Light and Momentary

Is that a threat?

I wrote a letter to my HMO. I said, "You should cover my CNM's services. It will save you a ton of money. Outcomes for low-risk out-of-hospital birth are just as good for babies and much better for mothers. Also: much much cheaper for you! Save money! Support great (and did I mention cost-effective?) care for women! Cover my homebirth!"

They said no. I figured they would say no, but I also figured it was worth a try. One sentence in their reply, though, gives me pause. It says that if I pay privately for her services, they will refuse to cover any resulting complications.

Now maybe that's just boilerplate for out-of-network denials, aimed at keeping in-network doctors from having to pick up the pieces after out-of-network poor outcomes. If I were to pay for a nose job that went wrong, say, they wouldn't want to get stuck with the cost of follow-up care. But I've been wondering all afternoon -- are they threatening to refuse to pay for a transfer to hospital care if that's needed? If I hemorrhage and need monitoring afterward, are they going to attempt to stick me with the bill? If the baby needs help, are they going to deny the claim?

The doctor who wrote the letter quoted the ACOG statement. (For you non-earthy-birthy folks, the ACOG statement said essentially, "We don't like homebirth, evidence be damned." They cited no literature, because there is no literature for them to cite -- not a single study supports their contention that planned attended homebirth is more dangerous for low-risk mothers or their singleton full-term vertex babies.) But the C-section rate in my town exceeds 40% -- wouldn't you think the insurers would be on a mission to cut costs while improving satisfaction? Isn't it silly for them to turn me down when I hand them just such an alternative?

Risks, Benefits, Looming Catastrophes

I saw my OB this morning. He is a very pleasant guy, UK-trained and personable, and he seems to be convinced that I'm going to have a catastrophic hemorrhage when this baby is born. My two younger sons were born at home, one with a family practitioner and one with a CNM. While I would go back to the hospital in a flash if this pregnancy turned high-risk, I plan to stay home this time too. We've had an HMO for a couple of years now, and along with prenatal visits to my midwife I'm seeing an in-network OB so I can have my tests covered. I was up-front with him about my plans to stay home as long as I stay low-risk.

He has spent a fair amount of time telling me I could bleed out and die.

When my second son was born in an Edinburgh hospital, I was quite anemic going into the delivery and the third stage was actively managed (i.e., more tugging on that cord than I was comfortable with). I lost an estimated 850 ml of blood, but the hemorrhage was easily controlled -- one shot of methergine and that was that. I have no wish to repeat the experience, since the recovery was rather grim, but I also don't think it's an enormous red flag in my obstetric history. I have since had two perfectly normal births with utterly unremarkable third stages, and while I accept that I could hemorrhage again, I'm not losing sleep over it.

When I met my midwife during my pregnancy with Pete, the first question I asked her was what she carried to manage PPH; she said she always had pitocin, methergine, Cytotec, and IV fluids. I live half a mile from the hospital. I will pre-register there, just in case. I will transfer in a heartbeat if there is a problem. My midwife is licensed and legal; she would accompany me, chart in hand.

It doesn't seem very likely to me that I'm going to exsanguinate under those circumstances. Hemorrhage, maybe; lose my uterus, remotely possible; die, improbable. Call me an optimist.

I spent some time this morning trying to respond to the doctor's concerns: I didn't have even a hint of uterine atony after Pete's birth. I'll reconsider my plans if I'm anemic in the third trimester. My midwife can take the same first steps to intervene at home that she can in the hospital. I think, though, he has it burned in his brain: Homebirth = Too Risky. (Oddly, he has focused exclusively on the risks to me, not the risks to the baby.) But I believe I have read every paper published in English on homebirth safety in the past 15 years, and the results are clear: planned attended homebirth is a safe option for low-risk women carrying full-term vertex singletons. (Don't even get me started on Amy Tuteur, who should serve as a caution to any would-be amateur epidemiologists.)

I  am feeling a little cranky today because I threw up my breakfast (at 16w5d! on Unisom! enough already!) immediately before going to the doctor to hear about my impending demise. But I will end on a happy note: I am grateful for this baby, whose kicks and flutters are making me smile every day now, grateful for a thus-far low-risk pregnancy, grateful for my midwife. My first visit with her was such a welcome contrast to my first OB visit. Afterward I told my husband, "I wish every pregnant woman could see someone like her." I'm glad I can.