The home birth debate again rears its ugly head in public, and we spin the well-worn wheels of argument in the ever deepening intellectual (or not so intellectual) rut, hoping that somehow we will gain traction with one more scientific study or state mortality report and move the debate forwards in the direction that subscribes to our particular belief system.
After more than 20 years of reading, researching and being engaged in clinical practice I have come to the conclusion that the answer to this debate is not statistics but a shared responsibility. It is time to work together on what we agree on, while learning to compromise or accept that which we don’t agree on.
The principles we tend to agree on include respecting the right of women to choose where and how they give birth; making sure the best evidence is provided to women making this choice; ensuring that the practitioners attending women who choose home birth are skilled, regulated and networked into a responsive system that has women at the centre and not professional self interest.
Home birth has always been a choice women have sought in every country in the world and in every epoch in history. The numbers of women having a home birth have doubled in the US and Australia in the past four years.
Home birth will not go away, it is here to stay, so let us all share the responsibility for making it safe and satisfying, as should be our goal with all maternity care options.
The paradigm of risk in much of the developed world is one that holds home birth as risky and hospital birth as safe.
The assumption (not entirely wrong) is when things “go wrong” home is not the best place to be; however conversely we could argue when things are “going right”, hospital is not necessarily the best place to be and can be the cause of things going wrong as women enter what has been described as the cascade of intervention.
The reality is there are advantages and disadvantages with both places of birth, therefore we are left with a couple of options — we recognise women’s choice as valid and try to reduce the disadvantages and improve the advantages of all options of care (shared responsibility), or we obstinately put our heads in the sand and hope if we ignored it long enough home birth will go away (the current attitude to home birth in Australia).
Never in history and in no country has this ever happened but in some countries, concerted efforts to cater for women’s choice means hospital birth and home birth have been made safer.
The continued focus on the safety of home birth in research (primarily perinatal mortality) often leads us up a blind alley — not that perinatal outcomes are not important — but they hide agendas and underlying discourses and will not end the debate.
Hand-picking research to prove your point is something we are all expert in and sadly the public who trust us to provide an ethical and objective lens remain ever more confused.
So I will begin by agreeing with Dr Pesce (I think). While home birth advocates often cite research that is supportive of the safety of home birth and home birth critics cite papers that show a lack of safety, the studies examining the safety of home birth have consistently found comparable perinatal mortality among low-risk women giving birth at home with a midwife, and low-risk women giving birth in hospital, but lower intervention rates and maternal morbidity.
Likewise, studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased. In fact, the evidence is now substantial enough that we can identify where the greatest risk lies; for example, women giving birth to twins (especially the second twin) and breech babies.
Looking at small state reports of 160 births, where one or two deaths will alter the perinatal mortality rate dramatically, is not a sensible approach.
Any statistician will tell you when events are rare, large numbers are needed to make sure statistical errors are not made. However, we should never dismiss any evidence that may help us improve our practice and we must always be willing to learn and improve.
So, if we are agreed (mostly) that homebirth for women with risk factors in their pregnancy leads to an increase in adverse outcomes compared to hospital birth, where to next?
Well this is where we must move from the current kindergarten approach of beating one another up with hand-picked statistics, to the adult approach in the debate and towards a shared responsibility.
Keeping in mind the well-founded assumption that home birth is here to stay, there are three issues we need to consider. Firstly, why do women undertake a birth at home with risk factors? Secondly, how do we define safety? Thirdly, do we really want to take away a woman’s right to self-determination.