Is there no place like home? Where women give birth is a contentious issue across the rich world

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A RISKY and self-indulgent eccentricity, or a return to natural obstetrics? A medical and political row rages between supporters of home birth, many of them midwives and expectant parents, and its detractors, many of them doctors. Start telling women where they may or may not give birth, with hints that the choice may endanger their child’s life, and the gloves come off ...

Stereotypes and simplifications are in rich supply. Many doctors think they are trying to curb a bunch of lentil-munching fanatics who ignore the dangers of something going suddenly, and badly, wrong ... when even a few minutes’ delay can be fatal. The home-birthers decry grasping, bossy doctors who turn a natural experience into a near-emergency needing medical intervention. Hospital births are more likely to end in Caesarean sections, and to involve episiotomies ... and epidurals ...

Two kinds of risk are at issue. Giving birth at home may be safe most of the time, but when things do go wrong, they are more serious. In hospital more things go wrong because intervention is more common, but the complications are less likely to be lethal or to cause permanent damage.

Views on home birth vary widely between countries. In Hungary, Ms Gereb has helped at more than 3,500 home births (and attended more than 6,000 in hospital). But she was on shaky legal ground. Regulations there have for decades restricted the work of midwives ... to the point where it was, in effect, illegal for them to attend home births. Now a change in the law from May 1st will explicitly allow home births for a restricted category of younger mothers with uncomplicated pregnancies. Ms Gereb is appealing against her sentence ... Police have closed the birthing centre she founded and seized its records.

... In France, red tape snares most would-be home birthers; the costs are not fully reimbursed, as they are for births in hospital. Home births are rising in New Zealand, but not in Australia. In Britain only 2.7% of births take place at home, but the government wants them to be more readily available and both doctors and midwives agree.

The big outliers are the Dutch ... nearly a third of mothers still choose to give birth at home. The Dutch perinatal mortality rate is one of the highest in Europe, though the cause is contested. Supporters of home births say that the numbers are still not all that high, and have to do with poor assessments of how risky pregnancies are. Nonetheless, they highlight how difficult it can be to determine whether a pregnancy is “low risk” and thus suitable for a home birth. For first-time mothers, judging the ease of birth is particularly tricky. Some complications cannot be predicted.

... Critics of home births cite a meta-analysis of over 500,000 births ... that concluded that neonatal death ... was three times more likely in a home birth. But the perinatal mortality rate ... was about the same.

The National Childbirth Trust, a British parenting charity, questions the data behind the study. Only one of the studies used showed a big increase in neonatal deaths. Including unplanned home births, inevitably more dangerous, may have skewed the data. Lesley Page, a professor of midwifery at King’s College, London, has studied home births in Canada, where she and other researchers found that home births are just as safe as hospital ones—for healthy women expecting healthy babies, attended by a well-trained midwife, and with a hospital nearby if needed. The study compared home births only with hospital births where women were judged sufficiently low-risk to have given birth at home had they so wished.

At the end of last year Cathy Warwick, the head of the British Royal College of Midwives, which supports home birth, decried what she called a concerted and calculated backlash against home birth and midwife-led care, fuelled by a small number of doctors and a lot of poor research.

A definitive statistical answer to the relative perils of home and hospital births is unlikely. Randomised trials, which are the gold standard in medical research, will be tricky to impossible: women are unlikely to accept a researcher’s arbitrary instruction about where they should give birth. As with many other aspects of child-rearing, birth will come down to parental disposition—whether for a hospital’s bright lights and plentiful pain relief, or for the familiar comforts of home.