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Sunday
Nov282010

Thoughts on “When a Homebirth Doesn’t Happen”

Maryn Leister wrote a beautiful article in Indie Birth, “When a Homebirth Doesn’t Happen.” 

“There is a Higher consciousness that serves us all, and to act like we KNOW how things need to turn out is just plain arrogant and egotistical. Who’s to say that a woman needs or should have a certain kind of birth? How is that respecting the path that she walks? It is not my job or my goal to affect change on anybody’s path. We each have our own to walk, and our own lessons and trials and triumphs.” 

It’s a lovely self-reflection about a midwife’s desire for her clients to have their babies at home and the subsequent feelings in both midwife and mom if the birth moves into the hospital. At the beginning of the piece, Maryn says: 

“I’d like to approach the delicate subject of transports to the hospital from home; mainly for my own reflection and processing. I say ‘delicate’ because for many (midwives and mamas alike), a transport conveys the ‘failure’ of someone or something. In the past, I’ve been the midwife that, I’ll admit, has heard other midwives’ transport stories and thought indignantly, ‘You transported for THAT?’” 

I’ve found that, with time, all midwives eventually come up against this reality check. It really is pretty easy to second-guess another midwife’s actions, especially when not a midwife yourself. But when the woman and baby are in your charge, the scenario can look entirely different. I believe it would be a fairly immature midwife to not look at this issue with a brilliantly bright light and a daringly sober attitude several times over a career. 

Through the years, I’ve revised my Statement of Purpose as a midwife when the situations led me to do so. At the moment, my Statement of Purpose is: 

My main role as your midwife is to keep you and your baby alive. However that unfolds, I am here to serve you.

As Maryn and others have also experienced, the feelings of failure, of being a not-good-enough midwife have splashed about my ankles and calves. I’ve even had times when the guilty waters have, tsunami-like, threatened to take me under the waves. But, I force myself to remain in a place that does not include self-pity. There’s a difference between wishing things were different and beating one’s self up; the former can be productive if processed correctly –the latter is wasted energy. 

I’ve had my share of transfers (going to the hospital in a non-emergent fashion) and transports (going to the hospital in an ambulance) and I think with all but the clearest of reasons (i.e. placental abruption and posterior face presentation are two that come immediately to mind) I have wondered “Could I have done anything more?” There have even been a couple of births that haunt me, wishing I would have done things differently. While it might be a woman’s path to be in the hospital, perhaps if I had <fill-in-the-blank>, it might not have been in her cards in quite the same way. Blessedly, no mothers or babies were lost in the process, but I do believe at least a couple of women have been (cesarean)-scarred by my decision to move to the hospital. My heart aches with that belief. 

When I became licensed as a midwife in 2005, I’d had many years of experience as a doula and a few as a midwife in a birth center and even fewer as an assistant and then primary in the homebirth setting. During my homebirth apprenticeship, experienced homebirth midwives would say, over and over, homebirth was a different animal than hospital and birth center births. Really, all I could tell was it was a lot slower and gave the woman a ton of one-on-one care, especially compared to the high-volume Casa de Nacimiento birth center. I mean, wasn’t birth birth? Didn’t all women labor the same, birth from the same body part and have the same needs? It was even easier in the more relaxed settings because women didn’t have to struggle with The Establishment over her autonomy. I grew tired of their repetition… “Homebirth is different.” For goodness sake, most of them didn’t have nearly the number of births under their belts that I had. 

But they were right. Homebirth is a different animal than birth center and hospital birth. (I thought it would be a bitter taste in my mouth to say that, but it actually came out easily.) 

Now that I’m five years into being a Licensed Midwife, I feel I am just now coming into my own as a homebirth practitioner. I know that probably sounds ghastly, especially to past clients. I don’t mean I was a bad midwife before, but feel I am now a more mature midwife… less skittish than I’ve been in the past. All those years of erring on the side of extreme conservatism; was that really necessary? I’ve not heard other midwives speak about this learning curve, so I’m left wondering if this is a solitary experience… these feelings of previous inadequacy. (If you have written about this topic or know someone who has, please point me in the direction; I’d love to hear from others.) 

I don’t believe this was a technical lacking in my education or training. It is more of an intuitional process that can’t be taught… that place of balance between trusting all of my capabilities implicitly and knowing the exact moment to hand over the reigns to a medical professional. I’m not sure if this perfection is ever achieved, but I know I could have come a lot closer to the mark. 

I know this sounds crazy, but it is now that I wish I could apprentice with an experienced homebirth midwife. It is now that I know what I’m watching for in a domiciliary experience. I’m finally (I think) more balanced in my knowledge of all births, homebirth included. That doesn’t mean I still don’t have slews of things to learn, by any stretch of the imagination. It doesn’t mean I won’t still waver on the cusp of uncertainty. What an apprenticeship would do is validate my decision-making skills, allow me to say, “I did know everything to do after all,” or show me my blind spots, forcing me to acknowledge “I hadn’t thought of that; I will remember next time.” 

I would be more patient in an apprenticeship now. In the early 2000’s, I couldn’t wait to be on my own, really believing I didn’t have all that much to learn… perhaps how to do longer prenatals or organizing a birth kit… but not so much about birth itself. I wonder if I wasn’t arrogant even. I might have been at times, but think I was simply naïve more than anything else. 

Maryn says that even as she brings up the topic of transports…: 

“… I am trying to prove something, or maybe it’s to disprove something. That my transports (or lack of) somehow indicates my worth as a midwife. As if I am in control of the outcome, as if these births I attend are all about ME and how skilled, intuitive (substitute your favorite midwife attribute here) I am. These 2 transports, the most recent in particular, have shown me how ridiculous this mindset is. And how if I (or any midwife) operates under that notion, birth becomes ego-centric and also totally disempowering to the woman.”  

To me, midwives are in control of at least some of the transports. If they (I) don’t have certain skills, then some situations can be out of the scope of practice for the midwife… and a transport becomes (almost) inevitable (unless she sallies forth, trusting the knowledge is there and will pour out of her brain into her hands). While the outcome itself might not be in my hands, by making certain decisions, the selection of outcomes narrows. By making the decision to transport, I have removed the option of having a homebirth and, in all likelihood, thrust the woman into the pool of an uncontrollable cesarean rate. 

I have said, more times than I can count, “Who knows why your baby needed to be born in the hospital/by cesarean.” I’ve toddled along, counseling women after their complicated births, helping them to reframe their experiences into some (possibly) pre-destined ordeal. With Maryn’s unwitting help, it is this attitude I am questioning. Perhaps by believing birth is already written even before labor begins… by believing in fate… might not that absolve the midwife from any culpability? Isn’t that the selfish and egotistical notion? Might the midwife not accepting her role in the outcome be the disempowering factor in the mother’s attempts to make sense of it all? Might this attitude not be a subtle way to blame the victim for her own circumstances? 

I agree; it isn’t All About Me when it comes to a woman’s birth or her transport to the hospital because of a complication, but I feel there must be room for the client to ask, “What could you have done differently?” I mean, the woman hired me as a consultant in her birth, didn’t she? Even women who want autonomy, if they’ve chosen to have a midwife at their births, they (often) look to the midwife to make the ultimate decision to transfer/transport. If we/I can accept that our/my actions might have pulled the laboring mom down the path towards Intervention World, perhaps that creates the space for women to find their power surrounding their births. Perhaps this acknowledgement is the tipping point between a woman’s self-flagellation and the ability to retain/regain her sense of self-confidence… an attitude that, most assuredly, spills over into her mothering. 

None of this is meant as a recommendation for making the midwife the scapegoat in a transfer/transport… something I have seen happen before. But, as with all things, a balance of responsibility allows room for learning, explaining and even asking for forgiveness if that is appropriate. 

Just writing this, I have uncovered places where I now want/am ready to accept responsibility for my actions and apologize for them. I know it can’t fix the outcome, but it can, at least, acknowledge their own niggling questions about their births, letting them know their births were an integral part of my continued education as a homebirth midwife. Not many pregnant/birthing women would purposefully want a midwife learning on her, but, in a way, aren’t we always learning by caring for women? If I could do some of those births differently, I would. The fatalistic part of me says we chose each other; me to learn… they to teach.

But I can’t help but wonder, is that my justifying all over again?

(photo by Nova Bella DeLovely)

 

Reader Comments (12)

I really appreciate this blog and all the reflection you did. I have had experiences which left me rather shaken and wondering what the mother and I needed to process together and how I could go about doing it without seeming the victim/doubting/unskilled/etc. And without making the mother feel as if she was a failure or powerless.
I believe we all have a certain set of skills and we have those skills and are put in someone's life because of this. When I speak to women about what they want home/hospital/birth center, I tell them not only to ask statistical information but specifically what the attending believes are their skills in the entire pregnancy, childbirth and postpartum experience. It is enlightening for them when the speak to an OB who has never done a 'natural' birth except the occasional one popping into the ER crowning! Or a midwife who hasn't had to attend a woman with GD or pre-e or a number of other things which would typically land her in the care of an OB. Every facet is important and unless there is an intentional act of arrogance which caused a poor outcome I think we should feel blessed to have the various skilled hands available and know that we acted in the best interest of both mom and baby. Letting mom know ahead of time this is how you feel is important as well to relieve and guilt or fear that comes up following transport/transfer. Hospital does not equal evil or failure. Homebirth does not equal superior or champion. What matters is both mom and care giver have been equally involved and are knowledgable about what needs to happen to get baby here! At least that is how I feel.

November 28, 2010 | Unregistered CommenterAlicia

Thank YOU! I am honored that my post provoked you enough to write your own. And your post is wonderful....I was waiting for somebody to say what you did...I agree (although it just wasn't the focus of my post) that of COURSE we need to do/try everything and use every possible tool as midwives. It's not just like we say, hey screw it, this is just this baby's path....So, YES, try everything and pray to whoever you do about those things, but then...well, I still believe the end comes from a combination of factors. And for me, that means I believe that Spirit directs way more than we probably know.
It was also self healing for me to write (I'm sure you understand that:) because I WAS questioning everything I could have/should have/would have done. Totally. It's just for me, once I know I have done what was my absolute "best" at the time, I have to give up the rest. Otherwise I will drive myself crazy and feel no peace at all about it. I find myself (and again, I am sure you can relate!) creating this drama/story about it after the fact. And most of that stems from my own ideas and preferences about what a "good birth" looks like.
Anyway, the cool thing is that there are so many ways to think about these topics. What better way to try and cope with the sometimes difficult profession we have chosen for ourselves?:)
Hugs back to you,
Maryn

November 28, 2010 | Unregistered CommenterMaryn Leister

Speaking as a woman who ended up in the hospital with her first, after planning to be in a birth center, I've found that I've gone through several rounds of processing what happened - at times believing it was absolutely necessary and at times thinking it wasn't. And sometimes believing it was necessary left me feeling like a failure, like my body didn't work, even like my body would have killed my baby if left to it's own devices, which is a shattering thing for a new mother to be dwelling on. But believing that it wasn't necessary left me feeling betrayed. So sometimes I needed to think it was necessary and sometimes I needed to think it wasn't.

And that's not even having planned a home birth and having had a vaginal birth.

I've done a whole 'nother round of processing of that first experience, in light of my second birth, which was better in a lot of ways but was not without complications and also forced me to retrace a lot of the same territory.

Mostly, I'm in a good place with things now, which I very much wasn't after the first birth.

But with both of the births, I was never entirely sure what the midwives really thought about the whole thing. I was scared to ask the questions I needed to ask because I didn't want to insult or offend the midwife. Or when an answer was a little evasive or beside the point, I didn't press. And frankly, they didn't volunteer much that would have opened the way for me to go down that path with them.

We open up such difficult emotional terrain when we start caring about birth. Sometimes I think it would be better not to care, but I can't stop now.

November 28, 2010 | Unregistered Commenterchingona

Another wonderful post. This post clairfies, for me, the true difference between midwives and most Docs. A good midwife will look at a birth, help a mom try to make sense of it, and look for ways she can improve. She will not shirk from responsibility. So few Dr.'s seem capable of this. Some do, but usually we call them M.D.'s (Midwives in Disguise.) :)

November 29, 2010 | Unregistered CommenterCrowbabies

chingona: I am *sure* it would be better... um... easier (?) to not care, but that isn't midwifery, now is it. I've heard many a (hospital-based/medical-oriented) care-provider who's said they simply cannot get emotionally involved because they'd go crazy with worry about everyone. While it isn't the best thing to get “emotionally involved,” I feel it isn’t the best thing to be totally disassociated from the woman, either.

I know it’s hard to talk about disappointments in birth –on both sides of the experience. When I have clients who choose another provider, I rarely hear why… even when I ask. And when I’ve asked, I’ve been told I made the woman very uncomfortable… even when I tried to be very gentle and loving about it. I *want* to know why I wasn’t chosen again. Even if my feelings are hurt. I like to think I’m a big girl who can learn and grow from mistakes. But, it *is* hard to either confront someone about their difficult experience… much easier to avoid (on both counts). I have asked women *how* I should ask why I wasn’t chosen again, but still don’t know if I know the right way (if there *is* a right way). Maybe I should just make it a post.

Sorry to go off on that tangent. It’s intertwined with yours.

It *is* so hard when there is disappointment in birth and especially difficult when it was your body that seems to have “failed” you (or the baby). There isn’t any perfect way to soothe those feelings. Hearing that you both could have died if you hadn’t been in a Western country can exacerbate the whole issue… it does comfort some women, though. I do hope you’re able to find some peace eventually.

November 29, 2010 | Unregistered CommenterNavelgazing Midwife

Thank you for another thoughtful post. I had to be transported during my homebirth and 18 months after the subsequent cesarean, I still feel like a failure. I did not get the chance to talk to the midwife who was attending my birth as she moved to another part of the country. I've been processing this birth since, with whatever information I could gather from difference sources. I think she took the right decision at the time, what happened after was an unfortunate set of circumstances. I'm pretty sure she must be askig herself the same questions. It makes me feel so much better to know that midwives do process things after and take time to think about what could be done differently. It's so easy to go out and look for a scapegoat after a "missed" homebirth.

November 29, 2010 | Unregistered CommenterElodie

Please don't let distance be a barrier to your having a discussion with your midwife. If you know she will remember you, you can find her easily. If she's a CNM, you can find her on the ACNM website... a CPM, via the NARM website... not licensed, you can still search the Net and find almost anyone. If you need help, let me know and I'm glad to help.

And once you find her, you can either talk on the phone or, better yet, Skype with her.

I know it takes some hefty energy to instigate this conversation with the midwife, but if it, in the end, brings you peace and closure, it will have been worth the time and effort.

Let me know if you need a hand to hold or a hand to help.

November 29, 2010 | Registered CommenterNavelgazing Midwife

Thanks, Barb.

I am mostly at peace with it now. Where I'm at now is that there was a good medical indication for the decisions that were made, but there's obviously no way to know what would have happened if other decisions were made. It lets me feel that what happened was the safest decision that could have been made at the time, while allowing room for my body not have failed. And I've stopped thinking about it as "what went wrong" and focus instead on the ways I was strong in the face of difficult circumstances. I just don't allow myself to hate on my body any more. But I didn't get there just by saying it. It took a lot of time and other life experiences.

I wanted to share it, though, even though it is a bit tangential, because yes, the narrative of inevitability around a certain outcome can leave some women feeling damaged or inadequate.

I don't think there are easy answers. My thoughts have changed so many times over the years. A conversation that would have felt "right" at, say, 6 weeks postpartum, might have galled me at a year, but felt right again at some later point, and some of that was just where I was with things and some of it was new information that prompted new questions. I suspect the same is true of midwives. You might feel you did the right thing, then learn of a similar labor that had a good outcome at home, and wonder again about the decision to transport. Part of the problem is that life isn't some "Choose your own adventure" book, where you can mark your spot and go back and see what would have happened if you'd done the other thing.

November 29, 2010 | Unregistered Commenterchingona

This post was difficult for me to read because we planned a homebirth with our daughter and wound up transferring to the hospital about 20 hours into a 31-hour labor. I think the reasons for the transfer were legitimate, but my problem is with the midwives' behavior before the transfer; from the moment the first one walked in the door, things were said that I will never, ever forget. And as a result I have no desire whatsoever to have a conversation with either midwife ever again. This makes it difficult to process the experience. I'm in a much (MUCH) better place now that my daughter is 16 months old than I was her first year. But there are still things I wish I could go back and change, and I don't know how to let that go. And I had a vaginal birth! And the hospital staff were kind to me! So of course I feel like I should just get over it. Sigh.

December 4, 2010 | Unregistered CommenterAmelia

I transferred to the hospital after a long nonprogressive labor that eventually required a cesarean for "true CPD" (and I believe it!)

With 11 years of hindsight, I can say that insisting that we transport was the only correct thing that my midwife did. I was reluctant to transport and I am so thankful that she insisted it was necessary. (My baby was high; the midwife had me push on an incomplete cervix to try to bring the baby's head down to the cervix, and his heart rate went down.) By the time we got to the hospital, an infection was beginning and the baby had a ridge on his forehead from trying unsuccessfully to get under the pubic bone. Yes, that kid was only getting out with a c-section, and I'm thankful to the midwife for getting me there.

However, in the rest of the birth, the midwife was a real jerk. Because I was not progressing, therefore she thought that my labor was not painful enough. To "help" she added some more pain through manually dilating the cervix (which was not discussed with me prenatally. Yes, I recently learned she is a "Powerbirth" midwife.) I screamed because it was so painful, and I'm not a screamer. She asked me, "Is it really so horrible?" I screamed YEEEEEESSS!, but she didn't take her hands out!!!

She did not respect the pain I was in, and her attitude was that I was a whiny baby because 2 centimeters dilated is not painful by her definition.

The other big mistake I think she made: My baby was at -1 station at 37 weeks. At his birth, he was at a -3, up two stations. Apparently as he grew he moved out of the pelvis. Am I right in thinking this is a pretty near sure sign of CPD? Are there babies that get born to first-time vaginal birth moms who went up instead of down at the end of pregnancy? If that is a nearly sure sign of a cesarean being necessary, I wish she would have transferred my care to an OB then. That would have saved me from paying both her and the hospital people, and would have saved me a lot of pain and aggravation.

I felt a lot more respect from all of the hospital people compared to the midwife. I'm sure some of the nurses didn't think much of home birth, but they were professional enough to keep their opinions to themselves. I wish my midwife would have been as professional.

I discussed the birth with my midwife after the fact. She was distressed about the birth as well, but only because it ended in cesarean. I told her I was much more upset about her disrespectful treatment of me than the cesarean. She didn't see that she had done anything wrong, and we were at an impasse.

August 10, 2011 | Unregistered CommenterSara

What an experience, Sara. I'm so sorry it was so difficult. I thank you for sharing it with the others, though. Every birth story helps women with their decisions and processing later.

Re: the station decreasing, no that wouldn't be a referral situation. Babies' stations are up and down all the time. There *are* ways to check if the head will go down *into* the pelvis, however, and if a baby was that high, it would be something I would suggest or do. Even then, it isn't until labor that you can tell if the head will fit or not because the pelvis opens and those sutures do cross, making the head diameter smaller. Of course, if he's acynclitic, that doesn't help at all. The great majority of my clients who've had cesareans were for acynclitic, usually posterior, babies. The last baby I had was a vaginal birth of a posterior acynclitic baby, but she was really small, right at 6 lbs. I rarely have babies that small.

So, no... transferring your care because of the station wouldn't have been appropriate, but I can see why you would have rathered known then.

You obviously learned a lot, Sara. Thank you for teaching the rest of us your lessons.

August 10, 2011 | Registered CommenterNavelgazing Midwife

Yes, the baby did turn out to be OP, despite faithfully doing the optimal fetal positioning exercises during the 3rd trimester. Is there any evidence that those exercises work?

August 10, 2011 | Unregistered CommenterSara

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