Article about Risks of Home Births in the US

[Blob]

Seems a bizarre place to come for a scientific debate a parenting forum is not going to give you that.

 

[special_kala]

They are healthcare professionals.

They work in hospitals ant the community. We do not routinly deal with doctors during pregnancy or birth.

But I guess what I don't understand is who pays their salary (because it sounds like they're not volunteers)? Here in the states, Drs, nurses, and midwives are paid by the hospital or clinic where they work.

The goverment pays them. Regardless of what kind of birth though they get the same salary.

 

[Buttercup2]

Seems a bizarre place to come for a scientific debate a parenting forum is not going to give you that.

Everyone keeps saying how their opinions/choices are well-researched tho! I would like these people to share some of their research with the general community, because it's valuable to all of us to share the research we have done.

For example:
Special_kala has said she knows risks are lower for home birth. So I'd love to hear where she found that.

PreggyEggy said she's a smart, well-informed lady. She said " I've done my research and I chose homebirth." Creative said she is also. Please share that research with us!

Blob, you said "Noboody goes into a homebirth without doing a lot of research."

I don't see why it's weird to think these ladies (including you) would be interested in discussing the research they've obviously done. I'm having a hospital birth this time, but I was considering other options for future kids and I'd like to be well-informed also, beyond what google can give me. So far, the paper I posted is the most trustworthy piece of research I've read, which is why I shared it with this group of women who are telling me they are well-researched people.

 

[Creative]

Research does not have to come in the form of a scientific paper.

https://www.homebirth.org.uk/ is a great source of support and information as is the homebirth section on this very forum. My consultant and midwife have also talked at great length with me over the issues and I have read many books on the subject including Sheila kitzengers.
As well as this, I have spoken to many women who have been interested in the homebirth process some of whom have done it and some of whom have not.
Most people would be completely at a loss sitting down to read a scientific paper and often these papers take an awful lot of dissection and assumed knowledge. The resources I have used are more approachable and understandable than a wordy scientific publication.

 

[Foxy37]

Personally I think when we research something we try and find a positive or a negative. Through pregnancy we search baby's being born early or miscarriage or certain types of equipment. I personally always look for the positive articles. I am not against home births as they do seem an amazing and tranquil experience but they are not for me and my medical history. I think home births are more about choice for the individual and as lots of women have said even when suggested against they have still opted for. So I don't think medical opinion has really come into it at times its been more how the mother feels and what she wants. if we researched half the things we do in life would we do them? Ie: eat meat,drink alacahol or even have children lol. I think b and b is a discussion area and this is a fantastic board to post such posts as it has got us all discussing and understanding each others choices xx

 

[Bambola]

I have a question as I know nothing of home births and my sister is considering one. What happens if you are birthing at home and the baby's heart rate begins to drop and you discover that in the circumstances you can't deliver naturally as you had originally hoped and need an emergency c-section ASAP to get the baby out safely? Can the midwife perform a c-section in this case?

 

[Creative]

I have a question as I know nothing of home births and my sister is considering one. What happens if you are birthing at home and the baby's heart rate begins to drop and you discover that in the circumstances you can't deliver naturally as you had originally hoped and need an emergency c-section ASAP to get the baby out safely? Can the midwife perform a c-section in this case?

Source;https://www.homebirth.org.uk/ (under the head but what if on the left hand side)

The term 'emergency caesarean' can be confusing, because in fact an 'emergency' caesarean just means one which was not planned at the start of labour, regardless of whether mother or baby was in immediate danger. What most people worry about is a 'crash' or 'true emergency' caesarean, where the baby needs to be delivered urgently. This is rare in a low-risk pregnancy which ends in a physiological (natural, spontaneous) labour. Nonetheless, it can happen. The baby's heart rate might indicate to the midwife that the baby is in severe distress. Perhaps the cord is around its neck - this happens in about a third of all births and does not usually cause a major problem, but in some cases the baby does get severely deprived of oxygen. Perhaps the cord has become compressed inside the womb. The mother could be bleeding from a partial placental separation or, very rarely, a ruptured uterus.

In a dire emergency situation like this, the midwife would call an ambulance immediately, and would telephone ahead to the hospital and ask them to have the operating theatre made ready and the surgical team assembled. The ambulance team would take the mother straight to the operating theatre. While waiting for the ambulance and during transfer, the midwife might insert an intravenous drip or a Venflon needle, which would allow a drip to be put up straight away in the ambulance or in hospital.

In the past, obstetric 'flying squads' have sometimes been used to take emergency assistance to a home birth. However, these have been phased out in the UK as they were found to be, overall, less safe and effective than transferring people to hospital.

So how much time would you lose by having to transfer from home? Obviously it depends on your distance from the hospital, and traffic conditions, but even if you started off in hospital, the operating theatre would have to be prepared and a surgical team assembled. There is an interesting table in the paper by Tuffnell et al (see refs, below) listing steps from decision to delivery in a caesarean section. If you were labouring in hospital when your baby went into distress, you might be surprised at how long it could take from 'call to cut', ie the time it took the surgeon to actually begin operating.

The UK target for delivery by emergency caesarean is 30 minutes from decision to delivery, but research suggests that this target is not usually achieved. For example, MacKenzie and Cooke (2001) found that the average time from decision to delivery in emergency caesareans where there was fetal distress was 42.9 minutes in their large Oxford teaching hospital. Tuffnell et al (2001) found that:

"66.3% women were delivered in 30 minutes and 88.3% within 40 minutes; 29 (4.0%) were undelivered at 50 minutes. If the woman was taken to theatre in 10 minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%) in 40 minutes."
An interesting read on this subject is the National Sentinel audit of Caesarean Sections in the UK, published by the Royal College of Obstetricians and Gynaecologists (www.rcog.org.uk). To be reviewed for this article at a later date.

It seems inevitable that transferring from home for a crash caesarean will usually result in some time being lost, compared to a planned hospital birth. However, depending on your transfer times, the difference might not be as large as you would expect. If you could be in the operating theatre within 20 minutes, for instance, the difference is likely to be very small indeed.

The issue for most women is how likely it really is that they would require a 'crash' caesarean section. If you do not fall into a high-risk group, and you have not had interventions in your labour which increase risk (eg induction, augmentation of labour), the chances are very small indeed. Only you can decide which combination of risks is acceptable for your family.

Here are some birth stories from women who transferred from a home birth for caesarean sections: Kiara, Laura, Mel .

 

[Bambola]

I have a question as I know nothing of home births and my sister is considering one. What happens if you are birthing at home and the baby's heart rate begins to drop and you discover that in the circumstances you can't deliver naturally as you had originally hoped and need an emergency c-section ASAP to get the baby out safely? Can the midwife perform a c-section in this case?

Source;https://www.homebirth.org.uk/ (under the head but what if on the left hand side)

The term 'emergency caesarean' can be confusing, because in fact an 'emergency' caesarean just means one which was not planned at the start of labour, regardless of whether mother or baby was in immediate danger. What most people worry about is a 'crash' or 'true emergency' caesarean, where the baby needs to be delivered urgently. This is rare in a low-risk pregnancy which ends in a physiological (natural, spontaneous) labour. Nonetheless, it can happen. The baby's heart rate might indicate to the midwife that the baby is in severe distress. Perhaps the cord is around its neck - this happens in about a third of all births and does not usually cause a major problem, but in some cases the baby does get severely deprived of oxygen. Perhaps the cord has become compressed inside the womb. The mother could be bleeding from a partial placental separation or, very rarely, a ruptured uterus.

In a dire emergency situation like this, the midwife would call an ambulance immediately, and would telephone ahead to the hospital and ask them to have the operating theatre made ready and the surgical team assembled. The ambulance team would take the mother straight to the operating theatre. While waiting for the ambulance and during transfer, the midwife might insert an intravenous drip or a Venflon needle, which would allow a drip to be put up straight away in the ambulance or in hospital.

In the past, obstetric 'flying squads' have sometimes been used to take emergency assistance to a home birth. However, these have been phased out in the UK as they were found to be, overall, less safe and effective than transferring people to hospital.

So how much time would you lose by having to transfer from home? Obviously it depends on your distance from the hospital, and traffic conditions, but even if you started off in hospital, the operating theatre would have to be prepared and a surgical team assembled. There is an interesting table in the paper by Tuffnell et al (see refs, below) listing steps from decision to delivery in a caesarean section. If you were labouring in hospital when your baby went into distress, you might be surprised at how long it could take from 'call to cut', ie the time it took the surgeon to actually begin operating.

The UK target for delivery by emergency caesarean is 30 minutes from decision to delivery, but research suggests that this target is not usually achieved. For example, MacKenzie and Cooke (2001) found that the average time from decision to delivery in emergency caesareans where there was fetal distress was 42.9 minutes in their large Oxford teaching hospital. Tuffnell et al (2001) found that:

"66.3% women were delivered in 30 minutes and 88.3% within 40 minutes; 29 (4.0%) were undelivered at 50 minutes. If the woman was taken to theatre in 10 minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%) in 40 minutes."
An interesting read on this subject is the National Sentinel audit of Caesarean Sections in the UK, published by the Royal College of Obstetricians and Gynaecologists (www.rcog.org.uk). To be reviewed for this article at a later date.

It seems inevitable that transferring from home for a crash caesarean will usually result in some time being lost, compared to a planned hospital birth. However, depending on your transfer times, the difference might not be as large as you would expect. If you could be in the operating theatre within 20 minutes, for instance, the difference is likely to be very small indeed.

The issue for most women is how likely it really is that they would require a 'crash' caesarean section. If you do not fall into a high-risk group, and you have not had interventions in your labour which increase risk (eg induction, augmentation of labour), the chances are very small indeed. Only you can decide which combination of risks is acceptable for your family.

Here are some birth stories from women who transferred from a home birth for caesarean sections: Kiara, Laura, Mel .

Thank you for that info Creative- very interesting stuff. Am passing it on to my sister. How about in a rare instance where oxygen is cut to the baby, how much time would someone have before permanent damage is done to the baby? (I.e. brain damage due to lack of oxygen).

 

[Pearls18]

...perhaps it isn't surprising that American statistics don't correlate with those of other western cultures, however reliable the research.

I think this is 100% true! The US doesn't really support home birth well at all, which is, I think, why this paper found that home births in the US are not as safe as hospital (in the case of the specific, rare complications that were evaluated). But even with this research, there are still many good reasons for some women to choose home birth. Everybody has said that their choices are well-researched, and I'm really interested to read the research that other people are finding that helped them decide on a non-hospital birth.

I did hope this thread would be a discussion of a scientific paper and not just a sharing of opinions, tho. I'm really interested to hear where people got the information that caused them to form their opinions. That doesn't make your opinion not valid, so I'm sorry if I made you feel your opinion was un-valued.

This is a forum of mums not scientists, we can only discuss what we know from our experiences not necessarily from statistics although some mums are more wised up than others! I admit my own opinions are formed from the women I talk to on here and embarrassingly lol programmes on birth in the US, I don't pretend to be an expert or that my own conclusions are conclusive for the whole of the US, but can anyone tell me with scientific research if I am wrong to have come to the conclusion that there is a lot more intervention in birth in the US? Am I wrong for being skeptical that this is probably because healthcare is a business thus there are financial motivations for wanting to keep birth more medicalised? Genuine questions. You seem very interested in the scientific aspect (which is good!) you might be interested, for comparison, to look into how birth is dealt with in countries with universal health care, I'm not saying it is perfect in the slightest it has its flaws and it is part of the reason I am choosing to home birth myself, that said I do believe our attitude to birth is much healthier.

I guess the main difference between universal healthcare and what you have in the US to over simplify it, is in the US healthcare is business, doctors, insurance companies, pharmaceutical companies and insurance companies make money from people needing medical assistance, the more medical assistance people need the more money they make. A hospital makes more money from someone having an epidural who is 75% more like likely to need further intervention than someone who gives birth at home or has a natural hospital birth. In the UK health care is state funded, tax payers and the government pay for it, it is within all our interests to keep healthcare costs down while still providing a health care system that keeps people healthy. Now there are obvious flaws with this too I don't deny it, but on the matter of birth because the more natural you keep it, statistically (now don't ask me where from what I gather it is common knowledge) our attitude to maternity care whether it is driven by financial factors (which I don't believe it is, but there will be an aspect of this of course) or due to our understanding of birth, is healthier for the general population who have low risk births. I'm skeptical enough to accept there's always an agenda, others would say it is getting a balance between affordability but keeping care paramount, but in our case I think our system is "friendlier" for maternity services.

 

[steph.]

I havent done any research into homebirth, because from my personal experience I know its definitely not something I want. I have worked in a delivery suite and have seen things turn in the blink of an eye, where we had to get the baby out asap...and I mean from peaceful natural birth to crash csection and baby out in less than 10 minutes. I know it doesnt happen often, but once you have witnessed it, it stays with you and realise it can happen to anyone. I respect other people's decision to have a homebirth, but I feel much safer in hospital.

I dont think the op meant any offence by starting this thread. She was just sharing an article she found interesting. I think people took it the wrong way.

 

[Pearls18]

I have a question as I know nothing of home births and my sister is considering one. What happens if you are birthing at home and the baby's heart rate begins to drop and you discover that in the circumstances you can't deliver naturally as you had originally hoped and need an emergency c-section ASAP to get the baby out safely? Can the midwife perform a c-section in this case?

Source;https://www.homebirth.org.uk/ (under the head but what if on the left hand side)

The term 'emergency caesarean' can be confusing, because in fact an 'emergency' caesarean just means one which was not planned at the start of labour, regardless of whether mother or baby was in immediate danger. What most people worry about is a 'crash' or 'true emergency' caesarean, where the baby needs to be delivered urgently. This is rare in a low-risk pregnancy which ends in a physiological (natural, spontaneous) labour. Nonetheless, it can happen. The baby's heart rate might indicate to the midwife that the baby is in severe distress. Perhaps the cord is around its neck - this happens in about a third of all births and does not usually cause a major problem, but in some cases the baby does get severely deprived of oxygen. Perhaps the cord has become compressed inside the womb. The mother could be bleeding from a partial placental separation or, very rarely, a ruptured uterus.

In a dire emergency situation like this, the midwife would call an ambulance immediately, and would telephone ahead to the hospital and ask them to have the operating theatre made ready and the surgical team assembled. The ambulance team would take the mother straight to the operating theatre. While waiting for the ambulance and during transfer, the midwife might insert an intravenous drip or a Venflon needle, which would allow a drip to be put up straight away in the ambulance or in hospital.

In the past, obstetric 'flying squads' have sometimes been used to take emergency assistance to a home birth. However, these have been phased out in the UK as they were found to be, overall, less safe and effective than transferring people to hospital.

So how much time would you lose by having to transfer from home? Obviously it depends on your distance from the hospital, and traffic conditions, but even if you started off in hospital, the operating theatre would have to be prepared and a surgical team assembled. There is an interesting table in the paper by Tuffnell et al (see refs, below) listing steps from decision to delivery in a caesarean section. If you were labouring in hospital when your baby went into distress, you might be surprised at how long it could take from 'call to cut', ie the time it took the surgeon to actually begin operating.

The UK target for delivery by emergency caesarean is 30 minutes from decision to delivery, but research suggests that this target is not usually achieved. For example, MacKenzie and Cooke (2001) found that the average time from decision to delivery in emergency caesareans where there was fetal distress was 42.9 minutes in their large Oxford teaching hospital. Tuffnell et al (2001) found that:

"66.3% women were delivered in 30 minutes and 88.3% within 40 minutes; 29 (4.0%) were undelivered at 50 minutes. If the woman was taken to theatre in 10 minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%) in 40 minutes."
An interesting read on this subject is the National Sentinel audit of Caesarean Sections in the UK, published by the Royal College of Obstetricians and Gynaecologists (www.rcog.org.uk). To be reviewed for this article at a later date.

It seems inevitable that transferring from home for a crash caesarean will usually result in some time being lost, compared to a planned hospital birth. However, depending on your transfer times, the difference might not be as large as you would expect. If you could be in the operating theatre within 20 minutes, for instance, the difference is likely to be very small indeed.

The issue for most women is how likely it really is that they would require a 'crash' caesarean section. If you do not fall into a high-risk group, and you have not had interventions in your labour which increase risk (eg induction, augmentation of labour), the chances are very small indeed. Only you can decide which combination of risks is acceptable for your family.

Here are some birth stories from women who transferred from a home birth for caesarean sections: Kiara, Laura, Mel .

Thank you for that info Creative- very interesting stuff. Am passing it on to my sister. How about in a rare instance where oxygen is cut to the baby, how much time would someone have before permanent damage is done to the baby? (I.e. brain damage due to lack of oxygen).

They bring resuscitation kits for mum and baby and I believe they can give oxygen if needed at home.

 

[Pearls18]

I havent done any research into homebirth, because from my personal experience I know its definitely not something I want. I have worked in a delivery suite and have seen things turn in the blink of an eye, where we had to get the baby out asap...and I mean from peaceful natural birth to crash csection and baby out in less than 10 minutes. I know it doesnt happen often, but once you have witnessed it, it stays with you and realise it can happen to anyone. I respect other people's decision to have a homebirth, but I feel much safer in hospital.

I dont think the op meant any offence by starting this thread. She was just sharing an article she found interesting. I think people took it the wrong way.

At the end of the day people birth best where they feel safest, people forget the psychological impact on our own emotions during labour, I too felt safest at hospital for my first birth and I believe this contributed to my good labour, this time around I do not trust the hospital in the area I am in and having already had an experience of labour I feel I will labour better at home. The reason women get annoyed by comments such as what you have made (as an example not picking on you lots of women have these valid opinions and I felt the same for my first) is the assumption birth is safest in hospital when in actual fact if you want to talk about statistics, for second time mums who are low risk (in the UK) home birth actually beats hospital birth for safety, so by saying hospital birth is safer is not only a moot point because you're as safe as you feel but it is also technically speaking, wrong.

But I agree, I wasn't offended by the OP's post or the article, I like discussing topics such as this, just don't ask me to back every statement with a stat because most of my info comes from One Born Every Minute and BBC news articles

 

[steph.]

I didn't say hospital births are safer, I haven't done any research into the subject. Just that I feel safer in hospital. You are probably right, if a woman is scared and not at ease it will impact her labour wherever she is.

 

[Pearls18]

I didn't say hospital births are safer, I haven't done any research into the subject. Just that I feel safer in hospital. You are probably right, if a woman is scared and not at ease it will impact her labour wherever she is.

Sorry I see that now when other people make the comment then lol, the worst is "I just want my baby to be safe so couldn't imagine giving birth at home" ooooh it grates lol, sorry to misread yours, I can imagine what you have seen gives a different perspective. I'm looking forward to talking to my aunt about it because she has worked with community midwives at home and seen utter tragedy at hospital (not because they are hospitals of course but as you say seeing how labour can change) so would be interesting to see what her take on it is.

 

[irish_cob]

What I want to know is what do these figures mean?

What does a low APGAR score correlate with? I mean 5, 10, 30 days further onwards can you tell a baby who was born with a low APGAR score from one with a high one? (Obviously a score of 0 is pretty awful because it means the baby isn't breathing and has no pulse - but what about higher than 0 but not 8, 9 or 10?) Does a lower APGAR score correlate with higher mortality? In what way? Or is it fairly meaningless by itself?

Just because the baby has a low APGAR score at 1 minute, does that immediately mean that there's something desperately wrong with it? That immediate medical attention is needed?

I've read a lot of homebirth stories where the birth is so gentle for the baby especially into water, that the transition isn't traumatic at all, and the baby doesn't cry or looked shocked at all - but is perfectly healthy. Would a quiet and peaceful baby be more likely to be scored low, especially if the understood norm from a culture used to high-pressure deliveries in hospital is for a screaming infant? Also with a water birth you don't want the baby to start breathing underwater so you're not looking for respiration to start until the baby is brought out of the water, and as long as the baby is still attached to an unclamped umbilical cord, she will still be getting oxygen from Mum, so it might not be such a huge medical emergency as it sounds - no respiration sounds awful, but no baby is born breathing - they all take their first breath at some point!

Also the article seems to imply that there is nothing to be done about a low APGAR score or at least doesn't explain how to do anything about it - I'm pretty sure a homebirth midwife isn't just going to sit around looking at a blue, unresponsive, unbreathing baby thinking "oh dear". I'm pretty sure they're going to start stimulating the baby, rubbing her whilst providing resuscitation (in the UK at least all homebirth midwives carry resuscitation kit) probably all whilst the baby is still attached to the umbilical cord which is acting as the life support for the baby - there's absolutely no need to immediately sever the umbilical cord to provide emergency care, the umbilical cord will keep the baby alive for many minutes after birth, even if the baby isn't breathing on her own.

So again, to me what the article doesn't make clear is what having a low APGAR score actually means in reality. Just stating/proving that homebirth babies in the US are more likely to have a low APGAR score is pretty meaningless to me. That might be a fact but what does that actually mean to the baby? Did more babies die? Did they experience more negative outcomes? What does it all actually mean in terms of 6 months down the line, do you have a healthy baby or not? And also how do you know that every practitioner scores exactly the same way in terms of APGAR? Is there any bias? Perhaps if someone is uncomfortable with homebirth they're more likely to look for problems rather than look for positives, hence there is bias introduced that babies born at home are just more likely to be scored lower because of the bias of the attending medics? (Even if they're not outwardly aware of their bias).

 

[Tasha]

I've moved this to new & debates, as it does seem to be more of a debate.

 

[Tasha]

Creative, I agree the term emergency c-section is confusing, it should really be referred to as a non-elective c-section (it is widely said as such in the medical world) and then emergency or crash for the true emergencies, that need a section asap.

It is 30 minutes (Germany is twenty) as you say, but is often not met. There is also data that suggests an emergency section done within 10-20 minutes has a better outcome than one done between 30-40 minutes.

From my own personal experience, when my waters broke with Honey (28+6) they talked to me about the risk of a prolapsed cord and told me if that were to happen we would be looking at a grade one section (immediate threat to either baby or my life) and the guidelines say thirty minutes but they aim to have decision to incision within seven minutes I didn't need it with her but had a grade one section the following year (for cord compression and a degraded placental causing fetal distress) at a different hospital and that was done within fifteen minutes.

 

[Buttercup2]

What does a low APGAR score correlate with? I mean 5, 10, 30 days further onwards can you tell a baby who was born with a low APGAR score from one with a high one? (Obviously a score of 0 is pretty awful because it means the baby isn't breathing and has no pulse - but what about higher than 0 but not 8, 9 or 10?) Does a lower APGAR score correlate with higher mortality? In what way? Or is it fairly meaningless by itself?

Midrange Apgar score at birth/1min is fairly meaningless. Midrange APGAR score at 5 min (which is the next time its generally taken) means that the baby is in trouble and will potentially have permanent problems. The study only looked at 5 min APGAR scores.

If i go to the trouble of finding the citation for this statement, will anyone read it?

Also, as a side note about emergency c-section, I agree there is difference between non-elective and emergency c-section. My friend had a placental abruption during labor after a 100% complication free, full-term, normal pregnancy (which is how placental abruptions usually are) and a real emergency c-section. The baby was on the outside of mom within 3 minutes. If you don't know what a placental abruption is and you're still pregnant, I don't think I would google it because it's scary. But it's probably the number one reason I'll be in the hospital for this baby. Placental abruptions are rare, but if I had one, a 10 minutes drive in an ambulance to get to the hospital would mean the loss of the baby, and unless the ambulance could do a blood transfusion, possibly the loss of mom, too.

 

[Buttercup2]

So again, to me what the article doesn't make clear is what having a low APGAR score actually means in reality. ... And also how do you know that every practitioner scores exactly the same way in terms of APGAR? Is there any bias? Perhaps if someone is uncomfortable with homebirth they're more likely to look for problems rather than look for positives, hence there is bias introduced that babies born at home are just more likely to be scored lower because of the bias of the attending medics? (Even if they're not outwardly aware of their bias).

At least here in the US, APGAR is in place to attempt to reduce bias. Every baby gets a score of 0,1, or 2 based on 5 different categories. It's not something that can be affected by bias unless the Dr or midwife doing the test is intentionally trying to cover something up. Even a non-medical person could do a good job giving an APGAR score if they knew how it was done.

I can't help it. Here is the citation, even if nobody reads it. It's pretty simple and easy to understand.
https://www.nlm.nih.gov/medlineplus/ency/article/003402.htm

 

[Tasha]

That was interesting, thank you buttercup. I didn't know a 10 was rare, one of my daughters was a ten at birth