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.

Obstetric Drugs

In the final section of the article the authors decry the use of drugs during labor to treat pain.

They refer us to the early debate regarding whether or not it is appropriate to use pain relieving medications to treat women in labor.  It is well known, that many early religious (mostly Christian, but some Jewish as well) authorities felt that pain was a natural part of labor, and that women were supposed to have pain due to the curse associated with Eve's sin when she took a bite of the forbidden fruit.  They felt that it was therefore inappropriate to provide women with pain relief.

This philosophy would strike most modern readers as incredibly cruel, and indeed the overwhelming response of the Rabbinic authorities has been to support, and even encourage, the use of anesthetic and analgesic medications to relieve the pain of childbirth.  The authors quoted R' Moshe Feinstein in YD:2 p140 where he recommended that women be put to sleep for delivery so as not to feel pain.  This responsa was written in 1972, when it was common practice to give women heavy doses of sedatives during the final stages of labor to treat pain.  This usually required the physician to intervene and deliver the baby with forceps as the woman was not awake enough to push the baby out herself.

This practice fell out of favor well over 35 years ago when doctors realized the risks of forceps deliveries when done routinely, and the risks of the medications involved in heavy sedation.  I am not aware of any doctors or institutions that have practiced this way in almost two full generations.

So the authors agree that Judaism does support pain relief during labor and does not subscribe to the "curse of Eve" philosophy which would prohibit pain relief.  However, they then introduce us to another concern, which they feel should be a halachic basis for avoiding the use of drugs during childbirth:

"... Nevertheless, not all objections to obstetric analgesia and anesthesia can be dismissed as mistaken religious obscurantism based on the Genesis narrative.

As Rabbi Immanuel Jakobovits outlines, Christian objection to the use of drugs during childbirth was two-pronged. While some cited the curse of Eve as their source, others objected for medical reasons. Rabbi Jakobovits writes that, “towards the end of the last century, a Catholic medical moralist still forbade the use of chloroform at normal births because it might endanger the mother and the child…” Jakobovits then praises Judaism for being above any such considerations."

The authors are suggesting, that halachically speaking, we need to reconsider our use of drugs in labor because they may be dangerous.  They make this suggestion as if it can be assumed that drugs in labor are inherently dangerous, but they do not have evidence to back up this claim.  In fact, every treatment used in labor is subjected to controlled clinical trials and years of experience that have attested to their safety and efficacy.  It is far far beyond the scope of this blog to review every pain treatment and its' specific risk/benefit profile. However, we have established that in Judaism, treating pain in labor is an honorable and appropriate goal. Every woman is not religiously obligated to suffer to atone for Eve's sin.

A fascinating exchange about this topic took place in Montreal Canada in 1849, shortly after the discovery of anesthesia.  An article about this debate was published in the Journal of the American College of Obstetrics and Gynecology, also known as ACOG.  The Journal is called "Obstetrics and Gynecology", and in volume 88 No. 5, November 1996, pages 895-898, Dr Jack Cohen writes of the debate that took place in Montreal between Dr James Simpson and Rabbi Avraham De Sola.  Rabbi De Sola was the first rabbi in Canada, and he was the new young Rabbi of Montreal's oldest congregation, the Spanish Portugese synagogue - Shearith Israel.

Dr Simpson had argued against the use of anesthesia for women in labor based on Genesis 3:16, the verse declaring that "B'etsev Tayldi Banim".  By using his knowledge of Hebrew, and the Jewish commentators (primarily the Radak), Rabbi De Sola boldly took on the Christian interpretation of the verse and shows how the word "B'Etsev" refers to the uterine contractions of labor and not the pain experienced by the woman in labor.  Interestingly, Rabbi De Sola went on to become a Professor of Hebrew Language at McGill University in Montreal.

The poskim in the almost 175 years that have passed since Rabbi De Sola's debate have almost universally understood and acknowledged the importance of treating the pain of labor.  It is accepted that we must treat a woman's labor pain the same way we would treat all pain and suffering for every person.

This is true even though every treatment has some level of risk. When risk is balanced against benefit, halachah has determined that since these treatments are overwhelmingly safe and effective when administered by trained professionals, they are halachically desirable, not just permitted. Furthermore, every patient has the opportunity to choose whether or not to avail themselves of these treatments, and each person can evaluate the risks of benefits of each medication before deciding whether or not she desires to use it.

In their conclusion, the authors clarify their case, and they cite some "evidence" to back their claims:

"To begin with the third example, the dangers of drugs during pregnancy, including obstetric analgesia and anesthesia, are well documented today. In fact, they have been well documented since at least the 1980s. Both the mother and child can suffer side effects ranging from sluggishness to brain damage and death. The fact that no Jewish authority has restricted or discouraged the use of drugs during labor may not be an occasion for self-congratulation; it may call for some serious halakhic soul-searching."

As sources for their assertion that obstetric analgesia and anesthesia drugs are dangerous, they quote two articles from 1981 (see their footnote #24).  If one carefully examines the sources used to support this article's assertions, and the general tone of the article itself, one is struck by impression that the authors are reflecting a worldview that views modern medicine, and especially obstetric medicine, with an extreme amount of suspicion. I suspect that arguments like these will go on forever, as they are not amenable to resolution by providing evidence to support one point of view over the other. For example, one of the sources cited was titled "Malepractice: How Doctors Manipulate Women".  If someone believes that doctors are guilty of intentionally manipulating their patients, then it will be very difficult, in fact almost impossible, to convince him/her by quoting evidence from the medical literature.

I hope that I at least provided some information for those people who are open minded enough to look upon their physicians, midwives, nurses and other appropriate caregivers as their allies instead of their enemies.  I totally agree with the authors of the article that we should never engage in self congratulation.  However, the fact that "no Jewish authority has restricted or discouraged the use of drugs during labor..." does not reflect a lack of "serious halakhic soul-searching", as the authors declare.  Rather, it reflects centuries of serious halachic concern for the comfort and well-being of women in labor.

I do owe you one more brief post on this topic regarding the safety of home births, and then we can move on to our next topic.

My oh my, How Times Have Changed

We have now described the fundamental assumption upon which the article "Obstetrics and the Curse of Eve" is based.  According to the authors, a birthing woman is in a category not exactly equal in halachic status to the critically ill patient. Thus, in what they consider to be the classical halacha; on Shabbat one must use a shinuy whenever possible, prior to the final stage of labor one may do nothing other than to call the midwife, and generally speaking only the midwife is called upon to violate Shabbat restrictions.

From here they go on to describe how much things have "changed".  Here are the next few paragraphs:

"Such halakhot could be easily implemented in a society where midwife attended home births were the rule. The only person who, under normal circumstances, had to transgress the Sabbath was the midwife. From a global perspective, home birth is still the norm and hospital birth the alternative. In middle- and high-income countries the opposite is true: the home birth rate in these countries is very low, for example, less than 1 percent in the United States. Where hospital births are the norm, the traditional halakhot about Sabbath observance have quickly become inoperative. 

Even a brief examination of a respected 1979 halakhic compendium will show how much these laws have changed. According to Rabbi Joshua Neuwirth, a woman should travel to the hospital at the onset of the slightest sign of labor. She may carry her possessions with her to the hospital, even through an area without a permitting enclosure (‘eruv) and can be accompanied by an “escort” (presumably her husband), who may also transgress the Sabbath. She may even, under certain circumstances, travel home from the hospital on the Sabbath if in fact she had been mistaken about being in labor.

What sources does Rabbi Neuwirth quote when allowing wholesale transgression of the Sabbath before the final stages of labor? Almost invariably he says, “So I have heard from rabbinic authorities” or refers his readers to the general rule of life-threatening situations (piqquaḥ nefesh). There is no attempt to justify these radical changes; piqquaḥ nefesh apparently speaks for itself."

We have already demonstrated that the fundamental assumption made by the athors is deeply flawed.  That is because the majority of the poskim follow the simple meaning of the words of the Shulhan Arukh and the rambam and the Gemara that state unequivocally that a birthing woman is "B'sakanat nefashot", and that the same laws that apply to any critical patient apply to her as well.  The Maggid Mishna that was quoted by the authors which differentiated between a birthing woman and a critically ill patient was either not accepted by many poskim, or interpreted by the poskim to be refering only to things being done l'yashev da'atah - to calm her fears.

R' Neuwirth, in Shemirat Shabbat K'Hilchatah (SSKH), paskens exactly NOT like the authors of the article would have you assume is the accepted halacha.  In fact, he paskens exactly like many of the poskim we quoted before, and that there is no halachic difference whatsoever between a birthing woman and a critically ill patient.  See SSKH Vol 1, 34:4 note 6 where he states, and I quote:

"see earlier in 32:28 (where R' Neuwirth paskens that one must use a shinuy for every critically ill patient whenever possible), therefore, the law of a birthing woman is the same as the laws of a critically ill patient, in that whenever it is possible, a shinuy must be used."

It is unclear why in the text of the SSKH R' Neuwirth quotes the Maggid Mishna when he states that the pain of birthing is a natural process. However, he provides the source in his note and refers us to the Arukh Hashulkhan and the Mishna Berura.  It is well known that the normal style of the SSKH is to leave this type of detailed analysis to the reader, and simply to provide the sources for someone interested in further investigation.  Regardless, the SSKH is crystal clear, both in 32:28 when he discusses the laws of the critically ill patient, and in 36:4 when he discusses the laws of the birthing woman, that he considers them exactly the same.  He thus follows, not surprisingly at all, the pattern of most poskim throughout the centuries, who did not differentiate between the two.  Unlike the authors who would have you believe that "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient".

Thus it should be no surprise at all when he allows what the authors consider "wholesale transgression of the Sabbath".  He doesn't need any more sources, as the poskim, especially the Arukh HaShulkhan who WAS quoted by the SSKH, made abundantly clear that even things that are only needed to calm her down, but aren't medically necessary, are permitted on the Shabbat.

The next issue that the authors discuss is the use of male birth attendants.  In summary, they contend that Halakhah in general "severely limited the access of male physicians to women". Traditionally, births were attended by women only, and midwives were the attendents at births.  However, "today most Orthodox women standardly have their babies delivered by male physicians...", and this has been supported by the halachic authorities.  Consistent with the theme of their article, the assumption is made that the reason for this leniency of the modern poskim is that when life is in danger, we can allow transgressions of halachah, including the use of male birth attendants.  In their words, "The male physician is exempted from this rule (the rule prohibiting males from being present at the birth), presumably for reasons of piqquaḥ nefesh."

I will discuss this issue in detail in my next post.