Sunday, May 21, 2006

The alternate world of homebirth advocates

Homebirth advocates are well aware that doctors do not approve of homebirth. They are unwilling to take doctors' explanations at face value. Yes, doctors, such as myself, cite evidence that homebirth midwives simply don't have the qualifications necessary to prevent neonatal deaths in the case of complications. Homebirth advocates cannot and will not acknowledge the evidence. Instead, they have created a alternate world where obstetricians are so benighted by their lack of experience with normal birth that they are incapable of understanding it.

In this alternate world, all hospitals have epidural rates of 90%. In the alternate world, epidurals create lots of complications. That's good as far as obsetricians are concerned, because they like complications.

In the alternate world, obstetricians have rarely if ever seen natural childbirth. In fact, it is so rare, that obstetricians don't even know what natural childbirth is and, therefore, have no appreciation for how sublime and wonderful it can be.

Evidentally, there are no female obstetricians in the alternate world, since no obstetricians have any first hand knowledge of birth.

In the alternate world, obstetrics textbooks don't mention natural childbirth since it doesn't happen. Obstetrics textbooks are filled with ways to manage the complications that obstetricians like to cause.

In the alternate world, obstetricians have no patience. They invent reasons to complicate childbirth so they can intervene and get back to making more money. They are very afraid of midwives, too. That's also about the money. The obstetricians think that homebirth midwives will threaten their income stream.

What really remarkable is that homebirth advocates have never actually worked with obstetricians. Most have never worked in hospitals either, but they have such acute perception that they know what goes on in hospitals without actually being there.

Well, I'm an obstetrician and I come from the real world. The alternate world that homebirth advocates have created in their own minds simply does not exist. They are wrong about the pre-obstetrics mortality rates; they are wrong about the epidural rates; they are wrong about what obstetricians do and do not see in their training; they are wrong about what is in obstetrics textbooks; they are wrong about the "golden age" of midwifery; they are wrong about why midwives and homebirth were displaced, the list goes on and on.

Most importantly, they are wrong about the thinking and motivations of obstetricians themselves. Many obstetricians are women. Not only do they have extensive professional experience, but many have personal experience as well. We argue against homebirth because we have seen evidence that it is not safe. There is no other reason; there is no conspiracy; there is no ulterior motive.

86 Old Comments:

You've sunk to a new low Amy, Before, your posts had one tiny resembelance of an intelectual discussion. This one just points fingers.
Nobody said hospitals had a 90% epidural rate. Nobody said any of these things in fact.
But why don't you educate us. What is the national epidural rate? How many women birth medication-free in hospitals in the US? How many completely natural labors have you sat through beginning with active labor, all the way 2 hours past the delivery of the placenta? (Your own births don't count, since we all can claim that experience.) What qualifications DO midwives have? How many OBs have worked with midwives in a home birth? (how could they know how midwives practice if they've never worked out of hospital with one? You have such acute perception that you know what goes on out of hospitals without actually being there?)

By Anonymous Anonymous, at 9:45 PM  

Well, I am a certified nurse midwife. I have worked in hospitals for 20 years. I have also attended births at home and in birth centers. I think that you as polarized by your own experience as the home birth advocates that you castigate. I have seen births in the hospital that have been iatrogenic disasters. I have seen maternal deaths from hospital births. I have not seen maternal deaths from planned home births, although I have seen some disasters from moms whose only choice if they wanted to avoid a cesarean (prior c/s, breech baby) was to have an unattended home birth.
WHY are so few obstetricians nowadays trained in the arts of vaginal obstetrics? Any idea? Could it be that the ideal birth rate is such that the idea of permanently damaging a woman's uterus is not any longer an awe-inspiring decision making process? But I digress.

I have seen home births that also had problems. With a trained attendant, the need for transport to hospital is usually recognized. Every homebirth attendant that has a recognized credential (CPM, CM, CNM) knows that not every birth belongs in the home. But I also propose that not every birth belongs in the hospital.

For some women, home is safer than hospital. Becoming a patient in the hospital is not an entirely benign procedure. I think that we all recognize that mistakes happen - that babies are given CO2 instead of O2, MRSA happens, drug errors happen, babies get switched or stolen, femoral nerve palsies happen because moms can't feel that they are being poorly positioned for pushing because of a dense epidural. Moms have died during emergency (and how did it get to be an emergnecy?) cesareans because anesthesia couldn't intubate in time. And let's not forget the case written up in JAMA a while back -where a baby died in labor and a mom ended up with a hysterectomy - due to a constantly changing cast of characters. That would not have happened at home - for lots of reasons. #1 - you don't induce labor at home (and nowhere in there was there what I could see as a reasonable indication for induction) #2 - the lines of responsibility are pretty clear at home. The parents have the prime responsibility, and the senior midwife calls the rest of the way down the line. Everyone knows what the plan is and communications are pretty clear. (I am assuming that you are familiar with the classic JAMA article about medical error in a major Boston hospital).
For others, hospital is safer than home. I recently told a type one diabetic mom that not only should she not even think about a home birth, she shouldn't plan to deliver at the level one community hospital. And anyone who is likely to need risky interventions like Mag sulfate, induction of labor and the like, should be in a place equipped to run a code if things go south.

I'm a homebirth advocate - and I don't live in the alternate world that you describe. I currently practice in a hospital because that is where the patients are - but that doesn't mean that all of them need to be there or are even better off because that is where they are giving birth.

By Blogger alicia, at 10:01 PM  

Homebirth advocates are well aware that doctors do not approve of homebirth.

Hmm, I have met quite a few doctors that think homebirth is one of the best options for a low-risk pregnancy therefore "doctors do not approve of homebirth" is not a generalization that one can make.

By Anonymous Anonymous, at 11:01 PM  

Good points, Alicia. I would also like to point out that another reason why homebirth can often times be safer than a hospital birth is a very simple reason; stress. There are some women, like myself, who want a natural birth with no unnecessary interventions and with the same person who has been with me throughout my pregnancy that I trust and to choose who I do or do not want at this life-changing event. I also wanted to choose where I gave birth. When I first found out I was pregnant there was no doubt I would have my son with a midwife (my mother birthed her first child in the hospital and the other four with the assistance of a midwife at home - including me). However, until I found the right midwife, I went with the local hospital for my prenatal checkups. I only had two doctors that I liked and the other five or so that I saw in the two months I was going there were horrible. I got flipped around, never saw the same person, and some of them were even rude to me. I can't even imagine being a woman uninformed of her birthing options and having to give birth in a place with people I'd never met before. I would have freaked out. I would have been stressed out with different people that I had never met before going in and out, checking to see how far along I was, trying to hurry it up, and so on. Stress can slow or even stop labor ("fight or flight" reaction leading to pitocin and an IV) which can make it more painful (need for an epidural and EFM) which can all add up and lead to a cesarean that could have been avoided by having my son in a setting of my choosing. And this is just a few of the ways that the stress of the birth setting, attendants and procedures can affect the outcome of a birth and subsequently the safety of mother and child.

I have met many women who were unaware that they had alternatives and gave birth to their first children in a hospital and ended up with a very unsatisfactory birth and then found out about their options the second time around and had wonderful and safe home births because they were not stressed, they knew and loved the woman that was helping them birth their children, and because they were in a comfortable setting - they were home.

While no birth setting is perfect for every birth, it must be understood that there is a place that is best for each birth and since each birth is different, that place could be hospital, birth center or home just depending on the woman, her child and her pregnancy and body. Unfortunately some people assume something will always go wrong and react accordingly. If we really want to not only save lives and prevent complications but also strengthen the bond between mother and child then we need to look at each mother and child, their history, their beliefs and their situation and decide accordingly as to where their birth should take place.

By Anonymous Anonymous, at 11:25 PM  

"I would also like to point out that another reason why homebirth can often times be safer than a hospital birth is a very simple reason; stress."

But the point is that there is no EVIDENCE that homebirth is safer than hospital birth.

By Blogger Amy Tuteur, MD, at 11:28 PM  

Yes, doctors, such as myself, cite evidence that homebirth midwives simply don't have the qualifications necessary to prevent neonatal deaths in the case of complications.

Any midwife with a credential should have those qualifications. The experience and skill to know when to transport, and the skills and equipment to handle unforseen complications.

Instead, they have created a alternate world where obstetricians are so benighted by their lack of experience with normal birth that they are incapable of understanding it.

Not all. But many. I have witnessed this lack of faith in normal birth many times.

In this alternate world, all hospitals have epidural rates of 90%.

More like 95% where I am. But if that's what women want, they should get it. I don't know any midwives here (and there are many in my area) who are opposed to epidurals.

The obstetricians think that homebirth midwives will threaten their income stream.

Some do. Historically, that was certainly part of the motivation for eliminating midwives.

What really remarkable is that homebirth advocates have never actually worked with obstetricians.

Now that's just not true, at least for any midwife I've ever met in California. Many of us are fortunate to have close working relationships with excellent obstetricians. And those who don't are constantly seeking out such a collaboration. I would not feel safe without a good back-up plan, and a doctor who I could call when we're no longer on the "normal" curve. And when we do transport, I remain by the side of my patient, working with the doctor. I have tremendous respect for obstetricians. I just also happen to believe that women have the right to birth at home.

Most have never worked in hospitals either, but they have such acute perception that they know what goes on in hospitals without actually being there.

Some, I'm sure. You will always get crazy radical people. I've met crazy doctors who encourage women in their first trimester to schedule their surgery now to make their lives simpler. And you get crazy "midwives" who think they are qualified after a handful of births. But all the midwives with whome I associate and attend peer review, are qualified, skilled and conscientious.

...They are wrong about the pre-obstetrics mortality rates; they are wrong about the epidural rates; they are wrong about what obstetricians do and do not see in their training;...

They are clearly wrong about you, Amy. And they would be wrong about any of the half dozen OB/GYNs I work with. But I have WITNESSED the things you are talking about. That said, it is not because I feel "hospitals are bad" that I am pro homebirth. (Some hospitals may need a re-vamp and a new staff and new attitude...) I am pro homebirth because I think women deserve the choice. And, because of my training, skills, the equipment I carry, my relationship with several excellent doctors and my proximity to good hospitals, I can offer them that choice with an outstanding level of safely.

We argue against homebirth because we have seen evidence that it is not safe.

Obstetrics as it is praticed in a hospital, is not safe at home. Epidurals would not be safe at home. Neither is pitocin. Neither is a routine IV, or depriving a laboring mother of eating. And delivering a baby with someone who has no experience with hemorrhage, or the equipment or skills for resuscitation, is not safe. Or with someone who won't acknowledge when things are not working and you need to be in a hospital - that is not safe.

By Anonymous Diane West, LM CPM, at 11:45 PM  

But the point is that there is no EVIDENCE that homebirth is safer than hospital birth.

What sort of evidence are you looking for, Amy? Does the BMJ 2000 study not hold any weight for you? The statistics showed that a planned homebirth was as safe as hospital birth.

There is certainly no evidence to show that it is more dangerous than hospital birth. Unassisted, unplanned and with an unskilled attendant - yes. Definitely dangerous.

Another point to ponder... a c-section arguably carries more risk than a normal, spontaneous vaginal birth. And yet many people (myself included), accept that women should have the right to choose this option. And yet for women to plan to give birth at home with a skilled provider is not an acceptable choice? With it's very,very small risk assignment?

By Anonymous Diane West, LM CPM, at 11:56 PM  

Diane:

"What sort of evidence are you looking for, Amy? Does the BMJ 2000 study not hold any weight for you? The statistics showed that a planned homebirth was as safe as hospital birth."

If you read the study carefully, you will see that the authors claimed a low neonatal mortality rate because they arbitrarily removed deaths from the homebirth group. If you do the calculations, the death rate in the homebirth group was considerably higher than quoted, and higher than the neonatal mortality rate for hospital births.

In fact, if you read the paper closely, you will see that the authors made no direct comparison between the mortality rate in their study and the known mortality rates for white women at term. Instead, they compared their mortality rates to previous studies of homebirth.

Both the removal of deaths from the homebirth group, and the fact that the mortality rate in the homebirth group was not compared to known mortality rates for low risk hospital groups render the study so flawed as to be useless.

I know that this is not what you have been told, but if you read the papers themselves (not the abstracts), you will see that this is true.

There has not yet been a study of homebirth that shows it to be as safe as hospital birth for comparable low risk groups. Indeed, all the major homebirth studies done to date show an excess of preventable neonatal deaths in the homebirth group.

By Blogger Amy Tuteur, MD, at 12:38 AM  

Amy, you stated that the US neonatal death rate for 2000 was 2.4/1000. There were 9 neonatal deaths in the Johnson and Daviss study. They excluded three from consideration because they were the result of congenital anomalies. Even if we include those deaths in a revised calculation, we get a figure of 1.66/1000. (Nine neonatal deaths out of 5422 live births = 0.0016599)

1.66 < 2.4.

The rate of neonatal death in the Johnson & Daviss study was lower than the rate of neonatal death in the general population, even though the cohort was 12.3% Amish/Mennonite and those women face an increased burden of lethal genetic disease.

I am not persuaded that the choice to exclude congenital anomaly deaths was an effort to make their numbers look better. When I asked you about the exclusion of congenital anomalies in another study of delivery mode (vaginal vs. C-section for breech babies), you stated that hydrocephalus could preclude vaginal delivery. And yet many congenital anomalies are associated with IUGR and/or microcephaly, which might make it easier to deliver them vaginally. As far as I can tell, congenital anomalies are excluded because you can't make reliable statements about events that occur once in 20,000 births or 100,000 births when your population is on the order of a thousand births. It's a confounder, because you can't predict the mix of anomalies, and so they're removed from consideration.

If you have a citation from the epidemiological literature on the inclusion or exclusion of congenital anomalies, I'd very much like to see it.

In any case, it's incorrect to state that the neonatal death rate in Johnson & Daviss was higher than that of the population as a whole.

By Blogger Jamie, at 9:29 AM  

Jamie:

"In any case, it's incorrect to state that the neonatal death rate in Johnson & Daviss was higher than that of the population as a whole."

I think we have already discussed this in the past. The neonatal death rate of 2.4/1000 I quoted was derived from white women at term. It includes all possible complications such as pre-eclampsia, pre-existing medical conditions, etc. The rate for a low risk population of white women is likely to be substantially less than half of that, so the neonatal death rate at homebirth was definitely higher than a comparable low risk population.

What is especially troubling is this: the primary focus of the study is a comparison of interventions in the homebirth group to intervetions described in a study of all births in the US for 2000. Yet when it came to making a comparison about neonatal death rates, the authors used an entirely different group. They compared death rate in their group to the hospital death rates in previously published studies about homebirth. This is the ONLY time that they failed to use the 3 million+ US as births as the comparison group.

It's not like they couldn't get access to that information. I can think of no other plausible conclusion about this action than that it was a deliberate attempt to conceal the fact that the neonatal death rate in the homebirth group was actually substantially higher than the control population.

Can you think of another plausible explanation?

By Blogger Amy Tuteur, MD, at 10:06 AM  

The only plausible explanations I can think of are these:

1) The data which are available did not permit apportionment of neonatal deaths by risk category or population type; therefore 2.7 was the only number available; the authors knew it was improper to make the comparison.

2) The data for properly controlled (e.g. very low risk) hospital births WERE available, but were below 1.7, so the authors did not publish them.

By Blogger sailorman, at 11:21 AM  

Yes, I can think of a perfectly plausible explanation. Here's the citation for the information on demographics, interventions, etc.:

Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Births: final data for 2000. National vital statistics reports. Hyattsville, MD: National Center for Health Statistics, 2002;50(5).

I can't find that report online, but I've just been through the 2001 report and I can't find any information on neonatal death. On reflection, this makes perfect sense -- it's a compilation of information from birth certificates. Do birth certificates in your state report death in the neonatal period?

My computer is moving at glacial speed this morning, so I may be wrong here. But I can't find information about either stillbirths or neonatal deaths in the report cited. There's a report on deaths that popped up in the same Google search, but I'm going to have to wait until the computer ailment is resolved to dig through it.

Still don't see evidence of hidden bodies, Amy.

By Blogger Jamie, at 11:42 AM  

"I would also like to point out that another reason why homebirth can often times be safer than a hospital birth is a very simple reason; stress."

But the point is that there is no EVIDENCE that homebirth is safer than hospital birth.


There is plenty of evidence that is equally safe and quite a bit that shows that, with low-risk pregnancies, it is even safer. Where exactly are you getting YOUR evidence? Apparently you are only looking at biased things and completely ignoring anything that says otherwise.

By Anonymous Anonymous, at 1:29 PM  

Jamie:

What will you commit to before you see the data?

I.E. if the data show the adjusted neonatal rate for a population similar to the J&S study is LOWER in the hospitsal, how will that change your thinking, or your interactions with other midwives?

For example, I have read a lot of these home birth studies. I have discussed their statistical flaws in detail.

Generally, the studies tend to show no difference, or a miniscule difference in favor of home birth. However, the bias in their test po[ulations, if properly accounted for, would So far, they have only convinced me of the added danger of home birth.

However, if a good study were done (or if you could show me an existing study without those flaws) I would defend it to other scientists. You will note, for example, that I was the first person to comment (negatively) on the Scotland study.


You can find an interesting CDC publication HERE (warning: 85K, 500 page, PDF)
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary

Now, these are not very detailed. And they are certainly NOT worth basing an entire argument on. But they are informative.

If you look at Table , for example, you can see why we coplain

If you look at Tables 19 and 20, for example, you can see why we complain when all-white home birthers get compared to a national or mixed-race population. You can also see the problem when people don't control for education level, and have a high proportion of educated people in the home birth crowd.

You can ALSO see the enormous differences in those populations.

Table 19 (neonatal deaths by race) shows 3.8 for all whites and 9.1 for all blacks in 2000.

Now, let's say we look at a home birth study which shows the safety to be "equivalent".

And let's say the home birth population in the study was 98% white, and the comparison population was 20% nonwhite. (this was true in the Farm study, for example).

Unless a whole lot of that 20% were chinese or Japanese, the hospital numbers SHOULD have been higher.

And if a fair proportion of that 20% were black, the hospital numbers should have been a LOT higher.

uit they were close to equal.

Anyone want to know what my conclusion would be?

By Blogger sailorman, at 2:05 PM  

Maybe this isn't part of the agenda, but how about some good practical help for us midwives. I don't think homebirth or midwives are going to go away, and neither are obstetricians or impersonal hospital care. So, why can't we come to some kind of truce and if those who are able and willing, teach those who are wanting to be better care providers. Teach us to read studies. Teach us to develop our clinical skills and protocols. Or is the agenda really to make us go away? Or maybe it is just to argue, I don't know. I have learned by reading these posts, but won't continue if it is just argument for argument sake.

By Anonymous Anonymous, at 2:42 PM  

I'm all about the data, Sailorman. :-)

I'd love to see some good numbers for perinatal mortality but no dice so far. Please let me know if you find anything.

As you say, the CDC documents gives the neonatal mortality rate for babies born to white women in 2000-02 as 3.8/1000. Neonatal mortality rate for J&D babies was 1.7/1000.

I don't see education and SES skewing the results badly in favor of the women in the J&D study, though there is a demographic difference. Here's Table 1 again. I would guess that the old-order Amish families might have less money and less education than average, but it's only a guess.

Another interesting tidbit from the 2001 results I mentioned above: congenital anomalies are responsible for the large majority of infant deaths in the US. Now I don't know how the proportions break down as far as neonatal/post-neonatal death, but a population at higher risk of lethal anomalies will skew the results unfavorably.

I'm open to the idea that there's a problem with the data on homebirth safety, but I'm not seeing a problem.

I had a few more things I wanted to ask you about, Sailorman, but I think my computer has a broken fan. It gets very cranky and sluggish after just a brief time on. Let me post this comment so it doesn't vanish into the ether, and see if I can get the rest of my questions written down.

By Blogger Jamie, at 2:44 PM  

Okay, two related questions here. First, about control groups. You said somewhere a few threads back that homebirth researchers should compare to a control group and correct statistically for differences using weighting factors. But that's what Durand did, and you were not happy with those results at all.

Durand reported a death rate of 1.0% for The Farm midwives vs. 1.33% for controls, but the difference was not statistically significant after correcting for differences btw the two groups.

So I guess I'm confused by what sounds like two different viewpoints from you in different threads -- I understand that carefully matched controls are obviously best. Do you object to Durand's approach to statistical weighting, or do you think he should have used a smaller group from the NNS data to match more carefully?

Oh, my kids need help. Back soon with the second question.

By Blogger Jamie, at 2:53 PM  

I am shocked that in the same post you are saying homebirth advocates have negatively stereotyped OB's and hospital birth you also do the same to them and home birth... and in the process make yourself out to be that negatively stereotyped OB. Have you ever attended a home birth? Do you know anyone personally who has had a home birth? If all you have seen of home birth first hand is the transfers Midwives bring in to the hospital, then you would indeed believe home birth to be unsafe. What you are not seeing are the hundreds and thousands of home births that did NOT need to be transfered to you for help... which is exactly what hospitals and OB's are for: Help when birth is not normal. I am grateful everyday that there are hospitals and OB's trained to intervene when birth is not normal; however, I am saddened everyday that normal labors are interferred with by OB's who are not trained in normal birth.

By Anonymous Anonymous, at 2:55 PM  

My other question is about intrapartum deaths. When I first looked carefully at the J&D comparison studies, I was surprised to see the age of some of the studies listed. I thought it must be silly to compare intrapartum deaths in 2000 with intrapartum deaths in 1975.

But is it?

AFAIK, we haven't learned a ton about preventing stillbirth in that time. EFM was available then -- and EFM doesn't improve outcomes in low-risk pregnancies anyway. Do we have any great new antibiotics for treating infections? We certainly have more antibiotic-resistant bacteria. Can a hospital patient get a C-section any faster now than she could 30 years ago if her baby is in distress? There haven't really been huge advances in surgery to cut down the decision-to-incision time dramatically, have there? We can't really tell (again AFAIK) if a nuchal cord is going to cause trouble or not before the onset of labor.

I understand and am grateful for the advances in treatment of live-born babies -- like exogenous surfactant. But how far have we come in preventing stillbirth? Are the comparisons in J&D's Table 4 (low-risk physician-attended hospital births) useful? I think they may well be.

By Blogger Jamie, at 3:04 PM  

Jamie:

Here's a chart of neonatal and maternal mortality that offers a compact summary of the problem.

Even a brief glance at the chart reveals the major discrepancies between neonatal death rates at different time periods and between different races. You can see why it is critically important to pick the right control group, or the interpretation will be completely invalid.

In any homebirth study, the authors are required to use as a control group women who are white, well educated, at term, vertex presentation, no pre-existing medical problems, no pregnancy risk factors, no smoking, etc. Simply put, since homebirth candidates are the lowest of the low risk patients, the authors of a study must find a control group of the lowest of the low risk patients. Any attempt to compare their numbers to any other population renders the results meaningless.

Statistical weighting is not an acceptable substitute if actual numbers are available. When it comes to the Durand study, actual numbers are certainly available and they are probably in the range of about 3/1000. That is considerably lower than the mortality rate of greater than 9/1000 in the Farm group.

The fact is, Jamie, that 9/1000 is a very high number. That may not be obvious to people without a background in studying neonatal mortality, but it is obvious to people who do. The very idea that Durand tried to pass off such a high number as equivalent to low risk hospital births of the time, or even to suggest that it was in any way an acceptable number, shows that the paper was severely flawed.

The fact that Ina May Gaskin prominently features this study on her website to this very day, and claims that it shows that homebirth is safe is a tremendous indictment of homebirth advocacy. In essence in is a lie, and both Durand and Gaskin are smart enough to know by now that the paper proves exactly the opposite of what they claim: mortality rates at the Farm during that time period were unacceptably high, and many preventable neonatal deaths occurred.

The fact that homebirth advocates repeatedly cite this study shows either that they never read it, or that they never understood it. It should have been repudiated long ago.

By Blogger Amy Tuteur, MD, at 3:40 PM  

Amy, I'd just like to say that your sterotyping of homebirth advocates is pathetic. You don't want to be stereotyped, don't stereotype others.

Let me ask the debaters here about statistics. When you talk about neonatal death rates being an indicator of the safety of homebirth - is that really a good indicator? How many of the neonatal deaths from the homebirth group would not have happened had the birth been in the hospital? And, how many of the hospital neonatal deaths were iatrogenic and wouldn't have happened had the birth been at home?

Rather, shouldn't we look at home birth statistics by themselves to speak for themselves as to their safety. Maybe not a comparison like some like to say, "Home birth is safer for low-risk women." But rather, "home birth is safe."

I'd like to see the evidence, Amy, that homebirth midwives don't have the qualifications to prevent deaths in case of complications. Tell me: what are the major complications of home births, what is done to prevent death in those cases, and what qualifications are needed to do the death-preventing procedures?

Is there a study that compares home births with good outcomes to hospital births with good outcomes in regards to the satisfaction of the woman with her birth experience, the use of unnecessary interventions, long-term complications from interventions, etc?

Christine
(who has read an obstetric textbook and done many of the other things I'm said not to have done)

By Anonymous Christine, at 3:53 PM  

Jamie,

Hmm. I am happy to try to explain it to you, but the truth is that the Farm study is SO atrocious, it's not a great teaching tool. (If you haven't done so, you might read the various posts on my blog in which I discuss the failings of the Farm study).

I'll try doing a general explanation instead.

In a perfect world, you actually find a control group to match your home birth women.

In most homebirth studies, this group is the lowest of the lowest risk population. (And of course it is: a smart midwife will reject anyone else from home birth. There's nothing wrong with selecting a population this way).

So far, nobody has done a control accurately, at least not in the studies I have read. If someone DID do it, it would be a valuable study.

Not incidentally, you can have all the "high risk" people in the home birth study you want, so long as you select the right control.



As an alternative to doing a "proper" control, you might also compare your home birthers to a "riskier" population. But as I'm sure you can see, you've got problems at the outset. To a fair degree, your results can never be as good.

You can still get salvageable data. But to avoid accusations of bias--deserved or not--you would need to use the UPPER limits of risk.

This means that if your home birth population is all white, and your control is 20% nonwhite (without any other available details), a "safe" comparison would be to assume your control group was 20% black--NOT to assume it was 20% Japanese.

And if the reported neonatal death rates for black women range from 8.7 to 9.3 across the time period of your study, you would need to use the 9.3 number. In other words, if you're going to "assume" anything, it cannot be to your benefit.

Again, I have not seen anyone do this. I am certain the reason is that performing such assumptions would produce results well in favor of hospital births.

Now, you may not like to do this. But just for kicks and giggles, try it:

1) Find the Farm study. Record everything you know about the data of the Farm control group. 11% smokers, a large % nonwhite, a large percentage non-college, etc.

2) Pull the CDC data for the years of the Farm study. If you want to cheat (it'll be less accurate but still informative), use the link I posted above, and just get as close as you can.

3) Identify an INCREASE in risk factor and subtract it from the hospital group.

By this I mean:
If white women have a 4.0/1000 rate,
and black women have a 6.0/1000 rate,
and the hospital population had 20% more blacks than the home birth population,

Then the expected rate for the hospital if they had the population of the Farm group would be (the measured rate for the hospital, in deaths/1000), MINUS ((6.0 - 4.0) * 20%). For this instance (and these numbers are made up), this would reduce the hospital death rate by 0.4/1000.

3) Repeat this for EACH risk factor. If you happen to find a factor where the hospital group was LOWER risk than the home birth group (this is exceedingly rare) just add it to the hospital number, instead of substracting.

Don't forget there are a lot of risk factors. You may not be able to find data on all of them. For this example, try doing it using ONLY the factors for race, education, and smoking (if you can find one for smoking).

Once you have finished equalizing the control by subtracting some the increased risk from the hospital, compare the results again, to the home birth group. Post your numbers, if you're willing.

Remember that (unless you found some really good statistics) this probably doesn't even account for all the "benefits" of the home birth group.

Enlightening, isn't it? Or frightening, depending on your viewpoint. Now you understand how we can look at a "they're equal!" study and say "no, they're not equal at all".

This is a VERY VERY rough idea of how things work. Let me know if it helps.

By Blogger sailorman, at 4:07 PM  

P.S. If you want to save some time, you can check
" Statistics for Believers # 3 "
on my blog for some Farm study comments.

P.P.S. The Farm study, though problematic, at least gives good information about their controls and home births. But if you want to use another study instead, go for it :)

By Blogger sailorman, at 4:14 PM  

Christine:

As I have said many times before. There is not a single study that demonstrates that homebirth is as safe as hospital birth. Every study to date shows an excess of preventable deaths in the homebirth group.

By Blogger Amy Tuteur, MD, at 4:21 PM  

As I have said many times before. There is not a single study that demonstrates that homebirth is as safe as hospital birth. Every study to date shows an excess of preventable deaths in the homebirth group.

And what about the excess of preventable deaths in hospital births? Is that not of any importance to you?

By Anonymous Anonymous, at 4:48 PM  

"And what about the excess of preventable deaths in hospital births? Is that not of any importance to you?"

The excess of preventable deaths at homebirths is GREATER than the preventable deaths at hospital births. That's why hospital birth is safer. There has never been a study that has shown anything other than this.

By Blogger Amy Tuteur, MD, at 4:53 PM  

Sailorman, I have four small children.

Amt. of chaos four children cause while I am typing quick comments here = 4x

Amt. of chaos four children cause while I redo the statistical weighting for The Farm study = (x)(4!) (I was going to make that x to the 4! power, but I can't put in the superscript tag. It would be more accurate.)

So maybe I'll take that on someday when my kids are bigger, but not now. I've read your posts on the study; I was just curious about the degree to which statistical weighting can offset the difficulty of matching controls.

Amy, it wouldn't really surprise me if The Farm data had shown an excess of deaths, because in the beginning they were delivering babies on buses, with zero training, and apparently not seeking medical care for premies. (IIRC, Ina May's own baby was born a couple of months early and died not long after his birth.) But I'm still not convinced that it actually is an excessive number.

The 17/1707 figure includes antepartum deaths, intrapartum deaths, and neonatal deaths. We can't compare to neonatal deaths alone. The page you linked to doesn't support your contention that the value should be 3/1000, especially given the likelihood that deaths were distributed asymmetrically, with more deaths occurring in the early years of the community's existence.

In any case, the case for homebirth doesn't stand or fall with Durand's results. I was looking for clarification about weighting, not trying to re-open debate on the validity of the study's conclusions.

By Blogger Jamie, at 4:56 PM  

I think that instead of comparing flawed studies to prove one side or another, it may be better to compare countries and their success in having the safest births and postpartum periods.

http://www.cia.gov/cia/publications/
factbook/rankorder/2091rank.html

or

http://tinyurl.com/4yn6k

41 countries have better infant mortality rates than the US. Why is this? Are we so far down on the list because of our over use of technology and drugs or do we not intervene enough? What is different between us and the five or ten countries that have the best outcomes? I don't have the answers to this, but I think it would be worth while to look into it.

By Anonymous Anonymous, at 5:02 PM  

"I think that instead of comparing flawed studies to prove one side or another, it may be better to compare countries and their success in having the safest births and postpartum periods."

In other words, you don't have any data that shows homebirth to be safe in the US.

Comparing countries is not an acceptable way to determine the safety of homebirth. Unless their populations are exactly the same (and none of them are), the results will not be valid.

By Blogger Amy Tuteur, MD, at 5:09 PM  

Jamie:

"Amy, it wouldn't really surprise me if The Farm data had shown an excess of deaths, because in the beginning they were delivering babies on buses, with zero training, and apparently not seeking medical care for premies."

Yet Gaskin and other homebirth advocates are still quoting this study. This raises two important rhetorical questions rhetorical because you are not in a position to answer them, only Gaskin is).

First, isn't it dishonest to claim something about the study that you know to be untrue? Second, where is the rest of the data from the Farm. The study concluded decades ago and they have been doing deliveries in the interim. Gaskin's website is filled with flattering statistics about interventions, but mortality statistics are nowhere to be found. How many babies have died under Gaskin's care or supervision since then?

By Blogger Amy Tuteur, MD, at 5:14 PM  

I am not attached to your doing the Farm numberswork--I have young kids myself. Hopefully I explained my general point well enough. If not, let me know.

By Blogger sailorman, at 5:15 PM  

Amy said:

Comparing countries is not an acceptable way to determine the safety of home birth. Unless their populations are exactly the same (and none of them are), the results will not be valid.

Well, as a traveler who has lived in 14 different cities in six different states, I would argue that no one place in the US is like another. People in some places are more active than others and therefore healthier. Some communities practically live on fast food while others pride themselves on their wholesome diets. Environmental toxins that are prevalent in some neighborhoods are non-existent in others. Violent crime is common in some places and practically unheard of in others.

Since this is the case in the US, can we really rely on any studies unless done in our community? And what about the individual who differs from the norm in her community? I am a very healthy person and in some communities as an individual, I don't fit in so even if I lived in the place where the study was conducted the research from that place would not apply to me right?

So what is the point of discussing any facts at all? Can we not just claim that it does not apply to us because it was not studied in our zip code or that we are not identical to our neighbors?

Could we not look at what is different about those societies that do have better outcomes and try to model some of our behavior after theirs? Is that so unreasonable that the idea should just be dismissed?

If we cannot look at facts that come from communities that are not identical to our own then maybe the answer is to actually look at the problems in our own communities and try to solve them.

Why are almost one third of US women incapable of giving birth and require surgery to have a healthy baby? This seems like a problem to me.

Maybe instead of fighting the natural birth movement with flawed studies and facts from other places that cannot possibly apply to us, we can take a good look at our own problems and try to find solutions.

Why is VBAC banned in so many hospitals when even primips are at just as high a risk or even higher for other catastrophic complications, like cord prolapse, placenta abruption and such? Shouldn't we just ban vaginal birth all together since there are so many potential dangers?

Why is almost every laboring woman in US hospitals hooked up to CFM, when every study done shows it does not improve fetal outcome but doubles and sometimes even triples the c-section rate? Oh, that's right, the studies are flawed and even if they aren't they certainly cannot apply to every community as they are not all the same.

Why has ACOG just this year recommended that OBs stop routine episiotomies when we have known for decades that it does not prevent anything and can even cause bigger tears?

Why are women not informed of all of their risks and alternate treatments when offered elective cesarean, elective induction or epidurals? Most women I have spoken to never even heard the term uterine rupture until after their c-section. Many others complain about a back ache from their epidural that they had months earlier and they had no idea that it was so common. I don't even have the heart to tell those who ended up with an emergency cesarean that it could have been the Cytotec that caused fetal distress.

I think that the hospitals, as perfect as they are, can still use a lot of self review. What problems exists in US maternity services and how can they be fixed? What is it about hospitals that is driving maternity consumers away?

Every year more and more women are turning away from modern medicine and relying on midwives because they do not feel the hospital is safer. Most of these women are not looking at studies, they are looking at how they and their friends have been treated in the hospital and the outcome of that treatment. If you really want to stop women from depending on midwives and birthing their babies at home, you should ask them what they don't like about the medical management of birth and try to fix it.

By Anonymous Anonymous, at 6:26 PM  

How many babies have died under Gaskin's care or supervision since then?

Unless you have a lawyer on retainer, I'd suggest you use caution in proving your point.

By Anonymous Anonymous, at 6:47 PM  

"So what is the point of discussing any facts at all? Can we not just claim that it does not apply to us because it was not studied in our zip code or that we are not identical to our neighbors?"

I did not say that we could not discuss information from other countries. I said that we could not make direct comparisons of national mortality rates because the populations of the countries are so different.

You could, if you would like, compare the neonatal mortality rates from low risk groups in this country to comparable low risk goups in other countries. As I said before the US neonatal mortality rate for low risk white women at term is very small, and comparable to the neonatal mortality rate of any other countries.

"Why are almost one third of US women incapable of giving birth and require surgery to have a healthy baby?"

They are not incapable and it is misleading for you to suggest otherwise. Many C-sections are done to reduce the risk of the baby dying: breech, twins, fetal distress, etc. All these women could have vaginal deliveries; the risk is that the baby would be born dead.

"Why is VBAC banned in so many hospitals ..?"

That is a legal and financial issue, not a medical one. VBAC is not banned by any medical organization as long as there are appropriate personnel available to perform an emergency C-section. Many hospitals do not want to pay for 24 hour anesthesia coverage and so the hospitals have banned VBACs. There is no medical reason for this.

"Why is almost every laboring woman in US hospitals hooked up to CFM, when every study done shows it does not improve fetal outcome but doubles and sometimes even triples the c-section rate?"

Again, you are conflating medical and economic issues. EFM does not improve outcomes over very frequent intermittent auditory monitoring. It does improve outcomes as compared to no monitoring. It is cheaper to have electonic monitors as opposed to nursing personnel. Furthermore, in our extremely litigious society, a paper record of the fetal heartrate is necessary in court.

We could go on and on about the various interventions, and there is absolutely no doubt that the intervention rate is higher than it ought to be. However, that does not mean that it makes sense to sacrifice a few dead babies by giving birth at home in order to prevent a bunch of interventions in a hospital.

Nothing you have said about interventions changes the fact that hospital birth is safer than home birth.

If a woman wants to choose homebirth, that is her right. The extra risk is small. However, it is extremely important to acknowledge that it is real. I would have no problem with homebirth advocates who say, yes the risk of neonatal death at homebirth is slightly higher than at hospital birth, but some people are willing to accept that small additional risk.

Unfortunately, that is not what homebirth advocates say. They insist that homebirth is as safe or safer than hospital birth and that is simply not true. How can women make an informed decision if the information they are given is untrue?

By Blogger Amy Tuteur, MD, at 7:06 PM  

"Unless you have a lawyer on retainer, I'd suggest you use caution in proving your point."

You can't be sued for asking a question, and truth is an absolute defense against libel.

I am surmising that Gaskin has not published her data in the last two decades (or even made it public) because her neonatal mortality rate is unacceptably high. It would be easy to find out the truth. She just has to tell us. In fact, since she is promoting her services, she has an ethical obligation to tell us.

Doesn't it seem more than a little strange to you that she is hiding the single most important piece of data about her homebirth practice?

By Blogger Amy Tuteur, MD, at 7:11 PM  

The Farm's stats from 1970-2000 appear in the back of Ina May's Guide to Childbirth. Looks like an additional 321 births since 1989 and no more deaths.

They're midwives, Amy, not public health researchers. How many clinical practitioners are publishing research about their work?

By Blogger Jamie, at 10:29 PM  

"They're midwives, Amy, not public health researchers. How many clinical practitioners are publishing research about their work?"

You don't have to be a public health researcher to remember how many babies have died in your care. I don't think I could ever forget one even if I tried.

The information is known; it is just not public knowledge, and it should be public knowledge. As I said before, it the single most important piece of data about her practice and I cannot find it anywhere on her website.

By Blogger Amy Tuteur, MD, at 10:38 PM  

http://www.cmaj.ca/cgi/content/abstract/166/3/315


What about this study? I haven't seen it mentioned yet.

By Anonymous Anonymous, at 10:41 PM  

The excess of preventable deaths at homebirths is GREATER than the preventable deaths at hospital births. That's why hospital birth is safer. There has never been a study that has shown anything other than this.

First of all, yes there are studies showing this and when I get the chance I will show you some.

Maybe you and I have a different idea of what a "preventable" death is because as far as I'm concerned, the preventable deaths in hospitals are equal (or greater in some places) than homebirth. What I consider a preventable death in homebirth is when signs were ignored and things were done to create/further the situation. This is also what I consider a preventable death in hospital. Yet in hospitals there are many deaths that could have been prevented had the doctor overseeing the delivery not been so quick to prescribe one intervention after the other. The reason planned homebirths have less preventable deaths due to the overuse of interventions is because they use little interventions unless absolutely necessary. You are also leaving out the rates of complications, low breastfeeding rates, etc. With homebirths the complication rates are much lower than in hospitals. Breastfeeding rates, as well, are much higher with homebirths. And, while one might argue that women who have planned homebirths generally plan to breastfeed anyways, even when you compare a mother who wants to breastfeed and has had a homebirth with one who wants to breastfeed and has had a hospital birth, the rates for the homebirth families are much, much higher. So does something as important as that not hold any weight? Or do you believe that breastfeeding, too, is unimportant and unnecessary?

By Anonymous Anonymous, at 11:07 PM  

"As I have said many times before. There is not a single study that demonstrates that homebirth is as safe as hospital birth. Every study to date shows an excess of preventable deaths in the homebirth group."

What exactly is "an excess of preventable deaths?" (You didn't answer my other questions: what are the major complications of home births, what is done to prevent death in those cases, and what qualifications are needed to do the death-preventing procedures?)

In order to say something was preventable, you have to know *for sure* something could have prevented it. Are these preventable deaths due to mistakes made by caregivers? Do your studies eliminate those birthing at home with no caregivers or unqualified caregivers? Certainly not all homebirths are created equal! What about a hospital makes it safer? Is it just the access to immediate emergency care if anything should go wrong?

Driving in places that are a long way to the nearest hospital is certainly going to mean more "preventable" deaths than driving around the hospital parking lot. But wait, you say, that's just not the same. Driving is about convenience, pleasure, etc. But, think about it, is birth really all that different? Are successful outcomes to be judged on neonatal death rates alone?

*If* hospital births carry less risk of "preventable" death, that's not the only factor in considering the safety of home birth. Safety to me includes both physical and emotional health. It means that you have to factor in those cases where nobody died but the trauma from the birth will haunt a person for life. Or "preventable" birth injuries that cause long-lasting pain and suffering for mom or baby. You may downplay it - but I've seen it too much. A woman I know just had a VBAC at home attended by a CNM who has delivered over 1700 babies (it went perfect, btw). She did it because her first birth was so humiliating and traumatic that she never wants to set foot inside a hospital again.(because of the way her birth was "managed" and her treatment by the staff plus her c-section was because of iatrogenic complications) Statistics about "preventable" deaths would have meant nothing to her.

Let me ask you Amy: if you have no other motives but to help women, why don't you - like another poster said - start talking about how to make things better on your side? Or, better yet, since birth isn't an illness and homebirthers generally agree that the whole experience is much better - why don't you start talking about how to make homebirths safer?

By Anonymous Christine, at 11:20 PM  

I cannot find it anywhere on her website.

Here's her phone number: 931-964-2293. I found that on her website.

By Anonymous MetroMidwife, at 11:30 PM  

I hit the wrong button in the above post...

Amy it would seem more professional to pick up the phone and have a civilized conversation with Ina May if you are so interested in the truth for all the numbers you are sure she is hiding than it is to post innuendo and accusations in the name of honest reporting. I understand she is quite accessible and often answers her own phone.

By Anonymous MetroMidwife, at 11:47 PM  

If a woman wants to choose homebirth, that is her right. The extra risk is small. However, it is extremely important to acknowledge that it is real. I would have no problem with homebirth advocates who say, yes the risk of neonatal death at homebirth is slightly higher than at hospital birth, but some people are willing to accept that small additional risk.

Now here, Amy, we agree completely. Any responsible midwife I know would acknowledge to her clients (it's part of my informed consent at an interview), that there are situations that could arise where you would wish you were closer to a hospital. As you say, they are rare. And many of them, I can mediate to an almost negligible level because of my training and equipment and skilled assistants. A midwife who tells her clients that there is no situation that can't be handled at home is lying. I often say that the biggest safety factor for me is continuity of care. I am directly connected to my patient at all times and can act quickly when I need to without having to wait for the chain of communication that occurs in a hospital. We are also close to local hospitals and have pre-arranged back up if we need it. The risk is almost negligible.

The biggest risk in a hospital for me is that you have no guarantee over who will be taking care of you. And mistakes are made and things get lost in the shuffle... I've been at the occasional hospital birth where I thought - this woman would be better off at home.

I'm so glad we agree on one key point - the woman has a right to choose.

Something else I thought of too - midwifery and obstetrics may be separate practices, but we do need to exist together. As you said in a post elsewhere, homebirth is safer today because of what we have learned from obstetrics (carrying IVs, pitocin, oxygen, resuscitation equipment, etc.) It is also true that many OBs could learn from midwives in terms of not intervening unless necessary, and in the value of simple warmth and connection to ease a mother's stress. It still amazes me how much more I see non-reassuring FHT patterns in a hospital setting than I do at home.

I have had a couple of occasions where doctors have thanked me for a physiological suggestion that shifted something for a patient in labor.

By Anonymous Diane West, LM CPM, at 12:00 AM  

Amy wrote:
"The neonatal death rate of 2.4/1000 I quoted was derived from white women at term."

Why should a home birth study only be compared to an exclusively white population? and this study did include women who became pre-eclampltic and had other problems-- even if they transfered.
I think that we would need a series of these studies until they reached a statically significant number to really compare- many rare things occurred that contributed to the death rate attributed to the home-birth midwives- congenital anomalies that Amy just doesn't think can be true because the number is too high( although she probably doesn't have an anomaly rate for at risk populations who either don't test or don't have abortions as a result of testing) The Amish being one group- but there are others organized or not. and other oddities- sub-gleal hematoma-- how often would this event repeat in a home birth population? ---- now I will get to the cord prolapse that counts as a homebirth death even though the prolapse and death occurred in the hospital- in some reports cord prolapse happens about 3/1000 so in a group of over 5,000 there could have been 15 or more cords prolapse- which would make death due to cord prolapse either happens less at home or more babies survive it at home.

By Anonymous Anonymous, at 12:24 AM  

"Why should a home birth study only be compared to an exclusively white population?"

First, because race is a risk factor (sadly). Second, because the homebirth population is almost exclusively white, well educated and well off (compared to the average American).

The control group MUST match the homebirth group in all variables that can possibly be matched.

By Blogger Amy Tuteur, MD, at 7:23 AM  

Metromidwife:

"Amy it would seem more professional to pick up the phone and have a civilized conversation with Ina May if you are so interested in the truth for all the numbers you are sure she is hiding than it is to post innuendo and accusations in the name of honest reporting. I understand she is quite accessible and often answers her own phone."

What would be more professional is for her to make public her mortality statistics. It is neither my responsibility not my right to track her down and force her to do it.

As it happens, I have corresponded with Gaskin in the past (or at least someone who claimed to be her; she initially wrote to me). This was about 10 years ago. She did not supply any further information.

By Blogger Amy Tuteur, MD, at 7:27 AM  

As it happens, I have corresponded with Gaskin in the past (or at least someone who claimed to be her; she initially wrote to me). This was about 10 years ago. She did not supply any further information.

Do you not have access to this page? Are you suggesting that since she made the information public once that she is somehow bound to it forever? Where are your statistics?

By Anonymous MetroMidwife, at 9:06 AM  

I have seen that page and it illustrates my point. The page is missing the most important single piece of data, the neonatal mortality statistics. Why?

It makes absolutely no sense to leave that out unless you have something to hide. If Gaskin had a neonatal mortality rate lower than the hospital, she wouldn't forget to mention it, would she? In fact, she would probably be trumpeting it on the first page of the website.

I think it is logical to conlude that the neonatal mortality rate at the Farm is unacceptablely, embarrassingly high. Do you have any other plausible explanation?

By Blogger Amy Tuteur, MD, at 9:22 AM  

Amy, she published her stats in Spiritual Midwifery. She published updated stats in her Guide to Childbirth. How many ob-gyn practices publish their mortality stats on their websites, or anywhere else?

I also wanted to point out that the Johnson & Daviss cohort was not predominantly well-off and well-educated -- more so than average, but not vastly different.

Hm, there doesn't seem to be a way to make a table in the comments, but take a look at Table 1 from their study. Upper-class women: 12.3% in J&D, 21% general population; middle-class: 59.9% in J&D, 44% gen. pop.; lower-class: 23.2% in J&D, 19% gen. pop.

So fewer wealthy women, more poor women, and a larger slice of middle class women.

By Blogger Jamie, at 9:36 AM  

Jamie:

"Amy, she published her stats in Spiritual Midwifery. She published updated stats in her Guide to Childbirth."

Can you post them for us? How many deaths, over what period of time, etc?

By Blogger Amy Tuteur, MD, at 10:14 AM  

From Mothering Magazine (July-August 2004):

"The birth statistics for The Farm are outstanding. From 1970 to 2000, its cesarean rate was just 1.4 percent. Its induction rate was 5.1 percent. The infant loss rate has been less than 5 percent, and it has had no maternal deaths in 30 years. In addition, the midwives at The Farm have delivered 15 sets of twins, all born breech babies vaginally as well."

That's an infant loss rate of 50/1000! That's horrifying if it is true.

Perhaps the author meant 5/1000, in which case, it still quite high.

By Blogger Amy Tuteur, MD, at 10:24 AM  

I think it is logical to conlude that the neonatal mortality rate at the Farm is unacceptablely, embarrassingly high. Do you have any other plausible explanation?

I don't know why she doesn't publish her mortality statistics. I looked on your website and didn't see any of your statistics, much less your mortality statistics. Perhaps your statistics are also embarrassing.

By Anonymous MetroMidwife, at 11:53 AM  

And Amy you have been wrong about - hospitals and physicians - saving women since 1900 because of the science they used- when did the hospital/physician attended start having reduced maternal mortality rates that matched the midwives in the Pennsylvania and New Jersey studies?

By Anonymous Anonymous, at 12:13 PM  

Birth
Volume 28 Page 243  - December 2001
doi:10.1046/j.1523-536X.2001.00243.x
Volume 28 Issue 4
 
 
Epidural Analgesia Use as a Marker for Physician Approach to Birth: Implications for Maternal and Newborn Outcomes
Michael C. Klein, MD, CCFP, FCFP, FAAP, Dip ABFP, FCPS, Stefan Grzybowski, MD, CCFP, FCFP, MCISc, Sue Harris, MD, CCFP, FCFP, Robert Liston, MBChB, FRCSC, FRCOG, Andrea Spence, MSc, Grace Le, MD, MHSc, Dorothea Brummendorf, MD, Sharon Kim, BSc, and Janusz Kaczorowski, PhD

Background:Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes.Methods:Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low-riskwomen attended by 96 family physicians within an 18-month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay.Results: Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0–30 percent (15 physicians, 263 births); medium, 31–50 percent (55 physicians,1323 births); and high, 51–100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse)(23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%).Conclusions:In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity.
(BIRTH 28:4 December 2001)

By Anonymous Anonymous, at 12:59 PM  

"Epidural Analgesia Use as a Marker for Physician Approach to Birth: Implications for Maternal and Newborn Outcomes"

I'd need to see the actual article before I could be sure of what it says. However, I'm not sure what conclusions are appropriate to draw from this study.

First, while people tend to use the term "epidural" as if there were only one type of epidural, that is not the case. All epidurals involve pain medications injected into the epidural space, but there are different ways to administer an epidural and different mixtures of medications that you can put in. These make a very big difference in the effect of an epidural.

An epidural can be continuous or intermittent or even patient controlled (I've never seen this, but I've read about it).

The medications in an epidural can include pain medications and local anesthetics. The amounts and proportions can vary considerably. An epidural can render a woman without sensation or the ability to push or an epidural can provide pain relief while still preserving complete muscle function ("walking" epidural).

It's difficult to say what the practice styles of different physicians mean because patients choose doctors based on their practice style. Whenever someone asks me for a referral to an obstetrician, I always ask them how they imagine their obsetrician should be. Some women want a hyper-vigilant doctor and others want somebody very laid back. So it is not clear whether the increased use of epidurals for the patients of a particular doctor reflect the preference of the doctor or the patient or both.

If you could find a copy of the actual article, I'd be happy to read it and comment on it.

By Blogger Amy Tuteur, MD, at 3:34 PM  

Are you just not going to answer my questions, Amy?

By Anonymous Christine, at 4:24 PM  

Christine:

"Are you just not going to answer my questions, Amy?"

Which questions are those?

By Blogger Amy Tuteur, MD, at 8:11 PM  

First, I don't understand why you kept saying "I don't understand why Ina May doesn't maker her IMR public" even AFTER several people state that she has made it public.

Anyway, this is what she published (AND MADE PUBLIC) in Ina May's Guide to Childbirth published in 2003.

TH FARM: OUTCOMES OF 2,028 PREGNANCIES 1970-2000

Births completed at home 95.1%

tranports 4.9%

Emergency Transports 1.3%

First-time mothers 44.7%

Muligravadas 55.3%

Grand multiparas 5.4% (72% of this group were Amish)

Cesareans 1.4% (61% were first time moms)

Forcep deliveries .5%

Vacuum extractor deliveris 0.05%

Vaginal birhts after cesareans 5.4% (106 attempted, 104 completed)

Postpartum Hemorrhage 1.8%

Preciptious Births 8.9%

Inductions 5.4%

Castor Oil 4.9%
Swept membranes .5%

Ate and drank in labor 29.1%

Drank clear liquids 49.9%

Meconium staining 10.6%

Postpartum depression 1%

Intact perineum 68.8%

1st degree 19.1%
2nd degree 11.5%
3rd degree .3%
4th degree .1%

Preeclampsia .39%

Prematurity 2.9% (less than 37 weeks)

Ociput anterior 93.4%

Occiput posterior 2.2%

Frank Breech 2.1%

Footling Breech .7%

Complete Breech .1%

Face presentation .5% (all but one vaginally born)

Brow presentation .2% (2 were cesarean delivery/ 2 were vaginallly born)

Twins 15 sets all born vaginally

Initiation of breastfeeding 99%

Contiued breastfeeding 100% 4-5 were supplemented


lethal anomolies 5 (.2%)


Maternal Mortality 0

Neonatal mortality excluding lethal anomolies 8/2028 (.39%*)

4 of these deahts occured during labor

2 placental abruptions (one during the last ten minutes of an otherwise straightforward frank breech labor; the other in a first time mother transported to hospital because of protracted labor)

2 prolapsed cords (1 of these involved a mother whose legs were paralyzed from polio, whose cord prolapsed at the first sign of labor)


1 crib death

1 premie who died from hyaline membrane disease after hospital delivery in 1972

2 deaths from probable infection

By Anonymous Anonymous, at 10:10 PM  

on another note, I don't understand why you would state that she hasn't made her statistics public when you obviously haven't even looked!

By Anonymous Anonymous, at 10:14 PM  

Well, those numbers are very interesting.

In the Durand paper, it says that the Farm had 17 neonatal deaths from 1971-1989. So how can we possibly believe Gaskin when she now claims that there were only 13 neonatal deaths from 1970-2000?

By Blogger Amy Tuteur, MD, at 10:56 PM  

I'm curious about the discrepancy too. Does anyone have a copy of Spiritual Midwifery? I don't own it and am interested in what's reported there.

Durand included two antepartum deaths, and the Guide to Childbirth stats are intrapartum and neonatal deaths. That's part of the difference.

By Blogger Jamie, at 11:15 PM  

From Waaaaay up the comment list: "In any homebirth study, the authors are required to use as a control group women who are white, well educated, at term, vertex presentation, no pre-existing medical problems, no pregnancy risk factors, no smoking, etc. Simply put, since homebirth candidates are the lowest of the low risk patients, the authors of a study must find a control group of the lowest of the low risk patients. Any attempt to compare their numbers to any other population renders the results meaningless."

I can't accept that homebirth clients are lowest of the low risk patients. Maybe most of them are... but there are areas (like my home town)where DEMs work almost entirely with non-white migrants. DEMs also work with poor women with no insurance, and women from across the border with no previous prenatal care, often teens.

By Anonymous Anonymous, at 1:11 AM  

"DEMs also work with poor women with no insurance, and women from across the border with no previous prenatal care, often teens."

These are not the characteristics of the women in the homebirth studies. Almost every homebirth paper has described the group as being almost exclusively white, well educated and relatively well off.

By Blogger Amy Tuteur, MD, at 6:42 AM  

Go back and read my post about preventable deaths. About 15 or so posts up.

Those are the questions I want answered.

By Anonymous Christine, at 7:47 AM  

Interestingly my doctor fully supported my decision to have a homebirth. I live in the UK and homebirth is now an accepted part of medical care. The government and most doctors are supporting homebirth as an equally safe option for normal healthy pregnancies. It is not a subculture here. But the UK is different than the US. Midwife provide almost all of the prenatal care as well as deliver most babies. OBs, or counsultants as they are called here, only deal with cases that have additional risk factors. And interestingly, we have better birth stats than the USA, a lower number of both infant and mother mortality during labour.

Dawn

By Blogger Dawn, at 8:05 AM  

Christine:

"Those are the questions I want answered."

The answers to your questions are in the studies themselves. If you read them, you will find out.

By Blogger Amy Tuteur, MD, at 9:35 AM  

Which specific studies are you talking about? And, are they going to answer these questions?:

what are the major complications of home births, what is done to prevent death in those cases, and what qualifications are needed to do the death-preventing procedures?

What about a hospital makes it safer? Is it just the access to immediate emergency care if anything should go wrong?

Are successful outcomes to be judged on neonatal death rates alone?

By Anonymous Christine, at 10:06 AM  

But Dawn, that is only in the UK. It wouldn't work here because we are "different." It's not safe for Americans to give birth at home because our midwives are untrained and lack the skills to deliver babies safely. Only OBs in hospitals can deliver babies while keeping a low enough infant mortality. ; )

By Anonymous Christine, at 10:09 AM  

I say one of the things that make the UK have better birth statistics is that midwives are in charge of normal birth, not doctors. We have a lower rate of interventions, a higher rate of homebirths and a safer record. Other countries that even more exclusively use midwives have even better results. OBs are wonderful. Most are great doctors, at what they do...fix problems. If there is a problem, see a doctor. If you are just having a baby, see a midwife. I don't believe for one second that US midwives are not as good as those in other countries. The problem is that their skill is not embrassed and supported. The countries with the best birth statistics have midwife lead care.

Dawn

By Blogger Dawn, at 10:41 AM  

Dawn:

"The countries with the best birth statistics have midwife lead care."

No, the countries with the lowest neonatal mortality are the countries with the lowest black and ethnic minority populations. Unfortunately, race is a risk factor for poor prenatal outcomes.

Don't believe me? Just check out the proportion of black and other ethnic minority women in various countries and compare it to the neonatal mortality statistics.

Need more info? Look for the neonatal mortality statistics of minority women in countries that have low neonatal mortality rates. You will see that the neonatal mortality rates for minority women are substantially worse than their white counterparts, despite the fact that they get their care from the same midwives.

By Blogger Amy Tuteur, MD, at 11:13 AM  

you think race is the only answer to this riddle. I think not.
I also know that many times midwives do not ask race- related questions or we have clients who are rather offended by the questions and choose to answer what ever way they choose- you are black if you are 1/16 black and I am sure not all people with black heritage will put this on a midwifery form.

By Anonymous Anonymous, at 1:21 PM  

"No, the countries with the lowest neonatal mortality are the countries with the lowest black and ethnic minority populations. Unfortunately, race is a risk factor for poor prenatal outcomes."

Ethnic says nothing except that someone belongs to some cultural group. What other races besides black give a person a risk factor for poor prenatal outcomes?

And, given that homebirth is safe in the populations where the majority are white, will you say that homebirth is safe for healthy white women?

By Anonymous Christine, at 2:14 PM  

Christine:

"given that homebirth is safe in the populations where the majority are white, will you say that homebirth is safe for healthy white women?

No, homebirth has never been shown to be safer than hospital birth for white women or any women.

My point about race is that when you are comparing two different obstetric populations, they must be match for race or the results are not valid.

By Blogger Amy Tuteur, MD, at 2:23 PM  

Christine said...will you say that homebirth is safe for healthy white women?

Sure.

Surprised?

(here we go again....)

We are NOT discussing whether it is "safe".

We ARE discussing whether it is AS SAFE AS hospital birth using the limited criteria of infant mortality.

By Blogger sailorman, at 3:33 PM  

Dear Amy,

Do you believe you are objective? Or have you invested too much emotional energy in arguing your point of view that you are unable to take on board studies and reviews that do not support your point of view?

In 2003, following a comprehensive review of the data, Professor Bill Dunlop, President, Royal College of Obstetricians and Gynaecologists said:

"Choice is important in all areas of health care, but women must be provided with information on which to base their decisions. We do not currently have definitive evidence on the safety of home births, or free-standing midwifery-led units. Without this information we as health professionals are unable to provide women with the necessary information to allow them to make informed decisions. More research is urgently required in this area.”

You tell us that women should be aware that homebirth is more risky, but the evidence for this does not exist. In these circumstances, wouldn’t it more helpful to inform women of the potential drawbacks of home and potential drawbacks hospital births?

And I am interested in your opinion of the results of the National Birthday Trust Fund homebirth study. Do you feel this information is worth passing on to women?

Jane

By Anonymous Jane, at 5:23 AM  

Jane:

"And I am interested in your opinion of the results of the National Birthday Trust Fund homebirth study. Do you feel this information is worth passing on to women?"

To my knowledge, there was no study. It was just a pilot investigation that involved a very small number of women. It takes up just a few paragraphs in the book length Trust Fund report of that year.

You also have to keep in mind the motives of some of the people discussing the issue in the UK. They are thinking about the very large amount of money they will save if they deny women admission to the hospital for delivery. For some politicians and politically active doctors this is about choice, but for most this is about denying women the choice of a hospital in order to save money.

By Blogger Amy Tuteur, MD, at 7:32 AM  

Everybody has alterior motives, no study has been done right, OBs are saving the world...

(Can we all remember that Amy admitted herself that saving money is the reason the hospitals strap women to cotinuous EFM in labor)

By Anonymous Christine, at 9:27 AM  

"We are NOT discussing whether it is "safe".

We ARE discussing whether it is AS SAFE AS hospital birth using the limited criteria of infant mortality."

Then why is everyone here wasting their time? You admit you are using very limited criteria of infant mortality.

Stop trying to make people feel horrible for deciding on home birth. Birth is NEVER lacking inherant risks. The hospital can't change that. What it changes is that it adds on top of that iatrogenic risks. Sure, they may be able to save your baby in the end but did mom come out ok (or does she need reconstructive surgery due to an unnecessary high-forceps delivery or a hysterectomy due to c-section complications or was she traumatized so badly she's not having any more kids even though she wanted many)? Is the baby ok or is it just alive?

Even if I believed that neonatal death rate was lower in hospitals, I will never believe good outcomes should be judged on this factor alone. I know of someone who nearly died 15 years after a c-section due to small bowel obstruction caused by adhesions from that surgery. Is this sort of thing anywhere among your precious statistics?

By Anonymous Christine, at 9:46 AM  

Christine:

"Stop trying to make people feel horrible for deciding on home birth."

This is a very revealing statement.

No one is trying to make anyone FEEL anything about homebirth. We are simply discussing the fact that the assertion of homebirth advocates, that homebirth is as safe or safer for the baby, is not true. There is no evidence for it, and there is considerable evidence that hospital birth is safer.

There are a lot of different ways that you can feel about the truth. One of them is to say that a small increased risk is acceptable to you. However, if you truly feel that a small increased risk is unacceptable, there are only two possible responses to these discussions:

I unknowingly exposed my baby to a small increased risk during homebirth and fortunately everything turned out fine.

OR

I will never accept that homebirth is anything but safe because I could not acknowledge (to myself or others) the fact that I put my baby at risk.

By Blogger Amy Tuteur, MD, at 11:38 AM  

As a visitor to this site I find it amusing that you Amy are spending your time arguing with most of the other bloggers here. No one but you lives in the 'Alternate world' that you have dreamt up. I would suggest a nice cup of cocoa and a good fictious book that avoids statistics altogether :-)

By Anonymous Anonymous, at 3:56 PM  

"No one is trying to make anyone FEEL anything about homebirth."

I beg your pardon - you recently posted a blog entitled "what would the baby say?"

Don't tell me you are not trying to make people feel anything about their choice of homebirth.

By Anonymous Christine, at 9:09 AM  

Christine:

"I beg your pardon - you recently posted a blog entitled "what would the baby say?"

First of all, that post was in response to a particular statement, that neonatal mortality was not the only factor in deciding to have a homebirth. I posed that question to get people to really think about whether they meant what they said about mortality.

Second, if someone truly believes that neonatal mortality is only one factor and that interventions, the mother's experience, etc. are also very important factors, why should they feel bad about honestly saying that?

The only people who would feel bad about saying that are people who do not really believe that there is anything as remotely important as the safety of the baby during birth.

So it's very revealing when someone says that I am trying to make them feel bad. I am not trying to make anyone feel anything. I am trying to acquaint people with the real scientific information, because I believe that they have not been told the truth.

I understand that this is the source of some of the tremendous resistance that can be found among homebirth advocates. If they acknowledge that homebirth is not as safe or safer than hospital birth, it means acknowledging that they risked their babies' lives. Not many women who love their children would want to acknowledge that, to others and most especially to themselves.

By Blogger Amy Tuteur, MD, at 9:24 AM  

what I think is that the safety of mother and baby are important.
what I don't believe is that hospitals have cornered any market on safety- and because technology has afforded the hospital some things that may appear to be "safer" or life preserving on the surface does not make it true .Causing a problem and then saving someone from that problem is not the same as not having the problem in the first place.
Also how I am looking at neonatal mortality is that I know that there is now a TRICK to the mortality stats- babies that are born compromised in some way through pregnancy or the birth process may be kept alive long enough to make neonatal numbers look better but they die before they are a year old- they may even die before they are a month old so the very same baby death that occurs at home may still end up being a baby death in the hospital but it may just take a little longer to die in the hospital.

Looking at things like cord prolapse- at home we are encouraging mothers to be upright and moving around- a cord is lighter than the baby and floats, the baby's head acts like a stopper and the deeper into the pelvis the head gets the less room for a cord to float past- what things would act differently on this? reclining position , head not far down in pelvis when membranes are ruptured- put something that is weighted into a bottle that will stopper the bottle from the inside- then also stick something like a piece of yarn in along with it as long as it floats- now fill the bottle with water and turn up side down- what happens- the stopper comes down and stoppers the bottle- now lay it sidewise - what happens? gravity is to the side and the floating thing can slide out with the water- so if you break waters with a baby not well engaged and mom is reclining you are more likely to have a cord prolapse--- but even that does not happen all the time babies have an amazing ability to wind their cords around their necks and this is protective- it helps to take up the slack and keep a cord from prolapsing -- but 2 things we generally don't do in a home birth rupture membranes early and insist on mothers reclining the whole labor.

By Anonymous Anonymous, at 12:55 PM  

"Causing a problem and then saving someone from that problem is not the same as not having the problem in the first place."

That's true. However, it is far better than not being able to handle a problem. Even when you include iatrogenic problems, hospital birth is safer.

"2 things we generally don't do in a home birth rupture membranes early and insist on mothers reclining the whole labor."

It's an interesting theory, but that would mean that the incidence of cord prolapse would be substantially less at homebirth and it isn't. In fact, some of the preventable deaths in the homebirth studies are caused by cord prolapse.

By Blogger Amy Tuteur, MD, at 3:15 PM  

t's an interesting theory, but that would mean that the incidence of cord prolapse would be substantially less at homebirth and it isn't. In fact, some of the preventable deaths in the homebirth studies are caused by cord prolapse.

but the numbers are lower for cord prolapse at homebirth--
and not all cord prolapse deaths are preventable no matter the location.

By Anonymous Anonymous, at 1:39 PM  

"but the numbers are lower for cord prolapse at homebirth"

Lower? What numbers are you comparing them to?

By Blogger Amy Tuteur, MD, at 2:35 PM