A recent article in The Wall Street Journal, New Support for Home Births, adds fire to a the most significant boost homebirth advocates in the Western world have seen in recent years. Last spring, the British National Institute for Health and Care Excellence (NICE) issued guidelines indicating that “home births are safer than hospital births for women who are having their second or later child with a low-risk pregnancy.” This was followed in the United States by commentary from Harvard professor Neel Shah, MD, (pictured) in The New England Journal of Medicine suggesting a reconsideration of the role of homebirths in the United States: “What was so paradigm-shifting about the NICE guidelines [was] they emphasize the dangers of over-intervention. That’s huge.” Shah concluded, “There are lessons to be learned from the British system. The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” The writer for WSJ notes that a large Canadian study a decade ago of homebirth via midwives in British Columbia found parallel outcomes as those supporting the NICE guidelines.
The WSJ article quotes a representative of the American College of Obstetricians and Gynecologist (ACOG) who attributes ACOG’s continued opposition to homebirth, despite the evidence from the United Kingdom, to differences between the respective systems. In the United Kingdom, midwives are usually employees of the national healthcare system. They are built-in members of teams. Hand-offs from home to hospital are fluid. The head of midwifery at the Royal College of Midwives in London is quoted as speaking to this importance: “One of the riskiest times for a woman isn’t when things are going normally and she’s in her chosen place, but the point when she needs to transfer. Handover points are where things go wrong.”
Comment: My spouse, Jeana Kimball, ND, LM, MPH, was educated and licensed as a midwife in the early 1990s. She arranged to have training in Holland and in the United Kingdom, where midwifery services are valued—and indeed, a prideful treasure in the former and the subject of a successful TV series in the latter (see image). She also experienced births on the Texas-Mexico border and in Seattle, where they were not then embraced as part of the system.
In Seattle in the pre–“integrative health and medicine” days, only one obstetrician in the greater urban area respectfully collaborated with the area’s licensed midwives. If transport was required to most other obstetricians in the same facility, or to any other location, the interprofessional experience was proof positive of a system that was the opposite of patient-centered. With no formal transport relationship, mothers on the very verge of delivery had to be dropped off at ERs. The midwife was typically not allowed to accompany the laboring mother. If she was, it was only as a friend and not as a professional. The midwife’s experience was routinely disdained and disregarded. In some cases, patients were routinely shuttled miles away from their nearest delivery hospital so that a friendly hand-off could be managed with the single, open-minded obstetrician. The risk to the patients wasn’t due to the lack of communication between the licensed midwives and their local hospitals. It rested squarely with the antagonism of the obstetricians.
There is good news in this personal story here in Seattle. Three years ago, my spouse accompanied a close friend through a birthing process in a comfortably appointed hospital wing staffed by nurse-midwives in a hospital she knew well. She recalled her “PTSD” on walking those halls, remembering the interprofessional mistreatment and concern for the mother-child who was her responsibility and then suddenly utterly out of her hands. Here she was invited fully into the process. She recalled the experience as profoundly healing. Change is possible. While most of the rest of the country is likely more like Seattle 20 years ago, change is possible.
The importance of this article is its location: a source of information for people who are expected to care about business and costs. Moving US birth policy toward the NICE guidelines can be a significant money saver. Given the Canadian and British data—and even the experience in Washington States as reported here in the Huffington Post—this may be one of those places where health and medicine is too important to leave to the doctors.