to think home births are selfish?

[woozlet]

I just watched a 'desperate midwives' that I had recorded and there was a home birth on it which went wrong. It worked out ok in the end and the baby was ok. But I was really scared watching it, it just seemed like an unnecessary risk to take.

As I wasn't a carrier I can't comment on courses of treatment for strep b. The reputable American text I referenced talks about a reduction in risk of transmission from (argh not going to look it up its back there where I referenced! - what was it one/two in 100 to 1 in xooo - don't quote me!) ie from what is low to negligible - clearly other papers might quote different changes in transmission risks.

The actual point I was making was that strep b is not 'a virus you pick up in labour' but a bacterial infection transmitted from a mother who already has it. The poster seemed to be seeing it as a risk of a hospital birth. It's normally mild even if the baby gets it but it can be serious and I'm if there is no test at all.

But it's not specific to where you have the baby - even swinging from that chandelier. So in that sense it's a 'neutral' factor in this debate.

(Oh and NB the text makes clear you do not pick up strep b from getting very friendly with the rugby team. A certain percentage of the popln just carries it, that's all)

Not that I aim to get overly friendly with the hunky rugby team. (Chance would be a .....

Oh - one last thing - and this is probably pure unadulterated personal prejudice not backed up by any serious research whatsoever, okay, but I would have thought that the mortality/complication rate for unplanned home births was really low. Because these, surely, are the ones which always seem to happen because the baby rushes out so quickly (ergo no getting stuck etc) that the mother doesn't have time to get anywhere. Is it just me or do births at home/on the bus/in the back seat of the car rarely involve problems - or do I just watch too many soaps??

(Can see that in the case of very premature births this doesn't hold, although I suppose sadly the outcome might not be changed wherever they took place)

I'm with woozlet - women can give birth wherever they like but they shouldn't expect streched NHS resources to help them unless they are in hospital - it is so expensive and very very selfish to expect people to run round after them and then have to patch them up in hospital if it all goes wrong

not trawled all 9 pages but seems a sweeping statement to make woozlet!

ive had a hospital birth and a home birth. i know which one would have cost the NHS a lot less and it wasnt the hospital birth!

I used to think that women who wanted home births were well, a bit mental and scared of hospital and too earth motherish for their own or their baby's good. I had had a baby when I was very young and it was a horrendously long labour (72hrs+) on an epidural and never had so much as a wink of sleep or a drink of water throughout. The baby was born in serious distress. I always though how much worse that would have been at home.

What I realise now is that the labour was probably slowed by the epidural and my exhaustion and dehydration.

I recently had another baby and that was a horrible failed induction (because of my age) and that ended up in an emergency forceps delivery with a spinal and the baby's heart rate in freefall and finishing with a manual placenta extraction.

If it wasn't for the fact that I would be too high risk if I was having another one I would be seriously considering having it at home. Everything that went wrong seemed to go wrong because I was passive, in hospital and not in control.

Ferncottage - I don't have the figures to hand, but I think someone said earlier on in the thread, that a home birth is actually cheaper than a hospital birth.

As for the statement, "it is so expensive and very very selfish to expect people to run round after them and then have to patch them up in hospital if it all goes wrong" - well, words fail me.

why do words fail you? and people always say home births are cheaper but they are not - how can having 1 or 2 dedicated midwives having to come out to your house with all the equipment be cost effective?

yawn ferncottage

so do you stand by your logic then? should all women who want to have babies in hospital have to fork out for it themselves seeing as it's more expensive than a homebirth?

it's not more expensive than a homebirth - just because someone earlier says it is doesn't make it so

lol - go find the stats then ferncottage

Ferncottage - if homebirth is sooooo expensive then why do some US health insurers offer a cashback incentive to women wanting a homebirth?

Ferncottage - this is an american study, but hopefully sufficiently academic for you not to dismiss it out of hand.

"The Cost-Effectiveness of Home Birth
Anderson RE; Anderson DA (Dept. of Economics, Centre College, Danville, KY 40422, USA. )
J Nurse Midwifery, 44(1):30-5 1999 Jan-Feb

The authors compare costs of hospital, home and birth centre deliveries in the USA, noting that 40% of births there are covered by Medicaid. They state 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"

A further study showed that women who give birth at home are less likely to have Post Natal Depression. My PND has cost the taxpayer a fair amount of money over the years, in doctors' visits, CPN visits, psychologists' appointments and medication.

My home birthed baby had the highest APGAR score of all three of my babies. He had a very gentle, happy waterbirth. I don't see how it could have been a nicer experience for him. The midwives were prepared with full adult and neonatal resuscitation equipment.

Repeated studies show that home birth has no worse mortality rates for mother or infant.

Caesareans carry up to four times the mortality risk than natural birth and by going into hospital, you raise your risk of a caesarean enormously.

Take a look at this page which links to a recent, large Canadian study on home birth which found that home birth dramatically reduced intervention rates, haemorrhages and newborn trauma.

Addressing the 'low risk' issue, we have to be careful. There are a lot of ways of assessing risk and some of the criteria used are very dodgy. By the time you've eliminated people on grounds of age, size, first-time mother, multiparous mother, previous c-section, pre-38 weeks, after 40 weeks, GBS status etc. etc. you end up with very few low risk women. Some of the 'risky' factors such as VBAC have been found to make no difference at all (that Canadian study included 88 VBAC women and removing them from the statistics made no difference!)

Staying sunny - that study is not relevant to the UK because of the highly medicalised nature of US births
and how nice for Carmen to have full adult and neonatal resuscitation equipment available for her own private use

I paid for it, Fern. I was in California ;)

I don't have acces to J Nurse Midw - are they assuming the same ratios of midwives as we have in the UK? And they refer to 'births initiated in the home' so are they only contrasting with women who do all their labour in hospital as opposed to the NHS recs to stay home as long as possible before going to hospital?

If homebirths here all get at least one midwife all through, sometimes two, and hospital equally-uncomplicated births get 1 midwife to 2-3 women in labour and even fewer postnatally, plus the odd cleaner and assistant, can hospitals really be that expensive in comparison?

Unlike most people I got recommended to have a homebirth by all the midwives I met, but I figured that was because the homebirth team had recently expanded and my MLU/hospital team was severely stretched.

what will you do, ferncottage, if you can't find any stats saying hospital birth is cheaper? are you going to decide all hospital births should no longer be paid for by nhs funds? soooo curious

I have looked it up - a home birth does seem cheaper for the nhs, must be bed space etc.

But it is not even an option for most of us because there are not enough midwives to do them. So I guess it is taking away the resource from elsewhere.
OK so you have a homebirth team in some places, but if we didn't have increasing home births then those midwives would be in midwife units in hospitals giving more one on one care, out in the community etc.

Ftr my midwife pushed me in the direction of midwife unit as opposed to home birth.

Are there any midwives on here who could give their opinion?

I have a good friend who is a MW, I will ask her next time I speak to her!!

i had one midwife. i called her 40mins before i gave birth. she got to my house, delivered my baby, and went again. i had no drugs, one midwife for about an hour. my own gp came to check the baby over the afternoon i gave birth. it was stress free and cant have cost very much at all in terms of what a full hospital birth would have cost.

at the end of the day, we all pay into the NHS, we should have a choice.

"but I would have thought that the mortality/complication rate for unplanned home births was really low. Because these, surely, are the ones which always seem to happen because the baby rushes out so quickly (ergo no getting stuck etc) that the mother doesn't have time to get anywhere. Is it just me or do births at home/on the bus/in the back seat of the car rarely involve problems - or do I just watch too many soaps??"

I've seen a recent piece of research involving 39 bba's (born before arrival at hospital) which showed remarkably low rates of complications for mum and baby - despite the fact that many of the mothers included in the study were classified as 'high risk'. Of the 5 babies who needed admittance to SCBU, 4 were admitted for hypothermia - something that can usually be avoided with bit of common sense. All 5 babies admitted to SCBU were ok afterwards.

So yes - I think you're right in some ways Belissima! BUT - one group of women who are more likely to have bba's are women who've had no antenatal care (particularly women who've recently arrived in the UK, and very young women), and this group has the worst outcomes for their births of all - whether they give birth at home or in hospital. There is also the issue of preterm births and those women who have precipitate labours because of placental abruptions. I imagine these things would sway the stats quite a bit.

Ferncottage - I can ferret around and try to find you the stats on comparative cost of homebirth if you're interested. You are wrong you know - most homebirths only involve one midwife, except for the last couple of hours of the labour. In addition the vast majority of hb's are second and third time mums, who tend not to be in labour for that long, and also tend not to expect the midwife to lurk around until they're in good strong active labour. In other words - the 'manpower' issue isn't as you are thinking, particularly if you compare it to a birth centre where women are already receiving one to one care. If you compare it to a CLU where midwives are caring for several women at the same time, well perhaps it involves a few more midwife hours. However - everyone knows that this situation is very far from ideal and nobody should expect women to make the sacrifice of submitting to substandard care for the sake of saving the NHS a few bob. Not when their health and the health of their baby is at stake!

Would also want to add, would you want to restrict access to epidurals as well as homebirth on the basis of cost to the NHS? Epidurals are very expensive because of the necessity for obstetric input, and because women need one to one care after they've had one.

Re. cost of home birth vs hospital birth, IIRC then the Payment by Results charges were updated recently (earlier this year?) such that a PCT get the same amount regardless of place of delivery. My understanding is that these charge schedules were derived from average costs encountered - which suggests that for a straightforward birth, cost is not influenced significantly by location.

Re. unplanned vs. planned homebirths in the recent study - I think this was one of the big points of contention. In addition to the precipitous labours, "unplanned homebirth" also included those women who had declined all antenatal care for some reason (a sad one that sticks in my mind was that some were in denial about their pregnancy). Anticipated outcomes for these women would be expected to be poorer than for those that had a planned homebirth. (currently failing to find the ref for this, but I'm pretty sure it was made by a number of groups when that study was initially published, including the NCT)

I was leaning towards homebirth throughout my pregnancy, but DH took some more persuading. To me, the hospital was not a place where I felt safe. It wasn't a place where I felt cared for. It was a place where I felt out of control and scared by the noise of other women screaming.

In the end DH came round and I had a homebirth with DD. She was my first and breech. For us it wasn't a trivial decision - at the time there was no evidence to suggest CS gave better outcomes for either mother or baby over vaginal birth (the 2000 study being badly flawed), but everyone agreed that a vaginal birth with attendents lacking in experience was a more dangerous option. To guarantee breech experience we used IMs. IMs are rarely able to operate in NHS hospitals as MWs. So we had a choice of a CS or a homebirth. Was it an unnecessary risk? Not to us - we did the best risk/benefit analysis we could on the basis of the information available to us and took the option that seemed to have the best risk profile at the time (not made easier as few of the risks are directly comparable).

Our decision would not have been actively supported by the NHS, but they have no legal right to tell me I "cannot" do this. As has been said, none of the options are risk free - whether you're talking breech birth, VBAC, gestational diabetes or home vs. hospital, individually or in combination - there are risks and benefits to every course of action. Once maternal mental health starts being brought into play (and lets not forget that until obesity reared its head suicide due to post natal depression was one of the biggest, if not the biggest, causes of maternal death in the UK), one size doesn't fit all and maternal preference does become important.

Woozlet - the really big problem with midwife time is the fact that one in four births in the UK involves major abdominal surgery, and those mothers need proper nursing care. A large numbers of births also involve epidurals - which also makes for longer labours and more complex deliveries - and more intensive midwifery input.

Another stray thought - when I talked to the GP about homebirth initially (we didn't book with IMs till 36 weeks) one of the "reasons" given for not booking it was "there might not be enough MWs so you might have to go in anyway". But isn't that then a self fulfilling prophecy? If women who want a HB aren't prepared to stand their ground, there'll never be the information to say that there needs to be staffing to support this level of HB... I don't think its fair on anyone to be denied care at any stage of their pregnancy or birth or postnatally, wherever they are - but how do you instigate change except by showing the problems? How do you show the problems with CMW levels except by showing that demand exceeds supply?

Tangle - the thing that makes me angry with that sort of situation is that women who know how to go through the right channels (ie appeal directly to the supervisor of midwives) will almost always find a midwife is made available for their homebirth. I've known a head of midwifery to leave her warm bed to attend a homebirth because no other midwife was available.......

It's really crap. What about all the young women, and non-English speaking women, or less confident mothers, who wouldn't know how to 'work the system' in this way? Homebirth shouldn't be the sole preserve of the well off and articulate......