Home Delivery - When it comes to giving birth, some say there’s no place like home

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Home Delivery

Workers finished remodeling Leslie Stone’s master bath less than 24 hours before she went into labor with her third child. It was a good thing they’d completed the job and cleared out, because she nearly gave birth in the bathtub.

Stone had filled the 4-foot-long soaker tub with warm water and eased into it to soothe the pain when her contractions started. But the baby arrived so quickly she barely had time to get out of the tub and into her bed, where she delivered daughter Paloma as planned: with a view of the trees in her backyard and two midwives in attendance. Stone’s other two children were still asleep when their baby sister entered the world at 7 that November morning in 2010.

Stone lives in a 1950s rambler in the town of Somerset in Chevy Chase, not on a farm far from the nearest hospital. Now 38, she’s one of a small but increasingly vocal group of Maryland women who’ve decided that the safest and most comfortable place to give birth is at home, despite skepticism from the largest professional organization of obstetricians and gynecologists.

“There are normal, everyday women who are having deliveries at home,” says 35-year-old Dana Evans, a California native who in March 2011 delivered her first child, daughter Ever, in the bedroom of her 700-square-foot Bethesda condo. “It’s not just your super-crunchy Berkeley people.”

In 2011, about 500 Maryland women reported intentionally delivering their babies at home. Though home births still represent only a tiny fraction of U.S. births—fewer than 30,000, or less than 1 percent of all births in 2009, the latest year for which figures are available—they’re on the upswing. According to government data, home births increased by 29 percent from 2004 to 2009, though a small portion of those mothers simply didn’t make it to the hospital in time.

“Women may prefer a home birth over a hospital birth for a variety of reasons, including a desire for a low-intervention birth in a familiar environment surrounded by family and friends,” says a recent report by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC).

That was the case for Evans, who runs Daisy Baby & Kids, a Bethesda shop that sells furniture and accessories for nurseries and children’s rooms. “We wanted to birth at home because we wanted less intervention,” says Evans, whose husband, Frank Jones, works for FedEx. “The C-section rate in this area worries me.”

What really cemented the couple’s desire for a home birth, though, was watching The Business of Being Born, a 2008 documentary produced by actress and former talk-show host Ricki Lake that criticizes the overuse of technology in hospital births.

That’s why, Evans says, her husband, mother, mother-in-law, sister and best friend all were in her bedroom at 3:57 on a Monday morning when Ever “popped out.”

A few years ago, The American Congress of Obstetricians and Gynecologists (formerly the American College of Obstetricians and Gynecologists) distributed bumper stickers that said:  “Home delivery is for pizza.”

Sebastian Zanna-Stone and neighbor Ella Benson meet Sebastian’s new sister, Paloma, who was delivered in mom Leslie Stone’s bedroom in November 2010. Photo courtesy of Leslie Stone

In February 2011, however, the group’s Committee on Obstetric Practice appeared to soften its stance. The committee wrote in an opinion paper that although it “believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.”

The committee noted that the risk of a baby dying in a planned home delivery is quite low (one study it cited puts the figure at about 138 out of every 100,000 births). But the panel added that the risk is two to three times higher than with a planned hospital delivery, where roughly 52 out of every 100,000 babies die, according to that study.

“One of the hardest parts of the pregnancies...was dealing with all the comments and opinions from people: Why would I risk my baby’s life to do a home birth?” says Stone, who delivered her second child at home in July 2007. The skeptics weren’t aware, she says, of the complications that can arise from C-sections and other interventions performed in a hospital.

In fact, babies born in a hospital are at least twice as likely as those born at home to be preterm, low birth weight or multiples—all conditions that could increase the need for high-tech medicine such as a neonatal intensive care unit, according to the recent report from the National Center for Health Statistics. It notes that midwives, who attend the vast majority of home births, appear to be skilled at screening potential patients and accepting only appropriate candidates.

“The most important thing for us is that our moms and babies are safe,” says Erin Fulham, a certified nurse-midwife who lives in Silver Spring. In November 2007, she and her associate, Mairi Rothman of Takoma Park, incorporated Metro Area Midwives & Allied Services, or MAMAS. The pair provided prenatal care and attended Paloma’s and Ever’s births.

The midwives come equipped with IV supplies in case of bleeding or the need to rehydrate the mother because of nausea. They’re capable of resuscitating a newborn and stitching up a tear in the mother’s perineum. Fulham says she has never lost a mother or a baby, but like any midwife or physician who attends births, “I know it could happen.” She and Rothman end up transferring one of every 11 or 12 mothers to the hospital.

“It’s higher for first-time moms,” says Fulham, who delivered all three of her daughters, now in their 20s, at home. “We almost never transfer a second-time mom. And when we do transfer, it’s almost never an emergency.”

Reasons for a transfer include a baby who’s in an awkward position for birth, such as feet first, or a mom exhausted after a long labor. Fulham says she and Rothman stay with their hospitalized patients until the babies are born. Only about one in 16 or 17 of their patients ends up having a C-section, compared with about one in three of all U.S. deliveries.

When medically necessary, C-sections can be lifesaving for the mother and/or the baby, but some critics say doctors are too quick to perform them. Cesareans are major surgery, so they carry more risks and require a longer recovery time than a vaginal delivery.

Fulham didn’t become a nurse-midwife until she was in her 40s. “It was a long road to midwifery for me,” says the 53-year-old, who majored in Spanish and economics as an undergraduate.

Before her eldest was born in 1986, Fulham had been thinking about going to graduate school for a degree in women’s studies. But the experience of giving birth at home made her decide she’d rather be with women than study them. She assisted certified nurse-midwives with hundreds of births before she became one herself in 2003.

Alternating the roles of midwife and assistant, Fulham and Rothman attend about a half-dozen home births together each month, all within 10 miles of where they live. “Our dream is to have the Starbucks model of midwifery,” Fulham says. “We’d like Bethesda to have its own midwife.”

Dana Evans gazes at her new baby, Ever, as certified nurse-midwife Mairi Rothman checks out the newborn in March 2011. Photo courtesy of Dana Evans

For now, though, she and Rothman represent half the certified nurse-midwives in Maryland who’ll attend home births—not nearly enough to meet the demand, says 30-year-old Jeremy Galvan, whose wife delivered their son, Sam, in the living room of their Hagerstown home in January 2011. (The seven certified nurse-midwives at BirthCare & Women’s Health in Alexandria, Va., also serve Maryland families who want to deliver at home within 45 miles of Washington.) In Maryland and nationwide, the vast majority of certified nurse-midwives attend births only in hospitals.

Galvan, a Frederick County paramedic, says he’s not anti-hospital. “When there’s an emergency, there’s no place I’d rather be than in the hospital,” he says. But childbirth isn’t typically an emergency, Galvan says.

Unable to get a certified nurse-midwife to attend Sam’s birth, the Galvans turned to a certified professional midwife (CPM), a type of midwife allowed to practice in 26 states but not in Maryland, which banned all midwives who weren’t nurses in 1978.

“We asked a woman to come to our house and more or less commit a felony for us,” Galvan says.

CPMs care mainly for women planning out-of-hospital births, either at home or in freestanding birthing centers. Certified nurse-midwives must be licensed registered nurses who’ve earned a bachelor’s degree and completed an accredited midwifery graduate education program. CPMs, on the other hand, aren’t required to have a degree and can meet their education requirement through an apprenticeship with a certified midwife.

A few months after his son was born, Galvan launched Maryland Families for Safe Birth to lobby for the licensing and regulation of CPMs in the state. Delegate Ariana Kelly, a Democrat from Bethesda, worked with Galvan’s group to introduce bipartisan legislation that would set up a state midwifery board to do just that.

“The demand is just far exceeding the availability of licensed home birth providers,” says Kelly, who delivered her older daughter at the Maternity Center in Bethesda. She had to deliver her younger daughter at Sibley Memorial Hospital in the District after the Maternity Center, the last freestanding birth center in Montgomery County, closed in 2007 due to financial reasons. “In general, if you don’t sign up with a nurse-midwife who does home births very early in your pregnancy, you’re going to have a hard time finding someone.”

Fulham says she and Rothman turn away prospective patients every month because they don’t have room on their schedule. “It’s really heartbreaking,” Fulham says. Some of those women probably choose CPMs, Fulham says, though their illegality “does make it a little bit harder to get things like a birth certificate. [And] some women choose not to have anybody at their births. …That is just the saddest thing for me.”

Some 25 to 30 CPMs from the neighboring states that allow them—Virginia, Delaware and West Virginia—would jump at the chance to be licensed in Maryland, Galvan says.

Kelly’s legislation didn’t make it through the House or into the state Senate. She plans to reintroduce it when the General Assembly convenes in January. Meanwhile, the state Department of Health and Mental Hygiene is studying the shortage of certified nurse-midwives in Maryland, consumer concerns about hospital births, the safety of births attended by CPMs and legislation governing them in other states. Kelly, Galvan and Rothman are all members of the study group, which is supposed to submit a report to the chairs of the House and Senate health committees by Jan. 1.

Home births are less expensive than hospital births. Fulham says she and Rothman charge about $4,500 for a birth and prenatal and postnatal care, which many insurance plans cover. By contrast, the March of Dimes reported in 2008 that an uncomplicated vaginal delivery in a hospital, plus prenatal and postpartum care, cost about $9,500 on average. But “for me, this is not about saving money,” Kelly says. “It’s about women’s rights and women’s health.”

A demographer at the Inter-American Development Bank in Washington, D.C., who has worked in maternal and child health issues in developing countries, Stone read as much as she could about childbirth in the United States when she was pregnant with her firstborn.

“I had read a lot about women being happier with home births,” Stone says, “but I couldn’t convince my Colombian husband.” In Colombia, she says, the only women who give birth at home are those who don’t have access to a hospital.

 Patrick Earle of Takoma Park weighs his new child, Ailyn Kessler Earle, as certified nurse-midwife Erin Fulham looks on. Ailyn weighed in at 8 pounds, 11 ounces when she was born in January 2009. Photo courtesy of Shannon EarleAs a compromise, Stone received her prenatal care from a certified nurse-midwife, but delivered daughter Carolina, now 7, in a hospital. It was not a great experience. Stone had to share a room with a woman who’d had a C-section. Because of that, Stone’s husband, Felipe Vanna, who works for the International Monetary Fund, couldn’t spend the night. Plus, the nurses’ station was right outside her room and “it was loud.”

When Stone became pregnant the second time, her husband didn’t need much convincing that home birth was the way to go. It helped that in case of an emergency they lived only a 10- or 15-minute drive from Sibley. Fulham and Rothman attended the birth of Stone’s son, Sebastian, now 5, at her Glover Park home in Northwest D.C., where she and her family lived before moving to Somerset.

The midwives provide prenatal care in patients’ homes, and “it was fun for my son and daughter to be there” at the appointments, Stone says of her third pregnancy. Getting to listen to the fetal heartbeat “made it more real for them.”

Fulham and Rothman also hold monthly group prenatal care sessions for all the women due in the same month. “We all do better if we have other folks to talk to,” Fulham says.

When Stone was 36 weeks into her pregnancy with Paloma, the midwives set up a birth center at her home. If a baby arrives quickly, they don’t want to be scrambling for latex gloves or baby blankets. Other standard supplies include a bulb syringe, heating pad, laundry and trash containers, and reusable and disposable pads to protect the bed.

They ask the women they care for to call as soon as they think they might be in labor. “It doesn’t mean we rush right over,” Fulham says. “We keep in touch every couple of hours until the mom needs us. Then one of us goes over and calls the second midwife when needed.”

The two midwives have spent more than 24 hours at patients’ homes, dozing whenever possible so they can remain alert during a long labor. “We’re very good at napping,” Fulham says.

And they remind their patients that midwives need to eat, too. “We tell our families: ‘The trick is, if you have a lot of food, you’ll have a short labor, but if you don’t have any food in your house, you’ll have a long labor and your midwife will be starving,’ ” Fulham says.

Stone must have had a well-stocked pantry, because Paloma was born just under an hour after Fulham and Rothman arrived.

Although their baby sister’s birth occurred when Carolina and Sebastian were still asleep, Stone says she was open to having Carolina watch. She’d already warned her, “Mommy might seem like she’s in pain.”

Carolina and Sebastian did meet Paloma even before the umbilical cord was cut. “It was so special to have them there,” Stone says.

Maternity Ward Makeovers

Certified nurse-midwife Mairi Rothman holds 6-week-old Donatello Kidd Tidd during a community gathering where parents of newborns discuss their birthing experiences with parents-to-be. Photo by Laura-Chase McGeheeIt’s the classic image: the hospital nursery with its neat rows of newborns, proud papas pointing and making faces from the other side of a glass partition.      

You’re no longer likely to see that outside of TV commercials, sitcoms and movies, however. Healthy newborns are rarely separated from their mothers these days, thanks to the family-centered trend in hospital maternity care. Making maternity units more like home not only pleases mothers but, research has found, helps ease babies’ transition from the womb to the world.

“If you go by our nursery during the day, there’s nobody in it. It’s a ghost town,” says Terry Francis, a nurse who directs perinatal services at Shady Grove Adventist Hospital in Rockville, where nearly 100 babies on average are born each week.

On any given night, you might find a handful of babies snoozing in the two well-baby nurseries while their mothers grab one last restful night before heading home, Francis says.  “I don’t ever want to tell a mom who has multiple children at home that she can’t get a good night’s sleep.”

But in general, the nurseries are so deserted “I get housekeeping to dust them,” she says.

Until a few years ago, babies delivered by C-section were whisked to the nursery for a bath and checkup, Francis says, but now even they stay with their mothers in recovery. More recently, she says, Shady Grove instituted a policy where all moms, no matter how they deliver, are given the opportunity to spend at least an hour skin-to-skin with their newborn. “The moms love it,” Francis says. “This is whether they’re bottle-feeding or breast-feeding.”

Washington Adventist Hospital has a similar policy encouraging skin-to-skin contact, also known as kangaroo care. “It’s great for mom, but it’s also physically important for the baby,” says Miriam Rieger, the clinical nurse manager of labor and delivery. Spending time skin-to-skin with the mother gives a newborn the chance to transition from being in the womb, says Rieger, who has worked at the Takoma Park, Md., hospital for nearly four years. “Their blood sugar is regulated. Their heartbeat is more regulated. Also their temperature. Everything sort of comes in sync with the mom.”

Rieger says she has seen women breast-feed their newborns in the operating room after a cesarean, which used to be unheard of. “When you separate a mom and a baby, you’re taking away those first initial moments where they get to know each other,” she says.

Kangaroo care is encouraged the entire time the mother and baby are in the hospital, Francis says. As a result, “we rarely use an infant warmer on a healthy baby,” she says. If the mother isn’t up for it, the father or grandparents are encouraged to try.

Washington Adventist is on its way to eliminating the well-baby nursery, now that all routine infant care is provided at the bedside, Rieger says.

Studies suggest that bathing the babies immediately after birth in the nursery is unnecessary, she says. Plus, the earlier you bathe them, the less likely they are to be able to regulate their temperature, so they typically need to be kept under a warmer, away from their mothers. Delaying the bath also “becomes an educational opportunity to show the family how to bathe the new baby,” Rieger says.

One manifestation of the increasingly family-centered focus in hospital maternity care is the larger number of people who gather in the delivery room. Dads have been in attendance for more than 30 years, Francis says. But more people are crowding in. These days, she says, Shady Grove tries to limit friends and family to three or four during the actual delivery.

“It really is a safety issue,” Francis says. A crowd might prevent hospital personnel from entering or leaving quickly if necessary. “We have a beautiful waiting room for families,” she says. “After delivery we encourage them to go back and visit.”

Francis recalls one night when a guide dog was present as its owner gave birth. “The dog got a little upset when [the owner] had pain.”

Sibley Memorial Hospital in Northwest Washington doesn’t have a cap on the number of friends and relatives in the delivery room, says Dr. Mark Reiter, chairman of obstetrics and gynecology. Sometimes women will have as many as four or five, he says.

Not that they always stay for the entire delivery. Reiter says he has seen squeamish dads leave the room every five minutes.

Rita Rubin is a former USA Today health writer who lives in Bethesda.


http://www.bethesdamagazine.com/Bethesda-Magazine/November-December-2012/Home-Delivery/index.php?cparticle=5&siarticle=4#artanc


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