Mortality a limited view of homebirth safety?

The ever growing list of homebirth deaths has become so long that even Australian midwives have recognized that it is foolish to claim that homebirth is safe. The new tack? Proclaim that “mortality is in fact a very limited view of safety.”

That’s what Hannah Dahlen, national media spokesperson for the Australian College of Midwives, has to say in a piece in the Australian press that is a masterpiece of callousness and obfuscation, Home births: it’s time to broaden the focus of the debate.

First, Dahlen acknowledges what everyone but homebirth advocates have always recognized:

… 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.

In other words, one of the prime motivations for homebirth, to ignore medical advice on twins, breech, postdates and VBAC on the theory that avoiding a C-section is “safer” than hospital birth, is completely contradicted by “substantial” scientific evidence.

But wait! Whether the baby lives or dies is a “kindergarten” view of birth!

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

Really? On what planet would that be?

Can you imagine an obstetrician saying to patient that we ought to take a broader view of obstetrics than whether her baby lives or die? Can you imagine hospitals declaring to expectant parents that there is more to consider in choosing a place to give birth than whether the baby lives or die?

There may be factors in addition to perinatal mortality that contribute to safety, but there is no possible view of safety that does not place mortality (perinatal and maternal) at the center of obstetric care. I’d be the first to agree that there is more to safety than merely ensuring the baby lives, but there is no possible justification for a definition of “safety” that includes letting the baby die.

Dahlen’s claim is not simply an exercise in extreme callousness, it is a particularly clumsy effort at “re-framing the conversation.” Just like MANA (Midwives Alliance of North America), Australian midwives are taking a page out of the tobacco company playbook (What do homebirth midwives and tobacco executives have in common?).

As the Tobacco Institute explained to its members:

Our judgement, confirmed by research, was that the battle could not be waged successfully over the health issue. It was imperative, in our judgement, to shift the battleground from health to a field more distant and less volatile…

Now Australian midwives have recognized that the homebirth debate cannot not be waged successfully over the issue of safety, since hospital birth is clearly safer. Therefore, it’s time to change the battle field.

Let’s compare:

Tobacco industry:

… [W]e try to change the focus on the issues. Cigarette tax become[s] an issue of fairness and effective tax policy. Cigarette marketing is an issue of freedom of commercial speech. Environmental tobacco smoke becomes an issue of accommodation. Cigarette-related fires become an issue of prudent fire safety programs. And so on.


Freedom? Check.

Women’s right to control what happens to their bodies during pregnancy and birth may be enshrined in law but this right is frequently violated in practice. I find it ironic that the same professionals who fight for the right for a woman to terminate her pregnancy will fight against her right to give birth at home. The law in this country is on the side of women and self-determination.

Accommodation? Check.

It is time to stop talking about the statistics and start working together to make home birth and hospital birth as safe (physical, cultural, emotional, social, psychological and spiritual) as it can be.

Prudent safety programs? Check.

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.

And, above all else, changing the focus? Check

The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.

Nice try, Ms. Dahlen, but the rest of us are not fooled.

Dahlen has essentially conceded the homebirth debate. She acknowledges that the scientific evidence shows that hospital birth is safer. Now she’s merely making callous and clumsy attempts to change the subject.

Dahlen should be ashamed of herself. The birth of a live baby is not a priority, it is the priority. Any midwife who believes otherwise demeans the profession.