A lack of professional consensus means that pregnant women considering where to give birth should quiz their health-care provider closely on the matter and consider the circumstances of their own health and the health of their fetus before reaching a decision.
Women who choose home birth are, of course, returning to what was the universal—and only—way of delivering a baby until less than 100 years ago.
For women who have a particular medical or birth history—for example, a previous cesarean delivery or hypertension—home birth can be very risky. Plus, “A significant number of women will experience unpredictable events [during home birth] that could be fatal if blood products or surgery isn’t rapidly available,” Dr. Tracy cautions.
Nevertheless, she concludes, “there are certainly data to support the safety of home birth for the vast majority of women who choose it.”
OBG Management (www.obgmanagement.com), a Dowden Health Media publication, is a leading source of medical review and education for obstetricians, gynecologists, and other women’s health-care clinicians. Dr. Tracy’s analysis continues the publication’s 20-year mission of offering practice-enhancing and patient-supportive information for its audience, and asks: How safe is home birth, based on the accumulated scientific evidence? And do mistrust of the medical establishment, fear of cesarean, and other concerns affect a woman’s decision about where to deliver her infant?
Water birth carries additional risk
In an accompanying discussion, OBG Management Senior Editor Janelle Yates looks at what’s known about the safety of water birth—also an expanding practice, both as part of home birth and in some hospitals. Many in the medical community have expressed concern that the scientific evidence over delivery in a pool of water is just too murky to call the practice safe.
Several small studies have detected a high level of bacterial contamination in water-birth pools that can lead to infection in mother and baby. Numerous cases of drowning and a snapped umbilical cord have also been reported.
The American Academy of Pediatrics opposes water birth; the American College of Obstetricians and Gynecologists (ACOG) has yet to weigh in, Ms. Yates, notes; until it does, she proposes that Ob¬Gyns and mothers-to-be may be wise to heed the words of Ruth Gilbert, MD, of the Centre for Paediatric Epidemiology and Biostatistics at the Institute of Child Health in London:
“Can delivery in water cause serious adverse outcomes? Undoubtedly, the answer is ‘yes.’”
More about home birth
ACOG and the American Medical Association issued a policy against home birth in August 2008—although ACOG took that stance as far back as 1979. Considerable media attention has been paid to celebrities who deliver at home, particularly in the wake of Ricki Lake’s recent film, “The Business of Being Born.”
All studies of home birth have flaws in their methods of researching the practice, Dr. Tracy explains. In addition, the studies are difficult to interpret because, to name two problems, they didn’t follow mothers and babies after their home birth and the identity and education of the providers who delivered these babies weren’t clear.
The skill of the caregiver in home birth can vary—widely. A so-called certified professional midwife, or lay midwife, for example, isn’t required to have a high school diploma. Contrast that with the credentials of a certified nurse midwife, who must have a college degree—and, soon, will need a graduate degree as well.
Risk level can rise rapidly during home birth
Even a low-risk pregnancy that was complication-free during prenatal care can become a high-risk pregnancy in a matter of minutes, Dr. Tracy says. This change necessitates urgent, appropriate obstetric care. Classic examples of urgent events are a twisted or snagged (prolapsed) umbilical cord, excessive post-birth bleeding in the uterus, and a baby’s shoulder that is “stuck” in the birth canal (dystocia).
Taking a chance?
Women who choose home birth because of impassioned rhetoric about empowerment and choice may be deeply disappointed if it goes awry and transfer to a hospital is needed. Dr. Tracy offers tips to providers on how to counsel women about home birth and prepare for the possibility that they will need to deliver in hospital.
“Home birth isn’t going away,” Dr. Tracy ends by saying. “But, in light of the very high stakes involved, I wonder: Why take that chance?”
Dr. Erin Tracy is an attending physician in the Vincent Department of Obstetrics and Gynecology at the Massachusetts General Hospital and Assistant Professor in Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School in Boston. She is a member of the Working Group on Midwifery of the American College of Obstetricians and Gynecologists.
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