Monday, September 21, 2009

Home births get a bump, over obstetricians' objections

By Rita Rubin, USA TODAY

Although the delivery of her first son, Nicholas, went as planned, Mara Vaughan began thinking a change of venue for her second child's birth might be in order.In labor with Nicholas at a hospital, "I felt like I was so limited in how much I could move around, what positions I could be in. If I were at home, I could be a little more distracted. I could look out my windows. I could be on the first floor or the second floor."

READ MORE: Midwives' qualifications can vary

So on Aug. 17, Vaughan, 26, delivered Nicholas' little brother, Noah, all 7 pounds, 14 ounces of him, in the comfort of her own Bristow, Va., bedroom, with certified nurse-midwife Alice Bailes in attendance.

Compared with her first delivery, the time immediately after her second "was so leisurely," Vaughan says. As soon as Noah was born, Bailes went downstairs, leaving Vaughan and husband Brandon alone with their new son. A little later, Bailes came back upstairs to cut Noah's cord and weigh him.

Noah is one of only a tiny minority of U.S. babies born at home. During the first half of the 20th century, home births dropped dramatically. Today, fewer than 1% of U.S. births are at home, compared to just under 30% in the Netherlands.

Citing safety concerns, the American College of Obstetricians and Gynecologists (ACOG) has campaigned against home births, distributing bumper stickers that say "Home deliveries are for pizza."

And the American Medical Association's House of Delegates last year passed a resolution stating that "the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex."

Around the time Noah was born, though, researchers in Canada and the Netherlands published two large studies concluding that among low-risk women, planned home births attended by qualified midwives appear to be as safe as hospital births. The new studies have fueled the debate but have not convinced ACOG.

For one, says Erin Tracy, ACOG's delegate to the AMA, the studies weren't large enough. Problems are infrequent in childbirth, no matter where it takes place, so only "really large numbers" could reveal whether the home truly is as safe as the hospital, says Tracy, an OB/GYN at Boston's Massachusetts General Hospital.

"The majority of patients ... might get away with it," she says, but low-risk pregnancies can become high-risk in minutes: A baby's shoulder might get stuck in the birth canal, or heavy bleeding could necessitate a blood transfusion for the mother.

Patricia Jannsen, the University of British Columbia researcher who is the lead author of the new Canadian study, notes that it included all 862 planned home births attended by midwives in her province from Jan. 1, 1998, through Dec. 31, 1999. Canada was the last developed country to regulate midwives, she says, and 1998 was the first year British Columbia women could opt for a home birth with a regulated midwife.

Bailes, based in Alexandria, Va., has found a number of OB/GYNs to serve as backup for her home births. "We have wonderful relationships with hospital-based practices (both OB/GYNs and midwives) in the community," she says. "These relationships ... are important for peace of mind for us and our clients and for safety."

She says she doesn't call upon them often. She has attended about 3,500 home births and has had to transfer only six or seven women to a hospital because of excessive blood loss. Overall, about one in nine of her patients in labor end up being transferred to a hospital. One reason: They go into labor prematurely, or before 37 weeks, or post-term, which is after 42 weeks. In both cases, the chance that the baby will need hospital care is greater than that of a full-term baby.

The main reason for Bailes' practice's low rate of transfers is that the nurse-midwives refer higher-risk patients to hospital-based practices when problems arise before they go into labor. The nurse-midwives won't care for women who require insulin to manage their gestational diabetes or whose babies don't turn head down in their womb.
"We get to see one normal birth after another," Bailes says.

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