My View of Home Birth
Rarely does a topic elicit such passionate responses. Home birth advocates are most generally a zealous group. Home birth opponents are equally passionate. While these feelings are understandable, they have clouded the facts.
Before modern Obstetrics, birth took place at home with female midwives. Mortality rates for mother and baby were high. As medical care became centralized to the hospital, male physicians assumed care of the birthing mother. Birth practices changed and became more interventional. These early surgical interventions solved some problems and created others. A new phenomenon of hospital acquired infections came into play, and women gravitated back toward the home again. Mortality rates remained high in absolute terms.
With the advent of the women’s movement, feminist adherents began to define women’s historical status and oppression and define their effects on society. Some began to analyze problems in terms of the following polarity:
In their view, everything could be described as
While this matrix originally held many grains of truth, it is my opinion that it was oversimplified, and that currently it has outlived its usefulness. This metric was applied to the birth process, and of course a narrative about birth came into being. It goes like this: In earlier times when female midwives managed birth, birth was natural, woman centered, and even peaceful. Women were allowed to move about, eat, and were attended and supported by their female tribeswomen. In this manner, they labored with little or manageable pain and had fewer complications. When male doctors took over birthing and moved it to hospitals, it took control away from midwives and women. Birth became a series of barbaric surgical interventions and the patient would suffer through it or be drugged.
Again, this narrative bore many grains of truth, but also left out a great deal, so it was really just a myth. Times before hospital birth were grossly over romanticized. The gruesome realities of pre-hospital birth were glossed over. Likewise, the emerging benefits of the developing fields of Obstetrics and Anesthesia were ignored.
Fast forward to today.
Feminism has given way to gender equality. Sex discrimination, while still there, is passé, and illegal to boot. The field of Obstetrics, once populated by men, is now well over half women. Certified Nurse Midwifery is recognized as a nursing specialty field. These two professions work together formally in virtually all major hospitals. Evidence based medicine has come online, literally and figuratively, and modern practitioners of all kinds are expected to abide by it.
Hospitals post patient’s “ Bill of Rights” documents. They build appealing spaces dedicated to birth and call them birth centers, complete with room for birth attendants ( tribeswomen) and jacuzzis for use in labor. The American College of Obstetrics and Gynecology uses its considerable political clout and media resources to advocate for spontaneously-beginning full term vaginal birth with freedom of positioning and without the routine use of episiotomy.
So why is there a home birth movement?
Present day home birth advocates have made home birth an article of women’s rights. In certain circles one cannot be seen as a serious feminist if one does not favor home birth. Regardless of one’s analysis of the legitimacy of home birth, one has to allow that it has become fashionable.
A close reading of the principal home birth advocacy and direct entry midwife (also called lay midwife, or certified professional midwife ) sites reveal that a variety of additional polemics are utilized. Authors at cfmidwifery.org argue that doctors do not use evidence based birth practices. They assert that they are the practitioners practicing evidence based medicine, which they state equates with
continuous supportive environment and female birth attendant,
freedom of position
delayed cord cutting
no separation of mother and baby after birth
These are, of course, elements of the WHO /UNICEF “Baby friendly hospital policy”. They are also practices which have been formally institutionalized as Labor Unit policy in the hospital setting for many years, at least 25, by my direct observation.
Furthermore, home birth advocacy organizations claim home birth is as safe or safer than hospital birth. They supply references to research articles which they evidently think support this view. Perusal of several home birth websites reveals a repeated reliance on this same handful of old articles. Principle among them are the following:
Outcomes of planned home births with certified professional midwives: large prospective study in North America, Johnson and Daviss, British Medical Journal, year 2000.
When inspecting this paper, one sees first that it is a prospective cohort study, a study of limited power. Secondly, the 5418 of the women in this study were self selected for home birth. This introduces an enormous source of bias. Any woman with any reason to believe she would have trouble in birth wouldn’t even place herself in the home birth group in the first place. The study compared this self selected group’s outcomes with that of the 3.3 million term vertex births in the US in year 2000. The self selection bias alone would very much cause the home birth outcomes to be artificially better.
Additionally, it is important to note that this study was not blinded. There were no neutral third parties collecting data on the home birth outcomes. The direct entry midwives self reported on their own outcomes and validation of that data was done by patients themselves later by telephone call. These are also enormous sources of bias. I have seen many cases of midwives or resident physicians missing a vaginal laceration needing a repair. Additionally, for example, the tendency to underestimate blood loss at delivery is a well understood and common phenomenon.
What questions did this study aim to answer ? That is the same as asking, “What is the primary and what are the secondary outcomes of the study ?" Their primary outcome was mortality. Mortality means death. They screened their data for death of the baby either in labor or after. Their secondary outcomes were transfer to hospital, medical interventions in labor, breastfeeding, and maternal satisfaction.
I have a few thoughts on the choice of the primary outcome of mortality. Certainly death is an important outcome. But it is an outcome that is rare, and one we should rarely experience in any setting. I am going to argue that this is not an informative outcome for such a study. I am going to assert that the the preponderance of birth attendants in any setting have enough basic skills to avoid avoidable causes of infant death the vast majority of the time.
What should concern us is morbidity. How do the babies and mothers do, not only in the short term but also the longer term. In this day and age, we are concerned with quality of life, and with a different measure you could call health. When I assess a birth of my own, I ask, did I deliver that baby in such as way as to leave it with 100% of its natural potential ? I also ask, have I preserved the health of the mother and given her a positive experience as much as possible under the circumstances ?
Assessing for mortality reflect a scarcity mind set, and sets the bar at the lowest possible point. We should investigate with respect to optimizing the health of mothers and babies.
My idea of meaningful outcomes would include :
morbidity (injury or illness) to mother or infant
child development milestones at one year
maternal pelvic floor integrity at one year
incidence of infection at one week
blood loss at delivery
length of maternal recovery to 100%
Admittedly these kinds of outcomes would be more difficult to quantify. But they would also be more meaningful.
The second study is more heavily relied upon since it is more recent and less problematic than its predecessor.
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician, by Janssen et alia, Canadian Medical Association Journal, 2009.
This study starts by decrying the methodologies of prior studies on the subject. This section is worth quoting:
“The debate about the safety of home births continues in the literature, professional policy and practice. Planned home births attended by registered professional attendants have not been associated with an increased risk of adverse perinatal outcomes in large studies in North America,1–3 the United Kingdom,4 Europe,5–8 Australia9 and New Zealand.10 However, these studies have been limited by the voluntary submission of data,1,4,5,8,10 nonrepresentative sampling,6,7 lack of appropriate comparison groups,1,7,9 inadequate statistical power3,8 and the inability to exclude unplanned home births from the study sample.2,11,12
I should mention that comparing European midwives with our American direct entry midwives is comparing apples with oranges. British midwives, for example, take a minimum of three years post secondary (college) education devoted to Obstetrics. Direct entry midwives in Montana have to have a high school diploma or GED, first aid, and pass an online test. Together with another direct entry midwife, they must also do 100 prenatal checks, observe 40 deliveries and do 25 supervised deliveries. Canadian midwives are educated at the University level and receive at least a Baccalaureate degree.
This Canadian study compared three groups: home birth with midwife, hospital birth with midwife, and hospital birth with physician. The primary outcome was again perinatal mortality, and secondary outcomes were obstetric interventions and ( thank you !) adverse maternal and neonatal outcomes.
Here are my concerns with this supposed flagship study:
1. Again, self selection of patients for home birth is the elephant in the room.
2. The home birth group has a disproportionate number of multiparous women, meaning those who are not having their first baby. Any delivery caregiver is well aware that parity, or prior number of births, is a central determinant to the success of labor. It is a simple fact: Most generally, multiparous women deliver more easily than primiparous women. When you consider the statistic in the Johnson and Daviss study that nulliparous women have a fourfold rate of needing to be transferred to the hospital compared with multiparous women, you can see that discrepancies of parity have the potential for a significant effect on outcomes. Also closely related to parity is the tendency to incur obstetrical tears. Thus, not surprisingly the home birth group had fewer of them.
3. Those requiring pitocin for induction were excluded. Requiring pitocin indicates that something is not going ideally. Excluding these patients and including only patients beginning labor spontaneously left the study with an lower risk group of patients where complications would be less likely to show up.
4. Obstetric interventions are listed as a morbidity. This is invalid. Obstetric interventions have indications, and they are either met or not met. To observe the greater number of interventions in the hospital compared to the home and to then classify them as morbidities assumes that the interventions done in the hospital are unindicated. One may just as legitimately assume that the deficit of interventions in the home were improper omissions. It is somewhat ludicrous to consider that the reason home birth patients are transferred to hospital is to be able to HAVE needed interventions. Why then is the finding of more interventions in the hospital a surprise or a concern?
The most respected home birth certification and advocacy website NARM.org, posts the following claims:
Midwives are key to increasing access to effective maternity care:
• The American Public Health Association (APHA) and the World Health Organization recommends midwives as the primary maternity care providers for the majority of women
• The Millbank Report: Evidence-Based Maternity Care recognizes the CPM as the benchmark for low intervention and good outcomes
• Nations with the lowest infant mortality employ midwives as the primary maternity care providers for the majority of women
• Mounting evidence supports the value and cost-savings potential of midwifery care, according to a report issued by the Washington Department of Health in 2010
• Birth centers and planned home births have been shown to be safe for low-risk women with demonstrated potential to reduce costs.
However, a search on the the APHA website reveals nothing on the subject of home birth for the last five years, indicating that whatever its position, it was based on data in excess of five years old, the substance of which we have already reviewed and about which we have already raised concerns.
Regarding WHO’s endorsement of midwives, I would comment that they are attempting to address a severe lack of qualified birth attendants in third world countries. Their recommendations pertain to their goal of getting a modicum of care to the greatest possible number of people in underserved areas. In the developed world, we are trying to optimize outcomes.
Regarding the The Millbank Report, it is a 2008 product of a New York City based privately endowed think tank. The“ report" is not any sort of scientific study; it is a merely a report by two individuals holding public health degrees. In the foreword, the following is stated :
“ Childbirth Connection (CC), the Reforming States Group (RSG), and the Milbank Memorial Fund (MMF) collaborated to write, review, and publish this report.”
The Millbank Report is a poorly done literature review, done by those not intimately familiar with Obstetrics. Its recommendations on the role of CPMs (certified professional midwives) in the US are again based on the very flawed and misleading British Medical Journal article in 2000 by Johnson and Daviss. Even if they could have availed themselves of the later 2009 Janssen et alia study from British Columbia, they would have had to factor in the following penned by the authors themselves:
“ Our findings do not extend to settings where midwives do not have extensive academic and clinical training."
The assertion that “Nations with the lowest infant mortality employ midwives as the primary maternity care providers for the majority of women” may be true. However midwives in these European and Scandinavian countries are far more educated and regulated than ours are. Furthermore, an array of other variables such as cultural homogeneity, education, socioeconomic status and baseline health status are at work in this situation. Finally, in those countries, these midwives do not restrict their practices to the home. They also perform deliveries in hospitals.
Finally, to comment on safety.The American College of Obstetrics and Gynecology (ACOG) and the The American Academy of Pediatrics have both formally stated their position that hospitals and birthing centers are the safest places to deliver. ACOG sites a 2010 meta-analysis showing that among non-anomalous babies, there is a threefold risk of neonatal death with planned home birth versus planned hospital birth.
2013 data from the Center for Disease control ( Grunebaum et alia, AM J Ob Gyn 2013 ) reveal that there is a dramatic incidence of first Apgar score of zero, seizures, and serious neurologic dysfunction in babies born at home or even in freestanding birth centers.
Nearly 14 million births were evaluated over a four year period. Delivery types were:
freestanding birth center midwife
Compared to the hospital physician scenario, in women of all parities (birth number), home midwife deliveries carried over ten times higher risk of a first apgar of zero. The freestanding birth center carried 3 and a half times the risk, and hospital midwife deliveries (deliveries of low risk patients ) had half the risk. The effect was much more pronounced for women having their first baby. In the case of a nulliparous patient delivering at home with a midwife, the risk of first apgar of zero was over fourteen times as high as a hospital birth by a physician. Alarmingly, the authors report that the risks of adverse outcomes may be significantly underestimated in their study. This is because a substantial number of the the adverse outcomes attributed to hospital births were from transfers from home births.
Home birth is not adequately safe. It is especially unsafe in our country and perhaps extremely unsafe in our particular Valley. Over the last 20 years I and all my colleagues in Obstetrics, Nurse Midwifery and Pediatrics have had too many first hand experiences with home birth disasters transferred to the hospital to be under our care. None of these cases ever became a part of the literature. Rarely, did the patients ever fully understand what happened to them.
I entered Obstetrics because of my interest in science and my involvement with the women’s health movement in the 1980s. I had all my babies naturally but only because I lucked out on the anatomy and physiology. I share the feminist concerns of the home birth advocates. However, I cannot condone the proliferation of unsafe, unscientific thinking in our community regardless of the feminist, religious or other ideology to which it is attached.
Gina Nelson, MD