Babies, Birth, and Bajingos

mood: babies!
music: The Dividing Cells – Womb With A View

(Or, Hello, world!)

Before reading on, you should be aware that this entry throws anatomical terms around in a somewhat carefree manner, so if the mechanics of childbirth offend you, you might want to pass this one up.

A topic for which some will believe that I am eminently unqualified, lacking a uterus, ovaries, and a vagina. I’m sure there’s someone out there who has these organs who will decide that my even talking about this is an affront to her mystical mother-sense and that I should not even attempt to address the issues at hand. To these people, I will point out that the evidence is on my side. At any rate, I do have experience as a blogger, though, so that is what I shall do. And today, we’re going to talk about the relative merits of “homebirth” or “natural childbirth” versus a traditional (in the western world) birth at a hospital. This is not normally a topic I’d research on my own, since I’m not planning on creating any humans anytime soon, but I do have some friends who are, and this is for them. An aside: I had a variety of more creative names for this entry, but they got increasingly anatomical, so to avoid offending the sensibilities of those who aren’t comfortable with their reproductive systems, I abstained from using some of the more graphic visual puns. You’re welcome.

Also, and this needs to be said at the outset, my data and conclusions are based on research done in the United States – the Canadian and Dutch studies I was able to find don’t agree with the evidence I could find for American patients. (And the data is even more conflicting.) And it’s irrelevant, because the people I’m researching this for live in the United States, so it doesn’t matter if the Netherlands are safer or less safe or whatever. One more thing – I’m purposefully avoiding the topic of midwifery, which is related but separate and an even stickier subject.

Home births (hereafter “HB”) are a delivery method chosen by increasing numbers of women, the best information I could find puts the current numbers around 1 in 200, and midwife-assisted birth is common in other developed countries. How safe is it compared to birth in a hospital? What quickly becomes apparent in trying to research this is that one: there is a metric crapload of anecdotal evidence from women about their births, and every one of them believe that their experience represents the Golden And Immutable Truth About Birth Forever And Ever, Amen¹, and two: serious research is going to lead us into vast fields of statistics, so many statistics it would make my ovaries explode, if I had them.

Next to breathing, eating, locomotion, and sex, childbirth is the one of the most basic functions of humanity. There are few things more intimate or elemental in the human experience than bringing a child into the world. It is also one of the most dangerous and vulnerable times in any animal’s life – and it’s no different for humans. Childbirth is inherently dangerous. In every time, place, and culture, it is one of the leading causes of death for young women. Humans have competing interests from an evolutionary standpoint: babies with big heads are likely to be more neurologically mature, and being more neurologically mature is an advantage for a species with such an abnormally long infancy. Conversely, a small maternal pelvis makes it easier to women to walk and run. Those two advantages are often incompatible. The woman with a small pelvis may have been able to survive by outrunning wild animals, but when it came time to give birth, she was more likely to die because that small pelvis could not accommodate a large neonatal head. Modern society helped a great deal with this, and in the 1940s HB started dropping dramatically over the years, down to fewer than 1% in 1955. Infant mortality began dropping in the 1930s with the discovery of antibiotics, and since then easier access to C-sections, epidural anesthesia, newer and better antibiotics, blood banking, and neonatology led to dramatically lower mortality rates. And here’s where we start to run into our first problems with HB.

An overwhelming number of HB advocates emphasize how much more natural it is to give birth at home, in a place where the woman feels comfortable. Indeed, they imply (or outright say) humans have been giving birth to babies outside of a hospital environment since, literally, the dawn of humanity, and it’s clearly unnatural to give birth in such a brightly-lit, sterile, loud environment where there’s doctors, drugs, mechanical ventilators, and *gasp* cesarean sections. Clearly, natural is important to these people. Off the top of my head, I made a list of some other things that are natural:

Uranium-235
Hemlock
Deathstalker scorpions
Hurricanes
Anthrax
Micky Rourke

Clearly, while natural, these things can all be terribly destructive to human life. Natural does not equal good. Death is natural, but generally something we wish to avoid. Peeing into the lake that everyone has to drink from probably came naturally, but modern sanitation standards have helped us realize that it’s not a Good Idea. But enough poking fun at the prolific nature of the fallacious appeals to nature that HB advocates trumpet, let’s have a look at the latest and greatest analyses on home-birthing.

One of the problems with attempting to consider what the evidence says about HB is that you can’t randomly assign women to either give birth at home or a hospital. This would be ideal, but it’s not possible, so we have to fall back on studies that are possible. Just comparing HBs to hospital births isn’t good enough, because high-risk births occur primarily in hospitals, and between 9% and 37% of planned home births end up with transfer to the hospital during labor and are converted into hospital births. Studies comparing the intended delivery location would be helpful, and these have been done, but sadly the numbers studied were small and the results inconclusive. Lucky for us, an overview of the published literature is available, which combines the data into one large set for better understanding.

Wax et al. combed through the available literature and found studies covering a total of 342,056 planned HBs, and 207,551 planned hospital births. The results² are as follows:

Results: Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birth weight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates.
Conclusion: Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate. [Emphasis mine]

The raw data says that neonatal death was twice as likely overall with home birth and three times as likely for non-anomalous births⁴. However, while looking at the relative risk is striking, it’s important to note that the overall risk remains low because the overall incidence of mortality is low across the board.

HB, in fact, does seem to have a few benefits. According to Wax et al,⁵, women intending home deliveries had fewer infections, ≥3-degree lacerations, perineal and vaginal lacerations (Aside: Ouch!), hemorrhages, and retained placentas. (And, significantly or not, no difference in the rate of umbilical cord prolapse.) Perinatal mortality was similar by intended delivery location, overall as well as just among non-anomalous offspring. However, the overall neonatal death rate was almost twice as high in planned home births, and almost tripled among non-anomalous neonates. Importantly, that observation was consistent across all studies examining neonatal mortality, regardless of the covered time period.

One of the most striking things about the Wax et al. metaanalysis is that women planning home births were of similar and often lower obstetric risk than those planning hospital births. The planned home delivery women commonly exhibited fewer obstetric risk factors like obesity, not having given birth before, prior cesarean, and previous complications. This wasn’t unexpected, since women self-select for home birth, but it is worth mentioning.

Another study worth mentioning is the population-based study done by Chang and Macones in Missouri.⁶ Missouri was chosen because its vital record system is considered very reliable; the authors of the paper refer to it as the “gold standard” of birth record keeping. (Also, they specify that “‘Other’ birth attendant refers to any other person who delivered the baby, such as a family member, EMT, or taxi driver.” HA!) This study goes on for several pages about their methodology, the health and socioeconomic statuses they accounted for (Medicaid, smoking, obstetric risk factors, etc – they specifically wanted to examine the low-risk population) and their data set spans from 1989 to 2005, and includes data on almost 860,000 pregnancies. Their results emphasizes who does the delivering a little more than the previous metaanalysis – they differentiate between CNMs / M.D.s, non-CNMs, and the aforementioned “others”. Their results indicated that planned home birth by non-CNMs more frequently experienced prolonged labor, and that home births attended by non-CNMs had a fivefold increase in the odds of newborn seizures. In addition, they observed a higher rate of intrapartum fetal death in planned home births attended by physicians / CNMs compared to planned births in hospitals or birthing centers attended by physicians / CNMs. (24 times more likely when a home delivery was attended by physicians, and 13 times more likely when attended by a non-CNM. The discrepancy appears to be an artifact of the fact that among those choosing homebirths, physicians were rarely present.) They also found that the increased risk of of fetal death occurred despite clear evidence that mothers who had planned a home birth in general were more likely to be on the low end of the risk spectrum. They conclude that “…planned home births are associated with increased likelihood of intrapartum fetal death and newborn seizures, despite the fact that the lowest-risk women choose this birthing option.”⁷

Home-birthing is not a practice grounded on solid science, and I feel that’s a completely fair assessment. It may incorporate elements of medical science, and just how much it does depends largely on the parent’s beliefs and the beliefs of the midwife they choose. There are some great midwifes out there who are well-trained and genuinely concerned with the welfare of their patients, young and old. But the fact remains that, at best, giving birth at home represents an increased risk. All other things being equal, it’s small, but present. And the reasons generally given by women (Comfort, aesthetics, extra attention by a caregiver, lower hospital-acquired infection rates) do not, in my opinion, outweigh the increased risk that giving birth at home represents. Not having a room of ten people standing around staring intently at your vagina is an increased comfort, yes, but is the comfort worth it? No matter how low-risk a woman is, the fact is that complications can happen in an instant, and (again, at least in the US) the outcomes for home births are demonstrably worse than for hospital births. And remember the entire point of having a birthing attendant is to prevent, diagnose and manage complications. You don’t need any expertise to catch the baby and make sure it doesn’t hit the floor. (Ask any taxi driver.) No matter how well-equipped your midwife is, it’s not as good as a fully-staffed hospital attended by multiple childbirth experts with the resources to handle dangerous complications – remember that a non-trivial percentage of planned home births end up with transport to a hospital. It should be intuitively obvious that increasing the delay to skilled medical care is going to result is more adverse outcomes for patients – distance from the hospital of course being a crucial factor, but the optimal scenario is already being at the hospital.

There are reasons that the American College of Obstetricians and Gynecologists does not support home birth – safety concerns and lack of rigorous testing. Delayed treatment of unexpected emergencies constitutes a small but undeniable risk for these babies. Further, it has not been established that the benefits of home birth (lower maternal infection rate, etc.) can outweigh that risk. I support the right of informed patients to choose where they deliver their children, but I would personally feel terrified for the safety of anybody considering one. If you want fewer interventions, that doesn’t require giving birth at home. If you want more attention from a caregiver, ask. If you want increased aesthetics, bring your own curtains.⁸ There are ways to increase patient comfort and satisfaction without sacrificing the safety of mother or child.

One final word: help keep me real. If you find an error or problem with my conclusions or data, I’d love to hear about it. Also, if you’ve taken a statistics course, and would like to help me understand how to read statistics, that would be very helpful.

Exit, stage left.
Sparks

• 1: And a bizarre anti-male sentiment, especially where male OB/GYNs are concerned.
• 2: “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis”, by Wax et al., American Journal of Obstetrics and Gynecology.
• 3: It’s important to understand the difference between perinatal and neonatal mortality. The write-up of the study is confusing because a typo erroneously defines perinatal mortality as deaths up to 28 days after birth. Perinatal mortality includes stillbirths and deaths in the first 7 days of life; neonatal mortality includes all deaths in the first 28 days of life.
• 4: Non-anomalous in this sense means without congenital defects.
• 5: Ibid., 243.e2, “Results”.
• 6: “Birth Outcomes of Planned Home Births in Missouri: A Population-Based Study”, by Jen Jen Chang, Ph.D. and George Macones, M.D., M.S.C.E.
• 7: Ibid., page 8.
• 8: Lutheran is a horrible-looking and feeling hospital, I know. The Methodist Younker / Powell 6 wings are much nicer.