The debate is on.
The study is descriptive, meaning it can only speak to the women included in the data and cannot be generalized to the population at large.* That being said, the data indicates that homebirth for LOW RISK women (no prior cesarean; no gestational diabetes or pre-eclampsia; a singleton, vertex, term fetus) is not only safe regarding mortality, but is much, much safer regarding sources of maternal morbidity such as cesarean, instrumental delivery, administration of Pitocin, epidural use, and episiotomy. Here is a summary from Citizens for Midwifery that includes all of the births, not just the low risk ones. I have highlighted some notable points:
- High rate of completed home birth (89.1%): Primary reason for transport was “failure to progress.” Transfer for urgent reasons, such as “fetal distress” was rare.
- High rate of vaginal birth (93.6%)
- High rate of completed vaginal birth after cesarean (VBAC; 87.0%)
- Low intrapartum and neonatal fetal death rate overall: 2.06 per 1000 intended home births (includes all births); 1.61 per 1000 intended home births excluding breech, vbac, twins, gestational diabetes, and preeclampsia.
- Cesarean section rate of 5.2%
- Less than 5% used pitocin or epidural anesthesia
- Low rate of low APGAR scores
- Extremely high rate of breastfeeding (97.7%) at 6 weeks
Even for those in the “healthy baby is all that matters” club, the data don’t have much to condemn low risk homebirths. And for those of us who think that a woman’s physical and mental health are crucial measure of the “success” of a birth, the data indicate that low-risk women who want to birth at home, for the most part, may be better off doing so.
It is important to note that most of the births in the MANA registry are attended by Certified Professional Midwives (CPMs). While many obstetricians accept the professional capacities of Certified Nurse Midwives (CNMs) (who usually practice in hospitals), they generally disparage the credentials of CPMs, even when they don’t know what the requirements are for earning the CPM title. (See information on the different kinds of midwives here.)
As reported in the Huffington Post, Dr. Jeff Chapa, director of maternal fetal medicine at the Cleveland Clinic, who reviewed the new study, said that low-risk women having a home birth “can feel good in that they’re probably going to be OK,” but that the study had not affected his views on home birth because “the bottom line in all of this is you can’t predict who is going to have an issue or a complication.”
The silly thing about Chapa’s comment is that if the maternal, infant, and fetal death rates among low risk women are more or less the same for hospital or home birth, there is no indication that a fatal “issue or complication” could be avoided by going to the hospital. It is possible that some complications are unavoidable regardless of the setting. It is also possible that the hospital could prevent some complications while causing others–thus there is no overall advantage to birthing in either setting.
Given that the homebirthing women avoided many procedures that result in complications, it seems that the argument could be made that the hospital is actually less safe for low risk births. When obstetricians discuss birth outcomes, they often focus on a healthy baby and sometimes a healthy mother. But what does this mean? Is a baby who spends a week in the NICU “healthy” if it goes home healthy? Is a mother “healthy” if she develops post-traumatic stress disorder from a forced cesarean?
Many morbidities don’t enter into calculations of the risks of hospital birth. In many cases, unnecessary procedures conducted in hospitals are touted as positive, even when they have no positive effect. Few acknowledge that doctors sometimes cause the problems that a heroic intervention solves, as evidenced by the horrifying practice of “pit to distress.” Pit to distress NEVER happens at a home birth.
As Melissa Cheyney, a medical anthropologist and lead author of the study, said,
We need to start focusing on who might be a good candidate for a home or birth center birth and stop debating whether women should be allowed to choose these options.
Whether you think midwifery and home birth are viable alternatives or not, it’s hard to ignore the statistics that say what we’re currently doing isn’t working. We should be able to guarantee better (not perfect, but better) outcomes for parents and children. If I were to play the blame game, I’m going to look to where almost everyone is giving birth — the hospital.
Let’s focus our scrutiny on the system that is failing us, and figure out how we can make it better. A few things that would help greatly in this matter: transparency about c-section rates from hospitals, an independent body investigating deaths from pregnancy-related causes, and real pressure on the obstetrics community to follow their own advice on practicing evidence-based medicine.
If obstetricians and the medical community really care about maternal child health, then rather than railing against homebirths, they should focus on making birth as safe as possible for women and infants, wherever the woman chooses to birth.
To paraphrase Jesus, who had a lot of great things to say if you actually pay attention to them, it is always wise to remove the plank from your own eye before you go after the speck in your neighbor’s.
*In order to say something about homebirth for all women, the women in the sample would have had to be selected randomly. They were not. All of them chose homebirth. In addition, they are not representative of all women who homebirth–only women whose midwives submitted data to MANA are included, which means 70-80% of homebirths are NOT included in this data.