Part One of this post is here.
Birth is about more than perinatal death rates.
In the debate at Neonatal Doc's, Dr. Amy said over and over that homebirth increases perinatal death rates for babies born to low-risk women. I found her manipulations of the data unconvincing (do read the discussion yourself if you're interested -- these are some of the articles discussed), but just suppose she's right. Suppose you goose the numbers hard enough to rewrite an author's conclusions, or suppose you ignore the methodological flaws of the Pang study and take it at face value -- suppose you do that and you conclude that homebirth raises perinatal death rates by one- or two-tenths of one percent.
Does that mean no one should have a homebirth?
Erin posted on this question and I think it's worth addressing. Who decides how big a risk is acceptable for a pregnant woman? Would you say that obese women shouldn't attempt vaginal deliveries because they're at higher risk for shoulder dystocia? Where would you draw the line, personally, on delimiting another woman's birth choices?
Another philosophical question for those of you who find Dr. Amy's statistical maneuvers persuasive: is there some number of maternal morbidities that can be said to offset a fetal mortality? Obviously, if the choice is an intact perineum or a live baby, you can go right ahead and slice up my perineum. I'll hand you the scissors. But the number of women giving birth over an intact perineum at home is far higher (68.8% for women at The Farm) than the number who do so in the hospital (Alicia? maybe half that? a third?). A fourth-degree laceration isn't the worst thing in the world, but it's no picnic either. Ina May Gaskin reports a fourth-degree laceration rate of 0.1% among women giving birth at The Farm. How do hospital outcomes compare? How much does it matter?
This question quickly becomes less theoretical, with much higher stakes than comfortable sitting or sex. For instance: if we estimate that a low-risk woman planning a hospital birth faces a 20% chance of having a C-section while a low-risk woman planning a homebirth has a 5% risk of same, we can expect to see a corresponding increase in maternal morbidity and mortality for women planning hospital birth. The effects won't all be immediately apparent, either. Prior C-sections raise a mother's risk of stillbirth and abnormal placentation in future pregnancies, and in the long term the resulting abdominal adhesions can cause illness and occasionally death from bowel obstruction.
I deal regularly with another casualty of mainstream obstetrics: I can't tell you how many times I've spoken with crying mothers saying, "I wanted to breastfeed so badly but I just don't think it's going to work." Complicated birth is often followed by complicated breastfeeding, and complicated breastfeeding is often followed by premature weaning. (Kroeger & Smith lay it all out, with a great bibliography, for anyone who's interested in the details.)
If you took a thousand low-risk women planning a homebirth and a thousand low-risk women planning a hospital birth, all of whom described themselves as "highly motivated to breastfeed for a year," I would stake my IBCLC credential that breastfeeding rates would fall off more quickly among the women planning hospital births. Only some of the difference would be a result of birth interventions. Homebirth is empowering -- it's a wonderful feeling for a woman to see her body do something so amazing -- and the confidence can spill over into breastfeeding. Homebirthing women tend to find each other, either online or in real life, and they tend to seek out breastfeeding-friendly HCPs; readily available breastfeeding support from friends and doctors makes it much easier to sustain a nursing relationship. Regardless of how the reasons break down, babies born at home often get their mothers' milk for longer than babies born in a hospital. And that's an important consideration for anyone interested in public health.
Premature weaning exacts an immediate toll, both in healthcare costs (measured in billions per year) and in children's well-being [a huge but fascinating download]. It has a long-term cost as well. Long after infancy is over, bottle-fed children are at higher risk of respiratory and gastrointestinal illness and of some types of childhood cancer. As adults they appear to be at higher risk of alcoholism, breast cancer, heart attack, and stroke. Their mothers may be more vulnerable to osteoporosis, ovarian and endometrial cancer, and -- new information -- type II diabetes.
Human milk makes a difference, both now and in years to come. It's usually easier to breastfeed if you give birth without unnecessary intervention, and it's usually easier to give birth without unnecessary intervention at home.
Intangibles matter.
I hesitate to write about the subjective experience of homebirth because it provides fodder for people who say, "See? It's all about YOU and your EXPERIENCE and if you CARED about your baby you'd go to the hospital." But I have to tell you: my homebirths blew me away. They were almost sacramental, by which I mean that the ordinary (here I am in my living room...) was transected by the extraordinary (...and here is this little face no one has ever seen before) in an event that filled me up with transcendent joy and with solemn resolve to be the finest mother I can manage to be. My homebirths were like glimpses of heaven.
That will sound completely over the top to the skeptics among you, but it was a singular experience. (If you have a singular experience twice, does that make it a doubular experience?) Anyway, it was an experience I wish more women could have.
On a more practical note, the postpartum transition was much easier after my homebirths than after my hospital births. Some of it was the effect of homebirth on our marriage. My husband was a perfectly capable labor coach in the hospital but he came into his own as a labor companion at home. It was easier for him to love me through my labor here in our own house. And those memories, of the tenderness in his touch as I moved through a tough contraction and of the elation in his voice when he said, "Another boy!" -- I will always hold them close.
We also found a marked difference in the sibling adjustment after the homebirths. There are some confounding factors there -- one, I think it's easier to have a spring baby than a cold-weather baby and two, it gets easier to mother a newborn and an uncertain toddler as you become more practiced -- but I do think the births made a difference. There was less disruption in the older kids' routine; they didn't have to go visit me in a strange-smelling hospital. The home-born babies just eased right into our family. I was on such a high after the births, too, and when mama is happy -- well, we can't say with certainty that everybody's going to be happy, but it boosts the odds.
On the subject of odds:
Many people don't think sensibly about relative risk.
We live in this country where people say, "Oh, I want to buy an SUV so I'll be safe on the road," even though SUVs are associated with a higher risk of accidents. People don't observe basic food safety precautions, like washing up carefully after they handle raw meat, but they worry (as they spread pathogens far and wide) about whether cell phones might cause brain cancer. Many, many people find emotional arguments more persuasive than rigorous epidemiological research.
The World Health Organization says a low-risk woman should give birth wherever she feels safe, whether that's her home, a freestanding birth center, or a hospital. For most American women, the clear choice is a hospital. For most doctors, the risk of a congenital heart anomaly requiring immediate treatment looms larger than the risk of a fatal iatrogenic complication. You have to choose the set of risks you're comfortable with. I'd like to encourage everyone reading this, though, to find out more about the real risks involved. The first comment on Neonatal Doc's post stated that 10% of the time homebirths are "a parent's worst nightmare and the scourge of neonatology." As far as I can tell, that claim is simply unsupportable. And if the worst happens?
A bad outcome may or may not mean that you regret planning a homebirth.
Anecdotally, I know two women whose babies died while they were laboring at home. Though they were both heartbroken, neither regretted the choice to attempt a homebirth. (In both cases, the death was judged unpreventable.) Also anecdotally, I know two women whose planned homebirths changed course dramatically -- one because of a partial placental abruption and the other because of an undiagnosed congenital heart defect. Both times the transfer to hospital care went quickly and smoothly, and both babies are fine. And one more anecdote: I know a woman whose baby's life was probably saved by her plans to give birth at home. Because she had an attendant at her home in early labor, the cord prolapse was detected immediately when her water broke. The attendant overrode the EMTs who wanted my friend flat on her back in the ambulance, and her daughter is now a smart and healthy 10-year-old.
Anecdotes, however, are of limited value here. As Jo Leery Polyp wisely says, the plural of anecdote is not data. Something you have to think about seriously when you consider homebirth is the small chance that your baby could die a death that a hospital might have prevented. Consider, too, the chance that people around you will blame you for the outcome whether or not the death was preventable. Can you live with that? Are you more comfortable with the risks that attend hospital birth? In absolute terms, they are no smaller. But you have to decide which ones you'd rather face.
I'm curious about the incidence of malpractice suits among women whose homebirths went wrong -- it's hard for me to imagine suing either of my two homebirth providers. With homebirth, you know your provider can't offer you any sort of magical deliverance from the problems inherent in childbirth. You own the pain, even though she can give you lots of coping strategies and sympathy as you stare it down. And you own the risk that is inextricably bound up with bringing a child into this world. Together you and she will do everything you can to reduce it, but you both know it's there.
Of course informed consent is important at home. A woman considering a homebirth needs to ask good questions and consider the answers carefully. What will this midwife do if there's meconium when your water breaks? What does she carry to manage postpartum hemorrhage? How long has she been certified? Is she licensed? The licensure department in your state probably maintains online records of complaints against licensed practitioners. (While you're checking, you might want to check your OB's record too.) I think informed consent is equally important for women in the hospital. How many women get epidurals believing that the drugs won't affect their babies, when the anesthesiology literature shows otherwise? How many women have consented to Cytotec induction without realizing that it could cost them their babies, their uteri, their lives?
In sum:
If anybody ever tells you that homebirth is safe because it's natural, I urge you to run (shrieking is optional) in the opposite direction. Please run right to your computer and tell me about it in an email, because I am mystified by Dr. Amy's repeated assertion that homebirth advocates start from that premise. By the same token, if anybody tells you that homebirth can't be as safe as hospital birth, ask to see his references. If they're persuasive, send them my way. I'd like to know more.
If you choose to deliver at home, the odds are excellent that you will deliver a healthy baby. Statistics also suggest that you will find birth highly satisfying, less painful, and significantly cheaper than a hospital delivery. The World Health Organization, the Cochrane reviewers, the American Public Health Association, and the American College of Nurse-Midwives, among others, support homebirth as a safe option for low-risk mothers.
In the end, though, I'm not talking about homebirth just because it looks good statistically. I talk about my homebirths because I wish more women could know what it's like to scoop up a wee slippery baby and hold him close while he gets his first glimpse of home. I talk about them because I will never forget the joy of saying, You are right where you belong, little guy. Welcome home.
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