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Born free

Home » Blog » Sarah Heeringa » Born free

The recent Good article 'Eco mamas and papas' included a segment called 'Born Free' which considered some of the issues around birth in New Zealand. The item prompted the following conversation. 

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A letter from a reader ...

I felt the need to write a short response to the article “Born Free” (Good #09).  The article briefly talks about choosing the right location to give birth, and encourages women to pursue the ‘process of a natural birth’ by choosing to deliver at home or at a birth centre to avoid the use of “medicalised birth technology”.

The UK study that I think is being quoted (Symon et al, British Medical Journal 2009) shows that choosing an independent midwife and delivering outside of hospital will mean that you’re less likely to use medications for pain, need assistance with the delivery, or have difficulty breast feeding.  But the same study also showed that delivering outside of hospital with an independent midwife is associated with double the risk of giving birth to a stillborn baby or having an infant death within the first 7 days of life.

It’s easy to forget that although birth is a natural process, it still is a relatively risky time for the mother and baby.  In the UK, even in low-risk pregnancies, the risk of having a stillborn baby or infant death in the first 7 days of life is about 5 in every 1000 births.  (I tried to find comparable NZ data for this and haven’t been able to, but it is probably about the same.)

Nobody wants medical intervention in labour.  But in the last thirty years, our rates of neonatal death have fallen dramatically (by almost up to 50% in the US), and for this we have to pay tribute to the improvements in obstetric management and premature baby medical care.

"If you are attracted to the idea of giving birth outside of hospital, that’s okay.  But you need to ask yourself: how would I get to a doctor fast if something went wrong?"

If you are attracted to the idea of giving birth outside of hospital, that’s okay.  But you need to ask yourself: how would I get to a doctor fast if something went wrong?  Even normal pregnancies sometimes go wrong and the healthiest of mothers and babies can find themselves in situations where they need medical assistance quickly.

So let’s not get too fixated on the idea of just having a natural birth.  The environment in which we give birth is something that we like to control, but we must put safety first.  At the end of the day, what we all want to see is a healthy baby and healthy Mum, even if it doesn’t always go according to plan! —Dr Jin Teoh

My response

Thanks for your letter and your feedback about Good magazine. I am glad to hear you enjoy aspects of the magazine. Thanks also for your response to the 'Eco baby' feature. I agree with many of your comments—the ultimate outcome everyone wants is a healthy mother and baby, over and above any hopes for a positive birth experience. I also appreciate that that the topic of birth is huge and fraught with politics and emotion. Quoting fragments of studies and statistics can also be problematic. My feature was not intended as the last word on the subject but was an attempt to get readers thinking about the way we give birth and feed our babies in terms of 'eco' concerns, when perhaps this hasn't been considered before.

In my case, I was attracted to the idea of giving birth outside of hospital, in part due to the excellent (and rapid) birth histories of my mother, grandmothers and two older sisters. My husband and I had a plan for getting to a hospital fast if something went wrong and living in the inner city made this feasible. We chose our midwife carefully, ensuring she had a current practicing certificate, an access agreement with our city hospital and a clear understanding that our primary goal was not necessarily a home birth, but a healthy baby. We weren’t out to make a political statement and we didn’t have an attitude of home or be damned.

I agree that, even with normal pregnancies, births sometimes go wrong and the healthiest of mothers and babies can find themselves in situations where they need medical assistance quickly. But a well trained and experienced midwife is able to pick up any deviations from the normal early and take the appropriate action to proceed to hospital.

"You say that the environment in which we give birth is something that we like to control but that we must put safety first. My experience of birth suggests that it is the subtle cues of our environment that can control us and not the other way around."

You say that the environment in which we give birth is something that we like to control but that we must put safety first. My experience of birth suggests that it is the subtle cues of our environment that can control us and not the other way around. Here’s an example. During my fourth labour, and having regular contractions, I made the planned trip to a birthing unit. The labour immediately stopped. I was advised to go home, where it promptly started up again—resulting in an unplanned home birth 15 minutes later.

You say that no-one wants medical intervention, but injections of pethidine and epidural anaesthetics are now routine modern medical interventions, expected by many labouring women. And our high cesarean rate is due to some degree by 'maternal request'. (Not to mention scans and blood tests, induction, labour augmentation with syntocinon and electronic fetal monitoring during labour.) The reality is, in the case of most births today medical intervention, not natural labour, is the norm.

It seems to that the ‘safety first’ approach is contributing to the ever increasing medicalisation of birth and this is contributing to the increasing cesarean rate. Birth by cesarean is sometimes a necessity, but it’s not without its risks, medically, emotionally and in terms of bonding and the successful establishment of breastfeeding.

It seems to me that safety first is not the only consideration when approaching birth—psychological, cultural, emotional and, to a lesser extent, eco-issues matter as well. My aim in writing the article was to highlight this particular aspect for consideration and to remind people that a natural birth, including home births, and breast-feeding are still viable (and not necessarily unsafe) options as well as being better for the environment. —Sarah Heeringa

And a futher comment

I really appreciated your reply and the fuller picture of your thinking and understanding of this topic.  This reply was sensitively written. You are right. In modern-day medicine, eco-concerns seem to receive very little attention and I'm glad you and your team are shedding light on this. I am liking the balance that is achieved in your response. It's a real relief for me, as a medical practitioner, to read "we didn't have an attitude of home or be damned" as a concept being elucidated publicly. Every so often, I have dealt face to face with families who have been very stern, very inflexible, with their wishes for an all natural process and it's led to some tough conversations for both sides! So I'm very glad that your reply is more detailed, as I think it's exhibits a good approach.

I look forward to the reading the next edition! —Dr Jin Teoh

If you are attracted to the idea of giving birth outside of hospital, that’s okay.  But you need to ask yourself: how would I get to a doctor fast if something went wrong?

Comments

Sarah Tennant
 
Thu February 11, 2010 @ 06:27 PM
I'd just like to point out that the study cited noted an increased risk of infant mortality only in high-risk mothers. Rather than condemning home birth as a whole, I think this shows the need for adequate pre-natal care and on-to-it midwives who encourage high-risk mothers to choose the safest option. When only the low-risk mothers in both groups were compared, the differences between outcomes were not statistically significant. In other words, a low-risk homebirth and a low-risk hospital birth have equal stillbirth/infant mortality outcomes. With the added data in favour of homebirth for other outcomes (infant feeding, number of interventions etc), I think that tips the scale for low-risk women in favour of homebirth. Which is of course not to say that they aren't free to choose whichever location they prefer!

I planned a homebirth with my baby two years ago, and was very upset when I developed pre-eclampsia and had to give birth in the (at that time) extremely dank, grotty labor rooms of Waikato Hospital. Still, in retrospect I'm glad my midwives picked up on my condition so promptly and refused to endanger me for the sake of having a "beautiful birth". I'll probably use the same midwives next time, because I know their open-mindedness about home birth hasn't made them lax or la-la about serious medical conditions.
Heather Ririnui
 
Sun February 14, 2010 @ 04:08 PM
What an interesting debate and the 2 people have presented their cases so well.  A general comment on this subject; I find it interesting that people in general are quick to criticize mothers who choose a natural birth or advocate home birth and seem quick to dismiss them as uninformed or just plain crazy ...(why not just take the drugs)!  But those who choose to be induced or have a caesarean are seen as the norm.  I hope in the future we can trust that the medical interventions available to us are only used when necessary to a better outcome for mother and baby and are not based on fear as seems sometimes the case.
Annabel McAleer
 
Mon February 15, 2010 @ 10:51 AM
Meanwhile in Australia, homebirths are to effectively become illegal, with midwifes prevented from attending births outside hospitals: "Under the draft Health Practitioner Regulation National Law, released last week, a midwife cannot be registered unless she has insurance. But with insurance companies and the Government so far refusing to include homebirths in the indemnity scheme, midwives will face being de-registered if they attend a homebirth." 
Last Edit: March 18, 2010 @ 12:24PM by Annabel McAleer 
Amanda Bradley
 
Fri March 12, 2010 @ 05:08 PM
Wow, interesting debate.
I had my first baby in hospital and when I became pregnant three years later with my second my midwife encouraged me to explore the options of a home birth. She had attended my first "text book" birth and was confident that as a fit and healthy woman in my twenties all would be well.
My parents were very hesitant but she took the time to explain that she would have the same resources on hand that a midwife in a rural birthing unit would and that living only 10 minutes drive to a hospital we could have access to services quickly and relatively easily if needed. And so baby number two was born at home, as was three and four.
I believe that home birth as an option for uncomplicted low risk pregnancies should be advocated for by the health system. It puts less stress on health services and must result in lower costs.
Go for it!
Amber McKenzie
 
Sun March 14, 2010 @ 10:58 AM
I for one am glad that we live in a time where women have the choice and have access to medical help if they need it or choose it. Casaerians can save lives and I think women who judge other women for having them should count themselves lucky that they didn't need it !

from http://www.guardian.co.uk/lifeandstyle/2010/mar/13/natural-childbirth-caesarean-emily-woof
. . .I am deeply grateful that I live now, when medical intervention has
kept me and my children alive. I also know how important it is that the
NCT and similar organisations exist to support and empower women. But
in my experience, the division between health practitioners who
advocate the natural way, and those who encourage a more medicalised
route presents its own danger. It carries with it a sense of good and
bad, a gulf in which women can get caught. It is part of our culture to
want choice and to be in control, but with birth, this is probably
impossible.
Kelly Phillips
via letters@good.net.nz
 
Thu March 18, 2010 @ 12:19 PM
Dr Jin Teoh stated that the quoted study showed that "... delivering outside of hospital with an independent midwife is associated with double the risk of giving birth to a stillborn baby or having an infant death within the first seven days of life." This interpretation is actually incorrect as the increased incidence in this study was actually associated with any birth outside of a hospital, not for elected home births under the care of an independent midwife. Once the results of the study were controlled to look at just elected home births, the risk of neonatal death was found to be the same as for hospital births.

I agree that the focus of birth should always be to ensure the health of the mother and child, however choosing to birth at home with a midwife or in a birthing unit may be one of the best ways to support this outcome. One of the reasons for this is because of the much lower rates of medical intervention associated with births in these environments. While interventions can be beneficial and even life saving in some instances, they also carry significant risks and should only be used if absolutely necessary. For instance, the high incidence of cesareans in NZ hospitals is associated with increased risks for both mother and child according to the World Health Organisation. Another common intervention used is syntocinon to induce labour. This procedure carries the risk of causing decreased oxygenation to the baby which can result in fetal distress and may lead to an emergency cesarean or other intervention in order to birth the baby quickly. This procedure can also be very painful for the mother, often necessitating an epidural for pain relief which again increases the likelihood of further intervention.

It is vitally important for all mothers-to-be that they research their options so that they can make informed choices for their birth. This was essential for me during the birth of my child as I had a long labour which would have resulted in intervention if I had been transferred to hospital. As I was aware of my options, I felt confident to carry on labouring at home with the midwife monitoring myself and baby and we were able to have a safe and natural delivery at home.

A helpful organisation that provides support and resources for mums and dads-to-be around birthing options is Active Birth Taranaki (www.activebirthtaranaki.org.nz).

Yours sincerely,
Kelly Phillips
Naturopath, Ayurvedic Practitioner, Tutor and Mum.

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