Home Birth




Giving birth at home is a tradition in many parts of the world because of limited access to health care facilities. In parts of Europe, the United Kingdom, Australia, and North America, women may choose to give birth at home instead of in the hospital. The choice to give birth at home is undertaken for a variety of reasons: to enjoy the comfort of familiar surroundings; to have family and friends in attendance; to minimize separation from young children; to avoid contact with a “technological” environment; to have one-on-one care as opposed to care in a multidisciplinary, teaching environment; and to access the care that midwives qualified and experienced in attending healthy women are trained to provide. The term home birth implies that the birth is planned to take place at home. Unplanned home births are births that were intended to take place in hospital but happened at home or en route to the hospital because the labor was uncommonly fast, the mother couldn’t get access to transportation, or the mother didn’t know how far advanced she was in labor. Unplanned home births sometimes occur without professional attendants, and rates of adverse outcomes among unplanned home births versus planned home births are known to be higher. In North America, New Zealand, Australia, and some countries in Europe, for example, Switzerland, planned home births account for between 1% and 2% of births. In contrast, in the Netherlands, 30% of births are planned home births.

Planning For Home Birth

Birth at home requires advanced preparation. There is a requirement to purchase needed supplies for a cost of about $20.00 (U.S.) and to have available adequate linen, a protective cover and pads for the bed, baby supplies, and maternity supplies for the mother. Access to a telephone and transportation must be assured on a 24-hour basis. The midwife should have formal arrangements in place to transfer care to a physician consultant  if  necessary,  or  to  transport  the  mother or baby to hospital. Impending changes in weather and road conditions that could delay or eliminate the possibility of transport may influence the midwife or pregnant woman to initiate transport early in labor.

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Who Provides Care For Home Births?

Birth at home is most often attended by midwives. Physicians are generally not covered by malpractice insurance to attend home births. Practicing midwives vary in their training and experience, and it is important to know the qualifications of the midwife under consideration for attending a home birth. Some countries (e.g., the United States (Washington State) and Canada) license direct-entry midwives. These midwives have completed an accredited course of training but are not necessarily nurses. In other countries (e.g., England and Australia), all midwives are nurses and are referred to as registered or certified nurse-midwives. In contrast, some midwives practice without formal training and are known as lay midwives. The practice of lay midwives is not monitored or regulated by a professional practice organization, unlike licensed or registered midwives. Families who wish to have a home birth may contact the professional practice association for midwives in their region or country and find out how to obtain the services of a credentialed midwife.

Who Is Eligible To Have A Home Birth?

Consideration of a home birth requires an assessment of a woman’s health status. Most professional organizations governing the practice of midwifery issue strict guidelines about who should plan birth at home. These usually include a singleton fetus (not twins or triplets), baby in the cephalic presentation (head coming first instead of the buttocks), full term (37–41 completed weeks of pregnancy), and no more than one previous caesarean section. Exclusion criteria include preexisting serious medical conditions, for example cardiac (heart) or renal (kidney) disease, insulin-dependent diabetes, or health problems arising in pregnancy such as preeclampsia (elevated blood pressure with protein in the urine), placental abruption (placenta is detaching from the uterine wall), placenta previa (placenta is covering the opening to the cervix), or active genital herpes.

Safety Of Home Birth

A number of studies around the world have examined the safety of planned home birth among healthy women with a qualified midwife in attendance. These large studies from Canada, the United Kingdom, the United States, Switzerland, and New Zealand have not reported an increase in rates of adverse outcomes for mothers or babies compared with those among healthy women planning birth in hospital. In addition, planning birth at home is associated with reduced interventions during labor and delivery. About 15% of women initiating birth at home are transferred to the hospital at some point during their labor. Even including these women, planned birth at home is associated with reduced rates of use of narcotic drugs and epidural anesthetics for pain relief, amniotomy (rupturing the membranous sac around the baby), and administration of drugs such as oxytocin and prostaglandins to accelerate labor. Women who initiate labor at home are more likely to have a vaginal than a caesarean delivery, electronic monitoring of the fetal heart rate, and episiotomy  (an  incision  to  widen  the  vaginal  opening to hasten the birth of the baby). In addition to transfer during labor, a small percentage (1–2%) of mothers and babies require transport to hospital during the period immediately after birth. Whether reductions in interventions are attributable to the setting, home versus hospital, the practice of the attending midwife, or some aspect of the woman herself who has chosen home birth is not entirely clear because few studies have randomly assigned women to home or hospital birth. Certainly, women who chose birth at home are generally strongly motivated to have a natural or “physiological birth” because most midwifery professional organizations do not permit administration of drugs for pain relief in the home setting.

Payment For Home Birth

Midwifery  care  is  paid  for  by  the  government in most countries with public health care systems. Private insurers cover home birth in some cases, but polices vary and should be examined in detail before making the decision to give birth at home.

Women’s Satisfaction With Home Birth

Women who have completed birth at home, in comparison to women planning and completing birth in the hospital, report increased satisfaction with the birth experience, particularly in regard to having a feeling of control over the process of birth. Women giving birth at home are able to have whoever they want in attendance, to eat and drink nourishment of their choosing, and to engage in a variety of methods of pain management, including sitting in a hot tub, going for extended walks, and experiencing the comfort of familiar surroundings. Women also have reported a sense of accomplishment and readiness for mothering. Midwives attending a home birth stay at least 4 hours after the birth and visit daily thereafter for a number of days. This intensive contact with both the new mother and her family may allow for enhanced opportunities for teaching related to care and feeding of the baby and care of the new mother. Women giving birth in a hospital are discharged within 24 to 48 hours after an uncomplicated vaginal delivery and 72 hours after a caesarean birth. Home visits after the birth are rarely provided by physicians but often are by midwives. In most communities, public health nurses visit new mothers, but are often mandated to provide only one visit if the mother and infant are healthy.

Summary

In summary, healthy women experiencing normal pregnancies may choose to plan a home birth with a qualified midwife. Although no birth is risk free, home birth overall is not associated with increased risk for adverse  outcomes  for  the  mother  or  baby. Women planning birth at home are less likely to experience obstetrical interventions during labor and delivery.

References:

  1. American College of Nurse Midwiv (n.d.). Home birth. Retrieved from http://www.acnm.org/prof/factsheet.cfm
  2. Anderson, R., & Murphy, P. (1995). Outcomes of 11,788 planned home births attended by certified nurse-midwiv Journal of Nurse-Midwifery, 6, 584–492.
  3. Chamberlain, , Wraight, A., & Crowley, P. (1999). Birth at home: A report of the national survey of home births in the UK by the National Birthday Trust. Practising Midwife, 2,35–39.
  4. College of Midwives of British (n.d.). Bylaws, standards, and guidelines/Standards of practice/Indications for planned place  of  birth.  Available  from  http://www.cmbc.bc.ca
  5. Janssen, P. A., Lee, K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., et al. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Canadian Medical Association Journal, 166, 315–323.