“Advocacy of planned home birth is a compelling example of what happens when ideology replaces professionally disciplined clinical judgement and policy,” according to Frank A. Chervenak, MD. He is the lead author of Planned home birth: the professional responsibility response, an opinion paper published on 13th November, 2012, in the American Journal of Obstetrics and Gynecology, the Given Foundation Professor and chairman of the Department of Obstetrics and Gynecology at Weill Cornell Medical College, and obstetrician and gynecologist-in-chief and director of maternal-fetal medicine at New York-Presbyterian Hospital/Weill Cornell Medical Center.
Chervenak’s view, one which has the weight of scientific evidence behind it, is not supported by policy makers and health advisors in many nations beyond the USA. In 2010, a Hungarian woman complained to the European Court of Human Rights in Strasbourg that,
“she was prevented from [giving birth at home] because health professionals were effectively dissuaded by law from assisting her as they risked being convicted under national legislation.”
This was ruled to be a breach of her right to respect for private and family life (article 8).
“The Court observed that “private life” incorporated aspects of an individual’s physical and social identity including the right to respect for both the decisions to become and not to become a parent, hence the right of choosing the circumstances of becoming a parent. Although the applicant had not been prevented as such from giving birth at home, there had been an interference with the exercise of the right to respect for her private life given that legislation arguably dissuaded health professionals from providing the requisite assistance.”
The UK’s Royal College of Obstetricians and Gynaecologists (RCOG) published a report last year suggesting that, for most women, giving birth in hospital is “not necessarily the safer option.” It further states that a third of women should deliver “without a doctor going near them.”
“These recent statements by professional associations and by the European Court should not be allowed to stand unchallenged,”
States Chervenak and further:
“Positions taken about planned home birth, in our view, are not compatible with professional responsibility for patients….We call on obstetricians, other concerned physicians, midwives, and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.”
The authors of the most recent paper point out, hospital care of pregnant and birthing women and their babies needs improvement. The first portion of the RCOG report, too, highlights the current problems in the care and management of women under the UK’s current system, where around only 3% of women give birth at home. Doubtless, there are problems on traditional hospital maternity wards where pain-relieving procedures, such as epidural anaesthesia, are available and caesarian sections can be performed. The report states that the patient:midwife ratio is stretched from the ideal maximal 28:1 to, in some areas of London, 32:1. Appropriately qualified consultants (senior doctors) are not available round the clock, leaving women and their children in the hands of relatively inexperienced junior doctors.
The answer, according to the RCOG, is to promote home birth as the favoured option for all women with no obvious risk factors of complications – for example, multiple births or maternal obesity. Anthony Falconer president of the RCOG believes that pregnant women “should no longer think of hospital as the default option when giving birth.” If one were to read an article in any pregnancy magazine or visit a website by the major pregnancy and childbirth charities, you would see that this advice is akin to that which they dispense and synchronous with the zeitgeist for all things “natural”. You may even believe this is what expectant mothers want, and for some this is true. One would certainly expect that the RCOG would be making such recommendations about home birth on the basis of statistical evidence of its safety for mother and baby. This is not the case.
In a decade, the number of women giving birth in England and Wales has risen by 22%. Despite that fact, the RCOG is calling for under utilised maternity units to close, and rather than suggesting, in their place, substantive measures or reforms that would increase the quality of care mothers and babies receive in remaining units, it instead it proposes setting targets for the number of women giving birth at home. Of course, closing small and underutilised maternity units would save money, but home birth is far less cost effective. On an average maternity ward, one midwife can be assisting more than one woman at a time during their labour, provided those women are at different stages of the process. To minimise the risks of home birth, two midwives are required to attend. Labour can last for many hours – even days – and if complications arise and transferring to hospital becomes necessary, the risks to mother and baby are increased many-fold over a hospital delivery.
Consultant obstetrician and gynaecologist Lawrence Mascarenhas believes “it is dishonest to downplay the risks of home birth,” and should the number of women at least attempting to deliver at home rise, then “there would undoubtedly be an increase in the number of babies that died during labour.” A meta-analysis published in 2010 in the American Journal of Obstetrics and Gynecology (the Wax Report as it is known) substantiates Mascarenhas’ concern. It put neonatal mortality in home birth, even with midwives present, at three times that of hospital delivery.
” Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates…Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.”
The Centre for Maternal and Child Enquiries produced its latest report, Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. A whole chapter within it (chapter 13) is devoted to the role midwives play in maternal deaths. It attributes 29% of all those fatalities to midwife error or neglect. A further 15% died from existing medical problems indicating that they should have been under a consultant’s care. In the UK, as in other countries, midwives tend to care for women with no overriding risk factors – that is, healthy women. In the Netherlands, research has shown that maternal deaths among women deemed to be high-risk (and therefore under medical care) are lower than those categorised as low-risk and under the care of midwives. So, all the evidence collected, so far at least, points to hospital births with a doctor in attendance is the safest option for mother and baby. And yet, in its report, the RCOG promotes home birth and a reduction in medical care. Maternal age is rising and in line with this, the incidence of multiple births as older women, finding it difficult to conceive, use fertility treatments. Obesity is increasing, as are the complications associated with it such a diabetes. It seems the RCOG is resigned to the rates of maternal and neonatal mortality rising, it’s just cheaper if you and/or your baby die at home.
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