For midwives, doulas and childbirth educators, an often over-looked aspect of caring for a mother and family is preparing for the possibility of cesarean, and knowing what to do in the event that one does become necessary. Many birth professionals express uncertainty around how to approach this sensitive topic without seeming negative, and feel that they are inadequately trained on the proper care for mothers after surgery. In this introduction to the work of Homebirth Cesarean International, the founders address the unique needs of the HBC mother and mitigating her potential trauma, beginning during the prenatal period.
My midwives talked about why we might transfer and what we would do in that case, but they never talked to me about the possibility of a cesarean. Can you imagine teaching pilots how to fly planes, but not what to do in a crash landing? Empowering women means giving them a complete set of tools, not treating them like children who can’t handle hearing about the tough scenarios.
- Beth, Oregon. Mother of Dylan (2009)
Home births that end in cesareans often go unacknowledged in the natural birth community. To most women who seek an intervention-free birth at home, cesarean represents an undesirable outcome, leaving these mothers feeling marginalized and traumatized by their experience. While the percentage of women who transition from having an out-of-hospital birth to a cesarean is small, their stories are nonetheless powerful. As midwives and birth educators, it is critical that we are well-equipped to prepare families who are aiming for a home birth for the possibility of cesarean, and to support them in the days and weeks afterward. These families are known as “home birth cesarean” (HBC) families, and their needs are unique.
The need for cesarean education
Many midwives express that their midwife training provided minimal information on preparing mothers for the possibility of cesarean and how to help them post-surgery. Yet, midwives typically continue care with home birth cesarean mothers, filling the institutional healthcare gap left when families are discharged from the hospital. But they are not adequately prepared. Often a new mother will need professionals to assess her postpartum physical and mental well-being, and to help with wound care. A mother recovering from an unexpected surgery needs a postpartum care plan that a home birth does not always cover.
Maura, a graduate of a leading, accredited midwifery school says, “Based on my school experience, I was not adequately prepared in caring for clients who transport to the hospital and need a cesarean.” Midwives interviewed by Home birth Cesarean International (HBCI) said that they are rarely, if ever, allowed into the operating room during a cesarean, that they have little access to the information they need to care for cesarean families, and that they often have little support from OB/GYNs for their home birth practices. This need for information, education and support is at the heart of HBCI’s work with the birth community.
Prenatal preparation for families
We had a total of two transport conversations that I specifically brought up. My midwives were great about all my questions. They were very much, like, “We are going to try whatever we can at home, but if at any point something seems like a danger to you or the baby, we are transporting.” They had a very healthy view towards the hospital where it’s a tool that may need to be used. But cesarean was never mentioned.
- Brandy, Wisconsin. Mother of Micco (2011)
The lack of discussion of cesarean is all too familiar for many mothers sharing the HBC experience. Fear, desire to “stay positive,” or even just oversight, are the reasons for cesareans exclusion in prenatal conversations, and broaching this topic is not always easy for midwives who are not educated in HBC issues. In regions of the United States where certified professional midwifery practice is legal, midwives are minimally required to complete a written hospital transport plan nor explain to clients what constitutes an emergent and non-emergent transport. Despite the fact that there is not a legal requirement to discuss cesarean, failure to provide the information the family needs on the topic is a mis-step for a good midwife. This lack of conversation can increase the level of stress for everyone and may result in a difficult emotional and mental transition for the mother if surgical birth becomes necessary.
Bringing cesarean into the prenatal conversation, midwives, doulas, and childbirth educators should avoid illustrating birth as being unpredictable and out of the woman’s control. An alternative approach is to describe the hospital in positive terms, in order to begin building seeds of trust and understanding in the case of transport and cesarean. Another idea is to encourage clients to take a tour of the hospital to gain a sense of familiarity and comfort if the need for transport should arise. Some midwives make a point to discuss cesarean during prenatal visits so families can emotionally prepare for a potentially difficult conversation.
Prenatally we talked about different transport scenarios. Our midwife told us what we needed to know so my husband and I could discuss what we were comfortable with and under what circumstances we would want to leave home. When we actually did need to transport, we didn’t question whether we would go or not; we had a plan and we knew what to expect. It was good to have the information we needed ahead of time because we weren’t thinking very clearly in the moment.
- Heidi, Florida. Mother of Olivia (2003, HBC), Ellah (2008, VBAC) and Jett (2009, CS)
The conscious cesarean decision
Once at the hospital, it may become evident that a cesarean is a mother’s best, or only, option. This decision must be handled with care, and ideally, the mother and her partner have had ample time to make a consensual decision. In order for a mother to make a cesarean choice, rather than simply consenting to a cesarean, the midwives need to prepare the family to advocate for themselves, clarify reasons for cesarean, offer options, and negotiate for the must-haves that the family desires. A mother who is aware of her options and supported by her birth team is able to speak from her heart and make active decisions for herself and her baby. This ability carries over a key component of the home birth experience.
In the postpartum period, home birth cesarean mothers often have needs that go above and beyond those of a home birth mother. Many midwives are still unsure of what HBC mothers need, as these mothers are often unsure themselves of what would help. Corrine (CPM) says, “As a new apprentice I remember feeling under-prepared for the postpartum visits with the mamas who gave birth surgically. I didn’t know what to do to emotionally support them. I felt as lost and as alone as the moms probably did.”
Brooke, a labor doula and therapist, says, “It’s difficult when it doesn’t go the way a mother planned. These mothers are often so hard on themselves. Complimenting them goes a long way when they are so vulnerable. They might not be able to hear the kind words, but if they can, it’s great.”
Home Birth Cesarean International (HBCI)
The organization Home birth Cesarean International began as a conversation between Courtney, a mom whose dream of having a home birth became the reality of a cesarean and Laurie, her midwife. Realizing that birth professionals were not receiving the support they needed in order to fully care for HBC mothers, we began our research into the home birth cesarean experience by interviewing nearly 200 mothers, midwives, doulas, perinatal educators, physicians, therapists, and birth experts around the world; providing evidence for our forthcoming book and a goal to continue to provide support and education to birth workers and families around home birth cesarean. We also provide the following workshops for midwives, doulas and childbirth educators to take steps to educate themselves and evolve their practice:
Home birth Cesarean Workshops
These glimpses into the HBC experience inform the material for our ground-breaking continuing education program for birth professionals.
Our workshop series includes the following courses:
1. Speaking of Cesarean: Empowering midwives and birth professionals around difficult prenatal conversations about the possibility of cesarean
2. Transitioning to Cesarean: Supporting women to birth with dignity and power as they transport from home to the operating room
3. After a Cesarean: Caring for the physical, mental and emotional needs of the HBC family
HBC classes give specific dialog, concrete tools and education that attendees often don’t receive at school or from other training courses. These classes also help birth professionals understand their own discomfort around homebirth cesareans. For info about upcoming workshops or speaking engagements, email firstname.lastname@example.org
The home birth cesarean book, coupled with our workshops, aspires to bring deeper understanding to these unrecognized births, to celebrate the women transformed by a home birth cesarean, and to give childbirth and postpartum professionals the tools they need to support families prenatally, during transport and cesarean, and in the postpartum year.
Courtney Jarecki is an HBC mama, co-author of the upcoming book on HBC and co-founder and Executive Director of Home Birth Cesarean International (HBCI), a non-profit organization whose mission is to promote healing and support for women whose planned out-of-hospital births ended in the operating room. Laurie Perron Mednick is a Certified Professional Midwife, co-author and co-founder of HBCI. Ann Jamison is an HBC mama, co-founder and Executive Program Director of HBCI. Together they are advancing the conversation around what empowered birth means in our time. Conducting several interviews, their research serves as the foundation for their forthcoming book, which follows the home birth cesarean journey from pregnancy, labor, birth, and beyond the postpartum year. Home birth Cesarean International (HBCI) aspires for the continuation of support and education around the very real experiences and stories of Home birth Cesarean mothers. For info about upcoming workshops or speaking engagements: email@example.com or www.homebirthcesarean.com.
Whether you want to become a midwife or you are already a maternal health professional, it is a good idea to educate yourself about how to support women whose planned home birth ends in cesarean. Make an effort to learn about this important topic during your midwifery education, and begin finding ways to prepare mothers for the possibility of cesarean through your clinical experience.