EGG DONATION IN GREECE: ALL YOU NEED TO KNOW

Posted in Health by woman2womenblog

Assisted reproduction techniques help thousands of couples with infertility to circumvent their problem and become parents. Nevertheless, when it is not possible for a woman to conceive due to poor egg quality or from having no eggs at all, she may still become pregnant by using eggs from a donor.

The first pregnancy with egg donation was reported in 1983, and ever since, more and more women are choosing this procedure to achieve their dream of having children. The main reason for this trend is that women are increasingly postponing childbearing until later on in life, when their fertility is often reduced; another reason is that over the years, the process has become highly successful due to recent technologies advances and improved freezing techniques.

What is egg donation?

Egg donation is a form of assisted reproduction by which a woman donates her ova to enable another woman to conceive. These oocytes are fertilized by the recipient’s husband sperm, or alternatively by a donor sperm.

The resulting embryos are transferred into the recipient uterus, which has been adequately prepared to receive them. The difference with routine in vitro fertilization (IVF) is that the egg donor is not the recipient; that is, they are two different women.

If pregnancy occurs, the recipient will have a biological but not a genetic relationship to the child, and her partner (if he provided the sperm) will be both biologically and genetically related.

What are the indications for egg donation?

Egg donation may be considered in the following situations:

Premature ovarian insufficiency: a condition in which menopause begins earlier than usual, usually before the age of 40 years old. In most cases the cause is unknown, but it may be the result of certain diseases, chemotherapy, radiotherapy or surgical removal of the ovaries. Egg donation is also suitable for women who were born without ovaries.
Low ovarian reserve: when there is a decrease in the number of eggs, resulting in reduced chances of pregnancy. Generally, this is due to advanced reproductive age, as the number of oocytes -and therefore fertility- decreases rapidly after the age of 35-40 years old.
Genetically transmitted diseases: women affected by, or carriers of a significant genetic disease who would prefer not to pass this disease on to their child.
Previous history of failure with IVF: especially when egg quality seems to be the problem.

Who are the egg donors?

1) Anonymous, voluntary donors: According to the Greek law, candidate egg donors are covered by anonymity and are required to sign a specific consent for the donation of their genetic material. In order to accept a woman into an egg donation program she should meet the following requirements:

Age between 18 and 35 years old.
She should be healthy, non-smoker, with no personal or family history of genetic diseases.

By law, the donor receives financial compensation only for the loss of working days, travel and other expenses incurred during the treatment cycle in which she participates. In any case, egg donation is an altruistic, anonymous and voluntary act.

2) Egg sharing: Women undergoing IVF may agree to donate their surplus oocytes to other women with infertility.

3) Known donor: a person who is known to the recipient, usually a close relative of friend. According to the Greek law, oocyte donation is an anonymous procedure, that is, the donor has no access to the child born, nor the recipient to the donor. Therefore, in Greece the donation of ova to known persons is forbidden by law.

Evaluation of the egg donor

Each candidate donor, after being fully informed about the egg donation program, completes a thorough questionnaire on her family, medical and psychological history. In addition, she is the subject of a series of exams to determine whether her health is in good condition and she can respond properly to the hormonal therapy.

The evaluation involves a comprehensive physical and gynecological examination, as well as the assessment of her psychological and mental status, her genetic material and reproductive system.

In addition, donors undergo the following laboratory testing:

Blood type and Rhesus
Hepatitis B & C
HIV 1 & 2
Syphilis
Hemoglobin electrophoresis
Sickle cell trait testing
Cystic fibrosis (CF) mutation
Fragile X testing
Conventional karyotype. It is also possible to a perform a molecular karyotype, upon request of the recipient couple.

A donor is ineligible if either the questionnaire or the screening tests indicate the presence of risk factors, or clinical evidence of an infectious or genetic disease.

Evaluation of the recipient couple

Adequate screening and preparation of the recipient couple are essential for the success of an egg donation program.

According to the Greek law, a woman is considered suitable to receive oocytes when her uterus has normal morphology and functionality and has not exceeded the age of 50 years.

The evaluation of the recipient couple is similar to that of couples undergoing routine IVF. First, the physician obtains a thorough medical history from both partners.

The assessment of the woman includes an in-depth physical and gynecological examination, a detailed pelvic ultrasound and laboratory testing. Briefly, the ovarian function, her blood group, and exposure to certain infections are examined. In addition, a Pap smear test and cultures for certain microbes (Neisseria gonorrhoeae, Chlamydia trachomatis, etc) are obtained.

In some cases, the uterine cavity is evaluated with hysterosalpingography (HSG), sonohysterography or hysteroscopy. If the woman is over 45 years old, a more thorough assessment of her cardiac function, pregnancy-induced hypertension and gestational diabetes risk are recommended. The effect of advanced maternal age on pregnancy will be discussed extensively, as well as any medical conditions that may affect pregnancy.

An embryo transfer trial before the actual procedure (“mock” embryo transfer) is strongly recommended. It allows to determine the best way to place the embryos into the uterus, and ensures that there are no unexpected obstacles along the way. Sometimes the cervix is very narrow and hinders the transfer of the embryos into the uterus; this may result in significantly reduced chances of pregnancy. In case of a narrow or distorted cervical canal, a cervical dilation may be recommended.

A treatment trial in a previous cycle with the same medications used for the endometrial preparations is proposed when possible, in order to assess the uterine response to hormone therapy.

The male assessment includes a semen analysis, blood group and genetic testing, among other exams.

According to the Greek law, the recipient couple should be tested for syphilis, hepatitis B and C, HIV-1 and HIV-2 within the six months preceding the treatment cycle.

The procedure

Preparation of the donor for egg retrieval

The donor follows the procedure of a standard IVF. Initially, she undergoes ovarian stimulation, that is, she receives a combination of hormonal medications in order to achieve the development of a sufficient number of oocytes within the ovaries; egg development is monitored by ultrasound and blood exams at regular intervals. When the oocytes are at the appropriate size, ovulation is triggered by an injection of human chorionic gonadotropin (hCG). Oocyte retrieval, scheduled approximately 34-36 hours after hCG administration, entails the use of a needle which is inserted through the vagina into the ovaries, whereby the eggs are aspirated under ultrasound guidance. The procedure is carried out under a mild sedation.

The ova obtained are evaluated for their maturity and then fertilized with the partner’s sperm, which has been processed in the laboratory. Donor sperm may be also utilized when indicated.

The male partner should provide the semen sample the day of the donor’s egg retrieval. Alternatively, if the presence of the partner is not possible on that day, the semen can be cryopreserved (frozen) at an earlier time.

Preparation of the recipient for embryo transfer

In order for the embryos to implant into the recipient’s uterus, the endometrium (uterine lining) must be prepared and synchronized with the donor cycle.

There are numerous protocols for endometrial preparation. Briefly, women who still have menstrual period may receive an injectable medication for temporary suppression of the ovarian function. When the donor starts ovarian stimulation, the recipient receives a hormone called estradiol to achieve endometrial growth. Estradiol can be administered orally or through a transdermal patch. Ultrasound assessment of endometrial thickness -and occasionally blood tests- are performed during this period. On the day after the donor receives hCG, the recipient begins treatment with progesterone. Progesterone causes endometrial maturational changes that allow the embryo to implant. Progesterone can be administered by intramuscular injection, vaginally or orally. Besides estradiol and progesterone, other medications may be prescribed if required.

The embryos are transferred into the recipient’s uterus, usually within three to five days after fertilization of the eggs in the laboratory. Embryo transfer is done using a thin catheter inserted through the cervix into the uterus. If the recipient couple has extra embryos, they will be cryopreserved (frozen). Thus, it is possible to transfer these embryos at a later time without the need for another egg donation.

Hormonal therapy with estradiol and progesterone continues until the recipient takes a blood pregnancy test (β hCG). If the test is positive, the hormones are continued during the first trimester of pregnancy.

Success rates with egg donation

Since egg donors are young and healthy women, success rates are higher than those obtained with conventional IVF. The age of the recipient does not seem to affect the success of the procedure. According to data from the National Agency of Medically Assisted Reproduction, the pregnancy rate with egg donation in Greece is 54%.

Nevertheless, the greater the number of attempts with donor-egg IVF, the higher the odds of success. Thus, it is estimated that the success rates after the third attempt reach almost 90% in most cases.

Many factors play an important role in the success of the procedure: adequate evaluation and preparation of both donors and recipients, optimal synchronization between them, high laboratory standards and well-trained scientific staff, will all have a positive impact on pregnancy rates in an egg donation program.

Risks of egg donation

1) For the donor:

Egg donation is a very safe procedure. Nevertheless, it is not entirely risk-free. Medicines taken to stimulate the ovaries, oocyte retrieval and the anesthesia required are all possible sources of complications. Briefly, the side effects of medications are usually mild, as one of the most feared complications in assisted reproduction, ovarian hyperstimulation syndrome is very rare in these cases. The remaining risks are estimated as follows: anesthesia risks: 1 / 10,000; risk of severe bleeding from oocyte retrieval: 1 / 2,500; risk of infection: less than 1/500.

It should be noted that the fertility of women who become egg donors is in no way affected. In fact, the eggs donated would have been otherwise discarded by their bodies.

2) For the recipient:

The possibility a donor transmits an infectious disease to the recipient is virtually non-existent, provided that proper evaluation of the egg donor has been performed, as dictated by the Greek law.

The most common risk for the recipient is the occurrence of a multiple pregnancy (twins) if more than one embryo is transferred. In any case, in egg donation cycles, the transfer of more than two embryos is strictly forbidden by the Greek law. If the couple is opposed to the possibility of a twin pregnancy, then only one embryo may be transferred (single embryo transfer, SET).

Pregnancy complication risk in recipiens with advanced age should be assessed individually for each case.

3) For the child:

To date, thousands of children have been born with this procedure, and the available data is reassuring, and equivalent to that of conventional IVF: the rate of birth defects is the same as the general population.

THE LEGISLATION IN GREECE

On Egg Donation

Egg donation is an altruistic act, voluntary and with no financial benefit. Donors are compensated only for the working days they lose as part of the donation process and their travel expenses.
Donation of ova and sperm is allowed in Greece provided donor anonymity is ensured.
Egg donation is not allowed to women over 50 years old.
Donors must sign an oocyte concession consent.
Recipients sign a document stating that they are married and accept to undergo in vitro fertilization with egg donation. If they are not married, they should sign a notary act stating that they wish to undego IVF using the egg donation method.

On Assisted Reproduction

On January 27 2005, the law 3305/2005 on the application of assisted reproduction techniques was reported.

The Greek law on medically assisted reproduction is one of Europe’s most flexible. It safeguards the couple who wants to have a child based on medical, biological and bioethical principles. Its main purpose is, ultimately, the protection of the child to be born.

Basic principles of the current legislation

Some of the key points of the in-force law are the following:

1) Assisted reproduction methods are legal and allowed for women up to the age of 50 years, as this is considered the limit for natural conception.

2) The donation of ova and sperm is permitted, but the consent of the spouse or partner is also required.

3) Pre-implantation genetic diagnosis is allowed with the purpose of diagnosing whether the resulting embryos are carriers of genetic diseases. Consent of the concerned individuals is required.

4) Sex selection is prohibited unless a serious sex-related hereditary disease is avoided.

5) Cloning for reproductive purposes is prohibited.

6) Cryopreservation of genetic material or fertilized eggs is permitted.

7) The use of a gestational carrier (surrogacy) is allowed. A surrogate is a woman who carries a pregnancy for another couple or woman, who wishes to have a child but is unable to get pregnant for medical reasons. The surrogate woman must undergo medical and psychological examination. There should be no financial transaction other than the costs resulting from pregnancy exams, loss of work, etc. The procedure requires a special permit from a judge.

8) Assisted Reproduction Units are established and operate with the permission of the competent Authority, which shall give its agreement and verify that the legal requirements are met. For any violation, it sets administrative and criminal penalties.

9) The law sets age limits for sperm donors (younger than 40 years old) and egg donors (younger than 35 years).

10) Single women are allowed to conceive with assisted reproduction.

11) Donors must undergo clinical and laboratory testing and are not admitted to donation programs if they suffer from hereditary, genetic or infectious diseases. The use of fresh semen from donor is not permitted; only frozen semen may be used.

More info at gofertile.eu

4Dec2016

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 3)

Posted in Health, Pregnancy by woman2womenblog

In the Part 1 of Home birth: Smart choice or risky business? we analyzed the issues of personal satisfaction, maternal safety and baby’s risks. Part 2 dealt with hospital transfers, water birth and the situation in the Netherlands. Check out the last three reasons women choose home birth, and read the final conclusion to decide whether home birth is a clever or a dangerous option…

7) “Home birth is cheap”

Home birth is cheaper… provided that no transfer is needed and nothing goes wrong

Cost-effectiveness is an important issue in every country with an organized health system. Countries like England or the Netherlands, where the National Health System (NHS) covers the cost of deliveries, have calculated that is cheaper that women deliver at home, avoiding a more expensive hospital admission. For example, the UK NHS “prices” home birth £1066 and birth at a hospital £1631. The economical factor is one of the reasons certain professional organizations support home labor, such as the Royal College of Obstetrics and Gynaecologists (RCOG) which states that: “home birth is the most cost-effective place for delivery”.

But this cost analysis has been challenged, as it does not take in consideration the high transport rates; in fact, a Dutch report calculates a general 3-fold increase of costs in patients transported during labor, when the costs of the midwife, the transport system, the obstetrician and the hospital are included. In addition, the costs derived from the maintenance of an adequate transport system (ambulances and trained staff) should not be neglected. Assuming increased neonatal risks, admissions to the neonatal intensive care unit, the lifetime costs of supporting neurologically disabled children and potentially increased professional liability costs resulting from a complicated home birth can potentially inflate the costs.

Indicative of these unexpected expenses is the article Home birth: What the hell was I thinking? A journalist from The Guardian went on a mission following a home birth. After managing to deliver her child at home, both the woman and her baby had a complication and needed to be transferred to a hospital. Since the baby and the mother were not allowed to be in the same ambulance, two ambulances were required…

Regarding the costs arising from a private home birth, the situation varies in different countries; in the USA home births are not covered by health insurances, and a couple is expected to pay $1500 to 4500 to the midwife. Hospital births can range from $3,296 to 37,227, although they are usually covered totally or partially by the insurance. Of note: a doctor gets paid about $2500-4000, same as a midwife. Ιn Europe, a couple is expected to pay about 2000-3000 €; recently the Italian newspaper La Stampa published the article Home birth: a 3000 € luxury that does not convince doctors.

8) “Birth is not a disease, it’s a natural thing. Mother nature can’t go wrong”

Unassisted childbirth: don’t try this at home – or anywhere else

Indeed, Mother nature is great. If you think about it, the whole process of labor and delivery seems to be so perfect, almost magical… But “natural” is not a synonym of “risk-free”. Sometimes Mother nature can play strange games. We may believe we have everything under control, but things may flip just in a second: think earthquakes, or tsunamis… Exactly the same thing applies to childbirth: even when someone seems to be “low risk”, disaster can strike without any warning …

“Childbirth is inherently dangerous,” writes in her blog Amy Tuteur, an American obstetrician gynecologist. “In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood”. Finally, she adds: “Why does childbirth seem so safe? Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90 per cent and the maternal mortality rate 99 per cent over the past 100 years.”

The absolute confidence in a woman body’s ability to deliver is expressed by supporters of unassisted childbirth (UC), the “hard core” version of home birth, which, although practised already since the 70s, it has lately seen a resurgence. Also known as freebirth, DIY (do-it-yourself) birth, unhindered birth, or unassisted home birth, it refers to women that intentionally deliver without the assistance of a physician or midwife; they may be completely alone (“solo birth”) or assisted by a lay person, such as the spouse, family, friend, or a non-professional birth attendant. There are no data on safety of UC, except that coming from a religious group in Indiana (USA) that found a perinatal mortality rate 2,7 times higher, and a maternal mortality rate 97 times higher than the state average.

Among the most famous UC advocates is Janet Fraser who, ironically, lost her baby after five days of home labour; in spite of that she continues to advocate for freebirth. In fact, UC is not endorsed by any scientific organization, as it is considered too dangerous. According to André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada (SOGC):“Freebirth is the equivalent of playing Russian roulette with your child”.

9) “I have the right to deliver wherever I want”

A home birth oxymoron: right to privacy vs. social media exposure

This is a very complex issue with ethical and legal connotations, which has originated intense debate among experts. Even scientific organizations differ in their recommendations. For example, The American College of Obstetricians and Gynecologists, until recently opposed to home births, has decided to temper its position: “…hospitals and birthing centers are the safest setting for birth, but it respects the right of a woman to make a medically informed decision about delivery.” On the other side, the American College of Nurse-Midwives (ACNM) maintains that “every family has a right to experience child birth in an environment where human dignity, self-determination, and the family’s cultural context are respected” and that “every woman has a right to an informed choice regarding place of birth and access to safe home birth services”. Let’s analyze the ethical and legal aspects of home birth:

Ethical issues

These are some of the ethicals dilemmas related to home birth:

Mother vs child safety. Although hospital birth seems to increase maternal interventions in all studies (apparently without increasing severe risk), the baby’s safety remains a subject of debate; taking though in consideration all the studies, there seems to be increased risk for the baby. Let’s take for example the Birthplace study (which is in somewhere in the middle). This study found that, particularly for first time mothers, the baby’s risk is 3 times higher (of which more that half of the cases are death and brain damage). Is it ethically acceptable for a woman to value her birth experience over her baby’s welfare? Is maternal emotional wellbeing so important to justify risking the baby’s health?

Respect for dignity and privacy. “Dignity” may have a different meaning for each person. Some home births supporters feel that the presence of a doctor and the hospital staff make them feel “degraded”; moreover “for some women the possibility of the loss of privacy is a major issue, because privacy is a valued possession”.

Is it not contradictory that so many women, zealous advocates of home birth and their right to privacy, do not hesitate to publish their home birth photographs and videos -some of them with incredible details- in every social media site, where they are exposed to the eyes of millions of people?

Self-determination. In order to make truly informed decisions about childbirth options, women need to be informed of what they are and have the possibility to discuss them. Is it ethical to offer the option of home birth knowing that there is increased risk for her baby?

In theory, the person informing the pregnant woman should inform her objectively and avoid being paternalistic. The problem is that, informed decision-making implies accurate assessment of risks and benefits, but the safety of home birth remains debatable. Is it possible to inform objectively a pregnant woman about home birth? Or the information will be biased according to the health care provider beliefs or experiences?

Other possible ethical issues:

In the home birth situation, are a woman’s reproductive rights and medical responsibility incompatible with each other?
Where do a woman’s rights end and medical responsibility begins, especially considering that the physician is also responsible for the baby’s welfare?
In case of a baby adverse outcome that could have been prevented in a hospital setting, what will be the psychological consequences for the couple?
What is the psychological burden of a home birth in a family’s older children witnessing a home birth? What if a complication occur in their presence?

Legal issues

Legal issues can affect a woman’s decision to give birth at home in different countries. In certain places, home births are restricted, and even possibly criminally punishable, and family homes have been turned into crime scenes when women who have opted for homebirths experienced complications. In others countries, there are no regulating laws.

In Europe, the European Court of Human Rights (ECtHR) ruled in 2010 that Hungary had violated Article 8 of the European Convention on Human Rights (ECHR) because it had interfered with a woman’s right to choose where to give birth. Ms Ternovszky wanted to give birth at home but argued that she was prevented from doing so because a government decree dissuaded health care professionals from assisting home births. This case was the first decision by an international human rights organization on the right to choose the circumstances of giving birth, and was heralded by home birth advocates across Europe.

However, in a recent case against the Czech Republic, the Human rights judges decided that national authorities of each country has “considerable room for manoeuvre” when regulating home births, a matter for which there is no European consensus and which involves complex issues of health-care policy as well as allocation of State resources.

So, is home birth a smart choice or a risky business?

The Monty Python satirize the medicalisation of childbirth in The Meaning of Life

As an obstetrician who supports natural birth, I hear many times the women’s complaints about the excessive medicalization of childbirth. And I feel that sometimes they are right. However, being a mother myself, I never regretted my choice of a hospital birth for my children. After having helped so many women deliver their babies, I have seen many times complications that were totally unpredictable. Occasionally, these sudden complications are so serious, that we have to run -literally- from the delivery room to the operating room to save the baby or the mother! Therefore, even when having skilled professionals attending your home birth, even in countries with very organized structures, the distance to a hospital can prove fatal. Is for this reason that, in my opinion, a hospital birth is without any doubt the best choice for every woman. A birthing center attached to a hospital may also be a good choice.

True, the studies results are controversial, but for me “almost as safe as a hospital birth” is not enough to make me change my mind.

True also, a hospital birth is related to more epidurals, cesarean sections, instrumental deliveries and episiotomies. Regarding the epidural, if you can do it without one, that’s great! But sometimes labor pain is unbearable, and it’s not uncommon to see women without any pain relief who, when the moment to push comes, they are so exhausted and their pain is so overwhelming that they literally lose it. On the contrary, women with an epidural can be more focused and relaxed. The bottom line is: natural birth is not for everybody. And women don’t have to feel guilty because they chose to have an epidural. It’s better to have nice memories of your birth, and for that the epidural can help!

Whether too many cesareans sections are being done is a topic more controversial than home birth itself, and it would deserve a separate article. But what I can say is that, when cesarean sections are done in a judicious way by a conscious physician, they can save your life and your baby’s life. Since hospital births result in better neonatal outcome, it is clear to me that most interventions are an inevitable trade-off to save more babies or to avoid severe damage. The same goes for the controversial fetal monitoring, which may lead to more cesarean sections, it may not decrease perinatal mortality, but it reduces by 50% the risk of brain damage. Personally, I would do anything in my power to reduce the chances of having a brain damaged baby.

Of course, a lot that should be done -and can be done- to improve hospital birth: create home-like conditions to help women be relaxed and empowered, allow women to walk during labor, give them possibility to push and deliver in any position they wish, avoid unnecessary interventions such as systematic episiotomies, etc. I believe that some efforts are slowly being done worldwide, but we still have a long way to go!

In conclusion, a woman has the right to choose where to deliver; however, until the risks are clarified, maternal wellbeing may undermine the child’s welfare. Therefore, in my opinion, a natural hospital birth is the safest choice. Natural hospital birth IS possible! You just need motivation and a supportive team…

Hospitals should increase their efforts to provide women with a friendly environment so they can deliver their babies in comfort and total safety. Every baby is precious, every mother is precious!

Photo credits

7) screenterrier.blogspot.gr; 8) news.com.au; 9) vimeo.com, Wikimedia Commons, thebirthhour.com, Flickr.com, vimeo.com, homebirthaustralia.org, mindfulmamabirth.com, Flickr.com, huffingtonpost.co.uk, lifedaily.com

3Dec2016

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 2)

Posted in Health, Pregnancy by woman2womenblog

In the first part of this article we analyzed three important issues related to home birth: personal satisfaction, the mother’s safety and the baby’s risks. Check out the next three reasons women choose a home birth…

4) “I plan to have a home birth, but if something should happen I will go to a hospital”

Even when properly prepared for a home birth, transfer to a hospital is commonly required

As previously mentioned, hospital transportation is a common event: about 1 out of 2 first time mothers and 2 out of 10 second or subsequent time mothers need to be transferred to a hospital; moreover, hospital transfer is almost always perceived by the couple as a negative and disruptive experience (see part 1).

The need for transportation to a hospital can occur before, during of after birth, and can be related to the mother, the baby or both. The top reasons may vary in different countries, although prolonged labour is the first cause of transfer in almost every study, followed by pain relief or the midwife’s unavailability at the onset of labor.

In the UK, the most common reasons for transfer are:

Prolonged labour (32.4%)
Meconium staining (12.2%)
Repair of a perineal tear (10.9%)
Abnormal fetal heart rate (7.0%)
Retained placenta (7.0%)
Request for regional analgesia (epidural, spinal) (5.1%)
Neonatal concerns (postpartum) (5.1%)
Others (20.1%)

Australian Caroline Lovell died of complications after giving birth to her daughter in a pool. Justice found that her death was preventable.

Home birth activist Caroline Lovell died of complications after giving birth her second child at home. Her death was preventable, justice says.

Other reasons include:

–During labor: maternal fever, fetal malpresentation, shoulder dystocia (baby’s shoulders getting stuck inside the mother), cord prolapse, uterine rupture, acute bleeding, placental abruption, vasa previa, acute sepsis.

–After birth: tears of the vagina or cervix, sphincter rupture, uterine atony, placenta accreta, increta, or percreta.

–Baby-related (post partum): unexpected very low or very high birthweight, neonatal depression, signs of respiratory distress, unexpected malformations, acute sepsis.

These are some important facts to keep in mind:

Maternal and fetal necessity for transport is often impossible to predict.
For unpredictable, extremely sudden complications, even rapid transport may not prevent the baby or the woman from death or severe harm, such as shoulder dystocia, sudden cardiopulmonary arrest, or maternal exsaguination (bleeding to death, read Caroline Lovell story here).
Women with severe hemorrhage may already be in shock when arriving at a hospital. Even though the adequate treatment can be immediately instituted, death may nevertheless occur.
Perinatal mortality is higher when transport to the hospital is required.

5) “At home I can have a water birth”

The latest years there has been an increasing demand for water birth

Immersion in water during labor and delivery, although available for several decades, has seen a greatly renewed interest the latest years. In fact, even certain hospitals and birth centers have incorporated birth pools to their facilities. The results of studies analyzing maternal and fetal benefits and risks of water birth are inconsistent, and many times contradictory. The American College of Obstetricians and Gynecologists (ACOG) has just reviewed the subject and a few days ago (November 2016) published an updated statement. What are then the proposed pros and cons of water birth?

The benefits

For the mother. A Cochrane study found the following results:

Less need for regional analgesia (epidural, spinal, or paracervical; studies show a slight reduction, RR 0.90; 95% CI 0.82–0.99)
Shorter duration of the first stage of labor (32.4 minutes shorter in water immersion)
Improvement in satisfaction among those women delivering in water.
Studies results are contradictory regarding the reduced occurrence perineal tears (including third-degree and fourth-degree lacerations) and need for episiotomy.
One study found less antepartum transfers to hospitals, both from home and midwifery birth units.

Other possible benefits: Increased feelings of relaxation, warmth, privacy, improved ability to maintain control during labor (here, here, here).

For the baby. Supporters of water birth believe that the transition to the outside world is less traumatic for babies born in water as the warm water of the pool may feel like the amniotic fluid; thus water-born babies are supposedly calmer than babies born in air. In fact, no benefits for the newborn were found with maternal immersion during labor or delivery, neither in 2 systematic reviews including 12 studies and 29 studies respectively, neither in the 2009 Cochrane systematic review, or any individual trials included in ACOG’s review.

The risks

For the mother. ACOG’s review did not find increased risk for maternal infections or postpartum hemorrhage. However, this conclusion must be tempered by the lack of data on rare serious outcomes, such as severe morbidity and mortality.

For the baby. Most studies found that immersion during labor does not increase fetal or neonatal risk. However, concerns have been expressed that immersion during delivery may predispose the infant to potentially serious neonatal complications. Several studies have reported several serious adverse outcomes among neonates delivered in water, these include :

Infection: cases of severe infections with certain bacteria, mainly Pseudomonas aeruginosa (here, here) and Legionella pneumophila (here, here, here, here) have been observed, some of which were fatal. The bacteria causing infections my come from the woman’s body, the water or the pool itself. Recently, a fatal infection by a virus (adenovirus) was reported in a baby born from a mother with gastroenteritis giving birth in a pool.
Water aspiration (drowning or near-drowning): it has been claimed that babies delivered into the water do not breathe or swallow water because of the protective “diving reflex”; however, it has been demonstrated that in compromised newborns the diving reflex is overridden, leading to gasping and aspiration of water. Actually, it seems that even healthy babies may be at risk of water aspiration, which may result in hyponatremia and seizures.
Umbilical cord avulsion (cord “snapping” or cord rupture): this complication may happen in 1 out of 288 water births and occurs when the baby is lifted out of the water; in some instances the affected newborns have required intensive care unit admission and transfusion.

Other possible inconvenients:

The mess: setting a pool at home may be messy and even challenging in certain situations, such as living in a small apartment.
Unpleasant environment: women may feel uncomfortable about accidentally defecating in the pool; which, as stated above, may also predispose the baby to severe infections.
Disappointment with pain relief: for some women, immersion in water is not enough to relieve pain.
Monitoring and emergencies: it may be difficult to quantify blood loss (see photo); in cases of concern about the baby’s heartbeat, monitoring may be difficult; moreover, in the event of a severe maternal complication (such as fainting or heavy hemorrhage) it may be difficult to move the pregnant woman out of the water.

Several professional organizations, including the Royal College of Obstetricians and Gynaecologists and the American College of Nurse–Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water. According to ACOG, immersion in water during the first stage of labor may have benefits for the mother and may be offered to healthy women with uncomplicated pregnancies; however, there are insufficient data regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, “it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water”. The British National Institute for Health and Care Excellence (NICE) recommendations are in agreement with the ACOG.

6) “In the Netherlands women have been delivering at home for more than fifty years”

The Netherlands has the highest percentage of home births in the Western world

The Netherlands is a country with a long tradition of home birth, with well-trained midwifes, organized transport system and short distances to hospitals. However, it is one of the few countries in the world where the incidence of home births is decreasing: in 1965, two-thirds of Dutch births took place at home, but that figure has dropped to about 20% in 2013. Moreover, Dutch women have to pay an extra amount (around €250) when deciding for a “nonindicated hospital birth” under the guidance of an obstetrician or a midwife (here). According to Professor Simone Buitendijk, head of the child health programme at the Netherlands Organisation for Applied Scientific Research, “… home birth rates have dropped like a stone. Soon, there will not be enough demand to justify the infrastructure” she says. “Then the system will collapse – and let there be no misunderstanding: we won’t be able to rebuild it”.

This drop in home births seems to be related to the increasing awareness of the media, patients, and obstetricians about the risks of home birth (here). Even more skepticism originated the results of the Euro-Peristat study: the Netherlands is one of the countries with the worst perinatal outcomes of Western Europe.

Read the third part here: Home birth: smart choice or risky business? (Part 3)

Photo credits

4) birthbootcamp.com, dailymail.co.uk; 5) flickr.com, mthoodwomenshealth.com, popsugar.com, gravidanzaonline.it; 6) currystrumpet.com

2Dec2016

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 1)

Posted in Health, Pregnancy by woman2womenblog

Home births have been, for a long time now, the subject of endless controversy and polarized discussions among physicians, midwives and strongly opinionated women. Indeed, the idea of giving birth at home sounds attractive. With the growing interest for an “all natural” lifestyle, natural home birth looks like a logical way to go. What’s more, celebrities are doing it, and midwives are becoming a status symbol!

Even mass media has embraced the trend: since 2008, when the documentary The business of being born was aired in the USA many women were “converted” to fanatic home birth supporters. This documentary follows a New York midwife who delivers babies at home, while it “uncovers” -what they consider- the major business childbirth has become for doctors and hospitals. In the UK, the series Call the midwife, with its empathetic view of midwives have experts hoping that “it will spark a resurgence in home births…as women see the holistic care that midwives can deliver”.

And all this “campaign” seems to have worked! Home births have seen a considerable increase in many countries, including the USA, Canada, UK and Australia.

So why the fuss about giving birth at home? Why do women want to deliver like in the 1900s? The answer to these questions is not straightforward…

While reviewing the bibliography on home birth, I realized how massive the amount of information on this subject is, both in scientific and lay sites, and how contradictory it becomes sometimes…

If you are considering home birth, check out this article where I analyze the reasons women choose to have their child at home. In order to simplify reading, I divided it in three parts; read all three so that you can make your responsible and educated choice.

1) “A delivery at home is a wonderful experience”

Embed from Getty Images

Satisfaction is home birth’s raison d’être

There is no doubt that birth is a unique, life-changing experience for every woman, and no one can deny the importance of the emotional and psychological aspects of a bringing a child to the world. As mentioned earlier, the reasons women choose a home birth are many: some women feel that the privacy of their home will make them feel more comfortable, less stressed out, and with more control of their own labor. Others find that being surrounded by friends, relatives, or their older children is of utmost importance. Finally, many woman choose home birth out of curiosity, as they have heard so many stories about amazing, empowering, ecstatic, or even “orgasmic” home births. Actually, personal satisfaction seems to be the main reason women want to deliver at home.

But is home birth always this pleasurable, fantastic experience women expect? Unfortunately, this is not always the case. According to Birthplace, a recent British study, a high percentage of women will need a hospital transfer: up to 45% of first-time mums (nulliparous) and 13% of second and subsequent time mothers (multiparous) were transferred to a hospital. Similar figures are reported in the Netherlands, a country with a long tradition of home birth: 49% of primiparous and 17% of multiparous women are transported during labor. Most of the times, transfer to a hospital is not a great experience for the couple, as their expectations for a home birth are not fulfilled; this has been uniformly demonstrated by several studies from different countries (such as Sweden, Netherlands and Belgium). Moreover, a Dutch study evaluating women’s views of their birth experience 3 years after the event revealed persistent levels of frustration, including serious psychologic problems, in transported women compared with those who delivered at a hospital.

There is another fact we should not ignore: labor is inherently painful. Even though at home women may be more comfortable and this may result in less pain, sometimes it may be impossible to cope with pain and an epidural may be necessary. Pain relief is actually one of the most common reasons for transport to the hospital, since pain can become overwhelming, In fact, a recent study showed that inability to control labor pain may increase the risk of developing postpartum depression.

2) “Home births are safe for the mother”

Home births result in less interventions, including pain relief…

Besides personal satisfaction, another common reason women choose home birth is because it’s less invasive. The dreadful “cascade of events“, that is, one intervention leading to another during a hospital birth fills with terror most home birth supporters. Indeed, almost every study shows that home births are associated with less interventions as compared to hospital births. The term “interventions” includes: epidural anesthesia, ventouse or forceps delivery, cesarean section and episiotomy (see also here, here and here).

Another controversial intervention that has gained a bad reputation among home birth supporters is continuous fetal monitoring, as they think that it is not needed, it gets in the way of the natural birthing process and it increases interventions such as cesarean section and forceps delivery. But what is the scientific evidence on this subject? According to a Cochrane review, the use of fetal monitoring increases the cesarean delivery rate, vacuum and forceps operative vaginal delivery; in addition, fetal monitoring does not seem to reduce perinatal mortality, neither cerebral palsy risk; however, it reduces by 50% the risk of neonatal seizures, that is, of brain damage.

But while some women may experience fetal monitoring, episiotomy or vacuum delivery as a traumatic experience, others may not get particularly bothered by an episiotomy -and many will feel blessed by the epidural “intervention”. So maybe a more important question is: What about severe maternal complications and maternal deaths? In regard to this matter, there is not much information, and the studies’ conclusions are contradictory. A Dutch study looked at “severe acute maternal morbidity” (such as admission to intensive care unit, uterine rupture, blood transfusion, etc) and found that women who delivered their first baby at home had the same risk with women delivering at a hospital, but parous women had increased risk of postpartum hemorrhage and blood transfusion when delivering at a hospital; however, another study, also from the Netherlands, did not confirm these findings. Therefore, a hospital birth leads to more interventions, but it does not seem to increase the risk of serious maternal complications. Regarding maternal deaths, they are a rare event; thus it is not possible to draw conclusions from the studies.

There is something that every woman considering home birth should understand: the studies results apply only to very low-risk pregnancies. Higher risk women, such as those with twin pregnancies, previous cesarean sections, prematures, post term pregnancies, were excluded from most studies, although it is no secret that they are also having home births (it’s easy to realize it just by checking the social media…). It is certain that for these women the risks is much higher, not only for them, but also for their babies.

3) “Home births are safe for the baby”

A healthy baby and a healthy mother are supposed to be a birth’s ultimate goal…

Studies analyzing the baby’s risk yield completely different results according to the country they were done, but they also differ in different areas of the same country, or according to the scientist analyzing the data! In here, I mention the most important studies evaluating neonatal risk by country of origin:

Canada: A recent study showed that planned home birth was not associated with a difference in serious adverse neonatal outcomes as compared to hospital births (Hutton et al, 2016). This study was limited to the Ontario area, had very strict inclusion criteria and high transport rates (see below).

The Netherlands: The Netherlands are usually considered the “gold standard” due to their long tradition in home births. In 2009, de Jonge showed that home birth does not increase the risk of perinatal mortality and severe perinatal morbidity among low-risk women. However, some aspects of this paper may have underestimated the risk (e.g., paediatric data on intensive care admissions was missing for 50% of non-teaching hospitals, among others). In fact, a subsequent Dutch study showed that infants of pregnant woman at low risk under the supervision of a midwife had 2,3 times higher risk of perinatal death than infants of pregnant women at high risk under the supervision of an obstetrician. Moreover, infants of women who were referred by a midwife to an obstetrician during labor had a 3,66 times higher risk of delivery related perinatal death than women who started labor supervised by an obstetrician (See below for more details on home births in the Netherlands).

England: A 2011 large study, the Birthplace study showed that, for low-risk women, home birth had 60% higher chances of “baby events”. The events included death (13%), neonatal encephalopathy (brain damage due to lack of oxygen, 46%), meconium aspiration syndrome (the baby swallows stools, a sign of suffering, 30%), brachial plexus injury (damage of the nerves of the arm, 8%), fractured humerus or clavicle (4%); if the analysis was restricted only to nulliparous women, this risk was almost 3 times higher. For multiparous women (2 or more children), there were no significant differences in the incidence of adverse outcome by planned place of birth.

Australia: in a paper by Kennare et al, although there were no differences in perinatal mortality, home birth was associated with 7-times higher risk of intrapartum death, and 27-times higher risk of death from intrapartum asphyxia (lack of oxygen). Interesting enough, one of the authors (Dr. Keirse) was the chairperson of the working party that developed the Policy for Planned Birth at Home in South Australia.

USA: The largest American study comparing home and hospital births was published in 2013, including data on more than 13 million births. This study indicated that babies born at home are 10 times more likely to be born dead and have almost 4 times higher risk to have neonatal seizures or serious neurological dysfunction (that is, brain damage) when compared to babies born in hospitals. Moreover, the risk of stillbirth in women delivering their first baby at home was 14 times the risk of hospital births. Dr. Grunebaum, one of the authors, explains that most likely the risks are even higher than that: “… the outcomes for patients whose care began out of the hospital but were then transferred to the hospital due to complications are reported as hospital deliveries. If the data were corrected, the risk of out-of-hospital delivery is likely to be much greater.” Another American study confirmed these findings, which, contrary to the British study, showed that the neonatal outcome was worse both for nulliparous and multiparous delivering at home.

Pooled data from USA, Australia, Switzerland, Netherlands, Sweden, Canada & UK: A study by Wax et al. showed that home births are associated with a risk of neonatal death three times higher as compared to hospital births. The results of this study led the reputed medical journal The Lancet to write an editorial stating “Home birth: proceed with caution”. Wax’s study though was highly criticized on methodological grounds.

Why such a disparity in the results of the different studies?

There are many possible explanations:

The lack of randomized trials, as it is not possible to force women to deliver at home or at a hospital against their will. It is clear from different studies that women delivering at home are different from those delivering at hospitals (usually home birthers are more educated and come from a more socioeconomically advantaged area); populations may also differ from country to country.
Underreport. In many home births studies there are missing data; in others home births that were transferred to hospitals are included in the hospital group.
Midwives’ training. In most European countries and Canada, home births are attended only by midwives or physicians; midwives have a university degree and undergo intensive training. In most states of the United States, besides certified nurse midwives (with formation equivalent to European midwives), births are also attended by “direct-entry midwives” with no university degree and diverse training; the only requirement for them to practice is a high school degree.
Eligibility criteria for a home birth. Studies with good outcome had very strict inclusion criteria for home birth, that is, they excluded women with twin pregnancies, preterm labor, preeclampsia, etc.
Transport rates. Best outcome was associated with a very high transportation rate: about 40-50% for nulliparous, 10-20% for multiparous. On the contrary, the US studies -with more adverse results- report overall transportation rates of about 10%.
Efficiency of transport system, midwives’ integration to hospitals. Rapid availability of ambulances -such as the so-called Obstetric flying squad in the UK- and hospitals in tight collaboration with midwives working in the community seem to be essential. But even so, some complications may not be solved, even by the most efficient form of transport.
Distance to the hospital. Although shorter distance to hospital seems to be crucial, even this may not prevent certain complications. Hospitals have what is called the “decision to incision” rule, that is, the maximum time that should pass between the decision to make an emergency cesarean section and the time it is actually done. This rule is 20 or 30 minutes, according to different countries. It is clear that this time frame cannot be achieved with home birth, not even with close distance to a hospital.

Read the second part here: Home birth: smart choice or risky business? (Part 2)

Photo Credits:

Intro: Flickr.com, Pinterest.com, Wikipedia.org; 1) Gettyimages.com, which.co.uk, which.co.uk; 2) booshparrot.com, herb.co; 3) Flickr.com, moveoneinc.com, Pinterest.com, sheknows.com, blogqpot.com, babynames.allparenting.com, mercatornet.com, laineygossip.com

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HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 2)

4) “I plan to have a home birth, but if something should happen I will go to a hospital”

5) “At home I can have a water birth”

6) “In the Netherlands women have been delivering at home for more than fifty years”