The window for Home Birth after Caesarean (HBAC) in Ireland has opened again for some women
Prior to the Memorandum of Understanding (MOU) between self employed midwives and the HSE (which was drawn up in 2008 for the national homebirth service), women routinely availed of home births following a caesarean section, subject to an individual assessment by an independent midwife. The MOU stated that HBACs are too risky based on the HSE’s internal risk assessment and that all VBAC attempts should take place in a hospital setting.
The HSE’s risk assessment on VBAC in the community in turn informs the State’s Clinical Indemnity Scheme (CIS), which will not offer indemnity to self employed community midwives working in the community to attend HBACs. However, the self employed community midwives who carry out home birth care on behalf of the HSE are required by legislation (The Nurses and Midwives Act of 2012) to be fully indemnified in order to offer care in the community Currently, the only available indemnity for a self employed community midwife is that offered by the CIS. Self employed midwives are therefore prevented from taking women on who have had a previous caesarean birth, even if they have successfully birthed at home before. Therefore in Ireland as of 2008, there have been no indemnified HBACs attended by self employed community midwives.
Instead women travelled outside the jurisdiction to avail of a HBAC, or they birthed alone without professional medical attendance. Read Rachel Singleton s journey to the UK to have her HBAC here.
In 2013, Aja Teehan took a landmark high profile case against the HSE testing her right to individual assessment for a HBAC. http://www.ajateehan.com/2013/06/aja-teehan-vs-hse-and-minister-for-health/
She lost that high court case, and went on to have her baby in the UK.
Aja ‘s case threw into the limelight the issues surrounding the safety of VBAC and also the VBAC rates in Ireland. Until March 2014, there were no VBAC rates released by the HSE. However last year the HSE released its VBAC rates to AIMSI
The figures show that VBAC rates are very low, although AIMSI issued a caveat with the data saying that it was possible that some of the hospitals with a 0% VBAC rate may have had problems with data coding. The highest rate for VBAC in Ireland is in the National Maternity Hospital with a rate of 33%. Some hospitals however, have a very low rate indeed of less than 5%. Coupled with a high primary cesarean rate, these figures are understandably worrying for mothers who are hoping for a normal delivery on their first baby or for a VBAC on a subsequent baby in hospital. A point also worth bearing in mind with respect to the interpretation of published VBAC rates is whether the VBAC rate is based on all women with a previous cesarean, who birthed in that hospital or whether the rate quoted is just based on those women with a previous caesarean who have already been pre selected for a trial of labour in that hospital. So, a maternity unit might have a high rate of repeat cesarean and only allow a very small number of low risk women to attempt a VBAC and so that hospital may then achieve a high VBAC “rate.”
Why are the VBAC rates in Irish Maternity units so low? Part of the reason is our heavily medicalised approach to birth, but also partly because of the fear that health care professionals have of uterine rupture. However, the quoted rates of uterine rupture are often erroneous. It is often routinely quoted as 1 in 200 (0.5%). However, the research indicates that it is nowhere near that high in large maternity hospitals where women are properly screened. Neither of course, is it anywhere near that high at home.
“In a woman with one previous caesarean, the decision to opt for a planned elective repeat CS or a planned trial of labour may be influenced by the perceived risk of UR. National guidelines and large reviews quote different risks, for example, 0.2-1.5% (SOGC 2005), 1.0% (WHO 2005), 0.2-0.7% (RCOG 2007), 0.5-.7% (RANZCOG 2010), 0.5% (AHRQ 2010), 0.5-0.9% (ACOG 2010). In the setting of a large Irish maternity hospital with strict guidelines for a TOLAC, the UR rate was 2 per 1000 overall, and 1 per 1000 for women in spontaneous labour who did not receive oxytocin augmentation”
(Turner et al, 2006). Quoted in
In women with a previous low transverse CS, factors that have been reported to increase the risk of UR include multiple previous CS, no previous vaginal delivery, a short interpregnancy interval, one layer uterine closure, prior preterm CS, induction of labour and oxytocic augmentation
(Landon, 2010). Quoted in
Furthermore, if a uterine rupture should occur, the National Obstetric Guidelines Suggest that the the chances of a baby dying as a result are very low at 0.001%.
The overall rate of rupture-related death with a TOLAC is low and has been estimated as 1 in 1000 approximately (Landon et al 2004; Scott et al, 2011). One study reported no serious neonatal morbidity in 78 cases of UR when less than 17 minutes elapsed between a prolonged fetal heart rate abnormality and delivery (Leung AS et al, 1993). In a Dublin study of 4021 women undergoing TOLAC,
there were no cases of HIE or intrapartum death (Turner et al, 2006). Quoted in
It is not surprising that with the stresses and limitations placed on successful VBAC in hospital so many women are keen to have a VBAC at home; a HBAC. Many women who have previously birthed at home, but who may have been required to have a cesarean due to an isolated issue with a previous pregnancy e.g. transverse breech would also like to have a HBAC.
We already know that opting for a home birth for any woman will reduce her chances of a cesarean, so opting for a homebirth as a HBAC should be no different. It might in fact be the best treatment a woman with a previous cesarean needs in order to avoid a repeat unwanted cesarean.
A study way back in 1997 in the UK “Home Births – The report of the 1994 Confidential Enquiry by the National Birthday Trust Fund Edited by Geoffrey Chamberlain, Ann Wraight and Patricia Crowley
Parthenon Publishing, 1997.” looked at the safety of home births and part of the study included looking at the outcomes of a small number of HBAC mothers (53). The study found that 72% of them gave birth at home without incident and 28% transferred into hospital care (antenatally or during labour) where some of them went on to have a VBAC in hospital.
The primary risks associated with uterine rupture are unlikely to occur at home, for example there will be no oxytocic drugs used, there will be no induction of labour, there will be no CTG, and there will be no labouring by the clock. Equally as important, the mother will not be left on her own, but will be closely observed throughout her labour by a midwife who knows her and her baby, and who has given her and her baby full continuity of care, and as in a hospital setting she will have been screened as suitable for a HBAC. However, in the unlikely event that a mother having a VBAC should have a uterine rupture; hospital would definitely be the safer place to have one, due to potential issues with transfer times from a community setting.
There is also no getting around the fact that a woman with a previous cesarean is of a higher risk than a woman without one. Mary Cronk, MBE, independent midwife and breech presentation expert once commented at a HBA conference that a breech presentation was a “normal” presentation, but a woman with a previous cesarean was not. A previous cesarean is a risk factor that will follow the woman antenatally in all of her labours, so does this make birthing at home less safe than hospital for women with a previous cesarean? That we don’t know. We do however have data from Ina May’s birth centre The Farm, where she has carried out 2100 births with no uterine rupture and a section rate of 4%. And more importantly what we do know is that women should have the choice to birth where they feel most safe and most supported, and what we do know is that women should be entitled to an individual assessment.
Also recent research reported in the ICAN website (March 2014) suggests that the success rate for HBAC is higher than might previously have been thought.
“The Midwives Alliance of North America (MANA) recently published data from a large and well-tracked series of planned home births, the result of a home birth registry program that was initiated in 2004 . The data set included nearly 17,000 planned home births attended by a mix of midwives including CPMs (79%), CNMs (15%), and other unlicensed midwives. Within this cohort were 1054 women with a history of cesarean section who were planning a . . . “HBAC” . . . Within this subgroup, 87% had successful vaginal births, with 94% of those births occurring at home and the remaining 6% occurring after a transfer to a local hospital. This success rate is substantially higher than the 60-80% success rate reported across other large hospital-based cohorts and likely reflects the high level of commitment to and support of natural birth, both from the mothers and their care providers.”
Amy Haas in an article for Midwifery Today identified the following risk factors for HBAC
1. Previous infection of uterine scar site (weakens scar)
2. Pregnancy less than 18–24 months after previous c-section (causes greater stress on scar)
3. Induction of any kind (causes stress on scar)
4. Placenta covering uterine scar (cause physical stress on scar)
5. 42 weeks+ gestation (associated with greater risk of cesarean)
6. More than one previous cesarean (if no previous vaginal birth)
She also identified the following low risk factors
1. General health (if a woman is in good health then her chances of a successful HBAC are high)
2. Reproductive history
3. Number of previous c-sections(the fewer the previous sections the greater her chance of achieving a successful HBAC)
4. Previous vaginal births (the greater number of previous vaginal births the greater the chance of achieving a successful HBAC)
5. Time since last c-section (More than 24 months since a previous section will enhance a woman’s chance of a successful HBAC)
6. Infection experience (no previous scar infections will increase a woman s chance of a successful HBAC)
This blogger agrees that HBACs are on the whole safe but suggests two potential risks for HBAC
The other two main risks of HBAC are the family’s distance from a hospital, and the abilities of their care provider to support normal birth, to detect signs of problems and to address them in a timely, competent way. So, it is wise to carefully select HBAC assistance; most of the information you need is the same information about midwives that all families need with respect to a midwife’s training, knowledge, and usual routines. You should also ask about each available midwife’s knowledge and experience with HBAC.
For a few months in the late summer last year (2014) a private midwifery company, UK Birth Centres/Neighbourhood Midwives had clinical indemnity to offer HBAC as an option to women in a few locations in Ireland, and then out of the blue this indemnity was unexpectedly withdrawn. A couple of mothers managed to have a HBAC with the company, but many HBAC clients hoping for care in the community were devastated at the thought of having to go into hospital care and face into our medicalised maternity services with their low hospital VBAC rates.
However, today there is hope for HBAC women again as the clinical indemnity enabling UK Birth Centres/Neighbourhood Midwives to provide an individual assessment process for a HBAC service to women with a previous cesarean section is in place again.
“Neighbourhood Midwives are delighted to announce that our partner UK Birth Centres are now able to offer even more homebirth choices to families in Ireland, including mothers with a previous caesarean birth (VBAC). As always, the safety of our clients is our paramount responsibility and we will continue to offer individualised assessment to all our potential clients. Mothers with a more complex history, such as a previous caesarean birth, should be assessed by a specialist and fortunately we can now offer that service if needed. We intend to roll out our new choices cautiously to help maintain our 100% safety record, so mothers with more than one previous caesarean births will be offered support in hospital or private birth suite options when available in their areas.”
UK Birth Centres/Neighbourhood Midwives
At present the company are only offering individual assessment for HBAC to women with one previous cesarean. Women hoping for a HBACx2 are currently not eligible for the service, however, hopefully this will change with time, and women looking for HBACx2 will also be able to avail for the individual assessment process.
Our national guidelines on VBAC(2) state that it should be supported when the head is engaged, the cervix is favourable, when there is a history of prior vaginal birth and when the onset of labour is spontaneous. So all women hoping for a HBAC(2) should be aware of these during their negotiations in a hospital settings.
“Evidence for VBAC2 has shown that women choosing VBAC vs VBAC2 have similar rates of uncomplicated vaginal birth. The rate of major complications is slightly higher if you have had more than one previous Caesarean Section. However, while the risk of major complications is higher for women with 2 previous Caesarean Sections, when compared to the risks for elective Caesarean Section, the absolute risks of major complications are quite low.”
Women planning a VBAC in hospital settings, find that their birth choices are routinely held to ransom by the HSE’s National Consent Policy which cites the 8th Amendment to the Irish Constitution, (and therefore the safety of the unborn as defined by obstetricians and other HCPs rather than by the mother herself). Sometimes women are even threatened with high court actions. These women, will now be able to exercise autonomy in their birth choices and will hopefully have the option of a HBAC with UKBC/NM.
Obviously, this is only a choice for those who can afford it as it is a private service and so many women without insurance or women that are medical card holders may be priced out of the market. Hopefully by demonstrating safe outcomes, this private service might encourage the HSE;s public homebirth services to look more favourably at restoring a public HBAC service.