The Safety of Hospital Birth - The myth versus the reality

Beverley A. Lawrence Beech

AIMS Journal, 2000, Vol 11 No 4

Having travelled around the world presenting the users' views of maternity care I have found that, without exception, every country is vigorously developing and enhancing maternity care - under the control and influence of obstetretic thinking.

While midwifery has been described as the oldest profession in the world, it has been on a slippery slope since the Middle Ages when thousands of midwives, or wise women, were burned. I do not suggest for one moment that prior to the 20th Century midwives worked in an Arcadian world where all was sweetness and light. On the contrary, midwives have always struggled, either in conditions of poverty or battling to maintain the profession in the face of male domination and subsequent medicalisation of birth, or trying desperate to give care to far too many women at the same time. As Julia Allison has shown in her research into community midwifery in the 1930s some midwives committed suicide because of the pressures of work. Sadly one should not forget the recent case of an Australian midwife who committed suicide allegedly because of the tensions of trying to provide real midwifery care in a hostile technological environment.

During the eighteenth century the move to industrialisation and urbanisation encouraged greater interest and involvement of men in midwifery. But one of the biggest disasters (and there have been many for midwifery) occurred when the medical men developed hospitals for the treatment of the sick, and soon realised that there was an unending source of income from pregnancy and birth, and a captive group of women on whom to carry out medical experiments and 'research' (see page 8 Ethical Research).

Without dwelling on the safety of hospital verses home, it's safe to say that the supporters of hospital births have never been able to produce a single valid statistic which shows that hospital birth is safer for all women than home births. Marjorie Tew, in her analysis of birth outcomes demonstrated how, in every single risk category hospital birth produced higher mortality rates (see table 1).

Interestingly, the 1970 data upon which the analysis was based were the last opportunity to evaluate maternity statistics in this way. The medical profession abandoned the system of Labour Prediction Scores and were, therefore, able to dismiss future comparisons the spurious grounds that centralised maternity units admit a greater proportion of high risk women, and therefore comparisons cannot be made. A very convenient excuse which has bedevilled future analysis of birth outcomes.

By 1987 a comprehensive review of the medical evidence comparing the safety of home and hospital birth was published by the National Perinatal Epidemiology Unit in Oxford. It concluded:

"There is no evidence to support the claim that the shift to hospital delivery is responsible for the decline in perinatal mortality in England and Wales nor the claim that the safest policy is for all women to be delivered in hospital."

In 1996, the British Medical Journal published an unprecedented set of four research studies on home birth in the UK and other European countries. The overall conclusion of these research papers was that for low risk women, birth at home is safe, if not safer, than birth in hospital.

This journal focuses on what is often referred to in the press as "the safety of hospital birth". While it seems incredible that it should need restating, we have highlighted some of the recurring problems with routine procedures used in hospitals (see page 4 Over-Medicated and Under-informed). Far from being safe, the widespread and largely unevaluated routines such as electronic fetal monitoring and active management of labour have been shown to cause high rates of morbidity in women and their babies, yet bring no compensating improvement in the mortality rates.

We also take a look at why there is such a large and persistent gap between the medical evidence and clinical practice. In his article Dr Marsden Wagner (page 9 Bad Habits), who worked for many years at the World Health Organization also explores why WHO recommendations for normal birth continue to he ignored by so many practitioners.

Once again, it is a packed journal. The information it contains continues to be vital to every pregnant woman and every practitioner who is proud to call herself a midwife. May such information, no matter how challenging it is to conventional wisdom, continue to challenge and enrich us and provide a platform for greater understanding and debate.

Table 1

Labour Prediction Score Perinatal Mortality Rate per1000 births GP/Midwife Hospital
Very low risk 3.9 8.0
Low risk 5.2 17.9
Moderate risk 3.8 32.0
High risk 15.5 53.2
Very high risk 133.3 162.6
All risks 5.4 28.0

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