This past week, the US TV channel Lifetime released a trailer for its controversial new reality show, Born In The Wild, which—yes, you guessed it—shows mothers giving birth in the wild. In the trailer, we see (the appropriately named) Mrs. Bird giving birth to her third child, Piper, in a the raw frame of a homemade cabin in rural Alaska. The show isn’t quite as dangerous as it sounds; mothers may choose to have a medical professional on hand, and even those who refuse, like Audrey Bird, will have emergency personnel on standby (Bird herself trained as a midwife).
OK, so giving birth in the wild may be a bit extreme, but isn’t natural birth—i..e., giving birth vaginally at home with only midwife care—supposed to be better for mother and baby, both psychologically and medically? Indeed, the official recommendation in the UK is that low-risk births take place either at home or in a midwife-led unit.
A 2001 British Medical Journal editorial on this topic cited an influential 1996 survey of 206 London obstetricians, which found that 17% would choose caesarean section for themselves or their partners, even for a low risk birth (i.e., “in the absence of any clinical indication”), with most citing fear of perineal damage (tearing) as the reason. It’s hard to know exactly what to make of this finding. Is the current (ahem) push towards natural birth misplaced? Or does this finding support the view of many natural birth enthusiasts (including Caroline Flint, former President of the Royal College of Midwives) that doctors over-medicalize childbirth? That said, a more recent survey gave that figure as 10%; not significantly different from the general population.
Ultimately, the BMJ editorial emphasizes the importance of choice. And who could argue with that? Certainly, nobody wants a situation like that in Brazil, where many women choose a caesarean because they are frightened of “what they considered poor quality care and medical neglect, resulting from social prejudice.”
But on what basis should women make this choice: Are home or hospital births safer for normal, low-risk deliveries? Unfortunately, the answer is that, currently, it’s almost impossible to say. The Cochrane Collaboration is an independent and impartial organization that publishes comprehensive meta-analyses designed to answer exactly these types of questions. A meta-analysis uses rigorously-defined methods to combine the results of many different studies on the same topic into a single mega-study with, usually, many thousands of participants. But when researchers tried to conduct such a review for planned hospital births versus planned home births, they were able to find only one study that met the stringent inclusion criteria; and this study included just eleven women. The reason is that Cochrane insists on randomized control trials: studies in which pregnant women are randomly assigned to either home or hospital birth. But such studies are almost impossible in this particular domain. Even if we could find a large group of women who were happy to accept either a home or hospital birth on the flip of a coin, they would hardly constitute a typical cross-section of the pregnant population.
This places the burden on observational studies: those that simply compare the outcomes of home and hospital births, rather than randomly assigning women to one or the other. However, there is considerable debate regarding whether these types of studies can shoulder this burden. A 2010 meta-analysis of observational studies made headlines with its stark conclusion that “Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate”. Critics argued, however, that because there are huge differences between particular home births and particular hospital births “Lumping home birth studies from countries that vary widely in culture, geography, and health care systems together in a meta-analysis is akin to producing a fruit salad, not with apples and oranges, but with potatoes, pineapples, and celery”. Given the twin difficulties of conducting randomized control trials and interpreting observational studies, we may just have to accept that this is question to which we will never have a definitive answer. And, certainly, nothing in this column should be taken as constituting medical advice.
Fortunately for those who like the Born In The Wild ethos, but also want the option of state-of-the-art medical care, some hospitals are introducing home-like birthing rooms, and even ambient and Snoezelen rooms. A Cochrane comparison of alternative and conventional institutional birth settings—although again hampered by a lack of well-controlled trial data—found that mothers were more satisfied with alternative births, “with no apparent risks to mother or baby”. So if the show is a big hit, and if developments in artificial reality continue apace, maybe in future we will mothers giving birth in virtual Born In The Wild type environments inside hospitals. Now that would be wild.