Home birth

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home birth
A home birth

A Home birth is a birth that is planned to occur at home. It is contrasted to birth that occur in a hospital or a birth centre.

Contents

[edit] Types of home births

Homebirths are divided into two types — attended and unattended births.

  • Unassisted births, which are sometimes called freebirths may involve simply the woman herself, or a woman attended by her partner, friends, family or a birth attendant called a doula.

[edit] Factors in opting for a home birth

Being in familiar surroundings is an important factor in chosing home birth for many women. Discomfort or fear of hospitals, birthing centers or strangers can be a factor for others. Yet others feel that home birth is more natural and less stressful. [1] There is a view that the perception of pain is less in a home setting than a hospital setting. [2]

When women were asked Why did you choose a home birth? in a recent study published in the Journal of Midwifery and Women's Health [3] the five main reasons given were:

  • safety;
  • avoidance of unnecessary medical interventions common in hospital births;
  • previous negative hospital experiences;
  • more control; and
  • a comfortable and familiar environment.

While neither access to pharmaceutical pain relief or pharmaceutical labor induction, nor equipment and supplies for emergency cesarean section are available at planned homebirths, most midwives have working relationships with OBs and hospitals. In addition, many midwives carry oxygen (for mother or newborn), are trained in neonatal resuscitation, start IVs have and have oxytocin and other medications to halt postpartum hemorrhaging, as well as suturing supplies Births necessitating other interventions would require transfer to a hospital. Depending on the midwifery practice, transfer rates can range anywhere from 5% to 40%, but most studies cite a transfer rate of about 16%.[4]

[edit] World Health Organization position

The WHO has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home. [5]

[edit] Revival of home birth in western nations

In many Western countries, home birth declined rapidly over the 20th century. In the US home birth declined from 50% in 1938 to fewer than 1% in 1955; in the UK a similar but slower trend happened with approximately 80% of births occurring at home in the 1920s and only 1% in 1991. In Japan the change in birth location happened much later, but much faster: homebirth was at 95% in 1950, but only 1.2% in 1975 [6]. This decline was in large part due to the expansion of private insurance coverage in the US and taxpayer funded medical care in Europe and Canada, changes which included policies about where birth should take place. Additionally there was increased migration to urban centers, increased accessibility of hospitals, and unwillingness of doctors to attend to women in their homes. As one doctor described birth in a working class home in the 1920s.

You find a bed that has been slept on by the husband, wife and one or two children; it has frequently been soaked with urine, the sheets are dirty, and the patient's garments are soiled, she has not had a bath. Instead of sterile dressings you have a few old rags or the discharges are allowed to soak into a nightdress which is not changed for days.[7]

This experience is contrasted with a 1920s hospital birth by Adolf Weber:

The mother lies in a well-aired disinfected room, light and sunlight stream unhindered through a high window and you can make it light as day electrically too. She is well bathed and freshly clothed on linen sheets of blinding whitenes... You have a staff of assistants who respond to every signal... Only those who have to repair a perineum in a cottars's house in a cottar's bed with the poor light and help at hand can realize the joy. [8]

There was a revival of midwifery, the practice supporting a natural approach to birth, in the United States in the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing birth center and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years. [9]

Home birth in the United Kingdom has also received some press over the past few years as there has been a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%. [10] In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the Northern Territory to 0.1% in Queensland. [11] The New Zealand rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing. [12]

In the Netherlands, an opposite trend has taken place: in the 1965, two-thirds of Dutch births took place at home, but currently, that figure has dropped to less than a third – about 30%. [13]

[edit] Research on safety

In 2007, after a comprehensive review of the literature, the UK’s National Institute for Health and Clinical Excellence (NICE) released the following recommendations concerning the location of birth:

With relation to women’s and babies’ outcomes for home births, there is a lack of good quality evidence. The evidence in relation to perinatal mortality is not strong enough to support past or current policies of increasing or decreasing current provision outside consultant units. Women should be offered the choice of planning birth at home, in a midwifery-led unit, or a consultant-led unit [hospital]. Before making their choice, women should be informed of the potential risks and benefits of each birth setting.

"As a minimum," the NICE report continues to state, such information should include the following:

  • Planning birth at home: increases the likelihood of normal vaginal birth and satisfaction in women who are committed to giving birth in this setting, compared with planning birth in a hospital
  • Planning birth in a consultant-led unit: increases the likelihood of pharmacological analgesia, interventions and an instrumental birth, and decreases satisfaction, compared with planning birth in other birth settings. There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit." [14]

Since the 2007 review, a study of 529,688 low-risk planned home and hospital births was reported in the British Journal of Obstetrics and Gynaecology in 2009. The study concluded:

A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system. [15]

Further, the study noted there was evidence that low risk women with a planned home birth are less likely to experience referral to secondary care and subsequent obstetric interventions than those with a planned hospital birth. [16] The study has been criticised on several grounds, including that some data might be missing and that the findings may not be representative of other populations. [17]

[edit] Study design

Randomized controlled trials are the "gold standard" of research methodology with respect to applying findings to populations; however, such a study design is not feasible or ethical for location of birth. The studies that do exist, therefore, tend to be cohort studies conducted either retrospectively (by selecting hospital records that match the characteristics of the home birth records),[18] by matched pairs (by pairing study participants based on their background characteristics),[19] [20] or by using multivariate analysis to control for background variables. [21] The Midwives Alliance of North America is collecting prospective data from out of hospital births for future research. [5]

There are many differences between women who choose to give birth at home versus in hospital. There are unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth[18], and demographically, home birth patients tend towards being more multiparous, less ethnic minorities, attend more prenatal visits, be slightly taller and lighter, of better educational background, and have fewer previous obstetric complications, including cesarean sections.[21] None of the studies conducted were able to study a large enough group of matched births to make definitive statements concerning perinatal mortality and other rare complications.[citation needed]

The most recent Cochrane systematic review of the literature, (published on the Cochrane database; a source from which many hospital policies are created), states, "The review found only one small trial, which provided no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women." [6]

However, Hofmeyr goes on to say, on behalf of the Cochrane database; "The relative benefits and risks of different settings are difficult to quantify. For a woman and her baby with no complications, the risk of an unexpected adverse event during a home birth may be smaller than risks specific to hospitalization, such as hospital-acquired infections" (Hofmeyr et al.:2008). Olsen and Jewell (2000), the authors of the systematic review also state: "In countries where it is possible to establish a home birth service backed up by a modern hospital system, all low-risk women should be offered the possiblity of considering a planned home birth...." (Olsen & Jewell: 2000 (CD000352) in Buckley:2005:230).

[edit] Maternal safety

All medical interventions were substantially decreased in the home birth sample, including the use of any pain medication or analgesics including epidurals, forceps or vacuum extraction, episiotomy and cesarean sections. Accordingly, the likelihood of normal vaginal birth was also greatly increased in the home birth sample. The studies were able to establish that there was no difference between the home birth and the hospital birth groups in the incidence of pre-eclampsia, premature rupture of membranes, or premature birth. Except in the 1989-1992 Zurich study [19], the length of labor tended to be longer during home birth, which is unsurprising given the fivefold lower incidence of induction of labor in the home birth populations.

In terms of maternal outcome, no study found any statistically significant difference between the number of women that had third-degree perineal lacerations or postpartum hemorrhage. However, the 1998-1999 British Columbia study did find a three- to fourfold less likelihood of infection for both the infant and the mother,[21] and all studies reported a substantially higher likelihood of an intact perineum in the home birth sample.

[edit] Infant safety

Perinatal outcome is more complicated to assess due to the low incidence of mortality and the subjectivity of Apgar scoring. Most studies found a slight, but statistically significant, difference in Apgar score for infants at five minutes. However, the 1994 UK National Birthday Trust study found a slight advantage for home birthed infants at one minute and no difference at five minutes [20]. No cohort study has conducted long-term follow up on the infants. The perinatal mortality figure still remains controversial. The Zurich study[19] showed an equal perinatal death rate between the home birth group and the hospital birth group (2.3 / 1000), and the Birthday Trust study found a slightly higher perinatal death rate in the hospital birth group (1 / 1000 vs. 0.8/1000) [20]. However, two other studies [18] [21] did find a slightly higher perinatal mortality in the home birth group as compared to the hospital birth group. None of these results were seen to be statistically significant, since the actual mortality rate and the sample sizes were both so low, these figures have been the subject of much debate regarding the relative safety of home birth compared to hospital birth. [21][22]

[edit] Legal situation

While it is a woman's choice whether to opt for a home birth, birthing center, or hospital, there are some legal issues which may affect the choice.

[edit] Australia

Although some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia, independent (private) homebirthing in Australia may unintentionally become illegal by July 2010. On this date all health professionals are required to have insurance in order to register. Private midwives in most Australian States and Territories are not currently insurable, and hence by default will be unable to register as health professionals in 2010. A woman currently has the right to hire an uninsured independent midwife to attend her home birth, but after this date an uninsured midwife cannot register, and criminal charges can be laid against the midwife if she attends a birth without registration.[23][24]

Dr David Miller, the only registered rural doctor practicing homebirth in Australia, has advocated government funded insurance through the treasury managed fund in order to prevent "freebirth" - the risky DIY alternative to monitored labour, which takes place without any professional help or government support.

In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State.[25]

The 2009 Federal Budget provided additional funds to Medicare to allow more midwives to work as private practitioners, allow midwives prescribing rights under the Medicare Benefits Schedule and assist them with medical indemnity insurance.[26]. However, this plan will only be in place for hospital births. There are no current plans to exptend Medicare and PBS funding home birth services in Australia.

[edit] Canada

Legality of homebirth currently is not an issue in Canada. Coverage by public health services vary from province to province, however. Availability of doctors and midwives providing homebirth services also varies. Currently the Province of Ontario covers homebirth services as does British Columbia, Saskatchewan, Alberta, and Quebec. [27] [28]

A comprehensive 4-year study of all home births with midwives in British Columbia was published in August 2009, which demonstrates again the safety of home births with trained midwifery care. [29]

[edit] United Kingdom

The are few legal issues with a home birth in the UK. There is no way a woman can be forced to go to hospital[30], if she does not want to. Both the RCM (Royal College of Midwives) and the RCOG (Royal College of Obstetricians and Gynaecologists) support home births where there are no expected complications.[31]. The support of the various Health Authorities of the National Health Service may vary, but in general the Government is pro home birth - the Parliamentary Under-Secretary of State for Health, Lord Hunt of King's Heath has stated

“I turn to the issue of home births. The noble Lord, Lord Mancroft, made some helpful remarks. As I understand it, although the NHS has a legal duty to provide a maternity service, there is not a similar legal duty to provide a home birth service to every woman who requests one. However, I certainly hope that when a woman wants a home birth, and it is clinically appropriate, the NHS will do all it can to support that woman in her choice of a home birth.”[32]

and:

“My Lords, I have had two babies at home. I should say that my wife had the babies but I was an enthusiastic spectator. The Government want to ensure that, where it is clinically appropriate, if a woman wishes to have a home birth she should receive the appropriate support from the health service. At the end of the day, it must be the woman's choice.”[33]

[edit] United States

Practicing as a direct-entry midwife is illegal in states shown here in red

No state prosecutes mothers for giving birth outside of a hospital. In 37 states it is legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.

Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, North Carolina, South Dakota and Wyoming.[34] However, Certified Nurse Midwives can legally practice in these areas.

[edit] Additional reading

[edit] Material supporting home birth choice

[edit] Material regarding safety and risk relating to birth

  • Obstetric Myths versus Research Realities - a guide to the medical literature, Henci Goer, Bergin & Gavey, 1998
  • The Thinking Woman's Guide to a Better Birth, Henci Goer
  • Pursuing the Birth Machine - the search for appropriate birth technology, Marsden Wagner, Ace Graphics, 1988

[edit] Material against home birth choice

[edit] Material regarding birth culture

  • The American Way of Birth, Jessica Mitford
  • Misconceptions: Truth, Lies and the Unexpected in the journey to Motherhood by Naomi Wolf

[edit] See also

[edit] External links

  • Expert Group on Acute Maternity Services: Reference Report International Models of Maternity Care Report on maternity care released in Scotland, 2002, includes summary of how maternity care is dealt with in other countries besides the UK.
  • Intrapartum Care Guidelines (2007) National Center for Health and Clinical Excellence, an independent health care monitoring organization in the UK, reviewing the home birth literature.
  • Home Birth Reference Site, Index of Research on Home Birth
  • American Pregnancy Association, Home Birth, brief article outlining the pros and cons of home birth
  • World Health Organization, Care in Normal Birth: A practical guide, Chapter 2: General Aspects of Labor, 1997.
  • ACOG Statement on Home Birth, American College of Obstetricians and Gynecologists reiterates its long-standing opposition to home births (Feb 8, 2008)
  • Canadian Medical Association Journal, [7], Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician -- Jansen et al., 10.1503/cmaj.081869, August 2009. This was a 4-year study of all home births with midwives in British Columbia. Conclusion: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
  • Profile of home birth pioneer Ina May Gaskin, The Guardian, September 2009

[edit] References

  1. ^ Vernon, David "Men at Birth", Australian College of Midwives, Canberra, 2007, p8
  2. ^ Home birth and hospital deliveries: a comparison of the perceived painfulness of parturition", Morse J and Park C, Research into Nursing and Health, 1988 Jun; 11(3):175-81
  3. ^ Staying Home to Give Birth: Why Women in the United States Choose Home Birth, Journal of Midwifery & Women's Health, Volume 54, Issue 2, March-April 2009, Pages 119-126, Debora Boucher, Catherine Bennett, Barbara McFarlin and Rixa Freeze
  4. ^ Studies monitoring transfers Home birth reference site. Accessed: Aug 24, 2008
  5. ^ General aspects of Care in Labour, WHO’s Care in normal birth: a practical guide, 1997
  6. ^ Cassidy, Tina (2006). Birth. New York: Atlantic Monthly Press. pp. 54–55. ISBN 0-87113-938-3. 
  7. ^ A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p156
  8. ^ A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p157
  9. ^ Martin JA, et al. “Births: Final Data for 2005” [ http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf CDC National Vital Statistics Report] Vol 56, No 6. Dec 5, 2007.
  10. ^ http://news.netdoctor.co.uk/news_detail.php?id=17087027
  11. ^ Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney, p. 20.
  12. ^ New Zealand Information Service, 2007, Report on Maternity Maternal and Newborn Information 2004, p. 64
  13. ^ Wiegers TA, et al. “Maternity Care in The Netherlands: the changing home birth rate (1998) Birth 25:190-197.
  14. ^ National Collaborating Centre for Women's and Children's Health as Commissioned by the National Institute for Health and Clinical Excellence Final Draft of Guideline on Intrapartum Care, (Royal College of Obstetricians and Gynaecologists, London, 22 March 2007)
  15. ^ de Jonge A, van der Goes B, Ravelli A, Amelink-Verberg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S, Perinatal mortality and morbidity in a nationwide cohort of 529688 low-risk planned home and hospital births BJOG 2009
  16. ^ de Jonge A, van der Goes B, Ravelli A, Amelink-Verberg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S, Perinatal mortality and morbidity in a nationwide cohort of 529688 low-risk planned home and hospital births BJOG 2009, p9
  17. ^ Home birth "Safe as in hospital' NHS Knowledge Service http://www.nhs.uk/news/2009/04April/Pages/HomeBirthSafe.aspx
  18. ^ a b c Woodcock HC, et al. (1994) Midwifery 10:125-135.
  19. ^ a b c Ackerman-Liebrich U, et al. (1996) BMJ 313:1313-1318.
  20. ^ a b c Chamberlain G, et al. (1999) Pract Midwife 2:35. as summarized on the Home Birth Reference Site
  21. ^ a b c d e Janssen PA, et al. (2002) CMAJ 166:315-323.
  22. ^ Letters: The pleasures of home birth? (Response to Janssen PA, et al. 2002 CMAJ 166: 1509-1512
  23. ^ National Registration for Midwives http://www.midwives.org.au/News/NationalRegistration/tabid/1542/Default.aspx National Registration for Midwives
  24. ^ Miller, Dr. David, "Preventing death in homebirth" Byron Shire Echo 27(05) 7 July 2009, Australia
  25. ^ The Health Minister's controversial plan to encourage more home births.
  26. ^ Improving Maternity Services Package [1]
  27. ^ [2]
  28. ^ [3]
  29. ^ [4]
  30. ^ "Can a mother be forced to attend hospital? What about court-ordered caesareans?". http://www.homebirth.org.uk/law1.htm. Retrieved 2009-08-31. 
  31. ^ "Home Birth in the UK". http://www.homebirth.org.uk. Retrieved 2009-08-31. 
  32. ^ "Hansard 12 Jan 2000 : Column 743". http://www.publications.parliament.uk/pa/ld199900/ldhansrd/vo000112/text/00112-08.htm#00112-08_head0. Retrieved 2009-08-31. 
  33. ^ "Hansard 20 Dec 2000 : Column 734". http://www.publications.parliament.uk/pa/ld200001/ldhansrd/vo001220/text/01220-01.htm#01220-01_head0. Retrieved 2009-08-31. 
  34. ^ Midwives Alliance of North America.
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