Homebirth in Maryland

Homebirth-Ensuring Safety
Anni McLaughlin RN CNM
Prental Parent and Simply Born


Homebirth-Ensuring Safety
Abstract
Homebirths have increased dramatically in the last decade. While still representing only small number of births the rate is up significantly. That change is stimulated, in part, by the desire of the birthing woman to have a greater say in her care providers and care setting: Another aspect is concern over the dramatic increase in cesarean sections in hospitals across the United States.
While a few hospitals across the United States have implemented programs that improve patient satisfaction, (Coalition for Improving Maternity Services, 1996), a growing segment of women want the intimacy of birth in the safety of their own homes. Well-designed studies show birth is a normal, physiological event with high safety for mother and baby. It is also true that technology
has its place in high risk births. What homebirthing women want to avoid is unnecessary use of intervention and to birth in familiar surroundings with care givers they know well. This paper focuses on the cooperation needed to maximize safety in the homebirth setting.

Keywords: homebirth, safety, patient autonomy, midwives, health care system.

Homebirth –Ensuring Safety

Homebirths rose 29 percent in the United States from .56 percent in 2004 to 0.72 percent in 2009. The increase for white, non-Hispanic women was 36 percent. (MacDorman, Mathews, Declercq, 2012) Still, the number of women choosing homebirth, at less than 1 percent, is a small number leading one to wonder why it warrants such strong, continued opposition from the established medical community.

A study of the views of over 550 women in a planned homebirth study by Janssen, Henderson and Vedam (2009), noted that “the voices of women have largely been ignored in this debate.” How can an environment be created and programs developed that help ensure optimal safety for mothers and babies in the homebirth setting?

In an age where a vast array of books and internet access allows women to do their own research, medicine in general recognizes patient autonomy in their health care decisions. Patient’s right to choose care options has become the focus of medical decision making. In obstetrics, however, there appears to be a continued bias toward paternalism rather than autonomy or joint decision
making. This area is complex. While most doctors themselves operate autonomously, they often, by their training and belief systems impose their choices and beliefs on mothers in a paternalistic manner, especially in labor.

Women in labor acutely display the “tend and be-friend” concept proposed by Shelley Taylor, PhD, who, along with five colleagues, developed the model. Their study suggests the response by females under stress quickly moves from “fight or flight” to protecting themselves and their young and to "befriend" those who are creating the risk. (Azar, 2000).

These elements especially come into play in labor and delivery units. Frequently, during the course of labor, women are told their baby are at grave risk. Women commonly do whatever their care providers are recommending without evaluating the situation themselves. Birthing women want the best for their baby even if it means an untimely cesarean or other interventions. There is a remarkable tendency on the part of mothers to drop autonomy in favor of heteronomy—obeying blindly the mandates of others. In doing so, women often have deep regret in the ensuing months and years.

Many women come to the labor and delivery unit with well thought out birth plans. These encompass requests found in Healthy Birth Practices such as letting labor begin on its own, walking and changing positions frequently, bring a support person, avoiding interventions that are not medically indicated, avoiding lying on the back while birthing and keeping the mother and baby together after the birth. (Lamaze International, 2009).

Declercq, Sakala, Corry, and Applebaum surveyed American women who gave birth in hospitals in 2005 showing that “only 2% experienced all six of the care practices that promote normal birth,” as defined by the Healthy Birth Practices . The results of their survey concluded there are “large segments of this population experiencing clearly inappropriate care that does not reflect the best evidence, as well as other undesirable circumstances and adverse outcomes.”
Additionally, most mothers reported not being given adequate information about risks, benefits and alternative choices before interventions. (2007).

The United States is in the midst of a cesarean epidemic. The high risk of major surgery, even for low-risk women, is a major influence in the decision to have a homebirth. The World Health Organization maintains that the cesarean section rate should be no more than 10-15%. (2009). In the United States, the cesarean rate has sky-rocketed from 5.5% in 1970 to more than 32% in 2010 (National Center for Health Statistics, 2010). In many Maryland hospitals, and for individual doctors, the rate is even higher. The rise of more than 70% from 1996 (21%) to 2010 (32.8%) has sparked national attention. The increase of cesarean sections, along with the new mandates restricting the opportunity of a vaginal birth after a previous cesarean in the hospital setting, is a strong catalyst for women researching homebirth.

Women who have had homebirths rate it as a very satisfying experience. In a study by Davies, Hey, Reid, & Young (1996), eighty-five percent of women who gave birth at home after a previous hospital said they preferred their homebirth experience. Of those who were planning another child, 91 percent said they would plan another homebirth. Women typically spend months researching homebirth before making an informed decision. A Finnish interview-based study by Jouhki (2011) showed eight key areas as reasons for choosing homebirth. They were:

1.) Previous (usually a negative hospital)birth experience
2.) Women consider birth to be a natural process
3.) Increased autonomy
4.) Home environment
5.) Intuition
6.) Desire to choose the birth attendant
7.) Mistrust of medicine
8.) Ability to have siblings present at the birth

Homebirth is an integral part of safe healthcare in other countries such as Canada,
Switzerland, Australia, the United Kingdom, Sweden, and the Netherlands.
(Ackermann-Liebrich, 1996; Chamberlain 1997; De Jonge, 2009; Kennare 2009;
Lindgren 2008; Symon 2009). The maternal-infant health statistics, in these countries, are consistently better than those of the United States. Still, medical communities in the United States continue to have expressed marked controversy about women choosing to have their babies at home.

Well-designed studies in the United States and Canada have established that homebirth with professional, trained midwives is a safe alternative for women who choose that option with or without a system of support from the medical community. (Hutton 2009; Janssen 2002, 2009; Johnson 2005).

Specifically, the studies done in the US and Canada comparing planned home births with skilled attendants with hospital births have shown the safety of homebirths in North American
environments at least equal to that of similar low-risk women who birth in the hospital.

The best study design, the random control study (RCT), is difficult to create due to the birthing desire of individual mothers. Few women would be comfortable being randomized into homebirth or hospital environments. A study by Hendrix, Van Horck, Nieman,
Nieuwenhuijze, Severens and Nijhuis spoke to this issue. This study in the Netherlands, where 30% of women give birth at home, attempted to randomize women into either a home or
hospital care system. After six months, only one woman had enrolled. The team then redesigned the study to investigate the reasons women declined participating in the original study.
They found four main reasons:
1.) they had already chosen their preferred place of birth,
2.) they wished to choose their own place of birth,
3.) they wished to avoid delivering in the “wrong” place with their first child, or
4.) they wished to avoid unnecessary treatment. (2009).

The next most appropriate study design is the prospective study. The study by Johnson
and Daviss (2005) was such a design. The North American Registry of Midwives (NARM) recruited their members, Certified Professional Midwives (CPM) to enroll all of their patients in the study for the year 2000. In all, 5418 women enrolled in the study and were compared with women having low-risk births in the hospital during that same year. The results clearly showed the safety of homebirths. In their conclusion, the authors stated that “homebirths were as safe as hospital births for low risk women.” Not calculated into that statement was the increased infant and maternal mortality and the short term and long term risks for women who had cesarean sections. The national cesarean rate in 2000 was 23% (National Center for Health Statistics, 2010) while the study group had a mere 3.7% cesarean rate. The short and long term risks of cesarean section, which is major abdominal surgery and can be mild or significant, were
not included in the study. With a markedly lower cesarean rate, the homebirth group could rightfully be accorded a significantly better overall safety rate.

Recent homebirth studies in Canada also verify the safety of homebirths. One of these studies compared hospital based midwifery/physician care to homebirth midwifery care in Ontario Canada. (Hutton, Reitsma & Kaufman, 2009). The other, a study of British Columbia
homebirth practices, compared the statistics for homebirth and hospital birth
for licensed midwives. Again the homebirth arm of the studies had fewer complications and risks. (Janssen, Ryan, Etches, Klein, & Reime, 2007).

In contrast, the often quoted meta-analysis study by Wax et al. appears to show the high incident of danger at homebirths. The Wax study was reviewed and highly criticized by numerous authors and agencies, each citing the study’s strong selection bias and poor methodology. Most notably, an article entitled “A Flawed Analysis.” Co-authored by Michal, Janssen, Vedam, Hutton, and de Jonge, all highly regarded researchers, described “in detail the numerous mistakes in design,
methodology, and reporting in the Wax meta-analysis that place clinicians and
patients at risk for being misinformed.” (2011).
While it is impossible to know whether the bias in this article was the result of faulty workmanship or was deliberately misleading, Wax, et al. chose not to include the strong studies mentioned above but chose studies that did not differentiate between planned homebirths with professional midwives and unplanned homebirths with no professionals available. This study has become the basis for the opinion regarding homebirth for the largest obstetrical trade union, American College of Obstetricians and Gynecologists (ACOG).

The ACOG Position Paper on out-of-hospital birth, while approving of hospital and birth center birth, strongly discourages homebirth. This position reflects back to the Wax study as the basis for this assertion. Commonly, homebirths and birth centers are staffed by midwives with the same training and using the same protocols and equipment, making the dichotomy very curious. This most recently updated Position Paper was updated to include wording that allows that women have a right to choose homebirth. (2011).

The American College of Nurse Midwives (ACNM) has a homebirth position paper which includes defining the rights of mothers and families to both the place of birth and dignity of care both at home and during the relatively rare need to transfer into the hospital setting during or
after birth. The ACNM encourages “an integrated system that includes collaboration” and referral between midwives who specialize in normal pregnancies and births and doctors who are trained to handle more complicated pregnancies. (ACNM, 2011).

Well done studies of planned homebirths with trained caregivers found homebirth to be a safe and viable option for most low-risk women. Of the four recommendations presented in the Joint Statement on Planned Home Births in Maryland in October 2011, only one is under the direct control of the midwife. That recommendation is the individualized screening of all risk factors for a homebirth. The other three require the cooperation of the legislature and the medical communities. This joint statement only acknowledged nurse-midwives and physicians as care providers while disregarding the largest, most well trained homebirth providers, the certified professional midwife. The excellent results of the CPM2000 study (Johnson & Daviss, 2005), as well as the two Canadian studies (Hutton et. al., 2005; Janssen et. al. 2009), were results based, not on physicians or nurse midwives, but certified professional midwives. The joint statement recommends that care provider works “within an integrated and regulated health system” but even for nurse midwives doing homebirths in Maryland this is an elusive component as is
the third recommendation, “ready access to consultation.” (Joint Statement on Planned Home Births in Maryland, 2011). For nurse midwives, licensing requires that a physician with admitting privileges agree to collaborate with the nurse midwife. Finding a doctor to agree to that
collaboration is extremely difficult, whether from the doctor’s own bias against homebirth or from peer or hospital pressure. Many doctors are under the impressions that collaborating puts them at additional liability risk, though that is not the case. It has been suggested that the collaboration requirement has no usefulness purpose and that nurse midwives should be separate and independent providers.

Physicians and hospitals can work in concert with homebirth midwives to create a smoothly integrated program of care for women and their babies. Numerous international organizations have created blueprints for successfully implementing homebirth services into the
community. (FIGO, 2010; UNFPA-ICM Joint Initiative 2006; World Health Organization; Coalition for Improving Maternity Services 1996). Creating those frameworks has added a deep
safety net for many developed and developing countries. The United States is in the midst of a
maternity crisis. Homebirth midwifery is a key component to providing safe, low-cost care for low-risk women who want the personalized care given by midwives.

Midwives and homebirth have always been a part of the history of the United States.
It is time to fully integrate the services of homebirth midwives into the health care system. Following the recommendations for safe homebirth and implementing programs to ensure optimum safety is crucial. For families who choose homebirth a joint effort between legislation, the medical community and the midwifery community is required. Future research is needed for fully implementing these recommendations to ensure the best care for families choosing homebirth.


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