Tuesday, May 16, 2006

Homebirth philosophy

I thought we might switch gears for a moment and talk about the philosophy of the homebirth movement and whether the basic philosophy of the movement might interfere with the ability to understand and accept scientific research.

Here is the abstract I found from an article by O'Connor in the Journal of Medical Philosophy (J Med Philos. 1993 Apr;18(2):147-74.) :

The home birth movement in the United States is an alternative health belief system that promotes a model of pregnancy and childbirth contradictory to the conventional biomedical model. The alternative model stresses normalcy and non-intervention and is informed by an ideology that promotes individual authority and responsibility for health and health care. It is founded in an epistemological system that assigns primacy and goodness to the Natural, fuses moral and practical injunctions in the arena of health behavior, and valorizes subjective as well as objective sources of knowledge. (Natural = as found in nature without technical intervention). Differences of opinion with the conventional medical model of childbirth do not spring from misunderstanding of this model, but from disagreement with it. Members of this movement are typically educated, middle class, and white.

This sounds to me like a pretty accurate description of homebirth philosophy and would explain why homebirth advocates to not appear to understand what the scientific community is saying, or even the importance of science itself. It also provides a reason why the homebirth community supplies a constant stream of anecdotes in place of scientific evidence.

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50 Old Comments:

"whether the basic philosophy of the movement might interfere with the ability to understand and accept scientific research."

I think it's the opposite. I think the basick philosophy of medicalized birth interferes with the ability to understand and accept scientific research.

By Anonymous Anonymous, at 10:22 AM  

I think the abstract has a good point. the people choosing homebirth for reasons of philosophy are educated. They know how scientific studies work, and don't work. And they have a difference of opinion from the medical model.

However, I think it's quite a stretch to say that because they have a difference of opinion that they don't understand what the scientific community is saying. I think they understand quite well, and disagree.

By the way, can you please edit your entry to show a gap between the end of the abstract quote, and your own comments? Just for clarification.

By Anonymous Anonymous, at 10:48 AM  

Oh, sorry. It shows a gap on the front page, just not the comments page. My mistake.

By Anonymous Anonymous, at 10:49 AM  

I agree with this. I am a former homebirth advocate and have thought a lot about this and have followed this debate with a good deal of interest.

I think that a lot of other beliefs follow from this philosophy.

Many homebirth advocates are also breastfeeding advocates, practitioners of gentle discipline, wear their babies, and are cosleepers. I do not think there is a lot of surprise about this.

This is anecdotal, but in my experience, homebirth advocates often share the following characteristics: they are, as you state, middle class, educated, and white. They are also generally intelligent and maybe most importantly perceive themselves to have been injured by hierarchal models. It does not get much more hierarchal than a hospital. Many, many of the homebirth advocates I know personally were molested as children or as very young women, which I think explains a faith in the subjective and an absolute terror of putting their bodies into the hands of a practitioner they perceive as cold, detached, and in an atmosphere in which a doctor has ultimate power over them and their child.

Also, we live in a society today that is fractured and in which family is often far away or alienated. (Many homebirth advocates I know are alienated from their families). Homebirth advocacy and the attendant faith in breastfeeding and attached parenting gives one an almost tribal sense of belonging with other mothers with the same belief systems, whether these other mothers live down the street or, increasingly, one participates in a sort of tribe over the Internet.

I have never bonded with another mother because I gave birth twice up in stirrups, I must say. I will also add that both times, had I given birth at home, would have had, as they say, bad outcomes. I had a pph with my first and my second son was born with the cord wrapped twice very very tightly about his neck. I was grateful to have been near experienced help both times.

By Anonymous Joanna, at 10:50 AM  

"homebirth advocates to not appear to understand what the scientific community is saying, or even the importance of science itself. It also provides a reason why the homebirth community supplies a constant stream of anecdotes in place of scientific evidence."

It is science plus experience for me. Should I trust only abstract studies that may not specifically apply to my situation? What about my personal experiences of harm in the hospital? Please, Amy, tell me this:

Why is it that I should trust the judgment of ACOG and the NHA over the World Health Organization and the American Public Health Association? Please don't attribute the differences to politics. ACOG and the NHA are as mired in politics as the APHA and WHO. I also still don't grasp why we should dismiss the experiences of countries (and some counties in our own country) with successful models of midwifery care (in the home, birth center and hospital). There are scientists who disagree with your position.

I tend to discount what you have to say because I don't think you have made a real open-minded effort to understand (even if you don't utlimately agree with) the Midwives Model of Care. You are simply dismissive and demeaning. Who is the lay person supposed to trust?

Now, I will fully admit that I can't go down to the mat with you and Sailorman in your analysis of research and statistics. But, I do have a grasp. I have an economics degree and understand study design and statistics. You continually portray midwives as incompetent and those of us who choose homebirth as duped and intellectually unsophisticated.

This discussion is very disheartening because it illustrates the contentious relationship between the medical community and the homebirth movement. We would have an amazing maternity system in this country if we could integrate the two.

By Blogger Mama Liberty, at 11:14 AM  

Mama Liberty, what's the NHA?

Joanna, interesting perspective -- what do you mean when you say you're a "former homebirth advocate"? Where do you stand on the issue these days?

By Blogger Jamie, at 12:32 PM  

Hi Jamie, Thanks for replying to my post.
I'm not a homebirth dis-advocate, but I gave birth twice, in the hospital. One time was very difficult, the second a piece of cake and very pleasant (after it was ascertained my son had no ill effects from the tight cord issue).

With my first son, for lack of a better term, I joined the tribe: attached parenting and planned on having a homebirth the next time. I found that the dynamic (not just of homebirth, but of attached parenting and all that it entails) was not all that it is cracked up to be for me and my family. I could not take the pressure and lack of autonomy that such a lifestyle requires for the mother. We gradually moved away from it (except for the gentle discipline and breastfeeding of course).
\
Along with that, I guess I moved more into an objective rather than subjective view of things: more cut and dried, "logical," etc. It is where I am now. So the scientific basis put forth here works for me. My personal belief is, that I will give birth in hospitals and have those incredible transcendent moments at other times with my children...out in nature, for example, is when I feel those golden moments of happiness with them. I believe it is worth it to sacrifice having what must be an incredible experience at home for the sake of the safety of the hospital.
That is where I am.

By Anonymous Joanna, at 12:43 PM  

Mama Liberty:

"Why is it that I should trust the judgment of ACOG and the NHA over the World Health Organization and the American Public Health Association?"

No one has ever said you should. You should read the research and make your own judgment.

"You continually portray midwives as incompetent and those of us who choose homebirth as duped and intellectually unsophisticated."

No, not all. What I have said over and over again is that their views are not substantiated by scientific research and their knowledge is quite a bit more limited than they are willing to acknowledge.

This paper puts a rather different spin on it, though. It suggests that the very belief system in which doctors operate differs in fundamental ways from the belief system in which homebirth advocates operate. By the tenets of the scientific movement, subjective experience CANNOT be a form of proof, but, in contrast, the homebirth movement accepts subjective experience as a form of proof. By the tenets of scientific movement "natural" is a descriptive term and carries no special value. By the tenets of the homebirth movement, "natural" is by definition best.

The author of the paper is suggesting that we do not even speak the same language when we argue about homebirth.

By Blogger Amy Tuteur, MD, at 12:43 PM  

-The author of the paper is suggesting that we do not even speak the same language when we argue about homebirth.-

I fully agree with this sentance.

By Anonymous Anonymous, at 1:40 PM  

Amy, have you ever considered that there are fewer medical studies about homebirth and natural birth, simply because that's not where the money is?

Normal, low-technology birth doesn't benefit the drug companies, teaching hospitals, ACOG, or any other organization with the big bucks to fund large studies. In fact, it takes money *out* of their hands. Small wonder they're not interested in proving the safety of homebirth.

I also resent the implication that homebirth advocates just aren't bright enough to see the scientific evidence. We *have* seen the evidence, we've questioned the motives, and we've drawn our own conclusions, as have you.

By Blogger Anne, at 2:44 PM  

Joanna wrote:
"I had a pph with my first and my second son was born with the cord wrapped twice very very tightly about his neck. I was grateful to have been near experienced help both times."

Joanna, I'm sorry to hear that your birth experiences weren't what you'd hoped for. I respect your choice to give birth in the hospital, and I'm glad you had good outcomes.

I'd just like to point out, for the record, that the complications you experienced are frequently handled at home in much the same way as they were in the hospital.

When the cord is around the baby's neck so tightly that it prevents birth, it can be clamped and cut with no further complications. Homebirth midwives can do this just as easily, with the same tools, as hospital practitioners.

Postpartum hemorrhage is usually managed with Pitocin, misoprostol, and/or bimanual compression in the hospital. At home, the same techniques and drugs are often used. Sometimes herbs, traditional Chinese medicines, or other methods are added to the toolbox.

I think it's a widespread myth that if a complication comes up at a homebirth, a disaster is inevitable. Modern midwives don't show up with some dirty rags and a bucket - they're well prepared for most bumps in the road that can happen at birth.

By Blogger Anne, at 2:56 PM  

Anne:

"Amy, have you ever considered that there are fewer medical studies about homebirth and natural birth, simply because that's not where the money is?"

That is a conspiracy theory with no basis in reality. We are not talking here about studies sponsored by drug or device manufacturers. We are talking about basic scientific research which is usually funded by the government.

There are very few studies of homebirth because there are very few homebirths. In addition, the people who do homebirths seem to have no interest in studying it themselves. They've already decided it's safe without any evidence; apparently, they see no need for evidence. Furthermore, according to the article I posted, they accord anecdotes the status of evidence, so they do not necessarily care about the lack of studies.

By Blogger Amy Tuteur, MD, at 4:54 PM  

This sounds to me like a pretty accurate description of homebirth philosophy and would explain why homebirth advocates to not appear to understand what the scientific community is saying

Where exactly is the 'scientific community' saying this, Amy? There's no anti-homebirth movement. Just you, sailorman, and a few disgruntled doctors, which is expected.

You know what's really disappointing to me? I saw the title of this post and thought, wow, Amy wants to learn about our philosophy. No, just you posting someone else's version that matches your own take on our philosophy, framed in a negative way to again, belittle us. Fun fun fun.

By Anonymous maribeth, CNM, at 4:54 PM  

Anne:

"I think it's a widespread myth that if a complication comes up at a homebirth, a disaster is inevitable. Modern midwives don't show up with some dirty rags and a bucket - they're well prepared for most bumps in the road that can happen at birth."

Then why does every study done on the subject show an excess of neonatal deaths in the homebirth group?

By Blogger Amy Tuteur, MD, at 4:55 PM  

"That is a conspiracy theory with no basis in reality. We are not talking here about studies sponsored by drug or device manufacturers. We are talking about basic scientific research which is usually funded by the government."

Oh, now you really must give me a break. There is no conspiracy theory. This is fact. There is very little "government money" and very little of it with no strings attached. There has to be some financial incentive somewhere to study something. That financial incentive may be profits for pharmaceutical companies or tax savings for government agencies, to give two examples. Really think about this... where would the incentive to study natural childbirth come from? Research is expensive (I'm sure I don't have to tell you that) and there has to be some conceivable "return on investment". Perhaps my midwife might benefit from some positive research, but she certainly isn't in a position to fund research with her $1500 per delivery!

That being said and following on an earlier question I asked, which you evaded (about WHO and APHA)... I put more stock in the analysis of public health agencies say than what comes from trade unions!!!

Danielle

By Blogger Mama Liberty, at 5:25 PM  

"Mama Liberty, what's the NHA?"

Sorry, Jamie. I was mixing my state organizations and national organizations. The NHA is the Nebraska Hospital Association, whom I just had the pleasure of listening to testify against allowing midwives to practice in Nebraska because "home delivery is for pizzas, not for babies". (Yes, a real quote. How's that for science?) To tell you the truth, I'm not sure if the American Hospital Association has a position on home birth. It may be a state by state issue.

By Blogger Mama Liberty, at 5:31 PM  

Amy wrote:
"That is a conspiracy theory with no basis in reality."

I'm sorry...what was it that you said about how insults are always a sign that the speaker is losing the argument?

"Then why does every study done on the subject show an excess of neonatal deaths in the homebirth group?"

EVERY study? That's astounding! Just for the record, could you please provide us with citations for every study done on the safety of homebirth, and the rates of neonatal death as compared to hospital birth? Also, could you please define "an excess"?

In all seriousness, Amy, I respect that this is your blog and you make the rules. But if the universal rules say (1) don't insult people, and (2) don't make gross generalizations without citing scientific evidence, those rules apply to everyone in the debate, including yourself.

I also would ask - and I ask this seriously, with no sarcasm, and not rhetorically - have you seen any perinatal deaths among your patients and/or their babies? If you have, do you consider those deaths to be your fault? Do you consider them to be your patients' fault?

By Blogger Anne, at 7:34 PM  

Anne, it is not an insult to point out that someone who has just stated a conspiracy theory with no evidence has just stated a conspiracy theory with no evidence. It is the truth. A conspiracy theory does not turn into a fact until you present EVIDENCE. Until then, it is still a conspiracy theory.

The subject of this thread is whether homebirth advocates operate from a different philosphical system than scientists. Joanna wrote a very thought provoking response.

I'm not sure I even understand your response at all. Are you saying that the article is misrepresenting homebirth advocates, because they really do want to conduct research? Well, if that's the case, you'll have to give us some reason to believe that beyond the fact that it your opinion.

You ask if you should believe ACOG when no one has ever suggested that midwives should have anything to do with ACOG. All this time I have been arguing that midwives should educate themselves so that they can read and understand the scientific literature and make their own decisions.

You claim to have seen the evidence, but clearly you have never read the papers. You don't know what they say, and you have not offered any substantive critique of the papers.

As far as the rest of it goes, my response is the same that I posted to Mama Liberty in a thread above this one:

Why is it so hard to comment on the matter under discussion? Why do homebirth advocates reflexively sneer "well, I bet you do it, too" as if that were actually a defense.

Homebirth advocates make themselves look very foolish when they respond to a scientific paper with insults, with sarcasm, with conspiracies theories, with anything other than a rational critique of the information presented. It is the intellectual equivalent of the schoolyard taunt: "I'm rubber, you're glue. Everything you say bounces off me and sticks to you." If you thought that worked poorly in the schoolyard, observe how poorly it works in the world of scientific research.

By Blogger Amy Tuteur, MD, at 9:25 PM  

This is another example of Amy avoiding the questions (again). She thinks she has proven some fact, while the "debate" consists of her expousing her point of view, only responding to comments which suit her needs, then continuing on in the dialogue as if past issue was settled and proclared scientific fact. She then uses confidence as a front for reality.

Amy refuses to answer direct questions (while accusing others of such travesty), and ERASES posts which she doesn't want published. I sent a post, a direct answer to a question, outlining some of the educational requirements of a CNM. And she deleted it!

WHY are we wasting our energy? You can't win her game. Don't feed her any longer.

By Anonymous maribeth, CNM, at 9:38 PM  

In addition, the people who do homebirths seem to have no interest in studying it themselves. They've already decided it's safe without any evidence; apparently, they see no need for evidence. Furthermore, according to the article I posted, they accord anecdotes the status of evidence, so they do not necessarily care about the lack of studies.

One small change and tell me if you agree:

In addition, the people who get epidurals seem to have no interest in studying it themselves. They've already decided it's safe without any evidence; apparently, they see no need for evidence. Furthermore, according to the article I posted, they accord anecdotes the status of evidence, so they do not necessarily care about the lack of studies.

My point is, on what issue does what you said not apply?

I don't agree with it, but every woman hears plenty of both sides of the issue. They hear about how good or dangerous homebirth can be, and they hear about how wonderful or horrific hospitals can be.

People rely on the information they glean from others, particularly other people who have experienced the same thing they are considering. Shall we dismiss personal experiences as meaningless?

Of course not. Your own experiences, Amy, guided you to your beliefs. You did not research studies to find out where you stood; you worked in an environment where you saw and handled very serious situations. That shaped how you look at childbirth.

Vilifying people for relying on their experiences is not useful and only makes people feel attacked, or dismissed.

I for one am willing to concede the neonatal death point. That makes sense to me.

But it doesn't change my stance.

I will still defend homebirth as a reasonable option, because I find hospital birth nearly reprehensible. That is based on my experience. I personally know many, many homebirthers, and not one has lost a baby.

But I know women who have lost theirs in hospitals.

You can blame me for being anecdotal, but honestly, how can I be otherwise?

"we do not even speak the same language when we argue about homebirth."

By Anonymous Anonymous, at 9:38 PM  

So much passion here, and ferocious love and concern for mothers and their babies, on both sides. I am wondering what we can salvage here? Does in a sense all our conversations on this site boil down to, there is a different philosophy, a different language and never the twain shall meet?

By Anonymous Joanna, at 10:40 PM  

the demographic is not me-
I grew up very poor- blue collar family- homeless about 1/2 my childhood- I was the first in my family to graduate high school. Natural being better in the sense that it is something I understand better. All the poor folk wanting name brands- velveta on rainbow bread- but if you grow up with a reference then you find what an empty goal those things are.
amazing poor folk might actually have values beyond advertising propaganda . I don't ever want to live like that again but I could- a little unnatural climate control - is my preference with running tap water and a real place to live. On the other hand leave me alone- I don't want to die in a hospital, live in a nursing home- nor be abused by institutions ever again in my life- after one family crisis I really saw the cultural contrast- the senseless offensive, abusive behavior of the hospital the system the staff... -

By Anonymous Anonymous, at 3:20 AM  

Anonymous:

"In addition, the people who get epidurals seem to have no interest in studying it themselves."

Ahhh, but here is the very big difference:

They don't hold themselves out as well educated on the topic, you do.

Furthermore, I suspect that whatever you think you know probably isn't even true.

By Blogger Amy Tuteur, MD, at 7:22 AM  

Joanna:

"I am wondering what we can salvage here? Does in a sense all our conversations on this site boil down to, there is a different philosophy, a different language and never the twain shall meet?"

Actually, I think we are already accomplishing something here. People are thinking about issues that they have not thought about before (well, at least some people are thinking about them). Some people are asking themselves for the very first time: what does the evidence show? Is everything I trusted, because my preceptor told it was so, really true?

Furthermore, hundreds of women who aren't posting are reading the debates on the site. Different women will take different things away from that, but everyone is bound to learn.

By Blogger Amy Tuteur, MD, at 7:29 AM  

Furthermore, I suspect that whatever you think you know probably isn't even true.

I'm done here, Amy. I can tell without a doubt that while you claim to be committed to the truth, you aren't listening to arguments to the contrary. The moment we cease being teachable, we have ceased being honest. No one side is completely correct on any issue, and failing to see that, you cannot be a trustworthy source for any kind of information.

WHY are we wasting our energy? I don't know, Maribeth. I think I had hope for a dialogue.

By Anonymous Anonymous, at 8:45 AM  

since the discussion goes on no matter which header-
how about this statement-

'the only cause of post-neonatal death that has been increasing is that due to perinatal conditions
( RDS, birth trauma, complications of LBW, intrauterine hypoxia/birth asphyxia)
May be due to the increased survival of infants suffering from these conditions in the neonatal period, who then go on to die in the post-neonatal period. "
this is an additional confounder to stats presented -- almost want to do a long term follow up study--

By Anonymous Anonymous, at 10:16 AM  

Anonymous:

"the only cause of post-neonatal death that has been increasing is that due to perinatal conditions"

No, this is not a confounding variable. We are not discussing post-neonatal mortality (infant deaths beyond one month of age). Our discussion is restricted to neonatal mortality.

The phrase above, if I understand it correctly, means that babies who previously would have died immediately of problems such as prematurity, now live for weeks or more and then die.

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

In some ways it is too bad that we are not face to face because there has been humor here (aside from the mirthless, sardonic humor displayed on occasion).
I just wanted to post that I have laughed out loud twice during this thread: when Anne told me that she did not attend homebirths with a bucket and a few dirty rags and when Amy said, "prepare to be astounded."

By Anonymous Joanna, at 11:32 AM  

Please pardon the delay in my response - I was researching studies and taking a walk with my four-year-old daughter, who was born out of hospital and lived to tell the tale.

Amy wrote:
"Anne, it is not an insult to point out that someone who has just stated a conspiracy theory with no evidence has just stated a conspiracy theory with no evidence. It is the truth. A conspiracy theory does not turn into a fact until you present EVIDENCE."

Hmmm. I've seen you present your opinions a number of times without backing evidence, including the anecdote that you posted this morning. When you post your opinion without backup, is that a conspiracy theory too?

You're right - I don't have specific citations for the idea that many medical studies are funded by drug companies, professional medical associations, and the like. But I haven't seen you presenting evidence that I'm wrong, either. I'd be interested to see that proof.

"I'm not sure I even understand your response at all. Are you saying that the article is misrepresenting homebirth advocates, because they really do want to conduct research? Well, if that's the case, you'll have to give us some reason to believe that beyond the fact that it your opinion."

That wasn't exactly my point. My point was that it's insulting and patronizing to imply that midwives and other homebirth are benighted souls, or just plain aren't bright enough to read medical studies.

I haven't conducted extensive scientific research on how many midwives read studies, no. It's simply my opinion that most of the time, someone who's bright enough to be a competent professional midwife is also bright enough to read. I have never met a midwife - in hospital or otherwise - who did not pay attention to current research.

By the way, this morning I did a quick Google Scholar search on two terms: homebirth safety and "home birth" safety. In all honesty, I had difficulty finding studies that showed increased perinatal death in planned homebirths. I did find this opinion piece decrying homebirth for high-risk women; I would agree with that assessment.

On the other hand, I found one, two, three, four, five, six studies (okay, that last one is an opinion piece, but quotes extensively from another study) that show homebirth to be as safe as, if not safer than, hospital birth for low-risk women.

Again, this was just a quick search, and as a low-income person, I had to disregard studies that required me to pay to see the article. Perhaps I would have had different results with different search terms, or if I had been able to read more of the studies for free.

In any case, I believe I've presented evidence against your statement that "every study done on the subject show[s] an excess of neonatal deaths in the homebirth group."

I would still be truly interested to hear your answer to my question about infant and maternal deaths in your practice. I ask this not to condemn your work in any way; I'm simply trying to understand your point of view.

By Blogger Anne, at 1:07 PM  

Anne:

We have found you can't trust the abstracts. A lot of things which are "shown" are really the result of shitty statistical jobs, or (in some cases) what appears to be outright bias on the part of the authors.

Why don't you track down the actual studies and read them? Look at the data (not just the written conclusions). Look at the various threads here to see many of the objections which are raised as the result of the almost-inevitable gaffes commited by the authors of these studies.

For example, why don't you go read the Johnson/Daviss study.

Start by looking at the obvious isses with smoking/alcohol/race between the populations. Note the results notwithstanding those differences.

Then go and look att heir treatment of "fata" anomalies. There's a lot posted here on that.

And so on.

I don't mean to be accusatory, but you should really not post an abstract without having read the paper.

If you're a fan of the Farm study, you will find it fully dissected on my blog.

Look at:
moderatelyinsane.blogspot.com

By Blogger sailorman, at 2:23 PM  

I think it is confounding because the mortality rate really hasn't changed much - just prolonged some lives on the short term - don't think it said specifically "pre-term" , could also be post dates or other compromised infants--- so in an attempt at reduction of one statistic neonatal mortality - another has gone up and its isn't child or young adult it is if a baby dies at 30 days he/she is no longer a neonatal stat- post-neonatal stat but the baby still died from the same cause.
When I am thinking of improvements in health I mean survival- beyond 1 year.

By Anonymous Anonymous, at 2:31 PM  

Sailorman, don't jump down my throat here, but are you mixed up? Johnson & Daviss didn't use a control group -- they compared outcomes from a number of studies of low-risk hospital births attended by physicians. See Table 4. I think it's Durand you mean to criticize.

I know I'm jumping threads, but you never answered my question about the appropriateness of the Bonferroni correction in the Janssen et al. study. And, also from that thread, are you concerned that I'm not acknowledging some babies are better off in the hospital? I have tried to say that any time I write about homebirth -- that hospitals are safer for some babies and you can't always tell if your baby will be one of them. Curious about my score on your "psychological test." ;-)

By Blogger Jamie, at 2:33 PM  

Jamie:

"Sailorman, don't jump down my throat here, but are you mixed up?

I won't, and no (explanation follows)

Johnson & Daviss didn't use a control group -- they compared outcomes from a number of studies of low-risk hospital births attended by physicians.

This is not an accurate control. They should be using Table 1 (though this has some of the same flaws as many other studies in terms of population).

Look at this sentence (copied from the study):

We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics,10 which acted as a proxy for a comparable low risk group....Intrapartum and neonatal death rates were compared with those in other North American studies of at least 500 births that were either planned out of hospital or comparable studies of low risk hospital births.

Can you see the initial problem? First they find a nice set of rates. They define their population using these factors. Then--for some reason--they switch controls, and compare their results to those collected by other studies, in different time periods and geographical locations. God only knows what those other studies did with their data.

"Odd" may not be an accurate summation of this, "crazy" is more accurate.

Dr. Amy, I suspect you have access to the neonatal stats for 2000...? I'd be curious to know how their numbers add up, and why they didn't publish them.

See Table 4. I think it's Durand you mean to criticize.

You already heard all about Durand ;) but no, this was properly aimed.

I know I'm jumping threads, but you never answered my question about the appropriateness of the Bonferroni correction in the Janssen et al. study.

OK, but it'll take a bit of teaching.

Each time you look at a difference between two populations, the chance of a type 2 error increases. Put another way: If you run enough statistical tests, one of them is bound to show significance. But this is a mathematical error: it doesn't actually mean the groups are really different.

The Bonferoni correction simply says "run t tests on everything, and divide your required p value by the number of tests". It uses division to reduce the chance of a type 2 eror.

it's not a particularly advance test, and it can easily hide a true result. FWIW, the study's flaw (one of them) was in trying to test too much instead of focusing on the important variables. IOW, the bonferoni shouldn't have been necessatry at all.

And, also from that thread, are you concerned that I'm not acknowledging some babies are better off in the hospital? I have tried to say that any time I write about homebirth -- that hospitals are safer for some babies and you can't always tell if your baby will be one of them. Curious about my score on your "psychological test." ;-)"

You pass, lol

BTW, this study shares another major flaw commonly found in home birth studies (explained in detail elsewhere so I'll not go into it at length):

They exclude three deaths with "fatal" birth defects from the home birth group.

As you seem to be acknowledging, one major advantage of hospitals is that they have better success with "fatal" defects. Hopefully by now, you understand why taking them out of the stats is a big, big, problem.

By Blogger sailorman, at 9:39 AM  

Sailorman:

"Dr. Amy, I suspect you have access to the neonatal stats for 2000...?"

The neonatal mortality rates for infants born to white women at term in 2000 is 2.4/1000. That includes congenital anomalies, breech, twins, and all possible risk factors. The neonatal death rate for low risk women in this category is probably substantially lower, likely significantly less than half.

By Blogger Amy Tuteur, MD, at 10:16 AM  

That probably answers the question.

After we excluded four stillborns who died before labour but whose mothers still chose home birth, and three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period (see box). This was a rate of 2.0 deaths per 1000 intended home births.

If you do the math, and include those anomalies (who ARE included in the national stats) this results in a "real" rate of 14 deaths (not 11 deaths), which raises the rate to 2.5% per 1000.

This is higher than the national average death rate, even though the national average contains more high risk pregnancies, more high risk mothers!

I can understand why they didn't publish it ;)

And of course it may be even worse. Dr. Amy, do you know whether the national stats include stillborns who die before labor?

The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded.

Anyone want to bet these numbers are problematic as well?

By Blogger sailorman, at 10:49 AM  

Amy, I need a little more info about your source and definition. The online definitions I am finding for neonatal mortality state it as a fraction of live births, which would of course exclude IUFDs and intrapartum deaths. Unless you're defining it differently, neonatal mortality isn't what we need for looking at the Johnson and Daviss outcomes. How about perinatal mortality figures, with source and definition, please?

Do you know what statistic I find truly alarming at this precise moment? The very very small fraction of my family's clothing which is clean and put away. Topographers around the world are exclaiming about the emergence of a mountain in the previously monotonous landscape of my spare bedroom.

By Blogger Jamie, at 12:31 PM  

Jamie:

"I need a little more info about your source and definition."

There are some conventional definitions of terms, but not everyone follows them. That's why researchers need to specify the meaning of each term as they have used it in the paper.

The statistic that I quoted about neonatal mortality for 2000 does not include stillbirths.

By Blogger Amy Tuteur, MD, at 4:40 PM  

So Sailorman, the neonatal death number for Johnson & Daviss, if you include the congenital anomalies (about which more after my laundry mtn is leveled -- I'd say it's down to a laundry butte at the moment), would be 1.66/1000.

I'm curious whether you think that the presence of 12.3% Amish/Mennonite women in the cohort is likely to raise the incidence of congenital anomalies. Whether we agree on that or not, the neonatal death rate is significantly smaller than 2.5/1000.

By Blogger Jamie, at 7:25 PM  

"Jamie said...

So Sailorman, the neonatal death number for Johnson & Daviss, if you include the congenital anomalies (about which more after my laundry mtn is leveled -- I'd say it's down to a laundry butte at the moment), would be 1.66/1000. "

Um, no. It's 2.5/1000, actually:

14 / five thousand and something

(cant bear to look it up again, though I did when I calculated it)

= 2.5

The number you cited (1.66) is lower than the study authors got, even excluding some of the deaths. The study authors "counted" 11 (not 14) deaths, which divided by the ~5000+ people gave a rate of ~2.0/1000.

I don't know my amish/mennonite stats at all, so I won't guess at numbers. If that population has been shown to have a higher incidence of certain anomalies, this could affect the study just like smoking and drinking can.

As we're focusing on neonatal death, the anomalies would only be relevant if they produced a change in neonatal death (e.g. a higher incidence of 6 fingered kids wouldn't really matter).

By Blogger sailorman, at 8:58 AM  

No, Sailorman, neonatal death is the rate of deaths as a fraction of live births. In this study, that would require us to remove the antepartum and intrapartum deaths from consideration. That's why my number is lower than their 1.7/1000 number, even with the congenital anomalies added in.

By Blogger Jamie, at 9:18 AM  

They report that there were 9 neonatal deaths, three resulting from congenital anomalies.

9/5418=1.66/1000

It's a mistake to combine their total intrapartum and neonatal deaths (n=14), and compare that to the neonatal death rate for 2000.

By Blogger Jamie, at 9:26 AM  

Jamie:

"In this study, that would require us to remove the antepartum and intrapartum deaths from consideration."

If you want to do it that way, Jamie, you have to put the intrapartum deaths somewhere. So in that case, the intrapartum death rate would be 1/1000 for homebirth and the intrapartum death rate for hospital births would be essentially zero.

You can slice and dice the data any way you want, Jamie, hospital birth is still going to come out as safer.

The authors of the study were well aware of this. That's why they chose to compare their neonatal death rate to the death rates in other studies not the ACTUAL neonatal death rate for a low risk population delivering at term. which is probably significantly lower than 1/1000.

In some ways, I think this is the most damning evidence in the homebirth papers. The authors always are aware of how their mortality statistics compare with comparable low risk hospital groups (unfavorably) so they compare them to some other group, or they violate statistical rules and remove some of the deaths, or they massage their data in other ways.

These are not stupid people, Jamie, they are aware of what they are doing and the fingerprints of deliberately erroneous statistical analysis are all over these papers. The authors of these paper KNOW that hospital birth is safer than homebirth; that's why they try so desperately to hide it from other people. They are trying to trick you. Don't let them succeed.

By Blogger Amy Tuteur, MD, at 9:48 AM  

Look, there's a really easy way to do this, even retrospectively:

1) Go study home birth. Record all important details of your population.

2) Find a control hospital population to compare it to. Record all their important details.

3) Make sure your home birth population is NO BETTER THAN, or WORSE THAN, the other population in terms of expectancy.

A good way to think of it is this:
If you sent all your "home birth" population to the hospital, what would you expect to happen based on the home birth population characteristics?

If you would expect MORE deaths than your hospital control, great! Your study will be VERY good proof of your point, as you have no worries of accusations of bias.

If you would expect AS MANY deaths as your hospital control, great! You have made a really nice accurate control. Hopefully you've done good matching, but your study should be accepted.

If you would expect FEWER deaths than your hospital control, you've got a problem. A big one.

4) Run your study.

5) Provide the raw data showing home birth is safer.

6) Win enormous fame, and fortune!

Every single home birth study I have looked at fucks up #3.

Every one.


It is simply astounding. I mean, they could at least try to make things match.

Hell, the numbers for hospital births are so large, and so well known, they could probably even use a correction:

"Since our hospital control group had 10 % smokers and smoking is known to increase neonatal mortality by X%, we have decreased the effective neonatal mortality ascribed to the hospital by Y%"

If you use a conservative correction, nobody will mind.

Of course, if you use a conservative correction (or any correction) the underlying data in the EXISTING homebirth studies, done by people who give every appearance of bias in reporting their results, does appear to be clear: Home birth is less safe.

Sigh.

By Blogger sailorman, at 12:33 PM  

Come on, you two, I want a mea culpa (a nostra culpa, I guess it would be) about the neonatal death rate error. Is everybody clear on the mistake up above? If you put an apple and a plum in one bag and observe that it's heavier than the bag with just an apple in it, the comparison tells you nothing about the relative sizes of the apples.

It is not statistically appropriate to compare the Johnson & Daviss death rate (intrapartum plus neonatal deaths) with the national rate for neonatal deaths alone, and I do not expect you would have been very gracious about it if I had made a similar error.

By Blogger Jamie, at 12:49 PM  

Jamie:

"It is not statistically appropriate to compare the Johnson & Daviss death rate (intrapartum plus neonatal deaths) with the national rate for neonatal deaths alone, and I do not expect you would have been very gracious about it if I had made a similar error."

I'm not sure I understand what you are getting at here. In the first place, Johnson and Daviss made no attempt to compare their data with any kind of national rate; they were afraid to do it because it would look bad. Otherwise, why would they have compared their neonatality rates only with previous studies?

Second, we don't even know the precise neonatal death rate for the control group that Johnson and Daviss claimed to be using. The paper they cite is only about the characteristics of births in 2000, not the death rates. The death rate that I quoted you (2.4/1000) was white women at term, it included every possible risk factor. I found it myself by searching through the 2000 database and I haven't yet been able to find comparable stillbirth data so I can caluculate a neonatal mortality rate that includes stillbirths.

You are really grasping at straws here, but even that won't work. That study never showed that homebirth was as safe as hospital birth and the authors knew it.

By Blogger Amy Tuteur, MD, at 1:22 PM  

I'm referring to this comment from Sailorman:

If you do the math, and include those anomalies (who ARE included in the national stats) this results in a "real" rate of 14 deaths (not 11 deaths), which raises the rate to 2.5% per 1000.

This is higher than the national average death rate, even though the national average contains more high risk pregnancies, more high risk mothers!

I can understand why they didn't publish it ;)


If you compare every Johnson & Daviss death, both intrapartum and neonatal, with the figure for neonatal deaths alone in the population at large, you get a larger number for J&D. You also get a statistically invalid comparison.

By Blogger Jamie, at 1:47 PM  

Yup, here's an official apology. Sorry! I scratched my head a few times when I read your post and looked again; I misread it. My bad.

By Blogger sailorman, at 2:14 PM  

Thank you kindly, Sailorman.

By Blogger Jamie, at 2:26 PM  

Joanna, I don't know if you're still following this thread, but before it drops off the page I wanted to say how interesting your observations about characteristics of homebirthing women were. (I am glad to be mostly spending time with mothers of older kids these days, so that the competitive "more attached than thou" stuff is no longer an issue!)

By Blogger Jamie, at 8:34 PM  

How many hours did it take you to learn how to tear down midwifery?

I see your medical school god complex is shinning through just fine. Congrads on that!

You apperently have a ton of time to waste...selling lies just because you earned the title of MD.

Really, are you awhere of how many med students fail?

How many malpractice problems there are?
Insureance rates for doctors should be proof enough some of you are bull headed and don't know what your doing.

As with any title (such as MD) it don't mean a thing now days unless the person puts there heart and soul into being a good doctor.

Even doctors can and will fail...your not a god believe it or not and you can be wrong. Think about that before you fire off a blantly untrue statement about midwifery.

By Anonymous Anonymous, at 11:16 PM