Homebirth is a business

business red word and dollar on magnifying glass

In today’s NYTimes, pediatrician Aaron Carroll wonders How to Make Home birth a Safer Option.

Noting that a recent study in the New England Journal of Medicine showed out of hospital birth in Oregon doubles the risk of perinatal death, Dr. Carroll makes it clear that he and his wife did not think that homebirth was safe enough for their babies:

I and my wife, feared the deaths of our babies during delivery so much that we chose in-hospital births. Our zeal to minimize that specific risk outweighed any other considerations. If faced with the decision again, I don’t doubt we’d choose the same…

The overwhelming majority of American women (nearly 99%) feel exactly the same way. Homebirth is a fringe practice. The pressure to support homebirth is not being driven by women. It is being driven by midwives and the rest of the natural childbirth industry (doulas, childbirth educators, natural childbirth lobbying organizations). Why? Because homebirth is a business.

[pullquote align=”right” cite=”” link=”” color=”F40000″ class=”” size=””]The push for homebirth is not being driven by women. It is being driven by midwives.[/pullquote]

Homebirth represents 100% of the income of American homebirth midwives, and it represents professional autonomy and a lack of professional scrutiny for others.

Dr. Carroll cites the UK experience with midwifery and efforts to lower treatment intensity. But the UK experience has hardly been encouraging. There, too, midwives have been aggressively clawing for market share both in and out of hospitals and the results have been ugly.

1. At Morecambe Bay:

Frontline staff were responsible for “inappropriate and unsafe care” and the response to potentially fatal incidents by the trust hierarchy was “grossly deficient, with repeated failure to investigate properly and learn lessons”.

Kirkup [the author of the report] said this “lethal mix” of factors had led to 20 instances of significant or major failures of care at Furness general hospital, associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.

2. At Royal Oldham/Greater Manchester:

Seven babies and three mums have died in two Greater Manchester maternity units in the space of just eight months – sparking an independent investigation.

3. At Milton Keynes:

History is repeating itself with the deaths of FIVE more newborn babies following staff failures at the hospital maternity unit…

Milton Keynes has now seen at least eight such deaths in two separate periods over the last eight years.
The latest five deaths happened over eight months between 2013 and 2014…

Most of the deaths involved staff failing to recognise or act upon warning signs of foetal distress.
All the babies were full term and previously healthy, and in each case parents claim speedier medical intervention could have saved their lives.

This is not an isolated problem. Liability payments for dead and injured babies now represent fully 20% of the NHS maternity budget.

That’s what happens when health systems employ midwives to lower treatment intensity.

The question we ought to be asking is not how to make homebirth safer (although that is a worthy goal); the question we should be addressing is: why do midwives promote homebirth as safe when it manifestly increases the risk of death?

Midwives are infatuated with homebirth for a number of reasons:

1. It is the natural end point of their love affair with promoting what they can do and demonizing what they cannot. They’ve gone from favoring the employment of midwives in maternity units, to midwife led units and birth centers. Homebirth is the logical next step, freeing them from any scrutiny by other health professionals.

2. It reflects the intellectually and morally suspect philosophy that the “best” birth is NOT the safest birth, but the birth with the least interventions.

3. It ensures that women cannot get effective pain relief.

4. It is a midwife full-employment plan. In contrast to a hospital based unit where one midwife can care for multiple women at a time, homebirth (in many countries) requires two midwives to care for one woman.

Women (and their physicians) have very different priorities. Homebirth is not popular and will never be popular among pregnant women. Most women have no interest in anything that raises the risk of perinatal death. Homebirth is deeply unpopular among obstetricians; most of us abhor anything that increases the risk of perinatal death. Homebirth is anathema among neonatologists for the same reason.

Follow the money! Homebirth is a business. It isn’t about women or babies or birth; it’s about midwives … and women contemplating homebirth (and the doctors who care for them) need to understand both the risks of homebirth and the self-serving motivations of those who promote it.