You’ve known for days.
The urpy-ness before breakfast (when you can eat breakfast), the swollen bits, the tender bits, all good indications. Even the home-kit was positive but it wasn’t “official” until the doctor said it: you’re pregnant.

But after leaving your first prenatal exam – and after more tests than you’ve had in your lifetime – your mother (overjoyed) read through some information you received and said she never remembered half that stuff when you were born. Grandma (ecstatic) said she wasn’t even awake when your mom was delivered.

Have we come a long way, baby? Yes and no, as you’ll see when you read “Get Me Out” by Randi Hutter Epstein, M.D.

Let’s start in the year 1530. You’re about to become somebody’s mom. Because a sign on the door of your room says “no boys allowed,” you’re surrounded by girlfriends, female relatives and a midwife (if you could afford her). They would have herbs for you, food and drink. Someone might consult a book of pregnancy advice (available for thousands of years). You’d labor with people you knew.
But as an almost-mom in 1530, don’t expect anything for your pain. In 1591, a laboring mother (of twins!) was burned at the stake because she dared to ask for relief.

Fast forward three hundred years.
You’re at a lying-in hospital, so-called because post-delivery recovery takes weeks of bed rest. You might be allowed visitors, but no midwives; male doctors have convinced the general population that midwives are dangerous. Giving birth away from home and family, you’re told, is best for you and the baby.

… “Women wanting to conceive, or who are already pregnant or breast-feeding, need a minimum of 250 micrograms of iodine each day for the baby’s brain and nervous system development,” …

“Australians now get more iodine in their diets following the mandatory fortification of bread last October, though it is still appropriate for women to supplement their diet with an additional 150 micrograms of iodine every day,” he said.

… “The body does not store iodine, so amounts taken in excess of the body’s requirements will simply be excreted by the kidneys.”

“… there is no justification for the restriction of fluids and food in labor for women at low risk of complications,” …

… Until the 1940s, women were generally encouraged to eat and drink during labor … to keep up their strength.

… a 1946 paper … suggested that access to food increased the risk that women under anesthesia would aspirate acidic stomach contents during labor, potentially causing serious lung injury and even death.

Mendelson’s work persuaded many obstetricians to urge that women fast until after delivery …

… anesthesia procedures have changed markedly since the 1940s, with regurgitation of stomach contents now considered very rare.

They write:

…One of the problems is that the planned home birth group includes women who planned homebirth when booking in for care but then developed risk factors and had their babies in hospital. There are probably only two women whose babies died; who started labour at home planning a homebirth and one of these was a twin pregnancy (high risk). This latter woman persisted in having a homebirth due to ‘unsatisfactory hospital experiences.’ The others had all transferred before the onset of labour. The authors admit they ‘could not differentiate all planned homebirths according to whether transfer to hospital had occurred before or during labour.’ So for low risk women who started labour at home the risk was very low – 1 death in 16 years

There is no way to tell if these planned homebirths were under the care of a registered midwife.

This was not a low risk population of women – there was a high rate of post-term pregnancy … twins … and … previous caesarean section.

… There were two perinatal deaths that actually occurred at home. One baby had lethal congenital abnormalities (this was known before labour and a decision made for the baby to be born at home). The second death at home was after a waterbirth which was not found to be the cause of death but a review identified that increased monitoring may have identified the baby was in distress.

One perinatal death occurred in hospital after a transfer after the birth of the first twin. The first twin was born at home and second twin was born in hospital after a delay in transfer and subsequently died.

There were 6 perinatal deaths in the planned homebirth group where the baby was born in hospital. Presumably these women were transferred to hospital during the antenatal period as antenatal risk factors developed. Transferring to hospital if or when risk factors develop during pregnancy is appropriate practice.

Of the six deaths in hospital: one had hydrops fetalis … one death was unexplained with a cord entanglement seen after birth; one had pulmonary hypoplasia … after a early rupture of membranes; one was a growth restricted baby with an abnormal karotype … one was born to a woman who was very overdue … and underwent induction in hospital without fetal monitoring (the woman refused) and her labour eventuated in a stillbirth; and, one was a woman with known haematological … risk factors whose baby had a lethal abnormality … all these were born in hospital.

Only three of the deaths are thought to be related to perinatal asphyxia.

Three of the deaths were thought to be potentially preventable and related to the model of care. These were the baby born after the waterbirth at home; the second twin who was born after an intrapartum transfer and the baby born after being very postdates. Therefore, there were 3 deaths in 16 years – two of which had risk factors present. That means that there was only one death where there were no risk factors in the 16 year period.

… You would need more than 10,000 births at home to show clinical relevance and have some confidence in the statistical significance in relation to perinatal mortality rates. The authors acknowledge this in the paper and present their data with caution in the paper stating that the ‘small numbers with large confidence intervals limit the interpretation of these data.’

The facts are there was no difference in perinatal mortality … For those actually born at home the perinatal mortality rate is 2.5 per 1000 births, which is comparatively low.

… The paper highlights that the system must be so terrible for some women that they would choose to give birth outside of it than in it, even with risk factors. This is an indictment on the current maternity system in Australia – that needs fixing – removing homebirth won’t do this.

What was missed?

The conclusion of the paper is very sensible recommending risk assessment, transfer and fetal monitoring.

So then why did the data get so grossly misinterpreted?

The reality is despite a malfunctioning system in this country where midwives are uninsured and have no visiting rights, and homebirth is unfunded and often hard to access, the perinatal mortality rate was no different.

Risk assessment, transfer and fetal monitoring will be improved when private midwives are no longer excluded from mainstream services so we should be aiming for this not continuing the ‘witch hunt’ against private midwives.

… Some women will always choose homebirth so we should support this choice with safe responsive systems of care. The authors state that ‘women’s autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law’.

The excess mortality continues to be found in high-risk women and women need to be informed of this risk.

Mrs Willicombe and her husband … are now suing the … Hospital … for failing to monitor the baby …

Misoprostol is only licensed … for the treatment of stomach ulcers. Under official guidelines … it should not be used to induce labour unless as part of a clinical trial.

… the drug … is cheaper than other methods to induce birth …

Belinda Phipps, chief executive of the National Childbirth Trust, said she was “absolutely incredulous” that any hospital would give the drug to women …

She said: “This drug is not licensed for use in labour, and the NICE guidance is categorical on that point. In this country, misoprostol should only be used in labour if the baby is already dead, or after the birth, because otherwise the risks are simply too great.”

Mrs Willicombe was not informed the drug was only recommended for use in clinical trials – and nor was she told that she was taking part in any trial.

“I just remember them being very reassuring and saying this drug is fine,” …

… Mrs Willicombe … was not properly monitored and was treated in a room unsuitable for what should have then been classified a high-risk birth.

Within 10 minutes of being given the drug … her waters broke – almost certainly naturally because it was too soon for the Misoprostol to take effect. About four hours later, she was given a second dose leading to contractions which then became more frequent …

… The mother-to-be was moved from the maternity ward to the delivery suite but then placed in a room … without proper monitoring equipment … The midwife then ordered Mr Figus to hit the alarm button. A team of doctors raced in to deliver the baby, the first time Ms Willicombe realised her dream of a first child was turning into her worst nightmare.

“She just came out blue and lifeless,” recalled Ms Willicombe, “She was completely floppy. They held her up very briefly for us to see her and then took her away to resuscitate her … she … suffered severe brain damage due to a lack of oxygen … we agreed to take her off the ventilator. Three days later she died.”

… a coroner in east London concluded Sofia had died of natural causes as a result of neglect.

Their lawyer … said: “It appears clear that Mrs Willicombe received substandard monitoring during her labour with Sofia. This substandard monitoring also needs to be put in to the context of the use of an unlicensed drug which is known to have the side effect of uterine hyperstimulation. It appears that Sofia’s death could have been avoided, had the monitoring been appropriate.”

… inducing labor introduces a risk of 1 to 2 cesareans per 25 inductions that might have been avoided by waiting for spontaneous labor to begin.

… C-sections are major surgeries, and carry risk of infection, bleeding, blood clots, and injury to other organs …

… all labor induced groups faced increased risk for C-section, except for those women delivering after 39 weeks.

Bailey … is one of a handful born at home under the guidance of midwives from St George Hospital, which runs the first publicly funded scheme of its kind in NSW …

”After having a hospital birth for my first child, [Bailey's birth] was very, very different and it was amazing to be told that everything was my choice, my decision,” his mother, Claire, 32, said yesterday. ”It was unbelievably calm and relaxed.”

Home birthing … is now regarded by most obstetricians as controversial and dangerous.

Thirty women were sent to hospital before going into labour and seven were transferred during labour …

”It shows that in a controlled environment where midwives are protected by the policies and protocols of a public hospital, home birthing is a safe option for women at low-risk,” the co-director of Women’s and Children’s Health at St George Hospital, Michael Chapman, said yesterday. ”… I’d hate for this study to be used to support programs where there are not over-arching checks and balances in place, but this shows it can be a safe process.”

The program, launched in 2005, was helping to improve home birth’s poor public image, but was still too restrictive for most women, and had abandoned some in the late stages of their pregnancies, the secretary of Homebirth Australia, Justine Caines, said. ”… this program excludes women without a strong evidence base,” she said.

63% of … mothers … agreed that public maternity units resembled ”herding yards” when asked if it was an appropriate description.

Of … women who gave birth in the public system … more than a third said leaving hospital too soon was a problem, 47 per cent felt their postnatal care was inadequate, and 48 per cent experienced a lack of breastfeeding support.

Of [the] … women who gave birth in the private system … 17 per cent said they were discharged too early, 39 per cent felt their postnatal care was lacking, and 45 per cent said they did not receive adequate breastfeeding support.

Of the … mothers who gave birth in both the public and private systems, 43 per cent thought the private system was better; 30 per cent thought the public system was better.

… providing midwives with more independence to prescribe drugs would improve the system.

62% … said Australia’s 30 per cent caesarean rate was too high. A quarter thought it was mainly done for professional liability reasons and a fifth believed it was done at a mother’s request.

47% … said there was a shortage of midwives …

WHAT MOTHERS SAY
”There should be more continuity of care. Knowing your carer and trusting your carer removes the fear from childbirth and fear leads to more interventions.”

… ”There is a severe shortage of birth centre places available and in many areas it is not even an option.”

”There are so many time limits imposed on women which completely disregard the natural progression of labour in women’s bodies. Doctors are too quick to intervene, too impatient to wait and allow the body to do its job.”

… ”Women are not being given enough time to labour naturally.”

“I was not supported well enough to have a vaginal birth. I felt like they were more concerned with getting me in and out quickly so they could free up beds.”

Promoting normal births has been highlighted … to improve patient care …

… the proportion of births by Caesarean Section has been increasing … In 1989/1990 around 12% of all births were done by CS, whilst by 2005/6 that rate has doubled to 24%.

Boon Lim is the Chair of the Maternity and Newborn Programme Board of NHS East of England. He told Heart some of the benefits which come with a natural birth: “Be able to get home earlier, and be able to care for the babies in a better position rather than having to contend with having an operation to deliver their babies.”