10 overused procedures

Is 40 Weeks the Ideal Maternity Leave Length?

Long leaves are good for both babies and mothers, but extra-long leaves may not be, and other surprising lessons from Europe.

By Sharon Lerner|Posted Thursday, Dec. 22, 2011, at 7:08 AM ET

How long do working mothers stay home after having their first child? If you guessed the answer might be 12 weeks (not an unreasonable assumption, since that’s the amount of time allotted by our national family leave law), you’d be sadly mistaken. According to recently released census numbers, a majority of mothers who worked during pregnancy go back before that, some way before. More than a quarter are at work within two months of giving birth and one in 10—more than half a million women each year—go back to their jobs in four weeks or less.

Let’s take a moment to think about what’s going on just four weeks after birth. Babies haven’t even cracked their first real smiles yet. Mothers are still physically recovering from birth, particularly if they’ve had C-sections. They’re both probably getting up several times during the night to nurse. In fact, they’ve barely begun what’s supposed to be half a year of exclusive breast-feeding, according to the American Academy of Pediatrics.

Yet going back to work in such a short amount of time isn’t just tiring or unpleasant, new research demonstrates that it’s bad for both women and children. We now have enough evidence to blame the short amounts of time mothers have with newborns for developmental delays, sickness, and even death. (I say mothers because, while most leave laws apply to men and women, women are far more likely than men to take time off and, thus, are the subjects of most research.)

Advertisement

So leaving aside for a moment the backward politics in the United States that leave us without any paid time off, what does this growing body of knowledge tell us about how much time would actually be optimal? Some of the results are surprising. For one thing, there is some evidence that very long leaves have an economic and professional downside for women, and at best a neutral effect on children. So it’s not simply that more time off is better. Rather, certain amounts of leave may give the biggest bang, while longer periods of leave may yield diminishing returns, at best.

By looking to Europe, which has meticulous data collection practices and a history of paid leave stretching back to the 19th century, researchers have been getting a better and better handle on the extent to which varying amounts of paid leave can save kids’ lives. Two studies, one published in the Economic Journal in 2005 and another five years earlier, examined the results of the steady climb in paid leave in 16 European countries, starting in 1969. By charting death rates against those historical changes, while controlling for health care spending, health insurance, and wealth, the authors were able to attribute a 20 percent dip in infant deaths to a 10-week extension in paid leave. The biggest drop was in deaths of babies between 2 and 12 months, but deaths between 1 and 5 years also went down as paid leave went up. So what was the optimal amount of time off, according to all this research? According to Christopher Ruhm, the author of the first European study, paid leave of about 40 weeks saved the most lives. (After that point, according to Ruhm, “there may even be some partial reversal of those gains.”)

Here in the United States, the few paid leave programs we have may be too small to make much of a difference, as the authors of a study published this month suggested after being unable to find any impact of state leave policies on children’s health. Efforts to study paid leave in this country are further complicated by the fact that those American parents who do get paid time off often tend to be lucky in other ways, too. That recent census report shows that only 18 percent of mothers with less than a high school education got paid time off compared with 66 percent of women with at least a bachelor’s degree. This makes it hard to know whether differences between American families in which a parent was able to stay home and families in which the mother went right back to work might instead be attributable to poverty, education, or other factors.

Turning our eyes back to Europe, there is evidence that leave—even when it’s shorter than that apparently ideal 40-week span identified by Ruhm—has not just health effects but measurable developmental and behavioral benefits, too. One study tracked Norwegian children who were born after 1977, when that country increased its paid leave from zero to four months and its unpaid leave from three to 12 months, and found that the kids born after the change had lower high school dropout rates. Military draft data, moreover, tied lengthened leaves to increases in male IQ (and height, too).

It’s not entirely clear why having parents around would help babies grow taller or smarter, or live long longer, but the research points to a few potential advantages to kids whose mothers stay home for at least three months. In another study published in the Economic Journal in 2005, American babies whose mothers were back at work within 12 weeks were less likely to get doctors’ visits and immunizations and be breast-fed. All this makes intuitive sense, of course: Checkups can help diagnose and treat illnesses, but they are hard to schedule when you’re working. And while exclusive breast-feeding for at least six months has been shown to prevent respiratory infections, bacterial meningitis, and other illnesses, going back to work can make it difficult if not impossible.

In the developmental realm, the benefits of leave may be trickier to explain. That 2005 Economic Journal study of American women who returned to work within 12 weeks showed that infants whose mothers went back even earlier were likely to have more behavioral problems and lower cognitive test scores at age 4. The authors speculated that the difference might have stemmed from the superior care babies receive from parents, as opposed to other caregivers. It might also have something to do with attunement, the crucial developmental process through which parent and newborn adjust to each other.

But what about those parents—most of whom are mothers? What do we know about what the ideal length of leave time might be for them? In terms of American mothers’ mental health, the best answer for now may be simply: more. Numerous studies have tied the lack of time off to depression in working mothers. Conversely, a 2004 study found that an increase of just one week of time off decreased the number and frequency of symptoms of depression in American mothers.

It’s easy to understand why an American woman going back to work just four, eight, or even 12 weeks after birth might get depressed—especially if she looks to Europe, where at least six months of paid leave is the norm and several countries grant more than three years.

Maybe we American women can cheer ourselves with the several recent studies that have failed to find benefits of such very long leaves. It turns out that the increase from 12 to 15 months of paid leave—which Sweden made back in 1988—doesn’t have a dramatic effect on kids. There is even some evidence that laws granting more than a year and a half off paid can hinder women’s professional achievement. It may be cold comfort, but at least this is one problem that we American mothers, facing the prospect of caring for new babies while somehow holding onto our jobs, just don’t have.

The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.

Preamble

Whereas:

• In spite of spending far more money per capita on maternity and newborn care than any other country, the United States falls behind most industrialized countries in perinatal* morbidity* and mortality, and maternal mortality is four times greater for African-American women than for Euro-American women;
• Midwives attend the vast majority of births in those industrialized countries with the best perinatal outcomes, yet in the United States, midwives are the principal attendants at only a small percentage of births;
• Current maternity and newborn practices that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence;
• Increased dependence on technology has diminished confidence in women’s innate ability to give birth without intervention;
• The integrity of the mother-child relationship, which begins in pregnancy, is compromised by the obstetrical treatment of mother and baby as if they were separate units with conflicting needs;
• Although breastfeeding has been scientifically shown to provide optimum health, nutritional, and developmental benefits to newborns and their mothers, only a fraction of U.S. mothers are fully breastfeeding their babies by the age of six weeks;
• The current maternity care system in the United States does not provide equal access to health care resources for women from disadvantaged population groups, women without insurance, and women whose insurance dictates caregivers or place of birth;

Therefore,
We, the undersigned members of CIMS, hereby resolve to define and promote mother-friendly maternity services in accordance with the following principles:

Principles

We believe the philosophical cornerstones of mother-friendly care to be as follows:
Normalcy of the Birthing Process

• Birth is a normal, natural, and healthy process.
• Women and babies have the inherent wisdom necessary for birth.
• Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such.
• Breastfeeding provides the optimum nourishment for newborns and infants.
• Birth can safely take place in hospitals, birth centers, and homes.
• The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth.

Empowerment

• A woman’s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care, and by the environment in which she gives birth.
• A mother and baby are distinct yet interdependent during pregnancy, birth, and infancy. Their interconnected–ness is vital and must be respected.
• Pregnancy, birth, and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.

Autonomy

• Every woman should have the opportunity to:
• Have a healthy and joyous birth experience for herself and her family, regardless of her age or circumstances;
• Give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well-being, privacy, and personal preferences are respected;
• Have access to the full range of options for pregnancy, birth, and nurturing her baby, and to accurate information on all available birthing sites, caregivers, and practices;
• Receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests suggested for use during pregnancy, birth, and the postpartum period, with the rights to informed consent and informed refusal;
• Receive support for making informed choices about what is best for her and her baby based on her individual values and beliefs.

Do No Harm

• Interventions should not be applied routinely during pregnancy, birth, or the postpartum period. Many standard medical tests, procedures, technologies, and drugs carry risks to both mother and baby, and should be avoided in the absence of specific scientific indications for their use.
• If complications arise during pregnancy, birth, or the postpartum period, medical treatments should be evidence-based.

Responsibility

• Each caregiver is responsible for the quality of care she or he provides.
• Maternity care practice should be based not on the needs of the caregiver or provider, but solely on the needs of the mother and child.
• Each hospital and birth center is responsible for the periodic review and evaluation, according to current scientific evidence, of the effectiveness, risks, and rates of use of its medical procedures for mothers and babies.
• Society, through both its government and the public health establishment, is responsible for ensuring access to maternity services for all women, and for monitoring the quality of those services.
• Individuals are ultimately responsible for making informed choices about the health care they and their babies receive.

These principles give rise to the following steps, which support, protect, and promote mother-friendly maternity services:

Ten Steps of the Mother-Friendly Childbirth Initiative
For Mother-Friendly Hospitals, Birth Centers,* and Home Birth Services

To receive CIMS designation as “mother-friendly,” a hospital, birth center, or home birth service must carry out the above philosophical principles by fulfilling the Ten Steps of Mother-Friendly Care.

A mother-friendly hospital, birth center, or home birth service:

1. Offers all birthing mothers:
   • Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
   • Unrestricted access to continuous emotional and physical support from a skilled woman—for example, a doula,* or labor-support professional;
   • Access to professional midwifery care.
2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
3. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
5. Has clearly defined policies and procedures for:
   • collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
   • linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.
6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
   • shaving;
   • enemas;
   • IVs (intravenous drip);
   • withholding nourishment or water;
   • early rupture of membranes*;
   • electronic fetal monitoring;

   other interventions are limited as follows:

   • Has an induction* rate of 10% or less;†
   • Has an episiotomy* rate of 20% or less, with a goal of 5% or less;
   • Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
   • Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
7. Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
9. Discourages non-religious circumcision of the newborn.
10. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:
    1. Have a written breastfeeding policy that is routinely communicated to all health care staff;
    2. Train all health care staff in skills necessary to implement this policy;
    3. Inform all pregnant women about the benefits and management of breastfeeding;
    4. Help mothers initiate breastfeeding within a half-hour of birth;
    5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;
    6. Give newborn infants no food or drink other than breast milk unless medically indicated;
    7. Practice rooming in: allow mothers and infants to remain together 24 hours a day;
    8. Encourage breastfeeding on demand;
    9. Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
    10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics

† This criterion is presently under review.

* Glossary

Augmentation: Speeding up labor.
Birth Center: Free-standing maternity center.
Doula: A woman who gives continuous physical, emotional, and informational support during labor and birth—may also provide postpartum care in the home.
Episiotomy: Surgically cutting to widen the vaginal opening for birth.
Induction: Artificially starting labor.
Morbidity: Disease or injury.
Oxytocin: Synthetic form of oxytocin (a naturally occurring hormone) given intravenously to start or speed up labor.
Perinatal: Around the time of birth.
Rupture of Membranes: Breaking the “bag of waters.”

Rethinking the Obesity Paradigm: An Insider’s View (Part One)
The topic of obesity and pregnancy is being written about more and more in the medical literature and the popular media.   The tone of these stories, however, has changed over the years to become ever more sensationalistic. There is so much gloom and doom information that sometimes it sounds as if no obese* woman has ever had a normal pregnancy or a healthy baby, which of course is not true at all.

What’s missing is a sense of perspective around the risk for complications; what is the real risk of experiencing that complication? How many obese women will not experience it?  How can we communicate risk information to women without sensationalizing it or presenting it in a shaming way? How does the tone of these stories reflect the moral narrative we have set up around obesity in our society?

Second, research articles rarely have any critical discussion of confounding or iatrogenic factors.  Instead, they tend to be simplistic litanies of risk rather than thoughtful examinations of outcomes.  How can we make obesity and pregnancy research more meaningful, and what new directions of investigation should be pursued? And given the spectacular failure rate of most weight loss efforts, can we find alternate methods of risk mitigation?

But the most conspicuous missing piece in these discussions is the voice of ordinary women of size and their lived experiences of pregnancy and birth.  Women of size are weary of being lectured at but not listened to; we want to share our own experiences about what worked in our care, how we were treated, what our challenges and special needs are, and what we want from our care providers.  The voice of women of size is an important missing part of so much of the discussion on this topic.

Rethinking Communication about Risks
One of the most difficult tasks for care providers regarding obesity and pregnancy is how to discuss the risk of complications in obese women accurately yet sensitively.

Many studies point out the increased rate of complications in obese women.  As other posts in this series have discussed, there is strong evidence that obese women are at increased risk for gestational diabetes, pre-eclampsia, macrosomia (big baby), cesareans, medically indicated pre-term birth, and birth defects ─ and these risks appear to escalate with increasing levels of obesity. In addition, there is research that obese women are also at increased risk for miscarriage, urinary tract infection, postpartum hemorrhage, blood clots, stillbirth, and maternal mortality.

Yes, there are risks to pregnancy at larger sizes, and some high-BMI women do experience complication. But the fact is that these risks, while not negligible, are not universal either. The truth is that many women of size have healthy babies without complications ─ but you’d never know that from reading media articles or medical literature.

Yes, we should discuss possible risks; that’s an important part of the healthcare conversation. However, instead of fair and balanced counseling about risk, some care providers have become “Scare Providers” instead.  And that’s not effective or helpful.

As reported on my blog and other blogs, some obese women report that they aren’t just being told about their increased risk for complications, they’re being told that they will get that complication; some are told to just schedule their cesarean from the beginning of their pregnancy. Some women of size have been told that if they get pregnant they’ll surely die, that they’re committing suicide by pregnancy, that their baby will have only a 5% chance of survival, that their baby will be deformed, that they should abort their baby because it would never survive anyhow, or that they better make funeral arrangements before their cesarean.

Because of our society’s dogged belief that obesity is all about willful sloth and gluttony, communication about risks has taken on an ominous moral overtone. Some media commentators imply that if the mother would only show a little self-control, she could stop irresponsibly putting her baby at risk.  Some portray fat mothers as despicable food addicts, akin to drug addicts and alcoholics, endangering their babies with their addiction.  Some imply that obesity during pregnancy is equivalent to child abuse.  Often an apocryphal story of an obese woman with severe complications is trotted out as a cautionary tale, implying that all fat women are at equal risk for such a dire outcome, and that anyone who dares to be pregnant while fat is the ultimate Bad Mother. Or as one blogger puts it, “fat is the new crack” in bad-mother blaming.

Such fat-shaming tactics backfire in the long run.  The hyperbole around risk can become so extreme that many obese women stop listening, tune out the lectures, or avoid medical care entirely. Few things frustrate women of size more than medical bullying, and a common defense against it is avoidance.  If care providers want their message to be heard, fat-shaming is not the way to do it.

Another problem with obesity public health campaigns is that they don’t provide enough perspective around the risks. Mental inflation of risk occurs because many researchers use odds ratios instead of actual numerical risk.  For example, some studies have found 2-4 times the risk for Neural Tube Defects (NTDs) in obese and morbidly obese women.  Sounds scary, doesn’t it?  Yet rarely do the studies or articles mention that double or even quadruple a very small risk (about 1-2 per thousand) is still a very small risk. Do the math. Even if there is an increased risk, less than 1% of obese women will probably have a baby with a NTD.

Odds ratios inflate the sense of risk while obscuring the fact that the actual numerical risk for a complication is relatively low. It doesn’t mean that increased odds for a complication is meaningless; that does still have meaning and needs to be paid attention to. But it’s important not to overreact to it either.

Gestational Diabetes is another area in which risk gets amplified by the way it is presented. Many large studies find that the risk for GD hovers around 10-15% or so in morbidly obese or super obese women. This is compared to a risk of about 2-5% in the non-obese population, so it definitely is an increase in risk. However, it also means that about 85-90% of these women will not experience this complication.  Do you come away from articles on obesity and pregnancy with the impression that more than three-fourths of very fat women will not be diagnosed with gestational diabetes?

It’s important that care providers explain that when they say a certain group is more “at risk” for a certain complication, it doesn’t mean that all or even a majority of the group will experience that complication, nor does it predict individual outcome at all. Again, actual numerical estimates are helpful in putting the risk in perspective.

So how does a care provider or childbirth educator discuss risk with a woman of size?

First, don’t forget to mention that many women of size have normal pregnancies, births, and babies. This is information that is rarely mentioned but is deeply appreciated by women of size.

Second, compassionately present information about possible risks, using both odds ratios and actual numerical risks in order to place things in perspective.

Third, be sure to let the woman know that if she develops a complication, it doesn’t mean she’s a “bad” mother, that there are treatments available to try to minimize problems associated with that complication, and that women of all sizes experience complications.

Finally, emphasize the proactive things that women of size can do to minimize their risk of complications. (More on this soon.)

Knowledge is power. Yes, there are risks to obesity and pregnancy, but it’s important to know the real magnitude of those risks, and to know that if complications occur, they are usually manageable with supportive care.  More importantly, it’s helpful to know that proactive action may help mitigate the risks; this leaves women much more hopeful than when risks are presented without such context.

Women of size deserve to be informed consumers. They deserve accurate information about the potential risks; they deserve to hear it without scare tactics or shaming; and they deserve information about how to be as proactive as possible in minimizing these risks. Care providers need to do a better job of communicating this information non-judgmentally or risk women not listening at all.

Epidural anesthesia remains the most popular form of pain relief in labor. Nurses, physicians, and many midwives like epidurals because the mother is comfortable and quiet, resulting in less work for hospital staff.

Laboring women like epidurals because they can remain awake and alert, while feeling little or no pain during labor.

Many negative aspects of epidurals have been debated among researchers. Downsides to epidurals reportedly include delay in labor, increase in vacuum/forceps deliveries, and increase in c-sections.  But aren’t these possible side effects outweighed by the positive effect of a pain-free labor?

In one research study, investigators found that women who had pain eliminated during labor still reported that they suffered!  Concluding that no pain did not necessarily mean no suffering, Wuitchik¹ emphasized the need for women with epidural anesthesia to have continual labor support available.  In this study, women described distress over itching, numbness, and nausea–all side effects of epidural anesthetic.  The women also reported concern over the baby’s well-being.  A common effect of epidurals is a prolonged drop in the baby’s heart rate. While hospital staff may take this in stride, it can be very frightening to the laboring woman.  Another interesting finding was that women reported feelings of incompetence and fear over being left alone once they were “comfortable”. Wuitchik concluded, “With epidurals, pain levels were reduced or eliminated.  Despite having virtually no pain, these women also engaged in increased distress-related thought during active labor.  The balance of coping and distress-related thought for women with epidurals was virtually identical to that of women with no analgesia”.

Women who had epidurals expressed just as much need for continued support as women who had unmedicated births, concludes another research study.²  In fact, satisfaction with the support received during labor had more influence on the woman’s satisfaction with her birth experience than her level of pain relief did, according to Mother-Friendly Childbirth — Highlights of the Evidence.

If you are planning an epidural, or even if you are not planning an epidural but plan a hospital birth — do yourself a favor and hire a doula for continuous labor support.  It can make a huge difference in your satisfaction with your experience.  I think the fact that continuous support influenced birth satisfaction more than pain relief  explains why many studies conclude that women who had unmedicated births (most often these are women who have doulas and/or midwives during labor) were happier with their experiences than those with medicated births.  It’s not the medication or the absence of medication that made the difference, but the presence of someone there to give continual support.  A partner may give excellent support, but partners need support, too!  Partners get tired, need to eat, go to the bathroom, get discouraged, just like laboring moms do.  A doula is there for both of you, and a good doula will give you your space when you need it, time for just the two of you when you need it, yet be there with just the support you need at the right moment when it is needed.

1.  Wuitchik M,  et al.  (1990)  Relationships between pain, cognitive activity, and epidural analgesia in labor.  Pain 41:136-142.

2.  Lally JE,  et al.  (2008)  More in hope than expectation: A systematic review of women’s expectations and experience of pain relief  in labour.  http://www.biomedcentral.com/1741-7015/6/7/abstract

About the book:

“Do you know what a maternity ward, a mountain top, and a four-wheeler all have in common? The answer can be found in one of the many stories of  Birthing in Alaska: A Modern Woman’s Guide. Women from all over Alaska share their unique yet powerfully related birthing experiences involving failures, successes, accidental home births, and unexpected cesareans.”

You can order a copy online from Balli Birthing for $12.99 + $5.00 flat rate shipping.

I believe that having a good birth experience is and should be a factor in women’s decision-making about where to give birth. But I don’t believe it should be the primary factor, and don’t believe it is for most women, including those who chose homebirth. There is no doubt that for a women who wishes to avoid medical intervention as much as possible, the experience will almost always be better in her own home where she can feel more in control of what is done to her and it is easier to relax. However, some women (myself included) would be willing to give up these advantages to themselves if it equated to better outcomes for the baby.

So, the question is, how does homebirth affect babies? Does being born at home harm them, have no effect, or help them? Theoretically, homebirth is a “more peaceful transition” and the baby “benefits from the mother’s lack of trauma,” but is there anything clinically measureable? What follows is my attempt to answer these questions with research. I have included citations and links to all the studies I cited so you can look at them yourself and make your own judgments about them. What I have linked to is what I read–in some cases full studies, and in others an abstract or the results cited in another article.

Clinical benefits of homebirth for the baby:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6). Babies of mothers who plan homebirths also:

• are less likely to require resuscitation at birth (2, 3, 4)
• are less likely to take longer than 1 minute to establish respiration (4)
• may have higher 5 minute APGAR scores (4, 6)
• are less likely to need oxygen therapy beyond 24 hours (2)
• are less likely to experience meconium aspiration (2)
• may be less likely to be admitted to the NICU (1, 3) though in one study (1) this difference disappeared when the data was controlled for risk factors
• are less likely to be born by cesarean, forceps or vacuum extraction (4, 5)
• are less likely to have birth trauma (2)

Why the differences?

Some possible explanations for the differences in neonatal outcomes:

• Women who plan homebirths are less likely to have obstetric interventions, including electronic fetal monitoring, augmentation of labor, assisted vaginal delivery, cesarean section, and episiotomy (2).
• Women who give birth at home feel more free to move and be upright during labor, which can promote progress without the use of oxytocin augmentation (7), thereby avoiding pitocin’s potential side effects on the baby.
• Women who give birth at home are not under any pressure (direct or subliminal) to push in a bed. Studies show that upright birth results in a shorter pushing phase (8), higher APGAR scores, and lower arterial pCO2 with unchanged pO2, which indicates less transient cord compression (9).
• Women who give birth at home are not given any pain medications that have effects on the newborn’s breathing or that increase the need for assisted delivery (10, 11). The vacuum extractor, the most common method of assisted delivery used today, is associated with slightly higher rates of neonatal cephalhaematomata and retinal haemorrhages (12)
• Babies born at home do not have their cords cut immediately. Academic OB/GYN has covered the research about cord clamping timing–see this post and these videos. In my experience, delaying cord clamping in most hospitals is much easier said than done, though hopefully this is changing.
• Babies born at home are almost never separated from their mothers. Most hospitals fail to implement immediate skin-to-skin contact as standard practice, despite the well-documented benefits for the newborn, including a positive impact on breastfeeding rates, breastfeeding duration, temperature regulation, cardio-respiratory stability, and infant crying (13).

It could be questioned whether the good outcomes were more related to midwifery practices than the place of birth. Some argue that midwives working in hospitals where there is immediate access to emergency care could get better results than they get at home. One study (2) found better outcomes for homebirths when comparing between home and hospital births with the same cohort of midwives. The difference could be attributed to different patient preferences in the two groups, such as a desire for pain medication in the hospital group. However, as I learned in my first birth, sometimes women who desire low-intervention births find that the hospital environment and protocols make this more difficult. Hospital policies often require providers to intervene in certain situations, such as slow or stalled labor, prolonged rupture of membranes, or a certain amount of time passing between full dilation and birth of the baby. Homebirth protocols are usually less restrictive, allowing more women to birth without intervention (without compromising results, if the protocols they are using are appropriate). Theoretically, women who birth at home will need intervention less often because being in a low-stress environment with minimal disturbance will promote optimal labor hormone release, resulting in less protracted labor and better natural pain control. And the research I’ve cited here indicates that when birth can safely occur with less intervention, better outcomes for babies result.

 

Some Caveats

Of course, it is important to recognize that we are talking about low risk birth here. Some higher risk women probably are taking an increased risk to their baby by choosing homebirth. I don’t think all of them are necessarily “all about the experience” either. Most of them, I believe, are in a situation where they are certain or nearly certain to have a cesarean if they birth in a hospital, and they believe that the risks of surgery do not outweigh those of vaginal birth with their increased risk situation. However, these higher risk births would be much safer if they had immediate access to emergency care while still being able to give birth vaginally. While I am saddened by the lack of options for these women, homebirth is not meant to be a last resort for those in unusual circumstances that cause them to feel that the safest birth for them (vaginal birth in a hospital) is not an option.

It is also important to note the qualifiers “under a supportive system” and “with a qualified attendant.” I believe it is very important to have a well-trained person you can trust to help you determine when intervention is truly necessary for the safety of you or your baby. The majority of homebirth research I have cited here is international. Many other countries have different requirements for midwife training than what we have in the U.S. In most of the countries where large-scale homebirth research has been done, homebirth midwifery is integrated into the maternity care system, allowing for smooth transfer in the event of an emergency. In the U.S., it is very important to ask questions about your midwife’s qualifications, and be familiar your state’s laws about direct entry midwifery (see Citizens for Midwifery) and requirements for licensure. Twenty-two states currently do not license direct entry midwifes. If your state is one of these, The Big Push for Midwives, is a resource that may help you get involved if you are interested. The requirements for the national direct-entry midwifery credential (Certified Professional Midwife or CPM) have been criticized for not being extensive enough, and are currently going through a revision process. It is also important to take into account the attitudes towards homebirth in hospitals in your area, as many in the U.S. are not supportive, which may interfere with transfer and care after transfer, should it become necessary.

Please review the the studies below, and, as always, consult with a qualified medical provider to help you make decisions about your care.

References:

• Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
• Outcomes of planned home birth with registered midwife vs. planned hospital birth with midwife or physician
• 3. Ontario study, outcomes cited in this article
• 4. A matched cohort study of planned home and hospital births in Western Australia 1981–1987
• 5. The Farm Study
• 6. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
• 7. Ambulation vs. oxytocin in protracted labor: a pilot study
• 8. The Squatting Position for the Second Stage of Labor: Effects on labor and on Maternal and Fetal Well-being
• 9. A comaparision of fetal outcome in birth chair and delivery table births
• 10. Epidural vs Parenteral Opiod Anestheia on the Progress of Labor
• 11. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid anesthesia: systematic review
• 12. Vacuum extraction versus forceps for assisted vaginal delivery (Cochrane Review)
• 13. Early skin-to-skin contact for mothers and their healthy newborn infants

This wonderful blog post was borrowed from http://birthunplugged.blogspot.com/

by Tony Whitman

When my wife decided to have a homebirth – she did her best to furnish me with the best reading and preparatory material that was available. However, since I was neither a medical professional nor a woman, the material just did not really apply to me. I could not memorize the medical terminology or get all touchy-feely for the homebirthing guides to really sink in. After our birth, I decided to write my own guide – to touch on the things that I wish someone had told me, in ways that I could understand.

The approach of this guide centers on a checklist of things that I feel a man needs when being the other primary person in his wife’s homebirth. There may be doulas, midwives, family, friends, and a host of other related people at the homebirth – but even with these people present, I still feel that men are the most important person there in their wife’s eyes; and will need this information. The steps of the homebirth will be walked through and discussed in terms of the item on the checklist needed for it.

These are the items that men need to assist in a homebirth (not in order of use by the way): a black-light, princess wand (a Barbie wand or any other type of wand toy will do,) fun-house mirror, catchers mitt/fishing net/soccer gloves, pocket watch, thesaurus, woman who has witnessed a live birth, six pack of beer (or favorite alcohol), shovel, bucket, 1 dozen eggs, shredded mozzarella cheese, shower shoes, swimming shorts, push-up/pull-up bars or a wheelbarrow, old table covers (plastic holiday ones are best,) 1 big steak (or other red meat,) and 1 big cliche. Most of these items are for preparing for the birth, while a few are for the actual birthing.

The first real stage that lets a man know that labor is coming is what I call the “Hypno-Fog.” For example: my first child’s birth, (at a ‘birthing center’ – which for me seemed to be a glorified hotel room with an attendant who spoke English, but that’s not important,) I fell asleep when we got there while she was in labor. She gave me shit for years. With the second pregnancy I slept almost 18 hours a day for the week before she was due in preparation.

So when I came down the stairs and was informed that she was in labor at 9am-ish, I felt ready this time since I just slept for 10 friggin hours. Alas, after hanging around downstairs for about 10 minutes, my eyes rolled into the back of my head and I went and took a nap. On a side note, this is where the doula’s biggest strength lies – they are highly trained to withstand the Hypno-Fog. It was after that nap during the Hypno-Fog stage that I discovered that women who are about to go into labor cast this area-of-effect spell that can drop a man to the floor in a matter of minutes.

So, you can either do what I did and sleep till she has that five minute window of alertness when she tells you it’s time before she goes into labor la-la land…Or you can buy a pocket watch at month three of the pregnancy and try to hypnotize yourself once a week. Building up an immunity and resistance to trances will greatly increase your chances of withstanding the Hypno-Fog.

Now your wife is in labor-la-la land. You can tell her that President Reagan has crawled out of his grave, went to Burger King, and brought us some burgers – and she will say that sounds great! This is where the thesaurus comes in. Almost every guide out there says men need to say supportive things in-between contractions for thousands of reasons. But hey, I’m no PhD in English Composition – there are only so many different ways a person can say “Great Job Honey,” or “Doing Good!” So, during the last three months of the pregnancy I highly recommend writing down as many different ways of saying “good job” as you possibly can. Then take this list and write it on your wrist while she is maintaining her Hypno-Fog.

It’s been a while since the Hypno-Fog has dissipated. She’s knee-deep in contractions. Go have a beer. Seriously. One beer, or a few sips of wine, or even a shot of scotch. Even though you and Ronald Reagan are sharing that burger in the kitchen – your wife’s instincts are going strong in Superman mode. If you are tense, stressed, or panicky, she will sense it and she will become tense, stressed, or panicky. This is where I highly, highly, highly recommend the one beer an hour rule. My advice here is for taking the edge off. If you just hammer the beers and get drunk, then you are worthless and a moron; and you and your wife should not have procreated. Having said that, there is nothing wrong with stepping out for a second and having a few sips of beer. (Make sure you have gum as well, beer breath is nasty to women in general, but especially women in labor.)

Now you’re relaxed, your wife is relaxed, and her body is completely dedicated to pushing out Worf, Son of Mog. This is where the fun house mirror comes in. I learned that a woman’s body in labor is like a slinky made out of chicken bones. It bends and warps in ways unimaginable to us mere men. If you stand in front of that fun-house mirror once a week and practice viewing how the body warps, twists, and morphs like a long lost member of the X-Men – you will actually be able to assist your wife in active labor.

Basically, my wife asked me to push and pull in places that seemed entirely unrelated to me. For example, if you push on both sides of her hip bones, her pelvis fans out at the opposite end like a Chinese paper-fan. If you push on her tailbone, her uterus does a reverse-gainer with a triple-twist-Greg-Louganis style. During labor I really had to fight the urge to push on other places to see what else would happen. Maybe if I put my left index finger on the base of her skull, and my right elbow on the 5^th lateral vertebrae – I could get her to reflexively punch a hole in the shower wall. This is the type of mentality you need to have, by practicing with that fun-house mirror, when she asks you to push somewhere specific to help.

After some serious labor, the baby is close to ‘presenting’ (or popping out.) Your wife will start to plead with you to do something about the pain. You can do what I did – sit there like a buffoon with a confused look on your face. Or… you can bust out the Princess Wand with confidence and start waving it over her while chanting “Anall Na-thrach Uth-Vas Bethud….” There is nothing worse that sitting there helpless while she asks you to perform magic tricks. At least with the Barbie princess wand you can make it look like you are making the utmost effort to make that pain go away even though she repeatedly stated before the birth that she wanted a “natural birth.”

The pain is magically gone from the wand waving, and now the baby is presenting. If you took this manual seriously – then you are ready for what comes next. You took that black-light and bathed yourself in its hippy-trippy glow in a dark room a few times for this moment. The baby will be a splendid combination of purple and blue when it comes out. Don’t panic, you’re wife did not have an affair with Papa Smurf. That color is natural. You may have watched some you-tube videos of live birth, but it just doesn’t come close to seeing it in real life.

The baby’s Klingon-like head is starting to come out fully. This is where the woman who has witnessed a live birth comes in handy. It took every ounce of willpower I had to keep from blurting out “dear god I thought pterodactyl’s were extinct, where is the rest of his face?!?!” But luckily I had the quick wit to look at my wife’s friend and mouth the words “Is this normal?” And she also had the common sense to just nod instead of calling me a total idiot. The bottom line, the last thing your wife will want to hear while she is pushing a baby out is you exclaiming shockingly that the baby is a mutant and the other woman stating that you are in fact, an idiot. She might start to feel that there might indeed be something wrong with the baby, and panic herself.

While waiting for the baby’s shoulders to come out – I stumbled upon one of the most fascinating psychological phobias in the history of mankind. Even though your wife tells you she has the utmost confidence in you as a husband, lover, father, friend… she still harbors the very deep-seated fear that when the baby comes out you will be attempting to use a Jedi mind trick to make the infant levitate in place for fifteen minutes.

Yes, you heard me right, all woman have the real and serious fear that men will drop the baby when it comes out. She may be able to feel your forearms pressed on her thighs, she may see the top of your head as you are peering intently into her nether regions like you are deciphering Linear A writing, but she still thinks you are just hiding that apple and chainsaw and will start to juggle that baby when you have a firm grip on it. I wish that someone took a picture of my face so all could see the look of puzzlement when she asked me three times if I was ready to catch him.

This is where the catcher’s mitt, fishing net, or soccer gloves come in. Choose one of those three items (if I ever catch a baby again, I’m going with the soccer gloves with the rubber gripping.) Set that item next to the place where your wife plans on having her baby at least two months prior to the due date. Seeing it day after day will help to dispel her phobia and make the last stage of labor more pleasant for the both of you. She will instinctively know that when the baby comes out, you will indeed be very ready; and that is no need to worry about your silly Jedi mind tricks.

You’ve caught the baby, it is in your hands, and your wife is crying. After the glow wears off, you will notice that you are covered in more fluids than your favorite porn star. You will need to be able to walk around without slipping and falling like a bad cartoon. The shower shoes and swim trunks help serve this purpose. But furthermore, you wont be grossed out or panicky that you are now a walking petri dish for a new secret government biological weapon. I made the hilarious attempt to count how many different fluids were on me and baby. I stopped counting at seven.

One month prior to the due date, take an afternoon off. Grab that bucket, the eggs, the mozzarella cheese, and the shovel. Put a shovel-full of dirt in the bucket, put in the dozen egg yolks, and the cheese. Mix it all together. Pour it all over yourself, let it dry….and let it stay on you for roughly three or so hours. I think you get the gist. The mud is the mix of blood and feces, the egg yolks for that nice texture and consistency, and the cheese represents the mucous and vernix. Doing this exercise will make sure you will not be distracted when you are covered in this wonderful biological recipe.

For even though the baby is out of your wife’s body, the process is still far from over. I was under the naive assumption that hey, baby’s born, time to make some calls and get some rest…..oh no my friend. Not even close. While the wife is in labor, the plastic table cloths should be put any where on the floor where she plans on walking. Most men are not told that when the placenta comes out, it is also accompanied by golf-ball sized clots of blood, or just blood in general – along with leftovers of your famous Colonel Manly’s bucket recipe.

The placenta is out, and its friends are scattered on the floor like a Jackson Pollack painting. If you’re lucky, your wife didn’t have a too difficult delivery. But more often than not, she can barely stand up. Did you buy those push-up bars? If you are a well prepared man, you exercised for the whole nine months and are strong enough to wave your blond Fabio locks in the wind, pick her up like the Queen she is, and carry her to the designated place of rest while singing The Music of the Night from the Phantom of the Opera soundtrack.

Or…you are a lazy schlub like me who gets winded after retrieving the remote from the other couch. In this case, if necessary, bust out that wheelbarrow and cart her to the place of rest while resisting the urge to make livestock sounds. It is around this time that she is returning from her journey to labor-la-la land and will start to remember the things you said.

The birth is done, you have showered – but what is that smell? Ah yes, you wont notice it. During your preparatory afternoon of walking around covered in dried and sticky Colonel Manly sauce, you took that steak, cut it in half; and let half of it sit around in the sun for two hours while you put the other half in the oven and let it burn. Then you put the two differently prepared halves of the steak into a bowl, and let it sit on the counter for two days. This will imitate the lingering smell from the fluids released during the birth. But have no fear, it will go away. Just tell people visiting the baby that you sacrificed two baby lambs to the great fire of Zeus in your den in honor of the new arrival.

When all is said and done, there is one thing you will need throughout all of this. Your wife will never tell you what it is, but I will. It is a cliche. During her nesting stage your wife will have lists for other lists. She will have bags of items placed strategically around the house in case of nuclear attack. You don’t need to know what is on these lists, or what is in the bags. These are more for easing her recovery after birth than for you to administer and memorize.

In this case, that cliche is presence. She needs your strong presence. To be the clear-headed and commanding person there. This doesn’t mean be a control freak, a micro-manager, or a bossy dick. You don’t need to go to other end of the pendulum either and be the towering mute moron standing in the corner barely caring whats happening. It means just have that aura of confidence that lets her know that you know that everything will go perfectly. If she knows that, despite the overwhelming absurdity that men feel being an active participant in a birth, you are totally there and engaged – it will be better than any drug or shortcut a person could have up their sleeve. And by killing two birds with one stone, by being there with her to ease the whole process and making her memories of the birth more positive – she will repay you in the future. Women know men like rewards too.

Copyright 2010 – Tony Whitman, published here with permission.

Happy Father’s Day!