TRANSCRIPT EPISODE 64 – All About Pregnancy & Birth With Dr. Nicole C. Rankins

Transcript episode #64: Deciding If Home Birth Is Right For You And Your Baby

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(00:00):

Today, I am talking about a topic that I said I would never discuss on my podcast. And that is home birth.

(00:13):

Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN who's had the privilege of helping hundreds of moms bring their babies into this world. I'm here to help you be knowledgeable, prepared, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at www.ncrcoaching.com/disclaimer. Now let's get to it.

(00:52):

Hello, hello. Welcome to another episode of the podcast. This is episode number 64, thank you for being here with me today. So on today's episode I am talking about home birth, and when I created this podcast I actually said that I was never, ever, ever going to talk about home birth. And it is not because I am against home birth, I'm not. It's that I don't know home birth, I've never seen a home birth, so it didn't really feel right for me to talk about it. And also the purpose of my work has always been and will continue to be hospital birth. That is what I know and that is what my work focuses on. Changing, improving, and making the best possible that it can be with a hospital birth. However, in light of coronavirus, there's been a lot of talk about home birth and I also realize that a lot of women who listen to me may have considered home birth. So I decided that I was going to address it in a podcast episode.

(02:09):

So what I'm going to do is give you information on home birth that's evidenced based, non-biased. I am not trying to sway your decision either way, I'm just giving you information. That's what I do best. So we'll cover today or you'll learn today, why do women choose home birth, some reasons why women choose it, what are the characteristics of women who do choose home birth? We'll talk about is it safe, what you should do if you're thinking about home birth, a little bit about what home birth entails, society recommendations, what ACOG says about home birth and then I will end with my own personal thoughts about home birth.

(02:52):

Now the first thing that we need to do is that we need to clear up some terminology. I am talking today about planned home birth, so planned home birth is when you plan to give birth at home ahead of time so it's not a surprise or something that happens by accident. You plan to give birth at home ahead of time and you plan to do so with a birth attendant. Usually a midwife in the United States, it's most often a certified professional midwife. It could be a certified nurse midwife as well, although that's not as common in the United States. So I'm talking about planned home birth, which is a birth where you plan to give birth at home and with a birth attendant. I am not talking about free birth or unassisted birth. Free birth, also known as unassisted birth is exactly like what it sounds. It's a birth where you give birth without an attendant present and I will be very clear that I think free birth or unassisted birth is dangerous and irresponsible. Women have always or mostly throughout time given birth with an assistant present or attendant present. It's not a common phenomenon of human history for women to give birth without a skilled attendant present. I think unassisted or free birth is just flat out dangerous and irresponsible, so I will say very clearly that I do not recommend it.

(04:24):

But today I'm talking about planned home birth, which again is home birth with a skilled attendant present. Okay. So why do women choose home birth? Well, some advocates of home birth see hospital birth as a medicalization of what is a normally natural process. Birth is a natural process. It's not a disease, it's not a medical problem. And although folks recognize and acknowledge that hospitals are great for emergency situations, people who do home birth believe and rightfully so, that most birth is uncomplicated. It is not an emergency, it's not a medical process. And what can happen is when low risk birth in particular occurs in hospitals, just because of the way hospital birth system is designed, there is a higher chance of loss of control over the birth process.

(05:27):

There's a higher chance of unnecessary medical intervention and that can potentially lead to undesirable outcomes. So folks who choose home birth tend to want a low intervention birth, so avoid inducing labor, avoid artificial rupture of membranes or breaking the water, avoid use of Pitocin, continuous monitoring, epidural medications for pain relief, episiotomy, instrumental vaginal delivery, all of those things, cesarean birth. So people want a low intervention birth. Some people choose home birth as well because they feel like home is a more comfortable environment, it's familiar surroundings, it's relaxed. There can be more intimacy with just a partner or you can have other family members present, other friends present. It just creates a different type of an energy surrounding the birth. Also some women choose home birth in a response to a past negative experience from a hospital . I've heard that many times that women choose home birth because they had such a really bad experience in the hospital.

(06:39):

As a matter of fact, a few episodes back, I had a birth photographer on and she chose home birth because of a bad birth experience in the hospital too actually. So there is that possibility as well. And then the final reason is that some choose it because they want to be together with their baby. Hospitals have had a history, we've gotten better about this, but there had been a history at hospitals of separating moms and babies and that can interfere with bonding and establishing breastfeeding and just those really important moments that happen in that first hour we know after birth and even longer. So those are some reasons why women might choose home birth. So when you look at women in the United States who have a home birth, first of all, home birth is not that common. It happens in about 1% of births in the United States.

(07:33):

So in 2018 that's the last time we have data. It was 38,000 or so home births and 90% of those were planned home births and this is the highest home birth rate that has been recorded since home birth was added to the birth certificate in 1989. And we believe the higher rates are attributable to increases in home births among particularly white women. About 1.3% of white women had a planned delivery at home in 2018. It's a bit lower for other racial and ethnic groups, anywhere from 0.3 to 0.6%. And in addition to it mostly being among white women, women who had a home birth are more likely to be older, they've had a baby before. They have a normal body mass index and they live in like non-metropolitan or non urban areas. The highest rate of home birth is in Pennsylvania and that's due to a large Amish population where they traditionally do home birth.

(08:40):

So let's go ahead and address the question of is home birth safe? And I'm going to talk about the risk for baby, the risk for mom, and then the risk for transfer. Okay. So those are the things we get about when we think about the safety of home birth risk for baby mom and then risk for transfer to the hospital. And I'm specifically limiting the information I'm going to discuss to studies that have been done in the United States because I feel that that's most applicable to the folks who are listening. So, and I'm just going to go through a few studies here. So the first study that I'm going to talk about is one that included seventeen thousand low risk women who planned to deliver at home. And this was between 2004 and 2009 that this data was collected. And when you looked at these women, most of them were healthy, about 78% were multiparous, meaning that they had had a baby before.

(09:42):

Most of them were above average education and income. And the information for this study came from a database that was recorded by professional midwives. There was no data from hospital births that were available for comparison. So it's really just a summary of what happened among these 17,000 women. So when the rates of medical intervention were looked at, they were consistently low, which is pretty consistent with home birth across the world. So the episiotomy rate was 1.4% and then for folks who transferred to the hospital assisted vaginal birth 1.2% and cesarean delivery rate 5.2% so those are very low numbers. Then when you look at whether or not, or how often moms were transferred, about 11% of transfers occurred during labor. So 11% of women were transferred to the hospital during labor or intrapartum. And then another 1.5% were transferred postpartum. So after birth, first time moms were more likely to be transferred than moms who had a baby before.

(10:56):

So that was 23% for first time moms that were transferred versus 8% for moms that had a baby before. There was one pregnancy related maternal death in this among these 17,000 women. And it occurred from a heart problem three days after birth. And then when looking at issues of problems for the baby, the rate of intrapartum fetal death, so death during the course of labor was 1.3 per 1000 births. So that's 1.3 per 1000 births. So then that would translate into about among the 17,000 women, roughly 17 babies died somewhere around there a little bit more. And then for babies that were born alive, but then less than seven days of age passed away, 0.4 per 1000 births and late neonatal deaths. So deaths that occurred anywhere between seven days of age and 27 days of age was 0.35 per 1000 live births. So all very low numbers.

(12:07):

Now the risk of having bad outcomes for baby was higher in births to moms who were their first time baby, or if the baby was in a breech presentation or for women who had a prior cesarean birth. Okay. So looking at that one study of 17,000 low risk women, rates of medical intervention were low. About 11% were transferred, one death and then low rates of issues that happened with mom. Okay. The second study is one that was a retrospective study from people in the United States. And what it did was it used birth certificate data to compare the outcomes of out of hospital birth. Now this one is a little bit different because it included both home and birth center births and it compared those to hospital births and it included about 3,200 women who chose an out of hospital birth. Among those 1,968 where at home and 1,235 we're at a birth center. So a little more at home but fairly close in terms of the numbers.

(13:21):

And then it compared it to 75,000 planned hospital births. Okay. So it compared planned hospital birth with planned out of hospital birth. And that out of hospital birth could have been at a birth center or at home. So when you compare the two settings, so planned hospital birth versus planned out of hospital birth, there was an increased risk of both fetal, so intrapartum and also neonatal death. So babies early in the beginning part of life. So in the out of hospital birth it was 2.4 per 1000 births. In hospital birth is 1.2 per 1000 births. So twice the risk of a fetal death if the birth occurred outside of the hospital. For neonatal death, that's an early death within the first 28 days of life, it was 1.6 for out of hospital birth versus 0.6 for hospital birth. So almost three times the risk for neonatal death for out of hospital birth.

(14:43):

However, keep in mind that both of those numbers are very, very low. So the absolute risk, the difference in the groups is really, really small. Okay. So the absolute risk when you look at the risk between the different groups is very small. So although 1.2 versus 2.4 sounds like a lot, when you do it across a thousand births or a lot of births, then it's actually a pretty small number. So yes, that study suggested an increased risk of fetal and neonatal death, but the absolute risk, meaning the chances that it will happen for any given person are very low in both groups. A similar finding occurred when they looked at the risk of neonatal seizures and babies needing ventilator support. There was a higher risk for both in out of hospital birth, but again, the risk in both groups, the absolute risk is very, very small.

(15:42):

Now just like other studies, there is a major reduction in things like inducing labor, cesarean delivery, a major reduction in out of hospital birth. Out of hospital birth tends to have much fewer interventions and this study found the same thing. So when you look at transfer to the hospital, about 16% of out of hospital births involved transfer to the hospital and those moms who were transferred were more likely to be first time moms. All right.

(16:18):

Okay, so the last study I want to talk about is another retrospective study and retrospective just means they look back at data. It's not them collecting data going forward. So they pick a point in time and look backwards and collect information. And this one included information from 97,000 planned home births of a singleton baby full term. And in this particular study, the risk of neonatal death was four fold higher for planned home birth than for hospital birth by a midwife. So it was 1.2 versus 0.3 deaths per 1000 birth. But again, in both groups, the absolute risk is very low. So 0.3 deaths per 1000 births in the hospital, 1.2 deaths per 1000 births in the hospital. Those are both very low numbers.

(17:23):

Okay. And when they looked further to see which women were the at the highest risk for having issues at home, the death rates were highest for women who were having their first baby over the age of 35. That death rate was 5.2 deaths per 1000 births for women having their first baby and were over 41 weeks. That death rate was four deaths per 1000 births. And then a couple other areas where the neonatal death rate was increased were from women with a prior cesarean delivery where it was 8.3 times higher and women who had a breech birth or a breech presentation, it was 8.1 times higher.

(18:12):

So overall when you look at studies in the U S they pretty consistently show a higher risk of complications for baby with a home birth. But the overall risk is low for issues with the baby, short of severe issues like death. The overall risk is low wherever you give birth. So whether you give birth at home or at a hospital, the overall risk for complications is low. But there's a higher risk of issues for baby, for babies born at home and studies that are done in the US now, I should note that there are other studies including a very large study that looked at 500,000 home births and this was across the world and it actually showed no difference in outcomes, that things were the same. The outcomes were the same whether or not babies were born at home or in the hospital. But we have to be careful because this study included systems where home birth midwives are very well integrated into obstetric care services and that is not necessarily the case everywhere in the US. In fact, I would say that that is the exception rather than the rule.

(19:27):

And so the final word that I'll say about planned home birth is that it really just depends on making sure you have, when you look at all the data, it depends on having the appropriate candidates. So low risk women who preferably have had a baby before, the quality of the program, the training and experience level of the home birth provider, whether or not they have access to supplies and equipment, whether or not they have a good system for transfer to the hospital, including I should say good communication and relationships between the home birth providers and the hospital providers. And again, that's not always present in the United States. Okay. I know that was a lot. So hopefully that made sense.

(20:16):

All right, so what should you do if you are considering a home birth or the first thing I would encourage you to do is think about why, so what is your rationale? Why are you considering a home birth? Is it that you are afraid of the hospital? Is it that you're afraid of interventions? Is it because you had a prior bad experience in the hospital? Is it that someone recommended it to think about? Why you're considering home birth, what your rationale is and I would encourage you to look at whether or not hospital birth in a different setting or a different way or with a different provider could overcome some of your objections. It's just something to think about. Again, I'm not trying to sway you either way, but you just want to look at both options equally. I will mention that when you're thinking about home birth, it's usually not covered by insurance and that can be anywhere from three to $8,000 out of pocket.

(21:13):

Now, home birth is only appropriate for certain candidates and any good home birth midwife will tell you that it's really appropriate only for certain candidates. And if you don't meet those criteria, then you're not a good candidate for a home birth. Now, this is not an exhaustive list then I'm going to give you, and some people kind of disagree on some of the things, but I think for the most part people will agree. I think the biggest contention is a prior cesarean delivery. But for the most part, most people agree with these things as being criteria for women who can consider home birth. So number one, and this is very, very important, is that you understand the risk, the benefits, and the alternatives. It's just like anything else. It shouldn't be painted as one particular way. Everything has a risk, benefits and alternatives. So you should have an understanding of that very clearly before you go into a home birth or really any birth. It should be a single baby. So one baby with the head down, multiple births are not considered safe at home.

(22:24):

So a single baby head down between 37 weeks and 41 weeks. The 41 weeks is also a point of contention. Some people say 42 weeks, but 37 weeks and 41 weeks. And the estimated weight is normal for where you are in pregnancy. No serious medical conditions, no hypertension, no severe anemia, no kidney problems, lung problems, no diabetes with insulin. Severe obesity is considered a reason not to do a home birth. You can't have any serious obstetric problems, so no long rupture of membranes, birth centers or home birth providers will transfer you to the hospital if your water's been broken for a prolonged period of time. Everyone's a little bit different, but it at least usually around the 24 hour mark is when folks start getting concerned. You can't have, again, preeclampsia can't have any issues with the baby's growth, abnormal bleeding, baby being too large.

(23:30):

If you have a past history of having postpartum hemorrhage after a birth then you really should be in the hospital to handle any type of emergencies, you also can't have any contraindications to vaginal birth. So if you have any abnormalities with where the placenta is a placenta previa, then you should not do a home birth. Placenta previa is when the placenta covers the cervix and that can cause life threatening bleeding to you and the baby. If you have active genital herpes, you shouldn't have a vaginal birth as well. A prior vaginal birth is preferable, spontaneous labor. So no inducing at home and then no prior cesarean delivery. I will say that the Canadian guidelines are a little bit different where they consider one prior cesarean acceptable as a circumstance where you can attempt a home birth.

(24:23):

And then finally you need to be close to a backup hospital in case anything happens. So you don't want to be super far away from a hospital that can give you the higher level of care if you need it. Now, ideally, if you do a home birth, you want to be in what's called a good integrated system. That is really essential for making sure that home birth is safe and making sure that when issues pop up with moms or babies, that there is rapid access to the hospital and the emergency services that the hospital can provide. Now, as I said before in the United States, we don't have those systems very well in place. A place that does have it down pretty good is the Dutch system in the Netherlands. Im the Netherlands, about 10 to 15% of women give birth at home, it's the highest rate of home birth in the world, I believe. And let me just give you a few characteristics of their system so I can give you an idea of what I mean by a very well integrated system.

(25:31):

So they have lots of midwives who are trained to do either home birth or hospital birth and early pregnancy care is primarily done by midwives. If complications occur, then the midwife refers the woman to an obstetrician and the woman remains with the obstetrician for the rest of her pregnancy and she's not eligible for home birth. And I should say as a backdrop that obstetricians in their system are mostly considered specialists in high risk birth. Obstetricians do not do low risk birth in the Netherlands, it's primarily for midwives. Okay. A second feature is that there are formal written agreements for collaboration between home and hospital birth providers. So those formal written agreements are in place and that provides a good foundation for relationships and communication between all parties that are involved. A really important part of that is that there is mutually agreed upon categories for risk.

(26:40):

So they have clear distinctions for women who are low risk and clear distinctions or things that make women high risk and high risk women are promptly referred to an obstetrician. So when midwives identify any of those things, they escalate those women quickly. And mothers are used to or accustomed to knowing that very clearly if they have any of these issues, they're going to get transferred to a higher level of care because it's the more appropriate level of care. And then the final thing is that there are formal protocols for home to hospital transfer and a timely transfer system. Okay. So formal protocols for when a transfer is going to happen. So folks know ahead of time to anticipate that someone is coming. Let me give you an example of this. So if a woman is at home and she's bleeding heavily, then the midwife would call the hospital and say, "Hey, I have miss such and such. Here are her records, she's bleeding, here's what's going on, and the hospital can be prepared. Or Hey, I have miss such and such and the baby's heart rate has been low. It's been, you know, in the 90s for five minutes or 10 minutes."

(28:06):

Then the hospital can open up the or have the OR available, have all the staff ready for an emergency if necessary. Those type of formal agreements and communication are not very common in the US and then, one more thing that is present in that system is availability of lots of equipment. So they have cleaned delivery equipment, they have sterile instruments at home births about six weeks before a due date. Insurance companies, actually mail pregnant women what's called a maternity box, which has like pads and gauze and protection stuff and things for delivery and postpartum and then the midwife brings other things like medications, neonatal resuscitation equipment, and then oxygen. So that is what a very well integrated system looks like and that is how you have the safest home births possible.

(29:03):

All right. Now as far as what home birth looks like at home in general, the approach to labor management in home birth is just really allowing physiologic labor and birth to progress spontaneously. There's not a lot of medical intervention. Typically babies are monitored by intermittent auscultation with a handheld Doppler device. Of course there is no epidural, there's no IV pain medication and instead you rely mostly on non-pharmacologic methods for pain relief, so massage, acupressure, showers, bath, walking around, all of those kinds of things. Hypnobirthing to reduce pain in labor or reduce the sensation of pain or manage pain or however you want to call it, and women are typically encouraged to eat and drink however they feel like they want to, to follow the instinct of their bodies.

(29:56):

Then there will be a certain percentage of women who get transferred to the hospital. Different providers have different thresholds for transferring patients to the hospital and it really just kinda depends, but some things that can lead to transfer during labor. The most common one is a need for pain medication and this typically tends to be in first time moms. So need for pain medication, desire for an epidural. Some other issues that may cause transfer during labor are a persistent abnormal heart rate, labor has stopped or stalled and it's not responding to any nonpharmacologic interventions, fever or evidence of an infection meconium. So baby has pooped in the amniotic fluid, if high blood pressure develops and that would be a reason to transfer or an unanticipated situation like a baby flips from head down to breech during labor would be another reason to transfer during labor.

(30:57):

And then after delivery, common indications for postpartum transfer are postpartum bleeding, complex tears in the vagina that need to be repaired with more anesthesia and more supplies and things in place. Like a third or fourth degree laceration, a fever after delivery, high blood pressure after delivery or if there are issues going on with the baby. So an abnormal what's called neonatal assessment. Now, there are a couple issues with home birth that I do want to touch upon and that is if you are a group B strep positive, some home birth providers are able to administer IV antibiotics for group B strep positive women, some are not. Some home birth providers do alternative things for women who are GBS positive. But none of those have been proven. So the standard for GBS positive women is to get IV antibiotics wherever you give birth.

(31:58):

And then the other issue is newborn care. In the hospital, the American Academy of Pediatrics recommends that there are two individuals that attend all deliveries. So there's always a nurse for mom and then there is a separate baby nurse. So one is responsible for mom, one is responsible for baby, and it's recommended that that same sort of care happens at a home birth, that there's one person who's responsible for mom and somebody else who is responsible for baby. Very often home birth, midwives will bring a second attendant to help with that. So usually there is another person there, but it's difficult for any person to take care of two patients at once. So the midwives shouldn't really be responsible for both mom and baby at the same time. And then finally, as we close, society recommendations, the American College of Obstetricians and Gynecologists considers hospitals or accredited birth centers a safer location for birth than home because of the availability of physicians, transfusions, antibiotics, anesthesia, other resources for emergency care for moms and babies. So they recommend against home birth, however, support women's choices to give birth wherever they choose.

(33:23):

All right, so just to recap, women who choose home birth do so for a variety of reasons. That tends to be white women of higher socioeconomic status. As far as the safety of home birth, it is safe in most circumstances meaning the risk of issues for mom and baby are low. However, there appears to be for studies in the United States a higher risk for babies who are born at home compared to babies born in the hospital. If you are considering home birth then you need to be a good candidate. I mean a low risk candidate, no medical problems, no obstetric problems. All of those things that I talked about earlier and a good integrated system and I have seen integrated systems.

(34:13):

We actually have a certified nurse midwife near where I live who does home birth and she has a good relationship with one of the doctors in the community as her backup system. So it needs to be in a good integrated system. Also remember that you are going to probably have to pay out of pocket and you have to plan for that possibility of transfer as far as society recommendations, ACOG recommends against it. And then my personal feelings are I of course support women's choices to give birth in a setting that feels right for them as long as they are aware of the benefits and risk of what's involved in any setting. Home birth does make me nervous because I feel like babies when they're born they're new, they may be a little bit more fragile. So that's the part that makes me nervous. Babies not having access to the higher levels of care. I think the issues that come up with mom typically there's time to get to the hospital but sometimes babies can, things can turn South fairly quickly.

(35:24):

And then the other issue is that I have seen some providers who have a questionable level of skill who are doing home birth and they wait too late to transfer. So by the time they to the hospital, then I've seen some really unfortunate outcomes for mom and baby. It has not been anything that's frequent. I can count it probably on one hand that it's happened, that I've seen these bad outcomes, but you know, just one of those kind of sticks with you. So that's a problem that I see is that we don't have that good integrated system. Sometimes physicians on the other side are nasty. When women get transferred for home birth, we don't make it a good place. And a safe and welcoming place for home birth people to transfer into the hospital. And that's part of the problem, I think to why home birth providers may wait too late to transfer because they fear the backlash on the other side. So I see where that can happen, but that's the part that concerns me as well. And just like there're bad stories of hospital birth, there're bad stories of home birth. You can Google home birth gone wrong and find stories. So there's stories on both sides.

(36:38):

So I mean, and my final take, is that home birth of course it does, it works for some women. However, it is not for all women. And for those women who still want or need hospital birth. For some reason I am still here. I am committed to making sure that women have a beautiful birth in the hospital and that in a hospital setting they're treated with compassion, dignity, respect, all of the things that they deserve and that they're always placed at the center of their birth experience. So that's my personal feelings about home birth.

(37:14):

So that is it for this episode of the podcast. Please be sure to subscribe to the podcast in Apple podcast or wherever you listen, Spotify, Google Play, and I would love it if you leave an honest review in iTunes. Let me know what you think about the show. It also helps the show to grow and helps other women to find this show. Now, whether you're considering a home birth or a hospital birth, either way, you need to know some warning signs to look out for after birth. Actually most of the problems associated with maternal mortality, about 60% of deaths actually occur after birth. So I want you to go to www.ncrcoaching.com/warningsigns. And I'll put that link in the show notes and warning signs is together. Grab this free downloadable list of things that you can look for after birth, whether you give birth at home or the hospital so you can be safe after your delivery. Now next week on the podcast, it is a birth story episode, so you know those are always some of my favorites, so do come on back next week and until then, I wish you a beautiful well pregnancy and birth.

(38:23):

Thanks so much for listening to this episode of the all about pregnancy and birth podcast. Head to my website at www.ncrcoaching.com to get even more great info, free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on how to make a birth plan as well as everything you need to know about the birth preparation course. Again, that's www.ncrcoaching.com and I will see you next week.

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