Think | Home birth

Objective
To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.

Design
Prospective cohort study.

Setting
All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.

Participants
All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.

Main outcome measures
Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.

Results
655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.

Conclusions
Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.

The British Medical Journal (BMJ) has published the paper on-line http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom

Published in the June 18 2005 issue of the North America British Medical Journal, the study found that “planned home births for low risk women in the United States are associated with similar safety and less medical intervention as low risk hospital births,” according to the BMJ press release (see below).

According to co-author Ken Johnson, this is the largest study of its kind at this time. The study is prospective (initial data submitted before the birth took place, so no births could be “left out”) and includes data from more than 5000 births in the United States and Canada. It cannot be written off for being too small or not relevant to U.S. populations and circumstances.

The following is excerpted from a BMJ Press release:

Planned home births for low risk women in the United States are associated with similar safety and less medical intervention as low risk hospital births, finds a study in this week’s BMJ. In the largest study of its kind internationally to date, researchers analysed more than 5000 home births involving certified professional midwives across the United States and Canada in 2000. Outcomes and medical interventions were compared with those of low risk hospital births.

Rates of medical intervention such as epidural, forceps and caesarean section, were lower for planned home births than for low risk hospital births. Planned home births also had a low mortality rate during labour and delivery, similar to that in most studies of low risk hospital births in North America. A high degree of safety and maternal satisfaction was reported, and more than 87% of mothers and babies did not require transfer to hospital.

“Our study of certified professional midwives suggests that they achieve good outcomes among low risk women without routine use of expensive hospital interventions,” say the authors. “This evidence supports the American Public Health Association’s recommendation to increase access to out of hospital maternity care services with direct entry midwives in the United States.”

Further information from Betty-Anne Daviss, Registered Midwife, co-principal investigator of the study:

If you choose the home birth, intervention rates will be one-tenth to one-half of what they would be in hospital, compared with figures of the same time period from the National Health Institute of the United States.

The study is groundbreaking because former studies have been criticized for not being big enough, for not being able to distinguish between planned or unplanned births, and for being retrospective (considering only old records as opposed to requiring health professionals to register births they were going to do and then have to account for all outcomes). As well, more than 500 mothers were phoned to verify whether what the midwives said at the births actually happened.

The study suggests that legislators and policy makers should pay attention to the fact that this study supports the American Public Health Association resolution to increase out of hospital births attended by direct entry midwives.

Long-term impact of our current model of medicalised maternity care, and the high rates of medical interventions associated with its use.

Sarah J Buckley. GP
Anstead, Queensland 4070, Australia

Jacobson et al compared the rates of adult drug addiction between siblings born with and without exposure to opiates, barbiturates, and nitrous oxide in labour. Exposure to more than three doses of any of these analgesics was associated with an almost five times increased risk of drug addiction in adulthood.1

Caesarean section is another major birth intervention with poorly researched long-term implications for the offspring. Studies show that caesarean babies have lower levels of neonatal brain oxygenation,2 and slower neurological adaptation after birth.3-5 Animal studies have linked uncomplicated caesarean birth with abnormalities of dopamine pathways in adult rats and guinea pigs.6 Dysregulation of dopamine function has been implicated, in human studies, with the development of schizophrenia, as well as substance abuse and attention deficit hyperactivity disorder.6

Other researchers have studied the effects of epidurals and pethidine, administered at term to rhesus monkeys, and found abnormalities in behavioural maturation during specific periods of infancy.7 Golub comments, “Probably the most widespread exposure of the developing brain to central nervous system agents occurs at birth.”8

Csaba’s research into hormonal imprinting raises more concerns about perinatal exposure to drugs and hormone-like substances.9 For example, he found that a single perinatal exposure to exogenous beta-endorphin altered adult sexual and aggressive behaviour in rats.10 This author states, “Perinatally, the first encounter between the maturing receptor and its target hormone results in hormonal imprinting, which adjusts the binding capacity of the receptor for life. In the presence of an excess of the target hormone or foreign molecules than can be bound by the receptor, faulty imprinting carries life-long consequences.”11 Hormonal imprinting effects can persist for three generations.12

New thinking about brain development emphasises the plasticity of the developing brain,13 and the vulnerability of the brain, during the prenatal period of neuronal mulitiplication, migration and interconnection, to irreversible damage.14

These findings add important information in interpreting Johnson and Daviss’ study. Not only are the babies represented here equally safe, in terms of mortality, compared to low-risk babies born in hospital; they may also have significant long-term neurological and developmental advantages because of their low rates of exposure to obstetric drugs and procedures.

1. Jacobson B, et al. Opiate addiction in adult offspring through possible imprinting after obstetric treatment. Br Med J 1990;301(6760):1067-70. 2. Isobe K, et al. Measurement of cerebral oxygenation in neonates after vaginal delivery and cesarean section using full-spectrum near infrared spectroscopy. Comp Biochem Physiol A Mol Integr Physiol 2002;132(1):133-8. 3. Kim HR, et al. Delivery modes and neonatal EEG: spatial pattern analysis. Early Hum Dev 2003;75(1-2):35-53. 4. Otamiri G, et al. Delayed neurological adaptation in infants delivered by elective cesarean section and the relation to catecholamine levels. Early Hum Dev 1991;26(1):51-60. 5. Vladimirova E, Smirnova EE. [The CNS status of newborn infants delivered by cesarean section (based on EEG data)]. Zh Nevropatol Psikhiatr Im S S Korsakova 1994;94(3):16-8. 6. Boksa P, El-Khodor BF. Birth insult interacts with stress at adulthood to alter dopaminergic function in animal models: possible implications for schizophrenia and other disorders. Neurosci Biobehav Rev 2003;27(1-2):91- 101. 7. Golub MS. Labor analgesia and infant brain development. Pharmacol Biochem Behav 1996;55(4):619-28. 8. Golub MS. Labor analgesia and infant brain development. Pharmacol Biochem Behav 1996;55(4):619-28, p 619. 9. Csaba G. Hormonal imprinting: its role during the evolution and development of hormones and receptors. Cell Biol Int 2000;24(7):407-14. 10. Csaba G, et al. Effect of neonatal beta-endorphin imprinting on sexual behavior and brain serotonin level in adult rats. Life Sci 2003;73(1):103- 14. 11. Csaba G, et al. Endorphin excess at weaning durably influences sexual activity, uterine estrogen receptor’s binding capacity and brain serotonin level of female rats. Horm Metab Res 2004;36(1):39-43, p 39. 12. Csaba G, et al. Three-generation investigation on serotonin content in rat immune cells long after beta-endorphin exposure in late pregnancy. Horm Metab Res 2005;37(3):172-7. 13. Shore R. Rethinking the Brain: New Insights into Early Development. New York: Families and Work Institute, 1997, p 15. 14. Livezey GT, et al. Prenatal exposure to phenobarbital and quantifiable alterations in the electroencephalogram of adult rat offspring. Am J Obstet Gynecol 1992;167(6):1611-5, p 1614.

Although hospitals are widely believed to be the safest places to give birth, there has never been even one study that shows this belief to be based in fact. In reality, the studies which have been done (most in an attempt to discredit the safety of homebirth and midwifery) have proven overwhelmingly that hospitals and doctor attendance at birth do not result in the best outcomes for mothers and babies. In fact, the United States ranks 23rd -24th internationally among industrialised nations in infant mortality. Those nations with the lowest infant mortalities have one thing in common- the majority of their births are attended by midwives. If hospitals and doctors are what make birth safe why do we, with 98% hospital births and 94% physician attendance, rank so poorly? Clearly hospitals, physicians and technology do not, in and of themselves, ensure a safer outcome. Nevertheless, our belief is that they do. It is almost impossible for many people for many people to extract themselves from this belief system long enough to look at the matter objectively.

Perhaps an analogy to something that we do every day, eating, will shed some light on the childbirth safety in our country. Suppose physicians everywhere suddenly decided to focus on eliminating choking deaths resulting from the ingestion of food. The medical focus would become: avoid death by choking. To that end, public eating areas would be set up so that people could be observed by health professionals while dining. Standards of ‘’normal’’ eating would be established; perhaps times of the day, blood sugar levels, and chewing patterns would all be calculated in relation to the number of people who choked. Some who had choked before or who were especially at risk (the very young or very old) would be hospitalised during meals to be more carefully monitored. Foods would undoubtedly be chosen to minimise the possibility of choking: most would be mashed or pureed. Eventually, no doubt, doctors would advocate nutritive I.V.’s as a solution for the high risk and those who didn’t want to risk eating the more careless way. Of course, to completely eliminate this choking problem, everyone could receive nutritive I.V.’s. A lot of time, money and effort would be spent developing various nutritive I.V. fluids to meet everyone’s needs. People would discover where they stood as far as risk was concerned and those who ate at home unobserved would be seen as reckless and irresponsible.
It is easy for us to see how crazy this idea sounds. Who would want to be hospitalised to eat baby food? Would it really be more comforting to know that someone skilled in the Heimlich manoevre was right behind you, knife at the ready, waiting to do a tracheotomy if it didn’t work?

It is true that thousands of choking deaths happen every year and we should all be informed about how to assist when choking occurs. But wouldn’t so much focus on choking create a lot of unnecessary fear and intervention which might easily result in more choking deaths because everyone was so nervous? And would eliminating all the other pleasures and needs met by dining in a relaxed fashion be worth it? It is easy to see how absurd this would be because we are intimately knowledgeable about the risk/benefit ratio for choking involved in eating. Imposing this kind of fear on eating is something we readily reject as an overreaction to the reality of death by choking. This doesn’t sound safe, it sounds ridiculous.

Our society has essentially taken another normal process, childbirth, and done the very same thing. The focus of modern obstetrics is to avoid death at all costs. Technological interventions and the Caesarean rate are soaring ; some doctors have advocated 100% Caesarean as a prophylactic measure. People birth in hospital “just in case something goes wrong.” As a result, the myriad other aspects of childbirth have been ignored or simply paid lip service. An event that used to be as much a part of ones’ everyday life as eating has been removed to institutions and transformed into a purely medical event. Our focus on fear of problems prevents us from dealing with childbirth in a rational and balanced way.

Statistically, birth at home with skilled midwives provides the very safest care possible for most women. The few who are better off in a hospital are those who need the technology available there for very specific and relatively uncommon reasons, most of which are medical conditions that have nothing to do with pregnancy.

The reason why midwifery is safer is very simple: midwives are specialists in normal birth who respect the wisdom of this normal life process. We focus on solution, not problems. To even suggest we focus on the normal make everyone rush to ask “Well it’s fine if everything is normal, but what if there are problems?” To focus on the normal does not mean that problems go unrecognised and unattended. It means that the problems are viewed in a different way, one in which imbalances are righted, not expected and not feared.

In our culture today midwifery provides a haven for women who believe that pregnancy can be natural, normal and healthy, and a refuge for parents who want their experience to be seen as more than the sum of the total parts . A woman cannot relax and easily give birth with tubes hanging out of her and people standing over her waiting to see if her baby will die, any better than one can relax and enjoy a meal with the knowledge that someone is hovering nearby waiting to see of they will choke. We seek to support families who wish to rise above the culturally imposed terror surrounding birth and come to a more humane and rational approach which puts the medical aspects of birth back into perspective.

Anne Frye (B.A. Holistic Midwifery)
excerpt from Holistic Midwifer

It must be stressed that different caregivers have different philosophies in relation to birth. Their philosophies are generally referred to as the ‘midwifery’ and ‘medical’ models, although it is not accurate to say that all doctors believe in the medical model and all midwives in the midwifery model. The medical model sees childbirth as inherently dangerous and suggests that all women should undergo routine interventions to
ensure safety and give birth in hospital, and the midwifery model uses a more holistic approach and assesses women on an individual basis - a process which often enables women to give birth in their own homes.

Although the medical model has been the dominant model of birth in our society for a number of years, researchers in all fields are now showing the midwifery model to be
more accurate in the way it sees birth. Moreover, more women are seeking to reclaim the spiritual and developmental aspects of birth which have historically led this to be viewed as a ‘rite of passage’ rather than a potentially dangerous medical event.

Many women approach a ‘medical model’ practitioner for care during their pregnancy, although this is not necessarily the best option. While family doctors, obstetricians and
hospitals have a part to play in the care of women with serious medical conditions, or who develop a problem during pregnancy or labour, research shows that the vast majority of women might be better served by choosing a midwife for their care. Equally, this majority of women would also be well-advised to consider home birth as an option, due to its many advantages over hospital care.

Some of the advantages of home birth with a midwife are cited below:

WOMEN EXPERIENCE LESS PAIN AT HOME

It is well understood that sensations of pain in labour are regulated by hormones released by the woman’s body.

During the labour, oxytocin - the hormone which causes contractions and helps the baby to be born - works in harmony with endorphins - the body’s own pain relieving hormone. During a home birth, the woman’s body will release these hormones according to her needs and she will usually cope well with the sensations of labour.

However, when a woman attempts to give birth in another environment, such as a hospital, this process may not work as well. Even if a woman feels rationally that hospitals
are ’safer’ places in which to give birth, her subconscious mind knows that this is not the case, and she feels insecure.

This causes her body to secrete the hormone adrenalin, which causes the levels of both oxytocin and endorphins to drop. She experiences far more pain than she would in
her own home and this has several other effects on her labour which are described below.

WOMEN EXPERIENCE LOWER LEVELS OF INTERVENTION AT HOME

There are two main reasons for this. The first concerns the hormones described above. In a hospital environment, women often produce the hormone adrenalin in response to
subconscious or conscious fear. This inhibits the release of the hormone oxytocin and labour may well slow down.

Although this slowing of labour is a natural safety mechanism, designed to let the women know she needs to find another environment, it is interpreted by many medical professionals as ‘failure (of the woman’s body) to progress’.

Rather than suggesting that the woman talk about and work through her fears, or finds a different environment, they will turn instead to drugs to ’speed up’ the labour. This drug (usually syntocinon or pitocin) can cause distress in the baby, among other effects, and often itself leads to a ‘cascade of intervention’ which may result in an instrumental
delivery or a cesarean section.

The second reason is that hospitals are systems which need to run efficiently. They need to have procedures in place for workers to follow so that chaos does not ensue! Unfortunately, this often means that hospitals have policies where a certain number of interventions are carried out on all women who choose to give birth there. Often there is no evidence to support these interventions, and many of them (eg electronic fetal monitoring) are known to be harmful when used on a routine basis.

Every intervention is useful to a small number of women when used appropriately - but when applied to all women, they often cause far more harm than good. Women’s choices
are not sought and it is often difficult for staff to offer individualized care, because they feel restricted by the ‘hospital policy’. They may not be ‘allowed’ to walk around and adopt alternative positions which are known to facilitate effective progress in labour.

WOMEN HAVE MORE AUTONOMY AT HOME

There is another major difference between giving birth in your own environment or in someone else’s - that in your own home you are ‘in charge’. You would not feel you needed
to ask permission to make a drink in your own home, or visit the bathroom, yet that is exactly how many women feel in hospital. And the effects of feeling as if they need to ask
permission to do everyday things can lead to women feeling that they are not in control. This may then have an impact on a woman’s labour, because labour is a time when women
need to feel very strong and powerful within their own bodies, not as if they were small children who needed to ask if they could pee!

Eating and drinking is another important aspect of this. In your own home, you are free to eat and drink whatever you feel like. Although women often do not feel like eating in  strong labour, the choice is there. Many hospitals still refuse women food and drink in labour, even though all of the research evidence shows that this restriction is harmful
rather than beneficial. Consequently, women become dehydrated and have low energy levels - at a time when they need lots of energy. Hospital staff may site an iv drip to replace fluids but this is not ideal - it limits the women’s movement and adds to the feeling that she is ’sick’, rather than experiencing a perfectly normal event.

OTHER RISKS OF HOSPITAL BIRTH

A recent article in the journal of the Association for Improvements in Maternity Services, cites a number of other risks of hospital births.

These are summarized in the following list:

• Midwives may be looking after more than one woman in labour and individual women are not able to receive the support they need. This can also mean they are more likely to be ‘tied’ to fetal monitors rather than having the midwife listen to the baby’s heartbeat intermittently.
•  Hospital birth deprives the woman of contact from her family and friends. Being with other support people, particularly female relatives or friends, has been shown to have a very positive effect on labour and birth.
• Continuity of care is rare in hospitals - although you would have the same midwives throughout a home birth, especially if you chose to employ an independent midwife, shift changes in hospitals mean you may see a large number of carers during your birth. Some women report that, as soon as they have built up a rapport or relationship with one carer, she goes off duty and they have to ’start all over’. ‘Knowing your midwife’ has been shown to have very beneficial effects on labour.
• Levels of medical staff may also be low. It is a common fallacy that being in hospital is safer ‘if things go wrong’. In fact, as long as you are not a huge distance from a hospital, you may well be treated more quickly if you are transported from a home birth than if you were in hospital in the first place! The sort of emergencies which need truly immediate action are extremely rare and are almost always preceded by signs which your midwives will pick up and act upon.
• In hospital, decisions about your labour will sometimes be made by very junior medical staff. (You rarely have a choice about which staff care for you in hospital.) These people may have little experience in birth and certainly far less than midwives who specialize in this area. They are also unlikely to trust that your body knows what it is doing!
• Hospital and medical care, as discussed above, takes place in a philosophy where staff are ‘looking for problems’, rather than ensuring that things are progressing normally. This seemingly small difference actually makes a big difference in the approach that different carers take to the women and her labour and birth. Would you rather have a carer who trusts that your body knows what it is doing and either reassures you that all is going well or helps you if there are any problems, or a carer who is always checking to make sure that your body is ‘working’, while at the same time doubting your ability to actually give birth? As before, not all hospital midwives or nurses take the latter attitude, but the environment of the hospital itself tends to perpetuate this philosophy.

WOMEN ENJOY INCREASED SATISFACTION WITH HOME BIRTH

The proof of this pudding is in the eating, or the asking! Over 99% of women who have experienced both home and  hospital birth will tell you that they would choose to have a home birth in the future. But don’t take my word for it - ask some!

ARRANGING A HOME BIRTH

If you are thinking of having your baby at home,  talk to a midwife! She will be able to tell you what is on offer in your area, and the kind of care she can offer you. She will also be able to help you to make a realistic assessment of whether home birth is right for you.

In general, the only women who are truly better off in hospital are those with chronic medical problems, such as insulin-dependent diabetes, or those with a very small baby. But women need to be considered individually, and their unique circumstances taken
into account.

Remember that, in our society, there are many people who do not ‘trust birth’, and some midwives are among these people. If you encounter opposition to your plans, then seek a second opinion. You may have to interview several midwives before you find the one that is right for you. You may also want to seek support from other women who have made this choice.

The final thing that I would like to remind you of is to remember that women have been having babies for millions of years - without the aid of hospitals or medical intervention.  And if birth didn’t work, then we wouldn’t be here now! Women’s bodies are designed to have babies.

Trust your body. Trust your baby. Trust birth.