Debate around the safety of home versus hospital birth frequently comes to an apples and oranges draw; many people feel it’s difficult to compare outcomes between the two because planned home births are almost always low-risk in nature, while hospital births, which in the United States far outnumber home births, inherently include emergency scenarios and the statistical dips they cause.
There’s also little question that the intervention-heavy approach to birthing favored in most hospitals contributes directly to our nation’s unsettling birth safety statistics (we trail embarrassingly behind countless other countries when it comes to maternal death, for example, despite America’s unmatched financial expenditure), and increasing numbers of women are indeed choosing home birth as a response to that system’s failings. But so far, a dirth of truly comparable statistics, or comprehensive studies, has made it difficult to get an apples to apples view of whether home birth is actually more safe. Some people insist it’s far less so, although the same evidence problem exists for them. Thus, the debate swirls on.
The kind of controlled studies that would level the field for objective comparison would evaluate the outcomes of home or hospital deliveries by volunteers randomly assigned to one type of birth or the other. Of course, moms-to-be aren’t exactly breaking down the doors to participate in this kind of thing. Two Danish researchers, however, Ole Olsen and Jette Clausen , did find one such study involving a small group of women; the four randomly assigned to home births were happy with their experiences; while four out of the six randomly assigned to hospital births reported that they were disappointed with theirs. These results are fascinating and, in my opinion, telling, but we’re talking about a total of ten women here; it’s too small a sampling to indicate much about the big birth-practices picture.
Olsen and Clausen also thought the sample in that study too small, but they were able to draw some big-picture conclusions from another study, a review of 28,000 Canadian births which were broken down into similar risk categories. (I.e. apples with apples, oranges with oranges.) Among the low-risk births, outcomes were essentially comparable between planned home births assisted by midwives or physicians, and hospital births. The slight differences in outcome were not in hospitals’ favor, either: babies born in hospitals were slightly more likely to require resuscitation, oxygen therapy or hospitalization after birth.
This is huge. One of the most common refrains in hospital and home birth discussions, especially among moms who prefer low-intervention approaches and recognize the down-sides of hospital deliveries, is that the idea of home birth is nice, but the risk isn’t worth it. They want to be in a hospital in case an emergency goes down. I’m in this camp, too. But Olsen and Clausen’s study puts the perceived risk into perspective, which changes the risk-management game. The most relevant question for low-risk moms may not necessarily be “What about emergencies?”, but should perhaps revolve instead around which risks are most frequently incurred in each method of birth, and how to best manage and minimize those, whatever choice you end up making. As Dr. Gwen Dawar summarizes :
“There’s no denying it. Some emergencies can be deadly in the absence of immediate hospital care. Cord prolapse is one of these. Abruptio placenta may be another. But these complications are very unlikely to happen. Best estimates are that cord prolapse and abruptio placenta each occurs in about 1 in 10,000 home births.
As Olsen and Clausen note, that’s a very low risk indeed. ‘From a low-risk woman’s once-in-a-lifetime perspective, the risk of encountering such a complication is less than the risk of an average person being killed in a traffic accident during one year.’ Other complications, like shoulder dystocia, are more common. But such complications might be handled at home by a suitably trained midwife.”
In fact, Olsen and Clausen concluded “…there is no strong evidence to favor either planned hospital or planned home birth for selected, low risk pregnant women.” With this question out of the way, they deemed the down-sides of hospital birth – higher unnecessary intervention rates, for example – worthy of consideration. Of course, those risks can be managed in a hospital setting; birth plans, natural pain management, doulas, water births, and even midwives can all be incorporated into hospital deliveries, cutting down on intervention domino-effects while providing for emergency-care proximity.
Dr. Dawar also raises the issue of psychological down-sides to hospital birth, which can be offset by many of the measures listed above, or avoided in an at-home setting. One’s birth (and immediate postpartum) experience can, of course, have a lasting effect on baby and mom alike, but Olsen and Clausen’s study (and conclusions) allow the experience factor legitimate, long-overdue air-time. Home birth moms and advocates are frequently criticized for putting their emotional experiences ahead of their babies’ health and safety; if, as this recent study indicates, babies’ health and safety are equally sound whether born at home or in a hospital, a mom’s experience becomes a perfectly valid consideration in choosing to give birth at home.
In the United States, of course, the negative aspects to – and dangers associated with – hospital birth are even more pronounced than in Canada or the Netherlands; I’d be interested to see a review conducted here in the States of 28,000 similarly low-risk births… I wonder if, due to our high intervention domino effect and discrepancies in quality control from one hospital to another, home births would rank even more favorably?
How do you think we’d fare? Now that researchers are beginning to compare apples to apples, do the results make you think differently about home birth?