What's the difference between smoking in pregnancy and homebirth? Smoking is safer.

I have a question for homebirth advocates.

Imagine this scenario:

A woman, after reviewing the evidence from both sides, after carefully considering the increased risks, and after deciding that she is willing to accept the responsibility for the outcome, decides to ... smoke cigarettes during pregnancy.

This situation happens all the time. In 2012, just about everyone knows that cigarette smoking increases the risk of pregnancy complications. However, smokers will accurately point out that most women who smoke during pregnancy do not have smoking related complications, that smoking provides both pleasure and concrete benefits such as relaxation and increased concentration, and that women are entitled to make healthcare choices about their own bodies. In addition, there are scientists who assert, and who have testified under oath, that the harms from smoking have been dramatically exaggerated.

So if a woman claims to have made a knowledgeable decision to smoke cigarettes during pregnancy, and is aware of the potential consequences, does that mean it's okay for her to smoke during pregnancy? Would you support her in that decision? Would you admire her for doing her own "research" and refusing to simply follow her doctor's advice? Would you consider her brave and clever for listening to tobacco executives instead of her doctor? Why not? After all, the increase in perinatal mortality attributable to smoking in pregnancy is less than increase in perinatal mortality attributable to homebirth.

According to Adverse health effects of prenatal and postnatal tobacco smoke exposure on children, Hofhuis et al., Arch Dis Child 2003;88:1086–1090:

Smoking during pregnancy may be responsible for ... a 150% increase in overall perinatal mortality.

Compare that to the overall increase in perinatal mortality attributable to homebirth of anywhere from 200% - 600% (latest CDC figures).

Consider the arguments:

The absolute number of deaths is relatively small since the US perinatal mortality rate is relatively low.

A woman has a right to control her own body. If she's willing to accept the increased risk associated with smoking for both herself and her baby, no one should prevent her from doing so and no one should condemn her for her decision.

Smoking provides benefits like relaxation, pleasure and increased concentration on a day to day basis. Giving up smoking would mean hardship for 9 full months, whereas, for those who find hospitals unpleasant, giving birth there lasts a day or two at most.

Doctors don't know everything. They play the dead baby card all the time when it comes to smoking and pregnancy, yet the overwhelming majority of women who smoke during pregnancy have babies who are completely healthy.

Tobacco is natural. It's a plant just like the herbs given out like candy by homebirth midwives.

There's more to pregnancy and birth than a live baby. The mother's experience is important, too.

The bottom line is that every argument advanced in support of homebirth can be used to justify smoking in pregnancy. So I'm looking forward to homebirth advocates explaining to me why risking a baby's life by smoking during pregnancy is anathema, but risking a baby's life at homebirth is something to brag about.