Sunday, September 13, 2009

In defense of home birth

There is a big kerfuffle in Australian politics about home birth at the moment, and it was born out of good intentions. There has been a review of birth in Australia, and lots of good things came out of it, including that midwives should be protected by insurance, just like obstetricians.

I should declare my hand, I was treated by a private obstetrician in all my successful pregnancies, and also dealt with two miscarriages in the Sydney public system.

Home birth is not and never was for me. I am not afraid of home birth, I simply don't want to clean up after it. Frivolous - no, in reality, with good thought about this, as soon as I went into labour, I wanted to be elsewhere. I didn't want to be in my home for my deliveries, but I understand that I am not definitive. Lots of women feel much more comfortable in their own home. It doesn't take a great deal of understanding to get that mammals only progress in their labour when they feel safe. Any and all stress hormones delay and restrict labour. If you look at the science, the answer is clearly in favour of providing the best possible environment for a woman to give birth in. For me, that was a birth centre (the labour ward at my hospital was not as bad as I expected, but definitely inferior), but for others, that is a well-attended home birth.

In The Daily Telegraph there was an unbiased report (cough, hack) about this. It claimed that "All studies done on homebirth confirm there are three times more complications for the mother and baby". It failed to cite a single study.

Lauredhel has cited a study, and it conflicts violently.

Lauredhel's citation comes from Canada. Call me crazy, but it seems at least within the realms of possibility that the Terror's quote and Lauredhel's could both be right. (And I could be really wrong here - please shout if there is an Australian study that disputes this.) If there is insufficient support of home birth in Australia, we might see complications that produce the scary numbers quoted. In fact, in my ante-natal classes we were told about a tragic event in which a baby died because those responsible couldn't reach the baby from the folds of a bean bag in time. This isn't about home birth, this is about having well-prepared people present at a birth. Most babies are delivered without drama. 30% of babies in the Netherlands are delivered at home, and their infant mortality rate is lower than Australia's (thanks Mim).

Delivering a baby safely requires skill. So do home improvements. We expect that appropriately trained people can build or extend their own homes, why don't we expect that appropriately trained people can deliver children?

Part of this is clearly based in the fact that a baby is so directly involved. Everyone feels the need to advocate for the baby. That's not a bad thing - that we all feel some need to protect all infants, regardless of their association with ourselves. The problem is our evaluation of risk. We place faith in science, and we allocate that faith to doctors. I share that faith in science (although I know not everyone does), nevertheless I question every single claim to the authority of science. It can never claim right, only wrong. In the case of medicine, there is mostly neither. Science attempts to guess the best path. Science is done by people, many of whom have a vested interest in the outcome. In the case of obstetrics, this vested interest is obvious. It's about power. Science has no ability to overcome the intention of its protagonists. Anyone may pervert science to support their own ends. The only thing that keeps science in check is other scientists. It cannot find truth in an oligopoly (except by accident). FRANZCOG doesn't exactly represent diversity of opinion, and its estimate of risk needs to be seriously assessed on that basis.

As does the refusal of insurance companies to offer insurance to midwives practising in homes. There is no basis for this refusal. But I don't expect private insurance to offer a useful service, I gave up on any faith in that industry a long, long time ago. I expect our government to insure - it is easily covered by the reduction in costs as a result of boring deliveries like mine not using hospital beds. Efficiency is born of good sense, not capitalism.


  1. Post 70 here might interest you - it has some recent Australian data.

    There's a lot more than that one Hutton paper - check out the Janssen study, the de Jonge study, the Johnson study, and plenty more.

    That aside, in all this rush to intervene in the name of "the baby's safety", I'd like to see someone, anyone, other than feminists, talking about the woman, as something other than an obstructive, obstinate, misguided vessel.

    One of the primary objections obstetricians are voicing is about money: they're afraid they'll have to take a financial hit from homebirth transfers "gone wrong". At the same time, however, they're arguing strenuously against homebirth midwives being 'allowed' to have insurance (or exist at all), so it's back to them trumping up the whole thing into a pissing contest over women's bodies..

  2. (And just as a small addit - you don't have to clean up after an attended homebirth. That's part of midwifery service.)

  3. Thanks for the links. I am always stunned that anyone misrepresents data so blatantly.

    Yeah, I have been told before that midwives clean up afterwards. :)

    I get really pissed off about the assumption that all mothers need to be forced into doing the right thing by their babies too. I mean, even if you assume that women are all working at an entirely selfish level, after going through 9 months of pregnancy, who would want to not come out of it with a baby?

  4. I find it fascinating in this debate (by which I mean utterly depressing) to see this willful disregard of data from countries where homebirth is well supported. It reminds me rather forcefully of people in the US who manage to totally ignore all those countries with universal healthcare that actually works and insist that it would be disastrous to try and implement.

  5. With all due respect perhaps you would like to share with us all what research you did in order to choose a private surgeon and a private hospital as your maternity carer of choice? I have yet to see any safety data to indicate that this is in any way a safe choice for women and babies.

    WRT "cleaning up", personally I place a higher value on safety than what my support team need to fix up in my house after a birth. Plus my midwife visits every day for a week, brings food, provides lactation support and continues to have a relationship with me into the future.

    Has your surgeon provided you with that?

  6. @Sheelnagig: Well I didn't choose a private hospital, as it happens. But mostly, it doesn't matter what I chose. I think that's my point. I have my reasons for choosing a private obs (and they have nothing to do with the delivery, which was handled almost entirely by truly wonderful midwives anyway), but my choices aren't relevant.

    What matters to me is that all women get to choose the option that works for them, which is why I support home birth.

    I'm not entirely sure why you seem to think I believe a hospital birth is definitively better. One of the reasons I wrote this post is to make it clear that this isn't another example of the Mummy Wars - I'm not trying to defend my decision or condemn anyone else's. Each woman is different and should be able to assess her own needs and make decisions on that basis.

  7. Actually some things are proven safe and effective and some are not.

    Private surgeons are not. Private surgeons in public hospitals are still just surgeons.

    Since you invited comment about studies I'd like to see the ones which support your "choice". Homebirthers, who do the research and who have the evidence to support their choice (and logic since mammalian birth has developed fairly well over a longish period time, right?) are always being asked to demonstrate that we're making a Safe Choice. But those who choose otherwise are not.

    All choices are not equal. Some are dangerous and have a very wide ripple effect on the community by the damage done to women, babies and breastfeeding.

    Hence my question to you. My choice is constantly bandied about, discussed, roughed up, dismissed as too hard to clean up after, or whatever. Yours is not. So in the interests of equity and because of the privilege accorded you by your choice, it would be excellent to hear on what you base that choice.

    A disagreement between women does not have to be Mummy Wars. That's kinda patronising, don't you think? I'm forced by virtue of being a tax payer to more than support your choice so let's put the shoe on the other foot, for once, and see what that process involves.

    Hey how about some credit to you for birthing your babes? No one "handled the delivery", you gave birth. ;-) Women give birth, pizzas are delivered.

  8. I can understand why you are angry about being asked to justify your choices, but I haven't asked you to justify yours.

    I chose the options I chose in part because, as I described in my original post, as soon as I went into labour I wanted to be elsewhere. I didn't want to be in my home. I don't know why that is, but I don't ask anyone to justify why they want to be in their home either.

    I mostly chose to use a private obs because of the ante-natal treatment. I found the balance of midwife visits and obs visits worked for me. My obs has a very low intervention rate and operates out of a birth centre, which is quite unusual. I only saw her for half of my checkups and saw midwives for the other half. This offered me the widest range of options at every point. Had the obstetrician not been present at the birth, I wouldn't have been terribly bothered - although since she'd been there all the way through it would have been a bit of a shame. She was incredibly supportive during a couple of crises and was never once dictatorial.

    The problem with every study ever published is that they average across people. I wasn't comparing all home births with all hospital (or birth centre) births, I was comparing my needs and options. I am very lucky in that I had a birth centre and excellent obs at my disposal, not everyone does. This is why my choice doesn't mean anything to anyone but me.

    And believe me, the midwives handled my deliveries (I certainly felt like I'd been delivered when those babies came out, it just about was a biblical experience). They were the guiding lights, I did the grunt work and demanded specific things as required. I may well have been able to do it without them, but it would have been a much more unpleasant experience.

  9. @sheelnagig - It's my choice. I chose, and would choose the same again. Like Ariane, my choice was about me and my 'cost benefit' analysis is about me.

    I had a 'mythical' ob. - he trusted me, trusted my body and respected my choices. His primary concern was a healthy safe labour. Which I had, in spite of the midwives who attended me.

    The week after the birth I stayed in the hospital with an LC visiting to see how I was going with breastfeeding (I've seen her and talked to her since then as well). My obstetrician's locum checked up on me each day as well, as did the midwives. The paediatrician checked my daughter a few hours after she was born and each day after that. When we came back in because she ended up with severe jaundice he organised a room for me so I could stay with her.

    Over the pregnancy I had severe morning sickness, heartburn (that ended up being my gallbladder crapping out on me), very low blood pressure that became very high blood pressure with a headache for six weeks until I was induced and GD that got missed with the three hour test. My daughter also had an abdominal cyst (and the cord wrapped too tightly so it had to be cut while she was still inside me since it couldn't be slipped over her head and I was tearing each time she peeked out and got drawn back in).

    But the end result is that I have read the studies and the reports and I made my decision. Something about pregnancy seems to make people think you are stupid and unable to read and educate yourself. There is a lot of advocacy and education to be done regarding homebirths but don't insist that anyone who chose different didn't think about it enough. I will be going back to my ob. for my next child if I can. and I will be going back to the same hospital. I don't want a homebirth - that doesn't mean I don't support them.

  10. I think one of the issues here is the difference between analysis of studies from a public policy point of view and the same analysis from a private decision making point of view. My post was about the former, but sheelnagig has asked about the latter.

    Personal decisions take specific instances into account, public policy decisions look at overall patterns. I haven't done a full review of the literature, not least because it wasn't relevant to my personal decision, but what I've seen in casual reading suggests that well supported home birth is at least as safe or safer than hospital births in general. This doesn't make hospital births unsafe, although I suspect it indicates that many doctors practise in unsafe ways.

    As Mimbles pointed out, all the evidence from countries that do support home birth indicates the same thing.

    However, for personal decisions, local information matters. Not all hospital births are unsafe. It is possible to make sensible choices based on knowledge of yourself and the professionals involved.

    For these reasons, nobody should be required to justify their decisions. I appreciate that having chosen the mainstream option I am not required to do so and people who choose home birth are. That's wrong. However, I don't accept that requiring that justification from me is going to help solve the problem.