Earlier this month, Britain’s National Institute for Health and Care Excellence (NICE) declared that for women with very low-risk pregnancies – about 45 percent of prospective mothers there – it is safer to give birth at home or birthing centers run by midwives than in a hospital. The new recommendations could lead to a radical change on Britain’s maternity wards. According to the guidelines, currently nine out of 10 infants in England and Wales are born in hospitals, and caring for them is in the hands of doctors; only 2 percent are born at home.
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The new guidelines are the result of an interdisciplinary team set up by NICE, which also included women who have given birth. They are based, among other things, on a 2011 document called “Birthplace in England Research Programme,” financed by the British government and conducted by researchers at Oxford University, which was published in the British Medical Journal and elsewhere.
The researchers found that for a birth that was not the woman’s first, hospitalization increases the risk of complications such as episiotomies (56 women out of 1,000 in hospitals, as opposed to 15 at home); Cesarean sections (35 women out of 1,000, as opposed to seven at home); forceps births (38, as opposed to nine); and blood transfusions (eight, as opposed to four). Moreover, there is a greater chance of the woman receiving an epidural injection (121, as opposed to 28), which, while relieving pain during the birth, simultaneously increases the risk of prolonged labor and subsequent complications.
The figures on medical interventions at birthing centers fall between those of home births and hospital births. At an independent center, the level of intervention is less than at a center attached to a hospital.
Similar conclusions appeared in a November 2013 report from the Cochrane Collaboration, an international organization that publishes comparative research studies. According to that report, extensive access to medical technology in obstetrics departments leads to more interventions in a hospital birth. As for the safety of planned home births compared to hospital births, the authors preferred to refrain from firm conclusions, due to the paucity of random studies in the field. However, on the basis of the studies they could access, they noted that the two modes of delivery were equally safe, but that a hospital birth had the potential for more medical interventions, as noted.
In this respect, it appears the new guidelines have gone a step further – in part, on the basis of the Oxford University researchers’ findings that the risk of death or complications to the newborn was the same in all the examined settings (home, hospital, and both types of birthing center). However, there was one exception: For firstborns, a home birth increased the risk of serious complications (such as meconium aspiration syndrome, fractures and death during the first week) by 0.4 percent relative to hospitals and birthing centers.
In the context of these findings, it was recommended that women who have given birth before should be advised that a home birth or birthing center could be preferable to a hospital birth.
It is possible that there are also budgetary considerations behind these guidelines. In England, a hospital birth costs the National Health Service about £1,600; a birth at a birthing center (attached to a hospital) about £1,460 (a bit less than at an independent birthing center); and a home birth costs about £1,060. In other words, increased births away from hospitals will save the British government a lot of money.
A 60-year-old law
This simple calculation raises a question: Why is it that in Israel the state refuses to fund home births when they are performed in accordance with Health Ministry guidelines and conducted by licensed midwives? After all, their total cost is significantly lower than hospital births.
This question joins many other queries, such as why is there no legal possibility in Israel for setting up independent birthing centers under the management of a midwife? And why do so many healthy women here leave a hospital birth with physical or psychological damage caused by medical interventions? Generally, these interventions could have been avoided with one midwife for every woman giving birth – a measure that can be implemented more easily in a home or at a birthing center. Why has the Israeli government never funded research the way Britain has? And why has it never established a public committee to examine the welfare of women giving birth in Israel, never mind their preferences?
To all these questions, there is one main answer. With the establishment of the state, hospital doctors succeeded in convincing the state to give them a monopoly on treatment of women giving birth. Under the National Insurance Law that came into effect in 1954, the National Insurance Institute pays the hospitals a “hospitalization grant” equivalent to about 12,000 shekels (about $3,050) for every birth, with no connection to the actual treatment a woman received. They receive this even if the woman did not give birth at the hospital but was only hospitalized there after the birth (within 24 hours). Moreover, only new mothers who are hospitalized are entitled to a “birth grant.” This policy became law 60 years ago, even though, also at that time, there was no evidence that universal hospitalization of all women about to give birth was best for them all, with no distinctions.
Clearly, the Oxford researchers’ findings also apply to new mothers in Israel – the fact that hospitalization increases considerably the risk of a forceps delivery, Cesarean section and other complications. According to a summary of planned home births in Israel between 2008 and 2012 (conducted by Dr. Avner Shiftan), 2.3 percent of women had a Cesarean section, from 2,409 home births. In hospitals, by comparison, 19.6 percent of some 172,000 women had C-sections in 2013, according to figures from the Israeli Society of Maternal-Fetal Medicine. Among the home-birth mothers, 0.97 percent had forceps deliveries, compared to about 7.1 percent of hospital birthers.
Moreover, in 2012 there was one case of neonatal death two days after a home birth – that is, 0.29 deaths per 1,000 newborns – compared to 5.5 per 1,000 in hospitals in 2012, and 3.6 in 2013.
It must be remembered that among the pregnant women who are hospitalized for births, there are more who are defined as high risk. But this fact does not explain the striking differences between the outcomes of home and hospital births.
According to Dr. Shiftan, “The explanation for this clear difference, in which the home births are much healthier with respect both to the mother and the newborn, is in the different approach of people who engage in home births. They view birth as a natural physiological process and relate to it as such during the course of the birth. By contrast, the approach of labor room staff at the hospitals is that birth is a medical process with a high potential for becoming pathological. This approach by the labor room staff causes the birth to be that way.”
For decades now, there has been opposition expressed to the absence in Israel of pregnant women’s right to choose, and nothing has been done. The run-up to an election should mark the possibility of change, so here is a call to the political parties to introduce a reform in the area of births. To this end, they should study the British birth guidelines and try to change direction – to create a new, healthier reality, which, above all, takes into account the well-being and wishes of the woman giving birth.
Dr. Omi Leissner is a researcher and lecturer on the subject of women’s rights in the gender studies program at Bar-Ilan University and the Schechter Institute of Jewish Studies. She wrote her doctorate on the topic “Birthlore [sic] and the Law of Birth in Israel.”