I recently came across another home birth safety study that had been previously overlooked in my research. Neonatal mortality in Missouri home births, 1978-84 by Schramm, Barnes and Bakewell, published in the American Journal of Public Health, August 1987. You can access the full text of the study in pdf from that link.
I have chosen to list this study twice on my home birth safety page as it offers mixed results on the safety of home birth. On one hand, the study did find a higher neonatal mortality in the home birth group (almost twice the expected rate). On the other hand, the data teased out some important factors that are essential to consider when discussing home birth safety. Namely:
"Nearly all of the excess [infant mortality] was found in the two attendant types with the least training: non-Missouri Midwifery Association midwives [religious midwives, those who identified themselves as midwives on birth certificates or who were identified by other sources in the study as midwives but were not recognized by MMA], and the 'other' category [primarily fathers, but also paramedics, chiropractors, friends of family or anyone else not identified as a midwife or physician]."
"Neonatal deaths for unplanned home births were over 35 per cent higher than expected."
The important thing to consider when discussing the safety of home birth, and the fact that is highlighted by the results of this study, is that planned home birth attended by a skilled attendant is a safe option for low-risk women.
I am a frequent poster over at a natural family living forum where unassisted childbirth is a popular topic. This has always been a fascinating proposition for me and I find myself being asked for my opinion on the topic at an increasing frequency. My thoughts on the concept walk a fine line between upholding the natural physiologic process of birth while recognizing that the birth process does pose some inherent risk. However, that risk does not mean that most births would be safer in a hospital attended by a physician. It does mean, as the above research demonstrates, that the risk is greatly reduced by being attended by a skilled professional who is trained to recognize and manage unforeseen complications, whether that be a physician or a trained midwife.
Is unassisted birth dangerous? That depends on your concept of danger and what constitutes an acceptable rate of mortality and morbidity. I believe that "risk" is a fixed, absolute statistic while "danger" is a subjective evaluation. Some would argue that no amount of unnecessary risk is acceptable in any circumstance and that mothers who choose unassisted birth are negligent, dangerous, simply bad women. I do not fall into this camp. I do not believe unassisted birth is dangerous because I do not believe birth is dangerous. I know the risk that sometimes bad outcomes occur, and that risk can be reduced by the presence of a skilled midwife and the emergency equipment she brings to a planned home birth. However, ultimately, I believe it is a mother's right to examine that risk and evaluate for herself whether it is a "danger".
My personal opinion? It is a woman's sacred and autonomous right to apply her beliefs and world view to her decisions regarding her birth. But when asked my professional opinion, as in all aspects of midwifery care I must defer to evidence-based practice. Study after study has demonstrated the safety of planned home birth with a skilled attendant, but ultimately they do not uphold the same outcomes for unassisted birthing.
