Wednesday, June 07, 2006

Janssen says her study does not show that homebirth is as safe as hospital birth

Patricia Janssen's study Outcomes of Planned Home Births vs Planned Hospital Births in British Columbia (CMAJ, 2002) is often cited as showing that homebirth is as safe as hospital birth. I have criticized the study on several occasions in the past. Not surprisingly, I am not alone. The Canadian Medical Association Journal published 7 letters to the editor critical of the study's statistical methods and the conclusions of the study, specifically the fact that the homebirth and hospital groups were not the same and that the homebirth group had 2 perinatal deaths and the hospital group had none. The CMAJ offered Janssen an opportunity to reply to her critics. Her response includes the following:

Although we tried to ensure that comparison groups met eligibility criteria for home birth, women who choose home birth differ from those who select hospital birth in both measurable and unmeasurable ways...

Furthermore:

The purpose of our study was not to determine which method of care was better, home vs. hospital, [my emphasis] but rather to assess whether, at the 2-year interval, home birth was safe enough to continue to be offered as a choice for women in the context of ongoing evaluation.

And:

The small number of adverse outcomes among an essentially healthy population of women limits the power of a single study to make valid conclusions.
So Dr. Janssen herself, the lead author of the study, acknowledged in response to criticism that the homebirth group was NOT equivalent to the hospital group in risk, that the study was NOT to determine whether homebirth is as safe as hospital birth and that the study is limited in its ability to make VALID conclusions. Therefore, homebirth advocates should not be citing it as a study that shows homebirth to be as safe as hospital birth.

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37 Old Comments:

picky me will disagree again.

I think citing a study based on the DATA is OK, irrespective of the author's conclusions. After all, I think that authors generally can't be trusted to report conclusions accurately--positive or not. However, to the degree that Dr. Janssen discusses the data and their effect on statistics, I think it validates many of our earlier protests about the data themselves.

Some people have said you and I must have been be biased not to admit the study "proved" home birth was safe. Perhaps they'll retract their accusations now that Janssen has agreed.

I'll also take the opportunity to point out that Dr. Janssen IS well aware that "safe" and "as safe" are not the same thing. She is extraordinarily clear about this.

I know I've had a lot of arguments with some folks about that type of clarity, and hopefully you'll see that this recognition and specificity is a mark of good research, not a mark of bias.

By Blogger sailorman, at 12:19 PM  

other part of her reply--
With respect to perinatal mortality, note that the one perinatal death in the comparison groups occurred not in the group of hospital-intended births attended by midwives, as Farine's table indicates, but in the physician comparison group. No evidence suggests that any of the perinatal deaths in the home birth group were related to labour management at home.--
----- I also think that what she is saying is that she can't get a good matched case study-- like what we have been saying all along-

By Anonymous Anonymous, at 9:38 PM  

standards for routine suction and intubation has changed since this study was conducted-- and should be probably re-evaluated in that light as well.

By Anonymous Anonymous, at 9:40 PM  

"With respect to perinatal mortality, note that the one perinatal death in the comparison groups occurred not in the group of hospital-intended births attended by midwives, as Farine's table indicates, but in the physician comparison group."

That death was a stillbirth and it doesn't make any difference whether it occured in the hospital midwife group or the hospital doctor group.

"standards for routine suction and intubation has changed since this study was conducted-- and should be probably re-evaluated in that light as well.'

That also has nothing to do with Dr. Janssen's assessment that homebirth midwives were deficient in suctioning and intubating babies with meconium.

By Blogger Amy Tuteur, MD, at 11:17 PM  

yes it does because - in the past routine suctioning for all mec babies was the rule vigorous or not. Now it is no longer the standard- and there is also a new recommendation for intubation as well-- and some meds changes - read it here -- new books should be coming out.

http://www.aap.org/nrp/nrpmain.html

By Anonymous Anonymous, at 11:44 PM  

"yes it does because - in the past routine suctioning for all mec babies was the rule vigorous or not."

No, it does not. Dr. Janssen was commenting on the fact that DEMs were NOT COMPETENT in the skills of tracheal suction and intubation because they did not have enough experience.

That's a tangetial point anyway. The main point is that Dr. Janssen says that her study does NOT show that homebirth is as safe as hospital birth. Homebirth advocacy sites should include this acknowledgement whenever they reference her article.

By Blogger Amy Tuteur, MD, at 6:55 AM  

sp"" A study large enough to compare perinatal death rates accurately, if the rate of homebirths with regulated midwives in BC were to remain the same as today would require 7-8 years of data collection"

45% suction of infants with mec in home birth group
75% suction of infants with mec in hospital group

and lets look at the comparison here
50 with thick mec in home- 41 in hospital
24 tracheal suction in home- 42 in hospital
44 Ippv by mask in home 62 in hospital
3 IPPV by ETT in home 0 in hospital
2 chest compressions in home 1 in hospital
4 drugs for resuscitation in home 20 in hospital
5 birth asphyxia in home 6 in hospital
2 meconium aspiration in home 1 in hospital
7 birth weight under 2500 g in home 15 in hospital
6 transfer to other hospital in home 4 in hospital
2 seizures in home 2 in hopstal
5 assisted vent > 24 hrs in home 0 in hospital
14 receiving oxygen > 24 hrs in home 22 in hos

--------------------------------------------
whats up with the drugs for resuscitation in the hospital?

By Anonymous Anonymous, at 9:38 AM  

Are you going to post a whole post (and not keep it buried here under the the comments) about the remarks within the Pang study that stated that the data (being birth cert. data) are basically not controlled enough to draw accurate conclusions?

By Anonymous Anonymous, at 9:47 AM  

"Among home births, 110 (12.8%) were conducted by physicians, 8 (0.9%) by “other” persons (qualified second attendants, usually nurses, attended deliveries when back-up midwives were not available) and 6 (0.7%) were unattended. Midwives attended 738 deliveries (85.6%). In the midwife-attended hospital group, 162 (28.4%) clients had their babies delivered by physicians, 4 (0.7%) by nurses and one (0.2%) by “other.” Midwives attended 404 deliveries (70.8%)."

By Anonymous Anonymous, at 9:49 AM  

Amy Said: That's a tangetial point anyway. The main point is that Dr. Janssen says that her study does NOT show that homebirth is as safe as hospital birth. Homebirth advocacy sites should include this acknowledgement whenever they reference her article.


No Any, she did not say that. She said:

'The purpose of our study was not to determine which method of care was better, home vs. hospital, but rather to assess whether, at the 2-year interval, home birth was safe enough to continue to be offered as a choice for women in the context of ongoing evaluation.'

There is a BIG difference. She said her study wasn't designed to determine which method of care was better.

By Anonymous Anonymous, at 10:35 AM  

"She said her study wasn't designed to determine which method of care was better."

Right. So how can homebirth advocates claim that her study makes the comparison that homebirth is as safe hospital birth?

I'm not sure why anyone is arguing about this. I have said many times in the past that the study does NOT show that homebirth is as safe as hospital birth. Now we know that the author says so, too.

By Blogger Amy Tuteur, MD, at 8:43 PM  

So how can homebirth advocates claim that her study makes the comparison that homebirth is as safe hospital birth?

What home birth advocates claim this? Maybe you could point out a few links...

By Anonymous clever ID, at 9:24 PM  

I think it strongly points to the likliehood, but I woudn't state it outright.

Anyhoo -- here's an interseting link http://www.sciencebasedbirth.com/Blogs_06/AnnAlthouseRebuttal_06.htm

By Anonymous Anonymous, at 9:46 PM  

"What home birth advocates claim this?"

Almost all homebirth advocates claim that homebirth is "as safe as or safer than" hospital birth. In fact, I haven't been able to find an advocacy website that says otherwise. Perhaps you can find one.

By Blogger Amy Tuteur, MD, at 9:56 PM  

the portion about mec and suction- she speculated on the differences in the home and hospital suctioning and questioned if it would make a difference or not the increase was CPM midwives did more suctioning in the hospital not the physicians-...
What is now known is MAS isn't going to prevented by suctioning - this is a pre birth inhalation and suctioning on the perineum is no longer a recommendation ---
-------------------------------------------------------------

"Rates of low Apgar scores at 5 minutes did not differ among the groups (Table 5) (pvalue cut-off for statistical significance after Bonferroni correction 0.003). Rates of thick meconium at birth did not differ among the groups. Two babies in the home birth group, one in the physician comparison group and one in the midwife comparison group had meconium aspiration syndrome. Tracheal suction was performed more frequently among babies in the midwife comparison group compared with the home birth group. Drugs for neonatal resuscitation were used more frequently among the physician comparison group. "
-----------------------
this part addresses the trouble she had with matching the groups-
-----------------------------------------------
"Despite the care taken in this study to match the 3 groups, there may be differences regarding the women who chose home birth that placed them at either lower or higher risk for adverse outcomes that we are unable to measure. Our study has evaluated outcomes during the first 2 years of implementation of midwifery, including home birth, in BC. During this time, policy and protocols have continued to evolve. It may not be possible to generalize our findings to ensuing years as midwifery communication systems and practice become more integrated within our health care system. "

By Anonymous Anonymous, at 10:33 PM  

>>Amy Tuteur, MD said...
"What home birth advocates claim this?"

Almost all homebirth advocates claim that homebirth is "as safe as or safer than" hospital birth. In fact, I haven't been able to find an advocacy website that says otherwise. Perhaps you can find one.

9:56 PM<<

She asked specifically what home birth advocates point to this study (Janssen), in and of itself, as stating that.

This points to a flaw in your logic in this entire site. You don't answer direct questions, nor do you make sound conclusions. It think it points to a basic misunderstanding on your part. I think your vision is clouded.

Do you admit that mothers and babies have a much higher incidence of distress and other issues due to U.S. hospital routines? Do you admit that most transports are not dire emergencies, so the theoretical examples you use are a tiny proportion of the total picture of home birth?

All births are risky to a certain degree. One set of risks places mom and baby on a slippery slope to a greater likliehood of needing emergency measures to save their lives (one or both). The other set of risks is that, in an astonishingly small number, there might be a problem requiring further expertise (i.e. emergency transport -- but I would reiterate NOT ALL TRANSPORTS ARE EMERGENCY TRANSPORTS).

In the end, the two set of risks end in statistically the same risk of death for the baby. But home birth with a qualified attendant enjoys lower risk for the mom, and lower risk of morbidity for both mom and baby.

Until you admit that, your debate points are totally negated as you fail to recognize and acknowledge the truth.

http://www.acegraphics.com.au/articles/wagner03.html (this is about australia but the author, in personal conversation, assured me it applies at least as much in the U.S.)

By Anonymous Anonymous, at 10:49 PM  

Amy Tuteur, MD said...
"What home birth advocates claim this?"

Almost all homebirth advocates claim that homebirth is "as safe as or safer than" hospital birth. In fact, I haven't been able to find an advocacy website that says otherwise. Perhaps you can find one.


Dear Dodger, I wasn't asking that as you are well aware. I was asking you to point out the specific websites of home birth advocates who cite that study with the "as safe as" claim.

By Anonymous clever ID, at 11:24 PM  

"Do you admit that mothers and babies have a much higher incidence of distress and other issues due to U.S. hospital routines?"

No, babies do not have a higher incidence of distress or complications or deaths.

Mothers definitely have a higher risk of any and all interventions. That's the tradeoff. Most mothers willingly accept the increased risk to themselves so that the baby will have DECREASED risk.

"Do you admit that most transports are not dire emergencies, so the theoretical examples you use are a tiny proportion of the total picture of home birth?"

Absolutely. I've never said otherwise. The increased risk of a baby dying at home is relatively small, but it is really. Therefore, it accurate to say that there is no evidence that homebirth is as safe as hospital birth.

"In the end, the two set of risks end in statistically the same risk of death for the baby."

No, no, no. The risk of death of for the baby is HIGHER at homebirth. It is intuitively obvious and has been confirmed by virtually all the scientific studies. Babies born with unanticipated serious complications need immediate medical help and that is not available at home.

This is one of the central MYTHS of homebirth. The death rate in the hospital group does not counterbalance the death rate in the homebirth group. The death in the homebirth group is HIGHER.

By Blogger Amy Tuteur, MD, at 11:31 PM  

>>No, no, no. The risk of death of for the baby is HIGHER at homebirth. It is intuitively obvious and has been confirmed by virtually all the scientific studies. Babies born with unanticipated serious complications need immediate medical help and that is not available at home.<<

You can keep saying that, but your repeating it does not make your misinterpretation any truer.

By Anonymous Anonymous, at 11:34 PM  

"I was asking you to point out the specific websites of home birth advocates who cite that study with the "as safe as" claim."

Oh, please. Google "homebirth", check every website listed on the first page (throw in all the other pages too, if you want to waste your time). YOU won't be able to find an advocacy site that doesn't make the claim.

Why are you making such ridiculous arguments anyway? We all know that what I said is true, even if you want to waste everyone's time by denying it.

By Blogger Amy Tuteur, MD, at 11:35 PM  

"You can keep saying that, but your repeating it does not make your misinterpretation any truer."

You forget, I am not trying to convince you, because I know that there is nothing that would make you change your mind.

I am writing for people who want the facts about homebirth, not for people who simply want their personal beliefs to be ratified.

By Blogger Amy Tuteur, MD, at 11:37 PM  

Oh, please. Google "homebirth", check every website listed on the first page (throw in all the other pages too, if you want to waste your time). YOU won't be able to find an advocacy site that doesn't make the claim.

LOL Amy, no need to get your panties in a wad. YOU stated that home birth advocates cite the Janssen study regularly on their websites as proof. Since you seem to be pouring over Google yourself I thought you'd have the info handy. I'm sorry you've wasted so much of your time on a subject that you will never make advances in.

By Anonymous clever ID, at 11:52 PM  

>>You forget, I am not trying to convince you, because I know that there is nothing that would make you change your mind.

I am writing for people who want the facts about homebirth, not for people who simply want their personal beliefs to be ratified.<<

If you had a rational argument with substance, you would convince me. I have yet to see that.

Do you have an answer as to why the American Public Health Association disagrees with your erroneous assement of the data and, instead, recommends increasing access to state-regulated DEMs (primarily CPMs) and out-of-hospital birth?

By Anonymous Anonymous, at 1:48 AM  

Where do I find info on that web site? APHA?

By Anonymous Anonymous, at 2:08 AM  

"Do you have an answer as to why the American Public Health Association disagrees with your erroneous assement of the data and, instead, recommends increasing access to state-regulated DEMs (primarily CPMs) and out-of-hospital birth?"

Yes, they are a political organization. I have commented about this in the past. I do not need any organization to tell me what to think or whether there is evidence for their opinion. Just like I disagree with some of ACOGs pronouncements, I also disagree with this pronouncement from the APHA.

Did you believe in infant circumcision when the AAP (pediatricians group) strongly endorsed it? I suspect not.

It's sort of interesting how homebirth advocates are constantly patting themselves on the back for ignoring recommendations from medical organizations, but suddenly decide that everyone must listen to the APHA because it is a voice of "authority".

By Blogger Amy Tuteur, MD, at 6:32 AM  

OOPS, wrong again, the AAP does not strongly endorse routine circ. Here's a quote:

"Over the past several decades, the American Academy of Pediatrics has published several policy statements on neonatal circumcision of the male infant.1-3 Beginning in its 1971 manual, Standards and Recommendations of Hospital Care of Newborn Infants, and reiterated in the 1975 and 1983 revisions, the Academy concluded that there was no absolute medical indication for routine circumcision."

http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b103/3/686

By Anonymous Anonymous, at 11:00 AM  

I see a difference between trade union like organizations (aap, acog) and a public health organizations (apha, who). The former protect their profession, the latter attempt to take a more objective global look at the whole situation.

By Anonymous Anonymous, at 11:19 AM  

So, if a hospital birth is supposedely so much safer than a homebirth,why did infant and maternal mortality increase in America after the introduction of "modern" obstetrics (the past century)?

That's a statistical fact. I can't help but assume the two are directly related but maybe that's just me.

And why are so many people concerned about homebirthing anyway? If you don't want one, don't have one. That's pretty simple, I think. I don't think hospital births are such a fantastic thing but I'm not about to interfere with some woman's right to have one or bend over backwards trying to convince her it's wrong....

By Blogger Rebecca, at 12:27 PM  

"Yes, they are a political organization."

And what political objective can be met through the APHA's endorsement of home birth, with certified midwives, as a safe option for women? You've never answered that question.

By Blogger Mama Liberty, at 12:41 PM  

"OOPS, wrong again, the AAP does not strongly endorse routine circ."

No:oops, you didn't read what I wrote AGAIN because you were so excited to get in a "zinger" and strike a blow against me personally.

Here is what I said:

"Did you believe in infant circumcision WHEN the AAP strongly endorsed it? I suspect not."

The 1971 standards REVERSED previous recommendations.

By Blogger Amy Tuteur, MD, at 6:31 PM  

Rebecca:

"So, if a hospital birth is supposedly so much safer than a homebirth,why did infant and maternal mortality increase in America after the introduction of "modern" obstetrics"

It didn't. This is another one of those pernicious untruths/lies about obstetrics.

In 1900 only 5% of births took place in the hospital; in 1950, over 90% of births took place in the hospital. Look what happened during those 50 years:

1900 neonatal mortality 100/1000
maternal mortality 850/100,000

1920 neonatal 72
maternal 780

1930 neonatal 60
maternal 600

1940 neonatal 38
maternal 300

1950 neonatal 30
maternal 80

So, as birth switched from being almost exclusively at home to almost exclusively at the hospital, the neonatal mortality rate dropped by 70% and the maternal mortality rate dropped over 90%.

By now, over 99% of births take place in the hospital and the neonatal mortality rate in in the range of 7/1000 and the maternal mortality rate is about 12/100,000.

By Blogger Amy Tuteur, MD, at 6:36 PM  

If I was more ambitious and felt an internet debate was worth my time and trouble,I'd go fish out some publications I have that are based on census stats that show the ratio of hospital to homebirth fatalities in the early 1900's-1950 when maternity wards came into being.

I don't see this blog as being much of a "debate" or informative. to me,anyway.

By Blogger Rebecca, at 9:46 PM  

I'm laughing now. There may be a few among us who were old enough to have an opinion on the AAP recomendations of routine circ in 1971.

And how does this have anything at all to do with homebirth advocates patting themselves on the back?

By Anonymous Anonymous, at 11:21 PM  

well back to the history again-- should we put a list of other countries where home birth that was midwife attended had better and improving stats through the same time period?

the mortality rates for "colored" women remained very high double that of white women in hospital births - but black women attended at home by midwives almost the same death rates as white women with hospital births. stats for Alabama, Maryland and Virginia comparing midwife attended births to physician attended births- 1927-1928
1110/100,000 maternal mortality physician attended-
510/100,000 midwife attended
and if you look at your national standards- this is lower than your 1930 hospital standard...

By Anonymous Anonymous, at 1:57 AM  

I have forgotten which post we talked about this on - but this one will do -- has to do with risk and homebirth-- in this study by Janssen there is a Table 1

Use of illicit drugs---26 homebirth 7 hospital
use of alcohol 16 homebirth 9 hospital
use of tobacco 136 homebirth 121 hospital

By Anonymous Anonymous, at 3:54 AM  

"stats for Alabama, Maryland and Virginia comparing midwife attended births to physician attended births- 1927-1928
1110/100,000 maternal mortality physician attended-
510/100,000 midwife attended
and if you look at your national standards- this is lower than your 1930 hospital standard..."

And if people think that mortality statistics for Alabama, Maryland and Virginia in 1927-1928 are relevant to making a decision about homebirth in 2006, they will be very happy to learn that.

By Blogger Amy Tuteur, MD, at 4:04 PM  

this is in reply to your historic quotes-- no I will not go with your historic time line or the version of the history that you were taught-- as long as you bring up history I will not let it slide.... relevance- maybe none---topical yes and do you still want the matched mortality rates for home births by trained midwives of the day in other countries? Hospital was not the improvement that you are looking for- now I think that there were improvements and many I will credit to Scientists and doctors-- but do not make historic events about place- that is a distraction and given the numbers the trained midwives had in the 3 Northern states their homebirth death rates were far better very very small by comparison docs did not catch up to them till well after abx- -- I have the info used to train those gals and really no big shakes--probably the difference being they were women who had no other agenda than to serve well and if a thing worked they easily changed an incorporated it (practical that way)

how it is still current it the push from that century still hangs over everything a midwife does today-- social memory-- just like other things that were taught to us- racism, sexism.
Why do you think that granny midwives did such a better job of protecting those women's lives back then? 2 things racism and sexism....
in looking at the recent studies about medical schools in schools where there are less women students there are more sexual harassment abuses of women medical students... now which thing do you think is true- women go to women friendly medical schools or that more women in the school make for greater protection? sometimes studies just don't give enough information.

By Anonymous Anonymous, at 9:25 PM