Today, June 10, marks a landmark in reproductive rights and women’s sexual independence — the 50th anniversary of the debut of the Pill. Somewhat embarrassingly, my perspective of reproductive rights has always been largely self-centered, stemming from my own reproductive needs of the moment. From when I became sexually active until I became pregnant with my son, that was the need to avoid pregnancy.
A longtime committed proponent of access to sexual education and contraception, I view the abortion issue rather simplistically: Like it or not, abortions are going to happen; therefore, they must be kept safe and legal. My likely romanticized image of the sexual revolution of the 1960s is one of women finally being able to explore their sexuality without fear of pregnancy. For much of my life, these ideas and goals were things I believed in largely because they dovetailed so seamlessly with my own interests.
Only when my reproductive needs changed did my narrow-minded perspective broaden a bit. This is probably utterly obvious to everyone else, but I did not realize until my pregnancy and the birth of my son that reproductive rights include the right to choose not only whether to reproduce, but also how to reproduce.
The choice my husband and I made to pursue a midwife-attended homebirth was met with more opposition than we had expected. I was surprised how often it came up, usually when someone would ask which doctor or hospital we were using. Judging by people’s responses upon hearing our plans, one might think a midwife-attended birth was something radical and untested at best, if not outright deviant or dangerous.
On the contrary, midwifery is not a radical but in fact a traditional and time-honored medical profession, and midwife-attended births are backed by compelling statistics that made me want to have my child at home. Once I started looking at the numbers, it simply seemed safer. According to the Centers for Disease Control and Prevention, the risk of infant death is 19% lower in midwife-attended births — whether they occur at home, at a birthing center or in a hospital — than in physician-attended births. The national rate of Cesarean deliveries is currently at 32% and rising, despite the fact that the World Health Organization has set optimal Cesarean rates at around 5–10% of births (above which Cesareans veer into the territory of doing more harm than good). Another definition for “traditional” might be “exercising the conscious decision not to use limited resources needlessly,” and hospitals and medical care are certainly precious resources. With the vast majority of pregnancies and births being normal and complication-free, many costly medical interventions regularly used during labor and childbirth are both risky and unnecessary.
Here is a local example that is compelling to me: The wonderful midwife here in Austin who helped deliver our son has attended around 2,000 births, with a transport-to-hospital rate of about 3%. That means that, of those 2,000 births, some 60 have required transport to the hospital for interventions such as the use of medications, forceps or, in some cases, a Cesarean delivery; the other roughly 1,940 have been normal, safe, vaginal births. If her numbers matched the national Cesarean rate, she would have had a whopping 640 births resulting in Cesarean deliveries.
These issues come down to relatively simple truths, the basic differences between midwives and obstetricians. In the words of my midwife, midwives are “experienced in what’s normal,” trained to recognize when anything during pregnancy or labor deviates from the norm. Obstetricians, on the other hand, are trained in pregnancy-related illnesses and surgeries. It seems no wonder that the vast majority of midwife-attended births proceed without complications and result in normal, vaginal deliveries, while one-third of obstetrician-attended births end in major abdominal surgery.
Here is another unpopular reproductive choice I made: When our midwife recommended a sonogram at 20 weeks of pregnancy, as she recommends to all her clients, I researched sonograms and, based on my findings, declined. I did not want to expose my unborn child to potential harm if it was not necessary to do so, and from all indications, the baby was thriving. Besides, I felt I would continue the pregnancy no matter what a sonogram might reveal. My midwife and husband supported my choice. But most people who asked the right combination of questions to make me reveal, ultimately, that I had not had a sonogram looked at me as if I were a criminally or at least insanely neglectful mother-to-be.
Then, after an exceptionally healthy, happy, 41-week-and-four-day pregnancy, a beautiful, excited start to a homebirth and then a rushed transport to St. David’s Hospital, our son August died at birth of a birth defect we hadn’t known he had. It was a defect that could have been detected by sonogram, though it was not detectable by any other measure (his heart rate, growth, movements and neurological responses all seemed completely normal and healthy throughout the pregnancy; there was nothing that indicated anything was amiss).
In the months since August’s death, I have wrestled with a lot of guilt, much of it centered on that choice not to have a sonogram. Guilt is a strange beast in that it tends to trump truth and logic: It’s true that I based the choice in research, my desire to protect my unborn child, and my conviction that I would continue the pregnancy no matter what. It’s also true that not knowing August had a fatal birth defect made for an absolutely joyful pregnancy — and August himself was likely content and stress-free as a result. Still, even knowing those truths, and knowing August would have died no matter what, for months after his death I tortured myself with obsessive thoughts of what I “should” have done differently.
Thanks in large part to our incredibly supportive friends, family members and midwife, I have worked through most of that guilt. Part of working through it involved the realization that I was exercising my reproductive rights: In quitting taking the Pill, I was choosing whether and when to reproduce. When I got pregnant and we began interviewing midwives, we were choosing how we wanted our child to be born.
Once, a friend told me she believed every woman should get to choose the birth that is right for her. “Not me!” I blustered. “I think everyone should choose homebirth — it’s just so much safer!” Since then, fortunately, I have become more flexible on the subject. Another of my best friends just had her baby girl in the hospital, where she felt safest, with an epidural that helped her stay calm, relaxed and pain-free. Should she have had a homebirth instead? Of course not. She got to choose. If I am lucky enough to have another child, I will again choose a homebirth.
How wonderful that we have such agency in such personally important matters. Thank god we still have the freedom to choose.
Happy birthday to the Pill.
Dear Catherine,
Thank you for sharing your experiences with such beauty, straightforwardness and clarity. You are brilliant and a wonder.
Love,
Mary
Mary, I meant to say sooner — thank you so much for this comment, and for your support!
i had three homebirths here in austin texas. the last one was my daughter Aquila. she died at the birth- an almost 100% avoidable death, had i been at the hospital. i would never ever ever homebirth again, or recommend one to a friend. being a few minuted from a hospital, or having a healthy pregnancy in no way guarantees the safe outcome of mom and baby. i am so sorry for the loss of your son.
Thank you, Liz — and I am so sorry for the loss of your daughter, too. What a terrible loss. I'm glad you've weighed in on the whole point of this essay — that we all get to choose the birth that makes us feel best and safest. I hope nothing that awful ever happens to you again! Hugs to you.
we all have great grand-parents and or great greats and even friends who were delivered in situations other than hospitals and i pray that you don't feel any guilt for your choices. i am sorry for both of your family's losses. the pain is surely indescribable. i hope these thoughts are not inappropriate – they are not meant to be.
August is very lucky to have you as a mama! Wonderful piece.
To Anon — I agree with you completely — sometimes babies die, no matter the location or circumstances or interventions used to prevent that death. Thank you for hoping we don't feel too much guilt. From going through this grieving process — and this is my first experience with something so sad and terrible — it seems like guilt is just a part of the process. Our support group facilitators say guilt is anger turned toward oneself. I am really working toward letting it go! Because I know it doesn't help anything; it won't change history. Thank you for your comment.
To Nicole — thank you so much for your sweet comment.
Oh, and just to clarify — I don't feel guilty for my choice of a homebirth, thank goodness. I have had guilt about the sonogram, despite the fact that I still stand by my choice (no sonogram), I know why I made it, etc. I know August would have died anyway. His birth defect developed in week 3 of the pregnancy! So basically, he never had a chance. But I do feel lucky that I don't blame my midwife or the homebirth, etc., for what happened. I know many times, when bad things happen at a birth, the parents blame their health care practitioners. We really felt in such good hands with our midwife, and the doctor and nurses at St. Davids were just wonderful too.
This is a very lovely piece. I have given birth at home and in the hospital and each was right at the time. It may have taken me time to understand that though. The largest problem I see is access to accurate evidence based information and people being accountable for their decisions. Thank you for adding your voice to this conversation.
Parenting starts immediately. We are constantly making decisions for ourselves and our families the moment we know we are pregnant. We never know what the outcomes of our decisions will be but we have to be true to who we are and trust in ourselves that we have made the best most well informed decision for ourselves/families.
I am so sorry for your loss.
Thank you for sharing……I have learned over the years that we make decisions based on the evidence of the time… and most times we do what we feel is in the best interest……and we make decisions with the best intentions……I found your blog frank, honest and inspirational…..good luck in the future
Kate — you're right, parenting starts as soon as we know we're pregnant. I like that you pointed that out. It's so hard, at least for me, to accept it when I make a choice and then something goes wrong — even when that "something," in this case, was unrelated to the choice I made. This experience has been (and still is) a great lesson for me in learning that I can only do so much. I can try my hardest to do everything "right" and to minimize risk, and still, things can go wrong. That's life. It's a good thing to learn. Thank you for your comment.
infomidwife — thank you for your comment, as well, and for your good luck wishes. I need it!
Catherine. Thank you for your lucid and clear voice on such a challenging subject. I am sorry for your loss. As the son of an OBGYN who lobbied hard for midwives and as a result they now practice in my hometown, I appreciate your support of midwives! They are great for all the reasons you point out and also provide the nurturing, long-term support that can sometimes be absent in our modern, busy lives.
However I disagree with your stance on sonograms and homebirths. There is no scientific basis for avoiding a sonogram (you have not stated why you chose not to have one) and although you have stated that it would not have changed the outcome for your son, there are many circumstances where the use of the diagnostic tool can significantly impact the success of the pregnancy. I am concerned that others may emulate your now-public decision with disastrous result.
I am a strong advocate for women and feel that it is important that families are able to have the most positive birth experience possible, but I don't see why homebirths are the solution. It seems a false dichotomy. Especially when a birth at home significantly increases risk because there aren't the lifesaving personnel and tools available if something goes wrong. Why shouldn't we be working to provide a wide range of options and opportunities in a hospital birth? It is vogue now to bad mouth hospitals and modern medicine, but the births of our two girls were rich, rewarding experiences surrounded by friends and family. And our first daughter was born safely due to some quick action on the part of our nursing and delivery team.
Finally, I am an outspoken proponent of choice and as the son of the only abortion provider in Southwest Colorado, I have lived under constant threats to our lives as a result of that stance. I applaud your stance on choice. Let's work together to help ensure that women have access to the services and the best information they need to raise the families they want as safely as possible.
What a terrific post and thanks for the shout-out, my friend. It was such a gift to be pregnant at the same time as you, because you challenged me to examine all of my options instead of just accepting what has become the norm. Although I chose a hospital birth I respect the choices you made in your pregnancy and know they were the right ones for you.
Giving birth is such a life-changing event, thank goodness we all have the options to chose the way to deliver our babies in the fashion we each feel comfortable.
Dave, thank you for your comment. I'm glad people are bringing up different perspectives, points and facets to this issue and discussion.
So, since you asked, here goes…(get ready for a long reply! In fact, it's so long that I have to split it up, so here's part 1):
Actually, you're incorrect about sonograms. There is scientific evidence that there is potential for risk to the fetus when exposed to ultrasound waves. This applies to both sonograms and Doppler devices (which my midwife used to listen to August's heartbeat at all 14 prenatal appointments that I had throughout my pregnancy — yet another reason I declined the sonogram: the baby was already being regularly exposed to ultrasound). Here is some of the info and evidence I found in my research:
The Food and Drug Administration’s Web site states that sonograms raise tissue temperatures, affecting a fetus’s brain development in ways as yet unknown to scientists and doctors (URL here). A 2006 study found that baby mice, exposed in utero to ultrasound waves, had brain developmental abnormalities consistent with those of people with autism, mental retardation and schizophrenia (URL here). A 1993 study found that having a sonogram did not improve a baby’s chances of survival or of overall health (URL here). And the American Institute of Ultrasound in Medicine recommends that women with low-risk pregnancies not have sonograms unless medically indicated (URL here). That means, in women who are in good health, with a pregnancy that is progressing normally and with no indications of anything going wrong, and with no family history of abnormal pregnancies or births, there is no reason for an ultrasound (or sonogram — they're the same thing). There is no reason to use sonogram to check for growth of the fetus, when there are other ways to check the same thing (height of the fundus, etc.). All of those factors applied to me — I'm very healthy, no one in my family or my husband's family has ever had a baby with a birth defect, and my pregnancy was entirely low-risk.
On to response part 2 (posting in a second)…
Catherine. First let me say thanks for engaging in such a level and respectful dialog. It is a rare thing in today's inflammatory world. Upon rereading my comment, I don't think I was as sensitive as I had hoped and instead fell into the trap of sacrificing the subtitles of decorum for the brevity of my response.
I do not purport to be an expert in sonography, medicine or childbirth. Nor am I a practicing scientist, statistician or public health specialist. I am a dad that works hard to understand the world through informed logic. I was raised by an OBGYN and a Lamaze teacher in a household where models of the reproductive system, fetal development charts and even sonogram devices filled my life. I am married to a family doctor. I am obviously biased toward current medical ideas although I remain open to some eastern medicine techniques and ideas and am generally open minded. Please see my piece in Dog Canyon regarding my comfort level with unusual experiences.
Although I am not familiar with the specific studies you cite, it has been known for a long while that ultrasonic waves have an effect on human tissue. The question is under what conditions and what are the results of that effect. Does the benefit outweigh the risk? I have undergone ultrasonic therapy for orthopedic injuries and have felt the penetrating heat it can cause and the resulting swelling and healing. But the device that was used for that therapy is very different than the device that uses ultrasonic waves to visualize the uterus and fetus. The manner and the duration in which it is used is completely different, too. I am sure that there are studies that show that ultrasound can do great damage just as there are studies that show that it does absolutely no damage, but the consensus follows the median of all the studies and they indicate that sonography is a valuable tool with low risk to the fetus.
And there is risk in everything we do. Becoming a parent is one of the riskiest things we can do despite social assurances that parenthood is easy and now safer than ever. We live in a society that is unhealthy in its aversion to risk. Too many of us hover over our children protecting them from everything including reality; constantly immersing them in an antibiotic gel-world fearing predatory child-nappers and poisons in our vaccines around every corner. The results are the increasingly sick, feeble, coddled, common sense-lacking brats that run roughshod across every mall, fast food restaurant and big box store while neighborhoods are eerily silent; devoid of bike-riding, fort-building, tag-playing kids. Tens of thousands of parents are so afraid of their child "getting" autism that they believed a couple celebrities and a quack doctor and his lousy study and now refuse to vaccinate their children. They put more weight in the statistically insignificant (subsequently shown to be essentially non-existent) risk of a link between autism and vaccines than they did the very real risk of their child contracting the now increasingly prevalent measles, whooping cough, etc. Life is risky. Parenthood is very risky. You know that even more than I.
As a general rule, doctors prescribe too many tests. I am not advocating the overuse of sonography or any fetal imaging tool. I am advocating the use of this useful and valuable tool within the parameters established by the medical community, even if there is a very small risk of potential tissue damage as a result. The height of the fundus is a complimentary test used in a suite of evaluations to develop the gestational age and progress of the pregnancy. Although imperfect, being able to visualize and directly measure key landmarks, sonography is an important and frequently the most important tool in the suite of examinations to understand the mother and fetus' health and progress. When performed properly by a trained medical technician under the proper circumstances, ultrasound-based imaging technologies the benefits far outweigh the risks. Especially since an ever-growing percentage of mothers no longer fall into the category where sonography is not beneficial. And unfortunately, you don't either now that your medical history includes a birth defect, but still you stated that you wouldn't have a sonogram in the future.
It is this point that caught my attention. Although I hope that you remain healthy and if you choose to attempt to get pregnant again that everything proceeds to a good outcome, by your own admission, you are no longer a low-risk patient. I hope you will reevaluate your position with this understanding. Otherwise it seems like your decision is based more on faith than logic. Thank you for sharing your experience. I wish you the best in the future.
Dave, I thank you too! This has been a very good (and as you said, level and respectful) discussion.
I agree with all you said above. And I actually did not say I won't have a sonogram in the future — at least, I don't think I did; I hope it didn't come across that way. With my first pregnancy, I was considered very low-risk. You're exactly right about having a child with a birth defect: Now any subsequent pregnancy will be considered high-risk for me. Both my husband and midwife have insisted that I get sonograms next pregnancy. I'll do it, even though I still feel I wouldn't terminate a wanted pregnancy if I found out something was wrong. (And I know that is not the only purpose/use of sonograms; I know they can also, for example, reveal problems that will need to be addressed medically as soon as the baby is born.)
Thanks again for all your points. I think if anyone reads our back-and-forths, they will at least be more educated on the subject and therefore better able to make a sound decision of their own!
Response part 2:
As for your point/question about homebirth vs. hospital birth: That's what I was pointing out in the article — the statistics for maternal and fetal death and use of medical interventions are way better for homebirths than for hospital births. Many (including me) would argue that homebirths are much safer in terms of germs, because people tend to be inured to the germs in their home, whereas in the hospital, they are exposed to all kinds of germs that can make them and/or their babies really sick or worse. Ina May's Guide to Childbirth by Ina May Gaskin, an internationally renowned midwife and one of the founders of The Farm in Tennessee, is a great book if you're interested in learning more about these issues. She cites a lot of studies and research of note. Also good is the documentary "The Business of Being Born," which explains the process of why it's so very, very much more likely that you will undergo one or more medical interventions during childbirth if you do your birth in hospital.
Also, your assertion that hospitals are safer for childbirth by virtue of their providing the easiest access to medical supplies, etc., assumes that childbirth is a medical event, as opposed to a normal, natural event. Medical interventions are to be used when something goes wrong — an illness, complication, etc. But the vast majority of births — I forget the exact stat; I think it's 80% or 90%, and it's in the Ina May Gaskin book — have the potential to be normal births that do not require medical intervention. Midwives are medical professionals. That's why those who attend homebirths only take on clients who are in excellent health; they use many methods, medical and traditional, to check the fetus's development and the mother's health throughout the pregnancy; and many of them do pelvimetry (checking the size and shape of a woman's pelvic opening) to make sure all promises to go well at the birth.
Regarding your idea of providing a wide range of choices and options in a hospital — I think that is a wonderful idea, and I hope hospitals, and the medical profession, move decidedly in that direction, and soon. Homebirth and birthing centers, however, are still fine alternatives to hospital births. Depending on the region you live in, they are as viable and responsible a birthing choice as any other. In some places, they're even common! (Austin seems to be pretty homebirth- and midwife-friendly.)
That's basically the point I was trying to make in my essay: These are all reproductive choices, and it is our right as parents to make the ones that are right for us. And still, sometimes things go wrong, and actually that happens far more often in the hospital than away from it. Unfortunately, as I have learned, sometimes babies die, despite the best medical care and efforts.
(One more word about sonograms: They can be an excellent diagnostic tool, but they're as limited as anything else. One of my friends had a son who died at 7 months old, of a birth defect similar to my son's. Three sonograms through the course of the pregnancy did not reveal the problem. I know of another woman here whose twins died at birth because there was a problem not detected during three different sonograms — and, in fact, all three sonograms did not even pick up on the fact that there were two babies, not just one! I think that kind of thing is the basis for the findings of the study I mentioned earlier, that birth outcomes are not significantly affected by sonograms, or the lack thereof.)
And ha — I wouldn't worry that, based on my essay, people are going to start declining sonograms during pregnancy with disastrous results. Like I said, my choice not to have a mid-pregnancy sonogram was definitely not a popular one. Sonograms are used in the vast, overwhelming majority of pregnancies, at least here in the US. Another interesting fact that relates to the studies I read regarding ultrasound risks to the fetus: In countries in which sonograms are not routinely used during pregnancy, autism rates are significantly lower than in the US and other countries in which sonograms are used routinely.
Thank you, again, for reading my piece, thinking about it critically, and presenting your views and counterpoints. I certainly do not think we all have to agree on these issues. That’s the whole point…choice. We exercise choice and sound(er) judgment when we do our research, find out the facts, and make the best decisions that we possibly can. Right?
Thanks for such an interesting discussion, Dave.
It took me 2+ hours to reply to "part 1" above, but it is nearing midnight so I will try and address a few points, quickly. Please excuse the brevity and any baggage that may come with it.
You will find no argument with me that hospitals serve as significant hosts to germs; and some pretty scary ones at that. However, the prevalence of super-bugs like Merca in everyday locations including our skin and our homes is now equally significant therefore effectively nullifying your argument about germs.
I have seen "The Business of Being Born" although I don't remember it all, it does have some great and important points. However approaching childbirth as a natural human event instead of a medical event has nothing to do with where the child is born. It is a state of mind. But when a medical situation does occur during the natural event of childbirth, then it DOES matter where that child is being born. I have heard too many horror stories told by my father and by my wife of home births that end in preventable tragedy. Just as doctors have a financial stake in childbirth in hospitals, homebirth advocates have a financial stake in recommending mothers give birth at home. It is still a business of being born.
So let's encourage choices, but why not encourage a set of choices that are really best for the mother, child and family. Let's support birthing suites, relaxed, flexible environments with a variety of options where mothers and fathers are comfortable and mothers and babies are safe throughout the birthing experience, even when medical situations arise. Places where the full spectrum of medical assistance can be employed as needed and where midwives and birthing coaches can support the mother and family through this amazing experience. Real choices. Not dangerous choices that subject parents and babies to unnecessary risk so they can grow up and hang upside down on the climbing dome, ride their bikes no-handed, and run over to a friends house to play hide-and-seek.
With respect and hope. Dave
I loved being pregnant at the same time, too, my friend. Here's hoping we can do it again someday.
Thank you for posting this comment.