My midwife failed me: How homebirth transfer affects mothers

Homebirths account for just a small percentage of all births in the US: 0.59% of births happen at home. Interestingly, this number increased by 5% between 1990 and 2005, which we could call a surge in homebirths [1]!

Besides homebirths being more satisfying for women [7], one of the main reasons some women choose a planned homebirth over a hospital-based delivery is because both mothers and babies have better outcomes. The cesarean section rate in homebirths is around 4%, compared to over 30% nationwide [4]. Mothers have fewer interventions, including episiotomy (a surgical cut to open the vagina), and babies die less often [2].

There is no way to sugar-coat that. Babies born at home die less often -- because of the lack of unnecessary interventions. One meta-analysis found that the neonatal mortality rate tripled in planned homebirths versus hospital births, and attributed the better outcomes for babies to the decrease in interventions [2].

Not all mothers that plan to deliver at home end up doing so. For a variety of reasons, a transfer to a hospital may be necessary or preferable during or after childbirth. Sometimes the reason for transfer is maternal exhaustion -- labor takes a very long time and the mother is too tired to go on. Sometimes there are negative health signs with the baby -- heart rate decelerations, or meconium in the amniotic fluid. Rarely, the transfer is caused by something more grave. Usually, the decision to transfer from the home to the hospital rests on the midwife. In the US, the transfer rate is around 12.1% [4].

But how does a woman, who planned to deliver at home, who spent months preparing for her natural birth within the safety and comfort of her home, who anticipated an intimate experience, feel about a transfer to a hospital? Anecdotal evidence hints that something is missing from the birth experience. Does the mother blame herself for failing to deliver a baby at home? Does the blame later shift to her midwife, for letting her down? Is she grateful for being able to spend even part of her labor at home [6]?

We turn to science for an answer.

Is homebirth transfer traumatic?

Let's take a look at the Netherlands, where the homebirth rate is much higher than the US: In one study, over 38% of first-time moms and 67% of repeat mothers delivered at home (recall that the US average has risen to under 1%) [3]. For the first-time moms, 40% of the planned homebirths ended up transferring to the hospital at some point during birth or shortly thereafter; and 11% of repeat moms transferred to the hospital (compared to 12.1% of home-birthing mothers in the US, both first-time and otherwise). The Netherlands data is summarized in the table below.

	First-time mother	Repeat mother
Planned homebirth	38%	67%
Transfer to hospital	40%	11%

The women in this study rated their birth experience, their midwife, and their immediate postpartum days by marking agreement with specific adjectives on a five-point scale (where 1 is strongly agree and 5 is strongly disagree). The conclusion from this study?

Our research showed, contrary to expectations, that an unplanned transfer from a planned home birth to hospital has little influence on the experience of childbirth [3].

Let's look at Sweden.

In Sweden, homebirths are rare -- as rare as in the US -- that is, less than 0.1%.  In Lindgren, et al.'s study [5], the homebirth transfer rate was 25% for first-time mothers -- that is, one in four women that plan a homebirth end up in the hospital (much better than the 40% rate in the Netherlands). The most common reasons women transfer to the hospital are "lack of progress" and (this was surprising to me) the midwife being unavailable for the mother during labor.

The exciting conclusion in Sweden:

Being transferred during a planned home birth negatively affects the birth experience [5].

Looking elsewhere, we find agreement:

Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women [than for Belgian women] [7].

In fact, the Swedish study found that women really hated and resented their homebirth transfer experiences, as visualized (by me, from Lindgren's data) by the graphs shown below in Figure 1 and Figure 2.  In these graphs, the blue line indicates a "very satisfied" response and the red line is anything less than "very satisfied." The thing to take away from these graphs is the area inside the red line. A large red area is bad. In the homebirth without transfer case, you can see that women were more likely to be "very satisfied" with all aspects of their birth (except for being in control -- but can you really control birth?).  In the homebirth transfer case, women were more likely to be less than satisfied with everything except partner support and the midwife making the partner involved.

Figure 1. Satisfaction among Swedish women regarding their homebirth experience [5].

Figure 2. Satisfaction among Swedish women that planned a homebirth but transferred to the hospital during or as a consequence of childbirth [5].

Homebirth: Forbidden fruit


Could it be, then, that in places where homebirth is rare, women place undue emphasis on the location of birth? Could it be that birthing at home becomes kind of a holy grail that women strive for?  It is so rare in the US and Sweden that it is like a forbidden fruit. We hear and read so much about its beauty that we -- that is, those women that yearn for homebirth -- strive for it and are crushed when we do not get it.

Consider another birth outcome some women consider traumatic: the cesarean section. One thing that childbirth educators did to make the prevalence of the c-section more palatable and less scary is to demystify it. In childbirth education classes, c-section is presented as a possible birth outcome -- a real possibility. In a good prenatal education class, analgesia, surgical procedures, and postpartum recovery will be discussed in detail. When you think about it, this is a really good idea, because one in three people in the classroom will have this surgery, whether or not they planned for it.

It may be that one of the things that makes homebirth transfer an emotionally crushing outcome is that it is still an unknown evil. So why not demystify the homebirth transfer? Describe it in detail for women and their birth partners to take in: causes, procedures, outcomes. The Wiegers study made this interesting note:

It seems more important ... to reduce the fear of unplanned [homebirth to hospital] transfer, especially among nulliparas, than to advise women to choose a hospital birth in order to avoid such transfer [3].

Interesting because this is the only study that I found that did not result in negative emotions in the mothers resulting from homebirth transfer. Maybe in the Netherlands they drill the transfer as much as we (ought to) drill the c-section?

Lindgren had a different conclusion:

Treatments as well as organizational factors are considered to be obstacles for a positive birth experience when transfer is needed. Established links between the home birth setting and the hospital might enhance the opportunity for a positive birth experience irrespective of where the birth is completed [5].

In fact, in the Sweden study, one of the main reasons women were unhappy with the hospital setting was because everyone was so dang mean to them -- possibly for choosing a homebirth to begin with. They found that doctors -- obstetricians, general practice physicians -- simply do not understand what a midwife does in the home and why she should continue to be useful even after a transfer. Maybe the homebirth transfer education should start with the hospital.

Did my midwife fail me?

I do not know. But I do know that everywhere around the world where homebirth is rare, homebirth transfer to a hospital carries with it a negative weight. In the Sweden study, half of the women that underwent homebirth transfer were less than satisfied with their midwife's support, compared to over three-fourths (76%) of those that stayed home. Not surprising when you consider that the #2 reason for transfer is because the midwife simply could not come to the birth [5].

Conclusion

There are three ways to fix the problem of the negative affect of homebirth transfer.

1. Teach hospital staff about homebirth transfers. Drill it, demystify it. Emphasize that a transfer is not the mother's fault; it is not the midwife's fault. These things just happen.
2. Teach mothers that plan for homebirth about homebirth transfer. I mean, really drill it.  It is a real possibility and a mother should know the routine. Drill it, demystify it. Encourage that a transfer is not her fault.
3. Encourage homebirths. There is reason to believe that, when the overall percentage of women that plan for a homebirth is large, a transfer to the hospital is no big deal -- possibly because the hospital staff know what to expect from a woman and her support team, and how to best help.

Given our surge in national homebirth rates (still under 1%, but we do our best), you would think we would be quick to implement these items.


References


[1] United Press International (2010). US Homebirths Few, But on the Rise.  Retrieved 4/24/11.
[2] Wax JR, Lucas FL, Lamont M, et al. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.

[3] T. A. Wiegers, J. van der Zee, and M. J. N. C. Keirse (2001). Transfer from Home to Hospital: What Is Its Effect on the Experience of Childbirth? Birth, 25 (1).
[4] A. Haas (2008), Homebirth After Cesarean. Midwifery Today.

[5] H.E. Lindgren, I.J. Rådestad, and I. M. Hildingsson (2011). Transfer in planned home births in Sweden – effects on the experience of birth: A nationwide population-based study. Elsevier 2011.
[6] J. Davies, E. Hey, W. Reid, G. Young (1996).  Prospective regional study of planned home births. BMJ 1996.
[7] W. Christiaens, A. Gouwy and P. Bracke (2007). Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison. BMC Health Services Research 2007.