“All About Home Birth, Part 1” – With Midwives Lauren Abrams And Susanrachel Condon

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Lauren, Susanrachel, welcome to the podcast. Thank you so much for joining.
Lauren: Thanks, Natty.
Susanrachel: Thanks for inviting us.
Dr. Fox: Unbelievable. So, this is gonna be a really interesting podcast, I think. Lauren and Susanrachel, who also you go by Birdie, so that’s what I’m gonna be calling you for the podcast, are both midwives. Lauren has been on the podcast before a couple of years ago, and Birdie is new to the podcast. And we’re gonna be talking about I think a really interesting, and possibly, unfortunately, I would say, a controversial topic, which is home birth. So, thank you, guys, for both agreeing to join me and to talk about this, and hopefully, our listeners will appreciate what they get from us. And clearly, the three of us are coming at this from different angles, and that’s intentional. So, I’m gonna give you guys a chance first just to introduce yourselves so our listeners know who you are. Lauren, I’m gonna let you go first. You can just give our listeners a brief overview of who is Lauren Abrams.
Lauren: So, Lauren Abrams has been a midwife now for almost 30 years. I’ve worked in mostly the hospital setting, but I did spend five years in a birthing center in the South Bronx. I’ve been at Mount Sinai now, my most recent place of employment, for 20 years where I see mostly patients who are either high-risk or medium-risk. I attend birth in the hospital and see patients in the clinic. I’ve also done some overseas work. I was a Peace Corps volunteer and I also have done some midwifery work in Guatemala. So, that’s sort of an overview of my midwifery career.
Dr. Fox: Awesome. The high-risk midwife,
Lauren: Right. The med-wife.
Dr. Fox: Well, I like that. All right. And Birdie, tell us a little bit about yourself.
Susanrachel: Well, I have been a midwife in practice for about 22 years. And what happened for me when I finished midwifery school was I had intended to go into homebirth at some point, but I’d planned to get a job and worked for a couple of years first. And when I got out of school, there were no jobs. So, I started assisting an established home birth midwife who had some health problems and needed a lot of support and assistance. And I was working in New York City, attending home births with her and doing comprehensive care, because midwives do all prenatal care and screening and attend births and do postpartum screening and postpartum care and neonatal care and lactation support. So, we were doing full-scope perinatal services.
And then, I actually moved to a rural area about 100 miles from New York City, and I started a home birth practice at that point very, very slowly and gradually while I was also working per diem at Planned Parenthood, so doing ambulatory care. And then, that private practice in home birth grew and grew and grew, and my partner and I got very dizzy and I decided I had to leave the ambulatory position and I worked in home birth since then. I also do a lot of perimenopausal and postmenopause care, sexual counseling and sexual health, as well as cancer screening and hormone therapy. So, I have a pretty big scope, even though my biggest place is in home birth.
Dr. Fox: And so, I was gonna ask as a follow-up question to both of you. What is your personal experience with home birth? So, obviously, you’ve had the most… So, for how many years have you been doing it, you know, I guess if not full-time, you know, most-time?
Susanrachel: For me, I have been attending home births since 2004 full-time, and since 1998 altogether. So, I’m not gonna do the math, but however many years is that.
Dr. Fox: No. The three of us all sort of started our careers around the same time, which is… I didn’t realize that. I’ve never thought about it, actually, but it is interesting that we all came up at the same exact time. So, I guess that’s…
Susanrachel: Wow.
Dr. Fox: Yeah. So, we got different angles of the same timeframe. And so, currently, approximately would you say how many home births are you attending, you know, a week, a month, a year, however you count them?
Susanrachel: Well, our practice does probably, I would say, 7 to 10 a month.
Dr. Fox: Wow.
Susanrachel: And, you know, the way that we look at it is, for each home birth, each home birth is a 40-hour work week because you’ve got that person’s prenatal visit, you’ve got the birth, however many hours that is, and there’s the travel time to their home. And I live in a rural area, so we travel pretty widely. And then, we do actually a tremendous amount of postpartum care in the first week, which is something a lot of people don’t realize. So, we go back and see the baby and see the breastfeeding diet, as you would. We would see them between 24 and 48 hours because of the cardiac screen and jaundice screen. And then we go back on day three to check weight gain and see that the meconium has passed and all those things. And we come back on day 7, and then again at day 14. So, each time somebody has a baby on any given day, that person, that family, represents generally a 40-hour work week. So, we’re very, very busy.
Dr. Fox: Yeah. No, that makes a lot of sense. What about you, Lauren? I know that, you know, currently Mount Sinai you’re not doing any home births, except apparently there were three births in the lobby and the elevator last night, so whatever.
Lauren: For some reason, I think because we’re having this podcast, three unplanned out-of-hospital births last night. So, my personal experience with home birth, I have attended one home birth in Guatemala. I was there to teach some community midwives to do some teaching about handling obstetric emergencies. And one of the community midwives was actually a student midwife and asked me to attend a birth with her as sort of as her preceptor. And so, she and I attended really a lovely birth in a small village in Guatemala. And that was the only home birth I’ve ever attended. I’ve never attended a home birth here. I did personally plan a home birth with my first pregnancy. I did not have a home birth with my first pregnancy, and that’s another story. But the labor at home, I did enjoy that part of it.
Dr. Fox: Meaning you were a planned home birth and the plan changed mid-labor, not before labor?
Lauren: The plan changed. Exactly.
Dr. Fox: Okay.
Lauren: Mid-labor. I arrested. You know, I had arrest of dilation, went to the hospital, got Pitocin augmentation, eventually got to fully dilated, but then had a C-section for arrest of descent.
Dr. Fox: There you are. High-risk midwife.
Lauren: Yep. Yep. Exactly.
Dr. Fox: That’s so you, Lauren.
Lauren: Exactly.
Dr. Fox: All right. And so, you know, for full disclosure, I have no experience with home births. I’ve never attended one. I think one of my relatives had one, you know, for… This is, you know, we’re talking 40 years ago. But I have very little experience with it personally, so I’m gonna be doing mostly asking questions as opposed to giving statements, so just everyone knows where we’re all coming from. So, I wanted to start with, what are your thoughts on why is this such a hot topic in the U.S.? I mean, whenever it comes up, in my experience, people have such strong feelings about this. I mean, way stronger than anything else, right? Except maybe politics. But they’re very much like, “Home birth is amazing. It’s the greatest. It’s so much better than hospitals. I’m so for it. I really love it.” And other people are like the exact opposite, like, “You’re insane if you have a home birth.” And there’s like not that much in between. And I’m curious why you guys think that is.
Susanrachel: I would say there’s a lot of conditioning starting from the time where very little that, you know, facility-based birth is sort of normalized so that it seems very odd to not go to a hospital to have a baby. And in our area of the country at least, there are very, very few birth centers. So, we’re really talking about hospital or home. And when you look at the statistics, even though there are tremendously increased numbers of home births over the last couple of years, I mean, astonishingly. It has doubled. It’s still under 2%. So, it’s not something that a lot of people get exposed to in their personal lives unless they’re kind of dancing in those circles anyway. So, what we see is we see a lot of TV and movies, and it’s always very dramatic and something terrible always happens. You rarely see somebody just have a baby. The only example I can think of of a beautiful birth in a film was “The Scarlet Letter,” which Joan Plowright played the midwife and Demi Moore was Hester Prynne. And it was the most realistic, beautiful birth I’ve ever seen in a film.
Dr. Fox: Wait. Not Phoebe’s triplets on “Friends.”
Susanrachel: No. Exactly what I was gonna say.
Dr. Fox: That’s not realistic?
Susanrachel: That is the only episode of “Friends” I have ever seen because everybody said, “You have to see this.” And then I watched it and I just [inaudible 00:09:23] myself because I thought, “Okay, that is ridiculous.” But exactly. I mean, everything that we see is so over the top and so unrealistic and so fictitious that people don’t really have a grasp on what normal birth looks like, and also because it has been taken away from the family and the community and put in a place where sick people go, we associate it with sickness or danger or emergencies.
Lauren: Right. I agree with Birdie. And I think, you know, if you go back and look at the history of midwifery in this country, I think you can sort of see the reason for that. People had home births, attended by community midwives, that was the most common way to give birth, up until about the 1910s, ’20s, ’30s when really the history is that physicians began to realize that they could actually greatly increase their income by delivering babies themselves in the hospital. And there was a real cultural shift. Midwives were started to be considered “dirty.” There’s a lot of racism involved too because there were many community midwives in the south who were traditionally people of African descent. And birth in the home was considered unsafe, was described as unsafe by the mostly white male physicians. And so, birth generally moved into the hospital from the home. And the midwives didn’t go with.
Susanrachel: [crosstalk 00:10:58].
Lauren: No. And the midwives did not go with. No. And midwifery got moved at that point into nursing schools in this country, which is very different from the midwifery training in other countries. It’s a completely separate profession from nursing. And here, it was moved then into nursing schools in an effort to sort of regain credibility. But what that ended up doing was really limiting access to midwifery education and pushing midwifery sort of into its own area. That’s where the history comes from and that’s why we’ve sort of over the years associated birth with danger, with infection, with the need for hospital care.
Dr. Fox: When you guys are in, let’s say, social circles and people say, “What do you do?” And you say, “I’m a midwife,” what is typically the first response you get from folks? I’m curious. Lauren, what do you get?
Lauren: Mostly it’s, “Wow. What a great job.” That’s what I mostly get.
Dr. Fox: Okay. And you’re like, “No, it’s not. You try taking a call at Mount Sinai. See what happens.”
Lauren: You’re right. You’re right.
Dr. Fox: Birdie, what about you in the first? And then the second question is do they assume you’re doing home births because you’re a midwife? A lot of people just assume that’s what happens.
Lauren: Yeah. To answer the second part of that question, yes. Most people do assume that I attend home births.
Dr. Fox: Okay. Birdie, what about you? What do you get when you tell people you’re a midwife and then when you tell them I do home births? Are they fascinated? Do they just, like, pepper you with questions?
Susanrachel: It really depends on the demographics of who I’m talking to. Very often I get, “Oh, that must be so wonderful.” And I’d say, “Well, when it’s great, there’s nothing better. When it’s bad, there’s nothing worse.”
Dr. Fox: Right.
Susanrachel: It really runs the full gamut, because people don’t really think about it just like, you know, birth it must be a happy event and that kind of thing. And do people assume that I do home births? That’s really interesting. I think it’s 50-50. I think it really depends on who I’m with. But when they do ask, you know, if I say yes, no one is surprised, I don’t think. But that has changed. I don’t think that used to be the way it was. I don’t know.
Dr. Fox: Interesting.
Susanrachel: Yeah. I think it varies a lot.
Dr. Fox: Well, and I’m curious… I know, Lauren, you know, you’re a midwife and you practice in a hospital and, Birdie, you’re a midwife and you practice, you know, doing home births. I wanna get what your thoughts are on deliveries in hospitals. And that can range from, “I think they’re great. I think that they’re sort of good in concept, but they’ve gone a little bit too overboard with, you know, medicalization,” or they’re just like, “It’s a bad idea. We should get births out of there unless absolutely necessary.” And again, that’s arranged and this is…you know, you’re free to give any opinion you want. I’m curious what you feel about this. And I’m really curious because you guys have very different practices as midwives.
Susanrachel: Yeah. What I feel about that is actually a range. And I think it really depends on the person, how healthy they are, and what their desires are for their birth experience. I believe 100% that home birth should be absolutely available and actually should be integrated into the healthcare system for all women who want that and all women who are healthy enough to have a safe home birth. And many women do fall into that category. So, I really feel that it should be a completely integrated part of our labor…or our birthing system, basically. I’m also very glad that hospital birth is available to people who need it. I work with many, many women who have many underlying medical conditions that make pregnancy and birth dangerous for them, including just, you know, the basic stress of living in poverty and living with racism that can lead to things like hypertension and diabetes and, you know, all kinds of medical conditions that make it more dangerous to give birth at home. And so, I’m very glad that hospital birth is available to those who need it. It was really based on quality research and working with lots and lots of stakeholders from different disciplines, including consumers.
Dr. Fox: How exactly has it been a game changer? Do you mean in terms of making it safer, making it easier to practice, or, like, what exactly did you mean?
Susanrachel: Well, it means that you have a formal response. There’s an MFM in our area who is not my favorite person to collaborate with.
Dr. Fox: Oh. Shots fired. All right, here we go.
Susanrachel: She has said some really, really unfair, inappropriate things to our clients in the past. And one of them, she put this woman in tears. The woman came to me for a prenatal visit and said, “So, when I told the MFM that I was [inaudible 00:15:56] and I was planning a home birth, she looked at me and she said, “Oh, really? What’s your midwife gonna do when you’re bleeding out?” Which was a really inappropriate thing to say. And the woman was very upset about it. And I said, “You know what? I’m gonna send her our protocols and I’m gonna invite her to lunch.” So, I sent her the entire document, which is like 40 pages, and I said, “See page blah, blah, blah.” It’s not like, what do we do? We’re not knitting in the corner hoping for the best. We’re actually clinicians and we know what to do if somebody hemorrhages, and it’s really unfair and inappropriate for you to speak that way to a patient.
Dr. Fox: How did that lunch go?
Susanrachel: She never responded to my letter. But I felt like I had something in my…
Dr. Fox: Right.
Susanrachel: She hasn’t talked to other people who are clients of mine like that since. And in a way, I feel like I made my point. Anytime you wanna sit down and discuss the home birth guidelines, I would be delighted to meet with you. You want coffee? Great. You want a beer? Great. I’ll take you to lunch. And it was me saying, “I have protocols. I have guidelines. I follow them. And I’m happy to engage. But I want you to know so that you can feel assured that I carry IV equipment. I have the tools and I have misoprostol. And I know how to, you know, stop a hemorrhage. And if it’s not appropriate to transfer after a hemorrhage because either somebody is not hemodynamically stable or I think they need a transfusion, I’ll take them in. I will stabilize them first. I have a protocol. So, you know, just that. But also there have been those regional perinatal centers have written their own documents so that it is less likely that a midwife is gonna bring in a baby and say, “Look, you know, I resuscitated this baby. I’m not really happy with her tone. And I’d like for her to be evaluated.” And then for them to have them sit there, you know, in the ED for 10 hours because they’re punishing them. And these are the kind of things that used to happen. And fortunately, they happen less and less.
Dr. Fox: Lauren, has that been your experience as well about maybe the attitude in the community around home births?
Lauren: Yeah. It was a little less extreme than that. I had an experience here when I was director, and I was part also of the New York City Midwives, there was a lot of talk about how to create relationships between home birth midwives and hospital midwives to help facilitate those transfers. Because in a way it really does make sense since the majority of transfers are for labor dystocia where a woman may just need a little, you know, rest and help with the labor and is not very high-risk. It would be very appropriate to transfer to a hospital midwife to continue the care. So, during that whole discussion, I approached the leadership at Mount Sinai, and the people who were the leaders then are not the current leaders.
And the response, I was… I actually got a much better response than I expected. I expected, you know, them to sort of throw their hands up in horror and say, “Oh, my goodness. No, we’re so viable. We could never do this.” What they did say was, “We are concerned about the liability if we have a formal agreement for home birth. However, we understand that this will increase the safety of home birth and home birth patients. And if you have, as an individual midwife, received a phone call from somebody, you, you know, can use your judgment and accept them.”
And so we did actually have…we have had actually had several transfers, one for an induction at 42 weeks and one for a labor dystocia. There was another one that actually did not go that well. It was a woman who had a postpartum hemorrhage and came in and was not stable. But for the most part, they were really good experiences where the midwife would call us, we would take the patient, we had all of her records and we would just sort of take the care to that level because that particular woman needed it. It doesn’t happen a lot. And I was disappointed that we couldn’t formalize the relationship. I would’ve loved to have had a document, you know, that we could sign and the leadership here didn’t feel comfortable doing that. But they did express understanding of the rationale behind it. And I did get support in those individual cases that I was really happy about.
Dr. Fox: That’s cool. Guys, thank you so much for coming on the podcast to talk about home birth. I think this has been a really great start to the conversation. I’m gonna have you both on next week to talk about, for those of our listeners who are interested in themselves in a home birth, what kind of question should they be asking and how can they find a provider? So, thank you guys so much. We’re gonna have you back on next week. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
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