Growing Homebirth.

By Tammi Heap
Mar 2015

We as humans trust in the physiological miracle of the baby – from conception, through to the perfect form of a newborn baby.  The perfect synchrony of nature, of our cells, and our hormones in our bodies, creating this most amazing life.  We marvel in the splendour of pregnancy.

Our bodies, throughout time, have grown babies, often with little or no help from external agents.  The same continues to apply to labour, birthing women all around the world have born their babies. The event of birth is left to our birthing bodies and the natural processes it has so perfectly developed.  Homebirth supports this continued trust that babies from conception, to birth and beyond can birth just as naturally, through the very hormones and bodily functions, that it was conceived and grown by. Where outside help is only when there is genuine need is evident.

“Giving birth at home is a safe and satisfying choice for families who want the best possible start for themselves and their babies.” Sarah Buckley

In homebirth, we celebrate and embrace the understanding of the difference between a “normal” birth and a natural birth. It is a very different concept, and, in turn requires a different relationship in the role of true normal natural birth.

So why am I writing this?  In New Zealand We as homebirth midwives, understand this, and many homebirthing families understand this. Partnerships between midwives and homebirth women, is about giving a realistic and positive service that doesn’t promise unrealistic expectations. This relationship trusts in the body’s ability to birth, through shared information and education, and it promotes true responsibility intaking care of oneself and protecting the growing baby’s health. This can be undertaken by prioritising nourishing food and taking ownership for lifestyle choices that relate to maternal health.

Homebirth is continuing to grow in New Zealand, but our midwifery population, and in particular, homebirth midwives are not.  Many areas still currently are experiencing shortages of midwives.  For women wanting homebirths, the availability of the care that matches our needs is key to having true choice in place and in manner of birth. In some areas, shortage of homebirth midwives and long travelling distances leaves options short, and this puts pressure on the midwives as well.  Finding a midwife that we fully connect with and develop a healthy relationship with is core to homebirth. Homebirthing families want to know that their care provider fully supports their maternity experience plan, all the way from booking to discharge.

When I started out as a student myself, I knew that I wanted to become a homebirth midwife.  Yes, I loved the niceties of homebirth, fabulous emotional experience for families, babies and their midwives. However, being quite the analytical person, I am (I have a love of facts) my thoughts during training followed a particular path. “So why does homebirth result in fewer c-sections, neonatal birth injuries, deaths and interventions than hospital births? And what practices in homebirth, are resulting in this lowered morbidity and trauma?

The vast majority of women who have had both a hospital and homebirth, state that their preference is for homebirth, with their homebirth experience described as far superior and their best birth.  By attending, and being involved in home births, student midwives gain a greater understanding of normal natural birth, on a far more in-depth and intimate level. These understandings come both at a physiological and emotional level, for some it is even spiritual.  Many of the homebirth studies conducted, describe shorter lengths of labours, and pain experience, within a homebirth setting.

“The lack of disturbance associated with giving birth at home allows the full expression of the labouring woman’s “ecstatic hormones”. These four critical hormones — oxytocin, beta-endorphin, epinephrine/norepinephrine and prolactin — act to enhance ease, pleasure and safety for mother and baby in labour and birth, and also give mothers and newborn an optimal start to breastfeeding and bonding. Successful breastfeeding (which is more likely after homebirth), and mother-infant attachment give irreplaceable and life-long health advantages to both mother and baby”. Sarah Buckley, Giving Birth at Home

Honouring the hormonal and physiological processes as they occur in birth results in shorter, less painful labours.  Homebirth is a place where natural events such as the fetal ejection reflex can occur, thus resulting in short second stages of labour often less than 30mins (including first time labours) which in turn reduces incidences of large perineal traumas, prolonged second stages, fetal distress (from prolonged second stage), less risk of postpartumhaemorrhage, and hospital transfers.   When students attend homebirths, they experience true normal natural birth, and they gain an acute awareness of what normal birth looks like. This means that deviations of normal become very easy to assess, and act on or refer care as needed. Birth becomes responsive instead of reactive, or worse, pre-emptive.

So, what is the fetal ejection Reflex?

A genuine fetal ejection reflex can occur sometime before the descent of the presenting part or after, including at times before a woman has reached complete dilation.

The fetal ejection reflex is triggered by a hormonal cocktail including a short burst of adrenaline and morphine like endorphins.  High peak levels of the hormone oxytocin are released, causing the power and efficiency of the uterine contractions to become unconsciously expulsive. This removes the need for forced or ‘purple’ pushing. At the same time, the women may often feel euphoric or ecstatic.  The efficiency of the contractions results in a shortened second stage of labour, with many women pushing babies out within a few pushes.  The oxytocin peak also helps to create the bonding response and primal love protection bond between mother and baby.

“Oxytocin is crucial to our natural capacity to give birth”. Michel Odent describes the natural hormone (our”inner pharmacy”) oxytocin as “liquid peace”.  However, the opposite effect is reported with the synthetic version of Oxytocin.  When synthetic syntocinon, epidurals and C-sections are performed, there is no oxytocin release in the mother’s brain, with causes a significant interference in many of the immediate, and long term aspects of both the birth itself and the postnatal period.

The fetal ejection reflex can be inhibited by any interference with the state of privacy. It does not occur if there are factors such as a care provider instructing the women PUSH (or otherwise acting like a coach), labouring in a room that is too cold or bright, vaginal examinations, uncomfortable relationships, eye-to-eye contact, and change of environment to name a few.  “The role of the authentic midwife is to create and protect an environment that makes the ejection reflex possible”. Michel Odent

The Ferguson reflex, is related to oxytocin release and is managed by the pressure of the presenting part (usually the baby’s head) on the perineal muscles, causing the mother to bring baby forwards by pushing involuntarily.  This is an essential part of the fetal ejection reflex and is commonly seen in many homebirths.  Sadly, this event is rare in hospital birth environments, due to directed pushing practices, and other inhibitive factors, thus putting the mother and baby at risk of interventions related to prolonged and managed second stages.

With the knowledge of the world health organization stating the international accepted average for c-sections should only be between 10-15%, (which indicates that for the majority of women, vaginal birth is fully achievable) I was quite aghast that many regions in New Zealand have a comparable c-section rate of America, at 30% and over. Comparatively, recent studies on home births, show a primary C-section rate of around five percent.

C-sections carry significantly increased risk in current and subsequent pregnancies and can result in elevated maternal mortality, amniotic fluid embolism and placental abnormalities for the mother, including placenta accretia which is life threatening. For babies, risks include neonatal laceration and respiratory morbidity. The rise in C-sections has not been associated with improved outcomes for mothers or babies, suggesting that many are unnecessary. (WWW.VBACfacts.com)

Often the most common cause of a primary c-section is for fetal distress due to a prolonged second stage.  In my own midwifery training, the majority of births I observed within the hospitalsetting, had births that ended up as emergency c-sections for fetal distress. Long duration of exposure of synthetic oxytocin (used for augmentation, or in inductions) epidurals and other pain medications can result in fetal distress and are common risk factors for c-section. Following a primary c-section, many women are guided to consecutive elective c-sections. Which simply increases the risks with each c-section.

In the hospital environment, the harsh fluorescent lights (only dimmable to a point), unfamiliar hospital chemical smells, loud noises, unfamiliar staff and other factors all inhibit the body’s natural flow of normal labour hormones.  The more disturbance there is, the higher the risk is for prolonged labours, intervention cascades, fetal distress, and haemorrhage.  In hospitals, labours are “managed”, and babies are “delivered” by hands not of the mother or close family member.  Certain interventions are used in the hospital environment to speed labour for convenience, however these interventions often come with many possible risks and side effects.  The evidence to support interventions is limited, with most studies concluding that they often have little positive effect, which is balanced against a higher risk to mother and baby.

Evidence based research, does not support the use of directed pushing, yet from many hospital rooms you can often hear someone bellowing “bear down, PUUSSSHH, harder, hold your breath for 10seconds and push as hard as you can”.  Directed pushing can actually cause many adverse side effects such as exhaustion in the woman, fetal distress in the baby (from reduced oxygen), and damage to the perineal floor with extensive tears & haemorrhage. Directed pushing often leads to a diagnosis of prolonged second stage, or failure to progress, due to the women being directed to commence pushing at 10 centimetres dilation, regardless of whether the baby has descended well into the birth canal or not, and often in the absence of the urge to push.

With homebirth the third stage of labour occurs without intervention, facilitated by a natural hormonal flow that quickly and actively expels the placenta. With well, low risk women who labour without incident, the risk of haemorrhage is low.  Furthermore, in the experience of homebirths, blood loss will for the majority of women, be even lower, than in a hospital setting.  This again is due to the birthing setting, of birthing unhindered, and reducing unfamiliar stimuli, which in turn keeps the hormone flow in an optimum balance and allows the normal physiological processes to safely expel the placenta and contract the uterus.

Homebirth midwives practice to help students with their confidence and skills so that they can pass these on to the next generation. The ability to help and support normal labour and birth is not a midwifery “extra” it is the fundamental core of midwifery.

It is the New Zealand’s Midwifery Council’s expectation, that a practising midwife will be competent to provide midwifery care in any setting. This also includes women having their babies at home are supported to achieve this by a midwife who is able to practise within the home environment”. (Midwifery council of New Zealand)

Homebirth is the best place for a student midwife to fully learn, observe, and correlate how hormones impact labour positively, particularly in keeping the birthing mother and baby safe.  In the hospital environment, students will experience how birth looks in a managed setting, this is not normal birth.  By observing how birth occurs in a non-managed setting, they will gain confidence in dealing with healthy, normal women. Which will in turn reaffirm the normality of home birth.  By ensuring midwifery students have homebirth experiences during their study, we will foster the student midwife to gain a deeper understanding of how woman centric birth occurs. She will bring this knowledge to other birthing women and even into the hospital space where she can foster a respectful and responsive care style.

Current midwifery training in New Zealand requires students to facilitate 40 births and be part of many others. There is no requirement to attend a specified number of homebirths, but it is recommended.

It is the aim of the training institutions for students to be able to have experiences across the diversity of care that is midwifery, and that includes student midwives having adequate exposure to and experience of home birth and birthing units, which is supported by evidence and theory.

Over the course of their training, students must have facilitated

100 antenatal assessments

100 postnatal assessments of the women

100 postnatal assessments of babies

Follow through at least 25 women of more than two appointments

Facilitated a minimum of 40 normal vaginal births

Achieve a minimum of 2400 practice hours, and 1900 theory hours.

Unfortunately, here in New Zealand many student midwives state that, while being within a few months of qualifying, they accumulated their experience hours in obstetric hospital based units for the majority of their births. Many have yet to experience a homebirth or even a primary birthing unit birth before they graduate.  This creates an unbalanced view of what birth looks like. Bridie Foster of Otago polytechnic states she would love to have more homebirth families welcome student midwives to experience their journey.

Regular meetings for the midwives to meet new midwifery students are planned for the near future, as well as an initiative in encouraging students to join local homebirth groups and attend homebirth huis. Welcoming student midwives to these events to witness our kaupapa and meet our families is vital to carrying on the home birth story.

As homebirthing women, we love the quiet of an undisturbed birth.  Homebirth is an area where students are less often invited, by both midwives and homebirthing families, this is to protect the undisturbed and unobserved birth space. But are we keeping students out at the expense of other home birth families?  As a midwife and homebirthing women myself (having had two homebirths) I enjoy the quiet and share the apprehension at bringing additional unfamiliar people into the birth space. But a relationship developed with a student prior to a birth can be just as magical as with your primary midwife.

For us as homebirthing women to have choices in homebirth, we also need to nurture our future midwives by inviting more students to becoming involved in our pregnancies and birthing experiences.  The future educational base of the profession depends on the existence of home births,

The homebirth student midwife

Reyna 3rd year student.

I have recently started my 3rd year Continuity placement with a lovely homebirth midwife. I have always had a passion for homebirth from an early age, as it was the norm in Mexico, where I was born. A woman only went to hospital to birth if something was medically wrong. Growing up in Mexico, birth was mainly considered a natural event at home, with family celebrating the new arrivals. My uncle was a gynaecologist who while working at the hospital during the day, often delivered babies at night in his home.

On moving over here to New Zealand, I was quite surprised that homebirth rates were very low, despite the average New Zealand woman being very healthy and capable in general. Indeed, when I became pregnant with my first, my thoughts were to birth at the hospital because that felt ‘the safest to do over here’. Then with my second, since the first had been completely normal, it made sense to have a homebirth.

As a student, I personally feel homebirths are the ‘normal vaginal births’ that students don’t really get to participate in very often. Obviously, there are exceptions, but I feel it would be great to have more of our facilitated births in the home, so that homebirths can become the norm.

References:

Leaving Well Alone: A Natural Approach to the Third Stage of labour. Dr Sarah J. Buckley 2005

http://sarahbuckley.com/leaving-well-alone-a-natural-approach-to-the-third-stage-of-labour

http://transform.childbirthconnection.org/reports/physiology/

http://www.homebirthsummit.org/best-practice-transfer-guidelines

http://ww.mothering.com/articles/women-are-losing-the-capacity-to-give-birth/#sthash.rxntYPMi.dpuf October 27, 2012