Homebirth and cognitive biases

One of the most bizarre aspects of homebirth advocacy is the insistence that “babies die.” Why do homebirth advocates blithely offer this cold blooded claim, at odds with everything they profess to believe about the trustworthiness of birth, in the wake of every homebirth death?

They are desperate to resolve the cognitive dissonance between what they believe about birth (“trust birth”) and the homebirth disasters that result because birth is inherently dangerous and homebirth midwives are woefully incapable of preventing, diagnosing and managing homebirth disasters. Most people, in the face of scientific evidence, would alter their beliefs to conform with the evidence. However, many homebirth advocates are so desperate to believe in the safety of homebirth that they direct their efforts, instead, to bolstering their beliefs. To do that, they employ a variety of cognitive biases.

According to Michael Shermer, in The Believing Brain, subtitled in part How We Construct Beliefs and Reinforce Them as Truths allow people to confirm beliefs in the face of evidence that those beliefs are not true.

Cognitive biases come in very handy in homebirth advocacy. As the number of homebirths resulting in dead babies begins to climb, homebirth advocates fall back on cognitive biases that allow them to maintain belief in the safety of homebirth in the face of evidence that homebirth is not safe. There are many different types of cognitive biases.

1. Confirmation bias

Shermer describes confirmation bias as “the mother of all cognitive biases.” Confirmation bias is:

the tendency to seek and find confirmatory evidence in support of already existing beliefs and ignore or reinterpret disconfirming evidence.

Ever wonder why birth stories play such an important role in homebirth advocacy? This is why. Every story with a successful outcome serves to confirm the belief that homebirth is safe. The “best” stories, of course, are those in which women were warned of possible bad outcomes, but had a good outcome. Sure the woman was told that a VBAC after two previous C-sections could result in a ruptured uterus and a dead baby. But look! She had a healthy baby! Not only did she teach those doctors a lesson, she provided other homebirth advocates with a story that confirms their belief that homebirth is safe.

2. Hindsight bias

Birth stories with happy outcomes are a form of hindsight bias. Homebirth advocates love to make fun of the “fear-mongering” doctors who warn against dire outcomes. What better way to do it than to take a story that you already know will have a happy ending, and disparage the warnings of the doctors who had no way of knowing what the outcome would be?

3. Self-justification bias

Shermer defines self-justification bias as:

the tendency to rationalize decisions after the fact to convince ourselves that what we did was the best thing we could have done. Once we make a decision … we carefully screen subsequent data to filter out all contradictory information related to that decision … One of the practical benefits of self justification is that no matter what decision we make … we will be satisfied with the decision, even when the objective evidence is to the contrary.

Self justification bias leads a mother who has been warned repeatedly that she is not low risk to “why me?” in the wake of her baby’s death. That’s why Annie Bourgault, who was advised to have a C-section for malpositioned twins, “doesn’t understand” why one of her babies died. The reason, obviously, is that she made a bad decision, but she will not accept that reality. Instead, she insists that there was no way to know in advance that this would happen.

“Babies die” is a form of self-justification bias. The implication is that the baby would have died in the hospital anyway or in the variation “babies die in the hospital, too” would have died from some other, iatrogenic, cause in the hospital. This allows the mother to console herself that her decision to have a homebirth was correct, despite the dead baby that is objective evidence to the contrary.

These cognitive biases demonstrate why it is critical that the ever growing number of birth stories that end in disaster are not suppressed and are easily available for any woman to read. If every story of homebirth on the web ends with a happy outcome, it will merely confirm the beliefs of homebirth advocates without acknowledging the reality of homebirth dangers.

Birth stories that end in the death of the baby don’t confirm the homebirth advocacy assertion that trusting birth is all that is needed for a good outcome. They show that the hindsight bias of the happy stories is just that, bias. The outcome easily could have been disastrous. Most importantly, they provide objective evidence that homebirth is not safe.

Yes, homebirth advocates will use the self-justification bias that “babies die” to insist that the death was inevitable, but those who are not ideologically committed to the belief that homebirth is safe will see it for the self-justifying tactic that it is.