Homebirth: What Are the Issues?
by Sara Wickham, RM, BA (Hons)
© 1999 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 50, Summer 1999.]
There is no shortage of evidence to support the fact that homebirth is safe, satisfying and empowering for women and their families. It is also a much-neglected option for childbearing women in Western society today. This article seeks to discuss modern-day attitudes about birth and present the arguments for midwifery care and homebirth in an accessible format.
It must be stressed that different caregivers have different philosophies in relation to birth. These philosophies are generally referred to as the "midwifery" and "medical" models, although it is not accurate to say that all doctors believe in the medical model and all midwives in the midwifery model. The medical model sees childbirth as inherently dangerous and suggests that all women should undergo routine interventions to ensure safety and give birth in hospital, and the midwifery model uses a more holistic approach and assesses women on an individual basis—a process which often enables women to give birth in their own homes. Although the medical model has been the dominant model of birth in our society for a number of years, researchers in all fields are now showing the midwifery model to be more accurate in the way it sees birth.
Many women approach a "medical model" practitioner for care during their pregnancy, although this is not necessarily the best option. While obstetricians and hospitals have a part to play in the care of women with serious medical conditions or who develop a problem during pregnancy or labour, research shows that the vast majority of women would be better served by choosing a midwife for their care. Equally, this majority of women would also be well advised to consider homebirth as an option because of its many advantages over hospital care. Some of the advantages of homebirth with a midwife are cited below.
Women Experience Less Pain at Home
It is well understood that sensations of pain in labour are regulated by hormones released by the woman’s body. During labour, oxytocin—the hormone which causes contractions and helps the baby be born—works in harmony with endorphins—the body’s own pain relieving hormone. During a homebirth, the woman’s body will release these hormones according to her needs and she will usually cope well with the sensations of labour.
When a woman attempts to give birth in another environment such as a hospital, however, this process may not work as well. Even if a woman feels rationally that hospitals are "safer" places in which to give birth, her subconscious mind knows that this is not the case, and she feels insecure. This causes her body to secrete the hormone adrenaline, which causes the levels of both oxytocin and endorphins to drop. She experiences far more pain than she would in her own home, and this has several other effects on her labour which are described below.
Women Experience Lower Levels of Intervention at Home
There are two main reasons that women experience lower levels of intervention at home. The first concerns the hormones described above. In a hospital environment, women often produce the hormone adrenaline in response to subconscious or conscious fear. This inhibits the release of the hormone oxytocin, and labour may well slow down. Although this slowing of labour is a natural safety mechanism designed to let the woman know she needs to find another environment, it is interpreted by many medical professionals as "failure (of her body) to progress." Rather than suggesting that the woman talk about her fears or find a different environment, they will turn instead to drugs to "speed up" the labour. This drug (usually Pitocin or Syntocinon) can cause distress in the baby, among other effects, and often itself leads to a "cascade of intervention" which may result in an instrumental delivery or a cesarean.
The second reason is that hospitals are systems which need to run efficiently. They need to have procedures in place for workers to follow so that chaos does not ensue! Unfortunately, this often means that hospitals have policies where a certain number of interventions are carried out on all women who choose to give birth there. Often there is no evidence to support these interventions, and many of them (e.g. electronic fetal monitoring) are known to be harmful when used on a routine basis. Every intervention is useful to a small number of women when used appropriately, but when applied to all women, they often cause far more harm than good. Women's choices are not sought and it is often difficult for staff to offer individualized care, because they feel restricted by the "hospital policy."
Women Have More Autonomy at Home
Another major difference between giving birth in your own environment or in someone else’s is this: in your own home you are "in charge." You would not feel you needed to ask permission to make a drink in your own home or visit the bathroom, yet that is exactly the way many women feel in hospital. And the effects of feeling as if they need to ask permission to do everyday things can lead to women feeling they are not in control. This may then have an impact on a woman’s labour, because labour is a time when women need to feel very strong and powerful within their own bodies, not as if they were small children who needed to ask mommy to take them to pee!
Eating and drinking is another important aspect of this. In your own home, you are free to eat and drink whatever you feel like. Although women often do not feel like eating in strong labour, the choice is there. Many hospitals still refuse women food and drink in labour, even though all the research evidence shows that this restriction is harmful rather than beneficial. Consequently, women become dehydrated and have low energy levels at a time when they need lots of energy. Hospital staff may provide an IV drip to replace fluids but this is not ideal—it limits a woman’s movement and adds to the feeling that she is "sick" rather than experiencing a perfectly normal event.
Other Risks of Hospital Birth
A recent article in the journal of the Association for Improvements in Maternity Services cites a number of other risks of hospital births. These are summarised in the following list:
- Midwives or nurses may be looking after more than one woman in labour and individual women are not able to receive the support they need. This can also mean they are more likely to be "tied" to fetal monitors rather than having the midwife or nurse listen to the baby’s heartbeat intermittently.
- Hospital birth deprives the woman of contact with her family and friends. Being with other support people, particularly female relatives or friends, has been shown to have a very positive effect on labour and birth.
- Continuity of care is rare in hospitals—although you would have the same midwives throughout a homebirth, shift changes in hospitals mean you may see a large number of carers during your birth. Some women report that as soon as they have built a rapport or relationship with one carer, she goes off duty and they have to "start all over." "Knowing your midwife" has been shown to have very beneficial effects on labour.
- Levels of medical staff may also be low. It is a common fallacy that being in hospital is safer "if things go wrong." In fact, as long as you are not a huge distance from a hospital, you may well be treated more quickly if you are transported from a homebirth than if you were in hospital in the first place! The sort of emergencies that need truly immediate action are extremely rare and are almost always preceded by signs that your midwives will pick up and act upon.
- In hospital, decisions about your labour will sometimes be made by very junior medical staff. (You rarely have a choice about which staff cares for you in hospital.) These people may have little experience in birth and certainly far less than midwives who specialise in this area. They are also unlikely to trust that your body knows what it is doing!
- Hospital and medical care, as discussed above, takes place in the context of a philosophy where staff are "looking for problems" rather than ensuring that things are progressing normally. This seemingly small difference actually makes a big difference in the approach that different carers take to the woman and her labour and birth. Would you rather have a carer who trusts that your body knows what it is doing and either reassures you that all is going well or helps you if there are any problems, or a carer who is always checking to make sure that your body is "working" while at the same time doubting your ability to actually give birth? As before, not all hospital midwives or nurses take the latter attitude, but the environment of the hospital itself tends to perpetuate this philosophy.
Women Enjoy Increased Satisfaction with Homebirth
The proof of this pudding is in the eating, or the asking! Over 99 percent of women who have experienced both home and hospital birth will tell you that they would choose to have a homebirth in the future. But don’t take my word for it—ask some!
Arranging a Homebirth
If you are thinking of having your baby at home, talk to a midwife! She will be able to tell you what is available in your area and the kind of care she can offer you. She will also be able to help you make a realistic assessment of whether homebirth is right for you. In general, the only women who are truly better off in hospital are those with chronic medical problems, such as insulin-dependent diabetes, or those with a very small baby. But women need to be considered individually and their unique circumstances taken into account.
Remember that in our society there are many people who do not "trust birth" in all areas and professions, even midwifery. If you encounter opposition to your plans, then seek a second opinion. You may have to interview several caregivers before you find the one who is right for you. You may also want to seek support from other women who have made this choice.
And finally, remember that women have been having babies for millions of years—without the aid of hospitals or medical intervention. And if birth didn’t work, then we wouldn’t be here now! Women’s bodies are designed to have babies. Trust your body. Trust your baby. Trust birth.
The Safety of Homebirth: Annotated References
by Sara Wickham, RM, BA (Hons)
This section outlines a number of research papers that have sought to determine the safety of homebirth. The full reference for each is given so that readers may be able to acquire copies of the original if they wish. In order to help you decide whether or not you wish to read a paper in the original, a summary of each of the papers is included, which outlines the nature of the research study and brief details of the research, findings and conclusions.
Anderson, R. & Greener, D. (1991). A descriptive analysis of home births attended by CNMs in two nurse-midwifery services. J. Nurse-Midwifery, 36(2): 95–103.
- Analysis of outcomes of all clients who planned a homebirth in two nurse-midwifery practices in Texas, USA.
- Women who chose homebirth were more likely to be married, white and more educated when compared to the United States childbearing population in general.
- The need for analgesia, episiotomy and cesarean section was lower in this population than for hospital births.
- Complications occurred either at similar rates or were less common than in the homebirth literature or national statistics.
Campbell, R. & Macfarlane, A. (1986, July). Place of delivery; a review. Brit. J Obstetrics and Gynaecology, 93 (7): 675–83.
- These authors adjusted the mortality rate figures and selection biases to more accurately assess the evidence surrounding homebirth.
- They suggest that while there is no concrete evidence to support the relationship between a fall in the perinatal mortality rate (PMR) and homebirths, there is also no evidence to show that hospital is safer than home for all women.
- There is some evidence—although inconclusive—that maternal and neonatal morbidity may be higher in hospitals, especially consultant units.
- Perinatal mortality for women having homebirths is very low.
- Women who have had birth in home and hospital prefer homebirths.
Durand, A. M. (1992, March). The Safety of Home Birth; the Farm Study. American Journal of Public Health, 82(3): 450–53.
- Looks at outcomes of care of 1,707 women having homebirths with lay midwives in Tennessee between 1971 and 1989, and compares these with outcomes from 14,033 physician-attended hospital deliveries derived from the 1980 US National Natality/National Fetal Mortality Survey.
- Uses rates of perinatal death, low 5-minute APGAR scores, a composite index of labor complications, and use of assisted delivery.
- Under certain circumstances, home-births with lay midwives are as safe as, and need less intervention than, physician-attended hospital deliveries.
Ford, C. et al. (1991, Dec. 14). Outcome of planned home births in an inner city practice. Brit. Medical Journal, 303(6816): 1517–19.
- A retrospective study which looked at the outcome of 277 women who planned homebirths in this London practice.
- The authors used medical records to document the outcomes, including place of birth and the timing of any transfer to specialist care.
- Antenatally, the need for transfer to obstetrical services was not related to parity, but primiparous women were more likely than multiparous women to be transferred to obstetric care during labour.
- 77.6 percent of women had a normal birth at home without needing obstetric help.
- Postpartum problems requiring specialist attention were uncommon among both those mothers who gave birth at home and their babies.
[MT comment: Despite the results of this study, the author’s statement that "close co-operation between the general practitioner and both community midwives and hospital obstetricians is important in minimizing the risks of trial of labour at home" (p 1517) tells us a lot about which practitioner these researchers see as paramount, and the way they have approached this study in relation to their views on homebirth.]
Howe, K. A. (1988, Sept. 19). Home births in South-West Australia. Medical J. of Australia, 149: 296–302.
- Retrospective study, undertaken by a general practitioner, of 165 women who planned homebirth with midwifery care. Some of the women were considered "high risk" (e.g. VBAC, previous forceps).
- 16 percent of the women were transferred to hospital in labour, often for "failure to progress."
- The cesarean section rate in the study group was 1.2 percent, compared to 19 percent locally at that time.
- There was one neonatal death—a baby born with unformed lungs.
- Three cases of postpartum hemorrhage were recorded; all of these were treated by midwives and resolved without transfer to hospital.
- Concludes that homebirth is not only a safe option for women, but probably safer than seeking obstetric care in hospitals.
Olsen, O. (1997, March). Meta-analysis of the safety of home birth. Birth, 24(1): 4–13.
- Meta-analysis of six controlled studies which examines the safety of planned homebirth with hospital back up compared with planned hospital birth.
- Perinatal outcomes of 24,092 women were analyzed; measurements included Apgar scores, maternal lacerations and intervention rates.
- Perinatal mortality was not significantly different in the two groups.
- The homebirth group had higher Apgars and fewer lacerations than the hospital birth group. Fewer interventions of all types occurred in the homebirth group.
- No maternal deaths occurred in the studies.
- Homebirth is an acceptable alternative to hospital for selected women, and leads to fewer interventions.
Tew, M. (1986, July). Do obstetric intranatal interventions make birth safer? Brit. J. Obstetrics and Gynaecology, 93(7): 659–74.
- This researcher extrapolated statistical information in order to determine whether intranatal interventions make birth safer. "Risk status" was taken into account.
- In all risk groups, women giving birth in hospital have a greater chance of a stillbirth than women giving birth at home.
- One of the reasons that some studies show the PMR rate at home to be higher is because they include women who had unplanned homebirth, and often no prenatal care.
- Even when unplanned transfers to hospital are taken into account, homebirth is still safer than hospital birth.
- The fall in the PMR is not attributable to increasing hospitalization; in fact, the PMR fell least in the years when hospitalization increased most.
- Results from all sources consistently suggested that obstetric intranatal interventions make birth less safe for the vast majority of women.
Tew, M. (1990). Safer Childbirth? A critical history of maternity care. London: Chapman and Hall.
Tew, M. & Damstra-Wijmenga, S. (1991, June). Safest birth attendants; recent Dutch evidence. Midwifery, 7(2): 55–63.
- Analysis of the national perinatal mortality rate (PMR) of the 185,573 births in Holland in 1986.
- The PMR for all births is highest for doctors in hospital (18.9 perinatal deaths per 1000 births); then doctors at home (4.5); followed by midwives in hospital (2.1); with the lowest rate for midwives at home (1.0).
- The authors acknowledge that there may be differences in the "risk status" of women between care providers, which is impossible to quantify, but argues that this alone does not account for the higher rates of perinatal deaths for women who had obstetric care.
[Editor's note: Sara Wickham’s list of an additional 35 published papers on the subject of homebirth that either comprise original research in the area or reviews/discussions of the research is available in Midwifery Today's new Homebirth Pack.]
Sara Wickham, MA, BA, RM, is a direct-entry midwife in Maldon, England, and a midwifery lecturer at Anglia Polytechnic University. She is the UK country contact and a contributing editor of Midwifery Today.
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