By Tracy G. Cassels
I 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).
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”. [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. 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?
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. 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).
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…
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 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. 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, 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”.)
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. 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. 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 to 3x 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.
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. 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]
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