Monday, April 27, 2009

What is a Birth Center?

It is exciting to live in a day and age where there are several options for you to choose for your baby's birth place. One is your home, the other more obvious choice is the hospital, and finally there is the birth center. Birth centers are divided into two main categories (though there may be others)- there are hospital-owned birth centers staffed by midwives, and there are free standing birth centers owned and run by midwives. Birth centers of all types are inspected randomly by DHEC in South Carolina so you can be sure that they are always up to standard.

A birth center by definition is simply a place other than your home, and outside of the hospital, that is equipped to assist you in birthing your baby. Most birth centers offer the completely natural childbirth option, since they do not have doctors available to administer drugs like Stadol or epidurals. So, if you are choosing a birth center, you may need to take a childbirth preparation class like The Bradley Method. You can also be sure that you will not be encouraged to take any medication during your labor in a birth center. Midwives in general are experts in normal birth, and would love to see you birth your baby in the most natural way possible. Of course, if anything goes awry, your midwife would call emergency transport and get you to the nearest hospital as quickly as possible.

The World Health Organization recommends that midwives attend normal low-risk, healthy births but doesn't necessarily suggest where you are to be attended. But a birth center in your area is a great choice. In Spartanburg and Greenville there are several to choose from. Labors of Love Birth Center is located on Floyd Road Extension, and is about 6 minutes from Spartanburg Regional Hospital. Various other birth centers include Carolina Water Birth and Blessed Births, both located in the Greenville and Simpsonville area. Labors of Love is run by Linda Weaver and Amy Bixby, both licensed midwives with hundreds of healthy babies under their belts.

Why should you choose a birth center? Well, there are several reasons. Many birthing centers offer the huge jacuzzi type tubs to labor in. Studies have shown that water births are less painful than "dry" births and that babies are born more "gently" into the water. A great read for this type of birth is Gentle Birth Choices by Barbara Harper. She provides some significant data about water birth and is convincing about the positive aspects water allows. Another reason to choose a birthing center is if you live more than 30 minutes from a hospital staffed with a 24-hour anesthesiologist and obstetrician. The reason for most hospital transfers is not emergency- it's getting tired of the labor process and choosing to go in for an epidural. If it is 3am, and there is not an anesthesiologist on duty, you don't get your epidural, at least not until he/she arrives. Less commonly, something may go wrong with the baby or mom, and an emergency transport is required. An obstetrician needs to be available immediately for a potential cesearean section upon arrival at the hospital. Again, this isn't a likely outcome, but it is a possibility. A third reason that families choose a birth center is being uncomfortable with the idea of giving birth in their homes. Perhaps they have dogs or live in an apartment or condo. There are not reasons that prevent a home birth, but they can inhibit the natural process if the mother is consumed or distracted by them.

Statistically speaking, birth center births are not safer than home births, unless the home is more than a 30 minute drive from the hospital. If I had had the option of a birth center birth for the first baby, I would have done it in a heart beat. Sometimes it just feels like a more controlled environment since it is a place designated for births. And it is certainly a great option if you are not comfortable giving birth in your home, but don't want the added stress of going to the hospital for your normal, non-medicated birth experience.

I encourage you to do your homework. Interview midwives and tour birth centers. You can always fall back on the hospital. But a birth center will make your natural birth experience so incredibly special!!

Monday, April 20, 2009

Why Would I Choose a Midwife?

The majority of births in the United States happen in an actively managed hospital setting. Active management means that the medical staff has an active role in the labor process- doing vaginal exams, inserting an IV if the patient is hungry or thirsty, augmenting the labor via Pitocin or Cytotec to help speed things up, artificially breaking the amniotic sac... All of these things are active management of labor.

Midwives come from a different philosophy. They understand that the bell curve for pregnancy and labor is massive, with many variations being within the normal range. They care for the emotional and mental (and in some case, spiritual) needs of the mother, in addition to her physical needs. A point I found interesting when I switched from obstetric care to midwifery care was that I was no longer a "patient" but a "client". If you consider what this means, it is monumental. In obstetric care, you are viewed as a person who has a problem, an illness of sorts. You are pregnant and they must monitor you to make sure that you get better. But as a client, you are going to your midwife to continue to make sure everything is going well, as you assume it must be. Midwives are consummate experts when it comes to normality. And with that comes the immediate recognition of abnormality. For example, in banks the forgery department for legal US tender doesn't scrutinize all the variations of the dollar bills. They study the real deal over and over and over, and are able to immediately detect a fake. The same applies in midwifery. Midwives have attended the labors of hundreds of women, from whenever the woman calls them to the baby emerging. So, they have seen the hundreds of variations of normal.

Another difference in midwifery (and this is pronounced "mid-WIF-ery", though some choose to pronounce it "mid-WIFE-ery") is that they don't "deliver" babies. They "catch" babies, so some of them are called "baby catchers." If you think about what that means, it is again, interesting. Why do babies need to be delivered from their mothers' bodies, as if they were dangerous, malignent places? Midwives simply catch the babies who are making an entrance into the world.

Did you know that the majority of babies worldwide are caught by midwives or someone acting as a midwife? Did you know that the World Health Organization recommends that pregnant women who are low-risk and healthy should have midwives as their primary care providers? The statistics are staggering. The United States has the absolute highest mother and infant mortality rates of any of the industrialized countries. In fact, a friend of mine sent me an email about her friend who passed away during childbirth this past week. The routine epidural numbed her from the waist up, instead of the waist down. She went into respiratory distress, had an emergency cesarean section, hemorrhaged and died. It was her fifth child. Do you know who has the lowest maternal and infant death rates in the world? Finland. Why? Well, depending on who you ask, there are various reasons. One may be because Finland doesn't have the high rates of obesity that the US has, and therefore healthier babies are born there. Another may be that premature babies born before 25 weeks aren't counted as infant mortalities, but are considered miscarriages. But the most conclusive reason is because the majority of their births are attended by midwives. When a Finlander calls the hospital to let them know she is in labor, the hospital sends out a team of midwives to assist her. The midwives will transport her to the hospital if she needs to be. Otherwise the babies are born in their own homes. Is that strange? I don't think so. In the US, when a person calls 9-1-1 for an emergency (say he/she is having chest pains) a cardiac surgeon isn't sent out to assess the situation- a trained EMT is. That EMT can determine whether the person is having heartburn, indigestion, or is really having a heart attack. They can administer some oxygen and assist the person, or can immediately transport that individual to the hospital. It makes sense.

Another aspect of midwifery care that differs from obstetric care is the fact that midwives' practices run on a smaller scale than the local OB practice. This means that the amount of time spent on you is greater. My midwife scheduled my appointment for the following month or week at say, 10 am. I showed up at 5 minutes to 10 am, and was seen from 10am to 11am. What in the world takes an hour, you ask? Well, the first 30 minutes were spent in discussion- how I was feeling both physically and emotionally about the pregnancy, how my nutrition was, whether I was doing my Kegel exercises, and any questions I may have were answered. And the last 30 minutes was the "medical" side- the protein check, heart tones, blood pressure, and the like. In my OB practice, my appointment was at 10am. I was seen around 11:30am, and was walking out the door by 11:50am. The care in a midwifery practice is much more personal, more nurturing, more supportive of the natural process- in my opinion.

And finally, midwives don't have the fear of litigation that obstetricians have. Therefore they can feel able to treat you like a well person, instead of a sick person. The decisions that are made for you in an obstetric practice are based on the fear that you will sue them- ie. EFM (constantly listening to the baby's heart beat), IV (giving you liquids because of their non per oris mandate- or nothing by mouth, in the event that you must have an emergency c-section)... all of the interventions that seemingly prevent you from being able to sue them are actually probably creating the problems in the first place! In midwifery practice, you are accepting the fact that there is no medical intervention, but you are placing your trust in your midwife's ability to detect a problem and get you to the appropriate medical care if an emergency arises. A huge North American study was done a few years back that showed the safety of a planned homebirth with a certified birth professional (ie. midwife) versus hospital birth. You should read it.

Are you low-risk and healthy? Are you interested in having a natural childbirth experience? Then you should choose a midwife. There are more and more available and you can interview one within a few days. In the Upstate there are many wonderful women serving pregnant women as midwives. My personal experience has been with Labors of Love- Linda Weaver and Amy Bixby. I cannot sing their praises loudly enough. But there are others out there as well. Your childbirth experience is a once or twice (maybe more!) in a lifetime experience. Your pregnancy, labor, and birth is as special as you are. Find someone who treats you that way!

Monday, April 13, 2009

Do I Need a Doula?

In order to determine whether or not you need a doula, you must first understand what a doula is. The Greek for doula means "servant woman, slave" but in our vernacular is a woman who assists another woman in labor. She is not the same as a midwife- who is the prenatal caregiver, baby catcher, and postpartum caregiver to a pregnant woman. A midwife's role is similar to the care given by an obstetrician, but she is an expert in normal, low-risk pregnancy and birth and encourages normal, low-risk birth experiences either at home, in a birthing center, or in a hospital.

To figure out your need for a doula, there are some things you should discuss with your spouse or partner. First, are you trying to achieve specific goals in your childbirth experience? For example, trying to avoid induction, trying to have a natural childbirth, trying to avoid c-section or epidural. Or are you planning on going in to the hospital and doing what you are told? If you are planning on doing something other than what 95% of other women do, which is follow hospital/doctor protocol, then you may benefit from having a doula- preferably one who has worked with your particular doctor or hospital before.

Second, are you and your husband prepared for childbirth? Taking a comprehensive childbirth education class, like The Bradley Method, completely prepares the husband/partner to act as a coach during pregnancy and labor. If you, as a couple, are choosing to give birth at a birth center or in your home, you will have less of a need for a doula than if you are giving birth in a hospital setting. A doula may be beneficial as an assistant coach in the hospital and can advocate for the laboring couple, answer questions, and assist the husband/partner (taking over if he needs to rest, go to the restroom, grab a bite to eat.)

If your husband/partner is not willing to be an active participant in the labor process, then is it essential that you hire a doula to help you. The Hawthorne Effect was discovered in industrial engineering and showed the when people are watched while doing a job, they do their job much more efficiently and with higher quality. The laboring woman, assisted by either coach or doula, will progress better and labor more efficiently than a woman left to labor alone.

When choosing a doula, you should find a personality that fits yours. Do you need someone to take control? Do you need a gentle supporter and cheerleader? Do you need someone who gives great massages? Do you need an advocate? Interviewing doulas is important, and you want to develop a good rapport with the woman you choose. Some people prefer to have a woman who is certified through an accredited agency, like DONA, and some people just want a woman who has lots of experience, whether certified or not. Just like an other profession, there are many doulas out there and you should be able to find one who fits your needs.

Prices for doulas range just like any other profession. You may be able to find a woman who is trying to get her certification who will be your doula at no charge. And then you may find a doula whose services are upwards of $500-$1000. You must remember that these services are rendered regardless of the time spent in labor. If you have a quick birth, you may have paid $100 per hour. But if you labor is average (15-17 hours), you have a very effective means of help that is essentially very affordable. Given the amount of work that your doula will do and the amount of time she will spend with you, I would definitely recommend interviewing and hiring one, especially if you are having your baby in a hospital. Just like a childbirth education class, it doesn't matter how much you have to spend if you get the birth experience that you want and avoid unwanted or unnecessary interventions or procedures. Those interventions and procedures will cost you in the long run.

Choosing Natural Childbirth

During our first pregnancy, my husband and I chose to go against common and had a natural childbirth experience. I have to say that I have never gotten quite so much flack about a decision ever before in my life. Friends and acquaintances said things like, "Good luck- you just wait until that first contraction hits you." or "You will be begging for your epidural before too long." or "Why don't you just have a c-section?" I didn't want an epidural, nor did I want a c-section. I felt like my body had been created do have this baby and just to prove everyone wrong, I was determined to have a natural birth.

A few things I found out along the way:

First- some people call a vaginal birth a natural birth. I agree that this is the way that nature intended for the baby to come out, but I am not in agreement that this is natural birth, unless the following can be claimed:
1. No drugs given to induce labor (pitocin or cytotec)
2. No drugs given to augment labor (pitocin or cytotec)
3. No drugs given to dull the discomfort of labor (including epidurals and stadol)

I would agree that a natural birth had been experienced even if labor had to be induced or augmented, but was done so with a non-chemical method. There are lots of them out there that aren't widely used. Several methods for natural induction include, but are not limited to: walking, nipple stimulation, sexual intercourse, stripping membranes, castor oil, various herbal treatments, and acupressure. Methods for labor augmentation that don't require drugs but have been found relatively effective are: changing positions during labor, walking, nipple stimulation, sex, and the Foley bulb (a manual cervical dilation device).

Second- childbirth education classes are worth the cost. There are lots out there to choose from. Lamaze, Hypnobirthing, and The Bradley Method are just a few that are readily available in our area. Some cost money. Others don't. The local hospitals offer courses and you can find some held at birthing centers. Your primary goal is to find a class that coincides with your goals. I'm a personal fan of Bradley- I took it during my first pregnancy and have taught it for the past year. I like the common sense approach to childbirth and the fact that there is nothing in the curriculum that is earth-shattering. My students learn a lot, and I've been fortunate to have a 95% un-medicated vaginal birth rate.

Third- a natural childbirth can drastically reduce your hospital bills. There are some insurance companies out there that are happy to pay 100% of the cost of your birth regardless of what is billed, but those are few and far between and are generally offered by large corporations. For the rest of us, individual, small group, or other insurance is what we have to work with. Most of those plans offer maternity coverage at 80-90%, and you have to cover the remainder, probably up to some sort of deductible or maximum out-of-pocket expense. When I put a down payment for my intended hospital birth, I received an invoice for the anticipated total expense for the birth and stay. It was nearly $12,000 and didn't include all the newborn procedures. We all know that a Tylenol in the hospital can be billed at a ridiculous premium (I heard somewhere it could be $4- $7 for each tablet!) so can you imagine how much an IV, pitocin, Stadol, epidurals (plus the cost of the anesthesiologist), etc could be? I don't know exactly, but would imagine that $20,000 would not be out of the question. And all this is on top of the prenatal OB costs. If you are responsible for 10%, that would be $2,000 out-of-pocket vs. $1,200, and at 20% you are looking at $4,000 vs. $2,400. I don't know about you, but I can find something better to do with $800 or $2,400 than shove it in my back.

Fourth- everyone assumes that the worst is going to happen. While I completely understand that our healthcare professionals see the absolute worst case scenario on a regular basis, I also know that staying healthy and low-risk during pregnancy drastically reduces those instances. I must assume that I will have a textbook birth experience until otherwise advised. Because I didn't want my care based on all the things that could possibly go wrong, I eventually switched to the care of a midwifery practice, where normal is assumed unless otherwise assessed.

And finally- determination and staying low-risk mean everything. If you are determined to have a natural childbirth experience, you cannot listen to the naysayers. Surround yourself with people who support your decision and then stick to it. It's safer for you and your baby. It's less expensive. It's empowering. But you have to stay low-risk by having a healthy diet and a proper pregnancy exercise plan. Educate yourself and your spouse so you know what to expect during labor. And talk to other women who have done it. As Dr. Marsden Wagner said (and it is a loose interpretation of his quote)- How can a woman be expected to survive the challenge of motherhood if she is constantly being told that she is incapable of handling the challenge of labor?