There appears to be an increase in home births in the past 10 years. National data is unavaila-ble, but home birth advocates, and even obstetricians, concur that the number is increasing.
Local childbirth websites list numerous home birth stories. Home birth classes, some of which cost RM1,000 or more, are full or filling up fast.
There has been a marked reduction of maternal mortality in the last five decades. This has been attributed to socio-economic development, access to better quality health services, and specific initiatives, particularly the marked increase in hospital births.
The Confidential Enquiry into Maternal Deaths reported 28 maternal deaths from home births in 2009-2011, compared to 23 in 2006-2008. There have been recent media reports of mothers who died during or following home births.
Pros of home birth
Advocates of home births often quote data from studies in Holland, Canada, United Kingdom and the United States, which all report similar outcomes for low-risk women. Home births in these studies report high vaginal delivery rates with caesarean rates of less than 10%, low morbidity, reduced healthcare costs, and low intrapartum and neonatal death rates.
However, they also report higher intrapartum mortality for higher-risk women.
Home births are associated with high rates of breastfeeding, normal vaginal births and patient satisfaction.
Gross data from Holland on the safety of home births is always quoted by advocates.
However, what is often not stated is the patient selection; the collaborative relationships between midwives and doctors, in particular, the integration of home birth midwives into the healthcare system; and the transfer criteria to hospitals.
Another issue that is often quoted by home birth advocates is the intervention rates in hospital births, particularly caesarean sections of about 25-30% of women in labour.
Audit reports that some of these caesareans are medically unnecessary. The morbidity of caesareans is substantial and affects current and subsequent pregnancies.
Needless to say, the cost of hospital birth is substantially more than home birth.
Cons of home birth
There are various patient safety measures in hospital births, which include safety checklists; protocols; operative vaginal delivery and caesarean section; medical equipment; trained midwives and specialists (obstetricians, paediatricians, anaesthetists etc); and teamwork and audits.
These measures, which are absent in home births, have led to preventable adverse outcomes for mothers and babies.
Obstetric emergencies cannot be adequately addressed in home births. The transport to a hospital for the management of these emergencies is almost always delayed.
Obstetric problems may be maternal and/or foetal. Maternal problems include raised blood pressure, which can occur without warning and requires immediate treatment to prevent adverse maternal and foetal outcomes.
The medicines for its treatment cannot be appropriately administered in home births as it requires intensive monitoring of mother and foetus.
Bleeding – which is a potential nightmare in hospital births, let alone in home births – comprises 50% of the causes of maternal mortality in home births.
Foetal problems, which include heart rate abnormalities and cord problems, cannot be adequately addressed in home births.
Delivery problems like shoulder dystocia, in which the shoulder gets stuck in the mother’s body after delivery of the foetal head, often occur without warning and require a team effort to deliver the baby and resuscitate the newborn. This is unavailable in home births.
Timely caesarean section, an intervention that is almost always maligned by some home birth advocates, saves maternal and foetal lives daily. This is unavailable in home births.
Obstetric conditions like previous caesarean section(s), breech presentations and twin pregnancies have potential adverse outcomes. These conditions and maternal complications after delivery, like bleeding, may require equipment, anaesthesia, access to blood and/or its products, and specialists, all of which are unavailable in home births.
Complications in the newborn, which include breathing problems, can occur unexpectedly and may require immediate resuscitation and other life-saving measures, usually by paediatricians. This is unavailable in home births.
The most dangerous journey anyone takes in life is at the time of being born, when a foetus becomes a baby.
Every woman has a right to deliver in a setting of her choice, regardless of the potential risk to the foetus. The safety of home births, even in low-risk pregnancies, is still debated and is an emotionally-charged issue.
Home birth advocates claim that planned home birth is safe because of its selection of low-risk pregnancies. However, there is no such thing as no-risk or low-risk pregnancies or labour because risk(s) may develop at any time. A low-risk pregnancy or labour can become a high-risk one in a very short time.
There is no second chance in the management of maternal and/or foetal problems, especially in labour. It has to be appropriate the first time; otherwise, the consequences may be potentially disastrous for mother and/or baby.
Data from Holland has shown that home births can be safe. To achieve the same level of safety as in Holland, certain factors must be in place – stringent patient selection; strong collaboration between midwives and doctors; stringent transfer criteria; and efficient ambulance services.
There is no evidence that all these factors are in place in Malaysia. Until then, it would be sheer bravado to advocate or support home births, particularly unassisted ones, in our local setting.
Although the debate about home births has been dominated by risks and danger, it might be more productive if measures are taken to improve access to high quality obstetric care, also taking into account patient satisfaction, for all women across all settings.
It is advisable for those pregnant to discuss labour with the attending doctor, including issues like user-friendly hospital births and safety. Those who are insistent on home birth need to remember that whilst the birth experience is important, a safe journey when a foetus becomes a baby is not less, but even more important.
Any journey can only be described as safe at its end, and not at the beginning or middle of the journey.
Dr Milton Lum is a previous member of the International Federation of Gynaecology and Obstetrics executive board and a past president of the Obstetrical and Gynaecological Society of Malaysia. The views expressed do not represent that of any organisation the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.