Home Births on the Rise in U.S.

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After having her first child in a hospital, Lorra Jacobs decided it was an experience she did not care to repeat.

She had two more children, and she chose to have both of them at home.

"When I had my first child in the hospital, I was young and I didn't know of any alternatives. It wasn't a real positive experience," ... "It was a stark, very impersonal feeling, treating me like I was sick and not pregnant."

Jacobs explained she believed she had more control over many aspects of the birth when it took place at home, including whether she got to be with the baby after delivery and having the siblings there at the birth.

"Doing a home birth, I felt like I had a say," said Jacobs. "This is not the hospital's baby. This is my baby."

... a very small but slightly growing number of women are making the same choice that Jacobs did. While less than 1 percent of all births in the United States take place outside the hospital, the number of those births taking place at home has increased by 3.5 percent between 2003-04 and 2005-06 ...

The new numbers came after a period in which births outside the hospital ... had been decreasing since 1990.

... [the] trend might be a negative reaction to a hospital birth experience, since the majority of mothers choosing a home birth have had children before.

"The fact that it's primarily women who had kids before and had birth in hospitals before, certainly suggests it's a reaction to their prior birth," ... "It certainly suggests it's an experience they don't want to repeat."

... "I suspect consumers are becoming more informed & and seeing home births are a safe alternative for healthy women with a qualified provider."

She said a likely cause of any increase is a desire to avoid the interventions hospitals perform, ranging from cesarean sections and epidurals to controlling when the mother is with the newborn.

"I think a lot of consumers are really scared by the high cesarean rate, and they're becoming aware that Caesarian is a major surgical procedure," ...

She stressed that home birth is only a safe option for healthy mothers who are not expected to have complications.

... The American College of Obstetricians and Gynecologists has long opposed home births, citing a lack of data regarding their safety.

"Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous," ...

That's because you can't ramdomise women to home or hospital birth. It must remain the woman's choice. The only way homebirth can be studied is retrospectively - after the fact, and this is the most appropriate way to study it because the outcome of a homebirth that has been forced upon a woman will not be positive, simply because she will be labouring in an environment in which she feels is unsafe. Women labour best where they feel safest.

... "Until the results of such studies are convincing, ACOG strongly opposes home births. Although ACOG acknowledges a woman's right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide home births."

And that's how we get to situations where midwives are reluctant to transfer women in pregnancy or labour - because the doctors will not support the woman or her midwife - and so what we see happening is the doctor's attitudes making home birth unsafe. A spirit of consultation, collaboration, mutual support and trust can make a huge difference.

While the risk of neonatal death is low overall, it may be higher at home births and that is a problem, said Dr. William Barth, Jr., chair of ACOG's committee on obstetrics practice and chief of the division of maternal-fetal medicine at Massachusetts General Hospital

"May be" - so they don't really know for sure, they just suspect that it may be. When in fact, the studies show that the neonatal death rate is not higher for planned, midwife-attended, low-risk home births.

Barth cites a study presented by researchers from Maine Medical Center at the Society for Maternal-Fetal Medicine meeting in Chicago in early February. The study, a meta analysis of research from around the country comparing home births to hospital births, appeared to show a twofold increase in the rare event of neonatal death at a home births.

Declercq said one problem with relying on this study is the results may have been skewed because the researchers relied on the location the birth was planned for rather than where it actually took place.

There is a transfer rate for home birth, and it varies between 10% and 50%. What ought to be studied is the outcomes for the births that were intended to take place at home at the onset of labour. That eliminates from the study all the women who were transferred to hospital during pregnancy because the midwife detected problems and made a responsible decision to transfer the woman. This could be for issues such as high blood pressure, twins, babies who aren't growing well, a placenta that's too low in the uterus, maybe covering the cervix and so on.

While the gold standard of clinical research is the double-blind, placebo-controlled, randomized clinical trial, it is impossible to blind a mother to whether she is giving birth at home or in a hospital, and most mothers are unwilling to be randomized to a home birth or hospital birth.

Studies of home versus hospital birth are typically the less reliable cohort study, where women who chose one option or the other but have otherwise similar characteristics are compared.

... Home birth advocates have cited several studies supporting the safety of home births among low-risk women. However, those studies have taken place in the Netherlands and Canada.

Barth said its unrealistic to apply the findings to the United States.

"Those are highly regulated, highly integrated systems. Their system is prearranged -- it's very different from the systems available in the United States," he said.

Or Australia.

Agreeing with that notion, Declercq argued that it is the lack of such a setup that keeps safer home births from being a bigger option in the United States.

Exactly! The system can make home birth less safe, but the system can also make it optimally safe and acceptable.

"In the United States, people who want to have a home birth have to fight the system," he said, explaining that there is a lack of support for a midwife who decides a patient is too high-risk for a home birth and should be transferred to a hospital.

The same situation arises here in Australia, however some hospitals and their staff are very supportive and bend over backwards to make sure the woman and her mdiwife are comfortable, respected and safe.

"I think if you actually move to a system like that, it would be fine in the United States, because the evidence from other countries suggests that it is as well," said Declercq.

.. adopting such a system probably wouldn't lead to widespread home births in the United States. It would not climb to 30 percent like the Netherlands, but would be closer to the rise to 3 percent seen in the United Kingdom.

But for now, he said, it is likely to remain a highly charged issue, with some advocates of home birth irrationally opposing the choice of a hospital while opponents cite risks of home birth while ignoring complications that can happen at a hospital.

"The mothers who are having these home births are not crazy, unaware people," said Declercq. "They plan carefully, they think about this all the time. They think they're better off not having the interventions that they feel will happen unnecessarily at hospitals."

Melissa Maimann, Essential Birth Consulting 0400 418 448