By Cassidy Swanson
For most women who give birth, it is a normal, healthy function of the body. But it also can be extremely painful and fraught with complications. Throughout history, maternal death, stillborn babies, and babies who died shortly after birth were common, and still are in parts of the world.
With modern technology, obstetricians and midwives are generally able to identify problems with mom or baby before delivery and recommend a course of action if needed. Sometimes, this can mean the use of drugs to speed up dilation or contractions, a Caesarean section to get the baby out immediately, or other interventions.
Knowing that giving birth comes with the assurance it is natural and healthy but with the possibility of serious complications, how does a pregnant woman weigh her options?
To some practitioners, home birth is never a good idea
Toni Golen, M.D., practices obstetrics and gynecology at Beth Israel Deaconess Medical Center in Boston. Golen believes that the majority of pregnancies begin at low-risk status, and, most of the time, remain that way. However, because of the unknowns of what can happen in birth, she would not recommend home birth to any woman, low- or high-risk.
“Even in the best of hands, people are unable to predict some catastrophic events that can happen during the course of labor and delivery,” she said.
“Having a baby at home has some risk associated with it for the mother, although the likelihood of there being a life-threatening complication for the mother is extraordinarily small,” Golen explained. “[The] risk that the baby could need some resuscitation is actually quite high…I certainly would not advise them to do [a home birth]. I certainly wouldn’t do it myself for my own children. But…this is a personal choice. If someone decided if they had appendicitis and they didn’t want their appendix out, I mean, while it’s not the same choice that everyone would make, it’s certainly their own choice to make.
“I see my role as an advisor to give the best possible information so that a woman can make a choice that presents the least risk to both herself and her baby,” Golen added. “If someone were to ask me whether it would be advisable to have a home birth, I would say, ‘Well, there’s more risk associated with that, so I would say no, I wouldn’t advise you to do that.’”
Midwives excel in healthy births, while OBs are necessary in high-risk situations
Alison Stuebe, M.D., is an ob-gyn who specializes in high-risk births. She completed residencies at both Brigham & Women’s and Massachusetts General hospitals in Boston, and is now an assistant professor in the Department of Maternal-Fetal Medicine the University of North Carolina Medical School in Chapel Hill and practices medicine at N.C. Women’s Hospital. She works with other OBs and certified nurse midwives at her hospital, and said that both provider types are very skilled – just at different things.
“Midwives are really, really good at normal births,” Stuebe said. Her own area of expertise, however, are the “really messed up pregnancies – the un-routine, the person who has the heart arrhythmia that could kill them, the baby with the terrible anomaly, and that type of thing. So I love normal births, but I tend to come into a room and start catastrophizing about, ‘Oh my God, what if this thing is happening or that thing is happening?’ And I’m a pretty low-intervention mindset.”
Stuebe said certain complications require a doctor’s care, and sometimes an intervention.
“I think it’s incumbent upon the provider to help moms understand where we’re coming from, and hopefully reach some shared understanding, so that moms feel like we’re not trying to make you do it,” she said. “This is the situation we’re in, and this is how we can get out of it safely.”
Doulas advocate for low-risk moms
If a woman’s pregnancy is determined to be low-risk, at that point, she may consider delivering naturally. Hiring a birth doula – a birth assistant who advocates on a woman’s behalf and provides physical and emotional comfort and support to her and her partner – is increasingly common, especially if a woman is delivering in a hospital and wants her wishes for a natural birth to be respected. Bec Conant, of Jamaica Plain, is a doula, prenatal yoga instructor and HypnoBirthing educator. Her clientele are typically women who seek a natural birth.
“I have interviewed with people who wanted the epidural, and I sort of counseled them that I was not the probably not the right doula for them to be with, because I don’t like epidurals,” she said. “I don’t like what they do to the labor, I don’t like what they do to the baby.”
When her clients deliver in hospitals, Conant serves as an intermediary between the mother and her doctor, making sure she is not being pushed into things she doesn’t want to do, but also helping her understand the doctor’s advice when an intervention would be helpful or necessary.
“The doctors I like are the ones who will pretty much throw hospital policy out if it doesn’t fit with what the mom wants, provided she doesn’t want to do something that’s flat-out dangerous,” she said. “There’s a doctor I’ve worked with many, many times, love her, and she and I will actually pull aside and have little side conferences about, ‘What do you think will be helpful here?’”
Golen believes that a doula can be an important and helpful part of mom’s support team.
“I encourage people to bring the people with them that they feel are going to be the most supportive,” she said. “A doula is a support person for the person who’s having a baby. Often, they’ve seen births before, and they have some experience with different kinds of relaxation techniques. They often know the patient, and when they know the patient and they’ve talked to the patient ahead of time about what would be helpful to them, then it’s extremely helpful.”
When home births must transfer to a hospital
And then there are situations no on can plan for: when labor fails to progress after many hours, the umbilical cord is wrapped around the baby’s neck, poor heart rate for baby, etc. This is easily addressed in a hospital birth, but if the woman is delivering at home, she is then transferred to a hospital.
Rebecca Corliss Beck is a certified professional midwife who practices out of Turners Falls in Western Massachusetts, and also teaches midwifery classes at Birth & Beyond in Jamaica Plain. A midwife often still has a role in the birth after the woman is under a doctor’s care.
“I’ve stayed on as [my client’s] sort of liaison and a support person,” Beck said. “Because they’re so attached to you and they want you to help them through this process, they usually say, ‘No, I still want you [to help me].”
Before a hospital transfer, Beck explains available options to women, provides her own opinion about the situation, and outlines what to expect at the hospital.
“I really give them informed consent,” Beck said. She added that she explains “‘this is what it looks like if we stay home, this is what it looks like if we go to the hospital.’” Beck noted she provides the positives and negatives, “and I acknowledge the fact that this [can be] really disappointing.”
Beck said she is grateful for the care that OBs provide her clients once their condition is out her scope of capability.
“Doing enough of this work and realizing how vulnerable it is, I have this complete respect for the fact that the buck stops with them,” she said. “I get to do my home birth, and if it doesn’t go well, I get to hand the scary stuff off.”
While Golen does not personally endorse home birth, she does believe it’s important for the doctor and midwife to work together once a patient is transferred.
“Assuming that the patient wants her to be there, [the midwife] would be part of the patient support team and would have a voice,” she said. “Is the information that person has valuable? Absolutely.”