How to make Hospital Birth the same as Home Birth?
So many times I hear (or read) the opinions of others that home birth is risky, while hospital birth is safer, and that therefore the only thing we need to do is make hospitals more home-like. Rather than get into all the ways why that will never work, I figured I’d humor those people for once. So, let’s say we could make hospitals just like being at home. What would that look like? Well, if we’re going to bring the home birth to the hospital then here’s a few suggestions…
Abolish the routine admission testing and procedures
You know how you call your midwife at home in labor and she comes over with the urine test kit, the electronic fetal monitor (complete with the actual machine that prints out the strip), and a bunch of needles for the blood draw? Or how she immediately insists on checking your cervix for dilation without asking you if you actually WANT to be checked? Or how she makes you get onto a really uncomfortable bed, on your back, for all this stuff? And how you have to labor for 20 minutes on your back and try to stay completely immobile so that the fetal monitor can pick up the heart rate and contractions without slipping? If you’re saying “hey, wait a minute, they don’t do ANY of that!” then you’ve already figured out one major difference between home and hospital. Now, you can absolutely refuse the blood draw; I did, and it took 5 minutes (or however long it took for me to get through 5 really hard contractions) to kindly tell the nurse I was declining this routine procedure while she was standing outside my curtain waiting for me to consent to it so she could check it off her little checklist. Had my midwife not been there to “catch” her, she probably would have just walked in unannounced and been even more confrontational about it. But everything else, I was powerless. I was told I “had to” have the electronic monitor and I “had to” give a urine sample, even though peeing was very low on my list of things I needed to do at that moment and I didn’t feel like sitting on their cold toilet seat while in hard labor. As for the cervical check, I didn’t know what I didn’t know, so I thought I “had to” do that as well. I now know that I don’t have to consent to anything I don’t want, and that cervical checks are pointless unless there’s an actual suspected problem that would warrant assessing progress.
So, if we’re going to make the hospital into a home birth, then we need to get rid of these things for low risk mothers, or at least give them the option of declining. That means that rather than this being “routine” on a checklist, the nurse comes in (if the midwife hasn’t arrived yet) and greets the mother. She ASKS if the mother wants to do an electronic strip, or if she’d prefer a quick auscultation with the Doppler for one or two contractions. The nurse or midwife explains the benefits of movement in labor, and that it might be more comfortable with the Doppler, but that the strip provides a read-out of the contractions as well as the heart rate, however the mother would have to lie for 20 minutes on the bed strapped to the monitor. She would mention that lying down in labor can be more uncomfortable and the restricted movement may cause more pain or for baby to not be able to move down into the pelvis effectively for those 20 minutes. You know, INFORMED CONSENT. At this time she would also mention that there’s an optional urine test and blood draw, and explain what exactly they are testing for and what the potential outcomes would be if the results come back a certain way. Mother weighs the risks vs benefits of all these tests, and chooses what works for her.
IDEALLY, this would all be explained at a later prenatal appointment before labor begins, and the mother would go over this with her midwife or doctor and have all these things either checked off as consent or decline, so that upon arrival at the hospital the nurses already KNOW what has been consented to and what has been declined. Anything that was checked off as “consent” would once again be discussed with the mother, although more briefly (“do you still consent to x procedure/test?”) in case she has changed her mind. The longer explanation would only need to be done in the event that the mother shows up in labor before she has had a chance to have this important consultation with her doctor or midwife.
One Midwife for Every Woman
Obviously if a mother is at home she has a single midwife attending her for her ENTIRE labor. In the hospital, however, the mother may end up meeting a midwife or doctor, or even an OB whom she has never met or only met briefly, or with whom she does not feel a connection to. Even the maternity nurses change shifts, and if labor is long that means that the mother may see many different people all of which can interrupt her concentration on laboring effectively. The reason home birth is so appealing is because THERE ARE NO SHIFT CHANGES. The same midwife remains with the mother from start to finish, and more than likely the mother has had MONTHS to build up a level of trust and comfort with that midwife, which allows her to let go and just BE. So, if we want home birth mamas to choose the hospital, then we need to provide real one-to-one care. That means ONE midwife stays with ONE woman in labor or ONE nurse is assigned ahead of time to each mother scheduled to give birth in the hospital. They would be on-call, just like the midwives. They would meet with the mother during all the scheduled OB appointments. Ideally, midwives would take over the role of OBs and nurses in the majority of women needing care, but OBs and nurses would be the “high risk” option for those women who need more specialized care. Until complete funding was available to hire this many midwives to replace the OBs and nurses in hospitals, doulas would also be funded through the healthcare budget (which would suddenly have a lot more money since we’re not doing all the expensive interventions for EVERY woman) for every mother unable to have a full-time attending midwife, or for who just wish to have some extra non-medical support.
Birthing Tubs in Every Room
One criticism I have about the hospital is their policy that you can labor in the tub, but you’re out the second you start pushing. I’m sure it’s not this way in ALL hospitals, but it is true for most of them. At home, water birth isn’t only possible, but it’s pretty commonplace. So when women want to choose a water birth, then they really only have the choice to birth at home. In this new hospital-as-home environment we’re hypothetically creating, that choice would be available and encouraged in the hospital. There would be large tubs with unlimited hot water, and even Jacuzzi jets if the laboring mother wanted them. There would be no pressure to pull her from the tub as the baby started to descend into the birth canal, and baby would be born into the nice, warm water. Then the tub would be drained and cleaned as the mother climbs into her cozy bed with baby in her arms. Which leads me to…
Let’s be honest here; nobody likes sleeping in a hospital bed. They are cramped, uncomfortable, and the sheets are scratchy. They restrict your ability to get into a comfortable position and basically just SUCK in comparison to being in your own bed. Home birth mamas get to climb into their own beds with fresh, clean, soft sheets. They get their own pillows and blankets, and depending on the size of their bed there’s LOTS of room to have the whole family join her in snuggling up with baby. If she had a water birth, that bed is even MORE inviting, because she didn’t just give birth on it. So the simple solution to the bed problem is to give maternity rooms a major upgrade! Let’s replace the traditional “birthing bed” with a lovely Queen size bed with the option for mothers to use their own sheets, pillows, and blankets if they so choose after birth. Let her snuggle up with her family in that bed. Before the birth, have a plastic sheet over the clean sheets (to protect them) and then the hospital grade drapes over that sheet, since that’s pretty much what a home birth setup for birthing on the bed would look like. Of course, we’re not restricting mothers to just birthing on the bed, so these sheets might not even be used at all, and then the drape and plastic can be re-used since it wasn’t touched. That reminds me…
ACTUALLY letting mothers birth in any position they want, ANYWHERE in the room they want to
I KNOW what you’re going to say! “But don’t hospitals already do this?” Well, in written policy, yes, but in practice…NOPE! 95% of women are STILL giving birth while lying on their back, either flat on it or semi-reclined. Both positions SUCK at facilitating an easy birth and do a poor job of decreasing the chance of tearing or need for an assisted vaginal delivery with the vacuum extractor (and the accompanying episiotomy). Home birth mamas KNOW this, and we’d prefer NOT to tear or get our perineum cut, thank you very much. Most home birth videos have mothers in uprights positions, either squatting, sitting, or hands and knees. Very rarely are they lying down on their backs. Maybe they’re on their sides if they’re tired, but hardly EVER on their backs! Yet when I tried to lean over the bed that the nurse insisted I get onto, and I tried to squat down, I was firmly told “no” as if she was talking to a toddler or a dog that was doing something they weren’t supposed to be. It was infuriating. And guess what position I ended up in, after my side-lying position “wasn’t working”? On my back. For THREE HOURS!
So how do we fix this? WE JUST LET WOMEN PUSH IN WHATEVER GODDAMN POSITION THEY WANT, EVEN IF THEY END UP ON THE FLOOR OR LEANING OVER THE COUCH OR BED. Midwives are already trained to handle any birth position because they DO HOMEBIRTHS. Hell, most of the midwives I’ve met have had their own babies at home, so I’m pretty sure they understand that whatever position mothers assume is the one their instincts are telling them is right. Rather than force all women to birth a certain way, how about we have hospitals start letting women birth THEIR way. For real, not just in theory.
Banish the Arbitrary Timeline
Birth takes TIME, and not all women are the same. Some take a longer time than others to dilate and that’s OKAY! See, if we’re monitoring with the Doppler while mom is doing her thing, and baby’s heartrate is okay, then there’s no need to intervene AT ALL. So she’s taking 12 hours to dilate while the book said she should only take 5! SO WHAT? The only reason you’d even KNOW that would be if you were doing cervical checks, and as I explained earlier, the routine use of cervical exams to assess dilation should be OPTIONAL for women. In home birth, women have the option of having one or even zero checks for dilation and nobody freaks out. So rather than say “well, she’s only at 5cm and it’s been 4 hours” just accept that her labor is going to take a while and back the hell off! There is NO need to start pitocin or break her water (both of which carry risks that are rarely if ever told to the laboring mother). You know very well that if her water breaks then she’s on (yet another) arbitrary timeline before you whisk her away for a c-section. Or that pitocin can cause harder contractions that she can’t cope with (which leads to an epidural) and can cause fetal distress (which leads to a c-section). The same goes for pushing, people! In a home birth setting, as long as baby is doing fine and the mother is okay, then she can push for as long as she needs to. In the hospital there’s often a time limit before intervention is “needed”. I am SO lucky that my midwife was a tough woman who took crap from nobody, and who told the OBs to back off and let me just push; because three hours isn’t standard protocol for that hospital, and anyone else would have cut me. I cannot stress enough how much her presence in that hospital saved me that day!
Furthermore, the arbitrary “due date” needs to go the way of Twilight Sleep and become nothing more than a terrible chapter of our past. All this does is increase the rate of unnecessary inductions and c-sections that could have been avoided. Babies are all different and some take more time to mature than others. Also, how can you be 100% certain that the baby is “overdue”? If mother has no medical issues and baby is doing well, then it is safe to go to 43 completed weeks’ gestation with careful monitoring. The arbitrary policies of induction after a certain number of days past the “due date” cause more harm than good, as not all women will be ready for labor at that point and then they’re giving birth by cesarean for no other reason than the fact that the induction “didn’t work”. Failure To Progress is a Failure to WAIT; it doesn’t mean that women can’t birth their own babies, it just means that women aren’t given the CHANCE to birth them.
So here’s what we would do: get rid of the chart that says that women must be assessed and progressing at x number of hours. We assess women instead on the basis of how well THEY are coping, and how well their baby is doing. We stop ordering c-sections just because birth is “taking too long”. We stop ordering Pitocin to “speed up” normal labor, and we stop rupturing the membranes to “get things going”. We become OKAY with a longer pushing stage if it means that the mother is less likely to tear, and we become OKAY with the idea of babies being born in the caul (bag of waters intact at or just before birth). Finally, we stop pushing induction just because a mother has gone past 40 weeks, and instead look at her individual risk factors and the health of the baby. Once we do that, I pretty much guarantee that the rate of induction, augmentation, and c-sections will decrease and we’ll be able to re-allocate that money into a budget for extras like…
A TV complete with a Blu-Ray player, access to Netflix, and the ability to bring in one’s own Blu-Rays and DVDs
Let’s face it; labor sometimes takes a long time, and in early labor it might help to take your mind OFF the contractions. At home I have the option (and I intend to use it if needed) of watching a movie or several while in labor, so that I can relax, laugh, keep my oxytocin levels up, and take my mind off those contractions while I bounce on my ball or lounge in the tub. Obviously there will come a point when it will be an annoyance, in which case I can turn it off. But right after birth, while baby is sleeping and possibly my hubby is too, and I’ve had a nap but am now lying awake unable to sleep…yeah, it would be nice to have a show to watch to pass the time. In the hospital I was bored out of my mind, because I had to stay overnight and then I woke up in the morning and my hubby was still sleeping, and my phone didn’t have enough juice left to keep me entertained. It would have been so lovely to have been home and been able to pop in a Desperate Housewives DVD, but alas that amenity wasn’t included in the hospital. So if hospitals want to be more home-like, then they need to provide entertainment for us tired new moms.
A fully stocked kitchen attached to every birthing suite.
Hospital food SUCKS, and trying to pack enough food in your tiny little lunch box or cooler is a pain in the ass. This is one of the major perks of home birth; you have your own kitchen so that after birth or during early labor you can have someone fix you a snack to keep you going or replenish the energy you exerted birthing that baby. So if the hospitals want to be like home, then there needs to be a small kitchen for every birthing mother, so that her husband or doula can go in there, fix her or themselves a snack, and have it be hot, nutritious, and to their tastes. That means that there would obviously be all the essential spices, bottled sauces, canned, and dry goodies as well as the more perishable fruit, veggies, meats, eggs, etc in the fridge and freezer. The option to bake a “labor cake” to distract the mother from contractions and provide a yummy treat is especially appealing, though that could be because I’m currently almost-seven months pregnant and craving a yummy cake right now complete with boston cream filling, strawberries and whipped cream. But seriously, nobody wants to eat the hospital food. Even the TOAST was gross, and HOW do you screw up buttered toast? I’m very glad that I had pizza in that mini fridge otherwise I would have starved in those 12 hours after birth that it took for them to finally discharge me, despite me getting up at 7am and being not-so-patient and saying “I want to go home now” and then having to wait HOURS for them to finally get their crap together so I could actually LEAVE! Oh, and that reminds me…
Let Women LEAVE When They Want To
Yes, I’m aware that it “takes time” to discharge a patient, but we’re not actually patients. We’re women who gave birth and chose to do so in your facility rather than at home. That doesn’t make us prisoners, but it sure as hell FEELS like we are (or maybe that was just me). This is another reason home birth is so appealing to me: I don’t have to feel like I’m trapped. I could get in the car and go shopping if I felt like it (I probably won’t, but I’m just saying that IF I wanted to get in the car I COULD). In contrast, the hospital has their policies and their own schedule, and I was just another number on a list, WAITING for them to get to me so I could get the hell out of there. I was pretty much at their mercy, you might say, because until they gave the “okay” I couldn’t leave the damn place! How annoying do you think this would be for someone who was talked into staying overnight, even though she didn’t want to stay and lived 5 minutes from the hospital, and would have preferred her own bed? Like, on a scale of one to ten? And being assured that she could “go home first thing in the morning” only to then be awake at 7am ready to leave but being told she had to wait another hour. Then two. Then three. Then it was almost past lunch time and the pizza has been eaten and she’s starving, but she’ll be damned if she’ll eat that bland hospital concoction they call “food”. So then the doctor comes in (not her midwife, because her midwife has gone home to sleep for a few hours) and tries to get her to stay ANOTHER night because they can’t schedule the newborn hearing test until a certain time after birth. But she’s determined to go, because she’s now been in this hospital over 24 hours and she was sick of it the second the baby was out. Now, all this frustration could have been avoided if, at 7am or even right after birth, she had been able to pack up all her stuff, get herself and baby dressed, walk up to the nurse’s station, sign herself out like she was checking out of a hotel, and LEAVE! All without the interference of silly protocols, policies, or the need for someone to have the TIME to show up at her room and discharge her right when she wanted to go home?
So, what exactly would fix this annoyance? You have a sign in/sign out sheet. As soon as the mother feels up to leaving the facility she just signs herself out and goes home. Do we really HAVE to debrief new parents right after the baby is born? I mean, can’t we just assume that if they need help with something like putting the car seat into the car that they’ll ask for it? It’s a little ridiculous that I had to wait for someone to sign off on me bringing my own baby home, as if I’d not be able to put him in the car seat properly! You know who doesn’t do this? Midwives at home births! I seriously doubt that after birthing my baby in the comfort of my own home, that my midwife is going to make me dress said baby and then demonstrate that I know how to put her into the car seat in my car. But yet hospitals insist on it, and it’s just yet another thing that gets in the way of NORMALCY! So here’s the new plan: if parents would like to have someone help them with baby care or proper car seat safety, then they can check that on the little box on their list of preferences, just as they do for all the “routine” procedures they either consent to or decline. They can arrange for this to be done ahead of time, and then someone will be there to assist them. They might have to wait a while longer to go home, but that is their choice. It’s not imposed or forced on them to wait. If they decide they actually can figure this stuff out on their own, they simply make note of that on their sign out form and away they go! And we would stop making the hospitals liable for what individual adults choose to do, because it’s ridiculous to think of grown ass women and their partners as helpless children. Really, all it does is further enforce the false belief that new parents don’t know the “right” way to do things, should ignore their instincts, and just do what someone else says is right, even if it doesn’t work for their child or for themselves. And by that I mean…
Let Moms Co-Sleep (if that’s what they want to do)!
Obviously in the hospital it’s greatly discouraged for moms to sleep with their babies. Baby belongs in that plastic box, wrapped up in all those blankets, not in mommy’s warm arms where the breast is readily available and mother doesn’t have to press a button to get someone to bring her the baby! Everyone knows that! Even the other animals who…oops, they DO sleep with their babies, don’t they? Now, this isn’t saying that it’s wrong for mothers to NOT sleep with their babies, because to each their own, but for those of us who prefer co-sleeping it is damn frustrating! I really do NOT like sleeping away from my child. I never realized this preference until after my son was born; in fact, I was convinced that six months in my bedroom in a bassinet he would drive me insane. But then I realized that he was so content in my arms. He rarely cried. He LOVED skin-to-skin contact with both myself and his daddy, and he could sleep for hours just lying on our chests. He nursed in his sleep, and I could nurse him while sleeping. That sleep deprivation that they say all new parents go through? It didn’t happen unless I was TRYING TO BE “GOOD” AND PUT HIM IN HIS BASSINET. Once I stopped forcing myself to stay awake to do that, night feedings were so easy I literally did them in my sleep. My son rarely made a sound when he was able to access the breast within seconds of rooting for the nipple, compared to the cries of hunger that would rouse me from a deep sleep while he was in his bassinet away from my warmth. At 2 and a half years old he is content now to just hold my hand, or simply have me beside him. He drifts off SO easily! But that first night that I was forced to stay in the hospital, my baby boy wasn’t in my arms. I missed out on some precious bonding time with him, and I’m so looking forward to reclaiming it with my daughter at home. Because at home, there will be no nurses to whisk my baby away to the plastic box the second they catch me sleeping. There will be no scolding. My midwife co-sleeps too, so there will be no wagging fingers when I get out of the tub and curl up with my little girl in my nice warm bed.
So this one is really simple, especially if the upgrade from hospital bed to Queen has been implemented; you just let mom sleep with her baby. You might explain what to do to make it safe, but you certainly don’t insist baby sleep in the plastic box if the mother would rather have her baby in her arms. Maybe have her sign a form much like the “breastfeeding plan” where it outlines the risks and precautions to take to minimize those risks, and then you BACK OFF and let the mother make her choices. It’s HER baby, and honestly if you discourage her from sleeping with her newborn in the hospital that doesn’t mean she’s not going to go ahead and do it when she gets home. So rather than say “don’t ever do this” why not just provide the information a mother needs to make her own choices that are best for her?
I realize that all these changes would mean a complete overhaul of the entire institution, and that it might be costly, time consuming, and that there would be a lot of annoyed doctors and nurses. However, if you’re really dead set on changing the minds of the home-birth minded mamas, then these changes are necessary to truly turn the hospital into a home birth setting, because in the absence of any one of them you’re once again turning it into a HOSPITAL birth, not a home birth, and as I’ve already pointed out, home birth mamas don’t WANT a hospital birth. We prefer to have a more comfortable environment free of distractions, unnecessary interventions, or policies and procedures that don’t serve US, but instead serve the institution. We birth at home because at home we are FREE! We’re free to decline anything we deem unnecessary or uncomfortable, we are free to birth in any position we like, we get to immerse ourselves in a birthing pool, and we have a nice big bed to climb into after all is said and done. We are also not prisoners in our own home; we could go out to the store for some ice cream if we wanted to, or simply send our partners or friends out to get some for us. We can distract ourselves in labor by baking a birthday cake to eat after the baby is born, and we can watch our own TV shows and movies as well. To say that the hospitals are more “home-like” these days is a silly notion when I think of all the things that are different between what I’m planning at home for my daughter’s birth, versus what I experienced with my son. In the hospital I was on a strict timeline, and I KNEW it. I didn’t have to be told that I was on the clock, I could sense it in the way there were more people coming into my room. I sensed the OBs out in the hall, looking at their watches, tapping their feet, and basically wondering why the hell my midwife wasn’t letting them in to “save” my baby with a c-section. I felt the urgency in my midwife’s tone when she said “there’s the OB; she’s going to give you an episiotomy if you don’t push RIGHT NOW” and I believed her. She said she never would have let that happen, and I believe that she would have fought for me, but at the same time she might have been overruled by the head of the hospital, and then I would have had no choice. I don’t think I would have known that much THEN, but I certainly know it NOW. My work with Improving Birth, all the research I’ve done, and all the midwives and doulas I’ve spoken to have all confirmed that I was extremely lucky to have avoided a c-section. I don’t feel like being “lucky” again. I feel like being SUCCESSFUL, and the only way I can feel that sense of control and power over my own birth is by staying as far away from the hospital, in its current form, as I can.
Maybe, if the above changes to the institution were implemented, less women would choose home birth, but it would likely be the ones who wanted the security of the hospital all along, not the ones who preferred to be home. Some women don’t choose home birth because they WANT to be home; they do it because the alternative of over-intervention and routine care practices and little say in their experience (despite what the brochures and websites tell you) and they want better than that. But until we have birth centers here in the lower mainland and the rest of the country, one in every major city, the option remains to be in the institutionalized environment of the hospital, or to remain at home where mothers can call all the shots and control their environment and the people they invite into their homes.
So how about we stop telling women to just “go to the hospital” and instead focus on the real reason why women are choosing to birth at home, and why it would take so much more than just a few pictures on the wall and soft music to transform a hospital room into a home birth environment.