Wednesday, May 28, 2008

No support for some central tenets of homebirth advocacy

This month's issue of the journal Birth has not one, not two, but three separate studies that cast substantial doubt on certain important tenets of homebirth advocacy.

1. Homebirth advocates like to claim or imply that obstetricians are hiding the fact that C-sections are dangerous for both babies and mothers. Obstetricians aren't hiding anything. They know that the "dangers" of C-section are grossly overstated by homebirth advocates. Obstetricians and other doctors have higher rates of C-section than the general population and a substantial proportion would choose C-section in the absence of a medical indication.

Cesarean Section: Norwegian Women Do as Obstetricians Do Not as Obstetricians Say:
Background: The worrying trend of an ever-increasing incidence of delivery by cesarean section has been commented on repeatedly. Studies from the United Kingdom and the United States have found that many obstetricians would choose cesarean section for themselves without strict medical indication, whereas similar studies from Denmark and Norway have indicated that almost none would choose cesarean section for themselves. The purpose of this study was to report the proportion of Norwegian obstetricians who have children born by cesarean section and to compare the rate with that among other physicians and that with the general population. Methods: Questionnaires were sent to 1,500 random members of the Norwegian general public, 1,500 randomly selected physicians, and 423 random surgeons asking whether they had children born by cesarean section. All were between the ages of 40 and 65 years. Results: The response rate was 78 percent. In the general public with children, 12 percent reported that one or more of them were born by cesarean section. The average was 8 percent among those with only basic schooling compared with 16 percent (p < 0.02) among those who had been to university for more than 4 years. This figure was 19 percent among physicians in general (p < 0.001 compared with the general population), 26 percent among surgeons, and 27 percent among the 189 specialists in obstetrics and gynecology (p < 0.02 compared with the physicians in general). Conclusion: The rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section.
2. Homebirth advocates like to claim that women find vaginal birth inherently preferable to C-section, but that is not what investigators discovered. In this study, a substantial proportion of women changed from preferring a vaginal delivery after they had had the experience of labor or of vaginal birth.

Impact of First Childbirth on Changes in Women's Preference for Mode of Delivery:
Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty-four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth...
3. Homebirth advocates claim that homebirth and birth centers cost less, but research fails to confirm that claim. I have written about this in the past and cited similar papers. Both homebirth and birth centers are resource intensive (personnel and equipment) and are not offset by corresponding decreases in the need for resources elsewhere in the system.

Economic Implications of Home Births and Birth Centers:
Background: It is widely perceived that home births and birth centers may help decrease the costs of maternity care for women with uncomplicated pregnancies and deliveries. This structured review examines the literature relating to the economic implications of home births and birth center care compared with hospital maternity care... Results: Eleven studies were included from the United Kingdom, United States, Australia, and Canada. Two studies focused on home births versus other forms and locations of care, whereas nine focused on birth centers versus other forms and locations of care. Resource use was generally lower for women cared for at home and in birth centers due to lower rates of intervention, shorter lengths of stay, or both. However, this fact did not always translate into lower costs because, in the U.K. ... more midwives of a higher grade were employed to manage the birth centers than are usually employed in maternity units, and because of costs of converting existing facilities into delivery rooms... Conclusions: This review highlights the paucity of economic literature relating to home births and birth centers... Further economic research that involves detailed bottom-up costing of alternative options for place of birth and measures multiple outcomes, including women’s preferences, would help address the question of whether out-of-hospital birth is beneficial in economic terms.


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