Homebirth Debate

Judith Rooks forgets the cardinal rule

One of the most important rules for professional homebirth advocates is to avoiding appearing anywhere where knowledgeable people can question you. Judith Rooks, CNM, MPH seems to have forgotten that cardinal rule. In response to an article on the ABC News website, she wrote the following:

I can understand the concern about an emergency arising during a home birth resulting in a bad outcome for either the mother and/or the baby. That concern makes intuitive sense. But it isn't reflected by the actual facts... All of the countries with the ten lowest infant mortality rates rely primarily on midwives to provide care to women during labor. Physicians are essential too, but the midwifery approach to childbirth care seems to support and protect the normal physiology of labor, avoiding the need for so much surgery.

I posted a question in response:

Why are you using the wrong statistic? You know as well as I do that infant mortality is NOT the correct statistic to evaluate obstetric care. You know that perinatal mortality is the correct statistic. I'm sure you also know that the US has a better perinatal mortality rate than the industrialized countries with the highest proportion of homebirths. You know that the World Health Organization 2006 report on perinatal mortality shows the US has a lower rate than Denmark, the UK and the Netherlands. Why are you using the wrong statistic and why are you suggesting that countries with midwives have lower mortality rates when you know that's not true?

To her credit, Ms. Rooks did respond. However, she basically conceded defeat when she announced in advance that she didn't "have time" to respond to any more comments from me. In other words, it sounds like she knows she's wrong and she is not going to waste her time (and damage her reputation) by writing things she knows are not true.

I am writing in response to Dr. Amy Tuteur's post ... She said that I know as well as she does that infant mortality is not the correct statistic to evaluate obstetric care and that perinatal mortality is the correct statistic. In fact, perinatal mortality rates are not reliable for comparing international differences in pregnancy outcomes. The denominators for perinatal mortality rates combine late fetal deaths and neonatal deaths. Unfortunately, late fetal deaths are often under-reported, and different countries use different criteria for defining them. If Dr. Tuteru or any bloggers doubt this, I recommend the following three papers, all of which are published in well respected refereed professional journals: (1) "The reliability of perinatal and neonatal mortality rates: differential under-reporting in linked professional registers vs. Dutch civil registers", published in Paediatric and Perinatal Epidemiology 2001; 15 (3):306–314. (2) "Comparability of published perinatal mortality rates in Western Europe: the quantitative impact of differences in gestational age and birthweight criteria", published in BJOG: An International Journal of Obstetrics and Gynaecology 2001; 108 (12):1237–1245. (3) "The Perinatal Mortality Rate as an Indicator of Quality of Care in International Comparisons", published in Medical Care 1998; 36(1):54-66. All three papers concluded that direct comparisons of perinatal mortality rates from different countries are not reliable because of under-reporting of late fetal deaths and international differences in how late fetal death are defined in various countries. Judith Rooks. PS: I don't have time to respond to any more comments by Dr. Tuteur.

Of course, the claim about the unreliability of perinatal mortality is not true either. I replied:

Perinatal mortality is the international standard for measuring obstetric care because it is far more reliable than infant mortality. That's why the World Health Organization uses it for international comparisons. Perinatal mortality is measured the same way in every country; in contrast, each country has its own definition of infant mortality. For example, in the US, very premature babies who are born alive are registered as live births. If they dies, they are included in infant deaths. In the Netherlands, very premature babies who are alive are nonetheless registered as stillbirths. If they die, they are NOT included in infant deaths.

Here's what the World Health Organization says about its decision to use perinatal mortality as the international standard (http://www.who.int/making_pregnancy_safer/publications/neonatal.pdf):

"Neonatal deaths and stillbirths have many common causes and determinants. For the last 50 years, the term "perinatal mortality" has been used to include deaths that might somehow be attributed to obstetric events, such as stillbirths and neonatal deaths in the first week of life. This approach does not raise the question whether babies above a certain weight or gestational age (and thus showing some potential for survival) showed any signs of life at birth or not.

The perinatal mortality indicator plays an important role in providing the information needed to improve the health status of pregnant women, new mothers and newborns. That information allows decision-makers to identify problems, track temporal and geographical trends and disparities and assess changes in public health policy and practice."

The World Health Organization has set perinatal mortality as the international standard and believes that it is the correct statistic for international comparisons.

Obviously, I'm not expecting a response.

There are two possibilities here. Either Ms. Rooks does not understand perinatal mortality, infant mortality and public health statistics or she was trying to mislead lay people with information that she knows does not support her claims. I suspect the latter.

posted by Amy Tuteur, MD @ 10:04 PM