Edited by Daniela Ricci

 

New services for childbirth at home are starting to become available in our country, to help mothers and fathers live the birth of their children in the most natural way. Some initiatives have recently been presented in Modena, in a seminar sponsored by the Differenza Maternità association, during which the experiences of professional obstetricians, that have been working in the field since the 1970's and 1980's, were compared with the new support services for home delivery recently started by local health authorities. The most debated topics were the professional figure of the obstetrician, the quality of care and guidance of women throughout their "Birth-giving Path", safety and costs.

 

In Italy the percentage of home delivery is still very low, being, in fact, around 0.4%; while the average for the rest of Europe is 2%, and in culturally more advanced countries the percentages rise to 14%, and reaches as much as 32% in the Netherlands.

 

On this field, today, our country lacks not only comprehensive statistics and data but also appropriate legislative instruments. Only recently a bill on the protection of childbirth is moving forward in the Lower Chamber, which aims at offering women and their children the best available assistance and which establishes the women's right to choose between giving birth in the hospital, giving birth at home and in specific local facilities, putting an end to the discrimination between cesarean section birth and natural child birth, and equalizing, if approved, the corresponding healthcare refunds. Other bills have been sitting in Parliament, making no progress.

 

To fill this void, some Regional Administrations have passed their own laws in this field. One example is Emilia Romagna, where in 1998 a regional law on delivery was passed, granting women the right to choose to give birth at home or in maternity facilities beyond the classic hospitals, all being free of charge. Among the effects produced by the law: cultural awareness and change of the work environment in hospitals (humanization of the environment, ways of working and the training of operators). In 2004 the three healthcare facilities equipped for the service, Modena, Bologna and Reggio Emilia, cared for 76 home deliveries.

 

In Modena, the home delivery service was initiated by the USL public healthcare center last year. Its goal is to ensure safe delivery at home, close to loved ones. "Low risk" pregnancies are selected among the requests, on the basis of the criteria of the broadly agreed Kloostermann list of obstetric indications, according to methodologies that make home delivery safe. To date, 9 mothers have been cared for. Out of the 13 applicants, 5 were excluded before the beginning of the 38th week and one during labor. To apply, women must complete a form at one of the 7 Saub offices of the area.

 

"In the future," according to Paolo Accorsi, appointed to enforce the regional law on childbirth at the Modena USL public healthcare center, "over the next few months we will focus on adapting the protocols to the requirements of Modena and to new scientific evidence. We also plan to organize a training course for obstetricians, soon."

 

At Reggio Emilia, the service, sponsored by the USL local public healthcare center and hospital, was activated in 1999. "Our first home delivery," said Marilena Pedroni, Home Delivery Obstetrician Supervisor, Reggio Emilia, "occurred in December 1999. Since then we have cared for five to six deliveries per year. The service currently can count on the availability of 9 obstetricians who alternate hospital and home service."

 

Turinwas the first city in Italy to provide a public home childbirth service. The service was started in 1997 on the basis of a resolution of the Public Hospital of Turin, and is managed independently by hospital-employed obstetricians. "We cared for 294 pregnancies between 1 July 1997 and 31 December 2000" commented Ornella Nurisso, Home Delivery Obstetrician Supervisor, Torino, "and 196 of them were fit for home delivery. For 155 women labor began at home, while spontaneous delivery occurred at home for 130; 25 pregnant women were transferred to the hospital before giving birth due to the onset of problems. Selection is very accurate and we only accept complication-free cases. To date the service has 2 obstetricians available. We recommend interested mothers to start this route as soon as possible, possibly as early as the first quarter, to encourage the development of a good therapeutic relationship and trust between mother and obstetrician, one of the fundamental aspects of the service."

 

"The introduction of the service provided by public healthcare" underlined Laura Piretti, president of the Differenza Maternità association of Modena, contributes to the dissemination of a culture of birth and ensuing obstetric practices, able to satisfy the needs of psychological and physical well-being of the woman and of the newborn. And it makes the woman free to choose the place to give birth, how to live the experience before and during childbirth, gradually overcoming the generalized hospitalization and the discomfort created by the centralization of childbirth in large hospitals. The choice granted to women by law, however, may be exercised only if there is also the possibility to be informed. To make a service accessible means, above all, to make it known that it exists, and how and where it can take place."

 

The interventions reveal a large gap between the number of women cared for in institutional facilities and by those cared for in private institutions. In this latter case, the number of women cared for is 80%, while in the first case no more than 47%. In Bologna, for example, the obstetricians of the “Il Nido” association, accepted 188 of the 194 requests received between 2000 and 2004, and 164 women gave birth at home, according to Monica Padovani, freelance obstetrician, and founder of the association.

 

One possible cause could be examined in the time devoted to accepting women for care and creating a therapeutic relationship of trust and empathy between the obstetrician and the woman. If this time frame is not adequate, and if the decision occurs in advanced pregnancy, the tools to assess, prevent and reduce the risk accompanying the woman to recognize and enable all her internal resources which allow her to care for herself in the physiological recovery, fail to immerge and result insufficient.

 

The emergence of the needs related to the rediscovery of values such as the naturalness of childbirth and of women's protagonism in the path of motherhood, contrasts with recent survey data that shows that birth in Italy is an ever-increasingly medical model event, characterized by an excessive use of diagnostic tests, applied without differentiating between women with high-risk pregnancies and all others and by a high percentage of cesarean sections, with a national average of around 35%, compared to the 15-20% recommended by the World Health Organization.

 

"Giving birth is nothing but a simultaneous process of opening up, physically and emotionally" Verena Schmid, Obstetrician and Director of the Elemental School of  Obstetrical Arte in Florence, clarified during the conference.  “ In order to be able to open up and let yourself go, you must feel secure.”  Today the sense of security is often projected on the outside: security is the medicine, the expert that tells you what to do, the structure and the technology. Many women have internalized these aspects, attaching them to the sense of security and creating the need for them.  Other people have searched, instead, a sense of security within their personal sources; they trust themselves and they feel more safe in an environment in which they are able to stay with themselves or surrounded  by people who they trust.  The real question lies within the “sense of security” that a woman possess, which can be spontaneous or acquired through education, knowledge and information.