Tuesday, March 11

Childbirth in America: Homebirth

When I was pregnant with my daughter, Adam and I took a Bradley Method® childbirth class. I have mixed feelings about how well our class prepared us for the birth experience, but one thing the AAHCC folks do quite well is to encourage informed consumerism--asking questions, seeking second opinions, basically all the things we would expect to do when encountering any other procedure.

Just so there is no doubt where I'm coming from, I am 100% in favor of natural childbirth. There is great debate over just what "natural" entails when it comes to birth, but for me, a natural birth is one that is not interfered with unless necessity demands it. That means, barring medical complications which might require greater constraints, mothers should labor as they are most comfortable: in whatever location, in whichever position, with whomever they choose, eating and drinking as they desire, and not kept on a predetermined time schedule of when they "should" be delivering the baby. I am not against medical interventions, including pain medications. I do believe, however that medical procedures are overused in pregnancy and childbirth. In many cases, interventions into the natural process have become standard practice, rather than an appropriate response to medical need.

As I began to research my own birthing options, and as I continue researching now with an eye to expanding our family, I have become increasingly appalled at the current climate for childbirth in this country. My two biggest concerns are the lack of evidence-based practice in obstetrical medicine and the lack of information available from these same professionals. Not being a physician or educator myself, there is not much I can do to change modern obstetrical practice, but I can offer some easily accessible research.

Here is the first installment in a planned series of posts comparing popular beliefs about childbirth to what the research actually shows.

The Belief: Most women are safer giving birth in a hospital.

The Reality: Despite the recent ACOG statement against homebirth (which, among other things, dismisses homebirthers as women who put their own desire for a particular experience in childbirth over the safety of their babies), birthing at home is not any more dangerous in most cases. Multiple studies have compared birth outcomes of low-risk mothers and babies who birthed at home or in hospital. In nearly all cases mortality rates and overall measures of health were virtually the same, while intervention rates, including episiotomy, delivery by forceps or vacuum, and cesarean section, were considerably higher for hospital birthers.

The Research: For reasons of brevity, I did not include all the studies I reviewed, however below you will find a representative sampling of the research that has been published on the safety of homebirth.

Outcomes of planned home births with certified professional midwives: large prospective study in North America
Study of 98% of planned homebirths with a direct-entry midwife (as opposed to CNMs--certified nurse midwives--who must also be RNs) in the US and Canada for one year. Medical intervention rates for this group included 4.7% of women receiving an epidural (compared to the nationwide US rate of 59% and Canadian rate of 45% [source]) and only 3.7% requiring a cesarean section (considerably lower than the national average of 23% in both the US [source (PDF)] and Canada [source] for the same time period). Conclusion: "Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia (PDF)
Comparison of planned homebirths with a regulated midwife and hospital births with either a midwife or physician. Researchers noted, "Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician .... Comparison of home births with hospital births attended by a midwife showed very similar ... differences." They concluded, "There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife."

Home versus hospital birth (abstract)
Meta-analysis of studies comparing planned hospital births and planned homebirths with an experienced homebirth practitioner, backed up by a modern hospital system. The study authors concluded, "There is no strong evidence to favour either planned hospital birth or planned home birth for low risk pregnant women."

Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands
This study compared perinatal outcomes, based on an index “incorporating 22 items on childbirth, 9 on the condition of the newborn, and 5 on the mother after the birth.” The researchers found no relationship between birthplace and outcome for first-time mothers, but among women who had given birth before "perinatal outcome was significantly better for planned home births than for planned hospital births".

Simulated home delivery in hospital: a randomised controlled trial (abstract)
A study of women randomly assigned to either midwife-led care, birthing in hospital "rooms similar to those in one's own home to simulate home confinement" or standard obstetrical care and birth in "delivery suite rooms with resuscitation equipment for both mother and baby in evidence, monitors present and a delivery bed on which both anesthetic and obstetric procedures could be easily and safely carried out." Authors noted, "There was no difference in the percentage of mothers and babies discharged home alive and well. Generally higher levels of satisfaction with care antenatally and during labour and delivery were shown in those women allocated to midwife care."

The Safety of Home Birth: The Farm Study (PDF)
A study comparing outcomes of births from 1971-1989 attended by lay midwives at The Farm in Tennessee to those in the 1980 US National Natality/National Fetal Mortality Survey. There were no significant differences between the two groups in labor-related complications or deaths. The Farm group had a much lower intervention rate, including cesarean delivery. The author suggested that some differences in births may be attributable to lifestyle choices (such as a high percentage of vegetarians birthing at The Farm) or observer bias, however, he concedes, "the results regarding perinatal deaths, in particular, are hard to ascribe to observer bias." He also mentions that births taking place in the hospital "have a safety advantage in cases in which life-saving technology is immediately required. There is some evidence, however, that elective interventions, which are used more frequently in-hospital, may increase the risk of various adverse outcomes in low-risk women." The study concludes "for relatively low-risk pregnancies, home birth with attendance by lay midwives is not necessarily less safe than conventional (hospital-physician) delivery. Support by the medical and legal communities for those electing, and those attending, home birth should not be withheld on the grounds that this option is inherently unsafe."

The influence of the high-risk care environment on the practice of low-risk obstetrics (abstract)
A chart review of three urban hospital OB units, two set up to receive high-risk moms, the third mostly offering services for low-risk birth. Researchers found "physicians at the perinatal referral centers performed significantly more artificial rupture of membranes, epidural blocks, augmentations of labor, and episiotomies on their low-risk patients than did those at the low-risk hospital." They concluded "[C]aring for low-risk patients in a high-risk care environment is associated with a higher intervention rate." Or, as my friend who referred this article put it: Simply taking a low-risk normal pregnancy INTO a hospital increases the likelihood of intervention (and therefore raises risk).

When Research is Flawed: The Safety of Home Birth
Critique of the well-publicized but poorly executed study by Pang, et al. which "alarmingly concludes that planned home birth confers twice the neonatal death rate of planned hospital birth."

For Further Reading: Additional studies and information.

2 comments:

  1. Great post. Keep researching and digging! The more you know, the better prepapred you are to make an informed decision. I planned to have both my children with a midwife. The first ended up being a c-section (breech) the second was a V-bac in my midwife's birth center. My two birth experiences were like night and day. I feel passionately about the right for every woman to decide for herself where and how she wants to give birth. I presently live in a place where homebirth with a midwife is illegal. It is maddening that while you can terminate your pregnancy via abortion, you cannot make the choice here to give your baby the safest, best birth possible. Have you heard about Riki Lake's movie "The Buisness of Being Born"? I've heard good reviews about it.

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  2. You might find this book, with its history of childbirth practices interesting (I did): http://search.barnesandnoble.com/Birth/Tina-Cassidy/e/9780802143242/?itm=4.

    I'm trying to figure out what to do before we get pregnant again. After three miscarriages, all of my birthing dreams are pretty much shot. Statistically, I am higher risk, despite the fact that they can't find anything wrong with me. The birth center I so looked forward to seems unsure about keeping me as a patient and suggest a perinatologist for at least the first half. I've been seeing a reproductive endocrinologist and will continue through the first part of the next pregnancy.

    All of that's a lot to say - I'm so happy you can do this stuff. I wish I could too!

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