Home Birth Research
Safety of Home Birth
James Hughes, Ph.D.
all comments, additions or amendations to J. Hughes at email@example.com
or at his website at Changesurfer.com
birth can be a safe option for 90% of mothers, with appropriate prenatal care
and attendant personnel. It makes both financial sense and medical sense for state
laws to permit home birth attended by midwives, for insurers to reimburse for
home delivery, and for hospitals and obstetricians to provide medical back-up.
Obstetricians need to take their blinkers off and learn to cooperate with folks
who want to deliver in their own homes.
RE. Anderson DA.
[Dept. of Economics, Centre College, Danville, KY 40422,
The cost-effectiveness of home birth.
Journal of Nurse-Midwifery.
44(1):30-5, 1999 Jan-Feb.
As health care costs increase and a growing number
of women are without insurance, the one health service that every family needs
deserves further attention. Even for the 40% of births covered by Medicaid, safe
birthing alternatives that permit a reduction in the $150 billion Medicaid burden
would allow the United States to devote more resources to other urgent priorities.
Informed birthing decisions cannot be made without information on costs, success
rates, and any necessary tradeoffs between the two. This article provides the
relevant information for hospital, home, and birth center births. The average
uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births
initiated in the home offer a lower combined rate of intrapartum and neonatal
mortality and a lower incidence of cesarean delivery.
G, Wraight A, Crowley P
[Obstetrics at Singleton Hospital, Swansea, UK]
Birth at home.
Pract Midwife 1999 Jul-Aug;2(7):35-9
National Birthday Trust performed a confidential survey of home births in the
United Kingdom. A good response rate was obtained from midwives, who recruited
two groups of women prospectively; those planned and accepted as suitable for
a home delivery at 37 weeks and a matched group of similar women who were booked
for hospital by 37 weeks. Some 16% of such women were transferred to hospital
in late pregnancy (4%) or in labour (12%). This figure rose to 40% among the primiparous
women in the survey. The survey report presents an analysis of 4,500 home births
and 3,300 hospital controls. Outcomes could therefore be presented by the woman's
intent or by what actually happened. In essence it seems that a woman who is appropriately
selected and screened for a home birth is putting herself and her baby at no greater
risk than a mother of a similar low-risk profile who is hospital booked and delivered.
Home births will probably increase to 4-5% of all maternities in UK during the
next decade and this needs preparatory planning.
Murphy P, Feinland JB
Perineal outcomes in a home birth setting.
[Department of Obstetrics and Gynecology, Columbia University College of Physicians
and Surgeons, New York, USA.]
Birth 1998 Dec;25(4):226-34
Perineal lacerations are a source of significant discomfort to many women. This
descriptive study examined perineal outcomes in a home birth population, and provides
a preliminary description of factors associated with perineal laceration and episiotomy.
METHODS: Data were drawn from a prospective cohort study of 1404 intended home
births in nurse-midwifery practices. Analyses focused on a subgroup of 1068 women
in 28 midwifery practices who delivered at home with a midwife in attendance.
Perineal trauma included both episiotomy and lacerations. Minor abrasions and
superficial lacerations that did not require suturing were included with the intact
perineum group. Associations between perineal trauma and study variables were
examined in the pooled dataset and for multiparous and nulliparous women separately.
RESULTS: In this sample 69.6 percent of the women had an intact perineum, 15 (1.4%)
had an episiotomy, 28.9 percent had first- or second-degree lacerations, and 7
women (0.7%) had third- or fourth-degree lacerations. Logistic regression analyses
showed that in multiparas, low socioeconomic status and higher parity were associated
with intact perineum, whereas older age (>/= 40 yr), previous episiotomy, weight
gain of over 40 pounds, prolonged second stage, and the use of oils or lubricants
were associated with perineal trauma. Among nulliparas, low socioeconomic status,
kneeling or hands-and-knees position at delivery, and manual support of the perineum
at delivery were associated with intact perineum, whereas perineal massage during
delivery was associated with perineal trauma. CONCLUSIONS: The results of this
study suggest that it is possible for midwives to achieve a high rate of intact
perineums and a low rate of episiotomy in a select setting and with a select population.
Wiegers TA. van
der Zee J. Keirse MJ.
[The Netherlands Institute of Primary Health Care, Utrecht,
The Netherlands. ]
Maternity care in The Netherlands: the changing home
Birth. 25(3):190-7, 1998 Sep.
In 1965 two-thirds of all
births in The Netherlands occurred at home. In the next 25 years, that situation
became reversed with more than two-thirds of births occurring in hospital and
fewer than one-third at home. Several factors have influenced that change, including
the introduction of short-stay hospital birth, hospital facilities for independent
midwives, increased referral rates from primary to secondary care, changes in
the share of the different professionals involved in maternity care, medical technology,
and demographic changes. After a decline up to 1978 and a period of relative stability
between 1978 and 1988, the home birth rate started to decline further, to the
extent that it might destabilize the Dutch maternity care system and the role
of midwives in it. The Dutch maternity care system depends heavily on primary
caregivers, midwives and general practitioners who are responsible for the care
of women with low-risk pregnancies, and on obstetricians who provide care for
high-risk pregnancies. Its preservation requires a high level of cooperation among
the different caregivers, and a functional selection system to ensure that all
women receive the type of care that is best suited to their needs. Preserving
the home birth option in the Dutch maternity care system necessitates the maintenance
of high training and postgraduate standards for midwives, the continued provision
of maternity home care assistants, and giving women with uncomplicated pregnancies
enough confidence in themselves and the system to feel safe in choosing a home
Hafner-Eaton C. Pearce LK.
Oregon State University
Birth choices, the
law, and medicine: balancing individual freedoms and protection of the public's
health. Journal of Health Politics, Policy & Law. 19(4):813-35, 1994 Winter.
To many Americans, the idea of home birth, the use of a "direct-entry midwife,"
or both seem archaic. Although much of the professional medical community disapproves
of either, state laws regarding birth choices vary dramatically and are not necessarily
based on empirical findings of childbirth outcomes. Public health practitioners,
policymakers, and consumers view childbirth from the perspectives of safety, cost,
freedom of choice, quality of the care experience, and legality, yet the professional,
policy, and lay literatures have not offered an unemotional, balanced presentation
of evidence. Reviewing the full spectrum of literature from the United States
and abroad, we present a Constitutional medical-legal analysis of whether home
birth with direct-entry midwives is in fact a safe alternative to physician-attended
hospital births, and whether there is a legal basis for allowing alternative health
policy choices is such an important yet personal family matter as childbirth.
The literature shows that low- to moderate-risk home births attended by direct-entry
midwives are at least as safe as hospital births attended by either physicians
or midwives. The policy ramifications include important changes in state regulation
of medical and alternative health personnel, the allowance of the home as a medically
acceptable and legal birth setting, and reimbursement of this lower-cost option
through private and public health insurers.
PA. Fullerton J.
[Department of Obstetrics and Gynecology, Columbia University
College of Physicians and Surgeons, New York, New York 10032, USA. firstname.lastname@example.org
Outcomes of intended home births in nurse-midwifery practice: a prospective
Obstetrics & Gynecology. 92(3):461-70, 1998 Sep.
OBJECTIVE: To describe the outcomes of intended home birth in the practices of
certified nurse-midwives. METHODS: Twenty-nine US nurse-midwifery practices were
recruited for the study in 1994. Women presenting for intended home birth in these
practices were enrolled in the study from late 1994 to late 1995. Outcomes for
all enrolled women were ascertained. Validity and reliability of submitted data
were established. RESULTS: Of 1404 enrolled women intending home births, 6% miscarried,
terminated the pregnancy or changed plans. Another 7.4% became ineligible for
home birth prior to the onset of labor at term due to the development of perinatal
problems and were referred for planned hospital birth. Of those women beginning
labor with the intention of delivering at home, 102 (8.3%) were transferred to
the hospital during labor. Ten mothers (0.8%) were transferred to the hospital
after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal
fetal and neonatal mortality for women beginning labor with the intention of delivering
at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal
and neonatal mortality was 1.8 per 1000. CONCLUSION: Home birth can be accomplished
with good outcomes under the care of qualified practitioners and within a system
that facilitates transfer to hospital care when necessary. Intrapartal mortality
during intended home birth is concentrated in postdates pregnancies with evidence
of meconium passage.
H. Keirse MJ.
Lancaster PA. [PO Box 569, Blackwood SA 5051, Australia. email@example.com
Perinatal death associated with planned home birth in Australia: population
BMJ. 317(7155):384-8, 1998 Aug 8.
OBJECTIVE: To assess
the risk of perinatal death in planned home births in Australia. DESIGN: Comparison
of data on planned home births during 1985-90, notified to Homebirth Australia,
with national data on perinatal deaths and outcomes of home births internationally.
RESULTS: 50 perinatal deaths occurred in 7002 planned home births in Australia
during 1985-90: 7.1 per 1000 (95% confidence interval 5.2 to 9.1) according to
Australian definitions and 6.4 per 1000 (4.6 to 8.3) according to World Health
Organisation definitions. The perinatal death rate in infants weighing more than
2500 g was higher than the national average (5.7 versus 3.6 per 1000: relative
risk 1.6; 1.1 to 2.4) as were intrapartum deaths not due to malformations or immaturity
(2.7 versus 0.9 per 1000: 3.0; 1. 9 to 4.8). More than half (52%) of the deaths
were associated with intrapartum asphyxia. CONCLUSIONS: Australian home births
carried a high death rate compared with both all Australian births and home births
elsewhere. The two largest contributors to the excess mortality were underestimation
of the risks associated with post-term birth, twin pregnancy and breech presentation,
and a lack of response to fetal distress.
Janssen PA. Holt VL. Myers SJ
Licensed midwife-attended, out-of-hospital
births in Washington state: are they safe?
Birth. 21(3):141-8, 1994 Sep.
The safety of out-of-hospital births attended by midwives who are licensed according
to international standards has not been established in the United States. To address
this issue, outcomes of births attended out of hospital by licensed midwives in
Washington state were compared with those attended by physicians and certified
nurse-midwives in hospital and certified nurse-midwives out of hospital between
1981 and 1990. Outcomes measured included low birthweight, low five-minute Apgar
scores, and neonatal and postneonatal mortality. Associations between attendant
and outcomes were measured using odds ratios to estimate relative risks. Multivariate
analysis using logistic regression controlled for confounding variables. Overall,
births attended by licensed midwives out of hospital had a significantly lower
risk for low birthweight than those attended in hospital by certified nurse-midwives,
but no significant differences were found between licensed midwives and any of
the comparison groups on any other outcomes measured. When the analysis was limited
to low-risk women, certified nurse-midwives were no more likely to deliver low-birthweight
infants than were licensed midwives, but births attended by physicians had a higher
risk of low birthweight. The results of this study indicate that in Washington
state the practice of licensed nonnurse-midwives, whose training meets standards
set by international professional organizations, may be as safe as that of physicians
in hospital and certified nurse-midwives in and out of hospital.
Afdeling for Social Medicin, Kobenhavns Universitet
and scientific reasoning]. [Norwegian] Source Tidsskrift for Den Norske Laegeforening.
114(30):3655-7, 1994 Dec 10.
Doctors commonly assume that it is safer for
all women to give birth in hospital rather than at home. Nevertheless, all statistical
comparisons relevant to Nordic women today show that for healthy pregnant women
it is at least as safe to give birth at home--and perhaps even safer. Furthermore,
many randomised clinical trials consistently show that several of the elements
which characterize home births make the births proceed much easier. The question
is raised, in what ways it is possible to convince obstetricians that they should
base their judgements and advice regarding place of birth on empirical evidence
rather than on "well established" but pre-scientific dog-mas.
Read AW. Bower C. Stanley FJ. Moore DJ
A matched cohort study of planned
home and hospital births in Western Australia 1981-1987
OBJECTIVE: to evaluate practice comparing planned home birth with
planned hospital birth DESIGN: a retrospective analysis of a cohort who had planned
to have a home birth compared with a matched hospital birth group SETTING: Western
Australia (WA) PARTICIPANTS: all women (N = 976) who 'booked' to have a home birth
1981-1987 and 2928 matched women who had a planned hospital birth (singleton births
only). MEASUREMENTS AND FINDINGS: women in the home birth group had a longer labour,
were less likely to have had labour induced or to have had any sort of operative
delivery. They were less likely overall to have had complications of labour, but
more likely to have had a postpartum haemorrhage and more likely to have had a
retained placenta. Babies in the home birth group were heavier and more likely
to be post-term. They were less likely to have had an Apgar score below 8 at 5
minutes, to have taken more than 1 minute to establish respiration or to have
received resuscitation. The crude odds ratio for planned home births for perinatal
mortality was 1.25 (95% CI 0.44-3.55). Postneonatal mortality was more common
in the hospital group. Planned home births were generally associated with less
intervention than hospital births and with less maternal and neonatal morbidity,
with the exception of third stage complications. Although not significant, the
increase in perinatal mortality has been observed in other Australian studies
of home births and requires continuing evaluation. KEY CONCLUSIONS: Planned home
births in WA appear to be associated with less overall maternal and neonatal morbidity
and less intervention than hospital births. IMPLICATIONS FOR PRACTICE: whether
these observed differences in intervention and morbidity have any relationship
to the small, non-significant increase in perinatal mortality could not be determined
in this study. Continuing evaluation of home birth practice and outcome is essential.
S. Alzugaray M. Dowd J. Kalman J.
Santa Cruz Women's Health Center, California
A feminist perspective on the study of home birth. Application of a midwifery
Journal of Nurse-Midwifery. 39(3):142-9, 1994 May-Jun.
Studies of home birth have compared it with hospital birth, with a focus on perinatal
outcomes. Although such studies have established the safety of midwife-attended
home births, this narrow view does not include all of the concepts represented
in a proposed midwifery care framework derived from the philosophy of the American
College of Nurse-Midwives. In this essay, the authors recommend the employment
of qualitative research with a feminist perspective as a method to elucidate other
concepts in the midwifery care framework, and suggest that future home birth research
should explore the recognition and validation of the woman and her experiences,
appropriate use of technology, and the influences of the birth environment. [References:
[Department of Anthropology, University of Texas at Austin
The technocratic body: American childbirth as cultural expression.
[Review] Social Science & Medicine. 38(8): 1125-40, 1994 Apr.
dominant mythology of a culture is often displayed in the rituals with which it
surrounds birth. In contemporary Western society, that mythology--the mythology
of the technocracy--is enacted through obstetrical procedures, the rituals of
hospital birth. This article explores the links between our culture's mythological
technocratic model of birth and the body images, individual belief and value systems,
and birth choices of forty middle-class women--32 professional women who accept
the technocratic paradigm, and eight homebirthers who reject it. The conceptual
separation of mother and child is fundamental to technocratic notions of parenthood,
and constitutes a logical corollary of the Cartesian mind-body separation that
has been fundamental to the development of both industrial society and post-industrial
technocracy. The professionals' body images and lifestyles express these principles
of separation, while the holistic ideology of the homebirthers stresses mind-body
and parent-child integration. The conclusion considers the ideological hegemony
of the technocratic paradigm as potential future-shaper. [References: 45]
Patient satisfaction with home-birth care in The Netherlands.
Journal of Advanced Nursing 20(4), 1994: 344-50.
One of the necessary
elements in an obstetric system of home confinements is well-organized postnatal
home care. In The Netherlands home care assistants assist midwives during home
delivery, they care for the new mother as well as the newborn baby, instruct the
family on infant health care and carry out household duties. The growing demand
for postnatal home care is difficult to meet; this has resulted in a short supply
of the most popular day care programme and a level of provision which does not
result in adequate services. This study acknowledges the patient perspective of
maternity home care in order to contribute to its organization. The majority (79%)
of service centres were willing to participate. A total of 1812 (81%) women who
recently gave birth to a child responded to a postal questionnaire addressing
the quality of care according to five dimensions: availability, continuity, interpersonal
relationships, outcome and assistant's expertise. Almost one-third of the new
mothers rated the availability as inadequate while the assistant's expertise was
rated positively. Postnatal maternity home care is personalized, small-scale,
and recognizes childbirth as a life event. Furthermore, it is relatively inexpensive
and contributes to the satisfaction of recipients.
[Health Policy Institute, Boston University, MA 02215]
care and out-of-hospital birth settings: how do they reduce unnecessary cesarean
Social Science & Medicine. 37(10):1233-50, 1993 Nov.
In studies using matched or adjusted cohorts, U.S. women beginning labor with
midwives and/or in out-of-hospital settings have attained cesarean section rates
that are considerably lower than similar women using prevailing forms of care--physicians
in hospitals. This cesarean reduction involved no compromise in mortality and
morbidity outcome measures. Moreover, groups of women at elevated risk for adverse
perinatal outcomes have attained excellent outcomes and cesarean rates well below
the general population rate with these care arrangements. How do midwives and
out-of-hospital birth settings so effectively help women to avoid unnecessary
cesareans? This paper explores this question by presenting data from interviews
with midwives who work in home settings. The midwives' understanding of and approaches
to major medical indications for cesarean birth contrast strikingly with prevailing
medical knowledge and practice. From the midwives' perspective, many women receive
cesareans due to pseudo-problems, to problems that might easily be prevented,
or to problems that might be addressed through less drastic measures. Policy reports
addressing the problem of unnecessary cesarean births in the U.S. have failed
to highlight the substantial reduction in such births that may be expected to
accompany greatly expanded use of midwives and out-of-hospital birth settings.
The present study--together with cohort studies documenting such a reduction,
studies showing other benefits of such forms of care, and the increasing reluctance
of physicians to provide obstetrical services--suggests that childbearing families
would realize many benefits from greatly expanded use of midwives and out-of-hospital
Kenny P. King MT. Cameron S. Shiell A
Satisfaction with postnatal care--the
choice of home or hospital
Midwifery. 9(3):146-53, 1993 Sep.
paper reports the findings of a study of client satisfaction with postnatal midwifery
care. Women could choose one of two forms of care; either domiciliary care following
early discharge, or hospital care until discharge. Consumers' perceptions of their
postnatal care were examined at the end of the period of care. Women assessed
the midwives' interest and caring, education and information provided, their own
progress with feeding and baby care, and their own physical and emotional health.
They were also asked about their expectations of and gains from postnatal care.
The findings indicated that women choosing domiciliary care and women choosing
hospital care had different expectations of their postnatal care, but were largely
satisfied with the quality of the care they chose. The women who chose domiciliary
care rated their postnatal care more highly than the women who stayed in hospital.
The findings reinforce the importance of providing women with choices for the
maternity care which best suits their needs.
[Merrimack College, North Andover, Massachusetts]
babies are born and who attends their births: findings from the revised 1989 United
States Standard Certificate of Live Birth
Obstetrics & Gynecology.
81(6):997-1004, 1993 Jun.
OBJECTIVE: To examine the results of changes in
the birth certificate with regard to characteristics of the mothers and the birth
weights of their infants. The United States Standard Certificate of Live Birth
was revised in 1989 to include specific designations for the place of births out
of hospital and the presence of a nurse-midwife or other midwife at the birth.
METHODS: All results are based on data from the Natality, Marriage and Divorce
Statistics Branch of the National Center for Health Statistics, Centers for Disease
Control. In all cases reported here, the data represent at least 91% of all United
States births in 1989. RESULTS: Different patterns of birth attendance emerged
in different settings. In residential births, other midwives and "others" attended
66% of all births, whereas in freestanding birth centers, physicians and certified
nurse-midwives attended 75.1% of all births. The characteristics of the mothers
differed substantially according to who attended their births in these settings.
Substantial interstate variations in place and attendant were also documented.
CONCLUSION: The positive outcomes achieved in certain settings indicate a need
for further research into the factors that influence birth outcomes.
J. Dobbie G. Owen-Johnstone L. Jagger C. Hopkins M. Kennedy J.
of Obstetrics & Gynaecology, Leicester Royal Infirmary, UK
home delivery in hospital: a randomised controlled trial
of Obstetrics & Gynaecology. 100(4):316-23, 1993 Apr.
OBJECTIVES: To compare
the outcome of two methods of maternity care during the antenatal period and at
delivery. One was to be midwife-led for both antenatal care and delivery, the
latter taking place in rooms similar to those in one's own home to simulate home
confinement. The other would be consultant-led with the mothers labouring in the
delivery suite rooms with resuscitation equipment for both mother and baby in
evidence, monitors present and a delivery bed on which both anaesthetic and obstetric
procedures could be easily and safely carried out. DESIGN: Randomised controlled
trial. SETTING: Leicester Royal Infirmary Maternity Hospital. SUBJECTS: Of 3510
women who were randomised, 2304 were assigned to the midwife-led scheme and 1206
were assigned to the consultant-led scheme. MAIN OUTCOME MEASURES: Complications
in the antenatal, intrapartum and postpartum periods were compared as was maternal
morbidity and fetal mortality and morbidity. Satisfaction of the women with care
over different periods of the pregnancy and birth were assessed. RESULTS: There
were few significant differences in antepartum, intrapartum and postpartum events
between the two groups. There was no difference in the percentage of mothers and
babies discharged home alive and well. Generally higher levels of satisfaction
with care antenatally and during labour and delivery were shown in those women
allocated to midwife care.
[School of Behavioural Sciences, Macquarie University, Sydney,
Experiences of Australian mothers who gave birth either
at home, at a birth centre, or in hospital labour wards
& Medicine. 36(4):475-83, 1993 Feb.
In order to compare their antenatal
education levels, reasons for choosing the birthplace, experiences during labor
and childbirth, analgesia, satisfaction with birth attendants and others present,
and related attitudes 395 Sydney-area mothers were recruited within one year of
giving birth. Five sources were used to obtain mail-questionnaire responses from
239 who gave birth in a hospital labor ward, 35 at a birth centre, and 121 who
chose to give birth at home. Homebirth mothers were older, more educated, more
feminist, more willing to accept responsibility for maintaining their own health,
better read on childbirth, more likely to be multiparous, and gave higher rating
of their midwives than labour-ward mothers, with birth-centre mothers generally
scoring between the other two groups. As well, homebirth and birth-centre mothers
were more likely to feel the birthplace affected the bonding process and were
less likely to regard birth as a medical condition than labour-ward mothers. In
regression analysis birth venue (among other variables) significantly predicted
satisfaction with doctor, if present during labour and delivery, and five variables
correlated with birth venue significantly predicted satisfaction with midwife,
husband/partner, and other support person. Findings are discussed in the light
of the current struggle between medical and 'natural' models of childbirth.
[Department of Obstetrics and Gynaecology, University Hospital Nijmegen,
Home deliveries in The Netherlands--perinatal mortality
International Journal of Gynaecology & Obstetrics. 38(3):161-9,
The obstetrical organizational system in the Netherlands is based
on the selection for risk factors. We conclude that: (i) The reporting of perinatal
death is not complete. (ii) Perinatal mortality can be reduced. (iii) More iatrogenic
interventions are present in low-risk deliveries in hospitals. (iv) Neurological
behavior of low-risk babies born at home is equal to those born at the hospital,
despite the worse maternal profile of the latter and the level of acidemia at
birth in the first. Good data especially in referred cases are necessary before
adopting a similar system.
van Steensel-Moll HA. van Duijn CM. Valkenburg HA. van Zanen GE.
of Epidemiology and Biostatistics, Erasmus University Medical School, Rotterdam,
Predominance of hospital deliveries among children with
acute lymphocytic leukemia: speculations about neonatal exposure to fluorescent
Cancer Causes & Control. 3(4):389-90, 1992 Jul.
[Department of Health, Commonwealth of the Northern Marianas Islands,
The safety of home birth: the farm study
of Public Health. 82(3):450-3, 1992 Mar.
Pregnancy outcomes of 1707 women,
who enrolled for care between 1971 and 1989 with a home birth service run by lay
midwives in rural Tennessee, were compared with outcomes from 14,033 physician-attended
hospital deliveries derived from the 1980 US National Natality/National Fetal
Mortality Survey. Based on rates of perinatal death, of low 5-minute Apgar scores,
of a composite index of labor complications, and of use of assisted delivery,
the results suggest that, under certain circumstances, home births attended by
lay midwives can be accomplished as safely as, and with less intervention than,
physician-attended hospital deliveries.
Ford C. Iliffe S. Franklin O.
[Department of Primary Health Care, Whittington
Outcome of planned home births in an inner city practice
BMJ. 303(6816):1517-9, 1991 Dec 14.
OBJECTIVE--To assess the outcome of
pregnancy for women booking for home births in an inner London practice between
1977 and 1989. DESIGN--Retrospective review of practice obstetric records. SETTING--A
general practice in London. SUBJECTS--285 women registered with the practice or
referred by neighbouring general practitioners or local community midwives. MAIN
OUTCOME MEASURES--Place of birth and number of cases transferred to specialist
care before, during, and after labour. RESULTS--Of 285 women who booked for home
births, eight left the practice area before the onset of labour, giving a study
population of 277 women. Six had spontaneous abortions, 26 were transferred to
specialist care during pregnancy, another 26 were transferred during labour, and
four were transferred in the postpartum period. 215 women (77.6%, 95% confidence
interval 72.7 to 82.5) had normal births at home without needing specialist help.
Transfer to specialist care during pregnancy was not significantly related to
parity, but nulliparous women were significantly more likely to require transfer
during labour (p = 0.00002). Postnatal complications requiring specialist attention
were uncommon among mothers delivered at home (four cases) and rare among their
babies (three cases). CONCLUSIONS--Birth at home is practical and safe for a self
selected population of multiparous women, but nulliparous women are more likely
to require transfer to hospital during labour because of delay in labour. Close
cooperation between the general practitioner and both community midwives and hospital
obstetricians is important in minimising the risks of trial of labour at home.
S. Kearns RA.
[Department of Anthropology, University of Auckland, New Zealand]
Birth places: a geographical perspective on planned home birth in New Zealand
Social Science & Medicine. 33(7):825-34, 1991.
In New Zealand until
the 1920s, most births occurred at home or in small maternity hospitals under
the care of a midwife. Births subsequently came under the control of the medical
profession and the prevalent medical ideology continues to support hospitalised
birth in the interests of safety for mother and child. Despite resistance from
the medical profession, recent (1990) legislation has reinstated the autonomy
of midwives and this has come at a time when the demand for home births is increasing.
This paper locates these changes within the geographical context of home as a
primary place within human experience. It is argued that the medical profession
has been an agent of an essentially patriarchal society in engendering particular
experiences of time and place for women in labour. Narrative data indicate that
the choice of home as a birth place is related to three dimensions of experience
unavailable in a hospital context: control, continuity and the familiarity of
Albers LL. Katz VL.
[University of Medicine and Dentistry of New Jersey]
Birth setting for low-risk pregnancies. An analysis of the current literature
of Nurse-Midwifery. 36(4):215-20, 1991 Jul-Aug.
This article reviews the literature
on birth settings for women with low-risk pregnancies. Methodological issues of
the existing research include nonrandom designs, small samples, selection differences,
data limitation, and confounding bias. Studies for four birth sites are summarized:
the home, freestanding birth centers, in-hospital birthing centers or birthing
rooms, and traditional hospital settings. Despite the methodological limitations,
nontraditional birth settings present advantages for low-risk women as compared
with traditional hospital settings: lower costs for maternity care, and lower
use of childbirth procedures, without significant differences in perinatal mortality.
Chamberlain M. Soderstrom B. Kaitell C. Stewart P
Consumer interest in
alternatives to physician-centred hospital birth in Ottawa
7(2):74-81, 1991 Jun.
A survey of 1109 women who delivered in a hospital or
at home in a major city in Canada was conducted. The women were asked to respond
to questions concerning the type of health professional they would like to provide
reproductive care. The choices they were offered were: midwife, obstetrician,
general practitioner or nurse, or a combination. Respondents were also asked to
identify if they had an interest in an alternative such as a birthing room, birthing
centre or home birth, to hospital labour ward care. Almost 60% of women were interested
in some form of midwifery care with the major emphasis placed on counselling and
support. Of the women who expressed an interest in midwifery services a large
number elected for that service to be shared with an obstetrician. Women who were
older and had achieved a high level of education were more interested in midwifery
services than other women. If given choices of a hospital labour, birthing room,
birthing centre or home birth 53% of women would choose to give birth in a hospital
labour ward. A major reason for this choice was the accessibility of epidural
analgesia. The majority of women who had experienced a home birth would make the
same choice again. There was a strong positive association between interest in
using midwifery services and interest in a birthing centre and home birth.
G. Steen AM. Andersen I. Treffers PE. Everaerd W.
[Department of Obstetrics
and Gynaecology, Academic Medical Centre, University of Amsterdam, The Netherlands]
Place of delivery in The Netherlands: actual location of confinement
Journal of Obstetrics, Gynecology, & Reproductive Biology. 39(2):139-46, 1991
Preferred and actual locations of confinement were compared in a group
of 170 nulliparous women. Voluntary changes in preferred location for birth were
rare and concerned only changes from hospital to home confinement. Obligatory
changes due to referral to consultant obstetricians occurred frequently: 58.8%
of the total sample. Fewer referrals were found for women with an initial preference
for a home confinement (53%) than for those who preferred a hospital confinement
(64%). Most referrals occurred in the group of older women initially in doubt
about their preferred location for giving birth: 72%. The differences were not
significant, however. To reveal differences between referrals and non-referrals,
discriminant analysis was performed at the 18th week of gestation. The explained
variance for the total group of referrals was 64.7%. Partially, the variables
pertaining to the explained variance were the same as those related to a preferred
hospital confinement. The explained variance for the group of referrals in which
psychosocial influences were presupposed was not better, with the exception of
referrals due to insufficient progress during labour: 76.4% of the variance could
be explained at the 34th gestational week. When birth weight and amenorrhoea were
included, these percentages increased to 79.0 and 84.8%, respectively.
JJ. Zadak K.
[Loyola University Medical Center, Maywood, IL 60163]
alternative birth movement in the United States: history and current status
Women & Health. 17(1):39-56, 1991.
The alternative birth movement
is a consumer reaction to paternalistic and mechanistic medical obstetrical practices
which developed in the United States early in this century. Alternative birth
settings developed as single labor-delivery-recovery rooms in the hospital or
as free-standing birth centers. Both alternatives offer family-centered, home-like,
low technological maternity care. In order to overcome physician resistance to
non-traditional maternity care, alternative birth center policies eliminate all
women who are expected to have a complicated pregnancy or delivery. Physician
resistance to alternative birthing is publicly based on the issue of maternal
and infant safety. Additional issues, however, are that physicians fear economic
competition and resist loss of control over obstetric practice. This paper (1)
traces the historical antecedents and social factors leading to the alternative
birth movement, (2) describes the types of alternative birthing methods, and (3)
describes ways in which the obstetrical community has maintained and rationalized
dominance over the birthing process.
Anderson R. Greener D
A descriptive analysis of home births attended by
CNMs in two nurse-midwifery services
Journal of Nurse-Midwifery. 36(2):95-103,
This study examined outcome data from two nurse-midwifery operated
home birth services in Texas. All clients who planned a home birth within the
two services during 1987 comprised the population. Analyses revealed that women
choosing home birth with these nurse-midwives were more frequently married, usually
white, and more educated when compared with the overall U.S. childbearing population.
Analgesia, episiotomy, and cesarean delivery were all found at lower rates than
is reported when birth occurs in a hospital setting; complications occurred less
frequently or at similar rates to those reported in the home birth literature
and national statistics. Research, educational, and clinical implications of the
study are discussed.
Outcomes of 1001 midwife-attended home births in Toronto, 1983-1988
Birth. 18(1):14-9, 1991 Mar.
A retrospective descriptive study of 1001
midwife-attended home births in Toronto, Ontario, was carried out between January
1983 and July 1988. Interviews with 26 midwives and reviews of client records
provided data on maternal age, socio-economic status, gestation, ruptured membranes,
length of labor, episiotomies and perineal lacerations, transfer to hospital of
mother or baby or both, infant resuscitation, and breastfeeding. Of 1001 planned
home births, 361 involved primiparous women, of whom 245 (68%) remained at home
and 116 (32%) required transfer of mother or baby to hospital during labor or
the first four postpartum days. Of the 640 multiparous births, 591 (92%) women
remained at home and 49 (8%) required transfer to hospital. Among women transferred,
91 had spontaneous vaginal births, 34 had forceps deliveries, and 35 had cesarean
sections. Variables significantly associated with maternal transfer for both primiparas
and multiparas were length of latent and active phases of the first stage of labor,
length of the second stage of labor, and duration of ruptured membranes. Five
neonates were transferred and two died, one each after birth at home and in hospital.
There were no maternal deaths. The proportion of mothers breastfeeding without
supplement at 28 days postpartum was 98.6 percent.
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