Photo: Jon Lowenstein/Noor/Redux
Jon Barrett is accustomed to dealing with anxious mothers-to-be. As chief of maternal-fetal medicine at Toronto’s Sunnybrook Health Sciences Centre, one of the main concerns he hears from patients involves unnecessary medical interventions during delivery.
He acknowledges that the rate of Caesarian sections and episiotomies is far too high in Canadian hospitals. “A healthy young woman, coming into this hospital now for delivery, has almost a 40 per cent chance of having some sort of intervention that is not desired.” But he’s more unnerved by what that phenomenon appears to be triggering: a surge in demand for home births.
In Ontario, midwives performed 2,360 home births in fiscal 2008, an increase of 23 per cent in just five years. There are no national home birth statistics but the percentage of non-hospital births more than tripled in Canada between 1991 and 2007 (the latest year for which statistics are available), although they remain well under two per cent of total births. That rate is typical of much of Western Europe and the U.S.; the notable exception is the Netherlands, where roughly a third of women give birth at home.
Barrett’s concerns about home births stem from experience. Between 1990 and 1992, he was part of an obstetric “flying squad” in Newcastle, England. His job was to travel, by ambulance, to the bedsides of women whose home births had gone awry. “For two years of my life, I remember going to calls of people who got into trouble at home,” he recalls. “I just remember disasters.”
Two incidents are particularly vivid. The first occurred in winter. Navigating the ambulance through snowy laneways, Barrett’s team arrived to find two midwives frantically working over an unconscious woman. She was in shock and hemorrhaging badly. “I’ve never seen so much blood in my life.” She survived, but only after a massive blood transfusion in hospital. The second woman developed pre-eclampsia, which caused seizures, and went into cardiac arrest as his ambulance pulled up. His team was able to restart her heart and intubate her before rushing her to hospital. She also survived. He says both conditions were unpredictable and could have occurred anywhere, “But I know they would have come less close to dying if it would have happened in hospital.”
Unlike some of his colleagues on the squad who witnessed fetal deaths during home births, if Barrett’s memories were reduced to pure data in a typical study, they’d be unremarkable. That’s because most home birth data measures deaths, not complications, and his patients survived. “If you want a retrospective study, there’s no maternal mortality there . . . and so is that safe? No, it’s just bloody lucky.”
The question of how best to measure home birth safety has long plagued researchers. In Canada, national statistics don’t track birth outcomes by home versus hospital. Nor do they track the sorts of near-tragic outcomes described by Barrett. Yet what is counted— mortality rates for mothers and babies during childbirth—offers little insight on the maternal side because, in the industrialized world, maternal deaths from childbirth are rare. In 2007, 24 women died in Canada from pregnancy-related conditions, including delivery, compared to more than 4,000 stillbirths and deaths within 28 days of delivery. But stories like Barrett’s suggest the numbers don’t tell the whole story. In his view, the bottom line should be obvious: “Sooner or later you’re going to get a disaster because that’s the nature of obstetrics.” He adds, “It’s very rare that it will happen, but it’s got to happen more in home birth.”
That assertion is at the heart of a furious debate in the birthing community. Mothers who choose to give birth at home often cite research showing there are fewer medical interventions and no increased risk. But in the past year, a new study has emerged that contradicts this. It shows that home births are associated with significantly higher death rates for babies. If correct, the rights of women to control their own bodies and birth experience would seem to conflict with the best interests of their children.
When the American Journal of Obstetrics and Gynecology (AJOG) released the now-controversial “Wax Study” last summer, it created the medical equivalent of the Rift Valley amongst birthing experts. Led by U.S. obstetrician Joseph Wax, of the Maine Medical Center, it confirmed significant benefits to mothers who gave birth at home, including less hemorrhaging, vaginal tearing and epidural use, and fewer infections and Caesarean sections. Unfortunately, these benefits seemed to occur at the baby’s expense: shockingly, the report showed that neonatal deaths (defined as deaths within 28 days of birth) were two to three times higher for home births. Clearly, no woman who chooses home birth believes she’s jeopardizing her baby’s health, but the study suggested such faith in the safety of home birthing is undermined by medical evidence. For those who accepted Wax’s results, the benefits of giving birth at home suddenly appeared trivial compared to the risks.
In many ways, Wax’s study was groundbreaking. Because few women would agree to be arbitrarily assigned a birthing location, there are no randomized trials (the gold standard for accurate research) on home birth safety. Instead, researchers often fall back on “cohort” studies that analyze existing data, such as birth records. The biggest problems are selection bias—deciding which data to include—and, in the case of home births, self-selection: high-risk women tend to gravitate to hospitals while those more likely to opt for home births tend to be low-risk. There can also be issues with record-keeping; for example, if a home birth mother transfers to hospital because of an emergency, and her baby dies in hospital, it may be recorded as a hospital death, rather than a home birth death. Wax’s study, a meta-analysis, combined and re-analyzed existing studies, in order to create a bigger sample and, ideally, a more accurate result. He looked at more than 230 peer-reviewed papers published between 1950 and 2009, and selected a dozen that compared planned home births with planned hospital births by low-risk mothers in industrialized countries (Australia, Sweden, the Netherlands, Switzerland, Canada and the U.S.). The study’s vast scope—it encompassed more than 500,000 deliveries—boosted its credibility. As one doctor put it, “half a million births cuts out a lot of noise.”
Perhaps, but the momentary silence was followed by an outraged roar from home birth supporters, including some whose research showed very different results. “The Wax study is full of mathematical errors,” says Patti Janssen, a professor at the University of British Columbia’s School of Population and Public Health, and lead author of a 2009 cohort study that showed home births to be as safe as hospital births, for women and babies. “The design was wrong, and the calculations were wrong, and it just has to be thrown out the window.” Her objections encompass everything from Wax’s math to the studies he chose to exclude from analysis, and were published on Medscape.com in April in a critique whose co-authors include Ank de Jonge and Eileen Hutton, both lead authors of studies that conclude that home births are as safe, if not safer, than hospital births.
In the avalanche of media attention that followed, Wax initially defended his work, but then began refusing interviews, including for this article. As a flood of letters poured into the AJOG, some demanding the study be pulled, the publication convened an independent panel to examine the main complaints. In April, it published a sample of those letters, along with a detailed response from Wax. It also released the panel’s conclusion that the study did not need to be retracted.
But the debate has continued, and gained force, in the wake of a second study, led by Annemieke Evers out of the Netherlands. Published in the British Medical Journal last November, it concluded that babies born to low-risk women, under a midwife’s care (in hospital or at home) are more than twice as likely to die as those born to high-risk women who give birth under an obstetrician.
Although these results were specific to Holland, and may indicate problems in the way the Dutch system categorizes women as “low- risk,” the study nevertheless provided fresh ammunition to those who believe babies are best delivered by obstetricians, and added fuel to the home birth debate. More letters began to fly, adding to the stack of seemingly contradictory information through which pregnant women are required to sift in order to make an educated decision.
Nathalie Waite could be the poster mother for the perfect home birth. Waite’s considerations were largely pragmatic when she decided, two years ago, that her fifth baby should be born at home. She had four children attending three different Toronto schools, no nanny, and wanted her delivery to disrupt life as little as possible. It wasn’t a decision she made lightly. Her husband was nervous, but Waite’s midwife reassured them both. They lived near a hospital. Two attending midwives would be in close contact with Waite’s obstetrician and, at the slightest sign of trouble, an ambulance would be in her driveway. Most importantly, Waite knew her own body. She’d had four hospital births. During the two deliveries in which she’d fought—“and I had to fight because they always wanted to hurry the process”—for a natural birth she’d experienced far less pain. “By this time I was very well versed. I understood my pregnancies and I understood what kind of deliveries I have.”
Had she known what a home delivery would be like, Waite says none of her children would have been born in hospital. “It was purely beautiful.” While she laboured on the top floor of the house, her children played cards on the ground floor. Her husband checked on her between bouts of gardening, while her visiting parents kept an eye on the household. “I was left alone upstairs, peacefully, hearing all the activity happening through the house and it just felt so natural. It just felt right.”
This is why home births are special, says Anne Wilson, president of the Canadian Association of Midwives. “It’s a non-medicalized environment where birth becomes a normal part of your family life.” And they are safe, she stresses, in the standard response of home birth advocates: “Research says that for women experiencing low-risk birth, that outcomes are the same, in home or in hospital, with a lower risk of intervention.”
While the Wax study argues that outcomes aren’t the same, there is no debating the fact that home births have lower intervention rates. And everyone, on both sides of the argument, agrees that hospital intervention rates are too high. “In my opinion, the cascading interventions in hospital births start when the woman walks in the door,” says Tyler Shaw, the father of two children born at home.
His daughter’s birth, in Kingston, Ont., in 2007, was such “a spectacular experience” he and his wife decided to repeat it at their new home in Guelph this year. Unfortunately, their son was born with fluid in his lungs, which concerned their midwife enough to send them to hospital. Everything they experienced from that point on, Shaw says, reinforced their preconceptions. Their son was given blood tests, a chest X-ray and an IV for a condition Shaw believes would have cleared up on its own after several hours. They had to fight for permission to breastfeed (the doctors were concerned the liquid would enter the baby’s lungs) and, he says, when the pediatrician went home without leaving instructions for release, their son remained in an incubator for an additional 15 hours. “Our rights were completely taken away and doctors more or less said this is what we’re going to do to your baby and there’s nothing you can do about it.”
A musician, who also has a bachelor of education and master’s degree in environmental studies, Shaw’s mistrust of the medical system runs deep. “I’ve hung around scientists enough to be skeptical of everything I’m told,” he states matter-of-factly. He and his wife refused vitamin K and erythromycin ointment for their children, two treatments hospitals and midwives administer as standard protocol after birth. (Vitamin K ensures the baby’s blood can clot until it starts making the vitamin itself, and erythromycin is an antibiotic that protects against infections from the birth canal that can cause blindness.) It was the words of his sister, a doula, that convinced him and his wife to take that stand. “She said that a baby has the right to having a whole, intact, unadulterated body and that we should try to protect that right as a baby’s parents.”
In many ways, Shaw and Waite represent opposite ends of the home birth spectrum. Certainly Shaw’s rejection of many of the fundamental tenets of modern medicine contrasts with Waite’s attempt to adapt its benefits to a home birth. But they share an important piece of common ground: both chose to deliver their babies with the help of a midwife.
Freebirthers, women who deliver without assistance (and often shun prenatal care), represent the smallest sub-section of home birth mothers, and aren’t included in studies on home birth safety. Among their most famous advocates is Janet Fraser, an Australian woman who made famous the term “birth rape” to describe an emergency episiotomy during the birth of her son. “I don’t care if you don’t like the word or the idea, it’s real so get used to it,” she wrote on her site, JoyousBirth.info. “When you shove your arm in a woman who’s screaming no, that’s rape. When you rupture those membranes because you have to tick the box and comply with ‘protocol’ even when the woman screams no, that’s rape. When you slash a woman’s vagina with scissors and she’s screaming no, that’s rape and on the street it would earn you a jail sentence.”
In 2009, Fraser’s baby daughter died after five days of home labour. She continues to advocate for freebirth.
Freebirthers make most midwives nervous and they horrify obstetricians. Freebirth is the equivalent of playing “Russian roulette with your child,” says André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada (SOGC). “You don’t play with a child’s life. Especially not where [health care is] free.” That said, the SOGC does believe that midwife-assisted home births are “a reasonable alternative for low-risk women.”
Yet, asked if he would consider home birth a reasonable option for his family, Lalonde is unequivocal. “No. Definitely not.” He falls back on experience for explanation. “I’ve participated in over 6,000 deliveries in my career and I know that everything looks very fine and suddenly disaster strikes.”
That conflict between medical experience and faith in a woman’s body to deliver naturally lies at the heart of the home birth debate. But is the concept of natural childbirth in danger of being romanticized? The ideal of the less-medicalized birth experience, as extolled in Naomi Wolf’s 2001 book Misconceptions, has become part of the zeitgeist. There is a documentary, popular amongst home birth advocates, entitled Orgasmic Birth; its website invites viewers to “witness the passion as birth is revealed as an integral part of woman’s sexuality and a neglected human right.” Ami McKay’s award-winning novel The Birth House makes a compelling case for home births to a more mainstream audience. In it, the doctor is portrayed as a condescending, patriarchal figure who knocks out his protesting patients with ether, then yanks out their babies. In contrast, the methods of midwife Dora Rare are equally suspect (think mandrake root and witchcraft) yet portrayed with exquisite humanity. Even when things go wrong, the women are in control, being cared for by women.
That kind of experience need not be exclusive to home birth, insist obstetricians. “We should be working to make the environment of the hospital conducive to the home birth experience, rather than having more deliveries at home,” Sunnybrook’s Barrett says.
But midwives like Anne Wilson maintain there’s nothing to equal the experience of a home birth. “If I am delivering a baby in the hospital, you’re a guest in my house. If I’m delivering a baby at home, I’m a guest in your house. And there’s quite a lot of psychological difference there.” Wilson hopes the demand for home births will continue to rise in Canada. That said, she believes that all low-risk women, including those who choose to give birth in hospital, should deliver with a midwife.
That’s the system adopted by the Netherlands—and the Evers study suggests it’s failing dramatically. Amy Tuteur, an American obstetrician/gynecologist, thinks that the study’s results are just common sense. One of the harshest critics of home birth, Tuteur’s blog, The Skeptical OB, takes an unflinching look at labour and challenges the assumption that it’s best left to Mother Nature.
“Childbirth is inherently dangerous,” she writes. “In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood.” Educated at Harvard College and Boston University School of Medicine, Tuteur in her blog shines a harsh light on much of the romanticism surrounding home births, and includes first-hand accounts—harrowing and heart-breaking—of women whose babies died during home births. “Why does childbirth seem so safe?” she continues. “Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90 per cent and the maternal mortality rate 99 per cent over the past 100 years.”
Until recently her views, not surprisingly, were echoed by the American College of Obstetricians and Gynecologists (ACOG). But in January the college softened its position, replacing its formal statement against home birth with a committee opinion recognizing that women have the right to choose, although they should be made aware of the risks, including those highlighted in the Wax study.
That change represents a huge step away from attitudes that were considered paternalistic, says Richard Waldman, president of the ACOG. More importantly, it allows the debate to shift from trying to prevent home births to making them safer. “I don’t think it’s that important to debate whether it’s safe, safer or not safe. I think it’s very important to debate how we can make home birth safer because women are going to do it anyway.”
In the United States, one way to improve safety is by improving midwifery. Training and regulations are a patchwork across the country; in some states, midwives aren’t even required to finish high school. In that respect, the U.S. lags many industrialized countries, including Canada. It’s one of the reasons Canadian midwives bristle at comparisons.
In contrast to the U.S., our midwives are university educated, highly regulated, and well-trained in emergency skills, notes Vicki Van Wagner, Waite’s midwife and an associate professor of midwifery at Ryerson University. They can ventilate a newborn, provide oxygen, and stabilize a hemorrhaging mother with an IV and anti-coagulant drugs before sending her to hospital for a blood transfusion. While they can’t administer an epidural or oxytocin, or perform surgery, they’re trained to recognize warning signs and transfer patients to hospital if such treatment appears likely to be needed. “It may be that there are some problems that occur, very rarely, at home that would be better served in hospital, but there are problems, like infections, that occur in hospital as well,” says Van Wagner.
Obstetricians and midwives are in broad agreement on the key measures necessary to reduce risk during home birth. They are the steps taken by Waite: ideally, a low-risk woman would deliver with the assistance of two highly trained midwives who are in close contact with an obstetrician at a nearby hospital. When those steps are put in place, Waldman says, “it can work almost as safely as the hospital situation.”
Is “almost” good enough when you’re talking about the survival of a newborn baby? Although he describes himself as a long-time supporter of midwives and birthing centres, the ACOG’s Waldman echoes his Canadian counterpart, Lalonde, when he says he wouldn’t want a home birth for his wife or daughter. “The intrapartum loss rate has got to be higher at home, it’s just intuitional for anybody who does this work. How big that number is could be debated.”
And is being debated. As larger and larger studies are undertaken, Sunnybrook’s Jon Barrett believes the data will start to show consistently higher risks associated with home births—and science will remain a lightning rod. “There’s such a powerful natural childbirth lobby that anyone who publishes something like that is going to come under a lot of criticism, justified or unjustified.”
