How Safe are Home Births?

baby And so, maybe this week, I will become a parent. Today is our due date and everything (I think) is ready. We are feeling that huge sense of – well – impending change. Our NCT antenatal classes are something of a distant memory. Bags are packed. Car seats fitted. The dog has been told. This is the real thing and we are at the top of the roller coaster ride. Waiting.

But reflecting back on those NCT classes – an underlying unspoken assumption at the classes was that ‘natural is good’ and that ‘intervention must be avoided’. Its a common theme throughout almost all alternative medicine that naturalness is something desirable and beneficial when it comes to health. It is axiomatic that the best start to our babies life will be if birth is ‘natural’. And it is also a concept that is very quickly challenged. Any reader of Victorian novels or biographies will know that not long ago, the death of the mother and baby were common, natural, occurrences. Modern technology now allows many birth problems to be anticipated, corrected and overcome, so that giving birth is now nowhere near as dangerous as it used to be. There is nothing natural about this. These improvements are the result of technology – medical technology – in all its forms.

A consequence of this is though that so often birth takes place in a hospital setting. This is where that range of technology and knowledge is easiest to deploy. However, for many, a hospital environment has all the associations of illness and unpleasantness. It is quite understandable that so many women would like their birth to be in a more positive environment, if not even their own home. Home births avoid the dash to hospital, they are private, intimate and may provide a greater sense of control. There may be risks though as obviously reaching medical care may be much harder.

But how much more risk? That is an important question. One that needs to be addressed when deciding how best to approach the birth – and it is quite difficult to find reliable answers.

Our NCT class leader was obviously keen to promote the idea of home births. She told us that a huge study in the Netherlands had looked at half a million women and concluded that home births were as safe as hospital births. With a study that size, this result ought to be authoritative. But given that our course leader was also a homeopath and hedgewitch I decide it was probably best to check the references to that study for myself.

Indeed, such a study does exist. The Netherlands has the highest level of home births with about 30% of women giving birth at home. By contrast, less than 3% of women in the UK do. Worryingly, the Dutch also suffer the highest rates of infant death during or just after birth. Could the two be related? This Netherlands study was supposed to address this important question.

The study, Perinatal mortality and morbidity in a nationwide cohort of 529688 low-risk planned home and hospital births by Jonge et al, was published [pdf] in 2009. Its result was that “No significant differences were found between planned home and planned hospital birth”. This take-away message has been snapped up by those who wish to promote ‘natural’ birth. But, as usual, the science is a bit more complicated than that and we need to dig a bit deeper before coming to conclusions.

The study compared women who planned home births with those who planned a hospital birth. Of course, the women were not randomised into each group, a good technique to avoid bias. Each woman chose whether to give birth at home or in hospital. We would have to be aware that, therefore, we were not comparing like-with-like. The two groups of women might be on average quite different – age, health or prior births, for example. But more significantly, any woman who might be have been at risk of a complication, such as a breech or previous caesarean, was not included in the study. Any women who needed pain relief, monitoring or induction were excluded. Women who chose to remain under midwife care but were at higher risk were also excluded.

There is a risk here that we may be seeing a somewhat self-evident result – that women who can be reliably assessed to be at low risk, in a country with many facilities for homebirth, have few problems, and it does not really matter where they give birth or if they were under midwife or obstetrician care.

So, how does this study help inform a woman in the UK who wants to know how much more risk they will have if they chose to give birth at home? In short, it doesn’t. The authors of the study themselves recognise the limitations in their conclusions,

This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well trained midwives and through a good transportation and referral system.

Firstly, a women needs to know that she is at low risk. This is vital, because this study does not tell us how women at medium or high risk fare. Knowing you are at low risk will depend on your midwife giving you an accurate assessment. Given home births are much rarer in the UK, your typical midwife will be far less experienced than their Dutch counterpart. Furthermore, that risk assessment needs to also take into account how easily you can be transported to hospital, if risk factors develop during birth and that your homebirth midwife can correctly assess the best time to make the decision to move. In the Netherlands, the training of midwifes rams this home – and distances and times to hospital are short.

The problems here can be highlighted by comparing the situation with the USA where there is a doubling or tripling of risk for homebirths. The highest risks are with births assisted by ‘direct entry midwives’ – those trained by self-study, apprenticeship or other non-nursing based education. These midwifes might get training in assisting birth with homeopathy, naturopathy or other quackery and be completely unprepared to recognise and assist in getting women into medical care when it is indicated to do so.

For a women in the UK, it is therefore quite difficult to understand what extra risk they are taking on with a home birth. It should be better than the US, but probably not as good as the Netherlands. What is quite clear is that woman should not be told ‘it is just as safe’ as that is just not true. I must repeat, I understand why many women would choose a homebirth, but it ought to be done understanding that simplistic reassurances cannot really be given. That allows genuine informed choice.

If we are to encourage more women to have homebirths, as the government currently wishes, the information women receive needs to be honest, based on science, and free from the fantasies of the quacks and homebirth fanatics.

However, what undoubtedly increases risk is the quack-fuelled rhetoric of so-called natural birth. To say that the best start your child can have is a birth without drugs or medical intervention is just not true. I am wishing for my child to be healthy and my wife to not suffer too much. That may require a ‘medicalised approach’. NCT classes appear to delight in telling parents to be how 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. We were told that pain relief during labour increases the chance of our child becoming a drug addict. It was suggested that caesareans and other interventions were done to fit in with shift patterns rather than for medical need. We were taught techniques to delay intervention when a medical professional was advising it was done now.

The language of quackery like homeopathy seeps through these experiences with its deep hatred of the medical profession, its assumptions of drug harm and corruption from shadowy vested interests, and its mystical and irrational belief in the goodness of nature. Alternative medicine rarely directly harms people – sugar pills and foot massages do nothing – but the beliefs drive wedges between people and the medical professionals who can genuinely help them. Lay discussions of health, such as those that took place at our NCT classes, uses alternative medicine concepts as the default mode of discourse. In this fantasy world, we need to strive for naturalness, medical intervention is bad and to trust our instincts.

And many midwives appear to be enthralled by such language. This year, the Midwifery Today Conference to be held this Autumn in France is entitled, “Birth Is a Human Rights Issue”. How are human rights being suppressed according to this conference?

The right to have the most joyous and healthy pregnancy, birth and postpartum time possible should be a human right for both mother and baby… Women and babies are suffering abuses at the hands of medical professionals. Many of these abuses are similar to the travesties done to women in Africa and the Middle East. It is also similar to domestic violence. Women’s voices are being squashed.

In an editorial in Midwifery Today, Jan Tritten tells us that, “Birth today is a doctor dictatorship in many practices and in many hospitals. Mothers and babies are missing the healthiest possible beginning, both physically and emotionally. Their human rights are being violated… This is so unnecessary because women have within them the ability and the instinct to have a great childbearing experience.”

As the actress Emily Woof said in the Guardian this weekend, we need to be more honest about childbirth. “The gulf between natural birth and the medicalised approach puts mothers in an impossible situation.” If we are to encourage more women to have homebirths, as the government currently wishes, the information they receive needs to be honest, based on science, and free from the fantasies of the quacks and homebirth fanatics.

I shall tweet to you all to let you know how we get on.

On this theme…

32 Comments on How Safe are Home Births?

  1. You wouldn’t remember, Andy, but I wrote about some of this stuff (though much less coherently) in a post prompted by the birth of Junior Aust No 2 some time back (there is a bit of an extended discussion in the comments after the post).

    It is certainly a very “politicised” issue, as the comments threads on Dr Crippen’s blog whenever he touches on this would testify (see e.g. here.

    Anyway, good luck, and may you enjoy the many sleepless nights to come.

    PS Mrs Dr Aust flatly refused to go to a single ante-natal classes, NCT or otherwise, so we were spared the lectures.

  2. Frankly, I’ve read a lot about the potential horrors of hospital birth from sites that aren’t in the habit of promoting quackery of any kind, and from people who frequently analyse other areas they discuss in a scientific and rational manner. Seems a lot of hospital staff in English-speaking countries don’t recognise that there are two people affected by every procedure used during birth.

    Pity the home birth movement in the UK is so filled with quackery.

  3. Just wanted to wish you good luck, & best for the Duckling.
    Also somewhat bemused that you’re the third birth I know of due this week. Hmmmm. Hope all goes well, and you avoid weird aliens & stuff.

  4. I did my pre- and postgraduate stint in obstetrics at the John Radcliffe Hospital, Oxford, where there were (late ’70s) two schools of thought – Prof Turnbull, who encouraged co-operation with NCT and personally showed them around the hospital, and another obstetrician whose name escapes me who was into everyone being induced at 38 weeks. The best way is no doubt somewhere between the two, although I prefer the Prof’s approach – but both were trying to be based on science.

    For example, studies have shown that epidurals increase the intervention rate (forceps, Caesarians), routine episiotomy is not necessary (though it is necessary in some cases), that you don’t need to put everyone in stirrups (my daughter was born with my wife squatting – gravity acts downwards, remember) and that waiting until 43 weeks in otherwise uncomplicated cases leads to no worse outcomes than induction at 42 weeks.

    It also makes sense to see that delivery wards are as friendly as possible.

    Finally, it is well-known in any kind of medical practice, and especially where pain is involved, that if the patient feels in control the anxiety and pain are much less.

  5. Thank you so much for writing this.

    What the “natural birth” contingent have overlooked is that they have become as oppressive in their tone and highly selective dissemination of information as the medical profession they sought to combat in the treating of women like so many cows on a production line.

    Birth is a feminist issue by default, you don’t provide women with real, informed choices if you distort or misrepresent the reality to suit your own philosophy, be you a crystal waving wiccan or a white coated “god-complexed” doctor.

    If you don’t seek to provide a truthful basis for those real, informed choices you are automatically doing your upmost to suppress women by making them unable to take control of their body, their birth experience and the wellbeing of their baby.

    Both sides could really do with working on their patronizing, condescending “poor, brood mare-esque little woman can’t understand complexity so must simplify information to the point of rendering it black and white” attitude.

    We don’t need fancy birthing rooms and whale music as much as we need for EVERYBODY in the birth industry, whatever their position on the scale of “natural” to “high tech”, to give over on prioritizing their agenda over our need for valid information.

    High time for the “professionals” to stop manipulating and to start informing. If being told the unadulterated truth isn’t a human right I don’t know what is.

  6. Being a healthy chap, the birth of my children was the first real encounter I has had with a hospital, so I did appreciate the NCT classes to give me the confidence to assert the rights of my wife and me at what can be a stressful and confusing time. The best thing they can help with is navigating the politics and process of a hospital; when contractions suddenly stop in the second stage of labour, and you are asked by a doctor to sign some forms, it’s good to understand the difference between an epidural and and episiotomy. It is easy, if you get your views about medicine from TV, to be a bit misty eyed about nurses and midwives. They are in the caring profession, but don’t forget the second of those two words: it’s their job, and everyone has bad days at work. Detachment is necessary, but it can leave the recipients of treatment in the dark.

    NCT classes thrive because the NHS alternatives are poor. I attended both sets of instruction and NHS would have left me confused if I had relied on it solely.

  7. I, too, regret all the quackery around birthing and infant health. I also regret that the NCT isn’t seen to live up to its claim to value evidence based medicine.

    Our first son was born in hospital, but our other two were born at home, the last one being a waterbirth too. Our experiences were very good, and we considered that we were aware that my wife was taking a risk. But, having been assessed as low-risk, and having experienced an ‘easy’ first (and then second) birth, we were happy to go ahead.

  8. It is sad but true that many of those who provide NCT classes do so on the fringes of quackery. My wife taught quackery-free NCT classes for some 10 years, perhaps because she had earlier obtained a PhD in Neuroscience (from UCL) and had formed her own views based on reading the relevant primary scientific literature. Her stance was always to provide as much accurate information as possible, but to be assiduously careful not to ‘push’ expectant parents toward hospital or home birth.

    What seems clear is that providing you are low risk (no breech, no pre-eclampsia, diabetes etc) then the risks are probably equal at home or in hospital. In which case it comes down to personal preference. My two were born at home, my wife declined pain-relief (the TENS machine was pointless but apparently the birthing pool worked wonders), but had there been any sign of problems during labour we’d have been off to the nearest hospital without delay.

    Hope it goes well for you and Mrs Duck.

  9. Good luck to Duck, Duckling and Drake.

    Of course, if the duckling turns into a swan, questions will need to be asked!

  10. I was borned at home an I sure turned out orright!

    Actually, though I am an Australian in appearance, accent and inclination, I was born in Holland. And I was delivered at home by a midwife – apparently it was an extremely painful posterior position and my mother has never let me forget it!

  11. My children were all born in Maternity units. No problems turned into disasters. My eldest daughter was ‘blue’ on birth, but the correct kit with a capable midwife soon put that right. The Missus spent a few days in hospital having a rest and I believe that prevented her getting baby blues.

    All in all, I feel HMG is just trying to make cuts.

  12. I never subscribed to the Nu-NCT ‘breeething the baaaby out’ mantra, and thank God for common sense. No.1 sproglet took extended residence for a fortnight and needing pulling out when she got rather stuck. No.2 sproglet shot out in a bloodbath. 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.

    For those in the real world labour is a 12-48h painful event with guaranteed overdrafts for the next 18 years (so far). Anything that relieves the pain of the equivalent of passing a rugby ball through a toilet roll tube is to be welcomed. Believe me, in second stage it doesn’t matter what prints are on the wall or if the bouncy ball is available. May your duckling bob out in a speedy but measured manner

  13. The trouble with normal births is that they can go spectacularly wrong very quickly. If this happens at home, you now have added transportation risks, time delay risks, resuscitation risks and possible resource risks (obstetrician, anesthesiologist,&numerous other support resources that may be required) that would have been eliminated/minimized if the birth had occurred in hospital.

    The following can happen even if everything has been normal during the pregnancy:

    1) Cord prolapse with a contraction, trapping the cord and asphyxiating the baby. Cord prolapse is a real emergency and is something that is stressful even in a hospital setting. Definitely not something you want to get stuck with at home.

    2)Cord wrapped around the baby’s neck. This can happen with baby’s normal movement and can sometimes happen even if a previous high definition Ultrasound scan was normal during a previous checkup. Without a high def Ultrasound machine at home one can’t know if the cord is wrapped around the neck or not. It may not become evident until the mother is pushing and time is short.

    3)A significant bleed. It is very difficult to obtain and transfuse blood in a home setting. Furthermore as mother starts to bleed to death, the veins which can be used to start IV’s can disappear making treatment that much more difficult.

    If safety is of paramount importance to you than I recommend a hospital environment. If other factors are more important, than you should at least weigh the additional risks of your decision.

    Rob
    (anesthesiologist)

    • Absolutely Rob! I had a textbook, unmedicated birth in a hospital with a CNM. As soon as I delivered the placenta, everything went wrong. I was bleeding buckets, and wound up going to the OR for a cervical laceration. I was on the cusp of getting a blood transfusion, and I have no doubt that I would have died had I given birth at home. This complication was unpredictable, and proved to me that birth remains inherently dangerous.

      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.

  14. Best wishes for the trials ahead !

    If you think the oppression from midwives is tough before you hit the birthing suite, just wait for the recyclable nappy nazis and the breast-milk nazis to turn up! My wife was so anxious about upsetting the midwives in her maternity unit that she made me do all the nappy changes and baths, and she cried for hours because the breastfeeding was not going well and she had been made to feel incompetent and stupid by the so-called ‘mothercraft’ nurses. They may feel that it is a doctor’s dictatorship but on the ground it’s the midwives who rule with the obstetricians being whisked in and out once their services are no longer required.

    Still, it’s a wonderful time so I hope you enjoy it together..

    • Oh, god, the breastfeeding Nazis! The number of lectures I endured from the coven about how I ‘wasn’t trying’ and my ‘issues’ (darkly hinted at, never actually named). Every four hours the offspring would cry because he was hungry, and so would I.
      Finally I encountered a sensible one who agreed that, yes, it may have been relevant that both my mother and grandmother had failed breastfeeding, and that if I kept on trying to do it myself I’d probably starve the baby to death.
      If one of those harpies comes anywhere near Mrs Canard and the Canardette, just punch her. No reasonable court would convict you.

  15. What a refreshing article – thank you. If you talk to mothers and look on many mother and baby websites there is a growing trend for hospital births to be seen as ‘evil'(!!) and homebirths are what gives a serene and pain free, relaxing ‘chi’ experience for mother and baby. Im not saying it doesnt in some cases, but what I do object to are these homebirth natural advocates putting all the emphasis on how in control the woman is, when in reality, yes the woman maybe in control of her breathing and calm state to a certain extent, but there is so much out of her control (then if anything does go wrong or intervention is needed she is left feeling guilty and like she has ‘failed). I really think more needs to be done to address some of the quackery that goes on about pregnancy and childbirth.
    Hope your wifes birth goes/went well and congratulations.

  16. I attended NCT classes to meet other mums-to-be and wasn’t impressed by their advocation of homeopathy, however I did receive a lot of information about the birth and my choices which I did not get from the NHS (no classes or hospital tours due to swine flu). I went for a home birth and knew that I was low risk (even though it was my first) as the midwives sent me for extra scans just to be sure. My birth went as well as can be expected (aarrrrrggghhhhhh) on gas and air and a birthing pool (both fantastic) and the midwives were amazing- I had 4 at one point- hurrah for the NHS. Out of my NCT class, I was the only one to have a home-birth with no interventions. All those who were induced had cesaereans, all the others had forceps. So obviously the best place was to be in hospital for them. I however would have a home birth again even knowing what could go wrong.

    • Oooh yes. Forgot to let you know. My beautiful little man. Orson. 7lb 4oz. All went well, bar the midwives pushing for the aromatherapy spa bath birth. .

    • We have had 2 boys, the 1st with all the drugs on offer and the second with gas and air only.

      The results…………..so different.

      My advice……………..natural all the way for best long term results

  17. Ours was born in maternity hospital in Bristol and the 2 midwives were marvellous – definitely no qauckery – at the alloted time there were about 8 professionals in the room, which seemed a lot of spectators, but they all went away once baby out and well, and the missus was a little pre-occupied to notice anyway.

    “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.”
    🙂

  18. Two comments to try & bring some sanity too. First. We own a facsimily copy of the first Encyclopaedia Britannica. If you can find one, read the section on Midwifery, to see what “natural” might imply. But have your children first, otherwise it will put you off pregnancy forever. Second. I had both my children in the maternity section of a small cottage hospital under the care of my GP. The first needed induction, the second not. I was lucky in not needing pain relief, perhaps because I have a naturally high pain threshold. It was a better experience than a home birth would have been – less disruption of normal home routine and with the assurance of good facilities within reach.

  19. Hi

    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!

  20. Congrats etc etc.
    We had both our births at home – waterbirths both, we had independent midwives so quite costly, but super-professional. If my partner was not a very healthy person I would have had doubts about home birth. Everything went very smoothly both times. Only pain relief was a Boots TENS machine. It was an awsome experience to have it all happen here in our living room, cosey and relaxed with midwives we knew well, and I am very happy we did not do it in a hospital.

  21. …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….

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

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