by: Judy Cohain, CNM
July 5, 2012
Since the beginning of hospital birth, research supporting its use for low risk women has been lacking. The last 15 years has produced 17 studies all supporting attended planned homebirth as safer for low risk women.
Research reveals that there are only 2 acute conditions that might occur at homebirth in which the mother or baby may have a better outcome had they planned a hospital birth, namely: Cord prolapse and Amniotic Fluid Embolism (AFE). Although tragic, cord prolapse and AFE occur rarely at homebirth, 1/5000 and 1/500,000 respectively, when balanced with the dozens of acute emergency conditions endangering the health of mother and baby that occur at planned hospital birth caused by intervening in the birth process, the scales tip easily in favor of planned attended homebirth for low risk women. Acute conditions caused by hospital birth are discussed here, to allow low risk women to make informed choices as to place of birth.
Is Hospital birth ever safer than homebirth for low risk women?
The answer is an unequivocal ‘no’.
There are 12 high quality studies since 1995 (1-12) from Canada, Switzerland, Sweden, Holland, US, UK, New Zealand and Israel, which all show planned attended homebirth to have either lower or similar rates of perinatal mortality and very significantly lower rates of maternal morbidity, such as cesareans, hemorrhage, and third and fourth degree tears compared to matched groups of low risk women who plan to deliver in hospital.
Another 5 studies (13-17) claim homebirth to have a higher perinatal mortality rate compared to hospital birth but they all include high risk births in the planned homebirth group. Instead of excluding the high risk births from both groups, they include the homebirth outcomes of premature births at 34-37 weeks gestation (13-17) breech and twins (13,14) lethal anomalies incompatible with life(13,14) unattended homebirths (15,16) unplanned homebirths(15,16) or women who became risked out of homebirth by becoming high risk at the end of pregnancy, had hospital births, but are included in the homebirth group. (17)
These 5 studies conclude that homebirth is less safe than hospital birth, when what these papers actually found is that low risk births are safer at home but premature births have better outcomes in hospital. Possible explanations for the false conclusion of these studies could be paternalistic power games over women or hospital birth being not only the most common but also the most profitable reason for hospitalization. Remove the high risk births from those studies and they also confirm that homebirth is safer for low risk women than hospital birth.
Margaret Tew, a statistician, pointed out as early as 1977 (18) that hospital birth was never researched for safety before it was instituted. She analyzed whatever data she could find from the years in which birth transitioned to hospital 1920-1950, searching for evidence of improved outcomes of hospital birth, but did not find any. She found great resistance to publishing her findings in peer reviewed journals, with only the one scholarly reference in a journal(18) and the rest of her findings published in a chapter of a book and her own book. (19,20)
Dr. Shearer 1985: “When I started in general practice in 1954 about a third of all babies were born at home, and only women with problems and a few primiparas were able to book a bed in the local hospital, St. John’s Chelmsford. By the early 1970s this had changed greatly, and it was possible to book all mothers who wished for or needed a bed in the consultant unit. Although my partners and I continued to look after home deliveries, we were often asked about the risk of a home birth, and in the past decade the usual reason given by low risk mothers for a request for a hospital deliver was ‘because it is safer.’ There appears to be no firm evidence for this view.” (21)
No hospital birth perinatal death rates approximate the outcomes of experienced, motivated homebirth midwives at planned attended homebirth
Published perinatal mortality rates of low risk women at planned attended homebirth and hospital birth average 0.6/1000 for vaginal births and 1.8/1000 for cesareans (22,23). Perinatal mortality rates for hospital births of low risk women are similar to outcomes of planned homebirth in general, but the maternal morbidity at planned hospital births is much higher. The most optimal perinatal mortality and maternal outcomes are reported by excellently trained, motivated homebirth midwives:
0/1000 Poplar, East London District, UK 1950: Jennifer Worth reports having delivered well over 100 babies before qualification and several thousand after in the post WWII tenements, where there was no running water and a family of 10 lived in one room, and a family of 10 was common. “I do not recall any instance of an emergency occurring, still less a disaster during delivery. Young people today simply do not believe me when I say this but I can only say ask any midwife of my generation who has had a good deal of district experience and she will confirm this.