For a long time, I stayed away from the topic of homebirth, partly because it is such a controversial topic. I have only started writing about it recently because I am pregnant and currently am under the care of a team of homebirth midwives. My post titled "How Homebirth Benefits Babies" was the first post I wrote that "promoted" homebirth (with caveats!). It is also has been the most widely read, currently at 1,788 pageviews.
I have discovered that the evidence really is not clear on the most important point I make in that post when I talk about homebirth research. My words:
First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6).It has come to my attention that the results of one of the studies I cite in that post has been called into question by the results of another study--a study that nobody in the online natural birth community appears to be talking about, even though it was published 9 months ago.
The study I cited in my post was the de Jonge study from the Netherlands, which compared outcomes of home and hospital births attended by Dutch midwives among women classified as "low risk" by the Netherlands maternity care system. De Jonge found no difference in mortality or severe morbidity in the home and hospital groups.
The Evers study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study was published in the British Medical Journal in November 2010. It compared outcomes of term births classified as "low risk" by the Dutch system attended by midwives (primary care) with outcomes of births classified as "high risk" and attended by obstetricians (secondary care). It found higher rates of perinatal mortality in the primary care group, and no difference in rates of level 3 NICU admission (the measure the study used for severe morbidity). Yes, you read that right. More low risk babies died. There were 26 delivery-related perinatal deaths out of 18,686 who began labor in primary care(a rate of 1.39/1000) and there were 10 delivery-related perinatal deaths out of 16,739 who began labor in secondary care (rate: 0.60/1000). The transfer rate from primary care to secondary care during labor was 22.9%, and 12 if the delivery-related deaths occurred in those who were transferred. The number of intrapartum stillbirths was also higher in the group that began labor in primary care. The study excluded all instances of congenial anomalies.
This study calls into question the belief that the best and safest care for low risk births is low-intervention care. From the Discussion section of the paper:
This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels. Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes. Delay can occur at three moments. Firstly, diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours. Secondly, transport can delay treatment in case of an emergency. Finally, a delay can occur because the obstetrician underestimates the problem as the referred woman is a “low risk” patient. In addition, essential information can be lost during the referral. These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted.And this is in the Netherlands, where there is a universal standard for midwife education and there is supposedly to be a good system of transfer of care. Would having low risk women also be cared for by obstetricians be a better system for the Netherlands? That is basically what we have in the U.S., and we have a 33% cesarean rate. Cesareans increase the risk of maternal morality (see Deneux-Tharaux, 2006), though maternal mortality occurs much less frequently than perinatal morality does. Considering the increased risks associated with pregnancies and births in women with prior cesarean sections (see Kennare, 2007) , some of which impact both the mother and baby, I just don't see how this can be the optimal way to care for mothers and babies either. I'm not even going to try to answer the question of how many mothers (and any future babies they may have) should have to accept the risks of a cesarean section to save the life of one baby. It is something to think about.
The choices we have are between sets of risks. The absolute risk of a baby dying at all is low, especially if there is access to fetal monitoring and some level of emergency care (such as midwives who can perform neonatal resuscitation). When are talking about a rate of 1.39/1000, it means an individual has a 0.139% chance of it happening (and a 99.861% chance of it not happening)--and that's all primary care deaths in the Evers study, including ones who would have died no matter what kind of care they received. The risk of preventable death is presumably lower, though we don't know how much lower because there is no obstetrician-attended low-risk comparison group in the study. I don't want it to seem like I am trying to "explain away" the risk of preventable death. The statistics mean nothing when your baby is the unlucky one who dies. I believe in informed choice, and I believe you need accurate information to make informed choices.
After I wrote this post and was waiting to publish it (I usually space posts out further, but I moved this one up because I felt I needed get it out there), I saw this post from Birth Without Fear in my facebook newsfeed, and felt it applied to what I am trying to say. Like her, I am not here to advocate that you have a homebirth. I advocate that you look at the information, weigh your options, and make whatever is the best decision for you.