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Written by Heather Siebert
Overwhelming support for the safety of home birth with a midwife has recently been reported in two major studies, one conducted in the UK and another in Canada. In fact, these paradigm-shifting publications provide robust evidence that home births are as safe as, if not safer than, births in a traditional hospital setting. Another, much smaller, US study that was not specific to midwives was also recently published and while it showed an increased risk in perinatal mortality in out-of-hospital births, it emphasized that absolute risks in both settings are very low.
United Kingdom’s NICE demonstrates home birth safety
The idea that the hospital is the best location for birth is examined in a landmark press release published by the National Institute for Health and Care Excellence (NICE), an advisory entity for the United Kingdom’s National Health System.
The NICE publication makes two primary claims based upon evidence from 17,000 home births included in the UK’s population health data conducted by Birthplace:
- Midwife-led units, such as a birth center (freestanding) or a unit within the hospital (alongside) are safer than a traditional hospital setting with care by an OBGYN for women with “straightforward” pregnancies;
- Home births are just as safe as midwife-led units and traditional hospitals for women who have “straightforward” pregnancies and have given birth before.
What is a straightforward pregnancy?
A “straightforward” pregnancy is one in which there are no complications such as high blood pressure or gestational diabetes; the mother is considered low-risk for complications. While some may be surprised to learn this, in fact most women fall into this category. Dr. Baker, NICE’s clinical practice director is quoted as saying, “Most women are healthy and have straightforward pregnancies and births.”
What safety issues are avoided by giving birth at home?
Dr. Neel Shah, assistant professor of Obstetrics, Gynecology, and Reproductive Health at Harvard Medical School, examined the NICE recommendations, recognizing differences in treatment intensity between traditional hospital treatment and midwifery care. His response was published in June 2015 by the New England Journal of Medicine. Shah explained that obstetricians are trained as surgeons and are surrounded by operating rooms. Read his description of hospital birth:
Nearly all Americans are currently born in settings that are essentially intensive care units (ICUs): labor floors have multipaneled telemetry monitors, medications that require minute-by-minute titration, and some of the highest staffing ratios in the hospital. Most labor floors are actually more intensive than other ICUs in that they contain their own operating rooms.
There are dangers to over-intervention. Greene and Ecker write in a December 2015 editorial published in the New England Journal of Medicine that interventions have not demonstrated their worth; for example, the cesarean rate has doubled since the 1970s but the fetal death rate has not changed. Because of this, “…It is easy to see them [interventions] as unnecessary, meddlesome, and unacceptable.” Obstetricians are much more likely than midwives to routinely intervene with the birth process through inducing labor, electronic fetal monitoring, episiotomy, and cesarean birth, causing greater and perhaps unnecessary discomfort for women and increasing the risk of further interventions. Additionally, the risk for hospital-acquired infection increases. To top it off, Dr. Shah from the Harvard Medical School admits that birth interventions are rarely helpful to the newborn baby.
To put it simply: birthing with a midwife gives mothers peace of mind that their safety will not be compromised though routine, unnecessary intervention. Their uncomplicated pregnancies do not require ICU attention.
The UK’s NICE recommends mothers should have the option to birth with a midwife, whether at home or in a midwife-led unit. Healthcare providers should respect a mother’s choice if she decides to birth under the care of a midwife. Here in the United States, NICE recommendations are initiating important conversations about medicalized birth and treatment intensity in the US, reports Wang in a September 2015 Wall Street Journal article.
McMaster University researchers find home birth as safe as hospital birth
The Canadian Medical Association Journal published an article on December 22, 2015 comparing 11,493 planned home births to 11,493 planned hospital births. The study was conducted by researchers from McMaster University (Ontario); it found that home births, under the care of a midwife, showed no increased risk of harm to the baby compared to hospital births.
The McMaster University researchers included both first-time mothers and women who had previously given birth in their study. All women had low-risk pregnancies.
Eileen Hutton, a professor of Obstetrics and Gynecology at McMaster’s School of Medicine, is quoted as saying, “Among women who intended to birth at home with midwives, the risk of stillbirth, neonatal death or serious neonatal morbidity was low and did not differ from midwifery clients who chose hospital birth.”
As illustrated in the NICE publication, this study showed that women who gave birth at home were less likely to have interventions such as induction or labor augmentation, assisted vaginal birth, or cesarean delivery. The home birth mothers were also more likely to be exclusively breastfeeding at 3 and 10 days after delivery.
Small US study is not specific to midwives
On December 31, 2015, The New England Journal of Medicine published a study comparing outcomes for low-risk mothers in Oregon who planned to give birth in the hospital (75,923) with low-risk mothers who planned to give birth out-of-hospital (3,203) in the years 2012 and 2013. This study agreed with the other studies in finding that those giving birth out-of-hospital experienced much lower intervention rates including induction and cesarean section as well as lower admissions to NICU units. The study also showed that those planning out-of-hospital births were more likely to give birth at full term. Unlike the larger Canadian and UK studies, this study was not specific to licensed midwives – 90% of the births were with licensed providers (Naturopathic Doctor 13%, Certified Nurse Midwife 20%, Licensed Direct-Entry Midwife 57%); 10% of the births were with unlicensed providers (unlicensed midwives 8% and other person, such as a relative 2%). The Oregon study showed a higher risk of perinatal mortality for planned out-of-hospital births, although the authors emphasized that the absolute risk for both groups was still very low.
Home birth is a good option for low-risk women
While there are no risk-free locations to have a baby, these studies show that for low-risk women, there are many benefits to choosing an out-of-hospital birth with a skilled midwife. The lower intervention rates and higher breastfeeding rates experienced by those families planning out-of-hospital births, not only save them money but may help them maintain lower risks in subsequent births.
Could the slightly higher perinatal mortality rates experienced by out-of-hospital births in Oregon be attributed to a lack of established transfer protocols and respect and cooperation between hospital staff and home birth providers? We need to continue to explore how birth can be improved for all families in all locations.
Improving South Dakota outcomes
Our current policy in South Dakota of prohibiting our families from accessing Certified Professional Midwives, the only US healthcare provider that has required training in out-of-hospital maternity care, is leaving dangerous gaps in care in many parts of the state. Home birth friendly countries like Canada and the UK and home birth friendly states like Alaska, Montana and Oregon have better perinatal outcomes than South Dakota. It is time we join the 30 other states who safeguard the practice of these highly skilled midwives for their citizens.