The Birthplace Study, published just 3 weeks ago, is the largest, most comprehensive study of homebirth ever done. The authors summarized their findings as follows:
… [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).
In other words, the risk of death and serious injury was approximately double in the homebirth group and that increase was seen mainly among first time mothers.
There is a very significant limitation to this conclusion, however. The list of study exclusion criteria was far more restrictive than the actual exclusion criteria for homebirth in the UK. Therefore, a substantial proportion of the women who actually had a homebirth were excluded from the study even before it began. Of the 18,269 low risk women planning homebirth at the start of the study, 1346 (7.4%) were excluded from the study despite the fact that they went on to have a homebirth under the auspices of the National Health Service.
Fortunately, the authors of the study have published nearly a thousand pages of supplementary material. Buried in part 4 of the supplemental material is the outcomes for those women who had homebirths but did not meet the very restrictive criteria of the study. Outcomes are compared to the low risk women electing hospital birth who also failed to meet the more restrictive criteria for inclusion in the study. It is instructive to look at what happened in those births.
Not surprisingly, the incidence of adverse events was higher in the homebirth group, even when compared with higher risk women who delivered in the hospital.
The first thing to note is that in contrast to the women who did meet the rigorous exclusion criteria, in which 73% (12,050/16538) were multips, among those who did not meet the criteria, fully 83% (1096/1324) were multips. That’s not surprising when you consider that multiparous women were required to meet an additional level of scrutiny; specifically they had to have had no complications in any previous pregnancy.
Second, homebirth doubled the risk of an adverse outcome for both nulliparous women and multiparous women in the higher risk group. That’s not surprising, either. Disregarding outcomes of previous pregnancies makes the two higher risk groups more comparable to each other that the two lower risk groups are to each other.
This is just further confirmation of the central finding of the study. Homebirth, doubles the risk of adverse perinatal outcomes. Therefore, the claim of the Royal College of Midwives and other homebirth advocates that “.., [f]or women having a second or subsequent baby … homebirths appear to be safe for the baby” is not true.
Moreover, the more grandiose claim of homebirth advocates that “50% of women” could safely have a homebirth is a complete falsehood. The Birthplace study actually shows that homebirth is only safe in rigorously screened low risk multiparous women who in addition to having no risk factors in this pregnancy, have had no risk factors in any pregnancy.
In other words, homebirth is safe only when nothing goes wrong. To ensure that nothing goes wrong, candidates for homebirth must be screened very rigorously. Anything that could be remotely considered a risk factor in the current or any previous pregnancy renders homebirth unsafe.
The basic reality of childbirth, that it is inherently dangerous, and that life threatening events can happen without any warning, is confirmed by the Birthplace Study. Homebirth is safe only when nothing goes wrong. Since there is no way to predict with complete accuracy whether something is going to go wrong, homebirth can never be as safe as hospital birth.
Multips w zero previous complications showed NO increased risk compared with the same type of women who delivered in obstetrical units. But you say:
“Since there is no way to predict with complete accuracy whether something is going to go wrong, homebirth can never be as safe as hospital birth.”
So are you disagreeing w the findings?
If hospital birth didn’t carry it’s own risks (increase infection for one) maybe your statement would hold up.
For those interested, the skepchick’s piece on this study is more thoughtful and less biased.
http://skepchick.org/2012/01/nuance-of-risk-and-homebirth/
The criteria that the authors used in the study is far more stringent than the criteria currently in use for homebirth in the UK. So the study showed that homebirth was safe for multips under study conditions, but it did NOT show that homebirth as currently practiced is safe for multips or anyone else.
Dr. Amy,
Discerning risk assessment when choosing home v hospital birth involves countless variables unique to each woman. To assert that hospitals are always the safer option is wrong. In order to reconcile the results in the birthplace study w your point that homebirth is never the safer option, you claim that the conditions of the study were more stringent than any current midwife practices would be provided for the mother. But certainly those conditions exist in particular cases, even if they are not exercised widely in midwifery practices. Won’t you admit that in keeping with the ACOG recommendations for safer homebirth and being a multip w no previous complications that the risks compared between birth place is negligible?
Like you, I believe that even if these stringent conditions aren’t met, a woman has the freedom to choose where to deliver. I am particularly sympathetic to women who hope to have many children. A cesarean brings a higher probability of future physical risk to these women. The risk of secondary infertility may be more psychologically devastating to them as well. For these women, a birthcenter attached to a hospital or a hospital with a low section rate may be a preferred option. Unfortunately these options aren’t always available.
There are two commonly dismissed factors by those with extreme bias towards hospital birth: Maternal mortality/morbidity (the focus is almost exclusively on perinatal mortality) and inhuman conditions. Women don’t choose homebirth for the luxurious experience, but out of the desire to not go through a system which they understand as humiliating, coercive, and involving physically taxing regulations — like being denied food during labor and the ability to sleep postpartum. We can say in hindsight that twilight sleep was bad practice because it raised the risk of breathing problems but what about looking at it as a unethical practice? Maybe we’ll look back and understand certain current obstetrical practices as unethical, but why criticize those who don’t require hindsight and cultural consensus to see the inhumanity. It’s not about “intuition”. It’s about informed conscience. Most women of sound mind will choose physical and psychological torture over delivering a dead baby. The question is at what point is it clear that those are the only options? A: Obvious and immediate danger. If that’s the case, judge away. In most cases the overall risk of homebirth is low and in some cases the risk is insignificant compared to hospital birth, as indicated by this study.
I appreciate your responses to my post and other’s posts attempting to sort out information regarding birth options. The combox is often seen a circle of hell for many blog-authors, I admire your willingness to discuss these topics in this pedestrian format. I’m not a fan of your approach (or what I believe to be the dismissal of legit points made by the NCBers), but I respect your passion to inform women.
No, determining the safer option does NOT involve countless variable unique to each women. The idea of “radical uniqueness” is a staple of pseudoscience of all kinds.
We can never tell an idividual woman exactly what will happen in her specific case. When we counsel women will ALWAYS tell them the results of studying large populations.
The Birthplace Study looked at a large population. It is not find that homebirth is EVER the safest place to give birth. It found that under strict study conditiions, homebirth might be AS SAFE AS THE HOSPITAL for multips. It found that under strict study considtions, hospital birth is SAFER that homebirth for nullips.
It tells us NOTHING about homebirth is real world situations.
Posting in reply to Dr Amy instead of pburg to keep her reply above mine
pburg “To assert that hospitals are always the safer option is wrong”
I disagree: is there a blood bank and OR at your house? Because immediate access to medical care in the event of an emergency is always the safer option.
If it isn’t, we can dismiss all the paramedics and ambulances attending athletic competitions. What do you think, pburg?
With homebirth, the question is whether or not the statistics show a mother might require that emergency medical care — which is NOT available at her home. You seem to think that under the right conditions, a mother can bet on not needing any expert care and things will turn out great at home.
That does not mean being at home was the safer option. What it means is that particular mother won the bet.
You ask: “The question is at what point is it clear that those are the only options? A: Obvious and immediate danger.”
You ignore option B: the danger is not immediate and obvious even to the clueless, but still present and preventable with appropriate measures.
This is where you lose. Just because the danger is not obvious does not mean it’s not there.
You have the right to take risks. But please stop pretending that just because you were not the one who suffered the adverse event that the risk did not exist.
In order for birth to be safer at home than in the hospital, there must be something about the home condition that is medically better than in a hospital. Not aesthetically better (we aren’t talking scented candles), but actually medically better.
The one example that gets trotted out for this is MRSA, which is claimed can be acquired at the hospital. However, there are three problems with this assertion
1) MRSA is NOT restricted to hospitals, and community spread MRSA is absolutely a problem
2) Even within the hospital, to what extent is MRSA prevalent in the maternity ward? Likely NOT as much as overall in the hospital
3) OK, let’s grant the possibility of MRSA – but how common is it? How many babies or mothers die each year due to MRSA infections? As CC Math Prof estimated the other day, there are something like 60 maternal deaths each year due to infection of any type (which includes things like the flu), so clearly MRSA isn’t taking a lot of mothers. I don’t know the number of babies, but then again, I’m not the one claiming that MRSA is this major hospital problem worth avoiding.
OTOH, we KNOW there are lots of babies dying outside the hospital that wouldn’t die if they were hospital births. Which number is higher? The number of HB babies that die from GBS infection, or the number of hospital babies that die from MRSA? That given the number of hospital births is 100 times greater?
Where are those babies who die in a hospital that would have lived at home? Over the years I’ve been here, I think the number of times that has even be suggested can be counted on one hand, and there MIGHT be a single example we have heard where it could be true.
That despite the fact that we are constantly reminded that lots more babies die in hospitals than at home. Yet, none of them would have been saved if they had been born at home. In contrast, the number who die at home that would not have dies in the hospital? We heart that like every other week.
Bofa,
apologies for not responding sooner.
“In order for birth to be safer at home than in the hospital, there must be something about the home condition that is medically better than in a hospital.”
I hate sounding like a broken record but… I didn’t write that homebirth is ever “safer” than hospital birth.
All sorts of medical mistakes occur in hospitals. Epidurals can lead to heart attacks and infection –it’s rare, but it’s not a homebirth issue. Catheters can infect the urethra. Staff infections. Even driving to and from the hospital contains risk. Life is risk. The biggie is cesarean sections. This increases all kinds of problems for moms, including death.
So while the incidence of maternal mortality in a hospital is relatively low it does not seem to outweigh the risk of multips w/ no previous complications choosing homebirth. But home v hopital risks are themselves inherently different. Avoidable hospital deaths are mostly “possibly” would have been safer at home. Avoidable homebirth deaths are usually “probably” would have been safer at the hospital. I think this is what convinces so many people that hospitals are always safer than homebirth. But it is not true.
Then why did you write:
?
“hosptals are always the safer option is wrong” means that there are times when it is NOT the safer option.
So, yes, you claimed that homebirth is sometimes a safer option.
You’re missing the concept that it can be “as safe.” Though, it certainly could be speculated as safer for those who became sick or died from a hopital related intervention. And, I’ll hold my ground that asserting ‘hospital birth is always safer than homebirth’ is wrong.
Your “gound” is pretty worthless if you don’t have actual data to back up your claims.
My ground is your ground:
Dr. Amy- “homebirth might be AS SAFE AS THE HOSPITAL for multips.”
Don’t be so hard on yourself calling it worthless. And the data to back it up is in the study this debate is referring to.
No, it isn’t because the Birthplace Study did not address real world conditions. The eligibility criteria for the study were far more stringent that the criteria for homebirth.
Homebirth is not safe in and of itself. It is only safe when nothing goes wrong. If you risk out enough categories, the chance of something going wrong drops dramatically, and therefore it appears that homebirth is safe. It’s not different from restricting driving without a seatbelt to the hours of 1-2 PM on a sunny day, with no ice or snow on the ground, only on the dead end in your local neighborhood. The odds of you dying if you don’t put on your seatbelt in those conditions are very low, but that doesn’t mean that not wearing a seatbelt is as safe as wearing one.
Homebirth is only “safe” when nothing goes wrong. And since no one can know with certainty that nothing is going to go wrong, it is ALWAYS a gamble.
You can’t on one hand state that homebirth “might be as safe” and then assert that hospital birth “is always safer.”
You made your point about stringent conditions earlier. I responded:
“But certainly those conditions exist in particular cases, even if they are not exercised widely in midwifery practices. Won’t you admit that in keeping with the ACOG recommendations for safer homebirth and being a multip w no previous complications that the risks compared between birth place is negligible?”
You agreed, but now you are back-peddling.
“Homebirth is not safe in and of itself.”
Birth is not safe in and of itself. Ergo neither hospital or home birth is safe in and of itself.
your next line: “It is only safe when nothing goes wrong.”
Wait is “homebirth not safe in and of itself”? or is it “only safe if nothing goes wrong”?
“If you risk out enough categories, the chance of something going wrong drops dramatically, and therefore it appears that homebirth is safe.”
You often cite the 450% stat. But you admit it’s more nuanced then that. By omitting the fact that the low-risk category of the study you cite includes nullips you perpetuate the idea that homebirth always contains this type of extreme difference in risk. Are there moms under the age of 35 who have had previous uncomplicated labors and are able to follow safety standards cited by ACOG? Yes. Many.
“It’s not different from restricting driving without a seatbelt to the hours of 1-2 PM on a sunny day, with no ice or snow on the ground, only on the dead end in your local neighborhood. The odds of you dying if you don’t put on your seatbelt in those conditions are very low, but that doesn’t mean that not wearing a seatbelt is as safe as wearing one.”
But this seat belt is not an easy click of the buckle. The driver considers it burdensome and humiliating. And, most of all, there is a probability that the belt could cause it’s own complications. Even death. Would you blame someone for opting out?
“And since no one can know with certainty that nothing is going to go wrong, it is ALWAYS a gamble.”
And hospital birth is also ALWAYS a gamble because (1) birth is always a gamble and (2) hospitals contain their own risks.
Homebirth midwives don’t make mistakes?
Sure. But I wasn’t listing homebirth risks. Maybe I should have written: “medical mistakes involving medical interventions more commonly practiced in or exclusive to hospitals” for clarity’s sake.
Box of Salt,
Me: “To assert that hospitals are always the safer option is wrong.” You: “I disagree”
If you disagree with me, you are also disagreeing with Dr. Amy. She admits that under certain circumstances, homebirth might be as safe as the hospital.
” immediate access to medical care in the event of an emergency is always the safer option.If it isn’t, we can dismiss all the paramedics and ambulances attending athletic competitions. What do you think, pburg?”
Since it is a common analogy, let’s be more specific and use the example of a marathon. It’s dangerous, physically exhausting, and most of all, it tests limits of endurance. But let’s say you were running a marathon naked. That changes things, right? Who wants to be naked around strangers? Let’s also say that the regulations of the marathon require fasting beforehand and sleep deprivation after. More applicable to the study, you have ran this marathon several times before with no related problems. You’re a pro. This may not guarantee a safe run, but you chances of running the race in a more dignified way (but further from the paramedics) does not contain a obviously higher risk than running the humiliating marathon closer to the paramedics. Which would you choose?
“You ignore option B: the danger is not immediate and obvious even to the clueless, but still present and preventable with appropriate measures.”
Sure. But I was addressing the definition of neglect as an objective requirement for action (preventative or otherwise). I believe the term is used legally as clear and present danger. I would like to add that I do NOT advocate homebirth up to the point of obvious neglect. We can assume a woman may have legit reasons for homebirth up until that point. They have the right to discern risk. We cannot make that judgement for them.
“You have the right to take risks. But please stop pretending that just because you were not the one who suffered the adverse event that the risk did not exist.”
When did I pretend risks did not exist? What adverse event?
I hate your marathon analogy.
1. It bears potentially no resemblance to hospital conditions. Hospitals do not have to suck, and they don’t universally do so. The approach to NPO for labpring women, for example, is genuinely a safety step in case surgery is needed. Hospitals handle that all kinds of ways. Some require it only in specific cases, where the probability of c-section is high. Some have an extremely loose definition of “clear liquids”. Most will hook up a sugar iv. Given that hospital variation encompasses everything from “get this lady an iv” to “chocolate ice cream is a clear liquid” to “I brought you a sandwich”, maybe you could stop fearmongering about hospitals. All that crap genuinely makes women who need hospitals reluctant to go there.
2. Every five to ten years, a professional athlete dies running a marathon. I’m not talking about the cardiac cases among the charity runners, or the bandits on the course. Every now and then, an elite runner, someone with a history of running marathons, someone who runs for a living and has an expectation of finishing in the money, and a shoe endorsement deal, keels over mid-race, dead. And statistically, marathons are safer then childbirth.
pburg “If you disagree with me, you are also disagreeing with Dr. Amy.” So what?
“When did I pretend risks did not exist? What adverse event?”
Death, pburg. Yours or your baby’s – take your pick. The fact that you had to ask the question shows you are ignoring the risk.
“Since it is a common analogy, let’s be more specific and use the example of a marathon”
pburg, I’ve never run a marathon, but I suspect you don’t realize that I have competed in endurance events in other sports. Frankly, the way you are framing your analogy is absurd. And the whole idea that labor mimics an athletic competition fails. If you are competing, you can stop and quit. Exactly when does that happen during labor? The baby still has to come out.
“Let’s also say that the regulations of the marathon require”
It’s not my fault you did not read and understand them beforehand.
By the way, way back almost ten years ago the nurses at the hospital who found out we’d missed eating dinner on our way in brought me a sandwich (I still have no idea who paid for that).
You throw in a complaint about sleep deprivation? What were you expecting once you had a newborn?
pburg, many people do not internalize risk until they find themselves on the wrong side of it. I get that. I hope you never find out. But I also hope that you think about the fact that beating the odds is just that, even when the odds are in your favor.
Dr. Amy,
You write “homebirth can never be as safe as hospital birth” but then backtrack and write “homebirth might be AS SAFE AS THE HOSPITAL for multips.” You made a declaration then reversed, I didn’t. I did not assert that homebirth is ever a foreseeable safer option. Only that, depending on a woman’s unique situation, countless amount of risk factors apply which a study can never accurately account for and that hospital birth carries particular risks which some might want to consider.
You write “It found that under strict study conditions, hospital birth is SAFER than homebirth for nullips.” The study may have indicated that hospital birth is generally/typically/might be safer but I’ll quote your next line in declaring “It tells us NOTHING about [home]birth in real world situations.”
Birth is not safe. As far as assessing risk factors — one can only speculate. Studies, previous L&D information, and practical concerns are some aspects of consideration (which is why nullips should probably be placed in the high risk category since they have no previous L&D info).
Btw, I don’t know what “radical uniqueness” is but it sounds hilarious.
The Skepchick piece was written by a doula, in other words a lay person who lacks the education and training to evaluate the study.