Sunday, July 15, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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A GROWING TREND
Planned Birth at Home

Tara Scott, MD

Think you know what type of woman has a home birth? Does she smell faintly of patchouli oil, eschew childhood vaccination and avoid the doctor’s office in favor of alternative practitioners? You may be surprised to learn that a striking number of health care providers in Sonoma County are choosing to have their babies at home or in a birth center. These doctors and nurses understand odds ratios and interpret medical studies, and they are far from the “off-the-grid” stereotype that many physicians may hold about people who choose home birth.

The last 100 years have witnessed a dramatic shift in where American women deliver their babies. At the beginning of the 20th century, the great majority of them had their babies at home. By the 1980s, that number had dropped to less than 1%, where it stayed for decades.1 While the number of home births and births in a birth center in the United States remains quite low, the rate of planned births outside the hospital has doubled in the last 10 years to just over 1% of all births.1 In Sonoma County in 2012, 208 out of 5,144 births (4%) happened outside the hospital (see table).2 Of those, 89 (1.7%) occurred at a local birth center and 119 (2.3%) occurred at home—nearly twice the state average.

Even more surprisingly, it is estimated that close to 40% of all deliveries among graduates of the Santa Rosa Family Medicine Residency between 2005 and 2012 were planned home births.3 Despite little to no exposure to home birth in their training—and plenty of exposure to hospital birth—these new physicians chose to have their own babies at home at a much higher rate than the averages for Sonoma County and California. The rate is so high that a local group called “Why Not Home?” is making a film that documents numerous health care professionals who are choosing home birth.4

A woman with a low-risk pregnancy may choose home birth for a number of reasons, including the midwifery model of care, the freedom to be in control during labor, and the high likelihood of a low-intervention labor that results in vaginal delivery. Not all women, however, desire an unmedicated, low-intervention birth, nor do they have a safe or comfortable home that is within a reasonable distance from the hospital should a transfer be necessary. Many women don’t have a partner or family member who can or wants to play the important support role that is crucial for making home birth successful, and some of these women can’t afford a doula who fills this role.

Many women who have babies at home are cared for by midwives. While midwives are a heterogeneous group with varying levels of certification and experience, they share a model of care that trusts in the physiologic process of labor, highly values the relationship between the midwife and the woman, and delivers intimate, watchful care throughout the pregnancy, labor and puerperium. Much of the care is delivered in the home before, during and after the delivery.

A 2009 Cochrane review including more than 12,000 women who were considered to be low risk compared the intervention rates, complications and mortality rates of midwives working in the hospital to those of physicians.5 Women who had midwife-led models of care were less likely to be hospitalized before birth or to have an epidural, episiotomy or instrumented delivery. Conversely, they were more likely to experience spontaneous vaginal birth, to feel in control during childbirth, to have a known midwife in attendance at birth, and to initiate breastfeeding. There were no statistically significant differences in maternal or fetal/neonatal deaths between the two groups. While this review was focused on midwives practicing in the hospital setting, it demonstrates the safety and efficacy of the midwifery model of care.

Women who choose midwifery care for birth outside the hospital may believe that this model can safely reduce intervention without compromising their safety or that of their child. As Dr. Brooke Vezino (Santa Rosa residency class of 2009) writes: “My experience as a family medicine maternal health provider only solidified my belief in birth as a natural process, my own body’s ability to manifest that process, and my connection to generations of women before me. . . .  I felt most safe outside of the hospital but under the care of a trained midwife who had been practicing 17 years. . . .  During my pregnancy with Liam, I saw how much the midwife did to truly shepherd me through my own personal experience, and that was profoundly important.”

Many women who choose home birth also want the freedom to be in control of what they do during labor. In choosing home birth for her second child, Dr. Ann Figurski (residency class of 2010) recalls, “I wanted the option to get in a tub and soak during labor, which was not an option at the hospital. I had a long labor with my first, and was hoping that my second would be shorter—and if it wasn’t, that I would be more comfortable at home. . . .  I wanted to sleep in my own bed after giving birth, and eat the healthy, delicious food already at my house.”

Women who give birth at home may also want to involve their older children in the process and may feel more able to assume comfortable positions, wear whatever they like, and make whatever sounds they feel may help them cope with the intensity of labor. As Dr. Connie Earl (residency class of 2010) observes: “At home . . . I was able to be completely uninhibited and be loud while I marched up and down the stairs, two at a time, to get the baby to turn.”

While it is unlikely that we will ever have randomized, controlled trials comparing the safety of home and hospital birth, there is data from observational studies and meta-analyses that women and their providers can turn to for guidance. It is important to recognize that, on the whole, appropriately selected women who choose home birth are, by definition, lower risk than women who deliver in the hospital, which can make interpreting observational data challenging. Nonetheless, the data can be used to measure the risks and benefits of planned birth at home.

Women who plan to deliver at home, regardless of where they ultimately deliver, have a markedly lower risk of giving birth by cesarean section—in some studies as much as 50% lower than do women having planned hospital births.6–8 At least some, though by no means all, of this decreased risk of cesarean section can be attributed to the lower risk profile of women who plan home birth.

The literature also suggests that women who plan home birth are five times less likely to receive an epidural, undergo episiotomy or have an operative vaginal delivery. Woman who plan to deliver at home have a significantly decreased risk of infection, serious perineal lacerations and cord prolapse when compared to planned hospital birth. Also, the risk of both maternal and perinatal mortality in home birth is equal to that of planned hospital birth.7

On the downside, a large, multi-country meta-analysis from 2010 examining the safety of planned home versus hospital delivery found a nearly threefold increase in the risk of neonatal death (death in the first month of life) among normal babies intentionally born at home. To put this in absolute terms, the researchers reported that neonates die at a rate of 4/10,000 after planned hospital birth compared with a rate of 15/10,000 among babies born after planned home birth.6

This data prompted the American College of Gynecologists and Obstetricians to reaffirm their 2011 statement stressing the risks of home birth.9 However, when the data were analyzed with only trials in which certified midwives attended the births at home, there was no significant difference in neonatal mortality between the home and hospital birth groups.6 While the quality of the 2010 meta-analysis is debatable, and the applicability of its findings to home birth in the United States unclear, even the hint of increased death in the first month of life is a devastating outcome by anyone’s measure.

Many would argue that any increased risk of neonatal death, however small, is too great. But it is critical to keep the low absolute level of risk in context when weighing all the risks and benefits. If the outcomes of a healthy baby and a low-intervention, unmedicated birth at home are what a woman desires, the studies suggest overwhelmingly that a planned home birth has a high likelihood of success.6,7 Moreover, when a certified midwife attends the birth, the safety may be equal to that of hospital birth.6 As Dr. Earl notes, “We chose home birth because it was what we were most comfortable with. I worked as a doula before medical school so I attended hospital births, birth center births and homebirths. By the time I was in residency, I had seen the complications hospital births can bring to low-risk births, and I felt that as a low-risk pregnancy, we were likely to have a less complicated experience at home.”

The idea of home birth can be difficult for some physicians to grapple with. On the whole, we get little exposure to home birth, or the exposure we do receive involves only the most complicated cases. But if we look at another obstetrical intervention doctors are more familiar with, “trial of labor after cesarean section” or TOLAC, we find that they commonly engage in the type of risk/benefit analysis described above when considering maternal and neonatal outcomes from TOLAC.

Pregnant women who have had a previous cesarean delivery may be offered a “trial of labor” if their providers and local hospital are able to offer the standard of care. Despite the higher risks of TOLAC to both mother and baby (including maternal infection, uterine rupture and neonatal injury or death), successful TOLAC reduces the overall risk of complications when compared to planned repeat cesarean section.10

Like women who choose home birth, women who choose a trial of labor after cesarean accept these increased risks because they highly value the outcome of a vaginal delivery and a healthy baby and are counseled that, if accomplished, a successful vaginal birth is likely to result in fewer complications than a planned cesarean section.10 Many physicians agree that offering a TOLAC to appropriately selected women is a rational choice, given the low risk of complications and the high likelihood of success.

In a 2013 position statement, the American College of Gynecologists and Obstetricians reaffirmed their previous position from 2011 that “hospitals and birth centers are the safest setting for birth,” but they “respect the right of a woman to make a medically informed decision about delivery.”9 Furthermore, “women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence.”

A 2013 position statement by the American Academy of Pediatrics echoes these opinions.11 The American Academy of Family Practice has no official position statement on home birth as yet, but the American College of Nurse Midwives supports the safety of home birth, stating: “Certified Nurse Midwives and Certified Midwives are qualified to provide antepartum, intrapartum, postpartum and newborn care in the home.”12

Several potential disadvantages of home birth should be mentioned. Insurance coverage for home birth is widely variable, and the cost can be prohibitive for uninsured women or women whose insurance does not cover home birth. When transfer to the hospital occurs (about 11% of the time, according to one study) some women have a negative experience, even when transfer results in a healthy baby and mom.7 Women who transfer from home during labor may feel judged by the nurses, house-staff or physicians due to personal beliefs or lack of familiarity with the home birth process.

In addition, since the style of care is so different, the partnerships that are formed between the midwife, the laboring woman and her partner can be seriously disrupted once the birthing process moves to the hospital. As Dr. Earl reflects, “The thing that struck me the most when we went from home to hospital was how pushed out of the way Russ [my husband] was. We had been a team at home . . . . When we arrived at the hospital, he was handed papers and then given a place in the corner to rest. There were people physically between us while they put in my IV and prepped for the epidural.”

Given all the risks and disadvantages, why do some health care providers choose home birth? Perhaps our familiarity with the difficult task of separating true absolute risk from the emotional aspects of any risk makes us able to put the pros and cons of home birth in perspective.

In the interest of full disclosure, I am also one of those physicians who chose to have a home birth. With the support of my partner, Travers, our experience of pregnancy, labor and the birth of our son, under the experienced and watchful care of our midwife, was nothing short of transformative. Our preparation, our teamwork, the intensity of the labor process, our joy at the birth and then our comfort being in our home when it was all over remain highlights of our lives. We both gained confidence and a sense of self-efficacy. I can’t help but wonder what is lost by a system that creates barriers to low-risk women and their partners or family who want to experience labor and delivery in this way.

For Dr. Vezino, her mother’s positive experience with home birth influenced her own perceptions of labor and childbirth. “Since I had been present at my brother’s home birth as a 4-year-old, and since I was told the story of an empowering and safe labor, I was already predisposed to be open to home birth.” I think as physicians, it’s worth considering how these positive narratives of birth passed down from mother to child might shape our future generations’ approach to childbirth.

As physicians who may serve patients who have had home birth, or are planning for it, we should be aware of our personal biases, familiarize ourselves with the data and its limitations, and engage in a balanced discussion with our patients. Whenever possible, doctors and other providers should make their best effort to create a bridge: gaps can occur when patients seek care at the fringes of the medical establishment. We have the power to fill in those gaps. Our goal should be to give women who choose to have their babies at home the same well-integrated, patient-centered care we strive to provide for all our patients. ::

Dr. Scott, a family physician, practices at Vista Family Health Center and is an associate program director at the Santa Rosa Family Medicine Residency.

Email: ScottT3@sutterhealth.org

References
1. MacDorman MF, et al, “Trends in out-of-hospital births in the United States, 1990–2012,” National Center for Health Statistics Data Brief, No. 144 (2014).
2. California Department of Public Health, “Births by birth hospital, Sonoma County residents 2000-2013,” Birth Statistical Master File (2014).
3. Vezino B, Mercado J, “Estimated home/birth center rate for Santa Rosa Family Medicine Residency graduates by class, 2005-2012,” personal correspondence (2014).
4. www.whynothome.com
5. Hatem M, et al, “Midwife-led versus other models of care for childbearing women,” Cochrane Database Syst Rev (2008:4).
6. Wax JR, et al, “Maternal and newborn outcomes in planned home birth vs planned hospital births: a meta-analysis,” Am J Obstet Gynecol, 203:243.e241-248 (2010).
7. Cheyney M, et al, “Outcomes of care for 16,924 planned home births in the United States,” J Midwifery Womens Health, 59:17-27 (2014).
8. Martin J, et al, “Births: Final data for 2013,” National Vital Statistics Reports, 64:1 (2015).
9. ACOG, “Committee opinion: planned home birth,” Obstet Gynecol, 117:425–428 (2011).
10. Landon M, et al, “Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery,” NEJM, 351:2581-89 (2004).
11. AAP, “Planned home birth,” Pediatrics, 131:1016-20 (2013).
12. American College of Nurse Midwives, “Position statement: home birth,” www.midwife.org (2011).

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<< UNINTENDED CONSEQUENCES?
Cesarean Section and Long-Term Child Health
| BIRTH CENTERS
In the Space Between Home Birth and Hospital >>
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