Tuesday, 28 January 2014

Is Home Birth As Dangerous As Not Letting Your Child Wear A Seat Belt?

Choosing a home birth is dangerous, unethical and akin to driving your child around without a seat belt on according to recent stories in The Independent and Mail Online. The articles are based on a review published in the BMJ . So should we be enforcing tougher rules to prevent reckless women endangering their babies or should we first be looking at why some women choose home over hospital?

First of all, the headline is a little alarmist. The review isn't talking about razzing around country lanes with your kid hanging out the back window like an excited spaniel. The author suggested that the risk of home birth was equivalent to not strapping your child in for a single journey. The chances of them sustaining a major injury on that one particular trip are very low. But that risk does exist so it is foolish/unethical not to strap the child in every time.

So just how dangerous is giving birth at home? It is very difficult to get good data on this. For one thing only a small percentage of UK babies are born at home (about 2%) and they tend to be born to low risk mothers, who are often from a very educated and affluent demographic. So it is difficult to compare outcomes to those in hospitals which deal with a broader range of women and far more complicated cases.  Also, a large number of women who planned to have a home birth, end up transferring to hospital.  Many studies then count them and any negative outcomes they have, in the hospital group. Basically, it's hard for studies to ensure they are comparing like with like. One thing we do know (and can be very grateful for) is that the risk of anyone dying during birth, in any setting, is very low in the UK. 

Some of the best recent data comes from the 2011 Birthplace study. This looked at almost 65,000 UK births and concluded that, for low risk mothers having a second or subsequent child, home birth was as safe as hospital birth.  However for first time mums, home birth was riskier and not recommended.  So the second time, low risk mums are perhaps in the clear here, but what about the first timers? Or those who aren't considered low risk because, for example, they had a previous child by caesarean? There is certainly a case for arguing that these women are choosing their own comfort over their child's safety. That in their desire for the perfect, natural, "empowering birth experience", fully set-dressed with candles and essential oils, they have forgotten that the most important thing is getting the baby out safely. 

Now, I spend way too much time on the internet and I've come across a fair few individuals for whom I actually do think that is true. But I also read many more complicated stories of women who firmly believe that home birth is in fact safer than going to hospital or who are afraid of what hospital birth may entail.


Safer
Have a little dig around websites that advocate home birth and it won't take long to find someone claiming that it is actually safer than being in hospital. This sounds counter-intuitive but there is something to it. Women who have home births are less likely to have interventions such as instrumental deliveries. These interventions can be pretty unpleasant (I can testify to that personally) and carry risks of their own. The chances of having an instrumental birth in hospital are far greater than of having a baby die during a home birth. So if you consider any deviation from a straight forward natural birth to be a dangerous outcome then yes, home birth is safer. But this means putting an unplanned epidural in the same bracket as a life threatening haemorrhage.

These websites are often carefully worded to make interventions in hospital sound terrifying and almost inevitable, while at the same time portraying the risks of home birth as so vanishingly small that they aren't worth worrying about.  They are very persuasive and they can easily be the dominant voice of advice for pregnant women. NHS antenatal classes vary a great deal in quality and availability. Many of the wealthier, well educated mums who are more likely to choose home birth, may not be happy to wait for a half day class late in pregnancy with thirty others*. Instead they turn to books, websites and private antenatal groups. Often these will claim to be fair, unbiased and evidence based. Sometimes they are. But they are entirely unchecked and unregulated**. With all that in mind it's quite possible that some mothers criticised for choosing home birth, genuinely believe they are doing the best thing for their baby.


Kinder
Hospital births can be great, but they can be pretty very not great too. There are the midwife shortages and over crowded noisy postnatal wards etc. etc. etc. Where a woman's care has been lacking or complications have occurred during a birth, it can leave her with serious and lasting trauma. Imagine days of agony, humiliation, exhaustion and fear, then imagine knowing you may have to do it all again. Some such women choose to have a home birth. If they have had a complicated previous birth then they will not be considered low risk and will probably be advised against it by their doctor. But many will believe that it was the doctors who let them down last time. That trust is gone.

In many areas you even get a kind of NHS premium service if you select a home birth. When I had my first child I saw whichever midwife was at my GP surgery for my antenatal appointments, shared the midwives and doctors from several shift changes during the birth, endured some frankly cruel night staff on the post natal ward and then, at home, got whoever turned up (if they turned up) for care and advice in those first, difficult weeks. It was impersonal and often chaotic and confusing. Had I opted for a home birth I would have had many of my antenatal appointments in my own home with a named midwife or one of her small team. She would have been there for the birth and to settle me into my own bed afterwards and she would have visited me for weeks afterwards. Consistent care and advice from someone who knew me well. 

Perhaps those things don't seem enough to justify risking a home birth, and yes there will be those who are so caught up in creating their own amazing performance-art birth that they won't think clearly about the risks. There will be others who will make a careful and balanced judgement that for their particular circumstances those risks are small and worth it. But again, search the Internet, every woman is different and for many fear, misinformation or the promise of better care, are more than enough. We do those women a great injustice by condemning them as unethical. Instead we need to ask why they have made that decision. We need to ensure that all women have access to simply presented high quality information and we need to call bullshit when we see data being misrepresented. We need to do more for postnatal women, to recognise and treat those who have suffered trauma so that they feel able to make use of hospitals and doctors in the future, if they so wish and we need to provide better continuity of care for all. Not just those willing and fortunate enough to be able to choose home birth.  In a struggling NHS that is probably a big ask, but if we can't do that, we can't condemn those that we have let down.

SB

*At my first ever antenatal appointment, at a GP surgery in a very deprived part on London, the midwife took one look at me and my husband in his suit and told us to go to the NCT for childbirth classes "to meet people like us"

**My NCT teacher had a pretty strong pro-natural and home birth agenda. This isn't true of every teacher in the organisation, but, from talking to friends in other parts of the country, she doesn't seem to have been unique!

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