unassisited childbirth-what do you think?

[Ethan Thane Athen]

Thats the thing - nobody advocating the right to home birth (apart from the loony fringe that nobody here would defend) would argue for a second that other people should not have the right to birth in hospital if they want to, or that it should be for anyone other than low risk groups, or that they shouldn't be transferred to hospital if things aren't going to plan.

Exactly.

 

[Ivor the Engineer]

Thats the thing - nobody advocating the right to home birth (apart from the loony fringe that nobody here would defend) would argue for a second that other people should not have the right to birth in hospital if they want to, or that it should be for anyone other than low risk groups, or that they shouldn't be transferred to hospital if things aren't going to plan.

Would you advocate medical procedures with similar risks being performed at home?

What about the cost of sending medical professionals and supplies out to homes instead of centralizing care?

 

[Ethan Thane Athen]

I don't think anyone is saying that home births can't go well, or even that they don't go well in the majority of cases. It's that there is a difference in how complications can be recognized and handled, taking into consideration timeliness is often critical to the baby. Since your wife did not experience complications, your story does not serve to illustrate that the concerns are unjustified.

Linda

I wasn't presenting it as proof, it was merely a response to the assertion that all women would choose hospital.

Your points are well made.

Some would assert (and I don't know enough to validate) that home birthing itself generally leads to less complications (though obviously they can, and do, still occur) over and above the fact that most who do it are 'low risk'. What is your view on that?

Also, on the 'low risk' front. My wife wasn't particularly low risk as we left it relatively late to have children. Indeed, our GP struck us off as he wouldn't support home birth for a first child - regardless of our very supportive mid-wifes. Interestingly there are posters in our local hospital encouraging home births and pointing out that, statistically they are 'as safe' with no mention of the sort of selection you mention (which I agree is probably largely correct by the way).

As I said, to each his own. The idea of giving birth in hospital was complete anathema to my wife but if you're more relaxed in hospital then go for it.

 

[Professor Yaffle]

Would you advocate medical procedures with similar risks being performed at home?

What about the cost of sending medical professionals and supplies out to homes instead of centralizing care?

I don't consider an uncomplicated birth to be a medical procedure, but a natural function. Sometimes the natural function doesn't work as it should and medical intervention is required, this is why a person trained in normal childbirth and recognising when things aren't happening normally (and trained in what to do in an emergency) - ie a midwife - should be present.

I don't know what the comparative costs are, so I googled, and this was the only study I could find.

http://www.google.com/search?source...06-32,ADBS:en&q=cost+effectiveness+home+birth

I found one other study which apparently looked at cost (national birthday trust), but the text isnt available online, and the references to it were on a home birth advocacy site, so I am unsure if the figures actaully say what they said they were saying. I have a feeling they compared the cost of a homebirth with the cost of an average hospital birth, and therefore that would be skewed by high cost complicated deliveries that would never have been allowed to be home births. If anyone else finds the text of this report, i would be grateful if they could point me to it.

 

[ponderingturtle]

Thats the thing - nobody advocating the right to home birth (apart from the loony fringe that nobody here would defend) would argue for a second that other people should not have the right to birth in hospital if they want to, or that it should be for anyone other than low risk groups, or that they shouldn't be transferred to hospital if things aren't going to plan.

But they are argueing that it is not more dangerous given those protections and there are reasons that this is not true.

 

[Professor Yaffle]

From http://www.rcm.org.uk/info/docs/PP%2025%20Home%20birth.doc - royal college of midwives site.

1. Costs. One study has concluded that home births cost less because of the reduced need for interventions and for hospital stays overall, even after accounting for transfers to hospital (Henderson and Mugford, 1995). However, if numbers of home births increase significantly, but not substantially, then total costs are also likely to rise. This would probably be without any reduction in hospital costs, for these expensive facilities would have to be retained in order to care both for those booked for hospital and for those booked for home who are transferred into hospital. It is important that midwifery managers build these costs into their future budgets. However, if the demand for home births continues to rise, a point will be reached where there will be savings in hospital costs - the home birth service will become increasingly cost-effective and will reduce costs overall (Chamberlain et al, 1997).

 

[Ivor the Engineer]

From http://www.rcm.org.uk/info/docs/PP%2025%20Home%20birth.doc - royal college of midwives site.

A couple of interesting reports. I wonder why hospital costs are that much greater? I'd have thought economies of scale would have made hospital deliveries less expensive for a similar level of care.

I know in the UK some NHS hospitals are concerned about public-private-initiative (PPI) hospitals cherry-picking all the simple, low-cost/high-profit cases and leaving the NHS to handle all the complicated/high-cost ones.

 

[ponderingturtle]

From http://www.rcm.org.uk/info/docs/PP%2025%20Home%20birth.doc - royal college of midwives site.

It would seem to indicate that it costs less becuase they are selecting the group that does not require intervetion and comparing it to a group that has much higher risk patients and patients who required more.

So this is not a fair comparison either.

 

[Irish Murdoch]

I must admit my bias up front.

I don't see any bias in your post, just knowledge! Thank goodness for modern medicine, I say: had we not been in a hospital when our first child was born, I rather suspect we would have had a dead child on our hands (we almost certainly would have had there not been a trace machine, which monitored a furiously dipping heartbeat after every contraction). Instead we've got a lovable and clever eight year old, and that's good enough for me. Oh, and despite all the trauma and that pesky life-saving machinery, it was still a magical experience.

Don't even get me started on water births.

Our second child was an entirely unintentional water birth. To ease the pain of contractions, my wife had just slipped into the bath in the delivery suite when our daughter decided she was coming out now, and wasn't about to wait for her mother to get out of the bath! We were dismayed that people would think we were hopelessly woo-woo if they knew she was a water birth!

 

[Professor Yaffle]

For some reason it seems that it is ok to assume that hospital births are safer despite the lack of evidence for this - but if you are pro home birth, you have to have cast iron evidence. From a cochrane review summary:

No strong evidence about the benefits and safety of planned home birth compared to planned hospital birth for low-risk pregnant women

In some countries almost all births happen in hospital, whereas in other countries home birth is considered the first choice for healthy and otherwise low-risk women. The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women. The review found only one small trial, which provided no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women.

 

[PrincessIneffabelle]

I, for one, am extremely grateful for modern medical assisstance in pregnancy, childbirth, and just about every other serious condition or ailment I've ever had. As a healthy 33-year-old woman who received excellent prenatal care, I fully expected to have an uncomplicated delivery. At 38 weeks, my blood pressure climbed to a dangerous level and I was admitted to the local hospital. My labor was induced and it lasted almost 24 hours with no progression. I was fully dilated, but my baby's head was too big to fit in the birth canal. After a successful C-section, my pressure was still quite high. My mother, a retired nurse, told me later that my pressure was so high that I really could have died.

I truly do not understand why some people think that a home labor and delivery is "more natural" than a hospital labor and delivery and therefore somehow better. Perhaps it is a control issue for them. Birth is a basic natural function and nothing can make it less so. As many others have pointed out, dying in childbirth used to be "more natural", too. I've been doing genealogical research for 6 years, and I was shocked at the mortality rate for women and babies during pregnancy, birth, and complications afterwards even as late as the 1930s. Only during the last century have women gained more safety, knowledge, and control over their reproductive lives. I am lucky to have a myriad of options available to me. I am smart to choose the safest for me and my child.

 

[ponderingturtle]

For some reason it seems that it is ok to assume that hospital births are safer despite the lack of evidence for this - but if you are pro home birth, you have to have cast iron evidence. From a cochrane review summary:

Got it, we are to ignore the draumatic lowering in infant mortality and maternal death that corrisponded with moving birth from the home to the modern hospital?

 

[Professor Yaffle]

http://www.scotland.gov.uk/Publications/2003/01/16018/15754

Expert Group on Acute Maternity Services: Reference Report - Scottish Executive Publications 2003:

1. There is much debate about the safety and appropriateness of home birth. When Zander and Chamberlain (1999) stated that 'the assumption that hospital provides a safer environment for women at low risk as well as the high risk mothers is not evidence based' much debate ensued. In a published letter to the BMJ Drife (1999) argued, based on 3 international studies (Anderson & Murphy 1995, Bastian, Keirse, Lancaster 1998, Murphy & Fullerton 1998) but discounting available UK data, that hospital delivery is now three to four times safer than home delivery for the baby in cases of normal birth. This is countered by McFarlane (1999) and Bullock (1999). They argue that between the 4 datasets comprising the 3 international studies and the CEMD 1997, there was no consistency in the definitions of categories of death, or in the overall groups of births with which the deaths were compared. In their view this invalidates any attempt to use these data to make direct comparisons between the outcomes of births in these settings.
2. There is sufficient UK data to support the argument, that a planned home birth is a safe option for mother and baby (Northern Regional Perinatal Mortality Survey Coordinating Group, 1996)). Over the 14 years of the studies, the risk of death during delivery or in the first four weeks of life, in a baby of normal birth weight and without a lethal abnormality, was higher in those born to the 1% of women who had booked for a home delivery (1 in 538) compared with all other such births (1 in 810). However, during the last 10 years of that period, when the midwife was always the community lead professional, mortality in this subgroup was lower in those booking for home vs hospital delivery (1 in 1890 vs 1 in 904). The overall conclusion was that the perinatal hazard associated with planned home birth in the few women who exercised the option was low and, based on confidential enquiries, mostly unavoidable. Delays occasioned by the need to arrange and effect transfer probably contributed to only one neonatal death (Bulloch C 1999). Neither the National Birthday Trust Fund survey of 6044 planned home births in the United Kingdom (Chamberlain, Wraight, Crowley 1997) nor the prospective and retrospective studies in the former Northern Region of England (Davies, Hay, Reid &Young 1996, Northern Region Perinatal Mortality Survey Coordinating Group 1996) yielded results that would alter the key conclusion of Where to be Born?, which was that "there is no evidence to support the claim that the safest policy is for all women to give birth in hospital" (Campbell & Macfarlane 1994).
3. A Dutch study to investigate the relationship between the intended place of birth ( home or hospital) and perinatal outcome in women with low risk pregnancies (after controlling for parity and social, medical, and obstetric background) analysed prospective data from 97 midwives and 1836 women. The results concluded that there was no relation between the planned place of birth and perinatal outcome in primaparous women, when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables (Wiegers, Keirse van der Zee, Berghs, 1996).
4. A meta-analysis of 6 observational studies, including 24,092 primarily low-risk pregnant women, examined the safety of planned home birth compared with planned hospital birth (Olsen & Ole. 1997). The principal difference in outcomes were a reduced frequency of low Apgar scores and fewer medical interventions in the home birth group. The study concluded that "home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions." A Cochrane review of available evidence concluded that there is no strong evidence to favour either planned hospital birth or planned home birth for low risk pregnant women (Olsen O, Jewell MD, 2002 last substantial amendment 1999).

 

[Professor Yaffle]

Got it, we are to ignore the draumatic lowering in infant mortality and maternal death that corrisponded with moving birth from the home to the modern hospital?

But previous to the move, high risk births would have been at home too. And the corresponding drop in mortality would have been almost entirely due to the high risk cases being moved to hospital. The argument is whether low risk births should have been moved too - despite no evidence about whether safety increased in this group.

 

[Irish Murdoch]

Isn't part of the point that one can't tell which births will be likely to be high-risk and which low-risk in advance of admission to hospital? Without a trace machine, nobody would have known stuff was going wrong in the birth of my son (I suspect, anyway: mine is very much a lay-person's understanding, and so eminently fallible).

 

[Professor Yaffle]

I, for one, am extremely grateful for modern medical assisstance in pregnancy, childbirth, and just about every other serious condition or ailment I've ever had. As a healthy 33-year-old woman who received excellent prenatal care, I fully expected to have an uncomplicated delivery. At 38 weeks, my blood pressure climbed to a dangerous level and I was admitted to the local hospital. My labor was induced and it lasted almost 24 hours with no progression. I was fully dilated, but my baby's head was too big to fit in the birth canal. After a successful C-section, my pressure was still quite high. My mother, a retired nurse, told me later that my pressure was so high that I really could have died.

I truly do not understand why some people think that a home labor and delivery is "more natural" than a hospital labor and delivery and therefore somehow better. Perhaps it is a control issue for them. Birth is a basic natural function and nothing can make it less so. As many others have pointed out, dying in childbirth used to be "more natural", too. I've been doing genealogical research for 6 years, and I was shocked at the mortality rate for women and babies during pregnancy, birth, and complications afterwards even as late as the 1930s. Only during the last century have women gained more safety, knowledge, and control over their reproductive lives. I am lucky to have a myriad of options available to me. I am smart to choose the safest for me and my child.

And because of your high blood pressure, you would not have been considered low risk and wouldn't have been considered suitable for a home birth anyway.
Why do I get the impression that whenever you mention homebirth, people seem to think you believe that all women should be forced to give birth at home no matter what the risks and that no medical intervention should be allowed. For the record, I have had both my births in hospital under midwife led care. If I had chosen home births, in the first case I would have been transferred to hospital due to failure to progress/exhaustion and in the second case, I wouldn't have had the terrifying situation where I almost gave birth in the car. Neither my experiences nor yours, however, are particularly relevant to the debate as they tell us nothing of the relative risks.

 

[fls]

But previous to the move, high risk births would have been at home too. And the corresponding drop in mortality would have been almost entirely due to the high risk cases being moved to hospital. The argument is whether low risk births should have been moved too - despite no evidence about whether safety increased in this group.

Yeah. I think the concern is over assuming these questions can be answered by citing "natural" or "high-tech".

Linda

 

[fls]

I wasn't presenting it as proof, it was merely a response to the assertion that all women would choose hospital.

I think I forgot that once I got into the spirit of responding.

Your points are well made.

Some would assert (and I don't know enough to validate) that home birthing itself generally leads to less complications (though obviously they can, and do, still occur) over and above the fact that most who do it are 'low risk'. What is your view on that?

I can reasonably postulate ways that it would lead to less complications and ways that it would lead to more complications. Which is why hypothesis testing would be necessary to figure it out. And it is hard to do the right kind of studies to answer the question, since they are generally observational rather than experimental. The home-birth group may self-select on the basis of characteristics other than "low-risk". For example, transfers to a hospital after labour has started at home may average 10 percent in an observational study (i.e. women who chose home-birth). But transfers to a traditional obstetrical unit may average 50 percent if the women are randomly assigned to midwife vs. obstetrician. This suggests that women who choose home-birth are particularly low-risk on the basis of characteristics that are not being taken into account when assigning risk level. Which then makes mortality and morbidity comparisons questionable. If no difference is found, does that actually represent an increase in the mortality and morbidity in the home-birth group since we'd expect that group to have an even lower mortality and morbidity regardless of the place of birth.

Also, on the 'low risk' front. My wife wasn't particularly low risk as we left it relatively late to have children. Indeed, our GP struck us off as he wouldn't support home birth for a first child - regardless of our very supportive mid-wifes. Interestingly there are posters in our local hospital encouraging home births and pointing out that, statistically they are 'as safe' with no mention of the sort of selection you mention (which I agree is probably largely correct by the way).

As I said, to each his own. The idea of giving birth in hospital was complete anathema to my wife but if you're more relaxed in hospital then go for it.

I think the question is whether or not issues of danger are of enough significance to outweigh discomfort (I don't have an answer - components of that valuation are subjective). I have low regard for my own comfort, and (of course) I am comfortable in a hospital atmosphere, so it was a no-brainer for me anyway (four deliveries).

Linda

 

[Miss Anthrope]

To be honest, warm water is quite helpful early on in labor. The value it has for women later on in the more active stages of labor seems to vary widely.

Agreed from my own experience. I had always planned to get out during transition, and it became ver difficult to move as soon as I was in transition. Laboring on a nice King sized bed was great, I was able to change positions to relieve pain and get gravity working.

To the poster with wife at 35 weeks: I found my natural birth better FOR ME, but I had no complications, and again, I was in a facility that had all the necessary medical equipment, and an ambulance was less than 60 seconds away. The good part for me was getting home that evening, my milk came in within hours (took five days after my induced first birth), and my son was much more alert right away. I don't know how anecdotal and limited my own experience is. I know that second births are the safest and often the shortest. I'm also an endorphine junkie and felt very good about myself for having done it without medication. I felt proud I never lashed out, that I stayed focused and in control. But that's MY thing, not to be imposed on anyone else. That was my reward, it's not for everyone. The options for relief and assistance are there and I would never judge anyone for using them. If anything looked awry I knew I would be transported immediately, and that the birthing center had all manner of life saving equipment on hand.

Taking unnecessary risks with your life and your babies life, in a time where modern science is a "blessing" to our generation? WHY?

 

[PrincessIneffabelle]

And because of your high blood pressure, you would not have been considered low risk and wouldn't have been considered suitable for a home birth anyway.

And it took "medical intervention" with my "natural" state to find that out. How much modern medicine is acceptable in an "unassissted" birth? Everything but the doctor?