Open Letter to BC Homebirth Study Critics

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.

Birth Choices – what is right for you?

Today we have more choices than ever about how we birth. We have the choice of using a doctor or midwife for our practitioner. We have the choice of birthing in the hospital or at home. We can choose who is present at the birth. We can choose to hire a doula. We can choose between a multitude of prenatal classes ranging from hospital-run classes to private classes in Lamaze, the Bradley method or Birthing From Within. We can enroll our older children in Sibling Preparation classes, we can take prenatal yoga or prenatal pilates, we can bring music, pillows and massage oil to the hospital. We can choose to labour in the tub or the shower or on a birth ball. We can play cards or go for a walk. We can birth squatting or standing or via elective cesarean. We can even write up elaborate detailed lists of all of our preferences and give this Birth Plan to our practitioners.

Faced with all of these choices, how do you know what is right for you? How do you know that the choices you made before the big day will still be right when labour starts – especially if you are a first time mom?

Choice, in general, can be a double-edged sword. On the one hand, it is empowering and enriching to be given the opportunity to have a say in what happens to us. On the other, given too many choices or inadequate information to help in our decisions, the process of choosing can cause stress, anxiety and even guilt and depression. And when it comes to birth, it can give the misguided impression of control.

Relinquish Control (even those subconscious thoughts…)
The first thing you can do on your journey towards the right birth for you is to forget about those fantasies of your ideal birth. We all do it: we all have a vision in our heads of the way we hope our birth will proceed. These visions are rarely realistic (unless you imagined in your ideal birth that you would be half-naked on your hands and knees in a roomful of strangers). Birth is a dynamic process and we cannot control what happens. The woman who is determined to get her epidural before she’s finished with the hospital admitting desk may deliver baby at home in the bathroom attended by her partner. The woman who preaches natural birth from before conception may end up with a complication, or labour induction and a cesarean delivery. We’ve all read these stories and hoped it wouldn’t be us. But it could be. So the first step is to let go.

Read everything you can get your hands on
Knowledge is power. If you aren’t a reader, ask questions. Ask all the mothers you know what their experience was like. Ask your practioner all those nagging questions you’re afraid to speak out loud. Explore all the birth possibilities there are. Don’t shy away from those topics that you hope you won’t have to face (like having a long, drawn out back-labour or requiring a cesarean). Don’t write off ideas that are new to you (like homebirth, or hiring a doula). The more you can understand about the way labour progresses (or sometimes doesn’t) and the way labour is managed (or sometimes mis-managed), the better the chance that you will be able to play an active part in the process.

Be Flexible (but know your limits)
That is, be prepared to change your mind. Something that seemed right before birth may no longer be fitting during birth. Hell, something you asked for during one contraction, may not be what you want during the next. Accept the fact that you may need to revise your thinking in the face of new information. However, if at any time, you are uncomfortable with the care you are receiving, be confident that it is okay to assert yourself or have some intervene on your behalf. By trusting your instincts and your birth team, you’ll know when to stand your ground and when to adapt.

Gather good people around you
The people who support you and care for you during labour can make a huge difference. Consider carefully whether you want a doctor or a midwife, whether you will hire a doula and which friends and family members you would like present. Ask your care-givers questions and reserve the right to change your mind if you don’t feel comfortable. The time it takes at first to find good people could make the difference in how your birth unfolds or at least in how you feel (even when things don’t go as planned). Good people will give you information and not rush your decisions, will help keep you focused, will make you feel supported and empowered, will be positive and encouraging and will inspire trust.

Face your Fears
We all go into labour with a mixture of elation and apprehension but it’s good to ask yourself what it is you are afraid of before your water breaks. Hopefully a few weeks before. It’s hard to know how to manage a nebulous, nameless fear. But if you can seriously explore what scares you about birth (and motherhood) before the throes of labour send you into panic mode, the odds are you’ll be better equipped to deal with whatever comes your way. Try, if you can, to go a little deeper into your fears than the obvious like fear of pain or fear of a long labour. What about the pain scares you? Fear of not being strong enough? Fear of losing control? What about a long labour scares you? Facing your fears is emotionally exhausting but it would be a shame to let fear hold you back from the possibility of a truly rewarding experience.

Know yourself, know your situation
This is the easiest part because it might be decided for you. Are you a home-body who feels most comfortable with a few close friends rather than in the middle of a party? Maybe homebirth is an option for you. Are you an analytical person who is comforted by procedures and technology? Are you someone who always wants to be prepared for the worst case scenario? You might feel strongest birthing at a hospital or birth center. Are you totally against medicated birth? Perhaps a water birth is right for you. Is your baby breech? The safest bet for you and your baby could be a cesarean. Was your pregnancy a textbook case or did you suffer from multiple complications? Your health practitioner will be able to explain what your options are based on your personal situation and with a bit of self-analysis and thought, you’ll find the answers you’re looking for.

Often as labour day unfolds, it doesn’t come down to choice at all. We don’t choose when our babies will come or how they will make their entrance. Sometimes, circumstances arise that take the power from the mama and she needs to stretch and bend around the situation she is given. And sometimes, with trust, in our instincts, in ourselves, in our babies, in birth itself, our babies come just the way we knew they would. We do what we need to do and the most right thing of all is that they are safe.

Rebirth: Maternity Care Alternatives

Planning to have your baby in the hospital? You might have to contend with some of the symptoms of an over-burdened healthcare system. Maternity wards can be over-crowded and under-staffed. Hospital stays are getting shorter. And if you happen to go into labour at the wrong time, you could be sent to another city’s hospital because all of the hospitals nearby are at capacity. What if our maternity care system could be over-hauled to relieve the burden?

What are the realities?

Fewer doctors and nurses
Besides the well-publicized shortage of nurses, Canada also faces a shortage of physicians who attend births. Between 1992 and 2004, the percentage of general practitioners who attended births fell from 28% to only 13%.

Rising Costs
Having a baby in these technological times is not cheap. The average cost for a vaginal delivery is $2,800. For a caesarean, it is closer to $5,000. This does not include the added costs associated with length of hospital stay or neonatal care. With every epidural, there is an added expense for the anesthesiologist and with a BC cesarean rate approaching 30%, costs are rising for maternity care.

Shorter Stays
An obvious cost-cutting measure is to shorten hospital stays. The average length of stay for a vaginal birth in BC has fallen to only two days. For a cesarean birth, it is less than four days. Women are being sent home to care for newborns within a couple of days of major abdominal surgery. What happened to resting and recovering from birth?

How would a new system look?

Midwives
Midwives are trained specialists in birth. They have usually completed four years of practical training. Their appointments run about fifty minutes (as opposed to the standard ten minutes with your family doctor). They often do home visits in the first week after baby is born to help initiate breastfeeding and to monitor mom and baby. Mothers report excellent continuity of care and higher levels of satisfaction with their births and their care.

The midwifery model of care tends to be cheaper than the current medical model. Midwives believe that birth is a natural physiological process. Though trained to spot and mitigate problems, midwives adopt a fairly hands-off approach as caregivers. Births attended by midwives show a lower incidence of epidural use, episiotomy, and cesarean section. The benefits are not just higher maternal satisfaction, but also much lower costs.

Homebirth & Birth Centres
In the last two hundred years, medicine has managed to pull birth firmly into its clutches. Contrary to all logic, with birth, we take women who are healthy and place them in the hospital as a preventative measure (in case something goes wrong) and then we treat them the same way we treat the sick and injured. Since when is pregnancy a disease?

Modern medicine can be thanked for the low incidence of infant and mother mortality associated with birth today. We know more about the human body, more about birth, more about infection. We know to keep wounds clean. We have antibiotics and other modern drugs. We can save moms and babies from situations that would have claimed their lives only 100 years ago. But that does not necessarily mean that birth belongs in hospital.

We can transfer our medical knowledge to other places, like the home. Recent studies show that with healthy pregnancies free of complications, planned homebirths attended by trained midwives are as safe as hospital births. For low risk women, we can achieve safe birth at home and reap a dual benefit because there are advantages to birthing where a mother feels safest and most comfortable.

We can also find a middle ground instead of polarizing between hospital and home. Imagine the power of a birth centre: birthing in a homelike setting with a midwife, a birth pool, medical equipment tucked out of sight and the potential of a quick transfer to hospital if need be. On the flip side, imagine the benefits for our rural and northern communities that don’t have hospitals have their own. Mothers would no longer have to travel to cities far from their families and support systems to have their babies. Birth centres could begin powerful partnerships between doctors/obstetricians and midwives.

Imagine if everyone birthed in a birth centre or at home with a midwife unless it was medically necessary to birth in the hospital. Imagine the resources (hospital space, staff and money) that could be diverted to caring for sick people. Imagine how different our medical system might look.

Imagine…

Sources

Canadian Institute for Health Information, Giving Birth in Canada: The Costs, 2006
BC Vital Statistics, Annual Report on Births, Deaths and Marriages, 2005
Canadian Health Services Research Foundation, Evidence Boost for Quality: Allow Midwives to Participate as Full Members of the Healthcare Team.
Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia, Birth 34 (2), 140–147

Preparing The Nest – getting ready for your homebirth

Having a home birth can be an amazingly empowering and rewarding experience, not just for mom but for the whole family. In a world dependent on technology, enamored with science, it is indeed a rare accomplishment to birth a baby at home far from epidurals and laughing gas. There is also something magical about going through the birth experience in the place you live day to day, in your own private space where you feel safe and comfortable. Imagine how lovely it is, a year or two later, to look up from where you are sitting and think “wow, this is where we were when this sweet child joined us for the first time!”

A home birth is not particularly more complicated than a hospital birth. In fact, in many ways, it can be much simpler. No forms to fill out, no nurses coming and going, no shift changes, no electronic fetal monitoring—just you, your team and your space. However, you will need to cover a few basics:

Mindset
Try not to fixate on the idea of being at home. Prepare for the possibility of needing or wanting to transfer to the hospital not because you doubt the process but because there is always an element of unpredictability with birth. In the event of a transfer, you will need to remain focused on your birth and your baby rather than being disappointed about ending up at the hospital. Telling everyone in the weeks beforehand that we were “planning a home birth” rather than “having a home birth” helped me to mentally leave the door open for the possibility of a change of venue.

Cleaning
Several weeks before your due date give the place a serious clean. Afterwards you will only need to maintain with spot cleaning/maintenance. No need to feel embarrassed by the state of your housekeeping when welcoming your birth team.

Supplies
Your midwife will give you a list of supplies that you will need to have on hand for your birth. Every midwife tends to have a slightly different list but the basics are all the same. Some items can be found around the house; others will need to be picked up specifically for your birth. If you order your supplies online, keep them in the shipping box in a place that is relatively handy. Add a good pile of old clean sheets, towels and wash cloths. Choose linens that you don’t mind staining. You can also put everything in a laundry basket for easily carting to a different room when labour starts or if you are compelled to move around.

Remember to pack your hospital bag and keep it by the door in case you end up transferring to the hospital.

Food
Shop beforehand for snacks for yourself and your birth team. Good ideas are fruit, popsicles, juice, miso soup, crackers. You can also make up a batch of Labourade or drink Emergen-C. If your labour is long you may get hungry and you definitely need to stay hydrated.

Stock your freezer with healthy heat-and-eat meals to make those first weeks with a newborn a little easier. You can use up some of that late third trimester nesting energy making your own or enlist your family and friends to each donate a meal for your freezer when they ask, “What do you need?”

Siblings
You can choose the level of involvement for older children: whether they go to friend’s house, stay in the next room or wander in and out at will. Try to bear in mind the individual personalities of your little ones as you make this decision. You can prepare them for what to expect with classes, books or even colouring. Talking with kids ahead of time about what will happen during labour and birth will help them take it all in stride. If you plan on having your older children present, it is a good idea to have an adult there whose main role is to attend to them.

Pets
Dogs especially can find the commotion of birth slightly upsetting. Try to have a space for them out of the way or consider arranging a sitter.

From pets and people to prepping the nest, you do have to do a bit of extra leg work before your home birth. It will all be worth it when you don’t have to climb in the car and endure contractions for a twenty minute ride to the hospital. Picture yourself lounging in your own bed as your midwife weighs and measures baby and family members look on—what a great reward for a little extra planning.

What if I don’t think my home/space is appropriate for a homebirth?

Women have been having babies in all kinds of different spaces for a very long time. Women have given birth outside, in huts, on boats, on buses, even in trees. You can rest assurred that our modern houses, no matter how small, are more than likely adequate. You’ll probably want access to a bathroom and your space may dictate whether or not you can rent a birth pool but in most cases, you should find that your home will be just fine. Your midwives will usually do a home visit a few weeks before you are due (to make sure they know the way) and they will be able to go over any concerns you may have.

Is homebirth safe?

The most recent studies have shown that with healthy pregnancies free of complications, planned home births attended by trained midwives are as safe as hospital births.

There are some VERY important distinctions made in the above statement. Studies of home birth look at:

1. Low Risk women
2. Families who have planned ahead of time to have their birth at home and prepared for it. This does NOT include births that happened so fast that paramedics were called or mom delivered at home alone.
3. Home births attended by trained professional midwives.

These studies make no claim as to the safety of unassisted home birth, precipitous home birth or home birth for women who do not meet the criteria for being low risk.

Please note the overall findings of a study on home birth reported in the Canadian Medical Association Journal, including some very important benefits of home birth:

“there were fewer interventions during labour, including electronic fetal monitoring, induction of labour, episiotomy and cesarean section; women were more likely to have an intact perineum and fewer maternal infections and were no more likely to have third-degree or fourth-degree tears or postpartum hemorrhage; and there were no significant differences in perinatal mortality, 5-minute Apgar scores and meconium aspiration syndrome, as compared with women intending to deliver in hospital who were assisted by physicians or midwives.”

– Régis Blais, Are home births safe? CMAJ 2002;166(3):335-6

There is a wealth of information available on this subject:

Check out our articles & research section.