Safety Studies

"Wherever you feel the most safe and supported, is exactly where you should give birth."

-Genevieve Howland, Mama Natural

Why is it that as a country, the vast majority feel that homebirth is basically a death sentence for the unborn baby? Perhaps your feelings are not quite that strong, but ask any random stranger their thoughts, and you’ll get a lot of “more power to you,” and “there’s NO way I could deliver somewhere that doesn’t have a level 5 NICU,” and even, “why would you do that to your baby??” Do you know why you feel the way you do? You’ve probably never even considered homebirth before, and yet you inherently have alarms going off in your mind. “Today prevalent medical opinion is that "modern", i.e. Western obstetric-intensive maternity care saves lives and is part of development and attempts to bring maternity care excesses under control are retrogressive. The present situation in developing countries reinforces the idea that the only reason out-of-hospital, midwife intensive birth still exists in places is because modern medical practice is not yet available.” (Marsden 2001).

In the United States, the vast majority of women believe the only place to deliver their child is with a doctor in a hospital. Most have never even heard of homebirth, and despite having no knowledge on the subject, believe it to be dangerous once they do hear mention of it. Despite this however, homebirth remains the safest option for the majority of women in developed countries (Cheyney et al). In addition to the safety that comes from the mother feeling relaxed in her own home, homebirth is significantly less expensive and is covered by most insurances. The average non-medicated vaginal birth costs roughly 60% less at home than in a hospital. A 2014 study found that of 17,000 women who *planned a homebirth, only 5.2% needed a cesarean, only 4.5% needed an epidural or Pitocin in order to augment labor, and only 11% required a transfer of which the majority were for non-emergencies (Simkins 2014). In fact, according to a study by the American Association of Birth Centers, only 1.9% of transfers were due to emergency (Dekker 2013). The reason for including this study is because the study only included “true” birth centers, and not the somewhat deceptive hospital add-on birth centers. In stand alone birth centers, all the comforts of home are provided and they also have the same statistics as home as far as transfer rates, non-use of interventions, and cesarean rates. Yet another study performed by the New England Journal of Medicine found that women were less likely to be induced, had less vaginal tearing, and their babies were less likely to be admitted to the NICU. A 2013 study found women were less likely to have an instrument assisted birth and were also less likely to deliver a preterm baby (Benatar, et al 2013).

As Dr. Marsden Wagner stated in his "Fish can't see water: The need to humanize birth" article, most clinicians still rely on peer review to shape their practice. They use fellow doctors as a central element in developing and monitoring practice guidelines. This has failed. There are clear loyalties within practices to professional colleagues, leading to extremely biased practice. In a 1998 British study, 76% of practicing physicians surveyed were aware of the concept of evidence based practice, 40% believed that evidence is very applicable to their practice, and 27% were familiar with methods of critical literature review and, faced with a difficult clinical problem, the majority would first consult another doctor rather than the evidence (Olatunbosun, Edouard, Pierson 1998). Clinicians continue to believe in the dangers of out-of-hospital birth, despite the overwhelming evidence that it is safe for low-risk women. There are three assumptions that Dr. Wagner describes as plaguing clinicians:

“The first assumption is that in birth things happen fast. In fact, with very few exceptions, things happen slowly during labour and birth and a true emergency when seconds count is extremely rare...” (Marsden 2001).

“The second false assumption, that when trouble develops there is nothing an out-of-hospital midwife can do... A trained midwife can anticipate trouble and usually prevent it from happening in the first place as she is providing constant one-on-one care to the birthing woman, unlike in the hospital where usually nurses or midwives can only look in occasionally on the several women in labour for which they are responsible. If trouble does develop, with few exceptions, the out-of-hospital midwife can do everything which can be done in the hospital including giving oxygen, administering emergency medications, etc. For example, when a baby's head comes out but the shoulders get stuck, there is nothing which can be done in the hospital except certain maneuvers of the woman and baby, all of which can be done just as well by the out-of-hospital midwife. The most recent successful maneuver for such shoulder dystocia reported in the medical literature is named after the home birth midwife who first described it (Gaskin maneuver).” (Bruner, et al. 1998)

“The third false assumption is there can be faster action in the hospital. The truth is that in most private care the woman's doctor is not even in the hospital most of the time during her labour and must be called in by the nurse when trouble develops. The doctor "transport time" is as much as the "transport time" of a woman having a birth center or home birth. Even in hospital births, when a cesarean section is indicated, it takes on average 30 minutes for the hospital to set up for surgery, locate the anesthesiologist, etc. In one study of 117 hospital births with emergency cesarean section for fetal distress, 52% of cases had a decision--incision time of over 30 minutes.” (Chauhan, et al 1997). These are the reasons there are no data whatsoever to support the single anecdotal case, "what if" scenario used by some doctors to scare the public and politicians about out-of-hospital birth.” (Marsden 2001). “Another reason for the gap between evidence and practice is the excuses given by some physicians for why they reject evidence in their medical practice. These excuses include: the evidence is out-of-date; collecting evidence is too slow and prevents progress; I use clinical judgment and my experience; using anecdotal "horror stories" to try to prove the need for an intervention which the evidence has found unnecessary… In addition to these excuses, in maternity care common excuses include: our women have smaller pelvises (no evidence), our babies are getting bigger (no evidence), our population is not as homogenous (no evidence).” (Marsden 2001).

“So the idea is to conquer nature and results in the widespread application of attempts to improve on nature before scientific evaluation. This has led to a series of failed attempts in the twentieth century to improve on biological and social evolution. Doctors replaced midwives for low risk births, then science proved midwives safer. Hospital replaced home for low risk birth, then science proved home as safe with far less unnecessary intervention. Hospital staff replaced family as birth support, then science proved birth safer if family present. Lithotomy replaced vertical birth positions, then science proved vertical positions safer. Newborn examinations away from mothers in the first 20 minutes replaced leaving babies with mothers, then science proved the necessity for maternal attachment during this time. Man-made milk replaced woman-made milk, then science proved breast milk superior. The central nursery replaced the mother, then science proved rooming-in superior.” (Marsden 2001).

Looking at the physiological aspects of homebirth as well, it’s simple that nothing beats being at home. The landmark meta-analyses by the Midwives Alliance of North America, showed that in almost 17,000 cases of *planned homebirth there was no increase in adverse outcomes for mothers or babies. In fact, the study most commonly referred to by clinicians showing a threefold increase of risk to the newborns did not distinguish between planned homebirth, unplanned homebirth, or birth center births, which is what makes the 2014 MANA study so critical and influential. Previous studies have relied purely on birth certificate data, which only capture the final place of birth (Simkins, 2014). The 2014 study looked at medical records and only planned homebirth, meaning low-risk mothers and babies, and showed that both faired much better statistically at home compared to in a hospital.

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*Benatar, Sarah, et al. “Midwifery Care at a Freestanding Birth Center: A Safe and Effective Alternative to Conventional Maternity Care - Benatar - 2013 - Health Services Research - Wiley Online Library.” Health Services Research, John Wiley & Sons, Ltd (10.1111), 16 Apr. 2013, onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.12061.

*Bruner, J et al. "All-fours maneuver for reducing shoulder dystocia during labor." J Reprod. Med. 43:439-443, 1998

*Chauhan s, Roach H, et al "Cesarean section for suspected fetal distress: Does the decision-incision time make a difference?" J Reprod.Med. 42: 6, 347-352, 1997

*Cheyney, Melissa, et al. “Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009 - Cheyney - 2014 - Journal of Midwifery & Women's Health - Wiley Online Library.” Journal of Midwifery & Women's Health, John Wiley & Sons, Ltd (10.1111), 30 Jan. 2014, onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12172.

*Dekker, Rebecca. “National Birth Center Study.” National Birth Center Study II - American Association of Birth Centers, American Association of Birth Centers, 31 Jan. 2013, www.birthcenters.org/page/NBCSII.

*Hall M, Bewley S "Maternal mortality and mode of delivery" Lancet 354, p 776, 1999

“New Studies Confirm Safety of Home Birth With Midwives in the U.S.” Midwives Alliance of North America, 30 Jan. 2014, mana.org/blog/home-birth-safety-outcomes.

*Olatunbosun O, Edouard L, Pierson R "British physician's attitudes to evidence based obstetric practice" Br. Med J 316:365, 1998

*Rooks, Judith, et al. “Outcomes of Care in Birth Centers: NEJM.” Outcomes of Care in Birth Centers, The New England Journal of Medicine, 28 Dec. 1989, www.nejm.org/doi/full/10.1056/NEJM198912283212606.

*Wagner, Marsden. “Fish Can't See Water: The Need to Humanize Birth.” The Need to Humanize Birth... By Marsden Wagner., Journal of Gynecology and Obstetrics, 2001, www.wonderfulbirth.com/Services/ViewServices.asp?Ref=2312.