tag:theconversation.com,2011:/au/topics/homebirths-8855/articlesHomebirths – The Conversation2022-07-25T12:11:07Ztag:theconversation.com,2011:article/1874202022-07-25T12:11:07Z2022-07-25T12:11:07ZDispirited homebuyers show why Fed’s unprecedented fight against inflation is beginning to succeed<figure><img src="https://images.theconversation.com/files/475743/original/file-20220724-31994-pg1krm.jpeg?ixlib=rb-1.1.0&rect=422%2C244%2C5210%2C3504&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Home sales are slowing as the Fed hikes rates. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/HomeSales/044573b560da42c88b4c256b4dc2adb9/photo?Query=home%20for%20sale&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=2177&currentItemNo=8">AP Photo/John Raoux</a></span></figcaption></figure><p><a href="https://scholar.google.com/citations?user=ZMboFnoAAAAJ&hl=en&oi=ao">I’ve studied finance</a> and financial markets since the 1970s, and I have never seen the Federal Reserve’s monetary policy get such prominent news coverage as it has this past year. </p>
<p>And with good reason. What the Fed does has profound implications for companies, consumers and the U.S. economy, especially now as the U.S. central bank tries to tame the fastest jump in consumer prices in decades. In short, the Fed is jacking up interest rates in hopes that doing so slows the economy enough to bring down inflation.</p>
<p>The housing market is the sector most substantially influenced by interest rate changes, and as such, it’s a key indicator of whether the Fed’s plans are succeeding. To see why, I need only consider the experience of my son – or the many other Americans hunting for a new home at a time of rising interest rates. </p>
<h2>What the Fed is doing</h2>
<p>First, a little background.</p>
<p>The Federal Reserve <a href="https://www.federalreserve.gov/monetarypolicy/openmarket.htm">is raising interest rates</a> at the fastest pace in its 108-year history as part of its inflation battle. Today’s big policy steps are needed in part because the <a href="https://www.nytimes.com/2022/07/21/opinion/paul-krugman-inflation.html">Fed and many others</a> took awhile to understand what was causing the rise in inflation. </p>
<p>In fall 2021, while the <a href="https://fred.stlouisfed.org/series/CPIAUCNS#0">pace of inflation was accelerating</a> past 4% – <a href="https://www.federalreserve.gov/newsevents/pressreleases/monetary20220316a.htm">double the Fed’s targeted rate</a> – the prevailing view at the central bank and elsewhere was that it <a href="https://fortune.com/2022/03/25/why-was-federal-reserve-wrong-inflation-mary-daly/">reflected temporary disruptions</a> following two years of COVID-19-related slowdowns. The assumption was that inflation would abate automatically as supply chains worked themselves out.</p>
<p>Unfortunately, that assumption proved wrong because it did not recognize how much government <a href="https://www.usaspending.gov/disaster/covid-19?publicLaw=all">COVID-19 relief spending</a> <a href="https://www.nytimes.com/2021/10/18/business/economy/fed-inflation-stimulus-biden.html">had stimulated</a> what economists call “<a href="https://www.econlib.org/library/Topics/Details/aggregatedemand.html">aggregate demand</a>” – in other words, the total demand for goods and services produced in an economy. Put another way, consumer spending spurred by government aid created strong demand across the economy.</p>
<p>And so consumer prices continued to accelerate. Russia’s war in Ukraine made the problem worse, especially by <a href="https://www.theguardian.com/business/2022/apr/26/ukraine-war-food-energy-prices-world-bank">driving up global food and energy prices</a>. As of June 2022, inflation <a href="https://www.bls.gov/news.release/cpi.nr0.htm">was surging at 9.1%</a>, the fastest pace since 1981.</p>
<p>While the Fed can’t do much about the war or other supply-chain issues, it can address domestic aggregate demand. That’s where higher interest rates come in.</p>
<p>Higher borrowing costs choke off consumer demand for homes, cars and other goods and services that typically require a loan, while companies pare back their investments in factories and hiring, which should ease overall inflation. </p>
<p>The Fed began its most recent tightening policy in March 2022 with a 0.25 percentage point increase in its <a href="https://www.federalreserve.gov/monetarypolicy/openmarket.htm">target interest rate</a>, which acts as a benchmark for other borrowing costs in the U.S. and around the world. Since then, the central bank has raised its target rate twice more – by 0.5 percentage point in May and 0.75 percentage point in June. </p>
<p>On July 27, the Fed <a href="https://www.cnbc.com/2022/07/27/fed-decision-july-2022-.html">raised the rate</a> by another 0.75 percentage point.</p>
<h2>Why the housing market matters</h2>
<p>The trick to reducing inflation is to choke off enough aggregate demand to tame inflation without driving the economy into recession. One of the main ways to see whether this is happening is to look at housing, which <a href="https://www.cnbc.com/2022/07/20/mortgage-demand-drops-to-lowest-level-in-22-years.html">has always been particularly sensitive</a> to rate changes and constitutes more than <a href="https://www.federalreserve.gov/releases/z1/20220609/z1.pdf#page=138">one-quarter of total U.S. wealth</a>. </p>
<p>Because buying a house or apartment is such a large expenditure, nearly all purchasers must borrow a <a href="https://therealdeal.com/2022/01/02/in-2021-more-money-was-borrowed-to-buy-homes-than-ever-before/">pretty big share of the purchase price</a>. And just as <a href="https://fred.stlouisfed.org/series/MORTGAGE30US">record-low mortgages borrowing costs</a> in 2021 helped fuel a <a href="https://www.nar.realtor/newsroom/existing-home-sales-slid-5-4-in-june">housing market boom</a> by lowering the cost of servicing that debt, higher rates increase the cost, discouraging housing purchases.</p>
<p>The average rate on a 30-year mortgage <a href="https://fred.stlouisfed.org/series/MORTGAGE30US">hit 5.81% in June</a>, the highest level since 2008 and up from less than 3% throughout most of 2021. The rate currently stands at 5.54%. On a $200,000 mortgage, a 5.54% rate translates into over $400 in extra interest costs every month compared with 3%. </p>
<p>Confronted with such an increase, some house hunters – like my son – have stepped back and reconsidered whether now is the right time to buy. </p>
<p><iframe id="udCAS" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/udCAS/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Housing starting to stall</h2>
<p>In other words, higher mortgage rates lead individuals to invest less in housing. And the effect of falling demand doesn’t stop with the house. When people buy a new house, they also tend to purchase new furniture, lawn equipment, televisions and so on. And buying a used home often requires hiring contractors and others to remodel the kitchen or build a new closet in the kids’ room.</p>
<p>So if people are buying fewer homes, they also are purchasing less furniture, electronics and lawnmowers and have less need for electricians and plumbers. </p>
<p>The drop in demand for all these goods and services should take a meaningful bite out of inflation. While it’s still too early to say if this part of the Fed plan is working, we can already see the effects of rising mortgage rates in recent housing data.</p>
<p>In recent months, <a href="https://fred.stlouisfed.org/series/HOUST">fewer new houses are being built</a>, <a href="https://fred.stlouisfed.org/series/EXHOSLUSM495S">fewer existing homes are being sold</a> and homebuyers are walking away from signed deals at the <a href="https://www.cnbc.com/2022/07/11/homebuyers-are-canceling-deals-at-highest-rate-since-start-of-covid.html">highest rate since the start</a> of the COVID-19 pandemic.</p>
<p>At the same time, <a href="https://fred.stlouisfed.org/series/MICH">consumers</a> and <a href="https://www.stlouisfed.org/on-the-economy/2022/jun/what-financial-markets-say-about-future-inflation">investors</a> are beginning to anticipate less inflationary pressure in the next year or so. </p>
<h2>What it means for homebuyers</h2>
<p>So as the Fed continues to raise rates, what does all this mean for U.S. consumers, and especially my son and other people looking for a new home? </p>
<p>For one thing, don’t expect long-term interest rates, including for mortgages, to rise much, and certainly not by the same amount of the Fed’s interest rate hike.</p>
<p>Investors tend to factor expected Fed policy changes into its market rates. So unless there is a surprise from the Fed, like a full 1-point hike, long-term rates are unlikely to change much. And they may even begin to fall soon, either because inflation is subdued or the U.S. slips into recession.</p>
<p>And while it would be nice to know how tighter monetary policy – that is, higher interest rates – will affect today’s stratospheric house prices, this is hard to predict. The withdrawal of some buyers from the market should depress house prices by reducing demand, but sellers may also simply decide to delay selling rather than accept a lower price. </p>
<p>The challenge for would-be homebuyers like my son and his family is to find a seller who cannot hold their house off the market and to offer a lower price than the house would have attracted a few months ago to offset its higher financing cost. The more that happens, the more the Fed will know its rate hikes are working.</p><img src="https://counter.theconversation.com/content/187420/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Flannery does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Because housing is sensitive to changes in borrowing costs, it can tell policymakers and consumers a lot about whether the Fed’s plan is working.Mark Flannery, Professor of Finance, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1291092019-12-19T20:40:43Z2019-12-19T20:40:43ZWhy are so few people born on Christmas Day, New Year’s and other holidays?<figure><img src="https://images.theconversation.com/files/307998/original/file-20191219-11914-1qhr1u7.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C1164%2C871&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Holiday birthdays are lonely. </span> <span class="attribution"><span class="source">Bryan Keogh/The Conversation via Shutterstock.com</span></span></figcaption></figure><p>Christmas and New Year’s are days of celebration in many parts of the world when people gather with family and friends. One thing many typically don’t celebrate on those days is a birthday.</p>
<p>That’s because Dec. 25 is the least popular day in the <a href="https://www.nytimes.com/2006/12/19/business/20leonhardt-table.html">U.S.</a>, <a href="https://www.abs.gov.au/ausstats/abs@.nsf/lookup/3301.0Media%20Release12016">Australia</a> and <a href="http://archive.stats.govt.nz/browse_for_stats/population/pop-birthdays-table.aspx">New Zealand</a> to give birth. In <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/articles/howpopularisyourbirthday/2015-12-18">England, Wales</a> and <a href="https://www.cso.ie/en/interactivezone/visualisationtools/howpopularisyourbirthday/">Ireland</a>, it’s the second-least popular, behind Dec. 26, when Brits celebrate <a href="https://www.history.com/news/why-is-the-day-after-christmas-called-boxing-day">Boxing Day</a>. </p>
<p>So why do people have fewer babies on holidays like Christmas, Boxing Day and New Year’s – the second-least popular birthday in the U.S.?</p>
<p><a href="http://businessmacroeconomics.com/">I am</a> personally interested in the question because my wife was a <a href="https://www.unicefusa.org/press/releases/new-year%E2%80%99s-babies-over-11000-babies-will-be-born-us-new-year%E2%80%99s-day-%E2%80%93-unicef/35321">New Year’s Day baby</a>. And as an economist, I find these data puzzles fascinating.</p>
<h2>Least and most popular birthdays</h2>
<p>All of the least-favored days in the U.S. are tied to holidays, whether it’s Christmas, New Year’s, Fourth of July or Thanksgiving. </p>
<p>Depending on the year and place, between 30% and 40% fewer babies are born on Dec. 25 than on the peak day of the year.</p>
<p><iframe id="B7oZ4" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/B7oZ4/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>One <a href="https://www.ncbi.nlm.nih.gov/books/NBK541384/">reason why these days have so few births</a> is almost no cesarean births are scheduled by doctors to happen on public holidays or weekends. About <a href="https://www.thebump.com/a/c-section-rate-problems">one in three American babies</a> are born this way. </p>
<p>And even in the case of vaginal births, <a href="https://www.nhs.uk/conditions/pregnancy-and-baby/induction-labour/">doctors can induce labor</a>, which helps control when babies are born. Inductions also typically don’t happen when doctors want to be out of the office celebrating the holidays with family and friends. </p>
<p>One reason why births on Christmas and New Year’s plummet is that for many people <a href="https://www.fastcompany.com/3046429/the-highest-paying-jobs-of-the-future-will-eat-your-life">time management and scheduling is paramount</a>. </p>
<p>Interestingly, in England, Wales and New Zealand, relatively few babies are born on April 1. While that date is not a national holiday, mothers might avoid giving birth on <a href="https://daily.jstor.org/the-completely-true-history-of-april-fools-day/">April Fools’ Day</a> for fear of their children being taunted or bullied.</p>
<p>As for the <a href="https://www.livescience.com/32728-baby-month-is-almost-here-.html">most popular birthdays</a>, they tend to happen in the fall. In fact, the top 10 days to have a baby in the U.S. are all in September, while in England, Wales, Ireland and New Zealand they’re in that month or October. </p>
<p><iframe id="z0iZt" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/z0iZt/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Fall birthdays make sense since <a href="https://www.theatlantic.com/national/archive/2012/05/christmas-eve-busiest-time-year-get-busy/327997/">many babies are conceived</a> during the colder winter months. <a href="https://www.independent.co.uk/life-style/health-and-families/babies-conceive-christmas-why-most-parents-couples-conception-a8103201.html">Conception</a> is <a href="https://www.smithsonianmag.com/science-nature/more-babies-are-conceived-during-winter-fall-180971112/">tied to shorter days and lower outside temperatures</a>.</p>
<h2>Unrecorded births</h2>
<p>Unfortunately, similar data for non-English-speaking countries are not widely available.</p>
<p>Research into when people were born is relatively new because for centuries no one needed or completed a birth certificate. In the U.S., <a href="https://www.history.com/news/the-history-of-birth-certificates-is-shorter-than-you-might-think">birth certificates have been widely used</a> only since the end of World War II. </p>
<p>While some countries require all births to be registered, <a href="https://data.unicef.org/topic/child-protection/birth-registration/">one out of every four children born in the world today</a> does not officially exist, since there is <a href="https://www.independent.co.uk/news/world/politics/220-million-children-who-dont-exist-a-birth-certificate-is-a-passport-to-a-better-life-so-why-cant-8735046.html">no record of his or her birth</a>.</p>
<p>The United Nations has some <a href="http://data.un.org/Data.aspx?d=POP&f=tableCode%3A55">world data</a>, which show <a href="https://visme.co/blog/most-common-birthday">popular birth months tend to shift by latitude</a>. Countries at high latitudes, like Norway or Russia, have peak birth days in July or August. Countries closer to the equator, like El Salvador, have peak birth days later in the year, like October. </p>
<p>As for my wife, she was born a few hours after her parents welcomed in another year. Her birth was a surprise to all the guests they invited over to celebrate the New Year. We joke that being born then is the best day, because there is always a party with fireworks for her birthday. It is also a great day because there are never any competing birthday parties.</p>
<p>So if you are born on a holiday like Christmas, New Year’s or even April Fools’ Day, take some comfort in knowing the relative rarity of your birth makes you even more special than you already are.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129109/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jay L. Zagorsky does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>December 25 is the least popular day to give birth in the US, Australia and New Zealand, and second only to Boxing Day on Dec. 26 in England, Wales and Ireland.Jay L. Zagorsky, Senior Lecturer, Questrom School of Business, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/538042016-06-14T20:11:05Z2016-06-14T20:11:05ZWhy we need to support Aboriginal women’s choice to give birth on country<figure><img src="https://images.theconversation.com/files/120963/original/image-20160503-19521-145a061.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Birthing on country generally refers to an Aboriginal mother giving birth to her child on the lands of their ancestors.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-305361665/stock-photo-close-up-of-pregnant-woman-belly-on-the-dark.html?src=pp-same_artist-303448544-jBiGV14DHVAdxD_Mq2PK2w-1&ws=1">Skylines/Shutterstock</a></span></figcaption></figure><p>Around <a href="https://www.dpmc.gov.au/sites/default/files/publications/indigenous/Health-Performance-Framework-2014/tier-1-health-status-and-outcomes/121-perinatal-mortality.html">9.6 out of every 1,000 Aboriginal babies</a> are stillborn, or die in childbirth or the first 28 days of life, compared with 8.1 non-Aboriginal babies. Getting maternity care right for Aboriginal women is critical to closing this gap. </p>
<p>Not all Aboriginal women <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/maternity-pubs-cultur">have access</a> to high-quality, culturally competent maternity care. An <a href="http://www.ncbi.nlm.nih.gov/pubmed/20359414">audit in Western Australia</a>, for instance, found 75% of services failed to provide maternity care sensitive to Aboriginal culture. </p>
<p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/maternityservicesreview-report">federal government’s 2014 maternity services review</a> recommends improving access to care for Aboriginal mothers and increasing birthing choices. One such option is for Aboriginal women to choose <a href="http://catsinam.org.au/static/uploads/files/report-2014-conference-birthing-on-country-yarning-circles-final-wfcmdquycezm.pdf">birthing on country</a>.</p>
<h2>What is birthing on country?</h2>
<p>Birthing on country generally refers to an Aboriginal mother giving birth to her child on the lands of their ancestors. </p>
<p>A traditional midwife with specialist knowledge would once have provided care. These days non-Indigenous midwives, working in collaboration with community elders and/or traditional midwives, can provide “birthing on country” care. Birthing on country is provided in accordance with traditional and spiritual beliefs, which can vary according to community. </p>
<p>Increasingly, the term is being used to embody <a>broader principles</a> of a “birthing on country model”, which ensures a spiritual connection to the land for an Aboriginal mother and her baby, wherever she chooses to give birth. </p>
<p>Most Aboriginal women live in urban or rural areas and can easily reach a hospital for childbirth. The more difficult debate about birthing on country involves women living in remote areas. </p>
<p>Where birthing on country is not offered or supported, women must leave their families weeks before birth to wait in a regional centre. </p>
<p>Or the mother can choose to give birth in her community without skilled birth attendants (effectively a “freebirth”). This is <a href="http://www.ncbi.nlm.nih.gov/pubmed/19032658">risky</a>, particularly because Aboriginal women have high rates of pregnancy complications, which make childbirth less predictable and potentially more dangerous for both women and their babies. </p>
<p>So it is critical to have choices between these two polar options.</p>
<h2>Why do women want to birth on country?</h2>
<p>There are many reasons women may want to birth on country, with and without health care support. </p>
<p>Physical connection to country during birth may be very important to some women’s overall well-being. </p>
<p>Others feel it is simply not possible to have a spiritually and culturally enriching hospital birth, or have had traumatic hospital experiences. Paternalism within medical maternity models and racism <a href="http://www.austlii.edu.au/au/journals/AUIndigLawRw/2012/6.pdf">are ongoing issues</a> for Aboriginal women. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=840&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=840&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=840&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1056&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1056&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120964/original/image-20160503-19524-vfje3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1056&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some women want to give birth on country for the spiritual connection.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/k-girl/11286565/">Kristy/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Other women will have concerns about leaving their family for up to six weeks, with practical and social worries around care for other children and possibly other adult dependants. </p>
<p>Some women choose to birth on country against medical advice and there have been some concerning anecdotal reports of punitive responses in remote areas. These include threatening women who refused to board a plane with sectioning under the mental health act. </p>
<p>While clinicians are understandably fearful and anxious about women giving birth unassisted, Aboriginal women have a legal right to make decisions about their health care.</p>
<h2>Culturally sensitive care</h2>
<p>It is important service providers can communicate sensitively and build trust to discuss birthing options with Aboriginal women, particularly if the mother is considering an unassisted birth. Clinicians should:</p>
<ol>
<li><p>Ask about and discuss what issues are important to her. This will help the health provider understand each woman’s life, strengths and needs.</p></li>
<li><p>Provide evidence-based information about the models of care available. Encourage discussion about the risks and benefits, while reminding each woman of her right to make decisions. </p></li>
<li><p>If available care options do not meet her needs and she wishes to explore alternatives, including birthing on country without assistance, we need to understand the reasons for this decision. </p></li>
</ol>
<p>Some questions include: </p>
<ul>
<li><p>Are there practical issues that can be addressed? Has she had traumatic experiences with services? Is she worried about leaving her family behind? If these were addressed, what would her choice be?</p></li>
<li><p>Are there cultural aspects of birth that could be acknowledged in a hospital setting? What would her choice be if these were provided? </p></li>
<li><p>If a woman chooses to birth outside an existing service model, what can we do to optimise safety and quality? Preparation is safer than a woman turning up in late stages of labour. </p></li>
</ul>
<p>It’s safer to encourage and support all birthing choices than to silence women if choices are not respected.</p>
<p>It’s time to strengthen efforts to establish honest and respectful relationships between health professionals and Aboriginal women. We need to understand what women want and ensure they get the maternity care right, including culturally rich births in hospitals, and safer assisted births in the bush.</p><img src="https://counter.theconversation.com/content/53804/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Chamberlain receives funding from the National Health and Medical research Council (ECF 1088813). She is affiliated with Council of Aboriginal and Torres Strait Islander Nurses and Midwives. </span></em></p><p class="fine-print"><em><span>Rhonda Marriott receives funding from the National Health and Medical Research Council. She is affiliated with the WA Primary Health Alliance (as a Board Director).</span></em></p><p class="fine-print"><em><span>Sandy Campbell is supported by an National Health & Medical Research Council (NHMRC) Early Career Fellowship (ECF) Fellowship.</span></em></p>Where birthing on country is not offered, women leave their families weeks before birth. Or she can choose to give birth in her community without skilled birth attendants, which is risky.Catherine Chamberlain, Postdoctoral early career fellow, Baker Heart and Diabetes InstituteRhonda Marriott, Professor Aboriginal Health and Wellbeing, Murdoch UniversitySandy Campbell, Clinical Research Fellow, Centre for Chronic Disease Prevention, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/426542015-06-03T21:04:31Z2015-06-03T21:04:31ZAre hospitals the safest place for healthy women to have babies? An obstetrician thinks twice<figure><img src="https://images.theconversation.com/files/83738/original/image-20150602-19262-6iuk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For childbirth, how much intervention is too much?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-101285830/stock-photo-pregnant-woman-feels-hard-contraction-in-a-hospital-labor-delivery-room-concept-photo-of.html?src=ZQXTKVCyhZ7PhTly4Q7FgA-1-8">Image of pregnant woman via www.shutterstock.com.</a></span></figcaption></figure><p>There is a good chance that your grandparents were born at home. I am going to go ahead and assume they turned out fine, or at least fine enough, since you were eventually born too and are now reading this.</p>
<p>But since the late 1960s, very few babies in the United Kingdom or the United States have been born outside of hospitals. As a result, you may find the <a href="http://www.nice.org.uk/guidance/cg190">new guidelines</a> from the UK’s National Institutes for Health and Care Excellence (NICE) just as surprising as I did. For many healthy women, the NICE guidelines authors believe, there may be significant benefits to going back to the way things were.</p>
<p>Shortly after the NICE guidelines were issued, the New England Journal of Medicine invited me to <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1501461">write a response</a>. The idea that any pregnant patient might be safer giving birth outside the hospital seemed heretical, at least to an American obstetrician like me. Knowing that no study or guideline is foolproof, I began my task by looking for holes to form a rebuttal.</p>
<p>I soon realized that this rebuttal largely hinged on flaws in the American system, not the British one. While we take excellent care of sick patients, we do less well for healthy patients with routine pregnancies – largely in the form of turning to medical interventions more than strictly necessary.</p>
<p>As the guidelines suggest, some women in the UK with low-risk pregnancies may be better off staying out of the hospital. Why? Because the significant risks of over-intervention in hospitals, such as unnecessary C-sections, may be far more likely (and therefore more dangerous) for patients than the risks of under-intervention at home or in birth centers. But women in the UK have access to greater range of settings where they can give birth. For women in much of the US, the choice is often the hospital or nothing.</p>
<h2>Are hospitals always the best option? The view from the UK</h2>
<p>The British <a href="http://www.bmj.com/content/343/bmj.d7400">Birthplace Study</a>, upon which the NICE guidelines are based, reviewed 64,000 low-risk births to compare the relative safety of giving birth in one of four settings: a hospital obstetric unit led by physicians, an “alongside” midwifery-led birth center (on the same site as a hospital obstetric unit), a freestanding midwifery-led birth center, and at home. The study included only women with low-risk pregnancies. Women with obesity, diabetes, hypertension or other medical conditions were excluded from the study.</p>
<p>For low-risk women who had never given birth before, home birth led to bad outcomes (such as <a href="http://www.ninds.nih.gov/disorders/encephalopathy/encephalopathy.htm">encephalopathy</a> or stillbirth) slightly less than 1% of the time. That’s rare, but still twice as risky as the other options. Birth centers were no riskier than hospitals for first-time moms, and all options (including home) appeared equally safe for women who had given birth before.</p>
<p>By contrast, this same group of low-risk women was between four and eight times more likely to get a C-section if they started off getting their care in the hospital compared to other settings. Rather than being driven by patient risk or preference, this tendency toward C-sections appeared to be driven by proximity to the operating room. </p>
<p>While the NICE guidelines make it clear that women should be free to choose the birth setting they are most comfortable with, they point out that the risks of over-intervention in the hospital may outweigh the risks of under-intervention at a birth center or at home for the majority of expecting mothers.</p>
<p>The situation is different for women in the US. Last year 90% of births were attended by physicians, while just <a href="http://www.nytimes.com/2014/12/15/opinion/are-midwives-safer-than-doctors.html?_r=1">9% were attended by midwives</a>. Fewer than 1% of US women have their babies at <a href="http://healthland.time.com/2013/01/31/midwives-say-birthing-centers-could-cut-c-section-rates-and-save-billions/">birth centers</a>. While access to care is guaranteed in the UK, nearly <a href="http://www.midwife.org/ACOG-and-ACNM-Press-Release">half of US counties</a> have no midwife, obstetrician or other maternity care professional. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A baby born in the US has a one-in-three chance of being delivered via C-section.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-283045757/stock-photo-instrument-for-cesarean.html?src=r5WdI7g244v4K3XBYUnIUQ-3-26">C-section via www.shutterstock.com.</a></span>
</figcaption>
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<h2>C-sections are routine, but not without complications</h2>
<p>Today, newborn babies in the US have a <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf">one-in-three</a> chance of entering the world through an abdominal incision. In the UK, the odds are lower – more like <a href="http://dx.doi.org/10.1111/1471-0528.13284">one in four</a>, but everyone on both sides of the Atlantic agrees this still represents too much help. </p>
<p>Part of the challenge may be a feature of the species. <em>Homo sapiens</em> have always required some form of extra help being born. Narrow pelvises are required for walking upright, and large frontal lobes are required for nuanced thought. Neither works in our favor when it comes to navigating the birth canal. The unresolved question is how much help is truly necessary – and how much help is too much. </p>
<p>Cesareans are designed to be a lifesaving surgery, but they are now so routine that C-sections have become the most common major surgery performed on human beings, period. It hasn’t been until recently that we started to fully consider the downsides of cesarean deliveries.</p>
<p>For starters, caring for a newborn while dealing with a 12-centimeter skin incision in your own abdomen is the pits, especially when compared to caring for a newborn without having a 12-centimeter skin incision.</p>
<p>Though common, let’s not forget that C-sections are a major abdominal surgery that can lead to <a href="http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery">threefold higher rates of serious complications</a> for mothers compared to vaginal delivery (2.7% vs 0.9%). These complications can include severe infection, organ injury and hemorrhage.</p>
<p>I should also point out that the first C-section a woman has is an easy surgery – I can train an intern to do one safely in just a few weeks. But most women have more than one child, and most women who have a C-section the first time will have a C-section the next time. Obstetricians are among a small group of surgeons who regularly operate on the same part of the same patient over and over again, dissecting thicker layers of old scar tissue with each surgery. </p>
<p>By the second, third, or fourth C-section on the same patient, the anatomy becomes distorted and the surgery becomes increasingly technical. I recently did a cesarean where the woman’s abdominal muscles, bladder and uterus were fused together like a melted box of crayons.</p>
<p>In the most dreaded cases, a woman’s placenta (a large bag of blood vessels that nourishes the fetus) can get stuck in this mess of tissue and fail to detach normally. In these cases, pints of blood may be lost within minutes, and the only way to stop the bleeding is often to do a hysterectomy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">C-sections are 500% more common in the US today than in the 1970s.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-127442744/stock-photo-classic-cesarean-section-in-the-operating-theater.html?src=pp-photo-283045757-r5WdI7g244v4K3XBYUnIUQ-6&ws=1">Baby via www.shutterstock.com.</a></span>
</figcaption>
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<h2>Why do hospitals mean more interventions? It comes down to risk perception</h2>
<p>Since 1970, the number of C-sections performed in the US has gone up by <a href="http://www.consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm">500%</a>. Some of this increase is because mothers have become older and less healthy, conferring greater risks in pregnancy. But having a baby in this decade is not 500% riskier than having a baby in the 1970s. We know this because C-sections rates in just the women who are young and perfectly healthy have gone up just as quickly. And contrary to popular belief, this has little to do with maternal preferences. First-time mothers who request C-sections with no medical reason make up <a href="http://www.childbirthconnection.org/article.asp?ck=10372">fewer than 1% of the total</a>.</p>
<p>What’s driving the increase in C-sections in the US is unclear, but much of the drive to do more comes from our perception of risk. Although my professional contribution to childbirth is often just to catch, my responsibility as a scalpel-trained, general obstetrician in the United States is to mitigate risk. </p>
<p>I am acutely aware that even women with healthy pregnancies can develop life-threatening hemorrhage, fetal distress or other unanticipated emergencies during labor that require surgical intervention.</p>
<p>My job is to get the baby delivered before it is too late, and often I’m working with ambiguous information. I know how long labor should take on average, but don’t have a precise estimate of how long labor should take for the patient in front of me. What if the baby is too big or the pelvis is too narrow? C-sections often come down to a game-time decision.</p>
<p>Fortunately, I can make sure this decision is never wrong. If the baby looks a little blue and lackluster right after I do a C-section, I’m convinced I did it just in time. But if the baby is pink and vigorous after I do a C-section, I’m still convinced I did it just in time. Without evidence to the contrary, it is easy for me and many of my colleagues to believe that operating is always the right course of action.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When it comes to safety, it’s better to overshoot.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-101285830/stock-photo-pregnant-woman-feels-hard-contraction-in-a-hospital-labor-delivery-room-concept-photo-of.html?src=ZQXTKVCyhZ7PhTly4Q7FgA-1-8">Baby via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<p>When it comes to the safety of mothers and newborns, most would agree that it is better to overshoot than undershoot. The problem is that we are overshooting by a lot, in ways that lead to more insidious harm. Nearly half of the cesareans we do in the US currently appear to be unnecessary, and come at a cost of 20,000 avoidable surgical complications and <a href="http://transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-Having-a-Baby1.pdf">US$5 billion of budget-busting spending in the US annually</a>.</p>
<p>C-sections may have consequences for babies as well, in ways that we are just beginning to understand. Exposure to normal bacteria in the birth canal may play a role in the development of a baby’s immune system. A Danish study of two million children born at full term found that those born by cesarean were <a href="http://dx.doi.org/10.1542/peds.2014-0596">significantly more likely to develop chronic immune disorders</a>. Others have suggested that going from the womb to an artificial warmer can have an impact on immediate bonding, and even success with breastfeeding.</p>
<p>In parts of the world where women do not have access to skilled birth attendants, large numbers of mothers and babies die from preventable causes. Even for the healthiest among us, <a href="http://www.mylifetime.com/shows/born-in-the-wild">walking into the woods to have your baby</a> would be unwise. Still, much of the developed world offers only one pragmatic alternative: the hospital. For more than a half-century, we have believed that spending many hours, if not days, in a hospital bed with a smattering of ultrasound gel, clips, wires, heart tones, random beeps and routine alarms is the safest way to have a baby.</p>
<p>Many of the patients I care for benefit from my surgical training. I get to save lives while also sharing in one of the most profoundly joyous moments that families experience. But obstetricians like me may be hardwired to operate, and too many operations are harmful to patients. One strategy to fix this might be to change our wiring. Another may be the British way: for patients to stay away from obstetricians altogether – at least until you need one.</p><img src="https://counter.theconversation.com/content/42654/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neel Shah receives funding from the Rx Foundation, the CRICO/Harvard Risk Management Foundation, and the ABIM Foundation. He is affiliated with the nonprofit organization Costs of Care, Inc. as the Founder and Executive Director.</span></em></p>Humans have always required some form of extra help being born. But how much help is truly necessary – and how much is too much.Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/227322014-02-07T14:32:54Z2014-02-07T14:32:54ZThere is no moral imperative for women to give birth in hospital<figure><img src="https://images.theconversation.com/files/40937/original/97fgrwpt-1391708734.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Closer to home. </span> <span class="attribution"><span class="source">James Lander</span></span></figcaption></figure><p>Because of a supposed slight increase in the risk that the resulting child will be disabled, doubt has been cast on the morality of having a home delivery when one could have chosen to give birth in hospital.</p>
<p>It is akin to endangering a child by failing to fasten their safety belt while transporting them in a car, we’re led to believe. That it is unethical – even if it should not be illegal. This is what medical ethicists Lachlan de Crespigny and Julian Savulescu argue <a href="http://jme.bmj.com/content/early/2013/10/08/medethics-2012-101258.full">in a BMJ paper</a>: that women have a moral obligation not to do it.</p>
<p>According to de Crespigny and Savulescu: “… the choice to have a home birth might only be justified if it exposes the future child to a near-zero increased risk of avoidable disability.”</p>
<p>And they add: “Both professionals and pregnant women have an ethical obligation to minimise risk of long-term harm to the future child.”</p>
<p>Their conclusion is highly debatable on two grounds. It is not clear that home deliveries are riskier than hospital ones. Even if they are riskier, it doesn’t follow that it is morally wrong for women to choose to have them. </p>
<p>It is perhaps a more extreme extension of the principle, but taking abortion, you could argue that it is morally good for a woman to choose to remain pregnant and offer the growing foetus the hospitality of her womb rather than opt for an abortion. But not all of us would say that she has a moral obligation to remain pregnant or ascribe moral blame. </p>
<p>There might also be particular risks associated with hospital deliveries. For instance, mothers and babies might be more exposed to infectious diseases there. They could also run the risk of injury or death in a road accident on their journey to and from the hospital. These risks are slight but so too are the risks of disability that Crespigny and Savalescu talk of. </p>
<p>It is not clear that it is irrational for a women to choose to have a baby at home rather than a hospital. It isn’t possible to avoid risk if one chooses to have a baby. And it isn’t obvious that one could possibly know that, all things considered, one choice was riskier than the other. </p>
<p>Despite a widely held belief that hospital is best, the extent of the different risks isn’t known – both choices involve risks of different sorts of dangers. This makes the idea <a href="http://jme.bmj.com/content/38/7/423.abstract">of a rational comparison</a> between them dubious.</p>
<p>Take the parable of the Good Samaritan. In the story, a traveller is beaten and left beside the road. He is ignored by two passers by before the Good Samaritan comes to his aid. He tends his wounds and bandages him. Then, he takes him to an inn and pays the innkeeper for his board and lodgings.</p>
<p>Between the heinously bad behaviour of those who savagely robbed him and the superlatively good behaviour of the Good Samaritan there is a spectrum of grades of moral badness and goodness. The middling range of nondescript or morally mediocre is quite acceptable. We are morally obliged not to attack travellers. We are not morally obliged to act as generously as the Good Samaritan did. Judith Jarvis used this example <a href="http://spot.colorado.edu/%7Eheathwoo/Phil160,Fall02/thomson.htm">in her argument</a>in defence of abortion: by terminating a pregnancy, a woman doesn’t violate her moral obligations but is instead not the “Good Samaritan” who exceeds them.</p>
<p>It might be more in a baby’s interests, statistically, to be born in a hospital than born at home. However, it does not follow that an unborn child thereby has a moral right to be born in a hospital. And that, correspondingly, the mother has a moral duty to deliver her baby there. We are not morally obliged to be saints or superheroes. So even if we knew what was the morally superlative thing to do, we would not be morally obliged to do it, no matter how commendable such action might be.</p>
<p>It has not been shown by Crespigny and Savulescu that it is irrational or immoral for women to have home deliveries. The pivotal question is: whether having a home delivery will subject a child to not merely a risk but an unreasonable risk of disability. </p>
<p>What the Good Samaritan did was magnificent. But it was also beyond the call of duty, which is what makes it a worthy parable. He could have done less yet still acted well. Similarly, a woman might have a home delivery and act well enough. </p><img src="https://counter.theconversation.com/content/22732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hugh McLachlan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Because of a supposed slight increase in the risk that the resulting child will be disabled, doubt has been cast on the morality of having a home delivery when one could have chosen to give birth in hospital…Hugh McLachlan, Professor of Applied Philosophy, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.