Informed Choices in Childbirth

Manifesting the Birth You Desire

A woman gives birth easiest where she feels most comfortable”

Hospital Birth | Doulas & Monitrices | Birth Centers | Home Birth | FAQs About Homebirth

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Free Downloads from The Coalition for Improving Maternity Services (CIMS):

Questions to Ask When Choosing A Care Provider

Highlights of the Evidence Supporting the Mother-Friendly Childbirth Initiative.

 

Making Informed Choices in Childbirth

In preparing to have a baby, it is important to understand your options and make informed choices based on knowledge of alternatives. The Association for Wholistic Maternal and Newborn Health can give you a Birth Options Consultation to help you explore your values and needs for childbirth. We also offer Childbirth Preparation Classes which well help you prepare physically and emotionally  for the birth of your baby. Contact us for details.

Questions you may wish to consider are:

1. Place of Birth -Where will you have the baby? Options are hospital, freestanding birth center, or in your own home. Download: Choosing the Place of Birth

2. Birth Attendant/Care Provider-Who will you choose as your care provider/birth attendant? Midwives and Obstetricians are your choices.

3. Natural Childbirth or Medication? – Are you going to have pain medication or learn how to cope with labor without drugs?

These are some of the questions you might consider when you’re preparing to give birth. Let’s explore these options in more detail.

Take our Birth Planning: Values Clarification Exercise. Explore what’s important to you about your birth experience, and your medical provider. Download PDF

Print out our Sample Birth Plan for a Mother and Baby Friendly Birth. You can use this as a guideline for creating your own birth plan. Download PDF

PLACE OF BIRTH: HOSPITAL

Advantages:

• Insurance and/or Medi-Cal covers fees
  

  A natural birth in a hospital – Photo by Monet Moultrie

• Socially acceptable
• American College of Gynecologists  (ACOG) considers it safest because of availability of surgical suites, emergency equipment,  surgeons and neonatologists, NICU, etc.
• Equipped for high risk pregnancies, complicated labor and delivery with technology such as continuous electronic fetal monitoring, blood transfusions, anesthetics, vacuum extractions, forceps, NICUs, etc.
• For women who have little childbirth preparation skills, no friends or family for emotional support, low pain thresholds, long labors, etc. additional staff, pain medication may be helpful.
• Round the clock nursing care makes it possible for new mother  to be cared for, limited visiting hours allow for mother to rest undisturbed after birth
• Technology and medical expertise makes some women feel more comfortable
• Baby can be bottle fed  by nurses in the nursery  if  mother wants to sleep
• Many hospitals have Certified Lactation Counselors available

Disadvantages:

• Greater likelihood of routine medical intervention such as prepping, IVs, continuous electronic fetal monitoring, induced or augmented labor, anesthetics, etc.
• Higher risk of cesarean section
• Baby may not breastfeed well due to effects of maternal  pain medication, deep suctioning, separation from mother, etc.
• Greater risk of iatrogenic (medically caused) complications such as baby depressed due to anesthetics, cesarean section or vacuum/forceps-assisted delivery due to epidural anesthesia, mother or baby’s birth injuries resulting from forceps, episiotomy-caused severe vaginal tears,  hospital-acquired infection in mother or baby.
• Separation of mother and newborn  from family due to visiting hours, rules and regulations
• Lack of continuity of care providers due to changing shifts
• Hospital environment and procedures can be frightening, frustrating, confusing, insulting, degrading, traumatizing (see New Mothers Mothers Speak Out: Women’s Experiences of Postpartum, A Report by Childbirth Connection reported that a high number of women report Post-Traumatic Stress Disorder as a result of their childbirth experience).

Types of  Birth Providers Available  in this setting: Obstetrician-Gynecologist, Nurse-Midwife (in some hospitals)

Additional Support Personnel: Registered Nurses, Lactation Counselor, Pediatrician, Neonatologist, Perinatalogist, Doula

Cost: $10,000-15,000+

Insurance: PPO, HMO, AIM, Medi-Cal

About Hospital Birth

Most Americans do not make a conscious choice to give birth in a hospital setting or choose to have an obstetrician-attended birth. Since 93% of American women give birth the hospital with a doctor, few people realize that there are  alternatives. Some may have heard about midwives, homebirth and birth centers–but are quickly discouraged to attempt these options  by well-meaning yet uniformed  friends and family and  medical professionals as being  “too risky”.

Yet every setting for birth–Hospital, Birth Center or Home– have benefits and risks. Most Americans would consider out-of-hospital birth to be a dangerous choice. But most people do not examine the risks  involved with hospital birth. Because American culture is “technocratic” (technology-driven  and bureaucratic) the medical approach to maternity care is often toted as “safest” for mother and baby.   However,  many studies have shown that medical interventions such as induction and augmentation of labor, epidural anesthesia, instrumental extraction of fetus, episiotomy and separation of newborn and mother  may lead to undesirable complications for mothers and infants. These interventions all increase risks to mother and infant of  fetal distress, injury, respiratory depression, and other undesirable affects, yet they are standard  procedures in American hospitals.

Undoubtedly, there are circumstances where medical procedures such as these are necessary,  but the routine use of such medical practices  such as episiotomy, continuous electronic fetal monitoring, IVs, are not  supported by the scientific evidence (See The Evidence in Support of The Mother Friendly Childbirth Initiative as reported in the Journal of Perinatal Education. Download a copy.

Often one  medical procedure leads to another, creates side effects which require more medical procedures.  This is referred to as “Domino Effect of Medical Interventions”.  For example, the epidural anesthetic, while providing pain relief, has been shown to increase cesarean section and vacuum extraction rates. Women considering medical procedures and pain medications should learn about what other medical procedures will be done along with it and what the side-effects and risks are of these procedures to herself and her baby. Many procedures, such as continuous electronic fetal monitoring, induction and augmentation of labor and epidural anesthesia increase the chances of having a cesarean section.

Cesarean sections have risen 70% in the past ten years the U.S., despite the recommendations by WHO and  the recommendation of  Healthy People 2020 (the U.S. government’s objectives for the public’s  health) that they be no

more than 15% of births. In fact, 1 in 3 of births in American hospitals are  by cesarean section today.  According to the California Department of Public Health vital records data, in  2009, the overall cesarean state rate was 33%. In Los Angeles County, the rate was 37% in 2009 (the last date for which state data is available). Vaginal Birth After Cesarean (VBAC) rates have been declining steadily for the past decade throughout the U.S. In California, the VBAC  rate is between 1-3%.  The repeat Cesarean rate in California was 44% in 2009.

So what’s the big deal about having a cesarean, you may ask?  In fact, cesarean section is  major abdominal surgery and is much riskier than vaginal delivery. Potential complications include bowel  and bladder injury, anesthesia reactions, blood clots, infection, hemorrhage, postpartum pain, post-surgical adhesion, infant death and maternal death which is 3-7 times higher than for vaginal birth. (See Understanding The Dangers of Cesarean Birth by Nicette Jukelevics, Preager Books, 2009).  In addition, with each repeat cesarean,  the mother’s risk of life-threatening placenta problems (placenta accreta and placenta percreta)  increase her risk of serious complications (such as hysterectomy) and death.

Is it Possible to have a “Natural Childbirth” in the Hospital?

Yes, but it takes a great deal of education, preparation, and self-confidence. A supportive doctor, nurse  and doula helps too!  With childbirth education, careful selection of your birthing team and birthplace, it is possible to have a  woman-centered experience, though it requires a great deal of preparation and making wise choices. Additionally, a large amount of trust in the normalcy of birth is required.

In order to have a natural childbirth in a hospital setting:

• Take a childbirth preparation class which will help you learn advantages and disadvantages of medical interventions, and create a birth plan.
• Choose a hospital and doctor with a reputation for “Mother and Baby-Friendly Care” which are evidence-based practices such as ambulation in labor (walking, position changes), intermittent electronic fetal monitoring, natural approaches to pain management (use of showers, Jacuzzi), upright pushing positions (use of birth bar), etc.
• Discuss options with your physician or Nurse-Midwife and get his/her support for your choices.
• Hire a Doula (a professional labor companion) to help you stay home until you’re in active labor before going to the hospital.
•  Take a childbirth preparation class to learn labor coping skills
• Work with a hypnotherapist, to cope with fear of childbirth (this is just as important for dads too!).
• Take  childbirth preparation classes to learn to cultivate trust in birth and gain confidence in yourself.

Types of Hospital Birth Attendants: Obstetricians, Nurse-Midwives, Doulas and Monitrices

Obstetricians

Most people in America will have a hospital birth with an Obstetrician. Obstetricians are surgeons and high risk specialists and are trained in complications and pathology of pregnancy and emergencies of childbirth. Most are board certified by American College of Gynecologists (ACOG) who set the standards and recommendations for their practice.

Obstetricians vary widely in their approaches and philosophy. Some are supportive of women using natural methods for pain management, having a doula, pushing in upright positions, etc., and have low cesarean rates. Others  may not have ever seen a normal, spontaneous birth. One obstetrician stated that “though I have delivered thousands of babies in my career,  I have never once stood by the side of one woman for an entire labor, unlike the midwives I work with who are by the side of each woman day after day.” If you wish to have a hospital birth, your chances of having a natural, uncomplicated birth are optimized by carefully selecting your obstetrician and hospital.  Doctors who work with midwives usually have lower cesarean section rates. You will want to check out what kinds of births other women who have chosen this doctor have had. Just because your co-worker used “Dr. X” and loved him, does not mean he is right for you. It’s important that you determine your needs and values and choose a doctor who fits with your philosophy and birth plan.

Mother and Baby Friendly Care Initiatives

The Baby-Friendly Hospital Initiative

UNICEF and WHO developed the “Baby Friendly Hospital Initiative”(BFHI), 10 steps to optimize breastfeeding, a designation for institutions which have policies that promote breastfeeding. Hospitals can apply for designation as a “Baby Friendly Hospital.” For a list of Baby Friendly Hospitals in Los Angeles, go to Breastfeeding Taskforce of Greater Los Angeles website.

The Mother-Friendly Childbirth Initiative

The Coalition for Improving Maternity Services (CIMS), an international coalition of leading researchers, maternal infant health experts, 26 organizations representing over 90,000 members  and individuals concerned with the well-being of mothers and infants, developed the”Mother Friendly Childbirth Initiative” (MFCI), these are 10 evidence-based steps to improve the quality and outcomes of maternity care.

Certified Nurse Midwives

The Certified Nurse Midwife (CNM) is a registered nurse trained in midwifery. Nurse-Midwives  have Masters degrees and are certified and licensed to practice in all 50 states. They are regulated by The Board of Registered Nursing and accredited by The American College of Nurse-Midwives. They are qualified and licensed to conduct all aspects of maternity care, including prenatal care, labor management, postpartum care and family planning/well-woman gynecology care.

Choose a Nurse-Midwife if you desire natural childbirth in a hospital environment as they tend to view childbirth as a normal process and support and promote evidence-based practices such as ambulation in labor (moving into various positions and walking) , intermittent fetal monitoring, non-pharmaceutical pain relief methods such as water immersion, pushing in upright positions, and keeping mothers and babies together after birth.

What do Nurse-Midwives Provide?

CNMs provide all aspects of prenatal care,  labor and delivery and postpartum care; working under supervision of an  obstetrician so  referral can be made if a complication develops. CNMs conduct prenatal exams, prescribe medications, deliver the baby, repair perineal tears and provide well-woman gynecology and family planning care. In some places, they assist the Obstetrician if a cesarean is needed.

Results of Nurse-Midwifery Care

Nurse-Midwifery care is associated with fewer cesarean sections, low birth weight and premature babies, and fewer medical interventions.When comparing the U.S. cesarean rate to other western, industrialized countries, those countries which employ midwives for the majority of births have significantly lower rates than ours; and also have lower infant mortality rates and cesarean sections. The U.S., despite having the most advanced technology and highly trained medical personnel, ranks 23rd in infant mortality and 18th in perinatal mortality. That means 23 other countries–most of which have integrated midwives into their maternity care system–lose less babies in the first year of life and between 28 days gestation to 28 days after birth. This is the sad reality–that few U.S. births are with midwives, despite their great track record.

Finding a Nurse-Midwife

Certified Nurse-Midwives, though associated with maternal satisfaction, good outcomes and lower costs,  are under-utilized in America, attending about 7% of births.  Unfortunately, not all hospitals employ nurse-midwives, so you may not be able to get one if your hospital does not employ them. Nurse-midwives usually do not have the ability to admit their own patients to a hospital so you will have to choose a hospital which has CNMs on  staff. In California, Kaiser Permanente as well as university and charity hospitals serving  the uninsured or those on Medi-Cal employ Nurse-Midwives. Prenatal care  is often given by the Nurse-Midwives at a community clinic. Most PPO insurance plans will cover Nurse-Midwives, though reimbursements are usually lower as they’re not considered “preferred providers”.   See our website under Parent Support / Mother-Friendly Healthcare Providers for a list of local nurse-midwives.

Doulas and Monitrices

Doulas

“Doula” is a Greek word meaning “woman servant”. Unlike midwives, Doulas are not licensed maternity care  providers. They are lay women, usually mothers themselves,  who do not have medical training and do not provide nursing care, diagnose or make medical decisions. They work in collaboration with the woman’s   licensed maternity care provider (midwife or doctor) and nurses as part of the birth team, providing emotional support, physical comfort and advocacy. Professional Labor Companions are a smart choice if you’re planning a hospital birth.  Helping you with labor coping techniques such as breathing and relaxation, advocating for your needs with the hospital staff they can help you achieve your birthing goals. Also called a  “Labor Companion”, ”Birth Sister”  or “Childbirth Assistant”  or “Monitrice” these special women make giving birth a positive experience.  To find a Doula in Southern California, contact us.

Monitrices

Monitrices are  Registered Nurses, Licensed Midwives or Nurse-Midwives who provide labor support. They have skills to monitor maternal-infant  well-being. To find a Monitrice in Southern California, contact us.

What is the Professional Training of Doulas and Monitrices?

Doulas are certified through several organizations including Doulas of North America  and other organizations. They attend a weekend course, take a certification exam,  and attend 3-6 births to become certified.

In addition, Enhanced Labor Support by Monitrices is available. Monitrices are Registered Nurses, Licensed Midwives or Nurse-Midwives who provide support for women planning hospital births. However, unlike Doulas, Monitrices  assess fetal heart rate, perform cervical assessments, monitor temperature, blood pressure and pulse. This allows the laboring woman to remain at home before going to the hospital, thus avoiding strict time limits imposed by hospitals and reducing medical interventions.  In addition,  Monitrices provide  emotional support, physical comfort and advocacy in the hospital the same as a Doula. They work in collaboration with the hospital based  primary care provider–either an Obstetrician or Nurse-Midwife–but they do not make medical decisions or deliver the baby.

What Are the Benefits of Doula Care?

Studies by Drs. Marshall Klaus, M.D., Phyllis Klaus, M.Ed, C.S.W. and John H. Kennell, M.D. have shown that women who give birth with the help of  Doulas have shorter labors, less need for drugs and fewer interventions, including cesarean sections. Doula care is  especially beneficial for women desiring vaginal birth after cesarean (VBAC), want to minimize their use of pain medications  and interventions and increase breastfeeding success.  The Doula does not replace the care given by the woman’s partner, instead she offers knowledgeable and loving support to both the laboring woman and her partner.

Cost: Range from $300-$1,500 (in Southern CA). Volunteers are available to provide free doula support for women on Medi-Cal. Contact us for more information and a referral.

Insurance: Limited; but may be available on some PPO plans.

Recommendations for Hospital Birth:

• Take a childbirth education class and learn about all your options; take the hospital tour and ask about their policies and procedures (See The Mother Friendly Childbirth Initiative – 10 Evidence-Based Steps for Mother Friendly Care and the Lamaze Six Care Practices).
• Use  non-pharmaceutical methods of pain management (breathing, relaxation, visualization, water immersion) and have your partner learn labor support methods (i.e., massage).
• Develop trust in birth and work to become confident in yourself. Women who have less fear are less tense and those who are less tense have less pain. Stress hormones can inhibit the hormone oxytocin which makes your uterus contract.
• Hire a doula. Studies show that the presence of a labor companion can lower your need for pain medication, shorten your labor and decrease your risk for cesarean section.
• Stay out of the hospital until you are in active labor. This is when the contractions are coming four minutes apart (frequency), lasting one minute (duration) and  have been that way for  at least one hour (intensity). Remember “4-1-1”.
• Change your activity during labor. If the contractions go away or change their pattern, it is not active labor. Wait. Be patient. Alternate resting with walking. Just wait. Most times, your labor will kick into full gear. It may take many hours for labor to become “active”, however, so just be patient. Going to the hospital too soon can lead to restrictive time limits and unnecessary medical interventions such as augmentation of labor which can lead to cesarean section.
• Choose a hospital which has Nurse-Midwives or a doctor who works with or was trained by midwives, as they tend to be more supportive of women who want natural childbirth.

PLACE OF BIRTH: FREESTANDING BIRTH CENTERS

About Freestanding Birth Centers

Freestanding (out-of-hospital) birth centers provide a home like setting for birth and are designed for women having low-risk pregnancies who want drug-free birth with minimal intervention. Families are able to be present and fullyinvolved–including children and

grandparents. Women who have had a prior cesarean section may be able to optimize their chances of a Vaginal Birth After Cesarean by giving birth at the center. Freestanding Birth Centers are independently-run by midwives or physicians, often in collaboration, and have an arrangement with a hospital in  case transport of mother and baby is necessary. Family members and children may participate in the birth and it makes for a very positive bonding experience for the whole family. This is an excellent choice for the woman who does not wish to birth in a hospital environment yet is not comfortable giving birth at home.

Advantages

• Non-medical atmosphere; supports natural normal process; physicians, nurses and/or midwives tend to be less interventionist than in hospital setting
• Ability to move freely in labor, push in any position, use water immersion for pain management
• Family and siblings can be present at birth and involved totally in the experience
• Compared to homebirth there isn’t any preparation  of home or clean up by the family; the staff provides all that is needed.
• Fewer  cesarean sections than hospital births
• For women with prior cesarean,  may have better chance of delivering vaginally than in a hospital setting
• Less separation of mother and baby after birth; grandparents, fathers and siblings are allowed to be with the new baby and mother
• Increased maternal satisfaction and empowerment and less postpartum depression due to women having increased involvement in decision making during prenatal care and birth

Disadvantages

•  Unlike homebirth, must travel in labor and go home usually within a few hours after the birth. May not be able to arrive at center until labor is well-established. Therefore, couples may have to cope on their own for quite some time before coming into the center.

• Insurance may not cover fees. Most Medi-Cal and HMO plans will not cover birth centers.
• Limited number of birth centers; not every community has one; may have to travel a long distance to give birth there.
• Not appropriate for high risk pregnancies: women who smoke, who have complicated pregnancies such as  diabetes, hypertension, twins,  previous cesarean section or  breeches may not be able to deliver in a birth center.
• In case of emergency, must transport to hospital; therefore there is some delay in accessing medical attention if needed. However the National Birth Center Study revealed that transports occur less than 15%. For more information: go to The American Association of Birth Centers

Types of Birth Providers Available in this Setting: Certified Nurse-Midwives, Licensed Midwives, Medical Doctors (obstetricians, family practice doctors, osteopathic physicians).

Additional Support Available: Doulas, Midwife Assistants, Nurses, Childbirth Educators  and other complimentary professionals upon referral (i.e., acupuncturists, prenatal yoga instructors, chiropractors, etc.)

Cost: $4,000-5,000 (in Southern California).

Insurance: PPO

What Services Are Offered in A Birth Center?

Many birth centers provide the option to give birth in water. Water birth provides mothers with optimal pain relief and makes  for a gentle transition for the baby from the womb to world.

Are Birth Centers Safe?

The National Birth Center Study, which was published in the New England Journal of Medicine in December 1989 reported that about 15% of women who begin labor in a freestanding birth center require transfer to an acute care facility, while only 2% require emergency transfer. The others were mainly transferred for slow progress or because the woman requested anesthesia. The overall Cesearean section rate was 4.4%. Over 98% of the birthing women were satisfied with their birth experience. Accreditation for centers is based on carefully designed national standards and is provided by the Commission for the Accreditation of Freestanding Birth Centers. Licensing is provided by individual states. For more information contact The American Association of Birth Centers.

Are Birth Centers Safer Than Homebirth?

No. While birth centers do not provide any additional measure of safety than  planned homebirths with skilled midwifery care, they may provide the expectant couple who is not comfortable with homebirth with the psychological reassurance necessary to enable the mother to relax.

Things to Consider about Birth Centers:

• Is there a birth center close to you? If not how far will you have to travel for prenatal appointments and in labor?
• Does the birth center take your insurance? ( Few birth centers in Los Angeles take Medi-Cal).
• When in labor will you be allowed to arrive? How long can you stay after the birth? Most birth centers cannot accommodate you until you’re in active labor, and most require that you go home within 2-3 hours after the birth.
• What is the Medical Doctor and hospital back up arrangement?
• Do they have emergency equipment such as neonatal resuscitation, oxygen, anti-hemorrhaging medications, etc.
• What is the training and skill level of the birth team? How long have they been in practice? Are there any complaints or restrictions on their licenses?

PLACE OF BIRTH: HOME

About Homebirth

Childbirth at home provides families with the most autonomy and is a great option for those who want  a family-

centered experience, or who wish to maintain a private and spiritual environment for their birth of their baby. It is also a great way  to minimize  unnecessary medical intervention.

The Madeline Brand Show: Homebirth and Midwives

This radio clip from March 7, 2012 on KPCC 89.3 with Eve Troeh, interviewing Rikki Lake about her very popular film, The Business of Being Born, and Cordelia Hanna a certified childbirth educator and birth assistant in Los Angeles, about the reasons behind the increased numbers of women choosing to give birth at home and maternity care trends towards Mother and Baby Friendly Maternity Care in the U.S. Click here to listen the radio show:  20120307_mbrand_4HomeBirth

Advantages 

• Takes place in a familiar environment: the family’s home; can maintain privacy and control of environment and only invited guests are present, non-supportive people are not welcome
• Continuity of care: midwives are  present the whole time; can give you privacy or provide support if requested
• Fathers play a more active role; can catch baby
• Children may participate in the  birth lessening sibling rivalry
• Easier to maintain a spiritual perspective during  the birth
• No traveling in labor and afterward; midwives come to you
• Some midwives offer prenatal care in clients home ideal if family already has several older children
• Minimal medical intervention and ensuing medical problems
• Fewer restrictions on length of labor and pushing; labor is allowed to progress normally in its own time
• Can use portable watertub for pain management; babies born in water have a gentler transition into the world therefore are less stressed
• Very little separation of mother and infant after birth promoting attachment and bonding
• Less chance of cesarean section, infection, episiotomy, and other interventions and the ensuing complications resulting from them
• Increased breastfeeding success due to baby and mother never being separated, mothers not using pain medication, babies not requiring resuscitation, suctioning, etc.
• Increased maternal empowerment and satisfaction and less postpartum depression due to women having more ability to make informed choices during prenatal care and  birth
• Most medical procedures can be taken care of at the bedside by the midwife
• Least expensive option

Disadvantages

• Less immediate access to emergency medical procedures. In critical emergency, must transport to hospital.
• May not be possible if you have had a prior Cesarean Section or are pregnant with twins, or your baby is in a breech position.
• Insurance may not cover, Medi-Cal, AIM and HMO insurance does not cover.  Most PPO plans will cover but may be at lower rate. May have to pay for services out of pocket.
• Less socially acceptable. Parents may experience increased stress due to concerns by family members or friends.
• May be difficult to find back up doctor and hospital for a homebirth.
• Technical expertise among birth attendants may vary.
• Considered less safe than hospital birth by American College of Gynecologists (ACOG); although a number of studies indicate that it is as safe or safer than hospital birth for low risk pregnancies when a skilled assistant is present.

Types of Providers Available in This Setting: Certified Nurse-Midwives, Licensed Midwives, Certified Professional Midwives. Pediatrician (and in some places: family practice physicians, obstetricians, osteopathic physicians).

Additional Support Available: Midwife Assistant/Apprentice, Nurse, and other practitioners by referral (chiropractors, acupuncturists, yoga instructors, massage therapists, etc.).

Cost: $4,000-6,500 (in Southern CA)

Insurance Availability: PPO

What are the Benefits of Childbirth at Home?

Birth at home provides parents with intimacy, privacy, comfort and a family-centered experience. At home, the parents and midwife are in control of the birthing environment, and strict time perimeters for length of labor are not imposed, or routine medical interventions are done. “According to [a 1994] published study, direct-entry midwife (non-nurse) attended homebirths were accomplished with safety comparable to that of conventional births. In fact, physician-attended hospital birth has never been shown to be safer than midwife-attended homebirth for women having uncomplicated pregnancies”. (Citizens for Midwifery, summarizing American Journal of Public Health 1992: 450-453; Birth 1994; 21:141-148), In fact, The World Health Organization (WHO) states that the preferred location for most births is outside the hospital. Several studies support the safety of planned homebirth for low risk women with skilled birth attendants. The largest one ever conducted by Betty Ann Daviss and Kenneth C. Johnson on planned homebirths with midwives in North America and Canada. (BMJ 2005;330:1416).

Is Homebirth An Option for All Women?

No, generally speaking, out-of-hospital birth is for women with low risk pregnancies, who have a healthy lifestyle and whose medical history does not preclude them from doing so may have a homebirth. For example, these are some of the reasons why homebirth might not be appropriate for some women. (However, you should discuss your situation with a qualified midwife).

• Previous cesarean section
• Medical conditions such as Morbid Obesity, uncontrolled Diabetes or heart conditions
• Health behaviors which put them at higher risk for pregnancy complications (such as smoking or poor dietary habits)
• Excessive fear of hospitals and doctors (there is always a possibility of transport to a hospital so women need to be willing to allow their midwife to obtain medical help if necessary).
• Lack of family/spouse support for the choice of out-of-hospital birth
• Twins or breech presentation
• Lack of funds to hire a qualified homebirth midwife

Every  place of birth carries some degree of risk. The  primary risk with homebirth is the potential delay in accessing emergency and medical services in a critical emergency. Expectant parents deciding whether to have a homebirth should weighs the pros and cons carefully.  Some parents-to-be may want to have a homebirth because of their past negative experiences with hospitals and the medical profession, but fear of the hospital is not a good reason to attempt a homebirth.

What About Do-It-Yourself (Unassisted) Homebirth?

Some women decide to have their babies at home without a skilled midwife present either because of  financial reasons or past negative experiences in the hospital. Lack of money to

pay a professional midwife for a homebirth a justification for a do-it-yourself homebirth. This can be a risky thing to do, so don’t put yourself or your baby unnecessarily in  danger. There is state-funded medical insurance called Medi-Cal. Go to your local DPSS office or medical

clinic  to sign up. While Medi-Cal does not cover homebirth midwives, it will pay for in-hospital nurse-midwifery care. There  are several hospitals in the Los Angeles area which employ nurse-midwives. They  can  provide you with a home-like birth in the hospital, where you will have access to skilled medical personnel.  Birth is unpredictable, and parents planning homebirth must be prepared for all possibilities, including a transport to the hospital. Childbirth requires flexibility and an open mind, in every setting.

In conclusion, homebirth is not for everyone. Homebirth parents must take a very high level of responsibility which includes living a healthy lifestyle to keep the pregnancy low-risk, preparation of the home, procuring birth supplies, and arranging for hospital and physician back up.  The family must have the financial resources or insurance coverage  in case a transport to the hospital is necessary. Most midwives will not discount their fees and take on a last-minute client. They carry tremendous responsibility for the well being of the woman and unborn child, and thus they cannot “cut their fee” to accommodate a last minute client. Furthermore, most midwives have a limited number of births they take on each month. If you wait til the last minute, you may not find a midwife who can take you and  if you  do, it’s likely you will have to come up with the full fee all at once (plus have extra in case of hospital transport). So it is best to plan early on  in your pregnancy or before you get pregnant to have a homebirth. Start saving money before you get pregnant, switch to a PPO insurance plan that covers midwives, and meet  several midwives before you get pregnant or early in your pregnancy to be sure you find the right one for you. Midwives want to see that a  prospective client has demonstrated responsibility and has made a well-researched decision to have a homebirth. Finally, take good care of yourself in pregnancy, to avoid complications.

FREQUENTLY ASKED QUESTIONS ABOUT HOMEBIRTH

What Types of Birth Attendants Deliver Babies At Home ?

Homebirth midwives may be either Certified Nurse-Midwives (CNMs), Certified Professional Midwives (CPMs) or Licensed Midwives (LMs). In some areas, Medical Doctors also do homebirths.

CNMs are registered nurses trained in midwifery and are licensed to practice in all 50 states. They are regulated in California by the Board of Registered Nursing. They are  accredited by The American College of Nurse Midwives. Most have Masters Degrees in Nursing (MSN) with an emphasis in Nurse-Midwifery and Women’s Health.

CPMs  are usually not nurses, and have met requirements to become nationally certified by The North American Registry of Midwives.  They learned their trade through either special schools and/or  apprenticeship. CPMs are not legal in all 50 states. In California, the CPM is not legally recognized credential.

LMs  are usually not nurses. They learned their trade through special schooling, apprenticeship, and supervised clinical training.  Legality is not available for non-nurse midwives in all 50 states.  Since 1994, California has licensed midwives; they are regulated by The California Medical Board Division of Midwifery Licensing. As of 2013, Licensed Midwives work without supervision by physicians. The Amendment to the 1994  law: “AB 1308 incorporates into statute for the first time a definition of “normal pregnancy and childbirth.”  Specifically, a licensed midwife is only allowed to operate independently when “there is a singleton fetus,” “ there is a cephalic presentation,” “the gestational age of the fetus is greater than 37 0⁄7 weeks and less than 42 0⁄7 completed weeks of pregnancy,” and “labor is spontaneous or induced in an outpatient setting.”

Many California homebirth midwives are both LMs/CPMs.

To find a homebirth midwife in Southern California, go to our page on Homebirth Midwives.

What Do Homebirth Midwives Provide?

Homebirth midwives  provide complete prenatal care including monthly visits, laboratory tests, screening for infections. In addition, they may offer nutritional counseling, support for psychosocial issues and childbirth education, as well as labor management, postpartum care and newborn care.

What Happens if There’s an Emergency?

Responsible parents and midwives will arrange for hospital and physician back up for their planned homebirth. This includes both Obstetrician and Pediatrician back-up. At the birth, the homebirth midwife will bring fetal heart rate monitoring equipment (fetoscope or doppler) anti-hemorrhaging drugs (pitocin, methergine and cytotec), IV set up and fluids (normal saline), neonatal resuscitation equipment and oxygen tank(s), suturing materials, lidocaine and antibiotics, antibiotic eye ointment and vitamin K for the newborn. They usually have one or two assistants and/or students who are also trained in neonatal resuscitation.

I’d Like to Have a Homebirth, But I’m Uninsured and Can’t Afford a Midwife. I’m Afraid of The Hospital. I’m Considering Unassisted Birth. Is this recommended?

We do not recommend unassisted “do it yourself” homebirth. While most births proceed without complications, there are risks involved in all births. Complications such as obstructed labor, fetal distress, prolapse cord, bleeding after the birth, baby not breathing and other problems can occur quite unexpectedly and require skilled intervention.  WHO, FIGO, the International Confederation of Midwives (ICM) and other organizations have called for “skilled birth attendants” to attend all births outside the hospital in order to reduce maternal deaths worldwide.

Many homebirth midwives will respect your desire for privacy and will leave you undisturbed. Like a lifeguard, they will intervene only if necessary to assist you and the baby.

If you cannot afford a homebirth or do not have insurance, state funded insurance Medi-Cal is available to you, and there are charity hospitals which employ nurse-midwives that can help you have a homebirth-like experience in the hospital. A volunteer Doula may be available to help you as well. Contact us for further information and referrals.

Recommendations for Homebirth – Things to Consider:

• Consider your options carefully. Homebirth requires the highest level of responsibility of all birth options. There are no guarantees your birth will be perfect. Parents choosing this option will need to make extra effort to become prepared and take responsibility for the choice they make.
• Many complications can be diagnosed and corrected prenatally by a skilled midwife. Should they occur during the birth or postpartum, most can be remedied by an experienced midwife at the bedside. However, some critical emergencies require transport to the hospital and Medical Doctor back up. There is a small possibility that a delay in medical interface may occur.
• Homebirth midwives are trained to know when an emergency requires medical interface and can provide stabilizing measures until critical care can be obtained. Homebirth midwives have the training, equipment and medicine to handle complications such as excessive postpartum bleeding, fetal heart rate changes and repairing of vaginal tears.
• Have a back up plan. Homebirth midwives have a doctor they consult with or transfer care to in case a complication or emergency develops and transport to a hospital is required. If you don’t have insurance, you must be prepared to pay the doctor cash or have a credit card available to pay him or her if his or her assistance is needed. Your midwife may want you to meet with the doctor during the pregnancy, or you may meet him only if a complication arises and a consultation or transfer of care is needed.

FREQUENTLY ASKED QUESTIONS ABOUT MIDWIFERY AND HOMEBIRTH

How much do midwives charge for homebirth?

The going rate in 2011 for homebirth midwives in Los Angeles averages $4500 for prenatal care, labor and delivery and 6-8 weeks postpoartum care, plus laboratory fees. Usually fee is required in full 4 weeks prior to the estimated due date. Many midwives will work out payment plans, and some may even barter services.

I’m in my last trimester and just decided to have a homebirth. Will the midwife discount her fee since I am coming late into her care?

Not usually. The midwife has tremendous responsibility for the safety and well-being of the mother and infant. Even if the prospective client has received are elsewhere, she usually will require the full fee  a month paid in full prior to the estimated due date.

Does Insurance Cover Homebirth?

Depends upon the ype of insurance you have. PPO insurance will cover Certified Nurse Midwives and Licensed Midwives who do homebirth and birth center deliveries. HMO insurance, AIM Insurance will not cover homebirth midwives.

Does Medi-Cal  cover homebirth?

Medi-Caid, called Medi-Cal in California, is offered by few homebirth midwives. Your best option if you have Medi-Cal is to go to one of the hospitals in Los Angeles which employ Nurse-Midwives. Currently, there are three hospitals in Los Angeles with Nurse-Midwifery practices: California Hospital Medical Center, UCLA Westwood and Cedars Sinai Medical Center. See our page on Hospital Birth with Nurse Midwives for more information and contact information.

Can I hire a midwife and bring her to the hospital of my choice?

Few midwives who have independent homebirth  or birth center practices also have hospital admitting privileges.  Those that do are  Nurse-Midwives, as Licensed Midwives do not have hospital admitting privileges in the U.S. at this time.

What are the differences between a Midwives and Doulas?

Professional midwives are  skilled, licensed and or certified  primary care providers who have many years of training and have certification and/or licensure in the state in which they work. Midwives are responsible   for all aspects of prenatal care, labor management, postpartum  and newborn care. The Doula,  by comparison, has gone through a three day course and is a “lay” professional who works as a non-medical member of the birth team, providing emotional support, physical comfort, breastfeeding support, and advocacy for the woman and infant. The doula does not make medical decisions and does not do any physical assessments (i.e., blood pressure, vaginal exams, fetal heart rate assessment, etc).

I am afraid to give birth in a hospital because I had a bad first experience,  and I have no money to pay a midwife’s fees. Should I have a do-it-myself homebirth?

No. We do not recommend “unassisted” or “free birth” or do-it-yourself homebirth. Leading national and international organizations concerned with the health and safety of mothers and infants do not recommend attempting a homebirth without skilled and trained midwives in attendance and  hospital and Medical Doctor back up. We suggest you go to one of the hospitals which employ Nurse-Midwives and accept Medi-Cal. A hospital Nurse-Mdwife will be sensitive to your wishes and provide you with a “home-like” birth in the hospital environment, where you will have access to skilled personnel and emergency equipment. In addition, there are doulas ho will volunteer their services for women on Medi-Cal; this way you can stay home longer before coming to the hospital. Please look at our page on Nurse Midwives Providing Hospital Birth for more information, and call us for a referral to a volunteer doula.

Can I have a homebirth if I had a cesarean with my first baby, or my baby is breech, or I am pregnant with twins?

You may be able to find a homebirth midwife and physician back up who will allow you to attempt a home vaginal birth after cesarean. In California, Licensed Midwives and Nurse-Midwives are prohibited from doing  breech delivery or twins at home or in a birth center. There are a few unlicensed “lay” midwives who may be able to help you. However, this is a very risky situation medically and legally for everyone involved. If you choose an unlicensed “lay” midwife to help you, be sure you determine her level of experience with twins and breeches and be sure to plan for medical back up, as there is a higher risk for complications with breeches and twins, which may require immediate medical intervention.

I am over 40 years old, or under 18 years old. Can I have a homebirth?

Probably. In midwifery care, your chronological age is less important than your overall health. A healthy woman who has no chronic medical issues, has had no complications of pregnancy, does not smoke and leads a healthy lifestyle most likely will successfully be able to give birth at home or in a birth center.

Do midwives offer prenatal care or do I have to go to a doctor for my prenatal care?

Midwives provide complete prenatal care on the same schedule as medical doctors: once a month until 28 weeks, twice a month until 36 weeks, and once a week until you deliver. In addition, midwives who do out of hospital birth provide 6-8 weeks of postpartum care, breastfeeding support and newborn care, in collaboration with pediatricians. The goal in midwifery care is to support the pregnant woman in having a healthy, normal pregnancy. There is a “low-risk normal” perimeter for out-of-hospital birth. If at any point the pregnancy becomes complicated, the midwife will consult with the obstetrician, collaborate or transfer care if needed.

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