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The Business of Being Born

One of our readers asked for a critique of the movie “The Business of Being Born.” I guess my sex and specialty make me the best qualified to comment. I delivered over 200 babies as a family physician. I had two babies of my own (at age 37 and 39), one with intervention (forceps) and one 9-pounder who almost “fell” out before the obstetrician was ready.

“The Business of Being Born” is a movie about midwives, home births, and hospital births in America. It’s a sort of kinder, gentler “Sicko” with onscreen births, gooey, bloody newborns and fat naked women. The message of the movie is that for an uncomplicated pregnancy, natural home births with midwives are better and safer than medicalized hospital births with obstetricians. It’s strong on sound bites, emotional appeals, and superficial arguments, but weak on substance, depth, and scientific evidence for its claims.

Obstetric care in America can certainly be improved. Our neonatal statistics are far from the best in the world, but when we look for reasons, I don’t think we can blame a deficiency of home births. We don’t have universal health care. Some women’s prenatal care is inadequate. We have more immigrants and a more diverse population than a country like, for instance, Norway, and that may skew our statistics. It is very tricky to compare neonatal and maternal death rates between countries.

We are doing too many C-sections. Midwives suggest that if women were allowed to ambulate, to deliver squatting rather than supine, and to avoid certain interventions like epidurals and fetal monitoring, some C-sections could be avoided. Most C-sections are done because obstetricians truly believe they are the safest option in that individual case, but I suspect that sometimes those decisions are subtly influenced by a fear of lawsuits and the doctor’s need to be able to show the court that he did everything possible to avoid a poor outcome for the baby. Some doctors are apparently inducing labor and performing C-sections on request for patient preference or so-called designer births. I personally consider that appalling.

Hospitals have tried to involve the family and offer home-like birthing suites, but they are still perceived as insensitive to the needs and wants of their patients. (I suspect that a few people have unreasonable wants and can never be really satisfied.) Birth has become overly medicalized and overly expensive. Again, the American legal system must bear part of the blame. No doctor wants to be on that witness stand explaining why he didn’t do an ultrasound or use a fetal monitor. Malpractice insurance is so exorbitant that it has led a lot of doctors to stop doing obstetrics.

The movie dealt more with feelings and opinions, and didn’t talk much about evidence from controlled studies. There are many unanswered questions about how to achieve the best outcomes for babies and mothers. If you don’t think doctors are constantly trying to reassess and improve their methods, just read any obstetric journal. When I was an intern, episiotomies were standard practice. I was chastised for not doing an episiotomy on one patient, a multigravida who begged me not to do one and who really didn’t need one. Now routine episiotomies are no longer recommended. Not because women complained, but because controlled scientific studies re-examined the outcomes. We stopped shaving the perineum and giving enemas a long time ago. Maybe we will stop delivering our patients in a supine position – but only when evidence clearly shows a safer option.

The whole home birth thing was entirely too touchy-feely to suit me. I got the feeling that if the woman had to pee during labor, the midwife might go along and hold her hand and tell her what a good job of peeing she was doing and ask her to notice how relaxed and empty her bladder felt now. Some women delivered under water, which doesn’t make a bit of sense to me. I personally wouldn’t want my home invaded, a tub set up in the living room, a bloody mess in my house, and my toddler watching. That’s a matter of personal taste, I suppose.

They kept harping on empowerment, and made it seem like a woman had to endure great pain so she could feel she’d accomplished something so wonderful that now she knew she could do anything. This is unnecessary. We can provide good pain relief during labor with minimal risk to the baby, and I see no reason to have women screaming “I can’t stand this!” with a midwife telling her she has to tough it out. Despite their protestations, I wasn’t convinced that the midwives’ attitude was kinder to their patients than my obstetricians who made my labors and deliveries almost pain-free.

They interviewed a man who said monkeys reject their babies when they have C-sections, and that C-sections and other hospital births are preventing babies and mothers from bonding, making them bring babies into the world “without the love” produced by the surge of oxytocin. A woman who required an emergency C-section implied that she felt like a failure and said that it had prevented her from bonding with her baby. This is pernicious nonsense. Human mothers bond perfectly well with their babies after C-sections, and there is no evidence for any emotional harm. I think there is more likely to be emotional harm from the attitudes fostered by the movie.

Obstetricians may tend to get bored with typical routine deliveries, and they may have to rush off to the clinic or surgery; midwives see routine deliveries as their raison d’etre, and they can usually stay and talk. Midwives are wonderful. I’ve worked with them and I’d love to see them attend most routine deliveries. But not at home.

Home births scare me witless, because I’ve seen a normal delivery turn to disaster in a heartbeat. As one doctor says in the movie, a woman can hemorrhage and bleed out in a matter of minutes. In one scene in the movie, a home birth is interrupted in mid-dilation because the baby is breech and premature, and there is a mad rush to the hospital in a taxi, with the mother screaming “My water broke!” and “I can’t take another contraction like that in this taxi!”

In a recent discussion on the Quackwatch Healthfraud discussion list, we heard personal stories of ideal home births with qualified midwives, assistants, oxygen at hand, and planned backup within a few minutes’ reach. We also heard about a disaster with a prolonged labor, a midwife who rejected the family’s and assistant’s requests to transfer to a hospital, a floppy blue baby, and the father’s conviction that his son would not have cerebral palsy if he had been born in a hospital.

Normal birth is not a medical problem, but it can turn into a life-threatening medical problem with no advance warning. Published safety statistics for home births are pretty good, but their validity has been questioned. Safety is going to vary with training, patient selection, and circumstances like geographical constraints. Comparisons are problematic. There is undeniably a small risk. The perception of the size of that risk and its acceptability boils down to personal attitudes and risk-taking behaviors.

Highly-paid obstetrical expertise is not needed for most births. There is no reason well-trained, well-equipped midwives could not deliver babies at home for those who prefer it and are willing to accept the small risk. There is also no reason midwives could not deliver most babies within the hospital in a patient-friendly homelike environment with expert emergency backup right next door. That would be the best of both worlds.

Optimum outcome for the health of mother and child is a science-based goal that can seek evidence to support every detail of practice. That doesn’t preclude an additional non-science-based goal: patient satisfaction, with personal attention to the feelings of the patient and leeway for individual preferences that don’t interfere with outcome.

We need to do more science, we need to listen to our patients, and we need to be open to suggestions from midwives. But that’s what good doctors do anyway.

Posted in: Science and Medicine, Science and the Media

Leave a Comment (36) ↓

36 thoughts on “The Business of Being Born

  1. Joe says:

    Thank you.

  2. ellazimm says:

    As you allude to I cannot understand why prospective parents would not want the facilities of a modern hospital immediately available if something goes wrong. But then losing a baby at birth probably does affect one’s view.

  3. daedalus2u says:

    There is a very good blog set up to counter the misinformation put out by home birth advocates.

    http://homebirthdebate.blogspot.com/

    Very much science and evidenced based.

  4. Ed says:

    My girlfriend is a nanny for a wealthy couple who have an 18 month old, and were expecting a second child very soon. In the 9th month of pregnancy, the woman was at one of her last screenings with her physician. The physician noted the baby should be born at any day, but that he could induce the woman’s labor to be sure and to have the birth at a predetermined time and place. The woman declined, rather she wanted to wait until it ‘came naturally’.

    Two days later she stopped feeling the baby kick. She went into the ER and learned the baby’s heart had stopped beating. I didn’t find out the final reason why the baby died, but I can’t help but wonder if she had induced labor when the doctor recommended it, would the the baby have been born alive?

    In this day of high tech, low-infant mortality, people often forget how perilous life and nature can be. Science has harnessed a lot of the risk, pain and suffering, and put it aside. It is any wonder then that people would be up in arms against science based birthing (such as hospitals, doctors, and other PROFESSIONALS).

  5. Dacks says:

    As a earthy-type pregnant woman I was enamoured with the idea of home birth, until I met a mother with a young child whose serious brain damage was caused by being too far from the hospital when a home birth went bad.

    Months later, when I delivered in the hospital I found that many of my fears of “over-medicalization” did not come to pass. I did not need pain killers, nor were they urged on me; I gave birth in a sitting position attended by a midwife; I had my baby and husband with me at all times. I had a second child in a different hospital, but the details were basically the same. I also attended a third birth in yet another hospital with similar treatment.

    Normal, uncomplicated birth is still a travail, but in my experience it is often handled by midwives these days in a simple and supportive manner, inside the context of a fully equipped hospital.

  6. mufi says:

    As long as we’re relying on personal anecdotes in this thread, mine’s as good as any…

    Good doctors are not always so easy to find. For example, the OB/GYN who delivered my first child botched several attempts at troubleshooting a back-labor before we had to rush my wife to the emergency room for a c-section. The hour or two following the procedure, during which the hospital separated us from our newborn, was not so pleasant either, but that was nothing compared to the discovery that the doctor botched the c-section, leaving my wife with an ileus, which had us living in the hospital for the next week or so.

    After the ordeal, the doctor chalked up the experience to weight of our baby and recommended that we induce the next pregnancy early. We were also told that a vaginal birth would be unlikely.

    My next child was delivered (vaginally) by a mid-wife at home. The baby weighed over a pound more than our firstborn did at birth. The birth experience was a huge improvement over the previous one.

    Again, this is only an anecdote, but then so is the evidence against home births presented in this thread.

    mufi

  7. Dacks says:

    Mufi,
    Just wondering – it sounds like the first birth would have been a complicated one even if the doctor was not (dare I say?) incompetent. Do you think you would have had a better outcome with a home birth? Also, what was your contingency plan if the second birth did not go well?

  8. I think the key is, like everything else, medical claims and decisions should be evidence-based, not ideological. My impression as a physician and as a parent of two children is that when ideology (no matter how well meaning) intrudes on the decision-making process, poor decisions are made.

  9. Harriet Hall says:

    VBAC – vaginal birth after C-section, carries a small but very real risk of uterine rupture. A uterine rupture at home with a midwife could be expected to end in disaster. Mufi played the odds and won.

  10. superdewa says:

    For a blog about science-based medicine, I am surprised by how anecdotal the information in this article is. If one wants to argue that way, one can come up with plenty of anecdotes against hospital births, too.

    For example, regarding the woman who was uncomfortable during her taxi ride from her homebirth to the hospital — no-woman’s ever been uncomfortable driving from home to a planned hospital birth while in labor? I can think of many anecdotes to support miserable taxi rides to the hospital, when homebirth isn’t even a question.

    Her anecdote about the woman who felt she didn’t bond with her child after a c-section doesn’t begin to address the many real concerns about c-sections and the growing difficulty of finding a doctor who will agree to perform a VBAC (vaginal birth after cesarean) in this country.

    What I would like to see here are sources that prove that medicated births are safer than non-medicated ones or that hospital births are necessarily more safe that homebirths or that the US’s poor mortality rate is indeed the fault of our lack of health care or the other reasons she proposes.

    The responses are mostly from the hip as well. People — please think about your reactions. Are they based on science or based on your own personal revulsion?

  11. mufi says:

    Dacks,

    I’ll answer your second question first, since it was one that I thought alot about at the time (this was nine years ago, mind you): Our contingency plan was to call an ambulance and haul ass down to the nearest hospital (which was about 40 city blocks away).

    My wife did most of the research on the subject, so the best I can do to answer your second question is to recall her argument that there are midwifery techniques for handling back labor that, for whatever reason, her OB/GYN did not practice. If she was right about that (I took her word for it), and that technique was applied successfully to our first birth, then the experience would likely have been more positive, whether it had taken place at home or in the hospital, by a midwife or by an OB/GYN. (Of course, the first birth experience also would have more positive if the OB/GYN hadn’t botched the c-section.)

    Again, no statistics here, just my own anecdote vs. the (fear-inducing) anecdotes I read earlier in this thread.

    If I were to heed such arguments in other aspects of my life, I imagine I would lead it rather differently (e.g. I would never board a jet plane).

    mufi

  12. abra says:

    First of all, The Business of Being Born is not just advocating homebirth, and is certainly not suggesting that all women birth at home. Rather, the point of the movie is expose childbirth practices that are business-oriented at the expense of mothers and babies — such as routine interventions, birthing on one’s back, now allowing VBAC even though studies show it’s safer, etc.

    Speaking of VBAC, uterine rupture became fairly rare after doctors changed the type and direction of incision. What made the rupture rate start climbing again was the overzealous use of contraction-inducing drugs like Pitocin and Cytotec. Cytotec is not even labeled for obstetric use, because the drug company has never performed trials on pregnant women. The insert states that Cytotec is not for pregnant women, but doctors continue to use it “off-label.” Why, then is Cytotec so popular when Pitocin IS labeled for obstetric use? The only reason I can come up with is that Cytotec is much cheaper. (Not that women will find that discount on their bill….)

    Women who VBAC at home rarely experience ruptures. I know many women who have done it, and no ruptures. These women are not on dangerous drugs that cause overly strong contractions, and they are in optimal labor positions rather than on their backs. Like Mufi’s wife, most of these women have very satisfactory experiences.

    Things can go wrong in homebirth, quite true. I’ve had 5 births – two in hospital and then three at home. During my first homebirth, we experienced shoulder dystocia (shoulders stuck in pelvic girdle.) At the hospital, I would have been treated to a McRoberts (?) where they push your knees up to your ears and mash on your belly, a ‘vaginal c-section,’ or worse. But because I was at home with an experienced midwife, she told me to get on my hands and knees and she freed the baby using a technique learned from indigenous women and popularized by Ina May Gaskin. The baby was freed as quick as a wink.

    When I became pregnant again, I knew was going to have another homebirth! Chances of another large baby were good, and I didn’t trust a surgeon to be an expert in non-surgical techniques. (I mean, really, when is the last time you heard a doctor say, “Hands and knees!”)

    My next baby was 10# 5oz and did not become stuck. But the next one was even larger, and the technique was needed again. In fact, she was only 2oz shy of 12 pounds. And guess what? With all three of my homebirths, I didn’t even have a tear.

    The fact is that the statistics favor homebirth. That’s why ACOG, in renouncing homebirth earlier this year, dismissed the statistics rather than appealing to them.

    Getting back to the original blog post….Countries with better infant survival rates have universal health care AND they have midwifery as the primary caregivers for healthy women. It seems arbitrary to say that universal health care is causative and midwifery care is not.

  13. teresa says:

    Thank you for that informative reply, abra. It’s worth noting that hospitals often exclude nurse midwives (and other advanced practice nurses) from their list of privileged providers, thus limiting women’s choice of provider. An emphasis on safe, low-tech interventions as the first treatment choice distinguishes midwives from obstetricians and probably accounts for the superior outcomes achieved by midwifery care.

    I am not advocating avoidance of obstetricians in complicated circumstances, but nurse-midwives are providing safer, less expensive, evidence-based care for that great majority of births that are uncomplicated.

    The author does not distinguish lay midwives, who undergo informal training and are not required to have college preparation, from nurse-midwives, who are advanced practice nurses with graduate degrees and licensure to practice. It is crucial to make this distinction when discussing midwifery care.

    - Teresa, RN,PhD,APN

  14. daedalus2u says:

    To respond to abra, “statistics” do not support greater safety in a home birth. The statistics (when they are available and not suppressed and/or doctored by home birth advocates) support the logical inference that birth in a place where expert level emergency care is rapidly available results in fewer adverse outcomes than birth in places where expert level emergency care is not available.

    This is not a “close call”. When there are no difficulties, a home birth is as safe as a hospital birth. Some difficulties are completely unpredictable and if not dealt with rapidly via expert medical intervention will produce adverse outcomes (sometimes even then). Rapid expert medical intervention is not available at a home birth. The conclusion that there will be more adverse outcomes at home births is inescapable.

    The statistics that are used need to be looked at very carefully. Some of the definitions of mortality rates in different countries include mortality at times other than at birth (i.e. 1 month and 1 year) and immediately thereafter. It is necessary to compare low-risk hospital birth vs. low-risk home births (not all hospital births which include many high risk births).

    If anyone wants an in depth discussion of these things I recommend the blog I linked to above. The author of the blog has many links to relevant papers in the scientific literature.

  15. mufi says:

    FWIW, the midwife we used was a licensed RN, and I recall the impression that she was well-equipt to handle any *likely* emergencies.

    I should add, however, that we lived in an urban neighborhood back then, and we calculated that we could get to a hospital quickly enough if any *unexpected* emergencies arose. Given our current, semi-rural home’s distance from the nearest hospitals, we might very well calculate differently today.

    Again, it was not the general advocacy of modern, science-based medical technology or methodology that I objected to in this thread. Far from it. In fact, I consider myself a fan. Rather, it was the implied acceptance of over-simplified, one-sided, fear-inducing anecdotal evidence as a rational argument that raised my objection.

    To quote Dr. Novella above: “medical claims and decisions should be evidence-based, not ideological.” I agree, and would add that these decisions should also be context-based (i.e. based not only on personal risk factors, but also on the setting and the qualifications of the midwife).

    mufi

  16. apteryx says:

    daedalus2u writes:

    “The conclusion that there will be more adverse outcomes at home births is inescapable… It is necessary to compare low-risk hospital birth vs. low-risk home births (not all hospital births which include many high risk births).”

    Hardly. You are assuming that the number of serious natural complications home births will exceed the number of serious natural plus iatrogenic complications in hospital births. That assertion requires supporting evidence. Several reviews show favorable outcomes of home birth, compared to other options:

    http://www.ncbi.nlm.nih.gov/pubmed/17603954?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    Here’s a very large prospective North American study (several thousand babies) showing “lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births.”

    http://www.ncbi.nlm.nih.gov/pubmed/15961814?ordinalpos=48&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    It is easy to surmise that all the unnecessary medical interventions cause a few complications of their own. I imagine that midwife care in proximity to a hospital would be ideal, but there are reasons beyond cost why women might want to avoid the medical system. Harriet writes (in a generally well-balanced article):

    “Now routine episiotomies are no longer recommended. Not because women complained, but because controlled scientific studies re-examined the outcomes. We stopped shaving the perineum and giving enemas a long time ago. Maybe we will stop delivering our patients in a supine position – but only when evidence clearly shows a safer option.”

    That attitude — that the opinions of patients shouldn’t affect “treatment” decisions — makes women in particular feel disempowered. Your profession did not stop inflicting episiotomies (still common, I understand), shaving, and enemas until “controlled scientific studies” had shown they were worthless. The fact that women disliked them was previously irrelevant. Yet those practices had not initially been used because “controlled studies” seemed to show benefit. They were simply dreamed up by a medical profession that thought more intervention was always better. At that time, that profession was nearly all male. We have to be aware of gender-related power issues in the development of Western medicine.

    You now say that you will not stop “delivering your patients” flat on their backs until evidence “clearly” shows a safer position. The grammatical construction transforms women into passive objects to “be delivered,” with no voice in the method of that delivery. If they might like to try to minimize pain and complications by walking during labor or by giving birth in the position used by virtually all humans before the medical profession came along — well, tough. You won’t let them off their backs unless natural practices are proven to be not just as safe but safer, and the experiences of millions of women aren’t “clear” enough to matter. Yet the on-the-back position has never been proven to be even AS safe as the natural position; it was simply imposed by male physicians who found that it facilitated invasive practices. Why, then, is this relatively new-come posture grandfathered in, to be continued without scientific evidence, while more natural postures cannot be grandmothered in similarly?

    You refer to your sex in saying that you are particularly qualified to comment. It seems strange that you, as a woman, have so willingly accepted a philosophy that denies women’s autonomy.

  17. weing says:

    Comparing infant mortality between the US and other countries is very difficult. A 28 week old preemie in the US may or may not survive in the neonatal ICU. In other countries it may be considered a spontaneous abortion and not an infant mortality statistic.

  18. daedalus2u says:

    Actually, there are “problems” with the Johnson and Daviss study.

    The comparison group they used included deaths due to congenital malformations and some other problems. The home birth group did not.

    http://homebirthdebate.blogspot.com/2007/01/johnson-and-daviss-study-shows-death.html

    Even so, the homebirth group had a death rate ~3 times higher.

    Johnson and Daviss appear to acknowledge some of the deficiencies in their study.

    http://homebirthdebate.blogspot.com/2007/12/johnson-and-daviss-acknowledge-validity.html

    I don’t doubt that the rate of episiotomies is different, but it is my understanding that an episiotomy doesn’t increase mortality. If a woman wants to avoid an episiotomy and have a home birth while accepting a higher risk of mortality, that is her decision. That decision should be made on the basis of the most accurate science and evidence available, which as I understand it indicates that there is higher risk in a homebirth.

    I don’t doubt that unnecessary medical interventions cause “complications”. What they don’t cause is increased mortality.

  19. Deetee says:

    Abra, you say;

    Women who VBAC at home rarely experience ruptures. I know many women who have done it, and no ruptures.

    I appreciate that this thread contains many anecdotes, but as a reason to opt for home birth after caesarean section this must be the worst one I have encountered. Uterine rupture is a rare complication of VBAC, but if it occurs “at home” it would likely be fatal for the mother and baby both. To argue that because one has never seen a case among the relatively small number of one’s acquaintances as Abra does is ridiculous. VBAC is one of the strongest contraindications possible to having a home birth in these circumstances.

    As a corollory, I know many friends who have driven cars when drunk, and none has had an accident. You will undoubtedly agree that on the basis of this strong evidence it is perfectly alright to drive while drunk.

  20. apteryx says:

    The anti-home birth web site seems to make some good points regarding the weaknesses of the Johnson and Daviss study, e.g., that the hospital death rate used for comparison purposes may have been dated, but also some dubious points, e.g., that a few babies reportedly born dead should be counted as neonatal deaths because they can’t “prove” the babies weren’t alive.

    The real message of the study is that not one home birth in the year 2000 resulted in a maternal death, and that the infant death rate, while somewhat higher than for hospital births, is in absolute terms very low. If the primary use of the study is to give women an estimate of the risks associated with home birth, it is essential to exclude babies born dead or with terminal birth defects: a hospital birth would not have saved those babies. That leaves a total of five potentially avoidable infant deaths among 5132 white women having home births in 2000.

    Let us assume that three of those five would have been kept alive in the hospital. That’s 1711 women having hospital births for each infant saved. The average cost of hospital birth was reportedly $8800 last year. That’s $15.06 million per infant saved (a crude measure, but we have no basis for Quality Adjusted Life Year calculations related to how many of those will survive with significant problems). Even if we place no value on the physical and economic suffering of women who get C-sectioned or women and infants who suffer other complications in the hospital, this kind of cost is not an economical use of resources. There are any number of well-proven public health interventions that can save children’s lives for a minuscule fraction of $15 million apiece.

    I surely am not saying that low-risk women should be discouraged from having hospital births because of that cost. Birthing centers with midwives, where legal, may be an ideal option for many, and if such are not available, it’s perfectly rational for women to choose hospitals as the safest option. However, the odds that this will save their baby’s life are about as high as the odds that one of those private cord-blood banking scams will do so – very low indeed. Women who don’t choose to engage in either of those practices are also making a rational decision.

  21. daedalus2u says:

    Death is not the only complication of home birth. It is the one that is easiest to document. In the absence of reliable information, when the death rate is higher, it is a reasonable assumption that rates of other complications are higher too.

    In doing a cost/benefit analysis, you need to look at the incremental cost, not the average cost. The average cost includes all the high risk births. The cost of low risk births would be a lot lower.

    You also need to include the cost of care for children injured at birth. Here is a case where a woman chose a homebirth against a doctor’s advice, her baby was brain damaged at birth and will require life-long care. The people who ran her homebirth didn’t have insurance, so the person being sued is the doctor who advised against the homebirth.

    http://homebirthdebate.blogspot.com/2008/01/23-million-lawsuit-alleging-doctor.html

    The lawsuit is for $13 million. That is just about the “savings” you project.

  22. apteryx says:

    Okay, I don’t have huge reserves of knowledge when it comes to childbirth, so I won’t try to keep up an end of this for long. However, the March of Dimes cost survey further breaks birth costs down into $7737 for vaginal delivery versus “about $11,000″ for C-sections. Given that low-risk women who give birth in hospitals will usually be subjected to immobilization, fetal monitoring, etc., and often induction of labor, let’s estimate that 20% will be sectioned; that would be $8390 per birth. Not much lower than the average $8800.

    Something like a third of all women who get sectioned will have complications, sometimes lasting – including an increased risk to future pregnancies. A full cost-benefit analysis would have to include all related costs and risks, as well as the cost of treating increased respiratory disorders in children delivered by C-section. It would also, to be blunt, have to count against hospital birth the money required for long-term treatment of a defective infant who, at home, might indeed have simply died.

    Again, we can’t assume without evidence that “other complications” as a general category are higher in home births. In the early to middle part of the 20th century, home birth in the U.S. had much lower death rates; one reason probably was the risk of nosocomial infection. The laboring woman’s home will not be infested with antibiotic-resistant pathogens, as is the modern hospital, and midwives seeing one patient at a time will not transfer bacteria from one patient to another. I would expect postpartum infections to be lower in home births.

  23. Amy TuteurMD says:

    apteryx:

    “The real message of the study is that not one home birth in the year 2000 resulted in a maternal death, and that the infant death rate, while somewhat higher than for hospital births, is in absolute terms very low. If the primary use of the study is to give women an estimate of the risks associated with home birth, it is essential to exclude babies born dead or with terminal birth defects: a hospital birth would not have saved those babies. That leaves a total of five potentially avoidable infant deaths among 5132 white women having home births in 2000.”

    No, that’s not the real message of the study.

    First, maternal mortality is measured per 100,000. We would not expect to see any maternal deaths in a random sample of 5000 women whether they give birth at home or in the hospital, so the fact that there were no maternal deaths is meaningless.

    Second, the excess rate of preventable neonatal death is not insignificant. The Johnson and Daviss study showed that homebirth in 2000 had a neonatal death rate approximately TRIPLE the death rate in the hospital in 2000. Of course, that’s not what the paper says; the authors left out the hospital neonatal death rate in 2000 because it made the homebirth neonatal death rate look unacceptably high, and instead tried to fool people by comparing the neonatal death rate at homebirth in 2000 to the hospital neonatal death rate extending as far back as 1969. They have successfully fooled a lot of people with this trick.

    Third, Johnson and Daviss arbitrarily categorize live births as stillbirths. The US definition of live birth (which is the WHO definition) is that any baby who shows any sign of life, even one pulsation of the umbilical cord, is a live birth. At least one of the babies categorized by Johnson and Daviss as a “stillbirth” had an initial Apgar score of 1. That was clearly a live birth, and yet they chose to remove it.

    Fourth, you can remove babies with congenital anomalies (even those incompatible with life) from the homebirth group ONLY if you remove them from the hospital birth group. The neonatal death for rate low risk women in the hospital in 2000 was 0.9/1000 INCLUDING congenital anomalies.

    Fifth, Johnson and Daviss are not independent researchers. Johnson is the former Director of Research for the Midwives Alliance of North America (MANA); Daviss, his wife, is a homebirth midwife. The study was commissioned by MANA, data was collected by MANA, and the study was funded by money from a homebirth advocacy foundation. So two long time passionate advocates of homebirth undertook a study of homebirth at the behest of the homebirth trade union, using money from a homebirth foundation AND managed to obscure the fact that their study ACTUALLY showed homebirth to have a neonatal death rate almost TRIPLE that of hospital birth for low risk women.

    Finally, MANA has continued to collect detailed statistics (just like the ones they collected for Johnson and Daviss) from 2001 to the present. They have made a public offer of that data to midwives who can prove that they will use the data for the “advancement of midwifery”. Even so, anyone applying for access to the data must sign a legal confidentiality agreement promising not to disclose the data to anyone else. It does not take a rocket scientist to suspect that the data almost certainly confirms that homebirth has an increased risk of neonatal death, and that they don’t want women to know the truth.

  24. daedalus2u says:

    Interesting economic argument in favor of ineffective “treatment”. Individuals who die quickly with ineffectve treatment don’t require long term care.

    In the early part of the 20th century antibiotic resistance was not a factor because there were no antibiotics. Either patients recovered without antibiotics or they died.

    I think your idea that the death rate for home births was “much lower” 50 or more years ago is completely mistaken. I would like to see a citation of that.

  25. BlazingDragon says:

    There appear to be two forces at war here: Women who want to have a “normal as possible” delivery and unscrupulous doctors/hospitals/etc. wanting birthing mothers to spend as much money as possible (knowing that parents will spend whatever they are told is necessary to get a healthy baby).

    Focusing on the evidence for or against home birth ignores the profit motive that probably drives most of this issue in the real world.

    For the record, I think having an overly medicalized birth is an expensive pain in the ass, but a person who gives birth outside of a hospital (by choice) is an idiot. Being even a few minutes away from a blood transfusion (assuming an incredibly fast ambulance ride and instant diagnosis and treatment in an ER) could be life threatening to mother, child, or both, just to pick a single example.

    If all of the “medicalized” birth options were put in context of which ones make huge profits for hospitals and which ones don’t, the reason a technique is used or not used would be a clearer. This is not to say that making profit is “bad” or that a technique that makes a big profit for a hospital is “bad” just because of the profit. It would add necessary context to this discussion.

    The business of childbirth vs. what is necessary to have a safe delivery and a healthy child and mother probably don’t agree much, especially in this day and age when greedy, unscrupulous people have been allowed to infect every level of society. Of course, these greedheads are less of a percentage of the population among doctors and hospital staff than they are among CAM practitioners. Doctors and hospitals should do more to make sure procedures aren’t performed “just in case,” when “just in case” also makes a tidy profit for the person recommending the procedure “just in case.”

  26. mufi says:

    BlazingDragon wrote:

    “For the record, I think having an overly medicalized birth is an expensive pain in the ass, but a person who gives birth outside of a hospital (by choice) is an idiot.”

    Funny, I don’t feel like an idiot — at least no moreso than I do for having flown in an airplane (another statistically unlikely cause of death — but a real risk, nonetheless).

    This thread has gotten longer but is not much heavier in statistical facts than when it started. (I read something earlier about a flawed study — flawed, apparently, except for when it suggests something damning about homebirths.)

    In any case, I’m willing to accept that my wife and I “played the odds and won” (as Harriett put it). Given the nightmare we experienced around our hospital birth, the prospect of another one did indeed seem a bit like throwing good money after bad.

    mufi

  27. flygrrl says:

    Thank you for a really well-balanced and sensitive post on this topic. There is so much rhetoric on both sides, so it is great to see someone looking at why women are turning to the homebirth movement and allowing that standard obstetrics bears some of the blame for women’s attitudes towards homebirth. I just hope people can move past the strong emotions involved and truly weigh the evidence on both sides on its own merit.

  28. BlazingDragon says:

    mufi, you did “play the odds” and got lucky.

    I’ve had more trouble from physicians in 15 years than most people will have in a lifetime, mostly because I’m a medical oddball and doctors refuse to treat me as such, instead, they try to pigeon-hole me and when I still have symptoms, it’s “psychosomatic and your own damned fault.” I’ve got more reason to hate doctors and hate the modern medical profession than most people here, I’d wager. But even after all that, I wouldn’t rely on prayer, homeopathy, or any other “woo” or anecdotal crap when it comes to medicine. My frustration comes from not being able to be treated by medical professionals. I hate sitting, feeling alone, with life-altering symptoms and being ignored by modern medicine. But I’d still never substitute proper medical care and bet my life on herbals, homeopathy, acupuncture, etc.

    Just because you got lucky doesn’t mean anyone else should do it. One other addendum… if one has to look at the profit motive for “medicalized birth,” one should damned well also look at the profit motive for home-birth advocates. Anyone loudly trumpeting home birth should have their conflicts of interest probed with a microscope. I think we’d find that a lot of these home-birth advocates aren’t nearly as “pure” as they seem (just as many doctors turn up to have a financial interest in something they trumpet loudly).

  29. mufi says:

    BlazingDragon wrote:

    ‘mufi, you did “play the odds” and got lucky.’

    Hmm. I always thought it was luck when you play *against* the odds and win. In which case, I wasn’t so lucky at all (especially when you factor in the hospital nightmare that motivated us to seek a homebirth for our last child).

    Here we have a case where there’s no compelling statistical evidence to suggest a *probable* tragic result — only a *possible* one (again, like the risk associated with boarding an airplane). That’s probably why Harriett’s article and the comments on it are full of anecdotes — they simply lack a strong scientific basis for their critique of homebirths, despite the title of this blog.

    I’m sorry about your ailment, but I don’t accept that as an excuse to paint everyone who undergoes a homebirth with the same brush, much less to liken all of them to alt-med enthusiasts — some are, but others (like myself) are definitely not.

    mufi

  30. wbtittle says:

    I just finished paying off $14,000 for the natural birth of my second child. No meds. No extras, but because the baby came out so quick they wouldn’t let us go home for 48 hours. Life goes one.

    I was happy however that both of my children were born in the hospital. My first child’s heartbeat almost stopped during delivery. We knew this because of the monitor. As a result, the baby came out just fine. Had we not had the monitor, things could have gone very badly.

    The second child came out without much difficulty, but he was 10.5 lbs. The nurse made sure that the doctors checking up on the child the next day paid attention to his shoulder because he didn’t come out easily.

    Everything went fine, but I could see many places that disaster might have happened with a perfectly straight forward birth.

    I was not happy with the bill, but I didn’t argue too much about the service that was provided.

  31. CommonCents says:

    The problem is that these statistics don’t take into account the obvious socio-economic factors. People who have at-home mid-wife delivery are more likely to be financially stable, married couples who had planned pregnancies, who have a highly likelihood of having a normal delivery whether in a hospital or not.

    Hospitals have to deliver babies from anyone who walks in their doors. Their infant morality rates includes that of drug addicts, prostitutes, teen pregnancies, smokers, poor eaters, alcoholics, the impoverished (who had no prenatal care), and immigrants.

    Most home-births are from women who wanted to get pregnant and did everything possible leading up to their pregnancies to have a healthy delivery. It’s truly comparing apples to oranges.

    My personal opinion: Having a home birth means you’re a bad parent. Even though the complications are rare in both environments, I’d role the dice with a heart monitor and blood transfusion capabilities over a somebody telling my wife to use the indigenious hands and knees method anyday.

  32. drdr says:

    As far as I can tell, the central thesis of “The Business of Giving Birth” is not that home births are better than hospital births, or even that midwives are better than OBs. The central thesis is that a vaginal birth is better for the mother, the infant and the healthcare system than a C-section, and that the best way of increasing one’s chances of delivering vaginally is to have a home birth.

    The focus of these comments should not be whether home births are more or less safe than hospital births. The focus should be on figuring out why the US has the highest C-section rate in the industrialized world, and why it has increased so much in the last decades.

  33. weing says:

    John Edwards?

  34. Thank you for giving a voice of reason to what sometimes seems like an entired disconnect from reality.

    Birthing babies is what I love most in the world. The fact that I now have women ask me –is it really bad for me to have my baby in a hospital? –breaks my heart and has forced me to come out swinging. Enough is enough. I can no longer sit back and listen to this dialogue about homebirth come up again and again without inserting some badly needed facts and a serious reality check.

    The argument is always the same by homebirth advocates. Hospitals are loud, hectic, bright, insensitive, uncaring machines full of greedy doctors and overworked – medical personnel – (I am pretty sure as a nurse, that means me) who are just waiting to hook women up to unnecessary medications and prevent them from -trusting their bodies.

    The argument goes on to state that homebirth is safer, more satisfying, more loving, more empowering, less interventive, healthier for the baby, more spiritual and on and on. Anyway you shake it that very implicitly pronounces that to give birth at home is… – better -. Period. But always, at the end of any article, blog or comment about it by it’s proponents, are the words – but a woman should be encouraged to give birth wherever she feels most comfortable, including a hospital.

    Wait a minute. Is that what you just said? Let’s assume I am having my first baby. I am very excited and I want to learn everything I can, and of course, I want to do what is best for my baby and myself. Do I choose to have the -scary, cold hospital birth – that I was told about or the – loving, empowering, spiritually-fulfilling homebirth? I am very likely to make the choice to give birth in either a birth center or a hospital but wow – what a set-up for feeling badly about my choice.

    Let’s look at some actual facts about birth in the United States:

    Over 4 million women give birth each year

    97% of women give birth in a hospital

    2 million women live below the poverty line and have limited access to adequate maternity care

    100 years ago, a woman had a significantly high chance of dying during childbirth . Medical advances, including the use of antibiotics, oxytocin to induce labor, safe blood transfusions and better management of hypertensive conditions during pregnancy, are directly responsible for the decline in maternal death rate.

    Today, around the world, every 60 seconds, a woman dies during pregnancy or childbirth, often from an avoidable cause. There are no well-documented, large-scale studies that show that homebirth is either safer or more satisfying than hospital birth. We have -far from perfect – health–care in this country when it comes to taking care of moms and babies. However, there is truly a disconnect with what is really important here. Perhaps those who exert so much energy on faulting the U.S. maternal/health care system could spend even ¼ of their time working to provide better access to care for the 2 million underprivileged women here who really need it.

    I have shared in the births of several thousand women at homes, in birth centers and in hospitals. I have seen miracles, tragedies, difficulties and wonder in all of those places. What angers me so deeply is the direct insinuation that giving birth in a hospital denies a woman a safe, positive and life-affirming birth experience. What kind of support is that? A woman deserves to feel nurtured by other woman, not faulted, questioned or criticized. There is no -better or best -way to give birth and I am no longer going to be quiet about it.

  35. terren says:

    I’m the father of a daughter born at home and we have another one coming very soon. I consider myself to be more rational than the average bear. I carefully researched home birth and came to the conclusion that we were safer at home, all factors considered. I am no ideologue.

    Choosing where to birth requires investigating safety/risk, cost, and one’s personal preferences. It’s difficult to prescribe a one-size-fits-all mentality to birth because these decisions involve huge variances among the most rational of people.

    However you want to spin the studies, those that have shown home birth to be unsafe compared to hospital birth have also been shown to be flawed (e.g. using birth certificate data that doesn’t distinguish planned from unplanned home births). Most studies show that rates of mortality and morbidity are comparable between planned home birth and hospital births. Surely, if home birth attended by midwives was *much less safe* than hospital birth, then infact/maternal mortality rates would be significantly higher in countries such as the Netherlands where a third of births take place at home.

    On the other hand, where we live, in New Jersey, hospital C-section rates are over 40%. Anecdotally, virtually all of our friends and neighbors have been sectioned (in fact, all but 2 out of about 20). It is scary, and indeed all of the stories bear the similarities depicted in the movie: one intervention begets another, until the baby’s in distress and a section becomes urgent.

    Insurance in NJ is so out of control that there are no birthing centers anymore… all have been forced out of business. It is no surprise then that doctors in NJ are quicker to go to the surgery where they will stand a much better chance in court against malpractice claims.

    My wife and I entered into the idea of home birth with a realistic sense of risk and with a strong sense of the importance of connecting naturally with the body and all that entails. Our first birth only validated that we made, for us, the right decision.

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