Pandemic Baby Bust situation update

[Update: California released revised birth numbers, which added a trivial number to previous months, except December, where they added a few thousand, so now the state has a 10% decline for the month, relative to 2019. I hadn’t seen a revision that large before.]

Lots of people are talking about falling birth rates — even more than they were before. First a data snapshot, then a link roundup.

For US states, we have numbers through December for Arizona, California, Florida, Hawaii, and Ohio. They are all showing substantial declines in birth rates from previous years. Most dramatically, California just posted December numbers, and revised the numbers from earlier months, now showing a 19% 10% drop in December. After adding about 500 births to November and a few to October, the drop in those two months is now 9%. The state’s overall drop for the year is now 6.2%. These are, to put it mildly, very larges declines in historical terms. Even if California adds 500 to December later, it will still be down 18%. Yikes. One thing we don’t yet know is how much of this is driven by people moving around, rather than just changes in birth rates. California in 2019 had more people leaving the state (before the pandemic) than before, and presumably there have been essentially no international immigrants in 2020. Hawaii also has some “birth tourism”, which probably didn’t happen in 2020, and has had a bad year for tourism generally. So much remains to be learned.

Here are the state trends (figure updated Feb 18):

births 18-20 state small multiple by month

From the few non-US places that I’m getting monthly data so far, the trend is not so dramatic. Although British Columbia posted a steep drop in December. I don’t know why I keep hoping Scotland will settle down their numbers… (updated Feb 18):

births countries 18-20 small multiple by month

Here are some recent items from elsewhere on this topic:

  • That led to some local TV, including this from KARE11 in Minneapolis:

Good news / bad news clarification

There’s an unfortunate piece of editing in the NBCLX piece, where I’m quoted like this: “Well, this is a bad situation. [cut] The declines we’re seeing now are pretty substantial.” To clarify — and I said this in the interview, but accidents happen — I am not saying the decline in births is a bad situation, I’m saying the pandemic is a bad situation, which is causing a decline in births. Unfortunately, this has slipped. As when the Independent quoted the piece (without talking to me) and said, “Speaking to the outlet, Philip Cohen, a sociologist and demographer at the University of Maryland, called the decline a ‘bad situation’.”

The data for this project is available here: You’re free to use it.

For more on fertility decline, including whether it’s good or bad, and where it might be going, follow the fertility tag.

Acknowledgement: We have lots of good conversation about this on Twitter, where there is great demography going on. Also, Lisa Carlson, a graduate student at Bowling Green State University, who works in the National Center for Family and Marriage Research, pointed me toward some of this state data, which I appreciate.

COVID-19 Baby Bust update and data

Joe Pinsker at the Atlantic has a piece out on the coming (probable) baby bust. In it he reviews existing evidence for a coming decline in births as a result of the pandemic, especially including historical comparisons and Google search data. Could we see this already?

Pinsker writes:

The baby bust isn’t expected to begin in earnest until December. And it could take a bit longer than that, Sarah Hayford, a sociologist at Ohio State University, told me, if parents-to-be didn’t adjust their plans in response to the pandemic immediately back in March, when its duration wasn’t widely apparent.

If people immediately changed their plans in February, we might see a decline in births in October, but Hayford is right that’s early. And what about September, for which I’ve already observed declining births in Florida and California? If people who were pregnant already in January had miscarriages or abortions because of the pandemic, that would result in fewer births in September, but how big could that effect be? So maybe the Florida and California data are flukes, or data errors, or lots of pregnant people left those states and gave birth elsewhere (or pregnant people who normally come didn’t arrive). Perhaps more likely is that 2020 was already going to be a down year. As I told Pinsker:

“It might actually be that we were already heading for a record drop in births this year … If that’s the case, then birth rates in 2021 are probably going to be even more shockingly low.”

Anyway, we’ll find out soon enough. And to that end I’ve started assembling a dataset of monthly births where I can find them, which so far includes Florida, California, Oregon, Arizona, North Carolina, Ohio, Hawaii, Sweden, Finland, Scotland, and the Netherlands, to varying degrees of timeliness. As of today we have October data for some of them:

As of now Florida and California remain the strongest cases for a pandemic effect. But they are also both likely to add some more births to October (in November’s report, California increased the September number by 3%).

Anyway, lots of speculation while we’re killing time. You can get the little dataset here on the Open Science Framework: Check the date on the .csv or .xlsx file to see what I last updated it. I’ll add more countries or states if I find out about them.

Fertility rate implications explained

(Sorry for the over-promising title; thanks for the clicks.)

First where we are, then projections, with figures.

For background: Caroline Hartnett has an essay putting the numbers in context. Leslie Root has a recent piece explaining how these numbers are deployed by white supremacists (key point: over-hyping the downside of lower fertility rates has terrible real-world implications).


The National Center for Health Statistics released the 2018 fertility numbers yesterday, showing another drop in birth rates, and the lowest fertility since the Baby Boom. We are continuing a historical process of moving births from younger to older ages, which shows up as fewer births in the transition years. I illustrate this each year by updating this figure, showing the relative change in birth rates by age since 1989:

change in birthrates by age 1989-2016.xlsx

Historically, postponement was associated with reduction in lifetime births — which is what really matters for population trends. When people were having lots of children, any delay reduced the total number. With birth rates around two per woman, however, there is a lot more room for postponement — a lot of time to get to two. (At the societal level, both reduction and postponement are generally good for gender equality, if women have good health and healthcare.)

This means that drops in what we demographers call “period” fertility (births right now) are not the same as drops in “completed” fertility (births in a lifetime), or falling population in the long run. The period fertility measure most often used, the unfortunately named total fertility rate (TFR), is often misunderstood as an indicator of how many children women will have. It is actually how many births they are having right now, expressed in lifetime terms (I describe it in this video, with instructions).

Lawrence Wu and Nicholas Mark recently showed that despite several periods of below “replacement” fertility (in terms of TFR), no U.S. cohort of women has yet finished their childbearing years with fewer than two births per woman. Here is the completed fertility of U.S. women, by year of birth, as recorded by the General Social Survey. By this account, women born in the early 1970s (now in their late-forties by 2018) have had an average of 2.3 children.

Stata graph

Whether our streak of over-two completed fertility persists depends on what happens in in the next few years (and of course on immigration, which I’ll get to).

Last year at this time I summed up the fertility situation and concluded, “sell stock now,” because birth rates fell for women at all ages except over 40. That kind of postponement, I figured, based on history, reflected economic uncertainty and thus was an ill omen for the economy. The S&P 500 is up 5% since then, which isn’t bad as far as my advice goes. And I’m still bearish based on these birth trends (I bet I’ll be right before fertility increases).


It is very hard to have an intuitive sense of what demographic indicators mean, especially for the future. So I’ve made some projections to show the math of the situation, to get the various factors into scale. My point is to show what the current (or future) birth rates imply about future growth, and the relative role of immigration.

These projections run from 2016 to 2100. I made them using the Census Bureau’s Demographic Analysis and Population Projection System software, which lets me set the birth, death, and migration rates.* I started with the 2016 population because that’s the most recent set of life tables NCHS has released for mortality. Starting in 2018 I apply the current age-specific birth rates.

First, the most basic projection. This is what would happen if birth rates stayed the same as those in 2018 and we completely cut off all immigration (Projection A), or if we had net migration running at the current level of just under +1 million each year, using Census estimates for age and sex of the migrants (Projection B).


From the 2016 population of 323 million, if the birth rates by age in 2018 were locked in, the population would peak at 329 million in 2029 and then start to decline, reaching 235 million by 2100. However, if we maintain current immigration levels (by age and sex), the population would keep growing till 2066 before tapering only slightly. (Note this assumes, unrealistically, that the immigrants and their children have the same birth rates as the current population; they have generally been higher.) This the most important bottom line: there is no reason for the U.S. to experience population decline, with even moderate levels of immigration, and assuming no rebound in fertility rates. Immigration rates do not have to increase to maintain the current population indefinitely.

Note I also added the percentage of the population over age 65 on the figure. That number is about 16% now. If we cut off immigration and maintain current birth rates, it would rise to 25% by the end of the century, increasing the need for investment in old age stuff. If we allow current migration to continue, that growth is less and it only reaches 23%. This is going up no matter what.

To show the scale of other changes that we might expect — again, not predictions — I added a few other factors. Here are the same projections, but adding a transition to higher life expectancies by 2080 (using Japan’s current life tables; we can dream). In these scenarios, population decline is later and slower (and not just at older ages, since Japan also has lower child mortality).


Under these scenarios, with rising life expectancies, the old population rises more, to between 27% and 29%. Generally experts assume life expectancies will rise more than this, but that’s the assumed direction (now, unbelievably, in doubt).

Finally, I’ve been assuming birth rates will not fall further. If what we’re seeing now is fertility postponement, we wouldn’t expect much more decline. But what if fertility keeps falling? Here is what you get with the assumptions in Projection D, plus total fertility rates falling to 1.6, either by 2030 or 2050. As you can see, in the 1.6 to 1.8 range, the effects on population size aren’t great in this time scale.


Conclusion: We are on track for slowing population growth, followed by a plateau or modest decline, with population aging, by the end of the century, and immigration is a bigger question than fertility rates, for both population growth and aging.


In a global context where more people want to come here than want to leave (to date), worrying about low birth rates tends to lend itself to myopic, religious, or racist perspectives which I don’t share. I don’t think American culture is superior, whites are in danger of extinction, or God wants us to have more children.

I do not agree with Dowell Myers, who was quoted yesterday as saying, “The birthrate is a barometer of despair.” That even as some people are having fewer children than they want, or delaying childbearing when they would rather not. In the most recent cohort to finish childbearing, 23% gave an “ideal number of children for a family to have” that was greater than the number they had, and that number has trended up, as you can see here:

Stata graph

Is this rising despair? As individuals, people don’t need to have children any more. Ideally, they have as many as they want, when they want, but they are expensive and time consuming and it’s not surprising people end up with fewer than they think “ideal.” Not to be crass about it, but I assume the average person also has fewer boats than they consider ideal.

And how do we know what is the right level of fertility for the population? As Marina Adshade said on Twitter, “Did women actually have a desire for more children in the past? Or did they simply lack the bargaining power and means to avoid births?”

However, to the extent that low birth rates reflect frustrated dreams, or fear and uncertainty, or insufficient support for families with children, of course those are real problems. But then let’s name those problems and address them, rather than trying to change fertility rates or grow the population, which is a policy agenda with a very bad track record.

* I put the DAPPS file package I created on the Open Science Framework, here. If you install DAPPS you can open this and look at the projections output, with graphs and tables and population pyramids.

Fertility trends explained, 2017 edition

Not really, but some thoughts and a bunch of figures on the 2017 fertility situation.

There was a big drop in the U.S. fertility rate in 2017. As measured by the total fertility rate (TFR), which is a projection of lifetime births for the average woman based on one year’s data, the drop was 3.1%, from 1.82 projected births per woman to 1.76. (See this measure explained, and learn how to calculate it yourself, in my blockbuster video, “Total Fertility Rate.”) To put that change in perspective, here is the trend in TFR back to 1940, followed by a plot of the annual changes since 1971:



That drop in 2017 is the biggest since the last recession started. In fact, we have seen no drop that big that’s not associated with a time of national economic distress, at least since the Baby Boom. In 2010, I noted that the drop in fertility at that time preceded the official start of the recession and the big unemployment spike. There is now some more systematic evidence (pointed out by Karen Benjamin Guzzo) that fertility falls before economic indicators turn down. Which makes this New York Times headline a little funny, “US Births Hit a 30-Year Low, Despite Good Economy.” This is a pretty solid warning sign, although not definitive, of an economic downturn coming in the next year or so. (On the other hand, maybe it’s a Trump effect, as people are just freaking out and not thinking positively about the future; something to think about.)

Whatever the role of immediate economic conditions, the long-term trend is toward later births, which is generally going to mean fewer births — both because people who want later births tend to want fewer births, and because some people run out of time if they start late. And that is not wholly separable from economic factors, of course. People (especially women) delay childbearing to improve their economic situation, as they improve their economic situation when they delay births (if they have the right suite of economic opportunities). To show this trend, I’ve been updating this figure for a few years (you’ll find it, and a description, in my book Enduring Bonds).

change in birthrates by age 1989-2016.xlsx

The real reason I made this figure was to highlight the interconnected nature of teen births. Birth rates for teens have fallen dramatically, but it’s been along with drops among younger women generally, and increases among older women — it’s about delaying births overall. Note, however, that 2017 is the first time since the depths of the last recession that birth rates fell for all age groups except women over age 40.

So, sell stock now. But it is hard to know for sure what’s a local temporal reaction and what’s just the way things are going nowadays. For that it’s useful to compare the U.S. to other countries. The next figure shows the U.S. and 15 other hand-picked countries, from World Bank data. Rising fertility in the decade before the last recession wasn’t so unusual. We are a little like Spain and France in this figure, who had rising fertility then and falling now. But Germany and Japan are still rising, at least through 2016. All this is at below-replacement levels (about 2.0), meaning eventually these rates lead to population decline, in the absence of immigration. The figure really shows the amazing fertility transformation of the last half century, especially in giant countries like China, India, and Brazil. Who would have thought we’d live to see Brazil have lower fertility rates than the U.S.? It’s been that way for more than a decade (click to enlarge).

country fertilitiy trends.xlsx

Anyway, it’s my position that our below-replacement fertility levels are themselves nothing to worry about at present. There are still lots of people who want to move here (or, there were before Trump). And we can live with low fertility for a long time before the population starts to decline in a meaningful way. Eventually it will be a good idea to stop perpetual population growth anyway, so we may as well start working on it. This is better than trying to shape domestic policy to increase birth rates.

That said, there is an argument that Americans are having fewer children than they want to because of our stone age work-family policies, especially poor family leave support and the high costs of good childcare. I’m sure that’s happening to some degree, but it’s still the case that more privileged people, who should be able to overcome those things more readily — people with college degrees and Whites — have lower fertility rates than people who are getting squeezed more. People who assume their kids are going to college are naturally concerned with rising higher education costs, both their own loan payments and their kids’ future payments. So it’s a mixed bag story. Here are the predictors of childbearing for women ages 15-44 in the 2016 American Community Survey. These are the probabilities of having had a birth in the previous 12 months, estimated (with logistic regression) at the mean of all the variables shown.*

birth model simple 2016.xlsx

Interesting that there’s only a small foreign-born fertility edge in this multivariate model. In the unadjusted data, 7.4% of foreign-born versus 6.0% of U.S.-born women had a baby, but that’s mostly accounted for by their age, education, and race/ethnicity.

To summarize: 2017 was a big year for fertility decline (at all but the highest ages), the economy is probably about to tank, and the U.S. fertility rate is still relatively high for our income level, especially for racial-ethnic minorities.

Happy to have your thoughts in the comments. For more, check the fertility tag.

* Here’s the Stata code for the regression analysis. It’s just some simple recodes of the ACS data from Start with a file of women ages 15-44, with the variables you see here, and then do this to it:

recode educd (0/61=1) (62/64=2) (65/90=3) (101/116=4), gen(edcat)
label define edlbl 1 "Less than high school"
label define edlbl 2 "High school graduate", add
label define edlbl 3 "Some college", add
label define edlbl 4 "BA or higher", add
label values edcat edlbl
gen raceth=race
replace raceth=4 if race==5 | race==6 /* now 4 is all API */
replace raceth=5 if hispan>0
drop if race>5
label define raceth_lbl 1 "White"
label define raceth_lbl 2 "Black", add
label define raceth_lbl 3 "AIAN", add
label define raceth_lbl 4 "API", add
label define raceth_lbl 5 "Hispanic", add
label values raceth raceth_lbl
egen agecat=cut(age), at(15(5)50)
gen forborn=citizen!=0
gen birth=fertyr==2
logit birth i.agecat i.raceth i.forborn i.edcat i.marst [weight=perwt]
margins i.agecat i.raceth i.forborn i.edcat i.marst

Is there sex selection among Asian immigrants in the US?

There is a 2008 paper reported in the New York Times in 2009, which found skewed sex ratios among children of immigrants from China, Korea, and India, if their older siblings were girls, using the 2000 Census. The implication was that some parents were using IVF or abortion to select boy children if their first two were girls — as is the case in their home countries. There has been some other research on this from the early 2000s, but I haven’t seen it updated since then.

I took a quick stab at it, but don’t have time right now to pursue it more thoroughly. So here’s the quick answer I got, and I shared my data, code, and results in an Open Science Framework project, here. I hope someone will be interested and pursue it further (using my approach or not). The files there include all different ethnic/racial groups.

This is preliminary.

Using the American Community Survey data from 2010-2015, from, I took U.S.-born children ages 0-5, whose parents were both born in China, Korea, or India and both were present in the household. I counted the sex of any present siblings under age 15 (excluding step- and adopted children). Then I restricted the data to those with 2 older siblings, and compared the sex ratios among those who had 0 or 1 older sister to those who had 2 older sisters. I did this in a logistic regression controlling for individual years of age, and using ACS person weights. There are judgment calls to make about age, siblings, data and other issues. The older you get the more likely you are to have kids moving out in a way that is not sex-neutral (for example, if parents with girls are more or less likely to divorce), and so on. Should parents be matched on immigration status, siblings born abroad included, why the years 2010-2015, and so on. This is what I mean by preliminary. But these results are interesting enough to prompt me to post them and encourage discussion and more analysis.

Here’s what I got:

sex selection.xlsx

The sex differences between those with 0/1 older sister and 2 older sisters are not statistically significant at p.<.05 in each of the three groups, but they are for the combined set (.046). These comparison involve a few hundred cases. Here are the unweighted, unadjusted results:


As you can see, just a few families intervening to choose boys — or some other force rearranging the living arrangements, or survival, of children and families, and the difference would not hold. Still, I think it’s worth pursuing. Maybe someone already has. If you decide to get into it, feel free to use this stuff, and let me know what you come up with!

How do Black-White parents identify their children?

In 2015 the American Community Survey yields an estimate of 66,913 infants who have one Black parent and one White parent present in the household. (Either parent may be multiracial, too.)

What is the race of those infants? 73% of them were identified as both White and Black by whoever filled out the Census form.


(Note “other” doesn’t mean they specified “other,” it just means they used some other combination of races.)

These are children age 0 living with both parents, so it’s a pretty good bet they’re mostly biological parents, though some are presumably adopted. This is based on a sample of 507 such infants. If you pooled some years of ACS there is plenty to study here. Someone may already have done this – feel free to post in the comments.

That’s it, just FYI.

If the National Marriage Project told you it was going to rain, would you bring an umbrella?

Why do academics and journalists lend legitimacy to the National Marriage Project?

The Centers for Disease Control: You bought that.
The Centers for Disease Control: You bought that.

I today’s New York Times Week in Review, Andrew Cherlin offers this:

Having a child outside of marriage has also become common. According to a report by the National Marriage Project at the University of Virginia, 47 percent of American women who give birth in their 20s are unmarried at the time.

It took me 3 minutes to find the the 2010 report on birth data from the National Center for Health Statistics (NCHS), a branch of the Centers for Disease Control, and another 1/2 minute to locate the table with this information, which is table 15. Because of my weakness in algebra, it took me another 5 minutes to turn the number of babies born to unmarried women in the age range 20-24 (600,833) and in the age range 25-29 (384,865) and the percent unmarried that those represented (63.1% and 33.9%, respectively), into the total births to women in their 20s (2,087,487) and the percentage of all those to unmarried women (47.2%).

The New York Times paid for that statistic through taxes, which its government has provided. So why publish an essay by a sociologist with a named chair crediting the National Marriage Project, a right-wing front run by the discredited Brad Wilcox on behalf of big-money Christian conservatives? (In other news, the Heritage Foundation reported that the unemployment rate in February was 7.7%).

Maybe the media establishment simply doesn’t know a simple government statistic when they see one. But they see the university label and fancy website, and guy with the (implied) elbow patches, and they think the number is more complicated than it looksRather than hire a qualified unpaid intern to check facts and credit them to their actual sources, maybe they just trust the experts they rely on. (This is the David Brooks strategy.)

With resources for journalism and social science research on the decline, and foundation money playing a growing role in providing information to the media, this is predictable – but still lamentable.

Yes, mothers and fathers still exist

On, which (having retreated on opposing homogamous marriage) is busy promoting its “new conversation on marriage,” Elizabeth Marquardt writes: “Where do babies come from? The state of New York seems unsure.”

Her link to a “report” is to one of those “you wouldn’t believe what my friend saw” posts on the Christian conservative site First Things:

A friend’s wife recently gave birth. He reports that the New York birth certificate asks for the sex of the mother, and the sex of the father.

It goes on to mock people who think seriously about sex and gender. And so the thing starts spreading around the religious-conservative sky-is-falling blogosphere.


I’m not too embarrassed to say I spent 15 minutes trying to look this up. Live and learn.

It’s hard to find information about birth certificates, because everything online keeps steering you to ways to order birth certificates, not create them. But, in New York state it appears there is a state system, and a state system excluding New York City. On the New York City site, there is an Electronic Birth Registration System, described here. It asks for a lot of information about the mother and father, but not their sex or gender.

I didn’t find the equivalent for the rest of the state, but the state’s Department of Health reports that they follow National Center of Health Statistics (NCHS) guidelines, which seem to refer to this revised birth certificate recording form, which was revised in 2003. In addition to health information, it records the mother’s and father’s marital status (mother only), country of birth, education, Hispanic origin, and race. The mother is “the woman who gave birth to, or delivered the infant.”

The only mention of sex (or gender) pertains to the child: “Print or type whether the infant is male, female or if the sex of the infant is not yet determined.” And “not yet determined” is a temporary state, as the recording instructions clarify:

An N code for “not yet determined” should not be allowed for any record in the file at the time the file is closed. NCHS will query states to obtain the sex of the infant for all records still retaining the N code at the time the file is closed.


Births to mothers in their forties are less common now than in the old days

In my post the other day I suggested that, when it comes to children’s health, mothers’ health is a bigger issue than mothers’ (advancing) age when they give birth. I was motivated to post it by the widespread discussion of Judith Shulevitz’s essay in the New Republic, “How Older Parenthood Will Upend American Society” — discussion that has continued with today’s On Point (which I haven’t heard yet), including the author Elizabeth Gregory, who has written Ready: Why Women Are Embracing the New Later Motherhood (which I haven’t read yet).

In the comments, several people (Reeve Vannamen and relfal) brought up the issue of later births in the olden days (before 1970). We need to think about two different issues: having first children at a later age, and having any (or many) children at a later age. For some questions of children’s health – especially the sperm-mutation issue with autism – I don’t think it matters: an older-age birth is an older age birth. The same goes for the angst over whether children will know their grandparents, whether parents will be too old to take them to soccer practice, and so on.

On the other hand, “starting a family” at an older age (because, remember, it’s not a “family” until you have kids), is a different issue, with its own implications for total fertility rates, the age composition of the population, etc.

Both having any children and having first children at older ages have been increasing in recent decades, but having any children at older ages is not historically unprecedented. Here are the birth rates for women ages 40-44, from 1940 to 2011, along with the percentage of all children born to those women from 1960-2010:


Sources: Birth rates 1940-1969, 1970-2010, 2011; Percent of births 1960-1980, 1980-2008.

Birth rates to women ages 40-44 are still substantially lower than they were in the olden days. So the number of kids whose parents will be over 60 when the kids come back to live with them after college is lower now despite an increase for 30 years.

On the other hand, the percentage of kids born to older mothers has surpassed those rates, because these are more often first or second, rather than third or fourth or fifth children. Put another way, the chance that women will have their first, and possibly only, baby at an older age has increased since 1960. While the overall birth rate for older women is still lower than it was in 1960, the first-birth rate is much higher. Here is the birth rate among women with no previous births, for those aged 35, 40 and 45, from 1960 to 2005:

first birth rates 60-05

Source: Table 4 on this page.

In 1960, only 4% of women who reached age 35 without having a baby had one that year. They probably weren’t just delaying their childbearing intentionally or putting off finding a mate while they pursued their careers. On the other hand, by 2005 almost 9% of those who reached age 35 without having a baby had one that year. The late first birth has become much more common.

Now if you go back to the promo blurb for On Point, you see how the issues are jumbled together:

American parents are having kids old and older. Look around. Are those two that child’s parents? Or its grandparents? It is very often hard to know these days. In many ways, this has been liberating. Twenty-somethings with a child-free, diaper-free decade of youth. People with time and space to start careers. But there is a price, and it’s becoming clearer. Older parents juggling kid’s soccer and their own aches and pains. Kids who won’t know their grandparents. Parents who won’t know their grandkids. And a baby bust.

The hardships faced by older parents are nothing new, but parents used to have more kids around when they went through them. It’s good to keep an eye on the issues separately.

Note: there is some more background and analysis in my working paper: here.


Study shows home births are not as safe. So?

There’s an interesting example of how to interpret scientific results — and draw policy implications from them — from the world of birth practices and safety.

The subject of the debate is a major new study from the British Medical Journal. The study followed more than 60,000 women in England with uncomplicated pregnancies, excluding those who had planned caesarean sections and caesarean sections before the start of labor. They compared the number of bad outcomes — from death to broken clavicles — for women depending on where they had their births.

One comparison stands out in the results. From the abstract: “For nulliparous women [those having their first birth], the odds of the primary outcome [that is, any of the negative events] were higher for planned home births” than among those planned for delivery in obstetric units. That is, the home births had higher rates of negative events. The difference is large. Here’s a figure to illustrate:

The error bars show 95% confidence intervals, so you can see the difference between home births and obstetric-unit births is statistically significant at that level. These are the raw comparisons, but the home-versus-obstetric comparison was unchanged when the analysts controlled for age, ethnicity, understanding of English, marital or partner status, body mass index, “deprivation score,” previous pregnancies, and weeks of gestation. Further, by restricting the comparison to uncomplicated pregnancies and excluded all but last-minute c-sections, it seems to be a very strong result.

But what to make of it?

In their conclusion, the authors write:

Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting. Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome.

But in what way do the results “support a policy”? The “higher risks” they found for planned home births are still “uncommon,” by comparison, with those in poor countries, for example. But the home birth risk is 2.7-times greater.

The Skeptical OB, who is a reliable proponent of modern medical births, titled her post, “It’s official: homebirth increases the risk of death.” She added some tables from the supplemental material, showing the type of negative events and conditions that occurred. Her conclusion:

“In other words, any way you choose to look at it, no matter how carefully you slice and dice the data, there is simply no getting around the fact that homebirth increases the risk of perinatal death and brain damage.”

I guess the policy options might include include whether home births should be encouraged, more regulated, covered by public and/or private health insurance, banned, penalized or (further) stigmatized.

Home birth seems safer than letting children ride around unrestrained in the back of pickup trucks, which is legal in North Carolina — as long as they’re engaged in agricultural labor. On the other hand, we have helmet laws for kids on bicycles in many places. And if a child is injured in either situation, hopefully an ambulance would take them to the hospital even if the accident were preventable.

In other words, I don’t think policy questions can be resolved by a comparison of risks, however rigorous.