Homebirth: Mother v. Baby? More like Mother v. Medical Community

In july, we reported on the Guardian’s very ridiculous coverage of a very ridiculous meta-analysis of international data on homebirths that purported to show that homebirths are safer for the labouring woman, but more dangerous for baby.

Reader Wahine has just sent us links to a Lancet editorial about the findings, and its attendant angry letters. The editorial states that

Although home birth seems to be safe for low-risk mothers and, when compared with hospital delivery, is associated with a shorter recovery time and fewer lacerations, post-partum haemorrhages, retained placentae and infections, the evidence is contradictory for outcomes of newborn babies delivered at home.

The author goes on to claim that this is due to methodological problems, and continues,

Professional organisations, perhaps unsurprisingly, have issued contradictory policy statements regarding home deliveries.

This is followed by a list of various countries and their various contradictory policy statements. The author then goes on to cite the meta-analysis mentioned above, and conclude that, well, now we know it’s really unsafe for babies, everyone ought to fall in line and recommend hospital birth.

So… lots of different countries have lots of different healthcare systems, with lots of different approaches to midwifery, homebirth, and indeed birth more generally…and the evidence across all (or many) of these systems is (big surprise) conflicting (as it would be, given we’re not comparing like for like). And the fact that this ‘conflict’ is reflected in ‘conflicting’ international guidelines is…further evidence of confusion? What? Circumstances differ cross-nationally; so evidence differs cross-nationally; so advice differs cross-nationally. That’s a sign that the advice is good: that it reflects the applicable evidence.

So, alright, I’ve ranted about this already. Let me start a new rant. The author of the editorial concludes, no big surprise, that

Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk. There are competing interests that need to be weighed carefully.

And in letters there’s huge anger over this.

Reducing rights to mere interests that can be weighed changes the mother from the owner of to a mere factor in the perinatal decision process. This is directly deleterious to her right to self-determination. The weighing of interests, risks, and outcomes is part of a capable exercise of human autonomy, not the other way around.

Quite right. But here’s my further worry: the meta-analysis purports to show that standard practice (hospital birth) is less safe for the patient (the pregnant woman) than a viable alternative (home birth). This shows a problem with existing medical practice. And yet, seemingly across the board, the discussion has been (only) about whether and which way the patient herself might be at fault; what the patient ought to do; what rights the patient ought to have (NB. the rights discussion never seems to stray into the question of what the woman’s rights are wrt decent medical care; we only ever discuss her rights wrt maiming babies).

I don’t get it. Why aren’t we talking about what’s wrong with obstetrics? What the hell is going on here?

In related news, a midwife in Hungary has been arrested for assisting in home births. Read more here.

13 thoughts on “Homebirth: Mother v. Baby? More like Mother v. Medical Community

  1. Great post – your point at the end about why we never question obstetric practice but only women’s decisions is spot-on and illuminating. Thanks!

  2. Anyone considering homebirth might want to look at this great website to help get a handle on the issues: http://www.homebirth.org.uk/ It treats you like an adult and as well as stories and discussion sends you to the scientific/academic sources if you are so inclined.

    The site’s co-ordinator was, by the by, trained as a philosopher.

  3. You are quite right there – the Wax meta-analysis, with all its faults, COULD have been used to start a discussion about why hospital birth is less safe than homebirth, and what can done to correct that. Instead, it was used to attack homebirth as a viable choice. Which is, of course, what it was designed to do. If it had been different, the meta-analysis would have included reliable homebirth studies.

  4. Spot on about the problem of not discussing obstetrics, but only mothers choices. I believe there is almost no decent research comparing, for example, midwife led hospital birth in ‘home away from home units’ with those on ordinary obstetric wards – and surely that should give info on how to improve within hospital birth!

    the following letter was not linked but made very good point too: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61908-3/fulltext

    It discusses the oddity of not discussing obstetric solutions/improvement: “There is a flaw in logic to first suggest that the solution might be better training, equipment, and resources, then to suggest that women alone should remedy the problem through their choices.”

    All very aggravating. thanks for posting!

  5. ah! well, i’m glad it’s not just me, and i’m extra glad that the lancet has published a letter pointing out the strangeness. and btw, thanks for sending us the stories!

  6. The Netherlands have close to the highest number of neonatal deaths in Europe while having a very high proportion of home births (29% of the births). It is very easy to jump to conclusions, so thank heavens for decent research. The researchers conclude that women should be encouraged to have birth where they choose.
    There’s still no conclusive explanation why the neonatal mortality is high here, but it may have something to do with the reluctance here to treat very ill neonates.

  7. Hippocampa: I believe that part of the explanation may be the fact that the Netherlands have (comparatively), very old mothers. Age increases risk. But yes, I am sure comparative reluctance to treat at all costs contributes too. Did you see the recent reversal of the decision to not treat neonates born pre-26 weeks?

    Extendedlp: pleasure, I am glad you picked up on it so well!

  8. Lovely, skeptical OB – your own website is not big enough a place to be so hostile to homebirths that the facts no longer matter, so you come here too. Nice.

    Of course, there ARE debates going on about what is wrong with modern obstetrics. I see you also like using the internet, like anyone else. If you type in “US c-section rates”, you will gain more than just “pseudo-knowledge”! While modern obstetrics can rightfully be praised for some things, it is also deserves criticism. Criticism, when it comes from the right sources, can promote better maternal and fetal outcomes. Are we not all in favor of those?

  9. dr. amy, again, *this is not an american blog*, and *we are not discussing the state of american midwifery*. as i’ve said, i agree with you that it is not as it ought to be. but that is *not the conversation we’re having here*. you fail either to grasp or to engage with the discussion, and this is probably related to the fact that you are a troll. i’m removing your comments. please be clear: you are not welcome to comment on this blog.

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