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For me, homebirth represented something huge and unknown which I was eager to experience. My own personal birth experiences and those of friends and family have been within the `safety' of hospital. During my community placement I worked with two experienced midwives who supported women's choice and saw homebirth as a realistic option. As well as meeting several women who had experienced birth at home, I was lucky in witnessing two homebirths. Both left a deep impression and affected my views, not only of homebirth, but the process of giving birth itself.
As Eileen and I arrived, Alice was contracting strongly,1:3. Eileen quietly unpacked her bag, checked Alice's blood pressure, palpated and performed a vaginal examination to assess progress. Alice was fully dilated. Practical preparations for the birth were made, Alice adopted a squatting position with her husband John sitting, supporting her from behind. The membranes ruptured spontaneously during the second stage. While I recorded fetal heart rate intermittently using a sonicaid, Eileen encouraged Alice, observing her progress. A baby boy was delivered straight into his mother's arms and rubbed dry. Together with Alice and John we checked the baby, who was then placed at the breast. Once the third stage was complete, Eileen sutured the second degree tear and washed Alice down to make her comfortable. Eileen completed her records while I checked Alice's temperature, pulse, blood pressure and uterus, which was firm and well contracted. After clearing up and sharing breakfast with the family, Alice was settled in her own bed and we left to start the day's visits.
The intensity of my feelings after this delivery surprised me; this had been a very private, natural family event. The atmosphere of peace and the absence of interruptions and disturbances allowed Alice to work with the contractions, she appeared positive, calm, confident and in control. John played a very active role. He was comfortable in his own environment and an active participant in the birth. Even little Michael, their son aged two, was part of the proceedings, as the friend who should have arrived to look after him was too late. Although looking worried when Alice started to grunt and bear down, with reassurance he sat beside his dad and watched in amazement as his baby brother appeared. I had been very concerned when I realised that Michael would witness to the birth, but my fears were soon dispelled. During the birth Eileen watched and used her knowledge and skills, without intervening, allowing Alice to give birth with limited physical assistance. A couple of weeks after the birth of David, we returned to visit the family. Michael showed no ill effects of witnessing his brother's birth. He clearly recognised us, but merely looked at Eileen as if to say, "what magic trick are you going to perform today?"
Alice had only chosen a homebirth six weeks before, following a visit to hospital, when memories of her first medicalised birth, together with not wanting to leave Michael, made her decide that homebirth would be more practical and increase her control. Her GP, family and friends were surprised but did not oppose to her decision. Her faith in her midwife, instilled during antenatal care and classes, gave her confidence, which did not waiver when an unknown midwife and student arrived for the birth. The couple felt homebirth was a wonderful, relaxed and positive experience with Alice able to cope better with pain in her own home. Their only concern was whether Michael had been affected by witnessing the birth. Homebirth would definitely be their choice for any future pregnancies.
The other homebirth I witnessed was not so straightforward. The second stage of Sarah's labour (she was a primigravida) was long and exhausting but both midwives present encouraged her, keeping her focused and positive, knowing her determination to give birth naturally. I felt that in hospital, Sarah would have been persuaded to have an assisted delivery. Although the head was born without problem, both shoulders appeared to emerge together and Sarah sustained a third degree tear posteriorly and damage to her urethra. After examination and consultation with Sarah she was transferred to hospital. Despite this, she was still very positive about her experience and had no regrets about her choice when I saw her three weeks later. She again would choose homebirth in future.
Although some midwives working in community are enthusiastic about homebirth, others are reluctant to offer this service (Fordham, 1997). Many go through training without witnessing a homebirth (Allison, 1996), whereas others who have worked in the community for many years may have lost confidence (Cronk and Flint, 1989). Doctors too have mixed opinions. Some GPs are supportive, although many are protective of `their' patients (Fordham, 1997), or feel unable to participate in intrapartum care owing to lack of time or experience, fearing complications (Ford et al, 1991). This is understandable when during training, few normal deliveries are performed by doctors (Davies et al, 1996) and the only homebirths they are likely to encounter are those where something goes wrong (Gibb, 1996).
Changing Childbirth(DoH, 1993) advocates choice for women regarding place of birth and where choice is offered the home birth rate is higher (Davies et al, 1996). GPs, usually the first person approached during pregnancy, rarely offer such choice (Fordham, 1997). Women like their doctor to be involved with their care (Jones and Smith 1996) and where they give their added support the homebirth rate is increased further (Cronk and Flint, 1989). This was clearly seen in the two areas in which I worked in community. Both midwives were equally enthusiastic about homebirth, but the midwife who worked alongside supportive GPs had a much higher homebirth booking rate. Changes in childbirth have been so rapid this century that it is easy to forget that until the 1940s most babies were born at home (Leap and Hunter, 1993). Hospital has become the norm and most women believe this is the safest place to give birth (Fordham, 1997).
Recent studies (for example, Allison 1996, Davies et al, 1996) have supported previous statements made by Tew (1990) in the 1970s that planned homebirth is as safe, or safer, than hospital birth and unplanned homebirth was responsible for the increase in perinatal mortality figures quoted in previous years. Women having planned homebirths undergo less interventions, use less pain relief, have higher breastfeeding rates and their babies have higher Apgar scores (Wraight, 1997). However, primiparous women are at greater risk of transfer owing to a delay in the first or second stage of labour (Ford et al, 1991).
Most women I met gave practical reasons for choosing homebirth, such as not leaving other children, living a long distance from the hospital with previous rapid deliveries, wanting midwife-led care and wanting more control, although some chose this option because of a previous unpleasant hospital experience. Formal research substantiates these findings (Ogden, 1997a; Kitzinger, 1991; and Davies, 1997). Most women in Britain today still choose hospital birth, preferring the availability of technology should something go wrong (Johnson et al, 1992). Homebirth does involve a small risk, but so does birth in hospital, yet are the risks of hospital birth ever pointed out to women? Women should be given unbiased information and true choices provided (Wraight, 1997). Homebirth was described by women as "more relaxing, easier, satisfying, fulfilling, being in control, no disruption, husband more involved, private, family event", with midwives as "showing respect, confidence, relaxed attitude, enthusiasm and support." These comments also reflect the opinions of women in studies (for example, Ogden 1997b, Ogden, 1997c, and Smith, 1996). Homebirth offers the chance for midwives to act as true partners in care. Continuity of care and carer are more likely (Smith, 1996), holistic care, confidence (Flint, 1986), satisfaction and autonomy (Smith, 1996) are all increased. Gibb (1997) states that homebirth should never be seen as a hobby and Robinson (1997) warns about the dangers of bringing interventionist hospital practice into the home.
The long hours and increased nights on call necessary to facilitate homebirth demands greater commitment. If homebirth rates are to increase, time must be made available and more support given to midwives. Witnessing homebirth has changed my own ingrained medical views of childbirth. The experience has given me more confidence to view childbirth as a natural event and not a disaster waiting to happen. During my recent hospital placement I found myself looking for ways to bring the principles of homebirth into the hospital setting. Some hospital midwives do demonstrate the skills of watching and waiting, giving support without being intrusive. Small details make such a difference, for example, always knocking and waiting for permission to enter a room; leaving parents alone with their new baby to get to know each other; checking the baby with the parents, not merely in front of them. In future practice I will continue to look for further ways to enrich hospital care. Methods should be found to increase privacy in hospital. Women in early labour or being induced should be in a single room whenever possible and be treated as if they were in their own home (Page, 1995). Perhaps more deliveries could be performed in side rooms where women seem more relaxed, with equipment nearby in case of need. By moving women to a delivery room are we subconsciously giving the opinion that we feel they will need to use all the high tech equipment displayed there? Fathers should not be made to feel in the way or rushed to leave after delivery. Several women mentioned their feelings of loneliness and loss as their partners left after delivery. My taste of homebirth has been an enlightening experience. Both births I saw were positive, fulfilling experiences and similar feelings were expressed by other women I met, and confirmed by the research evidence. Homebirth should be seen as a viable option for those that choose it and skills should be developed by midwives to facilitate that choice. The safety of panned homebirth has been shown to equal, if not better, that of hospital delivery, although the majority of women still believe hospital to be the safest place to give birth, and for that reason most will continue to choose that option. The principles of care should be the same in any environment. Women should be given continuity, choice and control wherever possible. In homebirth I witnessed the true `art' of midwifery with midwives utilising all their skills, but I feel women and their partners must believe childbirth to be natural process for homebirth to be a positive experience.Above all homebirth emphasised the fact that birth is a private, family event and should be treated as such, with respect to the individuals involved. The following extract, taken directly from my reflective journal, describes the vivid impression homebirth left on my memory:
As we let ourselves out of the front door I could still picture Alice, John and Michael curled up on the family bed cuddling their new baby. They had been the main characters in this event; we played only minor roles. It felt so right that it was us, not the father who left after the birth. This alone must be one of the best reasons for choosing a homebirth.
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Ed. IK 14th June 1999