Home delivery

Last month, Ruth Haske left the hospital to have her baby.

She was a couple of weeks shy of her due date when she woke up feeling ill —back hurting, stomach hurting, fever. At UVA Medical Center, she underwent some tests and monitoring and was then sent home. Three days later, she still felt awful. Back to the hospital she went.

“I was convinced something was wrong with the baby,” she says. “I just wanted her out and safe.” She was asking for a Cesarean. But the next day, Thursday, her fever broke and she was discharged again.

By Friday morning she was clearly in labor, with contractions five minutes apart. Her husband, Chris, was at work. “I somehow knew I was waiting for him to come home,” she says. Once he did, labor took off. Ruth quickly found herself “naked in the bath, groaning through contractions very close together.”

Chris called Deren Bader and Brynne Potter, Ruth’s midwives, who came over and set up a tub of water in the living room. Ruth got into the tub about 6:30pm, kneeling with her arms over the side. She felt an urge to push, but Bader wanted to check to make sure Ruth was fully dilated. “I said, ‘I have to be pushing right now,’” Ruth says. “[Bader] said, ‘O.K., I trust your body,’” and didn’t perform the check.

Ruth felt her baby descending, put her hand down to feel a crowning head, and—along with Chris, who was also in the tub —caught her new daughter Noa as she emerged. “It was really us,” she says. “Really wonderful.”

The couple’s 2 1/2-year-old daughter, Maia, soon returned from a friend’s house, and all four Haskes climbed into bed together while the midwives tidied up, did a newborn exam and brought in some food.

Says Ruth, “I felt exhilarated. I’m just incredibly thankful for how it all panned out.”

This is a story about local women who give birth away from hospitals (and some who attempt birth at home, but end up in the hospital). I am not an objective reporter on this topic. My daughter was born last July on our back porch, so the topic of homebirth is the story of my own family. I feel it in a deeply personal way, with my body, heart and mother’s instinct.

There’s your warning, reader—I’m biased. But then, everybody has an opinion on birth. After all, it’s one of two events every human life has in common.

A number of people have told me I was “brave” for birthing as I did. But the truth is a lot more complicated than that.

“How did we see birth?”

When I put out a call for local homebirthers to tell me their stories, I got a healthy response. The tales ranged widely. One woman unexpectedly delivered in her driveway just after getting in the car to drive to Martha Jefferson. One woman had five hospital births, then chose homebirth for her sixth baby. One had two successful homebirths, then decided to become a midwife herself.

Jamie Leonard with her son Kai, born in their living room in 2009.

Jamie Leonard gave birth to her son at home in June 2009. She is in some ways typical of local homebirthers: educated, in her 30s, health-conscious and professional. Interestingly, she and her husband both work in the medical field: she in UVA’s office of student health, he as a physician.

When Leonard got pregnant, she began a process of research and decision-making that experts say more and more American women are undertaking. She read a book by Ina May Gaskin, the country’s best-known midwife. She attended Birth Circle, a monthly gathering where women tell their birth stories. And—apropos of someone who holds a master’s degree in public health—she looked at studies on the safety of different birth options.

“It came down to, how did we see birth?” she says. “On TV shows, either women are hysterical in pain in labor, or whisked off for emergency Cesareans, which often leads to maternal death. And I started questioning that and really thinking about how birth should not be a scary thing. Yes, there are bad outcomes of course, but I realized that my body was made to do this, and I became much more fearful about having unnecessary interventions in a hospital setting.”

“Interventions” during birth can mean anything from inducing labor via the drug Pitocin to pulling a baby out with forceps. Over the past several decades, America has seen a rise in many types of interventions, with about one third of births nationally occurring via Cesarean section. From The Business of Being Born, a 2008 documentary about homebirth made by Ricki Lake, many women have learned about the “cascade of interventions” that can happen in a hospital, with Pitocin starting labor and a Cesarean section finishing it off.

Leonard felt that to labor naturally, she needed a familiar, safe setting. “I make it analogous to someone having sex in a hospital, and strangers coming in and out all the time,” she says. “[You’re] under bright lights, and there’s someone telling you to be in a certain position because they want to see what’s going on… I would have been on guard all the time. I could just imagine myself crunching up and not having things run smoothly.”

Convinced by their research that homebirth would be safe for a low-risk pregnancy like hers, Leonard and her husband hired Bader and Potter (whose practice is called Mountain View Midwives). Her labor began in the middle of the night and progressed throughout the day. Kainoa was born at 11:30pm in the Leonards’ living room.

“I was squatting by the couch, and the midwives had on little coal miner’s flashlights on their heads, and they were laying down on the ground looking up to catch him,” says Leonard. “I love when people are over and I can point to the spot and say he was born right there.”

Baby trend

When I was pregnant, I became a Birth Circle regular, looking forward to the monthly meetings at which 25 or so women sat on well-worn pillows on the floor of the Body Mind Spirit yoga studio, passing around snacks and smiling at the half-dozen babies who’d invariably accompanied their mothers.

The first time I attended, five women told their birth stories. One was a Cesarean at Martha Jefferson. Three had birthed at home with midwives. And one had had a homebirth—her sixth—assisted only by her husband.

I felt energized hearing about such a range of experiences. Each birth had its own character, and each mother seemed to light up describing her journey through birth’s doorway.

Over the following months, I heard many more stories, including plenty from hospitals. Many Birth Circle-goers were interested in natural birth, though the group that sponsors the meetings—the local chapter of Birth Matters Virginia—is careful not to promote one type of birth over another.

It’s hard to say how many homebirths occur each year in the Charlottesville area. Bader and Potter have been attending roughly three per month in recent years, and at least one other midwife—Madison County-based Trinlie Wood—has about five Charlottesville clients annually. (Compare that with 3,432 births in 2010 between Charlottesville’s two hospitals.) Nationally, only about 1 percent of women birth away from hospitals, and many of those choose freestanding birth centers rather than their homes.

But the homebirth trend is growing. A recent study in the journal Birth found that from 2004 to 2008, homebirths in the U.S. increased by 20 percent. Kate White, who’s a local prenatal and postpartum massage and craniosacral therapist (and the secretary of Birth Matters Virginia), says that “Homebirth is on the rise…The Business of Being Born really galvanized women in this community and across the nation. They question their care and look for alternatives.”

White organized a birth expo at the Key Center Downtown last March and drew 500 attendees eager to learn about various birth options. Jen Fleisher, who has taught prenatal yoga since 2005, says she’s noticed “a movement toward prenatal wellness with a target of natural birth…More women are asking me how to stay fit for healthier labor.”

Why attempt natural birth? Fleisher echoes many childbirth experts when she says it can be deeply empowering for women. “The sense of accomplishment and achievement is unmatched by anything else they’ll do in their life. To attempt victory at something so immense changes your confidence level going forward.”

Local choices

For me, as for Leonard, natural birth seemed a lot more likely to happen away from the medical environment. It came down to this: Was I more afraid of pain, or of the hospital?

Years ago, a college roommate had galvanized me with talk about the medicalization of birth. Cynthia Corby calls this an “aha moment.” Corby directs the local Birth Matters chapter, and has run Birth Circle since it began meeting in 2005.

“The whole point,” she says, “is to get people to not judge, and hear that other women make other choices.” It’s about being informed, she says—taking responsibility for the dozens of choices to be made along the road of pregnancy and birth, rather than being the passive recipient of an obstetrician’s care.

Cynthia Corby rests after delivering her fourth child, Autumn, at home in 2009.

Corby herself is a mother of four, the first two born at UVA. She delivered naturally each time, but says she had to be “very confrontational” to avoid interventions—saying, for example, “No, I don’t want to be on this bed. Get me off this bed right now.” For her third and fourth pregnancies, she hired Mountain View and birthed at home.

Homebirth mothers tend to be educated, with the time and wherewithal to research their options. And if they want a natural birth, they quickly find there are a limited number of ways to meet that goal in Charlottesville.

There is birth at local hospitals, with or without a doula (a childbirth aide who encourages and assists mothers during labor). Hospital birth usually means doctor-attended birth, as there is only one Certified Nurse Midwife (CNM) delivering babies locally—Donna Vinal, who practices at Martha Jefferson. There is homebirth, with or without midwives. (As of this spring, there is one more option: a new midwife-run birth center, about which more below.)

At this point, the expectant mother confronts several major questions—among them, is homebirth safe? And how does a midwife’s care differ from a doctor’s?

“Sister, friend or mother”

Mountain View Midwives (Brynne Potter, left, Deren Bader, center, and Debbie Wong, right) have had the largest homebirth practice in CHarlottesville for the last several years, but will close their doors at the end of the year.

“More individualized care—that’s the hallmark of midwifery,” says Debbie Wong, who moved from Portland, Oregon, to join Mountain View Midwives last fall. Wong, like Bader, Potter and Wood, is a Certified Professional Midwife (CPM), a credential that’s administered nationally by the North American Registry of Midwives.

CPMs train primarily through apprenticeships with experienced midwives and must pass an exam to earn their certification. It’s only since 2005 that they’ve been able to obtain licensure to practice from the state of Virginia; Potter says that around 30 CPMs currently practice across the state. (The CNM designation is different in that it requires a nursing degree. At one time, Charlottesville had more CNMs delivering babies in hospitals, and most sources I interviewed agreed that one is not enough to meet demand.)

CPM is, Potter says, “the only credential where informed consent is woven into the model of care.” As a new Mountain View client, I signed a document that outlined my midwives’ practice guidelines, philosophy, education and training, as well as listing the equipment they were and were not permitted to carry. (In Virginia, for example, CPMs cannot administer oxygen.) The flow of information continued at each prenatal visit, as my husband and I confronted choices about ultrasounds, gestational diabetes screening and other tests that are simply routine in many obstetrical practices.

“The experience of being informed will send people in or out the door,” says Potter. “Some say, ‘Yeah, I need to be in the hospital.’ Other people lean in and say, ‘This is what I want. I feel empowered by it.’”

Prenatal appointments with a midwife are typically longer than OB visits, with more focus on talking than testing. Bader and Potter spend an hour with each client. Of that, 15-20 minutes are spent taking blood pressure, palpating the uterus and doing other routine assessments; for the rest of the hour, the midwives educate clients, answer questions and perform massages.

At her visits, Leonard says, “We talked about not just my tests or urinalysis. We talked about sex, we talked about balancing time…It was very holistic about this whole life change, not just the fact that my belly grew two inches.”

“We take on that role of sister, friend or mother,” Potter says. Bader concurs: “To me, knowing women is of paramount importance.”

Do it yourself

For some people, homebirth attended by midwives represents a major step away from the mainstream. For others, it’s a movement inward away from the fringe.

Aubrey Israel Hampton had her first two children at home assisted only by her mother. “I really just had that much trust in my body and I felt like I could certainly do it,” she says. And she did do it: Both babies, even one who was breech (head up), were born without incident.

But both times, Hampton and her mother ran into questions during delivery, and both times they called 911. Hampton’s first baby was halfway born when EMTs burst into the room. She finished birthing and laid her new son on a towel. “I told them don’t cut the cord,” she says. “I wanted him to stay connected until I delivered the placenta. They said ‘We have to take him to the hospital.’ [They] cut his cord, picked him up and walked out of the room with him.” With her mother, Hampton followed, and endured questioning by social services once they arrived at the hospital.

After a very similar scenario played out with her second delivery, she hired Mountain View to attend her three subsequent births. “Given the past two experiences where clearly I needed some help, some questions answered, and at that point, mid-labor, my only resource for help was 911,” she says. “And as it turns out, everything that happened with the first two births was normal. But we didn’t know that.”

“Watchful waiting”

During my daughter’s birth, I was dimly aware of Bader’s presence—filling the birth tub, taking notes, monitoring fetal heart tones with a handheld Doppler device—but mostly I was deep inside myself, breathing into contractions.

At crucial moments, though, I asked her for encouragement. (A few minutes before birth, I clearly remember saying, “Please tell me this is almost over!”) And when she calmly reassured me, I trusted her, knowing that her words carried the weight of her experience at more than 800 births.

The safety question Much ink has been spilled over the relative safety of birthing at home and in the hospital. The midwifery community maintains that, as Brynne Potter puts it, “There is plenty of scientific evidence to show that homebirth is as safe as hospital birth.” A 2005 study cited on the Mountain View website, for example, concluded that for low-risk women who planned to birth at home with a CPM, the risk of intrapartum and neonatal mortality was similar to that faced by low-risk mothers in hospital (1.7 deaths per 1,000 births). What’s more, the homebirth mothers had significantly lower rates of interventions like C-sections and epidurals. Potter points out that there is a screening process that begins with self-selection: “Unhealthy women do not generally seek us out for homebirth.” When her clients turn out to be pregnant with twins, or have breech babies, she and Bader recommend they transfer to obstetrical care. (Other homebirth midwives may have different policies.) Last year, the American Journal of Obstetrics and Gynecology published a paper, widely referred to as the Wax study, which concluded that “Less medical intervention during planned homebirth is associated with a tripling of the neonatal mortality rate.” But the homebirth community has vigorously refuted this study, pointing out that the Wax study included data on both planned and unplanned homebirths, as well as babies with congenital defects. UVA’s Dr. John Schmitt says, “I think if you’re going to [plan a homebirth], which I don’t condone, patient selection is the absolute key. You have to be the lowest risk of the low risk.” He says delivering in the hospital is “like a seat belt…you never know if you don’t need it until you need it.” Says Potter, “There are risks to birth that cannot be anticipated and can result in a bad outcome wherever you are. There is not a 0 percent mortality rate in hospitals, and the rates are equal for home and hospital.”

CPM Janna Grapperhaus, owner of the new birth center, says a major reason women choose out-of-hospital birth with midwives is to tap resources other than drugs for getting through labor. “It’s the things they don’t offer in the hospital—comfort measures, knowing someone [can] support you in a natural labor. We have more than an epidural to offer. Midwives are the experts in natural birth.”

A lot of midwifery, says Trinlie Wood, is “watchful waiting.” Since normal birth unfolds on its own, a midwife’s approach is largely to stay out of the way. “You’re observing and being available as needed, and monitoring the process,” says Wood. “As the child is born you’re already prepared, you know where the mother has gravitated—to the bed, floor or birth stool—and you’re moving things around to accommodate where this woman’s going to end up.”

Immediately after birth, “You help her get into a position where it’s easy for her to hold her child and be warm.” Midwives assess newborn health and perform resuscitation if needed. “Then at the same time you’re monitoring [the mother’s] blood loss and making sure the uterus is doing the work it’s so perfectly designed to do.”

Wood, who’s been a midwife since 1985, usually stays at the woman’s home for about four hours after birth. “Basically, in those next several hours, the primary things are establishing nursing, getting the mom to the bathroom, doing the newborn exam and placenta exam, and trying to stay out of the way as different family members come,” she says. “It’s a joyful time.”

Change of plans

The above describes the vast majority of homebirths (including, I’m happy to say, my own). But, just as in the hospital, complications can arise. Any mother planning a homebirth will inevitably be asked by concerned parents or friends, “But what if something goes wrong?”

Bader and Potter say that for first-time mothers especially, the possibility of transferring to a hospital is a top concern. About 10 percent of their clients, most of them first-timers, end up going to the hospital.

Potter says that usually, “It’s not urgent or an emergency. You have some advance warning most of the time. It’s a discussion with the client—making the decision together that interventions are feeling helpful.” The most common reason to transfer is simply that the mother is worn out and the baby has not yet arrived. Other scenarios include non-reassuring fetal heart tones, meconium (fetal stools) in the amniotic fluid and prolonged rupture of membranes (meaning too much time has elapsed since the mother’s water broke).

In such cases, midwives call ahead to the hospital and speak with an attending physician or charge nurse. When they arrive, hospital staff is ready and waiting, and the midwives stay with the client (now called a “patient”) until after the baby is born.

Transfers represent the point at which the world of natural birth collides with the medical establishment. It can be a tricky meeting; historically, some midwives have met with indifference or hostility from OBs and hospital staff, as have some of their clients. But local midwives praise the hospitals that receive homebirth mothers in need of help. Of UVA, Bader says, “They do an excellent job. They need to be commended.”

Grapperhaus says that both local hospitals have received her “as a professional and not as someone who needs to go sit in the hallway.” She’s seen the other side, too. At another hospital elsewhere in Virginia, she says, “the doctors were unwilling to hear what the midwives thought was going on. [The attitude was], ‘If you want to bring them in, drop them off, but we don’t want your assessment.’ There was no collaboration or cooperation. It felt hostile.”

Dr. John Schmitt, the head of the OB/GYN division at UVA, says that while he doesn’t condone homebirth, he doesn’t want midwives to hesitate to access UVA. “We don’t want any barriers,” he says. “I spoke to [Bader and Potter] over the years and made sure they were aware that we didn’t want any bad things happening in the community because people were reluctant to go to the hospital.”

Surprise endings

Still, transfers can be jarring to homebirth mothers. Fleisher’s son Theo was born in October 2009. After laboring all night, she’d called Bader to her house. When the midwife checked her, she discovered that Fleisher’s baby was breech. This meant a transfer to UVA. Fleisher insisted on walking, rather than being wheeled, into the operating room for her Cesarean.

After preparing for a gentle birth at home, Fleisher found herself at the center of a medical ordeal. A student bungled the administration of her spinal anesthetic. Then, once Theo had been delivered, she says, “All heck broke loose because he went into shock. There were tons of people, I’m puking my brains out, they called a code red, and I’m just waiting for [Theo to] cry. But no one’s responding to us.”

Fleisher had an allergic reaction to medication and, though Theo soon stabilized and was healthy, she felt “totally traumatized.”

Megan Bloom’s children were both born by Cesarean section at UVA after planned homebirths.

It was the nightmare of any expectant mother, much less one who’d hoped to avoid all interventions. Megan Bloom, a doula and the education coordinator for Birth Matters, also attempted a homebirth with her first child and ended up with a Cesarean. Though her surgery went smoothly, she says, “I was totally shaken up by it. I hadn’t really considered the option of a surgical birth. It was really confusing to me.”

When Bloom got pregnant a second time, she decided to try homebirth again, largely because she loved prenatal care with midwives. But when the big day came, she got stuck in the pushing stage of labor for an endless seven hours. “I just had this moment of clarity,” she says. “You know what, this isn’t working.” This time, she says, “when I entered the OR, I was overwhelmed with relief and appreciation and respect for these people who could help in this situation.”

Bloom’s daughter was wedged tightly in her pelvis and was in distress for several minutes after delivery. “Thank goodness she managed to be born,” she says. “In a way it was sort of a miracle birth….I cannot say enough wonderful things about my treatment at UVA.”

 

The bridge

Birth is as personal as sex. Not everybody wants it the same way. For many women, homebirth—even with professional help—does not appeal, but they still want to be cared for by a midwife.

What’s it cost? Brynne Potter says that her prospective clients’ number one question is, “Will my insurance cover a homebirth?” The answer, in short, is “kind of.” Most insurance pays only a portion of homebirth costs, if anything. On the other hand, homebirth midwives tend to charge far less than hospitals, and they include prenatal and postpartum care in their fees. For midwifery care across Virginia, “I think $2,000 to $4,000 is a pretty accurate range,” says Trinlie Wood. Mountain View, for example, charges $3,000. (By contrast, just giving birth in a U.S. hospital costs, on average, $8,802.) Grapperhaus, meanwhile, declined to name her exact fee for care at the Birthing Place, but said it’s about a third of what hospital birth costs. Many midwives accept barters or trades in lieu of cash. “I’ve had these wonderful services-in-kind over the years,” says Wood. “People have painted my fences. I got a living room rug.”

Enter Janna Grapperhaus, who at the end of April opened a new birth center, called the Birthing Place, at Pantops. “It’s a nice bridge between homebirth and hospital birth,” she says.

Put another way, the Birthing Place feels like a cross between a good hotel and a small doctor’s office. A poster in the waiting room reads “Peace on Earth begins with birth.” Across the hall is a “hangout room” with a sectional couch and a flatscreen TV, where families of laboring women can pass the hours with Wii or Netflix, munching snacks from the nearby kitchen.

The real action, though, happens in the center’s two fully equipped birthing rooms. Each has a comfy bed piled with pillows, a soaking tub with a sprayer for soothing pressure on moms’ backs, squat bars and kneeling pads to accommodate different labor positions, candles to set the atmosphere, and a private bathroom with, as Grapperhaus proudly points out, “naturally antimicrobial Marmoleum floors.”

In short, she’s thought of everything. Gauze pads and blood pressure cuffs hide behind doors, as does emergency resuscitation equipment. The new Martha Jefferson Hospital, Grapperhaus says, will be less than 60 seconds away. “One client decided to come because we are close to the hospital and everything was here—she didn’t have to make their home a birthing place. It’s here and already done.”

Other clients have come because they live far from hospitals, or in small apartments or with lots of dogs. Grapperhaus has already attended two births at her center and expects to have 30-35 clients per year. “We’ve had an incredible response,” she says—including mothers from the Shenandoah Valley and as far north as Fairfax.

 

To be continued

The Charlottesville birth landscape is changing in many ways. During my research for this story, Mountain View Midwives announced they will close their business at the end of the year. Brynne Potter will stop practicing to focus on the midwifery advocacy work she’s done for years. Deren Bader will take only a few repeat clients and Debbie Wong will begin her own midwifery and massage practice.

With the departure of Mountain View, at least for now, some local mothers may find it difficult to find a midwife to attend them at home. Yet, here and around the country, homebirth is part of a growing conversation. It happens woman-to-woman, one pregnancy at a time.

When I gave birth last summer, my sister-in-law was two months pregnant and planning a hospital birth. But she was unhappy with her care and began to ponder other options. And on February 18, my home-birthed daughter got a new home-birthed cousin.