You’re fielding questions about home birth from clients who hadn’t considered it until now. Here are some considerations…

 

Lots of families are afraid.  They don’t want to go to the hospital.  They’re asking about home birth.  How should you respond?   In this 2 part blog series, we look at implications for maternity care delivery methods, possibilities for these extraordinary times, and tools for supporting clients through fear and uncertainty, as well as informed-decision-making.

Home Birth Prevalence & Safety

Approximately 1% of all births in the U.S. take place in birth centers or at home.  In the UK, the rate of out of hospital births is 8% and in the Netherlands, 29%.  For low risk, healthy persons who choose trained birth attendants, home birth provides an empowering and calm alternative.  With the right conditions, home birth is safe, with fewer unnecessary interventions.

Home birth safety relies on:

• Low risk candidates who fit the criteria for home birth
• Attendance by a trained midwife or physician experienced in out of hospital birth
• Access to a nearby medical facility
• A plan for transfer of care in the event of complications
• A means to transfer if necessary (transportation, weather conditions, etc. )

Additional Considerations in the time of COVID-19

• In the screening for risk, consider coronavirus exposure and the possibility of asymptomatic presentations.
• Consider the impact of illness and Exclude from Duty in small practices with 1-3 midwives or physicians.
• Consider delays in admissions if hospitals are overextended.

Making Referrals to Qualified Providers & Exploring Collaborative Management

As families face the unfamiliar territory of this pandemic, you may have experienced more client questions about homebirth options.  For many reasons, it’s not as simple as making a referral.

Not all communities will have adequate resources and trained providers. Many providers had a full schedule before coronavirus hit.  Some groups may be facing illness within their organization and may be working with reduced caseloads.

So before shifting into a vision for avoiding the hospital and birthing at home, exploring the availability of providers is a good first step.

In this time of COVID-19, these questions bear more importance than ever.  The least safe option would be for a transport to end up in an overrun emergency department.  Unattended births or births attended by untrained or inexperienced providers, even in extraordinary times, is an extraordinarily unwise direction.

As you face the questions of “this” or “that” option, what if we envisioned new possibilities that could build on cooperation among providers?

Visioning the Possibility of Collaboration & Cooperation

As someone who has a mission to support both the providers of health care and the consumers of health care, the view I take is centered on the relationship and the possibilities of collaboration.  I’m not a systems person, I focus on relationships, and supporting us to care for one another and to collaborate with greater awareness.  Our mission is to enhance compassion, respect, safety, and equity, all qualities that are especially potent now.  And filling gaps in healthcare using psycho-social and non-medical supports, as well as the home-based care model, has been my focus for the last 25 years.  So here are my perspectives.

These times call for a compassionate response to both providers, who find themselves facing unimaginable risk and challenges, trauma exposures, and reduced staffing, and the consumers, who are experiencing a great vulnerability, profound stress, and trauma.

In the spirit of collaboration and emergency planning, I see a pool of health workers, home visitors, community health workers, midwives, doulas, and lactation consultants who can bridge the needs of both.  Here is a possible vision.

Construct collaborations for telehealth. 

Using home visitors to take blood pressures, fundal measurements, palpation and fetal heart checks could supplement telehealth options.

Reduce time in the hospital /clinic and consider early discharge.

Labor support at home with doulas or monitrices could reduce the prolonged hospital durations associated with prodromal or stalled labors.  The emotional and physical support provided by these attendants are associated with reduced complications and shorter labors overall.   Even when these providers don’t follow their clients into the tertiary care center, which I agree is a trade-off that is necessary in these times, they can still provide benefit and continuity through virtual support.

Early discharge for low-risk, uncomplicated deliveries can be an effective and safe solution. Yes, there were problems with 24 hour discharge models, from decades past, but with support at home, these risks can be mitigated. Lactation consultants and postpartum doulas, and as needed  and available, nurses, can provide early postpartum help at home, reducing the duration of the hospital stay and also minimizing the risk of HAI (Hospital Acquired Infections).  Baby weight checks can be performed at home.  The psychosocial support and emotional connection of the postpartum doula serves as a stress-buffer, and another safety net for those who may fall through the cracks with suboptimal feeding or unrecognized postpartum complications.  While non-medical, providers in our First Year Specialist program receive training in identifying red flags that warrant further attention from medical providers.  Also, and importantly, early planning can mitigate the mental health crisis ahead of us.

Consider Parallel Care.

Providers may be willing to provide what has been referred to as parallel care, where the prenatal visiting occurs with the hospital provider at the same time it is provided by a home birth provider.  If all goes well, the midwife or homebirth physician assumes care and followup.  If complications develop that preclude an out of hospital birth, or if complications arise in labor, the physician or midwife with hospital privileges can assume care instead.  This arrangement is one that tends to be exceptional, but perhaps, in these exceptional times when medical centers will be stretched thin, and managing increasingly complex cases, this option may be worthy of exploration.

 

Perhaps this environment can lead to an improved dialogue for Obstetricians who have held resistance to homebirth providers, and home birth providers who can demonstrate the potential for a model that is seen as an effective part of maternity care around the world.

I feel that this is an opportunity to build respect and appreciation.   This is where I hope we’ll continue to uphold the standards that make out of hospital birth a viable and safe alternative for communities throughout the country.

Mitigating spread and protecting health workers & consumers

Among the risks for persons giving birth now is not just the rare possibility of obstetric emergencies, but the risks of an asymptomatic COVID-19 infection that escalates with labor.  In 2 of 7 cases in a report from a New York Hospital,  the patient was well upon admission but developed severe symptoms requiring ICU care.  In 2 of the 9 cases originally reported from China, the presence of an elevated temperature, and in 1, a sore throat, were the only symptoms on admission.  (Chen, 2020)

The takeaways:

•  Every obstetric patient should be treated as potentially infected. (Breslin, et. al. 2020)
• When we consider that all birthing persons could be infected, the providers need the skill to recognize unusual symptoms and act accordingly (for instance, not ruling out COVID-19 in the presence of a low grade fever that occurs in labor).
• Providers need to be aware of their own exposures and use, with respect for and priority for front-line workers, of PPE.
• The number of persons in contact with each patient could be reduced if home-based care was implemented, or time in hospital reduced. (Breslin, 2020) estimated that between just these 2 patients in the New York tertiary center, up to 35 staff members had direct exposure.
• 8% of the infected population in Italy are health care professionals who were exposed through their care of patients. In Spain, this rate has been estimated to be 14%.  (New York Times).

Perhaps unfairly, I describe situations that may not reasonably be available, ones that may have troublesome tradeoffs, and imperfect conditions.  In these pandemic conditions, it’s par for the course.

But  those with babies on the way, want answers.

We can try to explore possibilities based on care effectiveness, on safety and availability.  But the conversations that could be most valuable relate to listening mindfully and creating the opportunity to explore fears, to build confidence, and to cultivate fearlessness.

In our next blog, we’ll discuss the importance of skillful listening, trauma-informed approaches, and informed decision-making, as well as addressing our own bias and perspectives when we discuss birth options.

It’s an imperfect world.  Let’s make it a little better together.

 

Are you a health care provider or administrator who is interested in a Community Conversation about your needs and the supports that would most help you in providing care?  Are you using innovations in your facility to address these needs?  We want to help you find the resources that you need in your departments. Send us an email at info@wisdomwayinstitute.com with your thoughts and ideas and we’ll keep you posted on an online panel discussion.

References:

Breslin N, Baptiste C, Miller R, Fuchs K,  Goffman D,  Gyamfi-Bannerman C, D’Alton M. (2020). COVID-19 in pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM, 100111,ISSN 2589-9333,https://doi.org/10.1016/j.ajogmf.2020.100111.

(http://www.sciencedirect.com/science/article/pii/S2589933320300410)

Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Development and Validation of a National Data Registry for Midwife‐Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset. (2014). J Midwifery Womens Health,  59(1):8–16.

Dunkel Schetter C, Tanner L. (2012). Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr Opin Psychiatry, 25(2):141–148. doi:10.1097/YCO.0b013e3283503680

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician [published correction appears in CMAJ, Oct 27;181(9):617]. CMAJ. 2009;181(6-7):377–383. doi:10.1503/cmaj.081869

Johnson KC, Daviss BA. (2005) Outcomes of planned home births with certified professional midwives: Large prospective study in North America. BMJ, ;330(7505):1416‐1422.

‘I Felt Like Crying’: Coronavirus Shakes China’s Expecting Mothers , by Alexandra Stevenson. New York Times . Updated Feb. 28, 2020

Pregnant and Worried About Coronavirus: Experts Weigh In. By Christina Caron. New York Times. Updated March 19, 2020. https://www.nytimes.com/2020/03/17/parenting/coronavirus-pregnancy-questions.html.