New Cornell study shows homebirth has 4X higher death rate than comparable risk hospital birth

The hits (to the safety of homebirth) just keep on coming.

The latest study, to be presented this Friday in New Orleans at the annual meeting of the Society for Maternal-Fetal Medicine, is titled Term neonatal deaths resulting from home births: an increasing trend.

The study was performed by analyzing CDC data, in exactly the same way that I have been analyzing it for the past 5 years. In this case, the authors chose to remove congenital anomalies as well.

There were a total of 10,453,778 term deliveries between 2007 and 2009 which met study criteria: 9,526,450 (91.13%) were by hospital physicians, 826,543 (7.91%) by hospital midwives, 30,415 (0.29%) by midwives in freestanding birthing centers, 48,202 (0.46%) by midwives at home, and 22,168 (0.21%) by others at home. NNM for those delivered at home by others and by midwives, and those delivered in a freestanding birthing center was significantly higher than those delivered by midwives in the hospital: hospital midwives: 3.1/10,000 (RR:1); home others: 18.2/10,000 (RR: 5.87; 95%CI: 4.21-8.19), home midwives: 13.2/10,000; (RR: 4.32 95%CI: 3.29-5.68), freestanding birthing center: 6.3/10,000;(RR: 2.03; 95%CI: 1.28-3.24)…

Hospital vs Out of Hospital Death Rates

Amos Grunebaum, the lead author, was interviewed by Live Science:

For first time mothers, midwife-attended home births had even worse outcomes: 21.9 babies died for every 10,000 births. Risks also increased for older women, and women who were at 41 weeks of pregnancy, meaning they were more than a week past their due-date, Grunebaum said…

Unlike in the Netherlands, where all home birth attendants are professionally trained, home birth attendants in the United States may be inadequately trained, Grunebaum said.

In addition, home birth attendants in the United States don’t have firm criteria limiting which patients they should see, and so they may attend deliveries for high-risk pregnancies.

“They take twins, they take women who have prior C-sections, they do home deliveries in breech babies,” Grunebaum told LiveScience.

But even when looking at low-risk patients, home births are riskier, Grunebaum said. That’s because even a simple, uncomplicated birth can turn into an emergency very quickly.

“When the baby is in trouble, you have literally minutes to deliver this baby,” Grunebuam said. “There’s no time to transfer the patient from the home to the hospital in sufficient time.”

Women who want fewer medical interventions during labor or delivery, but still lower the risks for their babies should consider having trained midwives attend their births in a hospital, Grunebaum said.

It is important to understand that this study includes only PLANNED homebirths, and UNDERCOUNTS the actual risk of death at homebirth in 3 separate ways:

  1. Transfers to the hospital during attempted homebirth ended up in the hospital group and were not counted in the homebirth death rate.
  2. Intrapartum stillbirths are not included in this data, so homebirth deaths are undercounted even further.
  3. The authors of this study looked at all races, but white women account for more than 90% of women choosing homebirth, and the neonatal death rate for white women is much lower than that for all races.

Once again, we find that the dramatic increased risk of death at US homebirth is a remarkably robust finding. No matter where you look, whether it’s at state data like that of Oregon (9X higher), CDC data or even MANA’s own database (5.5X higher), midwife attended homebirth has a risk of neonatal or perinatal death anywhere from 3-9X higher than hospital birth.

  • ScientistPete

    I was having a discussion about the risk of homebirth with a (scientist) colleague who said that risks in the region of 1/1000 were almost negligible and that it could be ignored for all intents and purposes, to my surprise a lot of my friends agreed with them.

    This has led me to think that a lot of people do not fully understand that risk involves both an appreciation of the likelihood of an event happening, AND the severity of that event.

    I look after some safety systems involving radiation, and if I was faced with a situation where one course of action carried a 1/1000 risk of a baby’s death, and another was even slightly less risky, there would be no debate over which course of action is taken, no matter how much more onerous and less palatable the safer option is. Because no matter how unlikely, the worst case scenario is a dead baby, which would signal the end of my career (and make me an unhappy man).

    Also, I think there is a disconnect between the risk assessment which an individual would do when considering a homebirth for themselves, and a healthcare professional would do before recommending homebirth for a population. Individually, a 1/1000 risk doesnt sound that bad (I have done some stuff that involves significantly higher risk for myself and others – particularly when I was in the military). However, when recommending homebirth to a population, the odds of you being responsible for death(s) becomes very real and non negligible.

    • KarenJJ

      I agree with you about this disconnect when assessing risk. 1/1000 sounds very rare to average people. Yet they buy lotto tickets! I work in a field that requires a high awareness of safety (high voltage) and risk. There are very few industry accidents a year but the consequences are devastating and therefore people take precautions. Perhaps because it is obvious that electricity will kill you; certainly nobody tries to ‘trust it’.

      I’ve sometimes thought that you could do a risk assessment of homebirth, similar to what I do when I go onto a mine site (haven’t been on site much for a while so going on memory):
      Hazard List : Ways to mitigate : Chance of occurring (High, med, low) : Potential outcome (death, disability, etc).

      For issues with a high chance of occurring OR a poor potential outcome then you look very closely at ways to mitigate the risk. In industries that are potentially dangerous with high insurance liabilities, the sort of potential outcomes that homebirth introduces would not be tolerated if there are safer alternatives. Nobody takes shortcuts when testing high voltage equipment because it feels better (or if they do it gets clamped down on pretty quickly or sometimes – rarely – something worse happens).

    • Lawyer Jane

      That’s a really excellent point. The risk analysis of a regulator or legislator or other policy-setter who is affecting an entire population has to be different from an individual. Never thought of it that way before.

    • Meredith Watson

      Most of us who don’t work in a hospital haven’t actually seen those tragic consequences, so it is easy to think, “It won’t be me.” Once you have been on the wrong side of statistical chance you tend to view things differently and you do think more about severity of the result, however rare it might be.

      • OBPI Mama

        So true, so true!

    • Daleth

      Edited to delete my poor math skills.

  • EllenL

    I liked this from the Huffington Post article: “the team is planning follow-up research to understand why home births are tied to increased death rates.”

    I think we know the reasons, but I am all for studying them scientifically – and publishing more studies!

    • The Bofa on the Sofa

      I don’t understand. I thought there was no increase in adverse events? What is there to study?

      Oh wait, that was the MANA study that found the same thing that didn’t have any increase in adverse events.

  • Sue

    ”But even when looking at low-risk patients, home births are riskier, Grunebaum said. That’s because even a simple, uncomplicated birth can turn into an emergency very quickly.”

    Yep.

  • Guesteleh
  • LMS1953

    EFM and EVIDENCE BASED MEDICINE

    The catechism is – there is no benefit or improved outcome from EFM and intermittent auscultation (done every 5 minutes by an experienced caregiver, etc, etc). Does that sound familiar? Home birth is as safe or safer than hospital birth (if mom is low risk, attended by a well trained provider with a well established consultation/referral/transportation system).

    The problem is, HBers are so quick to ignore the (modifiers). I think the MANA stats and the MFM papers completely debunk the canard that intermittent auscultation is the equivalent of EFM in either a theoretical and most certainly a practical sense. The Woo says it is EVEN BETTER than EFM because you don’t have to be tethered to a machine and lie flat on your back and invite the dreaded cascade of intervention.

    Moreover, there is absolutely NO REASON a blue tooth Doppler could not be attached to mom’s abdomen to give her COMPLETE MOBILITY. I bought a waterproof case for my wife’s iPhone 5s that submersible to 6.6 feet – well within the range of the most robust water birth experience. I also think, if we can pluck out fetal cells from the maternal circulation for genetic testing and do Holter telemetry, we can detect the fetal EKG signal externally which may be easier than picking up a reliable Doppler signal in a mobile mom and wiggly baby. EFM has not fundamentally changed in 40 years – when we were landing on the moon with less computer power in the capsule than an iPhone has. C’mon, let’s crank it up a notch!

    • Captain Obvious

      Lets all remember, Homebirth advocates all say EFM has never contributed any benefit except increase interventions and the cesarean rate. Yes, initially EFM was hoped to decrease the CP rate. It has not. But EFM has decreased the intrapartum stillbirth rate and the neonatal seizure rate by 50%. I believe the 5 minute APGAR study, the MANA “survey”, and the Cornell study all correlate with these findings.

    • Busbus

      I absolutely agree with that sentiment – let’s use science and technology to find ways to make giving birth more comfortable AND more safe for women!

  • KarenJJ

    Wow. Two studies in one week. Both giving similar numbers, one concluding that it shows the safety of homebirth and the other concluding the opposite. Even if you want to discount the conclusions of either researcher due to their apparent bias and strip out the conclusions, you can read the numbers and draw your own conclusions. It should be straight forward to recognise there is an increased risk. Whether it’s enough to make you change your mind regarding where you give birth or not is up to you, but at least you can make that decision with some idea of the risks you are taking.

  • When I think of things to avoid – it is things like maternal mortality, infant mortality and birth trauma. The NCB want to avoid c-sections. For some reason that just doesn’t make a whole lot of sense to me. I wish we could focus a bit more on those things that really matter – because to those impacted by those things that really matter deserve to have all the effort directed at avoiding things that don’t matter directed to those things that do matter. Thank-you Dr. Amy for refocussing those who care to listen on the things that really do matter.

    • mydoppleganger

      For me, dwelling too much in NCB’s views and beliefs have been traumatic for me! *My fault for doing it!* All the advice to be weary of hospitals, that a C-section is degrading and so forth kicked my common sense no matter how balanced I’ve tried to be. How many times have I read stories of women who ended up with a c-section and the experience is painted with sorrow as it didn’t meet the NCB clique mentality? Trusting birth but implying complete fear of hospitals and c-sections makes for a bumpy road for a weary mother to be. My advice for pregnant Moms in the same boat is to not drive themselves crazy with NCB movement, because it is rather difficult to go with the flow when things don’t work out as ideally as the internet suggests. Would have saved me a ton of NEEDLESS tears!:) Just a suggestion for any mommas to be reading who also tend to find ways to drive themselves crazy.

      • The Bofa on the Sofa

        From an outsider view, it’s really disturbing how the NCB movement sets women up to fail.

        Who is teaching that a c-section is degrading? Certainly not the hospitals.
        Who is teaching that a c-section indicates your body is broken? Not doctors.

        My wife doesn’t regret her c-sections in the least. Then again, she doesn’t hang out with people who judge her for them, either.

        • thepragmatist

          YES! I got shamed and ridiculed for encouraging women on a local board to enjoy their c-sections and for demystifying them by present youtube videos, explaining what I understood was the current surgical technique at our hospital, talking about my scar, etc, and was always shut down. Like the thread would be shut down. So I started receive private messages, and many of them, from first time moms either terrified of c-section or grieving a c-section. There was a total uproar on the board when I called my c-section a BIRTH and started to refer to it as c-birth. More uproar when I started to fight back with data supporting MRCS as a valid choice. And the final death knell for me was when I asked the vocal contingent of homebirthing NCBers that if they were all about freedom in birth, how could they look at the facts and NOT support c-section mums too? I STILL, despite the closure of the group, get messages in my others folder on FB from strangers asking for help pre or post section. I’ve read through so much shame and hurt and have walked women through recalling their c-sections (and made best guesses as to why they were called with what information I’ve gleaned) that I have an intimate understand of how the NCB movement works to shame women. Meanwhile, I love my scar, and I’m a bit pissed that it’s nearly invisible now because my son loves it more than me, as I told him that’s where he came out of me. He was quite worried for a bit because someone told him it hurt me, but I can honestly say, “No, baby, when you were born, it didn’t hurt a BIT!” And there’s such a joy in saying that. I don’t feel a bit ashamed about my MRCS and was probably a little obnoxious about it. Every time I give my OB/GYN her annual cookies and card for Christmas, I write triumphantly, “Baby Pragmatist. Delivered by Dr. Rockstar by MRCS!” Ok, so I am still overjoyed by it, to be honest.

          • The Bofa on the Sofa

            What I don’t get is how the group that is so quick to jump on anything as “a variation of normal” can’t admit that a c-section is just a variation of normal birth?

            For example, the MANA stats, which include the most hard core of those opposed to c-sections, and use the “reduction of c-sections” as a positive outcome, still had 5% of the babies born by c-section.

            If a breech birth, which also occurs about 5% of the time, can also be considered “normal,” (or at least a variation on the theme), then why wouldn’t a c-section be considered a normal mode of delivery?

            And, in fact, it is. By doctors. They will treat a c-section as a perfectly normal thing to do, because it is. They will focus on how everyone is different, and it’s not unusual for their to be things that make a vaginal delivery more risky than you would like, so we’ll just do that instead.

            It doesn’t come with a value judgement on anyone as a person, it is a recognition of everyone’s individuality. One shoe doesn’t fit everyone, some people have different situations that require something different. So that’s what we do.

          • Busbus

            I’m so glad you were posting all those things. It’s crazy there would even be a debate about calling c-sections birth – and that they would shut you down! Unbelievable.

    • Lawyer Jane

      To be fair, lots of women want to have 2 or 3 kids these days, and repeat c-sections do raise the risk of placenta accreta. Also it is major abdominal surgery. So I can’t blame women for wanting to avoid one if possible, within reason.

      • anon

        Between 1976 and 1986 my mother had three c-sections. One an emergency c-section, the second a failed vbac and the third a MRCS. I don’t think wanting 2 or 3 kids is at all affected by sections.

  • EllenL

    I am so glad that this study was done and will be presented Friday, although the results are horrifying.

    It will be interesting to see if, and how, the media covers this (Huffington Post??).

    I’m ready and willing to harass them aplenty if they don’t.

    • Amy M

      HuffPo did…they evidently didn’t read it, and merely reprinted the talking points that the midwives said, with the conclusions about the “safety of homebirth.”

      • EllenL

        I think I’ve found their coverage of this latest Cornell study, here:

        http://www.huffingtonpost.com/2014/02/03/home-birth-higher-rate-infant-deaths_n_4717618.html

        • fiftyfifty1

          That HuffPo article really burns me up! The author, Tia Ghose, is incompetent, lazy, or both. She cites a study among the Amish as evidence that homebirth is safe:

          “A 2012 study of Amish births attended by midwives found a lower rate of complications for mothers, and an equivalent rate of neonatal death for home births, compared with hospital births.”

          But you click on the article and it’s not a homebirth study at all! It takes place at a medical birthing center fully equipped with everything except an OR and staffed by a PHYSICIAN. And still the neonatal death rate is crappy compared to a hospital: 5.4 deaths per 1,000. This rate is high considering the population is largely low-risk married white multips with the high risk patients already weeded out and sent to a specialist.

          This birthing center was set up as a risk reduction alternative to homebirth. It’s still not safe but it’s better than delivering at home with a CPM!

          • Trixie

            Except, you can’t compare Amish to low risk white women in the general population. First, they have 8 children on average, so a lot of those births are among women who are grand multiparas. Second, due to a small pool of ancestors, they have much higher rates of potentially fatal genetic defects. Third, they are much less likely to have advanced prenatal testing or genetic screening to detect these anomalies in advance, because they would not terminate such a pregnancy anyway. They also have a higher than average incidence of being Rh-, although it sounds like this birth center probably gives Rhogam. And, they don’t carry health insurance, and are motivated to have a lower cost birth by staying out of the hospital. They also will never sue if they have a bad outcome.

            I also live in an area with a large Amish population, and an accredited birth center run by CNMs who also do homebirth and have hospital privileges. They absolutely have had a positive effect on the health and prenatal care of our Plain population, through decades of close collaboration. It takes time to build trust and credibility within that population.

            So, I guess I’m saying that that Amish study doesn’t seem too bad, for what it is, but it’s in no way applicable to the general population.

            ETA they’d also be much less likely to consent to induction for post dates.

          • Trixie

            Thought of a couple more things. Although most Amish I’ve met are very intelligent and good businesspeople, they only get an 8th grade education, and this includes little science education. So while they do not prohibit modern medicine, and in fact do use it (and do vaccinate!), their understanding of the risks of something like group b strep, and how prophylactic antibiotics work, may not be strong compared to middle class married white women in the English population. You’re going to have a percentage of them that just refuse it or insist on trying natural remedies instead.

          • fiftyfifty1

            Grand multip is a risk factor but largely a risk factor for the health of mom (postpartum bleed). And if it is true that they are reluctant to induce this will mainly increase fetal death (increased stillbirth) but this study looks at neonatal death (only babies born alive).

            I’m not trashing the idea of this birthing center. It sounds like a great idea considering the population and the alternative (birthing at home with a CPM). But the numbers still aren’t good. These are still married, clean living, white women with the high risk cases already weeded out. But the neonatal death rate is STILL higher than the general population which contains all ethnic and racial groups, women who drink or use drugs, women with pre-existing health conditions and most importantly PREEMIES.

          • Trixie

            I understand what you’re saying. I do suspect that genetic abnormalities are playing a role, especially because that Amish population doesn’t have the type of resources that the Lancaster, PA Amish do in obtaining special treatment and screening for such abnormalities. (Clinic for Special Children run by Dr. Holmes Morton).

          • EllenL

            Good points.

            Also, that Amish study covered 927 births at a single birth center. The Cornell study reviewed 14 MILLION births. Which study sounds more significant?

            By citing that Amish study, the author implies that the two studies are equivalent and essentially nullify each other, therefore we cannot reach any conclusions on this issue. Not true!

            Another thing that bugs me – the title of the article:
            New Study Suggests Risk of Death is Higher in Home Birth.

            Suggests is a very weak verb. The Cornell study FINDS, SHOWS, or DEMONSTRATES that home birth has a much higher rate of neonatal death than hospital birth.

          • Becky05

            The total intrapartum mortality rate in that Amish study was horrific. 20 per 1000.

          • fiftyfifty1

            what, intrapartum?! Alive at the beginning of labor but born dead is 1 out of 50???!!!

          • Becky05

            Damn, no I meant perinatal.

  • mydoppleganger

    The HBAC (Home Birth After Cesarean) seems to be the gold standard of choice and achievement on the homebirth market (aside from the other risky stuff.) I was told by a few folks homebirth would be best for my baby (I’ve had a c-section.) However, the folks who told me that are also in the natural birth industry and had something to gain from it. The issue of uterine rupture was made a “non issue” and the basic sales tactic was:
    -I can own my birth
    -it will be more intimate and peaceful
    -i had a higher chance of vaginal delivery
    -i get a cute born at home onesie upon delivery
    -the hospital is only 40 mins away (on a good day!)
    -there is always 911
    -it can be healing

    Focus on safety and good outcome were on the backburner, mixed with a fair amount of Trust Birth and infant CPR as a safety net. None of the talk felt safe for my child/situation. Besides the obvious, I also knew I could never tell anyone I had a homebirth, knowing I put so much to chance for a designer experience that was not about the outcome, and not focused on my child’s safety ABOVE my own little nerves about another section.

    • AmyP

      “the hospital is only 40 mins away (on a good day!)”

      Wow. I can’t imagine saying that with a straight face.

      • mydoppleganger

        The midwife was talking about how it takes 30 mins to prepare an OR anyway so I’d be fine as she would place a “call to cut”. I’ve actually heard many stories where they rushed patients into c-sections within mins, not 30 mins. And calling paramedics is not comforting as they can only do so much.

        • Young CC Prof

          I can’t imagine anyone who’s ever had surgery would think that. Checking in to the hospital in advance means they have your blood type, allergies and other medical history already on file, for one thing. If your medical history is entirely uneventful, that’s like 1 minute saved. If there’s anything relevant in there, that’s significantly more time saved. For example, I have multiple antibiotic allergies and needed a nonstandard antibiotic for surgical prophylaxis. Just figuring out which one to give me could have taken minutes.

          • Anj Fabian

            If you don’t wear a Medical Alert bracelet and you are unconscious and no one else knows…

          • Young CC Prof

            Hmm, yes, didn’t even think about that. I’ve never gone anaphylactic, but there’s a first time for everything. In my case, thankfully, the antibiotic choice was made weeks in advance. (For all I know, the OB made a note in my chart of appropriate antibiotics after my first visit!)

          • Dr Kitty

            I have the jewellery, the wallet card, an alert on my phone, and I have two medic alert tags on my key ring- one says “Multiple Antibiotic Allergies” and the other lists the antibiotics. I’m up to three of the major classes of antibiotics now, with different reactions (anaphylaxis, Stevens Johnson, confusion and rash) for each one.

            My hospital notes are COVERED in allergy alert stickers and my GP has a big flashing warning pop up on my computer record.

            Thankfully I rarely need antibiotics, because at this point my options are the crazy strong stuff (Vancomycin, Tigecycline, Gentamicin) or the crazy old stuff (Chloramphenicol, Co-Trimoxazole).

        • AlexisRT

          that “fact” drives me berserk because it is comparing apples and oranges.

          Even IF the average “decision to incision” time is 30mins (I don’t know that it is, but let’s posit that’s so, and if you count all the not-critical sections it may come close) that doesn’t mean it’s okay to ADD 30 mins to the time! It’s nonsensical. Remember Evelyn Muhlhan and the Hopkins case? She was very close, but it took a long time to get that mother into the OR once she was there.

          30 mins, in a system that does not facilitate transfers, is unacceptable. (Distance is always potentially catastrophic; it’s simply all that much more so under the circumstances. If midwives could call into the hospital and have the OR ready, distance would still be an issue but less of one.)

          • thepragmatist

            Never mind that, as far as I know (could be wrong) you are supposed to live less than 20 minutes from the hospital for a home birth. Living far out in the country might get you tranferred back to hospital in a country with integrative midwifery.

          • Amazed

            Never mind that, of course! You’re supposed to live as far from the hospital as you live, as evidenced by the homebirth death in Ireland (same distance on winding mountain roads it takes to reach my grandparents’ village for 40 minutes on the HIGHWAY. I was especially shocked by this one. How can anyone rely on this as a sane emergency plan is simply unfathomable to me.)

        • araikwao

          Grr. Disqus ate the comment I tried to post from my phone, which was approximately this:
          When I asked the ob registrar (?equivalent to a senior resident in the US?) how quickly he could get my son out if my uterus was to rupture during VBAC. I remember reading a post here about (I think) 17 minutes being the upper limit for avoiding hypoxic brain injury. He replied that he could have him out in SEVEN minutes – uterine rupture has its own emergency code, which means it is a well-practiced, well-resourced response. You just can’t get that at home, no matter how “awesome” you think your midwife is.

          • Captain Obvious

            I believe I have read after 8 minutes, the baby may have some issues.

          • araikwao

            Yes, that sounds about right. There were two figures quoted, and the ~8 minute mark had largely good outcomes, the ~17 minute mark was about as long as you have before HIE is pretty much inevitable

          • thepragmatist

            “But most babies don’t die during a rupture, Pragmatist! Stop fear-mongering.” No, *most* don’t die. Plenty get injured though. Very badly. They won’t take a chance on losing an IQ point for analgesia, but they WOULD lose half a brain to brain death. (Apologies for crudeness, but it makes me angry.) 2 out of 200 or 1.5 out of 200: anyway you slice it, way too high for my liking.

          • araikwao

            It’s interesting how much practices vary by country – my local hospital network recommends VBAC, so I went with it. I also probably was stupidly influenced by a relative who did it for her second baby too. Even though it was a horrifying experience, I figure it won’t hurt to know what it’s like if I do eventually specialise in ob/gyn

        • Anj Fabian

          Say I’m the on call OB at a hospital. A midwife calls me to say a patient is en route who needs an emergent c-section. At most, I can get the staff and OR prepped but that patient is a Jane Doe…

          Decision to incision requires that the OB gather the information necessary to make that decision.

          If the Jane Doe has no medical history on file, all of that will have to be obtained from the midwife and that won’t happen until the midwife arrives.

          If the Jane Doe hasn’t had pre admission testing done, that will have to happen and won’t happen until the Jane Doe arrives.

          Now if the situation is a trauma and the woman’s life is in danger, then things can be moved along more quickly – but that’s only going to happen if it is necessary to save her life. Making decisions without all the available information is bad medicine.

          • Trixie

            Which is why I had to have anesthesia and OB consults ahead of time before the hospital would accept me as a VBAC patient.

          • Amazed

            Once again, mother comes first and baby is a very distant second. “Only 40 minutes away” – not too bad for the mom. I bet they didn’t bother to mention that “only 40 minutes away” might mean some very critical differences for the birth accessory… err, I mean the baby. Of course. The baby. Don’t mind me.

          • The Computer Ate My Nym

            Now if the situation is a trauma and the woman’s life is in danger, then things can be moved along more quickly –

            At which point you’re doing surgery on a patient with an unknown medical history, unknown PT/PTT, possibly no cross match, no baseline cbc, no information about whether she might have a platelet function defect or have taken medications that reduce her platelet function, etc. IIRC, black cohosh has an antiplatelet activity. What if her midwife or doula gave that to her?

            Even with the best cooperation from the midwife and most efficient OR procedure, you’ve got a much riskier situation than necessary.

        • PrimaryCareDoc

          That’s insane. It does not take 30 minutes to prepare an OR for a crash section. Not in 2014 in the USA. I can’t speak to the rest of the world.

          • Certified Hamster Midwife

            What if the closest hospital doesn’t have an OB and anesthesiologist in the building and has to call them in?

          • The Bofa on the Sofa

            Well, they’ll just call them when they get the “prepare to cut” call from the MW, of course.

            Because you know, if the midwife yells jump, hospitals fall all over themselves to do it.

          • Susan

            I have seen instances where jumping would have led to an “unneccessarean”. The midwives aren’t always right about what to do.

          • KarenJJ

            In my job I never trust that something is not live until I check it myself and put on my own danger tag. Part of being a professional is that you have to use your own assessment because it is your professionalism and when lives are at stake you need to be certain that you are doing the right thing.

            I can easily imagine that the same thing happens in medicine. I remember reading Janet Fraser’s birth story from her first “birth rape” birth where she transferred to the hospital in the middle of the night demanding an epidural and a C-section and was shocked, horrified and angry that the hospital staff didn’t take her midwife’s or her word for it and checked out the situation themselves.

        • The Bofa on the Sofa

          ‘d be fine as she would place a “call to cut”

          Exactly what authority does your midwife have with the hospital? Is she a CNM with full hospital privileges? Are the doctors even aware that you would be in labor? Did you get the name of the doctor that she was going to call who was going to accept her information?

          As Anj notes below (and has Gene, I think, has written about), a homebirth patient shows up at the door of the hospital pretty much as a new arrival (of course, if the MW abandons her, it is completely a new arrival). The chance that the MW will be able to provide anything that the hospital can rely upon is pretty small.

          She seriously thinks that the hospital is going to just run the patient to the OR for a c-section on her word?

        • Squillo

          But that’s how it always worked on ER.

          (I especially liked the episode where the ER docs diagnosed and treated a life-threatening pheochromocytoma right there in the ED.)

          • The Bofa on the Sofa

            OK, I’ve asked others about this before, but never got a good answer. In The Fugitive, Richard Kimball diagnosis a kid on a gurney with an apparent emergency life threatening injury that required IMMEDIATE surgery.

            The kid had a suspected fractured sternum, but apparently there had to be much more than that, because if a fractured sternum were that dangerous, he wouldn’t have been triaged off to the side. But whatever was wrong with him showed up in the x-ray.

            So what was his injury that required immediate surgery, so much that he could just show up at the OR unannounced and have the surgeon jump into action like that?

            I’ve actually asked ER docs about it, and they didn’t have a clue.

          • Vyx

            Pneumothorax due to puncture?

          • The Bofa on the Sofa

            I always assumed a pneumothorax of some sort, but don’t know enough about it. Would it be evident on a radiograph?

          • Vyx

            I’ve seen tension pneumothorax on xray, but it’s not really my field. Anyone out there who is better with the Roentgenograms?

          • Dr Kitty

            You don’t want to see a tension pneumo on an X-ray, you want to have diagnosed it, stuck a needle in it and done an X-ray afterwards.

            Assuming the movies work like reality…
            I’d guess the kid either had a tension pneumo or cardiac tamponade.

            If the tension pneumo started as a small non tension pneumo, or the cardiac tamponade was from a slow leak that started as a small pericardial effusion it might have been missed on an initial chest X-ray.

            The treatment for tension pneumo is immediate needle decompression followed by a chest drain, and the treatment of cardiac tamponade is pericardiocentesis.

    • Sue

      So, what aspect did they think would be ”best for baby”?

    • What is “owning my birth?”

      • Jessica S.

        Future movie rights? 🙂

    • Susan

      Cute onesie showing my achievement? I am so in.

      • The Bofa on the Sofa

        I’ve seen a car driving around town with a “I heart homebirth” bumper sticker. You could get one of them, too.

        Maybe we should sell homebirth stick figures to put on your minivan back window?

        (disclosure: we have stickfigures on our minivan window; Wizard of Oz characters (Me- scarecrow, Mom-Dorothy, Boys – Tin Man & Lion, dog – Toto; then again, if you knew us in reallife, you would understand; Oz is our thing)

        • Susan

          Our baby was born at home is a bumper sticker… reminds me of the honor student ones,.. actually, my daughter had a t shirt for a happy birthday call a midwife. It was sweet. Hospitals do it too. I just thought the onesie thing was funny sure it’s organic cotton in that unbleached variety!… Actually, having done both hospitals win in the keepsake department (crib cards, bands, hat, footprints..ya know.)

          • The Bofa on the Sofa

            Our baby was born at home is a bumper sticker… reminds me of the honor student ones

            Not me. A student making the honor roll is an accomplishment, at least. We can debate about the appropriateness of parents boasting on it, but it is an accomplishment.

            “Born at home” isn’t.

  • The Bofa on the Sofa

    Midwife conclusion: The good agreement between the death rates reported in this study and the ones we found shows that our database is indeed a good reflection of the full pool of HB midwives! So that means our conclusions about the reduction of c-sections and the redefinition of a serious PPH are correct. Hence, HB is safe.

  • Mac Sherbert

    Just sent a link to this to my state senator! Maybe it will help for them to hear from voices other than the NCB crowd pushing to legalize cpms in my state!

  • Susan

    Homebirth is going to be a victim of it’s own popularity. The more mainstream it becomes the more it’s going to be studied and the studies just aren’t good. What’s good about that is moms who really want to do what’s safest may be have real data to examine instead the “it’s as safe or safer” crap. That’s what burns too about how MANA is presenting their data. Unless a mom is smart enough to delve into the actual data it’s all smoke and mirrors.

    • The Bofa on the Sofa

      Absolutely. The problem it faces is that, despite the claims, it is just not very safe on an absolute basis, such that as the number of attempts go up, the number of deaths will be non-trivial, and people will notice. They won’t be able to hide behind the “more babies die in hospitals” claim any more, because, even though it will be true, the deaths for HBs will be much more noticeable.

      I’ve compared it in the past to chainsaw juggling. Right now, the number of deaths due to chainsaw juggling is pretty small (are there any?). However, if lots of people were juggling chainsaws, it would become a problem that no one can deny.

    • Certified Hamster Midwife

      Those particular chickens might be coming home to roost now. The Business of Being Born-related boom in people seeking homebirths and new midwives educated to meet that need has finally met up with stats analysis.

  • Mel

    “But even when looking at low-risk patients, home births are riskier,
    Grunebaum said. That’s because even a simple, uncomplicated birth can
    turn into an emergency very quickly.

    “When the baby is in trouble, you have literally minutes to deliver
    this baby,” Grunebuam said. “There’s no time to transfer the patient
    from the home to the hospital in sufficient time.”

    It’s so simple; so obvious and yet so easily ignored.

    • Anj Fabian

      Standard midwife answer:
      “We have other ways of dealing with these problems.”.

      aka the Sekrit Womanly Wisdom gambit

      • Jessica S.

        Denial, seems to be their choice pick.

  • The Computer Ate My Nym

    One point to note about the CDC wonder data: there is no information in the database about maternal risk factors, apart from demographics. So one might expect that the hospital birth group would have more women who were high risk because of pre-existing conditions (hypertension, autoimmune disease, etc) as well as pregnancy complications (gestational diabetes, HELLP, etc). So the groups aren’t necessarily equal risk, despite the researchers’ best efforts.

    • thankfulmom

      Yes, but when the deck is stacked in hb’s favor by including high risk hospital births in the data and hb still has poorer outcomes…well that ought to make people think.

  • Busbus

    This is absolutely OT, but maybe something for a future SOB post? I was interested in looking at the implications of going post-dates and just found this article http://www.aafp.org/afp/2005/0515/p1935.html. Here, they found that routine induction at 41 weeks decreased (!) the number of c-sections when compared to expectant management (=ultrasound and NSTs and waiting for labor to start without intervention unless there is fetal distress). I don’t know if this has been shown elsewhere or if it is common knowledge amongst medical professionals? Anyone who can chime in…?

    Anyway, with all the NCB propaganda against inductions at 41 weeks, I was surprised to read that. If that’s a consistent outcome, it would mean that women interested in NCB and/or who want to avoid c-sections should be counseled to accept an induction at 41 weeks. That’s not what you hear on NCB forums and websites, though…

    • Busbus

      Sorry, I should have said the link I gave is not to a research paper but to a review of the research with recommendations. The data I was interested in came from the Canadian Multicenter Post-term Pregnancy Trial (CMPPT), which they cite in that article.

    • Actually, you do hear about it. I was told about it on an NCB/homebirth forum when I was almost 41 weeks and debating induction methods:

      http://babyandbump.momtastic.com/home-natural-birthing/2017203-induction-methods-most-favorable-natural-birth.html

      Another midwifery site where I saw it mentioned:

      http://midwifethinking.com/2010/09/16/induction-of-labour-balancing-risks/

      I imagine most women interested in managing their labor naturally would still be reluctant to induce at 41 weeks because induction usually necessitates continuous EFM, which comes with restriction of movement for coping with pain, unable to use a shower or birthing pool for pain relief, etc. My induction experience was overall very positive, but being tethered to the monitors and the bed was a huge pain.

      • Starling

        My induction used Cytotec. While I had to be monitored for an hour after each dose, I still had the option of walking or showering or using the birthing ball the rest of the time. As it happened, I ended up going from a 2 to a 10 in two hours, so there wasn’t much time for labor dancing, but I did spend about half an hour in the shower before saying, “Fuck this, where is my epidural?”

        • My providers did not offer Cytotec as an option. I’m not sure why. I was pretty upset about continuous EFM but they were (very politely and gently) insistent. They also did not offer a wireless EFM unit; not sure if the hospital had one. We made the best of it and used the yoga ball next to the bed.

          Eventually they let me get off the monitors and into the shower for 30 minutes. I’d gone from a 4 to a 10 and crowning with my daughter in 30 minutes back in 2006, so I’d expected things to move fast. I didn’t go quite this fast that time, but an 8 hour induction isn’t bad.

          • Susan

            I am not so sure I want to ever take a woman off of the monitors in a cytotec induction…at least not until the dose is totally out of her system.

          • Anj Fabian

            Cytotec increases the risk of uterine rupture more than the other drugs, so I see the desire to keep the patient monitored at all times.

          • LMS1953

            Especially since the manufacturer has a black box warning in the PDR that it should NOT be used to induce labor. The midwife in Utah who recently was censured after a rash of perinatal deaths got Cytotec from her pharmacist son to induce HBACs. The OB literature is adamant that it should not be used with a scarred uterus. IIRC – a five fold increase in uterine rupture.

          • Melly

            Hmmm…please ignore my earlier comment. I have only ever seen wireless monitors. Didn’t realize there were wired ones. That makes much more sense now.

      • Melly

        Call me ignorant, but I keep hearing the argument that continuous EFM restricts movement/is uncomfortable/etc. I don’t really understand. I had continuous EFM in both my births, and I could walk around the room, sit in the rocking chair, lean against the bed, pretty well whatever I wanted. I didn’t find the bands that uncomfortable, and as long as I stayed in range of the machine the tellemetry (sp?) worked just fine.
        Am I missing something?

        • I won’t call you ignorant. I’m sure the experience varies from person to person. I found them irritating because I had, at most, a 6 foot range around the bed. I also found them irritating because they would not stop slipping and sliding around. Perhaps I had crappy belts.

          I found it much easier to work through my contractions in the shower and sitting on the toilet, but only got limited time there because the bathroom was out of range.

        • Trixie

          I did find the bands to be uncomfortable. Also the contraction monitor never picked up my contractions and they spent hours trying to constantly rearrange them. Also neither hospital I delivered at had telemetry.

          However, the discomfort was worth it for the information about the baby’s safety. And, they let me unhook periodically as long as everything was looking good.

        • AlexisRT

          It’s very variable. I find all EFM uncomfortable, because they can’t keep the belts on. (I have never labored but done many NSTs.) So I do have to stay basically still. The idea of laboring in that way sounds frankly torturous–it’s uncomfortable enough for 40 minutes of monitoring without any contractions.

          That said, I’ve also been told (by an RN) that a nurse experienced in unmedicated labor has more tricks for keeping the belts secure. Some nurses don’t really know how to secure the belts well.

        • Klain

          I found it very irritating with my last as every time I changed position the signal would be lost till I got back into the original position. Once, after taking too long I had the midwives rush in to find out what was wrong, so I stopped trying to move around.

          • Anj Fabian

            Did you try adjusting the device so it picked up the signal again? I had so many NSTs that I knew how to do it.

            …and by “signal” I assume you mean “baby’s heart beat”. People tend to find a loss of the baby’s heart beat rather concerning.

      • mydoppleganger

        I read the advice the ladies gave you and can I just mention, if I get one more text from friends to stimulate my nipples I’m gonna scream.:) it’s been a torture that has not worked at all for me (but has made me very moody, LOL)

        • I’m with you there. Most of the “at-home induction” methods don’t seem to have a lot of evidence behind them. I got really tired of everyone telling me to try pineapple, sex, etc. Even my doctor told me to try going home and having sex on the night before my induction, and I frowned at him and said, “Does that really work?” He said, “I dunno, you could do a study and find out.” I said, “There was a study. It said it didn’t work.” “Oh.”

          I was feeling pretty irritated with my husband at the time (I have since asked for a divorce), but I still managed to have sex with him. Haven’t touched him since.

          Anyways, I hope your labor starts soon and all goes well.

          • araikwao

            Pineapple?? What the??

        • me

          I went 42 weeks all three times (one induced, two spontaneous) and no, none of the “natural” induction methods work worth a damn. If they do work, it’s likely coincidence.

          • Young CC Prof

            Women at term do go into labor all the time, and may attribute it to the last thing they tried. Hence, plenty of anecdotal evidence…

    • Kelly

      I am still at 38 weeks but my doctor told me that I could be induced at 39 weeks if I don’t go on my own. (My first daughter came at 38 weeks, so it is messing with my head) People around me tell me to let nature take its course but this overview of the studies makes me feel confident that being overdue would cause me undue stress and would not in fact be better for me or the baby. One women even told me she was praying for me to reach it to my due date. I really wanted to tell her that my prayers would hopefully counter hers but I just smiled and nodded. She had just given birth at home a few months prior and I was not willing to get into an argument at church. Thanks for bringing in actual research that helps me make better decisions and not listen to all the hoopla about doctors trying to just induce and cut people open.

      • mydoppleganger

        Kelly, my advice is to save yourself the stress. I’m almost 41 weeks and about to have a planned c-section. I will say, after 40 weeks hit I began to worry about the baby big time. All the encouragement to “keep baby in” went out the window when I’m always focused on if I am feeling the little one move or not. Also, some of my more church friends have been the most opinionated that baby will come on it’s own, vaginally, if I pray enough etc. Of course this advice has caused me to realize the damaging effects of making such blanket statements “You’re not praying enough/praying right/having faith/blah blah blah.” So, just from being in my shoes, I would not have extended this journey this far or this deeply if I had another chance. The nerves of waiting are getting higher by the day. A lesson in life for me to not worry so much about everyone’s views and to just err on the side of caution and peace.:)

        • Mom2Many

          All the best ‘mydoppleganger’! Exciting time for you! Hope all goes well.

        • Karen in SC

          I had my second at exactly 41 wks. Labor occurred naturally; I had been sucked into the woo a little, believing that 40 weeks was just an “average”. He had mec aspiration and was born blue – but since I was in the hospital, there was a pediatrician there who whisked him over to the isolette and he was fine. My placenta fell apart and some pieces were retained as well, complicating the third stage.

          In retrospect, I should have inquired about getting things going at my 40 week appointment. I am very glad that mothers are carefully watched with NSTs these days.

          • mydoppleganger

            My practice does not do late term scans/ultrasounds(unless there would be an alarm bell). I’ve been feeling my stomach/baby and waiting for the big day. It’s been a nervous week for me. I know I chose *41* weeks to give my body the opportunity to go into labor, but now I can’t what till my baby is safely out (for the baby’s sake, and for me to not have to worry about baby being hidden in a tummy where no one can see what’s happening.)

          • Kelly

            That is exactly how I feel. I want her out before 41 weeks so that I or a doctor can see what is happening instead of it all being hidden in my stomach. Then I will stress about SIDS for a while, but at least I can go check on her. Thanks for replying all. It helps to not feel bad about being induced or getting a c-section because you know you are doing the right thing and it is safe unlike what the media has convinced everyone.

          • mydoppleganger

            Believe me, Kelly….every morning I wake up I drink juice or something to jumpstart the baby’s movement. The moments I have to wait for confirmation feel so long. This isn’t a doctor suggestion, I’m just ready for baby to get here safe. Waiting till 41 weeks is not as hot of an idea as I first thought!

          • Kelly

            I will still have a conversation with my doctor and get her advice and will go with what she feels is the safest. She just mentioned allowing me to be induced at 39 weeks so it has been in the back of my mind. Good luck! Both babies will be here before we know it.

          • fiftyfifty1

            ” I am very glad that mothers are carefully watched with NSTs these days.”

            Except that that mainly just provides false reassurance, see my comment above. Better than nothing I suppose, but getting the baby out is what prevents problems.

        • rh1985

          Hope it goes well! If I have a scheduled CS it will be at 39 weeks only three weeks to go yikes!

      • AmyP

        I had my first at 37.5 weeks and my second at 38.5 weeks. My third was scheduled to be induced at exactly 39 weeks, so you can imagine that the last two weeks I was pretty keyed up and expecting to go into labor any minute. I did not believe I would make it to the induction date. Oddly, though, I went all the way. (It went fine and it worked perfectly with our family schedule.)

    • Young CC Prof

      That’s what gets my goat about the 39 weeks or more campaign. Many 37-38 week (or earlier) deliveries happen naturally and can’t be stopped. Others are medically advisable. But unlike prematurity, postmaturity is 100% preventable with modern medicine, never medically advisable, and it’s just as bad for the baby. But there isn’t any 41 weeks or fewer campaign!

      • LMS1953

        CC, terrific comment. I am going to have to remember that in my campaign against 39 week Nazis. The NCBers have obviously caught the ear of crunchy State Legislatures – states that license a hodgepodge of alphabet soup that are in essence “lay midwives” no matter how they squeeze in the word “professional”. States which command their Medicaid offices to recoup payments for inductions prior to 39w0d. States which command Medicaid and private insurers to pay lay midwives despite these hideous results. There needs to be an intense public health campaign to single out the representatives who are endangering the lives of newborns because they are inebriated by woo. Would that they have the same attitude about freedom, self-reliance and self-determination when it comes to conservative political views.

      • R T

        Yep, cs section scheduled at 39 weeks against my wishes to have my csection at 38 weeks. Went into labor in the middle of the night at 38 weeks and 2 days had to have an energency csection. Thanks a lot, Doc!

        • LMS1953

          It was NOT the “Doc’s” fault. You came blame the 39 week Nazi who is typically the Head Nurse of the Maternity unit who will NOT ALLOW a repeat C/S to be scheduled prior to 39w0d. “Doc” has no say.

          • Susan

            Agree with this. The doctors are typically disturbed by the rigidity of the 39 week thing and unfortunately, and I am a nurse and proud of it, but on this I think we nurses miss the boat. It’s usually nursing not getting the nuance and downsides of the 39 weeks push. There’s sadly also a bit of a powerplay going on sometimes from my perspective.So interesting to me that there isn’t a 41 or 42 week campaign as CC brought up. I think the stats would back up such a campaign.

        • thepragmatist

          My OB scheduled my c-section for 38 weeks and a few days. I spent the last days in agony, having prelabour, because every woman in my maternal line births at 38 weeks. We also make big babies and the fact mine was a small one (7.5 lbs) was disappointing for everyone (LOL!), though his head was in the 97 percentile, making me damn happy for that c-section, thanks, Doc. I wonder if she could still do that c-section now, as I no doubt would’ve gone into labour by 39 weeks, I was having crazy contractions, they just hadn’t formed a pattern yet.

    • Ob in OZ

      It is well known that the best outcomes for baby are to deliver at 39-40 weeks. It is equally well known that a c-section is safer for the baby at that time (even doctors misread fetal monitoring or have complicated forceps, vacuum , shoulder dystocia, etc). The reason not everyone has a c-section presumably because the absolute risk to the baby are low. We can debate forever whether the non has more risk than benefit in attempting a vaginal birth or requesting the c-section, but there should be no debate about what the baby would recommend.
      That being said, if someone wanted a vaginal delivery and minimise the risk to the baby and themselves, they should request an exam at 38-39 weeks and if favorable (dilated 2-3 cm is usually enough info- don’t worry about a bishop score) then request a stretch and sweep and induction if it doesn’t work by 39-40 weeks. If not favorable and an otherwise perfect pregnancy, then reexamine at 39-40 weeks and try agin (exam and s/s) and regardless plan induction so the baby is delivered by 41 weeks. If you summarise the info that you looked at and has been referred to elsewhere, this is the best for mom ( lowest risk of c-section) and baby (low point for stillbirth, morbidity). The only argument against is expense (may involve more inductions, but not even sure from a global perspective the financial argument holds up). As long as the patient is involved and understands the reasoning behin the decisions and what their goals are, then patient satisfaction is high as well (demonstrated in a study of term rupture of membranes where patients were happier when induced).
      I think when doctors are able to offer these options but don’t get pissy if a patient wants to wait a bit longer, everyone is happy in the end.

    • fiftyfifty1

      The Feb 1, 2014 edition of American Family Physician just did a review on that. It took its numbers from a Cochrane review comparing women induced at 41 weeks with women who were given “expectant management” which is close monitoring and then induction at 42 weeks if the baby is still not born.

      “The rate of perinatal death was 3.05 per 1,000 in the expectant management vs 0.33 per 1,000 in the induction group (the number needed to treat with induction to prevent one perinatal death was 378 women).”
      Also:

      “The rate of meconium aspiration syndrome was lower with induction, but there was no difference in rates of cesarean delivery, operative vaginal delivery, or epidural anesthesia”

      Also they note that it is standard of care to do close monitoring with nonstress tests and ultrasounds for women who refuse induction but that Cochrane did not find evidence that this testing was actually effective in decreasing perinatal death.

      This evidence totally contradicts what NCB philosophy says:
      -induced labor was NOT found to be more painful than spontaneous labor. The rate of needing an epidural was NOT higher.
      -induced labor at 41 weeks did NOT lead to a cascade of interventions. C-section and forceps rates were NOT higher.
      -NST tests and ultrasounds are NOT a substitute for induction. They just provide a false sense of reassurance. Your baby is still more likely to go to the NICU for breathing in meconium and is 9 times as likely to die even if you do the post-dates testing.

      • rh1985

        Is there a public link to this new study? I am sooo frustrated by the posters on my due date club who keep insisting going to 42 weeks has no increase in risk over 41 week inductions.

      • Busbus

        Wow, 3.05/1000 are pretty bad numbers… and that’s with NSTs and an induction at 42 weeks! So, the death rate increased almost ten-fold from 41 to 42 weeks, irrespective of special monitoring.

      • thepragmatist

        I watched a friend get pushed into going post-dates and having to cope with small children at home after having a c-section. Her fifth birth and first c-section. The rest well-managed inductions. Horrible of the “friends” around her who made her feel guilty for letting her doctor induce her. I can’t imagine how frustrating that must’ve been to the doctor. And it ended a friendship, as the duola/friend doing the most of the pressuring, literally DISAPPEARED on her afterwards, leaving her to care for her toddlers and heal from the c-section on her own.

        I remember reading similar numbers while researching c-sections during a debate on MRCS. It was something I filed away for future debate, but I do find it interesting and sad. Women are being pressured to go post-dates and I just want to scream that they are putting themselves at risk of interventions and their babies at risk of interventions and death by not just having the safer option. In the case of my friend, it was all about safety for her: she’d been hoodwinked and lied to, and really really believed the garbage she was being fed. No amount of us gently trying to pull her back to EBM helped with this nasty duola “friend” whispering in ear. I kept the duola on my FB feed just to watch her break HIPPA boasting about women she’s caring for, while they labour. I despise her, but I am waiting for an opportunity to bomb one of he status updates when it’s 50 comments long, and hit as many of her clients as possible in one go, before cutting her loose. She drives me crazy.

        • Busbus

          This is of personal interest to me, too, because I went to 41+6 with my last pregnancy (and home birth). Luckily, everything went well, but I have since become very uncomfortable with the fact that I went so far past my due date.

          And re: informed consent, there was NO discussion with my CPM midwife about increased risk associated with not inducing. I was scheduled for an induction at 42+2, and the understanding was that she would deliver me at home until that date. Maybe it was understood that I knew there was a risk (?), but in any case, no one ever said anything to me – not a single word. Not even my back-up OB (maybe he thought I would have had that discussion with my midwife??). I was kind of aware that I was running a risk, but I was nervous and emotionally unable to look up how bad it was, and no one sat me down to make sure I knew. I didn’t know then that the NSTs I was doing (and which served to calm me down) were basically worthless.

          However, when I was in the hospital for the NST, I actually had something like a bad premonition – the first nurse thought something didn’t look right, which scared me, and while I was disappointed at the prospect of not getting to have a home birth, I was also secretely relieved that I could stay here where I felt that I would be safe. (The hospital was also much nicer than NCB propaganda had led me to believe.) Later, when the doctor said it looked fine and I could go home, for a few minutes I considered asking for an induction anyway. Then my midwife came to the hospital and calmed me down (again, no mention of risk) and we went home. Had I known those numbers then, I might have made a different decision that day. As it was, if something had happened, I would have regretted my decision for the rest of my life. This is the moment that haunts me when I allow myself to consider the what-ifs of my almost post-dates, big baby home birth.

          Well, anyway, so much for informed consent. And my midwife wasn’t a “rogue midwife” or anything – she was happy I was doing the NSTs! It’s just that in the typical midwife-client relationship, it doesn’t seems like there is a space for discussing risk at all. If birth depends on creating a “safe space” (mentally safe, not actually safe) then discussing dangers is out of bounds.

          In addition, I got the impression (from the NCB community? from my midwife? I don’t know) that it was *my* job to investigate the risks of home birth and decide if I was ok with it, and that hiring the midwife was the signal that I had already made my decision, meaning there was nothing to talk about anymore. Had I had too many doubts, it seems to me that this wouldn’t have been the starting point for a conversation but rather been taken as a sign that I wasn’t a “good candidate” for home birth. In addition, voicing concerns equals doubting the midwife as a person since homebirth is what she does, so it’s uncomfortable to do so. But how should I – or any mother – be able to truly investigate risks? Maybe this shows the true problems of mixing up the roles of medical professional and “confidante”/”friend” that midwives pride themselves on. For my next pregnancy, I will be very glad to have a doctor who is open and honest about risks and who I can talk to about my options without tip-toeing around in an attempt not to hurt any feelings.

          In any case, I think it was that moment in the hospital where I suddenly wished I could stay that made me come back to this website several months after my baby was born, and started me on the process of questioning my previous beliefs and assumptions.

          • Guestll

            I had a similar experience. I went to 41+5 and had planned a homebirth. I was cared for by RMs (Ontario). In retrospect, I was not a good candidate for midwifery — IVF pregnancy, recurrent loss (3 in the prior year), narrow android pelvis, OP baby, first time mother, and, most glaringly, a month shy of 40 at delivery.

            Senior Midwife was most aggressive. Stripped membranes at 38 weeks, encouraged me to consider induction at 41 when I was 5 cms and 100% effaced, with nothing happening. Played dead baby card.

            Primary RM was most woo. Baby will come when she’s ready/You’re going to rock this birth/Homebirth homebirth homebirth/Have NSTs + BPPs = everything will be all right.

            Secondary RM (ended up delivering said baby, in hospital) was the youngest, the most junior, and clearly caught in a power play that I was only able to see with the benefit of hindsight. Science and evidence based. Told me quite frankly that she transferred during her own attempt at homebirth because the pain was unmanageable and she wanted an epidural. Suggested I consider giving birth in the hospital after I passed 40 weeks.

            My daughter is now a happy, healthy toddler, but she was born with a calcifying placenta, long nails, dry skin — eight and a half pounds, but long and skinny.

            It was the ultrasound tech at the hospital who had done the bulk of my ultrasounds (I’d had CVS in the first trimester, plus a subchorionic hematoma that went away, and had lots of monitoring) who spoke off record and told me at 41+4 that a good BPP is “just a snapshot of right then and there – while a bad result is uniformly bad, a good result is no guarantee of a good outcome.” She knew I was refusing induction (and I wasn’t getting any real pushback at that point from my midwives) — I felt her frustration that day — there was so much she clearly wanted to say, but she was hesitant to do so.

            It wasn’t until she laid it on the line, and until the senior RM played the dead baby card, that I agreed to be induced at 41+5.

            There is no point to going that late. It doesn’t benefit the baby in any way. I’m baffled to this day why it took so long for the senior RM at my clinic to spell it out for me, and I’m equally confused as to why there was such clear dissent amongst the midwives as to how to manage our care.

  • WELL now Melissa Cheyney can’t claim that Dr. Amy is doing ‘original research without peer review” when she brings up the CDC numbers.

  • anh

    that’s my alma mater! we know how to do the research! (don’t know why I am claiming credit, I majored in French literature)

  • DaisyGrrl

    Interesting. I note he’s also the one who published the study last year comparing 5 minute Apgars in home and hospital birth populations.

  • Christina Channell

    Are these nurse midwives or lay midwives?

    • Amy Tuteur, MD

      Both.

      • Christina Channell

        Thank you. This might be a helpful study to dispute the claim that nurse midwives make homebirth comparable to the hospital.

        • Trixie

          Nurse midwives probably do make it safer, in that they have actual medical training.

          • And, while I haven’t any figures to back up my assertion, I think that CNMs probably do not accept as homebirth clients as many women who are really high-risk as DEMs do.

          • meglo91

            Probably true, but depends on the birth center. My 40 year old, borderline GD, 42+1 week was not risked out by her center when she went into labor (and not induced 2 weeks earlier when she should have been). Result: dead baby. Birth centers need hard guidelines to manage risk.

          • The Bofa on the Sofa

            Is it possible that CNMs that are doing homebirths are not representative of CNMs on the whole, though, and are on the more extreme (careless) end?

          • meglo91

            My un-scientific answer: almost certainly.

          • Anj Fabian

            It seems to be. CNMs who will work OOH seem to be in hot demand. Birth centers seem to spring up around the one or two CNMs willing to do OOH. The rest of the staff tends to be CPMs, doulas and various interns and trainees.

            At least one business model makes money not only by billing clients, but by charging the various trainees. So they get some staff that is paying the birth center for the privilege of working there.

          • fiftyfifty1

            Hell yes, they are a bunch of damn woo loons.

          • Ob in OZ

            I could cry. Completely preventable. My thoughts are with your friend and her family.

          • fiftyfifty1

            tragic

        • Busbus

          I would assume that the majority of midwives for the “midwives at home” group were CPMs since most CNMs don’t do homebirths.

          • Christina Channell

            True. I’ve been curious about the data for CNM’s who do attend homebirths. How do they measure up? Need to do some digging.

          • Amy Tuteur, MD

            The death rate for CNM attended homebirth is double that of CNM attended hospital birth:

            http://www.nature.com/jp/journal/v30/n9/abs/jp201012a.html

          • R T

            Which is much better than the rate for CPMs or other lay midwives!

        • Sue

          Both the UK Birthplace study and the recent Australian review of the publicly-funded home birth schemes only used hospital-affiliated nurse-specialist midwives with guidelines – and there was still approx 3X neonatal mortality (and no measure of morbidity).

        • manabanana

          MANA has this data. They could have compared CNM attended home births to ‘other’ midwife attended homebirths and made a comparison.

          It might be the same. It might be different. Usually, CNMs have much stricter risk-out criteria. Oh, and they have licenses that they want to protect. CPMs aren’t always similarly motivated.

  • Shang Tsung

    Completely off topic, may I just say that I love when you say a paper is “titled” something as opposed to “entitled”? I know both are technically correct, but the latter bothers my ears and elicits pictures of a snooty research paper looking down at all those other foolish little abstracts. You’re one of the few people I read who follows my naming convention and it’s nice.

    /end derail