The following article is the first in a series examining birthing options in Sonoma County.
Last year, more than 5,300 babies were born in Sonoma County. According to the Office of Vital Statistics, 60 of those babies were born in a non-hospital setting—that is to say, approximately one percent of the total.
“Homebirth is alive and well in Sonoma County,” said Alicia Mutch, who teaches a HypnoBirthing class in Healdsburg and offers doula services to her students. “Homebirths do seem to come in waves. Sometimes every single woman in my class is planning a homebirth, and sometimes they’re all hospital births.”
While homebirth is undeniably the least common choice for pregnant women, some midwives believe that homebirths in Sonoma County may be underreported. Certainly there are more planned homebirths than actual homebirths, as midwives will oversee a transfer to a hospital setting should complications arise during labor. In that case, the birth would be recorded at the hospital.
“The gold standard for homebirth is to have two fully qualified midwives at every delivery,” said Dana Fox, a licensed midwife from Sebastopol who serves mothers within an hour radius of her Santa Rosa practice. “The primary midwife would accompany the mom to the hospital, if needed.”
At the hospital, the primary midwife would assume a role of a doula: part birth support, part labor coach, part patient advocate, part medical translator.
Dana Fox attends approximately 60 births per year, the vast majority of which are homebirths. (The others take place at the Women’s Health and Birth Center, where she is occasionally on call.) Fox is just one of a handful of homebirth midwives actively practicing in Sonoma County.
“I used to attend two or three homebirths per month, but now I’m in a transition period, and I only attend about one per month,” said Constance Miles, a licensed midwife near Occidental.
Homebirths are typically attended by practitioners who carry one or more of the following certifications: licensed midwife (LM), certified professional midwife (CPM), or certified nurse midwife (CNM). Some may be registered nurses (RN) as well, or have other related experience in the healthcare field.
For her part, Fox began her career as a medic in the Navy. She worked in an ob/gyn unit, where she came to the conclusion that viewing birth as a medical process carried its own set of risks and consequences.
“I learned about how drugs used in labor affect babies,” Fox recalled.
The midwife model of care views birth as a natural and normal process, albeit one that requires training and skill to successfully support. Midwives provide non-drug pain relief techniques including massage, water therapy, and guided relaxation.
While these techniques—and homebirth in general—sometimes conjures images of hippies giving birth in a commune, many of the people involved in homebirth are not as crunchy-granola as one might think.
Take Tracy Greenwald, who gave birth to her second daughter at home. She taught childbirth preparation classes at Kaiser for five years, has a Master’s in public health, and is a registered nurse as well as a certified doula.
“Midwives come from the approach that medical intervention should only be used when it’s truly necessary,” Greenwald explained.
And she noted that sometimes all it takes is a little training and effort—as opposed to an epidural or intravenous drugs—to support a woman in labor.
“I can tell when a woman’s getting frustrated. One position that had been working for a while might not be working anymore, so I’ll suggest that she change. Just changing the scenery, she can get new energy,” Greenwald said.
Homebirth midwives remain with the laboring woman throughout her entire labor, as opposed to hospitals, where medical personnel are managing a number of patients and pop in and out of the delivery room. (Doulas, who will be discussed in more depth in a subsequent article, can provide continuous support in clinical settings.)
Midwives point to a variety of other benefits of homebirth, including the freedom to eat and drink at will, the ability to labor in the position of the mother’s choosing, the ability to utilize a warm birthing tub for pain relief, and a reduced risk of infections.
“Women instinctively know what laboring positions they want to be in. At the birthing center and homebirths, you’re free to labor in whatever position you choose,” HypnoBirthing teacher Alicia Mutch said. “When you’re on your back, you have to push the baby up past your pubic bone, so you’re fighting gravity. You’re more likely to tear.”
A prone position is common in hospitals, partly because it makes monitoring easier for medical personnel. Women who receive epidurals are typically required to be on IV, which also limits movement.
Midwife Constance Miles noted that a homebirth also allows greater participation of partners and siblings.
“Partners are absolutely more involved at home. And studies have shown that if a partner is able to spend more time with the baby in the first 15 minutes of life, they spend more time with the baby in the first month,” Miles said.
Fox pointed out another benefit: the fact that women committed to giving birth without pain medication are much more likely to do so at home for the simple reason of availability.
If a dieter doesn’t have cake around the house, he or she won’t eat it. It’s much more difficult to refuse cake—or in this case, medication—when it is offered to you, or even encouraged. Homebirth midwives cannot provide epidurals so pain medication isn’t available, let alone offered or encouraged.
“Most women who have a natural birth at home do say that if the pain relief had been there, they would have gone for it. That’s partly why it’s so hard at the hospital,” Fox said.
But there are potential downsides.
Like doctors, midwives hold different core beliefs and have different levels of experience. Because midwives work independently, there is less oversight and quality control. Just because a midwife is certified, for instance, doesn’t mean she has kept up on continuing education courses. Just because she started practicing in 1980 doesn’t mean she has practiced continuously since then.
“Observe 20 and catch 20, that’s all it takes,” Fox said, referring to the certification. “Young midwives who’ve gotten that training, they think they’re ready. But they’ve not seen all the potential complications.”
Fox also acknowledged that there is a risk of being too natural.
“Now it’s back to all-natural birth—have an orgasmic birth, have an unattended birth… but it takes a good foundation in anatomy and physiology, nutrition, herbal medicine, psychology, breastfeeding, newborn care, and emergency skills to handle birth,” Fox said. “Yes, it’s normal. Yes, it can be healthy… but yes, it’s a time of risk, too.”
Homebirths may not be covered by insurance, which causes another problem for expecting parents. Fox charges $4,000 for pre-natal care, labor and delivery, and post-partum visits—a number she’s had to adjust for some clients.
“It’s a hard time economically for so many folks. A lot of us are working on a sliding scale or tithing some births,” said Constance Miles.
But the commitment on the midwife’s part is a serious one that involves sleeping with the phone right by the bed, every night, and leaving at a moment’s notice.
“You’re on call two to three weeks on either side of a due date. And you’re doing quite a few postpartum visits at their home afterwards,” Miles said.
But homebirth advocates say it’s worth it, both for the midwife and for the parents-to-be.
“You can select a random birth team because your insurance covers it, or you can interview and select your doctors or midwives based on how they reflect your preferences,” Mutch said. “I call it the mental attitude of being a consumer of birth—finding a provider who will follow your wishes.”
Tracy Greenwald agreed.
“If they have private insurance, they need to interview their obstetricians or midwives just like you’d interview anyone for a job. There may be a doctor you’ve been going to for Pap smears for years, but you interview him and you learn he’s just not the one for you. Don’t feel bad,” Greenwald said.
Many people put more effort into selecting a mechanic or a hair stylist than selecting the person who will oversee the birth of their child. Midwives noted that the vast majority of couples spend orders of magnitude more money on weddings than on the birth of their child.
And all midwives and doulas agreed that they wanted their clients to interview them—and were happy to refer them elsewhere if need be.