HOMEBIRTH: AS SAFE AS BIRTH GETS

Each year in America, approximately 1% of the births occur in home settings. In Illinois in 1992, 1,218 families filed birth certificates that reflected a homebirth. Approximately one-third of the births occurred to Black families. Wisconsin had 591 recorded homebirths for the same year of which 22 were to Black families. 1 It is probable that many more Illinois homebirths actually took place but weren't recorded due to a discriminatory birth registration practice that places the responsibility for registering midwife-attended homebirths on the parents and requires a different mechanism than is used for any other occurring births.

One measure of the safety of birth place is infant mortality, specifically, neonatal deaths within the first 28 days. According to the Center for Disease Control, there were 19,098 neonatal deaths for 1990 for babies born in a hospital. For those babies born at home, there were 260 newborn deaths. Infant mortality is figured as the number of deaths per 1,000 live births. The death rate for babies born in the hospital was 5.6 and for those born at home was 11.1, which would seem to indicate that a hospital is a better bet for a baby's survival. However, when the homebirth statistics are further broken down into who attended the birth, the picture changes dramatically. Direct Entry Midwives had the best outcomes with a death rate of 1.9 compared to CNM-attended births (2.9) or physicians -- D.O.'s (15.1) or M.D.'s (24.7). 2

History Until 1900, homebirth was the place of birth for most every American. In fact, over 90% of those alive on earth today were born at home! Hospital or institutional birth is a relatively new occurance which began to gain in popularity during the 1920's due to physician promotion and the increased use of the automobile. As is the case today, it is a much more economic use of a physician's time to attend patients in a single place. There is also an economic incentive since a physician can attend to more than one patient at a time in the hospital and other, less important helpers can attend to the more mundane tasks of birthing.

Part of this shift in birthplace must be attributed to the propaganda denouncing midwives which took place during this same time. With their economic and organized power, physician groups were able to legislatively increase hospital births by eliminating those who still attended homebirths -- by eliminating the midwife. From the 1930's through the 1960's state after state changed their laws to either restrict the practice of midwifery or wipe out the legal practice entirely. Yet no valid study then or to date has proven planned homebirth to be less safe than hospital birth.

Studies

Many studies have been done in an attempt to prove that hospitals are the safest place to birth. Some of the earlier ones included all births which took place out of the hospital regardless of the gestational age or planned place of delivery. Those studies included miscarriages which took place at home as well as precipitous births and births that were unattended. To be valid, a study must compare equals and change only one item. Lewis Mehl did this when he matched 2,092 women and compared their birth outcomes. The result was that homebirth with a trained attendant was safer than a hospital birth.

What does "safer" mean?

Most families do not want to know the statistical odds of having a good outcome, they want to know more concretely exactly how a homebirth will be safer. Many studies address this by listing criteria and comparing the results. For example, Lewis Mehl's study listed the percentage of mothers with various complications:

As you can see from the chart, many complications seem to occur with greater frequency in the hospital. Many women are told they will need an episiotomy in order to prevent tears but the data from these births shows that this is not so since there were 9 times as many tears in the hospital group! Fetal distress, often cited as the complication necessitating a cesarean section occurred 6 times more frequently in the hospital group. There were 4 times more newborn infections, 22 times more forceps deliveries, 30 times more birth injuries and 3 times more cesarean sections in the hospital group.

Estimating Preventable Childbirth Related Deaths

The following statistics, derived from data accumulated between 1940 and 1980, are conservative estimates of lives lost due to our system of treating pregnancy as a medical event requiring medical intervention and care. *about 1,000,000 babies died at or before birth that should have lived * about 1,600,000 babies died before their 1st Birthday who should have lived * at least 1,500,000 children were left severely brain damaged by medical procedures * at least 45,000,000 children had minimal brain damage who would have been normal Today, it is estimated that 50 newborns die unnecessarily each day whose deaths are preventable if "the five standards for safe childbearing" were employed. This breaks down into a preventable baby death every 29 minutes, every hour of the day, each day of the year. NAPSAC writes, "Since 1940 at least a million babies have died in American hospitals who would have lived were it not for the doctor dominated maternity system that dictates the Standards for American Childbirth."

Who should decide what is safer?

Childbirth is not a laboratory project that can be reproduced at will with the outcomes compared with each other. Nor is birth a medical event, like planned surgery, that can be timed, controlled or forced to obtain the desired outcome. Each year, it seems, scientists discover some aspect of birth that had been unknown or unverified. Also, it would seem that the technologies that are initially hailed as the "cure" for a certain problem are found to produce unacceptable side-effects or increase risks for more serious complications. Birth also has a psychological component which can place some women at incredible risk in a hospital.

A recent article in a prestigious magazine looked at homebirth and asked the question, "Is it safe? Is it ethical?" The physician writers concluded that homebirth has a "definite small risk" and that "hospital births entail a wider range of risks". They also felt that since the actual risk factors inherent in a home birth are very small, perhaps 1/1000, and the consequences of the birth decision will be borne exclusively by the parents, physicians should support parents who are willing to accept this risk so as to make the experience as safe as possible. The Oxford Perinatal Project also came to this conclusion after an exhaustive look at every scientifically valid study performed since the 1950's addressing aspects of care of pregnant and birthing women and their babies. Since science cannot prove homebirth to be less safe than hospital birth, I believe that each family has the constitutional right to choose where to give birth. I believe that until science can prove a detrimental effect on those who choose to birth at home, medical personal should support families in their decision. The InterNational Association of Parents and Professionals for Safe Alternatives in Childbirth, NAPSAC, shares this view and asks, "Who is to decide what is the optimal balance between medical and psychological risk? . . . It must be the parents."

Sources: 1. Center for Disease Control, "Live births by place of delivery and race of mother, 1992", section 1, Natality, page 246. 2. Center for Disease Control, "United States, Birth Cohort of 1990", Table 43, pages 2 and 5. 3. Litoff, Judy Barrett, The American Midwife Debate, pages 1-10. 4. Mehl, Lewis, "Scientific research on childbirth alternatives and what it tells us about hospital practice", NAPSAC, 21st Century Obstetrics, 1978, vol. 1, pp/ 171-207. 5. Stewart, The Five Standards for Safe Childbearing, pages 137-138. 6. Hoff and Schneiderman, "Having Babies at Home: Is It Safe? Is It Ethical?", Hastings Center Report, December 1985, pages 19-27. 7. Enkin, Keirse & Chalmers, A Guide to Effective Care in Pregnancy and Childbirth, Oxford University Press, New York, 1989.

NAPSAC is a non-profit and tax exempt organization that may be reached at Route 1, Box 646, Marble Hill, MO 63764, phone (314) 238-2010.

Some may argue that statistics do not tell the entire story, and that is true, but it is the best scientific way to diminish those who promote institutional birth as the only option for everyone regardless of risk status.

© Yvonne Lapp Cryns 1995

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