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Home birth

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Home birth is childbirth that occurs outside a hospital or birthing center setting, usually in the home of the mother. Most home births are assisted by midwives, but some home births are physician assisted. Others have no medical assistance at all. This is known as unassisted childbirth or freebirth.

In most Western countries, home birth declined over the 20th century, although there was some revival of the practice in 1970s. In The Netherlands, about 30% of all births occur at home, but this number is falling. In countries where midwives are the main carers for pregnant women, home birth is more prevalent. [citation needed]

Types of home birth

A home birth (permission : Lisa J. Patton)

Assisted home birth

For low-risk pregnancies, a number of studies have shown that planned, assisted home births are at least as safe as hospital births. There are fewer medical interventions, such as cesarean sections, forceps or ventouse deliveries, episiotomies and administration of pain medication such as epidurals, all of which may pose some risk to the health of the mother and baby.

Unassisted home birth

Main article: Unassisted childbirth

There have been no formal studies on unassisted birth. A mother having an unassisted home birth can do so in the environment in which she feels most comfortable.

Many mothers choose a "couple's birth" where the birthing mother and her spouse or partner are the only ones present while she gives birth. Other children may be sleeping, or busy elsewhere in the house. Advocates of unassisted birth believe that couple's birth is an intimate extension of babymaking.

Differing opinions

Proponents of home birth prefer the atmosphere and safety of a home birth. The mother has more control over her surroundings, and can eat and move around, sleep and do anything she pleases – activities which may be discouraged in a hospital setting. The mother is often more comfortable in her own home and increased comfort contributes to shorter labor. [1] Antibiotic resistant pathogens commonly found in hospitals [2] [3], such as staph (methicillin-resistant Staphylococcus aureus and others), are less likely to be transferred to the mother or child when the birth takes place at home. However, in the case of emergencies such as cord prolapse, breathing problems with the infant, inverted uterus, or bleeding of the mother, there is less access to life-saving equipment. Properly trained midwives can manage such emergencies until the woman can be transferred to a hospital.

Conversely, some mothers are more comfortable in a hospital setting because they implicitly trust the medical system and because they prefer to be closer to an operating room should an emergency arise. Most hospitals have a policy of trying to deliver the baby within 30 minutes of determining a caesarean is required, however, owing to the theatre preparation time, this goal is only achieved 66% of the time. Despite this, there is no statistical increase in morbidity or mortality when it takes longer than 30 minutes. This generally fits with the view that very few obstetric emergencies require immediate action. [4]

Safety

The safety of home birth has been questioned by some obstetricians and general practitioners, but designing randomized controlled trials to test the safety of home birth compared to hospital birth has significant ethical problems. Studies of safety have differing conclusions.

A recent study in the British Medical Journal, "Outcomes of planned home births with certified professional midwives: large prospective study in North America" (Johnson & Daviss, June 2005), concluded that outcomes were just as good and "medical intervention rates (such as epidural, episiotomy, forceps, ventouse, and caesarean section) were substantially lower than for low risk US women having hospital births." For example, amongst the home birth women, 3.7% ended up having a caesarean section compared to 19% for the US as a whole (for a similar risk profile) [2000 data]. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded.[5]However, Johnson and Daviss failed to note that the hospital neonatal mortality rate for comparable risk women in 2000 was 0.72/1000 (congenital anomalies included). Instead, they compare homebirth in 2000 to out of date papers on hospital birth as far back at 1969. Johnson and Daviss also have undisclosed conflicts of interest. Both Johnson and Daviss are long time public advocates of homebirth. Daviss is a homebirth midwife, and Johnson is the former director of research for the Midwives' Alliance of North America. Moreover, the study was comissioned by MANA and was funded by a homebirth advocacy group.

The National Center for Health and Clinical Excellence, a healthcare watchdog organization, has recently performed a comprehensive review of the entire homebirth literature and concluded that homebirth has an excess risk of neonatal death as compared to hospital birth:

"... The quality of evidence available is not as good as it ought to be for such an important health care issue, and most studies have inherent bias. The evidence for standalone midwife led units and home births is of a particularly poor quality.

The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality that is very difficult to accurately quantify, but is potentially a clinically important trend. Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population."

According to Enkin et al in the work A Guide To Effective Care in Pregnancy and Childbirth; "Women with low risk pregnancies considering out of hospital birth should not be discouraged."[6]

Of note, MANA (the Midwives' Alliance of North America), the group that collected the statistics for the BMJ study, continued collecting statistics for all registered midwives from 2001-2006 and up through the present. This database contains somewhere in the range of 30,000 deliveries, perhaps more. MANA is refusing to share that data with the public. MANA is offering to release the data, but only to pre-approved individuals who sign confidentiality agreements preventing them from sharing the data with anyone else.

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. However, midwives who assist at such births may be prosecuted in some areas.

In the early and mid 1900s, physicians pushed to have midwifery banned throughout the United States. Childbirth became very clinical with the mother generally subdued with leather straps and ether. In 37 states it is once again 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, Missouri, North Carolina, South Dakota and Wyoming.[7] However, Certified Nurse Midwives can legally practice in these areas.

People wishing to have a midwife-assisted home birth in the United States should always research the applicable laws in their home state.

Whilst there is no restriction on having homebirths in Australia, it is illegal for midwives to practice in some Australian States and Territories, because they are unable to obtain professional indemnity insurance. Medical practitioners in some Australian jurisdictions must have insurance before they can practice. After the collapse of the large Australian insurer HIH, the remaining Australian insurance companies ceased offering insurance to home birth midwives, as they claimed that the pool of midwives requiring insurance was too small to make it commercially viable. Without insurance, many independently practicing midwives have elected to discontinue providing independent services, even though they are qualified health professionals and are allowed to practice within hospitals.

When several large insurance companies threatened to withdraw insurance for obstetricians in 2002, the Australian Government immediately responded and provided a A$600 million dollar (over 4 years) subsidy to the obstetricians to allow them to continue to practice legally.

Some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia. In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State. [8]

Additional reading

See also

References

  1. ^ David Vernon Having a Great Birth in Australia, Canberra, 2005
  2. ^ Example in Ireland
  3. ^ Example in Australia
  4. ^ [http://www.bmj.com/cgi/content/abstract/322/7298/1330 Interval between decision and delivery by caesarean section are current standards achievable? Observational case series Tuffnell, Wilkinson and Beresford 2001
  5. ^ Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416 (18 June).
  6. ^ Enkin, M, A Guide to Effective Care in Pregnancy and Childbirth, (Oxford University Press, 2000)
  7. ^ Midwives Alliance of North America.
  8. ^ Need for Birthing at Home
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