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Reply turned post, “You say this is for the number crunchers but I find that rather laughable”

I recently received this comment from Angie in response to Homebirth vs hospital birth for the number cruncher:

You give statistics but don’t list any of the sources. If you want to lend any kind of credibility to this article you really should consider actually posting where you got your information from. Not to mention some people consider it plagiarism :)

All I see in this article is “I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.” You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up. If I was a true number cruncher interested in only facts and unbiased information then I most definitely would find this article completely useless. Numbers are supposed to be unbiased information, though they can be twisted, and this article is anything but. I would be far more impressed by an article that can show numbers AND an unbiased point of view. If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.

Nice try though, E for effort.

Angie,

Thank you so much for your comment and for bringing unreferenced statistics to my attention.

This is an article that I’ve been meaning to update and your comment has once again brought to my attention how I can make it better.

You said, “You say this is for the number crunchers but I find that rather laughable. I see only a few numbers that actually matter and, like I said before, you don’t say where these numbers came from. For all I know they are made up.”

Please read the very first sentence in the article where I state, “there are major limitations if you are going to rely solely on case controlled studies to decide between home and hospital birth.  There are so many variables and nuances that haven’t been ‘number crunched’ to that extent but make a HUGE difference in the how your birth progresses and the ultimate outcome.”

I state upfront that this is not a review of the literature, but rather a review of some factors that can have a significant impact on how a labor progresses and the ultimate success such as (please note the resources as I don’t think you saw them the first time):

  • the importance of privacy, or lack thereof (which linked to an article from the Journal of Perinatal Education) illustrated by…
  • how labor can change upon transfer to the hospital, which leads us to…
  • the risks of augmentation (which linked to a very well referenced chapter entitled “Slow Labor” from Henci Goer’s book “The Thinking Woman’s Guide to a Better Birth”)

Additionally, there are factors that women are often unaware of that might impact their perception of hospital vs. home birth:

  • some complications can be safely handled at home (such as my post-partum hemorrhage)
  • hospital birth carries risks and does not guarantee a good outcome (as demonstrated by the links provided)
  • American’s high maternal mortality rate relative to other industrialized nations (per figures cited by the CDC).

If you are interested in numbers, let’s review a few.  In the US, 1% of babies are born at home and only 8% of births are attended by midwives. The US has the second highest newborn mortality rate in the developed world. We rank 29th in the world in maternal mortality rates (meaning 28 countries have fewer moms dying) and 42nd in infant mortality rates (meaning 41 countries have fewer babies dying.) In the Netherlands, 30% of babies are born at home and they have one of the lowest infant and maternal mortality rates in the world.  Their infant mortality rate is 60% lower than America’s (4.1 deaths per 1,000 live births vs. 6.9 per 1,000.) (WebMD 2008, CDC 2008)  In fact, the countries that use midwives for low-risk pregnancies and OBs for high-risk pregnancies, have the best outcomes. (CDC 2008) Clearly there is some misconnect in how the US manages birth if we have all these births taking place “safely” in the hospital, yet we have these high rates of death. It was our country’s mortality rates that made me initially question the whole system. How can we spend so much money on obstetrics, and have all this technology available to us, yet we have these atrocious outcomes? Maybe all of those interventions, maybe how we handle birth in general, introduces more risks than rewards? A great book to read on this is Dr. Marsden Wagner’s Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First.

You can get more hard numbers by referring to the VBAC Class bibliography or reading articles like Scare tactics vs. informed consent aka why I started this website or Rebutting Dr. Amy’s Information.  While you might not be interested because it’s not research based, Interview with Dr. Fischbein – An Inside Look at Hospitals & VBAC Bans discusses factors such as hospital politics and the influence of hospital administers which are important pieces of the home vs. hospital decision making process.

I quoted two statistics (3% chance of emergency transfer vs. 10-15% chance of unnecessary repeat cesarean) in the original article without citing the references.

The 3% transfer rate is from the Johnson 2005 study entitled, “Outcomes of planned home births with certified professional midwives: large prospective study in North America.”

The “unnecessary cesarean surgery” rate comes from two pieces of information.  First, the USA’s cesarean rate was 31.8% in 2007 according to the CDC’s 2009 publication “Births: Preliminary Data for 2007.”  Secondly, the World Health Organization (WHO) has repeatedly stated that a 10-15% cesarean rate is optimal.   Below 10% and you have mothers and babies dying because they don’t have access to medically necessary cesarean section.  Over 15% and you see higher maternal and infant mortality and morbidity rates from cesarean related complications.  As the 2009 edition of WHO’s “Monitoring Emergency Obstetric Care: A Handbook” states, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded.”

When you subtract the total cesarean rate from the top end of WHO’s recommendation (30% – 15%), you get a risk of 15% of unnecessary cesarean.  Do the same with the low end of WHO’s recommendation (30% – 10%) and you get 20%.  This give us an unnecessary cesarean risk of 15% – 20%, higher than the conservative 10%-15% I stated. But, that is the total rate of unnecessary cesarean sections for all woman.  For women with a prior cesarean, the risk is even higher.

Again, let’s look at “Births: Preliminary Data for 2007.”  There, the CDC quotes a 90.8% repeat cesarean rate in the USA.  The average VBA1C success rate is 74% (Landon 2006) yet only 9.2% of women had a VBAC in 2007 (CDC 2009), so we can extrapolate that to mean that 12.4% of women attempted a VBAC.  Yet the national 2006 Listening to Mothers II survey found that 45% of women were interested in the option of a VBAC.  So while 45% of women want a VBAC, only 12.4% are permitted a trial of labor.  Listening to Mothers II explains the discrepancy: 57% of women interested in VBAC were denied the option primarily due to the “unwillingness” of their hospital or caregiver.  That figure is similar to ICAN’s 2009 Hospital Survey which found that 50% of American hospitals have either a formal or de facto VBAC ban in place.  (ICAN 2009)  So women seeking a VBAC have at least a 57% of having an unnecessary repeat cesarean solely because they can’t find someone to attend their birth.  Add to that women who have bait & switch care providers, and the risk rises.

But this is looking at the rate for the entire United States.  Depending on your local hospital’s rate, your odds might be higher or lower. Some areas, especially rural areas where there might be only one or two hospitals serving a large area, there might be no hospitals within a hundred miles that attend VBAC.  Obviously, a woman’s chances of a successful hospital VBAC there are slim to none.

Other areas, especially major metropolitan areas, have more hospitals and generally more options.  However, if we look at a large area like Southern California (including Los Angeles, Orange, Riverside, and San Bernardino counties), you might be surprised that the VBAC rate is only 5% (California Office of Statewide Health Planning and Development 2008).  This is why it’s so important to truly vet your local hospital and OB/midwife.

But the two statistics I originally quoted (3% chance of emergency transfer vs. 10-15% chance of unnecessary repeat cesarean) don’t give an accurate picture of the risks of homebirth vs. hospital birth and I have expanded the article to include that information.

When considering the risks of home vs. hospital, I think the following are three important questions to consider.

1. Do hospital mandated procedures, policies, and timelines interfere with the progression of labor resulting in an otherwise avoidable “failure to progress” repeat cesarean?

The answer to this question could be a whole book.  I think the Lothian 2004 article Do Not Disturb: The Importance of Privacy in Labor nods possibly yes by examining the impact of the lack of privacy available in the hospital setting.  Books like “Gentle Birth, Gentle Mothering,” “Born in the USA” and movies like “The Business of Being Born” touch on this question as well.

2. Are women more likely to need the advanced emergency equipment available at the hospital because in addition to naturally occurring unavoidable complications, they are at an increased risk for otherwise preventable compilations resulting from cascading interventions?

In other words, are OBs and hospital based nurses more likely to perform frequent vaginal exams, because they have the medications and facilities to perform an “emergency” cesarean if an infection does develop?  Are OBs more likely to perform episiotomies, even though women who have had episiotomies are more likely to tear into their rectum (4th degree tear) (Jandér 2001, Klein 1994, Signorello 2000), because they have the skill set to suture that severe of a tear?

And are women aware that frequent vaginal exams, especially once their water has broken, are linked to higher infection rates or that they are more likely to tear into their rectum if they have an episiotomy?  Or are they just thankful that they were in the hospital so when the infection developed or the tear occurred, they had access to advanced medical techniques?

3. How does fighting your way through labor with an OB who is not supportive of vaginal birth impact the progression of labor, if at all?

There are OBs who will patiently wait for labor to unfold provided that mother and baby are OK.  Most recently, a doctor at Good Samaritan in Downtown LA, attended a woman in labor who was at 8cm for over 8 hours.  Many OBs (the majority?) would have diagnosed a “failure to progress” and recommended/required a cesarean.  Counter that with the birth stories featured in VBACing Against the Odds and Hospital VBAC turned CS due to constant scare tactics.  How your labor plays out depends greatly on your care provider’s personal birth philosophy and your hospital’s standards and policy.  It’s not so much where you are as what is done to you.

Let’s now look at the primary risk of home birth which, in my opinion, is experiencing a 3% chance of a complication (Johnson 2005) that is outside your midwife’s scope of practice or training and requires emergency transfer to the hospital.  The primary question here is:

Does your midwife have the knowledge and skill set that will enable her to quickly diagnose complications, such as uterine rupture, placental abruption, umbilical cord prolapse, placenta previa, severe post partum hemorrhage (1), and coordinate rapid hospital transfer?

I talk about this more in the article, I’m pregnant and want a VBAC, what do I do?:

The most important thing when interviewing midwives is experience.  You need to know how many births she has attended and of those, how many was she the primary midwife (the responsible person at the birth as opposed to assisting a senior midwife.)  I am a full supporter of non-nurse midwives, but please do your homework.  If you have an inexperienced midwife with limited informal or formal education, you are taking on additional risk that is really unnecessary.

Additionally, you want a midwife who has enough experience to know when to go to the hospital as well as the professionalism to interface, and even take crap from, hospital employees.  You and your baby’s well being should come well before her possible discomfort.  In states where it is illegal for a midwife to attend a OOH (out-of-hospital) VBAC, your midwife is not likely to present herself as your midwife if you transfer and this is understandable.

You said, “All I see in this article is ‘I say home birth is awesome. These women agree with me because they had bad experiences in the hospital. Home birth is the best.’”  I did not select the birth stories of the women who had “bad experiences in the hospital” because they love home birth.  I highlighted their stories because I wanted to counter the conventional wisdom which states, if you are at home and a problem happens, you are out of luck but that if you are in the hospital, everything will be ok as well as demonstrate that you don’t even need an actual medical complication in order for your birth to become difficult in the hospital.

You said, “If home birth is as safe as you say then you needn’t go on a raging rant in your article about how it’s so amazing because the numbers and statistics would say it for you.”  Please find where I use the phrase “homebirth is safe/amazing/good/better.”  It’s not there.  The only reference I made in the original article about homebirth safety is to quote the 3% transfer rate per the Johnson 2005 study.  I don’t say whether home birth is safe or dangerous.  I leave that up to individual women to decide for themselves by weighting the risks and benefits of home vs. hospital birth.  There are risks to home birth and there are risks to hospital birth.  Each woman selects which set of risks she is willing to accept.  Is a 3% risk of emergency transfer a fair trade when your local hospital has a 96% repeat cesarean rate?  That is a quandary that woman seeking VBAC face daily.

I have to wonder if you even read the entire article including the part where I discuss my post-partum hemorrhage (PPH):

I’m glad I was home, but my story might have ended very different if my midwife didn’t have Pitocin and Methergin and was able to act quickly. This is a testament to hiring a good, experienced midwife and ensuring that they have drugs to manage PPH.

I trusted the skills of my midwife to diagnosis my PPH and I trusted those drugs to make my bleeding stop quickly when birth veered off course.  Complications do happen at home and when interviewing a homebirth midwife, I suggest asking her how she handles complications as well as hospital transfers.

The truth is, there are no guarantees regardless of where you give birth.

For the record, I thought my home birth was an awesome, incredible experience and I can’t imagine ever giving birth in a hospital again unless medically indicated.  But that doesn’t mean I think you should have a home birth.  Birth at home if that’s what you want to do.  Birth at the hospital if that is where you want to be.  As I say at the closing of the article, “I wish you the best wherever you chose to birth your children” and that is the genuine truth.  I have friends who have birthed in the home as well as hospital.  I have friends who have opted for multiple repeat cesareans.

I am not someone who thinks home birth is always good and hospital birth is always bad.  My objective is not to convince anyone to make any specific decision.  I give information, including references to medical research, to supplement women’s research.  I provide my personal, lay perspective on birth.  As I wrote over two years ago in the article Why Homebirth/HBAC?, “I think the most important thing is for every woman to birth where she, after much research and thought, feels safe and comfortable. Where she feels her wishes will be respected and not just viewed as requests. Where she feels she, and her baby, will receive the best care and experience the best outcome. And I know for many women, this is the hospital. And for a very small minority of us, it’s at home.”  I still believe that.

Warmly,

Jen from vbacfacts.com

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2 comments to Reply turned post, “You say this is for the number crunchers but I find that rather laughable”

  • Very good article, Jen. Thanks for pulling together all that research. I’ll be bookmarking this one.

  • Bonnie

    I wonder what Angie and her friends as “facts and unbiased information”. Does published in a medical journey denote “fact”? What is a fact in birth? And what pray tell meets the definition of ‘unbiased’? Got my stick and my 10 foot pole. Not touching that.

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