Fish can't see water

The place of birth is a subject of debate (Shah N Engl J Med 2015;372; 2181–3). Recently, the National Institute for Health and Care Excellence (NICE) concluded that for healthy women with uncomplicated pregnancies giving birth at home or in a midwife-led unit is safer than an obstetrician-led hospital delivery (Intrapartum care: care of healthy women and their babies during childbirth. London: NICE; 2014). Rowe et al. (BJOG 2016;123:1123– 1132) report on women planning vaginal birth after caesarean section (VBAC) at home versus in an obstetric unit. The probability of vaginal delivery increased from 70 to 88% when attempting the home delivery. Adverse perinatal outcome rates were 1.8% and 1.6% for home and hospital deliveries, but the study is underpowered on this outcome, making the author’s conclusion that ‘the risk of an adverse maternal or perinatal outcome is around 2–3%’ debatable. Other studies have shown that uterine rupture occurs in 1% of women who attempt VBAC, and is difficult to predict (Grobman et al. Am J Obstet Gynecol 2008;199:30.e1–5). Consequently, most women who attempt VBAC will choose to do so in the hospital. However, as medical interventions can only be performed after informed consent, shared decision-making should give women the autonomy to make independent choices. The importance of the present study is that it shows that home delivery after a previous caesarean section is a feasible option. At all times, we should prevent scenario’s such as occurred in Brazil last year, when a woman who had two previous caesarean deliveries left the hospital after she was denied an attempt for vaginal delivery by her gynaecologist, to find herself subsequently under arrest and having her baby born by caesarean delivery under force (Turner and Hill. ‘Kidnapped’ by the authorities: meet the woman forced to have a caesarean. The Telegraph, 17 April 2014 [Accessed 19 July 2015]). In my opinion, the autonomy of the woman over her own body prevails over the medical need for an intervention. Another important issue that arises from Rowe et al. is the fact that we should try to understand the difference in intervention rates between home and hospital deliveries. Whereas one explanation might be that women who opt for VBAC at home are more motivated to achieve vaginal delivery, it is beyond doubt that obstetricianled labour care is associated with higher intervention rates than midwife-led delivery care, be it in or outside a clinical setting. Importantly, it is not the individual person or place of labour that causally influences the differences in intervention rates, but it is the obstetrician trained to use scalpels in a high-tech environment that makes the difference. We should use a scientific approach that builds on understanding the course of natural labour, prediction of poor outcome, and testing the effectiveness of interventions in clinical trials. When there would exist subtle differences in safety between midwifeled and obstetrician-led delivery, we should identify those women that actually benefit from our interventions, thus allowing the majority of women to choose a delivery as natural as they want to. In fact, we can prevent much of the dilemma studied by Rowe at al. if we normalise intervention rates in the first pregnancy. The problem is that we seem to have forgotten what normality is. Fish can’t see water (Wagner Int J Gynaecol Obstet 2001;75 Suppl. 1:S25–37).