“The Case for Hospital Births”

Best place to have a baby?

Here’s a kind of counterpoint article, also from The Atlantic,  to the one by Alice Dreger M.D. on low-intervention birth in my previous post. The author, Adam Wolfberg M.D., is an obstetrician at Tufts University who specializes in high risk pregnancies. Right from the article’s first sentence he’s pretty up front about where he thinks births should happen:

“I believe babies ought to be born in a hospital.”

That belief seems to be based on personal experience (I say “seems,” because the only case presented is of a couple who wanted a home birth, ran into trouble that led to transfer, and then were “annoyed” to have had a healthy baby in the hospital) and backed up by a reference to the study by J.R. Wax that purported to show a three-fold increase in infant mortality for babies born at home.

This essay actually offers unintended support to Dr. Dreger’s claim that physicians sometimes confuse science with technology. The Wax study has been heavily criticized for presenting a distorted picture of home birth safety  (details here). Dr. Wolfberg ignores much research to the contrary in picking that particular study as evidence of the dangers of out-of-hospital birth, and his use of a badly flawed study to support hospital birth for all women is exactly the kind of thing Dr. Dreger decries.

As I said in my last post, I’ve been on both sides of this debate. Childbirth is sometimes a scary thing, and it doesn’t always end happily. I’ve seen the kind of birth disasters that make an aggressive approach to childbirth so attractive to physicians, and I’ve also taken care of babies harmed by that style of practice.

The trick is to find a safe balance of nature and technology for each mother and baby. That’s an elusive goal in the increasingly polarized world of American maternity care.

5 Comments

Filed under Cesareans, Home birth, Natural childbirth, Science

5 responses to ““The Case for Hospital Births”

  1. Hi Mark,

    I very much appreciate your thoughtful views. This reactor physicist has stopped trying to determine which model of maternity care is better/safer. Midwife-led maternity care in which an out-of-hospital setting is the planned place for birth is a valid choice (perhaps optimal for healthy women experiencing normal pregnancies & attended by skilled midwives, and not a very good choice for others). To evaluate which model is better (whatever better means) would require counting everything:

    Maternal mortality (rare, but perhaps elevated, advantage midwife-led home birth [MWHB])
    Intrapartum+neonatal mortality (similar rates if we do a good job with home birth)
    Peripartum hysterectomy (evaluated advantage for MWHB due to reduced C/S)
    Long term disability (not fully studied, but rates of cerebral palsy do not seem to be improving)
    Preterm low birthweight (advantage MWHB due to the time investment prenatally)
    Cesarean section (~4% for MWHB and ~20% for conventional obstetric care in hospital)
    Post-partum depression (not studied, but we believe there is a benefit for MWHB)
    Caseload care (advantage MWHB)
    One-on-one care during birth (advantage MWHB)
    Cost (MWHB is one-third the cost)
    Etcetera, etcetera…

    Then we need to establish the importance weighting factors and combine with the probabilities. We can then have lots of scholarly conversation about what our comprehensive quality-safety model concludes.

    If we don’t do a good job with MWHB, we degrade safety and we all know what that means. This is why we work so hard. There is little point in studying home birth to try and establish which model is better/safer until we manage it (in about half of the US we mismanage it). The only way to fully manage it is to license and regulate CPMs as they are the primary care provider, and we should enable the CNMs who would take this on to practice.

    Have a great weekend, Mark.

    Russ

  2. Catherine

    I know someone who just lost her newborn baby after a bad home birth attempt this year. The experienced midwife made a mistake about the baby’s position in the womb, and the baby’s brain-damage was so severe that it died after being taken off machines. I used to think that home birth was an OK decision for low-risk women, but now I think any mother with access to good health care would most wisely choose to benefit from it by giving birth in or next door to a hospital and with the assistance of medical staff, i.e. plural persons experienced in what pregnancy complications look like. I’m not for laws to make it that way, but I don’t like seeing unnecessary tragedies, either, and I wish that home birthing was not on the rise now.

    • Hi Catherine,
      Thanks for taking the time to write, and I’m very sorry to hear of your friend’s loss.

      I think it’s important, though, not to draw sweeping conclusions from individual cases. Childbirth is never risk-free, whether in home or hospital. Mistakes are made in both settings, sometimes with tragic consequences. Home birth tragedies, when they occur, are usually due to problems inherent with the current state of home birth in the U.S.–poor communication between home and hospital, delayed transport, etc.–not with home birth as such, which is safely done in other countries.

      You’re right, legislating when and where women can have their babies isn’t a workable idea for a number of reasons. Outlawing home births would just drive the practice underground, with increased risk to mothers (and their babies) who choose to go that route–and many women would still opt for home birth, legal issues or no. So for me the goal is to make childbirth as safe as possible for women and babies, regardless of where that birth takes place. Organizations like the Home Birth Consensus Summit are working to make home birth a seamless, integrated part of the U.S. maternity care system.
      Take care,
      Mark Sloan

      • Catherine

        I used to basically agree with your second paragraph, but my friend’s case was due to the midwife’s mistaken thought that she knew what was going on and could get the baby out herself, not to any structural factors. We’ve all heard the “what if something goes wrong?” argument against home birth, and I used to discount it for low-risk pregnancies attended by experienced midwives, but I didn’t realize then how important monitoring equipment and experience with problem births could be in an individual case. I guess what I’m saying is that all the intellectual arguments against home birth (i.e. slightly elevated fatality risk to infant compared to hospital birth for similar pregnancies, delayed access to OR, etc.) didn’t seem very weighty until I saw a tragedy happen to someone I know.

        I would hope that women considering home birth be aware of the elevated risk, even though small, and completely sure about their decision to forego immediately-available hospital resources. A bad outcome really can happen to them.

  3. Becky

    It isn’t simply the Wax study, which I agree is deeply flawed, that shows risks to homebirth. Besides the Pang study out of Washington State, you have data from Malloy showing increased risk with homebirth, even for CNMS: http://illinoisaap.org/wp-content/uploads/Outcomes-of-midwifery.pdf
    A recent study on births in Missouri:
    http://www.midwiveswashington.com/wp-content/uploads/2012/04/Missouri-study.pdf
    And of course the original Pang study, which is also often criticized: http://www.ncbi.nlm.nih.gov/pubmed/12151146

    The mortality rates reported by some states’ licensed midwives, such as in California and Colorado, are actually significantly higher than the overall perinatal mortality rates for pregnancies of all risk level in the hospital. There isn’t good data showing equivalent level of safety for homebirth in the United States. The Johnson and Daviss study claims that they found an equivalent rate of perinatal mortality for CPMs, but that study actually had no controlled comparison group, they simply compared their numbers for mortality to a range of previously published data, collected over the previous 30 years.

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