Thursday, June 16, 2011

How Homebirth Benefits Babies

EDIT 8/28/11: Things are not always as simple as they first appear. There are multiple sides to every story. I have written a follow up post to this one that looks at another study that is relevant to the homebirth research I cite here: Homebirth Research: Another Side of the Story. It is important that you read it as well because what I talk about there has implications for everything I wrote about here.

I believe that having a good birth experience is and should be a factor in women's decision-making about where to give birth. But I don't believe it should be the primary factor, and don't believe it is for most women, including those who chose homebirth. There is no doubt that for a women who wishes to avoid medical intervention as much as possible, the experience will almost always be better in her own home where she can feel more in control of what is done to her and it is easier to relax. However, some women (myself included) would be willing to give up these advantages to themselves if it equated to better outcomes for the baby.

So, the question is, how does homebirth affect babies? Does being born at home harm them, have no effect, or help them? Theoretically, homebirth is a "more peaceful transition" and the baby "benefits from the mother's lack of trauma," but is there anything clinically measureable? What follows is my attempt to answer these questions with research. I have included citations and links to all the studies I cited so you can look at them yourself and make your own judgments about them. What I have linked to is what I read--in some cases full studies, and in others an abstract or the results cited in another article.

Clinical benefits of homebirth for the baby:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6). Babies of mothers who plan homebirths also:
  • are less likely to require resuscitation at birth (2, 3, 4)
  • are less likely to take longer than 1 minute to establish respiration (4)
  • may have higher 5 minute APGAR scores (4, 6)
  • are less likely to need oxygen therapy beyond 24 hours (2)
  • are less likely to experience meconium aspiration (2)
  • may be less likely to be admitted to the NICU (1, 3) though in one study (1) this difference disappeared when the data was controlled for risk factors
  • are less likely to be born by cesarean, forceps or vacuum extraction (4, 5)
  • are less likely to have birth trauma (2)
Why the differences?

Some possible explanations for the differences in neonatal outcomes:
  • Women who plan homebirths are less likely to have obstetric interventions, including electronic fetal monitoring, augmentation of labor, assisted vaginal delivery, cesarean section, and episiotomy (2).
  • Women who give birth at home feel more free to move and be upright during labor, which can promote progress without the use of oxytocin augmentation (7), thereby avoiding pitocin's potential side effects on the baby.
  • Women who give birth at home are not under any pressure (direct or subliminal) to push in a bed. Studies show that upright birth results in a shorter pushing phase (8), higher APGAR scores, and lower arterial pCO2 with unchanged pO2, which indicates less transient cord compression (9).
  • Women who give birth at home are not given any pain medications that have effects on the newborn's breathing or that increase the need for assisted delivery (10, 11). The vacuum extractor, the most common method of assisted delivery used today, is associated with slightly higher rates of neonatal cephalhaematomata and retinal haemorrhages (12)
  • Babies born at home do not have their cords cut immediately. Academic OB/GYN has covered the research about cord clamping timing--see this post and these videos. In my experience, delaying cord clamping in most hospitals is much easier said than done, though hopefully this is changing.
  • Babies born at home are almost never separated from their mothers. Most hospitals fail to implement immediate skin-to-skin contact as standard practice, despite the well-documented benefits for the newborn, including a positive impact on breastfeeding rates, breastfeeding duration, temperature regulation, cardio-respiratory stability, and infant crying (13).
It could be questioned whether the good outcomes were more related to midwifery practices than the place of birth. Some argue that midwives working in hospitals where there is immediate access to emergency care could get better results than they get at home. One study (2) found better outcomes for homebirths when comparing between home and hospital births with the same cohort of midwives. The difference could be attributed to different patient preferences in the two groups, such as a desire for pain medication in the hospital group. However, as I learned in my first birth, sometimes women who desire low-intervention births find that the hospital environment and protocols make this more difficult. Hospital policies often require providers to intervene in certain situations, such as slow or stalled labor, prolonged rupture of membranes, or a certain amount of time passing between full dilation and birth of the baby. Homebirth protocols are usually less restrictive, allowing more women to birth without intervention (without compromising results, if the protocols they are using are appropriate). Theoretically, women who birth at home will need intervention less often because being in a low-stress environment with minimal disturbance will promote optimal labor hormone release, resulting in less protracted labor and better natural pain control. And the research I've cited here indicates that when birth can safely occur with less intervention, better outcomes for babies result.

baby boy two hours after homebirth
(image originally uploaded by Fretwurst)
Some Caveats

Of course, it is important to recognize that we are talking about low risk birth here. Some higher risk women probably are taking an increased risk to their baby by choosing homebirth. I don't think all of them are necessarily "all about the experience" either. Most of them, I believe, are in a situation where they are certain or nearly certain to have a cesarean if they birth in a hospital, and they believe that the risks of surgery do not outweigh those of vaginal birth with their increased risk situation. However, these higher risk births would be much safer if they had immediate access to emergency care while still being able to give birth vaginally. While I am saddened by the lack of options for these women, homebirth is not meant to be a last resort for those in unusual circumstances that cause them to feel that the safest birth for them (vaginal birth in a hospital) is not an option.

It is also important to note the qualifiers "under a supportive system" and "with a qualified attendant." I believe it is very important to have a well-trained person you can trust to help you determine when intervention is truly necessary for the safety of you or your baby. The majority of homebirth research I have cited here is international. Many other countries have different requirements for midwife training than what we have in the U.S. In most of the countries where large-scale homebirth research has been done, homebirth midwifery is integrated into the maternity care system, allowing for smooth transfer in the event of an emergency. In the U.S., it is very important to ask questions about your midwife's qualifications, and be familiar your state's laws about direct entry midwifery (see Citizens for Midwifery) and requirements for licensure. Twenty-two states currently do not license direct entry midwifes. If your state is one of these, The Big Push for Midwives, is a resource that may help you get involved if you are interested. The requirements for the national direct-entry midwifery credential (Certified Professional Midwife or CPM) have been criticized for not being extensive enough, and are currently going through a revision process. It is also important to take into account the attitudes towards homebirth in hospitals in your area, as many in the U.S. are not supportive, which may interfere with transfer and care after transfer, should it become necessary.

Please review the the studies below, and, as always, consult with a qualified medical provider to help you make decisions about your care.

References:
Here is the link to the follow up post again: Homebirth Research: Another Side of the Story

16 comments:

  1. This is an excellent post. I'm going to link to it on my blog if that's okay.

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  2. Bonnie--yes, feel free to link to my posts any time you would like!

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  3. This is absolutely the best article on home birth I have read. And I have read a LOT. May I also post a link on my blog?

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  4. Yes, Kristi, please do!

    Anyone else who wants to link, you may! No permission needed for linking!

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  5. FANTASTIC, Brittany. I'm sharing this!

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  6. p.s. Another great benefit is the higher population of healthy bacteria in homebirthed newborn guts: http://www.ncbi.nlm.nih.gov/pubmed/16882802

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  7. I likte this in october i will begin to give the cours hypnobirthing in the netherlands

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  8. Whilst I agree with everything you have said in this post, I do not like when the mother-baby dyad are "studied" independently when looking at aspects of the birth process. Unhindered childbirth at home highlights that birth works when mother and baby are viewed as a conscious and active until working towards a common and innately driven goal. I actually think it is primarily the relationship between the triad of the mother-father-baby that gives the most accurate view of "safety" and predicability of "good" physiological birth outcomes. It would be refreshing and progressive to see these inter personal relationship aspect of birth considered when studying the "benefits" of a homebirth.

    Again, whilst I completely understand why it is important share this information as many do not consider it when making their birthing "choices". I just think it feeds into the line of thinking that women choose homebirth for their own experience regardless of the needs of the baby; when in reality and fact the needs and experiences of a mother and baby can not and should not be separated.

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  9. While licensure of direct-entry midwives is one option that states can choose increase access to birth choices by birthing families, a more ideal situation is to just decriminalize midwifery. Licensure limits choices by preventing women who are not considered "low risk" (multiples, breech, advanced maternal age, etc.) from being attended at home by a midwife.

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  10. Loved my homebirth at 46 years of age in October 2008....I was considered high risk because of age...

    I was totally healthy, strong and empowered.....
    RISK is an interesting concept...whose risk...??

    All best and thank you

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  11. i think giving a home birth is very risky if you are a woman with many complication like asthma. but it would be riskier if you are in a hospital with a doctor who used a wrong forceps making the child head titled, in which i know that every doctor knows about the 2 Major Classifications of Forceps (http://www.ubscure.com/Art/166787/134/2-Major-Classifications-of-Forceps.html) before they are engaged in the profession.

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  12. where is your scientific based evidence on all the above information?...example "Women who give birth at home are not under any pressure (direct or subliminal) to push in a bed. Studies show that upright birth results in a shorter pushing phase (8), higher APGAR scores, and lower arterial pCO2 with unchanged pO2, which indicates less transient cord compression (9)." Your references (many) are not solid scientific based. It is more like observations and opinions. Also, why are you not showing the risks that could happen to. For example: Sure the baby does not leave the mother during a home birth, but in a hospital babies are screened right away for life threating issues. I have a friend that during her 3rd delivery found out during that first screening of tests that her child has thyroid condition that if not treated immediately she would have become severely mentally impaired. 1 out of 2000 births suffer that thyroid condition. I get you want to advocate for home birth, but share every face good or bad that comes with it. There are very committed mommies that want to do the best for their babies and the way you present this data is like they are making a choice that is as easy to decide on as going to the hair salon. Your movement is very dangerous when not showing BOTH sides of the story and have interviews and true stories posted along your evidence of people that have had issues or even experienced a death during homebirth. I think you are afraid to do that, because there are a lot and more are growing since your movement has increased by 20% in the past few years. I come from place that had a team of docs the truly cared for me and my babies and told it to me straight when i needed it and even though I was handed not the ideal birth experience and outcome two times in a row. I had a wonderful hospital experience where I was advocated for and in the end I have two perfect thriving kids. Things go wrong in hospitals, but at least the kid/mother gets a fighting chance at home those odds go down drastically. Again all I am asking is show all the facts good, bad and the ugly. That is how someone can make an informed choice.

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    Replies
    1. Re: thyroid condition if you are talking about the heel prick test, that is an option for homebirths too.

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    2. If above 'Anonymous' is annoyed then make you own clearly stated blog or research on the facts about hospital birth, but I do not see any of your own references or ciations just opinons.

      They have cited and references the information. If you click on the links in the references you can see that these are real scientific articles published by SCIENTIFIC journals and found from SCIENTIFIC research.

      Read through the above article and the references that match the appropriate information before getting on your high horse.

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  13. I am a home birth baby and I appreciate this so much! I didn't know that someone can actually benefit from it. Interesting!

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