Homebirth is not common in the US, and consequently many people are uncertain about how safe it is. Heck, before researching it I was against it myself. I recently wrote an email to a family member explaining how we reached our decision and describing the midwife that we have chosen. I decided to re-post the email here to reassure and educate anyone else who is uncertain about the appropriateness of homebirth in our case. (I have, however, removed references to the name of the midwife, as I don't think it's fair to publicly post all these details about her without her consent.)
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In Oregon there is another level of midwives between the lay midwife and the Certified Nurse midwives. They are licensed direct entry midwives and are licensed by Oregon state. The only Certified Nurse Midwives in my area will only deliver at the birthing center or the hospital, and we were going to go with them, but they are not sensitive to my issues of vaginismus and the pain and fear I experience with vaginal examinations. My main concerns, in order, are:
1) having a healthy baby at the end, and not putting it at risk in the process of birth, and
2) avoiding unnecessary vaginal examinations, and receiving information about when the practitioner feels they are necessary so I can choose whether or not to have one.
If declining a vag exam will put the baby at risk, I will not decline it. But if it's just a "we want to see how far you're dilated" I want the option of declining it. The Certified Nurse Midwives at the birth center will not consider that. Two of them told me on separate occasions "if you cannot tolerate or do not consent to a vaginal examination, we will transfer you to the hospital and give you an epidural so that we can do it without hurting you." Which, aside from all the other issues raised by an unnecessary epidural, doesn't mean that they're not hurting me. It just means I can't feel it. Vaginismus is an involuntary protective response by the body to a perceived danger. It's not under mental control. People with epidurals still spasm, even when they can't feel the exam. And I'd rather not traumatise that part of my body any more than I have to.
So, once it was established that I would not be able to relax properly at the birth center (you try relaxing when people are threatening you with unnecessary pain!), we started discussing the possibility of a home birth. I wasn't sure whether it would have enough safety to meet my first criterion above. But over the past couple of months my research indicates that it would be all right, given the proper circumstances. I spoke with my perinatologist today and he saw no reason (in terms of this pregnancy's health or risk factors) not to consider home birth. The licenced midwife whom we have interviewed and are likely to hire is well known to the perinatologist and he seemed to approve of the choice.
This midwife has been a midwife for 12 years and has done over 300 births. She is an Oregon Licensed Midwife and a NARM Certified Professional Midwife. Ten percent of those 300 births transferred to hospital, and seven percent of her patients have ended up with c-sections. (In contrast, our local hospital has a rate of 36% c-sections. The World Health Organization recommends a TOP rate limit of 15% in a developed country!) She has had one cord prolapse in twelve years, and she is fairly certain that the mother broke her own waters intentionally without telling her.
She was the midwife to one of my coworkers twice. Both times, this coworker planned for home birth but ended up transferring to hospital in a non-emergency situation (she hasn't told me the details yet, but I think it had to do with being very overdue). Even with the transfer she wanted to hire the same midwife for her second pregnancy, so I think that says a lot about my coworker's confidence in the midwife's abilities.
We asked her about hospital transfers during the interview. She said that she monitors the mother's behaviour and energy levels, and if she sees that labour is not progressing she will ask the mother to try various things like moving around, different positions etc. If labour still does not progress and the mother is showing signs of fatigue (contractions getting weaker or farther apart) she will recommend hospital transfer, and come with us to the hospital. The vast majority of the mothers whom she has transferred did so due to maternal exhaustion, and she sees it coming early enough that ambulances are not typically necessary. She does not hesitate to call one if she feels it is necessary. If there is excessive maternal bleeding or troubled heart tones (or breathing after birth) from the baby she calls an ambulance for hospital transfer. We live only about 15 minutes from the hospital by normal car. If the mother has third degree tears then that will need hospital treatment, but she is qualified to suture first and second degree tears.
She has also had patients with vaginismus before. She says that she will always tell me what she hopes to learn from a vaginal examination and how the information might change her actions, and let me decide whether or not I want it done. As my goal is to avoid the unnecessary ones while accepting the necessary ones for the good of the baby, this is an ideal match between her practices and my needs.
We're going to take the hospital tours and everything anyway, in case we do end up transferring either voluntarily or involuntarily, and I will be seeing the perinatologist again at 32 weeks to be sure everything is still continuing without problems. Overall, I think that for us a home birth with a qualified and professionally respected midwife is the best and safest option at this time.
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Postscript - I am certainly not saying that it is bad for a baby to be born by C-section! Neither I nor my nephew would be here without this medical capability. But birth is not ALWAYS a risky medical event, and given the proper circumstances of healthy mom, healthy baby, properly trained midwife and reasonable proximity to hospital care in the event that it becomes necessary, a home birth is perfectly safe.
Martin adds: We also learned recently that the hospital we would be required to attend has a c-section rate of 36%, above the national average. Our feeling is that about 2/3 of these c-sections were probably unnecessary, of the "let's hurry things along" [so I can get home] variety. c-sections, as Beth says above, is sometimes a necessary and proper procedure, but not without potential negative consequences. Guaranteed extended pain and healing for the mother being one, possible difficulty in breastfeeding another, and it is suspected that there are effects on the baby too. We'd like to avoid one of these unnecessary c-sections, or an unnecessary episiotomy, which is another surgical procedure often done to "hurry things up", with a short term benefit but longer term negatives.
For a mother to give birth it helps if she is comfortable, able to move about as she wants, and in control of her surroundings (light levels, heating etc.). The home environment offers the best control for the mother, with the additional benefit that she has books, TV etc. to act as distractions, and no journey to and from Hospital (assuming no need to transfer). For the Dad it's even better, no need to pack bags and sit around (or pace around) in hospital corridors and waiting rooms, or feel like a fifth wheel in the delivery room. I'll be an active part of the process as much as I can endure, and I'll have two dedicated professionals on hand (the midwife and her assistant), focussed on making the birth as comfortable and joyous as possible, and not distracted by other births, patients, or the end of their shift.
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