Condition and Community

While many of my forthcoming blogs will be scholarly and analytical in nature, this one definitely advocates for certain choices. I do try to be fair and acknowledge that my choices are not for everyone or every situation.

Earlier this week I visited a local birthing center. A what? A birthing center is a private clinic in which midwives and nurses, not OB-GYNs, attend women for all prenatal care, the birth itself, and postnatal care. On the spectrum between home births and hospital births, birth centers fall right into the middle, and so may be a good choice for women who are not made overly nervous by the idea of giving birth, whose pregnancies have progressed normally and healthily, or who prefer a less clinical, less hospital-y atmosphere. This blog, therefore, will be about approaching pregnancy and birth in terms of “condition” and “community.”

Birthing Center suite vs. Hospital delivery suite

On the left is one of the birthing suites at the birthing center I visited. It includes an attached private bathroom with shower as well. On the right is one of the delivery suites from one of my local hospitals. It has a private bathroom too.

Modern midwives do much the same thing that OB-GYNs do, except they tend to “interfere” less in the pregnancy and birth.  That word “interfere” has a lot of negative connotations, but in the interests of analysis, I’ll attempt to make the term more neutral. Think of interference in terms of interventions (medical, physical, technological) versus observation. During prenatal care, interventions may be anything from multiple blood draws, genetic testing via amniotic fluid collection, multiple ultrasounds, and/ or a pelvic exam at every visit. During birth, interventions can range from inducing labor via Pitocin, to constant fetal monitoring (either external or internal), to episiotomy, to cesarean section. There are many other specific interventions as well, some even to the extent of not letting the pregnant woman eat or change positions while laboring. Of course, some interventions are definitely medically indicated in certain cases, and should thus not be shunned.

Birthing centers encourage laboring mothers to let their bodies work without medication during labor. Midwives are trained in pain management techniques such as massage, counterpressure, positional changes, movement, and water therapy; however, most birthing centers do have some chemical ways of assuaging pain, such as the synthetic narcotic Nubain or the use of nitrous oxide. Midwives will advocate for medical intervention a) when they deem it necessary, but b) not without the mother’s consent. Of course, doctors must in general have patient consent for any procedures as well, but the overall environment of a birthing center versus that of a hospital may sway a laboring mother to be more relaxed and in tune with what she actually needs. Studies have clearly shown a higher correlation between hospital births and optional interventions, whereas birthing centers perform fewer interventions but have the same fetal and maternal safety rates as hospitals. Mothers might worry about their newborn’s health in a birthing center, but these centers have standard resuscitation gear (oxygen tanks, masks, pumps), anti-hemorrhage drugs and equipment, and many other tools to help mothers or babies who need it. The midwife with whom I spoke at my birthing center visit said that they will not hesitate to transport (either via car or ambulance) a mother or baby in distress to the nearest hospital if it becomes necessary.

Typically, a midwife’s philosophy is that pregnancy and birth are a state of being, rather than a medical condition or illness. In other words, midwives tend to treat all pregnancies as healthy and normal, unless otherwise indicated. This is in contrast to the views–and indeed, the training–of many OB-GYNs, who tend to approach pregnancy and birth as a medical condition akin to illness. This is not to say that OB-GYNs are insensitive to a woman and approach her only as a sick patient: I have had several OB-GYNs assure me that they prefer as much of a hands-off, normative, non-interventionist approach as possible during pregnancy. However, OB-GYNs, being doctors, tend to rely more on instruments, statistics, drugs, procedures, and policies during their care. It doesn’t help that hospital OB-GYNs tend to have many patients and not much time for each one of them. During labor, the OB-GYN is called for only periodically and in the final moments to catch the baby; hospital nurses will be in and out of the room because they can rely on electronic monitoring to tell them when to see the mother. Conversely, a midwife tends to help the woman understand her own body and its cues, prioritizing and trusting the innate human ability to carry and birth a child. Additionally, birthing centers see many fewer patients than hospital delivery wards do. The center I visited hosts between three and ten births a week, and laboring women seldom overlap with each other. Due to this low volume, someone (the midwife and her nurses will rotate with each other) stays with the mother the entire time, unless she and her partner ask for some privacy.

It’s not only labor where the difference between a birthing center and a hospital becomes apparent. During prenatal care, a hospital and a birthing center typically meet with a mother about the same number of times: once a month until Week 32, then once every two weeks until Week 36, then once a week until delivery. At hospitals and OB-GYN offices, these prenatal meetings tend to function like a doctor’s visit: they are relatively short and take place in an exam room. Hospitals offer birthing and childcare classes, but they are separate from the prenatal healthcare visits. Many birthing centers, on the other hand, do what is known as “centering.” Centering is a monthly meeting of women who are due around the same time–perhaps within one or two months of each other–coupled with short health visits. For example, at the birth center I visited, each Centering meeting begins with a private health check between the midwife and each mother. This short checkup allows the woman to ask private or sensitive questions specific to her own concerns, and assures both the midwife and mother than the pregnancy is progressing normally. Then, the group of mothers are either led in a specific class (e.g. pain management techniques in labor; pre- and post-natal yoga; breastfeeding) or encouraged to ask general questions and converse about their impending motherhood. The Centering cohort remains the same, so women often form friendships, or can at least organize shared group-style child care. Though some women (myself included) may balk at the notion of sharing our (silly? stupid? strange?) questions, I realize that if I were to have a silly question, then someone else probably does too.

If we had to divide up the birthing experience into binary halves (which of course is never quite accurate or fair, but a line has to be drawn somewhere for the sake of ease), then hospitals and OB-GYNs tend to view pregnancy and birth as medical conditions, whereas birthing centers and midwives tend to view them through a community lens. Both professions agree that birthing is a natural process; they tend to disagree on how natural we should let it be. Some interventions may be medically indicated and would have the wholehearted backing of a midwife; some may be unnecessary from a medical standpoint; some may be necessary for the individual woman, for example if she is overwhelmed by pain during labor.

Personally, because I know how my own mind and heart work, I know I am more likely to be nervous in spaces with obvious medical accoutrements; with people going in and out of the room; with being surrounded by beeping machinery. Constant monitoring of anything (like the watched pot which never boils) makes me second-guess myself, and makes me anxious. Therefore, after all my personal research and after meeting with the midwives at a birthing center, I know that if my own pregnancy is normal and healthy, I’ll choose a birthing center wholeheartedly.

(P.S. Birthing center costs tend to be much lower than a hospital birth, because birthing centers don’t need to pay for a big building, lots of equipment, staff, anesthesiologists, surgeons, etc. Typically, women stay in a birthing center less than 24 hours, compared to 2-4 days in a hospital. I’m lucky to have good insurance that accepts birthing centers, and the total price I was quoted was $1165, including insurance coverage, for all prenatal care, staff, facilities, 20-week ultrasound, the birth itself, and a home visit two days after birth. An early ultrasound would run an additional $145; nitrous oxide during labor is $50 for 15 minutes or $200 for the whole run. Considering that I’ve had hospital prices quoted between $3000-$5000 [after insurance kicks in] for a healthy, normal vaginal birth, the price tag is another reason to consider a birthing center!)


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