Home birth at the center of debate: reflecting on a lifetime of practice
President of the Royal College of Midwives and Head of Midwifery, Ealing Hospital Trust
I have been reading with interest the furore caused by the publishing of a meta-analysis of home births in America (Wax et al, 2010). The meta-analysis suggested that planned home birth is associated with less medical intervention and a tripling of the neonatal mortality rate; this assertion is based on evidence open to challenge and has caused a wide range of comment in the British press. The Lancet (2010) published an editorial suggesting that women who chose to give birth at home had no right to put their babies' lives at risk. This prompted The Guardian to interview Cathy Warwick who described the editorial as 'sweeping' and 'misogynistic' (Ramesh, 2010). This was followed by a poorly researched and biased article in The Daily Mail (Fraser, 2010) accusing women who choose a home birth of being selfish and reckless. This is a popular daily paper read by many women.
Having been a midwife for many years now, and having been privileged to facilitate many home births, I am appalled at this scapegoating of home birth. In over 30 years of practice and many home births I have never transferred a woman, or baby, as an acute emergency from home to hospital. In this same article (Lancet, 2010), Professor Steer from Chelsea and Westminster Hospital, suggests that home birth is suitable only for second-time mothers who had a normal first birth. Of course, women should be assessed and advised to have their baby in hospital if they have high risk factors. However, the most common reason for transfer, particularly for first time mothers, is slow progress in labour, a gradually developing picture allowing for planned transfer. Women and midwives are not reckless with babies’ lives; home births in this country are almost always well planned and safe. What is worrying is the assumption that hospital birth is safe and guarantees a good outcome and a healthy baby.
As midwives we are proud of our status as experts in normality and we need to take this seriously and work with women to help them have births that are both safe and satisfying. I believe that these things are not mutually exclusive. Home birth is midwifery-led care at its best, with women and midwife working in partnership, working with physiology, but with an understanding that if things are not going well the relationship they have built of mutual trust will ensure that they are in agreement about transfer to hospital if necessary.
AS midwives we are trained in normality and recognition of when things are changing from normal, we learn to support physiology and espouse a holistic woman-centered philosophy. Our obstetric colleagues are trained in empirical science to diagnose and treat either with medication or surgery, their experience with childbirth is with the high-risk women or when things err from normality. They rarely, if ever, have the privilege to watch a spontaneous labour progress to a normal birth without intervention or complications. From these differing educational and experiential backgrounds we build our personal philosophy, so the midwife who practices in out-of-hospital settings views birth as normal and intervention as unwarranted. The obstetrician who works in a tertiary referral centre seeing women with high-risk pregnancies sees a pathological process. We interpret research according to our personal philosophy; so many obstetricians will see home birth as inherently dangerous. A home birth midwife will discard the evidence that does not fit with her personal experience of home birth.
Like Cathy Warwick, I do think there is a backlash against home birth. I would, however, probably use the term ‘professional patriarchy’ rather than ‘misogyny’. I believe that obstetricians who think home birth unsafe have the best interests of women and babies in mind. They work in the NHS which is a patriarchal institution where we are bought up to believe that doctor knows best. This coupled with their personal philosophy built on their education and experience, might explain the viewpoint that women who choose home birth are reckless.
What does this mean then for our personal practice? It has certainly made me reflect on my automatic response to defend home birth. In a lifetime of practice I have never yet met a woman who wants to put her baby at risk. Women are not a homogenous group; they have different experiences, needs and wishes. My role as a midwife is surely to be aware of the evidence ensuring I can see all viewpoints and am able to put personal bias aside in order to give the woman evidence-based information that helps her to make a choice that is right for her on an individual basis.