Wednesday, September 30, 2009

The safety of home birth: Is the evidence good enough?

There have been three recent papers published, giving strong evidence of the safety and acceptability of homebirth: a large study from the Netherlands (deJonge et al 2009), and two Canadian studies (from Ontario, Hutton et al 2009 and from British Columbia, Janssen et al 2009).

The paper by Patricia Janssen PHD and colleagues (link above) reports on Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. The study included all planned homebirths attended by registered midwives from 1 Jan 2000 to 31 Dec 2004 in British Columbia, Canada. The interpretation of the data is that "Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared withplanned hospital birth attended by a midwife or physician." (p337)

Similar findings have been reported in the other 2009 studies.

A Commentary by two Melbourne midwife academics, Helen McLachlan PhD and Della Forster PhD, titled The safety of home birth: Is the evidence good enough? was published in the same journal. My curiosity was sparked. Helen and Della have been active researchers on the local maternity scene, and from memory their work has included randomised controlled trials of breastfeeding interventions, and some on team midwifery. But I haven't seen anything from either of them about homebirth in the past.

The commentary gives wise, predictable thoughts about the debate surrounding homebirth. It gives a good listing of current references on homebirth.

The fashionable refrain from a section of the health/medical research community is that the evidence is not good enough unless it was obtained after randomisation of subjects. An interesting discussion is entered into, and the authors come up with the conclusion that "Better evidence on the safety of home birth is needed, ideally from randomized controlled trials".

The paper quotes professional discussion around the reported finding that an attempt in the Netherlands to conduct a randomised controlled trial was aborted, because women "were not willing to be randomly assigned to home versus hospital birth and declined participation because they had already chosen their place of birth."

This is a no-brainer (imho)! Of course. Yet the authors go on to discuss the importance of high quality evidence, as if another group of women - possibly those in public maternity care in Melbourne - will think differently. Why would they? How much evidence do we need in order to give a tick to spontaneous, unmedicated, un-interfered-with birth?

I can imagine the outcry if someone suggested seriously that we really don't know if conception of babies is safer in the hospital laboratory or in the home. Therefore a randomised controlled trial needs to be conducted. All eligible potential parents are to be randomly allocated to either treatment or control.

It might be difficult to enlist participants in this reseach, might it not?

Some of those who read this blog will have given birth at home; some are midwives who attend homebirths; while others are interested onlookers. If you have any knowledge of the terrain of physiologically normal birth, either in hospital or in the home, you will probably agree with me that the mother and all her support team need to be intentional about protecting normal birth. There is the intention to actively choose to work in harmony with your body; to be ready for and accept the work your body and mind must do; and to actively make decisions as events unfold. This is not the stuff of managed care and research protocols. It requires the deep and intuitive knowledge that a woman has because she is a woman, and it is best facilitated when the labouring woman knows and trusts the midwife who is responsible for professional decision making at the time.

1 comment:

Joy Johnston said...

Having contacted Della and Helen about this discussion (I don't like to write about people without letting them know), Della has suggested that if we did a trial of homebirth in Victoria it would enhance the profile and increase homebirth.

I dont't think we need a trial on homebirth, but I'm not opposed to a trial that would include the option of homebirth. It would look something like this: the midwife is ‘with woman’, having the capability to go as the primary carer across the system – home or hospital – without placing any pressure on the woman or the midwife to decide on place of birth until that decision needs to be made. I look forward to having that possibility in my practice, and hope I see that in my working life.

There is really no question about the safety of homebirth when the midwife follows the simple principles outlined in our definition. The question is about the capacity of midwives to practise midwifery.

I would be able to accept a randomisation of women who all declare they intend to give birth ‘naturally’ (after receiving information and discussion of course) when they book in for care, and the service is able to provide caseload midwifery. The control group would be the standard hospital care for birth with the caseload midwife being the responsible professional throughout the episode of care; the intervention group would be that the woman had the choice of home or hospital for birth, also with her midwife. Of course you would need midwives who were competent in home birth – probably a system of contracting the services of experienced homebirth midwives to take caseloads and mentor hospital midwives until the hospital has upskilled its workforce sufficiently.