E-News 3:1 - Home and Hospital Birth

Empowering Women: Hospital Birth and Homebirth

Editor's note: Following are further responses to Zora's question about hospital and homebirth discussed in E-News Issue 2:52. Thank you for the many heartfelt and thoughtful responses!

I am a doula who mainly works in hospital settings. I love homebirth but we all know reasons why it isn't possible for some women. I really appreciate the CNMs who work in our area hospitals (Minneapolis, Minnesota). As a doula, I encourage the women I meet to go to a midwife rather than a doctor mainly because of the personal care and the huge difference in philosophy. I think it's possible to have a homebirth atmosphere in a hospital setting and if women are prepared to embrace the difference between birth and delivery, it will happen for them. I have seen the politics, I feel badly about that, but you really are needed right where you are. As you emit wonderful feelings of birth, faith in birth, etc., the women you work with will soak that in and truly birth their babies.
- Marla Lukes, certified doula, DONA

I, too, am a midwife working in the hospital. I have the soul of a homebirth midwife, but the grim reality is most women won't have a birth at home. I serve poor immigrant women--they came here to escape their homes! Many of my clients have been hospitalized just to feed them for a few days. They live with relatives, in shelters, or on the streets. Statistically, these women do much better under midwifery care than with the medical model, but because they are so high risk, no one would consider them ideal homebirth clients. It is draining to help such needy women but uplifting to see them become educated and empowered, something that can happen within (or in spite of) the context of hospital birth. But we need something to keep *us* going, I think. Taking care of the most needy people has some inherent rewards but is also taxing to the soul.

Know that there is a niche for you and what you do and the women you serve are helped by your presence. Many will know normal birth for the first time because of you. The ones who experience "managed" birth will still benefit from your concern. Never discount that.
- Margi

I am an RN currently working in the birth center of my local hospital. However, I prefer and totally support homebirth. I had all four of my babies at home and my son and his wife had their babies at home. Moreover, I trained with lay midwives during the 80s and even did a few births on my own before my family life became too much to juggle. I have been at the birth center for nearly a year and I find that I still have a deep love for this work. Like Zora, I do my best to empower women within the confines of the hospital, but the obstacles are intense. Most of the doctors favor epidurals. Their patients come in planning to have them even if they really don't want them. I got chewed out by one doc for supporting her patient into second stage without one. Everything went perfectly well and I overheard the patient phoning her friends afterward, exclaiming about how she did it "all naturally." But her doctor took me aside and threatened me, saying "If my patients want an epidural, they get an epidural." I told her the woman had been undecided and was breathing effectively and making fine progress and that's why I acted the way I did. She wasn't impressed with my reply. So I find I walk a very thin rope between being a patient advocate and catering to the OB's demands.
- Robin
Columbiaville, Michigan

I have been a midwife for 20 years. Ninety percent of my practice/births are in the hospital. A small percentage (about 10 births a year) are at home. I will freely admit that I am more comfortable in the hospital, but I know how nice and peaceful homebirth can be. That is my goal with my hospital clients. I wish we could stop the argument of which is better, home or hospital. Not everyone should have her baby at home. There are those who have physical risk factors and those who like myself are more comfortable in hospital. Several things can help create a wonderful hospital birth experience. With prenatal education and good family support, most women spend early labor at home if they have someone to touch base with.

Our nurses are good at assessing early labor and encouraging women to try some comfort measures at home. In the hospital we use intermittent monitoring, tub, shower, or the birth ball. Dim lights and classical music do a lot to change the atmosphere and set a quiet tone for the birth. It does mean that a midwife is in attendance at all times, modeling the quiet respect that will be sensed by those around you. Just because a woman chooses to have her baby in the hospital doesn't mean we cannot make it a beautiful experience.
- P.B.

Let's make homebirth the standard of care. I also would like autonomy in my profession and respect when I transport to a hospital because I *need* medical intervention. I am currently being supervised by the Board of Medical Examiners because I do homebirth and several doctors to whom I transported clients complained about my homebirth practice. It would be so nice if the docs realized that the transports were appropriate and that the midwife used good judgment. Instead we have to think twice about where and to whom we can transport. Even to practice we have to find a doc willing to risk the wrath of the medical community because he or she believes that women should have the choice to birth at home.

Regarding birth certificates: I found that local registrars are often ignorant about how to file a certificate for a baby born at home. I contacted the state registrar who understood the problem of misinformation at the local level and intervened. If you have the written rules for filing you can educate the local registrars and refer them to their superiors when a problem arises.
- Georgia Blair CNM CPM

The problem you see with lack of empowerment may be precisely because you are dealing with hospital births. It's part of the culture to play roles of helpless patient and hero doctor when one steps inside the hospital door. The few who are brave enough to stand up for their rights in the hospital usually have to fight every inch of the way, with untold numbers of staff as well as the doctor. Women in labor should be able to relax and have a baby, not be on guard, ready to fend off intruders at every turn. You sound like a very good, conscious midwife trying to give your couples a good, natural birth experience. But this is way bigger than you. In the hospital, staff changes every eight hours. One nurse may say you can walk or eat, etc. Then she's gone, and the next one has a completely different interpretation of the rules. I've seen docs rupture membranes without warning (not to mention asking)! I've seen CRNAs badger women into taking pain meds. I've seen lots of other stuff I won't mention here, but you get the idea. In the hospital there are too many uncontrollable variables for most women to really feel empowered there. Personally, I'd rather stay home and relax than fight off the hordes at the hospital. At home, I knew I was in charge--no one was going to do anything to me or my baby that I didn't want!

Of course not everyone can have, or even wants, a homebirth. I'm glad there's someone like you there for those people. Many of the homes where I attend births still have outhouses, wood stoves and other primitive conditions, but it doesn't take much to make a small clean spot to birth in, nor a lot of fancy equipment.
- Marlene

I applaud Zora for making birth nicer for the ladies she serves in the hospital. What a wonderful privilege, especially when those ladies may come from such a hard, oppressed life. I do homebirth in America and I recently had to risk someone out. Luckily we had a birth center to go to as I can't do hospital births. We all have our paths in life and I hope you don't feel like yours is any less important just because it's doing hospital births. I am sure you are a blessing to so many there.
- Lisa Hines LM in SC

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Midwifery Today's Online Forum

I am an aspiring midwife temporarily living in Sweden (I am not Swedish). I am very much looking forward to the time when I can start my education, and when I can finally be a midwife! I am considering moving to the United States, getting an education there, and possibly starting practicing. I get cold feet at times when I think about the huge change of my whole lifestyle, environment, etc. that will involve. It is completely new to me.
I need your input on WHAT IT IS LIKE TO BE A MIDWIFE. What kind of changes/adjustments/sacrifices should I be prepared to make? What are the main things I should know before getting started?
- Anna

Question of the Week Responses

The news article on HIV testing and false positives [Issue 2:44] was really frightening. Do all midwives require an HIV test?
- J.

A: I am a lactation consultant and for the past year have been reviewing literature on HIV and breastfeeding. But I have also been very much aware of the issues in regard to mandatory HIV testing for pregnant mothers and/or newborns. There are many scientists and researchers who question the premise that HIV even causes AIDS.

Midwives, like all healthcare providers of pregnant women, must abide by state laws. Currently, the laws on HIV testing vary from state to state. New York and Connecticut are the only states where newborn testing is required. (Newborn testing can only tell you whether the mother is infected, not the infant. Infants continue to have maternal antibodies circulating in their blood and may test positive until 18 months of age and then seroconvert.) New York and Connecticut, along with three or four other states, require HIV testing of pregnant women unless the woman objects or refuses. Several other states are required to offer HIV testing. The majority of states in the USA have voluntary testing and no requirement for newborn testing. The CDC guidelines advise healthcare professionals to counsel all pregnant women about HIV/AIDS and to offer them voluntary HIV testing. This information is from 2000 Health Policy Tracking Service dated 3/1/00.

Therefore the question, Do all midwives require an HIV test? is dependent upon the state where one resides. Pregnant mothers should be aware that they have the right to refuse such testing. Why refuse testing? All HIV testing is for the presence of antibodies to the HIV virus, not to the virus itself. The Elisa and Western Blot test and the PCR test used to test infants were never intended by the manufacturer to be used as a diagnostic test for HIV. Some 60-70 conditions may cause a false positive result, one of them being pregnancy in multiparous women.

What does it mean to be HIV-positive? Fear. The media's coverage of this health issue can only terrify most people. Yet there is another side to being HIV-positive. I highly recommend reading Christine Maggiore's book, "What If Everything You Thought You Knew About AIDS WAS WRONG?"

When a test has a high probability of inaccuracy, one might rethink whether it is worth taking the test, particularly when a positive result may mean there will be enormous pressure to take toxic drugs (AZT was first manufactured for use in cancer but was considered so lethal that they took it off the market until HIV/AIDS came along). And there will be enormous pressure to have a c-section, to formula feed, (and yes, I could write a book on the risks of infant formula in the USA as well as in developing countries) and if a son is born, to have him circumcised. A lot of major interventions may have serious health consequences not only to the mother but to her infant--and these consequences may be based on a false test. Women should be informed of these issues and also understand that they have a right to refuse testing.
- Valerie W. McClain, IBCLC

A: I don't require the testing. I don't "require" anything in general, but treat everyone appropriately in terms of their particular needs and desires. After all I am here to serve moms, not disservice them! Years ago I had read about a high incidence of false positives in nursing moms. I never put a lot of stock in the test. Of course, if one of my moms had reason to fear being HIV positive, I would recommend the testing for her peace of mind. Using universal precautions for everyone should be sufficient.
- Anon.

Coming E-News Themes

1. PRECONCEPTION COUNSELING: What do you tell the aspiring parents who ask you for preconception services/advice?
(Thanks to Sarah, an E-News subscriber, for this topic.)

2. CHARTING CAN BE AS UNIQUE AS EACH MIDWIFE'S CARE. Do you have charting methods you would like to share with E-News readers?

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

QUESTION OF THE QUARTER for Midwifery Today magazine

Issue No. 58
Mamatoto: Motherbaby
How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?

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Switchboard

How pregnant are you? First, second or third trimester? I doubt that evening primrose oil (EPO) is the cause of constipation. Pregnancy itself causes constipation. It is evident by the second trimester in most women, and sometimes occurs in the first trimester. Pregnancy changes our intestines so that we absorb the nutrients we eat more fully. Hormones slow down peristalsis. In addition, we tend to feel nauseated and avoid certain foods, and many clients don't drink enough water. It seems I am encouraging women over and over to drink more water. The longer feces sit in the intestines, the less moisture they contain and the more constipated one becomes.

I have all my clients take EPO. No one has ever claimed it caused constipation. I have heard one complaint of acne. My clients start EPO about 34-36 weeks gestation--not that it's bad to take it earlier. n fact it may be wonderful for baby's brain growth and intelligence, especially if one eats a lot of margarine and shortening-laced products. However, use caution; Anne Frye mentioned in one of her publications that taking it throughout pregnancy may have been the cause of a horrific tear that she witnessed. Just one case, and not a research study, however, drew that opinion--in the hospital, we are always confronted with women who have not taken EPO and still their tissues tear. I have heard doctors attribute it to poor protoplasm--lack of adequate tissue-repairing nutrients in the diet throughout the life span and pregnancy, such as lack of vitamins C and A, protein, and zinc. In my copy of the "Review of Natural Products, Facts and Comparisons," constipation is not listed as a side effect, and in fact no side effects were listed. EPO was studied in dosages up to 8000 mgs per day without side effect!

The simplest remedy for constipation is to increase fruit and vegetable consumption (5-8 servings per day), drink at least eight glasses of water per day, and for some, take a couple of teaspoons of fiber such as Metamucil or a more organic version followed by a second glass of water. Warm prune juice is an excellent remedy. Some people add 1/4 cup of Seven Up to prune juice heated for a minute or two in the microwave with excellent results. Prune juice is high in beta carotenes, so you are nourishing your skin, and women who are acne prone may notice improvement of their skin.
- Sandra Stine, CNM
====

I am a natural childbirth educator and mother. I was diagnosed with hypothyroidism (the opposite of Grave's disease) two and a half years after I gave birth to my son. I have done much research into how thyroid disease affects pregnancy. It is my understanding that women with hyperthyroidism (Grave's disease) usually become hypothyroid after taking anti-thyroid drugs. I do know that once you are hypothyroid you must continue taking your medication during pregnancy. Women with undetected or undiagnosed hypothyroidism have a much greater chance of having a baby with some degree of birth defects and/or congenital thyroid disease. I have had four childbirth students over the last year who have had thyroid disease. One of them was the daughter of a women who did not know she had thyroid disease during pregnancy. This women (my student) had congenital thyroid disease and has had to take medication since birth. Please be sure to check with your doctor/midwife about this issue before becoming pregnant again. It certainly is worth finding out all you can before conception.
- T. Brien
====

In response to the midwife named Azure who has Hashimoto's thyroiditis and is pregnant [Issue 2:52]: I am currently caring for a client with the same diagnosis. This 26-year-old had been prescribed thyroid meds but had been taking herbal supplements in lieu of the prescription thyroid for about a year before becoming pregnant. My first contact was at her initial history and physical at 9.4 weeks; her thyroid was enlarged to about 8 cms. I drew a thyroid panel and her thyroid-stimulating hormone (TSH) was significantly elevated at 13.6. She was referred back to my backup OB/perinatologist for consultation and he prescribed thyroid 0.15 mgs. daily and advised repeating her TSH every 4-6 weeks during pregnancy. We have increased her thyroid to 0.175 to maintain her TSH levels within normal limits, but other than retesting her every 4-6 weeks, my backup OB feels that this is sufficient follow-up and expects the neonate not to have any complications from her elevated TSH early in the pregnancy. Interestingly, her initial ultrasound revealed a two-vessel cord, which he also feels is not related to her thyroid status, and although we are collaboratively managing her care, he agrees that she should be safe to have a homebirth.
- Vicki
====

The grassroots organization Virginia Birthing Freedom, Inc. is in the process of trying to get VA HB 1582 passed to give birthing Virginia women the right to have a midwife-attended home birth. We have two petitions: the first is on the web site at www.vbfree.org/petition.html This is the one we're collecting to present to Delegate Hamilton, and maybe the governor or during a press conference.
The second is at www.ethepeople.com/affiliates/national/index.cfm?PC=PETFV1&PETID=46866 This one is going to Delegate Jay DeBoer, co-chair of the House Health Welfare and Institutions committee, who voted against the bill last year. There are 39 signatures so far--we could use a few more! You don't have to be a Virginia resident to sign the petition. Your support is greatly appreciated.
- Heather L. Maurer
====

It was stated in Switchboard that vitamin C is an emmenagogue and an implantation inhibitor, and also that it could cause miscarriage or trouble conceiving [Issue 2:52]. Where can I find more information about vitamin C in regard to this?
- Sheryl

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