This is an expanded version of a piece I wrote for Time.com.
Dr. Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School has written two pieces on the safety of homebirth. The first, A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth, appears in The New England Journal of Medicine; the second, Are hospitals the safest place for healthy women to have babies? An obstetrician thinks twice was published on The Conversation website.
Dr. Shah is also the Founder and Executive Director of nonprofit organization Costs of Care, Inc., which describes its mission as:
We believe that Americans can get their money back by trimming the fat out of medical bills – replacing or rejecting services that eat into our wallets without making us healthier.
The Problem: many medical bills are inflated with unnecessary care
So the real question being addressed in these pieces is not whether hospitals are the safest place to have a baby. There’s no question that they are. The real question that Dr. Shah appears to be asking is: Are homebirths safe enough that we can shunt pregnant women into lower cost homebirths in an effort to save money?
That’s a reasonable question to ask, but Dr. Shah’s answer is compromised by his failure to address two major issues, the existence of two different types of midwives in the US with wildly divergent perinatal deaths rates, and the growing body of literature that shows that homebirth in the US has a mortality rate anywhere from 3-9X higher than comparable risk hospital birth.
Here’s how Dr. Shah frames the issue in the NEJM piece:
For generations, both British and American mothers have assumed that the safest way to give birth is to spend many hours, if not days, in a hospital bed under the supervision of an obstetrician. Now, new guidelines are challenging these deeply held beliefs.
After completing an evidence-based review, the United Kingdom’s National Institute for Health and Care Excellence (NICE) concluded that healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician.1 Across the pond, eyebrows went up. The New York Times editorial board (and others) wondered, “Are midwives safer than doctors?”2 How can homes be safer than hospitals? And what implications will the British guidelines have for the United States?
Dr. Shah claims:
At its core, this debate is not about the superiority of midwives over doctors or hospitals over homes. It is about treatment intensity and when enough is enough.
However:
1. In contrast to the UK where there is only one type of midwife, highly educated and highly trained, in the US there are two types of midwives: certified nurse midwives (CNM), the best educated, best trained midwives in the world, and a second, inferior class of midwife, certified professional midwives (CPM), who lack the education and training of midwives in EVERY other industrialized country. Most US homebirths are attended by this second class of midwife, the bulk of whom have attained their credential by correspondence course (or no courses) and who have served an apprenticeship with another, equally poorly trained CPM. The mortality rates reflect this fact.
2. There is a large and growing body of research that demonstrates that homebirth with an American homebirth midwife has a death rate 3-9X higher than comparable risk hospital birth. Curiously Dr. Shah’s scant list of only 5 references, doesn’t include any of the many papers and datasets that demonstrate the wide gulf in outcomes between homebirth and hospital birth.
It’s not possible to review the entire scientific literature of homebirth death rates, but here are some highlights:
In March 2013, Oregon released an analysis of homebirth deaths prepared by Judith Rooks, CNM, MPH that showed that PLANNED homebirth with a LICENSED Oregon homebirth midwife had a death rate 800% higher than comparable risk hospital birth.
In June 2013, Grunebaum et al. demonstrated that homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%.
In January of 2014, Wasden et al. demonstrated that the risk of anoxic brain injury is more than 18 times higher at homebirth than comparable risk hospital birth.
In January of 2014, the Midwives Alliance of North America published their landmark study (actually a non-representative survey of less than 30% of their members completed 5 years ago) claiming that homebirth is safe but ACTUALLY showing that homebirth increases the risk of perinatal death by 450%.
So Dr. Shah’s question, are hospitals the safest place to give birth, has been repeatedly asked and answered: In the US, hospital birth is incontrovertibly safer than homebirth.
The real question is whether homebirth is safe enough to contemplate encouraging it as a cost saving measure as they are doing in the UK.
The answer to that question is debatable, but we are lacking important information that would allow us to debate it.
Are out of hospital births really cheaper than hospital births? On the face of it, the fee for giving birth outside a hospital is much lower than the fee for giving birth inside a hospital. However, the cost of the actual birth is not the only cost. What is the cost of transport and how does that add up when more than 40% of first time mothers are transferred to the hospital and then incur hospital fees as well? The most critical component, and it is a massive component, of any cost analysis of homebirth is the cost of caring for a brain injured child who might have avoided the injury in the hospital. Each one of those children requires tens of thousands or hundreds of thousands of dollars of expenditure each year, and if the brain injury is permanent, he or she may incur millions of dollars of care over a lifetime. And don’t forget to factor in the millions of dollars that will be paid out in legal judgments for damaged or dead infants, as well as the increased cost of liability insurance to cover these claims. It is quite possible that over large populations hospital birth costs less than homebirth.
Is homebirth safe enough? That’s an individual decision that can only be made by individual mothers considering their own wants and needs. Hospital births are like seatbelts. Most of the time you won’t be in a car accident so you don’t need them; but when you need them, they save lives. Just like failing to buckle your child in on a drive to the store in unlikely to result in that child’s death, homebirth is unlikely to result in the death of a child. But over large populations riding in cars repeatedly, routinely buckling seatbelts saves thousands of lives. When it comes to homebirth, each mother must decide whether she is willing to tolerate the risk to her baby of dying at homebirth, a risk that is higher than the risk of the same baby dying in a car accident.
Dr. Shah concludes his NEJM piece:
As a U.S.-trained obstetrician, I have little doubt that the United States offers outstanding care for medically complicated pregnancies. But there are lessons to be learned from the British system. The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.
That point is debatable, for a variety or reasons, but one thing is not debatable.
The majority of American women with straightforward pregnancies are far better off in hospitals and it is unfortunate that Dr. Shah did not share the scientific evidence that makes that clear.
