Home and Hospital Births Need Not Be Opposed
Denver, CO—Published data suggest that home births can be as safe as in-hospital births, but 
many obstetric and neonatal nurses remain fairly resistant to the idea. At the Association of Women’s Health, Obstetric and Neonatal Nurses 2011 annual convention, Ellise D. Adams, MSN, CNM, of the University of Alabama at Huntsville, asserted that the 2 approaches do not have to be “diametrically opposed.”
Regardless of the birth setting, there is a critical need to develop integrated systems of care that promote the best health for women and their newborns, Ms Adams said.Approximately 1% of all births in the United States occur outside of the hospital. Most are attended by a certified professional midwife (CPM) or direct-entry midwife (DEM), with the remainder attended by physicians (probably not by choice) or a relative.
The typical patient is aged 35 years or older, married, and multigravida. These are “not women making uninformed choices,” noted Ms Adams. “I have seen intelligent women making the choice to not go to the hospital. They feel a hospital birth is not as safe, and no one listens to them there.” Boucher and colleagues concluded that American women choose home birth to have a safe environment with better outcomes and fewer interventions, to avoid a negative hospital experience, to control their birth experience, and to ensure a comfortable and peaceful environment (J Midwifery Womens Health. 2009;54:119-126).
Of planned home births, 88% actually occur in the home, and 12% are transferred to the hospital setting. The literature indicates that most transfers are a result of failure to progress, need for pain medication, or maternal exhaustion; only 3% to 4% are for emergency reasons.
“But most of what we nurses see are train wrecks, so we may have a skewed view of home births,” she acknowledged. “In reality, most home births are successful.”
Legality and Safety of Home Births
Laws vary by state allowing certified nurse midwives to assist in home birth. Currently, 27 states license or regulate CPMs or DEMs; 23 have no regulation, and consider it illegal for CPMs or DEMs to assist in birth.
The American College of Obstetricians and Gynecologists does not support planned home births, but emphasizes that women who choose this option should work with a certified nurse midwife or a physician within an integrated health system, have ready access to consultation, and have a plan for safe and quick transportation to a nearby hospital.
Contrary to conventional belief, home births attended by certified providers actually appear safe, Ms Adams said. A 2009 analysis of the data from 5331 Canadian women showed very low and comparable rates of perinatal death, less need for medical interventions, and fewer adverse perinatal outcomes for planned home births versus hospital births (Janssen PA, et al. CMAJ. 2009;181:377-383). Similarly, a Dutch study of 530,000 planned home births showed no differences in maternal or neonatal mortality or admission to an intensive care unit (de Jonge A, et al. BJOG. 2009;116:1177-1184). And a much-quoted study of 5400 US and Canadian home births showed lower rates of intervention than, and similar intrapartum and neonatal mortality to, hospital births (Johnson KC, Daviss BA. BMJ. 2005;330:1416); however, the neonatal mortality analysis has been criticized.
In contrast, the recent meta-analysis by Wax and colleagues (Am J Obstet Gynecol. July 2, 2010. Epub ahead of print) was “a real kicker,” Ms Adams added. Although multiple superior outcomes were found for home births, neonatal mortality was increased 3-fold over hospital births. This generated widespread concern and comment, and has spurred a formal review of the data that is unpublished to date.
Can Hospital Births Be More “Homelike”?
The theory of “birth territory” is a concept that connects the birth environment with birth outcomes. It suggests that a positive outcome depends on the laboring woman having a safe environment that contains elements that reduce fear (Table), physical space that focuses on her needs, and power and control placed in her hands. Home births that occur in accordance with this theory “can teach us something,” Ms Adams suggested.
In a 2009 article, Hodnett and colleagues described their redesign of the hospital labor room to eliminate the standard hospital bed and include items “to promote relaxation, mobility, and calm,” which they called the “ambient room” (Birth. 2009;36:159-166). Not only were patients very satisfied with the change, but nurses lingered in the room longer, therefore, the patients received more labor support. In other studies, the same researchers found that homelike environments are associated with less need for anesthesia, more vaginal deliveries, and more breastfeeding.
“If we pay attention to the environment, we will make a difference in outcomes,” she said. “We need to work on this. Our patient satisfaction rates will increase and our perinatal outcomes will improve.”
Enhancing the Transport Scenario
“So if home birth is safe and if it is what women want, then why are we uncomfortable with the notion?” Ms Adams asked.
Beyond nurses’ comfort with having equipment close at hand, there is simply a degree of “mutual hostility and distrust” between home birth and hospital providers, she said. “If our worlds only intersect when things collide, we compromise quality of care,” she maintained.
“The transport scenario makes us shiver,” she said. “Botched home births are something we quake about.” There remains the feeling that home deliveries are unsafe, and resentment is felt when hospital providers must assume the risk of caring for another’s patient. “Turf power happens,” she added.
Nurses can ease the tension surrounding a transfer through appropriate, reassuring communication. The laboring mother, for example, is not a “failed home birth,” but a “successful transport.” Nurses should also treat the attendant with respect and understand that she can provide helpful information.
She suggested that nurses also try to establish productive communication with the home birth movement within their communities, and develop “cultural sensitivity” toward its members. “Until we all give up the need to be in charge,” Ms Adams concluded, “we won’t be able to collaborate.”