(4 of 5)
There is a big difference, of course, between having a baby in a planned home birth with a midwife who has cared for the mother throughout pregnancy and giving birth on the bathroom floor with a frantic spouse following instructions from a 911 dispatcher. Births that happen at home unexpectedly also tend to happen very precipitously, which is itself a risk factor for the baby.
The Washington study found a twofold increase in infant mortality associated with home birth compared with hospital birth. Given that it was one of only seven studies out of the 12 included in Wax's meta-analysis that assessed infant mortality in the first 28 days of life, the Washington study accounted for nearly 40% of all such data and contributed heavily to the final conclusions of Wax's meta-analysis.
Wax defends the inclusion of the Washington study, noting that its authors used various methods to exclude any home birth that was likely to have been unplanned. Moreover, he says, neonatal mortality rates were "fairly consistent across the included studies" in his review. Indeed, Wax and his colleagues think the conclusions of their analysis tend to underrate the risks of home birth. "The lower obstetric risk characterizing women self-selecting home birth likely underestimates the risk and overestimates the benefit of this delivery choice," the authors write.
Making Home Birth Safer
Understanding the relative risks of home birth has always been tricky, in large part because the subject is impossible to examine in a randomized controlled trial; few women would agree to let a study investigator randomly determine their birth plans. Meanwhile, broad reviews like Wax's of the existing research can be limited by the quality or relevance of the original data.
Some observers, including Wax, further suggest that American women should draw only limited conclusions about the safety of home birth from studies conducted in other countries. The experience of home birth in the Netherlands, for instance, where 1 out of 4 mothers delivers at home, bears little resemblance to the process most American women endure.
Two key factors contribute to a successful home birth: a mother who is at low obstetric risk and the possibility of a seamless transfer to the hospital in case of medical necessity. Because of eligibility requirements for home birth in the Netherlands, Dutch mothers who choose that route tend to be at lower risk from the start than their American counterparts. Dutch women who have had C-sections, for example, are not candidates for home birth, while in the U.S., previous C-sections are a major reason women choose to labor at home. Yet according to ACOG's 2008 statement, attempting VBAC at home is especially dangerous, because it puts the woman at risk of uterine rupture during labor, with no immediate access to necessary medical equipment or expertise.
In the Netherlands, moreover, midwives are fully integrated into the health care system and obstetrics practices, making transfers to hospitals routine. In the U.S., where 1 out of 200 women gives birth at home, midwives can be and have been arrested for bringing their patients to hospitals in states that do not license CPMs.