Above: Where should she give birth?
Out of hospital birth has been in the news. Two studies comparing outcomes between in- and out-of-hospital births were recently released, one in the New England Journal of Medicine (NEJM), the other in the Canadian Medical Association Journal (CMAJ).
The Lamaze International blog, Science and Sensibility, interviewed Dr. Jonathan Snowden, the Lead Author of the NEJM study. You can read his conclusions here.
Science and Sensibility also interviewed Melissa Cheyney, PhD, a medical anthropologist and practicing midwife, who is the chair of the Midwives Alliance Division of Research, on how to interpret the research. Read the interview here.
Finally, Henci Goer compares the two and provides an outstanding summary of the issues here.
The case is building for a revolution in maternity care.
Last year the UK’s NIH released new guidelines for home birth, declaring that low-risk women who have given birth vaginally once before are safer giving birth at home. I wrote about it here.
Dr. Neel Shah, an American obstetrician, wrote a widely-publicized editorial in the NEJM advocating that the US adopt a model of maternity care that was less intense and better coordinated, like the British system. Read it here.
Finally, just two years ago, the Midwives Alliance of North America published the biggest study of home birth to date, involving 17,000 mothers. It concluded that, “[P]lanned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.”
Though the two recent studies come to slightly different conclusions as the relative risks of hospital versus out-of-hospital, this is what the authors agree on:
- Rates of intervention in the hospital setting are too high;
- Outcomes are better when mothers are attended by a licensed professional;
- The absolute risk of maternal or fetal death across all settings is very low – Cheyney points out that the difference we’re talking about 2.4 deaths per 1000 in the home birth population versus 1.2 per 1000 in the hospital population, according to the NEJM study; she also points out that there is no risk-free option;
- The choice between out-of-hospital and hospital birth is a values-based decision, so there is not one right answer for every family – Cheyney again: “Families who opt for out-of-hospital birth settings are not being selfish when they consider the experience and well-being of the birthing parent. In my experience, they are looking at the larger picture of risks and benefits”;
- Risk is lowest where maternity care is integrated – meaning out-of-hospital transfer protocols and mutually-respectful professional relationships are in place.
A good friend of mine is a midwife with a passion for improving maternity care. Her mission is to “bridge and fill gaps to improve birth experiences and outcomes,” so she brings every stripe of birth keeper together: obstetricians, midwives, labor nurses, bedside technicians and doulas and childbirth educators, and she lets us all talk! Last night I dialed in on FaceTime to one of her meetings, and she asked us what was needed.
Based on the research, this is my answer.
- Full-spectrum training, where medical doctors learn from midwives as well as other doctors, and they learn in all birth settings, not only hospitals;
- Maternity care infrastructure that allows for continuity of care between birth settings;
- Maternity care that extends more robustly into postpartum. A government health panel recently recommended universal screening of women for depression during and after pregnancy. Stress is recognized as a contributing factor to maternal mental illness, and the way maternity care is delivered may increase stress. Right now new mothers go from feast – weekly medical appointments and a very high level of interest in their well-being – to famine – seen again only at 6 weeks postpartum, unless there is a problem.
- Build maternity care facilities to the purpose, adjacent to hospitals. Birth is usually very different from illness, but it’s treated in the same place, by the same people, with the same preference for action to control the body rather than support a physiologic process. Hospital architecture and furnishing is imposing and clinical, which inhibits labor hormones. Women are going to continue to choose hospitals “just in case,” so let’s design them to support physiologic birth while in close proximity to just-in-case medicine.
- More widespread use of “Centering Pregnancy.” This is group prenatal care, where women who are due around the same time gather with each other and their provider. They take their own health measurements, then center in for group discussion of topics relevant to pregnancy, birth and parenthood. This is an empowering model that demystifies the medical aspect of pregnancy, decreases fear, and builds lasting community.
Even if you’ve already had your children, this is a conversation worth following. Maternity care is a bellwether in medicine, reflecting the degree to which it is humane, patient-centered and evidence-based.