WARNING!!! If you have Aetna health insurance, you may want to change at the next opportunity, when your employer has their annual "open enrollment". Aetna doesn't cover homebirth, citing a single study based in rural Australia which shows that high-risk births far away from a hospital are high risk. They further cite the policies of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, both business competitors to homebirth providers. Their policy statement ignores a mountain of evidence that homebirth is as safe as or safer than hospital birth for normal, healthy pregnancies.. If their policymakers have any integrity, this logic will soon lead to cessation of coverage for planned VBAC's . . . there's no dearth of studies and AAP and ACOG policies proclaiming the danger of VBAC's . . . and then they'll stop coverage for any woman who declines standard ACOG/AAP recommendations regarding routine ultrasound, routine induction, routine IV's, routine use of continuous electronic fetal monitoring, routine administration of antibiotics for all GBS positive women (up to 40% of birthing women), and prompt cesareans for any woman who fails to progress in a timely fashion during labor and pushing. They may also stop coverage for children who are not vaccinated according to the full schedule of vaccinations recommended by the AAP, even though many intelligent parents decline the newborn hepatitis B vaccine and practice selective vaccination according to their child's own needs.
If this is troubling to you, as it should be, let them
know. You can easily send
e-mail
to
Aetna's
National Media Relations Contacts and simply tell them that
they should not be in the business of denying coverage for
reasonable healthcare choices, such as homebirth, waterbirth and
VBAC. They will especially want to know if you are choosing
another health insurance provider because of this unreasonable
policy. You might also suggest that they expand their
research beyond ACOG and AAP recommendations. They could Start Here.
Note to Hospital-Based Practitioners: In many of my conversations with hospital-based birth attendants, they'll inevitably recall labors where things went very bad very quickly. However, in asking more questions, it is almost always the case that dangerous hospital-only interventions were being used, e.g. intrapartum pitocin and/or anesthesia. Yes, artificially rupturing membranes can cause cord prolapse or rupture a velamentous insertion, and babies can crash very quickly after that. Yes, women with epidurals can have their blood pressure bottom out, and babies can crash very quickly after that. Yes, women on pitocin can experience uterine hyperstimulation, and babies can crash very quickly after that. Yes, babies born under the influence of narcotics may have a lot of trouble adjusting to breathing air, and they may require special drugs to reverse the effects of the narcotics. However, these dangerous procedures are not done at home, so these intervention-caused complications will not be seen at home. This is part of the reason why homebirth is safer than hospital birth.
Many hospital-based practitioners have never actually seen a
normal, physiological birth, where a woman is free to get into the
position that her body tells her is best for her baby, often
upright during much of labor, keeping baby off the cord, or
sometimes on hands and knees for pushing, helping to rotate baby
anterior to prevent shoulder dystocia. If you have no
experience with homebirth, then it's going to be very difficult to
imagine how homebirth can be safer. However, this leaves
exciting potential for you to learn much from these pages.
Enjoy!
By the way, midwives are prepared to handle emergencies.
Sometimes people assume that because we work in an out-of-hospital
environment that we eschew all things medical and
pharmaceutical. That would be irrational. Our goal is
to facilitate the safest possible birth. Safety starts with
avoiding problems, but we are still prepared to handle fetal
distress, shoulder dystocia, and postpartum hemorrhage. And
even though the hospital-based midwives you work with don't
resuscitate babies, they are thoroughly trained to do so. So
are we. Working at home without a neonatal team, we are the
ones who suction, ventilate, oxygenate and provide chest
compressions as necessary to help babies who need it. Just
imagine that YOU were going to set up a maternity clinic 500 miles
from the nearest operating room. What equipment and supplies
would you have with you? That's pretty much what we take to
homebirths, too.
Another confusing point for some hospital-based practitioners is
that they're not always sure about the difference between doulas
(who may help women labor at home for a while) and homebirth
midwives (who are professional birth attendants practicing in the
home). A doctor may have a conversation with a doula,
thinking he's talking with a midwife, and he may understand that
she does not have a deep clinical knowledge, and he may jump to
the conclusion that all midwives are uneducated. Ahhhh, human
nature!
Cochrane Collaboration Revises Homebirth Statement
(The Cochrane Collaboration is an international organization of
MDs who assess and summarize medical research.)
Planned
hospital birth versus planned home birth [12 SEP 2012] -
There is no strong evidence from
randomised trials to favour either planned hospital birth or
planned home birth for low-risk pregnant women. However,
the trials show that women living in areas where they are not well
informed about home birth may welcome ethically well-designed
trials that would ensure an informed choice. As the quality of
evidence in favour of home birth from observational studies seems
to be steadily increasing, it might be as important to prepare a
regularly updated systematic review including observational
studies . . .
Plain language summary
Most pregnancies among healthy women are normal, and most births
could take place without unnecessary medical intervention.
However, it is not possible to predict with certainty that
absolutely no complications will occur in the course of a birth.
Thus, in many countries it is believed that the safest option for
all women is to give birth at hospital. In a few countries it is
believed that as long as the woman is followed during pregnancy
and assisted by a midwife during birth, transfer between home and
hospital, if needed, is uncomplicated. In these countries home
birth is an integrated part of maternity care. It seems increasingly clear that
impatience and easy access to many medical procedures at
hospital may lead to increased levels of intervention which in
turn may lead to new interventions and finally to unnecessary
complications. In a planned home birth assisted by an
experienced midwife with collaborative medical back up in case
transfer should be necessary these drawbacks are avoided while
the benefit of access to medical intervention when needed is
maintained. Increasingly better observational studies
suggest that planned hospital birth is not any safer than planned
home birth assisted by an experienced midwife with collaborative
medical back up, but may lead to more interventions and more
complications. However, there is no strong evidence from
randomised trials to favour either planned hospital birth or
planned home birth for low-risk pregnant women. Only two very
small randomised trials have been performed. Only one trial
(involving 11 women) contributed data to the review. They did not
allow conclusions to be drawn except that women living in areas
where they are not well informed about home birth may
welcome ethically well-designed trials that would ensure an
informed choice.
These articles are written by Ronnie Falcao, LM MS CPM, the editor of the Midwife Archives and owner of gentlebirth.org
The
Home Birth Advantage: The Physical and Emotional Benefits of
Birthing at Home
Homebirth Benefits - Why Homebirth Is Most Appropriate for Normal Birth
Dangers
of Hospital Birth - Why Birthing in a Hospital Causes More
Problems Than It Solves for Normal Birth
The Birth Center in Your
Home - Modern midwives bring the safety of a birth center to
the safety and privacy of your home.
Introduction: The safety and effectiveness of birth center care
have been demonstrated in previous studies, including the National
Birth Center Study and the San Diego Birth Center Study. This
study examines outcomes of birth center care in the present
maternity care environment. Methods: This was a prospective cohort
study of women receiving care in 79 midwifery-led birth centers in
33 US states from 2007 to 2010. Data were entered into the
American Association of Birth Centers Uniform Data Set after
obtaining informed consent. Analysis was by intention to treat,
with descriptive statistics calculated for maternal and neonatal
outcomes for all women presenting to birth centers in labor
including those requiring transfer to hospital care. Results: Of
15,574 women who planned and were eligible for birth center birth
at the onset of labor, 84% gave birth at the birth center. Four
percent were transferred to a hospital prior to birth center
admission, and 12% were transferred in labor after admission.
Regardless of where they gave birth, 93% of women had a
spontaneous vaginal birth, 1% an assisted vaginal birth, and 6% a
cesarean birth. Of women giving birth in the birth center, 2.4%
required transfer postpartum, whereas 2.6% of newborns were
transferred after birth. Most transfers were nonemergent, with
1.9% of mothers or newborns requiring emergent transfer during
labor or after birth. There were no maternal deaths. The
intrapartum fetal mortality rate for women admitted to the birth
center in labor was 0.47/1000. The neonatal mortality rate was
0.40/1000 excluding anomalies. Discussion: This study demonstrates
the safety of the midwifery-led birth center model of
collaborative care as well as continued low obstetric intervention
rates, similar to previous studies of birth center care. These
findings are particularly remarkable in an era characterized by
increases in obstetric intervention and cesarean birth nationwide.
Some commentary on this study:
Consider
the Source: An Interview with Cara Osborne, SD, MSN, CNM,
co-author of The National Birth Center Study II [1/31/13] by
Amy Romano
New Study Shows Midwife-Led Birth Centers Improve Outcomes and Lower Health Care Costs [1/31/13] from the American Association of Birth Centers
Important New Research on Outcomes in Midwife-led Birth Centers -
not available online as of 2/3/13, but you can search for this key
paragraph:
What this study tells us - The study reported excellent outcomes, most notably a 6% cesarean rate, a 12% intrapartum transport rate, and very low rates of fetal and newborn deaths. This suggests that both Certified Professional Midwives and Certified Nurse-Midwives practicing in birth centers are providing competent, high-quality, low-intervention, cost-effective care to women and their newborns. Today, only about 0.3% of babies are born in midwife-led, freestanding birth centers, where the facility fee is about half that of hospitals. The study authors determined that over $30 million was saved in the costs of facility fees and potentially avoided cesareans by the 15,574 women who chose to deliver in these birth centers. Extrapolating this to the greater population would result in billions of dollars in savings every year if only 10% of babies were born in a midwife-led birth center.
The Short and Long term Dangers of
Hospital Birth for low risk women by Judy Slome Cohain, CNM
Wonder how ACOG will respond, as the CPSBC are hardly the folks
from a "cause celebre" that ACOG condescendingly asserts about
those interested in homebirth. The bibliography alone is
worth keeping handy.
Dr.
Stuart Fischbein's letter to ACOG protesting their opposition to
homebirth
From Medscape Ob/Gyn & Women's Health [02/25/2010]
Science and
Sensibility: Choice of Birth Place in the United States
Saraswathi Vedam, CNM, MSN, SciD(hc); Patricia A. Janssen, RN,
BSN, MPH, PhD; Ronnie Lichtman, CNM, PhD
The
Birth
Environment:
How
the place and people influence outcomes - excellent
slideshow from Penny Simkin.
Home Birth
- Excellent Patient Education from Kent Midwifery Practice in the
UK (Kay Hardie and Virginia Howes)
Dr Stuart
Fischbein, ob/gyn speaking on the benefits of midwifery care
and hands-poised physiological birth. Nine mins long.
Dr.
Mercola
writes
about
homebirth
Staying
Home
to
Give
Birth: Why Women in the United States Choose Home Birth
Debora Boucher, Catherine Bennett, Barbara McFarlin, Rixa Freeze
pages 119-126
Abstract | Full Text | Full-Text PDF (374 KB)
Staying Home to Give Birth: Why Women in the United States Choose
Home Birth
Journal of Midwifery & Womens Health
Volume 54 Issue 2. Pages 119-126 (March 2009)
Approximately 1% of American women give birth at home and face
substantial
obstacles when they make this choice. This study describes the
reasons that women in the United States choose home birth. A
qualitative descriptive secondary analysis was conducted in a
previously collected dataset obtained via an online survey. The
sample consisted of 160 women who were US residents and planned a
home birth at least once. Content analysis was used to study the
responses from women to one essay question: "Why did you choose
home birth?" Women who participated in the study were mostly
married (91%) and white (87%). The majority (62%) had a college
education. Our analysis revealed 508 separate statements about why
these women chose home birth. Responses were coded and categorized
into 26 common themes. The most common reasons given for wanting
to birth at home were: 1) safety (n = 38); 2) avoidance of
unnecessary medical interventions common in hospital births (n =
38); 3) previous negative hospital experience (n = 37); 4) more
control (n = 35); and 5) comfortable, familiar environment (n =
30). Another dominant
theme was women's trust in the birth process (n = 25). Women
equated medical intervention with reduced safety and trusted their
bodies' inherent ability to give birth without interference.
Who
is
a
Low-Risk
Woman? The NICE Guidelines (page 13) list risk
factors: "Table 1 Medical conditions indicating increased risk
suggesting planned birth at an obstetric unit"
Where's my midwife? is
a grassroots organization seeking to increase access to midwives
in hospitals, free-standing birth centers and at home through
education and advocacy.
Happy International Midwives Day
- a nice notice to celebrate the day - May 5.
Obstetricians in the United States continue to rely on
intellectual dishonesty to criticize homebirth and oppose
midwives. Their meta-analysis includes preterm births that
take moms by surprise so that they end up having an unplanned,
unassisted, homebirth.
Medscape showed their intellectual honesty and professional integrity by publishing this critique:
""... [I]t is incomprehensible that medical society opinion
can be formulated on research that does not hold to the most
basic standards of methodological rigor.
. . .
Despite the publication of statements and commentaries querying
the reliability of the findings,[2-6] this faulty study now forms
the evidentiary basis for an American College of Obstetricians and
Gynecologists Committee Opinion,[7] meaning that its results are
being presented to expectant parents as the state-of-the-art in
home birth safety research."
Planned
Home
vs
Hospital
Birth: A “Flawed Study” - This blog has a nice summary of
the dense article [from mamasonbedrest.com]
Epidemiologic
research
using administrative databases: garbage in, garbage out. [full
text]
Grimes DA.
Obstet Gynecol. 2010 Nov;116(5):1018-9.
"Using birth certificate information for epidemiologic analyses is inappropriate because of well-documented deficiencies in information quality.3"
"In recent decades, the computer science concept of “GIGO” (“garbage in, garbage out”) has somehow come to mean “garbage in, gospel out.”10"
"Trying to study obstetric and neonatal outcomes from data on birth certificates is analogous to trying to study the cause of motor vehicle accidents from data on drivers’ licenses (eg, sex, height, eye color, hair color). The information available is simply inadequate. When using administrative databases for epidemiologic research, if garbage goes in, garbage (not gospel) comes out."
Vital records, such as birth certificates, represent another
administrative database commonly used for epidemiologic research.
Again, these data are collected for civil and legal purposes, not
for research......
Epidemiologic analyses with birth certificate data are popular but
treacherous. This stems from the uneven quality of the data.
....
Using birth certificate information for epidemiologic analyses is
inappropriate because of well documented deficiencies in
information quality. .....
Sadly, no fancy statistical machinations can compensate for
poor-quality data.
Birth Sense
responds to the false implications from American OBs - The
investigators freely admit that planned home birth with a
certified birth attendant did not have any greater risks than
planned hospital birth.
MANA Press Release
about Meta-Analysis Regarding Home Birth in AJOG
ACNM Expresses Concerns Regarding Recent AJOG Publication on Home Birth - ACNM Press Release 7/7/10
It is important to note that the authors’ conclusion differs
significantly from findings of many recent high-quality studies on
home birth outcomes which found no significant differences in
perinatal outcomes between planned home and planned hospital
births. We therefore caution against over-interpretation of these
findings until there has been an in-depth review of this analysis
which we will be conducting. In the meantime, we express several
initial methodological concerns.
. . .
We are puzzled by the authors’ inclusion of older studies and
studies that have been discredited because they did not
sufficiently distinguish between planned and unplanned home births
— a critical factor in predicting outcomes.
New AJOG
Home Birth Study Political? from pushedbirth.com - Here’s
what’s particularly curious: Wax and coauthors acknowledge that
some of the included studies were not powered to report mortality
rates, and when they analyzed the data for mortality and excluded
those studies, they found “no significant differences between
planned home and planned hospital births,” to quote the study
verbatim. But this is not the study’s banner finding. Instead, the
authors include the very studies they had excluded and report as
their conclusion that “less medical intervention during planned
home birth is associated with a tripling of the neonatal mortality
rate.”
U.S. analysis on home birth risks seen as deeply flawed - doctor who produced some of the data calls the conclusion "sensationalist"
“We’re dealing with a politically motivated study,” said Dr.
Klein, who was a co-author with Dr. Janssen on the B.C. study.
A new
meta-analysis on the safety of home birth? by Amy Romano
International Expert Calls Study Deeply Flawed and Politically Motivated from thebigpushformidwives.org - 7/7/10
WASHINGTON, D.C. (July 7, 2010) – As New York and Massachusetts moved to pass pro-midwife bills in the final weeks of their legislative sessions, the American Journal of Obstetrics and Gynecology fast-tracked publicity surrounding the results of an anti-home birth study that is not scheduled for publication until September. Described as unscientific and politically motivated, the study draws conclusions about home birth that stand in direct contradiction to the large body of research establishing the safety of home birth for low-risk women whose babies are delivered by professional midwives.
“Many of the studies from which the author’s conclusions are
drawn are poor quality, out-of-date, and based on discredited
methodology. Garbage in, garbage out.” said Michael C. Klein, MD,
a University of British Columbia emeritus professor and senior
scientist at The Child and Family Research Institute. “The
conclusion that this study somehow confirms an increased risk for
home birth is pure fiction. In fact, the study is so deeply flawed
that the only real conclusion to draw is that the motive behind
its publication has more to do with politics than with science.”
Characteristics
of
planned
and
unplanned home births in 19 States.
Declercq E, Macdorman MF, Menacker F, Stotland N.
Obstet Gynecol. 2010 Jul;116(1):93-9.
OBJECTIVE: To estimate the differences in the characteristics of mothers having planned and unplanned home births that occurred at home in a 19-state reporting area in the United States in 2006.
METHODS: Data are from the 2006 U.S. vital statistics natality file. Information on whether a home birth was planned or unplanned was available from 19 states, representing 49% of all home births nationally. Data were examined by maternal age, race or ethnicity, education, marital status, live birth order, birthplace of mother, gestational age, prenatal care, smoking status, state, population of county of residence, and birth attendant. We could not identify planned home births that resulted in a transfer to the hospital.
RESULTS: Of the 11,787 home births with planning status recorded in the 19 states studied here, 9,810 (83.2%) were identified as planned home births. The proportion of all births that occurred at home that were planned varied from 54% to 98% across states. Unplanned home births are more likely to involve mothers who are non-white, younger, unmarried, foreign-born, smokers, not college-educated, and with no prenatal care. Unplanned home births are also more likely to be preterm and to be attended by someone who is neither a doctor nor a midwife and is listed as either "other" or "unknown."
CONCLUSION: Planned and unplanned home births differ
substantially in characteristics, and distinctions need to be
drawn between the two in subsequent analyses. LEVEL OF EVIDENCE:
III.
OB/GYN Journal Fast Tracks Anti-Home Birth Study in Advance of Pro-Midwife Legislation - International Expert Calls Study Deeply Flawed and Politically Motivated
“Many of the studies from which the author’s conclusions are
drawn are poor quality, out-of-date, and based on discredited
methodology. Garbage in, garbage out.” said Michael C. Klein, MD,
a University of British Columbia emeritus professor and senior
scientist at The Child and Family Research Institute. “The
conclusion that this study somehow confirms an increased risk for
home birth is pure fiction. In fact, the study is so deeply flawed
that the only real conclusion to draw is that the motive behind
its publication has more to do with politics than with science.”
New
Study
Identifies
Need
to Distinguish Planned from Unplanned Home Births - The
authors of a new study in the July 2010 issue of Obstetrics and
Gynecology found that in order for a successful analysis of home
birth to be conducted in the United States, a distinction needs to
be made between planned and unplanned home births. This study,
titled Characteristics of Planned and Unplanned Home Births in 19
States, by Eugene Declercq, PhD, Marian F. MacDorman, PhD, Fay
Menacker, DrPH, CPNP, and Naomi Stotland, MD has not received any
media coverage, while another home birth study scheduled to be
published in the American Journal of Obstetrics and Gynecology in
September 2010 has generated international attention.
"Home Birth
Triples the Neonatal Death Rate": Attention-Grabbing No Doubt,
But Uninformative
Andrew J. Vickers, PhD
This is worth reading for the thoughtful response, but it still assumes that all the underlying studies were valid, which is far off the mark. Personally, I don't care what the absolute numbers are. If I really believed that homebirth were more dangerous than hospital birth, I would work to make hospital birth as "homelike" as possible and stop practicing at home.
But the reality is that the underlying studies that were well done showed homebirth to be safer than hospital birth. It was only the underlying studies that included unattended homebirth that were able to show that it was more dangerous than hospital birth.
I am still waiting for the statistics comparing unattended
homebirth with unattended hospital birth.
Students of rhetoric will notice the attempt to establish that
there must be a tradeoff between maternal benefits and neonatal
benefits. This is not true. Midwifery provides care
for the mother-baby dyad and optimizes outcomes for both.
letter to editor from Patti Jansen:
American Journal of Obstetrics and Gynecology
Re: Wax J, Pinette M, Cartin A, Blackstone J. Maternal and newborn
morbidity by birth facility among selected United States 2006
low-risk births.
February 2010, Vol 202, Issue 2 152e1-152e5.
Standards for Validity in Home Birth Research
To the Editors:
The recent paper comparing maternal and newborn morbidity among
births at home, hospital and in birth centers by Wax et al,
reported that babies born at home more frequently experienced 5
minute Apgar scores below 7.1 The methodology employed brings into
question the validity of this conclusion.
This retrospective study utilized 2006 US Standard Certificates of
Live Birth, used by 19 states in the US. To establish a low
obstetrical risk population, multiple exclusions were applied to
the data with the result that only 36.0% (745, 690/2,073,368) of
women in participating states were included. Inclusion of only
slightly more than one third of the potentially eligible
population raises questions about the ability of birth
certificates to identify women at low risk and consequently the
generalizability of study findings.
Secondly, ascertainment of the type of birth attendant is missing
for 4801 women or 0.6% of the sample. It is possible that at least
some of these births were unattended. If this indeed the case,
then these births, which would be expected to have high rates of
suboptimal outcomes, might be over-represented in the home birth
group, where the attendants are less likely to arrive on time for
a precipitous birth. In addition, some women may have deliberately
chosen to have an unattended birth and these would of course take
place outside of a hospital or birth centre.
Since only 75% of the births studies were recorded as attended by
a physician or midwife, fully one quarter may have been unplanned
home births.
Unplanned home births are well known to be at higher risk for
adverse outcomes.
Lastly, the authors acknowledge that births for which complications necessitated transfer to hospital are attributed to hospital rather than to home or birth centre births. In contrast to the above biases, this bias would favor home births. They also acknowledge that perinatal mortality is not measured, which eliminates deaths occurring during labour.
In view of these serous flaws, the statement that this study provides a ³robust evaluation of maternal and newborn outcomes that is generalizable and reflects actual practice² cannot be supported. Without internal validity, placed in question by missing data and the inability to attribute births to planned place of birth, the issue of external validity or generalizability is irrelevant. Recent studies in Canada2, 3 and the Netherlands4 have used population-based perinatal databases with mandated participation by midwives and documentation of intended place of birth and attendant, as well as relevant outcomes including intrapartum fetal death.
American studies of place of birth must meet this standard in order to draw valid conclusions and allow international comparisons.
1. Wax J, Pinette M, Cartin A, Blackstone D. Maternal and newborn
morbidity by birth facility among selected United States 2006
low-risk births. Am J Obstet Gynecol. 2009;202(2):152e151-e155.
2. Janssen P, Saxell L, Page L, Klein M, LIston R, Lee S.
Outcomes of planned home birth with registered midwife versus
planned hospital birth with midwife or physician. Can Med Assoc J.
2009;181:277-383.
3. Hutton K, Reitsma A, Kaufman K. Outcomes associated with
planned home and planned hospital births in low-risk women
attended by midwives in Ontario, Canada, 2003-2006: A
retrospective cohort study. BIRTH.
2009;36(3):180-189.
4. de Jonge A, van der Goes B, Ravelli A, et al. Perinatal
mortality and morbidity in a nationalwide cohort of 529, 688
low-risk planned home and hospital births. BJOG.
2009;116:1177-1184.
I've seen this before. Instead of comparing apples to apples
(e.g. homebirths in the US or UK to hospital births in those
countries), they cherrypick the data to include countries where
"homebirth" is done by lay midwives who often have no medical
training at all, carry no O2, and are located in very remote
areas.
Limitations of Meta-Analyses from Improving Medical Statistics and the Interpretation of Clinical Trials
"A meta-analysis is particularly subject to biased conclusions
when it is created by advocates of a controversial opinion
regarding the same topic the meta-analysis is addressing."
Dear Editor, Regarding : NY Times article entitled: Why is
American Home Birth So Dangerous by AMY TUTEUR :
The author of this NYT article, Amy Tuteur, has a website, THE
SKEPTICAL OB, in which she misrepresents herself as an OB. The
only medicine she is licensed to practice is the armchair variety.
Her brief self proclaimed position decades ago as a clinical OB
instructor at Harvard Medical School, deserves confirmation. If it
is true, the reasons for her dismissal would be fascinating to
learn.
Knowledge of actual maternal mortality rates before 1900 are hard
to come by. What is well documented is that on Pubmed.com there is
no documentation of even one maternal death at an attended home
birth in the presence of a trained midwife anywhere in the world
in the last 40 years. Martha Ballard, in her diary 1785-1812,
documented zero maternal mortality at birth, among 812 consecutive
home births. The doctor Moses Ben Maimonides in 1100 documented
fewer than 1 in 1000 women die in childbirth in Egypt. Today, at
US hospital births there are 1 in 5000 avoidable maternal deaths
at the time of childbirth. (About 1 in 3000 die from bleeding or
anesthesia complications at avoidable cesareans and 1 in 15,000 as
a result of amniotic fluid embolism caused by induction and
artificial rupture of membranes.) A woman who is healthy enough to
have a baby, is healthy enough to survive childbirth if no one
hospitalizes her, induces her, breaks her water or cuts open her
abdomen. A myth was started with the imaginary death of the
biblical Rachel. The NYTimes builds on this biblical myth by
publishing Amy Tuteur's writings. There is reliable medical
documentation showing that routine hospital birth is not a cause
of improved outcomes as Amy Tuteur implies.
I encourage all investigative reporters to investigate Amy Tuteur
In Canada, it is not unusual for the same midwife to attend births in the home as well as in the hospital, so you can eliminate qualification biases in the research. This study compared the safety of homebirth with the safety of hospital births attended by the same midwives. HURRAY for truly useful research!
"The new Canadian study compares outcomes for planned midwife-attended home births, planned midwife-attended hospital births (with the same cohort of midwives), and planned physician-attended hospital births. The women in all three groups all met the requirements to be eligible for a home birth, so the study groups are as comparable as possible.
The study used data from one health region in British Columbia.
Canadian midwives practice in both home and hospital settings,
which allowed a comparison of midwife-attended home and midwife
attended hospital birth where ONLY the setting was different.
"
Home
birth
with
midwife
as safe as hospital birth [8/31/09]
Giving birth at home with a midwife present is as safe as a
hospital delivery accompanied by a doctor, suggests a new Canadian
study, which found home births were associated with fewer adverse
outcomes for both mother and baby.
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician [Full Text]
Results: The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife- attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09–1.85).
Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
Meanwhile, instead of acknowledging actual research already done,
ACOG is collecting "anecdotes", which are individual stories taken
out of context with no containing statistics and nothing to
compare with. If your OB/GYN is a member of ACOG, let them
know that you'd like them to write a letter to ACOG.
Instead of trying to badmouth their competition, why don't they
keep their own house in order and collect stories about mothers
and babies who are killed by aggressive treatments (Cytotec,
decapitation with vacuum extractors) or by hospital infections?
Outcomes of
planned home birth with registered midwife versus planned
hospital birth with midwife or physician.
Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK.
CMAJ. 2009 Sep 15;181(6-7):377-83
Home
Birth
With
Midwife
As Safe As Hospital Birth: Study - Canadian researchers find
lower rate of complications [from U.S.News and World Report.]
A new
era of home birth research - August 31st, 2009
by Amy Romano
For a great analysis of the new Canadian home birth study, go to www.scienceandsensibility.org.
You might want to sign up to receive notice of posts on this great
Lamaze-sponsored blog.
Perinatal
mortality and morbidity in a nationwide cohort of 529,688
low-risk planned home and hospital births. [full
text]
de Jonge A, van der Goes BY, Ravelli AC, Amelink-Verburg MP, Mol
BW, Nijhuis JG, Bennebroek Gravenhorst J, Buitendijk SE.
BJOG. 2009 Aug;116(9):1177-84.
CONCLUSIONS: This study shows that planning a home birth does not
increase the risks of perinatal mortality and severe perinatal
morbidity among low-risk women, provided the maternity care system
facilitates this choice through the availability of well-trained
midwives and through a good transportation and referral system.
In this large cohort study, planned home birth in a low-risk population was not associated with higher perinatal mortality rates or an increased risk of admission to a NICU compared to planned hospital birth after controlling for maternal characteristics. Although various factors, such as primiparity and age over 35, were associated with higher rates of adverse perinatal outcomes, no interaction effects were found between these factors and planned place of birth.
This study has some major strengths. As far as we know, this is
the largest study into the safety of home birth. Its large sample
size provided the power to detect differences in rare adverse
outcomes.
Finally, ACOG is showing signs that they are floundering and will soon founder under the weight of their own pomposity.
After the 2009 Canadian study came out, ACOG did something very strange. Instead of acknowledging actual, scientific research already done, ACOG started collecting "anecdotes", which are individual stories taken out of context with no containing statistics and nothing to compare with. (If your OB/GYN is a member of ACOG, let them know that you'd like them to write a letter to ACOG expressing their concern about ACOG's lack of scientific rigor on this subject.)
ACOG requests unsourced anecdotal home birth "data"
Instead of trying to badmouth their competition, why don't they keep their own house in order and collect stories about mothers and babies who are killed by aggressive treatments (Cytotec, decapitation with vacuum extractors) or by hospital infections? Apparently the need for large numbers disappears when they are the ones collecting the data. Really . . . anecdotes? As doctors say about any studies that show homebirth to be safe, they like to say that the studies weren't large enough. Problems are infrequent in childbirth, no matter where it takes place, so only "really large numbers" could reveal whether the home truly is as safe as the hospital, says Tracy, an OB/GYN at Boston's Massachusetts General Hospital. So I guess they'll solve the problem by trying to collect just the stories where problems occurred in a case where the woman was even thinking about a homebirth. Honestly, I've heard of OBs who have blamed Down Syndrome on a homebirth. Sheesh!
Meanwhile, on Sept. 11, 2009, The Today Show ran a segment called "The Perils of Home Births", in which they aired the opinions of OBs that homebirths are dangerous. No studies were cited, no midwives were interviewed. We just saw doctors who had strong opinions about homebirth, and reporters who parroted what the doctors said. Apparently not one of them knows how to use the internet to find actual scientific studies about the safety of homebirth.
They quoted a doctor as saying, "homebirth had become almost the equivalent of a spa treatment for women, that it was this sort of hedonistic concept of birthing."
The ACOG rep. quoted in the segment points out that if an emergency arises and we can't intervene within minutes, the life of the mother and the life of the baby could be endangered. She appears not to understand that midwives are trained and equipped to handle these emergencies or to get to the hospital for brewing problems. And she has no concept of the additional dangers that are introduced at the hospital.
In a stunning display of ignorance about homebirth safety, Erin Tracy, ACOG's delegate to the AMA, is quoted in USA TODAY [9/13/09] as saying, "low-risk pregnancies can become high-risk in minutes: A baby's shoulder might get stuck in the birth canal, or heavy bleeding could necessitate a blood transfusion for the mother." She actually chooses a really poor example when she cites shoulder dystocia, the situation when the baby's shoulder gets stuck. The remedies for shoulder dystocia are non-surgical . . . there is nothing that an OB can do for this in the hospital that a midwife cannot do at home. In fact, because women at home are unmedicated, they can change positions more easily, getting on hands and knees (the Gaskin maneuver), which is the solution for shoulder dystocia which is least likely to cause a serious tear in the woman's perineal tissues. And there is nothing magical about the hospital building to prevent too much bleeding after the birth. Many midwives employ techniques (delayed clamping of the cord) which appear to reduce maternal bleeding. And if the mother does bleed too much, they can use the same anti-hemorrhagic pharmaceutical medications as are used in the hospital.
Doctors say it's impossible to compare home and hospital because hospitals deal with so many more high-risk cases. Apparently, both the reporters and the doctors interviewed missed or forgot the 2009 Canadian safety study of midwives who practice in both the home and the hospital, and with matched population comparisons between midwife and OB for low-risk women.
You can read this excellent response from wheresmymidwife.org
Numerous birth advocacy organizations signed on to the excellent CIMS Letter to the Today Show. There are 16 references at the bottom.
By the way, if you enjoy irony, you'll particularly enjoy the end of the TODAY show piece, where the OB suggests questions to ask the midwife:
Does the midwife have malpractice insurance?
Does she have physician backup?
In the United States, the answer to this question is mostly going to be no because the MD-controlled malpractice insurance companies refuse to offer malpractice insurance to homebirth midwives. And the very same MD-controlled malpractice insurance companies do not allow physicians to backup homebirth midwives.
Given the level of hostility that ACOG and the AMA routinely
display towards midwives, it is beyond ludicrous that MDs are
still the ones regulating the licenses of homebirth midwives in
California.
The Cochrane Collaboration's international OB/GYN committee writes, "The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence." (See http://www.cochrane.org/reviews/en/ab000352.html) Recent studies such as the 2005 BMJ Retrospective North American Study and the 2009 Canadian "Same Midwife" and Matched Population Study duplicate results of historical comparisons of homebirth safety with hospital birth. The findings: home is as safe or safer than hospital, but women and baby experience more trauma in the hospital. When is ACOG going to learn to read the research? Erin Tracy, ACOG's delegate to the AMA, is quoted in USA TODAY [9/13/09] as saying, "low-risk pregnancies can become high-risk in minutes: A baby's shoulder might get stuck in the birth canal, or heavy bleeding could necessitate a blood transfusion for the mother." She actually chooses a really poor example when she cites shoulder dystocia, the situation when the baby's shoulder gets stuck. The remedies for shoulder dystocia are non-surgical . . . there is nothing that an OB can do for this in the hospital that a midwife cannot do at home. In fact, because women at home are unmedicated, they can change positions more easily, getting on hands and knees (the Gaskin maneuver), which is the solution for shoulder dystocia that is least likely to harm the woman or baby. And there is nothing magical about the hospital building to prevent too much bleeding after the birth. Many midwives employ techniques which appear to reduce maternal bleeding. And if the mother does bleed too much, they can use the same anti-hemorrhagic pharmaceutical medications as are used in the hospital, while transporting to the hospital if long-term, surgical remedies are necessary. Why is home safer than the hospital? Reduced maternal stress supports reduced fetal distress, and you can't get hospital-acquired infections in the home! For much more information, see http://www.gentlebirth.org/archives/homsafty.html
Little do they realize that every time they come out on some high-profile TV show to badmouth midwives and homebirths, I get an onslaught of phone calls from women who say they didn't know that there were still midwives out there and that women could still have their babies at home. I guess it's true that there's no such thing as bad publicity; all publicity is good publicity!
Keep up the good work, ACOG!
And if you want to enjoy a lot of chuckles, thanks to ACOG, check
out My OB said WHAT?!? -
read and contribute to this hilarious web page.
In the past, Medscape has been reliable for sharing good, unbiased information. I'm not sure why this has changed so drastically around the issue of homebirth, other than that ACOG and the AMA appear to be on the warpath against homebirth and midwifery.
In response to the article, "Home Birth Gone Awry":
The author describes a direct-entry midwife as a midwife who enters the profession of midwifery directly without earning a nursing degree, implying that this represents a lack of beneficial training. Yet this is just like a "direct entry" obstetrician, who enters the profession of obstetrics directly without earning a nursing degree. Are you concerned about their lack of appropriate skills and training because they specialized in medicine and obstetrics without first studying nursing?
A more accurate and less-biased definition of a direct-entry midwife is that she is a mid-level healthcare practitioner specializing in midwifery. Anyone who knows the kind of care that is provided at a homebirth by direct-entry midwives knows that there is plenty of nursing care provided. California Licensed Midwives are almost all direct-entry midwives, and we are trained and licensed to perform all of the nursing skills of a maternity/newborn nurse in addition to all the skills of a CNM, including IV and catheter insertion, although these are typically not necessary.
One significant difference between direct-entry midwives and CNMs is that we're typically trained in an out-of-hospital setting, where we also do the newborn resuscitation and provide newborn care as well as maternity care, both as the primary healthcare provider and as the nurse. So, you see, the joke is that direct-entry midwives who specialize as midwives without studying nursing as a separate specialty actually do lots more nursing than Certified-Nurse-Midwives. The world's a funny place sometimes. And, of course, CNMs are midwives who typically aren't skilled in newborn resuscitation and newborn care, which are considered essential midwifery skills in most of the world. And the same could be said of OBs.
So you could state that CNMs are nurses who are also primary birth attendents without specializing in newborn resuscitation or normal newborn care and that OBs are surgical specialists with little or no training in normal birth.
It seems kind of silly for ACOG to complain about a "lack of collaborative work with hospital-based providers" when they actively reject and alienate direct-entry midwives. In general, direct-entry midwives are specialists in out-of-hospital birth and more qualified to attend unmedicated births than OBs and CNMs, who are trained in medicated and interventive births.
It would have been helpful if you had pointed out that the Washington State Study was not well designed. In fact, it wasn't really designed as all, as it was a retrospective statistical analysis of records in a state that does not distinguish between unassisted homebirths and homebirths attended by a trained professional. If you want to compare unassisted homebirths with unassisted hospital births, I would be happy to refer you to a local mother whose baby was born at our local hospital without anybody assisting her because nobody was paying attention to her. She happened to be standing at the time, so the baby simply fell to the floor, snapping the umbilical cord. Thank goodness, the baby is still alive and is believed not to have suffered permanent damage from the lack of proper care.
Or if you would like a well-documented and publicized case of an under-assisted birth in the hospital, I refer you to the very sad case at Beth Israel where a baby died because of communicatoin problems among the staff.
It is truly specious of ACOG to support free-standing birth centers as being somehow safer than a homebirth. In my practice, a homebirth is simply a birth center birth where I take all the birth center equipment to their home. A birth center building does not offer any special safety, in and of itself. And there is no kind of equipment in a free-standing birth center that I cannot take into a home.
This article also missed a very important point regarding the clientele who choose homebirth. There are large homebirth communities among the religious communities in the Pennsylvania and Ohio areas--the Amish and Mennonite. I would assume that most of the breech births occurred among those populations, as most DEMs I know refer breech to hospital-based providers, who then tell them they must have a c-section because they (the OBs) don't have the good breech skills of the European OB communities. (This policy is devastating to the religious communities who plan on large families, where a c-section has drastic effects on their childbearing plans.) It is intellectualy dishonest to avoid this issue if you're aware of it. The Amish and Mennonite communities will typically stay at home to have their babies, whether or not a midwife will serve them. Statistically, we would expect more of the breech babies to have died if there had not been a midwife present to assist. Those midwives deserve respect for their willingness to learn the skills necessary for responsible attendance of breech births and to use those skills in the service of these religious communities.
And these same populations typically decline ultrasound screening, as they would not consider terminating a pregnancy under any circumstances. Thus they are going to have higher neontal mortality rates, as the babies born with anomalies incompatible with life will die at a homebirth just as they would have died at a hospital birth.
The article shines in the discussion of the importance of facilitating a rapid transfer of care to a hospital-based provider when necessary. Thank you for this.
The concluding paragraph is very touching, but it perpetuates that myth that women who choose hospital births will always have good outcomes. It denies the reality that there are babies who are born healthy in the hospital and then die from a hospital-acquired infection. It denies the reality that hospital interventions sometimes kill babies. (Do you need references regarding the babies who have been decapitated from overly aggressive use of vacuum extractors?) It denies the reality that seemingly unavoidable hospital procedures that routinely separate mothers and babies result in breastfeeding failure, which accounts for 20% of infant mortality.
Ronnie Falcao, LM MS
***************************************
Note that Medscape also highlighted the Malloy article.
For a more thorough discussion of overall homebirth safety and hospital dangers, please see:
Homebirth Benefits - Why Homebirth Is Most Appropriate for Normal Birth by Ronnie Falcao, LM MS
Dangers
of Hospital Birth - Why Birthing in a Hospital Causes More
Problems Than It Solves for Normal Birth by Ronnie Falcao,
LM MS
This study is not to be confused with the Australian
Outback Study, which showed that twin and breech births are
safer when done with reasonable access to surgical facilities, as
opposed to remote locations in the Australian outback, multiple
hours away from a surgical facility.
Planned
home
and hospital births in South Australia, 1991-2006: differences
in outcomes. [full
text]
Kennare RM, Keirse MJ, Tucker GR, Chan AC.
Med J Aust. 2010 Jan 18;192(2):76-80.
Epidemiology Branch, SA Health, Adelaide, SA, Australia.
marc.keirse@flinders.edu.au.
[from Susan Hodges at Citizens for Midwifery]
A new home birth study based on data from South Australia has just been published. Of course, an editorial on the topic in the same issue of the journal, penned by the President of the Australian Medical Association (“which is opposed to home birth in Australia”) helped to “spin” the findings to show that home birth is much more dangerous than hospital birth, even though the actual data show no such thing.
You can read the whole article at < http://www.mja.com.au/public/issues/192_02_180110/ken10465_fm.html > : “Planned home and hospital births in South Australia, 1991-2006: differences in outcomes” (Robyn Kennare, Marc Keirse, Graeme Tucker and Annabelle Chan, MJA 192(2), 18 January 2009).
You can also find some great analysis of what the study actually tells us. If you are interested in reading research critically and understanding how data and results can be twisted (on purpose or by not thinking about what they mean), these analyses are worth your time:
“That Homebirth Study in South Australia”
by Lauredhel on January 16, 2010
< http://hoydenabouttown.com/20100116.7157/that-homebirth-study-in-south-australia/
>
“More critique of the homebirth study and its reporting by the
media"
January 20, 2010 – 7:58 pm, by Croakey
< http://blogs.crikey.com.au/croakey/2010/01/20/more-critique-of-the-homebirth-study-and-its-reporting-by-the-media/
>
You can be sure that US medical organizations, especially ACOG,
are well aware of this study, and the chances are we’ll see and
hear references to it in the weeks and months ahead; we can be
prepared!
The AMA wants to make birth centers illegal, along with
homebirths, even though hospital births are causing more mothers and babies to die and suffer
lifelong injury.
Ricki
Lake
Attacked
by
the AMA
Well, all I can say is that they're getting really desperate, and
they apparently have very little respect for the intelligence of
American women. I don't think they've realized that the
world has changed with the invention of the Internet. Women
can now access PubMed and read BMJ articles, and they can easily
discover that ACOG continues to attack midwives and homebirth
without any evidence to support them. Sigh.
Fortunately, this is one old-boys' network that is dying a quick
death.
The Authorities Resolve Against Home Birth from JOGNN by Nancy K. Lowe, published in the recent Journal of Obstetric, Gynecologic, Neonatal Nursing, the official journal of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
‘‘Whereas, there has been much attention in the media by
celebrities having home deliveries, with recent ‘Today Show’
headings such as ‘Ricki Lake takes on baby birthing industry.’’’
The
heat
gets
turned
up..on home birth - response from the Lamaze Institute for
Normal Birth.
Big
Medicine's
blowback
on
home births - Why do U.S. doctors strong-arm women into our
standard maternity care system? By Jennifer Block
President’s
Editorial:
Doctors
Ignore
Evidence, AMA Seeks to Deny Women Choices in Childbirth from
The Midwives Alliance of North America; this includes excellent
information as well as references.
Read more about the ACOG 2008 Press Release from The
Big
Push
for
Midwives and Childbirth
Connections
Midwives Remain
Committed to Women’s Birth Choices, Despite AMA Resolution that
Aims to Restrict Them from The Maine Association of
Certified Professional Midwives
The American College of Nurse Midwives has responded to recent AMA Resolutions (regarding home birth and regarding doctor supervision of midwives) with a letter to the AMA and addenda. While these are understandably written from ACNM’s viewpoint and interests in the CNM and CM credentials, overall the documents are excellent, and do a good job of affirming home birth and pointing out the outrageousness of ACOG/AMA behavior regarding these issues. The addenda are organized by topic and the statements are well-documented. In my opinion the ACNM has done an outstanding job of refuting all the main issues raised by the AMA’s Resolutions, especially the anti-home birth resolution 205 (see Grassroots messages 806032, 806033, 806037 and 807038). The addenda in particular should prove to be excellent resources (including all the references) for supporting the option of planned home birth.
You can read (and download) these documents at:
http://www.midwife.org/siteFiles/policy/ACNM_Letter_to_AMA.pdf
http://www.midwife.org/siteFiles/policy/ACNM_Letter_to_AMA_addenda.pdf
Parenting
Group
Denounces
AMA
Resolution Against Homebirth: Members of the Holistic Moms
Network Say Homebirth is a Safe Choice And Must Remain a Legal
Right from the Holistic Moms Network
Physician
Group Seeks to Outlaw Home Birth—Is Jail for Moms Next? -
from th International Chiropractic Pediatric Association in
collaboration with the Holistic Pediatric Association.
Maria
Iorillo's Response - Her blog is great reading anyway!
Midwife-Attended Home Births Less Safe Than In-Hospital Deliveries By Jill Stein
"The risk of neonatal mortality among infants delivered by a certified nurse midwife (CNMW) in the home is considerably greater than among in-hospital CNMW deliveries, according to data released here at Pediatric Academic Societies (PAS) 2009."
Actually, this "study" shows a deep lack of understanding about
what statistics show.
This "study" isn't overtly connected with the ACOG attack on
homebirth, but the study author has a clear bias towards
MDs: "As for why in-hospital deliveries by certified nurse
midwives had a lower risk of mortality in his study than
in-hospital physician deliveries, Malloy said he assumes it's
because physicians are delivering babies at higher risk."
Malloy is apparently able to understand that the different
categories have different kinds of risks, but he is unable to
extend this thinking to the homebirthing demographics. He
completely ignores a well-known fact: Neonatal mortality in the
United States is falling overall because most babies with
anomalies incompatible with life are terminated during the
pregnancy and so never get to be born or counted as a neonatal
fatality . . . AND . . . this does not apply to religious groups
who oppose abortion and often, as it happens, also choose
homebirth.
At least he had the intellectual honesty to admit that he was just talking about his assumptions here, because he actually made quite a few different assumptions. For example, he assumed that the pool of women choosing to birth at home with a CNM started out with the same risk factors as the women choosing to birth in the hospital with a CNM. This is nothing more than an assumption. In fact, we know that many of the homebirth populations (Amish, Mennonite) decline prenatal ultrasound and specifically refuse to terminate a pregnancy that might result in the baby's death. If these same women chose to birth in the hospital, they would probably be risked out of the midwife practice and would end up in the pool of higher-risk women with higher mortality rates attended by OBs. It's also important to think about the fact that a study of Licensed Midwives attending homebirth showed homebirth to be safer than hospital birth. Is it possible that CNMs are safer in the hospital because they are trained in the hospital, and Licensed Midwives are safer at home because they are trained in out-of-hospital birth? These are important issues that aren't addressed by Dr. Malloy's opinion piece.
Safety of midwife-attended home births questioned
I poked around a little bit online and found this related article in PubMed:
Current issues
in Texas neonatology.
Escobedo MB, Malloy MH, Jesurun CA, Denson SE, Koops BL, Jarriel
WS, Hansen TN.
Tex Med. 1994 Jun;90(6):64-9.
"Since almost 10% of the births in the United States occur in Texas, issues that affect neonatal care in Texas are important for both the state and the nation. Although overall statistics are similar for the state and nation, closer examination reveals a need for improvement in specific areas, namely prenatal care, black and Hispanic mortality, and low birth-weight rates. Lay midwifery regulation has been an important concern in Texas."
I think this may be another factor in the difference found in Dr. Malloy's study: there are higher mortality rates among black and Hispanic populations in Texas, and these are the same populations that are more likely to use real lay midwives, i.e. the curanderas of the immigrant Hispanic population.
Apparently, Dr. Malloy also has a long-standing issue with homebirth and "lay midwifery". Right away, the phrase "lay midwifery" instead of "direct entry midwifery" belies a bias towards tight control by the medical establishment. A "lay midwife" has no formal training. A "direct-entry midwife" has formal training in the midwifery model instead of in the medical model; this is what puts a bee in the bonnet of MD-centric healthcare providers.
Dr. Malloy's "research" is a shining example of why reputable research must look at matched populations, such as the 2009 Canadian Same Provider / Matched Population Study, 2005 BMJ homebirth safety study.
"Overall, the results demonstrate that the safest setting for a delivery is in hospital attended by a certified nurse midwife. Women who decide to deliver in the home "need to recognize the greater risk associated with that choice," Malloy said." [Ed. I do appreciate good strategy, and the divide-and-conquer approach to midwives might have worked before ACOG showed their true colors about midwives in general.]
Can anybody guess why Dr. Malloy doesn't continue with "Women who
decide to deliver with an MD need to recognize the greater risk
associated with that choice."
Do you feel comfortable with the idea of giving birth at your local hospital with a midwife attending the birth?
Do you feel comfortable with the idea of giving birth at your local hospital with a family practice doctor attending the birth?
Do you feel comfortable with the idea of giving birth at your local free-standing birth center?
Do you feel comfortable with the idea of giving birth at home, attended by a qualified birth attendant?
Homebirth with a well-trained and equipped midwife is safer than every one of the other options listed above.
Family practice doctors and midwives working in hospitals and free-standing birth centers typically attend the births without the immediate presence of their backup obstetrician. Years of experience have confirmed that birth emergencies requiring cesarean birth tend to develop slowly and that there is a safety margin of 75 minutes between the signs of a serious development requiring a cesarean and the actual cesarean birth. I have seen obstetricians taking their time even with placental abruptions because the safety margin is so generous.
Midwives and family practice doctors are trained to handle the emergencies that may occur within a few minutes of the birth, i.e. shoulder dystocia, postpartum hemorrhage, placental problems. And, in fact, every one of these emergencies occurs at a time when cesarean section is no longer an option.
Homebirth midwives are further trained also to perform neonatal resuscitation as necessary. In the most extreme case, they can continue to perform resuscitation measures while a baby is transported to the hospital, where these functions can be taken over by mechanical ventilators.
So, women giving birth at home have the same safety net as all the above scenarios. In addition, they are not exposed to antibiotic-resistant and hospital-acquired infections, which can be so deadly to newborns because of their immature immune systems.
[NOTE - The one exception to the above is a situation where a baby who is experiencing fetal distress has passed meconium, in which case the baby is better off born at the hospital, where a special intubation team can be waiting in case the baby is not vigorous at birth. For this reason, I personally transport such clients to the hospital in time for the birth so that the baby's lungs can be washed out immediately after the birth. The likelihood of this is well below the likelihood that the baby will become sick from a hospital-acquired infection.]
Homebirth is also safer than giving birth at your local hospital
with an obstetrician, but this is more difficult to understand
intuitively. However, most women intuitively understand that
it is better NOT to have someone cut their perineum with a
scissors!
In England, they have a national healthcare system which values the health of a child throughout the child's entire lifetime. They understand the additional benefits of homebirth that might not show up in a birth-focused study. For example, they understand that babies born at home are more likely to breastfeed better and for many months longer than babies born in the hospital. They understand that babies born at home are not going to be colonized with hospital germs such as antibiotic-resistant infections. They understand that a mother who is happy and proud of her birth experience is going to be a happier mother and will have happier children. All of this is good for their health as well as their happiness.
Here's an excerpt from the British Joint statement No. 2, April, 2007 on Home Births:
"The Royal College of Midwives (RCM) and the Royal College of
Obstetricians and Gynaecologists (RCOG) support home birth for
women with uncomplicated pregnancies. There is no reason why
home birth should not be offered to women at low risk of
complications and it may confer considerable benefits for them and
their families. There is ample evidence showing that labouring at
home increases a woman's likelihood of a birth that is both
satisfying and safe, with implications for her health and that of
her baby."
Fact Sheet Summary of the New Landmark Study Showing that Planned Home Births Are Safe
Outcomes
of
planned
home
births with certified professional midwives: large prospective
study in North America [Full-text
article]
Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss,
project manager
BMJ. 2005 Jun 18;330(7505):1416.
Conclusions: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States. [NOTE - CPMs are equivalent to Licensed Midwives in some states.]
Answers to Questions About “Outcomes of planned home births with certified professional midwives: large prospective study in North America” from the authors, Kenneth C. Johnson, Betty-Anne Daviss
Understanding
Birth Better addresses the concerns Dr. Amy has written
about.
Here are press releases from midwifery organizations:
Landmark Study Reports Planned Home Births Are Safe from Citizens for Midwifery; they also published another overview and the BMJ press release.
And some OB/GYN newsletters:
Home superior to hospital birth - "Among low-risk women, home births assisted by certified midwives achieve similar rates of intrapartum and neonatal mortality as hospital births, with lower rates of medical intervention, reveal Canadian researchers." [from obgynworld.com]
Here's the popular press on the homebirth safety study:
Home birth safe for low-risk pregnancies from Reuter
Giving Birth at Home Is Safe, Study Show from foxnews.com or another version from WebMD. This one happens to quote Ronnie Falcao, LM, MS, the non-nurse editor of these web pages, who has also written her own comments about the article.
Bringing Out Baby ... at Home - Home Delivery also from WebMD - "You're bringing a baby into a home full of love rather than a hospital full of germs."
On Reuter's website: “Home birth as safe as hospital delivery for low-risk pregnancies”
On Fox News website: “Giving Birth at Home Is Safe, Study Shows”
On MSNBC website: “Home births Safe for low-risk women”
On CNN website MedPage: “Study: Low-risk home births safe”
On the CBC.CA (Canadian) Betty-Anne was on the national
television news Friday, the 17th:
”Home births safe for low-risk pregnancies: North American
study” and if you look to the right of this article, the video
clip is available, a story of Barbara Scrivers, Alberta midwife,
in her practice and Betty-Anne as co-author of the study
explaining its importance. You can go to
http://www.cbc.ca/story/science/national/2005/06/16/midwives050616.html
and if you go to the story to the right of the written story,
click on the video by Terry Reith.
In the Boston Globe: “Home Births as safe as hospital
deliveries for low-risk mothers”
In the Washington Post: “Home Births”
On Yahoo! News: “Home Birth safe for low-risk pregnancies”
On Forbes: “Childbirth at Home as Safe as Hospital Delivery: Study”
On KOMO 4 News & ABC News: “Midwives a Safe Alternative to
Hospital
Births, Study Finds”
On eMediaWire: “Study Shows Home Birth Lowers Cesarean
Risk”
I-Newswire.com: “Home>Friends of Wisconsin Midwives:
Study Shows Benefits of Licensed Home Birth Midwives”
On Kaisernetwork: Planned, Low-Risk Home Births With
Nurse-Midwives as Safe as Hospital Births, Involve Fewer
Interventions, Study Says
<http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=30842>
I was starting to think that the OB/GYN online journals were just going to ignore the most recent study about homebirth safety.
Then, what to my wondering eyes did appear, but the following heading from www.obgynworld.com:
The largest prospective study of planned home births to date evaluates the safety of such births supported by direct entry midwives.
Among low-risk women, home births assisted by certified midwives achieve similar rates of intrapartum and neonatal mortality as hospital births, with lower rates of medical intervention, reveal Canadian researchers.
"Despite a wealth of evidence supporting planned home birth as a safe option for women with low risk pregnancies, the setting remains controversial in most high resource settings," note Kenneth Johnson (Public Health Agency of Canada) and Betty-Anne Daviss (International Federation of Gynecology and Obstetrics, Ottawa).
To examine its safety further, the team compared perinatal outcomes for all planned home births (n = 5418) supported by the North American Registry of Midwives in 2000, with those previously reported for low-risk hospital births in the USA.
Overall, 12.1 percent of women were transferred to hospital for delivery. The incidence of neonatal mortality among those who remained at home was similar to that documented for low-risk hospital births, with no maternal deaths. Medical intervention, however, was substantially less common among home, versus hospital, births, with epidural, episiotomy, forceps, vacuum extraction, and cesarean section rates of 4.7 percent, 2.1 percent, 1.9 percent, 0.6 percent, and 3.7 percent, respectively.
"Our study of certified professional midwives suggests that they achieve good outcomes among low-risk women without routine use of expensive hospital interventions," conclude Johnson and Daviss.
Posted: 23 June 2005
I thought this reporting was remarkably favorable, considering
some of the knee-jerk interpretations that have come out of other
sources.
Study Shows Homebirth Superior to
Hospital Birth - A summary of the 2005 BMJ Homebirth Safety
Study suitable for publication in chiropractor newsletters.
Outcomes
of
planned
home
births in Washington State: 1989-1996.
Pang JW, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NS.
Obstet Gynecol 2002 Aug;100(2):253-9
"This study suggests that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births."
Obstetricians Use Dubious Method in Attempt to Discredit Homebirth from MANA, 2/11/03
4. Why does the Washington home birth study have different conclusions than almost all other articles on home birth? from Kenneth C. Johnson, Betty-Anne Daviss, the authors of the North American Prospective Study, 2005.
When Research is Flawed: The Safety of Home Birth by Henci Goer
Press Release from Midwives Alliance of North America (MANA)
Homebirth: Is it really a safe option? from ivillage.com
A Comprehensive Review & Critique on the Pang-Benedetti Study on Home-based Birth from Faith Gibson's site
"The Pang-Benedetti study appears to have been designed to mislead and to artificially create a media "event" to generate flattering publicity for obstetricians and hospital birth by making home-based birth care appear dangerous. Perhaps this is a misguided effort to neutralize the extensive media coverage of deaths in hospital patients as a result of medical mistakes, antibiotic-resistant infections and adverse drug reactions. Why we put healthy women and babies into such a bio-hazardous environment is a source of wonderment. However, two wrongs do not make a right. "
Homebirth Research and Resources from the Seattle Midwifery School contains a number of rebuttals to the Pang study.
Homebirth Under Fire - What the Headlines Don't Say - by Jill MacCorkle - Mothering Magazine, March/April, 2003, p. 38
Key points:
"We know, too, that hospital birth can be made safer by adopting
the midwifery model of care, which has been shown to result in
lower rates of intervention and better outcomes, regardless of
setting. We already have a comprehensive blueprint for how
to achieve better hospital birth: the Mother-Friendly
Childbirth Initiative from the Coalition for Improving
Maternity Services. (www.motherfriendly.org)."
Aetna bases their anti-choice policy on the single Australian
study that shows that high-risk births (twins, breeches, etc.) are
safer in the hospital than in rural areas without ready access to
emergency hospital transport. Lesson for American parents:
Don't plan to give birth in the Australian outback if you have
a high risk birth. Dhuh. [NOTE - A colleague said that
this study includes births attended by MDs, so it says little
about midwifery safety.]
Perinatal
death
associated
with
planned home birth in Australia: population based study [full
text]
Hilda Bastian, Marc JNC Keirse and Paul Lancaster
BMJ 1998; 317:384-388
Michael Coory has written a commentary that points out that for the period cited, "the perinatal mortality rate for Australian home births (7.1 per 1000 births) was much higher than that for home births in other industrialised countries." This was presumably because many of the births included in the study occurred in rural areas with no emergency transport to hospitals for problems that arose during labor. This is irrelevant to home birth in the United States, where many homebirth midwives discourage planning to give birth in locations that are remote, where transport to the hospital would take more than the 30 minutes recommended by ACOG.
Irene Shaw has written an excellent discussion of the study with some very useful quotes from the study itself:
While home birth for low risk women can compare favourably with hospital birth, high risk home birth is inadvisable and experimental.This is the only study that Aetna could come up with to justify its unreasonable anti-choice policy regarding homebirth.Australian home births carried a high death rate compared with both all Australian births and home births elsewhere. The two largest contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress.
Marsden Wagner, MD MSPH, an internationally recognized authority on childbirth and public health issues, addresses the issue in his article, "Fish Can't See Water: The need to humanize birth in Australia".
Another more recent publication on homebirth in Australia[34] has methodological flaws so serious as to make their conclusions unjustified. The appendix to this paper includes my scientific critique of this Australian study in which I conclude: "It is well known in Australia that the reason for the several shifts in data collection methods in this study (which effectively eliminated any possibility of scientific validity) is because so many midwives felt betrayed by the researchers that they refused further participation in the research. It is intellectually dishonest not to report this fact in this paper."
The subject of intellectual dishonesty in medicine and the decline
of evidence-based medicine was addressed recently by the New
England Journal of Medicine [June, 2002], which announced that it
has given up finding truly independent doctors to write and review
articles and editorials for it. It seems that Aetna is
having a similar problem in finding medical advisors who are more
interested in healthcare than in the dollar.
Pro-homebirth editorial in British Medical Journal, Home birth
BMJ No 7068 Volume 313, Editorial Saturday 23 November 1996
It basically says that for low and moderate risk mothers the safety of home-based midwifery care for both mothers and babies is equal or superior to hospital-based obstetrician care. If anything, homebirth has become even safer as portable technologies allow homebirth midwives to perform continuous electronic fetal monitoring, if necessary.
The following articles are referenced and available via hot links from the Home Birth editorial:
Prospective
regional
study
of
planned home births [full
text]
Davies J, Hey E, Reid W, Young G.
BMJ 1996;313:1302-5.
The
Northern
Region's
Perinatal
Mortality Survey Coordinating Group. Collaborative survey of
perinatal loss in planned and unplanned home births [full
text]
BMJ 1996;313:1306-9.
Outcome
of
planned
home
and planned hospital births in low risk pregnancies: prospective
study in midwifery practices in the Netherlands. [full
text]
Wiegers TA, Keirse MJNC, van der Zee J, Berghs GAH.,
BMJ 1996;313:1309-13.
Home
versus
hospital
deliveries:
follow up study of matched pairs for procedures and outcome.
[full
text]
Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig
M, Schindler C, Maurer M, Zurich Study Team
BMJ No 7068 Volume 313
Marjorie
Tew author of “Safer Childbirth?" - book review by Gloria
Lemay
Safer childbirth: a critical history of maternity care. Third
edition.
Gavin Young
GP in rural Cumbria and member of the UK government’s Expert
Maternity Group, which produced the report “Changing Childbirth”
Marjorie Tew. (442 pages, £15.95.) Free Association Books
Ltd, 1998. ISBN 1-85343-426-4.
The safest
place of birth: further evidence. [full
text]
Tew M.
Lancet. 1979 Jun 30;1(8131):1388-90.
Abstract: The distribution of births for each place of delivery
was studied with a composite antenatal prediction score,
incorporating the most important risk factors, which was developed
for the second volume of British Births 1970. Although consultant
hospitals are seen to have the greatest share of births at
moderate and high risk, this is not sufficient to account for the
whole amount by which perinatal mortality in these hospitals
exceeds that in other places of delivery.
Place of
birth and perinatal mortality. [full
text]
Tew M.
J R Coll Gen Pract. 1985 Aug;35(277):390-4.
Abstract: Analyses of the published results of national surveys
and specific studies, as well as of the official stillbirth
statistics, consistently point to the conclusion that perinatal
mortality is significantly higher in consultant obstetric
hospitals than in general practitioner maternity units or at home,
even after allowance has been made for the greater proportion of
births in hospital at high pre-delivery risk. Unpubliched results
of the British births 1970 survey, which have now become
available, make possible a direct and authoritative analysis of
data on the safest place of birth. Not only does this make the
earlier conclusion more certain, but it confounds the doctrine
that obstetric intranatal care is particularly beneficial for high
pre-delivery risk births. There is no evidence from recent years
that the findings of 1970 are not equally valid in the 1980s.
Place of
birth and perinatal delivery. [full
text]
Tew M.
J R Coll Gen Pract. 1986 Feb;36(283):84-5.
Outcomes
for
births booked under an independent midwife and births in NHS
maternity units: matched comparison study. [full
text]
Symon A, Winter C, Inkster M, Donnan PT.
BMJ. 2009 Jun 11;338:b2060. doi: 10.1136/bmj.b2060.
CONCLUSIONS: Healthcare policy tries to direct patient choice towards clinically appropriate and practicable options; nevertheless, pregnant women are free to make decisions about birth preferences, including place of delivery and staff in attendance. While clinical outcomes across a range of variables were significantly better for women accessing an independent midwife, the significantly higher perinatal mortality rates for high risk cases in this group indicate an urgent need for a review of these cases. The significantly higher prematurity and admission rates to intensive care in the NHS cohort also indicate an urgent need for review.
Editor: This study shows results similar to the "Australian Outback" study, i.e. high risk cases have higher mortality rates at home. This shouldn't be a surprise to anyone, as high risk cases are more likely to benefit from the technology available in hospitals. It is incumbent on midwives to make it very clear to high-risk women that there is a chance that there could be significantly worse outcomes at home. The families must then balance this information with the other important factors in their home life. Some families choose homebirth for high-risk cases for religious reasons. Others believe that the mother could be so seriously re-traumatized by a repeat of a previously traumatic hospital birth that they consider that the overall risk to the mother/baby dyad of a homebirth is still less than of a hospital birth, although statisticians have not yet figured out how to account for these other factors.
The language of this study is to be commended for re-affirming a woman's right to birth in the circumstances of her choice, and a family's right to shape the way in which their family lives, including the birth experience of their babies.
And it is also to be commended for making it clear that the study
confirms other studies showing that homebirth is as safe or
safer than hospital birth for low-risk cases.
Outcomes
of
intended
home
births in nurse-midwifery practice: a prospective descriptive
study.
Murphy PA, Fullerton J
Obstet Gynecol 1998 Sep;92(3):461-470
CONCLUSION: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.
Place
of birth
Luke Zander, Geoffrey Chamberlain.
BMJ 1999;318:721-723 ( 13 March )
"No evidence exists to support the claim that a hospital is the
safest place for women to have normal births "
Meta-analysis
of
the
safety
of home birth
Birth 1997 Mar;24(1):4-13; discussion 14-6
Olsen O
CONCLUSION: Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions.
Outcomes
of
planned
home
births versus planned hospital births after regulation of
midwifery in British Columbia [full-text
article]
P.A. Janssen, S.K. Lee, E.M. Ryan, D.J. Etches, D.F. Farquharson,
D. Peacock, M.C. Klein
CMAJ 2002:166(3)
According to Janssen, "In a home birth you have the focused and undivided attention of an experienced practitioner who may be able to pick up complications very early as opposed to being in a crowded hospital where there's a mix of both experienced and new practitioners who have other responsibilities."
Are home
births safe?
Régis Blais
CMAJ 2002;166(3):335-6
Do
obstetric
intranatal
interventions
make birth safer?
Tew M.
Br J Obstet Gynaecol. 1986 Jul;93(7):659-74.
Impartial analyses of the evidence from official statistics,
national surveys and specific studies consistently find that
perinatal mortality is much higher when obstetric intranatal
interventions are used, as in consultant hospitals, than when they
are little used, as in unattached general practitioner maternity
units and at home. The conclusion holds even after allowance has
been made for the higher pre-delivery risk status of hospital
births as a result of the booking and transfer policies. It holds
even more strongly for births at high than at low predicted risk.
It follows that the increased use of interventions, implied by
increased hospitalization, could not have been the cause of the
decline in the national perinatal mortality rate over the last 50
years and analysis of results by different methods confirms that
the latter would have declined more in the absence of the former.
Data are presented which point to the deleterious effect of
interventions on the incidence of low birthweight and short
gestation and their associated mortality. Also presented are data
supporting the alternative explanation of the decline in perinatal
mortality, namely the improvement in the health status of mothers
built up over several generations. The organization of the
maternity service stands indicted by the evidence. Despite the
beliefs of those responsible, it has not promoted, and cannot
promote, the objective of reducing perinatal mortality.
Is
Homebirth For You? 6 Myths About Childbirth Exposed
Online version of a pamphlet created by the now-defunct Friends
of
Homebirth in Texas.
Home
versus hospital birth (Cochrane Review) "The change to
planned hospital birth for low risk pregnant women in many
countries during this century was not supported by good evidence."
Excerpt from the World Health Organization's Summary of Research on Place of Birth
from Care
in
Normal
Birth:
A Practical Guide Report
Collection
of
Homebirth Safety Information On the Web
Collection
of
Homebirth
Safety
Information - Illinois Midwives' Pages
Angela
Horn's Home Birth Reference Page from England, including a
short article, "What if
your doctor advises against home birth?"
Bibliography
of
Midwifery
-
Home Birth Literature Review
The Farm Midwives (1994)
Physician and Midwife Attended Home Births
I highly recommend the fourth edition of Five Standards for Safe Childbearing by David Stewart, Ph.D.
The homebirth section has a lot of research:
What you will discover, by reviewing the research, is that every valid study every published - currently or in the past and in any country - shows home to be safer than the hospitals for many, if not most. . . .More excerpts from the chapter "Midwifery: Safe, Cost-Effective Maternity Care for All (from Faith Gibson's site)Since the founding of NAPSAC in 1975, we have searched for the data, if it exists, that supports 100% hospitalization for birth. We have not found it. We have formally requested all of the major medical associations (ACOG, AMA, AAP, AAFP) and any other professional organization who supports 100% hospitalization to share, with us, their data. To date, they have not. We have asked them to write chapters for the NAPSAC books. We have offered to publish their documentation. We have given them the opportunities to speak before large audiences at NAPSAC Conferences in order that their valid statistics, if they have any, can be made known. To date, they have failed to produce even one study in support of their contention.
The Midwifery chapter now has 157 references, and the Home Birth chapter has 218. This documentation can no longer be ignored. The Midwifery chapter and the Homebirth chapter will also be available as reprints.
The new, fourth edition costs $16.95, plus $3.00 shipping. The
Midwifery Reprint costs $4.95, plus $1.50 shipping, and the Home
Birth Chapter costs $3.95, plus $1.50 shipping. Quantity prices
are available for these two reprints.
Send check payable to NAPSAC, Route 1, Box 646, Marble Hill, MO
63764
Home
birth
in
New
Zealand 1973-93: incidence and mortality.
Gulbransen G, Hilton J, McKay L, Cox A
N Z Med J 1997 Mar 28;110(1040):87-89
CONCLUSION: Home birth was a safe and increasingly popular: though
minor, option for New Zealand women from 1973-93.
Midwifery Care and Medical Complications: The Role of Risk
Screening by Eugene R. Declercq PhD, BIRTH Journal, 22:2 June 1995
Safest
birth
attendants:
recent Dutch evidence
Marjorie Tew, S M I Damstra-Wijmenga
Midwifery (1991) 7, 55-63
"Analysis of national perinatal statistics from Holland, 1986,
demonstrates that for all births after 32 weeks' gestation
mortality is much lower under the non-interventionist care of
midwives than under the interventionist management of
obstetricians at all levels of predicted risk. This finding
confirms with great authority the conclusions of all earlier
impartial analyses from Britain and other countries which agree in
contradicting the claims on which the organisation of maternity
services in most developed countries is now based, namely, that
childbirth is made so much safer by the application of high
technology that only this option should be provided."
Here are some studies you all can look for to support homebirth as a safe way to birth:)
"Outcomes of Elective Homebirths: A Series of 1,146 Cases" By Lewis Mehl MD et al. Journal of Reproductive Medicine Nov 1977
"Neonatal Outcomes in Planned vs. Unplanned Out of Hospital Births in Kentucky" by M Ward Hinds MD MPH et al. Journal of The American Medical Hospital Association March 15th 1985
"Neonatal Mortality in Missouri Home Births 1978-1984" by Wayne F Schramm MA et al. American Journal of Public Health August 1987
"Having Babies at Home: Is It Safe? Is It Ethical?" by Gerald Hoff MD and Lawrence Schneiderman MD. Hastings Center Report December 1985
"Evaluation of Outcomes on Non Nurse Midwives. Matched Comparisons with Physicians" by Lewis Mehl et al. Women and Health Vol5 1980
A really good book on this is "Safer Childbirth?" by Marjorie Tew. She has a table contrasting the outcomes of similar risk group women hospital vs. home. The perinatal mortality rate per 1,000 births was:
for very low risk: hospital=8.0 home=3.9
for low risk: hospital=17.9 home=5.2
for moderate risk: hospital=32.2 home=3.8
for high risk: hospital=53.2 home=15.5
for very high risk: hospital=162.6 home=133.3
To add to the resources for Homebirth statistics. There is a
recent Journal of Nurse Midwifery issue that is devoted to
homebirth. One article in particular deals with the statistical
outcomes in homebirth in the US of around 12,000 planned
homebirths with CNMs. I was very impressed by the outcomes and had
been somewhat skeptical before about homebirth. This particular
version was published Nov/Dec 1995, Volume 40, Number 6.
From Sheila Kitzinger's Homebirth", 1986 stats in the Netherlands OB attended hospital births, 83,351 births, 18.9/1000 infant deaths GP attended home births, 21,653 births, 4.5/1000 infant deaths Midwife attended hospital births, 34,874 births, 2.1/1000 infant deaths Midwife attended home births, 44,676 births, 1.0/1000 infant deaths
These are the most recent stats. She also has charts of 1958 and
1970 home vs. hospital births in Britain, which show home birth
very favorably.
You should read Safer Homebirth by Marjorie
Tew. She compares apples to apples and still comes up with
the fact that midwife attended homebirth is safer than hospital
birthing especially with doctors. Her stats come from the
Netherlands where they have documented the origin of birthing
ladies forever and when she put it in her computer she came out
with a great study.
There is an excellent article in the BIRTH Journal, 22:2, June
1995 entitled Midwifery Care and Medical Complications: ( BIRTH
Journal on comparisons of outcomes of CNMs and "other" midwives in
different settings).
Physician-
and
midwife-attended
home
births. Effects of breech, twin, and post-dates outcome data on
mortality rates. [full text]
Mehl-Madrona L, Madrona MM.
J Nurse Midwifery. 1997 Mar-Apr;42(2):91-8.
Adverse outcomes were similar for midwife-attended and physician-attended births when twins, breech births, and postdates births were removed from the samples.
Homebirth
Safety - The Farm Statistics
Isle of Man Study Shows Medical
Interventions Causes Problems
In contrast to the ACOG position, the American Public
Health Association passed a resolution in 2001 to increase
access to out-of-hospital birth attended by credentialed
direct-entry midwives. They based their decision on
the weight of evidence about home birth demonstrated in the home
birth studies carried out with better methodologies than were used
in the Washington study.
Home
birth
'as
safe
as hospital' says RCM - 23/04/2004 - The Royal College of
Midwives (RCM) today (Thursday 22 April 2004) reassured
parents-to-be that home births are every bit as safe as hospital
births.
References on Homebirth
Prepared by Ina May Gaskin, CPM
Misconceptions
Surrounding
the
Safety
of Home Birth and Hospital Birth by Misty Dawn Richard - a
dissertation containing an excellent summary of midwifery history
and current issues.
Homebirth - Safety and Benefits
Britain's National
Childbirth
Trust discusses homebirth:
"The National Birthday Trust survey of 6000 home births in 1994,
published in 1997 (see references) found that outcomes from
planned home births were just as good as from planned hospital
births. They found that women's satisfaction with home birth was
greater than women's satisfaction with hospital birth."
The Heart
and Science of Homebirth - What are the facts about
homebirth? Find out: Order this collection of articles from
Midwifery Today!
home
birth:
what
are
the issues? by sara wickham - "There is no shortage of
evidence to support the fact that home birth is safe, satisfying
and empowering for women and their families. "
The
Homebirth Choice by Jill Cohen and Marti Dorsey
Homebirth
section from Sheila
Kitzinger's site with a nice extract
from her book, Homebirth.
Israel Gale's Homebirth Safety
Information
Summary of Homebirth Debate from
sci.med.obgyn (October, 1996)
This "research" sounds suspiciously like the sensationalized
stats that were done in the early 80's from one state (Montana?,
North Dakota?), that showed a 2-3 times higher risk of infant
mortality with home birth. Upon closer inspection, it was
found that these were "raw" statistics, done without regard to
choice in home birth, or caregiver. Some of those births
were late miscarriages, babies accidentally born at home or a
taxicab, in other words, anything out of the hospital was listed
as a "homebirth". Although this information was debunked, it
still keeps cropping back up now and again.
This is the way the stats were presented to our Legislative Study
Council, and even then mortality rates were the same. I could
forward the figures if anyone is interested. We had prepared the
Study Council members for possibly poor looking raw data, so I
think they were pretty impressed when the raw figures were
presented and the outcomes were almost identical. Doesn't say much
for the so-called advantages of hospital birth in this state
though.
I strongly suspect that the leaking of this dubious statistics is intended to lead to a knee-jerk response which leads to a change in clinical practice or political view on home birth, without anyone ever bothering to produce some reliable statistics.
This leak should not be regarded as credible nor as useful
information on which to make an informed choice.
Somehow I just felt that the article had to be based on dubious stats. After all, the work (in the Lancet?) last year was so positive about the outcomes for planned home births and seemed to show so clearly - along with everything else - that it's when births happen outside hospital and aren't planned that way that the outcomes are bad. At least in the UK anyway. Everything that ECPC and WHO etc. etc. say confirms it.
But I couldn't help wondering..........................and thinking that if it WERE the case, then what on earth are we all doing? I wanted to follow it up and get hold of the article for starters. One of the other antenatal teachers read it and said that there weren't any references cited.
I do so hate to be a cynic - in fact I got told off by a really
good friend only last night for being too soft about all kinds of
stuff - but isn't this yet another example of scare mongering that
happens all too often? There were some similar articles written by
obstetricians a few years ago about water birth. No evidence, just
hints as you say. The trouble is that the damage is done. Everyone
believes the doctor. "No way will I have my baby at home --
ever!" Not that home is right for everyone; I'm not saying that.
Yet again it just underpins the idea that birth is really
dangerous and we shouldn't risk our babies' safety on mere whims.
I think the reason it has come out in this way is because the
person responsible for the leak knew that many obstetricians and
others would have jumped on it if it were in a medical journal and
rubbished it! In fact it would probably not even gotten through
peer review.
There are homebirth midwives out there who do carry emergency IV
equipment, newborn resuscitation equipment, and meds. I can do
almost anything at home that I can do in the hospital within the
20 minutes that it might take to transport a serious emergency
from home. And, I have often seen that with the constant attention
of a midwife both during pregnancy and labor, many potentially
unfavorable situations are recognized early a nd the course
changed, something that often doesn't happen in the hospital with
sporadic nursing attention, even if you have a machine attached
through the whole labor. This is really an important issue in the
safety of homebirth!
Home Delivery By LIZ MITCHELL - from The Missourian - This article really got it right as to the risks of doctors attending homebirth: "The primary risk is the disapproval of colleagues, which could affect licensure and hospital privileges."
Lamaze blog response to ACOG anti out-of-hospital birth statement - a compilation of from invited commenters.
Time
of
birth
and
the risk of neonatal death.
Gould JB, Qin C, Chavez G.
Obstet Gynecol. 2005 Aug;106(2):352-8.
"Neonatal mortality was 1.88 for daytime births, increasing to 2.37 for early night and 2.31 for late night births. . . . The increased risk was identified in hospitals that provide intermediate, community, and regional neonatal intensive care, but not in hospitals that provide primary care."
The common interpretation of this study is that hospital
personnel at night aren't providing the same level of care as
during the day.
As
many
as
195,000
people a year could be dying in U.S. hospitals because of easily
prevented errors, a company said on Tuesday in an estimate
that doubles previous figures. [7/27/04]
Infants Too Easily Misidentified in Neonatal Intensive Care Units
Throughout the 1-year study period, "there was not a single calendar day without at least one pair of patients at risk for misidentification," the investigators report. On average, just over half the patients were at risk on any given day.
Pediatrics 2006;117:e43-e47.
Vancomycin-resistant enterococcus
is just one of the many hospital-acquired
infections which create a life-threatening risk to otherwise
healthy people admitted to the hospital.
Hazards
of
Modern Medicine - An Overview Based on a Selection of
Findings from the More than 10,000 Articles, Reports, and
Scientific Research Studies in the Medical LiteratureBy Barry M.
Charles, MD
HOW THE
MODERN MEDICINE MONOPOLY HAS FAILED US by Dr. Carolyn Dean,
MD, ND and Elissa Meininger [8/18/05] containing How
Modern
Medicine Killed My Brother by neurosurgeon and author,
Russell Blaylock, MD
A
38-year-old woman with fetal loss and hysterectomy.
Sachs BP.
JAMA. 2005 Aug 17;294(7):833-40.
This is a fabulous article from Mothering Magazine:
Revealing
the
Real
Risks:
Obstetrical Interventions and Maternal Mortality
Issue 118, May/June 2003
By Marsden Wagner
Cleaning
solutions
and
bacterial
colonization in promoting healing and early separation of the
umbilical cord in healthy newborns.
Medves JM, O'Brien BA.
Can J Public Health. 1997 Nov-Dec;88(6):380-2.
"The risk of umbilical infection has been reduced as a result of
earlier postpartum discharge from hospital." [From
CARE
OF
THE
UMBILICAL CORD] Umbilical infection is just one of the
types of newborn infection that occur more frequently in the
hospital.
I've never heard of a baby who got decapitated at a homebirth, but this apparently isn't that unusual in the U.S.:
From: http://www.collegeofmidwives.org/ReportHearing_sb_1950_Feb19.htm#Before%20leaving
[This web page is about political stuff; this extract is from
about 2/3 of the way down; search for "forceps".]
"Some of you living in Orange County will remember a series of five ‘expose’ articles on the Medical Board that ran in the Orange County Register in April of 2001. One was about a local obstetrician who had been sued by two sets of parents about 3-4 years apart for making the very same egregious “mistake” not once but twice -- two forceps deliveries in which the baby’s skull was pulled off its spine by overzealous traction, resulting in immediate death. While this doctor had a horrible reputation with the L&D nurses, the hospital never revoked his admitting privileges, those two as well as other malpractice awards against this doctor had never been reported as required by law and the Medical Board had never investigated him. After five of these articles in the newspaper, there were many “inquiring minds” that wanted to know why not!. "
If you have information about other decapitations happening in
the hospital, please
contact me. Thanks. :-(
One of the risks of homebirth is that a major catastrophe could happen, which could (possibly) be better handled in a hospital. This could be a catastrophic cord problem, uterine rupture, abrupted placenta... however, most of these things could also happen at home before labor begins, and even when they happen during labor, there is almost always plenty of time to get to the hospital, while taking appropriate measures en route.
Another factor to take into consideration is the dangers of the
hospital. There is a danger your doctor won't be there and an
inexperienced student or nurse might have to catch your baby, you
or your baby could contract a disease resistant to antibiotic
therapy (these are not usually found in your home), your baby
could be snatched from the hospital (I know, a wild idea, but the
above mentioned catastrophes are rare too, and we worry about
those!) You could end up with a cesarean section (1 out of 4!) -
these are some pretty high risks that should be taken seriously.
[from sci.med.obgyn]
I believe that hospital delivery is safer by a few percent,
and this percent is the percent of parturients who have
abruptions, cord prolapses, convulsions, hemorrhages from
cervical, uterine, or vaginal lacerations, undetected rapid
breeches, pulmonary embolisms, infections (undetected), fetal
stress, untreated obstructed labor, and on and on. Most gravidas
do not have disease, so are fine at home. But if yours is the
case, you become common parlance.
The Doctor has done a good job listing the risks of home birth relative to hospital birth, and he notes that these risks are small.
In other messages, however, he has continued to assert that there areno risks of hospital birth relative to home birth. This is a strong claim, and it's patently false. We know that in the United States about one out of twenty pregnant women who gives birth in a hospital has an unnecessary cesarean. Cesareans are major surgery, and some (few) women die from them; many thousand others get more minor complications like infections.
Some hospitals have practices that sabotage breastfeeding; these include supplying routine bottles and separation of mother and baby right after birth. Recovering from an unnecessary cesarean can also make it more difficult for the mother to establish breastfeeding. We know that breastfeeding is healthier for babies, so practices that discourage mothers from breastfeeding endanger the newborns.
The Doctor may have meant to state that on balance, he believes
the risk of giving birth in the hospital is less than the risk of
giving birth at home (for a woman who would qualify for home
birth). He hasn't provided any evidence to make us believe this,
however, or even to make us believe that he has considered the
hospital risks at all.
Blood Gases: Obvious geographical considerations aside, the
safety of homebirth has been questioned even in Holland, where
back up is usually excellent:
Umbilical
cord
gases
in
home deliveries vs. hospital based deliveries.
Eskes TK, Jongsma HW, Houx PC
J Reprod Med 1981;26:405-8.
However, there's no evidence that this represents any kind of
problems for the babies. In particular, see:
The
effect
of
labor
on the normal values of umbilical blood acid-base status.
Yoon BH, Kim SW
Acta Obstet Gynecol Scand 1994 Aug;73(7):555-561
CONCLUSION. There is a significant fall in umbilical artery pH and bicarbonate with the presence of labor and increased duration of second stage of labor in healthy term neonates. This should be taken into consideration in evaluating neonatal well-being by cord blood pH and acid-base measurements.And here's an article that concludes that the prognostic value of acidosis is low:
This humorous analogy about "home
sex" helps to put the issues of "home birth" in perspective.
One of the easiest reasons to understand is the infection issue -
Hospital-Acquired Infections and
Antibiotic Resistance
Homebirth Safety - What Really Keeps the
Baby Safe?
"The only additional risk of natural childbirth is possible
emotional trauma from mismatched expectations."
It's very important to be mindful that the historical
improvements have been because of access to timely medical care,
rather than the routine use of all obstetrical
interventions. The medical community defines timely access
as 30-70 minutes from noting a serious problem.
Why Homebirth is Safer, an excerpt from the book, A Woman in Residence, by Dr. Michelle Harrison, M.D. (who is a family practitioner and did residency work in OB/GYN) will make us all do some reflective thinking.
"Imagine dancers on a stage. Once, doing a pirouette, a woman sustained a cervical fracture as a result of a fall; she is now paralyzed. We try to make the stage safer, to have the dancers better prepared. But can a dancer wear a collar around her neck, just in case she falls? The presence of the collar will inhibit her free motion. We cannot say to her, 'This will be entirely natural except for the brace on your neck, just in case.' It cannot be "as if" it is not there, because we know that creative movement and creative expression cannot exist with those constraints. The dancer cannot dance with the brace on. In the same way, the birthing woman cannot "dance" with a brace on. The straps around her abdomen, the wires coming from her vagina, change her birth.
The birthing woman plays in an orchestra of her body, her soul, her baby, her loved ones, her past and her future. And we do not know who leads the orchestra.
Doctors cannot lead the orchestra, because they are not within the process. Unable to hear the music, trained only in modalities of power and control, they can only interfere with the music being played.
What should the be able to do? They should stand ready to help the player in trouble to get back into rhthym. Instead, they take over. Instead of supporting the mother, they say, 'Okay, you have failed. It's our piece now.'
How do you (doctors) get a 30 percent Cesarean rate? You
orchestrate it. You write a piece in which the third movement is a
Cesarean, then build the first two with that in mind. You write in
a different language; you write in terms of centimeters of
dilation, external fetal monitor, internal fetal monitor, pH,
scalp electrodes, Cesarean birth experience, arrest of labor,
protracted labor, fetal distress, episiotomy, prolapse,
cephalopelvic disproportion, ultrasound waves, amniocentesis,
"premium baby', post-mature (when the baby stays too long in the
uterus), "maternal environment" (formerly known as mother). Those
are the words, the notes, while the piece is played to the rhythm
of fear.
In response to: "Is homebirth safe?"
Rather a large number of studies have been done on this. To date, the studies show, without exception, a lower rate of mortality and morbidity for mothers and infants in all risk categories with home birth.
This runs counter to what we believe as a society: that hospitals are safer, and the right place to have a baby. All cultures have strong beliefs about the "right" way to give birth. From the outside, the beliefs of others may seem ridiculous. From the inside, anything else seems dangerous and weird. The US has very poor outcomes for a developed nation. We make up a lot of reasons why this must be so, but rarely face the fact that our birth practices are not the best.
Who does have the best? The country with the best statistics, by far, is Holland. They have about a 30% home birth rate. Pregnant women see a midwife first. The midwife is the "gatekeeper", and refers high risk mothers to OB/Gyns, who do hospital births. Healthy mothers birth at home. A significant factor in the good outcomes for infants is the birth assistant, who does light housework for a week after the birth, sparing the mother and allowing her to spend her energy bonding with her infant. The birth assistant is also a trained observer, who can detect unusual problems and alert a pediatrician, teach breast feeding techniques, etc.
How can home birth be safer than hospital birth? Most "problems" in hospital births come about due to "failure to progress". This leads to interventions, and interventions have consequences and side effects. In the hospital, this often leads to more interventions, etc. Why failure to progress? Imagine for a moment that your cat is about to have kittens. It will seek a warm comfortable place, where if feels safe. Imagine you bring it out into a strange, brightly lit area full of strangers, who poke it and examine it. Do you think it will give birth? Or will this profound and difficult process be interrupted while it takes in its new surroundings?
You certainly are safer giving birth with a trained practitioner, who has a deep understanding of the psychology and physiology of birth, who knows when to transport to a hospital, how to intervene if needed, has a certificate in infant resuscitation, knowledge of and license to use pitocin and suture, etc. And you are safer giving birth within a short transport of a hospital, should one be needed. Most licensed midwives in the US have post-graduate training, and are experts in normal birth, and will transfer you to the hospital from a home setting right away if your birth is not progressing normally.
But healthy mothers are generally safer at home. It defies what
most of us believe, but the statistics bear it out.
Homebirth and Postpartum Hemorrhage
Safe
interval
for
emergency
caesarean section is 75 minutes
BMJ 2004;328 (20 March), doi:10.1136/bmj.328.7441.0
When the decision to deliver by caesarean section is made, time
to intervention should be less than 75 minutes to avoid poor
maternal and baby
outcomes. Thomas and colleagues (p 665) analysed 17 780 singleton
births by caesarean section in Wales and England in 2000. They
found that,
compared with deliveries completed within 15 minutes of the
decision for an emergency caesarean section, mothers' and babies'
outcomes did not differ from deliveries within 75 minutes. Babies
delivered after 75 minutes were more likely to have an Apgar score
of less than 7, and their mothers were more likely to require
special care. Never the less, the target of 30 minutes should
remain as the benchmark for service provision, the authors say.
Women laboring at home within 20 minutes of a hospital operating room have the same access to emergency surgery as women laboring in that same hospital. Most surgeons are not physically present in the hospital while their clients are laboring; they are either at their office seeing patients, home sleeping in their beds, or simply going about their business. (Many doctors instruct the nurses not to call them until the baby's head begins to crown.) Whether an emergency arises at home or in the hospital, it still takes time for the surgeons to be paged, to drive to the hospital and to arrive at the scrub sinks. It takes time to assemble the anesthesiologists, nursing staff and neonatal teams necessary for a cesarean section. Hospitals offering labor and delivery services must be able to start cesarean surgery within 30 minutes of being notified of the need, which gives women laboring at home plenty of time to get to the operating room ahead of the surgeon.
How can this be safe? Childbirth "emergencies" usually
develop over the course of hours rather than minutes, especially
when they're not actively caused by interventions such as
artificial rupture of membranes, administration of pitocin,
spinal/epidural anesthesia or pulling on the umbilical cord to
deliver the placenta.
What is a reasonable time from
decision-to-delivery by caesarean section? Evidence
from 415 deliveries shows that fewer than 40% intrapartum
deliveries by caesarean section for fetal distress were achieved
within 30 minutes of the decision, despite that being the unit
standard.
Two papers and an editorial in this week's BMJ describe the difficulties in meeting the target of 30 minutes between the decision that an urgent caesarean section is necessary and delivering the baby. [May, 2001]
Interval
between decision and delivery by caesarean section -- are
current standards achievable? Observational case series
"Conclusions: The current recommendations for the interval between
decision and delivery are not being achieved in routine practice.
Failure to
meet the recommendations does not seem to increase neonatal
morbidity. "
Editorial:
Caesarean
section
for fetal distress
A placenta abrupted in the hospital. They did a stat c-sec 30
minutes later. How long does "stat" mean in your hospitals? 30
min. limit? 10 min. max? Can you please send me, tell me your
protocols/ experiences where you are?
The ACOG standard is currently "30 minutes call to cut" for all
non-scheduled c-sections. In a small community hospital that may
be an impossibly short time, especially at 3 in the morning on a
weekend, where you have to get anesthesia and a whole ER crew in
from home. And if the mom is a hard stick for the IV, hasn't had
any labwork drawn for the blood bank, or hasn't given her consent!
In a tertiary care setting where there is 24 hour coverage of all
specialties and the L&D nurses also have OR training, I have
seen a stat section done in 30 seconds call to cut (massive
antepartum hemorrhage, IV started and prepped for section during
admission, seemingly stable until the FHTs disappeared). I'm not
sure that the mom was asleep when they cut, but I know she didn't
care...her words as we were hauling her through the nurses station
were "save my baby". You can't judge a hospital in a small town
(which should probably really be considered more like a birth
center in capabilities) by the standards of a tertiary care
metropolitan trauma center.
By us, large tertiary Israeli medical center, it means less than 10 minutes if the woman was already admitted, around 15 if we have no paper work and blood. We have our own OR and staff on call 24 hours a day plus anesthesiologist. If you are a small center and have to transfer to another floor, wing or building and if you don't have your own OR staff waiting on the hospital grounds, you aren't going to be able to do the 7 minutes that we can.
P.s. just talked to a friend who works in Jerusalem...she says it
takes 5 minutes there. We're talking about centers with over 500
births a month.
Depends. At the private hospital I currently work in, MDs are required to live within 30 min of hospital. But if it is 0200, and they are sound asleep, it will be longer than 30 min before they get to the hospital. And the OR crew needs to be called. An assistant, and an anesthesiologist.
If you are at a hospital that has 24hr in house coverage by OB,
CNM and OB anesthesiologist, with C/S being scrubbed and
circulated by the L/D staff, or have in house OR crew, then you
can get from "decision to incision" within just a few minutes. The
shortest I have been involved in was 3 minutes.
A
Native American community with a 7% cesarean delivery rate: does
case mix, ethnicity, or labor management explain the low rate?
[full
text]
Leeman L, Leeman R.
Ann Fam Med. 2003 May-Jun;1(1):36-43.
This study is an object example of the principle of low-risk
women safely laboring without immediate access to cesarean
surgery. Most of the birth attendants were not
obstetricians, and in fact, cesarean delivery required transport
to another hospital!
First-Time Moms Ideal Candidates for
Homebirth
Faith Gibson's
Homebirth VBAC Consent Form
HBAC FAQ - Q&A about Homebirth After
Cesarean
Is Homebirth Appropriate for a VBAC?
[from ob-gyn-l]
It is my opinion that home VBAC regardless of the number of prior
cesareans is tempting fate. Perhaps one might get away with it
990+ times out of a thousand.
Yes, and perhaps one can "get away with" not having a severe shoulder dystocia or abruption or cord prolapse 990+ times out of a thousand, too. There are established risks to giving birth. Meconium does happen. By your logic giving birth is tempting fate. You say you don't oppose homebirth, but I would ask you to evaluate more closely the thinking underlying your statements.
This is not meant to dismiss the gravity of obstetrical complications, be they a uterine rupture or a terrible shoulder dystocia. Any time a mother or baby is harmed we all grieve. However, there are two important points.
1) We cannot eliminate all risks. Giving birth is as safe as life gets (here we should remember the people who die every day in "freak" accidents, like air conditioners falling on them, as well as all the predictable causes of death). Our medical and legal standards now assume that anytime a baby dies someone must be at fault. We all know that is not true.
2) We must be aware of the danger of adding new risks by trying to prevent others. A case in point is VBAC management. Bruce Flamm recommends continuous fetal monitoring for all VBACs because the commonest sign of rupture is fetal distress. While this may be an intelligent way to most of the time notice a rupture while you still have a chance to save the baby, we all know very well the risks of continuous fetal monitoring (increased use of pain meds, dysfunctional labor, more cesareans, etc.) In individual cases it doesn't make sense to argue that putting the mother at risk for an(other) unnecessary cesarean is worth saving one baby from death, however in the big picture treating every woman with a scar on her uterus as though she is a ticking time bomb is very destructive and sounds like all the arguments for hospital birth for any old laboring woman "Well anything might happen at any moment, so it is better to be on the safe side" etc. etc. etc., which has led us directly to current obstetrical "management" complete with routine inductions at 40 weeks, epidural on demand, continuous fetal monitoring, etc. (don't call me crazy, I worked as a nurse for three years in such a place).
The real reason for treating VBACs differently from other laboring women is POLITICS, despite the fact that depending on how you look at it, either all labors are potential disasters (shall we call it the "OB" approach without offending too many of our good docs?) or most labors will go smoothly and most complications are either can be anticipated or ameliorated without major intervention but occasionally "the big one will hit" and there is little we can do to avoid it (the "midwife" approach), .
The fact is that if there is a uterine rupture in a hospital and the baby dies, everyone will say "well, we did everything we could" and sweep it under the rug. If there is a uterine rupture outside of the hospital, even if the caregivers notice the rupture right away, give supportive care and transport immediately to a waiting surgical staff (where I work we could transport in less than ten minutes to a prepared labor suite) and the baby still dies, then the wrath of the entire medical community would rain down on that poor birth center or OOH midwife for "violating standards of care".
So, as long as you cover your butt, even if you are not actually making labor and birth any safer, you are doing the right thing???? And if in the process you are exposing the women and her baby to additional risks, such as overzealous medical staff, easy access to pain meds, the dangers of electronic fetal monitoring, the psychological stress of being in a "medical" environment to complete a natural biological process, etc., etc., you are still doing the right thing?? If you make the woman give birth in the hospital and thereby decrease her chances of giving birth vaginally because of her fears and you expose her and her baby to the attendant risks of surgery (infection, bleeding, etc.), then have you done the right thing??
I am sorry, but your argument sounds like the one the anesthesiologists at my former place of employment used to try to convince all laboring women that they needed an epidural -- IF there was an emergency then the anesthesia for the emergency cesarean would already be in place. That is kind of like saying, considering the high numbers of automobile accidents, we should all go around NPO all the time in case we crack up the car and need emergency surgery at least we won't have to worry about aspiration when the fresh-out-of-medical-school-resident attempts her first intubation.
If an intelligent woman carefully weighs the risks and feels
safer and more comfortable attempting a VBAC outside of the
hospital, then why shouldn't we support that and help her to do it
as safely as possible?
Abstracts about Pit and Home VBAC
[from ob-gyn-l about hospital VBAC]
I would think that Previous cesarean would be a High Risk
indication and hence should not be managed by a midwife unless
there was a MD there also. However, I agree that management by a
Midwife who is present is much better than management by a MD who
is not present.
OK, how many women here had the constant attendance of their OB once they were in active labor?
I'm assuming the answer is none.
So the set of {MDs who are not present} is the same as the set of {MDs}, and this OB is saying that Midwives offer better management of VBACs than MDs.
This is one of the reasons I think homebirth is safer for VBAC -
the caregiver providing constant attention is much more likely to
notice the earlier, less threatening signs of a rupture.
Is Weight a Contraindication for
Homebirth?
Choosing
a
Size-Friendly
Health
Practitioner [THIS FAQ TEMPORARILY DOWN. NEW UPDATE
COMING SOON]
I agree that smoking is a habit I would discourage in a pregnant woman - it introduces toxins into her system and potentially reduces the oxygen flow to her baby. Then again, I once knew a chain smoker who carried twins to term and gave birth to babies who weighed 7.5 and 8 pounds and were extremely healthy.
I don't think the question is whether smoking is beneficial or not. I see the questions as: "For someone who is addicted to smoking, where is the safest place for them to give birth?"
Since the primary consideration is maximizing the oxygen flow to the placenta and minimizing the stress on the baby, I see home as the most appropriate place. Hospitals have a strong tendency to introduce anxiety, pitocin, and epidurals. Anxiety and a stressful environment reduce a woman's blood flow and the amount of oxygen available to the placenta. Epidurals lower a woman's blood pressure, which also reduces oxygen flow to the placenta. Pitocin increases the stress on the baby, thereby increasing the oxygen need.
When people are talking about risk factors for homebirth, they often compare the ideal homebirth candidate with the high percentage of non-ideal candidates.
This makes no sense, since you can't turn a non-ideal candidate into an ideal candidate. All you can do in the real world is to look at your non-ideal candidates and figure out which is the safest place for them to give birth.
Research is crystal clear on this point. Homebirth is safer
for all risk categories except the highest, and I've never figured
out how sick you'd have to be to be in that highest category -
probably actively seizing from pre-eclampsia or actively bleeding
from a placental abruption or uterine rupture.
From Ken Johnson and Betty-Anne Daviss, co-authors of the 2005 Homebirth Safety Study.
Contacting your local media
We invite you, if you have not already done so, to contact your local radio stations and newspapers this week about the study, and if you cannot get to it this week, to contact any media people you know in local, national, or international community newspapers or magazines over the next week or two. Try the health reporters. Strategize with your consumer groups to figure out the best talk shows that might pick this up in your home town. The study has already appeared in numerous national media (see below), and your actions to bring the study to the attention of your local news media can generate more news coverage for the public as well as draw attention to your CPM credential and /or to local advocacy efforts. If you participated in the study, that might be a special interest story for the local press.
For ideas and materials you can give to a reporter, the following are available: the BMJ press release (at www.bmj.com); the Citizens for Midwifery press release and relevant grassroots network message (at http://www.cfmidwifery.org/Resources/Item.aspx?ID=84); the NACPM press release (at http://www.nacpm.net/) ; the ICAN press release (at www.ican-online.org). Also see “What to emphasize” below.
When contacting the media take the time to educate them on the CPM credential and make sure they know that NARM, MEAC, CfM, MANA, and NACPM have information on these maternity care providers.
We also want to formally thank all of you who have taken the time to contract your local newspaper or disseminate news of the article by postings on websites and listserves. We understand that Katie Prown and Steve Cochran helped organize an effective grassroots effort through the BirthPolicy network. Please be sure to write to us about your interactions with the press.
4) What to emphasize with the media:
You can still phone your local media today. Here are some pointers about things to emphasize:
* Why This Study Is Special: The study is groundbreaking because former studies have been criticized for not being big enough, for not being able to distinguish between planned or unplanned births, and/or for being retrospective, that is only looking at old records as opposed to engaging health professionals in the requirement of registering births they are going to do and then accounting for all outcomes. This is the only study ever published that has met all three of these criteria: the study is big enough, the study distinguished between planned and unplanned home births, and the data are prospective.
* Emphasize the low intervention rate: For the year 2000, your chances with a CPM in a planned home birth of having some kind of medical intervention -- a cesarean section, forceps or vacuum delivery, induction, episiotomy, epidural -- were 1/10 to ½ (depending on the intervention) of what they were if you planned a hospital birth, using statistical outcomes from the US population from the same year and comparing to largely low risk group in hospital by using US birth certificate data for all vertex, term, singleton births.
* Low Rate of Transfers: We purposely reported transfers as: “over 87% of mothers and neonates did not require transfer to hospital,” and most of the transfers were for lack of progress, because the mother was tired or wanted pain relief. This kind of detail is especially important when communicating with the media. For example “over 87% of the mothers…” conveys a sense of confidence, while “thirteen per cent of women still had to be transferred,” which one television broadcast did (even though it was overall a positive study) focuses on the negative end of the curve.
And to be clear: only 3.4% of women who began labour at home had a transfer which the midwife thought was urgent, and even these “urgent” transfers did not necessarily mean there was some avoidable trauma involved, just that it was felt that things needed to be checked out right away, e.g., anomalies in a baby, observation of babies having breathing difficulties but who had oxygen and bag and mask at home as they would in hospital, mothers losing more blood than was felt safe. The outcomes speak for themselves, but the rapid response from Rivet, and others which may follow, has said that the doctors don’t have the luxury of taking only low risk women. This clouds the point of the article; it is like saying, obstetricians don’t have the luxury like the midwives and family docs, of not doing cesareans. That is precisely a good use for their skills, so why complain? It is not that the CPMs do not get high risk women; we showed in our study precisely how the CPMs handle them – generally screen them out for hospital birth, but did the low risk women at home with good results , except in cases where obviously the mother chose not to go, which is an informed decision.
* Only “low risk” births were appropriate for this study. The study shows that, if you are not a high risk Mom -- that is, carrying twins or multiples, having a premature baby or having a baby coming bottom first or transverse, all of which can be judged before the baby is born --your chance of having a healthy normal safe delivery are the same whether you plan a home or hospital birth. One journalist actually tried to fault the study for this. It is precisely the methodology necessary – to compare as closely as possible to a similar low risk population in the U.S.
* A Validation Study Verified the Data. Over 500 mothers were phoned, including at least one client from every midwife, to verify that what the midwives said happened at the births actually did occur.
* Policy Implications: The study suggests that legislators and policy makers should pay attention to the fact that this study supports the American Public Health Association’s resolution to increase out of hospital births attended by direct entry midwives. The American College of Obstetricians and Gynecologists still opposes home birth, but has no valid evidence to support this position. The Society of Obstetricians and Gynecologists of Canada and several provinces have written statements either acknowledging that women have the right to choose their place of birth or supporting it.
For continuing information on creative and effective ways to highlight this study in the policy arena, consider joining the BirthPolicy listserve (birthpolicy@yahoogroups.com). It is a great resource for midwifery policy discussion. Plus list moderators Katie Prown and Steve Cochran have their own personal tips on how to become more media savvy.
6) Regarding Our Long term effort:
We understand that there are critics who do not understand the length of time it takes for scientific articles to be written and actually published. Let us assure you, our diligence has paid off, as we had anticipated: we made sure our methodologies met the highest standards; we followed up all CPMs who wanted to remain CPMs to make sure they got their data to us; and we had draft articles scrutinized by other professional epidemiologists. As some of you know, we originally sent the study to JAMA (the Journal of the American Medical Association), a publication that told us that they did not think their readers would be interested. Then, in December, 2004, we sent it to the BMJ. In contrast to the BMJ, the ACNM Journal takes one year from submission to publication, largely because they are an organization that very positively helps and encourages new researchers. On the other hand, the BMJ publishes only about 9% of papers they receive, and, although this study was accepted unanimously by all editors, it still took six months to process between submission and publication. We went the extra mile because we knew that at this time in North American history, home birth needs a credible boost, and this study will be critical for parents and professionals for many years to come.
Study: High-tech interventions deliver huge childbirth bill - Childbirth is the leading reason for hospitalization in the USA and one of the top reasons for outpatient visits, yet much maternity care consists of high-tech procedures that lack scientific evidence of benefit for most women, a report says today. [10/8/08]
REPORT REVEALS SERIOUS PROBLEMS IN MATERNITY CARE QUALITY AND
VALUE [Press
release] [Full
report]
Overuse of Cesarean Section and Other Interventions Puts Women and
Babies at Risk, Increases Costs
Over 31% of U.S. births are now by cesarean section although a 5% to 10% rate is best for mothers and babies. The extra cost is well over $2.5 billion per year. The excess cesareans buy no reduction in maternal and newborn deaths. But they cause unneeded exposure to the dozens of adverse effects more common with csections. This is just the most striking example of how health care provided to mothers giving birth exposes them to avoidable harm and expense. These conclusions are found in Evidence-Based Maternity Care: What It Is and What It Can Achieve, a report released today by Childbirth Connection, The Reforming States Group, and the Milbank Memorial Foundation.
The report cites an extensive body of evidence to make the case
that, despite paying top dollar, American women do not receive the
best maternity care. It is the most comprehensive review to date
of how maternity care is delivered, financed, and experienced by
mothers, families, and health care payers. It concludes that
maternity care can be significantly improved using evidence-based
care.
Look at numbers on midwife birth bill by Carol Leonard, Hopkinton - a cost analysis of home vs. hospital birth in New Hampshire.
HealthCost provides
information on the price of medical care in New Hampshire
Summary of
Critical Points from "Safety of Alternative Approaches to
Childbirth" by Peter F. Schlenzka - A doctoral thesis
comparing safety and costs of natural, out-of-hospital birth with
in-hospital obstetric births. He finds out-of-hospital
births to be slightly safer and significantly superior in terms of
economic costs ($13 billion annually) and social costs (reduced
incidence of birth trauma and bonding disorders).
HOME BIRTHS CHEAPER, SAFER. Low-risk home births are cheaper and safer than deliveries in hospitals and birthing centers, according to a recent study by Centre College professor David Anderson. He and certified nurse midwife Rondi Anderson reviewed data from more than 33,000 deliveries in the U.S. and found that home births could reduce delivery costs by more than two-thirds with no increase in the risk of infant mortality. "Childbirth makes up one-fifth of all health care expenditures in the U.S., and there is increasing interest in birthing alternatives that could free up resources for other healthcare needs." David Anderson: Phone 606-238-5282. News Contact: Patsi Trollinger: Phone 606-238-5719
The
cost-effectiveness
of
home
birth.
Anderson RE, Anderson DA.
J Nurse Midwifery. 1999 Jan-Feb;44(1):30-5.
As health care costs increase and a growing number of women are without insurance, the one health service that every family needs deserves further attention. Even for the 40% of births covered by Medicaid, safe birthing alternatives that permit a reduction in the $150 billion Medicaid burden would allow the United States to devote more resources to other urgent priorities. Informed birthing decisions cannot be made without information on costs, success rates, and any necessary tradeoffs between the two. This article provides the relevant information for hospital, home, and birth center births. The average uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births initiated in the home offer a lower combined rate of intrapartum and neonatal mortality and a lower incidence of cesarean delivery.
This article quantifies and compares birthing charges and safety figures among modalities. The combined analysis permits rational decisions based on cost-effectiveness tradeoffs.
Please send correspondence to:
David A. Anderson
Centre College
600 West Walnut Street
Danville, Kentucky 40422
After years of midwives' joking that with a homebirth, you don't
have to worry about having your baby switched with another baby,
I'm finally adding this section.
It's
a Girl... No Wait, Hospital Sends Mom Home With Boy Instead
- (11/7/08) - Staff said the mix-up was down to the babies having
similar family names and being in adjoining bassinets.
OK, here's a bit of levity . . . one of the benefits of homebirth
is that you can choose your own, deluxe mattress: Here's the
famous
Spanish
homebirth
mattress ad.
Home Birth and Breastfeeding May Set the Stage for Healthy Immune Systems in Infants
Factors
influencing
the
composition
of the intestinal microbiota in early infancy.
Penders J, Thijs C, Vink C, Stelma FF, Snijders B, Kummeling I,
van den Brandt PA, Stobberingh EE.
Pediatrics. 2006 Aug;118(2):511-21.
CONCLUSIONS: . . . Term infants who were born vaginally at
home and were breastfed exclusively seemed to have the most
"beneficial" gut microbiota (highest numbers of bifidobacteria and
lowest numbers of C difficile and E coli).
New
moms
and
newborns
need privacy, study shows by Barbara Morrison, a nursing
professor at Case Western Reserve University, published in
Journal of
Obstetric, Gynecologic, & Neonatal Nursing - The
official journal of AWHONN
Rise In Hospital Noise Poses Problems For Patients And Staff
Announcements blare from overhead speakers. Electronic devices beep. Heating and cooling systems rumble. Employees and visitors speak loudly.
This sound snapshot, researchers say, comes not from a factory or a sports stadium but from a typical hospital. In a new study, Johns Hopkins University acoustical engineers found that hospital noise levels internationally have grown steadily over the past five decades, disturbing patients and staff members, raising the risk of medical errors and hindering efforts to modernize hospitals with speech recognition systems. Some studies even indicate that excessive noise can slow the pace of healing and contribute to stress and burnout among hospital workers.
[Ilene
J.
Busch-Vishniac's
web
pages]
[From
the
Johns
Hopkins
web page]
I would love to see a study that compares the one-year outcomes of care with a homebirth midwife contrasted with care with a hospital-based obstetrician. You read newspaper stories about tragedies that happen to vulnerable new moms and babies who are getting standard care, and you just know these things would never happen with a homebirth midwife. I'm thinking of the tragic case where a new mom killed herself and her baby, and the dad is suing the OB for not noticing or treating signs of depression. Right off the bat, midwives help prevent postpartum depression through attention to good nutrition and simply by attention to the woman herself; their concern and the large amount of time they spend with their clients helps women to feel better about themselves, their superior birth experiences prevent the depression that comes from disappointment in the way they were treated at birth, and ideal midwifery care continues into the weeks after the birth. In my practice, I visit the moms and babies in their home at 24 hours, 48 hours, 4-6 days (depending on breastfeeding needs and scheduling of Newborn Screen heelstick), and 10 days. These home visits reinforce the idea that the mom is supposed to be RESTING and recovering, rather than getting right back into the swing of things and taking the baby back to the pediatrician for jaundice and weight checks at 5 and 14 days, which are tiring for the mom and serve to shift her focus to the baby's well-being at the expense of her own. And midwives are always asking about how moms are feeling, and paying special attention to any warning signs about moods or feelings that aren't quite normal. And even in the break between the 2-week home visit and the final 6-week office visit, a midwife would probably be checking in with a mom who hadn't been convincingly healthy from an emotional point of view at 2 weeks. And dads would feel more comfortable about calling the midwife on their own initiative to talk about any worrying signs. And there's always a thorough evaluation at 6 weeks; if I'm concerned, I'll use the Edinburgh test or refer for professional evaluation.
And that's just the issue of postpartum depression.
When I think of the studies that show that the infant mortality
rate in the first year is reduced by 20% just by breastfeeding, I
think of the fact that almost all the babies in my practice are
happily breastfeeding through to at least one year - often
longer. Right there, my practice has a 20% reduced infant
mortality rate compared with those babies in OB practices where
the birth experience or lack of breastfeeding support result in
the baby's being fed with artificial breastmilk shortly after
birth. And the reduced c-section rates result in reduced allergies
and asthma. And the list goes on and on . . . Why
haven't researchers taken the long view of how our birthing
practices affect the one-year health of mothers and babies?
Indie Birth - an online homebirth magazine. Here's the purpose of Indie Birth:
To fire up the minds of modern-day mamas, so that they are inspired, educated and aware of all the choices surrounding them concerning their pregnancies and births.
To cater to those that are already independent, free-thinking and
maybe a little bit radical... and to transform those mamas not yet
in touch with their instinctive abilities to birth and nurture
naturally.
A Field Guide to Birthing: A
Conversation With Michael Witte, M.D., and Heidi Bednar, R.N.
- A great discussion of homebirth options from Medical Self
Care, edited by Tom Ferguson, M.D., 1978.
Reclaiming the Rights of
Birthing Women: A Primer plus Fact Sheet, Tips and Appendix
from birthpolicy.org
The "Trust Birth Initiative"
is a La Leche League style organization for birth. Pretty
promising, actually.
Ward
environment hinders labor -14 June 2005 -A survey of new
mothers in the UK explores whether the environment in which they
gave birth influenced their delivery.
Angela Horn's Home Birth
Reference Page - from the UK
HOME
BIRTH BRIEFING by Angela Horn, NCT Home Birth Support
Coordinator. Reading Britain's
Homebirth Policy is refreshing!
Home Sweet Home
- Is Homebirth right for you? by Karina L. Fabian
Summary
of
Critical Points from "Safety of Alternative Approaches to
Childbirth" by Peter F. Schlenzka - A doctoral thesis
comparing safety and costs of natural, out-of-hospital birth with
in-hospital obstetric births. He finds out-of-hospital
births to be slightly safer and significantly superior in terms of
economic costs ($13 billion annually) and social costs (reduced
incidence of birth trauma and bonding disorders).
There’s
no
Place
Like
Home - The advantages – and joys – of giving birth where you
live By Pam England, author of Birthing From Within
Yvonne L. Crynn's site The Midwife and
Home Birth, including Midwifery/Homebirth
Articles and information about the video, Home Sweet Homebirth-
This site is intended to help you educate yourself and others
about the choice of midwifery and homebirth. Families need to be
aware of birthing options. Midwifery is a model of care
which includes good nutrition, skillful midwifery, natural
childbirth, homebirth and breastfeeding. Also available in Spanish
- LA PARTERA Y
PARTO DOMICILIARIO
Midwifery
care
and
out-of-hospital
birth settings: how do they reduce unnecessary cesarean section
births?
Sakala C
Soc Sci Med 1993 Nov;37(10):1233-50
U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care--physicians in hospitals.
National
Certified Professional Midwives Guild
Response to a Homebirth Complication or
Tragedy
A Mother's Letter to Illinois Gov Edgar
Group Health in Washington not only offers midwife attended home
births, they have written a very positive pamphlet about this
service and hand it out to all their clients -- both licensed
midwives and CNMs are covered.
Group Health Cooperative of Puget Sound (GHC), one of the country's oldest health maintenance organizations, was one of the first managed care plans in Washington to respond to a 1993 "every category of provider law." Although certified nurse-midwives were well-established at GHC hospitals, the law required that enrollees also have access to licensed midwives (i.e., direct-entry midwives attending births in out-of-hospital settings). In addition, GHC members had for years been requesting access to home birth services, so a panel of physicians, managers, and midwives was created to examine the evidence concerning safety of home birth, the qualifications of licensed midwives, and the demand for home births among GHC members.
GHC concluded that it should contract with licensed midwives as the preferred providers for home birth services, created a credentialing mechanism, and circulated a memo to inform enrollees about this option (excerpts follow):
[To contact Group Health
Cooperative of Puget Sound, write to 521 Wall Street,
Seattle, WA 98121 - Customer service: 206-901-4636,
888-901-4636. Public relations: 206-448-6135/]
Homebirth Policy at a British Hospital
Home Birth - An
Old Tradition, A Safe Choice by Jennifer Houston, CNM
"Women traditionally have attended other women in childbirth.
For thousands of years women have delivered their babies, at
home, in their own beds, supported by their friends and family,
calling on the strength of the collective wisdom and experience
of those who know birth. . . ."
Given the state of the evidence, we should now challenge the hospitalists to prove that hospital deliveries can match the results of home deliveries. The statistics are interesting when applied in the reverse direction. Also, showing that midwives at home do as well as physicians in the hospital is an entirely different matter than challenging physicians with all their expense and operative intervention to prove that their methods offer some advantages. When studies are done showing that indeed the hospital-medical-model offers no advantages, payors, be they third-party or be they private, will refuse to keep going along with the joke.
Modern obstetrics needs to be laughed out of existence and replaced with a cooperative science that complements the midwifery model. Farces don't usually respond to debate but to humour.
Proverbs 26:4 Do not answer a fool according to his folly, Lest
you also be like him. 5 Answer a fool as his folly deserves, Lest
he be wise in his own eyes.
A Comment on Natural Childbirth,
including mention of the "Steiger curve" of penile performance.
Spoof about Absurdity of Hospitals for Normal Births
A Thanksgiving Dinner to
Remember - some more humor about a medicalized family
event
Faith Gibson's
pages on Informed Consent for Special Circumstances
Here are 3 "Special Circumstances" informed consent documents for
home-based care and/or refusal of customary obstetrical protocols
for VBAC, Twins, Macrosomia
New York - Class Action Suit for
Homebirth Rights
5/31/97 Update on New York Class Action
Suit
5/31/97 Update on New York Class Action
Suit - Morning Session
EUROPE'S
HOME BIRTH CAPITAL SEES MOMS OPT FOR HOSPITAL - This article
states Homebirth rate in Holland dropped from 30% to 13% in only
11 years. It blames women wanting to 'follow the crowd' , media
hype and women wanting epidurals.
Someone else commented: It's more complicated than that. I don't
know the exact politics, but it has something to do with how
midwives are getting paid. Apparently, they lose money, if they
have to transfer to hospital care late in pregnancy. And since
they are overworked and underpaid they tend to transfer women
early in pregnancy.
I think it is, that if they transfer a woman, then only the
hospital gets paid. Not them. So they do it early if they even
think, complications might arise.
Home
births:
'Buy
some
black bin liners' - [8/14/09] More women in Britain are
giving birth at home, which a recent study suggests is as safe as
going to hospital.
UK recommends return to homebirth as the standard of care
More women should have babies at home, not in hospital, says Health Secretary
The move comes as new figures reveal that more than . . . a third of all who give birth every year, suffer some psychological distress after delivery.
"It has taken decades for this issue to be taken seriously, . . .
that having birth at home is as safe or safer than in hospital"
#include "trailer.incl"