Canadian study finds mothers & babies much less likely to be injured in homebirth

Via Science and Sensibility, this new homebirth study out of British Columbia should be required reading for our Health Department and policy-makers: “Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician”[1].

This high-quality study compared equivalent-risk homebirths (HB), midwife-attended hospital births (Midwife-in-Hospital, MiH), and doctor-attended hospital births (Doctor-in-Hospital, DiH). In British Columbia, registered midwives are obliged to offer homebirth if the woman meets the eligibility criteria, so the study is not confounded for type of caregiver. Further methodological elaboration is below the cut.

The homebirth cohort included all births in British Columbia from 2000-2004 that were planned to take place at the woman’s home at the onset of labour. In-labour transfers were not excluded, so this was a true intention-to-treat analysis. 79% of the women who planned a homebirth had one, and 97% of the women who planned a MiH birth had one.

No Deaths Occurred At Home

The results are striking. Perinatal deaths in the planned-homebirth group and hospital groups were statistically similar: 0.35 per 1000 (95% confidence interval 0-1.03) for homebirth; MiH 0.57 (0-1.43); and the DiH 0.64 (0-1.56). Apgar scores were similar, and there was no difference in diagnoses of asphyxia at birth, seizures, or the need for assisted ventilation beyond 24 hours of life. None of the perinatal deaths occurred in births that actually took place at home.

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Birth Injuries Lower at Home for Both Mothers and Babies

Both maternal and neonatal injuries were lowest in the homebirth group. Severe perineal tearing and postpartum haemorrhage were significantly lower in homebirth groups, as were neonatal complications such as birth trauma, the need for resuscitation at birth, and the need for oxygen therapy beyond 24 hours. Infections were lower in the HB group, but the difference was not statistically significant.

Neonatal birth trauma such as brain haemorrhage, skull and clavicle fractures, and nerve injuries was reduced by 75% in the homebirth group (values are rounded; see the study for full details). The need for resuscitation at birth was reduced by around 75%, and the need for prolonged oxygen therapy was decreased around 60%. Meconium aspiration was also less likely at home (remember, transfers to hospital were included in the analysis).

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The only adverse outcome measure that was slightly higher in the HB group was admission to hospital (or readmission if born in hospital). This is hardly surprising, as the majority of neonatal admissions are for jaundice, which is typically recognised and treated before first discharge in hospital births.

Interventions Less Likely at Home

The rates of interventions in the HB group was also much lower across the board. Women planning homebirths had a 40% drop in augmentation of labour, 70% drop in narcotic analgesia, 60% drop in epidural analgesia, 60% drop in assisted vaginal delivery (vacuum or forceps), 25% drop in C section, and 50% drop in episiotomy (values are rounded; see the study for full details). All of these differences were statistically significant. Note that the total C section rate in Canada is around 26% and the section rate for DiH births for the lowish-risk women in this study was only 11% (!); C section rates in Australia are well above 30% (>34% in WA), so reductions with similarly supported homebirth in the Australian setting could well be greater, perhaps dramatically so.

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These reductions in intervention are quoted from the midwife-at-home vs midwife-at-hospital model. The differences between midwife-at-home and doctor-in-hospital interventions were even larger across the board, with particularly large differences in rates of episiotomy, electronic fetal monitoring, and assisted vaginal delivery.

Key methodological points:

* The number of births in each scenario was in the thousands (2899 homebirths, 4752 midwife/hospital births, 5331 doctor/hospital births.)

* Only hospital births where the woman met the criteria for homebirth were included.

* The hospital cohorts were matched with the homebirth cohort for age, parity, marital status, and hospital where the midwife had privileges; and data was further collected for age, height, prepregnancy weight, BMI, income, drug/alcohol/tobacco use, gestations age at first visit, number of antenatal visits, and history of ultrasonography in early pregnancy.

* Unmeasured characteristics that may be related to self-selection remain uncontrolled-for. (Further comment in the CMAJ by McLachlan and Forster addresses the issue of randomisation in homebirth/hospital birth comparisons, and alludes to the current Australian political situation).

* The aim was to compare perinatal mortality, perinatal morbidity, and obstetric interventions.

* Homebirth qualification critera: gestational age 36-41 weeks, no more than one previous C section, spontaneous labour or outpatient induction (with intravaginal prosta- glandins or amniotomy). Excluded from homebirth are women who have certain disqualifying conditions: certain heart and kidney diseases, type I diabetes, pre-eclampsia, antepartum haemorrhage, active genital herpes, and placenta previa or abruption.

* Note particularly that vaginal homebirth after cesarean section is supported under the BC system, an idea that gives Australian OB/GYNs the vapours, and the study also included births where the fetus was found to be breech after the onset of labour. Additional subgroup analyses excluded women having VBAC and women having outpatient inductions, but this did not materially alter any of the conclusions.

Are We Looking at Risk the Right Way Around?

One of the interesting meta-things about this study is that hospital birth was considered the norm for the relative risk analyses, the “1.00” to which homebirth was compared. Flipping the numbers and considering homebirth to be the norm would mean that we would have to talk about the relative increase in risk for neonatal and maternal injuries, and that in many cases the risks would be more than double. We would have to talk about how babies were three times as likely to get brain haemorrhages and broken bones in hospital births, how they were three times as likely to need resuscitation. How women were twice as likely to have their perineum cut open in hospital for no improvement in outcomes, how they were twice as likely to have an electronic monitor applied with no benefit, how they were more than twice as likely to have their baby removed with a mechanical device, how they were more than twice as likely to get a severe perineal tear.

I wonder how that would look, how that would be interpreted differently by the scientific and mainstream media? Would it have a different impact on you?

~~~

[1] Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician
Patricia A. Janssen PhD, Lee Saxell MA, Lesley A. Page PhD, Michael C. Klein MD, Robert M. Liston MD, Shoo K. Lee MBBS PhD
Canadian Medical Association Journal (CMAJ) 181(6-7), September 15 2009 (early release)
doi: 10.1503/cmaj.081869



Categories: gender & feminism, health, medicine, Science

Tags: , , , , , , , , , , , , , , , ,

20 replies

  1. Hooray! Thank you for such a beautiful exposition which demonstrates what logic already tells us. This wingnut says thank you!

  2. Should I just give up on feminists outside of the marginalised ‘birthing’ niche ever giving a shit about institutionalised assault? Would anything make any difference?
    Feeling very dispirited right now.

  3. Fantastic post Lauredhel. I’ve learned so much from reading your posts on birthing and I’m deeply appreciative of your work in tracking down and analyzing all the studies and media coverage. It’s good and important work, thank you.

  4. *hugs* mimbles
    All the stuff around disability and maternity, and how this particular intersectionality (along with others, of course) are so ignored by ‘mainstream’ feminism (whatever that is) really makes me wonder sometimes. The world explodes when there are threats to abortion rights, which is all well and fine for me as I’m thoroughly on that train too, but these other threats to women’s bodies just seem to pass with barely a whisper.

  5. There is a very real and very nasty perception out there that homebirth advocates are just dirty hippies. Also, a big “why wouldn’t you want to be in a nice safe hospital” attitude which shows that most people either don’t know or choose not to believe that homebirth is safer. Not to mention lots of ‘it’s better for the baby to be in hospital’ brainwashing.

  6. I’m not going to have children, but I’m still deeply interested in this issue and love reading your posts on it, Lauredhel.

  7. Lauredhel, I appreciate it deeply, just it’s almost triggery for me right now in a high risk pregnancy (I have some ongoing issues around medical anxiety). Activism around birthing choices and maximum safety and positive experiences and outcomes for mothers and babies is more important than I can say and I point people at your useful analyses often, and I know other women who do too.

  8. This actually feeds directly into a post that I want to write (when I get time *sigh*) about doctors’ perception of risk vs other people’s perception of risk, specifically re birth.
    Or rather, had been planning to write, until I saw this post and wondered if I actually have anything useful to add ;)

  9. Thank you for all your comments! I just had that brickwall feeling, you know? (I’m pretty sure we’ve all been up against that one from time to time.)
    Mindy: Interesting point about optics. Do you think this is related to the “hairy lesbians, you’re making MY feminism look bad” trope?
    Rebekka: Same here. I’m deliberately barren now (I hope), and hope to never find this a personal issue; but for me this issue ties in very deeply with bodily sovereignty, reproductive choice, violence against women, and kyriarchal control of marginalised bodies. With bonus dodgy science here and there and skewed risk perception, which is another of my bloggy interests.
    Mary: I hear you. Fingers crossed and vibes for your pregnancy.
    Jo Tamar: I REALLY want to read your post now. There’s a Canadian news article on this paper up, and I think the reader comments might be useful background or examples for your piece. Just let me find it again…Here: “Home birth with midwife as safe as hospital birth”. For doctor’s ideas about risk, a great place to start would be the (organisational and personal) submissions to the various maternity services reviews and legislative changes that have happened in Australia recently – I believe there were three separate batches of submissions, first with the Maternity Services Review and then with the insurance and registration changes. I could try to dig them out for you if you can’t find them.
    Another thing I find really interesting about the media around this study is that it’s being quoted far and wide as “homebirth is just as safe”, ignoring the fact that the study found that for this group, which would be considered low-to-medium-risk here (possibly high-risk in some OBs minds), it found that hospital birth was considerably more dangerous – if you consider injuries and trauma and haemorrhage and surgery to be poor outcomes, instead of conveniently only looking at outcomes that are in numbers too small to reach statistical significance (deaths).

  10. “Should I just give up on feminists outside of the marginalised ‘birthing’ niche ever giving a shit about institutionalised assault? Would anything make any difference?
    Feeling very dispirited right now.”
    I feel your pain. I really do. I too feel mighty dispirited at the rebuffs of feminists I’ve experienced. I spent my youthful feminist learning time in the pro-choice struggle and now I look behind me and see almost no one standing there for me in my time of need around “choice’. Internalised misogyny, the surgical discourse in place of a birth discourse, the success of empowerfulised child-hating girlpower, they all add up to a shocking lack of understanding despite women like us working overtime on the issue. This “medical violence” euphemism is a spit in the eye to us all.
    In five years I’ve not managed to forge a single working relationship with another feminist group. When Joyous Birth turns up at feminist things it’s assumed we must be Forced Birthers because no one else is talking about birth, right? For the record, we strongly support women’s right to abortion because we support women’s right to autonomy, bodily integrity and reproductive freedom. Birthrape is a giggle to most people, made up by crazies because everyone thinks it’s “birth” that’s traumatic when if it was surely it would be homebirthers and freebirthers falling by the wayside with PTSD (the undiagnosed epidemic) and PND? I doubt there are homebirthers in that suicidal group that Hannah Dahlen referred to in the committee proceedings around the latest push to outlaw independent midwifery. But regardless of that, why aren’t feminists OUTRAGED that women are suiciding?? Why aren’t feminists OUTRAGED by the deaths of women from forced caesareans?? The experiments on women and babies at Wagga Wagga Base Hospital with a drug not approved in Australia for induction with live babies? Fell like a stone in a pond minus the ripples.
    The press are determined to silence women while printing lies from surgeons and everywhere a deafening silence from feminists despite birth being something most women do in their lives. That doesn’t mean I think parenting is the only thing a woman should do, it doesn’t mean I privilege mothers over those who choose to be childless and I find it laughable when women with children are told to check their privilege because we’re I’m sitting, there ain’t none. Mighty little kudos has come my way in the work I do from mainstream society or from feminists.
    I don’t know what it’s going to take, Lauredhel, but I fervently hope we both live long enough to see it. I console myself that women who fought for rape within marriage to be recognised, and for child abuse to be something that could be printed in the newspapers, and for the vote, were also treated like shit by those who didn’t see what the struggle was for yet now those things are taken for granted as part of a mainstream feminist platform.
    I find your expositions a joy and I thank you for them from the bottom of my heart.

  11. I need to comment more on these posts. Appalled silence doesn’t show the support required. Even when I don’t know exactly what to say, I should try and find something so you don’t feel so isolated.

  12. Thanks for the extra info. My post was just going to be based on my personal observations, but that’s kind of why it hadn’t been being written.
    Now I just need to find the time to do that research. (Heh, and I also have another post half-written about priorities. Ironic, that. ;) )

  13. @ Lauredhel
    I think so. I think it comes from the normalisation of hospital births and the accepted belief that hospital is the best place to be. I think the image most people have of women who homebirth is hairy legged feminist types who hate doctors. Which, like the feminist stereotype, is true for a small minority and not true for the rest.
    I suspect also, but only from my own experience, that many of us may have lost faith in our bodies ability to cope with labour. When I had braxston-hicks with my daughter I was thinking – geez these really hurt, I couldn’t do labour. But now I’m sorry that I didn’t stand up to the doctor and at least try. But then I found the “your baby will die if you don’t have a caesar” line pretty compelling too.

  14. Oh, and by the way, this:

    if you consider injuries and trauma and haemorrhage and surgery to be poor outcomes, instead of conveniently only looking at outcomes that are in numbers too small to reach statistical significance (deaths)

    was exactly what I’d picked up on and wanted to write about, too :)
    Especially the anecdata “but you/your baby might DIE!” (you will see that phrase a number of times in my post) argument, which I find completely intellectually dishonest, not to mention unscientific, illogical and irrational!

  15. @ Mindy
    I’m sure some of what you’re talking about is occurring. I’m sorry for your own experience of this stuff and I invite you to explore it further in a safe environment in order to learn for yourself what you make of it.
    Birth isn’t special, it’s just a normal, physiological function of the human body. Yep, it hurts. I’ve done it three times at home, first time ended in unnecessary transfer to birthrape and caesarean. Next two times I just gave birth – long, painful births. Birth hurts, I don’t actually like pain but I prefer giving birth for a few days to surgery and living with the fallout of that for the rest of my life. Support is what we lack. Support and information to show us birth is just normal.
    The continuum which once saw us attending births of our siblings, sisters, aunts, SILs, neighbours, anyone really, has been well and truly smashed as hospital birth, that recent and dangerous phenomenon, has become so normalised. As I keep saying, we no longer have a birth discourse, we only have a surgical discourse. Surgeons are very successful in their exploitation of our internalised misogyny. If I had to give birth in hospital I’d be shit scared too. But at home, women just birth.
    I wish you peace and healing. Birth trauma is a hard road and it cracks women’s lives open in ways that not much else does.
    “I think the image most people have of women who homebirth is hairy legged feminist types who hate doctors. Which, like the feminist stereotype, is true for a small minority and not true for the rest.”
    Would you like to rethink this? Do you remember the admirable entry here on Monica Dux telling us that normally haired women were dragging feminism down? I gotta tell you, there’s a negligible amount of feminism in birth and that includes homebirth populations. Homebirthing feminists are pretty much a tiny maligned minority of a larger maligned minority. I doubt very much that the stereotype in mainstream world around homebirth involves feminism, it tends to involve that bizarre term “hippy”. I don’t think I could get any further from “hippy” if I tried. It makes me snort with laughter when I’m lumped in there.
    And you know what? This “hating doctors” thing is also pretty bizarre and somewhat reminiscent of the dismissal of wider feminist movements and lesbian women into the bargain. Not everything in the world is a response to dudes. This kind of argument just positions men or their perceived agents (lots of surgeons are women, it’s a system not a sex thing) at the centre with the rest of us patrolling the outskirts. Feminists ain’t feminists because we hate men. Homebirthers aren’t homebirthers because they hate all things doctorish. Some of us have a deep and abiding disgust and revulsion at the way doctors are able to control women’s bodies and choices in maternity care when it’s none of their goddam business. It’s patriarchy at it’s finest, a nexus between commerce and misogyny woohoo.
    I’m glad to see a little dialogue occurring!

  16. That was actually a stereotype – both embodied in people and believed by others- that I encountered Blessed, but I am guilty of extrapolating my (limited) experience too generally. The women I met probably more hated forced hospital births rather than doctors. I apologise for that, I should have given it more thought. At the time midwives were unable to get insurance (as now) and the NT briefly made it illegal to have a homebirth. Thankfully, after a lot of politicking, the NT govt backed down and homebirths were able to continue.
    As for ‘feminist’ when I heard it it was used as a slur, on par with hippy. I think it was more ‘woman who knows what she wants and will do everything in her power to get what she wants/needs’ and all the attendant issues surrounding ideas about that type of woman (pushy, bitch, unfeminine etc), but who couldn’t be labelled directly as a hippy because she wears “normal clothes” like everyone else, unlike hippies who are “instantly recognisable by their tie die and loose fishermans pants etc.” /sarcasm
    Thanks for the peace and healing wishes. You think you’re over something and then something just opens it right back up again.

  17. I’m sorry for your pain. I spend a large part of my life supporting women to heal from birth trauma and an equally large part supporting women to avoid it in the first place. Please let me know how I can help. You may find some useful and interesting reading here.
    http://www.joyousbirth.info/birthtrauma.html

  18. Thanks Blessed. I am fortunate to have two healthy kids who are fully immunised and who were lucky enough to grow up in communities where immunisation rates were high so that they weren’t exposed to any of these godawful diseases.

  19. Oops wrong thread! But I’m still grateful for the link Blessed.

  20. Mindy: “I think so. I think it comes from the normalisation of hospital births and the accepted belief that hospital is the best place to be. I think the image most people have of women who homebirth is hairy legged feminist types who hate doctors. Which, like the feminist stereotype, is true for a small minority and not true for the rest. ”
    What I find really interesting (from a kind of meta-perspective) is that there’s a really weird intersection of women (particularly in the US) who choose home birth for religious reasons and women who choose it for what I’d loosely call feminist reasons (although they might not identify the reasons as feminist, specifically). And so there’s possibly an optics issue going on from both sides (dirty hippies vs religious freaks). Not to mention the background of reproductive rights against which, as a feminist, I would set home-birth activism is anathema to the religious women (for the most part).
    Lauredhel: “Rebekka: Same here. I’m deliberately barren now (I hope), and hope to never find this a personal issue; but for me this issue ties in very deeply with bodily sovereignty, reproductive choice, violence against women, and kyriarchal control of marginalised bodies. ”
    Lauredhel, yes, yes, and YES!
    And everyone, there is actually a fair amount of feminist writing on this subject, it’s not ignored completely – if anyone wants book recommendations I have a fairly massive library of books, because (a) I’m interested in it as a topic, and (b) I was going to write a thesis on it, until I got distracted by belief in the middle ages.

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