Circumcision: How to decide?

Circumcision: How to decide?

As a childbirth educator, there are a couple of topics that fill me with dread when addressing a group of soon-to-be parents, and one of them is circumcision.

If you’ve spent any time at all on the internet as it relates to parenting, you may have noticed that this topic can spark some very heated discussion, so much so that it can be hard to wade through the rhetoric to find solid information. Folks hold some strong opinions on this topic—and for good reason! The decision whether to circumcise or not will carry into every day of a boy’s life. So, how to give accurate information that will help parents decide? Here’s how I do it:

There are basically 3 things for parents to consider in deciding whether or not to circumcise their baby boy:

Religious or cultural reasons

On this point, I don’t figure I have too much to contribute as a childbirth educator, though occasionally I have helped Jewish clients who did not want to circumcise to explore the idea of holding an alternate ceremony (known as a brit shalom).

Aesthetic reasons

These usually fall under the headings of: “wanting him to look like Daddy” or “wanting him not to be bullied in the locker room.” Again, I don’t feel that I can speak to one person’s sense of what looks right or wrong, and I particularly don’t need to know which of the fathers in my class were circumcised or not. But I can note that since the rate of infant circumcisions performed nationwide in the US is around 55%, there is a high probability that there will be another boy in the locker room whose penis looks like your kid’s, whichever route they choose to take.

Health benefits and risks

Since I work very hard to research and present information based on current research evidence in my classes, this final category is the one to which I can really speak. And it can be surprisingly hard to sift through the claims that are out there about risk and benefit!

The American Academy of Pediatrics has been equivocal, to be sure. Their current statement on the one hand seems to endorse the practice, and on the other hand it doesn’t. This statement can be found on their website for parents:

“The American Academy of Pediatrics believes that circumcision has potential medical benefits and advantages, as well as risks. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it, however, existing scientific evidence is not sufficient to recommend routine circumcision.

Therefore, because the procedure is not essential to a child’s current well-being, we recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician, taking into account what is in the best interests of the child, including medical, religious, cultural, and ethnic traditions.”

Their longer policy statement can be found here and the very detailed and long article from the task force behind the policy statement is here.

So, according to the AAP, the benefits outweigh the risks, but not so much as to become “essential to a child’s current well-being.” Which leaves us where, exactly?

I did my best to dig for solid numbers, and came up with this handy chart to compare benefits and risks. Let’s work our way down the list together, shall we?

circumcision infographic

Yes, Circumcision is painful

First off, circumcision is painful, and medical professionals recommend adequate pain relief both during the procedure and during the healing process (which takes about a week). The choice to circumcise your baby means he will feel pain, and there is always a small risk that he will have an adverse reaction to the pain medication.

Complications can occur

Further, the choice to circumcise means incurring the risk that there will be complications to the procedure. It is basically impossible to get hard numbers on this, since there is no universal reporting standard on complications. The numbers in my chart are a good guess. Mild to moderate surgical complications include: irritation of the glans, infection, excessive bleeding, painful urination, or scarring of the urinary outlet. The much more rare severe surgical complications include: hemorrhage or having too much skin removed. Some babies will need to have the procedure redone, either because the first attempt was inadequate, or because the skin re-adhered while healing.

For a small number of babies whose parents chose to leave them intact, they will develop a medical reason (often phimosis) that will require circumcision in adolescence or as an adult.

in tact baby boy

Perceived benefits of circumcision

Now we get to one of the benefits of infant circumcision: the reduction in risk of UTI. It is important to note that most UTIs in males occur in the first year of life, but overall incidence is still low at 1%. Baby boys who are circumcised do have a three to ten-fold reduction in risk of contracting a UTI in the 1st year of life.

Sometimes a reduction in the risk of penile cancer is mentioned as a benefit of circumcision, but the overall incidence of this type of cancer is so low, that the slight reduction in risk for circumcised men is barely statistically significant.

Finally, the other major purported benefit of circumcision is the reduction in the risk of contracting HIV and some other STIs. There have been several high quality studies done in Africa that show significant reduction of these risks. Whether their findings can be generalized to the population of American men is debatable.

It is important to note that rates of contracting sexually transmitted infections are affected to a high degree by socio-cultural influences. For example, the rates of circumcision in Northern Europe are much lower than the United States, but their STI rates are much lower as well. Regardless, the reduction in risk for circumcised men would not be completely protective. In other words, parents would need to teach their sons to wear condoms.

And on the somewhat uncomfortable topic of considering one’s baby boy’s future sex life, it is debatable whether adult men who have been circumcised experience diminished sexual satisfaction and function. I’m not sure whether this could ever be definitively proven, but there are certainly plenty of people who like to argue this point.

And that’s it. The risk/benefit ratio for circumcision as it regards to health concerns. You can see why the AAP has had a hard time making a definitive recommendation in favor of circumcision. It is, as they wisely put it, a decision that parents must weigh for their own sons. If you want to read more science-based conclusions, check out The Informed Parent: A Science-Based Resource for Your Child’s First Four Years.

This guest post was written by Stephanie Spitzer-Hanks. Stephanie gave birth to her first child in the Netherlands, where the nurturing and encouragement she received from so many women there inspired her to become a doula. Now she strives to give unconditional support and evidence-based education to families so that they can be confident in making the choices that are right for them. She is an ICEA certified childbirth educator, an Evidence Based Birth® Instructor, a DONA certified birth and postpartum doula, a StillBirthday certified bereavement doula, and a certified lactation counselor through Healthy Children’s Center for Breastfeeding. On the side of all of that, Stephanie is an ordained minister in the United Church of Christ, and she serves as a chaplain at a hospital and writes and speaks about birtheology when she gets the chance. You can find out what she is up to at www.revdoula.com.

Do You Need a Doula? And How to Find One

Do You Need a Doula? And How to Find One

Advancements in technology, industry, and business have brought about many changes within the last century. Society has likewise evolved both for better or for worse. Among these evolutions has been a big shift in the standard process of childbirth. Back in the day it was fairly normal to live near extended family and close friends, so it was very natural to have many of them support a woman during labor and delivery. As we have changed over time, it is now more common to live far away from family and delivering in the hospital has become the norm. A side effect from these changes is that mothers have lost the standard support team of women around them while they labor. A possible replacement for this lack of support is to hire a doula. Despite the myriad of positive benefits of a professional doula, only a small percentage of women utilize them. Many newly pregnant women often wonder if a doula is a worthy investment.

Benefits of having a doula

Many studies have been conducted that show the positive effects of doula support, although currently only about 6% of women use one. These benefits include, but are not limited to: decreased labor time; and a lower rate of epidurals, c-sections, pitocin administration, and instrumental assistance during delivery. A Mother who hires a doula also tends to have a much more positive view of her experience. When she feels safe and protected, she lets go of fear (which interferes with progression). Stress levels decrease, and natural oxytocin levels rise, thus encouraging labor advancement. After babies are born, they are more likely to have higher apgar scores (Hodnett, Gates, Hofmeyr, Sakala, & Weston, 2013), and there is an earlier initiation of breastfeeding as well.

Do I need a doula?

There are many known benefits of doula support during labor, but do you really need one?

The large majority of women deliver babies in a hospital and are left to the care and attention of a medical team. A staff may be concerned and aware of a mother’s physical and emotional needs, but they are often distracted by their duties as part of hospital procedure and policy. A nurse, midwife, and doctor all have their own specific tasks to complete—monitoring the baby’s vitals, reading charts and logs, making sure mom is hydrated, and has good stats, etc. They are preoccupied with the safety of mother and baby and are also overseeing a large number of other laboring women at the same time. They will be in and out of the room constantly, and even monitoring moms from machines in the hall. Think of all that is going through the minds of these healthcare workers during delivery.

Making sure baby’s position is optimal, providing perineal support, trying to prevent tearing, coaching mom how to push, monitoring baby and mother’s vitals, assisting the baby when it emerges, making sure the baby is breathing, checking apgar scores, cleaning things up, performing sutures, baby care, delivering the placenta, avoiding hemorrhaging, and keeping things sterile. They have so much going on mentally and physically that although they may be sympathetic to the mother’s needs, they cannot be too preoccupied with them. Plus they have other patients simultaneously.

A Doula’s Purpose

Conversely a doula’s primary purpose is to provide emotional, physical, and informational support for the mother for the entire duration of labor, and afterward. She will be solely focused on you and at your side continually. But what if you have a partner, sister, mother or friend with you? It is highly recommended to have support from people you love and trust. Yet keep in mind that your support group is not always specifically trained in how to care for a laboring woman, no matter how much they love you, whereas a doula is. In order to become a certified doula, a candidate must meet many qualifications. DONA International, “the international leader in evidence-based doula training, certification, and continuing education,” requires that a doula meet the following criteria:

  • have a minimum of 28 hours of labor support time logged
  • read several required textbooks on labor and birth
  • attend at least 3 births and be evaluated by a doctor, nurse or midwife, and the mother.

This knowledge and skill set put into practice is truly invaluable in knowing intuitively how to support a laboring mother.

Doula Services Prior to Delivery

A doula will usually meet with a client about two times prior before the mother goes into labor. During these meetings, she will get to know you a bit, get a feel for what your birth vision and preferences are, and help with a birth plan. She can address any concerns and fears you have about birth, and offer educational materials to review. She can learn about your personality and what calms you, as well as what gives you a boost when you are tired, and how you best anticipate needing support.

A good doula will also be well connected to the birth community for additional support and education. This can be a great resource for women wanting to gain more childbirth education and to get involved with other moms and resources in the area.

Doulas Stay With You the Whole Time

The best thing about doulas is that they are usually available as early as you’d like them in the process, even from the first few contractions. They can come to your home and be with you while you labor there, then transfer with you to the hospital. One of the main advantages to hiring a doula is that you meet her and know her before you go into labor, whereas your nurse and perhaps the doctor on call at a hospital can be complete strangers. Having your doula with you can help you feel more at ease when you arrive. Another advantage is she will stay right with you whereas doctors and nurses, and sometimes even partners will be in and out throughout the process.

Doulas Support Your Partner Too

Doulas are also valuable resources for  birth partners. A doula does not replace a partner’s support; rather she assists both parties. She can allow the partner the main role of offering words of encouragement and emotional support while she provides some physical support, and vice versa. She can offer suggestions of what a partner can do to help mom. She can also support the partner should he start to feel anxious or overtired. In one recent study, it was recorded that on average, doulas touched the laboring mother 95 percent of the time, as compared with less than 20 percent by male partners. This in no way discredits the helpfulness of a partner, but rather sheds light on the fact that a doula and a partner have different primary roles. In the end she will be able to read signals from mom and partner of what their needs are in the moment.

A doula’s job is to be there for the mom and to encourage a safe and satisfying birth experience. She provides three kinds of support—informational, physical, and emotional.

Physical Support from a Doula

A doula draws upon her knowledge of many different labor positions and offers suggestions to the laboring mother to help ease discomfort and keep labor progressing. She can offer massage or counter pressure, adjust mother’s temperature with blankets or cool washcloths and fans. She can help to implement breathing and relaxation techniques, and will offer verbal reassurances. She can offer ice chips, drinks, and food if the hospital allows it. She remembers things mom might not think of like to use the bathroom frequently. She knows mom’s preferences and will guard the atmosphere so it remains as calm and peaceful as possible. This is invaluable, especially when the mother is focused and does not want to be bothered with details.

Doulas Offer Informational Support

A well-trained doula will be aware of the hospital policies where the mother is delivering, and will know what kinds of things are allowed and/or prohibited. She can offer advice and information if the mother has concerns or questions. A doula can be a liaison between the staff’s medical jargon and the procedures that are happening. Should unexpected complications arise, a doula can offer extra information, advice and encouragement for big decisions.

Emotional Support from Your Doula

Should some unexpected things arise during the course of the labor, a doula can offer emotional support and encouragement, especially if a c-section or epidural is ordered. She can help to ease fears and guilt and allow a mother to process her potential anxiety or confusion.

Keep in mind that a doula is not only valuable for mothers planning a natural birth, but for all kinds of deliveries. Birth can be an unpredictable event. Even if you plan on getting an epidural or having a planned c-section, a doula can offer tremendous emotional guidance during the process. She can help to aid in your comfort level both physically and mentally. She can be aware of the details that are happening while you are “in the zone.” If a lot of information is being thrown at a mother all at once, and she is already overwhelmed, it can be hard to process and remember what is being said. A doula can be a valuable second set of eyes and ears to absorb information and help answer your questions.

Postpartum Doula Services

Many doulas will offer care for postpartum mothers and charge an hourly rate. Their tasks can range anywhere from breastfeeding support, emotional support, physical care and healing of mother, to cleaning, cooking meals, or taking care of the baby so mother can rest. They will usually offer services up to a certain amount of time (like 4 hours), and some will even offer to sleep over and help with night feedings for an extra fee. The postpartum period can be a difficult time, especially for brand new moms, and the aid of a doula can be very valuable, so it’s something to consider. Even knowing the option is available can put one’s mind at ease.

An Example of a Positive Doula Experience

Elaine Stillerman of Massage Today tells of her positive experience with a doula.

“I called Ilana when I became pregnant. She came to my home to interview me and my husband about our hopes for the big day. Ilana took copious notes in the attempt to get to learn my likes, dislikes and what would be most helpful during labor. She gave us a realistic list of items I would need to make my labor more comfortable. Since then, I have provided my clients with that invaluable list and offer it in my textbook.

When the day came, Ilana had just returned from another birth she had stayed at for 13 hours. She had been home for two hours when I called. “Don’t worry,” she said, “I’m on mommy time.” My water broke and I went into active labor within minutes. The contractions were coming one after the other. She asked to hear a contraction. Did this mean put the phone on my abdomen? Or did she want to hear the sounds I was making? By this time, all rational thought was out the window. “What?” I asked. “Let me hear a contraction,” she repeated. Mine were silent. “I’ll meet you at the hospital.”

Once there, she directed my husband to get a different nurse and a private room for me. She disappeared for a few minutes and came back with a pile of waterproof pads and clean gowns. She opened her bag of goodies and asked if I was hungry or thirsty. And she held me. She massaged me. She danced with me. When the pains got intense, she took my face in her hands and said, “Give me the pain. Give it to me.” And the pains lessened.

When I felt I was losing strength, she told me to relax my feet and let Mother Earth’s power help me. She stayed by my side for 19 hours, encouraging me, honoring my efforts and nurturing me. And when my son was born, she told me how magnificent I had been. A week later, Ilana came to my home for a visit, bringing lunch, gifts, pictures and my birth story. We shared a life-affirming experience and I wasn’t going to let her out of my life since she had been such an important part of it.”

If this sounds like an experience you’d like to have, it is worth looking into hiring a doula.

How to find a doula

There are a few resources to help with finding the right doula for your specific needs. You’ll want to read reviews, choose several options, and then interview them to get a feel for the right fit for your personality. Here are some places to look.

  • Dona.org – Doulas of North America
  • Cappa.net– Childbirth and Postpartum Professional Association
  • Alace.org– Association of Labor Assistants and Childbirth Educators
  • Birthcenters.org– National Association of Childbearing Centers
  • Doulamatch.com– online database of certified doulas, where you can search by state, years of experience, and price.

Doctor or Midwife Office- many offices have a list of doulas in the area or that they have personally worked with before. This is a great sign that the office is mother-centered and practices evidence based birth!

Hospital—Similarly, some hospitals have doulas on staff full time that they offer to laboring mothers.

What does a doula cost?

A doula’s services can range anywhere from about $300-$1800. They will usually charge a down payment upfront and then collect the rest after delivery. Many doulas are willing to work with you on price if you are not able to afford their fee. Some believe that every woman has a right to have the support they need. Don’t rule someone out just because their fee is high. Check with them first and see if it is flexible, or if they would accept a payment plan. Many insurance companies are now helping to cover the cost of doulas as well, so check there to see if you qualify.

Having a baby is in itself a monumental accomplishment. A doula can provide the additional physical, emotional, and informational support a mother needs to navigate labor and delivery more easily. A mother’s birth experiences are some of the most significant she will have in life. Consider enlisting the aid of a doula to make it the most positive experience you can.

Sources:

  1. Bolbol-Haghighi N, Masoumi S, Kazemi, F. “Effect of Continued Support of Midwifery Students in Labour on the Childbirth and Labour Consequences: A Randomized Controlled Clinical Trial.” Journal of Clinical and Diagnostic Research. 10. 9 (2016):QC14-QC17. Effect of Continued Support of Midwifery Students in Labour on the Childbirth and Labour Consequences: A Randomized Controlled Clinical Trial-PubMed-NCBI. Feb. 2017. https://www.ncbi.nlm.nih.gov/pubmed/27790526
  1. Stillerman, Elaine. “In Honor of a Doula.” Massage Today. Dec. 2008. Massage Today Digital Issue. Web. Feb. 2017. http://www.massagetoday.com/mpacms/mt/article.php?t=38&id=13902

This guest post was written by Austyn Smith.

The Importance of Following Your Intuition in Pregnancy and Birth

The Importance of Following Your Intuition in Pregnancy and Birth

Your Intuition, Your Gut, Mama Instincts — Whatever You Call It, Listen to It

Pregnancy, labor, and birth are monumental, life changing events. Doing research, educating yourself, being fully prepared, taking proper precautions, and trusting your OB and/or midwife are all important. However, keep in mind that women have been going through this since the beginning of time. Our bodies are engineered to create, sustain, and bring life into this world.  Birth does not always go as planned, or as “textbook” as we’d like. There are times when preparation, education, and practitioner’s advice take a back seat and a powerful voice comes into play. Your intuition. A mother’s intuition is an important voice to pay attention to, and the more prepared and educated you are up front, the more you will be able to trust that your gut feelings are coming from a vital place, rather than from fear and panic. Below are some powerful accounts from women who paid attention to what their body was telling them, and the positive outcomes that followed.

Mamas Who Are Glad They Followed Their Intuition

“With my second baby’s birth, I had been 3 cm dilated for over two weeks and having contractions on and off, too. The night before my son was born (1.5 weeks after my due date and the day before my induction), I told my husband, that we needed to call my dad if I had three strong contractions and/or my water broke, because I just felt it would be a quick labor. At 2:30am I had those strong contractions, 3:00am my water broke and at 4:27am my baby was born!  If I hadn’t had that feeling of things going quickly after a slow buildup, Sullivan may have been born in the car or even at home!”   – Jesica Boro

“…My son was turned. I was feeling nauseous from not eating for so long. The midwife was trying to turn him and couldn’t so they wanted to get a doctor to help. I could feel it was coming time for me to have an emergency c-section. Before the doctor came into the room, I got on my hands and knees which [made me] throw up and that caused my son to turn so I delivered him naturally like I wanted. – @Celeste2401

“A week after i had my daughter in June, I was terribly ill. At a time when I was supposed to be mending and enjoying my new baby, I was so sick that all I could do was cry. My friends and family told me it was just after birth cramping and that I was still healing, but I finally decided to call in to the midwife and let her know what was going on. She advised me to go to the ER right away, and hours later I was having an emergency d&c for a retained placenta that was hemorrhaging. I am so glad I listened to my body. If I had waited any longer it could have been a much different outcome.”  — Jamie Van Nuys

“I was laboring in the labor tub. I had only been in for 15 minutes and was just checked 30 minutes prior and only 5 cm. My intuition told me to get out and go lay in the bed (they don’t let you deliver in the tubs). I was standing up and felt the urge to push. Two pushes later and about two minutes later my son was born.” — Brittani Fink  

first latch

“When I was in labor about a month ago, we were waiting for my mother-in-law to come watch our two older children. When she was about 40 minutes away, I got the feeling that we had to leave for the hospital NOW.  My husband was a bit skeptical because I had only been in labor for about two hours. But, he went and woke up the neighbors in the middle of the night and we left. Our baby was born about one hour later. If we had waited, I would have had him in the car!” — Nicole Kavanaugh  

“After three cesareans and no natural births I was told by my doctors that my body “wouldn’t know how to labor” so I decided to get a private midwife, not step foot in a hospital again for the rest of my pregnancy, and set my mind on a homebirth. Everyone gave me their unwanted opinions about it all and only my husband stood by me. After about 100 hours of labor, I gave birth at 42 weeks + 1 day to my biggest baby ever (all 9 lbs 10 oz. of him) in a pool in my living room! THE best feeling ever! I’m now 39 weeks with baby number 5, I have the same midwife as last time, and I cannot wait to give birth to this baby. I never believed for a second my body was broken, and I proved all the doctors and midwives at the hospital wrong. I did it.” — Rose McMurrie, Liverpool UK 

“After the birth of my son last Thursday I was over the moon…but something kept telling me something was wrong and after the experience I went through I will never doubt my intuition! Three days after birth I knew something was wrong when I had been experiencing severe edema, painful headaches that wouldn’t go away, and sky high blood pressure. I decided to go to the emergency room and the doctors then told me I had developed postpartum preeclampsia.  I was immediately admitted, I was at high risk for seizures, a stroke and even the possibility of going into a coma. After four very long, emotional, rough days I am finally responding to medication that is maintaining and stabilizing my blood pressure. I am back home with my baby and my fiance and most importantly I am alive and well…If I didn’t rush to the emergency room when I did, the signs I was showing could have been fatal for me. I appreciate my life so much more.” — @Ox.vs  

“My first birth, I was in labor barely an hour when I told my husband to call the midwife. I had to push before she even got there. She didn’t even check me, but when I said I had to push she called the backup and got set up and my daughter was born 20 minutes later. So glad I didn’t fall into the thought that first births take a long time, or else I would have been birthing unassisted. Very glad to have planned a homebirth from the get go!  Though my midwife training would have come in handy!” — Meganne Odile Coyle  

breastfeeding tips

“My baby’s bilirubin levels were high. Day three of life, the pediatrician made the assumption I wasn’t producing enough milk. “The baby will eat it if it’s there,” he said, and told us we needed to supplement with formula. I asked for a pump and made them weigh him before and after a feeding as well as pumped after. I was producing more than enough and wouldn’t you know it, his chart was being read wrong and he had been back to normal levels on day 2. Still breastfeeding like a champ nine months later.” — Marji Taylor  

“At 38 weeks 5 days pregnant with my first son, I woke up in the middle of the night and found myself bleeding. I called my midwife who immediately recommended that I go into L&D and she would meet us there. Upon arrival at L&D the attending doctor recommended an induction and suspected that I was likely experiencing placenta abruption (i also had a low lying placenta). My partner and I decided to wait on the induction and the hospital admitted me for observation and told us to let them know when we were ready to be induced. But somehow, I felt that my son wasn’t ready to come. The bleeding eventually subsided, and after 17 hours of being observed, after one doctor after another came in telling us we needed to be induced, and braving through judgemental looks and fending off their repeated push to have an induction; against doctor’s orders, we decided to check ourselves out and go home. A day later, I went into active labor. After 9 hours, in the safety and comfort of our small apartment, with my partner and midwife by my side, my son was born at home. It was the home birth that we had wanted. I listened to my body and my son. My partner stood by my side and although it was very scary to leave the hospital, it was the best decision we made that day.” – @Bbmee  

“The nurses wanted to check my dilation when I arrived at the hospital.  I told them not to bother—I wasn’t fully dilated yet but was in transition and it would be soon. I told them my second stage is always under 5 minutes. They didn’t believe me. When I felt a shift I told the doctor I was ready to push and baby was coming. She checked and said, “No, you’re only at an 8.” She stood up and walked to the sink, and I called to my husband (who always catches our babies and who was ready), “She’s coming, catch her! “I heard his calm voice reply “I’m here, I’ve got her.” And she was born into her father’s hands at that moment, with no assistance from others. Which was exactly as I had wished.”  — Elisabeth  

“After 26 hours of non-medicated labor with a baby who had his head turned sideways and was in no hurry to come out, I decided to transfer from the birth center to the hospital to get an epidural. I knew that even if I did dilate all the way, I wouldn’t have enough energy to push my baby out on my own. After the epidural, I was able to get a few hours of sleep and when I woke up I was fully dilated and ready to push! I truly believe I was able to have a vaginal birth because of the sleep I got after the epidural! I am happy that I listened to my body and I have no regrets! My birth was hard, but that is what it was. My birth.” — Kristi Merideth

“I was on hour 6 or 7 of my twelve hour homebirth when I began to hyperventilate. I was in the birth tub facing away from everyone, so I don’t think they knew I was starting to lose it. I hadn’t dilated much at that point; how little, I don’t know. But I sensed the air of concern. I didn’t want to go to the hospital. That was my greatest fear. I began going down the “what if” spiral of doom and lost control of my breathing. Just then my intuition kicked in and told me to look up and open my eyes. A birth affirmation my friend made me came into view. It said: Think strong. Feel strong. Be strong. I began saying that over and over in my mind, pushing away the fear. My breath calmed, my outlook improved. I could do this. I would do this. At the next check, I was fully dilated!” — Katie Bunten

“When you reach the end of what you should know, you will be at the beginning of what you should sense.” Kahlil Gibran, Sand and Foam

Homebirth Midwifery Philosophy & Model of Care

Homebirth Midwifery Philosophy & Model of Care

As a masters trained certified nurse-midwife with a thriving homebirth midwifery practice for over 2 decades, I have worked both in and out of hospital settings. I am passionate about preserving the option of homebirth and promoting the homebirth midwifery model of care in all settings, including the operating room.

Homebirth as a Safe Option in Collaboration with Obstetrician Support

There is a pervasive belief in our modern day culture, that hospitals are the safest place to give birth, despite the extensive scientific research that planned home births with skilled midwives suggest otherwise. Many studies around the globe document the safety of planned home birth by professionally trained midwives, with outcomes at least as good, if not better than those in a hospital, especially when women have given birth vaginally before. The slight increased newborn mortality risk of home birth is estimated to be 1 in 1000. The absolute risk for each homebirth baby is actually quite small. Although the United States spends the most money on obstetric care, it ranks among the lowest among industrialized countries around the world in neonatal mortality and morbidity, and also ranks low in maternal mortality and morbidity.

Countries that demonstrate the best mother and baby outcomes have a high percentage of midwife-led maternity care for healthy women having normal pregnancies (which is the vast majority of pregnant women). They also have a larger percentage of homebirth midwifery care with supportive hospital/medical transfer when necessary, and obstetricians who provide care for women with higher risk complications and serious illnesses —just as they are educated to do as surgeons and medical physicians.  When midwives and obstetricians work collaboratively as a team, both using their unique knowledge, training, skills and expertise, the mother and baby outcomes are far superior.

doppler waterbirth

Midwives are educated in safeguarding the normalcy of pregnancy, birth and postpartum, not interfering with it when all is well, knowing when to monitor with sensitive and supportive care, and when and how to use holistic modalities, or medical intervention only when needed. They are also trained in preventing, assessing and treating complications, which most of the time can be handled simply and naturally, but sometimes do require consultation, collaboration with, or referral to an obstetrician. Although unpredictable occurrences and emergencies can occur in any birth setting, a low risk healthy pregnant woman entering many standard hospitals expecting a normal vaginal birth, is subjected to a routine cascade of procedures and interventions that significantly increase the risk of problems and complications. These may have potentially long-term negative physical and psychological consequences for mother and baby.  

Be Aware of Perceived Risks of Birth in General

Focusing on the normal does not mean that problems go unrecognized or ignored; instead they are viewed as imbalances that need to be attended to. They are not expected or feared.  That being said, certain risks do exist, in all birth settings, whether childbirth occurs in or out of the hospital; and there are risks unique to each place of birth.  Some of these risks will never be eliminated no matter what our state of improved technology or medical progress. The safety of homebirth is well supported by the compilation of research, but childbirth is a pivotal threshold for baby and for mom.  Some babies are born with abnormalities and injuries in spite of all the testing, technology, and expertise of the attendants.  

Despite the fact that the relatively recent hospitalization of birth has failed to eradicate fetal or neonatal death, there is a cultural presumption that physicians and hospitals can guarantee a perfectly healthy mother and baby all of the time. This is a widespread myth. It not possible for any provider to guarantee anything. Birth defects may or may not be discernible by prenatal testing. The practice of nursing, midwifery, and medicine are not exact sciences, and no assurances can be made regarding the results of examinations, diagnostic tests, treatments, procedures, or interventions. It is impossible for any provider to provide full certainty of a normal healthy birth, mother or baby.

birth partner support

Advantages of a having a home birth

In addition to safety, there are many other advantages of homebirth midwifery care. It provides an alternative to the standard medical and hospital care that commonly occurs in the US—care that is perceived as impersonal, assembly line, high tech, fear-based, and oriented towards prevention of litigation.

Support team and comfortable environment

Other advantages include the healing power of human touch and presence, being surrounded by family or additional supportive people, security in giving birth in a familiar and comfortable environment of one’s home, feeling less inhibited in expressing unique responses to labor (such as freedom to eat and drink, vocalize, move, assume instinctual positions of comfort, express intimacy with a partner, breastfeed a toddler, practice individual cultural and faith based rituals to enhance coping). All of these can ease labor and birth.

No need for uncomfortable hospital transport

Another benefit includes not having to decide when to go to the hospital during labor. Going too early can slow progress and increase use of potentially risky interventions, while going too late can be extremely uncomfortable or even lead to a precarious unplanned birth en route.

Family Bonding at Home

Being able to choose how and when to include older siblings is another advantage to home birth. Siblings are making their own adjustments and can be challenged by an extended absence of their parents and excessive changes of the family routines. A home birth provides the opportunity for uninterrupted family bonding and nursing.

Cost Benefit of Homebirth to Families

Home births offer incredible cost savings for both insurance companies and those without insurance, and increased likelihood of having an empowering and deeply positive, beautiful, life-changing pregnancy and birth experience.

Getting holistic prenatal through postpartum care, and birthing in one’s own home attended by a well trained and skilled midwife, is a refuge for those who want to protect the normalcy and sanctity of childbearing.

The Midwifery Model of Care

interviewing midwives

My midwifery education and training enable me to provide prenatal, labor, delivery, postpartum and newborn care, as well as breastfeeding support for healthy low risk families. They may be planning to birth at home, in the birth center or hospital. I also provide gynecological and some primary care services to well women. I value a unique, comprehensive model of maternity care that provides an exceptional level of holistic support and services to achieve optimum health for mom and baby.

A Team of Pregnancy Support Professionals Encourage Overall Wellness

As a homebirth midwife, I address the wide range of ingredients that contribute to a profoundly positive and healthful pregnancy, birth and postpartum experience. These include: wholesome nutrition, healthy joyful living, personal education, connection with a supportive community, regular exercise and practice of yoga, meditation or other modalities to reduce internal stress and increase feelings of relaxation. I often draw on the expertise of additional professionals, from doulas and childbirth educators to lactation consultants, acupuncturists, massage therapists, chiropractors or osteopaths and other alternative health practitioners and specialists.

In an effort to bring back the needed village it takes to raise a new baby, and new parents, I also encourage each woman and her partner to take advantage of an array of classes and support groups. These include prenatal yoga, yoga for labor, postpartum mommy and me yoga classes, positive birth story pregnancy circles, community new mother blessing ceremonies, postpartum mom circles, pregnancy and new mom retreats, and a variety of other educational, supportive, and fun events, and ways to connect with other likeminded people and build community.

vaginal waterbirth

Personal Statistics, Practices, and Philosophies

Most women are candidates for homebirth midwifery care. In my individual practice, over 92% of pregnant women will have a home birth, and my cesarean section birth rate is less than 5% . This is comparable to most homebirth midwives, and much lower than the national average of 30% and rising. The great majority of hospital transfers in labor are non urgent—mostly first time vaginal birth mothers with stuck labors and exhaustion, after we have tried all possible modalities in the home setting.

My responsibilities include review of each woman’s complete health history, physical exam findings, and lab results to decide if she is eligible for continued homebirth midwifery care. I also provide ongoing evaluation and guidance throughout pregnancy, labor, birth and postpartum paying attention to signs of normalcy and/or signs of difficulties or problems. Situations are discussed openly, and there are no routine interventions unless medically needed and mutually agreed upon.  

Individualized Care

Ongoing individualized care determines the needs of each childbearing family. I have created practice guidelines in conjunction with other homebirth midwives, evidence based research and the current midwifery literature. They reflect core philosophies and professional standards for practice, and they are reviewed and evaluated periodically as needed. These practice guidelines are developed and followed to protect the health and safety of each individual in my care.

I believe that pregnancy, birth, and postpartum are normal, natural bodily functions, like breathing; but they are also profoundly spiritual and inspiring, as well an empowering rite of passage for women and their families. I believe that childbearing families are best served by caregivers who encourage a kind, sensitive, respectful, lovingly supportive, family-centered environment, and maintain trust and calm confidence in the normalcy of the process, until proven otherwise. Safety, comfort and a deeply positive journey to motherhood are top priorities, and I take every reasonable precaution to ensure them. A safe and wonderfully satisfying childbirth experience requires the joint cooperative efforts of both the expectant family and health care providers, with a relationship based upon good open communication, mutual respect, and shared responsibility.

sibling waterbirth

Education around birth

Education of women and their families is an integral part of my services, so that they are able to assume this responsibility for maintaining health and well-being, making informed decisions, planning and preparing for birth and postpartum, and actively participating in their health care throughout the process. The ideal outcome satisfies psychological, family and spiritual health beyond the obvious physical well-being. I believe that each person has the right to safe and satisfying health care by the provider of their choice, given with respect for individual preferences and cultural variations. I believe that normal, healthy women have the right to birth at home if they choose to do so, and as a licensed midwife, feel obliged to ensure that their experience is as safe and satisfying as possible for them. For the overwhelming majority of families, the experience of childbearing is one of health rather than illness, and there is a need for preventative and loving supportive care that is not only protected and free from harm, but also sensitive, compassionate and empowering.

Complications and making decisions

Although childbearing is a healthy, normal and natural process for most women and babies, problems can infrequently occur, and need to be noticed and attended to. Many complications can be prevented or dealt with simply at home, but some do require consultation with a collaborative physician or transfer to medical and hospital care to increase the likelihood of a healthy outcome. I support decisions regarding each woman’s care that are well informed and collaborative; however, rare emergencies may occur in which the professional judgment of the midwife and/or consulting physician must be relied on completely for the safety of mother and baby.

While I continue to grow in my academic, clinical and intuitive knowledge and wisdom, I am also expanding in understanding, appreciation and awe of the sanctity of life and its many facets, transitions and stages. I try as best as I can, within my human capacity, to give my utmost attention and care with integrity, honesty, and heartfelt commitment and dedication. I am forever appreciative for life saving hospital medical and surgical care when there are serious complications and illnesses. It is my hope that the homebirth midwifery model of care can be applied as much as possible in all birth settings, even if surgical birth is needed. It is my passion to do my part in improving and restoring humanity to maternity and newborn care.

This guest post was written by Anne Margolis CNM of www.homesweethomebirth.com. Connect with her on Instagram and Facebook.

Birthing Methods and Philosophies

Birthing Methods and Philosophies

Different Birthing Methods and Philosophies Plus Finding the One that’s Right for You

You’re pregnant. Congratulations!

Once you’ve moved past the first stage of pregnancy, in which you are so preoccupied with your body’s absolutely wonderful and amazing ability to build and sustain another human, you hit the next stage: contemplating the dizzying prospect of this human baby coming out of your body. For many of us, this thought of actually giving birth is a bit terrifying. Fortunately, education is a way of dispelling fear. And thus, the childbirth education class was born. (See what I did there?!?)

Selecting a Childbirth Class

Actually selecting a class proves to be another daunting prospect. There are so many possibilities to choose from! As a doula, I’ve helped many clients try to figure out which class to take. Here’s a handy little graphic I put together, which will hopefully help you sort through your options:

childbirth education options

In any class you sign up for, you will learn some of the same basic information: what are the stages of labor, what is a contraction, common interventions, when to call your care provider, etc. The differences are in the basic philosophy of the class.

Hospital-taught or Independent Classes?

Your first choice is between taking a class offered by a your hospital or care provider, or choosing an independent childbirth education class. Hospital/care provider classes tend to be focused on helping you be a good patient of that hospital or practice, which can be great if you feel very confident that your hospital or care provider has your best interests in mind. For example, women who plan to deliver at a particular birth center may find that the class they offer in-house helps them to know what to expect in that environment and with those caregivers. Another advantage of this type of class is that the cost tends to be much more affordable than an independent class, since the cost of the class is often heavily subsidized by the hospital or practice.

However, many birthing couples choose to pay a higher price to take an independent class, since the instructors of these classes can freely discuss options in birth without pressure from their employers. For example, a group of OBs or hospital administrators may not want mothers to deliver their babies in any position other than flat on their backs, and so they would not allow an educator in their employ to include information on upright pushing positions. If you want to be sure that you are educated on all of the options available to you, you may want to look into taking an independent class.

But once you choose to go outside the system, so to speak, that’s when things get really confusing. There are so.many.choices. How to decide which class is right for you?

doula taught group class

Which Birth Philosophy or Class is Right for You?

Independent classes can be subdivided into two groups: classes adhering to a specific philosophy of birth and employing methods that correlate to that philosophy, and classes that are more of a mash-up of methods.

In the specific philosophy camp are: Hypnobirthing®, Hypnobabies®, The Bradley Method®, Birthing From Within, Birth Boot Camp®, and many others, though the ones I’ve listed seem to be the most popular options going. Again, all of these will include some information on common interventions in birth, but they all share the goal of helping mothers avoid intervention in general, and pain medication in particular. An exception to this may be Birthing From Within, as it emphasizes acceptance of what comes, more than focusing on a specific (unmedicated) outcome as best.

Let’s go through them one by one, with a brief overview of each philosophy:

Hypnobirthing and Hypnobabies

Hypnobirthing® and Hypnobabies® share a lot in common. They both use guided relaxation scripts and self-hypnosis techniques as a means of coping in labor. Hypnobirthing® has been around longer, and there are more instructors out there teaching in-person classes. Hypnobabies® is newer, so it may be more difficult to find an instructor in your area. Hypnobabies® does offer a home-study course, while Hypnobirthing® does not, though it is possible to buy a book on Hypnobirthing® to read on your own.

The Bradley Method

The Bradley Method® has the subtitle “of Husband-Coached Natural Childbirth,” which gives you a good idea of what this method emphasizes. Bradley Method classes focus on keeping mothers low risk, and on the partner taking a very active role in helping her stay relaxed, and thus able to cope with the intensity of labor and achieve a low intervention, unmedicated birth. Important to note: Bradley classes are required to be 12 weeks long, so if you are interested in this philosophy, sign up early.

Birthing from Within

Birthing From Within takes a different view of the role of partners—rather than helping them to become birth coaches, they view partners as “birth guardians or loving partners.” The role of the instructor in Birthing From Within classes is that of mentor, guiding the parents in their own self-discovery. Above all, Birthing From Within sees birth as a rite of passage, which, regardless of birth outcome, can be an occasion to practice awareness. I once had a birth client asking me for help in choosing a class tell me, “You should know that creating birth art is more terrifying to my husband and me than the prospect of the birth itself.” I steered her very firmly away from Birthing From Within.

evidence based childbirth class

Birth Boot Camp

Birth Boot Camp® uses a unique frame for their classes. They use a militaristic theme throughout their materials, and their tagline is “Training Couples in Natural Birth.” The military theme is clever packaging for some really serious preparation for giving birth naturally and for breastfeeding. This course is 10 weeks long, so be sure to sign up early if this philosophy speaks to you. They also have an online version of the course, for those who don’t have an instructor in their area.

Again, these are the main options for classes promoting a specific philosophy in birth, though there are others out there (probably someone wrote a new one while I was typing this). The other class options are those that use a mixture of methods and philosophies. These vary widely, because the instructor of the class often writes her own curriculum, or at least she adapts a model to suit her own experience and preferences. The class may include a guided relaxation script and/or an exercise in releasing fears, or it may not—it all depends on the instructor. Often these classes will not focus so determinedly on achieving a low intervention birth, but will guide the parents in evaluating the risks/benefits of each intervention and encourage the parents to advocate for themselves in making the choices that are right for them. There are loads of training and certification programs out there—Lamaze*, ICEA, Childbirth International, CAPPA, and many others.

Knowing your Options and Feeling Empowered

I hope this post has helped you to cut the confusion and choose a class that will suit your preferences and help you prepare to meet your baby, whether it is through self-hypnosis or boot camp, the hospital class or mindfulness practice. Good luck! You can do it.

*A note on Lamaze, since a lot of people think it is something it isn’t (or at least isn’t anymore): Lamaze has been around for a long time, and used to be known primarily for their breathing and relaxation techniques. But over the past 50 years, Lamaze has adapted its curriculum, dropped the emphasis on learning specific breathing techniques, and now focuses on helping parents have a safe and healthy birth through knowledge of their “Six Healthy Birth Practices.” Lamaze instructors can be found teaching both in hospitals and independently.

This guest post was written by Stephanie Spitzer-Hanks. Stephanie gave birth to her first child in the Netherlands, where the nurturing and encouragement she received from so many women there inspired her to become a doula. Now she strives to give unconditional support and evidence-based education to families so that they can be confident in making the choices that are right for them. She is an ICEA certified childbirth educator, an Evidence Based Birth® Instructor, a DONA certified birth and postpartum doula, a StillBirthday certified bereavement doula, and a certified lactation counselor through Healthy Children’s Center for Breastfeeding. On the side of all of that, Stephanie is an ordained minister in the United Church of Christ, and she serves as a chaplain at a hospital and writes and speaks about birtheology when she gets the chance. You can find out what she is up to at www.revdoula.com.

Sources
https://us.hypnobirthing.com/
https://www.hypnobabies.com/
http://birthbootcamp.com/
http://www.birthingfromwithin.com/
http://www.bradleybirth.com/
http://www.lamaze.org/

Questions to Ask When Interviewing Midwives

Questions to Ask When Interviewing Midwives

Questions for Interviewing a Midwife

A midwife you can trust and feel comfortable with is worth her weight in gold. Birthing a baby is an incredibly personal and intense experience in it’s own right.  Having a professional there to assist you should only offer comfort and help. It’s vital that you find someone that you not only click with, but who you can trust wholeheartedly. Here’s a list of interview questions to start you on your journey to finding your midwife!

A good midwife will be able to speak frankly and to balance your needs/desires with the safety of you and your baby. The midwifery philosophy is generally hands off and more about trusting your body with guidance offered when desired by the mother and medical intervention implemented when required. At the same time they are extremely engaged with you throughout your care with appointments that usually last one hour and covering not only any physical concerns and questions, but also your emotional state as well. A good book to get you started if you’re new to the idea of hiring a midwife is Ina May’s Guide to Childbirth or watch The Business of Being Born.

Basics in Determining if a Midwife is Right for You

  1. How long have you been practicing?  How many births have you attended? What are your credentials?
  2. Are you available via phone/text? Specific days/hours you aren’t available?
  3. What is your practice like—are you in practice solo or with other midwives? Are there additional staff like doulas
  4. Is your practice involved in the natural birthing community at all? Are there resources for me to connect with other women?
  5. Do you work with specific OBs? Do you have a good rapport with OBs at the hospital?  How does the hospital view you and your practice?
  6. How many planned births do you accept per month? If you are not available when I go into labor, who is your back-up?
  7. What is your overall philosophy on pregnancy, delivery, and birth?
  8. What do you feel your role is as a midwife?
  9. Where do you attend deliveries? Birth center? Home? Hospital?
  10. How do you feel about water births?
  11. Have you ever lost a baby or mother? What happened?  
  12. What is your hospital transfer rate?
  13. What are your fees? Do you offer payment plans? Accept insurance?

Pregnancy Topics to Cover in Midwife Interviews

homebirth home visit

  1. What screenings and tests do you recommend? Which ones do you offer in house vs send me somewhere else to get?
  2. Have you ever worked with gestational diabetes? What is the process?
  3. What are your views on nutrition and exercise during pregnancy?  Do you offer resources?
  4. Voice specific pregnancy concerns — does she offer good solutions and recommendations?
  5. Do you require a Group B Strep test? What if I test positive for Group B Strep?
  6. If I become “high risk” what is the process? When would I have to transfer to an OB?
  7. What “high risk” situations do you have experience with? Twins? Breech? Advanced maternal age? Pre-eclampsia?

Labor and Delivery Questions When Choosing a Midwife

  1. At what point in labor do you prefer to get involved? When would I call you?
  2. What is your view on VBACs?  What is your success rate?
  3. Potential birth emergencies—what are they and how would you handle each one? Tell me some situations you have dealt with (Hemorrhaging, partial placenta delivery, shoulder dystocia, nuchal cord or limb).
  4. Are you equipped in neonatal resuscitation? How often do you refresh your training in this area? Tell me some experiences.  
  5. What equipment do you bring with you to a delivery?
  6. If my baby is breech before delivery, what would you recommend we try? If it does not turn, would you still deliver?  Have you had experience with this—both successful turning and breech delivery?
  7. In labor do you routinely perform vaginal checks?
  8. In what situation would an episiotomy be performed?
  9. If a labor stalls, what is the process?
  10. If my water breaks, is there a time limit to when I need to deliver by?
  11. In the event that I go past my due date, what is your philosophy and what would be the process?
  12. In the event I had to be transferred to a hospital, what would be the process? Who would drive me? Is there a specific hospital we’d go to? Would you come with me, or stay with me through delivery?
  13. Can you offer me some references from mothers who have had to transfer?
  14. How do you feel about delayed cord clamping?
  15. Can my husband catch the baby? Can I catch my own baby?

Postpartum Questions for your Midwife

evidence based ob

  1. What postpartum care do you offer (herbal baths, sleep in the bed, meals served, massage)?
  2. What newborn care do you provide?
  3. Do you offer newborn testing? Do you require it?
  4. If I deliver at a birth center, how long would I stay there afterward?
  5. Do you make postpartum home visits? When?
  6. Will you offer breastfeeding support?
  7. Do you offer placenta encapsulation?
  8. When will I switch over to pediatrician care for my baby?
  9. Can I continue to see you for annual well-woman visits?

Question to Ask Yourself After the Visit

Overall, what general feeling do you have after talking with the midwife? How does your partner feel? A good sign would be connection, feelings of excitement, trust, and calm. Uneasiness, trepidation, or uncertainty are good clues that you should continue looking.

When you are thorough with research and questions, your gut feeling can really carry a lot of weight. Trust your judgement.