Dr Abby Dennis, OB-GYN, Ray Rachlin, CPM of Refuge Midwifery, & Maggie Runyon, RNC-OB come together to explore the realities of transferring from a planned homebirth to the hosital.
Hospital transfers are at times a necessary and expected part of thriving homebirth care models. Recognizing this and the unpredictability of birth that will sometimes necessitate a change in plans can prepare us to view a homebirth transfer as a variation of normal rather than a fraught situation to be avoided at all costs.
Our biases around homebirth transfers to hospital are often reinforced by negative experiences. Many hospital-based birth professionals are only familiar with homebirth in the context of when things go awry and a transfer is needed, which reinforces a belief that homebirth is unsafe and needlessly risky. Similarly, when community midwives & birthworkers do not have relationships with hospital-based providers outside of the transfer environment there is limited time to establish shared beliefs.
Join Abby, Ray, & Maggie this week as we explore:
~When & how to transfer to preserve vaginal birth
~Routine vs emergent transfers
~Adversarial relationships between homebirth & hospital providers
~System challenges in the US that preclude collaborative relationships
~Establishing mutual trust & respect to avoid care delays
~Promoting physical, mental, & emotional safety during a transfer
Dr Abby Dennis, OB-GYN, Ray Rachlin, CPM of Refuge Midwifery, & Maggie Runyon, RNC-OB come together to explore the realities of transferring from a planned homebirth to the hosital.
Hospital transfers are at times a necessary and expected part of thriving homebirth care models. Recognizing this and the unpredictability of birth that will sometimes necessitate a change in plans can prepare us to view a homebirth transfer as a variation of normal rather than a fraught situation to be avoided at all costs.
Our biases around homebirth transfers to hospital are often reinforced by negative experiences. Many hospital-based birth professionals are only familiar with homebirth in the context of when things go awry and a transfer is needed, which reinforces a belief that homebirth is unsafe and needlessly risky. Similarly, when community midwives & birthworkers do not have relationships with hospital-based providers outside of the transfer environment there is limited time to establish shared beliefs.
Join Abby, Ray, & Maggie this week as we explore:
~When & how to transfer to preserve vaginal birth
~Routine vs emergent transfers
~Adversarial relationships between homebirth & hospital providers
~System challenges in the US that preclude collaborative relationships
~Establishing mutual trust & respect to avoid care delays
~Promoting physical, mental, & emotional safety during a transfer
Maggie, RNC-OB 0:06
Welcome to Your BIRTH Partners, where our mission is to cultivate inclusive collaborative birthcare communities rooted in autonomy, respect and equity. I'm your host, Maggie Runyon, labor and birth nurse, educator and advocate. And I invite you to join us in conversation as we step out of our silos, break down barriers and hierarchies and step into the future of better birth care.
In this week's episode, we'll be talking about navigating the transfers from a planned home birth to the hospital setting in a number of different contexts. I think this is one of those topics that certainly, like all the ones we've been highlighting the season, really draws us to question what we believe about birth and risk and safety, and evaluating our role within birth. My hope in creating this podcast last year was to draw diverse perspectives together, and to get a chance to talk with people who don't agree with each other, to get outside of the echo chamber, to question and explore what we've learned and why we learned it that way, and what we continue to believe and how that impacts our practice. And this topic is really one that's near and dear to my heart. As a labor and birth nurse, I've had the opportunity to support birth, in hospitals and at home. And I've always found myself kind of toeing the line between where I fall within these communities. Personally, I also had a baby at a hospital and I've had a baby at home. And so when I think about care transferring and how we do that, well, I think back to when I was having my home birth. Ultimately, everything went well, and I ended up having my baby at home. But there was a time when due to my baby's position pushing was just taking much longer than I anticipated and was much more difficult than I was expecting. And in the back of my mind, I kept thinking, Okay, well, if we need to leave home, if we need to transfer, what would that look like? What would that mean? What other services can I get from a hospital that I can't get here to help with it. And in the midst of kind of weighing options and thinking about what's available, I was cognitive, just how emotionally challenging the decision and process of transferring is. And I say this as someone who lives five minutes away from the hospital, and it's a hospital where I work at, where I have wonderful co workers who care about me and my baby's well being and who, you know, would receive us with open arms. I think about how much more challenging considering a transfer is, if you're finding yourself in a community that doesn't have good relationships between home birth and hospital providers. And a place where the person who's having a baby is also trying to weigh if they're gonna be received kindly and treated well by the hospital staff if they choose to transfer prob with hospital. Because the other side, I've also been in the hospital as a nurse, when we're receiving a transfer of a client from home who you don't know anything about. And you're concerned to see what situation is about to walk through the door, and you're worried that you might not be able to support them, or maybe an emergent situation. And there's a tension and stress that comes from that. And in experiencing some of the sides of this conversation, I'm just reminded of the complexities of birth, and my desire constantly to remember the human element of it and of us. I'm really grateful to have two people join this conversation whose practices I respect immensely, even though we all practice in different ways. Those who've been listening the podcast for a while, are both familiar with midwife Ray Rachlin and Dr. Abby Dennis, who's an OB GYN. And so as we share this conversation between the three of us, I hope we're able to highlight some of the challenges that we face on all sides of this discussion. And as we navigate the parts where there are issues, where we don't necessarily agree on a solution, I hope we're able to open up this dialogue and continue with you all so we can find better ways to function as a system and to support each other and provide better birth care onto the show.
So this week, we want to talk a little bit about the home birth to hospital transfer process and, you know, ways that that can go well, challenges that can come up during that and, and really speak to how can we both as you know, as birth workers and providers working in and out of the hospital system? How can we make that a just a smoother process as it possible? How can we minimize trauma? How can we help people to still have birth experiences that you know, match up as closely as we can to, you know, their values and their goals for birth? So, I am really excited to dive into this all. Ray and Abby if you want to just maybe introduce yourself to our listeners just remind everyone who you are and kind of your positionality within birth.
Abby, MD 4:29
Ray, wanna go first?
Ray, CPM 4:32
Sure Ray Rachlin, she they I'm a certified professional midwife doing home birth, midwifery care, in like the greater Philly area and South Jersey also do home IUI and Fertility Care, as well. And I guess I've now been doing home birth. I'll be a midwife for like five years next month.
Maggie, RNC-OB 4:50
That's so exciting.
Abby, MD 4:51
Yeah. I'm Abby Dennis. I am an OB GYN practicing in Baltimore, Maryland. I'm board certified in family medicine and OB GYN and practiced in a lot of different settings and formed some strong opinions over my years of practice. Period.
Maggie, RNC-OB 5:06
Haven't we all? [laughter] Maybe we can just kind of start a conversation by kind of framing the fact that you we do anticipate that there are planned home births that will end up in the hospital for a myriad of reasons. And if we could just start by kind of covering that piece of it, because I think often we picture that any transfer to the hospital from a planned home birth is like an emergency and that there's going to be a poor outcome. And that's, that's just not the case. So I don't know if Ray if he would start with that?
Ray, CPM 5:36
Sure, I can start I have a transfer conversation with a lot all my clients and many, many times, and, you know, the vast majority of homebirth transfer, I would say at least over 90% in my practice are for a long labor, you know, the most common reason to go to the hospital from a home birth is a first baby that's maybe in a funky position, or it's just taking forever. And you just like run out of tools at home, the parent has run out of steam, the contractions have run out of steam and like either a nap or like more, more oomp with contractions with pitocin is just like the next best step to make a vaginal birth happen. And you know, those transfers are not emergent. It's usually a decision that's like made over many hours and is a car ride and a call to the hospital and faxing over records and usually like kind of a stressful hour or two before someone gets an epidural. And if they're super tired, that's like very welcomed intervention and then a lot more waiting, you know, and then managing like a fatigue labor and there's definitely an art to transferring the like transferring for long labor as well that can preserve a vaginal birth that if you go too late, it's less likely to so there was kind of an art of like trying to figure out how to transfer early enough that you can typically preserve that option, but and not tire the person out as much. And then you know other homebirth transfers like people tend to risk out of home birth care at the end. So I think sometimes birth that are more likely to have emergencies like people risk out for blood pressure stuff, or malposition babies. So we tend to have like less emergencies associated with like abruption, because we don't have risk factors for abruption at home, those people have already been risked out of home birth. But you know, the other 10% of homebirth transfers are for medical indications, you know, and statistically about 1% are urgent medical indications. But you know, things like this person is developing a temperature, you know, an infection is not for home birth, or water breaks, and there's a lot of meconium getting a few high blood pressures, excessive bleeding, and you're just, yeah, this is like not a good medical picture for home. Or we're hearing things on the baby's heart rate that we can't correct whether it's, we have kind of like heart tone criteria at home. So like what level of variable decelerations we can tolerate and what we don't. And then if we ever hear late decelerations, and can't correct it within 10 minutes, you know, we go in, you know, typically when emergency transfers happen, it's for heart tones, which also could be associated with bleeding. And then emergency transfer always happens by ambulance, because we want access to surgery, or just like we need to not be home now. And that's a more stressful process where, you know, midwife calls 911. And we also call the closest hospital, let them know we're coming. I have electronic health records, I can like fax records from my phone, like while I'm in an ambulance. And then we're transitioning really quickly and in a way that I think can sometimes be scary for hospital providers that don't know us to suddenly like feel like they're getting something that's scary that they don't, they couldn't, didn't predict.
Abby, MD 8:29
That's interesting listening to those numbers because I feel like on the hospital side of things, we remember the transfers that haven't gone well, or the transfers where, in a short period of time, we've been really unable to establish trust with a patient and then an outcome that hasn't been ideal has been blamed on us as sort of the end of the line care involved. It's interesting to think about like one, you know, 1% being an emergent transfer, because certainly if you asked me those numbers, and I don't know those numbers, I would have guessed very different numbers in terms of what I've seen in the hospital side of practice. I have thought a lot about transfer of care. It's interesting, you have electronic medical records on your phone, like you're calling people on the way to the hospital. That's amazing, right. And I feel like that's much more consistent with, you know, a model of care that is European or elsewhere, not in the US. I think one of the issues, there are a lot of issues around home birth transfers, but I think one of the things that I think a lot about is is why that whole process is so broken in the United States specifically where there aren't always good relationships and those adversarial relationships have led to some really bad outcomes. And I always come to women's health care from a point of autonomy if somebody is well educated and they make the best decision for themselves and their body. That's the right decision. I should be clear in this conversation that I mean, I remember sitting with Maggie several years ago and talking about her plans for her birth and homebirth. It's probably important for me to state my bias that I can't imagine ever, ever choosing and out of hospital birth just because of what I've seen over the years, and I was also older when I had my kids and I had complications. But in the past couple years, a couple people who are really close to me chosen home birth, which very much has as just caused me to dig a little deeper and think about what we need to be doing differently, both in terms of home to hospital transfer. And in terms of just the hospital care we provide, that we're not driving people away so much.
Ray, CPM 10:32
Yeah, I think you just mentioned like the kind of key thing, which is like the integration or like lack of integration and hostility, because I think for me, you know, like, in other countries, the date, like other similar countries, the data is really clear on safety in the US, it's really unclear. And it seems like, the thing that causes worse outcomes for babies is the lack of integration, and then hostility, and then the clinical decisions people make on both sides of that, because of the lack of trust. And so for me, as a home birth midwife, I see it as like my responsibility that like I must build relationships of trust with hospital based providers, and I must transfer well, in order to be able to do my job, you know, like, if I don't feel confident in my ability to transfer, well, I shouldn't be doing that birth at home, and not that I will be received well, in every setting, like I have, you know, a primary hospital, I do backup care with which like, I know, all the midwives that can like really facilitate like, great relationships and transfers, and like, not all the, you know, obese or residents are on board with that. But I have like advocacy from the midwives that like really helps have smooth experiences. But I said, for wide radius, I can always go to that hospital, you know, and so that I have to, like, interact with all these other health systems that like, you know, have only maybe experienced like one or two homers, and they like went badly because, you know, like, I know, if I go an hour north of the city, like I'm pretty scared to transfer, I've had very bad experiences. And I'm still gonna do all those things where I'm like, I'm gonna practice like I am, you know, a legal fully integrated, perfect part of this healthcare system, and just expect the same thing. And if I like, you know, treat myself as a fully integrated part, and I'm like, asking you to also be this fully integrated part with me like, and do this as a partnership, like, maybe I'm gonna get better results. And sometimes I do, and a lot of times the most confusion and hostility, but I'm still gonna keep trying, but also like, the more negative experiences you have over the years, like maybe the way it like changes your decision making too.
Maggie, RNC-OB 12:16
yeah, there's so much to unpack there, I appreciate both of you, just the transparency, that you're speaking to your experiences, because I think there's often this perception that like people on either side, out of hospital based providers in hospital based ones, like they're just they're deeply entrenched in this and that there's no way to like, possibly move towards, or forge your bridge across. And like you said, certainly, there are some people out there who there are some out of hospital, you know, midwives who have absolutely no interest in ever interacting with the medical industrial complex at all. And there are absolutely some ob gyn who are not ever going to be welcoming or looking to integrate with community based midwives. But outside of that, I think there is an opportunity, there is a place to continue to forge those relationships. And you know, like, both of you are saying, you know, Ray, you just, you keep trying, you keep showing up as like, yep, here I am. I am trying to maintain safety, by being professional by sending these records right over by calling to let you know, coming by showing up with my, you know, with my client and keeping everything kind of in this like aboveboard feeling. And, you know, to your point to Abby, it's I think it is hard when so much of your experience has been in hospital settings where we have just higher risk, you know, patient populations, and that there are just these, a lot of these other things that can go awry, if a lot of your experience is in that it is hard to consider homebirth as a safe option, have always been in like a high risk kind of place. And you're used to seeing a lot of complications that do happen, because not every pregnancy does go smoothly. There are plenty of things that can happen in birth, if so much of your experience is that it's really hard to make like a mental shift to ever feel comfortable with, you know, out of hospital birth. And if you if you hold on to that piece of it too tightly. Each time that you meet someone who's playing at home birth, each time you meet with a provider who practices outside the hospital, you just immediately have this little bit of a wall up, because it doesn't feel safe to you. But there is a reason that we have homebirth midwives there's a reason that Ray you chose to practice in that environment like that aligned with how you want to provide care to birthing people. In the same way Abby, like you have chosen to practice in a bunch of different you know environments, but in environments that allow you to kind of work your muscles that you enjoy in handling complex situations. In dealing with high risk pregnancies on helping people to safely get through those situations when that's how their birth is unfolding. And I just feel like obviously, because I admire and respect to both of you so much I feel like there is, there's way more ways to try to help, like, bring that together. And like you said, there are so many model of collaborative care between midwifery and OB GYN around the world that works so much better than what we have here. And it's really easy, I think, to get like deeply entrenched in kind of either side of the coin here and feel like there's no, there's no way through. If either of you, both of you, maybe we can speak two ways when you've had that good collaborative relationship and a little bit more deeply about, like what that looks like.
Abby, MD 15:43
I had a really beautiful, my last job before my current job was as a hospitalist. So I was really just working in the capacity of supporting both midwives and obstetricians on labor and delivery. And it's interesting right around the time that one of my closest friends really opened my eyes and, and really made me think about home birth in a new way, because that was her choice. I was contacted by a local home birth provider who contacted me and basically said, you know, they had somebody who as breech, persistent breech presentation, first baby. And this is somebody who, you know, called me was so just her presentation of the patient and the case her knowledge of the patient, her knowledge of outcomes when you attempt to Singleton breech delivery in a home environment. She knew her stuff. And she was really thinking about her patient in such a wonderful way. And also was really committed to her patients sort of psychosocial situation, and the fact that she was terrified about a hospital situation than a hospital birth, in that case turned into an unfortunately unsuccessful attempt at version. And you know, one of the first, really truly like family centered or gentle c sections, whatever you call it that I did in hospital setting, we're now pretty much doing those universally. But I do remember walking away from that birth, just thinking, gosh, if we had this kind of communication and respect all the time, this could work really well, this could work like it does in Europe and other places where we're able to overcome that competition or negativity, or I think that a lot of the homebirth movement is driven by the way that women have been treated in hospital settings, particularly like in the 1940s, through 60s, when suddenly obstetrics became, you know, a very, unfortunately male driven but also a very interventional field, like it went from birthing came into the hospital and then suddenly became very much a medical procedure. And that culture in that dogma have really driven a lot of sort of the things that have come sense, even when I think there are a lot of us in hospital settings, who are very committed to actually delivering babies in a way that's still patient centered and respectful and beautiful.
Ray, CPM 18:08
Yeah, I really like the story you just shared, where it's just like if we could both like, hear and see each other and respect, like, patient autonomy and like, do things collaboratively. Like I've been in those care situations, and it feels wonderful to like be able to extend like, the hand of like home birth and referee and also, like, provide kind of like this, like all around safety, like I think about a few years ago, I had a client so the midwife that I use primarily as backup, I used to be at a different hospital and I had a client who had a previa, and you know, and I was doing co care with the midwives were doing follow up ultrasounds, you know, it, like became apparent that we were going to have to, like do a C section, like the previa wasn't going to move. And you know, like, I was able to schedule my clients c section and the midwives arranged for me to like, be in the C section with them and like, and kind of like checked on my client cuz they, you know, the baby went up at the NICU and just like, it was a really like, it was a challenging experience, right client and also like, a really well supported one. And at the end, she was like, that could have been so much more traumatic, but it was like, yeah, you know, like, and it was just because, like, you know, I had relationships with the midwives who then like helped me build relationships with the OBS and the residents. And there was like, mutual trust that like I was a good care provider and also we were all like making good clinical decisions together. And there are places I think sometimes where like homebirth midwives like will push boundaries on like, you know, things like VBAC or you know, in some places breaches in twins or for other places where are like going past 42 weeks like these places that are more firm rules and hospitals that people wanting more autonomy sometimes seek out of hospital for, some midwives, some comfort level with and some don't. And I think there's like when there's trust, there's like the ability to push that and when there's not trust, it's like, a flat out like this is dangerous and wrong. And I know for me like a lot of a lot of homebirth is done by a Certified Professional Midwives. And we don't train in the medical system, we train outside of it. And I think one of the things I've really come across is that people within the system, like don't understand our skill level or our training. And so part of me being able to do collaborative care as me being able to build personal relationships where they like learn that I'm like, actually, like a competent care provider who like went to school and like draws labs and reads labs and like a lot of like real basics. And I do that by like, participating in the ACM chapter. And I do that by like, going to study groups that have doctors at them and just end by like reaching out to consult with small things. So they like understand that I'm like, trying to make appropriate clinical decisions and like seeking help when something's outside my scope, it still takes time. And there's also, you know, I think there sometimes is more trust with like the providers trained in the system as nurse midwives. But there's really significant barriers to nurse midwives being able to do home birth, like one of the main ones being their malpractice costs, and also like some of their licensure regulations, like there's only like one nurse midwife doing calmbirth. And like my city right now, and, you know, their malpractice cost is over $20,000 a year, which is like, could sometimes be like a third of a homebirth salary. And that's, you know, one of the reasons that, you know, like, this other model of care and this other kind of provider are the ones doing the majority of homework, there's just a lot of ways that like, the way the financial insurance system in our practices are set up that like, doesn't work for people within the system, and then plus making different choices around malpractice, or not actually having access to malpractice, then makes hospital or med OB's that are just like, What do you mean? Like, you don't have malpractice? And I'm like, "Yeah, I actually can't get malpractice, like doing homebirth in Philadelphia is considered uninsurable." And they're just the idea of like people practicing without that is like, so yeah, is really intense and like, like kind of unconceivable. In other countries, the system is better set up for home birth integration. And here, the way that obstetrics developed, and then the way the midwifery movements developed, and also, like home birth was kind of crushed and then had a resurgence and has really exacerbated the lack of integration. And like the system, I don't feel like the gulf has gotten any closer. I mean, there has been movements around like licensure. But I think a lot of the more recent licensure wins, like on the East Coast are like, don't actually help with integration.
Maggie, RNC-OB 22:13
That piece of it is so challenging. And I think, like you said that when we're not integrating like that, like it is directly at the safety issue, right, like it is, it's a safety issue. If one like midwives don't feel comfortable reaching out to talk about issues to see if something is going on to initiate a transfer, when, you know, it's appropriate, because they're worried that they're going to be sued for practicing midwifery if, you know, they're worried that they're going to be received poorly by the people that they are trying to consult and collaborate with. And I feel like this is like so many things. It's not. It's not that there's one right way, but I think there's, I think part of my issue, my question around all of this is, you know, my belief and again, as like, I'm a labor and birth nurse who's mostly practicing hospital, I've also supported home birth, I've had both births myself, like, I think there is a power imbalance at play between out of hospital providers and hospital providers that a lot of the power rests with hospital systems, you know, because that is this other level of care. And I think there is a piece of it that that means that those of us who are based in the hospital, like we need to create welcoming environments for whoever seeks care with us. So whether that is someone who is sitting here, they've been seeing this ob their entire lives, and now they're having a baby, and of course, they're going to have the baby at this hospital, or that someone's coming in at 40 weeks from their home birth, that for whatever reason, they now need to receive care at the hospital. I think within that there, there has to be an awareness for us as you know, hospital based birth workers that we that we just were focused on that care provision piece of it, like hospitals are supposed to be a place where people come and receive care. And I think there is a lot of fear that is created around transfers, you know, on both sides and and I think it's important to call out that like OBs are not the bad guys. They are not practicing just to try to ruin people's, you know, birth plans or go against people's wishes. And obviously, that doesn't speak for everyone. But I think there's a piece of it that when we talk about these conversations, there's always just this a ton of fear that goes into how people will be received when they go to the hospital, which is valid because like we said, we know, oftentimes there are issues that come up where people do not have good transfers, but I also think we need to hold the humanity of everyone who's involved in it, in recognizing that, like, obstetricians are also facing a kind of unique set of circumstances when they go to receive the home birth transfer. And I don't know if you know, you all can kind of speak to that piece of it. And that that dynamic there.
Abby, MD 25:20
I think, you know, it should be implicit in any patient provider relationship, that as a health care provider, I'm there to respect; accept, respect my patient without judgment, I need to meet them where they're at. And I need to provide the best compassionate and evidence based care, it's I can't, I see these home to hospital birth transfers is an area where providers I work with every day who I watched, and I watched them able to do that so beautifully, suddenly, that respect and sort of patient provider relationship really breaks down. And I've thought about a lot about you know why that is, and I'm not sure I will, I will say, and you touched on this as an OB practicing in this day and age where malpractice is a real fear, it is really scary for somebody to just be dropped off at the door of my hospital. You know, if somebody is coming from home to the hospital to have a birth, it's because things aren't going well, things aren't going right. Although it's interesting, because Ray touched on this earlier, actually, maybe maybe most of the time is just because labor is obstructed and not progressing the way it should and, and we do have time, but it's really hard to suddenly have a patient that you're meeting for the first time you're figuring out what's going on, and you're trying to figure out if it's a situation where things are happening really quickly, because in obstetrics things can turn and you know, although these situations are rare, there are situations where you do need to act really, really quickly. You're simultaneously building a relationship with a patient, you're simultaneously asking this patient to trust you and they don't know you, and they don't know what you're, you know, ideas are about their choices about their birth. And then I think for a lot of people you throw in that there's a lot of fear, I think I see providers in the hospital end of things feel very threatened by home birth, which is really silly, because it's fewer than 1% of births. And if done the right way home births should be for patients who are low risk, but I think that providers in the hospital side of things feel a little threatened and there is a judgement that happens, overt or not over when these patients hit the door, I think, you know, in the US where the system of homebirth to hospital transfer is disintegrated. You know that there's a two fold increased risk and perinatal death in patients delivering and home birth setting and risk of neurologic complications, I think is threefold. I mean that that data in this country does not mimic the data in Canada or in Europe, or in places where there's an integrated model of care transfer and where it's just more regulated in terms of providers and the patients are taking on and those kinds of things. So I think people in the hospital side know that and then they get angry at the patients, which has absolutely no, it only serves to hinder things even further. But I but I see this like anger coming from certain providers at patients that they would have, but they've chosen us, they would have made this decision that you know, potentially puts their baby at risk or at higher risk, we need to fix the system, we need to fix the way we communicate with one another. And we need to be able to drop that judgment at the door. Like when a patient hits the door, we need to be respectful and provide the best care for them and include their midwife in the process and include their partner in the process. And if we did that, I think a lot of these situations wouldn't seem so scary to us as providers.
Ray, CPM 28:46
Yeah, I definitely have a lot of sympathy for the feeling of like, you know, when I know when I've done emergency transfers in areas where I don't have relationships in the hospital, how scary it could be to have an unknown midwife. And then this like client that you don't know, and you're getting records, but it's still like a chaotic situation that you don't know how to integrate in and that like, leads to bias. And I also know that on the homebirth side of things, like the lack of integration sometimes causes midwives to make choices that, you know, to delay transfer, and that can lead to a worse experience for everyone. And it's really hard to build trust. And I think something like we've talked about is just that like, I mean, I guess for me like one of the main barriers to like, how do we get integration is just that like being a for profit medicine and that like the ways that like hospitals are set up around meeting the needs of insurance and malpractice in the wait like homebirth isn't like outside and I think sometimes it's like easier to like be mistrustful and and fight them. They kind of organize against the kind of common enemy that's making it harder to provide good care and every health care setting provided like more like if you have to do really high volumes and like you can't do more individualized care. And the things that people want from home birth that like they maybe are not the best candidates for and that like, there's so much room for things to improve and like have moments of it, but it's definitely not consistent. Also, I do want to push back on the data you mentioned, because that data comes from birth certificate data. And birth certificates are really unreliable because they, they don't include people who had midwives versus not having midwives. And then there's also the other places where like, the data about like home birth is very unsafe in the US comes from the wax meta analysis that didn't include the largest study on home birth. So I think like, the answer is yes, the data is still unclear. And also like, is there a two fold death rate?Like, I don't think so.
Abby, MD 30:38
Like there shouldn't be if we're doing things the right way.
Ray, CPM 30:40
Yeah. And I think like, I love the MANA stats data. It's imperfect too. But there was this like, really large study on home birth, and like 2014. That was like 14,000 home births. And it's just like, Yeah, when we have a single head down baby between 37 to 42 weeks without high blood pressure, gestational diabetes, like VBAC breach, we have equivalent co outcomes to the hospital. And when we start...
Abby, MD 31:03
You also have more parous patients, right and more patients who are committed to their health during pregnancy. So I think we do you can't do a randomized control trial, right? You can't do that. And we're never going to do that. So rather than and I actually had a day where I pulled all these papers, like, Yeah, all the data on homework, because I really wanted to figure it out. And every single day, every single study I pulled, has some margin of error, which which I think really boils down to the fact that homebirth is done in its best capacity, if the right patients are choosing homebirths. Like you said, like, term, healthy, uncomplicated births in patients who haven't sought that out for reasons of fear of hospital fear of medical, right. I'm sorry, go ahead.
Ray, CPM 31:58
No, no, you're right. Like, I think I think we had this like clear dataset of like, who were really good home birth candidates, and like, it's challenging, because sometimes people were scared at the end. And it can be like, really expensive change of plans, in addition to like, you know, emotionally challenging. And also, like, Why do people who have increased risk factors go out of hospital? Like, is there a place for more complicated shared decision making? And is there a place for more complicated shared decision making, you know, with the ability to have good backup, my comfort level is not other midwives comfort level? Like, I am very uncomfortable with twins at home... And also, like, why are people seeking that out? they're seeking that out, because they're having a really difficult time having a vaginal twin birth in the hospital.
Abby, MD 32:37
So that my favorite thing to do, by the way, no, like, as long as you don't take my twins, I'm fine. [laughter]
Ray, CPM 32:45
I would love to attend someone in the hospital, like as like yet, like, be like, I was like, did some prenatal care for you, and then like, got to witness your twin birth? Like, I never got trained in that, like, because, like, it's really risky for the second twin at home. And also, like, should people be able to, like, make that choice about their body and their babies and like, you know, be able to, like, have really complicated informed choice conversations, like, "Yes, I don't personally want to be their midwife." But like, I'm theoretically glad that there's someone who is willing to hold that for them. But it does make trust more complicated. And we do have the ability to do really good informed choice out of hospital because of the relationship in a way that, you know, also, like, you know, like, because we don't have malpractice, like, you get me you don't like that, like, you don't like the outcomes like you get my car, like, it's just can have like, an hour long conversation and talk about what that looks like. And like how people like hold the nuances and the unknowns of like, have a really good shared decision making. And also that doesn't necessarily mean will make us my clients and I will make a decision that a hospital system would agree with, and also like, I have limits too as a provider, and like, someone might want to make those decisions. And I'm like, I can't make that with you. Like, I'm not that midwife, and that's okay. It can it can feel bad to be like, sometimes the gatekeeper of home birth in that capacity, because there's Yeah, because there isn't as good integration, and it can feel like, yeah, like you're being dropped off somewhere that you didn't want to be dropped off, which is not true. It's like, the ability to transfer is essential to the safety and longevity upon birth. You know, like I need to be able to transfer well, like, I, my practice is like had between a 10 to 12% c section rate since I started and I'm like, that is a good c section rate. That means I'm transferring appropriately that is like along the line, what's World Health Organization. I think people have a really low transfer rate, like for me, like gives me pause, because I'm like, why aren't you transferring more like, just statistically, like, 10 to 15% is like, where we see like the best outcomes, you know, worldwide. So like, that's what we should be aiming for, you know, and that's what we should be aiming for together. And it's not a battle like we, you know, like homebirth midwives need OBs, we need c sections to be able to do our job safely. But the mistrust and the money just like keeps, keeps us from forming this relationship that like allows us to provide good care for everyone and also like, have smoother transfers, so we can like get people who are not great to be at home that like not at home from the get go.
Abby, MD 35:02
It's funny too; you touched on this earlier. But I think the other really interesting thing is that all this for me is sort of, after you've done all this informed consent, and a patient has decided that the best choice for them is to have a home birth, and then things don't go as expected and they landed in a hospital setting, how can we best help patients continue to feel okay about the decisions they've made about their health care? Because I think that's one of the other really interesting sort of dynamics, particularly in the transfers that don't go well is like where is the patient?
Ray, CPM 35:35
I think so much of that falls on the midwife. So like if, if I do a good job of framing, hospital transfer in like a positive light and like as also like a normal, like variation of normal, then that homebirth is a model of care and not a place of birth. And like I set people up well for that, like, yes, like I once I've had a client who experienced retaliatory care in a hospital, but I'm fortunate that I've only had that happen once. But I think I really would say like, midwives who frame hospitals as the enemy or like combative, like are setting people up for having a bad experience.
Abby, MD 36:09
Yeah. And really suffering mentally about like, their experience after the fact, you know?
Ray, CPM 36:14
I mean, some people will have a lot of mourning and others won't. And I don't know if there's a way to save people who like, like, the bad experience, but I do think a lot of it has to do with like, you know, the midwife like the way the midwife frames transfer and frames safety. And, you know...
Abby, MD 36:31
And the way we accept, I mean, again, if on the accepting side of these transfers can just look at a patient and be like, I'm so sorry, this isn't going the way you planned. Let's move forward together. And still, you know, just, I think communicating to patients that we're we're there for them, and we're okay with their decisions, we're going to change things now because they're in the hospital, but we're not there to punish them or give them a horrible no birth experience. Like that is not what we do.
Ray, CPM 37:01
I think sometimes just acknowledgement being like, we know, this is what you wanted, like, what are the things that are important to you for this birth? Because like I tell people, I'm like we are, like, when you write a birth plan, or like birth preferences, whatever, it's like you get everything you want at home, great. Choose your big three preferences if you had a hospital birth originally, and then like, what would be like your two or three preferences? If you had a C section, like think about like, what are the things that are important to hold on to because like, you're going in, you're getting an IV, we're probably getting pitocin, an epidural, you're going to have a bladder cut, you're going to go, you're going to feel like a marionette puppet like these are going to change a bit. And also like we're like, like, we need those tools. Like we don't have them at home. Like these are great tools that are being appropriately, very appropriately used right now. It's not this, like overuse of intervention cascades here. So but like, Is it the way that you get to meet your baby? Is it like, kind of like, Is it a quiet? Is it the skin to skin? Like what are the things that are like, important for the homebirth that we can kind of hold for you here and like the hospital providers also, like, we know what you were planning? I'm sorry, that like, isn't working out for this baby. But like, what are the things that you want to hold from that? And that do that? And sometimes it's quiet, sometimes it's like, pushing, standing, you know, it's like, it's doable?
Abby, MD 38:09
Yeah, it is. And I think, you know, it's funny with birth plans, I often tell patients in the hospital, I'm like, if I start doing interventions, I'm usually doing them to help, you know, get you a healthy outcome, and ideally prevent you from having a C section. Like, that's how I try to think about interventions in the birth setting. In general, a birth plan is a great opportunity for somebody to think about all the things that could happen in their birth. Right. But it's not birthing is also your first exercise as a parent, things are going to be out of your control. Like, it's, it's you can't plan it, and you don't know how it's gonna go. And that first birth sets a lot of tone about how things are gonna go the next couple weeks and, and moving forward and then with other children.
Ray, CPM 38:50
Yeah. And I think the main thing is that people feel respected and heard, like, you can feel respected and heard and have like a crash the section but if you like, if you like, felt heard and understood and like, understand, like, why things happened the way they did, like, you might have sadness about it, but it's like, I think it's sometimes it's the feeling like you're not heard or respected. And that like, that leads to like, some of the tension. And it's like, those are like, you know, I know that there is like, it's impossible to communicate everything with birth, but like, those are things that like, yeah, relationships, trust, like slowing down on possible, like, very homebirth II things that also can totally happen in a hospital. Yeah.
Abby, MD 39:24
And I can be rolling somebody down the hall who's abrupting, and I know, I have like five minutes to get their baby out. I could still hold their hand, look at them in the face and be like, I promise I'm going to take good care of you. Are you okay? What do you need? You know, like, you actually can...I do struggle when I see that breakdown in the hospital setting?
Ray, CPM 39:42
Yeah, I mean, I think like, you know, for me at home, it's like, there is me and one other provider like, when we're in an emergency, it's like, we actually have to keep things calm and have to explain things like it's a part of like maintaining safety, like I had a shoulder dystocia on Monday, and I was you know, I was trying to help the grandma catch and that did not happen. And then I was like, your baby shoulders are stuck, I need you to flip now. And just like was able to communicate that they followed along. Got the baby out, flared my tendinitis, you know, and, you know, afterwards I was like, Did you understand what's going on? She's like, yeah, like, Yeah, I got it like you did what you had to do and I was like, great, you know, and it's just like, cuz you know, shoulder dystocia has a lot of hands in vaginas. And also like, if you're like, understand why your providers doing something, and that it's an emergency and like all that stuff. It's like you feel cared for and not like, why did someone put your hands on my vagina?
Maggie, RNC-OB 40:36
Yeah, yeah, something happening with your permission understanding is very different than something happening to you. Like, yeah, just it is. And I think that communication piece with transfers is huge. Like, that's, we have that opportunity, like you said, on both sides, both on, you know, the home birth midwife side in terms of prepping prenatally about the, you know, the possibility that a transfer could happen, what might that look like? And then like you didn't like on the receiving end, acknowledging, hey, I'm so sorry. Like, it's, it's these like the humanism piece of birth here. It's not hard. This is not the complicated stuff that we needed to go to school for years to do. Like, this is just treating people like a human right in front of you. And just responding in a human caring way and acknowledging when things don't go the way we wanted them to. And not and just not being a jerk about it. Like, it's really that simple. Like the retaliatory care, like it's inappropriate like it is that it's always the wrong thing to do. Even if you think this person or you made a series of terrible decisions, doesn't matter. It doesn't matter at all right? Now, what matters is that they're in your care, to take care of them, like, leave the rest of the stuff later. Like if you feel like you need to process that later, as a birth worker, as a professional to like, try to wrap your head around it and understand it. Absolutely. And there are avenues to do that later, after the birth, when you're off shift whenever to like, process and reflect and understand was there something you could have done differently, how could you have helped the situation a different way, but like, in that moment, just support the person who's in front of you, like, Don't let your own stuff overwhelm.
Abby, MD 42:20
Yeah, totally agree that if I am stressed, if I am angry, if I am screaming, if I like, I'm not doing my job, my job is to take a breath, and deliver baby and do that in the best way I can. Like, it's funny, one of our nurses recently said to me, when I can actually hear your voice, I get really nervous, because I have a bad tendency to mumble and be really quiet, but I just don't believe in.... And you said it really well. I like all those external emotions. That's not part of my job. My job is to be professional, and be compassionate. And then, hopefully practice evidence based medicine and be technically sound and do all those things, too.
Ray, CPM 43:05
I think one of the things I want one of the challenges I do want to mention on the like home good hospital challenges is that like, is sometimes not being believed, as a provider. And I've had this happen two times. And actually I was just with a client who's become a friend. And I told her about the podcast, and she's like, you need to tell my story. And I was like, Okay, sure. Basically, I had a client last year who had retained placenta, and I called... My protocol, so if I don't get the placenta out in an hour, I go to the hospital. And I called it an hour. And at that point, we were at, like, 1200ccs, and we went by ambulance. And I called and was like, I'm coming in for a retained placenta like, this is our blood loss right now, like, she's in compensated shock, like, you know, we need to remove all and we got there and it took over an hour for her to be brought back. And it was just like, that's stuck in the ER for a little while. And then we went up, and then they were kind of doing things slowly. And then a resident is like, oh, let's see if we get up here. And then like, and then they did a spinal, and then she was no longer in compensated shock, she was in uncompensated shock. And the total EBL by time their removal was done was about 3500. And, you know, was on pressors. And like, you know, hospitalized for a little while. And like, I feel like we could have saved 1000 CCS if they had, like, you know, I called, I faxed records. I did, like all the appropriate things. And like, I remember when I did like peer review on this, something like one of the midwives is like, yeah, like, it's just sometimes it's harder to believe the blood loss if you don't see it, but because I like wasn't believed they like didn't act as quickly. I'm, like, you know, made it a worse hemorrhage and worse recovery as a result. And I also had a time where I transferred a baby for respiratory distress and wasn't believed and they're like, Oh, just observe him until he got sicker. And at that point, like it was an intervention that happened earlier, and I was believed, like, intervention would have been done better and they might have been hospitalized for less time. And that's another challenge of just being like, Oh, yeah, like, if you like don't see the problem over there. A few hours and maybe like you don't have relationship with a provider to be like, Oh, yeah, like I trust this person taking it seriously. Yeah, we also that's another part that leads to worse outcomes.
Abby, MD 45:10
And it's hard on the provider side walking in and trying to figure out how sick somebody is or how much you need to do, you know? Yeah, it doesn't make me think that relationships between hospital and home birth providers like that, that is the like, we're gonna fix this, that's gonna be the key. Like, yeah, you and I in a community, knowing each other. Knowing our skill sets, yeah, communicating effectively going to trainings together. I mean, that's, that's what needs to happen for this to work.
Ray, CPM 45:40
Well, like, yeah, it's like, it's a 1200. And then we're continuing to lose blood. I'm just like, yeah, this should be happening quickly. And I was like, is this because they have more resources that they aren't intervening as much, but you know, just like, just like pouring clots, like, while we were waiting, and there wasn't a sense of urgency, and it was, yeah, like, it was, like a positive transfer in that like everyone was like, treated really well, and respectfully, but like, especially during COVID, but also like, it could have gone a lot better.
Maggie, RNC-OB 46:08
It's interesting, like you said, there is a, it just comes down that relationship piece, like, obviously, I have a different role. But if I was to call a provider, and say like, Hey, we're having hemorrhage here, we've already lost this much blood and they were to come and have to like, Alright, let me like really wait and see for a while by myself. Like, that's causing a delay in care anything, obviously, that piece of it like as a nurse, when I'm calling a midwife or a doctor and saying, like, Hey, this is what's happened, we have a relationship, they we do we have mutual trust that like, Okay, if Maggie is saying that, Oh, she went in, and they already have 1000 out on the pads, they're gonna act right away that what I said was, like, was accurate, was truth. And we keeps going in an integrative process, instead of this kind of, like, stop start fashion where you feel like there's a transition of care that then if we're taking so much time, in our like assessment piece, because we don't have that trust established, which I get it like, that's for the for that receiving provider, like, they don't know you, right? And so they're trying to figure out like, Ah, what did happen? When are we overreacting? And maybe there's especially if they think that they're trying to be like, protective of not being over interventional? Like, it's kind of this whole piece of like, like, almost like, you're...
Abby, MD 47:21
That's an interesting point.
Maggie, RNC-OB 47:22
Like you're going beyond in an attempt to be like, no, yeah, we're doing everything above board here, that you're trying to be almost use, like, again, that we're not then ready to react when, like, when it's necessary. Like when you actually like I came here the transfers, because we need some sort of intervention like that is why a transfer is done. It's because a, an intervention is needed. And yeah, cascade of interventions is a problem. But like intervention, when used appropriately, is a good thing.
Abby, MD 47:49
Somebody very wise told me once that if somebody is coming from the home to have a hospital transfer, it's either because their home birth midwife is really bad and they need intervention, or they're really good, and they know they need intervention. So either way, you should be ready to provide intervention. And I actually like thought about I was like, Yeah, I guess that sort of makes sense. And, again, that was the respect piece, the communication piece as an OB, I don't want to have to prove to anybody that I know how to do a low intervention birth. I actually do, I actually can do my job well, and I hate a situation where somebody is coming to me. We joked about this, you said this earlier, I mean, when you asked me to be part of this podcast, I was like, Okay, I get to be the supervillain of Maggie's podcast, like I don't want to be perceived as somebody that's always gonna do the most interventional thing. If I'm doing my job. Well, that's not what I'm doing all the time. But again, if there was better if there were better relationships and communication, that it wouldn't feel that way when there was transfer, and perhaps energy could be focused more on the patient, and the outcome.
Maggie, RNC-OB 48:54
Absolutely. And that's what's so important. Like I could keep talking to both of you about this, like, all day, it's such a, it's such a passionate subject for me personally. And I think it's saying that we need so many different levels to kind of help to move things forward. That said, I think we will wrap up here with that piece of just respect, because I think that if we had that if we had respect and good communication across the board, like birth care would look completely different in our country. And that's something that, you know, we all can have a hand in different ways in helping to get it there. But I just want to thank both of you were speaking just so clearly to your experiences. And I know this is like a very intense conversation, trying to figure out how to balance out and keep that focus on, you know, the birthing person and what they need and protect birth as much as we can. So I appreciate you both.
Abby, MD 49:38
Thank you. Okay.
Maggie, RNC-OB 49:40
Well, thank you so much for tuning in and sharing this conversation with us. You know, in talking with Ray and Abby and preparing for this episode, we were all just really cognizant of how multi-layered this is. And, you know, my hope is and having these conversations in all of our podcast episodes, but you know, particularly here, that, you know, we just have the opportunity to think of different perspectives to consider just all of the complications that are present in birth. And, and as always, these are system issues, these are things that I believe collectively, we can create something different, we can create something that helps everyone to feel respected, and taken care of. I think especially with this conversation, you know, there are so many pieces in within transferring there, there's sometimes this fear and, and shame and guilt. And there's that piece where if we're not, if we're not being honest with ourselves about what's going on, if we're not recognizing the pieces of our own stories that are showing up in how we take care of people, if we don't have enough trust, and we're not, you know, sharing accurate information with each other as providers, when we go to make these transfers. unsafe, you know, the whole cloak and dagger routine of, you know, some of these transfers where information isn't, you know, accurately shared or people aren't being forthright about, you know, what's going on and what their concerns are like, that has no place in, in collaborative care. And, and that's what I believe birth has to be so that we can all function to the best of our abilities. So we can all use the skills that we have, when they're what's needed to support the working person and their process. And so I hope that you enjoyed this conversation. I hope it gave you something to think about, we would love to hear from you and your feedback on it and what it brought up for you. You can join our Facebook group, Your BIRTH Partners Community, you can find us all across social media, we're Your BIRTH Partners, and you know, we'd love to engage in more dialogue with you and learn more with you. So we'll also be sharing some relevant articles and posts in the show notes. So you can tune into some of the data that's out there around over safety and transfers and all of that and we look forward to continuing this conversation more with you as you digest and reflect. Till next time!