Tuesday, July 31 at 1 p.m. ET
Tuesday, July 31, 2007; 1:00 PM
Laura Shanley, a freebirth advocate, and Mairi Breen-Rothman, a midwife, debated the advantages and disadvantages of delivering a baby at home without the help of doctors or other trained professionals.
Shanley and Breen-Rothman were online Tuesday, July 31 at 1 p.m ET.
A transcript follows.
Washington, D.C.: I don't have a dog in this fight, but one thing puzzles me. For as long as there have been people, childbirth has been one of the leading causes of death for women and children up until comparatively recently (the last 100 years or so). Why are these families so keen to go back to something so -- forgive me -- primitive? Backwards, even?
Saying that modern medicine has nothing to offer the perinatal mother or newborn is simply nonsense upon stilts.
Laura Shanley: If you truly research this you will find that throughout history, women and babies in healthy tribal cultures have NOT routinely died in childbirth. Anthropologists that observed healthy tribal cultures a hundred years ago often reported that they rarely saw a death or complication in childbirth.
For women in the cities, however, it was different. Poor city women were often overworked and underfed. Poor nutrition (i.e. little or no food) could and did cause rickets which literally deformed the pelvic bones, making childbirth difficult and dangerous. Wealthy women were generally corseted starting at the age of eleven which also led to pelvic bone deformities.
And of course doctors themselves were often the cause of death when it came to delivering babies. Doctors would often go directly from performing autopsies to delivering babies without washing their hands. This caused childbed fever which killed numerous women both in hospitals and at home.
Today there are indeed women and babies dying in childbirth in third world courtiers, but once again we have to ask ourselves why. These are not healthy, well-fed women. These women live in poverty. Without food, clean water, or safe living conditions people cannot expect to be healthy, let alone give birth safely. But to say that this proves that childbirth is inherently dangerous makes no more sense than saying digestion is inherently dangerous because people in third world countries are dying from dysentery. Give these people food, clean water, and proper housing and watch what happens to their maternal and infant mortality rates.
I've also discovered recently that the countries with the highest maternal and infant mortality rates are also the countries with the highest rates of female genital mutilation. These women have literally had their vaginas sown together. A birth attendant or midwife then cuts them (often with dirty instruments) so that they can give birth. This often leads to infection and death - both for mothers and babies, as the process is often performed on newborn baby girls.
Yes, modern medicine can be helpful. But as I said, many of the problems women experience in childbirth today could be solved by eliminating poverty (I know, easier said than done). The remaining problems I believe are caused by outside intervention - doctors and sometimes midwives poking, prodding, testing, drugging, cutting and generally interfering in birth every step of the way, and inside intervention - women triggering the fight/flight response which shuts down labor. This response is triggered by fear, so it's essential that women understand the process of birth and overcome their fear of it.
Washington, D.C.: I'm expecting my first child in about a month. He or she will be born in a hospital. I fully expect the experience to be rigid, frightening, and overly-medical -- for ME. This is a sacrifice I'm willing to make to ensure that my child has the very best chance.
This "freebirthing" movement sounds like something women to for themselves. Is childbirth really a time for a person to be thinking selfishly? After all, the baby doesn't know or care where he's born.
Laura Shanley: If you "fully expect the experience to be rigid, frightening, and overly-medical" for you, why do you assume it will be any different for your baby? There are indeed some babies that are helped by medical care but there are far too many babies that are harmed by it. Babies are injured during forceps and vacuum extractions, c-sections, episiotomies, and other medical proceedures - most of which I believe are unnecessary in the first place. A woman who appeared on a British TV show with me recently had a scar on her face from being cut during her mother's c-section. This happens more often than people realize. Those of us who choose unassisted birth ARE in fact thinking of our baby's safety. And from the research we have done we believe that in most cases this is the safest way to give birth, both for ourselves and our babies.
Georgia: Thanks for this article. As someone who's just a few weeks away from giving birth, it was quite an interesting read. Here's my question: I've only known one person who went this route knowingly (she also refused to seek prenatal care) and she was deeply religious. Her feeling was that if God had a plan for her or the baby or both to die, then that was the plan and she couldn't change it. In researching home births, is it more common for the women and their families who choose this route to be more fundamentalist? And if so, is it mainly Christians, or are members of other religions also going this way? Thanks!
Laura Shanley: There are women from all different faiths that give birth unassisted. I was raised in a Jewish household, but I don't identify with any organized religion at this point in my life. I would say I am spiritual in that I believe there is a larger, loving intelligence behind and within life.
Rockville, Md.: I am glad to see a midwife in this debate/discussion ... my only qualm with the article (and that qualm is small!) is that it didn't seem to emphasize enough the distinction between planned home-births with midwife assistance and completely unassisted "freebirths." I worry that those who attempt natural childbirth at home with a midwife will be lumped into the same category, and thus stigmatized when indeed realistically I think there is way too much medical intervention in hospital births these days, and the homebirthing-with-midwives mamas are onto something. (For the record, I happily birthed at hospitals, but with awesome midwives all the way.)
Mairi Breen-Rothman: I think you are right that it is different to have a planned home birth with a midwife in attendance than it is too have a home birth just with your loved ones around, but just how different it is can vary greatly. There are things that it is good to know about and good to have in place before a birth happens, but midwives are not the only ones who have access to that knowledge. Having a midwife present just means that you have invited someone with a body of knowledge and some tools and equipment and experience that might allow you and your family to concentrate on the wonderful event that is unfolding, and let someone else be the lifeguard, so to speak. I wish that no one would be stigmatized for their choices in this arena, and that the "mainstream" choice was more conducive to encouraging the natural flow of things and the presence and participation of family.
Washington, D.C.: Something that occurred this weekend to a dear friend has left me even more inclined to unassisted birth than I have ever been, when I am finally ready to have a child:
DF's doctors, after 10 weeks of near normal blood pressure, insisted she not carry past the date of July 27, though the baby still had not dropped, he was a good size and healthy, but not too big, and this was two weeks before her original due date. She went in on Thursday to be induced, had two rounds through Saturday morning, and was told Saturday afternoon, since the baby had not dropped, they couldn't break the water, and all other interventions were not working, that she could either try round 3 of Pitocin, or go home! In the end, after I'm sure a lot of anger and resentment, she had what is now being determined as an elective C-section. My blood just boils thinking about this -- this baby just wasn't ready to be born yet! Why can't the medical establishment just let mothers be, and let nature take it's course -- we have been reproducing for 1000s of years, if everyone is healthy, why arbitrarily force something so natural and beautiful as birth? She probably would have gone after the full moon on Sunday anyway -- it's just one more example of how Western medicine treats pregnancy as a disease, instead of a natural part of life.
Laura Shanley: Absolutely. One of the main causes of infant death in childbirth in industrialized countries is premature birth. According to Midwifery Today magazine, the biggest cause of premature birth is induction of labor! These babies are simply not ready to be born. Mothers are rarely asked if they feel they are ready to give birth. They are told by doctors who are basing their decisions on machines that are not always accurate.
The Hague, Netherlands: I live in Holland where home birthing is the norm rather than the exception and I myself am due in three weeks. I chose to deliver in a hospital because I do not believe that is prudent to take a chance to deliver at home, nor do I have any desire to do so.
Here they have all sorts of regulations in place to facilitate home birthing yet the mortality rate is the highest of any European country. The growing trend nowadays is to deliver in a hospital. I think advocating home birth in the U.S. is a step in the wrong direction. On the other hand if you want to deliver like someone in a third-world country, be my guest.
My question: Why do you think it would be something that people would want to do, apart from cost and novelty? I personally, did not see any benefits to this option and as long as the options remain to choose, I hope it never gets to where it is the accepted norm as it is here. I had to argue to be delivered by a GYN instead of a midwife. Incidentally, the Queen and the Crown Princess here BOTH delivered in a hospital.
Laura Shanley: I would say "cost" and "novelty" have very little to do with it. I chose to have unassisted births because my research led me to believe that childbirth is inherently safe. The problems some women encounter can be traced to 3 main causes: poverty, outside interference and inside interference.
I began by looking at inside interference. When a woman is afraid in labor (which most women are) she sends messages to her body telling it now is not the time to give birth. Blood and oxygen flow away from the uterus and into the arms and legs so that the frightened women can run from the supposed danger or fight it. Without blood and oxygen, the uterus cannot do its job and childbirth indeed becomes painful and dangerous.
This made sense to me, and so I was able to overcome my fear of birth. I then began to realize how outside interference affects birth. The most well-meaning midwife generally has rules she has to follow. Very few women can give birth in their own way and in their own time with a midwife or doctor in attendance.
Mairi Breen-Rothman: I would add that it is not the place a woman chooses to deliver that makes for a good or bad birth. There is no way for us to know why the royalty of the Netherlands delivered in a hospital--for all we know it was security issues or something, or maybe they wanted to do it the "American" way. Heaven knows we have exported many bad ideas from this country, including bottle-feeding, cigarette smoking, and McDonald's--why not hi-tech birth as well? I can't speak to the conditions in Dutch hospitals, but I can tell you that the "risks" of delivering at home are not greater than in the hospital here in the U.S. The average C-section rate in most hospitals where I live is over 30%. For the homebirth practice with whom I had my babies, it is 4%. Complications of cesarean birth are still the leading cause of death for women of childbearing age, and cesareans also increase the chances of neonatal death significantly. I am not arguing in favor of unattended home birth, but I certainly don't think a normal healthy woman increases risks for herself or her baby by delivering at home with a trained midwife. Why anyone would argue to be attended by a gyn rather than a midwife is a mystery to me. Gynecologists are great to have if you have a condition requiring surgery--that is their specialty. Midwives specialize in normal vaginal delivery. It makes sense to hire a professional trained to perform the service you require.
Hewitt, Tex.: Discuss how a CNM and/or professional midwife can assist a home birth to meet the goal of an unassisted birth.
Mairi Breen-Rothman: If the goal of unassisted birth is to be able to experience the birth process without unneccesary intervention, then a good midwife, whether CNM or CPM should be able to facilitate that. Midwives are trained to listen to the family's wishes and respect that WE are in THEIR home. Our job is to give you all the information we have about any problems or warning signs that arise, while recognizing that the ultimate choices are yours. Home birth midwives choose to work in that environment because we believe that home is the best place for almost all babies to be born, and that protecting a family's autonomy to birth the way they want to is easier at home than in a hospital where the hospital rules prevail over all. If the goal of an unassisted birth is to have the baby come out of the mom the way puppies and kittens do, which I have seen some people choose, the midwife can protect that choice as well. But in the rare cases where the baby needs some help breathing, or is tangled in the cord, or has trouble with shoulders, it sure is nice to have a trained midwife ready to help. Have I correctly understood the "goal of an unassisted birth?"
Clifton, Va.: So, are you willing to accept ALL of the risks, or just avoid the medical system until something goes wrong? Because if your child experiences a prolapsed umbilical cord which results in fetal distress and permanent brain damage that could have been easily addressed by a trained OB I really don't want to see your hand outstretched looking for government services. I should not be financially responsible for your bad decision making.
Mairi Breen-Rothman: I think people are sometimes under the mistaken impression that when we make decisions inside the hospital, it is the doctor's responsibility, and when we make them outside the hospital, it is our own responsibility. This is not the case. We are responsible for our decisions, whether or not we are in a hospital. Your question is actually very complex, because the fact is, something like a prolapsed cord, which is most often caused by artificially rupturing membranes before the baby is well-applied to the cervix, is much more likely to happen if you hand yourself over to a "trained OB." From the time you choose your care provider, you are making decisions that will affect your health and your baby's. If something goes wrong, it is no more your "fault" than it would be if it happened under a doctor's care. That being said, it is a good idea to choose a provider who you think will help you minimize the chances of anything going wrong from unneccesary interventions. Still no guarantee that nothing will go wrong, but as the famous midwife Ruth Lubic once said, birth is just as safe as anything else in life!
Laura Shanley: I agree with much of what Mairi said. I would have to ask a woman who gives birth in the hospital the same thing. Is she willing to accept all the risks of hospital birth? Has she done her research? Does she realize that both she and her baby have a greater risk of dying during a c-section than during a vaginal birth?
I have done my research and believe that what's going on in hospitals is not safe. Cutting 30% of women open during childbirth is not safe. Insisting that every woman push when she's 10 centimeters dilated - regardless of her shape and size - is not safe. Insisting that a woman be induced if she goes beyond her due date is not safe. I could go on and on.
Pittsburgh: I've read Tina Cassidy's "Birth," Wagner's "Born in the USA" and Block's "Pushed." Given the content of these books, care to comment on where maternity care is heading in the future. Also, given the message in these books, are we now or will we now start seeing more of a public awareness campaign aimed at women about birthing options, risks and trade offs? The books made me view OBs with less admiration, unfortunately, but did not convince me that home birth is the future trend.
Also, FWIW, I just had my second baby in February in a hospital and somehow managed to avoid having surgery (kicking and screaming and not before being lectured and put down by my practice docs). The experience and interactions I had with my OBGYN practice left such a negative impression on me, that it makes me glad I am done having babies ... but I fear for my daughter someday.
Laura Shanley: I am an optimist, so personally I believe someday unassisted childbirth will be the norm. More and more people are discovering the power of their own minds. They are no longer looking to the "experts" to save them in many ares of their lives. People are understanding that their bodies are responsive to their thoughts. When they apply this to childbirth, things will change.
However, before that happens we may see the c-section rate climb even higher. As long as women put their trust in doctors who I believe do not understand the process of birth, there are bound to be problems and more medical intervention.
Mairi Breen-Rothman: I am also an optimist, and I believe this is the last little bit of the feminist movement beginning to come into play here. Women in labor are not in a position to speak up for themselves--the part of their brain that needs to be in action to deliver well is not the same part that would stand up for her rights, and of course newborns cannot speak for themselves, either. However, it is finally beginning to dawn on women, once they regain their strength and focus on the system, that being strapped down, anesthetized, catheterized, and sometimes cut open, and then having their babies whisked away down the hall to be placed in a "warmer" that is heated to the exact temperature of a mother's breasts is wrong-headed at best, and abusive at worst. In my town, there was a small group of vocal women who met together once a month as a "birthing circle," until 2 very old, established midwifery practices closed down one after another because of the widening gap between poor reimbursement rates and increasing costs of malpractice insurance, and the group of women, outraged, grew to over 300. I see this happening all over the country, and I believe that as our broken health care system crumbles and falls apart, the smart young women of this generation will step forward and reclaim birth for their own. Midwifery will be the standard of care as it is in so many of the countries who rate above us in the rankings of maternal and infant mortality rates (we are about #30 right now, just above Latvia). I imagine we will see freebirth rise in popularity, too, with more classes and preparation for those families who choose it. That wouldn't be my choice, but I would defend another's right to choose it. If that is what women want, then I think it is incumbent upon us as a society to make it a safe option. The other way, where women accommodate the system, is backwards thinking, in my view.
Orlando, Fla.: I am curious to understand the insistence upon "unattended" birth other than the husband/partner of the mother. I think it's pretty well accepted across the board that a midwife is generally opposed to medical intervention unless it's necessary -- yet they're also experienced enough and trained to spot emergencies.
My husband -- an Army ranger with combat medical training -- I don't believe he'd have the first clue when it came to me in labor.
Mairi Breen-Rothman: In my experience, most people who prepare for an "un-attended" home birth do prepare pretty carefully. They read, they talk to others who have done it, they watch videos, etc. However, even as a midwife myself I chose to have another midwife (actually, two!) at my births, because I had enough on my plate just being the mom--I didn't want to also have to be the midwife. My husband had enough on his plate just being with me as my lover and friend and life companion, and I know enough about birth that I would have had a hard time handing over to him the responsiblity for being "lifeguard" for my baby and me. However, I do understand that some people are so turned off by our broken system of hospital birth, and at the same time so guided by faith in a deity to take care of them, that they are willing to stay home and just "hand it over to god," and accept whatever the outcome might be, knowing that in the vast majority of cases it will be fine. Others prefer to hedge their bets with a well-trained professional whose profession also trains them to respect the wishes of the family: a midwife.
Laura Shanley: While I believe in a larger consciousness, I did not simply hand my birth over to God. I took charge of it myself. And I trusted that my body had been properly designed to give birth. I simply cooperated with the process.
Why not have a midwife standing by just in case? Because most midwives are required by law to intervene. Often they must check dilation, for instance. Simply checking dilation changes the process of birth. What would happen if someone checked you during sex to see how close you were to orgasm? The very act of checking could and probably would delay the process. This is exactly what's happening in birth.
Midwives are often required to transport a woman to the hospital if her placenta isn't delivered within an hour of the birth. Many women who have given birth unassisted deliver the placenta several hours later with no problems. Midwives have a list of things they are required to do. And I'm sure many of them would rather not stick to that list. Unfortunatley if they don't, they may lose their license to practice.
Virginia: What exactly is the law on home birth?
Mairi Breen-Rothman: It varies greatly from state to state. In your state (Virginia) it is legal, and can legally be attended by a doctor, CNM (certified nurse-midwife), or CPM (certified professional midwife).
Laura Shanley: In case this isn't clear from Mairi's answer, it can also be unassisted.
academic article from U. of Indiana::"The birth of a child marks one of the great events of life in any culture, but in most societies it carries with it a high probability of death or serious illness for both mother and child."
this is just ONE example I pulled right now. The overall research is that death in childbirth was QUITE high in ancient cultures. The implcation that nature is good and modern science is bad is a horrible and false sentiment to spread.
Laura Shanley: Modern science isn't bad. But most doctors do not understand how the mind affects the body. When a doctor and a woman giving birth both BELIEVE that something is bound to go wrong, it is a self-fulfilling prophesy. Throughout history, healthy women have successfully given birth without medical assistance.
yikes: Sorry, but you folks are coming off as seriously loopy. Why would anyone want a Gyn present? Well, because of the chance of something going awry. Sure, that doctor might be overqualified if the birth proceeds without incident, but better safe than sorry. That's about it, really. There isn't necessarily time to call in the specialists if you're at home, and the baby's stuck, or you're bleeding, etc. Just common sense.
Mairi Breen-Rothman: It's not that simple, though. An OB/GYN is qualified to "save" the situation by surgical procedures, which are only needed in childbirth when a c/section becomes necessary. However, statistically there is more chance of HAVING an emergency if you are in a hospital. When you choose a midwife, you are choosing someone better trained to AVOID the emergency in the first place. That seems like common sense to me. 30% c-section rate, or 4% c-section rate. Common sense indeed.
North Carolina: So far it seems that you have highlighted the advantages of a home birth; what do you consider to be the disadvantages as compared to a hospital setting?
Mairi Breen-Rothman: I don't see any advantages, unless the mom is living in a situation in which she cannot be safe/comfortable at home. An example would be a woman living in a homeless shelter, or in a home where she is abused by her father or husband.
RE: Forced Birth: I'm sorry to hear about DC's friend being forced to deliever early, but given a situation like that, her friend really should have spoken up and said something and/or just flat-out refuse to induce labor.
I feel women (and men) need to stand up to doctors a bit more, and if your doctor is beginning to recommend things you're not comfortable with, you find a new one. I know, I know, easier said than done, but thie is your (and your baby's) health we're talking about here. You're paying these people (doctors) for a service and you have every right to demand better treatment.
Just my .02
Mairi Breen-Rothman: I agree. We tend to treat doctors like gods in this country. They are just people like you and me. If you had an accountant that was making decisions you didn't trust, you wouldn't hesitate to hire someone else. This goes back to the idea of hiring the person trained for the job: if you want a normal vaginal delivery, hire someone who specializes in that: a midwife.
Suzhou, Jiangsu, China: In the old days in China (before 1994) there were many kids with freebirth in the countryside, even in the eastern developed areas.
Laura Shanley: Yes, the majority of people in the world have been born unassisted - meaning without a paid, trained medical attendant. If it were truly as dangerous as people believe, the race would not have survived.
Arlington, Va.: I have friends who have had assisted home births (and one accidental unassisted, where the midwife got stuck in traffic), and don't deny that it was an extremely important experience for them. However, I'm annoyed that some freebirth advocates don't seem to acknowledge that having a hospital or midwife-assisted birth does not diminish us as women or mothers. That is a very insulting point of view -- I had an epidural so I don't really know what it's like to be a woman.
Laura Shanley: I have never said that women who don't have an unassisted birth are inferior to women that do. This was your choice, and who am I to question this or say it wasn't fulfilling for you? I prefer to give birth unassisted, as I know this is the best choice for ME.
Mairi Breen-Rothman: Women often feel judged about their choices in childbirth. I would contend that this is just you second-guessing your own judgement, and I would encourage you to honor your own choices. We are all different, and we should be allowed to make our own choices without fear of anyone else's judgement of them.
Bealeton, Va.: Ms. Shanley, you state that "You can have a better birth if you don't stand in your own way. or have other people stand in your way." All three of my children were born in Fairfax Hospital, without epidurals, episitomy, being tied down or a lot of uninvited prodding from medical staff. The anesthesiologist encouraged me to continue without medication because I was doing very well without it. My point being that hospital births are not so horrid. The parents need to be educated and ask for the kind of birth experience they want, then work with staff for the safety of child and mother. Since none of your children were born in hospitals, how do you know it's so bad?
Laura Shanley: I'm sure for some women it isn't bad. But I've gotten thousands of letters over the years from women who have been very unhappy with their hospital births. To each their own.
Laura Shanley: I've enjoyed this discussion! I encourage those who are interested in learning more about unassisted childbirth to visit my site, www.unassistedchildbirth.com
Mairi Breen-Rothman: I would love to continue this discussion, but our time is up. To answer a couple of last questions--you can google "complications of instrumental delivery" and find out the statistics about the harm caused by those procedures, which, again, can save lives, but do more harm than good by their overuse. Also, the question about sterilization--it is important that the area of a birth be very clean, but as the vagina itself is not sterile, birth cannot be considered a sterile procedure. Midwives bring sterilized instruments and create a sterile field in case stitches or other invasive procedures become necessary, but more than that is unnecessary. Thank you all for your thoughtful questions. Thanks, Laura, for sharing your experience and expertise! Mairi Breen Rothman, CNM
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