Critique of "The Business of Being Born"

I watched the documentary 'The Business of Being Born' last night.  It was primarily an argument in favour of homebirthing, and against doctor attended hospital births.

As a medical professional working in the field of developmental pediatrics, I see the results of births gone wrong on a daily basis. There's my bias. I have also never given birth, so one could argue that I have no right to an opinion on the matter. The movie stimulated a lot of criticism in my mind however.

The film goes through a historical summary of birthing and various trends that have fallen in and out of fashion.  Yes, women have been birthing babies for centuries, and it is a healthy natural human experience not a sickness or disease. What they forget to mention was that it wasn't that long ago that it was quite common for women to die during childbirth, and infants not to make it to their first birthday.

The film presents various stats on how home birthing is safer than hospital. The evidence behind it is not very strong. They mainly compare countries where prenatal care and women's lifestyles are very different than in the US. They also compare the number of maternal and fetal deaths in home vs. hospital settings. One would hope that if death were on the doorstep a home birth would result in a quick hospital transfer. If the death then occurred in the hospital would it be added to the hospital stats? Women who have preexisting medical conditions that put them at risk are also more likely to deliver in a hospital setting. Women who seek midwife care for home births are a handpicked bunch, and the higher risk people are weeded out of that equation and referred to OB's. You have a low risk population of women compared to a more complex group.  Apples to oranges.

While there is no question that many babies are delivered safely at home without issue, sometimes it only takes a matter of minutes (sometimes seconds) for a normal delivery to turn life threatening. There is often no way of knowing if you will be one of these people who has an uneventful delivery or a suddenly complex one. A hospital transfer takes time. Time that you might not have. Why risk it?

There was also a lot of discussion over the rise in c-section rates, especially in urban centres, and a suggestion that more and more women are "too posh to push" and opt for elective caesarians as an alternative. Firstly I would suspect that the increase in c-section rates probably has more to do with the litigation system. The Dr.'s primary responsibility is to get the mother and baby to the other side of the delivery safely.  While it used to be accepted that there were a certain number of deaths or major disabilities as a result of the childbirth process, this is now completely blamed on the attending doctor. Many GP's are giving up their maternity part of their practice because of the rising cost of the malpractice insurance. The higher incidence of c-sections in urban centres makes sense to me too. If you have a higher risk pregnancy you don't hang out in a rural area hundreds of miles from a hospital that does maternity care on a part time basis. You pack your bags and make a temporary move to a city that has the facilities and medical expertise equipped to handle your care. On the topic of "too push to push" the Canadian Society of Obstetricians and Gynecologists has clinical practice standards around when it is appropriate to perform c-sections and "too posh" is not one of the acceptable medical reasons for this major surgery.

I do think there has been a good movement toward midwifery care in hospital, and Dr.'s and midwives working much more collaboratively. The newer maternity units in hospitals are much more like birthing centres than the old school ones.

An interesting twist near the end of the film happens when one of the co-producers of the documentary goes into early labour with a footling breech, growth restricted baby and needed to be transferred to hospital for an emergency c-section. Thank goodness the taxi ride wasn't far and the baby suffered no long term consequences. I'm not quite sure how this scenario supported their argument, but it certainly solidified my opinion.