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STUDY: INFANT DEATH TWICE AS LIKELY IN HOME BIRTHSLOCAL NURSE-MIDWIVES REPORT DRASTIC DECLINE IN NUMBERS PERFORMED

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by Barbra Williams Cosentino, R.N., C.S.W.

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June is in labor with her first baby, and, although the contractions are coming every few minutes, she looks remarkably comfortable and relaxed. Propped up on lacy pillows, soft music playing, she squeezes her husband Jim's hand and smiles at Donna, the certified nurse-midwife who will help deliver the baby. Donna stands near the king-size bed, watching, observing, comforting, ready to facilitate the birth when it's time for the infant to be born. Giving birth at home, surrounded by familiar objects and loved ones, sounds like an idyllic experience. And, if everything goes well, it can be. But, a study published in a recent issue of Obstetrics and Gynecology, the peer-reviewed scientific journal of The American College of Obstetricians and Gynecologists, casts some new doubts about the safety of home birth. Conducted at the Washington School of Public Health in Seattle, the study looked at birth data for the period spanning 1989-1996, and compared the outcomes of 7,518 infants intended to be born at home to the outcomes of 14,038 babies intended to be born in the hospital. The women who had planned to deliver at home were, on average, older, more likely to be married, white, nonsmokers, and more likely to have given birth before. They also tended to be more highly educated. The study revealed that the risk of death to newborns delivered at home is nearly twice that of newborns delivered in hospitals, and the incidence of certain adverse infant outcomes (respiratory distress, low Apgar scores) and maternal outcomes (prolonged labor, postpartum bleeding) was significantly higher, especially for women who were having their first baby. Apgar scores, measured at one minute and five minutes after birth, assess functions such as heart rate, breathing and muscle tone. Deaths of infants with congenital heart disease or respiratory distress, deaths that conceivably could have been prevented if a hospital's specialized medical personnel and high-tech equipment had been immediately available, occurred with a relatively higher frequency among infants whose births were planned at home. Outcomes of all births were somewhat influenced by the training and experience of the birth attendant, with women whose births were attended by medical professionals (physicians or certified nurse-midwives) having better outcomes than those delivered by lay midwives. The study concluded: "Although the results suggest that planned home births are associated with an increased risk of adverse neonatal and maternal outcomes, more light needs to be shed on this controversial topic before practitioners and expectant parents can be fairly counseled about the safety of planned home births."

The safety of delivery at home has been the object of heated controversy for years. Physicians were not surprised by the findings of the most recent study, since the vast majority has always opposed home births, believing that even a seemingly normal birth can take a bad turn very rapidly. A baby can come out with the cord wrapped around its neck; a woman's uterus may be unable to contract effectively, leading to postpartum hemorrhage; and most physicians believe these situations require speedy intervention and all the resources that a hospital or a birth center with quick access to a hospital has to offer. With all the controversy, why would anyone choose home birth? A 1999 article published in the British Medical Journal listed several reasons — including the wish to avoid unnecessary intervention, the wish to be in a familiar setting, fear of the hospital setting, and satisfaction with previous home births. Sandra Fields, R.N., a masters-prepared certified nurse-midwife who has been assisting at home births in the New York area for more than 25 years, points out that this choice gives a woman the most freedom to determine how her labor and delivery will proceed, who will be with her, and what sort of interventions will be acceptable. For example, fetal monitoring, often routinely used in hospitals, limits mobility and prohibits the woman from walking during labor, even though walking has been shown to promote uterine contractions, relieve pain and speed up the process of labor. Women who must stay in bed during labor are more likely to experience increased pain, fear and anger. Fields adds, "When moms are in distress, often their babies are, too. Home births can actually decrease the risk of iatrogenic complications (those caused by medical procedures themselves) such as infection. Home births provide the nicest birth experience for mother and child, allowing labor to be tailored to the woman's individual preferences and needs, and allowing her to labor, deliver and recover without being moved from one place to another." The American College of Obstetricians and Gynecologists does not support home births, and Fields points out that physicians who are advocates of home birth and who agree to be back-up partners for home birth midwives are looked upon with great disdain by other doctors. Many have been threatened with loss of their hospital privileges or other formal or informal sanctions. Therefore, Fields says, there are now very few physicians in the New York City area who are willing to partner with or provide back-up for midwives. This is problematic because, if a woman needs to be transferred to a hospital during labor because of a complication, she does not have an attending physician there to facilitate the transfer and admission. Fields says that although home births were in great favor in the 1970s through the early 1980s, the numbers performed have greatly declined, particularly in the past 10 years, due to a number of social, political and economic factors. Although insurance companies are mandated to reimburse for midwifery services (most home birth health care providers are certified nurse-midwives), many plans do not make it easy for consumers to access these benefits. At present, there are less than 10 home birth nurse-midwives in the New York City area, she reports. "This is a shame, because these births are nonviolent, non-interventionist, respectful, and, in many cases, safer than a hospital delivery. " Fields remains hopeful that at some point in the future the pendulum will swing again. U.S. Lagging Behind Other Nations in Water Births

On a cold November evening 15 years ago, in a spacious loft on 22nd Street, Judith Elaine Halek, an experienced doula (labor coach), massage therapist and childbirth educator, attended the first home water birth with a midwife in attendance in New York. Since then, Halek, the director of Birth Balance: A Resource for Waterbirth, Doulas, Labor and Pregnancy, has helped to facilitate more than 100 water births in homes, hospitals and birthing centers, and has attended both the first water birth in a prominent New York City hospital and the first underwater breech birth in a United States hospital. Halek, a firm proponent of water birth, points out that the United States is at least five years behind the European nations in terms of water births being accepted in the hospital environment, but notes that midwives and home birth practitioners in this country have been offering water birth longer than most of their European counterparts. There are two ways in which water can be used to aid in the birth process. Water immersion means that the woman labors in the water, but gets out of the water to deliver the baby. In a water birth, both labor and delivery occur in the water. Barbara Harper, R.N., founder and director of the Waterbirth International/Global Maternal/Child Health Association, points out that human beings have always had a great affinity for water, and says that laboring/birthing in water has many benefits other than relaxation and comfort. These benefits include: — mother has greater freedom to change position to assist the descent of the baby — facilitates the progression of labor; stimulates dilation of the cervix — reduces pain; decreases anxiety, fear and stress — water helps the tissues of the perineum to become more elastic The Elizabeth Seton Childbearing Center on 14th Street in Manhattan, where approximately 95 percent of the clients use water as a tool for pain relief, enumerates numerous other benefits of water labor/birth. These include decreased maternal high blood pressure, less blood loss, less pressure on the abdomen which promotes stronger contractions, better blood circulation, better oxygen flow to mother and baby, the ability to reach a higher level of consciousness (which allows fears to dissolve), easier breathing for a woman who is asthmatic due to moisture in the air, and empowerment of the mother facilitating a positive start to the mother/child relationship. There are five inhibitory factors that prevent a baby from inhaling water, and the water birth baby doesn't breathe until it's actually exposed to cool, dry air. After the baby has gone from the fluid-filled environment of the womb, it goes down the birth canal and into the warm water of the tub; the baby is then immediately lifted out of the water and placed into the mother's arms, where it then takes its first breath of air. Conditions that preclude water birth include malpresentation of the baby, shoulder dystocia, certain medical conditions such as herpes and possibly hepatitis and/or HIV infection, excessive bleeding, premature labor, toxemia, severe meconium in the amniotic fluid. Twin or triplet pregnancies may or may not be appropriate for water delivery depending on the maturity of the fetuses and the mother’s overall obstetric condition. Water births have not been endorsed by the American College of Obstetrics and Gynecologists, whose obstetrics practice committee says there's not yet enough data to determine whether water births are safe. A report in the August 2002 issue of Pediatrics, the peer-reviewed, scientific journal of the American Academy of Pediatrics, suggests that delivering babies in water may not be as safe as traditional childbirth, and presented the cases of four New Zealand births, in which the newborns developed signs of moderate to severe respiratory distress after delivery. These infants improved rapidly with treatment and sustained no permanent damage. In an accompanying commentary, Ruth Gilbert, M.D., of the Institute of Health in London, said that complications, although rare, are more likely in poorly-managed water births, and neonatologist Joseph Gilhooly, M.D., of the Oregon Health and Science University, suggested that immersed babies should be removed from the water quickly to avoid the risk of aspirating water into the lungs. Dr. Gilbert, whose 1999 research study in the British Medical Journal found that perinatal mortality is not substantially higher for babies delivered in water, said that data comparing nonfatal risks are scarce, but also questioned claims that water births decrease pain, shorten labor or decrease injuries to the birth canal, concluding that more research is needed.


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