This is not meant to be a debate about home birth safety. I just want to consider things from a slightly different point of view. Perhaps it is not the fact that you are birthing at home that is inherently safe, but rather the fact that you are low risk enough to qualify for home birth that makes it safer.
Consider, home birth advocate are eager to point out that they have a low rate of interventions, particularly oxytocin, epidurals and c-sections. However, they have never had an appropriate study to rule out confounders. In my center, if you are a healthy multiparous lady and you present in active labour, you will have less than a 5% chance of ending up with a c-section. For first time moms meeting the same conditions, only about 10% will delivery via c-section. This of course is not what home birth advocates are portraying. They suggest that 1 in 3 women will delivery by c-section, suggesting that just walking into a hospital will increase your risk. They fail to consider the multitude of other reasons why women have c-sections – breech, elective repeat, placenta complications, etc. They also fail to consider that when we induce primips, we accept an increase risk for intervention because we have concern that leaving the pregnancy could also be associated with increased risks, and therefore acknowledge a trade off. In my region, going post-dates with disqualify you for a home birth. Funny thing is, going post-date will also increase the rate of c-section, whether or not you undergo an induction of labour. Therefore it is the pregnancy complication that is increasing the risk for intervention, not the location of birth, because these women no longer qualify for home birth in the strictest sense.
Home birth advocates also are proud to report low rates of epidurals. This is a bit of a dumb thing to be proud of. Who cares what an individual women wants. Some women may feel a sense of power and control by labouring without medications, other women will feel the exactly the same by getting pain relief. There is no inherent benefit of avoiding pain relief in pregnancy. However, home birth advocates also fail to consider that obstructive labour can some time be improved by giving an epidural. If mom is exhausted, in pain with all the associated catecholines, this can actually impair labour. When you are in pain, you may naturally tighten your pelvic floor muscles as a response, therefore making labour have to work even harder to descend the fetal head. I my experience, truly obstructive labour patterns, without cervical dilation or fetal descend may in fact be more painful. Perhaps the women lucky enough to deliver naturally have highly progressive quick labours – they don’t have to deal with malpresentation, maternal exhaustion and frustruation. The epidural is viewed as a negative, but for many women it is the exact opposite. However, it must be portrayed in a negative like by home birth advocates because it is not available at home.
Finally, they promote the low use of oxytocin. However, they fail to emphasis that women delivering at home are only women who have gone into labour spontaneously (hopefully . . . in this region they are). That already represents a subset of all pregnant women, because it excludes comparison to any woman who has a medical or social indication for an induction of labour.
Its easier to claim they have fewer interventions and promote that it is the home birth setting and care provider that makes these differences. However, I would argue that it is being low enough risk for a home birth that leads to the reduces need for intervention. Home birth can be safe, but it is not the same as a hospital birth. If you take the truly lowest risk women, the rate of severe complications with be low and may appear acceptable. However, the rare complications occur at rates of 1 in 1000 – 1 in 10,000. If you are unlucky enough to be one of those women, home birth won’t be safe for you or your baby. Too bad we don’t have a crystal ball to predict who will remain low risk though delivery into the neonatal and postpartum periods. Until, I like to have a good back up plan, and that can be done better at the hospital. Beside, the hospital is the back up plan for home birth complications.