Homebirth advocates never analyze bad outcomes. Here’s why.

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Yesterday I wrote about another in the endless parade of preventable homebirth deaths (Another unassisted birth, another brain damaged baby.).

Why are there so many deaths?

Besides the fact that homebirth advocates are ignorant and homebirth midwives are incompetent, that is.

Homebirth advocates never analyze bad outcomes. They never perform a root cause analysis as doctors are trained to do.

What is root cause analysis?

[pullquote align=”right” color=”#4157a6″]Homebirth advocates and midwives won’t analyze deaths because they are confident analysis will show they are the cause.[/pullquote]

This explanation from MindTools is spot on:

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

  • Determine what happened.
  • Determine why it happened.
  • Figure out what to do to reduce the likelihood that it will happen again.

There are three main types of causes:

  • Physical causes – Tangible, material items failed in some way (for example, a car’s brakes stopped working).
  • Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
  • Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).

Imagine, for example, that a new mother bleeds to death after giving birth.

Doctors don’t throw up their hands and say, “There’s nothing we could have done differently; it would have happened at any other hospital, too.”

In this setting, the physical cause may or may not be obvious. Yes, it is possible that the mother bled to death because her uterus simply wouldn’t contract after the placenta was expelled, but it is also possible that she had an underlying coagulation problem that may have contributed to the outcome. It is critical to determine what physical factors were involved, but that’s only the beginning of the analysis, not the end of it.

What about human causes?

Did the doctor fail to check the placenta after delivery to make sure that there were no pieces left behind in the uterus?
Did the nurse fail to monitor the patient adequately and therefore didn’t realize that the patient was bleeding to death?
Was the blood bank slow to preparing the units for blood transfusion leading to an unacceptable delay?

How about organizational causes?

Are nurses required to look after so many patients at once that they don’t have time to properly assess each patient?
Is the med room inappropriately stocked so that medications to stop the bleeding are unavailable when and where they are needed?
Is the hospital’s internal transportation system faulty leading to a delay in receiving blood transfusions from the blood bank?

In contrast, homebirth advocates and homebirth midwives from lay midwives on up to the Royal College of Midwives in the UK have no policy of root cause analysis. Indeed, root cause analysis is implicitly or explicitly discouraged or even forbidden.


Because homebirth advocates and homebirth midwives are well aware that the root causes of perinatal (and maternal) deaths are intrinsic to homebirth itself. Simply put, homebirth advocates and homebirth midwives don’t perform root cause analysis because they know that it is their own preferences and performances that are the root cause.

The Royal College of Midwives (RCM) in the UK has not performed and appears to have no intention of performing a root cause analysis of the multiple neonatal and maternal deaths that occurred at their hands (in the hospital) as detailed in the Morecambe Bay Report. Instead they have restricted themselves to criticizing the analysis in the Morecambe Bay report and blaming “bad actors” who are supposedly unrepresentative of midwives as a whole.

They fear a root cause analysis because, as the Morecambe Bay Report detailed, a primary root cause of the deaths was a massive organizational failure known as the “Campaign for Normal Birth” (name recently changed to “Better Birth”). Midwives officially value the process of birth as much or more than the outcome. They are so committed to maintaining control of patients that they literally refuse to call for lifesaving help from doctors even when lives are obviously in danger… and the RCM intends to keep it that way.

American homebirth midwives (CPMs and LMs) are equally committed to avoiding root cause analysis because they are equally certain that they are part of the root cause. The human causes of homebirth deaths are grossly undereducated, grossly undertrained midwives. The organizational causes include an extraordinary lack of safety standards, a peer-review process that functions to support the midwife regardless of her errors and deficiencies, and a professional ethic which values maternal and midwife choice above safety.

Homebirth advocates are only too happy to collude in avoiding root cause analysis, because they are well aware that mothers are often a major root cause of deaths at homebirth. They are more concerned with avoiding responsibility than with preventing tragedies. Hence any analysis of deaths is explicitly discouraged as being “unsupportive,” is generally deleted from birth blogs and Facebook pages, anyone who attempts to analyze deaths is banned from the blogs and groups, and babies are routinely “buried twice,” first in tiny coffins in the ground and then expunged from any internet record.

Consider the brain injury that occurred at the unassisted birth I detailed yesterday.

A root cause analysis would show that the mother’s decisions to ignore her history of severe shoulder dystocia in a previous birth, to avoid obstetrician prenatal care and to give birth without medical assistance at the root cause of her baby’s brain injury. But she doesn’t want to acknowledge that, and other supporters of unassisted birth are equally committed to avoiding analysis of the injury because they are afraid that the analysis will show the obvious: unassisted childbirth is an ignorant, narcissistic and often deadly childbirth choice.

Simply put, homebirth advocates and homebirth midwives refuse to analyze homebirth deaths because they are utterly confident that analysis will show that they are the cause of the endless parade of preventable homebirth deaths.

When homebirth advocates and homebirth midwives say, “It would have happened at the hospital, too.” what they really mean is, “I can’t bear to acknowledge that it’s my fault.”