10.02.10

Home Births Under Fire

Babies born at home make up a tiny fraction of U.S. births, but their numbers are growing—and mothers are fighting back against a recent study that calls the practice three times deadlier than hospital labor.

New York mother Tamyka Booth gave birth at home with a midwife. She pushed out baby Martina in a bathtub, then Booth and husband Shane Smith of Vice magazine “crawled into bed with her to bond and nurse and have—what we all needed—a nice, long family nap,” she said.

The medical community calls home births unsafe, but recent large studies comparing home to hospital show why women with uncomplicated pregnancies would choose the former: They are much more likely to avoid the complications of surgery or tearing, they are more likely to breastfeed, and they are happier.

Earlier this year, the Centers for Disease Control noted a slight uptick in women forgoing the high-tech labor inductions and epidurals and C-sections common to hospital maternity wards for at-home, “high touch” births, signaling, perhaps, a trend—more years of data are needed to know for sure— albeit a small one. Home births comprise less than 1 percent of the 4 million births in the U.S. each year. For babies, the studies show no significant difference: They are born just as safely under the care of a midwife.

That is, until a recent study began making headlines.

“You mean ‘Wax Paper’?” said Booth when I asked her if she’d heard about it. “Wax Paper” is what home birth supporters have taken to calling a metaanalysis that appears in the September issue of the American Journal of Obstetrics and Gynecology. A research method that has come under criticism in the past, a metaanalysis pools together data from several studies, and this one comes to a hotly contested conclusion: that babies are three times more likely to die if born at home, said the study, whose lead author is Joseph Wax, M.D.

The journal announced the article two months early and named it an “Editor’s Choice,” and its findings would have lent credence to safety concerns, were they not taking such a beating. Several researchers and providers are lambasting the study as not only “deeply flawed” but “politically motivated,” the result of “ intense medical lobbying.” (See: MOMS legislation introduced to the House last month.) Two independent experts who looked at the study for Time found it “weak and methodologically flawed.”

This time, Crosley-Corcoran said, she wants to labor in peace. “It’s not healthy that I feel like I need a lawyer to walk into the hospital.”

The main criticism of the metaanalysis is its inclusion of old, discredited data that did not distinguish between planned, attended home births and accidentals on the kitchen floor or back seat, which have worse outcomes to be sure. And while the study was presented as being based on “hundreds of thousands of births,” its banner finding, that home birth is “associated with a tripling of the neonatal mortality rate,” is based on just 9,811 home births. And most of those deaths come from said poor data (in particular, a 2002 study with another loaded name: Pang).

Amy Romano, midwife and Lamaze blogger, points out that traditionally, the impetus for a metaanalysis is to boost sample size. Last year, Dutch researchers studied 320,000 home births and found no increase in deaths in babies from birth to seven days. For his study, Dr. Wax chose to subtract stillbirths and count baby deaths up to 28 days, thereby excluding the largest study and, it would appear, defeating the purpose of a metaanalysis. (Dr. Wax said he was unavailable for comment and emailed a general statement through his hospital’s public affairs office.)

Now other journals have jumped into the fray. The British Medical Journal points out that “no compelling evidence has emerged that hospital delivery...routinely produces better outcomes in uncomplicated pregnancies.” The journal gives little credence to Dr. Wax’s findings, suggesting that “wise epidemiologists (not to mention midwives, obstetricians, and expectant mothers) will pass discreetly by.”

Meanwhile, rival journal The Lancet took the study at face value, publishing an editorial under the headline “Home Birth—Proceed with Caution,” with a stern warning: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.”

“That was really offensive,” said Marjorie Greenfield, M.D., a professor of OB/GYN at Case Western Reserve who submitted a letter to The Lancet along with several other physicians. “But you know, I can understand, because there’s such a deep, deep belief that it is unsafe to have a baby at home. I used to believe that! But when you look at the good studies of home birth, there’s no difference in baby outcomes, and probably improved outcomes for mothers.” Still, she added, “most people I work with think it’s self-indulgent and risky.”

That is the position of the American College of Obstetricians and Gynecologists: “Choosing to deliver a baby at home...is to place the process of giving birth over the goal of having a healthy baby,” said the group in its 2008 Statement on Home Birth.

“It pisses me off that I have to defend my right to birth naturally, without unnecessary intervention,” said Booth, who gave birth in July. “Women are not merely participants in this process, we are the process. All women want to have healthy babies.”

Indeed, a recent survey of women who planned home births found that their primary reason for doing so is precisely the thing they are accused of blowing off: safety.

“I never in a million years imagined that I’d be a home-birth mom,” said Gina Crosley-Corcoran, a.k.a. The Feminist Breeder. “Then I went through the hospital system, and I totally understand why so many women feel [home birth is] safer and healthier, and I’ve turned into one of those women.”

Crosley-Corcoran is due to give birth to her third child next year and is planning a home birth because of “miserable” hospital experiences, which she details on her blog. The first one was a failed labor induction followed by a cesarean and post-traumatic stress disorder, and the second was a 38-hour “battle” for a vaginal birth. This time, she said, she wants to labor in peace. “It’s not healthy that I feel like I need a lawyer to walk into the hospital.”

Stories like Crosley-Corcoran’s are one reason Dr. Greenfield changed her mind about home birth: “I was very affected by [the documentary] The Business of Being Born. I saw it and I just felt incredibly sad about what we offer people in the hospital.” She won’t go so far as to suggest home birth to her patients, however. Certified professional midwives aren’t legally recognized in Ohio, which means they practice quasi-underground.

“In Ohio, when a home-birth midwife needs to bring patient to hospital, it’s really awful. She may be treated badly, the patient may be treated badly; it’s not a seamless supported system,” said Dr. Greenfield.

At the same time, she conceded it’s “very, very hard to get” the kind of care women want at home in a typical hospital. “When people come in expecting those things—expecting to move around during labor, to eat and drink, to give birth in whatever position they want—it’s a mess!” Greenfield said she recently was able to help a woman give birth just like that: “She was ecstatic, I was ecstatic, everyone was ecstatic. But part of what worked was that I was there to protect her. It was a lucky confluence.”

Jennifer Block writes frequently about women's health and is the author of the award-winning book Pushed: The Painful Truth About Childbirth and Modern Maternity Care and the blog Pushedbirth.com. Formerly an editor at Ms. and later Plenty, her articles and commentary have also appeared in The Nation, The Village Voice, L.A. Times, Babble, ELLE, and The Guardian.