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August 7, 2003
I really, really wanted to backtrack and fully describe the weeks up until now. However, after a few days of trying to get started, I haven’t gotten anywhere. If I haven’t gotten it done during the slow times at work, it’s never going to happen, so I think I’ll just have to skip the month of July and move right along to August. I’ll try to sum up the important events and emotions that have come and gone when they tie in to the present so that they will not be lost entirely.
Yesterday, we had a consultation visit with a homebirth midwife (CPM) so I’ll use the opportunity to talk about my CNM visit two weeks ago, too. Dan and I have been debating between having a hospital birth with a Certified Nurse Midwife (CNM) fully paid and approved of by my insurance company, and having a homebirth attended by a lay midwife (CPM). The homebirth option would require a fight to be covered by insurance, but the hospital birth would require a fight while I labor in order to have the birth I want (as free from medical intervention as possible). I realize that most people out there think I must be more than a little nuts to contemplate giving birth with no possibility of an epidural. However, after hanging around iParenting for this many years, the more I’ve learned about labor drugs and interventions, the stronger I’ve felt that I want to avoid them if at all possible. With that mindset, I decided to take the CNM path within the HMO practice rather than go to an OB/GYN, and the only question is whether I will stay within the medical establishment at all, or go with a homebirth.
Tuesday, July 22, 2003
The long-awaited official CNM appointment finally arrives.
I prepared for the meeting (after six weeks of twiddling my thumbs) by bringing a list of questions I hoped to use to determine what sort of birth experience I was likely to have if I stayed with the HMO’s CNM. I was ready to demand C-section and episiotomy rates and was only worried that I’d put the midwife on the defensive and irritate her. Despite my readiness to fight, I was excited to FINALLY be having an appointment and to be told by a professional that we are truly having a baby.
Dan and I got to the 6:20pm appointment around quarter to six and I was promptly handed a nice stack of paperwork. I had fun seeing if I could check every single box labeled "I have a family member with this health problem" (I think I hit 4 out of 7) although I didn't have any of them myself. They don't give out WTEWYE, but the HMO made its own book with basic information. There were other goodies too, like parenting/childbirth class info. Around 6, a jovial nurse came to get us and brought us to a room. Do other clinics have scales in the individual exam rooms? I was really impressed that I didn't need to weigh myself in front of anyone, and I bet I'll appreciate it even more a few months down the line. I was up a pound from where I was the day I tested positive (I've been down a few pounds in the meantime, but settled about where I started since I resumed normal eating habits). She took my blood pressure, which at 118/72 was a little higher than normal for me. All this time, she's joking around with us and apologizing for the unending questions.
After the nurse took care of the basics, we got to meet the CNM. She's really nice, always laughing, and did a good job easing my nerves. She agreed that since I had a pap back in May, I really didn't need another one (yay!). She asked when my LMP was and wanted to know if I was sure. When I took out my book of charts and assured her that not only was I positive of my LMP, I also knew the 37 previous ones, she thought it was great. She started spinning the wheel and I explained my short cycles and showed my temp jump between May 31 and June 1. She respun the wheel and decided that Feb 22 will be my official EDD. I'm fine with that, although I'll stick with Saturdays as my 'new week' day and have Feb 21 in the back of my head as the 'real' edd. She then took out the Doppler as I assured her that I didn't expect to hear the h/b today, but would like to try at least. I heard a variety of weird sounds, but no baby heartbeat yet. Next time, next time.
About this time, I started worrying that I wouldn't have the nerve to ask the 50 questions I'd brought with me. I started with the easy ones, asking what my chances were I'd have her there for the birth. I'd have to hit a full moon to have her be at my birth (there's 13 midwives in the practice and only one on call with 12 hour shifts). You get who you get. I can choose to have prenatal appointments with different ones if I want, but since I can't hit them all, I figure I'll stick with this one. They have a joke that if you are delivering and see all the CNM's, your labor has gone on too long :)
She then explained that as far as prenatal testing goes, if I refuse the triple screen, they'd want me to do an 18-20 week u/s, but nothing else is routine. I'd be handed off to ob care for PIH, pre-eclampsia, multiples, or gestational diabetes (it sounds like the diabetes test is routine, too). I didn't need to pee in a cup (not sure if they just forgot, or if that's normal for them), and I couldn't feel the pin prick when the nurse drew blood. I’m a big needle-phobe, so I was very grateful that it went smoothly.
She wasn't put off at all when I started asking detailed questions about what's allowed during labor and what their various statistics are. She immediately rattled off the c-section rates--EIGHT TO TEN PERCENT for the CNM’s and 16-18% for the hospital's overall rate. Isn’t that amazing? She said she'd only done 2 episiotomies in 2 years and the same is true for most of her colleagues. When you show up, they do a 20 min EFM strip, then let you walk around. IV's aren't standard unless you're GBS+. Laboring in their shower/tub combos is encouraged. Birthing can happen in any position (she said going under the bed might be tricky, but everything goes). They discourage eating, but don't forbid it. She kept saying that nothing is done without asking the mother's permission first. If my water breaks, she said that if 24 hours have gone by without active labor starting, THEN they augment with Pit. Once it was pretty clear that I want as intervention-free a birth as possible, she made the point that towards the end of the pregnancy, she spends time figuring out what the mother wants and helping her determine how to obtain that outcome. If I'm going for no interventions, she said an important step would be to remain home as long as possible. She said that both the CNM's and nurses are in and out of patient rooms and that a doula would be great to ensure that there's constantly someone there for support (we’d already decided that if we go with hospital birth, we’re definitely hiring a doula). She asked if I planned to breastfeed and was pleased when I affirmed that. I think she's on some breastfeeding boards or something--I should go read her bio again.
I don't know what else I could have asked for in a CNM appointment. The only big concerns I forgot to bring up was limits to how overdue I could go, when inductions are used, and what her third-stage labor norms are. She really gave the impression that they’d ask before doing anything. I left the appointment more undecided than ever about where to birth. I really, really was not expecting to hear such low C-section/episiotomy rates. We definitely need to go check out the hospital's birthing center and see how 'homey' it really feels. If I am going to have nearly the same outcome and have it fully paid for with the exception of the cost of a doula, it's harder to convince myself that a CPM would necessarily be better. They could actually have a HIGHER C-section rate.
That brings us to the present. After talking with Dan and my online buddies (no one in real life seems to think it’s reasonable to consider a homebirth, with my mother the chief grumbler), I decided to call a CPM to arrange an initial consultation. I’ve gotten together with a group of local moms and doulas who advocate for natural births (www.childbirthcollective.org). One midwife’s name kept coming up as a favorite amongst the doulas, so I arranged to meet with her.
Monday, August 4, 2003 (our second anniversary!)
Unlike the CNM appointment, I went into this meeting really wanting to like this woman. A couple months back I spoke to a different CPM on the phone and wasn’t very happy with the numbers she gave me (half of primaparas transfer to the hospital being the key statement). After hearing only praises about this second CPM, J, I was somewhat afraid that she’s the best we’ll find in our area and if we don’t mesh well, I won’t mesh with any of the CPM’s. (There are about half a dozen within a reasonable distance.)
Dan picked me up from work at 3:30 and we drove to her home in a nearby suburb. She had said over the phone that she does prenatals all day Mondays, and we had the last slot of the day. We arrived a few minutes early and a man said we could come in (it turned out that he was waiting for the woman getting checked and didn’t live there, so it made more sense later). J. came down the stairs and told us to wait on the living room couch a few minutes while she finished her previous appointment. Right away, a few of my fears were extinguished by her initial appearance. I’d heard of many CPM’s being extra huggy and dressing fairly hippyish (probably a generalization, but hey, what else did I have to go on?). She was wearing a long cotton dress, but didn’t give off a vibe that she was stuck in the 70’s or anything like that. She smiled a lot and was very kind, but didn’t jump over to give us a bear hug. After a few visits, I’d be fine with hugs, but not on a first meeting.
Right at 4pm, a young woman and her two week old baby left, and J. ushered us up into a bedroom/office. She explained that once her 2nd child moved out of the house, she took over that bedroom and had her own space for the first time in two decades. She has four children of her own, all in their mid-twenties. Each was born at home. Once she’d birthed her own children, she realized that her fascination with birth was calling her to be a midwife. She seemed self-taught—she never apprenticed with anyone—and had a partner until last year when she died. She became certified through MANA when it became available but has chosen not to get licensed with the state. Over the past 22 years, she believes she has attended between 600-700 births. Now that her kids are older, she averages four births a month, but never turns anyone away, so there’s a lot of variation month to month. She works with four apprentices in various stages of learning. Once I’ve had a prenatal or two, she chooses an apprentice to come to all my remaining prenatals and the birth based upon our personalities. She uses a fetoscope to check the baby’s heart throughout pregnancy with one exception—if I’m laboring under water she uses a waterproof Doppler.
I’d already been given this impression by the doulas, but she made it clear that during labor, she stays as hands off as we’d like her to be. She encourages couples to take a childbirth preparation course, particularly the Bradley Method. She feels that giving birth is an empowering experience for the mother, but also for the couple.
Once we got started asking her various statistics, it was clear that she is not a data-oriented person. She does not keep her mothers’ records once their postpartum visits are done (she gives them to the mothers), and had to estimate all the details we asked. Since I have described myself as a numbers person, it surprised me how little her lack of detail bothered me. She was able to say that about one in five primaparas transfer to the hospital either in the last few weeks of pregnancy or during labor. Most she said were due to stalled labors that didn’t respond to anything in her bag of tricks or times when the moms or midwives got a bad feeling about how things were going. For instance, the mom who left as we came had delivered in the hospital. She was 42 weeks, 4 days, and at that point, neither she nor the midwives felt good about delivering at home. She was able to have a good birth experience at the hospital (I’m not sure if/how they induced her, but she birthed vaginally). J said that it was quite rare for multiparas to transfer to the hospital. The only one in recent memory had involved a woman with very bad tears.
Speaking of tears, J doesn’t suture. She does everything possible to prevent tearing, and instructs the mothers how to best care for tears, but she has chosen to let tears heal on their own. She said it was quite rare for tears requiring hospital visits to occur. Her view is that she is not part of the medical establishment. Suturing is a doctor’s job, and if she deems it the only way for a mother to heal properly, she will instruct the woman to go to a doctor to have this done. But it doesn’t happen often.
While I’m on the subject of hospital transfers, J. said that she does know of friendly ob’s that she can call when she determines that a mother needs to transfer to a doctor’s care for issues such as high blood pressure. During labor, if a quick transfer is necessary, she knows which hospitals are the most likely to provide good care to attempted homebirthers. She is able to birth breech babies and twins. She had a photo on the wall where she was helping birth a surprise footling breech. The birth had gone fine, although she had recommended the mother transfer to a hospital once the footling presentation was obvious.
One thing that surprised Dan and I were the number of postpartum visits J conducts. After staying 2-4 hours after the birth, she returns 24 hours later, three days later, and one week later. For primaparas and any mom with tears, she has them come to her at two weeks. For all moms, they also come to her for checkups at three weeks and six weeks. For the first week or two, she calls moms daily to check how they are doing, and after that, she encourages them to call with any concerns between visits.
Something I liked was that she brings some herbs to the birth in case of hemorrhage, but no Pitocin. I don’t know how common that is, but I don’t see how CPM’s can legally obtain Pit, and it makes me feel a little better knowing that she uses legal means of dealing with issues that may crop up. She also said that she doesn’t rely on the herbs, but gives the body time to deal with the 3rd stage of labor on its own. It sounded like cord traction and premature cord clamping/cutting aren’t things she does with any regularity. She also makes sure the baby has plenty of time to be with the mother and to get started breastfeeding before he’s washed or examined. The essential checks are done with the baby on the mother’s chest.
Then the nitty-gritty: J was quick to tell us that two babies have died during births she has attended. The first had a genetic defect that wouldn’t have been helped in any hospital. The second may have been avoided. Five minutes prior to her birth, the baby had a fine heartbeat, but at birth, she was in second stage apnea (oh darn, is that the right term?) and clearly hadn’t had a h/b for a few minutes. J was able to get her h/b back, but she never got a successful breathing rhythm. To exasperate the problem, after calling 911, many firemen/paramedics/etc came to their home but none were experienced in baby resuscitation. The one paramedic who took over didn’t breathe for the baby even when J insisted. The baby lived for a few days. J said this occurred a number of years ago. If it happened today, she wouldn’t allow a paramedic to give substandard care. She’ll never know whether the stopped heart would have been caught in time at a hospital or not.
And since money matters, whether we want it to or not, we asked about her fees. She charges $2,500, half due before the birth. At the time of the birth, she either needs the rest of the fee or a payment plan written up. She explained that she actually enjoys getting small checks every month as families continue to pay off their births. If a couple has insurance, once they’ve paid her, she sends the bill to a processor in Oregon who writes to the insurance company urging them to cover the birth, regardless of the policy’s stand on homebirth. J said that nearly everyone eventually gets reimbursed most of their money. It does require a fight for most people. Her stance is that anyone willing to pester the insurance company repeatedly and repeal their denied claims will eventually get their money back. Since I was under the impression that I would have no coverage for a homebirth, this was very good news. I’m stubborn enough to fight an insurance company darn it!
After visiting both the CNM and CPM, do we know which route we will take? No. Nothing’s that easy, right? As I mentioned earlier, the day of the CPM appointment was also our second anniversary. We are really cheap (and don’t have much money lying around even if we weren’t), which meant that we didn’t have any plans to celebrate. We ended up driving to a lake and walking around, discussing the differences between the two birthing options.
Some of the ways I expected to see large discrepancies turned out to not be so different after all. A variety of birthing positions are possible with either caregiver, episiotomies are equally unlikely, and the C-section rates don’t have as large a gap as I thought.
If we go with the CNM, there is a possibility of much more prenatal testing. Despite my lack of tests so far, I’d definitely have at least the midpoint u/s, and I’m sure if something out of the ordinary comes up, it would lead to future u/s’s as the pregnancy progresses (i.e. Laura R’s low-lying placenta). I’d also need to do the diabetes test and if I go overdue, I’m sure NST’s will be standard. None of those tests are routine with the CPM. If I’m two weeks over, she recommends an NST for reassurance. She keeps tabs on sugar levels using other methods. If I stay undecided for another two months, I would get the 19 wk u/s. I can’t decide whether I want it or not. And then there’s the fetoscope vs. Doppler debate, not to mention the fetal monitoring and guarantee that I’ll be at least occasionally hooked up to a machine while laboring in a hospital.
Most of me is leaning towards the CPM, I’m just trying to verify that I will indeed be most comfortable there. Dan was frustrated by her lack of hard numbers telling us exactly what happens in her births. I’d read him the Farm’s statistics given in Ina May’s Guide to Childbirth, and he was very impressed. J’s lack of state licensing doesn’t matter to me—if she wasn’t CPM certified that would make a bigger difference. I’m planning to look up the requirements for MANA certification. We figure that by seeing what they require, we’re guaranteed that J has experienced at least that variety of births. As I said earlier, I was surprised how little I cared about the exact statistics. I was comfortable knowing her approximate transfer rate and hearing what types of complications she has successfully encountered. We think I might be comforted hearing so many glowing recommendations from the doulas whereas Dan has had to take my word and therefore needs a little more reassurance.
I was quite surprised to hear about the insurance reimbursement. I have a feeling that when it comes down to it, money will play a part in our decision, and I’m glad to know there’s a good chance we wouldn’t be responsible for the entire fee. The other CPM I spoke with charged another $500, so I was happy to hear that J charges somewhat less.
Although J and I didn’t immediately click in a L.M. Montgomery “bosom friend” sort of way, I think we’d get along very well. I’m the same age as her kids, so she seems more motherly than peer-like. But she treated us as intelligent people who knew our stuff, and I was SO grateful for that. I’m sure the average homebirthing mother has spent much more time researching her options since it isn’t the status quo choice. Occasionally Dan would ask for explanations of terms, but she never talked down to us or did the intellectual equivalent of patting us on the head. Although the CNM hadn’t done that either, in her office I felt treated like a first-time mother who didn’t really know what was coming. The nurse in the CNM’s office particularly acted this way. I’d much rather have to request clarification now and then than have things glossed over. And as I said a few pages back, J seemed neither too hippie-ish, nor too medical. She seemed like the ultimate balance.
One thing we didn’t clarify as much as we wanted was the role of God in her life. We don’t expect her to have exactly the same background as us, but I’d be uncomfortable with a birth attendant whose religious ideas were in direct opposition to mine. She did say that in her life, God comes first, her family comes second, her midwifery comes third. That was enough for us to figure that we’re probably on the same wavelength. However, I left my sweater at her home, and I may ask her a little about her beliefs when I retrieve it.
After five pages of going on and on, I think I covered all possible angles of the midwife debate raging in my head. Our additional anniversary excitement involved going to Babies R Us and checking out furniture. Dan had fun unassembling and reassembling Pack and Play’s. We learned what brands we don’t like, at least! We’re thinking about buying one of those, but no “real” crib since there’s a good chance we’ll keep the baby in bed (or possibly a co-sleeper) with us for quite a few months. One aisle of BRU was all we could handle for one night. We finished the evening by heading to a burger and malt shop for dinner. My need for ice cream overcame my desire for a higher quality dinner.
In the 3 days since the appointment, we may have become homeowners (we’re currently waiting to hear if our offer was accepted). I’m hoping to write up that process before too long.
In the meantime, has anyone else sat on the fence determining whether homebirth is right for you? Any advice you can spit out would be greatly appreciated. I know in the end, we’ll go where we feel most comfortable. But where is that?
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