Injury and Death Rates Aren’t Relevant to Policy?
Philip Cohen has a strange post at Sociological Images entitled, “Study shows home birth is not as safe. So?”
What do you mean, “So?”
The new Birthplace Study, the largest and best-controlled study of its kind, found that homebirth sharply increases the risk of death or serious injury for babies born to first-time mothers with ultra-low-risk pregnancies. There were 9.3 adverse events per 1000 births in the planned homebirth group vs. 5.3 per thousand in the planned hospital birth group. So, the vast majority of women in both groups delivered healthy babies, but even so, the homebirth babies were almost twice as likely to die or be seriously injured.
There was no increased risk for babies born at home to women who had already had children, but the women who had already had children were an unusually low-risk group because women who had already had children were only eligible if they’d had zero risk factors in their current pregnancy and all prior pregnancies.
The real-life guidelines for homebirth are much more relaxed, so the stringent study criteria tend to make homebirth look better on paper by screening out higher risk women who would still be eligible. Sure enough, the researchers found that the babies of women who were at low-enough risk to qualify for a planned homebirth, but not sufficiently low-risk to be part of the study, had worse outcomes.
Cohen is convinced by these data that homebirth is more dangerous than hospital birth for babies of first time moms. It’s hard to argue otherwise. The study is well-designed and the difference between the two groups is stark, even when you take the error bars into account.
However, Cohen takes issue with the study authors’ assertion that their results support a policy that gives all women the right to choose where they give birth, which happens to be the status quo in their health care system. The study took place in the UK’s National Health Service, which currently covers either homebirth with a highly qualified midwife or hospital birth.
Cohen maintains that policy questions can’t be resolved by comparing risks, no matter how rigorous the comparison.
That’s trivially true, but it seems beside the point. People can always use the same study to argue for different and even conflicting policies. Someone might use The Birthplace Study study to support a policy of recommending hospital birth but offering home birth as an option. Someone else might argue that this study supports a policy of laying out the facts without making any official recommendation. Of course, someone could use these data to argue that homebirth should be officially discouraged or even banned, but I don’t see even the most enthusiastic supporters of hospital birth making that case.
Policy is about what we ought to do. What we ought to do depends on the facts as interpreted in light of our goals and values. This study suggests that if our overriding goal is to reduce infant injuries and deaths, we should discourage homebirth for first time mothers. However, since we value personal autonomy, we shouldn’t take this study as permission to violate women’s right to make their own decisions about how to give birth.
But here’s one policy implication that everyone should agree on. In light of the evidence, first time moms need to be told the following in order to give informed consent: The absolute risk of death or serious injury is quite low wherever you give birth in the NHS, but homebirth doubles the risk of the baby being hurt or killed. (We shouldn’t infer that US homebirth is as safe as UK homebirth because UK midwives are better trained than many of their US counterparts.)
Until now, the policy questions have been clouded by factual uncertainty. Some proponents of homebirth have argued that homebirth is just as safe as hospital birth. Now, the biggest and best study has decisively refuted that claim. Women have a right to know the truth.
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