Friday, August 24, 2012

St. George Home Birth Article and My Response

This article came out online yesterday. I take issue with much of what is said in it, and even the picture of the Midwife holding baby while mom is nothing but a blur in the background. One thing that I have learned is that I have to fight to be seen as credible. I do this by knowing what the research says. Writers and Obstetricians need to be held to the same accountability. 

My Response: 

Dear Alexa Morgan,

I recently read your article about home birth in Southern Utah, and find myself asking where the research is. I am a Home Birth Midwife here in St. George – one with a zero transfer rate in labor – and a birth advocate. I see that you mentioned a study that was released, highlighting why some women might choose to birth at home, but then you erroneously stated:

A myriad of studies have been conducted on the risks of home birth versus hospital birth with no conclusive results, due mainly to the low percentage of babies born at home.

Yes, many studies have been done comparing home birth to hospital birth among low risk women since the 1970s. In fact, there have been 17 studies in the last 15 years alone. Even more when you include the number of studies done outside of the U.S. which shows better outcomes over all, outside of the hospital. But they all have one thing in common: They all show, very conclusively, that not only is home birth just as safe as hospital birth but that there is a much lower incidence of maternal morbidity when birthing at home. Fewer unnecessary interventions such as induction/augmentation of labor, artificially rupturing the amniotic sac, delivering in the lithotomy position, episiotomy, and instrumental deliveries lead to much better outcomes on the level of injury to mom and/or baby. 

While I have had nothing but an amazing professional relationship with several Obstetricians in town, and while I thoroughly respect Dr. Fagnant for the positive changes that he has made within the labor and delivery department of DRMC, I disagree with a few of his statements. 

There is no research to back up his blanket statement of which conditions preclude birthing at home. While there are most definitely situations and circumstances that may preclude a woman from birthing at home with a Midwife, it is not evidence-based to simply state: 

“Any woman who has an illness, has had uterus surgery, is before or after their (due date), (is carrying) multiple babies, a large baby or (breech) baby should not deliver at home,”

It entirely depends upon which illness he speaks of. One cannot simply state that any women with an illness should not birth at home. While there are certainly illnesses that would necessitate a hospital birth, some chronic illnesses may not require it. Some conditions that might require hospital birth would be uncontrolled, insuline dependent diabetes; illness with medications that caused abnormalities in the fetus; certain heart conditions, etc. 

As a mother who has had a VBAC (Vaginal Birth After Cesarean) at home, as a woman who has been researching VBAC for the past seven years, and as a Midwife who fully supports women who have had prior cesarean surgery, I also disagree that this precludes women from birthing at home. The research shows us that the main risk associated with VBAC is uterine rupture, and this occurs in 0.3-07% of VBACs. Less than other emergencies, such as cord prolapse, that would necessitate immediate hospital transfer. With a care provider who knows the research, who is experienced with VBAC, and who isn't afraid to transfer if anything seems to be off, VBAC at home can be very safe and continues to be a reasonable choice. For many women, it is the hospital or physician protocol which puts them in the position of choosing to birth at home after a prior cesarean. Some hospitals have banned VBAC altogether. Most have certain criteria for VBAC labors that must be closely followed. Sadly, many VBAC hopefuls find themselves in the operating room again, and know it was avoidable. 

As to his statement about not birthing at home if you are before or after your due date, again I ask where the research is. Any skilled Midwife that I know would not attend a woman at home who is less than 36/37 weeks gestation. However, 37 weeks is full term and is normal for some women. For others, it can be completely normal and a part of their maternal history to gestate until 42/43 weeks. With proper monitoring, research shows us that expectant management is completely acceptable in terms of risk/benefit. Many women do not understand that normal gestation length is 38-42 weeks. Most believe that they are "overdue" and at risk beyond 40 weeks. This is simply not true. 

Twins and breech babies can also be birthed at home without complication, with a skilled care provider. A Midwife who is experienced with multiples and breech knows what to look for in risk assessment, and knows which women should be in the hospital and which are safe to deliver at home. In the hospital, moms of multiples or of breech babies are often limited to cesarean surgery. Or may be allowed to birth twins vaginally, but in the operating room. Understandably, some women don't want to spend this most incredible and life-changing event in a cold, bright operating room with the thought of surgery being so close. 

As a mom of ten pound babies, I am concerned with the blanket statement that women carrying a large baby should not birth at home. Weight is not nearly as relevant as head circumference. So much is misunderstood about the ability to birth babies of all sizes, particularly when there are no abnormalities causing the size of baby. There are things that make a dramatic difference in the ease of birthing a large baby. Mobility, ability to get into different positions that open the pelvis more than the semi-sitting or lithotomy position, and patience. Most often, these things are not available in the hospital. While there are wonderful Obstetricians who are thoroughly researched and are willing to offer these things to women, it is more the exception than the norm. One also takes into consideration that it is the structural size of the baby that matters, not how many pounds the baby weighs at birth. I have often heard of care providers stressing induction of labor at 40 or 41 weeks because, "The baby looks to be getting quite large.". However, the baby's structural size does not change between 40-42 weeks. For example, my 10lb 10oz VBAC baby, who was born onto my bed at home, had the same exact head, shoulder, and chest size as my friend's 8lb baby. It is simply not evidence-based to say that all women with a large baby should not birth at home. 

I can completely understand Dr. Fagnant's concern with the transfers that he sees each month. I am concerned with particular things as well, regarding the health and safety of moms and babies at home. There are certain practices and beliefs in our community which have caused incredibly concerning transfers. I know that sometimes all care providers are lumped together, and I find this particularly true of the reputation of Midwives as a whole. But it is damaging for Dr. Fagnant to mention transfers, and then mention the deaths that he has seen in his time as an Obstetrician. An Obstetrician is simply going to see more death than a home care provider, because Obstetricians deal with not only higher risk pregnancies, but also have much higher rates of intervention in labor. Obstetricians deal with things like labor-inducing drugs which have side effects - including death - to go with them. They deal with emergencies that are more prevalent with intervention, such as cord prolapse, hemorrhage, and embolism. 

So many aspects of pregnancy, labor, and birth are misrepresented and risks are inflated. Unfortunately, most people are less likely to do research than they are to take an authority figure's word as gospel. The concrete research is there. It is vitally important for families to thoroughly research their options in childbirth, and their potential care provider. But there has to be balanced information based on empirical research.


Alyssa said...

Well said!

Besmah said...

Thoroughly researched and explained. Thank you for taking the time to write this letter and post it!