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

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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