
British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies - acsillag
http://www.nytimes.com/2014/12/04/world/british-regulator-urges-home-births-over-hospitals-for-uncomplicated-pregnancies.html
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mturmon
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.

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

~~~
scott_karana
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.

~~~
DanBC
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.

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525
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
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
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

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lemming
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
You are arguing from emotion rather than logic.

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

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

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

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

~~~
viraptor
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.

------
refurb
_“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
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
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.

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

~~~
tarminian
That is a biased source of information.

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

~~~
tarminian
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)
.

~~~
mcv
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.

