Homebirth, like climbing trees … with a baby in your arms

image

I guess it’s progress of a sort.

As the evidence mounts that homebirth kills babies who didn’t have to die, advocates are switching gears from denying the increased risk of perinatal death to rationalizing it.

The latest effort, greeted rapturously in the homebirth community, is Climbing Trees by obstetrician Alison Barrett.

was one of those kids who loved to climb trees…

I want to be clear: climbing trees was not, to me, about taking risks. There was nothing about tree climbing that felt risky, in fact, it felt very safe, to be cradled in the canopy of a tree…

Climbing trees is a metaphor for homebirth.

Some people think children should not climb trees. They’ve banned it in school yards. Today some might claim that my parents were irresponsible. Perhaps they would have reported my mother …

There are people who believe that risk shouldn’t be allowed in childbirth either. Since it involves an unborn child, who cannot consent, parents should be made to do the right thing…

So Barrett acknowledges that homebirth carries the risk of death, just like climbing trees carries the risk of death. The important issue for her is that the benefits outweigh the risks:

When I look back, I am sure that climbing trees gave me some immeasurably important gifts. One was a belief in my own body. I’m not a star athlete; I don’t consider myself particularly stoic, or brave, or over-confident. That belief in my own body served me well later on during the birth of my children, and in attending the births of others…

Let’s leave aside for the moment the fact that that argument can be made for any practice, no matter how dangerous. Perhaps drunk driving gives you a thrill and a feeling of self-confidence. That does not rationalize drunk driving.

But the real problem with Barrett’s argument is not its weakness, but its inadequacy. Homebirth is not like climbing trees. It is like climbing trees with a baby in your arms; and the baby makes the risk calculus very different.

1. Carrying a baby in one arm makes climbing a tree much more dangerous. It reduces maneuverability, changes balance, makes it difficult to get a strong grip, putting the climber at much greater risk of falling. Similarly, giving birth to a baby entails many life threatening risks to the mother that simply don’t apply when she is not pregnant.

2. You could climb the tree safely, but drop the baby out of the tree to its death on the ground below. I suspect that we would all agree that climbing a tree with a baby in your arms would be a reckless parenting decision, no matter how much satisfaction it would give the mother to show her child the view and no matter how much pleasure the view might give to the baby. In many situations, homebirth is a reckless parenting decision because it is the baby who is in far greater danger than the mother.

3. Climbing a tree isn’t a metaphor for homebirth. It’s a metaphor for birth itself. Childbirth inevitably carries risk. Regardless of what tree you climb, or where the tree is located, there is always a risk for the climber. But you can make the climb more or less dangerous depending on the conditions. Climb in a hurricane, and you increase the risk. Climb a dead tree and you increase the risks. Climb with a baby in your arms and you’ve dramatically increased the risk. Similarly, give birth in a birth center far from the hospital and you increase the risks. Give birth at home and you increase the risks even more.

4. Climbing the tree holding a baby increases the risk, but climbing a tree holding two babies increases the risk even further. Similarly, giving birth to twins at home (or a breech baby, or after a previous C-section) increases the risk even further.

5. The risk of climbing is completely independent of whether you feel safe while climbing. It makes no difference if you feel safe inching out along dead branches. It makes no difference if climbing to the top of a redwood doesn’t frighten you. And it certainly makes no difference if you trust trees. The risk exists independent of the views of the person who undertakes it. That’s why the claim that feeling “safe” at homebirth is utterly irrelevant. Your safety and risks have nothing to do with how you feel about them.

I’m grateful that Barrett acknowledges the risk of homebirth. Homebirth kills babies who didn’t have to die and that is irrefutable. I find her effort to rationalize that increased risk to be deeply flawed, however. She wants to imply that the increased risk of death at homebirth can be justified by the personal growth experienced by the mother. She conveniently ignores that while the mother is knowingly adopting the risk, the baby is not and the baby is the one with the most to lose.

Homebirth isn’t like climbing trees. It’s like climbing trees with a baby in your arms. It’s the baby that makes the risk unacceptable for most women, not the trees.

  • http://freyjaw.dreamwidth.org/ FreyjaW

    Some trees you *just* *don’t* *climb*.

  • Anna

    I loved climbing trees, but I vividly remember the horror of climbing up and running into a bunch of fire ants. If childbirth is like climbing trees, then I would’ve been climbing into multiple swarms of ants and just hoping I wouldn’t get bit. And the only thing worse was when I ran into them but couldn’t get down fast enough because somebody else was in my way. Thankfully, I only got a couple of bites and didn’t end up falling out of the tree over it.
    If I’d gone with the woo mentality I’d been indoctrinated with before finding this blog, I might’ve ended up with only 1 child and a string of stillbirths due to rh incompatibility. I might’ve ended up with no children because of being GBS+ on top of that. I might’ve been too physically exhausted to give birth on my own before my daughter became distressed without the iv narcotic that allowed me to cat nap between contractions. I might’ve bled to death without the pitocin I was given after her birth. My daughter might’ve died from malnutrition if we hadn’t been surrounded by lactation consultants and pediatricians/nurse practitioners who recommended supplementation and then helped her with her latch difficulties and me with my supply issues before weaning her off the supplement when she was healthy again (before the formula, she was so hungry all she could do was sleep and cry weakly out of frustration when trying to latch).
    I’m really grateful to Dr. Amy and a lot of the commenters her for posts like this that encourage people to really think about their choices and what is truly the safest thing for them and their babies. Becoming informed enough to trust my providers has shown me what emotional comfort really is – it’s being home with my healthy baby, confident that those providers will help me keep her that way, not giving birth in my bathtub.

  • doctorex

    Unfortunately, these folks tend to think that carrying a baby in your arms instead of your sling or kangaroo pouch or organic cotton traditional African baby wearer is a grave parenting mistake. And from what I can tell, they already perform extremely risky behavior while “wearing” a non-consenting tiny human.

  • http://jtrader.hubpages.com/hub/How-to-Publish-on-Fanficitonnet-and-Gain-a-Loyal-Following Healthy

    I know someone who did a home birth recently, after her other tow births were done in hospital. The experience is not one just anybody should have, unless they are mentally prepared for it.

    http://jtrader.hubpages.com/hub/California-Baby-and-Other-Moisture-Barrier-Ointments-for-Incontinence-and-Irritant-Diaper-Dermatitis-Treatment

  • Kiwi

    I don’t understand the photo in the linked article of mum and baby after ‘traumatic hospital birth’ – how is this meant to be a negative (unless referring to forced roomingin).
    Also, really not a good time to be coming out with NZ homebirth articles considering there have been several newspaper articles recently regarding the Health & Disability Commisioner case decisions on midwives… http://www.hdc.org.nz/decisions–case-notes/commissioner's-decisions/search-results?search=Keyword(s)&filterBy=1511
    Should add, I had a midwife led birth in NZ at a hospital and it was great, I jst do not understand the push for homebirths.

    • yugaya

      mom + baby + hospital = traumatic birth
      mom + baby + home = birth experience

    • carr528

      I don’t get it either. I thought home birth advocates ranted on and on about how moms and babies were separated at the hospital, but here’s a picture of a mom with her baby sleeping quietly on her chest. I mean, whether you’re home or at the hospital, giving birth is hard work. Wouldn’t a little rest be appropriate in any circumstance?

  • PrudentPlanner

    There is a good 6th point to this analogy: The tree doesn’t care whether you live or die. ‘Nature’ doesn’t care whether an individual woman or her child(ren) die.

    • Young CC Prof

      Evolution doesn’t do perfect. It does “usually good enough.”

  • DiomedesV

    Telling. There is a graph of risks of death to women aged 20-44. Pregnancy and childbirth is the smallest in that list. Where’s the graph for the baby’s risk?

    • Young CC Prof

      It’s also presented deceptively, because most women are only pregnant for two of those years. Among pregnant or newly postpartum women in places like the USA or Australia, roughly half of all deaths are maternal deaths.

      • Young CC Prof

        Depending on how you define maternal death, of course. But even if you use a strict definition of direct maternal death, it’s still a big piece of the pie.

      • Amy M

        Also, what is the population included? UK only?

      • The Bofa, Being of the Sofa

        This is similar to the drunk driving death statistics, where they show the annual risk of death. However, that does not take into account the frequency of drunk driving. As I have shown here, the problem with drunk driving is not so much the risk per event, but the frequency at which it occurs.

        For example, if drunk driving were as common as homebirth, there would be a couple of accidents a year, and no deaths for anyone. The problem is that it is so damn prevalent and that adds up.

        Yes, it is important to compare risks of something happens at the appropriate time scale.

  • Meerkat

    Somewhat OT, what do you think of this article? My skeptic alarm is going off…http://www.iflscience.com/health-and-medicine/cesarean-delivery-may-cause-epigenetic-changes-babies-dna

    • Young CC Prof

      Epigenetic changes in newborns, which are not linked to any health problem and may not persist. Yeah, I’m not going to stress about it.

      • Meerkat

        I hate alarmist articles like that, all they do is make women feel guilty and scared.

      • Elizabeth A

        Not even epigenetic changes in newborns! Epigenetic changes in stem cells (tested from cord blood). What this study says, basically, is that c-section babies have different cord blood methylation rates than babies born vaginally. We don’t know that the methylation rate is the same throughout the infant as it is in cord blood.

        And then we haven’t linked these changes to any problems, or proved that these changes persist.

        “Epigenetic” deserves almost as big an eyeroll as “gut flora.”

        • Young CC Prof

          Oh, man, I missed that piece of idiocy. Cord blood cells. Not actual body cells.

          And everyone knows that the condition of the cord blood is closely linked to the circumstances of birth. Well, not everyone, but you know what I mean.

        • Amy M

          The gut flora people and now the epigenetic people are really short sighted. Any differences in environment can have an effect (on gut flora or methylation). This doesn’t mean its bad, just different. People living 100 miles away from you have different gut flora because of where they live. Certainly people who live in different cultures and eat different foods and live in different climates would have different gut flora, and it’s not a stretch to imagine that methylation of their DNA would also be different, in response to their environments.

    • Elizabeth A

      I am willing to pin any health problem my daughter ever has on the c-section. If not for the c/s, she’d never have any health problems, and neither would I.

    • QZ_101214

      Doctor Amy definitely did a post about epigenetics as a buzzword

      http://www.skepticalob.com/2014/01/microbirth.html

  • Who?

    When I climb a tree, if I fall I risk myself and potentially hurt myself. And perhaps anyone silly enough to be standing right under me.

    Homebirthers mostly risk their baby, who did not get a say-mums tend to survive, some babies who would have been okay in hospital are damaged or dead.

    It’s a silly analogy.

  • KarenJJ

    The other thing that strikes me is nobody is climbing trees without first doing other things that build up to it. My kids have started climbing trees but only go as far as their current ability lets them and they’ve been climbing on play equipment for a while, like monkey bars, and slowly building up their strength and balance to swing from their arms and get a grip onto the tree.

    Childbirth doesn’t get that sort of build up. It’s like saying to an adult – quick go climb that tree – you’ve never done this before – we’ve no idea if you have some sort of issue such as arthritis or muscular dystrophy or Meniere’s disease or epilepsy or similar that may make climbing the tree extremely dangerous/painful – but you HAVE to do it.

    NCB then takes it further by not doing any simple tests to make sure you’ve got some hope of making it up the tree (eg checking for balance for example and making sure you’ve got two arms or whatever) and telling you that if you do fall out of the tree they’ll pat you on the back, check if you’re a bit winded or not and might call an ambulance if you don’t perk up after they’ve administered a drop of flower water.

  • Dr Kitty

    Google “parkour crane”.
    Bet those guys feel amazing and empowered and safe and confident.
    Doesn’t mean it is in ANY WAY something to be recommended to the man in the street.

  • Amazed

    I’ve climbed trees. I have wonderful memory of that time. I also have four small scars, one on my breast and three on my fingers from the time I climbed a tree immediately after a rain after being explicitly warned not to. Of course, I did it in secret and by the time my grandma caught me red-handed (and red-breasted against the white of my T-shirt), I had been dripping blood quietly for a long time.

    I would never take a baby up that perfectly nice tree in my grandma’s garden. Because, you know, they might end up worse than I did. Scary to think that so many women are doing it, in a way.

  • Trixie

    Excellent article.
    I have a friend who is an arborist, and also a veteran of a Special Forces branch of the military. In other words, he’s spent a lot of time very high up in trees, and a lot of time doing things even more dangerous than being very high up in trees. Of course he uses safety gear and best practice, but he’s still often 100 feet in the air using a chainsaw on the very tree that he’s attached to. He told me once that he’s never allowed himself to be afraid when he’s high up in a tree, because fear could lead him to make a poor decision. He says he gets in “the zone” where he’s paying minute attention to every detail of everything that’s happening in that tree.
    Of course, you can’t do the same thing while giving birth, because a mother can’t know what could be going wrong just by being in “the zone”. You need science for that.

  • Mel

    Some people think children should not climb trees. They’ve banned it in school yards. Today some might claim that my parents were irresponsible. Perhaps they would have reported my mother …

    Oh, please.

    1) We weren’t allowed to climb trees at schools in the mid-1980′s. My parents weren’t allowed to climb trees at school in the late 1960′s. A mature adult should be able to realize that the ratio of teachers/playground monitors to students makes it impossible to safely supervise large, mixed-aged, mixed ability groups of minors trying to scale trees.

    Interestingly, the ratio of skilled medical professionals to women in child-birth at a home birth is much lower than playground adults to children. Plus, the playground adults are quick to get medical help when the rare emergency does occur.

    2) Did your parents encourage you climb NZ’s equivalent of black walnuts (riddled with dead limbs) or poplars (fast-growing trees that get really tall, die and remain standing)? That would be irresponsible. If your parents taught you basic tree-climbing common sense, then let you explore, that’s basic good-parenting.

    3) One parent/person can report another parent for anything. I could call CPS right now and file a report that my neighbor lets their son play with their dog (who is absurdly friendly and very gentle towards the little boy). Could my neighbor be investigated for that? Extremely doubtful. Could my neighbor be prosecuted for that? Oh, hell no. Stop using a CPS boogey-man.

  • Young CC Prof

    Two separate thoughts:

    1) No one is “forcing” parents. Again with the narrative of oppression, no one is in favor of going out and arresting women and dragging them to the hospital.

    2) Even when children do fall out of trees while climbing them, they usually don’t die. Broken arm, maybe, but you’d have to get pretty high up for death to be plausible.

    • auntbea

      Right. It isn’t really irresponsible to let your kids climb the apple tree in your backyard: if they fall, they will probably get an injury, but a fixable one. On the other hand, it would be WILDLY irresponsible to allow your children to climb a giant sequoia (assuming they even could) without a harness and a helmet. Birth might be an apple tree or a sequoia, but you won’t know until you’re already at the top.

      • Young CC Prof

        That’s a good way of extending the analogy, really.

        My husband owns a set of tree-climbing equipment. While buying it, he discovered that there are two different classes, and one is much more expensive than the other. One is for hunters, the other is for lumberjacks and recreational climbers.

        The hunters’ equipment is the cheap one. Why? Because when hunters climb a tree, they only go ten or fifteen feet up, just above the animals. Recreational climbers or lumberjacks may climb much higher, and if they fall, they die.

        • guest

          It seems pretty easy to find reports of hunters dying or being paralyzed from tree stand falls. The only formal thing I found was a 2009 study of Pennsylvania deer hunter tree stand falls in the American Journal of Preventive Medicine. It didn’t look good. I’d want the expensive stuff.

          • Young CC Prof

            Actually, a tree stand isn’t the same as a climbing harness. Harness is the belt thingie, the same thing you’d use for rock climbing, a tree stand is an actual platform or ladder of some kind. You often aren’t tied to anything at all. And you sit there for hours and hours in the freezing cold.

            One big issue with tree stands is that they are sometimes left out year-round. The person I know of who suffered a mild concussion falling out of a tree stand (yes, it apparently happens fairly often) was testing it at the beginning of the season. It failed spectacularly.

          • guest

            Yikes – this says that a 10 year survey of Ohio hunting injuries showed half of the injuries to deer hunters came from falls, and almost all (92 percent) are tree stand falls. Only 29 percent came from guns. This is a great/horrible article: http://usatoday30.usatoday.com/news/nation/2010-11-04-hunting04_ST_N.htm As this article points out, the commercial tree stands come equipped with harnesses to tie in with, but hunters often don’t use them. I’m not confused at all by the difference between a tree stand and a harness. My point is that even falls from the relatively low height of a tree stand do in fact lead to very serious injuries.

          • guest

            Best quote ever, and perhaps a really good metaphor for homebirth: “The presence of safety harnesses doesn’t mean anything if hunters won’t wear them, and they won’t,” Louk says. “It’s a mental block. They’re just assuming they can fly, but gravity will always win out in the end.”

    • guest

      Regarding 2), I’m not really sure. If you google “Morgan Spurlock” and “GoFundMe,” you’ll see a tree climbing death that happened a couple of months ago. And here’s another incident, from a few years ago, that happened just a few blocks from that one: https://www.facebook.com/felixgreenelilly. He didn’t die, thanks to great medical care. Here he is, a couple of months after he fell. https://www.youtube.com/watch?v=c9Q2iDqFi-E&feature=youtu.be I think he’s doing much better now. Interestingly, neither was reported in the newspaper or on tv (that I heard about, anyway), and the government doesn’t seem to collect stats just on falls from trees, as opposed to falls from playground equipment or fences or what have you. How do you know the proportion of injury and death compared to other activities?

  • lilin

    I don’t mind this. What I can’t stand is when homebirth advocates pretend homebirth is safer, and muddy the water so that women who would rather have lower risk births inadvertently have higher risk births because they don’t know who to trust.

    You want to sing a song about confidence, go ahead.

    • auntbea

      She is comparing the risk of homebirth to the risk of climbing a tree. Since most of us do not consider climbing trees, at least typical backyard trees, to be particularly risky, the analogy implies that homebirth isn’t really risky — or, at least, not risky for someone who isn’t one of those over-anxious helicopter parents. How is that not muddying the waters about risk?

    • Melissa

      They have to lie about the risk in order to avoid looking like narcissists.

      Option One: I want to have a homebirth because even though it is more dangerous, I want to have the experience of giving birth at home in order to take it off my bucket list and so that I can show that I am more xtreme than other women giving birth.

      Option Two: I’m giving birth at home because it is safer. Did you know more babies die in hospitals than at home (not per number of births, obviously, just raw totals).

      Even if your real reason is One you can’t tell your spouse, parents, and friends because they will think you are nuts. So an entire myth of the safety of homebirth has been created so that people can tell it and look responsible.

      The danger is when someone comes in who doesn’t realize that it is a myth and actually believes it. They think they are doing the safest thing for their child when they aren’t.

  • attitude devant

    Seriously? NZ has terrible terrible problems with obstetrical care. And here’s dear Allison to blather on about trees?

    • attitude devant

      Too bad she’s not in the States. The tort lawyers would roast her in record time.

    • Michelle

      I know a child that tore her leg and groin open climbing a tree at school, it was prohibited of course. It was an entirely preventable accident, and that’s the bit the author misses. There’s risk in everything but this is often modifiable. In the case of homebirth, the location poses risks should something go wrong let alone that it’s a low tech environment ill equipped to handle complications. I’m doubting this person would stake their registration on this, theorising is one thing, reality another.

      I’ve been doing a bit of reading on homebirth in NZ, and it’s difficult. You could ban, but it would be overall better if someone insists to have one anyway that trained care be available. Then there is the fact the rates are low but variable across areas of the country, very few in my city, but in some other areas like isolated communities in the West Coast quite a few. It’s a juggling act there, it may be several hours drive to the nearest tertiary facility, or in winter roads might be closed and the woman not be able to readily manage staying in a main centre for a month or so just in case. In those situations, the judgement call involved might be different.

      NZ has never had obstetric care in the American model (as in Obstetricians as default providers with nurses doing L&D as opposed to Obstretrician/doctors and midwives), but the latest figures I’ve seen have been showing continued improvement and they are not out of line with other developed nations like the UK or Australia which both have obstetricians plus midwifery care as part of their systems. That’s good in the sense that we aren’t a large country and are pretty isolated. The system is pretty transparent in terms of cases being reported but I don’t notice these being put into context of the amount of births, or overall error rates and whether these are out of line with other countries. There has also been extra funding going into areas like maternal mental health, maternal mortality has remained stable but a percentage is due to suicide and family violence and this can be addressed.

      My thing is that the complaints are maddeningly vague, no one is very specific about what the terrible terrible problems are, it’s just “well known”. Doesn’t convince me that there is much understanding there of real problems and issues within the system, nor any real idea of what might make it better and safer.

      Certainly there has been quite a bit of effort gone into reducing preventable incidents throughout the system, with reporting of serious and sentinel events and specific cases via the Health and Disability Commissioner. I wonder whether this leads to the perception that it’s crappy, when there are hundreds or thousands of events happening with health professionals every day, the majority of which do have satisfactory outcomes. http://www.hqsc.govt.nz/our-programmes/ has more information on that.

      • attitude devant
        • Michelle

          And that’s it? I’m already aware of the organisation and the advocacy work it does, which is good thing. Parents that have been affected by this need help, and if incidents are preventable someone’s got to keep on the authorities arses to fix it and make things better for other parents.

          However that is not the New Zealand health care system, it does not tell us about the quality of the system nor does it tell us if our error rates are any higher than anywhere else. This could be in the context of an OK system, but like with any health care systems it can do poorly sometimes but you can’t see that, or what exactly it is doing poorly at just from one website.

          Also in contrast to the claims on their website (may not have been updated in a while though) we had 3 deaths per 1000 births in New Zealand in 2011 (WHO measure of perinatal mortality). In 2007 it was 3.6 deaths per 1000 births. I call that an improvement.

          According to the PMMRC, which reviews perinatal and maternal mortality and has continued to make recommendations to improve care – Stillbirth 2011 rate of 0.16 per 1000 and in 2007 the rate was of 0.43 per 1000. For oxygen deprivation in 2011 there was a rate of 0.07 per thousand and in 2007 the rate was 0.26 per thousand births.
          http://www.hqsc.govt.nz/news-and-events/news/961/

          And I don’t think this is an issue: “The rate of Caesarean Section births has doubled since the late 1980′s.” (from AIM)

          According to what I’ve read in an article, the rate for NZ was only 9% in 1980. 2010, 23%. I for one, don’t understand why this should be an issue given that this is a safe way to give birth, and often is used to prevent poor outcomes with or without emergencies. I don’t think this should be used as a proxy for quality of care (a low rate that is).

          Now what did Dr. Amy just say? (An industry devoted to demonizing C-sections)

          But the fact is that the countries with the best maternal and perinatal mortality rates have an average C-section rate of 22%, and very high C-section rates (up to 42% or more in the case of Italy) are completely compatible with excellent maternal and perinatal outcomes.”

          Seems to me that our overall rate shouldn’t be an concern according to this, and it should go hand in hand with better outcomes.