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Safety of Home Birth and Midwives Model of Care

Home birth, is it safe? This is the million dollar question. The topic of home birth has been quite popular in the recent years and more specifically about whether home birth is safe for mothers and their babies. Less than 1% of mothers are choosing to deliver at home in the United States (Cheyney et al., 2014). It wasn’t too long ago that the majority of births took place at home, until the 1940s when it fell to 44%. (MacDorman, Mathews & Declercq, 2012). Birth became medicalized and it was the norm to give birth in a hospital. Between 2004 and 2009, however, the rate of home birth increased by 29% (MacDorman et al., 2012), and is most likely still on the rise. This significant increase has created more attention to the safety issue of midwifery care and home birth. The Midwives Model of Care, trademarked by Citizens for Midwifery, provides a great backbone when discussing how and why home birth is safe when attended by a qualified midwife because it is based on the certitude that pregnancy and birth is one of the most natural processes of life.

Midwives believe it is very important to monitor women’s physical, psychological, and social well-being during the childbearing cycle, and are very thorough in doing so. This is the first tenet of the Midwives Model of Care. Midwives pay close attention to a woman as a whole and know that several factors contribute to their overall health and wellness. During prenatal care as well as postpartum care, midwives spend anywhere from a half hour to an hour and a half discussing things that contribute to the health of their clients, from diet and exercise, to mental contributors such as stress and fears, and so much more. These long visits allow midwives to really know the health of their clients and discuss their options for better health if needed. Because their prenatal care is so thorough, this allows midwives to constantly be screening to make sure their clients are low-risk and good candidates for home birth, and they respond appropriately when things may fall out of normal range. Not only do they monitor the well-being of mother and baby during the prenatal period, they continue to monitor during labor, birth and the postpartum period. According to the North American Registry of Midwives (NARM) Certified Professional Midwives (CPMs) must be certified in CPR and neonatal resuscitation, have extensive training in natural pregnancy and birth, are educated on monitoring and decision making using Evidence-Based practices and insuring informed consent from their clients, and must take continuing education credits to recertify every 3 years (NARM, 2014). CPMs are qualified to insure that women are safe to deliver at home.

The second tenet of the Midwives Model of Care describes how midwives provide individualized care to every woman. This is so important in discussing the safety of home birth. Every woman is different and what one woman may need to have a safe delivery at home may not necessarily by something another woman needs. CPMs providing care determine baseline and normal health ranges for each client and when things fall out of normal range for that specific client, options are discussed between midwife and client and the client decides what option is best suited for their safety and their needs. “The focus stays on the birthing woman, it is her unique needs and rhythms that will be paramount in the unfolding of her birth” (Davis-Floyd, 2001, p. 14). Home birth midwives also provide continuous support throughout labor and delivery. Studies show that continuous support during childbirth result in better outcomes for mother with less medical interventions and more satisfaction for her birth experience (Hodnett, Gates, Hofmeyr, Sakala & Weston, 2013). Another very important aspect of home birth with qualified midwives is the quality of postpartum care and support. Evidence suggests that during the postpartum period, several stressors can arise that increase the risk of physical and mental illness (Fahey & Shenassa, 2013). Because of this increased risk during the postpartum period, midwives find it very important to provide extensive support and include in their services several visits between birth and at least 6 weeks postpartum to avoid and catch any issues that may arise. The support provided by midwives during the postpartum period contributes to women’s psychological well-being (Lavender & Walkinshaw, 1998).

Minimalizing medical and technological interventions is the third tenet of the Midwives Model of Care and is a main factor in insuring the safety of home birth when attended by a qualified midwife. Obstetric interventions have the potential to increase adverse effects, so low intervention rates are very important implications of good, quality care (A de Jonge et al., 2009). According to a study done by Kenneth Johnson and Betty-Anne Daviss on all home births in 2000 with Certified Professional Midwives in the United States and Canada, intended home births resulted in lower rates of intervention including electronic fetal monitoring, cesarean section, episiotomy, and vacuum extraction, when compared to low risk hospital births (2005). In a study done by Cheyney et al. on 16,924 planned home births in the United States between 2004 and 2009, the majority of women and newborns experienced very low rates of intervention with exemplary outcomes (2014). There were very low rates of oxytocin augmentation, epidural analgesia, operative vaginal birth, and cesarean section when compared to hospital births (Cheyney et al., 2014). The risks of all maternal adverse outcomes including perineal tears, postpartum hemorrhage, and infection were significantly lower in women who planned to have a home birth attended by a registered midwife in Canada compared to a physician attended hospital birth (Janssen et al., 2009). Not only is home birth safe for mothers, but it also supports favorable outcomes for newborns as well. Newborns of planned home birth resulted in low or similar risk of fetal and neonatal morbidity compared with hospital births (Janssen et al., 2009).

When a situation does fall outside of normal range for a specific client, qualified midwives are trained to recognize this and will refer women who require obstetrical intervention when needed, whether it be during prenatal care, labor, birth, or the postpartum period. This is the fourth tenet of the Midwives Model of Care. The availability of the hospital and its technologies is very important when it is needed, but most of the time, birth is a normal physiological process that works perfectly on its own. When a situation presents itself with red flags that something is just not right, midwives will discuss the options with their clients and they will choose what they want to do based on all of the information needed to make an informed decision. Sometimes going to the hospital is necessary, and because midwives are trained and experienced in the normalcy of birth, they know when that time comes. Of 16,924 women who planned a home birth, only 10.9% transferred to the hospital intrapartum with the most common reason being failure to progress (Cheyney et al., 2014). Only 1.7% of women who gave birth at home transferred postpartum and the most common reason were related to hemorrhage and/or retained placenta and laceration repair (Cheyney et al., 2014). Only 149 of the 15,134 newborns born at home transferred to the hospital most commonly for respiratory distress and/or low APGAR scores and congenital anomalies (Cheyney et al., 2014). CPMs are trained to deal with all of these outcomes and they carry with them to every birth the necessary equipment to do so, making home birth safe for women and babies even when adverse outcomes may arise. In the study by Johnson and Daviss done on all women who intended to have home births with Certified Profession Midwives in the United States and Canada, only 3.4% of the home births were considered urgent transfers by the midwife (2005).

In a sample of 160 women who completed an online survey about their home birth, the most common response for why they wanted a home birth was because they felt it was the safest place for them to give birth (Boucher, Bennett, McFarlin & Freeze, 2009). Several studies are out there that suggest the safety of home birth. Home birth with a qualified midwife can be very beneficial for women and babies because of the expertise and the quality of care that midwives provide. Home birth is becoming more popular because women are getting more educated about birth and evidence-based practices. Ultimately, the choice is up to the women where they want to give birth and whom they want their care provider to be. Home birth with a midwife is definitely a safe option.

 

 

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying Home to Give Birth: Why Women in the United States Choose Home Birth. The Journal of Midwifery & Women’s Health, 54(2), 119–126. doi:10.1016/j.jmwh.2008.09.006

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health, 59(1), 17–27. doi:10.1111/jmwh.12172

Davis-Floyd, R. (2001). The Technocratic, Humanistic, and Holistic Paradigms of Childbirth. International Journal of Gynecology and Obstetrics, 75(1), S5–S23.

De Jonge, A., van der Goes, B. Y., Ravelli, A. C. J., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., … Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG: An International Journal of Obstetrics & Gynaecology, 116(9), 1177–1184. doi:10.1111/j.1471-0528.2009.02175.x

Ed, H., Gates, S., Gj, H., & Sakala, C. (2013). Continuous support for women during childbirth (Review). The Cochrane Library, (7).

Fahey, J. O., & Shenassa, E. (2013). Understanding and Meeting the Needs of Women in the Postpartum Period: The Perinatal Maternal Health Promotion Model. Journal of Midwifery & Women’s Health, 58(6), 613–621. doi:10.1111/jmwh.12139

Janssen, P. a, Saxell, L., Page, L. a, Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 181(6-7), 377–83. doi:10.1503/cmaj.081869

Johnson, K. C., & Daviss, B. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ (Clinical Research Ed.), 330(7505), 1416. doi:10.1136/bmj.330.7505.1416

Lavender, T., Walkinshaw, S. A., (1998). Can Midwives Reduce Postpartum Psychological Morbidity? A Randomized Trial. Birth, 25(4), 215–219. doi:10.1046/j.1523-536X.1998.00215.x

 

MacDorman, M. F., Mathews, T. J., Declercq, E. Home Birth in the United States, 1990-2009. NCHS Data Brief, 84. Hyattsville, MD: National Center for Health Statistics. 2012.

North American Registry of Midwives. (2014).

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