"The humanization of childbirth does not represent a romantic return to the past, nor a devaluation of technology. Rather, it offers an ecological and sustainable pathway to the future."
(Ricardo Herbert Jones, Obstetrician)
Ana Paula Caldas, neonatologist. The picture was taken immediately after the birth of her daughter Lis, at home. Photo: Ana Cristina Duarte
When we started writing this series of articles on birth for Guia do Bebê (Baby Guide) in 2010, the very first article discussed a subject that was just then starting to attract the interest of Brazilian media: home birth (1). On that occasion, we reviewed the available scientific evidence and concluded that home birth, a common reality in other countries such as the Netherlands, England and Canada, represents a safe alternative for low-risk pregnant women, resulting in lower rates of interventions such as episiotomy, analgesia, cesarean section and instrumental delivery (forceps and vacuum extraction), without increasing the risk of complications for mothers and babies (2-4). We highlighted a 2009 publication of a large cohort study comparing more than 500,000 planned home and hospital births in low-risk pregnancies, in which there was no significant difference in risks of intrapartum stillbirth, early neonatal death and admission to neonatal intensive care unit (NICU) (4).
Interrupting our series of articles about “Normal delivery vs. Cesarean section” (5-7), we now have decided to discuss the home birth theme, which recently resumed media’s attention and aroused intense controversy after an online publication in the largest Brazilian news magazine, with the dramatic title "Home birth, when the risk is not necessary"(8). After publishing a controversial article about the miraculous effects of an anti-obesity drug (9) – which is not accepted by the scientific community for this purpose (10, 11) – the magazine made another venture into a healthcare subject, however this time in peace with local "medical councils", warning that homebirth could expose women and children to "complications that could be severe".
Even though we are not going to discuss semantics in this critique, it is worth noting that the article is a disservice to the Brazilian population, since it contains categorical assertions that are not based on scientific evidences, but on prejudice and therefore bad journalism, as exemplified in the following part of the first paragraph: "After the 20th century medical revolution, hospitals became the safest and most appropriate places for treatment of diseases and childbirth as well. It is a rule that, given the conditions, it does not make more sense to have home births, which are subject to problems with potentially devastating consequences that otherwise, would be solved in a hospital. This is a rule that, however, some women living in large urban areas – perfectly suitable to take advantage of advances in medicine – question and ignore. Those women approve of the birth the old fashion way, inside their homes" (8).
Now, who imposed this rule that transgressive “women living in large urban areas” have now decided to “ignore and question”, supporting the “old-fashioned way of giving birth”? Why does the magazine state that hospitals are “the safest and most appropriate places not only for disease treatment, but also for childbirth”? Why do council and society representatives insist on talking about “eminent risks” of home births? Are the risks that notorious or was it simply a spelling mistake? And finally, what are the real implications of the article published by Joseph Wax (12) in the “highly respected international medical journal”, the American Journal of Obstetrics and Gynecology (AJOG)?
Let us explain this further: first, there were great advances in Medicine in the 20th Century that yielded a remarkable decline in maternal and perinatal mortality. Antibiotics and antisepsis were developed and modern anesthetic techniques were introduced. As a result, cesarean section became safer. It is unquestionable that cesarean section is a life-saving procedure under certain circumstances (13, 14). Furthermore, blood transfusions, antibiotics use and magnesium sulfate therapy for preventing and treating eclampsia are all technologies that, if wisely applied, result in reduction of maternal death rate by hemorrhage, infection and hypertension. Hence, these are strategies that should be easily available in the health service for high-risk situations (15). Nevertheless, cesarean section rates higher than 15%-20% do not result in a reduction of complications and maternal and neonatal mortality; on the opposite, they can be associated with harmful results for both the mother and the newborn (16-18).
On the other hand, childbirth hospitalization process, along with those advances, led to an elaborated propagation of rites and rituals around this physiological event, as Robbie Davis-Floyd warns in her thought-provoking book “Birth as an American Rite of Passage” (19). Obstetric procedures adopted by the current technocratic birthing model in the western world have been introduced without any scientific evidence of their effectiveness. Indeed, they represent “ritual responses to our technocratic society’s extreme fear of the natural processes on which it still depends for its continued existence” (19). As a result, unnecessary interventions and procedures such as episiotomy (surgical cut to the perineum), shaving, enema, routine oxytocin for labor augmentation and cesarean sections without medical indications have been gradually incorporated into medical practice and still continue to be performed as routine in many hospitals in Brazil. Actually, each laboring women admitted to a hospital is seen as a “patient” and then submitted to hospital “rules” for all types of “illness”. (20)
The counterculture movements in the 1960s and 1970s protested against this excessive medicalization of a physiological process and as a result, the safety, effectiveness and the real need for many procedures established as routine in daily obstetric practice started being studied (21). The new "Evidence-Based Healthcare" paradigm, beginning in Medicine and moving progressively to other areas that are now being integrated in a transdisciplinary perspective, has its pillars in 1970 and 1980 in Maternal and Child Health (22), in response to questions about the complex and intricate unnecessary rituals that permeate through obstetric and neonatal assistance.
The return journey to what has been called “giving birth the old-fashioned way” is not new nor does it represent some sort of fashion. Neither does it intend to give up the positive nor the attractive side that technology offers, since necessary interventions are welcome. All health systems that offer home birth as an option for women who wish one include a risk rating system. Not only do they provide trained midwives but also a good system of transfer and transport, even though it is not true that it provides a mobile ICU ambulance at their doors (2-4). The World Health Organization recognizes doctors, nurse-midwives and certified midwives as skilled professionals to assist births (23) and recommends that women may choose to have a homebirth if they have low-risk pregnancies, receive appropriate care and prepare a contingency plan for transfer to an equipped health unit if any problem arises during birth (24,25). The International Federations of Gynecology and Obstetrics (FIGO) in turn, recommends that “a woman should give birth in a place she feels safe, and the most peripheral level at which appropriate care is feasible and safe” (26). The American College of Nurse-Midwives (27), the American Public Health Association, the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynecologists (RCOG) support homebirth for women with uncomplicated pregnancies. According to RCM and RCOG guidelines, “there is no reason why home birth should not be offered to women at low risk of complications. Home births may confer considerable benefits for them and their families” (29).
The novelty in the last few years is that home birth got bigger visibility in Brazil, with some celebrities openly talking about their experiences, but mainly with the constant debate in social networks, allowing women to share and compare their birth experience, being either at home or at a hospital. It became evident that there was a growing group of women dissatisfied with the current obstetric system in Brazil, excessively technocratic, with an unacceptably high cesarean section rate in the private sector and with traumatic births, full of interventions in the Public Health System. In spite of the politics of Birth Humanization advocated by the Ministry of Health in Brazil (30), it is a fact that the current model is based on the hospital and is disease-centered, and most women are attended by protocols that are not evidence-based nor humanized. Brazilian women still live in a country where “if they don’t cut above, they cut below", as well defined by Diniz and Chachan, when referring to unnecessary cesareans sections and episiotomies (31).
Last but not least, one in every four Brazilian women hospitalized in either public or private hospitals reports that they suffered from institutional violence perpetrated by healthcare providers. Not only do these aggressions involve unnecessary procedures, techniques and painful exams, but also social and racial prejudice, sarcasm and rudeness (32). Institutional violence during birth may be multifaceted and does represent a recognized international problem (33). Many Brazilian hospitals do not allow the presence of a birth partner, even though there is a legislation establishing that it should be mandatory to both public and private hospitals to allow the presence of a partner next to the parturient during the whole birth process: labor, birth and immediate postpartum period (34).
On the other hand, with the growing access to information and the disclosure of the raw and bare reality of the obstetric care model in Brazil, several women, wishing for a humanized and safe assistance, started looking for other potential models of assistance, some that already work well in other countries. These women also started to find out scientific evidences, effectiveness and safety of other options. An example is the obstetric model given by midwives, whose benefits were broadly reported in a systematic review of the Cochrane Library (35).
These empowered and confident women started to seek doctors, nurse-midwives or midwives to help them through this journey to a respectful, humanized and safe birth, not only in Brazil, but also in the United States and other countries, where the technocratic model of birth care prevails. They realized that giving birth in their homes was not only an option and for sure not a luxury, fashion or eccentricity for celebrities. These women researched and studied scientific evidences, and found professionals that were willing to work as partners, professionals that have been following their own transformative journey themselves (36), professionals that were then following a new and challenging Evidence-Based Health paradigm, employing birth care models that are both sustainable and ecological (37).
As a result, there has been an increasing number of planned homebirths in Brazil and USA (38-40) and, although there are no reliable statistics on the percentage of planned homebirths in Brazil, we know that nowadays large cities have transdisciplinary teams that work assisting these deliveries. Birth stories from so far anonymous women became available on blogs and social networks; communities about homebirth also overtly discuss this subject. Twitter, Orkut and Facebook have allowed thousands of women to exchange information and share their experiences. The theme is throbbing, the discussion is in the air and it is no wonder that the establishment reacts and medical associations begin to show their opinion, usually with an opposite view of home delivery practice. This was a predictable reaction, because that is how scientific revolutions happen and paradigm shifts occur: the current model, although broken and unsustainable in the long run, also allows for convenient solutions – as it is practical and “fast” to schedule elective cesarean sections, sometimes planned months before the due date, without a real medical indication for it. Interestingly, these are the same professionals who advocate that women have the "right" to choose how they want to deliver, even though this right only is available for the minority of women who want a cesarean section (6) and do not include those who wish a normal birth nor extends the decision to the place of birth. Thus, women’s voice and their right of choice have been fundamentally ignored (39, 41).
Therefore, it is no surprise that an article on the subject is published in the aforementioned news magazine. Unfortunately, as frequently happens with health-related articles from that particular publication, this one is biased, incomplete and does not consider and even mistakenly interprets the applicable scientific evidences. Even the stand taken by the American College of Obstetricians and Gynecologists (ACOG) is incorrectly presented. In its latest Guideline – while explicitly affirming that ACOG considers hospitals and birth centers to be the safest – ACOG recognizes as a woman’s RIGHT the choice of the place of birth. Literally citing the Guideline summary, published February 2011: “Even though the Obstetric Practice Committee believes hospitals and normal birth centers to be the safest places for birth, it respects the right of a woman to take a medically-informed decision about the birth. Women who ask about planned home birth should be informed about its risks and benefits based on recent evidences. Specifically, they should be informed that however the absolute risk may be low, planned home birth is associated with a two to three times higher risk of neonatal death when compared to planned birth in a hospital. It is important that women shall be informed that the adequate candidate selection for home birth, availability of nurse-midwives, certified midwives or medical doctors acting within an integrated and regulated health system, ready access to consultation and the guarantee of safe and fast transportation to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable homebirth outcomes” (42).
Interestingly enough, another magazine – this one international – published an article about homebirth in its March 31st, 2011 issue, The Economist addresses the subject with a well-round article, an example of good journalism. Titled “Home births: Is there no place like home?” and bearing as subtitle “Where women give birth is a contentious issue across the rich world”, the article thrives with critic sense, investigative accuracy and exemption, presenting pros and cons and discussing the same study cited by the Brazilian magazine, however underlining the criticism raised at the scientific community by such article. At its end, instead of terrorizing against home birth and postulating which one to be the best birth place for all women, an important reflection: “As with many other aspects of child-rearing, birth will come down to parental disposition — whether for a hospital’s bright lights and plentiful pain relief, or for the familiar comforts of home” (43).
The ACOG, in order to discourage home birth, relies on the cited study as evidence of home birth risks – which is a systematic review with meta-analysis (12) that has been severely criticized within the scientific community for methodological and statistical errors and bias (44-49). It is neither original nor does it include randomized clinical trials, only observational studies that have been misinterpreted and arbitrarily included or excluded in the outcomes by the authors, depending on their interest (49). Such meta-analysis has been widely promoted as “proof” of perinatal risks deriving from home births and constitutes the basis for ACOG recommendation with regards to information that should be presented as “state-of-the-art” of current research about home birth (50). Therefore, we shall discuss it in detail, presenting a summary of its results already published and the criticism in international scientific journals, even motivating the publication of an erratum acknowledging errors in the statistical analysis (51).
Wax and colleagues’ systematic review was first presented at the 30th Annual Meeting of the Society for Maternal-Fetal Medicine, in Chicago (February 2010), then published online in the American Journal of Obstetrics and Gynecology in July 2010 and in printed version in September of the same year (12). The meta-analysis included 12 original studies and a total of 342,056 home births and 207,551 planned hospital births. In the article summary, the authors conclude that planned home births are associated with lower risk of maternal interventions, including epidural analgesia, electronic fetal monitoring, episiotomy, operative delivery, and lower frequency of lacerations, bleeding and infection. Among the neonatal outcomes of planned home births, there was a lower rate of prematurity, low birth weight and need for assisted ventilation. Even though perinatal mortality rates were similar between home births and hospital births, the first were associated with an increase of about three times of the neonatal mortality rate.
This article raised intense controversy in the international scientific community, followed by several letters published in the same journal (44, 46, 47, 52) – one of which bearing the provocative title "Home birth triples the neonatal death rate: public communication of bad science?"(45). Confronted with such criticism, the AJOG decided to scrutinize the study, and its post-publication review actually found errors in the original analysis. Notwithstanding, AJOG did not alter their conclusions (51). The prestigious journal Nature manifested its concern about this issue, but even having requested several times that both ACOG and Wax made comments on the problems pointed out by several experts, they declined the invitation (53). Elsevier, the publisher responsible for AJOG, recognize the errors but do not believe that they could induce the author to issue a retraction statement (54).
In an attempt to summarize the huge amount of criticism about Wax’s meta-analysis, we can say that unlike Cochrane systematic reviews, it did not follow internationally established guidelines – such as PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (55) or the MOOSE (Meta-Analyses and Systematic Reviews of Observational Studies) (56) – for conducting and publishing meta-analysis. Several statistical errors occurred as the authors used a calculator to the meta-analysis that presents various shortcomings, recognized by the program designer himself (49), resulting in incorrect odds ratios and confidence intervals. However, the most remarkable deviation in the study wasn’t statistical but a rather biased selection of studies: the meta-analysis authors excluded the large Dutch cohort study (4) from the neonatal death risk calculation, but included it in the perinatal death risk one. In fact, the meta-analysis data are contradictory with regards to neonatal and perinatal deaths, basically because the authors defined perinatal death as fetal death beyond 20 weeks or live newborn death within first 28 days of life – instead of the seven days as internationally recommended! (57). On the other hand, the authors incorrectly included certain additional studies and excluded others, in order to calculate neonatal death risk, for unclear reasons. The data used to calculate neonatal death included births that had not been assisted by either midwives or certified nurse-midwives, a factor already demonstrated to be critical for reducing risks (49). Even revising data and presenting the graphics in a post-publication, with new numbers correctly calculated (51), the serious methodological problems related to term definition and inclusion/exclusion criteria are still there (49).
In short, as Keirse stated in his brilliant article published in Birth on December 2010 ("Home Birth: Gone Away, Gone Astray, and Here To Stay"), "combining studies of home versus hospital, without differentiating what is inside them, where they are, and what is around them, is akin to producing a fruit salad with potatoes, pineapples, and celery” (48).
The debate over home birth – in Brazil as much as worldwide – has become extremely polarized and politicized (48), in such a way that the controversy cannot be expected to be resolved by criticism in itself. Indeed, it may be difficult to generate strong recommendations based on weak evidence, derived from observational studies, but the least that professionals and entities should also recognize is that we do not have strong evidence supporting hospital birth safety for low-risk mothers and their neonates. The ideal study design to evaluate a practice or intervention is a randomized controlled trial (RCT), and meta-analysis of observational studies, even when carried out properly and without obvious errors, such as those found in Wax’s meta-analysis do not have the same power of systematic reviews of randomized controlled trials like those included in the Cochrane Library.
Nonetheless, randomizing women for a home birth or a hospital one is virtually impossible. According to Keirse, “pregnant women who are happy to leave the choice of where to give birth to the toss of a coin are about as abundant as white elephants” (48) but even if those women were found, the findings of a randomized clinical trial with this sample could hardly be extrapolated to different women in different clinical situations and settings. Women who wish to have their babies at home differ substantially from those who choose a hospital birth, just as the professionals who care for home or hospital births exclusively are also quite different (48).
Under the new Translational Research paradigm – which considers the implementation of solutions in "real life" within a sustainability perspective and a user-centered healthcare model – it is compulsory to accept that further studies beyond randomized clinical trials are needed, a fact that challenges the traditional study quality hierarchy (58). In the academic environment, which is traditionally dominated by randomized controlled trials; other non-hierarchical typological approaches will emerge in importance (59). Identifying needs, acceptability, effectiveness and developing sustainable solutions should define the health research in the 21st century.
In practice, we should consider that both pregnant women and health professionals have always the same and primary purpose which is to ensure a satisfying birth experience, with healthy mother and baby. On the other hand, it is a basic reproductive right for women to be able to choose how and where they will give birth (60, 61). Informed choice must be based on the best currently available scientific evidence, which would suggest – disregarding Wax’s flawed meta-analysis – that home birth is a safe option for low-risk pregnant women when attended by skilled professionals. Advantages over hospital delivery include less frequent interventions for the mother, and women’s comfort and satisfaction, as they go through a unique and transformative experience within their own homes (37, 39, 40). Perinatal and neonatal mortality rates are similar to those seen in low-risk births in a hospital (2-4). Nevertheless, the final decision should be based on evidence, on women’s characteristics and expectations, on providers’ experience and qualifications as well as ease of access to health services (25,26,28,29).
More important than criticizing women who choose a home birth and condemning them for violating an imaginary "rule", is to discuss and implement strategies to increase women’s safety and satisfaction in ALL childbirths (48). That includes not only improving and humanizing hospital care – so that assisted births in maternity hospitals or normal birth centers can be a rewarding experience for women, but also establishing guidelines for appropriate home birth client selection.
Photo: Ana Cristina Duarte
Acknowledgements: Ana Cristina Duarte, CM; Carla Andreucci Polido, MD, MSc; Roxana Knobel, MD, PhD; and Roselene de Araujo, MSc, for their comments and suggestions; Ana Paula Caldas, MD, for providing the picture and the inspiring example; Andréia Mortensen, PhD and Gabriela Hugues, BSc, for their invaluable help with the translation of this article.
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