Monday, 27 January 2014

perils of homebirth

Too many deaths in home births

FATAL CHOICES: For many preggies, the idea of giving birth in the comfort of their own home seems like the most natural thing. However, healthcare professionals warn against the dangers of unassisted home births. Mothers and doctors talk about this birthing style which is fast becoming a trend among highly educated and well-connected urbanites, writes Audrey Vijaindren

ANOTHER would-be joyous occasion ended in tragedy when Ang Lay Chin, 40, suffered excessive blood loss moments after giving birth to her first child in her house in Sri Kembangan, Selangor, in November last year.

Her death is not the first failed home birth and it will not be the last in the country, if women who are following this new trend throw caution to the wind. While healthcare professionals are worried about such senseless deaths, home birth support groups are sprouting up all over the Internet, with mothers encouraging other mothers to embark on this "natural" way of welcoming a newborn.

Although the idea of home births may be appealing, a recent study in the United States revealed that babies born at home were nearly ten times more likely to be stillborn, and the risk of stillbirth increased to 14 times for firstborns.

Babies born at home were also almost four times more likely to experience neonatal seizures or serious neurologic dysfunction compared with babies born in hospitals.

The Health Ministry's (MOH) national head of Obstetrics and Gynaecological Services and national head of Maternal Fetal Medicine Services Dr J. Ravichandran R. Jeganathan said there were about 10,000 home deliveries out of 420,000 deliveries per year in Malaysia.

"A delivery can only be classified as low risk in retrospect. So the home for delivery can be a dangerous place if the patient is not properly assessed and attended to by a trained midwife.
"Despite the best risks assessment, things still can go wrong. That's why the process of labour until delivery is said to be the most dangerous journey one will make in their life," he said.

Data from the Confidential Enquiries into Maternal Deaths (CEMD) from 2006 to 2008 shows that delivery at home is five times more risky than at the hospital.

"This is not to say that home deliveries can't occur. In fact, there were about 9,000 to 10,000 births at home in each of the years between 2006 and 2009. But the six to nine deaths that occurred in each of the years concerned were because they were largely not suited for home delivery.

"In fact, in those three years, there were only two white coded (low-risk) cases that died and more importantly, they were attended to by traditional birth attendants, other unskilled persons or were completely unattended. The main cause of death was postpartum haemorrhage," he added.

CEMD is a national level committee consisting of various experts and specialists who look into every case of maternal death in Malaysia.

However, there have been two needless deaths in recent months, that itself is one too many, said Dr Ravichandran, who is also chairman of the CEMD.

"There are many social groups that are actively advocating home deliveries. Many of these women are highly educated and of the higher socio-economic group. They have access to facilities as well as knowledge, but they seem to be swayed by these social groups.

"Many don't realise the perils they're exposing themselves and the foetus to. Issues of increased autonomy, empowerment, and choice of mode of delivery should be wisely tempered with probable risks.

"MOH doesn't want to see this become a problem. We're doing all that's needed to address the issues. We support home deliveries that are risks assessed and conducted by trained registered practitioners. There has to be a concerted and focused effort to increase this awareness to the public," he said, adding that non-governmental organisations, government and international agencies and other ministries should work together.

He said although rules and regulations are in place to facilitate safe deliveries, many women are adamant on delivering on their own.

"There are regulations and criteria available and midwives are trained to perform their midwifery duties professionally. However, issues arise when women refuse our services and prefer their own methods.

"The Midwifery Act clearly allows only trained personnel to conduct deliveries. Failure to do this is punishable by law."

Dr Ravichandran believes it's timely for Malaysia to look into successful home birth models.
"Home deliveries are quite readily practised in the United Kingdom and Holland. These countries have well-oiled and extensive community midwifery care. In these countries, midwives who look after the patient antenatally, assist in the home delivery.

"The important criterion that must be met is that the delivery must be conducted by a trained person, such as a midwife, in a conducive environment. This is so that any emergency can be recognised and attended to promptly by referral to a hospital if required.

"The home is not suited for everyone and the woman must not decide by herself. Worldwide, the reduction of maternal mortality is because of the increasing number of deliveries that are conducted by trained persons. The choice of delivery should always be an informed one, made by the mother, midwife and the doctor after having weighed all the pros and cons."

Unfortunately, many of these mothers don't disclose their home birth plans to their doctors, said the Obstetrical and Gynaecological Society of Malaysia president Dr Tang Boon Nee.

"From my experience, they go for their pre-natal check-ups, but most of them purposely did not tell their doctors about their choice to deliver at home. Instead of seeking medical advice, they surf the Internet for support groups which offer a false sense of security and confidence."

She said these groups can be so extreme as to not even allow intervention in delivering the placenta.
"Medically, the placenta should be out within 30 minutes, otherwise medication and injections are used to help. But these groups don't even approve of that, causing a condition called 'retained placenta', which may lead to bleeding and infection. We knew of cases where the placenta is in for 12 hours, and then hospitals need to take extraordinary measures to save that life.

"Many of the women and their natural childbirth advocates are so headstrong that even if there's a midwife present, their role is to just watch, without performing any monitoring whatsoever."

There should be a law against unsafe delivery for unassisted, planned home deliveries, Dr Tang said.
"We just want to promote safe delivery and sometimes that means intervention. Many home birthing groups are more worried about the process than the outcome. They may be pro-women, but we are pro-women, pro-baby and pro-safety. We don't condemn them. In the end they make their own decisions, but it has to be informed and they need to know that there are a lot of risks.

"While some mothers may feel that this is the most natural process, their unborn babies have no legal right or say.

"Currently in our country where we don't have a proper system for home birth, it's not fair for these support groups to carry on home birth classes and then blame the ministry for not providing better care when things go wrong," Dr Tang said.


Read more: Too many deaths in home births - General - New Straits Times

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