http://www.homebirth.net.au/2008/04/breech-birth.html

Aishwarya, I appreciate your comment. Of course I don’t mean to blame women in any way. So I’ll just say that, especially in reference to this video/post on breech birth, that a lot of what the medical community perceives as ‘complications’ are not necessarily so.

Erm. I find myself rather disturbed by the way you’ve framed this statement. If a breach birth does turn out to be a serious complication for a woman giving birth at home, are we to assume that it was her fault for having insufficient belief in her ability to give bith perfectly?

I realise this probably sounds rather petty and nitpicky. But words matter, and while I’m in favour of people choosing natural childbirth (as I’m in favour of people choosing anything related to their bodies) I feel that a tone of judgement has come into this debate (wherever I’ve encountered it) that implies that “natural” childbirth is somehow morally superior to medically assisted childbirth. That women should be/are just inherently able to give birth and if things go wrong they’re just not trying hard enough. Which is precisely the sort of thing feminism tries to avoid.

But I am not gutsy enough to explore an unassisted birth. While I agree that I dont want to be treated ‘sick’, nor do I want to get periodic checks done, I still feel that I am safe when I have a doctor (with all scary gadgets, of course) attending on me when I am ‘pushing’.

And about the supine position during labour, never knew all these things! I felt comfortable as they propped a couple of pillows beneath my back on the labour table.

But I will have to thank you for one thing – I had after my daughter (normal delivery), decided to avoid a normal delivery and have a planned c-section. I have doubts about it now. I am not pregnant yet, but I think when I have my next one, I would brave myself up for a normal delivery again, unless complications arise!

a) No, things haven’t changed in the last 12 years. Or if they have they’ve only got worse. An April 2008 study of booked home births in England and Wales in the BJOG finds some evidence of an increase in IPPM rates over the 1993-2004 period – this while the overall IPPM rates for the population were improving. Commentators have linked this increase to a paucity of trained midwives.

b) Yes, I’ve read the 2005 study. Did you notice that it’s a study only of ‘low-risk’ women, and systematically excludes high risk mothers from its sample? Did you also notice that 12.1% of the women in their sample who planned to give birth at home eventually had to be transferred to hospital? And did you notice that their sample consisted of home births attended by “certified professional midwives”? What the study says therefore, is that home births have comparable outcomes to hospital births for low-risk women who can be safely and quickly transfered to hospital in case things go wrong and where the home births are attended by trained professionals. Which is what I was saying in my comment. Any other conclusion from that study is your own, and potentially false.

c) As I’ve already said, the “thousands of women who’ve given birth unassisted” point is irrelevant. If the probability of complications is a fraction of 1% then obviously thousands of women will and could give birth unassisted – no one is disputing that. The question is whether giving birth at home increases the probability of an adverse health outcome significantly. In the BJOG study, IPPM rates for women who planned home births and needed to be transferred are 5 to 9 times as high as those for the overall population. They’re still under 1%, so the vast majority of women who had to be transferred to hospital during home birth came through safely, but they were at 5 to 9 times higher risk of losing their children as the general population (admittedly there are some selection issues that the study doesn’t control for, which is why I didn’t link to it the first time around, but still, it’s something to think about).

d) You say “the unquestioned assumption that birth must neccessarily be safer just because trained professionals are present really needs to be examined in my view.” Okay. How do you propose we do that? Nothing in your post suggests to me that that is not true (I’m still trying to figure out the point of the Laurie Morgan post – so someone wrote a nicely worded blog post. Big deal. As for the c-section article, it’s not comparing morbidity rates for home births at all, is it, so how does that help?). The only way to test that assumption would be to randomly assign women to condition where they gave birth without trained professionals and compare their health outcomes to a control group who were attended by trained professionals. I can’t imagine any ethics committee in the world okaying a study like that.

As I’ve said before, I’d love to see a scientific study comparing health outcomes of planned home births in India to hospital births. I’d also love to see a study that compared the health outcomes of high-risk women who chose to have home births without a professional present to those who had their children in hospital. Until we have such studies (and I doubt we ever will, because of the ethics issues involved) let’s be clear that the only scientifically valid conclusion we have is that home births are no riskier for low-risk women when attended by trained professionals and where transfers to a hospital are possible.

If you’re claiming more than that – and you are – you need to provide evidence that the risks to mother and child – however miniscule – are not going to go up. Or you need to argue that even if the risks do go up the additional risk is worth it. In either case you need to stop pretending that the research supports any conclusion more than the one outlined above. You want to make a sentimental case for unassisted home births, fine. Let’s be clear that there is no research to support the view that unassisted home births are, in all cases, as safe as hospital births. Nor is there any research to suggest that hospital births have worse outcomes than unassisted home births.

Whether or not you think I am irresponsible for my views, I also think it is irresponsible for people to wholly rely on doctors, who are as fallible as we are. Admittedly, the question I posed of why we are more willing to give doctors authority rather than our own instincts is too big to broach here. But the unquestioned assumption that birth must neccessarily be safer just because trained professionals are present really needs to be examined in my view.

It’s funny to me that you mention ‘opinions based on anecdotal evidence from news stories and personal accounts’. What about the countless women whose unassisted birth stories have gone untold, because there was nothing remarkable about them? If you call faith superstition, then perhaps you believe in science, which in any case is largely behind the theory of evolution. Women’s bodies are designed to give birth, and certainly have done so for millions of years before current obstetric practices were invented to ‘facilitate’ this process.

It is with sadness that I am bringing up a recent death in my extended family here due to repeat c-section, and I link this to the following study: http://www.greenjournal.org/cgi/content/abstract/107/6/1226

Rixa ( http://rixarixa.blogspot.com/2008/04/april-is-cesarean-awareness-month.html ) also directs us to a study showing that repeated Vaginal Birth After Cesarean (VBACs) become safer and more successful, though this is is not the current medical norm. The link is: http://www.greenjournal.org/cgi/content/abstract/111/2/285

I digress away from the discussion on the safety of homebirth/unassisted birth because I think it is crucial that we evaluate our deep-held beliefs that 1) birth is always a dangerous process, and 2) hospitals and doctors automatically make birth safer.

Lastly, I want to direct you to a long passage from a book called “The Power of Pleasurable Childbirth” by Laurie Morgan posted here:
http://homebirthissafe.blogspot.com/2007/03/birth-as-sexual-event.html

“Life itself is dangerous it’s true, and sometimes unfortunate things happen to perfectly good people. But just as healthy people would not take up residence in a hospital for fear of dying, it is insane to approach childbirth – a normal, healthy function of the female anatomy – with the focus on pre-empting disaster.

Our normal bodily functions are absolutely not made safer by monitoring and interference. Even the mere observation, or subtlest alterations, of childbirth processes have the potential to adversely affect the intricate organic symphony that plays out best in privacy and security. But childbirth itself – when it is naturally free from obstruction — is as trustworthy as breathing. Eventually we all must come to terms with our human frailty, but the fact that tragedies exist must not be accepted as an excuse for the blind application of unnecessary “safety measures” that actually cause harm. Giving birth unassisted is a responsible, safe thing to do for all but the microscopic percentage of women that have such serious medical conditions as to make even everyday activities a challenge…

We “mere mothers” are smart. Not only that, but by sheer virtue of our anatomies, women are the preeminent experts of our own bodily functions. Having previously been discouraged from taking up that role does not change the facts: women are created able to give birth without any assistance at all. We mustn’t be afraid to shout this truth from the mountain tops. If women can be trusted to care for their bodies during pregnancy and then to nurture their offspring until maturity, women can surely be trusted to make the right choices in childbirth, even if that means choosing to give birth unsupervised.”

Personally, I think the best summary comes from the editorial of a 1996 special issue of the BMJ on home births:

“General practitioners and midwives have responsibility for creating the right circumstances for safe and satisfying home births. This means, firstly, selecting women who are not at high risk of complications; secondly, establishing an infrastructure for safe obstetric interventions–such as providing elevated beds and ensuring adequate hygiene; thirdly, providing support during labour and in the days after delivery, for which maternity home care assistants are important; and, finally, allowing access to hospital facilities–this is vital, as serious complications during labour can never be excluded. Transfer during labour can be safe,6 7 but safety must not be assumed, and the availability of obstetric care must be established beforehand. Coordinated planning between primary care practitioners and obstetricians is crucial, and much will depend on local conditions: hospital facilities are usually available within 15 minutes in densely populated Holland, but transfer will take much longer in remote areas of North America and Australia. Such variation underlines the importance of comprehensive care for pregnant women. This should focus on patients’ individual needs, based on a proper assessment of risk and local circumstances, rather than simply accommodating patients’ demands.”

So: home birth may be an equivalent (not necessarily better) option for low-risk women (assuming low-risk is competently assessed) with adequate home conditions and rapid access to hospitals, who are attended by trained professionals (a category in which, I, for one, would not include dais).

I’m not aware of any research that scientifically examines the health outcomes of planned home births in the Indian context, and I’m not sure such a study would be feasible given the selection effects involved (though it would be worth trying, certainly). Extrapolating from studies in developed nations context is problematic, given that they’re really talking about a very different paradigm of ‘home birth’, but even if we are generalizing from such studies it’s clear that an unbiased look at the research suggests that home birth is only a safe alternative in selected cases and assuming appropriate safety conditions are met – advocating home birth without consideration of those contingencies is just plain irresponsible.

Henci Goer’s site and book has research based evidence about the safety of homebirth: http://www.hencigoer.com

Also, there are links to studies on Homebirth Safety/Advocacy here: http://www.gentlebirth.org/archives/homsafty.html

Ttraditional knowledge is not always accurate. Just as an example, my grandmothers and their grandmothers absolutely forbid eating gooseberries (amla or nellikaayi as we call them), guavas and sometimes even bananas and tender coconut during pregnancy and for a couple of months after the baby is born. I find this most ridiculous. Of course, there are many sensible practices that ought to be followed, but we really need to be sensible enough to reject the stuff that is absolute hogwash.

C-sections are – well, different. There are many people who consider it a minor surgery, and that it is safer for both the mother and the baby to be delivered this way! (My MIL is one, she had both her deliveries through C-section). I was initially influenced by her, and actually asked my gynecologist to do a C-section on me without even attempting a normal delivery! After a lot of counselling and reprimanding from my gynecologist, I had a normal delivery and am darned happy about it.

The solution, IMO, is to find a middle-ground. As long as there are no complications and a trained person available to intervene in case there is one, home-births should be fine.

I will say that in the book, “Three Cups of Tea,” about an American man who primarily builds schools in Pakistan, there is an example that is pertinent to this article.

I don’t have the book in front of me, so going by memory, this man’s organization assists villages per their needs. In one village they had no running water. There were many deaths, many childbirth related infant and maternal. The assistance they gave this village was running water as well as basic first aid medical supplies which were placed in the care of one woman who was not a doctor nor medically trained. (I believe they may have done other things to help the villagers be able to improve themselves economically.) In the following 5 years there were NO deaths in the village.

To me this means that birth is safe, and that sanitation, education and basic first aid improves birth outcomes. Medical assistance can be necessary at times, but for the majority of women homebirth is safe and women deserve the right and the information and support to choose for themselves.