8 ms·

British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies

42 points by acsillag 12y ago

fishnchips 12y ago
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.
- 525 12y ago
  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 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.
  - ryanhuff 12y ago
    Having witnessed the process, something tells me that a significant portion of the pain is not caused by laying down. So, citation please.
    - lotsofmangos 12y ago
      I would like to cite Newton here. Specifically his work on gravity as it applies to motion.
      - viraptor 12y ago
        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.
  - mcv 12y ago
    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).
- ars 12y ago
  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.
  - oaktowner 12y ago
    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.
    - mcv 12y ago
      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.
      - tarminian 12y ago
        There are a lot of variabilities in labour.
        mcv 12y ago
        Labour, yes, but pushing shouldn't take nearly that long.
        oaktowner 12y ago
        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).
      - oaktowner 12y ago
        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).
525 12y ago
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.
- gilgoomesh 12y ago
  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.
  - lsaferite 12y ago
    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
adamtj 12y ago
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.
- eitally 12y ago
  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/ 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/ 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.
  - inglesp 12y ago
    Can you expand a bit on what you mean by "midwifery is illegal"? To me, that sounds as odd as "dentistry is illegal" ...
    - deleted 12y ago
      [deleted]
    - pyre 12y ago
      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).
mturmon 12y ago
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.
refurb 12y ago
“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.
- lotsofmangos 12y ago
  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."
  - refurb 12y ago
    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.
rayiner 12y ago
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-homebirth-death-rates-and-they-are-hideous.html http://www.skepticalob.com/2013/03/oregon-releases-official-....
- mturmon 12y ago
  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-guidelines-midwives-win-babies-lose.html 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.)
  - tarminian 12y ago
    Easy to dismiss, she is biased against any kind of natural birth and uses flawed studies in her arguments.
- tarminian 12y ago
  That is a biased source of information.
  - rayiner 12y ago
    She's describing a study commissioned by Oregon, conducted by a midwife.
    - tarminian 12y ago
      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 http://www.ncbi.nlm.nih.gov/pubmed/22015871 .
lemming 12y ago
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.
- tarminian 12y ago
  You are arguing from emotion rather than logic.
  - dreamweapon 12y ago
    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.
    - tarminian 12y ago
      Having empathy is different that saying that my bad experience should make you consider a c-section.

42 points by acsillag 12y ago

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.

525 12y ago
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 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.
- ryanhuff 12y ago
  Having witnessed the process, something tells me that a significant portion of the pain is not caused by laying down. So, citation please.
  - lotsofmangos 12y ago
    I would like to cite Newton here. Specifically his work on gravity as it applies to motion.
    - viraptor 12y ago
      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.
- mcv 12y ago
  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).
ars 12y ago
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.
- oaktowner 12y ago
  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.
  - mcv 12y ago
    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.
    - tarminian 12y ago
      There are a lot of variabilities in labour.
      - mcv 12y ago
        Labour, yes, but pushing shouldn't take nearly that long.
        oaktowner 12y ago
        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).
    - oaktowner 12y ago
      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).

525 12y ago

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.

gilgoomesh 12y ago
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.
- lsaferite 12y ago
  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

adamtj 12y ago

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.

eitally 12y ago
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/ 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/ 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.
- inglesp 12y ago
  Can you expand a bit on what you mean by "midwifery is illegal"? To me, that sounds as odd as "dentistry is illegal" ...
  - deleted 12y ago
    [deleted]
  - pyre 12y ago
    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).

mturmon 12y ago

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.

refurb 12y ago

“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.

lotsofmangos 12y ago
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."
- refurb 12y ago
  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.

rayiner 12y ago

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-homebirth-death-rates-and-they-are-hideous.html http://www.skepticalob.com/2013/03/oregon-releases-official-....

mturmon 12y ago
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-guidelines-midwives-win-babies-lose.html 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.)
- tarminian 12y ago
  Easy to dismiss, she is biased against any kind of natural birth and uses flawed studies in her arguments.
tarminian 12y ago
That is a biased source of information.
- rayiner 12y ago
  She's describing a study commissioned by Oregon, conducted by a midwife.
  - tarminian 12y ago
    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 http://www.ncbi.nlm.nih.gov/pubmed/22015871 .

lemming 12y ago

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.

tarminian 12y ago
You are arguing from emotion rather than logic.
- dreamweapon 12y ago
  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.
  - tarminian 12y ago
    Having empathy is different that saying that my bad experience should make you consider a c-section.