Note: Thanks to Lauredhel for encouraging me to write this post; otherwise, it might have slipped through the cracks of “other priorities”.
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For various reasons – mostly because I seem to have a lot of friends who are doctors – I’ve had the opportunity to chat to a number of doctors, nurses and midwives about birth. Particularly topical at the moment is the home birth debate (as I’ve been drafting this post, I see that the government has announced that it will no longer be effectively prohibiting home birth, although it still won’t be supporting it).
All of the doctors with whom I have had the home birth vs hospital birth discussion have expressed a clear preference for hospital birth. This is not because they think hospitals are perfect – most of the doctors I know work in the (public!) hospital system, and are aware of at least some of the failures of that system. Similarly, the nurses and mid-wives that I’ve spoken to who work within the hospital system generally expressed a preference for hospital birth.
The reason for this near-universal preference is, I think, for two main reasons: (1) they spend more time with the births that go wrong (especially the doctors), and those stick in their minds, and (2) they are incredibly risk-averse.*
And fair enough, I say. However, I disagree with their assessment of risk.
Lauredhel’s recent post, and the study she talks about therein, highlights some of the reasons why. In particular, this:
One of the interesting meta-things about this study is that hospital birth was considered the norm for the relative risk analyses, the “1.00″ to which home birth was compared. Flipping the numbers and considering home birth to be the norm would mean that we would have to talk about the relative increase in risk for neonatal and maternal injuries, and that in many cases the risks would be more than double.
The people I’ve spoken to who work within the hospital industry (whether doctors, nurses or midwives), as well as various others (in particular, older white men who are, or may soon be, grandfathers), seem to follow a risk analysis that goes something like this:
1. Mothers and babies sometimes die in childbirth.
2. This can happen even when everything appears to be normal.
3. In fact, [anecdotal story about a woman for whom everything appeared to be normal, but whose baby needed to be resuscitated after birth - lucky she gave birth in a hospital or that baby would have died!].
4. Therefore everyone should give birth in hospitals, because otherwise death might occur.
You might notice that none of the other risks (the “lesser” risks) come into this argument. All the people who use that risk analysis are worried about is possible death.
And you know what? It’s difficult to argue with that; it’s difficult to say: “ok, on the one hand, my child might die but at least I won’t be unnecessarily hurt in the process – on the other hand, the doctors will do what they think is necessary to save my baby and I might get hurt, but at least my baby won’t die”.
It is especially difficult to make that argument when the person making the above argument is YOUR doctor, and zie is reminding you that zie needs to take into account your baby’s benefit as well as yours, particularly given our cultural respect for doctors and the authority they are generally accorded.
(It goes without saying that the enormous majority of mothers – as in, 99.99999% or so, I’d imagine – want the best outcome for their child. I’d also guess that the typical mother also does not want to be perceived as some crazy hippy who is ignoring SCIENCE and putting her baby’s life at risk.)
This is why research projects such as the one that Lauredhel outlined are so important. As she points out, the paper not only shows that home birth is safer, but there is a suggestion – although no conclusion – that being in hospital actively increases the risk, not only of injury, but of some event requiring resuscitation.
Why is that so important? It allows someone to argue against the anecdote at step 3 of the doctor’s argument I’ve outlined above. It’s intellectually dishonest – and unscientific! – for a doctor to use that argument. (An independent midwife I know referred to doctors being manipulative, and I believe that it’s that sort of behaviour – using anecdotes as if they are data, and doing so with a doctor-ish “I’m medically-trained” kind of authority – that she was talking about.) But I do understand that they’re doing it in good faith – they don’t want their patient (indeed, patients) to face the risk of death.**
What they need to be told, loudly and clearly, is that there’s a good chance that the risk of death that they’ve observed may exist only because the woman was in the hospital in the first place, not because of some innate risk in the pregnancy that wasn’t apparent until the baby emerged. So not only is their anecdote intellectually dishonest and unscientific, but, by using it, they are, potentially, actively putting their patient(s) at risk of the very event they are trying to prevent, in addition to the other risks outlined in the study (such as risk of injury).
Of course, the study makes no findings about correlation, so it is not possible to say, definitively, that going to hospital actually causes those higher risks. I’m not trying to say that it does. My point is that it is at least as valid a conclusion to draw as the “anecdata” approach I’ve heard several doctors use.
I noted above that I’ve heard several men (particularly of the older, white, grandfather-age variety) use a similar what-if argument. The context of at least two of those arguments was “women shouldn’t be allowed to give birth at home”. My take is that even if the risks of home birth were slightly higher than for hospital birth, that alone is not necessarily a reason to outlaw it (my opinion on that might have depended on precisely what the risks were, how likely, how possible it was to diagnose before pregnancy, etc), and that the important thing was that women should have the choice. One of them was turning the argument quite personal, and I assured him that nobody would force him to give birth at home.
Anyway, this attitude is reflected in the very first comment at this article, which Lauredhel pointed me to, although the comment is by a father, rather than a grandfather (there are similar comments later, one in fact by “Grandfather of 2″). It may also be worth noting that the older, white women who were grandmothers or potential grandmothers were much more open to the idea of home birth being safe (although they may not have been totally convinced that it was “as safe” as hospital birth).
This makes me wonder if the concept of control, or, rather, perception of control has anything to do with the attitudes of men. But that’s a digression that I’m simply not getting into here.
Ultimately, though, studies like this really show that where you stand on the home birth/hospital birth debate (assuming no diagnosed complications) really comes down to whether you think that any risk of death outweighs the risk of other injuries, which have a much higher probability of occurring, especially if you give birth in a hospital.
Given that we take hundreds of risks each day in which “you/your baby might DIE!” (travelled in a car recently?), I do think that we need to keep that in perspective. Where death is an incredibly low risk in any case, it is important to also consider other risks, which may be objectively “lesser” risks, but which undoubtedly have a much higher incidence.
(By the way, I find the “women have been giving birth for centuries without medical intervention so of course home birth is safe!” to be just as intellectually dishonest as “but you might DIE!” Better hygiene, medical technology and much better general health have made birth a lot safer. It seems to me that the medical technology contribution is largely because we can now diagnose so many potential complications (and then deal with them if/when they occur). That very fact (and the better hygiene and general health) is what allows home birth to be so safe. A woman who chooses a home birth has usually made use of medical technology to make that choice. The midwife attending the birth will most likely bring medical technology with her. It’s not that she’s rejecting medical technology; it’s not that she’s simply doing things the way our foremothers did them. She’s actively using medical technology in an entirely appropriate way to inform her decision.)
* By the way, I’m talking about individual doctors here, who I think usually do act in good faith. Not so sure about the AMA. My reading of the AMA’s submissions to the Maternity Services Review suggests that organisation has acted somewhat disingenuously. I say that because they base their submissions on a study that is 10 years old, which used data that were 10 years old and over at the time (ie the data are now 20 years old and over), and even then, the AMA misrepresented the findings in the study in order to bolster its own interests. Way to go, AMA, if you want people to trust you. I saw that the Good Weekend article on home birth – which was pretty good – picked up this little piece of dishonesty on the part of the AMA, too.
** My doctor friends tell me that my profession has something to answer for here, too.
ETA: Of course, I posted and THEN I saw Helen’s excellent and related post, looking at the perspective of risk in a different way. Which possibly ties in with my comment about control, the one I didn’t elaborate on.
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