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Comment by rayiner | Hacker News Reader

I'm talking about this part of your post:

> Women have given birth for a long time without medical intervention, using competent mid-wives[.]

My dad works in international development and has spent a better part of his career working on programs in Bangladesh to get people to use hospitals instead of mid-wives. Now rich people in the United States are using mid-wives instead of hospitals. It's pure insanity.

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It's not really as parallel as you suggest, though it is ironic. Using a mid-wife in the US means starting out in a birth center with a nurse midwife, and finishing there assuming no dangerous complications. There is usually a quick route to a hospital if needed, and screening for risky situations well in advance of the delivery.

This may be a first-world bias here, but would it be reasonable to expect that US midwives are generally better trained than their Bangladeshi peers, given the US's expanded access to educational resources and licensing oversight? Again I recognize a first-world bias here, but my reactionary rationalization process to justify this phenomenon is that in the US you have much easier access to a midwife of at least moderate training/expertise, whereas Bangladeshi midwives may have much wilder variations in level of expertise.

Would your dad be able to share his thoughts on this?

A large component of this is also emergency services; if a midwife delivery has complications, an ambulance is only a quick call away.

Also, 1st world homes are significantly sanitized when compared to other homes.

A college friend of mine wrote a blog post on how this logic is (sometimes tragically) flawed: https://www.dreamhost.com/blog/2011/03/09/wren-jones/

A recent study in Oregon found that the risk of maternal death for planned out-of hospital births was more than double that of planned in-hospital births when adjusted for various factors: http://www.ohsu.edu/news/media/images/NEJM-article-Snowden.p....

> risk of maternal death for planned out-of hospital births more than double

While your assertion is technically correct, this singular take is a misleading characterization of the source you linked. Per your source:

> Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings.

More specifically

> adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54

I'm not sure this necessarily follows your original description of "pure insanity."

More than a doubling of maternal death risk isn't pure insanity to you? It wipes out 20-30 years of progress on that statistic. It's also not that low in absolute terms. With 4 million births per year, an increased death rate of 1.52 deaths per 1000 births is an additional 6,000 deaths per year, under pretty much the most tragic circumstances imaginable.

And that's with the status quo of only the healthiest pregnancies being candidates for home birth. It'll only go downhill as it becomes more prevalent.

But it's not more than doubling if the confidence interval ranges from 0.5 to 2.5. It's somewhere between "halves the risk" and "quintuples the risk", which translates to "we don't really know what's going on here."

That's the absolute additional deaths, not the change ratio.

> Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures

> My dad works in international development and has spent a better part of his career working on programs in Bangladesh to get people to use hospitals instead of mid-wives. Now rich people in the United States are using mid-wives instead of hospitals. It's pure insanity.

Can you explain what part in particular about this is insane? My wife is 9 months pregnant and our hospital has midwives on staff. Having a midwife doesn't preclude going to a hospital.

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