Ten years ago an internet pal sent me a link to an online discussion of homebirth safety, in which a couple of neonatologists and an infamous OB-GYN were congratulating themselves for their perspicacity in grasping its obvious hazards. "Aha!" said the naive Jamie of 2006. "Some people are wrong on the internet! Perhaps I will enlighten them."
Over the next couple of months I read every research article about homebirth that I could get my hands on. I read the 2005 Johnson & Daviss study so many times that I wound up quoting it to myself in labor. I wrote some crazy number of words about homebirth that spring and spent an even crazier number of hours writing them. (They're all in the Birth category, if you're curious. They're probably some of the better pieces on this site, if you need a rabbit hole to fall down.) But guess what? Some people are still wrong on the internet. 2006 Jamie would be bitterly disappointed.
Here is a true statement about homebirth: in the right circumstances, homebirth can be as safe as hospital birth for babies and vastly safer (not to mention happier) for mothers. Here is another true statement about homebirth: in the wrong circumstances, homebirth can be a deadly act of folly, leaving heartbreak and fury in its wake. And here is one more true statement about homebirth: there is a big gray area between those first two true statements, and we in the US are doing a terrible job helping women to navigate it.
In 2009 an enormous study was published in the Netherlands, investigating perinatal death among low-risk women. The authors calculated an odds ratio, assessing the odds that a home-born baby would die vs. the odds that a hospital-born baby would die. If I were a betting woman, I would have predicted a marginally higher odds ratio for the women delivering at home -- something like 1.1, maybe as high as 1.2. But I would have lost that bet, because in that study of more than half a million women, the odds ratio was...1.0. Exactly the same odds of perinatal death for hospital-born vs. home-born babies. This is irrefutable evidence in support of my first assertion: in the right circumstances, home birth can be as safe as hospital birth.
Since I was immersed in the literature in 2006, there have been a spate of US studies published on homebirth. I haven't read them all, but many of them seem to have been written by OB-GYNs with an axe to grind. These findings do not invalidate the Dutch results described in the previous paragraph; instead, they illustrate the truth of my second assertion. Homebirth is only as safe as hospital birth in a limited set of circumstances: low-risk mother, singleton vertex baby, trained attendant, ready access to hospital care if needed. If any one of those elements is missing, the odds of an adverse outcome rise precipitously. Approximately 10% of the women who choose homebirth with CPMs in this country are Amish. They are more likely to be grand multiparae; their babies face a higher burden of potentially lethal genetic disease; they tend to live in rural areas where transport times are longer; they may choose birth attendants with limited expertise. The homebirth outcomes for the Amish women in my region have something to say about homebirth safety in the Midwest, but most of the women giving birth in Gladlyville are facing different circumstances. It would be a mistake to extrapolate too energetically from a higher-risk population about the risks that lower-risk women must confront.
And yet there's a lot of extrapolating. And finger-pointing. And polarizing. Which serves-- whom does it serve, exactly?
In 2011 researchers published a really interesting set of findings from a large UK study: for women who've had babies before, homebirth is just as safe for babies and considerably better for their mothers. For women having their first babies, homebirth is associated with a statistically significant increase in the risk of some adverse outcome. (It's not accurate to say that their babies are significantly more likely to die -- the investigators only looked at a composite outcome because the study was underpowered to detect differences in rare events like perinatal death.) This could mean a big scary adverse outcome, like death or brain damage, or a less serious adverse outcome, like nerve damage. The absolute risk was low, but it was higher among women planning to deliver at home.
This is an intriguing finding, I think, and it raises questions I'd like to talk about. Does it reflect the UK midwives' idea of a "duty of care," by which they mean that they can't require a laboring woman to jump in an ambulance even if ambulance-jumping is clearly the best decision? Are there ways to make homebirth safer for women having their first babies? There are many, many questions worth talking about when it comes to homebirth. Here in the US, for instance-- what coursework should be required for CPMs? How important is it for them to take a pharmacology class? How much do they need to know about suturing before they start a practice? Are outcomes worse in states where CPMs are working underground? Should women have the right to choose a high-risk homebirth?
Unfortunately, measured discussions are rare. The notorious OB-GYN I first encountered 10 years ago has a book coming out next month; she has spent the past ten years broadcasting misinformation about homebirth. (It makes me sigh to think of all the stats classes she could have taken during those ten years.) I shut my Facebook tab to write this post, because the "bong" tone announcing another salvo in a friend's comments kept distracting me. It is unlikely that this post will change any minds, because "it depends" is not a very clickbait-y headline.
But it's the most accurate one.