Homebirth outcomes and postnatal experiences in Canterbury (HOPE) study

Background: Homebirth and home postnatal outcomes are not well described within midwifery literature. What evidence exists supports the high value of continuity of midwifery care and the positive experiences of homebirth and a home postnatal course. What is considered ‘normal’ in relation to newborn weight change is also poorly understood and is informed almost entirely by institutional postnatal care outcomes. Despite implementation of policies protecting exclusive breastfeeding for newborns, breastfeeding outcomes in Aotearoa New Zealand are sub-optimal at six weeks postpartum. Aim: To describe neonatal outcomes in relation to breastfeeding and newborn weight change following homebirth in Aotearoa New Zealand and to understand how women’s experiences of a home postnatal course with continuity of midwifery care following homebirth might contribute to understanding these outcomes. Methods: This research employed a mixed methods triangulation design consisting of concurrent collection of equally weighted quantitative and qualitative data sets. There were two sets of participants: eight focus group participants (50% primiparous) and 90 survey participants (21% primiparous). Reflexive thematic analysis was used to identify key qualitative themes from focus group discussions with eight homebirth parents in Christchurch, New Zealand. Descriptive statistical analysis was applied to report quantitative homebirth postnatal outcomes from survey data of 90 homebirths in the Canterbury/West Coast region. This research was underpinned by a critical realist framework that enabled exploration of the complex social and cultural factors that shape midwifery practice and maternal and neonatal health outcomes. Findings: Women described the importance of support and creating a safe space for birth and early breastfeeding. Homebirth was described as a shared, empowering experience, and this positive birth experience had a direct impact on women’s postnatal experience. Continuity of midwifery care was a key factor in building maternal confidence and trust in normal physiology and progress. There was a high rate of physiological birth (both of baby (100%) and placenta (91%)) and low rates of postpartum haemorrhage >1000 mls (3%) and 3rd degree perineal tearing (1%). Most women used a range of labour coping strategies, and most gave birth in an upright position (92%). The postpartum hospital transfer rate was 7%. Babies born at home experienced a mean of 127 minutes of uninterrupted skin-to-skin contact with their mother after birth and on average initiated breastfeeding 36 minutes after birth. Babies fed for a mean 52 minutes during their first breastfeed and went on to establish a high rate of exclusive breastfeeding (95%) at discharge from midwifery care. Women described their commitment to establishing breastfeeding and some women described the need for perseverance in working through initial breastfeeding issues to achieve their breastfeeding goals. Nearly half (42%) of the babies born at home were at or above their birthweight at one week of age. The mean weight change at one week was -0.5% from birthweight (M= 21g loss, SD 155g). All women received full continuity of postnatal care from their LMC midwife and received a mean of 10 postnatal home visits over the six week postnatal period. The postnatal outcomes data, while not relating to the same families, affirms that such an environment can produce excellent conditions for optimal maternal and neonatal wellbeing. Discussion: Homeborn babies were able to thrive instinctively when they were allowed to take the lead on initiating feeding and resting periods. Reported weight change at one week found minimal weight loss and there were high rates of exclusive breastfeeding at six weeks. These research findings suggest that breastfeeding intervention for healthy term neonates is rarely needed, and mother/baby dyads will usually achieve breastfeeding success in a supportive environment with continuity of care. Conclusions: In this study, homebirth outcomes were consistently positive and laid the foundations for a positive postnatal course. Women felt empowered by their homebirth and home postnatal experiences and embraced a trust in their breastfeeding journey that enabled instinctive thriving for babies through the postnatal phase. This was enabled and enhanced by continuity of midwifery care, which women valued highly. Home born babies often lost minimal weight in the first week and they maintained high rates of exclusive breastfeeding through the first six weeks of life. These findings should encourage a challenge to the current approach to early postnatal support provided in an institutional environment.