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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.

Posted in: Obstetrics & gynecology

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257 thoughts on “The Tragic Death Toll of Homebirth

  1. mariawolters says:

    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.

  2. mccraigmccraig says:

    yr dataset link is broken : http://wonder.cdc.gov/lbd-icd10.html gives 404. dyu have the correct link ?

  3. Sc00ter says:

    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.

  4. Joe says:

    @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.

  5. “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,

  6. JerryM says:

    Welcome to SBM

    what are CNM? and what are CPM?

  7. BenDC says:

    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?

  8. tarran says:

    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,

  9. DrBadger says:

    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).

  10. DrBadger says:

    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.

  11. ADR150 says:

    the link to the entire data set doesn’t seem to be working:

    http://wonder.cdc.gov/lbd-icd10.html

  12. Sc00ter says:

    @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.

  13. 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.

  14. 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.

  15. 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.

  16. BenDC says:

    “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.

  17. storkdok says:

    *Stands up and takes hat off*

    Thank you, Amy!

  18. ADR150 says:

    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.

  19. JerryM says:

    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….

  20. Scott says:

    So then why is this post comparing these different populations?

    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).

    this returned a death rate of .98/1000 for MD’s and a rate of .89/1000 for doctors of osteopathy.

    Going to need the raw numbers, not just the rates, to make any judgement of statistical significance.

  21. 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.

  22. ADR150 says:

    MDs: 3205 deaths; 3,268,500 births
    DOs: 162; 182,452

  23. Scott says:

    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.

  24. ADR150 says:

    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?

  25. provaxmom says:

    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.

  26. windriven says:

    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.

  27. Scott says:

    thanks… how do you calculate uncertainty?

    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.

  28. Joe says:

    # 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.

  29. 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.

  30. 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.

  31. PINKYRN says:

    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?

  32. Harriet Hall says:

    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.

  33. Squillo says:

    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.

  34. carrie says:

    “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.

  35. BenDC says:

    “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?

  36. apteryx says:

    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.

  37. Scott says:

    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 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.

  38. magra178 says:

    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 . . .

  39. provaxmom says:

    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.

  40. moderation says:

    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.

  41. Basiorana says:

    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.

  42. SF Mom and Scientist says:

    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?

  43. AlexisT says:

    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.

  44. SF Mom and Scientist says:

    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.

  45. magra178 says:

    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.

  46. apteryx says:

    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.)

  47. windriven says:

    @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.

  48. apteryx says:

    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.

  49. Peter Lipson says:

    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.

  50. MOI says:

    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.

  51. apteryx says:

    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.

  52. provaxmom says:

    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.

  53. 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.

  54. Traveler says:

    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.

    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.

  55. daniel says:

    “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.

  56. 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.

  57. chaoticidealism says:

    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.

  58. 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.

  59. Scott says:

    Scott, did you state that a quick calculation of the raw numbers showed that the difference in death rate was not significant?

    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.)

  60. SF Mom and Scientist says:

    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.

  61. Noadi says:

    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?

  62. 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.

  63. 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.

  64. MOI says:

    @ Scott – Thank you for the clarification!

  65. 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.

  66. provaxmom says:

    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.

  67. provaxmom says:

    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.

  68. 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.

  69. Neil says:

    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?

  70. daniel says:

    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.)

  71. apteryx says:

    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.

  72. Lawrence C. says:

    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.

  73. MOI says:

    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.

  74. windriven says:

    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. “

  75. lizdexia says:

    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.

  76. MOI says:

    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.”

  77. apteryx says:

    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.)

  78. apteryx says:

    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?

  79. provaxmom says:

    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.

  80. daedalus2u says:

    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.

  81. apteryx says:

    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.

  82. apteryx says:

    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.

  83. Calli Arcale says:

    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.

  84. windriven says:

    @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.

  85. MOI says:

    @ 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. =)

  86. SF Mom and Scientist says:

    “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.)

  87. apteryx says:

    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.

  88. 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.

  89. dudelynurse says:

    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.”

  90. 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.

  91. Sid Offit says:

    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

  92. 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.

  93. daedalus2u says:

    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.

  94. windriven says:

    @ 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.

  95. overshoot says:

    Speaking of the welfare of babies.. my sister lives in Alaska and knows people whose choice of living conditions eliminates any choice about childbirth.

    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.

  96. squirrelelite says:

    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”.

  97. John Snyder says:

    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.

  98. Mark P says:

    -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.

  99. Basiorana says:

    “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.

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