Please welcome today’s guest blogger, Martha Reilly, M.D. Dr. Reilly is an Oregon OB/GYN with whom I have recently been corresponding about the state of homebirth in our great state.
One of the most curious features of homebirth loss stories on the web and elsewhere is the closing remark, most often seen on Mothering.com, that “the doctor said this would have happened in the hospital too.” Some examples (all are taken from publicly accessible blogs):
- A healthy mother labors with very painful contractions at home and, when the baby’s heart rate drops into the eighties, is taken to the hospital where a complete placental abruption is discovered and she undergoes emergency cesarean, but baby is born dead and mom nearly dies from the complications of the abruption
- Breech/breech twins are delivered at home, with a particularly traumatic birth of the second (described in harrowing detail by the father) resulting in a depressed skull fracture. A mom is transported when the fetal heart rate drops and delivered by emergency cesarean, with the infant in for brain surgery and a long NICU stay.
- A HBA2C with several hours of painful labor and no progress which ends in uterine rupture, the death of the baby, and near-death of the mother.
- A twin birth with placental abruption before the delivery of the second twin, resulting in the death of that baby.
In all these stories, the narrator takes time out to report that the doctors said that birthing in the hospital would not have prevented the complication. The father of the twins goes one further and insists that he was told by his daughter’s neurosurgeon that a hospital birth would have killed her. This is the moment when, reading these narratives, I mutter, “Yeah, right.”
Where does this idea come from, this certainty that what happened at home would have happened anywhere? Why is it such a fixed idea? As an obstetrician who has received many homebirth transports, I’ve had way too much time to ponder these questions.
Some of the blame lies in the rather fixed and rigid belief systems of homebirth adherents. Birth, they say, is inherently safe, and most birth complications and almost all cesareans are the result of unnecessary intervention, so nothing bad, nothing really bad, can happen at home. When a birth goes awry, they simply accept the (to me) astonishing concept that it would have happened anywhere.
More blame can be placed at the feet of unscrupulous midwives, who have the ear and the trust of the mom, and are busily promoting the idea that the baby’s death was inevitable from the start of the transport all the way to the baby’s gravesite and beyond. But it’s not just a lack of scruples that leads them to take this stance: many non-medical midwives (such as Certified Professional Midwives) are woefully undertrained and understand the mechanisms leading to intrapartum death poorly.
Sometimes this trope results from timing of the narrative. Particularly on Mothering, the posts are often made within days of the baby’s death. When I read homebirth loss blogs I am particularly interested in the understanding that parents develop over time as they wrestle with their child’s death. Many parents (and I am thinking in particular of Wren’s and Aquila’s and Mary’s) devastating realizations about the choices they made, but only after months have passed.
What about doctors, though? What information given to parents leads them to report that “the doctor said this would have happened in the hospital?”
To understand what might be going on in the hospital, you have to understand what really happens at an emergency homebirth transport. We usually get a call that a mother is coming, but very little detail. Arrival is chaotic. Often the midwife has brought the mother separately from her family and support team. Frequently the records have been “forgotten” or are coming in a second car. We encourage our local midwives to explain what is happening to us, but in emergencies we are doing this at the same time we are drawing blood, establishing IVs, placing fetal monitors, and performing ultrasound. One of the special challenges in these moments is that homebirth patients many times don’t trust doctors, so we need to establish rapport with them at the same time we are acting as quickly as possible. Since the mother is often exhausted and frightened, it’s a very tense situation.
Another challenge is that the midwife’s report of her patient’s labor is often not reliable. There is some outright lying, but most of the problem lies in concepts that are, to put it kindly, different from the model of care we use. A typical report is that “fetal heart tones were strong,” that is, until they weren’t. Well, thanks, but no thanks. “Strong” has no meaning in the realm of fetal monitoring. Fetal heart tones are either fast or slow, present or absent. The details that I want from fetal monitoring, the ones that REALLY matter (accels, decels, variability) are not discernible without electronic fetal monitoring. So “strong” is useless information. Additionally, many midwives don’t recognize, or don’t recognize the seriousness of certain factors (meconium, prolonged rupture of membranes, post-datism), so these might be left out of their story altogether. Sometimes these factors are present, but explained away, such as the time one of my own patients transferred to a homebirth midwife and then was transported back at 43+ weeks with a stalled labor AND meconium. Her far-past due date was airily brushed away as being an “unsure” due date, even though she’d had a six-week ultrasound. Some (to us hospital providers) basic information is often missing: some midwives don’t believe in vaginal exams and will allow moms to push based on urge alone, many don’t check temperature or blood pressure regularly.
In short, in an emergency transport we generally operate as if the patient has walked in off the street, since what information we have from the midwife may be limited or unhelpful, and do an independent assessment. It’s important to remember too that precious time has usually been lost by the time the family makes it to the hospital. Most of these mothers arrive by private car, and sometimes they get stuck in traffic. A laboring woman, in pain and possibly ill, can be difficult to get dressed and into a vehicle. Even if someone has dialed 911, sometimes the mother’s preferred birthing place is not easily accessible to the EMTs.
Remember that our focus at these times is NOT on the homebirth debate. We are simply trying to do the best by our patients. We are not political animals at these moments. Most of us are not even ideologically opposed to alternative birthing practices (as long as they do not compromise our notions of safety), no matter what popular midwifery blogs might say.
Suppose then that the worst has happened, and that a baby dies. What then? I will never forget my first emergency homebirth transport. It followed what I would later learn was the usual pattern: the call came, mom arrived with two midwives and no records, midwife told a story that made no sense (she claimed the baby had been vertex and “heart tones strong,” but at eight centimeters, the baby had leapt out of the pelvis and turned breech, so she brought mom in). With some difficulty I got the midwife to step out of the way (she had placed herself between me and “her” patient) and addressed the mother directly. My ultrasound showed a breech baby. No heart beat. Mom’s cervix was completely dilated.
I’ll leave for another narrative how I had to dissuade the midwife from taking charge of the delivery of what turned out to be a perfect baby girl, who was easily delivered as a vaginal breech, and how I finally had to remove her from the room on the mom’s request (she was “normalizing” the baby’s death by coaching the mom to “join in spirit with the many mothers who have lost their babies in birth, and draw strength from them”), and move on to the topic at hand: what did I say to the mother?
What would YOU say? To this day, I am not certain why that baby died. I don’t have enough information to go on, really. She certainly was dead on arrival at the hospital, and mom certainly had been laboring at home. I got calls from people I’d never met who told me the midwife had lied about the due date, that the mother was diabetic and untreated, and so forth. Why might she have died? Cord entanglement is common enough with breeches, and this might have been the fault. Or if she was truly post-dates, the placenta may not have been adequate to support the baby in labor. She was not, by any available measure, diabetic. Who knows exactly why this baby died? I surely don’t. Do I believe this birth was preventable? Yes, that I do believe. If this baby had been monitored properly, and had been in a place where the changes in her heart rate could be responded to appropriately, she would have made it.
Here’s the important thing: the question of whether the baby would have died in the hospital never came up between the mom and me. Then or later. This mother has kept in touch with me over the years, and she came to her own conclusion, that her daughter would be alive today if she’d been in the hospital, and possibly if she’d chosen a different midwife. I agree.
Parents, all parents, want desperately to do right by their children. I have NEVER met a parent who wasn’t trying, to the best of their abilities, to provide what their children need. Mothers always blame themselves when something bad happens to their baby. In the moments of new grief, when the loss is fresh, I would never add to their burden by blaming them or their choices. My actions are not politically oriented; I would never be answering their questions with an eye to what might wind up on Mothering or Birth Without Fear.
So where does “the doctor said this would have happened in the hospital too” come from? If a patient asked me why her baby died, I would answer to the best of my knowledge, but my answers would be focused on scientific answers: infection, abruption, meconium aspiration, etc. Keep in mind, “home birth” is not a cause of death. What causes death is failure to intervene soon enough when bad things are happening. Three factors make this more likely to lead to death at home: midwives not well-trained enough to recognize a problem in time to intervene, difficulty and delays in transport, and the tendency to view transport as failure. While they will never show up on the death certificate, these are the things that kill babies. The truth is, parents have never phrased their question to me as “If I delivered in the hospital, would this have happened?” at the time of first hospitalization. These questions come much later, and the parents usually know the answer by then.