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    Physicians and “natural birth”: The two can co-exist

    headshot of Yalda Afshar, MD, PhDAs an ob/gyn resident training on the west side of Los Angeles, I am used to encountering patients who have specific plans and expectations for childbirth. At our hospital we are very comfortable admitting mothers who have birth plans and we work alongside certified nurse midwives (CNMs), ally with doulas for birth support, and know not to ask our hypnobirthers about analgesia.

    Our hospital’s labor rooms often receive home-birth transfers. Anecdotally, the most common reasons for such transfers are maternal exhaustion, pain, abnormal labor, or fetal concerns. When these patients arrive on the unit, they are often sneeringly referred to as having “failed home birth.” I refuse to use that label. Throughout the United States, more women are choosing to undergo out-of-hospital births; nevertheless, they make up only 1.4% of all deliveries. Oregon has the highest rate of home births at 2.4%, and Louisiana the lowest at 0.2%.1 The overall percentage of out-of-hospital deliveries is low, yet these births increased by 24% between 2008 and 2012. More so, the percentage of women undergoing a trial of labor after cesarean (TOLAC) is increasing, while the percentage of TOLACs in hospitals is decreasing.

    The American College of Obstetricians Gynecologists’ (ACOG) Committee Opinion states “hospitals and birthing centers are the safest setting for birth,” but it respects the right of a woman to make a “medically informed decision about delivery (location)”. 3 More recently, the American Academy of Pediatrics (AAP) stated that “pediatricians should advise parents who are planning a home birth that AAP and ACOG recommend only midwives who are certified by the American Midwifery Certification Board.”4  Women who are home-birth transfers often arrive accompanied by a “lay-midwife,” aka a certified professional midwife (CPM) who does not have hospital privileges. Unlike CNMs, CPMs are direct-entry providers, without masters-level midwifery education.

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    I advocate vaginal deliveries, as would everyone with whom I trained. We promote TOLACs, admissions of women who are in active labor, no elective inductions of labor, and surely no cesarean deliveries on maternal request (CDMR). We understand that labor is natural and we trust “Mother Nature.”5  Hospital births and obstetricians are not the enemies of low-intervention spontaneous vaginal delivery. We know that home births have fewer obstetrics interventions, but are associated with concomitantly higher rates of infant mortality during the first month of life, and that babies delivered at home are more likely to have significant neurologic sequelae when compared to those delivered in a hospital.6 We train and practice with the understanding that a woman should be given the right to make an informed choice to deliver in a space that respects her dignity and safety.

    There are two goals in managing labor: a healthy mother and a healthy baby. Without a doubt, there are many ways to get from A to B; however, just because a patient is admitted to a hospital does not mean she will get “medicalized.” I’m not sure how to dispel this myth. Yes, more often than not, we insert a peripheral intravenous (IV), anticipating active management of the third stage of labor or a possible emergent need for IV administration of antihypertensive medication. Yes, we do put the baby on the monitor, but the mother is generally free to move around on telemetry as long as there is no concern for seizing or having a stroke. And yes, we care about the mother’s health and safety, so we get vitals to give us a sense of where the woman is hemodynamically.

    NEXT: “I don’t want you to learn your interventional birthing on me.”

    Yalda Afshar, MD, PhD
    Dr. Afshar is a Maternal-Fetal Medicine Fellow in the Department of Obstetrics and Gynecology, University of California, Los Angeles

    2 Comments

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    • RuthMielke
      Hi Yalda - Nicely put! So glad that I found this wonderful commentary! I will post this for my midwife students so that they can hear from an MD who is as proprietary about vaginal birth as they are! Grunebaum article is a good one for my students to analyze. Does not have a model of neonatal mortality based on site - just isolated factors. E.g. Advanced maternal age - which as we know can be anywhere from 35 to ....? plus more gestation >41 weeks at home which includes CNMs, LMs, self-identified MWs whom we do not know if they had any training at all! PS I work PT as a midwife at CHMC - thinking that you know who I am:)
    • Ms. JChapman
      Dr. Afshar, I can understand where the woman who commented about being practiced on is coming from. So many women these days have access to multiple sources of good information that many of them know the evidence but then don't see it being used in hospital. Where is the evidence for all of the 'just in case' intervention such as IVs and CFM. When I see this in hospital protocols I can see a group of professionals working from a point of fear of birth, not knowledge and faith in birth. I am a midwife in Australia and in the hospitals I have worked in those types of intervention are not used on low risk women. Maybe that is why these hospitals have better birth stats than those I read about from the USA. If you ever have the time go through the hospital policies one by one and research the evidence for each one. You may be surprised.

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