Open Letter to BC Homebirth Study Critics

3 09 2009

Dear Uniformed Commenter

After reading the newest study on the safety of homebirth, I sat back to read some reactions from the press and the public. I had a look at the CTV coverage and the CBC coverage and I read over the comments in reply to each story. Imagine my dismay when I read some of your reactions! I was rather glad that the comments were closed because I was too upset to post anything coherent or cool-headed. Frustrated, I can not stop thinking about your replies.

First, I shake my head as it appears that you’ve neither read the study nor understood the very article you’ve responded to. You seem to have missed the point entirely. Your arguments fall into one of several categories:

1. The Personal Anecdote Rebuttal

This is some variation of “I can only imagine how horrible our child’s birth would have turned out if we had tried to have a home birth” and then launching into your personal story where everything was touch-and-go but thankfully the medical staff at the hospital saved your baby.

First of all, this is not a logical rebuttal to a scientific study. This is an emotional reaction known as a pathetic appeal. You are rejecting “a claim based on how it makes you feel without fully analyzing the rationale behind the claim”. You are appealing to people’s very real emotions about the health and safety of a tiny baby at the expense of being able to actually hear what the study’s authors are trying to tell you. While it is totally understandable that this is an emotionally sensitive topic for many, the problem is that you are overemphasizing the emotional component at the expense of the message (the logical component) – this is a flawed argument. Effective, yes – ad campaigns do it all the time, but flawed nonetheless.

Secondly, while my heart goes out to you that you had a difficult and scary time at the birth of your baby and while I’m glad that modern medicine was able to save your baby, we can’t actually compare your situation with that of the study subjects. We have no way of knowing with the few details you’ve given if your particular circumstances would have made you an eligible sample for the hospital group. Perhaps you had complications or a high-risk pregnancy that would have excluded you from the study. Therefore, sadly, your situation is not a relevant point of comparison for a study that was looking at births fitting very specific criteria. If that is the case, even the study’s authors, home birth advocates, the BC College of Midwives etc. would all agree with you: your child’s birth should not have occurred at home because it did not meet the criteria to have a home birth safely.

2. The What If Question

This argument boils down to “Yes, homebirth is fine as long as nothing goes wrong. But why chance it?” You have missed the point completely; the study concluded that home birth is as safe as hospital birth because in all the cases studied, virtually nothing did go wrong. The perinatal death rate was the same as for both hospital groups (in fact, it was marginally lower in the homebirth group). This what-if-something-goes-wrong argument was essentially what the study was trying to find out – how often does something go wrong at home? And the conclusion was, provided certain guidelines are followed: no more often than something goes wrong in the hospital.

3. The Get With The Times Blow Off

This argument is the most uninformed of the bunch. You demonstrate your complete lack of understanding of maternity care and midwifery with variations of “Midwives are old hippies with no training and would be useless in an emergency” or “Stop being so full of yourself and your need to prove something – modern medicine is here for a reason, use it.” This brand of reaction is intended to silence anyone supportive of homebirth by insulting and denigrating but it only demonstrates your own ignorance.

Midwives, in BC at least, have a 4 year University degree during which time they attend hundreds of births and spend half of their studies in practical learning settings. They are specialists in birth, female physiology, the newborn, breastfeeding and more. They carry with them resuscitation equipment including oxygen, various drugs (including drugs to prevent haemorrhaging) and can start an IV or intubate if necessary. There are two midwives present at a homebirth, one for the mother and one for the baby so that if anything should happen there are enough hands there to make sure that everyone is being cared for. Furthermore, one of the criteria for being eligible for a homebirth in BC is to be within reasonable distance of a hospital for a rapid transfer if necessary. These are not old grannies from the bush; these are highly trained and skilled experts in childbirth and maternity care.

Compare this with a physician who only studied childbirth, babies and female physiology for a fraction of their total time at school. Consider the study’s findings that the mean number of antenatal visits with a midwife was 11.8 versus 9.3 for a physician. Consider that doctor’s appointments run ten minutes while midwifery appointments are fifty. You would choose a heart specialist if you were experiencing angina right? Why wouldn’t you choose a specialist for childbirth?

The misconception that homebirth advocates shun modern medicine because they have something to prove or think they are above the use of life-saving equipment/procedures, thumbing their noses in defiance is also at the heart of the Get-With-The-Times brush off. The beauty of homebirth in this day and age is that we can apply our knowledge of medicine to increase the safety without losing the sanctity of birth for mother AND baby (no, it isn’t just about the mother’s experience) and WITHOUT the misuse of technology and abuse of power that is rampant in the hospital setting. We can trust birth, we can use our intuition, we can give mother and baby time to get in the right position to birth safely and efficiently but we can also safeguard against haemorrhage, infection and multiple other complications because of scientific advances. Homebirth and midwifery advocates recognize this. It’s not a case of throwing the baby out with the bath water. The homebirths you are envisioning, you know alone in a cabin in the woods without electricity? Those births would have been excluded from the study.

4. The Caesarean Card

Your disappointed reaction to the homebirth study is to play the caesarean card: “That’s all wonderful news but we had to have a caesarean.” This is a tricky point. There is much debate about whether your caesarean was necessary. It is generally accepted that the caesarean rate is too high (almost 30% in BC) and yet, each individual caesarean is somehow deemed necessary by physicians and families. When it’s your baby you’re talking about, you can’t help but feel that your situation was different than the other 1 in 3 families that faced unnecessary caesareans.

You use this as evidence that it was lucky you were in the hospital. And yet even women who were low risk (they met all the criteria for having a safe homebirth) were almost twice as likely to birth by caesarean if they planned a birth in the hospital with a physician. How do we explain that? Perhaps you wouldn’t have “had to have a caesarean” if you were birthing at home, or at least in a hospital with a midwifery care provider?? Unfortunately we can’t answer that question but it is worth wondering about.

5. The Attack The Stats & Study Design Argument

You like to poke holes in the study’s findings to appear as though you’ve read it. You say things like “oh, homebirth is associated with a lower incidence of epidurals. Of course that’s true. Last time I checked there was no anaesthesiologist waiting in the kitchen.” Again, you are not reading the study clearly. The lower rate of interventions is like icing on the cake. The study found that homebirths carried the same risks as hospital births in terms of perinatal mortality. Thus, if you are eligible for a homebirth you can consider it equally as safe as birthing in a hospital. But if it’s also important to you to avoid an epidural, infection or caesarean or to keep your perineum intact then the benefits clearly lie in staying at home, precisely because there is NOT an “anaesthesiologist waiting in the kitchen” or an OB down the hall with a stop watch and a scalpel.

The other common mistake you make here is to assume the study, like some previous studies, is not comparing apples to apples. You claim that hospital births had higher rates of interventions because all the complicated births had been re-routed to physicians and hospitals by the system. The groundbreaking nature of this study is that they did manage to compare apples to apples. The comparison groups (hospital birth with midwife or physician) were very carefully matched to the study group (home birth with midwife) on multiple measures including income, age, geographic location, parity and most importantly, status of eligibility for homebirth. This means that women were excluded from the hospital group if they were high-risk or experiencing complications. Furthermore, because the study looked at planned place of birth rather than actual place of birth, homebirths that ended up as hospital transfers (for emergency or other reason, like mother fatigue) were still counted as homebirths, rather than skewing the hospital numbers. If a mother planned a homebirth but transferred and ended up with a caesarean, that caesarean went in the homebirth numbers not the hospital birth numbers; otherwise, all of the caesareans would have been in the hospital group and then the stats and study design surely would have been faulty.

So we come to a problem with all of these comments. It appears that no matter how many studies are published showing the safety of homebirth and of midwifery care, skeptics refuse to see what the study clearly shows. As Jennifer Block puts it in her article The Birth Wars: Who’s really winning the homebirth debate:

This is a natural human tendency, to base knowledge on anecdotal experience, ‘and we have science to help us get around it. But for this topic it’s not happening.’

‘What’s interesting is why these studies have not swayed public opinion and not been integrated into the medical establishment,” she says. “People deeply, deeply believe that a baby cannot be born without massive amounts of medical intervention, and it’s nearly impossible to overturn that cultural norm. There’s something blocking people from operating on the basis of the balance of evidence.’ (Quoting Cheney)

So what is blocking all of you from accepting the evidence?

In order to accept the evidence a major paradigm shift is necessary. You have been so conditioned to fear birth and to consider birth an emergent medical crisis waiting to happen that you can’t even hear what study after study is trying to tell you. You have been so blinded by the medical model’s approach to childbirth in our technological society that you no longer have any trust in or reverence for the natural world. And despite this love of science and medicine, you won’t allow yourself to be swayed by good clean science telling you that birth is safe. It’s bad enough you don’t understand that with your intuition, you also won’t allow yourself to see the scientific facts. This is the epitome of closed-mindedness and it makes me despairingly sad.

It appears that until you can trust birth you will never be convinced of the wondrous truth. The truth that the female body of all mammals is perfectly, amazingly designed to give birth, that somehow we managed to put 8 billion people on the planet without the benefit of hospitals and that all your faith in technology has caused you to lose faith in yourself.

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2 responses

4 09 2009
chris

Love it!

10 09 2009
canadiyank

Thank you for your thoughts!

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