When our daughter Hannah was not quite three years old, she participated in the birth of her younger sister, Leah, in our bedroom, the same room where she had been born. She gently placed washcloths on my head, helped bring up the bassinet from the basement, spent time in the kitchen with her Aunt Julie baking a cake for the baby, and held Leah within minutes of birth. When Hannah was almost five, she was present during the final days and the death of her grandfather, in the den, his room during his dying days. She put a washcloth on his head, helped smooth his sheets, brought her crayons in and colored pictures sitting by his side, and touched his body after he died.

Hannah is now 10 years old, and her memories of these events are neither profound nor startling -- they are, in fact, entirely ordinary.

She remembers the strawberries on the cake, and how Julie had to come upstairs and ask me where the flour was, in the middle of the noisy, hard contractions. She remembers how she ran to get her favorite doll right after Leah came out, and how Doctor Fred pretended to tie off her doll's umbilical cord just as he had done to Leah's. She saw the baby go directly into my arms for nursing at the breast.

And she remembers how we built our sukkah, the temporary shelter for the Jewish holiday of Sukkot, just outside the window of Grandpa Albert's room, and how pale and sleepy he was. She perhaps recalls that my dad, who hadn't been eating at the nursing home, eagerly polished off a bowl of my mother-in-law's chicken soup with matza balls the Friday night we first brought him home, and how he roused from his drowsy state to join us in the Hebrew blessing over the challah to mark what would be his last Sabbath. She observed me sitting at my father's side, holding his hand, humming a song while I nursed a sleepy toddler.

BIRTH AND DEATH -- A NORMAL PART OF LIFE

Hannah's memories are of events that seemed to her to be a normal part of our family's life, and she found nothing unusual about them. But of course, in modern American culture, it is not at all usual for a child to be so close to birth and death, to experience them so intimately. These days, birth and death are more often experienced at a distance, removed from the confines of people's homes and placed within the sterile walls of a hospital. Or they are not experienced at all, but simply occur elsewhere while children and other family members wait at home.

What might otherwise be formative events in children's lives are lost, and the adults that these children become are unable to draw on these memories.

We physicians have contributed, perhaps unwittingly, to the depersonalization of these deeply personal and primal moments. I see so many adults who bear the wounds of having been taken away from intense emotional family events, under the guise of being protected or sheltered from grief. What they tell me is that having been left out, not having had their questions answered or guilty feelings addressed, leaves wounds that have not and may never fully heal.

My daughter now carries with her an intimate, visceral familiarity with the ebb and flow of the birth and death processes. During my dad's last days, Hannah asked how we would know that he was dead, since he appeared to be sleeping so much of the time anyway. On the day he died, when she came back from nursery school she asked to go into the room and see his body.

For all of our talk of souls or spirits going to be with God, I think she was the most interested in seeing how we could tell he was really dead. Although cautious, she did not appear unduly frightened as she reached out and touched his arm, looking closely at his face in order to truly know that he was no longer breathing.

In a similar way, from the safety of her daddy's arms she pointed to the crowning, emerging head of her little sister as I grunted and moaned, commenting matter-of-factly, "That's the baby's head." Later that day she drew a picture of a baby with what looked like shoes near the bottom. When questioned about the shoes she replied, with a trace of disdain at the adult who had missed the obvious, "That's not a shoe, that's the placenta. And over here is the umbilical cord."

For my daughter, birth seems to have been perceived as an emotionally intense, special event; the painful moments appeared normal, not frightening or insurmountable. Death, while similarly intense and profoundly sad for all of us, was neither scary nor mysterious.

Hannah will recall that during both times there were many friends and family who were there to support us -- the community members who brought us food and who provided a circle of birthing support and energy, my brother and sister-in-law who maintained the vigil at my dad's bedside, my dad's brother and sister who came to say goodbye, and all the close family suspending their outside obligations during both events in order to be present in our home. Hannah will remember how, during the first breaths of a new life and the last breaths of a dying father, we were surrounded in our home by love, by support, by caring.

I can draw no definite conclusions about the impact of these experiences on Hannah's psyche or her own future life choices. It is certainly possible that sometime during adolescence she will view any of this body stuff, especially the birthing details, as "totally gross, eeeww, yucky."

The inevitable rebellion against her "hippie" parents could even lead her to a highly technical, hospital birth, perhaps with epidural anesthesia, or with formula feeding to follow! But it is my hope that somewhere in the recesses of her consciousness she will forever understand the very ordinariness of birth and death, trusting the process itself. At the same time, she hopefully will hold and cherish the spectacular and special qualities of these experiences.

ENTERING AND LEAVING LIFE WITH LOVED ONES PRESENT

As a family physician, I feel that the next generation needs many more people who feel safe and comfortable accompanying a friend or relative through the challenges of childbirth, relying on professionals to safeguard the woman and baby but not interfere with the integrity of the process.

Similarly, people all over are beginning to cry out for those who will accompany them or their loved ones "through the valley of the shadow of death," once again trusting the process, offering comfort and palliation without undue interference. It is my hope that Hannah's experiences in our home will enable her to become this kind of person.

I believe that other children, and other families, can benefit from these kinds of experiences. For while there are certainly many situations in which home birth or home death would not be appropriate, they are potentially empowering for individuals, family, friends, and community. As such they should be offered as options, with health care professionals supporting and safeguarding them.

We should support other options that enable families to be more intimately involved in the birth and death process, such as alternative birthing centers and hospice programs, as well as changes in hospital routines that might make possible further inclusion of family members in these pivotal moments.

For our family, the experiences of home birth and home death have offered us a sense of wholeness, of life coming full circle, of safety and love within the walls of our dwelling. My younger daughter, Leah, while not able to recall the events directly (certainly not her very own birth!) clearly knows the family lore, sees the pictures and watches the videotapes of her first moments, and even views the footage which includes my ailing father at home with us. Hannah was present and remembers these moments.

My husband and I made the choice to have our babies at home and bring my father home to die and I know that we will feel comfortable supporting other family members in making these kinds of choices, helping them to give birth at home and to live out their last days at home, if they choose to do so.

And I hope that I will be able to die as I gave birth, surrounded by friends and family taking care of me in my own home, giving myself over to and trusting the ongoing flow of the tide.

Reprinted with permission from the Journal of the American Board of Family Practice, July/August 1999