UK Birthplace Study tries to bury dead babies twice

got integrity

I’ve long maintained that the authors of the UK Birthplace Study, the largest study of its kind, started with the conclusion and worked backward to find evidence to support it.

The Birthplace Study began after the British government had declared that homebirth was safe and should be encouraged to save money. The study strained to bolster that claim, slicing and dicing the data every which way. But the authors of the Birthplace Study went one step further. They buried the dead babies twice.

First they buried the babies who died in tiny coffins; then they buried them again from public consciousness by refusing to acknowledge them within the papers themselves. Perinatal deaths were deliberately hidden in a “composite outcome” that amalgamated results ranging from trivial (arm injury from shoulder dystocia) to catastrophic (death). They literally would not reveal how many babies died at homebirth compared to how many died at hospital birth.

The death rate in the home VBAC group was 500% higher than in the hospital group.

Since the death rate at each location is the single most important piece of information to come from the study, the decision of the authors to bury it is inexplicable … unless they wanted to hide those deaths.

Now comes further evidence that the Birthplace Study plays fast and loose with the truth, and this one is even more egregious than the others that preceded it. Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England looks at the outcome of attempted VBAC in the Birthplace Study.

The single most important piece of data is buried in paragraph 27:

Four babies were stillborn, two in each group. Two of these four stillbirths were associated with uterine rupture.

The death rates were 2/1227 = 1.6/1000 in the hospital group and 2/209 = 9.5/1000 in the homebirth group.

In other words, the death rate in the homebirth group was 500% higher than in the hospital group.

You might think that was worthy of mention in the abstract. The authors chose to bury it with deliberate bit of obfuscation:

The risk of an adverse maternal outcome was around 2–3% in both settings, with a similar risk of an adverse neonatal outcome.

Not exactly.

Apparently the authors didn’t like the real conclusion of their study, so they buried those babies in a “composite index” outcome that combined dead babies with … babies who had a 5 minute Apgar less than 7, a trivial outcome. There is no possible scientific justification for such absurd amalgamation.

The authors conclude:

Women in the Birthplace cohort who planned VBAC at home had a significantly increased chance of achieving a vaginal birth compared with women who planned VBAC in an OU, but their chances of transfer were high (37%) and the risk of an adverse maternal outcome was 2–3%, with a similar risk of an adverse neonatal outcome.

And that is deeply and unacceptably misleading

The real conclusion ought to be: the risk of stillbirth at VBAC is 500% higher at home than in the hospital. Home VBAC has an unacceptably high mortality rate and should be strongly discouraged.

I’m not the only one who thinks so.

In an accompanying commentary, J Scott notes:

…[I]n my opinion the primary outcomes should be the rates of uterine rupture and infant morbidity and mortality, since these are much more important in assessing safety in this situation.

Scott concludes:

In my view, home birth VBAC cannot be endorsed based on these results, and the current recommendations that VBAC should occur in a hospital setting should remain.

In my view, there’s another take away from this study: the authors are determined to bury the dead babies in the Birthplace Study twice, once in tiny coffins in the ground and then again from public consciousness. Their clumsy efforts to obfuscate the deaths that occur as a result of homebirth mean that all their conclusions are suspect.

That’s hardly surprising. Starting with the conclusion and then manipulating the data to force it to fit isn’t science, it’s politics.

Homebirth kills babies who didn’t have to die … and no amount of composite indices, failures to disclose deaths and death rates, or desire to reach predetermined conclusions changes that. It simply deprives women of the opportunity to make the decisions that are best for themselves and their babies as opposed to the decisions that are cheapest or best for politicians.

  • Angie

    The cheapest and that says it all. Statistics will be manipulated to fit the agenda and the potential consequences will be manipulated to fit the agenda and the following enquiries will be manipulated to fit the agenda. The agenda of bargain basement maternity services in the UK.

  • Sue

    While looking for the study and commentary in BLOG, I found this Canadian Study from BC:
    “Maternal and neonatal outcomes after implementation of a hospital policy to limit low-risk planned caesarean deliveries before 39 weeks of gestation: an interrupted time-series analysis”:

    “We found little evidence that a hospital policy to limit planned caesareans before 39 weeks of gestation reduced adverse neonatal outcomes. Hospital administrators intending to introduce such policies should anticipate, and plan for, modest increases in out-of-hours and emergency-timing.”

    • Sue

      And this:
      “Home birth is unsafe: FOR: The safety of planned homebirths: a clinical fiction”

      “Despite an increase in unacceptable preventable adverse outcomes, homebirth proponents nevertheless claim that planned homebirth is safe because of the supposed selection of low-risk pregnancies. This claim of safe homebirths requires the adoption of clinical fiction—the existence of no-risk pregnancies. Such clinical fiction has no place in professionally responsible obstetric care (Chervenak FA et al. Am J Obstet Gynecol 2013;208:31-8).”

      • Sue

        And this

      • Daleth

        This claim of safe homebirths requires the adoption of clinical fiction—the existence of no-risk pregnancies. Such clinical fiction has no place in professionally responsible obstetric care

        THIS! Yes! Damn right.

    • Sue

      Whoops – these papers are in BJOG – not BLOG!

  • Hannah

    I would imagine that the reason it wasn’t included in the abstract was that it would be very unlikely for 2 deaths in each group to be statistically significant regardless of the denominator. This could also be the reason for using a composite outcome, which I would have thought would increase the likelihood of establishing statistically significant harm.

    • Young CC Prof

      Definitely, lack of statistical significance is an issue, and a composite measure is a good answer to that. The problem is, it’s a weird composite measure. Death, or 5-minute APGAR less than 7. Equally weighted.

      • Hannah

        In this instance, with 4 deaths and presumably a much larger number of Apgar<7, would that be likely to make much difference to the result?

        • Young CC Prof

          Obstetrical unit: composite of 20 out of 1225
          Home: composite of 4 out of 206.

          The sample size really is small for measuring severe adverse outcomes.

          • Hannah

            I presume that’s partially of necessity, since home VBACs are relatively uncommon.

          • Young CC Prof

            Indeed. That’s what makes the numbers so disturbing. 2 deaths out of 206 births of basically healthy term babies! You don’t get a LOT of statistical significance, but you do get a lower bound on the 95% confidence interval of about 1.2 per 1000, which is already way too high.

            Heck, even the hospital numbers are concerningly high. Other studies of VBAC outcomes show lower death rates, although the difference isn’t quite statistically significant.

      • Anne

        And the fact that one is objective (death) and the other subjective (low APGAR) makes it a nonsense- fudging of the results of APGARs if the baby is not in extremis is not too far-fetched a conspiracy theory! Cord lactate would be the more appropriate measure of neonatal morbidity.

        • Young CC Prof

          Some birth midwives in the USA do appear to be engaging in APGAR inflation, mostly because if you look at the birth record, there are way too many 10s given out. Actual perfect 10s almost never happen, because most babies are a bit blue around the edges when they first pop out.

          It’s less likely in the UK, with all of the midwives properly trained and working in a system, and two different ones present at each birth, but it’s not impossible that there could be some fudging of a point or two.

          • Daleth

            One of my twins got a 10 in a major university maternity hospital from a team of neonatologists after my c-section. The other got a 9. Oh I’m so proud 🙂

        • demodocus

          Fudging apgars wouldn’t have to be an active conspiracy. More like general human nature. If we have a reason to expect horses, then we might not notice that particular equine is actually a mule.

          • The Bofa on the Sofa

            Fudging apgars wouldn’t have to be an active conspiracy. More like general human nature.

            It’s a combination of ignorance and agenda.

            Given the rarity of actual 10s in the real world, you need to have lots and lots of experience to calibrate where a 10 actually is. All these perfect Apgars the midwives give, what do they do when they actually come across a baby who is a 10? Give it an 11? They aren’t calibrated.

            Nor do they want to be. See, the other problem is they don’t admit problems are problems. This is the group that calls everything a “variation of normal.” Fingers are blue? No big deal, they aren’t that blue, variation of normal. Don’t deduct anything.

            One thing that sticks in my head was the discussion of someone’s presentation (maybe Judith Rooks?) where she showed average Apgar scores given by hospitals and by midwives. She pointed out the midwife Apgar scores and proclaimed, “Virginia Apgar would be rolling in her grave” to see such distorted values.

          • Gene

            Agreed. Out of the hundreds of births I seen (500+), I think a mere handful (<5), received a 10 at the one minute mark. Even a vigorous screamer will more often than not have acrocyanosis (pale/blue hands and feet). It usually resolve pretty fast, though not always by the 5 min mark.

            I do remember one cute baby who was a 9/10 at both 1 and 5 minutes. He got 2 for color (great circulation, nice pink hands and feet), but only 1 for respiration because HE NEVER CRIED! He just calmly looked around, no matter what we did. Uber chill baby. He finally fussed a smidge about 10 minutes after birth, but he was 9/10 at both checks solely due to lack of crying.

            I think most homebirth midwives have no clue how to properly evaluate Apgars. Every crying newborn is assigned a ten as if to say: perfect! You gave birth! Judges award 10/10!

            I have no idea what my kids' Apgars were. I'm guessing 7-8 at 1 min (I know two were a bit stunned at birth), but their acrocyanosis didn't abate for still least an hour, so they would have never been a ten (like many babies). I honestly didn't care about it. I cared that they improved and then were healthy.

          • Roadstergal

            “what do they do when they actually come across a baby who is a 10? Give it an 11?”

            This baby goes to 11!

          • Mattie

            I actually was under the impression that an APGAR of 10 was incredibly rare because almost all babies have purple/blue fingers and toes for a while as their circulation needs to get going =/

          • The Bofa on the Sofa

            See Gene’s discussion below.

  • SO the health department in my state released a study that also says that home birth kills babies, and now the midwives are trying to do anything they can to prevent legislation. this is just an information link for anyone who wants to see another piece in a huge pile of evidence that this isn’t a good idea. https://safermidwiferyutah.wordpress.com/2015/08/27/utah-health-department-home-birth-kills-babies-that-would-otherwise-have-lived/

    • yugaya

      I remember when they announced this study earlier the health authorities were pretty clear that data was bad. The more mandatory reporting, the worse numbers we’ll see documented.

      • Amy M

        Perhaps mandatory reporting would increase the transfer rate? If the homebirth midwives don’t want to report something bad, get a suspicious birth off their hands asap—depending on their timing, and what needs to be reported, it could save lives. Some of the mandatory reported data should be intended place of birth, and if transfer took place.

  • Mattie

    So I totally see that the risk is MUCH higher with an HBAC than a hospital VBAC. But I’m a little confused, out of the 4 babies who died after/during VBAC (2 in each group) only 2 were uterine rupture, so logically that could either be one from each group, both the HBACs or both the hospital VBACs. I’d want to know the reason for the deaths of the other babies as well as what happened in the hospital that the rupture was not dealt with quickly enough to save the baby/babies (if they died in hospital). Is that important to know or am I just focussing on the ‘wrong’ thing?

    • Roadstergal

      Ja, I wondered the same thing below.

    • Young CC Prof

      If you look at the discussion of maternal outcomes, it says that of home VBAC mothers with severe morbidity, “one had a uterine rupture and a transfusion of six units of blood…” I imagine that baby died.

      It also mentions 3 uterine ruptures in the hospital group. It did not say whether those were the only ruptures, since their key maternal outcomes were blood transfusion or admission to higher level care.

      • Mattie

        Ok, so 2/3(known) uterine ruptures in hospital led to an alive mother and baby…but 1/1 uterine ruptures at home = a dead baby and significant harm to mother…that for me would be enough to not have an HBAC

        • Daleth

          A rupture in a home birth is a death sentence for the baby. The training of the midwife doesn’t matter in that scenario–there is no amount of training a midwife can have, or for that matter an OB can have, that will enable her to save a baby in an HBAC rupture, because what you need is not training but immediate access to an OR.

      • fiftyfifty1

        I can’t believe they didn’t specify how many ruptures.

        • Young CC Prof

          They may have been trying to say that there was 1 rupture at home and 3 in the hospital, but I found the wording ambiguous.

        • Sarah

          I can!

  • JellyCat

    This is very sad. I know what will happen to this study. The midwifes will take the excerpts from this study and add to their “home birth” binder that they have available in their offices to convince women that home birth is safe.
    At least, this is what they do in the midwifery office I go to for my prenatal care.

    • Roadstergal

      I wondered how my friend could be so convinced that home was better than hospital. Now I know. Midwife shows her the Results abstract, “Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06–1.24). The risk of an adverse maternal outcome was around 2–3% in both settings, with a similar risk of an adverse neonatal outcome.” Boom. Done. What woman isn’t going to take it as read that this means there’s no greater risk of death at home? Ugh, disgusting.

      • JellyCat

        This simply takes my breath away. Unless you are incapable of reading scientific studies, how can you as a healthcare provider misrepresent this vital information in such a way that your client is never able to make an informed decision.

        • Roadstergal

          Because it’s what the midwives want to believe. The abstract says those nice cozy home births that you love to attend are safe and give your clients those lovely healing kiddie pool HBACs. Why read any farther than the abstract?

          • JellyCat

            They do call it “healing” it is absolute truth. When I went to that midwifery practice for my first pregnancy, I didn’t understand much of who midwifes really are. At least some of them are. I knew that some of them graduated from the same university I did. For this reason, I was under impression that they are health care providers, deal with low risk pregnancies and are safe.
            Being a health care professional I found it a little weird that they have this inflatable birthing tubs for rent. I was always wondering what would they do in case of emergency if their patient is in the inflatable tub. Do they have mechanical lifts with them? Of course they do not, so what would they do? Well, the answer is nothing, just hope for the best.

          • Roadstergal

            Seriously. What do they do when a women ruptures in an inflatable tub? How can they even tell if a woman has ruptured in an inflatable tub at home?

          • JellyCat

            I assume nothing. They call 911 and hope they can get her out of the tub.
            But of course uterine rupture is not the only complication.
            And how about fetal monitoring? Do they do it under water?

          • Roadstergal

            _Can_ fetal monitoring be done underwater? Do HB MWs even do EFM? (Honest question, I don’t know.)

          • Ash

            there are fetal telemetry systems that can be used in a tub or shower.

          • Roadstergal

            Ah, so given your reply and Mattie’s, they _could_, but they _don’t_?

          • Mattie

            I mean all the midwives I worked with did, some women refused monitoring (even intermittent) or refused to move to allow a better reading but it was always offered. I believe the timing is every 15 mins in first stage and every 5 mins in second stage for 1 minute (but also after a contraction so could be much more frequent)

          • JellyCat

            Why would you refuse monitoring? It’s like deliberately turning the airbags off in your car or purposely driving the car without airbags.

          • guest

            It’s only like turning off the airbags if the airbags hold you in a position that’s uncomfortable and make you itchy the whole time you’re riding in a car.

            Yes, continual monitoring is safest and I suffered through it but HOLY HELL did I suffer. The straps were so incredibly itchy and I couldn’t lie on my side or get up at all. My hospital is at least trying with wireless monitoring being standard, but they can’t do that with multiples so I had to wear two of the damned itchy things.

            I’m not saying it’s a good idea to refuse monitoring, but I do understand why people want to.

          • JellyCat

            People refuse intermittent monitoring when no straps are attached. I didn’t even notice when that was done.

          • Fallow

            That’s not everyone’s experience. The monitors caused me no discomfort at all. And no one ever told me that I had to remain still during labor to keep the monitors in place, and in fact, they did stay in place. Even with my shifting and rolling. The monitors were only readjusted a few times.

            (I couldn’t get up because I was on mag, so the ability to leave the bed was irrelevant to me.)

            Related note – NCB people I have known, think it’s great to endure agony in the name of personal achievement and “protecting” their baby. But they’ll complain about the physical discomfort of monitors (which actually DO protect their baby), like it’s an intolerable insult too far. I really don’t get how that argument works in their heads.

          • Sarah

            It might perhaps be a UK thing then, being told not to move. I couldn’t be less bothered about the straps, but didn’t much enjoy having to remain still throughout hours of numerous painful, unanaesthetised contractions during two births (lack of pain relief entirely the hospital’s fault first time, not at all the second). I mean, it had to be done, and certainly in the second case it’s a good part of the reason I have a live baby. But it made the whole thing considerably more painful: I am not a believer in contractions becoming painless when you move around, mine don’t, but they were worst lying still on my back on a hard surface.

          • Mattie

            Yeh, I can understand (if not agree) with people not liking/wanting continuous monitoring, but we had women refuse intermittent monitoring (with a doppler), especially in second stage 🙁

          • Mattie

            IKR I never quite understood it either, like why have midwives there if you’re not going to let them do anything…but you can’t say that, you just offer and document.

          • Joy

            I had one in the UK, but I was on the Consultant led ward.

          • Mattie

            Most UK midwives use dopplers for EFM. Most can be used underwater, or women are asked to stand out of water while the fhr is auscultated. Midwives do not practice continuous monitoring at home (or in water) as a need for a CTG would be a deviation from normal and the woman would be transferred to hospital/high risk care.

          • Roadstergal

            I just noticed the “Tweetable abstract.”

            “Higher vaginal birth rates in planned VBAC at home versus in OU but 2–3% adverse outcomes and high transfer rate.”

            I would say the effing Tweetable abstract should be “Substantially higher risk of dead babies in planned VBAC at home vs OU, with high vaginal birth rates in OU.” If 37% is ‘high’ for transfer, 69% counts as ‘high’ for getting the baby out of your vagina, IMO.

      • Erin

        I think that definitely plays a part but I don’t just blame the “professionals” because it’s easy to interpret and believe statistics to suit yourself if you’re invested in doing so. A little bit of research would show the actual picture but I don’t think many of the women having home births after c-sections are interested in doing so because they might find flaws with their plans.
        My son was delivered by emergency c-section and I can honestly say his arrival was the worst experience of my life (primarily because I re-lived what was up to that point the worst experience of my life on top of thinking that he and/or I were going to die plus my family have more their fair share of natural childbirth nuts so I was indoctrinated early) and my gut reaction was to join vbac groups to see about options for another child if/when I feel brave enough. To say I was taken aback would be an understatement. There are so many women who bought the “natural, normal, amazing” lines which you get from the Midwives in the UK and then had experiences which for whatever reason fell short and given that’s human nature to want to blame someone… they’ve picked the hospitals and demonized them. Egging each other on to indulge what it’s being charitable to call risky behaviour in pursuit of the birth they think they deserve with apparent little regard for their baby.
        That said at the moment the only way anyone would get me on an operating table would be with a general anesthetic c-section or not so perhaps I’m no better.

        • Mattie

          Erin, by the sounds of it you’re in the UK. I encourage you to contact the hospital you delivered at and see if they offer a debriefing service, or if they have someone available to do that with you (when you feel able).

          It may help you to piece together the events in a less stressful environment/time, when you’re not in pain and/or fearing for yours and your baby’s life. Generally a doctor or midwife will talk you through your notes, the reasons for the EMCS and then explain the protocols the hospital used during the procedure…from decision to incision and aftercare.

          Sometimes an emergency can feel chaotic and rushed and ‘panicked’ when for the staff it is all very routine and mechanical (I mean routine as in planned and executed in a special order, not ‘non-urgent’)

          This process can help women to deal with and move past the trauma of their previous birth, which in turn will allow them to make informed decisions in any future care.

          I wish you all the best

          • Erin

            Unfortunately my trauma wasn’t the emergency section exactly and I had plenty of time to come to terms with the idea (Prom, posterior baby, augmented labour, failure to descend) even though no one actually came out and said it until the end. It was reliving being raped during said section and I’m not willing to risk that happening ever again and since no one can guarantee that an non-emergency section with a spinal would avoid all triggers, it wouldn’t be even up for debate as far as I’m concerned.

          • Mattie

            That’s awful I am so very very sorry, did the team know your history and were they at least as careful and compassionate as they could have been? It sounds like a CS with a general would be better if you end up needing another section (if you have another baby). Seriously wish you all the best and that you can get some support for your trauma *internet hugs*

          • Erin

            Whilst my memory is exceedingly hazy, very low blood pressure, far too much gas & air etc I’d hazard a guess that part of the problem was them trying to be compassionate. The hospital was aware of my history but I hadn’t explained my extreme triggers because I really didn’t think they would be an issue. I mean why would anyone stroke your hair or make you feel like you couldn’t breathe when you’re having a baby…
            The first thing the male Senior Registrar on introducing himself did was stroke my hair and whilst I was taken aback and upset, I didn’t feel I could say anything as I put it down to an attempt to be reassuring. Then during the operation itself, they’d had to give me more drugs than perhaps they wanted to ensure they got a high enough block because the Anesthetist hadn’t been able to site it where he wanted to so around about the moment he thought stroking my hair was a good idea, my chest decided it was paralyzed and that I couldn’t breathe. Not sure what happened after that, only lots of panic, flashbacks and negativity and then someone tried to give me a baby and I couldn’t understand why.
            We’re getting there though, to my eternal shame I got a bit too close to killing myself when he was around 30 hours old and a guest in NICU so to go from that to actually be willing to think about being pregnant again is progress.

          • Amy M

            (liked for your progress. Not your experience. I’m sorry that happened to you–both the original and the flashbacks.)

          • Roadstergal

            Oh god. So many people don’t have experience with and don’t understand triggers – and then it falls on you to say “Please avoid X, Y, Z, it will bring on a panic attack” and hope they understand. I’m so sorry. 🙁

    • fiftyfifty1

      I’m curious why you get your prenatal care from midwives who you know are lying. Is it that you have no choice?

      • JellyCat

        There is one adequate midwife in that practice. If they didn’t have her, I would never go there. I have to watch all my test results and be vigilant and this is certainly annoying. At the same time, I can always leave that practice and go to an OB. In fact, I’m contemplating doing that anyway. My next appointment coming up soon and I will have to discuss an option of getting an epidural and depending on how this will go I will make a decision.

        • fiftyfifty1

          So can you be sure of having the one adequate one when you are in labor?

          • Joy

            Not in my part of the UK. The midwives who were at the surgery don’t do births.

          • Mattie

            Do they not do home births? Our community midwives did antenatal and postnatal care and were on-call for home births during the day (for their team’s women) and on an on-call rota for the night-shift for home births

          • Joy

            Oh, maybe they do homebirths. I never asked because I wasn’t doing that and I never saw the same midwife at any appointment throughout my pregnancy so I didn’t get into any conversations with them.

          • JellyCat

            No, it cannot be guaranteed. I was lucky last time and ended up with an adequate one. The only thing that I count on is the fact that there will be an RN responsible for fetal monitoring. The same happens with OB as they are not able to stay with you in active labour anyway.

  • Anna

    This is plain awful. Maybe I am going to sound a bit on the radical side but why don’t they hold women who knowingly subjected their newborns to danger (say home VBAC, home breech, twins etc) to some legal responsibility? I mean when a newborn dies though mother’s negligence she is prosecuted. How is this any different?

    • Roadstergal

      “How is this any different?”

      Because the official government mouthpieces are saying things like “The risk of an adverse maternal outcome was around 2–3% in both settings, with a similar risk of an adverse neonatal outcome.”

    • Amazed

      Until the baby is born, it’s the woman’s body and the woman’s choice. I wouldn’t take it away from her, although I want it to be a truly informed choice. Even if I consider it morally repugnant, I don’t want her to be deprived of it.

      I feel free to criticize it, though.

      • Anna

        Medical care can not be forced upon anyone and then there’s always the chance that the woman just did not understand the situation fully, having been brainwashed by the NCB. But still, an infant dying a preventable death through their mother’s fault is one of the most heart breaking things. Certainly these women have punished themselves already more than anyone else could punish them. They will have to live with this forever.

        • Amazed

          Oh yes. Heartbreaking. And one of the hardest things for a mother to accept. They all find different ways to cope. But I can feel nothing but derision for women who lost their children to preventable deaths in homebirths and then keep convincing other women to also risk THEIR babies’ lives because homebirth rocks.

    • Sarah

      Because the woman’s right to dominion over her own body takes precedence over any rights the foetus may have whilst still in utero. And rightly so.

      • Daleth

        I’m not actually sure it’s accurate to say our right to dominion over our bodies takes precedence over ANY rights the fetus has in utero.

        Notice how there is nowhere on earth that we can legally get an abortion on demand when we’re 7 or 8 months pregnant?

        And notice how the logic of Roe v. Wade was structured? It went like so:

        – In the first trimester, the woman’s rights trump all. The state cannot constitutionally outlaw abortion or regulate it for any reason other than to ensure safety for the mother. (BTW many states are ignoring that last bit now, with absurd requirements for ultrasounds and lectures about the baby’s heartbeat, etc.) So basically, as you said, the woman’s dominion over her body trumps any and all rights the fetus may have.

        – In the third trimester, however–in other words, once the fetus is viable outside the womb–the state can outlaw abortion because it is constitutionally permissible to find that the state has an interest in protecting the life of the baby. In other words, your rights do not necessarily trump the baby’s right to live. The voters in your state are constitutionally free to pass a law banning post-viability abortions.

        The other rationale behind the constitutionality of a post-viability ban on elective abortion is that once you are that far along, there is very little difference in what you would have to go through to get an abortion vs. what you would go through to birth the child–in other words by that point you can’t just go get an outpatient D&C with little or no anesthesia; you practically have to give birth anyway, so the burden on your health that would be imposed by giving birth is basically the same as the burden imposed by an abortion… so there isn’t much in the way of your rights/your health that could be protected by allowing an abortion.

        Put another way, you have an interest in not being forced to undergo pregnancy and childbirth, but once you’ve already gone through most of pregnancy and basically have to give birth to get the kid out anyway, what rights of yours are left to protect? It’s not like you have a legal right to prevent a baby from living; the right to abortion is not a right to prevent the baby from living, it’s a right to prevent yourself from having to undergo pregnancy and childbirth.

        • Sarah

          Although I’m a lawyer I was speaking morally not legally, and have never read Roe v Wade. As I’m not an American and don’t live in the USA, much of what you write doesn’t pertain to me. Fortunately, while I can’t get abortion on demand past 24 weeks in my country, I can receive a termination right up to term if various stringent medical conditions are met. It is true that legislators where I live could pass a law banning abortions after any point, or indeed at all, but equally there are a number of ways this could be legally challenged. They also couldn’t actually stop me from doing it: you can make all the laws you want, but women have always had terminations if they’ve been desperate enough. You probably know that there are slightly more illegal abortions in the world than legal.

          As for the rights of mine that are left to protect, that would be my right to dominion over my own body. Personally I think that’s quite an important one. It didn’t suddenly evaporate when I hit the third trimester.

          • Daleth

            As for the rights of mine that are left to protect, that would be my right to dominion over my own body.

            Could you clarify what you mean by “dominion over your own body”? If you mean the right not to be pregnant one day longer than you want to be after you have already been pregnant for seven or more months, could you explain why you also have the right to kill a fetus who, if delivered, could live independently of you?

            In other words, why doesn’t “dominion over your own body” when you’re 7+ months pregnant just mean that you can be induced (or get a c-section, your choice) to deliver the baby early? Why does it (if I’m understanding you correctly) also mean you can kill the baby?

          • Sarah

            Why are you assuming my right to dominion over my own body doesn’t include having the foetus delivered early? There was nothing in my post to suggest that, and indeed it’s what I’d like to see for women carrying a healthy foetus post-viability who no longer wish to be pregnant (obviously there needs to be provision for full termination for medical reasons right up to term, we have this in the UK now and I consider the laws governing it to be appropriate, just as it’s also possible for parents to make the decision to remove breathing tubes, turn off life support etc for a seriously ill child post birth).

            In this specific discussion, however, dominion over one’s own body includes the right to attempt give birth in any of the ways Anna mentions. HBAC, breech twins and similarly ill advised variations.

          • Daleth

            I’m not talking about whether our rights over our bodies INCLUDE early delivery. What I’m asking is how/why our rights can possibly include killing a viable fetus and then delivering it (which is what a late-term abortion amounts to).

            In other words, I’m saying, why aren’t our rights limited to early delivery? Why do you feel we have the right to kill a 7+ month fetus that could live independently of us–could survive and thrive–if delivered early? What is your basis for arguing that “dominion over our bodies” means we have the right to kill that baby and then deliver it, instead of just delivering it alive?

            And just to be clear, I’m not talking about when there are medical reasons for it (severe health problems that mean the baby is going to die anyway). I’m just talking about our rights when we are 7+ months pregnant with a healthy or relatively healthy fetus.

          • Mattie

            I mean, UK law wouldn’t allow abortion in that scenario (healthy mother and baby). The limit for an abortion on non-health grounds is 24 weeks, which is viability.

            I do wish that women had the option of elective early delivery, however that would put excessive pressures on newborn intensive care services (which are limited and stretched as is). I don’t really know how I feel about abortion past 24 weeks (without medical reason) it does seem harsh, and as it’s not legal it’s sort of moot as to whether or not it should be =/

          • Sarah

            I don’t have any basis for arguing that because IT ISN’T WHAT I’M ARGUING.

          • Daleth

            Well, you did say “the woman’s right to dominion over her own body takes precedence over ANY rights the foetus may have whilst still in utero.” (I added the emphasis on “any”). If her right takes absolute precedence over absolutely any of its rights as long as it’s inside her body, then she does have the right to abort right up to the day or indeed the hour before delivery. In other words, she has the right to purposely kill it right up until the moment it’s born.

            But I doubt that you really think that. And if you don’t, then logically you must acknowledge that “the woman’s right to dominion over her own body takes precedence over any rights the foetus may have whilst still in utero” is far too sweeping a statement… in other words, is not actually true.

            And if it’s not, if there comes a point in pregnancy where the rights of the mother should be weighed against the rights of the fetus (with her right to protect her life and to avoid disability-threatening health problems always outweighing its life, but trivial problems of hers not outweighing its life), then what point is that? The Supreme Court says that point is viability. Do you have a better idea?

          • Sarah

            Frankly you’d have done better to highlight the ‘whilst in utero’ part.

            But anyway, yes I do have a much better idea than your Supreme Court, as I briefly explained in my last post. The mother always has the right to end the pregnancy. At any point. She doesn’t have the right to prevent medical treatment once the foetus is out. Prior to viability, it doesn’t matter that the life is terminated inside the womb because there is no possibility of survival anyway, so it’s ethically fine to kill it before removal because it makes no difference to the possibility of survival. Post viability, the foetus should be removed save where the life needs to be ended for medical reasons, which is morally comparable to eg turning off life support after birth. There’s no contradiction whatsoever here, because the mother’s rights to dominion over her own body are still being respected and are primary. Should she wish to do anything that could endanger or even kill the foetus, including ill advised HBAC etc, her right to do that takes precedence for as long as it is still inside her.

            This is what I think. Should you, your Supreme Court justices or anyone else disagree, I’m very comfortable with that: certainly I don’t delude myself that I have any power to enforce my views.

  • Roadstergal

    I looked at that study a little while back because of my UK HBAC friend, and I was shocked that the composite index was death + APGAR under 7. Really? _Really?_

    They also just say “Four babies were stillborn, two in each group. Two of these four stillbirths were associated with uterine rupture.” So, what were the other ones due to? They note that “Compared with women planning VBAC in an OU, fewer women planning VBAC at home had additional pre-existing risk factors and they were less likely to have ‘complicating conditions’ noted by the midwife at the start of care in labour.” So were the two deaths in the OU due to these complicating conditions, and were the HBAC deaths more straightforward and would have been saved in the hospital?

    One of the Main Findings: “Compared with women planning VBAC in an OU, women planning VBAC at home were significantly more likely to have a vaginal birth.” Yeah, and she’s also significantly more likely to have a dead baby. But who cares about that.

    They’re doing a very successful job misrepresenting the dangers of home birth to women, and it quite literally makes me sick to consider it.

    • Young CC Prof

      If you read through the paper, it also shows that the home VBAC group was significantly lower risk: More prior VBs, no obesity, better financial status, more likely to be married. The only risk factor higher in the home group was age.

      And the difference in success rate was not terribly high: 69% hospital versus 87% home. Assume all the home women had gone to the hospital and only 69% had VB. Then we’d be looking at an extra 42 c-sections, probably fewer. Losing 1-2 babies to prevent a mere 42 c-sections is a pretty awful tradeoff, IMHO, and once you start controlling for risk factors, it gets even worse.

      • Roadstergal

        Ah, yes, but 40 of those would be _unncesseareans_. They’re the worst kind. *banging head against the keyboard*

      • Ash

        42 c-sections to prevent 1 death is an awesome number to treat.

        • The Bofa on the Sofa

          1) I’m not sure where YCCP gets 42 additional c-sections. 209*(87%-69%) = 38
          2) The difference in mortality rate is closer to 2 (1.7) than 1. That means it’s more like 22 c-sections to save one baby. The statistical range is pretty big here, but that’s the middle.

          • Young CC Prof

            Sorry, yes, 38. That’s what happens when I do subtraction while a toddler is jumping on me and trying to steal the pictures out of the computer. But yeah, the numbers are small, which means the number needed to treat has a pretty broad confidence interval, but it’s still pretty darned low for, you know, preventing death.

          • The Bofa on the Sofa

            It’s possible, with rounding, that it could be 39…:)

    • fiftyfifty1

      ” I was shocked that the composite index was death + APGAR under 7. ”

      It would be like making a maternal composite that included unplanned hysterectomy and had to wear an ugly gown.

  • Pushing homebirth/natural birth to save money by denying the opportunity for truly informed consent is beyond the pale. Further, it might not even save money – as soon as the scope of outcomes is expanded past six weeks and includes things like PN-PTSD, pelvic organ prolapse, cerebral palsy, brachial plexus injuries, and a range of other difficulties (perhaps learning difficulties?) – the money saved by avoiding an epidural, or a caesarean quickly gets eaten up by the cost of care for these other issues. Hiving off pregnancy and childbirth from the rest of women’s and their children’s lives, inappropriately discounts the value of care given. (As an aside, for many women, pregnancy and childbirth is their first “intensive” experience of the health system – failures here, are likely to instill a lasting lack of confidence in the system.)

    • Sarah

      The NHS does have a very unfortunate habit of considering only the short term costs of different modes of birth. Not least because many of them fall elsewhere.

  • Young CC Prof

    The original Birthplace Study buried the deaths in an appendix, though you could dig it out if you wanted to, and pulled just that trick with composite measures.

    A composite measure isn’t a bad thing in itself, but if you’re mixing death with temporary morbidity, you’d better be weighting the deaths pretty heavily. Yes, the sample sizes are pretty small, and it’s tough to draw conclusions, but two deaths in 209 births is way too high. That’s just not going to happen if things are being done responsibly.

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    • Guest

      Do you know, how many deaths there where in the original Birthplace Study?

      • Young CC Prof

        Home: 6 stillbirths, 5 early neonatal deaths out of 16,553 births.

        Freestanding midwifery unit: 4 stillbirths, 5 early neonatal deaths out of 11,199 births.

        Alongside midwifery unit: 1 stillbirth, 3 early neonatal deaths out of 16,524 births.

        Obstetrical unit: 3 stillbirth, 5 early neonatal out of 19,551 births.

        • Roadstergal

          So, per 1000, rounding to the nearest tenth – do I have the numbers right?
          Home: 0.4 stillbirths, 0.3 ND, 0.7 total
          FWU: 0.4 stillbirths, 0.4 ND, 0.8 total
          AMU: 0.1 stillbirths, 0.2 ND, 0.3 total
          OU: 0.2 stillbirths, 0.3 ND, 0.5 total

          I’m sure there are some pretty substantial baseline imbalances, but AMU comes out looking the best, OU second best – are AMU the ones where they’re physically connected to the OU?

          I’d think the AMU would be most strict about risking patients out?

          • Young CC Prof

            FMU is a birthing center not connected to a hospital, and AMU is a birthing center physically connected to a hospital.

            This was a mostly low-risk cohort, but the OU patients are still higher-risk than the rest.

            The reason AMU has the best outcomes is that it’s lower risk patients, but with easy access to hospital resources if things go badly.

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