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Home Birth Safety

More and more American women (1 in 200) are opting for home birth, and midwife-assisted home birth is common in other developed countries. How safe is it compared to birth in a hospital? A new study sheds some light on the subject. It was recently published in the American Journal of Obstetrics and Gynecology: Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis, by Wax et al.

All the existing studies have flaws. It would be ideal to do a study where women were randomly assigned to home or hospital birth; that isn’t possible, so we have to fall back on studies that are possible. Just comparing home births to hospital births isn’t good enough, because high-risk births occur primarily in hospitals, and between 9% and 37% of planned home births end up with transfer to the hospital during labor and are converted into hospital births. Cohort studies comparing planned home with planned hospital births provide the best sources of data by intended delivery location. There have been several such studies, but the numbers were small and the results were inconclusive. This new study is a meta-analysis that combines the data into one large set for better understanding.

Wax et al. combed the published literature and found studies covering 342,056 planned home and 207,551 planned hospital deliveries. Studies were included in their analysis if they were performed in developed Western countries, published in English-language peer-reviewed literature, if maternal and newborn outcomes were analyzed by planned delivery location, and if data were presentable in a 2X2 table. They looked at several measures of maternal intervention (epidurals, C-sections, etc.), maternal outcomes (mortality, hemorrhage, infection, etc.), and neonatal outcomes (Apgar scores, perinatal deaths, etc.). Here’s what they found:

RESULTS: Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates.
CONCLUSION: Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.

It’s important to understand the difference between perinatal and neonatal mortality. The write-up of the study is confusing because a typo erroneously defines perinatal mortality as deaths up to 28 days after birth. Perinatal mortality includes stillbirths and deaths in the first 7 days of life; neonatal mortality includes all deaths in the first 28 days of life.

Neonatal death was twice as likely overall with home birth (Odds Ratio 1.98, 95% confidence interval 1.19–3.28) and three times as likely for non-anomalous births (OR 2.87, CI 1.32–6.25). Non-anomalous means without congenital defects. These findings are robust, consistent across all studies, and even more impressive in that women planning home deliveries had equal or lower obstetric risk. The relative risk is striking, but the absolute risk is small due to the small number of home births. They estimate the population-based attributable risk of overall neonatal death to be 0.3%.

One of the stated goals of women planning home births is to avoid unnecessary interventions. They did indeed have fewer interventions. But planned home births were characterized by a greater proportion of deaths attributed to respiratory distress and failed resuscitation. Intrapartum asphyxia is a major cause of death in hospital births, and it is decreased by interventions. This raises the question of whether the decreased obstetric intervention in the home birth group may have caused more neonatal deaths due to asphyxia.

Women intending home deliveries had better outcomes: fewer infections, 3rd-degree lacerations, perineal and vaginal lacerations, hemorrhages, and retained placentas; and there was no significant difference in the rate of umbilical cord prolapse. There were too few maternal deaths to analyze.

Babies of mothers planning home births were less likely to be born preterm or be of low birthweight, but were more likely to have an extended gestation of 42 weeks. Perinatal mortality was similar, but neonatal mortality was significantly greater. This is puzzling and it would have been helpful to know more about the cause of death and the course of illness. How could intrapartum events cause equal mortality up to one week and greater mortality only between 7 and 28 days? The incidence of infection in the babies was not reported. Fear of hospital-acquired infections is one stated reason for choosing home delivery: is it a valid reason? One could argue that the best solution is to reduce the rate of hospital-acquired infection, not to avoid the hospital. Mothers had fewer infections, but is it possible that more babies got infections during home births, infections that contributed to death between 7 and 28 days? What other factors might account for delayed deaths? And why should the death rate of normal babies exceed that of babies with congenital defects?

The authors commented that

the lower obstetric risk characterizing women self-selecting planned home birth likely underestimates the risk and overestimates the benefit of this delivery choice.

They reported that a study published after their analysis found similar perinatal mortality rates in planned home and hospital deliveries, but after adjustment for the later gestational ages at delivery and greater birthweights among home births, the perinatal mortality was actually greater for planned home deliveries, especially for women who required transfer to the hospital. Up to 37% of women planning a home birth with their first pregnancy end up being transferred to the hospital because of emergencies that arise during the labor process.

They commented that the studies analyzed were of low-risk women considering home birth with highly trained, regulated midwives who are fully integrated into existing health care systems. As such, they might not be generalizable to all women opting for home birth in the United States.

Midwives’ groups are already attacking this new study as flawed and politically motivated, but of course they themselves are politically motivated to show the safety of home birth, and their own studies are flawed. Passions run high on both sides of the debate. This study is far from perfect, and it’s certainly not the final answer, but it’s the best we’ve got to go on at the moment.

I think the real message from this study is that we need to develop a better understanding of which interventions are really necessary to save babies’ lives and how to improve the outcome of all deliveries, whether at home or in a hospital.

A non-trivial percentage of planned home births end up with transport to a hospital. Home birth advocates recognize that these emergencies occur. It seems intuitively obvious that increasing the time delay for emergency interventions ought to increase adverse outcomes, that distance from a hospital is a crucial factor, and that the optimum scenario is immediate availability of emergency response, i.e. labor in a hospital rather than at home.

I submit that delayed treatment of unexpected emergencies constitutes a small but undeniable risk for planned home births. It has not been established that the benefits of home birth (lower maternal infection rate, etc.) can outweigh that risk. And it has not been established that those benefits couldn’t be obtained just as well by improving hospital practices. What do women really want? If they just want to be at home, they may be willing to accept a small increase in risk. If they want fewer interventions, that doesn’t require that they give birth at home.

I admit to prejudice. I support the right of informed patients to choose home birth with a qualified midwife and reasonable precautions, but I personally want no part of it. Having delivered a lot of babies myself and having seen normal low-risk deliveries turn to disaster in a heartbeat, I would never have considered having my own babies at home, and I would personally be very frightened to attend a home birth, especially if there was a 37% chance of it ending with a nerve-wracking rush to the hospital. I would rather see babies born within easy reach of a C-section and other lifesaving interventions. I think this could be accomplished by integrating the “kinder, gentler,” less interventionist midwife approach into a home-like hospital birthing facility in close coordination and communication with obstetricians and pediatricians. This approach would increase patient satisfaction without sacrificing safety, and it is already being tried in many hospitals.

This study leaves a lot of questions unanswered, but it does give us better information to help patients make an informed decision.

Posted in: Obstetrics & gynecology

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56 thoughts on “Home Birth Safety

  1. You suggest that hospital births be made more home-birth like by reducing the infection rate and the numbers and kinds of interventions, while retaining the safety benefits for the infant.

    One reason there are more infections in hospitals is that hospitals are dirty; another is that there are fewer vaginal exams in homebirths. Are you proposing both a wash-your-hands campaign and a don’t-touch-that-vagina campaign?

    A common objection to the “hospital – only without the interventions” proposal is that the interventions are what make hospital births safer for the baby. How do you respond to that?

  2. BillyJoe says:

    “I would rather see babies born within easy reach of a C-section and other lifesaving interventions. I think this could be accomplished by integrating the “kinder, gentler,” less interventionist midwife approach into a home-like hospital birthing facility in close coordination and communication with obstetricians and pediatricians. This approach would increase patient satisfaction without sacrificing safety, and it is already being tried in many hospitals.”

    A conclusion that is hard to disagree with.
    Our local hospital has just such a setup – a home-like hospital birthing facility in close coordination and communication with obstetricians and pediatricians – and it has been completely uncontroversial.
    Though I don’t have any statistics, it might explain the apparently low rate of actual home births in the area.

  3. DevoutCatalyst says:

    Do any hospitals advise, “we have a midwife on board, just in case”?

  4. Enkidu says:

    One thing I noticed out on the parenting boards is that giving birth is becoming more about the “experience” and less about the outcome: a healthy baby.

    A lot of these parents just assume that since birth is “natural” it is therefore risk-free. I read one comment a few weeks ago even saying that the only reason that mothers feel “pain” during childbirth is because they expect it; this person was saying that mothers in tribal communities never experience pain during childbirth. What the…?

  5. Epinephrine says:

    I’m somewhat surprised by the results, as I’ve read of the lower rate of complications/infections associated with home births. We had midwives for all four of our children, and never transfered care to hospital – this is of course anecdotal. It would be disturbing if we have chosen the more dangerous option, as we looked at the then available evidence which suggested healthier mothers and babies with midwife care.

    If hospital birth is indeed that much safer (I haven’t read the analysis yet, but I’ll have to do so) I’d still recommend a midwife-led hospital birth, as the care provided by a midwife pre- and post-delivery is great, and they seem to have a good record with the process of birth itself, if perinatal mortality is similar.

    Comparing our experience with those of our friends using doctors we had substantially more time to ask questions, and we were provided with many more resources including house calls. And from what I gather, midwife care is less expensive, which is a good thing for provincial health care plans.

  6. Kylara says:

    I have many crunchy friends who all advised me to choose a home birth because of the low rate of fetal interventions and high rate of safe deliveries, but whatever I did, not to choose Large Hospital because at Large Hospital their C-section rate and birth complication rate and infant death rate is THROUGH THE ROOF! And that, therefore, if I went to Large Hospital I would be C-sectioned regardless of whether I wanted to be or not because that’s what Large Hospital does! If they’re just doing what’s medically necessary, they’d demand, then WHY is their C-section rate so much higher than other hospitals and so very much higher than home births? It’s never necessary during home births — nobody ever has one!

    No matter how hard I explained, they didn’t get that that was because Large Hospital had the only NICU for 28 counties and delivered EVERY problem pregnancy, congenital defect, and so forth for the surrounding 28 counties. (They also didn’t get that home births don’t include C-sections because people get transferred to hospitals. Srsly. They didn’t know anyone personally it had happened to, so they dismissed it entirely.) They seemed to truly believe that the choice of birth location determined the complications of the pregnancy (through magical time travel!) rather than the complications of the pregnancy determining the choice of birth location, with the most complicated pregnancies choosing the location with the most sophisticated interventions available.

    (In point of fact I went to Small Hospital, but had I had any complications, I would have gone to Large Hospital in a heartbeat.)

    Much home birth advocacy is frustrating because it’s based on such a deliberate blindness and on a belief that pregnancy and birth can all be normal and natural if women just try harder at being more natural. If you need a C-section, you’re just doing something WRONG; there’s little room in the worldview for necessary interventions. Interventions are what happens to women who fail. Problems don’t develop on their own; they’re a result of failure to adequately adhere to various lifestyle diktats.

    It’s too bad because home birth is common in other developed countries (such as the Netherlands) where it’s well-integrated with the traditional medical system. I suspect it could be made safer and more available in the U.S. by using this kind of data, but because of the social and political baggage, I doubt the data will have any impact at all.

  7. impaktdevices says:

    Warning – this post contains personal anecdotes and no real scientific evidence. The experiences contained herein are not to be construed as medical advice.

    I am a father of three. Our first was born in a hospital with no real interventions (what is often referred to as “natural” childbirth). Our second was born at home and our third was in a birthing center. The birthing experience was overwhelmingly positive for both myself and my wife. There were no complications and the kids are healthy and happy. We are statistically fortunate.

    The fact is that live birth, while it has been going on for as long as there have been mammals, is not 100% safe. Neither is anything else in this world. Being informed of the risks associated with your choices is important. We had several layers of backup plans. We chose our midwife carefully (a Registered Nurse with 20 years experience working in a labor and delivery ward who moonlights as a midwife). Both of those births cost us about $3500 each.

    Even for the hospital birth, we had a birth plan that excluded medical interventions such as pitosin and epidurals, while allowing for emergency interventions such as episiotomies or C-Sections (if absolutely necessary). The biggest problem with the hospital birth, and our biggest reason for avoiding the hospital later, was the compulsory two-day hospital stay afterward (this might just be regional, and not reflective of _all_ hospital births). My wife and I were free to go, but they would not “realease” the baby until the staff pediatrician got back from his golf junket. There was nothing wrong, no medical interventions, no drugs, no anesthesiologist, no NICU, no stiches. This birth cost us $18,000.

    One thing we noticed about hospital policies (around here in Texas, anyway) is that almost all of them would shoot you up with Pitosin the moment you walked in the door, regardless of necessity. This “little” intervention appears to be like kicking the little snowball at the top off the hill, leading to worse outcomes.

    My initial reaction to this study was bit visceral and defensive, but it is clear that there is something happening here that is resulting in higher infant mortality in the second-through-fourth weeks of life.

    A striking majority of hospitals are (ironically) very inhospitable places for laboring mothers, which is why we chose home birth. We honestly felt _safer_ doing it out of the reach of that seemingly hostile place.

    This is the problem that needs to be fixed. More comfortable, flexible, home-like birthing centers, without forced interventions, but with fast access to top-notch medical care should be more widely available, and _affordable_ too.

  8. urodovic says:

    The Lancet has a editorial on the subject:

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961165-8/fulltext

    “Home delivery is an option for mothers with uncomplicated pregnancies, provided they are advised of the risks involved, have one-to-one midwife care (that includes good resuscitation skills and accreditation by a local regulatory body), and live in a location that allows quick access to obstetric care.”

  9. Scott says:

    Much home birth advocacy is frustrating because it’s based on such a deliberate blindness and on a belief that pregnancy and birth can all be normal and natural if women just try harder at being more natural. If you need a C-section, you’re just doing something WRONG; there’s little room in the worldview for necessary interventions.

    Not unique to home birth – it seems to be an underlying theme of motherhood in general (and parenthood even more generally). There is ONE right way that MUST be applied to ALL babies/children and if you don’t then you’re a BAD MOTHER. Breastfeeding, specific sorts of toys, exact “bonding” rituals, particular extracurricular activities, etc. (In some circles including vaccine rejection…)

  10. Ash says:

    While anecdotal, I’ve known enough people who most likely would have lost a baby if they’d opted for home birth, despite normal low-risk pregnancies, that my wife and I didn’t even consider it (turn out it wasn’t an option for us anyhow since our first baby never even dropped due to the umbilical cord wrapped around his neck).

  11. moderation says:

    Excellent post … thank you.

    I wonder if there was much information about other comparables in these two groups, ie. income, education level, smoking, alcohol consumption, drug use, etc.?

  12. Kylara on home birth: “It’s too bad because home birth is common in other developed countries (such as the Netherlands) where it’s well-integrated with the traditional medical system. I suspect it could be made safer and more available in the U.S. by using this kind of data, but because of the social and political baggage, I doubt the data will have any impact at all.”

    Sadly, the data from the Netherlands support the threefold increase in neonatal deaths for home birth.

    Scott on what happens when parenthood is actively chosen: “Not unique to home birth – it seems to be an underlying theme of motherhood in general (and parenthood even more generally). There is ONE right way that MUST be applied to ALL babies/children and if you don’t then you’re a BAD MOTHER. Breastfeeding, specific sorts of toys, exact “bonding” rituals, particular extracurricular activities, etc. (In some circles including vaccine rejection…)”

    I have one piece of advice I give expectant parents. I ask them to think of all the terrible mistakes their parents made. I ask them to contemplate the fact that they themselves turned out mostly ok anyway. And then I tell them that they will make mistakes too, and that their kid will turn out ok too.

    (This is assuming that I’m talking to someone who is mostly ok.)

  13. hdauria says:

    I just want to thank you for providing intelligent, vetted information. While I chose home birth when I had my children, I deplore the skewed studies and lack of good information on both sides. Everybody seems to have an agenda. Studies like these, and the careful analysis of people like you, go a long way toward improving outcomes no matter the location of birth and, I believe, take the first steps toward understanding why someone would choose an out-of-hospital birth in the first place. Until we really get that, we won’t be in a position to address the issues that drive some women accept the risk of an out-of-hospital birth in lieu of the risk of a hospital birth.

  14. Harriet Hall says:

    Alison said, “A common objection to the “hospital – only without the interventions” proposal is that the interventions are what make hospital births safer for the baby. How do you respond to that?”

    “Interventions” is a term that is so broad it is meaningless. Some interventions make birth safer, some don’t. We need to figure out (with science) which ones are beneficial, to improve the safety of both home births and hospital births. The oversimplistic intervention/no intervention and home/hospital dichotomies are not useful.

  15. Calli Arcale says:

    Agreed, Harriet. Part of the trouble is that finding out the “best way” to have a baby is impossible. Each birth is different, so there is no best way; the best way for Baby A might kill Baby B. Reality, as always, is more nuanced. It’s about finding out how to detect problems early, what the best ways are of dealing with those problems, how different interventions interact with one another, the actual risks and benefits of different interventions in different situations and contexts, and then learning to translate that information into actual obstetric practice.

    Science-based medicine. ;-)

    In my opinion, the best place to give birth is in a hospital which is respectful of its patients and which uses science to guide its practices. This will necessarily lead to minimizing interventions, such that interventions are used only when it appears they are necessary, and as more information comes in, the judgment of “necessary” becomes more refined over time. The hospital where I had mine was one of these. While the fancy-schmancy Birth Center was available only on a first-come first-serve basis (and it was full both times, so I didn’t get to use it), the basic care is the same regardless at that hospital — the only difference is that if you use Labor & Delivery, you’ll be transferred to a different room after giving birth. No intervention was performed with my consent, and risks and benefits were explained. I was particularly impressed by how professional they were, managing to explain things in the limited time available for more urgent matters, and always answering my questions without a hint of condescension. The main thing I liked was how *calm* they all were. I had bad situations with both of my babies, but nobody was flustered or uneasy, and that allowed me to relax and let them work. They took charge when they needed to, but without reducing me to a number. It was good, and if some hospitals aren’t doing that, they need to learn how.

  16. Epinephrine says:

    “Interventions” is a term that is so broad it is meaningless. Some interventions make birth safer, some don’t. We need to figure out (with science) which ones are beneficial, to improve the safety of both home births and hospital births. The oversimplistic intervention/no intervention and home/hospital dichotomies are not useful.

    Emphasis mine.

    I think you are right on, Dr. Hall (though I will use the term “intervention” for lack of a better word). The fact that perinatal mortality is comparable, and that there are benefits in terms of infection, laceration, etc. suggest that there is room for improvement in the hospital approach, and if the neonatal mortality data is correct there is clearly room for improvement in having more interventions – the question is, which interventions?

    Those looking for “natural” labour are (I suspect, from personal experience) less likely to have a vitamin K injection, for example. This (for example) may affect the neonatal mortality rate for midwife care.

    Analgesia, however, can have effects on health. The area is complex, but there are studies that suggest breastfeeding issues, potential neurological damage caused by epidural-associated fever, etc…

    Having taken a look at the meta-analysis, the studies included are from the late 70′s through the 2000s; things have changed a lot in that time, and I would hesitate to group these at all. Midwifery care has become increasingly evidence-based, and the interventions allowed to midwives have expanded, for example, the midwives in Ontario have oxygen available now. I’d like to see the comparison when looking at modern methods, rather than looking back 30 years to compare how home and hospital births were. Further, while one gains power by combining studies, the discrepancies in interventions available in different locales prevents generalization of the results to any given area.

  17. valleyviolet says:

    I think the thing that makes me feel very hesitant to ever subject myself to a hospital delivery is the previous experiences I’ve had with doctors. Don’t get me wrong, I respect most people in the medical profession. They’ve worked very hard to get where they are and the vast majority are well meaning and very intelligent people. I have also met a number of them who have about as much bedside manner as a fence post.

    I need to be able to trust the person attending a delivery to ask before invading my personal space. I need to be able to trust them to ask before performing procedures on me. Unless it is a 10 second life or death decision or I’m unconscious/bleeding to death on the floor, I need to know that what I say will have weight in the situation. I need to know I will not be cut up or drugged without my knowledge or consent.

    I’m not sure I’ve yet met a doctor I could trust that much. Probably some of the ones I’ve met are trust worthy, but a lot of them don’t seem to understand that I want different rights and different handling than they’ve been trained to give me. I’m a smart person. I have a BA and an MS. I’ve suffered a lot of medical and dental indignities in my life and I’m a patient person. I understand that sometimes the “right” thing and the “safest” thing are not a lot of fun. The situation has to be pretty extreme for me to complain.

    I still sometimes have doctors treat me like I’m a hysterical 12 year old who can’t be told what’s wrong with her.

    I wouldn’t be alive if it weren’t for medical intervention at birth. I would have choked to death during my first day out in the world. I understand that we are better off than we were when we had no science or medicine to keep us well. I have to think there’s some happy medium where I can have human dignity and control over my body and children can be safer.

  18. Steve S says:

    Another viewpoint is what evolutionary medicine says. Our ancestors and work done with modern hunter gatherer groups shows that around 15% of births have dystocia or hemorrhage. It is interesting to note that primary c-section rate in the U.S. is around 16%. So there is a correlation. The problem is that we never know which of all the births are going to be associated with complications. I have also delivered a lot of babies in my career, but have also noticed that some I thought would be routine turned out not to be and the ones I worried about turned out just fine. So the problem boils down to is the mom to be and her family adequately informed and knows the risks involved then decides on home birth, then ok. But which is better equiped and able to handle the known 15% that will have major problems requiring surgical delivery.

  19. Scott says:

    I need to be able to trust the person attending a delivery to ask before invading my personal space. I need to be able to trust them to ask before performing procedures on me. Unless it is a 10 second life or death decision or I’m unconscious/bleeding to death on the floor, I need to know that what I say will have weight in the situation. I need to know I will not be cut up or drugged without my knowledge or consent.

    I’m not sure I’ve yet met a doctor I could trust that much. Probably some of the ones I’ve met are trust worthy, but a lot of them don’t seem to understand that I want different rights and different handling than they’ve been trained to give me.

    I find this very interesting, since those rights and handling are exactly what doctors are strictly required to give all patients. As I understand it, performing procedures without asking would get a doctor sued into oblivion, after losing their license, very fast – there could well even be jail time involved, I think.

  20. Bogeymama says:

    This may sound harsh, and it has been touched on by a few comments, but I just don’t understand why the birth “experience” has become more about the mother than the child?? How selfish have we become? It’s ONE day out of the rest of this child’s, and the parents’ lives. The mother’s experience shouldn’t really be a consideration at all. The ONLY important outcome is a healthy baby. I went into my births with a completely open agenda – get them out however they need to be gotten out as safely as possible. I had completely unremarkable pregnancies, and unpredictable deliveries. Had I been at home, I would surely have had to go to hospital anyways and the health of my babies might have been in jeopardy. I did not have C-Sections, although I would have been completely fine with that had the doctor decided it was necessary (actually, I think it would have been a better option… but the doctors seemed to only view C-Section as a last resort). So while my birth “experiences” were not entirely pleasant, I was not left disappointed due to unrealistic expectations that things would go perfectly. 10 years on I have wonderful, happy, healthy kids … who really don’t care how they arrived.

  21. JMG says:

    Well Violet, now you have clear evidence that your insistence on having your personal space and special handling only comes at the cost of tripling your infant’s death risk. Most sensible parents would not pay that price for a day of discomfort, but this is the Me-generation after all.

  22. Lisa K says:

    The only portion of the metastudy available to the public is the conclusion, there are no free reprints online yet, so as a member of the public, I have to rely on the opinions of those who have seen it firsthand. The conclusion doesn’t match with other studies on this topic that I have seen, and I can’t review anything of what was included in it on my own. I am skeptical about the meta study for that reason and meta studies, can be “garbage in, garbage out” to support any given bias.
    http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102271850.html

    The Globe has an article on the meta study that seems to suggest this might be the case for this meta analysis.

    Dr. Hall states that “Midwives’ groups are already attacking this new study as flawed and politically motivated” but that they are politically motivated.

    However, the Globe’s article demonstrates that the criticism is not exclusively from midwifery groups, it is also from medical doctors. Dr. Klein is quoted and Klein’s study was included in the meta-study. Excerpt:

    Canadian researchers say only the Canadian and Dutch data were as rigorous as they should be. Michael Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, says the analysis and its conclusion has to do with the climate in the United States around midwifery. It is less accepted by the medical profession there than it is in Canada, he said. “We’re dealing with a politically motivated study,” said Dr. Klein, who was a co-author with Dr. Janssen on the B.C. study.

    http://www.theglobeandmail.com/life/health/us-analysis-on-home-birth-risks-seen-as-deeply-flawed/article1624918/

    To her credit, Dr. Hall admits to prejudice on this topic. What about the authors of this study?

  23. raanne says:

    Another completely anecdotal story – but I delivered my son in a relatively crunchy area, in a comfortable birthing center attached to a small hospital. With major complications. He had to be transferred to “Large hospital” in the next city because that was the closest NICU. You can be damn sure that my next child will be born at the large hospital, because I had to have special permission to be discharged early just so I could go spend my days sitting at the NICU 10 miles away from where I gave birth.

    And mine was a completely uncomplicated pregnancy. I would have been a prime candidate for home birth. But as an earlier commenter stated, I have known too many situations (and I can add mine on to this as well now) where there have been complications that would have led to disaster in a home birth.

    Its purely anecdotal, but I’m not someone to take risks like that. Given the options, I would choose me being uncomfortable and having a horrible birth experience over something potentially going wrong and not having the available technology to address it.

  24. BillyJoe says:

    “It’s too bad because home birth is common in other developed countries (such as the Netherlands) where it’s well-integrated with the traditional medical system.”

    I was a product of this system and was delivered at home. Back then it was the norm and you only had hospital intervention if complications arose during the home birth. I’m not sure if that still applies today.

  25. Bogeymama on selfishness: “This may sound harsh, and it has been touched on by a few comments, but I just don’t understand why the birth “experience” has become more about the mother than the child?? How selfish have we become? It’s ONE day out of the rest of this child’s, and the parents’ lives. The mother’s experience shouldn’t really be a consideration at all.”

    I think different people have different tolerances for being interfered with. There’s the whole “birthrape” thing which I don’t want to get into — that implies a rapist, and I can’t make that call about any particular birth. But let’s draw an analogy. Most people are able to have sex just fine if they are comfortable enough with their partner(s). But also, most people really, really really hate being sexually assaulted and are permanently traumatized by it. Even professional sex workers are traumatized by non-consensual sex. We don’t think this is strange. Most people who think about it recognize that the advice to “lie back and enjoy it” is not helpful, even if the particular act would be enjoyable under different circumstances.

    But we call people selfish for reacting badly to having to fight their birth attendants for control over their bodies.

    Some people find the idea of pelvic and rectal exams unbearable. Most people find them unpleasant. Personally, I don’t mind them. I’ve never been pregnant, but I can easily imagine myself in the category of women who can focus on the outcome: a healthy baby. On the other hand, I can imagine things going pear-shaped pretty quickly if I didn’t trust the people who were making decisions about my body. When I saw a physiatrist I don’t trust, I didn’t go back and I found someone else. If I were being attended by an OB I didn’t trust I wouldn’t have that option in the middle of labour, and I might find my dependency on her very frightening.

    To the degree that women are having this type of visceral reaction — similar perhaps to the type of visceral reaction people have to sexual assault — I’m not sure it makes a lot of sense or is particularly useful to call this “selfishness.”

    To the extent that it’s a question of being the best earth-mama on the web, sure, it’s an “all-about-me” thing. Totally. But I’m not convinced there isn’t that other thing going on too, at least for some women.

    But I’ve never had a baby. I wouldn’t actually know.

  26. Epinephrine says:

    @JMG

    It’s not clear at all to me that the risk *is* tripled.

    I’m keen to champion good research and science-based medicine, but for my own area (where there is a well designed study published in 2009), I don’t see why the meta-analysis would possibly take precedence over the local study; sure, you can get more power, but if there were a three-fold increase in mortality rates in my area, the local study should have shown some minor indication of it.

    While I think that midwife care is very probably lacking important interventions, the practice varies temporally as well as spatially, and I don’t think that the meta-analysis takes this into account. I’d like to see an examination of whether a temporal effect exists. Meta-analysis is tricky, and it’s not clear to me that it is at all helpful in this case.

  27. Doctor Jay says:

    You state that there is a “small” increase in the risk of home delivery. However, the risk of neonatal fatality for home deliver is 0.3%, and the risk for hospital delivery is 0.1%.
    The risk reduction is similar to supine versus prone sleep position for newborns.
    I don’t know anyone advocating we start putting children to sleep on their bellies again because it is more “natural”. The excess deaths are preventable and therefore unnecessary.

  28. IndianaFran says:

    @Allison:
    “Sadly, the data from the Netherlands support the threefold increase in neonatal deaths for home birth. ”

    I would like to know exactly what data from the Netherlands supports this. The very large 2009 study does not.

  29. Enkidu says:

    Bogeymama: It’s like you are reading my mind. :)

    Of course, I had a very complicated pregnancy, so that definately plays into my feeligns on this subject. The entire focus of my pregnancy was a healthy baby and things like lighting, mood, etc (it’s like you’re reading a screenplay with some of these homebirth stories) were far, far from my mind. I just wanted competent doctors and all the medical technology possibly available in case of emergency, to save my baby. I now have a healthy 2 year old daughter… born 3 months early via emergency c-section, saved by wonderful doctors and nurses at Large Hospital. Heck, I even rode an ambulance to get there LOL!

  30. IndianaFran says:

    @Harriet:
    “Perinatal mortality was similar, but neonatal mortality was significantly greater. This is puzzling…..”

    Yes, it’s puzzling until you look at the numbers in Table 3, which show that these results were derived from entirely different subsets. The perinatal mortality results came from pooling over 500,000 births, and the neonatal mortality results come from a different subset which is barely 1/10 as large. Which result would you call “robust”?

    “Cohort studies comparing planned home with planned hospital births provide the best sources of data by intended delivery location. There have been several such studies, but the numbers were small and the results were inconclusive. ”

    Since the 2009 Netherlands study provided nearly 90% of the total births in the meta-analysis, it’s not true that only small studies were available prior to this analysis.

    “And why should the death rate of normal babies exceed that of babies with congenital defects?”

    I don’t know where you are seeing this.
    The death rates for nonanomalous (normal) babies are lower than the death rate for all (normal + anomalous). This is as expected. There are no separate death rates calculated for babies with congenital defects. Were you referring to the fact that the odds ratios were different?

    “Up to 37% of women planning a home birth with their first pregnancy end up being transferred to the hospital because of emergencies that arise during the labor process.”

    Well, not really. That may be the reported transfer rate from one study, but it says nothing about “emergencies”. Most home to hospital transfers are not because of emergencies. The vast majority are for prolonged labor, maternal exhaustion, or maternal desire for pharmacological pain relief. Only a small fraction are in a time-critical situation.

  31. IndianaFran says:

    @Harriet:

    “They commented that the studies analyzed were of low-risk women considering home birth with highly trained, regulated midwives who are fully integrated into existing health care systems. As such, they might not be generalizable to all women opting for home birth in the United States.”

    I’m afraid you are reading this wrong. Not all twelve of the studies in the meta-analysis were with “regulated, fully integrated midwives”. The Washington State (Pang) study most certainly was not. It included all home births where the attendant was listed as a midwife, nurse, or physician, (and included the category “other midwife” which could be basically anyone, trained or otherwise). (and since this study was based on birth registrations, it can only minimize, not eliminate, the inclusion of unplanned home births).

    The authors also report:
    “The analysis excluding
    studies that included home births attended
    by other than certified or certified
    nurse midwives had findings similar to
    the original study, except that the ORs
    for neonatal deaths among all (OR, 1.57;
    95% CI, 0.62–3.98) and nonanomalous
    (OR, 3.00; 95% CI, 0.61–14.88) newborns
    were not statistically significant.”

  32. IndianaFran says:

    @Steve S:

    “Our ancestors and work done with modern hunter gatherer groups shows that around 15% of births have dystocia or hemorrhage. It is interesting to note that primary c-section rate in the U.S. is around 16%. ”

    Not in this century, it isn’t…..

    “In the 19 states for which revised data are available for 2006, the primary cesarean rate was 23.5 per 100 live births to women who had not had a previous cesarean delivery”
    http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf

    And I’d like to know where your data on “our ancestors and modern hunter gatherers” comes from. You only have to go back to around 1970, when the US cesarean rate was 5.5%, (and neither mothers nor babies were dying at a rate anywhere near 10%) to realize that your supposed baseline rate of 15% is just wrong. It is certainly true that both infant and maternal mortality has improved since then, but not in any way proportional to the increase in c-sections. (and don’t forget a great deal of the improvement in infant survival has to do with improvements in NICU/neonatal care after birth).

  33. IndianaFran says:

    @Harriet:

    “I submit that delayed treatment of unexpected emergencies constitutes a small but undeniable risk for planned home births. ”

    True.

    “It has not been established that the benefits of home birth (lower maternal infection rate, etc.) can outweigh that risk.”

    And yet the most recent large study from the Netherlands says that they come out equal.

    ” And it has not been established that those benefits couldn’t be obtained just as well by improving hospital practices. ”

    I agree, and from a public-health advocacy standpoint, we should be striving for a day when all obstetrical units are both science-based, and respectful of individual preferences. But in the real-time real world, many women choose home birth because that ideal simply is not available to them.

  34. Steve S says:

    IndianFran;

    The information on 15% comes from Evolutionary Medicine by Hanson, Beedle et. al. That is not to say they all had c-sections or died. It just notes that was what the incidence in hunter gathers were as recorded by anthropologists. I just also say it is interesting according to the data in the ALSO course that primary c-section rate in this country is around 16%, the total is different. Today around 1/3 have c-sections. In Norway the c-section rate is 15%. I am not saying that it was not lower in the recent past. I also find it interesting that the United States has a worse record for newborn deathts than 30 other countries even with our so called more advanced technology.

  35. latenac says:

    @Bogeymama yes labor is one day (hopefully, mine was 2 days) out of the life of both baby and mama but the mother’s experience does matter b/c it affects how she parents in the weeks after giving birth.

    That said I think we need to reset expectations of what labor and delivery is. Getting rid of interventions that don’t improve outcomes would certain help. As well as recognizing risks in homebirth.

    I’ve seen way too many crunchy unassisted childbirth advocates promoting the idea that somehow a good birth is all about your attitude so don’t ready anything negative about the risks involved and then you won’t have any problems. If you end up in the hospital you’re a failure b/c you didn’t manifest hard enough. This I think makes it all too easy to feel that you lose power through any birth other than an unassisted one or even homebirth with assistance b/c you don’t know what could happen if something goes wrong.

    I read the Dr. Sears birth book before having my first and they advocated learning about everything all birth methods, all risks, etc, etc. so that when the time came you could have your ideal birth in mind but also recognize risks and be prepared to make decisions as needed or at least understand decisions that had to be made afterwards. The idea that knowledge is power I think is a good way of having a good outcome for the mother regardless of how the baby is born.

    Yes the primary outcome one wants to a achieve is a healthy baby but for that baby to continue to be a healthy baby and happy one you need to also take care of the mother. I think the original post is a good way of starting the discussion.

  36. Dawn says:

    I would still like to know the causes of death for those neonatal deaths. Were they infection? Dehydration? Hypoglycemia? What? I find that to be a frustrating lack of information. And were the deaths evenly spaced over the 7-28 day period? Were they more common at 7-10 days compared to 25-28?

    I am not a home birth “advocate”. However, neither do I think every woman must deliver in a hospital (and as far as birth and perinatal results, the studies seem to bear out this information). So, we need to know why babies born at home are dying at these ages.

    Here in the US, we definitely need to improve our statistics. Our c/section rates are much higher than most other countries and, even given our definition of live birth is different (and more inclusive) than most other countries, there is room for a lot of improvement.

  37. TsuDhoNimh says:

    Harriet – Unfortunately, home birth has gone from a pragmatic medical decision to a lifestyle choice or mystical experience. Just read some of the “mommy” boards … that saline IV will doom you and your child to a lifetime of sub-optimal bonding, misery and poor health.

    @Kylara – One obstetrician I knew had more than 60% C-section rate, but only because he was taking all the cases no one else wanted to handle. For women who were not having high-risk pregnancies, he was of the “you push, I’ll catch” minimal intervention style.

    But some women refused to see him because of the C-sec rate in his practice. And he LOVED doing low-risk patients.

  38. Calli Arcale says:

    IndianaFran:

    And I’d like to know where your data on “our ancestors and modern hunter gatherers” comes from. You only have to go back to around 1970, when the US cesarean rate was 5.5%, (and neither mothers nor babies were dying at a rate anywhere near 10%) to realize that your supposed baseline rate of 15% is just wrong.

    As Steve points out, you can’t tell from the death rate what the dystocia/hemorrhage rate is. My mother hemorrhaged after giving birth to me. As you can see, I am very much alive; she also went on to have three more children, so she didn’t die either. That was in 1975.

    Random thought: the c-section rate has gone up considerably, and part of me wonders if that isn’t at least partly because of improvements in c-section methods, such that obstetricians feel more comfortable recommending them now. For instance, the transverse incision which is standard nowdays has a much lower rate of complications than the traditional vertical incision.

    Steve S:

    I also find it interesting that the United States has a worse record for newborn deathts than 30 other countries even with our so called more advanced technology.

    It has nothing to do with our technology. There are two major factors:

    1) The US counts neonatal deaths differently. In Europe, I think the death has to happen within a few hours of birth to count, whereas here the child could die much later and still be considered a neonatal mortality.

    2) There is very inconsistent access to medical care in the US. We have access to the best medical care in the world — but not, universally, the ability to pay for it. Those without health insurance are far less likely to get the dozens of prenatal exams that are recommended, and a lack of prenatal care is strongly associated with an increased risk of infant mortality. There are also regions of the country with really disgraceful health care situations, and those affect the numbers as well; remember that Europe is far denser and more developed than the US, so it’s harder to find a residence where the nearest hospital is several hours drive away, which affects survival in emergency situations.

  39. Epinephrine says:

    @Calli Arcale:

    1) The USA is ranked horribly on infant mortality, period. So even if there is a problem with neonatal mortality (which I don’t think there is, though it’s not an indicator I’ve worked on), that doesn’t explain why they do so poorly with deaths in the first year.

    Heck, here’s a report on the subject.
    http://www.cdc.gov/nchs/data/databriefs/db23.htm

    They make some statements about what the US rate would be, if the USA had the same distribution as Sweden of birth ages, but that would require that the USA improve education, nutrition, and to have medical care like the socialised medicine in Sweden.

    2) Please don’t appeal to distance, that doesn’t explain the fact that the infant mortality rate is more than twice as high for black infants compared to white infants.

    Poverty, lack of socialized medicine, poor education and nutrition, and racism are the main problems.

  40. Bogeymama says:

    Skeptic North recently addressed the Canadian situation in terms of how it compares to other countries re infant mortality, and is linked to a news story from the Globe and Mail. Interesting reading, puts things in perspective.

    http://www.skepticnorth.com/2010/05/whos-killing-our-babies-2/

  41. IndianaFran says:

    @Steve S
    @Calli

    “Our ancestors and work done with modern hunter gatherer groups shows that around 15% of births have dystocia or hemorrhage. It is interesting to note that primary c-section rate in the U.S. is around 16%. So there is a correlation.”

    I’m sorry, that third sentence is just silly. That’s not a correlation, it’s a coincidence.
    If you had happened to have found the hunter gatherer research back in 1970, it would never have occurred to you that this was somehow correlated with cesarean birth.
    The cesarean rate in the US happened to be somewhere near 15 – 16 % for about 15 years, from the early 80′s to about the mid-nineties. And during the same years that the US had a cesarean rate in this range, many other developed countries had rates far lower.

    So any attempt to “correlate” a historical observation with a cesarean rate that happened to occur in a particular place for a limited amount of time, just doesn’t compute.

    And it certainly is not evidence that there is a “known 15% that will have major problems requiring surgical delivery” in any particular population.

  42. Zoe237 says:

    The fact that there was no difference in perinatal mortality, then a double increase in neonatal mortality makes me wonder. Why on earth would different studies be included in each analysis? The Jonge Netherlands study (500,000 subjects) was included in the perinatal analysis, while not in the neonatal. WHY? This is pretty much made up the conclusions of the former. While the Pang study supposedly made up most of the meta for the neonatal, but this included only birth certificate analysis. The globe and mail article notes that this metaanalysis, while attempting to distinguish between planned and unplanned homebirth, may not fully have separated them. My partner is a paramedic and occasionally hears about his colleagues running on homebirths to drug addicted mothers in crackhouses or simply precipitous births. Some of the studies went back 40 years, and one had only 12 participants. And I can’t make a judgement for myself, because AJOG has restricted access for laypeople.

    Personally, some of the “evidence” based practices particularly in obstetrics scare the crap out of me. Particularly convenience induction, including 12 hour time limits. I thankfully found an obstetrician who was up to date on her research, but would have considered homebirth if I couldn’t. (And no, I wasn’t going to be challenging a team of doctors in the middle of overpowering contractions). My choices had nothing to do with the experience, but the ultimate goal was the avoidance of cesarean section (unless absolutely necessary), which can lead to breathing problems in the baby, and a tripled neonatal mortality rate. Not to mention an increased risk in future pregnancies of uterine rupture and placental issues. And infection and bleeding complications for me (selfish mother that I am). I was up and about a few hours after my 3 natural childbirths and my children had zero health issues. We went home the next day. I have read that it takes less skill to manage a cesarean that a complicated vaginal birth; I wonder if this is a factor. I also wonder if obs aren’t trained in research and statistics and simply practice as they were taught 40 years ago. I understand that some of practice is defensive medicine and a fear of lawsuits as well.

    http://www.associatedcontent.com/article/1980192/cdc_says_cesarean_triples_neonatal.html

    A happy medium for mothers who wish to avoid unnecessary intervention would be nice.

  43. Zoe237 says:

    IMHO, a desire to homebirth is a direct response to the high c-section rate. 32% rate here, in some hospitals it’s well over 50%. In countries around the world, it’s 46% in China, 80% in some Latin American countries. C-sections are awesome if they’re necessary and have saved many thousands of lives. But they should be saved for emergencies.

  44. Epinephrine says:

    Well, I have managed to get most of the papers used in the meta-analysis, and the drivers of the increased neonatal mortality rate seem to be 2 papers, one of which I can’t get access to:

    Lingren HE, Radestad IJ, Christensson K, Hildengsson IM (2008) Outcomes of planned home births compared to hospital births in Sweden between 1992 and 2004: a population-based register study. Acta Obstetricia et Gynecologica Scandinavica, 87(7):751-9

    and

    Pang JWY, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NJ (2002) Outcomes of planned home births in Washington State: 1989-1996. Obstetrics and Gynecology, 100: 253-9.

    Interestingly, the two studies really help reinforce each other.

    The Swedish study (which is in an obscure journal, so I am relying on abstract) has a huge population for the hospital births (11,341) with a very low neonatal mortality rate, and a much smaller planned home birth group of only 897. It mentions home birth without specifying (at least in the abstract) the presence of midwives or health professionals, so I can’t be certain that it is even examining midwife care, or whether there are attending medical professionals of any sort.

    For the metaanalysis, this study contributes more than a third of the planned hospital births (11341 out of 33302), with only 8 neonatal deaths. Sweden’s exemplary health care, at least in this study, allows the neonatal death rate to drop from 1.1 per thousand without it to 0.9 per thousand, while adding 2 deaths from 897 home births (2.2 per 1000) that may or may not be midwife attended.

    The Washington study doesn’t count midwife births, either, but simply those attended by a “medical professional”, which could be a nurse or doctor. With 20 neonatal deaths in 6133 home births, the Washington study supplies 62% of the neonatal deaths on only 37% of the home births – and again, we aren’t looking at qualified midwives. The data is also from 1989-1996, so it’s 14-21 years old, making it a rather poor reflection of the current risks.

    There are also some biases when one starts to look at the numbers – the authors have taken liberties with rounding.

    When presenting the neonatal death rate for home birth they take 32/16500 which would be .1939%, and round it up (incorrectly) to 0.20%.
    When presenting the neonatal death rate for hospital birth they take 32/33302 which would be .0961%, and round it down (again, incorrectly) to 0.09%.

    This is deceptive, and seems to suggest an agenda. It could be an honest mistake, but given the paper’s presentation it seems like a deliberate attempt to present the findings in a way that is critical of home birth.

    Having delved into the papers themselves, I find that the recent papers that have specifically examined the subject of midwife care still stand, and that without the inclusion of some pretty odd choices the statistics still suggest that home birth is as safe as hospital birth, with fewer complications.

    The inclusion of the Swedish paper biases the results toward hospital birth, as it contributes a huge proportion of the hospital group’s population while contributing little toward the home birth group. The fact is that mortality rates in Sweden are much lower for any type of birth, so adding 11,341 Swedish births to one side of the equation while adding 897 to the other inherently biases it.

    The inclusion of the Washinton study brings very old data that is not at all a reflection of current home birth practice, of midwifery, or necessarily well collected, since it is from birth certificate data.

    If one wants to evaluate the risks properly, I suspect it makes much more sense to look at modern papers that examine the precise situation you are considering. A study of midwifery in Ontario from 2009 is much more relevant to the decision to have a midwife attended home birth in Ontario than this meta-analysis.

  45. Epinephrine says:

    Oh, also, a few nit-picks:

    You claimed, “between 9% and 37% of planned home births end up with transfer to the hospital during labor and are converted into hospital births.”

    This is incorrect. The highest rate reported for parous women was 9%, and the highest rate reported for nulliparous women was 37% – but that does not imply 9-37%. The overall rate in the 2009 Ontario study, for example, was 5.4% – presumably lower for parous women and higher for nulliparous. If it is similar to California study (at 5.8% overall) it could be about 2% for parous women and 10% for nulliparous.

    You also said of the doubling or tripling of risk that, “these findings are robust, consistent across all studies,” but analysis shows that it simply isn’t true – to get those figures on uses only some of the studies, and it’s far from consistent across those studies, with the majority of deaths coming from a single study! Eliminate the Washington data from 1989-1996 and you pretty much eliminate the difference between the groups. That is neither robust nor consistent.

  46. Steve S says:

    I gave a reply to where the information is. And whether you think it coincidence or correlation, doesn’t matter. The point is this: our ancestors and hunter-gatherers (and it doesn’t matter where or when the data was obtained go to the anthropology sources themselves, not me) have a certain percentage of complications that occur during childbirth. Not all need operative delivery or any other procedure. This is due to our anatomy secondary to our evolution and will happen. You can argue if you want about this percentage or that percentage, where, when and by who, but it doesn’t really matter. What does matter is if we can predict them, no not all, can we do something about them when they occur and where is the best and who, midwife, obstetrician, FP, or shaman to handle the problems. And even then, thanks to our history, some babies are not going to do well, no matter who, what technology or where the delivery occurs. This is not being silly, this is being realistic and the one being silly is the one argueing about numbers etc. One thing is certain as technology has developed we tend to use it, whether it contributes to good outcomes or not. And like in South America the trend is for more c-sections to avoid child birth pains, complications of vaginal delivery, timing and a whole host of reasons that have more to do with preferences and desires more than evidence. Enough said!

  47. IndianaFran says:

    @Steve S
    I apologize for using the word silly. My point was that your use of the word correlation was scientifically inappropriate in the context you used it. I understand now that you were using the word in a more colloquial way.

    I agree that our evolution makes some degree of childbirth complications inevitable, and use of technology can minimize, but not eliminate the risk. (and sometimes introduce new risks).

    And you seem to agree that the rate of surgical delivery in any place and time is also influenced by a host of cultural factors, above and beyond any underlying biological/anatomical imperative.

  48. IndianaFran says:

    @Epi
    You’re right about the huge imbalance in the Swedish study.
    Here’s another potential contributor:
    The oldest study included (Koehler, California) had far more home than hospital births (454 vs 67). So the total home birth component was burdened with a larger percentage of old data than the hospital comparison. Given the size of this particular study, it’s not a huge impact on the meta-analysis, but it’s not at all clear whether the author’s methodology made any adjustment for changes in mortality rates over the wide range of dates included.

    Good catch on the rounding problem. I’m not sure if that reflects an intentional bias, or just the general lack of tidiness in this pre-publication version. I strongly suspect that there are some other “typographical” errors in the tables presented. Some of the odds ratios presented in table 2 and 3 seem to be just weird compared to the raw numbers. It will be interesting to compare the final published version in September with the early version, and see what has changed.

    At any rate, the general impression that this paper was far from ready for publication seems to lend weight to the argument that its early release (and the press attention it drew) was intended to influence the course of midwifery legislation currently in process in a couple of states.

  49. IndianaFran says:

    @Epi,
    To be fair to Harriet, her statements about robustness were simply a restatement of the authors’ own words, rather than a statement of personal opinion (I think).
    From the Wax paper:
    “This finding is particularly
    robust considering the homogeneity
    of the observation across studies.”

    But I absolutely agree that the claim of robustness is not justified.
    It certainly seems to display a bias when the press release touts
    “The largest meta-analysis of home birth shows a doubling or tripling of neonatal death risk! And incidentally on page two we mention that perinatal death risk seems to be the same but we find that to be unexpected given the neonatal death results.”
    when a more fair rendering might be
    “The largest meta-analysis of home birth confirms the results of the recent large Netherlands study, showing no difference in perinatal deaths between intended home and hospital birth. A much smaller sub-analysis of studies that included deaths to 28 days showed an increase in neonatal death rates, however that analysis included some studies without certified birth attendants, and some with methodologies that could only approximate the intended place of birth”.

  50. Epinephrine says:

    Thanks IndianaTran, that’s a much better summary of the findings. I also agree with your idea that the release and press coverage was purposeful, though I think that it is unlikely that the “rounding” errors were accidental, since any stats program (or indeed, even an excel spreadsheet) will round things correctly.

  51. Calli Arcale says:

    Epineprhine:

    2) Please don’t appeal to distance, that doesn’t explain the fact that the infant mortality rate is more than twice as high for black infants compared to white infants.

    Poverty, lack of socialized medicine, poor education and nutrition, and racism are the main problems.

    I discussed more than just distance; that was simply one piece of the general problem of lack of access to medical care. Lack of access to care, regardless of why the person lacks access, is the single biggest predictor of health outcomes in the world, and that is no less true in America than it is in Afghanistan.

    And you don’t have to be poor (by the IRS’s understanding of the term) to have no access to health care. It is a bigger problem than poverty alone. That’s part of why I brought up distance. Also, I think not enough people realize how much of the *middle class* lacks assured access to health care, or how close quite a lot of us *with* health care are to losing it. Our health care system is considerably more fragile than we tend to realize.

    I’m not a fan of socialism, but if there ever were a place for it, this is it. We have the finances and the means to provide effective medical care to every man, woman, and child in this country. We simply choose not to, because we (as a people) are too selfish and judgmental and too fixed on the present to realize that all but a few of us are one medical emergency away from financial ruin.

    If you want a place in American with *really* disgraceful lack of medical care, don’t look to inner-city predominantly black areas. Look to the more remote Indian reservations. It’s like a third world country on many of those, and the United States actually has treaty obligations to provide medical care to the residents. This comes in such a pathetically piss-poor form that should disgrace every man, woman, and child in the country, even if they are morally opposed to socialized medicine. We made certain obligations when we seized their land and forced them to live the most godforsaken hellholes we could find. The least we could do is live up to those obligations. But we don’t, and the results are too often nightmarish.

  52. Epinephrine says:

    Re #49, above

    Ugh, typo – I meant IndianaFran, but got one (unfortunate) letter wrong. Very much unintentional, I can only say that when I am typing at home I frequently have a child on my lap, as my youngest doesn’t like it when I’m at a computer.

    Calli Arcale – I agree that lack of access to care (whatever the reason) is a huge problem, as is lack of care seeking (here I think of faith healing, quackery and so on taking the place of care, and the lack of knowledge about when to seek care). Socialised medicine works well here (in Canada), but we also have issues with the health of our First Nation peoples, despite their having greater health coverage than the rest of the population, and a whole branch of our health department devoted to Inuit and First Nations.

  53. Zoe237 says:

    @epinephrine:

    The inclusion of the Swedish paper biases the results toward hospital birth, as it contributes a huge proportion of the hospital group’s population while contributing little toward the home birth group. The fact is that mortality rates in Sweden are much lower for any type of birth, so adding 11,341 Swedish births to one side of the equation while adding 897 to the other inherently biases it.

    Yes, and this 11,000 hospital births adds a third to the total 33,000 births on the hospital side of the neonatal analysis. It seems there was some sort of bait and switch with the numbers there, when the perinatal analysis included 300,000 hospital births, with no difference between home and hospital. Along with rounding up with the homebirth number and down with the hospital ratio.

    Here’s what I don’t get. I finally got a copy of the in press paper and looked up the 12 studies in the metaanalysis. Every single one except one (Pang, about 17,000 out of 500,000 births) concludes no increased risk for homebirth, or no statistically significant difference found. How is that possible? I mean, I’ve heard that theoretically MA can take a bunch of negative studies, and come up with a positive result, but how? Besides the fact that these studies were done over the course of 30 years, in 7 different countries, using various research designs, including retrospective? Is this a fundamental weakness of meta-analysis, or this one in particular? What am I missing? There will always be homebirths, why are obstetricians in the U.S. so fundamentally against providing a “good transportation and referral system” and working with midwives to improve safety? Don’t forget that most major medical organizations are supportive of homebirth for low risk women, including RCOG, CMA, WHO, the U.S. and Australia are the only ones who oppose it.

    4.Ackermann-Liebrich U, Voegeli T, Günter-
    Witt K, et al. Home versus hospital deliveries:
    follow up study of matched pairs for procedure
    and outcome. BMJ 1996;313:1313-8.
    CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies

    7. Lindgren HE, Radestad IJ, Christensson K,
    Hildengsson IM. Outcomes of planned home
    births compared to hospital births in Sweden between
    1992 and 2004: a population-based register
    study. Acta Obstet Gynecol 2008;87:751-9.
    CONCLUSION: In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.

    17. Janssen PA, Lee SK, Ryan EM, et al. Outcomes
    of planned home births versus planned
    hospital births after regulation of midwifery in
    British Columbia. CMAJ 2002;166:315-23.
    INTERPRETATION: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warrant

    15. Pang JWY, Heffelfinger JD, Huang GJ,
    Benedetti TJ, Weiss NJ. Outcomes of planned
    home births in Washington State: 1989-1996.
    Obstet Gynecol 2002;100:253-9.
    CONCLUSION: This study suggests that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births.

    13. Koehler NU, Solomon DA, Murphy M. Outcomes
    of a rural Sonoma county home birth
    practice: 1976-1982. Birth 1984;11:165-9.
    Of the 273 who delivered at home, including 10 unplanned births, two were transferred to hospital for postpartum hemorrhage. One neonate was hospitalized for complications. The results of this study, as well as a review of the relevant literature, illustrate that, for a selected population, home birth is a reasonable alternative to hospital.

    10. Woodcock HC, Read AW, Bower C, Stanley
    FJ, Moore DJ.Amatched cohort study of planned
    home and hospital births in Western Australia
    1981-1987. Midwifery 1994;10:125-35.
    KEY CONCLUSIONS: Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births. IMPLICATIONS FOR PRACTICE: whether these observed differences in intervention and morbidity have any relationship to the small, non-significant increase in perinatal mortality could not be determined in this study. Continuing evaluation of home birth practice and outcome is essential.

    5. Shearer JML. Five year prospective survey of
    risk of booking for a home birth in Essex. BMJ
    1985;219:1478-80.
    A higher rate of episiotomy and second degree tears and more Apgar scores of 7 or below were found in those who were booked for hospital. There were no perinatal deaths in either group. The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital.

    6. Wiegars TA, Keirse MJNC, van der Zee J,
    Berghs GAH. Outcome of planned home and
    planned hospital births in low risk pregnancies:
    prospective study in midwifery practices in the
    Netherlands. BMJ 1996;313:1309-13.
    RESULTS: There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables. CONCLUSIONS: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.

    11. Hutton EK, Reitsma AH, Kaufman K. Outcomes
    associated with planned home and
    planned hospital births in low-risk women attended
    by midwives in Ontario, Canada, 2003-
    2006: a retrospective cohort study. Birth
    2009;36:180-9.
    CONCLUSIONS: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.

    12. Janssen PA, Saxell L, Page LA, Klein MC,
    Liston RM, Lee SK. Outcomes of planned home
    birth with registered midwife versus planned
    hospital birth with midwife or physician. CMAJ
    2009;181:377-83.
    INTERPRETATION: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

    14. Dowswell T, Thornton JG, Hewison J, Lilford
    RJL. Should there be a trial of home versus
    hospital delivery in the United Kingdom? BMJ
    1996;312:753-7.
    (this is the one of 11 births, also favorable for homebirth, can’t copy the abstract

    16. deJong A, van der Goes BY, Ravelli ACJ, et
    al. Perinatal mortality and morbidity in a nationwide
    cohort of 529,688 low-risk planned home
    and hospital births. BJOG 2009;116:1177-84.
    CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

  54. Zoe237 says:

    I discussed more than just distance; that was simply one piece of the general problem of lack of access to medical care. Lack of access to care, regardless of why the person lacks access, is the single biggest predictor of health outcomes in the world, and that is no less true in America than it is in Afghanistan.

    Also, African American infants and mothers have huge increases in mortality rates even AFTER controlling for economic factors, particularly wrt premature birth, and we don’t know why. This is the real story wrt to birth in this country and it rarely gets discussed.

  55. PennyLane says:

    I think your assertion that 37% of home births end with emergency transfer is wildly inaccurate, unless your definition of “emergency” is extremely liberal. Most licensed midwives have about a 10% transfer rate, and almost all transfers are non-emergency situations (exhaustion, desire for pain medication, meconium in amniotic fluid, prolonged pushing.) Although true home birth emergencies can and do happen, they absolutely do not occur in 37% of home births.

  56. squirrelelite says:

    @PennyLane,

    Dr Hall wrote that

    between 9% and 37% of planned home births end up with transfer to the hospital during labor and are converted into hospital births.

    A 10% transfer rate certainly falls within that stated range.

    In that statement of the transfer rate, at least, she did not use the word emergency.

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