Friday Fallacies: The Hospital Is Just Minutes Away

Anytime you come across someone defending homebirth, you’re going to hear that you can always transfer in case of an emergency. It comes up in almost every thread where someone mentions qualms — be it their own, their partner’s or their mother-in-law’s — about giving birth at home.
etc., etc., etc. This sentiment is all over the internet.
The problem with birth, however, is that when things go wrong, they go very, very wrong. And it can happen quickly. Cord accidents, uterine rupture, placental abruption, hemorrhage…all can occur in a matter of minutes, and all can be deadly.

There are plenty of problems with the “The hospital is only minutes away!” platitude with which all these women are comforting their worried family members.

One is the idea that being “ten minutes” from a hospital means that you can go from realizing there’s a problem to having the baby out and alive in ten minutes. This scenario is certainly realistic. IF YOU’RE ALREADY IN THE HOSPITAL. The hospital where I volunteer as a doula can perform a stat c-section in eight minutes.

If you’re having a homebirth, however, it simply isn’t going to happen. Let’s assume you got lucky and managed to hire a midwife who is not only competent enough to recognize a serious emergent situation and recommend a transfer in a timely fashion, but has a relationship with a hospital where they trust her judgement (read: this is a CNM). This midwife must also have accurate and complete records and bring the chart with her to the hospital. Now, this seems like a no-brainer, but ask these women or any number of L&D nurses that I know, and you will learn that it is sadly uncommon. But I digress.

You will have to get to the ER somehow. If you’ve called EMS, it will probably take them a minimum ten minutes to get to your house, five to ten minutes to grab you, load you in and get the hell out, and another ten minutes to get to the ER. Hopefully the paramedics have called in to let them know what to expect and the OBs are racing to the ER to meet you. If you don’t call an ambulance, it might take less time to get to the hospital (or not, seeing that your laboring body probably isn’t moving too quickly), but you don’t have the call ahead or stabilization the paramedics could provide.

Once you’ve arrived, an entire team flocks to you, hooking up monitors and placing IVs, all while trying to get the appropriate details. Since you’ve had all your care at home, the hospital has no records; if you had been laboring in the hospital, the history and physical notes, progress notes, labs (you’re going to need your blood typed and crossed for surgery), and IV sites WOULD ALREADY BE DONE. If you are dehydrated from laboring for an extended period of time or from an attempt to induce your labor using castor oil, they will have a hard time inserting the IV, which could cost precious minutes. They will use a portable ultrasound to check the baby unless the head (or body, as in the Lucian Kolberstein and Henry Bizzell cases) is out, in which case they will attempt to get the baby out or head straight for the OR. Even the very best and most efficient team is going to take an additional ten minutes after you show up in the ER to have you prepped and in the OR for an emergency cesarean, and that’s with rapid intubation and general anesthesia. The BEST CASE scenario is 30-45 minutes, not the eight it would take if you were already there.

Now, this scenario only applies if you happen to live in an area with a large teaching hospital and on-call OBs 24/7. What happens when the closest hospital is a smaller community hospital? More than likely, the only doctor there is going to be an ER doctor, not an obstetrician. The OB will have to be called in, as an ER doctor isn’t going to perform a cesarean unless you are dead and your baby is still alive, and may live up to 30 minutes away from the hospital. If the ER doctor is able to deliver your baby — which he hasn’t done since med school — he or she may be the only doctor at the hospital, so the focus will be split between you and your child. He or she may not have intubated an neonate since med school, either. He or she may not be required to have a neonatal resuscitation certification. By the time the OB and pediatrician arrive, an hour may have passed since your midwife first realized you were in desperate need of a transfer.

Do you want to go for an hour without breathing? What makes you think your baby does?

Friday Fallacy: The US Infant Mortality Rate is Worse than that of the “Third World”

A favorite argument in the anti-hospital contingent is that the US infant mortality rate is SO BAD, that it is worse than “third world” countries.

There are many things wrong with the above argument, not the least of which is that the US “has more infant mortality than most other countries, including 3rd world.” You’d think maybe this was one lone internet warrior, but the argument is everywhere.

My favorite part is that both of these women claim that anyone who doesn’t accept what they say just hasn’t done the research. Anyone want a drink?

Before I say anything else, let me mention that “third world” is an outdated term, and we now use “developing countries” to describe, well, developing countries. But, as I often do on this blog, I digress.

There are two things wrong with this argument. First, it simply isn’t true. The US infant mortality rate, while higher than it should be, in my opinion, is nowhere near the rates of developing nations. Let’s have a look at this map:

Huh. Would you look at that. We’re in the same basic category as all of Europe, Japan, South Korea, Australia…

A graph is a little more your style? Well, here you go:

Again, there is always improvement to be made when it comes to any kind of mortality, and the US rate is higher than many developed nations (The WHO says the American rate is a 5, and countries like Canada, the UK, New Zealand, and Ireland, are a 4 and many Scandinavian countries are a 3. Countries like Poland and Hungary are a 6.), but the United States is nothing like a “third world” country when it comes to infant mortality. We’re far lower than the world average.

The other  — larger — problem with this argument, is that infant mortality is not a measure of maternity care, it is a measure of pediatric care. It covers babies from birth through a year of age. The correct statistic to use is perinatal mortality, which is through 27 days of life. So how does US perinatal mortality measure up?

Have a gander. I used the data from the list of countries that the World Bank considers “high income or developed” to make my graph (I left out Trinidad and Tobago, as the World Bank has given them an asterisk and their PMR is significantly higher than all other nations on the list including, of course, the United States):

The US has numbers equal to or better than 18 of the 31 nations, including Great Britain, France, Finland, Denmark, the Netherlands, etc. In the category of perinatal mortality, the US does much better in comparison to the rest of the developed world than they do with infant mortality. Again, there is always room for improvement when it comes to death rates, but it is a flat out lie that the United States is on par with developing nations in this regard.

No Matter How You Run The Numbers, The Result Remains the Same:

Homebirth, with or without a non-CNM midwife, is more dangerous than giving birth in the hospital.

Keeping in mind that homebirth midwives all claim to work with only low-risk women, lets look at the numbers I posted Friday:

“This Must Be a Joke” rants and raves in the comments of the previous post, calls me biased and stupid, and claims I shouldn’t have used the numbers from 32 weeks on. Other than the insults, she has a point. (I assume she is a she. If not, I apologize profoundly.) So I re-ran the numbers. Several times. Keep in mind that homebirth midwives all claim to work only with low-risk women. If women are having footling breech babies at home, it is only because some CPMs and DEMs lack the education and skill to diagnose the problem ahead of time and are shocked to see feet coming out first down the birth canal.  Or they believe that breech is just a “variation of normal” and low risk enough for birth at home. But I digress. We’ll compare the “other midwife” category (Notice this is midwives who are not CNMs we’re talking about here. There are no women in this category who intended to give birth with their OB at the hospital and somehow ended up giving birth with a midwife in their car on the way instead) with both the hospital numbers that include high risk hospital births — those attended by all hospital caregivers — and those that are only low risk, which are the births attended by CNMs.

Here are the numbers from 37 weeks on:

 hmmm. Looks like homebirth midwives are doing even worse in comparison to the hospital than they were in the 32 weeks-and-beyond numbers. How could that be? Because the 32 week numbers were increasing the hospital death rates! Once the pregnancy approaches term, hospital numbers improve, but it sure looks like the homebirth midwives don’t. Keep in mind, homebirth midwives claim to work only with low-risk women. But wait! These numbers include those babies born before 39 weeks. We all know those are slightly more dangerous than those born after 40 weeks. What happens if you throw out weeks 37 through 39?

 

Even WORSE numbers for homebirth! The homebirth death rate with an other-than-CNM midwife is now virtually TWO TIMES the higher risk hospital numbers, and more than three times the lower-risk CNM numbers. Keep in mind that homebirth midwives claim they work only with low-risk women. But wait, that 42nd week can get dicey! Totally ignoring the fact that most homebirth midwives claim there’s no expiration date on pregnancy, lets just take that out of the numbers. SURELY that must be the problem for homebirth midwives.

 

 

Hmmmm…nope!  While in all three cases above — while their numbers are slightly higher than CNMs working in the hospital — homebirth CNMs have a much more reasonable rate of death than other homebirth midwife death rates, which are yet again twice as high as higher risk hospital rates and more than three times as high as lower risk hospital rates.

Ahhh, but then we have another commentor, NaturalMamaNZ, who takes issue with my numbers. She complains that I have not properly accounted for confounding factors. Fair enough, she could be right. However, a confounding variable in this case would be high risk situations- but it’s quite an anomaly because midwives themselves accept high risk patients — all the while claiming to accept only low risk patients — and create high risk situations (remember, there’s no expiration date on pregnancy…) so there is really no way to seperate that from the data because that would be “cherry picking” good numbers, just like Johnson and Daviss did in NaturalmamaNZ’s favorite study. The data shows what it shows because of the current unregulation of midwifery and the carelessness in their want to accept patients of all levels of risk. Other confounding variables can easily be accounted for by changing the comparison groups to make them more alike. In this case, I changed the search criteria to include the same criteria Johnson and Daviss used – U.S. non-hispanic white neonates of 37 weeks + gestation. I further narrowed the criteria to women between the ages of 25 and 45 attended by the “other midwife” category, in order to remove any higher risk teen moms. I also only included those women with 12 years or more of education, meaning those who are, at a minimum, high school graduates.

 

 

 

WHAT? These numbers are even higher!!! Two times higher than the higher risk hospital births, the ones that include all caregivers, malpresentations, fatal birth defects, and so on,  and MORE THAN THREE times higher than those numbers for the low risk women who deliver with CNMs in the hospital.

But I can hear it now. “This must be a joke” will not stand for the fact that I left women up to age 45 in the group, because we all know they are higher risk. And those numbers include other potential confounders — single mothers, lack of prenatal care, twins, etc., etc. OK. Lets run these numbers, then: non-Hispanic white, singleton, 37 weeks + gestation neonates born to married women ages 25-39 with a minimum 12 years of schooling who started prenatal care before the 7th month of pregnancy. Surely these women — who are the epitome of the woman who hires a homebirth midwife in the US — will have stats that show that homebirth is safe!

 

I’m shocked. SHOCKED. (that’s sarcasm, for those of you who couldn’t tell. By the time I ran these numbers, I had ceased to find any of it shocking. I kept thinking I would be proven wrong with the next set, but alas, it wasn’t the case). These numbers are just as bad. Two times as high for the higher risk hospital births, and three times as high for the lower risk ones.

These numbers are sad. Yes, sad. They represent PREVENTABLE deaths.  Preventable by restricting the kinds of births that homebirth midwives can attend and requiring much higher standards for CPM/DEM education.  Or, better yet, doing away with CPMs and DEMs altogether and requiring a CNM to attend h0mebirths.

(Keep in mind that homebirth midwives claim they work only with low-risk women.)

Friday Fallacy: The Netherlands Are a Fantastic Model When it Comes to Birth

It’s on every birth blog and pregnancy forum out there: the claim that, because the Netherlands has a high rate of homebirth, the country is some sort of exemplar for how birth should be done.

Case in point:

(side note: I love how not only do they delete any information that doesn’t fit their world view on their pages, but they flounce whenever they find a page that doesn’t delete it.)

First of all, the homebirth rate in Hollandthe Netherlands is nowhere near 92%. In fact, it’s currently around 29% and rapidly declining. Why is it declining you ask? Maybe it’s because they have some of the worst birth statistics in all of Europe.

According to a 2010 study published in the British Medical Journal, The Netherlands has a shockingly high perinatal mortality rate, one of the highest among European nations. In the study, the researchers found that infants of LOW RISK pregnant women whose labor started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU compared with infants of HIGH RISK pregnant women whose labor started in secondary care under the supervision of an obstetrician. Doesn’t sounds like all those Dutch homebirths are lowering the perinatal mortality rate to me.

And what about maternal health? That’s an indicator of the level of maternity care, too, right? Well, even with it’s relatively heterogeneous population and universal access to healthcare, the Netherlands has consistently had one of the highest maternal mortality rates in Europe as well, especially in the last 10 years.

You’ll notice that even though the Netherlands has by far the lowest c-section rate in Europe, they have a much higher maternal mortality rate than, say, Italy, whose rate of cesarean delivery exceeds 40%.

So…the next time you see someone lauding the Netherlands for their fabulous statistics, ask them for their proof. Chances are they don’t have any, because this country’s stats SUCK when it comes to maternity care.

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