07 November 2012

Home birth

Sometimes I find myself in arguments on medical subjects with non-medical people (for example, with seatmates on airplanes). One argument concerned "natural" home birth. My stance is that if I were a pregnant woman, I would be quite uncomfortable with having my birth at home.*

Pregnancy and birth is a wonderful, yet involved, process. Pregnancy stresses the female body, altering the homeostasis (the equilibrium) of many of the body's systems. For example, pregnant women are more likely to experience blood clots, in part because of a change in their hormones. They have to urinate more often. Some parts of the pregnant woman's brain grow new neurons (which is actually a huge deal, because adults weren't previously thought to be able to grow new brain tissue). Towards the end of the pregnancy, the gigantic uterus competes with the lungs for space in the body, making breathing more difficult. The spine has to adjust to carrying more weight. The heart is more likely to arrest. The list goes on.

Childbirth especially places the body under stress. Sometimes, deliveries have complications. Arterioles can rupture, causing hemorrhage. The fetus can be positioned the wrong way in the birth canal. The fetus's umbilical cord can wrap around its neck, strangling it. The variety of potential complications is substantial. Fortunately, obstetricians can do quite a lot to resolve these complications when they arise, sparing the life of the mother and the child. What is frightening is that grave complications can come on suddenly and without warning, and they need to be dealt with emergently.

As I alluded to in my recent post on diagnosis, when approaching a complex matter, it often helps to break it down into its simpler, constituent parts. Those working on maternal mortality worldwide have done just that. There is a "three-delay" model of contributors to maternal mortality in complicated deliveries:

1. delay in recognizing problems in labor and deciding to seek medical help;
2. delay in reaching a skilled medical facility; and
3. delay in obtaining the appropriate intervention on arrival.

The trouble with home birth (relative to at a hospital or a birth center) is that it definitely delays number 2 and usually delays numbers 1 and 3. Delays in medicine are costly. Regarding strokes, neurologists say that "time is brain." Regarding heart attacks, cardiologists say that "time is muscle." I am coining the aphorism that in obstetrics, "time is life"that of the mother and that of the fetus.

To be sure: most low-risk pregnancies result in uncomplicated deliveries, whether in one's home or in a hospital. It's when a delivery doesn't go smoothly that one will want to quickly find herself in the hands of a skilled physician.

* Summary statement of the American College of Obstetrics and Gynecology's Feb. 2011 position paper on planned home birth:
Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.