The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
Many medical students are taught this adage: “When you hear hoofbeats, think of horses, not zebras.” It means that we, as physicians, need to remember that common things are common, and that we shouldn’t immediately focus on the rare or esoteric.
As a pediatrician, for instance, I have to constantly remind myself that the vast, vast majority of children are healthy. Just because I encounter mostly sick children in the clinic doesn’t mean otherwise. I see a skewed population.
Recently, a new study comparing the safety of home or birth-center deliveries with hospital deliveries led to headlines proclaiming that babies not born in hospitals were significantly more likely to die. I have no trouble believing that’s the case.
That’s the zebra, though.
There are a number of people in the United States who would rather have their baby at home. I’m going to lay all of my cards (and biases) here on the table: I recoil at this thought. Why? Because pretty much the worst things I saw in residency occurred with a home birth. I can’t help myself. I hear home birth, and I think of zebras.
I, and my wife, feared the deaths of our babies during delivery so much that we chose in-hospital births. Our zeal to minimize that specific risk outweighed any other considerations. If faced with the decision again, I don’t doubt we’d choose the same. But that doesn’t mean everyone prioritizes risks the same way.
Women should also know that if they’re in the hospital, they are more likely to get an induction, augmentation or other labor-related procedure. They’re more likely to get a cesarean section. Their children are more likely to be admitted to the intensive care unit and spend time separated from them after birth. It’s perfectly rational for parents to accept a statistically significant, but relatively rarer, higher risk of one bad outcome to avoid another.
Home births are gaining in popularity. In Britain, about 10 percent of births don’t happen in a hospital. The Centers for Disease Control and Prevention estimates that in 2012, more than 53,000 births took place out of the hospital in the United States. More than 35,000 took place at home, the rest at dedicated birth centers. Out-of-hospital births are a small percentage of overall deliveries, about 1.36 percent, but the rate has been increasing since 2004, when they were about 0.8 percent. In some states, like Alaska (6 percent), Montana (3.9 percent) and Oregon (3.8 percent), out-of-hospital births are even more common.
In Oregon, data is recorded on birth certificates that allows researchers to know which births were planned for the home and which were planned for the hospital. They can compare outcomes.
In 2012 and 2013, researchers found that the rate of perinatal death was significantly higher for births planned at home: 3.9 versus 1.8 per 1,000. That would be an additional death for each 500 births at home. At-home births were also associated with an increased risk of neonatal seizures.
However, the risk of admission to an intensive care unit was significantly lower for those born at home. I recently wrote an editorial in JAMA Pediatrics discussing how increased neonatal intensive care use is a possible example of supply-induced care. In other words, those facilities might sometimes be used because they exist and need to be filled, not because infants need them.
In the hospital, you’re also more likely to get a procedure. More than 30 percent of women with planned in-hospital births had labor induced, versus 1.5 percent of those with planned at-home births. Almost 25 percent of those who planned to deliver in the hospital had a cesarean section versus 5.3 percent of those who planned to deliver at home.
It’s important to remember that the rates of severe morbidity (permanent harm or significant temporary harm) and death in women are 27 per 1,000 for planned (or “low-risk”) C-section deliveries versus 9 per 1,000 for planned vaginal deliveries. C-sections are probably more common in the United States than they need to be, and being in the hospital increases your chance of getting one, and the risks that come with it.
Unfortunately, the choice of birth location has become a charged debate in this country. In Britain, on the other hand, the medical system seems to have been adopting a more holistic view. The National Institute for Health and Care Excellence (NICE) released guidelines just over a year ago that recommended that health care providers explain to women at low risk of complications that home birth is a safe and acceptable option.
In fact, for British women who have given birth before and are at low risk, NICE recommends that providers explain that birth out of the hospital carries no differences in risk and is associated with higher rates of normal vaginal deliveries and lower rates of intervention.
In addition, there are “protocols and mechanisms” in place to coordinate care between home births and the hospital. An editorial in the New England Journal of Medicine last year noted that almost half of first-time mothers in Britain who intend to give birth out of the hospital wind up doing so in the hospital — and that this might be looked at as a sign of systemic success, not failure. If things don’t go well at home, everyone is prepared and ready to make the transfer because home and hospital delivery systems work closely together. The British safety net works.
The medical profession has a case that in-hospital births carry a lower risk of death, but many women still might be better off delivering elsewhere. A system could be created in which parents’ values and priorities are recognized, while also ensuring that more intensive care is available when needed.
Just because zebras exist doesn’t mean that horses can’t.
