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Wednesday, November 30, 2011

Is Homebirth Safe? What Can Go Wrong in a Hospital Birth?

This is post 2 in my series entitled "Why Homebirth?"

  • Midwives aren't able to handle complications during labor.
  • Being in a hospital will be less dangerous for the mother and the baby; too many things can go wrong quickly during childbirth for it to be safe to have a homebirth.
  • The reason fewer women and babies die during childbirth today is because its became standard practice to give birth in a hospital and midwife usage and homebirth rates have gone down.
  • Hospitals save lives.
  • Hospital births are totally safe.

Have you ever said or thought any of the above, or something along those lines? Have you ever heard anyone say any of the above, or something along those lines?

If you haven't either said these, thought these, or heard these, then I'm shocked. Because these are the most common arguments used against homebirth. In fact, even in the post I wrote about how I came to decide to homebirth, I got some of these in the comments, or comments echoing those thoughts.

But, for the sake of intellectual honesty here, are these statements true? That is what this post will address, but in a nutshell:

  • Midwives aren't able to handle complications during labor. Yes they are, for the most part. Some complications they're even able to handle better than hospitals.
  • Being in a hospital will be less dangerous for the mother and the baby; too many things can go wrong quickly during childbirth for it to be safe to have a homebirth. Statistics and studies show otherwise and prove this statement false.
  • The reason fewer women and babies die during childbirth today is because its became standard practice to give birth in a hospital and midwife usage and homebirth rates have gone down. Again, statistics and studies prove this statement wrong. In fact, the US has one of the highest maternal and infant mortality rates in the civilized world, even though 99% of births occur in hospitals.
  • Hospitals save lives. In many cases yes. In many cases, they're the reason lives are lost.
  • Hospital births are totally safe. No they're not. Then again, neither are homebirths.

Ok, those were really in a nutshell. But my point is to show that no, these statements aren't veritable truths. In fact, some are falsehoods either purposely disseminated or passed around because of lack of knowledge of how homebirth works or lack of knowledge about the possible problems involved in hospital births.

Before I get into it further, I need to clarify something.

Homebirths are not 100% safe. Things can go wrong in a homebirth. There are mothers who die in childbirth in a homebirth, and there are babies who die because of a homebirth suddenly turned problematic.
However-
Hospital births are not 100% safe. Things can go wrong in hospital births. There are mothers who die in childbirth or from ensuing complications in hospitals, even with the "best of care". There are babies who die in hospitals during or immediately after childbirth because of complications of childbirth.

No birth is 100% safe. In fact, birth, no matter whether at home, unmedicated, in the hospital unmedicated, in the hospital medicated, in the hospital via cesearian, is fraught with potential risks, and anyone who tries to tell you otherwise is pulling the wool over your eyes.
Either choice you make, whether to have a home birth or a hospital birth, is not going to guarantee a healthy outcome for mother and baby. At most, you can weigh the risks and benefits, and choose from there which is less risky, not which is risk free.

So, which is less risky? Home birth or hospital birth?

Well, if you have a high risk pregnancy, there is no doubt about it that giving birth in a hospital is safer. A friend of mine has a chronic problematic heart condition- if she were to fathom having a homebirth, I'd give her a severe talking to, because having a homebirth would be putting her's and the baby's lives in danger needlessly. As much as I don't judge people's choices for birth, I have no problem saying that hospital births are much safer both for the mother and for the child in high risk births. This includes but is not limited to premature babies, placenta previa, placenta acreta, placental issues, multiples, heart conditions, blood clotting conditions, etc...

However, studies have shown that low risk homebirths attended by qualified midwives, within a 30 minute drive of the nearest hospital with an OR, have the exact same rate of maternal and neonatal deaths as hospitals. That means, they're just as safe, or just as risky (depending which way you want to look at it) as a hospital birth, in terms of lives lost.
However, that is just talking about deaths. The rate of non-death complications and interventions for the mother or baby is actually lower in homebirths than in hospital births. Meaning, the same amount of people die either way, but of those that survive childbirth, people having done homebirths are better off than those with hospital births. (If you'd like to see a list of studies, this page has a long list of them, too long for me to list here, but here is one notable study.)

In the UK, the Royal College of Obstetricians and Gynecologists put out a statement saying:
The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.
Ok, so now we see that there are studies that show that homebirths for low risk pregnancies are just as safe, if not safer than hospital births.
How can that be? What can go wrong in a hospital birth that would make it just as unsafe as a homebirth, if not more unsafe? Isn't a hospital supposed to give as terrific care as possible?

Problems with Hospitals

First of all, I do need to preface this by saying I'm not anti hospitals. My sons were both hospitalized at approximately 4 months old with extremely low blood oxygen levels due to RSV (one with pneumonia, one with bronchitis), and I am really appreciative of the care they got there, which either saved their lives or at the very least, prevented long term damage due to oxygen deprivation. Hospitals are terrific and I am glad I live in the vicinity of 4 very good hospitals for times that they truly are needed.

However, that said, there are some truths about hospitals that go hand in hand with why a hospital may not be the best place necessarily to give birth in a low risk pregnancy.

  • Hospitals are for sick people; doctors there are trained to look out for, spot, and handle problems, sometimes finding problems even when they don't exist. They're alarmists by nature.
  • Reducing liability is an important concern for hospitals. With rampant malpractice suits being filed all the time, even when proper protocol is followed and the best care is given, doctors and hospitals try to make sure that no one can sue them for not doing "everything they possibly can", which often leads to interventions that aren't necessary that are done “just to be on the safe side” and .minimize risk of litigation.
  • Hospitals are a business. They may be in a service business, a business meant to help people, but they do make more money for certain things than for others, and they do have a certain amount of money they need to bring in so as to not “go under”. Even the best hospitals are run by humans; its to be expected that hospital policy and specific recommended interventions may be influenced by the monetary aspect involved.
None of these aforementioned points make hospitals bad or evil or problematic. However, these points may easily make the hospital's priorities be different than yours if you desire a completely natural and intervention free birth, which may conflict with the hospital's main concerns.


What can go wrong with a hospital birth? How can hospital policy cause problems?

One thing said about hospitals and their policies is that one intervention leads to another. Is that true? Lets take a look.

Lack of Comfort. Did you know that if an animal is in labor, and then the mother is chased by a predator, the labor will stop entirely, allowing the mother to pick up and move to a safer place, where she can resume her labor free of danger? There are many hormones at play during labor, the biggest and most important one being oxytocin. Oxytocin causes the uterus to contract to open the cervix and help push the baby down and out of the birth canal.
When a person or animal is stressed out, the body's nervous system puts them into "fight or flight" mode, where adrenaline is released to help the person either stave off the attack or run away. Adrenaline counteracts the oxytocin in the system, and this is what stops labor for an animal when she is in danger.
When a person is stressed out during labor, their adrenaline starts pumping, which counteracts their oxytocin, and this an either slow or even completely stall labor.
In order for labor to progress as easily as possible, the woman needs to be as stress free and relaxed as possible. If the woman is stressed, it can cause her labor to be much longer than necessary, or even stall completely. If a woman gets stressed out by being in the hospital (either because its unfamiliar, because she has bad associations with hospitals, or because she constantly is needing to fight with the hospital staff), this can cause problems with her labor, which could easily lead to other interventions. Mom needs to be in a place where she can fully relax to have as short and easy of a labor as possible.

The Ticking Clock. Every woman, and every individual labor, has its own unique pace. Some women and labors are extremely fast, with less than 2 hours from the first contraction until the babies are out, some women have longer labors, like my 18 and 19 hour labors, and some women have really long labors, like 5 days or so. Each of these lengths of labors are natural and normal; barring really rare cases, all babies will come out eventually and labor will end, even if the length of time of one labor can be radically different than another labor. There's nothing wrong or dangerous with long labors (generally), even if they are dreadfully annoying.
Hospital policy, however, is that labor should progress at a certain rate, otherwise it is considered to be stalled, and hospitals will be on your case to try to move things along, even if you'd be content to let labor take its own pace. (This happened to me last birth; I'll expand on that in another homebirth post in this series.) That is why they say that once you get admitted to the hospital, the clock starts ticking.
You don't have unlimited time to get the baby out. Maybe its because there isn't unlimited space in hospitals and hospital policy is designed to keep as many Labor and Delivery rooms free as possible; who knows?
But whatever the reason is, the fact remains that in almost every hospital and in almost every case, you're not given the freedom to labor without intervention if your labor isn't progressing “fast enough” according to the hospital's official policies. The standard interventions used for “stalled labor” is either artificial rupture of membranes (AROM for short) or pitocin.

AROM, also known as “breaking your waters”, is when a device is used to puncture the amniotic sac during or before labor. By doing this, often contractions either start or become more intense. Yes, some people have their “water break” on their own (called spontaneous rupture of membranes), but when it is done by hospital staff, it is considered to be an intervention. And it, as with all interventions, is not free from risk.
AROM done when the baby is not fully engaged can cause cord prolapse- the cord to come out past the cervix and be compressed by the baby's head. This can put the baby into distress (the cord is how the baby gets oxygen, etc...), necessitating an emergency Cesarean.
AROM → Emergency Cesarean (The arrows here show which intervention often leads to the next intervention in the hospital, and that is what all of these similar things in the post are intending to show.)
Even when cord prolapse doesn't occur, AROM is problematic specifically because of the aforementioned ticking clock at the hospital. Hospitals, because of fear of infection, will only allow a woman to go with her waters broken a certain amount of time before they will insist on either more interventions (usually pitocin) or emergency Cesarean section.
AROM → Pitocin

Pitocin, however, is not without risk.
Pitocin is the synthetic version of the hormone oxytocin, the hormone that causes the uterus to contract (among other things). Pitocin, unlike oxytocin, causes contractions that are more frequent and more intense than regular contractions. These contractions, in addition to causing the mother more pain than she would feel from regular contractions, also is harder for the baby to handle in utero, making fetal distress much more likely to be diagnosed. Fetal distress is nearly always the reason for emergency Cesareans. Pitocin, therefore, makes an emergency Cesarean far more likely, because of the fetal distress it can cause. And pitocin, often, is given not because of any specific problems in labor, but just because labor isn't progressing as fast as the hospital would like it to.
Hospital's ticking clock → Pitocin → Emergency cesareans. 
Even when pitocin doesn't end up causing fetal distress, the intense contractions are typically too much for the mother to bear on her own. Most women who go on pitocin end up opting for epidurals, even women who otherwise would go without epidurals.
Hospital's ticking clock → Pitocin → Epidural.

Epidurals, coined a wonder drug, a miracle by those non particularly “natural minded” mothers, who would prefer to eliminate the pain of childbirth as much as possible, works by inserting anesthetic via a needle between two vertebrae into the epidural space in the mother's spinal column. But are epidurals actually without risk at all?
Epidurals, unfortunately, do have potential negative side effects for the mother, ranging from the most common and mild headaches and backaches to the much rarer paraplegia or even maternal death. (You can read more about potential side effects of epidurals here; I'm not elaborating here because my point isn't to guilt trip mothers who chose to get epidurals, but rather to show how one intervention can lead to another).
Epidurals have been known to slow down labor, which often makes hospitals push for labor augmentation via pitocin, which can cause fetal distress, which generally leads to Cesarean sections.
Hospital's ticking clock → Pitocin → Epidural → More pitocin → Cesarean section
Epidural → Pitocin → Cesarean section
Epidurals, because they numb the lower half of the body, make the pushing stage more challenging, and possibly cause the mother to push ineffectively, which can make the baby take “too long to come out”. When the baby is “taking too long to come out”, doctors sometimes misdiagnose this as cephalopelvic disproportion.
Cephalopelvic disproportion is when the baby's skull is too big to actually fit through the mother's pelvis, and is, in fact, very, very rare. Babies' skulls are made of many plates that, during labor and delivery, will overlap each other and mold into a cone type shape, to shrink the circumference of the head and allow for easier passage through the pelvic outlet, given enough time.
The pelvic bones are also not one solid mass. They're made up of a few different bones connected by various ligaments which, due to pregnancy hormones, loosen during pregnancy to allow some extra room. (This loosening of the ligaments is what causes symphysis pubis dysfunction during pregnancy; something I plan on writing about in a future post.) In addition to the loosened ligaments, the bones in the pelvis do move apart during labor to make more room for the baby to descend.
During a hospital birth with an epidural, women generally delivery in what is referred to as the lithotomy position- lying down on the back with the legs up in stirrups. The lithotomy position puts pressure on a woman's pelvis and doesn't allow the bones to move to make room for a baby to descend. This makes misdiagnoses of cephlopelvic disproportion more common, leading to Cesareans which could have been avoided if the woman were able to make more room in her pelvis by delivering in a position other than the lithotomy position, which isn't really possible with an epidural.
Hospital's ticking clock → Pitocin → Epidural → Cesarean section
Epidural → Cesarean section
Because the delivery position and numbness with an epidural make the pushing stage more challenging, often the hospital staff will push for or insist on an assisted delivery via forceps, vacuum, and/or episiotomies.
Epidural → Forceps/vacuum assisted delivery → Episiotomy
Epidural → Episiotomy


Fetal Heartrate Monitoring. Another of the standard “non intervention” interventions in the hospital is fetal monitoring. Fetal heartrate monitoring (monitoring, for short) measures the fetus's heartrate to make sure that the baby is handling labor ok. It may seem that this can only serve to be beneficial to the mother and baby, but even fetal heartrate monitoring, the “least invasive” of the standard hospital inverventions, can cause problems in labor and lead to further interventions.
There are two main types of monitoring- internal and external. External monitors check the baby's heartrate via sensors strapped to the mother's belly; internal monitors consist of an electrode screwed into the baby's scalp and a sensor placed into the uterine cavity. Internal monitors can only be done once the amniotic sac is broken, and many times the doctor will rupture the amniotic sac in order to place an internal fetal monitor.
Internal fetal heartrate monitoring → Artificial rupture of membrane
Internal fetal heartrate monitoring → AROM → Emergency Cesarean
Internal fetal heartrate monitoring → AROM → Pitocin → Emergency Cesareans.
Internal fetal monitoring can also introduce vaginal bacteria into the uterus, causing a possible uterine infection. Internal monitoring can also lead to infections in the baby.
Both internal and external fetal monitoring often have false positive results, meaning, they assume that the baby is in distress when the baby is, in fact, fine. Babies heartrates are constantly changing during labor, with decelerations during contractions and while sleeping, and excellerations while the baby is awake and more active. Taking hot showers also will raise the baby's heartrate. Because of this, constant fetal monitoring can lead to diagnoses of fetal distress, which causes the doctors to push for an emergency Cesarean when the baby really wasn't in distress in the first place. Intermittent fetal monitoring, such as with a fetoscope, is much more accurate with less of a likelihood of false positives leading to unnecessary Cesareans.
Fetal monitoring → Emergency Cesareans.
Fetal monitors often aren't so sensitive; movement can make them lose the heartbeat. When hospitals insist on constant monitoring, they often want you to lie down in bed while being monitored, or stand or sit near the bed without moving so that they don't lose the heartbeat. Moving around and changing positions helps women both deal with the labor pain more effectively as well as allow the baby to move into optimal positioning, allowing labor to progress faster. Conversely, if a woman isn't allowed to move around, she may feel unable to cope with labor without an epidural, or her labor may stall or go too slow for the hospital's likings, causing the hospital to push pitocin augmentation of labor.
Fetal monitoring → Epidural
Fetal monitoring → Epidural → Emergency Cesarean
Fetal monitoring → Epidural → Episiotomy
Fetal monitoring → Epidural → Forcep/vacuum assisted delivery → Episiotomy
Fetal monitoring → Pitocin → Emergency Cesarean
Fetal monitoring → Pitocin → Epidural → Emergency Cesarean
Fetal monitoring → Pitocin → Epidural → Episiotomy
Fetal monitoring → Pitocin → Epidural → Forcep/vacuum assisted delivery → Episiotomy

Vacuum/Forceps Assisted Delivery. When doctors deem babies as "stuck in the birth canal", usually because the pushing stage is taking "too long", they often do an assisted delivery, where instead of the baby descending and coming out of the birth canal on their own, doctors take the baby out, either by cupping forceps (giant tong like things) on either side of the baby's head, and pulling the baby out, or with a ventouse, a suction cup that attaches to the baby's head, which then pulls the baby out of the birth canal via vacuum.
Both of these types of assisted deliveries carry a risk to the baby. Vacuum can cause a hemorrhagic in the baby's head, and forceps deliveries can cause anywhere from broken bones to brain damage and spinal cord damage, and even death in rare cases. There have been no conclusive studies on it, but vacuum and forceps deliveries have also been linked to milder, long term issues, such as learning disabilities, cerebral palsy, sensory issues, ADHD, autism, and many other types of issues linked to possible brain damage caused by assisted delivery.
Generally assisted deliveries require episiotomies to be done, to increase the amount of maneuvering room for the doctor doing the assisted delivery.
Forcep/vacuum assisted delivery → Episiotomy

Episiotomies are when the perineum, the area between the birth canal and the anus, is cut (usually with scissors) to provide more room for the baby to come out. In some hospitals, episiotomies are routinely done for every first time mother!
Episiotomies have a few risks. Episiotomies cause a very painful recovery for the mother after childbirth, making walking, sitting, and even using the bathroom excruciatingly painful. They can also cause pain and problems even after the mother is otherwise healed from childbirth, causing sexual issues, often from scar tissue that builds up because of the episiotomy.
Episiotomies, even small ones, make tearing more likely as well, as skin that is already perforated is more likely to tear than one that is not, which can lead to third and fourth degree tearing, possibly even until the anus. Such tearing, or even large episiotimies, can cause incontinence in the mother.

Cesarean Sections are surgery in which the mother's abdomen is cut open, and the uterus is cut, the baby is removed, and then the mother's uterus then abdomen are sewn back together. Cesarean sections are done for some women who are "too posh to push" and would rather undergo surgery than push a baby out the standard way.
Cesarean sections are often presented as "just another alternative" to giving birth that is "just as fine", but its actually the most dangerous intervention that can be done to a mother in childbirth. In fact, Cesarean sections are one of the reasons for a large percentage of women who die in childbirth. Cesareans are NOT safe. In choosing to have a homebirth, avoiding a possible Cesarean, which is very likely in hospitals (some hospitals have a 40-90% Cesarean rate!), is actually my biggest concern. Most of the potential interventions in childbirth in a hospital are problematic because they make Cesareans more likely, and Cesarean is pretty much the most risky thing possible that can be done to a woman in childbirth.
What problems exactly can a Cesarean section cause?
Well, aside for death (which fortunately isn't too common), Cesareans can cause lots of problems and create a host of other potential issues.
As with all major surgeries, Cesareans can cause all sorts of complications, whether hemorrhage, bad reaction to anesthesia, lung problems, shock, accidentally nicking the wrong thing (including injuring the baby by accidentally cutting the baby), etc.
Even after the surgery, the incision can easily get infected. In fact, two of my friends only discovered at their second Cesarean that their previous incision to their uterus was infected, more than a year after they had the previous Cesarean!
Previous Cesareans make all future pregnancies risky. In fact, women are advised to go on birth control for a specific length of time after a Cesarean to allow the uterus to fully heal. Sometimes birth control fails, and then the woman is pregnant with a uterus that is still not fully healed from the last Cesarean.
Once a woman has had a Cesarean, she is at risk of uterine rupture in all her subsequent pregnancies, making her pregnancies high risk (and making homebirths much less safe- in fact, licensed homebirth midwives in most places are not allowed to do HBACs- homebirths after cesareans- because they're considered to be too risky to be allowed). Uterine rupture is very dangerous and would require either surgical repair of the uterus, often blood transfusions, and possibly even an emergency hysterectomy. Uterine rupture is especially likely during inductions in subsequent labors, making repeat Cesareans likely if the doctor feels the baby needs to come out, because inductions can be too dangerous.
Previous Cesareans make placenta previa more likely.
Previous Cesareans make placenta accreta more likely. Placenta accreta is when the placenta embeds itself deeply in the uterine wall and/or possibly other organs, and doesn't come out on its own. This can be potentially fatal to the mother at worst, or can cause massive hemmoraging or even necessitate a hysterectomy. One friend of mine- and reader of this blog- nearly died from this and was hospitalized for a few months and needed to have multiple blood transfusions as well as a hysterectomy when she only 27 years old, and wasn't ready to stop having kids.
Many doctors and/or hospitals won't allow VBACs (vaginal births after Cesareans), often because of fear of litigation. This means that one Cesarean generally means all future births are via Cesarean, making each pregnancy high risk, and putting women through the risk of major abdominal surgery any time she gets pregnant again.
Many doctors say that its dangerous to have more than a certain number of Cesareans, and will put a cap on how many children/pregnancies you can have if you have Cesareans. If having a large family is something that is important to you, this can certainly pose problems.

On top of everything else, there are other more immediate concerns with Cesareans.
Babies born via Cesarean often have breathing trouble- passage through the birth canal helps squeeze liquid from the baby's lungs.
Cesareans cause the mother a lot of pain, making the recovery that much more difficult.
Cesareans often make it painful to breastfeed, lowering the likelihood of a successful breastfeeding relationship.

Cesareans do save lives sometimes. But they certainly are pretty risky and problematic, and if at all possible people should do what is necessary to avoid having a Cesarean.

Unfortunately, almost every single intervention in the hospital, from the ticking clock to pitocin to epidurals to fetal monitors to artificial rupture of membranes makes emergency Cesarean sections far more likely. Which contributes greatly to the fact that hospital births are certainly not entirely safe for childbirth, and can, in fact, be problematic and dangerous.

The other concern with hospitals is that babies are more likely to die because of antibiotic resistant hospital borne illnesses such as the very dangerous MRSA (staph infection) that they catch while in the hospital.

Because of all these reasons, hospital births have been shown to have the same mortality rate as homebirths, both for mothers and for babies, but have more interventions and more difficult recoveries and complications than home births.

If you've had any of the interventions listed in this post, especially if it was your choice to have the intervention, this post really wasn't meant to criticize you and your choices. This post was just meant to inform people who assume that hospital births are totally safe, and its only homebirths that are dangerous. Certainly sometimes these interventions help and can save lives; they're not evil or terrible or anything of the sort! At the same time, each of these interventions do carry with them different risks (which is why you need to sign consent forms in the hospital) as well as the likelihood to lead to further interventions.

If you want, there is a really terrific documentary done by Rikki Lake that talks about hospital births and home births, and I strong suggest you watch it. All of it is available on youtube aside for one part (I think part 4). Here is part 1.


If you had a hospital birth, did you have any of the aforementioned interventions? Did you feel those interventions were pushed on you, that you were pressured to accept the intervention, or did you choose gladly to have those interventions? Once you had one intervention, did you have other interventions afterward? What interventions did you have that led to others? In retrospect, were you happy or glad that you had those interventions?


I'll start. For my first birth, I had near constant external monitoring, and AROM (artificial rupture of membranes) at 10 centimeters, and fortunately no other interventions. For my second birth, the same thing, fortunately. :-D I have no regrets about the AROM (only not having had them do it sooner!!!) but I do wish I wasn't on the monitor nearly as much.


How about you?


And most importantly, did you know the information that I shared in this post? Did this post change your mind at all about the safety of hospital births? Or are you still convinced that its 100% safe to give birth in a hospital?

Next post in this series- what can go wrong in a homebirth, and are midwives actually equipped to handle everything?


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1 comment:

  1. My mom had six kids, four of us at home, including a set of twins. You sound just like her- she loves to tell us the dangers of hospital births. There's definitely something to be said for letting it all happen naturally.

    This was a good article. Well thought out, researched, focused, helpful, and positive. Thanks.

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