Wednesday, October 21, 2009

Our Birthing Decisions With Evidence!

Ok, we expect this to be difficult. There is a lot of information here, not all of it interesting. We have made a decision about the birth of our first child and this post will lay out our process and our decision.


For those who know me and my family you know that my mom had severe complications with pregnancy and birth. She went through a ton of hardship with pregnancies ending in still births, miscarriages, and complications. When I was 3 years old she had an amniotic fluid embolism during a still birth and passed away. I know, I know- TMI. I needed to tell you all that because there will probably be things posted on this blog about natural birthing that may or may not offend you. I want you to know we have been "in-depth" researching our options for birthing for a year and a half now preparing me emotionally to make this decision.
A year ago we interviewed ALL the hospitals and birthing centers within 45 minutes in every direction from our house in Lynnwood. We were quite discouraged with the philosophies and practices of local hospitals and some birth centers! We left that adventure thankful that we didn't have to make an immediate decision because I wasn't pregnant. We interviewed one last birth center with a pessimistic view to start off. Our experience there though was much better than all the rest! All of our concerns and questions were actually answered not avoided. As we left I was still not convinced to go to that particular clinic. We said our goodbyes to the midwives. As I took Daniel's hand, I felt the Spirit so strongly. Well, that was that. I can be confident with any decision if the Lord is on my side or in this case telling us what to choose! It is extremely important for each woman giving birth to know where she will be the most relaxed and feel the safest. Please don't think that the hospital is the only way. Learn about other options and actually talk to a certified midwife before dismissing them. Know your options! It is disappointing when there is more shopping around and comparing going on with our cars, appliances, and homes than our precious children who should mean more than all of those things!


In this post, we will be speaking generally unless we say otherwise. For example, when we say "hospitals overuse their options" we don't necessarily mean YOUR hospital does, we mean, generally speaking, or on average, hospitals overuse their options. Keep that in mind. Also, our critiques of obstetric practice are not a personal attack on any of our friends or anyone we know. We would be disappointed if anybody felt that, or responded as if we were attacking them.

While your birthing story may be interesting, it is not sufficient evidence to guide our birthing decisions. Anecdotal evidence like that is statistically meaningless and can be atypical. Scientific study will guide our decisions, not emotional testimonials.

Speaking of scientific study, we now present the following for your consideration. We have tried to be accurate and have quoted from our sources where we could. Please forgive any grammatical mistakes. If we have made a statistical mistake or come to the wrong conclusion, we will try to fix it if it comes to our attention. Without further ado:

Hospitals use continuous electronic fetal monitoring on women nearly exclusively during labor. The most common apparatus is a belt-like assembly that is worn around the waist and is connected to monitoring equipment. Beside being unwiedly, no studies have been able to demonstrate that routine electronic fetal monitoring decreases fetal birth asphyxia or its attending complications, such as cerebral palsy. In low risk labors, "electronic fetal monitoring did not decrease neonatal morbidity and mortality (illness or death of the baby) compared with intermittent auscultation" (usually meaning a check via stethoscope every few minutes to make sure the infant's heart rate is ok) (1). Continuous electronic fetal monitoring is shown to be totally ineffective. Totally ineffective. This is a well known fact which is beyond dispute. However, for a variety of reasons, most notably insurance reasons, continuous electronic fetal monitoring continues to be used.

Hospitals use an artificial version of oxytocin (a naturally produced hormone) called pitocin to induce and/or augment labor. Estimates vary, but the consensus is that somewhere in the range of about 80% of hospital deliveries are induced or augmented with pitocin. Pitocin causes longer, stronger contractions than are normal, which put longer and stronger pressure on both the umbilical cord and the fetus' body. Directly because of this, fetal distress (typically manifesting as large fluctuations in heart rate) is a common issue with pitocin aided deliveries. One hospital found that a reduction in the number of deliveries that were aided with pitocin from 93.3% of their total number of deliveries to 78.9% led to a 48% reduction in emergency cesarean sections and improvements in other measures of birth outcome (2). Using pitocin routinely to aid delivery is foolish, dangerous, and unfortunately, common.

Speaking of cesarean sections, national cesarean rates are increasing and currently are somewhere around 30%-40%. This is extremely high. Cesarean rates worldwide do not correspond to rates infant mortality. However, cesarean sections have been shown (3)(4) to reduce successful breastfeeding rates in infants. While occasionally necessary, cesarean sections happen more frequently than is optimal. WHO, as well as many studies that we are too lazy to cite suggest that the prime cesarean rate is about 10%. Anything over this tends to cause more problems than it prevents. The breastfeeding difficulty that cesarean section causes is a prime example of such a problem.

A primary reason for induction of labor is that the attending physician believes that the fetus is too large to deliver safely. However, once again, scientific studies show that this practice is extremely flawed. "Currently, there is no evidence to support labor induction in women with suspected fetal macrosomia" (large fetus). "The purpose of induction for fetal macrosomia (large fetus) would be to prevent maternal and neonatal morbidity (illness and death of mother and baby). However, studies have shown that the incidence of cesarean and instrumented deliveries was not decreased, and perinatal morbidity was not changed" (5). In other words, induction for this reason does not produce better results than allowing the birth to progress with no induction. The practice is not justified and evidence shows it is ineffective.

Clamping the umbilical cord as quickly as possible after delivery is standard practice in local hospitals. Immediate cord clamping does not allow the placenta to deliver a significant amount of blood, including stem cells and important hormones such as oxytocin, to the baby before it shuts down, and many newborns are hypovolemic (low blood volume) for this reason. Studies (6)(7)(8) show that delaying the clamping of the cord for a few minutes produces significant benefit for the baby. Some of the benefits for the baby are:

increased levels of iron
reduced rates of anemia
higher red blood cell flow to vital organs
increased duration of early breastfeeding
increased blood pressure and blood volume
increased hemocrit & hemoglobin levels
fewer blood transfusions

The studies also show that there are few, if any, risks associated with delayed clamping

Many women are told that their children were in danger during delivery because the umbilical cord was wrapped around the child's neck. This condition is called nuchal cord. Many people believe that nuchal cord is dangerous and a threat to perinatal health. However, nuchal cord occurs in approximately 20%-30% of all births. This makes it a common occurrence. It's about as common as weekends. It's not dangerous.

Studies (9) show that "nuchal cord is not associated with adverse perinatal outcome" (and, in fact, nuchal cord deliveries had lower cesarean section rates than normal non-nuchal cord deliveries), and furthermore, 5 minute APGAR scores were not adversely affected by nuchal cord! In fact, around the neck is an excellent place for the umbilical cord during delivery. The birth canal is tight, and the neck area provides a good open place for the cord to rest and still allow the baby benefit from the placental blood. The reason that nuchal cord deliveries had lower instances of cesarean section is likely that there were lower levels of fetal distress. The reason that there were lower levels of fetal distress is that nuchal cord allows the baby better access to oxygen via the placental blood.

A large scale and wide ranging survey of women (10) found some interesting and unfortunate things:

The survey "asked mothers if the person who was their primary birth attendant had been their primary prenatal provider, and in the clear majority of cases (70%), it was. For nearly one in three women, however, it was someone she had either met briefly (10%) or had never met (19%)." The primary birth attendant for nearly one in three women was someone they were unfamiliar with, a near stranger. Imagine that. That appalling problem is nearly completely confined to hospitals, where staff are busy and often relieved of duty at the end of their shift before delivery is complete.

"Just over half (56%) of mothers who took the survey said that they were interested in drinking something, and about a quarter (27%) stated that they were interested in eating something between the time their labor began and the time they actually gave birth. However, only about one in three (34%) indicated they were permitted to drink anything, and only about one in eight (13%) said that they were permitted to eat anything during this time." Imagine a woman who is having her first baby, and is experiencing a long and difficult labor. After 16 hours of labor, with no food and no drink, how is that woman going to feel? How well is she going to be able to focus and how well is her body going to respond to contractions? Not very well. The practice of not allowing eating or drinking is designed to prepare the woman for surgery, as it lessens the chance of her vomiting during surgery. Unfortunately, this ban of food and drink can quickly tire out even the most in-shape woman and cause her labor to stall and finally, to end in ceserean section. This practice is nearly completely confined to hospitals.

"Most (71%) women who gave birth in a hospital or birth center did not walk around once they were admitted... The primary reason selected by women for not walking around was being connected to things (67%)." Many women find that moving around causes a significant decrease in discomfort and helps progress labor along well. Being unable to do so is counterintuitive for most women, and can cause unnecessary discomfort and an unnecessary prolonging of labor.

The same survey found that the primary location of the infant in the first half hour after birth in 31% of births was not with the mother or father, but with hospital staff for "routine care." This is, in my mind, unacceptable.

As for episiotomies, "Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision" (11). Episiotomies are unneccessary and, in fact, do more harm than good. Need I point out that the use of episiotomies is nearly totally confined to hospitals?

All of these problems are nearly completely confined to hospitals. In order to avoid the mess entirely, we have decided that we will be birthing at Cascade Midwives and Birth Center, a freestanding birth center located in Everett near Providence Medical Center. Since 1999, Cascade has provided both cost effective and clinically efficacious delivery services. Of all deliveries that begin at Cascade, approximately 12% end up being transferred to the hospital (for a variety of reasons) and approximately 3% end up as cesareans. Ms. Darlene Curtis, the licensed midwife at Cascade, shares our beliefs about birthing and is committed to providing the experience that we want.

One objection we have heard in response to our decision is that people would rather give birth in a hospital just to be on the safe side. While we also want to be on the safe side, the evidence shows that planned home births with using certified professional midwives are as safe as hospital births. Read that last sentence again. It is a logical fallacy to say that one wants to be on the safe side and therefore will give birth in a hospital. The conclusion does not follow from the premise. The same study (12) shows that such home births may in fact BE SAFER than hospital births.
"Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."


"Individual rates of medical intervention for home births were consistently less than half those in hospital.... Compared with the relatively low risk hospital group, intended home births were associated with lower rates of electronic fetal monitoring (9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean section (3.7% versus 19.0%), and vacuum extraction (0.6% versus 5.5%). The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women."

The numbers may be a little skewed because hospitals have to take high-risk deliveries that are more likely to end in death, but the secondary conclusions in the previous paragraph are valid (as they compare low risk deliveries in and out of hospitals)- low risk deliveries are quite safe and, in some ways, are even safer, at home as opposed to the hospital.

There are real, scientifically proven reasons for nearly every protocol, intervention, procedure, and policy that is done in hospitals. Cesarean sections are necessary sometimes. Pitocin is necessary sometimes. You get the point. The problem is that generally, hospitals overuse their options. The list of ineffective methods is staggering: routine electronic fetal monitoring is totally unnecessary. Episiotomies are totally unnecessary. Immediate cord clamping is detrimental to the health of both the mother and child. Pitocin is overused and drastically increases the rates of cesarean section. Hospitals are overzealous in their concern for the mother and child, and often end up doing more damage than good.

In conclusion, planned birth with trained professionals outside of hospitals is cheaper and leads to more successful outcomes than births at hospitals. For these reasons, and backed by the above evidence, we will be delivering our first child, if all goes well, at Cascade Birth Center in Everett.

1) Impey, L. Reynolds, M. MacQuillan, K. Gates, S. Murphy, J. Sheil, O. (2003). Admission cardiotocography: a randomized trial. Lancet

2) Bates, B. (2009). Hospital’s oxytocin protocol change sharply reduces emergency c-section deliveries. Elsevier Global Medical News

3) Cakmak, H. Kuguoglu S. (2007). Comparison of the breastfeeding patterns of mothers who delivered their babies per vagina and via cesarean section: An observational study using the LATCH breastfeeding charting system
International Journal of Nursing Studies, Volume 44(7)

4) Wang, B. S. Zhou, L. F. Zhu, L. P. Gao, X. L. Gao, E. S. (2000). Prospective observational study on the effects of caesarean section on breastfeeding. Zhonghua Fu Chan Ke Za Zhi, 41(4)

5) Ruplinger, J. Marquardt, D. (2001). Should induction of labor be considered in a woman with a macrosomic baby?. Journal of Family Practice

6) Hutton, E. K. (2007). Late vs. early clamping of the umbilical in full-term neonates. The Journal of the American Medical Association, 297(11)

7) Eichenbaum-Pikser, G. & Zasloff, J. (2009). Delayed Clamping of the Umbilical Cord: A review with implications for practice. Journal of Midwifery & Women's Health, 54(4)

8) Mercer, J. S. (2001). Current best evidence: a review of the literature on umbilical cord clamping. Journal of Midwifery & Women's Health, 46(6)

9) Shrestha, N. S. Singh, N. (2007). Nuchal cord and perinatal outcome. Kathmandu University Medical Journal, 5(3)

10) Declercq, E. R. Sakala, C. Corry, M. P. Applebaum, S. Risher, P. (2002) Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association. (Note: there is a more recent "Listening to Mothers II" study that shows similar results)

11) Hartmann, K. Viswanathan, M. Palmieri, R. Gartlehner, G. Thorp, Jr, J. Lohr, K. (2005). Outcomes of routine episiotomy. The Journal of the American Medical Association, 293(17)

12) Daviss, B. Johnson, K. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America .
BMJ, 330(7505),


kaitlyn said...

can i just say that i read this with a lot of interest. i am SERIOUSLY considering (i.e. 90% sure) that the next time i give birth it will be in a birth center.

i will type up a lengthy response to this post in a bit... but thanks for bringing this all up!

Courtney said...

1) I agree with several things you have posted on here. You are not alone in a lot of your thinking.
2) I know you are entitled to your own opinions, and you are entitled to share them. But it is one thing to explain why you are making a decision and another to tell everyone else they are not entitled to the same. Some people are ignorant, but they are allowed to be so. Just as you are allowed to be informed and make whatever decision for your life that you would like.

The Kerr Klan said...

I hope that everything works out for you. I wish I had been able to have my babies in a birthing center but because of complications I ended up with planned c-sections. You've done a good job doing the research instead of just going with what others say or out of fear because of all the complications that your mom had. Does the birthing center offer water birth? Have you considered that? I hear it can make a world of difference during labor and delivery.

EPVCCorier said...

Good for you. You've obviously done your research and gone after what you want for a safe and loving birth experience.

I'm glad you interviewed so many doctors and midwives. I had both my daughters with OB's (I used midwives for prenatal care but due to complications and other circumstances I had OB's at both deliveries) and they both had very different styles and philosophies for how labor and delivery should go.

One labor was full of interventions (but due to health issues they were necessary, and I'm glad I had that Dr for that delivery) the other labor was very laid back and I was allowed to go at my own pace- even though I had an incredibly slow moving labor ( I stayed at a 4 for like 6 hours). I had an episiotomy with one delivery and was allowed to tear with the other. I had pitocin for one but not the other. I had an epidural with both and I'm glad I did, I definitely could have gone without but I just wanted one ( epidurals are not created equal either, one was incredibly heavy and I couldn't feel anything, and the other was just enough to take the edge off my contractions).

The only advice I would give and I feel I am qualified to give advice simply because I've been their before is: Every woman, pregnancy, baby, labor and delivery is different. Do all the research and preparation you need and want but be prepared to accept the unexpected and the allow for medical intervention when it is actually necessary (emphasis on necessary). You've done the work and you know when it will be necessary and you've chosen a midwife that supports your birth philosophy and she will know when it's necessary. Plus expecting the unexpected will prepare you for motherhood :)
Good Luck, I'm really excited for you. You will be a great mother.

Kevin & Sarah Lockard said...

It's good that you've done so much research. My only advice is to go into your labor with a very open mind. Speaking from experience, things don't always go how you plan. Every labor and delievery is different and it is a very different experience for every woman.

Sara Hammond said...

I really enjoyed reading this. It is well put together and matches a lot of results I have found in my own research. I plan on showing it to my husband to try and help him understand some of my own desires and reasonings. Thank you!

Baker said...

Best analogy ever:

"However, nuchal cord occurs in approximately 20%-30% of all births. This makes it a common occurrence. It's about as common as weekends."

Deb Cardinale said...

I am not at all surprised by your decisions. In fact, if I was young and pregnant I would likely go with a birthing center and midwifes instead of a hospital and Doctors. Too many of my friends have ended up having cecareans or scheduled their deliveries for a specific day with the expectation of induced labor on that day. What ever happened to letting childbirth be a natural thing. -- Aunt Deb

Heather said...

So great to meet you both last night!I am impressed by your research. Thank you. I am going to keep this so I can refer back when I am pregnant! Blessings to you both!!