Tienchin Ho

Raising Chickens and Fear of Death

I have spent the last two months building a chicken coop and run. At the end of February, we got six adorable chicks. I joined the BackyardChickens.com Forum and I am chronicling the construction project on a page there.

One day when the chicks were about eight weeks old, I went out to see them by the garden and found a Coopers' hawk stomping on a chick. This contradicts our local zoo's bird show which specifically says that hawks do not attack chickens. Following the attack and the loss of our chick, I read many posts about predators on the BackYardChickens Forum. Basically it comes down to completely confining the chicks to coop and covered run instead of allowing them to free range.

One particularly heated exchange caught my eye. It reminded me of the intense debates about home and hospital births. One BackyardChickens Forum member described free-range chickens as a free lunch. She is baffled by why people cannot understand that "loose chickens get hurt." She places little value of free-ranging itself, saying that her chickens don't "curse me for thwarting their dreams of freeranging adventure.  They don't know about the earthy, groovy, FREE delights of the open range.  They don't know and I don't let 'em and we are just fine!"

In reaction to this post, one Forum member remarked that her chickens had been "locked in fort knox and STILL got killed by a weasel!...if they had been free they would be alive today..they could have flown away from the weasel...please stop judging others." Some Forum posts refer to confined chickens as prisoners. Other suggestions for deterring hawks include keeping a big dog, a turkey or even a pig with the chickens. Crows and magpies chase hawks away. Pigeons and doves provide easier prey. Encouraging these other birds to live in your yard is another way to deter hawk chicken attacks.

I am struck by how different each person's values can be. Like the home birth critics, the free range critics see safety in the coop or hospital. Any poor outcomes are attributed to lacking coop design or hospital expertise. Basically, if you build a good enough coop, your chickens will be safe. If you choose your hospital and obstetrician wisely, you and your baby will be safe. On the other hand, the free range proponents place a high value on not just the life of the chickens, but on their quality of life. Women who choose to birth at home value the whole childbirth experience as an opportunity for personal growth. They are also quick to notice the poor outcomes that can occur even in the hospital.

Of course, my chickens are not my children and I do not mean to equate their importance. But still, life and death situations always seem to bring out a person's most basic value system. Clearly, neither side is right or wrong. Every person must figure out what is most important to them and their family.

We are now used to watching the Coopers hawks and red-tailed hawks circle our yard almost every day. I even felt the wind from one that was chasing a tiny songird over my head as I knelt attaching welded wire to a wooden frame. Both of my girls can identify a hawk from the other flying specks in the sky and run to verify that our chicks are safe. We miss the chick that was killed that day. She was an Easter Egger with a stripe on her head. Still, our chickens run around the yard as they choose.

Bias, Obstetricians, and Home Births

Not all obstetricians agree with ACOG's February 2008 statement reiterating its longstanding opposition to home births. Here are some obstetrician's letters that have been made public on the internet:

Dr. Lauren Plante
Dr. Andrew Kotaska
Dr. Stuart J Fischbein

These obstetricians discuss how ACOG's statement disregards the ethical concept of autonomy, or a person's right to make decisions about their own care, including place of birth and birth attendant.

Birth Action Coalition's website posts the response from ACOG's Executive Vice-President Ralph Hale to Dr. Stuart Fischbein's letter. Although Dr. Hale cites concerns over safety, he provides no evidence that planned hospital births are safer for mother or baby. Instead he refers to anecdotes from other obstetricians to justify condemning planned home births. The problem with using anecdotes is the bias involved.

Referral bias occurs when a referral center sees a different group of patients than those who are not referred. So for example, as a surgeon, almost every patient with abdominal pain I saw needed an operation. From my point of view, most people with abdominal pain need operations. In truth, however, many patients with abdominal pain never got to see me because the first doctor they saw correctly thought that they were unlikely to need a surgeon. The opposite of what I thought was true is actually true. Most people with abdominal pain do not need surgery. Which is why a general surgeon shouldn't be seeing every person with abdominal pain.

In the same way, obstetricians only see planned home births that required transfer to the hospital and further treatment. Therefore, they could conclude that births shouldn't be planned for home. They should be in the hospital. In fact, many planned home births (approximately 85%) never come to the hospital. If obstetricians could experience the uncomplicated home births, they might have a different opinion.

Confirmation bias is a bias to selectively focus on events that confirm what you already believe. For example, if I think that someone doesn't like me, I may notice that they didn't call me. I take this as evidence that they indeed do not like me. Of course, I forgot that they were going out of town that day.

Physicians generally already have a preconceived notion that home birth is unsafe. Caring for or hearing about a home birth transfer to the hospital is often enough to confirm this notion. They stop looking for more information about home births. Hearing about 1000 normal births wouldn't clear the memory of a single terrible complication.

People also confuse how memorable something is with how often it actually happens. This is called availability bias. For example, stories of lottery or casino winners are on billboards and in the newspaper. Losing lottery-ticket holders are not interviewed on the six o'clock news. Seeing ordinary people winning millions makes it seem more likely to happen to me. In reality I am more likely to be killed by lightning than I am to win the lottery.  A tragedy in the setting of a planned home birth is very memorable. Even a single poor outcome makes obstetricians think that complications happen more often with home births than they actually do.

Of course, these same biases exist for those who fear birthing in a hospital. Hmm .... sounds like another blog for another day.

The Emperor’s New Clothes: Lessons from Hans Christian Andersen on Understanding Home Birth Safety

This Hans Christian Andersen fairy tale reminds me of the ongoing online discussions about the safety of home birth.

Critics of home birth claim:

Babies born to parents who plan home births have triple the neonatal mortality of babies born to parents who plan hospital births.

There is no scientific data to support this.

Birth Certificate Error
Home birth critics cite various sources of mortality (death) rates for babies that are not even about planned home or planned hospital births. Having a baby at home with an experienced attendant and appropriate equipment is not the same as having a baby in the car on the way to the hospital. Information taken from birth certificates suffers from this problem since birth certificates only report where each birth actually happened, not where it was planned.

Sources with the birth certificate error include the Pang study and the CDC Wonder 2003 – 2004 dataset.

Error in Definitions
How a death is classified depends on when it happened. Looking at how many deaths happen during labor is not the same as how many happen during the first seven days of life.

When the death occurs	It is called
during labor	intrapartum mortality
during the first 28 days of life	neonatal mortality
during the first 7 days of life	early neonatal mortality
after day 7 up to day 28 of life	late neonatal mortality
during the first year of life	infant mortality

This simple error occurs when comparing the combined intrapartum and neonatal mortality rate in the  Johnson-Daviss study to rates of neonatal mortality alone.

Invisible Data
Home birth critics link readers to web pages implying that those who can't find the damning numbers are either uneducated or dishonest. To avoid appearing foolish, some readers pretend to see data that isn’t there. Then they go on to debate the qualities of the imaginary data. By the end of the discussion, everyone can quote the same imaginary death rates used by the critics.

Just as the emperor had no clothes, these references to the fabled triply dangerous home birth do not exist. There are no differences in interpretation when it comes to nonexistent data. And just as in the children's story, it is the most humble, unafraid of looking foolish, who can see the truth most clearly.

 

There was once an emperor who loved clothes. For his birthday each year, he commissioned a tailor to make a special set of clothes for him to wear in his birthday parade.

One year a tailor came to town claiming that his work was better than everyone else’s. The tailor claimed he could weave fabric that was invisible to fools. At first the emperor was skeptical. The tailor shrugged, and started to leave saying he would weave his magical cloth for a wiser emperor. This changed the emperor’s mind and the tailor was hired.

For weeks the tailor appeared to weave, cut and sew fabric. Advisors to the emperor came and went to check on the progress. Although all of them only pretended to see the fabric, they argued among themselves as to the color and texture of the fabric in order to appear wise. The tailor also often corrected them so that when the day of the emperor’s birthday finally arrived, they all had the same description of the spectacular new clothes.

Although the emperor could not see the clothes, he held his arms out as the tailor dressed him in his new clothes. Proudly, the emperor walked in his birthday parade as all the citizens praised the tailor’s ability. Suddenly a small child pointed at the emperor and exclaimed, “But he isn’t wearing any clothes!” A ripple went through the crowd as one person after another whispered, “He isn’t wearing any clothes. He’s naked!” Louder and louder the voices grew until finally only the emperor and his advisors were left, still insisting that they were wiser than everyone else.

                                                                                      Original Story by Hans Christian Andersen

Where should I have my baby?

You have a variety of options for where to labor and where to give birth. Labor progresses best when you feel safe and supported. In most cases labor begins at home. During this time, an experienced doula or midwife may provide professional support. You choose how long to labor at home and whether you want to transfer to a hospital or birthing center.

Birth in a Hospital
Hospitals differ in the resources available. Each hospital has resources such as emergency resuscitation, anesthesiology, or neonatal intensive care. Some are available “in house” immediately, others are “on call,” and yet others may require transport to other facilities. Hospital regulations also differ regarding who is present at a birth. Inquire in advance if you have specific concerns about who you wish to have with you. None of the hospitals in Fresno offer labor tubs. All have showers although policies vary in who is permitted to labor in the shower.

Finally, with staffing shortages, hospitals have been forced to make accommodations such as separating mother and baby immediately after birth or requiring laboring mothers to share a room. Hospital-enforced separation of a mother from her baby may cause unnecessary anxiety for a mother and interfere with baby’s initial breastfeeding and temperature regulation. Once babies are separated from the mother in a hospital, the process of returning the babies is potentially adversarial. Orders to maintain the mother-baby dyad after birth from a pediatrician are useful in preventing this.

One measure of a hospital’s dedication to reduce unnecessary interventions is its cesarean section rate. The World Health Organization publishes cesarean rates between 5 and 10% as optimally beneficial for mothers and babies. The cesarean section rate in the United States has risen from less than 5% in 1965 to over 30% today in 2007. In Fresno, our hospitals have cesarean section rates that range from 23% to 33%.

Birth at Home
Birthing without the constraints of hospital regulations in a familiar and personal environment may make you more at ease to cope with the work of labor. Some labor aids such as birthing tubs are only available at home. The mother-baby dyad is easily maintained at home. Although there may be some complications that are best handled in a hospital such as uncontrolled seizures or total placenta previa, most women can have a baby at home safely.

When considering birth at home, consider the accessibility of possibly needing to travel to a hospital. American Ambulance is the sole 9-1-1 provider for Fresno County. Contact American Ambulance to learn more about what resources they bring to a call and what average response times are for your area.

American Ambulance
2911 E. Tulare St.
Fresno, CA, 93721
(559) 443-5900

Each physician and midwife has their own plan for coverage in case they are not available and for transfer to another facility for higher level of care. Learn how they prepare for potential complications of birth.

Evaluate your local resources for experienced home birth attendants. The Medical Board of California regulates legal midwifery in California. These midwives are licensed or certified nurse midwives and work under the supervision of a physician. In California, there are also midwives who attend births outside the regulations of the Medical Board. Recommendations for home birth midwives come from word-of-mouth. Good resources in Fresno for meeting other home birth mothers include attachment parenting groups, International Cesarean Awareness Network, or La Leche League.

Birth in a Birth Center
Birth centers are a middle ground. They work to minimize the use of medications and interventions while still offering hospital accessibility if needed. For example, women are encouraged to labor moving about freely instead of being secured to a monitor. Some birth centers are physically and philosophically linked to a hospital while others are freestanding. Birth centers may also provide care before and after birth. Fresno has no freestanding birth centers. The nearest freestanding birth centers are in the greater Los Angeles and San Francisco areas.

HBACM Statement on Home Births

A response in parody to ACOG's Statement on Home Births

FRESNO, CALIF. – As a home birth after cesarean mom (HBACM), I reiterate my
support of home births. While complications can arise with little or no warning even among women with low-risk pregnancies, childbirth is a normal physiologic process that most women experience without problems. Continuous monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center has not improved maternal or fetal outcomes.

I acknowledge ACOG’s right not to support programs that advocate for, or individuals who provide, home births, but I do not support a system that denies families the essential information to make informed decisions regarding maternal care. Nor do I support a system that lacks the resources to make VBAC a viable option for all women and ensure the quality of the mother-child dyad immediately after birth.

Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by hospital birth advocates, a highly medicalized labor and delivery can physically and emotionally scar both the mother and baby. Attempting a vaginal birth after cesarean (VBAC) at the hospital is especially dangerous because seemingly benign interventions such as epidural anesthesia or Pitocin augmentation can lead to complications with potentially catastrophic consequences for both the mother and baby, including death. Unless a woman is in a supportive birth environment that allows the birth process to unfold on its own schedule, she puts herself and her baby’s health and life at unnecessary risk.

Advocates cite the lack of rigorous scientific studies as one justification for promoting hospital births. Consistent dismissal of existing Level I evidence defining the risks of unnecessary interventions such as episiotomy, epidural anesthesia, and amniotomy has concerned proponents of natural childbirth for the past several decades and we remain committed to changing this. Birth advocates throughout the world use childbirth education, grassroots childbirth networks, and recently, the media to provide mothers and caregivers with the evidence.

Multiple factors are responsible for the persistent exceptions to evidence-based medicine in maternal care, but emerging contributors include a fear-based climate that skews mothers’ decision-making abilities and forces caregivers to follow “standards of care” that ignore the scientific evidence. The availability of a birth attendant to provide continuous labor support and of a midwife to provide expertise and intervention may be life-saving for the mother or newborn and lower the likelihood of a bad outcome.

I believe that the safest setting for labor, childbirth, and the immediate postpartum period is one that respects and trusts the birthing process, that meets the Baby-Friendly and Mother-Friendly standards jointly outlined by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), and the Coalition for Improving Maternity Services(CIMS) and is supported by birth advocacy groups.

It should be emphasized that childbirth comes with inherent risks. Implying otherwise is misleading and unjust to a birthing mother and her family. Although able to perform live-saving emergency cesarean deliveries and other surgical and medical procedures, board-certified obstetricians have been cornered into practice styles that perpetuate the need for these same measures.

They have lost skills such as detecting and adjusting a baby in the occiput posterior position. Untreated, this condition can result in prolonged labors mislabeled as “dystocia” and in cesarean sections. They minimize the profound impact of a woman’s birth experience on her future relationship with her children as well as her own view of herself. Since suicide and substance abuse are leading causes of maternal mortality, disregard for a mother’s emotional health can lead to tragic consequences for her and her baby.

I encourage all pregnant women to get prenatal care and to make a birth plan. Safeguarding the process of giving birth promotes a healthy and safe outcome for both mother and baby. Every woman should seek balanced information to guide her decisions throughout pregnancy, childbirth and parenting. For women who despair in the lack of choices, they should look for hope in mothers who have navigated this climate of fear successfully. We are here.