Ornament

The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Ornament

Response to a Homebirth Complication or Tragedy

Practice Variation in Cesarean Rates: Not Due to Maternal Complications
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients.  This analysis shows that:

    Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
    Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
    Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.

Tips for Choosing a Care Provider - great overview! from Henci Goer

What a tragic situation.

I think everyone working with birth would love to have a crystal ball so that they could look into the future and know, for sure, whether a particular woman is going to have a normal birth or is going to have one with complications. Then we could recommend hospital birth for the women we know are going to have serious complications better handled in the hospitals, and we could recommend homebirth for the women who would labor dysfunctionally in the hospital and end up with life-threatening complications from a cesarean or whose baby would die from an antibiotic-resistant infection acquired at the hospital.

But we don't have a crystal ball. So we have to rely on statistics and probability to give us information about the safest place of birth. You should be quite comfortable recommending homebirth, knowing that for all but the highest risk category, homebirth is safer than hospital birth. (And those statistics only measure physical safety. The Association for Pre- And Perinatal Psychology and Health has a lot to say about emotional safety. And there are many women who have a lot to say about emotional repercussions of unsatisfactory birth experiences, as well. It's comforting to know that those who choose homebirth are probably making a choice that is as safe as or safer than hospital birth physically, and much safer emotionally.)

Those who favor homebirth sometimes forget that a hospital can sometimes be the safest place for a particular woman, and those who favor hospital birth sometimes forget that hospitals don't just fix problems - sometimes they cause them.

Wishing for safe births everywhere.


To A Bereaved Uncle

Your queries about the safety of homebirth were forwarded to the homebirth e-mail list, so I hope you don't mind a personal reply.

I am terribly sorry to hear about the problems with your sister's baby. Situations like these are heartbreaking, and even more so if there is a niggling guilty fear that they were somehow preventable. This is a common response to tragedy -- "if only I had....." -- and is one of the most destructive stages of grief

However, from everything you have relayed in your e-mail, it does not appear to me that the location of the birth could honestly be blamed as the primary culprit. Babies are frequently born at home (or in the hospital, for that matter) with cords wrapped around the head and depressed heart rates who are completely okay after a few minutes. The midwife applied the appropriate emergency measures (oxygen and CPR) which would have been applied no matter what the location of birth. I'm not sure what you believe "more immediate full-fledged medical attention" in the hospital would have entailed, since according to your e-mail the neonatal intensive care unit was not located at her local hospital anyway.

I agree with you that some C-sections are indeed needed. There are some situations in which c-sections save lives, specifically cases of placenta previa (placenta is covering cervix, so baby can't come out), or placental abruption (placenta pulls away from uterine wall before baby is out, severing its oxygen supply and causing mother to haemorrhage). Certain breech positions (footling breech) for larger babies might also be an indication for Caesarean, or twins where one is lying transverse. And there are very very few cases where women have deformed pelvises due to childhood polio or congenital defect, where a baby really can't fit through (true cephalo-pelvic disproportion). But all these kinds of cases taken together should amount to c-section rates of around 3%, and the rate in the US is nearing ten times that! In some hospitals, their c-section rate is over 50%!

You say "Even if C-sections are needed in a small number of births, by giving birth at home doesn't a woman thereby dismiss this potential option entirely?" This is absolutely not true, and my own case is a case in point. I planned a homebirth from day one of my pregnancy. The day before my due date, I awoke in the night feeling wet, thinking "All right -- my waters have broken!" I went to the bathroom only to discover that is wasn't amniotic fluid, but blood trickling down my leg. I was haemorrhaging from an abrupting placenta. We called our doctor and the ambulance, and under 2 hours later, my daughter was born by a completely and unambiguously necessary caesarean. Although I lost a lot of blood and had to be substantially transfused, we were both just fine.

The fact is, that even if the emergency arose while you were in the labour ward, it would take at least 20 or 30 minutes to prep an operating room and assemble the necessary staff for an emergency c-section. So if you live within a half-hour drive of a hospital and you call ahead, you are just as close to that operating table as if you were in the labour ward. So your statement " By the time the need for a C-section is determined I imagine it would be too late to transport the mother to a hospital" is simply not true in the vast vast majority of cases.

Of course complications can occur, and hospital is the place to go when serious complications do occur, and this is what happens. No midwife is going to endanger the life of her client by attempting to treat a problem for which she lacks the necessary technology or expertise -- like any practitioner, when the need for a specialist arises, she refers clients to the appropriate specialist. That's what hospitals are there for, handling emergencies.

But midwives ARE "trained medical personnel" and often have far more practical expertise than their M.D. counterparts. Their training and internship is just as long and rigorous as any doctor or nurse's, and indeed, many of them are nurses as well. (I'm sure your wife the RN has come home with horror stories of situations where the nurse on the case knew more than the doctor and just barely averted a bumbling disaster caused by his/her ignorance!) A medical degree does not guarantee competence.

But 97% of births are NOT emergencies, and yet by having your baby in the hospital, you are treated by the same protocols as those 3%, and that is wrong wrong wrong and the source of many many problems and complications. Most caesareans performed today are due to iatrogenic causes -- that is, the doctor's previous treatment regime has CAUSED the c-section to be (or at least be deemed) "necessary". If the baby had been born at home, this would not have happened. And make no bones about it, a c-section is major abdominal surgery and carries a significant risk of death for the mother, no matter what the "causes" of it were.

So one must always balance the relative risks involved -- the risk of maternal or fetal death due to an unnecessary iatrogenic c-section in the hospital (and your risk of an unnecessary c-section is about 1 in 4, and in some places much higher) versus the risk of having an emergency that could have been dealt with within the hospital faster than you could transport there (actually very very small). And unnecessary c-section is not the only risk of a hospital birth -- hospitals are full of sick people and sick people's germs, and rates of perinatal infections of both mother and baby are orders of magnitude higher in the hospital than at home.

There are many many scientific studies which confirm not only the safety of home birth, but many find that it is actually SAFER than a hospital birth in all but the highest risk cases (see Faith Gibson's pages for quotes from various studies). Check out the British Medical Journal (BMJ NO 7068 Volume 313 Saturday 23 November 1996) for some of the latest research.

When discussing my choice of a homebirth, someone once told me "yeah, I know what the statistics say [that homebirth is safe] but you're not just a statistic, and even in there's only a one in a thousand chance of something going wrong, don't you want to be in the hospital?" "Not when there's a 20 in a thousand chance that something will go wrong in the hospital!!" I said. This is how we make rational informed choices, by reading the scientific evidence and weighing the risks. And it seems to me that the fundamental mistaken assumption (propounded of course by doctors and OBs who work in hospitals) is that the hospital is the safest place to be -- study after study has shown it quite simply is not. So the rational choice 97% of the time is quite clearly homebirth.

But even if all the iatrogenic problems which arise in hospitals could be eliminated (and I honestly am not in the least hopeful about that), there are many other reasons why people choose to give birth at home.

If you look at it historically and globally, it is only in the last 50 or 60 years, and only in the industrialized west, that birth in hospital has become the norm. The common myth may be that is was this movement into hospital which reduced infant and maternal mortality, but careful studies have shown this not to be true -- that the drop in infant mortality occurred PRIOR to the shift in location, and that the improvement in the infant mortality rate actually dipped or even reversed itself in a given region when hospital births became the norm. Most medical historians now agree that the overall improvement in infant mortality rates occurred primarily because of improved maternal nutrition (same reason people are getting taller and menarche is getting younger) and has absolutely nothing to do with location of birth.

People have always given birth at home, and still do in most parts of the world. It is fundamentally not a medical happening, but a familial one. At home, a woman is in control. She is free to move and act as she wishes, and is not inhibited by being in a public place, but rather is content in the place she is more at ease, in the bosom of her family. The effect on the progress of labour of psychological factors cannot be overstated -- a woman who is tense, anxious, uncomfortable and feeling out of control will have a much more difficult labour and birth than one who is calm, relaxed, in control and comfortable. Hospitals, no matter how nice, aren't as comfortable and familiar as your own bed.

I firmly believe that women who WANT a hospital birth should be able to have one, but I also believe that homebirth is the rational and best choice for the vast majority of women.

Some useful references on the safety of homebirth and the lack of scientific basis (and indeed harmful nature) of common obstetrical practice :

A Good Birth, a Safe Birth
by Diana Korte, Roberta Scaer
Harvard Common Press 1992
ISBN: 1558320415
Obstetric Myths Versus Research Realities : A Guide to the Medical Literature by Henci Goer Bergin & Garvey, 1995 ISBN: 0897894278

Intrapartum Care : A Research-Based Approach by Jo Alexander (Editor), Valerie Levy, Sarah Roch (Editor) Univ of Toronto Press 1993 ISBN: 0802074510

I hope you have found my discussion useful, and again I want to express my deepest sympathy at your sister's misfortune.

Warm regards from a mom who is planning a home VBAC in 3 months time!


My first response would be that babies die in hospitals too. I know that sounds crass, but it's the truth. Location, either at home OR in a hospital is no guarantee. As he said himself, birth is mysterious. Unfortunately part of life is death, and sometimes, as painful as it is, the moments we have with our babies are fleeting. (I hope this doesn't sound insensitive; I mean like my own miscarriage, or stillbirths, or child deaths.)

Other than that I would not feel comfortable commenting on the circumstances surrounding the poster's own situation. Some questions, though. Is he implying the cord wrapped around the neck is what caused this? In approx. 1/3 of all births the cord is around the neck. I know a woman whose 3rd baby was wrapped up in the cord several times -- neck and shoulder (born at home no complications). How long after the hearttones dropped was the baby born? Is dropping to 100 really that bad (it's been a long time since I studied the actual parameters for that sort of thing)? Did the midwife have oxygen? How long did it take the ambulance to get there? How far away was the hospital?

This sort of tragedy quite sadly exemplifies why we need the medical community's BACK-UP with no hassles. In a hospital it often takes 10-30 minutes for an emergency c-section, anyway. In an ideal scenario for someone wanting a homebirth, back-up is pre-arranged, so that medical staff can be waiting And he mentioned the baby being transported to a hospital better equipped to handle neonatal intensive care, making it sounds as if the local hospital wasn't even equipped to handle a really bad situation anyway.

Another comment, while for some this might be the case, having my babies at home is NOT just a knee-jerk response to poor treatment from medical personnel. For us, it was something my husband I felt called to do, and we're damn glad we did it! We feel that birthing our baby was an intimate and very sexual experience that just would not have been right anywhere but in our own home. We began our journey at home in our bed, and we climaxed it, by having only my husband touch me for Jake's birth, with minimal assistance from a very respectful, loving friend that our midwife became during the pregnancy. Not that everyone needs to feel that way about birth; it's just an explanation of how we view it. And we feel that any children that come to us do so with the full understanding before conception of what we're about as a family. This is a religious/spiritual thing for us.

This man's letter sounds pretty sincere, but I can't help but wonder when I read things like this if it isn't bait to get homebirthers stirred up. But I'll comment on the 'if hospitals could be improved' comment. It's not just insensitive hospital staff or medical personnel with poor bedside manners that make people want a midwife or a homebirth ... it's the Midwifery Model of Care, which has been shown to be better for both mom and baby, as opposed to the obstetric interventive approach. It's not just how they talk to you, but how they handle the entire situation. I just added a page that is text of a NARM pamphlet that explains this in full detail. You can direct him, or anyone else interested, to http:

There's also a wonderful comparison between the two models of birth on the web.



This Web page is referenced from another page containing related information about Homebirth Safety/Advocacy

 




SEARCH gentlebirth.org

Main Index Page of the Midwife Archives

Main page of gentlebirth.org         Mirror site

Please e-mail feedback about errors of fact, spelling, grammar or semantics. Thank you.

Permission to link to this page is hereby granted.
About the Midwife Archives / Midwife Archives Disclaimer