A year ago, I wrote a blog about how hospital bans against vaginal birth after cesarean (VBAC) limit options for Muskegon families. I used birth data from the Michigan Department of Health and Human Services to compare percentages of people with low-risk pregnancies who have a cesarean after a prior cesarean in Muskegon and surrounding counties. Not surprisingly, VBACs are more common where hospitals support them.
The data available that I used was from 2008 to 2014. Since then, 2015 data has been released. I wanted to update this information to see if there were any changes, explore what might be impacting this change and predict how this situation might change in coming years based on current developments in healthcare policy and services.
Statewide, there has been improvement. In 2015, a total of 2,006 people had VBACs, compared to 1,882 in 2014, an increase of 124. When we look at West Michigan counties, however, only Muskegon County and District Health Department #10, which includes Oceana, Newaygo and eight other counties, saw an increase. Kent county births included 40 fewer VBACs and Ottawa county had 3 fewer than the year before.
There are a few issues with this data and that make it difficult to draw conclusions from. First, the two-to-three-year lag time from when the year ends until the data becomes available makes it less useful. We can reflect on what may have happened two years ago to impact these changes, but it is less relevant than being able to access real-time data. Secondly, the online database only provides this particular piece of information by county. In a large county, like Kent, it would be interesting to see how being in an urban, suburban or rural area or proximity to a specific hospital may impact access.
When applying this information to our doula practice, we see clients make a lot of different choices when it comes to choosing a provider and location for their planned VBAC. While some Muskegon area families are happy to travel to Spectrum Health Butterworth in Grand Rapids to deliver, others prefer the intimacy of the small practice at Gerber Memorial Women’s Health, also under Spectrum, in Fremont. Still others have decided to stay in Muskegon and show up in labor at Mercy Health Hackley, while home birth after cesarean (HBAC) is a clear choice for others.
Things may change in 2018. Dr. Tami Michele, who has practiced at Spectrum Health Gerber Memorial for many years, is switching over to Spectrum Health Medical Group Ob/Gyn, with locations on 68th St. and on Mid Towne in Grand Rapids. Some say the move is to help increase the access to VBACs at Butterworth, which serves more patients. Dr. Michele is former doula, whose advocacy for those who wish to plan a VBAC has earned her a national reputation. What is less known at this time is how her moving from a small, rural hospital to a large metropolitan one will impact access to VBACs for those outside of Grand Rapids. Some will surely follow her, while others may feel that they lost a resource.
Another recent change on the national landscape was the publication of the American Congress of Obstetricians and Gynecologists updated guidelines on VBAC, which appeared in the November issue of Obstetrics and Gynecology. According to Mark Turrentine, MD, chair of ACOG’s Committee on Practice Bulletins-Obstetrics, the guidelines are meant to ensure delivery at the safest facility, “However, this absolutely should not result in women having limited access to VBAC.”
According to Jen Kamel, founder of VBACFacts.com, the guidelines are an improvement over those released in 2010. She quotes the new guidelines, “Available data confirm that TOLAC [trial of labor after cesarean] may be safely attempted in both university and community hospitals and in facilities with or without residency programs.” She interprets this to mean that if a hospital can handle deliveries, they should offer VBAC, because an emergency cesarean may be required in any birth, even a low-risk one.
How local staff changes and changes in the ACOG guidelines will impact local access remains to be seen. Will more people be able to access VBACs at Butterworth, or will support at Gerber decline? Will the 2017 ACOG guidelines result in a reversal of bans at Mercy Health Hackley, North Ottawa Community Hospital and Spectrum Health Gerber Memorial, or will the liability concerns prevail? Time will tell, but we won’t be able to see the data until 2020!
In the meantime, we will continue to support families in all their choices, whether they choose a repeat cesarean, a VBAC at a hospital or birth center of their choice, or at home.
“Although this moment is bittersweet, it’s one of my favorite photos and I’m glad it was captured. Just before I was taken into surgery, after 24 hours of hard labor at home. My #doula, Faith, never left my side.”
— Ottawa County client, after a homebirth transfer to hospital
“[Faith] provided me with many resources, and I also really appreciated the teas she made me. Her evidence based approach was very unbiased and nonjudgmental. I felt like I could be honest about my needs with her… She really proved herself when the birthday came. She was my knight in shining armor! She made me feel so confident and comforted through my labor. Her knowledge of a birthing woman’s body and need for support was obvious. I credit my smooth labor and delivery to her…”
— Norton Shores mom, of her homebirth with Birth Quest
When I tell people that I’m a birth doula, the most common response I get is, “Oh, so you help women having their babies at home?”. To which I reply, “Yes, doulas support women at homebirths, but all of the women I’ve supported have given birth in hospitals”.
Because the word doula is not a part of everyday vocabulary for most people, I think many confuse a doula with a midwife. This is usually the second thing I have to explain to people about my job. I don’t catch the babies; I hold space for mom and support her through the process.
The next question usually revolves around why doulas attend more hospital births than homebirths. Several factors impact a woman’s decision on whether or not to hire a doula. For the woman choosing to give birth at home, the biggest factor is likely financial. Homebirths are generally paid for out-of-pocket, as are doulas. Since doulas don’t provide the clinical support a pregnant woman needs and they don’t catch babies, women who desire a homebirth are often faced with the decision to choose between hiring a midwife or a doula. In this scenario, the midwife is usually chosen because of the necessity of her services.
But what if having a doula AND a midwife were an option?
It’s true that your midwife will spend more time with you while you labor and provide a different model of care during pregnancy and delivery. It’s also true that she will likely have assistants who can attend to some of your needs. However, with their focus primarily on the clinical aspects of care, there are other elements left unaccounted for.
Generally, a doula will meet with you in your home at least a couple of times before you have your baby. She’ll be familiar with you and your surroundings. It’s during these meetings that doula and mom become acquainted and comfortable with one another. If there are pets, the doula will get to know them. If there are other children or family members, the doula will get to know them, too. This process is vital in developing a safe relationship as the mother will depend on the doula to cover the non-clinical elements that are a part of the birth process. It’s during these visits that mom can share her hopes and her fears. While she’s probably also done this with her midwife, the doula provides more time for mom to process and plan. The more informational and emotional support a woman receives during her pregnancy, the better.
And in the event of a hospital transfer?
Your doula will be with you. Your midwife probably will be, too, but if your doula is the one you’ve been leaning on emotionally during your pregnancy and labor, her presence is vital. Odds are, she was with you earlier in your labor than your midwife was, as well. That’s the beauty of a doula: no shift changes and present with you from the beginning to the end. Another benefit is that a doula is likely to be very familiar with the hospital environment and maybe even some of the staff, so she can help to explain what is going on and bridge the gaps between a homebirth and a hospital birth.
Regardless of the outcome, whether you had your baby at home or had to transfer to the hospital, your doula will be there postpartum for you to process the experience. Your midwife will, too, but depending on how the birth went compared to how you had envisioned it, your doula provides added space and opportunity to share things that you might not wish to share with your midwife. I know for me, I’m no good at confrontation and had I been upset with my midwife or disappointed, there’s no way I could have told her that (fortunately, that wasn’t the case for me!). A doula is trained to listen to your grievances and your joys. Validating your feelings and helping you to pick through the pieces and put them together, a doula can offer perspective, encouragement, and reassurance.
Birth is one of the most unpredictable events in nature. No matter how much you know about it, curveballs often appear in the form of all the little things that surface in the midst of the limbo of labor that no one had planned on.
I think back to my last pregnancy, when I had finally planned the homebirth I’d always wanted. It honestly was an amazing experience to labor at home and push my baby out the way I wanted with a supportive group of women (midwives, assistants, my mom and mother-in-law) and my husband. All of it was golden. I was even doing “doula talk” in my head, like focusing on the words soft and open. You see, I’d had my birth doula training through DONA only a few short months before the birth. So at the very least, I was able to focus and feel pretty in control during the more intense moments of labor. Super proud of myself for that!
However, the entire day leading up to my precious little one’s arrival, my anxiety and the negative self-talk going on in my head was relentless. Fourth baby, longest labor. Why? Was I not moving around enough? How long was it going to take? Why were the contractions that woke me in the wee hours of the morning that were 4 minutes apart and very uncomfortable spacing out to 15 minutes and not as painful? And there went my thoughts for the better part of an entire day. It’s the one part of my labor I look back on and wish I’d had a better attitude about. As helpful and supportive as my husband was physically for me that last time around (so grateful for the counter pressure and back rubs!), I needed someone to help ease my mind. I needed someone to remind me that every labor is different and that what I was experiencing was normal. I’d fed my fear of waking in labor and things moving quickly, as they had in the past (with my third baby, I went from 5cm to holding my baby in under a couple of hours after painfully relentless contractions). Instead, I spent the better part of the 24 hours that I was in labor anxious, discouraged, and feeling guilty for having sent my kids away first thing in the morning because I was sure “this is it!”. I wasn’t mentally prepared for a long labor. I’d never had one.
Don’t get me wrong; my birth team was incredible! I’d depend on them again in a heartbeat for their care and support during pregnancy and birth. Looking back, though, I know I needed more in those long hours before my little guy finally made his arrival.
Doulas meet so many needs that are maybe overlooked or not considered.
I know when my son was born, my house was a mess. Pretty sure there were dishes and laundry that needed to be done. I didn’t feel like cooking and no one brought food while I was in labor. It was a long, lonely day. I struggled to find distractions. There were so many things during that entire day of early labor that a doula could have helped me and my husband with. We were both so tired.
When I was in active labor and pushing, I soaked up every encouraging word and touch my birth team provided me. They were tender, attentive, and confident. In hindsight, I realize I had needed that all day to better cope with my apprehension about the imminent arrival of my baby. I needed someone to hold that space for me and remind me that everything would be okay. I needed someone to tend to the things my husband and I couldn’t get to while I tried to rest.
My other children were born in the hospital, where food and laundry weren’t an issue. While the hospital environment is not my personal favorite for giving birth, those two things ended up being huge oversights for me with my homebirth. I don’t have sisters or super close girlfriends that I would have felt comfortable having with me while I labored; and I wanted my mom and mother-in-law present for the birth, not running around my house cleaning and cooking. While having my son at home was truly a dream, waking up the next day to the reality of…well, real life, wasn’t. Looking back, I hadn’t planned for how to handle those seemingly tiny details. Who knew that while I did the hard work of bringing life into the world that my house wouldn’t clean itself or cook a meal for me! Or take care of my other children when they returned home the very next day (totally needed a postpartum doula, too).
My business partner and Birth Quest founder, Faith, also had her last baby at home. Her labor, which was the complete opposite of mine, was quick and intense. Despite her doula training, she found herself in need of one and speaking the words women the world over often say when it’s become too much…“I can’t do this! Make it stop!”
I needed a doula; but even if I’d wanted one, I couldn’t have afforded one anyway.
At least, that’s what I thought. I know better now. I could have asked family to help with the expense or sought a doula out that would take my finances into consideration and work with me to make it affordable. Our vision is to increase access to doulas for every person who wants one, so please contact us if you have a financial hardship, especially if that is due to the unreimbursed expense of an out-of-hospital birth. Everyone deserves a doula!
As one Birth Quest client of her having a doula for her homebirth said, “My parents paid for my doula as a gift for our Homebirth. If they hadn’t, cost might had been an issue but I definitely would choose to hire a doula again. Their knowledge and support are so priceless if you can find one you love!”
My story and Faith’s are just two of many stories. Doulas do so many things. If any one part of your labor and birth could be considered customizable, it’s who you choose as your doula. With you from the moment you feel like you need her, she’s the one you’ll have expressed your desires to about labor and birth. Whether you need someone behind the scenes – doing your dishes, folding laundry, or getting a meal ready – or someone to be a part of the action – holding your hand, taking pictures, or showing your partner where to apply counterpressure – your doula is the one person attuned to your wants and needs. And if at any time you want what your doulas doing to change, just say the words…that’s what she’s there for.
What does a doula do at a homebirth anyway?
At a homebirth, a doula is going to do everything she’d do for you in a hospital, except that she is in your space where there are more personal elements that might need tending to. Because the list could go on and on, here are a few examples:
- Ideally, she arrives earlier in your labor to provide support (informational, emotional, physical, etc.)
- Support for your partner (in the form of breaks, encouragement, direction on how to apply pain management techniques, etc.)
- Support for others present during your labor and birth (friends, relatives, children, etc.)
- Light household chores (dishes, laundry, etc.)
- Meal preparation
- Tending to the needs of pets
- Taking pictures
- Crowd control (making sure mom has the space and privacy she desires)
- Immediate postpartum support
- Assistance with breastfeeding
- Preparing a place to rest postpartum
- Meeting needs specific to the individual
- Hold space for the woman in labor
- Create/maintain a peaceful and calm environment
Who could use a doula at a homebirth?
There’s no denying that as a doula, I feel the benefits are universal and for all women. With that being said, specific reasons a doula is perfect for a homebirth include:
- Women whose family/friends are not near enough to provide support
- Women without a partner or whose partner might not be available for support
- Women with anxiety or other health issues that might impact their confidence in their ability to give birth
- Women who want to be prepared in the event of a hospital transfer
- Women who know they need a lot of support
- Women who don’t want to worry about meals or cleaning during labor and after birth
- Women who know their partners will need additional support
- Women who want support but aren’t comfortable with family/friends present
- Women who have specific wants and needs
- Women who have other children that will be present that need support
- Women who want someone to promote and maintain a calm, peaceful environment
- Women who want a safe person to hold space for them
Since doulas aren’t as commonly present at homebirths as they are for hospital births, we did a little investigating into why.
Thanks to the women who took part in our Facebook poll (@birthquestservices) to find out why they, women who’d had homebirths, didn’t have a doula. Not surprisingly, the leading reason was cost. A close second were women who felt they already had enough support while the third reason was a desire for privacy.
However, because women were allowed to choose more than one option, some chose both cost and sufficient support as their primary reasons for not hiring a doula. This leaves us to wonder…which was the biggest factor?
Answers to a 2017 Muskegon-area Facebook post asking, “If you had a homebirth and didn’t hire a doula, why not?”
— Blog written by Beth Singleton, DONA-trained Birth Quest birth doula and photographer,
who had her fourth child at home in Muskegon
As a doula, two of the most important people in my life are my sitter and my back-up doula! Through the Lakeshore Doula Network, I have been fortunate to have had several area doulas willing to support my clients in the rare event that back-up is needed.
One time, I had two clients due the same week. Beth Singleton was my back-up doula. When they both went into labor at the same time, she was there for me. I cannot tell you what a relief it was to know my client was in good hands!
Beth and I have met to talk about working together since then. After making lists of our strengths and weaknesses, we identified ways that we are similar as well as ways we can mentor and support each other as we continue to develop our businesses. We recently signed a formal agreement outlining our commitment to provide back-up for each other.
Let me introduce to you, Beth Singelton, Birth Doula!
Hello! My name is Beth Singleton. I have lived in Muskegon my entire life and graduated from Reeths Puffer High School in 2000. I am the proud mother of 4 awesome kids and have been married to my husband for almost 14 years. I have given birth in both a hospital setting and at home. In 2014 while pregnant with my 4th child, I completed my DONA training and am currently working towards my certification. Aside from my life as a wife, mother, and birth doula, I have spent many years working as a floral designer and I LOVE writing poetry (I have self published two poetry collections so far!). Free time with my family is best spent in nature, preferably by the river or in the woods, with my camera in hand. I am also a huge fan of watching the sun rise.
I have always had a passion for pregnancy and birth and am very grateful to the women in my life that have allowed me to be present during the birth of their children. What I’ve witnessed while watching other women labor and experienced during my own is that having support is vital to a positive birth experience yet, it is something so many women do not have. Giving birth is one of the most challenging and life changing experiences a woman can go through and how she experiences it can have a lasting effect on how she feels about herself, her baby, and the bonding experience. I know the importance of achieving the desired labor and birth and it is my hope to provide women with the information and support needed to do this. There is no crystal ball that can predict how labor will go. That is why I think it is so important for a woman to have support.
During pregnancy, I believe it is pertinent for women to educate themselves and build a good support team. It is also the perfect time for a woman to learn about self care and begin implementing this into her daily life if not already doing so. As your doula, I will be there for you during your pregnancy to answer questions, provide moral support, go over the importance of self care, help you with a birth plan if you’d like one and go over what you ideally think you will need from me. When you are in labor, it is my goal to be there for you and do all that I can to make sure you feel in control and empowered, providing you with the support you need to be a better advocate for yourself. Whether it is simply my presence that is needed, encouraging words, a shoulder to cry on, or hands on support like massage, I will be there for you. In the instance that complications do arise, I will remain with you and support you through those challenges as well. I believe all women have an inherent sense within them that guides them instinctively through labor and childbirth. My hope is that in all I do, I am able to hold that space for you, allowing you as an individual to experience labor and birth in whatever way you so desire. After birth I will visit with you, talk about the birth, talk about how you are feeling, and I can provide some help with breastfeeding if you need it.
I view birth as something sacred and a laboring woman as someone to be respected and held in the highest regard. There is a transformation that takes place whether a woman is having her first baby or her fifteenth and I consider my being allowed to bear witness and provide support during that transformation an honor. I also believe that a doula’s support is meant to complement and enhance the care that is already being provided by those who are giving clinical support and by loved ones who are also present to help. In birth (as in most of life), there are no do-overs. That is why I feel it is imperative that a woman who will be giving birth is surrounded by people who understand and are sensitive to the significance of the moment.
I’ve wanted another baby since I had Felipe 16 years ago. At that time, I was living in a squat in the lower East Side of Manhattan with his father, a jealous man who already had two children with a woman he was still legally married to. My parents were here in MI and his parents lived in Puerto Rico. As if that wasn’t isolating enough, he was delusionally convinced that I conceived Felipe when cheating (I hadn’t) and that I lied to him in order to get pregnant (I didn’t). So, for 8 months, I had no affection from a crazy person who screamed at me every day that I needed to get an abortion because I was ruining his life. I otherwise enjoyed being pregnant and thought, “This would be so much better with someone else.” It just took me 16 years to find someone. It was worth the wait.
As far as hospital births go, I had a pretty good one with my son in 1998. After 22 hours of labor, I showed up at the hospital at 8 cm, 100% effaced and delivered him attended by midwives with three pushes about 1 and ½ hours after I arrived. Aside from several things that made getting breastfeeding off to a good start harder than it should have been, I was satisfied with the experience, but felt overall that being there was unnecessary and the staff were just in my way. I decided then that I wanted to have my next one at home.
This time around, making it to term was my goal. Both my parents were extremely premature and my son was a month early, so I didn’t expect to make it to 40 weeks. Still, I kept scheduling activities as though my due date wasn’t real just to keep my sanity. At 38 weeks, I started getting Braxton Hicks contractions daily. I had back labor with Felipe and never felt my uterus contracting, so I really enjoyed the repetition and rhythm of these sensations. At first, we took this as a sign that something was about to happen, but after a few days it got old. After two weeks, I just ignored them so as not to alarm anyone in public and tried to forget I was pregnant.
My due date was on a Saturday. The following Thursday, I had an appointment with my midwife, Susan Wente, at her office in Newaygo. We had already discussed having her strip my membranes and I was all for it. My elderly and bedridden grandmother had come to live with me around 37 weeks and it was getting really hard to take care of her with the big belly. I had help lined up to get me through postpartum recovery, but I felt like the lives of everyone involved were on hold for this baby and I was ready to give birth. Susan has a reputation for being successful in starting labors in this way. In fact, she told me that 60% of her patients go into labor within 72 hours. I knew that I was already 100% effaced and felt like this should work. Having it done was moderately uncomfortable, but it was over quickly.
At about 6 AM the following morning, I was lying in bed when my water broke. The fluid was clear and odorless. I texted Susan and woke up Matt to get me something to put between my legs so that I could get downstairs. I spoke to Susan on the phone. The night before, her dog got in a fight with a porcupine and needed medical attention. I hadn’t had any contractions at that point, so I told her to tend to her dog and I’d keep her posted.
The moment I stood up, I started getting contractions. I had enough time to tend to my grandmother, use the bathroom and call my bestie, Rachelle, to come over before they really started to demand my full attention. Rachelle started timing the contractions, which lasted 45 seconds to 1 minute with no break in between. I kept trying to wrap my head around relentless contractions at the onset of labor. It was the kind of labors people have in movies, but not in real life. I was hoping this was real, but kept thinking it wasn’t because I knew labor wasn’t supposed to be like this. My bestie got in touch with all of the people who were supposed to be there with actual experience: my midwife, my doula (Cindy) and my doula friend (Laurie). Rachelle timed my contractions, looking scared and concerned, while I instructed Matt (my baby’s daddy) in hip squeezes and sacral massages, the only things that were even remotely helpful. I stood up for each contraction, roaring through them. When they were over, I’d get on my knees, thinking I’d get a break, only to jump right up again. I started to doubt myself: there was no way I was going to be able to keep this up for 24 more hours!
I thought I’d try the shower. I stood at the back of the tub with the water on my lower back, but ended up getting out. I was in so much pain and there were no breaks and no relief. At the height of the contractions, I felt like my hips were stretching so far apart that they were going to snap and go flying in opposite directions. I was leaning against the bathroom wall, howling at the top of my lungs, when Janis Flint, the midwife’s assistant, arrived. I told her all of the things that I hear women say at births, but never thought I’d say myself: “I can’t do this! Make it stop!” And she said the simple words that myself and other doulas have said to so many other laboring women: “Of course you can! You are doing it!” What magic there is in positive support at that moment!
Somewhere between running around to find the supplies for the birth I had stored away and supporting me, Janis told me that, due to liability, she couldn’t check me for cervical dilation, but that I should reach down and check myself to see if I could feel the baby coming. Her request made no sense to me. It was as if she was asking me to fly a plane when I had never flown before. I tried to check myself, but didn’t feel a head. How much longer could this go on? Just about then, Susan arrived. I was never so happy to see anyone in my entire life and I’m not exaggerating. Her words of, “You’re fine. Your baby’s fine. Everything is perfectly normal,” was like stardust sprinkled over my head. She wasn’t just calm, she was cheerful.
Susan checked me and I was fully dilated. She asked me where I wanted to deliver. I was naked in my bathroom and my brother, grandmother and son were in the other room. I was in intense pain and wanted to not be in labor anymore as quickly as possible. We weren’t going anywhere. How did I want to push? I tried to get into a supported squat with Matt, but that was just awkward and uncomfortable. I got on my hands and knees on the bathroom floor and, leaning against the bathtub, pushed out my baby in three pushes.
My baby was wrapped in a towel under me while I was trying to recover from that whirlwind labor. I looked down between her legs and saw she was a girl and let Matt know. Felipe came in and cut the cord. Matt took off his shirt and held Chani Alice while I delivered the placenta and got cleaned up. By then, my other support people had arrived. Janis and I measured and weighed Chani. Laurie gave me a leg massage and gave us all a tour of Chani’s heart-shaped placenta before preparing it for a smoothie. Cindy helped me with breastfeeding. Matt contacted family and friends, who started arriving. It was 10:30 PM before everyone left and the house was quiet.
That’s my birth story for my daughter who came into the world one morning in the late summer of 2014, 20 ½ inches and 7# 9 oz.