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.midwiferyservi
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-c
3. Health at a Glance 2011. OECD Indicators.
5. World Health Organization. "WHO statement on caesarean section rates." (2015). http://apps.who.int/iris/
6. Moore, Ben. "Appropriate technology for birth." The Lancet 326.8458 (1985): 787).
8. Tirumalai Kamala's answer to Do you think there is sufficient evidence for the "hygiene hypothesis"?
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/
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.g
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/conten
13. Medical errors in America kill more people than AIDS or drug overdoses. Here's why. Vox, Sarah Cliff, April 22, 2015.
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/vie
15. Delivery, Deadly. "The Maternal Health Care Crisis in the USA." London: Amnesty International (2010). http://www.amnestyusa.org
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/conten
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
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