Ask the Midwife: Home Birth

Presenting round two of Ask the Midwife! This time, your questions were sent to Caroline Cusenza, LM, CPM who practices home births in California. A big thanks to Caroline for sharing her wisdom and taking the time to answer everyone's questions!

Caroline Cusenza is licensed by the Medical Board of California and certified by the North American Registry of Midwives. She graduated from the National Midwifery Institute and received her clinical training during a seven year apprenticeship with her midwife and mentor. After the completion of her midwifery training, Caroline joined forces with her mentor to form a practice that strives to provide excellent midwifery care to the families of Monterey County.

Questions:

Is home birth really a safe option?

This is a question that can only be answered by the birthing parents. I can tell you that I believe it is safe for a low risk, healthy pregnancy but no birth is with out risk, life is not without risk. Even a hospital birth is not with out risk. Most people that choose to birth at home have only chosen after extensive research and feel that the small risk of a serious complication is preferable to the high rate of interventions in a hospital setting including the 33% national caesarean section rate.[1]

What happens is something goes wrong?

Midwives are trained to deal with complications and transport as necessary. I do not take complications lightly and am always striving for safety for mother and baby. This is definitely a subject you should discuss with your midwife.

What happens if you have to get transferred to the hospital? Does the midwife come with you?

Yes, in the case of transport your midwife will accompany you and facilitate the transfer of care to the hospital by bringing your medical records and giving a verbal report to the receiving care providers. I stay with my clients until after the birth and take on the role of advocate and birth coach (and this is pretty universal among home birth midwives). I think it is important to help the parents understand what is happening and help them get the information they need to make an informed decisions.

Why choose homebirth?

Choosing homebirth is a very personal decision. It is not common (less than 1% in the US [2]) and many people will encounter resistance from family members and friends. People generally choose to birth at home because they feel more comfortable there and wish to avoid routine hospital interventions such as continuous electronic fetal monitoring or IV fluids. There are many more personal reasons that are given, for example, I chose to birth at home because I desired a natural birth and wanted to avoid an unnecessary caesarean section. I have had other home birth mothers state that they view pregnancy and birth as a natural process not an illness and therefore felt that the hospital was not the appropriate approach to childbirth.

When is homebirth not a good option?

Homebirth is not a good option for a person with preexisting disease or condition making pregnancy and birth high-risk for them. Some examples are women with diabetes, certain types of heart conditions, thyroid problems or hypertension. In some instances a pregnancy may begin as low-risk and a complication can develop such as preeclampsia and in those instances, the care of the woman must be transferred to an OB and home birth is no longer a good option. The midwife can continue to work with the mother but the primary care is taken over by the OB and the birth will need to take place in the hospital.

How close do you need to be to a hospital?

There are no guidelines in place for this, it’s more about what the birthing couple is comfortable with…I have heard of people living more than an hour away to rent a place closer the hospital.

How much does a homebirth cost? Do midwives accept insurance?

Homebirth costs vary by region. Here in Monterey County the range is about $5-6,000 for prenatal care, delivery and postpartum care. Many midwives do accept insurance, but it varies. Even if your midwife doesn’t bill insurance you can always submit your invoice for reimbursement from your insurance company. However there is no guarantee that they will reimburse you, it depends on your policy.

What is the difference between a CPM and a CNM?

Certified Nurse Midwives have graduated from nursing school and are further trained in midwifery. They are certified through the American College of Nurse Midwives (ACNM). CNMs primarily work in hospitals and doctors offices, however, some CNMs attend out of hospital births (OOH). Certified Professional Midwife (CPM) CPMs are certified through the North American Registry of Midwives (NARM). This is a national credential and in order to be certified, they must meet many qualifications. The NARM requires knowledge and experience with out of hospital birth. CPMs primarily attend OOH births in homes and birth centers. CPMs do not become nurses before they receive their midwifery training.

Who all attends the birth at a homebirth?

Midwives work in teams you can expect your midwife to bring a very experienced student midwife or another licensed midwife to your birth. Additional attendants are chosen by the birthing mother or couple.

Where do midwives get their training?

CPMs generally receive their clinical training through the apprenticeship model and/or in a birthing center and their didactic training from a midwifery school. How long does the midwife stay at your house? Midwives generally arrive around the onset of active labor or sooner if the client wishes. They will stay until mother and baby are stabilized following the birth, usually between 2 to 4 hours after the birth. Your midwife will stay longer if there is a complication or if mother or baby are not quite stable.

Do midwives come to my home for prenatal and postnatal checks?

In general yes, prenatal appointments are done in the client’s home or the midwife’s office. If the appointments are conducted in the office there will be at least one home visit. The postpartum visits are generally done at home. For example, I would do the first 3 postpartum visits at home (24 hour, 3 day, 7-10 day) and usually the 6 week check up is in the office.

What emergency procedures can midwives perform? What are they and what are they not qualified to do?

Midwives are trained in CPR and Neonatal Resuscitation. We are also trained to deal with complications such as cord prolapse, breech, shoulder dystocia, hemorrhage, placental abruption, placenta previa and many others. We are not permitted to use forceps, vacuum extractor, perform surgical birth or external cephalic version (ECV is used to turn a baby from a breech to vertex presentation). Midwives are qualified attend the birth of a normal low-risk pregnancy and deal with complications if the arise. If a complication arises that can not be dealt with at home, the midwife will stabilize and initiate transport to the nearest hospital.

How does your prenatal and postnatal care with a midwife differ than with an OBGYN?

You will spend much more time with a midwife during your prenatal care than with an OB. Most midwives, including myself, spend an hour each prenatal visit. During that visit they will do the same things such as test urine, take your blood pressure, listen to the baby’s heart, screen for abnormal symptoms, measure the fundal height, etc. Midwives will spend a fair amount of time on palpating to determine the position of the baby and it’s my understanding that most OBs do not palpate during a prenatal visit. In addition, we will spend the majority of the visit discussing general health, diet, exercise, pregnancy, including psycho-social issues. I do my very best to make sure that my clients get all their questions answered at each and every visit. Another big difference is that I spend time discussing each and every diagnostic test with my clients so that they understand what the test is for and they will decided if they want the test or wish to decline. Postpartum care is a minimum of 4 visits, 3 home visits (1 day, 3 days and 7-10 days postpartum) and a 6 week office visit. Additional visits are available upon request and encouraged, including visits just for breastfeeding support.

What happens if I want pain medication at a home birth?

I will offer natural and non-drug alternatives along with love and encouragement. If these are not effective and the mother wishes to have medication we will transport to the hospital. I accompany the mother and make sure she gets settled and taken care as soon as possible.

Can I still have a doula attend my birth?

Yes, a doula is a wonderful addition to a home birth. However, many home birth couples do not choose to hire a doula. I usually arrive when the mother moves into active labor, however, I will come as soon as the mother wants me there. I have had couples that hired a doula to be there in early labor and then called me when they reached active labor.

What happens if two of your clients are in labor at the same time?

I work with a partner and our clients know us both very well. If two clients go into labor at the same time, we split up and call two other midwives to assist us. That way each birthing mother is attended by at least one midwife they know well, we call this continuity of care.

Do I still need to see an OBGYN at all during my pregnancy?

It is not necessary to see an OB during your pregnancy, as a midwife is the primary care provider for your low-risk pregnancy. If a serious complication arrises during prenatal care, I will consult and/or refer to an OB. Most clients do not continue or seek care with an OB once they have hired a midwife.

What does a midwife bring to labor? What do I have to provide?

You will have to provide some basic supplies, often referred to as a “birth kit”. Some examples of what you might find in a “birth kit” are: under-pads, peri-bottles, gloves for the midwife, maternity pads, sitz bath herbs, bulb syringe to suction baby, etc. What I bring (and most midwives) are items like a doppler to monitor the baby’s heart, oxygen and equipment to help the baby if they have trouble breathing, drugs to control hemorrhage, sutures and lidocaine to repair a laceration, instruments to use to cut the cord or repair the perineum, IV supplies, and many other things that might be needed.

There are multiple midwives in my area, how do I go about choosing which one to use?

You should interview them and see who you feel most comfortable with. A home birth is a very intimate event and you will be spending many hours with your midwife during prenatal visits, the birth and postpartum. Many midwives offer similar services and have similar philosophies but we do differ, ask lots of questions and choose someone you think you can work well with as a team. Ultimately, you should really like your midwife, it’s a very different relationship than you may be used to having with other healthcare providers.

[1] http://www.news-medical.net/news/20120619/C-section-rates-in-US-stabilize-after-eight-years-of-steady-increase.aspx

[2] http://www.cdc.gov/nchs/data/databriefs/db84.htm

Have some more questions? Send them my way and I will make sure to have them answered in the next Ask The Midwife post!

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