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Home Birth: a realistic possibility?

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held jointly with the Association of Community Based Maternity Care and the Royal College of Midwives, on Wednesday 13th November 2002.

This report first appeared in the RCM Midwives Journal.

Luke Zander , chair of the first session and founder in 1982 of the Forum which shared in the organization of the meeting, adverted to the book (1984) published after an earlier and similar meeting and to the passages referring to home birth in all its aspects. He also credited the two other organizing groups, outlining their various and worthy activities.

Reference.
Zander L, Chamberlain G (Eds.). (1984) Pregnancy Care in the 1980s. The Royal Society of Medicine and Macmillan Press.

Sessions 1 and 2.

The present state of our knowledge, practice, and policies

Reconfiguring the needs of women and caregivers in home birth. Medical and social views of birth: the compromise with medical science.

Dr. Jo Murphy-Lawless (JM-L), Department of Social Policy and Social Work, University College Dublin.

As an increasingly technological society, we have come to invest much thinking on risk.

“Scientists can measure the efficacy (the chance that a desired outcome will occur),
and the risks (the chance that an undesired outcome will occur)”. Value judgements about these measurements “must be assessed by those on whom it is used…….the woman who takes these chances is the only one who can legitimately decide whether one chance outweighs another…the doctor's role is limited to explaining the level of risk involved” (Wagner 1994).Wagner also states that the other feature central to the social model of birth is that the body is seen to be competent and trustworthy from the outset.

In many ways, his approach represents the best of the scientific discussion of the reasons why the social model of birth should be favoured. This is a questionable approach, for his arguments are about facts and measurability which, forming the very essence of randomized controlled trials (RCTs), are a scientific knowledge which remains fundamentally problematic because of its positivist roots.

“Scientific theories neither mirror reality nor do they correspond to reality. Scientific theories are models; they are especially models for - they strive to represent a reality in order to intervene, at the very least in order to confirm their validity”.
(Evelyn Fox Keller 1992)

The mathematician and philosopher Ian Hacking(1990) argues that science cannot measure everything, and that scientific fact is a construction and no more than an approximation. Of course all other representations of reality also operate as models, but they lack the signal capacity of science to intervene and to do so consistently and successfully.

The model of active management of labour requires that labour be augmented if cervical dilatation does not proceed at 1cm. per hour or more. But we cannot fully understand the causes of variable dilatation; our science is unable to explain the not unusual slowing of progress in labour when a woman is transferred to hospital. Oxytocic drugs do speed up labour and permit predictability of birth times. However much those of us involved in promoting the case for the social model may object to this, predictability has been a prized aspect of modernity, and science and its technologies have helped in a very major way to reinforce it as a value, making many women and practitioners feel more secure. While we may and do fault such a construction that certainly does not mirror reality, we cannot deny the success of the intervention that flows from that model. It then becomes far more difficult for those working to define birth as a social space to promote it as something that should remain within the grasp of a woman, and about which she should make the decisions. How secure are those scientific facts on which many practitioners rely?

We see the incomplete nature of scientific representation especially in relation to the question of risk. But how certain are those 'facts' on efficacy and risk presented by science upon which a woman is to make her decision? To measure risk, we have to use the conventions of statistical analysis that rely on the notion of probability as predictable and quantifiable. There is no recognition that the mushrooming of numerical series and equations still raises significant problems to do with the meaning and definition of the constants being used. There are problems which go largely unacknowledged when the notion of measurement is taken outside the discipline of mathematics, which is what medicine has done. This is where Wagner's reliance on risk measurement as a 'fact' begins to unravel.

There is a general presumption that the scientificity of the process of measuring what we term risk enables us to have confidence in the end results of schedules of risk, and that these will prove to be genuinely beneficial. This is what the meta-analyses of the Cochrane review system have hoped to achieve in order to codify beneficial and harmful practices and so eliminate risk. But we cannot do this because our models will never be adequate to the task of capturing the multiple complexities of realities in birth. The notion of risk has great salience in a modern society dominated by science and its technologies, and if we are in doubt about the rigour and quality of the science then we redouble our efforts to make studies and assessments more scientific. Our society is saturated with the risk discourse.

Two recent research reports (Pang 2002, Hodnett 2002) cast serious doubt on the safety of planned home birth, the second, in a Cochrane review, expressing concerns about whether a focus on 'normality' may have a 'negative impact on the ability of caregivers and their clients to detect, act upon, and/or receive assistance with complications'. Do these findings indicate that we must redouble our efforts to make the training of primary caregivers even more scientific? Or do they rather suggest that we must instead debate far more widely the limitations of the scientific project and the illusory quests for both a perfect science and zero death rates?

My disquiet is about whether methodological rigour can ever capture what it is to give care to a woman as it subtly shifts outside the parameters of a research study. We need to discover how science might be different, what the obstacles are that prevent science from being an agent for change in our society, rather than an agent of control as now. We need to take the subtle, unmeasurable, unanswerable complexities and extend our use of qualitative method to begin to illuminate what RCTs cannot do. In this way we can begin to help the general public understand how the issue of risk has been used to fend off fundamental questions about how obstetric science has worked to produce more and greater technologies to dominate birth.

The sociologist and philosopher Zygmunt Bauman (1993) points out that people currently perceive risk as a reality, not as a construction embedded within a science that can be challenged. I suspect that a large part of what decisions about home birth really comprise is not a review of evidence-based data, but an arena where women can exercise agency, drawing on commonsense judgements about what constitutes risk in our daily lives. We sense that scientific rigour and reliability are not straightforward, due to the very social processes which produce scientific rationality and its need for predictability. But that kind of rationality has also helped to create distance, alienation, degradation, and confusion around the deeply social act of giving birth; women and their primary caregivers, midwives, have suffered a loss of confidence, while also being deprived of the moral agency that makes us truly human.

Suppose we go in a different direction now; rather than increasing our scientific grip on childbirth, suppose we loosen it, and in so doing increase the opportunities and capacities of women and caregivers to create a better engagement and real proximity during birth; rather than trying to produce a predictable labour, we admit that the 'future is always a new birth, an absolute beginning.' Bauman argues that touch is pure approach, pure proximity, and the nearness of being; that a caress can be the metaphor and paradigm of a moral relationship because it abolishes distance. How is this to describe the work of a midwife assisting a woman through labour:

“The caressing hand characteristically remains open, never tightening in a grip, never getting hold of, it touches without pressing, it moves obeying the shape of the caressed body”. (Bauman, 1993).

This metaphor, I suggest, rather than intensified science, could secure home birth as a valid social undertaking, focusing on the agency of the woman, the expressiveness of the body, the negotiable context of care-giving, and the subjective capacities to act and respond to women in birth.

References.

  1. Bauman, Z. (1993) Postmodern Ethics. London: Blackwell.
Fox Keller, E. (1992) Secrets of Life, Secrets of Death: Essays on Language, Gender and Science. London: Routledge.

Hacking, I. (1990) The Taming of Chance. Cambridge: Cambridge University Press.

Hodnett, E. et al. (2002) Effectiveness of Nurses as Providers of Birth: Labor Support in North American Hospitals: A Randomised Controlled Trial. In JAMA, 288 : 1373-1381.

Pang, J.W.Y. et al. (2002) Outcomes of planned home births in Washington State: 1989-1996. In Obstetrics and Gynecology, August 2002, 253-259.

Wagner, M. (1994) Pursuing the Birth Machine: The search for appropriate birth technology. Sevenoaks, Kent: ACE Graphics.


Home birth: What does it mean to women? How is it perceived? How much is happening?
From Belinda Phipps (BP), Chief Executive, National Childbirth Trust (NCT)

Home birth stories provide lifelong memories of the events and of the gift granted them by the midwives who supported them. These women can rejoice in their experiences, may feel changed by them, and often contrast them with something traumatic associated with hospital births, which often lack the meaning for a family that home birth affords.

What do women say?

“I had the power, and my midwife respected that, in a way I feel she may not have done in hospital”.

“…….home was the ideal environment for me, emotionally and physically; I felt very safe, and I'm sure this contributed to a quick and easy labour”.

“As a result of regaining my self confidence through the birth I have experienced a huge improvement in my general wellbeing and in my relationship with my husband. I realised that I had been depressed since the first birth; this has gone. I enjoy sex again and have lost 3 stones in weight”.

“All in my own home; no white walls, bright lights or distracting noises, just Pete and the two midwives with me all the time”.

“At home you know where everything is, and afterwards there is nothing like your own bed - and no-one sending your husband away”.

“The best pain relief is your own child patting your shoulder during a contraction!”.

“…..how different the two births were. During the home birth I felt relaxed, in control, unpressured. I could eat and drink”.

In October 2000 the NCT sent a survey to heads of midwifery at 271 NHS Trusts with a view to investigating their opinions and variations in home birth rates, and to provide women with information about access to home birth; 62% replied. 2.6% of all births take place at home, with striking regional variations from almost zero in Northern Ireland to 4.5% in the South West. The Trust with the highest rate of planned home birth was Scunthorpe, 11.1%. The best could be replicated anywhere within the NHS, given the will to change attitudes and practices.

The responses implied that GPs promoted hospital birth over home birth. “Some GPs refuse their support, leaving mothers with the dilemma of acting against the advice of their doctors”. Family doctors and ancillary staff share a belief that hospital birth is safer; the GPs are often erroneously concerned that they may be liable in law or may have to attend in emergency, and they lack confidence in the adequacy of their skills for home birth. Paradoxically they like some involvement in maternity care as a nicer part of their work.

Midwives have concerns around their capabilities when attending home births, about safety, and about the intrusion of the service into their personal lives (whereas by cooperation with colleagues space can be found for their families and other interests). They feel a lack of support from Trusts and GPs, they believe that the service may reduce the availability of staff in hospitals, and they are unclear on their legal position in relation to it. (In fact as independent practitioners they are legally responsible). Family doctors, obstetricians, health service managers and importantly families should have confidence in the training of midwives to identify potential problems in time for unhurried transfer to hospital.

For obstetricians home birth lies below the horizon of their interest; they see all pregnancy as carrying potential risk and tend to recommend birth in hospital. They should see that a strong home birth service leaves them more freedom to focus on high risk pregnancies, and should value the service to low risk healthy mothers outside the hospital.

Health service managers give the maternity services a low priority; they are preoccupied with risk management, believing home birth to carry an increased risk; this includes concerns for the safety and management (shift and rota issues) of involved midwives. They see it as bringing an added expense to their budgets and jeopardising labour ward staffing. They should be aware that the enthusiasm of many midwives for home birth encourages the retention of staff, and that it reduces costs by reduction of obstetric interventions, and alleviates work pressure for the hospital and the overall risk it has to bear.

Women and their families lack awareness that home birth is permissible, especially for the first baby. They see the choice as a 'brave' one, and are concerned about what will happen if something goes wrong. They worry about coping with pain at home, and do not realise how excellent are the abilities of midwives to leave their homes as tidy as they find them.

About one fifth of pregnant women would like more information on the subject of home birth, and the NCT has published an information sheet. It has a widespread image which demands correction. It is regarded as odd, homespun, uninformed, not for a modern woman, rather cultish and risky. It has to become seen as mainstream, something most women could do, sensible and informed. It is a responsible and safe choice for healthy women with uncomplicated pregnancies, and a good way to ensure the continuous support of a midwife, leading to a straightforward labour and birth.

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