One woman's path through doula training, childrearing, and a computer science Ph. D. program

Monday, February 13, 2012

Choosing a birth facility in five easy steps

How do you choose where to give birth? This post attempts to answer the question of how to choose where to give birth -- where to look for data, and what questions to ask yourself.

In the region of the US where I practice, for low-risk pregnancies, there are basically two options: birth at home with a midwife, and birth in a hospital with whoever happens to be on call (sometimes this is your own doctor or midwife).

Birth at home

Choosing a safe homebirth requires forethought. I am not an advocate for unassisted birth, with no medical professional on hand to help. I think that choosing a homebirth is a big deal and requires sufficient preparation. Selecting a homebirth midwife is a lot like selecting a doula, except there is more responsibility involved in a midwife. (And, you should have a doula as well.) Here are some things to ask your midwife when you consider birth at home.

  • How long do you spend in prenatal visits with me? Midwives are known to spend longer in each prenatal visit with their clients than obstetricians or doctors.
  • How do I prepare and educate myself for birth? Some midwives teach their own homebirth childbirth preparation classes.
  • When I am in labor, when will you come to my house? How long will you spend with me in labor? Midwives vary widely on when they will arrive. Some will arrive in active labor and will provide doula-like support throughout the birth. Most will arrive at the end of active labor, in time for pushing, to help you have the baby.
  • How many assistants do you have, and will they be coming to help with the labor? Some midwives send their assistant(s) first for support, and will come later. Others come with their assistants. There should be at least two trained midwives with you: one for you, and one for the baby.
  • What kind of equipment do you provide? Some midwives will bring a birth (yoga) ball and/or birth stool, and may rent a tub for you to labor in.
  • What kind of emergency equipment do you have in your midwifery kit, and under what circumstances do you use it? This should be standard, but should include oxygen, Pitocin, sutures, etc. The oxygen can be administered to the mother or the baby; Pitocin helps with postpartum bleeding; and sutures are used to sew up any lacerations (tears) in the mother.
  • What are the factors that will cause a transfer to the hospital in labor? This is fairly standard as well. Expect answers such as labor before 36 weeks gestation (preterm baby),  induced labor (ask when induction will occur), meconium in the amniotic fluid at any point in labor, baby's heart rate decelerating (measured with intermittent monitoring), bag of waters being open for over a certain amount of time (24 hours, 36 hours), and maternal fever, to name a few. Some midwives will not deliver breech babies and multiples (twins, triplets).
  • How long will you stay with me postpartum, and how often will you check on me and the baby? Expect that the midwife will stay at least a couple hours postpartum, until you are settled with the baby, and will check on you frequently in the following days.
Of course, you can also ask about transfer rates (the percentage of mothers that transfer to the hospital), c-section rates, emergency intervention rates, and so on, but that may not give you a good idea of what the midwife brings to the birth. These numbers could tell you her willingness to relinquish control, or to "allow" interventions to happen to the mother, but there is a chance that all it tells you is whether she has had a run of good luck or a run of bad luck.

Research what other mothers said about their home birth. Check out The Birth Survey project, which is a self-reporting tool in which mothers can enter their own experiences and information in the months after their birth. Keep in mind that these data may be skewed because of selection bias: this is not a randomized study, and mothers choose whether or not to participate.

Finally, skip to Step 5: You are not locked in. Though it may be trickier to switch home birth providers later in pregnancy, it can be done.

Birth in a hospital

Choosing a hospital can be a hairy task. No two hospitals are alike. I hope this guide will help you narrow down your choices.

Step 1: Choose a non-profit hospital.
Nathaneal Johnson of California Watch (2010) reported that for-profit hospitals have a higher c-section rate than non-profit hospitals. And that increase in c-section rates is nontrivial: mothers giving birth at a for-profit hospital have a 17% higher chance of delivering surgically. For-profit hospitals are more likely to perform costly procedures, less likely to serve under-served populations, and less likely to have breastfeeding success.

Step 2: Figure out what's important.
Priorities the importance of the following things: cost of birth, mode of delivery (vaginal vs c-section), c-section rate, breastfeeding success, diversity of population served, infant outcomes, whether you will have a room mate, what language(s) are spoken, where your doctor/midwife practices, how many residents (trainees) there are, how close the facility is to where you will spend most of your labor, and any other factors you consider important to you.

Step 3: Do the research.
There are several ways to look at birth facts. Check out Health Grades and search for the hospitals in your area. In California, you can use California Watch to look at statistics. For example, say I wanted to compare San Francisco General Hospital (SFGH) and UCSF Medical Center (UCSF) -- both non-profit teaching hospitals in the center of San Francisco, California.

Figure 1 shows the California Watch page for SFGH. Interesting things to note here: the decreasing trend of the low-risk c-section rate across three years, and the most recent reported average is 11.10% in 2007, much lower than the US average of 33%. This is very reassuring if mode of delivery is important to you and/or you wish to avoid a c-section. The Hospital Info section below tells you that SFGH is a non-profit teaching hospital that caters to under-served families, with over 60% of the patients coming from a low-income household. If breastfeeding is important, the 88.90% exclusive breastfeeding rate is a very good sign, and there is a positive correlation between beginning breastfeeding in the hospital before discharge and continuing to breastfeed for at least a few months postpartum. Finally, the (risk-adjusted) VBAC (vaginal birth after c-section) rate is a promising 30.23%.
Figure 1: Decreasing c-section rate for
San Francisco General Hospital (California Watch)
Click to enlarge

Figure 2 shows the California Watch page for UCSF. You will notice that it is very similar to SFGH: relatively low c-section rate of 14.20% in 2007 (compared to the US average of 33%), even when you look at the base c-section rate: 19.47% of all mothers, even high-risk mothers, deliver surgically. About 30% of the patients are low-income, judging by the insurance carrier. The breastfeeding success rate is 74.77%, which is still very good -- three quarters of all babies born at UCSF are exclusively breastfed when they check out. The risk-adjusted VBAC rate is 24.23%, which is fairly good.
Figure 2: Information on the University of California - San Francisco
Medical Center (California Watch)
Click to enlarge
Another thing these charts do not tell you include whether or not vaginal breech birth is attempted at each hospital (it is).

Health Grades gives both of these hospitals one star for maternity (worst grade possible), but it is unclear why. So let's take a look.  Figure 3 shows that San Francisco General Hospital (SFGH) and UCSF Medical Center (UCSF) each has one star. SFGH reports 64% of the cases that UCSF received in 2011 -- implying that SFGH is a smaller hospital. But here is where it gets interesting.

At SFGH, 2544 women delivered vaginally (79.62% of all women that delivered at SFGH in 2011), 12.23% (N=311) had complications related to the vaginal delivery.  But the national average for complications is 8.21% so we would expect only 209 women to have had complications. So more women have complications at SFGH due to vaginal delivery than the US average.

We know that SFGH had a 11.10% c-section rate (in 2007) from Figure 1 and we will assume the same c-section rate in 2011. In Figure 3, we see that there is a 20.28% c-section complication rate. That is, of the 651 women that delivered by c-section at SFGH, 20.28% of them (N=132) had complications related to the surgery (e.g., infection, excessive bleeding, etc.).  But, the national average is 4.34% so we would have expected only 29 women to have had complications. So, the c-section complication rate at SFGH is more than four times the US average.

At UCSF, 3745 women delivered vaginally (74.81%). Of these, 15.09% had complications (N=565). The national average for complications related to vaginal delivery is 8.21%, so we would have expected only 308 women to have complications. The vaginal delivery complication rate at UCSF is almost twice the US average.

Now, UCSF's c-section complication rate is a little worse than SFGH's, at 13.16%. That is, of the 1261 women that had c-sections, 13.16% of them (N=166) had complications. Since the national average is 4.34%, we would have expected 55 women to have had complications. The c-section complication rate at UCSF is three times the US average.

Health Grades does not explain the "Newborn Survival" column so we have to take it at face value, and, if possible, compare the newborn survival (text) across the hospitals we wish to examine.

Figure 3: One-star ratings in maternity care for San Francisco General Hospital
and UCSF Medical Center (Health Grades)
Click to enlarge

If we wish to investigate whether there is a difference between any of the following, we can run a quick Chi-square on the data from Figure 3.

  • SFGH and the national average, in terms of vaginal and c-section complications
  • UCSF and the national average, in terms of vaginal and c-section complications
  • SFGH and the UCSF, in terms of vaginal and c-section complications

We find that indeed, there is a difference in all of these categories. Although calculating Chi-square does not give us the direction of the relationship, we can see that SFGH and UCSF both fare poorer than the national average, and that c-section births at UCSF are more than twice as likely as expected to have associated complications. Yikes! Figure 4 contains all of these calculations.
Figure 4: All correlations for SFGH, UCSF, and the national average.

Research what other mothers said about their birth experience at the facility you choose. Check out The Birth Survey project, which is a self-reporting tool in which mothers can enter their own experiences and information in the months after their birth. Keep in mind that these data may be skewed because of selection bias. For example, SFGH has 60% under-served population; are mothers from this group more or less likely to fill out an online survey than higher-income mothers, in the interests of science?

Ask your friends about their experiences in the facilities. One gal I know praised her birth facility for its harp music and tea time in tones that I understood to be insincere. Then she divulged that she had a room mate, and she hated the experience of someone else's baby crying in the night next to her own bed. No amount of tea could make that memory go away.

Step 4: Visit.
Knowing, on paper, that these hospitals are so similar, how can you choose the right one for you? Visit. Maybe it is a prenatal appointment with a midwife or obstetrician. Maybe it is a procedure, like lab work or the 20-week ultrasound. Maybe it is a maternity center tour. Get a feel for the dynamics of the hospital, for the nursing staff, and for the check-in and check-out procedure. Imagine arriving in labor at rush hour. Is it crazy, with papers flying and nurses pulling their hair out? Or is it a smooth and calm atmosphere? If it is a teaching hospital, ask when the new residents start their training. If their first week corresponds to your due date, and that makes you nervous, that could be a strike in the "no" column. If you are taking a tour, look around the birth room and ask what kinds of things the nurses usually try to help a mother labor. Look for answers that promote relaxation (e.g., birth ball, music player), movement (e.g., waterproof wireless fetal monitors), and hydrotherapy (e.g., bath tub, shower). Ask about routine procedures and if any of them can be skipped (e.g., pubic shaving, IV, Pitocin for labor augmentation).

Step 5: You are not locked in.
Even if you have made your choice of birth facility, or obstetrician, or midwife, or doctor -- whatever -- you are not married to that choice. You can always, always switch. Remember that you are paying good money for the services that will be rendered to you. You are hiring a medical professional. If you are unhappy with your choice, and you are unable to reconcile it (by talking about it, e.g.), you can switch. I have asked doulas, midwives, and nurses in the past: When is it too late to switch providers? The answer: After the baby has come.

Good luck, and happy birthing!

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