The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”
Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients. This analysis shows that:
Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.
This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.
Tips for Choosing a Care Provider - great overview! from Henci Goer
[Please be advised that this article is about California law - other states'
laws may be very different.]
Watta's face was panic-stricken. I must have overdone staying calm,
because when I told her we needed to go to the hospital
for an ultrasound, she wanted to change her clothes, take care of little details around the house. No, NOW, I almost snapped.
I called labor & delivery from the car, told them I was bringing in a client; they asked me for my name, and hers. I spelled out
my name, first and last, then Watta's first name… "The last name is the same; she's my domestic partner." The nurse on the
other end lost her professional demeanor and became incredibly compassionate in her tone: "Just come in. Well be ready for
I cannot write the details of the hospital experience, yet. It is indescribable,
the moment when it is confirmed that your baby,
your dream, is dead. The doctors were…well, that part could have been better, but the nurse was amazing. I am crying now
as I think of her many kindnesses, small and large. Respecting our shock and grief, she reminded us that no matter what the
doctors said, we could just go home. The doctor came and offered us immediate induction, or a DIC panel and the option to
just wait for as long as it took, with weekly labwork. We had them draw Watta's blood; then we went home.
I have been trying for three months now to write about the emotional
experiences which ensued, but I cannot. However, I feel
that it is vitally important for other midwives to know how they can facilitate births for families who choose to have a stillbirth
in the privacy of their homes. Our daughter was born into the sacred circle of our family, in stillness and quiet and darkness. It
was the most beautiful and most painful moment of our lives. We feel blessed that we were able to completely preserve the
integrity of the experience.
The home induction took five days: evening primrose oil, cottonroot,
blue and black cohosh, castor oil, walks, acupuncture,
and more acupuncture. What worked was the combination of it all. The arrangements took five days as well, as if she didn't
want to come out until everything was ready. Not the physical arrangements—at 36 weeks, we had everything ready for the
birth, and the day after she died, a friend came over and set up the birth tub. But the bureaucratic arrangements, that part took
time, mostly because we didn't even know what we had to do. That’s why I want to write this article: not everyone has five
days and an incredibly supportive community to help sort it all out. Really it’s not that complicated. But since our baby died
on a Friday, we couldn't even find out what we needed to do until Monday. By Wednesday night, everything was in place. It
seems fast, but five days is forever if you are carrying your dead child in your belly.
As for the birth itself, that experience remains very personal and private.
It was beautiful. Watta and I both feel that everyone
who must birth a stillborn child should have the opportunity to do it underwater. The water kept her body warm and
supported her limbs, which became much limper- and floppier-seeming once she was out of the water. We held her in the tub
for an hour, just feeling her spirit.
So, the practicalities:
[Note: I have to credit my apprentice Julie Hunn with having done the
research which led not only to this article, but also led
to our home stillbirth going without a hitch. She spent many hours talking to county officials.]
First, in California, you need a doctor. S/He doesn’t have to be an
OB or a pediatrician or... anything. Just someone with an
MD. Without an MD signature confirming that the death was of natural causes, a stillbirth is classified as an unexplained death,
and is therefore under the jurisdiction of the coroners office, with an accompanying police investigation. Not that the police or
coroner will be disrespectful, but they do have to do their jobs, which include questioning the parents and performing an
autopsy on the baby. Even if you have proof that the baby died before the birth, such as an ultrasound report, they still have to
do an autopsy. And that means that they take the baby’s body away as soon as they can after the birth, within a few hours.
So you need a doctor. The doctor is technically supposed to be in attendance at the birth, but it may be possible to find
someone who is willing to arrive after the birth and examine the baby. When filing the death certificate, the doctor is signing a
statement that s/he was present at the birth, so legally, s/he must be there. (Although there may be some leeway for looser
interpretations of the phrase "attending physician.") This requirement puts some otherwise willing doctors in a bind because if
they are present at the birth, they may feel (or be) legally responsible for anything that happens during the birth, and many
doctors may feel that they cannot take on that level of responsibility. You may need to concoct a document absolving the
doctor of any responsibility beyond examining the baby.
Our local midwifery community really came through and found us the perfect
doctor. A few pediatricians whom I had met
surprised us by refusing to come, but we located (well, Julie and the network of midwives located) an incredibly kind family
practice doctor who had himself lost a child at 33 weeks gestation a few months earlier. He agreed to be on call to attend the
birth if we wanted (although he had to be clear that he could not be responsible for the birth itself), or to come immediately
afterwards if we preferred. We felt more comfortable calling him afterwards (not to mention that when the baby came, she
came quickly). It was important that we had done the ultrasound, and had a report confirming that the baby had died before
labor began, as having the report in hand made the doctor feel more comfortable about the whole matter. He was incredibly
respectful of our space and of our daughter. We held her in the birth tub until he arrived, and then we handed her to the
midwives to weigh her. He held a stethoscope ever so gently to her chest, and we could tell that he saw her true beauty, just
as we did. He accepted no money from us.
[When Julie read this article, she let me know that by the time Cedar
was born, the midwifery community had actually located
five physicians willing to do the job. Sending out a call across the community network got amazing results.]
The doctor must file a certificate of fetal death with the county health
department. For us, this meant that he had to personally
spend part of the morning after the birth down at the health department. Julie had already gotten a death certificate template
and had us fill out everything except the gender of the baby (we had chosen a gender-neutral name), to minimize questioning in
the intimate hours following the birth. Apparently it took some persistence to get the fetal death certificate template to fill out
ahead of time; it’s not standard procedure, but they can write "void" across one and give it out. As far as we can understand
it, you are not allowed to transport the body from the location of the birth to any other location until the death certificate is
filed, unless by ambulance or by the coroner. A fetal death certificate is necessary for any stillbirth which happens after 20
weeks gestation; before 20 weeks, there is no legal requirement or mechanism to file papers with the state. Depending on
your county, a family member or funeral director may even be able to take a blank certificate and fill it out at home, get the
MD signature, and file it without the doctor having to go down to the Vital Stats office.
If you cant find a doctor, other options include calling an ambulance
once the baby is born and transporting to the hospital,
where they have mechanisms for dealing with the practical matters. But I am under the impression that in this case, the coroner
is still involved, taking the choice of whether to have an autopsy out of the parents hands. Or, you can just call the police, and
they will come and call the coroner themselves. The coroner will pick up the body from your house, and no one else will have
to leave. But you never know how your local police and coroners office will react to this situation. I think it would be best to
alert them in advance of your plan to birth the child at home, rather than surprise them.
Not involving the coroner does not mean that you cant get an autopsy
if you want one; it just leaves the choice up to the
parents. You can arrange for an autopsy through your local hospital. We chose not to get one done, which is a decision that
was right for us, but leaves us with a lot of questions. We did take the placenta in to a pathologist a few weeks after the birth;
it stayed in our freezer until we made that decision. Of course, nothing can answer the really big question: why did my baby
die? No matter how many medical explanations are given, that question will always remain. I feel that had we chosen an
autopsy, the search for an explanation would have distracted us from the more profound spiritual experience. But for Watta,
having those questions unanswered is very hard now. Families can only decide for themselves what they need; different
families will choose differently.
You need to decide ahead of time where the body will be buried or cremated,
or at least what funeral home you will use, if
you use one. This information is needed for a Disposition of Remains form, which must be filled out at the same time as
the death certificate. If you are not positive, a good faith answer will do, but it will smooth the process considerably to have
the correct information on the form from the beginning. Family and friends can help locate a good cemetery or crematorium,
while preparations for the birth are still underway. Our doctor appointed himself as the funeral director, but a family member
can also serve as ("in lieu of") the funeral director. Some county offices are unfamiliar with the right of family members to take
this role, but it is clearly printed in the law. You can also use a funeral home, and they will do the paperwork, but you cannot
transport the body there until the death certificate is filed. If you don’t use a funeral home, the cemetery or crematorium will
need a copy of the Disposition of Remains and the death certificate, so make sure to pick one up when it is filed. [Note:
Home burials are illegal in California. You may not receive a death certificate for anyone who will not be buried or cremated
in a legally designated cemetery or crematorium, so do not try to file one.]
For us it felt right to keep Cedar Makai at home until we buried her.
A friend of ours got in touch with the Natural Death Care
Project (NDCP), and they helped a lot with knowing how to simplify everything. We got a large ice chest, put ice in the
bottom, and then covered the ice with chux to keep the body dry. We also wrapped chux around ziploc bags of ice and
placed these around her body. We kept the ice chest closed, except for once a day we took her out, cuddled her, and
changed the ice. We were very afraid of the body decomposing, as the NCDP folks weren't sure how long a stillborn baby
will "keep," as decomposition can begin to occur in utero. Cedars skin was exceedingly fragile, after having only been dead
for five days inside the womb. She was born Wednesday night, and buried on Saturday morning, without any further signs of
decomposition at all. In retrospect, I wish that we had not been so worried about keeping her cold, and held her more. But it
was nice having her there with us. We placed her ice chest on a dresser in our bedroom, and decorated it beautifully.
Someone was always with her.
The other factors which have made our home stillbirth a beautiful, if
painful, memory came out of the support we received
from our community. Cards, poems, and letters arrived daily. A friend made us a gorgeous casket from sustainably harvested
wood. Many, many people gathered in our back yard at sundown the day after the birth, and cried, wailed, sang songs, lit
candles, left flowers and otherwise lent us strength, without asking for any energy from us: we stayed in the bedroom with
Cedar and watched through the window as people came and went for hours, helping us carry our grief. Our families gathered
for the funeral. We had an amazing postpartum doula come. A lactation consultant helped Watta with engorgement, and
provided information on both drying up milk and donating to milk banks, allowing her to make her own decision (she pumped
and donated). People magically showed up to walk our dogs. And we didn't cook for a month; fairies brought food every
day, including a huge Thanksgiving feast, which was waiting on our doorstep when we returned from spending the day at the
gravesite. We are grateful for all of these things, these gifts which our daughter brought us.
Please keep this article in your files somewhere. I hope you never need
it for any of your clients. But if you ever are in a
situation where a family wants to have their stillbirth at home, I hope that you will support them. I used to recoil when I heard
stories about midwives burying babies in backyards. Now I feel that the family should be able to choose whatever they want
to do, even if it is not state-sanctioned. But it would help families to know that there is a way to completely preserve the
privacy and dignity of the birth and the death, without going outside of the bounds of the law. The Natural Death Care Project
is a great resource, and does consultations; they also have an informative website. You can contact them at:
The Natural Death Care Project (NDCP) - www.naturaldeathcare.org
I would also be more than willing to help in any way possible. I can be contacted at firstname.lastname@example.org.
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