Henci Goer: Sure, homebirth is dangerous in reality, but what about in theory?

What if analysis

I almost feel sorry for Henci Goer. She has styled herself an advocate of evidence based obstetric practice, but the evidence continues to mount that homebirth, which she supports, increases the risk of perinatal death.

What evidence?

  1. Well, there’s the CDC data on planned homebirth, collected since 2003, that consistently shows homebirth to have a death rate 3-7X higher than comparable risk hospital birth.
  2. There’s the data from Colorado that shows that homebirth has a death rate more than 15X higher than expected.
  3. There’s the data from Oregon, probably the most definitive American dataset, that shows homebirth has a death rate 9X higher than comparable risk hospital birth.
  4. There’s the Birthplace Study from the UK, rigorously controlled for all possible risk factors, which still showed that homebirth increases the risk of adverse outcomes.
  5. There’s the Grunebaum study that shows that homebirth increases the risk of 5 minute Apgar score of 0 by nearly 1000%.
  6. There’s not a single study of homebirth with a CPM (certified professional midwife) that shows it to be safe; the Johnson and Daviss study is a bait and switch.
  7. The Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, has been hiding its own death rates for nearly 5 years, while simultaneously boasting about the low rate of C-sections and interventions in the same group.

But Goer is still out there gamely trying to put on a brave front. This is especially impressive since she tries to have some integrity. Unlike MANA and its executives, who simply issue bald faced lies, and refuse to correct them even when it is pointed out they are lies, Goer tries to stick to the truth.

And now she’s been reduced to this: acknowledging that in practice homebirth increases the risk of death, but wondering what might happen theoretically.

Her latest piece of the Lamaze International blog Science and Sensibility is Safe at Home? New Home Vs. Hospital Birth Study Reviewed by Henci Goer.

The paper Goer reviews is yet another that shows that homebirth increases the risk of death. The paper is Selected perinatal outcomes associated with planned home births in the United States by Cheng, Snowden, King and Caughey. I had the pleasure of participating in a panel with Dr. Caughey at the ACOG conference in Maui and reviewing the dangers of homebirth.

The study looked at 2,081,753 births term singleton live births in 2008 in the United States. Of these, 12,039 births (0.58%) were planned home births. The authors found:

Women who were multiparous,35 years old, of non-Hispanic white ethnicity/ background, married, and college-level education or higher were more likely to have planned home births. Women who had planned home births had lower rates of obstetric intervention than those who gave birth in hospitals.However, neonates of planned home births were more likely to have critically low 5-minute Apgar scores (<4) and seizure activity, both of which are known prognosticators of neonatal death and poor neurologic outcomes such as cerebral palsy and longterm developmental impairment.

Goer doesn’t really quibble with the fact that the study shows that in practice, homebirth increases the risk of adverse outcomes. Instead, she tries to divert attention away from reality by musing about theory.

Goer claims:

To begin with, the relevant question isn’t the tradeoffs between planned home birth per se and hospital birth. It is: “What are the excess risks for healthy women at low risk of urgent complications who plan home birth with qualified home birth attendants compared with similar women planning hospital birth?”

That’s nothing more than wishful thinking. Goer’s target audience is women considering homebirth. They want to know whether choosing homebirth puts their babies at risk. In other words, they want to know what actually happens. It makes no difference to them whether homebirth might be safe in a theoretical world that doesn’t exist.

Goer is shocked, shocked that women with high risk conditions are giving birth at home:

Not all women planning home birth were low-risk. For one thing, women with prior cesareans were included. For another, the methods section states that the analysis adjusted for medical risk, and the discussion notes that women with prior children in the home birth group were more likely to have babies with low Apgar scores even after removing women with medical risk, which implies that some of them had medical problems.

Yet, I’ve never seen Goer criticize MANA or the many state groups of CPMs who consistently lobby for increasing scope of practice to embrace high risk conditions.

And Goer is shocked, shocked that not all homebirth midwives are actually qualified to represent themselves as midwives:

Not all women in the home birth group had qualified home birth attendants. Outcome data on the overall population came from women recorded as being attended by MDs, DOs, “other midwife,” “others,” and “unknown/not stated” as well as by professional midwives.

But that’s hardly the problem. “Professional” midwives, such as CPMs have hideous homebirth death rates.

Then, as homebirth advocates typically do, she cites studies from foreign countries that have higher standards for midwives, dedicated transport systems, and greater integration into the hospital system. Look, look, see the Netherlands and Canada!!! Well, in the first place, we are not talking about those countries, and in the second place, the Netherlands has nothing to boast about. Low risk births attended by midwives (home or hospital) have HIGHER death rates than high risk births attended by obstetricians.

Goer’s conclusions are rather bizarre, since they aren’t supported by anything she presented:

Women desiring home birth should have access to professional midwifery care, which argues for making CPMs legal in all 50 states.

But legal, licensed CPMs in Colorado and Oregon have extraordinarily high death rates, so that’s obviously not the answer.

Second, less than optimal candidates are birthing at home, and some women may be continuing labor at home who shouldn’t… [H]ospital-based practitioners need to address the behaviors, practices, and policies that drive women away from hospital birth.

No, Henci, that conclusion is unfair to the women choosing homebirth in high risk situations. They are not deliberately choosing unsafe birth. They’ve “educated themselves” to believe that homebirth in high risk situations IS safe, in part by reading pieces such as the one you have just written, and by listening to the counsel of CPMs.

The correct conclusion is precisely the opposite: Homebirth proponents like Goer need to address their own rhetoric to determine why women are reaching the erroneous conclusion that homebirth is a responsible choice even in high risk situations.

Personally, I would have written a shorter, crisper analysis of this study:

  1. It is yet another study that shows that planned homebirth in the US increases the risk of death.
  2. It is very valuable because it represents the real world risk that women should contemplate when choosing homebirth.
  3. It doesn’t matter whether homebirth is safe in some other country or in some theoretical world that doesn’t exist.
  4. We need to have much higher standards for midwives; the CPM is grossly inadequate.
  5. Homebirth midwives and advocates need to do a great deal of soul searching to determine where women are getting the idea that homebirth is safe in high risk conditions.

I feel for Goer. She’s staked out a position that homebirth in the US is safe, and it clearly is not. Unlike MANA and other homebirth advocates, she appears to have some integrity. Therefore, she should start telling women the truth. Homebirth in the US increases the risk of death compared to hospital birth. Unless and until she does that, Goer is part of the problem, not part of the solution.