Are home births safe?

Home births may need less intervention and cause fewer injuries for mom. But they may be riskier for babies.

Don’t try this at home

Photo: Jon Lowenstein/Noor/Redux

Jon Barrett is accustomed to dealing with anxious mothers-to-be. As chief of maternal-fetal medicine at Toronto’s Sunnybrook Health Sciences Centre, one of the main concerns he hears from patients involves unnecessary medical interventions during delivery.

He acknowledges that the rate of Caesarian sections and episiotomies is far too high in Canadian hospitals. “A healthy young woman, coming into this hospital now for delivery, has almost a 40 per cent chance of having some sort of intervention that is not desired.” But he’s more unnerved by what that phenomenon appears to be triggering: a surge in demand for home births.

In Ontario, midwives performed 2,360 home births in fiscal 2008, an increase of 23 per cent in just five years. There are no national home birth statistics but the percentage of non-hospital births more than tripled in Canada between 1991 and 2007 (the latest year for which statistics are available), although they remain well under two per cent of total births. That rate is typical of much of Western Europe and the U.S.; the notable exception is the Netherlands, where roughly a third of women give birth at home.

Barrett’s concerns about home births stem from experience. Between 1990 and 1992, he was part of an obstetric “flying squad” in Newcastle, England. His job was to travel, by ambulance, to the bedsides of women whose home births had gone awry. “For two years of my life, I remember going to calls of people who got into trouble at home,” he recalls. “I just remember disasters.”

Two incidents are particularly vivid. The first occurred in winter. Navigating the ambulance through snowy laneways, Barrett’s team arrived to find two midwives frantically working over an unconscious woman. She was in shock and hemorrhaging badly. “I’ve never seen so much blood in my life.” She survived, but only after a massive blood transfusion in hospital. The second woman developed pre-eclampsia, which caused seizures, and went into cardiac arrest as his ambulance pulled up. His team was able to restart her heart and intubate her before rushing her to hospital. She also survived. He says both conditions were unpredictable and could have occurred anywhere, “But I know they would have come less close to dying if it would have happened in hospital.”

Unlike some of his colleagues on the squad who witnessed fetal deaths during home births, if Barrett’s memories were reduced to pure data in a typical study, they’d be unremarkable. That’s because most home birth data measures deaths, not complications, and his patients survived. “If you want a retrospective study, there’s no maternal mortality there . . . and so is that safe? No, it’s just bloody lucky.”

The question of how best to measure home birth safety has long plagued researchers. In Canada, national statistics don’t track birth outcomes by home versus hospital. Nor do they track the sorts of near-tragic outcomes described by Barrett. Yet what is counted— mortality rates for mothers and babies during childbirth—offers little insight on the maternal side because, in the industrialized world, maternal deaths from childbirth are rare. In 2007, 24 women died in Canada from pregnancy-related conditions, including delivery, compared to more than 4,000 stillbirths and deaths within 28 days of delivery. But stories like Barrett’s suggest the numbers don’t tell the whole story. In his view, the bottom line should be obvious: “Sooner or later you’re going to get a disaster because that’s the nature of obstetrics.” He adds, “It’s very rare that it will happen, but it’s got to happen more in home birth.”

That assertion is at the heart of a furious debate in the birthing community. Mothers who choose to give birth at home often cite research showing there are fewer medical interventions and no increased risk. But in the past year, a new study has emerged that contradicts this. It shows that home births are associated with significantly higher death rates for babies. If correct, the rights of women to control their own bodies and birth experience would seem to conflict with the best interests of their children.

When the American Journal of Obstetrics and Gynecology (AJOG) released the now-controversial “Wax Study” last summer, it created the medical equivalent of the Rift Valley amongst birthing experts. Led by U.S. obstetrician Joseph Wax, of the Maine Medical Center, it confirmed significant benefits to mothers who gave birth at home, including less hemorrhaging, vaginal tearing and epidural use, and fewer infections and Caesarean sections. Unfortunately, these benefits seemed to occur at the baby’s expense: shockingly, the report showed that neonatal deaths (defined as deaths within 28 days of birth) were two to three times higher for home births. Clearly, no woman who chooses home birth believes she’s jeopardizing her baby’s health, but the study suggested such faith in the safety of home birthing is undermined by medical evidence. For those who accepted Wax’s results, the benefits of giving birth at home suddenly appeared trivial compared to the risks.

In many ways, Wax’s study was groundbreaking. Because few women would agree to be arbitrarily assigned a birthing location, there are no randomized trials (the gold standard for accurate research) on home birth safety. Instead, researchers often fall back on “cohort” studies that analyze existing data, such as birth records. The biggest problems are selection bias—deciding which data to include—and, in the case of home births, self-selection: high-risk women tend to gravitate to hospitals while those more likely to opt for home births tend to be low-risk. There can also be issues with record-keeping; for example, if a home birth mother transfers to hospital because of an emergency, and her baby dies in hospital, it may be recorded as a hospital death, rather than a home birth death. Wax’s study, a meta-analysis, combined and re-analyzed existing studies, in order to create a bigger sample and, ideally, a more accurate result. He looked at more than 230 peer-reviewed papers published between 1950 and 2009, and selected a dozen that compared planned home births with planned hospital births by low-risk mothers in industrialized countries (Australia, Sweden, the Netherlands, Switzerland, Canada and the U.S.). The study’s vast scope—it encompassed more than 500,000 deliveries—boosted its credibility. As one doctor put it, “half a million births cuts out a lot of noise.”

Perhaps, but the momentary silence was followed by an outraged roar from home birth supporters, including some whose research showed very different results. “The Wax study is full of mathematical errors,” says Patti Janssen, a professor at the University of British Columbia’s School of Population and Public Health, and lead author of a 2009 cohort study that showed home births to be as safe as hospital births, for women and babies. “The design was wrong, and the calculations were wrong, and it just has to be thrown out the window.” Her objections encompass everything from Wax’s math to the studies he chose to exclude from analysis, and were published on Medscape.com in April in a critique whose co-authors include Ank de Jonge and Eileen Hutton, both lead authors of studies that conclude that home births are as safe, if not safer, than hospital births.

In the avalanche of media attention that followed, Wax initially defended his work, but then began refusing interviews, including for this article. As a flood of letters poured into the AJOG, some demanding the study be pulled, the publication convened an independent panel to examine the main complaints. In April, it published a sample of those letters, along with a detailed response from Wax. It also released the panel’s conclusion that the study did not need to be retracted.

But the debate has continued, and gained force, in the wake of a second study, led by Annemieke Evers out of the Netherlands. Published in the British Medical Journal last November, it concluded that babies born to low-risk women, under a midwife’s care (in hospital or at home) are more than twice as likely to die as those born to high-risk women who give birth under an obstetrician.

Although these results were specific to Holland, and may indicate problems in the way the Dutch system categorizes women as “low- risk,” the study nevertheless provided fresh ammunition to those who believe babies are best delivered by obstetricians, and added fuel to the home birth debate. More letters began to fly, adding to the stack of seemingly contradictory information through which pregnant women are required to sift in order to make an educated decision.

Nathalie Waite could be the poster mother for the perfect home birth. Waite’s considerations were largely pragmatic when she decided, two years ago, that her fifth baby should be born at home. She had four children attending three different Toronto schools, no nanny, and wanted her delivery to disrupt life as little as possible. It wasn’t a decision she made lightly. Her husband was nervous, but Waite’s midwife reassured them both. They lived near a hospital. Two attending midwives would be in close contact with Waite’s obstetrician and, at the slightest sign of trouble, an ambulance would be in her driveway. Most importantly, Waite knew her own body. She’d had four hospital births. During the two deliveries in which she’d fought—“and I had to fight because they always wanted to hurry the process”—for a natural birth she’d experienced far less pain. “By this time I was very well versed. I understood my pregnancies and I understood what kind of deliveries I have.”

Had she known what a home delivery would be like, Waite says none of her children would have been born in hospital. “It was purely beautiful.” While she laboured on the top floor of the house, her children played cards on the ground floor. Her husband checked on her between bouts of gardening, while her visiting parents kept an eye on the household. “I was left alone upstairs, peacefully, hearing all the activity happening through the house and it just felt so natural. It just felt right.”

This is why home births are special, says Anne Wilson, president of the Canadian Association of Midwives. “It’s a non-medicalized environment where birth becomes a normal part of your family life.” And they are safe, she stresses, in the standard response of home birth advocates: “Research says that for women experiencing low-risk birth, that outcomes are the same, in home or in hospital, with a lower risk of intervention.”

While the Wax study argues that outcomes aren’t the same, there is no debating the fact that home births have lower intervention rates. And everyone, on both sides of the argument, agrees that hospital intervention rates are too high. “In my opinion, the cascading interventions in hospital births start when the woman walks in the door,” says Tyler Shaw, the father of two children born at home.

His daughter’s birth, in Kingston, Ont., in 2007, was such “a spectacular experience” he and his wife decided to repeat it at their new home in Guelph this year. Unfortunately, their son was born with fluid in his lungs, which concerned their midwife enough to send them to hospital. Everything they experienced from that point on, Shaw says, reinforced their preconceptions. Their son was given blood tests, a chest X-ray and an IV for a condition Shaw believes would have cleared up on its own after several hours. They had to fight for permission to breastfeed (the doctors were concerned the liquid would enter the baby’s lungs) and, he says, when the pediatrician went home without leaving instructions for release, their son remained in an incubator for an additional 15 hours. “Our rights were completely taken away and doctors more or less said this is what we’re going to do to your baby and there’s nothing you can do about it.”

A musician, who also has a bachelor of education and master’s degree in environmental studies, Shaw’s mistrust of the medical system runs deep. “I’ve hung around scientists enough to be skeptical of everything I’m told,” he states matter-of-factly. He and his wife refused vitamin K and erythromycin ointment for their children, two treatments hospitals and midwives administer as standard protocol after birth. (Vitamin K ensures the baby’s blood can clot until it starts making the vitamin itself, and erythromycin is an antibiotic that protects against infections from the birth canal that can cause blindness.) It was the words of his sister, a doula, that convinced him and his wife to take that stand. “She said that a baby has the right to having a whole, intact, unadulterated body and that we should try to protect that right as a baby’s parents.”

In many ways, Shaw and Waite represent opposite ends of the home birth spectrum. Certainly Shaw’s rejection of many of the fundamental tenets of modern medicine contrasts with Waite’s attempt to adapt its benefits to a home birth. But they share an important piece of common ground: both chose to deliver their babies with the help of a midwife.

Freebirthers, women who deliver without assistance (and often shun prenatal care), represent the smallest sub-section of home birth mothers, and aren’t included in studies on home birth safety. Among their most famous advocates is Janet Fraser, an Australian woman who made famous the term “birth rape” to describe an emergency episiotomy during the birth of her son. “I don’t care if you don’t like the word or the idea, it’s real so get used to it,” she wrote on her site, JoyousBirth.info. “When you shove your arm in a woman who’s screaming no, that’s rape. When you rupture those membranes because you have to tick the box and comply with ‘protocol’ even when the woman screams no, that’s rape. When you slash a woman’s vagina with scissors and she’s screaming no, that’s rape and on the street it would earn you a jail sentence.”

In 2009, Fraser’s baby daughter died after five days of home labour. She continues to advocate for freebirth.

Freebirthers make most midwives nervous and they horrify obstetricians. Freebirth is the equivalent of playing “Russian roulette with your child,” says André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada (SOGC). “You don’t play with a child’s life. Especially not where [health care is] free.” That said, the SOGC does believe that midwife-assisted home births are “a reasonable alternative for low-risk women.”

Yet, asked if he would consider home birth a reasonable option for his family, Lalonde is unequivocal. “No. Definitely not.” He falls back on experience for explanation. “I’ve participated in over 6,000 deliveries in my career and I know that everything looks very fine and suddenly disaster strikes.”

That conflict between medical experience and faith in a woman’s body to deliver naturally lies at the heart of the home birth debate. But is the concept of natural childbirth in danger of being romanticized? The ideal of the less-medicalized birth experience, as extolled in Naomi Wolf’s 2001 book Misconceptions, has become part of the zeitgeist. There is a documentary, popular amongst home birth advocates, entitled Orgasmic Birth; its website invites viewers to “witness the passion as birth is revealed as an integral part of woman’s sexuality and a neglected human right.” Ami McKay’s award-winning novel The Birth House makes a compelling case for home births to a more mainstream audience. In it, the doctor is portrayed as a condescending, patriarchal figure who knocks out his protesting patients with ether, then yanks out their babies. In contrast, the methods of midwife Dora Rare are equally suspect (think mandrake root and witchcraft) yet portrayed with exquisite humanity. Even when things go wrong, the women are in control, being cared for by women.

That kind of experience need not be exclusive to home birth, insist obstetricians. “We should be working to make the environment of the hospital conducive to the home birth experience, rather than having more deliveries at home,” Sunnybrook’s Barrett says.

But midwives like Anne Wilson maintain there’s nothing to equal the experience of a home birth. “If I am delivering a baby in the hospital, you’re a guest in my house. If I’m delivering a baby at home, I’m a guest in your house. And there’s quite a lot of psychological difference there.” Wilson hopes the demand for home births will continue to rise in Canada. That said, she believes that all low-risk women, including those who choose to give birth in hospital, should deliver with a midwife.

That’s the system adopted by the Netherlands—and the Evers study suggests it’s failing dramatically. Amy Tuteur, an American obstetrician/gynecologist, thinks that the study’s results are just common sense. One of the harshest critics of home birth, Tuteur’s blog, The Skeptical OB, takes an unflinching look at labour and challenges the assumption that it’s best left to Mother Nature.

“Childbirth is inherently dangerous,” she writes. “In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood.” Educated at Harvard College and Boston University School of Medicine, Tuteur in her blog shines a harsh light on much of the romanticism surrounding home births, and includes first-hand accounts—harrowing and heart-breaking—of women whose babies died during home births. “Why does childbirth seem so safe?” she continues. “Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90 per cent and the maternal mortality rate 99 per cent over the past 100 years.”

Until recently her views, not surprisingly, were echoed by the American College of Obstetricians and Gynecologists (ACOG). But in January the college softened its position, replacing its formal statement against home birth with a committee opinion recognizing that women have the right to choose, although they should be made aware of the risks, including those highlighted in the Wax study.

That change represents a huge step away from attitudes that were considered paternalistic, says Richard Waldman, president of the ACOG. More importantly, it allows the debate to shift from trying to prevent home births to making them safer. “I don’t think it’s that important to debate whether it’s safe, safer or not safe. I think it’s very important to debate how we can make home birth safer because women are going to do it anyway.”

In the United States, one way to improve safety is by improving midwifery. Training and regulations are a patchwork across the country; in some states, midwives aren’t even required to finish high school. In that respect, the U.S. lags many industrialized countries, including Canada. It’s one of the reasons Canadian midwives bristle at comparisons.

In contrast to the U.S., our midwives are university educated, highly regulated, and well-trained in emergency skills, notes Vicki Van Wagner, Waite’s midwife and an associate professor of midwifery at Ryerson University. They can ventilate a newborn, provide oxygen, and stabilize a hemorrhaging mother with an IV and anti-coagulant drugs before sending her to hospital for a blood transfusion. While they can’t administer an epidural or oxytocin, or perform surgery, they’re trained to recognize warning signs and transfer patients to hospital if such treatment appears likely to be needed. “It may be that there are some problems that occur, very rarely, at home that would be better served in hospital, but there are problems, like infections, that occur in hospital as well,” says Van Wagner.

Obstetricians and midwives are in broad agreement on the key measures necessary to reduce risk during home birth. They are the steps taken by Waite: ideally, a low-risk woman would deliver with the assistance of two highly trained midwives who are in close contact with an obstetrician at a nearby hospital. When those steps are put in place, Wald­man says, “it can work almost as safely as the hospital situation.”

Is “almost” good enough when you’re talking about the survival of a newborn baby? Although he describes himself as a long-time supporter of midwives and birthing centres, the ACOG’s Waldman echoes his Canadian counterpart, Lalonde, when he says he wouldn’t want a home birth for his wife or daughter. “The intrapartum loss rate has got to be higher at home, it’s just intuitional for anybody who does this work. How big that number is could be debated.”

And is being debated. As larger and larger studies are undertaken, Sunnybrook’s Jon Barrett believes the data will start to show consistently higher risks associated with home births—and science will remain a lightning rod. “There’s such a powerful natural childbirth lobby that anyone who publishes something like that is going to come under a lot of criticism, justified or unjustified.”




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Are home births safe?

  1. When you have an intervention rate of nearly 40% in hospitals in regards to birth, it’s not surprising that some people are starting to resist even entering hospitals.

    Of course I find this rate unsurprising. The second you enter a doctor’s care the legal ramifications of inaction or improper action become overwhelming and unneccesary interventions are bound to sky-rocket as a result.

    I wonder what can be done to combat this tendency?

  2. The best way to combat the tendancy of unnecessary interventions is for a pregnant woman to have open communication with her physician about what her wishes are prior to going into labor.  There are physicians who do not do routine episiotomies,  who will allow you to have anyone you chose in the birthing room (including your older children – with an adult support), etc.
    Sometimes however, interventions are necessary and people need to trust the medical team.  What is the goal of a labor & delivery afterall….is it to have no interventions or is it to deliver and healthy baby and maintain the health of the mother?  To pretend that we cannot improve on this “natural” process is to say that we are okay with the rate of infant/maternal mortality that occured before the advent of modern medicine. 

    • Seems reasonable, but then the 40% intervention rate smacks you in the head again.

      The status quo isn’t working, obviously, so we need a better answer than that.

      And for the record, if my wife wanted a home birth I’d be freaking out with worry, so it’s not like I’m an advocate.

      • I am not sure about the definition of  “intervention”.  Would that include fetal heart monitoring?   As for the status quo not working….we have a whole bunch of other people who want caesaren sections with epidurals…..as far from natural birthing as you can get.  I think the truth of the matter is that most women are okay to go to the hospital, giving birth and return home in fairly short order.  Once you are in active labor, you don’t think about much but getting through it.

        • First of all, outcomes were affected in the past by many other variables aside from being in the hospital. Overall awareness about basic health and nutrition have improved dramatically during the time hospital births have been promoted as the “norm.” For a woman who is in good health and has every reason to view her pregnancy and birth as normal it should be her choice. If doctors would like fewer cases of malpractice, they should be in favor of greater choice, and eschew the paternalistic model that they have promoted to dominate people’s lives and choices. Real preventive care is knowing your body in its natural state and trusting in your being at all levels, physical, emotional and spiritual. The modern model of medicine views the body on a merely mechanistic level, which is diametrically opposed to the experience of being embodied by anyone who is spiritually aware, something a home birth can help women tune in to on a deeply profound level. This is not particular to any religious belief, but a fact that can only be experienced on a personal level. The dominating modality promotes fear and anxiety to obtain the outcome of submission from those it preys upon.

          On the other hand, I support any woman who feels instinctively safer in a hospital for whatever reasons of her own. No one is threatening the right of any woman to go to the hospital. And certainly it would be advisable for women to educate themselves, and pay close attention to any signs or indications that there may be a problem, even if it is “merely” a gut feeling at the last minute that you would rather be in the hospital. I had a midwife whom I trusted implicitly who told me she would insist we transfer to the hospital if anything went wrong. I would not have questioned her judgment if that had happened, merely to preserve for myself and “ideal birth” and I highly resent the implication that because I chose a home birth that it was for purely selfish reasons!

          • Very few physicians in Canada are successfully for malpractice….this is not the US.

          • No amount of good nutrition or trusting your body is going to prevent cord prolapse, shoulder dystocia, placental abruption, or post-partum hemorrhage – all of which are unpredictable and can occur even in women with low risk pregnancies.

          • And no amount of hospital intervention is going to eliminate any of those situations, either. What’s your point? That we should accept the baby mill approach of hospitals as inherently safer? How about the kids who’ve had their heads punctured by forceps over the years? Or that we’d never have seen advances like birthing pools if we’d left things up to doctors?

          • The point, Ben, is that when those complications arise, it is far better for the labouring woman to be in a hospital with access to a surgical suite than at home.  Don’t pretend you don’t know this.

          • Actually, well conducted Canadian studies (Janssen et. al. 2009) show that counter to your intuition, it is just as safe for these emergencies to occur at home with a trained midwife (or just as dangerous for them to occur at the hospital). 

          • UNCDave, so your point is what, then? That homebirths shouldn’t be allowed because of some rare instance where complications arise that the midwife can’t deal with or that can’t be solved by a quick ambulance ride to the hospital? That we should just shut up and put up with the baby mill approach of hospitals, with all its warts?

            The question becomes one of balance — what’s better, on the balance? That mothers have access to the kind of care that best suits their pregnancy? That we reduce the number of unnecessary medical interventions? That we reduce the risk to the mother and child, not just from the rare emergent complications, but also from the hospital experience?

            Are you suggesting we ban homebirths entirely? I fail to get the thrust of your arguments, other than to basically claim the medical profession is blameless and above reproach. I certainly don’t claim that for midwives.

            So…again: what’s your point?

          • Yes, a well trained midwife should be able to resolve shoulder dystocia at home, but other emergencies, like a cord prolapse or placental abruption, can result in fetal death or brain damage in a matter of minutes. Midwives do not offer emergency c-sections at home, and I am personally not willing to risk my life or that of my child on the speed of a hospital transfer during an obstetrical emergency. Perhaps that is relying on “intuition” but in this case, I’ll take intuition over a study.

            I would also note that the Janssen study is limited by sample bias, because the subjects self-selected either a home or hospital birth. Also, the study does not reveal any clinical details of the perinatal deaths involved, so it is difficult to evaluate which births may have reasonably been expected to have better outcomes in a hospital setting.

            You may point out that things like cord prolapse are very rare, which is true. But that is cold comfort if you happen to be unlucky, even just once.

            It all comes down to your individual level of risk tolerance, and families have a right to evaluate the risks and make the decision they are most comfortable with. But it is difficult to have an honest discussion about those risks when home birth advocates exaggerate the risks of hospital interventions (and ignore any possible benefits), while minimizing the risks of home birth or ignoring anything that puts home birth in a negative light.

            Calling hospitals “baby mills” adds absolutely nothing the discussion, either.

      • I wrote this response earlier but Macleans seems glitchy today and it disappeared after I edited it for spelling errors, so apologies if it shows up twice:

        I am curious about the 40 per cent unwanted intervention rate too. What exactly does this include? Are the reasons for these interventions being fully explained to women? Do women discuss them with their doctors beforehand? Do they understand the risk / benefit analysis behind these interventions? Do these interventions, although perhaps unpleasant or less than ideal, improve outcomes? And how heavily should the discomfort vs risk decision weigh in the discussion? (E.g. being given oxytocin to encourage the uterus to contract after birth, vs the risk of post-partum hemorrhage? An episiotomy vs a 3rd degree tear?)

        It’s very difficult to have these conversations in a sane, polite, and rational way when one woman’s mild inconvenience is another woman’s “birth rape.”

    • It is impossible to have open communication with many doctors! They simply consider their ideas superior and condescend to anyone who holds an independent thought! This is more the norm, than the exception, I am sorry to be the one to break this to you!

      • That has not been my experience at all.  I have a family physician who invites my input and I had two different physicians deliver my children who were completely open to whatever I wanted to do.  I had almost no interventions – not that I would not have welcomed some great pain management; my 61/2 year old daughter attended the birth of my second child with a family friend and I went home 2 hours after the birth.  I think people want to believe that the hospital is very paternalistic and all doctors are taskmasters.  It just is not so.  In Alberta, you can actually hire the midwife or a doula to come with you to the hospital for the birth. 

      • I too have no trouble communicating with doctors. Perhaps because I start from an assumption of mutual respect rather than paranoid inferiority.

        • Or perhaps because you’ve been extraordinarily fortunate with physicians, or have a natural more assertive personality. I was raised around doctors and even I’ve had to deal with the overbearing “we know what’s best for you and will not be questioned” attitude they drill into physicians in med school.

    • The fact that you have to specify that there are physicians who do not do routine episiotomies I think speaks quite loudly for why some people are looking to home births.

      Actually, just the idea of “routine episiotomy” is argument enough.  There should be nothing “routine” about using a scalpel to slice a woman’s vagina.  It is unfortunate that we pay our surgeons per procedure, as that just incentivizes this kind of behavior.

      • Thwim, I am not sure how many births you have been to but unless the head comes out slowly allowing the vaginal opening to stretch (with massage), there is going to be some “tearing” going on.  Now, if that head is really big and comes really fast, the tear might be big & ragged and might go all the way to the anus…in which case a woman could have anal leakage for the rest of her life.  Some physicians think it is better to do a surgical cut (after freezing the area with lidocane).  Others think the tearing is better.
        Regardless, in Alberta, physicians are paid for the delivery…not for each part of the process.

        • Tears heal better than episiotomies. The research is quite clear. 

          If a woman is going to have a 4th degree tear, she will tear into her anus even with an episiotomy, except now she will not have torn in the best way possible for her body, as a doctor will have guessed at the structure of her perineum (which are not all the same). The only reason to cut an episiotomy is if there is an actual acute emergency and the baby needs to come out in the next 30 seconds. It is (should be) the job of the care provider to support the woman in a slow delivery, in a warm tub if possible. The woman should be educated that it is important not to push hard when the baby is crowning. And 4th degree tears do not necessarily result in anal leakage for the rest of your life–pelvic floor exercises are important for all woman who have given birth, and help women who have torn to solve incontinence and leakage problems. 

          • Actually, if you make a cut in a different part of the perineum you may be able to avoid a third degree tear toward the anus.
            I know the research supports that tears heal better than cuts.

    • The point is, is that interventions are pushed on women because hospitals set an arbitrary timeline on labour and birth. Of course the safety of mother and child is the most important concern during labour, but so should be a woman’s wish for a natural birth if everything is going smoothly in labour.
      That is also so very black and white to say that if you don’t agree with interventions, means you are okay with a mother or baby dying. It is in what circumstance these interventions are put into place.

  3. I think it’s unfortunate that the best the good doctor can say against home birth is “The intrapartum loss rate has got to be higher at home, it’s just intuitional for anybody who does this work.” Notice the use of the term “got to be”. Barret isn’t discussing facts here, he is discussing his opinion and projecting an outcome he isn’t confident enough in to assert.

    He is also not very certain about the hospital’s ability to help with the trauma cases he attended in England saying  “But I know they would have come less close to dying if it would have happened in hospital.” This time, birth at hospital would have meant these women would be “less close to dying” than at home. Not safe. A degree or a few less almost dead. From the sounds of it, his and the midwives response to the unexpected emergencies were appropriate and successful and he experienced no deaths due to choice of place of birth. Would those women have the same emergency problems in hospital had they chosen to give birth there? Yes! And, likely, their outcomes would have been the same: they were treated in a timely manner using the appropriate measures with good effect.

    Essentially, the doc, personally, doesn’t feel like he’d be safe at a home birth. Luckily, those women in Canada who are low risk and attended by qualified midwives or family practitioners (some family docs still go to births) have the choice to give birth at home. And, ultimately, it’s the ability to choose that matters.

    • So you expect doctors to have crystal balls that tell them without any doubt the outcome for every patient in any given situation? Sorry, medicine doesn’t work that way. Barrett may not be able to give any guarantees or make concrete promises in retrospect, but being “less close to dying” is a good enough reason for me to choose a hospital.

      • Why are the people defending the doctors all using pseudonyms? Just saying . . .

        • Ad hominems will get you nowhere. (And ‘defending doctors’? Are they on some kind of trial or are we in some kind of war I wasn’t aware of?)

          • They’re absolutely on trial. When a quarter of the births in Canada are c-sections, yes, the doctors need to be held accountable for unnecessary medical interventions.

          • How can you tell if a CS was unnecessary before it was done?  OBs, using the best clinical information they have, make a decision to section b/c they’re worried about the baby.  It may turn out that the section was not required, but that’s only apparent after the fact.  Or do you believe that OBs are doing CS just so they can ‘make their tee-time’?

          • UNCDave, that’s a load, and if you’d ever worked in a OB ward, you’d know that. A large number of c-sections are pre-planned, by the mother’s choice, and encouraged by the physician so as to essentially skip labour. Another chunk are done to meet schedules.

            Sounds like you’ve been drinking the “doctor’s always right” kool-aid.

          • Ben, in one instance you’re claiming that the woman’s right to choose home birth or to be attended by a midwife is extremely important, but then you mock the choices of women who would choose a cesarean (for whatever reason) ?
            Choice is either important or it’s not. You can’t have it both ways.

          • Meagan, I’m not mocking them. I’m suggesting that doctors are not
            keeping them well-informed as to potential side effects of c-sections on
            themselves. I have a certain personal distaste for people who treat
            birth as if it ought to be somehow convenient, yes, but that’s a
            personal bias that’s not relevant to the issue at hand.

          • Funny how home birth supporters are all about women’s choices – as long as women choose a natural, unmedicated birth.

            Ben, you’ve made a lot of statements about c-sections that you simply can’t support, and I wonder why you have so much animosity towards a life-saving medical procedure? Do you feel the same way about coronary bypass surgery or appendectomies?

            Unless you have the medical records of every c-section patient in Canada, you are in no position to decide which c-sections were necessary and which weren’t.

        • Yes, after all, it’s not like just anybody could come up with the moniker “Henry Dinglefarber” or  “Suzanne Montalalou” those must be real names after all and as such the opinions posted by them more deserving of respect.. even though I just made at least one of them up.

    • The physician is saying he attended many home births and he does not understand why women feel the need to take the additional risk to have a baby at home because he has been a few where it was touch & go for the mother. 
      Yes, in Canada you have the choice to have a home birth but as someone who has experienced giving birth in a hospital with a birthing room that allowed me to have all my family there, including my daughter and invites you to have a midwife….I don’t know why you wouldn’t want a neonatalogist there & an anaethetist……..  there seems to be some misconception about what goes on at a birth in a hospital.
      Shop around.

      • Sounds like what is was like when my wife gave birth.  A very nice room where she was attended by two midwives.  When things weren’t going well, we had two OBs come in, along with two peds for when he was out.  Hate to imagine what would have happened at home.

      • Actually, the OB, Jon Barrett, is saying that he was part of an ambulance team that was called when emergencies happened at a home birth. So by definition, ALL he saw was ‘disasters.’ Access to ambulance services and paramedics makes home birth (and our lives in general–which we live at home and not in the hospital) safer. However, the OB did not have a chance to attend home births that went beautifully, which are the majority. He had a skewed experience and came away with a skewed perspective, not surprisingly.

      • Funny. I thought that’s exactly what someone going for a home birth was doing.. shopping around.

        • I am not aware of a whole lot of physicians that participate in home births – usually midwives do.  I was saying that if you have a physician who is not open to your ideas and who you feel intimidated by, you should “shop around” until you find one you feel more comfortable with. 
          However,  a home birth is absolutely an option for anyone who is considered a low risk.

          • The only problem with the “shop around” is when you are in hospital giving birth you don’t always get your doctor.
            I’ve had 3 children. Each birth was different. All three were with midwives. My first was in hospital, went very smoothly and everything “to plan”(I also stayed home until 8cm). My second was in hospital, we needed assistance and no one was available. My son was born within 5 minutes of arriving at the hospital and was born not breathing due to the cord around his neck and I was in need of assistance as well, no doctors were available.
            My third was born at home, She got stuck on my pelvis and needed to be fairly forcefully removed.
            I enjoyed my home birth and would entertain the idea with a fourth pregnancy, although I believe it should only be considered if the pregnancy is healthy. I love that we have the choice.

          • The only problem with the “shop around” is when you are in hospital giving birth you don’t always get your doctor.
            I’ve had 3 children. Each birth was different. All three were with midwives. My first was in hospital, went very smoothly and everything “to plan”(I also stayed home until 8cm). My second was in hospital, we needed assistance and no one was available. My son was born within 5 minutes of arriving at the hospital and was born not breathing due to the cord around his neck and I was in need of assistance as well, no doctors were available.
            My third was born at home, She got stuck on my pelvis and needed to be fairly forcefully removed.
            I enjoyed my home birth and would entertain the idea with a fourth pregnancy, although I believe it should only be considered if the pregnancy is healthy. I love that we have the choice.

      • I work in birth rooms at home and in hospital. I know what goes on in both. No matter how inviting you make a hospital room, it is not home. There is a distinct difference between birth in hospital and birth at home. And I’m not knocking hospital births. I’ve had one (and one home birth), I’ve attended many that were blissful. They are fundamentally different than home birth. And, if home is not where a woman feels confident birthing, she should absolutely go to hospital. But, more than 1% of Canadian women either prefer to birth at home or they have no safer choice (in northern communities, home birth often happens due to the distance to hospitals) and those women deserve not our doubt but our work to continue to make available and improve the safety of home birth.

  4. Why is it okay for this doctor to site “intuitional” and “personal experience” as if it had weight when the rest of us would be scoffed at for such remarks? I am sick of doctors who enthrone themselves as supreme in their so-called knowledge while they unquestioningly prescribe boatloads of drugs that have been sold to them, without giving proper consideration to side effects, and flat out denying they could even be occurring even when confronted with the evidence? My kids have had reactions from shots that were unilaterally dismissed as having any connection with the vaccination, given medications that I had to monitor for side effects because the doctors act as if this is not even an issue, nor a real concern, and I had my daughter in the hospital and my son at home. Neither one was a “disaster” just as my intuition had led me to expect. I am sick of main stream medicine and have no use for except under very limited circumstances. If doctors cared about their patients they would be railing against corporation that cavalierly pollute our environment and our food supply and then provide the answer in the form of drugs, appliances and procedures that would not be necessary if they were not poisoning us in the first place. They just laugh all the way to the bank and the doctors get rich right along with them, looking down on their patients as if they were the idiots.

    • The doctor’s personal experience carries more weight because it includes many births over a couse of several years, to which he comes as an impassioned outsider. The “rest of us” would cite personal experiences of our own or close aquaintances, a much smaller figure from which to draw data.

      • Okay. How about the midwife’s opinions? The average midwife has delivered as many children as the average ob/gyn, and had more training in doing so, at least in Ontario.

        • Unmitigated BS.  An average OB will have delivered hundreds or thousands of babies; heck, by the time they’ve done their four (or five) years of residency training, they’ll already be in the mid hundreds.  Midwives?  They average one birth per week (my wife and I used a midwife for our baby (planned hospital birth), although it was necessary to transfer care to an OB, and they are limited in how many clients they can take on at one time.

          As for training, get real.  A BSc in midwifery is a four year program, with two years of that being a practicum.  As I mentioned, the OB will have four years of med school, followed by four years of residency training.  To be fair, not all of that is in obstetrics, but during the time she will see a far greater variety of pregnancies and complications, and will have a far better idea of what to do about them.

          • A question worth asking is what type of births are these OB’s/MD’s witnessing? fyi- the mother does the delivering of the baby.
            These thousands of births you are referring to involve the doctor being present for short periods of time and often only showing up as the baby arrives. What they are skilled at is managing the birth process from afar. What they are not skilled at (speaking in generally) is what a normal, healthy woman in labour looks like.Medical professionals (I am including MDs and RNs here, having been an RN myself) are given minimal training on what a ‘normal’ labouring woman looks and acts like (hint-it is not flat on her back in a bed, strapped to machines and IV poles). 

            I am not saying that MD’s/OB’s don’t have a place in high-risk childbirth but for the average woman it doesn’t make sense. For the births of my children I had highly educated and skilled midwives who  helped me avoid many of the interventions that would have put me and my babies at risk.

          • The things is, most of those births in hospital are normal births.  Either no complications or very minor, easily managed ones, so they do know what a normal labour looks like.

            Now, if you want to argue that OBs are not involved in the early stages of labour, hey, I agree.  But in most cases, they don’t need to be.  The most dangerous part of labour is the second and third stages, and that’s when you want a doc there.  

          • in reply to UNCDave’s comment 
            “The things is, most of those births in hospital are normal births”
            I guess in the sense that those are the ‘norm’ for our North American culture you are correct. 
            I am not saying these are good or bad births, that is for the mother to decide. However, I do not consider that standard to be normal as do many others. 

          • Precisely. Obstretrics is an afterthought to a plethora of general training to be an MD. A midwife has had specialized training.

            And one birth a week? Sorry, where are you getting that number from? It has the distinctive scent of “pulled out of thin air.”

          • In Ontario, midwives each look after approximately 40 women a year, and there are two midwives at each delivery.  On average, you could expect a midwife to attend 80 deliveries a year.  That works out to about 1-3 deliveries a week.  Babies don’t come on regular schedules, hence the variability week to week.

          • Obstetrics is a surgical specialty. An OB is well versed in management of non-physiologically normal birth. I know of no single OB or RN education that requires the student/resident to attend the birth process from early active through to post third stage, which is what midwives do. As a doula, arguably, through my career, I will have spent more time with women experiencing phsysiologically normal birth than an OB. Now, you wouldn’t want me or a midwife performing a c-section or a vacuum delivery – totally outside of our scope – but midwives are really, really good at knowing when things aren’t normal anymore and that’s the point when doctors are needed for guidance or to take over care and management.

    • Because he’s delivered thousands of babies, whereas even the most procreative women have given birth to but a handful. Personal experience borne of thousands of repetitions is worth more than personal experience of 2 or 3. 

      • What about all those babies that were born before there was even such a thing as doctors?

        • And how many of those babies died?

          • Babies don’t die in doctors’ care?

          • Of course not. But modern obstetrics has greatly improved maternal and perinatal mortality rates. Ask your great-grandma.

          • Sorry, D.O.T., ran out of reply buttons, so I had to bop up here to answer. But anyway, I can’t ask my great grandma, as she’s dead. Weird, we just can’t seem to figure out whether this “death” thing is a bug or a feature of our design.

          • The problem with your argument is that it presumes that midwifery is essential a throwback to the 1800s. Modern midwives balance the best of both worlds.

          • I’ve read my exchange with caigola13 twice now and am 100 per cent confident that I did not state or imply anything negative about the skill of modern midwives, the majority of which (at least in Canada, the UK, and Australia) work in a hospital setting with OBs as back-ups, and therefore can be be considered part of the modern obstetric system. Either your reading comprehension is poor in general, or you are becoming slightly hysterical in your single-minded defence of home birth.

          • There was a dramatic rise in fetal and maternal death when obstetrics began taking over normal maternity care.

            It’s not either / or, you know: modern obstetric care can works in tandem with midwifery care to provide the best of both worlds where appropriate (supported physiologically normal birth in hospital, safe birth support at home).

          • If you are referring to the high rates of puerperal fever that existed in the first lying-in hospitals before germ theory was understood, you may be interested to know that early midwives were also responsible for their share of spreading the infection. One German doctor made many enemies in the midwife community following various midwives to try and determine why some had very high rates of puerperal fever and why some did not. Mary Wollstonecraft was delivered by a midwife and later died of puerperal fever associated with retained placenta, which the midwife left behind. As my original comment stated, modern obstetrics, which as I have mentioned up thread, which can include highly trained midwives who know when to transfer care to an OB, has greatly improved maternal and perinatal mortality rates.

            I am not sure what you mean by “normal” maternity care, since midwives, at the time you seem to be referring to, were hardly the equivalent of the kind of highly skilled midwives we have today in Canada, the UK, and Australia. There was a reason the church licensed midwives in parts of Europe during the middle ages – they were trained to perform the last rites.

            I agree wholeheartedly that it is not either or, which is why I roundly reject the false dichotomy that OBs are all evil and want to cut you open just for kicks, while midwives are all sweetness and light and never do anything wrong.

      • Yes. he’s attended the births of many babies. You have to keep in mind though, that we see things through the lenses of our experience. An obstetrician is the doctor who is trained in cesarean section and emergency procedures for when things go wrong. When a family doctor or a midwife has an emergency, they call an obstetrician. So over the course of his career, the obstetrician sees many more emergencies and out of the range of normal births than a family doctor or a midwife. The OB is the expert in ABNORMAL birth and what to do, and this shapes his view of the world of birth. Family doctors and midwives are experts in NORMAL birth, which is the category that most births are in (except that now we have such a high rate of unnecessary interventions that there are a lot of births that start out normal and become abnormal through the use of routine and unnecessary medical interventions–even something as innocuous seeming as continuous electronic fetal monitoring leads to higher cesarean section rates, compared to intermittent auscultation with a handheld Doppler or fetoscope). While it may seem that OBs are the experts on birth, in reality midwives are the experts on normal birth and are better able to speak to the issues of normal birth. As the OBs statements reveal, they tend to see birth as a disease state and a disaster waiting to happen, while midwives view birth as a normal life process and a miracle waiting to happen (the birth of the baby!) Family doctors tend to fall somewhere in between. See Dr. Klein’s recent research published in JCOG and Birth for the studies on care providers attitudes and beliefs about birth. 

        • Another hoary old trope.  A mid career OB will have seen thousands of births.  Even if only half are normal, they will still have far more experience with normal births than any MW or GP.

          As for your concluding remarks, it is because they have seen so many births that they know that a birth is BOTH a miracle and a disaster waiting to happen.  Those who only see the miracle part are the ones who are not prepared when things go badly.

    • Well Suzanne, I am glad to at least have use for physicians under limited circumstances….like if your child requires an appendectomy or some other emergency intervention.

    • “If doctors cared about their patients they would be railing against corporation that cavalierly pollute our environment and our food supply and then provide the answer in the form of drugs, appliances and procedures that would not be necessary if they were not poisoning us in the first place.”

      Fear of poisoning is a common symptom of paranoia. I would talk to my doctor about these feelings if I were you.

      • DOT, stop being naive. She’s talking about concerns over genetically modified crops on one hand and that drugs are overprescribed in our society on the other. I doubt even you can argue that those are significant issues beyond your contemptuous dismissal of them as paranoia.

    • I hope to God you are not a midwife. If you are and have that militant attitude towards doctors, you will no doubt be putting lives at risk. Why do you have so much anger towards the medical profession?

  5. I just can’t believe the author of this piece took Amy Teuter’s sensationalist views seriously enough to quote some of her blog entries.

    Apart from that, comparing stats from ACOG and ACOG’s OB’s and applying them to the state of homebirth in Canada is like comparing apples to oranges. Homebirth under a qualified, regulated midwife in Canada is safe, for both baby and mother. This is, in fact, the reason that midwifery care and choice of birthplace is completely covered by OHIP – when midwifery was first regulated in Ontario in 1996, numerous government studies failed to find one place of birth any safer than the other, with qualified attendants. On the other hand, midwifery in the United States is completely unregulated. For too many American women, to have a homebirth means to be attended (often illegally) by a lay midwife with no actual medical training, or to have no midwife at all. Of course the outcomes are going to be worse, and ACOG’s stats reflect that, and their OB’s speak from their experiences within that environment. Context is everything – isn’t that an important law of journalism? Or am I reading The National Inquirer?

    The only thing this article left me with was the impression that the author had an axe to grind with the Homebirth/Natural Birth set, and was willing to use some creative selection of statistics to that end.

    • But what about the Dutch study showing that low-risk women’s babies were twice as likely to die under a midwife’s care than high-risk women’s babies under the care of an OB? Are Dutch midwives less qualified than Canadian midwives?

      • Again, you’re comparing the state of midwifery in Canada with a completely different system from a completely different country. “Midwife” is a name and a term, not a level of education or even a method of providing care – there’s nothing universal about it, so how are statistics from Holland relevant to the safety of homebirth here in Canada, other than that the attendants have the same title and similar mindset?

        So my question is, what ABOUT the Dutch study? If it shows the results that are claimed in this article, than the Dutch really need to bring change to their system, and soon. It’s entirely possible that their midwives are less qualified. A study done in Holland has no bearing on whether or not it is reasonable for Canadian women to birth at home in the provinces where Midwifery is regulated, provided they (and their babies, obviously) are receiving our country’s standard of care.

        • Well it’s concerning because the Dutch midwife-as-primary-careprovider model is often cited as something Canada should emulate. People like Dr. Michael Klein, a retired GP doing research at UBC, has repeatedly called for this kind of model, and Anne Wilson of the Canadian Association of Midwives is also quoted in this story as believing that all Canadian women should be seen by midwives.  (I’ve read some of Dr. Klein’s stuff and I came away feeling that, in addition to disliking women choosing epidurals, he also has some kind of axe to grind with OBs.)

          I don’t know much about Dutch midwifery, but it is concerning to see those kinds of numbers coming out of the kind of care model some are proposing for Canada. Simply put, I would hate for Canadian women to lose the choice of primary maternal care provider (OB, GP, or midwife) in exchange for a system which may have less interventions, but may not have better outcomes.

          The Waxman analysis apparently also included data from Canada, but even if you choose to disregard that, the article states that Canada doesn’t nationally  track outcomes by home or hospital birth, in which case it would be difficult to know exactly what the numbers for Canada are.

          • So, basically, two studies among dozens that have analyzed the risk of homebirths somehow have all the weight we need to worry about? How about that Wax refuses interviews and that his study has been savaged by his peer group?

            This isn’t cut and dried.

          • It would be more accurate to look towards the NHS and that’s the system Klein and Wilson are looking towards.

    • My wife and I are 2 for 2 with the midwife-guided births. While I’ll admit that they’re not for everybody, I too detected an alarmist tone in the article.

      • Remember, a midwife attended birth does not necessarily mean a home birth.

        • Thanks for the reminder. One at the hospital, one at home, neither with a bunch of hospital staff telling a woman pushing a baby from her body that she’s doing it all wrong and intervening all over our birth plan.

          • So, you’re saying it’s possible to have a good birth at the hospital? Huh. From reading all these comments I was almost completely convinced that if I stepped foot in one of those notorious “baby mills” I’d be drugged out of my mind before being callously sliced open like a side of beef. ;)

          • Is it that you’re not a careful reader, or you’re feeling needlessly argumentative? From reading ALL these comments, the conclusion you’ve “almost completely” reached is that a good birth at the hospital is imposssible? 

            You might consider a bit of time away from the computer.

          • I used think you had a good sense of humour craigola13. Guess I was mistaken.

          • Ha ha?

          • I was only trying to light-heartledly remark that unlike most (granted not ALL) commenters on this thread you posted one of
            the few positive stories or statements about hospital birth. I thought it was quite balanced actually, unlike some other opinions I’ve read here. I’m frankly puzzled that you felt that I was
            being argumentative in making the remark; that was certainly not my intent.

  6. I cannot help but think there must be a happy medium here.  Some of the more, um, ardent supporters of midwifery might like to settle down a notch on the whole conspiracy crap.  And OB’s have GOT to bring down the rate of unnecessary procedures for healthy deliveries.

    There.  Now that that’s solved…

  7. This article is primitive scare-mongering. I find it telling that the author quotes the anti-homebirth fringe on one hand, and the freebirth fringe on the other. I’m sure I can find the crazy edge on virtually any debate to give it a bit of juice for the readership, too. She also puts for two new studies as a basis for criticizing homebirth in Canada — neither of which addressed homebirths in Canada, and one of which as been publicly savaged by its peers.

    The article further paints homebirth as some sort of wild and crazy approach, conjuring images of women with grubby hands and patchouli incense just telling you to “go natural, dude.” My son was born via homebirth. We had three midwives present, a hospital on standby, and a cavalcade of tools and drugs in our home weeks before he was due. At every juncture, my wife and our son were tested and re-tested to ensure they were good candidates for homebirth. When relating this story to friends who had hospital births, they expressed surprise at the amount of care and attention my wife and our son received before he was born.

    Our family doctor criticized our choice heavily and basically told us he washed his hands of the entire thing…after talking about how his father, also a doctor, had attended homebirths for decades with nary a problem to report.

    This article is incredibly slanted. It quotes anecdotal evidence, dismisses the numbers when they’re inconvenient. “But stories like Barrett’s suggest the numbers don’t tell the whole story.” That’s not a scientific analysis — that’s opinion, and has no place in a rational discussion.

    Portraying homebirths as some sort of selfish choice on the part of the mother is disgusting. We chose a homebirth primarily for the health of our child, not because we were trying to stick it to the man. We should not be demonizing mothers, especially when the predominant literature on the topic paints homebirths as being as safe as hospital births, with far fewer unnecessary interventions.

    Interesting sidenote — I discovered while researching homebirths that the doctor who delivered me (Murray Enkin) turned out to be have co-authored a paper recommending homebirths as safe in Canada. So I guess not all OBs are against it, huh?

    • I think the problem is there is a big disconnect between the two groups.  Not everyone in the medical profession is against home births.  They may not want to participate or agree with your choice but then you don’t agree with people who chose to have their babies in the hospital.
      You have to admit that it is your physician’s choice not to endorse or attend your home birth.  The physician who delivered my second child said if it was a boy, she would not be doing a circumcision because she does not believe they are necessary.
      Again, in Canada , you do have the choice to have the home birth. It sounds like a nice experience.   However, do not try to make the hospital birth experience something horrible because it is not.

      • Hospital births are certainly not -always- something horrible. I’ve heard a lot more hospital horror stories than I’ve ever heard about homebirth, but that may have as much to do with the prevalence of hospital births than anything else. That’s not to say there aren’t issues with both — there are. But neither should be flat-out castigated just because of what they are.

        Please note that I’m not against hospital births. I’m against unnecessary medical intervention, which is an entirely separate issue. Being -for- homebirths doesn’t mean one is necessarily -against- anything.

        Some births are more suitable for a hospital. Some are more suitable for a homebirth. But this article and others like it are reactionary and biased in the extreme, and paint an untrue picture of homebirths.

  8. When I was born I needed to be on a ventilator because I didn’t breath, there was no evidence of anything wrong prior to my birth. My older sibling was born without complications.  If I’d been a home birth I’d be dead. The training of the mid-wife wouldn’t matter because the equipment that kept me alive wouldn’t be available and is to expensive and immobile to provide for a home birth. Getting rid of the safety net that a hospital provides is simply foolish beyond measure.

    • No, you wouldn’t have been dead, Trevor354. At least, not at my house — my midwives were prepared for a baby that needed a ventilator. There is no “getting rid of the safety net that a hospital provides.” Midwives have hospital access and are ready to move the mother and child to hospital at the first sign of danger.

      I really wish people would stop making these ignorant comments based on what amounts to guesswork about how homebirths work.

      • Midwives bring oxygen for resuscitating both mom and baby to a home birth, and are trained in emergency measures while a transfer to the hospital is being made so that the baby can receive more continuous measures if necessary. This is the same thing that would happen in a delivery room. The baby would be given emergency measures while being transferred to a NICU in the same hospital, or at a different hospital if that hospital does not have a NICU (many hospitals in Canada don’t).

        • Are midwives in Canada all licensed? Oxygen is a drug and needs to be ordered by a doctor or determined necessary by an RN or RPN.

          • Most provinces and territories have regulated and government funded midwifery, the exceptions being PEI, Yukon, I think Newfoundland, and Nunavut has funded but not regulated.

          • Midwives in Ontario are all licensed and have to be a member of the College of Midwives of Ontario which is a regulating body present to look out for the interests of the public. You can see their website at http://www.cmo.on.ca. Under the Communications link you will see another link to Policies, Guidelines, Standards. This lists all authorized acts, scope, medical equipment and drugs/medications that midwives can perform/prescribe/order/administer. Hope this helps.

    • You would have been placed on ventilation immediately. Oxygen tanks and the checking of them is standard ops for home birth AND hospital birth. You’d have been ventilated and transferred to hospital. It’s not like some woman in a dashiki would have pulled you out, noticed you didn’t breath and chucked you in the laundry bin! There are tonnes of safety measures in place, including regular and frequent fetal heart tone checks that might have revealed you were in distress before even being born, which would have meant an immediate call for transfer to hospital via ambulance and obstetric staff waiting for you and your mom to roll in while the midwives and EMTs continued to provide services.

      It seems to me that there is a fundamental understanding of what a home birth is.

  9. Waldman’s statement that ACOG’s new position on home birth is less paternalistic than its previous statements made me laugh out loud. We’re supposed to be grateful that they’ve officially recognized the rights of women to choose home birth, as if we ever needed ACOG’s permission? And even more insulting is that their new position essentially comes down to this: women may have the right to choose home birth but obstetricians should counsel them, based on thoroughly debunked junk science, that to do so can benefit them but will put their babies at risk. 

    The take home? Women who choose home births are selfish mothers who put the birth “experience” ahead of their babies’ safety. How convenient that the Wax paper’s conclusions just so happen to support ACOG’s longstanding rhetoric against home birth, which has always relied on portraying the women who choose it as bad mothers who knowingly put their babies at risk or are too stupid to realize that they’re putting their babies at risk. So their new position statement, like their previous ones, is not only paternalistic but insulting as well. 

    And why ACOG continues to devote so much time, energy, and money to discrediting a birth practice that accounts for approximately 1% of the maternity care market in the US, when our system is in crisis and outcomes and racial disparities are only increasing, is beyond me. Perhaps it’s meant to be a distraction against the very real problems with maternity care in our country which, last I checked, happened on ACOG’s watch. 

  10. Let’s imagine for a minute that the Wax meta-analysis is a good one (this takes a lot of imagination) and relevant to Canada. And let’s imagine that we will use this data to recommend that all births happen in the hospital, because we want to prevent babies dying, and maybe we can even prevent more mothers dying too!

    Our goal: to reduce fetal and maternal death. How else could we achieve this goal?

    Since the rate of death due to accidental injury is 9.5 out of 100,000 for women aged 20-44 (childbearing age), we should recommend that all women of childbearing age live their lives in the hospital, so that in case of accidental injury they have immediate access to medical care. Maternal mortality in Canada is 7 out of 100,000 (up from 6 a few years ago), so the death rate due to accidental injury is higher than the maternal mortality rate in Canada. We can obviously make some serious improvements to the death rate by accidental injury in this population through the hospitalization of all women aged 20-44.

    The infant mortality rate (death in first year of life) in Canada is 5.1 in 1000. The early neonatal mortality rate (death in the first week of life, excluding stillbirth) is 3.3 in 1000. So 1.8 out of 5.1 infant deaths (about 35%) occur after the infant is a week old and not in the hospital. We should 
    recommend that all infants under a year live in the hospital so that in case of an emergency or life threatening condition they have instant access to medical care, in order to reduce the infant mortality rate.

    Neither of these options sounds practical? Should it be a woman’s choice whether to live at home or in the hospital? What if she chooses to live at home with her infant in the first year of life? Is she putting her child in danger? 

    Perhaps 100 years from now we will be absolutely horrified at the idea of any childbearing aged woman or less than one year old infant living at home, without doctors and sophisticated medical and surgical equipment immediately on hand. We will tell stories about women and babies who almost died at home–it’s a good thing the paramedics arrived to save them, and that we have an ER to take them to. And we will shake our heads over the babies that do die at home, wondering why on earth 
    they weren’t living in the hospital, while we ignore and make a point of not publicizing the infant deaths that occur in the hospital.

    We will do studies comparing infants who live at home in the first year of life compared to those who live in the hospital, and then we will do a meta-analysis of these studies and discard the study with the most data (320,000 subjects), for no apparent reason, so that we can rely on the smaller studies (9,811 subjects total) with less reliable data, and we will mysteriously exclude stillbirths from our calculation, counting only neonatal deaths (occuring in first 28 days of life) to give us our politically motivated conclusion that more infant deaths occur at home than at the hospital!!! Oh, and we would release our findings before they have gone through the peer review process, and then completely 
    ignore independent experts who looked at our study for Time magazine and found it ‘weak and methodologically flawed.” http://www.time.com/time/magazine/article/0,9171,2011940-3,00.html 

    Lucky for us, writers at magazines like Macleans won’t be so thorough, and will also ignore the independent experts review. They will also ignore the fact that the a large proportion of data used to draw our final conclusions about infant mortality being higher at home was from the U.S., where care of infants who live at home is not integrated into the health care system.

    Note that only 2% of births in Canada occur at home, but the perinatal mortality rate (stillbirths plus early neonatal deaths) is 6.4 out of 1000 total births. Even if the Wax study was correct, this would still mean that 94% of these deaths happen in the hospital. Yes, BABIES DIE IN THE HOSPITAL. 

    There are far more stories of fetal deaths and maternal near-misses in the hospital in Canada than at home.

    I would like to see Macleans do an article on this, ‘Is Hospital Birth Safe?” or ‘Risks of Hospital Birth,’ or “Abandon Ship! Hospital Birth is Sinking–Do We Know How to Swim?” complete with interviews with doctors, midwives, and nurses who have seen birth go horribly wrong in the hospital due to unnecessary and/or routine medical interventions. 

    0.6 out of 100,000 is the mortality rate in the general population in Canada as a result of a medical or surgical complication. And this is when treatment is being given to help cure a DISEASE, but the treatment itself has risks, including leading to death. Pregnancy and childbirth are normal life processes, not a disease that needs to be cured, and any treatment or intervention has risks, including death.

    Maternal mortality in Canada is rising. So is the cesarean section rate. Liu et. al. (http://www.ecmaj.ca/content/176/4/455.full) show that planned cesarean increases ALMOST DEATHS (severe morbidity) compared to vaginal birth–and the risks of emergency cesarean are even higher than a planned cesarean. (http://www.ncbi.nlm.nih.gov/pubmed/12962927)

    There is a problem with childbirth in Canada, and it is not related to home birth.

    Death rate statistics from statcan.gc.ca
    Maternal mortality statistics from http://www.womenshealthdata.ca/category.aspx?catid=115&rt=1
    http://www.medicalnewstoday.com/articles/185154.php

    • Of course there are more “stories of fetal deaths and maternal near-misses in the hospital in Canada than at home” considering that: 1) the shear number of births that occur in the hospital v. at home;   2) that when a home birth goes “south’, the mother is delivered to the hospital via ambulance;  3) that all high-risk births occur in hospital.
      No one ever said that pregnancy and child birth were not normal life processes, however, the truth is that even the people who have opted for home births prepare to go to hospital if there are complications so even they are aware that there are risks inherent in the process.
      As for discussing the maternal mortality in relation to caesarean section v. vaginal birth….especially an “emergency caesarean”…..no doubt there is a greater risk for mortality…the reason for the emergency caesarean in the first place is because the baby and or the mother is in acute distress.   If there was not a medical emergency, there would be no need for an emergency caesarean.

      • Actually, if a birth starts at home with a midwife and is transferred to the hospital, and the baby dies, that death is recorded as a home birth death. If you look at the high quality 2009 Canadian study by Janssen et. al., it only compares low risk home births with low risk hospital births. And there was no statistically significant difference in perinatal deaths between the two environments. 

        Re: cesareans. The Liu et. al. study showed significantly increased severe morbidity (almost death) with planned cesarean in HEALTHY women. Some emergency cesareans may be more risky because of acute distress of mother or baby; other unplanned cesareans are done because in the opinion of the care provider the birth is taking too long (dystocia) and they may say that is due to cephalo-pelvic disproportion (CPD-baby is too big for the mother’s pelvis). Many women diagnosed this way go on to have successful VBACs (vaginal birth after cesarean) to babies of approximately the same size as their first delivery that ended in a cesarean. Impatience on the part of care providers is not a medical emergency, and there may be no indicators of distress in the baby and the only thing the mother is experiencing is that she is tired. This is normal with birth, and in fact her body may be trying to give her a rest, but care providers may see this as stalled labour and give her Pitocin to augment her contractions and keep things going, instead of letting her rest.

        And then the care provider walks into the room and says ‘I’m not sure this is going to happen, I’ll give you x amount of time and then we’ll do a cesarean,’ and the psychological effects on the mother’s perception of her own exhaustion and her ability to push her baby out are entirely degrading to her belief in herself. A care provider that says instead ‘Birth/Pushing often takes a long time. I know you’re getting tired and I also know you have resources within you you don’t even know about yet,” contributes to a positive psychological effect on the mother and her ability to birth her baby. 

        I just heard a story today of a 42 year old first time mother whose doctor said almost exactly the first thing to her, then walked out of the room. The mom had been pushing for 2 1/2 hours. Her doula and the nurse said the second thing to her, and in the 25 minutes the doctor was out of the room, the mom pushed her baby to almost crowning. She birthed the baby vaginally. The doctor afterward said that she was sure of her diagnosis of CPD (baby too big, mom too small) and would have definitely done a cesarean if the baby hadn’t been so far down when she came back.

        This happens all the time, except most women aren’t so fortunate as to have such a great nurse and a doula to carry them through the negative predictions of the doctor. What they have is a cesarean. And that cesarean carries higher risk of severe morbidity (almost death) for the mother, greater risk of respiratory problems for the baby, is correlated with greater incidence of asthma and obesity, and creates a greater likelihood of stillbirth and other complications for both mother and baby in any future pregnancies.

        If you want statistics on the issue, a recent U.S. study titled ‘Indications Contributing to the Increasing Cesarean Delivery Rate’ by Barber et. al. show that subjective indications such as nonreassuring fetal status (32%), labor arrest disorders (18%), and suspected macrosomia (10%) contributed more to the rising cesarean rate than objective indications such as multiple gestation (16%), preeclampsia (10%), maternal-fetal conditions (5%), and other obstetric conditions (1%). Maternal request accounted for 8%, which includes a subsequent cesarean in areas that are unwilling to provide VBAC. Percentages are the relative contributions of each indication to the total increase in primary cesarean rate. How this translates exactly to Canada we can’t say for sure, but it does give some indication of what mother’s experiences in Canada are telling us, and similar trends are occurring in terms of interventions and cesarean rates in both countries.

        • The article gave a great example of a person – Ms. Fraser – who decided to stay in labor 5 days and her baby passed away. 
          It is up to the mother but WHY would anyone want to continue in labor for an unreasonable amount of time when the goal is to have a healthy baby?  What pressure are we putting on these mothers?  I don’t understand it? I will be honest with you and with Ben and with all these people who want women to suffer……my mother said if men were giving birth to every 2nd child, she would have had 3.  As it is, she had 9.  For some reason, surgical procedures and every thing else has been encouraged to advance but child birth including pain management is discourged from advancing.  Why is that?   I am sorry….I experienced it twice…I thought I was dying….I didn’t have any pain mangement….I didn’t see it as a wonderful spiritual experience.  Ben, it is like crapping out a watermelon.  Try that and tell me what a great spirtual experience you had…..especially after 9 months of nausea, heartburn & a baby kicking you in the abdomen……then there is the joys of breastfeeding.

          • Cesareans in the US have increased by 18% for ‘labor arrest disorders,’ which is a subjective call made the physician. Which means that neonatal mortality was just as good a few years ago, and there were 18% more vaginal births where the physician was more patient. I agree with you that there are limits to what a woman can do on her own–but I think the call as to where those limits are should be determined by the woman, in an atmosphere of supportive encouragement and where she is not afraid to access medical care when needed. I was recently at a birth (as a doula) that was 24 hours long–the mom was doing great. She was obviously getting tired, but she said herself that she would have the resources to push the baby out if she was making any progress. The reality is she had been pushing for a long time and the baby just wasn’t descending. The baby’s heart rate was great and the baby kept moving, so the baby was in great condition, but just in an off-kilter position. She decided at the same time that the midwife was thinking about it, that no progress was being made and there was no way to get the baby out but through a cesarean. In this instance, after hours of unmedicated, very effective and powerful pushing with no descent, the baby truly was stuck and I am very thankful that a cesarean was available to her. The difference here is that it wasn’t an outside person telling the mom she couldn’t do it anymore–the mom knew that something was wrong. And she had been encouraged and supported that she could do it. In most hospital stories I hear of, the mom is getting tired, but a bit of progress is being made, but not fast enough for the care provider. That’s a huge difference.

            I have given birth 3 times, so I do know what it’s like to be pregnant and give birth. Birth is painful and a lot of work, no doubt about it. And each woman’s perception of her own pain and what it means to her is different. I did not perceive my pain as suffering; I knew that the pain did not mean there was something wrong with my body but that my body was changing to birth my baby. I could manage the pain I experienced, even though I couldn’t make it go away. Was I relieved when birth was over? Of course! Intensely relieved. But for me, birth is a spiritual experience, in the sense that the pain and the changes occurring required me to be totally in the present, one moment at a time, in tune with myself and my breath, paying attention to what I need to do to feel a bit more comfortable, a bit more relaxed. And I think it’s also such a paradox, and so revealing, that the amazing miracle of giving birth to a totally new person happens amidst sweat, blood, tears, poop, and pee. There is something profoundly spiritual in that for me–the visceral and raw nature of birth, and that to get through it you have to listen to yourself and your baby. Very much like parenting, except the agonies and joys of parenting go on a lot longer!

          • I don’t have any problem with mom’s making the choices but what I do have an issue with is them feeling guilty when they don’t succeed in going the natural route.  For some reason, women feel like they’ve failed because they accept pain medication or require syntocin or horror of horrors have to have a caesarean.  Yes, it is great to have a vaginal birth; sure, have a home birth if that is what you want but gee, let’s keep our eye on the bottom line….let’s deliver a healthy baby and end up with a healthy, happy , mom.    However we get there is really secondary.   Alot more attention should be given to what the family can expect after the birth…the breastfeeding; the exhaustion, etc.

      • Also, you acknowledge that childbirth is a normal life process. And of course there are risks to any part of life, as a death rate due to accidental injury of 9.5 per 100,000 indicates. However, I continue to live my life outside of hospital walls, as do all of us who are healthy and not in need of hospitalization, and rely on paramedics and the hospital to be there for me WHEN I ACTUALLY NEED IT. The great thing about birthing at home is that I have a professional trained in emergency measures to help me and my baby (and to help identify if there is a problem) as well as access to ambulance service and a hospital. It’s easy to tell if I’ve accidently cut my leg (accidental injury that could lead to death) — not always so easy to tell if I’m hemorrhaging after a birth, or to diagnose problems that may happen to me or the baby while in labour. Thus, the midwife.

    • “Maternal mortality in Canada is rising. So is the cesarean section rate.”

      That couldn’t have anything to do with rising maternal age and other risk factors for pregnancy complications, such as maternal obesity? Correlation =/= causation.

      • And by the same token, it couldn’t have anything to do with a puppy mill attitude in hospitals across the country and doctors who are aiming for speed of delivery and convenience over long term effects? Could it be (gasp!) a combination of a number of complex factors, none of which forgive this article’s abominable slamming of homebirths, nor demonize hospital births unnecessarily?

      • absolutely!

    • For a good review of the Wax paper, see Jennifer Block’s article http://www.thedailybeast.com/articles/2010/10/02/home-births-under-fire-amid-outcry-over-wax-paper.html

  11. You talk about care providers in hospitals deciding progress is being made too slowly and deciding to move on to other interventions like it’s a bad thing.
    The longer the labour lasts with little to no progress – the higher the risk.

    • A study was released a couple years ago pointing out that provider impatience was a leading factor of intervention, not emergent health concerns of mother and child.

      The Aussie mom who laboured at home for 5 days and lost her child is a really extreme example and really isn’t very relevant in a discussion of midwifery care in Canada. Ontario midwives (to use their example because I am most familiar with them) have parameters within which mums and babies must stay to continue to be eligible for home birth. Had the Aussie woman had a registered midwife in ON, she would have been in hospital long before the baby went into distress.

      But, in hospital, the determinant for health and safety in birth is the almight Fetal Heart Tones. If baby and mom are healthy, there is no reason at all to speed up or otherwise intervene in their birth. A mom could labour 24 or more hours with very slow progress and as long as she and baby were healthy and willing to proceed, there would be no indication for intervening in their labour. I’ve seen moms (admittedly, those with epidurals for whom the discomfort of contractions was not an issue) have 4 and 5 hour stage 2 (pushing stage). Baby’s heart rate was always solid as a rock and therefore none of the OBs attending felt the need to raise the chance of harm by introducing pitocin, forceps, vacuum or surgery.

      I have to say, while I whole-heartedly support home birth, I work in a fantastic community of progressive doctors in Hamilton, ON whose support is always amazing in comparison to some stories I hear from birth workers in other areas of the province. Maybe I just work when all the good docs are on call :) Of course, our midwives are awesome, too.

  12. I want to correct a bit of incomplete information in this article about American midwives. Differences in education and licensing requirements among US states are a
    huge problem contributing to misconceptions like the statement about
    American midwives in this article.  Many have university education; it depends on what group of midwives you’re talking about.  Certified nurse-midwives and certified midwives are now educated at the master’s degree level at a minimum.  I would not say that master’s education is critical; it’s just what’s evolved down here. What makes them safe beginning practitioners is having had to achieve a long list of core competencies before being allowed to graduate, and these competencies are the same in every CNM/CM program.  Certified professional midwives, who are not required by their professional standard-setting group to have university education, also have to achieve competencies before they can use the title CPM. 

    These are minimum standards that were developed for the protection of mothers and babies.  It doesn’t follow necessarily that midwives without any of these credentials are unsafe practitioners, only that in that case you have no guide to know what you’re getting.

  13. Most births whether they are home births or not, will progress as an uneventful course. The reality is that if a time dependent intervention is needed for either the mother or baby, one needs to be in a hospital – not close to a hospital. You could have the most experienced Emergency Physician in Canada doing a home birth and if things go wrong, he/she is still in a suboptimal environment for management. That is the reality. Anyone that thinks otherwise has been either misled, misinformed or is ignorant. For example, outcomes of infant morbidity/mortality for New Zealand home births are frightening. There GPs are essentially cut out of the pregnancy birthing process with their patients so even if a woman wants their GP to deliver a baby, they are forced to either use a midwife or pay for an Obstetrician. In addition, midwifery there is a technical course and I have been told (might be inaccurate) that nurses are discouraged from applying. Therefore applicants tend to have no medical background. If a midwife in NZ decides she needs medical assistance, their fee is cut. This has resulted in many either calling for help late or not at all with multiple preventable adverse outcomes – particularly for babies. 

    I personally think the idea of home birth is fantastic and I get the whole reaction against medicalising birth. But a home birth is much riskier. You can manipulate whatever paper you like to whichever argument you support. An experienced, hospital based midwife – that does not have an axe to grind with the medical profession (eg. not reluctant to call early) is probably the safest compromise. If a similar thing happened in our family as it unfortunately did to Ms Fraser, I would never forgive myself if that death could have been prevented in a hospital setting. 

    • Ms. Fraser was not attended by a midwife–she chose to give birth unassisted, which is a completely different thing when discussing the issue of home birth. When we discuss home birth in Canada, we are talking about home birth attended by a midwife who has received the same training in emergency measures (i.e. ALARM course) as a physician, and carries the same equipment to the home that is available on the maternity ward (pitocin for hemorrhaging, IV fluids, oxygen for both mother and baby). You are incorrect in your assumption that if there is an emergency the home is a suboptimal environment compared to the hospital, with a trained midwife in attendance. First of all, there is less chance of something going wrong at home, because there are less unnecessary interventions and the birthing environment is more familiar to the mother, more private, and therefore her hormonal process is more likely to work better. Second, even if you are in a hospital it takes AT LEAST 30 MINUTES to get an OR ready for surgery, and that is if there is one available and they are not all being used for other surgeries. If you live 30 minutes or less from a hospital, the midwife can call and while the woman is in the ambulance the hospital can get the OR ready, not losing any time from what a woman would have to wait if she was in the hospital.

      • It does not appear that you read my post correctly before replying. I was not discussing the rate of complications between a homebirth vs hospital. Nor was I discussing levels of training of midwives. I’m sure your ALARM course is good. I was saying that if there is a time dependent intervention needed, the home is absolutely suboptimal. Of course it is. You can bring as much equipment as you want but you are still delaying transfer if it becomes necessary. If you seriously believe otherwise, you are deluded or trying to mislead. 

        I would like you to respond to a personal scenario and tell me how this could have been managed better by yourself in our home. My partner is an RN and we seriously contemplated a homebirth but for various reasons (partly expense) we didn’t. Long story short, she had a massive PPH losing an estimated 2-2.5 litres of blood. Within 1 minute, there was another 2 midwives in attendance and an O&G Registrar whilst our midwife was performing a bimanual compression. In less than 3 minutes (NOT 30 MNUTES – 3 MINUTES), she had 2 wide bore cannulas inserted, stat crystalloid running, blood cross matched and was wheeled into theatre to definitively control the bleeding. THIS ALL HAPPENED IMMEDIATELY. A theatre was ready. There was no delay that as you claim occurs in your hospital.

        Now I assume you would have learned from your ALARM course that >40% blood loss is essentially premorbid and the correct treatment (as ell as controlling bleeding) is blood. You may have been able to control the bleeding temporarily but it would have been difficult for anyone – you included – to establish IV access and run fluids at the same time. In addition, you would not have been able to show up to the home with cross matched blood (for obvious reasons) so there is a delay there, as well as the delay in transport time to the hospital. In that scenario, the problems are still going to be a delay in transport time, delay in blood and additional staff support needed. Are you seriously going to respond that you could have deftly handled this situation off site when 3 midwives and a doctor struggled – in a major hospital? What if the baby needed attention concurrently? 

        For certain obstetric emergencies (thankfully few), you are more likely to survive in a hospital (better support, access to theatres, blood etc). You can kid yourself of otherwise – but do not mislead others. 

        • First, to clarify, I am not a midwife. I am the founder and executive director of Mothers of Change for Maternity Care, a Canadian, grassroots organization advancing mother-friendly care and representing women’s voices on maternity care. I am also involved with research and education at the Child and Family Research Institute, UBC, Vancouver with Dr. Michael Klein. I also do some birth mentoring (i.e. doula) work.

          Now to respond: 
          I am very sorry to hear about your partner’s postpartum hemorrhage. That would be scary for anyone to go through, and our views are definitely shaped by our personal experiences, regardless of what the research says.

          However, this is what the high quality, Canadian research by Janssen et al. published in the Canadian Medical Association Journal in 2009 says: women are significantly more likely to hemorrhage in the hospital than at home (6.7% at hospital with a doctor, 3.8% at home with midwife). Two high quality Canadian studies in 2009 (Janssen and Hutton et. al. in Birth) showed no maternal deaths in either hospital or home, but increased adverse outcomes for women in the hospital.

          What this means is that those women who hemorrhaged at home survived the same as the women who hemorrhaged at the hospital–but if you planned a hospital birth, you were more likely to hemorrhage. Therefore, having trained midwives in attendance at your birth (in BC where this study was done there is a requirement for either a second midwife or a second attendant trained in emergency procedures) is JUST AS SAFE if you hemorrhage as being in the hospital. 

          I’m glad your wife had instant attention by medical professionals, but the sad reality is that in the hospital staff are not always so quick to respond. At a home birth, the midwife stays with the woman and observes her for a few hours, while in a hospital a woman is usually left alone for long periods of time. The midwife at home does not have multiple cases to attend to, and her observation of the woman often leads to diagnosis of a problem before it becomes severe. Women in the hospital often hemorrhage without anyone noticing for a while, so that when someone does notice it is a true life or death emergency. 

          At a home birth, if the blood loss is rapid, emergency measures are applied and an ambulance is called, similar to if you cut your leg at home and were bleeding out from your femoral artery. In the worst case scenario, a midwife can insert her entire fist in the woman’s uterus (bi-manual compression) to stanch the bleeding. Midwives and paramedics both use IV fluids to replace blood loss while in transfer–this is a standard emergency procedure that works, until the blood can be replaced by new blood.

  14. I am very disappointed with Macleans for presenting only one side of this issue! Clearly the author has personally feelings against home birth which she chose to air out here. It is irresponsible to present this as a one-sided issue that’s only purpose is to instill fear.

    I am a Canadian who has recently moved to the US and my husband and I have chosen a certified nurse midwife (CNM) with 26 years of experience delivering 2-8 babies per week to be our provider. Not only has she never had an emergency transport in all that time (she identifies “problem” births ahead of time and moves them to a hospital if necessary), but she is trained and experienced with delivering breech, twins, VBAC, administering oxygen, preventing (yes I said PREVENTING) tears, and sewing them up if they do occur. Any OBs out there wondering how to prevent a tear? Ask an experienced midwife. While your at it, ask yourself how many OBs have experience delivering breech or twins? This can be done and can be done safely, however the majority of OBs in the US perform mandatory cesarean sections for breech, twins, and previous c-section. No arguments, no questions asked. As such, they no longer have the skills to do so. One can forget how to ride a bike, it seems. They go so far as to refuse to treat women that insist on a vaginal birth. Interestingly, many of these women choose to come to Canada to deliver where they can still find some OBs willing to deliver these types of babies vaginally. I wonder how long this will be the case? In a few years will Canadian OBs also start turning these women away?

    Having experienced both, I still view the Canadian healthcare system to be superior to the US in many respects, including unnecessary interventions. However, I fear that Canada is beginning to follow too closely in the footsteps of its neighbour to the south, rather than emulating European countries with more preventative care, healthier citizens, and much lower maternal and fetal death rates. I have a doctorate degree and completed a lot of literature searches on this issue prior to settling on a midwife birth. The statistics quoted in this article are inaccurate and skewed. Do some investigation on your own, rather than giving weight to this article or listening to the “intuitive experience” of your OB who is trained to look for emergencies. If you are interested in a good read that discusses many of these issues, pick up PUSHED by Jennifer Block or BORN IN THE USA by Marsden Wagner (who happens to be an OB and the former director of Women’s and Children’s Health at the World Health Organization). Even though these books primarily address the state of maternal-fetal health in the US, they also cite many studies from other countries, including Canada, which often comes off favourably. Their focus is on the facts surrounding birth and that the focus should be on identifying births appropriate for home vs those necessitating hospital intervention. Another great resource is: http://birth-media.com/laboring-under-an-illusion/

    Yes, things can go wrong. In these instances hospitals, OBs, and interventions can be helpful. But most of the time things don’t go wrong. In fact, interventions such as lying supine (on your back) for pushing, epidurals, refusing to allow positions changes or walking, an epidurals can all INCREASE the chances of things going wrong. As can being in a crowed, unfamiliar, noisy, intimidating environment.

    I would like to see Macleans present the other side of this issue, lest they be considered a conservative magazine that relies on scare-mongering to influence women to tow-the-line, rather than making their own informed decisions.

  15. Wow, this is a really bad article. 

  16. Wow, this is a really bad article. It’s mostly ‘anecdata’, and the studies she does discuss have nothing whatsoever to do with the state of homebirth in Canada – we have a completely different system from the US, the UK, the Netherlands, etc! Would the author also take hospital or OB stats from those countries and extrapolate them to Canada? No? Then why is she doing it with regards to homebirth? I am actually somewhat conflicted about the whole issue and am not some sort of homebirth crusader, but the two studies that have been done in Ontario and BC have both shown that for low risk women, planned homebirth is as safe as planned hospital birth. (Abstracts are easily available online.) Shame Ms. Bochove didn’t choose to write an acticle that’s actually relevant to Canadians. 

  17. I am a maternity nurse with 35 years experience as well as a lactation consultant and midwife homebirth assistant. I would like to remind us all of the rapidly rising hospital aquired infection rates and also the World Health Organization’s guidelines recommending that safe cesarean section rates should be between 10-15%. In British Columbia, where I live, the C-section rates are over 30% – leading to increased complications/risks for both mother and baby.
     

  18. Ditto across the world not confined to Canada.  Unnecessarians and inductions are in Australia reaching 50% in one private hospital 37% in public hospitals. 

    The new mantra from the Medical Profession “It is as safe as vaginal birth”.
    sounds like the good ole Formula companies and Cow’s milk formula is now as good as breast milk” Obstetricians are booking women for theatre at 38 weeks in 9-5 obstetrics ? final installment. The first installment was machinery to measure the heartbeat saved talking to the woman then epidurals to keep them numb and dumb – some nearly paralysed to their tongue.
    Then came they could walk around because women had managed to demand movement and gravity as the force in labour. Next came measurement of the liquor failure to be 10 cms at term. Then came “your baby might die” if we dont start your labour and after wards rupture your membranes, then came if you want a healthy baby (more subtle) even though it is compromised – llow oxygen levels and retarded growth (good term that most babies turn out to be at least 7 kgs or more we find. We will now give you a gel with Misoprostol dangerous cancer cell destruction drug hidden in the Cytotec for the softening of the cervix. Added to this we have the help of horses urine prostaglandin.. If you”failed” then you will be able to have the re-introduction of sytnetic ostyocics called Syntocinon in an infusion. Which if given too close to the gel would rupture your uterus and it does especially in the hands of gung ho obstetricians.. This does not mean they can mend the uterus it means permanent infertility. No more uterus and dead baby.
    Failure to produce a baby in 24 hours now counting down to 9 hours would result in a Caesarian birth – = to cut. Now we know that in California, maternal deaths (mostly in the black population (the esearch for which was held back for 2 years until 2010).See Amnesty International Maternal deaths had doubled from Placenta Acreta = attaches to internal wall Increta = or Percreta = grows through the wall into the abdominal cavity and bleeds severely in to the cavity.. The fact is that where the scar exists from the previous surgery on the uterus the placenta tends to attach in this scar. RESULT haemorrhage from retained placenta and at least infertility after 2nd or 3rd babies. Death is occurring also from severe infections.The Misoprostol by virtue of its action – killing off normal as well as abnormal cells causes less resistance to resident bacteria and terrible infections are occurring post caesarian. If you would like confirmation look up Marsden Wagner and Misoprostol on the weblink.

  19. It would be nice if those against homebirth in Canada could use Canadian studies and even Canadian examples when saying whether it is safe or not.  Dr. Barrett’s example are from how long ago and in a completely different country.  Has he ever attended a home birth in Ontario with our amazing Ontario Midwives? No. 
    And a rate of 40% for interventions? I would say that amount is a low estimate.  There are some hospitals where an episiotomy rate of 80% is common.  And some hospitals tout a 90% epidural rate.  Not because 90% of women want them but because they are pushed and prodded into getting one so they can remain in bed.  I’ve seen women offered epidurals at 9 and 10cms dilated when they walk in.  Um…how about you push your baby out that will stop the discomfort. 
    It blows my mind when medical professionals who push interventions for reasons of their own convenience shake their head at such high rates.  How about we start trusting women’s bodies and see them as individuals and not stick them into a box of averages. 
    I have attended births all over the GTA and some of the things I’ve seen would make your hair curl.  Start making hospital birth safer for mum and baby emotionally and spiritually and then we’ll see a shift. 

  20. Funny that some people saw this article as unbalanced.  I think she went to some trouble to give perspective from both sides.  The trouble is, many people don’t want to hear both sides.

    I put most of the criticism of this article in the same category with those who deny the holocaust or evolution.  There’s good hard data there.  You can say you choose to believe otherwise, despite the data, but that makes you crazy.  It’s funny how when science disproves someone’s belief they don’t say, “Wow, I learned something today.”  Instead they say, “This is bad science, or the author has a vendetta, or they manipulated the results.”

    Bottom line: People don’t want science to teach us anything.  We want science to back up our current beliefs.

    • The problem is, there is not good hard data here. Anecdotes by physicians (or ‘anecdata’ as one commenter noted) is not research. The Wax study has a number of serious problems, which the reporter did not go into detail to educate the public about, instead making it appear that it is home birth supporters who simply want to ‘believe’ something, no matter what science says, that are objecting, and the writer makes it appear that their objections are invalid.

      I wrote this below in a comment, I wrote it in a letter to the editor, I published it at http://www.mothersofchange.com

      Here’s the real critique of the Wax study:
      To get the higher neonatal death rate (first 28 days of life, excluding stillbirths) at home births, the Wax study:
      - excluded data from a larger Netherlands study (320,000 homebirths), for no apparent reason, other than that the data was collected only for the perinatal period (stillbirths + deaths in the first week of life) and did not include deaths to 28 days of life. Standard measurement for this type of study is perinatal deaths.
      - used data that only totalled 9,811 home births, a large portion of which included unreliable data from studies that make it hard to differentiate between planned home births with a midwife and unplanned home births. An unplanned home birth is by nature often precipitous (fast), which in itself is a risk factor, as well as the lack of a trained midwife. 
      - excluded stillbirths (babies that die before they are born–so this would be what most people think of in terms of the ‘risk’ of home births: babies dying while the woman is in labour and before the baby is born).
      - Wax study released findings before going through the peer review process. The British Medical Journal has since published articles questioning the study, detailing many of the things I’ve pointed out, as well as more concrete mathematical and methodological errors http://www.bmj.com/content/341/bmj.c3551/reply

      So, while half a million births might cut out a lot of noise, 9,811 births hardly has the same power, especially as the data was mostly unreliable and the studies poorly constructed. The purpose of a meta-analysis is to use a lot of data to increase statistical power.

      The Wax study did not concentrate on its findings that there were no significant differences in perinatal mortality (stillbirths + deaths in first week of life) for planned home births attended by certified midwives. These findings included the Netherlands study with 320,000 home births, and therefore had appropriate statistical power for this kind of study.

    • The URL for the article is titled ‘Don’t Try This at Home.” Balanced? Hmm…

  21. A Summary of Recent, High Quality, Canadian Studies on Home Birth
    For Those Who Want Science To Teach Them Something
    Janssen et. al. 2009 in the Canadian Medical Association Journal. (2889 planned home births with a registered midwife in British Columbia from Jan 1. 2000 – Dec. 31 2004).
    Hutton et. al. 2009 in Birth. (6692 planned home births with a registered midwife in Ontario from 2003 – 2006).

    These studies are methodologically sound in the ways home and hospital deaths are counted (home births that transfer to the hospital and end in death are counted as home birth deaths),
    the way populations of women and babies are compared (only low-risk women who would qualify for a home birth are included), and Janssen also compares the same care providers in the two settings (midwives who practice at home and hospital).

    These Canadian studies show no maternal deaths in either setting, and a comparable rate of perinatal (stillbirths + first week of life) deaths (per 1000 births) of 0.35 in the group of planned home births, 0.57 in the group of planned hospital births with a midwife, and 0.64 among those attended by a physician. Of the women who actually delivered at home and did not transfer to the hospital, there were no perinatal deaths.

    Janssen’s study shows that women who planned a home birth were significantly less likely to experience electronic fetal monitoring, augmentation of labour, assisted vaginal delivery (forceps or vacuum), cesarean delivery, and episiotomy. Women who planned a home birth were also significantly less likely to have a third- or fourth-degree perineal tear and postpartum haemorrhage. The risk of all adverse maternal outcomes assessed was significantly lower among the women who planned a home birth than among those who planned a physician-attended hospital birth. 

    Women who planned a home birth were less likely to have a newborn who had birth trauma, required resuscitation at birth, had meconium aspiration, or required oxygen therapy beyond 24 hours. No significant differences were observed between the home-birth group and either comparison group with respect to a 5-minute Apgar score of less than 7, a diagnosis of asphyxia (lack of oxygen) at birth, seizures, or the need for assisted ventilation beyond the first 24 hours of life.

  22. I raise the questions of the use of Wax in this article. WAX excited a number of criticisms which included the hidden inclusion of a small study and the exclusion of a significant large study. Much more needs to be done to prove hypothesis in this article. The use of meta analysis is also questioned as a suitable tool given the complexities and variations in systems across the world. Comparing apples with pears. The study done by Jannsen and Sexall et al was in my opinion worthy of note – comparing apples with apples.

    WA Health Review of Evidence which outlines the flaws around Wax – see http://www.healthnetworks.health.wa.gov.au/publications/docs/plannedhomebirthsafety.pdf

    “The recently published meta-analysis of observational studies
    comparing planned home birth versus planned hospital birth was excluded
    after review (Wax, Lucas et al. 2010). Wax et al. (2010) performed a
    meta-analysis of 12 studies reporting on pregnancy outcomes that
    occurred between 1976 and 2006. The meta-analysis concluded no
    differences in perinatal mortality, but significantly increased neonatal
    mortality for planned home birth.
    This meta-analysis has several
    methodological flaws that are particularly important when combining
    results from observational studies where matching for confounders is not
    likely to be adequate. In such instances, a detailed evaluation of
    quality of all studies is essential; this was not sufficiently described
    in the manuscript. Moreover, not all studies were included in analyses
    of perinatal mortality as reporting of perinatal mortality differed
    across studies. Wax et al. (2010) evaluated neonatal deaths using 6
    observational studies that reported neonatal deaths until 28 days of age
    (Woodcock, Read et al. 1994; Ackermann-Liebrich, Voegli et al. 1996;
    Janssen, Lee et al. 2002; Pang, Heffelfinger et al. 2002; Lindgren,
    Radestad et al. 2008). The authors also appear to have included another
    study that reported neonatal mortality (Hutton, Reitsma et al. 2009),
    but this was not explicitly stated in the review. The neonatal mortality
    data were available mainly from small studies, and one large
    retrospective study of birth registry data where unplanned home births
    may have been misclassified as planned births because birth certificates
    used in the study may have not distinguish between all planned and
    unplanned births, and where the qualification of birth attendant was not
    always known (Pang, Heffelfinger et al. 2002). Other large studies
    included in the meta-analysis of maternal and neonatal outcomes (de
    Jonge, van der Goes et al. 2009; Janssen, Saxell et al. 2009) were not
    included in the evaluation of neonatal mortality. De Jonge et al. (2009)
    only reported neonatal deaths within the first 24 hours and 7 days
    after birth, Janssen et al. (2009) only reported perinatal mortality.
    Both studies present the data on recent planned home birth outcomes
    within the Canadian and Dutch midwifery-led care for low risk women and
    provide best evidence for the Australian setting.
    The publication of
    the meta-analysis by Wax et al. (2010) was followed with several
    editorials commenting on risks of home birth (such as the Lancet
    editorial: ‘Home birth – proceed with caution’, 2010) and critiques of
    the study limitations and validity of its conclusions (e.g. Gyte, Dowell
    et al. 2010; Keirse 2010). One of the crucial questions raised is
    whether meta-analysis is a correct tool for analysis of observational
    studies that describe planned home birth within very different
    healthcare systems (Keirse 2010).”

  23. Baby Keaton – Born September 2nd, 2011 at home in the tub.  9lbs 11oz.  Everybody healthy and happy.  This was the absolute best experience we’ve ever had.  Compaired to our first born with numerous “pushed” interventions at the hospital, this was beautiful and just felt right through the whole process.  This article did frustrate me slightly due to the negative tone regarding home births – having experienced both now I certainly have a different perspective about both settings.

    As a dad, I was intially nervous about the process but then conducting my own fact based research, I felt that the process was quite safe and very rewarding…turns out I was right!  For us, the decision to have a home based birth was the perfect choice which is not to say that would be the case for all.  I dont like the “scare” tactics used in this publication but….. everyone is certainly entitled to their opinion.

    Just as info – Our team constisted of 2 midwives (and a student), our doula, and a great supporting cast of family and friends who stopped in during the day to play with our first born and stock the freezer. :)

    Just my 2 cents.

  24. Stabilizing a hemorrhagic mother with anti-coagulants? I’m a midwifery student in Ontario. We do not give women anti-coagulants, just so you know. Not in our scope. Giving a hemorrhaging patient anti-coagulants would make them bleed to death… is just crazy. Please research some basic medicine before publishing such nonsense about midwives.

  25. A lot of people here are not looking at the big picture. I liked how this article examined professional opinions from both ‘sides’ of birthing, home and hospital.
    Yes, you can know if a C-section is unnecessary. Some OBs freely write “Labour Dystocia”, aka failure to progress, as a reason for a section. This is basically a judgement call; do I want to wait around for this woman to labour for yet another 6 hours, or do I want to make that round of golf with my buddies? A failure to progress can frequently be exhausting for the mom, so that if she eventually does get to pushing, she has no energy left and a C-section looks oh so welcoming (forgetting of course, that it still is major abdominal surgery). A failure to progress can be a doctor putting a woman on a clock as soon as she walks in the hospital doors, or as soon as her membranes rupture, or as soon as he expects his wife’s famous lasagna to be on his dinner table.

    Keep in mind if the plan for a woman is an emergency C-section, it’ll take around half an hour to set up the room and get everybody dressed, so if the woman lives withing half an hour of the hospital, she will simply be waiting at the hospital for a shorter period of time.

    We need to get away from the mindset that as long as a woman has a happy, healthy child at the end of the day, she shouldn’t be complaining about the care she received. Who cares I cut your vagina open? You have a healthy baby. No please, don’t kiss my feet, I don’t want any of those 11 unnecessary stitches to further aggravate your tissues. The woman’s experience of her birth CAN be very healthy, fulfilling, and happy, so she has every right to pursue a birth in the environment she finds herself most comfortable in. Her experience of the birth does still matter at the end of the day.

    Recent studies show that episiotomies are more harmful to the vagina than a tear, and a tear heals much easier than a cut. (These cuts are not made with scalpels, but with scissors.) It is not up to the OB to decide if he/she likes episiotomies or not. Evidence shows they should only be used to speed up delivery when the baby is right on the perineum and is showing signs of fetal distress (no, not just from head compression, but maybe something like sinusoidal FHR). Also, when a woman tears clear to her anus? You know what we do to prevent leakage? We stitch her back up. Surprising, I know. We actually can prevent lifelong anal leakage regardless of where she gives birth.
    The Canadian midwives are smart, careful medical professionals. There are steps they can take in the case of a PPH, a cord prolapse, or a baby who isn’t ready to breathe, even if these things occur quite suddenly, while waiting for more advanced help.
    Big picture: Why bother fighting about this? Many people simply need more education on how birthing works. I think as long as the mother is given an honest and complete informed choice discussion, she has the full right to choose where she will give birth and whether or not she and her offspring will participate in any medical procedures. Even if home births were slightly less safe, if mothers are given the best and most recent information, then they will decide for themselves, without your input, thank you very much.

  26. It’s unbelievable how biased this article is. I’ve read countless books and other articles on the topic, not to mention speaking to experts, and it’s agreed that European countries are among the safest to give birth. They also say that home birth is just as safe, if not safer, than hospital birth because of fewer unnecessary interventions. Make not mistake, it’s not just the mothers who benefit from fewer interventions, but the babies too. But the risks of induction, epidurals, and caesarians are rarely discussed with parent, especially if they don’t ask. Pregnancy and birth are NOT medical emergencies, a labouring woman is not sick and in need of rescuing.

    The problem here is that they interview obstetricians who are trained to see an emergency and respond to it, and a lot of the women they see either actually need emergency interventions or have been forced into an emergency situation because of all the meddling they get from paranoid doctors. That first guy who was part of the ‘flying squad’ shouldn’t be given so much credit: his JOB is to go to women and babies in distress, so he’s not even going to see all the home births that are completely successful. If he went to every single home birth in his area, and then compared it to the emergencies he’d be singing a different tune. This article is full of scary words and guilt trips. Better to go read studies for yourself and make your own informed decision.

    It’s also a known fact that Canada and the US aren’t exactly the top-ranked developed countries in which to give birth. Can’t find the exact numbers, but I’ve heard from several qualified people that America is ranked somewhere around #50, and that’s with a home birth rate of less than 2% and a c-section rate of 33%. That is truly disgraceful.

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