Many women, especially those seeking VBAC, are between a rock and a hard place. Women are faced with hospital VBAC bans which mandate repeat cesarean sections and they don’t know what to do. They don’t want another surgery. Or their local hospital technically allows VBAC, but the requirements in place greatly diminish the likelihood of success. Or an OB will tell them that they “Do VBACs all the time” when the reality is, they don’t. Or they felt deceived during their last birth and have subsequently lost all faith and confidence in the medical system. Trust is paramount between provider and patient and when that is so damaged, it’s difficult, if not impossible, to repair. Other women report that their prior birth, either vaginal or cesarean, was so traumatizing that they developed PTSD and cannot step into another hospital again. Or they simply feel that physiological birth is impossible in a hospital. Or they want something simple like freedom of movement during labor and their local hospital requires VBAC moms, or all moms, to labor in bed. Many women cannot travel 5-6 hours to birth at a VBAC supportive hospital, let alone move closer to the hospital, and away from their social support system, for the last weeks of their pregnancy. Women simply want to birth normally after a cesarean and they want to avoid the risks associated with multiple repeat cesarean sections. Some women have found that the only way they can do this in their community is to birth at home.
The American College of Obstetricians and Gynecologists (ACOG, 2010) describes VBAC as a reasonable and appropriate choice for “most women” with one prior cesarean and for “some women” with two prior cesareans. The National Institutes of Health (2010) says “trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.” There was even a presentation at the 2010 NIH VBAC Conference discussing how there are not enough anesthesiologists in the United States to provide 24/7 coverage of all birthing units nationwide, but that VBAC could be offered safely nonetheless.
There are hospitals and hospital-based care providers who actively support VBAC. Yet not all women have access to such facilities and professionals. Even among women who do have access to a facility that attends VBAC, a recent study showed that the median VBAC rate at such facilities was about 10% (Barger, 2013).
So increasingly, more women are opting to birth at home because they feel like they have no other choice or due to the many benefits of home birth. As the CDC recently reported, “After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009” (MacDorman, 2012). Women feel like if they go to the hospital, they will ultimately have another cesarean because their OB or hospital administrators are not really supportive.
Types of care providers
And this becomes complicated because there is such a wide, wide range of experience and skills present among home birth midwives. A lot of women think a midwife is a midwife is a midwife and don’t realize the difference in (in)formal education and clinical skills. As I share in the article, I’m pregnant and want a VBAC, what do I do?:
The most important thing when interviewing midwives is experience. You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.) I am a full supporter of non-nurse midwives, but please do your homework. If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.
Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees. You and your baby’s well being should come well before her possible discomfort. In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.
CNMs are able to legally practice in all 50 states. Some are hospital-based, while others have birth centers and/or attend home births. CPM designation is not recognized in all 50 states and they focus on birth center and/or home births. You can read more about CNMs vs CPMs at Midwife International, this exchange from the Midwifery Today forum, and one CPM’s analysis. There are other midwives who are called direct entry midwifes (DEMs).
There are also OBs who rarely attend births at home. The CDC’s latest report on home birth stated, “Only 5% of home births were attended by physicians, and a previous study suggested that many of these were unplanned home births (possibly involving emergency situations)” (MacDorman, 2012).
The fact is, you can have a great birth in the home and you can have a great birth in the hospital. It really, really, really depends on your care provider. There are excellent CNMs, CPMs, DEMs, and OBs, but that doesn’t mean that all are supportive of VBAC and can safely attend your home birth.
Whoever you hired, there is a great benefit in hiring someone who has attended a lot of births. The more births someone attends, the more complications they will see, the more their skills will be tested. If your care provider hasn’t attended many births, it’s likely s/he hasn’t come across many serious complications. It’s likely his/her skills have never been tested. This can make some moms nervous.
Also be aware that sometimes in an effort to counter how VBAC has been demonized in the conventional wisdom, some care providers sometimes overcompensate by inaccurately minimizing the risk of uterine rupture. The midwife (or OB, but it’s generally a midwife) who gives false information that minimizes the risk of rupture is just as harmful to the VBAC mom. One Florida midwife told her client that since Florida was the “lightning capital” of the country, a VBAC mom was more likely to be struck by lightning that have a uterine rupture. This is false. Other midwives have told their clients that their risk of uterine rupture doesn’t change much due to having a cesarean. This is also false. Still more midwives misinform their clients by telling them that the risk of uterine rupture in a VBAC mom is the same as an induced, unscarred mom. This is also false.
It does not benefit anyone, least of which the mom, to receive inflated lies about the risks of post-cesarean birth options. But it’s horrifying that there are midwives, who attend home VBACs, and are giving their clients such inaccurate information. At the very least, women planning out-of-hospital birth should be given accurate statistics on the risk.
On the other hand, OBs are often vilified (rightfully so) for providing inaccurate information to women in regards to post-cesarean birth options as well as coercing, threatening to “force a cesarean,” or even outright lying. Read more in the New England Journal of Medicine and the Journal of Health Politics, Policy, and Law.
This is why it is very important for you to have a basic understanding of the risks and benefits of VBAC vs. repeat cesarean. How else will you know if your care provider is being straight with you?
For more on hiring a care provider, check out: The Three Types of Care Providers Amongst OBs and Midwives, Questions to Ask a Provider, Scare tactics vs. informed consent aka why I started this website, you can go to Finding a VBAC Supportive OB or Midwife.
First, understand how birth works
There are many benefits of birthing at home and in order to fully appreciate them, you really need to understand how birth works. I highly suggest you read any book by Ina May Gaskin. Sarah Buckley also has an amazing book about pregnancy and delivery. I really enjoyed her detailed discussion on the normal flow of hormones that facilitates birth. I agree with her that these hormones are interrupted in the hospital environment due to the release of adrenaline. It’s likely that this very basic interaction is the cause of (most? some?) of the “failure to progress” diagnoses. For more on this subject, check out Buckley’s book or read Lowe (2007). (Check out the articles that have cited Lowe for more recent resources.)
The great “what if.”
Most women will be fine giving birth at home, but there will be women who have urgent, time sensitive complications at home that require immediate hospital transfer which is only possible if your care provider identifies the symptoms in a timely manner. And if that hospital-based advanced medical care (i.e., drugs, surgery, blood products, etc.) is not reached in time, dire consequences could occur. This is the risk of home birth.
How a complication plays out depends on many variables: the type and severity of complication, how quickly it is diagnosed (based on the skills and experience of your care provider), if it is something that can be managed at home (based on the skills, experience, and supplies of your care provider), if not, how quickly can you get to the hospital (based on the distance, driving conditions, etc), and how quickly the hospital personnel can respond to your complication. Does your home-based care provider have a good professional relationship with the hospital? Can s/he call ahead, inform them of your transfer, and have them ready the OR (if necessary)?
Uterine rupture and home birth
Some research on infant cord blood gases has suggested that if the baby isn’t delivered (almost always by cesarean) within 16 – 17 minutes of a uterine rupture, there can be serious brain damage or death to baby. This is something to consider especially if you live in a rural area far from a hospital. You can watch a presentation from the 2010 NIH VBAC Conference entitled “The Immediately Available Physician Standard” by Howard Minkoff, M.D. for more information or read his presentation abstract.
The myth of the “unmessed with” birth
Some women believe the very false and dangerous belief that nothing can go wrong in a spontaneous “unmessed with” birth. I’m here to tell you that you can do everything “right” and still have a complication/ bad outcome. While doing everything “right” decreases the risks that various interventions or restrictions introduce (such as elective induction, artificial breaking of the water, prohibiting movement during labor, etc), it does not eliminate the “naturally occurring” complications that are sometimes just the luck of the draw. Here is one mom’s story of placental abruption at home. She survived, her baby girl Aquila did not. Her midwife was a CPM who had attended less than 150 births. Her midwife did not recognize the symptoms and they did not get to the hospital in time.
I share Aquila’s story to illustrate how important is it to hire someone who has sufficient clinical knowledge and experience. In my opinion, the number one factor determining the safety and success of your VBAC is your care provider. It’s not enough for them just to be supportive of VBAC, they need to be familiar with the symptoms of uterine rupture and other serious complications so that they may facilitate a rapid hospital transfer.
Because I share Aquila’s story, I’ve been accused of being anti-home birth and even anti-VBAC. That is no more true than I’m anti-hospital birth because of some of the hospital birth stories I have shared. I myself had a wonderful VBAC home birth, but that does erase the fact that there are risks and benefits to home birth and hospital birth. To ignore those is to deny yourself the information you need to give true informed consent and to make an informed decision. Only you can decide which set of risks and benefits you are willing to accept.
The risks of hospital birth
Hospital birth comes with its risks as well and just because your care provider is an OB doesn’t ensure that you will receive accurate information or care that is in line with the latest ACOG VBAC Practice Bulletin. Here’s one doctor who was unaware and shocked to learn that 18 months prior, ACOG released an updated VBAC Practice Bulletin stating that VBA2C was appropriate in “some women.” You can read more poor outcomes from hospital birth here: Home birth vs. hospital birth for the number cruncher.
In the end at the hospital, your wishes, desires, requests, and birth plan will likely be subject to the policies and procedures of the hospital which will almost always prevail unless you have a really wonderful VBAC supportive OB who is able to circumvent unsupportive hospital administrators if needed. Unfortunately most women birthing in the hospital are subject to its rules which were created and enforced for expediency and convenience, not necessarily for their safety. And it’s these policies and procedures that women who choose home birth are looking to avoid. (Read more: OB lists reasons for rising cesarean rate, and Neonatal nurse has a homebirth VBAC.)
Not where, but how
As “Birth After Cesarean” points out:
Natural childbirth also has to do with the way the laboring woman is treated by those around her. Is she perceived as a healthy woman about to have a baby or as a hospitalized patient in need of intensive care?
There are are variety of books that offer different perspectives on hospital vs. home birth. Read Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner, MD. He talks a lot about home birth, safety, myths, and other countries where home birth is more of the norm. But note that in those countries, the midwives have training that is comparable to a CNM. Read The Thinking Woman’s Guide to a Better Birth by Henci Goer. She lists the pros and cons for medical interventions and has extensive endnotes. I also really enjoyed Birth by Tina Cassidy.
I never thought I would have a home birth until I was faced with my post-cesarean birth options. I am fortunate in that I had a wonderful birth and a good outcome.
How I Decided to Have a Home Birth/HBAC (Home Birth After Cesarean)
My road to home birth was a long one. With my first pregnancy, I contacted a CPM, but wasn’t ready to take the plunge. I hired a hospital-based CNM and that pregnancy ended with a cesarean section for single footling breech presentation. Within a few months of my daughter’s birth, I started researching VBAC and while trying to conceive our next child, I started to entertain home VBAC (HBAC).
But I quickly reached a point where I was afraid to birth at home and I was afraid to birth in a hospital. I did not feel completely safe in either location. What if something went horribly wrong at home? So, I should be in the hospital. But there, I have no control, no privacy and in the face with hospital protocol, I would likely have to battle my way through my labor. . . and I just didn’t want to fight while in labor. I looked at everything I had to give up, everything I had to compromise, and everything I had to fight for to birth in a hospital . . . just to hedge my bets. And that is the rub. Most women find that compromises must be made in order to deliver in a hospital (assuming that your local hospital allows VBACs and you can find a provider who is actually supportive.)
I emailed around and found a wonderful OB who was truly supportive of VBAC. I interviewed him and he took the time to answer my questions and everything he said made me feel confident that I would VBAC. The stage was set. But I still felt that nagging feeling. The more I thought about it, the more I realized that a supportive OB is only part of the equation.
As much as I really liked this OB, I would still have to deal with the nurses and hospital policy. While I could interview my OB, I couldn’t interview the nurses. And since my OB wouldn’t be there for my entire labor, I could just see myself saying to the nurses, “Well, my OB said that XYZ was OK,” and them telling me “That’s not what we do.” And then being stuck. And then being in the hospital, in labor, and wishing I could go back in time and plan a home birth.
Who knows? Maybe the nurses would have been fantastic… and I have read birth stories where they are, such as this wonderful birth story of a woman who VBACed at a Southern California Kaiser: The Birth Story of James Liam. But knowing what a huge impact nurses can make on your labor, I didn’t want to leave it to chance. Home birth was the right decision for me and fortunately, I had a good outcome.