Why attended homebirth is safer than hospital birth for low risk women

What is it about?

Alligators, Hospital Birth & other Urban Legends Abstract: The belief that hospital birth for low risk pregnancies has better outcomes than planned attended homebirth is an urban legend. The choice of low risk women to deliver in hospital is a result of the dominant and irrational human propensities to gossip, to follow the crowd and to cling to irrational hope. Rational analysis shows that planned homebirth with experienced trained attendants has the best outcomes for both mother and newborn for low risk pregnancy. Why is it that over 99% of people in every westernized country, except England and Holland, are convinced that attended homebirth for low-risk women is more dangerous and has worse outcomes than hospital birth? There are several answers, and they all involve irrational thinking. Daniel Tammet’s book, Embracing the Wide Sky: A Tour Across the Horizons of the Mind (2009), summarizes the latest research about the way people think. Tammet reviews research showing that human decisions have emotional rather than rational bases and that gossip is the main basis for decisions. Although scientists have a hard time understanding the purpose of gossip, it appears to be a deeply rooted human instinct. Robin Dunbar, professor of psychology at the University of Liverpool, points out that most people devote around two-thirds of their conversations to gossip (Dunbar, 1998). Gossip may be the human equivalent of primate grooming. Primates spend hours grooming each other’s fur as a form of social bonding to help keep the community together. Humans, Dunbar suggests, evolved to use language instead because it is less time intensive and allows the individual to work at the same time. One common form of gossip is the urban myth or legend—a story of doubtful authenticity that is nonetheless presented as true. Urban legends are a modern form of narrative folklore. Often the teller claims the story happened to a friend of a friend or to a distant relative. The enduring popularity of urban legends rests on their ability to reflect man’s fears and anxieties. These same anxieties make negative news more attractive to people than positive stories. The most persistent urban myths that succeed in capturing the public’s imagination have a solid narrative structure, vague plausibility and an underlying message or moral. One long-running legend has it that alligators live in the sewers of New York. Another legend claims that MMR (measles, mumps and rubella) vaccinations can cause autism, even though a mechanism for how the MMR vaccine could cause autism doesn’t exist and an increase in autism did not accompany the introduction of the MMR vaccine in 1988. (Taylor et al., 1999) An even more persistent legend than either of those is the legend that hospital birth is safer for low risk women than planned attended homebirth. The Wax et al. meta-analysis (2010) is a perfect example of narrative folklore or urban legend. It provides classic gossip for those who choose to only read the 17 word conclusion in the abstract or who choose to believe media hype promoted by those who only read the 17 word conclusion. The conclusion published in the journal, as it happens, does not reflect the findings in the paper. Anyone who reads the article recognizes it’s inability to identify and isolate data relevant to the question being studied and it’s inability to perform simple math like addition. When people are asked why they are so sure homebirth is more dangerous than hospital birth, most do not refer to research, but answer authoritatively, “What if something goes wrong?” reflecting that man’s fears and anxieties are often foremost in his thoughts. When this group is provoked further to fill the gap and answer the question, “What is the something that could go wrong?” They usually answer, “I don’t know.” A 2010 review of the literature did not find a single citation documenting a single case of a planned attended homebirth, in the absence of gross negligence which can happen anywhere, which would have had a better outcome had the woman planned a hospital birth. (Cohain, 2010a) When pushed further to suggest something that might make planned homebirth dangerous compared to hospital birth, the first thing they usually say is, “What if the cord is around the neck?” Research evidence shows that births with cords wrapped one to four times around the neck have better outcomes than births without a cord around the neck. (Cohain, 2010b) Another common answer is, “What if you need a cesarean?” inferring that a 30-60 minute long transfer to hospital would result in worse outcomes. The same person will often admit that when an ‘emergency’ cesarean on a hospital patient is supposedly needed, there may be a wait of hours for the operating room, anesthesiologist, nurses and doctors to be available. Unknown numbers of healthy babies deliver vaginally while waiting for an ‘emergency’ cesarean. The highest level of evidence using the best data base, published in the Journal of the American Medical Association showed cesarean surgery has yet to be shown to improve outcomes (Pasupathy et al., 2009). Cesarean has only been shown to lower perinatal mortality in the case of prolapsed cords that prolapse during hospitalization, however it has never been studied how many of those prolapsed cords that happened in hospital happened because of the unnecessary intervention in hospitals to routinely rupture membranes in the absence of a engaged head, or occurred among pregnancies at high risk for prolapse like premature, breech, twins, and IUGR which are not suitable for planned homebirths. Although one might imagine newborn resuscitation to be more successful in hospital due to the proximity of pediatric experts, research showed that the presence of skilled personnel in the hospital in cases of asphyxia did not improve outcomes because hospital births were found to have “slow paging of skilled personnel,” whereas, at homebirths, the skilled personnel are already at the birth. (Menticoglou, 2008) . The theory that women choose hospital birth due to reverence for technology appears overly simplistic. When a home appliance or car brake systems, for examples, are shown to cause rare injury or deaths in the way vacuum births and cesarean births do, the model is taken off the market. For the 80% - 90% of low risk birthing women, technology causes fatalities. In about 1 in 20,000 vacuum extractions, a perfectly healthy baby who would have been born healthy using expectant management, dies from the pressure on its brain of vacuum extraction. In 1 in 3000 cesareans, the mother dies due to exsanguination or amniotic fluid embolism, both causes of death are increasing whereever cesareans are increasing. In 1 in 10,000 cesareans, the mother dies from the anesthesia. In an unknown number of near misses, mothers after cesarean almost die but are heroically saved. Women risk their own death and that of their fetus to use technology which has not been shown to be effective. A 2006 round table of birth experts that explored the question, “Why do women go along with this stuff?” concluded that what women want is to trust both their caregiver and what their friends tell them. (Klein et al., 2006) Yet, it seems that after several pregnancies, women often trust their friends and doctors less and trust themselves more, veering away from unnecessary interventions. (Van den Bussche et al., 2007) Since most women today have only one or two children, many don’t arrive at this deeper understanding of the birth process. Tammet (2009) agrees. He says one of the most important reasons why people might accept an inferior idea in favor of a better one is a natural preference for following the crowd. Given the choice between an idea that is simple and one that requires more effort to comprehend, most people will gravitate towards the simpler option, regardless of the relative merits of the ideas. Without considering the fact that pregnancy is not an illness, many people reason that if a woman in labor has pain, she should be in hospital. In addition to a propensity for gossip and following the crowd rather than objective in depth analysis, people sometimes display irrational hope. Women hear stories about painless births and they hope to have one, ignoring the universal observation that humans are the only animals who disregard instincts to birth in familiar, private settings without the presence of strangers. They choose to swallow the myth of epidural promising a painless birth simultaneously choosing to ignore the well-publicized fact that in US hospitals, where they must go to get their epidural, more than 30% of the time the result is extremely painful major abdominal cesarean surgery. Gossip, the desire to follow the crowd and irrational hope all have one thing in common: they are not rational. Careful, logical thinking requires effort and does not come naturally. We are not naturally endowed with the ability to think clearly and logically without learning how and repeatedly practicing the skill. People with untrained minds should no more expect to think clearly and logically than people who have never learned and never practiced to be good carpenters or pianists. Thinking for oneself is more work than not thinking for oneself, but the price for not doing so maybe infinitely higher. References Cohain JS (2010a) Is there a scenario for which planned hospital birth has safety advantages for low risk women over planned attended homebirth? Review. Midwifery Today 94:30-32,67-68. Cohain JS (2010b) Nuchal cords are necklaces, not nooses. Midwifery Today (93):46-48, 67-68. Dunbar R (1998) Grooming, Gossip, and the Evolution of Language. Cambridge, Mass: Harvard University Press. Klein MC, Sakala C, Simkin P, Davis-Floyd R, Rooks JP, Pincus J (2006) Why do women go along with this stuff? Birth 33(3)245–50. Menticoglou, SM (2008) How often do perinatal events at full term cause cerebral palsy? J Obstet Gynaecol Can 30(5): 396–403. Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GC (2009) Rates of and factors associated with delivery-related perinatal death among term infants in Scotland. JAMA 302 (6): 660–68. Tammet D (2009) Embracing the Wide Sky: A Tour Across the Horizons of the Mind. New York: Free Press. Taylor B, Miller E, Farrington CP, Petropoulos MC, Favot-Mayaud I, Li J, Waight PA. (1999) Autism and measles, mumps and rubella vaccine: no epidemiological evidence for a causal association. Lancet 353 (9169) 2026–29. Van den Bussche E, Crombez G, Eccleston C, Sullivan MJ (2007) Why women prefer epidural analgesia during childbirth: the role of beliefs about epidural analgesia and pain catastrophizing. Eur J Pain 11(3)275-82. Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. (2010) Maternal and newborn outcomes in planned home birth vs. planned hospital births: a meta-analysis. Am J Obstet Gynecol 203(3):243.e1-8.

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Why is it important?

1 in 5000 low risk women die at hospital birth from AFE caused by medical inductions and hemorrhages caused by unnecessary cesareans who would not have died if they had attended homebirths.