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Professional perspectives on planned home births

By Mary Dahl Maher, PhD, MPH, RN, CNM, and Elizabeth Heavey, PhD, RN, CNM

www.Nursing2014.com

THE ANTICIPATED BIRTH of a new baby is an exciting time for prospective parents. Although most U.S. births take place in a hospital or free-standing birthing center, a growing number of women consider a planned home birth to be a more personal experience for themselves, their babies, and their families.1,2 This article explores professional organizations’ position statements about planned home births, discusses how to help women make an informed choice, and provides guidelines to improve patient safety. According to the National Center for Health Statistics, U.S. home births increased sharply by 29% from 2004 to 2009 and continue to rise. These rates are highest among women living in the Northwest and lowest in the Southeast. Planned homebirths are more common among women age 35 and older and among women with several previous children. The most recent report includes the final data for 2012, indicating the number of births occurring at home was 35,184. This is the highest number of homebirths recorded since reporting began in 1989.

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Nevertheless, home births are still rare in the United States, comprising less than 1% of annual births.1,2 Professional organizations weigh in The decision for a home birth isn’t generally supported by maternalchild medical professional organizations such as the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) that have issued position statements on home births. In contrast to the positions of ACOG and AAP, the Association for Women’s Health, Obstetric and Neonatal Nurses supports a woman’s right to choose and have access to a full range of providers and settings for pregnancy, birth, and women’s healthcare. The Midwives Alliance of North America has compiled a database of 16,924 planned home births, which was recently analyzed in a study supporting the safety of this choice.3,4 The various position statements on home births have generated much discussion and controversy. In many cases, critics have failed to differentiate between planned and unplanned home births or to consider the professional qualifications, or lack thereof, of those attending home births. Such omissions significantly impact conclusions drawn about the available perinatal outcomes data. Considering worldviews Many healthcare professionals in the United States consider planned

home birth unsafe and irresponsible. However, infant mortality is much lower in the European Union, where planned deliveries at home are accepted, frequently encouraged, and covered by health insurance. In fact, in the Netherlands, women must pay a fee of about $340 if they choose a nonindicated hospital birth under the guidance of an obstetrician.5 Nevertheless, the perception in the United States persists that home birth, no matter how well planned, is an unsafe childbirth practice. This thinking impacts the educational information provided by healthcare professionals as well as our subsequent interactions with both our patients who chose to deliver their babies in a home environment and the professionals who provide care in this environment: a certified nurse midwife, a certified professional midwife, or a physician.6 These professionals should practice within an integrated and regulated health system with ready access to consultation and the assurance of safe and timely transport to a nearby hospital.6 When women and their families are considering where to give birth, they often look to friends and family, as well as to professionals, for input and advice. Some women may feel safer in the high-tech atmosphere of a hospital while others prefer the comfort of their own home. Because one of nursing’s foundational skills is assessment, we’re in a unique position to help women make safe decisions. As always, we must consider the lens through which we make assessments and not let personal

Screening criteria for a planned home birth9 According to the AAP, a planned home birth should first involve appropriate screening criteria, including: • the absence of maternal disease before and during the pregnancy • a single fetus with a gestational age of 37 to less than 41 weeks • a cephalic presentation • spontaneous labor (or labor induced in an outpatient setting) • a mother who’s not referred from another hospital.

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biases and fears interfere with evidencebased counsel. A nurse’s worldview, which is shaped by many factors, will influence the assessment process. Perhaps foremost among these factors are values and mores that we learned within the context of our own family life and from our friends. As we mature, other influences shape our attitudes and beliefs. These include our education and socioeconomic status, as well as our religious or spiritual beliefs and political views. All such cultural factors impact not only healthcare providers but also patients as they choose a provider and a location for birth. Providing informed consent First, the patient would be screened to make sure she’s an appropriate candidate for a home birth. (See Screening criteria for a planned home birth.) In addition to a thorough health history and physical exam, an assessment should include a discussion of cultural origins, communication, values, environment, social supports, religion, diet, and health beliefs. Nurses know informed consent is essential for any healthcare intervention. Informed consent involves the provision of accurate information to the patient regarding the intervention, who will participate, and the alternatives. The patient should have more than one choice and not be compelled to choose any particular one. The patient’s permission should be given or withheld based on a clear understanding of the risks and benefits involved in this choice and the alternatives.7 According to the American College of Nurse Midwives, informed choice regarding home birth must include an assessment of maternal/fetal health, a delineation of potential risks and benefits of each available birth site, and an evaluation of transport mechanisms if conditions develop that require personnel or equipment www.Nursing2014.com

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available only in the hospital setting.8 The best outcomes for both mothers and their babies born at home are achieved after appropriate patient screening and selection, including the attendance of a qualified maternity care provider and a system that supports appropriate care if a change of site is needed.8 Providers have the responsibility for ensuring that the tenets of informed consent are in place and patients aren’t coerced or misled into making choices that aren’t autonomous and fully informed. In 2013, the ACOG Committee on Planned Home Births reaffirmed its previous statement that hospitals and birthing centers are the safest settings for birth. However, the Committee also states its respect for a woman’s right to make a medically informed decision about home birth. The Committee recommends that women who inquire about planned home births be informed about risks and benefits based on evidence while acknowledging that high-quality evidence to inform this decision is limited. The Committee emphasizes the importance of the professional preparation of the care provider. The position of the AAP also includes the goal of providing information and counseling to women considering a planned home birth, a choice that isn’t well supported in this country as the AAP notes. The AAP reinforces the need to ensure the same standard of care for infants born at home and those born in a hospital or birth center. The AAP further includes provisions that help ensure optimal outcomes for a planned home birth. These include the attendance of a certified nurse midwife, certified professional midwife, or physician who has an agreement with a nearby hospital and the ability to provide safely and timely transport there. In addition, the attendance of at least one appropriately trained individual whose primary responsibility is the care and safety of the newborn infant must be a priority.9 www.Nursing2014.com

as the Maternity Center Association. Its mission is to improve the quality and value of maternity care through consumer engagement and health system transformation. Regardless of the chosen place of childbirth, the best outcomes are achieved when healthcare professionals work together with mutual respect for each other and their patients. ■ REFERENCES 1. MacDorman MF, Mathews TJ, Declercq E. Home births in the United States, 1990-2009. NCHS Data Brief. 2012;(84):1-8. http://www.cdc.gov/nchs/data/ databriefs/db84.htm. 2. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Wilson EC, Mathews TJ. Births: final data for 2010. Natl Vital Stat Rep. 2012;61(1):1-72. http:// www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_09.pdf.

Nurses are in a unique position to help women make safe decisions about where to give birth. The same care should be provided to all infants regardless of whether they’re born at home or in a hospital setting. For example, infants born at home should receive routine screening and be administered ocular prophylaxis, parenteral vitamin K, and hepatitis B vaccine following the same protocol as infants born in the hospital.9 Improving safety All three professional organizations recognize that the greatest safety is provided with continued effort among involved healthcare providers and institutions to ensure good communication, collaboration, and the safe transfer of care from home to hospital when needed.6,8,9 One of the most accessible sources of information for women and healthcare professionals is Childbirth Connection (http://www.childbirth connection.org), a national not-forprofit organization founded in 1918

3. Association of Women’s Health, Obstetric and Neonatal Nurses. Position Statement: Midwifery. JOGNN. 2010;39(6):735. 4. Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014;59(1):17-27. 5. Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol. 2013;208(1):31-38. 6. American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. Planned Home Birth. 2011; reaffirmed 2013. https:// www.acog.org/Resources_And_Publications/ Committee_Opinions/Committee_on_Obstetric_ Practice/Planned_Home_Birth. 7. American College of Obstetricians and Gynecologists, Committee on Ethics. Informed Consent. 2009; reaffirmed 2012. http://www.acog. org/Resources-And-Publications/CommitteeOpinions/Committee-on-Ethics/Informed-Consent. 8. American College of Nurse-Midwives. Home Birth (Position Statement). 2005; revised and reviewed, 2011. http://www.midwife.org/ACNM/ files/ACNMLibraryData/UPLOADFILENAME/ 000000000251/Home%20Birth%20Aug%20 2011.pdf. 9. American Academy of Pediatrics. AAP issues guidelines for care of infants in planned home births. 2013. http://www.aap.org/en-us/about-theaap/aap-press-room/Pages/AAP-Issues-GuidelinesFor-Care-of-Infants-in-Planned-Home-Births.aspx. Mary Dahl Maher is an assistant professor of nursing at Nazareth College in Rochester, N.Y., and Elizabeth Heavey is an associate professor of nursing at The College at Brockport, State University of New York, in Brockport, N.Y. Both authors are certified nurse midwives. Dr. Heavey is also a member of the Nursing2014 editorial board. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000452998.41535.4c

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