An updated Cochrane review says that giving birth in an alternative setting within a hospital-like bed-free birthing room or one designed to be "homelike" is just as safe for healthy women as laboring in a traditional hospital bed and women who use these rooms are nearly twice as likely to be satisfied with their birth experiences.
The review found that alternative birthing rooms reduced the use of epidural and other anesthesia by 18 percent, cut the need for the drug oxytocin to speed labor by 22 percent and increased the probability that a woman would be breastfeeding her baby at six to eight weeks by 4 percent. The likelihood of birth by Caesarian section surgery declined by 11 percent.
The review included nine studies of more than 10,000 women who agreed to a random assignment to give birth in an ordinary hospital room or a hospital room designed to be less medical and supportive of natural birth. No appropriate studies compared women randomized to either hospitals or freestanding alternative birthing centers â' so these results are not applicable to them.
Even within a hospital, however, the rooms had an impact.
"Birth environment affects not only the women who are laboring but also the behavior of care providers," says lead author and registered nurse Ellen Hodnett Ph.D., chair of Perinatal Nursing Research at the University of Toronto. In a setting that seems less "medical," staff might listen to women more, empowering them to make their own choices.
"Most typical hospital labor wards really have two competing interests," Hodnett added: they want to support natural birth, but they are also trying to manage medical risks. "If you change the physical environment such that it supports normal labor and birth, good things can happen."
Most important, the review showed that "safety was not compromised in any of these nontraditional sites for birth and labor," said Teri Stone-Godena, R.N., director of the Midwifery Educational Program at Yale University, who was not associated with the review.
The review appears in the latest issue of The Cochrane Library
, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
A previous Cochrane review had found a possible trend towards higher risk of death for the child in the alternative settings in hospitals, but this was not the case in this updated version, which included data that are more recent.
Interestingly, satisfaction with birthing rooms remained high despite the fact that about one-half to two-thirds of the women required transfers to traditional hospital rooms at some point during labor, mainly because labor was not progressing or because they requested anesthesia.
"I think many times we as human beings are in love with a concept but the reality isn''t quite what we expect," Stone-Godena said. "I think [the women] had good positive feelings because at least they had the opportunity to try. Even if they transfer out, they still have that sense of control because they got to do it." Many studies find that having a sense of control relieves stress and reduces pain.
Though it might seem that women who would agree to a random assignment to either to a hospital room or an alternative birth room would be unrepresentative of typical women, in fact, strong opinions on birth practices are rare relatively. Despite media portrayals of a battle between women who choose a natural birth and those who want their pain relief NOW, most women tend to fall in between these camps and prefer to have choices.
Unfortunately, it can be hard to change hospital practices to support women''s decisions. Often, research is not enough.
Hodnett described an instructive incident that occurred at an Australian hospital. Staff attempted to reduce medical interventions like the use of continuous electronic fetal monitoring, which prevents women from moving around during labor and can lead to unnecessary C-sections.
The hospital recently underwent renovations to provide more woman-friendly birthing rooms, with large tubs, beautiful furniture and even carpeted hallways. "The manager was concerned that even with this new environment stressing normality, reliance on the old way would still be there," she said.
To avoid that, fetal monitors were stored at the end of a long hallway. "Not only were they far away," she says, "they were hard to drag across the carpet. The likelihood of using them inappropriately went down."
Hodnett said, "I think providers should think creatively about how to use the environment that they have to promote the message that they want to send and, hopefully, that message is that birth is a normal experience."