Trust newborns?

When I created Hurt by Homebirth, I anticipated stories of homebirth gone wrong. I anticipated stories of life threatening disasters that occurred without warning, like abruption, and babies who succumbed to lack of oxygen during labor and were unexpectedly born without a pulse. I did not anticipate many stories like Angela’s story.

Angela was born at home apparently healthy, developed subtle signs of severe illness and died less than 24 hours after birth. It is strikingly similar to Mary Beth’s story and Wren’s story. If these stories on Hurt by Homebirth are any indication, such tragedies may be far more common than we realize. Moreover, they represented yet another unjustified assumption at the heart of homebirth advocacy.

Homebirth advocates routinely counsel women to “trust birth” or, as in the startlingly stupid formulation of the CIMS’ Mother Friendly Childbirth Initiative:

Women and babies have the inherent wisdom necessary for birth.

Let’s leave aside for the moment the fact that neither women nor babies have “inherent wisdom” about birth. Let’s also leave aside the fact that childbirth is, and has always been, in every time place and culture, a leading cause of death of young women, and the leading cause of death of infants. Even if birth were trustworthy (and it most definitely is not), a newborn can face a host of common, yet deadly threats.

Homebirth advocates explicitly counsel “trust,” but can a newborn be trusted to master breathing difficulties, circulatory problems and infections?

Within the first 24 hours, a newborn must:

1. Learn to breathe

Babies are born with non-functioning, collapsed lungs. The baby must generated the force necessary to expand those lungs (think blowing up a balloon), must be able to keep the lungs fully expanded (special substances produced in the lungs make it easier to do so), and must master and be able to sustain the effort of regular breathing.

2. Switch its circulatory system from fetal pathways that transport oxygen from the placenta to new pathways that transport oxygen from the lungs.

The fetal circulation bypasses the non-functioning lungs, whereas after birth all blood must circulate through the lungs to pick up oxygen. Bypass routes exist in both the heart and the lung blood vessels. Those bypass routes must close in order for the baby to survive.

3. Fight off the bacteria and viruses encountered in the vagina.

The primary infectious threat to newborns is not bacteria and viruses in the air, but bacteria and viruses in the vagina. Group B strep and herpes are potentially deadly threats that can begin attacking a baby during birth. Because of their immature immune systems, newborns are uniquely vulnerable to these threats.

Problems with any of these three tasks, particularly early problems, may show only the most subtle signs, signs that may not be recognized by anyone but a medical professional.

1. It is obvious whether or not a baby begins breathing, but it may not be apparent that a baby is having trouble keeping his or her lungs open or maintaining the fast breathing rate that newborns require. Newly expanded lungs have a tendency to collapse and it takes a considerable amount of effort to keep them open.

The baby produces a substance (surfactant) that dramatically lowers the amount of effort needed to keep the lungs open, but even slightly premature babies may not have the amount of surfactant needed. The problem is often not immediately apparent, since the baby does begin breathing and maintains a normal breathing rate. However, the effort required is enormous and within hours, the baby begins to tire, can no longer fully inflate his or her lungs and therefore cannot get enough oxygen. The signs are subtle, and a parent may not realize that there is a problem until the baby stops breathing altogether.

2. If the the fetal circulatory bypass of the lungs fails to close, the baby will breathe, but won’t send nearly enough blood through the lungs to pick up adequate oxygen. If the bypass stays wide open, the baby will turn blue (cyanotic heart disease). Even then, a parent may attribute the baby’s poor coloring to the unusual coloring of newborns.

If the bypass remains only partially open, the signs will be even more subtle and even harder to recognize. The parent may not realize there is a problem until the baby stops breathing altogether.

3. The infectious threat is particularly insidious. A baby may be born appearing entirely healthy, but the bacteria picked up in the vagina (such as Group B strep) may already be invading and multiplying in the baby’s tissues, particularly the baby’s lungs.

When an older child develops pneumonia, it’s hard to miss. The child is usually coughing, has a fever, and may complain of chest pain. In contrast, a newborn can quickly develop pneumonia without ever coughing and with only a low grade fever if any. Over time, the baby very gradually develops subtle breathing difficulties such as small noises during breathing. The baby continues to struggle, getting ever more ill, but the parent may not realize that there is a problem until the baby stops breathing altogether.

There’s a theme here: the signs of serious newborn illness are subtle can often can be diagnosed only by a medical professional. In a hospital, the baby can be examined by a pediatrician. Even more importantly, there are always nurses about, nurses who have been specifically trained to recognize subtle signs of newborn illness. At home, there is only the midwife. Homebirth midwives have very little training in recognizing newborn problems (after all, there aren’t supposed to be any problems) and are gone within an hour or so. The parents are on their own, without any counseling about what to look for.

There is one warning sign that every parent of a newborn should be taught to attend to: a baby who refuses to nurse.

Nursing takes effort away from breathing. A baby using every bit of its energy to get enough oxygen has no effort to spare. The baby may latch willingly but quickly become hypoxic and release the latch in order to expend its effort breathing.

Homebirth involves a great deal of misplace trust. It’s bad enough that homebirth advocates trust birth, but most don’t know enough about childbirth to know any better. But does anyone really “trust” a newborn to master breathing problems or fight off serious infections without help?

Who is supposed to be trusting whom here? Should a homebirth advocate trust her baby to handle serious health problems? Or should a newborn be able to trust his or her mother to give birth in a place where those with the requisite training and experience can diagnose subtle signs of serious illness?

These questions never crossed the minds of mothers and fathers who lost apparently healthy babies in the hours after homebirth. They have generously shared their pain in the hope that it will cross yours.

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