Thursday, August 14, 2014

Home Births and Halacha

The authors conclude their article with a discussion of the issue of planned homebirth vs. hospital birth. In their words:

"Similarly it is commonly believed that the twentieth-century transfer of births from the home to the hospital has aided the cause of piqquaḥ nefesh by lowering infant mortality. Statistics, however, do not support such a belief. Western countries with more home births than in the United States have lower maternal mortality rates and lower infant mortality rates than ours.26 Australia, New Zealand, Japan, and all Western and Central European countries all have lower mortality rates than the U.S.’s, yet more than one-third of all of their births are planned home births attended by a midwife. ...
Within the United States, studies also show that for normal pregnancies, home births are at least as safe as hospital births and that births attended by midwives are safer than births attended by physicians. Certain procedures such as multiple vaginal examinations and routine premature rupture of membranes are commonly performed by obstetricians, but not by midwives. Rather than promoting piqquaḥ nefesh, these interventive procedures, which naturally necessitate viewing of and contact with female genitalia, have actually been shown to be dangerous to the birthing woman and to her child.  There is also growing concern—even among some obstetricians—that other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs to hasten labor all have few health benefits and may indeed harm the baby."
The issue of planned homebirth has been the subject of significant discussion in recent decades, and there is no way that I can do it justice on this blog.  However, I will respond to the authors contentions with a few simple points that I believe are very important.  I will first refer the readers to the statement of ACOG on this topic here.  It is worthwhile reading, but as is often the case with medical literature, some important points still seem to be misunderstood by the public.

Before I explain anything, I need to remind the readers of this blog, that it is a blog for medical halacha and not meant to be a discussion of medicine.  So we need to establish the halachic issue here before we move on.  The halachic issue that the authors of the article are raising is that they contend that having a baby in a hospital may potentially be more risky then a home birth.  This would be a halachic problem, suggesting that a home birth may actually be safer and thus halachically preferable.  In their words, having a baby in a hospital exposes one to " ... interventive procedures ... [which] have actually been shown to be dangerous to the birthing woman and to her child..." Furthermore, according to the authors, " ... other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs ... may indeed harm the baby."

Could it be that having a baby in a hospital is riskier than a home birth, and thus halachically prohibited?

The best and most comprehensive study evaluating this issue, is the one quoted in the ACOG statement that I linked to above.  This was a meta analysis evaluating all known scientific studies of home birth vs. hospital birth.  The bottom line is that even under the best of circumstances (and I will describe briefly those circumstances in just a moment) a home birth has a rate of neonatal death that is 2-3 times higher than hospital births.  Now it is extremely important to understand that the actual rates are so low, (1.5-2/1,000 vs. .4-.9/1,000) that the studies certainly confirm that a planned home birth can be considered safe if done properly.  But to claim that it is less dangerous than, and thus halachically preferable to a hospital birth is simply wrong.

Now here are the points that need to be understood.

  1. No studies can actually be ever done that will truly answer the question of which birth is safer.  That is because in order to do this study, we would need to randomize women to planned hospital vs. planned home borth.  This is impossible in today's society.
  2. In every study that did try to retrospectively compare (or prospectively without randomization)  the two birth locations; only women that were healthy, had uncomplicated pregnancies, and with normal and healthy babies were allowed as participants in the studies.  So the studies only established that in these types of cases (of course this represents the significant majority of pregnancies) that it is safe to have a home birth. No one disputes that this is true.
  3. In all of the countries mentioned by the authors, those countries have in place highly integrated health care systems that address which women are candidates for home delivery, which personnel are certified and qualified to attend and supervise home deliveries, and transportation systems and communications for emergent transfer to a hospital are in place.
So we can all agree, that if proper systems and safeguards are in place; that a home birth can be a viable, safe, and halachically sound option for people who want to choose that type of delivery.  However, to suggest that a home birth is somehow halachically more preferable than a hospital birth is misleading and wrong.

In the United States, (I am not intimately familiar with the system in Israel) our health care system is set up to take care of women in labor in hospitals.  The poskim have thus overwhelmingly permitted (and encouraged) women to travel to the hospital, even on Shabbat, when they are in labor.  Whether or not it is preferable to have a baby at home (assuming that all of the conditions we mentioned above are in place), is a decision a woman needs to make with her qualified health care provider, and depends on many factors which are well beyond the scope of this blog.

I think that should conclude my discussion of this topic, but if you have any questions, comments, criticisms, etc... please let me know as I would love to hear what you have to say.


  1. I really enjoyed your latest posts, and found them both informative and interesting. Keep up the great work!

  2. Excellent critique. I have one picayune comment that relates to this whole thread - humor me, it's my nature to notice things like this. It is Maggid MIshne and not Mishna (which results from hypercorrection, I think). Maggid Mishne, is, of course, a commentary on the Mishne Tora, and the name is cleverly derived from Zekharya 9:12.

  3. Devora; Thanks so much for your correction! You are absolutely correct regarding the proper transliteration of Maggid Mishne. I also appreciate your reference to Zechariah. I think I mentioned this somewhere before, but my transliterations will be all over the place, reflecting my varied background. Please forgive me for this, it is not that it is not important, it is only that it is a skill that I lack.