Home Birther Logic. or “Logic” actually

August 24, 2011

Riddle me this.

For background, Isis the Scientist started some shit by posting

Your Home Birth is Not a Feminist Statement

which sounds totally noncontroversial right from the start. But since it reviewed some data on home birth suggesting up to 37% of planned home births result in emergency hospital visits and noting as much as a 0.3% uptick in the neonatal death rate, well, the home birth fans went shitnutz.

One can only hope that this homebirth person who had one kid die, one need resuscitation and still can’t understand why anyone would think she’s high risk is rare. Very rare.

Kate Clancy, for whom I have a great deal of respect on most issues, has a somewhat reasonable post up on the motivations for home birther fanaticism.

And these motivations are key, I agree. Because these motivations are driving otherwise reasonable people into a frenzy of woo based illogic that is really something to see.

There is one particular bit of thinking that I cannot for the life of me grasp. I’m going to pick on this post from homebirthercurious Dr.B

Hospitals are clearly equipped for dealing with the worst case scenarios. But it also seems that they are big fans of unnecessary interventions.

but really it pops up everywhere. Such as on the Twitts:

Given that it’s kinda a one way trip, how does one determine this? RT @DrSnit: @drisis I don’t see your blog about unnecessary c-sections

and

absent evidence of convenience scheduling, you simply have no idea what the “unnecessary” rate actually IS. No way to tell. @DrSnit

Right? RIGHT??????

In birthing, the only way to know if a procedure was “unnecessary” or “necessary” is to either do it or not do it and figure out if the bad consequence is prevented, ameliorated or unaffected. And unfortunately you only get one try for each case study. Which means that you cannot actually know for sure for any particular case whether the procedures were in fact “necessary”.

Amirite?

Please explain to me, homebirther fans who wield the “unnecessary intervention” cudgel, exactly how you can determine which procedures were and were not necessary in advance. Because I am missing your logic here.

Look, science-based and/or evidence-based medicine recognizes that in the cases that are interesting*, there is rarely such a thing as a clear cut 100% accurate prediction of the future. What there is are probability distributions. If the kid’s heart rate slows down by such and such, the damn cord is wrapped around it’s neck X% of the time. Or, when the kid is in breech, Y% of the time the delivery ain’t going well.

Which always leaves some percentage of the time that everything is going to be fine and dandy.

Between fine-and-dandy land and 100% of births, however, you are playing with the health, well-being and even viability of a new human being. And this, mind you, is just for the stuff we can actually detect with high confidence is an adverse effect on the child. Dying is a pretty good one there, also hypoxia induced brain damage.

We do not know, however, if there are more subtle effects. Maybe you knock 5 pts off the kid’s IQ because you insist on laboring too long for “the experience”. Maybe you bathe that little wackaloon in hormonal responses that produce a raft of a subtle effects on development? Or maybe the child’s innate stress responses set a different stage. Who knows? Me, I’m betting on the side of smooth deliveries. Relatively rapid appearance of the kid once the laboring commences is my preference.

This last part is MY version of birth woo. I’d rather not take chances.

__
*i.e., debatable.

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10 Responses to “Home Birther Logic. or “Logic” actually”

  1. Anonymous Says:

    Easy–you just do across-subject comparisons. Compare centers with low rates of a given procedure to centers with high rates.

    http://ajph.aphapublications.org/cgi/content/abstract/82/3/450

    From the abstract:
    “the results suggest that, under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries”

    Caesarean section rates are 1.6% at the home birth center and 16.4% at the hospitals in that study and there are no significant differences in mortality or Apgar scores. That suggests that the rate could be lowered safely, and thus the interventions are not strictly necessary. Caesarean rates in the US are now over 30%.

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  2. DrugMonkey Says:

    This fails to make any prediction for a given mother which group she is in before the fact. When birthing decisions are made.

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  3. becca Says:

    “Maybe you bathe that little wackaloon in hormonal responses that produce a raft of a subtle effects on development?”
    This is actually one of the most interesting factors, and one of the ways I’m pretty sure homebirth is different from hospital birth.

    The only birth ‘intervention’ I had was an IV drip that they didn’t add pitocin to until after birth (which they do to help the uterus shrink back). What I’d really like to know is whether much of that came through the first breastmilk.

    Now, use of pitocin is associated with increased likelihood for other interventions (because it’s often given to intensify contractions, which speeds things up ‘unnaturally’-according to critics). But if you *do* give pitocin, and you *don’t* have an epidural/spinal, you epigenetically program the infant brain *toward* a profile that is associated with increased bonding proclivity (inasmuch as we understand any of this stuff yet). The combination of pitocin and an epidural (more common) produces a different epigenetic signature, less ‘bondy’.
    Yep, went to awesome seminar from madame prairie vole (http://en.wikipedia.org/wiki/C._Sue_Carter).

    Basically, if my kid turns out to be a really lovesick teen, I will blame it on the hospital birth!
    (kidding! sort of)

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  4. […] midwife/home birth/virtue of crunchiness/feminist debate has surfaced again, and the talk seems to be centered (again) on the choice a woman makes between home birth […]

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  5. […] midwife/home birth/virtue of crunchiness/feminist debate has surfaced again, and the talk seems to be centered (again) on the choice a woman makes between home birth […]

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  6. Confused Says:

    As the parent of a teenager, I can tell you that you can’t tell which of my kid’s friends were born naturally or with assistance, and you can’t tell how they were born based on how bonded they are with their parents. (In fact, I’m pretty sure the teen who I know for a fact was home birthed and breast fed within 5 minutes says “Fuck you” to her mother just as frequently as mine, who was born in a hospital, with pitocin, and didn’t breastfeed till the next day). The whole focus on the first few supposedly crucial hours of bonding is ridiculous and, frankly, just sounds like a fun new way to make new mothers anxious and crazy.

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  7. becca Says:

    I agree absolutely that it’s not worth worrying about on an individual level- new mothers have plenty to be concerned about.

    I’m not even sure what I think we could be epigenetically programming people for (frankly, I was thinking more about how the teenagers bonded with their sexual partners, not their parents. Teenagers are not known for being all warm and fuzzy to parents). Even if birth conditions did change the oxytocin signaling tendencies that wouldn’t necessarily predict behavior- people are more complex than prairie voles.
    On a population level, I do wonder if a lot of births with epidurals could have some effects (to be clear- from the epigenetics, neither a ‘home birth with immediate breastfeeding’ nor a hospital birth with pitocin alone would be expected to have detrimental effects. It’s hospital births with pitocin that also included epidurals et al that caused the relatively increased methlylation in the oxytocin signaling gene). Autism is the easiest thing to wonder about, but the science is so tentative it’s not worth considering unless you are just really interested in neurohormones as a researcher, particularly given the history of autism and specious claims.

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  8. The logical argument you’re making here completely invalidates the entire field of empirical economics. Also argues strongly for the existence of both God and the Flying Spaghetti Monster simultaneously. (And for that matter, the same argument can be used to say that women should not give birth in the hospital, because we don’t know what would not have gone wrong if they’d just stayed at home.)

    Don’t tell anyone that we can’t statistically figure out our best guess as to counter-factuals because I’ll be out of a job if they find out.

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  9. Anonymous Says:

    I see some significant issues with that study. For one thing the power is very bad; for another, the years are not comparable. It is not immediately obvious to me that the cohorts are comparable either. I would feel much better if they had pre-matched pairs of women with comparable backgrounds, one who planned a homebirth and one who did not, and followed the results.

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  10. kate b Says:

    No – you are missing the point of this article. It’s *because* we can’t know in advance whether an intervention is necessary or not that medical professionals have to make decisions based on the best available research. And because this only gives an indicator of the risk of a particular course of action; this means some interventions will inevitably transpire to be ‘unnecessary’. But, the point is, we can’t know WHICH interventions were unnecessary until afterwards. But the risk involved in not intervening; when there are valid medical concerns; is greater than the risk of intervening.

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