New Dutch study shows homebirth increases the risk of death — and not just for the poor

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You may have read about a new Dutch study of homebirth that shows that homebirth increases the risk of neonatal death.

You may have also read the spin, that the risk of homebirth is confined to poor women. This piece in The Washington Post is typical:

The infant mortality rate is also higher in the Netherlands than in European countries with similar medical resources. But as more Dutch mothers have switched in recent years to delivering their babies in hospitals, rather than their homes, doctors have noticed a drop in newborn deaths.

So far, so good.

Researchers wanted to understand why, between 1980 and 2009, the country’s infant mortality rate fell from 4.25 deaths per 1,000 births to 2.42 deaths per thousand births. Over the same period, the share of deliveries in maternity wards swelled from about 61 percent to 73 percent. On the surface, it appeared the home method may simply be riskier for babies.

But the story isn’t that simple. What happened to the women during their home births depended a lot on their income, and relatedly, their access to routine medical care before and after pregnancy, according to a study published this month in the American Economic Journal: Applied Economics

… [A] poorer woman who preferred a home birth was more likely to encounter tragedy. The 28-day infant mortality rate for them more than doubled, from about 2 deaths per 1,000 births to 5 deaths per 1,000 births.

The rise in hospital births explains roughly 46–49% of the reduction in infant mortality in the Netherlands between 1980-2009.

One possible interpretation of the findings of the study is that the danger of homebirth is restricted to poor women, but there is another, far more likely interpretation of the data: homebirth is safe ONLY when nothing goes wrong. Any unforeseen complications double the risk that the baby will die.

The paper Saving Lives at Birth: The Impact of Home Births on Infant Outcomes by Daysal, et al. was written by economists. The math in the paper is probably perfect; however, some of the medical assumptions are problematic.

The basic statistics are incontrovertible: homebirth increases the risk of neonatal death and the recent increase in hospital birth in The Netherlands has been associated with a fall in mortality rates.

According to Daysal, et al.:

Historical data show that 7-day (28-day) mortality declined from 4.25 (5.35) deaths per 1,000 births in 1980–1985 to 2.42 (3.18) deaths in 2005-2009, while the share of hospital births increased from 61.25 percent to 72.06 percent. In addition, using a decomposition … we find that most of the mortality decline between 2000–2008 comes from newborns over 2,500 grams, who are more likely to be low-risk and thus eligible for home births.

This is a critical point. Not only has the neonatal death rate decline in proportion to an increase in hospital birth, but that decline occurred in babies of normal size, suggesting that these were term babies.

Indeed:

Back-of-the-envelope calculations suggest that the rise in hospital births explains roughly 46– 49 percent of the reduction in infant mortality in the Netherlands between 1980 and 2009.

In this paper, the authors looked at all births in The Netherlands from 2000 to 2008. The key finding:

We find that giving birth in a hospital leads to substantial reductions in newborn mortality. We provide suggestive evidence that proximity to medical technologies may be an important channel contributing to these health gains.

That seems pretty definitive, so why is the mainstream media hedging about maternal income?

The study found that the increase in deaths was confined to postal codes with low median incomes. In other words, most of the deaths occurred in poor areas. But that DOESN’T mean that the proximate cause of those deaths is poverty.

In the first place, the authors looked only at addresses, not at actual maternal income. Second, maternal income is likely a proxy for the incidence of complications. It is well known that lower socio-economic status in pregnancy is associated with greater risk of complications. Therefore, a more realistic conclusion is not that homebirth is dangerous for poor women only, but rather that homebirth is dangerous if anything goes wrong. Homebirth is safe only if nothing goes wrong. Once a complication develops, the risk of neonatal death rises dramatically if the baby is anywhere but a hospital.

In fact:

The lack of an impact on the 5-minute Apgar score suggests that the general health of low-risk babies born in a hospital is similar to those born at home shortly after birth. Hence, any mortality reductions from a hospital birth are likely due to the medical care provided after delivery. A hospital birth may reduce infant mortality through various channels, such as the availability of better facilities and equipment, potentially better hygiene or the proximity to other medical services.

As I’ve written many times before, hospitals are like seatbelts; most of the time you don’t need them but wearing them all the time dramatically lowers the risk of death.

The take home message from this paper is NOT that homebirth is safe for wealthy women. The take home message is that homebirth is safe ONLY when nothing goes wrong.

Homebirth is gambling with your baby’s life. You’re gambling that there won’t be any unexpected complications. But if there are complications, your baby is more likely to pay for your gamble with his or her life.

  • Amy Tuteur, MD

    I love this piece. Jenny Splitter nails it!

    http://groundedparents.com/2015/07/29/i-dont-need-your-birth-feminism/

    “Mariah Sixkiller’s Why I Am a Birth Feminist is one of the most privileged and myopic pieces of drivel I have ever read.

    Why exactly is she a birth feminist? Is it because she wants to see improved birth outcomes for women in third world countries? No. Is it because she wants to fight against inequities in our health care system? Also no. She’s a birth feminist because she had a c-section in 2009 and she’s still bummed out about it.

    Listen. I get that it’s a downer when there’s a discrepancy between expectation and reality but maybe it’s time to stop treating the surgical procedure that resulted in the birth of your healthy child like an epic tragedy.”

    • guest

      i agree. but: bedtime in the UK

    • fiftyfifty1

      Damn! Straight to the point and funny too!

    • RMY

      Well I haven’t given birth, but let me tell you about my “wisdom tooth experience” which was great, only local novocaine! My wife had an okay, but not as happy wisdom tooth experience, sedation.

      • Mattie

        funny, I had a root canal experience that included sedation and was the best experience ever, it was conscious sedation not full on sedation but seriously amazing times.

        • RMY

          I enjoyed being awake for mine, my dentist was great and narrated everything he was doing. It was very interesting (all 4 of mine were impacted).

          • My first root canal was an emergency and the dentist took out one of the nerves whole & showed it to me. I thought it was cool! He knew I would be interested.

  • What are the drivers of the home/hospital decision that are associated with income? Are women in those areas more likely to have been born at home themselves? Are hospitals not “family friendly” – and as a result of a lack of childcare for older children, home becomes attractive because of cost/convenience? Do women who deliver at home enjoy benefits that women who deliver at hospital do not? Are those benefits more likely to be persuasive with lower levels of income? Is it education, rather than income at play?

    • American in NL

      In the NL, basic insurance fully covers home birth, while hospital birth is covered only if it is deemed “medically necessary”. The cost of a hospital birth is not terribly expensive, about EUR 250-300, but even this may be prohibitive for poor families.

  • Nick Sanders

    OT- Well, sort of, it’s not related to this post, but it’s relevant to SkepOB overall, someone shared this to a facebook group I’m in to make fun of it, and I thought it was worth showing here too:

    https://scontent-atl1-1.xx.fbcdn.net/hphotos-xat1/v/t1.0-9/p720x720/11204952_10153249700858355_2187130164597082615_n.jpg?oh=b2d2925acb16c6f710699de4eac39ef8&oe=565AD858

    Who comes up with these things?

    • guest

      I love it!!!!! [that means I hate it!]. Especially blaming someone for taking prozac!!! it’s like a charicature of evil. Note also the ‘virtuous’ woman’s decidedly blond and white appearance……..

      • araikwao

        Yes! A touch of Aryan about her, I thought

      • Spamamander

        That really caught my attention… the blond, slender except for her baby bump “virtuous” woman, and the heavier, dark haired, pig-snouted “bad” woman. And oddly enough, my OB thought prozac was a better option than my not eating at all because of my depression, silly him!

    • Megan

      Where do you get IM Prozac?

      • Roadstergal

        It looks like it’s going straight in her ear, actually.
        What are all of those pills that the Less Ethnic Awesome Mom is taking with the glass of water? Uppers? Downers? Ludes?

        • Megan

          Going by how high she looks, I’m saying ludes.

        • LibrarianSarah

          Citalopram

    • Megan

      Also, it should be titled “indoctrination starts in the womb”

    • demodocus

      Oh no, not sanctimonious at all. And what’s with blondie’s baby’s unnaturally green eyes?

      • Nick Sanders

        Too much chlorophyll in mom’s diet.

        • demodocus

          Or maybe mutagenics in those “vitamins”, like the XMen.

          • Amy M

            It’s the GMOs. Oh wait, the other mother is eating those.

          • momofone

            Exactly. It’s the LACK of GMOs.

      • Joy

        Indigo baby.

      • Mishimoo

        Reptilian?

    • LibrarianSarah

      2 things jumped out at me when I saw this picture.

      1. Do these idiots really thing Prozac comes from a syringe? Cause if it did I would be in big trouble.

      2. HOLY FUCK THAT BLOND LADY IS GOING TO GIVE BIRTH TO MR. CLEAN!!!!

      • Amy M

        Mr. Clean-baby looks decidedly like a mature female (sans nipples and hair.) Maybe its “Ms. Clean.” Although both babies (including baby-Buddha) have larger breasts than some adult women.

    • Who?

      I’m no expert but both those babies look past dates and both those mothers will need a cs-baby on its side, other baby heading out hand first.

      So turns out-according to this image anyway-it doesn’t matter what you eat or otherwise ingest.

    • Cobalt

      So if I don’t want a sparkle bedecked, tiny headed, in utero breast groping baby, I need to inject Prozac into my head?

      Sold. Where do I sign up?

      • Nick Sanders

        And eat pizza. The pizza is critical.

        • Cobalt

          I was doing that already! Pizza is gooooood.

    • Sue

      The blonde with black eyebrows clearly dyes her hair. Is peroxide conducive to making healthy green-eyed babies?

    • The Computer Ate My Nym

      I don’t think that there even is an injectable form of prozac.

      Also, they don’t have any idea of how a fetus lies in the uterus, do they?

  • Mel

    The study points out on pg 16-17 that 98% of the Dutch population lives within a 30 minute drive of a hospital.

    Entirely conjecture on my part – I doubt that only 2% of people in Michigan live more than 30 minutes from a hospital. Just in my local area, there are several counties that don’t have hospitals in the them OR people like me are equidistantly located between two hospitals that are more than 30 minutes away.

    I doubt many (if any) NCB advocates read that far – or could follow the modeling assumptions for that matter.

    • KarenJJ

      I was wondering if those poorer postcodes the study looked at were a further 10-15 minutes away from the hospital than the wealthier postcodes.

      • American in NL

        Probably not, but many people in the NL don’t have cars and lower income people even less so, so even a 30 min journey could be prohibitive

  • fiftyfifty1

    For argument’s sake, let’s take the idea that homebirth is dangerous only for poor women at face value.
    I suppose then that midwives will now refuse to take poor women, will stop proclaiming that poor women of color just need more midwives, and will lobby the legislatures in states where they fought to get homebirths covered by Medicaid to have that reversed?
    I won’t be holding my breath.

  • Amy M

    The authors of this papers clearly mentioned the (obvious) problem with homebirth: It is too far from emergency medical equipment and personnel, in the event that something goes wrong. I don’t understand how people who advocate for more homebirths gloss right over that. Do they not recognize it? Or are they just ignoring it, in favor of hyping the benefits? (Your own home! Low lighting! More breastfeeding!) And even if they are deliberately ignoring it, the vast majority of people can figure it out for themselves—usually its the number one reason given for why a woman wouldn’t attempt a homebirth. Homebirth promoters have some real chutzpah with how they try to equalize the benefits of homebirth, with the benefits of hospital birth. Mortality and morbidity carry much more weight than increased rates of breastfeeding and low lighting. Maybe this is just a thing in the US, and in countries where homebirth is integrated into the hospital system, the women know perfectly well what they are risking and are ok with it?

    • Ash

      People are told that the evidence shows that HB is as safe as hospital birth for appropriately chosen women, transfers are usually not urgent (thus, the emphasis that most transfers are a private car rather than ambulance), and that midwives carry medication to be used in emergencies (not all of them do)

      • Amy M

        I know, but I just can’t over how obvious it is: if there is no OR in your house, no doctor with resus equipment, and time is of the essence, how can anyone believe its safe as or safer than hospital birth? Sure, most of the time things go fine, but god help you and your baby should something go wrong. I guess so many of the NCB types also believe in positive thinking, that nothing can go wrong if they have the right mindset? I know the answers to my questions, but even after reading this blog for more than 5yrs, it still blows my mind that people can contort their brains into believing that “no safety net = A-OK.”

        • Azuran

          I’d say the overly negative opinion of NCB on hospital intervention is the main reason. Those people see everything a doctor does as inherently negative.
          To them, the very slight chance of death to their baby is nothing compared to the way higher ‘risk’ or having interventions. Of course, those interventions are to make sure they have a healthy baby, but NCB don’t see it that way. When they talk about the ‘risk’ of intervention, they include fetal monitoring and epidurals……. They list those things as negative.

          • Ash

            I disagree. The majority of NCBers say that OOH is safer for both mom and baby for appropriately selected candidates. The homebirth supporters I see that say “HB has a higher rate of death and brain injury” are former homebirth supporters, or those who think that homebirth as it is in the US is unsustainable. Never heard of a practicing CPM that says “out of hospital birth is more likely to result in death or brain injury than hospital birth”

          • Azuran

            Because they don’t really pay attention to the deaths of babies. They have a head in the sand mentality. It only happens to other, babies die in hospital too, some babies are just not meant to live, there was no way it could be prevented, she would have ruptured in the hospital too.
            They convince themselves that all the babies who died in homebirth would have died no matter where they were born.
            So, once you’ve convinced yourself that death is not a factor, then you start looking at other things: interventions.
            If you consider any and all intervention to by negative or a risk, then of course, homebirth is safer because there are no ‘negative’ interventions.

          • Amy M

            Yes, this is a great point. They are looking at different risks than I (and most of the population) are looking at. Having no access to an OR is a good thing when a Csection is the worst that could happen.

        • Ash

          I truly believe that among the USA white middle middle class and upper middle class, OBGYN is now more vilified than any other area of medicine, so there’s that. HB is still very not normative in the US, though. Plus, most women of childbearing age in the US do not know other women who had intrapartum deaths, or babies that died shortly after death excluding severe congenital defects. The US has hit a home run in terms of reducing neonatal deaths and maternal deaths. The concept of death and injury is so far removed, NCB frames c-sections, inductions, hospital acquired infections, and episiotomies as the worst things that can happen during hospital birth

          • Megan

            It’s like vaccines: modern obstetrics is a victim of its own success.

        • guest

          I can only speak for one person – but maybe that answers your question a bit. I was a thoroughly low-risk multip who didn’t want pain-relief and liked being left alone with my partner during birth as much as possible. I liked the idea of giving birth at home – especially not having to to stress over when to go to hospital after labour starts, and not having to return to home after birth; I fancied hopping straight into my own giant bed with my family and newborn after birth. I give this background so you know had no reason to be in hospital, other than safety (and I recognise that that is different for other people, e.g. desire for pain-relief). I was in the UK. So taking the Birthplace study at face value, this was my choice. Home: 98% chance of my emerging entirely unscathed (no episiotomies, c-sec, forceps, etc). Hospital: the hassle and stress of going there, etc + 5% risk of c-section, with also increased risk (combined – of the top of my head – 10%?) of episiotomy, forceps, etc. None of which I fancy. WRT to the baby-outcomes, as you know, the birthplace could not find a difference for multips. So what I had to trade-off was this: hospital: the benefit, as you note, that in the small chance that something would go wrong with baby, the paediatricians + paraphernalia would be close. This benefit would only apply to half the cases of something going wrong with baby (in the other half you would according to the data already be in hospital for the actual birth, even if you planned home-birth (half the bad outcomes in planned home-birth are in fact delivered in hospital, post-transfer). So we are talking a tiny benefit here – which, as I note in a moment may be hypothetical. I had to trade that tiny benefit against the extra 5% risk of caesarean section + additional forceps, episiotomy, etc. Note that these risks aren’t purely self-interested. Forceps have a (small) risk for baby ; a c-sec increases risks for potential future babies. So, this is the choice: a very small – perhaps 1 in 1000 if not less – risk of perhaps relevantly delayed neonatal care, versus at least 5% risk of laparotomy and other real damage to me, including and increased risk to future children. I found it a difficult choice (well, not really – but still it was a relevant choice) – and went for the less in 1 and a 1000: I plopped at home.One further consideration played a role, which you are welcome to comment on. I note that the benefit in hospital may be hypothetical. My reason for this is two-fold. First, we don’t find it in the data on birth-outcomes. (But likely it is simply too small too detect; composite outcomes and so on). But, second, I happen NOT to think that obstetricians are a bunch of power-hungry overly-keen butchers! I think they are skilled professionals, who care an awful lot. And so I think that that extra 4.5% c-secs in hospital going multips is NOT – certainly not entirely – due to OB/GYNS being to keen to cut – let alone evil. So, what then is the explanation? I favour this (rather kind, I think, on the medical profession! explanation): that the stress and hassle of going to hospital and strange environment and such (yes, all that NCB waffle – well, some of it!) means that the birth in hospital does in fact go less well. Thus more c-sections (and forceps) arise in hospital because they are in fact necessary there – because the birth goes less well. But they would not have been necessary at home – where the birth goes more smoothly. That is my best explanation of the data. It does not vilify OB/gyns. But it does mean that the ‘what would have happened had I gong to hospital/stayed at home’ becomes very difficult to analyse. Problems arising in hospital necessitating intervention might not have happened at home. That also means that the neonatal harms and dangers arising in hospital may be more severe than those at home (and more frequent – a frequency that is then reduced back by the increase in c-sections). This may negate the delay in neonatal care when things go wrong – or it may augment it. We simply do not know. But will I take on a 5% risk of c sec and other harms to me and possibly future children, to avoid a possible, or possibly non-existing – we really don’t know – but certainly too small to measure chance of harm to the baby. That just seems irrational to me. So there, maybe that explains. That is what I mean when I say home-birth is safe for low-risk multips. And why I say for low-risk multips that HB is, according to Brocklehurst data – much safer for mothers but slightly less safe for infants in low-risk primps – so you’ll have to make your own trade-off there. I hope that answers your question a bit? (and – yes – i took distance to hospital and likely traffic levels into account. it was acceptable. )

          • guest

            ps I am constantly placed with the ‘crazy NCBers’ on this blog – so don’t say ‘that sounds reasonably but NCB-ers don’t say that’. A lot of NCB-ers I know are exactly trying to constantly emphasise that we shouldn’t overlook the real cost to women of going to hospital, and trade that against benefit to baby (if any). When I do that on this blog, I am usually vilified 😉

          • guest

            pps please also don’t say ‘but low-risk women is a tiny proportion’. Sure, it is not everyone – but it is a sizeable proportion – and they are entitled to good care – which means a well-integrated home-birth system as one of their choices – just as anyone else is. We also cater especially for specific versions of high-risk pregnancies and wouldn’t say ‘oh that is just a tiny proportion – let’s not worry about e.g. twin pregnancies but lop them in with the rest. And the majority of people choosing home-birth (at least in countries where things are well organised) are in fact low-risk.

          • guest

            ppps which is also why I find your feminism wanting, Dr Amy. (although I grant you are pretty good – better than most !!!). My feminism demands well-organised, well-integrated, well-informed home-birht provision for those who want it – i.e. a dutch or UK-like system. In the USA I would be deprived of my safest option. That is appalling. As a good feminist I would expect you to advocate for that too – but you aren’t. (which is not to say all NCB=ers are good feminists. Many – as you point out often and well, aren’t. but some are. ).

          • PrimaryCareDoc

            How are you deprived of your safest option in the US? The safest option is hospital birth, hands down, no matter if you’re in the US, UK, or the Netherlands.

          • guest

            read my original comment. as i explain – home was safest and more desirable in UK for low-risk multip like me. I am not going to explain again – read the original comment above.

          • fiftyfifty1

            What do you make of the fact that *high* risk women under OB care in the Netherlands had lower perinatal death rates than *low* risk women under midwife care?

            But yet you want the US to invest its limited resources in replicating Netherlands’ system here in the US so that the tiny subgroup that you belong to (multip, low risk, not desiring pain relief, desiring a homebirth) can be catered to? Tell me why that is a good use of our resources. Why you and not somebody else? Why here in the US when we are so geographically dispersed? What you say doesn’t add up.

          • T.

            … So Guest gambled and got lucky.
            The end.
            No really. Guest gambled a 5% “risk” of CS against a dead or severely damaged baby and got lucky.

            Also, Guest keep touting ONE study, ignoring all the others being done which shows the opposite, which is a typical quack tactic.

            There are several studies that show that HB is less safe for babies, A LOT less safe, and it is logical too. But Quacks like Guests will take one study that seems to show it is not (without actually citing death rates) and latches to it.

            Look, I sometime chose not to tie my seatbelt when I am not going far. Sure, the risk of getting in a serious incident in the 1km between my house and the supermarket is low (it is a low-risk area) and seatbelts are a hassle. I am not dead yet. Maybe I won’t ever be.
            This doesn’t make driving without seatbelts as safe as driving with them, the end. You can do it and get lucky.
            The end.

          • Roadstergal

            From that study on midwifery care in the Netherlands, it sounds like the safest option there is to be _just_ high-risk enough to skip the midwives and be seen by an OB?

          • guest

            ps that wasn’t meant to shut you up – very keen to hear what you think after you’ve read my original comment…

          • Lawyer jane

            You are leaving out the fact that most mothers want pain relief that they can only get in the hospital. How is it feminist to fight for women to believe that the safest option is the one that forces them to endure the most pain? Surely you see that it is not as simple as bloodlessly declaring an option safest, but also the propaganda that would arise forcing women to chose the supposedly safest option even if they would prefer pain relief.

          • Roadstergal

            I think what people are referring to is not so much that ‘low-risk’ is a tiny proportion of women overall, but that the ‘low-risk’ multips in the Birthplace study were a tiny and not-pre-specified subgroup in that study, making the stats on the equivalence of the outcomes dodgy? Folk here can correct me if I’m wrong on that.

          • Amazed

            I, for one, place you with the more refined NCBers. I totally believe Dr Amy when she says you’re an academic and prominent supporter of homebirth. Unlike the “crazy NCBers” you know what you’re talking about – and you’re deliberately wiggling out of the hard questions that would make your cherished homebirth not so great in comparison.

            I have a few questions for you:

            1) Why won’t you address the fact that your beloved Birthplace study only looks at homebirth in ideal, non real life conditions?

            2) Why do you keep lying that fetal outcomes for multips are the same when you know we don’t know it? We only know the mortality rate.

            3) How would you explain (away) the fact that the researchers who took such painstaking efforts to only choose the healthiest of healthiest, the lowest risk of low risk women for their homebirthing cohort suddenly couldn’t be bothered to find out the morbidity rate?

            4) Why do you want the UK to emulate the system that is more dangerous to babies specifically because it utilizes midwives who are given too much power?

            5) What is your name?

            In conclusion, I find it disingenuous of a prominent homebirth proponent to write here pretending to be your average homebirthing mother. Could it be that you don’t dare engage under your real name out of fear that you’d lose the sympathy commenters here show you and you’ll be treated like any other proponent of a theory who is expected to provide proof and then wiggling and innocent “I don’t know” won’t hold?

          • guest

            Amazed, I feel I should respond to this.

            5) (and re: your final paragraph): I don’t think it matters who I am. It matters what I say. Not how many titles I have or where I work. Nor am I (I think) a prominent home-birth proponent. I certainly don’t think I am prominent. And I do advocate that women have the right to make their own choices – which includes a health care system facilitating them. But there are many MANY women who I wouldn’t advice a home-birht (though I would respect their choice to have it).

            1) I have in fact addressed this, in a reply to DrAmy. Here it comes again. First, it doesn’t look at it in ideal conditions, but as it happens in the UK (which is more ideal than US – yes – qualified midwives and integrated birth system, etc. but these are ordinary practice data in the UK). Second, what it DOES do is look at the women, only, who were in fact low-risk – not all those who gave birth at home. I think that is right. For if a women is low-risk I would want to give her the information on actual low-risk women – just as I would give a woman expecting twins the info on all twin births – not all hospital births!!! It is called stratification. What we can ask is ‘why were there also not-low risk women give birth at home’? I don’t know the answer – nor do you. I suspect it is because they wanted to, despite the risk-advice. In which case I am glad they live in a system where their choice is supported: if we compare health care systems, it is not just medical outcomes we should look at; but also whether people are respected. note that the group of non-low risk home-birthers was even older, whiter and higher educated in this study than all home-birhters. Sounds to me like it was their choice – not bad risk selection by midwives. But I absolutely grant this can be up for debate – and different people will have different interpretations (which is again a point that seems to me quite straightforward – but rarely seems granted on this blog, in comments).

            2) this is not quite right. we know the composite outcome. which included morbidity. Yes, that is sub-ideal. better would be individual comparisons of mortality, and for every single morbidity separately. . But the outcomes are so rare we won’t get significant results. So we have to go on the data we have. And here’s the rub: what we do know is that going to hospital increases the mother’s risk of a whole bunch of bad stuff. As far as I am concerned the onus is not on me to prove that home-birth is safe. The onus on you is to prove that home-birth is more dangerous for the fetus AND (moreover) that it is more dangerous in a way that outweighs those increased risks for the mother. Of course that is ultimately something that only the mother can and must decide (if she wants to). But all outcomes need to be taken into account. If, as you say “we don’t know that fetal outcomes for multips are the same” – if we don’t know fetal outcomes – then on what grounds can you justify inflicting the (statistical) damage that sending all low-risk women to hospital would result in? It is the sending to hospital that needs to be justified – not the staying at home.

            3) composite outcome does include morbidity.

            4) because I don’t JUST care about present fetal outcomes; I care about fetal outcomes AND maternal outcomes AND maternal autonomy AND future fetal and maternal outcomes and autonomy. THat is a complicated set. And so it is a complicated question. I that features the option for home-birth (as well as lots of other options, such as e.g. elective c-sec)

          • Mel

            I appreciate you explaining your logic, but I am a bit concerned by an assumption you made.

            You assume that a CS has an increased risk to you but do not take into account the fact that the CS would be done to prevent or minimize morbidity or mortality to your child. Likewise, the use of forceps, epis etc are an attempt to reduce morbidity or mortality for the infant while increasing – slightly to moderately – the risk for the mother.

            Shorter version: Any woman’s risk for a CS is tied intimately to fetal health and wellbeing. The two are not mutually exclusive.

          • guest

            Thank you for replying, but please read the study – and my post. fetal outcomes are the same in this group – low-risk multips – in home and hospital. So in THAT CASE the increased risk of c-sec etc is NOT justified by reducing risks to baby. (of course in other subgroups – e.g. breech -it evidently is). We can’t assume that c-secs rates are justified – you have to look at the outcomes to see whether they made a difference, In this group home or hospital makes no difference to the outcomes to the baby, but the hospital does result in much more c-sec. hope that explains?

          • Azuran

            My own interpretation of why hospital has more c section is preventive medicine, not that the stress of hospital birth cause c section.
            When something happens during a birth, say, sign of fetal distress, you are faced with two choice: Keep going, which will have, let’s say, a X chance of negative outcomes, or have a C-section, which will have a Y chance of negative outcomes. If Y is lower than X, than, a c-section will most likely be recommended, even if both X and Y are small.
            Chances are, everything would have gone well, since X was small to begin with, which explains why homebirth has a higher rate of birth without C-section than hospital births for same risk women.

          • guest

            That is also a viable explanation. But if that is the only one than current UK obstetrical practice has to seriously reconsider their practice in low-risk women, esp multips, given the amount of genuinely unnecessary c-sec; no benefit to fetus of the higher rates whatsoever. Then the Ob/gyns are like a miscalibarated detection test; far too sensitive, not enough specificity; they’d be better of leaving the midwives in charge whose risk-perceptions appears much better calibrated for this cohort. In that case what the ob/gyns do to low-risk multips is genuinely problematic. I don’t want to think that. I think the explanation is a mixture – both a different ‘risk-detection’ setting on ob/gyns, but also more actually complications due to all aspects of hospital setting. But – this is all guess work for anyone.

          • Daleth

            What’s your citation for there being no increased benefit/reduced risk to babies of XYZ c-section rate? I’ve seen a few articles saying that, but they typically look at too few parameters to reach an accurate conclusion. For instance, I’ve seen both of the following arguments:

            (1) “A higher c-section rate doesn’t reduce perinatal mortality, therefore some of those c-sections are clearly unnecessary”

            (2) “A higher c-section rate doesn’t reduce cerebral palsy rates, therefore some of those c-sections are clearly unnecessary” (one of my doctors said essentially this to me when I was explaining why I wanted a c-section and he was trying to bully me into trying for a vaginal birth).

            Both those arguments completely miss the fact that c-sections are not done only to reduce mortality and cerebral palsy, but also to reduce all types of brain damage (mild, moderate and severe), nerve damage (e.g. brachial plexus palsy), infants born with broken bones due to efforts to get them out during shoulder dystocia, and more, not to mention maternal morbidity (e.g. third and fourth-degree tears).

          • guest

            birthplace england study brocklehurst 2011

          • Daleth

            I’d appreciate it if a doctor, nurse or statistician could take a look at that study to confirm (or not confirm) the couple of issues that I think I see with it.

            First, that study had a bit of an issue with its definition of “low risk women.” As it said, “Almost 20% of women in the obstetric unit group had at least one complicating condition noted at the start of care in labour, compared with ≤7% in each of the other settings. This finding was unexpected and suggested that the risk profile of the ‘low risk women’ varied between the different groups.”
            http://www.bmj.com/content/343/bmj.d7400

            Second, “Compared with the obstetric unit group, women planning to give birth at home were more likely to be older, white, have a fluent understanding of English, and live in a more socioeconomically advantaged area.” Greater wealth and English proficiency all but guarantees they would have gotten, on average, better prenatal care because they would have been better able to advocate for themselves. If this study had been done in the US it could be argued that differences in prenatal care might balance out because the doctors in the obstetric group likely practiced “defensive medicine,” testing and monitoring for all sorts of potential problems whether or not the patient requested it, but “defensive medicine” is not really an issue in the UK–at least not nearly to the extent it is here. So in the UK, the socioeconomic and linguistic advantages of the planned homebirthers relative to the planned hospital OB birthers likely got them better prenatal care, which would inherently reduce the risk of complications.

          • guest

            there has been a lot of discussion on this blog. But yes – the data can be disputed. we have some hard facts though – you want me run that risk of the c-sec and the forceps – real, measured, considerable and significant risk just, because – you know – maybe we can explain away the data as you do above? it is the NHS – poor people get care too. And if you are low-risk, prenatal care isn’t a big difference maker. but yes, there is lifestyle= etc. Not convinced enough to balance the real, measured and bigger risks though. see also some of the other posts on explanations. As to your first paragraph – as a competent, white, upper-middle etc – I could do the risk screening better than the midwives (also in subsequent study on the higher risk women – see their webiste – who birthed at home: they were even whiter and upper-classer. sounds to me like they weren’t not-screened out by the midwives, but rather committed NCB’ers demanding their home birth nonetheless….

          • Daleth

            **”And if you are low-risk, prenatal care isn’t a big difference maker.”**

            But prenatal care is a major factor in determining who is and is not low risk. Without decent prenatal care, how do you diagnose gestational diabetes or preeclampsia, for instance? How do you diagnose intrauterine growth restriction? Macrosomia? Anterior placenta or placenta previa? How do you diagnose anything?

          • Joy

            As an American living in the UK I found it difficult to communicate my concerns to the midwives and HV. Everyone thinks that because we share a common language then things should be fine, but so much is missed with inflection, tone, and word choice. Which is probably why no one paid attention when I said my baby wasn’t bfing and then she wound up with an N-G tube because she was too weak to even take a bottle. I can’t imagine if I didn’t speak the language well. Just because the access is there (and it wasn’t for everyone. There were no midwife appointments at my GP’s surgery for many of the dates I needed, which meant a 15 minute car trip. Or a 1:45 minute bus journey if you didn’t have a car, not always doable for a pregnant lady if you have another child.)

          • Sue

            Doesn’t report neonatal morbidity – only mortality

          • Azuran

            Then the question you have to ask yourself is: How many avoided c-section is a dead baby worth?
            Let’s assume a totally random number: Your baby shows sign of distress on the monitoring, and there is a 1% chance of this being serious and causing the death of the baby if you don’t do a c-section. But you have no way of knowing which one is the 1%.

            In a homebirth, you do nothing, and 99% of the time, everything will go fine, but 1% of the babies will die. you will pride youself in avoiding c section for the 99% of women. But 1% of the babies still died.
            In a hospital birth, you will have a c-section, 99% of those would have been fine without it, but you don’t know which one of those was the 1%. You saved the 1% of the babies that would have died.

            Personally, I’d take the c-section any time if it means less risk for my baby.

          • Erin

            As a British woman who came far closer to death in childbirth than I think is acceptable in this day and age five months ago due to the NHS’s determination to reduce the c-section rate, I have to question your statement about “genuinely unnecessary c-sec”.
            In fact 24 hours into a premature rupture of the membranes a Midwife at the hospital told me I would the perfect candidate for a home birth, ignoring my posterior baby sitting only partially on my cervix, my sporadic contractions despite birthing ball, spinning babies routines etc and how slowly I was dilating. In fact by the time anyone mentioned c-sections, my waters had been broken for over 81 hours, I had been on a saline drip for at least 10 hours, my diastolic blood pressure was extremely low to the point that both baby and I were suffering, apparently the pathology on the cord told a fascinating story and I’d been at 10 cms for around 6 hours without my son budging a millimeter because he was stuck on my pelvic bone, oh and I was almost out of amniotic fluid.
            On top of that, when I was speaking to an OB afterwards they suggested that if I wanted another child, I should try for a vbac because although my son was only 6 pounds 9 ounces and was stuck fast inside me… that the next baby may fit. (Now possibly they might, I know angles are important but the way in which it was pushed was frightening in it’s intensity).
            I’m not saying that every c-section the NHS does has a medical requirement but given that I was in the condition I was in and they offered me a choice of trying for a bit longer or signing the consent forms… I just can’t see them as the mad butchers some people portray them as.

          • Tiffany Aching

            “That is also a viable explanation.”

            This IS the explanation. Not your BS about hospital being a stressful environment that slows labour.

            The statistical risk assessment that Azuran described is at the heart of any medicine practice – this is how doctors make their decisions, and this is also why their training make them more able to make these decisions than less-trained though experienced practitioners: experience isn’t that valuable when you deal with very low risks, because the probability that you encountered that risk in your experience is low. Thus you misrepresent the risk. To have an accurate idea of the risk, you need to know that decision A is more risky than decision B, and you need to have learned that. You might think that midwives are better “calibrated” (what a strange comparison) at detecting risks, but it is only because they know less and rely more heavily on experience that they have an optimistic representation of the risks. Anyone who has a rational mind understands that if a risk of complication, even small, can be avoided by an even less risky intervention, then the intervention is the way to go. Of course it will lead to some – in retrospect – unecessary c-sections but that is precisely the point of risk management. Do you think that every time you buckled you seatbelt and didn’t have an accident, buckling your seatbelt wasn’t necessary ?

            What you express is a cognitive bias in the way we assess risks that most of the time make us believe that doing nothing is intrisincally less risky than actively doing something to avoid the risk.

          • guest

            Dear Mel, sorry if my response below is a bit curt. I get frustrated on this blog because people constantly accuse NCB’ers of not looking at the evidence and not reading, and just reasoning from ideology. But then it is widely assumed here that going to hospital/a particular c-sec rate is ALWAYS justified by the benefits to the baby, regardless of what the evidence says about whether those benefits obtain. That is equally ideological, and not based in evidence. In some cohorts – the one I was lucky to belong to – that benefit can’t be found. in others there is such benefit, but of course what choices that justified depends on the magnitude of the benefits, and how that is traded against risks to the mother. THat is a lengthy and interesting question on which people are likely to differ – but not one I have time to discuss tonight.

          • Amy Tuteur, MD

            Glad to see you’ve returned. Still don’t understand why, as a prominent academic philosopher and proponent of homebirth you won’t comment under your real name.

            It is NOT assumed that hospital birth is always justified by benefits to the baby. Hospital birth IS safer for babies (in the same way that carseats are safer for babies). That doesn’t mean that you are obligated to give birth in the hospital, merely that you are gambling with your baby’s life if you don’t.

            Homebirth advocates are habitually dishonest on this point.

          • guest

            Look, Dr Amy, two points.

            First, either you stratisfy, which I think is what medicine is about. Different risk-profiles for different people (e.g. primp, multip, breech, etc). I think that is how medicine works – we should get as good as we can about that. but if we stratify then hospital birth is NOT safer for babies of low-risk multips. (nor is it less safe). If we don’t stratify, then you can hardly blame NCB’ers for failing to distinguish low- and high risk (i do blame them for that.

            Second, if we do – as you propose analyse mothers and babies separately, then fine – hospital is nearly always safer for babies (exception mentioned). But then hospital is nearly always massively dangerous for women. for a few very high-risk cohorts aside, women are always much safer staying away from hospital as far as they can. anti-HB advocates are habitually failing to mention that. If you constantly mention both in the same breath – as I try to do – then we can do business. And then also let’s be realistic about the frequencies and magnitudes.

            Finally – I have just disclosed a lot of private information about me and my family that I would only disclose anonymously. by ‘sort of’ identifying me, that makes it very difficult for me to now (or in future) disclose who I am. – I will now have to wait until aren’t likely to connect up the dots

            but thanks for replying.

          • guest

            ps i think a lot of your commenters DO assume just that: ” hospital birth is always justified by benefits to the baby. ” Anyway, that is what they keep telling me in response. And I don’t see anyone else correcting them.

          • Amy Tuteur, MD

            Well, it’s my blog and you were addressing me and I have never claimed that hospital birth is always justified by the benefits to the baby.

          • Amy Tuteur, MD

            Of course we stratify risk, which means that homebirth increases the risk of perinatal death by a greater or less amount based on the risk status of the mother.

            The Birthplace Study is ONE piece of data about homebirth in the UK. Curiously, the piece of data that we really need, the death rate of planned homebirth in actual practice has been withheld from women. I suspect that there’s a reason for that; it actually practice homebirth may be much riskier for everyone.

            Care to provide any DATA for your claim that hospital birth is “massively dangerous” for women. Last I looked, maternal mortality had dropped 99% as hospital birth approached 100%. That’s even steeper drop that the decrease in perinatal mortality in the same time period.

            This is the problem with homebirth advocates like yourself, guest. You have no idea what the real medical risks are. Hence you provide women with inaccurate risk assessments.

          • guest

            hey – stratification again!!!!! sure, hospitals – as a back up – massively improve birth safety for everyone. but we are talking low risk mums.

            you want to do maternal outcomes separately. check the original comment. birthplace study. 5% instead of 0.5% risk of laparotomy, for no reason of fetal outcomes or maternal? plus additional forceps risk? yes – you’d find that massively a dangerous place. if we do fetal outmodes separately, we must do material one sees too. be consistent. that was precisely my point. – it makes no sense. that’s i always mention both. stratified and all. you don’t.

            but still appreciating your engagement!

          • Amy Tuteur, MD

            A laparotomy is what you consider “massively dangerous”? A C-section does indeed carry more risk for the mother, but that risk is dwarfed by the increased risk to the baby. So if you want to say that hospital birth is “massively dangerous” for mothers, in honesty you MUST describe the risk of homebirth to babies as astronomical.

            There is no equivalence between a C-section and a perinatal death. It is disingenuous to imply that there is.

          • Cobalt

            So if you stay home, maternal risk of intervention drops to 5% to 0.5%. What about the baby’s risk of brain damage? Cerebral palsy? Brachial nerve damage?

            We do like to aim a bit higher than “not dead”, if at all possible.

          • moto_librarian

            People like you make me want to rip my hair out. The hospital is “massively dangerous for women?!” Giving birth at home would have killed me, yet I constantly have NCB advocates brushing off what happened to me and claiming that a midwife could have taken care of me just fine. At least one midwife admitted that LifeFlight would be my only real hope of surviving a cervical laceration that caused a massive pph. The hospital saved my life, yet you expect me to take you seriously when your major complaint (e.g., the “massive danger”) is having a c-section or a forceps delivery? Get over yourself.

          • fiftyfifty1

            ” But then hospital is nearly always massively dangerous for women”
            This is an extreme and bizarre statement. Care to back it up?

          • guest

            check the original comment. birthplace study. 5% to instead of 0.5% risk of laparotomy, for no reason of fetal outcomes? yes – you’d find a dangerous place. if we do fetal outmodes separately, we must do material one sees too. be consistent. that was precisely my point.

          • Roadstergal

            “98% chance of my emerging entirely unscathed”
            I thought the Birthplace study didn’t look at the incidence of tears, incontinence, pelvic floor damage, maternal morbidities like that? It’s been a while since I read it…

          • guest

            sure – it can’t measure anything. but that really takes us into area of conjecture – for hospital births have those risks too – and yes, you might avoid some by more c-sec, but then you will equally aggravate them with all the forceps! I was trying to stick to where we have reasonable date. Evidence based choice and all that.

          • Roadstergal

            But that’s what I’m saying – you said you would have a 98% chance of being ‘entirely unscathed’ at home, but that isn’t what the evidence shows. You had a 98% chance of not being scathed by doctors, as it were, but there’s plenty of scathing to still go around, and some scathing – epis in particular – are done to try to spare worse scathes. That tradeoff is a little murkier than you present it.

          • guest

            sure – I cut a corner. If not, the comment would be EVEN longer. but do we have good evidence that the additional scathing is worse at home than in s hospital? the study did measure third degree tears, which weren’t worse at home than hospital, so the episios did not prevent those. Again they are ‘intended’ to prevent worse – but there is little evidence that they do. not in this cohort anyway. And I would take a second-degree tear over an episotomy any day; less pain, better healing. So, should i take on all the hospital risks for an – again – ‘potential’ benefit for which we lack good evidence? isn’t dreaming up all these ‘potential benefits’ just what NCB’ers are vilified for here? Sure, it is always murkier than i present it. That is why they are hard choices. this blog pretends they are easy – which bugs me. I am glad we agree there is a trade-off.

          • Roadstergal

            “And I would take a second-degree tear over an episotomy any day; less pain, better healing.”

            Citation for that? My friend tells me the midwives tell her that all the time, but never give citations…
            That’s the thing. To say “I’m as low-risk as low-risk multips get – the overall risk is low, and the importance of being at home to me is high, so I decided to stay home.” That’s fair, and I don’t think anyone would disagree. But then to try to spin that hospitals are worse for you – it does involve some scraping and fudging, it seems.

          • guest

            i could ask you the same question: what is your citation that episiotomy isn’t worse? what we do know is that Ob/gyns retreated from universal episios. Either way – the episios and second degree tears weren’t a major feature in decision-making ; forceps and c-secs were.

          • moto_librarian

            They stopped doing them routinely because the research showed that a controlled cut didn’t necessarily heal better than a natural tear. I think there was also some evidence that epsisiotomies tended to split even further, but I have to look that up. Practice changed based on evidence. That’s what I like to see.

          • Inmara

            I would like to see some solid data regarding “cut vs. tear” too, but as far as I can recall, routine episiotomies were done rather to improve fetal outcomes, and it turned out that they didn’t. Maybe someone with medical background could tell better.

          • Ash

            Episiotomies may be protective against anal sphincter injuries in selected situations as well:

            http://www.skepticalob.com/2013/02/the-hideous-racial-insensitivity-of-white-homebirth-advocates.html#comment-801226716

          • guest

            what bothers me is that you seem utterly unconcerned by the i think very real and realistic concerns re c-sec and forceps – evidence for that is virtually undisputed (just never mentioned on this blog) and make this a decision about the stuff for which we have poor or no evidence either way. it;s not just midwives who say that – women who have had both do too. it would be really nice to have some research on that coz i too worry about having a proper citation. anyone know of any? experience of episiosoty vs 2nd degree tear.

          • Daleth

            I don’t know about hospitals in your country but in the US the use of forceps is something like 1% of births. And as I said above, you can refuse a doctor’s suggestion of using forceps. You may well get pushback from the doctor, most likely because the doctor has seen things go very badly wrong before and doesn’t want to see that happen to you and your baby, whereas you wouldn’t get pushback from a homebirth midwife–not because your baby isn’t in danger, but simply because she is not able to use forceps so it’s a moot point.

            That said, I’m not trying to diminish your concerns–my own concerns about forceps were so strong (my mom was permanently handicapped by a forceps accident at her own birth) that it’s one of the reasons I opted for a c-section: to ensure that my babies and I wouldn’t have to go through that. Even a 1% risk was more than I wanted.

            All I’m trying to understand here was whether you really believed that at the hospital you would be forced into forceps or a c-section that you didn’t need even if you refused consent? Or believed that by staying home you would ensure that your baby wouldn’t get into difficulties and need instrumental or c-section delivery? That’s what I don’t understand.

          • guest

            i explained this in one of my other comments – of course it wasn’t about force. but if the doctor says ‘ we really think it is necessary now’ i am unlikely to disagree. I was merely basing my decision on the data. that suggests that in hospital the doctor says ‘ it is really necessary now’ far more often than if you plan home birth. WITHOUT any improvement in fetal outcomes. but look for the other comments where we dsicusse explanations

          • Sue

            But guest, we don’t know fetal outcomes – we only know mortality rates.

          • Joy

            Forceps use in the UK is just below 5%. Or was in 2013 when I had my baby. I looked it up to reassure myself that forceps were unlikely. D’oh! But then c-section rates are lower. I would have rather had a section, even though everything is currently fine.

          • Daleth

            +1. I would way rather have a CS than forceps.

          • Joy

            In retrospect, a year later everything is in place and working just as well as it did before. But I was really stressed about it for about a month and there is no guarantee for after menopause.

          • Amy M

            Why would the 2nd degree tear involve less pain and heal better? Either way, your flesh is rent, and you might/probably have stitches.

          • MaineJen

            I can tell you with certainty that a 2nd degree tear involves considerable pain, a few stitches, and about 6 months before you feel completely normal and pain-free again. Those ice packs in the hospital were my friends. And you are going to let a CPM repair that for you? Or worse, NOT repair it? No thanks.

          • Amy M

            I was lucky in that regard–I had only a small tear, with a few stitches, and it didn’t really bother me much. However, the moment my skin tore, it hurt like a mofo and I screamed. I had an epidural, but it wasn’t touching that area.

          • moto_librarian

            In the States, the rate of episiotomy is around 12%. They have not been routine in a very long time, so I’m guessing that they are not routine in the UK either. I have not had an episiotomy, but I have had second degree tears (twice) and a cervical laceration (first delivery). The repairs were done well, but I was definitely in a lot of pain during the healing process. You would get stitches either way, so I guess I don’t understand how you can be so certain that a natural tear’s healing process is less painful than that from an episiotomy.

          • Amy M

            WRT to your theory about birth going less well at the hospital–I think birth “goes” about the same in either location. The difference is in the hospital, there is more, sometimes continuous, monitoring. Anything that comes up questionable might lead to a conservative doctor to favor Csection, even though the baby might be able to survive vaginal birth unscathed. At home, if there is monitoring, it is 1)intermittant, and 2)less likely that the listener will catch subtleties. If the attendant has no idea that the baby had a decel or two, she would have no reason to suggest transfer.

            Overall, the hospital certainly has higher-risk women giving birth, so yes, that right there contributes to the Csection rate/complication, but says nothing about an individual woman’s chance for having a Csection or complications. I gave birth in a large teaching hospital with a Level 3 NICU—high risk women go there in larger numbers than the hospital down the street that has no NICU, so the Csection rate is undoubtedly higher in the teaching hospital, and birth (on the whole) “goes less smoothly” based on the population of patients.

            At any rate, I appreciate your taking the time to explain your mindset to me. It sounds like you were an excellent candidate for homebirth, as long as you have a low-risk pregnancy.

          • guest

            the c-sec rate i noted was specific to the low-risk women. they were comparable groups for analysis. so not influenced by high-risk women – and indeed the risk I faced. not the general hospital c-sec risk.

            As to your explanation – as I said to Azuram: “that is also a viable explanation. But if that is the only one than current UK obstetrical practice has to seriously reconsider their practice in low-risk women, esp multips, given the amount of genuinely unnecessary c-sec; no benefit to fetus of the higher rates whatsoever. Then the Ob/gyns are like a miscalibarated detection test; far too sensitive, not enough specificity; they’d be better of leaving the midwives in charge whose risk-perceptions appears much better calibrated for this cohort. In that case what the ob/gyns do to low-risk multips is genuinely problematic. I don’t want to think that. I think the explanation is a mixture – both a different ‘risk-detection’ setting on ob/gyns, but also more actually complications due to all aspects of hospital setting. But – this is all guess work for anyone.”

            I am glad my explanation helped. Yes i was an excellent candidate. yes I was low-risk (ex ante). It bothers me that people on this blog don’t want to advocate for the best option for me and people like me being routinely provided by the health care system AND being made as safe as possible.

          • SporkParade

            I think that’s unfair to say that we “don’t want to advocate for the best option for [you] and people like [you].” Several of the commenters here are advocates of better regulation of homebirth in the US, where it’s basically the wild west in most places. Many of us also have no problem with homebirth, but we have a problem with the lies being told to women considering homebirth and we have a problem with public health systems promoting homebirth in order to save money because then they don’t have to provide things like effective pain relief.

          • guest

            but better regulation as advocated here usually doesn’t include better integration – or making the systems safer. merely outlawing CPM’s (further). there may be exceptions, but anybody suggesting what i say (indeed i myself when saying it) is generally met with ridicule, or, at best, disbelief. and that, only, if they are willing to write 10.000 words explaining.

          • SporkParade

            Yes, because CPMs are not medical professionals and would not be qualified to practice in any developed country other than the US. Where I live, midwifery programs are highly competitive and only open to RNs with at least one year of experience working R&D. Then, in order to attend homebirths, midwives must have at least 3 years of hospital experience. So a homebirth midwife here has 10 years of education/training and has attended hundreds of births, both low-risk and high-risk. Compare with a CPM, who is only required to have a high school diploma, complete a correspondence course, and be present (not necessarily in charge) at dozens of births in presumably low-risk women.

          • Azuran

            And outlawing CPM should be done. You want to be a midwife? Then you should have the proper medical education to be one. Birth is not a joke. It is dangerous and should be handled by competent people. The fact that CPMs are even allowed to exist is ridiculous.

          • Amy M

            I didn’t see your other reply before I answered. I see what you are saying, but I don’t agree that we should have less sensitive monitoring. Improving the efm, for accuracy would be a good goal. But I’d rather have an “unnecessary” Csection, than a dead or damaged baby because no one noticed the signs of distress.

            I suppose if an integrated system with robust risk-out criteria could be implemented in the US, that would be loads better than the American homebirth system as it stands (untrained lay-people w/no hospital affiliation, in your living room). But, considering the current state of health care in this country and how massively things would need re-organizing to do this, I don’t really see it happening soon. Evidently, most (American) women are pretty happy with the current system of hospital birth.

          • guest

            but the whole point is – you DON’t avoid a dead or damaged baby in this cohort. the outcomes are the same.

          • Amy M

            But you don’t know until afterwards…its Schroedinger’s baby. It’s impossible to say, before the child is actually born, whether or not a Csection will be necessary, nor can it be determined from the outcomes which Csections weren’t necessary. The only way to get this info accurately would be to do no Csections, and see who lives, but of course, that’s unethical.

          • guest

            no. you can compare women planning the home-birth, and women planning the hospital birth. and if they have the same fetal outcomes, but hospital has much higher interventions then I think you can legitimately say: don’t plan the hospital brith. [fair enough – it is not to say that the c-secs weren’t necessary. indeed in my explanation i granted the possibility that they may be necessary in the hospital context as birth progresses less smoothly there. but it does show that they can be avoided at no cost to baby – and that’s what you’d want to know for your decisions. in the cohort we talk about – that is.

          • Amy Tuteur, MD

            We don’t really know how safe homebirth in the UK is because the government won’t release those stats. As a gynecologist I would be wrong to counsel patients about birth control based on failure rates under ideal use; I would be remiss if I did not explain failure rates in real world use. Similarly, without the ACTUAL homebirth death rates in the UK, we don’t know that it is safe for anyone.

          • guest

            good. this is something i mean to hash out, as we evidently think differently about it. I note your point about contraception. Correct. But here’s the difference: home-birth isn;t choice independent. We may well find a higher mortality amongts high-risk home-birthers – and hence home-birthers as a group. I am sure we do – and I would expect it. But if we start to evaluate care-systems (which is a different questions from how safe an option is for me) I don’t just care about mortality and morbidity – I also care, for example, about autonomy; about facilitating women’s (free = as free as they can be) choices. And evidently some women do choose home-birht in what I consider for from ideal circumstance. THus what matters for the women trying to decide what to plan, she does not need to data on all home-birht in the UK, but those one women like her facing the decision. the Brocklehurst study provide that. it is an improtnat piece of the puzzle – though i would like to have the data you mention too. I am sure you have soon that, as i expected, the analysis on the high-risk home-birhters who were excluded from the main brockleuhurst analysis was even whiter, older and higher SES than the low-rush home-birthers. doesn’t sound like poor midwifery risk selection to me, but headstrong ncb’ers. And i hope we can agree that a headstrong NCB’er should still have a midwife present (if not for herself than for her foetus) rather than be left without any care?

          • Amy Tuteur, MD

            If you care about autonomy then you should care that homebirth advocates are manipulating women by keeping the most important information from them.

            There’s simply no ethical justification for hiding the real world evidence.

          • fiftyfifty1

            Oh she doesn’t care about maternal autonomy, she cares about her own personal choices being catered to.

          • fiftyfifty1

            Yes, why not RELEASE THE NUMBERS?! Why did they fund the Birthplace Study where they cleaned up the homebirth cohort so much that it no longer was representative of the real women who homebirth.

          • yugaya

            Here is a number for everyone in natural childbirth industry to ponder on – from the beginning of this year there have been ten homebirth disaster deaths in USA that I can track back to real people.

            Five more months to go, and if these are the only deaths that happened (more than highly unlikely), and if 1% of abt 4 000 000 births per year in USA take place out of hospital, current death rate of American Homebirth™ in 2015 is 1/400 and counting.

          • fiftyfifty1

            ” As a gynecologist I would be wrong to counsel patients about birth control based on failure rates under ideal use”

            And you would be even more wrong to do what “guest” does which is to compare homebirth under ideal conditions, with hospital birth under typical conditions.

          • Amy M

            I’m a little confused now, but you seem to be convinced that the location strongly affects how a birth goes? That makes no sense—what about setting foot in a hospital suddenly increases complications?

          • moto_librarian

            If you are in a hospital, you are monitored with EFM, correct? EFM often detects subtle problems that even a well-trained midwife cannot detect via doppler. This additional information does sometimes lead to a c-section, which is entirely the point. You need to intervene before a situation results not just in death, but before oxygen deprivation results in disability as well.

            I just don’t buy this argument that being inside a hospital disturbs or changes the birthing process in of itself. If stress alone could cause cessation of labor or dilation, why do so many women have preterm babies? One could argue that there are few situations more stressful for a pregnant woman than having a preemie or micro-preemie, yet that anxiety doesn’t stop labor.

          • yugaya

            What disturbs the birthing process of 99% women who die in childbirth nowadays? They are in the developing world, giving birth mostly at home, and without any medically qualified birth attendant present. Their births are as natural as birth gets, and as naturally deadly as birth is.

            That hospitals-disturb-hormones bullshit is pure bigotry on top of being nonsense because it suggests that all of these women are giving birth *naturally* the wrong way and that they would end up dead even if they had access to medical interventions and hospitals.

          • Sue

            The UK Birthpalce Study only reported deaths – not disability.

          • Dr Kitty

            No, Birthplace reported morbidity as a combined statistic, so you couldn’t actually tease out what damage was actually done and how severe it was.

            Think of it this way, if the study reported “1% of babies delivered by CS suffered morbidity and 1% of babies delivered at home suffered morbidity” both look equally safe. which is how Birthplace reported the data.

            To take an entirely made up example:
            If a study instead reported:
            “1% of babies delivered in hospital reported morbidity. This consisted of infection requiring IV antibiotics, TTN requiring NICU, hypoglycaemia requiring blood glucose monitoring and one baby who received a minor laceration to the skin of their shoulder during CS. No babies suffered any long term ill effects, and all were home within a week of delivery.

            1% of babies delivered at home reported morbidity. This consisted of shoulder dystocia resulting in one case of OBPI, one case of hypoxic-ischaemic encephalopathy and three fractured clavicles. There was one case of cephalhaematoma from instrumental delivery, two cases of GBS sepsis requiring NICU admission, and several cases of meconium aspiration syndrome. One baby suffered a fractured skull from a forceps delivery. Several of the babies required prolonged NICU stays and 5 have ongoing profound physical or developmental disability.”

            Birthplace published all morbidity together, as if all morbidity is the same, and doesn’t allow you to see what you’re actually talking about in terms of outcome.

            What you actually WANT i the data presented as in my hypothetical, so you can actually compare and contrast meaningfully what harms are being risked.

          • Roadstergal

            “It bothers me that people on this blog don’t want to advocate for the best option for me”

            That’s the thing. You’re going from one subgroup analysis in one study that did rather work at making HB look good (effective pain relief is a negative outcome? Really?) to say what’s ‘best’ rather than what you prefer. Like I said below – “To say “I’m as low-risk as low-risk multips get – the overall risk is low, and the importance of being at home to me is high, so I decided to stay home.” That’s fair, and I don’t think anyone would disagree.”
            There’s a lot in the UK that needs to be made as safe as possible. Given that most women aren’t low-risk multips, I would think that improving hospital care is more important – we have had recent evidence that midwives are interfering with appropriate hospital care in the UK, resulting in the preventable deaths of women and babies, and that should definitely not be happening. Perhaps if they were straightened out, we would have a clearer picture of how HB and hospital birth compare.

          • guest

            but a lot of people are. yes there was one problem in the UK. I am sure I can dig up some info on a misbehaving OB – I won’t vilify the whole system on that basis. I rather prefer to do both things you propose – make everything safer.

          • Roadstergal

            “yes there was one problem in the UK”

            Are you serious?

          • guest

            yes of course. What – you think the whole midwifery profession in the UK is rotten to the core based on one hospital? I know dr Amy presents it that way – but she is hardly neutral. I mean – I am not going to vilify the obstetric profession based on the (many) stories I hear of instances gone wrong, its historical non-evidence based practice. etc. That is just irrational. But clearly we disagree on this

          • Poogles

            “What – you think the whole midwifery profession in the UK is rotten to the core based on one hospital?”

            But it’s not just 1 hospital, there are at least 3 involved in the recent investigations into preventable maternal and infant deaths.

          • Poogles

            So, 4 maternal deaths and 18 infant deaths count as “one problem” to you? And those did not even all take place in the same hospital – Furness, Royal Oldham, and North Manchester General Hospitals were all involved. How can you just gloss over that as not possibly indicating that low-risk hospital birth as currently practiced by midwives in the UK is causing preventable deaths that can influence the data you are relying on?

          • Roadstergal

            Of the ~1 billion pounds for payouts for over a thousand maternity claims in the past year, the biggest were for lack of fetal heart rate monitoring and/or failure to escalate due to that. The Kirkup report indicted a culture of natural birth at all costs in hospitals. Nowhere were negative hospital outcomes associated with a lack of sufficient cheerleading for low-risk multips wanting to stay home.

          • guest

            ps i agree that putting ‘epidural’ in the box with e.g. forceps was a really weird choice. I exclude that as a (negative) outcome in my analysis and decision making.

          • fiftyfifty1

            ” the Ob/gyns are like a miscalibarated detection test; far too sensitive, not enough specificity; they’d be better of leaving the midwives in charge whose risk-perceptions appears much better calibrated for this cohort.”

            Except the data don’t actually support that in the Netherlands, a country with a system you say the US should copy. LOW risk pregnancies under midwife care in the Netherlands have higher death rates than HIGH risk pregnancies under OB care. The Netherlands numbers are far more convincing to me than the Birthplace Study because they measure what actually happened in the country rather than handpicking a superstar homebirth cohort and comparing it to a hospital cohort with uncorrected confounders.

          • Daleth

            What I don’t understand in your post is the assumption that by going to the hospital, you would somehow cause yourself to run a 5% risk of c-section/forceps etc., and you would be able to avoid that risk by staying home.

            For instance, if a baby is so badly stuck at such a point in labor that forceps are needed, then that’s the situation you’re in–whether you’re at home or in the hospital. Going to the hospital didn’t CAUSE the baby to get badly stuck at that point in labor.

            Or to put it another way, the reason there is a 0% c-section rate for home births is not because women reduce their NEED for a c-section by giving birth at home–it’s because you can’t do a c-section at home.

            And if you want more of a chance to deliver vaginally rather than being whisked into forceps or a c-section when complications arise, you can refuse forceps or a c-section.

          • guest

            it’s not an assumption. it is what the data say. check out the full comments – or the birthplace study. re: your final paragraph: the data are for where you plan to give birth – not where you actually give birth.

          • Daleth

            No, I think it’s how you’re interpreting it. You want to believe that being at home actually CAUSES birth to be safer, so you read the study that way (confirmation bias). So let’s put this another way: how would giving birth at home cause fewer babies to get shoulder dystocia? Repeat that question for every complication. The answer is, “Oh right… it wouldn’t.”

          • fiftyfifty1

            “Repeat that question for every complication. The answer is, “Oh right… it wouldn’t.””

            What being at home does is allows you to stick your head in the sand. What complications you don’t notice are complications you don’t have to treat. And most babies still turn out fine…unless they don’t. What’s a little brain damage in comparison to mom having an episiotomy?

          • Roadstergal

            Brain damage and hypoxia weren’t measured in the BP study, were they?

          • Kesiana

            by going to the hospital, you would somehow cause yourself to run a 5% risk of c-section/forceps etc., and you would be able to avoid that risk by staying home.

            I think it’s the “cascade of interventions” theory, where supposedly doctors get impatient with how slowly labor is progressing, so they use various drugs and procedures to speed it up, which doesn’t work (on account of not being natural?) , so c-section it is.

            Of course, logically this doesn’t make much sense with issues like shoulder dystocia… and if a healthcare professional is saying your baby needs to be born NOW, it’s generally not because they’re anxious about missing their tee time.

          • Daleth

            Seriously. I was on a forum recently where a woman joined and said that X years ago she was bullied into a c-section because her doctor was “late for his golf game.” She was asked to tell her story in more detail and it turned out that:

            – She had her c-section at 9PM, which obviously means her doctor wasn’t trying to get to a golf game–who ever heard of a 10PM tee time?!

            – Her doctor said she needed a c-section, and then arranged for the next OB coming in on shift to perform the operation. Again, obviously her CS had nothing to do with her doctor’s golf game, since he was leaving her in the care of the next OB on call whether she had a CS or not.

            – Oh, and when the CS was called she had been pushing for three hours with a baby–her first, BTW–in brow presentation. Which somehow she thought was not a legit reason for a CS…

            It blows my mind what people can willfully ignore in order to believe the story they want to believe.

          • EmbraceYourInnerCrone

            When in actuality you have situations like my niece. Her baby had been measuring big at her last few OB visits. At about 38+5 they said he is getting too big, we should schedule an induction, for tomorrow if thats ok with you. She agreed and went home to make sure everything was organized for the care of her 2 older kids. At 11pm that night she went into labor on her own. 10 hours later her 10lb 11 oz son is in distress and then has a shoulder dystocia. The OB and her team were able to resolve it but it was scary and messy and not as fast as they would have liked. The baby was in NICU and on ventilator and naso-gastric tube for almost a week. The original fears when he went home, of brachial plexus injury seem to have been resolved and while he may need some physical therapy he has most of the use of that arm. But I wish they had gone with a pre-labor C/S for macrosomia a few days earlier…

          • Cobalt

            I was as low risk as multips get- and I delivered in a hospital without drugs, incisions, excess exams, and all those other terrible interventions. Until my placenta wouldn’t deliver completely, even after a shot of pitocin, massage, and waiting. My OB had to do a manual evacuation (still no painkillers-no time to get an epidural). I’d have bled out on the way to the hospital if I had been at home. There were no warning signs of placental issues until it happened. None of my prior births had any issues or interventions.

            Point being, “natural” childbirth is completely possible in the hospital. And if “natural” childbirth suddenly becomes an unsafe choice, interventions are immediately available.

            If hospitals make you nervous, why not work on your anxiety instead?

          • KarenJJ

            “If hospitals make you nervous, why not work on your anxiety instead?”

            Why are women told not to fear birth and to manage their anxiety about something going wrong at home and not to do the same thing with a hospital birth?

            Hospitals make a lot of people nervous. Some of us have had bad experiences. Doesn’t mean I should be denying my kids access to the best possible care for them because I’m anxious and have had bad experiences in the past. I needed to work on my relationship with the doctor and also found a way to try and manage my anxiety while in hospital.

            I mainly had big trust issues. I’m still not a fan of hospitals but we came through fine and getting past some of that trust problem has been incredibly beneficial for my kids, especially the one which needs to go to regular hospital clinics due to her rare disease.

          • Cobalt

            Exactly. Learning how to recognize, acknowledge, manage and address anxiety so it doesn’t overly interfere with life is an important set of skills with massive benefits. Deciding to just not have medical care until disaster is imminent sets yourself up for major trauma.

          • Sue

            But that’s a mature and insightful approach, Karen. There isn’t a lot of that amongst the radical-NCB crowd.

          • yentavegan

            I was a low risk mom who labored at home for baby number 3, and then went to the hospital to have an unmedicated intervention free birth. My husband stayed with me the entire time and I did not need any pain management/relief. Everything went smoothly along including the birth of the baby …and then I started to lose blood , the nurse without skipping a beat administered a shot of whatever “magic elixir” (pitocin?) hospitals have at the ready to save me from bleeding out and dying. Had I been at home I would have died.

          • Sue

            Hi, “guest” . When you think about the fact that the UK Birthplace Study showed a mortality benefit in hospital only for babies of first-timers, do you ever wonder about the outcomes other than death – such as hypoxic/ischaemia?

            ALso, have you looked at the “risk of harms of CS to future children” in terms of the number of children you plan to have? The risk of uterine rupture increases significantly after multiple cesareans.

      • Roadstergal

        For my friend and her UK NCB circle, the spin around the Birthplace study was “Homebirth is safer than hospital birth.” Full stop. They didn’t read it, they’re not interested in reading it – they just want their own feelings confirmed, and the interpretation of the Birthplace study in the popular press gave them that.

  • Roadstergal

    It’s never about one study – it’s about the data all building up. The study showing that Dutch midwives perform poorly with women at home or hospital, the Birthplace study showing double the risk to babies of low-risk primps at home v hospital, the MANA data, the Oregon data – it all points in the same direction. This study adds to a growing consensus, it seems to me.

  • FortyMegabytes

    Excellent article. In an ideal world this would shut up the homebirth hazard deniers. But, of course, the deniers will simply ignore the study or the “data doulas” will dig through and find some perceived flaw that will allow midwives to decry the study as worthless.

    • Ash

      No one needs to describe the study as worthless to get it to promote the homebirth side, all you do is cite “[A] poorer woman who preferred a home birth was more likely to encounter tragedy.” “On the surface, it appeared the home method may simply be riskier for babies.
      But the story isn’t that simple. What happened to the women during their home births depended a lot on their income,” and then advocate for societal efforts to close the gap.

      Lifting ppl out of poverty is worthwhile, of course, but that’s how you spin it in NCB favor

      • Roadstergal

        “advocate for societal efforts to close the gap”
        I doubt they’ll even bother to do that. They’ll just note “_I’m_ not low SES,” then charge ahead.

        Or just act like they did when they saw the results of the Birthplace study. Take the results of the lowest-risk group and expand it to everyone.