What a headline! What medical reporter could resist rushing to the news editor on sighting an academic article which packs such a quotable punch in its conclusions? No wonder Lachlan de Crespigny and Julian Savulescu, authors of “Homebirth and the Future Child” in the Journal of Medical Ethics in January 2014, have achieved a degree of publicity beyond the dreams of most childbirth researchers. Since dozens of midwives and obstetricians every year would give their eye teeth for such coverage, I was interested to find out who these chaps are.
Lachlan de Crespigny is an obstetrician and senior research associate at the University of Oxford’s Centre for Practical Ethics. His biography on the Centre’s website does not reveal how much experience of home birth he has, but it does make clear that he works “exclusively in prenatal testing and gynaecologic ultrasound”.
Julian Savalescu is an expert in prenatal testing as well, especially in the ethics of embryonic research, genetic research and the like. His biography does not tell us of his experience of home birth and like his colleague, it would not appear to be close to his field of expertise.
The article opens by declaring that “debate around home birth typically focuses on the risk of maternal and perinatal mortality and morbidity — the primary focus is on deaths”. The authors assert: “there is little discussion on the risk of long-term disability to the future child”. I have spent much of the past ten years debating the relative wellbeing and safety of mother and child in different birth settings and hearing mothers thinking aloud as they laboriously weighed up the various risks to their precious babies at home or in hospital — yet apparently none of the discussions I’ve taken part in have taken place.
The authors quote the utilitarian philosopher John Stuart Mill to the effect that someone who brings a child into existence “irresponsibly” is a criminal, and move swiftly on to a case of a mother dying within hours of giving birth at home. Let not be said that our Oxford ethicists allow dry academic style to get in their way; even scholars of their status are not above rampant sensationalism.
They do mention that the woman in question had “previously delivered twins by emergency caesarean section, one later dying, a history which, according to the Royal College of Obstetricians and Gynaecologists, is a strong indication for hospital birth” Later, in criticising “some healthcare professionals and organisations” who “enthusiastically promote” home birth, they note in their references that one of those organisations is the RCOG: in other words, the very case they have decided to use as an emotive poster child against home birth is one which the “enthusiastically” pro-home birth RCOG would not have recommended in the first place. It is an arresting introductory anecdote — and it is completely irrelevant to the debate. But what a gloomy aftertaste it leaves in the reader’s memory!
The argument of these two Oxford-based Australians is that long-term disability is more likely to result from home birth than from hospital birth. Therefore home birth is immoral and doctors should dissuade women from choosing it. “Doctors and midwives often do not currently tell patients [sic] that there are predictable avoidable risks of future child disability with homebirth. They should do so.”
The first question which pops into the casual reader’s mind is firstly, have they no idea at all of how many hoops women (or, as they would say, “patients”) have to jump through to be “allowed” to book a home birth? The second question is: if home birth is more dangerous, then where are all the disabled home birth babies?
De Crespigny’s and Savulescu’s main source turns out to be none other than the infamous Wax report of 2011. This was an American meta-analysis of a dozen studies on the safety of home birth which concluded that babies were three times more likely to die in home births than in hospital, in contrast to a number of other studies over the years that, comparing like with like, have concluded that safety rates are the same in home and hospital.
The Wax report is often described as “infamous” because it gives the appearance of having been cobbled together from old studies dug up from all over the shop in order to make home birth look as bad as possible. Some of the studies dated back 30 years, with no account taken by the report’s authors of how midwifery training and resources have moved on. It included studies of births in a big rural area where it might take hours to get to a hospital in an emergency (in my urban area, it takes a maximum 10 minutes by ambulance) and home births attended by midwives with varying degrees of professional training.
The studies used different criteria for planned, assisted births — a planned, assisted birth might be in a hippy colony or in some cult where medical aid is banned; or it might be one arranged by an educated woman who has had a previous straightforward labour, with a trained midwife and full antenatal care – they are not the same thing. No information was provided by the authors as to what weight was given to different studies of different sizes. Most shocking of all, when unassisted, unplanned home births were taken out of the picture, the safety of mother and baby were found to be the same.
De Crespigny and Savulescu, who both apparently hail from Australia, a country whose maternity culture has a reputation for extreme hostility towards home birth, offer no caveats in interpreting Wax; instead they choose to take issue with the methods underpinning the widely respected Birthplace Study, which showed in 2011 that in England, the home is as safe as (indeed for many women, arguably safer) a hospital for low-risk multiparous women and for first time mothers, very, very marginally more risky.
De Crespigny and Savulescu focus their argument on the risk of hypoxic ischaemic encephalopathy (HIE) — this is when a baby’s brain is starved of oxygen and the baby suffers irreversible disability, even quadriplegia. They object that the Birthplace Study’s identification of adverse outcomes did not distinguish between irreversible damage such as HIE and things that can be fixed, such as broken clavicles and “even” delayed initiation of breastfeeding. But this issue was foreseen by the Birthplace Study’s creators. Lecturing at University College, London in January 2013, Professor Peter Brocklehurst, leader of the Birthplace Study team, explained: “We knew that we were putting together [as adverse outcomes] things which were not of equal importance, but the anticipation was that if there was a problem with a planned setting for birth, or the quality of care in that setting, those outcomes would go in a similar direction.” (Incidentally, Brocklehurst’s list of adverse outcomes did not include delayed initiation of breastfeeding, as implied by De Crespigny and Savulescu.)
De Crespigny and Savulescu believe that at a home birth there may be a danger of late diagnosis of HIE and there may be not enough time to get to hospital to save the baby. Therefore, they conclude, home birth increases the risk of disability due to HIE and is therefore as immoral as allowing your child to sit in the car with no seatbelt on. Instead, they should have taken more careful note of the ways in which HIE is diagnosed either at home or in hospital, and most importantly on what causes HIE in the first place.
Is it really easier to diagnose the early signs of HIE from a continuous fetal monitoring device than by intermittent auscultation? Midwifery professor Denis Walsh — also an Australian by birth — has written extensively on the over-reliance on continuous fetal monitoring. Continuous fetal monitoring is more likely to lead to a caesarean and associated with a high level of false positives. It tethers the mother to the bed, making it harder for her to cope with her labour and thus more likely to have an epidural — which in turn makes it more likely that the baby may suffer cord compression…and/or that she will have an assisted birth under emergency conditions.
Hayes et al (AJOG 2013) compared 245 cases of HIE with 489 control births (babies without HIE). Of the HIE cases only 3% did not have continuous fetal monitoring; of the control babies, ten per cent did not have continuous fetal monitoring. Surely if continuous electronic monitoring were so important for diagnosis, the healthy babies would have been monitored more than the unwell babies? I am not a doctor, or a midwife, but I don’t see how this supports a view that EFM gives better early warning of HIE than a midwife with a watch and a well-maintained Sonicaid. In a home birth a vigilant, trained midwife knows what to look for; at hospital the woman may be left alone in a room strapped to a monitor, which shifts around whenever she dares move from the pain-magnifying upside-down-turtle position she must maintain. The CTG trace is only as good as the mother is compliant.
Hayes et al noted that the most important risk factors in HIE were;
Every single one of these risk factors can be noted by a home birth midwife as promptly as by a hospital midwife. The most interesting one, to my eyes, is that of increased uterine contractions. De Crespigny and Savulescu take no account of the likely causes of a woman’s uterus becoming so hyperstimulated that it contracts so fast that the baby’s heart beat cannot recover between contractions.
A quiz question: what drug is most implicated in childbirth injury lawsuits where a baby has suffered brain damage in the USA and the UK? Answer: It is the drug we call in this country Syntocinon, which is known in the USA as Pitocin, and which medical professionals often lazily refer to as oxytocin.
Syntocinon produces fast, strong contractions and is delivered in a continuous stream, not in waves like natural oxytocin. It does not affect the brain and emotions in the same way as endogenous oxytocin, which is sometimes referred to as the “love hormone” because of its presence in breastfeeding and sexual intercourse. By contrast with oxytocin, women usually find Syntocinon-induced contractions unbearable and immediately request an epidural. If used with great care, Syntocinon probably won’t do harm — but Professor Philip Steer of Chelsea and Westminster Hospital is currently travelling the world lecturing on its dangers to the baby, especially in augmented labour (labour which is “speeded up” by the drug).
Hayes et al don’t cite induction or augmentation of labour by drugs per se as a significant risk factor in HIE — which is a relief, as it suggests most inductions do not end in a brain damaged baby. But problems occur when staff are not observant of or familiar with hospital protocol, or don’t turn it off when the signs of uterine hyperstimulation occur, or don’t recognise those signs — and the results are sometimes tragic.
I do not know what percentage of children suffering HIE at birth are damaged because of Syntocinon/Pitocin. But I do know that five percent of all childbirth injury lawsuits in the USA involve the drug’s alleged misuse. A US attorney specialising in childbirth injury lawsuits went further and told me: “I know of no available statistics but in my many years of experience Pitocin misuse is a major factor in a substantial majority of our birth injury cases.”
Prof Steer, a man who, I suspect, has seen rather more births than either De Crespigny or Savulescu, compares the misuse of it to someone hitting a stuck screw with a hammer and then being surprised that the screw gets bent. In this country at least 70% of malpractice cases against NHS maternity services involving brain damage involve the use of Syntocinon. Syntocinon is powerful, dangerous stuff. Surely it would be incredibly stubborn to deny that these figures imply that the risk of HIE increases as soon as the decision is taken to put up a Syntocinon drip?
But you don’t see Syntocinon used to “speed up labour” at a home birth. You might see it used where a home birth has transferred to hospital because the woman wasn’t progressing “fast enough”. The only Syntocinon midwives carry to a home birth is a small quantity of 40 IU’s purely to be used in the event of a postpartum haemorrhage, or to assist with active management of the third stage if required or requested by the mother — after the baby is born.
So a significant factor in the incidence of HIE in newborn babies, the very issue on which De Crespigny and Savulescu centre their argument, is not even present, not even possibly present in home births. In addition, all the other significant risk factors are observable by a midwife at a home birth long before the baby is in danger. And those of us who have been at home births know that responsible home birth midwives observe their clients very carefully, and are trained to act decisively and quickly, often erring on the side of caution (a staggering 45% of first time mothers planning a home birth are transferred to hospital in the UK).
And yet De Crespigny and Savulescu base their argument about the morality of home birth on the assumption that HIE is just as likely in a home birth as in a hospital birth. This article, which made headlines across the whole press in one week in January 2014, sits on a massive misunderstanding, an embarrassing ignorance of the real world of midwifery, and a worrying reliance on vague, scaremongering, unsubstantiated “risks”.
The section of their article headed “Risks of Disability from Homebirth” is packed with hypotheticals. It at no point delivers what it promises — namely, the risk of disability from choosing a home birth.
We read that delay in transferring to hospital may be disastrous…Vital delays are inevitable in some cases (which cases? Perhaps those long-ago backwoods home births from the Wax study are being invoked here?)…which can lead to disability…which was avoidable in hospital (note the verb shift from subjunctive to indicative mood: if the disability is so certainly avoidable in hospital, where are all those brain injury lawsuits coming from?)…the lack of equipment at home might result in avoidable quadriplegia.
Is there an actual case of “avoidable quadriplegia” they can name that is at all comparable with the kind of home birth which the Royal Colleges say is safe? Perhaps there is. There must be one. But these authors haven’t found it. I must emphasise that I am a layperson, I am not a medic or a statistician — but even I can recognise the sound of a barrel being scraped.
Why are De Crespigny and Savulescu not more concerned about the use of Syntocinon in hospitals? Surely this is where their interest in “immoral” choices should be focussed? The evidence seems to suggest birth injuries are occurring in hospital at an unacceptable rate — not in planned home births with trained, responsible attendants who have access to local emergency services.
If, to quote de Crespigny and Savulescu, “it is usually wrong to knowingly allow such a risk” [of future child disability], then to recommend to a woman that she be given a drug with such potentially tragic effects simply to “speed up” a natural process strikes me as potentially far more blatantly immoral than offering her a choice of place of birth. De Crespigny and Savulescu believe that doctors and midwives “often do not” warn their “patients” of the dangers of home birth. They are wrong — women who choose home birth have shrouds waved at them all over the world. Doctors and midwives very, very rarely, on the other hand, offer women Synto “to get things moving” with the rider, “By the way, you ought to be aware that it will increase the risk of a permanently brain-damaged baby”. Well, you wouldn’t, would you? But on this ethical issue, de Crespigny and Savulescu are silent.
When I first read about Homebirth and the Future Child I wept, because the media have magnified beyond recognition the authors’ weak little point. I have been trying to encourage women locally to consider home birth as an option for the past decade. For even longer, a battle has been fought against over-medicalisation of birth and sometimes it seems that common sense and trust in the human body’s ability to birth are winning — had these two men destroyed everything I’d worked for?
But when I read the article, I laughed. I need not have worried. I asked my last National Childbirth Trust antenatal group — “Home birth is as risky as letting your child not wear a seatbelt in the car: true or false?” And without hesitation they chorused, “False”.
I was surprised. We hadn’t covered home birth in the course. None of them were even planning a home birth. They were all first time parents and were doing all they could to inform themselves about birth and parenting. They had all seen the scary headlines.
“Why do you all think this?” I said in astonishment. The answers I got back restored my faith in human nature and common sense.
Here, for the benefit of de Crespigny and Savulescu, is my Brief History of Birth.
Birth used to take place at home — always, with midwives attending. Sometimes babies died or were disabled, and sometimes mothers died too. Doctors came in and tried to save babies. Babies still died and were disabled, and mothers died, just as much as before. Doctors tried putting women in maternity hospitals — babies went on dying and being disabled and suddenly mothers began dying at alarming rates, of puerperal fever. Then the wonders of modern medicine came along — penicillin, safe caesarean sections, blood transfusions, early diagnosis of pre-eclampsia and a whole lot else. Mothers were better fed and educated. Lo and behold, they and their babies began dying less and less often. Alas, sometimes babies die, and mothers too, but nothing like as often — and certainly not purely because they have chosen to birth at home with a trained midwife. Some women are best off in a hospital and some are best off at home, and that’s the way it’s probably always going to be.
Marjorie Tew was a statistician who discovered that, contrary to expectations, home birth was as safe as hospital birth as long as you compared like with like. She started a revolution and made everyone look again at home birth just when it had completely gone out of favour. Tew found that improved maternal and infant mortality rates had no connection with the rise in hospital birth except for the most high-risk women. In fact, as women in the UK are now screened carefully — some would say too carefully — for home birth, their risks are lower than ever before — and so are their baby’s risks.
It is hard to sum up how disturbing Homebirth and the Future Child is. It reveals that people can write authoritatively about childbirth in international academic journals who have no basic understanding of the significance to the progress of labour of the flow of oxytocin, the woman’s mental state and the quality of support she has; the effect of environment; the disturbance to labour of moving from a familiar place to a strange one; or even of what happens at a home birth attended by a well-trained midwife with good emergency back-up.
Equally distressing, in fact quite insulting, is their implication that women who choose home birth are immoral and do not care about the risk to their child; along with the seatbelt image, a clumsy analogy with drinking alcohol in pregnancy is brought in at the end of the article. How tabloid can you get, and still call yourself an Oxford University academic?
To put the seatbelt analogy alongside my short history of birth: first people just walked to get from A to B for ages and ages. Some got killed by footpads. Then we invented cars, whereupon people started getting killed in car accidents. We invented seat belts, so the people in cars died less often. But lawlessness on footpaths also dwindled, thanks to better policing and lighting, so the people moving from A to B on foot, as long as they avoided the cars, also died less often. Meanwhile, the number of people killed in cars was shrinking not just because of the seatbelts but also because we have safer cars, better signage and less drink-driving. But even with all these improvements, some people are still are killed in cars, including around 60 children a year. There is no one single cause of deaths, either in childbirth — or on the roads.
So it is not good science, good ethics or good philosophy to lump together the people on foot and the people in cars as though they were all using the same form of transport — that is, as the parents in my antenatal class immediately saw, just stupid.
As Professor Brocklehurst has said, regarding the Birthplace Study: “I can’t tell you where to give birth. Safety isn’t a yes-or-no answer. Safety depends on what your views and beliefs are, what you’re prepared to accept. Some of you will go skiing or do even more dangerous sports which put your life and your family’s happiness at risk; but we make those choices.
“What I can now do is give you some data which allows you to make a more informed choice. Ultimately it is up to women to decide where they give birth.”