Birth :Who and Where

This Episode we are looking at the "who and where" of giving birth. Midwives, Doctors, hospitals, birth centers, and home births! I dive into the history, the current science and how you can make your birth a spiritual experience (whatever that means for you) no matter where you are or who is supporting you!   

Show Notes:

"Birth" by Tina Cassidy

"Pushed" by Jennifer Block

"Expecting Better"- Emily Oster

Da Vinci Drawing: (apologies I called it a painting): https://fn.bmj.com/content/77/3/F249

Reasons for transfer to hospital   https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-14-27

Evidence Based Birth: https://evidencebasedbirth.com/

Births in Europe:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8796104/

The music you here at the start of this and every episode was created by the "Wonderful" Obediya Jones-Darrell. You can check out his work here.

Transcript

0:31

Birth with who and where. If you've listened to other episodes of this podcast, you may have already heard, I gave birth to both of my babies at home. I'm not going to tell you the whole story right now. I've got some great pictures from the second birth, but this is an audioed. Maybe I'll put one or two of them on Instagram, but I can tell you there are several reasons why I chose to have home births, some of which I have or will address in other episodes. But one of the big things I will say here, I don't like hospitals. I've spent more time in hospitals than probably most people have in their mid thirties. I had an appendectomy when I was 13. That's a relatively standard procedure. I also had a less standard when I was in my early twenties. I had a benign brain tumor removed, so I spent the time. During the actual brain surgery and recovery, as well as lots of time before and after,, with seizures and having lots of MRIs and other procedures done. So very grateful for being healthy and well. I am extremely grateful and will always be grateful for all my amazing doctors. Shout out to NYU Hospital. I don't like hospitals, and if I don't have to be in one, I don't want to be. I've been to lots of hospital births as a doula, and the births are amazing, and I just know I don't really enjoy being in the hospital besides being at the birth, which is always great. Before I gave birth to my son, we were working with midwives. I'm going to talk a lot about midwives. In this episode, but we visited the hospital that they typically work at this group of midwives, and as soon as we walked into the hospital, that hospital smell just hit me. And I looked at my husband and I said, I don't wanna give birth here if I don't have to. So I know for me, hospitals just automatically sort of put me in a fight or flight response, and that's just me personally. And I will say, knowing all that I know how important hospitals are first, since we're personal, as I'm starting, I'm was born of an emergency C-section, so I was definitely a hospital birth and I've also spent a lot of time working in public health, in maternal health, in countries that lack a lot of modern medical care. So I've seen the real devastation that can come from a lack of modern medicine, including access to hospital and hospital care. So I will say that with the caveat that is, Not the topic of this episode, that that doesn't just mean built hospitals. That's a solution that has been tried and it's not necessarily the one, the right one to save the lives of mothers and babies. But I do know how important modern medical care is. So this isn't, me just saying, you know, I hate hospitals. No one should give birth in hospitals. I am telling you my personal experience. So I always like to check my biases and I will say that I come to being in a hospital with the many of them. but I'm going to be objective for this episode. Like I said, I've been to lots of amazing birth set hospitals, so I think I can be objective about where people give birth and with who. So I mentioned the hospital versus home birth first, but what I really wanna talk about first is who we are giving birth with. So typically we're going to be talking about. midwives and doctors. So I'm gonna just chat a little bit about the history and some of the evidence about behind midwifery care. So up until about two centuries ago, midwives were major figures in most communities around the world. They existed in slightly different ways, but most communities would have a woman or women that were overseeing birth, but also. Preparing the dead using herbal and folk remedies. Doing a lot of the healthcare before the age of modern medicine, their credentials would vary. But you know, the word for midwife in French is sa Femme, which translates to Wise woman. And in ancient Greece, midwives had to have had their own children. And be post-menopausal. So there was this idea that they had a lot of knowledge because of their age, and they also had the lived experience of having born and raised children. And in most cultures, we're talking to, up to 200 years ago, women were often banned from school. So their information was usually informal and passed down, you know, from mother to child or from student to teacher, from teacher to student. midwives were often the source of blame for lots of things. The big classic example would be the witch trials. So church leaders have sort of historically have been uncomfortable with midwives. They've had knowledge. They've also often known how to do potions. They might have suggested things that were different than what the church would suggest as a cure for something. midwives were often seen to fit the profile of a witch. They were often widowed or single. They were often independent, and they were often around if there was a negative occurrence. So if someone did die during birth or a baby got harmed or died during birth, or if someone was sick and then died, but a midwife had been called while they were sick, this was part of their job, but they were maybe there more than a usual person when something bad happened. So there's no evidence of exactly how many of the witches that were burned throughout the witch, the history of the witch trials, were midwives. But there's a lot of information to suggest that many of them were formally or informally doing midwifery services. So like I said, that was about till about 200 years ago, and then in the late 19th, early 20th century, medicine started to evolve. This is a great thing. We had germ theory, vaccines were starting to be understood and developed. One thing that started to happen though was that doctors were becoming more informed. They were able to do more things, but they began to really view midwives as their competi. So they were doctors began when it came to birth, promising pain relief and safer deliveries, and were depicting midwives as dirty and unsafe and unclean. What started happening was, births with doctors and with hospitals, we will get to that as well. Were seen as the more upper class thing to do, and midwives, were only serving poorer people. In the US and North America, immigrants, people of color, midwives tended to be more affordable. They would often be okay being paid with trades instead of with. So some statistics just about America. Before the 20th century, most births happened with midwives, but by 1910, only 50% of births did. And by 1930, only 15% of births were with midwives. And by 1973, less than 1% of births were happening with midwives. So part of this was happening was in the 1910s and twenties, there were lots of campaigns against midwives from doctors and from the state. they were banned from practice in America and there were usually more strict requirements in Europe, so they weren't banned completely. And midwifery really at this time was only existing in the US at least due to poor black women that nobody else was, was willing to serve. So the midwifery community really hung on through, through these amazing women that were serving people that no one else would. and the midwifery profession had really almost died out. Like I said, in 1973, it was less than 1% when you started to see an uptick in a trend of natural birth. We're going to talk about that a bit more, and the pain relief episode, which began, so this trend really started in the 19 seven. And at the same time, boomers, baby boomers, especially early baby boomers, began having babies and there weren't necessarily enough doctors to keep up with the demand cuz you had this high population, this big population there was at the same time going on throughout the world, a growing distrust of establishment and a growing interest in. and a growing counterculture in general. Those all go together and all of these things combined to increase the interest in giving birth with midwives. So brought the profession of midwifery back. So today midwives exist in many different contexts, I'm American, so it's a lot of my books we're talking about specifically America. And in America, all states allow nurse midwives, which are midwives that are part of a hospital birth, and some allow for what they call certified midwives, which can be part of a home birth. Those are not legal in every state in the us. In Belgium, which is where I currently live in Canada. Where I also have nationality. Midwives are allowed to work in the home or the hospital in Canada. It's a bit of complicated with all the different provinces have different rules with where midwives can work, and Canada just introduced it, reintroduced a midwifery training program in the last few decades, so definitely more of a demand for midwives than there's necessarily a supply. There's only about, I think, five universities. That five or six universities that are training midwives in Canada and here in Belgium, many midwives are the primary care at the hospital. So they're the people that are assisting you during most of the birth, and people will then sometimes choose to also have a doctor. And it's also the doctor that's following them throughout their prenatal experience. But the midwife will often act as, as a labor and delivery nurse would act in the us. So I've mentioned hospitals and let's talk a little bit about where people give birth. So I noted that they were giving birth to midwives up until about 200 years ago, and they were mainly doing. At home. So before the 18th century and the start of industry and urbanization, there really weren't very many hospitals, but industry urbanization and all the diseases and injuries that came with those things. People living closer together, more infectious diseases, people working in really unsafe conditions in factories, lots of injuries, created a need for hospitals, but they weren't really seen as a place for birth. at that time, except for women who were poor or unmarried, and this was seen as like a place that they could go and no one would know about the birth. They were often experimented on, these were not really nice places. These hospitals were often dirty and disease ridden. I read a really horrible story about a hospital in Boston that in 1883 had an outbreak of Child Bed Fever, which is known as sepsis that infected 75% of the mothers in the hospital that year and killed 20% of them. So really horrible statistics. There was most people were not at this time wanting to give birth. Germ theory was not really understood at this time. So doctors would often go from an autopsy or from treating a sick patient right to a birth. They weren't washing their hands, they certainly weren't wearing gloves. And of course, this was happening with midwives as well. Like I said, midwives weren't always just dealing with. with birth. They were working with other things like sickness and death as well, but their caseloads were often much lower and they were often working one-on-one, so they wouldn't,, necessarily go from an autopsy to a birth, to another birth, to another autopsy, to another birth. So the impact of these things was not going to be as great as the concentrated number of people that were at a hospital. A doctor might see a large number of births at one day. So at the time, mothers were being blamed for child bed fever. Nobody understood why it was happening. People thought that breast milk was going to the wrong place. There's a famous da Vinci drawing, I'll, I'll put a link to it here where it shows like a misunderstanding of where breast milk was coming from and going. Some, some theorist thought that it was vaginal fluid that was going to the wrong place, that was causing people to get. So the true cause had actually been suspected since the 17 hundreds. There was a start of understanding of germ theory, but it wasn't until a doctor in Austria in 1847 whose name I will now butcher Igna Sem lies, apologies for that. Had discovered microscopic proof of the origin of child bed fever, but he was basically ignored. And it wasn't until Louise, pastor and Lester determined that hand washing couldn't pre prevent infection, that it became standard for doctors to wash their hands in between patients and whenever they were seeing a patient. I will say that globally sepsis is still one of the leading causes of maternal mortality globally. We don't see it as much in the global. At the time in the 18 and 19, early 19 hundreds, women were often birthing in the same room. So there was a 1933 White House report that showed that even with the rise in hospitals, like I said, in the 1930s, Only 30% of women were giving birth with midwives, but this 1933 report showed that there was no decline in maternal mortality. Even though so many more births had begun happening in hospitals and infant death from birth injury had increased to. almost 50%. So it actually increased from when more people were giving birth at home. There was, I'm not going to mention the specifics. You can Google them. I'll, I'll list some of the books this came from, but really brutal stories for how women were treated and why there were so many birth injuries to women and babies dying from injuries in hospitals. But at the same time, even with these statistics, more and more women were going to hospitals because urban areas didn't have a space for. there were less and less midwives. It was sort of a self-fulfilling prophecy. As midwives were bad talk, less people went to them. So there was less need for them. So less people became midwives. So there were less midwives available, so less people went to them, and on and on. The messaging, even with these poor statistics, was still that midwives were unsanitary, that they were unsafe. One thing that was important at this time was the development of a safe C-section. So this became a safe outcome for obstructed or prolonged labor. And with increased hygiene, it actually became safe. So with an improvement in hygiene, this was the first time that C-sections could be done safely and could really help people that had obstructed or prolonged labor. So that was seen and is was a good reason for people to be giving birth at the hospital. and there was this idea of pain relief. I'm not going to talk too, too much about pain relief in this episode cuz we're going to do a whole episode on it. That was actually what I was planning to do first. Think of those as like sister episodes. but the appeal of pain relief was another reason that people were going to hospitals. I am jumping back in here and I apologize if the sound is a little different. I'm in a slightly different setup, but I'm editing my podcast as I say this, and I'm realizing that it's. Spent all this time talking about midwives and doctors and hospitals and home births, and I didn't really mention besides my own experience and the history why people would choose one or another. So this is just a quick roundup of why some people choose midwives versus doctors, or doctors versus midwives, home versus hospital births. When it comes to midwives, as I mentioned in our feminism episode, there is. a perception that in some cases may be true, that midwives are going to allow more autonomy at births. They're going to allow for more movement, more positions, less focus on numbers. So you might not have to have your cervix measured. You might not have to wear a fetal monitor if you don't want to at a home birth. You wouldn't. So there's a, an idea of more freedom. And this differs of course, by midwife and by doctors. There's lots of doctors that would be a little bit more hands off. And of course also the needs of the patient. Midwives are seen in general as less interventions. And when it comes to hospitals, there would be more of a sense of comfort than in a hospital. hospitals tend to be brighter. You might not know your nurses, the nurse, if you're in a long labor, the nurse shift might change. So that might be why someone would choose a midwife or a home birth when it comes to hospital births, as I said, some people like myself just don't really like hospitals. There's also questions of pain relief. As I mentioned, we're going to have a whole separate episode of that. So what options are available for pain relief? is definitely factors into a decision on who and where someone is going to give birth. And there is of course the question of safety when we are talking in this case specifically about births in the global north in current times. So when we are looking at home births, people are often asking about the safety. So I will say that it is really, really challenging to do any research on home birth. This is something I had known for a while and when. Expecting Better landed in my hands, so many years ago, which is still one of my favorite books. I mentioned Emily Oster all the time., I will put a link again to Emily Osters, expecting better in the show notes. One thing she talks about is how challenging this research is to really discern the safety of home verse birth versus hospital births, or really even midwifery births versus doctor birth. Because one of the big things is, is. There's a selection process for home births in that only low risk births are happening at home birth so people are self-selecting for home birth. So it's impossible. People will always say, how could you have a home birth? You know, this happened to me at my hospital birth, if that had happened at home. And it's like, yes, but you knew you were preeclamptic before you gave birth, or you had had a previous C-section before that birth. So a lot of these things are sort of self-selected out, so it's really challenging to do the research for that. Another common thing is that one of the most common reasons for someone transferring out of a home birth, so someone who starts giving birth at home and ends up at the hospital is for pain relief. So this isn't someone who themselves or the baby was at any risk at that moment. but they decided, this is not for me. I want more pain relief than this can provide. So it's really challenging to include that in the research because is that someone that's considered home birth? Is that someone that's considered a hospital birth? How would their birth have progressed if things had gone differently? How do the emotions of changing affect their birth? So really, really challenging to look at those things and. You know, most of the most high risk births to begin with are self-selected or happening at c-sections are managed in a certain way. Emily Oster talks a lot about this in her chapter on where to give birth. She talks about a meta-analysis that came out in the early two thousands that had everyone up in arms,, because this study had found. that home birth was much, much more dangerous than hospital birth. And,, the ACOG changed their recommendations. All the midwifery groups were very, very angry. And what was shown almost right away was the study had lots of flaws. One the big problems was it was a meta analysis, so it was combining data from lots of different studies. But studies all look at. Safety of birth and outcomes of birth in different ways. So when you're looking at neonatal outcomes, you can look at stillbirth or you can look at stillbirth and early neonatal death, and those are gonna be measured in different ways, and we have to think that those are going to be affected by home birth in different ways. Oster talks all about this, so I won't get too into that. If you're interested, I highly, highly, highly recommend her book and how she concludes that chapter is. A lot of these risks, especially when you talk about maternal mortality in the global North, are so low to begin with. They're really challenging to measure, and you need to sort of weigh those risks for yourself. Modern midwives are often depicted as risk takers when really, for them it's in their best interests and legally required to only take the most low risk clients. I think one thing that I've noticed a lot is whatever I hear people love to, would love when they had heard I was planning a home birth or even after I had had one or two wonderful home births. They love to share home birth horror stories, which is just not a nice thing to do. But they, people did that to me a lot, and the blame was always on the birthing person and the midwife, but I've heard some not great stories from hospital birth as well. I've been at births that haven't been great in hospitals, and I've never heard a person being blamed for giving birth at the hospital as they shouldn't be. And I've never heard a doctor being blamed for something that happened at the hospital. so I, I think that's an important thing to note, that there's this assumption that if you give birth at a hospital and something bad happens, There was nothing to be done, but at home it was someone's fault and the person should hold that blame. So I think that's just an important thing to remember. And when it comes to this decision, if this is something you're weighing, you need to to look a little bit at what risks we're talking about and what these numbers actually mean versus your own safety and how you feel. So I can say today, in most of the global North, only about one to 2% of births happen at home. One of the only exceptions to this is the Netherlands. where about 16% of births are happening at home. It's very much built into the healthcare system for births to be happening at home, happening with midwives. Lots of other countries in Europe have. Even though hospital births is the most common, more standards of midwifery led care. So this is where I'm going to start combining these two ideas, the where you're giving birth and with who you're giving birth with. So in many countries in Europe, even if most people are giving birth at hospitals, the midwives are performing most of the prenatal services and attending most births. This is definitely true in the UK and in many Scandinavian countries, and home birth is becoming more popular. The same as the interest in midwifery increased, there was also an increased interest in home birth. One thing I think we need to think about whenever we think about, who's giving birth with midwives and who's giving birth at home. Is how did these traditions get preserved? And as I noted, when it comes to midwives, it was really black midwives, often poor black midwives that maintain many of the traditional knowledge that midwives use, the traditional practices. Yet today, home birth has become for very, in many places, this very trendy thing. It requires a lot of knowledge. You need to know to ask for it. You need to know it's available. You need to know who to contact to do it. Certainly in Canada there's a higher demand for midwives than there is supply. So I often have heard people say, when you find out you're pregnant, you call your a midwife before you call your partner so that you can get a place with a midwife. So this really requires a lot of privilege to have access to that knowledge. I think what's happening certainly in much of the global North is the people that are now having access to home births and midwifery led births are often the most privileged people, wealthy upper class, upper middle class white people. Even though it was generally the, the poor, the people of color who were having these tradition, who were maintaining much of this knowledge, and we don't think about that enough. So I really just wanted to call. And another place that we can think about that's sometimes thought of as a middle ground are birth centers. birth centers can be freestanding. Or they can be part of a hospital, and if they're free standing, then they're a place where someone can give birth that maybe has access to slightly more pain medications. Some things like air and gas, which we'll talk about in the pain relief episode. They might have a big tub, have access to a big bed, if there is a problem, someone would still be transferred to a hospital. Some hospitals have birth centers built into them, so they feel. birth center, like, which is to say home like a big, big bed, not a hospital bed, a big tub, low lights. But if needed you could be transferred right to a higher risk situation. So some people really like those as a middle ground, they're not that common. And again, you need to know about them. So I mentioned risk. So when we talk about home re birth, we are talking about births that in any place where we're talking about a legal home birth. So a home birth with a practitioner that is designed to be part of a home birth is for a low risk birth. So what does a low risk birth means? It means that the person hasn't had a. Cesarean section, so it's not a V B A C, it's not a vaginal birth after C-section. The birth is happening between 38 and 42 weeks of pregnancy. So it's not preterm there's no pre-eclampsia or other diseases of pregnancy. Sometimes age or weight is considered a risk factor and no multiple births. Twin birth or triplet birth, so on is only happening at a hospital. And whether or not that's happening from a vaginal birth is another question maybe interesting for another episode. And this is where we come to this sense of spirituality because giving birth is a medical act, but often it can often be a spiritual experience. I know for me, both my births were probably two of the most spiritual experiences I've ever had. I know for me, my home birth, I was a place where I felt really safe. the only people that were there were me with people that I had met before were people that I knew I was able to adopt. Any ritual I wanted, I was really meant, felt to be held in this space. I mentioned in the feminism episode, that nobody put their hands in me without asking. So I felt really safe. I was able to move however I wanted. For me, I was low risk. I understood the risks of birth at home, and I also knew how I felt intuitively and how safe I would feel in my house. That was the decision that I made both times. I was also very close to a hospital, but these were the decisions I made understanding what risk meant of something that was already a very low risk. What the difference is in these risks. So all that said, birth can be spiritual anywhere. Birth can be spiritual as long as you feel safe. Hospitals are often adopting more and more things that can feel homelike. There's often what they call a quote unquote natural birthing room that often has a big tub that has rezos. Those, those strings you can sort of hold onto. For some people, hospitals have this real sense of safety. Like I said, I'm really grateful for my doctors and some people might have felt that this was this, had a similar experience to me and known a hospital as a place of healing and coming full circle and might have felt a hospital being the perfect place for a spiritual experience. So a spiritual experience shouldn't have anything to do with the place in reality. It really has to do with who's holding the space for you. I know for me, with my midwives, I had space, I had energy to move, to feel safe, to feel like I wasn't being judged or rushed or anything else. And that can happen with doctors as well. That can happen with midwives at hospitals as well. Spirituality requires safety and it requires comfort. So this can happen anywhere. It just requires. The space and the holding space for that. This for me was one of my more personal episodes so far., home birth is something I'm really passionate about. I, as many of you listeners know I have a background in public health. And I also have a background in yoga and as a doula, so I had all the information when it came to making my decision about my birth, I was able to really read all the research and understand the decisions I was making. I know that's not for everyone. We're very lucky to have. Amazing resources like Emily Oster. another great resource is evidence-based birth. I will put that in the show notes that really break down. You know what, when we talk about risk, what we're actually talking about, so many of these events are so rare. It's hard to really say if something's much riskier than something. One other thing I know that came up for me was during Covid, lots of people, including people who maybe had been a little bit more judgmental about my home birth, were contacting me for information about home birth. I would say in March and early April, 2020, I received numerous emails and messages asking, for my experience with the home birth, could I tell them more about it for people in Brussels asking how I did it because suddenly the hospitals seemed less safe. So when I talk about calculating risk, that's what I'm talking about. It changes, it changes with us. It changes with how we view things in the world around. So if you are making the decision to where to give birth I hope you're able to make a decision that sits right for you and your family. They're able to make it without judgment, without pressure, and you can do what feels right for you. Understanding the information and understanding the spirituality and the ease that your, your mind, and your body. Thank you so much for listening. As always, please subscribe and like this podcast in this episode. It really helps. I would love to be able to keep creating content. You can follow me on Instagram and on Facebook at Evidence-based Crunch. Please share, I am looking forward to coming back to you soon with another birth episode looking at pain relief. Thank.