Home Birth: Just as Safe as Birth Centers

We bring equipment too! Note the oxygen tank in the background.

Open letter to The New York Times

Re “Should You Give Birth at a Birth Center” (Family, nytimes.com, Sept. 25):

Thank you for the recent spotlight on birth centers - I wholeheartedly agree that they are an appropriate option for many families.

I’ve worked in both birth centers and home birth and I take issue with only one line in the article.

The author, Alice Callahan, implies that birth centers differ from home birth in that birth centers have “basic equipment on-site and a plan to transfer to the hospital if necessary”. Home birth midwives carry identical equipment and similarly transport when needed. The safety of both has been well established.

In fact, almost every I midwife I know working in a birth center has also done home birth. Most, like me, go back and forth between the two environments over the course of their careers.

There is no need to denigrate home birth to promote birth centers - they are both necessary components of any comprehensive maternity care system.

A quiet, gentle birth

 Ana in bed with her baby

Ana's Birth Story

Around 5pm, I started contracting. Around six my water broke and by eight I was ready to push. The midwives came shortly after and guided me through a beautiful, gentle birth. The three of them surrounded me, but kept so quiet that sometimes I didn’t feel their presence at all.

The lights were low and the atmosphere intimate. I remember wishing to relieve the pressure I was feeling. I was so focused on the task that I hardly gave thought to the baby’s arrival. In fact whenever the midwives tried to bring my attention to the baby, I focused back on the pressure. The midwives were giving me verbal cues that reminded me of my body’s capabilities. They reassured me that what I was going through was natural and expected.

After 3.5 hours of pushing hard and strong, out came a whole human—a jiggly baby that super-manned into my arms. How magical and surreal! I saw it was a little baby girl, which was a surprise. My husband had such deep conviction that it was going to be a boy that he had persuaded me.

The feeling of her passing through my belly and coming into my arms was the most satisfying, fulfilling physical sensation of my life. I wasn’t instantly in love as I have heard some women describe their reaction to seeing the baby for the first time. I was in awe. My love grew with time.

In the first 3 days I couldn’t get enough of her. I kept her jiggly little body in my arms and on my breasts and tummy as long as I possibly could. I didn’t want to miss a thing. I lamented each passing minute because I was in bliss and I wanted it to last. At 6 days, I already missed those first few moments. I just wanted to stay suspended in time.

I’m grateful to my mom who gave me the opportunity to enjoy my baby girl without any household responsibilities. She allowed Eric and me to bond with our new baby. I also feel grateful to the midwives and Eric who did a wonderful job supporting me through the birth and first few days of Maritza’s life.

St Luke's Women Center moves to new building

CPMC's new Mission Bernal Campus has bigger, more comfortable, and safer rooms for birth

 Labor and delivery room at the new Mission Bernal Campus - check out the views!

Labor and delivery room at the new Mission Bernal Campus - check out the views!

I’ll focus on the nuts and bolts of the new labor and delivery unit, which I toured along with a group of doulas and midwives before it opened.

Hannah Epstein, the lead midwife for the St Luke's Women Center, organized and led the tour. She says the new building won’t change the care - it’s just moving to a lovelier environment. In addition to looking nicer for patients, she emphasizes that the majority of the improvements are meant to streamline operations for the providers. Instead of wires literally underfoot in the operating and delivery rooms, cords run from the ceiling and the medical equipment is organized for a smoother workflow.

It’s also substantially more secure, with locking doors that patients and families will have to get buzzed into. But Hannah says that if your baby is coming very fast it’s okay to go straight through the doors and trigger the alarm - that will alert the staff to attend to you right away!

The new unit is twice of the size of the old, with 6 labor and delivery rooms, 16 postpartum rooms, and 2 operating rooms. There is also a 4 bed nursery. All of the birth rooms have large tubs for laboring in (not birthing, I’m assuming) and nitrous oxide for pain relief. They also have sleeper sofas which are slightly bigger and more comfy than the old. All the rooms had big windows and great views.

 The tubs are more roomy than most hospital tubs although they aren’t meant for birthing in

The tubs are more roomy than most hospital tubs although they aren’t meant for birthing in

There are 4 triage rooms, which will do double duty as antepartum testing rooms until eventually that function is moved to the Hartzell building. They will also be called on as needed for early inductions.

The main entrance to the building on Cesar Chavez will be locked after 7pm, and everyone in labor, regardless of the time, is encouraged to use the ER entrance on 27th St off Guerrero. There will be a pull in spot on the street where you can leave your car, drop your keys with security and go up to Labor and Delivery on the 7th floor. Once the laboring person is settled, someone can come down and move the car into the Duncan garage, which also have two dedicated OB spots closer to the entrance.

The heightened security of the new unit comes with a few downsides - only nurses have access to the kitchen for example (where there is a fridge for patient food). Also, if you want to stair-walk in labor, there is no way to get back into the unit after you’ve been badged onto the stairs, so the only option is to walk all the way down to the first floor and take the elevator back up.

The new cafeteria will be open from 6:30am - 6:30pm with the same food but in a nicer space. Eventually, the current hospital building will be razed to make way for outdoor garden space and there will be a conference room available to rent. Other amenities include a meditation room open 24/7, a family waiting room and play area outside of the locked unit, and a lactation and breastfeeding room.

 This is a typical postpartum room - same views, much smaller. The loveseat pulls out to a bed.

This is a typical postpartum room - same views, much smaller. The loveseat pulls out to a bed.

Although Hannah hopes that the care won’t change, Sutter does want the new unit to increase their volume to 120-150 births per month. There will still be one midwife and one doctor on duty around the clock, just like now. Currently St Luke’s only has one full time lactation consultant, which results in spotty coverage, although Hannah says that she would like to hire more as the volume increases.

There is also the possibility that other medical practices will have privileges at the hospital, and that there could be some shared call in the future. That means that St Luke’s Women’s Center patients could potentially end up with a doctor from another practice managing their birth.

My colleague Firen Jones already wrote a great blog post on the care and policies at the old unit. Ultimately, those factors are more important than the physical building - but the new space is an upgrade that will definitely feel nicer and positively impact family's birth experience.

No: selling babies' blood is not the answer

 Early cord clamping with cord blood visible in the cord

The recent Guardian and Medium article by Matilda Battersby on cord blood, placenta and amniotic membrane donation is premised on inaccurate medical information and troubling assumptions about how to fix inequities in our healthcare system.

Although the article is titled “Should US mothers be paid to donate placentas?”, Battersby focuses on cord blood, as the more valuable “byproduct” of birth.

Battersby argues that selling cord blood could provide a source of revenue to offset costs of prenatal care for uninsured or underinsured parents. She cites the high costs of maternity care in the United States and the seemingly untapped reservoir of cord blood that could be sold to research or other medical uses.

Battersby quotes a parent promoting cord blood donation because it's "really of little to no consequence for the donor". She earlier writes that “collection is painless, and there’s no risk to either mother or baby”.

Unfortunately for researchers who would benefit from access to it, cord blood already has a natural home - in the baby that it came from. The donor is in fact the baby, not the person who gave birth, because it is the baby’s blood circulating in the cord and the placenta.

When the baby is born, a third or more of its blood volume is circulating in the cord and the placenta, where it goes to oxygenate and receive the nutrients that grow the baby. If you clamp and cut the cord right away, the baby loses that blood, rich in oxygen, stem cells, immunoglobulins, and iron. If you wait, much or all of it will end up in the baby.

Early cord clamping robs babies of blood that they need to optimally perfuse their lungs and other organs, bank iron stores, and build their immune system.

Battersby is right that the vast majority of cord blood in the United States is currently wasted, as physicians increasingly took over and medicalized birth over the course of the 20th century and early cord clamping became the norm. However, the tide is shifting.

Delayed cord clamping is like climate change: there's a mountain of scientific evidence and consensus among the research community for decades, and a stalwart bunch of non-believers. Or at least non-practicers. Most babies around the world also have their cord clamped immediately, thanks to our global exporting of the medical-industrial model of childbirth.

Thankfully, recommendations are slowly starting to catch up with this research, and in 2017 the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion recommending delayed cord clamping.

The World Health Organization has also recommended delayed cord clamping since 2012 "for improved maternal and infant health and nutrition outcomes”.

 This cord still connects the placenta to the baby and the cord is visibly drained of blood

This cord still connects the placenta to the baby and the cord is visibly drained of blood

Battersby fails to acknowledge any of this information, and only tosses out a one sentence nod to the disturbing aspects of her proposal: “Naturally, there are considerable ethical ramifications, and nobody wants to start a baby farm where placentas are manufactured and women are treated like chattel”.

The ethics are clear when it comes to the idea that cord blood could be a band-aid fix for the gaping wound of our healthcare system. As more and more parents educate themselves and request delayed cord clamping, how could it possibly be ethical to pay some parents to deny their babies cord blood in order to pay their bill?

There are a few relatively simple interventions that could cut the exorbitant maternity care costs that Battersby cites. First, a universal, single payer healthcare system would eliminate most of the insurance company overhead.

Second, the United States could also follow the model of most of Europe, where midwives are the first line providers for normal birth and costly obstetricians are reserved for high-risk situations that demand their level of specialized expertise. In many countries, home birth is actively encouraged by the government for low-risk pregnancies as a safe and cheaper option.

Selling cord blood is not the answer. It’s an either/or: either that blood is harvested in an interruption of the normal physiologic process for all mammals or the baby receives its full placental transfusion that is every child’s birthright.

Already the World - Victoria Redel

I’ve loved Victoria Redel’s poetry since I stumbled across her first book of poems for a dollar in the basement of a Saint Paul discount book store. Look at her, coolly facing down the reader in a leather jacket on the back cover - how could I not take her home?

I bought this book in my early twenties, before the idea of becoming a midwife had implanted itself into my consciousness. How satisfying, then, to revisit these poems after years of walking with families through pregnancy, birth and the postpartum wonderment of suddenly cohabiting with an almost alien being.

VictoriaRedel

Redel captures those moments so well - the loss of sovereignty as the pregnancy takes root and can sometimes seem to take over, the bittersweet of the last few weeks as the first separation approaches, and the desperate patience parenting demands.

***

Third Month

At first you were in the mouth,
nausea uncalmable.
Or you were the hard stools of constipation.
At night rocked
over to sleep at a child’s hour,
I slept with pillows layered
to ease my swollen breasts.
In books they claimed you were
no bigger than a fingernail,
but I could feel you, gargantuan,
settling in my body, assuming
what you needed to live,
risking everything
even if it meant risking
mother love.

 

Ninth Month

Already you are moving down.

Already your floating head
engaged in the inlet
from where you will head out.

Already the world, the world.

And you are slipping
down, away from my heart.

 

Psalm

All night pacing.
The baby hanging off my tit.
He has been at it for hours.
Four to be exact.
My one with eyes open
cannot cast himself
out into his blue sleep.
In the darkness singing,
in the darkness singing,
my off-pitched voice
trying every note
to save us both.