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Entries in homebirth transfer (2)

Monday
Sep052011

37 Percent

Continuing from the blog piece entitled “Your Home Birth is Not a Feminist Statement” by a research scientist “named” Isis, she makes this comment: 

Even more interesting, up to 37% of home births result in emergency transport to a hospital.” 

In Science-Based Medicine, the August 3, 2010 post by Harriet Hall, “Home Birth Safety,” talks about the infamous Wax Study’s contention that 37% primip homebirths transport to the hospital, saying: 

“Having delivered a lot of babies myself and having seen normal low-risk deliveries turn to disaster in a heartbeat, I would never have considered having my own babies at home, and I would personally be very frightened to attend a home birth, especially if there was a 37% chance of it ending with a nerve-wracking rush to the hospital. I would rather see babies born within easy reach of a C-section and other lifesaving interventions.” 

To clarify what the Wax Study says: 

“However, such investigations likely underestimate the risks associated with planned home birth, as up to 9% of parous (women with one previous delivery [presuming vaginal] and 37% of nulliparous (women who’ve never had a baby [presuming vaginal]) women intending home birth require intrapartum transfer to hospital.” 

Homebirth midwives move women to the hospital two ways: via transfer and via transport. I’ve been very careful to make the distinction and if the writers above would have, it would make things clearer for their readers. The Wax Study doesn’t clarify which transfers are emergency and which are not, but they should have. 

My definition of transfer is it’s a get-in-the-car-and-head-to-the-hospital type of trip, whereas a transport is a call-the-ambulance,-it’s-an-emergency (and not even necessarily a life and death emergency!) experience. Note the huge difference between the two? Life and death emergencies are rare even when transports might not be. I cannot imagine there being a 37% transport rate anywhere in the US. 

To point out once again, if the Wax Study were exactly correct (and that’s highly debatable, but not for me to do so as I am not a statistician), “up to 9%” of women who’ve had a baby before and “(up to) 37%... require intrapartum transfer to hospital.” Looking at most bloggers and reporters around the Net, one would think the entirety of homebirthers in “first world” countries have a 37% emergency transport rate. Not true! 

Even I, with a higher transfer/transport (combined) rate than many midwives (who report about a 10% transfer rate, with a 1% emergency transport rate) did not have “emergency transport(s) to a hospital” at 37%. I will acknowledge, however, that my combined transfers and transports fell in almost exact line with what the Wax Study; about 10% for multips and about 40% for primips. I can hear homebirth advocates gasping, but I feel vindicated by the statistics stated in the study/studies. Remember, some definitions of “intrapartum” include from one to four hours postpartum; the Wax Study does not state their definition of intrapartum, but seems to include several postpartum (post-placental delivery) indications for transfer/transport. 

Before reviewing my own stats several months after closing my homebirth practice January 1 of this year, I felt that people’s shock at the 37% was unwarranted. I would never have guessed my own rates would be that high, but thought, instead of being horrified by the number, midwives should be applauded for seeing the changes from low-risk to higher/high-risk in labor and immediately postpartum. Isn’t that what a midwife is for? To assess the risk and move the woman to the hospital? Personally, I would love to believe there was a nearly 40% recognition of a woman’s need to be in the hospital. That way, the hospital is not receiving what they so frequently call “train wrecks,” but are  seeing the women long before an absolute crisis occurs. 

The 37% number is bandied about like it’s a demonstration that that percentage of women should have been risked out of a home in the first place, but I see it as an acknowledgement that 37% of all women who start out low-risk might be transported during labor or the birth. I do not believe just because a woman moves to the hospital she automatically shifts to high risk. It merely says she has moved out of the realm of a straightforward homebirth. Hospitals are places for far more than emergencies. 

(Some) Reasons women might transfer (in a car, unless mom requests ambulance) from home to hospital during labor (the types of situations the Wax Study would include… from my memory, then checked with my Standards of Care): 

-         Continuous vomiting

-         Fever or even just the mom’s temp increasing over time

-         Prolonged rupture of membranes

-         Abnormal bleeding

-         Active HSV genital lesion

-         Exhaustion

-         Fear (of home/situation/gut instinct)

-         Increasing blood pressure

-         Prolonged labor

-         Prolonged pushing

-         Mal-position of the baby

-         Thick meconium upon rupture of membranes 

(Some) Reasons women might transport (in an emergency, via ambulance) from home to hospital (again, the types of transports the Wax Study would include): 

(From the Medical Board of California’s Standards of Care -) 

-         “Prolapsed umbilical cord

-         Uncontrolled hemorrhage

-         Preeclampsia or eclampsia

-         Severe abdominal pain inconsistent with normal labor

-         Chorioamnionitis

-         Ominous fetal heart rate pattern or other manifestation of fetal distress

-         Seizures or unconsciousness in mother

-         Evidence of maternal shock

-         Presentation not compatible with spontaneous vaginal delivery

-         Any other condition or symptom which could threaten the life of the mother, fetus or neonate as assessed by the licensed midwife exercising ordinary skill or knowledge.”

-         Retained placenta or placental fragments 

Two questionable intrapartum reasons from the Standards’ list are “laceration requiring repair outside the scope of practice or practice policies of the individual midwife” and “neonate with unstable vital signs.” I say questionable because they could be considered postpartum reasons versus intrapartum reasons, depending on whose definition you’re using. 

Can I tell you how many times I (and others) have transferred for something that resolved mid-trip and the thought, “We could have stayed home after all!”? My mantra for transferring/transporting to the hospital is: I’d rather be told “You didn’t need to come in,” than “Why the hell didn’t you come in sooner?” While moving into the hospital can create hardship for the families, most specifically, financially, I hope they would rather be there and not need to be than staying at home and needing to be in the hospital. It’s totally a judgment call… one that takes a great deal of experience to tell the difference. Even with experience, I know I erred on the side of caution. Too many midwives become complacent, thinking they know better than the law and don’t transfer or transport for reasons they would expect another midwife to transfer/transport for. Yet, when someone has a bad outcome, interestingly, rates of getting a mom or baby to the hospital go up. What made the difference? Complacency went down. 

One of the most common questions a midwife is asked during an interview is how often she transports. Instead of looking for a midwife who transports only a very few women a year, women must take her years of experience into consideration. I’d even go so far as to say the newer the midwife, the higher her transport rate should be. Unless she is meticulously within the understood limitations in most midwifery communities: no breeches, twins, older moms, VBACs, etc., her rate will be higher than a more seasoned midwife. Sure, the limitations are controversial, but they are there for a reason; they increase a woman’s risk of moving out of the realm of normal, whether during pregnancy or the birth. With experience, the midwife might expand her competency in variations of such pregnancies. This, of course, begs the question: “Where will she get the experience if she’s not doing them?” The answer is: “By attending births with midwives who have more experience,” or even by being in the hospital where the safety net is standing by. On-the-job training is unacceptable for midwives. 

And who wants to be the practice client for an inexperienced midwife, especially with a complicated pregnancy or with the upcoming birth? If you say, “Me,” I worry about your motivations for a homebirth. If you say, “Not me!” I applaud you. I know I wouldn’t let someone practice on my body or baby… without the supervision of a very experienced midwife. 

Instead of being ashamed of higher rates of transfers and transports, I hope midwives will now be proud of their statistics because they can accurately demonstrate her appreciation for mid-labor, birth and postpartum movement from low-risk to higher-risk. Isn’t that what we hire her for in the first place?

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)