Sunday, December 11, 2016

Why is home birth in America so dangerous when compared to other comparable countries?


Refers to article: http://www.nytimes.com/2016/05/01/opinion/sunday/why-is-american-home-birth-so-dangerous.html?ref=opinion
 
Firm conclusions aren't possible from the New York Times article referred in the question since it examines a minuscule piece of the pie. However, analyzing in conjunction with other relevant data such as excess medicalization propensity of US births, total US maternal mortality and overall medical error rates suggests US home births are unlikely to get a fair chance because they simply aren't integrated with OB/GYN practices and hospitals, making it practically impossible to optimally co-ordinate care, if and when an in-labor transfer is necessary from home/birthing center to hospital. However, doing so would not only greatly reduce short- and long-term costs and rates of medically unnecessary C-sections but also improve both short- and long-term outcomes for maternal and fetal health.
Unfortunately this is easier said than done since, perhaps more than in other countries, US medicine in general and US births in particular exist at the uneasy intersection of medicine, politics and law. Unfortunately, this toxic mix pollutes every aspect of the birth process, from greater propensity for unnecessary medicalization (off-label use of Misoprostol for cervical ripening and excessive C-section rates being examples) to questionable data, all predictable responses of a system driven more by need for institutional control and liability avoidance rather than scientific allegiance to evidence-based medicine.

US Births Increasingly Medicalized, Having Among The Highest Rates Of C-Sections
The late American perinatologist and perinatal epidemiologist Marsden Wagner, divided current human birth processes into 3 broad categories (1).
  • Highly medicalized, 'high tech', doctor-centric, midwife-marginalized. Examples found in Belgium, urban Brazil, Czech Republic, France, Ireland, Russia, USA.
  • Humanized, more autonomous, strongly midwife-centric with much lower intervention rates. Examples found in the Netherlands, New Zealand and Scandinavia.
  • Mixture of both approaches. Examples found in Australia, Britain, Canada, Germany, Japan.
Problem with the first option that dominates in the US is that over the course of the 20th century and beyond, it helped inculcate an institutional and cultural memory of medicalized birth at the expense of humanized birth. To quote from the 1985 report Wagner helped publish as the Director of the WHO's Women's and Children's Health (1) (emphasis mine),
'By medicalizing birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her, the woman’s state of mind and body is so altered that her way of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result it that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what “non-medicalized” birth is. The entire modern obstetric and neonatological literature is essentially based on observations of “medicalized” birth.'
For example, according to the US National Center for Health Statistics, 1 in 3 babies is delivered by C-section in the US (2). US C-section rates are much higher compared to other OECD countries (see figures below from 2, 3, 4, 5). This even though the WHO has recommended for more than 30 years that C-sections shouldn't be >10 to 15% of total births (5, 6).


US C-sections rates are one of the clearest pieces of evidence for excess medicalization of US births. C-section risks aren't limited to mothers' immediate higher risks of post-surgical complications either. As we learn more about the importance of immediate post-birth microbial colonization, epidemiology is steadily building a hefty database of children's long-term adverse outcomes of C-sections, namely life-long increased risks of allergies and autoimmunities (7, 8).
Since home births are a minuscule proportion of total births, accounting for a mere 1.47% of total births as recently as 2014 (see table below from 9), obviously US C-sections can't simply be attributed to home birth complications that necessitate in-labor transfers to hospitals for emergency C-sections. Rather, they're a logical expansion of excessive medicalization of US births in general.


No Firm Conclusions Possible When Available Data Are Suspect
Inextricably linked to the larger issue of births and maternal health in general, not just home births but also maternal mortality rates in the US buck global trends. A 2014 assessment of global maternal mortality rates shockingly revealed that the US is the only developed country where the maternal mortality rate seems to be increasing even as it's decreasing across the globe (10). According to this study, US maternal mortality rate per 100000 live births were 12.4 in 1990, 17.6 in 2003 and 18.5 in 2013, meaning they increased 2.7% from 1990 to 2003, increased 0.5% from 2003 to 2013, and increased 1.7% from 1990 to 2013 (see figures below from 11). Since home births are a minuscule proportion of total US births, this implies maternal mortality rate is increasing in US hospital births.


Increasing US maternal mortality fits into the larger issue of medical errors. A 2016 study extrapolated data to suggest medical errors have now become the 3rd leading cause of deaths in the US (12). While statistical over-reach is a major weakness of this study, it's long been an open secret that frank admission of error is practically impossible in medical culture (13). Since deaths incurred during or through hospital births (complications following C-sections for example) fall under the medical error rubric, data related to births, be they home or hospital, especially data on adverse outcomes, can only be taken with a generous pinch of salt.
Doubts about accuracy of maternal death data become an even more pressing issue given that there are no US federal requirements to report maternal deaths and US authorities themselves concede they may be twice as high as reported (14). According to Amnesty International (15) (emphasis mine),
'reporting of pregnancy -related deaths as a distinct category is mandatory in only six states – Florida, Illinois, Massachusetts, New York, Pennsylvania and Washington. Despite voluntary efforts in some other states, systematic undercounting of pregnancy -related deaths persists'
Bottomline, data on US deaths due to either home or hospital births are far from reliable.

Amy Tuteur, Author Of This New York Times Article, Has A Patently Clear Conflict Of Interest
As author of the blog, The Skeptical OB, Amy Tuteur, the author of this New York Times piece, has a patently clear conflict of interest regarding home births. She herself revealed this bias in her incorrect criticism (16) of a large, thorough 2013 British Medical Journal study comparing maternal mortality between home and hospital births in the Netherlands (17). After misunderstanding this Netherlands data and incorrectly critiquing it, a volte-face to say the least when she writes in this New York Times piece 'there are places in the world where home birth is relatively safe, like the Netherlands, where it is popular at 16 percent of births' (18). So, per this author, are home births in the Netherlands safe or not? When an author's opinion varies based on the context, better not to take such opinions at face value.

Birth Is A Normal Physiologic Process. Medicalizing It Changes It From A Sanctuary To Surveillance, Often To Mother And Child's Detriment
As we understand better the short- and long-term harms of birth medicalization, we see its costs are paid not just by mothers and children but by all of society, economic, physiological and psychological costs from avoidable chronic health conditions.
A highly medicalized, overweeningly C-section-favoring approach to birth prevails in the US. It represents a financial medico-legal culture highly resistant to the notion of home births. Primed to regard midwifery as a potentially harmful interloper, such a culture easily gives it short shrift, depriving it the integration and co-ordination necessary to thrive and succeed. This reveals a schism in the US birth process, a schism between need for sanctuary during birth to ensure physiological processes prevail and need for surveillance to ensure technology provides state-of-the-art safe care (19).
Examining and importing best practices and structures from countries like Netherlands, adept at straddling the divide between home births and best of medical care, is an obvious approach. However, such measures require humility and an open mind. Is US medico-legal culture up to that challenge? That's the crucial question.

Bibliography
1. Wagner, Marsden. "Fish can't see water: the need to humanize birth." International Journal of Gynecology & Obstetrics 75 (2001): S25-S37. http://www.midwiferyservices.org...
2. Menacker, Fay, and Brady E. Hamilton. Recent trends in cesarean delivery in the United States. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2010. http://www.gapha.org/wp-content/...
3. Health at a Glance 2011. OECD Indicators.
5. World Health Organization. "WHO statement on caesarean section rates." (2015). http://apps.who.int/iris/bitstre...
6. Moore, Ben. "Appropriate technology for birth." The Lancet 326.8458 (1985): 787).
9. Grunebaum, Amos, and Frank A. Chervenak. "Out-of-hospital births in the United States 2009–2014." Journal of perinatal medicine (2016). http://www.degruyter.com/dg/view...
10. Kassebaum, Nicholas J., et al. "Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013." The Lancet 384.9947 (2014): 980-1004. http://www.ncbi.nlm.nih.gov/pmc/...
11. The US Is The Only Developed Nation With A Rising Maternal Mortality Rate. Anna Almendrala, The Huffington Post, May 19, 2014. This Is The Deadliest Industrialized Country For Pregnant Moms
12. Makary, Martin A., and Michael Daniel. "Medical error—the third leading cause of death in the US." BMJ 353 (2016): i2139. http://www.bmj.com/content/bmj/3...
14. Berg, Cynthia, et al. "Strategies to reduce pregnancy-related deaths: from identification and review to action." (2001)., Centers for Disease Control and Prevention, 2001. http://stacks.cdc.gov/view/cdc/6...
15. Delivery, Deadly. "The Maternal Health Care Crisis in the USA." London: Amnesty International (2010). http://www.amnestyusa.org/sites/...
17. de Jonge, Ank, et al. "Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study." BMJ 346 (2013): f3263. http://www.bmj.com/content/bmj/3...
18. Why Is American Home Birth So Dangerous? The New York Times, Amy Tuteur, April 30, 2016.
19. Stenglin, Maree, and Maralyn Foureur. "Designing out the Fear Cascade to increase the likelihood of normal birth." Midwifery 29.8 (2013): 819-825.


https://www.quora.com/Why-is-home-birth-in-America-so-dangerous-when-compared-to-other-comparable-countries/answer/Tirumalai-Kamala


No comments:

Post a Comment