Giving Birth: How To Reduce Risk Of Badness

First things first: the mother is basically not going to die in childbirth.  Maternal mortality rates in the US are 14 per 100,000, or a 0.0014% chance, or a few hundred deaths a year. This is not a thing to worry about. You are not gonna die.

Maternal mortality is much more likely, by a 3:1 ratio, among black mothers than white (or Hispanic) mothers. Nobody really knows why.

Most of the things that kill mothers in childbirth are hemorrhage, eclampsia, stroke, pulmonary embolism, high blood pressure, or other factors associated with the higher blood pressure and clotting associated with pregnancy.[2]

Severe maternal morbidity, or life-threatening consequences of childbirth, are more common, affecting about 65,000 women in the US per year.  This is quite a bit more common, though still unlikely overall; there is a 1.6% chance something seriously bad will happen to you during birth.

How about babies?  Perinatal mortality, or a child dying within a week of childbirth, happens at a rate of 6.24 per 1000, or 0.6%.  Perinatal morbidity (i.e. something going wrong enough to require NICU admission) has higher rates, at 77.9 per 1000 births, or 7.8%.[4]  The majority of these are low-birth-weight infants.

Want to avoid bad things happening to your baby during birth? Don’t have a preemie.

How do you avoid having a preemie again? Twins are bad; smoking is bad; treat your gum disease and vaginal infections; don’t be underweight; get cervical incompetence fixed if that’s an issue.

Badness around birth happens mostly to babies and especially to preterm babies.

Is Homebirth Safe?

According to a Cochrane Review, randomized trials on low-risk women (70%-80% of pregnant women are “low risk”) find no difference in outcomes between home birth and hospital birth.[4] Among 24,092 low-risk pregnant women, perinatal (infant) mortality was not significantly different between home births and hospital births; there was a lower incidence of low Apgar scores (OR = 0.55) in the home birth group. Home births were less likely to involve interventions such as induction or augmentation of labor, episiotomy, caesarian section, or using forceps.  A large (529,688 low-risk pregnancy) cohort study in the Netherlands also found no significant differences in perinatal mortality between planned home births and planned hospital births.[6]

However, another meta-analysis found that home birth tripled the neonatal mortality rate compared to hospital birth.[7]  This study, by contrast, included not randomized trials but cohort studies of planned home birth vs. planned hospital births.  A total of 342,056 planned home and 207,551 planned hospital births were included. Home births had significantly fewer interventions (such as epidurals, forceps, or caesarean sections) and better maternal outcomes (OR of infection = 0.27, OR of hemorrhage = 0.66, etc.)  Perinatal deaths, e.g. infant deaths within seven days of birth, were the same between home birth and hospital birth; but neonatal death, within 28 days of birth, was higher in home births (OR = 1.98).  0.2% of home births, compared to 0.1% of hospital births, resulted in neonatal death.

The authors give the explanation that intrapartum anoxia (due to laboring without a fetal heart rate monitor and not switching to caesarean or forceps as often) can cause infant mortality.

Bottom lines:

  • home births definitely involve much less medical intervention
  • home births involve fewer maternal complications
  • home births seem to involve higher risk of neonatal but not perinatal deaths
  • all of the above evidence is for low-risk pregnancies.
  • If you have a low-risk pregnancy your baby is probably not gonna die either way. 0.1%-0.2% risks.

If all you care about is baby safety, it looks like hospital > home birth, even for low-risk pregnancies. If you include mother’s safety, it becomes more complicated, because maternal outcomes tend to be better with home births; but keep in mind that maternal deaths are still extremely rare either way, much more so than infant deaths. If you include maternal pain, it becomes more complicated still, because you can get an epidural at the hospital.  And if you include maternal stress, then, some people report that being in a “medicalized” environment is more worrying than being at home. The tradeoffs, as always, are individual.

 

 

References

[1]http://data.worldbank.org/indicator/SH.STA.MMRT

[2]http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

[3]http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_08.pdf

[4]Harrison, Wade, and David Goodman. “Epidemiologic trends in neonatal intensive care, 2007-2012.” JAMA pediatrics 169.9 (2015): 855-862.

[4]Olsen, Ole, and Jette A. Clausen. “Planned hospital birth versus planned home birth.” The Cochrane Library (2012).

[5]Olsen, Ole. “Meta‐analysis of the safety of home birth.” Birth 24.1 (1997): 4-13

[6]de Jonge, Ank, et al. “Perinatal mortality and morbidity in a nationwide cohort of 529 688 low‐risk planned home and hospital births.” BJOG: An International Journal of Obstetrics & Gynaecology 116.9 (2009): 1177-1184..

[6]Wax, Joseph R., et al. “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” American journal of obstetrics and gynecology 203.3 (2010): 243-e1.

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4 thoughts on “Giving Birth: How To Reduce Risk Of Badness

  1. These studies only cover big, obvious outcomes like deaths or needing a NICU. After two births in a birth center across the street from a hospital, and then watching a hospital birth, I realized that I would prefer a hospital if I were doing it again. Having a pediatric team ready and waiting is very different than them needing to come across the street. One midwife can catch a baby and start resuscitation pretty fast, but not as fast as a team, and if my child needed oxygen I wouldn’t want any delay at all. That’s the kind of thing I expect to make a difference to how easy it is for my child to learn to read, but isn’t going to show up in the statistics about perinatal health.

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    1. Good point – although the midwifery practice I go to has a policy of having two registered midwives in attendence for each birth so that there is a team. They also carry oxygen.

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