Tuesday, August 3, 2010

Which is more safe: home birth or hospital birth?

ResearchBlogging.orgYou have probably seen the buzz about the recent American Journal of Obstetrics and Gynecology article (Wax et al 2010) on home birth safety, and the editorial in the Lancet that took the article’s shaky meta-analysis to crazytown: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk,” they write.

I have a lot of thoughts about this study and how it has been covered, by medical doctors and by the media. My main issues revolve around: 1) what these statistics mean from a personal versus a public health perspective, 2) maternal recovery and mortality, 3) the problem with criminalizing home birth, 4) the literature around birth experiences and the process of birth and resources for women, and 5) how we should look at this topic in the future.

What do these statistics mean?

According to the Wax et al (2010) meta-analysis, the difference in infant mortality between hospital births and home births is 0.2% versus 0.9% (other people have already done a nice take-down of the cherry-picking of older studies that have received significant criticism, yet were included). While headlines have screamed that this is a three-fold difference, it makes sense for us to pay attention to the absolute values. Infant mortality, in hospital or home births, is under one percent. We can’t even say that one in one hundred babies die in childbirth in developed countries any more (at least not as a whole – for now I’ll side-step some major differences relating to social disparities and race). If you are pregnant and considering where you want to give birth, I’m not sure how this slight difference could really sway you one way or the other. The problem is that the editors of the Lancet (and others) are conflating public health recommendations with personal recommendations… and shaming women in the process.

From a public health perspective, I suppose I can grudgingly understand why the difference in infant mortality in home versus hospital births matters. But you cannot take population-wide statistics and apply them to individuals. To do so is to ignore inter and intrapopulational variation, and to take a women’s decision about her body out of the context in which it should be understood.

Another thing to notice, Wax et al (2010) found that “neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation.” So of the more than 99% of babies who were fine, home birth babies tended to be healthier. This of course could be a bias of who chooses a planned home birth versus someone who does not, so I am not assuming the directionality to be that the home birth predicts healthier kids. But I wouldn’t be surprised if further analysis showed both directions to be causal; that is, that women more likely to have healthier kids choose to plan a home birth, but also that because home births have fewer interventions those kids are more likely to be healthy.

What about maternal health?

What the Lancet editorial and Wax et al (2010) mention only briefly, is that for maternal mortality and morbidity in low-risk births, to me, home births (and, I would contend, birth center births) are the clear winner. By not being in the same room as epidural medicine (it’s right behind you in big cabinets, just waiting for you to say “ow”*), single beds with little room to maneuver, continuous fetal monitoring and an IV under your skin as soon as you’re admitted, you avoid interventions that often carry their own significant risks and precipitate a cascade of other interventions.

Many women in the US don’t want to give birth in hospitals because being in a hospital increases the risk of maternal mortality and morbidity and, perhaps more importantly, slows recovery time. I say the recovery time issue may be more important, because while the US is embarrassingly bad at keeping mothers alive, the numbers are still better than in infant mortality (though, obviously, this makes sense from a life history perspective). The US is ranked 40th in the world in terms of maternal mortality – that means 39 countries do a better job keeping women alive during childbirth. Our incidence of maternal mortality is increasing, not decreasing, with the latest figures for 2008 being 17 deaths out of 100,000 births (Canada, for instance, has 7/100,000). Developed countries with higher rates of home birth have lower rates of maternal mortality.

Criminalizing home birth

Another problem I have is that part of the reason they cite home births as unsafe is that so few of them are staffed by certified midwives (only one third according to the Lancet editorial). The only reason more home births are not staffed by certified midwives is that organizations like the American Medical Association and others have lobbied to keep home births illegal in many states. Midwives cannot legally help a family give birth at home where I now live, in Illinois. Instead, I have been told by local homebirth supporters that there is an underground movement of lay midwives who try to help women stay out of hospitals, if it’s what they want. Is this a safe way to give birth if you are low-risk? Maybe, maybe not. I’m not sure I would be keen on a home birth that did not have a Certified Professional Midwife or Certified Nurse Midwife attending, who also had a good relationship to a doctor at the nearest hospital. But I also would not want to give low-risk birth in a hospital, even if I had a midwife, because of the major risks you incur just by stepping into a hospital (like infection). Women in states like mine are stuck between a rock and a hard place: give birth at home and risk not having someone with the right qualifications (and potentially face legal action), or risk giving birth under conditions where you may have interventions you don't want, and treated like something less than human (which I'll get to more in the next section).

By criminalizing home birth, medical doctors and their lobbyists force women who don’t want a medical birth to find less-than-perfect alternatives. So when Lancet editors and others criticize US women for not having the right people at their home births, I call shenanigans: they were complicit in making the laws that prohibit it in the first place.

Birth experiences in hospitals, birth centers and the home

There is a huge literature already on the medicalization and pathologization of femaleness, and I encourage you to devour it all, from Emily Martin’s The Woman in the Body to Robbie Davis-Floyd’s Birth as an American Rite of Passage.

So the other issue I want to make sure to include here is that pregnant patients don’t have the same rights as non-pregnant patients in a hospital (link to pdf), to refuse treatment, to leave, to contest a decision; hospitals can and do get court orders to force pregnant women to receive treatments they have refused. On the one hand, I can understand that sometimes decisions need to be made quickly during labor. On the other hand, I think there is a problem when we place a fetus’s rights above that of its mother’s. This recent story of police violence against a pregnant woman links to several problems with pregnant patient rights. Here are examples of court-ordered interventions. And here is more information on pregnant patient rights.

These are other reasons many women find the idea of a hospital birth frightening, and thus choose home birth or a birthing center. And if you read Davis-Floyd and others, you will see the interviews of women who have had hospital births how they were disempowered by the experience. This isn’t to say there aren’t many, many women who aren’t totally satisfied with hospital births, and would never consider home birth. It’s just to say that to acknowledge differences in infant mortality risk that are not necessarily meaningful to an individual making a decision about this, in the absence of all this other information, is disingenuous on the part of the editorial writers at the Lancet.

Future work on this topic

My daughter, just born at the birth center.
Rather than blaming the women who are trying to make the best decisions for themselves and their families and fetuses, medical doctors should be doing more to make different kinds of birth options available for women. In 2008, I gave birth in a birth center that was across the street from a hospital – the Cambridge Birth Center in Cambridge, MA. I had midwives, doulas, a labor and delivery nurse, my husband and sister to help me. I had a nice big king-size bed, a big tub to labor in, and just about every device you can think of to help me labor and push out the baby, from floating noodles for the tub, to a yoga ball, to a birthing stool. The time to get from the birth center to operating room if there was a complication was 4 minutes – the same amount of time had I been in the delivery room at the same hospital. This option is not available to me now, as a resident of the state of Illinois.

I’d like to see is re-analysis of the literature, where only home births with a certified midwife are analyzed. This is what is possible if we allow women more choices in where they give birth, so this is what we should examine. When we decriminalize women who don’t want the higher risk of epidurals or cesareans or infections, when we provide women more options for how and when to labor and give birth to their babies, and when we are honest with the failings of the medical system towards pregnant women and women in general, we’ll be heading in the right direction.

References

Wax, J., Lucas, F., Lamont, M., Pinette, M., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis American Journal of Obstetrics and Gynecology DOI: 10.1016/j.ajog.2010.05.028

Editorial staff (2010). Home birth--proceed with caution. Lancet, 376 (9738) PMID: 20674705


*What bothers me about epidurals and narcotics is not that women choose to use them during birth. I have given birth, I know how much it hurts and how it feels like the pain will never, ever end. I would never, ever begrudge a woman for choosing pain relief under those circumstances. What bothers me is that it is presented almost as a given in most hospital settings these days, since the medicine is already in the mother’s hospital room. There are many interventions one can give for pain that are not pharmaceutical, but few doctors are trained in these interventions. My midwives and doulas had so many tricks up their sleeves that even though I was in excruciating pain, I was able to remain in the birth center and have a totally normal, natural childbirth. I also want to be clear that if I hadn’t clearly stated I wanted this in my birth plan, they would not have worked so hard to make this possible. I wanted to be kept out of the hospital, kept away from the risk of infection and the risk of narcotics and the risk of cesareans and episiotomies, so they helped facilitate that within what was safe for me and my baby.

7 comments:

  1. Kate, I want to thank you for posting this. It is very refreshing to see such a clear distinction being made between individual risk (and decision-making) and population level hazard ratios.
    Medical community: "OMGZ, your risk TRIPLES! Scary!!! You should be crazy scared!! Booga-booga-booga!!"
    Mom: "But wait, my overall risk is still pretty teeny and I'm in great health, and anyway it's my choice and I'm willing to take that very small risk in order to have the experience I know is better for me and my family."
    Medical community: "How can you be expected to sort all of this out with your tiny girly pea brain? Up in the stirrups you go, and how's about an epidural-episiotomy cocktail!"

    The ongoing medicalization/pathologization of pregnancy and childbirth is very troubling, largely because educated women who want something different (and something that in many, many ways is healthier for mother, fetus/infant, and the entire family) are so demonized. And maybe more troubling is that the very information that women deserve to have in order to educate themselves and their practitioners is simply unavailable to most. More broadly, this issue also speaks to a larger issue of gender bias in the medical industry and the infantilization of women. I would think reaction to the study would be an excellent litmus test for women searching for their birth practitioner.

    ReplyDelete
  2. Andrew SchlademanAugust 4, 2010 at 5:07 PM

    Home birth is fairly common here in Germany, midwives are numerous and experienced. Since the size of the baby and pelvis and any other medical informaion is known before birth, most risks can be considered in the choice.

    We had Wolfgang in a women and children's hospital because the insurance paid for everything anyway and we're getting old. But with the costs in the US, I could see that many would like to choose to have a baby and be able to afford to send it to college. (We can assume tuition will have at least doubled if not quadrupled 18 years from now).

    Learning that home birth is criminal in the Land of Lincoln - who's mother gave birth to him in a log cabin - or so the story goes - strikes me as yet another bright star in the cosmos of modern American irony.

    I imagine giving birth in a car or taxi or walking down the road to a hospital wouldn't land you in jail would it?

    ReplyDelete
  3. I really enjoyed this comment. I read the report, and the paper, and immediately had many of the same concerns. I think the real message that should have emerged from this article, but was overlooked, is the problem that only 1/3 of home births are attended in the US, exactly because of the problems you discussed here - the lack of medical support, and often legal problems, associated with home births. What I would like to have seen was more of a discussion of overall maternal mortality in the article, comparing saw the Netherlands and US, with total mortality. What was never clear to me was whether or not c-sections were included in the analyses, which would tend to increase risk and be greater (almost 1/3 of US births now)among hospital patients. I agree with your thoughts on comparing midwife attended births versus hospital births - that would be really interesting. It was also interesting how little attention is paid to c-sections - I think, based on some of the comments I was reading after some of the newspapers reporting the Lancet editorial that everyone assumes the c-section is the emergency, ideal ending, not the product of dozens of other decisions that lead to the "Crisis" it solved, as articulated in "The Business of Being Born".


    Thanks for your thoughts on this.

    ReplyDelete
  4. First, thanks to all of you who wandered over here because of Julienne's thoughtful comment on Facebook :).

    Julienne, somehow this line made me laugh the most: "How can you be expected to sort all of this out with your tiny girly pea brain?"

    Though I read conflicting stories about this, I think that technically pregnant patients are supposed to have the same rights as regular patients to refuse treatment. However, if you are one of those uppity women who dares to refuse continuous fetal monitoring, an IV, or having your pubic hair shaved off (yes, there are a few hospitals left that do this), you risk being labeled a problem patient who doesn't know what she's talking about (i.e., tiny girly pea brain) or being forced (via court order) or shamed (by pulling aside your husband or partner) into doing what they want you to do. Unfortunately, I witnessed a birth where the last example happened only a few years ago.

    Andrew, my understanding is that if you act like it's an accident to give birth outside of a hospital (or it is an accident) then you don't necessarily get in trouble.

    And gotmilk, I completely agree. The fact that only a third of US home births occur with a certified midwife really troubles me; the Lancet editorial said themselves that the biggest issue was not having someone trained in resuscitation at the birth. If THAT'S the reason for the difference in infant mortality, is it really that women need to be in a hospital? Do the costs outweigh the benefits? Some women would say yes, and others would say no... for exactly what you're outlining regarding C-sections. I show "The Business of Being Born" in my Evolutionary Medicine course, and it's amazing how many students don't even know there are people who would choose a home birth (one student told me afterwards he thought the only time they happened were accidents, like someone being stuck at home during a blizzard), and who don't know about the cascade of interventions you guarantee by walking into a hospital.

    Thanks again, everyone, I really enjoy hearing your thinking on this.

    ReplyDelete
  5. I enjoyed reading this post! The increasing medicalization of women--not just women's reproductive health, but being a woman in general--has been something I've been following loosely, but I didn't realize that home births are illegal in some states. In my family, home birth was the norm, so this seems even more incredible to me. It makes me wonder how widespread this legislation is, and also how the AMA's attitude towards non-hospital birth has changed over the years.

    ReplyDelete
  6. I appreciate your perspective on the subject. The Wax meta-analysis should not be given any credibility on account of the numerous methodological flaws. Like you said, epidemiologists and other scientists have written extensively about this. My concern is how this piece is being used in the anti-homebirth, anti-midwife propaganda campaign, and how it is being used to limit to rights of childbearing women.

    ReplyDelete
  7. This is a good and informative post. I like the way you present this post. Thanks for this informative read. Keep blogging.

    ReplyDelete