The Baby Tribe
The Baby Tribe podcast is dedicated to providing parents and caregivers with the latest information and expert advice on maternal health and well-being during pregnancy and the postpartum period, in addition to infant health, nutrition, and growth. This podcast covers all the important topics to ensure both you and your little one get off to the best start. The podcast is hosted by the husband and wife duo, Professor Afif El-Khuffash, a neonatologist, paediatrician, and lactation consultant, and Doctor Anne Doherty, an obstetric anesthesiologist with expertise in maternal care. Both Anne and Afif work at the Rotunda Hospital in Dublin and together bring over 40 years of combined experience in newborn and maternal health. We share our knowledge and insights on everything from breastfeeding and formula feeding, to introducing solid foods, maternal recovery, and dealing with common health concerns for both mother and baby. We’ll have regular guests to share their expertise and experiences on various topics of interest, and we’ll also hear from real parents sharing their personal experiences and tips for raising healthy and happy families. Whether you're expecting your first child or navigating the postpartum period, this podcast is for you. Tune in each week for valuable information and practical advice to help you and your baby thrive. Please be sure to subscribe to our podcast, and follow us on Instagram! Thanks for joining us, and let’s continue this exciting journey together!
The Baby Tribe
114: Home Birth: Choice, Safety, and What Informed Consent Needs
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This show is part of the Headstuff Podcast Network.
SPEAKER_01The Baby Tribe is proudly sponsored by Happytummy.ie, the exclusive distributor of Bayagaya Probiotics, providing support for gut and oral health for the whole family. Welcome back to the Baby Tribe. We have been away for a few weeks over Christmas, which for most parents is not a break, it's just parenting with more chocolate and lower expectations. We're back for a new season. And we're easing ourselves gently into it, aren't we, Anne?
SPEAKER_03Oh, absolutely, Feef, as would be typical for you.
SPEAKER_01So, yes, welcome back. Today we are talking about home births, free births, and what actually happens when birth doesn't follow the script people were promised online. This episode isn't about shaming women, it's not about taking choice away from anyone, and it's definitely not about pretending hospitals are perfect, but it is about risk, and it's about the uncomfortable reality that birth can change very quickly, sometimes in ways that no amount of planning, intention, lighting, or affirmations can control. We're gonna talk honestly about what can go wrong for mothers and babies, why we'll transfer if needed sounds reassuring, but sometimes it isn't, and why immediate access to hospital grade care matters when things stop being straightforward. Some of this may be uncomfortable to listen to, but that's okay. If parenting has taught us anything, it is that discomfort usually arrives whether you're invited it or not. Before we get into it, I want to say a genuine thank you to happytomi.ie for sponsoring the season of the baby tribe. Their support helps us make episodes like this, the ones that take time, research, and a fair bit of careful thinking. And if you like to support the show more directly, you can subscribe to Headstuff Plus, where you'll get access to the Baby Tribe shorts. Those are going to be shorter episodes where Anne and I break down the science, the headlines, and questions parents send us that don't always fit neatly into a full episode. And as always, follow the podcast, rate it, subscribe, or sharing it with somebody really does help more than you think. Alright, take a deep breath. Let's talk about breath, but not the Instagram version, the real one. Anne, happy new year.
SPEAKER_03Thanks. Happy New Year. We're just heading into like a little easy, easy wind in with a non-controversial topic, yeah.
SPEAKER_01Absolutely. It's gonna be fantastic. New Year, new me, and have taken up hiking. It's incredible.
SPEAKER_03Oh my god. Yes, he a fief a FIF now hikes. He does. I know, and I can confirm that.
SPEAKER_01And you know what, Anne? It's actually really good for your mental health and wellbeing.
SPEAKER_03I've I had no idea, FIF.
SPEAKER_01I know, and you should really try it.
SPEAKER_03Oh my god.
SPEAKER_01You should really, really try it.
SPEAKER_03It's the best to live close to the Dublin Mountains.
SPEAKER_01Yes.
SPEAKER_03And I've always loved going for walks up the Dublin Mountains, and you were completely allergic to it until until What? I used to ask you, I used to talk to you about how great it is for you on so many levels, and you'd be like, Yeah, I have zero interest.
SPEAKER_01Until I I I don't know what you're talking about.
SPEAKER_03One of your friends said, A thief, you should consider hiking. And he went, That is a great idea. And I've decided that if a blonde woman tells you something, you will do it. But until then, no.
SPEAKER_01Um, I don't know what you're talking about.
SPEAKER_03I know you don't. Yeah, yeah, yeah. Plausible deniability there, yeah.
SPEAKER_01I think that's the very blondest of you.
SPEAKER_03Blondest of me. Yeah. I'm gonna I'm actually seriously gonna invest in blonde wig. I'm just gonna put it in the kitchen press. And every time I need you to listen to me, I'm just gonna put it on.
SPEAKER_01When I first met her, she had blonde highlights and I think she lulled me.
SPEAKER_03Lulled you into a full sense of security. Now we've just got grey.
SPEAKER_01I know, I know, and I'm stuck now. Yeah, exactly. Yeah, and always says, if you need me to do something, send a blonde woman to ask me to do it. And I will just do it. Yeah. That's true. But anyway, hiking is great. It's great for um, you know, our mental health and well-being, and you should you should really consider it.
SPEAKER_03I swear I'm gonna actually, I need so if anybody out there knows of any kind of blonde woman who talks a lot about like kind of cold water immersion and sea swimming, because that's what I actually think he needs to get into. Um, can you just uh DM a fief with that link and uh just like literally like spam them with a load of blonde blonde people talking about how good sea swimming is for you? That'd be really helpful.
SPEAKER_01Oh, all of a sudden it sounds very appealing. Oh my god. So we've we've we've we've survived Christmas and um and by the way, guys, Ann didn't get me a present for Christmas.
SPEAKER_03I got you the present I always get you. Which is which is I don't give out when you buy something ridiculously some ridiculous expensive piece of tech for yourself that I can't figure out which one to buy for. That is true. So I just don't give out, and that is my Christmas present.
SPEAKER_01I did invest in a new PC. There's a RAM crisis going on, Anne, in the world. Have you heard about the RAM crisis?
SPEAKER_03Yes, Safe, because I don't need a blonde wig on your head to listen to you, so I'm aware of the RAM crisis. Thanks, Amelia.
SPEAKER_01So I invested in a new PC before this the price is skyrocketed. If anybody wants to buy a PC, buy it now, because in three months' time it's gonna like double or triple in price. That's what I've heard anyway. Anyway, let's focus on today's episode. And I am gonna start a timer, and because we are going to limit our tight, keep it tight and not waffle because you tend to waffle. And I would like to stop.
SPEAKER_03Him of the extraordinarily long, monotonous introductions, I tend to waffle, do I?
SPEAKER_01So why does this episode matter? Because and first of all, actually, I think we need to make a clear distinction between the two types of birth that we're going to talk about. The first one is free birthing.
SPEAKER_03Yes.
SPEAKER_01And then the next one, which we will focus on more, is home birth. So Anne, tell us the difference.
SPEAKER_03So a free birth um is a kind of a growing movement um internationally and uh was kind of uh mainly through social media, and it's essentially women who choose to under like undertake pretty much minimal or no medical care during their pregnancy and delivery. So it's done outside of any kind of medical system or medical care system at all. Yes. Okay, so there's no credentialed individuals undertaking kind of ultrasound screening and kind of doing all the checks that would normally happen in pregnancy antenately. They give birth with no trained medical assistant available or with them during their delivery, and they give birth essentially outside the the medical infrastructure, the healthcare infrastructure completely.
SPEAKER_01Yes, and how is that different to a home birth or a planned home birth?
SPEAKER_03So a home birth, a planned home birth is where somebody goes through all of the usual antenatal care, okay, with a trained midwife or combined care or potentially care within a hospital system but gives birth at home. So it's done and coordinated very much through the normal pathways of care available within that particular jurisdiction. Yes. Okay. And then at home, when they are labouring and ideally birthing at home, they have a trained midwife, potentially a second trained midwife as well as backup available to them. And they have a set kind of escalation plan with kind of knowledge of what that would entail, the timeline that that would take. They have um, you know, undertaking care with kind of the backup of hospital transfers available to them.
SPEAKER_01One thing important to mention is that women undergoing a planned home birth undergo a risk assessment.
SPEAKER_03Yeah, so really for a planned home birth, your pregnancy need to be deemed needs to be deemed a normal risk pregnancy.
SPEAKER_04Yeah.
SPEAKER_03So it's like pregnancy, as we all know, is never without risk, and that can change. So you can go from a normal risk to a higher risk depending on how your pregnancy progresses. But any patient who is of normal risk as per as as as assessed within a catchment area that allows or supports home birthing services could potentially request to see if it's possible for them.
SPEAKER_01And you said normal risk, not low risk.
SPEAKER_03No.
SPEAKER_01Why didn't you say low risk?
SPEAKER_03Because as we've discussed actually with Sam Coulter Smith and other people on the podcast, a low-risk pregnancy is kind of diagnosed after you've given birth, recovered from the pregnancy, and the baby as well. Yeah. So you know that you've had a low-risk pregnancy when everybody is all Hyundai P at the end of it. And I mean like a couple of months postpartum.
SPEAKER_04Yeah.
SPEAKER_03Because then you're back to toward moving toward a non-pregnant state and you haven't had any postpartum PET or any of those things. So that's a low-risk pregnancy. You know, you've had a low-risk pregnancy, but if you're currently pregnant and you've no risk factors, you're in a normal risk pregnancy. But one thing I will say is that like if you go back to free birthing, these are women who choose to conduct their pregnancy and give birth completely outside of the medical infrastructure available to them, okay, or the healthcare infrastructure available to them. And like that was the norm for like so so very long, like in our history as a species. But like if you look at the numbers from say 1870 onwards, in the UK and Ireland, we have reliable maternal mortality figures, okay? So the number of women who died related to being pregnant or giving birth. And that was about 40 or 50 women per thousand, okay, for the longest time, up until about the 1930s. So in Ireland, you're talking about like we now we measure it as like 100 out of 100,000 because it's a rare event. Okay, in Ireland, our current maternal mortality rate is about eight or nine per tho per 100,000. Okay. So if we have about 50,000 deliveries a year, which we do, you're talking about kind of about maybe four women per year dying related specifically to pregnancy and birth. The equivalent number of what that would be pre-1930, right, is in the thousands. It's about 2,000 women per year would have died in Ireland with the same birth rate.
SPEAKER_04Yes.
SPEAKER_03Okay. And what has changed that in the 1930s is a few things. Antibiotics. So really well-managed maternal sepsis, active management of labour, even though it's vilified, but uterotonics and having somebody who understands how to ensure that your labour progresses appropriately and troubleshoot it with you, changed things. And it dropped things like maternal hemorrhage. When women choose to give birth outside that infrastructure, you take on the risk of having none of those life-changing elements of care available to you. So that is the risk. You're talking about moving from three women a year back to the risk of 2,000 women a year. And I just think for me, it seems like a no-brainer.
SPEAKER_01And extending that to the baby as well.
SPEAKER_03Yeah, the the baby is a whole other kind of thing.
SPEAKER_01And a significant number of infants didn't see their first birthday.
SPEAKER_03Yes.
SPEAKER_01And with the you know, medical advancements, the neonatal resuscitation, the intensive care that we can provide, and also the antenatal scanning and monitoring of babies, and sometimes making decisions for the baby's well-being in terms of faltering growth or abnormal blood flow across the placenta, twin-to-twin transfusion, congenital anomalies that may dictate when you deliver a baby for various reasons. That has resulted in a massive reduction in neonatal mortality. So when if you avail of a free birth, you're basically putting your risk category.
SPEAKER_03Back to about 1920.
SPEAKER_01Yes, or even earlier. Even earlier. So that's free birth. It's never something that we would advocate, and we'll move on from it from now.
SPEAKER_03100%.
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SPEAKER_01Visit happytummy.ie to learn more and give your crew the gift of a happy tummy and a healthy smile. Hey there, Baby Tribe listeners. Did you know that we've got some amazing bonus material just for you? Baby Tribe Shorts is here. Quick evidence-based breakdown of all things science when it comes to mum and baby. You can find it as part of the Head Stuff Podcast Network. You can subscribe to Headstuff Plus for as little as 5 euro a month. We'll give you quick evidence-based takes on science behind maternal and infant health.
SPEAKER_03And the best part is it's just 5 euro a month, which helps support us and supports Headstuff and all the incredible shows they produce.
SPEAKER_01You can find all the details on Headstuff Podcasts.com. So let's now focus for the rest of the episode on home birth. There has been a lot of debate about home birth recently. There has been a couple of high-profile cases in the news, and I think people are looking for, I guess, objective information on the implications of having a home birth in the current infrastructure and what that means. We have to acknowledge that a lot of women are availing of home birth because there is this increasing sentiment of being scared or mistrustful of hospital care. You know, the recent surveys allude to the fact that that is there. And also, I think sometimes women are sold a fantasy online about home birth, where there is misinformation being pushed by sometimes people that aren't medically trained, such as Doolas, about the safety of home birth. And by and large, it is important to acknowledge that home birth done properly is generally safe for mother and baby.
SPEAKER_03I agree.
SPEAKER_01But we are not here to bash home birth. But I think we need to, I guess, talk about when things go wrong. And that's the issue that sometimes can increase the rate of adverse outcomes for both mum and baby.
SPEAKER_03Yeah.
SPEAKER_01Because you don't have immediate access to care.
SPEAKER_03Absolutely. So I think first of all, it's it's not just people who don't trust the system who would choose a home birth. I think for any woman, the idea of being able to give birth at home with a trusted midwife who has cared for you and you who you've gotten to know throughout the last nine months of your pregnancy really well, um, in the comfort of your home without having to deal with um a change of staff, change of shifts, you know, people that you don't know well, um, and then being able to sleep in your bed that night with your newborn baby, um, you know, in your arms. Um, like it's absolutely idyllic that idea, right? And I can understand why women would choose that if they feel like it is a safe option for them. But I think what we need to talk about is um the escalation of care and the infrastructure. Because as we said, like normal risk can change very, very quickly, especially in relating to childbirth and at the time of delivery for both you and the baby. So the infrastructure to respond to that is actually key to ensuring safety.
SPEAKER_01Pregnancy is unpredictable.
SPEAKER_03Yeah.
SPEAKER_01Women also find home birth attractive because we know that the rate of breastfeeding is higher. Yeah, the rate of C-sections is lower, yeah, the rate of obviously you know, interventions are lower.
SPEAKER_03Yeah.
SPEAKER_01But generally without an increase in the rate of adverse outcomes if the woman remains at normal risk throughout labor and delivery.
SPEAKER_03Okay.
SPEAKER_01Right.
SPEAKER_03But when you look at the absolute numbers, though, comparable for normal risk pregnancies delivery in pro in hospital versus normal risk pregnancy delivery at home in terms of neonatal outcomes, there's a difference.
SPEAKER_01There is a difference, and we'll talk about that. Yeah. So let's start with issues that can go wrong with mum.
SPEAKER_03Okay.
SPEAKER_01Okay. Because again, that's what's been, I guess, in the news and in the media recently. So let's talk about what can go wrong for mum at home.
SPEAKER_03Okay, so the big ticket items, right, in terms of delivery is things like maternal sepsis, maternal hemorrhage. Okay, and they're the two big things, peripartum, that would need medical intervention. They're also historically the two big issues that killed women in the past, okay? Um, before the 1930 introduction of the scientific management of labour and delivery. Okay. So those two things, like uh maternal sepsis, the thing with maternal sepsis, and we've talked about it before, is that the win the female physiology is designed to withstand so much um stress and challenges because she's spent the last eight months, nine months growing this baby, okay, which is a huge physiological stressor, and women do it very well. But it also means that women present rather late in terms of things like sepsis and septic shock. We have in hospital early warning signs and a score that's get get that gets measured and totted up to try and spot women who are showing early signs, and without that kind of level of management and observation, you don't necessarily catch it early enough. Yeah. Okay. The other thing is hemorrhage, so bleeding. Everybody knows that, and I've said it before, babies come out and they are covered in their mother's blood to some degree. Bleeding is a part of labor and delivery to some degree, okay? Um, but it can escalate. And like the rate of postpartum hemorrhage, so bleeding of an abnormal level, is about eight or nine percent and is consistent internationally. And in other countries without well-developed healthcare systems, it's much higher. That bleeding can be really significant and be really hemodynamically challenging, and it requires what would normal have normally happen in hospital is that you get a multidisciplinary team of midwives, obstetricians, and anesithists who will come in and do kind of rapid response assessment and escalation so that you get like re repeated and numerous different kinds of uh medications to try and help your uterus contract. You get um an obstetrician who's trained at looking at kind of any sorts of trauma or any tearing or anything like that might that might be contributing to bleeding. Um, and you have the the midwives who will spot this early and escalate it early and help with things like uterine massage and stuff like that to help make your uterus uh uterine tone and the the uterine contract nice and strongly afterwards. Um and that literally you'll and any woman who's had that um postpartum hemorrhage call go out will know that all of a sudden their room has a lot of people in it. Um, and everybody's just generally fairly quietly and consistently working through what needs to be done, and then we all potter off after a few minutes when it's all managed, and that's it for the most part.
SPEAKER_01So the key thing that I'm getting is that it's the response needs to be very quick, it's rapid, it's multidisciplinary, and sometimes and it's it's it's individualized. Yes, and sometimes the signs of a bleed can be very subtle initially.
SPEAKER_03Yeah, so women mask that again, we cope with so much so well. We really, really do. Um, and it it it's just estimating blood loss is is different for every woman, actually, as well. So don't forget everybody's a different size, everybody's a slightly different blood volume. So given a specific cutoff of X amount of mils is the problem, it doesn't work like that.
SPEAKER_01No, it doesn't. And I think it's worth emphasizing is that unlike a usual, I guess, um, deterioration in somebody where they slowly get worse, women around peripartum, because of their unique physiology with both sepsis and bleeding, can be fine, fine, fine, fine, fine, and then there's a sudden deterioration. Yes, you know, rather than the slow decline that you may spot before it's too late. Yeah. When the women show symptoms, it is likely at an advanced stage.
SPEAKER_03100%. Um and it's similar to kids, actually. Yeah, it's very similar to children. Um, and it's it's hard to spot illness in both of those populations. Yeah. And you kind of that's why we have so many different kinds of early warning scores and stuff like that to try and tease that out very early.
SPEAKER_01And I guess that demonstrates being at home in a situation like this is not ideal. And we'll talk about how sometimes there can be a delay in in getting help.
SPEAKER_03Well, I think that being at home with a trained midwife, yes, uh one or two trained midwives, um, who can spot that moment where things are tipping and moving away from what would be the expected care pathway.
SPEAKER_04Yes.
SPEAKER_03That's the key moment.
SPEAKER_04Yes.
SPEAKER_03And these women are I say women, but there's male midwives out to out there too. But these people are they're well trained.
SPEAKER_01But then sometimes there could be a delay in help coming arriving, right? And we'll talk about that because we have some data on this from a recent audit that we'll talk about in a minute. The other thing I guess I wanted to chat about would be amniotic fluid embolus.
SPEAKER_03It's exceedingly rare. You're looking at about maybe Three or five per 100,000 for severe amniotic fluid embolism. And it's it's a funny syndrome that it's hard to study because it is so exceedingly rare, but it can be a catastrophic event. So I wouldn't really put it under one of the more common events that can happen, people. It is it's one of those unpredictable catastrophic events that can happen relating to pregnancy, but again, exceedingly rare. So I don't think that you could build um a plan like plan a health service necessarily around that as something that would be that's fair enough.
SPEAKER_01I want to move on to issues that can happen with the baby in a home birth, and that's I guess where my discomfort with home birth comes from. Well, because of your specialty, because of my specialty, because I tend to see the worst-case scenarios.
SPEAKER_03Yes.
SPEAKER_01And I know and I acknowledge it is a bias. It is a bias, and it is somewhat uncommon, but we do see and we have data demonstrating that neonatal outcomes are worse when you compare normal risk women delivering in hospital versus normal risk women delivering at home.
SPEAKER_03Okay.
SPEAKER_01And the the big ones that we know about is neonatal mortality or death.
SPEAKER_03Okay, so that's a a binary outcome and it's quite severe.
SPEAKER_01Yes, exactly. So in hospital, the rate is between 0.5 to 1 per thousand deliveries.
SPEAKER_03Okay, so that's r so if even if you take the top level of that, you have one in a thousand chance of a normal risk woman having a neonatal de uh sorry, a neonatal death.
SPEAKER_01A neonatal death.
SPEAKER_03Okay, okay at home.
SPEAKER_01In hospital care. Yeah, in hospital care. At home, depending on which data you see. In Irish data, it is reported as 5.8. That's the latest figures that we have. So it's still about 0.6%.
SPEAKER_03Yeah.
SPEAKER_01But tiny number. Tiny number, but it is neonatal death that we're talking about.
SPEAKER_03Yeah. So when you're looking at risk, you look at the frequency of the event, but then you look at the severity of the event. Yeah. And like a very severe event, um, which is relatively uncommon, yeah, is still of more significance than a common event that it was really minor.
SPEAKER_01So if I was alarmist, I would say it is triple, right? And that headline, that you know, that is sometimes what media say as a headline figure.
SPEAKER_03However, it's more than triple, actually.
SPEAKER_01It's triple at best, you know, um six times, sixfold at worst. So, but you're going up from 0.1% to 0.6%. Yes. Right. We don't have hard data in Ireland about the rate of neonatal encephalopathy or hypoxic ischemic encephalopathy.
SPEAKER_03Okay, so that's a brain injury related to um oxygen limits, limited oxygen loan to the brain at birth.
SPEAKER_01In the states, it is around three to four times higher.
SPEAKER_03In hospital or at home?
SPEAKER_01At home compared to hospital. Plant home births compared to planned hospital births. I acknowledge that the system is different in the states, but that is that is the data that we have.
SPEAKER_03Okay. And do you think that's down to intrapartum monitoring? Do you think that's down to uh issues at the time of delivery? Because obviously instrumental births and stuff like that in a hospital would be significantly higher because they would not really be done in a home environment.
SPEAKER_01It's a combination, but if you stick to an inatal resuscitation, there's only so much you can do outside of a hospital setting in terms of resuscitating an Eonate that is not breathing.
SPEAKER_03But a midwife is trained to do that initial those initial steps.
SPEAKER_01They're trained to do the initial steps of bag and mask, but if that is not working, then the next step cannot happen until you reach hospital.
SPEAKER_03What is the next step?
SPEAKER_01Which is intubation, fluid resuscitation, okay, and all of those things.
SPEAKER_03So putting a tube down between the vocal cords and giving some breaths down through that tube directly into the lungs.
SPEAKER_01Yes, but also getting emergency access to the umbilical cord if there was significant blood loss for mum and baby to resuscitate the baby circulation, looking for pneumothoraces, which are air leaks that need to be managed that way.
SPEAKER_03So So pneumothoraces.
SPEAKER_01Yes.
SPEAKER_03So that is literally like a little collapsed lung on one side. Yeah. Okay. And that can happen in normal babies in normal deliveries. And it's what's the incidence?
SPEAKER_01So if you if you x-rayed a hundred babies that are happily sitting on the postnatal board, yes, there's a like five to ten percent of them will have some some degree of pneumothorax. And that will self-resolve and go away. These aren't the ones I'm talking about.
SPEAKER_03Okay. I find that really interesting because in adults it's like a big deal. Yeah. But obviously, in babies, and that's because of the pressure changes in their lungs when they take their first breath, because that first breath is such a big thing. Yeah.
SPEAKER_01Yeah.
SPEAKER_03Okay. So normal babies can have small little degrees of collapse in their lungs when they take their first breath because it's a big deal.
SPEAKER_01Yeah, because one thing that made me uncomfortable that I heard in the media was a description that kneonatal resuscitation can fully be done at home if need be. And that is not true. The initial steps can be done. Yes. And that is good for the majority of babies.
SPEAKER_03Yes, and it that's actually a very good point.
SPEAKER_01Yes.
SPEAKER_03The vast majority of babies do not need that extra step that's done in a hospital that requires hospital care. What's the number of babies that would require that to be done?
SPEAKER_01So about 10% of babies will need some form of resuscitation.
SPEAKER_03Okay, that's fine. That's the that's the support into trans transitioning.
SPEAKER_01And then 1% will need the additional steps that I talked about.
SPEAKER_03So 1% of all babies? Yes. Okay, so all babies out if you take okay, that's a lot.
SPEAKER_01So it is a big number.
SPEAKER_03That's actually a lot.
SPEAKER_01Yeah, it is a big number. And that's why we have a neonatal resuscitation team available 24-7 in the hospital.
SPEAKER_03Like 50,000 births happen in this hospital in this country year.
SPEAKER_01And and unlike with adults where parabedics can intubate, yes. They can't do that for babies.
SPEAKER_03Babies. So it's 500 babies a year require some degree of intubation for some period of time for lung support.
SPEAKER_01Exactly. And sometimes for longer. So things, you know, for shoulder dystosia.
SPEAKER_03And these are term babies normal pregnancies.
SPEAKER_01I'm just talking about term babies. Yeah. Okay, term babies.
SPEAKER_03Okay.
SPEAKER_01So shoulder dystosia, if it happens in the community, that can be an issue. A cord prolapse.
SPEAKER_03Yes. We had this conversation, and I said, I don't think you can include cord prolapse because any woman whose membranes go at home can have a cord prolapse. Yes. It's not to do with laboring and delivering at home. Correct, but the response. Membranes rupturing and they rupture where they rupture.
SPEAKER_01I'm not saying that that increases that that having a home birth increases the risk of it. I'm saying the response to a cord prolapse.
SPEAKER_03Yeah. Would be the same as if you had a cord prolapse walking down the street, love.
SPEAKER_01Yeah. So true.
SPEAKER_03But I don't, that's what I mean. I think there's I wouldn't put it into the home birth category necessarily.
SPEAKER_01And then the you know, failure to breathe at birth can sometimes happen. And again, if you can't after all of the steps of manipulation of the mask, can't get the baby to breathe, the next step is transferring the baby to the hospital. Yeah. And I want to then in a minute talk about the transfer if needed issue.
SPEAKER_03Yeah.
SPEAKER_01Um, but before that, I want to mention labouring in water and birthing in water.
SPEAKER_03Okay. So it is it's becoming more popular because the pain relief element with it, uh the maternal satisfaction from like labouring in water as pain relief is is very good apparently. Now I've never tried it myself. And obviously, I only tend to see women who, if they've gone for that option, it hasn't worked to the degree that they want it. So they they're looking for alternative options. So um, but I do one of my colleagues always says, like what we worry about is things like um eternal collapse or a complication while they're in the pool.
SPEAKER_04Yes.
SPEAKER_03Because as as one of my friends uh work always says, I'm only qualified to resuscitate on land. But yeah, it's a joke, I promise. We would always help.
SPEAKER_01Labouring in water is safe in general, but there has been a move to birthing in water as well, and that is happening.
SPEAKER_03Yeah.
SPEAKER_01Right? And that is where my concern happens.
SPEAKER_03Okay.
SPEAKER_01There are documented case reports. Now we do not know the exact incidence because it's relatively new and we never have the denominator. We have cases of freshwater drowning where the babies inhale the hypotonic water, it goes into their lungs, and then they they drown. And I've personally cared for two babies like this now in my 10-year career as a few years.
SPEAKER_03You have again, I I will I'll caveat what you're saying. Right. Okay, because you have to remember that like what you're talking about is a massively severe permanent outcome. Yes. Okay, but it is a minority. So in the 20 years as a consultant, yeah, there's been 50,000 babies born a year, right?
SPEAKER_01Yes, but we don't know the problem is the denominator of water births is unknown.
SPEAKER_03This is true.
SPEAKER_01Okay, so and that's my issue. The second thing is we can have what is called hyponatremia, and that is far more common, and that can lead to seizures in babies.
SPEAKER_03Two things we need to explain. First of all, you said hypotonic.
SPEAKER_01Yes.
SPEAKER_03Right? And what we mean by that, okay. So our bodies are built on salt water, okay. Uh we have a certain amount of salt in our blood that keeps everything in terms of how various molecules move across membranes for signaling and all this kind of stuff. It's how we're designed. We're a sack of salt water. Um, and obviously the water that comes out of your tap is just water. There's no salt in it. Yeah. Okay. So when our salt levels as in our species drop past a critical point, it can cause a significant problem in our brains because our nerve signaling gets interrupted and it can have a huge amount of follow-on consequences, like seizures and confusion and unconsciousness, and then like prolonged other issues, right? So obviously, because we are designed to only work within a specific concentration of salt in our bodies.
SPEAKER_01Okay. So and again, I've cared with a few of those babies throughout the years where their salt levels became so low that they ended up having seizures.
SPEAKER_03Okay.
SPEAKER_01Um, because they inhaled fresh water into their lungs, and then that water seeped into their bloodstream and lowered the concentration of everything, of salt and everything. And then the third issue that I've dealt with But how common is that? So I don't we do not know how common they are. We just know that they happen. They are not common.
SPEAKER_03They happen rarely.
SPEAKER_01They happen rarely, but we're only labeling it rarely now because we do not really have a good grasp of the denominator. Okay. Most women only labor in water.
SPEAKER_03And give birth on land.
SPEAKER_01And give birth on land, right? Okay. The risks of these things happening is extremely low. Good. Okay. I am talking about out of the women that end up delivering in water, if we do not have the denominator of that, we don't know how how what the incidence is. It does happen, but I don't know how common it is. It is likely rare. Okay. The third thing that we need to think about is it increases your infection rates of pseudo monas and lesionella as well in babies. And these are waterborne things that babies can get. So it is not without risk delivering in water. Okay. And these risks do not happen when you deliver on land. On land.
SPEAKER_03Yeah.
SPEAKER_01And that's important to be acknowledged, right? So whoever tells you the birthing in water is as safe for baby, it is not.
SPEAKER_03Okay.
SPEAKER_01Okay. And that's important.
SPEAKER_03What you're saying is that birthing on water is not as safe, and we do not have enough information to adequately assess the risks.
SPEAKER_01Correct.
SPEAKER_03But we have anecdotal individual cases. Yes.
SPEAKER_01And they're reported in the literature. And you know, the the before we finish, I just want to talk about the transfer time.
SPEAKER_03Transfer time. This is this is actually a huge part of the infrastructural components that we actually really need to address because we talk about all of these risks and stuff like that and the escalation of care. But really, like what has to be identified is for the Irish service, because it is literally individualized to various different regions of Ireland.
SPEAKER_01Yeah.
SPEAKER_03Like what does a transfer time mean?
SPEAKER_01Yeah. So there has been an audit recently. And but before we do that, I just want to talk about the kinds of transfers that happen.
SPEAKER_03Yes. Okay.
SPEAKER_01There are some preventative transfers.
SPEAKER_03Okay, yes.
SPEAKER_01And there are some reactive transfers.
SPEAKER_03That's a very good way to look at it.
SPEAKER_01So, you know, some of the transfers from labouring at home could be a mum has decided that she would like an epidural.
SPEAKER_03Yeah, that's fair.
SPEAKER_01Okay.
SPEAKER_03Or the midwife was monitoring and found some of those flags that said this is the time to transfer, and she's preempting the increasing risk, which is very appropriate.
SPEAKER_01And usually things end up being fine.
SPEAKER_03But it was just Yes, but it's the right decision to make.
SPEAKER_01Absolutely, 100%.
SPEAKER_03Things do not end up being fine and she's still in the right place and things go okay because she's there.
SPEAKER_01Yeah. And and in that situation, a transfer can be regarded as a safety net.
SPEAKER_03Yes.
SPEAKER_01Okay. But sometimes a transfer becomes damage control rather than a safety net. Yes. And that's when you get this unexpected postpartum hemorrhage. Yes. Right. Um or a difficult delivery with the neonatal. Difficult delivery and neonaton collapse. So we do have an audit, and there has been this arbitrary cutoff that it should be 30 minutes.
SPEAKER_03Okay. And do we know what that was based on?
SPEAKER_01It's not based on any hard evidence. Okay. It's based on I think looking at data showing that by and large things are okay if the transfer time is less than 30 minutes. However, as you alluded to earlier, if there's a large hemorrhage, significant hemorrhage, half an hour is way too long. And what we forget is half an hour is the door-to-door driving distance.
SPEAKER_03It's not the ambulance finding the right house.
SPEAKER_01Yes.
SPEAKER_03It's not the assessment from the paramedics.
SPEAKER_01Yes.
SPEAKER_03It's not the, you know, yeah.
SPEAKER_01And it's not the time it takes to make a decision to call, right? There sometimes can be a delay in calling the ambulance, a delay in recognizing how significant the hemorrhage is. And then, like you said, a delay in the ambulance being dispatched, a delay in the ambulance arriving. The transfer time usually just counts from the time apparently.
SPEAKER_03If you live within a half an hour drive of the hospital.
SPEAKER_01Yes. So it doesn't take into account all of that. So it's never really half an hour.
SPEAKER_03Okay. Unless you have an ambulance outside your door.
SPEAKER_01Which is never the case.
SPEAKER_03No.
SPEAKER_01Right? That's never the case.
SPEAKER_03So there has been an audit and what they one thing I would say though is like for most home birth policy infrastructures, when there is a home birth happening, there's usually a call made to the ambulance services to say that this is happening in this house. Yes. So if you get a call, this is the context of it. So that's done as part of their policy preemptively.
SPEAKER_01But sometimes there's a misconception that there's an ambulance on standby. Okay. And there isn't. No, because we do not have that infrastructure. That is not the case. No, we don't. And you know, and that comes from the ambulance service themselves. Yeah. I've heard people go on the radio and say there's an ambulance on standby.
SPEAKER_03No, there's no ambulance on standby, but they're happy to have the information and the knowledge to know that something is happening. Yes. In case they need to respond.
SPEAKER_01Okay. So there was an audit of the HSC Home Birth Service covering 2012 to 2021, so a 10-year period.
SPEAKER_04Okay.
SPEAKER_01Okay. And they basically wanted to look at the outcomes of mothers, and this is really welcome information, because up until now that has been missing. The outcomes of mothers and babies that have been transferred from laboring at home to the hospital.
SPEAKER_03Okay. And do we know if they were antenatal transfers or postpartum transfers?
SPEAKER_01A mixture. There was a significant proportion of outcomes that were missing in this audit, and that made me um a little bit wary. Neonatal outcomes were not recorded in about a third of cases, which is a big number. Okay.
SPEAKER_03Like neonatal outcomes, for example, like death, need for resuscitation. Okay.
SPEAKER_01So these were missing in a third of cases. Maternal outcomes such as ICU or HDU admissions were unrecorded in over 40%.
SPEAKER_03Okay. So of the women who transferred from home because of issues, we do not know ultimately what level of care they required in terms of escalation.
SPEAKER_01Yes.
SPEAKER_03Okay.
SPEAKER_01Missing data and safety and research are not reassuring. There was also no data collected on HIE. So we have no idea.
SPEAKER_03So of the babies who were transferred to hospital, we don't know how many of those babies ended up with that diagnosis relating to oxygen delivery to the brain at birth. Okay.
SPEAKER_01I attended the presentation live and they acknowledged that they should have collected. There was a limitation, but they didn't. Okay. So there were 2,615 women who registered for a planned home birth. About three-quarters actually went into labor at home. And one in five required an interpartum transfer. So this isn't something that is not common. For first-time mothers, it was half. So half of the first-time mothers labouring at home ended up being transferred. And yes, acknowledge a lot of them. Does that make sense? Yeah, for epiderals.
SPEAKER_03Because the labor is longer.
SPEAKER_01Yeah.
SPEAKER_03The pain relief requests across the board worldwide are higher in first time mothers, first time first-time mothers. Your uterus is different on your second labor and delivery because it learns a lot the first time around. It's an amazing organ. So all of that is appropriate, I think.
SPEAKER_01And then for women who had given birth before, the rate was one in ten. Right?
SPEAKER_03Yeah, fine.
SPEAKER_01Here's um the transfer times. So the median transfer time was 30 minutes.
SPEAKER_03Okay.
SPEAKER_0157% arrived within 30 minutes. One in five took longer than 45, and nearly one in ten took over an hour. But that is only travel time. Doesn't include decision-making delay, calling the emergency services, ambulance arrival, handover and arrival. To me, if something goes wrong, that is delayed care. And there's no other ways around it.
SPEAKER_03Yeah, it's delayed access to multidisciplinary and escalated kind of infrastructures that that that's needed.
SPEAKER_01Absolutely. And for mothers, 40% required either an instrumental delivery or a C-section, which makes sense.
SPEAKER_03That's that's in line with inter in like with national numbers.
SPEAKER_01And nearly a quarter had a postpartum hemorrhage.
SPEAKER_03Okay, so that's higher, that would be higher than a hospital birth postpartum hemorrhage rates, which are in or around about 9%, 8, 9% in most places.
SPEAKER_01Planning to transfer if needed is not always a safety strategy. And we need to accept that in some cases definitive care is going to be delayed for some women.
SPEAKER_03It's a real problem though, because obviously women are, you know, there's a more and more kind of a greater push toward being able to have home birth as an option. Yeah. Because there are women who really do not want to go into hospital.
SPEAKER_01Yeah.
SPEAKER_03Um, and for a variety of reasons.
SPEAKER_01Yeah.
SPEAKER_03Um, so we need to look at that.
SPEAKER_01Absolutely. And one thing I wanted to also mention that I f that I didn't is the rate of neonatal death in the transfer group is eight per thousand. So it jumps up a little bit more again. So when something goes wrong for a baby, again, delayed care.
SPEAKER_02It's still a low number.
SPEAKER_01It's still it's 0.8%. But it's it's much higher than the 0.1% in hospitals.
SPEAKER_03I know. And you see, the people would then argue the the coral I am plain devil's advocate on purpose, but yeah, like you know, 992 babies were were fine.
SPEAKER_01And but but alive. And and I am not saying this to say that all of this is bad.
SPEAKER_02No, it's a bad thing. I am saying this this is what the number says.
SPEAKER_01This is what the number says. This is what an informed decision is.
SPEAKER_02Yeah.
SPEAKER_01Right? If you accept those risks, you're not a bad person. There's still very low risks. But having somebody say it is as safe for babies as a hospital birth, that is factually incorrect.
SPEAKER_03I think what we can take from this is that we do need to look at what's driving women to look for labour and delivery outside of the hospital infrastructure. And I think like there's enough um data out there now that we should look at it in another episode. Yes, right. Because, like in terms of maternal satisfaction scores and the reasons why women are seeking this out and highlighting the need to have this as a safe option, no matter how much we would like it to be comparable, it's not completely comparable in terms of outcomes. Yes, right, and that is even though you know the vast majority of mothers and babies do very well, it's still not comparable. If you want the safest place with the lowest number of maternal mortality, maternal morbidity, neonatal morbidity, neonatal mortality, yeah, it's still a hospital. Yeah. Okay. But I think that the the safety net component for home birth in terms of accessing the multidisciplinary care, the infrastructure, the monitoring, the escalated interventions, which are necessary, yeah, even if not desired. Yes, they are necessary sometimes.
SPEAKER_01Yeah.
SPEAKER_03We just don't have that in place in Ireland. It's it's it's a compromise.
SPEAKER_01Yeah, absolutely. And I think there has been a recent push on social media in terms of the importance and the value of certain outcomes over others when it comes to childbirth, right? The experience is being over-emphasized and the clinical outcomes is being downplayed by certain individuals, and I think we need to reframe that conversation. These are all important. The experience of birth, feeling listened to, and all of those things are absolutely 100% important, and we'll talk about that more in a future episode. But we also need to bring into the conversation the fact that there is a small increase in risks for baby and mum.
SPEAKER_03But that the outcome of those risks is binary, it's death, death, you know, death and significant morbidity. So, yeah, like like I said, when you're looking, it might be a small increase, yeah, but the severity of outcome with that small increase in numbers is really significant. So it's not a small thing. So that's fair.
SPEAKER_01To conclude, birth can be beautiful, but birth can also turn in minutes. And loving your baby means planning for the boring clinical life-saving stuff too. And we know that this conversation may have been uncomfortable for some people, but that is fine. Discomfort is better than silence. And on that bombshell, we will chat to you next week. The Baby Tribe is proudly sponsored by Happytummy.ie, the exclusive distributor of Bayagaya Probiotics, providing support for gut and oral health for the whole family.
SPEAKER_00This show is part of the Headstuff Podcast Network, a hub for the creative and the curious. Shows are produced in association with Headstuff and the Podcast Studios Dublin. Find out more or become a member at Headstuff Podcasts.com.