Homebirth: A “Narcissistic” Choice?

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homebirthI came across this interesting discussion on Facebook the other day (be warned, it’s long so make sure you have time to read it all if interested, which I believe many of you will be).  What struck me most about it was the idea that, for some, to birth at home is a “narcissistic” choice.  (I take issue with the term itself as I don’t believe the choice is made with a grandiose sense of self, I believe people mean “selfish”. I still disagree with that assessment, but at least would make some logical sense.  However, the words are chosen by others so I stick with them.)

Now, I’ve written at length about the problems with many of the studies that have condemned homebirth, but I have also written that in the USA, the failure to have an integrated system puts women and babies at higher risk than necessary.  Oddly, anti-homebirth advocates seem bent on making sure that we see the problem as being inherent in homebirth instead of with the system in which it resides.  This is odd because even the ACOG has had to admit that integration is an issue when considering the safety of homebirth:

Another factor influencing the safety of planned home birth is the availability of safe and timely intrapartum transfer of the laboring patient. The relatively low perinatal and newborn mortality rates reported for planned home births from Ontario, British Columbia, and the Netherlands were from highly integrated health care systems with established criteria and provisions for emergency intrapartum transport (12–14).[1]

The one thing everyone seems to agree on is the relatively low risk of any complication or death, regardless of location, or as ACOG puts it, “the absolute risk may be low”[1].  [As an aside, I personally would love to see stats on the cause of death instead of planned location.  Although planned is better than final location (as most problems will end up in the hospital), I have read reports where a “planned homebirth death” was something that happened after the mother had transferred to the hospital or due to negligence from hospital staff[2].  But that’s a topic for another day.]

The interesting part is that many anti-homebirth activists who shout about “narcissistic” choices when it comes to homebirth are quick to jump on any mother who speaks about potential problems with putting babies in separate rooms to sleep or the overuse of formula in our society.  These are “valid” choices and any suggestion otherwise is a manifestation of the “mommy wars”.

One has to ask: Do numbers support this view?

Homebirth

Based on the most recent meta-analysis in the US looking at midwives only in homebirth, the highest death rate was for other midwives at home (i.e., non-certified midwives) with a death rate of 1.8 per 1000 live births[3].  Now, this was the rate though the mothers in this group had higher risk factors than those of the hospital groups (i.e., one could not say they were a “low-risk” group).  With a certified midwife, the death rate was 1.0 per 1000 live births.  Given that at the moment, 25% of homebirths are with a certified midwife, we can extrapolate a death rate of 1.6 per 1000 live births for homebirth in the US if all individuals gave birth at home (it obviously wouldn’t be this exactly because of myriad factors, but we’ll stick with it as it’s the closest we can get).  Now, the anti-homebirth advocates argue for hospitals being safest and the best estimate we can get for low-risk births is 0.8 per 1000 live births in a hospital (and it’s from a study they love to cite despite its many flaws so they shouldn’t complain about it)[4].

So, either a 2x increase or 1.6 deaths per 1000 live births is our “narcissistic” choice baseline.  Anything close to or above this should therefore be considered a “narcissistic” choice, right?  After all, if the shoe fits…

Formula Feeding

Let’s first look at formula use.  Now, before I begin this, I must add the following caveat: I have no problems with parents using formula.  I have problems with the degree it is pushed and promoted in our society.  I have problems with the fact that many women don’t have access to the support they need to breastfeed (if it’s what they want).  I have problems with formula companies making billions off women and advertising a product that should be a final resort.  I have problems with the fact that we don’t have better alternatives (e.g., milk banks or peer sharing) for women who can’t or don’t want to breastfeed.  Those are my problems.  If you have used formula for any number of reasons, I have no problem with you as a person or your choices.  However, I will retain my right to have a problem with a society which engages in the aforementioned practices.

Now… is the choice to use formula associated with any increased risk of death for a baby?  If so, what is this risk?  There are two main areas of death here: infections or disease and SIDS/SUID.  In a study looking at the cost of “suboptimal” breastfeeding rates in the USA, based on current rates (which are not 0 so this will be an underestimate), it was found that raising the breastfeeding rates to 90% of women complying with the WHO recommendations of 6 months or more breastfeeding exclusively (from 12.3% based on the 2005 data[5] used for the modeling, but also included the rates of 74.1% for any breastfeeding and 42.9% for any at six months which would have some effects), 911 deaths would be prevented[6].  This is an underestimate as it includes all data, not a sole breastfeeding to formula comparison, but is a rate of 0.23 deaths per 1000 live births.  However, based on the numbers for any disease risk, the risk ratio of exclusive breastfeeding compared to exclusive formula is 2, or a 2x risk of contracting a disease, even if it does not lead to death.

Let’s turn to SIDS data.  Remember that, like birth, the absolute risk is very low for any SIDS event (now terms SUID to include other means of death), with a total death rate of approximately 0.6 to 1 death per 1000 live births.  However, when a parent chooses to use formula, what risk are they placing on their infant?  Based on the most recent large meta-analysis looking at breastfeeding and SIDS[7], the risk ratio for exclusive formula use compared to exclusive breastfeeding of any duration (this is someone disingenuous as many of the studies looked at exclusive at 2 months or 3 months or 6 months, not 1 week or 2 weeks, so there is some limit to this) is 3.7.  That is, there is a 3.7x risk of your baby dying from SIDS when you choose formula.  [Notably, many families choose formula after attempting breastfeeding and their rates would be lower than this, though still higher than those who exclusively breastfeed.]

Between the SIDS deaths and disease rates, we have a 3.7x increase of death for one of the leading causes of death for infants and a 2x increase of contracting various diseases, many of which lead to death. When compared to the risk for homebirth in the USA, if one wants to call having a homebirth “narcissistic”, one must also call using formula “narcissistic”.  (Or, like me, you could call neither “narcissistic”.)

Sleeping Arrangements

In today’s modern, Western world, when you find out you’re pregnant, people start planning “the nursery”.  From the time a baby is born, many of them start out in their own room.  This is very common.  On the flipside we have co-sleeping, which includes both room-sharing (i.e., the baby in his/her own sleep space but in the parent’s room) and bedsharing (i.e., the baby in the parental bed).  A lot has been written on the “dangers” of bedsharing and there is some validity to it that I want to address here.

Bedsharing is as old as human life.  Anthropologically and biologically speaking, it is the norm for almost all animals who care for their young (and I say “almost all” only because I don’t actually know how all animals sleep, but I also don’t can’t come up with a species who cares for their young and sleeps separate).  However, in our modern world with our big, soft beds and fluffy pillows and big duvets, it can be incredibly dangerous for a young baby who cannot move.  As such, it is paramount that if anyone chooses to bedshare, they are given information on how to do it safely.  From a population study in Alaska, it was found that 99% of bedsharing deaths included at least one risk factor[8]This should tell us that many of the bedsharing deaths are completely avoidable if we teach people how to do it safely.  (Interestingly, this is the same argument many homebirth advocates make: It can be unsafe and it can be safe, we need to focus on making the changes to make homebirth as safe as it is in other countries.)

Some may come out here and say it’s impossible, basing their opinion on a recent highly-publicized meta-analysis by Dr. Carpenter and colleagues[9].  This analysis was full of immense flaws – including a massive amount of non-random missing data, failure to include key variables known to influence the risk of SIDS (e.g., togs value of bedding), the incorrect use of the baseline group as being only females, the failure to disentangle intentional versus unintentional bedsharing and more.  I took part in a rebuttal which you can read here (prior to having access to all statistics so our rebuttal was based on other factors) and there are myriad responses that deal with the plethora of flaws in the article itself (including statistical) which you can read on BMJ Open here.  A full analysis of the bedsharing and SIDS discussion can be read here.

What is consistent is that we see a risk of SIDS when infants are placed in their own room (something Carpenter et al. do not address).  The question at hand has to now become: How much of a risk?  Is it enough to warrant calling the choice to have a nursery and place infants in that nursery a “narcissistic” choice?  The numbers vary, but generally we’re looking at around a 2x[10] to 3x[11] increased risk of death from placing your baby in another room.  When other factors are controlled for, this can raise to as high as 10x the risk[10].

Conclusion?  If a 2x increased risk of death (regardless of reason) for homebirth in the USA makes the choice to birth at home “narcissistic” then the same has to be said for families who choose to put their babies in a separate room.  Or again, we could just not call any of them narcissistic.

***

Although some people may point out that in addition to these numbers, homebirth makes up a very small percentage of births (less than 1%) in the USA and thus the other practices, which are far more widespread, deserve more attention.  If we’re talking about reducing infant deaths, then yes.  However, if someone truly wants to call a behaviour selfish or “narcissistic”, it doesn’t matter how many people partake it in if the risk is high enough.  Just because it’s unbelievably rare for people to take babies on roller-coasters, it wouldn’t stop it from being risky or dangerous just because it’s rare.  That said, if someone is only focusing on one behaviour and not others that have equal or higher risk, then they start to lose credibility.

But all of this ignores what I personally believe to be the key point that I hope has been made clear: Homebirth is not inherently unsafe as evidenced by studies looking at the safety in countries like Canada and the Netherlands[12][13][14].  If there are ways to minimize the risks while respecting a woman’s right to birth where she feels comfortable, surrounded by people she trusts, why are we not focusing on that?  It seems that it’s not homebirth that’s increasing the risks for women and babies but rather a system that refuses to change to make birth as safe as possible.  If you really care about babies, why not focus on that?

 [Image Credit: Baby Dickey]



[2] de Jonge A, Mesman JAJM, Mannien J, Zwart JJ, van Dillen J, van Roosmalen J.  Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study.  BMJ 2013; 346: f3263, doi:10.1136/bmj.f3263.

[3] Ehiri et al. Outcomes of home vs hospital births by attended by midwives: a systematic review and meta-analysis.  Prepared for the Arizona Department of Health Services 2013.

[4] Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J.  Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.  AJOG 2010; 243: e1-e8.

[6] Bartick M, Reinhold A.  The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis.  Pediatrics 2010; 125: e1048-e1056.

[7] Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM.  Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.  Pediatrics 2011; 128: doi:10.1542/peds.2010-3000.

[8] Blabey, M.H., & Gessner, B.D. Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska. Public Health Reports 2009; 124: 527 -534.

[9] Carpenter, R., McGarvey, C., Mitchell, E.A., Tappin, D.M., Vennemann, M.M., Smuk, M., Carpenter, J.R. Bedsharing when parents do not smoke: Is there a risk of SIDS? An individual level analysis of five major case-control studies. British Medical Journal Open 2013;3:e002299. doi:10.1136/bmjopen-2012-002299

[10] Blair PS, Fleming PJ, Smith IJ, Platt MW, Young J, et al.  Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome.  BMJ 1999; 319: 1457-62.

[11] Hunt CE, Hauck FR.  Sudden infant death syndrome.  CMAJ 2006; 174: 1861-69.

[12] Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995;40:483–92.

[13] Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol 1998;92:461–70.

[14] Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416.

 

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Comments

  1. says

    One thing I have a problem with homebirth is that the risk is actually much higher than stated here. The problem is that most states are not keeping track. Oregon is one exception, those stats were released and highly discussed but you don’t mention them here. I was a planned OR state homebirth and I was shocked at the real numbers when you have midwives report deaths and don’t try to grab data from the CDC (which has its own problems).

    In Oregon, for the year they collected stats, there were zero hospital births of full term babies. For planned homebirths (whether they transferred or not) there were 7 deaths of full term babies. We are comparing almost 40,000 hospital births, of all types of risk — this includes women who would never be a good candidate for homebirth. The homebirth group had just over 3,000 births and should have been all low risk.

    This is the state were I planned my homebirth and the idea of SEVEN babies dying, when clearly as low risk births, they should have never had die, makes me sick. Yet that number is completely ignored in your article in favor of the best possible statistic you could find. In the report, given by a midwife, to the state, she says that planned homebirth with a DEM midwife had a 6-8x increase in death.

    https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

    In fact, you cite Canada and the Netherlands. Both countries don’t use CPM midwives and they only use CNM midwives, who are trained nurses plus midwifery training (unlike the US where you just need a HS degree and in some states you don’t even have to be licensed). They are also integrated into the health care system.

    Here’s the problem: We don’t even track homebirths. We don’t know how bad it is. The only real data we have is Oregon. And it’s really bad. I can understand a few years ago relying on other data because the absence of US data sets, but there’s no excuse now. The oregon stats should be included in ANY discussion about homebirth safety from this point forward, to do otherwise is to blatantly obscure the truth.

    Second issue, as someone who breastfed my child until he was over three years old, and tandem breastfed with my second is that you go to great lengths to say you don’t have a problem with formula yet, “a product that should be a final resort”. A final resort? Why? Because of two studies you state show that it will KILL YOUR BABY. Well the first study is just showing a hypothetical cost savings if almost all women breastfed based on current infant deaths. The second study says right in the summary: “Benefits of breastfeeding include lower risk of postneonatal mortality. However, it is unclear whether breastfeeding specifically lowers sudden infant death syndrome (SIDS) risk, because study results have been conflicting.”

    Yet you leave that out. It’s weird because you don’t even link to those studies, even though they are on the web.

    I also cosleep, I know the risks, which are real.

    I am not against taking on risk and giving women the option to make their own choices. You talked about three areas, homebirth, breastfeeding and cosleeping. You underestimated the risk in homebirth, you overstated the benefit of breastfeeding and you try to imply that putting the baby in the other room is somehow equally or more risky than cosleeping.

    What is more narcissistic than manipulating data to make YOUR choices seem superior, when the data and reality do not mirror that?

    • says

      First, I can only take the meta-analyses as given. If they don’t include all US data then that is a flaw, but one that is a limitation; however, the meta-analysis is often superior to any given study.

      Second, the argument still stands: Work on the SYSTEM instead of condemning homebirth. I am lucky to live in Canada where we have a wonderful, integrated system where the risk of having a homebirth is nothing over a hospital birth (and confers benefits with respect to morbidity). Are you suggesting such a system would be *impossible* in the USA?

      Third, the summary part you speak of was part of the *justification* for the meta-analysis, not the results of this particular study. They did the meta-analysis in order to ascertain what the real effect was when studies have conflicting results. The results I share are that of the amalgamation of all of these studies – including those that were well-done and included null effects (which can happen by chance when you have a true effect).

      Fourth, the comparison to cosleeping was to room-sharing. I discussed bedsharing as well because it’s an area that is often discussed with respect to sleep risk but not separate room sharing.

      Frankly, I don’t think ANY of the choices are narcissistic, but rather ones families make for various reasons. I make no bones about my stance on formula though – yes, from a population-level, breastfeeding absolutely should be considered the norm, with donor milk second, and formula third. At an individual level, things are different (I’ve spoken of this issue here: http://evolutionaryparenting.com/thoughts-on-sleep-training-promotion-and-parents/) and I understand that, but when we’re speaking to masses, we have to think population-level.

    • says

      One more thing – Canada has CPM midwives and in fact most are CPMs. In fact, in BC that’s more common. None of the midwives at my clinic were CNMs. They were trained in midwifery but the nurse-practitioner is very different. I believe in the UK most are CNMs, but I may be wrong on that front.

  2. says

    I participated heavily in that discussion and while I don’t have time to participate in another epic discussion here, I just want to clarify why the problem was alleged to be inherent in home birth.

    The problem was transfer time. Do the studies from the (only two… that I see mentioned in the ACOG’s statement) other nations include studies of long-term mild brain damage? My understanding is that they do not. My father, as a pediatrician, has seen children come in from the local birthing center which is “highly integrated” with the local hospital but not actually attached, with brain damage that he suspects at birth *based on how the birth went* but that is only “really” discovered later in childhood. He hasn’t seen a home birth transfer death… or a transfer death from that birthing center… because usually death isn’t usually the issue.

    If you could show me otherwise, I’d certainly change my opinion. But the other thing is that you’re presenting Amy with a false choice: “Why not advocate for better integration, instead of warning people about the dangers of home birth?” I’m all for both, but that doesn’t mean that Amy has to do both, or choose the first option – *especially* where warning people about the current situation in the U.S. is a much more urgent concern. Plus, it really isn’t clear that they type of “integration” in the (again… just two…out of how many other nations??) other nationalized health care nations is a *realistic* possibility for the U.S., in any way that would render Dr. Amy’s warnings moot. Seems more like a pipe dream to me. The liability situation here alone would be a major hurdle – most health. My understanding is that malpractice liability carriers generally prohibit OBs from involvement with home birth.

    • says

      The Canadians one consider all morbidity and mortality. Your father may suspect brain damage, but I would be very cautious in suggesting that birth was the cause. Suspicious are just that without any data to back them up. I’ve never heard any ped or doctor here worry about that. As for transfer time, I was informed by our hospital (in integration we get a lot of information pre-birth to help us make our decision) that there’s a certain period of time in which they have to prep too for any emergency. Often it was about 5-10 minutes to get everything ready, thus if we lived within 5-10 minutes of the hospital and called ahead, it would be like we were there. Now, often the transfer time is considered to be 20-30 minutes here because our midwives are wonderful at detecting things early and transferring when necessary.

      As for the other countries, many others have integrated systems, what they don’t have (and why it isn’t cited in ACOG or here) are LARGE-scale studies looking at outcomes. Only Canada and the Netherlands have done them (technically there’s no large-scale study in the US, just smaller ones).

      Whether you decide if integration is realistic for the US or not, the issue itself isn’t with homebirth. And if you want to change things, the approach taken by Dr. Amy and others of bashing women who have made a choice they deemed best for them and their families certainly isn’t going to win people over. But I don’t know that that’s actually the goal is it?

      • says

        Well, in our birthing prep course which was put on by the hospital in conjunction with a local maternity center, I recall them saying that if a true emergency arose they could have the child safely out by a c-section in under 3 minutes. I don’t know if that’s true of all hospitals; this was MGH which is one of the top hospitals in the nation.

        The cases my dad was talking about, the child lost time without oxygen in transfer. I don’t see how that danger would ever not be present. It’s additional time that would never go away.

        In the thread, Dr. Amy said her reason for “bashing” was to attract attention. Personally, I first became aware of this issue via her “HurtByHomeBirth” blog where women recount their stories… I think the horror (and astounding incompetence) in those stories attracts the most attention. But apart from that, it’s true that fire attracts attention. It’s probably what has us all talking about it right now, really. It could also be a cultural thing, honestly. I’m from the Midwest and I now live in Boston, which is I believe where she lives and is from. They don’t hold any punches here. I don’t know… my interest isn’t in Amy’s bashing, the reason I care about this is because I listened to a lot of false information from mommy list serves that my husband was, thankfully, able to debunk for me. And I hate to think that someone would read that home birth is safe and then go have one of the experiences on HurtByHomebirth. And that is exactly what happens.

        • says

          We were told that once in the ER, it was about 3 minutes – but with prep time for ER and moving even within the hospital, it was closer to 5-10 (depending on a host of other factors). But yes, I would imagine there is also huge cultural variability. The timing also ignores the question of how much do the interventions that are overused in hospitals lead to the emergencies that they end up fixing? And the numbers of deaths relative to time – are hospitals keeping babies alive for 1 week, 2 weeks, etc. but losing them after? Or sending them home severely ill or brain-damaged? These are all questions that we NEED more answers to.

          So wait – was your dad talking about 1 case? If so, that’s a little weak, sorry. But didn’t the transfering ambulance have oxygen? Our midwives here come to your house with life-saving and resuscitation equipment. They are all trained in that as well so they would be doing what would be done in a hospital room before surgical transfer.

          I agree bashing can attract attention. I have many friends from Boston and even they agree there’s a distinction between pulling no punches and bashing. Being open and honest is one thing, attacking another person is often a sign that you don’t have the capacity to tackle the more cogent arguments. As for the stories – I could send you to other places where people have recounted horror stories of being in the hospital (and have heard women say exactly the same thing you have, just replace “home birth” with “hospital birth”). It’s why anecdotes should never be used.

          I can respect that your opinion is that homebirth isn’t for you and that you want to make sure everyone is safe. I think the latter is paramount. The question becomes, at what point do we take away women’s rights based on fears of safety (though honestly, it will vary region to region but overall meta-analyses show it’s a double risk, but of a small baseline)? And at what point do we not get angry at the system and fight to allow women to have rightful choices while making sure it’s as safe as it can be? We also then have to weigh the risk of higher morbidity that is associated with hospital births (at least here in Canada) and the costs associated with that. Morbidity is at a higher rate than mortality and these are numbers that also must be considered.

          • says

            Well, I didn’t specifically ask what he’d seen over the course of his (35-year) career. He was warning a friend of mine who was moving to the area not to birth there and it was a “I have a brand new patient right now who…” kind of a thing. But for me, once over the course of his career would be enough, if it’s true that transfer time contributed in any way to brain damage. Because transfer time could just simply be removed, so to commit to a method that included it isn’t thinkable to me. And maybe it IS to others, but if that’s true then they should acknowledge the risk rather than presenting it as equally safe.

            I also do feel really passionately about doctors being competent. And I know (first hand, unfortunately, but not with an obstetrical issue) that that’s not always the case. But it seems like the way it’s portrayed in most social media, at least in my crunchy area, OBs are to be feared because they want you to have a c-section for money. My OB actually strongly discouraged my request with #2 to be induced at 39 weeks. I was terrified of having another baby as big as my first (he was 9 lbs 10 oz but the real problem was his 99th/100th percentile head). I then read that the ACOG’s position is that induction on suspicion of macrosomia is not recommended because it turns out a wash with c-section rates because we’re so bad at predicting it.

            My main beef is that there is a lot of unfounded fear about hospital birthing. There are real reasons the US has a high c-section rate, like our low use of forceps/vacuums and our obesity rates that lead to bigger babies (a macrosomic baby doubles your chance of a c-section). But if you listen to NCB, you’ll hear falsehoods like (1) epidurals increase your chance for a c-section (2) Our c-section rate is high because OBs want more money; (3) the size of your baby doesn’t matter; (4) pitocin is the cause of all this autism; etc etc etc. And often it’s prefaced with “My midwife says X.” Honestly, the frequency I hear “My midwife says X” and X is some nonscientific anti-vaccination propaganda, I do shudder to imagine these midwifes, presumably CPNs, performing births.

          • says

            The “only once” doesn’t really hold water for me because if one thing happened in a hospital that would have been preventable at home, would you take the same stance? No. The transfer time issue seems to not be an issue in countries like Canada and the Netherlands so I would really want to understand more about why it is that way here and not in the US. What’s happening with transfers that they aren’t getting there on time? I agree women should know all the risks (and benefits) associated with home birth. Many I know do know these things. Many actually had such awful experiences in the hospital which has led them to choose a home birth.

            I would say looking at the data, there is evidence of some of the “falsehoods” you claim. The most recent review on epidurals has found a link with greater other interventions leading to higher c-section rates. There is early research that pitocin may play a role in some forms of ASDs. Clearly it’s an area where a great deal of research is needed to clear things up; however, when we look at the maternal and infant mortality rates compared to other Westernized nations, sometimes is clearly amiss in the USA. Even when we consider things like obesity rates.

            As an aside – my daughter too had a 99th percentile head (she was 8lbs 10ounces) but not a tear thanks to my wonderful midwives :) Slower than average pushing stage that the hospital wanted to “speed up” (when you transfer in Canada you have a doctor oversee everything though the midwife remains your primary care provider) and she had to fight him on it. There was no reason – no fetal distress and luckily the nurse (former midwife) was on my side for no reason to give me pitocin just based on the clock. And I flat out refused. But the size issue really is dependent on the woman’s body! Luckily I’ve never heard anyone say it flat-out didn’t matter at all. Just that often what’s considered “too big” isn’t always “too big”.

  3. says

    Sorry for typos, by the way, the comment form on this website doesn’t let me scroll down after my typing gets too long for the visible part of the box – had to type the bottom part “blind.”

  4. Lisa says

    But I have yet to hear of a *systemic* thing that happened in a hospital that is preventable at home. If I say “I chose to birth in a hospital to eliminate potential transfer time” what is the response? “I chose to birth at home to eliminate potential X that causes brain damage and death, that exists in *all* hospital births but never in any home birth?”

    Very interesting about your birth. My son was under distress… I had been laboring and pushing forever and he was maconium stained, came out with an Apgar of 2. I think that’s one reason I cannot imagine having birthed at home. I actually think I had a vaginal birth *because* I was in a hospital. I avoided an emergency c-section and that enabled my OB to deliver with forceps, which paved the way for my easy vaginal birth with #2.

    My good friend is an MD/PhD in anesthesia, MD out of Wash U and was invited to interview at Harvard for residency. He has no financial incentive because he’s going into research, not practice. He looked into the epidural issue for his wife, a pediatric nurse, when she was pregnant. What he told me is that there is no dispute that an epidural at 4 cm doesn’t increase the c-section rate. I even once had someone try to tell me the opposite and the study she showed me, which was from a Canadian “journal” with an impact factor of just 1, itself acknowledged no debate at 4 cm but argued that its very small sample size showed that an epidural very early in labor did increase it. I then asked my friend for what he looked at… I cannot figure out how to get his attachment from the email to something like this because it’s not a link. But this was his preface at least:

    Attached is an article with way more information than you probably wanted. It is from the “gold standard” for reviews done pooling many individual trials to increase the power and reliability of the conclusions. Many of the complication ( i.e. low blood pressure, inability to move legs, urine retention are very common side effects which are anticipated and easily treated.)

    My pregnant classmates in anesthesia are planning on getting epidurals for delivery what it is worth.

    The study shows no increase in C sections overall but that there is an increase for section done for fetal distress. The notion of distress is controversial because fetal monitoring increases section rates and has not been shown to improve outcomes presumably because it identifies false distress situations. I have heard OB go as far as to say it is contra indicated but no one says “don’t monitor my baby.”

    Hope all is well….

    • says

      Sounds like our births started off very similar. I laboured for a total of 83 hours – 75 at home before my midwife broke waters and there was meconium so we transferred (that’s one of the indications here). But I had vaginal birth, no tearing, and no distress for my baby. I actually credit my time at home with that ;)

      I have read the epidural research and I think timing is definitely an issue. One of the things I do hear regularly though (in journals) is the link with high fever and then neonatal problems. When there is no associated increased fever then no negative outcomes, but right now we have no way to know what causes a woman to develop a high temp in response to the epidural.

      One thing I would add about “systematic” problems would be the potential overuse of interventions in the hospital. That’s one concern many people have – and of course, it’s going to depend on the individual hospitals too.

      Must run though to deal with dinner :)

  5. Lisa says

    Okay, but what “interventions” exist in every hospital case that would never exist at a home birth? The transfer time is so cut and dry: It doesn’t exist in the hospital, it always exists at home. What kind of potentially lethal or brain damaging intervention is absolutely precluded by choosing to birth at home?

    Re: Epidural I guess I would need to know how strong the link with high fever is, how “high” the fever is, and what the “other” neonatal problems you allude to are. And whether studies controlled for the fact that epidurals are more likely to be used in more difficult labors (because people trying to avoid them cave). The one study someone tried to show me to prove that pitocin could cause autism specifically found that it is *not* likely that any obstetrical intervention, including piton, causes autism, but that autism is associated with more traumatic births… and older parents, among other things. It was very strange, almost as if she didn’t really read the study. Increasingly we are finding that autism is hereditary and related to the age of the parents. Older moms are more likely to have traumatic labors, including c-sections and other complications. Regardless, though, I am not making the point that a med-free childbirth confers no benefits whatsoever; I’m just making the point that epidurals do not increase your risk of a c-section. Giving women choice means nothing if we don’t give them accurate information right?

    I am curious what it was about being at home that you think caused something physical to change with your birth. I labored intensely for 15 hours at home before they admitted me to the hospital. It took forever for me to get to a 4, and for some reason my contractions were always 2.5 minutes apart, never 5, so the part at home was the hardest and frankly the scariest thing (because I had no idea why I wasn’t progressing… my mother never did progress and I was an emergency c-section after two days of labor at home – she was finally admitted dehydrated, nauseated, and severely sleep-deprived) I have ever been through. I have never in my life been so relieved as I was when they admitted me. And I got past a 9 with #2 before they got the epidural in and that pain was nothing compared to the 15 hours with #1.

    FTR, not sure if you put “systematic” in quotes to correct me but systemic and systematic both work in that sentence (wouldn’t overuse of interventions be systemic in hospitals rather than systematic, unless every hospital did everything the exact same way for all situations?). But I don’t proofread social media postings; to me that’s like bothering with proper grammar when you’re just chatting with a friend!

    Last I am curious what your opinion on CPMs performing home births is. It seems like if they got rid of that, home birth here would have a better name and be that much more similar to home birth in other nations. Are home birth advocates fighting to get rid of CPMs? I’m not being sarcastic here; I’m new to this issue (or newer, anyway) and curious. My understanding is that the training required is very minimal, and only a high school degree is required… ?

    • says

      As I said I don’t think it’s hospitals in every situation, just as a person who lives within 3/5/whatever minutes of the hospital doesn’t have the transfer issue. And apparently transfer isn’t an issue in Canada for relative rates of death or other problems, so what is happening in the US that makes it a problem? For me, the issue then is ease and quickness of transfer, not being at home or hospital. If you can quickly transfer and they will have everything ready for you, then transfer is a moot issue. When I had to transfer we drove to the hospital and it took us about 7 minutes and based on my hospital’s 5-10 minutes to get things ready in a clear emergency, I was okay with that. (Of course it wasn’t an emergency so we just went and spent the ages getting registered, etc.)

      Here’s some of the most recent research on epidurals and intrapartum fever: Greenwell, E.A., Wyshak, G., Ringer, S.A., Johnson, L.C., Rivkin, M.J., Lieberman, E., 2012. Intrapartum temperature elevation, epidural use, and adverse outcome in term infants. Pediatrics 129, e447-e545.

      I was at home with back labour – hence the prolonged labour and frankly, extremely painful labour. My daughter was sunny-side up and just refused to budge and because I was in so much pain, I couldn’t relax in between contractions so she couldn’t “fall” into place properly. I did have one round of water shots and it was great – I would have continued with those at home if there hadn’t been meconium. As to why I credit being at home? Knowing women that birthed in the same hospital I transferred to, I would not have been allowed to labour naturally for as long as I did at home without a massive fight and I most likely would have ended up with pitocin and probably a c-section (the staff on my labour said 9/10 it would have been a c-section). I was at home – in pain – but calm and doing what we could to help it along. I felt mentally comfortable and safe. And had I had pitocin when the doctor wanted it, my contractions would have been stronger and I doubt I’d have been able to slow down as I did at the end to attempt to reduce (and in my case, eliminate) tearing.

      Quotation marks – I used them to signal (oddly as I’m tired and not paying attention) to mean that I think overuse of interventions is a systematic problem in the US, but I also realize that it’s not. There are great hospitals that don’t have this problem. It was my way of saying I can’t think of a better word :) Sorry!!

      As for CPMs, it’s a US-centric debate. In Canada, most midwives are not CNMs but CPMs. We have CNMs but our process of certification will accept ANY midwife – nurse, from a degree program, lay, direct-entry – so long as they pass the certification process and then maintain their certification. So to me that’s the real issue. I don’t love the idea of only have CNMs quite honestly and I know of no group trying to look for just that. To me it’s the certification issue that’s key which is what my country believes and we have some damn good midwife stats to back it up :)

  6. says

    Well, for one thing, looking at NNH is actually a better way of thinking about risk than risk ratio. From the figures you gave, it does look as though home birth in the USA at this point in time is riskier than using formula (and that’s before you even start getting into the problems Christine pointed out above with the figures).

    However, that’s an aside, because I don’t think the ‘narcissistic’ comment about women choosing homebirth actually is about there being some magic cut-off between what’s considered acceptable or unacceptable in terms of risk level. I think it has a lot more to do with the reasons why many women choose home birth and the attitude they show towards it.

    Now, I absolutely do not want to make generalisations on this one, because they wouldn’t be correct. There are lots of women having homebirths because they’ve weighed up what they see as the pros and cons (often on a basis of misinformation, but that’s a whole other story) and honestly believe that home is going to be a better place than hospital for getting the baby out. (And sadly, as you say, for many women the background to this is a previous horrible hospital experience.) Although I would disagree with many of those decisions, I don’t think there’s anything in the least narcissistic about that.

    But… what we also see a LOT of is women who are actively seeking out the homebirth experience as an end in itself, as an experience that they want *for its own sake*. Women who want a homebirth even if they don’t actually think there’d be a problem with the particular hospital that’s the alternative for them, or who talk about how disappointed they’ll be if they don’t get one, or talk about how wonderful and empowering their experience was. Without wanting to be a party pooper here, and certainly without wanting in the least to have with a system where it’s considered perfectly acceptable for women to have a terrible experience and where they’re just expected to suck that up and accept it in the name of getting a baby… well, I do have to agree there seems to be an increasing trend of women focusing on the birth experience as a goal in itself rather than as being about getting a baby into the world without anyone actually getting hurt in the process.

    I simply don’t see an equivalent to that with formula or with sleeping arrangements. Sure, there are women choosing formula-feeding because they actively prefer it to breastfeeding or separate-room sleeping because they prefer it to roomsharing. I just don’t see women talking about how wonderful and empowering the formula-feeding experience is going to be and how disappointed they’ll be if they end up not getting the chance to formula-feed. Even when women prefer formula-feeding to breastfeeding, they’re still not dwelling on it as a goal in itself in the way many women do with homebirth.

    So, I think that’s where the ‘narcissistic’ accusation comes from.

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