The increased risk of death at out of hospital birth isn’t small after all

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The new out of hospital birth study, Planned Out-of-Hospital Birth and Birth Outcomes, by Snowden et al. is getting a lot of media attention.

As I explained in yesterday’s post the authors deliberately 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.

That strategy seemed to have worked to mute the criticism of homebirth supporters, but the fact is that the increased risk of death at out of hospital birth isn’t small all. To understand why, it helps to compare the death rates at out of hospital birth to the death rates from SIDS.

The absolute increased death rate from out of hospital birth far exceeds the absolute increased death rate of placing a baby to sleep on her stomach.

SIDS haunts the nightmares of new parents and prospective parents. It is so frightening because apparently healthy infants die suddenly for no discernible reason. The first real breakthrough in preventing infant deaths from SIDS came with the “back to sleep” campaign when researchers noted that babies were more likely to die of SIDS when sleeping in their stomachs than on their backs. Since the beginning of the campaign, death rates from SIDS have dropped from 1.2/1000 in 1992 to 0.5/1000 in 2010. The campaign is considered a great success and it is the rare parent who ignores the advice.

Who would now say that the increased risk of death from infants sleeping on their stomachs is acceptable because the absolute risk of death is small? No one, right?

So how can it be that the increased risk of death at out of hospital birth from 1.06/1000 to 2.58/1000 is acceptable because the absolute risk of death is small?

Here’s a bar chart that sets out the absolute rates of death. You can see that the absolute increased death rate from out of hospital birth far exceeds the absolute increased death rate of placing a baby to sleep on her stomach.

death rate OOH birth

Out of hospital births ought to haunt the nightmares of prospective parents. It should be frightening when apparently healthy infants die for entirely preventable reasons especially when the increased risk of death is far larger than the increased risk of death from SIDS when ignoring the back to sleep warning.

Drs. Snowden, Caughey and their colleagues are to be congratulated for publishing a paper that is so clear, meticulous and measured that even the homebirth community cannot argue with that finding that out of hospital birth more than doubles the risk of perinatal death. As Dr. Caughey noted, the authors chose a non-judgmental tone so that homebirth advocates would not be able to accuse them demonizing out of hospital birth.

But the increased risk of death at out of hospital birth isn’t small after all. The mainstream media and American women should take note.

 

You can find the SIDS statistics here.

  • Sara Barnson

    SIDS is definitely the stuff of nightmares, but I’ve known at least one mother who didn’t care that having her baby sleep prone with pillows tucked around her dramatically increased the risk of SIDS. In her mind, she was breastfeeding and cosleeping (same room, not usually bedsharing) so her little girl was taken care of. And the child could only sleep on her stomach, because that’s how she’d always slept. People are really good at not caring about increased risks when it suits them.

  • Hannah

    I thought you might appreciate this article by Catherine Bennett:

    http://www.theguardian.com/commentisfree/2016/jan/03/nct-male-ceo-wrong-national-childbirth-trust-appointment

    What she doesn’t seem to realise is that this isn’t at all unprecedented:

    https://en.wikipedia.org/wiki/Grantly_Dick-Read#Career_and_work

  • yugaya

    We know the full extent of how deadly OOH birth in Oregon is from Rooks report for 2012. Here is the raw data for 2013:

    -term fetal deaths according to planned place of birth and attendant: https://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/Volume2/Documents/2013/table719.pdf

    – term early neonatal deaths according to planned place of birth and attendant: https://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/Volume2/Documents/2013/table720.pdf

    number of births by attendant, gestational age and planned place of birth: https://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/annualreports/Volume1/Documents/2013/Table0238.pdf

    There were 40 145 planned hospital births and 1856 planned OOH births in Oregon in 2013. Rates for homebirth death, especially with Cheyney’s clown CPM midwives were still hideous. And let’s not forget that overall planned OOH cohort is lower than average risk.

    Data for 2014 is also available: https://public.health.oregon.gov/BIRTHDEATHCERTIFICATES/VITALSTATISTICS/Pages/index.aspx

    • yugaya

      There were 1119 planned OOH births with DEMs in Oregon in 2013. There were 4 term intrapartum fetal deaths + 3 early neonatal deaths.
      Rooks report, which concluded that DEMs were unacceptably deadly in 2012 showed 5.6/1000 mortality rate ( 1235 planned births with DEMs and 3+4 deaths).

      2013 was worse, there was same total of deaths for less births attended by DEMs and their mortality rate went up to 6.25/1000 for that year.

      No wonder Cheyney likes this whitewash of a study that excluded everything and anything in order to falsely show the mortality in Oregon OOH births for these two years to be “only” 2.58/1000.

  • Amazed

    OT again for the doctors here: it just occurred to me that that my brother might be doing something potentially dangerous for my niece. When the kid arranges herself in certain positions that give SIL much pain and cannot be convinced to move over, he starts pushing her and rearranging her until her mother can breathe. Cold he potentially place her somewhere where she really shouldn’t be? On the cord or something?

  • Amy Tuteur, MD

    A doula math “genius” weighs in on the study:

    http://heartofbirth.net/the-dec-2015-home-birth-study-understanding-risk/

    • yugaya

      Jeeeeeeezus what an absolute math idiot she is. Only someone completely science stupid would take the results of a study looking into the difference between OOH and hospital perinatal mortality rates expressed in /1000 and conclude that “No matter where you give birth, there is a less than 1% chance your baby will die.”

    • PrimaryCareDoc

      Wow. That’s like Abby Reinhardt level math.

    • BeatriceC

      My brain hurts now.

  • SporkParade

    “Who would now say that the increased risk of death from infants sleeping on their stomachs is acceptable because the absolute risk of death is small? No one, right?”
    Dr. Amy clearly doesn’t move in the right circles because I’ve seen many women openly state that they let their babies sleep on their stomachs unsupervised, and no one says a word against them. But if you ask for advice on how to sleep train your baby, you get a lecture on how you are a heartless monster, followed by an explanation of how that isn’t judging, it’s just stating an opinion.

    • BeatriceC

      Speaking of putting babies to sleep on their backs, I just read an article recently (maybe here? I forget where) where the parents of a baby who died of SIDS is being charged with manslaughter because the baby was put to sleep on her stomach. Maybe we should start charging the parents and attendants of home birth deaths and injuries with similar crimes.

      • Medwife

        i disagree. If the parents fail to get help for their child once it’s born, sure. An attendant misrepresenting herself or practicing outside of the law, yes. But a woman can give birth where she wants. It’s her body.

        • BeatriceC

          I’m on the fence about that. Legally, you’re correct, but at some point the woman has made a choice to bring another human into the world. At what point does that person’s health begin to matter? I’m not talking about terminating an unwanted pregnancy, or even a late term pregnancy that’s incompatible with life. I’m talking about the situation where the baby is very much wanted and already thought of as his own person. After all, in many states a person can be charged with a second count of homicide for killing a pregnant woman, so there is some precedent for considering the baby his own person when the parents are intending for him to be born. There’s no good answer, hence the legal line being drawn where it is.

  • The Computer Ate My Nym

    That was interesting. I’ve only skimmed the article so far, but the first thing that struck me was that the perinatal death rate is higher for home birth, but the infant mortality rate is not. This suggests that the home birth babies are probably healthier to start with since they “catch up” by the first year of life, despite their higher early mortality. Also, Apgar scores are lower for the home birth babies, but neonatal ICU admissions are higher for IN hospital births. Almost as though having the NICU right there saves babies who would have died without ever entering the ICU in the home birth setting. Finally, comparing out of hospital births, birth center mortality and morbidity appears to be higher than home birth morbidity and mortality. Possibly due to more transfers from home birth?

    • The Computer Ate My Nym

      Sorry, another thought re the notorious “c-section risk” thing: Women who planned OOH had lower c-section rates but higher perinatal mortality and more blood transfusions. I love my c-section scar.

      • Megan

        Plus, the in hospital group including many more women with chronic medical issues, previous CS and pregnancy complications. Many of those CS were probably planned.

      • Sarah

        I like mine too. I’ve showed it to loads of people.

  • StephanieA

    OT: I have an acquaintance who just lost her baby at 39 weeks. There was a true knot in the cord. She went in for a scheduled section on Wednesday and the baby was gone. I was told he looked perfect, so he had probably died very shortly before she came in. I’m 35 weeks and don’t normally worry excessively, but this is bothering me. How do I not worry about something like that, even though I don’t have control over things like true knots? So, so, sad.

    • Allie P

      Oh, that’s so tragic. I’m sorry. I am also of a neurotic state of mind and this was my fear, too. Just keep doing your kick counts and if you notice decreased movement, call the doctor. That’s really all you can do.

    • Megan

      It is really scary to hear stories like that. I’m 27 weeks and purposefully try to push things like that out of my brain. It’s really hard when you actually know the bad things that can happen. I’m afraid I can’t really reassure you except to say I’m right there with you and at least cords accidents are not common. Hope you have an uneventful last few weeks and a boring delivery!

    • Medwife

      I know it’s really hard. My baby is three months old. I worked through 36 weeks of my pregnancy, and in that time I saw pregnancy loss, preterm birth, emergency c-sections, hemorrhages, congenital defects… I found doing kick counts to be very comforting. That and holding onto the rarity of most of the scary things.

      • Gatita

        This is completely tangential but was I the only person who had a really hard time doing kick counts? I was always stressed out that I was missing kicks or misinterpreting a feeling as a kick.

        • Montserrat Blanco

          I think it depends on the kick intensity. I was routinely woken up during the night by my son’s kicks so counting was not exactly a problem. But there are women out there that barely notice them, each baby is different.

          • BeatriceC

            My middle son has been a ball of fire pretty much since conception. During one appointment he kicked so hard he knocked the dopler out of the nurse’s hand. Another time he kicked my computer keyboard off my belly. This is the kid that’s now the figure skating, ballet dancing football player.

          • Bugsy

            Completely agree, and to add, the placenta location also can affect it. I felt #1 as early as 12 weeks (but figured it was way too early to feel movement). Had an anterior placenta with #2, and barely felt any movement until 21-22 weeks. It made for a long second trimester!

        • demodocus

          I had a hard time too. Dunno if #1’s placenta was in the front like #2 (who I can’t feel yet at 17 weeks) or if I’m just not very sensitive.

        • Charybdis

          I had a hard time too, although I don’t really remember having to do them.

        • Medwife

          It’s a pretty common thing that I personally didn’t experience. I’ve definitely had patients who needed some exterior feedback from me or from an ultrasound that what they were feeling was movement.

        • guest

          My midwives didn’t ask me to do kick counts, and I didn’t try. I certainly maintained awareness of movement, but I had twins and I could never tell the difference between the two of them, even when the ultrasounds told me where they were. I think I also had poor placenta placement for feeling kicks, because what I felt never really matched the descriptions of others I read about.

        • swbarnes2

          I as more stressed out about finding the right interval to count. There’s no reason for the fetus to be active just when the mother is at liberty to really count things, or to be active at the same time every say. And if you can’t do it consistently, because it is by nature inconsistent (at least at the 1 counting interval a day frequency) , it’s hard to see how helpful it is. I was kind of stressing out about doing them right in the last month, happily something like a well-placed kick made kickcounts and NST and all that unnecessary ahead of schedule (but not too early)

      • StephanieA

        My little guy kicks like crazy, just like his brother. The kicks are painful at times so I have no problems feeling them, I just find myself worrying more now when he’s not active, which is usually when I’m up doing things.

        • Amy M

          At one, around 25wks, I wasn’t feeling as much movement, so I hied to the L&D. They found the fetuses moving like crazy, but they were kicking each other instead of me, so I couldn’t feel it.

          • demodocus

            Sibling love and affections starts early. 😉

    • demodocus

      Oh, the poor things.Your anxiety is totally understandable, too. Mom lost her first at 8 months; she attributed it to being punched in the stomach by a robber at work. Her other 5 who got past 4 months are now adults.

    • Bugsy

      Hugs, Stephanie. I was petrified of losing my now 8-week-old in a similar fashion; he didn’t have a knot but did have a nuchal cord. I spoke with my OB and the L&D ward about my concerns, which helped. From what they told me, cord issues such as a nuchal cord are fairly common – affecting up to 1 out of every 3 births – and generally not problematic.

      That being said, I still asked them to check his cord at every ultrasound and provide fetal monitoring every chance I could. Can you do similar? The irony of it for my situation? Kiddo was born without a nuchal cord despite having had one consistently from 18 weeks up to and including my final 39-week ultrasound.

      (I could have the numbers wrong on how common these issues are…this is just what I remember from our casual conversations.)

      I wish you – and your friend – all the best.

      • StephanieA

        I only had a first trimester dating ultrasound and the anatomy scan, so I don’t really have the option of having more ultrasounds since I’m low risk.

        • Bugsy

          Another thing that helped me was using my fetal doppler at home between appointments, particularly during kiddo’s quiet points. Best wishes.

          • Megan

            I love my Doppler. This is one of the ways I coped when I didn’t feel ovement for a while too. Only problem is, you can technically still miss problems that way, so I always still tell patients to go get checked out if they have not felt movement. I sometimes worry that not everyone can accurately find the baby’s heart tones, but sometimes hear their own/the placenta and assume all is well.

          • Susan

            I was a labor nurse and did not use a Doppler when I felt decreased fetal movement. I would not have found it reassuring knowing only an NST would tell me the baby was good to stay a fetus for now. Curious if you really used it that way? You said technically miss, but I think it’s more than technical, and I think a Doppler instead of an NST could reassure someone with a non reactive baby who might need to be delivered to wait until there was no heartbeat. I am not convinced I couldn’t miss a non reactive tracing using only a Doppler.
            I am curious what you mean? I don’t mean this snarky I am curious.

          • Megan

            I used it in coordination with kick counts. If I had gotten good fetal heart tones but still not felt movement, I would’ve gone to L&D. I would never recommend it to someone who didn’t know what they were doing and didn’t have a good Doppler. I would always suggest going to L&D for an NST to anyone else. In my case, I was usually just busy and would realize I hadn’t noticed movement, would check heart tones and then do a kick count. I always got movement once I slowed down enough to notice. If I hadn’t, I would have been at L&D.

          • Medwife

            I did that a bunch before I started feeling movement at about 18 weeks. That’s the most anxious time for me, once I can feel movement it’s so reassuring. I discourage patients from using the Doppler on themselves that early because unless you know where to look, you’re probably not going to find it, in which case panic ensues. Just come in for a quick heartbeat check.

          • Megan

            Yes, I used it most in the beginning with my first pregnancy too because I was an anxious mess. I’m pretty good at FHT’s and was able to get it at 8.5 weeks though it took me a half hour. It really is harder to do it on yourself. Once I started feeling movement I used it much less, though I did still use it. This pregnancy I’m much less anxious and use it much less.

          • Susan

            Thanks that makes sense. Though I think that the kick counts alone are more important there is something nice about listening. I just worry about people not realizing that the heart tones by themselves shouldn’t change what you do.. not an improvement over kick counts.

  • Addie

    You all realize this bitch hasn’t been licensed since 2003, right?! She’s a huge joke on the web, and anyone who agrees with any of her bullshit can crawl in a hole with her and never come out. 🙂

    • Amazed

      Come on, asshole. School us.

      And choose a better nickname. I have a person whom I love dearly called Addie. I don’t want the name besmirched all over the internet by thoughtless and heartless babykillers wannabe.

      Come on, cunt. Spout what passes for knowledge in the vast empty space your ilk calls your brains.

    • Charybdis

      She does not actively practice medicine, but she is plenty involved and up to date on medical issues. How about you?

    • Gene

      Oh honey… Are you really going to bring up the license thing? Does retired mean nothing yo you? Want to go up against my current one?

    • Allie P

      She doesn’t seem to be in a hole. She has a book coming out from a major NY publisher in a few months. But sure, keep up with the name-calling. Much easier than providing facts and arguments.

    • niteseer

      I am a retired nurse. I kept my license up to date for years, until I admitted that it was a waste of money to pay for the license and for my malpractice insurance when I was not practicing. What is your point, hmmm?

      • BeatriceC

        Similarly, I let my teaching license expire when I moved out of state and got a job in a different industry. By Addie’s logic, I shouldn’t volunteer to tutor math to at-risk, inner city kids because apparently no longer having a license removes all that math education and teaching experience I had.

    • mostlyclueless

      Weird, I haven’t been licensed since ever (not an MD, different kind of doctor) and I can still tell that 2.58 deaths per 1,000 is more than 1.06 deaths per 1,000.

      Am I some kind of savant? Should the USMLE award me some kind of honorary license? Do you want my autograph?

    • Sue

      I doubt there are any practising OBs who have the time to keep up with the literature on outcomes in the way Dr Amy is able to do.

    • Sarah

      You can crawl into my hole.

    • The Computer Ate My Nym

      And yet you felt compelled to come to her site and insult her. With ad homs. Almost as though you recognized that she was right and getting attention for being right and those facts made you angry.

    • yugaya

      “This bitch” still has her full medical education and experience as an OB regardless of when she stopped practicing. I believe it was last year that she was invited to speak at ACOG conference as expert on homebirth. Only ignorant idiots like yourself will fail to acknowledge that dr Tuteur’s professional credentials and knowledge are now as good as they were in 2003.

    • The Computer Ate My Nym

      Anyone else feel like we’ve not just had a parachuter, but a parachuter whose parachute failed to deploy here? This one’s contentless even for an anti-vaxxer homebirther.

    • Tiffany Aching

      Wow. I used to think that the well documented posts of Dr Tuteur were very informative and that she was good at vulgarizing research while providing links to the original articles, but now that you called here “a bitch” and remarked that “she’s is a huge joke on the web”, I’m totally convinced she is wrong and you are right. Thank you for your helpful, insightful, and well documented post.

    • Green Fish

      “Oh, look another study came out showing that OOH births are killing babies!”
      “Yeah, I saw that as well. Let’s go and call Dr. Tuteur names!”

      It’s good to see you have your priorities right.

    • araikwao

      I’m sure, in certain corners of the web her writing threatens to cause some serious cognitive dissonance, and that humour is used as a defence mechanism by those people. It doesn’t reduce the credibility of the author, though, and neither does the fact that she’s retired. And using hateful terms like that doesn’t help yours.

      • The Bofa on the Sofa

        The goofy thing, to me, is that most of what Dr Amy writes is actually the mainstream position of the ACOG. Addie made the exact same comment in the Vitamin K thread. Dr Amy’s position on Vitamin K, even moreso than her adamant opposition of homebirth,*** is completely in line with the ACOG and the AAP.

        So Dr Amy doesn’t have a license, what’s their excuse?

        ***While the ACOG and AAP do not support homebirth, they take a political approach of being gentle about it. In contrast, there is no gentleness or ambiguity to their recommendation for the Vitamin K shot

    • Cat10

      Because ad hominem attacks help win arguments, no one ever said.

    • demodocus

      Also, Pres. Obama is half alien, half Luo muslim socialist nazi who was born in Nairobi. Not sure if he himself is part of the illuminati or if the masons are controlling him, but he’s going to take all our guns and sterilize us with contrails. The internet told me so.

      • The Computer Ate My Nym

        It’s times like this that I wish that Disqus still allowed people without accounts to “like” posts.

  • Sue

    Does anyone know of research looking at neonatal or maternal MORBIDITY in HB? Or are the records so poor that it can;t be done, except prospectively? What about the data they used for the UK Birthplace Study?

  • araikwao

    Excellent comparison

  • AA

    I’m looking forward to Honest Midwife updating her FB and site with commentary about this article.

  • Amy Tuteur, MD

    Wonder what Neel Shah has to say about his recommendation for more homebirths in the US in light of this data.

    • attitude devant

      Neel is misled by his inexperience: the midwives he knows are top-level CNMs practicing within their scope. He has NO idea what is happening IRL

      • Amazed

        I suggest that he gets some before gushing over baby murders.

      • AA

        It looks like Shah probably practices exclusively works with CNMs at Beth Deaconess, so that would be CNMs with Harvard Vanguard Medical Associates.

        If Shah read through the Oregon Disciplinary Actions for DEMs, what would he have to say about that?

        • yugaya

          41+1, in active labour for two days with signs of infection, one chiropractor adjustment and NINE failed vacuum attempts by a ND later and the woman is still not adequately informed of the risks of continuing with OOH birth. Baby was born without any signs of life. Even after that, and significant blood loss “Client is told by Respondent ( midwife) that transport is not necessary”. She finally makes it to the hospital two hours later with a retained placenta, severe infection and empty arms.
          http://www.oregon.gov/OHLA/DEM/docs/NOIs_FinalOrders_Posted_in_2015/ROSE_ADELE_NOTICE_10_5969.pdf

          • yugaya

            Oregon HBAC = bingo of high risks ignored: 42+4 weeks of gestation, history of macrosomia, no GBS testing, membranes ruptured for over 30 hours at delivery. No BPP and AFI, client was never informed properly of the need for these monitoring procedures at all. Signs of fetal distress ignored throughout labour, loss of fetal heart tones noted but no one calls 911 or discusses transport. Baby is born dead two hours later. This woman was not a good candidate for a VBAC at all, and she was extremely high risk once the labour began. And the authors of this study are still stuck talking about VBAC bans.

            http://www.oregon.gov/OHLA/DEM/docs/NOIs_FinalOrders_Posted_in_2015/GALLARDO_JENNIFER_10_5963_FINAL_ORDER.pdf

          • yugaya

            You don’t want to give birth in a hospital because you don’t want to be “on the clock”? This is what homebirth midwives in Oregon have to offer – a completely natural labour where you will be inhumanely encouraged into pushing for TWO DAYS on and off, and delivering a severely compromised infant after transfer and the baby “requiring months of medical treatment and additional surgery”:
            http://www.oregon.gov/OHLA/DEM/docs/NOIs_FinalOrders_Posted_in_2015/SHIBLEY_DANA_FINAL_ORDER_10_6219.pdf

          • AA

            Where is the disciplinary order for the ND? I know it wouldn’t the midwifery board, but was this brought to Board of Naturopathic Medicine (I hate typing that) in Oregon?

          • Medwife

            Even if she’d done 3 pulls instead of NINE!!!!?! is it legal for anyone but an OB or obstetrically credentialed FP to use a vacuum? I know it’s Oregon we’re talking about, but come on!

    • Sue

      I’ve asked him on twitter. Let’s see if he replies.

      • Karen in SC

        Tweet him this picture of the list of healthy term babies that were lost at homebirth.

        • Deborah

          So many. So sad. So unnecessary. So sorry for your loss xx

    • Sarah

      Probably something inaccurate about the UK system. That’s usually how he rolls, no?

  • attitude devant

    I’ve been surfing around various groups where the NEJM article is being discussed and I’m so amused. I’ve been following this issue (and this blog) for many years and we’ve come so very far. It was only a few years ago that we had homebirth advocates insisting that their way was safer. Then we had Missy Cheyney claiming she had the data to SHOW it was safe but that it wasn’t hers to release. Now the studies are overwhelming: homebirth kills, and the NCB nutterati are reduced to saying “Well, the death rate is over two times higher….that’s not that much…is it?”

    • Amy Tuteur, MD

      I suspect that part of the reason that Caughey et al. decided to soft pedal the results is so that Cheyney and her cohorts couldn’t argue with the data and they could try to minimize it. Now the authors can break down the data by place and provider and that will show that the death rate for CPMs at homebirth is 5-10 times higher.

    • araikwao

      Oh my gosh, “nutterati”! I love it!!!

      • attitude devant

        (to be honest it’s stolen from Carolyn Hax, who uses it in a much more positive sense)

    • Gatita

      Can you post links? Are they discussing it over on Mothering.nut?

    • Deborah

      And it’s ok though because “we value the acceptance of death as a possible outcome of birth”
      http://www.skepticalob.com/2015/3update-on-one-march-homebirth-death-and-report-of-a-second-death

  • AA

    On a facebook MW chat for a case study:
    Woman with baseline BP of 110/60-120/70. After delivery, the woman feels dizzy when sitting or standing and feels nauseated. BP decreases 80/58 over the course of ~2 hours and pulse ranges from 90-94. Not a single one of the respondents advised calling 911 or transport to hospital at all.

    • yugaya

      That’s how you get two maternal deaths with CPMs in a single state in 2015. Plus several more elsewhere in USA.

    • EmbraceYourInnerCrone

      What the hell, those bops are an indication of shock most likely. The only medical training I have was a nurses aide course I took at 18 and I know that,why are these unskilled health care providers allowed to practice?

    • Medwife

      Abnormal vital signs is one of the latest signs of postpartum hypovolemic shock. That is very, very scary.

    • The Computer Ate My Nym

      Is this a real case? Did the patient survive?

      • AA

        Real case. The homebirth midwife removed a piece of retained placenta and encouraged the mother to eat and drink. One person suggested transfer for antibiotics due to manual removal of the placenta…but no one even had a clue about the danger of this situation.

        The cool learning lesson (/sarcasm) was that 1 HB midwife (not the MW attending the birth) has an herbal for balance [sic]. Everyone is falling over themselves to give this to postpartum women.

  • The Computer Ate My Nym

    I haven’t been able to access the full text yet but something tells me they underestimated the true risk. Could just be my bias that makes me think that.

  • mostlyclueless

    Just reading the article now and finding some interesting stuff. If you look at the rates of hospital transfer (Table 2), nearly half of the women delivering out of hospital with a CNM were ultimately transferred to the hospital (46%), whereas only DEMs only transferred 8% of the time.

    • Valerie

      So clearly women should choose to deliver with a DEM over a CNM because their risk of intervention is lower and the birth is still “very safe.”

  • MLE

    This made me irrationally angry:

    • Megan

      Me too.

    • Valerie

      Yeah- it’s like saying “Bottom line: sleep is very safe for your baby, no matter how you lay him down” or “Driving without a seatbelt is a little riskier.” These same moms who chose homebirth would probably never drive around wearing their baby in a sling instead of a carseat, but the risk of injury to the baby is probably much lower (car crashes are certainly less than 1/1000 trips).

    • Anne Catherine

      I herd an NPR story on this yesterday too –they didn’t seem to think that the extra risk was a big deal. It was so stupid!!! The kept talking about the mothers and choices–ugh!!!

  • Young CC Prof

    Just to put that in context, as per CDC records from 2013, the risk of a 1-year old child in the USA dying of any cause at all before age 15 is about 2.3 per 1000. So, pretty much anything you might worry about happening to your child? Home birth is worse, and no, you’re really NOT more likely to die in a car accident.

  • Amy Tuteur, MD

    I added a meme to the post.

    • Sue

      Good one.

      My teenager thinks it’s funny when us older people indulge in meme-making. Does typical eye-roll. It only encourages me, though. 🙂

      • BeatriceC

        I have three teens. I don’t think they realize that eye-rolling is just fuel for Mom’s fire. 😉

        • Sue

          Exactly…a mother’s role, and all that.

  • KBCme

    I’m glad Oregon is making it much harder for women on Medicaid to use birth centers and CPM’s. It only driven by very clear evidence that it is not as safe for babies.

  • mostlyclueless

    Isn’t 1.06 per 1,000 quite a bit higher than what other data has shown for low-risk hospital births?

    • Montserrat Blanco

      Yes, and it makes a lot of sense.

      They used birth certificates, that means they did not have acces to all the medical information regarding the pregnancy. If you want to exclude IUGR for example you are simply not able to do that because you do not have access to those data. They could not exclude babies with malformations, congenital defects or genetical problems that would likely be delivered at a hospital in any case.

      That is partly why you do not see a bigger difference and why the results are so valid and strong.

      • mostlyclueless

        Oh my god. I had just assumed they were doing an apples to apples comparison of low risk hospital birth vs home birth who at least in theory are supposed to be low risk.

        So the study actually gave the home birth odds a HUGE advantage — and home birth was still way, way riskier.

        Jesus.

        • Montserrat Blanco

          It is impossible to compare apples to apples. To do that they should have performed a prospective clinical trial with randomized allocation of intended place of birth. As this is not ethical, recruitment would be extremely slow and the number or women you need would likely be huge, they performed this study instead.

          They knew they were not comparing apples to apples and that was not the idea at any point.

          Even with those problems the risk is higher if you intend to birth at home.

          Also, the moms in the out of hospital cohort did have higher education levels, where multips more frequently, where white more frequently, etc, etc. So, basically, better group to start with but worse outcomes.

      • mostlyclueless

        OH MY GOD. I actually read the article this time. So the planned hospital birth group had:

        7x higher rate of chronic hypertension
        8x higher rate of hypertension, eclampsia, or pre-eclampsia
        4x higher rate of gestational diabetes
        3.7 higher rate of prior cesarean
        2x higher rate of early term (37 weeks) delivery

        YET STILL HAD BETTER OUTCOMES ON EVERY MEASURE OF NEONATAL HEALTH THAN THE OOH GROUP.

        • Megan

          Wow. I wondered about the risk level of the hospital cohort but haven’t been able to read the actual study since I’m not at work where I have institutional access to the NEJM. Wish someone would have shared this info with the general public. Paints a very different picture than we’ve been hearing from the news media.

        • Amazed

          I second this. OH MY GOD.

          No wonder Missy Cheyney is so eager to embrace the results. She can now shut up the critics who say homebirth is 3 times more dangerous. It’s only 2.4 times! And she seems so honest! Who would think to check further?

          • Squillo

            Funny how now, when the elevated risk of homebirth is reaching the mainstream media, Cheyney says “We should turn the lens on ourselves and ask how can we provide better care.” The time to do that, Ms. Cheyney, was years ago, when you had all the data to tell you that your practices were unacceptable and dangerous for families. When will MANA, or OR midwives, do anything to actually improve the safety of their practices? I won’t hold my breath.

        • Megan

          Hope you don’t mind if I post these stats in a comment on NPR.

          • mostlyclueless

            Go for it.

        • Montserrat Blanco

          You got it.

          And there are a lot of things that I am pretty sure were not accountedge for: blood clotting problems in mom, mom heart disease, babies heart disease, etc, etc.

          My previous comment was published before I could correct something, and as I am not a disquss registered person I am not able to edit it: they did exclude anomalous babies, I can not find the criteria for anomalous, but probably babies with severe malformations were excluded from the analysis.

          So basically yes, it is far safer to give birth in a hospital even if you are sick than giving birth out of the hospital even if you are healthy.

          • Roadstergal

            “So basically yes, it is far safer to give birth in a hospital even if you are sick than giving birth out of the hospital even if you are healthy.”

            Again, echoes of the Dutch study, where high-risk + OB had better outcomes than low risk + midwife. These findings are robust. (And kind of logical.)

  • BeatriceC

    I think part of the problem is that people (particularly middle class and higher people), is that we’re just so far removed from anything bad happening that we can no longer imagine the horrors that even our grandmothers. let alone ancestors went through to bring babies into the world (and keep them from dying in childhood, but that’s a whole different post). Even if we do recall the historical maternal/fetal death rate, today’s numbers are “small”, so many women poo-pah them. They think “this can’t happen to me.” Maybe I should put an end to my policy of not telling my OB history to first time pregnant women. I don’t because my history is so awful, but maybe hearing that this stuff does happen to real people in real life might get through to somebody before they go full woo.

    • Madtowngirl

      I think you’re right. I’ve never been the “it won’t happen to me” type, so I don’t understand this line of thinking. Then again, I actually knew a woman who died after giving birth, and one of my grandmother’s children was stillborn. So, I’m not as far removed from that horror as others may be.

    • Ash

      Well…tbh, to whom are you telling your OB history that is not a healthcare professional or partner? To me this is info that I would not share, simply because I can’t think of many situations in which it’d be relevant. I don’t ask friends with children about their pregnancy and delivery experiences, as I consider that to be their private business.

      • the wingless one

        I don’t go around telling every one I meet my OB history but it’s certainly something I’ve shared with others. Usually it comes up either because someone (usually a pregnant friend/acquaintance) wants to know about my experience with pregnancy/birth. I don’t think it’s that odd?

        • Ash

          If someone asked, I may share some experiences, but I would not bring it up without being asked.

      • BeatriceC

        I’m not. That was the point of saying “Maybe I should end my policy of NOT telling…” I generally respond to questions by saying something along the lines of “you don’t want to hear it, it’ll just scare you. And the wingless one perfectly describes the scenarios in which it comes up. Just casual conversation.

    • Zoey

      I have a pretty awful obstetric history too, and usually refrain from sharing it. But judicious use of my story has prevented at least one home birth and convinced a first-time mother with some scary pre-e symptoms (that matched mine) in a crazy woo group to go get checked by an actual doctor when the rest of the group was telling her to “just relax” and “trust her body.” I consider those small wins.

      • FormerPhysicist

        I don’t. I consider those BIG wins. Especially to those 2 mothers.

        • Kelly

          Me too. Someone sharing what happened to two of their friends got me to my doctor and an induction the next day. I did not have any kind of emergency but it was preventative medicine that made sure I did not end up with a stillborn baby. I am grateful for those who share their experiences to help others.

    • An Actual Attorney

      Maybe. I think that the “best” thing to happen to keep me out of the woo was having my good friend, the first in my circle to have a planned pregnancy, get eclampsia and have to face being told that if they didn’t get the baby out immediately, they likely could not save her, but if it did come immediately, they weren’t sure the baby would survive. Smashed any rose collered glasses I might have had to bits.

      • BeatriceC

        And that’s essentially the circumstances under which my youngest was born. I was still in pre-eclampsia, but quickly heading towards eclampsia. The little one was born at 24 weeks and did manage to survive, but it was a tough six months.

    • LizzieSt

      My friend was just telling me that she had morning sickness for all 9 months of her first pregnancy. And then the baby had colic for 8 months. Oh, and she also has had 6 miscarriages. Poor woman. 🙁

      Luckily I used to work in Maternity/NICU so none of this is new to me.

    • This is an interesting perspective. I don’t talk about my OB history IRL either (which is why I come on here and bore all of you with it). When asked I just say “my birth stories aren’t the kind you want to hear.” I don’t want to go around scaring pregnant ladies, and I certainly don’t want to participate in the martyr competition some people seem to have going, but maybe people need to hear the scary stories too (both of mine have very happy endings thanks to my amazing MFM).

      • Bugsy

        I think the scary stories can be powerful lessons. I was pro-hospital birth well before #1, in part because all three of my cousins had had healthy pregnancies but difficult deliveries the year prior. We very well may have lost one mother and another one’s baby if they’d gone for homebirth. Frankly, even hearing the notion of “trusting birth” seems appallingly arrogant and smug in the context of having family members who almost didn’t make it.

        • Azuran

          Sadly, the home birth advocate are using the same tactics with their own scary stories of hospital birth.

          • Bugsy

            Really good point – it’s sad.

    • Bombshellrisa

      I think this is true. If we have seen something first hand, it’s hard to displace it from how us when we calculate risks (if we are reasonable). I have a friend who is anti vax (she takes a lemon juice, ginger, garlic, cayenne concoction and calls it “nature’s flu shot), paranoid about chem trails, thinks she is educated because she has watched documentaries on Netflix-yet thinks the only place a baby should be born is the hospital and only with a health care provider who tests for GBS. The reason for her stance? While pregnant with her first child, a mutual friend had a stillbirth due to untreated GBS. Getting a phone call from our friend who was choking and sobbing that her daughter was dead, going to the hospital and holding that baby girl who we were meeting and saying goodbye to at the same time and going to a funeral with a tiny coffin seared the importance of GBS testing into our heads. My husband is very pro vaccine because he has seen what polio and post polio syndrome have done to the beloved aunt who raised him. Most women who are from my mom’s home country and are her age saw siblings being born at home and at least one who died during birth or shortly after. They are the ones with the least amount of sympathy for someone giving birth in a hospital who complains about things like not being able to wear their own clothes, having pain medication offered often and how ugly they find the decor.

  • Gatita

    What I’ve been saying is that if you put a thousand people into an auditorium and then said that two of the people are going to die would you step into the auditorium? Does that seem like good odds to you? People don’t know how to number.

    • Ash

      Let’s say that there were 2 hospitals in the same city. The hospital has their baby death rate posted for fullterm infants.

      “Choose us! We have a death rate of 2.5 out of 1000! We have flowery sheets and bigger bathtubs!”
      “Choose us! We have a death rate of 1 out of 1000! Sorry, we have plain sheets and smaller bathtubs”

      Most prospective parents would be terrified to go to EITHER of these hospitals. We privileged first world residents have been shielded from the terrible risk of childbirth.

      In light of that, which hospital do you think most patients would choose, even though the absolute risk is small?

      There is hope, though. Incremental change can happen. I do not think my state will ever stop the CPM certification but I do think that there is hope for stricter risk out criteria.

      • Gatita

        And then there’s this from the NYT comments: If an airline had twice the crash rate of its competitor would anyone choose it?

    • attitude devant

      A Pennsylvania midwife is saying in her FB group that people need to understand that it’s the difference between a 99% live birth rate and a 97% live birth rate, and that’s not a big difference! I howled with laughter. She clearly has no clue how to math.

      • AA

        Considering how cold some of the “Sisters in Chains” have been…some people don’t really care as long as their ritualistic ceremonies get done. Injuries and deaths be damned.

  • Amy Tuteur, MD

    Readers, please check my math to be sure I haven’t made any mistakes.