The Home Birth, "Natural" Child Birth, and U.S. Hospital Birth Debate Part I: Hospital Safety, C-Section Rates, and Paternalism

Aaaaah friends.  Just when I vowed to extricate myself from the black hole of vaccine debates and finally start going to bed on time, along came a parallel and equally frustrating universe:  That of the home birth (HB), "natural" child birth (NCB), and U.S. hospital birth debates.  Without further ado, here's what I think you should know about all this:

In direct contradiction to what you might have heard, U.S. hospitals have excellent safety stats.

Although it seems incredible, there is no shortage of NCB/HB proponents who will tell you that "infant mortality" in the U.S. is very high, as if that's a reason you should birth at home and/or live in fear of your healthcare providers.  Alarmingly, many of the people spouting this nonsense are paid birthing "professionals" ("childbirth educators," "doulas," and even so-called CPM "midwives" - paraprofessionals, really).  Here's the deal:  Infant mortality is a statistic counting every baby born alive who dies before 12 months of age.  Ours is high compared to other first-world nations because we lack universal health care coverage and we have bigger pockets of poverty.  

The relevant statistic is perinatal mortality.  Perinatal mortality counts deaths during labor (intrapartum deaths - stillborn babies) and deaths within a week of birth.  Guess what?  We are not too shabby.  The World Heath Organization gives us a rate of .7%, comparable to other Western nations and better than many of them - better than the U.K.   Other Western nations that have us beat generally have a rate of .6%, so just a .1% difference.  You can check out the WHO's report on perinatal mortality here.  And keep in mind that maternal obesity increases the risk of perinatal death by about 20% per every 5 BMI points… so really, our safety stats are actually pretty darn phenomenal.  And that's without universal coverage too!

On our c-section rate.

Speaking of comparative statistics, here's a fact you won't hear from NCB/HB advocates:  Yes, Canada (for example) has a lower c-section rate than we do (22.5% versus 33%).  But their rate of operative vaginal birth (OVB), meaning forceps and vacuum-assisted deliveries, is much higher.  Theirs is 14.9% versus ours, which recently dropped again to 3.5%.  Guess what that means?  It means that our rate of unassisted vaginal delivery is actually just about the same, or higher, than theirs.  And this is true of other comparable nations as well.  Check out the U.K. (12.8%; 25.5% c-section rate), Australia (11.1%), and Ireland (16%).  None of those other nations have our legal climate, and none of them have our (alleged) profit incentives, either.  What gives?  Probably that doctors fear hypoxic brain injury whether or not they also fear a law suit, and whether or not they can charge extra for a c-section.  

Why have our doctors essentially replaced OVBs with c-sections?  It's a complex topic.  If you're interested, I would encourage you to read "The Score" by Atul Gawanda - a fascinating article on the history of childbirth in the U.S.  You should also be aware that there is a new movement to bring back more OVBs - check out the ACOG's press release about the new c-section reduction guidelines.

So why is our c-section rate high, other than our OVB rate being so low?  Here are a few other reasons.

And for the record, I'm not arguing that our c-section rate isn't "high."  I don't know what an "ideal" c-section rate would be for our demographics, and neither does the WHO; the oft-quoted 10-15% is a 27-year old statement that was retracted in 2005.  I'm simply pointing out that our c-section rate is not as comparatively "high" as it's made out to be and that there are many legitimate reasons behind it … reasons you never hear about from NCB proponents or uber-crunchy "mommy blogs."

• Obesity.  As is commonly known, the U.S. obesity rate is the highest in the world.  Nearly 33% of U.S. adults are obese - about 10-12% higher than any other comparable country.  Obesity significantly increases your risk of the following conditions that in turn make it more likely that you'll need a c-section:  (1) high blood pressure; (2) preeclampsia; (3) gestational diabetes; (4) preterm birth; and (5) other complications during labor and birth.  In particular, having a BMI greater than 30 - the technical definition of "obese" - doubles your chance of having a macrosomic baby (a baby 8 lbs 13 oz or more) which, in turn, doubles your chance of needing a c-section.  And as I mentioned above, it significantly increases the risk of perinatal death.  It's a sensitive subject for both patients and doctors but one that cannot be left unaddressed; click here for a thoughtful commentary written by an OB.   
• Herpes.  Genital herpes is significantly more common in the U.S. than in other comparable nations, and it poses serious risks to a baby.  While about half of babies who contract Neonatal Herpes will have no permanent damage if treated with antiviral medications, others will suffer serious neurological damage, mental retardation, or even death.  For that reason, a c-section is standard procedure for any mother with an active outbreak of herpes at time of delivery (10-14% of women with herpes).  Where one in six adults in our nation has herpes (and other sources I checked said higher, 20-25%), this means that herpes alone probably accounts for 2 - 3.5% of our 33% rate of c-sections.  And none of these women are going to tell you the real reason for the c-section.  So next time you hear a suspect reason, keep in mind that you might not know the whole story.
• Advanced Maternal Age Pregnancy.  The younger a mother is (obviously, to a certain point), the less likely she is to need a c-section or an assisted vaginal delivery, and mothers 34 years of age and older are at a significantly increased chance of needing a c-section delivery.  This remains true when we control for the fact that older moms are more likely to electively induce; even naturally occurring labors in older moms are more likely to fail to progress and/or result in a c-section for fetal distress - and moms over 40 are more than twice as likely to have a breech baby (see also this CDC chart, showing c-section rate by age of mother).  Here in the U.S. about 14% of birthing mothers are 35+ years of age - and that was true even back in 2008.  Compare to 11% in Canada and fewer still in most other Western nations.  I suspect that, if anything, our rate has continued to increase over the past six years; indeed, rates did continue to rise in 2013.  Advanced maternal age in pregnancy (and advanced parental age in pregnancy - dads too) also increases the risks of other complications and of certain birth defects including Down syndrome and autism.  So the next time someone tries to tell you that autism is caused by "interventions" like pitocin (or by vaccines), you can remind them that correlation is not the same thing as causation; births to older parents are more likely to produce autistic children and they are more likely to involve complications.  There is no reason to believe that the complications "cause" the autism.
• Multiples.  As maternal age goes up, fertility goes down.  That - coupled with advancements in fertility treatments for couples of all ages - means that multiples are far more common now than they used to be, especially in the U.S. where lots of couples have the resources to pay for them (or health insurance companies are legally required to cover them, as is the case in my state Massachusetts).  While protocol for twin births has recently changed to encourage attempting vaginal birth in situations that meet certain criteria (first twin head down, babies at a healthy weight for their gestational age, and delivery occurs between 37w5d and 38w6d of gestation), 44.2% of attempted vaginal twin births still end either in a c-section (40%) or in a combination vaginal and c-section birth (4.2% - yeeeowch).  To say nothing of triplets, etc.  Check out this article on "The Problem with America's Twin Epidemic." 
• Other Speculative Reasons.  I haven't seen any studies on this but it does seem to make sense that a "melting pot" nation might entail more c-sections or OVBs.  Different races have different builds, and if you mix a larger skull with a narrower pelvis, it does seem like you'd be more likely to run into difficulty (whereas the opposite wouldn't change anything).  I'm thinking of my sister-in-law who, like my husband, is half-Asian and very petite.  She and her much taller, bigger-boned (not a euphemism) Scandinavian-descent husband made a pretty big baby who was delivered with forceps.
• Epidurals.  Nope!  I was just as surprised as you are, but epidurals given at 4 cm dilation and beyond do not increase your chance of having a c-section.  You can read a more thorough discussion of this in my other blog entry "Five Mommy Myths I Believed."  And be aware that many NCB courses teach completely outdated information on pain relief methods.  Did you know that you can now control your epidural such that you can still feel your contractions?  I didn't get an epidural with my #2 until I was over 9 centimeters, and I clicked just enough to make my experience pleasant.  Which it really, really was.  Nor will it make your baby groggy.  I had an epidural for 18 hours with my #1 - he was not groggy and nursed just fine.  The medicine doesn't go into your blood stream; it goes into your spinal cord fluid.  And an epidural can actually relax your pelvic muscles so that you dilate faster.

On the alleged "Paternalism" of U.S. OBs and whether you can expect your hospital experience to be miserable.

If you're following this topic at all, you've likely heard that U.S. hospital births are miserable experiences in which women are utterly disrespected, to the point of being "birth-raped."  Here's what I think is worth noting on this issue:

• It's definitely true that some physicians have terrible bedside manners and/or are incompetent - not even following the current ACOG guidelines themselves.  All professions have incompetent practitioners, midwifery and nursing included.  As someone who sacrifices every day so that my perfectionistic husband can offer the best care possible to his oncology patients, I have to say that I find incompetent and/or slacking doctors really reprehensible.  Physicians who short-change their jobs are not only endangering their own patients, but they are making it more difficult for other people to trust and feel comfortable with medical providers; they are directly fueling the anti-vaxx and the home birth/NCB movements.  Plus, their slacking is making more work for dedicated physicians like my husband - physicians who do care and who will take the time to explain everything to the questioning, misled patient.  
• All that said, many NCB/HB courses and proponents give a highly skewed idea of what a typical hospital birth is like.  This sets women up not only to go into their births with fear, but also to find things wrong with their experiences that are not, in fact, wrong.  Here's an article with statistics on that, but possibly more compellingly, here is my friend Dani's blog that describes what she was led to expect from a hospital birth versus what her experience actually was, when she ended up unable to avoid one.  She's a doula, by the way, and remains supportive of natural child birth… but she's science-based and she doesn't inflate the "benefits."  
• On "pushing interventions" - I really think it's of utmost importance that physicians explain why they are "pushing" an intervention; if they don't, they're leaving the door WIDE open for some new mom's friend to tell her that her birth was "ruined" for no reason - and that will happen.  I hear so many stories where (allegedly, anyway) all the OB says is "I feel strongly that we should do X right now."  No.  If studies show that given the conditions presented, there would be a 5 per thousand (.5%) increase of perinatal mortality if, for example, labor continues past a certain time, tell the patient!  Tell them that since you deliver an average of 500 babies per year, you WILL SEE babies die or be born damaged who didn't have to be, if you aren't risk-averse!  Admit to them that yes, not intervening might significantly increase their chance of a vaginal delivery… but tell them that in your opinion, even a small risk to the baby's life or long term health isn't worth even a significantly greater chance of a vaginal birth!  And please be sure to also tell the women who are not fighting or questioning you!  They are questioning in their minds but too polite and/or overwhelmed to ask, and they deserve to know.
• Meanwhile, some patients need to realize that the laboring mother is NOT the OB's only patient. The baby is equally the OB's patient and the OB's highest duty is to protect life, not to avoid c-sections.  
• Did you know that over 80% of current OB residents are female, and OBs as a demographic are getting younger?  These women are feminists and trail-blazers ... they're strong and dedicated women who usually care deeply about getting it right.  They're not out to cut you open for money.  When I asked my OB about an induction at 39 weeks with my second baby (because of my first baby's macrosomia) she strongly discouraged it.  Now… compare all that to the roots of the NCB movement:  Male physicians deciding that childbirth pain was all in women's heads.  And to the current NCB movement - paraprofessionals feeding women inaccurate, misleading, and false information in order to make their system look more necessary than it actually is - see my other post on myths about epidurals and 41 week inductions.  Who's paternalistic now?  And whose business is completely dependent on all this ... and who has the luxury (and the scientific resources) to simply seek truth?  I'll give you a clue:  Home births represent .5-1% of all U.S. births - ZERO impact on any OB's salary.  But they represent 100% of the revenue for home birth practitioners.
• I often see the idea perpetuated that OBs will perform a c-section because it's "better for their schedule."  ????  Are you living in a rural area?  I labored 15 hours at home and 18 more at the hospital.  I went through at least two OBs; when their shift was over, they left.  My labor didn't make any difference to anybody's work schedule.   

I have to cut this off for tonight.  But here's some food for thought:  If you didn't like your attorney, or you suspected that he or she was incompetent, would you replace your attorney with a paralegal or a legal secretary?  Why not just find a better attorney?  CPMs (lay midwives) and "childbirth educators" are not professionals.  No professional organization is holding them accountable for anything they say or present to you.  Compare that to OBs and hospital-based CNMs (nurse midwives) who function as part of a team under layers of accountability in hospital settings - oversight boards, patient satisfaction surveys, safety protocols, and potential legal action.  It's cost-prohibitive to sue CPMs or "lay midwives" because they don't carry malpractice insurance … more on that later.

Like vaccines, the best answer here is to find a physician or hospital-based CNM you trust.  Just as surely as you cannot adequately represent yourself in court (or fly your own airplane), you cannot be your own "best" physician via google, mommy blogs, or any other non-science based source.  

Part II discusses the dangers of U.S. home birth and how NCB propaganda fuels home births.

My first baby was 9 lbs 10 oz and at a bad angle for pushing, as seen in his swollen-shut eye.
As with many macrosomic (8 lbs 13 oz+) babies, my labor (NOT induced) was protracted -
15 hours at home to get to a 4, 18 more before he came out.
His head was 99/100th percentile circumference, and It.  Was.  Stuck.

My second baby was a full 3 lbs lighter and with a much smaller head.  She came out in 5 pushes.

My OB is a mom herself.
She strongly discouraged my request for a 39-week induction with #2,
which I made because of #1's macrosomia.
… was that "paternalistic" of her?
… did she "push" a natural childbirth on me??
(Irony intended).

Click HERE for Part II.