Home Births

For a variety of reasons, this post is about home births.

I ran across this post (courtesy of the folks at MedBlogs Grand Rounds). I was hoping to find something concrete to reinforce my grudging acceptance of home birthing, as there does not seem to be very much that is scientifically unfavorable out there. Well . . .

Louise (the blogger here) cites an article that shows that outcomes for low-risk women who deliver at home are just as good as those for low-risk women who deliver in a medical setting. I tend to agree with some of what Louise says in the post, like the fact that"medical doctors are a vital part of health care. But they are not the only piece of the puzzle, especially when it comes to childbirth." It makes me think of the countless times I have attended a woman who had the "misfortune" (that's sarcasm, folks) of delivering outside of the hospital; better yet, for how many deliveries does the doctor arrive late?

But there are a couple of points that I can't agree with.

"A long, painful birth in an of itself is not a medical problem." For you, Louise, perhaps, but not for every woman. Painful birth does not harm the mother, although the Scientologists might argue about its effects on newborns. You know, you can go to the dentist and have your teeth extracted and filled without anaesthetic, too, but it's not how I would choose to spend my afternoon. Some women are highly motivated to deliver naturally, but to imply somehow that it is superior to a hospital birth is a bit much to swallow. Not even the study which she cites claims as such.

The study does seem to be well constructed, but I find it interesting that the vast majority of the women were white (89.4%), middle class (59.9%), and non-smokers (94.1%); I suspect that this does not reflect a typical mix of patients in the United States (the study was Canadian-based, but supposedly drew patients from North America). It would be prudent to know what the statistics would be for a more realistic mix of patients. I was also surprised that in the paragraph "Outcomes," the authors mention an actual total of 18 intrapartum and neonatal deaths, but excluded 7 of those 18 (38.8%) in their calculations, for reasons that I am not sure are methodologically valid. And even though the authors admit that "Breech and multiple births at home are controversial among home birth practitioners," there were still 80 planned breech deliveries at home, and 13 sets of twins delivered at home. How did these pregnancies get assessed as "low-risk"? I agree that this study is an important one in actually elucidating the risks and outcomes involved in home births, but it is not the definitive answer.

Louise is not a fan of ACOG. "Unfortunately," she states, "ACOG would like to impose artificial time frames on a natural process that was never set up around a clock or a doctor’s schedule." Whoa--there are no time frames imposed on the birth process. There are practice guidelines that are set up (some proposed by ACOG, some by other entities) that serve as suggestions in improving patient care and outcomes. They are based on actual, peer-reviewed research and studies on patients in labor and what happens when certain events occur in certain time frames. ACOG is not a bunch of old guys sitting around making up numbers to torture women with.

Louise continues: "The conflict of interest for ACOG and the AMA is glaring like a neon sign." How is concern about women's health and childbirth a conflict of interest for ACOG? Oh, wait, she explains it to us: "Every woman who chooses to give birth at home with a midwife means one fewer patient for ACOG. That’s pretty much the whole story."

Huh? ACOG isn't in the business of taking care of patients, doctors are. A woman who gives birth at home, or in a car, or at the hospital probably has no idea who ACOG is or what they do. "So ACOG and the AMA have chosen to take the undeniably sleazy route of hiding their primary interest (money) under the thin disguise of being concerned about the safety of mothers and babies." This statement is so ridiculous that I don't know what to say. Maybe she equates ACOG with BigPharma and the whole military-industrial complex run by the Rothschilds. Exactly how does ACOG make money when a woman delivers?

According to Louise, "each woman should be able to labor and birth where she is most comfortable, and have access to competent, licensed caregivers, regardless of where she chooses to give birth. It seems that ACOG and the AMA do not want to offer me that same measure of respect."

This is an admirable sentiment; I trained alongside midwives as a resident in Texas, and I found them to be knowledgable, competent and compassionate caregivers. But each woman should be offered appropriate info about the benefits as well as the actual risks of home birth, and I am not sure that this is being done. The statement that "midwives generally don’t accept unhealthy women or high risk pregnancies" made me cringe. As opposed to the midwives that I associated with during my training, many of the midwives (licensed and unlicensed) that I have encountered in private practice have seemed unwilling or unable to correctly assess high-risk conditions such as a previous C-section or diabetes.

I could go on and on. What's the bottom line? Louise presents one well-done study suggesting that outcomes in low-risk patients are comparable (not superior) for homebirth and hospital birth. Much of her post is spent demonizing two influential medical organizations, without backing up her opinions. And that's pretty much her "whole story." I was hoping for something a little more constructive.

I am not a fan of ACOG (nor a current member). I have become more open to the idea of home birth as a result of my lovely wife, and her experience with the process. She delivered at home 4 years ago, attended by a midwife. Her older daughter was born at Charity Hospital in New Orleans (I tell Nika that a lot of famous people were born there, but I'm not sure she believes me), and although it was not a bad experience, she much prefers the home birth experience, which for her was extremely positive and healthy. I no longer argue the point with her; who am I to argue with that success? Even though I haven't run across any negative studies comparable in scope and construction to this positive one, I still have some misgivings about it, but I think I deserve some credit for being very open to the idea.

I won't even go into the issues of depth of training, or the malpractice issue (hey--you want to jump in the water, maybe you should swim with the malpractice sharks just like us docs have to do). It's a neat idea to be able to categorize patients into high-and low-risk categories, but it can also be dangerously misleading, for a simple "low-risk" patient can turn into a obstetrical catastrophe very quickly.

I'd like to see more studies like this one. I'd also like to see less posturing by both sides; we don't need ACOG talking about the need to "legislate" the issue, and we don't need Louise or Ricki Lake generally bashing the medical establishment. The word of the day is evidence-based medicine, and not anecdotal-based medicine, something that has been practiced for far too long. More evidence, less rhetoric.