Home birth after caesarean

Home birth after caesarean (or HBAC) is an increasingly popular option. Women and families know that they will be less subject to monitoring and interference at home. It is thought by some that this may lead to a higher chance of successful, safe vaginal birth. To date though, we haven’t seen much research on this. That’s partly because, although it is becoming better known about, home birth after caesarean isn’t always offered by care providers. So anyone interested in this area is likely to need to do their own reading and dig about for good information.

But a recent study has added to our knowledge about HBAC, which is just one option open to those seeking VBAC, or vaginal birth after caesarean. This blog post is based on an article I wrote for my February 2021 Birth Information Update. I wanted to highlight a Canadian study which was published in Birth: Issues in Perinatal Care. The researchers looked at whether the mode of delivery and maternal and neonatal outcomes differed between planned home VBAC (HBAC) and planned hospital VBAC (Bayrampour et al 2021). This is an important question for those considering VBAC, because we know that the monitoring that is associated with the hospital setting can be detrimental to a woman’s ability to labour and birth physiologically. So it’s important to have good evidence about the different options.

 

What did the researchers find?

Here’s an outline of the key elements of the study:

“All midwifery clients with at least one prior cesarean birth delivered between April 2000 and March 2017 (N = 4741; n = 4180 planned hospital VBAC, n = 561 planned HBAC) were included.” 

“Planned HBAC was associated with a significant 39% decrease in the odds of having a cesarean birth (aOR 0.61, 95% CI 0.47‐0.79) adjusting for the prepregnancy and pregnancy characteristics.” (Bayrampour et al 2021).

  • So women who gave birth at home were more likely to give birth vaginally than to end up having another caesarean. That’s compared to women who gave birth in hospital. The bit about ‘adjusting’ means that the researchers took into account the factors which might have made some women more or less likely to have a vaginal birth. They showed that, even when you considered those factors, the setting (or being at home) appeared to make a positive difference.

“Severe adverse outcomes were relatively rare in both settings; thus, our study did not have sufficient power to detect the true differences associated with the place of birth.” (Bayrampour et al 2021).

  • We know that the chance of a problem in a VBAC is really low, so even with hundreds of women included in the study, we’re not going to see enough problems to know if there is a difference. That’s not a flaw in the study. It’s actually great news that problems are rare! The researchers can’t suddenly conjure up ten thousand women wanting home birth after caesarean just to get enough data to see if there’s a possible tiny difference. The lack of a difference in this study is what we would expect to see, given that the chance of a problem is so low in the first place.

And if you’re looking for a short summary, the authors concluded that, “Home births for those eligible for VBACs and attended by registered midwives within an integrated health system were associated with higher vaginal birth rates compared with planned hospital VBACs. Severe adverse outcomes were relatively rare in both settings.” (Bayrampour et al 2021).

The study only compared the outcomes of midwifery clients, so the differences here are about setting (that is, hospital versus home) rather than another factor such as the type of care provider. That said, we do know that some midwives are more likely to promote and support home birth than others. So that’s a reminder that research findings are often not as clear cut as we might like them to be. It’s also important to note that these figures are for HBACs which were attended by registered midwives who were practising within an integrated health system. In other words, the birth was attended by a trained midwife who had access to hospital facilities if needed. So the results can’t be extrapolated to other situations, e.g. an HBAC with no midwife present, which might have different results again.

 

What are we really measuring?

I’ve recently been recording some materials for my online course Gathering in the Knowledge 2021. And I chat in those about how important it is to think about what is really going on when we look at data on outcomes from different settings or situations. This is often more clearly seen in research which takes place in hospital settings, where care providers are often more medically focused. That’s not likely to be the case with the midwives in this study. Midwives who support HBAC and have such outcomes are highly unlikely to be medically focused.

But if you’re interested in thinking about research or in understanding birth-related issues more deeply, this principle is still worth considering. In a nutshell, the outcomes that are recorded in the different arms of a research study aren’t necessarily the outcomes that would be recorded in a different setting. Or with a different care provider. It’s easy to forget that. A baby who is perceived to be distressed after a labour that was made longer by the inhibition of movement, frequent monitoring, constant references to time constraints and interruptions by staff, epidural anaesthesia and then the addition of an oxytocin drip might well not have become ‘distressed’ if its mother had laboured while surrounded by her loved ones at home. Context and environment can affect outcomes. Put someone in a nicer, more comfortable, kinder environment, without interruption, and they might labour better. But there’s more. We need to remember that some outcomes, such as the decision to offer a caesarean, are human decisions. They may tell us more about the beliefs of the care provider than about the capability of the woman’s or baby’s body.

If you say the words ‘home birth after caesarean’ to a care provider and they look afraid, concerned or aghast, that tells you everything you need to know about their beliefs. Though let me also note that if someone looks delighted and cheers you on without a thought for your individual situation, that might not be a good sign either. A good care provider should offer you information about the pros and cons of any decision. They should be clear about the benefits and risks to ALL options. And there are always benefits AND risks, no matter the setting. That’s why one should beware of those who totally gloss over the risks just as much as those who can only see the risks. It’s all about balance.

 

Whose failure?

The findings of this research also illustrate another important principle. Many people understand that the context and environment in which we give birth can affect the outcome. Midwives and birth workers often discuss how, when oxytocin doesn’t flow well, the journey of birth can be inhibited. In our obstetrically-dominated culture, however, that is frequently defined as a failure on the part of the woman’s body. Many women themselves tell the story of how their body didn’t work. Or how their baby didn’t co-operate. I worry that they’ve been told something that’s untrue. A friend recently told me the story of her birth, some eleven years ago. Her baby couldn’t cope with labour, she said. After I heard more, I realised that it wasn’t necessarily labour that was the problem. It could well have been the fact that her care provider had kept her on the bed, attached to a monitor. And then started giving an oxytocin drip because things weren’t going as fast as the care provider wanted. Perhaps it was the drugs that the baby couldn’t cope with. He would likely have been fine without them.

It’s so important that women and families are able to understand the context of modern maternity care, and have tools to help them navigate decision making. What’s Right For Me? Making decisions in pregnancy and childbirth offers a guide through the maze. It’s not about telling you what the “right” decisions are. There’s no universal “right” decision. It’s about helping you gain the tools you need to help you make the decisions that are right for you.

In a birth culture that defines progress by the clock, there is little patience for individual variation. So “failure” to progress according to the graph is “treated” with drugs that speed up labour. That’s the medicalised way, anyway.

But from a different perspective, however, the real failure is on the part of those who believe that birth is a risky, medical event. Those who try to monitor and manage it at every turn. Proponents of the obstetric paradigm, if you like. It’s their failure to understand physiology. To understand that individuals vary. To understand that, sometimes, a slowing or stalling of labour can be a normal and probably quite helpful fight-or-flight response to feeling threatened. The solution is not drugs, but to change whatever it is about the environment that feels so threatening to someone that they need to temporarily (and involuntarily) put the brakes on their own labour.

That’s not the story that most women and families are told, though.

 

Why setting and context matter

So the expectations, decisions and practice that women encounter in a particular setting can have just as much of an effect on whether they end up with a particular outcome than anything to do with their own physiology, preparation or companions. Those things are all very important, yes, but setting, environment and context are important too. That’s why research like this is so needed. That’s why it’s valuable to understand the deeper issues, rather than just scratching the surface.

So I think it’s vital that we talk about studies like the one by Bayrampour et al (2021), which show what women’s bodies are capable of when we trust and support them. It’s just so important that we understand why and how there can be such a difference in outcomes between different settings. And why we need to take into account the fact that the simple act of moving from home to hospital in labour is in itself an intervention that have have an effect on the outcome.

 

You can read the study that I discussed in this blog post here.

If you’d like more information on home birth in general, I have a home birth resources hub.
 
If you’re a midwife or birth worker then you might be interested to know why I’m talking about this more in Gathering in the Knowledge 2021. It’s because this is such an important topic right now. It’s a key issue in research on topics such as induction of labour and whether it reduces the chance of caesarean. Join me for a course this year to learn more.
 
 

 

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Bayrampour H, Lisonkova S, Tamana S et al (2021). Perinatal outcomes of planned home birth after cesarean and planned hospital vaginal birth after cesarean at term gestation in British Columbia, Canada: A retrospective population‐based cohort study. Online ahead of print. https://doi.org/10.1111/birt.12539