Hospitals are seat belts for birth


In the last 30 years we have engaged in a huge public health campaign to increase the use of car seats. Not only have we spent millions, we’ve enacted laws that actually make it illegal for parents to drive infants without buckling them into car seats.

The campaign has been spectacularly successful. According to the Insurance Institute for Highway Safety, from 1975 to 2013, infant fatalities fell from 6/100,000 to 1.3/100,000 while car seat use rose to 99% of children under age 1. Of course car seat use is the not the only reason why infant fatalities dropped; cars themselves are safer, but the use of car seats has played an important role.

Out of hospital birth has a death rate more than 50X higher than failing to put an infant in a car seat.

Forgoing car seat use for infants is not merely illegal, it is social anathema. Who would defend a mother who chooses not to use a car seat for her infant. No one, right? Who would claim that the risk of not using a car seat is so small that it should be left to the mother’s choice? No one, right?

Yet, many home birth midwives defend it as a reasonable choice because the risk of death is small. But small is a relative term. That’s why it is instructive to compare the risk of refusing to use a car seat with the risk of giving birth outside a hospital.

I’ve attempted to do that in the graph below:


The graph reflects information from the Insurance Institute for Highway Safety and the data from a 2016 paper in The New England Journal on out of hospital birth suggested that the increased risk of giving birth outside a hospital was small.

Even a cursory glance reveals an inconvenient truth (inconvenient for natural childbirth advocates that is). Childbirth, even for low risk women with singleton term babies in the head first position is inherently dangerous. Infants who are unrestrained had a death rate of 4.6/100,000 whereas the infants of low risk women faced a death rate of 106/100,000 even in a hospital. Childbirth is 100X more dangerous than failing to restrain an infant in a car seat.

The graph actually dramatically understates the risk. The automobile fatality data reflects deaths per 100,000 children, most of whom rode in cars multiple times. The per trip mortality rate is substantially lower. Furthermore, the birth data is from low risk women. The true gulf between automobile infant deaths and deaths from childbirth is probably another order of magnitude.

The graph also shows that the risk of death for an infant riding in a car is actually very small, whether riding in a car seat or not (1.3/100,000 vs. 4.6/100,000). Nonetheless, we value the lives of our infants so much that we are willing to spend millions of dollars and enact laws in all 50 states to protect them from this small increase.

In contrast, there’s a much larger difference between delivering a baby outside a hospital vs. in a hospital (258/100,000 vs. 106/100,000). If 100,000 mothers of infants chose to drive with their infants unrestrained, there would be an absolute increased risk of 3 infant deaths per year. If 100,000 low risk women chose to give birth outside the hospital, however, there would be an absolute increased risk of 152 deaths!

That doesn’t change the fact that it is up to each woman to decide for herself where to give birth. But it does suggest that the increased risk of death at out of hospital birth isn’t small after all.

Simply put, no one could call the failure to buckle an infant into a car seat a safe choice. If no one would call that choice safe, no one should call the choice to deliver outside a hospital, which has an absolute increased risk of death that is 50X higher, a safe choice.

5 Responses to “Hospitals are seat belts for birth”

  1. Amazed
    April 21, 2020 at 4:26 pm #

    Oh my, the NYT piece comment section is full of disasters waiting to happen. A bunch of ignorant, self-entitled POSs presuming to teach Amos G. on the safety of homebirth and proudly declaring their intentions to have homebirths because it’s so safe.

    My compassion for women like these who thump themselves in their undoubtedly-to-be-milky mama chests and teach obstetricians on the safety of homebirth because “studies show”… especially obstetricians who CONDUCT studies… ran out years ago. When one of them encounters a tragedy, we’re supposed to be all hugs and comforting pats and “you coudn’t have known better mama”s? Not this cold-blooded bitch here. They know, they know, they just don’t want to believe what they know. And heavens only know how many babies THEY have killed by edging OTHER pregnant women on homebirth. But hey, the moment their own baby dies, all is forgotten and poor dears are sweet ignorants.

    This is quite like a mother who fights a c-section till the bitter end because “her body knows how to give birth and her baby knows how to be born”, whereupon she promptly makes a circle, sues for a c-section not done in time and the jury gets caught in sympathy because hey, this is a weeping mother who was let down by her medical team. If she had known, she would have had a c-section, OF COURSE she would have had. She’s the mother!

    What a pack of howling she-wolves that comment section over there is.

  2. The Bofa on the Sofa
    April 21, 2020 at 12:22 pm #

    I always like the “per event” comparison, too. I realized it didn’t make sense to compare the risk of an event that happens once every 2 years with something that you do every day by looking at the “annual” risk. For example, with that you can come up with a fatality risk for drunk driving of something like 2/million drunken drives.

    I tend to think the same thing about birth control. They need to be compared on a per-incident basis. “What is the failure rate when you use a condom?” is a very different question from “what is the failure rate if you plan to use a condom but get careless on occasion and don’t bother?” Even then, you could break it down by “if you use a condom during the middle 4 day stretch between menses” (or however you want to reflect the most fertile period) and distinguish that from other times.

  3. AnnaPDE
    April 21, 2020 at 9:42 am #

    The bitter irony of this analogy is that the same people who happily have a home birth because it’s oh so safe and natural will be horrified if you even consider a forward-facing car seat for a 1yo. It has to be a rear facing seat and preferably an expensive Scandinavian model, otherwise you may as well just chuck your kid through the windscreen right now.
    Maybe if hospitals offered an extra-expensive and somewhat inconvenient safety option, it would suddenly become attractive?

  4. fiftyfifty1
    April 21, 2020 at 8:22 am #

    I chose not to tie down my baby in a car seat. Instead I hired a car doula. She supports (flatters) me as I drive the car, and in the event of a car crash I’m sure she will have time to reach over and grab onto the baby and keep it from flying through the windshield.

    • rational thinker
      April 21, 2020 at 4:48 pm #

      All babies naturally know how to land safely on their feet after flying through a windshield. That’s just a fact.

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