Homebirth isn’t about women or birth; it’s about midwives


I’ve been engaged in an online discussion with other healthcare providers about the NEJM Oregon study of out of hospital birth and it has crystallized for me something I’ve suspected for a long time:

Homebirth isn’t about women, babies or birth; it’s about midwives.

[pullquote align=”right” cite=”” link=”” color=”#C61210″ class=”” size=””]Homebirth is not popular among women. Most have no interest in anything that raises the perinatal death rate.[/pullquote]

Think about it: Except in the Netherlands, homebirth is (and has been for decades) a fringe practice. Anything that engages 2% of the population or less is almost by definition a fringe practice. So why does it receive so much attention? In part it’s because of the high death rate. The people who care for women and babies have a particular revulsion for preventable infant death and anything more likely to cause it. They pay attention to it because they are trying to prevent those deaths.

But I would argue that the real reason for so much attention is that the entire project is being driven by midwives. The proportion of midwives in the US, the UK, Canada and Australia who favor homebirth exceeds the proportion of women who favor homebirth by an extraordinary margin. Midwives are infatuated with homebirth for a number of reasons:

1. It is the natural end point of their obsession 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 moral bankrupt 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.

The truth is that 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.

The provider discussion about homebirth crystallized that point. Among the participants, there was only one obstetrician on the record as favoring homebirth (though, to my knowledge, he doesn’t provide coverage for homebirth). There is not a single neonatologist who favors homebirth. Homebirth is relentlessly promoted by the midwives in the group. Sure, they dress it up with the usual nonsense that maternity care is in crisis, that we need to look at why women choose homebirth in the first place, etc.

But maternity care is not in crisis: neonatal mortality has never been lower. Women who in the past could not get pregnant, women who did not survive their serious medical illnesses to get pregnant or did not survive pregnancy are now having healthy babies. To the extent that there is a crisis it is reflected in maternal mortality and too LITTLE technology; some women with serious medical complications don’t have easy access to the technology that could save their lives.

The cries of “crisis” come from those who think that failure to privilege unmedicated vaginal birth is the crisis.

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).Homebirth represents 100% of the income of American homebirth midwives, and it represents professional autonomy and a lack of professional scrutiny for others. The question we ought to be asking is not why some women choose homebirth; it’s why midwives promote homebirth as safe when it manifestly increases the risk of death.

The NEJM paper indicates the risk of homebirth death is underestimated, that at least in the US (and possibly in other countries as well), homebirth leads to preventable perinatal deaths. Yes, some women will choose it anyway despite the increased risk of death, but then some women will refuse to vaccinate. We don’t spend our time trying to make refusing vaccination safe; we educate our patients on the deadly consequences of their choice; that’s what we should do here, too.

Homebirth isn’t about women or babies or birth; it’s about midwives … and women contemplating homebirth need to understand both the risks of homebirth and the self-serving motivations of those who promote it.