Home births

Mink

As someone planning a homebirth for end of the summer, I am glad the hospital is there along with the medical procedures in place for mothers & babies. I'd only continue with the homebirth plan as long as my situation stays low-risk & no complications. The fact that I will be scanned & tested almost weekly at the hospital towards the end of the pregnancy helps me & my carers monitor that.

But things can go wrong, ie; pre-term, pre-eclampsia, placenta previa, meconium in the waters, etc etc. and I'm glad the hospital is there as I'd absolutely need medical care at that point. Independent midwives are trained to watch out for things that bring in any kind of risk factor and will transfer in that case.

Moonbeam

Rosy Posy wrote: »

Having been at the confluence of these arguments between family and friends, I find it fairly pointless. Its one of those emotive topics, like breastfeeding or vaccinations. There is a wealth of inconclusive 'evidence' on either side, ultimately each person is going to chose with their heart and defend their own position.

*Mod warning*

I do not want to bring this thread off topic.
Breast feeding and vaccinations are both emotive topics,I will agree to that but there is not inconclusive "evidence" as you put it on either side.
Evidence points to it on average being safer getting your child their childhood vaccinations and there is no arguing that breast feeding is better for a baby except in exceptional circumstances.
Please do not suggest that their is a wealth of evidence against either.

LegacyUser

GoerGirl wrote: »

The choice to have a baby at home is individual - its not for everyone - but it has been shown to be a safe option.

Safe is a relative and subjective term IMO. Everyone's definition of safe is different.
What is an acceptable level of safety to one person may not be another, so saying that it is 'a safe option' is a very ambiguous statement. What is quite sure is that there is no absolute safety of pregnancy/ birthing in any situation. Really what is needed is the irish studies/figures about birthing- then we could talk about relative safety in hospitals versus the home.

When talking about this, people tend not to consider risks as much as safety.
Risk can be mitigated by being regularly and carefully monitored to ensure you remain classified low risk at all times during the pregnancy or see if something worrysome happens. However when labour begins your risk level can change suddenly and constantly. As someone else said anecdotes are nice and everything, but are not data, and a persons risk level has nothing to do with all the lovely stories in the world.
People tend to generalise about safety then to bolster their choice, when any risk could occur to anyone really.

I guess the irish system with only low risk mothers, qualified independant midwives and proximity to medical care is more set up for success than information I've seen on the US system or similar though. In which case I would expect the mortality figures to be pretty low? Does anyone know if this data is out there, being recorded by someone somewhere?

Rosy Posy

Moonbeam wrote: »

*Mod warning*

I do not want to bring this thread off topic.
Breast feeding and vaccinations are both emotive topics,I will agree to that but there is not inconclusive "evidence" as you put it on either side.
Evidence points to it on average being safer getting your child their childhood vaccinations and there is no arguing that breast feeding is better for a baby except in exceptional circumstances.
Please do not suggest that their is a wealth of evidence against either.

Sorry, I didn't phrase that very well. What I meant was that people generally make their minds up about these things based on a 'gut' reaction and then look for the evidence to support their decisions. Generally people don't change their mind or heart about these things based on the evidence given on an internet forum.

When I said that there was a wealth of evidence for and against I was only referring specifically to home births, NOT breastfeeding or vaccinations, but I can see that it didn't read that way...sorry- I'm not getting a whole lot of sleep at the moment.....

GoerGirl

RiskSafety wrote: »

Safe is a relative and subjective term IMO. Everyone's definition of safe is different.
What is an acceptable level of safety to one person may not be another, so saying that it is 'a safe option' is a very ambiguous statement. What is quite sure is that there is no absolute safety of pregnancy/ birthing in any situation.

There is no absolute safety in any choice of birthplace; hospital, home or midwife led. Which is precisely the reason that systematic reviews of international best practice/evidence is important in order to aide informed decison making on place of birth.

RiskSafety wrote: »

Really what is needed is the irish studies/figures about birthing- then we could talk about relative safety in hospitals versus the home.

Maternity services in Ireland relies heavily on international evidence in determining clinical guidelines. Hospital based policy is based on UK, US, and EU research. Very little evidence is sourced locally.

The HSE's criteria for homebirth is based on UK recommendations from NICE's Guidelines for Intrapartum Care - Guideline 55.

"Home birth can be a safe option for low risk healthy women. Research shows that a planned home birth is an acceptable and safe alternative to a planned hospital birth for some pregnant women. " http://www.hse.ie/eng/services/Find_a_Service/maternity/homebirth.html

RiskSafety wrote: »

When talking about this, people tend not to consider risks as much as safety. Risk can be mitigated by being regularly and carefully monitored to ensure you remain classified low risk at all times during the pregnancy or see if something worrysome happens. However when labour begins your risk level can change suddenly and constantly. As someone else said anecdotes are nice and everything, but are not data, and a persons risk level has nothing to do with all the lovely stories in the world.

Women are monitored at home intermittantly, as they would be in hospital based midwife led care (MLUs) and some CLUs. As you are aware, there is no evidence to support that CEFM is of benefit to mother or baby - there is no reduction of adverse perinatal outcome. However, CEFM does increase the mother's risk of intervention.

SECMs are regulated through the HSE. Transfer to hospital is recommended if medically indicated.

RiskSafety wrote: »

People tend to generalise about safety then to bolster their choice, when any risk could occur to anyone really.

As you posted above, safety and risk is subjective. There is "risk" with every birth choice. (see Midwife led vs Consultant led links I put up earlier) Safety is not absolute in any birth choice. Ultimately, it is the woman's decision and this should be respected.

GoerGirl

Originally Posted by RiskSafety
When talking about this, people tend not to consider risks as much as safety. Risk can be mitigated by being regularly and carefully monitored to ensure you remain classified low risk at all times during the pregnancy or see if something worrysome happens. However when labour begins your risk level can change suddenly and constantly. As someone else said anecdotes are nice and everything, but are not data, and a persons risk level has nothing to do with all the lovely stories in the world.

GoerGirl wrote: »

Women are monitored at home intermittantly, as they would be in hospital based midwife led care (MLUs) and some CLUs. As you are aware, there is no evidence to support that CEFM is of benefit to mother or baby - there is no reduction of adverse perinatal outcome. However, CEFM does increase the mother's risk of intervention.

SECMs are regulated through the HSE. Transfer to hospital is recommended if medically indicated..

Just to add to this point, a woman at home or in MLU receives 1:1 care from a midwife. This level of observation and clinical support is not matched in the CLU. Curent staffing levels are below par for patient to staff ratio - for example, the current midwife to patient ratio in the Rotunda is 1:47...safe levels are recommended 1:33max.

these concerns have been echoed in units across the Country

nesf

I just want to say thanks to people for turning this into an evidence based discussion.

LegacyUser

GoerGirl wrote: »

There is no absolute safety in any choice of birthplace; hospital, home or midwife led. Which is precisely the reason that systematic reviews of international best practice/evidence is important in order to aide informed decison making on place of birth.

Yes, that's what I said- there is no absolute safety.

GoerGirl wrote: »

Maternity services in Ireland relies heavily on international evidence in determining clinical guidelines. Hospital based policy is based on UK, US, and EU research. Very little evidence is sourced locally.

The data should be sourced locally though, relavant to Irish Processes, systems and data and then we can talk about relative safety. Using data from other countries doesn't really cut it.

GoerGirl wrote: »

Women are monitored at home intermittantly, as they would be in hospital based midwife led care (MLUs) and some CLUs. As you are aware, there is no evidence to support that CEFM is of benefit to mother or baby - there is no reduction of adverse perinatal outcome. However, CEFM does increase the mother's risk of intervention.

There does seem to be a growing body trying to link monitoring to intervention. I cannot agree. Monitoring- whatever ay you do it- is absolutely vital. What data are you referencing when you say that there is no evidence to support CEFM being beneficial or increasing intervention. Again I believe a huge Irish study is required on all processes.

GoerGirl wrote: »

As you posted above, safety and risk is subjective. There is "risk" with every birth choice. (see Midwife led vs Consultant led links I put up earlier) Safety is not absolute in any birth choice. Ultimately, it is the woman's decision and this should be respected.

Choice is a different subject completely to safety and risk??? I never made any comments on not respecting choice? I could choose to smoke but it is proven to be relatively unsafe and carries huge risks.
So, on the topic of choice, yes I believe choice should absolutely be respected.
You give people the safety and risk information to make informed choices. And then you respect their decision.

Squiggler

RiskSafety wrote: »

You give people the safety and risk information to make informed choices. And then you respect their decision.

Ideally, but the reality is that in a Consultant led situation that does not always
happen. My own personal experience is of a consultant who did everything in his power to force a procedure that was not medically necessary (he admitted as much) or our choice, and I mean everything, including a failed attempt to convince the HSE to invoke their powers to have the gardai drag me to the hospital. His irrational and ungrounded actions put my life and the life of my baby at risk, and ultimately killed my baby.


Edit: If further, substantiated, evidence that consultants do not always act in the best interests of mother and baby, or respect their right to choice, is felt to be necessary you need only look at the hysterectomy scandal that took place in our Lady of Lourdes in Drogheda (thanks goergirl, always get the two confused).

LegacyUser

Squiggler wrote: »

Ideally, but the reality is that in a Consultant led situation that does not always
happen. My own personal experience is of a consultant who did everything in his power to force a procedure that was not medically necessary (he admitted as much) or our choice, and I mean everything, including a failed attempt to convince the HSE to invoke their powers to have the gardai drag me to the hospital. His irrational and ungrounded actions put my life and the life of my baby at risk, and ultimately killed my baby.

That is awful, I am so sorry for your loss and I hope you are coping ok
I don't know anything about your story so I cannot comment and I won't ask you any Q's as you've been through enough as it is. However, I really hope you are following up both within the hospital system and even a civil case if there is professional neglect involved

Squiggler wrote: »

Edit: If further, substantiated, evidence that consultants do not always act in the best interests of mother and baby, or respect their right to choice, is felt to be necessary you need only look at the hysterectomy scandal that took place in our Lady of Lourdes in Dundalk.

The Hysterectomy scandal is not current, and occured in Our lady of Lourdes, Drogheda.
Again, a completely different topic!!

GoerGirl

RiskSafety wrote: »

Yes, that's what I said- there is no absolute safety.

The data should be sourced locally though, relavant to Irish Processes, systems and data and then we can talk about relative safety. Using data from other countries doesn't really cut it.

Guidelines are created based on the highest quality and most current evidence. In all realms of health. This may or may not be sourced locally. Are you suggesting that we only create policy based on locally sourced evidence, regardless of the quality of the evidence in question?

There was a paper out awhile ago by Dr McKenna in the Rotunda on homebirth. This was completely rubbished by researchers and is considered very poor quality evidence. Are you suggesting the HSE and obstetric/midwifery leads in Ireland create guidelines for homebirth based on this evidence as it is locally sourced? Rather than the high quality internationally respected evidence from NICE?

RiskSafety wrote: »

There does seem to be a growing body trying to link monitoring to intervention. I cannot agree. Monitoring- whatever ay you do it- is absolutely vital. What data are you referencing when you say that there is no evidence to support CEFM being beneficial or increasing intervention. Again I believe a huge Irish study is required on all processes.

There is no suggestion in my post that monitoring is not vital. However the evidence has shown us that intermittant monitoring produces less instance of intervention and adverse affects to women.

Electronic fetal monitoring was developed to detect intrapartum asphyxia associated with death or cerebral palsy. However, the evidence has illustrated that CEFM does not reduce infant mortality, cerebral palsy.

http://apps.who.int/rhl/pregnancy_childbirth/childbirth/routine_care/jncom/en/index.html

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006066/abstract;jsessionid=7CF75543FA9C9F5E54DD8D362DE08491.d01t01

The New England Journal of Medicine has specifically looked into Cerebral Palsy and claims that CEFM reduces this outcome. The findings are that (on par with other evidence) CEFM has very high rates of false positives. The conclusions of this evidence are:

Conclusions Specific abnormal findings on electronic monitoring of the fetal heart rate were associated with an increased risk of cerebral palsy. However, the false positive rate was extremely high. Since cesarean
section is often performed when such abnormalities are noted and is associated with risk to the mother, our findings arouse concern that, if these indications were widely used, many cesarean sections would be
performed without benefit and with the potential for harm. http://www.nejm.org/doi/full/10.1056/NEJM199603073341001

RiskSafety wrote: »

I never made any comments on not respecting choice? I could choose to smoke but it is proven to be relatively unsafe and carries huge risks.
So, on the topic of choice, yes I believe choice should absolutely be respected.
You give people the safety and risk information to make informed choices. And then you respect their decision.

My response was to this part of your first post " As someone else said anecdotes are nice and everything, but are not data, and a persons risk level has nothing to do with all the lovely stories in the world. People tend to generalise about safety then to bolster their choice, when any risk could occur to anyone really."



I am relieved to hear that you support informed choice and that a woman's informed choice should be fully respected, regardless of hospital policy.

GoerGirl

Squiggler wrote: »

Edit: If further, substantiated, evidence that consultants do not always act in the best interests of mother and baby, or respect their right to choice, is felt to be necessary you need only look at the hysterectomy scandal that took place in our Lady of Lourdes in Dundalk.

Our Lady of Lourdes Drogheda - Dr Neary

mickydcork

Should a decision be respected though if it is a poor decision? Regardless of whether it is informed or not?

Also there are two individuals involved in childbirth, one has an input on decisions that are made around childbirth, the other obviously hasn't.

I think it's quite right that medical personnel/hospitals should advocate on behalf of the unborn if they feel it is right to do so.

Squiggler

mickydcork wrote: »

Should a decision be respected though if it is a poor decision? Regardless of whether it is informed or not?

Also there are two individuals involved in childbirth, one has an input on decisions that are made around childbirth, the other obviously hasn't.

I think it's quite right that medical personal/hospitals should advocate on behalf of the unborn if they feel it is right to do so.

Of course not, and especially not if the poor decision is being made by the consultant, which is why the consultant in my case was told by the HSE to desist from harassing me and never attempt to contact me again.

And I would argue, in most consultant led hospital situations that none of the people directly involved in childbirth (parents or baby) actually have an imput into the decision making process, and that is wrong.

I agree with your final point, to a degree, yes when the decision is based on medical evidence or indications in the individual case, but not when it is on a whim, or because of a personal prejudice.

Mr Neary felt he was right in preventing those women from having further children (without their agreement, permission or knowledge)... but I seriously doubt any sane person would agree with him.

GoerGirl

mickydcork wrote: »

Should a decision be respected though if it is a poor decision? Regardless of whether it is informed or not?

Also there are two individuals involved in childbirth, one has an input on decisions that are made around childbirth, the other obviously hasn't.

I think it's quite right that medical personal/hospitals should advocate on behalf of the unborn if they feel it is right to do so.

"poor decision" is a subjective expression - one person's idea of a "poor decision" will differ greatly to the next.

Hospital policy is not standardized in Ireland, varies from unit to unit, and often does not reflect evidence based recommendations (for example, most units use routine CEFM, which evidence shows us leads to instrumental birth and caesarean without benefit to infant mortality).

The right to bodily integrity and informed choice are recognised as key prinipals in effective health services and are considered basic rights of an individual's personal freedoms

LegacyUser

GoerGirl wrote: »

Are you suggesting that we only create policy based on locally sourced evidence, regardless of the quality of the evidence in question?
...........
Are you suggesting the HSE and obstetric/midwifery leads in Ireland create guidelines for homebirth based on this evidence as it is locally sourced? Rather than the high quality internationally respected evidence from NICE?

I am suggesting that in evaluating Irish outcomes, in order to discuss relative safety and outcomes that we need all Ireland, all birth data over a long period of time. Maybe even as an ongoing data collection. I'm not sure how much clearer I can make that.
Also, no I am not suggesting policy creation based on one study from the Rotunda?!

You do seem to be quite on the attack on this subject, and whilst it's great to have homebirth advocates (as advocates in any area are very necessary for choice), one's argument is much better served by seeing all sides of the subject even those which do not prove your view.

GoerGirl

RiskSafety wrote: »

I am suggesting that in evaluating Irish outcomes, in order to discuss relative safety and outcomes that we need all Ireland, all birth data over a long period of time. Maybe even as an ongoing data collection. I'm not sure how much clearer I can make that.
Also, no I am not suggesting policy creation based on one study from the Rotunda?!

You are looking for a full National review of data collected for place of birth, clinical practice, and outcomes. In order to do this properly it would require the data collection of every unit in Ireland, each individual consultant, each SECM, and the MLUs/DOMINO programs in place. I am saying we are nowhere near in the position to do this.

The stumbling blocks to which I see is there are many factors/biases which need to be addressed in order for such data collection/research be of a high quality; the quality in which you would base recommendations on.



Ireland has no standardized guidelines. Turner - the obstetric lead for Ireland is in the process of creating National Guidelines but we have a long way to go. At present policy is made locally and varies from unit to unit. It can also vary from consultant to consultant. Also, there is no regulatory body to (i) enforce the implementation of these standardized guidelines and (ii) hold those units/individuals accountable for deviations. The MIS system is also not up to par and there are still units not fully committed to the technology; hand written notes, etc. In terms of homebirth, there is no differenciating in our classification system between planned homebirth with a trained community based midwife vs unplanned homebirth with no midwife or BBAs. This was also one of the issues with the Wax paper in the US, which was discredited.

I agree full transparency of these issues is required urgently; annual clinical reports should be fully published and available to the public for each unit, mlu/DOMINO, SECMs, and consultants in order to aide full informed decision making.

However, at present, as we are not in the position to offer such comparisons locally, international research of similar sample groups, which is of high quality, is the method used when looking at place of birth risk assessment and safety.

RiskSafety wrote: »

You do seem to be quite on the attack on this subject, and whilst it's great to have homebirth advocates (as advocates in any area are very necessary for choice), one's argument is much better served by seeing all sides of the subject even those which do not prove your view.

You are misreading my posts entirely. I am not an advocate for homebirth. I am an advocate for evidence based practice and informed decision making. Its unclear to me where I have attacked you or anyone else on this thread – you have asked me for evidence and queried issues in my posts – I have provided the research and my point of view in relation to the discussion.

LegacyUser

GoerGirl wrote: »

You are looking for a full National review of data collected for place of birth, clinical practice, and outcomes. In order to do this properly it would require the data collection of every unit in Ireland, each individual consultant, each SECM, and the MLUs/DOMINO programs in place. I am saying we are nowhere near in the position to do this.
The stumbling blocks to which I see is there are many factors/biases which need to be addressed in order for such data collection/research be of a high quality; the quality in which you would base recommendations on.

Yes, that's exactly what I'm saying. It is done in other countries though I don't have the info to hand right now, though it's stuff that's easily found. The one I'm thinking of is UK.
I don't believe we aren't in a position to do this since almost every birth is already hospital/ Independant Midwife. We already collect data.

There are no stumbling blocks in collecting that data actually. You simply collect the facts.
Collating the data into a study is again a different Question, however if allowed the simple facts can and will stand out for themselves. Or they can be assembled into whatever studies whatever advocates want.
I'm going to leave it at that now, take the best of what you will.
To the OP, the very, very best of luck to your friend and his missus

LegacyUser

The data collection study is:
UK’s national audit programme, the Clinical Outcome Review Programme (CORP) Maternal and Newborn Health, which is tasked with collecting perinatal mortality data.

It was suspended April 2011, and due to recommence April 2012.

Mothman

Moonbeam wrote: »

Talk to Mothman about home births he has a lovely birth story up.

Have just come across this thread, I'm a few months beyond this stage now

My 3 have been born at home.
Even for first it was easy decision to make for us. We had 100% confidence in midwife and my wife was confident in her self, though ignorance is bliss

My wife would not be comfortable in hospital and I believe that the chances of complications occurring while birthing in hospital would have increased many times. I know for many mothers to be, the situation is reversed and that they need the hospital environment to feel safe/comfortable.

Progress of labour is dependent on many things, but one is the mother feeling safe/happy etc. For us home provided this environment.

Regarding transfers for planned home birth to hospital, these are generally not emergencies. In my circle, (I hasten to add may not be an accurate representation), I have not heard of any emergency transfers. The monitoring by the homebirth midwifes is so skilled and thorough that potential emergency issues are pre-empted.

And just to clarify and agree with an earlier post, we are delighted that the hospital was there, if it was needed...thankfully I could stay at home and make myself a coffee :pac:

Squiggler

AmyLoe wrote: »

Lots of care and attention requires in home birth.

Lots of care and attention is required no more in a planned home birth than any other type of birth.

Home birth is only permitted for healthy women, experiencing a normal, low-risk, pregnancy. It is always backed up by registration with a maternity hospital - who will therefore have blood results and scan results (if any) on file in case of requirement to transfer. Closer to the EDD an ambulance service will be contacted and put on notice, given full contact details, address and detailed directions etc.

Contingency planning and support during labour for a home birth (where their chosen midwife is either at the end of the phone or standing there with them)is, in my experience, far superior to that for planned hospital births (where women are often not fully informed and are often left in doubt as to when they should go to the hospital).