US Home Birth: Join me on a casual meta analysis and personal case study

[ajay004]

Hello fellow science-minded parents!

My spouse and I are discussing trying to get pregnant with our second child. As part of that discussion, we are contemplating if home birth would be a suitable option. There are a number of personal reasons why we are considering this, but none of them are related to anti-science or anti-medical establishment sentiments. With that said, the current scientific literature on US home birth is sparse. I would like help collecting, reviewing, and applying what current studies are available in order to make a better informed decision. Below I have included details from our life that can act as a case study of sorts to aid in discussion and application.

PLEASE NOTE: I am not interested in anecdotes or scary stories. However, I understand that some statistics related to infant mortality are inherently fear inducing. I believe those types of details are acceptable and a necessary part of the discussion.

Case Study:

• Mother has 1 prior uncomplicated L&D at local hospital

• Mother has no underlying health conditions and is under the age of 35

• Mother successfully breastfed previous baby with intentions to breastfeed the 2nd. Bottles would be easily accessible as backup.

• Distance:

-3 miles from local hospital (7 minutes at speed limit)

-.4 miles from fire station (2 min drive)

-50 miles to one of the nation's leading children's hospitals (local hospital has a helipad)

• Mother plans to follow basic guidelines for care through pregnancy (2 ultrasounds, screenings for GD, anemia, etc., routinely check BP and fetal heart rate), and would change to a hospital birth if anything indicates an expected complication.

• Family would be hiring a certified professional midwife and the assistant midwife-in-training

-Both birthing professionals have multi year experience

-They are part of a larger, long standing midwifery practice located about 30 minutes away

-They are trained and experienced in adult & infant resuscitation, nuchal cords, suturing, and administering IV medication for hemorrhaging

-They provide follow up care of infant and mother in days/weeks following birth

-There is a continuous education/training model for this particular midwifery practice

• Family is already established with a pediatric practice. New baby would be seen by a doctor within 24-48 hours.

One source that may be a useful jumping off point:
https://www.acog.org/clinical/clini...e-opinion/articles/2017/04/planned-home-birth

I look forward to reading through your findings and the resulting discussions!

EDIT: I am struggling with mobile formatting. I apologize.

 

[kjv4me]

@ajay004 I'm in Canada, where there was a large study a few years ago in BC.

"There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted."

https://www.cmaj.ca/content/166/3/315

 

[lizmoshes]

@kjv4me I am pretty sure the requirements to be one a Canadian midwife vs a US midwife are very different as well so something to keep in mind when comparing to US outcomes.

 

[ajay004]

@lizmoshes This is a good point. I did find the handbook for AMCB certification, which is very helpful to review, but I haven't yet taken the time to search for Canadian or other countries' midwife certification requirements. It would be really helpful if someone already did a deep-dive comparison online, but I doubt I'd be lucky enough for that.

edit: It appears there is another common midwifery certification group, NARMA. Here is their testing handbook. See pages 33-49 for the list of topics that are tested.

 

[lizmoshes]

@ajay004 Not scientific but an overview of the differences between US and Canadian midwives

Based on that, Canadian midwives have a higher degree of education and are more equivalent to American certified nurse midwives which delivery typically in hospitals.

My concern with comparing outcomes with midwives that are college trained vs outcomes with what are potentially high school graduates is that it’s an apples to oranges one. I mean, could call myself a midwife and delivery a baby at home but my degree is in criminology; or you could have my sister who’s a nurse practitioner (one level lower than an MD in Canada) who’s worked at the local children’s hospital in the NICU with 3 kids of her own; or vs go with a fully licensed midwife.

All that to say, if there are different levels of midwives in the US (assuming that is where you are), there’s be a huuuuuuge difference between having a direct entry midwife call a nurse midwife and the outcomes.

For what it’s worth, I had a hospital birth with the head midwife overseeing it as the OB was occupied with another birth. My care was supposed to of been transferred to Obstetrics due to a sudden elevated BP but they couldn’t be bothered to attend apparently and I am forever grateful to my midwifery team. They advised against a home birth or a birth centre birth for me because I had a history of unexplained hemorrhages so there are risk factors beyond our control (as I am sure you know!) for who can safety due a home birth. Turns out I did hemorrhage and they need ALL THE TOOLS to stop the bleeding so it was the right call to be at the hospital.

 

[andybrooks]

@ajay004 I had a planned homebirth in the US. I also read that the minimum education requirements are different in the US vs. Canada vs UK vs. NZ etc. BUT just because the minimum is lower, doesn’t mean individual midwives don’t go above and beyond to learn more. One of the things I did was ask the midwife exactly how she learned, what she learned, and what her experience is. The one we had had spent quite a bit expanding her knowledge base and we felt very comfortable with her, she was awesome. Doesn’t mean every other midwife in our state knows the same things, sadly.

 

[ajay004]

@andybrooks Right, I think this is one reason why science can break down at the individual level. There is only so much you can quantify and predict, including the quality of care you will get from a specific midwife.

 

[andybrooks]

@ajay004 Yep. Though that is true for any care provider. Just because they pass exams doesn’t always make them good providers. Sadly.

So I think it’s good when people ask these questions.

 

[marie1980]

@ajay004 Ok I can’t find the story, but EBB did an episode with an OBGYN who was pro hospital birth but after her experience did a home birth for her second child. Maybe someone else will remember the episode. I did find this one Home Birth Nurse Advocate

EBB has some research on Homebirth, I am debating it too for the if/when second kid. Everything i read was 1) If it was planned, 2) If you had a successful first vaginal birth 3) If your midwife was tied into the medical system and could transfer you without issue and ideally be involved with your care and then Constant monitoring throughout pregnancy as things develop and you might risk out of it being an option. All lead to a successful home birth, the statistics are skewed in the us b/c planned home birth and unplanned home births are lumped together along with planned home birth with a lay midwife who isn’t plugged into the larger medical system.

 

[ellyflowers]

@ajay004 https://evidencebasedbirth.com/wp-content/uploads/2018/04/Home-Birth-Webinar-Handout.pdf

Before I had my first of 2 uncomplicated homebirths, I listened to this webinar and felt more confident about my decision. I can’t find the video webinar link but I could find the slides. Perhaps the references will be helpful. How quick was your first? My first was fairly quick (no noticeable early labor, 5 hours active labor and 2.5 hours pushing). My second was (11 hours easy early labor, 45 min active labor and 5 min pushing…). For the second, it would have been tough to make it to the hospital in time as I prob wouldn’t have left early enough. i think it’s safest to have a planned homebirth than a car baby! I had concurrent care with an ob then pediatrician office and also midwives and the midwife care was so much better for me. Especially postpartum. Good luck!

 

[lorimidwife]

@ajay004 You might enjoy this video. She references many studies.

 

[ajay004]

@lorimidwife Mama Doctor Jones! I love her material. She does a great job here of giving an overview of the major studies and emphasizing the difference between relative risk and absolute risk. I think her points about the potential for midwifery care in the US are important.

 

[sarahsknight]

@ajay004 This is the reference list for the homebirth chapter in Emily Oster’s book Expecting Better. Thought some of these might help you, although the book is getting a little old now, so there are probably newer studies.

J. R. Wax et al., “Maternal and Newborn Outcomes in Planned Home Birth Vs Planned Hospital Births: A Metaanalysis,” American Journal of Obstetrics and Gynecology 203, no. 3 (2010): 243.e1, 243.e8.

https://obgyn.mcw.edu/wp-content/up...nd-Newborn-Outcomes-in-Planned-Home-Birth.pdf

Birthplace in England Collaborative Group, “Perinatal and Maternal Outcomes by Planned Place of Birth for Healthy Women with Low Risk Pregnancies: The Birthplace in England National Prospective Cohort Study,” BMJ 343 (2011): d7400.

A. de Jonge et al., “Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-Risk Planned Home and Hospital Births,” BJOG 116, no. 9 (2009): 1177–84.

A. C. Evers et al., “Perinatal Mortality and Severe Morbidity in Low and High Risk Term Pregnancies in the Netherlands: Prospective Cohort Study,” BMJ 341 (2010): c5639.

J. W. Y. Pang et al., “Outcomes of Planned Home Births in Washington State: 1989–1996,” Obstetrics & Gynecology 100, no. 2 (2002): 253–59.

P. A. Janssen et al., “Outcomes of Planned Home Birth with Registered Midwife Versus Planned Hospital Birth with Midwife or Physician,” CMAJ 181, no. 6 (2009): 377–83.

 

[ajay004]

@sarahsknight Thank you! I will look over these studies. Do you recall what Oster's conclusions were?

 

[sarahsknight]

@ajay004 I can look, but her conclusions are usually just to tell the reader “weigh the risks and decide what you are comfortable with.” Which I think is what you’re trying to do, right?

Here’s her summary from the end of the chapter.

If you don’t want any pain medication, there are some pros to home birth. There are fewer C-sections, less instrument delivery, easier recovery for Mom, and less tearing.

If you haven’t done this before [meaning it’s your first birth], there is about a 30 percent chance you’ll end up in the hospital anyway.

Some studies suggest that mortality risks are higher with home birth, others do not. Risks are low in any case.

If you do decide to go this route, make sure you choose as experienced a midwife as possible, ideally a certified nurse-midwife, who has had nursing, midwifery, and infant resuscitation training.

Excerpt From
Expecting Better
Emily Oster
https://books.apple.com/us/book/expecting-better/id580646334

 

[huskmc]

@ajay004 This study might be helpful: https://pubmed.ncbi.nlm.nih.gov/24479690/

 

[ajay004]

@huskmc I'm reviewing this article now. One part that stands out to me is the causes of the observed fetal deaths.

"Of the 22 fetuses who died after the onset of labor but prior to birth, 2 were attributed to intrauterine infections, 2 were attributed to placental abruption, 3 were attributed to cord accidents, 2 were attributed to complications from maternal GDM, one was attributed to meconium aspiration, one was attributed secondary to shoulder dystocia, one was attributed to preeclampsia-related complications, and one was attributed to autopsy-confirmed liver rupture and hypoxia. The causes of the remaining 9 intrapartum deaths were unknown. For the 7 newborns who died during the early neonatal period, 2 were secondary to cord accidents during birth (one with shoulder dystocia), and the remaining 5 were attributed to hypoxia or ischemia of unknown origin. Of the 6 newborns that died in the late neonatal period, 2 were secondary to cord accidents during birth, and the causes of the remaining 4 deaths were unknown."

Many of these appear to be either easily prevented as long as you are aware of the indicators that should lead you to forego home birth and seek hospital care instead. For example, if someone experiences premature rupture of membranes, putting them at risk for intrauterine infection , they should be referred to the hospital if labor has not started within 24 hours. Similarly, GDM and preeclampsia are usually easy to catch prior to labor and should indicate that the mother is no longer a candidate for home birth. I am curious about the relationship of cord accidents and midwifery care, though. I understand that some cord accidents such us nuchal cords can be managed during a home birth as long as the midwife is trained in the proper maneuvers, which is a prerequisite for AMCB certified midwives. Cord prolapses can be observed with visual examination and compressed cords can be observed through fetal doppler monitoring.. I would assume either of those cord-related complications would require a hospital transfer, but then it is a matter of timing and how quickly the mother can get to the hospital for proper treatment.

All in all I guess my personal conclusion from this study is that the absolute risks of home births are low, and they could be reduced even more so if the family is willing to remain flexible in the birth location should circumstances indicate a need for hospital birth.

 

[huskmc]

@ajay004 I imagine it would also be important to compare these numbers to rates of death at the hospital - the numbers here seem quite low generally, and I’m sure there are of course also fetal deaths in the hospital related to placenta abrubtion, intrauterine infection, pre-e, etc. (ETA - obviously would want to compare to only similarly low-risk women)

Just a small note that GDM is not a risk-out for home birth, esp if diet-controlled (which is a majority of GDM cases). I had GDM with my first and I’m planning a home birth this time - as long as I stay diet-controlled I can stay with their practice as long as my numbers are in range and my scans are normal.

 

[camero]

@ajay004 I'll add to this... I made a comment that included my 3 healthy births. My first pregnancy was delivered early as a PPROM. Due to the partial rupture, the hospital was unable to confirm and treated me as a new mom who couldn't tell the difference between peeing myself and a gush of fluid from a partial rupture. The midwife who knew me provided the best care which included advice and supplies for sterile practices, a doppler, and regular checks for Temps and additional signs of rupture and leakage. Even though the hospital didn't believe me, the midwife did and treated it very seriously. I attribute this to the positive birth outcome, even though I suffered from severe ppd.

 

[cap1975]

@ajay004 This study was very comforting in my decision to do a birth centre birth: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1996-6

It went great and I plan to do home births for my next babies. Good luck in your decision!