Nuance of Risk and Homebirth

The British Medical Journal released a study with the perfectly cromulent title of “Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study”. Damn, that was a mouthful. The full text of the article can be found online, and all the numbers referenced are pulled from their data tables. The authors divide a cohort of women into four categories, dependent upon where they plan on giving birth: Obstetrical units, freestanding birth centers, attached birth centers, and home. The women were all of similar risk factors, with previous cesarean sections, elective cesarean surgery of current pregnancy, presentation of preterm labour, presentation of complicating factors (such as gestational diabetes or pre-eclampsia), or no documented prenatal care being reasons that women were removed from the cohort. From their results section:

“Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome [adverse events for infants] were higher for planned home births… but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth.”

In sort of plain English: Women who haven’t ever had children had slightly higher rates of bad things happening to their infant in a home birth setting when compared to a hospital setting, but that midwifery attended births in a center had similar numbers of bad things happening as a hospital setting. For women who have had more than one child (and were classed as low risk), bad things happening to infants were equally rare in all planned settings. Fairly straight forward, and it’s tempting to make some quick judgments about who should be giving birth and where. However, there’s a bit of nuance to be found within the data that seems like it would be worth exploring.

Adverse events within the study were rare, so event categories lumped together mild, moderate, and severe events. This means that:

“…although many of the outcomes included in the composite are likely to reflect problems which occur during labour and birth, their long term implications for the baby are uncertain. For example, although moderate and severe neonatal encephalopathy are associated with development of cerebral palsy and long term morbidity, mild encephalopathy has not been associated with detectable longer term impacts.”

This means that we don’t have a good measure of whether or not adverse events in a particular setting are more or less likely to have long-term effects, or if severe adverse events are more likely to occur in one setting over another.

It’s also uncertain how these findings can be extrapolated to differing healthcare systems, as there are fundamental differences between the way that the UK medical system is run versus the US healthcare system or Canadian healthcare system. So, sorry, those of us in the US – our healthcare system is still especially screwed and I haven’t a clue what to tell you about what science says regarding where we give birth with well trained health care providers.

So, how to interpret this data? Nullip women (women who haven’t had children) have a higher chance for adverse effects! Opponents of home birth have argued that this study supports the position that home birth is never an acceptable option for first time mothers. These critics have gone so far to say that no matter how carefully you slice and dice the data, giving birth at home increases the risk of perinatal death and brain damage.

This data cannot be applied to policy in isolation. The absolute risk factor of perinatal death should not be the sole deciding input on where a woman plans to give birth. All risk factors should be taken into account, and women are allowed to decide which rare risks are preferable and which are to be avoided. Not all risks are equal, nor are all risks apparent.

Amniocentesis is a routine procedure that is done for genetic screening, to check for metabolic disorders, and to screen for neural tube defects. These benefits are generally presented as acceptable for the level of risk involved for the fetus. The risk of pregnancy loss is 60 per 10,000 events. For someone who has an increased risk of genetic abnormalities (older nullip women, women with family histories of chromosomal problems or are otherwise high risk), this risk rate may acceptable. For someone with low risk or who doesn’t want to know, that risk rate may be unacceptable.

If amniocentesis has an acceptable risk of loss, for birth at home to be unacceptable, we would expect the risk of perinatal loss to be higher. This is not the case. The increased risk rate for perinatal death in a planned home birth as derived from this study is 8 per 10,000 in nullip women*. It seems as if the risk of giving birth at home is within standard tolerances for beneficial medical decisions, no?

Birth within an obstetrical setting isn’t a risk free choice, either. As noted in the study, intrapartum cesarean section rates for planned obstetrical births were 111 per 1000. The rates for planned home births were 28 per 1000. The authors don’t break down the division of nullip women versus multip women receiving intrapartum cesarean surgery, but the study’s rates can explain why a nullip woman may choose a planned home birth versus a planned hospital birth. Risks associated with cesarean surgery that expand beyond the immediate pregnancy are not addressed within this paper, but there are risks for decreased fertility, placenta previa, and uterine rupture for future pregnancies.

Nullips who are choosing to pursue a planned home birth instead of birth in an obstetrical setting are not choosing to pursue an increased risk of perinatal mortality versus no risk, but instead are choosing which risks to take on and which to mitigate. In either setting, the likelihood of poor outcomes are rare, with some outcomes containing long-term risks and others containing short-term risks.

It’s exciting to have good data and good numbers with which to work when making decisions about something as emotionally charged as birth. However, the temptation to look only at specific outcomes and adopt a very black and white attitude towards interpretation of results ultimately is a disservice to people seeking guidance and attempting to make informed decisions based on science based medicine. And, at least within the UK healthcare system, it seems as if there are many viable alternatives to obstetrics attended birth for low-risk women.

*As Henci Goer of Science and Sensibility notes, the confidence interval for this particular measurement overlaps, which means that we don’t count the 0.8 per 1000 as statistically significant. But for the purposes of our discussion, we’ll pretend that there is a real difference and go from there.

Michelle Bell

Michelle is an aspiring cat lady and managing editor of Queereka. Only one of these causes her partners to have much chagrin. She lives next to the most phallic water tower in the United States and occasionally gets paid to play with pregnant ladies and their families while she goes to school to become a nurse. She also has an unhealthy lust for infectious disease and vaccines. You can follow her on twitter at @MerrieMelodyxx for updates on her obscene coffee and whiskey habits.

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  1. The problem is that while you are examining things in a sensible and rational way, and weighing risks/costs/benefits and so on, a lot of women make decisions based on “OMG the medical conspiracy!” or “yes, but this is NATURAL!” This is often because of ignorance, or peer pressure, or whatever.

    Thanks for a good discussion, this is the kind of thing lots of women should be reading before making their minds up about where to give birth.

  2. That’s really interesting! I’m so glad to see that real research is being done on this.

    I have a question for any UKers in the audience: How are midwives/home birth attendants in the UK certified (if at all)?

    As Michelle noted, there’s an issue with extrapolating this to a different health care system since I assume that the level of education/experience of the attendant probably has a large impact if things start to go sour.

    1. @mrpopularsentiment: I don’t know about the UK, but I suspect it’s similar to Australia (where I live); we usually base our terminology on the UK system.

      Just like a specialist doctor (surgeon, obstetrician, paediatrician, etc), a nurse can specialise in some area (geriatric, psychiatric, etc.). A “midwife” is a specialist obstetric nurse.

      The qualifications required, therefore, are that you have to be a fully trained and accredited nurse, with the specialisation qualification too. As with general medicine and general nursing, it is illegal to practice midwifery without a licence.

      In other words, if you have a midwife-assisted birth at home, you’re getting the expertise of an actual, honest-to-deity, qualified and appropriately specialised medical professional.

      1. Thank you! The reason I asked is that this is how it is in Ontario, where I am actually fully in favour of a midwife-assisted birth (and had one myself).

        My understanding of the US system is that it’s much more complicated, with competing licensing boards that have different requirements, one of which focuses on ideology rather than medicine and doesn’t require anything more than a high school degree and apprenticeship.

        I imagine that this difference means that the UK really has no applicability in the US, and that we should be quite wary if we see US midwife groups citing it.

        I also think that relationships between midwives and doctors matter, just in case something goes wrong. When I was having trouble in my labour, my midwife could just go to the OB and consult. The staff OB trusted my midwife’s professional opinion, so no time was wasted duplicating tests. And because my midwife trusted the OB, she was able to do what the OB recommended and there was never an issue. Here in Ontario, each midwifery group is associated with a particular hospital, so my midwife had worked with the staff at my hospital many times before and they worked smoothly together as a team whenever needed.

        If in the US, you have some midwives with an ideological bone to pick with doctors, and doctors being angry that unqualified midwives are given charge of women and babies both going through one of the most dangerous times of their lives, I imagine that this hinders quality care if anything goes wrong and a transfer becomes necessary.

  3. In the UK, things, as I understand it are a bit different. Midwives are respected members of the medical community. But they are different here (and I’m not talking about nurse midwives, who can do basically anything an OB/GYN can but prescribe certain drugs).

    For me, the line is how far away a surgeon is during labor and how well the baby’s vitals are monitored. When there is a cord accident, you have, what?, about 7 minutes to get the adorable little sucker out before you start having permanent brain damage. That’s the determinant for me. Is there a real surgeon closer than 7 minutes away and do you know when that clock starts ticking? Have your baby in a vat of yogurt, for all I care, but have a surgeon around. And you CANNOT predict a cord accident. You can’t. A perfect pregnancy can end in a cord accident without warning, a brute fact of reality. That’s why, when baby decides to blow this taco stand, you need to have a surgeon on hand. Otherwise, yes, the doctors are usually just catching babies for otherwise low-risk deliveries. (Though not always.)

    When you look at the statistics that home birth advocates cite, they invariably show that home birth has better outcomes, but those numbers are misleading. 49-hour labors at home end up in the hospital, and the actual physicians there take care of the midwives’ mess. And that’s a mark against the hospital in those studies. If a midwife says they’ve never seen a “bad baby”; they simply haven’t done enough deliveries to have an opinion worth listening to.

    7 minutes. Failure to monitor the baby or putting any unnecessary distance between your baby and a qualified surgeon are, in my opinion, unacceptable and unnecessary risks.


    1. That’s why I personally like the idea of birthing centers. That way, women can have more control over their birthing process while still being at or near a hospital (which is the case with most birthing centers).

      1. I’m a huge supporter of birthing centers. If it was up to me, that would be the default option, really.

    2. You raise an excellent point… but the phrase “blow this taco stand” in this particular setting is nauseating to me. :)

    3. That, for me, was the deciding factor in choosing the hospital. I totally lucked out, though, because the hospital I went to had just rebuilt its maternity ward and modelled it off birthing centres. So I had a really nice private suite with a huge jacuzzi bathtub and a chair that converted into a bed so my husband could stay with me overnight after our baby was born. It was a really good experience.

      And it makes me angry at the homebirth movement (as opposed to people who choose to homebirth). This “hospitals = bad, so let’s just stay home” mentality is counter productive. I’d much rather they put their energies into making hospitals positive places to give birth instead.

  4. I don’t think that I understand the crux of your argument. Amniocentesis is an accepted practice, despite the risk that it induces miscarriage, because it provides an amazing number of benefits. It can detect fetal abnormalities that might jeopardize the life or health of the mother, for instance. For you to draw an analogy between the dangers of amniocentesis and the dangers of home birth, you need to also describe the benefits of home birth that outweigh the danger, right?

  5. Midwives within the UK medical system have a masters level education that is similar to (and in some sense better established than) the Certified Nurse Midwifery masters education that you can receive in the United States. In the UK (and throughout the majority of the European Union) the midwives who attend birth at home are the same midwives that attend birth at centers and attached to obstetrical units. This is also true in Canada but definitely not the case in the United States

    I would contend that it is NOT the level of education that would not allow us to extrapolate this data to the United States (and to some extent the other places mentioned above). What is different in the UK system is HOW the midwives are integrated within the system and how seamless transfers are handled. There are well established connections and rules about how to risk patients out, how transfers happen, and they are pretty well adhered to. There is a continuity of care that is quite enviable and definitely offers benefits.

  6. RJB – one of the benefits of this study is that they delineate outcomes NOT on the basis on where the baby is delivered, but on where the intended place of delivery. Not that this helps the home birth advocates in the US who would really like to use this data as support for our (at best) haphazard lack of system.

  7. Jason, I struggled with brevity and levity versus thoroughness within this article so I can best match the tone of awesomesauce that we expect from Skepchicks. A statistics heavy post isn’t exactly the most thrilling thing to read (I read research articles for sorta fun, but this ain’t normal…), but I would recommend Science Based Medicine or Academic OB/Gyn for good forums to pursue further discussions that may be much more specific. Obligatory warning about a way too long comment to follow.

    Home birth (in this research article) brings benefits in what it avoids, the mitigation of specific risks as mentioned above. There is a pretty significant drop in cesarean sections, a decrease in interventions such as vacuum delivery, forceps delivery, epidurals and episiotomies. (I’m on my mobile, so I’m having a hard time referencing the specific numbers. I strongly encourage you to reference the data tables for the ratios of home birth versus obstetrical units).

    All of these interventions DO carry some small risk, usually to the woman’s body and health (although also to the fetus/infant). Very small and the big risks are very rare. Cesarean sections probably carry the highest risk in terms of impact on future fertility and reproductive experience, which is why I chose to use that example above as a juxtaposition to a non-statistically-significant difference between perinatal death.

    Clear the thought process up at all?

  8. “If amniocentesis has an acceptable risk of loss, for birth at home to be unacceptable, we would expect the risk of perinatal loss to be higher. This is not the case. The increased risk rate for perinatal death in a planned home birth as derived from this study is 8 per 10,000 in nullip women*. It seems as if the risk of giving birth at home is within standard tolerances for beneficial medical decisions, no?”
    Wait, heck, no.
    There’s a pretty big difference between having a miscarriage somewhere around week 14 and losing your fully developed baby after 9 months during birth.
    Therefore, I’d put the acceptable risk for the latter much lower.
    That doesn’t deny the problems that are there with rushing women into having an amniocentesis, but that’s another point of discussion.

    Yes, in most of Europe, health-care systems are very different from the USA, with the average distance to a hospital and especially with the quality of what we call midwives.

    “Home birth (in this research article) brings benefits in what it avoids, the mitigation of specific risks as mentioned above. There is a pretty significant drop in cesarean sections, a decrease in interventions such as vacuum delivery, forceps delivery, epidurals and episiotomies.”
    I fully agree that they do a cesarian way too often in hospitals. There’s actually more money to be had.
    But I would say that corelation doesn’t imply causation.
    Women who decide to have a home-birth are often women who educate themselves a lot (although no always in the right places), have their own opinion and are, in short, confident in their pregnancies and decissions.
    In a hospital setting, some types of OBs (and midwives) tend to make decissions over your head, or simply tell you what they’ll do now.
    Now, if that confident, educated woman is in a hospital, if in preparation she has chosen a team with whom she can work together, I would guess that the interventions drop drastically as compared to an uneducated, probably frightened (fuck the media, they’re so bad at portraying births) woman who’ll say yes to whatever the doc says.
    So, I’d say that the reason for the decreased level of intervention isn’t so much the setting but the mindset of the woman.
    Also, for some of those “interventions”, I disagree that it’s “beneficial to avoid them”. For some women, having an epidural is the one thing they need for having a positive birth experience. Not everybody is alike, and although epidural come with a risk, the alternative of having a traumatized woman is less acceptable. I’d guess that those women who consciously decide against pain-medication and see the pain as an essential part of their positive birth experience. I doubt that they’d get one in a hospital.

    Personall, I’d prefer birth-centres or good hospital-settings. I think the key in this doesn’t lie so much as in where to give birth, but how to treat and educate women.
    The key to my good, healthy births was not that I was in a hospital, they were very low risk and and the only difference between doing it in hospital and at home would have been the mess on the floor. The key was having a very good team of midwives and an OB/Gyn at my side who worked with me and respected my wishes and decissions. In turn, I could trust their advice.

    1. Not to mention that when faced with the actual pain and given the opportunity to mitigate it, it’s probably unsurprising that some women would elect for an epidural even if they hadn’t planned on it beforehand.

  9. When comparing the possible bad outcomes of a birth planned at home or in an obstetrical setting, it’s also useful to compare what kind of risks we are talking about in each case.

    All right, in this study, nulliparous women having a baby at home had an increased losing their baby (still birth) or of brain damage to the baby (neonatal encephalopathy). The most striking difference to me is the incidence of still births in nullip women: 0.9 per thousand in home planned births against 0.1 to 0.3 per thousand. At best, three times more often.

    On the other hand, for women giving birth in an obstetrical setting, the probability of having more procedures, like surgical sections, is increased, and these procedures each have a certain risk of adverse outcomes, including problems for future pregnancies.

    So there’s an increased risk of loosing your baby on the one hand, an increased of loosing fertility on the other? (*)

    I think I know what I’d choose, myself.

    (*) At least for low-risk nulliparous women, in a country where home births benefit from the assistance of trained and certified midwives.

  10. So I can only comment on how things work here in Canada, but I’d just like to point out that opting for home birth is not the same as opting out of hospitals all together. In Ontario, nurse-midwives will have privileges with a local hospital; should things go wrong with a delivery they’re not just going to be waving their hands helplessly. They’re going to get the woman to the hospital for appropriate medical intervention.

    Nor are women opting for home-births automatically science-hating or anti-medicine. I’ve had several friends have their first babies at home with attending nurse-midwives, and they’re some intelligent, science-loving, non-woo-accepting folks. Furthermore, they had only positive things to say about the experience.

    Home birth isn’t for everyone. Some women feel more comfortable in hospitals, and some women want a middle road with something like a birth center. And that’s cool! Balancing the health of ones baby with the health of the mother is a difficult balance to make, and it’s hard to point fingers because what’s right for one woman isn’t right for another. So let’s not demonize all women who opt to go for home birth as anti-medicine morons who hate their babies.

  11. From the table:

    Incident of events/1000 women (95% CI) for Nulliparous women:

    Obstetric unit 3.5 (2.4 to 5.1)
    Home 9.5 (6.6 to 13.7) 2.80 (1.59 to 4.92)
    midwifery unit 4.5 (2.8 to 7.4)
    midwifery unit 4.4 (2.7 to 7.0)

    So it appears that, for women giving birth for the first time, home birth does come with a rather substantial increase in risk for this sort of all encompassing measure of adverse outcomes.

    Also I’m not sure what you mean by saying home birth decreases risk of intervention? First, most interventions aren’t available at homebirth, so if you need one, you go to the hospital. In the study in question, ~35% of nulliparous women planning to give birth outside of a hospital were transferred to the hospital. Second, while interventions confer some risks, lack of them confer other risks. Is giving pitocin riskier for the child or pregnant woman then letting her labor for hours and hours? Is getting an epidural a greater risk than being in a great deal of pain?

    Finally, there is this idea that doctors just run roughshod over vulnerable women, but I have heard similar complaints about some midwives. People are people and some are more sensitive than others.

    1. If we’d like to talk about risk, we would want to choose specific factors to talk about — as the authors of this study note, they don’t do a good job differentiating between mild and moderate and severe instances of events, because instances of things are very rare. They also conflate a cervical fracture with perinatal mortality within those numbers you’ve quoted above. The reality that meconium aspiration and fractured clavicles and humerus, while serious in the moment, aren’t things that usually result in severe lifelong consequences for the infant. Minimising them is absolutely a worthwhile goal, but fracturing a clavicle to retrieve an infant is an effective technique for resolving shoulder dystocia. I’d rather attempt that than a cesarean section, as the clavicle will heal with little problems — cesarean section carries very real risks for future fertility and pregnancies and results in severely limited options for future birthing options. It’s not great implementation of science, but there are certainly places that have defacto bans on VBAC attempts (all of the hospitals in the Toledo Ohio area, for example).

      For the purposes of this study, all evaluations were done on where the family planned on giving birth, not where they actually gave birth. So, when I say things like “This study demonstrates a correlation between home birth and a decrease in intervention”, I actually mean that families choosing to birth with midwives at home (or, funnily enough, in birthing centers where interventions are available), opt to not access those interventions as often, even when they end up in the obstetrical unit because of transfer.

      1. Well, if I had to chose between pain and risk for me and pain and risk for my baby, I’d chose mine.
        The babe didn’t ask to be in this world, while I, as long as I live somewhere I have a choice, made the conscious decision to have that child, and made the choice to carry the risk.
        To say that inflicting that pain on a child is worth my lower risk for further pregnancies seems pretty cruel to me.
        But it#s risks you take and risks you don’t take and I think the place where you have the child is not so much the deciding factor:
        It’s the woman who does.
        The woman who opts for homebirth decides that she’ll set the bar for such interventions much higher than the woman who is in a hospital.
        You can hardly say what those women would have chosen if the options had been readily avaible.
        I had two vaginal deliveries. The first one was without any medication (my midwife cut me as I was tearing badly already. I know, the jury’s still out on that), the second one I opted for something to soften the mouth of the cervix because the baby was pushing hard and fast ( less than 40 min in the delivery ward).
        Could I have done so without? Sure, but it would have meant prolonged pain and exhaustion for me and prolonged exhaustion for my daughter.
        It’s about choice.

  12. What would stop me having a home birth (though the question is about to become academic as I proceed through my forties) is that the increased risk is not actually borne by me.

    I am essentially forcing another human being to take on an increased risk of death or disability.

    It doesn’t matter that the absolute risk is still small, that I would probably do all right and so would the child. This isn’t like a firefighter risking their life to pull me from a burning building – the individual in question has no agency over the method of its birth.

    Say you had to undergo a medical procedure; you have two choices, one of which doubles the small risk that you would die or be left disabled. The only one who benefits from the more dangerous procedure is not you. Which path would you take?

  13. There is so much ideology surrounding child birth.

    I would like to say to all the mothers-to-be out there, by the time your child is old enough to understand or care, he/she will not feel like you love them any less if you:
    have a water birth,
    get an epidural,
    have a c-section,
    successfully breastfeed for 2 weeks or 2 years,
    have him circumcised or get her ears pierced,
    sleep in a cradle, crib, or next to you,
    diaper with disposable or cloth,
    “wear” them or cart them around in a stroller.

    The kid doesn’t know your home from the hospital.

    1. Your kid will be very familiar with whether he got circumcised or not. :D

      And while of course your child won’t know if they were breastfed, studies show they will be smarter.

      I mean the bottom-line is that parenting is very important. If you agree with that you can’t argue that it doesn’t matter how you parent. Reminds me of how teacher’s unions promote the importance of teachers but simultaneously decry assessing teachers performance as unfair since out-of-school factors like poverty and parent involvement are the only things that matter. You can’t have it both ways

  14. “It’s not great implementation of science, but there are certainly places that have defacto bans on VBAC attempts (all of the hospitals in the Toledo Ohio area, for example).”
    This is a highly dubious claim.

    Ok, you’re in a Nursing program? Was this “defacto ban on VBAC attempts” something you encountered during your OB clinical rotation? What entity gave this decree?
    When I graduated (at a university in Ohio, BTW)and sat for the NCLEX (in Columbus, where the Ohio Board of Nursing held the RN licensure exam), the old “repeat c-section” standard of care was already becoming antiquated. That was 1986.
    By 1988 I happily jumped at the chance to leave the chaotic atmosphere of the Med/Surg floor. The OR was desperate enough for nursing staff, that they were interviewing candidates in-house for OTJ training. The Surgery staff was stretched pretty thin at the time. We were THE regional trauma center (complete with a heliport). Every surgery, emergency and elective, inpatient and outpatient, was performed in these 6 OR suites. We did everything from Open Heart, to Sports Medicine, to Cataracts, to appendectomies, to Nose jobs, to fractured hips, … laser surgery was getting popular, etc. On top of all these cases, we had to bump elective surgeries every day, hop the elevator to the L&D unit and staff all C-sections. Now, L&D has it’s own staffing for C-sections in most hospitals, including my former employer. So over 20 years ago, VBAC’s were something I was well aware of because we were put on notice. I honestly can’t even give an anecdotal estimate of how frequently they morphed into urgent c-sections. OR is such a task-focused occupation, especially c-sections. So discussing the patients history or observed trends, did not transpire during C-sects. The patient (mother) and a wide-eyed civilian (father) are respectfully spared the usual medical shop-talk which we typically indulge in the OR.
    So now in 2012, with the variety of locations and healthcare professionals competing for even Medi-Caid reimbursement, I can fathom how this could be the situation in a reasonably cosmopolitan area.
    But I wouldn’t put all this effort into writing this comment, unless I was less than sincerely interested in your extraordinary (or just adequate)evidence for this extraordinary claim.
    Is this a policy? A law? A standard of practice that applies to physicians and hospitals, but NOT midwives or birthing centers (I suppose anything goes at home.) Perhaps a credentialed midwife would jeopardize her license attending a home VBAC?
    Thanks, future comrade!
    Links would be great!

  15. I will also add, at the risk of derailing a Skepchick thread…
    the above hospital was Catholic. Founded and established by the Sisters of Mercy. Before I came aboard, the facility came under the auspices of Catholic HealthCare West (I moved to S. Calif about 6 months after I graduated. That NCLEX sure came in handy!)
    So I can confirm that tubal pregnancies and incomplete abortions (aka miscarriages) posed no ethical dilemma and received the appropriate interventions without hesitation. There is a lot of misconceptions thriving as memes in atheist-themed online communities, that I find disturbing.
    I hope this statement is within the boundaries of the comment policy of Skepchick management.
    I have 2 X chromosomes, if that is a relevant qualifier.

  16. THANK YOU for a reasonable, truly skeptical look at home birth. Too much “skeptical” writing on the subject is only skeptical of the natural birthing community (which, granted, does involve a lot of woo), while blithely buying into the assumption that the hospital/OB choice is zero risk.

    We need more rational people in the gray area between swallowing mainstream hospital practices without question and whackaloons who want a dolphin-assisted birth. Right now I think that gray area is occupied by you, me, and like 3 other people.

  17. I’ve had a slow skim and I don’t anyone has correctly described UK midwifery registration. RMs [registered midwives] are a stand alone profession. Training is by 2 routes: Direct Entry – 3 years of higher education in a university and associated hospital/s to achieve a BSc and registration; or Short Programme – only available to registered nurses which covers the same curriculum in 18 months. Direct entry now predominates.
    RMs are independent practitioners and can practice as self-employed, National Health Service [NHS – state sector] or private sector (although self employment will soon be unfeasible due to an anomalous situation in which EU health professionals will require liability insurance and no insurance company worldwide is willing to provide midwives with single practitioner insurance – long story).
    Regardless of practice RMs all follow the same code, supervisory system and training and are (intensively) regulated by the Nursing and Midwifery Council [NMC].
    In normal birth (a technical term about physiology, health and risk I personally dislike) RMs are the lead professional – higher risk women (RMs say ‘women’ not ‘patients’) have shared care with a consultant obstetrician (who may be the lead depending on risk or may pass this back to a named midwife).
    Training is rigorous and it is illegal for anyone to work with a woman as though that person were a midwife if that person is not registered with the NMC. RMs work with women antenatally, intrapartum and postnatally to around 2 weeks post-birth. In the NHS care is often fractured with different midwives taking different roles. All RMs have to accredit continuing professional development throughout their careers and retrain if out of profession for extended periods of time. This means all midwives should be able to work safely in a woman’s home, birth centre or consultant unit – in practice RMs tend to specialise.
    British RMs maintain that UK training is some of the most intensive and scrupulous in the world and have fought long battles to maintain midwifery as a specific profession in partnership not subservience to obstetricians.


  18. also on risk – I think the risk for homebirth for nulips of ‘big bad thing’is x3 [it’s a few weeks since I read the stats]
    But this is just not socially relevant – x3 what? the answer is x3 of a very small risk. [=still a very small risk]

    Evidence based medicine and healthcare has tried various ways to represent risk to non-statisticians so they can make informed choices.

    Most humans are not skilled at understanding risk and I think the following are important:

    women choosing hospital or homebirth are all doing so on the basis of protecting their child’s health.

    women are likely going to be more mindful of a risk to their child than a professional – so no *need* to powertrip them but very easy *to* powertrip them if it suits your practice.

    hospital birth has raised risk of many things but data is presented comparing 1* as hospital and RR as ‘alternative’ – I don’t think this is fair reporting or evidence based.

    a sad ps. the reason why abortion due to amnio is acceptable risk is because it costs the health service very little and may avoid the costs of healthcare needs over a lifetime for a person with impairment i.e. from Downs. Insurance claims for ‘birth injury’ i.e. leading to cerebral palsy are the largest single payouts in UK from the health service despite midwifery and obstetrics having a better safety level than many disciplines – as they are full life care payouts.
    so the insurance system is causing massive bias in risk perception and care options.

  19. Excellent post. As a lot of research has confirmed, sometimes it is the intervention that can be against the evidence, not the lack of intervention. Cynicism should equally apply to new interventions as it is to “alternative” medicine. Trying to retroactively investigate already common interventions in obstetrics, many of which did not stand up to the scrutiny well, was the impetus for the first Cochrane reviews.

    Speaking of an “A” evidence rating from the USPSTF and one of the most recent MeSH terms to be added to PubMed, it’s great to see a doula on here.

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