Macleans recently published a poorly researched article on home birth, relying heavily on ‘anecdata’ of obstetricians and the infamous Wax study (see our critique here), and completely ignoring the high quality Canadian studies. I left a LOT of comments to clear up misperceptions, and replied to many other commenters. Here is part of my response, which I have also sent as a letter to the editor.
A Modest Proposal
Let’s imagine for a minute that the Wax meta-analysis is a good one (this takes a lot of imagination) and relevant to Canada. And let’s imagine that we will use this data to recommend that all births happen in the hospital, because we want to prevent babies dying, and maybe we can even prevent more women dying too!
Our goal: to reduce the deaths of babies and women. How else could we achieve this goal?
Since the rate of death due to accidental injury is 9.5 out of 100,000 for women aged 20-44 (childbearing age), we should recommend that all women of childbearing age live their lives in the hospital, so that in case of accidental injury they have immediate access to medical care. Maternal mortality in Canada is 7 out of 100,000 (up from 6 a few years ago), so the death rate due to accidental injury is higher than the maternal mortality rate in Canada. We can obviously make some serious improvements to the death rate by accidental injury in this population through the hospitalization of all women aged 20-44.
The infant mortality rate (death in first year of life) in Canada is 5.1 in 1000. The early neonatal mortality rate (death in the first week of life, excluding stillbirth) is 3.3 in 1000. So 1.8 out of 5.1 infant deaths (about 35%) occur after the infant is a week old and not in the hospital. We should recommend that all infants under a year live in the hospital so that in case of an emergency or life threatening condition they have instant access to medical care, in order to reduce the infant mortality rate.
This shouldn’t be too inconvenient or a burden on our already stressed health care system—after all, the life of even one baby would be worth the limitations on the freedom and privacy of childbearing aged women, the stress to the national budget, and an even greater shortage of doctors and nurses for those who are actually sick. We definitely shouldn’t do any studies examining the mortality rate for women and infants from antibiotic resistant bacteria in the hospital compared to home. The only question that remains is whether it should be a woman’s choice to live at home or in the hospital? What if she chooses to live at home with her infant in the first year of life? Is she putting her child in danger? Is the availability of ambulance services, paramedics, and an ER to take women and babies to in an emergency really the best way to balance safety, autonomy, health care costs, and a human resource shortage in the medical professions?
Perhaps 100 years from now we will be absolutely horrified at the idea of any childbearing aged woman or less than one year old infant living at home, without doctors and sophisticated medical and surgical equipment immediately on hand. We will tell stories about women and babies who almost died in the hospital—how on earth could they have gotten timely and appropriate medical treatment if they had been at home? And we will shake our heads over the babies that do die at home, wondering why on earth they weren’t living in the hospital, while we ignore and make a point of not publicizing the infant deaths that occur in the hospital.
We will do studies comparing infants who live at home in the first year of life compared to those who live in the hospital, and then we will do a meta-analysis of these studies and discard the study with the most data (320,000 subjects), for no apparent reason, so that we can rely on the smaller studies (9,811 subjects total) with less reliable data, and we will mysteriously exclude stillbirths from our calculation, counting only neonatal deaths (occurring in first 28 days of life) to give us our politically motivated conclusion that more infant deaths occur at home than at the hospital! Oh, and we would release our findings before they have gone through the peer review process, and then completely ignore independent experts who looked at our study for Time magazine and found it ‘weak and methodologically flawed.”
Lucky for us, writers at magazines like Macleans won’t be so thorough, and will also ignore the independent experts review. They will also ignore the fact that a large proportion of data used to draw our final conclusions about infant mortality being higher at home was from the U.S., where care of infants who live at home is not integrated into the health care system.
Janssen’s study shows that women who planned a home birth were significantly less likely to experience electronic fetal monitoring, augmentation of labour, assisted vaginal delivery (forceps or vacuum), cesarean delivery, and episiotomy. Women who planned a home birth were also significantly less likely to have a third- or fourth-degree perineal tear and postpartum haemorrhage. The risk of all adverse maternal outcomes assessed was significantly lower among the women who planned a home birth than among those who planned a physician-attended hospital birth.
Note that only 2% of births in Canada occur at home, but the perinatal mortality rate (stillbirths from 28 weeks gestation on plus early neonatal deaths) is 6.4 out of 1000 total births. 98% of infant deaths related to childbirth in Canada happen in the hospital. Yes, BABIES DIE IN THE HOSPITAL. The deaths that do occur with planned home births are not preventable by being in the hospital, as the rate of perinatal death is comparable in both settings with a trained midwife in attendance and access to emergency hospital care. In fact, babies whose births start at HOME (whether they transfer to the hospital or not) are LESS LIKELY to ALMOST DIE, because they are less likely to need resuscitation and inhale meconium.
There are far more stories of newborn and maternal near-misses in the hospital in Canada than at home, many of them iatrogenic (caused by medical treatment).
I would like to see Macleans do an article on this, ‘Is Hospital Birth Safe?” or ‘Risks of Hospital Birth,’ or “Abandon Ship! Hospital Birth is Sinking–Do We Know How to Swim?” complete with interviews with doctors, midwives, and nurses who have seen birth go horribly wrong in the hospital due to unnecessary and/or routine medical interventions.
0.6 out of 100,000 is the mortality rate in the general population in Canada as a result of a medical or surgical complication. And this is when treatment is being given to help cure a DISEASE, but the treatment itself has risks, including leading to death. Pregnancy and childbirth are normal life processes, not a disease that needs to be cured, and any treatment or intervention has risks, including death.
Maternal mortality in Canada is rising. So is the cesarean section rate. Liu et. al. show that planned cesarean increases ALMOST DEATHS (severe morbidity) compared to vaginal birth–and the risks of emergency cesarean are even higher than a planned cesarean.
Maternal mortality statistics from
{ 7 comments… read them below or add one }
Daaaamn, Asheya. AWESOME POST. This was insanely informative and creative in the comparitive narrative. I loved it. Can I use excerpts from it in the future?
Thank you, Asheya, for saying what I felt in words I did not have. I just read this article yesterday and was disappointed and disheartened at the misleading (and wrong) information that Maclean's is disseminating. Shame on them.
Rachel: yes, you may use excerpts–please link to the full text here on Mothers of Change. Thanks!
"I would like to see Macleans do an article on this, 'Is Hospital Birth Safe?" or 'Risks of Hospital Birth,' or "Abandon Ship! Hospital Birth is Sinking–Do We Know How to Swim?" complete with interviews with doctors, midwives, and nurses who have seen birth go horribly wrong in the hospital due to unnecessary and/or routine medical interventions. "
I totally agree — my husband and I were both disgusted by the article. The author so clearly has an axe to grind – it's really disappointing that Maclean's would print something so patently biased and full of anecdotes passed off as fact. Just shameful. Kudos to you for setting so many of the commenters straight.
Did anyone else notice the web address for the article: http://www2.macleans.ca/2011/08/26/DONT-TRY-THIS-AT-HOME?
Shameful is right.
Thanks Asheya!
Bravo! Very well done post. I too would love to refer to it in the future in my childbirth classes if I have questions arise in class. Keep up the fantastic work!!!!
Lisa, feel free to print off any of the info or the full post. Please just provide the link to Mothers of Change and my name with it (Asheya Hennessey). Thanks!