HowtoMakeHomeBirthaSaferOption

AaronE.Carroll
THENEWHEALTHCAREJAN.25,2016

Manymedicalstudentsaretaughtthisadage:Whenyouhearhoofbeats,thinkofhorses,notzebras.It
meansthatwe,asphysicians,needtorememberthatcommonthingsarecommon,andthatweshouldnt
immediatelyfocusontherareoresoteric.
Asapediatrician,forinstance,Ihavetoconstantlyremindmyselfthatthevast,vastmajorityofchildren
arehealthy.JustbecauseIencountermostlysickchildrenintheclinicdoesntmeanotherwise.Iseea
skewedpopulation.
Recently,anewstudycomparingthesafetyofhomeorbirthcenterdeliverieswithhospitaldeliveriesled
toheadlinesproclaimingthatbabiesnotborninhospitalsweresignificantlymorelikelytodie.Ihaveno
troublebelievingthatsthecase.
Thatsthezebra,though.
ThereareanumberofpeopleintheUnitedStateswhowouldratherhavetheirbabyathome.Imgoingto
layallofmycards(andbiases)hereonthetable:Irecoilatthisthought.Why?Becauseprettymuchthe
worstthingsIsawinresidencyoccurredwithahomebirth.Icanthelpmyself.Ihearhomebirth,andI
thinkofzebras.
I,andmywife,fearedthedeathsofourbabiesduringdeliverysomuchthatwechoseinhospitalbirths.
Ourzealtominimizethatspecificriskoutweighedanyotherconsiderations.Iffacedwiththedecision
again,Idontdoubtwedchoosethesame.Butthatdoesntmeaneveryoneprioritizesrisksthesameway.
Womenshouldalsoknowthatiftheyreinthehospital,theyaremorelikelytogetaninduction,
augmentationorotherlaborrelatedprocedure.Theyremorelikelytogetacesareansection.Theirchildren
aremorelikelytobeadmittedtotheintensivecareunitandspendtimeseparatedfromthemafterbirth.Its
perfectlyrationalforparentstoacceptastatisticallysignificant,butrelativelyrarer,higherriskofonebad
outcometoavoidanother.
Homebirthsaregaininginpopularity.InBritain,about10percentofbirthsdonthappeninahospital.The
CentersforDiseaseControlandPreventionestimatesthatin2012,morethan53,000birthstookplaceout
ofthehospitalintheUnitedStates.Morethan35,000tookplaceathome,therestatdedicatedbirth
centers.Outofhospitalbirthsareasmallpercentageofoveralldeliveries,about1.36percent,buttherate
hasbeenincreasingsince2004,whentheywereabout0.8percent.Insomestates,likeAlaska(6percent),
Montana(3.9percent)andOregon(3.8percent),outofhospitalbirthsareevenmorecommon.
InOregon,dataisrecordedonbirthcertificatesthatallowsresearcherstoknowwhichbirthswereplanned
forthehomeandwhichwereplannedforthehospital.Theycancompareoutcomes.

In2012and2013,researchersfoundthattherateofperinataldeathwassignificantlyhigherforbirths
plannedathome:3.9versus1.8per1,000.Thatwouldbeanadditionaldeathforeach500birthsathome.
Athomebirthswerealsoassociatedwithanincreasedriskofneonatalseizures.
However,theriskofadmissiontoanintensivecareunitwassignificantlylowerforthosebornathome.I
recentlywroteaneditorialinJAMAPediatricsdiscussinghowincreasedneonatalintensivecareuseisa
possibleexampleofsupplyinducedcare.Inotherwords,thosefacilitiesmightsometimesbeusedbecause
theyexistandneedtobefilled,notbecauseinfantsneedthem.
Inthehospital,yourealsomorelikelytogetaprocedure.Morethan30percentofwomenwithplannedin
hospitalbirthshadlaborinduced,versus1.5percentofthosewithplannedathomebirths.Almost25
percentofthosewhoplannedtodeliverinthehospitalhadacesareansectionversus5.3percentofthose
whoplannedtodeliverathome.
Itsimportanttorememberthattheratesofseveremorbidity(permanentharmorsignificanttemporary
harm)anddeathinwomenare27per1,000forplanned(orlowrisk)Csectiondeliveriesversus9per
1,000forplannedvaginaldeliveries.CsectionsareprobablymorecommonintheUnitedStatesthanthey
needtobe,andbeinginthehospitalincreasesyourchanceofgettingone,andtherisksthatcomewithit.
Unfortunately,thechoiceofbirthlocationhasbecomeachargeddebateinthiscountry.InBritain,onthe
otherhand,themedicalsystemseemstohavebeenadoptingamoreholisticview.TheNationalInstitute
forHealthandCareExcellence(NICE)releasedguidelinesjustoverayearagothatrecommendedthat
healthcareprovidersexplaintowomenatlowriskofcomplicationsthathomebirthisasafeand
acceptableoption.
Infact,forBritishwomenwhohavegivenbirthbeforeandareatlowrisk,NICErecommendsthat
providersexplainthatbirthoutofthehospitalcarriesnodifferencesinriskandisassociatedwithhigher
ratesofnormalvaginaldeliveriesandlowerratesofintervention.
Inaddition,thereareprotocolsandmechanismsinplacetocoordinatecarebetweenhomebirthsandthe
hospital.AneditorialintheNewEnglandJournalofMedicinelastyearnotedthatalmosthalfoffirsttime
mothersinBritainwhointendtogivebirthoutofthehospitalwindupdoingsointhehospitalandthat
thismightbelookedatasasignofsystemicsuccess,notfailure.Ifthingsdontgowellathome,everyone
ispreparedandreadytomakethetransferbecausehomeandhospitaldeliverysystemsworkclosely
together.TheBritishsafetynetworks.
Themedicalprofessionhasacasethatinhospitalbirthscarryalowerriskofdeath,butmanywomenstill
mightbebetteroffdeliveringelsewhere.Asystemcouldbecreatedinwhichparentsvaluesandpriorities
arerecognized,whilealsoensuringthatmoreintensivecareisavailablewhenneeded.
Justbecausezebrasexistdoesntmeanthathorsescant.
AaronE.CarrollisaprofessorofpediatricsatIndianaUniversitySchoolofMedicine.Heblogsonhealth
researchandpolicyatTheIncidentalEconomist,andyoucanfollowhimonTwitterat@aaronecarroll.
TheUpshotprovidesnews,analysisandgraphicsaboutpolitics,policyandeverydaylife.Followuson
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