The Site of Delivery

GUJHS. 2007 March; Vol. 4, No. 1

Emily Robbins
Department of Philosophy
Georgetown University

 

The Governing Council of the American Public Health Association, along with expert advisory panels around the world, recommends that “a woman’s informed choice to birth at home must be respected and appropriate home birth maternity services be made available” (ACNM, 2003).  This official endorsement suggests both that home birth is a reasonable alternative to hospital birth and that it is morally appropriate to respect a woman’s right to determine the site of her child’s birth.  However, a tension exists between that which is accepted and that which is suggested.  Studies show that midwives will support home birth as a safe alternative to hospital birth but will not introduce it as an option to their patients.  By failing to present the home as a potential site of childbirth, midwives tacitly imply that a hospital birth is a woman’s only option. For a woman to make a truly informed decision as to the site of her labor and delivery, she must be presented with accurate and complete information about alternative birth environments.

In order to determine the extent to which women are making truly informed decisions about their chosen site of labor, I will examine prospective parents’ foremost considerations for birth environment put forth by a prospective study published in the Journal of Marriage and the Family.  Prospective parents who chose a home birth in this study cited the principle deciding factors to be: 1) to feel in control, 2) to avoid separation from child, and 3) to avoid excessive obstetrical management.  Parents who opted for a hospital birth described the most important considerations as: 1) to have the utmost safety, 2) to freely choose who would be present at delivery, and 3) to feel in control.  By assessing the scientific accuracy of these considerations based on the results of clinical studies, I will attempt put forth an evidence-based analysis of home birth so that women can make informed decisions (Sacks and Donnenfeld, 1984).

According to England’s Department of Health, midwives are in the best position to take charge of the care of all women during normal pregnancies.  The Department also believes that women should be “empowered by being given adequate information about all services and choices available to them so that they may make informed decisions,” including the choice of their child’s site of birth (Madi and Crow, 2003).  “Adequate information” must be grounded in scientific evidence and must also reflect women’s experiences of alternative birth environments.  A study conducted in South East of England found that out of 33 pregnant women, 20 planning hospital birth and 13 planning home, those who were preparing for a home birth were well informed about options available to them, whereas the majority of those planning a hospital birth believed it to be their only option.  Midwives, the study determined, did not introduce the availability of home births but supported those women who initiated the discussion (Madi and Crow, 2003).  One woman describes her choice to give birth in a hospital:

“I don’t know how I came to the decision that I’m going to have a baby in hospital; um (pause) I suppose I probably assumed from the started that I would… I didn’t even think about having it at home… I just presumed that was the normal thing to do you know” (Madi and Crow, 2003).

The phrases “I don’t know” and “didn’t even think about” are clear indications that this woman did not make an informed decision, the consequence of her midwife’s failure to present home birth as a live option.  Women may either not know to ask for alternatives to a hospital birth or may fear that she will be seen as selfish or defective for choosing that which is not “the normal thing to do”.  Some studies suggest that the failure of midwives to inform their patients about home births is due to their fear of being blamed for complications that arise during labor and delivery (Madi and Crow, 2003). Regardless of the root of this tension between what a midwife will practice and what she will present, it is the responsibility of the midwife to ensure that her patient comes to an informed decision about the site of her child’s birth.  A genuine decision cannot be reached if a woman is unable to determine from a range of options what is best both for herself and for her child.

When analyzing studies of midwife-attended home births, it is important to note the inherent difficulties.  Women who give birth at home tend to self-select, which may introduce confounding variables.  Also, many of the complications that are described are so rare that large numbers of births are required to compare the outcomes between hospital and home births.  Given the small number of home births in the United States, such cohorts are difficult to obtain.  The analysis is further complicated by the ambiguity between planned and unplanned home births, as well as the variations in attitudes and practices among midwives and physicians (Mehl-Madrona and Mehl Madrona, 1997).

Susan Sacks and Penny Donnenfield published a study in the Journal of Marriage and the Family in which they followed 64 prospective mother-father pairs, each expecting their first child and in their third trimester.  The subjects had similar demographics and each pair planned to establish a home together with the infant after birth.  Of the twelve pairs who chose to give birth at home, thirty-six percent cited the desire “to feel in control” as one of the key determinants of their decision (Sacks and Donnenfeld, 1984).  This sentiment was echoed by the House of Commons Health Committee in England in 1992, when it pointed to women’s demand for choice about the type of maternity care and women’s dissatisfaction with the choices provided by maternity services (Madi and Crow, 2003).

Midwife-attended home births offer a women-centered approach to maternity care. “[W]hile physicians in hospital settings control the birth process, nurse-midwives in home settings permit the birth process to transpire under the mother’s control” (Rothman, 1983). Midwives emphasize each prospective mother as an individual, and each birth as unique.  “At home, the mother as patient must coexist or take second place to the mother as mother, wife, daughter, sister, friend, or lover” (Rothman, 1983). By recognizing the woman’s role of prospective mother as embedded within an expansive network of relationships, a midwife enriches the woman’s sense of agency rather than reducing her to the role of baby-bearer.

This woman-centered approach to home birth can be found in the very staging of labor and delivery.  The stages of birth as understood in the hospital are based on “objective” scientific data, rather than the woman’s experience.  For example, in hospital births the second stage of labor is determined by the “objective” measure of full dilation.  In contrast, when performing home births nurse-midwives often use the subjective measure of a woman’s urge to push.  “I would not, and this is really a fine point, encourage a mother to start pushing just because she felt fully dilated to me. I think I tend to wait till the mother gets a natural urge to push… the baby’s been in there for nine months” (Rothman, 1983). Not only does this mother-centered approach acknowledge the importance of the woman’s birthing experience, but it also recognizes gestation as intimate and childbirth as natural.

One may better evaluate the degree to which a woman feels in control of her childbirth by looking to her reflections on her own home birth experience.  According to a study in the Northern region of England, 85% (188/221) of women who had delivered in the home but had previously delivered in the hospital preferred home birth, and 91% (136/149) said they would opt for home birth again (Davies et al, 1996).  This positive affirmation of the home birth experience suggests that women who gave birth at home under the care of midwives did in fact feel in control, and thus this consideration put forth by prospective parents in Sack’s study is a legitimate one.
Sixty-four percent of women who chose to give birth at home said that they did so in part to “avoid separation from (their) child” (Sacks and Donnenfeld, 1984).  The home provides a setting in which childbirth can become a family event.  By engaging the family in the experience of childbirth, the prospective mother gains support, the father may assume a more active role, and a woman’s other children may participate in the growth of the family.  A six-year old child who has suddenly become a big brother can bear witness to the family’s newest addition rather than face the confusion of an unknown baby suddenly arriving home from the hospital.

The third deciding factor in choosing to give birth at home, put forth by 27% of women in the study, was the wish to “avoid excessive obstetrical management” (Sacks and Donnenfeld, 1984).  According to World Health Organization (WHO), the caretaker’s goal is to promote the health and safety of both the mother and the child with the least possible intervention.  This suggests that in the case of a normal birth, there should be a medically-based reason to interfere with the natural process.  Patricia A. Janssen and colleagues conducted a study in British Columbia that compared the outcomes of 862 planned home births by midwives with planned hospital births attended by either midwives or physicians.  Researchers found that women in the home birth group were less likely to have epidural analgesia, be induced, have labors augmented with oxytocin or prostaglandins, or have an episiotomy (Janssen et al, 2002).  Another prospective regional study found that of 142 planned home births, only 36 employed the use of opioid analgesic, and 49 (30%) did not use any prescribable pain relief (Davies et al, 1996).

Is childbirth to be understood as natural or pathological?  “Without obstetrical interventions, medically defined “pathologies” may be seen as to right themselves, and so the very conceptualization of pathology and normality is challenged” (Rothman, 1983). The divergence between midwives and physicians on this issue can be seen clearly by their treatment of “post-maturity”.  The medical treatment for post-maturity is the induction of labor, either by rupturing the membranes which contain the fetus or by administering hormones to start labor contractions, or both.  Induced labor is more taxing both for mother and baby; contractions are longer, more frequent, and more intense.  Intense contractions reduce the baby’s oxygen supply and induced labor often requires additional medications, which may pose a risk to the baby.  After induction, physicians will shortly thereafter deliver the baby, by Cesarian section if necessary (Rothman, 1983).

Home-birth advocates claim that the length of pregnancy as described by physicians is based on the observation of women in medical care, and therefore reflect the gestational trends of malnourished women who have been subject to medically ordered weight-gain limits.  Such advocates suggest that well-nourished women are capable of maintaining pregnancy for a longer period of time.  The notion of healthy women going past term is “reconceptualized in this developing model as an indication of even greater health, rather than a pathological condition of “post-maturity”” (Rothman, 1983).

Hospital labors are shorter than home-birth labors, averaging 14.5 hours and 10.4 hrs respectively.   If a woman’s labor is taking “too long,” physicians will move her along by means of hormone stimulation, breaking of membranes, or Cesarian.  The importance “timing and tempo in hospital management of birth,” as Barbara Katz Rothman calls it, is upheld by the words of one resident, who said that “(the residents’) average length of delivery is about 50 minutes, and the pros’ (the private doctors’) is about 40 minutes” (Rothman, 1983). The pacing of births becomes a competition and a measure of aptitude.  Rothman describes the use of forceps, often without medical necessity, as a means by which the “tempo is maintained in the delivery room” (Rothman, 1983).

If unaware of the details of the home birth procedure, a mother may choose a hospital birth to reduce the time she spends in labor.  Home-birth advocates want to point out that a longer duration of birthing does not imply a longer duration of pain.  “A women at home may spend those long hours going for a walk, napping ,listening to music, even gardening or going to a movie” (Rothman, 1983). Communicating the true nature of home delivery is a necessary part of the midwife’s duty to ensure the informed consent of her patients.

Concerns about the safety of home births are widespread.  The majority of prospective parents in Sacks’ study who chose to give birth in a hospital did so in part “to have the utmost safety” (Sacks and Donnenfeld, 1984). In an issue of Perspectives on Sexual and Reproductive Health, C. Coren summarizes the findings of a retrospective analysis of births in Washington State from 1989 to 1996 conducted by Pang JWY et al.  The author’s conclusion can be found in the article’s title, “Health of Mothers, Babies May Be Compromised in Planned Home Births” (Coren, 2002).  Coren suggests that “newborns of women who planned a home delivery are twice as likely to have a very low Apgar score (0-3 on 0-10 scale) or to die as are newborns of women who planned a hospital delivery” (Coren, 2002).  The study also highlights the elevated risks for prolonged labor and postpartum bleeding that are supposedly associated with home births (Coren, 2002).  The study itself compared 6,133 planned home deliveries, with 10,593 randomly selected hospital births (Coren, 2002).  The study did not employ a matching system to control for contributing factors such as a mother’s age, socioeconomic status, parity and medical risks.

Janssen’s aforementioned study of the outcomes of planned home births versus planned hospital births in British Columbia avoided such problems (Janssen et al, 2002).  This prospective study of 2176 births used the exclusion criteria of breech, multiple birth, serious maternal health conditions, and matched the mothers according to socioeconomic and demographic factors, as well as pregnancy characteristics (age, parity and lone parent status), which are known to affect obstetric outcomes (Janssen et al, 2002).  Janssen and her colleagues found that women who gave birth at home were more likely to have intact perineum, exhibited the same rate of postpartum hemorrhage, and contracted fewer infections.  They found the rate of perinatal death to be 0.9-9.0 per thousand babies delivered at home, compared to 0.1-8.9 per thousand delivered in the hospital, hardly a significant difference.  The prevalence of Apgar scores less than 7 at 5 minutes did not differ among infants born in the home or in hospital, nor did the rates of birth weight less than 2500 grams.  Janssen et al concluded that “there are no indications of increased risk associated with planned home birth attended by regulated midwives, compared with those attended by either midwives or physicians in hospital” (Janssen et al, 2002).

The findings of Jannsen et al are upheld by the American College of Nurse-Midwives’ (ACNM) 2003 Clinical Bulletin entitled “Criteria for Provision of Home Birth Services” (ACNM, 2003).  In a meta-analysis of six controlled studies, which included 24,092 planned home births, Olsen concluded that “home birth is an acceptable alternative to hospital confinement for selected pregnant women and leads to reduced medical intervention” (ACNM, 2003).

Another study, conducted by Dr. Lewis Mehl-Madrona and Morgaine Mehl Madrona, followed 2000 women, 1000 midwife births and 1000 family physician births.  Each of the 1000 pairs of white women were matched by maternal age group, insurance status (as indicator of socioeconomic status), parity and medical risk score.  The study’s initial findings suggest that the midwife group had appreciably more neonatal resuscitations and greater total mortality rate, but when twins, post-dates pregnancies, and breech presentations were excluded from the analysis, all differences between births performed by physicians and midwives became insignificant (Mehl-Madrona and Mehl Madrona, 1997).

Births Included in This Analysis Midwife Births Family Physician Births Probability Level (P)
Entire Matched Set 14 5 <0.05
Outcomes minus babies with lethal congenital anomalies 12 2 <0.05
Outcomes minus twins and lethal anomalies 10 2 <0.05
Outcomes minus breeches and lethal anomalies 10 2 <0.05
Outcomes minus post-dates and lethal anomalies 7 2 Not significant
Outcomes minus post-dates, breeches, twins, and lethal anomalies 3 2 Not significant

Table adapted from Mehl-Madrona et al, 1997

The findings of this study, published in the Journal of Nurse-Midwifery , demonstrate the importance of understanding the background probabilities of complicated pregnancies.  The authors note that births involving these conditions are associated with higher perinatal mortality regardless of place of birth (Mehl-Madrona and Mehl Madrona, 1997).The authors conclude that “midwifery care and home births are appropriate choices for normal low-risk births” but suggest that “services that may be needed at higher-risk births are not available as quickly or readily at home, and few midwives have enough experience with complicated births to acquire the necessary competency for their delivery at home” (Mehl-Madrona and Mehl Madrona, 1997).  Most of the women in Sacks’ study who chose a hospital birth because of safety concerns did not experience high-risk pregnancies, and thus may not have been making truly informed decisions.

Another key consideration for 34% of parents who chose to give birth in a hospital was the desire “to freely choose who would be present at delivery”(Sacks and Donnenfeld, 1984). Studies show that women with low-risk delivery giving birth to their first child in a teaching hospital may be accompanied by up to sixteen people during the six hours of her labor and still be left alone for the majority of her childbirth.   Not only does the presence of strangers conflict with the woman’s desire to choose her company, but it may also contribute to her stress, which may in turn lead to adverse birth outcomes (World Health Organization, 1996).

Fifty-three percent of women who selected a hospital birth did so out of the desire “to feel in control” (Sacks and Donnenfeld, 1984).  A woman cannot consider herself to be in control if she has not made a truly informed decision as to the site of her childbirth.  Sacks et al found that all maternity-center and home-birth mothers and fathers indicated that they were aware of three possible birthing environments (hospital, maternity center and home birth), whereas in the hospital group 28% of mothers and 47% of fathers had not heard of maternity centers, and 16% of mothers and 37% of fathers did not know that home birth was an option (Sacks and Donnenfeld, 1984).  Each of the 64 mother-father pairs were from the same metropolitan area, exhibited similar demographic features and had equivalent access to information regarding site of birth (Sacks and Donnenfeld, 1984).

The limits of “normality” are the limits of a woman’s ability to choose.  The World Health Organization’s report on Safe Motherhood notes that obstetricians approach the risks of labor and delivery with similar methods of care for both complicated and uncomplicated pregnancies.  The consequence of such an orientation is that a disproportionately high number of women are categorized as “at risk,” which corresponds to associated levels of medical intervention.   The overly inclusive conceptualization of what it is to be at risk “interferes with the freedom of women to experience the birth of their child in their own way, in the place of their choice.  It leads to unnecessary interventions…” (World Health Organization, 1996).

The support of home births as a live option for women is both practically advantageous and morally appropriate.  International research shows that home birth is cost-effective.  The World Health Organization suggests that the large number of in-hospital low-risk births “requires a concentration of large numbers of laboring women in technically well-equipped hospitals with the concomitant costs” (World Health Organization, 1996).  This is not to say that a woman should choose to give birth at home solely based on monetary constraints, but rather that the cost-effectiveness of home births may help a safe practice gain support when considering rising health care costs (ACNM, 2003).  Maternity services must be fashioned according to the reality of childbirth; some women will always deliver in the home, whether by choice or due to the unexpected onset of labor.  If a woman finds herself unable to access a hospital delivery room, she should be aware of alternative forms of care.

The Royal College of Obstetricians, the Royal College of Midwives, and the Royal College of General practitioners acknowledge the principle of free choice.  The support of midwife-managed, low-risk planned home births not only promotes the health and safety of both the mother and the child but also empowers women.  The recognition of safe home births acknowledges that a mother’s interests almost always coincide with those of her child, and that her decision to give birth at home is probably not a selfish one.  Presenting home births as a live option allows mother to make the best informed decision and also facilitates an open doctor-patient relationship.

The science proves that home birth is a safe and reasonable option for a select group of women with specific standards of care by educated and experienced midwives.  This analysis of the factors contributing to the chosen site of birth for the 64 pairs of prospective parents presented in the study conducted by Sacks et al suggests that the deciding factors which led to home births are consistent with scientifically-proven evidence, whereas the considerations which led to hospital births are not.  This is not to say, of course, that all women should give birth in the home, but rather that many woman are not making truly informed decisions as to the site of their childbirth.   In order to achieve a truly woman-centered model of maternity care, women must be made aware of their options, must understand the risks and benefits of each, and must feel empowered to choose.

References

  • Coren, C.  “Health of Mothers, Babies May Be Compromised in Planned Home Births.” Perspectives on Sexual and Reproductive Health Nov.-Dec., 2002; Vol. 34, No. 6: 320-321.
  • “Criteria for Provision of Home Birth Services.” ACNM Clinical Bulletin. Journal of Midwifery & Women’s Health March, 2003; No. 7: 299-301.

 

  • Davies, J., et al “Prospective regional study of planned home births.” British Medical Journal November 1996; 313:1302-1306.
  • Janssen, Patricia A., et al. “Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia.” Canadian Medical Association Journal 2002; 166(3):315-23.

 

  • Madi, Banyana Cecilia and Rosemary Crow. “A qualitative study of information about available options for childbirth venue and pregnant women’s preference for a place of delivery.” Midwifery 2003; 19: 323-338
  • Mehl-Madrona, Lewis and Morgaine Mehl Madrona.  “Physician- and Midwife-Attended Home Births.  Effects of Breech, Twin, and Post-Dates Outcome Data on Mortality Rates.” Journal of Nurse-Midwifery March/April 1997; Vol. 42 No. 2: 91-97.

 

  • Rothman, Barbara Katz.  “Midwives in Transition: The Structure of a Clinical Revolution.” Social Problems Feb., 1983; Vol. 30, No. 3: 262-271.
  • Sacks, Susan Riemer and Penny B. Donnenfeld.  “Parental Choice of Alternative Birth Environments and Attitudes toward Childrearing Philosophy.” Journal of Marriage and the Family May 1984; Vol. 46, No. 2: 469-475.

 

  • World Health Organization.  Division of Reproductive Health.  Maternal and Newborn Health/Safe Motherhood.  1996.  Geneva: WHO/FRH/MSM/96.24.

 

 

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