Homebirth Research: Another Side of the Story

Information about this has been showing up everywhere for me lately, though I have not sought it out intentionally, and I feel like I would be irresponsible not to write about it.

For a long time, I stayed away from the topic of homebirth, partly because it is such a controversial topic. I have only started writing about it recently because I am pregnant and currently am under the care of a team of homebirth midwives. My post titled "How Homebirth Benefits Babies" was the first post I wrote that "promoted" homebirth (with caveats!). It is also has been the most widely read, currently at 1,788 pageviews.

I have discovered that the evidence really is not clear on the most important point I make in that post when I talk about homebirth research. My words:

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).

It has come to my attention that the results of one of the studies I cite in that post has been called into question by the results of another study--a study that nobody in the online natural birth community appears to be talking about, even though it was published 9 months ago.

The study I cited in my post was the de Jonge study from the Netherlands, which compared outcomes of home and hospital births attended by Dutch midwives among women classified as "low risk" by the Netherlands maternity care system. De Jonge found no difference in mortality or severe morbidity in the home and hospital groups.

The Evers study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study was published in the British Medical Journal in November 2010. It compared outcomes of term births classified as "low risk" by the Dutch system attended by midwives (primary care) with outcomes of births classified as "high risk" and attended by obstetricians (secondary care). It found higher rates of perinatal mortality in the primary care group, and no difference in rates of level 3 NICU admission (the measure the study used for severe morbidity). Yes, you read that right. More low risk babies died. There were 26 delivery-related perinatal deaths out of 18,686 who began labor in primary care(a rate of 1.39/1000) and there were 10 delivery-related perinatal deaths out of 16,739 who began labor in secondary care (rate: 0.60/1000). The transfer rate from primary care to secondary care during labor was 22.9%, and 12 if the delivery-related deaths occurred in those who were transferred. The number of intrapartum stillbirths was also higher in the group that began labor in primary care. The study excluded all instances of congenial anomalies.

This study calls into question the belief that the best and safest care for low risk births is low-intervention care. From the Discussion section of the paper:

This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels. Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes. Delay can occur at three moments. Firstly, diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours. Secondly, transport can delay treatment in case of an emergency. Finally, a delay can occur because the obstetrician underestimates the problem as the referred woman is a “low risk” patient. In addition, essential information can be lost during the referral. These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted.

And this is in the Netherlands, where there is a universal standard for midwife education and there is supposedly to be a good system of transfer of care. Would having low risk women also be cared for by obstetricians be a better system for the Netherlands? That is basically what we have in the U.S., and we have a 33% cesarean rate. Cesareans increase the risk of maternal morality (see Deneux-Tharaux, 2006), though maternal mortality occurs much less frequently than perinatal morality does. Considering the increased risks associated with pregnancies and births in women with prior cesarean sections (see Kennare, 2007) , some of which impact both the mother and baby, I just don't see how this can be the optimal way to care for mothers and babies either. I'm not even going to try to answer the question of how many mothers (and any future babies they may have) should have to accept the risks of a cesarean section to save the life of one baby. It is something to think about.

The choices we have are between sets of risks. The absolute risk of a baby dying at all is low, especially if there is access to fetal monitoring and some level of emergency care (such as midwives who can perform neonatal resuscitation). When are talking about a rate of 1.39/1000, it means an individual has a 0.139% chance of it happening (and a 99.861% chance of it not happening)--and that's all primary care deaths in the Evers study, including ones who would have died no matter what kind of care they received. The risk of preventable death is presumably lower, though we don't know how much lower because there is no obstetrician-attended low-risk comparison group in the study. I don't want it to seem like I am trying to "explain away" the risk of preventable death. The statistics mean nothing when your baby is the unlucky one who dies. I believe in informed choice, and I believe you need accurate information to make informed choices.

After I wrote this post and was waiting to publish it (I usually space posts out further, but I moved this one up because I felt I needed get it out there), I saw this post from Birth Without Fear in my facebook newsfeed, and felt it applied to what I am trying to say. Like her, I am not here to advocate that you have a homebirth. I advocate that you look at the information, weigh your options, and make whatever is the best decision for you.

giveaway of book for birth workers

Sheridan at Enjoy Birth reviewed the book Keep the Fires Burning: Conquering Stress and Burnout as a Mother-Baby Professional by Mickey Jones, and she is giving a way a free copy! The life of a birth worker can be very demanding, and this book sounds like a great resource.

Click here to read the review and enter the giveaway!

Hypnobabies Certified!

I received word a few days ago that my certification as a Hypnobabies Childbirth Hypnosis Instructor (HCHI) and Hypnobabies Certified Hypno-Doula (HCHD) is official! Yesterday, my information was posted on the Hypnobabies Instructor listing. If you are local and interested in joining my first class (most likely stating in late September or early October) please contact me here or through my website (link on sidebar). If you are not local, check out the link above for an instructor in your area.

New Website, Facebook Page, and Twitter Account!

I bought a domain name for my doula services website, and I decided to do away with "Peaceful Waves Birth." The new website for my Yakima area doula services is:

www.birthspecialist.com

The new website which will also be the location of information on the schedule of my Hypnobabies classes, and updates for my Dancing For Birth™ classes, when I get them started. I also made an accompanying facebook page, which you can find at The Birth Specialist. I also finally joined Twitter. Unfortunately @BirthSpecialist was taken (by someone who apparently created the account, but never used it), so I just went with my first and last name: @BrittanyCromar. So, now you can like and follow me if you are on Facebook and Twitter!

I &hearts Dancing for Birth&trade!

The Dancing for Birth™ training was awesome! I learned so much! I am currently planning on finishing up certification and teaching the classes, in addition to my Hypnobabies courses, but we will see if it works out.

In a nutshell, Dancing for Birth™ is a prenatal and postpartum fitness class and a birth and new motherhood support circle, with bits of birth empowerment and childbirth education incorporated into it. There is a basic flow to the structure of the classes, but the content is flexible--instructors can choose what to include each week based on the needs of their students. There is a huge list of benefits to dancing during pregnancy, birthing itself, and the postpartum time. Not to mention it is a whole lot of fun!

I had a wonderful time bonding with all of the other women who were at the training. It was a very passionate group, and the nature of the workshop allowed us all to become close very fast. Most of the other trainees were doulas, but we also had some midwives and belly dancers. One thing I really liked about the workshop was the opportunity to practice some comfort techniques, including the double hip-squeeze and several rebozo techniques.

I found that the vast majority of what was taught was very compatible with Hypnobabies. We talked about how having "sensation" is necessary to follow your instincts in childbirth, but there was not talk of "preparing for pain." There was some of the idea that "you don't birth in your brain, you birth in your body," which is not what we teach in Hypnobabies, because we teach that you most definitely do use your mind during birth--it is where your birthing hormones come from. However, I think "birthing in your body," it is just different wording for a concept that is taught in Hypnobabies--birthing in a state where our conscious, analytical thinking is pushed aside, a state we call hypnosis, but other people have different words for it. Dancing is a naturally hypnotic activity, so it makes sense that dancing during your birthing time would promote the ideal mental state.

We also did a game where music plays and everyone dances, then the music fades and people pretend to be having pressure waves (most people chose to stop dancing and lean forward onto something, which would work with using the Hypnobabies lighswitch), then the music fades back in and everyone gets up and dances again. This exercise reminded me a lot of something we do in Hypnobabies called a "birth rehearsal," and I could see how the techniques of both programs could work together as we did it.

We did another exercise where we compared the measurements of the pelvic outlet (from pubic bone to tail bone) in a deep squat (with hips below knees) versus a standing squat (hips above knees, pelvis tilted back, upper body leaning forward). I recommend trying this yourself--you may be surprised at what you find!

All instructor training workshop participants take home a copy of the Dancing for Birth™ DVD, and I have been practicing with it every other day since I got back. I have difficulty sticking to exercise routines, but since dancing is so fun, I'm more likely to do it (plus, I'm trying to get a good grasp on the moves for teaching it, if that works out) I am looking forward to having dance to use along with my hypnosis during this baby's birth!

Doula Certification!

I submitted all of my forms to complete my doula certification yesterday and was notified today that they have been received. It is official: I am a certified doula! I will be changing the image at the bottom of my blog to this:

I'm going to the Dancing for Birth training!

Ever since writing my Dancing Your Baby Out post, I have been really interested in dance as a form of prenatal exercise and as a comfort and positioning measure during childbirth. I have always loved to dance. Although my parents never signed me up for classes when I was growing up (I'm sure they had good reasons) and my high school did not offer dance as an elective, in college, I took a ballet class, a modern dance class, and two ballroom dance classes, and I loved all of them. My husband took ballroom classes, too (he is actually better at ballroom than I am!) Since marrying into a Tahitian family, I have also tried to learn Tahitian dance. Tahitian slow dances probably have some some things in common with what is in prenatal dance classes.

Performing Tahitian dance at a family wedding reception (I am second from the right)

I think that teaching pregnancy dance classes would be a great way for me to combine my interests in dance and birth. It also will be an opportunity to expand my market (women who typically might not be looking for a Hypnobabies class or a doula might come to a prenatal dance class and then might find out about my other services that way), and will give me another birth-related thing I can do that won't disrupt my family life too much. Like teaching Hypnobabies, it is something I can schedule around my husband's work schedule, which avoids needing a babysitter, and since classes are for both prenatal and postpartum women, who can do the dances while wearing their baby, I will be able teach it while babywearing.

When I first learned that there was going to be a Dancing for Birth instructor training at the Simkin Center for Allied Birth Vocations at Bastyr University in Seattle, I wasn't sure if I would be able to go, even though I wanted to, because I had a doula client whose due date was about 10 days after the training. She gave birth at 37 weeks gestation last week (I will write more about that experience later, if I get permission from the mom), so I looked to see if they were still taking registrations, and they were! So, after discussing it with my husband, I decided to sign up! I will try to write a blog post about the training after I go!