The Safety of Home Birth – New Study of 530,000 Women

A recent study in the Netherlands, a country known for it’s fantastic maternal and infant outcomes, has proven that home birth is safe.  It is the largest study of it’s kind and found that low-risk women planning to give birth at home had as good outcomes as low-risk women birthing in the hospital.

Check it out!

Home births ‘as safe as hospital’

Newborn baby

There have been few comprehensive studies into home births

The largest study of its kind has found that for low-risk women, giving birth at home is as safe as doing so in hospital with a midwife.

Research from the Netherlands – which has a high rate of home births – found no difference in death rates of either mothers or babies in 530,000 births.

Home births have long been debated amid concerns about their safety.

UK obstetricians welcomed the study – published in the journal BJOG – but said it may not apply universally.

The number of mothers giving birth at home in the UK has been rising since it dipped to a low in 1988. Of all births in England and Wales in 2006, 2.7% took place at home, the most recent figures from the Office for National Statistics showed.

The research was carried out in the Netherlands after figures showed the country had one of the highest rates in Europe of babies dying during or just after birth.

FROM THE TODAY PROGRAMME

It was suggested that home births could be a factor, as Dutch women are able and encouraged to choose this option. One third do so.

But a comparison of “low-risk” women who planned to give birth at home with those who planned to give birth in hospital with a midwife found no difference in death or serious illness among either baby or mother.

“We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife,” said Professor Simone Buitendijk of the TNO Institute for Applied Scientific Research.

“These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth.”

Hospital transfer

Low-risk women in the study were those who had no known complications – such as a baby in breech or one with a congenital abnormality, or a previous caesarean section.

Nearly a third of women who planned and started their labours at home ended up being transferred as complications arose – including for instance an abnormal fetal heart rate, or if the mother required more effective pain relief in the form of an epidural.

The NHS is simply not set up to meet the potential demand for home births
Louise Silverton
Royal College of Midwives

But even when she needed to be transferred to the care of a doctor in a hospital, the risk to her or her baby was no higher than if she had started out her labour under the care of a midwife in hospital.

The researchers noted the importance of both highly-trained midwives who knew when to refer a home birth to hospital as well as rapid transportation.

While stressing the study was the most comprehensive yet into the safety of home births, they also acknowledged some caveats.

The group who chose to give birth in hospital rather than at home were more likely to be first-time mothers or of an ethnic minority background – the risk of complications is higher in both these groups.

The study did not compare the relative safety of home births against low-risk women who opted for doctor rather than midwife-led care. This is to be the subject of a future investigation.

Home option

But Professor Buitendijk said the study did have relevance for other countries like the UK with a highly developed health infrastructure and well-trained midwives.

Women need to be counselled on the unexpected emergencies which can arise during labour and can only be managed in a maternity hospital
RCOG

In the UK, the government has pledged to give all women the option of a home birth by the end of this year. At present just 2.7% of births in England and Wales take place at home, but there are considerable regional variations.

Louise Silverton, deputy general secretary of the Royal College of Midwives, said, the study was “a major step forward in showing that home is as safe as hospital, for low risk women giving birth when support services are in place.

“However, to begin providing more home births there has to be a seismic shift in the way maternity services are organised. The NHS is simply not set up to meet the potential demand for home births, because we are still in a culture where the vast majority of births are in hospital.

“There also has to be a major increase in the number of midwives because they are the people who will be in the homes delivering the babies.”

Mary Newburn, of the National Childbirth Trust, said: “This makes a significant contribution to the growing body of reassuring evidence that suggests offering women a choice of place of birth is entirely appropriate.”

The Royal College of Obstetricians and Gynaecologists (RCOG) said it supported home births “in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system.

But it added: “Women need to be counselled on the unexpected emergencies – such as cord prolapse, fetal heart rate abnormalities, undiagnosed breech, prolonged labour and postpartum haemorrhage – which can arise during labour and can only be managed in a maternity hospital.

“Such emergencies would always require the transfer of women by ambulance to the hospital as extra medical support is only present in hospital settings and would not be available to them when they deliver at home.”

The Department of Health said that giving more mothers-to-be the opportunity to choose to give birth at home was one of its priority targets for 2009/10.

A spokesman said: “All Strategic Health Authorities (SHAs) have set out plans for implementing Maternity Matters to provide high-quality, safe maternity care for women and their babies.”

Trying my hand at belly casts…

I also am able to paint your blank belly cast to something meaningful to you!  I have a BFA in illustration and use it to work with you and your vision for the cast.

Cost:

1.  All over color (you can add more decorations yourself if you’d like): $50

2.  All over color plus a simple design on the belly:  $100-175

3.  All over color plus a mural of your choice:  $175 and up

For #2 and #3 the fee is $40 an hour plus materials.

To give you an idea of how long things cost, the below “Tree of Life” mural took 26.5 hours to complete plus $30 in materials.  This is a very elaborate piece, the most elaborate I’ve ever done, and is on the more expensive end of the spectrum.  The second cast (blue with the vines) took me about 10 hours plus $30 of materials.  These represent the middle and high-end of the range.   Contact me and I can definitely create something within your budget!

The first cast is Brandy’s cast.  She wanted to incorporate a tree of life, sparrows, a “mother” symbol, her son’s zodiac symbol (Cancer), a labyrinth (which turned into a beautiful placenta), and a mandala.

View my process!  Click here to see a slide show of the cast going from blank to decorated.

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The birds are the Jamaican doctor birds, a hummingbird with a really long tail.  This baby is half-Jamaican and mama wanted to add something from that country (also the Rasta colors and blue like the Carribbean)

Jamie with her henna belly

Jamie with her henna belly

STUDY – Vitamin D deficiency linked to primary C-section rate

image-3931619-35797336-2-websmall_0_dd0f5a04af6e73346ed777299ec88556_1A small study found that twice as many women (28%) who were vitamin D deficient at the time of giving birth had a Caesarean delivery compared with those with normal levels (14%).

Read the article from Medscape

Karen Robinson, a local Certified Professional Midwife, said the following about the benefits of vitamin D during pregnancy:

Vitamin D is getting a lot of scrutiny lately and is being found to be a superstar vitamin that we haven’t paid enough attention to.

Vitamin D supplementation can help increase immunity and decrease the impact and frequency of colds and common viruses.

Its role is also being looked at closely in the implantation of the placenta, how well the placenta functions, and therefore prevention of pre-eclampsia.

In our world of indoor jobs and layers of sunscreen when we do go outside, it’s easy to see how the majority of us may be deficient in Vitamin D.

The best places to get Vitamin D include a bit of sun exposure every week (so that the body can manufacture its own Vitamin D), fatty fish (salmon, mackerel, tuna, etc), fish oil (especially cod liver oil) and beef liver.

So, one thing doulas can do for their clients is to encourage good diet (lots of fresh fruits and vegetables, clean meats and plenty of fats) and suggest they consider supplementation of Calcium/Magnesium, Folic Acid, and Vitamin D.

Excercize, Pregnancy, and Pre-eclampsia

A new study has appeared in orgyn.com, a website dedicated to the research in the field of women’s health.  This study details the effects of exercise during pregnancy and the preventative factors with respect to preeclampsia (a condition diagnosed by high blood pressure and protein in the urine during pregnancy which, if left untreated, can lead to maternal seizure and death mother and/or baby).

Previously it had been thought that exercise could prevent preeclampsia since exercise lowers blood pressure.  This study showed that among the low to moderate exercise groups the rate of preeclampsia wasn’t affected at all.  However, in the high exercise group (over 420 minutes of exercise per week) the rate of preeclampsia actually increased.  While it’s good to be in general good health during pregnancy and exercise is a part of that, this seems to show that it’s not a good idea to exercise to the brink of body-builder status 🙂

Here is the full article:

AXX9K1Exercise and pre-eclampsia risks

Issue 25: 5 Jan 2009
Source: BJOG: An International Journal of Obstetrics and Gynaecology 2008;in press
Researchers have found that physical activity in early pregnancy may not have a protective effect against pre-eclampsia, and that high levels of exercise may actually increase the risk of developing the condition.

In a new paper published in the BJOG: An International Journal of Obstetrics and Gynaecology, the researchers from centers in Copenhagen and Odense, Denmark, in Oslo, Norway, and in Boston, Massachusetts, USA, write that it has been thought that physical activity in pregnancy protects against pre-eclampsia. This is based at least in part on physiological principles (such as exercise being understood to lower blood pressure) and has been supported by the findings of some case-control studies.

However, the researchers write, high quality empirical evidence on the association between physical activity and pre-eclampsia is limited. For the new study they analyzed data in the Danish National Birth Cohort, the largest prospective database of its kind, which enrolled 101,045 pregnant women between 1996 and 2002.

The study population consisted of 93,315 women with singleton pregnancies, of which 92,676 resulted in a liveborn child.

The women in the cohort were categorized into seven groups according to the amount of leisure-time physical activity they performed in the first trimester, as documented by telephone interviews. The groups were: 0, 1-44, 45-74, 75-149, 150-269, 270-419, and 420 or more minutes per week.

The researchers assessed the risks of pre-eclampsia and of severe subtypes of pre-eclampsia (including HELLP and eclampsia), according to the level of activity. They found no statistically significant relationships, including no protective effects, except for in the two groups with the highest levels of physical activity – where the risk of severe subtypes of pre-eclampsia was significantly raised.

The odds ratios for severe subtypes of pre-eclampsia, compared with the reference group who took no exercise, were 1.65 (95 percent confidence interval 1.11-2.43) for the women who took 270-419 minutes of physical activity per week, and 1.78 (95 percent confidence interval 1.07-2.95) for the women who took 420 minutes or more of physical activity per week.

Lead author of the paper Dr Sjurdur Ollsen said: “In our study we were unable to substantiate that physical activity in early pregnancy has a protective effect against pre-eclampsia. Another unexpected finding was that leisure-time exercise, in amounts that were only slightly higher than the recommended amount, seemed even to be associated with an increased risk of severe types of pre-eclampsia.” He suggested that further research is need to investigate this association, ideally utilizing large prospective cohort databases, but that in the meantime current recommendations on exercise in pregnancy should remain unchanged.

The journal’s editor-in-chief, Professor Philip Steer, commented that clinical guidelines in the UK stress that selective and moderate exercise during pregnancy, including aerobic and strength-conditioning exercises, can be beneficial, but he added: “While general fitness is a good thing in many respects, these data suggest that it may be unwise to exercise to peak fitness levels.

“This new research is useful as it provides us with an indication of how much exercise pregnant women should take. As with everything in life, too much of a good thing can be bad for you, and moderation in all things remains a good policy.”

Mother Blessings/Blessingways

In lieu of traditional baby showers, more and more women are planning Mother Blessings or Blessingways for the mother-to-be.   Unlike a baby shower, where the focus is on the baby, Mother Blessings celebrate the upcoming birth of woman into motherhood!  Birth is a rite of passage for many women and it’s great to show our support of her in her journey.  I also have two books, Mother Rising and Blessingways, in my library.

Here are some ideas of things you can do pamper the mother-to-be in your life.

  1. Start by naming the mothers in your lineage (children, mother, grandmothers, great grandmothers).  If you want you can link all of your wrists together with yarn or ribbon.  After everyone shares their lineage the ribbon is cut to make bracelets.  If you like, you can keep the ribbon on until the woman goes into labor to keep her in mind and support her.
  2. Cleanse the air with a sage smudge stick or salt lamp.
  3. Give the mom a relaxing foot soak or massage.
  4. Make the pregnant woman’s favorite food.
  5. Bring a “Bead and Seed.” Everyone brings a special bead and something from nature to symbolize the life growing inside her.  The beads are made into a bracelet that the mother wears until labor is over.
  6. Henna, of course, is my favorite addition to this! It’s particularly fun when the stain is still visible when the mother goes into labor.
  7. Think about hiring a belly dancer or take a belly dance class with friends.  Belly dancing was originally only for women dancing for women during labor, to show them how to use their abdominal muscles to move the baby out.
  8. Do some sort of fire/water/sand ceremony where each guest either lights a candle, pours a cup of scented water into a bowl, or layers colored sand in a glass while sharing a bit of advice or well-wishing (you can also do this with presenting your bead). You can pour the water into a special vial and keep it as a reminder of the support of your friends.
  9. If your friends have had children already, share a birth experience of your own.
  10. Instead of decorating onesies like so many baby showers do these days, have your guests decorate a square of fabric to be sewn into a blanket.
  11. You can even send the fabric out with the invitations. If you have the party early enough, you can finish the blanket or pillow case by the time the mother starts labor to remind her of the women who stand behind her.  A less time intensive option is to decorate a pillow case with positive birth phrases, encouragement, and quotes.
  12. Do a belly cast to preserve her shapeshift into motherhood.  You can purchase kits online and decorate them after they harden.  Some people put the baby’s hand prints on the belly after the baby is born or paint them with an image that is meaningful to them.  You can also have guests at the Mother Blessing decorate the belly themselves.  Another option is to hire a professional lifecaster to do the cast for you.  Unlike do-it-yourself kits where the finished product is the strips of plaster and gauze, lifecasting creates an exact replica of yourself by creating a cast and pouring medium into it (see right).  It’s definitely the more beautiful option, but also more expensive (around $150-300).  Some lifecasters in Denver are Chris Guarino, or to find other artists you can visit the Association of Lifecasters.
  13. Make a “Help” list where the guests can sign up to do chores or bring meals after the baby is born.
  14. Make a “Belly Bowl.” Some casting studios in your area may have the option to make a cast from the mom’s belly and turn it into either a bronze or ceramic bowl.  With the ceramic bowls you can decorate them yourself before firing.  With the bronze bowls you can choose different patinas (bronze finishes) and it “rings” when struck to the individual tone of mom and baby.

Tips on Writing a Birth Plan

Here are some things to consider when writing a birth plan:

Some people like birth plans, others feel it’s too restrictive.  If you’ve thought about what you want and talked with your provider and feel comfortable that everyone’s on the same page and you just want to go with the flow, please do!  If it feels better for you to have things organized on paper rather than in your brain, here are some tips to help you along!

  • Know your options – They say if you don’t know your options, you don’t have any.  Research different elements of labor, birth, and postpartum.  A great place to start is to read The Thinking Woman’s Guide to a Better Birth by Henci Goer and Gentle Birth Choices by Barbara Harper
  • Keep it brief – No hospital staff is willing to read a 20-page manifesto!  Keep it simple and use bullets or numbers.
  • Prioritize – There are so many things you might want in your birth but choose the few that really mean a lot to you, ie, keeping the baby with you skin-to-skin after birth.  Don’t put things in your birth plan that you know aren’t allowed, for example if the hospital doesn’t allow waterbirth, it won’t mean much that it’s in your plan.
  • Use positive language – No one wants to deal with a belligerent person!  Instead of “We don’t want the baby taken away” say “We prefer the baby to be examined on mom’s chest and to stay skin-to-skin as long as possible”
  • Separate wishes into categories – By organizing the list into “Labor”, “Birth”, “Postpartum”, and “Newborn Care” staff can easily find what your wishes are.
  • Talk with your Partner – It’s important you’re on the same page
  • Show the plan to everyone involved – Make sure your midwife/OB/doula know what your wishes are and can respect them.  If they can’t respect a vital point, it may be time to find a new care provider.  Remember, it’s never too late to make a change that could mean a world of difference to your birth!
  • Find out about waivers – See if you need to sign waivers to decline something in hospital/birth center policy.  For example, you may need to sign a waiver if you don’t want eye drops for the baby because you don’t, say, have a venereal disease.
  • Have care providers sign the plan – Keep the plan in your chart and carry one with you in your bag if it makes you feel more at ease.
  • BE FLEXIBLE! – Everyone has an idea of their ideal birth but it’s important to be flexible if something unexpected happens.  The main point is that you feel respected and consulted at every twist and turn of labor and birth.

Red Raspberry Leaf Tea Story

Many women and midwives swear by red raspberry leaf tea during pregnancy.  Here is information on the benefits of drinking the tea during pregnancy, though as always please consult your provider before taking any herbs:

This is from Rodale’s Encyclopedia of Natural Home Remedies:

The Raspberry Leaf Tea Story

Tea made from raspberry leaves is the best-known herbal aid in pregnancy. Rather than go into all the traditional lore about this herb, we present the following lengthy account, because it is both contemporaneous and highly specific.

“My mother was born and raised in Scotland, coming to America at the age of 26. Whenever a member of her family became ill or had a health problem, her mother had consulted an herbalist or herb doctor. As a result of this, I was treated with herbs as a child.
“Mother had always told me that red raspberry leaf tea would prevent miscarriage and was excellent for pregnancy and childbirth. When I became pregnant, I immediately sent for some raspberry leaf tea and began taking one cup of it each day, made from one teaspoon of dried leaves added to one cup of boiling water and steeped for 15 minutes. I had a very normal pregnancy. Then I went into labor, I truly expected to have an easy labor and delivery because I had faithfully taken the tea. While it is true that I did not have a complicated or extremely difficult time, it was not by any means easy. The tea had not lived up to my expectations.

“It was not until sometimes after the birth of my daughter that I read a book my mother had brought with her from Scotland entitled Dragged to Light by W.H. Box of Plymouth, England. In it I found the secret of just how to take the tea so it would truly work wonders during labor and delivery. Box said, ‘On one ounce of raspberry leaves pour one pint of boiling water, cover and let steep for 30 minutes. Strain, and when the time for delivery is approaching drink the whole as hot as possible.’

“There were a number of testimonials in the book written by women who had used this herb. Several took the strong solution over a period of time before going into labor. They were instructed in that case to take a wine glass full three times a day. They had ‘only two stiff pains and it was all over’ or ‘no after pains and very slight before.’ They never made it out of the house. Box’s instructions were, ‘But those who take the tea considerably before the time should not leave the house when the time is approaching as many mothers are delivered almost suddenly when at their work, to the great vexation of doctors and nurses.’

“When I became pregnant again I was determined to try it that way. I still took a cup a day as I had before. but this time when I went into labor I made a strong solution of it as I had read in the book. I put it in a container and took it to the hospital with me. I wasn’t sure how quickly it would work and I didn’t want to have the baby in the car. I didn’t think they’d allow me to drink it in the hospital so I drank half of it in the parking lot. I was afraid to drink all of it as it was so strong and I didn’t personally know anyone who had taken it this strong before. I had been having strong contractions but by the time I registered and was taken up to the labor room the contractions were so mild I hardly felt them. Upon examination they said I was ready to deliver and would not even give me an enema. In the delivery room I was quite comfortable and hardly felt anything. One hour after entering the hospital my son was born.

“In the recovery room there were several other young women who had just given birth also. They were moaning and groaning. I couldn’t imagine what they were making a fuss about as I felt like I could have gotten up and gone home. I had always read and heard about women getting after-pains with a second child. I never had even one. This was also the testimony of a number of women who were treated with the tea by Box.

“Later I thought I would have had an easy time anyway since it was my second child. I was anxious for someone else to try it.  A friend of mine was expecting a baby in a few weeks and she had been taking a cup of the tea daily and was also going to take the strong solution when she went into labor. She had had two previous pregnancies and both times nearly miscarried and had to take drugs and be in bed a good deal of the time. Both deliveries were extremely difficult. When she became pregnant this time she began spotting and it looked like she would have to go through the same kind of trouble she had before. Having used an herb I had given her for another problem, with success, she asked if there was an herb for this problem and I recommended raspberry leaf tea.

“She started taking it and the spotting stopped immediately and she had a normal pregnancy, much to the amazement of her family who remembered her difficulties in the past. When she went into labor she took the tea as I had and told me she had only 25 minutes of hard labor before her baby was born.

“I have told a number of women about this amazing herb through the years, but no one else seemed interested enough to try it. However, 1978 my daughter became pregnant and she was very much interested in having an easy delivery. She took the tea each day and had a normal pregnancy. She, too, took the strong solution of the tea with her to the hospital and also being a little wary drank only half of it. When the doctor examined her, it was late in the evening. He said the baby wouldn’t be born until six o’clock in the the morning so he went home. She was having hard contractions at this time and I was very disappointed and felt the tea hadn’t worked. An hour and a half later we recieved a call from our son-in-law saying we had a little grandson. The tea started working and the doctor had no sooner reached his home when he had to turn around and come right back to the hospital. My daughter said the next time she is going to drink all of the tea.”

Choosing a Birth Attendant

Most people see pregnancy as a time to prepare for the baby.  I see early pregnancy as a time to figure out what you want before you even go to your first appointment.  A lot of women don’t even think about the actual birth until a few months or weeks before the baby is born!  It can be difficult to make a change that late in the game.  You should choose the provider who has the same philosophy as you instead of hoping to change them by the end of the pregnancy.

Tips for choosing a birth attendant

  • Think about your core birthing philosophy.  Do you feel that birth is a natural physiological process?  If so, a midwife is your best bet.  Do you have physical issues that dictate that there could be a potential problem?  Do you see birth as dangerous with lots of opportunities for things to go wrong?  Then an OB might be your preferred provider.
  • Visit The Birth Survey, a consumer reporting site dedicated to birth.  Go to rate your OB, midwife, and place of birth.  As of now the site is just up and running and they should have formulated the results by Fall of 08
  • Get recomendations from people who share your birthing point of view, visit online forums (like mothering.com) and ask questions.
  • Interview your potential care provider.  Remember, they are working for you, not the other way around.  Related posts:  Interviewing your OB, Interviewing your Midwife, and Interviewing your Place of Birth
  • Create a birth plan well before your second or third trimester.  Going to your provider interview with a birth plan or at least an idea of what you want can help you ask the right questions.  Just make sure to not be negative or badger the doctor!
  • How much one-on-one, hands-on support do you want during pregnancy? Midwives generally treat the whole woman:  mentally, physically, socially, psychologically, spiritually.  Prenatal appointments generally last about an hour and they are usually there for the majority of labor and birth.  OBs on the other hand are primarily surgical specialists who have a prenatal appointment time of about five minutes and generally just come in at the end to catch the baby.
  • How much involvement do you want in your pregnancy and birth? Many times in midwifery practices the mom gets to do her own urine dip and weigh herself at her appointments.  The midwife tries to explain things to her and tries to get her to interact during her visits.  An OB visit is more in-and-out with the nurses doing everything behind the scenes.
  • Where do you want to give birth? Some women just go to an OB because they think they’re supposed to and then realize late in pregnancy that they want a home birth!  Where you give birth automatically dictates who will be there.  For example in Colorado at this time, OBs work in the hospital, only Certified Nurse Midwives (CNM) can work at a birth center, and Certified Professional Midwives (CPM) and CNMs can do home births.  Most CNMs (90-95%) work with doctors in the hospital.
  • Do you want to have a waterbirth? Some hospitals allow it, some do not.  If you have to give birth in a hospital and want to fight a policy that does not allow waterbirth, having a provider who supports it can go a long way.  Yes, it is possible to change hospital policy!  In Gentle Birth Choices Barbara Harper talks about how to do this.
  • Choose someone you’re comfortable with. If you’re not comfortable with your provider there is no way you can let your body open up and relax enough to have a baby.
  • If a provider or place (like home or birthing center) is out of your insurance network, talk to your insurance provider.  Also, often times a home birth or birthing center is cheaper even though you have to pay in full.  For example, in Colorado a typical, no-intervention birth in a hospital usually costs around $12,000-13,000.  In an insurance plan where you pay 10% of hospital and doctor’s costs you’re looking at a few thousand dollars.  A home birth or birth center birth usually costs around that if you’re paying in full.
  • Do you feel more comfortable with a male or female doctor?  Remember that just because a doctor is female doesn’t mean she believes in the same birthing philosophy as you do.

Interviewing Your Midwife

Know your Midwife

It is so important to know what you’re getting into before you’re in labor!  Interview any OBs, midwives, hospitals, and birth centers you are considering and make the best decision for you.  Also, a great new website, The Birth Survey, provides consumer reporting for doctors, midwives, and hospitals (at this point you can take the survey, but the results are said to be formulated by Fall 2008).

Here are some questions to ask your Midwife to make sure you find one who is on the same page with your birthing beliefs.  These are taken from Gentle Birth Choices, written by Barbara Harper, 2005, p. 249 (a great book, also in my library).

  1. What is your education and training as a midwife?
    It is good to discern if you are hiring a certified nurse-midwife (CNM), a certified professional midwife (CPM), or a direct-entry midwife.  Find out what their training or midwifery school was like.  The three groups represent vast differences in educational experience but not necessarily in the way they practice.
  2. What kind of testing or licensing procedure did you go through to become a midwife?
  3. How many years have you been practicing?
    Do you want to trust a midwife who is just starting out in independent practice or do you continue your search for a more experienced midwife?  Find this out right away.
  4. What is your general philosophy about pregnancy and birth?
    Midwives in general hold the philosophy that normal birth is not a medical event and needs to be respected for the creative process that it is.  I would be surprised if you found a midwife who viewed birth as a potential emergency to be prepared for.
  5. Are you a mother yourself?  How old are your children now?
    If you are choosing a midwife with young children, how will she be able to attend your birth if there are family needs?  Are you open to her bringing her young children and perhaps nursing child with her to your birth?  Ask her to share her birth stories with you.  Many women become midwives after a not-so-wonderful birth experience.  Find out about your midwife’s births.  Some argue that midwives who have never given birth cannot be as good as those who have had children.  I don’t agree with this assumption; I know some wonderful, talented, caring midwives who have not had the opportunity to give birth.
  6. Do you work alone or with a partner or assistant?  If you work with someone, what is his or her experience?
    It is important to meet all the people who will have any responsibility concerning your prenatal care, labor, or birth.  Some midwives take on apprentices or students.  Find this out in the beginning.
  7. How many births have you attended as the primary caregiver?
    How long has your midwife been in independent practice?  Has she always worked with an experienced partner?  You may ask for references from former clients.  Some midwives provide a chance for past clients and future clients to meet each other at informal classes or support groups.
  8. Do you attend births in a birth center or hospital?
    Perhaps this midwife has hospital privileges or attends births at home or in a birth center.
  9. How many births do you typically attend each month?
    For a home-birth practice, the most births that one midwife with one assistant can possibly attend is six to eight per month.  If she tries to attend more, there could be two women in labor at the same time, leaving one with no coverage.  Midwives in birth centers can handle many more births per month because they can attend more than one laboring woman at a time.
  10. Who takes over for you if you go on vacation or get sick?
    A very important consideration is who will take over the midwife’s practice if she is unable to continue or needs to leave for a certain period of time.  Make these plans with your midwife early on in your pregnancy.  Know that if you will be covered if anything happens to your midwife.
  11. Do you have guidelines or restrictions about who can give birth at home?
  12. Are these your policies or those that the state licensing requires?
    A midwife should have the same screening criteria as a doctor screening for risk factors.  Depending on licensing status, some midwives must refer to a physician for cases of breech or twins or even VBAC.  Other states have less restrictive or no guidelines.  This must be discussed.
  13. Do you require that I see a physician during my pregnancy even if everything is all right?
    A visit to a backup physician is usually in order just so you can meet and he or she can establish a chart on you.  If your midwife does not have an active relationship with a backup physician, it may be your responsibility to obtain a doctor and see him or her.
  14. What are your fees and what do they include?
    Just as with a doctor, most midwives’ fees cover all prenatal care, birth, newborn assessment, home care, and follow-up for six weeks.  Any lab tests, diagnostic tests, or extra doctor’s visits are not included.  Also not included are the costs of a hospital transfer, including ambulance, hospital, and doctor’s fees.
  15. Can you submit your charges to my insurance company?
    Many CPM and CNM services are covered by health insurance plans or state-funded Medicaid programs.
  16. What payment arrangements do you make?
    Most midwives will make an affordable arrangement to take payments throughout pregnancy.  Many even have payment forms and billing systems on their computers.  Payment of services in full is usually required before the birth.  Be considerate about the midwife’s bill and make clear and early arrangements for payment.
  17. How often will I see you?
    Visits are scheduled once a month until the seventh month, every two weeks until thirty-six weeks, and once a week after that.  Extra appointments can be scheduled at any time between regular visits.
  18. What are your guidelines concerning weight gain, nutrition, and exercise?
    Nutritional status will be monitored throughout pregnancy.  Most midwives focus on the importance of a healthy balanced diet and work with women to get the most out of what they eat.  Many midwives have special education in the use of herbs, food supplements, and homeopathy for pregnancy.
  19. Do you require that I take a childbirth education class?  Do you teach a childbirth preparation class?
    Midwives will often teach their own preparation classes.  Some midwives feel that they give so much individualized attention that couples do not need extra classes to prepare for birth.
  20. If I am planning a home birth, do you visit my home before I go into labor?
    Midwives generally make at least one home visit before they come to the house for labor.  They assure that the home is adequate and clean, and they help plan any necessary details with the couples, such as where the birth pool should go.
  21. When should I call you after my labor begins?
    Each midwife sets her own protocols about when and the reasons why to call after labor begins.  Generally midwives want to know as soon as contractions begin so they can plan their day (or night).  Some midwives will have apprentices who come right away, others arrive when they are needed.  Most encourage women to enjoy the early stages of labor and to get plenty of rest and eat if they are hungry.
  22. How do you handle emergencies?
    Ask very carefully just what kind of emergencies she is prepared to deal with and has dealt with in different situations.  A very experienced midwife may have different answers from someone just graduating from midwifery school, but their protocols should be very similar.
  23. In what situations would I need to go to the hospital?
    Find out exactly why you might be transported.  Transports can sometimes be an emergency, but more than likely they are for women who have been laboring for more than a day and become exhausted.  Find out what your midwife’s transport rate is and evaluate it.  Most home birth midwives and birth centers have a rate of less than fifteen percent.
  24. Would you stay with me in the hospital?
    Most midwives can accompany their clients into the hospital and stay with them, but in some states where midwifery is still illegal, the midwife cannot come into the hospital and admit that she has been attending a home birth.  Find out if your midwife has a good working relationship with a local hospital.
  25. What is your experience with water for labor and birth?
    Midwives traditionally have used water for pain relief during labor.  Many are now advocating its use by all of their clients.   It is difficult to find a midwife today who doesn’t use water in labor or for birth.
  26. Can I give birth in water?
    Ask if your midwife has access to a birth pool for her clients or if she knows where you can rent or purchase one.  Find out if she truly supports the option of waterbirth.  I have talked with many women who have said that their midwives talked about waterbirth prenatally and even encouraged water labor, but then asked the mother to get out of the birth pool at the last minute.
  27. How ‘hands off’ are you during a birth?
    Is your midwife is willing to “allow” the family to conduct the birth under her supervision?  Ask if she is willing to give you complete control.  Will she encourage or instruct you and your partner when and how to catch the baby?  Will she leave you alone in another room if that is what you want?  How involved can your children be in the labor and birth?
  28. What is your experience with breech births?  How many have you attended?
    Breech may be beyond the scope of practice for some licensed midwives.  Others handle it just like any other birth and specialize in breeches, especially in water.
  29. What in your experience with twins?  How many have you attended?
    Twins may also be beyond the scope of practice.  Find this out before you make further plans. (It is also illegal to have twins anywhere but in a hospital in Colorado)
  30. Do you cut episiotomies and suture perineal tears?
    Home-birth can birth-center midwives usually have an episiotomy rate of close to zero, but tears do sometimes happen during birth.  Unless your midwife sutures well, you may need to travel to a hospital if you need stitches.  This might influence your choice of practitioners.
  31. What is your experience with a VBAC?
  32. Will you attended a VBAC at home? in the hospital?
    Many midwives cannot legally attend a first-time VBAC at home because of licensing restrictions.  Some are willing to look the other way in order to give the woman a chance.  This is a very serious consideration that requires much discussion with your midwife.
  33. Have you ever had to resuscitate a baby?
    Assess the resuscitation skills of the midwife.  Midwifery organizations and nursing schools teach courses in neonatal resuscitations, and your midwife should have a current certificate.  As to see it.  Ask if her resuscitation course focused on the latest information about the consciousness of newborns.
  34. What kind of equipment do you bring to a birth?
    Find out what kind of drugs, oxygen, resuscitation equipment, intravenous (IV) equipment, and other emergency equipment your midwife keep sin her bags.
  35. Do you examine the baby after birth?
    Midwives perform a normal newborn exam on the baby usually an hour or two after the baby has been born and breast-fed.  Assess from the midwife what her routines are for newborn exams and what she uses for eye drops and vitamin K.  She may use alternatives such as oral vitamin K.
  36. Will you help me with breast-feeding?
    Midwives should be on call twenty-four hours a day, seven days a week, for all problems after birth, especially breast-feeding.  Many even have special classes or private sessions to evaluate breastfeeding readiness and answer any questions.  Some have great relationships with lactation conselors or consultants for more difficult problems.  Babies born without medications usually have an easier time breast-feeding, but that doesn’t mean every mother automatically has an easy time.
  37. How often do you come to see me after I give birth?
    Home-birth midwives generally come back for follow-up visits after twenty-four hours, two days, five days, and ten days.
  38. Do you provide or know of anyone who will help new mothers after birth?
    Some home-birth services provide a postpartum doula or can recommend one for help after the baby’s birth.  There is generally an extra charge that is well worth every penny.
  39. Do you have a pediatrician you work with or recommend?
    Some naturopathic doctors who attend home births automatically become the pediatrician.  Midwives often have collaborative relationships with pediatricians who support home birth and possibly delayed immunizations or not immunizing at all.  Interview pediatricians the same way you would your provider.
  40. How do you feel about circumcision?
    I don’t know of very many midwives who will present both viewpoints about circumcision unless their clients are Jewish or Muslim.  If there is a religious consideration, the thoughtful midwife will support her clients’ decision.

Interviewing Your Place of Birth

It is so important to know what you’re getting into before you’re in labor!  Interview any OBs, midwives, hospitals, and birth centers you are considering and make the best decision for you.  Also, a great new website, The Birth Survey, provides consumer reporting for doctors, midwives, and hospitals (at this point you can take the survey, but the results are said to be formulated by Fall 2008).

Here are some questions to ask your hospital or birth center to make sure you find a place that is on the same page with your birthing beliefs.  These are taken from Gentle Birth Choices, written by Barbara Harper, 2005, p. 246 (a great book, also in my library).

  1. Does the hospital [/birth center] encourage women to follow written birth plans?
    This is a question for a hospital [/birth center] but it may also be asked of the physician.
  2. Could you tell me how a routine vaginal birth is handled here?
  3. When do I need to check into the hospital [/birth center]?
    The longer you stay at home in early labor, the less possibility there will be for interventions.
  4. Can I labor, give birth, and stay with my baby in the same room?
    The concept of labor, delivery, recovery, and postpartum (LDRP) in the same room has been promoted for the last ten years.  If your prospective hospital is one that still transfers women into a delivery room, request that they make an exception in your case.  (There is nothing worse than being moved right before pushing!) Also be aware of the “cosmetic cover-up” discussed in chapter 8.  Not all LDRP rooms are alike, and not all allow women to do what they want.
  5. Do you routinely require an IV?
  6. Do you routinely require electronic fetal monitoring during labor?
  7. How often does someone do a vaginal exam to assess progress?
  8. What mechanism is in place so that I can refuse routine interventions like vaginal exams?
  9. How soon after my labor begins will you (or the doctor on call) come to see me?
  10. Whill you stay with me during labor?
  11. Can my partner stay with me the entire time?
  12. Can the rest of my family members, including my children or my mother and father, be present during labor and birth?
  13. Does the hospital have showers or baths in each room?
  14. Can I eat and drink during my labor?
  15. Do you encourage women to walk, squat, or be on their hands and knees during labor?
    Understanding the philosophy behind why you need to remain active during labor encourages women to move.  Lying still on a bed during labor is probably the hardest thing for women to cope with.
  16. Can I birth the baby in the position of my choice?
    Hospital beds often break apart at the foot to “allow” a woman to semi-squat.  What some women have found easier is to simply put the mattress on the floor or be supported by their partners while they squat on the floor.  Assess early on if those alternatives are acceptable to your doctor and the hospital.
  17. Can I use a warm bath for pain relief during my labor, even if my water has broken?
    There is absolutely no reason to restrict the bath even with ruptured membranes.  One woman at Santa Monica Hospital was promised that she would be able to use the brand-new baths that had been installed for labor.  What her doctor did not tell her was his list of restrictions:  A woman could not take a bath if her water had not broken and the head had not engaged into the pelvis (for fear of a cord prolapse), and she could not enter the water after her water had broken (for fear of infection).  She never once used the new baths and ended up with an epidural and her baby experienced the application of low-forceps.
  18. Can I stay in the water to birth my baby?
    Find out right away what position your doctor takes on waterbirth.  It might be your opportunity to educate him or her.
  19. What kind of pain medication do you routinely use?
  20. What kinds of nonpharmacological pain management techniques do you recommend?
  21. If I want an epidural, what are your guidelines?
    Some doctors offer a “walking epidural” which is a different kind of epidural.  Question your doctor carefully about the kids of medication used and the guidelines with which they are administered.
  22. Do you do episiotomies?  Why?  In what percentage of births?
    Does your doctor think that episiotomies are necessary?  Is he or she willing to allow you to try other techniques?  If a doctor cuts more than 10 percent of birthing clients, look for a new doctor.
  23. Do you ever use vacuum extractor?  In what percentage of births?
    Vacuum extractors were developed to take the place of low forceps.  A large suction cup (usually made of hard plastic and sometimes silicone) is placed on the baby’s scalp.  The cup is attached to a tube that is attached to a vacuum.  When a suction on te baby’s head has been achieved, constant suction will quite literally pull the baby out within ten to twenty minutes.  There are some risks with extraction, such as perineal lacerations, hematomas on the baby’s scalp, and pain for both mother and baby.  It requires a fully dilated cervix, a baby with at least some part of the scalp visible in the birth canal, and the cooperation of the mother.  Vacuum extraction is preferred over the use of forceps.
  24. Do you ever use forceps?  In what percentage of births?
  25. What is your policy concerning stripping or rupturing membranes?
    Rupturing membranes is often the first intervention that doctors do to “get labor going.”  Ask your doctor if a labor can progress normally and slowly without rupturing the membranes.  Will you be informed of his or her desire to break your water?  Do you have the right to refuse this intervention?  Assess your doctor’s guidelines for ruptured membranes.  How long will he or she allow you to go without starting labor?  What lab tests are required? Some doctors take white blood counts every twenty-four hours and body temperatures every hour and leave a woman alone.  Others want her hospitalized immediately and induce labor with Pitocin.  Studies have shown that women who walk and remain active have fewer cesareans and generally give birth before those who receive Pitocin.
  26. How long will you allow me to labor before starting interventions?
    Does your doctor go by the book in judging length of labor?  What are his or her considerations:  maternal exhaustion, nutritional needs, movement?
  27. How long will you wait to cut the cord and deliver the placenta?
    (Cutting the cord after it stops pulsing allows the baby’s organs to perfuse with much-needed blood, replenishes iron stores, and creates a smoother transition from oxygen from placenta to oxygen from baby’s lungs)
  28. Can my partner cut the cord?
    Is cord cutting viewed as a medical procedure or simply part of the process of birth that the couple has shared?  Are fathers included in this process?
  29. Is it necessary to put antibiotics in the baby’s eyes right away or can we delay that for 24 hours?
    State laws mandate that an antibacterial agent be put into the baby’s eyes to reduce the incidence of blindness from venereal disease that has been passed from the mother to the baby.  The use of silver nitrate has been abandoned by most hospitals.  More common antibiotic agents are now used.  Find out from your doctor what he or she recommends, and ask if you can choose not to use anything at all, especially if your baby is not at risk.
  30. Do you routinely give vitamin K shots to newborns?
    Vitamin K is routinely given to prevent hemorrhagic disease in newborns.  The incidence of intracranial hemmorhage is extremely low.  The administration of vitamin K has also been given to counteract the possibilities of bleeding after circumcision.  There has been an unusually high incidence of childhood ancer linked to vitamin K shots.  Oral vitamin K has not shown any relationship to cancer in children.  Ask your doctor if oral vitamin K may be substituted and if he or she has access to the latest research.
  31. Can I breast-feed immediately after birth?
  32. Can I delay weighing and measuring the baby for at least an hour?
  33. Can the baby stay with me in my room (rooming-in)?
  34. Do you routinely recommend circumcision?
    If your doctor is still suggesting circumcision and does not stress the normalcy of the intact penis, take the opportunity to educate him or her before you find another doctor.
  35. How soon after the birth can we leave the hospital?
    Most doctors recommend a short stay in the hospital.  Some are even willing to discharge after twenty-four hours.  Find out if your doctor is open to discharge after six to twelve hours, especially if you have given birth vaginally and you have adequate help at home.