Planned Home Births in Ireland Annual Report 2012

Planned Home Births in Ireland

ANNUAL REPORT 2012

Planned Home Births in Ireland

ANNUAL REPORT 2012 Citation for this report: Meaney S, Sweeney S, Delaney J, Corcoran P, Greene RA, Sugrue S. Planned Home Births in Ireland Annual 0071000 083 Duggan by Design/Artwork Report 2012; HSE National Home Birth Service provided by Self Employed Community Midwives. Cork: Health Service Executive, 2013

Funded by the Irish Health Service Executive

Printed by Woodland Print and Design, 307 Harbour Point Business Park, Little Island, Cork.

Contact: National Perinatal Epidemiology Centre, Department of Obstetrics and Gynaecology, UCC, 5th Floor, Cork University Maternity Hospital, Wilton, Cork, Ireland +353 21 4205017 [email protected] www.ucc.ie/en/npec/ Contents

List of figures...... Page 4 List of tables...... Page 5 Acknowledgements...... Page 6 Background...... Page 8 Methods...... Page 11 Results...... Page 13 Summary...... Page 31 Appendix A: Designated Midwife Officers...... Page 33 Appendix B: Medical conditions and other factors indicating increased risk suggesting planned birth at an obstetric unit...... Page 34 Appendix C: Medical conditions and other factors indicating individual assessment when planning place of birth...... Page 36 Appendix D: Indications for intrapartum transfer...... Page 38 Appendix E: Indications for postpartum transfer...... Page 39

3 List of figures

Figure 1: Pathway of care for planned home birth enquiries...... Page 10 Figure 2: Flow of information in the NPEC data collection process...... Page 11 Figure 3: Flowchart of planned home births...... Page 13 Figure 4: Percentage of births by month, 2012...... Page 14 Figure 5: Duration of labour (hours completed) by parity, 2012...... Page 23 Figure 6: Management of the third stage...... Page 24 Figure 7: Pain relief used by women delivered in the home, 2012...... Page 25 Figure 8: Estimated blood loss for women who delivered in the home, 2012...... Page 26 Figure 9: Distribution of birth weight in babies delivered in the home, 2012...... Page 27 Figure 10: Apgar scores at 1 and 5 minutes for babies delivered in the home, 2012...... Page 27

4 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 List of tables

Table 1: Distribution of mothers intending on having a home birth by HSE, 2012...... Page 14 Table 2: Age distribution of mothers intending on having a home birth, 2012...... Page 15 Table 3: Marital status of women intending on having a home birth, 2012...... Page 15 Table 4: Ethnicity of women intending on having a home birth, 2012...... Page16 Table 5: Weeks gestation at date of booking, 2012...... Page 16 Table 6: Body mass index of women intending on having a home birth, 2012...... Page 16 Table 7: Distribution of parity of women intending on having a home birth, 2012...... Page 17 Table 8: Gravida/parity of women prior to pregnancy in 2012...... Page 18 Table 9: Number of antenatal visits to the SECM, 2012 ...... Page19 Table 10: Transfer rates by parity, 2012...... Page 19 Table 11: Mode of transport for antepartum transfers, 2012...... Page 19 Table 12: Mode of delivery for women with an antenatal transfer, 2012...... Page 20 Table 13: Transfer rates by parity, 2012...... Page 20 Table 14: Stage of labour when transferred, 2012...... Page 21 Table 15: Mode of delivery for women with an intrapartum transfer, 2012...... Page 21 Table 16: Distribution of women intending on having a home birth by HSE, 2012...... Page 22 Table 17: Rupture of membranes, 2012...... Page 22 Table 18: Liquor colour, 2012...... Page 22 Table 19: Who was present at the birth by HSE area, 2012 ...... Page 23 Table 20: Maternal position for birth by parity, 2012...... Page 24 Table 21: Perineum post birth...... Page 25 Table 22: Medical examination of the newborn, 2012...... Page 28 Table 23: Vitamin K administration, 2012...... Page 28 Table 24: Method of feeding, 2012...... Page 28 Table 25: Reasons for baby transfer, 2012...... Page 29

5 Acknowledgements

The Health Service Executive (HSE) is pleased NPEC for designing the Data Set and for the to publish the data from the first Planned new online development which will make it Home Birth Annual Report (2012). There is easier in the future. a long history of home birth in Ireland but in recent decades the figures have fallen to less The Self Employed Community Midwives than 0.5% of all births. The Office of the Nursing who provide the home birth service on and Midwifery Services Directorate have over behalf of the HSE are passionate about the last two years under the Chairmanship their work. They provide excellent quality of Dr Michael Shannon, attempted to develop care to low risk women across the country. and support a safe, quality home birth service Without them there would be no service. It for women considered to be “low-risk” and is my wish that the outcomes published therefore increasing choice available to in this Report will help support the further women. I would like to acknowledge Michael’s development of this service. The vision of a support and encouragement. number of maternity services to support and encourage the development of the service Measurement of the outcome of care is is to be welcomed and nourished. On behalf essential for the development of the home of the Designated Midwifery Officers I look birth service and it is to this end that it was forward to collaborating together on future decided that a national clinical audit on developments. planned home births was established and figures published in an Annual Report. The Report is supported by the Clinical Programme for Obstetrics and Gynaecology in the HSE.

A number of Designated Midwifery Officers Sheila Sugrue recently joined the service and I would like National Lead Midwife, Office of Nursing and to acknowledge their role in the delivery of a Midwifery Services Director, HSE quality service, supporting the women who opt for home birth. They are instrumental in collecting and collating all of the relevant data which is contained within this Report and which may be used to contribute to midwifery research and development. I want to thank

6 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Welcome to the Planned Home Births Annual I extend my sincere thanks and appreciation Report 2012 from the Health Service Executive to the many midwives who have supported (HSE) in collaboration with the National and contributed data to the NPEC. Their Perinatal Epidemiology Centre (NPEC). At the work is greatly acknowledged. An important NPEC we endeavour to provide Irish maternity advancement within the NPEC has been the services with a facility to undertake in-depth development and implementation of the reviews of its own medical practices, through online home births database which will allow monitoring outcomes and regular audit. As for data to be audited in an even timelier such it is not only valuable that the HSE is manner in the future. auditing these data but essential to ensure that standards of home birth in Ireland are Lastly, I would like to thank the staff of the met. It is intended that results of these NPEC for their hard work and dedication to clinical audits will be reported in successive the mission of the Centre. Assessing the annual reports into the future. outcomes of maternity care provided, learning from the data and working together, we have Studies across Europe indicate that home great potential to improve the care of mothers birth should be an option for low risk women. and babies in Ireland. On behalf of all the staff Measurement of the outcome of care is at the NPEC, we look forward to a challenging central to the development of safe and high and fruitful future. quality health care services. Support from The Office of Nursing and Midwifery Services Director, the Designated Midwife Officers and the Self Employed Community Midwives has been crucial in order to ensure that the data from this audit can provide a transparent Richard A Greene, Director, NPEC account of the national home birth service, as National Perinatal Epidemiology Centre provided by the SECMs on behalf of the HSE.

7 Background

In Ireland today 0.2% of births occur at home.1 Home birth in Ireland This rate is slightly lower than the home birth rate Up until the first half of the 20th Century, the in the United States of America (0.7%),2 much majority of births in Ireland were home births. lower than England (2.2%) and Wales (3.1%)3 and Following the establishment of the Department significantly lower than the Netherlands where of Health, Comhairle na nOspideal (The National almost one quarter of births are reported to be in Hospital Advisory Council) was set up, in 1947, the home.4 to decide where maternity services should be located. It advocated, as did the Peel Report in the The Royal College of Midwives (RCM) and the UK, that a hospital was the safest place to give Royal College of Obstetricians and Gynaecologists birth.9 (RCOG) support home birth for women with uncomplicated pregnancies.5 The World Health During the 1950’s and 1960’s the construction Organization (WHO) states that women may and expansion of maternity hospitals brought choose to deliver at home if they have a low risk about a rapid decline in home confinement. There pregnancy and receive appropriate care, however were approximately 18,000 home births in 1957: should complications arise during pregnancy, by 1967 there were approximately 4,000 and by labour and delivery; a plan for transfer to a 1977, this figure was 265, representing less than suitably equipped unit is necessary and should 1% of the births in Ireland.10 The Department of be in place in advance of the birth.6 There is Health provided a grant to women who wished to ample evidence showing that labouring at home have a home birth, with which they could employ increases a woman’s likelihood of a birth that is the services of Independent Midwives. In 2003, a both satisfying and safe, with implications for her two-year pilot project demonstrated that a home health and that of her baby. birth service provided by domiciliary community midwives for low risk women was effective, Recent research into planned home birth found viable and provided high levels of satisfaction to that having a baby at home is as safe an option both women and midwives.11 for women when it is supported and structured in a maternity care system with well-trained The Domiciliary Birth Report of 2004 stated midwives and a good referral and transportation that ‘home birth is a safe option for low risk system.7, 8 Findings indicate that home births women within an agreed criterion in Ireland’. It have similar rates not only of perinatal mortality outlined that a safe outcome for the mother and and morbidity but also maternal mortality and baby is the most important factor and that the morbidity, compared to their counterparts who need for continuity of care is essential.12 The delivered in a hospital setting.4 Studies also newly formed Health Services Executive (HSE) indicate that mothers who birth at home are less accepted this report as a dynamic working likely to have medical interventions and have document and a National Implementation lower rates of caesarean section compared to Committee was established to address the planned hospital births.4 recommendations, progress the work and involve 1 Economic and Social Research Institute. (2012) Perinatal Statistics Report 2011.National Perinatal Reporting System. Dublin : ESRI 2 Rooks J. Midwifery and childbirth in America, Temple University Press, Philadelphia 1997. 3 http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-279449 Last accessed November 8th 2013 4 de Jonge A, van der Goes BY, Ravelli AC et al Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG. 2009 Aug;116(9):1177-84 5 Royal College of Obstetricians and Gynaecologists/Royal College of Midwives. Joint statement No.2, April 2007 6 Maternal and Newborn Health/Safe Motherhood Unit of the World Health Organization, Care in Normal Birth: A practical guide. 7 Lindgren HE, Rådestad IJ, Christensson K, et al. Perceptions of risk and risk management among 735 women who opted for a home birth. Midwifery 2010; 26:163. 8 Ackermann-Liebrich U, Voegeli T, Günter-Witt K, et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team. BMJ 1996; 313:1313. 9 Department of Health and Social Security. (1970) Domiciliary midwifery and maternity bed needs (Peel Report). London: HMSO 10 St Leger A. Born in Cork; A history of Erinville Maternity Hospital, St Finbarr’s Maternity Unit and Bon Secours Maternity Hospital. Health Services Executive, Dublin 2006 11 Southern Health Board (2003) Domiciliary Midwifery Project for Cork City and County; Evaulation for the Southern Health Board home birth pilot project. Cork: Southern Health Board. 12 Health Service Executive (2004) Report to the Chief Executive Officers of the Health Boards / Domiciliary Births Group. Dublin: HSE. 8 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 the wider stakeholders. The decisions of this form and consent is signed between the SECM Committee were informed by the deliberations and the woman, and then forwarded to the DMO of four sub-committees representing all to confirm eligibility as some women may require stakeholders. During the course of deliberations an individual assessment by a Consultant of the committee and associated subgroups, Obstetrician. The DMO informs the Director of it emerged that the Irish Nursing Organisation Public Health Nursing, Local Public Health Nurse, (INO) which insured Self Employed Community the expectant mothers GP and the Administration Midwives (SECMs) signalled its intent to withdraw Department of the HSE, Local Health Office (LHO) its insurance provision to SECMs. In this context, about the forthcoming home birth. Expectant and supported by the then Minister for Health Ms women intending to have a home birth are Mary Harney TD, future clinical indemnity cover advised by the SECM to register with a GP and was to be provided by the HSE through the Clinical also to register and avail of antenatal services Indemnity Scheme. The HSE has committed with their local maternity hospital. The SECM will through the National Home Birth Service to be the primary carer for the mother and child up provide midwifery services to low risk women in to the age of 14 days.13 order to facilitate an informed choice by women. Purpose of this report The HSE provides planned home birth services The primary aim of this report is to present an to families choosing this model of maternity care overview and national statistics on the home predominantly in association with SECMs, along births service in the Republic of Ireland for the with two hospital-based services in Waterford year 2012. As outlined in the MOU between HSE Regional Hospital and the National Maternity and the SECMs, each SECM is required to partake Hospital, Dublin. Since 2008, SECM’s (previously in clinical audit. Each SECM forwards case notes known as Independent Midwives) sign an annual to the DMO in their respective HSE area. The DMO Memorandum of Understanding (MOU) with the then collates the data using a standardised audit HSE, to provide planned home birth services tool and that data are forwarded to the National to eligible women. While it was acknowledged Perinatal Epidemiology Centre (NPEC) for that this system did not provide for equity of analysis. This clinical audit is a national record access on a nationwide basis, “it is underpinned of planned home births in the Republic of Ireland by a commitment to women centred care, an for 2012. The purpose of the audit is to examine integrated model of service delivery and an both the maternal and fetal outcomes of planned overarching concern for the safety of mother, home births, including outcomes whereby the child and professionals involved”. care of the woman is transferred for hospital care antenatally, during labour or postnatally. The National Steering Committee for Home Births Consequently this report aims to provide was set up in 2010 to further review the 2008 baseline data to firstly ascertain adherence to MOU in order to advance the HSE National Home the national evidence based guidelines, protocols Birth Service with the introduction of Designated and standards and, secondly, to provide evidence Midwife Officers (Appendix A) in each region and which facilitates maternity healthcare providers the establishment of a national database for all to review practice in the home setting, where planned home births. appropriate.

Pathway of care in Ireland As illustrated in Figure 1 when an expectant woman enquires about having a home birth, she can contact a Designated Midwife Officer (DMO) or the SECM directly. The expectant woman and the SECM discuss the criteria for home births and agree on eligibility for the service. An application

13Health Services Executive (2008) Delivery on choice Home birth options for women in Ireland Dublin: HSE

Expectant mother makes an e nquiry

HSE Dublin HSE Dublin North Mid-‐Leinster East HSE South HSE West DMO DMO DMO DMO

SECMs SECMs SECMs SECMs

Eligibility ssessed a by home birth service

Eligible Ineligible

Mother continues Mother continues under care of the under care of the

SECM maternity hospital

FigureFigure 1: Pathway 1 : Pathway of care for of planned care home for birth enquiries planned home birth enquiries

10 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 MethodsMethods

Data recording

DataIn recording 2012 there were 20 Self Employed Missing Community data Midwives (SECMs) in Ireland involved in In home 2012 there birth deliveries were in 20 Ireland. Self Employed All Missing SECMs or incomplete contributed data data which were recorded were sought and are from Communitypresented Midwives in this (SECMs) report. Women involved who in are respective considered SECMs low and maternity risk, units within by an the agreed criterion, homeare birth eligibl deliveriese for in home birth Ireland. in All Ireland. SECMs Upon engagement DMOs. For analysis of purposes, a woman percentages with the service, contributedSECM opens data which a case were recorded file (midwifery and were calculated notes) for excluding the cases woman. with missing This is updated and maintained are throughout presented in this the report. service. Women who Following are data. discharge However, from the service , the extent the of missingSECM forwarded datathe is midwifery notes to the Designated Midwifery Officer (DMO) in their respective HSE area. considered low risk, within an agreed criterion, reported throughout the results section. The DMO reviewed the midwifery notes and completed the National Perinatal Epidemiology are eligible for home birth in Ireland. Upon Centre (NPEC) home birth data collection form. Data were recorded by the DMOs on all engagement of a woman with the service, the home births delivered by SECMs between Comparison January to 1 national and statistics December 31 2012. Figure 1 SECM opens a case file (midwifery notes) for illustrates the flow of information involved. Comparisons are made with the most recent the woman. This is updated and maintained national statistics available taken from the throughout the service. Following discharge Central Statistics Office’s Vital Statistics from the service, the SECM forwarded the Fourth Quarter and Yearly Summary as well as Missing data midwifery notes to the Designated Midwifery the Economic and Social Research Institute’s OfficerMissing (DMO) or in their incomplete respective data HSE were area. Perinatal sought from respective SECMsStatistics and Report maternity 2011. units by the TheDMOs DMO .reviewed For analysis the midwifery purposes, percentages notes and were calculated excluding cases with missing completeddata. the National However, Perinatal the Epidemiology extent of missing data is reported throughout the results section. Centre (NPEC) home birth data collection form. DataComparison were recorded to byn ational the DMOs statistics on all home births delivered by SECMs between January 1 andComparisons December 31 are 2012. made Figure with 1 illustrates the most recent national statistics available taken from the the Central flow of information Statistics involved. Office’s Vital Statistics Fourth Quarter and Yearly Summary as well the Economic and Social Research Institute’s Perinatal Statistics Report 2011.

• The woman idenmﬁed an SECM to plan her home birth and applies to DMO for the service

• Upon complemon of the homebirth service, midwifery notes are forwarded from the SECM to DMO

• DMO completes the NPEC Homebirths Data Collecmon form

• NPEC data manager reviews all data and refers back to the local DMO

• Disseminamon to various stakeholders and the public

FigureFigure 2: Flow 2: Flow of information of information in the NPEC data in collection the NPEC process. data collection process. 11

11 Definitions and terminology Antepartum referrals: Referral to hospital due To ensure comparison the Designated to complications which have arisen during Midwifery Officer and the NPEC used the pregnancy. following definitions which are included in this report: Intrapartum transfer: Transfer to hospital due to complications (Appendix D) which have Exclusion criteria: The medical and other arisen during labour. conditions that indicate increased risk for the pregnancy that and therefore suggesting Postpartum transfer: Transfer to hospital due planned birth at an obstetric unit (Appendix B). to complications (Appendix E) following birth. Table 3 and Table 4 outline medical and other conditions indicating individual assessment Booking: Booking in this report relates to the when planning place of birth (Appendix C) mother’s first antenatal visit with the SECM.

12 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Results

Planned home births

n=224

Antenatal referral No antenatal referral n=39 n=185

Remain under the care of the Return to the maternity care of the SECM hospital n=35 n=4

Mothers who began Mothers who began labouring in hospital labouring at home

(n=35) (n=189)

Intralabour transfer n=28

Hospital deliveries Home birth deliveries

n=63 n=161

Figure 3: Flowchart of planned home births

13 For the period from January 1st to December st 31 2012, 224 women intended having a home birth. During the same period 70,520 births were recorded in the 20 maternity units throughout the Republic of Ireland. The distribution of home births by Health Service Executive (HSE) region is markedly different to the overall distribution e of births. Th percentage For the period from of January home 1st births to December ranged from 8.9% of births.HSE in The Dublin percentage North of home births East, ranged 18.3% in HSE Dublin Mid31st-‐ 2012,Leinster, 224 women 25.0% intended in HSE West having a home and from 47.8% 8.9%HSE in in South HSE Dublin (Table North East, 1). 18.3% in HSE These figures show an overrepresentation birth. During the same period of 70,520 home births were births Dublin in Mid-Leinster, HSE 25.0% South in HSE and an underrepresentation West and 47.8% of home births in recorded HSE in the Dublin 20 maternity North East. units throughout in HSE South (Table 1). These figures show an the Republic of Ireland. The distribution of home overrepresentation of home births in HSE South births by Health Service Executive (HSE) region and an underrepresentation of home births in is markedly different to the overall distribution HSE Dublin North East. Table 1: Distribution of women intending on having a home birth by HSE region, 2012 Table 1: Distribution of women intending on having a home birth by HSE area, 2012 HSE area Home births All births HSE area Home births All births (N=224) (%) (N=224) (%) Dublin Dublin North North E Eastast 20(8.9) 20(8.9) 32.0 32.0 Dublin Dublin Mid-Leinster Mid-‐Leinster 41(18.3)41(18.3) 20.7 20.7 WestWest 56(25.0)56(25.0) 22.2 22.2 South 107(47.8) 25.2 South 107(47.8) 25.2 Note: Values are shown as n (%) unless otherwise stated.

The monthly number of home births and hospital births was 17 and 5877, respectively. s A outlined The monthly in number Figure of 4 home there births was and hospital a marked (12.1% versus increase 8.3%). Otherwise in home home births births in August compared to the births was 17 and 5877, respectively. As outlined were evenly distributed over the year as was the overall average (12.1% versus 8.3%). Otherwise home births were evenly distributed over in Figure 4 there was a marked increase in home case for all births. the births in year August compared as was to the the overall case average for all births.

14 Home births Total births 12

8 % 6

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Figure 4: Percentage of births by month, 2012 Figure 4: Percentage of births by month, 2012

Maternal Characteristics

14 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Maternal Characteristics Age The age range of the women who booked in for three quarters of women (78.0%) intending a home birth was 23-45years. These women to give birth at home were aged 30-39 years tended to be older than the population of compared to 62.1% of all women. women who gave birth in Ireland (Table 2). Over

Table 2: Age distribution of mothers intending on having a home birth, 2012 Age group Home births All births, (N=223*) CSO 2012 (%)1 <20yrs 0(0) 2.3 20-24yrs 6(2.7) 9.3 25-29yrs 27(12.1) 20.6 30-34yrs 96(43.0) 36.7 35-39yrs 78(35.0) 25.4 >40yrs 16(7.2) 5.8 Note: Values are shown as n (%) unless otherwise stated. *Maternal age unknown for one woman. Abbreviation: CSO, Central Statistics Office

Marital status As outlined in Table 3 almost all the women either married (61.6%; n=138) or with a who intended on having a home birth were partner (29.0%; n=65). Table 3: Marital status of women intending on having a home birth, 2012 Marital status Home births (N=224) Married 138(61.6) Partner 65(30.2) Never married 12(5.6) Separated 0(0) Divorced 0(0) Widowed 0(0) Note: Values are shown as n (%) unless otherwise stated. Unknown for 9 women.

1. Central Statistics Office. (2013) Vital Statistics Fourth Quarter and Yearly Summary 2012. Cork: CSO.

15 Ethnicity The distribution by ethnic group of the women of the female population aged 15-49 years who booked for a home birth reflected that (Table 4). Table 4: Ethnicity of women intending on having a home birth, 2012 Ethnicity Home births 15-49 year old female population (N=220*) 2011, CSO (%) White Irish 181(82.3) 80.4 Irish Traveller 0(0) 0.7 Other white background 33(15.0) 12.5 Asian/Asian Irish 1(0.5) 2.4 Black/Black Irish 3(1.4) 1.6 Other/mixed 2(0.9) 1.0 Note: Values are shown as n (%) unless otherwise stated. *Maternal ethnicity unknown for four women.

Gestation at booking Gestation at the time of the women’s antenatal be noted that in Ireland most women attend a scan was unrecorded in a fifth of the cases general practitioner in early pregnancy prior to (n=47). Of those recorded almost two-thirds their first contact with the maternity services booked with the SECM between 12 and 19 thereby undergoing earlier review by a health weeks gestation and over one-quarter booked professional. at 20 weeks gestation or later (Table 5). It must Table 5: Weeks gestation at date of booking, 2012 Gestation at booking Home births (N=177*) Less than 12 Weeks 21(11.9) 12-19 Weeks 107(60.5) 20 Weeks or Later 49(27.7) Note: Values are shown as n (%) unless otherwise stated. *Gestation at booking unknown for 47 women

Body mass index Body mass index (BMI) was available for only classified as overweight (25.0-29.9kgm-2). 43.3% (n=97) of the women (Table 6). The BMI For women who were recorded as obese, all of over half of those women (58.8%; n=57) cases were recorded as having a BMI of 30. was in the healthy range (18.5-24.9kgm- Women with a BMI greater than 30 are not 2). Just over a quarter (28.9%; n=28) were eligible for a home birth.

Table 6: BMI of women intending on having a home birth, 2012 BMI of mothers intending on Home births 2007 SLÁN** having a home birth, 2012 (kgm-2) (N=97*) % Underweight (<18.5) 3(3.1) 2 Healthy (18.5-24.9) 57(58.8) 44 Overweight (25.0-29.9) 28(28.9) 31 Obese (>30.0) 9(9.3) 23 Note: Values are shown as n (%) unless otherwise stated. *BMI unknown for 127 women. **SLÁN, Survey of Lifestyle, Attitudes and Nutrition

16 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Smoking and alcohol consumption Smoking status of the women at their time of but rates of 12%, 15%, 16% and 19% have been booking was recorded for 222 (99.1%) of the reported for England, Northern Ireland, Wales 224 women. Ten women (4.5%) were smokers and Scotland, respectively. at the time, two of whom gave up during pregnancy. These figures suggest a 20% (2 Alcohol consumption was known for 206 of of 10) cessation rate although this estimated the 224 women (92.0%). Of these the vast rate is based on small numbers. Thus, eight majority of women (175 of 206, 85.0%) did of 222 women (3.6%) smoked throughout not consume alcohol during pregnancy. Of the their pregnancy. The prevalence of smoking 31 who drank alcohol during pregnancy eight during pregnancy or in the last trimester is drank alcohol 2-4 times a month and 23 drank not routinely known for all Irish pregnancies alcohol monthly.

Previous pregnancy As indicated in Table 7, three quarters of the (gravida = parity, indicated by green shading); women who intended on having a home birth 23% (n=38, 22.8%) experienced completed had a previous birth (161 of 218, 73.5%). pregnancies but also at least one pregnancy Table 8 specifies gravida/parity for 219 of less than 24 weeks gestation and under 500g the 224 women who intended on having a birthweight (gravida > parity > 0, indicated home birth in 2012. A quarter of the women by orange shading) and 4% (n=6, 3.6%) had (n=52, 23.7%) were never pregnant before miscarriages, their previous pregnancies (gravida=0). Of the women who had been never exceeded 24 weeks gestation or 500g pregnant (gravida > 0), three quarters (n=123 birthweight (gravida > parity = 0, indicated by of 167, 73.7%) had complete pregnancies red shading).

Table 7: Distribution of parity of women intending on having a home birth, 2012 Parity Home births All Births (N=219*) ESRI (%) Primiparous 58(26.5) 73.8 Multiparous 161(73.5) 26.2 Note: Values are shown as n (%) unless otherwise stated. *Parity unknown for 5 mothers.

17 Table 8: Gravida/parity of women prior to pregnancy in 2012 Parity 0 1 2 3 4 5 6 7 Total 0 52 52 1 6 65 71 2 0 11 36 47 3 0 3 9 14 26 4 0 0 3 1 6 10 5 0 1 1 2 2 1 7

Gravida 6 0 0 0 1 0 0 0 1 7 0 0 0 0 0 2 1 1 4 8 0 0 0 0 0 0 0 1 1 10 0 0 0 0 0 0 0 0 0 11 0 0 0 0 0 0 0 0 0 12 0 0 0 0 0 0 0 0 0 Total 58 80 49 18 8 3 1 2 219 Note: Data unknown for five cases. We refer to gravida and parity prior to the pregnancy in 2012. Green represents women with previous pregnancies that were always complete; orange represents women who had experienced complete pregnancy and pregnancy <24 weeks gestation and birthweight<500g; and red represents women whose previous pregnancies were always <24 weeks gestation and birthweight<500g

Obstetric and medical conditions All but three women registered during Of the 224 women who intended on having pregnancy with their general practitioner and a home birth six women(2.7%) were only one woman did not register with her local reported to have an obstetric problem as maternity unit. outlined in Appendix C which included; postnatal depression, hyperglycemia, PPH, Of the 161 women who had a previous polyhydramnios (mal-presentation) and pregnancy 10 (6.2%) were reported to placenta praevia. have had medical or obstetric problems. As outlined in Appendix B, these problems Of the 224 women who intended on having a included baby born before arrival, previous home birth eight (3.6%) were known to have forceps delivery, history of pernicious medical conditions as outlined in Appendix anaemia, premature rupture of membranes C including hemochromatosis carrier, carpel (PROM), retained products of conception, tunnel syndrome, palpitations, history of postpartum haemorrhage, herpes and baby asthma, diabetes, penicillin and food allergies. with respiratory problems.

18 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Planning for the delivery It was reported that 7% of the women (16 of The number of antepartum visits by the 222, 7.2%, unknown for two women) did not midwives to women who intended on having a have an ultrasound scan. The estimated date home birth ranged from two to 17. The average of delivery was calculated by last menstrual number of visits was seven. Primiparous period in 151 of 224 (67.4%) of cases and/or women tended to receive more visits. Thirty by scan in 89 of 224 (39.7%) of cases. percent (29.9%) received at least 10 visits which was the case for 22.0 of the multiparous women (Table 9).

Table 9: Number of antenatal visits to the SECM, 2012 Primiparous Multiparous (n=57) (n=159) Up to 3 visits 3(5.3) 9(5.7) 4-6 visits 18(31.6) 60(37.7) 7-9 visits 19(33.3) 55(34.6) 10-12 visits 16(28.1) 32(20.1) 13-15 visits 1(1.8) 2(1.3) More than 15 visits 0(0.0) 1(0.6)

Antenatal referrals Of the 224 women intending to have a home were slightly more likely to be referred to birth, 39 (17.4%) were referred to a maternity the maternity hospital antenatally than hospital due to complications arising during multiparous women (22.4% versus 16.1%; the antenatal period. Primiparous women Table 10).

Table 10: Transfer rates by parity, 2012 Primiparous Multiparous (n=58) (n=161) No antenatal referral 45(77.6) 135(83.9) Antenatal referral 13(22.4) 26(16.1) Note: Values are shown as n (%) unless otherwise stated.

The vast majority of the women (28 of 31, two of 31 (6.5%) transferred by ambulance 90.3%) were transferred by private car with (Table 11). Table 11: Mode of transport for antepartum transfers, 2012 Primiparous Multiparous (n=13) (n=18*) Private car 13(100) 15(83.3) Ambulance 0(0.0) 2(11.1) Other 0(0.0) 1(5.6) Note: Values are shown as n (%) unless otherwise stated. *Unknown for 8 women

19 Of the 13 primiparous women referred to the maternity hospital during the antenatal antenatally almost half (46.2%, n=6) were period had a spontaneous vertex delivery. due to breech presentation. Multiparious Primiparous women were almost three times women were more likely to transfer as they more likely to have a caesarean section had past their estimated date of delivery. delivery than multiparous women (Table 12). Almost half of all women who were referred Table 12: Mode of delivery for women with an antenatal transfer, 2012 Primiparous Multiparous (n=13) (n=26) Spontaneous Vertex 6(46.2) 12(46.3) Vaginal Breech 0(0.0) 0(0.0) Ventouse 1(7.7) 0(0.0) Forceps 0(0.0) 0(0.0) Caesarean Section 6(46.2) 4(15.4) Unknown 0(0.0) 10(38.5) Note: Values are shown as n (%) unless otherwise stated.

Of the 39 women referred to the maternity remaining under the care of the maternity hospital for antenatal care four (10.3%) hospital one woman miscarried. No other women were returned to the care of the SECM, adverse outcomes were recorded during the one case of hypertension, one case of post antenatal period for any of the other women maturity, one case of breech presentation who were referred. and one case low platelet count. Of the women

Intrapartum transfers Of the 189 women who began labouring 46.4%) of the women were primiparous. As at home 28 (14.8%) were transferred to a demonstrated in Table 13, primiparous women maternity hospital to deliver the baby. Over were almost three times more likely to be half of these transfers were by ambulance transferred during labour than multiparous (53.6%; n=15) and almost half (n=13, women (28.3% versus 10.7%)

Table 13: Transfer rates by parity, 2012 Primiparous Multiparous (n=46) (n=140) Home birth not transferred 33(71.7) 125(89.3) Intrapartum transfer 13(28.3) 15(10.7) Note: Values are shown as n (%) unless otherwise stated.

20 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Over two thirds of intrapartum transfers more likely to transfer during the 2nd or occurred during the first stage of labour 3rd stage compared to primiparous women (65.4%; n=17). Multiparous women were (40.0% versus 27.3%) as outlined in Table 14. Table 14: Stage of labour when transferred, 2012 Primiparous Multiparous (n=11*) (n=15) 1st Stage 8(72.7) 9(60.0) 2nd Stage 2(18.2) 4(26.7) 3rd Stage 1(9.1) 2(13.3) Note: Values are shown as n (%) unless otherwise stated. *Unknown for two women

Medical interventions Half of intrapartum transfers to the maternity delivery was similar for women irrespective of unit were associated with failure to progress in parity (Table 15). labour (50.0% n=14). Labour was augmented by syntocinon for most of these women (10 Of the 28 recorded, three women (10.7%) had of 14, 71.4%)”. an epidural and four women (14.2%) had a general anaesthetic (16.1%). One adverse Almost half of women who transferred during outcome was identified; undiagnosed breech labour to the maternity unit had a spontaneous presentation, which was reported. vaginal delivery (46.4%; n=13). The mode of

Table 15: Mode of delivery for women with an intrapartum transfer, 2012 Primiparous Multiparous (n=13) (n=15) Spontaneous Vertex 6(46.2) 7(46.6) Vaginal Breech 0(0.0) 2(13.3) Ventouse 1(7.7) 2(13.3) Forceps 1(7.7) 0(0.0) Caesarean Section 2(15.4) 3(20.0) Unknown 3(24.1) 1(6.6) Note: Values are shown as n (%) unless otherwise stated.

21 Home birth deliveries Delivery Of the 189 women who began labouring at in 158 of cases. Over three-quarters of the home 161 gave birth at home (85.2%). The women who had a home birth delivery were distribution of home births by HSE region multiparious (79.1%, n=125) while 33 (20.8%) was similar to the distribution of planned were primiparous. home births (Table 16). Parity was recorded

Table 16: Distribution of women intending on having a home birth by HSE, 2012 Home births Planned home births (N=161) (N=224) Dublin NE 18(11.2) 20(8.9) Dublin Mid-Leinster 30(18.6) 41(18.3) West 38(23.6) 56(25.0) South 75(46.6) 107(47.8) Note: Values are shown as n (%) unless otherwise stated. Of the women who birthed at home rupture and 18). Multiparous women were marginally of membranes occurred spontaneously and more likely to have meconium stained liquor liquor was clear for almost all cases (Tables 17 than primparous women (7.2% versus 3.0%).

Table 17: Rupture of membranes, 2012 Primiparous Multiparous (n=33) (n=125) Spontaneous Rupture of Membranes 33(100) 119(95.2) Artificial Rupture of Membranes 0(0.0) 4(3.2) Unknown 0(0.0) 2(1.6) Note: Values are shown as n (%) unless otherwise stated.

Table 18: Liquor colour, 2012 Liquor Primiparous Multiparous (n=33) (n=125) Clear 30(90.9) 115(92.0) Meconium 1(3.0) 9(7.2) Other 2(6.1) 1(0.8) Note: Values are shown as n (%) unless otherwise stated.

22 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 women were more likely to have a second midwife at the birth if they were registered to have the home birth with HSE South or the HSE West (Table 19). A number of other auxiliary health care professionals or family members were also present at the birth. In a number of cases the SECM or second midwife was contacted and in transit however due to the women’s short labour the baby was born before arrival.

Table 19: Who was present at the birth by HSE area, 2012 Overall Dublin North Dublin Mid-‐ West South A Self Employed Community Midwife (SECM)East (n=18) the HSE WestLeinster (Table (n=30) 19). A number (n=38) of other (n=75) was present at the vast majority of births auxiliary health care professionals or family (95.7%).SECM A second midwife154(95.7) was present17(94.4) at members were25(83.3 also present) at the38(100) birth. In a 75(100) almost two thirds of births (65.2%). However, number of cases the SECM or second midwife womenSecond were more likely105(65.2) to have a second0(0.0) was contacted 4(13.3)and in transit however31(81.6) due to 70(93.3) midwifeMidwife at the birth if they were registered the women’s short labour the baby was born to have the home birth with HSE South or before arrival. TableDoula 19: Who was present3(1.9) at the birth by HSE0(0.0) area, 2012 0(0.0) 1(2.6) 2(2.7) Partner 154(95.7)Overall 17(94.4)Dublin North Dublin29(96.7) Mid- West34(89.5) South74(98.7) East (n=18) Leinster (n=30) (n=38) (n=75) SECMOther 24(14.7)154(95.7) 3(16.7)17(94.4) 25(83.3)8(26.7) 38(100)6(15.8) 75(100)7(9.3) Second Midwife 105(65.2) 0(0.0) 4(13.3) 31(81.6) 70(93.3) Doula 3(1.9) 0(0.0) 0(0.0) 1(2.6) 2(2.7) Partner 154(95.7) 17(94.4) 29(96.7) 34(89.5) 74(98.7) Other 24(14.7) 3(16.7) 8(26.7) 6(15.8) 7(9.3) Duration Note: Values are shown of as n (%) labour unless otherwise stated.

The Duration majority of labour of women laboured between three and six hours (mean duration 5.6 hours). The The majority longest of women labour laboured for between women (Figure who birthed at home 5) multiparous was 24 hours. women As expected laboured (Figure 5) multiparous three and six hours women (mean laboured duration 5.6 faster faster than than primiparous primiparous women women with the with vast the vast majority having laboured hours). The for longest less than labour seven for hours women who (81.1% majority versus having 33.3%). laboured for less than seven birthed at home was 24 hours. As expected hours (81.1% versus 33.3%).

60 54.9

40 33.3 33.3

% 30 26.2 Primiparous Mulkparous 20 15.2 12.3 12.1

10 4.9 6.1 0 1.6 0 0 <=3 3-‐6 7-‐9 10-‐14 15-‐19 >=20 Hours in labour Figure 5: Duration of labour (hours completed) by parity, 2012 12

23 women were more likely to have a second midwife at the birth if they were registered to have the home birth with HSE South or the HSE West (Table 19). A number of other auxiliary health care professionals or family members were also present at the birth. In a number of cases the SECM or second midwife was contacted and in transit however due to the women’sFigure short 5: Duration labour of the labour baby (hours was completed) born before arrival. by parity, 2012

Table 19: Who was present at the birth by HSE area, 2012 Overall Dublin North Dublin Mid-‐ West South As As documented documented in in Table 20 Table thereEast was20 (n=18)there clear was n=41). Leinster clear Primiparous (n=30) variation women in (n=38) maternal were position for birth. more (n=75) Multiparous variation in women maternal favoured position for either birth. kneeling likely to stand (42.7%; or squator n=53) to be or in a being lateral on all fours (33.1%; Multiparous women favoured either kneeling birthing position. (24.2 %; n=8) compared to n=41). SECM Primiparous 154(95.7) women 17(94.4) were more likely 25(83.3) to stand 38(100) or squator to be in a lateral birthing 75(100) As documented(42.7%; n=53) in Tableor being 20 there on all was fours clear (33.1%; n=41). multiparous Primiparous women women (0.8%; were n=1) more variationposition. in (24.2 maternal %; n=8) position compared for birth. to likely to multiparous stand or squator women to (0.8%; n=1) be in a lateral Second 105(65.2) 0(0.0) 4(13.3) 31(81.6) 70(93.3) MultiparousTable 20: women Maternal favoured position either for birthkneeling by parity, birthing 2012 position. (24.2 %; n=8) compared to (42.7%;MidwifeTable n=53) 20: or being Maternal on all fours position (33.1%; for multiparous birth by parity, 2012 women (0.8%; n=1) Primiparous Multiparous Primiparous Multiparous TableDoula 20: Maternal position3(1.9) for birth by parity,(n=33)0(0.0) 2012 (n=33) 0(0.0)(n=124) (n=124)1(2.6) 2(2.7) Kneeling Kneeling 7(21.2)Primiparous7(21.2) M53(42.7)ultiparous53(42.7) All Partner foursAll fours 154(95.7) 17(94.4)6(18.2)(n=33) 6(18.2) 29(96.7)41(33.1)(n=1 24) 41(33.1)34(89.5) 74(98.7) StandingKneelingStanding 3(9.1)7(21.2)3(9.1) 55(4.0)3(42.7) 5(4.0) Other 24(14.7) 3(16.7) 8(26.7) 6(15.8) 7(9.3) SquattingAll foursSquatting 5(15.2)6(18.2)5(15.2) 41(38(6.5)3.1) 8(6.5) SittingStandingSitting 1(3.0)3(9.1) 1(3.0) 10(8.1)5(4.0) 10(8.1) Lateral SquattingLateral position position 8(24.2)5(15.2)8(24.2) 1(0.8)8(6.5) 1(0.8) OtherSittingOther 3(9.1)1(3.0) 3(9.1) 16(4.8)0(8.1) 6(4.8) Note:LateralNote: Values Values position are are shown shown as n (%) as unless n otherwise (%) unless stated.8(24 .2) otherwise stated. 1(0.8) Duration Other of labour 3(9.1) 6(4.8) Note:Management Values are shown of as nthe (%) unlessthird otherwise stage stated.of labour is respectively. Use of syntocinon was more The outlined majority in Figure of 6. women Over three laboured quarter between threeof common and six hours with primiparous (mean women duration (62.5%; 5.6 hours). The ManagementManagement cases longest are of themanaged labour of third the stage physiologically for third of labour stage women is of labour is withrespectively. who birthed at outlined n=5 home of Use 8) in whileof was 24 syntocinon Figure hours. syntometrine 6. As expected was more was Over (Figure used three in 5 quarter of cases ) outlined in Figure 6. Over three quarter of common with primiparous women (62.5%; are minor mana variationged physiologically by parity. Of with the women minor almost variation half of by the cases parity. Of the women where who multiparous were multiparous cases are managed women physiologically laboured with faster n=5 of than 8) while syntometrine primiparous was women with the used vast in majority having laboured minoractively who variation forwere less managed byactively than parity. seven syntocinon managed Of hours the women syntocinon (81 .1% and almost versus syntometrine womenhalf of thewere 33.3%). cases activelywas where used managed multiparous in (46.2%; 15 n=12). cases respectively. Use of whosyntocinon and were syntometrine actively was managed was more used syntocinon common in 15 cases women with were primiparous actively managed women (46.2%; n=12). (62.5%; n=5of 8) while andsyntometrine syntometrine was was used used in in 15 cases almost half of the cases where multiparous women were actively 60 54.9 managed (46.2%; n=12). 50 100 80 40 75.8 80 33.3 33.3

% 60 26.2 Primiparous 30 % Primiparous 40 24.2 Mulkparous 20 19.2 Mulkparous 20 15.2 12.3 12.1 10 0 6.1 4.9 Physiological Ackve 1.6 0 Management of the third s tage 0 0 <=3 3-‐6 7-‐9 10-‐14 15-‐19 >=20 Figure 6: Management of the third stage FigureFigure 6: Management 6: Management of the third stage of the Hours third in stageoflabour labour

13 12

24 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 24 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Pain Relief Pain relief UseUse of of pain pain relief was relief recorded was for recorded for 153 153 of of the birth 161 (27.3%). As women illustrated who in gave Figure birth at home. 6 this theApproximately 161 women who half (54.5% gave birth of at primiparous home. accounts and for 48.0% over one of third multiparous) of primiparousief. used no pain rel 42 Approximatelywomen who half (54.5% had a home of birth primiparous had and a water women birth (36.4; (27.3%). As illustrated n=12) and almost in one Figure 6 this fifth of 48.0%accounts of multiparous) for over one used no third pain relief. of 42 primiparous multiparous women women (24.2%; (36.4; n=29). n=12) and almost one fifth of womenmultiparous who had women a home (24.2%; birth had n=29). a water

60 100 54.5 80 48 75.8 50 80

40 60 36.4 Primiparous % % 40 30 24.2 23.2 19.2 17.6 Mulmparous 20 20 12.1 9.1 7.2 10 0 3 2.4 1.6 Acmve Physiological 0 0.8 0 0 None Entonox Management Water Homeopathy of the third TENS stage Acupuncture Other Primiparous Mulkparous Figure 7: Pain relief used by women delivered in the home, 2012 Figure Figure 6: 7: Management Pain relief used by of women the delivered third stage in the home, 2012

Other incidences at birth Pain ShoulderOther Relief dystocia Incidences occurred at in four birth of the 161 Although proportionally more primiparous cases of home birth (2.5%), and there was women had an episiotomy (6.1% versus 1.6%) Shoulder dystocia occurred in four of the 161 cases of home birth (2.5%), and there was one Of one case the of undiagnosed 153 recorded, breech presentation 42 women the number who had a home birth of cases had involved a water were very birth small. (27.3%). As case of undiagnosed breech presentation (0.6%). For two thirds of the women who gave illustrated (0.6%). For two in thirds Figure of 6 this the women accounts who gave for over While one the third occurrence of of tears primiparous was similar in women (36.4; n=12) and birthbirth at almost at home home the one the perineum fifth perineum of multiparous remained remained intact women intact (Table both groups, (24.2%; 21). There primiparous n=29). was little women variation were between almost (Tableprimiparous 21). There and was little multiparous variation between women. twice Although proportionally as likely to more be sutured primiparous (34.3% versus women primiparoushad 60 an 54.5 episiotomy and multiparous (6.1% women. versus 18.7%). 1.6%) the number of cases involved was very small. While the occurrence 48 of tears was similar in both groups, primiparous women were almost twice Tableas 50 likely 21: Perineum to post be birth sutured (34.3% versus 18.7%). 40 36.4 Primiparous Multiparous (n=33) (n=125) % 30 Table Intact 22 : Perineum post birth 23.2 21(63.6) 80(64.0) 17.6 20 Episiotomy 2(6.1) 2(1.6) 12.1 Primiparous Multiparous 1ST Degree Tear (n=33)5(15.2) (n=125) 9.1 25(20.0)7.2 10 3 2.4 Intact2nd Degree Tear 21(63.6)5(15.2) 80(64.0) 18(14.4) 0 0.8 0 1.6 Episiotomy3rd0 Degree Tear 2(6.1)0(0.0) 2(1.6) 0(0.0) ST 1 4th Degree DegreeNone TearTear Entonox Water 5(15.2) 0(0.0) Homeopathy 25(20.0) TENS 0(0.0) Acupuncture Other nd Primiparous Mulmparous 2Note: Degree Values are shown Tear as n (%) unless otherwise stated.5(15.2) 18(14.4) Figure 3rd Degree 7: Pain Tear relief used by women delivered 0(0.0) in the 0(0.0) home, 2012

14 Other Incidences at birth

In four cases of home births (2.5%) shoulder dystocia was recorded and one case of undiagnosed breech (0.6%). As documented in Table 22 of the women who gave birth in the home the perineum remained intact in over two thirds of cases. Not much variation can be observed between primiparous and multiparous women. Although more primiparous

26 25

women had an episiotomy (6.1% versus 1.6%) the numbers are small. Primiparous women were also more likely to be sutured than multiparous women (34.3% versus 18.7%)

Table 22: Perineum post birth Primiparous Multiparous (n=33) (n=125) Intact 21(63.6) 80(64.0) Episiotomy 2(6.1) 2(1.6) 1ST Degree Tear 5(15.2) 25(20.0) 2nd Degree Tear 5(15.2) 18(14.4)

3rd Degree Tear 0(0.0) 0(0.0)

4th Degree Tear 0(0.0) 0(0.0)

Note: Values are shown as n (%) unless otherwise stated.

Blood Blood loss loss The The average majority estimated of women blood loss who was birthed 258 than at multiparous home were estimated to have women lost to between experience 100 and blood 499 ml. The mls women of who blood birthed at (mean 258 mls). home The generally greatest loss amount in excess of of 500ml, blood although lost it was estimated at should be 800mls. either lost As 100-249ml outlined or 250-499ml in Figure of blood. 8 multiparous women borne were in mind recorded that this as was loosing observed less blood for two during delivery than primiparious women. The maximum blood loss was estimated at women in each group (Figure 8). 800ml. Primiparous women were more likely

100 80 60 52.9 75.8 80 50 43.8 43.8 42.9 60 40 Primiparous % %40 30 24.2 Primiparous 19.2 20 Mulmparous 20 Mulmparious 6.3 6.3 10 1.7 1.7 0 0 0.8 0 0 0 Acmve Physiological <100 100-‐249 250-‐499 500-‐749 750-999 >=1000 Management Esgmated Blood of the Loss (mls) third stage

Figure 8: Estimated blood loss for women who delivered in the home, 2012 Figure Figure 6: 8: Management Estimated blood of loss for the women third stage who delivered in the home, 2012

Pain Relief

Of the 153 recorded, 42 women who had a home birth had a water birth (27.3%). As 27 illustrated in Figure 6 this accounts for over one third of primiparous women (36.4; n=12) and almost one fifth of multiparous women (24.2%; n=29).

60 54.5 48 50

40 36.4

% 30 23.2 17.6 20 12.1 9.1 7.2 10 3 2.4 0 0.8 0 1.6 0 None Entonox Water Homeopathy TENS Acupuncture Other Primiparous Mulmparous

Figure 7: Pain relief used by women delivered in the home, 2012

Other Incidences at birth

26 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 26

Characteristics of babies who were delivered at home Sex There was one baby born at home for which were female (50%). These are comparable to the sex of the baby was missing. Of the 160 all babies in the country whereby 51.3% were other babies, 80 were male (50%) and 80 male and 48.7% were female in 2011.

Birth weight grams. The mean Almost birth weight a quarter for infants of born babies at babies (23.6%) (23.6%) who were delivered at who home were had delivered a at birth weight home bhomeetween was 4,000 3,697 grams. and 4,499 This is (Figure 9). 230 There grams were had no a birth low weight birth between weight babies (2,500 4,000 grams) and 4,499 whereas or 6.6% greater this than was the the mean case birth for weight 5% (Figure of all 9). babies born in the country There in were 2011. no low birth weight for all infants born in 2011 (3,467 grams). babies (2,500 grams) whereas this was the grams. Almost a quarter of babies (23.6%) who were delivered at home had a birth weight For over two thirds of births delivered at case for 5% of all babies born in the country b50 etween 4,000 and 4,499 (Figure 9). There were no low birth weight babies (2,500 grams) home (69.0%) the birth weight was between in 2011. whereas 45 Home this births was All the births case for 5% of all babies born in the country in 2011. 3,000 and 3,999 grams. Almost a quarter of 40 37.3 34.4 50 35 31.7 32.2

30 45 Home births All births 23.6 25 40 37.3 34.4 20 35 31.7 32.2 13.7 15 30 11.7 23.6 10 25 5.4 3.1 4.3 20 5 2.6 0 13.7 15 0 11.7 <=2,500 2,500-‐2,999 3,000-‐3,499 3,500-‐3,999 4,000-‐4,499 >=4,500 10 5.4 4.3 5 3.1 2.6 Figure 9: 0 Distribution of birth weight in babies delivered in the home, 2012 0 <=2,500 2,500-‐2,999 3,000-‐3,499 3,500-‐3,999 4,000-‐4,499 >=4,500 Figure 9: Distribution of birth weight in babies delivered in the home, 2012 Figure Apgar 9: Scores Distribution of birth weight in babies delivered in the home, 2012 At Apgar one minute scores after birth at home, almost one third of the babies (30.3%) had an Apgar score At one of minute eight after while over birth two at home, thirds almost of babies (68.4%) (68.4%) had a had score a score of nine of (Figure nine (Figure 10). 10). At five At Apgar Scores minutes one third all of the babies babies (30.3%) had had an an Apgar Apgar score of either ninefive (53.8%) minutes or all 10 babies (46.2%). had an Apgar score of At score one minute of eight after while over birth two at thirds home, almost of babies one either third of the nine babies (53.8%) (30.3%) or 10 had (46.2%). an Apgar score of eight while over two thirds of babies (68.4%) had a score of nine (Figure 10). At five minutes 80 all babies had an Apgar score of either nine (53.8%) or 10 (46.2%). 68.4 70 1 minute 5 minutes 60 53.8 46.2 50 80 % 68.4 40 70 1 minute 5 minutes 30.3 30 60 53.8 46.2 20 50 % 10 40 0.6 0.0 30.3 0.0 0.6 30 0 7 8 9 10 20 Apgar scores at 1 & 5 minutes Figure10 10: Apgar scores at 1 and 5 minutes for babies delivered in the home, 2012 0.6 0.0 0.0 0.6 0 Figure 10: Apgar 7 scores at 1 and 5 minutes 8 for babies delivered 9 in the home, 2012 10 Apgar scores at 1 & 5 minutes 16

Figure 10: Apgar scores at 1 and 5 minutes for babies delivered in the home, 2012 27

16 Resuscitation Ten of the 161 babies born at home (6.2%) suction only, three received oxygen and one needed some form of resuscitation. Six of baby was resuscitated by stimulation with a these 10 babies were resuscitated with warm towel. Delivery examination and screening Four of the 161 babies (2.5%) were suspected baby). Medical examination of the newborn was of having a congenital abnormality, specifically carried out by a general practitioner in over 90% hydronephrosis and spina bifida occulta. of cases (92.6%, 150 of 161) and by a hospital paediatrician in 4.3% of cases (7 of 161). Thus, A newborn bloodspot screen was performed on 3.1% of babies were not examined by a doctor (4 98.1% of the babies (157 of 160, unknown of one of 161; see Table 22).

Table 22: Medical examination of the newborn, 2012 N=161 Yes, by General Practitioner 150(92.6) Yes, by Hospital Paediatrician 7(4.3) No 4(3.1) Note: Values are shown as n (%) unless otherwise stated.

Almost two thirds of babies had vitamin K Vitamin K was not administered to 39.1% administered either orally (40.4%, n=65) (n=63) of newborns (Table 24). or intramuscular injection (20.5%; n=33). Table 23: Vitamin K administration, 2012 N=161 Yes, administered orally 65(40.4) Yes, administered IM 33(20.5) No 63(39.1) Note: Values are shown as n (%) unless otherwise stated.

Method of feeding Method of feeding was recorded on both discharged after three days. In 2011, 46.6% of day one and on day of discharge from the all babies were being exclusively breastfed on care of the SECM. As outlined in Table 24, day of discharge. Despite the much later day of the vast majority of women were exclusively discharge, women who birthed at home were breastfeeding on both day one (n=156, 97.5%) twice as likely to breastfeed exclusively as the and on day of discharge (n=153, 96.2%). Day total population on day of discharge (96.2% v of discharge from the care of the SECM was, 46.6%1). It is likely that this difference would on average, 16 days after the birth. Almost all be more striking if exclusively breastfeeding births occur in maternity units and are usually were assessed at the same time post-delivery. Table 24: Method of feeding, 2012 Day one Day of Discharge (n=160) (n=159) Exclusive breastfeeding 156(97.5) 153(96.2) Partial breastfeeding 3(1.9) 5(3.1) Artificial 1(0.6) 1(0.6) Note: Values are shown as n (%) unless otherwise stated.

28 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Baby Transfers Three of the 161 babies delivered at home Intensive Care Unit for reasons specified in (1.8%) were transferred to hospital by Table 25. ambulance and admitted to the Neonatal

Table 25: Reasons for baby transfer, 2012 N Tetralogy of fallot 1 Baby grunting (respiratory) 1 Tachypnoea 3 hours post-delivery. 1 Persistent pulmonaryhypertension Note: Values are shown as n (%) unless otherwise stated. Postnatal transfers Three primiparous women were transferred retained placenta and severe hypertension. postnatally to a maternity unit. Of the three Medical interventions undertaken in women two were transferred by ambulance. the maternity hospital included; manual Indications for transfer included; nausea, removal of placenta, administration of palpitations, unable to sleep and anxiety, antihypertensives and stemetil injection.

29 Women’s feedback on the home birth service Mothers’ feedback on the home birth service There are a number of reasons why women Women who registered with the Home birth choose toThere birth are at home a rather number than of in a reasons Service in why the HSE: women South choose Area to birth at home rather provided than in a hospital setting.hospital settingPrevious. Previous studies studies have have the following indicated feedback that there are while a number completing of reasons indicated thatincluding there; are dissatisfaction a number of reasons with previous a hospital satisfaction care, the survey aspiration on the to home have birth a low-‐ including; dissatisfaction with previous service in 2012, four to six months following intervention birth and the wish to birth in a comfortable and familiar setting han rather t in a hospital care, the aspiration to have a low- the birth: clinical one (ref). intervention birth and the wish to birth in a comfortableWomen and familiar who setting registered rather than with the Home birth Service in the HSE South Area provided the 14 in a clinicalfollowing one. feedback while completing a satisfaction survey on he t home birth service in 2012 4-‐6 months following the birth:

My partner and I were delighted with Great to get another angle on the home birth service. I got great care and the service and the care we personal attention. My midwife gave me great confidence. Disappointed that I had to transfer but felt I had a great start at home which helped me received. I would like to see the home birth option more widely carry on even after transfer. advertised and positively promoted as it would have been my preferred choice for the two previous births but I did not find information easily to hand at the time, but when I did take the time to look into it this time I was happily surprised to find this I feel that this service is the best I have had four home amazing service. Thank you. kept secret. Having had a births now with the same wonderful home birth the last time two midwives and each I really didn’t think it could be time the care and support I received excellent care from my improved on but this birth was just has been excellent. Also midwife. I had three home births in as wonderful, the care and surprisingly the hospital England and the service in Kerry is practical support is so fantastic gave me great support excellent. particularly in the days and weeks also. I hope this service is after the birth when most women available for my The two midwives in question were are left to manage alone at the daughters in the future. fabulous. Long may your service last. time when they really need Keep up the good work support even more. The midwife was so unobtrusive during the I am delighted with the service birth and is like a revered family received. Such a personal and member whose visits are welcome excellent service would not be by all the family after the birth. possible in a hospital setting. I have Thanks to all the midwives. Ye do no hesitation in promoting the home more than ye know. birth service to anyone.

13Health Services Executive (2008) Delivery on choice Home birth options for women in Ireland Dublin: HSE

30 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Summary

This is the first national clinical audit on home birth 17% were referred to the maternity planned home births in Ireland under the hospital antenatally. Primiparous women care of Self Employed Community Midwives were more likely to be referred than parous (SECMs). Anonymised data were reported by women (22% versus 16%). Almost half of the four Designated Midwife Officers on a total the primiparous mothers who transferred of 224 planned home births in 2012. Almost antentally were due to breech presentation half of all planned home births were arranged (46%) while multiparious women were more through the Health Service Executive (HSE) likely to transfer as they had past their South home birth service (48%) while one estimated date of delivery. One quarter quarter were organised through the HSE West of women who were referred antenatally service (25%). delivered by caesarean section (26%) and primiparous mothers were three times more Three quarters of the women who booked in likely to be delivered by caesarean section for a home birth (74%) had previously given than multiparous mothers (46% versus 15%). birth and one in four were first-time mothers (26%). This is a complete reversal of the Of the women who began labouring at home, percentage of all mothers who gave birth in 15% were transferred to a maternity hospital. 2012 whereby 40% were nulliparious, 33.8 Half (50%) of these transfers were attributed primiparious and 26% multiparious. Women to failure to progress in labour. Over two intent on a home birth had an older age profile thirds of transfers occurred in the first stage to all mothers who gave birth in the country of labour (65%) and most of the women with 78% aged 30-39 years versus 62% for travelled by ambulance (54%). Primiparous all giving birth. Body mass index (BMI) was mothers were almost three times more likely not reported for most women who planned to be transferred than multiparous mothers to have a home birth (57%). Of the 43% with (28% versus 11%). Of the mothers who data, most were in the healthy range (59%), transferred during labour 18% were recorded 29% were overweight, and 9% had a BMI of 30. as being delivered by caesarean section, with In line with the selection criteria, no women multiparous mothers marginally more likely with a BMI greater than 30 were booked for to be delivered by caesarean section than home birth. Efforts will be made to improve primiparous mothers (20% versus 15%). the completeness of data on BMI. There was no maternal or perinatal death Smoking prevalence is unknown for the associated with the 224 planned home pregnant population in Ireland. In UK births in 2012. Of the babies born at home countries, 12-19% of pregnant women smoke 6% needed some form of resuscitation. throughout their pregnancy. This was the case Three of all babies who were born at home for just 4% of the women with a planned home were transferred to a maternity hospital and birth in Ireland in 2012. Data reported for this admitted to the neonatal intensive care unit. clinical audit also indicated that two of the ten A General Practitioner or hospital paediatrician mothers who smoked (20%) stopped smoking examined 96% of the babies born at home. during pregnancy. As smoking is a risk factor for perinatal outcomes it is encouraging to On average, mothers stayed under the care see a lower rate of smokers in this population. of the SECM for 16 days after the birth and Regarding alcohol, the vast majority (92%) received an average of six postnatal visits. of the home birth pregnant women did not Three women (2%) were transferred to a consume alcohol during pregnancy. maternity hospital for postnatal care. Of the women who intended on having a

31 On the day of the home birth, 98% of mothers were breastfeeding exclusively. The figure was 96% on the day of discharge from the care of the SECM. Mothers who birthed at home were twice as likely to be breastfeeding exclusively on day of discharge compared to all women who gave birth (96% versus 47%). It is important to note that mothers who birth at home are discharged on average 16 days after the birth of their from the care of the SECM while mothers who have their baby in the maternity hospital are discharged 3 days after the birth.

In summary, this national clinical audit of planned home births in Ireland provides baseline information for maternity care professionals and prospective women. Clinical audit will be on-going to ensure that care provision adheres to the standards and guidelines as included in the selection criteria, as specified in the memorandum of understanding between the HSE and the SECMs. Specific issues warranting in depth investigation, for example the presence of meconium stained liquor, will be reviewed and addressed in future reports. The SECMs work across the four HSE areas and as such must contend with differing geographical constraints therefore information relating to the woman’s distance from the SECM as well as the closest maternity hospital will be examined in the future. The National Perinatal Epidemiology Centre in collaboration with the Designated Midwife Officers continues to develop the audit tool for home births in order for this to be achieved. It is hoped that hospital based home birth services will also partake in the audit and therefore allow added information about options of care for women during pregnancy and delivery. This report is the most informative resource for clinicians to inform women in a clear and transparent manner in relation to planned home birth as a delivery option in Ireland.

32 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Appendix A: Designated Midwife Officers

HSE Area Contact

Dublin Mid-Leinster Anne Clarke Designated Midwifery Officer HSE Dublin Mid-Leinster Mill Lane Palmerstown Dublin 20 Tel: (01) 6201698 Mobile: 086 4107217 Email: [email protected]

Dublin North East Michelle Waldron Designated Midwifery Officer HSE DNE, Project Officer NMPDU Swords Business Campus Balheary Road Swords Co. Dublin Mobile: 087 7585024 Email: [email protected]

South Jo Delaney & Siobhán Sweeney Designated Midwifery Officers Home Birth Service Cork & Kerry Old Dr’s Residence, St. Finbarrs Hospital Cork Tel: (021) 4923483 Mobile: 087 2889499 Email: Home [email protected]

West Mary T Gibbons Designated Midwifery Officer, HSE West Office of Nursing/Midwifery Service Directorate. Mobile: 087 0525060 E-mail: [email protected]

A list of the Self Employed Community Midwives is available from the following link to the HSE website; http://www.hse. ie/eng/services/list/3/maternity/home birth.html

33 Appendix B: Medical conditions and other factors indicating increased risk suggesting planned birth at an obstetric unit

Table 1: Medical conditions indicating increased risk suggesting planned birth at an obstetric unit Disease area Medical condition Cardiovascular Confirmed cardiac disease Hypertensive disorders Respiratory Asthma requiring an increase in treatment or hospital treatment or requiring steroid treatment in last year Cystic fibrosis Haematological Haemoglobinopathies – sickle-cell disease, beta thalassaemia major History of thromboembolic disorders Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100 000 Von Willebrand’s disease Bleeding disorder in the woman or unborn baby Atypical antibodies which carry a risk of haemolytic disease of the newborn Infective Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended Infective Hepatitis B or Hepatitis C Carrier of/infected with HIV Toxoplasmosis – women receiving treatment Current active infection of chicken pox/rubella/genital herpes in the woman or baby Tuberculosis under treatment Immune Scleroderma Systemic lupus erythematosus Endocrine Diabetes Maternal thyrotoxicosis Renal Abnormal renal function Renal disease requiring supervision by a renal specialist Neurological Epilepsy Myasthenia gravis Previous cerebrovascular accident Gastrointestinal Liver disease associated with current abnormal liver function tests Psychiatric Psychiatric disorder requiring current in-hospital care and / or requiring specialist care.

34 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Table 2: Other factors indicating increased risk suggesting planned birth at an obstetric unit Factor Additional information Previous pregnancy Unexplained stillbirth/neonatal death or previous death complications related to intrapartum difficulty [to be discussed with neonataologists] Previous baby with neonatal encephalopathy Pre-eclampsia requiring preterm birth Placental abruption with adverse outcome Eclampsia Uterine rupture Primary postpartum haemorrhage requiring additional pharmacological treatment or blood transfusion Caesarean section Shoulder dystocia Current pregnancy Multiple birth Placenta praevia Pre-eclampsia or pregnancy-induced hypertension Post-term pregnancy [ For medical review by 42 weeks] Preterm labour< 37 +0 Preterm pre-labour rupture of membranes Term pregnancy (37+0 to 42+0) pre-labour rupture of membranes for more than 24hrs Placental abruption Anaemia – haemoglobin less than 10g/dl at onset of labour Confirmed intrauterine death Induction of labour Substance misuse Alcohol dependency requiring assessment or treatment Onset of gestational diabetes Malpresentation – breech or transverse lie Recurrent antepartum haemorrhage Fetal indications Small for gestational age in this pregnancy (less than 5th centile or reduced growth velocity on ultrasound) Abnormal fetal heart rate (FHR)/Doppler studies Ultrasound diagnosis of oligo/polyhydramnios Previous gynaecological Myomectomy history Hysterotomy

35 Appendix C: Medical conditions and other factors indicating individual assessment when planning place of birth

Table 3: Medical conditions indicating individual assessment when planning place of birth Disease area Medical condition Cardiovascular Cardiac disease without intrapartum implications Haematological Atypical antibodies not putting the baby at risk of haemolytic disease Sickle-cell trait Thalassaemia trait Immune Nonspecific connective tissue disorders Endocrine • Hyperthyroidism • Unstable hypothyroidism such that a change in treatment is required Skeletal/neurological Spinal abnormalities Previous fractured pelvis Neurological deficits Gastrointestinal Liver disease without current abnormal liver function Crohn’s disease Ulcerative colitis

36 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Table 4: Other factors indicating individual assessment when planning place of birth Disease area Medical condition Previous complications Stillbirth/neonatal death with a known non-recurrent cause Pre-eclampsia developing at term Placental abruption with good outcome History of previous baby more than 4.5 kg Extensive vaginal, cervical, or third- or fourth-degree perineal trauma Previous term baby with jaundice requiring exchange transfusion Retained placenta requiring manual removal in theatre Current pregnancy Antepartum bleeding of unknown origin (single episode after 24 weeks of gestation) Body mass index at booking of ≥ 35 or < 18 kg/m² Blood pressure of 140 mmHg systolic or 90 mmHg diastolic on two occasions Clinical or ultrasound suspicion of macrosomia Para 6 or more Recreational drug use Under current outpatient psychiatric care Age over 40 at booking Fetal indications Fetal abnormality Previous gynaecological Major gynaecological surgery history Cone biopsy or large loop excision of the transformation zone Fibroids Female circumcision

37 Appendix D: Indications for intrapartum transfer

Spontaneous rupture of membranes > 24 hours Indications for electronic fetal monitoring (EFM) including abnormalities of the fetal heart rate (FHR) on intermittent auscultation Delay in the first or second stages of labour Meconium stained liquor Maternal request for epidural pain relief Obstetric emergency – antepartum haemorrhage, cord presentation/prolapse, postpartum haemorrhage, maternal collapse or a need for advanced neonatal resuscitation Retained placenta Maternal pyrexia in labour (38.0 °C on one occasions or 37.5 °C on two occasions 2 hours apart) Malpresentation or breech presentation diagnosed for the first time at the onset of labour, taking into account imminence of birth Either raised diastolic blood pressure (over 90 mmHg) or raised systolic blood pressure (over 140 mmHg) on two consecutive readings taken 30 minutes apart Uncertainty about the presence of a fetal heartbeat Third or fourth degree tear or other complicated perineal trauma requiring suturing

38 PLANNED HOMEBIRTHS IN IRELAND ANNUAL REPORT 2012 Appendix E: Indications for postpartum transfer

Mother Postpartum haemorrhage (>500mls) or any amount that causes the mothers condition to deteriorate Pyrexia (38.0 °C on one occasions or 37.5 °C on two occasions 2 hours apart) Concerns for psychological wellbeing Signs of thromboembolic disease Infant Congenital or genetic abnormality Respiratory symptoms – tachypnoea (RR>60/minute), grunting, recession Cyanosis, plethora, pallor Bile-stained vomiting, persistent vomiting or abdominal distension Delay in passing urine or meconium >24 hours Fits, jitteriness, abnormal lethargy, floppiness, high pitched cry Jaundice <24 hours

National Perinatal Epidemiology Centre, Department of Obstetrics and Gynaecology, UCC, 5th Floor, Cork University Maternity Hospital, Wilton, Cork, Ireland T: +353 21 4205017 E: [email protected] W: www.ucc.ie/en/npec/