The battle for control

AIMS Journal, 2010, Vol 22 No 3

Gill Boden asks whether we are winning the battle for control over women's bodies

In June this year headlines in the world's press reported that three times as many babies die in home births. This is because the American Congress of Obstetricians and Gynecologists published a meta-analysis of maternity and newborn outcomes of planned home births versus planned hospital births¹ on its website (www.ajog.org). It concluded that 'less medical intervention during planned home births is associated with a tripling of the neonatal mortality rate'.

This is not the case, and never has been, but wild claims repeated often enough tend to be believed: these headlines will be seized upon to confirm the prejudice of people who think that mothers can't be trusted to make decisions about their unborn children.

A whole series of influential and authoritative bodies immediately exposed the major flaws in this meta-analysis but the damage was done: another generation of GPs will be informing women that 'home birth is not safe' and obstetricians will be repeating that 'birth is only safe in retrospect'. On page 8 Beverley Beech takes a look at the meta-analysis and highlights some of the issues raised.

Added to this misreporting on home births are badly researched and inflammatory opinion pieces in the British press taking up the strain and discouraging choice without taking proper account of the facts, or even seeming much to care about them. Two prime examples from The Guardian and the Daily Mail are explored on pages 10 and 12.

Birthing at home with a skilled midwife has been shown to be safe and has numbers of advantages for women and babies. As AIMS' readers will know, unproven assertions that birth in hospital was safer than home birth had been largely accepted by professionals and public alike until statistician Marjorie Tew published her analysis of the risks of home birth.² Her analysis has never been refuted and further research has supported her findings. In 1992 a House of Commons investigation concluded that:

'On the basis of what we have heard, this Committee must draw the conclusion that the policy of encouraging all women to give birth in hospitals cannot be justified on grounds of safety.'³

What is still unanswered is why the American Congress publicised Wax and colleagues' claims and why an editorial in the respected Lancet supported these claims,⁴ when anyone with a smattering of understanding of research methods would recognise that this study was not in the least robust.

Even wilder media reports appeared in Australia where claims were made that home birth babies were seven times more likely to die during birth, based on a study where, as the authors themselves stated, 'small numbers with large confidence intervals limit interpretation of these data.'⁵ Never the less Andrew F Pesce, President of the Australian Medical Association (which is opposed to home birth), picked up this claim in an editorial accompanying the study and repeated it in his argument against home birth.⁶

When viewed in the context of the highly controversial closure of the Albany Midwifery Practice (see Margaret Jowitt's review on page 13 and the CMACE critique on page 5) and the current issues faced by women bir thing at King's (page 4 and page 22), one must start to wonder if it is safety at all which is driving these attacks on home birth and midwifery care. It becomes all too clear in the plight of Hungarian midwife Agnes Gereb (see page 17), who has been jailed for simply supporting women's bir thing decisions, that something other than the best interests of women has a controlling interest.

Amnesty International suggests more mothers are now dying in the US during birth than in perceived danger zones such as Bosnia. Clearly there are inequalities in life, care and perhaps in reporting. Why are more questions not being asked? Why has this not created the same level of press interest as the home birth debate?

However, birth does not usually require high levels of intervention in order to be safe. On page 20 Jo Dagustun writes about women who decide to birth unassisted by choice, rather than because they reject or cannot access care, and our book reviews look at how midwifery care could and should be. Page 19 contains a summary of the NCT's response to the government's NHS White Paper, Equity and Excellence: Liberating the NHS. Is this a golden opportunity for reform of the health service and a chance to improve access to flexible maternity care or a step towards privatisation and a reduction in service?

We could almost be persuaded that we live in a world of equality and rationality where women's decisions about their own bodies and lives are respected, unless, that is, we are aware of the backlash. In fact women's bodies and minds are still very much the sites of struggle. UK Government policy, based on the evidence, states clearly that women should be enabled to decide where and how birth but increasingly the right to home birth is being undermined by medical definitions of safety, for example in the recent Government White Paper on health. In actuality, women already have the unqualified right to decide and the strong resistance from the medical profession suggests that it is feeling under pressure. Our autonomy is enshrined in law and it is important that we retain that right.

References

1. Wax JR, Lucas FL, Lamont M, et al. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.
2. Tew M (1977). Where to be born?, New Society, 27 January, p120-1.
3. House of Commons, (1992), House of Commons Health Committee on Maternity Services Report (Winterton Report ). London: H M S O
4. The Lancet (2010) Home birth - proceed with caution, editorial in The Lancet, Vol;. 376, 31 July 2010.p 30.
5. Kennare RM, Keirse MJNC, Tucker GR, Chan AC. (2010) Planned home and hospital births in South Australia, 1991-2006: differences in outcomes, Med J Aust, 2010; 192: 76-80. (eMJA full text)
6. The Medical Journal of Australia MJA 2010; 192 (2)