Doula Dani: Homebirth After C-section A Gamble

Giving birth is, no doubt, among the most profound and life-changing experiences any woman can ever have — it marks the start of new life, after all. It's hardly surprising that modern women and their partners frequently turn to the internet in search of answers to questions such as "Where can I have the safest, most comfortable birth?". 

Over recent years, women have started to exercise more control over their birth choices — and the natural childbirth movement has gained popularity. Increasing numbers of expectant moms are aware they have many possibilities, including homebirth, vaginal birth after c-section, and even homebirth after a prior cesarean. Natural birth and homebirth websites can quickly give the impression that these choices are perfectly safe. Are they, though?

SteadyHealth spoke to Danielle Repp, AKA Doula Dani, a former homebirth advocate who doesn't gloss over the possible consequences of choosing homebirth in high-risk situations. Her blog, "What Ifs And Fears Are Welcome", does not shy away from tough topics. Homebirth advocates may not like her conclusions, but she speaks out because she believes women deserve to see the less idyllic side of the natural birth movement. Danielle shared her thoughts on vaginal birth after c-section, homebirth after c-section, supporting women, and the natural birth movement with us. 

'Concern, dissent and stories of home birth loss or injury are too frequently not "acceptable"'

What I wrote about VBAC (vaginal birth after cesarean), and in particular what I wrote about HBAC (home birth after cesarean), goes against what the home birth movement promotes. It threatens what they believe, threatens choices they have made, and threatens their livelihood. At this point, I am not really shocked anymore by anything from home birth advocates.

In ways, it is cult-like. There’s a tendency to create echo chambers isolated from any counter opinions. Concern, dissent and stories of home birth loss or injury are too frequently not "acceptable" in home birth circles and forums. They will call it fear mongering or hide behind the guise of "we allow support only" when the reality is, they don’t want people to question the safety of home birth and they don’t want people to share information or stories that make people question the safety of home birth.

I think there are a lot of well-meaning midwives and home birth advocates out there who put their trust in the leaders of the home birth movement. I think those at the "top" – the leaders and more outspoken advocates – know the deliberate lies and misinformation they are spreading… and it just trickles down through the home birth community, shared as the truth.

The midwife/client relationship is another aspect that makes it hard for women who choose home birth to see what is and is not acceptable/ethical care, what is and is not true informed consent. It can easily become an us (home birthers) versus them (the hospital/doctors/medical world) situation – which makes collaborative care very difficult and makes it hard for home birth mothers to know who to trust.

'I Realized I was Duped By All Of The Home Birth Propaganda'

You were once a homebirth advocate yourself. Can you describe what led you to change your mind? 

It was a combination of factors. It started with being involved in an emergency home birth transfer as a doula. From there, it just took off into several different avenues, searching for answers to the mounting questions and concerns I had. The process and the aftermath have made me a much more skeptical person. In the end, I realized I was duped by all of the home birth propaganda. I realized I only had part of the story when we were hoping/planning for our home birth.

Using infant mortality [as a yardstick by which to measure the safety of home birth], for example, is a deliberate attempt to fool someone about our maternity care here, to scare women away from hospitals and obstetrics in the USA. You see, infant mortality is live birth through the entire first year of life. Perinatal mortality is a much more accurate measure for maternity care. It includes prematurity, antepartum mortality, intrapartum mortality and neonatal mortality. That is obstetrics. That is maternity care. So why don’t the leaders of the home birth movement discuss perinatal mortality? Because the United States does very well with perinatal mortality, tied with countries like France and Japan, and actually better than countries like the Netherlands and the UK. It doesn’t help the home birth agenda to share that information, though.

We took into account every logical and emotional argument we could. The last piece was just me being brutally honest with myself, which was the hardest piece of all. But our bottom line was safety. I knew the hospital was the safest place. It’s a matter of fact, not opinion. It’s a greater risk of (potentially unnecessary) intervention in the hospital but a greater risk of death when not in a hospital. I felt my chances of avoiding unnecessary intervention in a hospital would be greater with a support system, having a good "birth team".

See Also: Tragic Homebirth Death Begs The Question: How Skilled Is Your Midwife?

The process taught me so much about home birth in our country. I don’t have respect for the home birth movement here. I can’t support it because I feel I am trading in a piece of my integrity by doing so. I support a woman’s right to have a home birth. But I have lost so much respect for our home birth "system".

Doula Dani On Cesareans And Post-Cesarean Birth Choices

'Don't Be Afraid To Have Those Conversations With Doctors'

What advice would you give to women who are not sure whether to choose a trial of labor after c-section (TOLAC), or a repeat cesarean (RCS)?

It’s important to know who is and who is not a good candidate for TOLAC; RCS is the best option for some women and babies but TOLAC may be the best option for others. There are a lot of factors at play. And that isn’t something I’d be able to answer for anyone. That answer comes from honest conversations with a woman’s care provider about the benefits and risks.

Personalized care means continued assessment throughout pregnancy. That doesn’t mean a care provider should never be questioned. But it also doesn’t mean concern is a "bait and switch". So really, the only advice I can give is to not be afraid to have those conversations with doctors. Don’t be afraid to ask questions. Write them down ahead of time, if need be. Be your own advocate.

'Being "five minutes from a hospital" doesn’t mean transfers are quick and easy'

Do you think a woman should ever attempt to have a HBAC, a homebirth after cesarean section?

When you are looking a TOLAC mortality rate in a hospital setting of 1.30/1000 versus a TOLAC mortality rate in an out-of-hospital setting of 4.75/1000, and knowing that a baby needs to be delivered relatively quickly – less than 30 minutes after rupture – HBAC is just a huge gamble. Being "five minutes from a hospital" doesn’t mean transfers are quick and easy. They take time. Getting a laboring woman out of the house, travel time, hospital assessment, preparing an OR… it’s not a quick process.

Do you believe, after your recent investigation, that it is possible to detect a uterine rupture at home, accurately and in a timely manner? What are the main symptoms for most women? 

To quote the American College of Obstetricians and Gynecologists: "The most common sign associated with uterine rupture is fetal heart rate abnormality, which has been associated with up to 70 percent of cases of uterine ruptures. This supports the recommendation of continuous fetal heart rate monitoring in labor."

To quote the Guise study: "As stated in a prior VBAC evidence report, and echoed in studies contained in this report, there is no single sign for the occurrence of uterine rupture; however, fetal heart tracing abnormalities, particularly fetal bradycardia (reported in 33 to 100 percent of all studies) is the most frequently reported sign of uterine rupture. Other signs reported in uterine rupture studies in descending order are maternal vaginal bleeding, maternal pain, and uterine contraction disturbances."

Continuous electronic fetal monitoring for TOLAC is recommended by the ACOG, American Academy of Family Physicians, SOGC, RCOG and others. Based on these recommendations, it certainly seems wise to have electronic fetal monitoring at least as an option. And at home, it’s not an option. A handheld Doppler or fetoscope is not the same as electronic fetal monitoring.

Again, knowing the limited amount of time a woman has in order to avoid serious morbidity or mortality for her baby, it’s a gamble.

You mentioned that the rate of uterine rupture coincides with the HBAC infant mortality rate as shown by MANA's statistics. Does this mean it is nearly impossible for a baby to survive a uterine rupture that occurs at home? 

We don’t know for certain if those five deaths were due to uterine rupture. We don’t know anything about uterine rupture in the MANA study because the authors didn’t include any information about it. But again, based on the information available for how quickly a cesarean section must be performed when uterine rupture does happen, it’s not a stretch to say that a uterine rupture at home would likely have deadly consequences. What can be done to help a baby in the case of uterine rupture at home? Nothing. There is nothing that can be done to help a baby at all other than get the woman to a hospital in an operating room as quickly as possible. 

'I felt so well-informed and educated' 

Interpreting statistics is really hard for a lay person. Do you have any advice for people struggling to interpret how safe certain birth options truly are?

I am a lay person. I'm not an expert. So I completely understand how challenging it can be. It's part of what had me confused when we were initially planning our home birth. I felt so well-informed and educated on the matter. I didn't realize the sources I trusted were not actually trustworthy.

More than anything, it’s just a matter of having information available and an awareness of the agenda of those interpreting the information. It’s a matter of knowing where to look for objective information. The MANA study authors did not provide any comparison rates for mortality rates.

A home birth mortality rate of 1.62/1000 for babies born to low risk women might not mean much of anything without having something to compare it to. 1.62/1000 just sounds low. However, when you compare it to the 2013 Birth Center study, for example, which has a mortality rate of 0.87/1000 for babies born to comparable risk women, then it makes you wonder why is the MANA study mortality rate twice as high? 

These numbers all seem low, though. But it’s important to remember how many babies are born every year in the USA, specifically how many are born in an out-of-hospital setting. According to the CDC Wonder Database, in 2012 there were 38,997 midwife-attended out-of-hospital births - some in birth centers, some at home. So just for the sake of illustrating a point here, let’s round up to 40,000 births and let’s pretend they are all low risk women. According to the MANA study mortality rate of 1.62/1000, approximately 65 babies would die out of 40,000. According to the Birth Center study mortality rate of 0.87/1000, approximately 35 babies would die. According to the hospital mortality rate of 0.38-0.58/1000, approximately 15-23 babies would die.

See Also: Cesarean Delivery Risk Factor

What is home birth in America doing so wrong that their mortality rates are so much worse than hospitals and CABC-accredited birth centers? 1.62/1000 is the mortality rate for babies born to low risk women. This is not acceptable. Instead of addressing this issue and figuring out ways to make home birth better, safer they instead are spending their time trying to pull the wool over everyone’s eyes. They want people to think that 1.62/1000 is good. But it isn’t. 

Patient Experience After C-Section

What role would a doula play in making a hospital TOLAC or RCS a more pleasant experience for the patient? 

A doula is there for support – no matter what “type” of birth unfolds or is planned ahead of time. Just being there to check in with the mother, to see how she is emotionally coping and validating her feelings… it can make a big difference. Some nurses, midwives and doctors are also great at doing this, but they have other patients and other duties. A doula is there just for the mother (and her partner, too)… no matter how the mother is giving birth. Doulas can help in other ways, of course, like giving mom ideas for position changes, for example. But I personally believe our greatest asset is to just be there for the mother, emotionally.

Do you think women who choose a repeat c-section suffer negative psychological consequences? If so, how does this possibility influence their choices? And how do women who had an unsuccessful trial or labor after c-section feel? Is there anything we can do, as a society, to prevent women from feeling "broken" if they are not able to give birth vaginally?

I have had women write to me and share the sadness they felt when their birth turned out differently than they hoped. I’ve had women say they felt judged by other women if they’ve had a cesarean section. And in childbirth forums, I’ve seen this a lot as well, that women feel like failures because things don’t go as they hoped for their birth – sometimes it’s a smaller issue, sometimes it’s a larger issue. It’s quite heartbreaking. It makes me feel that sometimes the natural childbirth movement is doing more harm than good. Are we empowering women? Or are we setting them up for failure if things don’t go exactly as planned?

'The Way We Give birth Does Not Make Us Superior Or Inferior To Any Other Woman'

From the pain experienced in childbirth to the way women feel after birth to the recovery to the unexpected twists and turns that come up in each labor. It is all so very different. And it’s easy for women to get wrapped up in how things should be or how things should feel that it can have devastatingly negative emotional consequences. Home birth is often presented in such a romanticized way that women feel bad if they have anything less than a pain-free birth with candlelight and professional photography. Not just a certain "type" of birth is beautiful. Birth is beautiful for many reasons, process aside.

I think all of us have a part to play in helping women/mothers not feel "broken" for whatever reason. For care providers, it comes from having honest conversations and allowing women to share their hopes and fears, without making them feel bad for doing so. Just a simple "Are you OK with that? How does it make you feel?" can go a long way in helping a woman feel like she has some control in a very vulnerable situation. It comes from informed consent, no matter where or how a woman gives birth. It comes from the way we, as mothers, respond to each other. If a woman says "I had a cesarean section" it shouldn’t be met with pity and a "Do you feel cheated?" questioning or attitude. Pity can be just as destructive as blame.

The only thing we can do is change what we are putting out there. It comes from accepting that the way we give birth does not make us superior or inferior to any other woman, it doesn’t make us better or worse mothers. We don’t need to feel sorry for or jealous of anyone for how they gave birth. Our bond with our children is not dependent on a certain type of birth. The bond we have with our children is so much more than any one particular moment in time.

See Also: Vaginal Birth After C-Section - When Is It Safe?

We can’t control others. We can’t control the things other people say. We can’t control how they feel. We can only control ourselves and what we say. I have my own regrets for things I have said to other mothers, things that I’m certain probably made another mother feel bad. I find it helpful for myself to just remember: My child’s birth does not make me better or worse than any other mother.