Tuesday, December 9, 2008

We visited the local hospital and had an OB consult...
We got our 'Go- Ahead' for the home birth!
I plan to have my baby right here!
I am planning a home birth in Sweden, but first had to get an "OK" or consult with a local OB due to having had a c-section before. Swedes usually do VBACS (normal birth after c-sections) but not home birth, and not VBACS at home. So this Tuesday, we went and had our meeting with an OB to get 'permission' for our plan, and it looks like we got an 'all clear'. He really said something along the lines of there are risks, not ones I would personally want to take at home, but you can do what you want as you clearly know what you are doing. His little talk was good enough for me, and good enough to give the midwife the 'permission' she needed to attend me, so we are all clear! I brought along the informed consent I used with my clients in the US that had all the studies and numbers about VBAC risks. For me the bottom line is there is a 0.8-0.2% chance of there being a problem with a VBAC, which is a 99.2%- 99.8% chance of there not being a problem. I mean really, people, how much more can you hope for? In the National Birth Center Study, the chance of there being a problem with the baby that was related to the previous c-section was as likely as the placenta tearing off in labor in a woman with no risk factors- o.2%. Neither of those things are very likely to happen, and if I can have a random bad thing happen I have no risk factors for, like a placental abruption, why worry much about the risks from having had the c-section? I think 0.2% chance of a problem is a totally acceptable risk range for me, given the benefits of a home birth- the relaxation, comfort, peace and empowerment of being at home add a degree of safety and reassurance that I can not put a number on.
Laboring at home while giving birth to my daughter in 2005
It was a huge relief to get that out of the way, and to just settle into the idea we will have nice birth at home. I had done a consult to get an OK for a home birth in Florida already, so it felt a bit redundant to discuss it again. I did home VBACs as a midwife in Florida, and am not worried from a well-being stand point. But there are always politics with birth, and I was concerned I would not be able to find a local midwife to attend me. Now, I am imagining laboring in a water tub set up in front of the nice wood stove....
Doesn't this look cozier than any hospital?
In the US, I was a midwife who attended births at home and in a free standing birth center. I am not working right now and will have a number of hoops to go through, not the least of which is learning Swedish, before I can work here as a midwife. I can do other things I used to do- teach childbirth education, water prenatal classes, baby massage classes, do doula work etc. if I get restless. However with a new country to get used to, a new culture, a new life -not to mention being happy to be off work after being on call for over ten years straight while starting and running a birthing center- I am not all that anxious to get my work life figured out just now, especially with a new baby on the way.
Me at the free standing Birth Center I started in the USA
My first experience of the Swedish Maternity system will be as a patient! This is kinda of cool, it's like being an anthropologist studying the culture from the inside. In my last last pregnancy, I had friends care for me, and there were some definite pitfalls to that. Since I know almost every home birth midwife in Florida, it would be hard for me to do otherwise. It is nice to be here and be cared for by random and competent professionals.
My husband in the birth room at the Swedish hospital

This hospital has a 14% c-section rate. The hospital in my Florida hometown has a 39% c-section rate.

Sweden is known for it's great outcomes in birth, for both the mother and baby. The US, by contrast, ranks about 27th internationally for baby outcomes- as in more babies die in the US in birth that in most other western countries- and 42nd in the world for mothers. Yes, more mothers die in birth in the US than in about every western country but Lativia. Let me just say it was pretty discouraging to work as a midwife in the US, because there is no debate on what is the safest thing to do in birth, it is just that it is not done. Private medical practices that are too busy lead to too many inductions, c-sections, and over managed births that result in complications for all involved. This results in the worst outcomes in the world. In Sweden, they know do what is best for birth- leave women alone, intervene only when needed. And have a midwife tend to them individually through out labor. And this results in the best outcomes in the world. I will get into this again, I am sure, it is my life and soap box, but for now, let's just say this is a really, really good place to have a baby.
The Chart of Births for 2008 in the Hallway at the Hospital
First off, care is paid for. There will be no hassling with Blue Cross Blue Shield about who is in and out of network, using special labs or services for lower co-pays. I just call the clinic, and give them the personnummer (which is the Swedish equivalent of a social security number) and I was seen the next day.
I go to a clinic one village over, where there are two midwives that work full time as prenatal care givers. They do nothing else. This is typical in the Swedish system that the midwife will either works in prenatal care or birth, not in both. This means there is no continuity of care, in that who you see for your prenatals is different than who will be there for the birth. But they are all good, so it kinda of does not matter as much as in the US where care givers may have wildly different approaches and practices.
Old Birth Instruments in a display case in the waiting area at the Swedish Hospital
My first prenatal was a very non-chalant affair. I first waited 15 minutes. While I was there a gaggle of teenagers walked in to get free condoms from the clinic. When the midwife saw me, she apologized profusely for making me wait so long. Knowing many women have to wait 2 hours to see an OB for each visit in the US, this was amusing. We went to her office and she asked me questions to fill in my chart, just basic medical history stuff. Then she took my blood pressure while I sat in the office chair, and took me to a room for a blood sample, and I left pee in a cup when I took a restroom break. I then went to another room and she used the pinard horn (a wooden horn) to listen to the heart beat. She did not measure my belly, or do a pelvic exam. I was given a folder and a book, and scheduled for an appointment one month later, when I would do the 28 week glucose test. Pretty simple. Though I did notice that on the cover of the folder I was given there is a pregnant woman's torso and a child listening to a baby heart beat with a pinard horn. Two things struck me- first , Americans rarely use pinards horns (they use doppler with radiation), and second, the photo of pregnant woman had both some nipple and pubic hair showing. Those would have been edited off any photo in American mainstream health care for sure!

I was also scheduled for childbirth classes (in English) that will be offered in January. I am taking the classes in hopes of learning more about the maternity system here, as well as possibly meeting other English speaking couples with new babies. The surprise was that all childbirth classes are during the day. Mine are at 9 am on Friday mornings! Because midwives don't want to work at night for classes, right? This was funny, since all American childbirth classes are at night, to accommodate working parents. Here, you generally get pay if you take time off work for family stuff, so its no big deal to offer them in the day I guess.
Birth Art in The display Case at the Swedish Hospital

If I was like most normal people here, and I would just keep going to the clinic, take my classes, and when I was in labor I would go to the hospital and who ever was on call would take care of me. But I am not normal, so I am choosing a home birth! But for the average person who goes for the hospital birth, there would be one midwife assigned to them on arrival at the hospital, a second or third if she labored through multiple shifts. The midwife would be the primary care giver for labor and birth. There would be no labor and delivery nurse (taking care of 6 people at once) trying to monitor the baby and report to a doctor who was off site at his office doing clinic or at home in bed...I think this may be one of the big keys to the success of the Swedish system- it is safer when the same person who collects information - who knows how mom is, how is labor going, how is the baby- is the same person who makes decisions about the pair. In the US, I think both doctors and nurses are in a bad situation, since the nurses collect the information but have no power to decide what to do with it, and doctors decide what to do but are not with the patient to know what is really going on. It creates a situation where everyone ends up thinking the best thing is to just do something, just in case, since they are out of touch with what is really happening (or needs to) for the patient. The Swedish midwives do as I did at my birth center, and attend a mother for all of labor and birth. The Swedes have water tubs for labor in the rooms, and use water for labor, but there is a national policy against water birth. This is one of my reasons for having a home birth here- I really like using water for labor and want to birth in it if I feel like it, which I can only do if I go outside of the system.

In the hospitals, you can get epidurals, but most women do not. At my hospital in Florida, there was a 90% epidural rate. Women are often signed up for them at their first prenatal visit!!! In the US, epidurals are pushed because 1) A hospital needs to do enough of them to pay the anesthesiologist on staff and keep him busy 2) If you are under staffed, it is far easier for one nurse to monitor six numb and bed ridden patients with belt that's printing out the status report at the nurses station than monitoring six women who are moaning, groaning, and walking the halls and getting in and out of bathtubs 3) Women in Sweden are met with reassurance and guidance when they feel afraid in birth, instead of offered medicine 4) Swedes use nitrous oxide/ laughing gas (yes, whippets!) as the most common pain relief for labor. After giving birth, women can stay anywhere from a few hours to week, depending on their preference. There is a patient hotel where they can stay postpartum and get served food, and get breast feeding help, for about as long as they choose.

Painting in the waiting area at the Swedish Hospital

I am the type that would want to go home as as quick as I was allowed, so I will just plan to stay home for the whole birth! I guess I will miss out on the gas/whippets for labor. In the UK, home birth is part of the official national health system and the midwives do carry gas with them.Here, home birth is not very common. As far as I can tell there were only about 100 home births in all of Sweden last year. In the Stockholm area, you can have a home birth as part of the standard care, but it is a fairly new choice. Home birth was phased out sometime ago in Sweden and is considered very fringey. The criteria for home birth is very selective in Stockholm- only women who have had previously had a vaginal birth are eligible. And so of course no home birth after a previous Cesarean. The strict risk screening, like the water birth policy, is actually pretty Swedish. I find Swedes to be a bit over cautious in many ways. There is a big push for evidenced based medicine here, but it is not with out biases against things that are new and different to them. Alternative medicine is integrated into the system in many ways- like you can get acute acupuncture for birth issues, dentistry, or back pain, but systemic treatment and healing from acupuncture is uncommon.

I would be disqualified from home birth in Stockholm, the one place there is an official Swedish home birth policy, due to the previous c-section. So it is a blessing and curse that home birth is not officially part of the health care system in my region. On one hand, I have to pay out of pocket for my midwife to come to the birth, but on the other hand, home birth is still an option for us.

I arranged for a home birth by contacting a home birth midwife I found from the the Fodda Hemma website. We set up a time to meet, and after talking sometime she determined that with my history of c-section, I would need an OB consult for her to feel comfortable attending me. So that is what we did this week.

We are hiring her only for the birth. She works at the hospital, and only attends births, and does not do prenatal care, as per the normal version of maternity care in Sweden. She does home births as a side business. She does not do prenatal care, even for the homebirthers. Hommebirthers go through the regular village clinic for prenatal care like everyone else. When I was a midwife, I always did the whole person's care- prenatal, birth, and follow up. For many years, I also taught water prenatal exercises classes and childbirth classes. The advantage of that is it gave me many times to meet the woman and her partner, and really build a relationship. I will have one home visit by the midwife and her midwifery partner before the birth. We set it up for 36 weeks, since that is when I did home visits for people. I am a bit discouraged that I will not have more chances to get to know her better, feel out her style, as well as for her to get to know me. But if I was going to a Swedish hospital, I would not know the midwife at all until I got there. She said I can call and email her, so I am sure I will to check on her style and approach to specific things and well as let her know my preferences on things before hand. But she has been doing births for 30 years, really believes in natural births, and has a passion and love of home birth. She got turned on to home birth after reading Ina May Gaskins, and had a home birth herself. She seemed sweet, capable, level headed, and had little turquoise earrings, which made me feel she had a bit of a bohemian edge in her.... I like that I will have someone from a good system, but willing to come meet me with in my own environment. And should we need to transfer for birth, she can still care for me at the hospital.

So we are on our way, we are planning our homebirth!


Kangaroo said...

YAYAYAYAY!!!!!!!!!!!!!! I cannot BELIEVE you are 28 weeks. Tonya, Liz and I were all flabbergasted by how fast an ocean apart can make a typical human gestation. You know our ju-ju knows no geography, though...

Johan Z said...

Swedish Surgeons will only use the finest quality steel drills when it comes to drill holes in your head to let the demon sout... ;-)

Anonymous said...

Hi Swedee. I'm a friend of Jennie O-now-T. She forwarded me your blog and it's very inspiring. I wanted to ask you a couple questions--you, being the experienced natural birther and midwifer! First one: What are your top three recommended prenatal vitamins? I'm currently taking New Chapter Organics Perfect Prenatal...but I don't do well with soy.