(Still, I ain’t voting for the guy…)
Category Archives: Home birth
Many of you are no doubt aware of the study released last week by the Birthplace in England Collaborative Group. The purpose of the study was to take a detailed look at the risks associated with different settings where women with low-risk pregnancies plan to give birth: hospital OB units, midwifery-run birth centers within or close to hospitals, freestanding birth centers, and at home.
The study ran from April 2008 to April 2010. The measured outcome was a composite of things that can go wrong for babies at birth: death at or just after birth, and injuries that may occur during birth such as broken bones, traumatic nerve injury, brain injury and a type of respiratory distress called meconium aspiration syndrome .
The findings: overall, birth for low-risk women was equally safe in all four settings. In other words, low-risk births anywhere in England tended to have low rates of bad outcomes.
When the data was carved up a bit more, one difference popped up: women having their first babies at home were 2 to 3 times more likely to have bad outcomes than those giving birth in any of the other settings. The risks were still quite low, but the increase was statistically significant.
The British press jumped all over that statistic. Many were quick to condemn all home birth as dangerous and not all the reporting was accurate. (See the Daily Mail story here, which exaggerates the risk of death or brain damage.)
Cooler heads are still trying to have themselves heard over the tabloid din. Britain’s National Health Service, which directs midwifery care in England, has an excellent review of the study’s findings and the risks of home birth (which includes the definition of a low-risk pregnancy, too). It’s well worth the read.
What seems to have been somewhat overlooked in all hubbub about risks to first-time mothers is what the study found about women having second or later babies. There was no safety difference for these mothers in any of the birth settings – birth at home was as safe as anywhere else. Fortunately, some reporters picked up on that part of the story.
So what’s the Birthplace in England study’s bottom line? That low-risk births generally go well, regardless of where they happen. A first-time mother planning a home birth needs to be aware of the small but significantly increased risk her choice entails, and second-time moms should be fine regardless of birth setting.
Ah, but that’s in England, where home birth is integrated into the larger maternity care system. The U.S. is a whole different story. And there’s more to assessing risk of place of birth than focusing on immediate outcomes. More on that soon.
Here’s a YouTube link to Congresswoman Lucille Roybal-Allard (D-CA) speaking in the House of Representatives yesterday about the Home Birth Consensus Summit. She does a great job of summing up why the Summit was so important. I’ll be adding another post soon about the “next steps” based on the Summit’s nine vision statements.
“We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.”
My first exposure to home birth was in 1980, during my pediatric residency, when a paramedic burst through the NICU doors with a limp, blue baby in his arms–the product of a home birth gone very wrong. We cared for her as best we could, but she died a few hours later.
The baby’s young parents were devastated, of course. They had chosen to deliver their baby themselves at home rather than opt to give birth in the hospital. Though they had read volumes on normal birth, they’d given little thought to the possibility of complications–in this case shoulder dystocia and a tight nuchal cord–and by the time the paramedics were called it was simply too late.
That tragic experience shaped my opinion of home birth for the next twenty-five years: I concluded that having a baby at home was a risky, irresponsible thing to do. Not until long afterward did I stop to think that maybe the problem with this particular birth was not that it was a home birth per se, but that it had been poorly planned by inexperienced/overconfident parents with no midwife and no access to timely emergency aid.
The big question here in 2011, then: Is home birth a safe alternative to hospital birth? What are the real risks?
Let’s take a quick look at the pros and cons in the medical literature. (A big thank you to Professor Saraswathi Vedam, Director of the Division of Midwifery at the University of British Columbia–and the driving force behind the Home Birth Consensus Summit–for her Annotated Guide to Home Birth Literature.)
Evidence supporting home birth as a safe alternative to hospital birth:
A number of studies in North America and particularly in Europe have demonstrated that planned, midwife-assisted home births within an organized system of care can be safe for low-risk mothers and their babies (more on my italicized qualifiers below), and in many cases results in fewer complication-prone interventions as well. Some highlights (more can be found in the Annotated Guide):
1) Maternal and infant mortality and morbidity (complications resulting from birth):
- Janssen and colleagues (British Columbia, 2009): found no increase in risk of death or serious morbidity for either mother or baby from low-risk, registered midwife-attended home birth compared with hospital birth.
- de Jonge, et al, (the Netherlands, 2009): studied 529,000 low-risk women; no increased risk of death or severe newborn morbidity in home birth vs. hospital.
- Leslie and Romano (United Stated, 2007): low-risk out-of-hospital births had similar rates of neonatal mortality and morbidity, including birth trauma and NICU admission, compared with hospital births.
- Janssen, et al (British Columbia, 2002): found no difference between low-risk home and hospital birth in regard to serious neonatal complications requiring NICU care.
2) Obstetric interventions:
A number of studies cited in the Annotated Guide found that home birth is associated with a significant reduction in obstetric interventions, such as epidurals, induction or augmentation of labor, episiotomies, maternal fever, hemorrhage and severe tears or lacerations. Some of this has to do with the lack of certain technologies at a home birth (it’s darn hard to get an epidural at home, for one thing…), but regardless, there are clearly fewer interventions with home vs. hospital birth.
Evidence unfavorable to home birth:
1) Maternal and infant mortality and morbidity
- Wax and colleagues (click on “Wax Maternal and Newborn outcomes” in link for article PDF) performed a meta-analysis of international studies related to home birth safety. They concluded that a baby was three times more likely to die in a home birth than in a hospital birth. This study was both widely publicized and heavily criticized for a number of significant flaws, which cast doubt on its findings. See Gyte’s critique here for much, much more detail.
- Similarly, Chang and Macones (Missouri, 2011; to be published in the American Journal of Perinatology soon) concluded that home birth increases the risk of seizures and death for newborns. As with the Wax analysis, the authors have been criticized for irregularities in study design and execution, not the least of which were an unusually broad definition of “low-risk” pregnancies (which included both some premature and nearly all post-mature pregnancies) and the inclusion of a class of midwives that did not exist in Missouri at the time of the study.
* * *
My opinion of home birth has changed considerably since 1980. Based on current research, planned, midwife-attended home birth for low-risk mothers in an integrated maternity care system does appear to be at least as safe for babies, and in some ways safer for mothers, as hospital birth.
Ah, but here’s the rub: What constitutes a “planned, low-risk” birth? What is an “integrated maternity care system”? And are safety studies from the Netherlands and British Columbia, where home birth midwives are an accepted part of the larger maternity care universe, applicable to the United States, where a tradition of acrimony and mutual suspicion in the childbirthing world has led to a badly fractured system of care?
Here’s just one example of that fracture: while home births are supported in states like Washington, hiring a home birth midwife, no matter how well-trained, is illegal in 10 states including the three I lived in as a child (Iowa, Indiana and Illinois).
This is a set-up for bad outcomes. A home birth midwife working under the radar in Indiana, say, might delay seeking consultation with an obstetrician or transferring a mother to a hospital for fear of prosecution, which in turn could lead to disaster. It’s not that my fellow Hoosiers are any less capable of giving birth safely at home. Poor communication between maternity caregivers increases the risk of delayed and uncoordinated care, making a home birth in Indiana theoretically riskier overall than a home birth in Washington.
An enormous amount of work will need to be done before home birth becomes a safe option for all low-risk women in the United States, regardless of location. But new research on the benefits of vaginal birth, particularly home birth, for the development of a child’s immune system makes it important that we get started on this critical work now.
And that’s why the vision statements from the Home Birth Consensus Summit are so important. They reflect a set of common agreements among very disparate groups–a big first step in what I hope will be an interesting, thoughtful process leading to healthy outcomes for mothers and babies.
The Home Birth Consensus Summit statements came out today, and a person who isn’t familiar with the issues and groups involved might well read them and wonder: Why are these even necessary? Aren’t a woman’s choices about childbirth already respected? Don’t doctors, midwives, nurses and mothers already communicate with one another? For this you needed a fancy summit (with really good food) in Virginia?
The answer: In a perfect world all this respecting and communicating would be done automatically, seamlessly, and without fuss and feathers. In that same perfect world the Mideast would be a haven of peace, too. The real world, though, is immensely messier. Given the history of animosity between some groups in the childbirthing world–most notably, between obstetricians and midwives–the fact that these statements were ever agreed upon is a minor miracle.
Let’s walk back in time for a moment. The conflict over who should help mothers birth their babies has been with us for quite a while, but not forever. In ancient times, in virtually all cultures, midwives attended to a mother during labor and to her baby afterward. Pain control, labor induction and augmentation, control of bleeding and such were managed through a combination of folk medicine and practical experience.
Things changed with the arrival of the Enlightenment, with its increasing emphasis on men (and they were nearly all men) of science and reason. The invention of forceps in the 1600s led to the establishment of obstetrics as a profession, again with men providing the muscle behind the technology. Midwives, with their “women’s work” and mysterious herbs and potions, came under an increasing suspicion that spilled beyond the confines of childbirth. It’s no coincidence that 22 of the 79 women tried for witchcraft at Salem, Massachusetts, were midwives.
The 20th century saw the near-extinction of midwives in much of the U.S., as the promise of safer births and the push for painless childbirth in turn “pushed” childbirth into the hospital. Where once nearly every baby was born at home, today the move to hospital birth is nearly complete–more than 96% of American babies are delivered in hospitals. Midwife-assisted home birth isn’t just frowned on by much of the obstetric community–it’s downright illegal in many states. And you wonder why midwives and obstetricians sometimes don’t get along?
That’s the context for this agreement, and it goes a long way to explain the remarkable nature of this document. The representatives of all the major midwifery organizations–MANA (Midwives Alliance of North America) and ACNM (American College of Nurse-Midwives–as well as ACOG (American College of Obstetricians and Gynecologists), FIGO (International Federation of Gynecology and Obstetrics, and the AAP (American Academy of Pediatrics) sat together in the same room to discuss home birth for probably the first time in history.
Next: Safety of home birth, communication among childbirth practitioners (or the lack thereof), and more…
A quick Home Birth Consensus Summit post on my way out the door…
Here are the Summit Statement and a statement of Context & Scope, just released. I will be commenting on these later today and invite your comments as well. I think this represents a very big first step in normalizing childbirth care across all settings, both in and out of hospital. Just getting all parties involved to agree to joint statements was an accomplishment. More soon!
Here’s a preliminary statement from the HBCS Steering Committee:
This national summit of stakeholders and leaders met October 20-22, 2011 in Warrenton, VA to discuss the status of homebirth within the greater context of US Maternity care. The dialogue was held in good faith, was respectful, complex, and revealed multiple issues for future discussion and action. Common ground was discovered across several areas of concern about maternity care in the United States. Statements reflecting shared commitments by delegates will be posted by November 1, 2011.
So, much more to come next week.
Well, the Home Birth Consensus Summit is over, and I’m beat. Day 3 was a nonstop flurry of activity: proposals, counter-proposals, wordsmithing and action plans, followed by a quick dash to the airport. It’s going to take some time to sort all this out, and I’ll be talking with the Summit organizers this week in Vancouver (I’m giving the keynote address at a Family Medicine conference at the University of British Columbia) to help with that. I’ve offered my writing services to help get the Summit proceedings out to the public, and I’ll be posting that writing here first, in the form of a series of posts. It’ll take me a bit of time, so please be patient.
In the meantime, if home birth is an important issue for you, please go to the HBCS website and donate. Funds are needed to keep the work going! (Full disclosure: Zero percent of the proceeds end up in my pocket, dang it.)
Just a quick update. The Summit organizers have asked the delegates not to publish any particulars, as the meeting is still in progress. Suffice to say that Friday’s session lasted about ten hours, there was a bit more heat in the discussion, and progress was made. The word heard most often is “collaboration”–there seems to be a genuine willingness to try to heal some very old and deep divisions, both between and within stakeholder groups. It won’t be easy or quick–and that’s the subject of today’s session. More later.
Well, the Airlie Center is certainly beautiful in bright October morning light. I took a “fat tire” bike tour of the grounds early today–really lovely.
Day One is over, and there was remarkably little conflict. I had a nice conversation with Dr. Richard Waldman (the immediate past president of the American College of Obstetricians and Gynecologists–ACOG) this morning. I had some preconceived notion of what the former head of ACOG would say about home birth, given that that organization had routinely condemned the practice as unsafe in the past, and only recently softened its stance somewhat. But he talked about setting up one of the first hospital-based birthing centers in his part of New York–water birthing, no electrical fetal monitoring and such–in 1981 with his wife, a certified nurse midwife. His goal is to make birth safer for all women and babies, regardless of place of delivery. So much for my internal stereotyping–bad doctor!
We spent several hours today examining the last 100 years of global events that had shaped both home birth in and our attitudes toward it . This was followed by a very extensive “mind mapping” of recent trends in home birth in the U.S. and overseas. Tomorrow will be focused on the present, finding connections among key trends and learning what people are doing today. Saturday’s session will involve future planning.
The issue of home birth safety, which wasn’t much discussed today, will receive either a boost or a body slam in early November, when the Birthplace in England study is scheduled to be released. It’s a massive undertaking that should give a fairly accurate picture of childbirth practices in England. There are five studies in all–of particular interest is this one:
“Study 3: The Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth”
This should answer (at least for England) whether home birth poses an increased risk to mothers and babies. I’ll report on that when the study is released.
Now, off to bed.