Monday, May 29, 2006

Homebirth and the disadvatages and wisdom of hospital birth

The studies of homebirth can tell us a lot about hospital birth. A lot of things that happen in the hospital have been instituted because they presumably insure better outcomes. By looking at the homebirths, we can see that much of the technology is not needed.

Obviously the C-section, forceps and vacuum delivery rates are too high. Most women do not need or benefit from electonic fetal monitoring. Most deliveries will never require any resucitation.

However, homebirth also tells us something very important about birth that goes a long way toward justifying the overuse of certain procedures in hospitals. No matter how carefully midwives screen for risk, 10% or more of low risk women in labor will develop complications that necessitate transfer to the hospital. That undoubtedly applies to hospital deliveries, too. No matter how carefully the hospital staff screens low risk patients, 10% or more of them will go on to develop serious complications. There does not appear to be any way for midwives or doctors to tell in advance which patients will make up that 10%.

Homebirth midwives and doctors deal with this uncertainty in strikingly different ways. Homebirth midwives essentially assume that nothing bad will happen; these complications will make themselves known long before they can harm the baby, and the midwife will be able to transfer the mother to the hospital before any damage is done. The doctors go in the other direction. They institute procedures like electronic fetal monitoring to pick up the 10% complications as early as possible. They reason that although 90% of low risk women never need EFM, we can't figure out in advance who they are so we should monitor everyone.

The studies of homebirth tell us something important about the assumptions of homebirth midwives: when it comes to the ability to handle complications, they are wrong that place of labor makes no difference. The strikingly high neonatal mortality rates among patients transferred during homebirth attest to the fact that if a complication occurs at home, the chance of a bad outcome is dramatically increased.

There is no doubt that homebirth has advantages. If you have a homebirth you will dramatically reduce the risk of an unnecessary C-section or forceps delivery; you will not have EFM, you will not have an episiotomy. In exchange, you only put one thing at risk at homebirth: the life of your baby.

32 Old Comments:

First of all. I personally had EFM throughout both of my homebirths... not sure if I don't understand the definition? I on the other hand did not have CONTINUOUS EFM. Which is a mandate of both maternity hospitals in my city for vbac... as well as a time limits and comfort measures being discouraged etc (another discussion entirely!).
From what I can tell from your last paragraph, you are behind a measure of punishment for parents who have catastrophic outcomes from a homebirth? Perhaps criminal charges? I'm sure at least you see a child advocacy group getting involved? Damn them for wanting to avoid that iotrogenic label many women give their birth "experiences"! Must prosecute, or is that persecute? them too.

By Anonymous Anonymous, at 9:53 PM  

Let's be clear: babies can and will die during birth no matter where they're born. Hospitals don't have any better a mortality rate for mothers and babies... haven't you seen the articles that make it clear that something is WRONG with the fact that the United States has a worse maternal-infant mortailty rate than any other developed country in the world? And doesn't the fact that 99% of women birth in a hospital point to the fact that hospitals might contribute to this fact? And isn't it interesting that many of the developed countries with better rates have healthcare based on a midwifery model?

Any woman giving birth anywhere risks her baby's life, whether it's from undetected problems during the birth, consequences of technological interventions, or unexplained phenomena. Women who choose homebirth wish to avoid problems that hospitals often CAUSE because of their paranoia and fear of litigation. Studies like those cited in Henci Goer's works have shown that the c-section rate has risen in perfect harmony with the rise of fetal monitoring and restrictions on mothers during hospital births -- if you say there are certain aspects of a hospital birth that need improvement, how can you argue in the same breath that continuous EFM and other preventive/predictive measures are beneficial?

By Blogger Lauren Prairie, at 10:25 PM  

"From what I can tell from your last paragraph, you are behind a measure of punishment for parents who have catastrophic outcomes from a homebirth?"

Absolutely not. I never said or implied any such thing. My concern is that women have accurate information about the risks associated with homebirth. The risk that something will go wrong at homebirth is small, but it is real and it can have devastating consequences.

By Blogger Amy Tuteur, MD, at 11:02 PM  

Lauren:

"Hospitals don't have any better a mortality rate for mothers and babies"

No, you are wrong about that. Every study done to date shows that hospitals have lower neonatal death rates than homebirth.

"something is WRONG with the fact that the United States has a worse maternal-infant mortailty rate than any other developed country in the world?"

Yes, the US does not have universal health care and has large minority and migrant populations who have inadequate prenatal care or none at all.

"And doesn't the fact that 99% of women birth in a hospital point to the fact that hospitals might contribute to this fact?"

No, of course not. The history of obstetrics in the 20th century shows that the neonatal and maternal mortality rates dropped dramatically as birth moved from home to hospital. Furthermore, hospitals have a lower neonatal mortality rate for low risk women than homebirth does and obviously, they have dramatically lower neonatal mortality for high risk women.

"Women who choose homebirth wish to avoid problems that hospitals often CAUSE because of their paranoia and fear of litigation."

There is no doubt that hospitals have higher rates of interventions, but they also have lower rates of neonatal mortality for low risk women. As I said, by having a homebirth a woman can protect herself from interventions which may be unnecessary. Unfortunately, the result of that is that the baby carries a higher risk of dying.

By Blogger Amy Tuteur, MD, at 11:09 PM  

"No matter how carefully midwives screen for risk, 10% or more of low risk women in labor will develop complications that necessitate transfer to the hospital"

Where do you get this statistic? According to the American Academy of Pediatric's Neonatal Resuscitation Guide, 10% of babies need some help coming around, such as PPV. This does not mean that they develop complications that necessitate transfer to the hospital. I had a homebirth (and I am an RN and a midwifery student) and my son had a shoulder dystocia. He required resuscitation (PPV only) and did not end up needing to be transferred.

So I am wondering where this 10% statistic is from? Surely you did not take it from the source I mentioned as they did not mention that all 10% of these babies need to be born in the hospital. I know you are against statistics being wrongly used, and so I am assuming you are not doing that very thing. Please enlighten me to the source this statistic is from.

By Anonymous Anonymous, at 12:02 AM  

"Where do you get this statistic?"

Every homebirth paper shows a transfer rate in labor of 10% or more. In some studies, the transfer rate was as high as 40% of primips.

By Blogger Amy Tuteur, MD, at 6:45 AM  

Amy, seriously, did you really say that about EFM? Aren't you a stickler for science and numbers? Where oh where is the proof that continous EFM versus intermittent fetal monitoring improves outcomes?

I'll make it real simple for you:

Disadvantage of homebirth: There is a small chance that you will have a sick baby who will die because there wasn't immediate access to hospital emergency facilities. Every midwife I have ever known has acknowledged this. Every homebirth mother I have ever known is aware of this.

Disadvantage of hospital birth: There is a small chance that because technologies are routinely applied with no scientific basis whatsoever (among other reasons) you will have a PERFECTLY HEALTHY BABY who will die or be seriously injured.

You HAVE NOT proven that neonatal death rates are higher at home. Just because you say it over and over doesn't make it true. Yes, it is POSSIBLE that there might be a slightly lower NEONATAL death rate in hospitals because technology now allows us to prolong death. But I will reiterate it once again... you have NOT proven that fact. Homebirth mothers are trying to protect their PERFECTLY HEALTHY babies and their own bodily integrity.

Amy, healthy babies are being harmed in hospitals and maternal mortality rates are underreported. No homebirth mother wants her baby to die, but I would speak for most of us that we believe that there is a greater chance of a healthy baby dying or being seriously injured in a hospital than having the homebirth catastrophe that you describe.

You have said repeatedly that you want homebirth mothers to have the truth. I assure you, we understand the truth. If you are so committed to women having the truth I think you should spend your time editing your book and starting with your chapter on episiotomy.

By Blogger Mama Liberty, at 9:54 AM  

Mama, it is apparent that you do not really intend to respond to Amy's points. Why? Because she's making her points which are both specific and limited and you are failing to recognize them as such.

This implies, to me, that it is really about "belief" for you, more than "facts" or "data". In which case, why argue? If your mind can't be changed, there's not much point.

Where oh where is the proof that continous EFM versus intermittent fetal monitoring improves outcomes?

Was this the claim? (no). The issue Amy was discussing was one of different approaches to management of risk.

Disadvantage of homebirth: There is a small chance that you will have a sick baby who will die because there wasn't immediate access to hospital emergency facilities. Every midwife I have ever known has acknowledged this. Every homebirth mother I have ever known is aware of this.

That's funny, because I'm not sure I'm hearing this really come from the home birth crowd. If people are minimizing the true risk which it seems they are, there's not informed consent.

You also seem to be engaging in blatant lying here, at least insofar as I can tell from your next paragraph.

A decent proportion of the babies who will die at home are, or would be, "perfectly healthy." They're just dead.

Disadvantage of hospital birth: There is a small chance that because technologies are routinely applied with no scientific basis whatsoever
(among other reasons) you will have a PERFECTLY HEALTHY BABY who will die or be seriously injured.


Well the "routinely applied with no scientific basis whatsoever" bit is drivel. But as for the risk, this is true: the main risk in a hospital is a procedure error.

You HAVE NOT proven that neonatal death rates are higher at home. Just because you say it over and over doesn't make it true.

Heh. Can I quote you on this?

Yes, it is POSSIBLE that there might be a slightly lower NEONATAL death rate in hospitals because technology now allows us to prolong death.
This is a statement which is depending on a LOT of very odd assumptions. Given your supposedly high standards of proof, why are you even bringing this up?

But I will reiterate it once again...
See "can I quote you" above. That was fast!

you have NOT proven that fact. Homebirth mothers are trying to protect their PERFECTLY HEALTHY babies and their own bodily integrity.

Actually, it seems they're focusing mainly on their bodily integrity. I think there's almost no debate that the MOTHER may prefer a home birth. It is merely a transfer of risk to the infant.

And yes: Show me an 8 hour old healthy infant and it's probably safer at home. But show me that same infant 8 hours BEFORE delivery and it's better off in a hospital.


Amy, healthy babies are being harmed in hospitals

This is not debated. Though you really should provide some statistics, as you seem to be claiming enormous mortality rates.

I might note that if you think this is true, you should deliver in a hospital and then leave. I mean hell: if hospitals are killing all those healthy babies after delivery and they're STILL managing neonatal mortality which is equal to or better than home birth, they must have AMAZING delivery safety rates! Right?

and maternal mortality rates are underreported.
Stats, please. Studies, please. Hospitals are highly documented places, why on earth would you make such a random claim? Mothers dying in hospitals and nobody knows about it but you?

No homebirth mother wants her baby to die, but I would speak for most of us that we believe that there is a greater chance of a healthy baby dying or being seriously injured in a hospital than having the homebirth catastrophe that you describe.

This belief is, simply, incorrect.

You have said repeatedly that you want homebirth mothers to have the truth. I assure you, we understand the truth.
I do not believe that assurance. To be honest, many don't even seem to be able to understand what Dr. Amy is saying in her short posts.

Here, for example, Dr. Amy is talking about a difference in philosophy, and you are responding by discussing a hypothetical number of dead but unreported mothers. How is someone else to think you understand even this post, much less the many which have been made here?

When I make a criticism of a specific data point and you (or someone else) responds with an entirely irrelevant or ad hominem attack, why would I think this exhibits understanding? If anything, it shows an INABILITY to understand the actual issues, replaced by a constant desire to discuss something else.

Many don't seem to have read the papers on which they base their beliefs. And fewer still seem able to even follow the detailed discussions of the issues raised by those papers. How can you claim to "know the truth"?

By Blogger sailorman, at 11:17 AM  

Sailorman,

Amy made the claim that EFM helps 10% of women who are "at risk". There is no evidence that EFM helps. But there is ample evidence that it leads to unnecessary interventions which cause unnecessary harm. There is no evidence that continuous EFM saves babies!

Look, before I investigated homebirth, I looked at the "facts" and "data" about common procedures and obstetrical management. The truth of the matter is that most of what is routinely done has no real scientific basis. I don't really have time to chronicle everything here for you. Those interventions pose the risk of death and injury to baby and mother.

As for your request for stats and studies, you'll have to look them up for yourself. The US is something like 26th in maternal mortality and you can investigate why some believe that maternal mortality is being underreported. I am not making up this claim. We are getting ready to move so I don't have time to dig this stuff up for you, but it is out there & you can find it.

You bring up the fact that we can't understand Amy from her short posts. Well, I don't think it is any easy to communicate where we are coming from with our short posts, either. This is a very complicated subject. The numbers are really too close and the variables too many to have any definitive answers.

Danielle

By Blogger Mama Liberty, at 12:28 PM  

Mama Liberty:

"There is a small chance that because technologies are routinely applied with no scientific basis whatsoever (among other reasons) you will have a PERFECTLY HEALTHY BABY who will die or be seriously injured."

There is zero evidence that healthy babies die in the hospital because of routine use of technology. ZERO. If you believe otherwise, then you are obligated to provide some proof. There is evidence that MOTHERS may be at increased risk in hospitals, but not babies.

That gets back to my original claim. Homebirth is always about the mother, her experience, her desires. It is never about the baby since the data about the baby is pretty clear. Babies are less likely to die when born in the hospital.

"maternal mortality rates are underreported."

More conspiracy theories, and you know what I say about conspiracy theories. They are a sign that you've got nothing to say about the actual argument.

This one is especially ridiculous. Adult women are dying and people are successfully covering it up? How likely is it that no one notices when a perfectly healthy adult woman drops dead?

My own state requires a STATE investigation into every single maternal death. That's right, a government investigation. Maternal death in childbirth is now so rare that the government wants to investigate when it happens, to make sure that the doctor and hospital are not a threat to public health.

"seriously, did you really say that about EFM? Aren't you a stickler for science and numbers? Where oh where is the proof that continous EFM versus intermittent fetal monitoring improves outcomes?"

This is a completely tangential comment. Nonetheless, it is important that you understand what studies show about EFM. EFM has not been shown to be better than frequent intermittent auditory monitoring. In other words, it appears to convey no advantage over a nurse listening for 60 seconds every 5 minutes.

MONITORING the baby's heart rate is important and saves lives. The studies about EFM just say that it doesn't matter whether you do it with a machine or with a nurse.

By Blogger Amy Tuteur, MD, at 12:29 PM  

So what's wrong with the birthing center model? Birthing centers located in hospitals insure that the high tech intervention is available if it is needed without having it immediately in the way of low risk women who prefer to do without it. In the 90% of cases where all goes well, the baby can be born without all the technical interventions that can be a nuisance and iatrogenic risk but if there is a problem the OR and other interventions are just down the hall or upstairs and can be gotten to much quicker than they can from home.

By Anonymous Dianne, at 2:56 PM  

In your original post you said "No matter how carefully the hospital staff screens low risk patients, 10% or more of them will go on to develop serious complications. There does not appear to be any way for midwives or doctors to tell in advance which patients will make up that 10%."

So I asked where this statistic came from and you said "Every homebirth paper shows a transfer rate in labor of 10% or more. In some studies, the transfer rate was as high as 40% of primips."

So how can you correlate that those transfers are all due to a serious complication? How do you know some of those are not transferred for pain relief, or exhaustion or something nonemergent. I think the statistic is being misused by you.

By Anonymous Anonymous, at 11:16 PM  

"So how can you correlate that those transfers are all due to a serious complication? How do you know some of those are not transferred for pain relief, or exhaustion or something nonemergent. I think the statistic is being misused by you."

Almost all of the transfers are for problems that must be treated by a physician. They are not all emergencies, but they cannot be managed by midwives.

Whether the number is 10% or 20% or 5% does not change the basic point. Some babies are going to get into serious trouble at a homebirth and they may die because they did not have the personnel and equipment of a hospital available.

By Blogger Amy Tuteur, MD, at 12:41 AM  

I understand that you have a basic point that you are trying to make. Just as you have a problem with the statistics and such used by homebirth advocates, I have a problem with the way you are using these numbers. You feel that homebirth advocates are giving false information, and I feel that is just what you are doing here with your "10% will have serious complications" statement.

You said "No matter how carefully the hospital staff screens low risk patients, 10% or more of them will go on to develop serious complications. They institute procedures like electronic fetal monitoring to pick up the 10% complications as early as possible. They reason that although 90% of low risk women never need EFM, we can't figure out in advance who they are so we should monitor everyone."

You say that 10% have serious complications. This is inaccurate information. I too think informed choice is very important, and I don't agree with giving out inaccurate information, therefore I do not appreciate this "statistic" that you give.

You then said "almost all of the transfers are for problems that must be treated by a physician. They are not all emergencies, but they cannot be managed by midwives." Where is this data on 10% being serious complications? Now you are saying that not all of them are serious complications? If they are not all serious complications, why would you state that as a fact in your original post?

You say that it doesn't matter, you still have a "basic point." That is fine, but I don't feel it is okay for either side of this to use inaccurate information to prove their point.

By Anonymous Anonymous, at 1:16 AM  

Ah yes. Women and babies never die in hospitals.

No wait: they do. Oops, there goes that theory.

By Anonymous Anonymous, at 9:37 AM  

Amy, can we talk about numbers for hospital birth? You keep saying that the mortality rates for homebirth are too high, but I'm not sure what your frame of reference is.

At Neonatal Doc's, you said the incidence of IUFD in the general population is 5.1/1000 and the neonatal mortality rate is a hair under 7/1000. You've said that the intrapartum mortality rate in hospitals is "vanishingly small" -- how would you quantify it? 5/10,000? 1/1000? Using those numbers, can we say that combined antepartum, intrapartum, and neonatal mortality for all US pregnancies is between 12 and 13 per thousand?

I've been digging around in search of numbers for low-risk women and having trouble finding much. One interesting piece of information that's turned up in a couple of places is that low-risk women are at higher risk of IUFD, because women identified as high-risk have much more frequent monitoring to detect problems with the fetus.

You've stated that prematurity accounts for two-thirds of US neonatal mortality, but I was looking at CDC documents on deaths in the US that describe congenital anomalies as the number one killer of US newborns. I'm not sure how to break down the risks.

What fraction of those 12-13/1000 deaths should we expect to see in the lower-risk population? The total death rate for Johnson & Daviss, combining antepartum, intrapartum, and neonatal deaths and including congenital anomalies and higher-risk births, was 3.3/1000 (.7/1000 antepartum, .9/1000 intrapartum, 1.1 neonatal, .5/1000 congenital anomaly deaths, with rounding accounting for the small difference in the totals).

What research are you looking at to say that's too high?

By Blogger Jamie, at 9:44 AM  

Jamie:

"At Neonatal Doc's, you said the incidence of IUFD in the general population is 5.1/1000 and the neonatal mortality rate is a hair under 7/1000. You've said that the intrapartum mortality rate in hospitals is "vanishingly small" --how would you quantify it? 5/10,000? 1/1000? Using those numbers, can we say that combined antepartum, intrapartum, and neonatal mortality for all US pregnancies is between 12 and 13 per thousand?"

No, Jamie. The numbers drop almost every year and I was referring to a particular year. Also, stillbirths and intrapartum deaths are usually INCLUDED in the neonatal mortality rate. So when I say that the neonatal mortality rate is 7% in a given year, that usually accounts for stillbirths after 28 weeks, deaths during and immediately after labor, and often deaths in the first 28 days of life as well.

The CDC has a great publication on Infant, neonatal and post neonatal deaths in 2003. As far as I can tell, stillbirths are NOT included in the neonatal death rate in this publication.

The statistics are very interesting:

Neonatal mortality is 4.62/1000.

Neonatal mortality for all WHITE infants is 3.87/1000.

When you subtract prematurity and maternal high risk, the death rate drops to 2.7/1000.

When you subtract congenital anomalies, the death rate drops to 1.7/1000.

In unfortunate contrast, the neonatal death rate for BLACK infants is 9.4/1000.

When you subtract prematurity and maternal complications, it drops to 5.3/1000.

When you subtract congenital anomalies, it is 4.2/1000.

The category "intrauterine hypoxia and birth asphyxia" probably captures the best approximation of INTRAPARTUM death rate.

The total is 0.13/1000 (518 infants).

For white infants it is 0.11/1000 (363 infants).

For black infants it is 0.22/1000 (133 infants).

Keep in mind that these neonatal and intrapartum mortality figures include the deaths at homebirths.

By Blogger Amy Tuteur, MD, at 10:53 AM  

Amy,

This is fascinating. You should post directly on this so it doesn't get lost in the comments.

By Blogger sailorman, at 11:52 AM  

Okay, Amy, thanks very much for those numbers and the citation. So you're saying that for white low-risk women in 2003, combined intrapartum/neonatal mortality was 2.8/1000 including congenital anomalies, or 1.8/1000 if they're excluded -- correct?

J&D found a combined intrapartum/neonatal mortality rate of 2.6/1000 including high-risk births and congenital anomalies, a rate of 2.0/1000 excluding congenital anomalies, and a rate of 1.7/1000 excluding both congenital anomalies and high-risk births.

2.6/1000 (all CPM births in 2000) < 2.8/1000 (births for low-risk white women in 2003)

1.7/1000 (low-risk, anomaly-free CPM births in 2000) < 1.8/1000 (low-risk, anomaly-free white women in 2003)

What's the problem?

By Blogger Jamie, at 11:55 AM  

As I see it, you could make a case that homebirth is associated with higher intrapartum mortality, but not neonatal mortality (1.1/1000 for babies without anomalies in J&D), and not for combined mortality rates. And the intrapartum stats from hospitals are another conversation...

By Blogger Jamie, at 12:02 PM  

Jamie,

Before she explains it, I'm curious: are you implying you would be conviced by these numbers? Or are you just digging for the hell of it?

Neither are "wrong" but it might be nice to know: if you request that someone give you an explanation and they do so, the counter expectation is that you asked for some reason other than to try to make them do more work.

I mean, let's say Amy DOES explain this, and explains why the numbers aren't what you think.

What then?

I feel like you keep asking questions, they get answered, and if the answer doesn't suit you, you run around to ask something else instead of discussing the effect of the answer to your question. That doesn't seem very fair to me, especially since the questions you're asking tend to require a lot of work to answer.

For example, I could ask you a few simple questions:

Given that we know these numbers are available, and that we're discussing many more studies than J&D, can you compare them to all the various studies?

For the J&D study, can you look at their population here:
http://bmj.bmjjournals.com/cgi/
content-nw/full/330/7505/1416/TBL1

and compare it to the various CDC tables which are available, to come up with and explain why you think their expected numbers would be better than, the same as, or worse than the national average listed above?

S

By Blogger sailorman, at 1:03 PM  

Where am I running away from questions, Sailorman? Not my intent. I don't reply immediately if I am chewing on something (like your question yesterday, on why I keep talking about congenital anomaly deaths among homebirth families -- working on that one), but I do try to acknowledge where you have a point and make it clear when and why I disagree.

The other studies we've discussed are older, which makes it less appropriate to compare them to 2003 figures, and smaller, which gives them less power statistically. Janssen et al., studying births in BC in 1998, reported a neonatal death rate of 1.2/1000 and a stillbirth rate of 2.3/1000 (don't know about antepartum/intrapartum there) for babies without anomalies. With an n of 860 and the stillbirth category not broken down into antepartum/intrapartum, the comparison isn't as useful.

Murphy-Fullerton is even older, looking at deaths from 1994-95. They report: "Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000."

I can't get to the full text of the Murphy-Fullerton paper for free any longer -- I'll have to dig around a bit and see if I still have the temporary file on my hard drive. I don't know how that summary breaks down as far as high-risk presentation, congenital anomalies, etc.

We've talked before about the demographics of the J&D cohort. There are more middle-class women and more women with graduate degrees in their study than in the general population of childbearing women. There are also more poor women, and a good chunk (note statistically sophisticated phrasing) of women who had a high school education or less.

Oh, Amy, I thought of something that might have skewed my comparison. You said that high-risk women were excluded from those figures. How do obstetricians assess risk? Is it low/high or low/moderate/high? Is there a uniform approach to categorization? I looked at your numbers as if excluding high-risk would leave only low-risk, but I realized afterward that I might be mistaken about that.

By Blogger Jamie, at 1:52 PM  

I'm not finding much out there on moderate-risk pregnancy (except one abstract translated from Croatian, in which moderate-risk mothers had outcomes much closer to low-risk mothers than to high-risk mothers).

The WHO talks about low-risk vs. high-risk (no mention of moderate risk in my search results), but stresses that it's a continuum and not a clear demarcation. So it looks like there's not a commonly used "moderate risk" category that would account for a slice of those deaths -- true or false?

By Blogger Jamie, at 2:56 PM  

Jamie:

"J&D found a combined intrapartum/neonatal mortality rate of 2.6/1000 including high-risk births and congenital anomalies, a rate of 2.0/1000 excluding congenital anomalies, and a rate of 1.7/1000 excluding both congenital anomalies and high-risk births."

Yes, Johnson and Daviss have the most favorable statistics of any homebirth study.

1.7/1000 was the closest I could come to approximating the homebirth population. I excluded the categories of prematurity, maternal risk factors and congenital anomalies. I was not able to exclude twins and triplets, breech, transverse lie, unintended out of hospital delivery and maternal trauma and fetal risk factors like intra-uterine growth retardation. Also, the 1.7/1000 includes any deaths at homebirths because these were not identified separately. So the real mortality rate for hospital birth in low risk women is surely lower than 1.7/1000.

Furthermore, while Johnson and Daviss were able to survey 94% of midwives, 6% did not respond. No one knows how many deaths there were in that population and the fact that these midwives did not cooperate may have skewed the homebirth statistics. Even one additional homebirth death would have a big impact on the resulting neonatal mortality rate.

By Blogger Amy Tuteur, MD, at 4:20 PM  

"Homebirth midwives essentially assume that nothing bad will happen; these complications will make themselves known long before they can harm the baby, and the midwife will be able to transfer the mother to the hospital before any damage is done."

You make very general statements about midwives. Yes, normally things do go fine, and if something does go wrong, the transfer is done in time. But I can assure you, that my midwife (who I am training with and who caught my son) tells people that there is always a possibility and a risk that something could go wrong where they would have been better off in the hospital because some major complications are unpredictable even with low risk women. Our clients are aware that birth normally goes okay, and that there is less risk of intervention at homebirths. But they are also aware that not all complications are able to be predicted before it's too late.

Our clients are aware of these things, and still choose homebirth. Many choose free standing birth center births, where they are a 3 minute drive to a major hospital (though awaiting an ambulance and transfer does take longer and they are aware of that).

People choose out of hospital births for different reasons. They are aware of the risk of something going wrong that could have been handled quicker in a hospital, and they are okay with that because of other reasons. To them, maybe that risk is small, but the risk of other things is big to them (such as instrumental delivery, cesarean, etc). Maybe you and others don't agree with their reasoning, and that is perfectly fine. Some people feel much safer in the hospital, and that is fine as well.

What I have a hard time with is all the judgment being passed by people to the homebirthers, calling them "selfish." For me, choosing a homebirth took a lot of research and thought, and soul searching.

I chose a homebirth because I did feel that overall it was a safe option. I was aware that major complications could arise (though I very much disagree with your 10% statement- that is false information) that could be managed better in the hospital. But to me, the risk of that happening was low. I found midwives who were very experienced, had done many births, and I trusted. I found out about their training, and what they carry to births (and ended up using some things as my son needed resuscitation after his shoulder dystocia).

For me, I wanted to decrease the chances of having a cesarean, an instrumental delivery, separation after birth, hospital germs, a not-as-gentle birth for my son. I wanted my son to come into the world in a familiar environment, in a gentle way. I wanted him to be welcomed in to the world in a very gentle way, because that is VERY important to me. To others, maybe none of that is as important to them as having all hospital equipment and staff available in case of emergency. That's okay. But please don't pass judgment on me or other homebirthers. We are not selfish, we just feel differently.

I am an RN and I've seen hospital births and they are not without risks either. My first was born in the hospital.

I think hospital birthers and homebirthers love their babies the same. Nobody is better than the other. We all make choices that feel right to us.

As women, as mothers, why can't we all just support each other and the choices we make?

By Anonymous Anonymous, at 1:06 PM  

"There is no doubt that homebirth has advantages. If you have a homebirth you will dramatically reduce the risk of an unnecessary C-section or forceps delivery; you will not have EFM, you will not have an episiotomy. In exchange, you only put one thing at risk at homebirth: the life of your baby."

Please see my above post in response to this.

Also,this is from your competitive mothering thread: "Competetive mothering is hardly exclusive to homebirth and natural childbirth. It is a pervasive feature of mothering among women of all philosophies. Mothering is a very difficult job and one of the most difficult things about it is that you don't know how you're doing until your children are much older, and maybe not even then. This engenders tremendous insecurity in mothers and they try to compensate by arbitrarily selecting some practice or practices and insisting that doing them a certain way automatically."

I feel that is how this whole thing is here. You are saying we are risking our babies live, etc, like we are making selfish decisions, like we have no reasoning behind our choices. You may not agree with our reasoning, but to us it is valid and important. You are challenging how we bring our babies in to the world, how we enter parenthood. You are doing the competitive mothering thing on this thread.

By Anonymous Anonymous, at 1:16 PM  

Yes, Johnson and Daviss have the most favorable statistics of any homebirth study.

Actually, the NBDT outcomes are better.

1.7/1000 was the closest I could come to approximating the homebirth population.

I'm saying 1.8/1000 for the low-risk population as a whole because that's combined intrapartum and neonatal mortality. If you want to use neonatal alone, J&D looks significantly better in comparison (1.1/1000).

I was not able to exclude twins and triplets, breech, transverse lie, unintended out of hospital delivery and maternal trauma and fetal risk factors like intra-uterine growth retardation.

Ah, Amy, I give you full marks for determination. Some people might look at those numbers and say, "Huh, maybe homebirth is a safe choice for low-risk women and their full-term vertex babies." You look at them and say, "No, it's the triplets! All those 37-week triplets are skewing the numbers and making it appear that homebirth is safe even though I know better!"

I acknowledge that unplanned out-of-hospital birth would skew the numbers for the worse. But breech and transverse lie are only a problem if undetected, or if ROM leads to cord prolapse -- right?

Do note that for neonatal figures alone, planned homebirth would bring the overall numbers down, not up. There are more intrapartum deaths in the homebirth studies, but significantly fewer neonatal deaths (1.1/1000 for J&D, 1.2/1000 for Janssen, .8/1000 for M&F (IIRC)).

Furthermore, while Johnson and Daviss were able to survey 94% of midwives, 6% did not respond. No one knows how many deaths there were in that population and the fact that these midwives did not cooperate may have skewed the homebirth statistics. Even one additional homebirth death would have a big impact on the resulting neonatal mortality rate.

If the study were retrospective, it would be reasonable to wonder whether the non-responding midwives had something to hide. This study is prospective, though, so I think that's a pretty wobbly argument.

By Blogger Jamie, at 2:57 PM  

"I feel that is how this whole thing is here. You are saying we are risking our babies live, etc, like we are making selfish decisions, like we have no reasoning behind our choices. You may not agree with our reasoning, but to us it is valid and important."

Your reasoning is your own and I would not challenge that. I am challenging the FACTS that you use in your reasoning. Facts are either true or not true. A lot of the "facts" that I see on homebirth advocacy websites and in publications are simply FALSE.

I wouldn't call most homebirthing mothers selfish, because they are not well educated about the facts of neonatal death at homebirth. They think they are well educated. They are constantly trumpeting that they are well educated, but if the central "facts" that you use in your reasoning process are untrue, you can't really be very educated, can you?

Homebirth advocates claim that they read widely. Maybe so, but they read only things from homebirth advocates. Before we began discussing the scientific research on this site, not one person had ever read any of the scientific papers. They simply accepted what homebirth advocates told them was in the papers.

If you want to be able to claim that you are educated about a controversial issue, you have to be knowledgeable about BOTH sides of the issue. Right now, most homebirth advocates have very little, if any, knowledge about the scientific issues involved.

By Blogger Amy Tuteur, MD, at 4:16 PM  

Jamie:

"Ah, Amy, I give you full marks for determination. Some people might look at those numbers and say, "Huh, maybe homebirth is a safe choice for low-risk women and their full-term vertex babies." You look at them and say, "No, it's the triplets! All those 37-week triplets are skewing the numbers and making it appear that homebirth is safe even though I know better!"

Well, Jamie, the category other accounts for 23.6% of the deaths and we don't know what is in that group. If we were to just subtract it on the assumption that it had nothing to do with place of birth, the hospital neonatal death rate would be 1/1000. If you'd prefer, I'd be happy to use that figure for the hospital death rate.

By Blogger Amy Tuteur, MD, at 4:27 PM  

Amy Tuteur, MD said...
Well, Jamie, the category other accounts for 23.6% of the deaths and we don't know what is in that group. If we were to just subtract it on the assumption that it had nothing to do with place of birth, the hospital neonatal death rate would be 1/1000. If you'd prefer, I'd be happy to use that figure for the hospital death rate.


And why not try? You'd be approaching the honesty level of some of the home birth papers ;) (that was a joke, BTW)

Amy, which of the 15 numbered rates are you "counting" and which are you not? You can list them by number if it'd be easier...

By Blogger sailorman, at 7:33 PM  

Hey, Amy, are you using the asphyxia line from the report you linked to get the intrapartum death rate? I'm pretty sure that doesn't work, because neonatal deaths are reported as a fraction of live births. I think that line represents the babies who were resuscitated after intrapartum asphyxia but died during the first 28 days -- not stillbirths.

Having computer trouble so I won't be around as much while we're figuring it out.

By Blogger Jamie, at 11:54 PM  

Sailorman:

"Amy, which of the 15 numbered rates are you "counting" and which are you not? You can list them by number if it'd be easier..."

I took the total for white babies of both sexes and subtracted prematurity and maternal complications, and in some comparisons, congenital anomalies (if it had also been done in the homebirth group). I'm undoubtedly including many more deaths that should be subtracted. I would guess that the true rate of neonatal death is 1/1000 or less.

By Blogger Amy Tuteur, MD, at 7:04 AM