No, new Dutch study does NOT show that homebirth is safe

Salad preparation

Dutch midwife Ank de Jonge is at it again, slicing and dicing data in yet another unsuccessful attempt to show that homebirth is safe.

She thought that she had succeeded in  Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births (2009)  which appeared to show that homebirth with a midwife in the Netherlands is as safe as hospital birth with a midwife. Unfortunately for her, the subsequent study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study, was a stunning indictment of Dutch midwives, demonstrating that Dutch midwives caring for low risk women (home and hospital) had a higher mortality rate than Dutch obstetricians.

Two months ago, de Jonge in a paper in the journal Midwifery Perinatal mortality rate in the Netherlands compared to other European countries: A secondary analysis of Euro-PERISTAT data that attempted to absolve Dutch midwives, but actually CONFIRMED their poor mortality statistics .

de Jonge continues to slice and dice the Dutch homebirth data is an effort to somehow prove that homebirth is safe, when the data suggests that it is not. Her latest effort is Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. She and her colleagues found:

Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval −0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, −6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, −6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8.5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%).

Conclusions: Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.

There’s just one teensy, weensy problem. de Jonge left out the mortality rates. Severe maternal morbidity is an appropriate measure of safely ONLY when death rate is zero or nearly zero. If the death rate is not zero, that MUST be taken into account in assessing safety.

To understand the problem, it helps to look at a graphical representation. The image below compares the incidence of severe maternal morbidity in two groups.

Stickfigures dead covered

It’s easy to see that there were a greater number of serious complications in the second group than in the first. It is tempting to conclude that the place of birth for the first group is safer than the place of birth for the second group.

Look what happens, though, when we add the number of women who died in each group.

Stickfigures dead

Now it’s easy to see that the place of birth of the first group is far more dangerous than that of the second group. Notice that the rate of serious SURVIVABLE maternal complications is unchanged. But the dead women had complications, too, and they can’t be excluded simply because they died. If 6 women have serious complications in the first group and 3 die, compared to 5 women in the second group who suffer serious complications, and one dies, we CANNOT conclude that the group that had more survivors is the safer group.

de Jonge has shown us the equivalent of the first image, but it’s meaningless unless she shows us the equivalent of the second image. In other words, the MOST important piece of information, the information we MUST have in order to draw conclusions about safety is missing from the new paper and its absence is both inexplicable and impossible to justify. de Jonge does not explain what she did with the maternal deaths. It appears that she excluded them altogether.

If so, de Jonge compared the number of women who SURVIVED severe complications at homebirth to the number of women who SURVIVED severe complications at hospital birth. She didn’t compare the number of women who EXPERIENCED severe complications in each place. And she didn’t compare how many women DIED at each place. Without that information, de Jonge is not entitled to conclude anything.

This paper doesn’t show that homebirth is safe. In the absence of mortality data, this paper is meaningless.

  • Hcm

    Funny, that’s what we keep telling Obama about the unemployment rate. Can’t stop counting the people who stopped job-hunting. ;o)

  • Expat in Germany

    this is more than just slicing and dicing and ignoring deaths, this is full scale misrepresentation of the data. In a later post, there is a link to de Jong admitting that there were 2 deaths at homebirth (one of which was potentially preventable) and 3 deaths in the hospital group, two of which were unrelated to the birth at all. de Jonge included these unrelated births in the severe maternal mortality calculation and if you look at the numbers above, you can make a pretty good guess as to where: look at the difference in the relative risk for the nullips with respect to placenta removal, bleeding, and severe maternal mortality – there is only an increased risk of severe maternal mortality (where the non birth related deaths were counted) and not in the other categories. Taking this into consideration, there were only relative risks detected in the multip mom population, but since one has to consider that moms who had a rough first birth self selected themselves out of that group, de Jong shows very clearly the exact opposite of what she concludes: the risk for bleeding and placenta removal is the same for home and hospital birth, but the risk of preventable death is possibly higher in the homebirth group (although not statistically significant in this study).

  • Wow, really good for this. I’m afraid to share information with my family and friends.

  • ratiomom

    I`m a bit late to the party here but just wanted to add some background to the Dutch homebirth debate. A Dutch midwife gets a lot more money for doing a homebirth than for a hospital birth or transfer. Dutch midwives are currently fighting tooth and nail to keep the traditional homebirth-based system from undergoing a major reform after it has been proven to be less safe than hospital-based birth arrangements in surrounding countries.

    The midwives stand to lose a lot of money and professional independence and they are defending themselves by any means possible. A big newspaper coined the term `homebirth mafia` for this movement. They try to raise the dwindling homebirth numbers by any means possible in an attempt to convince the Dutch government that a majority of women desire it. Some midwives put genuine pressure on clients to make them choose homebirth. So far it`s not working, with only about 20% of births happening at home, a rate that is falling fast. When the number goes below 10-15%, most midwives won`t be able to maintain their proficiency and will have to limit their practice to pre-and postnatal care. This is projected to happen within the next 10 years. While bemoaning the end of the homebirth era, the midwives conveniently leave out the fact that it is disappearing because the women decide for themselves to birth with safety and pain relief.

    • The Bofa on the Sofa

      Thanks for this information. Very interesting…

    • Sullivan ThePoop

      I will be glad when that happens. Then US midwives can stop using the Dutch system as faux proof that homebirth is safe.

      • Lizzie Dee

        The Dutch system is well regulated and isn’t safe. The UK system is well regulated and isn’t safe. Doesn’t anyone do Comparison of Adjectives any more? Safe…safer…safest. Some may be happy with the Comparitive, I”ll stick with the Superlative, thank you…safEST.

    • That is very interesting indeed. I I don’t see them pushing homebirths, but rather pushing natural births- also in the hospital. And the midwife loses money only if she has to transfer a patient to OB care (or to a secondary-line midwife) and it doesn’t matter if that happens at home or in the hospital. What I see is quite the opposite from what you describe: on one hand, yes, women prefer to give birth in the hospital, and more and more are choosing the epidural. On the other hand, the competencies of midwives has been increased so that they can administer gas and air in labor, put in IUD’s. I think they’re moving in the direction of midwives being responsible for women’s health in general… which isn’t that bad if they have the knowledge for that. In fact, I would prefer to see a midwife for any woman-related thing (that doesn’t require seeing a specialist) than a family doctor which is basically the choice I have here- OBGYNs work in hospitals and can only bee seen with a referral.

      • Lizzie Dee

        Seems to me that IDEA of midwives as an alternative more in tune with women is. fine, but the reality is working out differently. I haven’t read the report of the scandal at Furness Hospital, but it does seem as if turf battles and cracpot ideologies had something to do with it.

        I accept that a properly trained midwife is better than an optimistic, badly informed idiot – but if you are genuinely low risk, it won’t make that much difference. Whereas if the risky bits are unexpected, even a well trained midwife is going to have problems away from hospitals and if woo comes into it, you are sunk anyway. I liked my midwives. Woo free and working WITH doctors, fine. Following Midwifery Today and poor leaders I wouldn’t want anything to do with some of them.

        The idea that women can or should be fully informed about all the hazards also seems unrealistic to me. The trick is to be clear when low risk stops being reliable. If it doesn’t, birth is safe; when it does, start praying for providers who know what they are doing.

        • Eddie

          I just wanted to highlight this portion:

          The idea that women can or should be fully informed about all the hazards also seems unrealistic to me.

          We often get people swooping in here after a spectacular failure by a midwife to “defend” the midwife by saying the mother chose the midwife and was properly informed. E.g., Caveat emptor. As if that’s a defence of anything.

          Caveat emptor is just an excuse for quackery and “anything goes.”

      • ratiomom

        I don’t see how it is to a woman’s advantage to have her gynaecological care done by an undertraind, second tier provider. Womens health is so much more than just pregnancy and birth. It’s also STD prevention and treatment, contraception, screening for and treatment of various cancers, perimenopausal care, urogynaecology,… If midwives want to offer all that with consistent quality, they need to do medical school and a residency.
        We wouldn’t dream of having men see anyone but a fully trained urologist for their BPH, cancer screening and sexual health. Why do women deserve less in your opinion?

        • ratiomom, I see where you’re coming from and I would agree with you. Except, in the Netherlands, my only choices for woman’s health are: a midwife (who, does mostly the pregnancy- birth-postpartum period) or a GP, who- just like a midwife is trained in recognizing problems which need tbeing transferred to a specialist. So, at least they’re being fair- woman get to see a GP but so do men. If I knew a midwife who was fully trained in all things woman-related, I would opt for her than a GP (besides, in the NL GPs, not OBGYN’s check for cervical cancer, do breastscreenings, etc. Hence, I would really prefer a midwife, but that’s just my preference. Others are happy with their GP doing all their check-ups.

          • ratiomom

            It seems that the real problem is not the lack of trained midwives, but the difficult access to ob/gyns! There is no need to create a whole new type of provider who has the privileges of an ob/gyn but not the training or the responsibility. Women deserve no less than men in that they should have their problems diagnosed and treated by a real doc. Just think about it: no-one expects people who need the services of a urologist, cardiologist or ENT doc to make do with care from an undrtrained provider (midwives operate on a nursing level) Why then expect that from women? And why assume that they are better at it than your GP?

          • Eddie

            As the US Federal government pays for a greater and greater fraction of health care, I see it as inevitable that an increasing amount of care is provided by mid-level staff as a means of cost control. To be fair, insurance companies would also push this as a means of cost control where they cannot be sued for doing so.

          • Sullivan ThePoop

            Why would the US government pay for any fraction of health care?

          • Eddie

            It already does. Medicare + Medicaid together account for very roughly half of total medical spending in the US, and also very roughly equal the per-capita medical spending of many European countries. Medicaid is about half funded by the federal government, with the rest coming from the states. The affordable care act will increase federal government spending on medical care starting in 2014. Whether that’s good or bad or neutral is up to the reader.

          • Turkey Sandwich

            This is not unique to women’s health issues in the NL. The entire healthcare system is based on referrals to see specialists of any kind. It would take a massive overhaul to change it.

    • Brass

      Sorry, but you do not seem to know what you are talking about. Midwifes that deliver in the hospital still get the same compensation; only the room has to be paid for by the expectant mother. Only when transferring the birth to a gynocologist due to a medical indication (complication) or when the pregnant mother wants a ceasarian (which normally is only the case with a medical reason) the midwife does not get compensated.

      Also, referring to your later post, a midwife is not responsible for screening for STD’s, infection and so forth. She/he is only responsible for natal care. A pregnancy is NOT a desease.

  • Anon

    OT: epic epic stupidity from midwifery today: http://www.midwiferytoday.com/articles/epiduraltrip.asp

    “The epidural trip-why so many women are taking dangerous drugs during labor”

    • Box of Salt

      It’s a reprint from 2010.

      My only other comment on the piece is that I’d be more interested to hear what its author has to say after she undergoes a root canal in the comfort of her home, with only the same analgesic methods she advocates in this piece available to her.

      • realityycheque

        No doubt the response would be that that’s a “different” kind of pain, because it is the pain from something being wrong in your body, as opposed to the ‘pain with a purpose’ of labour.

        • Box of Salt

          And if by chance she and I ever meet in person, I’ll refute that notion with this: the only “purpose” of pain is to stop doing whatever put you into it.

          That is it. Stop.

          I’ve had all kinds of pain, and I do mean all kinds of pain. If pain has a purpose, it’s to be avoided. With apologies to Rob Reiner: anyone who tells you differently is trying to sell you something.

        • Squillo

          I think knowing that made the pain in my first labor less frightening early on. It was still pain and still unpleasant. Once we hit transition, the only idea that was comforting was that the guy with the big needle was right down the hall.

          Pain is pain, and the only objective reason to suffer it is if the alternative is worse.

      • Antigonos CNM

        The title says it all — “dangerous drugs”. The whole concept that drugs are always and inevitably “dangerous”, while anything “natural” [whatever that is] is safe and benign while having as good an effect as the “unnatural” and dangerous “drug” [a word with connotations of narcotics and addiction, btw] is a very subtle and pervasive concept indeed. Just walk into any pharmacy, or health food store, and see the shelves lined with products that are mostly unstandardized and unregulated [“food supplements”] which are ostensibly as good as, if not better, than tested and approved medications. When I was working in a Women’s Health Center I was facing this every day.

    • Eddie

      Wow, that was above-and-beyond irresponsible and silly at the same time.

    • sue

      What a load of nonsense and self-contradiction. Labor is not painful, but it’s impossible to sit still for the epidural. Women aren’t aware of the risks, but they get a long list of potential risks and a long consent form to sign. Women getting epidurals are like people dying of drug abuse in the 1970’s, and yet more than half of women are getting them. Does she even read back over her own rants?

      • realityycheque

        Not the only contradiction I’ve come across from HB advocates. A few that immediately spring to mind:

        Childbirth isn’t painful vs. Here’s a birthing pool, doula, tens machine, etc. to deal with the pain.

        Babies know when to be born/inductions are bad vs. Castor oil, bouncing on a birthing ball and sex will help bring on labour.

        Birth is as safe as life gets vs. Some babies aren’t meant to live (let’s not forget the elevated HB mortality rate for something so ‘safe’).

        Women should be able to have choice regarding how they give birth vs. Ban maternal request cesarians!

        Doctors are never there for the whole labour vs. Midwife sleep the entire time or doesn’t show up at all.

        I could go on…

    • ratiomom

      I`m beginning to understand why so many midwives seem to lose the plot about things like risk assessment, pain relief, cesareans,…. If this drivel is the literature available to them for professional education, how can they become anything but ignorant and irresponsible? Are there better midwifery journals around? What`s the midwifery community`s opinion on this particular one?

    • Sullivan ThePoop

      This might as well have been written by a blogger at age of autism because the understanding of anything related to epidurals is just as poor as the understanding of science in general. First off even though epidurals are usually made up of the synthetic opiate Fentanyl and Bupivacaine, Bupivacaine (as anyone with any knowledge of pharmaceutical or chemical names should know) is a local anesthetic not even remotely similar to an opiate. Also, the local anesthetic makes up most of the solution because the opiate is just for quick starting and breakthrough pain while most of the job is done by the local anesthetic (again pretty obvious). Next, even though Fentanyl is more potent than morphine in the world of opiates that does not mean it gets you higher or has more side effects, and in many cases means just the opposite. Fentanyl is actually a better agonist (bind more efficiently) to the opioid receptors in the CNS and has less nonspecific binding so it actually causes less general side effects. Also, Fentanyl is used because its effects begin quickly and are very short lived, not to mention it cannot efficiently cross the placenta as natural opioids do. So the strong binding to its intended receptors, its short half life, its specificity to receptors in the CNS, and its lipophilicity which makes it difficult to cross the placenta all make Fentanyl a good choice for laboring women and unlikely to have much effect on the baby.

  • Jenny McLelland

    The comparison would be the aggravated assault rate vs. the homicide rate in a given city. The homicide rate is greatly affected by the quality of the hospital’s trauma center, but the aggravated assault rate is the rate at which people are actually trying to kill or seriously injure each other. Ah apples to oranges.

  • Squillo

    Looking at the paper again, it appears de Jonge did address it in the discussion:

    “Women with planned home birth had lower rates of all adverse maternal outcomes, albeit not significantly so for nulliparous women.”

    • Karen in SC

      I’m surprised (and maybe confused) about why nulliparous women are allowed a planned homebirth in the first place.

      • Antigonos CNM

        In my time in the UK, [mid 70s] it was not allowed. With no previous labor or delivery experience, there are a number of things that one cannot be sure won’t happen [for example, although my pelvis was estimated to be “big enough for a truck to get through”, I never dilated, and my 4+ kilo son would never have gone through it in actuality. In my second pregnancy, everyone was prepared for this scenario, and it did reoccur].

        However, pressure from various sources has changed that policy, and not for the better, IMO.

  • SB

    Actually, she didn’t even compare “true” complication rates. Do you really think it’s likely that homebirth midwives classify events as complications in the same way that doctors do?

  • Guest

    This one is more on topic, but from the same birth center and same google review: “The experience I had at the austin area birthing center was aweful. When my husband and I visited the center we were excited. Jean was a little crazy about natural birth slamming hospitals the whole time but we were into natural birth so the red flags didn’t go up. The midwives really do not know what they are doing. Jean herself told me that our baby was going to be about 7 lbs. Our little girl ended up being over 10 lbs. After being 10 days late I finally called the birthing center and begged them to see me and asked if there was anything they could do. With some herbs I finally went into labor. When they broke my water there was almost no amniotic fluid. It wasn’t till I had my second child in a hospital that I realized just how much fluid there is supposed to be and how in danger my daughter was. The midwife who was helping us was in and out of the room constantly. She was barely there for more than five minutes at a time and to answer the phone no less! You’d think they’d have someone to answer the phone. When I pushed my daughter out I began to bleed heavily. I could feel myself getting cold. They gave me pitocin in my leg to start contractions and stop the bleeding. It took awhile. The same thing happened with my 2nd child in the hospital only they gave it to me in an IV and the bleeding stopped almost immediately and I was fine. When the bleeding finally stopped I could barely lift my head off the bed. I couldn’t get up without passing out. I was dizzy everytime I got up for three days after. At the time I didn’t know childbirth was not supposed to be like this. I could barely hold my baby up. And of course they kicked me out 8 hours later. Had I been in a hospital with that amount of bloodloss they would have kept me for at least three days to make sure I was ok. The midwives told us that women couldn’t wait to leave the center, they had so much energy after birth, hahahahaha. Not true! It is dangerous to be sent home like that. We were told later by a doctor that we were lucky that my daughter did not have any complications like shoulder dystocia because of her size. Also, I have friend who also had her baby there. Her baby barely lived because of their incompetence! Jean Stokes has a huge ego and lacks the humility it takes to safely deliver a child. She’ll wait to call the hospital if there is a complication. Isn’t it better to be safe than sorry? The center is NOT INSURED!!!!! Jean has a history of things going wrong. That’s why the birthing center switched locations and used to be called something else. Don’t go here, not if you value your baby’s life and yours.”

    • Guest

      This sort of easy to access info has got to cut into their business eventually. I knew a woman who chose this birth center about a year ago, and I’m sure she had no idea about these outcomes. She was a highschool friend on facebook and she blocked me when I sent her a few articles from this site. She is a phd student who could think analytically, but she got convinced by the mistrust of hospitals propaganda that this birth center, which was just a few minutes from a major hospital, was a happy medium between homebirth and a 40% c section rate (she didn’t know that the primary c section rate was only 10% at the hospital).

    • Guest

      also scattered in the google reviews: a terrible story about a baby who died due to their negligence, the revelation that when they have a disaster transfer, they don’t take them to the hospital down the road as they tell patients, and a mom who was rejected as a client because she didn’t have time for their full indoctrination procedure because she traveled for her work and would need to have some appointments with another care provider in another state.

  • yentavegan

    Posts like this one is what makes Dr. Amy unique in the Pregnancy/Birth blogosphere. Most of the times, the articles are for the general population and you don’t need a science background to understand them. This one however uses terminology that is beyond my comprehension.
    So for me, when the subject of homebirth comes up and this study is cited, I am at a loss as to how to refute the findings.
    Homebirth as an option is raised often enough at lay lead peer to peer breastfeeding support groups and when the general media touts the safety of Homebirth i am left shaking my head in disbelief.
    I have started to recommend the website Hurt by Homebirth when other trained breastfeeding counselors begin to sing the praises of homebirth with a midwife.

    • Laura

      That would be a good suggestion – if other hb mothers and hb advocates didn’t immediately say, “Don’t listen to those home birth horror stories!” And with a wave of their hand they dismiss them very readily and offer support and encouragement to the worried mom.

  • Bomb

    OT: according to ‘the purple line’ I’m fully dilated and ready to push! Yipee! Oh wait no, actually I’m 2cm and the baby is no kind of engaged in the pelvis. Other ways of knowing fail.

    • fiftyfifty1

      Best wishes!

    • realityycheque

      Best of luck!!

      Alternative methods of measuring dilation are rubbish. My mw said she could tell how dilated I would be without cervical checks. Had no idea I was in transition or anywhere near 2nd stage and when my son came out she turned around and exclaimed, “Oh! Would you look at that!!”

      Nice one.

      • Squillo

        My cousin’s doula said the same.

        “No, I can tell it’s nowhere near time to go to the hospital, and they’ll just sabotage your VBAC.”

        Five minutes later, baby was seriously on its way and after an ambulance ride, the baby was born in the corridor of the hospital ED.

        • realityycheque

          A friend of mine went to the hospital while in labour with her first. Despite her mother having a history precipitous labours, they didn’t to an internal exam and didn’t do a proper monitoring of contractions. She was sent home and within a short amount of time had given birth on their lounge room floor.

          The cord had been wrapped around her baby’s neck and she needed to be monitored for a few days because she was very small and there were some concerns relating to that, thankfully they were both alright in the end. Very frightening experience for her and her partner.

          • Squillo

            Sounds like malpractice to me.

      • Antigonos CNM

        Well, if a woman who is in active labor suddenly turns onto her side and vomits, more often than not, she’s in transition [7 cm at least]. Believe it. But I do a PV to check

        I too, in my time, have been sure we have a while to go before Jr. shows up, only to have Mom say a few minutes later “It’s time”. Once, I sent a rather sheepish and highly apologetic father to an important conference because his primip wife was undoubtedly still in latent phase — only to have her deliver an hour later. When I apologized to her, she said “Oh, that’s all right. He didn’t really want to be with me. He’s the sort who faints when he cuts his finger. I’ve been telling him that it’s OK, but after reading all the books, he feels that if he’s not in the delivery room, he’s letting me down.”

        • Squillo

          My midwife made the same “almost error.” Said she thought I had at least a few hours to go, but she did an exam to be sure, and I was nearly complete.

          Which points to something one of the SBM folks wrote the other day: “In my experience” is one of the most dangerous phrases in medicine.

    • Good luck Bomb!

    • Squillo

      Best wishes for an uneventful labor and a healthy and happy mother and baby.

    • Karen in SC

      what, no pictures? video? Congratulations! Nice timing to have a baby on Father’s Day (or weekend)

    • I don’t have a creative name

      Good luck Bomb! At least there won’t be a whacked out lay midwife in your driveway trying to block you from going to the hospital this time! Keep us posted when your new little gets here!

    • Bomb

      Born at 5:37pm, 5# 11oz, 18 inches. Min 2 day NICU stay, possibly longer. Could have easily been another sad statistic if it weren’t for proper medical care.

      • Box of Salt

        C O N G R A T U L A T I O N S ! !

        Best wishes for your whole family! Especially the newest member.

        Please keep us updated.

      • Eddie

        Congratulations!

      • Anj Fabian

        Congratulations!

        I hope the NICU stay is short and recovery is quick and uncomplicated.

      • moto_librarian

        Congratulations! I hope that the NICU stay is short, and I am so glad that you both came through it safely!

      • I don’t have a creative name

        Why does baby need a NICU stay? Hope everything is alright. Congratulations!

    • Bomb

      And thank you everyone for the well wishes 🙂

  • Hush

    A bit topic from this post, apologies. The name of the mother who had high blood pressure that died this week two weeks after her home birth is Heather Rivera.

    • I don’t have a creative name

      Where was this discussed before? I missed it.

      • Hush

        It was not.

    • Hush

      https://www.youtube.com/user/hrivera5/videos?sort=dd&view=0&tag_id=&shelf_index=0 This is her and her family. Such senseless loss. Senseless.

    • areawomanpdx

      oh, no 🙁 how did she die?

      • Hush

        Blood clot.

        • Susan

          That’s terribly sad. Is there a reason to think this was preventable?

          • Hush

            She was high risk.. history of GD and high BP. She had untreated high blood pressure. She was told multiple times by NCB sorts that she was a good candidate for home birth; her midwife brushed off her blood pressure repeatedly, the NCB sorts told her this was a good midwife. She was not doing anything to lower the blood pressure besides eating more protein.

          • Antigonos CNM

            In that case, an ounce of prevention is worth a pound of cure. Inadequate, or improper, antenatal care was much more to blame. And lack of intensive PP followup. Birth was the least of her problems. Blood sugar can return to normal within hours of birth with GD, but BP can take a much longer time, and she certainly should not have been discharged without treatment. But then, she hadn’t been admitted, or worked up, had she?

          • Hush

            I was under the impression they did no blood tests. She was never admitted because the midwife did not send her to the hospital because she was not “really” high risk.. even though she was obese, had GD, and had uncontrolled high BP. I don’t know if this was a midwife with a license or not, I do know that they used to run an Arizona birth center but that they closed up shop shortly after she had her 3rdborn with them. She did say that her first two were born in hospital and her blood pressure was higher than what is considered normal then, too, but the doctor never did anything about it because it wasn’t “too much higher than baseline” and she never lost protein in her urine. She had several readings of /100 in her last pregnancy and this one, so I think it is safe to say baseline was surpassed by at least 15 pts this time. I understand why she didn’t want to seek high risk care; last time everything was ok, she did not want any judgment or a fight, she didn’t want induced, she did not want to lose her home birth.. but I’m sure if she’d known the price she would pay, her baby would pay, her older children would pay, her husband would pay, her family, her community.. she’d have done things so, so, so, much differently regardless of what she wanted.

          • Antigonos CNM

            I’d like to think she would have taken better care of herself, also, but you can’t be sure. The lay public doesn’t really understand the difference between hypertension in pregnancy [HIP] and pre-eclampsia, but both are dangerous. No protein? No worry…

            Antenatal care is SO boring…pee into this cup, BP, weight, see you in 4 weeks [or more frequently as pregnancy advances]. For this you have to leave work, possibly drive quite a way, get someone to look after the kids, yawn — do I REALLY have to disrupt my life for this “junk”? And of course, if you do get told that you have GD, wow, you’ve got to keep a strict diet [as if cooking for a family of picky eaters isn’t enough, I ask you?] and test your blood sugar [ouch!] as much as 7 [!!??] times a day. Fuggedaboudit….

            And the kicker is that, if you are really a good little girl and follow instructions to the letter, you probably are going to be told in the end that you can’t have the homebirth you’ve set your heart on, anyway. So why bother? Birthin’s normal, man!

          • Lizzie Dee

            What exactly DO these midwives regard as high risk?

          • Hush

            Well, I think that normally they would have considered her high risk but she was pretty well begging to be taken on. So, the midwife thought she’d be “nice”, probably wanted the money, and played the odds. What were the odds that someone with pre-existing hypertension that actually hadn’t caused much of an issue before, well controlled GD, and 3 completely straightforward births under her belt is going to have some sort of profound issue with time 4? And, you know, the midwife was half right. There was nothing noticeable, at first. 2 weeks later, though, momma dropped dead from a blood clot. 🙁 I don’t know for certain that it was directly related to her lack of real health care.. but I cannot help but strongly suspect that appropriate health care might have done SOMETHING.. treated her blood pressure? discovered she was over-coagulating in her blood work? identified a symptom she may have been having? Something other than the non-treatment she received.

          • Eddie

            What kind of midwife was this? Lay? Licensed?

            This seems like the kind of thing a doctor would lose a license for, but I’m sure this midwife will go on practicing. Sigh.

          • Hush

            I don’t know. I know that the midwife used to belong to an Arizona birth center called Casa midwifery with her sisters and her mother .. and it closed.

        • FormerPhysicist

          Can someone medically trained address this? I had post-partum pre-eclampsia. So, I guess I was well on my way to seizing.
          Is a blood clot related? Or just a different thing that can happen with high BP.
          I’m not even truly clear as to whether (super) high BP is a result of pre-E, or is pre-E.

          • Lizzie Dee

            Not medically trained, so also interested in an answer. I believed that delivery was the only “cure” for pre-e, so was surprised when my daughter’s continued post-partum. Far as I understand it the difference between PIH and pre-e is that other systems can rapidly fail, and seizures are only one of the bad things that can happen quickly.

          • Hush

            Pre-e is a constellation of signs/symptoms that signal you are about to get eclampsia..

            As far as I know, she did not have pre-eclampsia, but she also wasn’t given appropriate blood tests, only given little strips to pee on testing for protein, so it’s not really certain that she didn’t have pre-eclampsia at some point.. I would hazard a guess that her midwife never even checked her blood pressure post-partum, but don’t be so certain, she might have. This woman had pre-existing borderline high blood pressure that was worsened significantly by pregnancy. So, at very least PIH.

            Blood clots are related to high blood pressure of any cause.. They are also sometimes freak events that can happen to anyone, but are particularly likely surrounding pregnancy because of the excess of estrogen. Having other risk factors in addition like smoking/high blood pressure/inactivity increases risk more. Uncontrolled high blood pressure is particularly one to increase the risk.

            I’m not a medical professional of any sort. If anything I’m saying is wrong, then it’s googles fault and correct me please.

          • Antigonos CNM

            Pre-eclampsia can occur up to 24, and some say 48, hours post delivery. One of the reasons why, unless you’ve got a homebirth midwife who will come for postpartum checks for the first few days, you are much better off in hospital, even if the Evil Nurse wakes you at 5 a.m. to take your blood pressure.

            Generally speaking, blood clots are not connected with PE, but this woman seems to have had a number of other conditions such as gestational diabetes and obesity.

            The difference between hypertension in pregnancy and pre-E is that [1] in HIP, the woman often has a history of hypertension when not pregnant while in pre-E, onset is extremely rare before the 28th week, and never before 20 weeks, [2] her blood pressure remains consistently high for weeks after delivery, but in pre-E it usually goes back to normal within a short time after delivery, and there isn’t any protein in the urine. HIP women also tend not to have hyperreflexia, which pre-E women do have.

            The classic symptoms of pre-E are: protein in the urine, hyperreflexia, generalized edema [swelling] and hypertension. It is commonest in very young primips, or “elderly” ones [over 35], and it sometimes can reoccur but not always does so. The earlier the onset, generally the more severe the condition.

            In HIP, the blood circulation to the fetus can be impaired, leading to a small-for-dates or IUGR [intrauterine growth retardation] baby, and the woman can suffer permanent kidney damage.

    • Meredith Watson

      How sad.

    • Hush
  • I don’t have a creative name

    OT:

    *headdesk*

    “If my midwife won’t do what I want, I’ll just have this baby without her!”

    http://community.babycenter.com/post/a42577897/

    • Eddie

      At least most of the responses are calling her to task. I like this quote: “i would not atempt this if i thought something was wrong.” Well, duh. Who would?

      • Meredith Watson

        She also says she has all the “tools” necessary for birth – what could she mean by that? Goodness, I hope she doesn’t go through with it.

        • I don’t have a creative name

          Like on TV, where they boil water and rip up bed sheets?
          Yeah, that will help if she has a cord prolapse.

          • auntbea

            What is the point of ripping up bedsheets again? And why can’t that be done ahead of time?

          • Bombshellrisa

            I thought torn up bed sheets were to tie off the cord!

          • auntbea

            Because the Victorians did not have string! Of course!

  • Becky05

    Except that maternal mortality rates are now so low in nearly any developed countries that you couldn’t expect to see a statistically significant difference even in nationwide data. Comparing rates of severe morbidity is typically used as a marker instead, it isn’t something uncommon or underhanded at all.

    • fiftyfifty1

      So if the numbers are so small in both group just show them for completeness sake and then be done with the mortality piece and move on, rightly, to morbidity. Why not? I’m sure they have the numbers. Why not publish them? I can’t think of a reason why not….oh, maybe I can….

      • Becky05

        Oh, I do agree with that. They should include all the data they have available, certainly.

    • Amy Tuteur, MD

      This study uses data from another, larger study of all births in the Netherlands from 2004-2006. That study contained 371,000 women of whom 2552 experienced severe maternal morbidity and 48 died.

      This study involved a subset of 147,000 low risk women, of whom 288 experienced severe maternal morbidity. That’s pretty typical; 90% of the complications occur in high risk women. It is possible that there were zero maternal deaths among low risk women, but that would be unusual. We would expect 4 or 5 deaths. The question is how they were distributed between homebirth and hospital birth.

      • Becky05

        Even if we knew how they were distributed, isn’t it exceedingly unlikely that there would have been a statistically significant difference?

        • fiftyfifty1

          Mortality needs to be addressed. If I were a woman in the Netherlands I would want to know. Let’s say there were 5 deaths and 3 were at home and 2 were in the hospital. Well that wouldn’t bother me. But let’s say it were 4 and 1 or 5 and 0. And that the home deaths were all secondary to PPH (and thus possibly prevantable in a hospital setting). This is info I would certainly want, even if the numbers were only a trend toward significance. Wouldn’t you?

          • Turkey Sandwich

            I, for one, want to know. Midwives usually only address this on a superficial level when discussing settings (“there is no significant difference in outcomes” etc etc) and that is good enough for most women.

            I am interested to see if Ank answers Dr. Amy. In my experience with her she is not part of some unethical, home birth promotion machine (which is not to say she isn’t..just IME). She actually earned quite a bit of my respect last time we had a conversation about her research, because she genuinely seems to appreciate criticism and questioning. Admittedly I am somewhat biased since she was one of my midwives in my last pregnancy. I had the loveliest hospital birth imaginable and felt 100% supported by her and her colleagues in doing so.

          • I am a woman in the Netherlands, and I would like to know that, and the only thing I can find is infant mortality, not perinatal mortality- which as far as I remember is the correct criteria for measuring birth outcomes.

    • fiftyfifty1

      But this paper was written by a promoter of home birth. Her published works have shown her bias before. The fact that she leaves out the maternal mortality numbers makes me suspicious in just the same way that it did when MANA published their morbidity stats but left out the perinatal mortality stats. Don’t you think that if it were good news or even neutral news MANA would have published the death rates? Likewise, doesn’t it seem likely that if de Jonge’s numbers were good or even neutral she would have published them?
      Please people, just publish the damn death numbers!!!

  • fiftyfifty1

    Does anybody know if active management of the 3rd stage is the norm in the Netherlands? If it is practiced, is it practiced both at home and in the hospital? Do all women get it or only some?

    • Turkey Sandwich

      It is standard practice in both settings.

    • I gave births in the NL twice and both times I got pitocin for getting the placenta out. However, I was in the hospital both times, and my midwives told that it can vary from midwife to midwife- some are more hands-on (giving a shot of pitocin to get the placenta out quicker), and others wait. Hope that helps. I am not sure how it’s done at home.

  • The Computer Ate My Nym

    I find this study confusing. Dr. Tuteur already pointed out one major flaw, i.e. the complete lack of mortality data. I’ve got a few other issues…

    1. There’s no information at all about hematocrit in either group. It may be that patients were less likely to receive 4 or more units of PRBCs because midwives, justifiably or not, were less willing to transfuse. I’d like to know how often women had hematocrits under 20 at the end of labor rather than just how many units they were transfused.

    2. The confidence intervals for the various complications in nulliparous women include 1. Therefore, there is no identifiable difference between the groups in terms of the given outcome and one can not justifiably claim that the risks for nulliparous women were lower. (Even leaving aside any other questions about the handling of the data.)

    3. Post-partum hemorrhage is notoriously difficult to estimate. Do midwives perhaps downplay PPH?

    4. HELLP syndrome appears to be more common in the hospital group. This suggests that the groups are not equivalent risk since there is no intervention that will provoke HELLP. Or, possibly, it is underdiagnosed in the midwife group.

    • Lizzie Dee

      How are women supposed to become informed when access to full versions of research papers is so difficult? I gather you have read the full version, but most of us can’t, abstracts can be misleading, and the statistics can be baffling to the innumerate.

      The idea that interventions cause complications drives me nuts. And even the term interventions without clarifying which ones might, occasionally, be a problem and lumping all morbidities together is misleading. There is a huge difference between someone who is admitted to ICU (or NICU) as a precaution or as a matter of life and death, but it all gets blurred together. I can never tell which is poor research and which I am misunderstanding. Professionals can read between the lines but lay people can’t, always.

      These post may not be as popular, but there should be more of them. The discussions that follow publication might be more enlightening – who agrees, who disagrees, what the flaws are.

      • The Computer Ate My Nym

        Strange. I got the paper as a free full text. It wasn’t accessible for you?

        It’s a good point about the difference between a routine and an emergent admission. Maybe time in ICU would be a useful criterion to look at: routine, prophylactic admissions will likely be shorter than emergent admissions.

      • areawomanpdx
    • fiftyfifty1

      “3. Post-partum hemorrhage is notoriously difficult to estimate. Do midwives perhaps downplay PPH?”
      I share your concern. However these numbers are probably the most RELIABLE ones we will ever be able to get on the matter. Here’s why:
      1.BOTH groups are midwife-led deliveries (at least at the start of labor), and the midwives in both hospital and home have the same university training.
      2. The nullip numbers are identical for home and hospital, reassuring me that the midwives are probably not systematically underestimating blood loss in the home setting.
      3. Unlike in the MANA study, midwives in this study did not know ahead of time they were being studied. They weren’t trying to impress anybody.
      But PPH rates are STILL not as reliable as many other measures because they are estimates. Also rates of PPH are VERY subject to confounding, even if estimation were to be perfect.
      In my experience, estimated blood loss goes UP the more people there are in the room. If it’s you alone, and it’s “your” patient, you might look at it all and estimate “Ahhh 400cc”. But doing it as a team drives the estimate up. You then say “Ahhh 450?” (because you don’t want to come across as one of those biased-low people) and someone else says “Don’t forget that bloody drape over there in the corner” and then somebody says “Look at this puddle over here, this has got to be another 50cc”. And then there you go, the total is above 500 and it’s a PPH. This is one of the nice things in the hospital. There is always at least you and the labor nurse–2 people to talk it out and get it more accurate.
      Complicated births are more likely to have higher blood loss both because they are more complicated and because they often have more people in on the estimation process. The hospital multip group in this study was almost certainly enriched for women at higher risk to begin with. And then, because they were in hospital, they had easier access to calling in others (like doctors) for help. This drives the estimate up.

      • auntbea

        Fifty, I like you.

        • Karen in SC

          We have so many intelligent, insightful and just plain hilarious commenters. I think the community here is one of the key reasons the NCB crowd hate this site.

      • Turkey Sandwich

        “This is one of the nice things in the hospital. There is always at least you and the labor nurse–2 people to talk it out and get it more accurate.”

        Homebirths in the NL are assisted by a nurse as well. I have had a homebirth and a hospital birth here and they measured my blood loss in the same exact way in both settings: they weigh the underpads with a scale. In both instances the midwives asked the nurse to confirm the estimate.

    • Antigonos CNM

      1.Midwives, out of hospital, can’t administer blood products. So any PPH requiring transfer to hospital moves the goal posts. If you declare that PPHs at home “don’t require blood” and so are “less severe” than in the hospital, that’s a bit like saying you drank your coffee this morning black “for a change” when really you ran out and were too lazy to go to the corner store for milk.

      3. To be honest, just about everyone gets the amount of blood lost in a PPH wrong, both in hospital and at home. But at home, the estimation is made more difficult because, in a hospital it is easy to weigh an equivalent amount of dry clean laundry, disposable underpads, etc. while in the home, no one has scales and the linen, etc. isn’t standardized anyway.

      4. I am completely sure HELLP is underdiagnosed in home births. It does not always develop immediately after birth, in any case.

    • Squillo

      Interesting points. It underscores the difficulty of studying home vs. hospital birth. In a setting in which particular resources are unavailable (or additional steps must be taken to access them), it’s highly likely that they will be used less than when they are readily available, and that’s a problem with using resource usage (transfusion, ICU admission) as a measure.

      That said, the NL is probably the best setting in which to do it, thanks to the highly regulated and integrated system for home birth. I suspect you’re far less likely to have a midwife try to convince a patient not to transfer to hospital at a yellow light than in the U.S.

    • Eddie

      They say that manual removal of the placenta for parous women is more than twice as high in the hospital group for . I cannot imagine any mechanism that would cause that. My guess is that in the hospital they don’t wait as long, that in a home birth they’re willing to wait longer before deciding they need to take manual action. Is there any other explanation that is reasonable?

      The fact that for nullparous women, the numbers are near identical, and that both home birth and hospital birth numbers are significantly lower for parous women suggests that the women are self-selecting into different risk pools.

      • Turkey Sandwich

        I have no doubt that some amount of self selection is going on and skewing the numbers. However the VIL, which indicates what kind of care a woman receives and in what setting she should give birth, would prevent women from NEEDING to self-select. Retained placenta (and other “near misses” such as previous PPH addressed elsewhere in the comments) is a D indication, which means primary midwifery care, but indication to birth in the hospital. This is the indication I have. I can’t imagine that women with a D indication would be included in the study.

      • Antigonos CNM

        Parous women have more placental problems for several reasons. Uterine atony can keep the placenta attached, for example, and although placentas tend not to be sited in exactly the same place, it sometimes happens and this can lead to abnormalities. Grand multips are especially prone tp third stage complications.

    • Becky05

      I think your fourth point is the really important one. We know from the Birthplace study that the low risk populations were not at all equivalently low risk. And the authors do acknowledge this, that previous experience could have influenced the mothers’ choice of birthplace for subsequent births.

      Another fault with this paper is the complete lack of BMI information. Higher BMI leads to higher risk for PPH, so this is a really big missing piece.

      • fiftyfifty1

        This study seems much less well controlled for confounders than the Birthplace study.

        • Becky05

          I absolutely agree! There is much, much less information included in the study, too. The Birthplace study, besides the full published report, has numerous free online appendices further exploring the data.

      • Turkey Sandwich

        Could this be because women with high BMI would have already been removed from the sample? High BMI would be an “indication” and therefore would disqualify the patient from homebirth and possibly primary care.

        • Turkey Sandwich

          Apparently I am incorrect, apologies. Now that I can access the study, I see the portion related to BMI.

          ” For example, we had no information on body mass index. Although a high body mass index is not an official medium risk indication according to the obstetric indication list, midwives may have advised these women to give birth in hospital. They may have ticked the medium risk box but they could not record body mass index as the reason for medium risk in the national perinatal database-1.”

          Interesting that it isn’t an official indication after all. My first group of midwives were notorious for rejecting women with high BMI as too high risk.

        • Becky05

          Nope, the study itself says that BMI is not considered a high risk indication in the Netherlands, but some midwives treat it as an unofficially “medium risk” indication.

    • Anne

      I agree with the need for objective data (hematocrit, EBL). It also goes for the manual removal data- length of 3rd stage is not included, though very easy to ascertain in most perinatal databases.

      Point 4- HELLP is a laboratory diagnosis, not requiring and clinical signs- therefore you have to think about it, be concerned about it and do the blood tests. You can’t find a fever if you don’t take a temperature (with a shout-out to Samuel Shem)

      • Anne

        “any” clinical signs, sorry!

  • fiftyfifty1

    I think the nullip vs. primip numbers are telling. For example in nullips the rate of PPH at home compared to in the hospital is identical at 4.3% (43/1000). Same is true for retained placenta. But among multips, the rates in the hospital are higher than at home. The author seems to be implying that the hospital is doing some sort of bad thing to the multips that is causing them to bleed and retain at higher rates than they would have if they had stayed home. But that seems hard to believe. If the evil hospitals are doing this “bad thing” to multips, why wouldn’t they be doing it to nullips as well?
    The more likely reason for the apparent worsening of outcomes for hospital multips is self-sorting. Multips already have at least one birth under their belts. If that birth went perfect–no bleeding, no stuck placenta, no dysfunctional labor–they would be more likely to feel comfortable choosing a home setting for subsequent births. But if they had any trouble on the first, even just a little trouble like need for augmentation or borderline hemorrhage, most reasonable mothers would choose hospital their next.
    So among the multip group the hospital group is enriched for higher risk women. They are still “low risk” women overall (i.e. not VBAC or twins or breech) but still higher risk than the home cohort.

    • Eddie

      de Jonge does pay lip service to the point you raise, but she kind of hand-waves away that point. If others are interested in reading her discussion of this point, it’s in the section “Strengths and limitations of this study” starting in the 4th paragraph, including:

      However, the fact that odds ratios for adverse maternal outcomes were much lower for parous women than for nulliparous women, suggests that other factors played an important part. Those women who had a relatively difficult previous birth may have been more likely to plan a hospital birth next time, even if there was no official medical indication. If so, this self selection may have resulted in better outcomes among women with planned home birth.

      The fact that mortality is not mentioned at all is surprising. The word shows up only in one of the references, and is not otherwise in the paper at all.

  • fiftyfifty1

    I really would NOT want to have my placenta manually removed in a home setting! OUCH!!

    • Laural

      I imagine that would be extremely painful, and traumatic.

      I had the experience of having my placenta pulled/yanked out by a hospital based midwife with #3. It was -ugh- disgusting. I felt like a fish on the end of a ‘line’ which was the umbilical cord. She would pull and keep pressure for a while, then leave it alone for a while and then just give a few yanks, then more pulling… It took a while, there was a lot of blood. My husband was very concerned and it stayed with him. It was only the first birth he had actually attended as our other two came a wee bit too early for our planning at 37 weeks, so he was not really confident enough to say something, but, a lot of things worried him; not least this aspect. He was home on leave from Afghanistan and has done three combat tours and knows what amount of blood to start to be concerned about and he remains upset about the amount. There was interminable pulling and yanking and then there was tons of the manual uterus pressing after- HOW is that not a more extreme intervention than giving some stinking Pitocin????

      After that birth I suffered (and still do) from pelvic floor prolapse. I wonder if there is any correlation. With #4 I received Pitocin during and after delivery, and, placenta came right away and hardly any blood- it was the most amazing recovery ever, as well. I felt awesome.

  • theadequatemother

    I don’t know if this has been mentioned yet, but when you look at a retrospective cohort study like this, do you not want some assurances that the two groups are comparable? Even within the low risk category there must still be some unequal distribution of risk. Are the women in the two groups the same? Age? Parity? SES? Race? Etc. I would prefer the authors to match cohorts based on known risk factors within the “low risk group”. In this day with lg data sets and cheap computing power is propensity case matching really too much to ask for? I’m losing faith in the editorial staff at the BMJ

    • auntbea

      I have also been wondering why matching is not used in a number of these studies. Seems like a pretty standard epidemiological method, right?

  • Therese

    What is a typical maternal mortality rate for low risk women? I’ve only seen maternal mortality rates for women over all. I wonder maternal mortality among low risk women is just so rare that there weren’t any in the data that she looked at?

    • Becky05

      It is almost certainly the case that there were not enough maternal deaths for a valid statistical comparison. The overall maternal mortality rate in the Netherlands is around 10 per 100,000, and there were less than 150,000 women included in this data. There is nothing underhanded in her not including mortality data, it would have been worthless.

      • fiftyfifty1

        “There is nothing underhanded in her not including mortality data, it would have been worthless.”
        I think the audience would like to be in the position of judging that for themselves.

  • Laura

    Dr. Amy: I think I must be missing something: where did you get the mortality rates featured in this study? Were they published along with this study, but not included in the analysis or results? just curious….

  • Felicitasz

    Thank you so much.
    I did not like the previous two pieces. I do not really know Ina May Gaskin, I met her only once at a midwifery conference where no one bashed OBs, on the contrary, one day Ina May and I had lunch, just the two of us, we talked, we even disagreed about a couple of things, but I left the conversation – I almost apologize to say so but this is the truth – empowered. My own story and thoughts were received with a very kind, supportive and problem solving approach, and then, when speaking about modern birth and healthcare system issues all over the place, I was encouraged to think and read and be critical and compare things, and it wasn’t within the “frame” at all, that is, I wasn’t told to read “their” literature and be critical towards the “mainstream”. Therefore, I can’t form an opinion about the blog posts about Ina May – I just simply did not like them. I registered them as pieces of information, put them into my mental archives, and wondered about my slight dismay concerning the “ad hominem” part of the homebirth debate, regardless of who is the author and who is the target.

    However, I do like, and I profoundly, immensely, wholeheartedly appreciate the pieces like this one here today. There are a million studies, and as I have discovered, on needs to be very-very aware of what the question of the paper is, as opposed to what MY question is, and what the question that wants to find out the truth should be, and what to do to find the answer, however unpleasant that answer might end up being. Thanks again for this post.

    • guest

      If I were to try to guess who this is…

      • Felicitasz

        Me? Whom would you guess? 🙂

        Dr Amy knows me (by correspondance), and anyway I have nothing to hide from anyone else either as I write my own blog using the same name. You are welcome to google it with a site:hu specification and see where that takes you. Almost anyone in Hungary having anything to do about the home birth debate will know about me.
        However, I am interested who else I sound like if it is up to you to guess…

    • Karen in SC

      I don’t think the last two posts were ad hominem attacks. In the first, Gaskin was criticized for how she performs as a homebirth attendant. In the second, I felt there was more criticism of her followers.
      IMHO

    • Guestll

      The problem with cult leaders like Gaskin is that they can be much as you describe. Warm, charismatic, empathetic. I have no doubt that Gaskin is a nice person; it’s part of why she’s venerated in natural birth circles.
      Personal characteristics aside, Gaskin’s words and actions tell us exactly who she is and what she thinks of women.

      • Guest

        My ex boyfriend was abusive, but he didn’t start off that way. In the beginning, he was charming, sweet, doted on me… I thought I’d found the perfect guy; the abuse started so slowly and subtly that by the time it was bad I had built up a tolerance and didn’t even recognise the severity.

        A LOT of abusers are like this… they’re charming and charismatic in the beginning because it allows them to get close to their victims and establish trust. I stayed with my abuser for so long because (one reason of many) I kept excusing his actions with, “But he was so nice in the beginning…” and naively believed him when he explained away a lot of the abusive behaviour as being done to “help” me.

        Just because someone seems nice on first impression (or even second, third, forth…) doesn’t mean that they can’t be abusive.

    • Laura

      The challenging thing for you might be to reconcile the positive and empowering conversation you had with Ina May Gaskin and what she has written, and not edited, out of her very popular book. Her inappropriate description of how she handles certain births, whether she actually sexually stimulates women at all during birth, is entirely inappropriate for any person caring for a woman delivering a baby. That doesn’t take away from her encouragement to you, but, certainly, you wouldn’t defend her sexual fondling of women during birth, would you? Most people, just like us, have are good parts and our bad parts.

    • suchende

      I once spent an afternoon with a prominent public figure who I enjoyed very much, but who was widely criticized in the media. Later, when he was forced to step down due to mental health problems (among other things), I realized that even deeply disturbed people can keep it together in the short term.

      • Eddie

        In fact, most disturbed people are quite good at hiding it.

        • suchende

          Apparently. They can become prominent public figures.

          • Eddie

            Can and do! People are routinely fooled by charisma. Sometimes I even think that an especially strong charisma might be associated with deeper personality disorders. Some of the most seductive women I ever knew were BPD.

          • The Bofa on the Sofa

            As I’ve explained previously, pretty much by definition every successful snake oil salesman will be charming and charismatic. They have to be. That applies just as much to public figures.

            Now, charming and charismatic does not mean that someone is a snake oil salesman or otherwise a quack, but it absolutely does not preclude it. That’s what people need to recognize.

            I don’t CARE how “nice” IMG is in person, she is still sexual predator and an awful caregiver.

        • Box of Salt

          Two words: Ted Bundy.

    • Amy Tuteur, MD

      I’m glad you like this. It interests me, too. Unfortunately, we are among the few. Traffic and comments drop significantly on days I write posts like this.

      • realityycheque

        It’s such a shame that views and comments drop on posts like these, because THIS is the kind of important information people need to have when making decisions about their place of birth.

        That she left out such important data goes to show that she is either completely unethical (if done deliberately to manipulate the appearance of the outcome) or just too under-qualified to even understand why it’s a problem…. and neither of those possibilities make her come across as anyone who should be helping women makes decisions regarding homebirth.

        • Squillo

          Yes and no. I’m sure page views drop precipitously, but I think there are a few reasons the comments drop:

          For one, it’s harder to argue with these posts. The typical folks who drop in on other posts just don’t when they don’t have the ability or inclination to read research. There are times when I feel like whatever paper she’s discussing is out of my league in terms of understanding (or simply not available full-text), so I don’t have much to say, although I appreciate her post and the comments of those who are smarter than I am.

          On a related note, they just don’t generate the same kind of anger her opinion posts do. People aren’t commenting in ALL CAPS with spittle-flecked spelling errors, and they’re not posting about their outrage elsewhere.

          Another reason, I think, is that in some of Amy’s other types of posts, there’s a fair amount of philosophizing and speculation about psychology, motives, what-have-you, that goes on in the comments. Not as much here.

          While I agree that these are among the most important posts Amy does, I think she’s smart to run the blog the way she does, alternating science with horrible anecdotal stories, satire, direct attacks on NCB leaders, and other posts that are deliberately provocative.

          • At least some pageviews would relate to the lack of comments. If there’s a big comment-fest going on, lots of people will return to read and comment more. If there’s few comments, then we read it once and move on.

          • Eddie

            I agree. One person swooping in to comment on the more emotionally triggering blog posts can easily generate 100 comments in a day or two.

          • Squillo

            Newton’s first law.

          • realityycheque

            Good point, I hadn’t considered some of those factors.

            I agree that variation in the types of posts made is valuable. As much as some people dislike Dr. Amy’s tone, her blunt, unapologetic approach does seem to bring people by – even if it is just to gawk at how ebil we are, express hate, or try to “educate” us with a round of Homebirth Bingo. With that said, I see more and more people saying that they started over here hate-reading and ended up staying and changing their views.

            It’s just a shame that the less controversial, more fact-focused posts like this one don’t generate the same reaction and anger within the HB community; they only seem to come by when Dr. Amy posts something ‘controversial’ (usually about a person) or “meen”, and typically in response to someone sharing it in HB circles with the intention of, “Look at how ebil Dr. Amy is being today”.

            THIS blatant manipulation of data should be what makes them angry. Don’t they feel deceived? Lied to? I know I did.

      • Laura

        I think these are your post important posts, IMHO. Many people will read these dutch study results and draw erroneous conclusions. I find these posts very enlightening. They sharpen my critical thinking skills and make me aware of how desperately I need a thorough education is statistics. I also like your medically related posts that get to the heart of the matter. The one you did awhile back on fetal monitoring and how easy it is to miss subtle but revealing clues of possible fetal distress was very eye opening. Keep ’em coming! Thank you.

        • Felicitasz

          Yes, we seem to have similar taste 🙂 I too remember how my jaw dropped when I read the fetal monitoring post. The other day, I saved the picture about the pelvic shape variations, I don’t think I have ever seen that before. I translated (with permission) the “Attachment parenting causes autism” piece, to share the fun I had reading it, and share a very spectacular demonstartion of how correlation is not a cause-and-effect thing.
          Yes, these are the types of materials I keep coming back for.

      • Felicitasz

        Shame / pity (whichever is more accurate). This is the international year of statistics, and I think we (= human beings as a worldwide community) desperately need materials that teach us to think about data and not believe everything just because it is written in a scientific language and kind of makes sense on the first read.

      • AmyM

        Partly because you posted it on a Friday, I think. Things always slow down around here on Fridays. With the possible exception of AP posts. Anyway, I like the posts about the studies too. I have to delve into scientific literature for my job sometimes,( though not ob/gyn), and certainly these kinds of posts have broadened my critical thinking skills, which serve me well at work. I do not have a PhD myself, so though I can usually understand what the papers are about, there are little things that lay-people like me wouldn’t necessarily notice or think of.

      • mollyb

        I think it must have something to do with the highly technical nature of the subject. I really enjoy reading these types of analyses but as someone with no advanced medical or statistical training, I don’t feel comfortable adding my uneducated two cents. Where if it’s an opinion piece, well, we all have those. I think many agree and when there are fewer comments, there are probably fewer pageviews. That said, this is the meat of your work here, Dr. Amy. Anyone can point out the obvious but not everyone can dig into the medicine and the data as you can. THIS is why we need you.

        • Laural

          Well put!

        • Meredith Watson

          Exactly! I read these pieces, but don’t feel like I have anything to add.

          Though this is technical information, Dr. Amy does an excellent job explaining it in layman’s terms. I’m thankful for the illustrations that made the point extremely clearly.

      • Box of Salt

        One way you might be able to drive more traffic to the research-based posts is creating an index for them. Specific links to posts falling under certain categories (i.e., fetal monitoring, the Netherlands, etc) would help, especially when folks drop by on an opinion piece or summary piece (such as the Twelve Things) and complain that there’s no evidence posted. Just a suggestion.

  • Dr Kitty

    This is like a study that says “people who have a elective AAA repair are more likely to end up in an ICU than people who suffer AAA rupture at home”… And forget to say that this is because most people who have AAA rupture at home die before they get to hospital, or on the table in the OR, while EVERYONE who has an elective open AAA repair spends time in ICU as a precaution.

    What were the mortality stats?
    Because in 50,000 low risk women it shouldn’t be more than 3 or 4.

  • Squillo

    Can anyone enlighten me: How common is it to study an intervention and included morbidity rates without mortality rates?

    • Amy Tuteur, MD

      If the mortality rate is extremely low or zero, using morbidity is acceptable. For example, in studies of C-section vs. vaginal birth for breech babies, the maternal mortality is often zero in both groups. Therefore, when attempting to assess maternal effects, it makes sense to look at morbidity.

      • Squillo

        So is it possible that that is the case with this study?

        • guesty

          Of course that is the case. Dr. Amy is making you all look like idiots especially with the imagined graphics somehow becoming truth.

          • KarenJJ

            How can you be so sure it is the case, except that you personally want it to be the case?

            You think we don’t know the graphics are representing her point, not actually representing the numbers involved?

            I don’t think we are idiots for asking the questions either Dr Amy or Squillo have asked. I think we’d be idiots for not asking them. But sure, point out another blog that is asking these sorts of questions and discussing them with different viewpoints and doesn’t delete or edit the conversation beyond recognition.

          • Captain Obvious

            Nice karenjj, troll comes in and basically doesn’t want to discuss the case, just try and convince us that Dr Amy is an idiot, and people following the post are idiots, and Homebirth must be safer no matter what.
            All comments get left on here (so the real biased idiots stand out like a herpes whitlow), but go to any crunchy blog and debate the topic and all the comments get deleted.

          • KarenJJ

            “just try and convince us that Dr Amy is an idiot,”

            Well, no offense to Dr Amy, but I’d be interested if someone does come in here with some information to back up their claim that Dr Amy is an idiot in her questions and issues with this paper (or anything else they take issue with). But they don’t seem to get that far and I’m not going to just take their word for it.

          • Eddie

            It’s the challenges that keep science honest. Without them, it’s so easy for even the best-intended people to go astray. The fact that essentially no-one comes here with hard facts in hand to argue with Dr Amy is telling.

          • Squillo

            I’m not prepared to simply assume that, given that the maternal mortality rate for the Netherlands is 7.6/100,000 (according to the large 2003 Lancet study) and this study included 146,752 women. Possibly there were no maternal deaths–they were classified as low risk at the onset of labor. But when the study specifically looks at “severe, acute morbidity,” I find it a bit surprising that there weren’t enough deaths to signify, so that’s why I asked.

            I’d rather be an idiot that asks a question than one who makes an assumption based on zero data.

          • Box of Salt

            guesty, “Of course that is the case.”
            Show me.

        • auntbea

          I checked the maternal mortality rates for the Netherlands and got 6 deaths/100000 live births. So in the (massive) sample she had, there should have been 30 or so deaths. There may or may not turn out to be a statistically significant difference between hospital and homebirth if you run the numbers, but there is absolutely no reason not to address it.

          • Squillo

            [I]f you run the numbers, but there is absolutely no reason not to address it.

            That’s what I’m wondering. In a study in which you would expect the data to include mortality, even if it doesn’t end up being statistically significant, why would you not add a line to that effect?

            In any event, it should be a simple matter for de Jonge to provide the answer to Amy’s query in the rapid responses.

          • Becky05

            What massive sample? I am only seeing 150,000 births included in this study?

          • auntbea

            I accidentally pulled the 500,000 from the first linked study. But, since I usually work with samples of 2000 or less, 150,000 still seems massive to me!

      • The Computer Ate My Nym

        But there should be at least a brief statement that the mortality was zero (if it was) to avoid the very sort of criticisms we are giving here.

  • Squillo

    It’s a terrible waste of resources. What might have been a good study (it’s obviously important to study the rate of serious morbidity) is rendered absolutely useless for informing decision-making without the mortality stats.

    Are we meant to assume that a lower rate of a subset of severe morbidities correlates with lower mortality? That doesn’t seem unreasonable, but why not spell it out?

  • There needs to be a shift in how maternity care is thought about – intervention=bad needs to be challenged as often intervention=vastly better outcome than might have been otherwise. I’m also really tired of the focus on short term outcomes – when the long term is entirely discounted. Death is a pretty awful long-term outcome. Lifelong disability also sucks. PTSD is not fun. Incontinance isn’t fun. But overwhelmingly the 96 hours of birth get the focus…..

    Death matters….a lot, for most women.

    • Antigonos CNM

      Hopefully a lot less than 96 hours I would rate death as a fairly severe complication, myself.

  • Karen in SC

    Homebirth is too safer!! As long as you don’t count the deaths, it’s really really safer!! Some mothers must not be meant to live, right? Right??

  • Antigonos CNM

    I presume, Dr. Amy, that you saw this: http://www.theatlantic.com/health/archive/2013/06/study-home-birth-might-be-safer-for-low-risk-mothers/276863/#comment-930785775 or http://tinyurl.com/koxfmon

    So far I have been accused of being you, and that you are a quack.

    • Amy Tuteur, MD

      I left a comment, too.

    • GuestB

      I’m having trouble commenting over there, but that woman has no idea what the work “quack” means.

      • Antigonos CNM

        That should be her only problem . The canard that Dr. Amy isn’t a “real” doctor because she let her license lapse [or be put on an inactive list — I’ll tell you all a big secret, my US nursing licenses are inactive because I’m saving a lot of money by doing so, the annual fees are not peanuts, and I probably won’t ever work in the US again, so I guess that somehow makes me “not a real nurse” any more — pops up all the time. It is really amazing how many people think your brain is wiped clean the minute you stop actually seeing patients. That would mean all the doctors in academia, or research, must be idiots.

        If she thinks I’m Dr. Amy, perhaps we should be asking ourselves if she is Gina Whatsis…

        Frankly, if even a couple of readers of Atlantic are curious enough to come over here for a look-see, that’s progress, IMO.

        • The Bofa on the Sofa

          t is really amazing how many people think your brain is wiped clean the minute you stop actually seeing patients.

          Well, it would be if they actually thought that. Of course, they don’t. That’s just their reason for dismissing someone they don’t like.

          If it were something they liked, they wouldn’t care in the least if they ever even had a license in the first place.

          • GuestB

            That is such a good point.

  • Happy Spider

    Could you explain what “severe acute maternal morbidity” is?
    I thought the reason for giving birth in a hospital was that if complications occur, like post-partum hemmorrage, they will be handled better. But she seems to be claiming that hospitals cause pph? What is the mechanism for that.
    I think if you go to a hospital you are at more likely to end up with a c-section. That’s surgery. Surgery is bad. Is that by definition maternal morbidity? Because the argument for c-sections is that having lots of c-sections in exchange for a small decrease in fetal death is worthwhile because infant death is worse than a fairly safe surgery. I think you, Tuteor, have said this. But the quote here says nothing about this trade off.
    Similarly, aren’t there situations which left untreated have a small chance of maternal death? If those could be treated by c-section then again there would be a situation of lots of c-sections in exchange for a vary small decrease in maternal death. Is that what you are getting at by talking about the importance of including maternal death in the study? But what exactly is causing all the maternal morbidity in the hospitals? I am just making up “complications from surgery” because I don’t know what severe acute morbidity is.

    • Sullivan ThePoop

      You are not looking at it correctly. If there were 3 women that suffered maternal morbidity in the hospital and 2 that died compared to 1 woman with maternal morbidity at home and 4 deaths, the number of complications are exactly the same but the hospital can better prevent those complications from leading to death.

      • Eddie

        Wouldn’t it be less confusing, in this example, to say: five women who suffered maternal morbidity in the hospital, two of whom died, compared to five women who suffered maternal morbidity at home, four of whom died? Or is someone who experiences morbidity but then dies no longer counted in that category?

      • Happy Spider

        I understand Tuteor implied this here by 1) saying that the study was wrong to count when who survived morbidity instead of women who experienced morbidity and 2) making a graph with the number of dead women being comparable to the number of sick women….
        …. But I didn’t believe she really meant it. I thought in the past she’s always said that morbidity was magnitudes more common than death. I thought that the problem is that death is a much worse outcome than morbidity. So if you just count them all together, morbidity and death, then the absolute numbers don’t change much from counting morbidity alone. However if you weight the outcomes and count morbidity and death together with death weighing a lot more, than adding deaths affects the final numbers.
        But maybe I am wrong. Maybe Tuteor does mean that death and mortality numbers are comparable here. The definition of “acute maternal morbidity” given by another poster really seemed to me to be the sort of thing where there would be lots more morbidity than death.

        • Happy Spider

          The point is that, to make a ridiculous made-up example, if you invented a procedure that gave you 10 fewer deaths but 100 more hospitalized morbid patients, than that would be a great trade-off because death is much worse than morbidity. Some people would say, look, since the procedure gave 10 fewer deaths than only 10 of the woman really needed the procedure, so, since 100 of the woman had bad outcomes, that means 90% of the women had an unnecessary procedure with bad outcomes.
          It’s not necessary for death and morbidity to happen at comparably the same rate in order for it to be bad count only morbidity. Death may be magnitudes less common and still be important.

          • auntbea

            Hmm…I may be misunderstanding you, but I think you are making the same point as Dr. A. She is definitely arguing that death is a worse outcome. And it is not necessarily true that death+morbidity is equal in the two groups. The point is that we don’t know because we don’t have the mortality data. *If* morbidity is lower in the homebirth group because more of those ill women died, and were thus removed from the sample, the apparent rate of “severe adverse maternal” outcomes has been artificially deflated in the homebirth group — by an unknown amount — and therefore is evidence of pretty much nothing.

        • Sullivan ThePoop

          No, I am not saying that the point was that death and morbidity are comparable because they are not. I was just saying that I believe she was pointing out that without the mortality rates the morbidity rates are just meaningless even for measuring morbidity because if someone died there was some kind of morbidity that led to that outcome. The whole death is worse that morbidity is another issue IMO.

    • Squillo

      For data analysis purposes, they define severe acute maternal morbidity as: ICU admission, transfusion of 4 or more packed cells, PPH, and manual removal of the placenta.

    • Antigonos CNM

      OF COURSE you are going to have a higher C/S rate in a hospital! You can’t do a C/S in the home! And once you are transferred to a hospital you cannot be included in homebirth statistics, so there you are, a way to avoid the dreaded operation–just be somwhere where you can’t be operated on. You can’t be called to jury duty in a place where ther isn’t any trial by jury, either.

    • Expat in Germany

      The answer to your question is simple: when the axe falls at home, you may get to the hospital too late to get the blood you need to stay alive. When it falls in the hospital, you survive, but end up in the ICU.

  • Jenna

    As someone who is terrible at all things math and statistics related, I really, really appreciate your graphics!

  • Expat in Germany

    this reminds me of the evidence based medicine blog recently taking a bunch of studies of induction as a treatment for macrocosmia and saying, look,
    induction just increases the maternal complication rate while not affecting the fetal complication rate. BUT, all of the studies were underpowered to say anything about the fetal complication rate. I asked the author about this and she swept it aside with something along the lines of: since there was no trend towards improvement, everybody has just decided not to study the issue any more and let all big babies get as big as they want to get because ultrasound is worthless. It is like crying about scraped knees when the real issue is more serious.

    • Expat in Germany

      sorry : evidence based birth.. not medicine

      • Expat in Germany

        and macrosomia, not macrocosmia.. I make myself laugh.

        • Jocelyn

          I don’t know if even induction could help a macrocosmic baby. 🙂

    • Expat in Germany

      ugh, I shouldn’t have looked at that site again. I see that I have earned a stern rebuke and the punishment that all of the comments that she previously let through moderation have been removed. My beloved comments! Gone! I really wasn’t hostile or harrassing.. a bit disparaging maybe after she told me to go away (I questioned if she was qualified to portray herself as an expert in obstetrics, that was sort of mean, since she clearly sees herself as one) but it was sort of justified and I hate misleading numbers and if a lay person like me can see flaws in her reasoning, well, its gotta be bad. I really hate it that on the internet, you only get the last word when you are the moderator. Nobody here warned me not to waste my time!

      • Anj Fabian

        I thought you made a fine effort!

        I also suspected her article was cherry picked propaganda by the way she only included anecdotes that supported her premise, but failed to include any stories of women or babies who had serious problems VBing a macrosomic baby.

        • Expat in Germany

          well, the comments live on in the “mine is bigger than yours” thread of the SOB. you lose, rebecca, but not as much as if you had left them on your thread, because it was your answers that made you look bad. (oh, I am so childish, but this is as much entertainment as education)

      • Eddie

        IMHO, it reflects very poorly on Rebecca that she feels she has to remove comments from people who question her.

    • Becky05

      The most recent Cochrane review did note a trend towards improvement and recommended more and larger studies.

  • Amy Tuteur, MD

    My letter to the BMJ questioning the absence of mortality data:

    http://www.bmj.com/content/346/bmj.f3263/rr/649975