Originally published in
a professional journal
for physicians
"Continuing Education" June 1984 * pages 315-320Editorial
Michael Fleming, MD, Assistant Professor
Department of Family Medicine,
School Medicine,
University of North Carolina, Chapel HillHome Delivery
-- Why?Michael F. Fleming, MD
Lengthy Excerpt..... (original suffered from very poor print quality)
"The challenge to those of us who practice obstetrics is to ascertain these reasons [for choosing home-based birth care], to examine them critically and, if appropriate, to change the way we practice obstetrics. The notion that women choose home birth are somehow abnormal or badly informed is no longer an acceptable explanation for the continuing interest in home births.
Why do so many women choose to give birth at home? Why do women and their families take the risk of having their child delivered away from a hospital?
Could home deliveries that use as little medical intervention as possible have morbidity and mortality outcomes as low as those typical of hospital deliveries? Most physicians who practice obstetrics find it difficult to accept home deliveries as a reasonable alternative to hospital deliveries, yet health professionals who operate home birth centers in the US are convinced that women who give birth at home have fewer medical problems, improved bonding with their newborn child, and fewer psychological problems in the postpartum period. [2]
As in other areas of medicine where advanced technology and medical interventions have become the accepted standard of care without having been compared scientifically with the previous standard, there are few data comparing home deliveries with hospital deliveries and the few we have are conflicting. Though there is little doubt that unplanned home deliveries carry an unacceptably high risk of complications, planned birthing programs like those in Europe and many areas of the US appear to have outcomes similar to those of hospital based programs. [3 -- 5]
In Sweden and Denmark, where the neonatal infant mortality rates are among the lowest in the world, nurse midwives are employed in the hospital setting and all all deliveries take place in hospitals. Holland has a similar neonatal mortality rate but 40% of all Dutch children are born at home according to F.J. Huygen (oral communication, April 1984).
Burnette and associates [1] studies all 1,296 home deliveries that took place in North Carolina from 1974 to 1976. ....... The neonatal mortality rate for group one (unplanned, unattended) was 120 deaths per 1,000 live births; for group two (planned but unattended) , 30 per 1000; and for group three (planned and lay midwife-attended), 4 deaths per 1000. The overall hospital delivery neonatal mortality rate in North Carolina was 12 per 1000; 7/1000 if the infants weighing less than 2000 grams were excluded. Three of the four neonatal deaths that occurred in group 3, died of congenital anomalies.
The only controlled study that compared home birth to hospital birth was done by Mehl and coworkers [6] in Wisconsin in 1977. The investigators compared 1046 home with with 1046 hospital deliveries. The two groups were matched forage, parity, gestational length, risk factors and socioeconomic status. An independent observer randomly selected the cases to be included in the study by means of a fact sheet that contained no information of labor and delivery. The following conclusion were made:
(1) Perinatal outcome was the same in the two groups (i.e. same in both home and hospital)
(2) Whereas the hospitalized patients underwent shorter labors, they had significantly
more perineal tears
(3) Infants born in the hospital had lower APGAR scores, higher rates of neonatal infection,
more birth injuries, and more respiratory distress
(4) Rates of maternal infection were the same
(5) Postpartum hemorrhage was higher in the hospitalized group
(6) The major difference between the two groups was in the attitude of the person
conducting the delivery.The physicians and nurse-midwives who performed the home deliveries considered labor a natural process that required little intervention and this attitude resulted in longer labors, rupture of membranes later in the labor, fewer episiotomies and less medical intervention than was the case of patients managed by physicians in the hospital.
We have brought about great improvement in the obstetrical and neonatal outcomes of hospital deliveries, but is it possible that by changing our attitudes toward what is, after all, a natural process and by using the minimal intervention strategies practiced in homebirth programs, we could improve them ever further? Does every obstetrical patient in labor require intervention with electron fetal monitoring, intravenous infusions, artificial rupture of membranes and epidural blocks---standard procedure in many American hospitals? Could we reduce the need for oxytocin augmentation and cesarean birth if ewe practiced the relaxation methods home birth attendants find so helpful in women undergoing prolonged labor? And what about the long-term psychological benefits inherent in home births?
The importance of newborn-family bonding is unquestioned. Faranoff and colleagues [7] were the first to report the close association between premature babies and child abuse. Animal and human studies by Mercer [8] and Klaus and associates [9-11] have found that bonding begins immediately after birth and depends on close physical and visual contact between infant and family. Peterson and Mehl [12] examined father-infant bonding during the immediate postpartum period and found a strong correlation between father-infant contact time and subsequent behavior towards both the infant and the mother. If bonding is important, how can we best foster it?
Fear, stress, and other psychological factors have a profound effect on labor and delivery. Cramond [13] reported the association of psychological factors with dysfunctional labor patterns; Kapp and Hornstein [14] studies their association with prolonged labor and inefficient uterine contractions; and Lederman and Lederman [15] found that the serum epinephrine and cortisol levels had a positive correlation with the length of labor and a negative one with uterine contractility. The need to reduce stress and anxiety in order to minimize dysfunctional labor is obvious, but how can this be done?
Reducing stress and anxiety is one of the major benefits of home delivery programs. It is achieved by
(1) providing a relaxed, safe, and comfortable place for the patient to undergo labor in;
(2) encouraging the patient to be in control of her labor;
(3) allowing the patient to have supportive, loving people around her, such as her spouse,
children and close friends;
(4) allowing the patient to walk around and to eat and drink;
(5) practicing relaxation techniques to reduce stress;
(6) ensuring constant attendance by the nurse midwife or physician assisting
in the labor and delivery.None of these strategies are limited to the home; all are possible in a hospital setting. [Note: This was written before the negative influence of medical malpractice became all pervasive]
The ideas and birth experiences of women who have given birth at home [note -- and also their midwives!] can help physicians practicing obstetrics to improve maternal and neonatal outcomes. For these women and for their families, psychologic outcomes and family-child bonding are as important as medical outcomes.
References:
1. Burnette CA, Jones JA, Rooks, J et al Home delivery and neonatal mortality in North Carolina JAMA 1980; 244:2741-2745
2. White G, Eisenstein M: The American College of Home Obstetrics philosophy towards homebirth, in Steward D, Steward L
(eds) Twenty First Century Obstetrics Now Marble Hill, MO. (NAPSAC), 1997, vol2:359-372
3. Huygen FJ; Home Deliveries in Holland JR; College of General Practice 1976 26:244-248
4. Dally DR: Home Births -- A Review of overseas and local experience, New Zealand Family Physician, summer 1983 6-10
5. Mehl, LE: Scientific research on childbirth alternatives: What can it tell us about hospital practice? in Steward D, Steward L
(eds) Twenty First Century Obstetrics Now, Marble Hill, MO. (NAPSAC), 1977, vol1:171-208
6. Mehl LE, Peterson GH, White M: Outcomes of elective home births: A series of 1046 cases J Reproductive Med 1977:
19:281-290
7. Farnoff A, Kennell J, Klaus M: Followup of low birth weight infants: he predictive values of visiting patterns Pediactrics
1972; 49:287-290
8. Mercer RA: Maternal Behavior in the domestic man: The role of physical contact. Comp Phyiol Pschol 1963; 56:357-361
9. Klaus MH, Kennell JH: Human maternal behavior at first contact with her young; Pediactrics 1970:46:1987-1991
10. Klaus MH, Jerauld R, Hreger NC, et al: Maternal attachment: Importance of the first postpartum days. New England Journal
of Medicine 1972; 286:460-464
11. Klaus MH, Kennell JH: Maternal Infant Bonding: The Impact of early separation or loss on family development;
St Louis CV Mosby 1976
12. Peterson G, Mehl LE: Studies of psychological outcome for various childbirth alternatives, in Steward D, Steward L
(eds) Twenty First Century Obstetrics Now, Marble Hill, MO. (NAPSAC), 1997, vol 1 209-238
13. Cramond WA: Psychological aspects of uterine dysfunction Lancet 1954; 2:1241-1245 .
14. Kapp FT, Hornstein S: Some psychological factors prolonged labor due to prolonged labor due to inefficient
uterine actions; Compr Pschiatry 1963: 4:9
15. Lederman RP, Lederman E: The relationship of maternal anxiety, plasma catecholamines and plasma cortisol
to progress in labor. Am Journal of Obstetrics and Gynecology 1978: 132:495-500
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