Wind Song Midwifery

Birth Outside the Hospital

TRENDS IN BIRTH SETTING:

In 1940, 50% of births in this country took place at home, with a doctor or midwife in attendance. By 1960, birth had been moved almost exclusively into the hospital. During the 1970's, a notable increase in out-of-hospital birth signaled a new debate among consumers and health professionals regarding the appropriate place for labor and birth.

Today, approximately 1% of American families choose to give birth outside the hospital. In Washington State, this proportion is larger, about 2%. These families choose either home birth or deliver in a free-standing birth center, licensed in Washington by the state's Department of Health. The majority of out-of-hospital births, in Washington as well as throughout the United States are attended by midwives.

REASONS FOR OUT-OF-HOSPITAL BIRTH:

Why do families choose out-of-hospital birth? A number of consistent themes emerge from the literature, including:

increased control over the childbirth experience;

avoidance of unnecessary medical routines and interventions;

continuous care by a known and supportive birth attendant;

labor and deliver among loved ones and in familiar surroundings;

avoidance of the high cost of hospitalization.

SAFETY: WHAT THE STUDIES SAY

For most people concerned with childbirth, a central issue is safety. What do we know about the relative risks of childbirth in various settings? Studies reporting outcomes from well- organized out-of-hospital birth practices, both in the United States and abroad, show very low rates of adverse outcomes for mothers and infants. Holland, for example, where 35% of deliveries take place in the home, has one of the lowest perinatal mortality rates in the world. There is no evidence that birth in the hospital is safest for women at low medical risk.

Some early reports on outcomes of out-of-hospital births in this country were misleading because they compared hospital and non-hospital births without determining whether these births were planned and/or attended by a qualified person. In other words, late miscarriages, premature births, taxi-cab deliveries, and other unexpected out-of-hospital births were included in the outcome data.

Other studies which considered these factors found that the neonatal mortality rates of the planned out- of-hospital births with a qualified attendant averaged 4/1000, below the national rate (of 6/1000); while for the unplanned groups the rates averaged 97/1000. Neonatal mortality rates from other reports of planned out-of-hospital births are similarly low. In a 1989 study of 11,826 women who began labor in one of 84 free-standing birth centers in the U.S., the neonatal mortality rate was 0.8/1000.

In several controlled studies, those births planned to occur outside the hospital, with midwives in attendance, were associated with significantly lower rates of obstetrical interventions than births planned to occur in the hospital with physicians and other care providers. These include very low rates of cesarean section:1.5% vs.16.5% in one study. In some studies, planned out-of-hospital births also had lower rates of complications for mothers and babies than the matched hospital births.

Several authors have estimated that the probability of an emergent complication arising during an out- of-hospital labor, in a well screened, healthy population of women, in which the loss of time in transit to a hospital could increase the risk of an adverse outcome, would be less than 1 in 1,000.

MIDWIFERY PRACTICE ENSURES SAFETY

Midwives who attend out-of-hospital births ensure optimum safety for their clients by:

Accepting into care only women who have no pre-existing medical conditions; who are experiencing a normal pregnancy; and who want to have natural labor and birth (without medical interventions or pain medication.)

Providing comprehensive prenatal care that includes on-going screening for complications, education, support and individualized attention.

Ensuring continuous, one-to-one care during labor, carefully monitoring the progress of labor and the maternal/fetal condition.

Maintaining the skills and equipment to treat emergent conditions such as maternal hemorrhage, or the need to perform neonatal resuscitation, which could arise unexpectedly.

Establishing consultation and referral relationships with obstetricians pediatricians and family practice physicians who can provide hospital treatment if indicated.

In summary, an out-of-hospital birth that is planned, with a well-trained attendant; is a safe, satisfying and economical choice.

This information is provided by the Midwives' Association of Washington State, the professional organization of certified Nurse-Midwives and Licensed Midwives in Washington State. 6/93.

Send KatiAnn an email message to answer your questions or request bibliographic citations of studies mentioned.