September 2012

Respect for the Nature of Birth

Pregnancy and birth are expressions of wellness in a healthy woman. Finely tuned physiological processes guide safe passage for the mother and infant through the experience of labor, birth, and bonding.  A woman’s health and wellness are sustained by access to healthy food, safe housing, loving support, and quality health care that addresses her needs.

Birth works best when a woman is inspired to be confident in her abilities, well informed about her choices, and supported and affirmed throughout labor. A significant transformative experience for women, babies, and families, birth is best supported when it takes place in quiet, undisturbed surroundings.  Midwives have reverence for the individual woman, are responsive to the complex factors that affect pregnancy and the unique unfolding of labor, and are patient and attentive to each woman during birth. Homebirth midwives are experts in supporting the maternal well-being that fosters normal birth. Midwives provide thorough, personalized care throughout the childbearing cycle and protect the period of intimate bonding that is at the center of the experience for mother, baby, and family.

Woman’s Autonomy

Homebirth is an expression of a woman’s autonomy and a process in which her autonomy and privacy are assured. A woman has the right and responsibility to choose the place and care provider for pregnancy, birth, and postpartum and to make decisions based on her knowledge, intuition, experiences, values, and beliefs.  When a midwife encourages a woman to gather information, explore options, and make decisions, Homebirth Position Paper As Adopted by the Midwives Alliance Board and Membership September, 2012 the woman is empowered to face the challenges of birthing, parenting, and living her life with greater confidence.

Midwives listen carefully, affirming a woman’s attunement to her body, her pregnancy, and the child growing within her. Midwives know that women are able to care for themselves and recognize that mothers are the primary caregivers to their unborn and newborn children.

Every woman has the right to be fully involved in all aspects of decision making for her own and her child’s well-being, and to receive respectful, sensitive care during pregnancy and birth, regardless of her color, race, ethnicity, religion, culture, class, sexual orientation, health challenges, need for specialized care, or hospitalization.

Significance of Place

The Midwives Alliance recognizes that place of birth affects how labor unfolds, how women experience and cope with labor, and how those attending a birth relate to women. In the familial setting of the home, women are able to labor according to their unique rhythms, to be surrounded and supported by family and friends of their choosing, and to receive continuous care from their midwives. As an invited guest in someone’s home, the midwife has the responsibility to notice as much, interfere as little, and behave as unobtrusively as possible, performing necessary procedures with permission and ceremony.

Homebirth contributes to comfort, mobility, ability to cope, and sense of confidence.  Reflecting a woman’s family and cultural traditions, the homebirth setting enables her to follow the innate wisdom of her body to direct the course of labor and birth. At home a laboring woman is free to be guided instinctively to birth her baby in whatever position feels right, in or out of water, as she desires. Bonding occurs naturally in the homebirth setting as mother and baby meet face to face and embrace skin to skin. The heightened senses of the new mother and baby are stimulated by uninterrupted closeness and familiar voices rather than being disrupted by the jarring lights, noises, and separations that so often occur in an institutional setting. Welcomed with love and reverence, the newly born is home.

Nursing the newborn in the first hours is undisturbed in the homebirth setting. Motherbaby closeness, motivation, encouragement, and knowledgeable guidance contribute to high success rates of breast-feeding for homebirth families.

Safety of Homebirth

The Midwives Alliance recognizes the safety of homebirth for healthy women with a skilled midwife and timely access to medical care when needed. Childbirth has inherent risks,  as does all of life. Each birth setting carries a particular set of risks and benefits. Each woman must evaluate which set of risks and benefits are most acceptable to her and most in keeping with her belief system and her family’s best interests.  There is no significant statistical difference in outcome in terms of maternal or perinatal mortality between hospital and out-of-hospital birth; however, there is increased morbidity in the hospital.  Complications for mothers and babies associated with the unacceptably high rates of inductions, cesarean sections, and other overused interventions in U.S. hospitals are well documented and cause for concern.

Relationship

Throughout recorded history, women have assisted other women in giving birth.

Midwives enter into a relationship of equality with women that constitutes the foundation of midwifery care and contributes significantly to the safety of homebirth,  low rates of intervention, and satisfaction with the experience.

Because the relationship is the cornerstone of quality care, homebirth midwives spend generous amounts of time with women to foster familiarity, comfort, and mutual trust. Through open communication, deep listening, and respect for the woman’s culture, self-knowledge, intuition, and values, the midwife honors each woman’s journey. Individualized care by her midwife helps a woman address issues early and make changes to enhance her health.  Good communication, honesty, and personal knowledge of a woman’s life facilitate effective problem solving during pregnancy, labor, birth, and postpartum.

Informed Decision Making

The Midwives Alliance recognizes the basic human right of women and families to make informed decisions regarding maternity and newborn care and to accept personal responsibility for these decisions. True informed decision making is predicated on women being fully informed about the risks, benefits, and alternatives for all prenatal, labor, and postpartum procedures.  Midwives promote both informed consent and informed refusal in health-care decision making. Informed decision making requires direct access to accurate and unbiased information that is readily understood. While respecting the unique needs and cultural considerations of each family, honest and frank discussions that explore the risks and responsibilities associated with choice of caregivers, settings for birth, and perinatal interventions and technology, along with their potential outcomes, are essential components of homebirth midwifery care.

Midwifery Knowledge, Evidence-Based Practice, and Homebirth Care

Midwifery practice is rooted in an extensive body of knowledge and collective wisdom about pregnancy and birth that have developed over generations and across cultures.  It continues to grow as research, often conducted by midwives, has refined understanding of the physiology of birth and the factors that contribute to the health of women and promote natural birth.

Both informed and substantiated by high-quality research, the best midwifery practice is also shaped by a critical evaluation of relevant scientific evidence that takes into account the limitations of various research methodologies and the appropriate application of the findings. Evidence-based midwifery practice involves informing women about research findings so that each woman can use this information as she makes decisions about her pregnancy and labor.

Homebirth preserves skills, knowledge, and ways of knowing in relationship to birth and midwifery practice that are uniquely possible in the home setting,  where birth unfolds naturally without routine interference and with only judicious use of technology appropriate to that setting. Guided by each woman’s journey through labor and birth, homebirth midwives gain an understanding of subtle variations and the wide range of what may be considered normal. This is more difficult for caregivers practicing in institutions with restrictive protocols and many routine interventions.  The midwife’s wealth of experience combined with extensive knowledge and training enables quick decision making and effective action.

Consultation and Collaborative Care

Ideally, in an integrated maternity system, women choosing homebirth and the midwives who provide care for them consult and collaborate with other professionals who value client autonomy and informed decision making and who relate to midwives and women as equal partners in care.

Homebirth midwives employ appropriate knowledge, skills, and equipment to handle emergencies and unforeseen labor challenges. Sometimes transfer of care to a hospital with maternity services is necessary. Collaboration with obstetrical and neonatal personnel is integral to the provision of seamless care that is in the best interests of all mothers and babies.

Obstetrical expertise and technological support need to be readily accessible and provided in a direct, respectful manner. To assure safe and efficient care, homebirth midwives remain with women throughout the transfer process and birth to provide valuable information to hospital staff and continuity of care to the mother, baby, and family.

Cost-Effectiveness

While the safety of homebirth for a healthy woman with a skilled attendant is well established, the cost-effectiveness of this option is also compelling. A woman who chooses homebirth is much less likely to be subjected to costly and often unnecessary interventions than her healthy counterpart in the hospital.
A 2007 review in Washington State found that the cesarean rate with licensed homebirth midwives was 11.9%, compared to the statewide cesarean rate of 24% for low-risk women in hospital care, which saved the state Medicaid program an estimated $2.7 million over two years.  The US cesarean rate of 32.9% in 2009 55  is more than double the World Health Organization’s recommended maximum cesarean rate of 15%, adding at least $2.5 billion to the national health-care bill, according to a conservative estimate published in a Milbank Report. Clearly homebirth is a judicious and cost-effective option for healthy women and communities.

Homebirth Midwifery and National Maternity Care

The United States faces serious and costly problems in maternity and family health care,  including disparities in outcome,  lack of access to primary care,  and lack of access to pre-determinants of health, such as adequate nutrition and adequate housing. Added to these challenges are litigation, unacceptably high cesarean rates,  and increasing maternal mortality, premature birth,  developmental disabilities, and childhood obesity.

Labor and birth that begins, proceeds, and concludes as nature designed is rare in institutional settings. The majority of maternity care providers have never seen it and are not trained to accommodate it, thus women must go outside an institution to achieve it. As cost-effective primary maternity care providers,  homebirth midwives focus on promoting optimal well-being, encouraging healthy lifestyle choices, avoiding unnecessary interventions, facilitating successful breast-feeding, and engaging in education and political advocacy, making midwives an important part of the solution to the maternity care crisis facing the United States.  Attentive, loving midwifery care is critical to improving maternal and infant health and achieving equity in pregnancy outcomes for all communities.

Research on homebirth has produced a body of knowledge about normal labor and birth, as well as the conditions and practices that enable women to birth successfully and that contribute to infant well-being. Increasingly, scientific research has validated this knowledge and the principles of care underlying homebirth midwifery practice. These principles can inform and improve health care in the United States. Evidence-based practice with informed choice leads to less litigation, fewer drugs and procedures, lower costs, and greater client satisfaction. When applied to maternity care, the results include fewer interventions such as labor inductions, pain medications, episiotomies, and cesarean sections, fewer low birth-weight infants, lower rates of infection, stronger parent–infant bonding, higher rates of breast-feeding success, greater satisfaction for women and families, and many long-term physiological and emotional health benefits to mothers, babies, and families.

Regional, national, and international studies show that healthy women who choose homebirth with skilled attendants have excellent outcomes for themselves and their babies. The benefits afforded by a trusting relationship, the familiarity and privacy of the home setting, individualized, woman-led, and time-intensive care, and informed decision making--all hallmarks of homebirth midwifery care--extend well beyond the childbearing year.

To offer women true informed decision making in maternity care, birth professionals must collaborate within an integrated maternity care system. Every woman has a right to birth in a community in which maternity caregivers consult, cooperate, and collaborate directly and freely in order to provide full- spectrum, high-quality childbirth options for all mothers, infants, and families. True support of a woman’s right to choose homebirth includes federal and state programs to eliminate disparities in underserved and marginalized communities, funding of multiple routes to homebirth midwifery education, legalization of homebirth midwives in all states, and public and private insurance coverage for homebirths and homebirth midwives.

For the full document, including references, please click the followng download link.