"The risk of death or serious complications for babies was the same in all three settings, with one exception: In the case of first-time mothers, home birth slightly increased that risk. Nine in 1,000 cases would experience serious complications, compared with five in 1,000 for babies born in a hospital."

0.5% versus 0.9% is nearly a doubling of risk. That looks significant to me, not slight at all.

And the base rate (~1%) is large enough to make the impact worth considering. (Where on the other hand, a doubling of risk in airplane travel, a very low-risk activity, would not be worth worrying much about.)

The guidance given takes this into account, differentiating between first-time and repeat mothers, but the article sidesteps it.

Midwives can do their work in a hospital room down the hall from surgical facilities just as easily as they can in your bedroom 20 minutes away from major life-saving surgery.

My mother-in-law is a retired nurse midwife who delivered >600 babies in England & Scotland during her career before moving to the US. I don't know if it's still true, but she tells us that in the UK, midwives have special privileges for things like transportation -- free bus/train/subway, and the ability to hail a cab and get a free ride if it's necessary. This may not be true any longer. She relocated in 1969.

I have zero doubt that had she been born at home she would have died or had severe brain damage before she could get to a facility capable of saving her.

I am a huge opponent of having children away from medical facilities.

As the GP said, it's uncomplicated until it isn't.

for a bit of insight into the US legal situation.

It's a protected term - you can't call yourself a midwife withoutthe qualification and registration.

Most midwives are employed by the NHS.

Obviously they're not doctors - they can't prescribe medication or perform surgery.

I have an aunt that's a neo-natal nurse, and I've never heard her refer to fellow nurses as midwives (but I've never directly asked her before).

When we had our child in May there were two midwifes with us during the process, the doctor joined once it got serious.

We could have had the child at home or at a birthing house, however we wanted to have the security of knowing that there is surgery available if something should go wrong (the hospital had a special icu for babies, I don't know the english phrase for it, but they basically could do every procedure that might have been necessary).

In addition to that, we really enjoyed the "we don't have to do shit" during the next three days (we got a familiy room, so I could stay with my significant ohter and child. Giving birth at home would have added to the stress (cleaning, getting food, trying to keep visitors away until we had slept a little etc), so for us the hospital was perfect.

That beeing said, I have tremendous respect for midwives. They do a hard job with really shitty hours and a lot of responsibility. And they get screwed over with the insurance, especially in Germany (the premiums for insurance skyrocket while the payment doesn't (http://www.huffingtonpost.co.uk/-camalo-gaskin/the-other-upr...)

The best if-you're-pregnant-right-now solution, though, is different, since currently very few hospitals allow birth in their physical location without a hospital physician.

The calculus in that case is probably a tradeoff of unlikely but very bad outcomes (death by homebirth) vs quite likely somewhat-bad outcomes (unnecessary Caesarean, unnecessary rushing, etc., by hospital), I'd think.

So, nurse midwifes do deliver in hospitals. I actually think they are not allowed to do home births or they can lose their license.

(In the US)

But moving to a home setting still seems like a poor choice. Even ignoring the higher fatality rate for home births, having the doctor available to sew up the 20% of "normal" deliveries involving vaginal tearing seems like a good move.

3 months later she suffered a prolapse as a result of the labour. Prolapse is the huge dirty secret of vaginal delivery - one woman in two will suffer some degree of prolapse as a result of childbirth, but probably only one in 5 of those will have it badly enough to have symptoms. But once you have it there's basically no cure and it can be hugely debilitating. My wife has always been very active, when she was younger she was going to try out for the Spanish national handball team, she has always run a lot, and so on. She will never run again, she shouldn't lift any weight at all (not even our daughter), she is basically an invalid by her previous standards. Her sex life has been severely compromised due to nerves in the vaginal wall being crushed - that will never improve either. All this was probably not 100% avoidable but we could have massively improved her odds if we had had access to accurate information ante-natally.

Natural childbirth is the biggest lie we have ever suffered from. If we had known then what we know now she would have had an elective caesarian, and I recommend everyone consider it.

Note that hospital deliveries can also have complications. Due to high blood pressure, my wife had to deliver our first child in the hospital[0], and under the care of the hospital, rather than the midwife[1]. She spent 17 hours in labour, and only after pushing for 2 hours did the hospital's midwife discover that the baby was stuck, which I suspect was a serious fuck up; only after I insisted that they figure out how the baby progressed, did they discover it had been stuck this whole time. While the caesarean team was preparing, the hospital's midwife managed to deliver the baby with a pump. My wife spent the next two years walking like an elderly person due to instability of the pelvis. Fortunately she eventually recovered, and she's in a much better condition now, a few weeks after delivering our second child.

[0] I'm Dutch; home births are the standard here. [1] Our second child was delivered in the hospital but under the care of the midwife; home birth was not an option due to the complications with the first pregnancy.

Then getting rushed to hospital takes longer than you'd think - 45 mins end to end for us, and we live in a small town. Once there my wife was assessed for risk, the ob/gyn came about 30 mins later because there didn't seem to be any immediate danger for her, then there's a protocol to be followed before any intervention takes place - it all adds up to a surprisingly long time.

Congratulations on your second child, I'm glad that went well and that your wife has recovered - that's really great.

Basically, there is zero information about this risk ante-natally, so people cannot make informed decisions. If we had had all the information that we have now before the birth, we would have at the very least considered a c-section and probably insisted on one, which is why I recommend everyone investigate it for themselves and consider it.

But better to have too much empathy than too little -- or none at all.

That being said, a significant portion of the pain is from giving birth on a hospital bed - or just lying flat in general. It is said (as a man, I have never given birth) that it is less painful, and therefore less in need of an epidural, if the birthing is done in a upright or crouching position. Like how an orangutan does it : http://youtu.be/JfVnFJDjUyQ?t=30s

The very idea of lying down for a birth dates back to the 18th century, when some French king wanted to see the birth of his heir. Of course men were not allowed in the birthing room, so he had to peek through a hole in the wall - or something like that. And the queen had to be in a position that allowed the king to see, so she was lying down facing so the king could see what was going on.

My wife had two pregnancies: one was 52 hours (with five hours of pushing!). The second was about 2 hours total.

Neither involved pitocin.

Baby was 9 lbs, 9 oz (4.3 kg).

This is not a knock against the UK or US healthcare systems at all.

What worries me about this type of thinking is that you're looking at the cost/benefit in the aggregate. Of course, when you're running a national health system you have to. However, this is also happening in the US (the biggest US insurance companies cover 30M+ lives).

You can describe the cost/benefits overall, but it's (mostly) impossible to at the individual level. Sure the average overall survival for an expensive cancer drug might only be 6 months, but if you look at the data you'd likely see that the range if 15 days to 3 years.

Health authorities might make the call that 6 months of additional life isn't work $XX,XXX dollars, but for some of the patients whose life is extended 2-3 years, it certainly is worth it. But in the end, the call is made to not fund the drug.

I have no idea how to solve this issue. I think linking outcome with genetic information is super helpful (it's already being used), but dam, there are a lot of folks out there that could have been helped, but won't be.

Triage is not fun, but even with infinite money it is still necessary, and with finite money it has to be coldly pragmatic.

So NICE has a standard limit of £20,000 per QALY, or up to £30,000 per QALY, if certain extenuating conditions are met.

A QALY being: "A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health. QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to 1 scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance."

If NICE determines that a drug isn't cost-effective, no one gets it (unless you pay out of pocket), regardless if it would have helped that individual patient.

http://www.skepticalob.com/2014/12/new-uk-homebirth-guidelin...

Clearly she has virtually the opposite perspective from the one in the NYT, and one that seems hard to dismiss.

(My kid was delivered in a hospital, and I tell myself that I'm being impartial, but who knows.)