Saturday, October 21, 2006

The inherent risks of childbirth

So we've seen that homebirth and natural childbirth advocates (like many Americans) have trouble evaluating risk. They have difficulty understanding relative risk (how one risk compares to another risk) and they have difficulty evaluating sources for the accuracy of their claims. There is an additional component to risk assessment for homebirth and natural childbirth advocates. They are often factually misinformed about the actual risks. Nowhere is that more apparent than in their almost complete lack of knowledge about the inherent risks of pregnancy and childbirth.

The first clue to this serious misunderstanding is the claim that childbirth must be safe because it is "natural". Natural does not mean safe, and we are pretty clear about that in other areas of life. For example, natural disasters, such as hurricanes and earthquakes are 100% natural. Nonetheless, we know that they are responsible for a tremendous amount of death, suffering and destruction. Natural means one thing only: it happens in nature. It tells us absolutely nothing about whether it causes death or other serious effects.

The second clue to this serious misunderstanding is the claim that childbirth must be safe because "we are still here". This is evidence of basic lack of knowledge about biology. The fact that "we are still here" only tells us that in every generation, the number of people who lived exceeded the number who died. It doesn't tell us anything about the ratio. So, for example the population will grow at a certain rate if each couple has 3 surviving children. It does not matter whether the couple had 3 children, all of whom survived, or 10 children, 7 of whom died.

We know from the biology of other animals that reproduction has a tremendous amount of wastage. We've all seen nature shows about sea turtles who lay hundreds of eggs, with the result that only a few baby turtles survive the treacherous walk across the beach to the safety of the ocean. We know that some animals, like salmon, give up their own lives in the process of reproduction. The fact is, there is a tremendous amount of wastage in human reproduction also. The miscarriage rate for established pregnancies is 20%. That means that 1 in 5 pregnancies will not survive to result in a live birth. Pregnancy and childbirth also have a "wastage" rate. In nature, many women and babies did not survive the process. That is a natural part of human reproduction.

Let's take a look at historical evidence about death in pregnancy and childbirth. Irvine Loudon is one of the premier historians working to understand the history of human pregnancy and birth. In the article Maternal mortality in the past and its relevance to developing countries today, there is extensive exploration of the historical data on maternal mortality in the United Kingdom. Looking at the maternal mortality data for 1872-1876, we find a maternal mortality rate of approximately 400/100,000 with the following causes:
cause of death %
Puerperal fever 55.5
Hemorrhage 22.5
Eclampsia 11.6
Miscarriage and abortion 4.0
Postpartum psychosis 2.5
Ectopic 0.2
Other 0.8
By contrast, the maternal mortality rate today is in the range of 8/100,000.

What were maternal mortality rates prior to the late 19th century? According to the works of other historians which Louden quotes:
They found maternal mortality rates were certainly higher at 400-500 per 100000 births throughout the 19th century. It was a bit higher at the beginning of the 19th century and was up to perhaps 1000 per 100000 births in the early part of the 18th century. I have a graph in my book [Loudon I. Death in childbirth. Oxford: Clarendon Press, 1992] that shows maternal mortality stretching back in history and, as you go back, it goes up very slightly and then we lose track because there really are no data as yet.
This data is fairly consistent with the maternal mortality rates that we see today in parts of the world that don't have access to modern obstetrics.

What conclusion can we draw from this data? Giving birth is and has always been inherently dangerous. From the early 18th century on back, 1% or more of births resulted in the death of the mother. What's really amazing to consider is that the chance of the baby dying was always dramatically higher.

Addendum: To put a 1% maternal mortality rate in perspective, it is twice as high as the mortality rate for receiving a kidney transplant, and a bit less than half the mortality rate of having "triple bypass" heart surgery.


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