How We Decided on a Home Birth

Before I got pregnant, I never would have thought of myself as the type to have a home birth. My husband and I had one older friend, a lovable but somewhat dotty and New Age-y woman with three teenaged kids, who had given birth to all three kids at home. She told us with pride about having had her babies at home, right on her couch in her living room, and we were like: "Oh, uh, ummm, okay, that's nice," and just chalked it up as another one of her odd behaviors, like making totally confident, totally wrong predictions about when I would get pregnant.

Getting pregnant was actually not nearly as quick and easy as we thought it would be. It's funny, because it seems like up until you decide you want to have kids, you've spent your whole life trying very hard not to get pregnant, and so you somehow have it in your head that the instant you stop using birth control your stomach will pop out like a balloon, and hey presto, you'll be preggers. To our surprise, it took us five months, and we were starting to get worried. Every other month I would be absolutely convinced that I was finally pregnant, only to take a home pregnancy test and be confronted with one sad lonely little line emerging out of my pee-soaked stick.

"It's me, I know it's me," I would say to my husband.

"No, no, it's probably me," my husband would say. And we would argue back and forth, each of us preemptively trying to take the blame. Just when we were on the verge of going to the Down-There-ologist to get ourselves checked out, I decided to take one last home test, and there it finally was --- the little pink cross, like some Neo-Celtic symbol of fertility.

My family was the first to know. For months, my mom had been answering the phone every time I called with "Oh, oh, oh, let me guess, you're pregnant?!" And my big sister, who has four kids, kept calling me and asking if I'd gotten my period yet. Hello, do I go around asking you about your menstrual cycles? So, yeah, my family was pretty excited. When we went to visit my folks at Christmas, it seemed like no one could talk about anything else. My little sister, who at the time was in medical school, had a best friend who was a trained doula. (For those of you who don't know, a doula is a woman you pay to support you during labor or after you give birth --- she functions like a combination of cheerleader, medical advocate, birth guidance counselor, and lactation consultant all rolled into one. In classical Greek, doula meant female slave or servant, but it has evolved this modern definition that means specifically a person who helps a woman through the birth process.) My sister's doula friend was over and they both starting asking about how I liked our OB/GYN and our plans for the birth.

At the time I was going to Reiter, Hill, and Johnson in Washington, D.C. I had gone in for my first OB appointment at ten weeks, and was excited that I was finally going to get to see actual doctors at my appointments---for my gynecological appointments I always saw nurse practitioners, so it felt like I was getting the VIP treatment now that I was pregnant. I was also impressed that I got a sonogram around the same time, because I was thinking we would only get the mid-pregnancy one and that it wouldn't come till much later. I had to drink something like two liters of water in five minutes an hour before the sonogram, so that my bladder would be full and my uterus would show up better on the screen. Yousers, was that uncomfortable---although it was good practice for the last couple of months of my pregnancy, when I felt like I had to go to the bathroom pretty much all the time. We were thrilled to see the little black and white blob swim into focus on the monitor and then turn and wave its tiny arms at us like it was hailing a cab. It looked like a happy lima bean, except with arms.

The OB I met with at that first appointment (I don't remember her name) was a confidence-inspiring woman with a pleasant bedside manner, probably not much more than five or ten years older than me. I liked her and thought I wouldn't mind having her deliver our baby. It was true that the appointment went pretty quickly, and that almost immediately afterwards I thought of several questions I would like to have asked, that would have to wait till the next time. But I was pleased by how the practice seemed so high-tech, and I felt like I would be getting state-of-the-art care there.

One of the things I wondered about but hadn't asked at my OB visit was having a drug-free birth. It wasn't something I was passionate about wanting to do at that point, but I was vaguely hoping to follow the model of my older sister (not the doctor sister, but the one with four kids). Her first baby had come so quickly at the hospital that there hadn't been time for an epidural. Afterwards, she said she had felt like it really wan't that bad---it probably helped that her entire labor only lasted a few hours---and so when she had each of her other kids she decided not to get the epidural on purpose. All four of her kids arrived the same way---relatively short and easy labors with no epidural. I hoped my labor would be similar and thought it would be nice to avoid the pain medication if I could, although I was definitely open to having it if it turned out that my labor was unbearably painful. I was curious about whether there were ways to make it more likely that I could avoid pressure to get an epidural, but I hesitated to ask the doctor, I guess in part because I was afraid of being laughed at or labeled as the crazy wannabe natural-birth hippie.

So I told my little sister and her doula friend this, how I liked the modern, high-tech obstetrician's office but was kind of intrigued by the idea of trying for a natural birth and was uncertain about how that might go down, there. The doula friend asked if I had ever considered going to a birth center instead of a hospital for the birth. I'd never heard of such a thing. She explained that birth centers were set up specifically for women who wanted a drug-free birth, and usually offered a much cosier and more home-like environment where you were taken care of by trained nurse-midwives instead of doctors, and would get much more personalized attention, too. There was often even a jacuzzi where you could hang out in soothing warm water during labor. And if you changed your mind or something went wrong and you needed or wanted an epidural after all, it was usually not a problem to transfer to a nearby hospital.

The more she told me about it, the more I liked the sound of that. I really dreaded the thought of going to a hospital, period. My dad is a doctor, too, and he would always say that a hospital is the last place you want to go, in general, if you can avoid it, because they are full of so many germs. I also liked the idea of going to a care provider who I could trust not to think secretly that I was nuts for even considering going without the epidural.

When we got back home to D.C., I started googling on the internet to see if there were any of those birth center thingies near where we lived. I found there was one in the District, one in Bethesda, and one in Alexandria as well. The DC Birth Center looked nice, but I wondered about its location, which was kind of in the 'hood. I used to live near there back in my single days, and wouldn't have minded going there for prenatal visits. I knew that my husband would nix the idea, though, because he'd recently gotten mugged at a gas station in Northeast D.C., and was still so traumatized by the experience that he wanted to stay as far away from any 'hood-like area as possible. The Alexandria one, Birthcare, was kind of far from us, while the Bethesda one, the Maternity Center, was within a half hour's drive.

At my next OB visit, which again went well, I finally screwed up my courage at end and told the doctor that someone had recommended the birth center idea to me, and asked if she could give me her honest opinion about it. I mainly wanted to hear if she thought it would be medically irresponsible to let women give birth outside of a hospital setting. Her response was measured. She said that it was kind of funny with these things, because in 95 percent of cases, giving birth is a pretty low-risk proposition. But it's just that last five percent where if something goes wrong, it can be extremely serious and life-threatening. It was that last five percent that really made it a concern. She said that if I was considering it, to be sure above all that I went someplace with a solid reputation. She said she had heard good things about the Maternity Center in Bethesda, but wasn't familiar with the other birth centers in the area.

At the time, the Maternity Center was holding periodic free information sessions in the evenings. My husband and I went to one and got the tour and saw that it really was a relatively homelike setting, and even did actually have a jacuzzi. We listened to a woman who had given birth there twice tell a long story about her two drug-free births at the birth center, which was pretty impressive. Most of the other couples at the information session were fairly crunchy or hip-looking, or had foreign accents. I could see myself giving birth there. My husband wasn't so sure, mainly, I think, because he was worried about it being too painful for me. But the more we thought and read about it, the more it seemed doable, and we finally decided to go ahead and transfer to the Maternity Center.

With only a few twinges of regret, as I entered my second trimester I cancelled all of my "VIP" appointments with the obstetricians and started going in for prenatal appointments with the certified nurse-midwives in Bethesda. Incidentally, I learned that certified nurse-midwives (CNMs) have a pretty rigorous education. They have to have a first degree in nursing, a master's degree in midwifery, and a long clinical training.

At the Maternity Center appointments, the visits were more leisurely, with unlimited time for questions. The clinic didn't have that high-tech, state-of-the-art feel--- some of their equipment seemed to be aging, and I wouldn't have gotten the early ultrasound with them---but there was no question that there was more personalized attention. I had to keep a journal of everything I ate for two weeks and then go over it with a CNM at one of my visits. She pursed her lips and tsk-tsked about how many carbs there were, and wondered aloud why I wasn't eating more meals like that beet and walnut salad with feta cheese ... At another appointment I complained of heartburn, and the CNM asked if I'd tried papya enzymes, a homeopathic remedy. (I had, and while they were really tasty, just like candy, they hadn't helped my heartburn at all.)

If the truth be told, I felt like I would rather have had my prenatal care at Reiter, Hill, and Johnson, but I still felt confident that when the time came to give birth, I was making the right decision by going with the birth center. Then, just as my second three months of pregnancy was coming to a close, the bomb dropped. We got a letter in the mail from the Maternity Center telling us that the birth center would be closing at the end of the month. While we could still give birth at Shady Grove Hospital with their CNMs attending, there would be no more births at the birth center itself.

I felt like I'd had the wind knocked out of me. Here I'd gone to all this trouble to switch health care providers, and now I was back to giving birth at the hospital---only with the midwives instead of the doctors (whom I had actually liked) and at a hospital that was farther away than we would have gone to otherwise. I called Birthcare, the Alexandria birth center, to put my name on their waiting list, but there was little hope of getting in, since they were already flooded with other patients from the Maternity Center.

It was at this point, as my husband and I were going over what our options were, that home birth started to look like a viable option along with the others we were considering. Birthcare offered both home births and birth center births attended by CNMs, and if I couldn't have a birth center birth, I realized I would be willing to take a home birth. It struck me that there wasn't really much difference between a birth center birth and a home birth attended by CNMs, besides where the mess and goo would be located. The equipment and training would be basically the same, and as we lived just five minutes away from Sibley hospital, an emergency hospital transfer could potential happen even more quickly than at the birth center.

My husband was very doubtful about the idea of having the baby in our home. At the time we were living in a one-bedroom condo. The walls were thin enough for us to hear our neighbors' salsa music, so we could pretty much bet on them hearing my labor screams. And while it was a fairly roomy one-bedroom condo, it still seemed like it could be a little small to accommodate a birth. But more than anything, he was worried about safety. What if something went wrong?

As discouraging as his resistance was, I figured there was no harm in looking into whether the home birth idea might be feasible and safe, since there was still always the default option of birthing with the Maternity Center midwives at Shady Grove. I started looking around for a home birth midwife. I googled on the internet. I wrote to the Midwives Alliance of North America and got a list of midwives in the area. I asked everyone I knew if they had any recommendations. I stalked the discussion boards on Mothering.com.

It was surprisingly difficult to find a home birth midwife. I heard that one of the Maternity Center CNMs, Joey Pascarella, was leaving to start her own home birth practice, and left several messages for her at the Maternity Center, but never heard back from her. The list from the Midwives Alliance of North America was hard to work with because I didn't know where to start. Most of the midwives on their list who were located nearby were not CNMs, but rather "Certified Professional Midwives" (CPMs) or "Direct Entry Midwives." I knew that these midwives' qualifications and background and training were somewhat different from those of CNMs. I really wanted to get a CNM, because it seemed to me that the nursing degree and clinical training were a relatively objective standard for determining who was really well-qualified to be delivering babies, and I felt I could put more trust in someone with a medical degree.

I found a few prospects that were about an hour's drive away, including a CPM who also had a nursing degree and tons of experience. But an hour was a long way to drive for prenatal appointments. My husband and I only had one car between us, and he needed it during the day to get to and from work. Both of us were working and fairly new at our jobs, so we wouldn't be able to take off a lot of time for the more frequent prenatal visits in the last trimester. It also wasn't clear whether we would be able to get any sort of insurance coverage for a home birth. I started to lose hope and tried to resign myself to a hospital birth.

In my spare time, I browsed web sites with women's birth stories on them. I probably read hundreds of birth stories, and was struck by the fact that the vast majority of hospital birth stories were negative. Probably 90 percent or more of them expressed disappointment, frustration, anger, and feelings of violation or betrayal regarding the way the women who wrote them were treated in the hospital. By contrast, the majority of the home birth stories were glowing and positive. The more I read, the more dissatisfied I felt with my lack my options.

I went in for my next appointment at the birth center, and to my surprise, the CNM I saw that day was Joey Pascarella ---the one I had heard was leaving to start her own home birth practice. I told her I had tried to contact her, and she said she had never gotten my messages. Possibly the Maternity Center was trying to keep patients from leaving and transferring to Joey, and so they never gave her the messages at all---I guess we'll never know.

But it was an enormous stroke of luck to meet Joey. She was about my age and really nice, and gave off an aura of competence. I asked her whether she might be willing to take me on as a patient and asked a lot of other questions about her experience and how a home birth would work with insurance and what the contingency plans would be if something went wrong. We exchanged contact information and after my appointment we started e-mailing.

One by one, my concerns were resolved. I learned that Joey had worked for five years as a labor and delivery nurse before going to midwifery school and had attended over a thousand births before even starting her midwifery training. She sent me links to safety data on home birth and information about contingency procedures, which I showed to my husband and which lessened his worries.

We switched insurance plans so that we would get out-of-network coverage of the home birth. I think in the end our out-of-pocket costs for the birth and all of the prenatal and postpartum visits together ended up being less than $2,000, even with the $600 birth assistant fee. That was probably less than a lot of people end up paying who have in-network coverage but have to pay a percentage of the hospital costs.

Joey was also willing to do the prenatal visits in our condo outside of business hours, so not only did I not have to miss work, but my husband was also able to be there for most of the remaining visits and get all his questions answered and his concerns addressed at each one.

So for the last trimester of my pregnancy, we had in-home prenatal visits with Joey. I can't imagine a better way to have done it. I love to cook and have friends over for dinner, and I'm also one of those people who has to feed everyone who sets foot in my home, so I invited Joey to eat with us whenever she was there around a mealtime. How many people are lucky enough literally to break bread with the person who will deliver their baby? How many people actually get to know their OB like that? Joey in her turn occasionally brought us wonderful just-picked vegetables from her garden. And when I kept complaining about heartburn, she brought me a home-mixed medicinal herbal tea with dried camomile from her own garden, too.

Another one of the neat things about Joey's visits was how she was always able to tell how the baby was positioned by palpating my abdomen. She would take my measurements and then press down in different spots to see where the baby was lying. Then she would put the monitor on the exact right spot to pick up the baby's heartbeat. I have never heard of OBs doing that at prenatal visits---I don't know if they even learn to determine fetal positioning by palpating. It's definitely a real skill, because even with all the kicks and backflips the baby was doing inside of me, I couldn't have told you where her head was or which way her back was facing if my life depended on it.

Joey gave us a list of items to keep on hand in the house in preparation for the birth. It was quite an interesting list, ranging from mundane things like laundry baskets and trash bags to hydrogen peroxide and raw honey. We paid about $50 as well to order a birth kit online.

Around the same time as we started working with Joey, it was also time to start our childbirth education classes. I had decided I wanted to try the Bradley method, because with 12 weeks of classes, it seemed like it would be really in-depth. If I was going to try for a natural birth, I figured I couldn't be too prepared. I also liked how it sounded like the Bradley philosophy was to accept that birth would be painful and to try to find ways of coping with the pain, rather than relying on what I saw as hocus-pocus methods to make the pain go away, like self-hypnosis. So we signed up for a class. It was expensive at $350, on top of what we were paying out of pocket for the birth and the kit, and the classes were three hours long.

At our first class, our instructor, who also worked as a birth assistant, opened up her purse and pulled out a placenta. Yes, a real, live, genuine, in-the-flesh, bloody placenta. In a plastic Ziplock baggie. She had brought it from a birth she had just assisted with. She laid it out on a Chux pad on the floor and proceeded to unravel the umbilical cord like a garden hose and show us what a healthy placenta looked like. It was kind of hilarious, because my husband had been very pissed off about being railroaded into signing up for a three-hour twelve-week-long class where he was sure he was going to be forced humiliatingly to hyperventilate with me and say mushy supportive things in public. He showed up late to the class, missing the introductions, but right in time for the placenta.

Unfortunately, the Bradley classes were not very helpful, and we dropped out a few classes before the end. Although the other couples in our class were extremely cool people, our instructor was not so great. Most of the classes consisted of her going around the room asking for our stories and thoughts on various things, and then telling us scary stories about how terrible it could be giving birth in the hospital and all the things that could go wrong with birth generally. There were also endlessly repetitive lectures about how bad all the hospital drugs were. She was clearly preaching to the choir, as surely not one of us there would have paid $350 for that class had we not already felt convinced that we wanted a natural birth. We also watched gut-wrenching videos of partially naked women with ginormous boobs howling and moaning and sweating and writhing around in pain, and then getting into tubs and pushing out babies. At one point I even cried.

It wasn't all bad, though. One of the other couples in the class ended up deciding they wanted a home birth and transferring to Joey just like we had done. I also borrowed and read Henci Goerr's book The Thinking Woman's Guide to a Better Birth, which I highly recommend to anyone who is a thinking woman and is going to give birth, or is even just interested in the topic.

Time passed, and I got bigger. And bigger. And bigger. I had heartburn so bad that all I could eat was buttered noodles and plain rice. I got all excited when I discovered Zantac, and subsequently managed to eat a turkey sandwich with mustard one day. I started my maternity leave two weeks before my due date. My husband and I were hoping against hope that our daughter would come early, because we had an appointment scheduled with US Citizenship and Immigration Services (USCIS) for my husband to get his green card (he's Canadian) just a week or so after the baby's due date. There had already been a mix-up with USCIS where they had scheduled an earlier appointment for us and then told us it was cancelled, and then told us that our case was closed because we hadn't shown up to the (cancelled) appointment, and then told us that my husband was being kicked out of the country. So we really didn't want to miss this green card appointment.

However, my due date came and went. And then another day. And then another day, and I could not believe I was still pregnant. I was using evening primrose oil and unripe papaya and we were going for long walks around the neighborhood every night in hopes of getting labor started. Practically the only things we didn't try were eating spicy food (because of my heartburn) and castor oil (because I wasn't interested in vomiting and diarrhea). Unfortunately, our daughter was a little procrastinator (... um, totally unlike her mother ... yeah, that's right ...) and kept us on the edge of our seats right up until the last minute ...

Read the next installment ... Story of a Home Birth Part II: How Our Home Birth Went.