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"Have you considered a home birth" This booklet was developed by the Waikato Home Birth Association and may be reproduced with acknowledgement. Click on the image to the right to download a copy.  Please note:  This booklet is provided in .pdf format so you will require the latest version of Abode Reader to view this.  Click here to download a free copy.
Home or Hospital:  What's the big deal?
By Ruth Hungerford
Home Birth:  A Safe Option
By Sheryl Wright
Are all home births created equal?
By Ruth Hungerford
Lets celebrate the Home Birth Midwife
by Andrea Herrick
Home Birth – is it Safe?      by Anitra Carr, PhD
Home or hospital: What’s the big deal? In this article Ruth Hungerford asks the questions: How did hospital birth become the norm in New Zealand? And does it matter? Prior to European colonisation of Aotearoa New Zealand, 100% of births took place in the home. Whilst some European women birthed in public hospitals as early as 1882 the number who did so was minimal and up to the 1920s home was still the usual birthing place for the majority of New Zealand women (Banks, 2000). In 1920 most births were still occurring at home with 35% of births taking place in hospitals. However by 1926, 58% of births were occurring in hospital and by 1938 this number had risen to 87% (Banks, 2000). In 2003 over 95% of births in New Zealand take place in hospital. So, what happened? Why did birth move from the home to the hospital? and does this really matter? A gallop through birth herstory In the mid 1800’s childbirth for New Zealand European women happened at home and lay midwives were the primary birth attendants.  These women supported women in childbirth and often assumed responsibility for looking after the woman’s family and household while the mother recuperated (Banks, 2000; Donley, 1986). For Maori women, childbirth was centred around the family, with the birthing processes traditionally attended by mother, grandmother, tohunga (spiritual healers) and other relatives. Lay midwives were generally regarded within their communities as women who possessed considerable skills and despite the harsh pioneering conditions consistently good outcomes were reported for mothers and babies. For example in one West Coast town in 1894 there were over 400 births attended in turn by one of three married women. Of these not one mother died and no doctor ever attended (Greymouth Branch of the National Council of Women, 1959 cited in Banks, 2000). Lizzie Lean, a Dunedin midwife in the 1890s “delivered [sic] a thousand or more babies on her own” and never lost a baby (Donley, 1986, p. 27) Alison Drummond claims that between 1814 and 1840 not one European woman died in childbirth (cited in Donley, 1986, p. 28). However the Midwives Registration Act in 1904 signaled the beginning of the end for the lay midwife. The Act set up St Helen’s Maternity hospitals and provided training for midwives. Lay midwives who continued to practice had to be certified for registration by a doctor (Banks, 2000; Donley, 1986).   Other laws also changed childbirth practices for both European and Maori  women.  For example, the Tohunga Suppression Act of 1908 caused traditional Maori birth practices to go underground, and the passing of the Nurses and Midwives Registration Act of 1925 saw birth attendance become unlawful practice unless that person was a doctor, a certified lay midwife, or a registered maternity nurse or midwife (Banks, 2000).  As a consequence of these laws, the traditional birth attendant for women all but vanished. Pregnancy and birth becomes a disease Up to the 1920s pregnancy and birth were generally viewed as normal states of health and as such did not entirely fit within the medical domain, which is concerned of course with ill-health or disease. In fact in the 1920s the Minster of Health advised women to have neither doctors nor anesthetics during labour. This was because the presence of doctors was associated with an increased rate of puerperal sepsis (childbed fever) as practices such as vaginal examinations and forceps deliveries were commonplace and contributed to infection. Midwives did not commonly practice these so their rates of puerperal sepsis were significantly lower than that of doctors (Banks, 2000; Donley, 1986; Mein Smith, 1986). Childbed fever or puerperal sepsis - an  infection of the uterus which in severe cases results in death – was one of the key causes of maternal deaths.  Rich (1986) notes that the occurrence of childbed fever was “directly related to the increase in obstetric practice by men… With the growth of lying in hospitals in the cities of Europe, the disease, rarely known in earlier times – reached epidemic proportions. In the French province of Lombardy in one year no single women survived childbirth.”  (cited in Banks, 2000, p.64) Today it is accepted that childbed fever is an acquired infection – that is it is caused by germs introduced into the woman’s body by others – the primary way that this occurs is through vaginal examinations carried out with unclean hands although other procedures such as forceps deliveries and surgical interventions are also ways that infection is transmitted.  This was determined as early as 1848 by Ignaz Semmelweiss who identified ‘putrid particles’ (germs) as the cause of puerperal sepsis. However until 1935 the Obstetrical Society in New Zealand held to the belief that childbed fever was caused by virulent organisms lying dormant in the woman’s body which for no apparent reason became active after birth causing infection (Banks, 2000; Donley, 1986). Ironically the high rate of puerperal sepsis was one of the catalysts that resulted in birth becoming medicalised as it paved the way for birth to be reclassified from a normal physiological process to a state or ill health or disease.  Thus it was that in 1937 The Obstetrical Society declared that labour, by the process of civilisation had become ‘abnormal and pathological’ and was now a ‘surgical operation” and that even the seemingly normal case was “fraught with pain and penalty”.   Birth was on its way to becoming a ‘medical condition’. But it was the lure of pain relief that cemented the move to hospital (Banks, 2000). So what about pain relief? Birth is painful.  Over the centuries midwives and women have worked together to help women to bear the pain of childbirth using methods such as changing positions, warm water, massage, and support. Scientific studies of birthing women have ‘discovered’ the endorphins which women produce during labour and which act as a natural pain relief.  Research has also shown that women have higher pain thresholds during labour (Donley, 1986) and that women having home births (without drugs) frequently report experiencing less pain that women having hospital births. Drugs of the pharmacological kind claim to block out physical pain (although some merely sedated the woman and caused amnesia, thus she experienced the pain but did not remember it).  The Department of Health initially opposed anesthetising drugs in childbirth as they were correlated with an increase in forceps deliveries (Banks 2000; Donley 1986). However the lure of pain-free labours was strong and despite a lack of knowledge about the impact of pain relieving drugs on mother and baby, sedation and the use of anaesthetics for labouring women became widely used in New Zealand in the 1930s and 1940s.   Today, despite the evidence of negative and tetragenic (something which can damage foetal genetic development) effects on mothers and babies, interfering with breastfeeding and bonding, and their use contributing to increased operative deliveries, drugs continue to be used widely in labour and birth (Brackbill, Rice, & Young, 1984) But is birth safe? As medicalised birth gained momentum, hospital births became recommended to women as being the ‘safer’ option compared to birth at home. Hospitals were perceived as providing a hygienic environment, necessary obstetric interventions and pain relief, all of which women were assured ensured the safety of both mother and baby.  A study conducted by the Society for Research on Women in New Zealand (1985), for instance, found that eighty percent of women within their sample considered hospitals safer for giving birth than home delivery.  The well-established norm of medicalised births saw health departments advocate only for hospital birth.  In 1985, for instance, the Department of Health in an about-face from it’s 1920s stand, suggested that mothers should have their babies in hospital because “no delivery can be regarded as normal until it is over” (Donley, 1986, p.27).   So is hospital birth safer than home birth?  Actually, no. And in fact the reverse is true. Study after study has shown that when “matched samples of women planning to birth at home are compared with women planning to birth at hospitals, the outcomes for women and their babies with planned home births are more favourable and they have less complications. Even when the outcomes of home birth transfers are included, babies whose mothers plan to birth at home have better outcomes and fewer interventions than those of planned hospital births” (Banks 2000, p.113) Campbell and MacFarlane from the National Perinatal Epidemiological Unit in Oxford stated “There is no evidence to support the claim that the safest policy is for all women to give birth in hospital . There is some evidence that morbidity is higher amongst mothers and babies delivered and cared for in institutional facilities in general and … obstetric units in particular” (1986, cited in Goer, 1995) To sum up… Birth moved from home to hospital in the space of one generation. The normal birth at home was superceded by the medicalised birth in hospital. The medicalisation of birth was not some great conspiracy or caused by one particular incident. It was a combination of laws that outlawed traditional practices or made them difficult to continue, concerns over the maternal mortality rate and the lure of pain relief. And does it matter? Yes.  Birth in hospital is has more risks and causes more trauma for women and babies. Who does not know a woman with a ‘war story’ about birth?  Consider these facts: Support groups for woman recovering from traumatic birth experiences have recently sprung up in our country. The cesarean section rate in New Zealand is 22.1% and rising (Report on Maternity, 2002). The World Health Organisation (WHO) notes that cesarean rates above 15 percent represent a danger to women and babies.  A first time mum in New Zealand today, who births in a hospital facility, has a 50% chance of a cesarean or an operative delivery (forceps or ventouse). The effect of obstetric drugs is well documented yet they continue to be used in most hospital births (Brackbill, Rice, & Young, 1984). The World Health Organisation in 2002 stated that 80% of women should have a normal birth with no intervention. Birth is a powerful, affirming, normal physiological process. If allowed to proceed naturally, birth reinforces family bonds, empowers women and enhances their self-confidence all of which they need to effectively mother their babies (Donley, 1986). Evidence shows that home birth supported by a home birth midwife provides the best possible opportunity for women to regain responsibility for their own reproduction and to have a normal, natural birth. References Banks, M. (2000). Home birth bound: Mending the broken weave. Hamilton: Birthspirit Books Ltd. Bennett, A., Etherington, W. & Hewson, D. (1993). Childbirth Choices. Auckland: Penguin Books Ltd.  Brackbill, Y. Rice, J. & Young, D., (1984). Birth trap: The legal low-down on high-tech obstetrics. Missouri, USA: The Mosby Press. Donley, J. (1986). Save the midwife. Auckland: New Women’s Press. Goer, H. (1995 ) Obstetric myths vs research realities: A guide to the medical literature. London: Bergin & Garvey. McBurney, D.H. (1998). Research Methods (4th ed.). Pacific Grove: Brooks/Cole Publishing. Mein Smith (1986) Maternity in dispue: New Zealand 1920-1939.  Wellington: Government Printer. Report on Maternity, (2002), Ministry of Health, Wellington, New Zealand. Society for Research on Women in New Zealand (Inc). (1985). Having a baby: The experiences of some Wellington women. Wellington: Author. Ruth Hungerford (B SocSc; MocSci(Hons I); PGDipPsych(Community) is a self-employed researcher, community psychologist, and mother to two beautiful healthy girls, both born at home. She lives in Hamilton, New Zealand.     Home Birth:  A Safe Option by Sheryl Wright When you are pregnant there are three questions you are asked a lot – when is the baby due, what gender are you hoping for and where do you plan to give birth.   There is not a lot you can do about the when and what but the answer to “where” is one area where parents today have a real choice. Our culture still assumes that hospital is the best place for birth so because of this, and the many myths that surround homebirth, the majority of women don’t consider home as an option.  But each year in NZ around 7% of women choose to birth their babies at home – why?   Two of my three children were born at home and having experienced both, for me there could be no other way.   My personal belief is that birth is a natural process, not a medical procedure, and with homebirth it also becomes a family event.   The shift early this century from home birthing to hospital birthing occurred mainly for the convenience of medical staff, and while undoubtedly medical care has improved outcomes for high risk pregnancies, for healthy women with normal uncomplicated pregnancies who feel comfortable in the privacy of their own home homebirth is very real option.  My aim in writing this article is not to convince you to have a home birth.   Birth is an experience which every woman has the right to experience in a way that suits her and her families needs best, and it is not the right choice for everyone.   What I would instead like to do is provide some information so you can decide if it might also be the right choice for you. Firstly let me say I don’t fit the profile many people have of home birthers.   This is the biggest myth that surrounds homebirth – that the only people “who do that” are candle burning, new age, hippy radicals!    In fact the reality is that women of all ages, races, beliefs and economic brackets choose homebirth – and most are just average women like me!  Some of the more common reasons for choosing a homebirth are: Midwifery led care More involvement for partner, other children and family Familiar surroundings and home comforts Privacy, freedom of movement and expression Less interventions Less disruption to regular family life No uncomfortable (or embarrassing!) travel to and from hospital Not having to comply with hospital protocols  No separation from baby Drug free No risk of cross infection (remember hospitals are full of sick people!)  The biggest concern people seem to have about homebirth is that it is not safe and it’s best to be at the hospital “just in case”.   In fact the reverse is true and study after study has shown that for healthy women with uncomplicated pregnancies birth at home is as safe – if not safer!   A study published in the British Medical Journal found that Home Birth is “safe in selected women, and with adequate infrastructure and support”.  Another study published in the NZ Medical Journal (110(1040):87-9 1997 Mar 28) concluded that 'Home birth was a safe and increasingly popular, though minor, option for New Zealand women from 1973-93'.    Even the World Health Organisation reports "it has never been scientifically proven that the hospital is a safer place than home for a woman who has had an uncomplicated pregnancy to have her baby”. So with all these benefits and proof that it’s as safe why do so many people choose the hospital?   One issue is often the lack of pain-relief.  People say they are “not brave enough”.  While pharmaceutical options are limited at home there are some other very effective pain relief options such as water, birth pools, relaxation techniques, massage, heat packs, music, aromatherapy, hypnotherapy, homeopathy, herbal remedies etc to consider and in fact generally women find labour and birth less painful at home.   In a study into the pain of birth researchers compared couples planning both home and hospital births and asked them to rate the pain of childbirth, compared with other painful events. They found that "the hospital birth group rated childbirth pain significantly higher than the homebirth group".   The UK based National Birthday Trust Report into home births in the UK also found that 95% of home birth mothers said they enjoyed the birth, compared to 76% of hospital birth mothers.  In the same study, 62% of home birth mothers felt completely in control during labour, compared to 29% of hospital birth mothers; and a fortunate 14% of home birth mothers felt either no pain or very little pain, compared to 8% of hospital birth mothers. This may be due to the three factors which have been shown to hinder or obstruct the progression of labour in mammals:  the feeling of being watched, labouring in an unfamiliar environment and being moved from one place to another.   Sheila Kitzinger a UK midwife and author says, “"The right environment for birth is exactly the same as the environment in which to make love".  Another myth is that you can’t have your first baby at home.  The most likely "problem" with first births is things "taking too long".  Fortunately, that isn't an emergency.  It might mean that you end up transporting to the hospital, but it's not going to be life threatening. Birth is never without risk, whatever the location, but generally birth is a gradual process and there is usually ample time to transport.   even in the rare case of a true emergency. Midwives attending a homebirth carry a lot of equipment (often as much as small maternity units) and with experienced skilled one-on-one care potential problems are picked up long before they cause concern. In closing I always like to point out that just because you plan to birth at home you can at any time change your mind and go to the hospital but the reverse is not true!     Maybe it’s an option worth considering when next you are asked “where”.   Are all home births created equal? By Ruth Hungerford This article was originally printed in the Waikato Home Birth Association Newsmagazine, October 2003. The views expressed in this article are those of the author and do not necessarily represent those of the Waikato Home Birth Association or Home Birth Aotearoa Midwives are extraordinary women with a truly admirable and necessary role to play in guarding natural childbirth and supporting us to have our babies without unnecessary intervention. So it is with great difficulty that I sit down to write an article that is critical of the practice of some midwives. But it is an article that needs to be written. I have had two babies both born at home attended by a home birth midwife. I had births that were perfectly normal with no unnecessary interventions, no stitches and very alert, very healthy babies with high Apgar scores. Yet my labours did not fit the strict criteria for normal as advocated by some obstetric textbooks or hospital policies. If I had planned a hospital birth I would probably have wound up with an unnecessary operative delivery of some description and almost certainly would have had an unnecessary induction for my second birth. Sadly I also have to acknowledge that if I had chosen a midwife that did not have a home birth philosophy I would also have been likely to end up with less than optimal birth experiences. Let me stress some fundamentals and debunk some myths. There is a difference between a home birth midwife and a midwife who attends births at home. A home birth cannot take place in a birthing unit or a hospital that has a ‘homelike’ atmosphere. Home birth is not about décor nor is it just about having no medical pain relief. As a birthing woman and active member of my local home birth association I work hard to promote home birth and to encourage women to have home births and to have a home birth midwife. It pains me to hear stories like the following from women who planned home births but did not choose a home birth midwife. The woman whose midwife told her to push when she didn‘t feel like it, complied, exhausted herself, transferred to hospital, to find she was only 4 cm dilated, and had an epidural, an episiotomy and a forceps delivery.  The woman who started pre-labouring on a Sunday. Her midwife attended, did an internal and told her the baby was definitely on its way. She was excited and psyched for seeing her baby very soon. On the Wednesday night after three nights of pre-labouring on and off every night labour finally started in earnest and she was so overtired and exhausted she transferred to hospital on the Thursday morning, had an epidural and a forceps delivery. Her midwife told her that this all happened because her baby was “too big” - she was 10lbs. As Maggie Banks points out in her book Homebirth Bound: Mending the Broken Weave (2000), midwives are not the ones who are cutting women open or handling the forceps but they do need to recognize and acknowledge the things that they are doing in the Cascade of Intervention that set women up for birth injuries. Things like rupturing membranes, vaginal exams, telling a woman to push or even as seemingly minor as  telling a woman in pre-labour that her baby will arrive imminently can all interfere with the natural process and set her up to have further unnecessary interventions. We are all trying to be so careful not to offend anyone – midwives who do not have home birth philosophies and birthing women who choose them – that we don’t say anything.  Home birth associations are consumer organisations.  As a consumer organisation I believe we have a right and a responsibility to inform women about the differences between a home birth midwife and a midwife who attends home births and what this difference might mean for their birthing experience. And I say might mean because if you have a strong birthing woman who knows and trusts that she can birth her baby without interference she will in all likelihood just birth her baby without any hassles. Or be like another friend who just ignored her midwife during the birth because the midwife was in my friend’s words “Useless. She kept making suggestions and wanted to do (internal) exams and break my waters.  I just ignored her and got on and had my baby” I don’t know why this friend did not change her LMC – maybe she thought all midwives were the same and another midwife would have interfered just as much so she chose to ignore her rather than ‘fire’ her and get one with a different philosophy. Maybe she only found out in labour what her midwife’s philosophy was. I don’t know. But sadly that midwife probably never changed her practice because it wasn’t challenged and I hate to think what sort of births her other clients, who weren’t as stubborn or as strong as my friend, ended up with. But bottom line is that we as birthing women need to make sure we do not hand over control of our birth to the midwife or anyone else – birthing our babies is our responsibility – the midwife’s role is to support us, guard the natural process and be available if there are situations requiring necessary intervention (medical and midwifery interventions). So what are the solutions here? We as birthing women need to inform ourselves. We need to read books like Immaculate Deception by Suzanne Arms and Homebirth Bound: Mending the Broken Weave. We need to ask our midwives about their practice. We need to take responsibility for our births, which may mean, for example, that we change our LMC if we feel that their philosophy about birth is not in line with our own. We need to determine early on what our midwife’s birth philosophy is. We need to support the home birth midwives that are in our community so that they can practice. We need to be vocal about the importance of midwives with a home birth philosophy in the practice of home birth. We need to get involved with the midwifery review process and tell our midwives our concerns. We need to stand up and say these things and not be afraid of offending anyone. Birth and home birth is too important to us, to our babies and to our futures to let it be medicalised. We need to hold on to it, to protect it and to guard it and we need strong birthing women and strong home birth midwives to do this. Ruth Hungerford (MocSci(Hons I); PGDipPsyc(Comm) is a self-employed researcher and evaluator, a community psychologist, and mother to two beautiful healthy home birthed girls. She lives in Hamilton, New Zealand.       Lets celebrate the Homebirth Midwife by Andrea Herrick When we have our babies at home, we don’t just settle for any old midwife, we turn to the best of them all; the home birth midwife. Home birth midwives are a rare and special breed, related too yet different from the standard. In addition to the skills of the basic midwife, the homebirth midwife has evolved in such a way as to develop a new range of behaviours perfectly suited to the home and family environment. Homebirth midwives are fully housetrained and able to be welcomed into any home regardless of its size and condition. This removes the need for pregnant women to travel to far flung places and visits become social occasions sometimes complete with tea and baking. As homebirth midwives are also child friendly, you can be assured that any older children in your family will be quite safe and free to share your special time with you. The homebirth midwife has excellent flexibility and is able to adapt with ease   to any wish, whim, need, aversion, fancy, desire or obsession that arises before, during and after birth. No conveyor belt birthing here! Be it water birth, lotus birth, homeopathy, aromatherapy, massage, scan, no scan, cord clamp, cord ties, silence, singing, moaning or mooing, the homebirth midwife’s aim is to fit into your family, and support you to have the birth you want. Birth only happens a few times in our lives. When we choose to birth at home with our family and friends we need midwives who are confident in our ability to give birth and in their ability to give us the support we need. In the jungle of life there are many midwives, but only a few Homebirth Midwives. Midwives day is the perfect time for us to show our gratitude to those women who support and celebrate our choice to birth at home.

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