Birth is a common happening in every household. While in urbanized nations, birth occurs mostly in a hospital or birth care center, home birth is still a practice in many developing and underdeveloped parts of the world. Many issues arise while considering where a baby must be born. Some of the important issues are safety and health of the mother and the child, convenience and comfort, and financial aspects.
Safety is dependent on the health condition of the mother and the fetus, the knowledge and expertise of the birth attendant or mid wife or health professional, and the availability of immediate access to higher services in case of emergency. When a mother is advised where her baby must be born, these issues need to be evaluated. In this assignment, I shall explore various aspects of home birth as brought to discussion by a mother. Intriguing Event 22 years old Laura, came to the primary health center with her husband. She was 32 weeks pregnant.
She conceived after 2 years after marriage, this being her first pregnancy. Fetal scans were normal. There were no complications so far and Laura had a regular antenatal check up till date. Laura wanted to deliver in her parents’ home town which was about 40 miles away from the nearest birth center. She wanted to know if she could opt for home birth since it was an uncomplicated pregnancy. She had many questions to ask the practitioner about homebirth. These included: 1. Is it safe to deliver at home and who should attend the delivery? 2.
Is it safe to shift to a hospital in case of emergency while in labor? 3. What are the pros and cons of home delivery? 4. What are the costs involved in home delivery? To answer these questions, it is important for the practitioner to understand various aspects of homebirth so as to deliver evidence-based practice. Home Birth Child birth that occurs outside a hospital or the setting of a birth center, usually in the home of the mother is known a home birth. The delivery may or may not be attended by a midwife or any other health professional.
When the delivery occurs without the assistance of a health professional, it is known as ‘unassisted home birth’. Home birth is not much in practice now especially in the urbanized cities and towns. Though in yester years, it was much in vogue, it declined in the 20th century. This is because of the assumption that hospital based deliveries supervised by obstetricians and pediatricians are safer for both the mother and child. However, there again seems to be a rise in the homebirths even in industrialized nations. Politically and academically ‘homebirth’ is a much debated topic.
Though there are many studies conducted to evaluate homebirth, the benefits remain unproved as yet. An ideal method of assessing the benefits of homebirth would be to conduct a randomized control trail. However, this seems less practical in the event of need for large numbers to get enrolled in the study, and also to have a proper environment for home delivery (Springger & van Weel, 1996). Currently, home birth is being promoted in many parts of the world including Europe, Australia and the US. In Netherlands, the incidence of home delivery is as high as 30%.
This is because; there is “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 and, there is 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 birth. ” (Weigers & Keirse, 1998). Incidence The incidence of home birth varies from country to country worldwide depending on the industrialization.
It is lowest in developed countries. In Britain, the incidence of homebirth is estimated to be 0. 6% (Macfarlane, McCandlish, & Campbell, 2000). In the Netherlands, 30% of births are planned to be at home (Bastian, Keirse & Lancaster, 1998). Safety aspects of home birth Though hospital settings have more infrastructures and expertise to take care of complications occurring during and after delivery, since most of the deliveries are uncomplicated, home delivery is safe for uncomplicated pregnancies under the supervision of midwives or any other trained health personnel.
Infact, most of the studies on the safety of homebirth are on low-risk pregnancies. Low-risk pregnancy means pregnancy which is less likely to have medical complications. This is determined by the fact that there are no obvious medical problems during pregnancy, the woman has started her prenatal care before19 weeks of gestation, has had 4 visits of antenatal care through the 28th week, every 2 weeks for the next 8 weeks and then weekly for the last 4 weeks. It is obvious that high-risk pregnancies need to be delivered in the hospitals under expertise supervision and monitoring.
Also, high risk mothers seldom opt for home delivery (Davies et al, 1996, quoted in Macfarlane, McCandlish, & Campbell, 2000). Olsen (1997) did a meta-analysis of the safety of home birth in low-risk pregnant women. The study revealed that perinatal mortality and maternal death rates were actually similar to both home and hospital deliveries. Also, there was a lower frequency of low Apgar scores and severe lacerations and also fewer medical interventions in home deliveries. The author concluded that “it is at least as safe for healthy women to give birth at home as in hospital, and perhaps safer.
” He insisted that obstetricians should be encouraged to base their judgements on empirical evidence rather than ‘pre-scientific dogmas’. Johnson & Daviss (2005) evaluated the safety of home births in North America involving direct entry midwives. They concluded that planned home birth for low risk women using certified professional midwives was associated with lower rates of medical intervention. The researchers also reported that the intrapartum and neonatal mortality was similar to that of low risk hospital births in the United States.
Similar reports were inferred from other studies (Weigers et al, 1996, Ackermann-Liebrich , 1996). Infact, Weiger et al (1996) opined that “there was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background, and in multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables.
” Davies et al (1996) studied the experience and outcome of pregnancy, the indications for hospital transfer, and the attitudes of mothers, midwives, and general practitioners amongst women requesting a home birth. The study revealed that the women who delivered at home were at ease because of family setting. Most of the times, the care-givers were midwives. General practitioners were apprehensive about inability to handle complications arising during homebirth. However, study by Bastian, Keirse & Lancaster (1998) showed different results.
In their study they found that home births in Australia carried a high death rate compared with both all Australian births and home births elsewhere. The cause of these high rates was accounted to “underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress”. Certain emergencies like cord prolapse, inverted uterus, or bleeding of the mother and breathing problems with the infant, may need immediate intervention which can be instituted only when the patient is in the hospital.
Benefits of home birth Since homebirth occurs in the setting of the mother’s house, she is naturally comfortable. The mother has a good control of the surroundings. She can eat, move around, talk to her family members and do any thing she pleases to comfort herself. The incidence of medical interventions like episiotomy, forceps application, cesearean section, vaccum application and epidural anagesia is reduced (Johnson & Daviss, 2005). All these pose some risk to the health of the mother and baby, which a homebirth can help minimize. Also, homebirth is cost effective.
Child birth makes up one-fifth of all health care expenditures and is also and is the most frequent cause for hospital admission. World wide, there is a surge in the health care costs and many women are without insurance. Costs in home birth are defined as charges to the mother for a routine birth. Hospital birth in the US costs about 6000-10,000 dollars for vaginal birth. But homebirth costs between 1500-3000 dollars (Home birth guide, 2007). In the US only 40% of births are covered by medicaid. Anderson & Anderson (1999) compared costs of hospital, home and birth centre deliveries in the US.
They concluded that “informed birthing decisions cannot be made without information on costs, success rates, and any necessary trade-offs between the two. 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”. Women who deliver in their homes are less likely to have painful perception of parturition. This is evident from the study by Morse & park (1988).
Also, there is less risk of acquisition of hospital acquired infections like multi-drug resistant staphylococcus which when transferred to baby during deliverycan cause significant morbidity. Perineal outcomes in home birth Aikins & Feinland (1998) studied the damage in the perineum in those women who delivered at home and compared with those who delivered n the hospital. Their study revealed that about 70% of the women had an ‘intact perineum’, in the sense, there were no tears, minor abrasions (grazes) or small tears that were not stitched. This is a very good rate when compared to the high rates of episiotomy in hospital-based deliveries.
Episiotomy is actually equivalent to second degree perineal tear. Aikins & Feinland (1998) concluded that it is indeed possible for or midwives to achieve a high rate of intact perineums and a low rate of episiotomy in a select setting and with a select population. Studies by Oslen (1997) and Johnson & Daviss (2005) also reveal that the incidence of severe lacerations is much low in homebirths. Choosing between homebirth and hospital- delivery The women should be given accurate and balanced information about the pros and cons of home delivery.
The women must be told that home delivery is safe as long as they follow professional advice. Those with high risk pregnancies including twin, breech and post-term pregnancies have increased risk involved in home-births when compared to low-risk pregnancies (Macfarlane, McCandlish, & Campbell, 2000). The women must be given individualized specific advice. One important aspect during homebirth that taunts most mothers while choosing between home and hospital delivery is, whether transfer during labor is safe, in case of any unexpected complications.
Studies have shown that transfer during labor is safe ((Macfarlane, McCandlish, & Campbell, 2000). Role of the midwives and general practitioners during home delivery It is important for general practitioners to create the right circumstances for safe and satisfying home births (Springer & Van Weel, 1996). The care delivers have a responsibility to select women who are not at high risk of complications and to establish an infrastructure for safe obstetric interventions. They need to provide basic obstetric infrastructure like elevated beds. They also need to provide support during labor and also after delivery.
Maternity home care assistants have a pivotal role in taking care of the baby and the mother. The health care attendants must also allow access to hospital facilities in the rise of serious complications which need the immediate attention of expertise care. Hence there should be good coordination between the primary care health personnel and the obstetrician (Springer & Van Weel, 1996). Conclusion Home births are considerably safe, as much as birth-care center or hospital deliveries as long as there is appropriate prenatal care and attendant personnel. They offer the comfort of family setting to the mother.
The cost to health care is low. Also, the incidence of medical interventions is drastically reduced contributing further to low cost. Meticulous selection of women at low risk of obstetric complications is the key to achieve good results in homebirth. Both financially and medically, it makes sense for state laws to permit home birth attended by midwives. Insurers must be pressed to reimburse for home delivery. Obstetricians and pediatricians of near-by hospitals must provide support, so that the mother or the baby can be shifted immediately in case of any emergency.
Thus, it can be said 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.
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