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About Lamaze

You Are Pregnant: First Important Choices

Q1: When do I sign up for Lamaze classes?
Q2: Would I benefit from Lamaze class if I am having my fourth birth?
Q3: How do I prepare for birth when traditional classes are not available?
Q4: Do I really need to take childbirth classes?
Q5: Should I take a birthing class if there is a large gap between my children?
Q6: How do I find a care provider that supports natural birth?
Q7: How do I find a midwife that performs water birth?
Q8: How do I choose between a birthing center and a hospital for my birth?
Q9: What does the research say about distance from hospital and safety of home birth?
Q10: Are there any studies about having a homebirth with gestational diabetes?
Q11: Is homebirth recommended if I had a prior cesarean?
Q12: Is homebirth recommended if I had a prior cesarean and short duration between deliveries?
Q13: Is homebirth recommended if I had a LEEP procedure?
Q14: Is homebirth recommended for my fourth birth?
Q15: Should I really transfer from a birth center to a hospital if my contractions have not started 24 hours after my membranes rupture?
Q16: How do postpartum hemorrhage and neonatal resuscitation protocols differ in home births and hospital births?
Q17: Can you discuss unassisted homebirth?
Q18: Can you speak to the Kennare et al. 2010 study about homebirth safety?
Q19: Can you speak to this study about homebirth safety?
Q20: Can I have your thoughts on this study about homebirth and hospital birth outcomes?
Q21: Does research conclude that homebirth is safe or not safe?


 

Your're Pregnant! First Important Choices

- Choose birth professionals
- Choose birth location

Topic 1: You’re pregnant! Your first important choices

Choose Birth Professionals

Q1: When do I sign up for Lamaze classes?

Q: During what week in pregnancy should one sign up for Lamaze classes?

A: You want to be finished with your Lamaze classes by the last month of pregnancy to be sure of completing them before the baby is likely to come. When you should start depends, then, on how long the series is. Once you figure that out, start looking early enough to find the class that is the best fit for you and your partner. As general principles, I recommend that you:

  • Seek out a class with at least 12 instructional hours. It takes time to learn new skills, get questions answered, and explore issues.
  • Look for an independent class. The bottom line is that we are all obliged to please the person who pays us. Classes offered by a hospital or clinic may be fine, but they may simply prepare you to be a good patient and not buck the system rather than empower you to make informed decisions. You want a class that teaches healthy birth practices.
  • Make sure the instructor is, in fact, Lamaze certified. I hope this has changed, but some years ago, at least, "Lamaze" was all too often being used as a generic name for childbirth classes.

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Q2: Would I benefit from Lamaze class if I am having my fourth birth?

Q: I am 10 weeks pregnant with our 4th baby, our first birth was rough with an induction & many interventions, my second I had a group of midwives but was able to deliver vaginally frank breech with an OB but the birth seemed unnatural with a large crowd of nurses and hospital staff then our healthy baby swept away for "observation" and our third was a terrific homebirth. Our health insurance will not cover homebirth or a birth center birth and we cannot afford to pay for a birth out of pocket. We will be delivering at a small hospital with the same group of midwives we had our second time around. Would I benefit from Lamaze courses? My last two births were unmedicated, I am a little nervous about going back into the hospital setting though. Any suggestions for me?

A: Having had two unmedicated births, I'm thinking you know how to cope with labor just fine. It sounds like your issue is more making sure you are making informed decisions. For that, the acronym "BRAIN" can help. Barring an emergency, if any test, drug, procedure, or restriction is proposed, consider:

B enefits
R isks
A lternatives, including doing nothing, and the benefits and risks of those
I nstinct or intuition, i.e. what your gut is telling you
N o or not now, i.e. your right to informed refusal

Again, barring an urgent situation, ask for time alone to consider before making your decision so that you don't feel pressured.

My book, the Thinking Woman's Guide to a Better Birth, is aimed at helping women make decisions based on what the research evidence establishes as safe, effective care. It is getting long in the tooth, but the information in it is still sound. Other books that might help you have an optimal hospital birth include Pregnancy, Childbirth, and the Newborn and The Lamaze Guide: Giving Birth with Confidence.

If you have some discretionary money, you may wish to consider hiring a doula. Many have sliding scale or will take time payments or possibly even barter. A doula offers emotional and physical support. She is in your corner. The best known of the doula organizations is DONA International. Come to that, before giving up on home birth with a midwife, see if your prior midwife or another qualified home birth midwife in your community will do the same.

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Q3: How do I prepare for birth when traditional classes are not available?

Q: I live in a Brigham City, UT and I am due with my fourth child.  With the first 3 pregnancies I have had epidurals and 2 out of the 3 did not work.  My epidural scared both my husband and myself and we would like to avoid that option if possible.  The problem is I feel in order to do this I need knowledge about the other options out there.  I've looked into classes and nothing is offered with in 30 minutes of me.  When I did finally find something the nearest thing was the Bradley Method Classes and after class fees, babysitting, & gas we would be paying $500 dollars just to take classes.  I found a Lamaze class but they were even farther and unreachable. Do you have any suggestions - I'm beginning to feel frustrated and a little overwhelmed.

A: I have two things to suggest: Penny Simkin's book the Birth Partner, which will give your partner all kinds of strategies to help you attain your goal of avoiding pain medication, and hire a doula, which will provide you someone trained in labor support skills to be with you and your partner throughout labor. You can find out more about doulas as well as locate a certified doula at these websites:  http://dona.org/ and http://www.cappa.net/. Hiring a doula will be more expensive, of course, but many doulas will negotiate with couples in financial need, e.g. discounts, time payments, barter. I hope this helps.

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Q4: Do I really need to take childbirth classes?

Q: I'm pregnant with my first child, a boy, and I'm really excited. At first I really wanted to do birth classes just so I would be totally prepared and what not. However after going to my first class, which was basically an introduction, I decided against doing it again. I don’t have any experience with the breathing part and so forth but how necessary is it really? My mom never did it nor my husband's mom and many pregnant women I know and they had great babies plus they pulled through fine. Secondly I don’t have the money to be spending on these classes as we have to be focusing on so many other things in our lives. Am I being silly when I say I don’t want to do the classes?

A: Of course you are not silly to want to spend your time and money on other things if you felt the class would not be useful. But the question I have is "What turned you off?" Unfortunately, there are a lot of not-very-good-classes out there taught by people who have no qualifications to teach them. (Training as a maternity nurse, BTW, no more qualifies someone to teach expectant couples than certification as a childbirth educator qualifies someone to be a nurse.) Or perhaps the class simply wasn't a good fit for you. Before you abandon the idea of childbirth classes, consider what a class can give you:

  • Knowledge about the last months of pregnancy, labor, breastfeeding, early life with a new baby
  • Labor coping skills for you and your partner
  • The ability to get questions answered and participate in discussions
  • Information on what policies and practices are most likely to promote a healthy, satisfying birth experience
  • Peer support--the chance to get to know and share with other people in the same life phase you are to name a few. Take a look at Choosing a Childbirth Educator for general information on how to find a good class that's right for you before you give up the idea. You can also get questions answered elsewhere on the Lamaze International website.

If you choose not to take childbirth classes--or even if you do--I strongly suggest you hire a doula. I also recommend getting The Birth Partner by Penny Simkin for specific information for your partner on helping a woman during labor, and for all-around basic information, get ahold of The Official Lamaze Guide: Giving Birth with Confidence. I also suggest you sign up for Lamaze's weekly e-newsletter. It's free.

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Q5: Should I take a birthing class if there is a large gap between my children?

Q: I have kind of a unique problem.  Lamaze classes are not available in my area, but first time birthing classes are.  I am not a first time mom.  This is my fourth baby, but my youngest is 13 as of yesterday.  I feel like a first time mom, and feel like I'm not going to remember anything.  My last Lamaze class was actually 16 years ago with my first.  Is it all going to come back to me??

A: I think that it will come back to you, but if you are feeling rusty, why not take another series? Also, it isn't so much about you remembering your coping skills but about you and your partner working together and finding your groove again. I'm betting, too, that with three other children, life is pretty busy, and it would be nice to commit time together that is focused on this coming baby.

That being said, I suggest you find out more about the content of the classes that are available, the setup--number of classes, number of couples, length of classes, and so forth--and the qualifications of the teacher. Specifically, being a labor and delivery nurse does not qualify a person to teach birthing classes. If the class is substandard, you would be better off not wasting your time. The Lamaze website has some considerations when choosing a class that might be helpful. 

Alternatively, if the class doesn't measure up--or even if it does and you plan to take it--consider hiring a doula. You can find out more about doulas on the Childbirth Connection website and on the DONA International website as well. Both sites have considerations and interview questions to help you choose a doula.

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Q6: How do I find a care provider that supports natural birth?

Q: When I first got pregnant I selected an OBGYN based on my primary care physician's (and also a family friend’s) recommendation.  My original goals were to have a safe birth that was as pain free as possible and a healthy child.  After researching and changing my views to a more natural birth stance, I find myself wondering, is it too late to find the resources to have a natural birth? I'm taking Lamaze classes, looking into hiring a doula, and trying to be informed.  My real question is, how can you have a natural birth without having a supportive OBGYN as there don't seem to be any in my area. 

A1: You can certainly change providers, and you are on the money that an approach that minimizes use of potentially harmful interventions best promotes safe, satisfying childbirth. Nonetheless, while it is true that midwives are more likely to have a practice style more supportive of normal birth, you get no guarantee of that. Likewise, OB’s are more likely to have a medical-model practice style, but not necessarily. One good winnowing technique is to tap into any local grassroots organizations such as a birth network or an International Cesarean Awareness Network chapter, a pregnancy resource center (not a commercial one!), or the local doulas. They are likely to know who offers care supportive of normal birth. However you gather names, you will also want to interview prospective providers. I have a section with suggested questions and considerations in my book, The Thinking Woman's Guide to a Better Birth, which includes red flag responses, but you can also find a section on interview questions for care providers on the Childbirth Connection website. While I'm at it, they have questions for potential birth sites as well.

A2: Another great resource from the Childbirth Connection is their 'The Rights of Childbearing Women'. You can order or download it. I always advise bringing it with you to the hospital. That way, if you encounter any adversity, you can pull it out and say, "I know my rights." Being informed is crucial to obtaining a normal birth experience in a hospital.

A3: I also think that things will go smoother if any exceptions to usual hospital policy or practice are, if possible, worked out ahead of time with care providers and hospital staff, that couples pick their battles, and that being polite and diplomatic as well as firm are most likely to get couples where they want to go.

A4: All 4 of my children were born in a hospital, and all were natural births.  My first (almost 20 years ago) was not "exactly" like I wanted, yet I still achieved a non-medicated, vaginal birth.  I did have to endure an IV, episiotomy, separation from my baby, etc.  I learned much from the experience; mainly what I didn't want to happen next time! The next time was only 15 months later, with the same OB and at the same hospital.  The difference?  ME.....  I knew that I wanted it to be different, and through planning and communication - it was awesome. By the births of my 3rd and 4th children, I was a practicing childbirth educator and Doula. I do agree that having a Doula who is knowledgeable of hospital "norms" is very beneficial.  Most first-time mothers "don't know what they don't know”.  It helps to have an advocate. Have a wonderful birth!

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Q7: How do I find a midwife that performs water birth?

Q: I am 33 years old and gave birth to my first child via cesarean due to "failure to progress". I recently became a doula (DONA) and have immersed myself in childbirth education. I am convinced now that I was laboring perfectly normally but b/c of unnecessary hospital interventions and because of just feeling "under surveillance" in the hospital setting, was subject to C-section. I am not pregnant yet, but am planning to be soon and would like to find out more on how to hire a midwife for a home water birth. I live in NJ and have heard that NJ insurance companies do not reimburse for homebirth after VBAC. Is this true? If this is the case, what are the estimated costs and how can I circumvent this to fulfill my dream. This is very important to me because of my new beliefs about birth and also to completely heal from the experience of my first birth.

A: I don't know the details about home birth coverage in New Jersey. I think your best bet is to get in touch with the International Cesarean Awareness chapter closest to you.

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Choose Birth Location

Q8: How do I choose between a birthing center and a hospital for my birth?

Q: I’m pregnant with my first child and I’m a bit nervous about the delivery. I'm having trouble deciding if I should go to the hospital or a birth center. I've read lots of thing from different sites that other women have posted and the birthing center sounds so much more enjoyable and relaxing than the hospital, but I can't find any information on if they give you pain medication at a birthing center. I want to try to have it naturally but if I can't then I want to have the option of having pain medication. I haven't taken any classes and I'm not going to have time to finish them; I'm moving in May, then again in June, then having the baby in July and I’m not sure if I could handle doing it naturally without them. I can't figure out if I should go to the birthing center and risk not being able to deal with the pain, or go to the hospital.

A: First the bad news: a few freestanding birth centers may give pain medication but most don't because of the potential adverse effects on mom and baby. The good news is that it is rare for a woman to transfer to the hospital in labor solely because she wants pain meds--although that will certainly be an option should that be the case for you. Why? Not because women who choose birth centers are somehow different from the common run but because: (1) routine and frequently used hospital procedures (labor induction, oxytocin to strengthen contractions, IV drips) and restrictions (confinement to bed, forbidding food and drink) increase pain, and (2) birth centers offer comfort measures in labor that women themselves rate as highly effective that hospitals rarely do (deep tub immersion, showers, birth balls, rocking chairs) and, as you yourself said, a relaxed, homey environment where staff are supportive and encouraging. Anxiety and stress also increase pain. I also recommend that whether you can get childbirth classes or not, hire a doula. A doula is a woman with training and experience in doing labor support. Several organizations certify doulas. Here is an article of mine that will answer some questions you might have and another that will help you choose one.

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Q9: What does the research say about distance from hospital and safety of home birth?

Q: I have been trying to find information about studies that would show how the safety of homebirth relates to the distance to the hospital. In other words, what is, or is there a safe distance from hospital for a homebirth. I have come across many places that say that about 30 minutes is a safe distance and many midwives refuse to attend homebirths if the distance is longer, but I haven't been able to find what basis this decision is usually made on. I also found that for example in England, in a place called Cornwall local midwives favor homebirths although the closest hospitals are 45-60 minutes away because they say the long journey is an unnecessary risk to the birthing mothers.

The reason I am asking this is because I live about 50-60 minutes away from the closest birthing hospital, and am still considering a home birth. Where I live there really are no options, no birth centers, etc. The hospital (as well as the others further away) are places where you cannot even chose who your care provider is going to be. It is midwife led, but there are countless "standard procedures" (=interventions) that are unnecessary and I would like to avoid. I also have no way of choosing who the midwife who would be in charge of me would be as it just depends on who's in turn when the birth takes place (care during pregnancy is done by community nurses who are not involved in birth). I had a very negative experience with the birth of my second child in a local hospital, which amounted to birth trauma and ppd. I don't want this to happen again, but I also don't want to be stupid and take a risk if I simply live too far from a hospital to have a safe home birth. The distance is an issue to local home birth midwives. Ironically the ones closer refused to assist a birth here, but I have found one who lives 2hrs away who is willing to travel here for my birth (my previous two have been very slow births). If you are aware of any studies or facts that would help me research and understand this issue and make a truly informed choice I would be very thankful for your help.

A: I am not aware of any research on this point. I think, though, that the 30 minute limit is based on a rule of thumb that a hospital ought to be able to perform an urgent cesarean within 30 minutes of making the decision, a.k.a. "30 minutes decision-to-incision." By extension, women laboring outside of the hospital should live no further than 30 minutes away so that by calling ahead, the hospital could be prepared to operate within that time frame.

I am not aware of any evidence basis for this rule--in fact, just the opposite. As Amy Romano, my co-author, wrote in the birth center chapter of Optimal Care in Childbirth, because the 30 minute rule is invoked by plaintiffs in malpractice cases, obstetricians have been motivated to establish that they should not be held to it. We have studies, therefore, showing that outcomes correlate poorly with decision-to-incision times, that even in well-equipped and staffed hospitals many urgent cesareans begin beyond that 30-minute limit, and that no interval between decision and cesarean, however brief, guarantees a healthy baby. (See below.)

Is it possible that something could go so seriously wrong in this next labor that inability to get to the hospital within 30 minutes could make a difference? Yes, but it isn't likely, especially if you have no medical risk factors and considering that this is your third baby. That being said, if something went that wrong, that fast, it is also possible that living closer or even being in the hospital, especially if it is a community hospital and not equipped and staffed for urgent cesareans 24/7, wouldn't make a difference. If you could obtain optimal care in your local hospital, a case could be made that you might be better off there, but as you relate, your local hospital is far from providing care that best promotes safe, healthy birth.

Bloom SL, Leveno KJ, Spong CY, et al. Decision-to-incision times and maternal and infant outcomes. Obstet Gynecol 2006;108(1):6-11.

Hillemanns P, Strauss A, Hasbargen U, et al. Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH. Arch Gynecol Obstet 2005;273(3):161-5.

Leung TY, Chung PW, Rogers MS, et al. Urgent cesarean delivery for fetal bradycardia. Obstet Gynecol 2009;114(5):1023-8.

MacKenzie IZ, Cooke I. Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section. BMJ 2001;322(7298):1334-5.

Nasrallah FK, Harirah HM, Vadhera R, et al. The 30-minute decision-to-incision interval for emergency cesarean delivery: fact or fiction? Am J Perinatol 2004;21(2):63-8.

Tuffnell DJ, Wilkinson K, Beresford N. Interval between decision and delivery by caesarean section--are current standards achievable? Observatiional case series. BMJ 2001;322(7298):1330-3.

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Q10: Are there any studies about having a homebirth with gestational diabetes?

Q: Are there any studies about having a homebirth with gestational diabetes? My friend is due in June and she had her first at home and would like to stay home again. Unfortunately she has GD and has to inject insulin. They told her she had to birth in a hospital. Is that true? (Btw, she lives about 10 minutes from the hospital)

A: Not that I'm aware of. The inability to control blood sugar with diet does indicate a more serious problem, however, so it is not unreasonable that this would risk her out of a home birth.

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Q11: Is homebirth recommended if I had a prior cesarean?

Q: I have read through several of your forums and noticed you do recommend waiting 15 months to conceive after a c-section to allow for a better chance of VBAC success... my question is I conceived 13 months post section but miscarried 1 month later on... I conceived again 15 and a half months post c-section.  My question is did the miscarriage (natural) put extra stress on my uterine scar? And also since I did end up pregnant again after the 15th month mark, but only by a few weeks, am I in the low risk .5 percent chance of rupture or do I fall into the 1-3 percent... I am thinking of a homebirth and would rather be in the .5 percent category. I am also wondering if the miscarriage could up that risk with added stress of contractions during the miscarriage. I feel like homebirth is my only choice besides induction because with my first baby I did not go into labor until 42 weeks and 4 days (refused induction) and I know I would be under too much pressure to be induced this time. Do you feel it is reasonable to attempt a homebirth with this history or do you think the risk or meconium and rupture might be too high? There was meconium with my first birth... I hope this isn't asking too many questions. Thank you so much for your time.

A: Investigators theorize that the reason scar rupture rates go up with a short interval between the cesarean and the next labor is because the scar takes time to heal. I don't know that this gets you much further, though. 

One thing that might help you make your decision is to find the hospital-based care provider in your community who is the most supportive of VBAC and have a heart-to-heart with her or him about your concerns, including that since you seem to run long pregnancies, you are worried that you might be pressured to agree to a repeat cesarean. I say "repeat cesarean" because most clinicians are leery of inductions when a woman has a uterine scar. The research shows that induction can increase the risk of scar rupture. (FYI: it doesn't necessarily, but that is a post for another time.) Then see what this person says.

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Q12: Is homebirth recommended if I had a prior cesarean and short duration between deliveries?

Q: I am currently 5.5 months pregnant with my second baby. I had my first baby via C-section because of breech presentation and deliveries will be about 16 months apart. Due to the fact that I've been automatically labeled high risk by my HMO and have been recommended for a repeat c-section, I have decided to attempt a homebirth with a very qualified midwife (over 30 years exp.). However, I have been reading some literature that suggests my risks for uterine rupture are increased because of the short time in between pregnancies and deliveries. What information can you provide me? Also, what research have you seen to support having an ultrasound at 37 weeks to determine rupture risk?

A: I have the research on the association between interdelivery interval and scar rupture to hand because I recently finished writing the chapter on VBAC for the forthcoming new edition of Obstetric Myths Vs. Research Realities. The biggest of the studies, 18,000 women with prior cesareans, reported a rate of 1.1% with interdelivery interval less than or equal to 24 months compared with an overall rate in women with one prior cesarean of 0.7%. That was without adjusting for labor management that could increase the risk of scar rupture such as inducing labor or giving oxytocin to strengthen contractions. (A different analysis of the same database found that the odds of scar rupture were 0.4% with spontaneous labor onset and no oxytocin augmentation compared with 1% with induction and 0.9% with augmentation.) In other words, you have a 99% chance of having no problems with the scar and probably even better than 99%.

Landon MB, Spong CY, Thom E, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 2006;108(1):12-20.

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Q13: Is homebirth recommended if I had a LEEP procedure?

Q: My friend recently had a homebirth and I was privileged to be at her home while she labored/delivered the baby and I was convinced THIS IS THE WAY! I am actually 8 weeks pregnant, and am debating what to do. I had a LEEP procedure done where they removed 1cm of my cervix, my OB said it wasn't a lot and shouldn't cause any complications but they would do vaginal ultrasounds throughout my next pregnancy to assure my cervix was not thinning out prematurely. I am wondering if it would be safe to be in the care of a midwife and do a home birth rather than have to mess around with all that hospital stuff!

A: I think your best bet would be to discuss this with your chosen midwife. However, as I understand it, the risk of having this procedure is that it may lead to preterm labor. If you went into labor too early for the baby to be born at home, your care would be transferred to a hospital. This would be the case for any pregnant or laboring woman planning home birth who develops a complication requiring the resources of a hospital.

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Q14: Is homebirth recommended for my fourth birth?

Q: I have decided to have a home birth this time (my fourth), and I have had a series of problems with my OBs. I am very healthy, 42, and had vaginal births with no complications, augmentation, etc. The doctor I knew well is ill and not seeing patients, and I was transferred to someone new in the practice. When I told her that I wanted a home birth, she was amenable to being my back-up OB. At my 36 week visit today, she told me she could not be my back-up (or, as she put it, "supervise midwives") because the legal department of the hospital would not let her, nor did she feel comfortable with the idea because of concerns for postpartum hemorrhage. From the little bit of looking I have been able to do today, it seems that PPH is most associated with common obstetric practices in the second stage of labor (induction, instrumental delivery, use of oxytocin) that would not be part of a home birth. She also said that uterine atony increases with each birth, but from what I read, PPH does not have a significant correlation with grand multiparity. Furthermore, I couldn't find a study with rates of PPH comparing normal births in hospitals versus home births. Seems like a lot of rationalization rather than good science.

A: In a word, "yup," and you are quite correct that typical hospital management tends to increase the risk of excessive bleeding. In any case, midwives can treat excessive bleeding at home in the same ways it would be done in the hospital: with meds and massaging the uterus. As I have said before, the urgent problems that may occur at the time of birth can be treated or stabilized for hospital transport by a home birth attendant with the appropriate skills, easily portable equipment, and the proper meds. And, of course, these problems will occur more rarely in women and babies not subjected to the harms of conventional hospital practices and policies.

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Q15: Should I really transfer from a birth center to a hospital if my contractions have not started 24 hours after my membranes rupture?

Q: My husband and I are planning our second child. With our first we had the whole in the hospital, being induced, epidural, experience. This time we want an all- natural birth at a birthing center with a midwife. My concern is that, like my first child, my water will break and I won’t go into labor and the midwife will transfer me to a hospital after 24 hours. If the baby’s heart rate is monitored is it safe to wait longer than that? I really want as natural as possible experience.

A: If that is the birth center's policy, I think you are stuck with it. But to answer your question, yes, it is safe to wait for onset of labor if your water breaks. If you test positive for group B strep, though, you should have antibiotic treatment.

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Q16: How do postpartum hemorrhage and neonatal resuscitation protocols differ in home births and hospital births?

Q: The two biggest reasons that "concerned" individuals try to talk me out of homebirth are post-partum hemorrhage and the need for neonatal resuscitation.   From having had two homebirths, I know directly and personally that my midwives are capable of handling both.  I'm preparing to give birth to my third and will most likely use these midwives again. But specifically how do the protocols for each scenario differ in home v. hospital settings? Are there any other differing protocols/procedures/equipment that I would experience in a hospital setting, and would I be at any disadvantage not to have them employed?

A: For starters, you are at substantially less risk for postpartum hemorrhage birthing at home because conventional obstetric management exposes women to treatment that increases their risk of excessive postpartum bleeding, notably, oxytocin induction and augmentation of labor, especially using high-dose regimens, preventable cesarean surgery, preventable instrumental vaginal delivery, and unnecessary manual placental removal. Next, we actually have some data coming from low resource environments. In a Vietnamese trial, outcomes were compared between one district in which midwives were trained in active management of 3rd-stage labor (AMTSL) versus other districts in which midwives administered oxytocin as needed. Most women in both groups gave birth in community health centers. Virtually identical percentages experienced measured blood loss of 1000 mL or more (0.7% AMTSL vs. 0.5% control), despite 97% being given postpartum oxytocin in the AMTSL group compared with 15-30%, depending on comparison district, given oxytocin therapeutically. The take-home for you and other low-risk women planning home birth with a qualified birth attendant is that severe bleeding is rare and that it can successfully be treated should it occur.

Home-born babies are also at decreased risk for breathing problems, again, because they and their mothers are less likely to be exposed to narcotics, which depress respiration, unphysiologic pushing position and technique, and early cord clamping. Furthermore, typical hospital resuscitation procedures are actually counterproductive, if not downright harmful. Immediate cord clamping is problematic for any baby because it deprives the newborn of a substantial percentage of its blood volume, and blood flow to the capillaries surrounding the lung alveoli is an important factor in initiating and maintaining respiration, but cutting the cord on a baby who isn't breathing so that it can be removed for treatment is like cutting the air hose of a diver. So long as the cord is intact and the placenta attached, the newborn will continue to receive oxygen via placental circulation. Oxygen and suctioning, if necessary, can be carried out with the cord intact. As for intubation, a 10-year-old trial showed that, intubation and suctioning were not needed for meconium aspiration in a vigorous newborn, but I would bet that most hospital-born babies with even minimal meconium staining--let alone aspiration--continue to be intubated thus exposing them to its harms.

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Q17: Can you discuss unassisted homebirth?

Q: I was reading in The Thinking Woman's Guide and the paragraph on Unassisted Homebirth really hit me. It wasn't very detailed, and so I just wanted to get a little more information or opinion on it. If that is what I feel is truly the best option for me, what can I do to prepare myself and what signs can I watch for to know if an emergency situation should come up?

A: Here is where I stand personally on the issue of unassisted home birth:

The research unequivocally establishes that planned home birth in a woman at low-risk of complications attended by a qualified home birth practitioner produces equally good or better outcomes compared with low-risk women planning hospital births. Change any of those parameters, and all bets are off, and the research shows that too. You can see why that would be so, but turning specifically to the "qualified home birth practitioner" element, there are things that can go wrong even in a low-risk woman that can be caught early and allow for transfer to the hospital, or, if they occur at the time of birth, they can either be put right or stabilized until hospital resources can be accessed by someone who knows what she is doing and carries the appropriate equipment and medications.

On the other hand, I put the paragraph on unassisted home birth in my book because women may find themselves in situations where no qualified home birth attendant can be found. Conventional obstetric management in hospitals poses considerable hazards, as Thinking Woman's Guide to a Better Birth makes clear. A woman may weigh the benefits versus harms of hospital versus unassisted home birth and decide that unassisted home birth is the less risky option. I respect a woman’s right to do that. I firmly believe that women have the right to make informed decisions about what, in their minds, constitutes the best and safest care and that no one has the right to override their decision. I stress the word “informed” because all too many decisions about maternity care are made on the basis of incomplete, incorrect, or no information, or are driven by factors such as fear that do not permit making a free choice.

So that’s my stance. I cannot, however, advise you on how to prepare for an unassisted home birth or what to watch out for during one.

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Q18: Can you speak to the Kennare et al. 2010 study about homebirth safety?

Q: While recognizing that Australian medical authorities and government officials are notoriously repressive when it comes to women's autonomy in childbirth, I was disturbed to hear of this study on home births in Australia. Among the claims are that babies are 7 times more likely to die in planned home birth than hospital birth and 27 times more likely to die from asphyxiation in home birth.

As with all studies on controversial issues, this one has had at least one critic come forward to deconstruct it.  Unfortunately, I'm not a BMJ subscriber, so I can't access this rebuttal. Because there's little talk of this study in the U.S., I was curious to hear your thoughts.  I've home birthed two babies safely.  But on the surface, I find this disturbingly compelling.

A: The study you are looking for is Kennare et al. 2010. You can find a critique of the study here. I think it will satisfy your concerns. In addition, my co-author on the forthcoming new edition of Obstetric Myths Vs. Research Realities, Amy Romano, took the lead on the home birth chapter. She points out in the chapter essay that "Three out of the four perinatal deaths occurring in labor or after birth among normally formed babies . . . occurred in cases where the parents were advised against planning home births but refused or delayed hospitalization, and in at least one case a prior poor experience with hospital birth contributed to this refusal." When women are so traumatized by their treatment in labor that they refuse to risk a repeat of the experience, who deserves the blame for that?

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Q19: Can you speak to this study about homebirth safety?

Q: Would you look at this study and tell me if this is of any value when talking about the safety of homebirth in low risk women? Isn't the home birth perinatal death still lower than the hospital one? Is that because there were less preemies? What are 'late neonatal death rates'?

A: I have looked at it and have it in my files. To start with your question about definitions, the study looked at perinatal deaths, which investigators defined as stillbirths plus deaths within 28 days after birth. They further broke down neonatal deaths into deaths within the first week and late neonatal deaths. In other words, late neonatal deaths are deaths after day 7 through day 28. The core issue was that the still birth plus death rate in the first 7 days (6.4 per 1000) was substantially higher than in other large studies of planned home birth with a qualified birth attendant conducted in the U.S., U.K., and the Netherlands (2.0-3.5 per 1000). The investigators attributed the difference to two main factors: First, Australian midwives were caring for babies who were not low risk (breech, twin, less than 37 weeks gestation, 42 weeks gestation or more) in the home birth setting. Study authors speculated that, "Overintervention and lack of choice for women with high risk pregnancies, however, could well encourage some to choose home rather than hospital birth. In many Australian hospitals, women with breech presentation or twins, for example, would only be offered caesarean section" (p. 387). (Sound like another country we know and love?) There also appeared to be failure of timely transfer in cases where there was meconium, episodes of slow heart rate, or both for several hours before fetal death. Study authors comment, "Our study highlights the need for objective guidance on what constitutes safe practice for birth at home" (p. 387), and conclude, "Australian women, like women elsewhere, will continue to choose to give birth at home. They and their infants are entitled to effective care and support in their choice." I would add that they are also entitled to hospital care that does not force them outside of the hospital in order to avoid overly interventive care with its attendant risks and unnecessary cesarean surgery. 

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Q20: Can I have your thoughts on this study about homebirth and hospital birth outcomes?

Q: Can I have your thoughts on this study? If I understand correctly the planned homebirth group was compared to a group of random hospital births. Does the last include at-risk women or are they comparing equal groups, ie all low-risk women since this is the group homebirthers would be in? This is where these studies get confusing to me! It seems that these studies cannot really compare the groups well enough.

A: I had the chance to review the Swedish home birth study.

Lindgren HE, et al. Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study. Acta Obstet Gynecol Scand 2008;13:1-9.

Objective. The aim of this population-based study was to measure the risk of adverse outcome for mother and child in planned home births in a Swedish population irrespective of where the birth actually occurred, at home or in hospital after transfer. Design. A population-based study using data from the Swedish Medical Birth Register. Setting. Sweden 1992-2004. Participants. A total of 897 planned home births were compared with a randomly selected group of 11,341 planned hospital births. Main outcome measures. Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared. Results. During this period in Sweden the neonatal mortality rate was 2.2 per thousand in the home birth group and 0.7 in the hospital group (RR 3.6, 95% CI 0.2-14.7). No cases of emergency complications were found in the home birth group. The risk of having a sphincter rupture was lower in the planned home birth group (RR 0.2, 95% CI 0.0-0.7). The risk of having a cesarean section (RR 0.4, 95% CI 0.2-0.7) or instrumental delivery (RR 0.3, 95% CI 0.2-0.5) was significantly lower in the planned home birth group. Conclusion. In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.

To begin with, the fact that the confidence interval (CI) includes "1" means that the difference is not statistically significant, meaning that it could have occurred by chance. However, failure to find a statistically significant difference may be because the study lacked sufficient power to detect a difference, that is, the population of home births was small and there were few deaths (2 deaths among the 897 home births; 7 deaths among 11,341 hospital births). In a larger study, the difference might have achieved statistical significance. Study authors note that 47,361 home births would have been needed to have a reasonable chance of detecting a difference. But let's look closer at the deaths themselves. One death in the home birth population resulted from congenital anomalies. Birth site would have made no difference. If we remove that death from consideration, the death rate in the home birth population falls to 1/897 = 1.1 per 1000. The other death occurred in a water birth, and three experts reviewing the case concluded that the water birth was the main reason for the death. No further details are given, so it is not clear whether this was, in fact, the case, but even if it was, poor care is the likely culprit, for example, not lifting the baby to the surface immediately.

It is also worthwhile to point out that two of the five hospital deaths that did not involve congenital anomalies might have been related to hospital management and might have been avoided had the women been at home. They occurred in women who had epidurals and, as is required more often when a woman has an epidural, vacuum deliveries. One death is specified as relating to hemorrhage resulting from the delivery, and the other related to shoulder dystocia (the head is born, but the shoulders hang up) in a 4000 g (8 lb 13 oz) baby. These tragedies might have been averted had the women been able to push effectively in upright positions. In the latter case, if the baby had still had shoulder dystocia, having a midwife who knew the Gaskin maneuver might have made a difference too. Finally, note the statistically significant differences in anal sphincter tears (0.3% vs. 2.7%), vacuum deliveries (2% vs. 10%), and cesarean surgeries (2% vs. 7%). This was despite that fact that the home birth population contained 8 sets of twins, 11 preterm births, and 79 post-term (more than 42 w) births while the hospital comparison population was composed of term, singleton births.

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Q21: Does research conclude that homebirth is safe or not safe?

Q: What does the body of research on homebirth have to say about it? Safe or not safe?

A: There is, in fact, a large body of research on home birth going back over 25 years, including a systematic review, in addition to the two studies you mention. Studies with sound methodology uniformly conclude that planned home birth with a qualified birth attendant produces equally good, and often better, outcomes than are found in similar women planning hospital birth.

Let's look in more detail at what actually happened to the 7286 women who registered for home births in the Johnson 2005 study:

Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330(7505):1416.

-- 103 women made an initial visit and never returned

-- 436 (6%) had social reasons (chose hospital birth, moved, changed midwife, cost, other) for not having a home birth

-- 469 were referred for medical reasons (6.5%), including pregnancy complications (205), miscarried (171), preterm labor (58), antepartum fetal death at 20 wks or more (19), twins (16)

-- Of the women continuing care with the midwife, 667 (11%) intended care in a birth center at labor onset, and 163 (2.5%) intended a hospital birth.

-- Of the 5418 women still planning a home birth at labor onset, 655 (12%) were transferred to hospital during labor or afterwards. Almost all (83%) of these transfers were before the birth, and in half of these cases, the reason was poor progress, desire for pain relief, or exhaustion. The cesarean rate among these 5418 women was less than 4%, so the vast majority of the transfers in labor resulted in vaginal births.

So you see, when you look at the details, a very different picture emerges: Less than 7% of the original population were transferred out of midwifery care in pregnancy, of which only half had pregnancy complications of some kind, and nearly 90% of women intending home birth at the onset of labor gave birth and recovered at home.

As for a bibliography of home birth studies, I append a list. In addition to these, there is the infamous Pang 2002 study, concluding that home birth was dangerous. I have deconstructed that study elsewhere on this site.

Ackermann-Liebrich U et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ 1996;313(7068):1276-7.

Bastian H, Keirse MJ, and Lancaster PA. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317(7155):348-8.

Duran AM. The safety of home birth: the Farm study. Am J Public Health 1992;82(3):450-453.

Gulbransen G, Hilton J, McKay L, et al. Home birth in New Zealand 1973-93: incidence and mortality. N Z Med J 1997;110(1040):87-9.

Janssen PA, Lee SK, Ryan EM, et al. Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 2002;166(3):315-23.

Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330(7505):1416.

Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24(1):4-13.

Weigers TA et al. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ 1996;313(7068):1309-13.

Woodcock HC et al. A matched cohort study of planned home and hospital births in Western Australia 1981-1987. Midwifery 1994;10(3):125-35.

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The questions and answers offered in this section are from evidence-based information, and archived from the Lamaze Ask Henci forum that was available through 2014. For medical advice, please see your care provider.