March 2000 Vol. 27.1
Sheila Kitzinger's Letter from Europe
Home Birth Matters
The home birth issue is alive and kicking in the U.K. In a paper on the place of birth in the British Medical Journal two obstetricians, one working in general practice and the other a professor of obstetrics, wrote: It has long been assumed that hospital provides a safer environment for women at low risk as well as the high risk mothers. This assumption, however, is not evidence-based.1 In swept Batman in the form of Professor James Drife, who stated that women must be warned that home birth is three to four times more dangerous than hospital birth. He has come to this conclusion by comparing home birth outcomes in the USA and Australia with hospital birth outcomes in the UK.2,3,4,5 He also called for research, ignoring the audit of home births in Northern England 6, Olsen's meta-analysis 7 and the British Medical Journal's supplement on birth research in 1996.8
Selecting statistics from different countries, as general practitioner obstetrician Gavin Young and pediatrician Edmund Hey quickly pointed out, is a failure to compare like with like: It is about as helpful as saying that a man and a dog have an average of three legs.9
|Birth statistics can
only be discussed with validity in a socio-cultural context. Leaping to conclusions about
the risk of home birth from figures compiled in Pakistan or Turkey and comparing them with
hospital births in the UK, for example, would obviously be ridiculous. Home and hospital
births have to be evaluated within a specific health care system.
Alison Macfarlane and Rona Campbell, health statisticians, commenting on the studies to which Drife referred, said that there was inconsistency in the definitions of death and the overall groups of birth with which the deaths were compared.10 Their publication, `Birth Counts', brings home and hospital birth statistics in the U.K. to the end of 1997.11 Analysis confirms the results of their previous research: for women who are at low risk planned home birth is as safe as hospital birth.
The confidential enquiry of 1994 12 had already produced some telling statistics, and in meticulous detail. 3,896 women had planned home births, 3,319 planned hospital births, and 769 women planned a home birth but were transferred to hospital. Those giving birth at home had far fewer interventions: 0.2% had labour induced, compared with 19% of the planned hospital delivery group. 7% of home birth mothers had their membranes artificially ruptured at 4cms dilatation or less, compared with a quarter of those giving birth in hospitals. 8% of women at home used pethidine (Demerol) compared with 30% in hospital. Women at home usually avoided pain-relieving drugs - less than 10% took any analgesia.
The labours were very different, too. Prolonged labour was reported four times more often in hospital and fetal distress three times more frequently. A woman who planned a hospital delivery was twice as likely to have an operative vaginal delivery or a Cesarean section. 48% of women who gave birth at home had an intact perineum, compared with 39% in hospital. Only 4% of women at home received episiotomies, but 21% in hospital. Women lost less blood when they gave birth at home. In this study 75% lost less than 200ml compared with 65% of hospital-booked women.
Very few babies died in either group, so they cannot be compared. But the home birth babies were in better condition. Only 4% of babies with home-booked births had Apgar scores below 7 at one minute and 0.6% at five minutes, compared with 9% and 1% of those booked for hospital deliveries. 13% of babies in the home group were resuscitated, usually simply being given a whiff of oxygen, compared with 28% of the hospital group.
"I sat on a low stool and they wrapped us in soft, warm towels. Then the cord was cut and I held him close, and we marvelled at him and the whole miricle of birth. We were all so high the champagne was nice, but I don't think it added much to the occasion."
Women's experiences of birth need to be considered, too, both because this is a major life event and because it is much easier to start out on mothering when birth brings fulfillment and triumph. An unhappy women may find it difficult to enjoy building a relationship with her new baby, and also to breastfeed. 80% of the home birth mothers breastfed within the first 48 hours, compared with 58% of the women delivered in hospital. Home birth mothers were less likely to have backache or headache, too, and were physically more comfortable during he puerperim. An important element in women's experiences of home birth was that they were free of stress and in control of their own territory. No woman who gave birth at home said that she felt she was not in control. In contrast, women in hospital said that the most important thing for them about being in hospital was that it made them feel safe.
Because close on three quarters of all babiesin the U.K. are delivered by midwives, not doctors, North Americans sometimes think of Britain as a country that accepts home birth as a normal alternative to hospital, and where it can be organised without hassle. This is far from true now. Home births are just 2.7% of all births in England and Wales though many women consider home birth and are dissuaded from it.
General Practitioners are the gate-keepers to the place of birth. Some warn women that they may haemorrhage to death, and that their babies may die or be brain-damaged if they insist on home birth. As Chair of the International Home Birth Movement (U.K) I hear every week from women who are told It's not safe to have a first baby at home you might bleed to death and asked,Do you want to have a dead baby? How could you ever forgive yourself? G.Ps can strike a recalcitrant patient off their register without any further explanation, or, alternatively, play along with her until at the end of pregnancy they announce that her blood pressure is up or the baby is too large, or too small, or in a difficult position, without producing evidence for this. Women are also told that they are being `selfish' in taking up a midwife's time at home, when she could be overseeing three or four births simultaneously on the labour ward. There is an acute midwife shortage. Many midwives leave the profession because of low job satisfaction. Accordingly, letters are sent out by Health Trusts instructing pregnant women already booked for home birth that they may have to come into the hospital. In some cases women have been told this as late as 39 weeks.
The UKCC, the regulatory body for all nurses, midwives and health visitors, is concerned that Trusts no longer accept responsibility to provide a community midwifery service. Care is fragmented and women are being directed to hospital whether they like it or not. There are indications that some women may have no option if they want a home birth but to `go it alone' with a neighbour or family member to help.
Legally Trusts have not had a statutory duty to provide a domiciliary birth service since the NHS was re-organised in the 1970s. By an oversight, provision for this was omitted from the Bill. Yet it is government policy that women have the right to give birth at home and it is the midwife's professional responsibility to attend a women wherever she is when she is in labour.12,14 The result is head-on collision between women seeking home birth and a centralised, rigid, hierarchical and hospital-dominated medical system.
Even when a woman is booked for a home birth, she may not know which of a team of anything up to 11 midwives will attend her in labour. It is often someone whom she has never met before. Midwives do not as a rule get any training in home birth. A midwife who lacks confidence communicates her anxiety to the mother, and may put her under pressure to accept transfer to the hospital. She insists on this because the membranes have ruptured early, or dilatation is not fast enough, and may persuade the mother that her baby is `in distress', though there is no evidence of it on the labour chart.
Where in the USA a midwife is usually someone who supports a woman in giving birth at home, in the UK she is now part of a medical system which is based on hospital and permeated by a philosophy of care that is focussed on pathology.
We may have reached the stage where legal action is necessary. Barbara Hewson, the barrister who appealed against court-enforced Cesarean sections, and won this landmark case, considers that home birth is a question of human rights.
The creation of the National Health Service was a brave and splendid revolution. As a child, I remember my mother's excitement. She had been a midwife and had also worked in one of England's first family planning clinics. She used to talk about the distress surrounding pregnancy and birth for many impoverished women who were unable to have any control over their reproductive lives. They saved money in a tin on the kitchen shelf so that their children could get medical care, but could not afford it themselves. Together with the improved nutrition that came about as the result of food rationing, the NHS changed the health of a nation.
Government policy on birth initiated in 1993 13 seemed to herald another revolution and for the first time promised woman-centered care. But the changes made have not matched the fine talk. The system is fettered by fortress-like management structures and insensitive, defensive attitudes. I think it was Kafka who said, Every revolution evaporates and leaves behind it only the slime of a new bureaucracy. I believe that the birth revolution has to be continually recreated if we are to improve the quality of childbirth for women and their babies everywhere.
|1||Zander L, Chamberlain G.ABC of labour care Place of Birth. BMJ 1999;318:721-723|
|2||Drife J O. Data on babies' safety during hospital are being ignored, (letter) BMJ 1999;319:1008|
|3||Anderson R E, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. J Nurse Midwif ery 1995;40:483-492|
|4||Murphy P A, Fullerton J. Outcomes of intended home births in nurse- midwifery practice. Obstet Gynecol 1998:92;461-470|
|5||Bastian H, Kierse MJNC, Lancaster PL. Perinatal deaths associated with planned home births in Australia, BMJ, 1998; 317:384-388|
|6||Northern Region Perinatal Mortality Survey Coordinating Group, Collaborative survey of perinatal loss in planned and unplanned home births. BMJ. 1996;313;1302-1306|
|7||Ole Olsen. Meta-analysis of the safety of home birth, Birth 24:1997;24 (1):4-13|
|8||Davies J, Hey E, Reid W, Young G. Prospective regional study of planned home births.BMJ 1996, 313:1302-1306|
|9||Young G, Hey E. Home birth in the uk can be safe (letter) BMJ 1999:319:|
|10||Macfarlane A, Campbell R, McCandlish R. Data on babies' home births are being ignored (letter) BMJ 1999:319:1008|
|11||Macfarlane A, Mugford M. Birth Counts: statistics of pregnancy and childbirth, 2nd ed. National Perinatal Epidemiology Unit, Oxford, 2000|
|12||Chamberlain G, Wraight A, Crowley P. Home Births: The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Parthenon, Carnforth: 1997|
|13||Department of Health, Changing Childbirth, Report of the Expert Maternity Group. London: Her Majesty's Stationery Officer 1993|
|14||United Kingdom Central Council. Midwives' Rules and Code of Practice. UKCC, London: 1998:27-28|