British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies | Hacker News Reader

British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies

nytimes.com

42 pointsacsillag50 comments

I found the word "slightly" here to be misleading:

"The risk of death or serious complications for babies was the same in all three settings, with one exception: In the case of first-time mothers, home birth slightly increased that risk. Nine in 1,000 cases would experience serious complications, compared with five in 1,000 for babies born in a hospital."

0.5% versus 0.9% is nearly a doubling of risk. That looks significant to me, not slight at all.

And the base rate (~1%) is large enough to make the impact worth considering. (Where on the other hand, a doubling of risk in airplane travel, a very low-risk activity, would not be worth worrying much about.)

The guidance given takes this into account, differentiating between first-time and repeat mothers, but the article sidesteps it.

It's only uncomplicated until it's not. The solution to avoiding unnecessary surgery is not to physically locate farther away from all surgery.

Midwives can do their work in a hospital room down the hall from surgical facilities just as easily as they can in your bedroom 20 minutes away from major life-saving surgery.

This is, of course, the obvious counter-argument, but even in cases of complication it's usually not a problem getting EMS there in time. In parts of the US, midwifery is illegal, but there are places like this (http://www.ncbirthcenter.com/) that provide midwife services in a natural, homelike setting, but which also have hospital privileges and an OB/GYN on staff in case anything goes wrong. There's another important bit, too. Doulas (http://www.dona.org/mothers/) are becoming much more popular, in an effort to provide a similar kind of support through labor & delivery as a midwife might, but within a hospital setting. We used one with our two children and it was really calming to have someone around who wasn't hospital staff AND had experienced hundreds of births AND was there to do whatever my wife needed throughout.

My mother-in-law is a retired nurse midwife who delivered >600 babies in England & Scotland during her career before moving to the US. I don't know if it's still true, but she tells us that in the UK, midwives have special privileges for things like transportation -- free bus/train/subway, and the ability to hail a cab and get a free ride if it's necessary. This may not be true any longer. She relocated in 1969.

Can you expand a bit on what you mean by "midwifery is illegal"? To me, that sounds as odd as "dentistry is illegal" ...

This could be a translation error, but "birth nurses" seem to be called "midwives" in the UK whereas that's not the case in the US (at least as I understand it).

There are different certifications. One in the US is Certified Nurse Midwife, essentially they are RNs with a certification in midwifery as well. They can have privileges at hospitals, which is a very useful backup in cases where something goes wrong in a non-911 sort of manner. There are also Certified Midwifes, which have a somewhat less medical oriented training and may not be able to bring patients into a hospital as 'their patient'.

(A little late but...) I said that because, for example I stubbled across a UK show called 'Midwives' and it was about a maternity ward. Most of the people there are what I would call 'nurses' in the US, even if they are Nurse-Midwives by certification. I was expecting the show to be about something more akin to home-births.

I have an aunt that's a neo-natal nurse, and I've never heard her refer to fellow nurses as midwives (but I've never directly asked her before).

I suspect he means that in some jurisdictions, you need to be a licensed medical practitioner of some sort, so the traditional "on the ground" experience of midwives by itself won't qualify.

In the UK a midwife is a qualified registered specialist nurse.

It's a protected term - you can't call yourself a midwife withoutthe qualification and registration.

Most midwives are employed by the NHS.

Obviously they're not doctors - they can't prescribe medication or perform surgery.

See https://en.wikipedia.org/wiki/Home_birth#United_States

for a bit of insight into the US legal situation.

In the case of my daughter, an uncomplicated pregnancy almost resulted in her death. She had severe MAS when she was born and could not use her lungs. It took a team of nurses and a doctor to keep her alive long enough for a medivac to another hospital with a NICU3. She ended up on ECMO (life-support) for 10 days and a respirator for another week after that.

I have zero doubt that had she been born at home she would have died or had severe brain damage before she could get to a facility capable of saving her.

I am a huge opponent of having children away from medical facilities.

As the GP said, it's uncomplicated until it isn't.

Just to clarify: I think you're saying that the best societal answer is what you suggest. I agree (as I agree with eitally).

The best if-you're-pregnant-right-now solution, though, is different, since currently very few hospitals allow birth in their physical location without a hospital physician.

The calculus in that case is probably a tradeoff of unlikely but very bad outcomes (death by homebirth) vs quite likely somewhat-bad outcomes (unnecessary Caesarean, unnecessary rushing, etc., by hospital), I'd think.

Our son was delivered at a hospital by a midwife that was part of a team of 2 midwives (CPNP/CNM) and 2 doctors (OB/GYN). If things got beyond her capability she could call in the doctors for backup. Our daughter was delivered by one of the doctors due to him being on call.

So, nurse midwifes do deliver in hospitals. I actually think they are not allowed to do home births or they can lose their license.

(In the US)

Agreed. This is how it is done in most hospitals in Germany.

When we had our child in May there were two midwifes with us during the process, the doctor joined once it got serious.

We could have had the child at home or at a birthing house, however we wanted to have the security of knowing that there is surgery available if something should go wrong (the hospital had a special icu for babies, I don't know the english phrase for it, but they basically could do every procedure that might have been necessary).

In addition to that, we really enjoyed the "we don't have to do shit" during the next three days (we got a familiy room, so I could stay with my significant ohter and child. Giving birth at home would have added to the stress (cleaning, getting food, trying to keep visitors away until we had slept a little etc), so for us the hospital was perfect.

That beeing said, I have tremendous respect for midwives. They do a hard job with really shitty hours and a lot of responsibility. And they get screwed over with the insurance, especially in Germany (the premiums for insurance skyrocket while the payment doesn't (http://www.huffingtonpost.co.uk/-camalo-gaskin/the-other-upr...)

It should be noted that in the UK, as opposed to the US and Australia, most births don't have doctors present. Births are normally monitored by a midwife in a maternity ward, as opposed to a doctor in a ob/gen clinic. So the move from a hospital setting into a home setting is not such a big leap in the UK.

Actually, that's the same as Australia: standard procedure in public hospitals is two midwives in a maternity room with 1 doctor on call overseeing the whole ward.

But moving to a home setting still seems like a poor choice. Even ignoring the higher fatality rate for home births, having the doctor available to sew up the 20% of "normal" deliveries involving vaginal tearing seems like a good move.

That's a good point. Our son was delivered by a midwife but due to his size (10 pounds) the OB/GYN came in after to repair the damage caused by delivery. I'm more that a little grateful for that. :O

My wife and I decided to try for a home birth since she had had basically a perfect pregnancy. It may turn out to be the worst decision we ever made. She ended up in second stage (pushing) for 6 hours due to an awkward presentation and was rushed to hospital in an ambulance. She suffered a pretty bad tear and was seriously traumatised by the whole experience - she still has flashbacks almost a year later.

3 months later she suffered a prolapse as a result of the labour. Prolapse is the huge dirty secret of vaginal delivery - one woman in two will suffer some degree of prolapse as a result of childbirth, but probably only one in 5 of those will have it badly enough to have symptoms. But once you have it there's basically no cure and it can be hugely debilitating. My wife has always been very active, when she was younger she was going to try out for the Spanish national handball team, she has always run a lot, and so on. She will never run again, she shouldn't lift any weight at all (not even our daughter), she is basically an invalid by her previous standards. Her sex life has been severely compromised due to nerves in the vaginal wall being crushed - that will never improve either. All this was probably not 100% avoidable but we could have massively improved her odds if we had had access to accurate information ante-natally.

Natural childbirth is the biggest lie we have ever suffered from. If we had known then what we know now she would have had an elective caesarian, and I recommend everyone consider it.

You are arguing from emotion rather than logic.

It's called "empathy", and it's a very valuable cognitive skill. Of course it achieves optimal analytic results when balanced with detachment, causal analysis, and hard statistical reasoning.

But better to have too much empathy than too little -- or none at all.

Having empathy is different that saying that my bad experience should make you consider a c-section.

Of course. But I didn't read that as the main point of the post.

It's true that I'm arguing from emotion, I'm extremely angry about the biased information available to prospective parents. There's plenty of evidence about that in the OP. I'm also arguing based on research I've done subsequent to our daughter's birth. One in ten women will suffer a prolapse with significant symptoms at some point after a vaginal delivery. Because it happens after the birth, not during it, it never gets included in any statistics about birth complications.

Basically, there is zero information about this risk ante-natally, so people cannot make informed decisions. If we had had all the information that we have now before the birth, we would have at the very least considered a c-section and probably insisted on one, which is why I recommend everyone investigate it for themselves and consider it.

Pushing for 6 hours? That's certainly not normal. I'd expect the midwife to rush you to the hospital after 2. Why did your midwife wait so long?

Note that hospital deliveries can also have complications. Due to high blood pressure, my wife had to deliver our first child in the hospital[0], and under the care of the hospital, rather than the midwife[1]. She spent 17 hours in labour, and only after pushing for 2 hours did the hospital's midwife discover that the baby was stuck, which I suspect was a serious fuck up; only after I insisted that they figure out how the baby progressed, did they discover it had been stuck this whole time. While the caesarean team was preparing, the hospital's midwife managed to deliver the baby with a pump. My wife spent the next two years walking like an elderly person due to instability of the pelvis. Fortunately she eventually recovered, and she's in a much better condition now, a few weeks after delivering our second child.

[0] I'm Dutch; home births are the standard here. [1] Our second child was delivered in the hospital but under the care of the midwife; home birth was not an option due to the complications with the first pregnancy.

The midwife waited much longer than I would consider safe with the information I have now - at the time we had no idea of how bad the long term consequences could be, we just knew it was agonising for my wife but everyone always goes on about how painful childbirth is so we had no idea what was normal. We later had an appointment with our attending obstetrician to go over our case notes, and she said that midwives with a stronger focus on natural childbirth will often leave mothers pushing for longer than a hospital or more "conventional" midwife would.

Then getting rushed to hospital takes longer than you'd think - 45 mins end to end for us, and we live in a small town. Once there my wife was assessed for risk, the ob/gyn came about 30 mins later because there didn't seem to be any immediate danger for her, then there's a protocol to be followed before any intervention takes place - it all adds up to a surprisingly long time.

Congratulations on your second child, I'm glad that went well and that your wife has recovered - that's really great.

As long as it's a choice it's OK. But if it is forced onto women by circumstances or even propaganda then it would be a huge step back. I witnessed my son's birth (5 hours with no complications) and I could see how much suffering was saved by an epidural - which would not be an option with a home birth.

I agree that it should definitely be a choice.

That being said, a significant portion of the pain is from giving birth on a hospital bed - or just lying flat in general. It is said (as a man, I have never given birth) that it is less painful, and therefore less in need of an epidural, if the birthing is done in a upright or crouching position. Like how an orangutan does it : http://youtu.be/JfVnFJDjUyQ?t=30s

The very idea of lying down for a birth dates back to the 18th century, when some French king wanted to see the birth of his heir. Of course men were not allowed in the birthing room, so he had to peek through a hole in the wall - or something like that. And the queen had to be in a position that allowed the king to see, so she was lying down facing so the king could see what was going on.

Having witnessed the process, something tells me that a significant portion of the pain is not caused by laying down. So, citation please.

I would like to cite Newton here. Specifically his work on gravity as it applies to motion.

I believe parent meant that position doesn't change size. It may be faster, but one way or another the pain does come from pushing the baby out and potentially making lots of damage to someone's crotch in the process.

You don't have to lie on a bed in the hospital. You can still use a birthing stool or something (assuming the hospital has them, but they're cheap, so there's no reason not to).

5 hours is very fast - did they use pitocin (Oxytocin)? Without pitocin, and without breaking the bag of waters, labor takes much longer (so Dr's hate it), but it hurts much less.

It varies widely.

My wife had two pregnancies: one was 52 hours (with five hours of pushing!). The second was about 2 hours total.

Neither involved pitocin.

5 hours of pushing? Not to mention the 47 hours of labour? That can't be right. Is that really normal? My impression is that after 2 hours, artificial methods get used (pump, caesarean). And that's in Netherland, the country of natural home births.

There are a lot of variabilities in labour.

Labour, yes, but pushing shouldn't take nearly that long.

Yep. Normally doesn't. She made slow but steady progress the whole time, so they never resorted to any other means (besides the aforementioned suction device in the end).

It's right. But it's not normal! After 5 hours we employed a suction device (and would have gone to emergency c-section if that failed after 3 pushes).

Baby was 9 lbs, 9 oz (4.3 kg).

No oxitocin, no breaking of waters, first birth. Of course, YMMV.

“Yes, it’s a very expensive way to deliver healthy babies to healthy women,” Dr. Baker said about hospital births. “Saving money is not a crime.”

This is not a knock against the UK or US healthcare systems at all.

What worries me about this type of thinking is that you're looking at the cost/benefit in the aggregate. Of course, when you're running a national health system you have to. However, this is also happening in the US (the biggest US insurance companies cover 30M+ lives).

You can describe the cost/benefits overall, but it's (mostly) impossible to at the individual level. Sure the average overall survival for an expensive cancer drug might only be 6 months, but if you look at the data you'd likely see that the range if 15 days to 3 years.

Health authorities might make the call that 6 months of additional life isn't work $XX,XXX dollars, but for some of the patients whose life is extended 2-3 years, it certainly is worth it. But in the end, the call is made to not fund the drug.

I have no idea how to solve this issue. I think linking outcome with genetic information is super helpful (it's already being used), but dam, there are a lot of folks out there that could have been helped, but won't be.

NICE is not perfect, but it is not bad at this problem.

Triage is not fun, but even with infinite money it is still necessary, and with finite money it has to be coldly pragmatic.

So NICE has a standard limit of £20,000 per QALY, or up to £30,000 per QALY, if certain extenuating conditions are met.

A QALY being: "A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health. QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to 1 scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance."

The NICE system is a good implementation of rating cost-effectiveness, but it still has the aggregation issue.

If NICE determines that a drug isn't cost-effective, no one gets it (unless you pay out of pocket), regardless if it would have helped that individual patient.

The state of Oregon did a study of the relative risk, and the results aren't pretty: http://www.skepticalob.com/2013/03/oregon-releases-official-....

Indeed, here is her take on the report referenced in the NY Times article that is the OP:

http://www.skepticalob.com/2014/12/new-uk-homebirth-guidelin...

Clearly she has virtually the opposite perspective from the one in the NYT, and one that seems hard to dismiss.

(My kid was delivered in a hospital, and I tell myself that I'm being impartial, but who knows.)

Easy to dismiss, she is biased against any kind of natural birth and uses flawed studies in her arguments.

That is a biased source of information.

She's describing a study commissioned by Oregon, conducted by a midwife.

The study was a retrospective study, they looked at data from birth certificates that did not sort out planned and unplanned homebirths and did not sort out the type of midwife (trained vs untrained). Here is a better study to consider: http://www.ncbi.nlm.nih.gov/pubmed/22015871 .

I think if you want to do a good study, you need to compare a system where home births are the default (like in Netherland) with one where hospital births are the default, but the health care situation is otherwise comparable.

Much better source of information. http://www.scienceandsensibility.org/?p=7625

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