49. Midwives and the Home Birth Demonstration Project
Home birth can teach us lots about hospital birth. As part of the introduction of midwifery in BC, in the pre-legalization or pre-regulation era, I was asked to lead a study to evaluate home births in the province. I declined, as I felt that my association with the development of midwifery was so strong that the project could be seen as a conflict of interest and therefore could endanger the results. Nevertheless, I was part of the project’s design and was delighted to recommend that Dr. Patti Janssen take on the role as principal investigator. The unique design of the project allowed for a five-year study of every home birth in BC. And there were to be three comparison groups: all home births, all hospital births by the same midwives and a matched sample of physician births from the same settings for women who had the same characteristics, meaning that the women would have been eligible for a home birth, if physicians did home births, which they did not.
Another unique aspect of the study was that we did not sit around and wait for bad things to happen. A panel of experts including obstetricians, family doctors, nurses and midwives would review every transfer and every potentially problematic outcome so that a report could be sent to the BC College of Midwives, which could then issue directives to correct problems before they became serious.
The results of the study were startling to some.31 The outcomes for the newborns were similar for the three groups. However, midwives at home had the best outcomes in terms of much lower use of procedures, based on intention to treat, meaning that once labour began at home, the outcome was assigned to the home birth category, not to the hospital. Otherwise, the hospital might be credited with outcomes that belonged with the home birth analysis. Interestingly, the planned hospital births by the very same midwives had more in common with physician births in hospital than with their own births at home, illustrating the pernicious effect of the hospital environment.
The results of the study, and two related ones from Ontario, demonstrated the safety of home birth when midwifery is regulated and conducted by university-educated midwives who are fully integrated into a health care system, which accepts the midwives as valuable partners.
Despite the studies’ clearly demonstrated safety of home birth, a substantial number of practitioners and members of the public cannot accept that home birth could be as safe as hospital birth, where all the needed bells and whistles are ready at hand, this despite the fact that midwives are fully and repeatedly trained in maternal and newborn emergencies, and they carry oxygen and other emergency supplies to every home birth. Of course I have never said that home birth is safe in all situations. In BC and Ontario, where midwives are university educated and home birth is regulated and fully integrated into the birth system, it is safe. The same positive result might not occur in situations where the system is not there to support the midwives. In the US, in settings where midwives are unsupported or where the conventional medical system is hostile to home birth, we can hardly expect that home birth is as safe as it is in Canada or in certain European settings.
Canadian obstetricians’ mostly negative attitudes toward home birth are based on lack of experience with “ordinary” home birth or collaboration with midwives. Each discipline operates in its own silo. Medical practitioners tend to remember only the cases sent to hospital for problems, even though the most common problem is the need for additional pain relief that is not available at home, like epidurals. Furthermore, medical practitioners can all remember particular cases where rapid response to either maternal or newborn emergencies saved the day. How could such emergencies be anything other than worse off at home?
Home birth is not intrinsically safe. Hospital birth is also not intrinsically safe. It depends. It depends on the individual setting and the individual skills of the practitioners. If home birth is as safe as the BC and Ontario studies indicate, when it seems like hospital birth ought to be safer, then something has to be going on in the hospital to cause problems that are avoided at home. It is a case of apples and oranges. In the home, the comfortable setting and intimacy of midwifery care prevent some problems that are actually caused by the hospital environment. In contrast, there are undeniably some rare problems that can occur at home that might be better managed in the hospital. These two systems of care each have their issues, but they are not the same issues. Even though these different environmental issues balance out in the raw numbers of maternal and newborn outcomes, showing an equivalency of maternal-newborn outcomes in hospital and at home, in the two settings the risks and benefits are different, as are the complications and protections. How do you quantify the benefits of intimacy in the home versus availability of immediate backup in the hospital? Or how do you quantify the effect of overuse and misuse of technology in the hospital versus the potentially protective effect of being in the home. Mistakes can occur in both settings, but they are different mistakes. In summary, if we could make the hospital as comfortable as home, who would not want to give birth in hospital? But we can’t, so informed women will select the type of provider that fits their needs and values.