In two minds about having a home birth

[ViolaCrayola]

I had a horrible hospital induction 1st time around (have posted about this before), now 31 weeks with DC2.

Have been seriously considering a home water birth - have terrible SPD and water really helps. Plus all the other pros about home comforts, privacy, 1-1 care etc.

But I am very unsure that I actually want to have a baby at home! People seem to often be either very definite about home births one way or another, but I just feel undecided. Has anyone else felt like this? How did you decide eventually? Time is running out! :)

FFS, the Birthplace study did NOT show that homebirths are safer.

I quote directly from the birthplace study-

"There was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).
In other words, the risk of death and serious injury was approximately double in the homebirth group and that increase was seen mainly among first time mothers."

"Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome..."

Homebirth increases the rate of perinatal death in most cases.

It is acceptable to say homebirth is safe enough for certain low risk women, but to pass a statement that says homebirth is safer is ridiculously inaccurate.

I'm with you Carrie. I don't trust homebirth and I would never opt for it.

WhattheHell, if you are looking just at the 'primary outcome', as they called it, then yes the study found that HB is as safe as hospital birth for multiparous women, not necessarily safer (the rates overall were slightly better for multiparous women at home rather than in a CLU but I don't think they were statistically significant). If you are looking at outcome (morbidity) for mother AND baby overall, then I think there could definitely be an argument that HB is safest for that group.

Homebirth increases the rate of perinatal death in most cases.
Source? They didn't specifically looked at perinatal death in this study. Yes the total numbers are recorded somewhere but they are so small that they couldn't draw any significant conclusions overall.

FFS, the Birthplace study did NOT show that homebirths are safer.

I have read back through the thread and as far as I can see, no-one has claimed that it does. What has been said is that it does say that it's as safe for multiparous women and that a woman herself is more likely to have intervention in a CLU. I am personally not of the opinion that 'the only thing that matters is a healthy baby' - I think the mother's health matters too, and the risks of having an intervention is something which a woman needs to consider when weighing up her options.

You personally don't trust home birth and would never opt for it. Others may find if they read the research that they came to a different conclusion. The Place of Birth study says

Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting. Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings....

For healthy multiparous women with a low risk pregnancy, there are no differences in adverse perinatal outcomes between planned births at home or in a midwifery unit compared with planned births in an obstetric unit.

For healthy multiparous women with a low risk pregnancy, there are no differences in adverse perinatal outcomes between planned births at home or in a midwifery unit compared with planned births in an obstetric unit.

Statistically, maybe. Over a large sample of women, stratified for risk. Unless you are the unfortunate person who labours at home with an unanticipated obstetric emergency, or the fortunate person who chooses the hospital and ends up with a healthy baby rather than a dead one?

You won't be interested in statistics then.

Of course you could be the unfortunate person who has a baby die in hospital because of understaffing or negligence, or picking up MRSA...

Carrie370

What other information do we have to go on? Isn't a rigourous report as good or better than anecdotal evidence? We could all argue what if I were the one person? What if you were the one whose baby died because the hospital was too short staffed to give you an acceptable standard of care? Someone up thread did refer to a friend's baby dying because no-one was around to read the monitor.

We have to balance the risks as they are likely to affect us.

it did show babies outcome better - to 0.1% for low-risk multi paras - poss not statistically significant but also significantly better in terms of secondaries such as neo-natal admission. MLU also significantly better in terms of secondary outcomes.

not spending a day or two with your baby in hospital after the birth is a definite benefit to both baby and mother. so safer.

definitely safer for mothers.

you'd have to read more than the summary to get that though.

"There is a truism that the length of a woman's birth plan is in direct proportion to the likelihood of her needing intervention"

Yes - and there have been speculation that this is because a long birth plan is greeted with arrogance and hostility by care givers and impacts on the quality of the care they provide.

I have certainly seen midwives sniggering over a woman's birth plan in a corridor.

"but to pass a statement that says homebirth is safer is ridiculously inaccurate"

I'd say that anything that halves the likelihood of you having emergency abdominal surgery and reduces the risk of you ending up in HDU (as homebirth appears to do) could reasonably be called safer.

"You won't be interested in statistics then."

Carrie - when you are making clinical decisions at work, do you generally go on gut feeling, or do you try to base your decision making on best evidence?

Would you ignore good quality research which suggests that a certain technique or drug is associated with a doubling of the risk of serious complications, because it didn't fit with what you'd seen in your practice?

Personally, given that the history of obstetrics in particular is littered with examples of doctors harming women and babies with practices that they were convinced were beneficial (routine forceps birth; routine episiotomy; scopolamine birth; induction at term for all), I'm profoundly grateful to live in an era of evidence based medicine.

Statistically, maybe. Over a large sample of women, stratified for risk. Unless you are the unfortunate person who labours at home with an unanticipated obstetric emergency, or the fortunate person who chooses the hospital and ends up with a healthy baby rather than a dead one?

"You won't be interested in statistics then."

I agree - statistics mean nothing in the event of a poor outcome. I often think of the women who have complications during emergency c/s - the bowels and bladders nicked during surgery, the ones who have a catastrophic bleed and end up needing a transfusion, the ones who go home with a serious infection or end up with placenta accreta or percreta in their next pregnancy, or a scar rupture in a labour following first c/s. Wonder if those women ever consider that they might have halved their risk of having emergency surgery if they'd stayed at home to give birth?

"but I think we should do well to remember how the hospitalisation of women in labour has reduced the maternal and child death rates over time"

Actually I think you'll find that the biggest reductions in maternal mortality and morbidity happened when the majority of women were still giving birth at home, and were the result of antibiotics, higher standards of living and better antenatal care.

This book explains it all: here

"
Homebirth increases the rate of perinatal death in most cases. "

no it didn't.

no conclusion could be drawn in the birthplace studies - a good thing as it meant very low recorded incidence in all settings.

"the researchers focused solely on women planning to have their first baby at home, they found they were almost three times more likely to suffer complications than if they went to hospital.""

actually the difference was +0.4% (o.5% to 0.9%)

not three times. this they found to be sae.

and as shag says no difference from CLU and freestanding MW units with a longer average transfer time than from home (39 mins vs 29 mins).

the three times figure comes from disincluding 20% turning up at CLU with prev unknown risk factors - which the study didn't know the cause of (comparable figure 7% and 3% for HB and MLu)

my speculation would be the stress and stalling of CLU admission procedures (which are recorded in the case study part) cause these additional risks. obviously you can't choose in advance to not be in that 20%, so for decision making purposes they should be included and the study acknowledges this.

What's it like working at holby city, carrie?

Or, if by any chance you are actually a qualified doctor, could you stop scaring me more about the crappy attitude of the average healthcare worker wrt evidence based medicine. Please please at least pretend you prefer it to 'I reckon' - it makes me feel better to think the people I entrust my health to, do actually both read and understand scientific studies

"if that baby has a problem, in hospital you will get the most senior paediatric doctor on site with you in minutes.."

only 8% of CLUs have more than 60 hours a week of on-ward consultant cover (24 hour bleep cover is universal)
more than half of women labour in a clu with only midwife care.

Holby City :o

Yes, I am a qualified doctor with many years of experience. That experience allows me read and understand scientific studies, but at the same time to use my clinical judgement to do what I believe is best for my patients in their particular circumstances. They are, of course, completely at liberty to ignore my advice or refuse treatment. At the same time, doctors are also human, and their experiences will influence what they believe.

I know obsteticians who are vociferously opposed to home birth, and those who think it's wonderful. These are surely the people best qualified to have an opinion on the matter, so the fact that opinion is so polarised in this group says it all.

We (as in doctors) take evidence based medicine with a healthy pinch of salt. There is no one-size-fits all in clinical medicine. I know you will find that comment depressing.

Edgarallenpimms What the hell just happened is right - I've just looked up the stat and it does say it triples the rate but only for first time mums.

Then again the risks are fairly small in actual numerical terms.

What I don't understand is why people get so bothered about how other people want to give birth.

I'm in the 97% who wouldn't touch home birth with a barge pole but I don't have a problem with the 3% who want it.

You're having the baby, do whatever you feel is right for you. Good luck

i explained the three times business.

0.9% is not three times 0.5% - those are the figures for 'serious adverse outcomes' for first timers in the birthplace study.

i quote

[[https://www.npeu.ox.ac.uk/birthplace/results "For women having a first baby, a planned home birth increases the risk for the baby

For nulliparous women, there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units, and this finding was statistically significant."]]

so, actually wrong :)

I agree that there is no 'one size fits all' when it comes to clinical medicine.

Which is why it's so odd that doctors routinely choose and recommend hospital births for healthy women - given the absolute dearth of evidence in support of their view that it's safer and better for all mums and babies.

Honestly - I think there's some really unethical behaviour going on in relation to this issue. Doctors have a duty to make recommendations based on best evidence. They can't and shouldn't allow what they know to be a distorted personal perspective to override the evidence. Not when women's future reproductive health is at stake.

We (as in doctors) take evidence based medicine with a healthy pinch of salt. There is no one-size-fits all in clinical medicine. I know you will find that comment depressing.

Very few of us would find that depressing - we would be only too glad if we were treated as individuals instead of being treated as units to be shunted through the system driven by protocols.

I would never recommend a home birth to any one I know. Er forgive me, but isn't that a one size fits all approach? What of the woman who had previously had a rapid birth? Do you really think that giving birth unattended in a car by the side of the road is a better option?

I am curious though - have you read the Place of Birth Study? If you take evidence based medicine with a pinch of salt, on what basis do you base your practice? I do note that you sidestep the question of iatrogenic problems each time.

^Lovebunny.
You say your daughter was saved, HB didn't cause her pph and the emergency protocols worked.
You had a hospital birth with complications, your mother had a sucessful home birth an was treated for pph successfully.

I don't get your reasoning for thinking a hospital birth is safer.

Pph happens t home and I hospital. If it happens at home women are taken to hospital and treated. Everyone who has a HB knows that there is a possibility they will transfer.

On balance it seems better to have a HB and only go to hospital if you need to.^

hmm. i might just as well say that arriving at hospital between 8 and 9 am on a monday morning saved my daughter, as everyone was there ready to spring into action - seventeen of them.

but i think, be in hospital, to cut out the time taken for the transfer. if the road had been up, or there had been a car accident blocking the way, i would have lost my daughter and my world would have been very dark indeed.

My first baby was prem and I wound up giving birth in the car. We decided to be safe and have planned home birth second time around. It was perfect for us. After we put DD1 to bed, I went into labour, had a bath, and midwife just made it in time to put her gloves on and catch DD2 (2hrs end to end!!!). It was great being in my space and at the end get into my bed, with my husband and baby next to me! No stress, no cars, no noisy hospital, and the best was my DD1 the next morning when she came in a saw the baby in the moses basket and said 'Mummy look! It's a baby!' :o. I say go with what feels right for you and your family. Good luck!

"Which is why it's so odd that doctors routinely choose and recommend hospital births for healthy women - given the absolute dearth of evidence in support of their view that it's safer and better for all mums and babies."

I don't think it's odd at all. A Doctor's job is to help people who are unwell get better. If a birth goes wrong their job is to help the mother and/or baby. They would rather do that in their own hospital, with everything to hand, and with as much time in hand as they can muster. Hence they would rather not have to do their job when a lot of time has been lost in a transfer.

As I am prone to constructing poor analogies, and I offer this one - I suspect that most car mechanics would prefer fixing your car in their own garage, during daylight hours, not peering under your bonnet in the pouring rain by the side of the road at midnight.

Obviously, the issue should not be about "what makes life easier for Doctors."

I have had 2 (planned) home births and am currently pg with dc3. I'm not anti hospital in any way, my logic was simply why go to hospital if there is no medical need? I wouldn't hesitate to be transferred if there was any doubt about the safety of me or the baby.

My experiences are mostly positive, although the MW at the first birth wasn't great and I believe she could've slowed the second stage down avoiding the almost 3rd degree tear I had (and subsequent transfer for stitches after the birth). With my 2nd baby, only one midwife arrived in time, she was calm and unobtrusive and everything went well. I had gas & air with dc2, nothing with dc1 as didn't feel the need.

In 2 home births I have never once had an internal examination - nobody has ever felt the need to see 'how far along' I am- this has been a big plus point for me as I go very quiet and like to be left well alone when labouring. That said, all foetal heartbeat checks took place just as they would in hospital.

Interestingly I'm probably having my biggest wobble this time, after watching OBEM with the horrific shoulder discotia birth. I told my MW of my concerns, she reassured me that this is very rare, particularly with 3rd babies, and interestingly particularly with home births.

As an anaesthetist, I am not the person who advises women on where they should give birth - that is a discussion for the GP/midwife/obstetrician to have with the patient (OK, client :)) so I am not using my 'distorted personal perspective' to sway anybody. I do concede that a rapid previous labour might be an exception, though!

All I am trying to do here is to make people aware of the catastrophes that can befall a labouring woman, because I have seen them first hand, and to make people think a little harder perhaps about what is often viewed as a normal, natural physiological event, but which, infact, not infrequently leads to significant morbidity or mortality for mother or baby. In my view, when this happens, it is better that it happens in a hospital. That is all.

In my own area of practice, I keep up to date with the evidence, but use my clinical freedom to first 'do no harm' but secondly to tweak the evidence as I see fit for each individual patient and situation. An example is putting in large drips in the neck - the NICE guidelines say ultrasound should be used to locate the vein, but for me and many of my colleagues this is a new technique that we have managed without for years, and we are perfectly free to ignore the guidelines without any fear of comeback.

"All I am trying to do here is to make people aware of the catastrophes that can befall a labouring woman",

What - do you think the majority of pregnant women live in a cave or something, and have no idea that 1 birth in 4 is a surgical birth, and that 1 in 10 is assisted? Why do you think 98% of women go to hospital to have their baby? Because they see birth as primarily a medical event which should take place in a medical environment.

Women on the whole didn't used to think about birth this way. Even when more births ended in tragedy.

"and to make people think a little harder perhaps about what is often viewed as a normal, natural physiological event, but which, infact, not infrequently leads to significant morbidity or mortality for mother or baby"

To translate: "some women have confidence that their birth is likely to be uncomplicated and that it is safe for them to have their baby in a non-medical setting. I want to remind them that it can all go horribly wrong and that they could lose their baby. I appreciate they already know this to be true, but if they hear me say it, it'll really affect the way they think and feel about birth, because I'm a doctor, and I speak with authority"

Well thanks for that that Carrie.

"and we are perfectly free to ignore the guidelines without any fear of comeback"

Is that because you believe the way you do things at the moment is genuinely better for patients?

Or is that because you all watch each others backs and if something goes shit-shaped because you're not following best practice guidelines, you'll get away with it because it's hard for patients to prove malpractice when medics are all covering each others arses?