AIMS

Successful home birth despite 'low' iron count

In common with many women, Alison was told that she could not have a home birth because of the Trust's policy of an iron count less than 10. However, Professor Page in her book 'The New Midwifery' states:

The total red cell mass in fact increases so the oxygen-carrying capacity of the blood increases. Therefore, assuming that there is an adequate diatary intake of iron (and in the absence of other chronic causes of anaemia such as malaria, worm infestation, malnutrition and laabsorption) the resulting physiological fall in haemoglobin concentration does not necessarily require treatment.... There is controversy over how low the haemoglobin concentration may fall in normal pregnancy without recorse to iron supplementation. On balance, most authorities believe that haemoglobin concentrations below either 10.00 or 10.5 g/dl require treatment (Letsky 1995). However, in generally healthy populations, there is no convincing evidence that routine iron supplementation is advantageous to either the mother or the baby; neither are there data to confirm that it is safe (Mahomed 1998). The only proven value of routine iron supplementation is a reduction in the incidence of low haemoglobin level, but it is probable that regular estimations of haemoglobin concentrations and selective iron supplementation could have a similar effect.'

A letter to AIMS:

Dear AIMS,

I emailed Nadine Edwards (AIMS Vice Chair) a few weeks ago after an Hb result of 10.8. This is my local Trust's cut off point for home birth! I duly played the game right -took extra iron on top of a pregnancy multi-vitamin, ate masses of greens and oranges etc etc. I have just found out that even with this increase in iron consumption, I have dropped to 10.6 - a clear indication (in addition to embarrassing irritable bowel symptoms) to me that my body does not want/need iron. I am still working, have more energy than at this stage in my two previous pregnancies and am in no way anaemic.

My home birth is in jeopardy. The community midwives are going to speak to my consultant (whom I have never met) to try to pursuade him/her. I have no history of PPH, have agreed to syntometrine and live 8 minutes drive from the hospital. I would agree even to a domino but funding for these stopped last year.

The midwives are trying to suggest ways of getting the Hb up - give up work, pay for childcare closer to the birth etc but I do not believe that any of these tactics will increase my Hb. I have read the information on low Hb and better outcomes but am frustrated beyond belief that the medical profession is resisting the obvious conclusions.

I do not want to fall out with my potential caregivers but do not want to be cared for by hospital based midwives (some excellent, some not nice at all!). I am agreeable to transfer if the need arises and I am even being remarkably understanding that the midwife team here is so decimated (sickness and leave) it cannot go on call for me before 38 weeks.

I have spent this afternoon stressed out and in tears because I feel I have no control. Rationality and clear thought are fast disappearing.

Any advice? Much appreciated.

Alison

AIMS advised Alison of the lack of evidence that an iron count of 10.6 has an adverse effect on the labour that would preclude a home birth, and that this was no reason to suggest that she should not have a home birth. Alison decided to go ahead with her planned home birth and then emailed us again.

The Outcome

Well, we have another beautiful daughter born on 24th Feb (39/3 weeks) nearly 81/2 lbs and called Rosa. The midwife team were excellent although most of them were off ill! The senior midwife visited me (to say hello as she might be needed to cover the on calls) and told me that the Trust is lowering its Hb cut-off to 10. Although I was meant to have another test before the birth, somehow this didn't happen. We also came to an agreement that if two midwives could not be available for a home birth, I would have a domino delivery at the hospital. My main priority was to know my main caregiver and have an advocate at the hospital so this was an ok option for me (I had a wonderful domino last year).

The birth went remarkably smoothly and quickly - less than an hour of the sore bit and what felt like about three pushes. No stiches and little blood loss at all. The commumity midwife was meant to take more blood on the Monday for another Hb test but due to snow and time forgot until the Friday when I had to suggest that it was quite clear that I was surprising active and energetic and highly unlikely to be anaemic. My impression is that some midwives were concerned about the Hb level and others were not when they considered my other blood chemistry and obvious good health.

The Trust has reconsidered its policy which should make things more reasonable. I did note that throughout my discussions not one of the health workers acknowledged my right to a home birth. I also feel that now domino births are no longer available here, there is less flexible birth choice for women and their families. The community midwives can only do two home births per team per month so all others will be hospital based.

So ... all worked out exactly as I had hoped. Thank you for your reply - it is good to know that there are people who are concerned about these issues.

Alison Bavidge, Dundee

Note:

Even though the community midwives 'can only do two home births per team per month', if other women decide to have a home birth the Trust will have to find the midwives to attend them. They cannot force women into hospital.

Beverley A Lawrence Beech
Hon Chair, AIMS

Reference:

The New Midwifery: science and sensitivity in practice. Edited by Professor Lesley Page.
Published by Churchill Livingstone, 2000

Further information:

See correspondence on low iron count from the UK Midwifery discussion group, on the Association of Radical Midwives' website.
(www.radmid.demon.co.uk/anaemia.htm)

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