Archive for the ‘Midwifery’ Category

Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making – Interview with Study Author Melissa Cheyney, PhD, CPM, LDM

September 15th, 2015 by avatar


“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. To help the birth professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Melissa “Missy” Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, CNM, PhD and co-authored by Marit Bovbjerg PhD, MS and Lawrence M. Leeman MD, MPH, can be found in an online-only version here. Additional insights specifically for midwives can be found at the MANA blog. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: Tell me about the new study looking at outcomes for families planning a trial of labor after cesarean (TOLAC) at home.

Melissa Cheyney: This study is significant because it is the largest study to date on outcomes for women and babies who attempt a TOLAC at home in the United States. We were able to create two subsamples from the MANA Stats 2.0 data set: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. This enabled us to compare outcomes for women who went into labor intending to deliver at home and had a previously scarred uterus with those who did not. Our goal was to provide whatever information we could (given our sample size) about the potential risks and benefits of attempting a VBAC at home.

JMc: The actual number of people who are planning TOLACs is relatively small. Why did you think this research was important?

MC: We know that as long as the primary cesarean section rate in the US remains above 20% (it’s currently 21.5%), and as long as many women continue to desire more than one baby, families will be faced with important decisions about what to do in subsequent deliveries. Because there are well-known risks to repeat cesareans as well as to a trial of labor after cesarean, we wanted to make sure that we could provide women who are considering a VBAC (and especially a VBAC outside of the hospital) with as much information as possible to support shared decision making.

JMc: What were the top findings of the study?

MC: First off, we found relatively high success rates. Overall, women with a prior cesarean had a VBAC success rate of 87%. Most of these were HBACs. While some women who who transferred to the hospital during labor went on to have a VBAC in the hospital, most had cesareans for “failure to progress.” Women who had also had a previous vaginal birth had a success rate of 90.2%, and those who had a previous VBAC had an even higher rate of success at 95.6%. These rates are among the highest reported in the literature across places of delivery and provider types.

We also found that women who had a previous cesarean were more likely to need to transfer care to the hospital in the intrapartum period than were women without a previous cesarean. So the transfer rate for women who were attempting a VBAC at home was 21.7% compared to 8.5% for multiparous women who did not have a previously scarred uterus.

We also found that, for those women who transferred, the most common reason that they transferred was a slow, non-progressive labor and not a uterine rupture or anything emergent. We also were able to calculate a combined intrapartum and neonatal mortality rate in the group that had a prior cesarean, and that was 4.75 out of 1000 compared with a rate of 1.24 out of 1000 in multiparous women without a history of cesarean. This is a highly statistically significant difference, and means that we know there is some elevated risk for women who’ve had a prior cesarean relative to a woman who’s already had a baby and who has no scarring of the uterus.

JMc: You had some interesting findings that suggest that not all TOLACs have the same outcomes. Tell us about that.

MC: We also performed some sub-group analyses where we compared women who were having a trial of labor after cesarean with other groups. We compared them to first-time mothers and to women who had a previous vaginal birth and a cesarean and were now attempting a VBAC after a cesarean. We were able to get pretty nuanced findings about relative risk within the TOLAC group.

In other words, we found that there is variation in risk within the TOLAC subsamples. So, just to say that VBAC is dangerous or that TOLAC at home has a high success rate doesn’t really give the full picture. You can break down this group, look at it much more closely, and get a better sense of how to talk with clients about the risks of TOLAC at home under their specific circumstances. Just as success rates vary by obstetric history, so do risks associated with VBAC. Our study is certainly the first study to do that for a large sample of planned HBACs

JMc: What advice do you give to families that may be considering HBAC in your practice?



MC: I say that it’s important to look at success rates, but that it is also important to think about the likelihood of an intrapartum transfer, distance from the hospital, and a variety of other factors that are unique to each person. I actually think that looking at the cases that did not have good outcomes can be very informative. They help us to see who might be a reasonable candidate for an HBAC and who might not be. For example, in our dataset there were five deaths overall—three during labor or in what we call the intrapartum period, one that was early neonatal (or the first 7 days of life), and one that was late neonatal (out to 28 days after birth). Those all occurred in the TOLAC group, yielding death rates of 2.85 for intrapartum, .95 for early neonatal, and .95 for late neonatal. So for the combined intrapartum and neonatal mortality rate, the total is 4.75 out of 1000.

When we look at these cases more closely, we see that two of the cases were very likely uterine ruptures, based on the heart tone patterns that the midwife was able to distinguish at home. The three other ones were deaths that were totally unrelated to the TOLAC status of the mother. One involved known risk factors related to giving birth to a twin, the second one was a surprise breech with an entrapped head, and the third one was a cord prolapse. So three of the five deaths likely had nothing to do with the fact that the mother had had a previous cesarean.

JMc: It’s surprising to see mothers with this kind of risk profile delivering at home. Can you help us understand why you think a mother, for instance, one that is attempting a twin VBAC birth at home, might choose that?

MC: In these kinds of cases, you have to ask this: if you have someone who has a cesarean for her first birth and she gets pregnant subsequently, what happens to her if she has twins in her second pregnancy? Who is going to offer her a TOLAC? What if she happens to be breech at term in the pregnancy following an unplanned and often unwanted cesarean? These women, who have a compounding of risk, have no chance, very likely, of finding a provider in the hospital who’s going to support these births. So, it might seem odd that out of only 1000 VBACs, you’d have this scenario. But it does make sense, if you think about the fact that these women might be the most likely to be excluded from a trial of labor in the hospital. This actually kind of fits with something else we found.

Regions of the US that have low rates of VBAC access in the hospital, the southeast, for example, have a higher percentage of the total births contributed to MANA Stats that are VBACs. When you look on the west coast, in states like Oregon, Washington, and California, where VBACs are more readily available in the hospital, even though there are more contributors and more data coming from the west coast, the total proportion of births that are VBACs is significantly lower in our data set. We take that to mean that when women have the option to try VBAC in the hospital, there is less pressure to attend those women at home. In a state where you have very limited access to hospital VBAC, those midwives are more commonly approached by women who are feeling forced to explore the option of a home birth for a VBAC because they can’t acquire one in their local hospital. That is both concerning and a reminder that even though we often discuss the US maternity care system as less well integrated than, say, the Netherlands, nonetheless, the various models and options for birthing care in this country do impact each other. We should all be working together to make birth safer for all women.

JMc: How do you think these findings should influence families that are considering a trial of labor after cesarean at home? What advice do you have for them?

MC: I think these findings have ramifications for everyone who’s considering a home birth, not just women who are considering a home birth after a cesarean, because one of the most interesting things that we’ve found is that that risk within our sample varies considerably by obstetric history and parity. What I mean by that is that a woman who does not have a previously scarred uterus, and she’s already had a baby vaginally, her risk is incredibly low. It is difficult to find a negative outcome in that group.

The next safest group to be delivering at home is actually women who have had a cesarean, but have also had a vaginal birth. They are less risky than first time mothers as a group. Then the highest risk, along the VBAC status and parity continuum, is a woman who has never had a vaginal birth, but has had a cesarean.

So, the range of risk goes from the lowest risk: a multiparous woman (multip); to a multip with a cesarean and a previous vaginal birth; to a nulliparous woman: and then to a woman who has never had a vaginal birth but has had a previous cesarean. Both deaths from suspected uterine rupture occurred in this later group. Each mother had had only one prior cesarean. That’s a really important thing to keep in mind, and I think that’s where our policy implications lie as well. States that want to restrict all HBACs need to be looking much more closely at the research, especially if some of this work is replicable with larger samples, because there is a nuancing of risk within subgroup. It may not make sense, for example, to allow nulliparous births at home but restrict all VBAC mothers with any prior cesarean history, regardless of the fact that they may have had a previous vaginal birth or a prior VBAC. These women who live within an appropriate distance to a hospital, have well documented placenta positions and adequate time between births may actually be lower risk than a first time mother.

JMc: What advice do you have for policy makers who might be considering HBAC regulations in their state?

MC: Over the course of my career, I’ve seen the data on home and birth center safety, patient selection, ethics, the benefits of normal physiologic birth — so multiple components of midwifery care and birth outside of the hospital — grow so quickly. I recommend setting the scope of practice for midwives in rule (sometimes called regulations or administrative laws) rather than statute. In many states, it is very difficult to get a statute changed, whereas it is often much easier to open your rules or regulations over a period of every few years, for example, to examine new research and make sure that you are writing rules/regulations that support evidence-based practice for midwives. It is an exciting time to be working on some of these questions. Data from registries like MANA Stats and the American Association of Birth Centers’ Perinatal Data Registry should enable us to engage in critical, ongoing quality assurance and quality improvement at national, state and individual practice levels. I think we need to find ways of regulating home birth that stay open, flexible and responsive to the data, to the needs of the families we serve, and to the guidance of medical ethicists who are equipped to help us sort through difficult questions related to choice, individual autonomy and relative risk.

About Melissa Cheyney and Jeanette McCulloch

Melissa Cheyney head shot 2015Melissa Cheyney, PhD CPM LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several, peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

Jeanette McCulloch head shot 2015Jeanette McCulloch, BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years.  Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.


Babies, Cesarean Birth, Guest Posts, Home Birth, informed Consent, Maternity Care, Midwifery, New Research, Newborns, Research, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , ,

Meet Jennie Joseph, LM, CPM – Lamaze/ICEA 2015 Conference Plenary Speaker

September 10th, 2015 by avatar
© Jennie Joseph

© Jennie Joseph

Today on Science & Sensibility, we have the opportunity to meet our final Lamaze/ICEA 2015 plenary speaker- Jennie Joseph, LM, CPM.  This British born midwife is the founder and executive director of Florida’s Commonsense Childbirth Inc. whose vision states “We believe that all women deserve a healthy pregnancy, birth and baby!” Jennie is also the creator of the The JJ Way® which has been remarkably effective at reducing disparities and improving outcomes for both women and babies. Jennie owns a birth center in West Orlando, FL. She also operates a midwifery school as well as certifications for a variety of birth professionals  Jennie will be closing the conference with her plenary session: The Perinatal Revolution: Reducing Disparities & Saving Lives Through Perinatal Education. What role do childbirth educators like you play in improving outcomes for families of color?  Today, Jennie speaks a bit about this topic in advance of her presentation at the conference.  I have had the pleasure of hearing Jennie speak several times in recent years, and I know that conference attendees are in for a treat.  For more information about this year’s conference, head to the 2015 Lamaze/ICEA Conference website.

Sharon Muza: What role do childbirth educators play in helping to reduce the disparities that exist in pregnancy, birth and newborn/infant outcomes for women of color?

Jennie Joseph: Today’s educators can play an essential role in reducing disparities simply by educating themselves about what those statistics are, what they represent, who they represent and why. Once an educator understands the extent and the cause of the problem he/she is able to really embrace the need to reach women and families in meaningful and practical ways – ways that will ultimately make an impact on the outcome.

SM: What changes have you observed over time in the perception of the value of childbirth education in the communities you work with?

JJ: I think that in every community in this country there is and has been a movement away from the traditional childbirth classes of the past. Women and their partners are busy and overwhelmed, with a false sense of security engendered by internet searches and with the hope that someone else, or some other entity will take care of everything when the time comes.

SM: Why do you think that many families are not attending childbirth classes in their communities? Is it lack of offerings? Cost? Accessibility? Do new families feel it is irrelevant to their experience?

JJ: When families are disenfranchised in so many other ways there is little value seen, or interest in an additional expense, or reaching for non-existent support, given that time is at a premium and resources are low. The institutionalization of birth inherently leaves one believing that the system is already set in stone, that the options and opportunities for autonomy and independence are not going to be available, and the benefit of doing the required hours of class are not likely to avail much as far as having any say at all. Cost and accessibility may be a factor for low socio-economic communities but more importantly the fact that few independent educators are open to the outreach and innovative thinking that is needed to engage new families, leaves a void which does not appear likely to be filled anytime soon.

SM: What can Lamaze International do to support and encourage people of color to become childbirth educators and be prepared to offer evidence based programs in their communities?

JJ: Childbirth education organizations that recognize and acknowledge the inequities in perinatal health and outcomes, and that are committed to that change, will lead the way in recruiting, training and retaining a diversity of educators. Cultural humility and practical support, not only for the communities themselves, but the providers and the educators that service them typically is what is needed. Supporting from a grass-roots perspective and embracing the dedicated entry-level or non-credentialed perinatal workers and volunteers who are on the ground already will provide a pipeline to further grow the ranks of educators and practitioners able to make a difference.

SM: You have been actively involved in birth work and supporting families for many years. What keeps you from getting discouraged about the slow progress we are making in reducing preterm births, low birth weight babies, maternal complications amongst families of color.

Jennie Joseph with clientJJ: I often feel overwhelmed with the glacial changes that occur and wondered how you continue to make progress and change lives in the face of often discouraging news. I get very discouraged working with families that are disenfranchised in one way or another. I find myself sometimes at my wits end because the agreement that we have in the United States is that we just don’t know the reason why we have such a high prematurity rate and in working in my field and doing the things that I do, the way that I do them, I have been able, as have many others, to not only reduce but all but eradicate prematurity in a population of women who are considered to be at highest risk for prematurity. Low birth weight babies, complications for the mothers, maternal morbidity and mortality is rampant inside African-American communities in particular. So, how I keep from getting totally discouraged is the fact that in seeing the change brought about by applying some very simple and essentially easily applied tenents to how I provide the maternity care that we offer, we have been able to turn the tide. I know that other people are willing and are doing the work the same way. I know that they are seeing the results the same way, so I continue to hope that there will be a turning of the tide that more and more practices and practitioners will embrace these few simple steps and show that they too believe we can stop the scrounge of prematurity and low birth weight in the United States.

SM: What are you looking forward to most about being a plenary speaker and presenting to the Lamaze/ICEA 2015 conference attendees?

JJ: I am very excited about being able to present at Lamaze/ICEA 2015. I am more than thrilled. This is something that has been on my heart for a long time and I am really clear that until we embrace and involve all the perinatal team in the work at hand we will not be successful. I think that childbirth educators have a pivotal role to play in bringing about change and I know there is an openness and a willingness to hear about new and innovative ideas as far as providing that education across the board. This is an awesome opportunity for me and I am very much looking forward to it.


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Meet Elan McAllister – Lamaze/ICEA Conference Plenary Speaker

September 8th, 2015 by avatar

ElanMcAllister head shot-220x220The countdown to the Lamaze/ICEA 2015 Conference in Las Vegas is in single digits and the excitement is building. I recently had an opportunity to interview plenary conference speaker Elan McAllister, founder of Choices in Childbirth, an education and advocacy group for pregnant people and their families.  Elan will be opening the conference with her plenary session “No Day But Today” and I am very excited to hear her presentation as she shares how we all can make a difference in birth outcomes and experiences for parents and babies.  Still time to register if you have the flexibility to join us in Las Vegas.  A joint Lamaze International/ICEA conference means great networking opportunities, plenty of continuing education and two great organizations coming together to collaborate on the things that matter.

Sharon Muza: You have long been involved in theater and then went on to found Choices in Childbirth. Do you see any commonalities between a theater production and a birth? In the way one prepares for both? In what is needed to be “successful” in both?

EMc: There are so many similarities! Essentially, both are acts of creation. My role (and its been my honor) in both theater and birth has been to hold space for creation to unfold. Bringing something new into the world, whether a new life or a work of art, challenges us in remarkable ways. It takes tremendous courage to let your self be vulnerable to the creative process and I believe that no one should do it alone. As a producer, I have supported artists and encouraged them to believe in themselves and connect with their voice and vision.   As a doula, I have supported women and encouraged them to own their power in birth.

SM:  I have had the deepest respect for Choices in Childbirth and have so appreciated their invaluable consumer booklets that have been a part of my client and student information packets for many years. Can you share some of the feedback you have gotten from both consumers and professionals regarding their value?

EMc: Thank you so much and I’m thrilled to hear that the Guide to a Healthy Birth has been useful to you! Over the years we’ve distributed thousands of Guides all across the country and have had the most remarkable feedback. Women have told us that it opened a door and encouraged them to think more deeply about their birth choices. Many have referred to it as their birth bible. We worked really hard to create something that would be useful to any woman who picked it up – regardless of her birth choices. We wanted to create something that would be respected by the birth community but that could be embraced by the mainstream. I think we succeeded in that goal and it truly warms the heart to know that something you’ve created has made a difference to people.

choices in childbirth logoSM: Choices in Childbirth has been a leader in maternity care reform and has long been committed to consumer education. The CiC organization along with other maternal-infant health advocates have consistently raised their voices to help improve outcomes for mothers and babies in our country. When you look at all of the programs that CiC has had a hand in, can you share what has made you the most proud? What has been the most challenging?

EMc: Thank you for this opportunity to reflect on the work that CiC has done over the last 12 years and to feel profound gratitude to all of the people who have contributed to CiC’s successes. When you’re in the middle of things, you sometimes lose perspective, so I am grateful for this chance to reflect. In this moment, I’m most proud of the work we did last year to petition the city to reopen the labor and delivery services at North Central Bronx Hospital (NCBH).   For over 30 years, NCBH provided high quality, teamed-based midwifery care to an at risk population in the Bronx. Women who were used to an impersonal, clinic-based health care experience received personalized and continuous care at NCBH with midwives that they were able to build relationship and trust with. While cesarean section rates were skyrocketing all across the city and the nation, NCBH maintained a c-section rate of about 17%, largely due to the fact that 85-90% of births there were attended by midwives. When the services were suddenly closed in 2013, CiC joined a coalition of community organizers that worked together for nearly a year to demand not only that L&D services be returned to the community, but that the midwifery program be returned in tact. Together with local community members and organizations, we were able to make such a compelling argument to the city that they not only reopened the services but invested a million dollars in upgrading the facility!

SM: How do you think childbirth educators can help families to understand the family’s critical role and rights in shared decision-making and informed consent?

EMc: This is such a challenge. We are all faced with the frustrating reality that a huge percent of birthing families are scared about birth and feel most comfortable turning the experience and power over to the “experts.” Negative reinforcement in the form of, say, warning them about the routine overuse of unnecessary medical interventions will typically shut them down further. I have found that the most effective way to encourage families to be more engaged in the decision making process is to inspire them.   Fear of birth is prevalent in our culture and fear shuts us down. The only way to overcome that fear is to awaken families to the deep, essential truth that birth is a sacred, powerful and profoundly important life experience. Be the voice of awe and wonder that inspires them to show up fully and take a higher level of interest and responsibility for this miraculous event in their lives.

Elan McAllister and NCBH Midwives at L&D re-opening

Elan McAllister and NCBH Midwives at L&D re-opening

SM:  If a childbirth educator wanted to spend time (or increase their current level of involvement) in the birth advocacy role – what do you suggest they consider doing on both a local and on a national level? How could they get effectively get involved?

EMc: I love this question and I will be talking a lot about this at the conference. There is both inner and outer work that needs to happen in order for childbirth educators, (and all birth workers) to better engage in birth advocacy work. The inner work consists of two important shifts – 1) Step into the role of Consumer Advocate. Recognize that you are in a critical and powerful position to amplify the voices of the women and families that you are in direct contact with and 2) Become a Bridge Builder. If we’re going to have an impact on the system we must let go of the “us vs. them” victim mentality and start building relationships with decision makers.

The Affordable Care Act offers countless opportunities for us to engage and impact health care reform.   I’ll be talking more at the conference about how to take advantage of this important moment as well as providing examples of work that CiC has been doing over the last couple of years.

SM:  What are the three most important things that families can do to help ensure that their birth experience is both safe and healthy as well as positive?

EMc:  1) Be well informed and in touch with your desires and beliefs so that you can create and communicate a clear vision for your birth.

2) Choose the provider, setting and birth team that will give you the best opportunity to realize the birth that you’ve envisioned.

3) Let go and surrender.   Trust that you have done all that you can, you are stepping into a divine mystery that cannot be controlled and that will unfold exactly as it is meant to.

SM: Can you share a little about how you made the switch from theater producer to tireless advocate for families during their childbearing years? Were you always drawn to birth and birth advocacy and women’s rights? Or was that a “role” you grew into after experiencing specific events in your life?

EMc: I became involved with both theater and birth at around the same time, about 20 years ago. My early career as a professional dancer lead me to theater production right around the time that the young feminist in me picked up a book on midwifery and had her mind blown! I juggled these two passions/ straddled these two worlds for about 15 years before retiring from producing 5 years ago. Though I turned Choices in Childbirth over to new leadership last Fall, I remain devoted to my calling in service of women, babies and families.

SM:  What are you looking forward to most about being a plenary speaker and presenting to the Lamaze/ICEA 2015 conference attendees?

EMc: It’s always a pleasure to speak to a receptive, well informed audience! I look forward to sharing ideas and learning from my peers.

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Looking Back in Time: What Women’s Bodies are Telling Us about Modern Maternity Care

June 18th, 2015 by avatar

By Christina Gebel, MPH, LCCE, Birth Doula

Christina Gebel, MPH, LCCE, Doula writes a reflective post examining current birthing conditions to see how today’s practices might be interfering with the the normal hormonal physiology and consequently impacting women’s ability to give birth.  Times have certainly changed and birth has moved from the home to the hospital.  A slow but steady increase in out of hospital births is examined and Christina asks us to consider why women are increasingly choosing to birth outside the hospital – and what do hormones have to do with it? – Sharon Muza, Science & Sensibility Community Manager

“Pregnancy is not a disease, but a beautiful office of nature.” These are the words of Victoria Woodhull, the first female candidate for President of the United States in 1872.

Lajja_gauri ancient birth art

© “Lajja gauri

The world in which pregnant women find themselves today looks a lot different than the time of Woodhull’s campaign run. For instance, hospitals didn’t become the mainstream setting for labor and delivery until the 1930s and 40s. While modern medicine has undoubtedly helped millions of women who may have otherwise died in childbirth, mothers and birth advocates across the nation are beginning to ask if we are paying a price for today’s standard maternity care. With increasing protocols and interventions, pregnancy is viewed less like the office of nature Woodhull spoke of and more like a pathological condition.

The Hormonal Physiology of Childbearing, a recent report by Sarah Buckley, systematically reviews existing research about the impact that common maternity practices may have on innate hormonal physiology in women and fetuses/newborns. The report finds strong evidence to suggest that our maternity care interventions may disturb these processes, reduce their benefits, or even create new challenges. To find out more, read an interview that Science & Sensibility did with Dr. Buckley when her groundbreaking report was released.

Let’s examine something as simple as the environment that a woman gives birth in. In prehistoric times, laboring women faced immediate threats and dangers. They possessed the typical mammalian “fight-or-flight” reaction to these stressors. The hormones epinephrine and norepinephrine caused blood to be diverted away from the baby and uterus to the heart, lungs, and muscles of the mother so that she could flee. This elevation in stress hormones also stalled labor, to give the mother more time to escape. Essentially, she told her body ‘this place is not safe,’ and her body responded appropriately by stopping the labor to protect the mother and her child during a very vulnerable time.

Today, mothers are not fleeing wild animals but rather giving birth in hospitals, the setting for nearly 99% of today’s births, where this innate response may cause their labor to stall. The sometimes frenetic environment or numerous brief encounters with unfamiliar faces may trigger a sense of unease and, consequently, the fight-or-flight response, stalling the mother’s labor. Prolonged labor in a hospital invariably leads to concern and a need to intervene, often by the administration of Pitocin, synthetic oxytocin, to facilitate regular contractions. Arrested labor could lead to further interventions up to and including a cesarean section. The fight-or-flight response may be further reinforced by these interventions, as they potentially come one after the other, in what is often referred to as the “cascade of interventions.”

This is just one example of how a woman’s body’s natural physiology can go from purposeful to working against the labor, the mother and the baby. Epinephrine and norepinephrine are both necessary in labor and delivery. In fact, at appropriate levels, these hormones support vital processes protecting the infant from hypoxia and facilitating neonatal transitions such as optimal breathing, temperature, and glucose regulation, all markers for a healthy infant at birth.

Recent data show that mothers themselves may already think what the Hormonal Physiology of Childbearing report suggests. The series of Listening to Mothers (LtM) studies, a nationally-representative survey of childbearing women, shows a shift in mothers’ attitudes towards normal physiologic birth: In 2012, 58% of mothers agreed somewhat or strongly that giving birth is a process that should not be interfered with unless medically necessary, up from 45% in 2000. According to 2013 national birth data, out-of-hospital (home and birth center) births have increased 55% since 2004, but the overall percentage is still only 1.35% of all births nationwide. While low, this shows that a small core of mothers are voting with their feet and choosing to give birth out of the hospital. Though their choice may seem extreme, they’re not alone. In the LtM data, which only surveys women who have given birth in a US hospital, 29% of mothers said they would definitely want or would consider giving birth at home for a future birth, and 64% said the same of a birth center. All this raises the question: What’s happening in a hospital that is leading mothers to consider other settings for their next birth?

One answer to upholding women’s preferences, autonomy, and the value of normal physiologic birth is a mother’s involvement in shared decision making with her provider, along with increasing access to models of care that support innate physiologic childbearing, like midwives in birth centers. Increasing access to these options may present a challenge, as demand seems to outweigh availability.

Leslie Ludka (MSN, CNM) has been the Director of the Cambridge Health Alliance Birth Center (Cambridge, Mass.) as well as the Director of Midwifery since 2008. Like other birth centers, the center has seen a steady increase in demand each year, with patients coming from all over New England. Ludka sees many barriers to having more birth centers available including finances (the reimbursement for birth not being comparable to an in-hospital birth), “vacuums in institutional comprehension” of the advantages of the birth center model for low-risk women, and the rigorous process to be nationally certified by the Commission for the Accreditation of Birth Centers (CABC), requiring “a great commitment and a lot of support by all involved.” In order to overcome these barriers, Ludka suggests marketing the safety of birth centers to the general public, sharing outcome statistics for women and infants cared for in birth centers, and educating insurers and providers about the overall benefits and financial savings of midwifery and the birth center model. With supportive policy and better understanding on the part of insurers, the public, and healthcare institutions, models like the birth center could become more plentiful, more easily meeting the demand.

Women’s bodies are sending subtle messages that our current healthcare system is, at times, not serving their needs. It’s time to respond to these messages, beginning by viewing childbirth foundationally as a life event and not first as pathology, and adapting our models of care to speak to this viewpoint. If we fail to do so, we run the risk of creating excess risk for women and newborns.

It’s been 143 years since Woodhull ran for president. We’ve made progress in getting much closer to seeing our first woman president, but with childbirth, perhaps our progress now starts with looking back in time.

About Christina Gebel

© Christina Gebel

© Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter: @ChristinaGebel and contact her through her website duallovedoula.com

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Medical Interventions, Midwifery , , , ,

American Obstetrician Takes Rational Position on Home Birth

June 16th, 2015 by avatar

Neel Shah, Harvard Medical School assistant professor and practicing obstetrician, commenting in the New England Journal of Medicine Perspectives section –  “A NICE Delivery – The Cross-Atlantic Divide over Treatment Intensity in Childbirth“, agrees with new United Kingdom National Institute for Health and Care Excellence (NICE) guidelines concluding that healthy, low-risk women are better off at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Citing a table comparing outcomes in low-risk multiparous women from the Birthplace in England data, Shah writes:

The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. For women giving birth, the many interventions that have become commonplace during childbirth are unpleasant and may lead to complications . . . .

He quite reasonably adds the caveat that the guidelines apply to low-risk women only and that even these women may develop labor complications without warning, but then, responsible home birth advocates acknowledge those same two points. That being said, I can’t resist adding a couple of caveats of my own.

© Families Upon ThamesFirst, one reason why women with risk factors plan home birth, women with prior cesareans being a common example, is that doctors and hospitals deny them the possibility of vaginal birth (Declercq 2013). With their only hospital alternative being unwanted and unneeded cesarean surgery, planned home birth becomes their least, worst option. This dilemma puts their choice squarely in the lap of the medical system. Another reason is that some women have been so emotionally traumatized by their treatment during a previous birth that they reject planned hospital birth and refuse intrapartum transfer even when this may be the safer option (Boucher 2009; Symon 2010). Again, the failure and its remedy lie with the system, not the woman.

Second, if the hospital lacks 24/7 obstetric, anesthesia, and pediatric coverage and at least a Level 2 nursery, which many do, then a woman is probably no better off in the hospital in an emergency than she would be at home or at a freestanding birth center. Furthermore, most urgent situations—a baby who doesn’t breathe, excessive bleeding, even umbilical cord prolapse—can be managed or stabilized by a properly trained and equipped home birth attendant. In fact, what would be done in the hospital is no different from what would be done at home: neonatal resuscitation, oxygen, medications to stop bleeding, maternal knee-chest position and manually holding the fetal head off the cord until cesarean.

Finally, with admirable frankness, Shah notes that unlike the U.K., and to the detriment of safety, “[A]ccess to obstetric care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon.” And while he doesn’t cast any blame, once more, the fault lies with the system. (Just as an FYI, a model guideline for transfer of care developed by a workgroup that included all stakeholders is publically available.)

Shah concludes: “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” True that, but it doesn’t have to be that way. Dialing back the overuse of medical intervention and cesarean surgery; respecting the woman’s right to give informed consent and refusal; implementing a culture of care that is kind, compassionate, and respects a woman’s dignity; and ensuring that out-of-hospital birth attendants can consult, collaborate, and transfer care appropriately would have two benefits: it would reduce the number of women refusing hospital birth while minimizing the chance of adverse outcomes in those who continue to prefer to birth at home or in a freestanding birth center. Nonetheless, despite the generally positive responses accompanying Shah’s commentary, rather than inspiring a wave of reform, I would lay odds that the more common reaction to Shah’s piece within the medical community will be to shoot the messenger.


Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126.

Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, Ariel. (2013). Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection.

Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4), 280-287.

About Henci Goer

© Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.

Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery , , , , , ,

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