This conversation took place in a most interesting fashion. It began on the day of the San Francisco Marathon, July 9, 1978. Michael Witte and I had just completed the twenty-six-plus miles and were soaking away our aches and pains in the Medical Self-Care Magazine office hot tub. We were getting into some interesting things about birthing, so I brought the tape recorder out by the tub and turned it on.
Medical Self-Care Magazine’s women’s health editor Carol Berry listened to the tape, agreed that it would make a good article, and suggested that she conduct a follow-up interview with Dr. Witte and Heidi Bednar, a midwife who works with Michael. She did, and it broadened and deepened the original interview immensely.
Finally, I edited the two transcripts and dovetailed them together, so that somewhere in the middle Carol and Heidi appear and I disappear. I guess you could call it collaborative journalism.
TF: Michael, you were saying that many people are thinking and feeling differently about having their babies than they did five years ago?
MW: Yes. Many, many more people are actively looking for just the right person to attend their birth. People are much more concerned with the environment in which the birth will take place. The underlying concept seems to be that the mother, the pregnant woman, should command a lot of respect. Prospective parents are getting more assertive about wanting things done their way.
TF: Has that concern for people’s individual preferences been lacking?
MW: I think it has. Both I myself and the group I work with are constantly being approached by people who haven’t been able to find the kind of prenatal care and deliveries they wanted. They’re determined to create a way to have their own birth experience meet their needs.
People are becoming much more deeply involved with the birthing experience than they’ve ever been. They’re realizing that there’s an independent, benign force at work changing a pregnant woman’s life and her body in monumental ways, and there’s a widespread feeling that those changes need to be respected by health workers, by her man, by her friends, and by herself. She’s different than she was before she was pregnant, and she gets more different the more pregnant she gets.
TF: I certainly didn’t hear anything about any of that in medical school. We just learned about all the possible complications.
MW: Yes. The medical professions have focused almost exclusively on the technology. We’ve really approached childbirth as though it was a diseased state, full of potential complications. The technology of childbirth has been kept as secret and magical tools to be used only by physicians.
The technology has saved a lot of lives, but it’s been controlled by the obstetricians, nearly all of them men, which created a built-in insensitivity, and birthing got dragged into the hospitals. Human values were subjugated to the hospital routine, with delivery rooms modeled on operating rooms, even though birth is not really very much like surgery at all.
TF: All right, suppose you’re talking to a couple thinking about having a baby. What are the choices they should start taking into consideration? What are their alternatives? When should prospective parents start looking for someone to attend their birth
MW: When you’re planning a pregnancy is an excellent time. You have a lot more time to explore options. Certainly by the time you first find you are pregnant.
The first step is to find out what’s available locally. I would talk to your local doctor or a couple of local doctors. Another good resource can be the local public health nurse. Public health nurses are often pretty sensitive to people’s needs, and they should know what the local resources are.
TF: So you could just call the county health department and ask for the public health nurse?
MW: Right. Free clinics or women’s clinics are also good resources, if you’re lucky enough to have one in your community. If you don’t, you can get in touch with such clinics in the nearest big city. Two nationwide organizations can help refer you to a sympathetic doctor, too: the La Leche League and the International Childbirth Education Association You can write to both of these and they’ll send you the address of their nearest local chapter.
TF: Could you suggest some good books to be reading around this time?
MW: Yes. Commonsense Childbirth, by Lester Hazell and Birth by Catherine Milinaire are both good. The birth chapter in Our Bodies, Ourselves, also has a lot of good practical information.
Once you’ve really gotten along into pregnancy, some good books are Spiritual Midwifery and Immaculate Deception. Then there’s a super picture book, A Child Is Born, which has excellent color photographs of the fetus at the various stages of development. Pregnant women can spend hours with that one.
The midwives we work with have a library of books on these subjects which they loan out to prospective mothers. It’s a really nice service to be able to provide.
TF: What are the most important things to focus on in the prenatal period?
MW: The single most important thing is that the mother respect herself and take care of herself. Prenatal care is not something the doctor does. You can only do it for yourself. What we’re doing is monitoring the mother’s and baby’s well-being. It’s the mother who’s doing the real work.
TF: What can a couple do if they can’t find a local doctor that does things the way they’d like?
MW: I would hope that they would tell their doctor what they’d like. Impress on her or him that these requests are very important to them. Hang in there, and be prepared to negotiate.
If you’re assertive and persistent, you may find a great deal more flexibility than you expected. Ask the doctor what his reservations are about your requests. If the physician is worried about legal liability, you may be able to work out a legal waiver stating the things you want and the risks you’re willing to accept. For instance, you may want to try to deliver vaginally in the case of a breech presentation, instead of automatically going to a cesarean. It’s very important for you and your doctor to discuss these possibilities and choices in advance.
If you are negotiating with your doctor, it’s vital to get good counseling regarding risks and procedures. A good deal of this can be done by phone if necessary.
TF: What are the possibilities as to where the birth will take place and who will attend it?
MW: Well, the alternatives range all the way from having the baby at home and delivering it yourself, to home birth with a lay midwife, to home birth with a nurse-midwife, to home birth with a physician.
In the hospital, the alternatives might be an alternative birth-canter-type room, where you can have your friends and family in to witness the birth but have a doctor or midwife in attendance. Or you might choose to have your baby in a regular delivery room, again with a midwife or a physician in attendance.
TF: Could you say some more about alternative birth renters?
MW: Sure. They’re a good example of hospitals being responsive to people who want more control over their own birthing experience. The alternative birth centers are often scheduled months in advance.
The labor and birth usually take place in a room down the hall from the delivery room. The family has a good deal of control over this room—they can decorate it as they like, play their favorite music, and have their kids and friends and family members present. So on the one hand, there are many of the benefits of a home delivery.
On the other hand, if any complications develop—if the baby starts to come out feet first, or if the mother or the baby are having any difficulty at all—the parents and the doctor or midwife have the option of zipping down to the delivery room in a few seconds.
TF: An obstetrician friend said that he advises prospective mothers to pick the hospital first, then pick the doctor.
MW: If you’re planning a hospital birth, that’s not a bad idea. Most hospitals have regular tours of the labor and delivery facilities for prospective parents. If you pick a doctor first, you’re limited to the hospitals where he or she practices.
TF: You were saying that the changes in obstetrical practice here in Marin County over the last five years may foreshadow the kinds of changes we can expect in the country as a whole. How have things changed here?
MW: Five years ago the doctors here took a very interventionist, technical view of birthing. Deliveries were done in the hospital delivery room, period. Now we’ve become very family oriented. There’s much more concern for the quality of the birth experience. A significant percentage of babies born in Marin last year were born at home. This certainly reflects a change in consciousness among health workers and potential parents alike. It also indicates the power consumer demand can really have.
Probably the most important reason for this change is that the families have put on economic pressure. They’ve said, “If you don’t provide what we want, we’ll go elsewhere. We’ll do it at home, or in another hospital, or in another city.” We’ve had people from all over the state coming here to deliver because they couldn’t get what they wanted in their home town.
And what’s happened is that the health workers and the hospitals have responded to the economic pressure. Obstetrical units are usually real money-makers for a hospital, but not unless they’re active. When a few hospitals offered alternative birthing services, the staff at the ones that didn’t ended up sitting around twiddling their thumbs. They were forced to offer those services. Now you walk in the door of any obstetrical unit, and you’ll see this sign, “Family Birthing Experience.”
HB: Yes, they talk about it all the time, about losing patients to other hospitals.
CB: How should a family go about choosing between a home birth and a birth in an alternative birthing center in a hospital?
HB: It really depends on the family—especially the mother. Very few alternative birthing centers offer an atmosphere as supportive as being at home. If they went to the hospital, they might feel too out of their culture to really relax and have the quality of experience they want.
MW: Some women have a terrifying image of the hospital, or see it as a place very foreign and scary. Heidi and I have seen that lots of times—where a woman who’s in labor at the hospital has trouble because she can’t relax. On the other hand, there are plenty of women who wouldn’t be able to relax anywhere but in a hospital.
CB: How can women get in touch with their feelings about the hospital beforehand ?
HB: By all means, take a tour of the hospital. Talk with friends who’ve had babies there—and with friends who’ve had babies at home. I always encourage pregnant women to take the tour. The results are sometimes very striking—people who were definitely going to give birth at home may realize they’d rather have it at the hospital, or, just as commonly, the exact opposite will happen, and a couple who’s planned a hospital birth will decide to have it at home.
CB: What should a woman ask herself when she visits the hospital and takes the tour of the labor and delivery rooms?
HB: They should ask, “How do I feel about technology?” “How do I feel about being handled by competent strangers?” “How do I feel about mechanical things?” Sometimes the number of electric and electronic gadgets a woman has in her home will reflect her feelings about technology.
MW: Sometimes reading the right books helps people explore their feelings, too. It can make you aware that there are really more possibilities than you might have thought.
CB: Why do you think there’s been such heated controversy about home births in some places, while in other areas it’s just seemed to slowly evolve and be well accepted ?
HB: I think that some health workers are scared. They’re afraid that they’ll lose financially, or that obstetricians might be phased out completely. And some non-health workers have just turned their backs on health workers altogether and gone off to deliver their own babies at home.
My feeling is that both extremes are off the mark. A certain degree of technical training and experience is clearly helpful in figuring out the small percentage of women who are at higher than normal risk. At the same time, families need to be able to arrange a birthing experience that meets their needs, not the health workers’ needs. Birthing should be a collaborative effort, with input from both the family and the health workers involved. Neither party can manage as well without the other.
CB: What are the qualities to look for in the person you want to attend your birth?
HB: How you feel about a person is very important. When it came to choosing someone for my own birth, I passed up a number of doctors I knew and picked one I hardly knew at all because I had very good feelings about him.
MW: I would also want to check on their competence. Ask somebody they’ve helped to deliver, or ask other health workers who’ve worked with them. I’d ask a health worker friend whom he or she would go to. It’s also important to consider who has hospital privileges where.
HB: Another important thing is whether the person really listens to you. Birthing works best when both attendants and parents are really listening to each other and learning from each other.
Also, a doctor who delivers fifty or sixty times a month by himself is not going to have time to give you much personal attention. He’ll be forced to scoot you in and scoot you out. So be sure and ask how heavy a case load the person carries.
Finally, I’d choose a person who’s not locked into either a home birth or a hospital birth.
MW: Yes, the parents’ feelings may change at any point and they should be supported. The option to have a baby at home or to go to the hospital should be kept open as long as possible.
HB: To realize that you can change your mind, shift plans, and still have a positive birth experience is very important. Maybe you have been planning on a hospital birth, and once you get there, realize that it would have been better at home. Or maybe your game plan has been home birth and you feel yourself wishing you were in the hospital. It’s okay to say, ” Hey, wait a minute. This doesn’t feel right.” And change the game plan so that it does feel right.
CB: Heidi, you were saying that prospective parents should think in terms of having two birth attendants.
HB: Yes. There’ll be more than two at the hospital, and I personally don’t consider home birth safe unless there are at least two knowledgeable birth attendants there. It may be a nurse-midwife and a lay-midwife, it might be a midwife and a doctor. If all goes well, there’ll be one person to organize things and make phone calls, while the other stays by the bedside. If there are complications, it’s vital. After all, there can be two patients—the mother and the baby. The two health workers should not only be competent, they should work well together.
CB: What are the risks of home birth?
HB: Except for the mother who lives miles and miles from the hospital, I think they’re about the same as for being at the hospital. The important thing is who’s attending your birth. Are they monitoring the fetal heart tones? Do they have emergency equipment with them? If you have the right people, they can do nearly anything that could be done at the hospital—and in a less intrusive way. Competent attendants at home, with a good attitude, are much safer than less competent attendants in the hospital who are working at cross purposes. Technology is only a tool. It’s the people and the attitudes behind the tools that are even more important.
MW: I think that many obstetricians still believe that home births are less safe than hospital births. That may have been true at some time in the past, but with birth attendants who are well equipped and well trained, that’s simply not true any more.
CB: When people talk about the complications at home births, the most scary one is excessive bleeding. Can that be handled just as well at home as it can in a hospital ?
HB: Yes, it can. We have intravenous fluids and plasma expanders and oxygen and all the medications right there with us. We use the same technologies and techniques they would use at the hospital. The only woman I ever heard of who bled to death at childbirth did so in a hospital.
MW: The problem is more legal than technical, really. If a mother bled to death at home, the attendants might be charged with manslaughter.
HB: Yes. People assume that if a woman bleeds to death in the hospital, it’s justified because the assumption is that everything that could have been done was done. There’s a real double standard operating here. If a doctor delivered a woman in the hospital and she died, there would very likely be no recriminations. If a midwife delivered the same woman at home, provided exactly the same care, and the woman died, the midwife would undoubtedly be charged with murder.
CB: How about the risk of infection at home births?
MW: Well, generally speaking the baby comes out sterile and is immediately exposed to bacteria and viruses in the environment—he has to get used to them in order for his immunological system to develop. Babies born at home are exposed to the flora on the parents’ skin—and they have antibodies to these germs already. On the other hand, the germs in hospital nurseries are more likely to be the disease-causing kind, and therefore much more dangerous.
HB: In the hospital you’re at added risk of surgical intervention—episiotomies, invasive techniques— which increase the risk of infection. Hospital birth attendants are more likely to get tired of waiting and give a drug to induce labor. It may well be safer to wait—as we do when we deliver at home.
CB: How many home births have each of you done, would you estimate?
HB: Probably 150 over two years. And this doesn’t include the hundreds of births I’ve attended as a labor and delivery nurse in the hospital.
MW: I’ve been involved in about 350 births.
CB: Have you ever run into anything you felt you weren’t equipped to handle?
HB: No, not once. We can start emergency measures and get the woman to a hospital by ambulance in about the same amount of time it would take to set everything up in the hospital.
MW: And you have to remember that one reason for that is that we don’t try to deliver everybody at home. Any woman with a pre-existing illness or a disease of pregnancy is advised to plan for a hospital birth.
CB: What are the benefits of giving birth at home?
HB: I think that in many cases it’s safer. The home birth attendants I’ve worked with watch the patient more closely. I’ve seen complications arise in the hospital because there are six or seven women in labor at once, people are busy, and there’s a false sense of security because of all the technology. No machine can replace a birth attendant who’s totally there with you, so that if any little thing starts to happen, we can catch it right away.
MW: You can create your own routine at home— you’re not at the mercy of the hospital’s routine. This is your first chance to meet this new little creature, and it’s important not to have a lot of regulations getting in the way.
CB: It sounds as though a real polarity has developed between people doing home births and people doing hospital births.
HB: It has in some places, and it’s a real shame. My experience working both in the hospital and at home has been invaluable for me. In the places where things have gotten polarized, everybody loses. The hospital birth attendants have a great deal to learn from the people doing home births, and vice versa, and some of the home birth people could use more technical knowledge. In places like Marin, where there is a lot of communication between people attending home births and people delivering babies in the hospital, it’s been wonderful. Birthing doesn’t need to be divided into two warring camps. We need one whole flowing continuum with an emphasis on alternatives and individual choice.