A Look At Homebirths

NB: I originally wrote this article three years ago for a different blog. Having now completed an obs and gynae placement I thought it would be a good time to re-release it. It’s mostly in it’s original form, though I’ve edited some bits of it.

Browsing my Twitter feed, I saw an interesting story pop up from Health Impact News. According to Judy Colhain, the American Journal of Obstetricians and Gynaecologists (AJOG) have ‘issued a warning to all doctors and midwives to refuse to attend homebirth under all circumstances. ‘ See the full text of Judy’s article here and see the full text of the AJOG statement here. I’ll be referring to them a lot so it’s probably a good idea to at least skim through them

Wow. That seems like a big step. You mean that if a woman was suffering a severe haemorrhage during labour, not one obstetrician would go to her aid? You’ll probably be unsurprised to here that this isn’t what they’ve said. They actually said that ‘We urge obstetricians, other concerned physicians, midwives, and other obstetric providers, and their professional associations to eschew rights-based reductionism in the ethics of planned home birth and replace rights-based reductionism with an ethics based on professional responsibility.’

In non-medical speech, this means ‘We ask every health professional involved in pregnancy and birth to act based on what is best for the patient, not based on what the patient thinks they should have.’

Just because a woman wants a homebirth it does not automatically make it an obstetrician’s responsibility to let her have one. It is his/her professional duty to tell the woman what is the best course of action based on the collective published evidence and to act upon this. If the obstetrician feels a homebirth is appropriate and safe, then here in Blighty at least, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) approves them. I happen to agree with them, and think wider use of midwifery led care in appropriate cases would help ease the considerable pressure maternity units are under. The AJOG disagrees with on this issue, and that is their prerogative, though I think they are probably a bit over zealous,

Continuing through her article, Mrs Colhain quotes the AJOG as recommending ‘that all obstetricians and other concerned physicians, midwives and other obstetric providers, and their professional associations not support planned home birth… refuse to participate in planned home birth.. and recommend strongly against planned home birth’. Note the ellipses that Mrs Colhain has correctly used. For the non-grammatical amongst you, an ellipsis is used to indicate where someone has omitted words from a quote. Or in this case, taken a quote out of its context to make it support her own position. The above quotes actually comes from a sixteen line paragraph. Mrs Colhain has also changed the order of these quotes and changed the wording of them. Hopefully, I’ll clarify the picture for you.

This is what the first part of the above quote should say –

We call on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.’

The AJOG are recommending that health professionals support a safer yet still compassionate alternative to homebirths, and that even in hospital, the experiences should be ‘home-birth-like’. Having seen a labour in a hospital birthing pool, I can attest that it was a very relaxing experience. The scented oils, classical music and copious amounts of tea made me very comfortable. Can’t speak for the lady giving birth.

The second part of the quote comes from earlier in the paragraph and put in context says:

 ‘refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth’.

Yes, the AJOG are recommending that health professionals don’t participate in homebirths as they are generally less safe and often, women who choose homebirth end up being transported to hospital due to complications. For example, the lady I saw in a hospital birthing pool ended up transferring for an emergency C-section. I’d say it was a good job she was in hospital, rather than in her living room.

As we can see from above, doctors will still give care to these women, somewhat ruining the ‘people-in-hospitals-are-monsters’ angle that the article is seemingly going for. This also explains why the Royal College of Obstetricians and Midwifes here in Britain thinks home births are OK. Generally in Britain, you are very close to an obstetrics unit if something goes wrong, as Britain is a minuscule island. In the US, there are large stretches of the country without easy access to an obstetrics unit so home-based difficulties are much likely to cause morbidity or mortality.

The third part of the quote is mysterious. Certainly, the words Mrs Colhain quotes never seem to appear in the article, I can’t find them anywhere and neither can the search function of Microsoft Word (other word processors are available). Strangely what I think Mrs Colhain is quoting appears earlier in the article, and she appears to put this quote last solely for a dramatic finish. I’m going to be extremely generous and suggest that the changes in words and order were not deliberate obfuscations but she was merely paraphrasing for ease of reading. Let’s compare what should have been written and what was actually written next to each other.

QUOTED: and recommend strongly against planned home birth

ACTUAL: respond to expressions of interest in planned home birth by women with evidence-based recommendations against it

As I have highlighted above, Mrs Colhain neglects to mention a small thing. What’s that? Oh, just the small fact that the evidence goes against her position. Which, when you’re trying to be persuasive, is not the best of things.

Next, Judy Colhain talks about the ‘splendorous diversity of human conditions’ after a long list of reasons that may cause a woman to choose a homebirth. This doesn’t alter the fact if something goes wrong, which it can often do, then the hospital is a much safer place to be. Yes, it would nice if every woman could give birth at home surrounded by family in comfortable conditions. But the cold hard truth is that this would probably result in more mothers dying in childbirth. Something to think about.

Mrs Colhain states that ladies that have embolisms may die in hospital anyway, the mortality rate in hospitals being 27%. To me that shows the three quarters of ladies would survive. Now I don’t know about you but I think suffering an embolism in a homebirth scenario might have a slightly worse survival rate than 73%. I’d also like to point out that the statistics she gives are for amniotic fluid embolisms, and not the much more common thromboembolism. Why does she assume a lady with an embolism would have an amnoitic fluid one? I’ve absolutely no idea.

I’ve split this article into two parts – I’ll post the link to part two here when it’s published

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