Issue of home birth
is about quality of care
It has far-reaching consequences that the profession of midwifery has been allowed become the poorly-regarded handmaiden of obstetrics

Once, after attending the launch of a medical textbook, I found myself chatting to a group comprised entirely of doctors and lawyers. One of them noticed that I was pregnant, and inquired where I was going to have the baby. There was a long pause, during which I wondered frantically whether honesty is really all it is cracked up to be. Finally, and very reluctantly, I admitted, "At home", writes Breda O'Brien.

There was the polite, middle-class equivalent of a gasp, and then one of the doctors said briskly, "You do know you are mad?" in the kind of tones reserved for those who announce that they are considering alfalfa sprouts as a treatment for cancer. Suffice to say, after that experience, I was not particularly surprised at this week's Supreme Court finding that there is no statutory obligation on health boards to provide home birth services. There is a virtually unshakeable institutional prejudice against home birth. Prejudice is the right word, because there have been numerous studies
internationally which suggest that for healthy women, home birth is as safe, if not safer, than hospital birth.

Furthermore, those who give birth at home are much less likely to have surgical interventions, including Caesarean sections. Given that Caesarean section is classified as major abdominal surgery, and carries a significant risk factor for mothers and babies of its own, one would think that the value of the low-intervention model of giving birth would be supported. Somehow, it is not.

The myth has grown that the only safe place to give birth is in hospital, despite the fact that the British Medical Journal in a 1996 editorial "supports the safety of home birth provided it is offered to women at low risk of obstetric complications". The same edition of the BMJ includes four studies which show that with adequate infrastructure and support, home birth is as safe as hospital for healthy women.

Micheál Martin has stated that the position of the Department of Health remains unchanged, which is to support choice in childbirth. Ultimately, it is not just about choice. If choice is the supreme value, it would be a matter of indifference whether women choose, for example, to opt for elective Caesarean, despite the fact that it carries significant health risks for both mother and baby. The issue is quality of care. Most of us who have opted for home births have done so after careful
research which has convinced us that the safest place to give birth in low-risk pregnancies is at home. That decision is reinforced by experiencing the consistent care provided by expert midwives, some of whom have decades of experience.

The ideal situation would be a harmonious continuum of care, with midwife-led services for the majority of women, and the best of obstetric care for the minority who encounter serious difficulties. None of us would wish to return to a situation where obstetric care did not exist, but it has far-reaching consequences that the profession of midwifery has become the poorly-regarded handmaiden of obstetrics. It is a statistical
fact that the routine application of medical interventions increases the likelihood of medical complications. How many women know that every intervention, such as breaking the waters and epidurals, reduces their chance of a normal birth?

The much lower rate of medical intervention of the midwifery-led approach, whether at home or in hospital, leads to not just a happier birth experience, but a safer birth for all.

Parents just want what is best for their babies. They do not want to get caught up in crossfire between two branches of the medical profession. The former Master of the Rotunda, Dr Peter McKenna, as reported in yesterday's paper, complains about the lack of supervision of independent midwives. He neglects to mention that independent midwives have themselves started to put in place a peer review and monitoring system, and that the current gap in such support is not the fault of midwives.

He also fails to mention that the three biggest Dublin maternity hospitals have withdrawn basic facilities such as blood tests and scans from home birth mothers. Dr McKenna has hardly advanced the cause of reconciliation of midwifery and obstetrics, much less the cause of good science, by his suggestion that a death rate of one in 70 occurs in home birth. He has concentrated on an unusual cluster of five deaths in a short period of four years, and from that has deduced a high death rate that is completely misleading.

A study of home birth from 1979 to 1998 shows a death rate of one in 1,000 babies. Any death of a baby is a tragedy, but because the numbers of people who opt for home birth are so low, it is very easy to introduce statistical distortion.

It is also hotly contested whether the deaths that Dr McKenna attributes to hypoxia (lack of oxygen) in labour were in fact caused by this. According to a statement by independent midwifes, one death, for example, was a stillbirth which happened before labour began. They go on to say that the five deaths were not related to the place of birth. "Babies die from infection, abruption, cord problems, maternal disorders and unknown causes in hospital: to pretend otherwise is wrong."

There is little to be gained by suggesting, as Dr McKenna does, that deaths which would be just as likely to have occurred if the mothers had chosen hospital birth, can somehow be blamed on lack of supervision of independent midwives.

We need a move away from the defensive practice of medicine in childbirth, to a situation where more and more women can experience the natural pace of birth, under the care of a highly-qualified professional; that is, a midwife. For some women, that will be at home. For most others, it will take place in a hospital. Would it not make great sense to designate as midwife-led units those maternity units now destined for closure? Not only would the service be more woman-friendly, it would be far cheaper.