Out of hospital birth increases the risk of death! Who could have seen that coming?

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A new paper just published in The New England Journal shows — yet again — that homebirth in the US increases the risk of perinatal death. The paper is Planned Out-of-Hospital Birth and Birth Outcomes by Snowden et al.

I’m not surprised. I’ve been saying the same thing for nearly two decades.

Interventions are the price we pay to save babies’ lives.

Let’s start with the take home message first:

Interventions are the price we pay to save babies’ lives.

It’s an inevitable trade off. Reducing interventions increases the number of babies who die. That’s not surprising because obstetrics is fundamentally preventive care. Obstetricians recommend interventions for the express purpose of preventing, diagnosing and managing complications. A woman who chooses to give birth outside the hospital is gambling that her baby won’t need lifesaving interventions. If she guesses wrong, her baby will die. It’s just that simple.

What specifically did the authors find?

They looked at nearly 80,000 “cephalic, singleton, term, nonanomalous deliveries in Oregon in 2012 and 2013.”

They did not look exclusively at home births or at homebirth midwives.

We compared planned hospital births with planned out-of-hospital births (an aggregate group of planned home births and planned birth-center births), including the out-of-hospital-to-hospital transfers.

In other words, they included birth center births and births attended by CNMs (certified nurse midwives) at home or at a birth center as well as homebirths and birth center births attended by CPMs (a second, poorly educated, poorly trained group of lay people who don’t meet international midwifery qualifications).

That’s important because it means that the study isn’t about homebirth but about all births outside the hospital.

What did they find?

Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures.

Planned out of hospital birth has a mortality rate 2.4X higher than hospital birth. The increased risk of death at homebirth is undoubtedly much higher. When Judith Rooks, CNM MPH looked at planned homebirth with licensed CPMs in Oregon in 2012, she found a death rate 9X higher than hospital birth.

The authors tell the NYTimes that they soft pedaled the findings:

Dr. Aaron Caughey, a co-author who heads the university’s obstetrics department, said the researchers consciously adopted a nonjudgmental tone so critics would not say that the in-hospital providers were demonizing out-of-hospital births.

Even Melissa Cheyney, CPM (who spent years presiding over Oregon homebirth midwifery and doing everything in her power to deny the increased risk of death) is quoted in the NYTimes article accepting the study’s results.

In truth, the findings are alarming. Although the authors tried to correct for the fact that the out of hospital group was whiter, wealthier and had fewer risk factors than the hospital group, they acknowledge that the hospital group was almost certainly a higher risk group. That means that the real difference in death rates is higher than 2.4X.

Most importantly, the increased risk of death reflects the lack of adequate regulation of out of hospital birth. In Canada and the Netherlands, midwives have the same perinatal death rates in the hospital or at home. If we want to lower the US out of hospital death rate, we need to adopt the same strict criteria for out of hospital birth that they use. We also need to abolish the CPM credential. Our midwifery standards should be in line with those of all other industrialized countries.

The authors of the study noted that the intervention rates outside the hospital were far lower than those in the hospital. The mainstream media appears to be emphasizing this point as well. Yet many if not most of the babies who died at home would NOT have died in the hospital. The central insight is this: interventions are the price we pay to save babies’ lives.

Could we lower intervention rates? Possibly. Could we safely lower them to the rates found at out of hospital birth? No, not unless we are willing to let babies die preventable deaths.

There’s also another critical take home message. American homebirth is and has always been less safe than hospital birth. Homebirth midwives have done everything in their power to hide the truth from American women. It’s not an accident than CPMs have no official safety standards. Safety has never been a priority for them, and the consequences have been — inevitably — dead babies who didn’t have to die.

Thinking about homebirth? Think again.

  • Brian Lear

    I agree with you that CPM is a problem. But the fact that US homebirth by CPM is risky is not an argument against homebirth. It’s actually an argument to make a better homebirth system, like in the UK where there data is very good and homebirths are extremely safe. I just can’t for the life of me figure out why you don’t take that angle, and just end up dismissing all home delivery as unsafe. All I can come up with is that you are pathologically attached to your chosen profession and can’t see things any other way.
    Brian Lear, MD family practice

    • Who?

      Have a read, Brian, of yesterday’s post about homebirth being a business.

      The people who sell homebirth in the US are unqualified birth hobbyists with an income to secure. They encourage women to not have basic pre-natal testing, and won’t risk out even the most dangerous complications, including twins, breech, and multiple prior cs. They resist calling for help, fail to keep records of pregnancy or delivery, don’t carry insurance, and blame and shun loss parents,

      They are paid cash up front, no refunds.

      They could improve homebirth by getting proper qualifications, which it is open to anyone to do by studying and working with professionals in the field.

      No one objects to homebirth, provided women understand the risks they are running when they choose it. It seems many do not.

    • Amazed

      Hahaha, I somehow missed it but I knew you’d come up with the extremely safe UK homebirths. What a joke!

      Are you a personal friend of the so competent and ethical UK midwife Sheena Byrom? By your mocking tone and your dismissal of safety I gather that telling a victim (a father who lost his son to a preventable death by the hands and the very good and extremely safe UK midwives) that he’s playing the victim card by doubting the safety of homebirth is just in line with your ethical values.

      You disgust me, doctor dude.

      • Who?

        In the world Brian occupies, a few dead babies is an appropriate price to pay for the mother’s experience, and to keep the pockets of birth hobbyists lined.

        • Amazed

          Come on, Who, let’s be fair. He might not have the time to read studies and see what they carefully leave out. He might just relies on their abstracts. After all, advising women daily to breasfeed is a time-consuming activity.

          On the other hand, he might boast that his office is just as safe for people with a cardiac disease as a university hospital. He might have a mortality rate of 0,00000000% while the university hospital has higher rate, no doubt.

          • Who?

            You are a model of kindness and forebearance I will strive to emulate.

            😉

    • Charybdis

      Why are you so sure homebirth is extremely safe? You should be required to opt into a homebirth scenario if you wish, it should never be the default option.

  • Amazed

    Susan Moray, in the comments section of the NY Times piece:

    In my 20 YEARS as a homebirth midwife, attending close to 800 BIRTHS I
    transported 10 women for what might have been signs of infection, with
    only 2 of them testing as positive. It is not clear what caused the
    infection but the setting was unlikely. Women are more colonized to
    their environment than that of the hospital so infections are rare.

    I capitalized the most relevant bits. Please take note of what passes for vast experience that a homebirth midwives prides herself for.

    • Bombshellrisa

      Thank goodness she is retired recently!

    • Nick Sanders

      And how much did she get paid for working only 40 times a year? Apparently the only thing standing between me and the financial security I need is my conscience…

      • Amazed

        Ah Nick! Have a heart! I mean, all that loving support can last for 2, 3, or 8 days per each of those 40 times. Obstructed labour is no joke and midwives stay from the beginning to the end. She might have ended up working 320 days a year!

      • Roadstergal

        Midwifery and homeopathy – all profit. Damn our consciences.

    • yugaya

      Susan Moray, who was one of the highest ranking MANA CPMs and was sitting on Oregon midwifery boards for years, all of a sudden, without any explanation and contrary to the fact that fake CPM midwives NEVER retire – sold up her business and retired in November 2015.

      The only question is how much shit did Cheyney have to pull in order to cover up the disaster that was the reason for Moray’s untimely departure from midwifery.

      • Amazed

        I shudder to think about the scale of that disaster.

  • moto_librarian

    I suggested the the NY Times do a bit more investigation of Melissa Cheyney since they saw fit to quote her, noting that she refused to give the state of Oregon access to the MANA data back in 2010. I was going to supply the link when I was called a liar, but lo and behold, the minutes for that meeting of the Board of Direct Entry Midwifery are no longer available. They only have minutes going back to 2012 on their webpage now: http://www.oregon.gov/OHLA/DEM/Pages/meetings.aspx.

    I find that quite interesting.

    • yugaya

      Cheyney had Oregon as her own private playground of preventable deaths for years and years. Things got so bad that Oregon ended up first mandating reporting all OOH outcomes, then closing the reporting loopholes that kept OOH deaths hidden in hospital stats after transfer, and becoming the first state in USA to mandate risking out of homebirth for Medicaid patients this year.

      It is quite telling to read through those Oregon board meeting reports. Cheyney kept gaslighting and claiming throughout 2012 and 2013 even after Rooks report that MANA had better quality data, and that no one should be jumping to any conclusions or regulating killer midwives of hers based on vital statistics data ( I know, the irony).

      Eventually no one was buying any of that anymore, so in this meeting when the Oregon MANAstats were questioned she ended up telling the Board “do your own research” and flounced out of the conversation:

      “”Melissa Cheyney joined the meeting by telephone at approximately 10:20am. Cheyney reported that on March 21 she is scheduled to present MANAstats (Midwives Alliance of North America) data to the Oregon Midwifery Council. Data to be presented will include national statistics and statistics specific to
      Oregon. Cheyney described quality assurance processes conducted by MANA.”

      When pressed and shown evidence that the MANA data is for Oregon of rather rubbish quality and that no one is interested in for the topic irrelevant MANA national stats:

      “MANAstats reporting requirements were discussed further.
      It was noted that the national data gathered by MANA is more reliable than the data obtained through submission of MANAstats annual reports by individual licensed direct entry midwives upon renewal. Cheyney explained that the Board can apply to obtain national statistics from MANA.Melissa Cheyney exited the meeting at approximately 11:15am. ”
      http://www.oregon.gov/OHLA/DEM/docs/DEM_minutes/DEM_Board_Minutes_2-20-2014.pdf

  • Ash

    One of the top rated comments from NYTimes about planned out of hospital birth–
    “Hospitals need to start granting privileges to home birth midwives,
    enabling them to transfer patients in for pitocin augmentation,
    physician consultation, c-sections, pain relief, and resuscitations.”

    Right, because hospitals are notorious for not resuscitating patients who come screeching into the hospital parking lot at the brink of death. And barely trained people who call themselves “midwives” should be allowed to admit patients. The average American don’t know that the majority of OOH midwives have appallingly low education standards and training. If you told a registered nurse, doctor, or midlevel provider about their training standards (I use the term “standards” lightly), they would be appalled.

    Next, a comment saying that the rate of C-sections in the US is too high compared to Europe. If a hospital, or even a region in the US, lowered its overall C-section rate by 10%, how much of a tradeoff in neonatal mortality and neonatal brain damage would be acceptable? It is rare for internet commenters to obliquely acknowledge this tradeoff.

    • Gatita

      That second comment is ignorant. The US CS rate is lower than Italy and about the same as Germany.

      • Ash

        Y’know, “Europe”…which is over 40 countries!

        • demodocus

          And Africa is apparently a small, homogenous place. Geography is woefully neglected in some of our schools. Doesn’t help when you have some social studies teachers who don’t see the point of teaching it. Sorry. Serious pet peeve from my student teaching days.

    • Bombshellrisa

      When it’s suggested that hospitals grant privileges to CPMs I want to laugh. If a midwife wants privileges, they need to go about the way other healthcare professionals do: be educated and trained.

      • namaste863

        Well, if Ina May Gaskin is anything to go by, there’s very little professionalism involved.

    • Sue

      So hospitals should grant privileges to anyone who calls themselves a health care provider, now? No credentialling? They have no idea.

      • Ash

        I’ve found a new profession. “Hi, I’m a Certified Professional Injector. As you know, there are many women appropriate for cosmetic injectables but going to a doctor typically involves a lot more interventions and costs. My experience is an apprenticeship with another woman who learned at home. Injections at home with an experienced injector is very safe. I injected a woman’s undereye area with homeopathic organic fillter a few hours ago, and now she’s saying she can’t see out of her left eye. This is why CPIs need admitting privileges! I should have privileges to sign orders, get physician consultation and administer medications. Speaking of medications, could you tell me exactly what medications I should use? Sorry, I reviewed a book about medication once and took a quiz where I had to list 1 medication of each category. However, I can rub some black and blue cohosh on my client.”

      • attitude devant

        Actually, it’s a fine idea. The hospitals will require malpractice insurance, and the insurers will require all SORTS of credentials and limits in the scope of practice…..and the fake midwives won’t/can’t comply.

  • lawyer jane

    I love the comment from the woman who got properly sutured in the hospital at her second birth after her midwife didn’t suture her tear at her first homebirth: “they stitched me right up and I healed so quickly and I felt great,” Ms. Dietrich said. “I was shocked: This is what actual care can do.” Yes, amazing how actually *needing* care makes you value actual, expert medical care! It seems like a lot of die-hard homebirthers have never actually needed expert medical care … or are in deep denial about it (like the other women in her story who was pissed that they sent her baby to the NICU after 40 hrs of ruptured membranes and a maternal fever … and presumably an unknown or positive GBS status)

    • moto_librarian

      And wasn’t the woman who was bitching about her baby going to the NICU a L&D nurse? Cognitive dissonance.

    • Amazed

      The woman with sutures still sings the praises of homebirth as a great choice for those who want it. She made clear, in the comments section, that she only went to the hospital because her insurance wouldn’t cover homebirth. She had a midwife there.

      I might be mean but I’m starting to think that refusing to save privileged assholes like this from tears for a second time might be a great option. Asshole would have been thrilled to push her baby at home, secure in the knowledge that she could trot over to the hospital again to be rescued from her own judgment. So she could pull the stint a third time, of course!

  • lawyer jane

    Oh wow, so are you saying that this study conflates birth centers with home births? Also, can somebody explain how this properly represents the risks if the control for twins, breech, and other risk factors … isn’t part of the problem that home birth midwives are accepting high-risk clients?

  • Megan

    Love that man.

    • Megan

      Oops that was supposed to be in reply to Gatita’s Amos Grunebaum comment.

  • Gatita

    Amos Grunebaum fans: he’s commenting on the NYT article on the study: http://mobile.nytimes.com/2015/12/31/health/as-home-births-grow-in-us-a-new-study-examines-the-risks.html. He points out that 2 extra dead babies per 1,000 is not a slight increase in deaths.

    • yugaya

      Dr Grunebaum should do update CDC data studies that translate these “slight increases” into hard numbers of how many babies die excess, completely preventable deaths due to homebirth every year. I poked arounf Wonder database for the years following the ones he already examined and it looks like things have gotten even worse. 🙁

      • Amazed

        Dr G. is still my hero! No sugarcoating and ego tending from this one! No bleeding heart involved, of course, but a cool head. I love him.

      • Megan

        I really wish he would do that. Most people don’t really understand numbers in abstract concepts like relative risk. Unfortunately, somehow I doubt that would make national news, though it should.

  • MaineJen

    I heard this story on NPR last night and…my jaw dropped. There was just…a notable lack of ALARM. I think they soft-pedaled things too much. “Slightly more dangerous for the baby, but the absolute numbers are still very small, and you won’t have to have augmented labor or a c section!” Terrible reporting by all outlets.

    • OttawaAlison

      It’s all fun and games until somebody loses a baby. That’s part of the problem, of course losing a baby sounds like a terrible thing, but the reality and the grieving are far worse than anyone can really know unless they themselves or have someone close who has seen the actual fallout of a dead baby. A slight increased risk doesn’t really tell the story when you can’t really make the leap that a baby’s life is on the line here, which most of us can’t, because losing a baby happens to someone else.

      • Christy

        Excellent point!

    • Megan

      Yes, and it was portrayed as hospital birth vs HOME birth, not hospital birth vs out of hospital birth (home and birth center), which is really disingenuous. I really got the impression that the journalist who did the NPR story not only simply read the abstract and nothing else, but also doesn’t understand absolute vs relative risk. They also completely failed to mention increased risk of PPH out of hospital, but of course lauded the “less intervention” BS. Who cares if I avoid a CS or forceps delivery but bleed to death and/or have a dead baby? Where are people’s priorities?? And don’t get me started on the comments on the article on NPR’s site…

      The only bright side is that there have got to be a good proportion of sane people out there who realize how ridiculous it sounds when they say, “maybe for some moms the risk of intervention matters more than the risk of a dead baby.” My husband’s jaw dropped when he heard the story and his words were, “Why on Earth does that matter? The point is to have a live baby!”

      • Christy

        I started to read the comments. I should really know better.

      • Sarah

        Although it is actually true that for some mothers, avoiding intervention is more important. I mean, not many, but clearly more than zero.

        • Megan

          If avoiding all intervention is more important than actually having a baby then why get pregnant at all? I don’t understand.

          • Amazed

            Well, I guess they can heed the examples of the four mothers who gave birth in a town hospital around here last night. They all gave their babies up. The mothers who are after the experience could follow suit – have the experience and then walk away without that meddling baby in tow.

            Feel free to think me a bitch.

        • Angharad

          I try not to judge other parents, but I feel like that crosses a line. I do jusge anyone who would double the risk of their child dying in order to have a better personal experience.

  • Gene

    They mentioned this on the ABC news show this morning. But no details. Just “twice as dangerous for the baby”.

    • Sue

      Not to mention that the “twice as dangerous” means twice as many DEATHS. Complications, injuries, morbidity – short or long-term – not even reported!

  • PrimaryCareDoc

    The saddest thing about this is that Amy, you’ve been sounding the alarm for YEARS. YEARS. How many babies could have been saved if people had woken up to this horror a bit earlier?

  • Megan

    This makes me even more angry with how NPR spun this story. The problem is that most people will not look at the article at all but will accept at face value what a science journalist says. Too bad they don’t seem to read beyond the abstract either.

    Can’t wait to actually read the whole study for myself when I’m back at work and have institutional access again.

    • the wingless one

      I was also shocked and disturbed at how NPR framed the findings. Even the title of their article suggested the increase in death rate for the baby was really no big deal. Wtf is wrong with people.

      • OttawaAlison

        I think there is always an assumption we have of a healthy baby. People don’t realize how much stuff can go wrong with pregnancy and birth.

  • JJ

    I am so happy to be holding my newest 2.5 month baby tonight and that I chose hospital birth for her after 3 homebirths. I was overdue and I wanted to get induced because I have had big babies before. I am so glad I did. At 40.5 weeks she was 9lb 6oz and her collar bone broke being born even though everything went smoothly/quickly. How would that have gone with HB midwives? How long could I have gone overdue and how big could that baby have grown? So thankful for the intervention (induction) that could have saved her life. And the epidural was pretty awesome too.

    • Erin

      So glad you had a positive outcome! Good call. Congratulations on your little one!

      My first pregnancy ended in a stilbirth (this was at a hospital, just to clarify. I had an acute onset of symptoms in the middle of the night which ultimately resulted in a placental abruption that woke me up before I even realized anything else was amiss). So, I was high-risk from the start with my current pregnancy, taking any desire to birth anywhere else out of my hands. As my particular trifecta of complications was rare and very unlikely to happen again, I’m sure there would be a CPM somewhere who would assure me I could safely deliver at home…THAT is what scares me about the US homebirth industry. Too many quacks out there that parade around like medically trained professionals. I believe it really needs to be better regulated like other countries so women KNOW they, and their babied, are safe , instead of just being lied to about it.

    • Megan

      Congrats to you and I’m so glad you and baby made it through ok!

    • demodocus

      Collar bone all better?

      • JJ

        Yes! The pediatrician caught it at her 2 day check up but she seems to have recovered well.