MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

Asking questions about where to give birth

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This is a paper that I wrote for an assignment my mentor midwife gave to me. The assignment was to create a referenced handout that will give famlies informed consent about the risks and benefits of home birth. I did not think that families could have clarity without a comparison to hospital birth so that was the angle I chose. Sorry it is so long:

Home vs. Hospital: Choosing your child’s birth place

Choosing a birthplace requires critical thinking. Most people will offer the simple argument that ‘well obviously the hospital is safer because of the possible need for emergency services’ but the choice is actually not so clear-cut. Birth in the hospital comes with risks that you do not encounter at home, and many people are not aware of some of the benefits that come with giving birth at home. Ultimately birth in both locations is quite safe, especially with qualified care providers. Parents must look at the risks and benefits on both sides of the equation and decide what is best for them.

So let us look at some of benefits and risks that we accept when we choose our place of birth. And let us ask ourselves some thought-provoking questions as we do so. There is data available on some of these questions, use the Internet and books like Henci Goer’s Obstetric Myths Vs Research Realities, to find out what the most recent studies have shown. Some of these questions will depend on the situation and can’t be answered on a broad level, only on a case-by-case basis. You may have opinions and preferences but often you can’t know for sure what will be best until the decisions present themselves. Maybe the questions will only tell you that you need to do more research before you can form your opinions.

Benefits to hospital birth:

· No responsibility for supplies or cleaning of the birthplace.

Giving birth in your own home does require a certain amount of preparation and supplies. The issue will be handled differently depending on your midwife, some will provide the supplies and some will provide a list of necessary supplies and guidance on protecting your mattress, carpets, etc. Most midwives do clean up after the birth. Some provide towel service and take care of all the laundry. Midwives will expect a certain level of cleanliness and order in your home prior to the birth. This often works out fine for nesting moms who are cleaning everything in sight at the end of the pregnancy anyway! Hospitals take care of all of this for us, but of course we do pay for it!

How clean is the hospital?
How clean is my home?
What services does my midwife provide?
What supplies does my midwife provide?

· Medical equipment is available.

Certainly there are times when an electronic fetal monitor or forceps can be of tremendous benefit to a mother or baby. But how often are they dangerous? (This will be addressed more later on)

What risks are there to using the various pieces of equipment and what are the benefits?
What equipment does your midwife carry?
How often does she use it?
If a midwife feels a piece of equipment is necessary can she transfer the mother to the hospital in order make it available?
What will she try before she makes the decision to transfer?
What factors will go into the hospital care providers’ decision to use a piece of equipment?
How often do they use the equipment?

· Medications are available.

Similar to equipment, medications at times can be a real benefit, but of course they also have risks, sometimes very serious ones. This is of course going to depend on the drug being used and of course there are times when the benefits certainly outweigh the risks. Some midwives carry only herbal preparations and some carry drugs, and that may be a factor in which midwife is right for you or whether homebirth is a good option for you. In general pain medications are not available at home, but many midwives do carry drugs to treat excessive postpartum bleeding.

What medications does your midwife carry?
How often does she use them?
What medications are used at the hospital?
How often?
What are the risks and benefits of each medication?

· Emergency services

In most people’s minds this is the big one of course, everyone imagines that worst-case scenario where the mother or baby is “crashing” and an immediate cesarean or other life-saving procedure is required. Certainly an emergency cesarean has saved babies or mothers, but how often? Are emergencies over-diagnosed in hospitals? Are services always available any faster when you are actually IN the hospital? In regards to cesarean sections the American College of Obstetricians and Gynecologists has recommended that hospitals have a 30-minute ‘decision to incision’ time[i]. In other words even in the hospital it may take 30 minutes for the physicians and nurses required to arrive, and the preparations to be made for a cesarean to be done. Sometimes it is done faster; it would depend on the circumstances. But the reality is that it does take some time and most homes are near enough to a hospital that when a midwife recognizes a complication, she can call the hospital and by the time the operating room is prepared and the physician readied the laboring mother has arrived for a very timely cesarean. The distance from your own home to a hospital is another factor in your decision as to whether home birth is a good choice for you.

What is your own personal risk level?
Do you have any pre-existing conditions?
Has your pregnancy been normal and healthy?
Would your doctor be present the whole time you are in the hospital?

Risks of hospital birth:

· Serious infections, often antibiotic-resistant are common in hospitals.

The Centers for Disease Control and Prevention estimates that 90,000 people die annually from infections they contract in U.S. hospitals.[ii] This problem is unique to hospitals and does not exist in homes. You have already had exposure to the germs in your own home and have good resistance to them.

Can I prevent infections in the hospital?
Can I prevent infections at home?

· Medical mistakes are incredibly common and major cause of death in the United States.

There are approximately 110,000 deaths per year from medical mistakes.[iii] This is a serious problem that speaks for itself.

What can be done to prevent errors?
Are errors made at home?

In 1976 Lewis Mehl and his associates did a study that compared two equivalent groups of 1146 patients, one group giving birth at home and one group giving birth in the hospital. In both groups there were very few, and essentially the same number, of infant deaths and no maternal deaths. The hospital group had more complications, including the following:

· More cases of maternal high blood pressure
· More infants in distress during labor
· More cases of birth injuries to the infants (there were no infants injured at home)
· More babies that needed resuscitation
· More cases of postpartum hemorrhage

The following interventions are not required in a hospital birth, but aren’t available at home, thus there is no pressure to use them (or more accurately MISUSE them). They are all used very commonly in hospital births[iv]. They may still be needed for some attempted homebirths, but midwives feel they are necessary far less often.[v]

· Electronic fetal monitoring (EFM)

Electronic monitoring introduces risks to the baby and mother without any statistical improvement in outcomes. Risks include: increased number of operative deliveries for fetal distress, infection (with internal monitoring), and a difficult to quantify risk of how the labor progress and pain relief is affected by the mother’s restricted movement. [vi]

· Cesarean section

The attitudes about cesarean section have contributed to the belief that it is just as safe as a vaginal delivery, but this is absolutely not true. Cesarean sections are major surgery and carry the same serious risks including infections, blood clots, and complications from anesthesia. A mother’s risk of postpartum death is increased three-fold with a cesarean.[vii]

· Forceps

Clearly when forceps are truly needed they can be very helpful, but the large differences in their rates of use by midwives and doctors leads one to believe that they are over-used by some providers. Forceps can cause damage to both baby and mother.[viii]

· Pitocin and other medications to induce or augment labor.

Risks of uterine stimulants include, uterine rupture, fetal distress, increased pain for the mother, and increased rates of neonatal jaundice.[ix]

· Pain medications

More use of medications increases the likelihood of a bad reaction or dosage error. There are 7000 deaths per year from medication errors[x] and non-fatal errors occur in about 1 of every 5 doses administered in hospitals.[xi] Epidurals carry a myriad of their own risks including potentially serious complications from the anesthesia and increased rates of instrumental, drug, and surgical interventions.[xii]

· Episiotomy

Experts agree that episiotomies rarely have any benefit and carry many risks, but they are still performed in as many as a quarter of all births in the U.S.[xiii]

Benefits to home birth:

· One-on-one care from a midwife

In the European countries that have with the best infant mortality rates midwives provide the majority of the care for pregnancy and birth. America spends billions of dollars on health care for pregnant women, but approximately 39 other countries had better infant mortality rates according to 2005 data.[xiv]

What kind of care will you receive in the hospital?
How often will you see your doctor?
How many patients is your doctor or nurse caring for?
What is prenatal care like with a doctor?
What is prenatal care like with a midwife?

· More effective labor when women are in the comfort of their own home

While this is difficult to quantify in studies it does seem to be suggested by the lower rates of interventions that are used in home births. Is Pitocin used so much more often in hospitals because the new, possibly scary, hospital atmosphere isn’t conducive to birthing?

Where will I feel most comfortable giving birth?
Do I feel comfortable in hospitals?

· Less medical intervention

Midwives try to use the most gentle ways possible to help mothers cope with labor and to encourage progress. These positional, psychological and otherwise less intrusive interventions carry far less risk to both mother and child and achieve excellent results.

What kind of interventions do I prefer?
What if I do need medical help?

· Lower cost[xv]

Who doesn’t want to pay less for more personal, dedicated attention? Often insurance covers a larger percentage of hospital birth, but because it is significantly more expensive the families out of pocket costs are about the same for both options.

What will my costs be for home birth?
What will my costs be for hospital birth?

· No arbitrary time limits are put on the progress of labor.

Hospitals and doctors use guidelines that establish what is a “normal” labor pattern and are often compelled to intervene with a labor when it does not follow the averages. Midwives do not consider there to be a normal time-frame for labor and will allow labor to determine its own course, only intervening if the health of the mother or baby are in jeopardy.

What are my provider’s beliefs about how long labor should last?

· Less separation of baby and mother

At home babies are placed in their mother’s arms and are almost never taken out of them. Hospitals generally have a ‘nursery’ nurse who’s job it is to take care of the baby as soon as it is born, when she is called to a delivery she isn’t able to go back to the nursery until the baby has been assessed, footprints have been made, hospital bracelets attached and paperwork is done. Often mothers receive their babies into their arms, but they nurse generally doesn’t want to wait for them to bond for an hour before she can get her “job” done. The baby is whisked off to the warmer and the procedures are done. Some hospitals and providers do better at facilitating the bonding process than others, but hospital patients have no choice about whom their nursery nurse will be and how this process will be handled. Midwives are only caring for one person and have no reason to rush the bonding process in order to get to the next baby. They are very conscientious of the importance of this bonding process for mother and baby and will do all the assessment of the newborn while the baby is in his mother’s arms. Weighing, measuring, and paperwork can all wait until hours after the birth and is then done at the mother’s bedside.

· Higher breastfeeding rates

This is due in part to the people who choose to birth at home and the increased likelihood that they are very committed to breastfeeding, but also because there are few disruptions to the bonding process at home and midwives have a lot of knowledge that can help mothers to be successful at breastfeeding.

Risks to home birth:

· Some emergency equipment is not available at home

This will vary depending on what your midwife carries, but obviously they cannot carry everything that is available in a hospital. Most midwives are qualified to perform both neonatal and adult CPR and carry the equipment to do so, including oxygen.

What equipment does your midwife carry?
Is she certified in CPR?
How often are emergency measures necessary in childbirth?

· No immediate availability of a cesarean section

Again, if a midwife has determined that there is a need for an immediate cesarean, a call is made to the nearest hospital alerting them to prepare for the woman’s arrival and a transfer is made as quickly as possible. Some midwives will not attend births at homes that are further than a half hour from a hospital.

How often is a cesarean needed immediately?
Are they truly going to be immediate even if you are in the hospital?)
What emergency techniques is your midwife trained in?

The choice of birthplace is an individual one, each woman brings her own history and desires to the situation. Each woman must decide what is right for her. She needs to know that she has choices, and that all are valid and deserve support. Every choice has benefits and risks. In all likelihood the birthplace that is the most safe is the one in which the woman feels the most comfortable. In an environment where a woman feels safe, relaxed and well cared for her body will release the optimal hormones for birthing, she and her baby will experience the least amount of stress and everyone will emerge from the birth healthier and happier.

[i] ACOG Practice Bulletin No. 5, July 1999
[iii] Health Grades Inc. “Patient Safety in American Hospitals,” July 27, 2004. News release, Health Grades Inc. Institute of Medicine, “To Err Is Human,” Sept. 1, 1999.
[iv] Declercq ER, Sakala C et al. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences: October 2006
[v] Koehler MS, Solomon DA et al. Outcomes of a rural Sonoma County home birth practice: 1976-1982. Birth 1984; 11(3): 165-169.
Mehl, LE et al. Outcomes of elective home births: a series of 1146 cases. J Reprod Med 1977
Duran AM. The safety of home birth: the Farm study. Am. J Public Health 1992; 82(3): 450-453
[vi] Shy KK, Larson EB et al. Evaluating a new technology: the effectiveness of electronic fetal monitoring. Ann Rev Public Health 1987; 8: 165-190
Nelson KB, Emery ES. Birth asphyxia and the neonatal brain: what do we know and when do we know it? Clin Perinatol 1993; 20(2): 327-344
Albers, Leah and C. J. Krulewitch. 1993. “Electronic fetal monitoring in the United States in the 1980s.” Obstetrics & Gynecology 82:8-10.
[vii] Deneux-Tharaux C. Carmona E. et al. Postpartum Maternal Mortality and Cesarean Delivery. Obstetrics and Gynecology. 2006
[viii] Carmona F, Martinez-Roman S, Manau D, et al: Immediate maternal and neonatal effects of low-forceps delivery according to the new criteria of The American College of Obstetricians and Gynecologists compared with spontaneous vaginal delivery in term pregnancies. Am J Obstet Gynecol 1995 Jul; 173(1): 55-9.
[ix] Akoury HA et al. Oxytocin augmentation of labor and perinatal outcome in nulliparas. Obstet Gynecol 1991; 78(2): 227-230
Satin AJ et al. High- versus low-dose oxytocin for labor stimulation. Obstet Gynecol1992; 80(1): 111-116. (U.S.)
[x] Tipton DJ, Giannetti VJ, Kristofik JM. Managing the aftermath of medication errors: managed care’s role. J Am Pharm Assoc. 2003; 43:622-9
[xi] The Academy of Managed Care Pharmacy website: Medication errors
[xii] Avard DM. Nimrod CM. Risks and benefits of obstetric epidural analgesia: a review. Birth 1985; 12(4): 215-225
Studd JWW et al. The effect of lumbar epidural analgesia on the rate of cervical dilatation and the outcome of labour of spontaneous onset. Br J Obstet Gynaecol 1980; 87:1015-1021.
[xiii] Graham, I., Birth, September 2005; vol 32: pp 219-223.
[xiv] World Factbook Estimates
Madrona, Lewis & Morgaine, “The Future of Midwifery in the United States,” NAPSAC News, Fall-Winter, 1993, p. 30
[xv] Anderson RE. Anderson DA. [Dept. of Economics, Centre College, Danville, KY 40422, USA. ] The cost-effectiveness of home birth. Journal of Nurse-Midwifery. 44(1):30-5, 1999 Jan-Feb.