Homebirth
http://parenting.ivillage.com/pregnancy/plabor/0,,6rl1-p,00.htmlby Henci Goer
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Is homebirth safe?
Safety has been held up as the reason why all women should give birth in the hospital. This is despite the fact that no data support the contention that homebirth holds any excess risk provided:
* the mother is low risk
* the homebirth is planned
* she has a trained, experienced birth attendant
* there is a modern hospital within a reasonable distance
In particular, an analysis of six homebirth studies totaling 24,100 women came to exactly this conclusion (10). Homebirth studies have not only failed to show more than the expected number of stillbirths and newborn deaths (perinatal mortality), but they have not found excesses of other, more common adverse outcomes, such as low Apgar scores (a measure of the baby’s condition at birth), the need for resuscitation, or admission to newborn intensive care units (1, 4-5, 12, 15-16).
As further evidence, researchers in Holland, a country where homebirth never disappeared, compared the perinatal mortality rate in the early 1980s for various cities and regions with the percentage of homebirths and found no correlation, although homebirth rates ranged from very few, to fifty percent of the births (13). In the U.S., an analysis of California data for 1989 and 1990 calculated that low-risk women opting for birth outside of a hospital had a slightly lower perinatal death rate --- including births moved into the hospital for complications, compared with low-risk women managed by obstetricians in hospitals (11).
One recent study of planned homebirths in Australia did find a higher perinatal death rate than for comparable women having hospital births (2). However, the authors note that the perinatal mortality rate was two to three times greater than reported in six other large home birth studies from the Netherlands, the U.K. and the U.S. (6.4 per 1,000 versus 1.1 to 3.5 per 1,000). The authors concluded that the reasons for the difference had nothing to do with home birth per se, but to births that were not low risk and also that most Australian midwives attend only a few births a year, which meant they lacked experience. In other words, the excess risk was due to births that didn’t meet the above criteria.
Page Two: Find out when a homebirth would be inadvisable
Page Three: Learn the advantages of having your baby at home
Page Four: See the potential drawbacks of a homebirth
Page Five: Read the author's references
When would a homebirth be inadvisable?
* When there are risk factors. Homebirth practitioners agree that some risk factors should rule out home birth. The mother having high blood pressure, or the baby coming early would be two of those factors, while they disagree on others such as the mother having a prior cesarean. In the end, it comes down to you making an informed decision based on the balance between the risks you run at home versus the risks you run in the hospital. To make this assessment, you must weigh your particular circumstances and the skills and experience of the homebirth practitioner against the local hospital care available to you. This last point should be emphasized. For the reasons listed in homebirth advantages, sometimes it isn’t a clear-cut choice.
* When no trained, experienced homebirth attendant is available. Most of the emergencies that arise without warning at a low-risk birth: the baby’s shoulders are stuck (shoulder dystocia), the baby doesn’t breathe or heavy bleeding, can be resolved or stabilized for hospital transport by a skilled pair of hands and readily portable medication and equipment.
* If you think you will probably want pain medication. You may also feel hesitant or uncomfortable about having a homebirth. No matter what your intellect says, if your gut says “I shouldn’t be at home,” labor may progress poorly. If you plan a home birth, you must be well prepared and confident of your ability to cope with the pain of labor. A difficult labor may eventually lead to transfer into the hospital for, among other things, pain medication, but you shouldn’t start off indecisive about using it.
What other factors should be considered?
* Lack of a smooth, efficient means of transferring care. You may need an obstetrician or care in a hospital during labor or for postpartum complications. In many communities, on the grounds that homebirth is dangerous and should be discouraged, doctors have made it difficult or impossible for homebirth practitioners to work with obstetricians or to transfer their clients to an obstetrician’s care or into the hospital. Ironically, these doctors create a safety issue where none would otherwise exist.
* When there is no back up hospital within a reasonable driving distance that is capable of handling urgent problems. Here’s the dilemma: On the one hand, the ability to get to a hospital in a timely matter may make a difference. On the other hand, a low-risk woman runs risks in the typical hospital that she doesn’t run at home. At home, she would be under close observation by someone who could spot problems early, head most of them off and who wouldn’t potentially be causing complications by inappropriate use of procedures, drugs and restrictions.
Page Three: Learn the advantages of having your baby at home
Page Four: See the potential drawbacks of a homebirth
Page Five: Read the author's references
What are some advantages of homebirth?
* You are much less likely to be subjected to potentially problematic procedures, drugs and restrictions. Every obstetric intervention carries risk as well as benefit. When interventions are used with women who don’t need them, on a routine or “just in case” basis, or on women whose problem could be resolved by waiting or by simple, risk free measures such as: walking, change of position, talking over worries, or a warm bath, than those women are exposed to the risks without any chance of benefit. The end result is that some women and babies will develop complications, minor or major, that never would have occurred had they not been subjected to the intervention. This truth is why numerous studies examining individual procedures, drugs and restrictions have consistently concluded that outcomes are equally good and often better with restricted use of the intervention (6, 8, 14).
Likewise, numerous studies comparing outcomes between low-risk women receiving standard obstetric management versus similar women receiving the less interventive, midwifery style of care have found that women and their babies receiving the midwifery style of care did equally well or better (
.
* You will have greatly increased attention, care, observation, and monitoring by a trained person or persons. Doctors don’t come into the hospital until close to the birth, and they may never have met the woman before, or know her only through a few brief office visits. Some hospital based midwives may labor sit with their clients, but not all do. Even before the money crunch forced cutbacks in staff, few nurses spent extended time with laboring women (7, 9).This system of providing care has important disadvantages: It flies in the face of a large body of research that says women have fewer problems and complications and feel better about themselves and their babies when accompanied throughout labor by a caring, experienced woman (
. A woman’s physical and psychological status has profound consequences for her ability to meet the challenges of adjusting to parenthood.
* The best judgments will be made by caregivers who are familiar with the woman and whose presence on the scene enables them to pick up subtleties that would be missed by someone who doesn’t know her and pops in now and then. Small problems can be addressed before they become big ones, and overreaction can be avoided because the caregiver has context and perspective.
* You have a greatly decreased chance of infection. This is for two reasons: Hospitals are reservoirs for microbes the likes of which are never found in homes, including and especially antibiotic resistant ones (3). Women are far less likely to have procedures that increase the risk of infection, such as cesarean section, internal monitoring and rupture of membranes and subsequent vaginal exams.
* You will be in a familiar, supportive, relaxed environment. It’s a classic tale: The woman has been experiencing strong, regular contractions at home, but they disappear when she gets to the hospital and do not resume until she settles into her new environment. It may take hours before the contractions return to the same intensity. Few stop to think of the reason why, namely that stress and anxiety inhibit labor. Any veterinarian will tell you that laboring animals require a quiet, dimly lit, familiar environment with no strangers and nothing to alarm or disturb them. Humans need the same, and hospitals are generally none of the above.
* Your family is in charge and you are the center of undivided attention. At a homebirth, all others, including the midwife, are invited guests. This makes for a very different social dynamic than in even the best-intentioned hospital. Moreover, with few exceptions, hospital policies are not intended to meet the needs of the individual woman. Maternity care policies are designed to process as many women and babies as efficiently, cost-effectively, and conveniently for staff as possible.
Page Four: See the potential drawbacks of a homebirth
Page Five: Read the author's references
What are some potential drawbacks of homebirth?
* You may face considerable disapproval from family, friends, and medical professionals. This can be very unpleasant and difficult during pregnancy and may actually lead to problems with care should a woman need to move into the hospital during labor or for problems after the birth.
* You take on greater responsibility for making decisions and preparing for the birth. Some couples find this liberating, while others find it a burden.
* The proximity of neighbors or lack of privacy within your home may inhibit you. This, in turn, can inhibit the labor.
How might having a homebirth affect your birth experience and postpartum recovery?
Emerging from the birth feeling capable and confident puts you in the ideal position to meet the challenges of new motherhood. A homebirth gives you your best chance to do this because:
* You are on your own “turf” where you make the rules.
* You have the opportunity to discover that you can cope with labor using your own resources and strengths.
* You have a caregiver who nurtures, encourages and supports you and who respects your right to participate fully in any decisions made about your care.
* You are least likely to be subjected to procedures such as episiotomy or cesarean section that cause pain and debility.
* Even the need to move into the hospital, however disappointing, can be empowering. You will have the ultimate say-so, and it will be because you agree that appropriate intervention is now right and necessary.
Page Five: Read the author's references
References
1. Ackermann-Liebrich U et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ 1996;313(7068):1276-7.
2. Bastian H, Keirse MJ, and Lancaster PA. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317(7155):348-8.
3. Brumfield CG, Hauth JC, and Andrews WW. Puerperal infection after cesarean delivery: evaluation of a standardized protocol. Am J Obstet Gynecol 2000;182(5):1147-51.
4. Damstra-Wijmenga SM. Home confinement: the positive results in Holland. J R Coll Gen Pract 1984;34(265):425-430.
5. Duran AM. The safety of home birth: the Farm study. Am J Public Health 1992;82(3):450-453.
6. Enkin M et al. A Guide to Effective Care in Pregnancy and Childbirth. 2d ed. Oxford: Oxford University Press, 2000.
7. Gagnon A and Waghorn K. Supportive care by maternity nurses: a work sampling study in an intrapartum unit. Birth 1996;23(1):1-6.
8. Goer H. The Thinking Woman’s Guide to a Better Birth. New York: Perigee Books, 1999.
9. McNiven P, Hodnett E, and O’Brien-Pallas LL. Supporting women in labor: a work sampling study of the activities of labor and delivery nurses. Birth 1992; 19(1):3-8.
10. Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24(1):4-13.
11. Schlenzka PF. Safety of alternative approaches to childbirth. PhD diss, Stanford University, 1999.
12. Shearer JM. Five year prospective survey of risk of booking for a home birth in Essex. Br Med J 1985;291(6507):1478-1480.
13. Treffers PE and Laan R. Regional perinatal mortality and regional hospitalization at delivery in the Netherlands. Br J Obstet Gynaecol 1986;93(7):690-693.
14. Wagner M. Pursuing the Birth Machine. Camperdown, Australia: Ace Graphics, 1994.
15. Weigers TA et al. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ 1996;313(7068):1309-13.
16. Woodcock HC et al. A matched cohort study of planned home and hospital births in Western Australia 1981-1987. Midwifery 1994;10(3):125-35.