machine will run her over in order to finally gain the ability to negotiate around them.

Before my first labor, I thought I was well-read enough on the subject of labor that I thought I would manage just fine. When I discussed my thoughts with my doctor, she smiled and nodded, and I stupidly thought all would be well.

When I got to the hospital, everything turned on its head. My presentation was nonstandard--my water broke before the contractions started--and everything I thought I understood was gone. I was not allowed out of bed. I was not allowed to move. I was strapped to several machines that kept me on my back in agony.

The nurses spouted platitudes about increased dangers to the baby because my water was broken and how it was essential to keep the baby monitored at all times. I did not know enough to know they were spewing cow manure at me. Everything I had read had assured me that while the possibility of ruptured waters being the beginning of labor existed, it really only happened on TV and not to expect it. Not much else was said about it so I didn't read further and couldn't argue against them.

My labor progressed very quickly without my crack, professional nursing staff noticing. I received no support while I thought I might be dying on the table, expecting labor to go for eight or ten hours in this manner. They were shocked to find me complete and ready to push after an hour while my doctor was not even at the hospital yet. They made me fight for nearly an hour the intense biological urge to push while we waited for the doctor to arrive. I was chided constantly and repeatedly not to push. To breathe and not push.

When the doctor arrived, it was hard to give in to the feeling after fighting it for an hour. I attempted to push unsuccessfully. It took me a long while to get the hang of it. Finally, as things began to move along, I had nurse come to my bedside whose sole job was to press a heart monitor into my abdomen to keep the baby's heartrate on the machines even as the baby moved out of my uterus. This was total agony.

After 45 minutes of pushing--a rather short second stage for a primipara--my doctor lost patience with this scene and started talking episiotomy. I was laying on my back with my feet in the air with a hard metal device being pressed firmly into my abdomen and my doctor was convinced I could not give birth without a surgical procedure.

Now this situation was one I had read about. I knew it was generally better to tear naturally rather than being cut. I knew that if I could get off my back, delivery might be easier. None of my knowledge or preferences mattered. I spent some amount of time with a baby in my birth canal arguing with my doctor about whether I would consent to likely unnecessary surgery. Nothing encourages a laboring woman to relax and work through crowning like telling her she isn't capable of doing it. After some time and attempts, while never being given the option to change positions, I was worn down by her continual insistence I couldn't do it and "consented" to the procedure. Yes, those scare quotes are intentional. I tore from here all the way to there and my baby, with the low percentile head circumference, was born. It took weeks for me to be able to sit normally again.

At no point during my labor was there anything medically wrong with me or my baby. We were not in distress. We were not bleeding abnormally. We were not showing signs of infection or intolerance of labor. We were just run over by a doctor and hospital policies.

In preparation for my second labor, I took the knowledge gained by previous experience to advocate for myself in this next go around. My new OB turned out to be much more trustworthy than my previous one. We discussed my preferences and she explained her medical guidelines. As it turned out, we induced labor to control for precipitousness and since I was on pitocin, she wanted me on all the monitors again. While this was not my first choice, I understood her reasoning for wanting to monitor how I and the baby might respond to a medication. She had real medical reasons apart from the irrational fear that we might spontaneously combust as exhibited at my first labor.

This labor was much smoother but still I had to listen to a nurse scold me through the bathroom door that I had better not attempt to deliver on the toilet as I emptied my bladder. Yes, it's a little thing, but the little things matter in labor. Was I the patient whose needs were being attended or was I a problem who was crimping the nurse's style?

After a labor that was under two hours and a straight forward delivery, the unexpected happened. No, not a medical crisis, but hospital policy again. I knew that at this new hospital, recovery would be in a separate room from delivery. What I did not know is how tightly they would adhere to a schedule to move me. I delivered at 10:40am. By 11:40am, I was out of that room. In the intervening hour, I had delivered a placenta, been sutured along that old unnecessary episiotomy line, attempted to nurse, had to get out of bed to get cleaned up and changed, get my urine output measured, and signed a pile of paperwork. It was an absolute whirlwind. There was nothing relaxing or undisturbed about that golden hour which the hospital claimed to keep.

In spite of this, I knew once we were back in the recovery room, we would have the rest of the day to spend together. Except we didn't. Somehow my baby didn't make it back to my room with any due speed. Instead of coming to my room, she went to the nursery where she was held hostage for four hours. I was crawling out of my skin, but instead of my need to hold my baby being affirmed and accommodated, I was told repeatedly to calm down, wait, and trust the hospital stuff to bring her when she was ready. I had no idea to expect such a situation and was in no position to advocate for myself. No one else wanted to advocate for me either. I just had to wait until they decided they were finished, whomever they were.

Again there was nothing medically wrong with either us. She was in need of a warm body and a blanket, and amazingly enough I had both that I wanted to provide for her. But that was not allowed. Once again I and my baby had been run over by hospital policy.

As I mentioned above, my third hospital birth was about as good as birth can get. I used my hard won previous knowledge and negotiated every contingency I knew about, and yet I still had to endure one nurse who threatened me with catheterization because my urine output did not meet her preconceived standards because she hadn't bothered to read my chart and see I had not been blown up like a water balloon with IV fluids therefore was not capable of producing the volume of urine she required. I also had another nurse who introduced herself at shift change and I never saw her again, in spite of the fact that two doses of my pain medicine came due over the course of her shift. Note to self: Next time bring your own bottle of advil because you can't count on the nurse showing up with the pain meds. 

Notice that my requests and expectations around birth have had nothing to do with medical requirements being subordinated in favor of some wackadoo, mother-earth goddess zen, orgasmic birth. No. My requirements are that if everything is progressing normally, I will be allowed to move around, find a position that is less agonizing--there is no comfortable position--not deliver on my back with my legs up in the air, and hold my baby for as long as I want after birth. These are not diva-like expectations.

None of my complaints about my hospital experiences will show up in mortality rates. It is the drips of water that strip away the desire to go to the hospital when it becomes clear their medically unnecessary protocols and their own convenience take precedent over the care and comfort of a laboring/postpartum mother and newborn. It should not require two previous births and extensive negotiations to have an undisrupted natal experience when, again, there is nothing medically wrong with either the mother or the neonate. But, sadly, it is required. Without foreknowledge and negotiation, you will get run over by hospital policy because you will be in no position or state of mind to advocate for yourself on the fly in those moments.

Why did I choose a homebirth the fourth time even though I was confident I could reproduce another good hospital experience?

Frankly, my number one concern was delivering on the side of the road. With a history of precipitous labor, it's not an irrational fear. The standard medical treatment of precipitous labor is induction. I don't really like being induced. By the time of my fourth pregnancy, I was somewhat psychologically fragile. I was so very tired of working. I had hoped I would have been able to quit my job by the time of delivery. I felt powerless over my life and schedule. To submit to induction again was once again giving someone else control over my life. With induction, I would likely work until delivery and then be admitted to the same hospital I was employed by. Someone, on their own schedule, would start the process of birth and I, once again, would only be along for the ride. Ironically choosing not to control when birth would happen was a way I could take a small amount of control over my schedule.

I was tired. I longed to hole up in my own home with my own children, but I knew allowing birth to proceed on its own schedule was not compatible with me arriving at a hospital to give birth. If I wanted to avoid induction, I would have to give birth at home. It was too risky to attempt a mad dash to the hospital. I was also afraid that labor might start unexpectedly even if we planned a hospital birth, and we would be unprepared because, again, with my labor history, a mad dash to the hospital is foolish.

I investigated the risks associated with homebirth and compared them to my own medical history. I spoke with people I trust about their own homebirth experiences. I was comfortable with my midwife's credentials and monitoring procedures, a woman who had herself given birth at home and also transferred into a hospital when it became medically advisable. We decided to go ahead with the homebirth, and lo, we all survived.

I am not being flip. It just strikes me as odd which risks we find objectionable and which risks we find acceptable. No one gave any pause to the fact that I was driving up to three hours a day, every day, on a highly congested interstate at speeds up to 70 or 80 MPH while nine months pregnant (and 8 months and 7 months and...). This action was considered an acceptable and unavoidable risk of life. But take equivalent risks in childbirth and people lose their minds.

If I were pregnant again, would I have another homebirth? I might or I might not. I found many advantages to staying at my home for birth, but I am not in that same psychologically fragile place where I feel powerless over my circumstances. I am not compelled to leave my house and children every day anymore. I would not have a maternity leave clock ticking incessantly in my mind reminding me that time is almost up. I am not financially tied to my hospital of employment anymore. I wonder if I gave enough attention to the ambulance response times for my neighborhood. Right now, in my non-pregnant state, induction does not seem like the last straw it felt like the last time I was pregnant.

These are all very intangible criteria and this is the point. Why are women increasingly choosing to birth outside of hospital settings? Because hospitals have shown themselves unwilling or unable to treat normal, uneventful births as normal and uneventful without a massive effort on the part of the mother. The birth culture in this country loudly states that what happens to a mother and baby during the course of childbirth does not matter as long as everyone makes it out alive. I reject this paradigm.

It matters. The little things matter. The unwelcome and unnecessary surgeries matter. The inattentive nurses matter. The counterproductive and unsupportive doctors matter. The denial of gravity matters. The unnecessary and unwanted separations matter. The instinct to tell mothers to suck it up and be grateful everyone is alive matters.

A pregnant mother is a human being. Her physical and psychological integrity matter. She is more than just a baby-producing machine made of meat. Her outcomes matter, even if they don't make a blip on the mortality charts. And none of these things have anything to do with a bathtub. It's time for hospitals to figure it out.


mandamum said...

Thank you Jenny - this is a lovely explanation of something that, as you say, doesn't show up in the stats.

Your story of baby being "held hostage" for 4hrs in the nursery really resonated with me - a few months ago, I was the care partner for my husband during/after his outpatient surgery, and was past frustrated by how long it was (and how much effort/demand *I* had to put in) before I could see him while he was in recovery. Because it was less convenient to have me, the putative "care partner", to be back there with him helping ice his neck and forehead, helping him manage some food so they could give him the overdue pain meds (!! because the previous nurse was "15 min to the end of her shift" and that was that), sticking my head out the curtain to demand someone respond to his repeated request for a pillow ("I don't know why you don't have one, I'll go see..." ) etc. I was practically out of my head with the waiting/asking before I got to see him, an ADULT, and then oh so annoyed with how he had been treated while vulnerable and without a spokesperson once I got to him - I can't even imagine waiting/needing to be with my BABY, while also being newly postpartum. Crawling out of your skin indeed.

I think you put your finger on a very important point - it is asking a lot of a primip mom to know ALL the pitfalls *and* how to avoid them - shouldn't it really be part of the care provided, to 1) distinguish what is low-risk birth, and then 2) make the most of the low-risk by helping *educate the mother* about how to effectively manage her low-risk labor for the best outcome (and we have plenty of stats on this, but OB is the least-science-effected branch of medicine)? Instead of a first-time laboring mom, *while in labor*, trying to educate her care team, or at least get them to back off for a moment?

Jenny said...

The stupid thing about them keeping my baby is that they caused the "problem." They gave her a bath while I was being transferred between rooms. They didn't ask or even inform. I was told after the fact that her body temperature dropped below their acceptable threshold after they bathed her and they would not release her until it had risen. So she spent four hours, naked and wide awake, underneath a heat lamp while her temp sat at 97.9 and they wouldn't release her until her temp was over 98.2. I was so mad I could chew glass.

Fixed the problem next time by requesting a non-separation order from my OB unless the baby's life was endangered. Didn't fall prey to the stupid bath a second time.