The following news piece appeared in March’s edition of Essentially MIDIRS
A narrative review on the long-term outcomes of home births by an Australian obstetrician and gynaecologist and an Oxford University ethics professor (de Crespigny & Savulescu 2014) published in The Journal of Medical Ethics caused a flurry of interest in the media recently. Headlines such as, Home births could be as dangerous as ‘driving without putting your child’s seatbelt on’ (Cooper 2014) appeared in the British press.
These alarmist headlines were not entirely of the paper’s own making, but picked up on the authors’ conclusion:
‘Having a homebirth may be like not putting your child’s car seat belt on. The risk of being injured in a single trip by not wearing a seat belt is extremely low. Still, we expect people to wear a seat belt to make the risks as low as possible, despite some inconvenience and diminution of driving pleasure. Most children will be unharmed. Some trips are very safe. And wearing a seat belt will not remove all risk of injury or death. Indeed, wearing a seat belt in an accident will, on rare occasions, cause greater injury than not wearing a seat belt. But on balance it is much safer with a seat belt. And if one child is permanently brain damaged because she/he did not wear a seat belt, that is one child too many’ (de Crespigny & Savulescu 2014:4).
It is definitely worth examining how the authors arrived at this conclusion.
The abstract highlights the fact that much of the debate on home birth centres on the risk of maternal and perinatal mortality and morbidity and the authors point out that it should also take into consideration the risk of long-term disability to the offspring. This review is intended to begin to rectify this, but it is important to note that they do so by means of a narrative, rather than a systematic review, although the latter would have been far less open to bias. Whereas a systematic review uses comprehensive methods to search for research on the topic, includes as much as possible that is relevant, and often insists on the research meeting a minimum quality: a narrative review discusses and summarises literature. It doesn’t involve meta-analysis to synthesise pooled figures and, as in this case, does not report how the literature was searched for, or give the authors’ criteria for selecting literature for inclusion. This leaves the door open for the authors’ own opinions to affect the results and given that the authors of this study elect to open up with the following quote from John Stuart Mill, one strongly suspects that the authors had an idea of what they were looking for before they embarked on the research:
‘The fact itself, of causing the existence of a human being, is one of the most responsible acts in the range of human life. To undertake this responsibility — to bestow a life which may be either a curse or a blessing — unless the being on whom it is to be bestowed will have at least the ordinary chance of a desirable existence, is a crime against that being’ (Mill 1869).
A systematic review of the evidence would have been far preferable for the purposes of examining the risk of long-term negative outcomes. Geographical factors would need to be taken into consideration in such a study too. The authors’ include examples of outcomes from the US in their conclusion to argue that ‘Birth is an inherently risky time for mother and baby’ (2014) and that modern obstetrics has reduced the mortality rate. Not only is the introduction of new evidence in the conclusion questionable, but it is irrelevant to the argument about home birth as the figures relate to childbirth in general, neither is it appropriate to generalise from one country to another. In order to make a judgement on whether home birth is ‘risky’, one needs to examine each country individually, but nowhere do the authors factor in that training for midwives is very different in different countries and this may impact on the rates and outcomes. For example, the statistical outcomes for giving birth at home in the States or Australia may not be the same as those in the Netherlands or similar, where midwives are likely to have greater involvement and training in home birth and the system is configured to support home birth.
Sadly, rather than arguing that home birth should be better supported, the authors’ declare that women who decide to give birth at home are behaving unethically by refusing to strap their baby in for the ride. This comparison is limited, one could equally argue that crossing a road whilst pregnant puts an unborn baby’s life at risk and so all pregnant women should be banned from crossing the road.
Cooper C (2014). Home births could be as dangerous as ‘driving without putting your child’s seatbelt on’. Independent. 22 January. http://tinyurl.com/q5r7xrg [Accessed 29 January 2014].
de Crespigny L, Savulescu J (2014). Homebirth and the future child. Journal of Medical Ethics. 22 January. [Online version ahead of print]. http://tinyurl.com/ojruzd9 [Accessed 29 January 2014].
Mill JS (1869). On Liberty. 4th ed. London: Longman, Roberts, & Green Co. http://www.econlib.org/library/Mill/mlLbty4.html [Accessed 29 January 2014].