Thoughts on Homebirth and Safety

When we were getting our fetal echocardiogram, before looking at the results, the doctor talked to us about the risks. He said that, if he wanted to scare us, he’d say “You have doubled the risk”, if he wanted to set us more at ease, he’d say “You only have a 1 in 1000 risk”.

This came to me when seeing a debate about homebirth safety. One person put forth that this study showed triple the rates of infant mortality than in hospital births. That got me thinking- okay, so what rate are we talking? In trying to find out I found an even more disturbing rate- the US has a 50% higher first-day infant mortality rate than all other industrialized nations combined. That’s still not saying what rate we’re talking about here, but it does suggest that giving birth in the US in general is risky.

According to that article, it’s 2.6 deaths per 1000 livebirths. 0.26%. The study I quoted actually found infant mortality to be 1.3 per 1000 livebirths, half that number. I imagine the person was basing their “3 times higher” on low-risk hospital births rather than births in general, but according to this study, home births had a 1.5% rate of infant mortality and hospitals had a 1.8% rate, and after adjusting for the risk factor there was still a non-significant difference in the rate.

I still haven’t been able to find a study to justify the “3 times higher”, so I can’t address that directly, I’ll presume one exists, though, so let’s say that home births have a infant mortality rate of about 1.5% and hospital births of 0.5%. That’s a 1% difference. For some parents- that difference is plenty. 1% is far too much. For other parents, the benefits of home birth are still worth it. 1% isn’t that high.

Now, that non-significant difference is UNLESS risk conditions emerge- that bumps up the risk by 20%. (note: this is still included in the overall total, even with this raise homebirth still came out as statistically the same as hospital birth) This is why a lot of people don’t choose homebirth, you can never ensure that risk conditions won’t emerge and 20% is damn high.

One thing this got me thinking about is how we can increase the safety of homebirth.

Requiring a high level of midwifery education is something that seems like it really should be standard. I appreciate that some people would feel like this limits their choices, but as I said I’m thinking about how to limit the risks. I don’t know for sure, but I would really expect better outcomes from better trained midwives. And, ultimately, people can still have an unassisted birth if they’re really opposed to medical professionals attending. I’m not advocating it, but it’s an option, people still have choices. (whether an unassisted birth or a birth attended by an unqualified professional is safer is a debate well outside my knowledge)

There’s no way to completely determine if risk factors exist, but based on my experience- not all midwives are making any real attempts to try, nor are their patients. Homebirth midwives are overall part of a crunchy, natural, trust birth group- many of their patients don’t want the tests to determine their risk level. They don’t want ultrasounds, they don’t want doppler, they don’t want to get tested for GBS or gestational diabetes. Some people in that group want a totally unassisted pregnancy- not even getting medical check-ups with a midwife. Now, not ALL patients by any stretch. There does seem to be an anti-ultrasound slant, but many are fine with the other tests and our midwives did require the GBS and gestational diabetes tests.

This is complicated. A lot of the reason people choose homebirth is because they feel hospital birth denies them choices. Removing choices in homebirth may cause more people to turn to unassisted pregnancies, which I imagine are even more dangerous. They’re still an option, it’s impossible to force people to get medical care during pregnancy when some people dont’ even know they’re pregnant until they’re giving birth, but it shouldn’t be an option people turn to out of desperation. I think that, for things that can make homebirth significantly less safe, those tests should be required. Ultrasounds in a healthy, low-risk, no family history pregnancy may not be necessary, I believe some people refuse them even with OBs and a hospital birth. HOWEVER- they should be offered and the patients shouldn’t be scared off of them with baseless scare-mongering.

The midwives I worked with seriously dragged their feet on allowing me to get the fetal echo we needed to be fairly confident there wasn’t a serious condition (1 in 1000 is high enough for me). If the OB we worked with for the first trimester hadn’t told us we needed it, we may not have known to push for it. I want to think I would have, because I knew I had one as a baby and the risk was there, but it’s hard to go against your healthcare provider. In hindsight, I also would have felt a lot better getting a third trimester ultrasound as well- just for peace of mind. I wasn’t given the option and didn’t know to ask for it. After the birth, I’m really not sure what they checked with the baby- but they didn’t check my health nearly well enough. They didn’t test me for anemia or if I might need a transfusion even after I passed out from high (according to them) blood loss or even suggested I might want to increase my iron intake. That’s a problem that should be easily fixed.

At the same time, the OB presented the intensely painful and dysphoric vaginal ultrasound as non-optional, even though there was really no reason not to wait until they could do the belly one. Actually, based on others’ experiences, it seems like they could have done the belly one at 12 weeks- this guy was just being cruel for no reason. OBs presenting optional treatments as mandatory and acting without any empathy is precisely why some people run to homebirth.

After my experience, I’d honestly, strongly suggest anyone who plans a homebirth be shadowed by an OB as well as getting check-ups with the midwife. First, so that if you do need a hospital birth you can go to a hospital and doctor who knows you.  Second, because midwives won’t always suggest the same things doctors will- there are a lot of things I didn’t know that I wish I did.

I’m not opposed to home birth, but I want it to be as safe an option as possible- just like hospital birth should be.  Again, I realize that it’s a complicated situation and I’m not suggesting the changes will come easily, and I don’t want to push people to unassisted births if they are less safe (I really don’t know), but I would like home birth to be as safe as possible.

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