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.
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.