Caretakers of Homebirth: Doctors Who Come to You
by Wendy Correa
Issue 112 May/June 2002, Mothering Magazine

On a bright May morning, 17-year-old Matthew Smith and his 15-year-old sister Emily watched their mother, Elaine, give birth to their baby sister Katherine. Until the early 20th century, this would have been a very common family event in rural America. But this was 1993, in Chicago, and the setting was not a hospital but the Smiths' own home.
Matthew and Emily themselves were born in hospitals. Both births had been induced with pitocin; for Emily's birth, Elaine was flat on her back, feet in stirrups, attached to a myriad of catheters, IVs, and monitors. Because Matthew's pediatrician recommended artificial baby milk supplementation within three months of his birth, presumably due to slow weight gain, Elaine sought the advice of La Leche League, which recommended that she simply breastfeed more often. Matthew thrived, Elaine's interest was piqued, and she became a La Leche League leader.

Elaine's co-leader was a nursing student with Homefirst Health Services, a family practice group that also attends homebirths. Fifteen years after her last baby was born, with numerous miscarriages in between, Elaine gratefully learned that she was pregnant. Armed with the knowledge of Homefirst's success and reputation, Elaine and her husband, Donald, decided that their baby would be born at home. "I knew that a homebirth would be better than what I had experienced with both of my hospital births," Elaine explains. "I'm much more comfortable at home, and I did not want my baby taken away from me."

To prepare Matthew and Emily for the birth, the Smith family went to an informational evening at Homefirst, at which the homebirth process was explained by doctors and nurses with videos and testimonials. Matthew remembers that he felt queasy while watching footage of a birth and feared that he would have the same reaction at his sister's birth. But by the time Katherine arrived, he says, his experience was more about the joy, excitement, and wonder of watching a new life coming into the world.

That day Matthew was responsible for answering the door to let in the nurse, Jude Wrezesinski, and the doctor, Mayer Eisenstein, getting his mother cold washcloths and drinks, and helping his father hold his mother's legs as she pushed her daughter into the world. Finally, Matthew got to cut Katherine's umbilical cord. Two years later, Matthew and Emily attended their sister Rachel's homebirth. This time, Matthew photographed the birth, and Emily got to cut Rachel's umbilical cord.

Mayer Eisenstein is the medical director of Homefirst, now the largest physician- and midwife-attended homebirth practice in the nation. Eisenstein maintains that homebirth is many times safer than hospital birth for over 90 percent of low-risk women, especially if you can take the hospital to them. Since 1973 he and his practice have delivered 15,000 babies at home, including five of his six children and all six of his grandchildren; they are now delivering second-generation babies for women who themselves were born at home with Homefirst.

With six medical centers in the greater Chicago metropolitan area, Homefirst has TEN doctors, four certified nurse-midwives, and 45 registered nurses and certified nurse assistants. They provide preconception counseling, prenatal and postpartum care, delivery, and breastfeeding instruction and support. Homefirst also offers a full range of pediatric services as well as women and men's health care.

Eisenstein's unusual career began while he was still in medical school at the University of Illinois. The birth of his own first child was a less than satisfactory hospital experience, so, for their second birth, he and his wife sought the help of Gregory White, a physician who had quietly been doing homebirths for a number of years. Eisenstein was so awed by the birth of his second child that he began attending homebirths with White. He saw that the pregnant women were walking around until it was time for the actual birth, that they were empowered by the presence of family and friends, and that there were no episiotomies, forceps, or drugs. "The birth was a joyful, spiritual experience for the mother, rather than the climax of many fearful and helpless hours spent on her back at the mercy of medical staff. Dr. White was the most patient person in the world and could make everyone feel comfortable. The simplicity of his techniques amazed me. He would watch and watch at a birth, just really watch what was happening, and soon the baby would come out," Eisenstein recalls.

At the same time, Eisenstein began working at Chicago's Cook County Hospital to learn all he could about forceps delivery, episiotomies, and other intervention techniques because, White assured him, "You won't learn about these things at homebirths; they just aren't necessary." At the hospital, he soon began to "accidentally" drop the episiotomy scissors on the floor so that they could not be used. Consequently, he was the doctor called whenever a laboring woman did not want drugs or an episiotomy.

In addition to working with White, Eisenstein was also trained by White's teacher, Herbert Ratner, a general practitioner and professor of philosophy at Loyola University who conducted monthly forums on family life. He also began assisting Beatrice Tucker, America's first woman obstetrician. Tucker was then 81 and had been director of the Chicago Maternity Center for 50 years, during which time she and her staff delivered over 100,000 babies at home with an unsurpassed safety record. Tucker told her doctors and nurses, "Your role at the birth is not to deliver the baby. Your role is to be the lifeguard, to employ a watchful expectancy." "The goal of Homefirst is to practice scientific medicine, follow scientific literature, and produce the healthiest possible mothers and babies by delivering the largest percentage of women at home," Eisenstein says. The medical profession in general, he believes, does not follow its own studies, which demonstrate that homebirth is as safe as, if not safer than, hospital birth. "Just look at the cesarean section rate of 22 to 27 percent and higher in US hospitals. That is not scientific medicine," he adds.

Indeed, according to the National Center for Health Statistics, after falling steadily from 1989 to 1996 the rate of cesarean delivery increased again in 1999 to a national average of 22 percent, up 4 percent from 1998.1 According to a 1999 Reuters report, in a study of more than 1,200 women, researchers at Brigham and Women's Hospital in Boston found that first-time mothers who develop a fever during labor are three times more likely to deliver by cesarean section than those who don't. Ninety percent of the 301 women in the study who developed a fever during childbirth had been given an epidural, suggesting a link between the two.2 Studies at the University of Houston Medical School showed two to three times more cesareans for dystocia in first labors in the epidural group than in the group of women without anesthesia.3

In spite of these and other related studies, the rate of epidural anesthesia use continues to rise. Comprehensive reports from many hospitals indicate that almost all (80 to 98 percent of birthing women, depending on the hospital) receive (oral) medication, anesthesia (epidural analgesia), or both. In contrast, 90 percent of Homefirst mothers succeed at having uncomplicated and nonmedicated homebirths, and of the 10 percent who are transferred to the hospital half still have a vaginal birth.

Eisenstein minces no words when he declares that homebirth is safer than hospital birth for those 90 percent of mothers who are low risk. The problem is that obstetricians treat all women as high risk. "Obstetrics, which is really a combined philosophy, business, and religion, does not have science as its base," Eisenstein says. "Obstetricians practice much more philosophy than science. Pregnant women are tested, medicated, and operated on to excess every day by this profession in an unethical and dangerous way. This unscientific medicine is dangerous to us as a nation. Our maternal and infant mortality rate is unacceptable for a society as sophisticated as ours. We produce more premature infants than any other country with our interventionist technology and then praise ourselves for saving some of their lives."

Support for the safety of out-of-hospital and nonintervention births is abundant. According to a 1994 study, after "reviewing the full spectrum of literature from the United States and abroad, the literature shows that low- to moderate-risk home births attended by direct-entry midwives are at least as safe as hospital births attended by either physicians or midwives."4

A study at Columbia University College of Physicians and Surgeons concluded, "Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary."5 Despite such scientific reports, Eisenstein comments, "Modern obstetricians continue to intervene excessively at births, to maintain their system of large consultant hospitals, and to find homebirth unthinkable."

Both the American Medical Association (AMA) and the American College of Obstetrics and Gynecology (ACOG) have issued policy statements cautioning against homebirths, whether attended by midwives (as in the majority of cases in the US) or physicians. The AMA policy states, "Obstetrical deliveries should be performed in properly licensed accredited, equipped, and staffed obstetrical units." According to ACOG, "Labor and delivery, while a physiologic process, clearly presents hazards to both mother and fetus before and after birth. These hazards require standards of safety which are provided in the hospital setting and cannot be matched in the home situation."

Perhaps Henci Goer offers the best answer to the home or hospital safety question in her book Obstetric Myths versus Research Realities: "The real question about safety is not, 'Do you want a pleasant birth at home or a safe birth in the hospital?' It is, 'Do you want to give birth at home and run the miniscule risk of an emergency that might (but not necessarily would) be handled better in the hospital, or do you want to give birth in the hospital and run the considerably increased risk of infection, the certainty of additional stress, and the near certainty of unnecessary (and potentially risky) interventions?"6

The convictions of the Homefirst doctors certainly put them at odds with the AMA and ACOG; on the other hand, Homefirst might be perceived by some childbirth reform advocates and midwives as the "medical model at home." Eisenstein contends, "The model that is important to us is not midwife or doctor; the right obstetrical model is homebirth. If a midwife delivers babies in a hospital, that is no better to me than an obstetrician. Once midwives start working in the hospital, they fall into the same trench as the obstetrician. The care may be nicer and gentler, but they are still altering the experience."

Paul Schattauer, one of the doctors present at Rachel Smith's birth, has been with Homefirst since 1987 and tells prospective clients, "Our goal is to bring the hospital to you." And that they do. The "hospital" arrives in a van filled with more than a hundred pieces of medical equipment. In addition, as a physician organization Homefirst is hospital-supported in the event of an emergency-one of the main obstacles facing midwives working on their own.) The combination of doctors and midwives seems to be mutually advantageous. According to Jennifer Gagnon, a certified nurse- midwife with Homefirst, the benefits for midwives include the comfort of a well-established and respected practice; the opportunity for homebirth mentoring experience; and more established hours and less stress than being in a solo or small midwifery practice.

"Having recently come from working as a labor and delivery nurse in a hospital, my view is that childbirth in a hospital is bad," Gagnon says. "The last year of my education as a CNM was very difficult because I was still working as a labor and delivery nurse. I had a lot of internal conflict because I could not resolve what I was seeing happening to women with what I knew should be the correct way. And what was even worse was hearing women thank their doctors, who, in my opinion, had really done them wrong. There was a lot of subtle misogynistic language directed toward laboring women. I saw so many examples of women getting the cascade of interventions they didn't need."

A recent study published by the Robert Wood Johnson Foundation found that 95 percent of doctors and 89 percent of nurses reported witnessing a colleague commit "serious" medical error(s).7 Eisenstein laments, "It is frightening to realize that most hospital-trained obstetricians have never seen a truly normal labor and delivery. Intervention gives power, control, and credit to the doctors for birth itself. Many obstetricians have been known to say behind the scenes that they only feel they have delivered the baby when they perform a cesarean section. It is a powerful feeling to 'deliver' babies rather than leaving delivery to the mothers themselves."

Asked if hospitals could ever be as comfortable and safe as home, Eisenstein answers with a firm, "No." He adds, "There is something about just walking into a hospital that changes the dynamics of labor. Scientific studies have shown that the length of labor is significantly increased in the hospital versus the home."

Schattauer expounds on this theory, referring to what he calls the "safe and secure response" promoted by the safety and security of homebirth, which releases endorphins that create a sense of well-being and provide pain relief. In contrast to "safe and secure," is the "fight or flight" response created by the unfamiliar territory of the hospital and doctors' interventions, which promote the release of adrenaline, hence potentially stopping or stalling labor and creating tension and pain.

"The majority of problems that develop in a labor situation stem not from some inherent health problem in the woman but from the normal physiological response to an artificial, stressful situation," Schattauer says. "Our whole focus can change once we realize that the built-in mechanisms for labor are more intricate and sophisticated than anything we could possibly develop in the biomedical industry. The new paradigm requires an emphasis on withdrawing any stimuli that would trigger the fight or flight response. Through the course of evolution, the body has adapted beautifully to labor in a most efficient way. That's the kind of confidence and belief system we need to have as doctors and medical caregivers so that we understand that the environment we provide can make a difference in whether the laboring woman succeeds and the normal physiology of the 'safe and secure response' is turned on."

In September 1999, four years after attending his sister Rachel's birth, Matthew Smith and his wife, Lisa, gave birth at home to a daughter, Caroline, attended by Homefirst staff. Lisa and Matthew had taken weeks of Homefirst homebirth preparation classes. For every "What if?" Lisa could think of, the doctors of Homefirst had an answer. The emergency equipment that the doctors bring to every birth, and the knowledge that a hospital was nearby in case of any problem and that her Homefirst doctor would still be her doctor in the event of a hospital transfer, soothed Lisa's concerns. It is this empowering kind of response from Lisa Smith and the other Homefirst mothers that seems to drive and inspire the Homefirst staff.

At first glance there appear to be insurmountable obstacles to the childbirth reform movement, but the desire for change continues to grow on a grassroots level. Homefirst recognizes the need to educate not only the consumer and the public but also insurance companies and legislators. Wearing one or more of these educational hats in addition to being the clinician can be taxing, but Homefirst is doing its part.

Eisenstein has written two books, The Home Birth Advantage and Safer Medicine, and appears weekly on the Homefirst Family Health Forum radio call-in program. In addition, Homefirst offers free educational seminars and free one-hour private consultations with prospective homebirth families. It also offers educational programs for students in medical, nursing, and midwifery schools, one-year fellowships for physicians and certified nurse-midwives, and rotations for resident medical students and nurses. "There have been so many medical students on the brink of quitting when they come to us to do a rotation, and their mouths just drop to the floor," Schattauer says. "They catch the inspiration again. They don't care about the economics and the politics, because they have regained the whole essence of why they went into medicine."

Once insurance companies understand that they will save millions of dollars each year by covering homebirths and reducing the rate of cesarean sections, Eisenstein and Schattauer believe they will provide services. Certainly the help of influential state and federal legislators could help expedite that process. Florida, for example, is considered a "midwifery-friendly" state, in contrast to Illinois, where lay midwives are prosecuted. According to Florida statute 641.31, "Health maintenance contracts that provide coverage, benefits, or services for maternity care must provide, as an option to the subscriber, the services of nurse-midwives (licensed midwives) and the services of birth centers." The statute goes on to say that this "does not require a mother who is a participant to give birth in a hospital or stay in a hospital."

Considering that the US now ranks a low 24th among industrialized nations in infant and maternal mortality,8 perhaps our legislators will finally look at the many European countries whose standard for childbirth is the midwifery model. In the Netherlands, for example, midwives have always maintained full autonomy, providing all primary maternity care, while obstetricians are reserved for medical necessity. Dutch insurance reimburses only for midwifery care; if a woman chooses to use an obstetrician, she must pay for the services herself, unless it is medically warranted. In addition, women may choose home or hospital, and about one-third choose to have their babies at home.

Eisenstein firmly believes that the demise of the American family is rooted in the displacement of birth from home to hospital, saying, "The family starts with birth, and homebirth traditionally was a cornerstone of strength in a family's life. Hospital birth deprives the new family of this most primal and strengthening experience."

NOTES
1. National Center for Health Sciences, press release, April 17, 2001.
2. Suzanne D. Dixon, editorial based on study in American Journal of Public Health, April 6, 1999. Editorial published by Pampers.com, July 1, 1999.
3. Diana Korte and Roberta M. Scaer, A Good Birth, a Safe Birth (Cambridge, MA: Harvard Common Press, 1992), 145.
4. C. Hafner-Eaton and L. K. Pearce, "Birth Choices, the Law, and Medicine: Balancing Individual Freedoms and Protection of the Public's Health," Journal of Health Politics, Policy and Law 19, no. 4 (Winter 1994): 813-835.
5. P. A. Murphy and J. Fullerton, "Outcomes of Intended Home Births in Nurse-Midwifery Practice: A Prospective Descriptive Study," Obstetrics & Gynecology 92, no. 3 (1998): 461-470.
6. Henci Goer, Obstetric Myths versus Research Realities: A Guide to the Medical Literature (Westport, CT: Bergin & Garvey, 1995), 334.
7. Robert Wood Johnson Foundation, press release, May 8, 2001. Regarding a nationwide survey of healthcare professionals and the multimillion-dollar initiative launched by RWJF to help providers and administrators pursue healthcare perfection.
8. Mayer Eisenstein, The Home Birth Advantage (Chicago, IL: CMI Press, 2000), 18.