Nordic homebirth Denmark Nordic home births

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1 Nordic homebirth Denmark 2013 Nordic home births

2 Welcome to the second seminar on homebirth in Denmark Especially to our participants from Sweden please rise Norway Iceland Working in hospital setting Working in independent midwife settings Students Managers Press

3 Practical Please wear your badge Coats can also be placed in the room opposite There is breakfast in our next break as well Smokers: Outside the door at the reception or at the back of the building

4 Program Arrival, registration and breakfast 10:30-11:15 Perinatal mortality and morbidity and maternal outcomes after planned homebirths in the Netherlands. Ank de Jonge, midwife, assistant professor, Ph.D. VU University Medical Center, Amsterdam Break 11:30-12:15 The Nordic Homebirth Study, overall status and plans Helena Lindgren, midwife, associate professor, Ph.D., Department of Women s and Children s Health, Karolinska Institutet, Stockholm, Sweden 12:15-13:15 Lunch 13:15-13:45 Transfers to hospital in planned homebirth - a systematic review Ellen Blix, midwife, Ph.D., Acting Head, Department of Clinical Research, University Hospital of North Norway, Tromsø Associate Professor, Department of Clinical medicine, University of Tromsø 13:45-14:15 Fathers experiences of planned home birth and status on home birth of Iceland Olof Asta Olafsdottir, midwife, associate professor, Ph.D.,School of Health Sciences, Department of Midwifery, Faculty of Nursing, University of Iceland 14:15-14:30 Break 14:30-15:00 Status and Results Nordic home birth Denmark, Hanne Kjærgaard, midwife, Ph.D., Head of research, the Research Unit Women s and Children s Health, the Juliane Marie Centre, Copenhagen University Hospital and associate professor, Faculty of Health and Medical Sciences, Copenhagen University Karen Ingversen midwife, MSc, the Home Delivery Team Sjælland 15:00-15:20 Should we encourage home birth? Ank de Jonge 15:20-15:40 Group discussions on this subject 15:40-16:00 Plenum discussion on this subject and end

5 Our dear colleague Hanne is seriously ill and could not be here today

6 Welcome to Ank de Jonge, midwife, assistant professor, Ph.D. VU University Medical Center, Amsterdam.

7 Break until 11:30

8 Welcome to Helena Lindgren, midwife, associate professor, Ph.D., Department of Women s and Children s Health, Karolinska Institutet, Stockholm, Sweden

9 Lunch to 13:15 Lunch is in room D Tables in the cafe, room A and B Please put your own Please put your own plate at the cleanuptables after the meal

10 Welcome to Ellen Blix, midwife, Ph.D., Acting Head, Department of Clinical Research, University Hospital of North Norway, Tromsø

11 Welcome to Olof Asta Olafsdottir, midwife, associate professor, Ph.D., School of Health Sciences, Department of Midwifery, Faculty of Nursing, University of Iceland

12 Break until 14:30

13 Status and Results Nordic home birth Denmark

14 Thank you Helena, for deducting the data All results are preliminary

15 My Background Midwife 1999 MSc in Midwifery from University of Amsterdam Danish project coordinator on Nordic Homebirth Have worked 3 years as homebirth midwife in The Netherlands Currently working as a homebirth midwife in Region Sjællands hjemmefødselsordning

16 Homebirth in Denmark

17 What you will learn today among other things Danish homebirth geografy Who are delivering the danish homeborn babies and what are their qualifications? Why are women transfered to the hospital and how (did anyone actually go to hospital by horse in the research period?)? Who tells the mothers NOT to give birth at home? Are midwives good at supporting the partners during birth? How did the women rate the help they had?

18 Compared with the rest of Scandinavia S 0,1% 100 N 0,2% 100 I 2,2% 100*has doubelt every years the last 5 years DK 1,3% 750

19 Combination care DK Known midwife Home birth specialiced midwife - - Horsens ex - + Hvidovre + + Ålborg, Haderslev + - Hospital births Næstved

20 data for this project came from 34 units 29 hospital settings (some smaller ones on islands, some closed by now) 5 independent midwife units approx. 800 different midwives filled out forms for this research Every unit had a contact person

21 Homebirth in Denmark in the research period

22 But The National Board of Health says they have had registration problems in 2011, so the correct number of homebirths is probably more like 2011 and 2012

23 Homebirth in percentages

24 Response rate Absolute numbers of questionnaires answered Midwives: 1747 Mothers: 1130 Percentage of total homebirths (estimate 2324) Midwives: 78% Mothers: 52% Refused to participate: 74 Refused to participate: 3% But the midwives are not to be blamed for this.

25 Did you give the mother information about the project? (1) Ja ,1% (2) Nej 115 6,8% (3) Vet ej 68 4,0%

26 All births in total pr region

27 Homebirths per region (numbers) (1) Region Syd ,1% (2) Region Midt 159 9,1% (3) Region Nord 164 9,4% (4) Region Sjælland ,6% (5) Region Hovedstaden ,0% (6) Antal som ej svarat 31 1,8%

28 In another way Total births % births syd 18,9 midt 19,4 nord 12,8 sjælland 10,8 hovedstaden 35,6 unknown 0,5 Homebirths

29 This shows Region Sjælland has the highest rate of homebirths, probably due to a system of publicly funded independent midwives (Hjemmefødselsordning Sjælland). Compared with the number of total births it is three times as many homebirths as region Hovedstaden, that has 4% homebirths. Some areas ( kommuner ) have 10 % homebirth Region Nord and lately Syd also have birth units, that offer different care:

30 Nord: Ålborg known midwife and homebirth team homebirths homebirths Know your midwife from 1. th september

31 Number of births pr year by Hjemmefødselsordning Sjælland 300 women women

32 It seems The way homebirth is organized has much impact om numbers of homebirth What would happen if all regions had a group of publicly funded independent home birth midwives? 4% homebirths in DK? Or more than 2300 homebirths pr year political issue. This could mean about 80 midwives in DK could work fulltime as home birth midwives

33 Births by hospitals and by independent midwife numbers (1) Jeg er ansat ved et sygehus. (2) Jeg er ansat ved en hjemmefødselsordning drevet af et sygehus. (3) Jeg er selvstændig i en ordning med offentlig financiering. (4) Jeg er selvstændig og kvinden har selv betalt for min assistance. (5) Jeg er selvstændig i Hjemmefødsels Ordningen Sjælland, område: ,4% ,6% 7 0,4% 19 1,1% ,4% (6) Område, Andet, skriv ,7% (7) Antal som ej svarat 44 2,6%

34 How many known midwife (1) Ja ,9% (2) Nej ,5% (3) Antal som ej svarat 19 1,7%

35 How many homebirths have you attended as a midwife? (1)Mere end ,2% (2)Mellem ,2% (3)Mindre end ,2% (4)Antal som ej svarat 412,4%

36 Small group af midwives takes care of a large proportion of homebirths About 0,5 % of all midwives in DK works in a publicly funded independent home birth group, but they deliver 30 % of alle homebirths

37 Outcome homebirths

38 Primiparas/multiparas 80% multi 20 % primis

39 Transfer rates (1) Ja ,7% (2) Nej ,4% (3) Antal som ej svarat 37 2,1%

40 Transfer rates Hjemmefødselsordning Sjælland Primis ,6 % ,9 % ,1 % Balance is 30% PO/70% P multi approx Average is total 11 % transfer Multis 20113,7 % ,1 % 20133,4 %.

41 Reasons to transfer (1) Manglende fremgang 51 22,2% (2) Behov for anden smertelindring (3) Mistanke/tegn på foetal distress (4) Jordmoder kunne ikke komme 14 6,1% 24 10,4% 0 0% (5) Andet, beskriv i 80 34,8% kommentarfeltet: (6) Antal som ej svarat 61 26,5%

42 Diagnosis for transfer in all homebirths Others (Other reasons were mainly meconium stained amnion liquid and suturing) 4,5% Lack of progress 2,9% (consider 350 are primis) Suspecting fetal distress 1,3% Need for pain relief 0,8% Or no answer 3,4%

43 Vehicle for transfer (1) Privat bil 56 24,3% (2) Taxi 9 3,9% (3) Ambulance ,9% (4) Helikopter 0 0% (5) Andet 2 0,9% (6) Antal som ej svarat 16 7,0%

44 Other ways to transfer? Walked! By bicycle! No one on horse though

45 At least 30 % undramatic transfers Dramatic transfer is the fear of both midwives en families

46 Emergency transfers (1) Ja 58 25,2% (2) Nej ,7% (3) Antal som ej svarat 30 13,0%

47 Treatment in hospital for the 12,7 %

48 Treatment in hospital for the 12,7%

49 Medical interventions in all homebirths

50 Baby complication rates numbers Infection suspect.0,1% Hypoxia/asfyxia 0,3% Malformation 0,0% Others complications: Respiratory distress, broken clavicula, observed for heart malformations 1,0% (1) Mistanke om infektion 2 (2) Hypoxi/asfyxi 6 (3) Medfødt misdannelse 0

51 How many % refused transfer during birth? 0,0 % Heart stories but not in in DK

52 Opinions and experiences of the Why do they chose for a homebirth in the first place? How many where advised against home birth? By who? Why? mothers Satisfaction? Would they give birth at home again?

53 Why do they chose for a homebirth in the first place? (1) Min jordemoder mente godt jeg kunne føde hjemme (2) Min egen læge mente godt jeg kunne føde hjemme (3) Jeg havde tillid til min krop og mente jeg godt kunne føde hjemme ,0% 79 7,0% ,2% (4) Jeg har født normalt før ,4% (5) Mine omgivelser bakkede ,5% mig op i at føde hjemme (6) Jeg søgte informationer og baseret på dem, mente jeg at jeg godt kunne føde hjemme ,2% (7) Andet, skriv 58 5,1% (8) Antal som ej svarat ,6%

54 According to the women how many were advised against giving birth at home (1) Nej ,1% (2) Ja ,8% (3) Antal som ej svarat 24 2,1%

55 According to the midwife: How many were advised not to give birth at home before birth? (1) Nej ,5% (2) Ja 92 5,3% (3) Antal som ej svarat 38 2,2%

56 Midwife reasons to advise against homebirth Reasons for advice against home birth: Age, BMI, previous hemorrhage, high blood pressure, VBAC, pregnancy more than 42 weeks, (grand) multipara, medication during pregnancy (anti-depressive) Sometimes the midwife agrees, sometimes it is advise of the obstetric

57 Large difference? According to women: 33% According to midwife: 5%

58 According to women. Who advised against homebirth (1) Fødselslæge 45 4,0% (2) Min egen privatpraktiserende læge (3) En af de jordemødre jeg gik hos i graviditeten 81 7,2% 17 1,5% (4) En anden jordemoder 15 1,3% (5) Din familie/venner ,3% (6) Din partner 21 1,9% (7) Andre, skriv 81 7,2% (8) Antal som ej svarat ,6%

59 So there is Medical (probably some overlap) private (1) Fødselslæge 45 4,0% (2) Min egen privatpraktiserende læge (3) En af de jordemødre jeg gik hos i graviditeten 81 7,2% 17 1,5% (4) En anden jordemoder 15 1,3% (5) Din familie/venner ,3% (6) Din partner 21 1,9% (7) Andre, skriv 81 7,2%

60 Old war zone: Doctors versus Midwives Practitioners (7%)/obstericts (4%) versus midwives (1%) in the question of homebirth There is no total agreement (approx 10% versus 1%) But it does not seem like this is a large problem, with these results (But these are off course the ones that gave birth at home, not all the ones who choosed not to) Mostly the private network, advising families against homebirth

61 This tells us Partners are loyal to womens choice But many (about 30%) are advised against homebirth fromfriends, colleagues and relatives Why? With what reason

62 With what reason? (1) Pågældende mente hjemmefødsler er farlige ,5% (2) Helbredsproblemer hos mig 16 1,4% (3) Graviditetskomplikationer 43 3,8% (4) Andet, skriv 109 9,7% (5) Antal som ej svarat ,1%

63 Birth culture problem Main reason idea: Homebirth is dangerous Where does this idea come from? Not from science Cultural issue Large difference with the Netherlands, at least how it was 10 years ago Midwife task to help change this culture

64 Why did they still chose for a home birth? (1)Min jordemoder mente godt jeg kunne føde hjemme27124,0% (2)Min egen læge mente godt jeg kunne føde hjemme797,0% (3)Jeg havde tillid til min krop og mente jeg godt kunne føde hjemme44339,2% (4)Jeg har født normalt før25322,4% (5)Mine omgivelser bakkede mig op i at føde hjemme24321,5% (6)Jeg søgte informationer og baseret på dem, mente jeg at jeg godt kunne føde hjemme23921,2% (7)Andet, skriv585,1% (8)Antal som ej svarat65057,6%

65 2 main reasons Trust in body Advise from midwife/practitioner Assumptions: Important to facilitate womens trust in own capacity A close and trusty A close and trusty relalionship with the midwife/practitioner

66 Satisfaction (1) Information om fødsels forløbet (2) Din egen indflydelse på de beslutninger der blev taget Meget tilfreds ,3% ,1% Tilfreds ,0% 93 8,2% Hverken tilfreds eller utillfreds 43 3,8% 15 1,3% Utilfreds 3 0,3% 1 0,1% Meget utilfreds 8 0,7% 6 0,5% 22 1,9% 20 1,8% (3) Samarbejdet med jordemoderen 89,1% 7,3% 1,0% 0,4% 0,4% 1,8% (4) Samarbejdet med din partner (5) Miljøet omkring dig (6) Den medicinske omsorg (7) Den følelsesmæssige omsorg (8) Fødslen i sin helhed ,6% ,0% ,9% ,4% ,6% 51 4,5% 83 7,3% ,2% 98 8,7% 94 8,3% 4 0,4% 13 1,2% ,2% 17 1,5% 14 1,2% 1 0,1% 3 0,3% 7 0,6% 3 0,3% 5 0,4% 5 0,4% 6 0,5% 4 0,4% 4 0,4% 6 0,5% 23 2,0% 19 1,7% 42 3,7% 20 1,8% 21 1,9% Inget svar

67 90% is very satisfied or satisfied with Decisionmaking, midwife, emotional care, information level, partner, environment, the birth as a whole (less than 1% is unsatisfied or very unsatisfied) only 71 % is very satisfied or satisfied with the medical care

68 Perception of midwife Passer (1) Det virkede som om hun havde viden om medicinske spørgsmål (fødselsforløb, komplikationer...) (2) Det virkede som om hun havde viden i tekniske spørgsmål (smertelindringsmetoder, blodprøver ) (3) Det virkede som om hun havde viden omkring følelsesmæssige spørgsmål overhovedet ikke 28 2,5% 27 2,4% 26 2,3% (4) Ro 31 2,7% (5) Støtte 30 2,7% (6) Opmuntrende 31 2,7% (7) Respektfuld 28 2,5% (8) Tillidsvækkende 32 2,8% (9) Opmærksom på mine behov (10) Opmærksom på min partners behov 28 2,5% 25 2,2% Passer lidt 4 0,4% 4 0,4% 16 1,4% 10 0,9% 7 0,6% 20 1,8% 9 0,8% 10 0,9% 10 0,9% 21 1,9% Passer nogenlunde 45 4,0% 55 4,9% 77 6,8% 38 3,4% 52 4,6% 54 4,8% 26 2,3% 56 5,0% 71 6,3% ,7% Passer helt ,5% ,4% ,8% ,9% ,8% ,4% ,3% ,9% ,1% ,8% Inget svar 42 3,7% 45 4,0% 42 3,7% 35 3,1% 37 3,3% 37 3,3% 35 3,1% 39 3,5% 37 3,3% 50 4,4%

69 But when you ask if the midwife had Medical knowledge, technical knowledge, respect, care for the woman, was encouraging, calm, confident and offered support more than 85% agrees totally (and about 2,5% not at all) Only on attention for the needs of my partner it is only 78%

70 Would you choose a home birth again? (1) Ja ,4% (2) Nej 12 1,1% (3) Ved ikke 29 2,6% (4) Antal som ej svarat 22 1,9%

71 That is quite good considering 12% i transfered 33% are advised against homebirth by private network About 10 % are advised against homebirth by doctor Danish midwives have a good reason to be proud of their work at the homebirths

72 Conclusions and key points More special home birth units, specially out of hospital with independent midwives will likely create more homebirths 2. Today about half of all homebirths are done by Special home birth units (in/outside hospital settings), though only offered to approx 15% of all pregnant women 3. It seems like choosing for a homebirth will have a positive effect on avoiding complications and medical interventions in birth

73 Conclusions and key points Most homebirth to hospital transfers are undramatically 5. In spite of being very capabel of giving birth, 33 % of this group where advised not to give birth at home 6. Doctors are not so badly against homebirth as some midwives suspected 7. Women rate the care they had from the midwives at the homebirth very high

74 Thank you for your attention

75 Welcome back: Ank de Jonge

76 Feedback & future Feedbach about today, please send to I hope to be able to raise funds to present some results of Nordic Homebirth on a midwife meeting on your work place please mail me I you are interested Future articles published about Nordic Homebirth: See

77 Sponsorer & helpers Midwife students:thank You

78 Lillian Bondo will finish this day

79 Have a safe trip home Pictures, video and the precentations from today can be seen on dk Please leave your badge in the basket ind the lobby Thank you so much for coming today