I once led a community service project for which middle schoolers baked cookies to deliver to a local shelter. We brought out the ingredients and began giving instructions when one kid asked if they could eat some of the cookie dough. Another kid immediately said eating cookie dough would give everyone salmonella. Within seconds, we had two camps of shrieking middle schoolers, one with members who had eaten raw cookie dough all their lives and were just fine, and the other with members that insisted that eating raw cookie dough would lead straight to a week-long date with the toilet followed by certain death.
A Google search on the subject breaks into similar camps, from “Rejoice! you Probably Won’t Get Salmonella from Eating Raw Cookie Dough” to “Eating Raw Cookie Dough Can Actually Be Deadly.”
In fact, there is a tiny risk of contracting salmonella from eating anything with raw eggs in it, including cookie dough, but that risk is very small, and the risk of dying from salmonella is even smaller. There is also a risk of choking on raw cookie dough, or having an unexpected allergic reaction to an ingredient, or eating too much of it and having a stomach rupture. And there is a risk of getting salmonella from other foods, such as meat or salad greens–in fact, almost any food could be contaminated.
All of this is to say that everyone assesses risks differently, and that people can get very upset when others don’t assess risks the same way they do.
Enter home birth.
In the New York Times’ “Is Home Birth Ever a Safe Choice?” risk assessment is on everyone’s mind. Two obstetricians who specifically address risk come to two very different conclusions.
In “Emergency Care Can Be Too Urgently Needed for Home Births,” John Jennings, the current president of the American Congress of Obstetricians and Gynecologists (ACOG) writes,
When women decide where to give birth, they should understand the potential risks involved with their options….evidence shows that although the overall risk of serious childbirth complications remains low, there is still a twofold to threefold increased risk of neonatal death associated with home birth.
This line is almost verbatim from ACOG’s 2011 Committee Opinion, “Planned Home Birth,” which says that “it respects the right of a woman to make a medically informed decision about delivery,” but goes on to say that the only risk obstetricians are obligated to share is the neonatal death death risk as determined by the Wax study. The Wax study, a meta-analysis of a number of other studies, was widely criticized for drawing faulty conclusions from flawed methods (see e.g. here, here, and here).
Like OBs Grunebaum and Chervenak, who I critiqued in my previous post, Jennings, a professor at Texas Tech, suggests that hospitals strive for more home-like settings and partner more with nurse midwives (CNMs). He also suggests working with patients to create “action plans”–aka birth plans.
Texas Tech OBs attend births at the Medical Center Health System’s Center for Women and Infants. The hospital reports to the Leapfrog Group, which says that they have made progress on reducing episiotomies (current rate is 12.2%,), but have low adherence to clinical guidelines for high risk deliveries, which would seem to negate the purpose of having a high-risk birth at the hospital. In their favor, they do appear to have one of the lower primary cesarean rates in the state for uncomplicated births at just over 12% (an uncomplicated or low-risk birth is generally defined as a healthy mother with a single, head-down, vertex fetus).
It’s hard to determine much from the website other than that they have a lot of nice rooms and that they appear not to do skin-to-skin contact at birth (the nurse takes the baby for suctioning). They have a short video that shows a woman on a gurney with a nurse showing her what look like two English muffins on a headphone cord. There is a long sequence on the Ronald McDonald Room where a towheaded boy eats cookies, and then a segment on “Family Centered Care,” which shows a nurse holding a baby in the hospital nursery. Despite Jennings’ apparent promotion of CNMs, no midwives are listed as practicing there, and a search for midwives on the site yields nothing. There is no information about developing or following an “action plan.”
OBs who say that hospitals should provide home-like setting, employ nurse midwives, and honor birth plans might want to begin at the hospitals where they themselves practice.
Jennings also says, “As obstetrician-gynecologists, our goal with any delivery is a healthy mother and a healthy baby.” It’s not as if mothers’ and midwives’ goal is mothers and babies who are sick or dead. Jennings definition of “healthy” seems to be “alive.” Superfluous slicing, dicing, and infections are not even noted.
The problem with assessing risk only in terms of neonatal death is that the risk of neonatal death is very small, while the risk of other birth complications is fairly large. Jennings’ hospital aside, the national cesarean rate for low risk births is 26.9% (the overall rate is 32.7%). This varies tremendously by hospital, with some achieving rates below 5% while others have rates that are over 80%.
Aaron Caughey, who is chair of the department of obstetrics and gynecology and the associate dean for Women’s Health Research and Policy at Oregon Health and Science University’s School of Medicine, does not assume that the risks in home birth are automatically unacceptable. Instead he asks, “In Home Birth, What Risk is Acceptable?”
In discussing a recent British report about home birth, Caughey acknowledges “increased C-sections, episiotomies and epidurals as a reason to avoid in-hospital births” and “[t]he tradeoff of an increased risk of C-section for a small decreased risk in neonatal morbidity and mortality is not worth it for some women.” He goes on to emphasize neonatal death risks, but says that women should be educated and assess trade-offs for themselves.
Oregon Health and Science University actually does offer some of the options that other OBs said hospitals should provide. They have midwives on staff attending births, tout their low C-section rates (which actually aren’t that low, but are below 30%), and offer waterbirth and vaginal breech births. Even though Caughey chairs the department at a hospital with many “home-like” options, he is the most open to the idea that some women might still choose to birth at home.
Obstetricians are the people most likely to see the rare birth disaster, and understandably, such emergencies make an impression. Because even a low-risk birth can go wrong, many OBs see low-risk home births as risky, and Caughey pretty obviously believes hospital births are the better choice–which is absolutely his prerogative. At least he doesn’t imply that women who make different choices than he would simply don’t know what they are doing.
Home and hospital births, however, are often compared to each other with little consideration of circumstances. For instance, home-to-hospital transfer rates for women who have had a previous birth are far lower than they are for women having a first birth–in the largest home birth study done in the United States, transfers were three times more common among first time mothers–22.9%–vs. 7.5 % for women who had birthed before. As mentioned above, the risk of an unnecessary C-section is very high at some hospitals and almost unheard of at others. Some hospitals are not even equipped to do on-the-spot emergency cesareans, resulting in bans on vaginal birth after cesarean. Thus, a woman might want to consider more than just home vs. hospital, but individual circumstances–does her pregnancy have elevated risk? Does the hospital available to her offer evidence-based care? What are the skill levels of the various practitioners available at the hospital or at home?
Even the Wax report acknowledges
Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation.
It is presumptuous for obstetricians to offer only neonatal death rates when giving women information about risks of home vs. hospital births. While the risk of neonatal death is a very serious one, it hardly ever happens. Wax estimates the risk to be about 2/1,000 for home births vs. a little less than 1/1,000 for hospital birth. On the other hand, a hospital with an 80% cesarean rate for low-risk births would give a woman an 800/1,000 chance of having a cesarean vs around 50/1,000 if she births at home.
Women take the lives of their babies very, very seriously. It is almost certain that every mother loves her baby more than any obstetrician does. With accurate facts about all aspects of birth, women are capable of doing their own risk assessments, and they have the right to choose even high risk home births, despite the opinion of you, an obstetrician, or anyone else who doesn’t agree with her choice.
For the record, I have eaten raw cookie dough all my life and am just fine, but you don’t have to have any. As for the service project, we had bought pasteurized eggs, and all of the kids enjoyed cookie dough to their heart’s content.