Home births are a controversial topic among many people who care about birth. Personally, I have had conversations about this with all sorts of people including obstetricians, midwives, doulas, women who have had home births, women who have had hospital births, (no women who have had birth centre births yet), fathers and other partners prepping for an upcoming birth, fathers and other partners who have been at their baby’s birth and some who have not, and parents, friends, siblings, and cousins of moms and moms-to-be. What strikes me most interesting in all of these conversations is the attitudes that persist and, even more interesting, is where everyone gets their attitude from. What I have noticed throughout these conversations is that attitudes vary significantly and can, at times, be predicted based on a person’s background, education, and experience. This is not that surprising given how much our attitudes formed are, in general, influenced by the environment in which we live, work, and educate ourselves.
This environmental influence inevitably leads to what some might call a bias. Our biases become a problem when we attempt to make informed and free-will choices. When being presented with information, bias can happen on the part of the person consuming the information and/or presenting the information. It seems warranted then, that anyone who is seriously aiming to make a truly informed decision, should at the very least be made more aware of potential biases that exist. On that note, below, I present a summary of a study from researchers in the Faculty of Medicine at the University of British Columbia in which attitudes regarding home births was assessed among obstetricians, midwives, and family physicians across Canada.
The medical researchers who authored this paper believed it was important to assess these attitudes because currently, there are unprecedented rates of operative deliveries and intrapartum (i.e., labour and birth) interventions in Canada and abroad. They claim that these rates have sparked a call for research and reflective practice into improving rates of physiologic (i.e., “normal”) labours and births. They also say that there is a call for models of maternity care and birth environments that make use of good-sense obstetric technology when caring for healthy women and newborns, implying that overuse of technology is unwarranted and should be thwarted. That is to say, members of the medical community and general public seeks a better way of treating births that are healthy in nature.
Before, I get to the data, perhaps it is of interest to you, the reader, to assess your own attitudes regarding place of birth. Below is a list of 17 of the statements sent to the over 4000 birth practitioners of 3 different categories (i.e., midwives, family physicians, and obstetricians). Respondents were asked to what degree they believed with the statement, from 1 (strongly disagree) to 5 (strongly agree). Do this now for yourself, if you are so inclined. I have many times over.
. Registered Midwives have sufficient skills to handle most emergencies safely at planned home births.
. Women who give birth in the hospital are more likely to experience morbidity associated with medical interventions than women who give birth at home.
. First time mothers should have the option of having a planned home birth.
. I would feel comfortable if a close family member planned to give birth at home.
. I am more comfortable with hospital birth than I am with planned home birth.
. It worries me when people I care about decide to have planned home births.
. There is scientific evidence that supports the greater safety of hospital births compared to planned home births.
. Women who plan home births tend to be risk takers.
. Planned home birth is not as safe as hospital birth.
. Because of the risk of postpartum hemorrhage, the home is not an ideal birth setting.
. I would consider having my own (or my partner’s) planned home birth with a Registered Midwife.
. I am more comfortable providing intrapartum care in the hospital because of the personnel and equipment available only in the hospital (reverse scored).
. A move towards more planned home births in this country would save our health care system a significant amount of money.
. Even in urban areas, planned home births are less safe because of the amount of time it takes to transfer mothers/babies to hospital.
. A woman who plans a hospital birth is more likely to have an unnecessary cesarean section than a woman who plans a home birth.
. A mother’s cultural background is easier to respect at home births than hospital births.
. I like attending planned home births.
From those who were asked, 950 practitioners responded and the data from a final 825 were used in this study (after excluding some data that was incomplete). The resulting pool of participants included 451 midwives, 235 obstetricians and 139 family physicians. As far as science goes, this response rate is pretty good.
A few things struck me as interesting right off the bat. First, less than < 1% of obstetricians learned about planned home birth as part of their core curriculum in medical school. Although surprising to some degree, this is consistent with what is known regarding medical curriculum across the country. Unless it has changed recently, home birth education is not a requirement but in some programs can be learned through electives and certain placements.
Second, while 99.1% of midwives reported providing intrapartum care in the home, only 5% of family physicians and < 1% of obstetricians had this experience. From a bias-consideration perspective, it is important to note that obstetricians providing consultation on home births are doing so with little-to-no formal medical training or experience with home births. It was a bit surprising for me to then read that on average, family physicians and obstetricians held unfavourable attitudes toward home births compared to midwives. I couldn’t help but wonder how they were forming these attitudes without actual knowledge or experience of home births per se.
A few other things were interesting regarding the demographics of the obstetricians themselves. First, those who did have more favourable attitudes toward home births tended to A) be female, B) have more higher education (i.e., they tended to have graduate degrees, either Master's or PhDs), and C), and had reported more involvement in research. The researchers of this study addressed this finding specifically in the discussion section of this paper. They argue that these obstetricians were more able to maintain favourable attitudes because of being more exposed to emerging science and because they were more fluent and able to critical appraise the science as it came out in a way that resulted in more evidence-based attitudes regarding the safety and benefits of home births.
In addition to education and research exposure influencing attitudes toward home births, the researchers of this study found that practitioners’ exposure to a home birth was a major influences. For example:
- obstetricians who had been present at one or more home deliveries in a support role during practice had more favourable attitudes compared to obstetricians without this experience
- family physicians who had attended at least one planned home birth as an observer or support person during clinical practice had more favourable attitudes towards homebirth
- family physicians who graduated from medical school after the introduction of registered midwives in Ontario (1993), displayed more favourable attitudes towards planned home birth compared to physicians who graduated prior to 1993
- family physicians who were taught by planned homebirth providers during medical school were more favourable towards planned homebirths compared to physicians without this educational exposure
It’s also worthy to note that those who did view home births favourably, whether obstetricians or midwives, tended to also maintain beliefs that mother-infant bonding was easier in the home, that home birth is more empowering, that it is easier to individualize care in the home, and that resuscitation of the newborn was not more effective in the hospital.
Knowing any of this doesn’t make coming up with your answer any less difficult, but what I hope it does is serve to remind both those for and those against home birth, to check their attitudes and to consider how experiences, education, backgrounds, and people might be influencing a true information process. I myself had to do this after spending years as a medical researcher.
Trying to make an informed decision is challenging but often time we are are doing so under the guise that medicine is unbiased. Medicine IS biased. So am I and so are you. These biases are natural parts of our how our brain works more efficiently. We maintain biases so we don’t have to think so hard on everyone decision. But some decisions might require a bit more thought. For me, place of birth was one such decisions.
As a result of my pre-existing bias, I had to consciously try on a new lens to see what a natural birth might be like. In the end, I’m happy to be planning my own home birth without fear. I would hope that some others out there will check their biases too.
Bias Disclosure: Although I value all places of birth, my hope is for a home birth. In the process of coming to this decision, I had invested my trust in the evidence that guides the midwives in assessing me as a candidate for a home birth. I trust their education and as having ample experience with the deliver of babies in homes, birth centres, and hospitals. Ultimately, I wish everyone the power to chose with awareness, whatever that choice ends up being.
The study in which I was reviewing is available here: http://www.biomedcentral.com/1471-2393/14/353.