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Homebirth Abstracts

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Hafner-Eaton C. Pearce LK.
Oregon State University
Birth choices, the law, and medicine: balancing individual freedoms and
protection of the public's health. Journal of Health Politics, Policy & Law.
19(4):813-35, 1994 Winter.
To many Americans, the idea of home birth, the use of a "direct-entry midwife," or both seem archaic. Although much of the professional medical community disapproves of either, state laws regarding birth choices vary dramatically and are not necessarily based on empirical findings of childbirth outcomes. Public health practitioners, policymakers, and consumers view childbirth from the perspectives of safety, cost, freedom of choice, quality of the care experience, and legality, yet the professional, policy, and lay literatures have not offered an unemotional, balanced presentation of evidence. Reviewing the full spectrum of literature from the United States and abroad, we present a Constitutional medical-legal analysis of whether home birth with direct-entry midwives is in fact a safe alternative to physician-attended hospital births, and whether there is a legal basis for allowing alternative health policy choices is such an important yet personal family matter as childbirth. The literature shows that low- to moderate-risk home births attended by direct-entry midwives are at least as safe as hospital births attended by either physicians or midwives. The policy ramifications include important changes in state regulation of medical and alternative health personnel, the allowance of the home as a medically acceptable and legal birth setting, and reimbursement of this lower-cost option through private and public health insurers. [References: 64]

Janssen PA. Holt VL. Myers SJ
Licensed midwife-attended, out-of-hospital births in Washington state: are
they safe?
Birth. 21(3):141-8, 1994 Sep.
The safety of out-of-hospital births attended by midwives who are licensed according to international standards has not been established in the United States. To address this issue, outcomes of births attended out of hospital by licensed midwives in Washington state were compared with those attended by physicians and certified nurse-midwives in hospital and certified nurse-midwives out of hospital between 1981 and 1990. Outcomes measured included low birthweight, low five-minute Apgar scores, and neonatal and postneonatal mortality. Associations between attendant and outcomes were measured using odds ratios to estimate relative risks. Multivariate analysis using logistic regression controlled for confounding variables. Overall, births attended by licensed midwives out of hospital had a significantly lower risk for low birthweight than those attended in hospital by certified nurse-midwives, but no significant differences were found between licensed midwives and any of the comparison groups on any other outcomes measured. When the analysis was limited to low-risk women, certified nurse-midwives were no more likely to deliver low-birthweight infants than were licensed midwives, but births attended by physicians had a higher risk of low birthweight. The results of this study indicate that in Washington state the practice of licensed nonnurse-midwives, whose training meets standards set by international professional organizations, may be as safe as that of physicians in hospital and certified nurse-midwives in and out of hospital. 
Olsen O.
Afdeling for Social Medicine, Kobenhavns Universitet
[Home delivery and scientific reasoning]. [Norwegian] Source Tidsskrift for
Den Norske Laegeforening. 114(30):3655-7, 1994 Dec 10.
Doctors commonly assume that it is safer for all women to give birth in hospital rather than at home. Nevertheless, all statistical comparisons relevant to Nordic women today show that for healthy pregnant women it is at least as safe to give birth at home--and perhaps even safer. Furthermore, many randomised clinical trials consistently show that several of the elements which characterize home births make the births proceed much easier. The question is raised, in what ways it is possible to convince obstetricians that they should base their judgments and advice regarding place of birth on empirical evidence rather than on "well established" but pre-scientific dogmas.

Woodcock HC. Read AW. Bower C. Stanley FJ. Moore DJ
A matched cohort study of planned home and hospital births in Western
Australia 1981-1987
Midwifery. 10(3):125-35, 1994 Sep.
OBJECTIVE: to evaluate practice comparing planned home birth with planned hospital birth DESIGN: a retrospective analysis of a cohort who had planned to have a home birth compared with a matched hospital birth group SETTING: Western Australia (WA) PARTICIPANTS: all women (N = 976) who 'booked' to have a home birth 1981-1987 and 2928 matched women who had a planned hospital birth (singleton births only). MEASUREMENTS AND FINDINGS: women in the home birth group had a longer labour, were less likely to have had labour induced or to have had any sort of operative delivery. They were less likely overall to have had complications of labour, but more likely to have had a postpartum haemorrhage and more likely to have had a retained placenta. Babies in the home birth group were heavier and more likely to be post-term. They were less likely to have had an Apgar score below 8 at 5 minutes, to have taken more than 1 minute to establish respiration or to have received resuscitation. The crude odds ratio for planned home births for perinatal mortality was 1.25 (95% CI 0.44-3.55). Postneonatal mortality was more common in the hospital group. Planned home births were generally associated with less intervention than hospital births and with less maternal and neonatal morbidity, with the exception of third stage complications. Although not significant, the increase in perinatal mortality has been observed in other Australian studies of home births and requires continuing evaluation. KEY CONCLUSIONS: Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births. IMPLICATIONS FOR PRACTICE: whether these observed differences in intervention and morbidity have any relationship to the small, non-significant increase in perinatal mortality could not be determined in this study. Continuing evaluation of home birth practice and outcome is essential.

Bortin S. Alzugaray M. Dowd J. Kalman J.
Santa Cruz Women's Health Center, California
A feminist perspective on the study of home birth. Application of a
midwifery care framework Journal of Nurse-Midwifery. 39(3):142-9, 1994
Studies of home birth have compared it with hospital birth, with a focus on perinatal outcomes. Although such studies have established the safety of midwife-attended home births, this narrow view does not include all of the concepts represented in a proposed midwifery care framework derived from the philosophy of the American College of Nurse-Midwives. In this essay, the authors recommend the employment of qualitative research with a feminist perspective as a method to elucidate other concepts in the midwifery care framework, and suggest that future home birth research should explore the recognition and validation of the woman and her experiences, appropriate use of technology, and the influences of the birth environment. [References: 51]

Davis-Floyd RE.
Department of Anthropology, University of Texas at Austin 78712
The technocratic body: American childbirth as cultural expression. [Review]
Social Science & Medicine. 38(8): 1125-40, 1994 Apr.
The dominant mythology of a culture is often displayed in the rituals with which it surrounds birth. In contemporary Western society, that mythology--the mythology of the technocracy--is enacted through obstetrical procedures, the rituals of hospital birth. This article explores the links between our culture's mythological technocratic model of birth and the body images, individual belief and value systems, and birth choices of forty middle-class women--32 professional women who accept the technocratic paradigm, and eight homebirthers who reject it. The conceptual separation of mother and child is fundamental to technocratic notions of parenthood, and constitutes a logical corollary of the Cartesian mind-body separation that has been fundamental to the development of both industrial society and post-industrial technocracy. The professionals' body images and lifestyles express these principles of separation, while the holistic ideology of the homebirthers stresses mind-body and parent-child integration. The conclusion considers the ideological hegemony of the technocratic paradigm as potential future-shaper. [References: 45]

Sakala C.
Health Policy Institute, Boston University, MA 02215
Midwifery care and out-of-hospital birth settings: how do they reduce
unnecessary cesarean section births? Social Science & Medicine.
37(10):1233-50, 1993 Nov.
In studies using matched or adjusted cohorts, U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care--physicians in hospitals. This cesarean reduction involved no compromise in mortality and morbidity outcome measures. Moreover, groups of women at elevated risk for adverse perinatal outcomes have attained excellent outcomes and cesarean rates well below the general population rate with these care arrangements. How do midwives and out-of-hospital birth settings so effectively help women to avoid unnecessary cesareans? This paper explores this question by presenting data from interviews with midwives who work in home settings. The midwives' understanding of and approaches to major medical indications for cesarean birth contrast strikingly with prevailing medical knowledge and practice. From the midwives' perspective, many women receive cesareans due to pseudo-problems, to problems that might easily be prevented, or to problems that might be addressed through less drastic measures. Policy reports addressing the problem of unnecessary cesarean births in the U.S. have failed to highlight the substantial reduction in such births that may be expected to accompany greatly expanded use of midwives and out-of-hospital birth settings. The present study--together with cohort studies documenting such a reduction, studies showing other benefits of such forms of care, and the increasing reluctance of physicians to provide obstetrical services--suggests that childbearing families would realize many benefits from greatly expanded use of midwives and out-of-hospital birth settings.

Kenny P. King MT. Cameron S. Shiell A
Satisfaction with postnatal care--the choice of home or hospital
Midwifery. 9(3):146-53, 1993 Sep.
This paper reports the findings of a study of client satisfaction with postnatal midwifery care. Women could choose one of two forms of care; either domiciliary care following early discharge, or hospital care until discharge. Consumers' perceptions of their postnatal care were examined at the end of the period of care. Women assessed the midwives' interest and caring, education and information provided, their own progress with feeding and baby care, and their own physical and emotional health. They were also asked about their expectations of and gains from postnatal care. The findings indicated that women choosing domiciliary care and women choosing hospital care had different expectations of their postnatal care, but were largely satisfied with the quality of the care they chose. The women who chose domiciliary care rated their postnatal care more highly than the women who stayed in hospital. The findings reinforce the importance of providing women with choices for the maternity care which best suits their needs.

Declercq ER.
Merrimack College, North Andover, Massachusetts
Where babies are born and who attends their births: findings from the
revised 1989 United States Standard Certificate of Live Birth
Obstetrics & Gynecology. 81(6):997-1004, 1993 Jun.
OBJECTIVE: To examine the results of changes in the birth certificate with regard to characteristics of the mothers and the birth weights of their infants. The United States Standard Certificate of Live Birth was revised in 1989 to include specific designations for the place of births out of hospital and the presence of a nurse-midwife or other midwife at the birth. METHODS: All results are based on data from the Natality, Marriage and Divorce Statistics Branch of the National Center for Health Statistics, Centers for Disease Control. In all cases reported here, the data represent at least 91% of all United States births in 1989. RESULTS: Different patterns of birth attendance emerged in different settings. In residential births, other midwives and "others" attended 66% of all births, whereas in freestanding birth centers, physicians and certified nurse-midwives attended 75.1% of all births. The characteristics of the mothers differed substantially according to who attended their births in these settings. Substantial interstate variations in place and attendant were also documented. CONCLUSION: The positive outcomes achieved in certain settings indicate a need for further research into the factors that influence birth outcomes.

MacVicar J. Dobbie G. Owen-Johnstone L. Jagger C. Hopkins M. Kennedy J.
Department of Obstetrics & Gynaecology, Leicester Royal Infirmary, UK
Simulated home delivery in hospital: a randomised controlled trial
British Journal of Obstetrics & Gynaecology. 100(4):316-23, 1993 Apr.
OBJECTIVES: To compare the outcome of two methods of maternity care during the antenatal period and at delivery. One was to be midwife-led for both antenatal care and delivery, the latter taking place in rooms similar to those in one's own home to simulate home confinement. The other would be consultant-led with the mothers labouring in the delivery suite rooms with resuscitation equipment for both mother and baby in evidence, monitors present and a delivery bed on which both anaesthetic and obstetric procedures could be easily and safely carried out. DESIGN: Randomised controlled trial. SETTING: Leicester Royal Infirmary Maternity Hospital. SUBJECTS: Of 3510 women who were randomised, 2304 were assigned to the midwife-led scheme and 1206 were assigned to the consultant-led scheme. MAIN OUTCOME MEASURES: Complications in the antenatal, intrapartum and postpartum periods were compared as was maternal morbidity and fetal mortality and morbidity. Satisfaction of the women with care over different periods of the pregnancy and birth were assessed. RESULTS: There were few significant differences in antepartum, intrapartum and postpartum events between the two groups. There was no difference in the percentage of mothers and babies discharged home alive and well. Generally higher levels of satisfaction with care antenatally and during labour and delivery were shown in those women allocated to midwife care.

Cunningham JD.
School of Behavioural Sciences, Macquarie University, Sydney, NSW, Australia
Experiences of Australian mothers who gave birth either at home, at a birth
centre, or in hospital labour wards
Social Science & Medicine. 36(4):475-83, 1993 Feb.
In order to compare their antenatal education levels, reasons for choosing the birthplace, experiences during labor and childbirth, analgesia, satisfaction with birth attendants and others present, and related attitudes 395 Sydney-area mothers were recruited within one year of giving birth. Five sources were used to obtain mail-questionnaire responses from 239 who gave birth in a hospital labor ward, 35 at a birth centre, and 121 who chose to give birth at home. Homebirth mothers were older, more educated, more feminist, more willing to accept responsibility for maintaining their own health, better read on childbirth, more likely to be multiparous, and gave higher rating of their midwives than labour-ward mothers, with birth-centre mothers generally scoring between the other two groups. As well, homebirth and birth-centre mothers were more likely to feel the birthplace affected the bonding process and were less likely to regard birth as a medical condition than labour-ward mothers. In regression analysis birth venue (among other variables) significantly predicted satisfaction with doctor, if present during labour and delivery, and five variables correlated with birth venue significantly predicted satisfaction with midwife, husband/partner, and other support person. Findings are discussed in the light of the current struggle between medical and 'natural' models of childbirth.

Eskes TK.
Department of Obstetrics and Gynaecology, University Hospital Nijmegen, The
Home deliveries in The Netherlands--perinatal mortality and morbidity
International Journal of Gynaecology & Obstetrics. 38(3):161-9, 1992 Jul.
The obstetrical organizational system in the Netherlands is based on the selection for risk factors. We conclude that: (i) The reporting of perinatal death is not complete. (ii) Perinatal mortality can be reduced. (iii) More iatrogenic interventions are present in low-risk deliveries in hospitals. (iv) Neurological behavior of low-risk babies born at home is equal to those born at the hospital, despite the worse maternal profile of the latter and the level of acidemia at birth in the first. Good data especially in referred cases are necessary before adopting a similar system.

van Steensel-Moll HA. van Duijn CM. Valkenburg HA. van Zanen GE.
Department of Epidemiology and Biostatistics, Erasmus University Medical
School, Rotterdam, The Netherlands
Predominance of hospital deliveries among children with acute lymphocytic
leukemia: speculations about neonatal exposure to fluorescent light
Cancer Causes & Control. 3(4):389-90, 1992 Jul.

Duran AM.

Department of Health, Commonwealth of the Northern Marianas Islands, Rota
The safety of home birth: the farm study
American Journal of Public Health. 82(3):450-3, 1992 Mar.
Pregnancy outcomes of 1707 women, who enrolled for care between 1971 and 1989 with a home birth service run by lay midwives in rural Tennessee, were compared with outcomes from 14,033 physician-attended hospital deliveries derived from the 1980 US National Natality/National Fetal Mortality Survey. Based on rates of perinatal death, of low 5-minute Apgar scores, of a composite index of labor complications, and of use of assisted delivery, the results suggest that, under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries.

Ford C. Iliffe S. Franklin O.
Department of Primary Health Care, Whittington Hospital, London
Outcome of planned home births in an inner city practice
BMJ. 303(6816):1517-9, 1991 Dec 14.
OBJECTIVE--To assess the outcome of pregnancy for women booking for home births in an inner London practice between 1977 and 1989. DESIGN--Retrospective review of practice obstetric records. SETTING--A general practice in London. SUBJECTS--285 women registered with the practice or referred by neighbouring general practitioners or local community midwives. MAIN OUTCOME MEASURES--Place of birth and number of cases transferred to specialist care before, during, and after labour. RESULTS--Of 285 women who booked for home births, eight left the practice area before the onset of labour, giving a study population of 277 women. Six had spontaneous abortions, 26 were transferred to specialist care during pregnancy, another 26 were transferred during labour, and four were transferred in the postpartum period. 215 women (77.6%, 95% confidence interval 72.7 to 82.5) had normal births at home without needing specialist help. Transfer to specialist care during pregnancy was not significantly related to parity, but nulliparous women were significantly more likely to require transfer during labour (p = 0.00002). Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases). CONCLUSIONS--Birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to hospital during labour because of delay in labour. Close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimising the risks of trial of labour at home.

Abel S. Kearns RA.
Department of Anthropology, University of Auckland, New Zealand
Birth places: a geographical perspective on planned home birth in New
Social Science & Medicine. 33(7):825-34, 1991.
In New Zealand until the 1920s, most births occurred at home or in small maternity hospitals under the care of a midwife. Births subsequently came under the control of the medical profession and the prevalent medical ideology continues to support hospitalised birth in the interests of safety for mother and child. Despite resistance from the medical profession, recent (1990) legislation has reinstated the autonomy of midwives and this has come at a time when the demand for home births is increasing. This paper locates these changes within the geographical context of home as a primary place within human experience. It is argued that the medical profession has been an agent of an essentially patriarchal society in engendering particular experiences of time and place for women in labour. Narrative data indicate that the choice of home as a birth place is related to three dimensions of experience unavailable in a hospital context: control, continuity and the familiarity of home.

Albers LL. Katz VL.
University of Medicine and Dentistry of New Jersey
Birth setting for low-risk pregnancies. An analysis of the current
literature Journal of Nurse-Midwifery. 36(4):215-20, 1991 Jul-Aug.
This article reviews the literature on birth settings for women with low-risk pregnancies. Methodological issues of the existing research include nonrandom designs, small samples, selection differences, data limitation, and confounding bias. Studies for four birth sites are summarized: the home, freestanding birth centers, in-hospital birthing centers or birthing rooms, and traditional hospital settings. Despite the methodological limitations, nontraditional birth settings present advantages for low-risk women as compared with traditional hospital settings: lower costs for maternity care, and lower use of childbirth procedures, without significant differences in perinatal mortality. [References: 57]

Chamberlain M. Soderstrom B. Kaitell C. Stewart P
Consumer interest in alternatives to physician-centred hospital birth in
Midwifery. 7(2):74-81, 1991 Jun.
A survey of 1109 women who delivered in a hospital or at home in a major city in Canada was conducted. The women were asked to respond to questions concerning the type of health professional they would like to provide reproductive care. The choices they were offered were: midwife, obstetrician, general practitioner or nurse, or a combination. Respondents were also asked to identify if they had an interest in an alternative such as a birthing room, birthing centre or home birth, to hospital labour ward care. Almost 60% of women were interested in some form of midwifery care with the major emphasis placed on counseling and support. Of the women who expressed an interest in midwifery services a large number elected for that service to be shared with an obstetrician. Women who were older and had achieved a high level of education were more interested in midwifery services than other women. If given choices of a hospital labour, birthing room, birthing centre or home birth 53% of women would choose to give birth in a hospital labour ward. A major reason for this choice was the accessibility of epidural analgesia. The majority of women who had experienced a home birth would make the same choice again. There was a strong positive association between interest in using midwifery services and interest in a birthing centre and home birth.

Kleiverda G. Steen AM. Andersen I. Treffers PE. Everaerd W.
Department of Obstetrics and Gynaecology, Academic Medical Centre,
University of Amsterdam, The Netherlands
Place of delivery in The Netherlands: actual location of confinement
European Journal of Obstetrics, Gynecology, & Reproductive Biology.
39(2):139-46, 1991 Apr 16.
Preferred and actual locations of confinement were compared in a group of 170 nulliparous women. Voluntary changes in preferred location for birth were rare and concerned only changes from hospital to home confinement. Obligatory changes due to referral to consultant obstetricians occurred frequently: 58.8% of the total sample. Fewer referrals were found for women with an initial preference for a home confinement (53%) than for those who preferred a hospital confinement (64%). Most referrals occurred in the group of older women initially in doubt about their preferred location for giving birth: 72%. The differences were not significant, however. To reveal differences between referrals and non-referrals, discriminant analysis was performed at the 18th week of gestation. The explained variance for the total group of referrals was 64.7%. Partially, the variables pertaining to the explained variance were the same as those related to a preferred hospital confinement. The explained variance for the group of referrals in which psychosocial influences were presupposed was not better, with the exception of referrals due to insufficient progress during labour: 76.4% of the variance could be explained at the 34th gestational week. When birth weight and amenorrhoea were included, these percentages increased to 79.0 and 84.8%, respectively.

Mathews JJ. Zadak K.
Loyola University Medical Center, Maywood, IL 60163
The alternative birth movement in the United States: history and current
Women & Health. 17(1):39-56, 1991.
The alternative birth movement is a consumer reaction to paternalistic and mechanistic medical obstetrical practices which developed in the United States early in this century. Alternative birth settings developed as single labor-delivery-recovery rooms in the hospital or as free-standing birth centers. Both alternatives offer family-centered, home-like, low technological maternity care. In order to overcome physician resistance to non-traditional maternity care, alternative birth center policies eliminate all women who are expected to have a complicated pregnancy or delivery. Physician resistance to alternative birthing is publicly based on the issue of maternal and infant safety. Additional issues, however, are that physicians fear economic competition and resist loss of control over obstetric practice. This paper (1) traces the historical antecedents and social factors leading to the alternative birth movement, (2) describes the types of alternative birthing methods, and (3) describes ways in which the obstetrical community has maintained and rationalized dominance over the birthing process.

Anderson R. Greener D
A descriptive analysis of home births attended by CNMs in two
nurse-midwifery services
Journal of Nurse-Midwifery. 36(2):95-103, 1991 Mar-Apr.
This study examined outcome data from two nurse-midwifery operated home birth services in Texas. All clients who planned a home birth within the two services during 1987 comprised the population. Analyses revealed that women choosing home birth with these nurse-midwives were more frequently married, usually white, and more educated when compared with the overall U.S. childbearing population. Analgesia, episiotomy, and cesarean delivery were all found at lower rates than is reported when birth occurs in a hospital setting; complications occurred less frequently or at similar rates to those reported in the home birth literature and national statistics. Research, educational, and clinical implications of the study are discussed.

Tyson H
Outcomes of 1001 midwife-attended home births in Toronto, 1983-1988
Birth. 18(1):14-9, 1991 Mar.
A retrospective descriptive study of 1001 midwife-attended home births in Toronto, Ontario, was carried out between January 1983 and July 1988. Interviews with 26 midwives and reviews of client records provided data on maternal age, socio-economic status, gestation, ruptured membranes, length of labor, episiotomies and perineal lacerations, transfer to hospital of mother or baby or both, infant resuscitation, and breastfeeding. Of 1001 planned home births, 361 involved primiparous women, of whom 245 (68%) remained at home and 116 (32%) required transfer of mother or baby to hospital during labor or the first four postpartum days. Of the 640 multiparous births, 591 (92%) women remained at home and 49 (8%) required transfer to hospital. Among women transferred, 91 had spontaneous vaginal births, 34 had forceps deliveries, and 35 had cesarean sections. Variables significantly associated with maternal transfer for both primiparas and multiparas were length of latent and active phases of the first stage of labor, length of the second stage of labor, and duration of ruptured membranes. Five neonates were transferred and two died, one each after birth at home and in hospital. There were no maternal deaths. The proportion of mothers breastfeeding without supplement at 28 days postpartum was 98.6 percent.

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