A recent article from BBC News, Home Births “as safe as Hospital”, highlights the largest study of its kind, with over a half million participants. It indicates that for low-risk women, giving birth at home is as safe as doing so in hospital with a midwife.
This study may dispel the negative stigma of home birth as a dangerous and irresponsible choice. Several countries support the practice of home birth with a qualified midwife and are having very favorable outcomes. In fact, countries that incorporate home birth and low intervention practices into their culture tend to have a lower infant mortality rate than those that don’t. Scandinavian (Sweden, Norway, Finland) and East Asian (Japan, Hong Kong, Singapore) countries have the lowest infant mortality rates of 3.5 deaths per 1,000, and 22 countries have infant mortality rates below 5 deaths per 1,000 in 2004. The US infant mortality rate is 6.78 infant deaths per 1,000 live births in 2004; we share the 29th place with Poland and Slovakia.. In the US, approximately 1% of births are currently taking place outside the hospital, while the Netherlands has a home birth rate of 30%, New Zealand about 7%, the UK 2.7% and Japan around 1%. (On a side note, one of our teacher trainees from Japan mentioned that in Japan epidurals are rarely used. Out of 10 of her friends, only one opted for pain medication. She explained to me that the epidural is not widely advertised or encouraged in Japan, and that there is a negative connotation attached to it. Perhaps the lack of intervention could explain their very low infant mortality rates.)
The American College of Obstetricians and Gynecologists (ACOG) stated in 2008 that they do not support births out side of a hospital setting. They maintain that “there is not enough research to substantiate its safety.” But there is now!
“Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births.” Professor Simone Buitendijk of the TNO Institute for Applied Scientific Research said, “We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife.” In the UK, The Royal College of Obstetricians and Gynaecologists (RCOG), recently said it supported home births “in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system. In fact the British government has pledged to give all women the option of a home birth by the end of this year.
Part of setting up such a system involves creating a strong maternity service, much like that of the Netherlands. The infrastructure has been designed to meet the high demands of home birth, there is a large pool of qualified midwives, transport services are strong and distances are short if emergency transfer to the hospital is needed. Although, many women start out at home,nearly a third of women who planned and started their labours at home ended up being transferred as complications arose - including for instance an abnormal fetal heart rate, or if the mother required more effective pain relief in the form of an epidural. But even when she needed to be transferred to the care of a doctor in a hospital, the risk to her or her baby was no higher than if she had started out her labour under the care of a midwife in hospital.
While it still is far from the norm to give birth outside the hospital in many places, it is exciting to see that research is supporting a shift in our current paradigm. American culture has embraced diversity and choice in so many areas of society; it seems unfortunate that birth, one of the most basic parts of our existence, is being so stifled and controlled by one ideology. There is no one right way or place to give birth.
April 30th, 2009
Part of my job as a doula is to hold a prenatal meeting with the couple I’m working with, then type up notes from that meeting and return them to the couple for review. Over the years I have established a format for the questions I ask, although I do change them each time according to the couple’s intentions for their birth. One question that remains unchanged, though, is this: “Would you like immediate skin-to-skin contact (SSC)?” Rarely do I hear a parent say no to this question. After my notes are typed up, I encourage the parents to share these birth preferences with their care provider – this ensures everyone is on the same page. The feedback about SSC is generally the same and unless there is a medical reason, new mothers always get skin-to-skin contact with their babies. It’s no surprise that new parents would want the mother to hold her delicious new bundle, allow the oxytocin to flow, look deeply into her baby’s innocent eyes and fall in love with her child immediately after giving birth. Additionally, if her baby is interested in breastfeeding right away, the mother will continue to produce oxytocin, which allows her to have the contractions that will help expel the placenta and shrink the uterus.
Despite these benefits, I usually witness the mother holding baby for mere moments before that baby is whisked away and placed under the heater, administered the vitamin K shot and eye drops, weighed, foot-printed, swaddled and then returned to the mother. Though parents have the option to postpone these hospital procedures for up to an hour, they often (unfortunately) take precedence over prolonged and immediate SSC, delaying the mother receiving her baby by about 30 minutes. During this time, the mother is delivering the placenta, which can take anywhere from 5 to 30 minutes, and being stitched up in the event of tearing or an episotomy. It is possible, as long as everything looks normal and there is no hemorrhaging, for the mother to keep the baby on her chest during these procedures and spend time with her baby.
Why is it so important that the moments immediately after birth be undisturbed? The Cochrane Review, an authority on evidence-based maternity care, concluded in a study which included over 30 studies and involves 1,925 mothers, that “Skin-to-skin contact between mother and baby at birth reduces crying, improves mother-baby interaction, keeps the baby warmer, and helps women breastfeed successfully.” In his article The Importance of Skin to Skin Contact, Dr. Jack Newman says: “Skin to skin contact immediately after birth allows the baby to be colonized by the same bacteria as the mother. This, plus breastfeeding, are thought to be important in the prevention of allergic diseases. When a baby is put into an incubator, his skin and gut are often colonized by bacteria different from his mother’s.”
Another study from Boston Medical Center that studied 30 newborns found that during a standard heel lancing (a procedure where the newborn gets a heel-stick to screen for inborn errors of the metabolism), if the baby was receiving SSC, crying and grimacing were reduced by 82% and 65%, respectively, from control infant levels during the same procedure. Heart rate also was reduced substantially by contact.
The separation of mother and newborn is unique to humans, something other mammals do not experience. It is also newer to our culture, and results from the fact that more births are taking place in hospitals where immediate separation is more commonly seen. “In order for a mammalian species to survive, newborns must learn to nurse, and their mothers must learn to protect and care for them. Researchers have described a ‘sensitive period’ in the first hour after birth, during which hormonal changes and innate behaviors coincide to produce optimal outcomes. They have also identified care practices that disrupt these processes with detrimental effects. Even apparently benign practices can disrupt their innate behaviors if they occur in the first 1-2 hours after birth.” (Journal of Perinatal Education, Volume 16, Number 4, pg 71)
But what can you do if the baby has to be separated from mom due to complications or cesarean birth? According to a new study by Swedish researchers published in the journal Birth: Issues in Perinatal Care, “A father providing skin-to-skin contact with his newborn immediately after a cesarean birth offers the same calming and comforting benefits as a mother.” This might take some negotiating with your care provider and will be difficult in the operating room (OR) since everything is sterile and the father can not expose his skin. It is not unusual for the baby to be separated from the parents anywhere from 1 to 3 hours after the baby is born via cesarean. However, once the baby has been cleared by the pediatrician, it is in the best interest of the baby to have the father, a family member or even a doula have SSC with the baby outside the OR. The Swedish study shows that a father can soothe his newborn as effectively as a mother, and more effectively than if the baby is placed in a crib during the first two hours after birth.
I have yet to find a study that demonstrates negative side effects or outcomes from SSC between mother and newborn. In most cases, since the majority of births these days take place in a hospital, it will likely take some orchestrating and persistence to have prolonged, immediate skin-to-skin contact, but it is unarguably extremely beneficial for the newest member of your family, your baby.
April 7th, 2009
