Surprise! There were homebirth deaths in the Dutch study that claimed to show that homebirth has lower risks.

Surprised girl

On June 14, I wrote about Ank de Jonge’s latest attempt to show that homebirth is safe (No, new Dutch study does NOT show that homebirth is safe). As I mentioned at the time, 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.

In the latest paper discussed in that post, Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study,  de Jonge concluded:

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…

In other words, there was no difference in severe acute maternal morbidity (SAMM) between home and hospital among nulliparous women and a slightly lower rate of SAMM for parous women at homebirth.

There was 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. My Letter to the Editor of the BMJ regarding this inexplicable oversight was published the same day. de Jonge and colleagues have finally responded, and what do you know, the maternal mortality was NOT zero.

The reply appears to continue the trend of apparent obfuscation of the results.

The authors claim:

We did not mention maternal deaths in our study, but they were included among the women with severe acute maternal morbidity (SAMM). There were two maternal deaths in the planned home birth group (2 per 100,000) and three in the planned hospital birth group (6 per 100,000). The differences between these rates were not statistically significant (Fisher’s exact test, P=0.367).

They described 1 homebirth death due to cerebral hemorrhage possibly secondary to pre-eclampsia. The authors try to blame the doctors who evaluated the woman at 37 weeks, at which time she was felt to fine. A lot can and does happen in the last week of pregnancy. To blame the doctors who saw the woman a week before her collapse and absolve the midwife who cared for her at the time of birth is bizarre.

What about the other homebirth death? Funny you should mention that. The authors did not say. They lumped the second homebirth death in with the hospital deaths and reported:

The other four women were referred during labour from primary to secondary care because of meconium stained liquor. One woman suffered from sudden collapse during labour, when she was already in secondary care, and died. Although no definite diagnosis was made at postmortem examination, a cardiac cause appeared to be most likely.

A woman who gave birth spontaneously was discharged after one day. On the fourth day postpartum she was readmitted because of profuse vaginal bleeding and shortness of breath. She had a sudden collapse and died. Postmortem examination showed sinus sagittalis superior thrombosis.

Two women died a few weeks after they gave birth from causes not related to the delivery; one from a severe asthma attack, the other one fell down the stairs, had a skull fracture and died of a subarachnoid haemorrhage.

Since the authors did not specify that either of the woman who died of causes unrelated to delivery was in the homebirth group, it seems safe to assume that they were both in the hospital group.

Therefore, as far as I can determine, there were 3 maternal deaths attributable to pregnancy in the entire study, 2 in the homebirth group and one in the hospital group, for a death rate of 2/100,000 in each group. The only one that appears to have been potentially preventable was the one that occurred in the homebirth group. Therefore, the homebirth group had one death that was potentially preventable in the hospital, while the hospital group had none.

The study is underpowered to determine whether there is a statistically significant difference in the death rate between the two groups, but the fact that even one woman in the homebirth group died of a potentially preventable cause means that there is no basis for concluding that homebirth is as safer or safer than hospital birth among the women in this study.

Simply put, the death rate was not zero and until the difference (if any) between maternal deaths at home and in the hospital is determined, we cannot draw any conclusions about the safety of homebirth for Dutch mothers.

A more appropriate conclusions for the study would be:

Low risk women in primary care at the onset of labor with planned home birth had lower rates of severe acute maternal morbidity, but this difference was statistically significant only for parous women. However, there was a potentially preventable death in the homebirth group, while there were no potentially preventable deaths in the hospital group. The study is underpowered to detect a difference in maternal mortality between home and hospital, therefore, no conclusion can be drawn about the safety of homebirth.

Yes, fewer women in the homebirth group experienced severe acute maternal morbidity, but that’s nothing to crow about if one of them died and might have been saved in the hospital.

  • Captain Obvious

    Another thread of homebirthers who read the abstract and not the paper.

    http://community.babycenter.com/post/a43007650/new_research_on_safety_of_homebirth

  • Captain Obvious
  • ol

    I noticed one thing: such researches focuses on measures and outcomes that are more common in hospitals not in OOH birth and obviously they are more frequent in hospitals. But (I think) there some interventions and consequences that are more common in OOH birth but they are not counted or compared with hospitals data.

  • Turkey Sandwich

    In other current hot topics in Dutch midwifery, three midwives who are notorious for practicing outside of the protocols went in front of the review board earlier this month. I don’t know the details, but there was apparently one death involved and one of the midwives left a couple laboring with TWINS at home alone for 17 hours. I am very interested to hear the verdict, which should be in in the coming weeks. I hope they throw the book at them. It’s a sticky subject since a woman’s decision to chose where and with whom she births is considered a human rights issue here, and they are of course using the “but they would have UCed otherwise!” defense.

    And for a bit of nostalgia, anybody remember the thread on MDC a couple of years ago where the midwife covered the poster’s vagina with warm towels to help her cope with her mother’s c-section in some weird ritual in the woods? That is one of them. Quack, quack.

  • auntbea

    I think I am more confused now. So they *had* included deaths, but didn’t say so? And now the problem is that we don’t know which death was assigned to which place, so we can’t confirm their numbers?

    • Amy Tuteur, MD

      They included them as severe maternal morbidity and neglected to mention that they resulted in death.

      • fiftyfifty1

        Bizarre.

      • Expat in Germany

        I bet they included the non birth related deaths in the hospital column for severe maternal mortality. That also sounds like cheating.

  • Amy Tuteur, MD

    The BMJ published my letter responding to de Jonge’s acknowedgement of the homebirth deaths:

    http://www.bmj.com/content/346/bmj.f3263/rr/651393

  • I would love to see a study that compares the rates of trauma sustained between PLANNED homebirth and PLANNED hospital birth — I’d be willing to bet that planned homebirth is actually more likely to be traumatic than planned hospital birth. I just can’t imagine a hospital transfer that far in labour being fun – not can I imagine an emergency knowing help isn’t right there being overly fun either. Add to it some pretty serious prior beliefs about birth, and it just seems like a recipe for trauma…

    • guestK

      I can affirm that it is indeed traumatic, even if you are not transferring for an emergency.

      And traumatic for the father, as well. Perhaps a successful home birth feels “empowering” but a transfer is frightening. The loss of control (or more accurately the realization that control was an illusion) is incredibly scary for both the mother and the father – who is seeing his partner suffer and his child in danger and is powerless to help. As an aside, I remember so many people concerned and talking to me about signs of PPD; no one talked to my husband, who had gone through a pretty terrifying experience.

      • Not just ppd but PTSD…they are distinct, however I think PTSD after birth tends to fly entirely under the radar.

      • theadequatemother

        PTSD and ppd in dads is not uncommon. It also flys under the radar.

      • Deborah

        I love that line about control being an illusion – spot on.

  • The Computer Ate My Nym

    I’m not convinced that the other deaths were unavoidable. Take the woman with the superior sinus thrombosis. It sounds like she was readmitted with vaginal bleeding, possibly due to DIC from the sinus thrombosis. Did she have any symptoms prior to that? For example, a severe headache from the blood clot in her brain? Prompt anticoagulation and supportive care might (but only MIGHT) have saved her.

    I wonder if the woman who collapsed during labor might have had an AFE (though that can sometimes be seen on autopsy) or maybe a torsades, possibly due to medications interactions. I’d be interested to know what medications she received. (Though, again, this may be completely wrong.)

    Finally, how does a woman with asthma get to be called “low risk”? The stress of labor can bring on an asthma exacerbation that could only be treated effectively with prompt nebs and maybe intubation. (This happened to a relative of mine. She’s fine because she was in a tertiary care center and had immediate intubation when she began to tire from excess work of breathing.) The actual death may have been unrelated, but the fact that she was included suggests that the definition of “low risk” category was a bit laxer than I’d like. (In fairness, it’s possible, but not likely, that this was her first asthma attack. In which case my criticism is unjust.)

    • fiftyfifty1

      I agree, it would be nice to have more info….

  • ol

    I don’t understand – how can it be?

    “The other four women were referred during labour from primary to secondary care because of meconium stained liquor.” and “There were two maternal deaths in the planned home birth group (2 per 100,000) and three in the planned hospital birth group” – some women were referred during labour from primary to secondary care because of meconium stained liquor and were planning a hospital birth?

    • Because the idea is that a midwife comes to your house first to check whether you are far enough to go into the hospital (seems like “are you worthy enough to be admitted to the all-glorious hospital?). The midwife they calls the hospital to inform them that the woman is coming soon, and off everybody goes to the hospital. Of course, many women just go to the hospital and then inform their midwife, but that’s not the plan. The plan is to keep the hospital stay as short as possible.

      • ol

        Thank you for the explanation.

      • Wren

        Actually, that sounds better than the pregnant woman getting to the hospital to be told she isn’t really in established labour and to go home. That almost happened to me with my first, except that a good midwife noticed he was breech. I guess it wasn’t very noticeable as a GP, an OB and another midwife all missed it in the few days beforehand and all involved agree he turned a few days before that. We didn’t have a car at the time and getting a taxi home, then another back would have been at best annoying.

      • Turkey Sandwich

        While this is true, I think Fiftyfifty1 hit the nail on the head above. There do seem to be lots of misconceptions/misunderstandings about the Dutch system in conversations like these though, and not just about the homebirth side but planned hospital births as well. The fact is that planned hospital births here bear little to no semblance to those elsewhere in the world and your post is one example of why. I was in and out of the hospital in exactly four hours with my last. Push out the baby, then have some beschuit met muisjes and a shower and go home. Done. Then again, who would WANT to stay for an extended amount of time in a Dutch hospital? The shared recovery room isn’t my thing. If that isn’t motivation to forego the epidural, I don’t know what is.

    • attitude devant

      I agree, the way she presents all of this seems deliberately obfuscatory.

    • fiftyfifty1

      I interpreted the phrase “referred during labor from primary to secondary care” as meaning when a transfer occurs from midwife care to OB care. That transfer can occur in the hospital (if the woman started off in the planned hospital group) or from home to the hospital (if she started off in the homebirth group).

  • attitude devant

    I just cannot BELIEVE the BMJ. Seriously? They published this article that didn’t even see maternal death as an outcome? And what about the authors? Did they just figure the message is “You’ll be better off at home as long as you don’t die?”

    • Captain Obvious

      She died in the hospital :-/

      • attitude devant

        Captain, I’d laugh, but I was involved in a discussion about homebirth safety where a midwife said that a maternal death in NZ couldn’t have been related to birth because it happened two weeks later.

        • Susan

          Yeah, I had an argument with some HBAs online who tried to say that the McGlade maternal death was the hospital’s fault because if she arrived at the hospital alive then the hospital should have been able to save her.

          • Eddie

            I’d just want to ask that person … is there a point where someone can arrive at a hospital near death where the hospital cannot be expected to save her? Sadly, though, this is a particular way of thinking about things that is not uncommon enough, and not just about hospitals or doctors.