New analysis from Arizona shows — yet again — that homebirth triples the neonatal death rate

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It’s a remarkably robust finding, repeated in a wide variety of scientific papers and both national and state statistics: homebirth increases the risk of neonatal death by a factor of 3 or more.

The latest example is an analysis prepared by faculty at the College of Public Health of the University of Arizona, Tucson and the Arizona Public Health Training Center for the Arizona Department of Health Services entitled Outcomes of Home vs. Hospital Births Attended by Midwives: A Systematic Review and Meta-analysis.

The authors, 5 professors of public health and 1 doctor, explain why the analysis was commissioned:

Most recently, the licensed midwife community has utilized the democratic process to their advantage to pass legislation to allow for an overhaul of the regulations overseeing homebirths and their profession in the state. Pursuant to HB 2247, AzDHS has formed a Midwife Scope of Practice Advisory Committee, which will evaluate evidence based literature and data to make informed decisions regarding regulation over licensing procedures, scope of practice, and education requirements for licensed midwives in Arizona by July 2013. Of particular salience will be changes in regulations overseeing licensed midwife attendance at births for mothers undergoing a vaginal birth after cesarean (VBAC), breech birth presentation, and multiple fetuses…

In light of Arizona homebirth practitioners’ and clients’ interest in midwives’ scope of practice in the US and elsewhere, we seek in this meta-analysis to compare and contrast direct entry midwives’ outcomes for homebirths with their outcomes in hospital or health care facility settings. The current
limited and conflicting evidence on the outcomes of homebirths versus hospital births with midwives in attendance generates both a need and justification for a review of the available evidenced-based literature.

What did they find?

Nine studies were included in the meta-analysis of child health outcome of births attended by midwives in homes or in hospitals. We analyzed 8 outcomes of child health (neonatal deaths, prenatal deaths, Apgar

Pooled results indicated that homebirths attended by midwives were associated with increased risks for neonatal deaths [pooled OR (95%CI): 3.11 (2.49, 3.89)]. There were no significant differences in outcome of home or hospital births attended by midwives for the other child health measures.

How about maternal outcomes?

… [W]omen who delivered at home with midwives were more likely to have spontaneous delivery and intact lacerations/perineal tear [pooled ORs (95%CIs): 1.64 (1.35, 2.00) and 1.94 (1.25, 3.01) respectively.

Women who delivered in hospitals under the supervision of midwives were more likely to experience assist ed delivery, caesarean sections, forceps, episiotomy, and lacerations/perineal tear (3-4 degrees) [pooled ORs (95%CI s): 0.58 (0.40, 0.84); 0.55 (0.49, 0.60); 0.54 (0.33, 0.9 0); 0.56 (0.41, 0.77) and 0.48 (0.32, 0.72) respectively. Results of the meta-analysis also revealed that homebirths attended by midwives were associated with decreased risk for postpartum hemorrhage >500ml and retained placenta [pooled ORs (95%CI s 0.60 (0.44, 0.81) and 0.58 (0.40, 0.86) respectively.
Homebirths were also not associated increased risk for vacuum extraction, cervical tear, blood transfusion and prolapsed cord.

The authors conclude:

These results suggest that homebirth is a suitable alternative to the traditional hospital setting, as it reduces medical interventions and has been found to have positive maternal health outcomes. However, homebirths should only be recommended to women who are classified as low-risk, as this data demonstrates an increased risk of neonatal mortality among homebirths

For reasons that are unclear to me, the authors state:

The findings suggest that homebirths attended by midwives may be equally safe if not safer for women with low-risk pregnancies.

I find that statement surprising for two reasons. First, that is not what their own data showed. Second, claiming that is “may be” equally safe acknowledges that possibility that it may NOT be equally safe.

Regardless, there is one inescapable conclusion of the analysis; homebirth increases the risk of neonatal death by a factor of 3 or more.

For mothers, homebirth poses a much lower risk of interventions and the complications that may arise from those interventions. But that advantage is purchased at the price of increased risk of neonatal death, demonstrating yet again that much of obstetrics is preventive medicine, designed to prevent neonatal deaths … and that’s exactly how it works. Give birth at home and you are twice as likely to avoid interventions, but three times as likely to end up with a dead baby as the result.

  • Cautious Optimist

    I’d like to see an effort to assess what makes home births lead to better outcomes for women, and an attempt to replicate those factors in a hospital setting. It’s not enough to ignore outcomes for women for the sake of the infant.

    • Box of Salt

      Could you specify what you mean by “better outcomes for women”?

      And could you explain why you don’t consider the infant important to the mother’s outcome?

  • Mary herrington

    Calling all healthy birth advocates!! I am in a “hot” debate with The Feminist Breeder on her Facebook page, ICAN post. Come to FB and support safe birth!!

  • Public Health Employee

    There is a false dichotomy being presented here, which implies that a woman must choose between a hospital birth with increased interventions or a homebirth with increased risks of fetal mortality. Where is the conversation about improving hospital care for birthing women? How much of the increased morbidity in hospital births has an iatrogenic cause, such as medically unnecessary induction? Bodily autonomy during birth and the need for supportive caregivers are not “wooful” birth quackitvist issues. Instead of focusing on where we can make positive change, the people on this forum groupthink themselves into a spiteful tizzy about how nutty the homebirth advocates are. How can we improve outcomes for women in the hospital and create an environment that is conducive to normal birth? A woman who wants to ensure that her healthy infant is placed in skin-to-skin contact with her after the birth and to have routine interventions delayed is not a nutbag who is only concerned with her personal “experience”. This simple practice that is so beneficial for the establishment of breastfeeding is treated in many hospitals like a disruptive nuisance to nursing staff schedules. There is much that can be done to improve outcomes in hospitals but instead of discussing this, this blog and the people who comment are so absorbed with sarcastic hatred for natural birth that this crucial issue has been ignored. I completely agree that something must be done about unqualified, profit-hungry homebirth midwives who provide unsafe care during childbirth at the expense of precious infant lives. There is another side of this issue though.
    Giving birth is a reproductive act that is incredibly momentous within the lifespan of a woman. In the U.S. nearly 30% of women are induced, 30% of women have C-sections, and our mortality rate is much worse than other industrialized countries. Let’s not pretend that hospital maternity care in this country has no room for improvement.

    • Eddie

      There is a false dichotomy being presented here, which implies that a woman must choose between a hospital birth with increased interventions or a homebirth with increased risks of fetal mortality

      In the quote above and in much of the rest of your post, you present a false view of what people here argue in favor of. I understand that is how you see it, but honestly, you are not hearing what people are actually saying if that is what you see.

      Yes, there’s a lot of sarcasm here about the NCB extremism. Is that a terrible thing? *No-one* here is pretending that the US medical system is perfect, nor that it has no room for improvement. However, please check this blog entry http://10centimeters.com/friday-fallacy-the-us-infant-mortality-rate-is-worse-than-that-of-the-third-world/ and come back when you’ve realized that our mortality rate is just not much worse than other industrialized countries. if you believe that, then you’re looking at the wrong data. We do have more children under 1 dying than many other industrialized countries, but that is hardly the fault of anything that happened at their birth.

      Besides, is it the task of every blog about any aspect of childbirth to address every single possible angle of improvement?

    • Dr Kitty

      Don’t get it.
      I had an elective CS and my kid was lifted directed out of my abdomen into my arms for skin to skin. Lots of hospitals are totally down with this stuff.

      It is your baby.
      Decline whatever interventions after birth you don’t want.
      You want skin to skin, do it and tell the staff they can’t touch your child. Job done.

      Rather than bemoan the CS and induction rates as evils in and of themselves, there needs to be work into identifying risk factors for maternal morbidity and mortality and addressing them. The USA has higher rates of HIV, obesity, poor access to antenatal care, gestational diabetes, drug addiction and pre-eclampsia than many developed nations. This may justify higher rates of intervention. It might not. We don’t have the data.

      Simply saying “we have higher rates of interventions and higher rates of maternal mortality therefore X=Y” is incorrect.

    • Bombshellrisa

      ” create an environment that is conducive to normal birth”
      Can you please define normal birth?

    • Box of Salt

      Public Health Employee,
      if that’s really your profession, you should know that the 30% of births via c-section includes all of the repeats. That’s not “30% of women.”

    • auntbea

      Hmmm…are you sure you are not a “public health scholar”?

      • Another PHS (not Whapio).

        No, the comment is too measured for that! I agree that PHE has a point, but this particular blog focuses specifically on homebirth, and is not a campaign to improve maternity care per se. There are some very good sites that deal with the topics of improving hospital birth or birth in general. Doesn’t mean you can’t participate here, PHE!

        • Siri

          P.s. none of us hate normal birth. I have had five babies, all came out of my nether regions, one was born at home with fantastic community midwives, and one started out as a homebirth and ended up in hospital. They were good experiences, apart from the pain. And the stitches. Hell, I was a midwife! My bias was always towards spontaneous births (not that I let on to my patients; I was there for them, not they for me. Assisting in theatre is vastly less enjoyable than catching babies, but I did it with a good grace (so saintly). I’ve never met anyone who was ‘against’ normal birth.. Except for one registrar who would perform c/s on women whose labours were progressing normally, so as to free up her time and theatre space for those who were looking a bit dodgy and might need c/s later in the shift. She could pretty much create a ‘normal birth-free’ zone all by herself, and would leave midwives crying with frustration on their patients’ (not their own) behalf.

    • yentavegan

      How much the “increased morbidity in hospital births is due to iatrogenic cause”?
      This line of thinking is the by product of a propaganda infused education.
      I am not an anomaly. I had 5 hospital birth. All but one had medical interventions,( and even that word is part of the anti-medical propaganda).

      • public health employee

        Perhaps your line of thinking is a product of self-infused personal bias. Your experience may not be the norm… in fact, the numbers say something quite different. The overuse of Pitocin is a real issue in obstetrics. Also, the practice of placing infants skin-to-skin after C-sections is NOT the norm in maternity care for my county, which has three hospitals.

        • FormerPhysicist

          So ask for what you want. It is forbidden, or just not the norm? Maybe some of those mothers actually *want* the baby cleaned up first, and weighed, and checked. I was very happy having an experienced team check my baby over while the OB sewed up my incision and such. And my husband was too.

          • LibrarianSarah

            Yeah I am sure I’d be kind of ticked if they just put a gooey baby on my chest. Maybe that means I’d be a terrible parent but afterbirth = ewwww.

          • Siri

            It is rare these days for mums to want their babies cleaned first, although we always ask as a courtesy. Most new parents are surprised to find that the baby isn’t covered in goop and blood, just a bit damp. And you wouldn’t need to see the afterbirth, as the cord will be cut (EEEBIL!!) quickly, and the cord is normally more than long enough. I would say keep your options open if possible, but if you know what you want, don’t hesitate to say so. And it has no relevance to your merit as a mother! None whatsoever. 🙂

          • LibrarianSarah

            Aww thanks, The whole point is kind of moot because the likelihood of me having kids is very small (bum ovaries).

          • Eddie

            as the cord will be cut (EEEBIL!!) quickly,

            I don’t know why, but I think of Robin Williams, “It’s a boy and he’s hung like a bear!” “That’s the umbilical Mr Williams.” “No, don’t cut it! Let him dream for a day!”

          • Eddie

            When our youngest was born, she was quickly weighed, assessed, cleaned, and swaddled. I was actually stunned (and IMPRESSED) at how quick and efficient the nurse was, as it seemed as if it took a few seconds. Before we knew what happened, she was in my wife’s arms. My wife didn’t care for skin-to-skin. If that was what she’d wanted, she would have gotten it. I remember cutting the cord. It was thicker than I expected.

        • Eddie

          What numbers say something quite different? Please be specific. If you want to pursuade people here, you’ll have to be willing to provide facts, and better yet, references.

          Where my wife delivered, the hospital was VERY friendly to the mother driving how things progressed. When the doctor wanted to induce because labor wasn’t progressing, she explained exactly why, benefits, risks. My wife had the ability to say “no” if she wanted. More and more in America, the consumer is driving the hospital birthing experience. Every state, every county is different, but this change is on average occuring across the US.

          Please don’t generalize the experience in your country as if it is the norm in the rest of the world. Different parts of the world have different problems that need to be solved. Hell, even in the US, different counties have different problems.

        • Sullivan ThePoop

          It is the norm for maternity care in scheduled C-sections. It might not always be possible in emergent C-section.

        • Box of Salt

          phe, “in fact, the numbers say something quite different”

          You might have an actual argument here if you show us those numbers. Until that happens – and that means verifiable numbers, with links – all you’ve provided is your opinion. Not “fact.”

          “Perhaps your line of thinking is a product of self-infused personal bias.”
          Right back at you.

        • Eddie

          PHE: What the numbers show from everywhere in the world, it seems, is that babies die at a higher rate for intended home births when compared to intended hospital births. That is pretty universal. As to medical practices, those are far from universal. Every country differs not only in medical practices, but in education and how they count statistics. Of the very few universal stats is that babies die more often in homebirth. Do you disagree with this?

        • yentavegan

          i am biases because I assumed you were referring to iatrogenic deaths in USA maternity wards.

    • yentavegan

      “our mortality rate is much worse than any other industrial nation” Even this is a propaganda infused statement.
      Do we really have a higher rate of death for full term. healthy medically supervised infants whose mothers had their pregnancies monitored by ob/gyns?
      Or is this number skewed due to fertility treatments resulting in pregnancy’s in older mothers and twins, triplets?
      Is this number skewed by mothers with underlying health issues whose pregnancies are supported by drugs to help them reach term but the infants are born with problems?
      Is this number skewed by our ability to stabilise newborns born to early but who later succumb to prematurity?
      Or is this number skewed by mothers who chose out of hospital births who then are transferred to the hospital as a virtually unknown entity with no doctor charts when the sh*t has hit the fan?

      • AmyM

        And don’t forget the high poverty levels in the US, many of whom do not have access to health care, or to adequate health care. I would wager that a majority of infants who die between birth and a year, (after the preemies) are living in poverty. And maternal mortality due to underlying conditions that can become deadly during pregnancy/labor.

    • Guest

      Myth: nurses take the baby away right after birth so that nursing schedules aren’t disrupted. Where do you get this stuff? complaint boards on the internet where all of the women either have no clue what is medically necessary or they last had a baby in the 80s? I’ve had 3 recently and the only reason they ever took my baby away was for resuscitation and sucking out meconium. I’ll take that any day over a newborn with an infection.

    • LukesCook

      “How much of the increased morbidity in hospital births has an iatrogenic cause, such as medically unnecessary induction? ”

      Go on then – how much?

    • Bombshellrisa

      ” How much of the increased morbidity in hospital births has an iatrogenic cause” http://www.quackometer.net/blog/2007/07/quack-word-20-iatrogenic.html

  • Eddie

    If it weren’t too long, I’d suggest changing the title of this blog post to:

    New analysis from Arizona shows that homebirth triples the neonatal death rate — even in other countries where midwives are far better trained than American non-nurse midwives.

    I mean, the article talks about foreign midwives as if their education is at all comparable to CPMs, rather than being far superior to that of CPMs. And then handwaves as to why this striking educational difference doesn’t matter and is thus relevant to the United States.

    • And for the UK, add:

      safe if you risk out 40%, very few choose it, and you don’t count the transfers and the disasters.

      The point of these studies presumably is to get more to choose it. Does anybody stop to consider why it went out of favour?

      I have never understood properly why my sister got bullied into a homebirth. I think it was a kind of small pilot experiment, that said anyone who had a straightforward first birth could not use the hospital. It didn’t last long.

  • Allie P

    I do not understand how any study can say “oh, lower risk of episiotomy, so who cares if your baby dies?”

    I had an episiotomy. I did not notice it even a week later. I certainly never think about it now. But had my baby died during delivery, it would haunt me daily for the rest of my life. How can you even compare???

  • EK

    But it reduces medical interventions!! Including the medical interventions that could save your baby’s life…

  • Squillo

    This study is heretofore known in my head as the “Other than that, Mrs. Lincoln…” study.

  • Becky05

    This report really needed some help from an editor.

    • Eddie

      Yeah, I noticed that as well. When i read a paper with that many obvious grammar and spelling errors, I wonder how careful they were with the actual analysis.

  • Amazed

    Hey, just coming from MDC. My favourite clown, mwherbs, is informing them that she spoke to someone in Oregon and out of the 6 death mentioned by Rooks, two were of second twins and one of them died after the hospital transfer. Yeah, it just invalidates Rooks’ report, just so you know. Homebirth is safe or safer than hospital birth because when you exlude women who midwives shouldn’t have taken at all and those who doctors and real miwives couldn’t save after homebirth clowns botched deliveries – well, it totally works! Give midwives the perfect statistics and let hospitals and families deal with very unperfect outcomes. Nice and clean. Safe or safer. Three cheers for mwherbs!

    • Guestll

      Do second twins routinely die in hospitals? //sarcasm

    • Survival of the Whapiest

      Twins are cursed by the mingi anyway, as are babies who cut their top teeth first. Just ask some people in Ethiopia…

  • Eddie

    What I didn’t realize at first is that this analysis doesn’t compare homebirth with a midwife to hospital birth with any attendant. It is compares homebirth with a midwife to hospital birth with a midwife. A midwife working in a hospital and outside a hospital are not likely to be equally skilled. Anyway, I would naively expect hospital births attended by a CNM or Ob/Gyn to have even better outcomes than hospital births attended by a midwife (assuming you adjust for equivalent risk).

    One thing I don’t see … when they refer to a hospital birth attended by a midwife, does that include births that started at home and ended up in the hospital? If so, this would explain some of the results. In their analysis, they appear to assume that the hospital deliveries with a midwife were planned that way, but I didn’t see any reference to that assumption or that fact (if the studies spelled that out).

    Actually reading the source document, it is just poorly written. The grammer is not the worst I’ve ever seen, but it is sloppy. Words are missing. Words are misspelled. Where they say “… were about twice more likely …” Is that a common turn of phrase? Is it only me that finds that awkward and ambiguous? Does “twice more likely” mean 200% or 300%? I could read it either way.

    The analysis does say this:

    Heterogeneity among the studies may also pose as a limitation, as studies were included from several different countries where education and regulation of midwives may differ from that in the United States in addition to any differences in the actual place of birth. This variation may affect overall differences in findings or conclusions. However, these differences were accounted for in part through the use of the random effects model.

    I find that statement (that they accounted for these differences) unconvincing. Also, after proving at the 95% confidence level that there is increased risk for the baby, their very last sentence ends with, “however, there may be some increased risk for infants among births that occur in the home.”

    There “may” be some increased risk? MAY be? I thought they conclusively (95% CL) proved that there IS increased risk. What the? Especially when they earlier say “Positive maternal outcomes in homebirths settings, such as those found in this analysis, are supported by other relevant literature.” So the WEAKER positive maternal outcome differences are solid, but the STRONGER risk to the fetus MAY be present? I smell bias.

    • LukesCook

      ” A midwife working in a hospital and outside a hospital are not likely to be equally skilled.”

      I think, given that the data came from countries like Canada, Australia and the Netherlands, that they are likely to be equally skilled. In other words the increased risk doesn’t even represent the deficiencies of the attendant, but of home birth per se.

      • Eddie

        That’s pretty much what I was wondering. My reasoning was that hospitals won’t be willing to work with the less skilled midwives, but maybe this is not true in practice. For example, if it’s not obvious who is less skilled until death or injury occurs and someone loses their license anyway as a result, then there will be no difference.

        In America, would you say there is any difference in skill level between Ob/Gyns with hospital privileges and those without? Or is this not a fair comparison?

        When my reasoning is wrong, I want to be corrected so that I don’t continue to be wrong! 🙂

        • fiftyfifty1

          The percentage of OBs without hospital privileges is vanishingly small. Just a few who are semi-retired (perhaps still doing a little office practice but no longer doing surgery), and the rare Dr. Biter type.

        • LukesCook

          I don’t know anything about the American system. I was thinking of a system along the lines of the NHS, where the requirements to practise as a midwife would be the same, regardless of whether the midwife practises in or out of hospital. One could speculate about differences in skill levels – the hospital midwife probably sees more deliveries, and more complicated ones, for example – but the training and registration requirements are the same.

          • Eddie

            I was thinking of a system along the lines of the NHS, where the requirements to practise as a midwife would be the same, regardless of whether the midwife practises in or out of hospital

            Ah, that’s very reassuring, and the right way to do it. If you’re not skilled & trained well enough to work in a hospital, then you’re not skilled or trained well enough to provide medical care outside of one.

          • LukesCook

            Well no, it isn’t reassuring, because these theoretically equally skilled attendants are getting worse results.

          • Eddie

            Good point. When I said it was reassuring, I didn’t mean it was: “All good, let’s have everyone give birth at home.” I meant, “Think of how much worse it would be otherwise.”

          • I tended to assume that NHS Community midwives were chosen from the more experienced – and that they stay with the mother on transfer?

            I’ve never come across anyone who wanted or got a homebirth. The demographics here in the UK might be interesting.

          • Siri

            When I qualified, a staff midwife started as an E-grade; to be a community midwife, you needed an F, which meant acquiring skills such as suturing, cannulation, scrubbing in theatre, and being in charge of the labour ward if no G-grade were available. Agenda for Change has replaced the old grade system with band 5, 6 etc, but the principle remains. All community midwives have to do stints in a consultant-led unit to refresh their skills, maintain their PREP and attend drills-and-skills sessions, CTG interpretation updates etc.

        • Could someone explain to me what a skilled midwife does other than spot the point where her skills are inadequate and an OB is required? If you are low risk and everything is normal, you don’t actually need skill – though I accept that a midwife can be reassuring and helpful – but what can they actually DO if they are in a place without help/resources? Are there grey-ish areas where these skills can make a big difference?

          I met some lovely – and skilled – midwives during my adventures, but they were powerless to do anything. Funnily enough, they were keener for my daughter to come out than the doctors were, so they were knowledgeable and very caring.

          • Siri

            A skilled and experienced midwife might need to conduct an undiagnosed breech delivery if there is no time to transfer/get the registrar, or resolve a shoulder dystocia using certain manoeuvres, or cannulate a haemorrhaging woman (plus put up fluids, rub up a contraction etc), or suture a 2nd degree tear, or resuscitate a flat neonate. She will use her skill and knowledge to help women avoid perineal tears, and use her clinical judgement to decide when a labouring woman should be left alone for a while (contractions tapering off at 2am? Mum tired? Give her some pethidine and let her sleep on her left for a while, and she’ll wake up fully dilated and ready to push) and when to call the reg on call and put up syntocinon (pitocin). Remember the OB who used ‘tricks’ like little bits of pitocin? Well, good midwives have tricks of their own to keep labour normal and avoid – yes, I’m going to say it – UNNECESSARY INTERVENTIONS!

          • Siri

            Remember Rosie Kacary, midwife to poor Claire Teague, who bled to death in the comfort of her own living room? She could have saved this mother’s life by a) calling for an ambulance ‘nil delay’, inserting two wide-bore cannulas, giving further (or a first, depending) of syntometrine, rubbing up a contraction and putting up emergency fluids (eg Gelofusine). This would likely have been more than enough, and Claire could have had a manual removal in theatre, followed by a couple of units of blood, and been home a couple of days later, with a dramatic birth story to tell and a new baby daughter to snuggle. Kacary was an independent midwife, but she was still subject to the same registration as all other midwives.

        • theadequatemother

          In BC it’s the same midwives home and hospital… They aren’t allowed to only work in the hospital setting. Not sure about the other provinces like on or sk

          • Eddie

            Thanks for the response. I thought you might say that they aren’t allowed to work only in the home setting. Why would they not allow them to work only in the hospital setting? So Canada is like the US in that each province has different laws in this area?

          • theadequatemother

            Because of how confederation was written, healthcare in Canada is a provincial domain. We have universal health insurance but it is organized and delivered by the provincial governments, under the provisions set out in the Canada health act. Midwifery is licensed by the provinces and what they can or can’t do is set out by that. Not all provincial insurance plans will pay for midwife care and in provinces where they aren’t provincially reimbursed they are also not licensed….and may not be legally able to work, I’m unsure on that point.

            In bc midwives iirc have to offer home birth. If you are cared for by a midwife they come and assess you at home when you go into labor even if you are planning on a hospital birth (unless you choose to go right in and meet them there but most midwife clients want to be at home as long a possible from what I understand). They will then stay with you or leave nd reassess if its really early and when you decide to go to hospital they accompany you. I don’t think any of the legitidwives do home birth only.

            After the birth, because you are discharged to the care of te midwife, you are free to go in 6 hrs if you want. They see you in your home for six weeks of follow up care and feeding support

          • Eddie

            I continue to learn a LOT here. Thank you so much!

  • theadequatemother

    take a look at the studies that were included in the metaanalysis!

    three from canada: two from BC, one from Ontario, one for australia, one from NZ, one from the Netherlands, and one from nepal.

    There isn’t any american data in this meta-analysis…and it primarily includes data from countries where homebirth is supposed to be “safe.”

    • ..here we go again.

      They left out the UK and the Netherlands.

    • Eddie

      In other words, it primarily uses data from countries that have a very different training and licensing model for midwives. So then, what can we conclude about the meaning of this study for America? Nothing new. Feh. How can researchers miss something so obvious as a vast difference in licensure requirements?

      • auntbea

        Because a lot of researchers are really, really bad at their job. And work without oversight or consequences for bad work. You know. Like midwives.

        • Eddie

          Sadly, you are right. I wish I could say this problem was confined to one area of research or one science, but it’s not. Also, a study that says, “three times the death rate … but as safe or safer than …” (without putting enough qualifiers there to prevent cognitive dissonance) suggests a bias.

      • Bombshellrisa

        These are the same type of studies that all the CPM websites link to….which is misleading. And shows how either untruthful they are (since if they read through them, they would understand that the studies aren’t about midwives like them) or stupid (didn’t read them at all, but liked what they saw and think it makes them look better)

      • LukesCook

        Doh, this can easily be resolved by just licensing lay midwives! Then the situation in America will be the same as those other countries, because there will only be licensed midwives and not lay midwives!!

        • I have now taken to referring to “non-CNM midwives” in order to clearly indicate a midwife with low/er levels of education and training. (Plus the lack of accountability and oversight and so on..)

    • Sue

      So – if HB neonatal deaths are 3X with the use of specialist-nurse MWs, how much worse are they for CPMs/DEMs/Lay MWs?

    • fiftyfifty1

      Holy shit! But their commentary is all about the issue of direct entry midwives here in the United States. “Direct Entry” midwives in the Netherlands, Canada and Australia all go through a University training program (not sure about Nepal). They just are called “direct entry” because they don’t work as nurses first (as United States CNMs typically do). “Direct Entry” in the United States means lay midwives. This study is comparing apples to oranges (or rather apples to horseshit).

    • Antigonos CNM

      Homebirth is safe in NEPAL??

      Of course, it isn’t safe anywhere, or perhaps that should read “it’s safe everywhere, except when it isn’t– but those are obviously exceptions that prove the rule” .

  • Renee Martin

    Let me guess, they use the data that doesn’t include hospital transfers.

    • Eddie

      From reading the analysis, you cannot tell at all. It isn’t mentioned anywhere that I saw.

  • Alenushka

    You are all silly people. Birth is not about the baby. It is about the experience!

    • theNormalDistribution

      You are so right. I was just on the phone discussing MRCS with my sister, and she said to me “I don’t care what you say, my vag needs to push out a baby.”

      • She might think differently after her vag has actually pushed out a baby….

      • The Bofa on the Sofa

        OK, am I the only one who reads this and this of Mr(s) Garrison on South Park (after the sex change)?

  • Charlotte

    OT, but did anyone else see that Fox did a piece on Lotus Birth? They interviewed a midwife who said that the placenta only rots if you wrap it in plastic sandwich bags. I can’t believe this crap is going mainstream and that people believe it could in any way benefit the baby. I’m afraid to see what the woo crowd comes up with next when they have to raise the bar higher once Lotus Birth gets too common to be a brag-worthy accomplishment.

    • Elle

      “I delayed cord clamping”
      “I didn’t clamp the cord at all.”
      “I didn’t CUT the cord at all.”
      “I saved the cord and use it as a drinking straw!”

      • Eddie

        “My baby is still attached — the NEW attachment parenting! Sure, the placenta is getting a little ragged, but I trust it.”

        • Sue

          No Eddie – TRUE attachment parenting is where the placenta doesn’t detach from the uterine wall…

          • Susan

            I just renewed NRP and one of the questions used “the umbilical vein of the placenta” as a wrong answer for appropriate choices for volume replacement. I had to laugh.

      • Eddie

        “I saved the cord. Next time I need an IV (shudder, ‘medical intervention’) I’m going to use the cord as a ‘natural IV’.” It’s natural. How can I go wrong?

      • We Need to Talk About Whapio

        I cut the placenta up into tiny bits and wrapped them in foil to make a lovely advent calendar for the kids. The leftovers went into the mix for haggis.

  • EB

    Laywoman raising her hand, here: is this an apples-to-apples comparison? Ie. were the hospital group and homebirth group comprised both of low-risk women with singleton pregnancies who were striving for vaginal birth?

    • The Computer Ate My Nym

      It’s a meta-analysis, which means that the answer to an either/or question may be and often is “yes”. Some of the papers analyzed seem to have used groups that were as close as possible to equivalent, others not so much.

      • EB

        Thanks, I appreciate it. Going in to an area hospital for my third baby, a woo woman said to me, “But their section rate is soooo high!” Um. I was going in for a section. To a hospital that specialized in high-risk deliveries. Of course they had a high section rate, it’s one of the things they’re very good at. (Which is why I picked them. See, see??) That was when I got my first glimmer into how ill-informed the natural birth movement can be. A “C-section rate” is meaningless measure of a doctor’s skill with natural birth if it includes all the women who never intended a natural birth at all. I was not a candidate for VBAC and it’s not reasonable or logical to measure my doctor negatively by that fact.

  • Oh come on- it’s only triple the rate if you include Phoenix and Flagstaff!

    • The Bofa on the Sofa

      (Chelsea wins!)

      • Susan

        yep..she does 🙂

  • Elle

    And how on earth is a woman to truly KNOW whether she is low risk unless she undergoes testing and, *gasp* interventions! That’s what those tests are for. A woman who works with midwives who are against ultrasounds and other routine tests is only low risk as far as she knows.

    (Of course, not all midwives encourage the refusal of standard tests, but if they do, then they are categorizing women using obsolete methods, which can be disastrous for the woman AND the baby.)

    • Captain Obvious

      Low risk pregnancy is a retrospective diagnosis.

      • Sue

        Or perhaps “low-risk pregnancy” is a reality (ie lack of high-risk factors), but it doesn’t predict the outcome of labor and delivery.

      • Lisa from NY

        Also, a mother with no medical history but a large weight gain would be assessed as low risk by a midwife but high-risk by a doctor.

    • yentavegan

      this is such an important distinction. if a mother employs a midwife who adheres to the philosophy of “trust birth” and if the midwife discourages testing than how the heck can a mother know if she is truly low risk!?

      • Sue

        I don’t get why someone who trusts birth would need to pay a birth attendant at all…..doesn’t this show distrust in itself? If babies know how to be born and women’s bodies know how to birth them, save your money for the champagne afterwards.

        • Poogles

          ” don’t get why someone who trusts birth would need to pay a birth attendant at all…..doesn’t this show distrust in itself?”

          It is exactly that line of reasoning that leads many homebirthers or would-be HBers to UC – it was what led me to want a UC. Thank goodness I learned better before I had a chance to try it…

    • Sullivan ThePoop

      Right, not to mention a proven cervix is required to be truly low risk.

      • Amazed

        I’ve always wondered what ‘proven pelvis” means. It should mean that a mother’s vagina has managed to push out a baby as big as her last one. My mom, for example, had a proven pelvis, meaning that when properly vacuumed, it pushed out 9 pounds of a baby, most of it head. Alas, that said nothing about said pelvis’ ability yo push out 10 pounds of a baby. So, the tunnel of light, waking up to being massages not in a spa, and a midwife saying, “It isn’t there, it isn’t there|. Meaning, her pulse wasn’t there. What was her pelvis proven for afterwards? That it could push out 10 pounds all naturally and then haemorrage almost to death? Is that a proven pelvis?

        • fiftyfifty1

          That does indeed qualify as a proven pelvis. However your mom also has proven herself to be someone with history of macrosomic baby x2 and history of massive post partum hemorrhage. She is high risk. She actually lost her designation of low risk after the first macrosomic baby. Of note, your mom would have been risked out of, for example, the UK homebirth study because of the first baby’s size. 9 pounds is not a variation of normal. And it is a risk factor for the next one being 10 pounds. And it’s a risk factor for postpartum bleed. But a proven pelvis…yes she has that.

          • Amazed

            Thanks. I really didn’t get it.

            And it doesn’t take a genius to see that a 9 pound baby wasn’t a variation of normal for this particular woman. A few years ago, I came across a picture of mom leaving hospital with brand new me. It was a close shot and she looked terrible. She also looked shockingly skinny. It was May and she was in a sundress showing no belly, nothing. I asked her how much she weighed then. Her answer was, 96 pounds. A few days after giving birth. My 6.2 tall father looked like a giant to her 5.3. I think that nowadays, such women should be offered the option of an elective C-section for their next baby. She simply looked sick, sick, sick… but hey, she did it through the right opening.

          • Amazed

            Sorry, I meant 5.4. Never been good at converting cms to other measurements.

          • Eddie

            So just give us Americans proper metric units then and let us convert. 🙂

          • Dr Kitty

            I was reassured recently when a doctor recently said “Oh, of course you had a CS- well, I mean, obviously- look at the two of you”.
            He was alluding to the fact that my husband is a foot taller than me, and I can buy clothing and shoes from the Kids’ section of most stores.
            I most definitely DID grow a baby too big for my pelvis- of course in my case that meant 6lbs 3oz, not 10lbs.

          • fiftyfifty1

            I’ve said it before and I’ll say it again. If we really are serious about helping women deliver vaginally and lowering the c-section rate we have to start hiring terminal sires as they do in livestock husbandry. Famers buy the semen of small bulls who are known to have sired small headed and small bodied offspring. This ensures a safer vaginal delivery for their milk cows, especially for heifers (first time cow mothers). The young are not purebred but are perfectly fine for veal. We could do something similar with first time human mothers, and sell the resulting rather undesirable offspring for meat or perhaps allow gay couples to adopt them.

          • Amazed

            I’ve said it before and I’ll say it again. If we really are serious
            about helping women deliver vaginally and lowering the c-section rate we
            have to start hiring terminal sires as they do in livestock husbandry.

            Or even of we want to keep the women deliver at all. After the two natural experiences my dad put his foot down and said that there was no way there would be a third baby coming. Does that sound like a birth trauma to you? He obviously didn’t treat it in tme. And there was no one to tell him that hey, he just needed to see his next child being homebirthed and all would be OK. How much higher was the mortality for the safe or safer mode of delivery, namely at home?

          • Dr Kitty

            That seems like a perfectly sensible solution, a modest proposal even.

          • theadequatemother

            I often comment on the fact that I chose my husband for his small pointy head.

          • fiftyfifty1

            Sign him up for stud service!

          • yentavegan

            woman who can not naturally childbirth their babies were not meant to be mothers. We are altering the genetic make up of future generations by all this medical intervention. we are allowing our population to be filled with heartless robot like people who will then enter adult hood and change the course of the world’s history. The only way to save humanity from peril is to insist on homebirth with hands-off midwives.
            any questions?

          • Amazed

            David abd Victoria Beckam. I read somewhere that she was too posh to push. When I look at them, I simply cannot imagine why she’d want to push. Surely not for pushing her babies out. Looks nearly impossible to me.

            Kids’ section and a kid of your own without a kids’ section customer dad? A CS looks in order.

        • Sullivan ThePoop

          Well, since she had a vacuum extraction, I am not sure. I was just talking about how all these first time mothers think they are low risk enough and they are not.

  • ol

    I think it’s a very bad outcome for a woman to lose a baby, it’s much more trauma than c-section or PPH

    • Alenushka

      Birth Rapist!

  • The Computer Ate My Nym

    Looked through the article briefly and have a couple of initial complaints:
    1. They talk about tables that aren’t, as far as I can tell, actually included in the text. What the? Where is table 4? Or even table 5?

    2. This paper has not been peer reviewed.

    3. It’s relatively easy to fudge certain data. One can overestimate Apgars, underestimate blood loss, ignore perineal laceration. Maternal and fetal deaths are difficult to gloss over. Therefore, the mortality numbers are most likely the most reliable ones.

    4. Some of the studies included used inappropriate control groups.

    It all looks like something that was either meant as preliminary data and not for distribution to anyone other than the authors or a work where the authors weren’t paying attention to what they were doing.

    • Squillo

      It seems to this layperson that it would be unexpected to find that neonatal death is the only negative outcome that increases; wouldn’t one expect that, if the death rate is increased, other negatives (like Apgars) would have a corresponding (or similar) increase? Could this be because death is an objective measure and pretty hard to fudge?

    • Of course, when they’re telling women with 2nd and third degree tears to “keep [their] legs together” instead of suturing, and routinely under-diagnosing the severity of tears, their stats are going to appear better. I’d wager that their maternal outcomes are nowhere near as good as they claim… and even in the unlikely event that they were, is anyone really willing to significantly increase the risk of their child dying or suffering severe brain damage to avoid a perineal tear?

      Oh, wait… what am I talking about? Of course they are.

  • The good is being sacrificed on the alter of the perfect….it’s like the NCB slogan should be “Intervention free or DIE!”…. Personally I’d rather sacrifice all chances of the “perfect” to maximize the chance of the good, and nearly eliminate the chance of the horrific.

  • Susan

    Other than the risk of the baby dying homebirth is as safe or safer. ( Is that the take away message?)

    • Sue

      Except that they don’t even mention hypoxic injury….

    • Yeah, because that’s a pretty dismissible down-side!

      It’s quite telling, isn’t it. Even in a study that plainly reports a 3x neonatal mortality rate, they manage to gloss over the shocking mortality rate to focus on the “positive” birth experience. “Hey! Your baby died, but at least you avoided an episiotomy!”

  • Karen in SC

    So a 3.11x increased risk of neonatal death should be ignored for the 0.6x less risk of PPH. This can only make sense to the NCB world. Do the authors have any biases?

    • Captain Obvious

      And again, do the Homebirth midwives know how to estimate blood loss? Have they taken the Obstetrical Hemorrhage Project’s course regarding PPH and accurate EBL assessment? 1 gram of blood equals 1 ml of blood. And weighing blood loss is more accurate than estimating blood loss. And Dr Amy already has a thread about how Homebirth midwives all have Apgars of 9+9 or 9+10.

      • Aunti Po Dean

        That’s if you don’t include the ones with 0 and 0 🙁

      • Sue

        Good point. They should weigh the pool water pre- and post.

        • Laural

          oh ewe yuck.

      • Antigonos CNM

        Blood loss is notoriously hard to estimate correctly, and not just in PPH. Even accurately estimating normal MENSTRUAL blood loss is quite a job (one of my professors wryly said that he was convinced all nursing students suffered from menorrhagia, judging by the estimates he’d heard during his years as an OB). Unless every piece of clean linen is weighed prior to use, and the water content of a birhting pool is measured before and after a birth, one is really only guessing (and even then other fluids such as amniotic fluid will distort the results). Changes to hemoglobin levels do not occur immediately, as well.

  • Renee Martin

    How did they get “as safe, or safer” from a death rate 3x higher?

    • anonomom_LLLL_IBCLC

      I just emailed the first author to ask exactly this. The only thing I can think of was that their exact language is: “equally safe if not safer FOR WOMEN” (my emphasis). cringe.

      • I was surprised to see a lower incidence of PPH for home births, as well as no difference for Apgar scores. (assuming I read that correctly.)

        My impression for HBs in general is that midwives tend to skew Apgar scores high and that they tend to deal with PPH reactively as opposed to proactively.

        • The Computer Ate My Nym

          The metaanalysis depended at least in part on data provided by midwife assessments of Apgar score and extent of PPH. Thus, the numbers will tend to be skewed in favor of midwives. There is simply no way that a higher incidence of neonatal death can not be associated with a higher incidence of low Apgar scores: there must be more near misses in the home birth group.

          • Sullivan ThePoop

            Maybe most of the near misses end up transferring so they are given their APGAR scores at the hospital.

        • The Bofa on the Sofa

          Your second paragraph nails it. Remember that Apgar scores by midwives are grossly inflated.

        • L&DLaura

          We had a homebirth transfer a couple of weeks ago (baby magically flipped to breech at 10 cm). Anyway, babe delivered in parking garage. Blue, limp, HR >60. Our nurses gave APGARD of 1 and 9. Midwife gave 7 and 9.

          • Amazed

            You’ve saud it: it was blue. Blue is a natural colour. Dolphins are blue. Absolutely worth a 10. I wonder why she downgraded to 1.

            Really, how hard it is to not report on a problem that was subsequentrly resolved when no one knew that there was a problem in the first place? Make you look good.

            Where is “safe or safer”, do tell? Intervention safer, maybe. I didn;t notice any mention of maternal danger of dying. Babies, on the other hand…

          • LukesCook

            “baby magically flipped to breech at 10 cm”

            Doesn’t this in itself establish that the midwife is ignorant, incompetent and a liar to boot, and that any “information” she may have to offer is utterly worthless?

          • Bombshellrisa

            You know that midwives say babies know how to be born. Maybe those babies want to be born via C-section!

          • Box of Salt

            babies want to be born via C-section = SROM followed by FTP.

            The joke at my house is that my daughter decided to come out, then changed her mind.

          • Bombshellrisa

            To hear the CPMs and sadly some of the CNMs that practice at the local hospital, you would think that babies are constantly flipping into breech when it’s time to push.

          • Susan

            I have seen a couple doctors miss a breech. Neither one “pretended” he hadn’t missed it.

          • Susan

            That always makes me think of Lake Wobegon. Hard to imagine making a 1 into a 7. Glad about the 9 though!

          • Oh my god. That’s shocking and disgraceful.

          • I had a baby flip to breech during labor, but he was the second twin and suddenly had a LOT more room than before. I can’t imagine how a head-down singleton would flip to breech.

          • Therese

            Were the nurses in the parking garage??

        • LukesCook

          “There were no significant differences in outcome of home or hospital births attended by midwives for the other child health measures.”

          This seemed counterintuitive to me. But on reflection, it strikes me as perfectly possible that a fair number of the most compromised babies, who would end up ill or disabled (for whatever reason) if born in hospital will simply die if born at home. Implying that the “advantages” of home birth are twofold –

          1. Less risk of interventions, possibly (but not certainly) without any additional risk to the mother.
          2. The baby will most likely be reasonably healthy, even taking into account fudged Apgars, alternately probably dead. Less chance of an inconvenient, expensive and embarrassing defective in the family.

          Oh, and your own wallpaper and the placenta goody bag. It’s a win all the way- for a certain type of person.

          • Eddie

            I think that’s a good an accurate synopsis, given what we know. A good explanation for some of the otherwise counter-intuitive results.

          • Lisa from NY

            Lets not forget the oxygen deprived babies.

        • PrecipMom

          You are assuming that HB midwives in general know how to accurately clock EBL. I know a decent number who can and a decent number who can’t.

          • The Computer Ate My Nym

            That’s the thing. EBL and Apgars are easy to fudge. Neonatal mortality is harder to ignore or explain away.

        • Renee Martin

          You cannot use self reported “data” from HB MWs. They are notoriously unreliable.

      • Lost in Suburbia

        That’s what I’m thinking – they were very specific in saying women, and not saying anything about the safety for babies.

        • anonomom_LLLL_IBCLC

          If that’s true, there’s not enough vomit in me to adequately react to that idea. Last I checked, the death of a child is high on the list — maybe the highest — of the worst things that can happen to a person.

          • LukesCook

            Save some for this unctuous little snippet –

            “Most recently, the licensed midwife community has utilized the democratic process to their advantage to pass legislation to allow for an overhaul of the regulations overseeing homebirths and their profession in the state.”

            On top of everything else, they’re also DEMOCRATIC!

          • Amy Tuteur, MD

            I wondered if this was a swipe at direct entry midwives for trying to use the legislature to make decisions that are properly left to the Department of Public Health.

        • LukesCook

          That’s not what I took away from “…We seek in this meta-analysis to compare and contrast direct entry midwives’ outcomes for homebirths with their outcomes in hospital or health care facility settings” and “Nine studies were included in the meta-analysis of child health outcome of births attended by midwives in homes or in hospitals. We analyzed 8 outcomes of child health (neonatal deaths, prenatal deaths, Apgar…”, or even “The findings suggest that homebirths attended by midwives may be equally safe if not safer for women with low-risk pregnancies”, which could mean “safer for women” who have “low-risk pregnancies” or equally “safer” for “women who have low-risk pregnancies”.

      • anonomom_LLLL_IBCLC

        Holy crap, the author responded with this: “Thank you for bringing this to my attention. We have addressed this oversight in the report as you can now see.” It looks like they added the sentence: “Unfortunately, home births attended by midwives increase safety concerns for the child.”

        • auntbea

          Good work!

  • anonomom_LLLL_IBCLC

    Wow. I wonder what those authors have to say to “low-risk” women who have lost their babies at “maybe equally safe if not safer” homebirths?