Are home births really more dangerous? Like most things, it depends.
From the NY Times Well Blog, new data on the safety of home birth vs. hospital birth:
Researchers analyzed data collected by the Centers for Disease Control and Prevention from 2006 to 2009 on almost 14 million births, including 130,000 non-hospital deliveries. Their results appear online in The American Journal of Obstetrics & Gynecology.
They examined both early death (within seven days of birth) and neonatal death (within 28 days) among singleton full-term babies without congenital malformations. No matter how they parsed the numbers, babies born outside hospitals had higher rates of death.
Food for thought for someone like me who’s always wanted to deliver my future babies at home.
That said, my understanding for a long time has been that for low-risk pregnancies, home birth is just as safe as delivering in a hospital. Here’s a corroborating BMJ study from 2005. It was a prospective study of the outcomes of all 5,418 planned home births in North America in the year 2000. It found that “[p]lanned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”
In other words, for the 12.1% of women who planned to deliver at home but needed to transfer to the hospital, there were lower rates of interventions such as epidurals, episiotomies, forceps- or vacuum-assisted deliveries, and cesarean sections compared to women who planned their births in the hospital. And the overall risk of neonatal death was similar to that of hospital births.
So color me skeptical of the Well blog’s claim that “no matter how they parsed the numbers, babies born outside the hospital had higher rates of death.”
The BMJ study suggests that we should compare apples to apples when we assess outcomes of births in different settings.
- Compare low-risk pregnancies. No good midwife would recommend planning a home birth for a high-risk pregnancy. She’d advise delivering in the hospital with an obstetrician.
- Compare planned home births with planned hospital births. You’ll get skewed data by including unplanned home births — cases where, by definition, something’s already gone wrong, and there may not even be any health professional present at all.
- Compare home births attended by Certified Professional Midwives, and exclude those attended by unlicensed, untrained practitioners.
These are just a few examples, but it seems pretty biased not to control for some of these variables where logistics don’t go as planned, or when whackadoos out there take unnecessary risks.
There was one other thing that was funny about the study on the Well blog. It says that babies delivered at home had nearly “four times the risk for death” compared with babies delivered by hospital-based midwives. A few paragraphs down, it says that babies delivered by non-healthcare providers such as policemen and taxi drivers had a “death rate…four times that of hospital births.” Are we really to believe that cabbies are as skilled as midwives in the work of delivering a child? Or that midwives are as unskilled as cabbies? I haven’t read the whole study yet, but that tidbit was a little strange.
While I disagree with the lead author of the study, Dr. Amos Grünebaum, a professor of obstetrics and gynecology at Weill Cornell Medical College, when he discourages women from giving birth at home, I support this statement of his wholeheartedly: “We need to make hospitals provide some of the amenities you have at home…. We need to make hospitals more like homes instead of making homes more like hospitals.”
A friend and fellow MD (who just had a baby at home) points out a couple more variables that might bias study data:
Two other major issue they are not digging into: how far away [laboring women] were from a back up hospital if something did go wrong, and choices the mother made that may have influenced mortality. Ie, the Vitamin K shot [to help baby’s early blood clotting and prevent brain hemorrhage] and agreeing to take Penicillin for Group B Strep [a vaginal bacteria that can cause life-threatening infections in newborns] seem anecdotally much less common in women who choose home births. I imagine the issue is that it’s already a huge challenge adequately powering these studies with the extremely low mortality rates in all settings.
I’ve also looked back at the comments section (never a good idea!!) of the original NY Times Well Blog post about the study, and I cannot find a single comment from a doctor that cites any data. It’s all scary anecdotes about fetal hypoxia and blindness and mental retardation, and tsk-tsking the selfish women who put their own “experience” ahead of their baby’s health and safety.
So, a couple things to address:
It saddens me how resistant so many physicians are to all the data that show that *planned* home births with *certified* midwives for *low-risk* pregnancies are just as safe as hospital births — and also resistant to data from other countries that show that home births can actually be safer than those in the hospital. These data suggest that place of birth is not an independent risk factor for morbidity and mortality, though of course more studies are always needed.
“Saddens me” sounds patronizing — so why do I put it that way? Because the longer these attitudes hold, the longer doctors continue not to see home birth in low risk cases as a reasonable, responsible option chosen by reasonable, responsible people, the longer midwives and home births will be ostracized in the healthcare community. Laboring women who need to transfer to the hospital will continue to be disdainfully referred to as "the failed home birth in room 6,″ and the OBs will talk smack about them in the physician work room. This is self-fulfilling. In countries where midwives are trained and integrated and work closely with doctors, and can seamlessly transfer care to specialists when things go wrong (usually well before the situation is emergent), the outcomes are even better than in U.S. hospitals.
Doctors need to learn to disentangle the reasonable desires of women to have home births from the silliness of the 20-page birth plan. My experience has shown me that women who approach their birth with an inflexible attitude may be the most likely to end up with escalating interventions because they resisted physician advice when the stakes were lower. So I hear you there, physician community, when your patience wears thin with women who show up in L&D with their 20-page birth plans. And women do need to think hard about their own personal desires for a transcendent birthing experience versus placing the health of their baby above everything.
But I truly don’t believe that these two things are mutually exclusive, and doctors and hospitals need to do a much better job to understand why women want the former so badly, to feel connected to their labor and their baby — and to make those things eminently possible in the hospital. My sense as a woman and an MD is that the 20-page birth plans are less about selfishness and more about wanting a feeling of control, which is only human for a woman who is usually having her first baby and is simply afraid. There’s a lot doctors can do to address a woman’s fears and desires — during prenatal visits and during labor itself — without simply bowing down to every demand.
Doctors should also try to have some historical perspective about this, to understand why there’s been a building backlash after what were honestly many decades of horrible birth practices in the hospital: shaving women, forced lithotomy position and stirrups, unconsciousness during delivery, sky-high epidural doses… It’s not a coincidence that so many hospitals now give women more choices during their labor — to move around, choose positions that are comfortable for them in a given moment, get in a tub of warm water to ease pain, turn out lights, have whatever supporters they want in the room, and so on. Some empathy would be a good first step toward easing this stalemate.