Is home birth a safe option?
The first thing most women do when they discover that they are expecting a child is to contact their doctor and arrange combined care. The combination in the phrase refers to the fact that antenatal care is shared between the pregnant woman's GP and the maternity hospital where she will give birth.
But this regime is not followed by all women and hospital births only became the norm just a few decades ago. An increasing minority of women are returning to the system which saw generations of Irish women in labour at home in the company of a midwife.
But what possible advantage can there be for women to give birth at home rather than in what doctors argue are the safe confines of a maternity hospital? Women who give birth at home refer to the familiarity and informality of having a baby in the comforting surroundings of their own home, compared to the high-tech environment of a modern hospital ward.
"One of the main incentives for women giving birth at home is the desire to have a natural birth", says Paidricin Ni Mhurchu of the Home Birth Association. "In maternity hospitals women in labour are subjected to various managed labour routines, such as having their waters broken and they often have recourse to strong painkillers".
She believes that many of the women choosing to give birth at home are mothers already. If a woman had a previous birth in a hospital that was unpleasant or too clinical, they may opt for a home birth the next time they become pregnant.
"If women have had a bad experience in hospital, that can lead them to choosing a home birth second time around. Once you start having your labour augmented in hospital, you can have contractions without a break, which in turn can lead to painkillers or a Caesarean section".
An estimated 200 women each year choose to have their children at home in Ireland and the figure is growing the Irish Home Birth Association says. Proponents of home birth argue that a labour overseen by a midwife in the family surroundings is not merely more comfortable than a hospital birth. It is, they claim, safer and less stressful for the newborn than a birth in a clinical environment.
"The obstetric view is that every labour is potentially abnormal", argues Ms Ni Mhurchu. "In Ireland the system is obstetrician led, not midwife led. Hospitals often engage in preventative action because of the fear of litigation".
'No home can compete with the facilities of
a maternity hospital, should an emergency occur'.
Most family doctors tend to argue against a home birth and for obvious reasons. The home environment cannot possibly be as sterile as a hospital ward and is certainly not equipped with the facilities of a hospital if anything were to go wrong, the say.
"I understand the desire for home birth and agree that there is an obligation on the Department of Health to provide the option", says Dr Liam Lynch, the GP leader of the Irish Medical Organisation. "But if there is a perinatal problem, how do you resuscitate? A lot of equipment that is par for the course in a maternity ward is not going to be available at a home birth."
Fear of a crisis
Many women find the concept of home birth appealing, but are put off by the fear of what would happen if the labour began to go wrong. In the event of a crisis, or when specialist monitoring is required, home births can still transfer to a hospital. The 'Domino' system, so-called because it combines domiciliary antenatal care with an in-and-out visit to the maternity ward is popular in England.
Because of the low number of home births in Ireland, statistical comparisons between home birth and hospital birth here are not possible. However, studies in other countries make for surprising reading. In the UK, the perinatal mortality rate for home birth is in the region of four per thousand, compared to around 9 per thousand in hospital environments. Similar studies in Holland and Australia have confirmed these findings, which appeared in the 'British Medical Journal' back in 1996.
'Many women find the concept of
giving birth at home appealing'.
Home births can occur in a bed, as in hospital, or in a specially designed birthing pool, as depicted above. Women who give birth in a pool do so because the water is considered to be a particularly relaxing medium for labour. This could be important when contractions are at their height, especially for women who desire the 'natural' experience of labour without drugs. Birthing pools are available for hire in Ireland and the Home Birth Association maintains a list of suppliers.
"One of the other reasons I use water in labour is that I want the transition from life in the womb to life in the air to be as gentle as possible for the baby", explains Judith Crowe, an American childbirth educator who has had her five children in pools.
"Babies who are born gently in a warm watery environment and who do not have the cord cut, play with their first breaths instead of the panic stricken gasp which was the first experience of breathing our generation had".
Giving birth in a pool currently remains the preserve of women who give birth at home, since no Irish maternity hospital currently has a birthing pool. The cost of hiring a pool is in the region of £120 to £160 and the practicalities of space in the home will dictate what kind of pool is advisable. Similarly, where the pool should be placed depends on where the floor can support the weight and how easily the midwife can access the mother. After the birth, the water is drained away using a pump.
"Using a birthing pool produces the most obvious physiological effects in labour, such as reducing strain on the joints, muscles and ligaments that have to stretch during birth", says Ms Crowe. "I am convinced that the water helps the mother to enter the deeply centred, relaxed, flowing, instinctive state of mind that enables her to pay attention exclusively to the signals she is receiving from her body and the baby".
All health boards are obliged by law to
offer mothers-to-be the option of giving birth at home'.
A woman's right to give birth at home is enshrined in Section 62 of the Health Act 1970, which obliges health boards to provide 'medical, surgical and midwifery services' to all eligible women. These services include antenatal care and a birth attendant to provide care during labour and delivery. The birth attendant is usually a public health nurse, as all public health nurses are also qualified midwives.
Following complaints to the Ombudsman about health boards not complying with the home birth provision, pilot schemes were set up at the National Maternity Hospital in Holles Street and at University Hospital Galway. A further scheme is due to begin soon in Cork. The Holles Street scheme has been running now for more than a year and employs eight midwives, but it is limited in scope, according to the Home Birth Association.
Geographically, only women living in a small section of South Dublin are eligible for the Holles Street scheme and there are certain other limiting criteria, such as the exclusion of women who have had a Caesarean section previously. Similar limitations affect eligibility for the Galway scheme. Mothers-to-be from the catchment area can find out more by contacting Dr Mary Wingfield at the National Maternity Hospital, Holles St.
Though these schemes are still nascent and limited in scope, GP representatives feel that the benefits of introducing widely available home birth could be over-exaggerated. They point to a lack of government support for the primary care system and claim that this is how resources could be better targeted at mothers to ensure healthy and fulfilling births.
"Obstetricians are becoming uninsurable because claims are so excessive", says Dr Lynch. "The expectation is that every baby should be perfect and there is a problem between that expectation and the reality. I feel it might be more useful to support GPs in educating mothers about smoking while pregnant and getting their child vaccinated, than to put a lot of money into home birth schemes".
Midwives are qualified to provide full antenatal care, as well as care during labour and delivery. That care can include prescribing painkillers. However, if something goes wrong, they have an obligation to have the mother taken to hospital as quickly as possible.
Some are domiciliary midwives, meaning that they specialise in home births. The majority of Irish home births are overseen by domiciliary midwives. They work in private practice predominately and using their services will mean paying a fee, though much of this can usually be recouped from the local health board.
Availability of midwives
There are around 16 specialist domiciliary midwives in the state and they are mostly based in Dublin and Cork. They charge in the region of £1,200 per birth, although if they have to travel some distance, the fee can be extra. Contributory payments can vary from health board to health board and even within health board regions.
"The Southern Health Board and Western Health Board will pay the full amount", says Padraicin Ni Mhurchu. "In the SEHB region, however, there is a ridiculous situation. In Kilkenny, the board will pay for everything, including travel, whereas Wexford inhabitants only get the £1,200 fee paid for. Waterford will only pay £650".
The Department of Health requires that a minimum payment of £650 per birth be made and some health boards, such as the MHB and the three health boards in the ERHA region, will only offer this amount. The fees vary within the North Western Health Board and the SEHB.
In Donegal, a fee of £650 plus travel is allowed, but the NWHB stresses that decisions are made on a case by case basis. The service for Sligo and Leitrim is administered by two midwives who are salaried employees at Sligo General Hospital, so no fee is payable.
As so few home births occur in Ireland, some boards will make their decisions based on the merits of the case. Any mothers-to-be seeking the latest information on how much their local health board is willing to pay for domiciliary midwife care should contact them directly before birth, as payment levels above £650 are discretionary.
Women who have undergone a home birth speak very highly of the experience, often referring to a great sense of fulfilment resulting from the labour. Home birth seems to empower such mothers with a greater sense of ownership over their own labour. Though it remains difficult to arrange a home birth in Ireland, the minority who do so are almost universally glad that they did.
"Labour was quite different to what I expected, which just goes to prove - if proof were needed - that it is different for everyone", says Jo O'Donoghue of the birth of her daughter Fionnuala. "Firstly I found it very painful, though bearable and I would never just call it hard work or exhilarating or exhausting, although it was all those things as well".
It was also very intense, she adds. "The midwife and my husband held me, one on either side during the contractions. I couldn't have done it without them but I didn't want anyone else. Was it easy? No. Was it worthwhile? Yes. Would I do it again? Yes".
Around 20 years ago, all hospitals had 'flying squads' which would attend a woman in her home and assist her with her labour. Without these, home birth has become a much more difficult option in the practical sense. Finding a midwife, arranging domiciliary care, informing your GP and negotiating with the health board are all required before a woman can have a home birth in Ireland today.
The future of home birth in Ireland may depend on the success or otherwise of the pilot schemes currently in operation. For women elsewhere in the country, the difficulties in arranging a home birth are enough to put many off.
The controversy over the Ann Kelly case has brought the issue to a high profile. A complaint about the safety of her home birth service was overturned by the Supreme Court last year when An Board Altranais attempted to stop her practising as a domicilary midwife.
Also, the scarcity and cost of domiciliary midwives undoubtedly limits the number of home births that could occur in Ireland.
Ann Kelly, (centre), the domiciliary midwife who had a complaint
about the safety of her home birth care overturned by the Supreme Court
in May 2000. The Nursing Board had sought to stop her practising
following a complaint by the Master of a maternity hospital,
but lost the right to do so in a £1 million legal battle.
Many doctors, both GPs and hospital staff, still view home birth with some scepticism. Home birth proponents argue that this is because home birth takes control of the labour away from doctors and gives it to the mother.
The fact is that in 1968 there were 3,050 home births here - which represented 5% of all births. Today, there are just over 200 home births, representing just 0.4% of all births.
The medical view
Doctors simply feel that a birth in a maternity hospital cannot be bettered for support and emergency care, should anything go wrong. While maternity hospitals are coming to accept the safety of birth in the home, the preference is still for women to have their children in the carefully monitored environment of a hospital.
"I don't see pregnancy and birth as an illness or a disease", says Dr Lynch. "But maternity hospitals have the back-up facilities and resources to maintain care for mother and child at the highest level throughout pregnancy, labour and beyond. When you remove some of the care responsibility from the maternity hospital, inevitably it will be GPs who have to pick up some of the slack".
There have to be choices for mothers, maintains Padraicin Ni Mhurchu. "If maternity hospitals do not offer home birth as a viable choice, mothers will not have the option. Women of two generations back have no problem with the concept of giving birth at home. Women today, however, seem to have no confidence in their ability to give birth, which is the ultimate female experience".
For more information about arranging a home birth in Ireland, contact the Home Birth Association or one of the hospitals currently running home birth schemes:
Home Birth Association,
National Maternity Hospital,
Contact: Dr Mary Wingfield.
University Hospital Galway,
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