by Jessi Vining
In 2013, the planned homebirth of my daughter became an unexpected hospital birth fraught with complications. I had been working as a doula and midwife’s assistant for 3 years, and I felt pretty confident and prepared going into my first birth experience. I had done everything “right” in order to have the peaceful homebirth that I wanted and that I felt was best for my baby and my body. I had eaten well, exercised, taken Hypnobirthing classes, and had trusted midwives who were committed to supporting me.
I had also professionally supported dozens of people in achieving their birth goals as a doula, and had even facilitated several transfers from community birth to the hospital as a midwife’s assistant. I thought I was ready. But I wasn’t. Childbearing brings everyone to their knees in some way or another, and the transfer into the hospital caught me completely off guard. I wasn’t going to be one of those people, I thought.
My daughter was born into my arms following a long labor resulting in a transfer to the hospital and filled with interventions I had never even considered being needed or used during my birth. She was healthy and well, and I was bruised and surprised. In the wake of my experience I wondered how in the world I could have missed the memo: sometimes transfer to the hospital happens, and we can’t always see it coming.
I started reflecting on my prenatal care, the childbirth class, discussions with my midwives and even the conversations I had initiated as a birth worker with my clients. The general theme was that we didn’t seem to want to talk about transfer from community birth to the hospital. It was a subject tap-danced around and almost discouraged within the culture of the “natural” birthing community.
How often does transfer actually happen?
I’m often surprised by how midwives downplay the possibility of transfer to prospective or current clients. My experience is that many midwives lead the conversation by saying, “The most common reason for transfer is a very long labor that isn’t progressing. This isn’t an emergency, and we are usually going in for pitocin or an epidural.” Then, they might go on to list several other indictions for transfer of care. Rarely, they might then list their own transfer rates from previous years. This approach does very little to help clients gauge the actual risk for themselves as they consider the option of community based birth, and I believe this method of approaching the conversation stems from midwives not really knowing what the evidence shows about how often transfer truly takes place.
Transfer from community-based birth (including homebirth or birth center) into the hospital actually happens pretty regularly. In the largest U.S. based study of planned, midwife-attended, community-based births, it was found that out of 16,924 births, roughly 1,692 ended up transferring to the hospital in labor, or about 10.9%. Overall, the research on home birth seems to reflect that this number remains relatively consistent ranging from 9-13%, depending on the study. However, for first-time birthers, the rate has been shown to be higher with at least one large study citing transfers rates of about 36-45% for first-time birthers.
It is true that most of these transfers are not emergency situations, and simply occur because some type of hospital intervention is needed to achieve a healthy birth experience for parent or baby. While midwives are correct in stating that most low-risk homebirths occur without the need for these interventions, a significant minority will experience the need for a transfer of care.
I like to compare the risk of transfer to that of shoulder dystocia in terms of preparation and prenatal discussion with clients. If this specific complication were occurring in 10% of all of our births, we would be discussing its management and risks in depth with all of our clients – not just the ones with a history of the complication. Since at least 10% of midwifery clientele is likely to transfer into the hospital in labor for one reason or another, it seems appropriate for us to discuss recommended preparation and management with all of our clients regardless of risk factors.
After my own birth experience, I started to reach out to people I knew had similar experiences, wanting to hear their birth stories. I was primarily interested in finding out how the birth community could better support people like us in both preparing for the possibility of transfer and in recovering from the experience postpartum.
What Parents Had to Say:
When I asked clients about their experiences directly, many of them expressed similar thoughts and feelings regarding their births and the care their midwives provided. They graciously gave me recommendations for how to improve my own care for transfer clients, and allowed me to compile their thoughts into 10 primary recommendations for practicing community-based midwives:
- Initiate the possibly uncomfortable, yet honest and structured prenatal discussion about how often transfer into the hospital takes place and what the process entails. Include actual information/statistics from the research in this discussion.
- Make prenatal recommendations and referrals so that families can pursue education about hospital procedures and interventions, despite planning for a community-based birth or anticipating that these procedures will be unnecessary. One parent in particular expressed that her midwife discouraged her from learning about hospital interventions since it “wasn’t going to be used” in her case. When these interventions were introduced during her labor she felt underprepared and uneducated.
- Routinely recommend practical preparation steps to clients such as packing a hospital bag prior to labor, preparation of a back-up birth plan (intended for use in the hospital), or arrangements for child or animal care in case of transfer etc.
- Initiate an early prenatal discussion about financial planning for unexpected transfer (a review of insurance coverage, preferred hospitals etc).
- Demonstrate willingness to bring up the subject of transfer during labor and to have open, conversations about the possibility prior to the moment of needing to actually transfer, when possible (such as when the first signs of labor moving outside of the normal range pop up). Universally, the parents I spoke with felt that this would have made the transfer less traumatic and did NOT feel that an early discussion would have undermined their confidence.
- Careful cleaning up of the birth site by the birth team (when possible), so that when returning home from the hospital there is not an instant reminder (open birth kit, inflated birth pool etc) of a lost home birth experience. Several parents expressed frustration that the birth site was left in such disarray, with no effort on the part of the midwifery team to straighten up.
- Initiate structured and intentional processing of the birth experience between the parents the midwifery team in the postpartum period. Many parents felt that this got lost in postpartum appointments, which were primarily focused on infant feeding or physical recovery.
- Increased understanding from midwives regarding the emotional recovery process when birth is complicated and involves aspects of loss.
- Provide the opportunity for parents to give feedback to the midwifery team about their experiences, and for their story to be represented among the midwife’s other clients (such as being asked for testimonials, having their photos/ births posted on social media too etc). Many parents expressed that they felt their midwife was embarrassed or secretive about their transfer experience due to lack of contact postpartum, and felt left out of the ways in which midwives celebrate or discuss community birth online.
- Provide referrals and access to outside resources which can help with healing and birth processing in the postpartum. If you are unsure of what some of these resources are you can visit: www.toolkitformidwives.com
What the Research Shows:
After I hearing the same themes repeatedly from parents, I dove into the research wanting to know what the evidences shows about best practices for transferring into the hospital. Very little information is discussed within the literature about the client’s perception of their experience during the transfer process. Despite limited evidence on overall client experiences, several identifiable themes which improve client perceptions of their birth in cases of transfer have been identified:
- Communication – including honest prenatal education and clear communication about reasons for transport and the rates.
- Connection – a sense of trust and knowing between the client and midwife.
- Continuity – the same midwife remaining with the client throughout the transfer and subsequent birth.
- Smooth transfer processes – including friendly hospital reception.
- Postpartum processing – Actively supporting clients to make sense of the events that took place during their birth.
These themes mirrored the recommendations made to me by parents, and make complete sense within the values the Midwifery Model of Care attempts to uphold.
Though midwives are often unable to predict or influence the reception of the hospital staff during a transfer of care, all of the other identifiable factors/themes are under the influence of a midwife. It is clear that the choices and type of care provided by the midwife in these situations can significantly impact the chances of a client viewing their birth in a positive light, despite the development of complications or unexpected events.
The recommendations made by parents and supported by the research include things I personally didn’t know to place such emphasis on with my own clients, and I certainly didn’t know to pursue them during my own pregnancy. Some of them I might even have thought unnecessary effort. But with the knowledge I now have years later as a midwife, I think that every birthing parent can benefit from forethought and preparation, whether or not they end up needing to go to the hospital.
Perhaps the biggest misconception with transferring to the hospital is the assumption that the birth is automatically disappointing or traumatic. I don’t believe this has to be the case. While any birth has the potential for these types of outcomes to take place, when we open up an honest conversation surrounding transfer from community-based birth to the hospital, any shame and stigma attached to these outcomes is dissolved, leaving behind the incredibly human story of birth: a story which is inspiring and amazing in ANY setting.
Birthplace in England Collaborative Group (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the birthplace in England national prospective cohort study. BMJ, 343. doi: 10.1136/bmj.d7400
Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., Vedam, S. (2014). Outcomes of care for 16,924 planned home births in the United States: The midwives alliance of north america statistics project, 2004 to 2009. Journal of midwifery and women’s health, 59, 17-27. Doi:10.1111/jmwh.12172
Fox, D., Sheehan, A., Homer, C. (2014). Experiences of women planning a homebirth who require intrapartum transfer to hospital: A metasynthesis of the qualitative literature. International journal of childbirth, 4(2), 103-119. Doi: http://dx.doi.org/10.1891/2156-52184.108.40.206
Vedam, S., Leeman, L., Cheyney, M., Fisher, T., Myers, S., Low, L.K., Ruhl, C. (2014). Transfer from planned home birth to hospital: Improving interprofessional collaboration. Journal of midwifery and women’s health, 59, 624-634. Doi:10.1111/jmwh.12251
Jessi Vining is a Certified Professional Midwife licensed in Oregon. She feels passionate about all things reading, writing and birth related. She co-owns Wilder Midwifery, a bilingual, LGBTQ+ positive and gender inclusive homebirth practice.