Child Birth Labor: Do you know your child birth options?Birth Choices: Do you know your child birth options? By Lisa Meng [Please note: This article was written quite a few years ago, so some of the statistics may have changed. However, I think it is well written and informative, so I obtained the reprint rights to enable my visitors to read it. Enjoy! Suzanne] In 1989, Althea Arnold gave birth to her daughter at home. The only people present besides Althea and her child were her midwife, her husband, and two close friends. Before accepting Althea as a client, the midwife screened her carefully to make sure she was healthy: a good candidate for home birth can't have conditions like diabetes or heart problems. During Althea's pregnancy, her midwife spent an hour at each prenatal visit caring for her client, answering her questions and getting to know her as a person. The rapport built by the women over the course of the pregnancy, and the thorough preparation for birth that Althea received from her midwife, proved invaluable during labor. Because the medical equipment and drugs necessary for some pain relief measures are only available in hospitals, Althea needed to rely on other methods, such as breathing, relaxation, and emotional support, to manage her pain. Her labor lasted 17 hours. During the first 12 of those hours, she was able to eat and drink lightly, and alternated walks around her neighborhood with rest breaks at home. Before the final stages of birth, the midwife applied warm oil compresses to the area between Althea's vagina and rectum, called the perineum, in order to help the skin stretch. As a result, Althea did not need an episiotomy, which is an operation where a vertical cut is made with a scalpel through the perineum. Immediately after the birth, Althea's daughter never left her or her husband's side, and spent her first night sleeping between her parents. Birth experiences like Althea's have become increasingly rare over the past century. In the United States today, 98% of all babies are born in hospitals, most of them delivered by obstetricians. In contrast, at the turn of the century, about 50% of all babies were born at home. Most out-of-hospital births today are attended by midwives. A midwife is someone who assists women throughout the normal progression of pregnancy and childbirth. Unlike a doctor or nurse, who is trained to cure illness or injury and as a result is focused on what can go wrong, a midwife sees birth as a natural process and believes medical intervention is only necessary in the case of an emergency. This fundamental difference in philosophy between midwives and doctors influences the care women receive from members of either profession. There are several kinds of midwives practicing in the United States today. Direct Entry Midwives (DEMs), also referred to as lay midwives, receive their training through an apprenticeship with an experienced midwife. They may have taken classes or workshops to supplement their education. Certified Midwives, or CMs, have taken an exam and met other qualifications, such as training in CPR, in order to be certified by their state or by a midwifery organization, such as the National Association of Registered Midwives. They have also been educated in midwifery through a four-year degree or an apprenticeship. Certified Nurse Midwives (CNMs) are registered nurses who have completed a master's degree in midwifery. In Texas, the large majority of practicing midwives have the qualifications of CMs. However, medical groups have lobbied heavily to prevent Texas midwives from calling themselves "certified" in order to avoid confusion among the general public between CNMs and CMs. Instead, midwives in Texas must refer to themselves as "documented". The practice of midwifery by DEMs or CMs is illegal in 21 states. Licensure, certification or documentation of midwives is available in 17 states, while 6 states provide Medicaid reimbursement for a midwife's services. In Texas, Medicaid reimbursement for home births attended by midwives is available. There are also regulations by the state which see that Texas midwives have appropriate training, and are documented. In order to conform with the law, Texas midwives must have served an apprenticeship under an experienced midwife for a certain number of births and gain clinical experience. They must then pass a course administered by the Association of Texas Midwives. Yearly updates in training are required, including CPR certification. A documented midwife in Texas must provide her clients with a statement of informed choice and disclosure, listing the procedures she is and isn't authorized to perform. Most doctors and nurses discourage midwife-attended births outside of a hospital setting, claiming they are unsafe. However, the scientific literature does not support this belief. For example, a six-year study by the Texas Department of Health showed that midwife-attended home births had lower infant mortality rates than hospital births managed by physicians. When it comes to choosing a birth setting, however, the actual safety of a practice is not as important as the perception of safety. Many women are uneasy about giving birth at home. For these women, hospital births are the best choice. In contrast, women who have had bad experiences giving birth in a hospital may feel safer at home. These women, even though they are a minority, also deserve choices. Women need to be educated about the advantages and risks, no matter where they choose to give birth. Only then can they make an informed decision about the best place for their child to be born.
Hospital birth
When used appropriately, medical technology saves the lives of mothers and infants in high-risk pregnancy and birth situations. It is vital for premature babies and infants born with serious health problems, and when a situation arises during a birth which threatens the life of mother or child. However, since the early 1970s, there has been a steady increase in the use of some routine, unnecessary medical interventions during the normal process of a low-risk birth. Both doctors and their patients are responsible for this increase. While doctors have been trained to see birth as inherently risky and to err on the side of caution when it comes to medical treatment, some women, out of fear of the birth process or a desire to make the birth convenient, will pressure their physicians for unnecessary interventions, such as labor induction or planned cesareans. Studies have estimated that approximately 50% of all cesarean sections done in this country today are unnecessary. The reasons for this are complex, but the largest problem is that doctors are afraid of potential lawsuits. Birth can be risky, and Americans can sue a doctor for any damage a child may have undergone at birth until the child reaches adulthood. While cesarean sections accounted for 5% of all births in 1960, today they account for 22%. According to the United States Department of Health and Human Services, Texas has a cesarean rate of 27%, greatly exceeding the national average. Some hospitals have better records than others -- at St. Joseph's Hospital in Bryan, the cesarean rate is 20%. The high rate of cesarean births in the United States would be easier to accept if it were proven that it has caused a decrease in infant mortality, but scientific research has shown that this is not the case. Another intervention which contributes to unnecessary cesareans is the increasing use of continuous electronic fetal monitoring. While doctors may like them because their use deters lawsuits, studies have shown that they frequently record false alarms for fetal distress. Rose Eder, a nurse in the obstetrics department at St. Joseph's Hospital in Bryan, commented, "Sometimes the monitor will record fetal distress, we'll do a cesarean section, and the baby will be absolutely fine." Recent research has found that the old method of monitoring the baby's heart rate with a stethoscope every five to fifteen minutes, called intermittent auscultation, has been proved just as effective at detecting when a baby is in trouble, and its use decreases the chances of an unnecessary cesarean. However, in today's hospitals, heavy patient loads may prevent nurses from paying such close attention to an individual person. It's become more practical to attach an electronic fetal monitor to a patient as a substitute for attentive personal care. One reason hospitals are so popular is the problem of pain relief during labor. Many women giving birth in American hospitals today ask for epidurals to relieve pain. An epidural is a method of administering local anesthesia. A needle is used to insert a catheter into the area surrounding a woman's spinal cord, called the epidural space. Medicines for pain relief can then be administered through this catheter. This method of pain relief has become increasingly popular throughout the United States, including the Brazos Valley. Eder noted that the number of women asking for epidurals has more than tripled over the past year. Problems arise when, out of fear, women decide they want an epidural for pain relief even before they've experienced labor, without researching the potential risks of the procedure or other options of managing their pain. "Women who won't even take an aspirin during their pregnancies go in to the hospital asking for an epidural, without considering the effects the drugs may have on their baby," says Andrea Hendon, a midwife practicing in the Bryan/College Station area. Women who choose epidurals should be aware of the risks and potential problems, as well as the benefits. For a woman who has been in labor for hours and is exhausted, an epidural can provide much-needed relief, allowing her time to rest and regain her strength. However, epidurals, while much safer than other forms of anesthesia, have inherent risks. Minor complications for women include headaches, decreased blood pressure, and temporary urinary incontinence; more serious complications include convulsions, respiratory paralysis, allergic shock, and cardiac arrest. There are problems for babies as well, since epidurals may cause an abnormal fetal heart rate and contribute to jaundice in newborns. While unnecessary cesareans expose women and babies to the risks of major surgery, and epidurals have their own problems, health is not the only cause for concern. The increasing use of such practices is financially costly. In a country where the price of medical insurance is high, we all literally pay for the misuse of expensive medical treatment. While many people don't question the necessity or safety of some routine medical interventions occurring today, there are those who do. For those women who are concerned about receiving needless medical treatment during labor, there are several options available which may reduce the risk of unnecessary intervention, including the following: 1. Try to avoid having an epidural. Become educated on alternative methods of managing the pain. Such methods may include breathing and relaxation exercises, massage, or the use of Jacuzzis and showers. 2. Hire a labor support person, or doula. A doula acts as an intermediary between hospital staff and parents-to-be during labor, making sure the patient's wishes are known when a woman is in no condition to communicate her needs to nurses. She also provides emotional support for a couple. Studies have shown that having a doula present at a birth decreases the occurrence of unnecessary cesarean sections. 3. Write a birth plan and give it to your doctor. A birth plan is a "wish list" detailing a woman's preferences with respect to her treatment during labor. Birth plans may specify that a woman would like to be allowed to eat or drink if she wants to; what pain medications, if any, she would prefer; and whether or not the doctor should avoid giving her an episiotomy, among many other things. 4. Pick your doctor carefully. Before choosing an obstetrician, interview several doctors and find the one whose opinions about birth most closely reflect your own. Ask questions about hospital policy as well as the doctor's philosophy on birth. What is his or her personal cesarean rate? Does he perform routine episiotomies? Will the hospital allow you to eat or drink during labor? 5. You have the right to question or refuse any treatment. For example, if you know that continuous electronic fetal monitoring contributes to unnecessary cesareans, you can request periodic monitoring instead. 6. Accept the inevitable. Every birth is different, and never goes exactly as planned. Even if you've educated yourself, chosen a good doctor whom you trust, and made an effort to get the kind of treatment you'd prefer, you may still end up needing some intervention. If this is true, you can still feel confident that you did everything in your power to be informed and take responsibility for the quality of your own health care.
Home birth
People choose home birth for many reasons. Some women, like Althea, are terrified of hospitals. Others prefer the personalized care they can receive from a midwife. Still others have had bad experiences with previous hospital births, and turn to a home birth to avoid repeating these experiences. Whatever a woman's reasons for having a home birth, they are just as valid as those of a woman who prefers to give birth in a hospital. Contrary to popular belief, many studies have demonstrated that home birth for women with low-risk pregnancies is as safe or safer than hospital birth. Midwives who attend home births carefully screen their clients throughout pregnancy. If at any point a client develops a condition which decreases her chances of having a healthy birth, the midwife will immediately refer her to a doctor. In cases where an emergency condition develops during a birth and a client needs to be transported to the hospital, the midwife is prepared to recognize the emergency in its early stages, take immediate first-aid measures to help both mother and child, and arrange transport. With home birth, safety isn't the issue: the perception of safety by medical practitioners and the general public is. The common misconception that home birth is unsafe will cause problems for any woman planning to give birth at home. Many home birthers limit the number of people they tell to immediate family and close friends in order to avoid insensitive comments. Unfortunately, this silence leads to continued ignorance of the general public, and less acceptance of home birth as a safe option. Home birth is not for everyone. Women who are prone to high blood pressure, who have diabetes, a heart condition, or who smoke aren't good candidates for home birth. If you develop a condition called pre-eclampsia, if your baby is in a breech position, if you go into labor before the 37th week of gestation, or if any other complication arises, your midwife will transfer you to a doctor's care. When planning a home birth, a woman needs to find a physician who will act as a backup for her midwife, in case she needs to go to the hospital. Unfortunately, in many states, including Texas, a lack of coordinated care between obstetricians and midwives makes this difficult. In California, where CNMs are the only people who can legally practice midwifery, those who work in hospitals or birthing centers are under the direct supervision of a doctor; the few CNMs who will attend home births in California don't have this automatic physician backup. Because Althea had her daughter while living in California, she had difficulty finding an obstetrician who would act as backup in case she needed to be transferred. Once she found a doctor, he backed out of the agreement two months before she gave birth. Even though her birth went smoothly, a transfer would have been handled by going to the hospital emergency room. An additional problem of the lack of coordinated care between physician and midwife is that of medication. In Texas, midwives can't prescribe medication, but they may need certain drugs in an emergency situation, such as pitocin to control bleeding. To obtain these drugs, the midwife must have a prescription from a physician. Because this is a gray area in Texas law, she must find a doctor who is sympathetic and willing to work with her. The tolerance of the medical profession towards midwives varies greatly in Texas. While midwives in College Station or Houston may be allowed to stay with their client in the hospital if she needs to be transferred, midwives in Waco must leave their clients at the hospital door. Because the midwife has built a close relationship with her client, this forced abandonment can be extremely distressing to the pregnant woman, especially if she has a fear of hospitals to begin with. One of the problems with home birth is that insurance coverage may be difficult to find. Health Maintenance Organizations like the Scott & White Health Plan won't pay for home births. Some private insurance companies may cover costs, and depending upon which state you live in, so will Medicaid. However, because midwife-attended home birth costs much less than the average birth in a hospital, cost isn't an issue for many people. In the Bryan/College Station area, midwives charge about $1000 to $1500 for a home birth. This cost includes the actual birth, as well as prenatal and postpartum care. In contrast, equivalent care in a Texas hospital costs $4000 or more, for the birth alone. If a patient in a hospital elects to have an epidural or needs a cesarean, the costs are even higher. Cost should be one of the least important factors in deciding whether or not to give birth at home. Andrea Hendon described the experience of one client who was nervous about planning a home birth, but made the decision because she felt she couldn't afford hospital care. Because of the woman's unease, her labor didn't progress, and she needed to be transported to the hospital anyway. The quality of care is a deciding factor for many people who choose home birth. While the average obstetrician's visit for prenatal care lasts 15 minutes, midwives spend up to an hour at prenatal appointments. Unlike physicians, many midwives make house calls, providing a level of personalized care that is no longer available from the medical community in this country. If you are interested in planning a home birth, interview midwives in your area carefully, and check their references. Just as there are good and bad doctors, there are good and bad midwives. If you are having trouble finding a midwife, the Association of Texas Midwives maintains a list of all their members, and can be contacted at 512/928-2311. In addition, the Texas Department of Health has records of all midwives in Texas who meet documentation requirements.
Other options: Birth centers, and nurse midwives (CNMs)
Another option for pregnant women who prefer midwifery care is a birth center. Birth centers may be staffed by nurse midwives under the direction of a physician, or by DEMs or CMs. They provide prenatal care and birth classes, and offer a comfortable, home-like setting in which a woman can give birth. As is the case with home births, women desiring care at birth centers are carefully screened, and only women with low-risk pregnancies are accepted as clients. Birth centers staffed by midwives are a good option for those who want to avoid unnecessary medical intervention, but feel uncomfortable giving birth at home. There are no birth centers in the Bryan/College Station area. Another problem in the Bryan/College Station area is that there are no locally practicing nurse midwives. While the number of nurse midwives is rapidly growing across the country and their practice is beginning to be accepted by the health care community, they are relatively rare. The current number of nurse midwives practicing in the US is about 4000. "I would love to see a birth center built across the street from St. Joseph's, and have it staffed by nurse midwives," says Eder. Unfortunately, this may be a while in coming. While the number of nurse midwives has almost doubled over the past ten years, birth centers and nurse midwives are still mostly found in urban areas. The future of nurse midwifery in the United States looks promising. A study published in 1995 by Public Citizen, a consumer advocacy group, demonstrated that midwifery care in hospitals can reduce the cesarean birth rate to 12%, almost half the national average. In addition, vaginal birth after cesarean (VBAC) has enormously high success rates with midwifery care, compared with the rates seen in patients treated by physicians. Nationwide, only 20% of women who have had one cesarean will deliver vaginally in subsequent births. Texas has a particu- larly poor VBAC rate of 13%. Midwives can greatly improve these outcomes: the Public Citizen study indicates that the VBAC rate for women attended by a midwife during a hospital birth was 69%, almost three times the national average. While nurse midwifery may be the wave of the future, it hasn't quite hit Bryan/College Station yet. If you would like to see nurse midwives working for your local hospital, call your doctor or hospital and let them know. Only by encouraging change in our community's hospitals can we gain the benefits of decreased medical costs and fewer unnecessary interventions which midwifery care brings.
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