It’s amazes me that must state the common sense obvious
Best regards from Much Kneaded Massage of NYC

I probably fall into the category of natural birth fanatic by your definition! I had a home hypno waterbirth with my first baby attended by independent midwives. It was not easy, but it was good and we felt that it was the best start that we could give our son. For me an NHS homebirth would have been too problematic, too stressful and I wanted an expert in natural birth as the NHS don’t know often know a lot about that. I based my decision on research results and a belief that pregnancy is not an illness to be managed, but a normal expression of health for the vast majority of women. This is of course not the ‘lived’ experience of many women – but there is a whole cause and effect thing which is very difficult to unpick.

I was quite surprised that your piece seems to ignore all of the key evidence available relating to safety in the UK. Your comment about not being able to directly compare safety between different countries is correct but you make some gross simplifications about the Dutch neonatal death rates (see an article here http://www.demographic-research.org/volumes/vol11/13/) and do not bother to compare home versus hospital rates now that the Dutch are choosing to homebirth less than in the past. Certainly research from North America is of little use here in the UK as there are major problems with their lack of interdisciplinary working – essential for safety when things go wrong.

Anyway I thought it would be useful for your readers to know about the UK research. The question at the head of your article is “How Safe are Homebirths?”

References to historical literature and Victorian precedent is completely irrelevant to modern homebirth. The 1970 Peel Report which recommended that all births were safest in hospital was known to be flawed almost since its date of publication. The clear unbiased evidence presented by Marjorie Tew was ignored by obstetricians for nearly a decade until her paper was published in 1985. It is perhaps no wonder, when her analysis concluded:
“apart from women at the highest risk, birth was safer at home or in a GP unit” and that “care from a midwife at home was safer than care from midwifes in hospital, and that even first babies were safer born at home with a midwife than with an obstetrician”. She concluded “the threat of homebirth is not a threat to mother and baby, but a threat to the healthy survival of obstetric and medical practitioners”. In other words, although maternity care had changed beyond recognition in the space of about 30 years, the associated improvements in neonatal and maternal death rates are actually more to do with reductions in poverty and improved health in society!

Archie Cochrane himself awarded the wooden spoon to obstetrics for its lack of scientific practice (later withdrawn) so your quackometer may need re-calibrating on this particular issue.

Although impressed with Tew, I think she overstated the case and I put more store in the Cochrane Collaboration’s review (Olsen, O & Jewell, D. (2009). Home versus hospital birth. Cochrane Collaboration. Wiley.) which says:
“The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence.” and
“Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women.” and
“one could argue that for low-risk pregnancies both home and hospital births are sufficiently safe for safety no longer to be of overriding importance”.

The main conclusions of this report were based on an RCT of only 11 women (the study actually was intended to show it is possible to randomise place of birth) but its results correlate with almost all other research done in the UK in the last 30 years: neonatal death rates are broadly the same at home or hospital for low risk women. Maternal death is so rare now as to be difficult to assess in either setting. There are risks associated with both home and hospital, and these are broadly equal. I am very much looking forward to the publication of the largest study into birth place which is due out from Oxford Uni later this year. Hopefully that will finally draw a line under the safety debate once and for all!

It is important to note that these homebirths are “planned modern homebirths”. That means attended by suitably equipped midwives and backed up by nearby medical facilities should they be required.
Clearly the conclusions of the Cochrane review have to be assessed for each woman’s case. For example, someone living 10-15 minutes from a hospital has very different issues to consider than someone much further afield. Also it is important to establish what emergency drills would be in place when one of the rare problems come up and to see how these would be dealt with at home versus hospital. Placenta abruptio and cord prolapse are basically not going to have happy outcomes wherever one happens to be, but procedures for management of blood loss and shoulder dystocia are similar in hospital or home. People who are interested should check out http://www.homebirth.org.uk for all relevant facts, figures and research – including a comprehensive section on all the “What ifs?”

Notwithstanding all that, there are some very very rare situations where a woman would want to be in hospital in order to get the quickest possible caesarean (hospital waiting time is 30-40 minutes from time of decision, but it can often be more than double this when they are busy). So it always amazes me when women who choose to homebirth are accused of being ‘experience seekers’ or ‘selfish risk takers’. But why on earth would anyone take unnecessary risks with their baby? Everyone wants the outcome of a healthy baby – there is simply debate about how this is best achieved.

So why are women driven to birth at home? It comes down to a variety of reasons, but a large one is that unless women choose homebirth, it is practically impossible to birth physiologically in hospital despite the enormous body of evidence which supports this and its health benefits. Less than 17% of first time mums manage this is the current system – which is a surprising low number given that the vast majority of women are supposed to be low risk.

The disadvantages of hospital requires consideration of the difference in health outcomes for low risk women in the two settings. The biggest study on the effect of place of birth to date was the National Birthday Trust Report By Chamberlain et al, 1997 – enquiry into UK home births in 1994. This research involved matched pairs of women to minimise the confounding factors you mention above. The results showed that women who planned homebirths (even if they ended up in hospital) halved their chances of a caesarean, halved their chances of an assisted delivery, doubled their chances of having babies with high APGAR scores at birth and were five times less likely to suffer a post partum infection. Given the morbidity associated with the above interventions, homebirth looks to give considerable health benefits in the vast majority of cases and, while everyone would be grateful for obstetric assistance if medically indicated, the implications of these figures are disturbing. After all, no-one would like to think that they had undergone avoidable abdominal surgery….. Certainly it is not quack fuelled rhetoric to say that low risk women birthing at home have much more chance of having better health outcomes than having a problem necessitating urgent medical care.

In your opening statement you said “an underlying unspoken assumption at the classes was that ‘natural is good’ and that ‘intervention must be avoided’”. I might be missing something, but I thought that the point of evidence based medicine was that we did not perform medical treatment unless it was shown to do more harm than good? So, yes intervention should be avoided where possible.

Certainly that is what the authors of the seminal obstetric textbook “A Guide to Effective Care in Pregnancy and Childbirth” think. They state that all treatment should pass the following tests:
1) Do not intervene in physiology unless the intervention is known to be more effective than nature.
2) Ensure that the intervention has no side effects that outweigh benefit.

You also state that the classes say that “…drugs can harm the baby and how interventions can go horribly wrong. Yes – sometimes – but the lives they save and the suffering reduced outweigh rare problems”. You seem to be confusing pain relief with safety outcomes and saying that the routine use of interventions does more good than harm, as though it is self evident. Could you refer us to research on those points?

Williams F. et al., UK study of intrapartum care for low risk primigravidas: a survey of interventions, J. Epidemiol Community Health, 1998; 52: 494- 500, say that
1) a number of interventions are used more often than would be expected in low risk pregnancies; 2) that there is substantial geographical variation (meaning that the care women get depends not on need, but on local habits) and 3) the interventions being used are not evidence-based.

There are quite a number of obstetric techniques in widespread use today which are known to have more risks than benefits for women. So where exactly do you think the quacks are?

A cursory review of obstetric practice reveals very little evidence supporting the use of a number of techniques that many assume improve safety: routine electronic foetal monitoring (some readings indicating foetal distress have false positive rates of over 99% and the only measurable outcome of routine monitoring is an increase in assisted and caesarean deliveries with no reduction in neonatal death or injury), vaginal examinations for estimation of labour progress (there are other non-invasive methods which have been used for longer than obstetrics has existed which disrupt physiology considerably less) and the use of beds & stirrups in labour rooms (the lithotomy position is well known to result in more pain, more analgesia, more lengthy labours and more perineal damage, all with associated morbidity). Jan Tritten’s editorial is perhaps not so far off the mark then?

One might ask why is it possible for women to choose opiates and epidurals (with the well documented and long list of risky side effects – that most women keen on epidurals rarely understand, so how is that informed consent?) while the choice to labour in water or to receive continuous one to one care in labour (despite having few side effects and the improved outcomes being well supported by research evidence) is unavailable to the vast majority of low risk women? Homebirth is practically the only way of getting both in the UK.

The continuity of care issue is also critical in the safety debate. At home a woman will be attended in active labour by one midwife, and a second for the birth. In hospital she will receive much less attention and serious conditions go un-noticed on busy hospital wards. In hospital, high risk women are induced and left for 6 hours or more alone, un-monitored and unattended. Does that sound safe? Does it sound safe that a recent study showed that more babies die in hospital overnight and at weekends than any other time? Then there are the problems caused by staff mistakes over drug types and doses. Look up the Association for the Improvement of Maternity Services website if you think I am exaggerating.

Mary Cronk puts it very well:
“One of my rants about place of birth is this – Sadly not all women have homes that they either can, or would want to give birth in, BUT why do women have to stay at home in order to give birth in peace? A woman should be able to give birth in peace attended by a midwife of her choice regardless of whether that labour and birth takes place in a huge central obstetric unit, or a midwive led birth unit, or her home. Why, by entering the doors of an institution, is a woman routinely subjected to a medically managed birth ??”.

Campaigners for normal birth (not “low risk” or even natural – but normal, physiological birth) walk two tightropes at once. One provides support for women to choose whatever types of birth they wish and the other supports the premise that care should be based on the evidence. The two are not mutually exclusive but, as the trend for elective caesarean has shown, they can be challenging to reconcile. The reason for this is that women do not make choices about their maternity care in a vacuum. They make it on the basis of their life history, the views of people around them and their carers, their sexual history, their birthing history and their views about and relationships with their own bodies. Increasingly they are making choices based on information they receive from the media and the internet.

NCT antenatal class information is ‘beginner’ level information because most people are either too scared or un-interested – after all the NHS will ‘take care of it all’. There is plenty of honest, unbiased information about natural birth out there – its just that most people believe in the orthodoxy of hospitalisation and don’t bother to look for it.

To quote you: “These days, we all have access to vast amounts of information on the web. I want to debate what is good evidence and what is rubbish. I want to see who is presenting good arguments for their claims and who is talking gobbledegook.”

I’m afraid that your blog on homebirth safety falls into the latter.

Regards
Fiona

PS Congratulations on your new arrival!

I might also add that I don’t have a lot of warm fuzzy feelings about unmedicated birth. If I had known how agonizingly painful pushing would be (for 1.5 hours), I would have asked for an epidural even though I arrived at the hospital at 9 cm. There’s good reason that women have sought pain relief during labor for hundreds of years, and I’m personally tired of the natural childbirth movement.

“Either or all of us may not have been here if I’d been wallowing in a paddling pool in front of the Bose with whale music in the background.”

Is the dog showing any signs of jealousy, BTW?