The Home Birth Revolution

"When I was pregnant with my first child, I went through five different gynaecologists. Each time, I felt they didn’t respect my birth plan. By the time I found a gynaecologist I was comfortable with, I was in my last trimester. I had a natural birth at a hospital, but when I got pregnant again, I was certain I wanted to give birth at home."

-Vimala (name changed); chose home birth.

Vimala, like many other women in India, have now started to embrace the idea of home birthing, as opposed to institutional deliveries, to bring their children into this world. As unconventional, unsafe and unprofessional as it might sound, home birthing was a norm before institutional deliveries were aggressively pushed on a global scale.

Medical Paternalism

The very premise of promoting institutional deliveries lies in the proposition that prenatal complications and complications during parturition cannot be predicted. Therefore, the expectant mothers should be encouraged to approach hospitals and similar care facilities where babies would be delivered safely, thus safety of both mother and child are kept intact. While that might be true in the context of high risk and moderate risk pregnancies, we all can generally agree upon the fact that most of the pregnancies are normal and without any complications by nature. Although in India, some studies suggest that prevalence of high risk pregnancies is pegged in between 20-30%, it still doesn’t outweigh the other relatively low risk pregnancies at around 70%. In fact studies, conducted by Shareen Joshi and Quy-Toan indeed reflect that the rise of institutional deliveries is remarkably consistent with the halting of a slow decline in infant mortality from the 1970s onwards. The figure mentioned below, sourced from the same study reflects the same.

Also, the rising trend of cesarean deliveries is one of the major concerns. A WHO review report in 2014 had some interesting insights to offer. It stated that beyond 10% of populations levels, increase in percentage of cesarean sections has no associations with reduction in maternal and infant mortality rates. It also stated that Caesarean sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications. Caesarean sections should ideally only be undertaken when medically necessary. The effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being are still unclear. More research is needed to understand the health effects of caesarean section on immediate and future outcomes. These are significant set of observations as recent NFHS survey stated that the national rate of cesarean sections went up from 8.5% to 17.2%. Also noteworthy is the fact that although rates of cesarean section have fallen in public health units, the rate has skyrocketed to nearly 40% in private healthcare setting where most of our population seeks medical care.

Safety?

Before the advent of modern medicine and the global push for institutionalized deliveries, home births were considered safe and till a certain point even desired by the expectant mothers. Home births were, therefore the de-facto method. The traditional personnel involved in home birthing scenario were midwives along with a few traditional birth assistants. Their education and training equips them to recognize the variations of normal progress of labor, and understand how to deal with deviations from normal. They intervene in high risk situations as well if required.

The primary opposition to home births were based on idea that conditions existing in household/places are ill-equipped, unsanitary and lack appropriate human resources to deal with any untoward incident or complication that may arise in due course of parturition. One doctor described birth in a working-class home in the 1920s:

"You find a bed that has been slept on by the husband, wife and one or two children; it has frequently been soaked with urine, the sheets are dirty, and the patient's garments are soiled, she has not had a bath. Instead of sterile dressings you have a few old rags, or the discharges are allowed to soak into a nightdress which is not changed for days."

However, there is emerging evidence that would suggest otherwise. According to a Cochrane review on “Midwife led continuity model of care”, evidence suggests that women who received midwife-led continuity of care were less likely to have an epidural. In addition, fewer women had episiotomies or instrumental births. Women’s chances of a spontaneous vaginal birth were also increased and there was no difference in the number of caesarean births. Women were less likely to experience preterm birth, and they were also at a lower risk of losing their babies. In addition, women were more likely to be cared for in labour by midwives they already knew. The review identified no adverse effects compared with other models. Also, a meta analysis conducted on safety of home birth concluded that home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions.

Johnson and Daviss's (2005) “Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America” is the largest study of home birth to date. This was a prospective cohort study of 5,418 home births (98% of the births attended by direct-entry midwives with a common certification in the United States and Canada). The planned home births had similar rates of intrapartum and neonatal mortality to those of low-risk births, but the medical intervention rates for planned home births were lower than for planned, low-risk hospital births. The cesarean rate in the home birth-group was 3.7%, substantially lower than in the hospital cohort. A high degree of satisfaction was reported, and <12% required transfer to a hospital.

No stakeholder considerations

What’s even more disturbing, is that there is no consideration given to perhaps the most important stakeholder of the whole issue- mothers. A study conducted on factors influencing the place of delivery in rural Meghalaya, India revealed that misbehavior and unfriendly attitudes of some of the health personnel hinder rural women from using health facility for future deliveries. The study also came across cases of unnecessary referrals and improper management which led to loss of trust of the pregnant women and her family. O'Connor's (1995) national study of home birth in Ireland was groundbreaking. She interviewed 138 women who gave birth at home, most having to fight hard to have that happen, and most having had a previous traumatic birth experience. In Ireland, where home birth is not normal (the birthplace of active management), these women saw their decision as a revolt against the way obstetricians manage birth, as the way to avoid interventions, and as a way to be listened to and really supported. In the preface of O'Connor's book, Sheila Kitzinger says, “Only when women control the territory in which they give birth can they reclaim childbirth” . Women clearly want to have the choice of where to birth their babies, and women like giving birth at home.

Perhaps it is time to review our current discourse as to how we can promote maternal and child health by exploring alternatives to institutional deliveries? As Bertrand Russel had once stated:

“There have been ages when everybody thought they knew everything, ages when nobody thought they knew anything, ages when clever people thought they knew much and stupid people thought they knew little, and ages when stupid people thought they knew much and clever people thought they knew little. The first sort of age is one of stability, the second of slow decay, the third of progress, the fourth of disaster.”

We probably should consider the possibility what we know now may be irrelevant in the future, and what we ignore now might be relevant in the future.

- Aditya Andhansare, MPH-HPEF (2018-2020)