Ágnes Geréb, the Hungarian home birth midwife, was arrested in October 5th, 2010 after an ambulance, and then the police, were called to a precipitous birth at Sunlight Birth House in Budapest, Hungary. Dr. Geréb is an obstetrician with more than 10 years of hospital experience, and more than 20 years of out-of-hospital experience. In her career, she has attended more than 3000 births. Of these 3000 births, there were fatalities in 3 cases, which gives her an infant mortality rate of 1 in 1000.
Home birth with a midwife is as safe as hospital birth only if 3 conditions are met: 1. if home birth is well regulated, so it is extremely well defined who falls into a high risk vs low risk category and under what circumstances hospital transfers have to be made 2, if the midwife is well trained to recognize boundaries between normal and pathological, 3. if transfer conditions between home and hospital are good, which would include features like distance to transfer, cooperation of the hospital staff, or perhaps even access for the midwife to hospital resources to continue the woman’s care.
If one of the conditions is not met, home birth becomes more risky than hospital birth in terms of neonatal mortality. This risk is relative, of course. In the US, in those states where the above 3 conditions are met, the risk of a baby dying in a home birth is 0.37 in 1000, which is the same as a low risk woman in a hospital, attended by a midwife. Those attended by obstetricians have higher mortality rates, but there is a large confounding factor there of doctors attending complicated births, and midwives attending uncomplicated ones. The risk of a baby dying in a home birth if those 3 conditions are not necessarily met is 1 in 1000 in the United States.
As we can see, Dr Geréb’s infant mortality rate is right on the dot. She is working in an unregulated environment where transfer conditions and health care staff cooperation is poor. There are also no written guidelines for who falls into a low risk or a high risk category.
Dr Geréb’s imprisonment has sparked intense and at times acrimonious debate in Hungary, where public opinion tends to consider home birth as criminally irresponsible, and only a little short of criminally insane. Ironically, in this country where home birth used to be the norm just two generations ago, and where it was still officially allowed for doctors to attend births at home as recently as 1984, by now the majority of the population considers it absolutely unthinkable to have a baby anywhere other than a hospital. And when hospital transfers are made from home births, the majority of people consider this proof that home birth is dangerous and irresponsible.
Hungarian people do not know that hospital births are more dangerous to the mother than home births. True, infant mortality rates tend to be slightly better in hospitals, but maternal mortality and especially maternal morbidity (injuries to the mother) are 3 times more likely in the hospital. And the increase in the rate of maternal morbidity is directly linked to the routine hospital procedures that mothers are subjected to in a hospital setting.
In a recent interview on Hungarian television, a very pretty, young reporter, who herself has actually served a celebrity advocate for improving birth in Hungary, was talking to a Hungarian midwife who happened to be trained in the United States in out-of-hospital births. The midwife was trying to explain that in a hospital, mothers are subjected to unnecessary procedures. The reporter interrupted with a tone of utter incredulity: „There are no unnecessary procedures in hospitals!”
This one instance perfectly embodies the fundamental assumptions that separate the two camps. Members of the homebirth movement know full well that many hospital procedures are a matter of routine, and that many of them actually interfere in the birth process, even as they are trying to ensure its safety. The reason hospital-based birth workers (doctors and midwives) are so adamant that home birth is not safe is that, quite literally, they may never have seen a physiological birth unfold. Think about that. The people who were trained for years to ensure the safety of birth may have never actually seen how it is supposed to work. They have always relied on their routine interventions. And their routines (removing the birthing woman from her safety zone, making her subject to hospital procedures, inducing or speeding up labor, confining the mother to certain postures or spaces in order to be able to monitor her, making her follow instructions instead of her instincts) slow down or even completely stop the birth process. Have you ever seen animals birth? They find a safe place to hide, and birth their babies away from all disturbances. What happens when this process is disturbed? The birth process is disturbed, the mother and baby may die, or the mother may abandon her young.
We ARE animals. For all our culture and learning and socialization, we still are. Birthing women work the same way as other animals. Disturb the process, and you increase the risk that birth will not function the way it should. So then once the birth process has been disturbed, we need to introduce even more interventions to set it right again. This is called the cascade of interventions and it starts with innocuous things like checking into the hospital, getting an IV (just in case) and a fetal monitor (just in case) and pubic shave and enema (just because) regular vaginal exams (just to see) and it ends with an operative delivery for failure to progress, which is the most common reason given for performing cesarean sections.
In Hungary, 70-90% of women receive an episiotomy during birth. An episiotomy is a cut made on the perineum, the area between the vaginal opening and the anus, the routine use of which has been contraindicated by the WHO since 1997. Most Hungarian doctors will tell their patients that they „only do one if it’s necessary.” But apparently, they feel it is necessary 90% of the time. In the meanwhile, episiotomy rates in the United States are around 30% and in midwifery practices they are less than 1%. In Hungary, women accept the episiotomy as a necessary part of giving birth. They cannot conceive that birth could be safe without one, for them or their babies.
This is where the reporter’s utter dismay came from, this is why she, after giving birth twice in a Hungarian hospital, felt that there had been no unnecessary interventions. Because as far as she is concerned, all of those interventions really were necessary to ensure her and her babies’ safety.
It takes a certain kind of mental (dare I say, paradigm) shift to perceive birth in its normal setting as the way it is supposed to be, and hospital procedures as interventive. Obviously, there are occasions when interventions are necessary. The problem is how one defines necessity. In Hungary, they feel that the whole arsenal of interventions from enemas to IVs to episiotomies and routine separation of mother and baby is necessary to ensure their safety.
The fact that this is not so is eloquently illustrated by other birth models where these routine procedures are not performed, and yet maternal and infant mortality and morbidity rates are superior. Where these statistics are achieved, the salient feature is a reliance on letting nature take its course, and treating mothers and babies with dignity and respect. And for maternal satisfaction, only the latter is necessary. Those are the immaterial factors that so strongly influence a mother’s experience of birth. How she was treated at birth is something that is etched into a woman’s mind forever after.
What is missing from a balanced discussion of home birth in Hungary and everywhere else in the world, is the honest examination of hospital routines and their effects both on the birth process and on mothers’ experience. We often hear about the safety records of home birth, and safety is of course vitally important. But it is time to admit that women’s and babies’ experience of childbirth is also vitally important – and that their experience is not a factor of material surroundings, but of human attitudes.