Home birth, all you need to know

When it comes to pregnancy and childbirth, one of the most controversial topics is undoubtedly home birth.

It divides the experts (doctors and midwives) and also divides women, between those who do not even want to hear about them and those who imagine the house as the more intimate and respectful place in which to bring your child into the world.

It is certainly a topic that is talked about a lot, even if it is little known and burdened by many prejudices. Let's try to do some clarity.

Read also: Natural childbirth, the 10 things to know

Home births, how many are in the country

Let's face it immediately: we do not have a precise data on how many births at home in our country. "An official register is missing" confirms midwife Marta Campiotti, president of the National Association of Midwives for home and maternity home births.

Cedap data, birth assistance certificates, are also often incomplete. “In many regions they do not have a specific entry for home or maternity home births, so the data is missing or comes from very different situations. Because it is one thing to speak of a planned and assisted home birth from midwives, another account of a hasty, unscheduled birth that occurs in emergency conditions, perhaps not even at home but in the car ".

The latest report on Cedaps from the Ministry of Health states that in 2022 they would have been less than one in a thousand - that is, less than 500 - children born outside public or private hospitals. But it's definitely an underestimated number. According to Campiotti, in 2022 the only midwives affiliated to his association (the largest in the country) would have attended about 800 births at home. To which must be added the births assisted by specialists from other associations, such as Olpi, or without special affiliations.

Who prefers to give birth at home

A first identikit of Del Paesene mothers who prefer to give birth at home are the results of a survey conducted in collaboration between the Association of obstetricians for home birth and the Laboratory for maternal and child health of the Mario Negri Institute. of our city, led by Maurizio Bonati.

"We analyzed the data of about 600 pregnant women followed by the association's midwives between 2022 and 2022: of these, 443 actually gave birth at home or (some) in the maternity home," says researcher Rita Campi. "By comparing their characteristics with those of women who have given birth in the hospital, we have seen that they typically have a higher education level andespecially in the Center North, in particular in Emilia, Piedmont and Marche. Regions that offer the possibility of reimbursement and have a good number of midwives specialized precisely in home birth ".

It was a strong force that pushed these women to stay at home deso of intimacy and the desire for naturalness to begin the experience of motherhood. Or a previous bad hospital experience.

Birth position, hospital transfers and cord cutting

The data made available by the Association, however, also tell much more. For example, none of the 443 women followed required an emergency transfer to hospital during labor and delivery. "Seven of them were hospitalized after giving birth, as well as 11 newborns, but there were no adverse events, that is, cases of maternal or neonatal mortality "states Campiotti, who nevertheless underlines the need to continue with a widespread data collection in order to have an even more precise idea of ​​the situation.

Only 17% of the women followed gave birth in a lying position: many preferred one kneeling position (36%) or squatting (27%). The cord was never cut immediately after birth: in half of the cases the cut took place within one hour, in a quarter of cases within 12 hours (mini lotus birth) and in the remaining quarter the practice of lotus birth, which consists of leaving the cord attached to the placenta until it detaches by itself.

Read also: Cutting the cord, when to do it

I leave in the event, but is it safe or not?

The terrain of the clash between supporters and detractors of home birth concerns safety, for mother and child. The clearest opposition to home births today comes from many gynecologists but above all from neonatologists of the Del Paesena Society of Neonatology (SIN), who periodically define it as a "risky choice".

"Even in ideal conditions - reads a statement from 2022 (but the position was clearly reaffirmed in 2022) - it is not possible to exclude the possibility that they will arise. complications that would put the health of mother and baby at risk and that would imply a necessary and immediate transfer to hospital, which in itself is risky ". Furthermore, it must be considered that there would be a increased risk of neonatal diseases compared to a planned delivery in the hospital.

As specified in the document, the SIN shares the position of the American College of Obstetricians and Gynecologists (ACOG), which in its latest statement on the subject, updated in April 2022, concludes that " accredited hospitals and birth centers as the safest place to give birth"At the same time, however, he stresses that compliance with certain conditions allows for make the outcome of home birth more favorable. In particular:

• appropriate selection of women "candidate";
• assistance from specialized midwives;
• adequate distance from the hospital.

"Despite some jokes, home birth today is certainly not that of our great-grandmothers"says the anthropologist Patrizia Quattrocchi, who for some years has been dealing with childbirth out of hospital." Today the midwives who assist have skills and abilities acquired in university courses and work safely, following precise guidelines based on scientific evidence and collaborating with doctors and health facilities ". As if to say: at home, yes, but not for this left to itself.

Even according to Maurizio Bonati, director of the Laboratory for maternal and child health of the Mario Negri Institute in our city, there is no need to polarize the conflict: "Now many studies document that in the women without risk factors, followed appropriately during pregnancy e with appropriate assistance during labor, delivery and in the hours following, the risk of giving birth at home or in the maternity home is similar to that of giving birth in a hospital ".

The reference is, for example, to the Guidelines of the NICE, the British institute for clinical excellence, published in 2022 and updated in 2022, or to a systematic review by the Cochrane Collaboration, according to which there is not, at the moment, sufficient data to recommend delivery in hospital over home birth (or vice versa), again for low-risk women.

Also read: I leave in the event, that's when it's safe according to the Great Britain Guidelines

Obviously, "similar risk between home and hospital" does not mean that there is no risk, but that what exists is independent of the place of birth and instead depends on other factors, such as staff preparation or the enlarged support network, which must include a hospital capable of providing adequate care.

Campiotti explains it with a metaphor: "Asking whether home birth is safe or not is like asking whether it is safe to drive. It depends. If you get behind the wheel without a license and travel at insane speed without clearly respecting the road signs. it is not. If you take your driving license, respect the highway code, don't talk on your cell phone and so on, it becomes an activity with minimal and acceptable risk. zero risk does not exist for any human activity".

Read also: Fear of childbirth, how to deal with it

What the English Guidelines say

The British NICE Guidelines are undoubtedly the reference point for any advocate of home birth and say that this place can be considered as safe as the hospital for women who have already given birth and are at low risk of complications. In these cases there are no differences with respect to neonatal outcomes, while invasive medical procedures such as episiotomy, caesarean section or use of a suction cup decrease for the mother.

If, on the other hand, it is the first birth, home birth is associated with a increased risk of complications for the newborn. True we talk about however very low absolute risks, but it is a fact that the woman must be informed of and that she must take into consideration when deciding where to give birth.

A matter of free choice

According to Patrizia Quattrocchi, it makes no sense to ideologically oppose different models, but we must call into question the right to free choice.

“There are women who could never give birth at home, and women who, although they could, certainly would not want to do so and believe that childbirth in hospital is the most appropriate to their expectations and needs. Well, so be it, obviously respecting their times, their needs and their physiology. At the same time, it would be absurd to propose home birth to all women ".

Read also: Violence in the delivery room, 21% of women suffer it

Of course, the fact remains that, beyond any ideological prejudices, the choice in our country, at this moment, is only relatively free. Because it is not enough to say that according to international scientific literature "it can be done". The conditions are needed to do so, and these do not always exist, whether it is availability of trained personnel (in the South the midwives specialized in home birth are very few) or disposable income (home birth costs and there are few regions that reimburse it).

How it works in Del Paese

For a woman who desires to give birth at home, in Del Paese, today there are two main possibilities (one, the first, still limited to very few realities). Here they are:

1. Childbirth assisted by a hospital midwife - it can be done in Turin, using the Sant'Anna Hospital, or in Reggio Emilia (Santa Maria Nuova Hospital) - or by a midwife of the clinic, in Modena and Parma. Either way the costs are paid by the National Health Service.

2. Childbirth assisted by a freelance midwife. The costs are borne by the woman, but in some regions reimbursements are provided, up to 80% of the expenditure and often up to a maximum of 1000 euros. It happens in Emilia of the city, Piedmont, Lazio, Marche and in the provinces of Trento and Bolzano. The Regional Council of the Calabria it is deliberating a law on the subject: it has just passed the scrutiny of the Health Commission, now it must pass that of the Budget Commission. Final approval is expected in early 2022.

Childbirth at home, how much does it cost?

In Del Paese, a home birth costs on average 2300-2500 euros. "But be careful - explains Quattrocchi - we are only talking about childbirth". Post-partum has to be counted separately (some midwives offer a "puerpuerum package") and the same goes for individual visits during pregnancy, if you want to be followed by a private midwife. After all, these are freelancers, each with its own tariff (there is no category): generally the costs of the various phases of assistance are clarified in the very first meetings, so that the woman knows exactly what she is going to meet. .

Who can do it

The Association chaired by Campiotti has drawn up guidelines for labor and physiological delivery at home and in the maternity home. "They are inspired by the English ones, but also by the guidelines for physiological pregnancy and those on caesarean section of our Higher Institute of Health" says the midwife. Similar guidelines are proposed by the various regions that mention the possibility of home birth.

Fundamental requirements to give birth safely at home I am one physiological pregnancy, ie low risk, elonset of labor at the "right" time, i.e. between 37 and 41 + 6 weeks. The mother must not have a fever or high blood pressure. The fetus must be single, with cephalic presentation and heart rate without alteration.

Women with twin pregnancies and those with babies in positions other than the head are therefore excluded from the possibility of giving birth at home. And again, you have to go to the hospital in case of:

• chronic maternal diseases, such as heart disease or epilepsy;
• gestational diabetes, especially if treated with insulin;
• uterine malformations;
• obesity;
• pre-eclampsia;
• fetal pathology, such as severe growth retardation or, conversely, macrosomia, malformations.

Home birth, the stages

"In the case of a birth that will be followed by a freelance midwife - or better yet by two midwives, as the guidelines of the Association suggest - the ideal thing to do is to think about it in time, to get in touch with the professional as soon as possible "suggests Marta Campiotti. In any case, better not to go beyond 28-32 weeks of pregnancy.

Midwives who assist home births do not have to be registered in special registers: like all midwives, they must be enrolled in provincial obstetric colleges and can be members of particular associations (obviously this is not compulsory). It is important to verify that they have made gods specific courses on home emergency management: "Our associates do it every two years" says Campiotti.

Definitive taking in charge, with the signing of a document that commits the midwife or midwives to being available, usually takes place a couple of weeks before the deadline. Only at the end, in fact, does one see if everything is really going well and there are no obstacles.

When the time X comes, the midwife arrives: "Often the first phase of the birth attends only one and the second arrives when the expulsive phase approaches, but different arrangements can also be made" explains Campiotti.

Read also: The stages of childbirth

Choosing to give birth at home means privileging an intimate, discreet, "natural" and familiar environment. The midwife, therefore, tends to intervene as little as possible: if there are no particular conditions, for example, obstetric visits are made every three, four hours, no more.

Immediately after birth, the baby is covered and placed on the mother's chest, in skin-to-skin contact. The cord is not cut immediately: usually after about an hour, or even later. Meanwhile, the afterbirth occurs, that is, the expulsion of the placenta. "Generally we stay with the mother and the baby for about three to five hours after the birth, checking the mother's pressure and heart rate, the loss of blood, the fact that she pees and the baby's attachment "says Campiotti. And in the meantime the pediatrician is notified, who will usually visit the baby 10-12 hours later childbirth.

But that's not all: the midwife comes back to see mother and baby every day for the first 3-5 days after the birth, and a few more times up to 10 days after delivery. In these visits, both the clinical parameters of the mother and the newborn are evaluated (including the physiological decrease, weight regain, the emission of meconium and urine), and the emotional and "managerial" aspects of the first days together. In addition, two days after birth the midwife gives the newborn the test for the screening of metabolic diseases, collecting a drop of blood that is sent to the reference laboratories.

Read also: The feces of the newborn, everything you need to know

What if there is an emergency?

The NICE Guidelines clearly state that, in the case of a low-risk pregnancy, the birth event is generally very safe, for both mother and baby.

But it is useless to hide behind a finger: "generally" does not mean "always" and there is a possibility that something will go wrong. It happens in the hospital (tragic news stories are reminded periodically), and it can also happen at home.

Campiotti, however, insists that - in case of adequate assistance - there are no particular additional risks in giving birth at home. "It is not just a question of training the midwives, but also of the fact that we work as a team. When labor begins, we alert our referral hospital, which in any case must never be more than 30-40 minutes away from home. And if we have to wait for an ambulance, we know how to handle the emergency in the meantime. "

Not just home or hospital: maternity homes and birth centers

Although in Del Paese they are not yet widespread, there are two other possibilities for women who do not want a classic hospital birth, but do not even feel like staying at home: they are maternity homes and birth centers.

Le maternity homes they are structures managed completely by midwives. They are not health facilities, therefore they are not linked to a hospital either from an administrative or a physical point of view. The same characteristics of intimacy and safeguarding of physiology are maintained as in home birth. According to Marta Campiotti they could represent the future, even more than birth at home. In Del Paese there aren't many, here they are:
- The Milky Way in our city;
- Montallegro in the province of the city;
- The oak in the province of Como;
- First light in Turin
- The nest in Bologna;
- Caterina's house in Trieste;
- Zoe and The Town's Nest.

The birth centers (or birth houses) instead they are structures intra-hospital. "They are always managed by midwives - specifies Patrizia Quattrocchi - but they are physically placed inside a hospital, and therefore dependent, even symbolically, on the medical approach". They are:
- San Martino Hospital in Genoa;
- Careggi hospital in the city (La margherita birth center);
- Sant'Anna Hospital in Turin;
- San Luca di Trecenta Hospital (Rovigo);
- Hospital of Cittiglio (Varese);
- Valduce Hospital in Como;
- University Hospital of Modena.

(Photo credit: Anathea/Flickr)

Updated on 07.06.2022

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• I am leaving at home
• place of birth
• maternity home
• birth center