7 Reasons to consider an out-of-hospital birth with a midwife
When planning for where to give birth there are a few things you might not be considering but that you SHOULD consider. Unfortunately, many new parents don’t know, what they don’t know, until they are in the throws of labor. Giving birth is hard work and it’s really not easy where ever you do it. Sometimes new parents fall prey to the mentality of “the hospital is covered under my insurance and therefore is the way to go” and “the hospital has my best interests at heart”.
If you are having a low-risk healthy pregnancy, then out-of-hospital birth with a midwife might be right for you.
Read on for 7 top reasons clients have given me for choosing a homebirth or birth center birth with a midwife!
During the course of care you will have plenty of time to ask all of your questions. Most midwives schedule appointments for about an hour or in busy birth center practices sometimes 30 mins versus 5-15 min with most hospital providers. Having more time for appointments means you can ask your questions and that there is time for getting the answers you need! Your midwife will also provide some education during appointments on variety of topics that come up in pregnancy, labor, birth and postpartum. I consistently have heard from clients that they enjoy midwifery care because they don’t feel rushed and they don’t feel like they are “just another number”.
How busy a midwife is and her ability to not over-schedule is another important factor! I recommend asking her how many births she takes per month and if she takes any regular time off.Individualized care is a cornerstone of midwifery care and receiving that level of care has many benefits. If you choose midwifery care in any setting you, have a good chance of receiving great individualized care. Some hospital CNM practices with several midwives in one practice have more regimented protocols for care - that is less individualized - so if that’s not your preference, then plan accordingly. An out-of-hospital private practice midwife has a lot more freedom to provide individualized and autonomy focused care to their clients.
You will have greater access to your care provider between visits and in most cases if anything more emergent comes up you will have direct communication with your midwife. It’s a real luxury to have your midwife on speed-dial. If a problem comes up, you can get help right away. For example, sometimes I’ve have clients with an acute UTI, gallstones, taken a fall or have preterm labor symptoms - they can call for guidance early to get treatment sooner.
Midwives have lower rates of interventions across the board but if you have an out-of-hospital birth then you can expect to be monitored intermittently with a hand-held doppler and vitals taken every 4 hours with a BP cuff and thermometer. Furthermore, you likely will not be getting IV fluids (unless truly needed). This means you will not be hooked up to wires and tubes. Essentially nothing stays on you between those quick health checks - this naturally promotes more movement, changing positions and eating/hydrating during labor. All things that support normal birth.
Staying home means you won’t have to get in your car during active labor to go to the hospital or birth center. This is something many clients have told me they particularly did not enjoy when they have had a previous hospital or birth center birth. The simple process of leaving your space can also disrupt the normal flow of labor hormones, which can sometimes take hours to get back into your labor groove.
Midwives routinely follow the birthing persons lead when it comes to choosing positions to labor in or give birth in. If you would like the freedom to give birth in any position of your choosing in the moment, then an out-of-hospital birth is a great choice. There are some forward thinking OBGYNs and CNM’s (certified nurse midwives) out there that do support choosing your birth position at the hospital - with the caveat of staying on the bed.
When you choose to birth with a midwife out-of-hospital, they follow the scope of care for any credianials they have but are not guided by hospital administrators with keeping up profit margins. Policies and red tape are unfortunately part of the industrialized medical model of care for hospital based care. There are hospital administrators and legal teams in charge of making the “rules” you are supposed to follow AND worse yet, they are also making “rules” for the physicians and midwives who work there to follow as well. In essence, the care provider with great intentions may have their hands tied (so to speak) or face being disciplined for breaking hospital policy in favor of respecting patient autonomy. This sometimes means you need to “fight” for what you want and it is not automatically given. Hospitals have become corporations and they do not run based on what is best for a normal physiological birth.
Pregnancy nutrition: meeting needs can be done in more ways than one
When you glance at social media these days in relation to pregnancy nutrition a few things pop up. One is protein, protein, protein! We are absolutely obsessed with protein!!! I’ll add here, “yes” protein needs DO increase during pregnancy and there are many benefits to eating it. However, there is more to it than simply inhaling a basket of chicken nuggets and string cheese. OK…I kid…pun intended, that was an extreme example but I hope it brings my point home. Often our food choices are based on convenience, habit and cultural dishes. Most pregnant women and pregnant people do best when they have a flexible approach to eating with an emphasis on meeting nutritional needs. It’s okay to do so, while staying within their own tastes. So let’s explore!
So what does the research suggest helps when it comes to having a healthy pregnancy and reducing complications in pregnancy?
A diet rich in whole foods that includes adequate amounts of hydration, minerals, amino acids, proteins, fats, electrolytes and micronutrients. Additionally, minimizing sugars (especially processed sugars), process meats, white flour and white rice whenever possible. This can be done in a variety of ways. My own midwifery clients have healthy pregnancies while meeting said needs AND while following a number of eating styles from VEGAN to PALEO, from traditional to low carb to high complex carb diets. We work together to find a balance of nutrients while honoring their preferences.
Lets start by taking a look at some overarching positive research! The Mediterranean diet is a great starting place for anyone who is unsure of what to include for balance pregnancy nutrition. The evidence keeps rolling in, in favor of this way of eating and shows great benefits.
“The dietary pattern followed during pregnancy, specifically healthy dietary patterns such as the Mediterranean diet, is a key factor in the mother’s and the offspring’s health. Pregnant women dietary intake is not enough to cover the micronutrient requirements of pregnancy, and higher adherence to the Mediterranean diet may improve dietary quality and nutritional density.” (Castro-Barquero et al., 2023)
Additionally according to a large 2019 systematic review: “Maternal dietary patterns which reflect the (Mediterranean Diet) showed consistent associations with a lower risk for allergic disease in children, appropriate infant birthweight, and lower risk of pre-eclampsia and preterm birth.” (Amati et al.)
Whether you like to eat lots of animal foods, you really hit the produce aisle hard or you are an avid gardener, it is important to minimize pesticide exposure. Pesticide and insecticide exposure is associated with a lot of negative outcomes for pregnancy (I will spare you the list but you can click here to read more). Aim for grass-fed meats, pasture raised eggs, organic milks, organic produce or consult the annual dirty dozen and clean 15 to reduce pregnancy exposure.
What about plant based diets? There are actually some benefits. For example, a 2009 study of 23,423 first time birth parents done in Norway looked at dietary patterns and pre-eclampsia risk. They concluded that “a dietary pattern characterized by high intake of vegetables, plant foods, and vegetable oils decreases the risk of preeclampsia, whereas a dietary pattern characterized by high consumption of processed meat, sweet drinks, and salty snacks increases the risk.” (Brantsaeter et al.) This result was essentially replicated by a recent study done 2022 in China - you can click here to read about it.
Taking it a step further. What about vegan diets? According to a 2019 panel review of the available data and literature, “A completely plant-based diet is suitable during pregnancy, lactation, infancy, and childhood, provided that it is well-planned. Balanced vegan diets meet energy requirements on a wide variety of plant foods and pay attention to some nutrients that may be critical, such as protein, fiber, omega-3 fatty acids, iron, zinc, iodine, calcium, vitamin D, and vitamin B12.” (Baroni et al., 2019) The key being that vegan diets take planning and can be healthy when done with a proactive approach to avoiding deficiencies.
There is so much up to date research available now and I will spare you from more. Suffice it to say that there are many ways to eat healthfully during pregnancy. The components that most research available seem to agree on is the inclusion of whole foods, fruits, vegetable and unprocessed protein sources.
Overview of My Pregnancy and Postpartum Nutrition Recommendations are:
Expect to increase your calorie intake by about 500 calories per day. This can be easily done by adding a snack or two to your daily routine. Individual needs may vary.
Eat a Rainbow of vegetables and fruit - aim for 5-10 servings per day combined with a focus on vegetables. Vegetables are mineral and micronutrient powerhouses.
Aim to include 70 to 100 grams of protein daily. Another way to think of this - Aim for eating a protein with each meal and snack. Protein helps keep fluid retention at bay while giving your body plenty of building blocks for tissue and blood building.
Adequate Mineral intake including trace minerals can stave off many complications of pregnancy and postpartum. Try drinking pregnancy friendly teas daily and make sure you include Sea Salt in your meals (salt to taste).
Drink 2 to 3 liters of liquid daily, including water, fresh juices, broths, milk and herbal tea.
Eat foods that look, smell and taste good to you! During pregnancy individuals may develop food aversions to naturally avoid toxins and cravings to naturally meet nutritional needs.
Being 35 & older does not mean high risk!
According the California Midwifery Law being 35 or older does not make a pregnant person high risk!
Being a certain age - whether 35 or 40 - DOES NOT mean you can’t have a homebirth or care with a licensed midwife. Many pregnant people 35 or 40 years or older can and do have healthy out-of-hospital births. Potential clients need to meet specific criteria - having a healthy pregnancy being the key factor! (I have copied and pasted those criteria for you).
I should preface this by saying I live in California and therefore sharing information based on the regulations for licensed midwifery care in California. Please consult your state midwifery laws if you are living elsewhere.
Actual reasons that California midwives consider a person “high risk” are clearly defined for California midwives. Usually pertaining to pre-existing health conditions that significantly affect pregnancy or birth.
“CRITERIA FOR CLIENT SELECTION
Criteria for initial selection of clients for community-based midwifery care assumes:
• Healthy mother without serious pre-existing medical or mental conditions
• History, physical assessment and laboratory results within limits commonly
accepted as normal and consistent with Business and Professions Code Section 2507(b)(1) with no clinically significant evidence of the following, including but not limited to:
a. cardiac disease
b. pulmonary disease
c. renal disease
d. hepatic disease
e. endocrine disease
f. neurological disease
g. malignant disease in an active phase
h. significant hematological disorders or coagulopathies
i. essential hypertension (blood pressure greater than 140/90 on two or more occasions, six hours apart)
j. insulin-dependent diabetes mellitus
k. serious congenital abnormalities affecting childbirth
l. family history of serious genetic disorders or hereditary diseases that may impact on the current pregnancy
m. adverse obstetrical history that may impact on the current pregnancy
n. significant pelvic or uterine abnormalities, including tumors, malformations, or invasive uterine surgery that may impact on the current pregnancy
o. isoimmunization
p. alcoholism or abuse
q. drug addiction or abuse
r. positive HIV status or AIDS
s. current serious psychiatric illness
t. social or familiar conditions unsatisfactory for domiciliary birth services
u. other significant physical abnormality, social or mental functioning that affects
pregnancy, parturition and/or the ability to safely care for a newborn
v. other as defined by the licensed midwife“
How we give birth and with whom matters!
I understand that some people out there do not want any regulations and think that even the above list should not apply. While I do agree that each individual and family should ultimately have the right to give birth in the location of their choice and with the provider of their choice, I also think there are real reasons that we should keep true high risk birth in the hospital with an obstetrician, the biggest reason being timely access to interventions for at risk pregnancies.
You might think giving birth in a hospital and, therefore, having easier access to those same interventions would actually be better for all pregnancies. That’s where you’d be wrong. I won’t get into all of those examples right now because that would require an entirely different article.
Instead, consider the countries that have such wonderful birth outcomes. We often refer to the fact that the US has the worst birth outcomes of any developed nation, not a title many of us want. We, also, note that in the countries such as Norway, Switzerland, Japan and the Netherlands, with great outcomes that midwifery care is the gold standard for normal pregnancies. We have seen over and over again that the countries we idealize for their great outcomes have one thing in common: Obstetric care is reserved for “high risk” pregnancy, birth and postpartum.
When we blur the lines by calling something like age “high risk” when it’s not, or when we push to have someone with true high risk factors such as uncontrolled seizures, a known clotting disorder or significant heart problems deliver at home we are hurting everyone. These approaches cause confusion among most non-birth folks. While also making homebirth less safe in some cases. I for one appreciate living in a state that has clearly defined actual risk factors. Which to be clear does not include age nor weight!
Bring the birth center home
There are many reasons a person might want to give birth at a freestanding birth center rather than a hospital. Most birth centers are owned and operated by midwives. Giving birth with a midwife has many advantages including great outcomes such as: fewer perineal tears, fewer c-sections, holistic approaches to preventing prenatal complications, extended delayed cord clamping, fewer interventions, increased autonomy in birth and the list could easily go on for a while here! According to one research study from the UK published in 2015: “Women who have a planned home birth have high rates of satisfaction related to home being a more comfortable environment and feeling more in control of the experience.”
Many individuals would rather give birth in a birth center, because to them it feels safer than giving birth at home. Well, I’m sorry to spoil that perception but it is just NOT true. When you choose to give birth at home with a midwife present, you are essentially bringing the birth center to your home!
Homebirth midwives have the same background and training that birth center midwives do. Additionally, they bring all the same supplies TO YOU that would be at a birth center including but not limited to anti-bleeding meds, antibiotics, lidocaine (for stitches), IV fluids, oxygen, resuscitation equipment, sutures, catheters, cord clamps, vitamin K shot and oral, erythromycin eye ointment, pulse oximeter, stethoscopes, BP cuff, thermometer, gloves, chux pads, gauze, sterile instruments and more! Many midwives bring herbs, homeopathy, essential oils, peanut balls, birth balls, rebozo, birth stools and have birth tubs available along with water birth supplies.
Homebirth supply setup (Medications, gloves, BPcuff, stethoscope, etc)
All the essentials at your midwife’s finger tips. You may not need any of it but it’s there for when you do!
When you give birth at home there are a number of potential advantages. I’ve created a list of some of the top benefits of having a home birth with a midwife.
1) You can give birth in your own microbiome! Meaning when you go to another location whether it is a hospital or birth center, there will be exposure to the germs, viruses and bacteria in that location. I won’t go into details about the benefits of being in your own microbiome and flora, but suffice it to say there are many benefits.
2) You don’t need to leave your space which often pulls labor people out of their labor flow. It can take hours to get back to the same place you were at prior to leaving your home. Mindset and coping are more easily managed in your own space.
3) Having attended countless births at home and in birth centers, I have noticed that staying home is less disruptive to the natural hormones of labor. Not interrupting this delicate balance has the potential to make labors shorter with less complications. That has been my experience antidotally (as a midwife) too.
Laboring with partner at home
Without interruptions that may impact the flow of labor hormones
4) When you arrive too early to the birth center, you will most likely be sent back home until you are in strong active labor. First time parents are especially likely to come in when they are still in early labor and end up going back and forth one or more times. If at the hospital you may end up staying when it is still early labor and this is also more likely to lead to interventions such as augmenting labor with Pitocin.
5) When you arrive to the birth center to check-in, unless you are clearly about to have your baby, then you can expect to have a cervical check to see if it’s time to stay. If you go back and forth several times, that might mean a few extra cervical checks. However, when you give birth at home, at least in my practice, if it seems like I’ve arrived too early then I will simply listen to fetal heart tones, take maternal vitals, set up my supplies and leave to await your call for when things have progressed to active labor. Essentially, most home birthers will have fewer or even no cervical exams in labor - it is up to the person giving birth to decide.
6) There are slightly higher transfer rates from birth center to hospital (16%) vs home to hospital (10.9%). I believe to some degree (this is only my opinion), that this can be attributed to multiple factors such as: the birthing person may have a disturbance in the flow of labor hormones, may have unwanted cervical checks, may feel “watched” if they arrive in early labor and possibly if the midwife providing care in labor puts the laboring person on any kind of time line. Some birth centers have policies on how long a client can labor at the center prior to initiating a transfer to the hospital. Ask your midwife if they have any such time limits!
7) Another advantage of home birth vs birth center is the postpartum care. When you give birth at a birth center, you will go home in most cases somewhere between 4 hours and 6 hours after birth. In both locations you will receive similar care which includes checking you and baby’s vitals, getting stitches if needed, eating something, establishing breastfeeding/chestfeeding, a head to toe newborn exam including measurements, weight and checking newborn reflexes. The main difference is that at home the midwives will tuck you into bed afterward vs you needing to get into your car to drive home. That may sound like a small difference, but I have heard of it being a downside repeatedly from those who went the birth center route.
Hopefully, this has been a helpful list in explaining some of the advantages of giving birth at home with a midwife vs giving birth at a birth center. Both are truly wonderful options and offer lower overall interventions when compared to traditional hospital care. Ultimately, giving birth at the location you feel best has a host of benefits and there is no “right” answer.
10 reasons to consider laboring or giving birth in water
10 reasons to consider laboring or giving birth in water?
It’s not just for the pictures and instagram there are some great benefits of using water submersion for labor and/or birth. Before I share the list, I would like to preface it by saying water birth may not be right for you if: you don’t like being in water, you naturally feel drawn to a land birth or you have a health condition where your care provider may need to have greater access to you during birth or immediately after birth. For example, some conditions that make person “high risk” such as a clotting disorder, a baby in distress during labor, giving birth to a pre-term baby or having an infection.
It is also important to make sure that any birth pool or tub is completely and thoroughly cleaned. In my practice, clients may birth using one of my clean tubs and a new birth tub liner. They must also provide a brand new (ideally led free) hose to fill and drain the tub with. The pool should be filled with water that is kept at a temperature that is “not too cold” and “not too hot”.
I know some individuals who enjoyed full water submersion in labor and others who found more relief from the shower - including staying there it give birth. When babies are born fully submerged in water the DIVE REFLEX keeps the glottis closed when the baby is submerged which is why they do NOT breath while under water. It is important to bring baby to the surface as they are born and not keep them underwater, but due to the dive reflex a baby does not take its first breath until they come to the surface and their face touches the air.
Here are the top reasons to consider laboring or giving birth in water!
Drumroll please…
1) Water is a natural pain reliever and promotes relaxation.
2) Less likely to have tearing or perineal damage.
3) Birthing people report greater feelings of well-being and control.
4) An easier birth for the birth parent and a gentle way to welcome a baby.
5) May speed up labor if you are in active labor.
6) May help blood pressure and stress hormones.
7) May help the laboring person conserve energy.
8) Gives the laboring parent a private protected space, as well as greater intimacy for the couple if desired.
9) Allows for easy of movement and change of position.
10) Most who have birthed in water state that they would do it again!
Things I wish I knew about miscarriage as a midwife before having my own
Please do not read this content if you find it personally triggering.
October is Pregnancy and Infant Loss Awareness Month. So, I would like to talk a little about the things I learned by going through several miscarriages myself, that I wish were taught to care providers and discussed more with those experiencing a loss. Providers are taught about the different types of loss, the risks associated, signs and symptoms, as well as options available for the loss itself (such as passing the miscarriage at home or going for a D&C. Midwives and doctors don’t often know more of the nitty gritty, unless they have personal experience.
I have personally been through early miscarriage and late first trimester miscarriage. These losses have made me a better midwife for those going through loss or those pregnant with their rainbow baby (one name for a baby born after a loss). There are things you can’t learn in books and it is taboo to talk about this topic in many circles. If you are reading this and know me, then you know I don’t often share about this from my own experiences. I decided to open up in order to shine a light on some symptoms that may be surprising.
First, I didn’t know that a miscarriage could feel like labor with real contractions that come and go, that peaks with passing fetal tissue and even a placenta - or it could feel just like a particularly crampy menstrual period.
Second, I didn’t know that my water would break similar to any labor. For me this happened with a loss that occurred at the end of the first trimester. This may not happen in most cases but it could depending on how far along the loss has occurred.
(There may be a period of time with light brown, pink or red spotting that leads to heavier bleeding with clots and tissue. After passing most of the pregnancy tissue and clots, the bleeding should become lighter. If you are having a miscarriage and ever have heavy bleeding that leads to feeling faint, dizzy or unwell you should go to the nearest hospital immediately. If you develop a fever you should go to the hospital because you may have an infection.)
Third, I didn’t know that for losses occurring several weeks into a pregnancy or beyond that there is a very real postpartum period. It is not unusual to bleed for a few weeks after a loss or if it is an early miscarriage to only bleed a week or a little longer. Our bodies need time to recover and even joints may be looser - meaning getting back to exercise may take a few weeks.
Fourth, there may be hormonal changes and emotional ups/downs. This might not be too surprising but it is normal to need some time to grieve the loss. Some people going through a loss may seek privacy, while others may seek comfort from close friends or family.
Fifth, I believe this is fairly rare but I experienced intense headaches for a few weeks after one of my losses. Postpartum headaches are associate with preeclampsia but can also be a benign, yet unpleasant symptom in the postpartum (including after a loss). Any persistent postpartum headaches indicate a need to get your blood pressure checked asap and seek care with your doctor or midwife.
Sixth, if you have experienced a loss you may always remember and feel some sense of grief. It does take time but it gets better.
Lastly, in subsequent pregnancies, it is normal to need lots of extra reassurance. It’s perfectly normal to want additional ultrasounds, heartbeat checks and labs work. Getting to the point of feeling baby move is often very reassuring.
Why I Offer One Year of Postpartum Care
The care we give postpartum folks in the first days, months and year can lower rates of postpartum depression and anxiety.
The answer to this is simple. I offer one year of postpartum care to midwifery clients because the average 1-2 postpartum visits offered by OBGYN’s and average 3-4 visits offered by midwives aren’t enough for many new parents. It is common for me to hear that new families desired care beyond the standard 6 weeks. Rainbow Midwifery offers up to 9 postpartum visits spanning from 1 day to 1 year after birth.
Did you know that extended postpartum care has benefits like:
screening for diastasis recti during the optimal window of (at least) 6-12 weeks postpartum. Any earlier than 6 weeks is too early and 7-8 weeks or more is ideal.
screening for Postpartum Depression and Anxiety which can present any time in the first year but often do not appear until 2-3 weeks postpartum.
helping transition back to work or discussion of sibling dynamics/adjustment.
discuss things such as babywearing, sleep, parent connection, family planning, creation of a support network, community building with other families, etc.
midwife available for birth processing throughout that first year.
a smoother transition postpartum because your midwife can share a variety of resources and referrals as needed well beyond 6 weeks.
Postpartum care in the United States has traditionally been limited to immediately after the birth and a check up at six weeks postpartum. That has left American mothers and birthing people with limited access to guidance and support from the time they leave the hospital until they go to their 6 week check up. In 2018, the American College of Obstetricians and Gynecologists (ACOG) updated their recommended postpartum schedule to include a 3 week check up and a comprehensive check up by 12 weeks postpartum (McKinney et al., 2018) Unfortunately according to a 2022 systemic review by Attanasio et al, many women do not attend even one postpartum check up. Most common complications first emerge during this critical time and this is the time that interventions and support are needed most.
Contrast that to Switzerland, as one example, where they have some of the best maternal and infant health outcomes. If you live in Switzerland you can expect to be seen regularly at home by midwives for the first few weeks after giving birth. The Swiss midwifery model of care allows for up to 16 home visits after the birth of a first child and up to 10 home visits for subsequent births. In most cases, midwives focus on the birth experience, common physiologic signs and symptoms, assessment for possible birth injury, nutritional interventions, lactation support, physical assessments of the birth person and newborn, checks for hyperbilirubinemia, newborn growth and development, sleep, contraception, sexual health, transitions to parenthood and communication is available with the midwife between visits (Edmonds et al. 2024).
The US could learn a lot from the Swiss system of midwifery care and other countries with significantly superior health outcomes among their birthing populations. I, for one, am committed to taking one tiny step by offering families in my care extended postpartum care in the community setting. My dream and my wish is for this level of care to become more available to the people giving birth throughout the United States because one tiny ripple has the potential to be a catalyst into the mainstream.