Friday Fallacy: Babies Die in the Hospital, Too

So this Friday, we’re going to debunk 3 things.

1. The homebirther battle cry every time a homebirth death is mentioned, “But babies die in the hospital, too!”

 

2. The “fact”  that hospitals actually cause deaths.

 

 

3. and finally, that homebirth is “as safe or safer” than hospital birth.

 

 

So what does the data ACTUALLY say? I “did my research” using the CDC Wonder data sets for all births from 1998-2006.  In the search, I used the following parameters:

 

I used the ages from birth up through 27 days, which is the accepted definition of perinatal mortality. I searched using place of birth (either in hospital or out of hospital) and I searched for all care providers as well as searching only for CNM delivery data.
I also searched the most common causes of perinatal death: Respiratory issues, which includes things like birth asphyxia, neonatal hypoxia; Complications of labor and delivery, which covers everything from malpresentations (breech, etc.) and injuries from the use of forceps or a vacuum to complications of cesarean section andabnormal contractions; and complications of the placenta, cord, and membranes. In addition, I searched maternal (pregnancy) complications — high blood pressure, multiple gestations, etc. — complications of anesthesia during delivery, and infection. Because the argument I’ve often heard against using the CDC database numbers is, “It includes all those babies born in the car on the way to the hospital,” I did the complications of labor and delivery search twice, once with precipitate delivery removed as a cause of death. I also only included data from 32 weeks of gestation and beyond, because I imagine that even the most hardcore homebirthers would head for the hospital if they went into labor earlier than that.

 

This is what I found:

 


So here’s the thing. Technically, “Babies die in the hospital, too,” is true. However, the implication is that “Babies die in the hospital at the same rate and because of the same things as they do in homebirth.” And THAT is not true. Out of the hospital, babies die at a rate 2.5 times the hospital death rate. And with Certified Nurse Midwives? It’s better, but still one-and-a-half times the rate with CNMs in a hospital! So babies do not die at the same rate in the hospital as they do in homebirth.
Not only that, they don’t die of the same things.
  • Babies outside the hospital die at nearly 3 times the rate of in-hospital babies of complications of the placenta, cord, and membranes. That’s things like placental abruption, nuchal cords, true knots, and so on.
  • They die of respiratory issues (birth asphyxia, neonatal aspiration, hypoxia…) at four times the rate.
  • Infection causes death at nearly twice the rate outside of the hospital.

But the most shocking number of all is the number for complications of labor and delivery. It is nearly eleven times –ELEVEN TIMES!!! — as high for babies born outside the hospital. This is the category that contains breech birth and other malpresentations. These babies aren’t dying from congenital abnormalities; they’re dying preventable deaths. The only category where homebirth is better than the hospital is maternal pregnancy complications, and that’s nearly equal. Homebirth should be blowing hospital birth out of the water, here — they are all “low risk” women, whereas the hospital numbers include all risk levels.

As for hospitals causing deaths, look at the numbers.
  • Not a single death attributed to complications of anesthesia and analgesia, which can only be done in the hospital.
  • I hear lots of scare mongering going on about infection in the hospital, but the out-of-hospital numbers are more than TWICE as high!
  • Complications of delivery — the category with those awful c-sections that are slicing babies open and vacuums crushing babies’ skulls — are, best-case-scenario, more than eight times higher outside the hospital, and if you add in precipitous birth, it’s almost eleven times.

Now, I know what you’re thinking: “Those numbers include all births outside the hospital, even those which are unattended!” That’s right. Many births attended by midwives are not reported as such, simply because the midwife is illegal and hides in a closet before the EMTs arrive, telling her clients not to mention she was there when the you-know-what hit the fan. Not only that, many of the same people promoting homebirth are also promoting unassisted childbirth as safe. But I understand your great concern. That is why I ran some numbers for the “other midwife” category out of the hospital:

 

 The death rates are 1.3 times higher than hospital rates, but that is for all risk levels. The best comparison is to CNM’s in the hospital. Other midwives outside the hospital have a death rate almost THREE TIMES the rate of CNMs in the hospital. And in comparing respiratory related deaths with ALL hospital births (including those attending by doctors), the rate of death for out-of-hospital births is more than four times for other midwives, and is a shocking nine-and-a-half times higher than the rate for CNMs in the hospital.

These are the cold, hard numbers. Excel did all the math for me, so I’m pretty sure they’re correct! These clearly preventable deaths are the reason that I am so passionate about this. Please, the next time someone tells you that homebirth is “as safe or safer” than hospital birth, do me a favor and tell them they haven’t done their research.

223 thoughts on “Friday Fallacy: Babies Die in the Hospital, Too

  1. Two thoughts:

    The first is that this 2-3X increase in death at home is a very robust finding, seen in study, after study, after study.

    The second is regarding the truly jaw-dropping increases seen with breech, multiples, etc. Homebirth will never be as safe as hospital birth, but all of us (Oregon LMs, I’m talking to you!) should be aware that higher risk pregnancies do spectacularly poorly at home.

    Because the licensing requirements in Oregon are so laughably minimal, most LMs haven’t seen enough births to recognize just how badly and how fast things can go waaay wrong in a birth, and the LM community encourages midwives and mothers alike to see these things as “variants of normal,” instead of recognizing the big red flashing lights warning of trouble. And if they get lucky (and they often will) and everything goes OK, they don’t realize what a bullet they’ve dodged. Then when the inevitably predictably terribly bad disaster happens, they’re dumbfounded. And then they say……”Well, babies die in hospital…”

  2. Thank you for this post! I’m so glad to see this information getting processed and posted in a noninflammatory way. Still, I’m presuming that an out-of-hospital birth gone bad that resulted in transfer would still have its results in the hospital/doctor category?

    • YES! This only covers babies BORN out of the hospital. Those born IN the hospital are counted in the hospital numbers, even when it was an intended homebirth. The numbers really are even worse if you consider that plus the fact that out-of-hospital births are supposed to be low risk.

      • I’m happy to have found this site, although I imagine I will disagree with most of the things said here. 🙂 My question is what about the fact that live babies that transferred from home to hospital for birth would also be included in these hospital births? Might these non-deaths cancel out or even more than replace the deaths following transfer to hospitals? I’m just basing this on the two midwives I’ve been a client of who have each transferred far more mothers during birth resulting in live babies than have had mothers lose babies (at home or after getting to the hospital)…

  3. It’s been proven, time and again, that low risk women who have home births attended by a skilled midwife have just as good or better birth outcomes as women who deliver in the hospital. Please don’t group irresponsible UC’ers and people who use poorly trained midwives in with the responsible CNM’s.

    My hero, Navelgazing Midwife Barb Herrera, just had a guest post on her blog about licensing requirements for midwives and why they are so important. It’s a short, but great read.
    http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2011/8/9/guest-post-licensing-midwives.html

    I’m all for natural birth, and for homebirth when it’s low risk and attended by a licensed midwife. Hospital births have their place, of course, but they have their negative sides too. I hope that people understand that there are pros and cons to both sides and the key to it all is education and information. With those things, you can make the decision that is right for you. Scaremongering on either side doesn’t help anyone.

    AHodges

    • The data clearly shows that CNMs fare better than both other midwives and out-of-hospital birth in general, especially in the hospital. This certainly indicates that what you are saying is true regarding well-trained midwives.

      However, I take issue with two things you’ve said. First, it seems you’re implying that licensed midwives are well-trained. Here in Oregon, that is certainly not the case — the requirements for licensure are less than even those requirements for CPMs, which I think are woefully inadequate. The “other midwife” category clearly shows this.

      Secondly, this is not “scaremongering.” This is providing the education you are talking about. As I indicated at the beginning of the post, it is repeated again and again that “homebirth is as safe or safer than hospital birth,” and it’s simply not true, even with CNMs!

    • AH, how has it been proven? Science is never really proven, and changes with evidence. TheNetherlands, which has better trained midwives than CPMs, have worse HB perinatal mortality than high risk patients in hospital with OB (last weeks post). And, above shows CNM OOH as worse outcomes than in hospital. HB stats of CO and WI are worse than hospital. Can you provide proper evidence it’s as safe (or safer)? I don’t buy the safer at all, there is just no plausibility to childbirth being safer outside of modern technology invented and designed to create better outcomes (and I understand there is always room for improvement).

    • “It’s been proven, time and again, that low risk women who have home births attended by a skilled midwife have just as good or better birth outcomes as women who deliver in the hospital.”

      Nope, sorry. The data on homebirth safety is actually mixed. Some studies show no significant different in perinatal mortality, others show an increase. All studies have flaws, not the least of which is sample size and matched controls. No single study “proves” anything, this analysis of data doesn’t “prove” anything but is one more piece of information for women to consider.

      There is no data indicating that the hospital is more dangerous than home, as I’ve often seen claimed.

    • I agree that CNMs are the best sutied for homebirth and that they are the ones who should be doing it. Sadly, the risk is still higher. The Dutch study of 2009, the CDC and the Aussie study are all coming back with the 2-3xs higher rate tham hospital birth. It might be a small risk to some but it IS there. You can’t argue that if something goes wrong and time is important (Abruption: 10 minutes until infant death) that a homebirth is safer than a hospital …or even as safe. It is simply not true. Again thoguh, I must state that CNMs are a great provider to have if a woman chooses to take the additional risk.

    • Which midwife only matters a small bit.

      One recent study showed that CNMs had twice the rate of death when doing homebirths.

      They don’t, all of a sudden, have twice as many sudden emergencies. They obviously get rid of all those pesky precautions that the hospital makes them do because they just know they really aren’t needed. Twice the death rate with CNMs.

      When will people wake up. You take less precautions, you get more death.

  4. Thanks, this is a great post. If you were screened and low-risk, it seems you’re still accepting an increase in disastrous outcome if something goes wrong.

  5. AHodges, I know you’ve been told homebirth is safe, so I’m not going to poke fun at you, but seriously you must re-examine this belief.

    There have been some very limited studies that suggest that homebirth with very low-risk women, attended by highly trained midwives, following strict protocols, and having access to rapid, facilitated hospital transport is not tremendously riskier than hospital birth.

    But really, how many of those preconditions apply here in the States? Most of our homebirth midwives are NOT highly trained, high-risk cases are being handled at home, and protocols are NOT being followed. Please don’t look at this data through what your midwifery community is telling you. Open your eyes. This is real. This is what we have in the US. To refuse to see it is foolish.

  6. It’s chilling to see it laid out in it’s stark cold entirety, people need to know this. Excellent post Heather. I hate reading charts and numbers and I’m thrilled to have something so clear to look at. I’ll be passing this around!

  7. From the evidence I’ve read, provided homebirths undergo strict risk assessment, have emergency equipment, well trained birth attendant & close transport to hospital, homebirths have the same mortality rate, or lower, and a lower morbidity rate, than hospital births (that are also low risk). Here’s a summary of studies:
    http://naturalmamanz.blogspot.com/2011/07/studies-confirm-homebirth-safer-for.html

    I appreciate the work you’ve put into your blogpost, but I can’t imagine it comes close to the work put into the myriad of studies showing homebirth for normal births in as safe, and even safer, than normal hospital births.

    • Unfortunately that isn’t the case with a vast number of home births, doesn’t apply to the UC subset, and may look great on paper but just doesn’t happen in practice. There is absolutely no shortage of message boards and midwives that are happy to promote studies that show “low risk” home birth to be safe while not risking out their patients and/or otherwise ignoring science. Aside from the vast mounds of anecdata displaying this negligence, it’s perfectly demonstrated in the numbers above.

      In general if you have all of the things you list MOST studies show you only have a 3x increased risk of death. Only. That’s not as safe or safer as hospital birth.

      • “In general if you have all of the things you list MOST studies show you only have a 3x increased risk of death.”

        Mary, please provide the studies that show this, because the studies I’ve provided don’t say the opposite. There was one study I read that said home births have a 3 fold risk of neonatal death (Wax), but his study was shown to be badly flawed & had many bad critiques. Here’s a critique by Medscape that pretty much says it all: http://www.medscape.com/viewarticle/739987

    • NaturalMamaNZ,

      No doubt you posted those studies in good faith. I’m sure you read them in NCB publications and they impressed you.

      But they are not impressive, as you might realize if you reviewed ALL the literature, not just the citations you find on other NCB websites.

      To take just one example, the recent Dutch study showing homebirth with midwives as having the same death rate as hospital birth with midwives seems impressive. That’s until you find out the death rate in both groups was much higher than would be expected in a low risk population. Indeed, a recent study in the BMJ showed that any LOW risk birth with a Dutch midwife (home or hospital) has a higher death rate that HIGH risk birth with a Dutch obstetrician. That’s a pretty damning indictment of midwifery in The Netherlands.

      You are probably also unaware that The Netherlands, the country with the highest homebirth rate in the industrialized world, also has one of the HIGHEST perinatal death rates in Western Europe and a high and rising rate of maternal mortality.

      So that Dutch study of homebirth midwifery, which sounded great, doesn’t show that homebirth is safe, it shows that midwives are dangerous.

      • Amy, I didn’t read any of the studies on NBC sites, I researched them myself, and many of them were fortunately full text. The results I’ve listed are indeed impressive. I’m not sure which dutch study you’re talking about (maybe you could link it), but I’m yet to find any damning critiques to the studies I’ve listed. They seem to be very well done. Unless you can find substantial holes in each and every one of those studies, your “midwives are dangerous” comment is full of holes (though I agree there certainly are some dangerous, under-trained MW’s).

        • http://www.bmj.com/content/341/bmj.c5639.full.pdf

          From the conclusion:

          “Our in-depth analysis of the perinatal mortality of normal term infants has shown that delivery related deaths are higher in the so-called low risk pregnancies supervised by a midwife in primary care than in the high risk pregnancies supervised by an obstetrician in secondary care. This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels…”

          • I also have a list of studies about midwives vs obstetricians:

            Midwife-led versus other models of care for childbearing women
            http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004667/frame.html

            We included 11 trials (12,276 women). Women who had midwife-led models of care were less likely to experience:
            antenatal hospitalization = 10% less
            regional analgesia = 19% less
            episiotomy = 18% less
            instrumental delivery = 14% less
            no intrapartum analgesia/anaesthesia = 16% more
            spontaneous vaginal birth = 4% more
            feeling in control during childbirth = 74% more
            attendance at birth by a known midwife = 7.8 fold more
            initiate breastfeeding = 35% more
            caesarean births = 4% less
            fetal loss before 24 weeks’ gestation = 21% less
            fetal loss/neonatal death of at least 24 weeks = 1% more
            fetal/neonatal death overall = 17% less
            hospital stay = 2 fold less

            “Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”
            “Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.”

            The effect/use of the drug oxytocin as a treatment for slow progress in labour
            http://www2.cochrane.org/reviews/en/ab007123.html

            “For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.”

            Increasing Access to Out-of-Hospital Maternity Care Services through State-Regulated and Nationally-Certified Direct-Entry Midwives
            THE AMERICAN PUBLIC HEALTH ASSOCIATION, 2001
            http://www.apha.org/advocacy/policy/policysearch/default.htm?id=242

            “The APHA supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services.”

            Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared With Traditional Physician-Based Perinatal Care
            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447883/

            Our study suggests that the collaborative care model, with birth center delivery for women who remain at low risk, and the traditional physician-based perinatal care model are different health care service routes to a common end point: safe outcomes for mothers and infants. But our study also indicates that these 2 models are associated with substantially different levels of use of medical resources and procedures.

            Satisfaction with Team Midwifery Care for Low- and High-Risk Women: A Randomized Controlled Trial
            http://onlinelibrary.wiley.com/doi/10.1046/j.1523-536X.2003.00211.x/abstract

            “Team midwifery care was associated with increased satisfaction with antenatal, intrapartum, and some aspects of postpartum care. The differences were most obvious for antenatal care. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service and is associated with increased satisfaction.”

            Does Team Midwife Care Increase Satisfaction with Antenatal, Intrapartum, and Postpartum Care? A Randomized Controlled Trial
            http://onlinelibrary.wiley.com/doi/10.1046/j.1523-536x.2000.00156.x/abstract

            “Midwife care was associated with increased satisfaction (compared to care under a physician, of which continuity of the caregiver was lacking), and the differences between the groups were most noticeable for antenatal care. Satisfaction with intrapartum care was related to continuity of the caregiver.”

            Team midwife care: maternal and infant outcomes
            http://onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.2001.tb01225.x/abstract

            “The study revealed no statistical differences between team midwife care and standard care in medical interventions, maternal health and infant health. These findings suggest that team midwifery as it is practised in this study is a safe alternative for women.”

            A COMPARISON OF THE OUTCOMES OF PARTNERSHIP CASELOAD MIDWIFERY AND STANDARD HOSPITAL CARE IN LOW RISK MOTHERS
            http://www.ajan.com.au/Vol22/Vol22.3-4.pdf

            Induction = 30% less
            Augmentation = 15% less
            Epidural = 9% less
            Normal vaginal delivery = 29% more
            Cesarean = 23% less
            Instrumental delivery = 24% less
            Episiotomy = 25% less
            Agpar scores less than 7 at 5 mins = 26% less
            Admission to NICU = 18% more

            “This study provides additional support for existing evidence that midwifery-led practice for low risk women has improved maternal outcomes and similar infant outcomes. This study has provided support for some improved maternal outcomes for low risk women experiencing partnership caseload midwifery practice. We support this model of practice as another midwifery-led option of care based on the principles of continuity of care.”

            Combining the perspectives of midwives and doctors improves risk assessment in early pregnancy.
            http://www.ncbi.nlm.nih.gov/pubmed/17378102

            “Replacing the routine consultation with the doctor early in pregnancy with a planning conference ( where midwives reported new mothers to a doctor) had no negative impact on risk identification. The results support that the different perspectives of the two professions in combination are important for the safety of surveillance and the psychosocial support expected from antenatal care.”

            Alternative versus conventional institutional settings for birth
            http://www2.cochrane.org/reviews/en/ab000012.html

            Allocation to an alternative setting (‘home-like’ birthing bedrooms or units in or adjacent to labor wards) resulted in:

            Very positive views of care = 96% more
            Epidural analgesia = 18% less
            Oxytocin augmentation of labour = 22% less
            Episiotomy = 23% less

            “There was no apparent effect on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or postpartum hemorrhage.”

            “When compared to conventional settings, hospital-based alternative birth settings are associated with increased likelihood of spontaneous vaginal birth, reduced medical interventions and increased maternal satisfaction.”

            I’ll look into your study though too.

          • It’s not a good critique. It a complaint from the midwives who wrote the study that showed that midwife attended homebirths had the same death rate as midwife attended hospital births. They’re upset because the new paper made them look foolish.

          • “Midwife-led versus other models of care for childbearing women
            http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004667/frame.html

            Let’s start with the first study. You’ve thoroughly misunderstood it.

            You are not the only midwifery advocate who didn’t understand it, and it is a great example of how midwifery and “natural” childbirth advocates don’t bother to read the scientific papers they cite, don’t understand what they say, and promptly disseminate misinformation to others.

            First, let’s look at what the study was trying to investigate. According to the authors:

            “Midwife-led care has been defined as care where the midwife is the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period.”

            Here’s how the authors describe the other models of care that served as the comparison group:

            “Care is often shared by family doctors and midwives, by obstetricians and midwives, or by providers from all three groups.”

            In other words, this study compared two different models of TEAM care. This study did NOT compare midwife care to doctor care. Virtually every woman in both arms of the study was cared for by midwives AND doctors. The study only looked at the role of the midwife within the team.

            Let’s look at the problems within the study itself. How did the authors determine which studies to include in this review?

            “Our search strategy identified … 31 studies for potential inclusion. Of those, we included 11 trials involving 12,276 randomised women in total … Included studies were conducted in the public health systems in Australia, Canada, New Zealand and the United Kingdom with variations in model of care, risk status of participating women and practice settings…

            Seven studies compared a midwife-led model of care to a shared model of care, three studies compared a midwife-led model of care to medical-led models of care and one study compared midwife-led care with various options of standard care including medical-led care and shared care.”

            Note that not a single study compared midwife care with doctor care.

            This study NEVER compared midwife care to doctor care. Therefore, midwifery advocates who are cite it as evidence that midwife care is superior are only demonstrating that they never even bothered to read the study.

          • Sorry Amy, the only one misunderstanding (and trying desperately to explain away this study) is you. Please read carefully this quote from the study:
            “The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care.”

            The study went say:
            “Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.”

          • Again, just to make it a little clearer for you:
            “Other models of care include a) where the physician/obstetrician is the lead professional, and midwives and/or nurses provide intrapartum care and in-hospital postpartum care under medical supervision; b) shared care, where the lead professional changes depending on whether the woman is pregnant, in labour or has given birth, and on whether the care is given in the hospital, birth centre (free standing or integrated) or in the community setting(s); and c) where the majority of care is provided by physicians or obstetricians.”

          • Which part of this statement are you having trouble with?

            In other words, this study compared two different models of TEAM care. This study did NOT compare midwife care to doctor care. Virtually every woman in both arms of the study was cared for by midwives AND doctors. The study only looked at the role of the midwife within the team.

          • I’m having no trouble, it’s you that is trying skew this study. As the name of the study says, this study compares births that are ‘led’ by either midwives, obstetricians, or shared care. Births that were ‘led’ by midwives fared better. The only mention of ‘teams’ was when a subgroup analysis was done between caseload vs team midwifery care.

            “Midwife-led care has been defined as care where “the midwife is the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period” (RCOG 2001). Some antenatal and/or intrapartum and/or postpartum care may be provided in consultation with medical staff as appropriate.”

          • NaturalMamaNZ – how many of the studies you listed actually encompassed homebirth? They seem to be drawn from countries where midwives provide a lot of the in-hospital prenatal and labour and delivery care, and generally seem to be comparing various models of hospital or other health-service based care.

            I have no problem with midwifery care in the hospital – it’s how all my children have been born – but that doesn’t mean you can automatically extend these findings to homebirth with midwives.

          • NaturalMamaNZ,

            You are now 0 for 3 in quoting studies that supposedly suppport the safety of homebirth.

            1. The Dutch study you cited is not particularly meaningful in light of the fact that LOW risk births with Dutch midwives (at home or in the hospital) have a higher mortality rate that HIGH risk births with a Dutch obstetrician.

            2. The Johnson and Daviss study NEVER showed that homebirth with a CPM is as safe as hospital birth because it never compared mortality rates for homebirth to low risk hospital birth in the SAME YEAR.

            3. The Cochrane review of midwifery that you cited does NOT compare midwifery care to OB care. It only looks at how TEAM care is organized. And, of course, it tells us nothing about homebirth.

          • Amy, if you want to be taken seriously you can’t explain away studies by skewing them. The authors in these studies state in black and white that homebirth can be safe, and that midwives have better outcomes.

            I’ve asked you for evidence that the US study has taken mortality stats from the 1960’s (as you claim), you haven’t provided any.

            Again, since you seem to have trouble comprehending:
            “Midwife-led care has been defined as care where “the midwife is the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period”. Some antenatal and/or intrapartum and/or postpartum care may be provided in consultation with medical staff as appropriate.”

            This is not ‘team care’, and no matter how many times you say it, it will not be true lol.

            I’ll give you your one dutch study for now. But I’ve already provided studies showing the opposite.

            I’ve also provided a page of studies showing homebirth can be safe. I realise it might be hard hearing the results of these studies as an OB (I’m guessing) but it’s through these studies medical attendant’s can learn where they’re lacking and can improve.

          • “Amy, if you want to be taken seriously you can’t explain away studies by skewing them.”

            If YOU want to be taken seriously you can’t expect us to accept the studies just because you cite them.

            You seem to be unaware of some basic principles of evaluating scientific evidence. First, you must draw conclusions from the preponderance of the evidence, not just the studies you like. Second. just because a study exists does not make it true. That’s why you have to present the data in the study and the appropriate quotes. That’s what doctors do and if you expect to be taken seriously, you MUST do it, too.

          • “First, you must draw conclusions from the preponderance of the evidence, not just the studies you like. Second. just because a study exists does not make it true. That’s why you have to present the data in the study and the appropriate quotes.”

            Amy I’ve provided studies, quotes and figures – a multitude of them. You are trying every way possible to avoid them. If you wish to investigate the studies further you are welcome, the links are provided (and as an OB I would expect nothing less of you).

            You need to take your own advice, come up with something substantial. You’ve provided next to nothing, while ignoring a large amount of evidence presented to you for no other reason than you are stuck in your own ideologies.

    • This is crazy.

      Homebirth has a lot less intervention because most are dead before they reach the hospital when needed.

      The lower rates of death are because all the difficult patients are in the hospital.

      If you don’t appreciate that standardizing for risk is important, no one can help you.

      If you don’t detect the flaws in midwifery advocate studies and how they routinely declare themselves “safe” by comparing their low risk patients to higher risk hospital, all the while denying it. Or comparing deaths including timeframes either not related to birth attendant errors and/or ommiting timeframes related. Or arbitrarily
      declaring all homebirth deaths as unpreventable than no one can help you.

      The netherlands had a study with everyone. Low risk in the home had higher deaths than the high risk in hospital.

    • From the first study you cited:
      “It should add confidence to the safety of home birth in a context such as ours in which registered midwives have a baccalaureate degree or equivalent and are an integral part of the health care system. Our findings do not extend to settings where midwives do not have extensive academic and clinical training.”

      That leaves out the majority of US midwives, many of whom advocate for mothers who fall well outside of the low-risk categories listed in the study you cited. Yes, in women who are optimally healthy, as the study listed, who have a well-trained midwife who is working WITH the health care system and not against it, home birth is reasonably safe. That’s a lot of qualifications, and I do not see most homebirth advocates in the US speaking up for those. Cheyney, for example, who is with a prominent midwife association in the US, seems to think Oregon has “rigorous” midwife standards even though you not only do not need a nursing degree to be a midwife, but you can legally practice as a midwife WITHOUT A LICENSE.

      These people are running wild and killing both women and their babies.

      • Yes ‘Reality’, it’s so important birth attendants are well trained (I advocate CNM’s). I understand the situation isn’t so hot in the US with midwives being so unregulated & undertrained, very sad.

        Now we know the specific situations homebirths are safe in, it’s a matter of ensuring ONLY those births happen at home, by following strict risk assessment.

        ‘Mom’, the studies I’ve linked to use low risk births for both the midwives & doctors being studied. Midwives came out on top, with lower rates of intervention & morbidity, & similar or lower rates of mortality. The ‘doctors have higher risk patients’ line doesn’t apply here, because the doctors studied also attended low risk births, along side midwives.

  8. Naturalmamanz, you say:
    From the evidence I’ve read, provided homebirths undergo strict risk assessment, have emergency equipment, well trained birth attendant & close transport to hospital, homebirths have the same mortality rate, or lower, and a lower morbidity rate, than hospital births (that are also low risk).

    I don’t know how things are in New Zealand (actually, I DO– a good friend is involved with the Action to Improve Maternity care in NZ, but that is another story), but here in the U.S. the midwives who attend home births have NOT attended university, have NO scientific or medical backgrounds, carry NO insurance whatsoever, may not have even graduated from high school, have NEVER worked in a hospital or seen enough births to know what complications really look like, have no proper overseeing or regulatory body, and quite often are working illegally. They carry NO “emergency” equipment, unless you consider a tank of oxygen (if you’re LUCKY– most don’t even have this) emergency equipment. They do NOT have relationships with doctors or Nurse-Midwives at hospitals. So when their patients go into crisis, the “midwife” just dumps them off at the local Emergency Room, or simply calls an ambulance. The hospital is left to clean up the mess that the homebirth midwife made– all too often, homebirth and midwifery-related morbidity and mortality winds up in the records at the *hospital* because by the time a patient is finally transferred for appropriate care, it is too late even for the most advanced practitioners and technology to save. Where do you think the Centers for Disease Control gets their numbers? They get them from “study after study!!!” Also, the “studies” on your blog are tragically flawed, and made all the less credible by the fact that they are supported by known “quack” doctors such as Michael Klein. The CDC data is far more reputable, and there is no agenda on the part of the people who compiled these numbers from countless studies (unlike the studies you cite, which are all backed by natural childbirth advocates). But good on you, love, because I’m sure you worked very hard to put together your blog full of hopelessly biased and agenda-driven pieces.

    • The problem with such “strict risk assessments” is that to buy them, you have to ignore the vast swaths of the internet dedicated to getting your midwife to fail to test you for maternal complications, tricking those tests, finding unlicensed midwives, birthing with just a doula, etc. These strict risk assessments are only followed in select areas where the states have taken a keen interest in regulating midwives and even then there is a whole industry dedicated to flouting such requirements.

      • Whatpalebluedot, I view these types of comments as being in the same vein as those from people that tout that cocaine really really is a theraputic drug and should be available to people because “in this really strict controlled environment it was totally awesome’, while then completely ignoring how cocaine is actually used in the real world and all of its negative affects on society.

        (and no, for you extra slow home birth supporters I’m NOT comparing cocaine use to home birth)

        • Hmm you just compared birth to cocaine, and then said you’re not, so which is it? What you’re not mentioning, or may not know, is that homebirth has many benefits – lower rates of intervention and morbidity, and higher rates of spontaneous vaginal birth and satisfaction with birth. Those are some pretty big pluses and as long as it is safe (and these studies show it certainly can be), I’m failing to see the problem here?

          • Thank you for demonstrating your inability to grasp exceedingly simple concepts. I was comparing the promotion of two totally different subjects, not comparing the two subjects. Fail.

          • Promoting something as safe and good but with tons of caveats while ignoring how it is applied in the real world is stupid and unethical, which is what both of those camps do. Your inability to grasp the difference between critiquing marketing strategy of two subjects and comparing participation in those two subjects indicates you would have failed to understand the argument regardless of what the other example was.

            Believe it or not your own stupidity doesn’t negate arguments or make them poor examples. Shocking I know.

          • Mary, these studies describe in detail how safe home birth can be achieved, and it’s application in the real world was proven with the thousands of midwives who participated.

            Ofcourse midwives can and do replicate the same results in real life. Ensuring protocols are followed is the next step. Though I agree there needs to be more regulation, training and supervision of midwives, especially in the US.

    • Marlo, I included the study: Outcomes of planned home births with certified professional midwives: Large prospective study in North America http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558373/?tool=pubmed

      This study concluded: “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.”

      Take note this study was using Certified Professional Midwives, not just Certified Nurse Midwives. I do agree though, I think MW’s in the states should do a university course.

      As for NZ, we are 23rd in the world for the lowest perinatal mortality, while US is 35. Clearly our midwife led model of care is doing well. For more global stats:
      https://www.facebook.com/photo.php?fbid=266162433400450&set=a.259497457400281.83485.159375377412490&type=1&theater

      • Natural MamaNZ-

        Ah, so it’s midwives that are the cause of better perinatal mortality rates?
        It’s not, um, access to biomedical care? Because about 50 million people in the US do NOT have that.

        What are the poverty rates in NZ compared to the US? How about differences in perinatal rates as they relate to SES and race/ethnicity? Who has the best perinatal rates?

        I am truly tired of hearing that midwives are the root cause of lower perinatal mortality rates in other countries. I find it cruel and highly naive to believe that women are suffering from over-intervention rather than illiteracy, poverty, and a complete lack of access to health care. It not only denies reality, but also belittles the structural injustices of our times.

        • Bethany, ofcourse things like socioeconomic status & access to medical care matter, but you’re kidding yourself if you think the US is the only country with those problems. Do you really think the type of medical attendant at a birth is not a significant factor? Ofcourse the medical attendant has a HUGE impact on the outcome of a birth. I’ve listed a number of studies further up the thread showing that midwife attended births have less intervention, less complication, & more spontaneous birth, than OB attended births (these studies involve all low risk women & are confounded for things like socioeconomic status etc).

    • Marlo: “here in the U.S. the midwives who attend home births have NOT attended university, have NO scientific or medical backgrounds, carry NO insurance whatsoever, may not have even graduated from high school, have NEVER worked in a hospital or seen enough births to know what complications really look like, have no proper overseeing or regulatory body, and quite often are working illegally. They carry NO “emergency” equipment, unless you consider a tank of oxygen (if you’re LUCKY– most don’t even have this) emergency equipment. They do NOT have relationships with doctors or Nurse-Midwives at hospitals. So when their patients go into crisis, the “midwife” just dumps them off at the local Emergency Room, or simply calls an ambulance.”

      How about you add a “some midwives” to this statement Marlo… I am a CPM and I HAVE attended University, (I have 2 separate degree’s), I DO have medical background, a number of years, Definitely DID graduate from high school, Have worked many years in the hospital and seen attended many births inside and outside the hospital, and have seen and manages complications in both settings, I WISH I had a proper national regulatory body, but I DO work LEGALLY 🙂 I carry an O2 tank and resus equipment, Pitocin, Methergine and Cytotec for PP hemorrhage, IV supplies and Suturing supplies (I re-certify to use these every 2 years),
      I DO have a good working relationship with several OB’s and CNM’s, and I have never “dumped” a client but instead call and confer with these caregivers and arrange transports for my clients and then stay with them at the hospital working with the staff until my clients have had their babies. I then see them during their postpartum care for 8 weeks.

      I am not saying that there may not be some midwifes who fit your description, but in no way do all CPM’s fit this description, please do not lump us all together. I am sure I could make generalized statement about any group of people and would be correct about some but not all…

      Oh and referring to an earlier post to clarify a false statement…. “Here in Oregon,….. the requirements for licensure are less than even those requirements for CPMs, which I think are woefully inadequate”

      The requirements for licensure in Oregon require each midwife to obtain their CPM and then do additional births and clinical hours on top of that requirement. So it is not just the additional births and hours that are needed but both those and the CPM required births and hours, and skills assessment and testing. Just wanted to clarify so you are not spreading false information around…

      • Oops forgot to say you are correct in that I do not have insurance…. I also do not bill insurance. I do very low income births for those who are of low risk. While insurance may be a possibility in my future at this time I do not have it….. I always look back to my instructors comments while in nursing school about malpractice insurance being like painting a bullseye on your back. 🙂

        • Bliss it’s all very good to claim that YOU are a good midwife, and that SOME other CPMs are good midwives TOO, and bitch that Heather is not being fair to the GOOD CPMs (all three of you), but until (most of) the entire group of you gets your shit together and insists on excellence, adheres to standards, follows protocols, and behaves like the professionals you claim to be, DON’T BE CLAIMING THAT THE CPM IS AN ADEQUATE CREDENTIAL!!! ONE CPM WITH SENSE DOES NOT MAKE HOMEBIRTH SAFE!

          Sheesh!

          • Crone,
            Allow me to also point out that being with a Doctor in a hospital doesn’t make hospital birth safe either. Talk to a few maternity ward nurses sometime, the horror stories they will tell you of Doctors performing C-Sections in order to get home in time for dinner, etc. would blow your mind.

            Home births can be done in a safe manner, hospital births can be done in a safe manner. They both have their pro’s and cons.

      • No, Bliss, you don’t have to be a CPM to get your Oregon license. You can just take the NARM exam, observe 25 births, and attend 25.

        • No attitude devant you do need to be a CPM in the state of Oregon to license. When you take the NARM you are testing to become a CPM, you cannot just walk up and take the NARM test

          http://www.narm.org/pdffiles/cib.pdf

          To take the exam you may be educated through a variety of routes, including programs accredited by the Midwifery Education Accreditation Council (MEAC), the American Midwifery Certification Board (AMCB), apprenticeship education, and self-study. If the midwife’s education has been validated through graduation from a MEAC-accredited program; certification by the AMCB as a CNM/CM; or legal recognition in a state evaluated by NARM for educational equivalency, the midwife may submit that credential as evidence of educational evaluation and may apply to take the CPM examination.

          The NARM Portfolio Evaluation Process (PEP) involves documentation of midwifery training under the supervision of a preceptor. This category includes entry-level midwives, internationally educated
          midwives, and experienced midwives. Upon successful completion of the documentation portion of PEP, the applicant must successfully complete the NARM Skills Verification. Then the applicant will be issued a Letter of Completion that can be submitted to NARM’s Application Department as validation of midwifery education.

          The state requires that midwives must have taken their NARM within the last 3 years of applying for their license It in no way states they can just take it and not be a CPM, http://www.oregon.gov/OHLA/DEM/Midwifery_How_to_Get_Licensed.shtml#Qualification_Requirements

          Oregon Clinical Experience Requirements: As revised January 2011

          *Participation as an assistant at 25 deliveries (5 more than NARM)
          *25 deliveries as the primary birth attendant (5 more than NARM)
          *Participation in 100 prenatal care visits (25 more than NARM)
          *25 newborn examinations (5 more than NARM requires)
          *40 postnatal examinations

          Have provided continuity care for at least 10 of the primary birth attendant deliveries, (7more than NARM required) including four prenatal visits, one newborn examination and one postpartum exam.

          Of these 50 births, at least 25 deliveries must have taken place in an out-of-hospital setting and 10 births must have occurred within the two years or 24 months preceding the date of application.

          • Bliss, you’d be a better advocate for CPMs if you actually took the time to go to the OHLA website. You’re wrong. You can take the NARM exam and do 25 births and you’re in. You don’t have to be a CPM.

          • How many times do you have to recognize fetal distress and transfer? 0

            How many times do you have to recognize placental abruption and transfer? 0

            How many times do you have to treat bleeds that don’t stop with a shot of pitocin? 0

            How does catching 25 babies help women in crisis?

            If you don’t have enough experience with reversing problems, many times, enough to master them, then what are you doing besides taking our money?

            People hire health providers for problems, not normalcy.

      • Then you should have become a CNM am been a real midwife. Our problem is not that you exist. YOu do. WE know you exist. Our problem is taht you don’t have to have all that stuff to be a midwife. An 18 year old with no college canbe a midwife. THAT is a problem!

      • Except…none of that matters for a damn even if it’s completely true because licensure is not MANDATORY in Oregon, and from a consumer’s point of view it can be extremely difficult to tell who is licensed and who is not just from looking at their business card/website/practice. Anyone can be a midwife in Oregon, even if they don’t meet the miniscule requirements to gain a license.

  9. Naturalmamanz, have a look at this blog. It is written by a woman who started out going down the path of homebirth midwife, but had a change of heart when she realized just how low that bar was set, and how it increased the risk to an unacceptably high level for mothers and babies. She is now in university to become a Certified Nurse Midwife. http://www.midwifeology.blogspot.com/

    • “Where do you think the Centers for Disease Control gets their numbers? They get them from “study after study!!!” Also, the “studies” on your blog are tragically flawed, and made all the less credible by the fact that they are supported by known “quack” doctors such as Michael Klein.”

      Please point out how these studies are tragically flawed if you want to be taken seriously. And please provide the studies that the CDC uses.

      No the CDC data is not confounded to the degree it needs to be accurate. It does not include vital info about the health of mother and baby, info that is critical in assessing whether a homebirth is an appropriate option for a mother and baby. The CDC’s data is too simplistic, which is why detailed studies are needed. And they’ve been done, the results are in, and it’s concluded that under certain circumstances homebirth is safe.

      • No,the CDCs numbers come from manditory reporting at the birth of a child. They are a primary source– not from a study. There is no study. This is data only, computed by Excel…you do know the difference between a primary source and a study , right?

  10. And P.S., There is NO study on your list there that ever has used the number of births that these numbers represent. The CDC data that the author here on 10cm is referencing are from ALL the births in the US! No cherry-picking of data, no deliberately mismatched test populations. This is ALL THE INFORMATION on ALL THE DOCUMENTED BIRTHS IN AMERICA for the time period in question.

  11. Oh, and I need to add that unless the study says that homebirth is as safe with AMERICAN midwives (IE CPMs and DEMs ) it it deos not count. our midwives do not have college educations like they do in the rest of the world does it DOES matter.

    • Outcomes of planned home births with certified professional midwives: Large prospective study in North America http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558373/?tool=pubmed

      This study concluded: “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.”

      Take note this study was using Certified Professional Midwives, not just Certified Nurse Midwives. I do agree though, I think MW’s in the states should do a university course.

      • Dr. Amy has done several critiques of the Johnson and Daviss Study.

        http://skepticalob.blogspot.com/2011/04/being-published-doesnt-make-it-true.html

        There are several problems, not the least of which is that they compared homebirth with a CPM in 2000 to hospital stats from 1969. If they’d used the numbers from 2000, they would have found…homebirth has a mortality rate of almost triple that of comparable risk hospital birth, just like my numbers above show.

        • NaturalMamaNZ, I wouldn’t argue with Heather on this one. You’ve read an abstract, and she has analyzed the study. Guess who actually understands what she’s talking about? (Hint: her country’s flag has 50 stars). Seriously, you clearly have NO IDEA what you’re talking about. The study you reference compared home birth in 2000 to hospital birth in 1969. Skewed analysis much?

          • btw, I’m surprised that our NZ guest has never heard of Action to Improve Maternity, the NZ organization of parents whose children were injured or killed by the poor out-of-hospital maternity care in New Zealand.

          • Crone, it’s a full text study, not an abstract. And if you read it, you’d see it clearly states:
            “We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics.”

            Either you’ve got the wrong study, or Skeptical OB is full of it.

          • Please follow the link Heather has provided. Seriously, just read it. We are all talking about the same study.

          • “We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics.”

            Right. They compared INTERVENTION RATES for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics.

            But when it came to MORTALITY, they did something different:

            “The results for intrapartum and neonatal mortality are consistent with most North American studies of intended births out of hospital and low risk hospital births ”

            And those studies date back to 1969. They didn’t compare homebirth with a CPM in 2000 with low risk hospital birth IN 2000. Why not? Because that would have shows that homebirth had nearly triple the rate of neonatal death.

            It was a deliberate bait and switch. Johnson was the former Director of Research for MANA and Daviss, his wife, is a homebirth midwife.

            Did you know that MANA has continued to collect data since the 2000 study? There are 23,000 births in their database and they won’t release the death rates. What does that tell you? It tells me that even MANA knows that homebirth with a CPM has an unacceptably high rate of neonatal death.

          • How is it possible? It’s a bait and switch and everyone fell for it, including the editors of the BMJ.

            Do I have proof? Of course I have proof. Johnson and Daviss have already acknowledged it publicly, but you don’t notice them retracting the paper. That’s because they knew all along it didn’t show what they wanted people to believe it showed.

            But the most recent data from MANA (the 23,000 births) has such terrible death rates that MANA can’t publish it in any form; there is no trick that was obscure the truth.

            Just because something is in a journal does not mean that it is true. It just means that it is piece of research that is worthy of being included in the conversation about the issue. You can can only reach conclusions based on the totality of the evidence, not individual papers.

          • Well ofcourse a study is not always true just because it’s in a journal lol. If you have proof, then where is it, do you have a link? And if the study has been amended then it’s been settled and doesn’t matter anyway (apart from ruining their reputation). Also if MANA’s mortality rate is not published how do you know it’s terrible?

            I agree you need a multitude of studies to be sure of anything, & there are a multitude of studies showing in certain circumstances homebirth is safe.

          • I went through that study word for word and found no mention of a study from 1969 (as Amy quoted). There was mention of a study by Schlenzka in which data was used from 1989-90. The reason quoted was because it was the only study that used similar study methods. I don’t know whether a better comparison study exists. If you think there is then go ahead and present it.

            If you can find mention of a study from 1969 be my guest and please quote it. Neither you or Amy have given any proof!
            http://www.bmj.com/content/330/7505/1416.long or
            http://www.homebirthdebate.com/BMJCPM2000_corrected.pdf

          • Johnson and Daviss *themselves* admitted that they did not use the right numbers the first time (the second link you have there). They released an update in which they claimed the numbers from the year 2000 were not available at the time that they published the study the first time. Dr. Amy claims they were. I don’t know who is right and I don’t care — it doesn’t really matter. They then reanalyzed the data using the numbers from the year 2000 and came to the same conclusion they had originally. However, when they used the updated numbers, they threw out 5 intrapartum deaths, apparently for the heck of it, instead of comparing them to the intrapartum deaths in the hospital group. They then threw out three neonatal deaths due to birth defects from the homebirth group, but did not do the same for the hospital group. Therefore, they were comparing homebirth neonatal deaths WITHOUT birth defects to hospital neonatal deaths WITH birth defects. Hardly a fair comparison, but ingenious if you are trying to show that homebirth is as safe as hospital birth.

          • Even if Amy made a typo and meant 1989, it makes no difference. They should have compared the same year! Comparing 1989 to the year 2000 is really no different than comparing 1969 to 2000. They’re both unequal comparisons.

          • Heather I’ve read through the documents, and the more I read the more valid their study becomes. The only study that they claim was comparable was from ’89. Though I agree that wasn’t the best decision.

            When they compared their figures to more recent figures (Matthews), the studies used weren’t ‘like for like’, so they had to eliminate certain groups of women to make the studies comparable. That seems pretty valid.

            The 3 deaths that were excluded due to fatal birth defects would have been terminated if under obstetrician supervision. One Amish couple knew the fatal birth defect, but chose to go ahead with the pregnancy. Two other couples refused testing.

            Problem is, were their any deaths in the Matthews study that had similar outcomes and WERE included in their figures?

          • Oh, please. All this caterwauling about confounding, and you’re just going to assume all these babies would be terminated by someone who would use an OB? That’s insulting. I would not terminate a pregnancy for any reason, and i have only used OBs for prenatal care. If you take fatal birth defects out of one group, you have to remove them from the other, and not just assume they aren’t there.

      • Honey, this isn’t a study at all.

        They presented their numbers. They presented numbers a bunch kind of similar studies, going back the to 60’s.

        There’s no data analysis. The quote is (again) declared by fiat.

        If you pull numbers of comparable patients off the CDC database, they are 3-5 X more deadly.

        And BTW, the midwives claim nearly all their deaths are neonatal SIDS. If you believe them (as opposed to concluding it was ignored distress leading to asphyxiation) They have an epidemic. Their rates is about 300X the rest of the country.

      • Yes, because compainring hospital birth in the 60s to midwifery today is fair? Um, no. All this study is saying is that by going with a midwife you are getting the same numbers as a 1960s hospital birth (Yes that was when they were using twilight sleep). I do so wonder what the parinatal mortality rate was in the 60s? I’m betting it’s gone down a hell of a lot since then.

        • Really? Where’s the proof they used a study from the 60’s as a comparison? Prove it.I’ve been over that study with a fine tooth comb, there’s no study from the 60’s. There’s was a large study from 1989-90 used. Maybe that’s the one you’re talking about? Maybe you’re right, who knows, provide some proof.

        • Oh another one lol. Tao groupie, maybe you can dish up an actual quote from the study mentioning a study from 1969, instead of spewing, lame bitchy comments, or is that beyond you & your cronies?

          • Table 4 shows the studies that J&D used in comparison to homebirth with a CPM in 2000, including:

            Neutra et al One academic hospital in Boston (lowest risk women), 1969-75

          • Amy thankyou for providing a quote. However there are a collection of 10 different studies used to determine a combined intrapartum and neonatal mortality, including the Neutra study. The Neutra study was not used on it’s own, as you’re proclaiming it was.

          • Not all of them go back to 1969 (which was 30 years before the date in question), but all of them are out of date, some decades out of date. That means that Johnson and Daviss deliberately used a mortality rate that they knew to be inappropriately high.

            The 2000 hospital birth mortality rates were available to them (they were published by the CDC in 2002), so there was no excuse not to use them besides the desire to make the bad homebirth statistics look good by comparison.

            The key point that you have to keep in mind is that the ONLY people who think homebirth is safe are homebirth advocates. It’s not that we unaware of what the literature shows. We are quite aware, having read the papers. The Johnson and Daviss paper does NOT show homebirth to have a the same mortality rate as comparable risk hospital birth.

            You’ve also ducked a really important question. If home birth is so safe, why is MANA hiding the number of deaths in the 23,000 homebirths they have records for? We both know that if those numbers showed homebirth to be safe, they’d be shouting it from the rooftops. But these data are so bad that even a bait and switch isn’t possible. They must be completely hidden.

          • Amy, I’m not part of MANA, I can’t answer for them. But until they show their stats we can’t assume what their stats are.

            J & D claim the numbers weren’t available to them, you say they were. Can you prove that they were? Otherwise there’s no point saying it. Also, most of their numbers used for mortality were not out of date. They used studies, both for homebirth and for hospital birth, that were similar, ranging from 1969 – 2000 in BOTH groups. It wasn’t a matter of taking only figures from 2000 and comparing them to figures only from 1969. A wide range of studies on homebirth and hospital birth were taken from the last 30 years and compared.

            It’s seems pretty legit, and it seems you’re one of the only ones complaining, almost everyone else who’s written critiques has no issue.

            About homebirth advocates – I’m an advocate for safe birth, I go by what the studies show us. In the US birthing options seem quite polarized, if you want a hospital birth, you’re often at the mercy of an OB, who prompts you to have a interventions that are shown to cause worse outcomes.

            Here in NZ, midwives are the lead maternity carers, even in hospital. So there’s usually no risk of unnecessary intervention. And if help is needed from an OB, they’re right there to help.

          • Of course I can prove they were available. They were published in 2002. Johnson and Daviss had the data in hand. You were the one who pointed out the control group they used to compare intervention rates. That’s the same data set that they should have used for mortality rates, but didn’t.

            And even if they were telling the truth that they didn’t have those statistics available at the time, they certainly do now. So they KNOW that homebirth with a CPM in 2000 had nearly triple the mortality rate of low risk hospital birth, but they have not amended their study to reflect the most accurate information.

            Regardless of what J&D thought at the time, the fact is that when you do the appropriate comparison, homebirth with a CPM has nearly triple the rate of neonatal death.

          • Johnson & Daviss, quote:
            “Since our article was submitted for publication in 2004, the NIH has published analysis more closely comparable than was available at that time.”
            Obviously the data was there when they submitted their study, but not close enough in comparison.

            “While we still do not offer the comparison as a completely direct one, as it is the closest we have and the comparison is occurring regardless of our cautions, we offer the following adjustments that have to be made to provide the comparison of the CPM2000 analysis in as accurate a manner as is possible with the published NIH analysis.”
            Now that they are using the NIH data for comparison, they have now amended their own findings to make them as closely comparable to NIH data.

            The only part I have issue with is the fact they removed 3 infant deaths with fatal birth defects. If they remove the infant deaths with fatal birth defects from the NIH data aswell, then all seems fair.

          • Amy, thanks for providing the CDC doc. But the only person that is wrong here is YOU (ironic), but you can’t seem to accept it or publicly acknowledge it. Any ‘claims’ I’ve made have been virtually direct quotes from reliable studies (not counting J&D). I stick to the evidence. You however make broad, prejudice & ignorant statements about natural birth & midwives especially. When the evidence shows you are wrong, you try to twist the evidence into your own warped reality. Then you project onto others what is true of yourself (which you just can’t accept) – “You’ve been wrong about every single empirical claim you’ve made about the scientific literature. Exactly how many times do you have to have that pointed out before you accept that you have no idea what you are talking about?”

          • Here’s an example of your neurotic attitude:

            You said:

            “midwives are dangerous”

            A list of studies was provided for you showing midwives have better outcomes than doctors. You picked the first study & tried to warp it into something it wasn’t:

            “this study compared two different models of TEAM care. This study did NOT compare midwife care to doctor care”

            It was then pointed out the study CLEARLY was about midwife, doctor or shared care, inwhich midwives came out on top:

            “Midwife-led care has been defined as care where “the midwife is the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period.”

            “Other models of care include a) where the physician/obstetrician is the lead professional, and midwives and/or nurses provide intrapartum care and in-hospital postpartum care under medical supervision; b) shared care, where the lead professional changes depending on whether the woman is pregnant, in labour or has given birth, and on whether the care is given in the hospital, birth centre (free standing or integrated) or in the community setting(s); and c) where the majority of care is provided by physicians or obstetricians.”

            Still you refused to acknowledge it:

            “It only looks at how TEAM care is organized. And, of course, it tells us nothing about homebirth.”

            Obviously no matter how much evidence is shown to you, & no matter the quality of the study, you will ignore it, in favor of your own warped views.

            Another example:

            I said:

            “The point is being relaxed during birth leads to less complication & less need for intervention.”

            You said:

            “No. No scientific evidence for that, either. That’s just another thing that NCB advocates made up.”

            A raft of studies with quotes & figures was provided for you, but you still go on:

            “If the evidence is there, it should be very easy for you to provide the appropriate quotations, yet I haven’t seen you provide any.”

            There was an entire page of studies with quotes & figures provided for you.

  12. Great job Heather! Sadly even with this much evidence there will still be a lot of hard core home birth advocates who just ignore the numbers or claim they are fake (Heaven forbid they have to crunch the numbers themselves so that they can see this is for real..). The fact that more babies die at home (three times as many) with those births being the LOW RISK women than in hospital births (some of the most HIGH RISK women included in those numbers) should speak for itself. Add in the fact that when a home birth goes wrong it gets dumped at the hospital by the midwives and then counted as a hospital death and yet STILL the home birth death numbers are higher should really cause people to pause before considering home birth. The amount of women giving birth at home is a much smaller number than the amount of women giving birth in the hospital and yet they are coming up with a higher death rate? If people are going to preach about how much better home birth is than the least they need to do it be up front with the facts. Home birth is in no way safer than a hospital birth.

  13. Heather, I went through the ‘rapid responses’ listed at the bottom of the study. And while many praised the the study, there were important issues brought up by ‘A pediatric perspective’, like the fact that it’s difficult to pick out truly low-risk births from CDC stats. I think that alone is enough to put it out of the running. The study should have included matched study groups, like other studies have. On it’s own, the study may have merit, but without a matched study group, it’s hard to compare the results to hospital birth. This is the same problem you face, will you continue to post results that are not fully confounded?

    • It is hard to pull low risk births off the CDC database. They will always be far worse than the homebirth cohort.

      Nevertheless, they (hospital “low” riskers) have lower death rates.

      What more do you need?

      It is always so pathetic when midwives’ criticisms of studies that show how dangerous they are, are errors that true are there, but that work in their favor.

      • Mom, many studies show low risk hospital births & low risk home births (along with a well trained MW, close transport to hospital, & onhand emergency equipment) have the same mortality rate. Some studies show homebirths have a lower mortality rate, & almost always a lower morbidity rate. If you want to stick to broad unconfounded stats go ahead, but I prefer detailed info.
        http://naturalmamanz.blogspot.com/2011/07/studies-confirm-homebirth-safer-for.html

        • Sure, the Canadian study shows this, and I have no problem with a low-risk woman having a homebirth with a well-trained midwife, close transport to hospital, and onhand emergency equipment. However, that simply isn’t the situation we have here in the US. The CPM is a joke certification. You have midwives with a master’s degree from Bastyr and a good variety of clinical experience on one hand, and they are probably very good midwives. On the other hand, however, you have women who haven’t bothered to take a single college course taking correspondence training from hacks like Carla Hartley at AAMI who is constantly advocating LESS education on her facebook page, and apprenticing with a single midwife who’s lucky if she’s doing 15 births a year. They’re complaining all over the MANA students email list about how hard it is to meet the 3 continuity of care cases they’re currently required to have and how it’s going to be impossible to meet the requirement if they raise it to 10.

          • Not only that, but Bastyr only takes a few midwives on in a year (5-6), and they are quite selective. In fact, I would say they are the only institution training specifically homebirth midwives in the US that is doing even a reasonable job. They claim that they meet the requirements for Canada’s registered midwives, and I have no reason to doubt that is true. However, like I said, they are training only a tiny fraction of these midwives. The vast majority get their CPM through the portfolio method.

  14. This is how you read studies, NaturalMamaNZ? You read the rapid responses? Jeez, no wonder you seem to have no clue about what the studies really say.

  15. These numbers are very different from what i’d been “quoted” by the NCB community I found after my difficult delivery with my first. I think it’s also be helpful to pull up maybe the top 3 (or 4?) “journal articles” cited that supposedly show hb to have the same mortality rate as hospital, and discuss their weaknesses. I know dr. Amy references one from the NEJM (I think?) thats popular with hb advocates and says that the actual study does not show what the hb community claims it does. And some of the studies were done in countries with much higher educational requirements than the US, and with cooperation between OBs and a solid transfer plan.

    You’d be my hero forever if you wrote a blog like that, or even had Dr Amy write a guest post if you feel like her experience with statistics is better (I don’t know what yours has been so that’s just a random suggestion.). I think some women see a biography and think “this looks official!” and don’t bother to consult any of the sources, or even READ the titles of the articles or books.

  16. I’ve had one hospital birth and one homebirth. EVERYTHING before birth, during labor, and postpartum was easier at home. In the hospital I was on antibiotic drip, epidural tap, pitocin drip, mag drip, pitocin shot,and pain killer (pill) afterward! ..my baby was pulled from my body w/ forceps..I was threatened with a c-section. I ended up with a tremendous amount of bleeding after my doctor pulled the ambilical cord to ‘manage’ my 3rd stage. My placenta was no longer mine and was ‘waste’. I ended up BACK in the hospital A week later bc they thought I retained A peice of my placenta. I was so sick PP. Weak from blood loss and traumatized by the experience. My two births were like night and day. SO DIFFERENT! At home I delivered my child myself. Peacefully, in the water with midwife, myself, my partner, and my first child. My midwife who is also A massage therapist, and herbalist was wonderful and always three steps ahead of me! My 41week, seemingly pain free water birth with ZERO complications & ZERO drugs was amazing. Postpartum healing was SO different. Bleeding for 10days and minimal swelling. I got to keep MY placenta which I ate for hormone balance and to jump start lactation. I will NEVER opt for another hospital birth EVER! I wouldn’t purposly put my child in that kind of danger (immediate cord clamping, immediate shots, surrounded by random people, germy hospital, constantly taking blood, JAUNDICE!!). ZERO doubts- Giving birth at home WAS much, much, much more safe for us. Either way home or hospital birth, CONFIDENCE in your own body is what it takes to have a safe birth. It is just reallllly hard to be confident in your body with A team of people telling you your body can not do it. Fight or flight response will END your bodies ability to continue laboring. If the laboring woman gets scared–>contractions weaken–>cervix closes–>complications begin->intervention. You have to be able to completely let go..HARRRD to do with that bright light on your vagina.

    • Thank you mommyRAW for that gorgeous example of magical thinking. I’ll be sure to tell all those women in afghanistan losing their babies that it is their fault their children are dying – MommyRAW says that if they had more confidence their children would survive.

      • The ability to relax has A LOT to do with having an uncomplicated birth. It’s certainly not all that makes the difference, but it most definitely plays a role as far as the length of labor and the likelihood of intervention is concerned.

        • I’d like to see some for real, no conflict of interest studies showing the effect “relaxation” has on childbirth outcomes. Not the experiential outcome, but like APGARs and NICU stays and postpartum hemorrhages. You can reply here or email me at the address on my blog, thanks.

        • “The point is being relaxed during birth leads to less complication & less need for intervention.”

          No. No scientific evidence for that, either. That’s just another thing that NCB advocates made up.

          • Amy, there’s plenty of studies showing that being relaxed improves birth. Any women who has given birth can tell you that. Arguing it just seems irrational, petty and pointless. There are complications that simply can’t be prevented, but it doesn’t negate the fact relaxation during labor is integral.

            Here’s a collection of studies on techniques to do with relaxation during labor & pregnancy, as well as a few other studies on improving maternal mental health:
            https://www.facebook.com/notes/natural-mama-nz/collection-of-studies-on-labor-education-relaxation-techniques/281295235219257

          • Ahh, yes, bibliography salad.

            Sorry, that won’t do. You must READ the whole study and analyze the data in it to find out if the data supports the conclusion. Then you must quote the relevant data.

            Copy stuff from other NCB websites just doesn’t cut it in a discussion of scientific evidence.

          • Lol I researched these studies, and went through each of these studies myself. I barely ever read any blogs, instead I research studies to write my own blog posts.

            The evidence is there, but if you’re wrapped up in your own ideologies you’ll never be able to learn anything new.

          • “The evidence is there, but if you’re wrapped up in your own ideologies you’ll never be able to learn anything new.”

            If the evidence is there, it should be very easy for you to provide the appropriate quotations, yet I haven’t seen you provide any.

          • Amy I just provided you with a page of quotations. A quotation from the first study:
            “When labor and delivery outcome measures were compared in the 2 groups, significant differences favoring the hypnosis intervention group were found in the number of complicated deliveries, surgical procedures, and length of hospital stay.”

            There is an entire page of quotations, read it.

          • It’s not just the homebirth community. I hear ob’s and nurses telling women the same thing about epidurals. In fact, I’ve seen it reccommended to woman for that reason. And just from experience, it seems to sometimes work. So it’s not just the homebirth/natural community that believes that. The medical/scientific community believe it also. Now whether or not there is any research on it, that’s a whole other matter.

        • Too bad all these women dropping premature babies are just too fucking relaxed! They need to just stress out some more and then premature birth would end! Hurray!

        • How do you that it isn’t those who are uncomplicated from the get-go find it easier to relax?

          Another major flaw in NCB studies is that all the do-nothing methods has a serious tendency to select out those whose births are the easiest. Everyone else bails.

          • Mom, the studies comparing homebirth to hospital birth, or midwives to obstetricians, all use low risk mothers (there are no high risk mothers in these studies for either MW’s or OB’s). It’s not a ‘flaw’, high risk mothers are supposed to be referred to an OB.

            The studies above about hypnotherapy, birth education etc as a means of promoting a relaxed birth show that those who use these methods have a much lower rate of complication. These studies are not measured by observing the level of relaxation in the mother giving birth, but by whether she has previously taken classes that promote relaxation, and then birth outcomes were recorded.

      • Wow Debi. Way to be a grown-up. What are we, on school grounds at recess or something? If you have something to say it would serve you, and everyone here participating, to say it clearly, and without a childish attitude.

    • If you were on abx and mag is it safe to say you had complications? Like GBS and pre-e? How do you think a homebirth would have gone under those circumstances? Having a successful homebirth makes you LUCKY, it doesn’t mean anything but that you bucked the odds. Tell that to the women who weren’t so lucky. They aren’t snuggling with their babies right now complaining about bright lights on their vagina. They had to put their babies in one of those tiny little coffins and say goodbye forever.

    • mommysRAWarkansas – you were on magnesium and induced? If you were on magnesium, I’m guessing that you had pre-eclampsia? If you have pre-eclampsia, they’re in a big hurry to deliver your baby because you can have a seizure or a stroke, and delivering the baby is the only effective “cure” for pre-E. I’m sorry that your labor and delivery were so tough, but it sounds like your doctor was really worried about you, and probably your baby too.

      Additionally, second births are usually easier than first births.

  17. I think it is tremendously difficult to try and parse out US studies to anything else. Apart from the qualifications issue, in NZ and Australia, there are nowhere near as many financial concerns with home birthing. As in, you pay a bunch out of pocket in Oz to home birth, and I think in NZ it is part of the regular socialized health care. Occasionally in Oz it is as well. Home birth is not a choice made out of poverty, the way it can be in the US. That massively skews the data. Same with UC since ERs are totally free in Australia (unless you attend a private hospital) so there is no financial coercion to avoid medical intervention unless they are non residents and do not have a Medicare card.

    Distance is an issue though, but the environment for the home birth debate is so different between countries like the US and Europe and Australia or NZ.

    That all said, after hearing a midwife say blue babies are normal and a ten minute APGAR of seven is healthy, I wonder how many of the perinatal deaths are from actions like that. Same with the GBS ‘treatments’ and GD avoidance and hypertension avoidance. All result in issues for infants that may or may not get picked up. If someone is so keen to include outliers as normal. And who can’t tell the difference between common and normal.

    • 1 in 98 white women has a home birth, 1 in 357 black women, and 1 in 500 hispanic women in the US. If cost of care were the issue I think these statistics would look different.

      When surveyed about why they chose home birth, cost was not in the top 5 reasons women claimed to have gone that route.

      A previous study of over 500,000 home births found that “Women who were planning a home birth were more likely to be aged over 25, to have had previous children and to be of medium-to-high social/economic status than those planning a hospital birth.”

      It’s possible to be of medium to high socio economic status and be without health insurance in the US. That said every single person I’ve known IRL (including myself) that planned a home birth had health insurance and either chose to pay out of pocket for their home birth, or found a midwife that accepted insurance. I know the plural of anecdote isn’t data though. I would be interested to read what info others have found on home birth and socio economic status and access to insurance in the US.

  18. The death from labor complications in homebirth number is a real tragedy. Not much of a shock, though, given the number of stories I have heard.

    I would like to see a corresponding Friday Fallacy column addressing the myth that homebirth is safer for the mother, especially in light of the terrible tragedy in Florida this week.

  19. Sorry, try as I might, I can see the data for homebirths only those “in hospital” and “outside hospital”. Where is the specific homebirth data please?

  20. Just because you don’t like the statistics doesn’t make them disappear. And one really shouldn’t advocate for women to attempt something that increases the risk of their own deaths as well as their babies, just because you’d like for it to be safe. Wishes are not horses kids.

  21. I may not have the right idea here, (Although I’m sure there will be no shortage of replies if so!), but wouldn’t the best way to do this sort of study be to take the same number of births, at the same timing, in both situations?
    To be more clear, wouldn’t it be best, or at least better, to compare 100 low risk home births (No previous complications like gestational diabetes or pre-eclampsia, all at 38 weeks or more, etc.), to 100 low risk hospital births in the same area? With all the mothers also being within the same age range? Like say 25 to 35. Also, with all the home medical attendants being specifically midwives, or CNM’s, – not varying degrees of education/experience. Obviously this would be a harder study to set up but it seems as if it could be done with a bit of effort.
    Just a thought.

    • Dana, yes you’re exactly right. Here’s a large study that did exactly that: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/

      The results in summary:

      Planned home births attended by a registered midwife were associated with 55% less perinatal death compared to planned hospital birth with a physician. There were also significantly reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital births attended by a physician:

      Electronic fetal monitoring = 17% less
      Augmentation of labour = 47% less
      Narcotic analgesia, intramuscular or intravenous = 12% less
      Epidural = 28% less
      Assisted vaginal delivery = 22% less
      Cesarean = 65% less
      Episiotomy = 19% less
      Third or fourth degree perineal tear = 34% less
      Post partum hemorrhage = 57% less
      Infection = 26% less
      Pyrexia = 23% less
      Prolapsed cord = 2 fold less
      Postpartum hemorrhage = 2 fold less
      Blood transfusion = 3 fold less
      Manual removal of placenta = 2 fold less
      Uterine prolapse = 30% less

      Dystocia = 2 fold less
      Nonreassuring fetal heart rate = 2.5 fold less
      Malposition or malpresentation = 15% less
      Prolapsed cord = 2 fold less
      Postpartum hemorrhage = 2 fold less
      Blood transfusion = 3 fold less
      Manual removal of placenta = 70% less
      Uterine prolapse = 30% less
      Pyrexia = 4 fold less
      None = 26% less
      First- or second-degree tear = 22% less
      Third- or fourth-degree tear = 3 fold less

      Perinatal death = 55% less
      Meconium aspiration = 45% less
      Asphyxia at birth = 70% less
      Birth trauma = 33% less (Birth trauma include subdural or cerebral hemorrhage; fracture of clavicle, long bones or skull; facial nerve injury; Erb palsy; or unspecified birth trauma)
      Resuscitation at birth = 56% less
      Seizures = 66% less
      Oxygen therapy > 24 h = 38% less
      Assisted ventilation > 24 h = 68% less
      Readmission to hospital = 139% less

      More studies here:
      http://naturalmamanz.blogspot.com/2011/07/studies-confirm-homebirth-safer-for.html

    • Dana-

      Essentially this is the births/deaths per 1,000. Since there are more hospital births, the way we do it is take all hospital births, and divide by 1000 to get a number.

      Same with home/natural births. This is what generates the most accurate and “hardest to fake” information. A sample size of 1 birth is too small, so is 10, and so is, probably 1,000. We have to get a larger number in order to make this work.

      -Chris

      • Chris, you’ve ignored what Dana has said. CDC data is a mix of all sorts of women, it’s in no way confounded to the extent it needs to be to be considered any value. You need a group of women with all the same characteristics, you can’t find that in CDC stats. You can only find it in specifically designed study’s, like the one above.

        So why not trot off and find a reliable study instead of clinging to broad stats that can’t tell us anything.

        • Hmm. This is an interesting point.

          IT seems that you’ve just acknowledged that if we include all women that we might have data unfavorable to your side.

          I can understand why you would want to do that, NICELY PLAYED!

          • Chris this isn’t a game of ‘sides’ to me, I’m not on any side. This is about defining birth as accurately as we can. If you’re on a ‘side’ I’d say you’re less interested in accuracy & more interested in ‘winning’ = biased BS.

          • well, if that were true – and we’re not picking sides- you’d want ALL the data included in a study, not just the one that supports one premise.

          • Oh come now CJ. That’s a bit unfair. If you include everyone in any study things will be skewed to some degree, so NaturalMamaNZ does have a point. The point of controlled studies is controlling the variables.

            Say I want to study the difference in medical care in home births and medical births. If I study 100 home births, 50% of which have no medical attendant,and 100 hospital births, all of which do have medical attendants, this study is already flawed.

            It would be great to have a controlled study of like participants in two separate control groups. 100 healthy women between 25 and 30, with low risk pregnancies, that choose to give birth at home with a CNM, that reach at least 38 weeks – so obviously one would need alternates in the study as babies come when they please! -, and 100 healthy low risk birth women that choose a hospital. Any complications that arise during birth would not be a variable as everyone would have the same prenatal care, and the same likelihood of a healthy, safe delivery.

            I would be very interested in a study of this nature. How many of the low risk home births resulted in transfers to the hospital? For what reason? How many of the hospital births included unforeseen complications despite modern monitoring equipment? How many of the home births were given Pitocin as opposed to hospital births? How many home births required a C-Section – and therefore transfer to the hospital -, how many of the hospital births?

            Right now what makes separating the chaff from the wheat so difficult is all the variables. Home births with no assistance, home births with minimally trained assistance, hospital births that result in unnecessary C-Sections, babies born on the way to the hospital, babies born at home to mothers that may have done drugs or alcohol during pregnancy, babies born in hospitals with addicted mothers, etc. CDC statistics include all babies, born under all conditions, if I am understanding correctly, and therefore the outcome is births under a broad cross section of circumstances.

          • Chris we’re already well aware high risk women should not home birth, studies have shown us that. What’s also been defined is that certain women can homebirth safely in the right circumstances.

            Lumping all homebirths together you can get one result, defining results you will get another. Women are always going to want to homebirth. Instead of repeating the “homebirth is dangerous” mantra (which they won’t listen to & will simply polarize them further), providing detailed studies showing “yes you can homebirth safely in the right circumstances, and these are the right circumstances…”, will more likely get people to listen to you and hopefully promote safer births – which is what it’s all about at the end of the day.

          • Dana-

            What segment of women then will have equal risk?

            12 years of education,
            between 25-40? 25-35?

            Something like that?

    • Dana,
      the study design you’re suggesting would great if the question being asked is: “is homebirth with a qualified provider trained for assisting deliveries as safe as a hospital birth?”

      That’s not what this post and Heather’s analysis is about. The question that Heather is asking is: “is homebirth as currently practiced in the United States as safe as hospital birth?”

      Do you see the difference?

      • Hi Box Of Salt,

        Oh yes, I am very clear on what the post is about. Thank you though.

        What I’m trying to say is that it’s too vast a field to comb accurately because of the many variables I listed above and that I would be very interested in a controlled study.

        It was just a thought.

  22. Is This A Joke, you sound just like the husband of a friend of mine. He’s a guy who got a law degree but didn’t bother to take the bar, and now complains that people should “be allowed to do the job if they can do the work,” and thinks that “arbitrary standards” should be done away with. He thinks that the American CPM is a fine credential and that DEMs who “do the work” should absolutely have the privilege of taking lives into their hands. In order to support his own insecurities about his total lack of follow-through, he has to make this type of argument. But that’s another talk show.

    I wanna know, do you think it’s okay that the majority of homebirth midwives are far less educated and experienced than Nurse-Midwives? Do you think it’s okay that totally unlicensed, untrained people are currently overseeing childbirth? In a homebirth situation, a woman and child are already at a disadvantage should emergency arise since advanced care is not immediately available. The disadvantage worsens into a full-on danger when the birth attendant is not highly skilled. If the only people who were attending home births were Nurse-Midwives– that is, if the absolute standard for all midwifery in the states was the CNM degree– then maybe we’d have something to talk about. But right now, that’s not what’s going on. When homebirth attendants and advocates raise their standards, then we can resume talks on safety. Until that day, homebirth as a practice will carry what many consider an unacceptably high risk. The people who suffer the most are the babies when mom’s and dad’s “experience” and the midwives’ desire for “freedom” take precedence over life itself. Until the day that all homebirths involve ONLY “low-risk” women (an uneventful pregnancy does NOT absolutely predict an uneventful birth) and ONLY the most highly-qualified attendants, and ALL the mothers receive the best prenatal care and testing to verify all along the way that they *stay* “low-risk,” there will be no way homebirth can be taken seriously as a “safe” option. This is one area of life when freedom of choice and personal preference need to take a back seat to what is safest.

  23. Marlo,

    You hit the nail on the head! Instead of constant discussions and opinions about which birth method is best/safest/more dangerous, etc., we should be focusing on a high standard of care for both mother and child.

    The only ones giving birth are women. As women we must demand a level of care that is in our best interest and the interest of our babies. This would increase our birthing options instead of decreasing them!

    What if we all rallied and demanded each and every state regulate that all home births must be attended by a CNM? (No discrimination intended of course. Anyone is free to have a mid-wife, a doula, an herbalist, and whomever else they would like in attendance at their birthing.)

    Birthing centers should be right next door to hospitals making necessary transfers as quick as possible.

    If someone wishes to birth at home it could be regulated that they have a private ambulance service ready and waiting in case of emergency.

    These are just some ideas off the top of my head. I’m sure there are better one’s out there. Mostly I think, as home birthing will never go away, (and personally I like the IDEA of having my baby at home, in comfort, as opposed to at the hospital with strangers milling about, hooked up to machines etc. even though I know it likely would not be ideal health-wise), it’s best we call for regulations that enforce the highest possible training and care for home births. Also, that we work with Doctors and hospitals to create a more personal environment in maternity wards. Would love it if more hospitals allowed birthing tubs and the like.

  24. This is awesome 🙂 Now we’re getting somewhere! Home birth can’t be safe until the safety net is really shored-up, and that’s just not the case right now. We could all go round and round (and have done) about it, but at the end of the day, the general state of planned out-of-hospital birth is very shaky. Babies deserve better. Two hospitals I can think of just right here in Oklahoma that have huge nice birthing suites in totally separate areas of the hospital from the “sick people” and they have showers, large soaking tubs, exercise balls, and all those things if you want to use them (and you know OK isn’t the most progressive state by any stretch of the imagination!). Hospitals are improving and stepping up their game! So the question remains, why aren’t homebirth midwives and advocates stepping up *their* game? Until they do, we’ll still be seeing these frustrating statistics. The best way to make the numbers better is to make the level of care and safety much better. Right on, ladies!

  25. Box of Salt said: The question that Heather is asking is: “is homebirth as currently practiced in the United States as safe as hospital birth?”

    This, exactly. Is homebirth, *as currently practiced in the United States*, as safe as hospital birth [in the United States]? The answer to this, for all the reasons we’ve discussed (fast access to advanced emergency care, level of skill/training of attendants, actual “risk-level” of the pregnancy…) is a resounding, “NO.”

    • I unfortunately agree, midwifery in the States is not looking so hot (NZ needs to improve too, but not to the degree the US does). I’m sure there’s great midwives out there, but then there could be really crap midwives out there too (and obviously there is). The system is so unregulated, and the NARM qualification is not something I’d ever trust for the birth of my own child.

      • “I’m sure there’s great midwives out there, but then there could be really crap midwives out there too (and obviously there is). ”

        Exactly! So often the folks here will talk about the risks of midwives, and people will counter by talking about their excellent midwife. While I’m thrilled that those folks found a wonderful midwife, I wish they more often understood that under the current system, there’s very little way to weed out the ones who aren’t so wonderful.

  26. I’ve known about the state of midwifery in US for a long time, the whole birthing system there seems polarized – highly medical, or laid back midwives (with of course lots in between).

    If anyone is polarized on either end we need to say something. If you’re going to talk about homebirth, talk about it properly, in detail. Don’t just say “home birth is dangerous”, because that’s not the whole truth – we know that under the right circumstances homebirth is as safe as hospital birth. And if you’re going to talk about hospital birth tell the whole truth, in the US you will more than likely be pushed to have unnecessary intervention.

    In NZ we have a mix of both, the midwife is the lead maternity carer provided it’s a low risk birth, even in hospital (CNM’s always the best). Then if anything goes wrong, an OB is just around the corner.

  27. It’s hard to say what is and isn’t “unnecessary intervention.” What seems unnecessary to the layperson may in fact be the difference between a nice pink healthy baby and a hypoxic brain-damaged one, or worse. Letting things get to the critical point before “intervening” is not a good idea. We talk a lot about preventive medicine in other areas because it *prevents* conditions from worsening or ever even getting bad in the first place. Some preventive “interventions” do happen in the hospital, and just because we don’t understand them all the time doesn’t make them unnecessary. FWIW, contrary to what the propaganda say, there is excellent informed consent in the hospital for all procedures. Unless someone is literally on the brink of death, they can and do tell you what is going on and why they would recommend doing this-or-that. Most people agree to it, and only gripe later because everything turned out okay. When everything turns out okay, they figure, “well none of that was necessary at all!!” Well, the complainers rarely consider the thought that everything very likely came out fine *because* the “interventions” prevented things from taking a wrong turn. I’d like to see people get educated about how the “interventions” are used, how they work, and when and why they are done. Actually, I’d rather call them “safety options” than interventions– and I started out an avid NCB fan and homebirther if that tells you anything. I had a very normal, low-risk pregnancy that turned into the labor and delivery from hell, landing me in the hospital. And you know what? They didn’t do anything that they didn’t explain to me first. Even in my emergency situation, they took the time they could to make sure I knew what was up. That was a revelation for me, because of course my homebirth midwives (yes, uneducated hacks I later found out!) had told me how awful and intervention-happy and anti-mother and scary hospitals and doctors were… and they turned out to be so very wrong.
    I would caution against leaping to believe popular Natural Childbirth claims of American doctors and hospitals that are “out to get” patients, or who “bully” people into unnecessary procedures. Often the people who make these claims have never stepped foot into a labor & delivery unit, have never talked to any doctors, and really have no idea what they’re talking about. These same people think that CNMs are “interventionist!” LOL Doctors and CNMs would honestly rather let well enough alone when things are going normally, but they err on the side of caution. Unlike the homebirth midwives here, who just throw caution to the wind and figure that “nature knows best” and “babies know how to be born” and all sorts of other rubbish.

    • Marlo, I have friends in the States who’ve had terrible hospital births. I’ve also read many stories from women who’ve had terrible hospital births, and studies showing the lack of communication between doctor and patient, lack of consent, and blatant disrespect of birthing mothers. I’ll try to dig one up. And I’ve also heard from women who had the most amazing home births.

      I think our own experience often colours our own opinions, for you your midwives sucked, and the doctors were a breath of fresh air. For me my CNM was amazing for all 3 births in hospital (she’s inspired me to be a CNM). I never saw a doctor once during my stay, until the next day when one did the rounds checking on each room. But whatever our own experience, we all need to stick to the studies when making more generalized statements about birth.

  28. But back to the topic at hand, “Is homebirth safe in the United States,” the answer is still No. Homebirth is not safe in the United States. It’s very much a game of russian roulette, that sadly people play with their children’s lives. Some people end up lucky and have good outcomes, but this does not mean that the practice itself– or the “professionals” presiding over it– is safe as a rule.

  29. I just have one thing to say. If you have never taking care of a snuffed-out brain damaged baby born at home, breech, with head entrapment, then you haven’t thought through your decision to deliver at home. If you haven’t watched a baby have seizures for days, then you haven’t thought If you haven’t put your baby’s well-being ahead of your own, you haven’t thought through your decision to deliver at home. Most hospitals are striving to offer many of the features that are found at home- birthing tubs, no IV or monitors, privacy and the such. It just takes a few minutes to destroy your baby’s brain. I have seen it for myself.

  30. I really don’t think most of the studies done on homebirth are very valid. This is what I would use if I were to do my own study…
    -homebirths and hospital births attended by a CNM that has hospital privileges(that way we know the education is the same-we also know that they have quick access to a hospital and ob back up)
    -gestational weeks 39-41 weeks
    -no other health problems
    -no breech, vbac, or twins
    -death rate would be determined based on autopsies that determined that the baby died due to birth trauma(and I would include babies up to year old as long as it was determined that it was due to what happened at birth-a baby can be kept alive for a long time on a ventilator, but still die due to birth trauma, therefore, we need to know that why they die, not just that they die-same goes for homebirths. It needs to be verified as a SIDS death, not just claimed as one).

    I don’t think we have enough good research to say one way or the other whether or not homebirth is safe. Even the cdc stats have too many variables that are not accounted for…ie education level of provider, ability to transfer quickly, the deaths need to be investigated more.

    • 1. Homebirth midwives are not restricting themselves to 39-41 weeks. In my state, they can legally proceed with homebirth at 35 weeks.

      2. Birth trauma is not the only cause of death related to being born at home. Prematurity, undiagnosed treatable birth defects, and infection are also common killers of homebirth babies.

    • The CDC stats DOES give us cause-of-death information, as you can see from the tables above.

      Yes, RCTs using specific criteria are generally considered the best evidence. Unfortunately when it comes to this subject, you would need to enroll tens of thousands of women in order for the numbers to be statistically significant, since many of these labor complications occur so rarely. This is why most of the studies done are retrospective. Part of this could be remedied with better data collection via vital stats. We can currently tell whether midwives are CNMs or other midwives, which does roughly indicate educational level. If CPM were added as a category on birth certificates, it would certainly give us more information.

  31. Heather, I think trying to get together a true RCT research trial would be horrendous:) But that doesn’t change the fact that it should be done in order to really get at the real picture. I’ve just seen too many people playing games with those cdc stats(on both sides of the picture). It’s been awhile since I looked at the cdc site, but if I recall, I couldn’t find a place to find how the babies died. I’ll go back a check it out. It could be that new stats are available.

    Anonoregonian-I agree that those are reasons that babies may die needlessly in a homebirth, but that speaks more to certain homebirth midwifes practices. If we had restrictions put on them or they practiced in a way that transfered baby quicker and more safely, the picture would change. Possibly. I’m more in the mindset that not much of the research we currently have gives us a very good view of what is true. What we do know(via the cdc stats) that in some instances homebirth could be safe and with some it could be much more dangerous. I just don’t think we’ve nailed down what those variables are. I would propose that a homebirth with a well educated midwife, under certain restrictions, in an enviromnent that works to make the transfer of the baby quick and safe, that homebirth could be safe. Though, I wouldn’t throw my cards in too quick with that camp unless we had more information.

    • “I would propose that a homebirth with a well educated midwife, under certain restrictions, in an enviromnent that works to make the transfer of the baby quick and safe, that homebirth could be safe.”

      Exactly. And that is what we are proposing.

  32. Oh my, I’m so embarassed at my previous comments. I just had to comment again to say that my views on this topic have changed dramatically. I don’t know what my thinking was before, perhaps too much reading and belief in the NCB community’s claims. At any rate, I was wrong, very very wrong, and I had to come back and admit that.

    AHodges

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