Chris Warren and Colleagues
NADIA was born at home, weighing 2.300 kg and Nasreem was born in hospital and she weighed 2.356 kg. Both women were correctly diagnosed as having small for dates babies. Both had intensive fetal surveillance, which raised many anxieties and both gave birth around term, spontaneously, vaginally.
Here the similarities ended. At Nadia's birth, there was "darkness, or almost, and …silence," and the other ingredient needed according to Leboyer (1991): "Patience. Or rather, the sense that one should slow down and thereby enter into another rhythm: the profound rhythm of life…. which is also the tempo of the child."
The birth went fine, it was hard work - as it often is - and the longish second stage gave a good opportunity to try out different positions. There were moments of desperation, humour, anger, exhilaration threaded through a sense of it being right for this baby to be born here and now, but in her own time.
Being born at home does not, necessarily make all things well. Nadia's mum and Dad had lots of anxieties but there was never a time when it was felt that transfer to hospital would be likely to improve life for anyone. For Nadia, there was no interference to keep monitoring her temperature or her blood sugar or her breathing rate. She was kept in skin-to-skin contact with Mum or Dad, not bathed and fed quite well and frequently. It was three days before she wore clothes.
NASREEM was, after a short cuddle, transferred to special care where she obviously was separated from her parents. She did have routine swabs, heelpricks for blood sugar levels, frequent measurements of all sorts of things done. Initially, she lost some weight, nearly 10% and then started to gain. Her Mum struggled but succeeded in getting her to feed at the breast by seven days. It was not easy trekking into the hospital twice a day, only getting a lift in the evening. Nasreem was tube fed initially but soon progressed to cup feeds and test weighing showed she was getting half her feed from the breast at 10 days. At 12 days Nasreem was discharged home, she had regained her birth weight and took the bottle well. The midwife visited once and handed over to the health visitor. And we don't know what happened next.
NADIA was slow to gain weight and lost more weight at 10 days and at 14 days we were talking of maybe needing to supplement. With a midwife, a La Leche League helper and the health visitor all visiting, there was no lack of help and advice and, despite very sore nipples, Nadia's Mum kept going. Artificial milk was started on day 23 and Nadia lost that pinched look. At six weeks, she was thriving, having 90% of her nutrition through expressed breast milk via a bottle and a nightly top up of propriety formula feed.
Was Nadia at risk because she was not in a Special Care Unit? Would Nasreem have been better off sent home within five hours of birth and provided with lots of community back up? Did the quiet, calm respectful birth environment make any difference to Nadia and her parents? Did the noise, bright lights and dramatic arrival of the paediatrician at Nasreem's birth affect her?
Was there any advantage to either baby in being diagnosed as 'small for dates'? Did the subsequent monitoring allay more worries than it raised?
What evidence do we have to promote Special Care Baby Units? I believe ill babies need hospital care, but well babies need parental care and some parents and some babies may need lots of care. With their parents, they get one-to-one or two-to-one care and there is no way we can emulate that. Parents can be taught most things and initially they may need to care for their baby within an environment where techniques can be safely learnt. Parents care for kids at home with tracheotomies, having dialysis, with stomas and insulin dependent and needing blood sugar monitoring. Don't let us underestimate them. But we can't abandon new parents either. They need support and help from professionals and peers, but it should be offered not pushed.
Leboyer F (1991). Birth Without Violence, Mandarin, 52-53.
LW updated February 4, 2005