About
Birth
Should
American Women Learn to Give Birth at Home?
By Catherine Elton Saturday, Sep. 04, 2010
New York
Times
When Hillary McLaughlin found out she was pregnant, she was unable
to legally obtain the service she needed. So she looked for an
underground contact. She got a woman's name--just a first name--and
a phone number from a friend who advised her to destroy the evidence
as soon as she made the call. When McLaughlin reached the woman,
however, the woman told her she no longer "did that" and that she
wasn't willing to risk going to jail for it anymore. Turned off by
all the "whisper, whisper, cloak-and-dagger stuff," McLaughlin
decided to "jump state lines" from Illinois to Missouri to find a
legal provider.
Forty years ago, you might have assumed McLaughlin was looking for
an unlawful abortion. Rather, what the small-business owner, 33,
sought was a certified midwife who could deliver her baby at home in
Edwardsville, Ill. "It's completely ridiculous that I had to do all
this because midwives aren't licensed to practice here," says
McLaughlin, who delivered her son in April at her parents' home in
St. Louis. "I wanted a home birth, but I wanted to do it legally,
because I wanted some assurance that the midwife I chose knew what
she was doing."
Each year, some 25,000 American women like McLaughlin opt to deliver
their babies at home. Although that accounts for fewer than 1% of
all births in the U.S., the figure is probably on the rise. From
2004 to 2006, the most recent year for which estimates are
available, home birthing in the U.S. increased 5% after having
gradually declined since 1990, according the Centers for Disease
Control and Prevention. While the recent uptick is not conclusive
proof of a trend, home-birth advocates say anecdotal evidence and
informal surveys from the field also point to growing demand.
Why? Largely because women wish to avoid what they deem over-medicalized childbirth. Compared with hospital deliveries, 32%
of which end in cesarean section, those taking place at home involve
far fewer medical interventions and complications. Some women, like
McLaughlin, who have had cesareans in the past, elect to have a home
birth because they want to attempt vaginal delivery--what is known
as vaginal birth after cesarean, or VBAC, a procedure that most
obstetricians and hospitals have banned to avoid liability lawsuits.
But midwife-assisted home births are not always easily or legally
arranged. Today, just 27 states license or regulate so-called
direct-entry midwives--or certified professional midwives (CPMs)--whose
level of training has met national standards for attending planned
home births. In the 23 states that lack licensing laws,
midwife-attended births are illegal, and midwives may be arrested
and prosecuted on charges of practicing medicine or nursing without
a license. (Unlike CPMs, certified nurse midwives, or CNMs, who are
trained nurses, may legally assist home births in any state. But in
practice, they rarely do, since most of them work in hospitals.)
Putting aside the fact that the threat of arrest makes for a
stressful work environment, midwives say it also increases risks for
the mother and child. In the worst case, it could dissuade or delay
a midwife from transferring a patient in medical need to a hospital.
(Doing so might expose the midwife to the attention of law
enforcement.) But now a campaign is under way to expand state
licensing of CPMs, which would not only grant mothers increased
access to home births, midwives say, but also make them safer.
Momentum appears to be growing. Of the 27 midwife-friendly states,
eight began licensing midwives only in the past decade. And
legislatures in 10 other states are now considering bills to
institute licensing of CPMs--a fact that has not gone unnoticed by
the medical establishment.
The Battle over Birth
The turf war between midwifery and medicine has been long-running. Both the American Medical Association (AMA) and the American
Congress of Obstetricians and Gynecologists (ACOG)--the professional
groups that write official medical and obstetrics guidelines in the
U.S.--oppose home birthing on grounds of safety. In 2007 ACOG stated
that the "safest setting for labor, delivery and the immediate
postpartum period is in the hospital or a birthing center within a
hospital ... or in a freestanding birthing center." The statement
was supported in a resolution passed by the AMA in 2008. Choosing to
deliver a baby at home, ACOG said, is to give preference to the
process of giving birth over the goal of having a healthy baby.
Midwives counter that for low-risk mothers, planned home births are
no less safe than hospital births. A study published in the BMJ in
2005 found that among 5,418 mothers in the U.S. and Canada who
planned home births, the rate of neonatal or intrapartum death was
1.7 per 1,000 births--similar to the rate of neonatal deaths (those
occurring within the first 28 days) in hospital births found in
other studies. And home birth can be a favorable experience for both
mother and child, midwives say. Women who give birth at home not
only recover faster after delivery but also are more likely to
breast-feed and avoid postpartum depression, according to home-birth
advocates.
The political debate ratcheted up on July 1, when the American
Journal of Obstetrics & Gynecology published online a controversial
new meta-analysis of the safety of planned home births. The authors
of the paper, which consists of a review of 12 previous studies,
acknowledged significant benefits associated with home birth: fewer
maternal interventions, including epidurals, episiotomies and
C-sections; and fewer cases of premature birth and low birth weight.
But the finding that made headlines was that planned home births led
to a two-to-three-times higher risk of neonatal death than planned
hospital deliveries among healthy, low-risk women. The result was
especially striking, the authors wrote, because women planning home
births generally had fewer obstetric risk factors than those who
chose hospital births: they were less likely to be obese and had
fewer previous C-sections or pregnancy complications.
Lead author Dr. Joseph Wax cautions against alarm, noting that the
absolute risk of neonatal death is still extremely small in any
birthing environment in the U.S. According to the review, the rate
of neonatal death was 2 to 3 for every 1,000 home births. The rate
among hospital births was 1 for every 1,000 births. "Home birth is
quite safe for the baby," says Wax, a maternal-and-fetal-medicine
specialist at Maine Medical Center. "But not as safe as a hospital
birth."
All the more reason for women to eschew home birth, say
obstetricians. Wax's study found that the increase in neonatal death
could be attributed in part to babies' breathing difficulties and
failed resuscitation--factors associated with inadequate midwife
training and lack of access to hospital equipment. The obvious
solution: give birth in a hospital. "During the labor process,
emergencies can arise that we cannot predict. In some of those
cases, you only have moments to intervene successfully," says Dr.
Erin Tracy, an ob-gyn at Massachusetts General Hospital and an
outspoken detractor of home birthing. "It's a tragedy in those rare
instances [of infant death] where medical intervention could have
saved the life of the baby."
Informing the Patients
In terms of scientific evidence, meta-analysis sets a high bar.
Because it aggregates data from multiple studies, a meta-analysis is
useful for revealing medical trends that cannot be picked up by
individual studies. Perhaps more important, the results of
meta-analyses hold great sway in doctors' offices. They are kind of
like medical Cliffs Notes: doctors often prefer to read a single
review paper rather than 20-odd original studies to make a judgment
about a particular treatment or intervention.
It would seem that the editors of the American Journal of Obstetrics
& Gynecology, who highlighted Wax's paper as an Editor's Choice,
hoped the study would inform patient decisions. The 12 studies
analyzed were from seven countries (two from the U.S.; the rest from
Australia, Britain, Canada and Western Europe) and compared data on
maternal and infant outcomes in a total of 342,056 planned home
births and 207,551 planned hospital births . But two independent
experts in meta-analysis who reviewed the paper for TIME concluded
that it was weak and methodologically flawed. Other critics say some
of the studies included are outdated or misleading, thus limiting
the conclusions of the review.
One such study, published in the journal Obstetrics & Gynecology in
2002, compared the outcomes of 6,133 home births and 10,593 hospital
births in the state of Washington from 1989 to 1996. But the paper
did not make clear whether any of the babies who died had birth
defects that would have resulted in death regardless of where they
were born. The study also could not determine in every case where
exactly the birth had been intended to occur; the authors relied on
birth-certificate data, which indicated whether a baby was delivered
at home but not whether the home birth was accidental.
There is a big difference, of course, between having a baby in a
planned home birth with a midwife who has cared for the mother
throughout pregnancy and giving birth on the bathroom floor with a
frantic spouse following instructions from a 911 dispatcher. Births
that happen at home unexpectedly also tend to happen very
precipitously, which is itself a risk factor for the baby.
The Washington study found a twofold increase in infant mortality
associated with home birth compared with hospital birth. Given that
it was one of only seven studies out of the 12 included in Wax's
meta-analysis that assessed infant mortality in the first 28 days of
life, the Washington study accounted for nearly 40% of all such data
and contributed heavily to the final conclusions of Wax's
meta-analysis.
Wax defends the inclusion of the Washington study, noting that its
authors used various methods to exclude any home birth that was
likely to have been unplanned. Moreover, he says, neonatal mortality
rates were "fairly consistent across the included studies" in his
review. Indeed, Wax and his colleagues think the conclusions of
their analysis tend to underrate the risks of home birth. "The lower
obstetric risk characterizing women self-selecting home birth likely
underestimates the risk and overestimates the benefit of this
delivery choice," the authors write.
Making Home Birth Safer
Understanding the relative risks of home birth has always been
tricky, in large part because the subject is impossible to examine
in a randomized controlled trial; few women would agree to let a
study investigator randomly determine their birth plans. Meanwhile,
broad reviews like Wax's of the existing research can be limited by
the quality or relevance of the original data.
Some observers, including Wax, further suggest that American women
should draw only limited conclusions about the safety of home birth
from studies conducted in other countries. The experience of home
birth in the Netherlands, for instance, where 1 out of 4 mothers
delivers at home, bears little resemblance to the process most
American women endure.
Two key factors contribute to a successful home birth: a mother who
is at low obstetric risk and the possibility of a seamless transfer
to the hospital in case of medical necessity. Because of eligibility
requirements for home birth in the Netherlands, Dutch mothers who
choose that route tend to be at lower risk from the start than their
American counterparts. Dutch women who have had C-sections, for
example, are not candidates for home birth, while in the U.S.,
previous C-sections are a major reason women choose to labor at
home. Yet according to ACOG's 2008 statement, attempting VBAC at
home is especially dangerous, because it puts the woman at risk of
uterine rupture during labor, with no immediate access to necessary
medical equipment or expertise.
In the Netherlands, moreover, midwives are fully integrated into the
health care system and obstetrics practices, making transfers to
hospitals routine. In the U.S., where 1 out of 200 women gives birth
at home, midwives can be and have been arrested for bringing their
patients to hospitals in states that do not license CPMs.
So it is no surprise that a large 2009 Dutch study showed home birth
to be safe. What that means for women elsewhere is less clear,
however, and results of various U.S.-based studies tend to conflict.
"Research in this area is desperately needed, particularly for women
in the United States," says Wax.
The lack of definitive data guarantees that the birth wars won't
soon end. But many obstetricians and midwives can at least agree on
one thing: easy and immediate access to hospitals can improve birth
outcomes and increase home-birth safety overall. Which is precisely
why midwives say they are pushing to expand state licensing of CPMs.
In states where licensing already exists, home-birth advocates say,
there is, on the whole, good cooperation between midwives and
hospitals.
A midwife's working relationship with a hospital aside, what really
matters is her competence. The reality is that licensed or not,
midwives are already practicing in every state, many in the shadows
and many lacking any certification whatsoever. Certification is
granted on the basis of a candidate's attainment of obstetric
knowledge--acquired at midwifery school, through distance learning
or in an apprenticeship--along with her experience attending births.
A midwife must assist 20 births and serve as the primary midwife on
at least another 20 to become certified, a process that typically
takes three to five years.
In states without licensing programs, the danger is that women
seeking a home birth will not know whether the women delivering
their babies are CPMs. Many don't even think to question whether
certified and uncertified midwives have different training. That's
why in two states where legislators have recently considered
licensing CPMs--Wisconsin, where a law was passed, and
Massachusetts, where the matter is still pending--the bills were
championed by unexpected proponents: women whose babies died during
home birth. Their babies didn't die because the women chose to give
birth at home, they said, but because the midwives who attended
their births had not been certified as competent. In the absence of
a state licensing system, women can be none the wiser.
View
full article:
here
'Behold, I will bring them from the north country, And gather them
from the ends of the earth,
Among them the blind and the lame,
The woman with child and The one who labors with child, together,
A
great throng shall return there...And My people shall be satisfied with My goodness, says the LORD.'
Jeremiah 31:8, 14~~~
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September 2010
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