Safety in home births
With only about five percent of Canadians giving birth at home, one might think the practice is dangerous and that is why the number is so low. On the contrary. Studies show that, as long as the mother is at low risk, it is as safe to give birth at home as it is to give birth in a hospital.
Dr. Michael Klein is a family physician, pediatrician, newborn-intensive-care specialist, maternity care researcher and senior scientist emeritus at Vancouver’s Child and Family Research Institute.
“I am a part of a number of ongoing research projects,” said Klein. “We look at old and new technologies and assess them in relation to birth. I’m about normal birth – not complicated birth – keeping birth normal.”
In 2009, Klein worked on a study that looked at the safety of home births, evaluating three groups of births: home births by a midwife, hospital births by the same midwives, and a matched sample of physician births. The researchers looked at women who were identical in their risk profile and found that, regarding fetus development and the newborn baby, there was no difference in these three groups.
“Home birth seemed to be as safe as hospital birth, whether by the doctor or by the same midwife,” said Klein. “There are now two other studies from Ontario that show the same thing.
“Home birth is integrated within the health-care system in B.C.,” he continued. “Midwives are supported and part of the system, so when the midwife needs help from a hospital backup system, she gets it.
“Of course, what you also see is dramatically more interventions on the physician-hospital side than at home. And you find, interestingly, that the midwives – the same midwives delivering in hospitals – have results in terms of interventions of various sorts that are closer to the doctor’s side than they are to themselves at home.”
Klein attributes this observation to the influence of the hospital itself, a setting that is anxiety-driven. There may also be differences in the population, with women wanting a midwife in a hospital differently motivated from those wanting a midwife in a home setting.
In terms of the methodology of the study, it was very important that, once a woman was beginning her labor at home, no matter if the birth ended up being in a hospital or not, that she was counted in the home birth column or category.
“Roughly, a third of midwifery births will be home births,” said Klein. “That’s because this is what women are requesting. The model is what is called a ‘woman-centred model.’ If a woman wants a home birth and she meets the criteria in terms of her risk profile, then the midwife is obligated to deliver that service in the way she wants.
“I think there’s no question that we should have more home births. You may be unaware, but the minister of health in B.C. has supported that notion – that home births should be … I wouldn’t say promoted, but certainly made available.
“Women need to know what the options are and they need to know if they need help during labor that they will get it. A home birth, to be safe, needs to be within 30 minutes of an operating room. Contrary to what most people believe, things don’t suddenly go wrong. They evolve.”
Something else that can be a limiting factor in increasing home birth numbers is the lack of midwives across Canada.
“The joke is that you have to register with a midwife before conception,” said Klein.
In British Columbia, the midwifery class recently doubled in size. Why not quadruple the class size to keep up with demand? The simple answer is that the system is not currently able to support that, although it is estimated that a home birth costs the system between a third and half as much as a hospital birth.
“I think it’s too complex,” said Klein. “What we are talking about now is a serious planning exercise. That’s not happening. I think it will take time for the system to collapse a little bit more before it happens.
“The other player in all of this, which we haven’t talked about yet, is the doula. That movement is, of course, gaining more and more popularity. In some settings, it’s been so successful that some hospitals are supporting the doulas’ salaries.”
According to Klein, doulas are successful in lowering the caesarean-section rate and other interventions. “When you lower the c-section rate, it has a big impact on the hospital budget, because a person who has a caesarean stays twice as long in the hospital than one who has a vaginal birth,” he said.
Avoiding a c-section means less likelihood of a uterine scar in subsequent pregnancies. “Once a pregnant woman has a uterine scar, the whole reproductive trajectory is changed,” said Klein. “One is more likely to have a whole series of problems, complicated next pregnancies, placental attachment problems, ectopic pregnancies, stillborn births and infertility. With the c-section rate at four percent in home births and up to 30% in hospital births, that many more women will end up with a uterine scar and be at higher risk of complications.”
Dr. Brian Goldman, an emergency physician at Mount Sinai Hospital in Toronto, and the host of White Coat, Black Art on CBC Radio One, has, for years, had an eye on the growing demand among women in Canada for licensed midwives.
“Midwives are experts in low-risk, uncomplicated births, as are family doctors,” said Goldman. “However, even though low-risk birth is a core part of the training of family physicians, very few of them want to attend low-risk births once out in practice.
“In Canada, we have a situation in which the vast majority of births – high-risk and low-risk alike – are attended by obstetricians. These specialists have tremendous knowledge, skill and experience which, in my opinion, is best put to use managing women who are likely to have a complicated pregnancy and birth. We need more professionals like midwives and family doctors to attend low-risk births.
“Most family doctors run busy practices and find it difficult for practice, family and social reasons to devote a significant amount of time to attending women in labor through the night. To me, midwives represent the likeliest prospect for increasing the pool of professionals qualified and interested in attending low-risk births.”
Rebeca Kuropatwa is a Winnipeg freelance writer.