Nov 05 2009
The Tragic Death Toll of Homebirth
More than 10,000 American women each year choose planned homebirth with a homebirth midwife in the mistaken belief that it is a safe choice. In fact, homebirth with a homebirth midwife is the most dangerous form of planned birth in the US.
In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. In both the 2003 and 2004 Linked Birth Infant Death Statistics, mention was made of this data, but it was not included in the reports. Now the CDC has made the entire dataset available for review and the statistics for homebirth are quite remarkable. Homebirth increases the risk of neonatal death to double or triple the neonatal death rate at hospital birth.
As this chart shows, the neonatal mortality rate for DEM (direct entry midwife, another name for homebirth midwife) assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.
The chart shows the data for 2003-2004, but the data for 2005 has recently become available. Homebirth death continues to be far higher than death in the hospital for comparable risk women. In 2005 the neonatal death rates were CNM in hospital 0.51/1000, MD in hospital 0.63/1000 and DEM attended homebirth 1.4/1000.
No wonder the Midwives Alliance of North American (MANA), the trade union for homebirth midwives, is suppressing their safety statistics. From 2001-2008, they have collected the single largest repository of data on homebirth. The data is publicly available, but only to those who can prove they will use them for the “advancement” of midwifery, and even then, a legal non-disclosure agreement must be signed as part of the process. MANA’s data may very well confirm that homebirth with a DEM has triple the neonatal mortality rate of hospital birth for comparable risk women in the same year.
What is also notable is that the results are consistent with all existing scientific studies, including the Johnson and Daviss study (Outcomes of planned home births with certified professional midwives: large prospective study in North America). Johnson and Daviss actually showed that homebirth with a CPM has a neonatal mortality rate almost triple that of hospital birth for low risk women. The latest statistics are the most recent and most reliable confirmation of that fact.
There really is no question about it. Homebirth with a homebirth midwife dramatically increases the risk of neonatal death.
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257 Responses to “The Tragic Death Toll of Homebirth”
Amy,
those are very pertinent points. However, in case somebody stops by to cite safety statistics from the UK, Germany or the Netherlands, it might be worth adding the caveat that these numbers reflect the particular training of US Direct Entry Midwives.
Most of the midwives that supervise home births in the UK are actually affiliated with the National Health Service. They have received extensive training over several years. Typically, Midwifery and Nursing will be taught in the same School within a university. Even independent midwives, who do not work for the NHS, will have received this long evidence-based training. The same NHS midwives who assist with homebirths also supervise hospital births and care for the mother during Caesarean birth. Therefore, NHS midwives are much more likely to spot potentially dangerous situations and arrange a transfer to hospital in time.
So, homebirth safety statistics from different countries cannot be compared without looking at the training that these midwives receive and the way they are integrated in the overall health system.
yr dataset link is broken : http://wonder.cdc.gov/lbd-icd10.html gives 404. dyu have the correct link ?
It doesn’t matter. This is a religion for these people. I’ve shared this story before but my brother-in-law and his wife did a home birth. In a nutshell the baby was fine, my sister-in-law had a tear that was bleeding internally, she went to the local hospital, then was airlifted to a local medical center, needed two units of blood and almost died.
But… They’d do it again. They think hospitals are evil and just want to dope you up and cut out your baby.
Rikki Lake’s “documentary” “The Business of Being Born” is what they’ll use as “evidence” as to why home birthing is better.
@mariawolters on 05 Nov 2009 at 6:12 am
I am given to believe that birthing can go from normal to life-threatening in moments. Regardless of a person’s training, if it happens outside a hospital the odds are stacked against someone giving birth at home (both the mother and the baby) if the worst happens.
“They have received extensive training over several years.”
Absolutely. NHS midwives, like all EU midwives, have extensive training and much better hospital support. Interestingly, though, homebirth was recommended as a government policy without any evidence that it is safe.
When NICE (the National Institute for Clinical Excellence) first looked at the issue in 2006 they concluded that the existing homebirth studies suggest that homebirth has an increased risk of perinatal death. After a furor generated by homebirth advocates, the report was revised. A watered down version (http://www.nice.org.uk/nicemedia/pdf/IPC2ndConsChapter3.pdf) was ultimately released in 2007 nonetheless included the following observations:
“The uncertain evidence suggests intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.”
and:
“When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.”
A study designed to definitively address the issue of homebirth safety is currently underway at the National Perinatal Epidemiology Unit (NPEU). The results should be available in 2010,
Welcome to SBM
what are CNM? and what are CPM?
Ok, when I look at WONDER for Linked Birth / Infant Death Records, 2003-2005 – the rate of infant mortality (across all regions & groups) is much lower (2.7) for CNM deliveries outside of hospitals than MD deliveries inside hospitals (7.15). So doesn’t that show that home births with a CNM are safer than hospital births with a MD?
Of course, there are some benefits to doing the deed at home:
1) Giving birth at home can be less expensive than giving birth in a hospital.
2) Getting to the hospital while in labor can be painful/uncomfortable or very difficult.
3) Giving birth at home can give mom more control over what happens. (Of course, once a complication arises, and they are waiting for the ambulance, how much control do they really have?)
These benefits may be worth more to a pregnant woman than the increased risk of her death or the death of her baby. If I am reading the table correctly, out of every thousand women who choose to have a baby at home with a midwife, we can expect more than 7 but probably less than 10 of them to lose their baby where they wouldn’t have lost their baby if they’d gone to the hospital. This ~1% chance of death might not be so scary when contrasted with a 99% chance they perceive of having a more pleasant/affordable birth.
Of course, keeping the stats a secret implies that the Midwives society is afraid that the increased risk of death will be a deal breaker with their potential customers, that indeed moms to be would find that additional 1% chance unacceptable.
For OBGYN’s competing in the market for the custom of pregnant moms, it might be a good idea to make hospital births also provide these benefits. Ideas like putting in a hotel where their customers can stay as their due date approaches so that they don’t have to travel to the hospital while in labor,
Just anecdotally, the people whom I’ve known to choose homebirth tend to be the same people who distrust the medical system, choose alternative treatments for pregnancy complications* and decide not to vaccinate their kids. So part of the increase in death rates may be from a selection bias of the other idiotic medical decisions that these mothers make.
*A friend’s wife who is an alternative medicine nut once literally told me that if there’s any complication in her pregnancy during her homebirth her midwife will give her “some herbs.” When I asked her which herbs, she couldn’t answer (and got mad at me).
BenDC, MDs take on all types of births, including very high risk ones. If there is any potential for complications, CNMs transfer their patient to an MD. So it’s not exactly fair to compare the two since they’re two very different patient populations.
the link to the entire data set doesn’t seem to be working:
http://wonder.cdc.gov/lbd-icd10.html
@tarran
“1) Giving birth at home can be less expensive than giving birth in a hospital.” – True, but you can do the middle ground and go to a birthing center. It gives the “at home” experience with the security of a doctor and equipment around in case things go south. And that’s a LOT cheaper than an ambulance and emergency services if things go wrong during the home birth, not to mention the risk.
“3) Giving birth at home can give mom more control over what happens. (Of course, once a complication arises, and they are waiting for the ambulance, how much control do they really have?)” How so? A doctor can’t do anything to you that you don’t want them to, they don’t want to risk getting sued. The pro-homebirth movement likes to say that the doctors and nurses at a hospital like to push drugs and surgery, but that’s just not true in most cases.
JerryM:
“what are CNM? and what are CPM?”
CNM is certified nurse midwife. CPM is certified professional midwife (homebirth midwife).
A CNM is comparable to midwives in the EU, Canada, Australia, albeit with even more training and experience. American homebirth midwives were called lay midwives or direct entry (no college degree) midwives. A few years ago, direct entry midwives created a “degree” for themselves and dubbed it the CPM. Any confusion with the CNM credential is almost certainly deliberate.
BenDC:
“the rate of infant mortality (across all regions & groups) is much lower (2.7) for CNM deliveries outside of hospitals than MD deliveries inside hospitals (7.15). So doesn’t that show that home births with a CNM are safer than hospital births with a MD?”
No, not at all.
First, infant mortality includes infants up to one year of age. A better statistic for evaluating obstetric care is neonatal mortality, deaths from birth to 1 month of life.
Second, all the high risk patients are in the MD group. So all the premature babies, multiple pregnancies, pre-existing medical problems, medical complications of pregnancy and all C-sections are in the MD group. In the case of C-sections, all C-sections are in the MD group regardless of whether the patients were under the care of a CNM or a homebirth midwife.
tarran:
“This ~1% chance of death might not be so scary when contrasted with a 99% chance they perceive of having a more pleasant/affordable birth.”
If only 10% of American women had a homebirth (a stated goal of some homebirth advocacy organizations), that would mean an additional 400+ babies would die each year, making homebirth one of the top ten causes of neonatal mortality.
“So it’s not exactly fair to compare the two since they’re two very different patient populations.”
So then why is this post comparing these different populations?
“First, infant mortality includes infants up to one year of age. A better statistic for evaluating obstetric care is neonatal mortality, deaths from birth to 1 month of life.”
That is what your chart shows correct? If I were a mother looking that chart, I would opt for the CNM, as it has the lowest mortality rate. But do CNMs not practice home-births? Is this chart showing CNM deliveries in hospitals, MD deliveries in hospitals and DEM deliveries at home? If so, then that would clear up my confusion.
*Stands up and takes hat off*
Thank you, Amy!
I did a similar query: mortality 0-27 days, 36+ weeks, and grouped by attendant
The results triggered a related but off topic question:
this returned a death rate of .98/1000 for MD’s and a rate of .89/1000 for doctors of osteopathy.
I’m curious to hear your take on this specifically and your thoughts on osteopathy generally.
btw
“When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.”
Duh….
When the MDs still have a lower mortality rate, that shows that the differential in outcomes is so large that it more than offsets the difference in populations.
Essentially, in the presence of a biasing factor of known direction but unknown magnitude, what conclusions you can draw depends very sensitively on which direction the observed difference is. If the observed difference goes in the same direction as the biasing factor, you can’t conclude whether there is a real difference or if it’s due to the bias. But when the observed difference goes in the other direction, you CAN conclude that there is a real difference.
Hence it’s justified to conclude that the DEMs have worse outcomes than the MDs (observed difference is opposite the biasing factor), but not that the CPMs do (observed difference is the same direction as the bias).
Going to need the raw numbers, not just the rates, to make any judgement of statistical significance.
[...] me that licensing doctors was a pretty good idea) on the subject. But I happened to stumble across this tidbit that I wasn’t aware of before: In 2003 the US standard birth certificate form was revised to [...]
BenDC:
“If I were a mother looking that chart, I would opt for the CNM, as it has the lowest mortality rate. But do CNMs not practice home-births?”
I did not include the information on the chart, but homebirth with a CNM has double the neonatal mortality rate of hospital birth with a CNM.
The chart does not show that CNM hospital birth is safer than MD hospital birth since the CNM patient population is much lower risk and because all CNM patients who require physician transfer end up in the MD group. If we looked at outcomes based on the attendant at the beginning of labor, the CNM mortality rate would be higher than stated and the MD mortality rate would be lower than stated.
MDs: 3205 deaths; 3,268,500 births
DOs: 162; 182,452
Not statistically significant then. The uncertainty on the 162 (which dominates the total uncertainty in the comparison) is approximately its square root (12.7), which means the rate for DOs is essentially (0.89 +/- 0.07) / 1000. The observed difference is only 1.3 sigma, so does not reliably demonstrate that a real difference exists.
thanks… how do you calculate uncertainty?
also, that there isnt a significant difference leads me to the second question of the practice of osteopathy in general:
to what extent has it, in academia and practice, adopted science-based practices?
As one of the earlier commenters posted, this is a religion to these people. Hospitals are full of germs and infections. Doctors only want your money, same with pharm companies. To me, there is no difference between them and the non-vaxers, and I do find that they frequently overlap. They get locked into the “it won’t happen to me sydrome” whether it be a dangerous birthing experience or contracting a vax-preventable disease. They don’t interpet it as triple the risk; they interpret it as 1 in 1000, and they’re ok with that. Mind you, I don’t want any mom or baby to die, I’m just not as passionate about this issue because unlike non-vaxing, if they go out into the woods with a blanket & have a baby, it doesn’t put my family in danger.
Discovery Health TV also glamorizes this on their mom/baby shows.
Thanks for an interesting debut blog Dr. Tuteur. I look forward to following your entries. My then wife and I considered home birth many years ago and decided against it. Hospital labor and delivery units have come a long way since the days when fathers-to-be smoked in waiting rooms while mothers labored. It is hard to imagine a compelling argument in favor of home delivery these days.
I have one small quibble though. In today’s blog you said:
“MANA’s data may very well confirm that homebirth with a DEM has triple the neonatal mortality rate of hospital birth for comparable risk women in the same year.”
Unfortunately, we don’t know what MANA’s data actually confirms or contradicts. Many of us in the skeptical community would jump on such a purely speculative assertion if tendered by the woo-crazies.
In many situations where you’re counting the number of something, the square root of the number you got is a reasonable estimate of the statistical uncertainty. It’s only *strictly* correct for a Poisson distribution, but for quite a few other cases (like the binomial distribution relevant here) it’s a decent approximation.
Not something you’d use for a publication (which calls for much more rigorous and involved calculations), but it’s typically adequate for back-of-the-envelope situations.
# tarran on 05 Nov 2009 at 7:38 am “These benefits may be worth more to a pregnant woman than the increased risk of her death or the death of her baby.”
Let me guess- you have no experience with the devastation of losing a child and/or a spouse. Even one avoidable event is too many.
It is not an experience that one approaches academically i.e., “We knowingly took that chance, we rolled the dice and lost; ho hum …” I could go on … not about me; but some of my friends had those experiences (scientists don’t favor anecdotes).
Some people may not understand the risks they undertake; but reality may overwhelm them and cause regret.
provaxmom:
“To me, there is no difference between them and the non-vaxers, and I do find that they frequently overlap.”
You’re right. Last year at the 42nd annual National Immunization Conference sponsored by the CDC, officials of the Oregon Department of Health Services presented an educational session on The Association between Birth Place, Birth Attendant, and Early Childhood Immunizations. Reviewing Oregon births they found:
“Overall 132,473 Oregon births were included in this study. While 97.9% of births were in hospitals, 82.7% had a M.D. as the attendant. The 2,200 children who were born in locations other than a hospital or freestanding birthing center were 8.8 times more likely not to be seeking or receiving immunizations than those born in hospitals. Those with a direct-entry or non-certified midwife in attendance were 7.4 and 8.8 times more likely to not be shot seeking as those with an M.D. However the 19,600 children born with a certified nurse midwife in attendance at a hospital were 1.1 times more likely to be shot seeking than those with an M.D. Similar results were obtained for UTD rates for these groups.”
This finding is not surprising. Homebirth advocacy and vaccine rejectionism are linked by fundamental traits. Both depend on a lack of understanding of basic science. Both depend on a lack of understanding of statistics. Both depend on a lack of understanding of the subject matter, childbirth or immunology. Because of this lack of basic understanding, both groups of parents are easily manipulated and misled by “alternative” practitioners. Moreover, both groups have a reflexive distrust in authority, and a belief that rejecting authority is, in itself, a mark of being “educated”. In other words, both are philosophical orientations that have more to do with the parents’ views of themselves than with the actual risks and benefits.
Perhaps the most important way in which homebirth advocacy and vaccine rejectionism are linked is that both place young children at increased risk of death or disability as a result of parental ignorance.
windriven:
“Unfortunately, we don’t know what MANA’s data actually confirms or contradicts. Many of us in the skeptical community would jump on such a purely speculative assertion if tendered by the woo-crazies.”
I see your point. However, skepticism does not rule out speculation, does it? I certainly could not present the fact that MANA is showing their data to “friends” of midwifery but not the general public as proof that the data shows homebirth to have an increased risk of neonatal death. But it isn’t unreasonable to consider the possibility.
So, it looks like your best bet for a homebirth would be a CNM. I am a bit biased of course. But it makes sense to me because, nurses are used to looking for signs that things are not going well and the patient is developing a complication. So I think nurses would be quicker to transfer to a hospital at the yellow lights. They would not wait for the red light!
I have been reading your blog in various forms for years now. Always enjoyed it. What are your thought on Free standing Birth centers across the street from a tertiary care center. A non busy street of course. Maybe right across from the ER entrance.
My thoughts are that it may be the answer to folks who would other wise homebirth. And it could be the answer to folks who want a noninterventive birth.
I think MANA has got it wrong. We don’t need to protect midwifery. Midwives are needed to deliver babies. With so many Obstetricians quitting, who is going to be delivering the babies?
I wrote about home births last year: http://www.sciencebasedmedicine.org/?p=64
Thanks for presenting the statistics to confirm what my common sense had been telling me all along.
The obvious compromise is to create a home-birth-like environment within a hospital setting. But that won’t even begin to satisfy the hard-core home-birthers. We’re talking about the emotion-driven ideology of mothers, not about the objective welfare of the baby.
Speaking of the welfare of babies.. my sister lives in Alaska and knows people whose choice of living conditions eliminates any choice about childbirth. When she was teaching in a very small and isolated Alaskan town, one of her friends lived miles up a foot trail with no vehicle access. When her due date came near, she and her entire family moved into my sister’s home and the baby was born there. Fortunately all went well. There was no hospital within reach, no doctors, no midwives, only an EMT. When my sister had to take her dog to the nearest vet for an emergency, it involved a 4 hour drive. These people realize they are putting their babies at risk, but they accept the risk in order to enjoy the lifestyle they have chosen.
Nice to see you here, Amy.
A while back I crunched the CDC WONDER numbers myself, and found similar patterns (I used similar criteria, but limited my search to deaths attributed to the ICD-10 group labeled “Deaths due to certain conditions originating in the perinatal period.”)
I was also interested in how post-dates babies fared, since induction due to post-dates is one of the pet peeves of homebirth advocates (and I had my own 42-weeker.) I compared outcomes (using same parameters as above) for births at 41+ weeks’ gestation. You can see the full data in my blog post, but the mortality rates for the group were: CNM-0.09, MD-0.14, DO-0.14, Other Midwife-0.66 (all per thousand.) A major limitation is, of course, small sample for both the CNM and Other Midwife groups.
I’m obviously not well-versed in statistics or statistical analysis, so maybe none of this means much at all, but this layman found it interesting that all the data I looked at showed patterns similar to those Amy has laid out.
“CNM is certified nurse midwife. CPM is certified professional midwife (homebirth midwife).
A CNM is comparable to midwives in the EU, Canada, Australia, albeit with even more training and experience. American homebirth midwives were called lay midwives or direct entry (no college degree) midwives.”
CNMs attend homebirths in the USA as well- just thought I would point that out. In my home state CNMs can attend homebirths with OB backup. I can think of at least 10 in this immediate area that do this.
“The chart does not show that CNM hospital birth is safer than MD hospital birth since the CNM patient population is much lower risk and because all CNM patients who require physician transfer end up in the MD group. If we looked at outcomes based on the attendant at the beginning of labor, the CNM mortality rate would be higher than stated and the MD mortality rate would be lower than stated.”
Ok, so you use the chart to say that DEM births have the highest mortality rate (I am not arguing that). But when I say the chart shows CNMs having the lowest mortality rate, then you say that no, that is not the case because of the above argument. So what stops me from coming up with some reasoning as to why the DEM number would really be lower if we took into account other factors? If we are using that chart to make this argument about home-births being more dangers, then we can’t have different conditions for interpreting each mortality rate for the different groups, can we?
Making infant death rates the sole consideration is not required by “science”; it’s a philosophical or emotional choice, thus it’s not acceptable to dismiss anyone who disagrees as simply too stupid or deranged to understand “the statistics.” From other people’s perpectives, it may be legitimate to take other factors into account:
1. The mother may give her own interests some weight. Suppose your child were trapped in a burning building, and you were informed that trying to save it would give you a 30% chance of suffering a significant injury (whose financial costs you would be left to bear); you would very likely run in anyway. I don’t personally have a child, but I’d do the same for my cat. But suppose I were told that there was only a 1 in 1250 chance she was still inside, and that I had to decide immediately whether to run into the fire. In that case, I would not do it.
If you would choose otherwise, you might respond with name-calling: I am selfish, or I don’t love the cat as much as I claim to. Not true; I would simply be making what seemed to me a rational decision, based on the odds, and while I’d certainly bear regrets if it turned out to be the wrong choice, I would still say it had been a reasonable decision at the time. You might find that immoral, but a matter of conflicting moral judgements is not a matter that science can arbitrate.
2. Your use of a single statistic as an unchallengeable trump card also presumes that all infant deaths are bad. Some people might feel that if their baby is born inside out or lacking most of its brain, it would actually be a mercy for the family, and for the baby itself if it can feel pain, if it died before it could fall into the hands of a neonatologist. Some, perhaps many, of the additional deaths with home birth are of infants with birth defects who stood a low chance of growing up to be healthy adults. It can be proven by statistics that such infants are more likely to survive the first month if born in a hospital; whether that’s a good thing in the long run is an ethical question in which an MD’s opinion carries no more weight than anyone else’s.
3. Medicalized pregnancy and childbirth, aside from its health risks, has additional financial costs of perhaps $10,000 to $15,000 – or, if you are unlucky, much more. That does not count the indirect costs of missing work, or losing a job, if you have a complicated C-section and can’t work for months. (And it’s simply not true that nobody is emotionally coerced or outright forced into a C-section or other costly treatments, even including ones like bed rest that have been shown to be worthless in clinical trials.) This amounts to a cost of some millions of dollars per infant saved, which on a societal level is pretty steep compared to other lifesaving interventions.
But society does not pay; individual mothers do, and for uninsured families in particular, these are heavy burdens. If they do not spend the first years of the child’s life paying off the MD and hospital, they may be able to live in a safer and less polluted neighborhood; put better food on the table, with implications for the child’s long-term health and brain development; or pay for private education if local schools are very poor. The poor in our country have much shorter life expectancies than the rich; interventions like these to give a child a good start in life might add years to a newborn’s statistical lifespan. By contrast, hospital birth adds a few statistical weeks to each infant’s life (assuming that even those with birth defects would end up having a normal lifespan).
Again, you might not prefer to look at the issue that way, but science doesn’t and can’t say that one view is “right” and one is “wrong.” You have a habit – I’ve gone and read some of your blog – of assuming that those who disagree with you can only be doing so because they are mentally or emotionally inferior in some way. That habit will help you fit in well at this site, but it won’t help you deal with potential patients, who know at some level that they are being gamed and resent it.
If you could assert a convincing factor that would have that effect, nothing. But you can’t simply say that there might be one and expect that to carry any weight.
Noting a known confounding factor and arguing based on its expected effect on the data is a fundamentally different proposition from invoking some purely hypothetical confounder. The former is legitimate – the latter is not.
I’m so happy to have an OB/GYN on the team, and thanks for the great article! someone mentioned “birthing centers” and I looked into the only one in my area, and it’s ran by an ND! no thank you . . .
apteryx said:
2. Your use of a single statistic as an unchallengeable trump card also presumes that all infant deaths are bad. Some people might feel that if their baby is born inside out or lacking most of its brain, it would actually be a mercy for the family, and for the baby itself if it can feel pain, if it died before it could fall into the hands of a neonatologist. Some, perhaps many, of the additional deaths with home birth are of infants with birth defects who stood a low chance of growing up to be healthy adults. It can be proven by statistics that such infants are more likely to survive the first month if born in a hospital; whether that’s a good thing in the long run is an ethical question in which an MD’s opinion carries no more weight than anyone else’s.
Using this argument, you would have to assume that those who choose homebirth would be at higher risk for having an abnormal pregnancy. Why would that be the case? It wouldn’t.
As far as costs, it has been my experience, and purely anecdotal, but the acquaintances that I have who choose to not vax and choose to home birth also do not have health insurance. And that’s really tragic. Because consciously or unconsciously, I think it’s much easier to be anti-modern medical establishment when you have to pay for everything out of pocket.
BenDC:
I have noticed a few post from you on several articles, and your questions seem to mostly revolve around the statistical interpretation of medical studies. I would highly recommend the book “Studying a Study and Testing a Test: How to Read the Medical Evidence” (Amazon has it) … it was required reading during some of my training and does a very good job of showing how to spot statistical misinterpretations.
JerryM, CNMs are Certified Nurse Midwives. They have nursing training then additional graduate-level training in midwifery. They handle low- to moderate-risk births in hospitals, working with doctors, and can handle most situations that don’t involve surgery. Some also assist in home births or births at freestanding “birthing centers,” but they have extensive training, including witnessing hundreds of births of all risk levels before they practice alone. They have the advantage of costing less to the patient, usually, and lightening patient loads for OBs. The only increased risk of a CNM at home vs. a hospital is that if a blood transfusion or C-section is needed, or emergency surgery on the infant, the transfer to the hospital will take long enough the mother and/or baby could die en route, or arrive too close to death.
CPMs are certified professional midwives. They have a high school diploma, maybe some college but no nursing degree, and a short course (unregulated, can be anything from a few months to two years) in birth, usually only with one or two births to witness. They usually have no idea what to do with even the most common complications, so something that even a CNM trapped in an elevator could solve in an heartbeat becomes deadly under the supervision of a CPMs
DEMs are another, third category, in that they have no training at all except job-shadowing another midwife in an apprentice situation. They have no actual education and are akin to hiring the OB ward janitor or your grandmother who was there when her grandkids were born to deliver your baby.
Amy, did you lump CPMs and DEMs in the same category for this? I can’t remember. There is a distinct difference, though.
provaxmom said
“Mind you, I don’t want any mom or baby to die, I’m just not as passionate about this issue because unlike non-vaxing, if they go out into the woods with a blanket & have a baby, it doesn’t put my family in danger.”
This is basically my opinion. I know it seems harsh, of course I don’t want any child to needlessly suffer/die, but the anti-vax groups just get my blood boiling much more. The one thing that does really annoys me with homebirthers is the idea that the birth experience is equal to or more important than the actual outcome. I have met several women who were very upset that their birth experience was not what they wanted (they ended up with an epidural, C-section, etc.), even though they and their babies were healthy. I’m not sure they would feel this way if these groups did not push the importance of having this “perfect experience”. Since when is having a healthy family not good enough? This is one of the reasons why this “movement” is really of the middle and upper classes.
Both of my grandmothers had all of their births at home, because they had to. If they were alive today and someone told them how wonderful homebirth was, I’m sure they would give them a good shouting.
I do have one question. Homebirth advocates always say that, for low-risk pregnancies, homebirth is safer than hospital birth. I’ve never been able to get a real statistic out of them, but they say this with such utter confidence, it really is like a religion. Do you have any idea where they get this information from?
Basiorana, CPMs are a subset of DEMs. All “DEM” means is that they are not a nurse. Technically, this includes everyone from graduates of the SUNY Downstate master’s degree program to the granny midwives practicing near me.
Of course, this entire post is only a repost of something Dr. Amy has posted on at least 3 other blogs, by my count.
One more thing to provaxmom. I like your screen name, but also find it sad that one has to actually say they are pro-vax. It is kind of like saying anti-disease and anti-preventable-death.
I do wish hospitals allowed a less-interventionist setting for those who wish to have that. My problem with the “homebirth” and more broadly, natural birth movement, is when they try to discredit medical interventions, and it’s just not true. I enjoyed reading “Our Bodies Ourselves: Pregnancy and Birth” but found it to be promoting natural birth, and worse, cited a side effect of epidurals I knew not to be true. when i checked the citation, it was from a CAM journal! They also had personal quotes of women stating unsubstantiated claims. I think there are many positive points to natural birth, telling lies to influence women to support your side is not a tactic I respect.
Provaxmom – I don’t see how you arrived at that interpretation of what I said. In fact, women who give birth in hospitals are more likely to have babies with life-threatening defects (because if the defect has been identified with prenatal testing, or the mother has a condition that may cause defects, the pregnancy will have been deemed high-risk and the mother directed to a hospital birth). However, defective infants born in a hospital are much less likely to die perinatally, because they can be hustled straight to the neonatal ICU. (The parents often are denied the right to refuse that treatment, yet can be billed for the results.)
@apteryx:
Huh?
1. “The mother may giver her own interests some weight…”
What interests? Post partum mothers hemorrhaging out for lack of surgical intervention is in her interests? I don’t want to be flippant here but I am at a loss to understand what interests are best served by a non-hospital delivery.
2. “[S]ome people might feel that if their baby is born inside out or lacking most of its brain…” Many delivery misadventures are the result of out-of-position babies, pinched umbilicals and other factors that are easily addressed in a hospital setting. And proper prenatal care including amniocentesis where appropriate allows the mother-to-be to address gross deformities in a far more controlled setting than a bloody bedroom in Peoria.
3. “Medicalized pregnancy and childbirth, aside from its health risks, has additional financial costs…” Good grief, do you suppose that botched at-home deliveries always result in nice inexpensive dead babies? Hospital care has a cost, yes, but also a benefit. Even some Mennonites go to hospitals to deliver their babies.
And it is also cheaper if you use a #2 pencil instead of a Mac Air, if you walk instead of driving a car, if you simply die instead of having diagnostic tests.
SF Mom – As a scientist you ought to spot the distortion in that argument. Just because you get C-sectioned and have a healthy baby does not mean that you would have had an unhealthy or dead baby had you not had major surgery. Many OBs these days have a 25% to 33% C-section rate. Look at women who give birth in places where there are no C-sections available (and such places are far less sanitary than the average American home or birthing center). Yes, complications occur; women and babies die or are seriously injured. But does it happen in one-quarter to one-third of all pregnancies? Not even close. From an evolutionary perspective, it’s just not possible to develop anatomy such that a third of all pregnancies would be fatal if you didn’t have someone standing by to slice your belly open. How could a species survive in nature at all in such a condition, much less become grossly overpopulated? So some of those C-sections are not really necessary.
The flip side is that C-sections are shown to increase the risk of chronic respiratory problems, which you can’t see when you pronounce their babies “healthy”. Just because it has the right number of arms and heads, that doesn’t mean it’s not going to wind up with asthma down the line. Thus, while not having C-sections available would cause increased morbidity, doing them for people who don’t really need them also causes morbidity in people who otherwise would have been healthy (including the mothers, who suffer a pretty high complication rate).
And here you are with the same idea: people who disagree with you are bad people with inferior motives. How dare these women feel unhappy about having painful and expensive major surgery? How selfish of them to care at all about what happens to themselves. “Really of the middle and upper classes,” indeed.
Just a little clarification re: point upthread.
DO’s (osteopaths) were historically trained in a system emphasizing a woo-ish form of physical manipulation. While rudiments of this system still exist in DO schools, most DOs these days train in “MD” residency programs and have pretty much the same training.
Some of us MD’s out there have a pretty negative view of old-style DO family docs, but over the last 10-15 years, those who train in MD programs aren’t any different in their practice than MDs.
Scott, did you state that a quick calculation of the raw numbers showed that the difference in death rate was not significant?
I’m curious as to why many of these infants died in a homebirth and what can be done to decrease those numbers. I belong to a very large group of moms online, many of which who are fierce advocates of homebirth because of the awful way they were treated in a hospital setting (many women are totally unaware of what rights they have when giving birth). They see many interventions as unnessary and based on outdated stats (for instance, how many stats are based women laying down to give birth. Women should be squatting or at least not on their back when pushing out a child). The movement of promoting homebirths is a reaction to what many consider the “medicalization” of something that has been done since the dawn of time. Yes giving birth carries great risk but I think the science-based information on it is lacking.
Telling people that having a homebirth carries a greater risk of infant mortality doesn’t tell anyone anything, especially if the conditions surrounding the deaths are not known. Please fill in the details so something can be learned from this.
windriven -
Yep, a couple of every hundred thousand women who give birth at home will die because they bleed to death without a transfusion. It would certainly be in their interests to avoid that. On the other hand, about 25,000 of them will avoid a C-section, and 8000 will avoid complications thereof. They will be “allowed” to relieve their pain by walking, and to give birth in a more natural position if it suits them. And they will not risk being charged a huge amount of money for episiotomies and the like. Those might also be in their interest.
When a medical intervention prevents a lot of suffering and has a very small risk of death (say, flu or rotavirus vaccines), the prevailing wisdom around here is that there is Only One Right (or even sane) Choice, and that is to shell out for it, pronto. OTOH, if the medical intervention causes a lot of suffering while preventing a very small risk of death, likewise one is supposed to shell out. Clearly, there’s no universal principle involved. It seems obvious to me that the real right choice is situational and may depend on many factors – one’s tolerance for the various risks, how big each risk is, how costly the intervention is, and so forth.
It can be hard for individuals to balance those competing interests, and you may feel frustration or resentment toward those who make choices you consider unwise. But it does not help to pretend that the interests that might weigh against your own choice do not exist, as you do when you imply that death counts are the only possible interest to be considered.
apertyx-
I think that the assumption can be made, that if a preggo chooses a home birth with a non-ob, they have not had the extensive prenatal testing. From what I’ve heard from those who have made this choice, they buy a “package” for about $6000 or so. This includes all their prenatal visits with midwife (or whoever) and delivery. It has been my experience that most do not get u/s, so therefore they would not know. u/s harms babies, don’t you know that?
So if their higher infant mortality rate was due to ‘inside out babies’ then you would have to assume that those who choose home births have higher birth defect rates, which would not be the case.
SF Mom–I couldn’t agree more about putting their own personal “choice” above the actual outcome. And here’s my issue with the homebirth crowd: If it’s truly about a woman’s right to give birth on her own terms, than you have to allow the whole spectrum–she should also have the right to schedule a c-section–and for no better reason than because you just don’t want to go through labor or because you don’t want to miss the season finale of your favorite tv show. It’s about “childbirth CHOICES,” right? But if you go there (and I have), they quickly harp back that no woman who “did her research” would ever do that. Yet, they claim it’s the rest of us who are not open-minded. So it turns out to only be about choices for them. Same with vax–they all claim it’s about personal choice. Unless you’re a baby too young for certain vax or you’re immunocompromised–then I guess you don’t get to choose whether or not to expose yourself to disease.
As far as my screenname, yeah, true. But I actually lost a 7 month old niece to one of the non-PCV7 serotypes of bacterial meningitis. And I have a special needs child who falls into the “high risk groups” always mentioned. So I am working with my sister-in-law to get vax mandates passed and to try to get some serotypes included in Prevnar, etc.
Harriet:
“Thanks for presenting the statistics to confirm what my common sense had been telling me all along.”
My pleasure. Homebirth advocates are constantly insisting that “studies show” that homebirth is as safe as hospital birth. In fact the scientific evidence shows the opposite.
So home birth might not be as dangerous as it appears, as long as you aren’t using it as a passive form of infanticide? Yay.
“Triple the risk” isn’t necessarily bad, although journalists love that. As science-based folk, we should realize that what matters is the change in total risk.
It looks like 10,000 births would have 6 deaths under an MD, and 11 or 12 under a home birth.
So this is pushing the risk of death from .06% to .12%.
Getting a home birth seems less risky than getting an amniocentesis.
Although it won’t take much to convince me that the homebirth people are nuts, it doesn’t seem that much riskier. Spending a lot of resources to reduce a cause of death that starts at around 1 in a 1000 doesn’t seem too efficient.
Squillo:
“I was also interested in how post-dates babies fared”
The numbers are even more dramatic when you look at postdates (over 42 weeks) deaths for from all causes. MDs and most CNMs follow the ACOG guidelines and induce women at 42 weeks of pregnancy. Homebirth midwives do not.
The death rates were:
CNM 0.38/1000
MD 0.77/1000
DEM 2.43/1000
This highlights the fact that inadequate training is not the only reason for poor outcomes with homebirth midwives. Another reason is a philosophy that eschews all interventions, even the lifesaving ones.
Shouldn’t this title be more like, “The Tragic Death Toll of Poorly Trained Midwives”? If, as some of the other replies are saying, a well-trained midwife does just as well as a doctor, then it’s not the home birth that’s the issue, but the lack of training.
In any case, I think some of this could be solved if hospitals did allow more choices for women giving birth there. Many hospitals already are; but others still have the idea that the patient is supposed to be a passive recipient of medical treatment, not an active agent. Maybe in our grandparents’ day, that was the common thought about medicine; but people today want to know for themselves what’s up and make their own decisions. If the doctors still expect them to be submissive and stupid and don’t want to let them make their own choices, they might as well refer them to the nearest quack, because that’s exactly where those people are going to go. That’s half of why alternative “medicine” is so popular–it gives people a false feeling of power over their own circumstances.
apteryx:
“Making infant death rates the sole consideration is not required by “science”; it’s a philosophical or emotional choice, thus it’s not acceptable to dismiss anyone who disagrees as simply too stupid or deranged to understand “the statistics.”
Sure, if you are aware that homebirth has triple the rate of neonatal death and you feel that your “experience” is worth that risk, then you have every right to make that informed choice.
The biggest problem with homebirth advocacy is that its proponents are not honest about the risk. Most professional homebirth advocates claim that homebirth is as safe as hospital birth. That’s simply not true, and it denies women the right to make an informed choice.
No, I said that it showed the difference between the death rates for DOs and MDs wasn’t statistically significant. The numbers in the original post are definitely significant. (~4 sigma between DEM and CNM, though the square-root estimate is less good with a number as small as 27.)
apteryx said “Just because you get C-sectioned and have a healthy baby does not mean that you would have had an unhealthy or dead baby had you not had major surgery.”
You missed my point. What I was saying is that I don’t see the need to look back on an “imperfect” experience as being a failure even though everyone came out healthy. I have seen some of these natural-birth “advocates” aggressively telling women that they failed if they did not go all-natural. I saw an opinion piece where this woman said that every woman who had had a C-section is emotionally scarred, even if she hasn’t realized it yet.
In any case, it is all about risk. Theoretically speaking, maybe something is detected in your pregnancy that would give you a 10% chance of stillbirth if delivered vaginally. In this case, most women would opt for the C-section. That means that, in 9 out of 10 cases, the C-section was “unnecessary”, but that does not mean everyone is comfortable with that risk.
Are there any stats available on deaths and complications for mothers during homebirth? My sister-in-law recently had a baby, she was induced a couple weeks early due to preeclampsia. Are these CPMs monitoring blood pressure and other signs of serious complications in the mother? Not being nurses like CNMs do they even know what to look for? The infant mortality rate only tells part of the story here, what is the toll on the mothers?
apteryx:
“Just because you get C-sectioned and have a healthy baby does not mean that you would have had an unhealthy or dead baby had you not had major surgery.”
Obstetrics is preventive medicine. No one is claiming that every C-section is necessary in retrospect, just like no one would claim that every Pap smear is necessary in retrospect.
If we had a diagnostic test that would tell use definitely which babies were at risk of anoxic brain damage and which simply had abnormal heart rates, we could make sure that all C-sections are necessary even in retrospect. But we don’t yet have such a test, and we have to work with what we have.
Electronic fetal monitoring has a very low false negative rate and a very high false positive rate. That means that when the fetal heart rate tracing is normal, the baby is almost certainly doing well, but only some of the babies who have abnormal tracings are suffering from lack of oxygen. In other words, we are limited by are current technology.
Both the inferior training and the philosophy of homebirth midwives leads them to miss warning signs or to ignore them altogether … and babies die unnecessarily as a result.
apteryx:
“The flip side is that C-sections are shown to increase the risk of chronic respiratory problems”
No, that’s not true. C-sections, particularly those done before 38 weeks, raise the risk of TTN (transient tachypnea of the newborn), a brief, self-limited condition.
@ Scott – Thank you for the clarification!
Noadi:
“Are there any stats available on deaths and complications for mothers during homebirth?”
Maternal death is a rare event. Neonatal deaths are measure per 1000. Homebirth deaths are measured per 100,000. Not enough data has been collected yet to see if there is a difference.
There was a homebirth death in the UK last year. The mother bled to death.
Daniel said: Getting a home birth seems less risky than getting an amniocentesis.
Risky for who? Mom or baby?
A quick bing search led me to the Mayo clinic site, which claims that the amnio risk is somewhere between 1:300 and 1:500. That is, risk of miscarriage. I believe that the risk for mom for amnios is so low it’s not significant. Dr. Amy?
The same cannot be said for home birth. It puts both at increased risk.
Like SF mom pointed out, the pressure that moms put on other moms is unbelievable. I too, have seen moms consider themselves a failure for not doing an entire birth naturally. I have personally witnessed a pregnant mom walk around for days, leaking amniotic fluid, not going to the dr/hospital, because she wanted to go “naturally” and not be a failure.
Oh, and another one of the arguments I always hear is that in a hospital you have a 10+% chance of picking up an infection. I would be interested in learning if there is any legitimacy to that argument. Has anyone cross-referenced that data? Moms who went into hospitals perfectly fine, gave birth to perfectly healthy babies, then either baby or mom died as a result of infection picked up at hospital.
provaxmom:
“I believe that the risk for mom for amnios is so low it’s not significant. Dr. Amy?”
It is a very real risk that women must consider before opting for amniocentesis.
The problem with homebirth is not that women don’t have a right to choose something that might put their babies at risk. The problem is that most women are making an uninformed choice. I have yet to see a homebirth website or publication that is honest about the risk.
I’m a regular reader of the blog who is also planning a home-birth with a CNM. I was obviously concerned by the data you presented and went to the CDC data set to confirm the figures.
I ran a query on CNM not in hospital/in hospital/MD for all three years combined for neonatal mortality from 0-27 days and came out with the following figures (I didn’t filter by race [my wife isn't white], birth weight or age of mother):
CNM at Home: 38/29,219 1.30
CNM at Hospital: 1,233/895,557 1.38
CNM all locations: 1,272/924,866 1.38
MD in Hospital: 51,393/10,709,246 4.80
I fully take the point that MDs are seeing a disporportionate number of high risk patients and so the higher rate for MDs I expect and understand, but the figures I generated don’t make me worried that CNM@home is more risky than CNM @hospital – it seems right in line.
Can you help me understand why the added filters you included are more appropriate and, especially, why you excluded 2005?
I’m talking about the chance of the baby dying, because that’s what’s in the original posting. According to the chart at the top of this page, the neonatal death rate goes from around 1:2000 to around 2:2000 in a home birth.
While home births are riskier to the baby, the change in total risk is small, a lot smaller than your smallest 1:500 amnio risk.
If something puts my risk of face cancer from 1 in a billion to 10 in a billion, it’s not something I’m going to worry much about avoiding, even though it “increases my risk of face cancer tenfold!!”
If we are trying to persuade rather than understand, then by all means say “three times more dangerous to homebirth.” And moms being pressured into homebirths need this information.
(My kids were born in hospitals, and a friend would have died from blood loss after she gave birth to her twins had she not been in a hospital. But these are anecdotes, not data.)
Dr. Tuteur writes:
“apteryx:
““The flip side is that C-sections are shown to increase the risk of chronic respiratory problems”
“No, that’s not true. C-sections, particularly those done before 38 weeks, raise the risk of TTN (transient tachypnea of the newborn), a brief, self-limited condition.”
Sorry, the facts simply do not support this blanket dismissal. For example, a new Dutch study:
Roduit C et al. Asthma at 8 years of age in children born by caesarian section. Thorax 64:107-13.
In this study, the odds ratio (OR) of asthma was 1.79 in children born by C-section. OR was 2.91 in predisposed children (with two allergic parents), reduced to 1.36 in children with non-allergic parents. OR of allergic sensitization in these children was significantly higher with C-section (OR = 2.14) only in the children of non-allergic parents.
There are a LOT of studies that show the same. There is a meta-analysis by Thavagnanam et al. (2008 – you can look up the citation) using 23 studies that estimated a 20% increased risk of asthma. Other studies suggest higher rates of allergic rhinitis. One argument is that failure to be colonized with commensal bacteria in the vagina is responsible – if this is so, it’s something I don’t expect modern medicine to set out to remedy soon.
To be fair, there seem to be a few studies that do not show significantly increased risk. If you want to be a public expert, you can say there’s still some doubt, or you can assert that the benefits of American-style C-sectioning outweigh any asthma and allergy risk. But you do not have the right to cherry-pick the few studies you like and deny that the main body of research exists or could possibly be correct. Do that, and you are engaging in exactly the same behavior as homebirth advocates who do not want to admit that there is any increased infant death risk.
My thanks to Dr. Tuteur for an eye-opening entry. And thanks to everyone else for the eye-popping comments.
This is a contemporary subject about which I knew very little and now that I know a little I feel quite alarmed at some of the trends in the US. The only births I’ve been present at were in hospitals with “home-like” birthing centers and everyone seemed to approve of what all went on. In one instance it went as easily as it could and in another there was a complication which needed the immediate attention of a surgeon. In all cases mother and baby left the hospital in excellent health.
Are there any numbers as to the cause of death of those who died at a homebirth? Was the contributing factor simply because they were not in a hospital? Were the complications that arose due to truly unforseen circumstances? Is there a “right” and “wrong” way to approach homebirthing? I’m not an advocate of homebirthing (my daughter was born in a hospital with mommy feeling great due to an epidural. The next one will be born in a hospital, with the option of an epidural being highly considered again). But I feel like we’re “throwing the baby out with the bathwater”.
This reminds me a bit of the co-sleeping debates. Many (if not most) co-sleeping deaths are due to stupidity. There is a right and wrong way to co-sleep.
apteryx-
I wonder if you would be so kind as to cite the source(s) of:
-Yep, a couple of every hundred thousand women who give birth at home will die because they bleed to death;
-about 25,000 of them will avoid a C-section;
- and 8000 will avoid complications thereof.
I am not challenging these numbers, just interested in the details.
And finally, though I still fail to see compelling interests arguing against hospital deliveries (perhaps I am obtuse), I for one would never argue against the right of a competent adult to make any personal healthcare choices that s/he desires. I don’t pretend to speak for the skeptical community but most of the skeptics I know simply want the truth spoken. The beauty of science based medicine – of science based anything – is that it is fundamentally grounded in the search for truth.
If you or anyone in the home-birthing community has rigorous and compelling evidence that non-hospital based deliveries offer objectively superior outcomes, advocates of science-based medicine would investigate them carefully.
Michael Faraday once said, “The laws of nature, as we understand them, are the foundation of our knowledge in natural things. So much as we know of them has been developed by the successive energies of the highest intellects, exerted through many ages. After a most rigid and scrutinizing examination upon principle and trial, a definite expression has been given to them; they have become, as it were, our belief or trust. From day to day we still examine and test our expressions of them. We have no interest in their retention if erroneous. On the contrary, the greatest discovery a man could make would be to prove that one of these accepted laws was erroneous, and his greatest honour would be the discovery. “
Dr. Amy-
Thank you for distinguishing between levels of midwifery education and training. As a future CNM who believes strongly in evidence-based medicine and that midwives and OBs are natural partners in childbirth, it drives me crazy when people lump all midwives together. The difference between CNMs and DEM’s is huge and I’m not sure that the general public understands that. Nurse-midwifery =/= anti-science, anti-vax quackery.
It’s also nice to have confirmation that there are OB’s who recognize the education and training of CNM’s, and that the relationship between professional, certified nurse-midwifery and obstetrics need not always be adversarial.
In trying to find the causes of infant death in home births, I found this article:
http://www.sciencedaily.com/releases/2009/08/090831130043.htm
“The risk of infant death following planned home birth attended by a registered midwife does not differ from that of a planned hospital birth, found a study published in CMAJ (Canadian Medical Association Journal).”
…
“Women planning birth at home experienced reduced risk for all obstetric interventions measured, and similar or reduced risk for adverse maternal outcomes,” writes Dr. Patricia Janssen from the University of British Columbia and coauthors. Newborns born after planned home births were at similar or reduced risk of death, although the likelihood of admission to hospital was higher.
Factors in the home environment that decrease risks are not well-understood and could be due to sample bias. “We do not underestimate the degree of self-selection that takes place in a population of women choosing home birth. This self-selection may be an important component of risk management for home birth.” They write that the eligibility screening by registered midwives safely supports a policy of choice in birth setting.
“Our population rate of less than 1 perinatal death per 1000 births may serve as a benchmark to other jurisdictions as they evaluate their home birth programs,” the authors conclude.”
Some publicly available numbers on amniocentesis:
Tabor et al. 2009 Ultrasound Obstet Gynecol 34:19-24. Based on an 11-year population registry survey – miscarriage rate 1.4% after amniocentesis, 1.9% after CVS. Rate was more than twice as high at centers that performed under 500 than at centers performing over 1500.
Cahill et al. 2009 Am J Obstet Gynecol 200: 257.e1-6. In twin pregnancies, loss rate 1.8% (3.2% in women who had the procedure vs. 1.4% in women who did not).
Kozlowski et al. 2008 Ultraschall Med 29:165-172. Excess risk estimated at 0.5%.
Seeds 2004 Am J Obstet Gynecol 191:607-15. Review that estimates 0.6% rate with concurrent ultrasound guidance (higher without).
It looks like the risk of death of a normal fetus from amniocentesis is roughly an order of magnitude higher than the risk of death from homebirth. Are you a rotten mommy if you get amnio to further your “selfish” desire to know in advance whether you’re going to have a defective child? One of the posters above has managed to suggest that you are a rotten mommy if you don’t – even though one major rationale for getting amnio is so, to be blunt, you can get an abortion and not give birth to the disabled baby. How can it be eeevil to let such an infant die naturally rather than putting it in intensive care until the family is bankrupt, but just fine to have it D&Ced? (Note I am not antichoice; I just don’t see how this set of beliefs is anything but hypocritical.)
windriven – You can look up exact figures as well as I can, so I’d rather not go to the effort. Roughly speaking:
Maternal deaths at birth are in our country very rare, home or hospital; as someone noted above they are measured per hundred thousand, rather than per thousand. Even if the delivery goes badly, there’s usually time to get a woman to the hospital.
The C-section rate is now over (sometimes way over) 25% in much of the U.S. However, since some portion of those C-sections are done for real emergencies, and those women who give birth at home by definition did not have a real emergency, their C-section rate would have been slightly lower than average had they gone to the hospital. No way of telling exactly.
The complication rate for C-sections has been stated to be about 1 in 3. Of course, whenever you have major abdominal surgery this is a significant injury, causing pain and temporary disability. It is also true that some women who are not C-sectioned are injured e.g., by needless episiotomies that then tear.
The assumption that one should endure any pain, and go to any expense, to spare one’s child the slightest risk seems silly to me. Most of us live in cities, where people’s lives are shortened by air pollution, car crashes, and in some communities violence; should a loving parent uproot herself and move to an Amish community where those risks will be minimized or absent?
apertyx said: “It looks like the risk of death of a normal fetus from amniocentesis is roughly an order of magnitude higher than the risk of death from homebirth. Are you a rotten mommy if you get amnio to further your “selfish” desire to know in advance whether you’re going to have a defective child? One of the posters above has managed to suggest that you are a rotten mommy if you don’t – even though one major rationale for getting amnio is so, to be blunt, you can get an abortion and not give birth to the disabled baby. How can it be eeevil to let such an infant die naturally rather than putting it in intensive care until the family is bankrupt, but just fine to have it D&Ced? (Note I am not antichoice; I just don’t see how this set of beliefs is anything but hypocritical.)”
First, I hope you were not referencing any of my comments, as if you were, then you have misinterpreted what I wrote, or I did not write clearly.
You’re assuming that all moms who get less than desirable amnio results choose to terminate. That is not the case. You’re also assuming that moms only do this to determine disabilities. It’s also used to determine things like hemophilia and lung maturity. Some want to know, so that they can prepare. So that they can mourn the loss of their typical child and begin to prepare for a special needs child. They do it so they have the knowledge to have a neonatologist on hand during delivery.
I can only assume that you are not a parent at this point, nor do you know much about pregnancy. Are you aware of the fatal trisomies? Do you not think that women are entitled to this information?
As the mom of a special needs child, the term “defective” child is highly offensive. He is not defective, he is different. Your posts are beginning to get more and more ignorant as the day goes on.
apteryx, there are cases of cephalopelvic disproportion, where the baby’s head is too big to be born through the maternal pelvis. In the absence of medical c-section, either the mother, the baby, or both are going to not do well. Death due to cephalopelvic disproportion is not rare when c-sections are unavailable.
In the case of an association of c-sections with allergies, this is probably because both are caused by the same thing (low NO leading to preeclampsia, gestational diabetes, placental insufficiency, and some other things) rather than because the c-section caused the allergies.
There are researchers (namely me) who are working on commensal bacteria to prevent the development of allergies. I have no doubt that it will be successful; getting the research to the point where that can be demonstrated is not easy.
Nice strawman there.
Provaxmom -No, I did not assume any of the things you claimed – for example, please note that acknowledging SOME women in a particular circumstance get abortions is not the same as saying they ALL do – nor am I the ignoramus you and others here wish to imagine your opponents as being. Don’t take things so personally. I was responding largely to SF Mom, who said derogatory things about women who were unhappy with their experience of being sectioned, and to Traveler, who sneeringly equated not doing everything possible for an infant with serious birth defects with infanticide.
However, your comments above about “wanting to know” so they can “mourn and begin to prepare” sound suspiciously like a concern for the mother’s “experience.” If we are going to say in one context that a good mother cares nothing for costs to herself if it can spare her baby risk, should we also not say that a good mother would run the risk of an emotionally traumatic surprise at birth in order to save her fetus from a (higher) risk? Yes, I think if women want to put the fetus at risk in order to have advance knowledge, they have the right to do that – but then if all is well, they certainly have an equal right to home birth.
BTW, I don’t know what your child’s disability is, but there is a big difference between a Down’s kid and an anencephalic infant. Some birth defects are simply incompatible with life, or with any functional life. If accurately referring to those fetuses as defective is painful to you or any other reader, no offense was intended. I have the greatest sympathy for parents who have such a loss – but if they have, or might later have, children who survive, I see no reason why they should be compelled to blow those kids’ college fund on keeping the dying child alive on machines as long as possible.
Heh. To cite clinical trials, and be accused of a “strawman” for it by Mister NO himself, is an entertaining irony. Speaking of strawmen, friend, is there anyone in this discussion who has said that women or fetuses never die in childbirth? Or has anyone said that when there is cephalopelvic disproportion, such that a woman genuinely cannot give birth vaginally even in a natural position, she should not go get a C-section but should just die? I had not noticed that.
However, your comments above about “wanting to know” so they can “mourn and begin to prepare” sound suspiciously like a concern for the mother’s “experience.” If we are going to say in one context that a good mother cares nothing for costs to herself if it can spare her baby risk, should we also not say that a good mother would run the risk of an emotionally traumatic surprise at birth in order to save her fetus from a (higher) risk? Yes, I think if women want to put the fetus at risk in order to have advance knowledge, they have the right to do that – but then if all is well, they certainly have an equal right to home birth.
There are many reasons to have amniocentesis done, and I think that was the point being made. If there is a family history of certain conditions, it is helpful to know if arrangements need to be made for support. Not just for the mother’s “experience” (and the father’s, for that matter, as this information pertains more to the decades that will follow the birth) but to ensure the best outcome for the child.
It really does help to know ahead of time what you’re getting into, rather than being surprised in the delivery room, because then you can start any treatment right away, especially if it’s something potentially life-threatening like hemophilia.
My feeling about home birth is that it is something that should only be attempted if there are no alternatives. I think it is a mistake that it is touted as a way of giving mothers more control, and more choices, because the reality is that when you are at home, you have far fewer choices. C-sections, epidurals, episiotomies, transfusions, forceps, vacuum extractors…. These interventions seem very scary, but the truth is that they are not used casually, and if you are at home and in need of these interventions, you will not have the choice of them. Perhaps you will not need them, but how can you know ahead of time? Why deny yourself the opportunity of choosing such things if circumstances arise? That’s how I feel about it.
@apteryx
Sorry apteryx, I call BS. You quoted statistics without citing the source. It is incumbent on you to back up your statistics, not upon me to try to figure out which of thousands of potential sources you might have quoted or misquoted.
You bandy about statistics and references but without backing them up. If I were to say: “Studies show that 7 out of 10 mothers electing to give birth at home are redheads,” why on earth would you or anyone else believe me?
In the UK in 1900 when deliveries by doctors were rare the maternal death rate was about 40 per 1000 live births (J R Soc Med 2006;99:559-563). How do you suppose those appalling numbers gave way to today’s vanishingly low maternal death rate?
Look, you are free to choose a midwife for your childbirth, coffee enemas for your pancreatic cancer or colloidal silver to amp up your immune system. But don’t hold those options out as intelligent choices for others unless you have more than specious statistics and emotional fuzzies to back it up.
@ apteryx – I’m not sure if I’m missing your point or the point of those who have responded to you. But my takeaway was that having risk of death (miscarriage) from an amnio is more than the risk of death from a homebirth. I’m not sure why the choice to have the former done is considered acceptable to some in the medical community but the choice to have the latter done is considered unwise.
*bad example alert* The woman OB in the “Drs” show was very emotional when talking about the risks of homebirths. I’m left wondering if she is that emotional when a patient of hers consideres an amino tests. Perhaps I’m comparing apples to oranges but I feel like there is a disconnect…I’m willing to admit that the disconnect is all mine. =)
“I was responding largely to SF Mom, who said derogatory things about women who were unhappy with their experience of being sectioned.”
Actually, I was making derogatory comments mostly about those who go after women who did not have an all-natural birth, trying to make them feel like failures. (This does not stop at women who had C-sections, but those who had epidurals and other types of interventions.)
Windriven – the homebirth death rate now is considerably less than the hospital death rate of a few decades ago, so I would say that practices such as sanitation constantly change.
“Bandy about” has no specific meaning, but it is false to say I “quoted statistics” or that they were “specious.” I gave rough estimated numbers, acknowledged to be such, and cited no source. And that’s all I’m willing to do for a blog I’m only commenting on, not writing. If you wish to claim, for example, that C-sections are so much rarer than all mainstream media report as to make my numbers unacceptable even as a very general estimate, you are free to go and find a large study in which that is true.
Speaking of specious, yutz, when did I ever say anything in favor of coffee enemas? Look, I loathe the way many of you here apply CSICOP standards of argument to health issues, but let me give you some genuinely meant advice. Do you only intend to sit around here congratulating each other on your superiority to other humans and nurturing your seething contempt of them, or do you want to educate [per you] and convince those who are not already convinced? If the latter, you need to move beyond an argument style that says:
1. If you disagree with me, you are too ignorant and/or stupid to understand these things as I do. Therefore, I am right and you are wrong.
2. If that doesn’t make you knuckle under at once, you are deluded, emotionally disturbed, or evil.
3. If you come up with an argument that might raise questions about my total rightness, it’s a strawman (which only further proves your intellectual inferiority, since I understand logic and you do not).
Look at how many of the above comments include personal attacks, sneering asides, and even name-calling. This may be the way to bludgeon a social animal into submission, but it is not the way to convince a reasoning individual of your rightness.
Also, I jumped into this thread with the intention of asserting not that you are wrong, but that it might be possible for you to be right, and for someone else with different values to arrive at an opposite conclusion and also be right, or at least not totally wrong. If you cannot accept that, then you’re not just saying your knowledge is superior, but that your values are superior. That’s not science; it’s religion.
Neil:
“Can you help me understand why the added filters you included are more appropriate and, especially, why you excluded 2005?”
What we want to know if how the choice of attendant affects the neonatal mortality rate for low risk women at term. The filters I used are an attempt to remove as many risk factors as possible. I looked at only pregnancies beyond 37 weeks, babies without growth retardation, and women who were not either very young or very old. I also eliminated multiple pregnancies. I looked at only white women because virtually all women who have a homebirth are white.
The resulting statistics almost certainly overcount deaths in the MD group and undercount deaths in the homebirth midwife group. First, the MD group still contains women with risk factors like pre-existing medical conditions and complications of pregnancy. Second, since many homebirth midwives have transfer rates in excess of 10%, many of their patients ended up in the MD group. Any deaths that occurred among transferred patients are inappropriately added to the MD group and inappropriately subtracted from the homebirth group.
I didn’t exclude 2005; I mention it in the post. However, I already had the graphic from 2003-2004 and I didn’t have one for 2003-2005, so I went with the graphic I had already made.
I think Neil and MOI (first post) brought up interesting points. I have had my wife’s September CMJ on our coffetable for awhile now and read that article he quoted. The Johnson/Daviss study seems to agree with the CMJ article in stating:
“Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”
apteryx:
“Roduit C et al. Asthma at 8 years of age in children born by caesarian section. Thorax 64:107-13.”
The first rule of citing studies is you have to read them in order to know what they actually show. The abstract is not enough; that’s what the authors claim they show, but they are required to publish an entire paper in order for everyone else to evaluate whether the data supports the claim.
There are a number of remarkable observations in the study that the authors fail to include in the abstract. The group under study had a very low C-section rate (8.5%), but among the 247 children born by C-section, the parents had an extremely high rate of parents who suffered from allergies. In 49% of parents of children born by C-section, either one or both parents suffered from allergies. That raises the possibility that allergy in the parents is a risk of C-section (strange, I know, but other studies have suggested similar associations).
Second, though the authors don’t mention it in the abstract, among children to non-allergic parents, there was no association between mode of delivery and development of asthma.
So the most that one could say is that for the children of parents with allergies, mode of delivery might predispose to asthma, but it is equally likely that parents’ allergic status predisposes to needing a C-section.
The bottom line is that this is hardly proof that C-section causes asthma.
1 out of every 25 pregnant women who contracted H1N1 died of it
Do you really expect anyone to take you seriously when you make statements like the above? After all if that were true only 700 women would have contracted H1N1 this season
MOI:
“Are there any numbers as to the cause of death of those who died at a homebirth?”
The database does not provide enough information on that topic. However, if we look at the largest study of CPM attended homebirth (Johnson and Davis, Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416) we find 8 deaths in 63 emergency transfers. The reason for transfer and the resulting deaths are as follows:
Thick meconium 13 – 0 deaths
Sustained fetal distress 31 – 2 deaths
Baby’s condition 5 – 4 deaths
Placenta abruptio or placenta previa 5
Cord prolapse 3 – 1 death
Breech 1 – 1 death
Those are extremely grim statistics.
The strawman I was referring to is:
” The assumption that one should endure any pain, and go to any expense, to spare one’s child the slightest risk seems silly to me. Most of us live in cities, where people’s lives are shortened by air pollution, car crashes, and in some communities violence; should a loving parent uproot herself and move to an Amish community where those risks will be minimized or absent?”
Having a hospital birth hardly seems equivalent to “enduring any pain” or “moving to an Amish community”. (Just to be clear to any Amish reading this, I have nothing against the Amish (individually or collectively) or the lifestyle that they choose to live.)
Amy, that is interesting about the c-section association with parental allergies. That is what I would expect due to the association of immune system deviation and disorders associated with low NO, which include a number of risk factors for c-section.
@ apteryx
Yutz? Now who is resorting to ad hominem attacks? I engaged in no name calling.
It is a deft sleight of hand to plunk hard numbers down and then claim them to be nothing more than your own estimates. I certainly didn’t read them that way.
The issue here is whether or not home birth attended by a non-physician offers the best standard of care as measured by outcomes – not whether you or I happen to like it, think it is too expensive or anything else. It is simply not valid to try to reframe the debate along lines that are subjectively more meaningful to you.
A large part of nonurban America fits in that category.
Short of moving to a metropolitan area, perhaps just for the last trimester, there are an awful lot of women who have no choice but to give birth impractical distances from anywhere equipped to deal with obstetric emergencies [1]. For some women living in major metropolitan areas the choice isn’t always there, either: I know a fair number of “back seat babies” (usually second or third children) whose labors progressed too quickly to make it to the hospital.
I even know one whose first labor was less than two hours. Her obstetrician advised her to prepare for home delivery for the next one. Good advice, as it happens: total elapsed time from first regular contractions to crowning was less than 45 minutes.
I’ll readily concede that homebirth has liabilities, but it’s not always a matter of realistic choice either. At least reasonable prenatal care (including ultrasound to screen for nasties like a placenta in the wrong place) can seriously reduce the worst risks. Not, mind, that the sanctimommies are likely to avail themselves of them — or to do anything different even if the screen does show a nightmare like a placenta over the cervix.
[1] Bear in mind that a lot of rural “regional medical centers” have nobody more qualified than a PA on duty and there may not be a surgeon on call.
Amy Tuteur,
Welcome to Science-Based Medicine. Obviously, you picked a hot topic to start out with. Many posts in this blog have gotten lots of comments, but you may have set a new record for comments in the first day of a posting.
I commend you for your many carefully reasoned, explained and supported responses to commenters and look forward to your future postings.
Overshoot raised an interesting point about natal (and general medical) care in rural America, so I will offer my perspective on that. 100 years ago over half the people in the United States were directly involved in producing food to feed themselves and the other 50%. Some time ago, that number dropped below 10% (although it’s a bit uncertain now with so much of our food being imported). As a result, we have the luxury of concentrating most of our population into major and semi-major metropolitan areas.
Unfortunately, the corollary to that is the reduction of infrastructure, like hospitals and doctors, in the remaining small towns which continue to support the rural economy. I grew up in the geographically largest county in Oklahoma (and second in the U.S. at the time…Alaska was still a territory) and later moved to the geographically largest county in Kansas. My mother worked as an R.N. in the OB/GYN wards in the hospitals in both towns. In both cases, it was no more than an hour drive to one of those hospitals (or to the major city nearby) for most of the county. For the Kansas hospital, it still is (I’m not sure of the status of the Oklahoma hospital). However, it functions now mainly as an adjunct to the much larger hospitals in nearby Wichita.
Some people are not so lucky. My sister is a doctor who practices in Wichita. Every other week, she drives several hours to visit a city in western Kansas and see patients there (not ob/gyn). A similar situation applies here in New Mexico, where the overwhelming majority of the medical support system is concentrated in Albuquerque (where we have one major hospital devoted to caring for the medical needs of women, including natal care) and many people have to drive many hours for any kind of medical attention.
Those people have to make difficult choices about how to get the best care for themselves and their soon-to-be children. Those choices need to be informed by real and accurate information, not just advertising and emotion.
Thank you for providing some of that information.
Finally, I will offer some sciuridean (sp?) advice.
Don’t get too upset by kiwis.
And, remember the Stark family motto: “Winter is coming”.
As stated in a previous comment, bad things can and do go wrong with uncomplicated pregnancies. As a resident in pediatrics, I can’t count the number of times my presence in the delivery room, for what was supposed to be a routine birth, ended up preventing a bad outcome in a newborn. Just the other day, a women was rushed to my hospital due to a failed attempt at a home VBAC (vaginal birth after cesarian section). She ended up with an emergent c-section as a result of a non-reassuring fetal heart tracing. I’ve always wondered what these women would do if their home-delivered babies didn’t survive, or if some horrible complication arose that resulted in a bad outcome. Many of these bad outcomes would likely be entirely preventable in the appropriate facility with trained staff and equipment. The inconvenience and relative unpleasantness of a brief hospital stay is a small price to pay for securing the safety of a newborn.
Selfishness alone puts these babies at risk.
-Yep, a couple of every hundred thousand women who give birth at home will die because they bleed to death;
-about 25,000 of them will avoid a C-section;
This is true only because people who really need a C-section do not stay and give birth at home.
If my wife had been forced to have a home-birth, then either she or the baby would have died. It’s head was too big to get out, literally. If she had merely wanted to have a home birth , then she would have gone to hospital rather than risk death.
Wanting homebirth might reduce the number of C-sections, but it won’t come close to eliminating them.
The whole vaguely fascist thing of births needing to be “natural” really bugs me. Tooth decay is natural, yet these froot-loops don’t let their teeth all rot and fall out.
And why is childbirth pain a bonus? I sometimes have my tooth cavities filled without painkilling injections. Sure it hurts, but I don’t want to pay for “unnecessary” treatment. I’ve had “no painkiller for birth” mommies look at me as if I’m crazy for doing that, which strikes me as wildly contradictory.
“Are you a rotten mommy if you get amnio to further your “selfish” desire to know in advance whether you’re going to have a defective child?”
It is not a selfish desire to want to know if your baby will suffer so much in their life that they should not be born, nor to want to decide so as early in the pregnancy as possible.
If you’ll keep the child anyway, then yeah, it seems unnecessary; find out later in pregnancy when the chance of pregnancy is less, a month or so is plenty of time to plan things like making sure a neonatologist is on hand and start to prepare your home for a special-needs child. If you intend to abort for certain conditions, then it might be worth it earlier on, before the baby is too developed. I think that’s an individual decision– especially since there is no clear consensus on when life begins or when a fetus can process pain, while once a baby is born, they are clearly a living being and can clearly feel pain.
Of course, I do not object to allowing very ill or hopeless babies to die without forcing them onto ventilators and into surgeries, but in a hospital at least they can be given medications to make them more comfortable in their dying moments. And most doctors are hardly going to tell you to put an anencephalic baby on a ventilator.
Windriven:
Look, you are free to choose a midwife for your childbirth, coffee enemas for your pancreatic cancer or colloidal silver to amp up your immune system.
Please be more careful with your terminology. Certified nurse-midwives (or fully trained direct-entry midwives, as used in other countries), working with proper backup and support, have an excellent safety record. There’s no reason why a woman having a normal pregnancy should not choose one if it suits her.
As for the dogma that “home birth is safer than hospital birth”: There are no studies showing that home birth has a lower mortality rate. There are studies showing that it is about as safe. (Some home birth advocates will then add the lowered likelihood of certain interventions and the lowered likelihood of CS to equal “safer”.) The catch? They were not done in the US and reflect standards and conditions that do not exist here. There were recent studies out of the Netherlands and Canada that showed good outcomes. However, they involved strict criteria, good transfer arrangements, and midwives with hospital privileges. The transfer rate in the Netherlands study was 30%.
Mark: It’s not that simple. If I choose one of my local hospitals, my chance of getting a section is 50% higher than if I choose another. Your place of birth influences your likelihood of undergoing surgery, independent of whatever is wrong with you.
First of all, I am from the Netherlands, where home births are much more the norm than in many other countries. Also, the link between a preference for home births and alt med is much less strong than it seems to be in the USA.
Our midwives are very well trained and they always work closely together with MD’s. The Dutch health insurance system differs vastly from the USA: in the Netherlands both home births and hospital births are fully funded in the basic insurance package, provided the midwife is a fully qualified professional. A maternity nurse taking care of mother and baby for a miminum of 5 days after the birth is also standard.
In april 2009 a new study was published on the safety on home births in the Netherlands:
http://www.bjog.org/details/news/182410/New_figures_from_the_Netherlands_on_the_safety_of_home_births_.html
I ‘m just a linguist, not a scientist like many on this blog, so please bear with me should my questions be stupid, but could it be that both level of training as well as logistic factors (hospital always close by) have anything to do with the Dutch outcomes, compared to those in the USA?
overshoot:
“I’ll readily concede that homebirth has liabilities, but it’s not always a matter of realistic choice either.”
Homebirth with a homebirth midwife is a fringe choice. Less than 1/4% of women opt for planned homebirth with a direct entry midwife. The studies done on those who plan homebirth show that it is almost always chosen for ideological reasons, not because of distance issues or insurance issues.
The purported “safety” of homebirth rests almost entirely on the notion that in the event of an emergency, you can simply transfer to the hospital. So being far from a hospital would be a reason not choose homebirth, not a reason to favor it.
Mark P:
“The whole vaguely fascist thing of births needing to be “natural” really bugs me.”
Ah, yes, the naturalistic fallacy.
The irony is that “natural” childbirth bears no relationship to childbirth in nature. “Natural” childbirth activists hark back to the past that never existed. I have written about “Birth Fantasyland”:
In Birth Fantasyland, women were healthy, strong, in meaningful relationships, and had chosen to have a child. There are no unwanted children in Birth Fantasyland, no teenage mothers, no rape or sexual violence. Every pregnancy is desired.
In Birth Fantasyland, maternal mortality was rare and neonatal mortality only slightly more common. There were no eclamptic seizures, no ruptured ectopics, no retained placentae. The few problems that existed could be prevented or treated with “good nutrition”.
Since there were only positive experiences in Birth Fantasyland, the midwives and mothers approached birth as a time of joy and had no fear. They viewed labor as safe, enjoyable, and possibly even orgasmic. They planned to be and were empowered by the experience.
Not surprisingly, Birth Fantasyland bears a striking resemblance to childbirth among homebirth advocates. Every baby is a wanted baby. There are few complications (because all the women who have risk factors are directed elsewhere) and birth is viewed as empowering and as an “achievement”.
The reality, of course, was quite different. In nature, the average woman became pregnant shortly after menarche and gave birth within the year (generally between ages 16-18), gave birth to 8-10 children over her lifetime, faced a 1 in 13 lifetime risk of childbirth death and had a life expectancy of 35 years.
We’re supposed to believe that in nature teenagers who had 1 in 13 lifetime chance of dying in childbirth, who could expect to have 8-10 children, who had no control over their fertility approached birth without fear. We’re supposed to believe that societies with a 1% maternal mortality rate and a 7% neonatal mortality rate “used to birth fine.” We’re supposed to believe that these same teenagers who left no record of any kind indicating that they found birth empowering, painless or ecstatic, actually approached birth in the same way as 30 year old Western, white women in the 20th century. The entire premise is absolutely absurd.
beatis:
“could it be that both level of training as well as logistic factors (hospital always close by) have anything to do with the Dutch outcomes, compared to those in the USA?”
Almost certainly, and in addition to the differences in training and logistical factors, there are important differences in philosophy.
The mantra of American homebirth midwives is “trust birth.” The studies of homebirth in The Netherlands make it clear that Dutch midwives don’t follow that philosophy. In fact, the fundamental premise is exactly opposite: birth is inherently dangerous and great care must be taken to prevent, diagnose and manage complications. The Netherlands mandates rigorous education and training of midwives; the eligibility criteria for homebirth are strict; and a dedicated transport system is in place.
Bear in mind that I live in the Western USA. Quite a few of the towns I visit are hours away from the nearest hospital, which means that getting there once labor starts is likely to just substitute “backseat birth” for “home birth.” Having a backseat brother and knowing a fair number of “backseat babies” I can understand people making the choice to deliver at home. In an emergency, a helicopter is going to have an easier time finding a house in town (or a ranch with GPS coordinates) than a milepost along US Highway 70 — out of cellular range, no less.
As for the prospect of birth complications, you’re preaching to the choir. Tomorrow will be the 26th anniversary of my emergency C-section 34-week sons. Their mother worked NICU for most of their childhoods, so I’ve heard plenty of the stories. Given a choice, my grandchildren (if any; I can hope) will be born with an obstetric resident seconds away.
I have several friends who have opted for homebirth, and the one thing they all have in common is this idea that “Your body knows what to do” or “Your body is made to do this.” So this is really a religious position (”God made me”), with related magical thinking. They are anti-evolutionists. Even if they’re not religious per se, they are “spiritual” to the point where they think the “universe” takes care of things. Garbled nonsense like this leads many women to risk their lives and their babies lives in this homebirth stupidity.
Thanks for this. Of course the other statistic I’d like to see is poor outcomes. A good friend of sisters’ had a home delivery and the midwife missed the signs of fetal distress. Then once it was clear that the baby wasn’t doing well it took time for the EMT to arrive and get to the hospital. The child is permanently disabled for reason that would have been totally preventable in a hospital. The parents thought they were choosing a “safe” delivery.
Hospital deliveries are very different than they were 25-50 years ago. Yet many home delivery supporters still tell stories horror stories from the 1950 and 70’s.
midheleinmichigan:
“Of course the other statistic I’d like to see is poor outcomes.”
To my knowledge, no one has looked at this. MANA (the Midwives’ Alliance of North America) has a very detailed collection of data on homebirths, and it may include data about adverse outcomes besides death, but they will not release their data to the general public.
For a website titled science based medicine, I am surprised at the number of anecdotal stories pillorying women who choose homebirth as sanctimommies, selfish, fanatics, idiots, uninformed, or [substitute negative adjective here].
Since so many deem it to be appropriate to contribute their anecdotes, I will add mine in the hope of providing some balance. I am currently pregnant with my second child and hoping to have a homebirth. With my first, I had natural childbirth in a hospital setting with no complications. My pregnancy was as uncomplicated as a pregnancy can be, and I feel very fortunate. Thus far, this pregnancy shows all signs of being the same, and I hope it cotinues this way. I am under the care of a CNM, who provides prenatal services indistinguishable from those I received from my OB/GYN during my last pregnancy. I will have an ultrasound and genetic testing (using a doctor whose related miscarriage rates I have researched and am quite comfortable with). If at any time it appears during my pregnancy that there will be any danger to me or my child if I give birth at home, I will change my plans and give birth in one of the two hospitals that are within a five minute drive of my house. Similarly, if in the course of my labor any shadow of a complication arises, I will transfer to a hospital with my midwife.
My decision is based on several factors, none of them religious or “magical.” The first is my medical history with my first birth. The second is the number of unnecessary hospital protocols I had to submit to (for myself and my child) because I gave birth in a hospital setting. The third is simply because, after having reviewed the available data on homebirth with CNMs and my own midwife’s past performance, I have concluded that the risk of additional complications from homebirth is infintesimal and one I can live with, and that all things being roughly equal I would simply prefer to give birth at home in comfort and not leave my toddler for a couple days.
If you think I am selfish, so be it, but I certainly don’t think I can be viewed as misinformed. Frankly, I”m not sure I understand where the line should be drawn for most people who spend their time clucking over the risks of homebirth with a qualified health care professional.* Amniocentesis has been raised as an example. Why not simply have women give birth in operating rooms as well, so that C-sections can be performed that much faster if warranted? Why not put all women on a government mandated prenatal diet to ensure their fetuses thrive? Why not require all women with newborns to quarantine themselves within their homes for the several weeks following birth to protect their infants’ fragile immune systems? Why not require selective abortions for women carrying multiples to ensure the health of the surviving siblings? Most homebirth advocates (and I admit, there are some zealots out there) are simply concerned with preserving choices for women, so that they can make educated decisions regarding their medical care without the constricutions of a “protocol” that may make little or no sense given their particular situations. Just my two cents.
* I do agree, however, that direct entry midwives are problematic and don’t seem to have the required training for the task.
lizdexia:
“It’s also nice to have confirmation that there are OB’s who recognize the education and training of CNM’s, and that the relationship between professional, certified nurse-midwifery and obstetrics need not always be adversarial.”
My OB practice has four doctors, and I think FIVE CNMs now (four when I was pregnant, but I believe they’ve expanded again). It’s widely considered the best practice in town, and it serves primarily a well-educated professional clientele. For routine care (yearly pelvics, etc.), you can choose a doctor or CNM; during pregnancy, you generally rotate through two doctors and two CNMs so that you’re familiar with several people and someone you know will be on call in case of emergency. We have the choice of laboring the whole time with the CNM of your choice, laboring with the hospital nurses and having the OB come at the end, or laboring with the CNM and having the OB come at the end. In case of emergency C-section, the CNM usually stays to hold the mother’s hand during the process.
The standard of care, both medical and emotional, is extremely high, and they’re able to cater to a variety of types of “birth plans” while ensuring that emergency OB care is always available and that transition from CNM to OB is seamless if it becomes necessary.
(These are all hospital births; in my state it is illegal for a licensed professional to attend a homebirth. One of the hospitals has a “birth center.”)
I don’t live in an area known for being on the cutting edge of medicine (or the cutting edge of woo, either) — pretty traditional in medical practice. But almost every Ob/Gyn practice here has at least one CNM on staff, and all the hospitals allow CNM deliveries, doulas, natural births, rooming in, immediate breastfeeding; and cater to most “birth plans” as long as the delivery remains safe.
@ Alexis T
I agree that it was inappropriate to conflate midwifery with coffee enemas and I apologize for it. But I stand unconvinced that home birthing, even with a CNM, is the best choice for even low risk mothers. In my limited experience physicians and hospitals have made tremendous efforts to make the birthing experience more comfortable and less ‘clinical’. The last two of my children were birthed in a room that was very much like a suburban bedroom – except that an operating room and NICC unit were right down the hall.
How are these stats affected by either patient being rushed to the hospital or a clinic for emergency response and being removed from the “home birth” count, or being rushed to the hosptical or clinic and being saved from death and thus lowering the death rate count?
The reason I ask is that I am very surprised that the number is so low.
Amy Tuteur says:
“The first rule of citing studies is you have to read them in order to know what they actually show. … That raises the possibility that allergy in the parents is a risk of C-section (strange, I know, but other studies have suggested similar associations)….Second, though the authors don’t mention it in the abstract, among children to non-allergic parents, there was no association between mode of delivery and development of asthma. The first rule of citing studies is you have to read them in order to know what they actually show. The abstract is not enough; that’s what the authors claim they show, but they are required to publish an entire paper in order for everyone else to evaluate whether the data supports the claim. So the most that one could say is that for the children of parents with allergies, mode of delivery might predispose to asthma, but it is equally likely that parents’ allergic status predisposes to needing a C-section.”
Good job of sneering, but a very poor job of interpreting scientific papers. Roduit et al. DID indicate in the abstract that if neither parent was allergic, the increase in asthma was not statistically significant. However, the significant increase in asthma in C-sectioned children with one or two allergic parents was compared to vaginally birthed children with the same number of allergic parents. Thus, trying to pin the excess asthma on those families’ genetic flaws simply does not work. You also ignore the fact that the risk of allergic sensitization was statistically significant only in children with no allergic parents (being, in that case, more than double), probably because the children of allergic parents had a higher baseline rate. Moreover, this is hardly the same study that shows similar effects; there are dozens. When you deny facts that do not suit your preferences, you raise doubts about your credibility on a broad scale.
Windriver:
“Yutz? Now who is resorting to ad hominem attacks? I engaged in no name calling.”
Yeah, I regret that. When I’m on the receiving end of a lot of ad homs at once, sometimes I let my buttons get pushed. You really got my goat with the following:
“Look, you are free to choose a midwife for your childbirth, coffee enemas for your pancreatic cancer or colloidal silver to amp up your immune system.”
Contrary to your repeated claim above, I have argued – so far irrefuted, and I think correctly – that the question of whether homebirth is ever a legitimate choice depends upon value judgements, rather than simply statistical analysis of one set of data, and thus cannot be answered by science alone. By contrast, the question of whether coffee enemas treat pancreatic cancer is one of fact, which science can (if never quite 100%) answer by the accumulation of data – and there is now enough information that anyone who is still relying on coffee enemas either is completely ignorant of recent scholarship, or isn’t interpreting it rationally.
Now, I ask myself, why do you assume – or pretend for the entertainment of your orthodox buddies to assume – that if someone thinks it may be legitimate to disagree with you on a question of values, they are not just wicked, but also stupid, ignorant, or delusional? The flip side is that if people differ with you on a question of fact – right or wrong – they may be accused of being not just ignoramuses but emotionally disturbed and possessed of ulterior motives. That is not how human character traits are distributed in real life, but it falls nicely into an Us vs. Them worldview where the expression of a single heresy puts one into the category of Bad People, who must be inferior to you not just in one way but in every way. The modern Western term for this is called “projection,” and you guys are great at it.
Here’s a hint: many of the people who are getting called preggos, nuts, woo-crazies, fascist, “these people,” and so forth actually already agree with you on most things, do most of what you would order them to do and don’t do most of what you would order them not to. If they show up here and see that their one doubt or dissent has caused you spokespeople for conventional medicine to move them into the subhuman category, it’s NOT going to make them embrace your philosophy wholesale. Don’t believe me if you want, but humans as a group are not that easily cowed.
Sorry about the doubled partial quote. The interface isn’t working very well this morning.
October27,
You are depending on the probability that your home delivery will be uncomplicated or that a 5 minute trip to the hospital will be a negligible delay. Probably all will go well, but it would scare me because of OB complications I have seen that you probably have not. Ignorance is bliss, and not having experienced OB emergencies may bias your judgment.
(1) I have seen the most normal delivery turn to impending disaster in a heartbeat.
(2) 5 minutes transport time does not include the time necessary for the hospital staff to evaluate the situation and get you to the OR. That process is much faster with a patient who has been in labor in the hospital.
Harriet Hall,
I appreciate your response. I have discussed emergency situations with my midwife and feel quite confident with my plan of action should any develop. My midwife has explained to me in detail how she handles hospital transfers, including the timing of a homebirth transfer v. the timing of a woman entering surgery from a hospital, and I am comfortable with proceeding with homebirth.
We are about to deliver (within a few weeks). Last week, we lived 35 minutes from the hospital. Then, we went there yesterday for an appointment and discovered that we are now 45 minutes away because a major road has been cut from three to two lanes for refurbishing of drainage and sewer systems.
I’m just sayin’
MOI:
There is a right way to co-sleep?
ADR150- Sorry about the late response but I just got to this posting. I am a DO student and would like to respond to your question. Just like MD students, we have some serious challenges with the encroachment of CAM in our studies. And just like our MD counterparts, we have choices to make about whether or not to accept that as truth. Beyond that the educational tracks are very similar and we end up with the same amount and depth of training as an MD physician. Let me know if you have any other questions about this… Thanks for the interest.
october27 on 06 Nov 2009 at 12:19 pm “I appreciate your response. I have discussed emergency situations with my midwife and feel quite confident with my plan of action should any develop.” [italics added]
Do you “appreciate” the meaning of the word emergency? I think you and your midwife do not. I wish you the best. My best wishes for you have no effect on the high likelihood that you will do well, or the small likelihood that you will wish you had obstetric care in a hospital if you suffer the worst. Are you prepared to shrug it off “We took a chance and lost” if your procedure ends in disaster?
Yes, there are bad results in hospitals; but the response to emergencies are better than yours.
“You are depending on the probability that your home delivery will be uncomplicated or that a 5 minute trip to the hospital will be a negligible delay.”
I strongly agree with Harriet.
Basically, choosing a homebirth is a gamble with a baby’s life. Most of the time, everything is fine. However, if there is a life threatening emergency that requires an immediate C-section or an expert neonatal resuscitation with intubation, the baby will die at home. It doesn’t matter where you live; by the time you transfer, it will be too late.
@ Skepchick – Yes, yes there is a right way to co-sleep! However, since I do not (kids are noisy and they move a lot, it’s bad enough I have to share a bed with my husband and cat), I cannot give you off the top of my head the proper guidelines. I do know that some co-sleepers do not use pillows or blankets when their infants are small and others have their mattress on the floor. Obviously the parents abstain from alcohol and any other drug that could affect their ability to be roused from sleep if there is a problem. I don’t believe it is recommended for “heavy” sleepers or those who thrash about when sleeping. Not everybody “can” or “should” co-sleep.
It appears that the infant mortality rate for home birth in Canada is the same as hospital births and it appears that the difference between Canada and the US is the education and experience of the mid-wives, the guidelines involved in chosing whether or not one is a low risk for complications and having quick access to a hospital. Has anyone looked at those stats (from Canada) to assess whether a proper comparison was made (ie, low-risk, full-term pregnancies) between the home birth and hospital births?
I for one would never chose a homebirth. I feel very comfortable in a hospital. I am also chosing one that is a little farther away from my doctor because it’s at a children’s hospital and is the best in the area (if not the state, right behind Madison). If there is a problem, I want the best available to him (or her) and I want it to be readily available.
Dr. Amy, you have been gracious and prompt in your responses. I hope I can use this information to better inform the many women I encounter on-line regarding this issue. I have already used your articles/blogs as resources to educate other women on the various subjects of pregancy and birth (this article, water birth and infant mortality in the US). LOL, it looks like I’m sucking up but I’m simply grateful.
Anecdote:
Seven years ago I was called stat to the OR of my hospital (community hosp.) for a delivery. I was in attendance when the ambulance arrived. It was a transport for attempted home delivery by a lay midwife. She “thought the baby might be breech but wasn’t sure” and assured the mother she could perform breech deliveries. At home.
I observed a fetal head entrapment and immediately performed a standard OB maneuver, delivering the baby. Apgars 0,0. Resuscitation was unsuccessful.
storkdok – No need to bum everyone out! Ugh, what are the stats on breech babies in regards to vaginal deliveries? I suppose it depends on the type of breech.
Oh, OT but I need you storkdok on CM!!
apteryx makes an interesting observation. The choice to home birth appears to involve an application of values and not just data. (Dr. Tuteur also rightly points out that the best data possible should be used in making that choice.)
Here is another such example. Suppose a physician advises an (adult) cancer patient that treatment has a high probability of extending his life for 1 year. The patient then makes the choice not to accept treatment based on his values (for example, because his quality of life will not be acceptable).
It appears to me that the critical difference here is that we are talking about two patients (mother and infant) and the risk of death at home is far greater for the infant than for the mother. Further, the infant is not the one making the choice. Oh, there it is. The “choice” word. I knew something about the vehemence of this debate seemed familiar.
[...] breaks right out of the gate with two articles on home birthing and c-sections. For those familiar with Dr. Tuteur, the information will not be new, but [...]
I think that some skepticism is warranted about making a statement of causality (”Homebirth with a homebirth midwife dramatically increases the risk of neonatal death”) based on loosely matched observational data involving a self-selected subgroup.
A history lesson: For several decades, mainstream MDs were strongly recommending the use of menopausal hormone replacement as a preventative measure against cardiovascular disease, based on observational studies that showed such benefits. Indeed, the evidence was believed to be so strong, that many believed an RCT would be unethical by denying the actual drugs to the placebo group. But now we know the rest of the story – not only was the earlier conventional wisdom not confirmed, it was strongly refuted. The earlier observational data was clearly contaminated by confounders, which were not adequately controlled or adjusted for. And the current consensus is to use HRT only in as low a dose for as short a time as needed for relief of menopausal symptoms, and explicitly NOT for prevention of cardiovascular disease.
Will there ever be a valid RCT comparing home birth to hospital birth? Highly doubtful that enough women could be recruited who would be willing to be randomized to gather data of sufficient power. But the unavailability of a stronger data set is no reason to exaggerate the conclusions that can be drawn from self-selected observational data.
And gregladen asks an interesting question here:
“How are these stats affected by either patient being rushed to the hospital or a clinic for emergency response and being removed from the “home birth” count, or being rushed to the hosptical or clinic and being saved from death and thus lowering the death rate count?”
The answer is, we don’t know.
We do know that the total number of attempted home births is perhaps 10 – 30% higher than the number actually registered on birth certificates (or maybe more!). How many of these hospital transfers are good outcomes versus bad outcomes? We don’t know, that data can’t be derived from the CDC data. Dr. Tuteur believes the home birth death rate would be higher if these transfers were accurately accounted. That’s possible. But it’s also plausible that home-to-hospital transfers are more common among the clients of the most prudent risk-averse homebirth midwives. So we can’t really say with certainty which way the numbers would move.
And, it must be noted, the exact same data uncertainty exists for CNM hospital deliveries. A significant percentage of labors which begin under the care of CNMs are also transferred to MDs for eventual delivery. Which attendant is ultimately recorded on the birth certificate can be a matter of hospital policy and local custom. (How do we know that? – because the CDC data includes some cesarean deliveries which are recorded as CNM-attended births). Again, we have no way of knowing for sure whether including these CNM-to-MD transfers would make the CNM numbers look better or worse.
So both cohorts as reported by birth certificates are known to be incomplete. This should make us especially wary of drawing conclusions from cohort death rates that have rather small absolute differences.
Even though “triple the risk” sounds more definitive.
These statistics may not be definitive, but they are consistent with everything we know about childbirth and consistent with common sense. Emergencies happen unexpectedly even in the most apparently normal labors, and even a short delay can be life-threatening. Even a home birth with an obstetrician in attendance cannot possibly be as responsive to emergencies as a hospital birth adjacent to an OR – unless you set up an operating suite in the home with appropriate personnel standing by.
The HRT story is frequently misrepresented. There was early evidence that made us think that HRT reduced cardiac risk. BUT I don’t think any doctor was prescribing HRT solely for cardiac risk; it was an additional factor that helped tip the balance towards prescription in women with peri-menopausal symptoms who also wanted to reduce their risk of osteoporosis. We recognized all along that there were risks associated with HRT. The studies that got all the attention did not show any increase in overall mortality with HRT, and it showed a protective effect for some coniditons like colon cancer. A new study shows a mortality benefit and improved quality of life for younger postmenopausal women. http://www.sciencedaily.com/releases/2009/10/091028162632.htm
IndianaFran:
“based on loosely matched observational data involving a self-selected subgroup.”
I did not mean to imply that this is the only data on the subject. It is consistent with the results of virtually every study of American homebirth. Although such studies are few, poorly done, and misrepresent their data, all show that homebirth increases the risk of neonatal death and (possibly coincidentally) all show that homebirth with a homebirth midwife has approximately triple the neonatal death rate of hospital birth for low risk women.
The most widely cited study on American homebirth (Johnson and Daviss, Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416), which claims to show that homebirth is as safe as hospital birth, actually shows that homebirth has triple the neonatal mortality rate of hospital birth for comparable risk women. The story of that paper is worthy of its own separate post.
Dr. Amy,
You keep mentioning that homebirth has triple the neonatal mortality rate of hospital birth for comparable risk women. You are slightly misrepresenting your statistics. As you noted up thread,
“I did not include the information on the chart, but homebirth with a CNM has double the neonatal mortality rate of hospital birth with a CNM.”
Not all hombirths are with lay midwives or DEMs. If homebirth with a CNM has double the neonatal mortality rate of hospital birth with a CNM (and I see no reason to doubt your calculations, although I haven’t doublechecked them), that would put the rate of neonatal death at 0.74 per 1,000 live births, significantly less than the rate for DEMs and only slightly higher than the rate for MDs (of course, I recognize that MDs will have a higher risk group of patients).
october27:
“You keep mentioning that homebirth has triple the neonatal mortality rate of hospital birth for comparable risk women.”
Using a DEM or a lay midwife is the typical scenario for American homebirth. So when American women choose homebirth, that is usually what they are choosing.
CNMs have better outcomes for homebirth, but that is probably more a reflection of philosophy than skills. CNMs are very skilled, but they can’t treat life threatening emergencies at home, either. The difference in neonatal mortality rates reflects greater rigor in eligibility requirements for homebirth.
At first glance, it seems that homebirth is simply about the place of birth. In reality, though, it reflects a philosophical orientation toward birth. The fundamental issue is whether birth is viewed as inherently safe or inherently dangerous.
American homebirth advocates insist that birth is inherently safe, complications are rare, and generally announce themselves with plenty of time to address them. Everyone else, and that includes midwives in countries besides the US, knows that birth is inherently dangerous, complications are common, and an immediately life threatening situation can arise from one moment to the next. Therefore, the utmost care is taken in excluding anyone who has any risk factor, no matter how apparently minor.
The end result is that fewer complications occur at homebirth with CNMs in the US or with midwives in The Netherlands, Canada, etc. However, when those fewer life threatening complications occur, the baby still dies.
So while CNMs may appear to be safer homebirth practitioners, the reality appears to be that they are simply less likely to gamble. Unfortunately, though, gambling is always a part of homebirth. You gamble that a life threatening emergency will not occur. And if you bet wrong, the baby dies, regardless of attendant.
Harriet:
Common sense is not the same as science. Obviously, there are risks associated with home birth, and responsiveness to unanticipated emergencies is the greatest one. Yes, there are cases of death associated with home birth that would have been averted by being in the hospital. But you are not looking at the full picture if your common sense tells you that there are zero offsetting risks inherent to hospital based birth. In the real world, some babies are actually harmed by hospital procedures, like the common overuse and abuse of induction and augmentation agents. Some neonatal deaths occur in hospitals that would not have occurred in a less aggressively “managed” environment. To what extent do those risks offset each other? That is still an unanswered question. It is certainly a common belief that hospital birth is the overall safer option, but that has never been “proven” to the standards of “science based medicine”.
If the issue of emergency responsiveness was an overwhelmingly large issue, then there wouldn’t be studies from Canada and the Netherlands that show that homebirth can be practiced safely.
IndianaFran:
“In the real world, some babies are actually harmed by hospital procedures, like the common overuse and abuse of induction and augmentation agents.”
It is axiomatic among homebirth advocates that the hospital increases the risk of neonatal death and those deaths offset the risks posed by homebirth. There’s a big problem with that analysis: there’s no evidence that hospital procedures increase the risk of neonatal death.
Moreover, as in the case of the data I presented, and in studies like those done by Johnson and Daviss, any purported deaths due to interventions are already included in the hospital group. So if you think the neonatal death rate in the hospital group could be lower (and you’d need to present evidence for it) that would make the homebirth group look even worse by comparison.
American homebirth advocacy is a mixture of mistruths, half truths and outright lies. American homebirth advocates insist that homebirth is as safe or safer than hospital birth when the reality is tragically different.
Dr. Tuteur:
You have made it very clear in many different venues that you disagree with the conclusions of the Johnson and Daviss study.
My observation is this:
The Johnson and Daviss study was submitted to peer review, published in a scientific journal with an excellent reputation for scholarship, and the original study has never been retracted.
Your personal re-analysis of the study has been widely disseminated on the internet, but has never been peer-reviewed or accepted for publication in an appropriate scholarly environment.
Your analysis and presentation of statistics extracted from the CDC database also does not meet the standards for publication in a scientific journal.
If it is true that “all the scientific evidence” leads to a clear and definitive answer about relative risk, then that evidence should be submitted through the accepted channels of scientific inquiry.
Until then, what you have is a hypothesis.
“American homebirth advocates insist that homebirth is as safe or safer than hospital birth when the reality is tragically different.”
A more valid restatement would be
American homebirth advocates insist that homebirth is as safe or safer than hospital birth when the reality is that we do not have enough evidence to answer the question either way, in a definitive scientific manner.
IndianaFran:
“Your personal re-analysis of the study has been widely disseminated on the internet, but has never been peer-reviewed or accepted for publication in an appropriate scholarly environment”
On their own website, Johnson and Daviss have acknowledged the validity of my analysis (without mentioning my name) and have actually performed another faulty calculation attempting to address the criticism.
I plan to devote a separate post to the issue, but for those unfamiliar with it, here’s a brief summary. Johnson and Daviss looked at the intervention rate and neonatal death rate for all homebirths attended by CPMs in 2000. The compared intervention rates for homebirth to low risk hospital births in 2000. Then they compared the neonatal death rate to … a bunch of out of date hospital studies extending back to 1969.
A comparison of the CPM death rate in 2000 to the death rate for low risk hospital birth in 2000 shows that planned homebirth with a CPM had a neonatal death rate approximately triple that of hospital birth for comparable risk women.
IndianaFran said,
“But you are not looking at the full picture if your common sense tells you that there are zero offsetting risks inherent to hospital based birth.”
You are putting words in my mouth. I never suggested any such thing.
“Some neonatal deaths occur in hospitals that would not have occurred in a less aggressively “managed” environment.” Do you have data to support that claim?
IndianaFran:
“A more valid restatement would be
American homebirth advocates insist that homebirth is as safe or safer than hospital birth when the reality is that we do not have enough evidence to answer the question either way, in a definitive scientific manner.”
That’s not true, either, but the key point is that homebirth advocacy websites and publications don’t temper their claims. They insist that “studies show” that homebirth is as safe as hospital birth.
The new mantra among “natural” childbirth and homebirth advocates is that obstetricians ignore the scientific evidence on this issue and many others. Just like they’re wrong about that claim in regard to homebirth, they’re wrong about that claim in regard to almost every obstetric intervention and practice.
apteryx, I appreciate your excellent comments. I have taken two quotes that sum up major flaws in Amy Tuteur’s pundit pieces on homebirth here and on her other blogs.
“… the question of whether homebirth is ever a legitimate choice depends upon value judgements, rather than simply statistical analysis of one set of data, and thus cannot be answered by science alone.” SO TRUE.
“You have a habit – I’ve gone and read some of your blog – of assuming that those who disagree with you can only be doing so because they are mentally or emotionally inferior in some way.” SO TRUE.
I have said before on Amy’s blog that even if the questionable statistics did show a 3x higher mortality rate, there would still be families choosing homebirth. What is the solution? Ban homebirth and jail anyone who does it? How is it that people can support abortion, but not a woman’s right to birth where she chooses?
Instead of spending time criticizing homebirthers as being intellectually or emotionally defective because they don’t make birth decisions based on a small set of statistics, why don’t people spend time trying to understand the complexities of birth choices and come up with ways to make birth better and safer for all women and babies?
————————————————————————–
lkw said, “It appears to me that the critical difference here is that we are talking about two patients (mother and infant) and the risk of death at home is far greater for the infant than for the mother. Further, the infant is not the one making the choice. Oh, there it is. The “choice” word. I knew something about the vehemence of this debate seemed familiar.”
Well, you can use the term “patients”, but I think “individuals” is more appropriate. What you discuss is exactly the core of the issue. In society, the baby’s rights seem to have more value than the mother’s rights, after x number of gestational weeks that is. Trauma to the mother is not factored in as she is simply seen as the vessel that brings forth the baby. No matter if there is damage to the vessel, the goal is a live baby at the end. A c-section, even if done as defensive medicine rather than in a clearly indicated emergency situation, is seen as acceptable because the outcome was a live baby. There is little consideration for the fact that a c-section affects the mother’s reproductive future. In the US, vaginal births after cesarian (VBAC) is being denied to women all over the country, which means all future births will be done by repeat cesarian. Reading more on the complications of c-sections and repeat c-sections should make it clear to anyone why some women want to do their best to avoid an unnecessary c-section. The c-section rate is too high, despite what Amy Tuteur says (and her own c-section rate never bore out).
There are many factors influencing a woman’s birth in hospital. There are staffing issues, resource issues, hospital protocols based on legal protection, not to mention the schedule of the ob-gyn and his/her preferred practices. That is a lot of interests influencing a birth that don’t necessarily have anything to do with the parents’ wishes or the health and best interests of mother or baby… Some women have had terrible birth experiences in hospital due to these factors, and therefore turn to homebirth to be left in peace to birth unhindered. Sure, some women choose a homebirth because of their own personal or spiritual beliefs, but there is a large number of women who homebirth because of dissatisfaction with previous hospital birth experiences. Something that needs consideration.
Just like they’re wrong about that claim in regard to homebirth, they’re wrong about that claim in regard to almost every obstetric intervention and practice.
+++++++++++++++
I will look forward to Dr Tuteur leading some science-based discussions of those obstetric interventions and practices, e.g. routine use of cEFM, valsalva pushing, drinking and eating in labour, routine IV access, mobility in labour, early cord-clamping.
I really don’t think this is fair or appropriate for this website:
“American homebirth advocacy is a mixture of mistruths, half truths and outright lies. American homebirth advocates insist that homebirth is as safe or safer than hospital birth when the reality is tragically different.”
Some homebirth “advocates” may hide or misrepresent data, but you are painting with a very broad brush here. I understand you are passionate about this issue, but when you resort to these types of statements you start sounding like the “all obstetricians are evil / out to cut you open / don’t care about their patients” crowd. There are plenty of midwives who are honest about the risks and benefits of homebirth and want their patients to be fully informed about their options. Obviously on some level they “advocate” homebirth or they wouldn’t attend homebirths. They work closely with other medical professionals, including obstetricians, and are valued members of their medical communities. Suggesting that all homebirth midwives are little better than snake oil salesmen is frankly pretty appalling.
Birth is not a competitve sport.
Birth is not a competitive sport.
Birth is not a competitive sport.
A woman doesn’t get extra special points for having a vaginal delivery without medications or other interventions or gets penalized for having an epidural or a c-section or whatever. Each birth is unique, has its own risks that are known or unknown, and and it’s not a competitive sport.
And did I mention that birth is not a competitive sport? Seriously. A c-section is not a failure. A vaginal birth is not a win. A win is a healthy mom and baby however that comes about. Labor and delivery can throw some serious curve balls. It also can go smoothly without any problems. Our ability to predict which is going to happen is not great. It’s not terrible, but it’s far from perfect.
And really, birth is a not a competitive sport. Anyone who tries to make it into that needs a reality check.
“Some homebirth “advocates” may hide or misrepresent data, but you are painting with a very broad brush here.”
As I intended.
Homebirth in the US is not really about place of birth. It is a philosophy with specific empirical claims, almost all of which are false. In is akin to “natural” childbirth, a philosophy that bears little or no relationship to childbirth in nature.
I have written extensively about the empirical claims of both “natural” childbirth and homebirth advocates and I plan to write about them here in the future.
As others have noted, this post seems far less even-handed than most of the others on SBM.
Where does the claim that most home births happen with DEMs and not CNMs come from? I’m not saying it’s wrong, just unsupported by the presented data.
Also, the “two or three times higher” thing is taking a page from the other team’s playbook: it makes the difference sound larger than it is, because double a small number is still a small number.
I am a physician, and I don’t think it’s too controversial to say that medicine in America sometimes uses procedures in a way that has limited benefit compared to the risk/cost (i.e. bypass). The idea that in a specialty as loaded with liability as OB/GYN might have some procedures that are overused (to demonstrate that all possible measures were taken at the slightest indication of risk) seems reasonable.
Also, the author seems to have an agenda about lumping many different kinds of “natural childbirth advocates” in with the numbers presented. These particular numbers speak to location and attendant of birth, and other extrapolations seems to be a bit of a reach.
With all of that in mind, I’m really glad to see these issues getting some activity on this blog. The “natural childbirth” movement plays fast and loose with their claims, and need to be held to account. Hopefully that can be done in a constructive way that acknowledges there are improvements to be made in the way babies are delivered in the US.
I see an emphasis on “American” homebirth. What about the cited Canadian study? Apparently it showed no difference in death rate. Are they doing it right?
Oh and I have a list of procedures that I would like to see covered in this blog as well: episiotomies, pushing at 10 cm and no sooner, being told when to push…
I have some concerns about both the recent Canadian and Dutch studies. Both are actually bad news for American homebirth midwives because they make the American homebirth statistics look dismal.
As regards various obstetrics interventions, I have written extensively about them in the past and will recap my observations here in the future.
The bottom line about homebirth remains the same. When nothing bad happens, everything turns out fine. When there is a life threatening emergency requiring immediate C-section or expert resuscitation with intubation, the baby almost always dies.
“… it makes the difference sound larger than it is, because double a small number is still a small number.”
Where you are dealing with preventable mortality in neonates, small numbers matter.
The UK NHS was criticized in the US health care debate, but at ~20,000 GBP per quality adjusted leap year, avoiding a single preventable neonatal death of this kind is worth spending of the order of 1 million GBP.
A million might not sound much spread over the 1200 births needed to prevent a single death in the US DEM. But midwives are recommended to have a maximum of 27.5 births a year here, assuming they are overworked (probably a safe bet) we’d be talking about a million pounds a year to improve training for ~50 midwives if these figures happened here. So you should be spending ~40,000 USD per DEM per year on improving the performance of these midwives by my back of the envelope calculation. I’m guessing that is more than enough training budget to turn them all into the more qualified midwives.
Note also mortality is usually just a marker in medicine, you can probably assume if (preventable) mortality is higher, other adverse outcomes are also higher.
If I understand Amy’s point, it is not home-birth as such (which works out well in my part of the UK according to the best evidence available), but that home birth with inadequately trained midwives, and a lack of acceptance of evidence based midwifery (i.e. when not to arrange home births, and how to spot issues as early as possible).
It looks like there are 13 states that are causing the home birth death rates to be skewed. If you’re giving birth in the other 37 states or D.C., the mortality rate is 4 out of 17,238 or .23, so much safer than hospital birth. (I included 2003-2005 data). If you’re giving birth in one of these 13 states, the rate is 2.25! The 13 states with the high rates are Arizona, Idaho, Indiana, Maine, Michigan, Missouri, Nevada, Pennsylvania, Tennessee, Texas, Utah, Vermont, and Wisconsin. In half of these states, home birth midwifery is either illegal or unregulated, so that could be why the numbers are so high. It does appear that the states with the worst stats tend to be the ones where it is illegal or unregulated. It could also be that homebirths are vastly underreported, especially in states where it is illegal for a midwife to attend a birth, many home births could go unreported to the CDC, except for ones where something goes wrong, thus skewing the statistics. Indiana, for example, had 171 homebirths in three years so the one death that they had is of course going to make their numbers look very bad. But the fact that 37 states had over 17,000 homebirths with only 4 deaths clearly shows that the rate you gave of 1.15 does not apply on a national level.
So maybe instead of being all “OMG HOME BIRTH TRIPLES THE CHANCE OF YOUR BABY DYING!” you should spend your energy finding out why the rate is so bad in 13 states and what we can do to make it as safe in those states as it is in the other 37 where it is apparently safer than hospital birth.
I am curious if anyone can give me a good reason why I personally should not homebirth. I live in Washington state which has 3,244 homebirths (twice the national average) and not a single fatality among homebirth babies during the first 27 days during 2003-2005. If you were right about homebirth being as risky as it is, there should have been at least two or three deaths in my state, but there’s not. So how can you say that I would be putting my baby at risk by homebirthing?
I agree that going to a hospital improves your odds of a good outcome, but it doesn’t always mean everything will work okay, either.
Anecdote: All three of my kids have been delivered at internationally known tertiary care centers. Children #1 & #3 were delivered under the supervision of a CNM. With child #2, however, my only option (insurance limitations) was a very well-known OB group. Because child #1 had been a fast delivery & I was concerned that #2 would be even faster, I dutifully called to let them know I was on my way to the hospital once it was clear I was in labor. Unfortuately, no one in the office notified Dr. On Call, who decided to go home. After being stuck in Friday afternoon rush-hour traffic, I finally arrive and am pushing within 5 minutes of walking in. (Triage nurse couldn’t be bothered to check me because I couldn’t possibly be that composed and be in hard labor.) Residents Tweedle dee and Tweedle dum haven’t a clue what to do and are panicking because there’s meconium and baby’s heart rate is decelerating with every contraction (there was a knot in the umbilical cord)–they want to know whether they can wait for Dr. On Call to show up—oops! too late, baby is crowning. Tweedlee dee decides to yank on baby’s head to hurry things along. I yell at him to stop (remember, no pain killers). Baby then flops onto the table (because no one remembers that you should actually catch the baby) and everyone just stands there, staring the child and doing nothing, as if they have never a baby being born before. Ten minutes later, Dr. On Call shows up, walks in, and says, “What happened?”
And this from an internationally acclaimed hospital.
Although everything seemed okay at first, this child has turned out to be a special needs child. I’ll never know for sure whether the delivery played a role in that. But it just goes to show that a hospital setting is no guarantee of competence.
First, let me point out that I agree with several of the points raised by Amy and others here: “natural” does not automatically mean “better”, anecdotes do not equal evidence, and there is an appalling amount of anti-science woo surrounding many people’s choice to have a home-birth.
Second, I’d like to point out that, after over 100 comments, the only actual peer-reviewed scientific studies mentioned in this discussion have shown planned homebirths to be as safe as planned hospital births, where a competent midwife is present and the woman is considered low-risk before labour. (Amy suggests that Johnson & Daviss 2005 and other studies that claim to support homebirth as no more dangerous than hospital birth have important failings; I’ll reserve judgment until she has made her case. Perhaps she could link to posts on SkepticalOB where she does this, if she has done it already.)
In case anyone is interested, here is the Cochrane review of studies comparing home to hospital birth: http://www.cochrane.org/reviews/en/ab000352.html.
The result: only one study met their criteria for quality (randomized controlled, etc), and it included only 11 women. Thus, no reliable conclusions could be drawn.
Upshot: by the strictest rules of medical scientific evidence, we cannot say that either homebirth or hospital birth is safer or more dangerous for women who are assessed before labour as being low-risk.
This review was assessed as up-to-date as of 30 April 2006.
The next-best paper I’ve come across, by one of the same authors, is Olson 1997. I can’t currently access the full article, but here are the highlights from the abstract:
“This study examined the safety of planned home birth backed up by a modern hospital system compared with planned hospital birth in the Western world.”
meta-analysis of 6 studies
controlled observational (ie, not randomized, but known variables controlled for)
combined population observed = 24092 women
“Perinatal mortality was not significantly different in the two groups.” (no maternal deaths)
APGAR scores and maternal lacerations were worse in the hospital group.
Several interventions measured were more common in the hospital group.
Conclusion: “Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions.”
When my wife and I were investigating birth choices here in the UK before our daughter was born, the research we came across seemed pretty clearly to support the safety of homebirth. That is, they seem to establish that homebirth is as safe as hospital birth, where the attendants have good training and are integrated into the health system, and where a well-equipped hospital is accessible in case of complications. If you’re interested, here are two other discussions of homebirth that I’ve seen and participated in on skeptical blogs: Bad Science and Rational Moms.
Looking forward to seeing where this discussion leads.
heyunyi:
“I live in Washington state which has 3,244 homebirths (twice the national average) and not a single fatality among homebirth babies during the first 27 days during 2003-2005.”
That’s not what I find when I look at the database. During 2003-2005, there was 1 neonatal death: a postdates baby who died of asphyxia at home.
Moreover, that might not be the only death. The database defines the birth attendant as the person who signs the birth certificate. Therefore, any homebirth transfers end up in the MD group. There could be additional deaths that are not reflected in the database. Since the transfer rate for direct entry midwives is 10-20%, that’s a very real possibility.
My elder daughter is staying with us for a few days. She would not be here if she had chosen a home birth or refused a cesarean when her son was born.
My wife is here but had she chosen a home birth for our second daughter she would not be here.
My younger daughter will turn 21 in a couple of weeks. She would not have survived a home birth.
Perhaps you understand why I was so annoyed when our local member of parliament announced that the Katoomba hospital would have 24/7 anesthetists and obstetricians in the birthing unit and the response of the women campaigning for a better service rejected this because it was just a “medicalisation” of childbirth and the MP should have arranged to spend the money on more doulas and home birth support.
I don’t believe it’s a coincidence that my local area has the second lowest rate of vaccination in the state.
TimMills,
In June 2006, attempting to address the issue of homebirth safety, NICE (National Institute for Health and Clinical Excellence) reviewed the existing homebirth studies. Their findings:
Janssen et al, Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia, CMAJ, February 5, 2002; 166 (3):
A cross-sectional study conducted in British Columbia … compared 862 women who planned a home birth with a matched control group of 571 women with a planned midwifery-led unit birth (MLU) and 743 women with a planned consultant-led unit birth (CLU)… Perinatal mortality involved 3 babies in 860 planned home births, 1 baby in 733 planned CLU births and no babies in 563 planned MLU births. No further details were given regarding the perinatal deaths… Furthermore, there were 5 infants out of 860 in the home birth group who received assisted ventilation for more than 24 hours, but none in the MLU and CLU groups.
Bastian et al, Perinatal death associated with planned home birth in Australia: population based study, BMJ 1998;317:384-388:
A cross-sectional study (N=1,502,756) was conducted in Australia between 1985 and 1990. This … included a comparison of planned home birth with data for the whole country, including details of perinatal deaths for home births. … birth weight specific mortality for babies > 2500g showed a higher mortality rate with home birth … The intrapartum-related perinatal mortality rate, excluding perinatal mortality associated with congenital malformation and/or extreme immaturity, was higher for babies born at home … Intrapartum asphyxia was responsible for about half (24 out of 50 deaths) of infants dying after a planned home birth in Australia between 1985 and 1990.
Chamberlain et al, The report of the 1994 Confidential Enquiry by the National Birthday Trust Fund:
A UK questionnaire-based cohort study conducted in 1994 compared 5971 women who had a planned home birth and 4634 women who had a planned hospital birth. Women were matched for age, parity and area of residence. A further 1337 women in the planned hospital birth group were not matched, but were included in the analysis. The complications in current pregnancies reported by women, differed between groups [higher risk in the hospital group] … The characteristics of the babies showed a marginal but significant difference between groups [higher risk in the hospital group] Perinatal mortality rates were 10.7 per 1000 livebirths for planned home birth and 15.6 per 1000 livebirths for planned hospital birth.
Durand, The Safety of Home Birth: The Farm Study, Am J Public Health, 1992;82:450-452:
A large cross-sectional study conducted in the US compared outcomes for 1707 planned home births from the Farm midwifery service in rural Tennessee (between 1971 and 1989) with 14033 comparators from the 1980 US National Natality/National Fetal Mortality Survey… The 2 groups cannot be compared directly and the study should be regarded as a case-series.
Johnson and Daviss, Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416:
A large case-series was conducted in the US and Canada upon 5418 women expecting to give birth at home in 2000 supported by midwives with a common certification…. There were 18 perinatal deaths in the 5418 planned home births (3.3 perinatal deaths per 1000 planned home births).
NICE concluded:
“The uncertain evidence suggests intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.”
and:
“When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.”
@harriethall
**************************************************“But you are not looking at the full picture if your common sense tells you that there are zero offsetting risks inherent to hospital based birth.”
You are putting words in my mouth. I never suggested any such thing.”
***************************************************
Sorry, I wasn’t trying to put words into your mouth. You made a statement which I read to say something like “common sense tells us that home birth is risky because of the inability to respond to emergencies promptly”. I was just making the point that reaching a science-based answer requires looking at risks and benefits in both environments. I’m sure that you know that. Your earlier response just seemed incomplete, and I was trying to point that out.
**************************************************“Some neonatal deaths occur in hospitals that would not have occurred in a less aggressively “managed” environment.” Do you have data to support that claim?”
***************************************************
Well, if you are looking for anecdotes like those provided in support of hospital birth, there’s Tatia Oden French and her baby Zorah – a case of both maternal and neonatal death from AFE after induction with misoprostol : http://tatia.org/index.html
Can we say for a fact that she and her baby would have survived a non-hospital birth? We don’t have a crystal ball, but we can certainly say that the hospital procedures used in that case most likely led to two deaths.
As for statistical numbers, there’s this:
An average of 195,000 people in the USA died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002
http://www.medicalnewstoday.com/articles/11856.php
Medical Errors Cost US $8.8 Billion, Result In 238,337 Potentially Preventable Deaths, Study Shows
http://www.sciencedaily.com/releases/2008/04/080408085458.htm
While maternity patients typically younger and healthier than other hospital patients, given that approximately 1/4 of all hospital admissions are for maternity care, the odds are that at least *some* of the preventable deaths occurred in obstetrical units. You can’t deny that nosocomial infections do exist, and that maternity departments are not immune from them.
Based on the inclusion categories used in the original post above, there were 4,360 neonatal deaths in hospital between 2003 – 2005. Is is possible to say how many of these were preventable? Not from the data provided. How many could have been prevented with “less aggressive treatment” versus “more aggressive treatment” versus “typical standard of care treatment”? Again, no one can say.
The same is true for the 44 neonatal deaths that occurred out of hospital, with an attendant listed as “other midwife”. We don’t know which or how many of them may have been prevented by additional medical care, or more competent midwifery.
My conclusion is to agree with TimMills:
Upshot: by the strictest rules of medical scientific evidence, we cannot say that either homebirth or hospital birth is safer or more dangerous for women who are assessed before labour as being low-risk.
IndianaFran,
Good lord, no, I’m not looking for anecdotes!!! The plural of anecdote is not evidence. For my comments on “Death by Medicine” see http://www.sciencebasedmedicine.org/?p=136
You might as well just admit that you don’t have any credible evidence to back up your belief. And you certainly can’t argue that the delay required to transport a home birth gone wrong has no impact on the outcome.
Amy, thanks for offering that.
It is certainly not the case that it’s always safe to have a homebirth. Certain maternal risk factors likely contra-indicate it. Lack of adequately-trained homebirth attendants would, too. As would living somewhere with a health system that does not adequately integrate homebirths into overall health care (ie, if it makes hospital transfer more complicated than necessary).
When the system, the attendant, and the maternal risk factors all line up (as they often do in the UK, Netherlands, and other places), then home birth is as safe as hospital birth. The obvious corollary of this is that, for studies that find an increased risk in homebirth, perhaps we should look to these other factors (the system, the attendant, maternal risk) to explain it.
I’d also like to explicitly address this point that is repeatedly raised in these discussions: “When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.”
While true, this is a bit of a red-herring. The overall mortality (or other outcome measure) is the same (given the right attendant, a suitable health care infrastructure, and low maternal risk). In that case, any increased risk for homebirth mothers due to emergency complications must, statistically-speaking, be offset by decreased risk for other mothers. There are plausible-sounding suggestions for what risks would be reduced (suggestions, I know, which the woo-peddlers also like to trot out), generally revolving around increased rates of interventions.
The evidence I have seen published tends to lead me to believe that the overall outcomes are, in fact, similar for homebirth and hospital birth (given ideal conditions).
Whenever someone says, “what if…” followed by some frightening scenario, the proper (skeptical) response is to ask for evidence. Is home birth more dangerous overall? Apparently not – unless you introduce further risk factors (incompatible health-care system, incompetent attendants, specific maternal contraindications).
IndianaFran:
“We don’t have a crystal ball, but we can certainly say that the hospital procedures used in that case most likely led to two deaths.”
You keep missing, or ignoring, the main point. Even when you include hospital errors, even when you include malpractice, homebirth has nearly triple the rate of neonatal death. So as “bad” as hospital birth may be, homebirth is 3X as bad.
Hospitals are not perfect; there is plenty of room for improvement, but homebirth is not as safe as hospital birth.
People who are cognizant of the risks may want to choose homebirth anyway, and they have the right to make that choice. But they are gambling with their baby’s life and if they bet wrong, the baby will die.
TimMills:
“The overall mortality (or other outcome measure) is the same (given the right attendant, a suitable health care infrastructure, and low maternal risk).”
No, I’m sorry, but that’s simply untrue. All the scientific evidence published prior to August of this year showed that homebirth has an increased risk of neonatal death. All the available national and state statistics published thusfar indicates that homebirth has an increased risk of neonatal death.
Recently, a large Dutch study of homebirth was published that purported to show that homebirth is as safe as hospital birth. However, the homebirth and hospital birth groups differed in at least one important factor: race. Since race in The Netherlands is a risk factor just as it is in the US, it is not clear that the comparison was an appropriate one.
The Canadian homebirth study also had some problems. The authors were quite vague about the circumstances of death in the two groups. They have not provided information about the deaths in the hospital group, but in subsequent communications revealed that the death in the homebirth group was exactly what we would expect. A serious problem occurred in labor, the patient was promptly transferred, but by the time the baby was delivered it was too late.
As I’ve said repeatedly in this thread and elsewhere, homebirth is a gamble. The parents gamble that a life threatening emergency will not occur during labor. If they guess wrong, the baby dies. It’s just that simple.
Thank you Tim for more clearly stating the point that I was trying to make in my earlier reply.
Well-stated, Tim Mills. Many risk factors for infant mortality associated with home birth clearly differ from risk factors for hospital births. The data above demonstrate that one risk factor for home births in the US (that hospital births do not share) is the presence of a DEM (and absence of a CNM or MD). Seems a worthy public health cause to eliminate this particular risk factor in the US.
Absent this particular risk factor, it appears to be difficult to tease out the relative risk between home birth and hospital birth (in the US), given the current data available, though perhaps they are roughly equal. More data needed.
Science based medicine, huh?
I am truly stunned at the interpretations in this post and subsequent responses. It seems to me that a truly scientific inquiry would say “Direct entry midwives have three times the neonatal mortailty rate in 2003-2004 why could that be?”.
1. What were the rates in other years? What was the trend across time?
2. Could it be that they are untrained/undertrained? Could it be that DEM includes many types of midwives? Are there different outcomes between CPMs and other midwives?
3. Is this increased rate a function of the small numbers, in which typically fluctuate wildly?
4. Could the rate actually be higher and thus even more dangerous because DEM’s refer to docs?
5. Could the rate be high because the Amish are a large contigent of homebirthers and have a higher rate of congenital issues?
6. Is using type of attendant an acceptable proxy for place of birth?
It it stunning to me that medical professionals do not ask these questions (and seek to find them, if they really care), and do not see that this single snapshot in time, cannot possibly give the answers that they are attributing to it. Stunning that they shout “Well, here is PROOF!” Stunning that they know so little about health surveillence.
And this is a site called SCIENCE BASED MEDICINE?
[...] Medicine has a great article on the dangers of homebirth with a midwife. It is the most dangerous form of planned birth in the U.S. As a friend on Twitter [...]
Amy,
I didn’t have postdate pregnancies included in my dataset so that’s how I missed that one. It’s not even legal in WA state for a homebirth midwife to attend a woman past 42 weeks (Though apparently it happens according to the data. The midwives I saw for my last pregnancy didn’t allow it though). I think that whether homebirth is safe between 37-41 weeks 6 days and whether it is safe after 42 weeks may be different issues that need to be examined separately, so I’m not really interested in what happens to homebirth postdate pregnancies as it relates to the relative safety of homebirth, though it would be interesting as an entirely different subject.
Transfer rates would not make up for the discrepancy in our stats. If 20% of the WA homebirthers had transferred, this would have been around 800 transfers. According to your rate of 1.15 per 1,000 this could have only added one more death, if even that. Let’s look the 37 states with good homebirth records (again, this is 37-41 weeks, not sure how much including postdates births would affect this.) With 17,000 homebirths, a 20% transfer rate would have meant starting with around 21,000 with 4,200 transfers. At most, that would add 4 deaths. So 8 deaths out of 21,000 gives us .38, still just as good as in hospital with a CNM.
edgar,
5. Could the rate be high because the Amish are a large contigent of homebirthers and have a higher rate of congenital issues?
I think this definitely needs more looking into.
The states with the worst stats also tend to be ones with Amish populations:
Ohio: 1/1277 #1 in Amish population
Pennsylvania: 8/3795 #2 in Amish population
Indiana:1/201 #3 Amish
Wisconsin 5/1845 #4
Michigan 4/1617 #5
Missouri 3/507 #6
Tennessee 2/419 #12
I believe there are only two states that have more than one death and are NOT Amish and that would be Texas and Utah. All the rest of the states that have had more than one death over three years all contain significant Amish populations (though when I ran the data initially, I didn’t include postdate pregnancies so there could possibly be more states with multiple deaths if you look at that.)
Lady, you’re a tornado of bullshit. Go away and come back when your bullshit dies over somebody else’s house.
The huge problem with using this as the “definitive” homebirth sample is that it is not accurate.
1. It does not distinguish between direct entry “lay” midwives and certified professional midwives (CPM). Oregon has both, for example. There is a HUGE difference in the training.
2. Not all states include non-nurse midwives in birth certificate data. In my county in Oregon, I know for a fact that I gave birth with a CPM at home in 2005. Yet there are ZERO “other midwife” births listed in Oregon in 2005, I assume they are all lumped in “other”… Oh, and my baby lived, which falls in the category of anecdote, but is a specific anecdote which actually DOES prove that the data is not accurate.
3. In states where direct entry midwifery (certified or not) is not legal, there is a disincentive for the birth certificates to be filled out accurately by attendant type.
4. The numbers of direct entry midwifery births are not a large enough sample to compare accurately.
I know that in my personal situation, with more certainty that most, that if my daughter had been born in a hospital she would have spent a significant time in the NICU for feeding issues with the confounding issues of iatrogenic infections looming large, and breastfeeding likely would have failed, as it barely succeeded with me birthing at home, and took heroic measures and constant kangaroo care for 6 weeks to get her so she was gaining consistently at the breast. The outcomes for babies with her condition who are given formula are pretty dismal, she has a rare chromosome disorder, she doesn’t tolerate citrates, all formulas have citrates… As it was she was born at home, I was able to be with her 100% of the time, nursing her, pumping for her, feeding with a bottle, expressing milk into her mouth, everything we could do to get more milk into her. Every other child with her condition spent time in NICU, of the 6 or so other kids with her exact deletion, 2 have died. None have language…except her.
When it comes down to it, people don’t generally choose their birth attendant for the absolute margin of statistical safety. If they did, CNMs would be a lot busier, they have the best stats by those figures.
Oh, and a second data point for Oregon, my sister, in 2009, was planning a homebirth, but started to develop pre-eclampsia, which the CPM detected, and went in for an induction, which turned into a VERY necessary c-section. She had had an ultrasound, and the usual number of prenatal visits, and blood tests, CPMs can order those in Oregon. Her little girl was born at 4 pounds 4 ounces, with a tiny placenta and short cord. Does this make me think homebirth isn’t “safe”? She’d planned one and transferred before things got dangerous, her little girl was tiny but able to go home with Mom and is now a petite but thriving 8 month old.
I don’t vaccinate my kids, my sister does, but my reasoning isn’t about “evil doctors bad” (I have a lot of medical issues myself and do get care from MDs for that, as do my children).
My reason is that on my older daughter’s third round of shots, she went lethargic and non-responsive for 12 hours, and lost developmental milestones that it took about 3 months to recover (she was getting up on her knees and rocking before the shot, and did not even try to crawl until she was closer to 10 months old.)
We’ve had pertussis (despite me being fully vaccinated and that being the thing she was vaccinated the most with) and it was scary but survivable. She’s had a tetanus booster since, and tolerated it well. Now that my younger child isn’t getting viral croup every 6 weeks, I might consider vaccinating her.
You can’t assume that people who make choices different from yours are “idiots”. My IQ is 145, I was a National Merit Scholar, I’ve spent most of my adult life reading about pregnancy and birth. I’m not uninformed, and I’m not cavalier about my children’s health.
I’ve seen a lot of doctors in births use completely inaccurate statements to bully women into interventions they did not want or need. One friend was actually screaming, “I do not consent” as they dragged her into a c-section for a baby who would have died anyway of a severe birth defect. And I know that some midwives do not give optimum care, and I *have* lost a baby. My mother has lost a baby. I have friends who have lost babies, and honestly, they weren’t situations the doctors had any control over at all. I understand both what it is to have a severely special needs child (which has nothing to do with how she was born, giving birth at home did not delete her genetic material), and to lose a child, and I STILL feel more comfortable with homebirth.
heyunyi:
“According to your rate of 1.15 per 1,000 this could have only added one more death, if even that. ”
Whoa, that’s not correct.
The death rate for 1.15/1000 is for patients who experienced no complications. The death rate for those who were transferred is higher, possibly several orders of magnitude higher.
In the Johnson and Daviss BMJ 2005 study, the authors provided information on transfers and cause of death. In their study of all CPM attended homebirths in North America in 2000, they found 8 deaths in 63 emergency transfers for a death rate of 127/1000! At that rate, there could have been one hundred additional deaths.
We don’t know what the death rate was for transferred homebirth patients, but it is undoubtedly much higher than the death rate for patients who experienced no complications, possibly dramatically higher.
“Could the rate be high because the Amish are a large contigent of homebirthers and have a higher rate of congenital issues?”
There’s no evidence of that. Indeed, the studies that have looked at cause of death in the homebirth populations revealed that most of deaths were the result of preventable causes that could have been addressed in a hospital.
Jenrose:
“It does not distinguish between direct entry “lay” midwives and certified professional midwives (CPM).”
The Johnson and Daviss study was restricted only to CPMs and the neonatal death rate in the homebirth group in 2000 was almost triple the neonatal death rate for low risk hospital birth in 2000.
The Midwives Alliance of North America (MANA) the national CPM organization is in possession of a very large database of CPM attended homebirths. According to MANA president Geradine Simkins:
MANA has collected data on planned midwife attended home births since 1993.
Data collection includes “evaluation of all aspects of midwifery care in terms of safety, optimal maternal, fetal, and family outcomes,and cost effectiveness.
Data collection “uses a very extensive data form! ~360 questions.”
MANA estimates approximately 20,000 cases will be in the database by the end of 2008.
MANA has no intention of releasing the statistics to the public. Only “qualified researchers” will be granted access based on “an application process/review.”
What is that application process/review?
“The association [requesting permission to view the data] needs to contact the Director of Research on association letterhead, with the following:
a. A statement that the decision has been made by the group
b. A list of participating members
c. The name of a contact person who has been chosen to manage the account
d. The name of the association official authorized to sign the contract for the account
4) The DOR will then send a contract which contains two parts:
a. The agreement between the association and the Midwives Alliance for the account
b. A Non-disclosure Agreement which prohibits inappropriate use of the data…”
By its own admission, MANA has a database of 20,000 CPM attended deliveries evaluated on 360 parameters … but you can’t see it, I can’t see, no one from the general public can see it.
It does not take a rocket scientist to surmise that the data shows that homebirth is not nearly as safe as hospital birth.
Jenrose:
“My IQ is 145, I was a National Merit Scholar, I’ve spent most of my adult life reading about pregnancy and birth. I’m not uninformed”
You are grossly uninformed. These are not issues intuited by “common sense” and they certainly don’t depend upon IQ. They depend solely on understanding immunology, virology, statistics and the scientific method. And sadly, although you don’t intend it, you are jeopardizing the health of your children AND mine.
“It does not take a rocket scientist to surmise that the data shows that homebirth is not nearly as safe as hospital birth.”
Well, a rocket scientist probably wouldn’t be interested. But a medical scientist wouldn’t just surmise – he or she would write up a validly designed research proposal and then approach the owners of the data for appropriate access.
By the way, in the interest of public disclosure, are you also calling for all hospitals to release the details of all their births and deaths to the general public, so that they can make fully informed choices about their options? Since 99% of American women choose to give birth in a hospital, wouldn’t that data be far more useful to them as consumers?
We’re not talking about data identifying individuals or practices. We’re talking about data about the safety of practitioners as a class. C-section rates, neonatal death rates, maternal deaths rates, you name it; they’re all available for doctors. And in many places they are already available for individual hospitals.
CPMs are currently in the midst of a big campaign for recognition and licensing in all 50 states. It seems that a minimal requirement ought to be to hand over their own safety data. I can’t imagine a valid reason for hiding it, can you?
My irony meter just got a good thump. I tweeted about this, and have just got an @reply from someone who tells me my ignorance is staggering, and that women should be allowed to make their own informed decisions … ummm, yeah .. that’s kind of the point of providing information – at least I thought so, anyway. Apparently “informed decision” actually means “informed of the good things about what we do and the bad things about anything else”.
I’m currently going over some of the papers you have mentioned, to see if they truly support your conclusions. (You’ll understand, based on our exchange re: C-sections, that I want to check for myself.)
In the meantime, I just wanted to voice my agreement that any dataset which comes with such strings attached as the MANA data is effectively useless to researchers. Any publications that do reference it won’t be checkable by peer reviewers, and so nobody (except insiders) will be able to truly know whether those publications meet scientific standards.
(I think that’s a damning enough criticism, and I don’t think we can speculate further that the data are in fact damning on their own. We all know how easy it is for cranks or media to distort data, and it could be that MANA is simply being over-paranoid about their data being misused in such a way. Unfortunately, we’ll never know.)
Having now read the Johnson & Daviss (2005) paper that Amy Tuteur keeps mentioning, I’d like to address her claims about it in detail. Apologies for length, but I want to be thorough.
She says that “in studies like those done by Johnson and Daviss, any purported deaths due to interventions are already included in the hospital group.” This is a common red-herring from the anti-homebirth side of these debates. The Johnson & Daviss study, like most of the others that find home birth to be safe (specifically, that fail to support the claim that it’s more dangerous than hospital birth), was conducted on an intention-to-treat basis. The “home birth” group includes all women who intended to give birth at home when labour began. Therefore, it includes all of the transfers – the births that (as Amy points out) turned out to be higher risk than anticipated.
“In the Johnson and Daviss BMJ 2005 study, the authors provided information on transfers and cause of death. In their study of all CPM attended homebirths in North America in 2000, they found 8 deaths in 63 emergency transfers for a death rate of 127/1000! At that rate, there could have been one hundred additional deaths.
”
Where do you get these numbers from? Table 2 in the paper reports 185 urgent transfers, and 655 transfers overall in the homebirth group. I was unable to find an explicit reference the number of deaths among either urgent or overall transfers. However, the box near the end of the paper laying out the cause for all 14 intrapartum and postpartum infant deaths in the home birth group mentions transport during or soon after labour for 6 of them. This (very informal) count gives a death rate of 6/655=9.2/1000, but see my next comment:
“We don’t know what the death rate was for transferred homebirth patients, but it is undoubtedly much higher than the death rate for patients who experienced no complications, possibly dramatically higher.”
This is true but largely irrelevant. The key question is whether planning a home birth is safe for a woman who appears low-risk before the onset of labour. To cherry-pick those planned home births after the fact where things didn’t go well (those with urgent transfers to hospital during or soon after labour) and say that they carry high risk is to state an obvious but irrelevant fact, in terms of decision-making by parents, medical staff, and policy-makers. What is important is the overall result for the prospectively-identified group (low-risk pregnant women being attended by CPMs).
“On their own website, Johnson and Daviss have acknowledged the validity of my analysis (without mentioning my name) and have actually performed another faulty calculation attempting to address the criticism.”
From another blog of hers, I infer that Amy is either referring to this document, where they address questions about their paper (but don’t do any re-calculations), or this conference abstract. In the abstract, they do seem to take on board the criticism (below) that the original article used out-of-date hospital mortality rates. It is not clear that the calculations they perform are faulty. (Based on the abstract, their reanalysis seems to be motivated by a desire to make the home birth and hospital figures more directly comparable – to match for the known confounding factors of race.) What is clear in Amy’s post is a tendency to attribute nefarious motives to those who disagree with her – soemthing that I tend to treat as a red flag in science-based debates. Amy, it is possible that someone can honestly disagree with you, can be wrong, and yet not be “[trying] to scam people”.
“Johnson and Daviss looked at the intervention rate and neonatal death rate for all homebirths attended by CPMs in 2000. The compared intervention rates for homebirth to low risk hospital births in 2000. Then they compared the neonatal death rate to … a bunch of out of date hospital studies extending back to 1969.”
This is, I think, the most substantive of Amy’s criticisms. The authors acknowledge point out in their paper that “the main study limitation was the inability to develop a workable design from which to collect a national prospective low risk group of hospital births to compare morbidity and mortality directly. Forms for vital statistics do not reliably collect the information on medical risk factors required to create a retrospective hospital birth group of comparable low risk“. (emphasis added) In other words, this data isn’t perfect, but the authors think it’s better than the alternatives. They seem to have tried to address this problem in this more recent analysis mentioned above (thanks to Amy’s other blog for the link). I look forward to a more detailed analysis from Amy on exactly how this re-analysis is misleading.
So, the data is imperfect. When is it not? But from looking at just this one paper that Amy has discussed, I find that her analysis is misleading, irrelevant, and/or inaccurate in several places. I think I’ll join IndianaFran in trusting the consensus of peer-reviewed research papers over the conclusion of someone with such clear shortcomings in her ability to objectively present other people’s research.
TimMills,
The criticism of the Johnson and Daviss study is straightforward. Instead of comparing homebirth in 2000 with low risk hospital birth in 2000, the authors compared it to a bunch of out of date papers extending back to 1969, because that was the only way to make homebirth with a CPM look safe by comparison.
Johnson and Daviss performed two separate comparisons in their study. First they compared intervention rates for homebirth to intervention rates for low risk hospital birth in 2000:
“We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics [Births: final data for 2000. National vital statistics reports. Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Hyattsville, MD: National Center for Health Statistics, 2002;50(5)]”
When comparing neonatal death rates, they should have used the exact same hospital group. What was the neonatal death rate in that group? The hospital neonatal death rate for white babies at term of 0.9/1000 is not corrected for congenital anomalies, pre-existing medical conditions, pregnancy complications or multiple births.
Johnson and Daviss reported a neonatal death rate at homebirth with a CPM of 2.7/1000 (uncorrected for congenital anomalies, breech or twins).
Johnson and Daviss have publicly claimed that the neonatal death rate for low risk birth in 2000 was unavailable when their paper was submitted for publication in 2004. That’s simply untrue. The data was published in 2002, but, more importantly, they had it in their own hands even before publication. It was the exact same dataset they used to calculate intervention rates.
As an aside, it is worth noting that Johnson and Daviss are not independent researchers. Johnson is the former Director of Research of the Midwives Alliance of North America (MANA) and Daviss, his wife, is a homebirth midwife. The study was commissioned by MANA and was funded by the Foundation for the Advancement of Midwifery, a homebirth advocacy group.
Amy,
While some of my criticisms of your comments stand, you have convinced me that the Johnson & Daviss paper is not reliable. Particularly, I hadn’t picked up on the (now obvious) fact that they used current data for other measures, but ignored that data for mortality.
Thanks for pointing that out, and for mentioning the authors’ conflicts of interest. (Just so everyone knows, there is a spot in such papers where conflicts of interest can be noted. In theirs, it says “None declared”.)
For the record, I accept your claim that homebirth as generally practiced in America is dangerous and goes against the best scientific evidence.
I remain skeptical about whether this claim can be generalized to countries where midwifery in general, and home birth in particular, are part of the mainstream health system, and where practitioners at both home and hospital births have comparable qualifications. The 2009 Dutch study is impressive in terms of raw numbers (321307 planned home births, and 163261 planned hospital births). It shows similar risks of mortality intrapartum, in the first 24 hours, and in the first 7 days, for home and hospital births, after adjusting for race and other known confounding factors.
Do you have some positive evidence that Dutch or British home births are less safe than hospital births? Or are you operating under the assumption that they are until proven otherwise?
TimMills:
“Do you have some positive evidence that Dutch or British home births are less safe than hospital births? Or are you operating under the assumption that they are until proven otherwise?”
The two new Dutch and Canadian studies appear to show that under rigorous guidelines, homebirth can be as safe as hospital birth. The Dutch situation is very different than anywhere else because of the short transport distances and the dedicated transport system. No other country can match those safety features.
Prior to those studies, there were none that showed homebirth to be as safe as hospital birth and quite a few that showed the opposite. Australian studies have repeatedly shown that homebirth has an increased neonatal death rate (approximately triple hospital birth) and their state and national statistics confirm the study results.
The bottom line, though, is pretty straightforward. When no complications occur at home, everything is fine. When certain complications occur and there is time and an efficient method of transport, the baby can be saved. When an immediately life threatening situation occurs (for example, the baby requires immediate intubation) the baby will die.
You are not allowing for the possibility that the incidence of complications requiring intervention may vary according to place of birth.
Plonit:
“You are not allowing for the possibility that the incidence of complications requiring intervention may vary according to place of birth.”
That’s is the wishful thinking that undergirds homebirth advocacy. There’s no evidence for it.
“That’s is the wishful thinking that undergirds homebirth advocacy. There’s no evidence for it.”
It may be a favorite mantra of the woo-birthers, but it’s also a plausible interpretation of the empirical data. Intervention rates are lower for planned home births than for planned hospital births in low-risk women (Janssen et al 2002 – the Canadian study – and others). You can either attribute that to uncontrolled confounding factors, or to the known variable “place of birth”.
If the latter, it may be because (a) when you’re not right next to the operating theatre, you’re more ready to try less intervention-based methods, (b) attendants with home birth experience are more aware of such alternative methods, or (c) labouring at home better enables the physiological conditions (hormone production, etc) that lead to an intervention-free birth.
I don’t know of any study that has probed this particular question more deeply, but the evidence suggests it’s worth researching.
I’d like to join the chorus calling for Dr. Tuteur to publish her analysis of the Johnson & Daviss in a peer-reviewed journal. At this point, any valid criticisms are smothered in Internet noise and have little chance of getting through to those who need the information most.
TimMills:
“Intervention rates are lower for planned home births than for planned hospital births in low-risk women”
Among homebirth advocates, an “intervention” is anything that homebirth advocates don’t approve of. For example, medication for pain relief is an “intervention” but acupuncture for pain relief is not. Electronic fetal monitoring is an “intervention,” but auscultation with a fetoscope or doppler is not.
Moreover, homebirth advocates like to ignore the role of patient choice. Some women want pain relief. The fact that they request is and then get it does not mean that they endured an “intervention.”
The idea that homebirth could be safer than hospital birth is counter-intuitive. Obviously hospitals have the personnel and equipment to deal with life threatening emergencies and homebirth midwives do not. Therefore, it is imperative for homebirth advocates to claim (falsely) that hospital birth increases the risk of neonatal and maternal death, and those putative deaths offset the deaths caused by lack of emergency care. There’s simply no evidence for that claim.
Moreover, homebirth to hospital comparisons always include these putative “hospital caused deaths” and homebirth has triple the neonatal mortality rate anyway.
lkw:
“I’d like to join the chorus calling for Dr. Tuteur to publish her analysis of the Johnson & Daviss in a peer-reviewed journal.”
This betrays a lack of understanding of how science works. Being published in a peer review scientific journal does not make something true, and a refutation does not have to be published in order to be correct.
Johnson and Daviss committed the scientific equivalent of a bait and switch. The evidence that they had in their possession told them that homebirth with a CPM in 2000 had nearly triple the neonatal death rate of low risk hospital birth in 2000. They simply withheld that information.
The idea that homebirth could be safer than hospital birth is counter-intuitive.
+++++++++
We’re talking about science-based medicine here not intuition-based medicine, so it doesn’t much matter whether the idea is counter-intuitive.
There are studies (e.g. Chamberlain et al 1994) that show less neonatal resuscitation required at home births than in hospital births (matched for risk, parity, socio-economic status). In other words, complications that prompt neonatal resuscitation were less frequent in home births. It may be counter-intuitive, but that is sometimes where the science leads you.
Dr. Tuteur: “a refutation does not have to be published in order to be correct”
You missed my point. It should be published to be *heard* above the din of the Internet. Without peer review, from a research point of view, it unfortunately stands on equal footing with the woo.
I am not seeinf where they used data from 2002 in the interventions It states quite clearly in the intervention table that they are usung 2000 data from NCHS. There is no mention of 2002 data in the references, either. Please clarify.
Amy,you could very well submit a refutation…At a bare minimum, an editorial.
Dr. Tuteur: “This betrays a lack of understanding of how science works.”
I find myself rather offended by this statement and see no reason for it. Is there an editorial policy on SBM regarding this type of thing?
I think SBM’s editorial policy on “this type of thing” is “the more the merrier.”
The reason electronic fetal monitoring is an “intervention” and occasional use of a stethoscope is not is that the former does not require the woman to stay motionless on her back to avoid dislodging the leads, which means she cannot walk to relieve pain, thus perhaps needing more medications, and her labor may be slower.
argh – of course, I means “the latter does not require…”
The reason electronic fetal monitoring is an “intervention” and occasional use of a stethoscope is not is that the former does not require the woman to stay motionless on her back to avoid dislodging the leads, which means she cannot walk to relieve pain, thus perhaps needing more medications, and her labor may be slower.
+++++++++
Actually, it is better to understand both intermittent auscultation and continuous monitoring as interventions, with potentially different harms and benefits that can be tested against each other. While it’s true that CTG interferes more with a woman’s labour, in terms of position – it is not clear to what extent the negative outcomes associated with CTG are mediated by factors such as position (which could be overcome with telemetry or greater efforts on the part of caregivers to achieve mobility with CTG monitoring) and to what extent they are the result of the low specificity of the technology.
Both forms of monitoring could, of course, also both be tested against genuine non-intervention (i.e. “don’t monitor”) provided you could get an ethics committee to approve such a study and women to participate in it – which I doubt.
apteryx:
“the reason electronic fetal monitoring is an “intervention” and occasional use of a stethoscope is not is that the former does not require the woman to stay motionless on her back to avoid dislodging the leads, which means she cannot walk to relieve pain, thus perhaps needing more medications, and her labor may be slower.”
But cEFM does not require a woman to stay motionless on her back. That’s just another canard made up by homebirth advocates. Fetal monitoring can be done wirelessly and a woman is entirely free to move.
Plonit:
“Chamberlain et al 1994″
That study, like almost all homebirth studies, resorted to comparing homebirth to hospital birth of high, moderate and low risk. Obviously hospital birth of high and moderate risk women is going to have higher neonatal resuscitation rates. The only valid comparison is with low risk hospital birth, and that’s a comparison they neglected to perform.
Not entirely a canard, since movement can result in loss of contact (if using external transducer) and therefore may be discouraged by a caregiver whose priority is consistency of the trace over the woman’s mobility. Personally, I’m happy to move with the woman, respositioning the transducer as necessary to ensure a consistent trace. Of course, that does require 1-2-1 care – something that is apparently too expensive.
lkw:
“It should be published to be *heard* above the din of the Internet.”
What difference does it make whether it is heard above the din on the internet? The point is that careful examination of the paper shows that rather than demonstrating the safety of homebirth, it demonstrates that homebirth with a CPM increases the risk of neonatal mortality. The authors deliberately made a deceptive comparison instead of the appropriate comparison and subsequently they lied about it, claiming publicly that the data was not available when it was in their hands all along.
What bothers me, and this is an ethical issue, not a scientific issue, is that professional homebirth advocates like Johnson and Daviss, Henci Goer and others KNOW that the J&D paper shows homebirth increases the risk of neonatal death; they’re are hiding the truth about homebirth and they are knowingly misleading women.
hospital birth of high, moderate and low risk.
++++++++++
That’s not an entirely fair judgment of the study. The study groups were matched as far as possible for obstetric history, as well as age, parity etc…
The home birth group was all women who chose home birth, and then matched with a woman in the same locality, close in age, socio-economic factors, While it is true that some obstetric risk factors were higher in the hospital group than the home birth group, the hospital group were still lower risk than the total population (e.g. previous low birth weight baby: 2% of the home birth population studied, 3% of the hospital population studied, as compared with 7% in the population overall). Looking at the comparison of the groups, it would be fair to say that the hospital group were much lower risk than the general population (as you would expect from the matching by obstetric history) but on several measures not as low risk as the home birth group.
That’s the difficulty with a case-control matched pair study. The difficulties of doing an RCT on place of birth are discussed by Chamberlain. These are some of the difficulties that the NPEU study has presumably been designed to resolve.
Plonit:
“While it is true that some obstetric risk factors were higher in the hospital group than the home birth group”
Which means that the groups were not comparable and no conclusion can be drawn.
“That’s the difficulty with a case-control matched pair study.”
Not necessarily. The authors could have excluded all women in the hospital group that had risk factors such as pre-existing medical conditions or pregnancy complications. Surely, if they could correct for economic status, they could correct for medical status.
Regardless of why they failed to make the appropriate adjustment, the conclusions are not valid.
Amy replied,
“lkw:
“It should be published to be *heard* above the din of the Internet.”
What difference does it make whether it is heard above the din on the internet? The point is that careful examination of the paper shows that rather than demonstrating the safety of homebirth, it demonstrates that homebirth with a CPM increases the risk of neonatal mortality. The authors deliberately made a deceptive comparison instead of the appropriate comparison and subsequently they lied about it, claiming publicly that the data was not available when it was in their hands all along.
What bothers me, and this is an ethical issue, not a scientific issue, is that professional homebirth advocates like Johnson and Daviss, Henci Goer and others KNOW that the J&D paper shows homebirth increases the risk of neonatal death; they’re are hiding the truth about homebirth and they are knowingly misleading women.”
———————————————————————————
Amy, you should publish a detailed analysis of Johnson and Daviss and other homebirth studies that you claim show triple the mortality rate. Why? Because a thorough critique published in the same journals that published the original research articles has more credibility. If you care about the abuse of statistics and misinformation you claim is going on and want to get the media’s attention and save the lives of many babies, isn’t it your duty to set the record straight in a professional forum of peers that will gain public attention? (And sorry, SBM or Skeptical OB blog don’t count.)
Isn’t it potentially slanderous to claim that Johnson and Daviss, Henci Goer and others are hiding the truth about homebirth and knowingly misleading women? Where is the proof?
StatlerWaldorf:
“Isn’t it potentially slanderous to claim that Johnson and Daviss, Henci Goer and others are hiding the truth about homebirth and knowingly misleading women?”
Truth is an absolute defense against claims of libel or slander.
Moreover, Johnson and Daviss, Henci Goer and others have not dared to contradict my claims. Why would they? That would only draw attention to the disingenuous attempts to hide the dangers of homebirth from the public.
I said “Intervention rates are lower for planned home births than for planned hospital births in low-risk women (Janssen et al 2002 – the Canadian study – and others).”
Amy replied “Among homebirth advocates, an “intervention” is anything that homebirth advocates don’t approve of. For example, medication for pain relief is an “intervention” but acupuncture for pain relief is not. Electronic fetal monitoring is an “intervention,” but auscultation with a fetoscope or doppler is not.”
This is yet another red herring. Amy has read the paper Janssen et al paper and should know better. For those who haven’t, let me share a relevant summary of Table 2. For brevity, I’ll just give the percent of women who had a given intervention. I’m also excluding rows where no statistical comparison is reported in the table. HB=homebirth group; PA=hospital, physician-assisted (no midwife); MA=hospital, midwife-assisted. The hospital midwives are the same people (with the same training) as the homebirth midwives.
Epidural analgesia or anesthesia: HB=7.7%, PA=27.6%, MA=26.3%
Narcotic analgesia: HB=2.7%, PA=34.7%, MA=13.1%
Spinal anesthesia: HB=3.0%, PA=9.6%, MA=7.5%
General anesthesia: HB=0.7%, PA=2.7%, MA=1.1%
Electronic fetal monitoring
Any: HB=14.7%, PA=82.6%, MA=58.0%
External: HB=14.7%, PA=82.2%, MA=57.3%
Internal: HB=1.6%, PA=10.1%, MA=7.7%
Induction (with oxytocin or prostaglandins): HB=4.3%, PA=22.3%, MA=14.0%
Augmentation of labour
Artificial membrane rupture: HB=15.8%, PA=37.0%, MA=27.1%
With oxytocin or prostaglandins: HB=6.4%, PA=16.8%, MA=19.1%
Episiotomy
Any: HB=3.8%, PA=15.3%, MA=10.9%
Mediolateral: HB=1.7%, PA=10.8%, MA=8.1%
Caesarean section: HB=6.4%, PA=18.2%, MA=11.9%
Nulliparous CS rate: HB=11.2%, PA=21.5%, MA=15.4%
Multiparous CS rate: HB=2.2%, PA=15.1%, MA=7.1%
Multiparous CS rate (no previous CS): HB=0.9%, PA=4.2%, MA=3.9%
Primary indication for CS
Breech: HB=0.8%, PA=0%, MA=0%
Dystocia or cephalopelvic disproportion: HB=2.0%, PA=5.4%, MA=7.0%
Fetal distress: HB=1.3%, PA=3.6%, MA=2.1%
Repeat CS: HB=0%, PA=4.2%, MA=0.2%
Abruptio placentae: HB=0%, PA=0%, MA=0.4%
Placenta previa: HB=0%, PA=0.5%, MA=0.2%
Other: HB=1.4%, PA=1.7%, MA=0.9%
Malposition/malpresentation: HB=0.8%, PA=2.7%, MA=1.2%
Genital herpes: HB=0.1%, PA=0%, MA=0%
Remember that HB means planned homebirth – those weren’t caesarean sections performed on the kitchen table!
The authors compared the homebirth group separately to the physician-assisted and the midwife-assisted hospital groups. Out of all that, the only differences that were not statistically significant (after Bonferoni correction for multiple comparisons) were:
General anesthesia: HB against MA
Nulliparous CS rate: HB against MA
Multiparous CS rate (no previous CS): HB against PA or MA
Primary indication for CS:
Most of these differences were non-significant. However, most also had too few cases (often less than ten) to allow for robust statistical comparison.
So, whether you look at pain-relief, fetal monitoring, induction rates, induction and augmentation, episiotomy, or CS, they all tend to occur more frequently in a hospital setting than a home setting, even when subjects are matched for all possible confounding risk factors. Contrary to what Amy suggested, I assert that this study supports my claim that intervention rates, measured as objectively as possible, are higher among hospital births than among home births.
Some women may not care; others might prefer to reduce their risk of chemical or surgical interventions. Given that mortality rates are not different between the two groups, there is no need to label such women as irrational. You may choose differently yourself, but they are not being anti-science in making such a choice, given this evidence. (Provided they are at low risk, have well-trained midwives, etc.)
TimMills:
“Given that mortality rates are not different between the two groups”
Actually, Janssen was forced to publicly retract the claim that the mortality rates were the same, which was the least she could do when you consider that the homebirth group had two perinatal deaths and the hospital birth groups had none.
The Canadian Medical Association Journal published 7 letters to the editor critical of the study’s statistical methods and the conclusions of the study, specifically the fact that the homebirth and hospital groups differed in risk level and that the homebirth group had 2 perinatal deaths and the hospital group had none. The CMAJ offered Janssen an opportunity to reply to her critics. Her response includes the following (CMAJ, June 11, 2002; 166 (12)):
“Although we tried to ensure that comparison groups met eligibility criteria for home birth, women who choose home birth differ from those who select hospital birth in both measurable and unmeasurable ways…”
Furthermore:
“The purpose of our study was not to determine which method of care was better, home vs. hospital, but rather to assess whether, at the 2-year interval, home birth was safe enough to continue to be offered as a choice for women in the context of ongoing evaluation.”
So the author herself was forced to acknowledge that the study cannot be used to support the safety of homebirth.
Amy Tuteur writes:
“But cEFM does not require a woman to stay motionless on her back. That’s just another canard made up by homebirth advocates.”
“Canard” means, in many people’s vocabulary, “Fact I don’t like.” I personally know a woman who had delivered two children in her native country without medication; when she had her third in an American hospital, she was indeed required to stay in bed, and because she could not walk to relieve the pain of contractions, needed analgesia. Fortunately, that did not further lead to the need for a C-section.
Dr. Amy’s argumentative style looks to me like the health version of global warming denialism: conflate values conflicts with facts, reject facts and research results you don’t like, demonize researchers who published them, and heap vitriol on nonscientists who disagree with you. It’s a popular style around here. Ironically, for many of your beliefs you’ve got enough facts on your side, or at least not completely or provably against you, that you could make a credible case for donig things your way with civil, logical, relatively unbiased arguments. Why not try it?
In discussing the Chamberlain study above, Dr Tuteur says
“Which means that the groups were not comparable and no conclusion can be drawn.”
The study was a case-control. The pairs were matched on a wide variety of attibutes; in the aggregate, the cohorts differed only marginally in a few factors.
But if any minor defect in cohort matching is sufficient to invalidate a result, then I don’t understand why Dr Tuteur (in this thread and now the newer one as well) seems to assign any import to the use of “state and national statistics”. In particular, her cohort analysis from the CDC Wonder database fails on a much larger scale than any of the published studies which she criticizes.
The largest flaw is the assumption that restricting the selection of hospital births to 37+ weeks of gestation, 2500+gram BW, white women, maternal age 20- 44, and further restricting to CNM-attended births, somehow yields a “low-risk” group that can be statistically compared to the self-selected cohort of women who choose homebirth with a non-nurse midwife. Dr Tuteur claims “The risk profile of CNM hospital patients is slightly higher than that of DEM patients” but this is an assertion without evidence. It is true that in an ideal world, all home birth clients ought to be at low risk. But the retrospective statistics capture results from the real world, and in the real world in the United States, some women choose home birth even though their risk profiles might be less than pristine.
Let me anticipate your response that this is evidence that home-birth midwives are incompetent because they cannot or do not screen their clients appropriately. Leave aside the ethical dilemma presented by abandoning a client who resists a recommended referral or refuses transfer; those are issues to pursue in another thread. They have no relevance at the moment to the issue of proper statistical matching. In order to draw a valid conclusion, you need to select a comparative cohort that matches the home-birth cohort as it actually exists in real life.
I assert that your choice of cohort matching is flawed in serious ways.
First, take note of the fact that in the CNM hospital cohort, approximately 5% (25,000 of 560,000) of your group consists of grand-multiparas. (women who have already had at least 4 children). In the out-of-hospital, other midwife group, the proportion is 21% (7500 of 35,000). This is on its face an independent confounding factor, which you have neither acknowledged nor adjusted for. But it also strongly suggests other demographic differences which were mentioned upthread by heyunyi, the fact that specific religious subgroups (Amish, Mennonite, certain offshoots of LDS and Seventh Day Adventists, and others) are far overrepresented in the homebirth group. While religion on its own is not a medical risk factor, isolated cultural subgroups can and do have many lifestyle factors that impact overall health.
Any serious analysis of raw birth statistics must at a minimum acknowledge the existence of such factors, in order to correctly match them.
Second, let’s take a closer look at the hospital cohort as well, to see what hidden confounders may be present. For rough analysis purposes, I have selected the state data for Indiana and Pennsylvania to compare against each other. For the record, this is not cherry picking. I selected these states because on the surface, you might expect them to have similar results. They are both middle-size states, with populations that are roughly balanced between large urban centers and many rural communities; there are few truly remote areas where distance to medical care is a large factor; among the white population already selected for, the ethnic profiles seem relatively comparable; income and socioeconomic factors are also relatively comparable. Now, I am not trying to make the case that these populations are totally identical, I am just pointing out that they are more similar than, for instance Massachusetts vs North Dakota or Mississippi vs Wisconsin.
That said, let’s look at neonatal mortality among hospital births, all providers (already limited by the same exclusion criteria in the original post) – the last column is neonatal mortality per 1000:
Indiana (18) In Hospital Total 132 168,019 0.79
Pennsylvania (42) In Hospital Total 140 268,838 0.52
(For the record, this difference is statistically significant at the 95% confidence level – CIs are 0.66 – 0.92 for IN and 0.44 – 0.60 for PA, in other words, the difference in neonatal death rate cannot be attributed to chance).
There are three plausible explanations for this difference. (1) Differences in quality of care (2) differences in underlying risk level (3) some combination of the above.
Now, if some hypothetical person (not I) were to apply the same standard of evidence as Dr Tuteur uses in her analysis, that person might say that the excess deaths in Indiana were the result of incompetent hospital practitioners, or incompetent hospital practices, since our prior restrictions (BW, gestation etc) have allegedly leveled out risk. While we can’t rule that out entirely, it would seem highly unlikely that the overall quality of hospital care in Indiana can explain this result, since hospital practitioners in Indiana are trained to the same standards as elsewhere.
Perhaps the Indiana statistics look worse due to contamination by home birth transfers? That explanation fails, because Pennsylvania has a higher proportion of out-of-hospital births than Indiana (3.2% vs 2.4%), so if hospital mortality rates were affected by home-birth transfers, it would affect Pennsylvania results more than Indiana’s.
So we are left with the conclusion that even after restricting birth statistics by race, age, gestational age, and birth weight, we still do not have a homogeneous level of underlying risk factors. At this point, we don’t have the tools to identify exactly what those factors are; as a resident of Indiana, I think it would be important to do further research. If it were possible for Indiana hospitals to achieve the same results as Pennsylvania hospitals, then approximately 50 deaths could have been prevented in Indiana over 3 years, which is incidentally a larger number than the number of deaths attributed nationally to homebirth over that same time.
But I digress; what is clear is that any serious cohort analysis for underlying risk factors is lacking in the orginal presentation at the top of the post.
And there is a third major flaw in this analysis introduced by restricting the cohort to CNM births. CNMs are not evenly distributed about the country. CNM-attended births as a proportion of all vaginal births range from 0.7% in Arkansas to 35.9% in New Mexico. http://www.midwife.org/siteFiles/news/TrendsinCNMBirthsfromJF07JMWH.pdf
Generally speaking, CNM births are more common in the Northeast and west coast, and least common in the midwest and mountain states. The result is that when you restrict your hospital cohort to CNM births only, you have introduced a serious geographical skewing, oversampling from areas where the underlying risk factors are smallest, and drastically undersampling from the regions where they are greater. Therefore any national cohort of CNM births is inherently biased toward good outcomes.
And finally, there is the unexamined issue of data quality. In a closer look at the IN/PA results referenced above, I noticed a specific peculiarity in the out-of-hospital data.
Indiana (18) Not in Hospital Other 8 2,023
Indiana (18) Not in Hospital Other Midwife 1 205
Pennsylvania (42) Not in Hospital Other 2 634
Pennsylvania (42) Not in Hospital Other Midwife 8 3,820
I’m not focusing on death rates now, the numerators are too small to be useful. I am focusing on the number of reported births. Now the “other” category of attendant is clearly a catch-all. It includes births which were unattended, attended only by untrained bystanders, husbands, partners, relatives, whatever. At least some of these were unplanned. But what catches my eye is the huge difference in the way the “other midwife vs other attendant” numbers are hugely unbalanced when comparing IN to PA. Indiana has ten times as many births recorded by “other” than by “other midwife” (CPM or other DEM). In Pennsylvania, the numbers are skewed 5 to 1 in the OTHER direction. I don’t claim to have a complete picture of home birth in Indiana, but I am close enough to it to know that Indiana is not a hotbed of “trendy” unattended childbirth (UC), and I highly doubt that a huge number of Indiana women who intend hospital birth are having trouble getting to a hospital on time. What I do know is that the legal environment for non-nurse midwives in Indiana is very hostile. What I strongly suspect, from the above numbers, is that there is a considerable number of midwife-attended homebirths in Indiana, where the birth certificate data, later registered by the family, does not reflect the midwife’s attendance. We can only speculate whether the “true” neonatal death rate would be better or worse with more accurate reporting. And we can only speculate to what extent this may be true in other areas. Any discussions of the legal and ethical import of this can be put aside for now, because again I am focusing on the validity of the statistical analysis. It is clear (at least to me) that the accuracy of the original dataset is questionable, and given that the homebirth numbers are relatively small, we should be somewhat skeptical of accepting the calculated mortality rates as accurate.
And I haven’t even touched on the issue of homebirth-tranfer-to-hospital vs CNM-transfer-to-MD. A serious statistical analysis would at least discuss some plausible estimate of the number of cases which are missing due to these factors.
So in summary, Dr Tuteur’s analysis of CDC statistics is flawed in these ways:
It is based on data where the underlying data quality is questionable for one cohort.
It fails to identify or discuss demographic factors which make the homebirth cohort unique.
It fails to evaluate or adjust for known confounding factors.
It uses a geographically skewed hospital cohort for comparison.
It fails to account for missing data due to transfer of care.
It is clear that the original statistical presentation in this post falls far short of anything resembling scientific evidence. And, in my opinion, it is unprofessional to use throw-away lines to dismiss the results of other serious researchers, and at the same time feature this sort of crude statistical analysis as being relevant. What’s also missing is a serious discussion of the legal and ethical obstacles involved in doing any valid scientific research on homebirth in the US.
If we are truly discussing science based medicine, then we should expect all evidence provided to meet the standards of science. (Thank you TimMills for your presentation of the Cochrane summary). I would hope that when we see future posts regarding specific childbirth practices, they will spend more time on an unbiased review of published valid research as a starting point, rather than a much later unannotated offhand reference to “all existing scientific studies”.
And I hope that this doesn’t come across as nitpicking or carping, but I think that in this forum it would be advisable to avoid the informal conflation of correlation and causation – i.e.
“homebirth with a CPM has a neonatal mortality rate almost triple that of hospital birth” as opposed to “Homebirth with a homebirth midwife dramatically increases the risk of neonatal death.” To a scientifically-minded reader, these two statements are not equivalent, and you could use more careful language to express your conclusions.
A comprehensive review of homebirth studies by NICE (National Institute of Health and Clinical Excellence) concluded that the hospital group was a higher risk group.
As regards the national statistics, you are claiming that the homebirth group was higher risk than the hospital group but you have not demonstrated it. Moreover the results are consistent with the Johnson & Daviss studies of CPMs.
Finally, MANA has the resultsof 20,000 CPM homebirth. A recent announcement declared that the results will not be released to anyone who can’t prove an ideological commitment to using the results in a way that is acceptable to MANA.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
A comprehensive review of homebirth studies by NICE (National Institute of Health and Clinical Excellence) concluded that the hospital group was a higher risk group.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
And your evidence that this is applicable to the US population in 2003 – 2005 is?
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>As regards the national statistics, you are claiming that the homebirth group was higher risk than the hospital group but you have not demonstrated it. Moreover the results are consistent with the Johnson & Daviss studies of CPMs.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
I have not made that claim. I have made the observation that you have not properly accounted for confounding factors, and I have noted that you are applying a double standard by criticizing the cohort matching in other studies, and following a much much much more lax approach to cohort matching in your own analysis.
The Johnson & Daviss study suffers from the same shortcoming, neither their original paper nor your commentary has properly identified a correct hospital cohort group for direct comparison. At least their paper discussed the obstacles involved in selecting such a cohort.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Finally, MANA has the results of 20,000 CPM homebirth. A recent announcement declared that the results will not be released to anyone who can’t prove an ideological commitment to using the results in a way that is acceptable to MANA.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
If you had access to those statistics, please describe how you would choose a comparable hospital group of births for comparison. If you will be starting with vital health statistics from the CDC, you need to explain how you would account for and adjust for all of the factors that I noted above, and hopefully as a professional you would go far deeper into statistical analysis.
IndianaFran:
“And your evidence that this is applicable to the US population in 2003 – 2005 is?”
It’s not applicable to the US population. I’m sorry I didn’t make it clear. It was NICE’s criticism of the Chamberlain study.
“I have made the observation that you have not properly accounted for confounding factors”
You haven’t shown that they are confounding factors.
“The Johnson & Daviss study suffers from the same shortcoming”
No, the J&D study suffers from a different, and more serious shortcoming. The authors didn’t compare the neonatal mortality rate in the homebirth group with the neonatal mortality rate in the hospital group that THEY USED for comparison of interventions.
That comparison shows that homebirth has nearly triple the neonatal death rate of hospital birth. They tried to hide that by comparing homebirth in 2000 with a bunch of out of date hospital studies extending back to 1969.
“If you had access to those statistics, please describe how you would choose a comparable hospital group of births for comparison.”
That’s easy. I’d use the same parameters they used in choosing homebirth patients, low risk patients with no pre-existing medical conditions and no pregnancy complications.
I can’t do any comparison, because MANA is insisting on an ideological litmus test for showing the data. They are explicit that they will not show the data to anyone who cannot be counted on in advance to use the data to support homebirth midwifery. Why would they need to do that unless they know that the data shows homebirth with a CPM is not as safe as hospital birth?
Frankly, I think withholding the data and applying an ideological litmus test to researchers is unethical. It deprives women of the information they need to make an informed choice about homebirth.
Do you really need evidence that grandmultiparity is an independent confounding factor?
here it is (I apologize for formatting ugliness)
Live Birth Order Deaths Births Death Rate Per 1,000
One child born alive to mother 1,640 2,657,850 0.62
Two children born alive to mother 1,386 2,576,366 0.54
Three children born alive to mother 776 1,357,767 0.57
Four children born alive to mother 370 505,147 0.73
Five children born alive to mother 146 170,360 0.86
Six or more children born alive to mother 142 120,835 1.18
Unknown or not stated 28 23,032 1.22
Total 4,488 7,411,357 0.61
After the second birth, there is a linearly increasing rate of neonatal death. The sixth and subsequent children have twice the incidence of neonatal death as the second child. A cohort that contains 20% grand multiparas cannot be directly compared to a cohort that contains 5%.
If you want to argue that this is not a known confounding factor, then I would suggest that you reread this post that you yourself made on Dec 26, 2006
http://homebirthdebate.blogspot.com/search/label/Johnson%20and%20Daviss
Here is an excerpt:
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
For a characteristic to be a confounder in a particular study, it must meet two criteria. The first is that it must be related to the outcome in terms of prognosis or susceptibility…
The second criterion that defines a confounder is that the distribution of the characteristic is different in the groups being compared.
The article highlights three questions that must be asked to identify confounders in a cohort study:
Has there been a systematic effort to identify and measure potential confounders?
Is there information on how the potential confounders are distributed between the comparison groups?
What methods are used to assess differences in the distribution of potential confounders?
>>>>>>>>>>>>>>>>>>>>>>>>>>>>end of excerpt
You can go ahead and adjust your calculations for this factor, but you can’t claim that there are no others, because it is clear that you have not even looked for them. I see no evidence here that you have performed even the most basic statistical analysis of this CDC data.
And you haven’t even tried to address the issue of geographic skewing I brought up. I demonstrated that there is significant state-by-state variation in neonatal death rates (not related to place of birth or birth attendant), and that using CNM data distorts the state-by-state balance in a significant way.
So if you were to propose using the same seriously deficient statistical analysis methods to evaluate the home birth data currently owned by MANA, well, I wouldn’t trust you to derive a meaningful result either.
IndianaFran:
“Live Birth Order Deaths Births Death Rate Per 1,000
One child born alive to mother 1,640 2,657,850 0.62 …”
We don’t need to adjust, we can do a direct comparison.
We can directly compare the death rates of CNM hospital birth with CPM homebirth for each level of parity.
1 child CNM 0.48/1000 CPM 1.40/1000
2 children CNM 0.30/1000 CPM 1.50/1000
3 children CNM 0.42/1000 CPM 0.46/1000
4 children CNM 0.42/1000 CPM 2.10/1000
5 children CNM 0.67/1000 CPM 1.20/1000
6+children CNM 0.28/1000 CPM 0.70/1000
As you can see, in almost every category homebirth with a CPM has triple or higher neonatal mortality compared with CNM hospital birth. That’s a pretty devastating indictment.
Your response is totally unresponsive to my original observation.
I have demonstrated the presence of at least one confounding factor in the CDC cohorts you have compared.
Therefore, you cannot claim that the cohorts are comparable.
Therefore, you cannot claim (based on the CDC data) that “homebirth has xx times the neonatal death rate of comparable risk hospital births”.
Your subanalysis does not magically make the cohorts equal.
It confirms the fact that high parity is a confounding factor – no matter who is taking care of these women, increasing parity above two increases the neonatal death rate.
(The result you show for the highest parity group for CNMs is likely an anomaly due to small numbers, the hospital-MD rate is 1.24. )
In fact, speaking of small numbers, it’s interesting that you have chosen to present only calculated mortality rates and not the counts. Is that perhaps because of this caveat which accompanies the CDC database:
“Rates are suppressed when there are fewer than 20 deaths in the numerator, because the figure does not meet the NCHS standard of reliability or precision.”
A closer looks shows that of the 12 calculated death rates you presented above, only 3 of them actually meet that standard, the rest were suppressed.
There’s nothing “wrong” with recalculating those rates by hand, and presenting them, but when you say that “we can directly compare” you are on very shaky ground based on statistical methodology.
But you knew that, since the CDC inquiry brings the actual rates up as “suppressed”. Some hypothetical person (not I) who might be prone to divining motives behind other people’s behavior, might actually come to the conclusion that you were trying to “hide” something by presenting the chart in this way. Others might simply ascribe this to a lack of familiarity with basis statistical concepts like valid sample size.
IndianaFran:
“Your response is totally unresponsive to my original observation.”
Hardly. You can slice and dice the data any way you want, but the end result is still the same. When you compare like with like, homebirth has a higher rate of neonatal death.
Merely announcing that there is a potentially confounding variable is not enough to discredit the overall result.
In the first place, you never showed that parity is a confounding variable. The fact that the neonatal death rate among all hospital births varies with parity does not necessarily make it a confounding variable. Indeed, there is scientific evidence that neonatal death may vary with parity in some circumstances because parity is a proxy for both age and social class.
As a general matter, women of higher parity are older (and therefore at greater risk) than women of lower parity. In addition, high parity in our society is generally associated with lower socioeconomic class, another risk factor for poor perinatal outcome.
If you look at the comparison of neonatal mortality rates with parity for CNM patients as I presented above, you will see that there is no association of neonatal mortality rates with parity.
Most importantly, if neonatal mortality rates are higher for homebirth at every level of parity, adjusting both populations for parity is still going to show that homebirth has a higher neonatal death rate.
Therefore, your claim that parity is a confounding factor is not justified by the data, comparing homebirth with low risk hospital birth at every level of parity shows homebirth has an increased rate of neonatal death, and even if parity were a confounding factor, adjusting for it would still show that homebirth has an increased rate of neonatal death.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>IndianaFran said”
“If you had access to those statistics, please describe how you would choose a comparable hospital group of births for comparison.”
Amy Tuteur, MD replied:
That’s easy. I’d use the same parameters they used in choosing homebirth patients, low risk patients with no pre-existing medical conditions and no pregnancy complications.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Your tossoff answer here again shows that you don’t fully get it. This is not an easy question to answer. If it were easy, then science would have arrived at a definitive answer.
ACOG says in their position paper
http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm
“It should be emphasized that studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous. ” They don’t say “the scientific evidence is clear”.
ACNM says
http://www.acnm.org/siteFiles/education/Direct_Entry_Midwifery_Nov_05.pdf
“Despite a plethora of published papers on related topics, there are very few studies that isolate DEM practice as
a variable. The outcomes documented in the literature are mixed, with some investigators reporting better than
average outcomes among women attended by direct entry midwives, while others document better outcomes
provided by physicians and/or nurse-midwives. It is difficult to draw a conclusion from these studies, since they
are few in number, have a number of design problems, provide limited information regarding the multiplicity of
educational models for preparing DEMs, and often do not address the most current models. For those who are
seeking evidence to support a particular model of education or regulation for DEMs, it is clear that more
definitive research is needed on the relationship between educational pathways and clinical outcomes.”
You seem to be the only “authority” who believes that science has reached a settled conclusion.
The issue of cohort matching is, indeed, a difficult one.
This is particularly true in the US, where home birth providers have faced legal and political pressures that are unique. As a result, the very small number of women who choose home birth here consists of a motley assortment of “odd ducks”. While “some” of them are middle-to-upper-class who identify largely with mainstream culture, there are also many who are some sort of cultural dropout – the fringe religious groups mentioned earlier, people who self-identify as counterculture for various reasons, women with economic hurdles to hospital birth, and women whose prior birth experience has left them with emotional trauma. (It is irrelevant whether you think they “ought” to feel traumatized).
Finding a group of hospital clients who “matches” this heterogeneous group is statistically difficult, if not impossible.
Indeed, even defining the characteristics of the home birth group is problematic, because of the inaccuracies in recording birth attendant, especially in states where direct-entry midwifery is illegal.
So, go ahead and tell us that this is an easy question. It only shows that you are interested in finding a short-cut to the answer, not in using the difficult tools of science to get there.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
If you look at the comparison of neonatal mortality rates with parity for CNM patients as I presented above, you will see that there is no association of neonatal mortality rates with parity.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>.
No, what you can see is that among the higher parity levels, the numbers are too small to draw any conclusions.
That’s why I presented the data for all women (within the 20-44 age group, etc) by parity, because the numbers related to parity meet the statistical levels for reliability and precision.
You are the one who is “slicing and dicing” the data into statistically questionable territory.
In fact, most CNMs likely refer most high-parity clients to MDs. The small numbers who remain in the CNM group are not representative of high-parity women in general.
“Indeed, there is scientific evidence that neonatal death may vary with parity in some circumstances because parity is a proxy for both age and social class.”
I have made the claim that parity is a confounding factor. I have NOT made the claim that parity is an independent confounding factor. Of course it is related to age and class.
If the cohorts were already proven to be equivalent in age and social class, then indeed parity might already be fully accounted for, and would not correctly be assessed as a confounder. But you haven’t even tried to show any attempt at matching for age or socioeconomic status.
To start, you lumped all women age 20 – 44 into one risk class for your analysis. Have you even attempted to verify that the homebirth and hospital CNM cohorts are balanced similarly within the age categories (20-24, 25-29, etc)? Can you show us your work?
And since you have also brought up the issue of socioeconomic class, there is no way to assert that the two cohorts you have selected for are matched in socioeconomic profile. That data point is not collected, and therefore cannot be assessed. Therefore you cannot assert that the groups are comparable. The differences in parity level, in fact, strongly imply that socioeconomic profiles would not match if they were available.
I ask you here to answer these three questions
“Has there been a systematic effort to identify and measure potential confounders?
Is there information on how the potential confounders are distributed between the comparison groups?
What methods are used to assess differences in the distribution of potential confounders?”
IndianaFran,
You need to decide what you are trying to argue.
First you claim that parity is a confounder.
I point out that when you control for parity, homebirth has a higher neonatal death rate.
Then you claim that we can’t rely on the death rates for homebirth at high parity because there are too few women in each parity cohort.
But if there are too few women, how can you claim that the data indicates that parity is a confounding factor? You certainly are not entitled to extrapolate from a higher risk group since we are talking only about low risk birth.
Moreover, as I keep pointing out, this dataset is not the only source of information. The data is consistent with the Johnson and Daviss study, the most carefully done study of American homebirth to date. When you look at the neonatal death rate for all CPM attended homebirths in North America in 2000 and compare it to the death rate for low risk hospital birth in 2000, you find that homebirth has nearly triple the neonatal death rate.
In fact, with the exception of the recent Dutch and Canadian studies, where the training of midwives are quite different from homebirth midwives in the US, there is no scientific study or dataset that shows homebirth to be as safe as hospital birth.
Finally, there is the situation with the MANA (the official organization of homebirth midwives) dataset. We don’t know what’s in it, or whether the data is valid. We do know that MANA is restricting access to ONLY those who can prove, in advance, that they will use the data to support the homebirth movement. Even these people must sign a legal non-disclosure agreement promising not to share the data with anyone else.
If you have to prove that you will use the data only to support the homebirth movement, the database must contain data that undermines the homebirth movement. I don’t know specifically what that data is, but it is not unreasonable to speculate that the largest database of its kind shows that homebirth with a CPM is not as safe as hospital birth. Why else would MANA need to hide it from the general public. I can’t think of a legitimate reason; can you?
“You need to decide what you are trying to argue.”
OK, let me make this very clear.
I am arguing that the CDC statistics which you have presented at the top of your original post, cannot be claimed to contribute to any definition of Science-Based Medicine because there has been insufficient statistical analysis of the data to meet the standards of contemporary science.
I have pointed out several specific flaws in the cohort matching.
Some of these (geographic skewing) you have made no attempt to answer.
Your answers to other questions (in my opinion) reveals the fact that you did not perform even minimal statistical testing to verify cohort matching before you presented these “results”.
The question of what other studies show remains open to debate. That debate is a valid way to attempt to find a science-based answer.
My focus has been on the results which you yourself have presented, as an introduction to the topic of home birth in this forum. I infer that you believe that this data adds evidence to the scientific debate. I contend that this does not qualify as scientific evidence.
IndianaFran,
I’d be the first to acknowledge that the dataset is not perfect. However, its biggest problem biases strongly toward homebirth. In other words, this dataset makes homebirth looks safer than it is. That’s because the homebirth to hospital transfers are not included in the homebirth group.
In the Johnson and Daviss study, for example, approximately 12% of the patients were transferred to the hospital. However, 8/14 deaths in the homebirth group were pronounced at the hospital. In a dataset such as the one we are analyzing, more than 50% of the homebirth deaths would be erroneously put into the hospital birth group.
You keep insisting that we should ignore this dataset because there must be some confounding factor that makes the homebirth group higher risk than the hospital birth group, but you haven’t provided evidence of such confounders.
Finally, what I consider the most important point is incontrovertible. Although professional homebirth advocates in websites and publications insist that the scientific evidence shows that homebirth is as safe as hospital birth, there is no such evidence supporting the safety of American homebirth and a considerable amount of evidence showing that homebirth increases the risk of neonatal death.
There is certainly no scientific justification for claiming that homebirth with an American homebirth midwife is as safe as hospital birth.
Tim Mills:
Epidural analgesia or anesthesia: HB=7.7%, PA=27.6%, MA=26.3%
7.7%of the home births had an epidural or anesthesia? Who did they get to do that?
“You keep insisting that we should ignore this dataset because there must be some confounding factor that makes the homebirth group higher risk than the hospital birth group, but you haven’t provided evidence of such confounders.”
I have not said that we should ignore this dataset. I have said that your cursory analysis of the data is not scientific.
I have asked you to answer this question, and the followups:
Has there been a systematic effort to identify and measure potential confounders?
It might be possible to tease out some meaningful results using the CDC dataset as a starting point. But the first hurdle is to find a hospital cohort that is truly comparable, and provide the evidence for comparability. Simply making an assertion about risk profiles and hoping that nobody looks any deeper is not science.
I really really hope that when Monday comes, we have some statistically minded feedback on this exchange.
“I’d be the first to acknowledge……….”
may I suggest that after 220+ comments over 10 days, this statement can be said to be objectively false?
TsuDhoNimh
7.7%of the home births had an epidural or anesthesia? Who did they get to do that?
_________
The study to which Tim Mills refers was intention to treat analysis of place of birth. His note on caesareans also applies to epidurals
“Remember that HB means planned homebirth – those weren’t caesarean sections performed on the kitchen table!” (i.e. a proportion of the home birth group transferred, and of those, some had epidurals).
“There is certainly no scientific justification for claiming that homebirth with an American homebirth midwife is as safe as hospital birth.”
I’m not sure why you have directed that comment to me; I have never made that claim.
The claim I have made can perhaps be stated
There is no scientific justification for claiming that homebirth with an American homebirth midwife is x times as dangerous as hospital birth, regardless of what value you supply for x.
“In the Johnson and Daviss study, for example, approximately 12% of the patients were transferred to the hospital. However, 8/14 deaths in the homebirth group were pronounced at the hospital. In a dataset such as the one we are analyzing, more than 50% of the homebirth deaths would be erroneously put into the hospital birth group.”
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
One last nitpick before I go to bed. The location where the death was pronounced has no relevance to how the birth location is registered on the birth certificate. For births which occur at home or in transit, where the baby later dies at the hospital, I’m pretty sure that the hospital administration/legal dept folks will insist that the birth certificate is correctly registered as an out-of-hospital birth, because they would not want that death to appear in their statistics. It’s far more likely that only the only transfers which are lost are the ones where the baby was actually delivered in the hospital after transporting the mother. By my count from the J/D paper, that is 2, not 8.
Perhaps someone here can check this out with a hospital admin contact? Maybe it varies with state health dept protocols?
IndianaFran:
“I’m pretty sure that the hospital administration/legal dept folks will insist that the birth certificate is correctly registered as an out-of-hospital birth, because they would not want that death to appear in their statistics.”
Absolutely not! The person who signs the birth certificate is the person who delivers the baby. If the baby is delivered at the hospital, the doctor attending is the one who signs. Hospitals don’t “register” births.
That’s why the statistics for homebirth are almost certainly worse that they appear in the dataset. Any hospital transfers before the baby is actually born appear as hospital births, even if the baby is born in the parking lot.
Moreover, and we have not yet discussed this, intrapartum stillbirths are not registered as births at all (only as fetal deaths)l and therefore would not appear in the dataset. The intrapartum stillbirth rate in the hospital if vanishingly small. According to almost all existing homebirth studies from a variety of countries, the intrapartum stillbirth rate at homebirth is much higher.
In other words, a baby rarely drops into the hands of a doctor or hospital based CNM already dead, since there is usually continuous monitoring. Unfortunately, the situation at homebirth is quite different.
@Plonit:
Thanks for picking up that point. I’m afraid I’ve lost the energy to pick at every little mis-statement that Amy or others make regarding the valid studies.
@All:
I’m going to have to bow out here. I’ve put the case as I see it (not “my” case, you realize, but the scientific case). Some points I have not made here can be found at the discussion (from a couple years back) at <a href="http://www.badscience.net/forum/viewtopic.php?f=3&t=2193"Bad Science. Any further energy I spend here is going to have a greatly diminishing return. I doubt any casual wanderer who stumbles on this blog entry is going to read all (at this point) 228 comments.
I encourage everyone to, where possible, look at the original literature. Or at least browse the abstracts. I assure you, it’s no more opaque than the discussion here, and at least it’s all peer-reviewed. That doesn’t mean it’s perfect – and I thank Amy for pointing out some of the later developments in some of these papers. But, as someone, somwhere in the mists of early comments above, said: in the absence of thorough personal knowledge on a topic, I’ll trust a published, peer-reviewed result over an unpublished blog entry, regardless of the writer’s credentials.
@Amy:
Thankyou for a bracing discussion. I look forward to seeing what else you have in store for us here at SBM.
Gah! Sorry about the bad link markup. Here it is again, if copying and pasting isn’t your style: Bad Science.
And I’m sorry about the arrogance of the statement “not my case, but the scientific case”. Perhaps I can blame it on the hours I spent up last night with the kids (both planned homebirths, one non-emergency transfer to hospital due to failure to progress, two very healthy babies, no regrets).
Anyway, carry on.
I absolutely agree that if the baby is delivered in the hospital after transport, that birth certificate will count as a hospital birth. As I read the descriptions of death cases in J/D, that is 2 cases.
I am questioning the other six cases where the baby was delivered by midwife at home or in transit, and later died at the hospital.
You implied that because the death was pronounced at the hospital, the birth would also be considered a hospital birth. I don’t think that is the case.
I am directing this question at the site editors, because I do not want to be perceived as a troll or a distraction:
Is it in any way inappropriate or harassment for me to ask Dr Tuteur, regarding her presentation of CDC statistics, this question:
Has there been a systematic effort to identify and measure potential confounders?
I have asked this question several times, and no direct answer has been given. Since the original data as presented in her post was originally composed over a year ago for another site, it ought to be a simple matter to answer this question with a yes or no.
Dr Tuteur has been reading and responding to other comments over the last few days.
Would it be inappropriate for me to press this matter further, and again ask for a direct answer to the question?
I have presented several specific factors (geographic imbalance, maternal age, parity as a medical risk, parity as a marker for socioeconomic factors) which strongly lead me to question the degree to which scientific methods were applied to this data before publishing it at this site.
At what point is it justified to assume that an honest answer to the question might be “no”?
Without a direct answer to the question, are the site editors here comfortable with having the chart presented above in a large font, to be representative of a science-based approach to the question of home birth safety?
IndianaFran:
“I am questioning the other six cases where the baby was delivered by midwife at home or in transit, and later died at the hospital.”
Two cases were characterized by the authors as intrapartum deaths and no mention was made of transport of any kind. They would not have received birth certificates at all.
Four other babies died at the hospital, but that poses another problem. Ordinarily, the person who delivered the baby would sign the birth certificate. However, many homebirth midwives are practicing in violation of the law. Therefore, in the event of transport, many midwives disappear and/or parents claim that the baby was accidently delivered at home without a medical attendant.
We don’t know what happened in these four cases, but it is possible that some or even all of them wound up in a group different from that of other midwife attended homebirth.
There is really no question that the truth homebirth death rate is higher than that indicated by the database.
The issue of inaccuracy in birth certificate filings for out-of-hospital births has already been discussed here.
Due to inconsistent legal policies, we cannot say with any degree of accuracy, what number of bad outcomes or good outcomes are actually missing from the CDC database.
We also cannot say what number of bad outcomes or good outcomes are missing from the CNM data due to transfer to MD before delivery.
I have been consistently trying to say that making a comparison is far more complex than just grabbing 3 lines of summary data from the CDC Wonder database.
I’m getting really tired of all the quibbling. The bottom line is that there are certain unpredictable emergencies that require immediate response. Arrangements for quick transport can diminish but can’t eliminate the risk. If home birthers understand this and are willing to take that small risk, that’s OK with me. But if they are deciding on home births because of false information, that’s a shame. Amy has shown that false information has been circulating. Can’t we leave it at that?
The bottom line is that there are certain unpredictable emergencies that require immediate response.
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That would only be the “bottom line” if you assume that incidence of emergenices and complications are unaffected by place of birth. This may be a faulty assumption. Studies of place of birth consistently show much lower rates of intervention such as caesarean section with planned home birth. Given that we don’t do caesarean section for the fun of it, the rates of intervention may stand as a surrogate measure for the complications that prompt them.
It is obvious that “if something does go unexpectedly seriously wrong during labour at home, the outcome for the woman and baby could be worse than if they were in the obstetric unit with access to specialised care.” (NICE guidelines on intrapartum care). In fact, I would say, is likely to be worse.
It does not logically follow that the outcomes of home birth are worse overall.
A dubious proposition, as lower rates can signify either (a) fewer complications necessitating such intervention or (b) a reduced rate of intervention when those complications arise. Or a combination of both.
Please not the “may” in that sentence.
The point is that there is uncertainty about the relative safety home and hospital birth for women at low-risk of developing complications in labour.
If it turns out that (in certain contexts) that home birth can be as safe as hospital birth for low-risk women, then the most likely mechanism is that lower incidence of complications at home offsets the poorer outcomes when complications occur.
How do you explain the outcomes of the recent Dutch and Canadian studies?
http://www.cmaj.ca/cgi/content/abstract/181/6-7/377
http://www3.interscience.wiley.com/journal/122323202/abstract?CRETRY=1&SRETRY=0
Plonit:
“That would only be the “bottom line” if you assume that incidence of emergencies and complications are unaffected by place of birth.”
This claim has already been raised and discredited multiple times in this thread alone.
First, it is up to you to show that the rate of emergencies and complications is affected by the place of birth. Otherwise, we have no reason to make that assumption.
Second, and even more importantly, the hospital group ALREADY includes iatrogenic deaths. The homebirth death rate is still triple the hospital death rate. While it might be possible to further reduced the hospital death rate, that would only make homebirth look even worse by comparison.
“Studies of place of birth consistently show much lower rates of intervention such as caesarean section with planned home birth.”
That’s hardly something to crow about if it leads to increased neonatal deaths.
It’s the equivalent of a breast surgeon who decides to biopsy breast lumps that are golf ball size or greater and then boasts that he does very few “unnecessary” breast biopsies. If the death rate of his patients is three times higher that negates any “benefit” from doing fewer biopsies.
First, it is up to you to show that the rate of emergencies and complications is affected by the place of birth. Otherwise, we have no reason to make that assumption.
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See Tim Mills post upthread, which quotes the recent Canadian study. The Dutch study shows similar results, as do others.
That’s hardly something to crow about if it leads to increased neonatal deaths.
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Which is not the case in the most robust studies to date (i.e. the recent Dutch and Canadian studies).
Plonit:
“See Tim Mills post upthread …”
I don’t see any quote that established that the risk of complications and emergencies is lower at homebirth. Perhaps you could repeat the relevant quote and present the relevant data.
And you haven’t explained why it even matters since the death toll of homebirth is still higher.
the hospital group ALREADY includes iatrogenic deaths.
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Which “hospital group”? If you mean the hospital group in the CDC figures that you have presented, I think it is worth addressing IndianaFran’s question:
“Has there been a systematic effort to identify and measure potential confounders?”
Would you say that “fetal distress” is a complication?
Fetal distress: HB=1.3%, PA=3.6%, MA=2.1%
Plonit:
“Has there been a systematic effort to identify and measure potential confounders?”
It is a dataset, not a scientific paper. If anyone can show that there are confounders, they should do so. Merely speculating is not enough.
This thread already contains 240 comments and there is not a single one that shows ANY evidence that homebirth with an American homebirth midwife is as safe as hospital birth. No papers, no datasets, nothing.
People need to present actual data if they expect anyone to believe that homebirth in the US is as safe as hospital birth. Clearly it is not dispositive, but it is impressive that no one can provide anything to support that claim.
Plonit:
“Would you say that “fetal distress” is a complication?”
Not when babies are dropping lifeless into the hands of homebirth midwives who had no idea they were already dead. That suggests that fetal distress was undiagnosed in the homebirth group.
not a single one that shows ANY evidence that homebirth with an American homebirth midwife is as safe as hospital birth.
People need to present actual data if they expect anyone to believe that homebirth in the US is as safe as hospital birth.
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This is a rather important qualification of the more absolute statements in your post that “Homebirth increases the risk of neonatal death to double or triple the neonatal death rate at hospital birth.” and that “Homebirth with a homebirth midwife dramatically increases the risk of neonatal death.”
This is becoming repetitive and annoying.
Enuf already!!!
Harriet:
Do you really think that it is quibbling to insist that when comparative statistics are presented as “scientific evidence”, those statistics should be based upon well-matched cohorts?
This is becoming repetitive and annoying.
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Do you have a science-based (rather than aesthetic) argument to put here?
I’ve never commented on SBM before, mainly because I’ve felt that the arguments presented are sound in most of the entries that I’ve read.
Dr Tuteur’s disdain for the practice of midwifery is so palpable. To conclude that “home birth is not safe” based on raw data is so blatantly unscientific and has no place in a blog like this.
I live in Ontario, where midwifery is highly regulated and embraced by OB’s, where Registered Midwives have hospital privileges and where women have a choice of place of birth if they meet strict criteria. I’m curious to how Dr Tuteur would respond to this recent study:
http://www.cfpc.ca/local/user/files/%7BB51825B6-44FF-4F63-9413-2B8829E117D6%7D/Ontario%20Home%20Birth.pdf with almost 7000 women in each well matched cohort.
This is more about lack of training in the US for midwives rather than the “safety” of home birth across the board.
I come here for science, not vitriolic speculation.
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Harriet said:
I’m getting really tired of all the quibbling. The bottom line is that there are certain unpredictable emergencies that require immediate response. Arrangements for quick transport can diminish but can’t eliminate the risk. If home birthers understand this and are willing to take that small risk, that’s OK with me. But if they are deciding on home births because of false information, that’s a shame. Amy has shown that false information has been circulating. Can’t we leave it at that?
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Well, I suppose we could. But we couldn’t do that and simultaneously claim that we are seeking a science-based answer to the question of birth location and safety.
A science-based approach requires you to look at the overall outcomes, not just the outcomes of the small minority who encounter a genuine emergency. And it requires you to look at those outcomes using rigorous science-based analysis.
Let me ask you this: if someone presented a “data set” similar to the original post, comparing neonatal death among women who consumed fish oil supplements during pregnancy with women who didn’t – and the author claimed that the data “showed” that lack of fish oil supplements “dramatically increases the rate of neonatal death”. Wouldn’t your first response be to question whether the two groups were equal in other ways? Wouldn’t your skeptical side be thinking that access to and use of various supplements is probably a marker for other health-conscious behaviors and socioeconomic status, and that the results were not likely causally related to the supplements? Why hasn’t your skeptic radar reacted the same way here?
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Amy said:
“Has there been a systematic effort to identify and measure potential confounders?”
It is a dataset, not a scientific paper.
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Did I kinda sorta almost hear the word NO whispered between the lines?
So, I guess it’s safe to assume that the answer is indeed NO.
Interestingly, Amy says here:
“It is a dataset, not a scientific paper.”
And later she says on the correlation/causation thread:
“The CDC database is not the only scientific evidence that shows…..”
You can’t have it both ways. A “dataset” only becomes “scientific evidence” after it is processed through the tools of rigorous scientific analysis and evaluation. Which has clearly not been done here.
I am one of “those” women who chose homebirth (3 times) successfully, no complications.
I think if you want to “woo” women like me back to birthing our babies in the hospital, you need to change how things go in the maternity ward. From start to finish- from the first visits to the Doctor-OB/GYN/CNM for prenatal care to the actual birth itself.
Frankly I don’t like being treated like cattle,like my opnions don’t matter,that I couldn’t possibly be informed because well, I didn’t spend 10 years in medical school. I have heard so many horror stories from friends who have birthed in the hospital, it makes me sick to my stomach literally.
You, the Ob/Gyns are pushing (literally) women to find alternatives outside the hospitals. We are willing to take the “risk of having a homebirth” because we believe the “risks” outway the “risk” of being stripped of our dignity and respect.
A complete overhaul of how the whole process of having a baby in the hospital needs to be made and including womens opinions and what they want out of it need to be addressed. Until then I will continue to have my babies at home and spread the word about the amazing experience.
Returning the discussion back here from the “causation and correlation” post, Amy says:
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“It is also biologically plausible that the higher proportion of older mothers in the home birth group is responsible for some part of the differing results.”
But analyzing the data shows that there is no association between neonatal death rate and maternal age for ages 20-44.
“It is also statistically plausible that the results are affected by geographic skewing.”
But analyzing the data shows that there is no association between neonatal death rate and geographical region.
“It is also biologically plausible that socioeconomic differences explain some of the difference in results.”
But analyzing the data shows that there is no association between neonatal death a maternal education status in this group.
“It is also biologically plausible that the disproportionate presence of certain isolated ethnic groups (e.g. Amish) in the homebirth group can account for some part of the difference”
Even if you remove congenital anomalies entirely, the CNM group has a neonatal mortality rate of 0.26/1000 and the homebirth group has a neonatal mortality rate of 0.61/1000.
Moreover, congenital anomalies are not necessarily incompatible life. Babies born with significant cardiac anomalies can be saved with appropriate resuscitation and surgery. Of course, if such a baby is born at home, the chances of survival drop precipitously.
There is really no evidence that the CNM hospital group and the homebirth group differ in any way likely to affect neonatal mortality rates. No matter how you analyze the data, the homebirth group always has higher neonatal mortality than the hospital birth group.
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It really strains any sense of credibility that after many days of completely evading the questions about the presence of confounders, after being presented with a list of specific differences in the cohorts, you now claim to have “analyzed” the data and ruled out any such effects. I’m not buying it. Any epidemiologist or public health expert would tell you that it is absurd to claim that two groups are equivalent in underlying risks when there is clear evidence that one group has a higher percentage of older mothers, a higher percentage of grandmultiparas, a higher percentage of low-education levels, a higher percentage of ethnic groups tending toward congenital anomalies, and a higher percentage of women from lower-income regions. Simply asserting that none of these factors has any meaningful effect on outcomes is, well, not at all scientific.
But let’s look at this claim from another perspective:
“There is really no evidence that the CNM hospital group and the homebirth group differ in any way likely to affect neonatal mortality rates. ”
If you believe this is true, then you are also saying that direct-entry midwives in the US are just as competent, meticulous, and prudent about evaluating their clients for risk factors as hospital-based CNMs are. Or that women who choose home birth are themselves capable of making a well-informed and educated self-evaluation of their own risk level and self-referring to hospital based care when appropriate. Can you agree with either of these statements?
IndianaFran:
“Can you agree with either of these statements?”
No.
We don’t have to venture into speculation. We have the data. We know what the data show.
I realize that you don’t wish to believe that homebirth increases the risk of neonatal death, and that you are casting about for some reason to ignore the data, but you haven’t found one yet.
I didn’t know that the range of science based medicine included long-distance psychic readings of what other people believe or wish to believe.
I believe in science-based evidence. I believe (with the majority consensus of experts) that at this time, the valid scientific evidence related to home birth safety is mixed and inconclusive. And I know that your personal “analysis” of the CDC dataset adds nothing genuinely scientific to that evidence base.