In Which ACOG Admits that Homebirth Can Be As Safe As Hospital Birth...

Neonatal mortality.

This has been used as the nail in the coffin of the homebirth debate. Opponents of homebirth will often concede that homebirths create a better experience for the mother, but usually present this benefit as being only for the mother with an increased risk of injury or death for the baby. In particularly vitriolic debates, this is where the "selfish mother" accusation kicks in.

However...

It’s not entirely true.

Which is why it’s important to go straight to the American Congress of Obstetricians and Gynecologists Bulletin No. 697 from April 2017.

What does ACOG Bulletin No. 697 Say About Homebirth?

ACOG’s Bulletin No. 697 is (in my opinion) a relatively balanced assessment of the research on homebirth. One of the first things that ACOG states is that high quality evidence comparing hospital birth and homebirth outcomes is limited. The “gold standard” in medical and scientific research is the randomized control trial (RCT) and this is almost impossible to pull off with birthing practices. A RCT is where you randomly assign your participants to receive one or the other treatment/intervention/ experience. So in the case of homebirth and hospital birth outcomes, we would need thousands of women who honestly don’t care whether they give birth in a hospital or at home. In developed nations where homebirth is more common than in the US, attempts have been made at conducting a RCT. But these have failed to launch because women were unwilling to have their birth experience be assigned at random.

Birth is also one of those things that is very hard not to affect by location and mother’s preference. It’s not like a surgical procedure where you can put your patient under anesthesia and implement certain procedures. Women who feel threatened during labor will often have a stalled labor as their body releases catecholamines in response to the stress. So whether it’s at home or in a hospital, the woman who wants to be birthing somewhere else is going to have a poorer outcome than the woman who feels safe where she is birthing. So a RCT is really not going to be a possibility. This leaves us with observational studies.

Observational studies present a number of problems. Some are so small that they can’t give us a picture of what homebirth would entail on a large scale. Many rely on birth certificate data— which is notoriously inaccurate. For example, when it says there was an attendant at the birth, was it a husband, boyfriend, CPM, DEM, old hippie lady, CNM, paramedic, naturopath, neighbor down the street...? Often, the birth certificate doesn’t specify what “attendant” means. Sometimes the studies don’t differentiate between planned and unplanned homebirths very well— a big problem because a woman who gives birth suddenly at home because of an emergency is in a different situation than a woman who has a full-term, spontaneous birth with a qualified attendant there. And it’s also hard to ascertain whether complications resulted from care during a transfer to after transfer to a hospital. ACOG does point out that there have been some studies from other countries where home birth is well-integrated into the hospital system and these studies have been high quality. Unfortunately, the results of these studies aren’t necessarily what we would see in America because homebirth tends to operate on a fringe here instead of being a part of the normal system of birth care.

But all that being said, ACOG says that there are some common threads that emerge from observational studies on homebirth where the neonatal mortality rates are comparable to those in hospitals...

What ACOG found in all the studies where homebirth and hospital birth neonatal mortality were similar:
Rigorous selection criteria 
Experienced, well-trained (usually credentialed) attendants
Safe and timely transfer

So in a nutshell, yes, homebirth for a low-risk pregnancy with a qualified attendant and a hospital close by for transfer is as safe as a hospital birth for a low-risk pregnancy. ACOG still believes that a hospital birth or birthing center with CNM are the safest options, however, they acknowledge that homebirth can have comparable rates of infant mortality.

That being said...

I think there is a potential for some “high-risk” pregnancies to be safely birthed at home, depending on the particulars of the pregnancy and skill of the attendant. The Farm in Tennessee has delivered breeches, VBAC’s and twins with an extremely high success rate. And while there are accounts of poor midwifery care for breeches, twins and VBAC’s we can dig up examples of successful homebirths for these conditions. As for hospital care, most twins and breeches are simply delivered by c-section and few VBAC’s are attempted and fewer achieved. This gives the illusion of safety since many twins, some breeches and most VBAC’s could probably be delivered safely vaginally with the right care. ACOG notes that research from the UK showed comparable levels of neonatal mortality VBAC’s at home and in hospital— but that in the US the rates of neonatal mortality were higher for HBAC’s. This indicates that safe HBAC is possible, but there are problems with how HBAC’s are sometimes managed in the US.

But here's where ACOG gets a little hypocritical...

The two criteria of low-risk pregnancy and competent attendant apply to hospital births as well!!!! Some pregnancies just can’t end in a natural birth like genuine CPD and some are just more likely to have a poorer outcome even with the best technology, like a very early pre-term birth. So skill of the attendant is also crucial even with a OB-GYN in a hospital. For example this doctor- an honors graduate from CalTech and elected vice-chair of obstetrics to Huntington Memorial Hospital- failed to treat a mother for retained placenta causing a severe hormonal deficiency, injured two babies during labor resulting in brain damage to both and failed to treat a mother or call in a perinatology specialist when a mother was leaking amniotic fluid at 30 weeks and the baby’s heartbeat was abnormal, resulting in the infant’s death. The hospital stuck by him during these and many more instances only taking action when the LA Times published an expose. Or this doctor who refused to perform additional tests on a mother classified as high risk despite recommendations from specialists and then caused permanent damage to the baby during birth.

Bad decisions and poor care from anyone can kill a baby and credentials- or lack thereof- are no guarantee of good or bad care. The aforementioned doctor at Huntington Memorial permanently injured a mother who was low-risk. After suddenly shouting that he needed to do an emergency c-section, he instead decided to make several deep cuts into the mother’s vagina. The baby was born healthy and the mother’s bowels were permanently damaged. Specialists who examined her were shocked that a woman under the care of a licensed physician in America could have such severe injury. Let’s ask ourselves a question: had she delivered in ambulance or by the side of the road, might there have been a better outcome? Remember, the doctor gave no reason for why a c-section needed to be done, then decided that it wasn’t necessary and medical examinations determined the injuries she suffered were shocking and unnecessary.

An obstetrician who fails to give appropriate care is just as dangerous to a baby or mother as a midwife or mother who fails to give appropriate care. Doctors who want the respect and trust of mothers can’t expect that their credentials are enough. They must be able to provide appropriate and competent care. And if a doctor is allowed to provide care that endangers the lives of mothers and babies and still be elected to a prominent position in a hospital, then how well can women trust the credential of OB-GYN over midwife? The same arguments that midwives are incompetent and unregulated can also be leveled at OB-GYN’s and pretending that one or the other credential is more or less safe distracts us from the real issue: competent birth attendants will have good outcomes for the vast majority of births. Incompetent attendants are dangerous. It’s not the place of birth or the credentials of the attendant that make a birth safe. It’s the competency of the attendant and supporting caregivers.

Why C-Sections Are Like Apollo 13

By April 1970 space travel was largely regarded as mundane. Two successful moon landings had taken place and the public had started to view space travel as an endeavor with as much risk as road tripping to see family in Ohio. For the crew of Apollo 13 though, it was the culmination of years of training. They were all stand out pilots who were excited to have the chance to go to the moon- a genuine, once-in-a-lifetime opportunity. For Commander Jim Lovell, this was the top of pyramid. He had clocked more time in space than almost any other astronaut and had even seen the moon on flyby
when he was part of the Apollo 8 crew's Christmas mission. (You can still  see the video coverage where they filmed the Moon from space, reading from the first chapter of Genesis.Whatever your religious views, it will give you chills as you think about just how vast and ancient our universe is.) Lovell had had an incredible career. Apollo 13 was his last mission and visiting the moon was everything he could have wished for as a pilot and astronaut.

The third moon landing mission Apollo 13 launched with little fanfare or attention... until a malfunction left astronauts Jim Lovell, Fred Haise and Jack Swigert stranded in space while NASA engineers worked day and night for almost six days to solve an ever increasing list of problems and bring the astronauts back home safely. The situation was far from ideal. A routine stir of the oxygen tanks had caused an explosion on the spacecraft leaving the astronauts with no other option than to leave the spacecraft Odyssey (which was meant to ferry the three men to and from the moon) into the lunar landing module or LM (which was designed to carry two of the crew to land on the moon from lunar orbit). With three occupants instead of two, the LM's carbon dioxide filters quickly started becoming overwhelmed and the filters between the Odyssey and the LM were not interchangeable, so NASA engineers had to figure out how create an adaptor using only the materials the astronauts would have on board. The LM was not designed for multi-day usage, so they had to turn the power down to an absolute minimum to subsist for the entire journey back to Earth. (For a point of comparison, there is a famous line in the movie where one engineer protests this idea shouting "You can't run a vacuum cleaner on 12 amps!")

This meant that the onboard guidance computers had to be shut down. It meant turning off the heat so the astronauts were floating around in temperatures as low as 38 degree temperature with no warm clothing. Water had to be rationed to last the entire trip (Fred Haise developed a UTI and subsequent kidney infections during the whole ordeal.) And no waste dumps were allowed for fear it would mess up the already tenuous trajectory of the injured space craft. All human waste was confined to bags and kept in the craft. The odds were not good. But as lead flight director Gene Kranz would later say, "Failure was not an option." They refused to let three men die in space and simply kept working problem after problem. After a lot of hard work, courage, and a few lucky breaks (like the onboard computer not shorting out when it was powered for reentry and missing a hurricane at splashdown), the crew of Apollo 13 made it safely home to their families. The mission was considered a successful failure. They failed to reach the moon and none of the crew would ever have the chance to visit the moon again. But despite all the challenges, they made it safely home. NASA and other space agencies don't make a habit of pushing spacecraft to work in ways that defy design and specification. It would sure save a lot of power, but turning onboard computers and heating off are not routine because of the risks involved to the astronauts. Nobody wants to make those types of sacrifices unless it's absolutely necessary.

On the other hand, if you ask anyone at NASA who had to live through Apollo 1 (fatal fire during training), Challenger (explosion on the launchpad) or Columbia (disintegration upon reentry), which they would choose, they would take Apollo 13 in a heartbeat. No one wants dead astronauts. A c-section should be the same way. It's not ideal. You are surgically cutting open the womb. There is a 12 percent chance of damage to the mother's internal organs. There is an increased chance of hysterectomy, blood transfusion, uterine infection and future placental abnormalities for the mother. There is a 1.1% chance of some kind of injury to the baby, ranging from minor to serious. The baby is very likely to experience respiratory problems which will require a NICU stay. Breastfeeding is frequently more difficult because of the problems associated with nursing after major surgery. We're talking about additional risks over a normal, uncomplicated vaginal birth, but when faced with a life and death situation, we all want safe mothers and babies. And if that means the obstetrical equivalent of pulling out a lifeboat in space, turning off the power, and fashioning a carbon dioxide filter adaptor from duct tape, we're going to do it because it has a good chance of saving lives.

When we talk about c-sections, we're not talking about a choice between risk and no-risk. C-sections carry additional risks over normal, uncomplicated vaginal birth. The engineers and astronauts realized that every decision they were making about the Apollo 13 mission carried an additional risk of death over an uncomplicated mission, but those risks were worth the chance of bringing the astronauts safely home because they were not dealing with a normal, uncomplicated mission. C-sections should not be seen as a routine procedure. Health professionals, parents and birth workers need to keep in mind that c-sections are the obstetrical equivalent of Apollo 13. If we start confusing "normal" with "emergency" we are creating a situation that exposes mothers and babies to additional risks.